During the COVID-19 pandemic, Luka (real name known to the editorial team), then 25 years old, was going through a difficult period in his life.
"I have a kind of predisposition to dark thoughts and at one time I used psychoactive substances excessively. Although I saw various psychiatrists, they could not help me. It was only after various events that I clearly understood that the harmful habits of that time, as well as the dark thoughts, were a symptom of other deeper processes," he told Center for Investigative Journalism of Montenegro (CIN-CG).
Isolation, increasingly complicated relationships with people, and a deteriorating mental state led him to attempt suicide. After that, he was first placed in the Clinical Center of Montenegro (KCCG), and from there he was referred to the Special Psychiatric Hospital in Dobrota (SBP Dobrota).
"When I arrived at Dobrota, the doctor on duty complained that there was no room for me. However, she soon found a solution, they discharged one patient to accommodate me."
The Director of SBP Dobrota, Dr. Aleksandar Mačić, will soon be eligible for retirement, after 38 years of work in healthcare. During his career, he spent seven years in the emergency department, 15 years at the Mental Health Center at the Kotor Health Center, and 16 years as a psychiatrist and in management positions at SBP Dobrota.
His successor will not have an easy task. SBP Dobrota is the only closed institution of its kind in Montenegro, opened in 1953. The average occupancy of the hospital is often higher than its capacity.
Mačić told CIN-CG that the hospital, although it has 233 beds, currently has 243 patients, with an additional 20 who come on weekends.
Some sleep on mattresses on the floor. The complex is not fenced, there are no elevators, and the buildings are connected only by stairs. Technicians are overworked, staff are understaffed.
"After I tried to kill myself, I was in the so-called week, or ward 7M, a men's ward for acute psychosis," says Luka.
Prison rules: Silence out of fear
Luka spent about two weeks in the hospital, and left on his own initiative because, as he says, the conditions in the acute psychosis ward are terrible. He describes the ward as being located along a long corridor with rooms on both sides. Each room has six beds, divided by a partition wall, which does not provide even a minimum of privacy - the whole thing, he says, was more like a prison than a hospital.
In just two weeks of his stay at the Dobrota SBP, Luka says he experienced a series of traumas that he still carries with him today. A few days after his admission, he witnessed the death of a patient who suffocated next to him.
"That man had health problems, in those days I witnessed two of his suffocation attacks, he was saved by other patients because due to the enormous workload, technicians often fail to react in time."
When the third attack happened, no one arrived.
"To this day I feel guilty because I failed to help that man."
The hospital did not want to confirm or comment on this case.
However, Luka points out that this is not the only trauma he carries from SBP Dobrota.
"It's amazing that auto-aggressive cases, like I was then, were placed in the same space with those who were aggressive towards others."
Shortly after the death, a physical altercation occurred between patients. One of his roommates was "craving" for cigarettes, while the other was sleeping with a pack of cigarettes next to him.
"When the first one went to get a cigarette, the second one woke up and physically attacked the one who tried to get the tobacco, accusing him of stealing."
The violence and abuse continued in the following days.
"It's not smart to report violent behavior because you spend 24 hours a day with that person," says our interlocutor.
Although SBP Dobrota is supposed to help people with serious mental disorders, as well as those who want to seek treatment on their own initiative, in practice this is often not possible. The hospital is under enormous pressure due to an overload of judicial and social patients, and illegal hospitalizations of minors continue, despite legal restrictions. All this brings this institution to the brink of functioning - both legally and humanly.
Court patients are exhausting.
SBP Dobrota is facing unresolved problems of the legal and social system. The judicial department was formed in 2006 by a decision of the Government of Montenegro as a temporary solution for the accommodation of so-called judicial or forensic patients who were sentenced by the court to mandatory psychiatric treatment and detention in a health institution, as well as mandatory treatment for addiction.
Although the forensic department at the Dobrota SBP has 21 beds, there are currently 98 forensic patients in the hospital.
Director Mačić explained that court patients are assigned to the forensic, acute, and addiction departments.
"These patients are therefore also accommodated in other departments, which poses certain security risks. For example, patients with court-imposed measures, as well as patients with alcohol and psychoactive substance addiction problems, are also hospitalized in the acute psychosis department," warns the Protector of Human Rights and Freedoms of Montenegro (Ombudsman).
The Ombudsman adds that this mixed pathology poses a significant challenge to clinical practice and meeting treatment requirements.
"Different therapeutic needs, safety risks, complexity of interaction between patients, challenges for staff... Such an environment requires an individualized approach to each patient, but also adequate organization of departments and resources. Balancing different therapeutic priorities can lead to conflicts in treatment and organization of resources," the Ombudsman points out.
