GOVERNMENT OF MONTENEGRO
MINISTRY OF HEALTH
National Committee for Mental Health
Mental Health Improvement Strategy
for the Republic of Montenegro
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CONTENTS
1. INTRODUCTION..………………………………………………………………………..1
1.1
Mental health in Montenegro.………..…………………………………………...4
1.2. Mental health in Montenegro "There is no health without mental health"............4
2. PATH TO FUTURE : WHO recommendations…...............……….………….………..7
3. GENERAL CHARACTERISTICS OF THE REPUBLIC..………………….……….10
3.1. Socio-demographic characteristics .…………………………………….………….10
3.2. Economic characteristics of the country……………………………….…………..13
3.3. Poverty........……………………………………………………………….………….14
4. MENTAL HEALTH AWARENESS ................................. .Error! Bookmark not defined.
4.1 Financing in the field of mental health protection .................................................. .15
4.2. Capacities for treatment of mental illnesses...................…………...……………..16
4.2.1 Staff coverage indicators in the mental health treatment units ........................... 16
5. HEALTH/MENTAL HEALTH....................................................................................... 16
5.1 Life expectancy at birth ............................................................................................ 16
5.2 Leading causes of death ................................................ Error! Bookmark not defined.
5.3 Calculation of early dying ........................................................................................ 18
5.4 Indicators of morbidity of mental disorders and behavioural disorders ............ 18
5.1.4.1
Alcoholism .............................................................................................. 18
5.4.1.
Morbidity as a result of the use of psychoactive substances .............. 18
5.5. Morbidity of mental disorders in hospitals ............................................................ 19
5.6 Morbidity of mental disorders in out-patient institutions.................................... .20
5.7 Mortality .................................................................................................................... 21
5.8. Advantages/disadvantages of the present mental health protection system..…..22
6. MENTAL HEALTH REFORM………………………………...…………….………..23
6.1. Vision of mental health.………..……………………………………………………23
6.2. FRAMEWORK OF THE NATIONAL POLICY OF MENTAL HEALTH…….24
6.3. Values and principles of the mental health policy..……………………….……….26
6.4. GOALS OF THE MENTAL HEALTH POLICY ……………………….………..27
6.5. PRIORITY FIELDS OF ACTIVITIES….………………………………………..28
7. ACTION PLAN FOR MENTAL HEALTH………..…………………………..……..30
7.1. General strategy …….………………………………………………………………30
7.2. Time frame and resources .…………………………………………………………31
8. ACTION PLAN FOR THE STRATEGY OF MENTAL HEALTH PROTECTION
AND IMPROVEMENT
Appendix 1. LEGISLATION IN THE FIELD OF MENTAL HEALTH ..……………..32
Appendix 2. Results of the field survey… ……………………………………………….. 35
REVIEW OF FACILITIES AND HUMAN RESOURCES IN MENTAL HEALTH BY
MUNICIPALITIES …………………….…………………………………………….…….37
NGOs as a model of communal psychiatry ………………….……………………………41
Appendix 3.
7.3.1. Profile of the country……………………………………………………………..42
7.4. Brief review of the condition of mental health institutions in Montenegro…......43
7.4.1. Capacities for treatment of mental illnesses…...………………………………..43
7.4.2. Staff coverage indicators in mental health treatment units…..………………..43
7.4.3. Indicators for morbidity of mental disorders and behavioural disorders .…..44
7.4.3.1. Alcoholism………………………………………………………...……………..44
7.4.3.2. Morbidity as a result of the use of psychoactive substances ….......…………44
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7.4.3.3. Morbidity of mental disorders in hospitals……………………………..……..44
7.4.3.4. Morbidity of mental disorders in out-patient institutions ………….………..45
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81. INTRODUCTION
1.1. Mental health in Montenegro
Mental health is one of significant segments of health, which is dealt with by the
World Health Organization and other international institutions through activities and
programs related to mental health care within health policy of each country. Upon the request
of the members, WHO carries out expertises of development strategies and mental health
programs as well as provides assistance in monitoring the implementation of national
strategies.
Mental health improvement is a complex process, which comprises numerous segments
of public infrastructure, not only those of the health system. Namely, the concept of mental
health development should respect the sensibility of the society so as to be adequately
accepted. For those reasons, social, cultural, economic and public milieu as well as the
necessity for having inter-sectorial approach to the problem of mental health must not be
neglected.
The definition of the World Health Organization extends the concept of mental health:
»Health is not only the absence of disease, but the state of physical, psychic and social
welfare». This definition points out the importance of mental health, but also at the same time
many existing problems /social, economic, public.../, that call for organized activities of the
society in this area.
Respecting socio-economic and public problems created the possibility for psychiatry
to indirectly influence drafting of the health policy, and to represent one of the conditions
when appraising living standard of a country.
Immediate living environment, for more than a decade, has been the ground for
transitional trends, ethnical conflicts, economic crises, migrational trends, and all that
together has changed living milieu of both domicile and immigrational population. Processes
within the socio-economic milieu itself led to decrease in employment, difficult functioning
of the families, acculturation, alienation, with tendency of increase of the number of mental
disorder cases. Generally speaking, we witness the ever growing open manifestation of the
forms of dissocial behaviour, alcoholism, use of psychoactive substances, delinquency,
crime, depression and suicide.
Being the traditional society with rigid system of values, where disease is considered to
be a flaw, and mental illness the shame to a family, it is very hard to establish the atmosphere
that will be accepted for civilised and rational treatment of mental illnesses. Stigmatization
of mental patients and their families is a prejudice and obstacle to development and
implementation of the national program for protection of mental health of the population in
Montenegro. The objective of this strategy is to define integral protection and response of the
health service in solving growing problems of mental health, as well as the ways of further
development of health service which should contribute to the improvement of health
condition of an individual and population as a whole.
