Although the Department of Forensic Psychiatry in Dobrota has 21 beds, at one point 141 patients were referred to the special hospital in Dobrota, so the administration was forced to allocate them to other departments. Thus, people with intellectual disabilities, acute psychosis, dementia, and perpetrators of serious crimes are treated together in the same rooms...
The team of the National Mechanism for the Prevention of Torture (NPT) of the Protector of Human Rights and Freedoms visited the Special Hospital for Psychiatry in September and October and found long-standing problems, as well as worrying practices. Juveniles with a court order are still being referred to the forensic department for adults, which is contrary to the Convention on the Rights of the Child and the recommendations of the European Committee for the Prevention of Torture.
The Ombudsman therefore recommended that the Ministry of Health take measures to urgently open a Department for Child and Adolescent Psychiatry. The hospital's overcrowding, according to the report, is further affected by the fact that about a third of patients are referred from Podgorica, despite the fact that the Clinical Center of Montenegro (KCCG) has a new clinic and the resources to care for them.
Treatment complications and compromised safety
The Department of Forensic Psychiatry in Dobrota hospitalizes patients with mental problems who were referred for forensic psychiatric observation for expert evaluation during the criminal or misdemeanor trial or who were declared partially or completely mentally incompetent at the end of the trial. The courts have imposed security measures of mandatory custody and treatment in a psychiatric institution on these patients, the NPM explains.
According to the report, the most common diagnoses of patients in the forensic department are mental illnesses from the range of endogenous psychoses and various personality disorders with psychotic decompensations.
"The accommodation capacity of 21 beds is intended only for male patients and is insufficient for the number of patients being referred, which was 141 at the time of the NPM team's visit. The overcrowding of patients is being addressed by reassigning them to other hospital departments," the document states.
The report notes that this leads to a mix of different psychiatric pathologies, which is problematic for several reasons:
“It can lead to complications in treatment - different diagnoses require specific therapeutic approaches, safety measures and levels of supervision. Also, the safety reason cannot be ignored, as forensic patients often carry a higher risk of violent, impulsive or self-aggressive behavior...” The Protector recalls that the European Committee for the Prevention of Torture (CPT) in its report on involuntary placement in psychiatric institutions states that “it is essential that appropriate procedures are established to protect certain psychiatric patients from other patients who might harm them”.
During the visit, the team noted that 36 patients were being treated in the forensic department alone, which exceeded the number of beds. This problem is being addressed by referring a certain number of patients to adaptation weekends based on the assessment and decision of the medical council in accordance with the regulations.
However, according to the allegations received by the NPM, the competent court is notified of the patient's referral to an adaptation weekend, but due to the long waiting time for court approval, the weekends are implemented without the court's consent, and if domestic violence occurs during the outing, the Center for Social Work and the Police Directorate are notified.
Instead of going to the new clinic, they are sending them to Dobrota
The NPM report showed that about a third of patients in Dobrota were referred from the Clinical Center of Montenegro (KCCG) with their first acute psychotic reaction, even though the largest health institution in the country has a new and modernly equipped psychiatric clinic that, according to staff, has the resources to care for such patients.
"This flow of referrals further burdens the capacities of Dobrota Hospital, which has been operating beyond its accommodation capacity for years," the NPM's opinion states.
The Protector recommended that the Ministry of Health, within its competence, conduct a comprehensive analysis of the use of the new psychiatric clinic of the KCCG in Podgorica, with a special focus on the number of available beds, the structure of admissions and the organization of care for patients with acute psychotic conditions with the aim of reducing hospitalizations at the Special Hospital in Dobrota.
The hospital doesn't even have money for bed linen.
The NPM report shows that the material conditions at the Dobrota court department are poor - some walls and ceilings are damaged, with water and moisture peeling off, while the improvised hanging of clothes on the window further indicates the lack of basic, dedicated space or equipment for maintaining personal hygiene and wardrobe.
"The supply of essential medicines is adequate. Of the antipsychotics prescribed to the largest number of patients, the most common are second-generation antipsychotics, which indicates positive pharmacotherapeutic practice," the Protector notes.
During the monitoring, the NPM reviewed pharmacotherapy in terms of the duration of benzodiazepine use. They recall that the CPT also drew attention in its findings to the long-term use of benzodiazepines, which can lead to dependence on these drugs, as well as possible adverse effects on cognitive function, physical health and mental health of the patient. They note that the guidelines of the Agency for Medicines and Medical Devices stipulate that the maximum duration of prescribing benzodiazepines should not exceed eight to 12 weeks. However, upon reviewing the documentation, they found that in a certain number of patients benzodiazepines are still being given as chronic therapy, i.e. for a longer period of time.
In practice, he claims, it happens that minors are also referred by court order to the Department of Forensic Psychiatry, which is primarily intended for adult patients. This approach creates multiple problems because minors are placed in an environment that is not adapted to their age and developmental needs.
The Protector as NPM once again pointed out the need to strengthen mental health centers at the primary level, so that patients have adequate, continuous and accessible support after hospitalization and to reduce the need for hospital treatment in the long term.
"The hospital as a whole remains largely dependent on donations, including the provision of basic needs such as bedding, clothing and footwear for patients, and this practice is not acceptable as a long-term model for ensuring basic standards of accommodation. The Protector as NPM notes that these are perennial problems that have been constantly pointed out and that it is finally necessary to approach their systemic solution," the opinion concludes.
The Protector, as the NPM, also recommended to the Ministry of Health to ensure regular and planned financing of the basic material needs of Dobrota Hospital.
They also repeated old recommendations.
The Special Hospital for Psychiatry was recommended that the management and doctors conduct a structured risk assessment before referring a patient to an adaptation weekend and that the results of this assessment be clearly documented as a basis for making a clinical decision on the implementation of this rehabilitation measure. They also recalled previous recommendations - that in the treatment of benzodiazepines, their use as a chronic therapy be reviewed, but also that in the treatment of patients on the drug clozapine, white blood cell values be systematically and promptly monitored.
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