Therapy between the mattress and a free weekend
Luka, from the beginning of the story, returned to SBP Dobrota after a few years to try to help his friend.
"Relatively recently I was there with a friend to try to help him, but the situation was similar to before. They couldn't admit him to the addiction ward, where he intended to go, because there was a waiting list, and there was no room in the acute psychosis ward either...".
During CIN-CG's visit in late February, the 21-bed addiction ward was home to 18 court-ordered patients, plus seven who only come on weekends. Although the ward is also intended for people who are quitting on their own, they have to wait. There are currently 16 people on the waiting list, and the first request was submitted on November 8, 2024.
Also, the acute psychosis ward, which has 37 beds, had 40 court-ordered patients at the time, plus 12 who came on weekends.
The hospital director explained that due to the overcrowding of court patients, at the time of our visit, 10 people were sleeping on mattresses on the floor.
Due to the facility's overcrowding, a weekend treatment system for court patients has been established, which means that patients take turns - some are free on certain days, while others come for treatment.
"Since we have nowhere to accommodate court patients, it happens that, if they are better, they go home and only come back on weekends. However, this creates additional problems," Macic points out.
He also notes that it is difficult to move court patients out of the hospital, because courts are often hesitant to lift the security measures of mandatory treatment and custody in a health facility.
"We pay for all the defects of the legal system. When treatment is nearing completion or has already been completed, we cannot release them until the court gives its approval. And that sometimes takes up to a year. Currently, the oldest request was sent three months ago. While we are waiting for approval, the number of court patients is only growing," he points out.
The Ministry of Health (MoH) told CIN-CG that the increase in this group of patients is being recorded in almost all European countries.
"The completion of the construction of the prison hospital (SZU) within the Administration for the Execution of Criminal Sanctions (UIKS) will significantly contribute to relieving the burden on the hospital in Dobrota. In this context, accelerating the procedure for discharging patients, in cases of modification of security measures, would be useful. However, this issue is within the jurisdiction of the courts that imposed these measures."
Unplanned special hospital within UIKS
Announced back in 2011, and insisted on in the recommendations of the European Committee for the Prevention of Torture (CPT) since 2013, the Special Health Institution (SHU) within UIKS has still not started operating, despite promises.
The Ministry of Justice (MoJ) told CIN-CG that the main project for the construction of the SZU was developed in 2020, and on March 7, 2023, the start of construction of four new facilities in the UIKS complex was officially announced, including a special health facility, a multifunctional facility, an open prison, and a registration office.
"The construction of the SZU has reached 65 percent completion," says the department of Justice Minister Bojan Božović.
The Ministry of Justice (MoJ) emphasizes that the SZU will be a closed facility for the execution of measures of mandatory psychiatric treatment and detention in a health institution, mandatory treatment of addicts of psychoactive substances and alcohol, as well as the treatment of persons with acute mental illnesses or health problems requiring inpatient hospital treatment. This hospital should relieve the capacities of the SBP in Dobrota, improve the conditions of treatment and the exercise of fundamental human rights, and take into account the recommendations of the relevant committees of the United Nations and the Council of Europe regarding the application of standards and good practices in prison conditions.
However, when it will start operating and who will work in the institution has not yet been defined.
"By the conclusion of December 19, 2024, the Government of Montenegro tasked the Ministry of Health with providing staff with the appropriate profile and qualifications necessary for the functionality of this health institution, after the completion of the construction of the SZU," the Ministry of Health points out.
Also, a working group has been formed to assess and systematize jobs for the needs of the SZU, with the support of experts from the Council of Europe.
Social patients and their status
According to Director Mačić, currently about one third of patients, or about 70 people, continue to be hospitalized in Dobrota not because of an additional need for treatment, but because they do not have a resolved housing issue or relatives who can provide them with support.
Luka states at the beginning of the story that, when he was in the Dobrota SBP, he did not understand why a man who was immobile and in overall poor health was in that institution.
"We were in the same room. They were preparing special food for him, which they put in a blender, because he had no teeth, but since the technicians were very busy, he had to wait until they found time. That's why I helped him eat so he could have a hot meal. He wasn't dangerous, I didn't understand why he was there at all."
The Ombudsman has been pointing out the problem of social patients in the hospital for years.
"Some patients are staying in the hospital without any medical indication for this. The Human Rights Defender reiterates that it is important to work systematically to resolve the problems of social patients and find adequate solutions for their care," says the Ombudsman.
Based on the Law on the Protection of the Rights of Mentally Ill Persons, when a mentally ill person needs to be released from a psychiatric institution, and due to their mental state, financial and family circumstances, they are unable to take care of themselves, they are transferred to a social welfare institution.