Minister of Health of the Republic of Montenegro, Chief of staff, Doctor M.Pavličić
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1.2.
Mental health in Montenegro «There is no health without mental health «
Mental health does not represent a personal failure, because it does not happen only to
the others. Mental and physical health are inseparable, their influence is deep and complex.
Mental illnesses are the consequence of presence of genetic, biological, social, and
environmental factors. Some estimates of the WHO show that over 450 million people suffer
from mental and neurological disorders or have psychosocial problems that are related to the
abuse of alcohol or drugs. Depression is one of the leading causes to invalidity and it is on the
fourth place on the top ten list of main causes to global burden of disease. In the world there
is around 70 million people who are addicted to alcohol. Around 50 million people suffer
from epilepsy, and 24 million from schizophrenia. Every year a million people commit
suicide. From 10 to 20 million people try to kill themselves according to the data from the
survey conducted by the World Health Organization.
Our country joined the global campaign of the World Health Organization aiming at
broadening public and professional awareness of the actual burden of mental disorders and
their expenses from human, social and economic aspects. This is the effort aimed at providing
to mental patients the treatment they have the right to and which they deserve, while
eliminating many obstacles, stigma, discrimination.
Following tendencies and recommendations of the World Health Organization, the
Ministry of Health of the Republic of Montenegro initiated a set of activities through
different programs aiming at taking measures to improve the protection of mental health of
the population, which represents one of the basic human rights, as well as to improve work
conditions of the staff dealing with them and make the organization of mental health
protection institutions of Montenegro more functional.
As a result of these tendencies the Ministry of Health launched the project » Mental
Health Strategy for Montenegro« in June 2003.
The project of drafting the Strategy for mental health development in Montenegro
consists of three phases: drafting the theoretical context, which aim is to track development
tendencies in the field of mental health protection that are set by the World Health
Organization. After that, it determines human resources, spatial and technical potentials of
Montenegro, and in the third phase it should give concrete propositions in terms of
institutions and kinds of psychiatric units, employment and professional development of the
staff working in them. On this project we engaged both our colleagues from the Republic of
Serbia and workers in the field of psychiatry, psychology and social medicine from
Montenegro.
In the period from June to September 2003, we carried out a very intensive activity,
whose objective was to determine the situation in the institutions for mental health, as well as
to examine the quality of education, capability and attitudes toward reorganization of
institutions for mental health. The basic instrument for appraisal of the analysis was a
questionnaire, upon which the data were processed and used for operationalization of project
tasks.
With regard to facilities and existing network of institutions for mental health, the
situation in the field was determined in four regions, two of which are situated in the north,
one in the central part and one in the southern part. We visited directly all institutions and
colleagued involved in drawing up of this project, which is to them of great future
professional, and it could be said also existential importance.
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The processed data represent the real base for engagement and making projections for
future development and implementation of mental health strategy.
Seriousness and complexity of examination of the field of mental health in this
strategy imposed some additional activities, that is the project task has been extended in the
course of realization of Mental health strategy in Montenegro, as follows:
 We produced the database of human resources in the mental health institutions,
compiling numerous information starting from socio-demographic, professional as well as
by means of specific interests of ancipated plans and proposed solutions for improvement
of mental health institutions functioning;
 We formed the database of institutions that deal with mental health, by registering
spatial, technical and environmental conditions.
 We collected the data pertaining to recommendations of the Stability Pact for Southeastern Europe, which refer to socio-demographic areas and country's economy, and it
will be, in a period to come, amended and processed;
 We collected the information on legislation in the field of protection of the rights of
mental patients, as well as of the staff working with them in relation to
recommended WHO guidelines.
 We extended the project task and we registered the data on spatial, technical and human
resources in the private sector of service provision, field of the Ministry of Interior
and Ministry of Defense, guided by the fact that these sectors will be subject to reform
(legislative, structural changes), and that in the period to come they should be integrated
in the system of mental health protection, as an overall system.
 Pursuant to the recommendations of the World Health Organization on
deinstitutionalization of psychiatric care there is a fact that NGO sector should be
involved in the overall system of protection. Within the activities related to drawing up
the strategy we registered NGOs according to their aims and activities they perform,
because they represent a significant factor in creating the public opinion.
 In order to deinstitutionalize protection of mental health there is an idea to, through intersectorial institutional cooperation of the Ministry of Health, Ministry of Labour and
Social Care, Employment Agency and others, examine the need for inclusion of the
unemployed, with adequate training, on the projects for the elderly.
 We particularly emphasized the activities determined in the Action plan for prevention
of drug addiction among the youth. The stand of the National committee is that this
plan should be incorporated in the activities of the Mental health development strategy,
since drug addiction is only one of psychopathological entities.
Overview of the above-mentioned activities is a good basis for directing to overall,
functional, and humane approach to the problem of improvement of mental health and taking
care of the beneficiaries of the institutional and out-of-institution care of the ill.
President of the Committee for Mental Health in Montenegro
doc.dr. Mirko Peković dr.sci. med
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2.
PATH TO FUTURE: WHO recommendations
WHO report on global health – 2001. Mental health: new understanding, new hope, gives ten
recommendations that could be followed by every country in order to improve mental health
of its population. Those recommendations can be adapted to each country respectively in
accordance with its needs and opportunities.
1. Provision of treatment in the primary health care
Taking care of the mental disorders and the treatment for those at the first level of protection
will provide for most people easier and quicker access to health services. Provision of
treatment in the primary health care can improve possibility of establishing the diagnosis in
due time, treatment and adequate monitoring of patients, and reduce unnecessary
examinations and improper or non-specific treatment. In order to achieve that, it is necessary
to provide training for medical staff in primary health care in basic skills for protection of
mental health.
Certain number of developing countries produced national programs which integrate mental
health in primary health care.