"The problem of patients in social need requires coordinated action by multiple services in society, synchronization of the work of health and social services. During the current period, constant efforts are being made to find an adequate solution applicable in our society," the Ministry of Health states.
Exponential growth in the number of minor patients
Although the Dobrota SBP does not have the staffing and institutional capacities prescribed by the Law on the Protection of Mentally Ill Persons for the hospitalization of minors, their number is illegally increasing.
Director Mačić told CIN-CG that in 2022, one minor was hospitalized, in 2023, eight, while in 2024, that number jumped to 16.
"In the Dbrota SBP, situations of hospitalization of minors continue to occur. During visits in 2024, we found minors in the acute psychosis ward," the Ombudsman points out.
Hospitalization takes place in acute wards, most often after emergency medical intervention and arrival accompanied by parents.
"Hospitalization of minors in practice is a complex process that requires a special approach due to their age and the sensitivity of the situation. The ward is not adapted for the stay of minors, it does not have a separate entrance, space and equipment that would meet the standard," the Ombudsman states.
The Ministry of Health claims that the hospitalizations were exclusively emergency and short-term, until adequate treatment is organized in competent institutions.
To prevent this problem, in September 2024, the new Clinic for Psychiatry "Dušan Kosović" in Podgorica was officially opened, in the presence of the Director of the KCCG, Aleksandar Radović, Minister of Health Vojislav Šimun, and Prime Minister Milojko Spajić.
Radović then stated:
"For the first time, we are also enabling hospital treatment for minors, which is crucial for their adequate care.".
However, seven months later, that department has not started operating.
General psychiatrists should be included in adolescent examinations.
The KCCG told CIN-CG that the department for treating minors has not yet started operating due to a lack of child psychiatrists.
"After intensive work by the management of the KCCG and the Clinic for Psychiatry, in a situation of staff shortage in this area, all activities for the operation of this department at full capacity are being finalized."
They point out that they are in contact with child and adolescent psychiatrists from Serbia who are helping to organize the work.
Child psychiatrist Milica Pejović-Milovančević, who works at the Institute of Mental Health in Serbia, tells CIN-CG that general psychiatrists are involved in examining minors.
"The number of child psychiatrists is very small compared to the needs. So in institutions where children and young people are hospitalized, and which have adult psychiatry as part of their staff, on-call hours are organized so that both adult and child psychiatrists can be on duty," Pejović-Milovančević points out.
What was the priority?
A child psychiatrist from Serbia, as well as the director of the SBP Dobrota, believe that for safety reasons it would be better to have a closed ward. They also believe that five beds are enough for emergency situations - acute psychosis, acute suicidality, etc.
"Hospitalizations occur in the smallest number of cases, but they require a quick response. Those who are not a danger to themselves or others can arrive abroad, while the priority in Montenegro is to resolve emergency cases."
The juvenile ward at the Podgorica Psychiatric Clinic currently has 12 beds, but the entire building is designed as an open-type facility, with the goal of deinstitutionalization.
"A closed ward is also necessary. They come to us because they could not survive in a family environment and needed to be indoors. First they have to protect themselves, and then from others," Macic points out.
Once the staffing problem is resolved and the juvenile department begins operating, there is a risk that the practice of referring the most difficult cases to the Dobrota SBP will continue.
Neglecting psychiatric needs creates fertile ground for violence
The Ombudsman told CIN-CG that he handled four cases related to SBP Dobrota in 2024. Among other things, he criticized the SBP Dobrota administration's attitude toward credible allegations of abuse.
"This criticism is based on the fact that the abuse was not reported in a timely manner to the competent Basic State Prosecutor's Office, nor was it effectively investigated internally. Also, no clear conclusion was reached as to whether the reported abuse occurred, and if so, what measures were taken in this regard," the Ombudsman said.
The Ombudsman also points out that his requests for a statement were not responded to, despite his repeated requests. Also, the representatives of the Protector were not allowed to directly seize the case files.
"Due to these omissions, the opinion was sent to the Ministry of Health, as the line ministry responsible for supervising the work of the hospital, as well as to the Basic State Prosecutor's Office in Kotor."
Although Montenegro has a long history when it comes to psychiatric institutions - back in 1902, Prince Nikola built the first hospital for this type of health problems, near Danilovgrad - we are still far from a system that respects basic human rights and the dignity of patients.
Solutions are not possible without coordinated action by multiple state actors - and without a change in political will.
Instead of healing, the system often hinders the recovery process. As in the movie One Flew Over the Cuckoo's Nest, behind the walls of this hospital, care sometimes ceases to be support.
This is evidenced by Luka's story: after attempting suicide, he left the hospital after only fifteen days, deeply shaken by what he experienced there. He found help later, through group therapy and in a community among people who, like him, had gone through the same painful experiences.
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