2. Provision of sufficient amount of psychotropic drugs
Drugs used for treatment of psychiatric disorders and epilepsy are divided into four groups:
antidepressant drugs for emotional depression; antipsychotic drugs for psychotic symptoms;
antiepileptic drugs for epilepsy; and anxiolytic drugs (or sedatives) for anxiety. Basic
psychotropic drugs should be provided at all levels of health care and they should be included
in the positive list of drugs of every country. Those drugs can lessen symptoms, reduce
invalidism, shorten the course of many disorders and prevent their recidivism. They often
represent the first line of treatment, especially in the situations when there is no opportunity
for providing psychosocial interventions, nor highly specialized experts.
Small number of drugs is necessary for treatment of most mental disorders. Major part of
those drugs are available. The choice of one drug instead of the other depends to a large
extend on their availability. While some drugs can be expensive, their price is often
compensated for with the reduction of the need for other kinds of protection and treatment.
Certain number of countries has already included basic drugs for protection of mental health
into the obligatory list of drugs for primary health care.
3. Provision of community treatment
There should be community mental health services instead of psychiatric hospitals and
institutions. Community mental health care leads to better outcomes of treatment and better
quality of life of a person suffering from chronic mental disorders. Treating the patients in a
community instead of psychiatric hospitals is cheaper and it provides respect of human rights,
limits stigma due to treatment and leads to treatment of illness in due time.
Large psychiatric hospitals of asylum type should be replaced by services for community
mental health protection. In order to achieve that, protection should be provided by opening
psychiatric wards in general hospitals and home care, so as to meet all the needs of the
mentally ill. This kind of shift to community protection requires engaging medical workers
and services for the rehabilitation at the local community level, as well as providing
assitance in crises situations, safe houses and employment to persons with mental disorders.
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4. Raising the public awareness
In all countries there is a need for initiating campaigns for educating the population and
raising public awareness on the importance of mental health. The main objective is to reduce
the obstacles to treatment and protection by raising the awareness of the people on frequency
of mental disorders, possibilities of treatment, recovery process and human rights of the
mentally ill. The information on availability of treatment and benefits from the treatment
should be spread so that reactions of general public, health experts, the media, legislators and
politicians change and become based upon accessible knowledge. Raising awareness of the
public can reduce stigma and discrimination, increase visits to mental health services and
change prevailing attitude that mental and physical health are two separate, different entities.
5. Inclusion of community, family and beneficiaries
It is necessary to include communities, families and beneficiaries into the process of planning
and developing the policy, programs and mental health services. That helps to adjust services
to the needs of the population, taking into account their age, sex, cultural and social
background. Then it will be easier for the patients with mental disorders and their families to
use such services.
The role of a community is to provide self-help and mutual help, lobby for bringing changes
to mental health protection and provide funds, carry out educational activities, participate in
monitoring and appraisal of effects of protection, and represent in alternation of attitudes
toward mental disorders and reduction of stigma.
Groups of beneficiaries proved to be a strong, loud and active factor for changes. Nowadays,
there are many associations of beneficiaries that are involved in the process of mental health
protection. Participation of beneficiaries in organizing the services, appraising the standard of
treatment as well as in the development and application of policy and the Law on mental
health, helps to increase responsibility of the experts.
Families are often primary in providing the protection. It is necessary to help families to
understand the illness, acquire skills of protection and support, encourage regular taking of
drugs and recognise early signs of recidivism, which leads to better recovery and reduction of
invalidism.
Exchange of the knowledge between the medical experts and families and beneficiaries is of
vital importance for creating confidence and efficient therapeutical relation. Such an
exchange helps the families that care for patients, enabling them to „move from passive care
to active care ”.
6. Setting the national policy, programs and legislation
Mental health policy, programs and legislation are very important for continuing action. The
policy of improvement of mental health should be based upon modern knowledge and respect
of human rights. Reform of mental health should make a constituent part of the overall
reform of the healthcare system. Most countries should increase their budget for mental
health. Drugs used to treat mental and neurological disorders are included in the obligatory
list of drugs.
7. Professional staff development
Many countries have to increase and improve education of mental health professionals who
provide specialized protection as well as of the health workers at all levels. Many developing
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countries do not have enough specialists for mental health services. After training those
professionals should be encouraged to stay in their country and occupy positions where their
skills will be used in the best possible way. This training should be taken by medical and nonmedical professionals such as psychiatrists, clinical psychologists, psychiatric nurses, social
workers and occupational therapists, who should all together provide overall protection and
integration of the patients into a community.
8. Links to other sectors
War, conflicts, catastrophies, unplanned urbanization, loss of jobs, and poverty affect mental
health and represent obstacles for treatment. Non-medical sectors, such as education, services
for labour and social issues, and judiciary, exert significant influence as well on the quality of
life of patients with mental disorders. Those sectors should take part in improvement of the
communal mental health. NGOs should be motivated as well to provide support and
participate in local initiatives.
Important role in improvement of mental health belongs to development of the policy of work
which ensures positive working environment free of discrimination as well as help to the
unemployed persons. Educational policy should meet requests of the groups with special
needs. Priority should be given to provision of accomodation to persons with mental
disorders within a community. The judiciary has to prevent unjust imprisonment of the
persons with mental disorders and provide treatment of mental and behavioural disorders in
prisons.
9. Monitoring community mental health
Community mental health should be monitored by including mental health indicators in
general information and reports on health. Those indicators should contain the number of
persons with mental disorders, as well as the quality of protection they receive. Improvement
of the information on health and reporting system help to monitor trends and discover
changes. Monitoring is necessary to define priorities, determine the needs and efficiency of
treatment of mental disorders and organize prevention programs.
10. Support the surveys
It is necessary to have more surveys on biological and psychosocial aspects of mental health
as well as on how much the services for mental health are equipped, to understand better the
cause, course and outcome of mental disorders and develop more efficient treatment services.
Such surveys should be conducted at a wider international level to understand variations in
different countries.
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3.
3.1.
GENERAL CHARACTERISTICS OF THE REPUBLIC
Socio- demographic characteristics
Montenegro, according to the census in 2003, has 616,258 inhabitants. According to the
census in 1991 there were 615 035 inhabitants, which means that the total number of
inhabitants rose by the rate of 0.6% at the annual level. Pursuant to the projection for
population in the next 20 years it is envisaged that the growth rate will decrease slowly, and
in the year 2020 it would reach the growth level of 0,2%.
In the overall population structure, there is 58, 2 % of urban population and 41, 8% of
rural population, with the increasing tendency of growth of urban and decrease of rural
population. In the structure of population, according to the estimate, ratio of the youth under
14 in urban and rural areas is 25%: 16%., and ratio of the inhabitants who are over 65 is 8% :
16%. The average age of the population in urban areas is estimated at around 34 years and
around 39 years in rural areas. Aging index for the overall population is estimated at 56, for
urban population 40, and around 90 for rural population.
Process of demographic transition, which started in Montenegro later than in the
western and northern European countries, and some of the ex-Yugoslav republics, is
conditioned by social, economic and political situation and in the past decades it was slowed
down by political and economic crisis and war surroundings. Birthrate is in the constant
process of decline in the last seven decades, with controlled fertility in marriages. There is a
decrease in death rate, especially in death rate of infants, and changes in the age structure of
the population as a result of demographic process of aging, changes in economic and social
structure of population. According to the latest available data of the national statistics in 2001
the birthrate was 13,3 , death rate 8,2 and the population growth rate was 5,1.
In Montenegro in 2001 there were 3893 registered marriages – or 5,9 per 1000
inhabitants, and 492 divorced marriages or 126,4 per 1000 registered marriages. In the
several past years there is a slight decrease in the number of marriages and increase in the
number of divorced marriages.
Under the influence of demographic transition the structure of population is being
changed with a slow tendency of aging, especially in rural areas, and seven municipalities
registered negative population growth. Participation of persons over 65 exceeds 11% of total
population and average age of population is estimated at over 35 years - 34 for men and 36,6
for women, and thus the population can be considered old. In the northern, economically
undeveloped region, and in some of the municipalities the situation is a lot worse than the
situation at the republic level.
Gender distribution of the population by age groups for 2002
Literacy of the population can be reliably estimated only according to the data of the
latest census carried out in 1991. Illiteracy of the population over 10 years was 5,9%,
population over 65 was 33%. Out of total number of illiterate old people 16,2% were men
and 83,8% women, which clearly shows that old women are very endangered population.
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When we consider the increase of the number of young people in compulsory
education and dying of old illiterate people and a trend of continuing decrease in participation
of illiterate people in the overall population from 16,7% in 1971, 9,4% in 1981 and 5, 9% in
1991, we can state that the situation in 2003 is far better.
In the primary education in the school year 2000/ 2001 there were 76 154 students,
48,4 % of which were girls. In the special needs primary schools there were 291 students.
In high schools in the same period there were 30 848 regular students, 50,8% of
which were girls. In special needs high schools there were 128 students.
Out of 125.764 children and youth (according to the estimate) from 7 to 18 years in
primary and high schools in the school year 2000/2001 there were 107 002 students or
85,1%. Special needs schools were attended by 419 students or 0,3% out of total number of
population aged 7 – 18.
Total number of the employed in Montenegro in 2002 was 113 827. On the list of the
unemployed in the Employment Agency in 2002 there were 80 584 people. Ratio of the
employed and unemployed according to the official record is 1:1,4. Employment rate in the
period 1990 – 2002 was decreasing on average by 2,9% per year.
Unemployment rate (calculated according to the methodology of ILO) in Montenegro
in the same period, according to the official data, viewed through the ratio of the unemployed
and active population was 30,4% ( 20,6% men and 40,4% women).
Basic characteristics of unemployment in Montenegro are the following: unfavourable
ratio of the employed and unemployed, more unfavourable position of the women regarding
getting an employment, long years of waiting for a job, unbalanced opportunities for finding
an employment by regions, high percentage of people active in the informal economy, on
which there are no valid data, and high percentage of so-called techno-economic surpluses
(redundancies).
In 2000, public institutions for children and youth housed 567 proteges. In the public
institutions for children without parental care there were 151 proteges. In the public
institutions for children and youth with psychophysical disorders there were 390 proteges
while in the public institutions for neglected children and youth there were 26 proteges. At
the end of 2001, 9.639 children from the families who are beneficiaries of MOP (family
allowance) received children allowance.
Lack of official data on the number of children in the street, homeless and number of
trafficked children, does not mean that there are no such cases, but it is very hard to monitor
and evaluate this segment.
Traffic in women and sex trafficking is an occurrence which is certainly present in our
near surroundings and so it could not bypass Montenegro as well. There are no available
official data on incidence and the number of cases, but the trials in courts that are related to
this issue are being monitored by the public and the media, which shows critical and active
attitude of the official state policy toward it.
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Prostitution is a problem that started to be the subject of disussion in the public, but
there are no available official data on the number of persons engaged in prostitution nor other
data that would reflect the scope of its occurence. This is a society in transition, where
traditional values still prevail, and it is very hard to register such an occurrence.
Number of people in prisons on various grounds in Montenegro, according to the data
of the Ministry of Justice, is cca. 450. During 2001, 2004 adults were convicted of crimes,
8,1% of which were women, and 101 juveniles, 3,0% of which were women.
According to the data of the Comessariat for displaced persons in Montenegro there
are 43 116 IDPs and refugees, which makes around 6,5% out of total number of domicile
population or 6,1% of the total population. In Podgorica there live around 28% of the total
number of IDPs and refugees.
In Montenegro, according to the census of 1991, in the structure of the population there
is 62% of Montenegrins, 14,6% of Muslims, 9,3% of Serbs, 6,6% of Albanians. Roma
population, according to the data collected with the census, participated in the structure of the
populated with 0,5%. According to the survey conducted by Roma centre for strategy,
development and democracy from Podgorica in Montenegro there live 20 470 persons who
belong to the ethnical group of Roma and their participation in the total population is 3,3%.
Their characteristics are high birthrate, low percentage of children who attend school and
illiteracy (76%). In primary schools there are 840 Roma children, while in high schools there
are 35 students, and 7 students at the university.
3.2.
Economic characteristics of the country
Economic system of Montenegro, as other economic systems in the neighbouring
countries, is burdened with consequences of a ten-year period of crisis, war surroundings,
embargo and transition. Consequences are reflected in reduced scope of overall commercial
activities and achieved production, high rate of unemployment, decreased employment and
increase in the number of redundancies, negative influence of inflation, worsening of the
structure and scope of total import and export, i.e. negative foreign trade balance.
Economic reform has been slowed down, and it could not follow processes in
countries in transition in Central and Eastern Europe at the expected rate. Burdened with
previous problems, Montenegro reports until 1994 fall of basic indicators of socio-economic
development and their slow recovery in the following years.
Domestic product (in $ mil), monitored in the period from 1990 to 2001 shows steep
fall from 1259 to 524,2 in 1993, and then a slight growth to 825 in 2001.
In the same period domestic product per capita (in dollars) with 2055 dollars in 1990
falls to 830 dollars in 1993, and after that it grows to 1240 dollars in 2001. Domestic product
in 2001 represents less than 60% DP from 1989, but in its structure cca. 37% is the share of
private sector, which is an encouraging fact.
Average net income was 189 DM in 2000 and 218 DM in 2001.
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Data on the national debt will be presented through some available indicators. In the
period from 1990 to 2001 the import was almost doubled from 278,6 million $, when it
particpated with 22,1% in DP, to 529,4 million $, when it participated with 64,1% in DP.
At the same period the export was reduced by 65%. In 1990 from 516 million $, when
it participated with 40,9% in DP, to 178 million $ in 2001 when it participated with 21,5% in
DP.
Beside the negative foreign trade balance there are other debts and deficits for which
there are no valid data. These are, above all, the following: foreign debts that become due,
accumulated and current economic loss, internal debts among the firms, debts between the
firms and banks, debts between the firms and the state, debts between the state and the
population, debts of the population to public firms, budget debts, etc.
Data on the economic aid in the overall and valid form are not presented by available
official statistics. There can be found only partial, unreliable data, so it can not be presented.
Health care in Montenegro is based on the model of compulsory health insurance.
Contributions in the amount of 15% of the gross income of the employee are being paid
through the institution of compulsory health insurance – Republic Health Insurance Fund –
and they represent the main source for financing the health care. Pension and disability
Insurance Fund finances health care of the pensioners, and Employment Agency pays
contributions for the unemployed. Additional finance source is republic budget and individual
participation of the insured.
Expenditures for the health care of the population at the republic level in 2001 amount
to 224 DM per capita.
By adopting the Strategy for health system development the main goals of
development have been set. Within the funds from the budget that are earmarked for health
care proportion for financing the mental health protection has not yet been defined. Within
the intensive social changes that are taking place, we started the reform of the healthcare
system in which the priority is given to preventive and primary health care. There is a plan to
build up the funds allocation system by the level of health care and geographic location,
which will be based on the principles of equal accessibility, solidarity, optimal quality, and
cost effectiveness. It will make access easier to all, in particular to vulnerable groups,
especially for mental health protection.
Within the financial planning of the health care, the private sector has not been
included until now, and it was mainly out of system control. It is because the private sector is
not yet integrated into the health system, there are no contracts with the private sector (save
for some exceptions, in particular in some deficit area of health services).
3.3.
Poverty
Unfavourable social milieu in Montenegro affects health of the population, including
mental health. Socio-economic and political crisis, war surroundings, unfavourable
migrational trends, immigration of a relatively high number of displaced persons and
refugees and emigration of the most educated active young people contribute to the general
poverty.
The standard of living of the population is affected by decrease of economic
effectiveness and maintenance of formal employment, which contributed to decrease of real
income, pensions, subsistence allowances, and other kinds of income of the population.
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Decrease of real income has affected social standard (health, education, housing, culture) as
well as personal standard of the citizens. Nutrition, hygienic conditions, drug supply, health
care and so on have become worse. The most affected groups are: the elderly, children,
disabled, sick and jobless. Situation is worsened by a relatively high number of displaced
persons, for which it is getting harder to provide humanitarian aid. Transitional recession is
followed also by worsening of social security of the citizens, which is evidenced by presence
of crime. High scope of informal economy in some years has been, according to estimates,
over 50%.
All the above-mentioned resulted in visible social differentiation – impoverishment of
the so-called middle class and extreme enrichment of a relatively small number of people in
the sphere of informal economy. Both groups are prone to increased risk for mental health.
According to the surveys conducted by the Institute for strategic studies and prognosis
(ISSP) 9, 4% of the population in Montenegro live under the poverty line, while 37%
reppresent economically vulnerable population. Poverty rate defined through expenditures of
the households compared to the minimal living standard (poverty line – 100 DEM) at the
republic level is 9,4 – in the northern 14, 9 central 6,5 and southern region 6,8. There is a
clear distinction between regions. 4,7% of the population is educationally poor, 6,4% is poor
in terms of their health, 22% are poor in terms of employment, 13,1% in terms of housing
conditions, 9,7% have no telephone, 3,7% have no TV set and 7,8% have no washing
machine.
Life in the impoverished villages, old age, illiteracy, low pensions, unemployment,
homelessness, alcoholism and abuse of psychoactive substances, domestic violence against
women and children, are some of the factors that affect mental health of different population
groups.
There are no valid data on the prevalence rate of mental illnesses, in particular in
relation to the factor of poverty, as well as the opposite: to what extent does the factor of
poverty affect mental health, nor to what extent does the population with mental illnesses,
who are inactive in terms of work, participate in the increase of poverty.
Development strategy and poverty reduction (PRSP) is the priority paper of the
Government of Montenegro, where the project of mental health protection and improvement
and prevention of drug addictions represents a significant parameter of maintenance and
improvement of health of more vulnerable population groups.
Achievement of goals set by PRSP for the field of health will be monitored by
indicators of incidence and prevalence of mental illnesses, protection of rights and communal
protection of mental patients, workload of psychiatrists.
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4. MENTAL HEALTH AWARENESS
Awareness of the mental health of the population in a communnity can be measured
through actual mental health policy as well as the fact regarding the extent to which it is
present in the global health policy of a country. Until now there was no official mental health
care policy, nor the national plan for its improvement.
With this document we set up the goals of general health policy and made initial steps
which would after drafting and adopting the national strategy for mental health protection and
improvement result in its integration into the already adopted government papers.
The situation is made more difficult by limited financial and human resources, and also
by prejudices and discrimination of mental patients, as a mental disease is considered a taboo.
Mental patients are usually being treated in unsuitable institutions or they get placed for
a long period in psychiatric hospitals, where some of them remain until they die. By this kind
of taking care of a patient we can see what the immediate family attitude toward the patient
is, and it should be one of support in the process of treatment and rehabilitation. Also, the
ways of health care should not back up stigmatization and discrimination of mental patients
through their institutional isolation (asylums) and depriving them of their human rights.
In a local community and at the global level there are no debates, campaigns and other
forms of destigmatization and eradication of prejudices toward mental patients. Surveys that
could serve as a basis for valid estimation of incidence of certain mental illnesses, addictions,
alcoholism, domestic violence against women and children, are sporadic and they are often
based on such methodological concepts that no reliable and general conclusions can be made.
4.1.
Financing in the area of mental health protection
The largest facility for treatment of psychiatric patients is the Special psychiatric hospital at
Dobrota, which is financed as follows:
Financing of the Special hospital for treatment of mental illnesses Dobrota
- income from the Health Fund -74,08%,
- income from co-payments - 0,08%,
- income from the funds from Serbia - 1,00%
Other public health facilities for treatment of mental illnesses are financed by the Health
Fund.
Private sector is not included in the structure of the Health Fund by scope and quality of
services, income and expenditures.
4.2.
Capacities for treatment of mental illnesses
Treatment of the patients with mental and behavioural disorders, as a compulsory aspect of
health protection, is provided in public health instututions of Montenegro. Out-patient care is
provided in referral centres, mental health centres which are in the process of establishing or
are incomplete, psychiatric ambulantas, within dom zdravlja and private psychiatric practice.
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Dispensary units (Special psychiatric hospital, Psychiatric Clinic, Psychiatric hospital,
Psychiatric Ward) for psychiatric patients are located in:
 Special hospital for treatment of psychiatric patients Dobrota which has 252 beds,
 Clinical centre of Montenegro – Psychiatric Clinic with 40 beds,
 General hospital Niksic – Psychiatric hospital with 30 beds,
TOTAL------------------------------------------------------323 beds
The above-mentioned data are collected in the survey - the data were obtained directly from
hospital services, and the survey was conducted in 2003.
4.2.1. Staff coverage indicators in the mental health treatment units
According to collected data, per 100.000 inhabitants there are 1,66 specialists in
psychiatry, 4,7 specialists in neuropsychiatry, 1,5 psychologists, 0,6 medical psychologists,
1,05 social workers and 0,3 special education teachers.
Staff norms, as determined standard in this field of health care, are the following: in
the primary healthcare per 15 000 inhabitants there should be mental health care team
consisting of 1 specialist doctor, 1 nurse, 0,30 clinical psychologist (or 1 clinical psychologist
per 50 000 inhabitants) and 0,25 social worker (or 1 social worker per 60 000 inhabitants).
Data on the existing staff show that the coverage of specialists in psychiatry is
significantly above the envisaged norms.
5. HEALTH/MENTAL HEALTH
5.1.
Life expectancy at birth
Life expectancy at birth, calculated based on the existing age specific mortality rates
(shortened approximative tables of mortality), is an overall indicator of the health condition
of the population.
Strategija za unaprijeđenja mentalnog zdravlja u Republici Crnoj Gori
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Graph 1. Life expectancy of the newborn
according to sex in Montenegro
Očekivano trajanje
života
100
80
60
MEN
WOMEN
40
20
0
1950/1951
1960/1961
1970/1971
1980/1981 1990/1991
Godine
1997/1998
1998/1999
1999/2000
This indicator represents the average number of years the newborn of a certain sex is
expected to live up to if the existing mortality rates are maintained.
In 1999/2000 the life expectancy at birth for Montenegro was 76,27 years for women and
71,05 years for men, and from 1950/1951 there is a growth tendency (Graph 1).
5.2.
Leading causes of death
Rank order of the main causes of death in Montenegro has not changed in the last
decade.
Given groups of diseases participated in the structure of mortality at over 90%, while
circulatory diseases and malignant diseases together represent more than two thirds of the
causes of death of the persons who are over 65.
Predominance of cardiovascular and malignant diseases in the structure of mortality
reflects the presence of risk-associated behaviour in the population, such as smoking,
alcoholism, unhealthy eating habits, insufficient physical activity, but also the influence of
environmental risk factors (polluted air, food and water). Insufficiently defined conditions on
the third place of this list result from uncertain information on the cause of death on the
territory of Montenegro. Injuries, poisoning and consequences of outer factors show that
there is an unadequate protection at work, home and in the street.
The value of health condition indicators for the population of Montenegro are within
limits of the value of the same indicators in South-Eastern European countries.
Strategija za unaprijeđenja mentalnog zdravlja u Republici Crnoj Gori
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Table 1. Overview of the leading causes of death of the population in Montenegro
in 2001
Groups of diseases
Number % participation in Mortality rate
of
the the structure of the
dead
dead
Circulatory diseases
2872
52,88%
4,34
Tumors
896
16,49%
1,35
Symptoms,
signs
and
abnormal clinical and lab
629
11,58%
0,95
findings
Injuries,
poisoning
and
consequences of outer factors
297
5,47%
0,45
Respiratory diseases
266
4,90%
0,40
5.3.
Calculation of early dying
Calculation of the number of lost years of possible life for persons below 75
(approximate value of life expectancy at birth in Montenegro) facilitates the process of
forming the priority list of diseases by the health authorities for prevention-related activities.
On average all the deceased in Montenegro lost 10,15 years each of possible life. The most
significant causes of early death are circulatory diseases 31,28% out of the total number of
lost years of life for all the deceased, then tumors 19,00% of the lost years of life and injuries
and poisoning 9,67%. All other causes of death caused 40% of lost years of life.
Average age of the dead in 2001 was 67,90, 64,74 years for men and 71,22 years for
women.
5.4.
Indicators for morbidity of mental disorders and behavioural disorders
5.1.4.1. Alcoholism
The problem of overconsumption of alcohol is particularly related to young
population of both sexes, with the more intensive growth among girls. According to the most
recent available data, alcohol is being consumed constantly or occasionally by 55% of the
young who are 15 to 30. Several times a year 11% of the young between 12 and 18 years,
60% of the young men and 14% of the girls between 19 and 30 get drunk. It is very worrying
that 4,3% of the young between 12 and 18 already show the signs of alcohol addiction.
In Montenegro during 2001 in the hospital institutions there were treated disorders
caused by alcohol consumption (F10 according to MKB-10) of 240 male patients during
6212 hospital days and 25 female patients during 1354 hospital days (in Podgorica 30/476
men and 3/34 women).
5.4.1. Morbidity as a result of the use of psychoactive substances
In 2001 in Montenegro there have been registered 69 cases of psychoactive
substances poisoning in outpatient and 7 in hospital morbidity. Certain derived indicators
show that there is an increase in number of persons addicted to psychoactive substances, with
a tendency of decreasing the age limit.
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5.5.
Morbidity of mental disorders in hospital institutions
Beside the ones that are given, in 2001 the following rates of mental disorders and
behavioural disorders have been registered:
In hospital services of Montenegro there have been registered 1800 cases of
mental disorders and behavioural disorders, and morbidity rate was 2692,2 per 100 000
inhabitants of Montenegro. The most common disease in this group was schizophrenia,
schizo-pathic disorders, madness, which participated in the general structure of all mental
disorders at 45,9%, then mood disorders at 16,1% and on the third place there are mental
disorders caused by alcohol 14,7%, and mental disorders caused by drugs. Out of the total
number of patients treated in hospitals there were 61,2% of men. The patients belong mainly
to the 40 – 49 age group (27,3%), then to 30 - 39 age group (22,1%), 20 - 29 age group
(18,2%) and 50 - 59 age group (17,9%), which shows that the greatest number of hospitalized
patients, due to mental and behavioural disorders, were capable of work (over 80%).
Mental disorder trends in the period from 1997 to 2003 show that were no statistically
significant changes in number of patients treated for mental disorders and behavioural
disorders in dispensaries of Montenegro for the given period, which can be seen in graph 2.
broj slučajeva
Graph 2.Tendency of mental disorders and mood
disorders from 1997 to 2001
1820
1800
1780
1760
1740
1720
1700
1680
1660
y = -2x + 1764,6
1997
1998
1999
2000
2001
godine
Total number of realized hospital days for treatment of mental diseases was 58028 or
on the average per a disease it was 32,2 days, which shows that the length of hospitalization
in such cases is pretty long. The longest treatments are the ones for schizophrenia, schizopathic disorders and insanity, on the average it is 41,7 days. Mental disorders caused by
alcohol have been treated for on the average 28,5 days, mood disorders 27,5 days, while
mental disorders caused by drugs and neurotic disorders were treated for 13,2 days on the
Strategija za unaprijeđenja mentalnog zdravlja u Republici Crnoj Gori
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average. Compared to all other diseases which are treated in dispensaries mental disorders
and behavioural disorders require the greatest length of hospitalization.
Bed occupancy for treatment of mental disorders and behavioural disorders was 122,7 days
during the year, which shows that beds were free for a relatively long period. Number of beds
according to the reports from the services for dispensary treatment of this group of diseases
shows that occupancy was 155,6 days during 2001.
5.6.
Morbidity of mental disorders in out-patient institutions
In out-patient services there are 9739 reported cases of mental disorders with
morbidity rate of 1456,7 per 100 000 inhabitants of Montenegro.
The most frequent illnesses from this group were neurotic, stressogenic and
somatoform disorders with morbidity rate of 542,6, followed by schizophrenia, schizopathic
disorders, insanity (morbidity rate 399,0) and on the third place there are mood disorders with
morbidity rate of 288,4. The biggest number of registered cases of mental disorders and mood
disorders was in the general medicine service 63,1%, followed by occupational medicine
services with 32%. In the service for health protection of preschool and school children there
were 463 treated children and most frequent illnesses were other mental disorders and mood
disorders.
Changes in the number of treated mental patients and patients with mood disorders
from 1997 to 2003 are shown in the Graph 2.
In the illustrated graph you can see there is a visible tendency of growth of the
number of treated patients with mental and behavioural disorders in the primary health care
units, with 2000 as a critical period, when the number of treated patients was significantly
less compared to the previous period, as well as to the year that followed, i.e. 2001.
Data is obtained from the registered hospital morbidity
Graph 3. Tendency of mental disorders in out-patient
morbidity from 1997 to 2003
number of treated
12000
y = 659x + 5476,6
10000
8000
6000
4000
2000
0
1997
1998
1999
2000
2001
year
Table 2 shows total morbidity of mental disorders and mood disorders in Montenegro
(both out-patient and hospital), as well as by the structure of most frequent conditions from
Strategija za unaprijeđenja mentalnog zdravlja u Republici Crnoj Gori
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this group. In addition to that, there are morbidity rates, percentage of participation of mental
disorders and behavioural disorders in total morbidity of Montenegro, as well as participation
in percentage of certain components of this group of conditions in the structure of the same
group.
Table 2. Total morbidity (out-patient and hospital) in Montenegro related to mental disorders
and behavioural disorders in 2001
CONDITION
NUMBER OF
MORBIDITY RATE
PERCENTAGE
CASES
MENTAL
DISORDERS
11539
1725,9
18,8%
AND MOOD
DISORDERS
Neurotic,
stressogenic
3730
557,9
32,3%*
disorders
Schizophrenia
3494
522,6
30,3%*
Mood disorders
2217
331,6
19,2%*
5.7.
Mortality
In 2001 suicide was the cause of death of 142 people (mortality rate where suicide is
the cause of death was 21,2 of the deceased per 100 000 inhabitants of Montenegro). In 2002
there was a significant increase in the number of persons who commited suicide (and that is
why we present it), 196 suicide cases were reported (mortality rate 29,3).
In accidents there died 123 people in 2001 (mortality rate 18,4).
There is the total of 46 reported cases where the causes of death were psychiatric
illnesses.
There are no special records for cases of death caused by epilepsy.
The cases of death caused by liver diseases are registered only in the records of
treated patients in the hospitals and there 28 such cases, and there is no indication on what
respective causes of disease are.
There is the total of 3 cases of death caused by poisoning.
Dying as a result of suicide, accident, poisoning, liver disease participated in the
overall structure of the deceased with 4,5%. At the same time the share of the cases of death
caused by cardiovascular diseases (which is the leading cause of death in Montenegro) was
52,9%, and cancer 16,5%.
Share of the cases of death caused by symptoms, signs and pathological clinical and
laboratory findings was 12,5%, and mortality rate was 101,9 per 100 000 inhabitants.
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5.8.
Advantages / disadvantages of the existing mental health protection system
Advantages of the existing mental health protection system in Montenegro are the
following:

Relatively easy access to professional care for all categories of mental
patients in places where such institutions exist.
Disadvantages of the existing mental health protection system in Montenegro are the
following:
 Lack of staff
 Insufficient education of the staff
 Nonexistence of continuing education in mental health protection for both
specialist psychiatrists and general practitioners in the primary health care and
middle medical staff
 Insufficient cooperation with primary health care services
 Bad conditions in services for the care of mental patients
 Nonexistence of specialised referral centres in primary health care
 Lack of research activities
 Nonexistence of unique database for monitoring patients and medications
 There are no services for taking care of certain vulnerable categories (children,
adolescents, the elderly...),nor for specialised diagnostics and care (forensic
cases).
 Incongruity of legislation in the field of mental health protection with
European standards regarding protection of human rights and the rights of the
mentally ill.
 Inequality in terms of institutional and staff coverage of the areas in
Montenegro.
 Insufficient cooperation with social care institutions.
 Isolation of the chronically ill mental patients, mentally retarded patients in
social care institutions without adequate health control.
These indicators are the result of surveys carried out in the field in Sept 2003 on the
whole territory of Montenegro, which comprised complete infrastructure of primary health
care, hospital care and mental health institutions.
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6. MENTAL HEALTH REFORM
6.1. Vision of mental health policy
Vision of mental health policy is improvement and protection of mental health of the
population, conformity with requirements and expectations of beneficiaries and provision of
overall, functional and coherent system of protection based on the principles of protection in
a community, which is not discriminatory and is based upon scientific knowledge of mental
health on the whole territory of Montenegro.
This policy defines standards and activities in state and private services for mental health.
As any other policy for strategic fields, this policy for mental health represents a set of
defined values, principles and objectives, which need to be implemented in order to improve
mental health and reduce the incidence of mental disorders among the population of
Montenegro.
Drafting and realization of the mental health policy will include all the aspects this policy
relates to either directly or indirectly:





Beneficiaries, their associations and their families,
Service providers in the primary medical care and specialized protection of mental
health, both state and private institutions, as well as their associations.
Governmental agencies and the ministries (of health, social protection, education,
internal affairs, employment), as representatives of the local self-government.
Academic institutions
NGO sector, in particular non-governmental organizations that deal with humanitarian
work, social protection and mental health protection.
Reform of the healthcare system of Montenegro represents a very complex process
which comprises all segments of healthcare system, and mental health is a part of overall
changes whose effects can be appraised after the relization of activities defined in this
strategy. The existing capacities of the services for mental health protection were conceived
two decades ago and have not changed significantly up to today, although the Law on health
protection and health insurance defines dispensary for mental health as an obligatory segment
of Dom zdravlja. In some municipalities there are Dom zdravlja with psychiatric ambulantas,
and there are only a few dispensaries that have referral centres for certain areas of mental
health protection, day care centres which do not operate, and there are no «halfway houses».
Care for forensic cases is provided in Special psychiatric hospital in Kotor because there is no
adequate institution, while there is no psychiatric ward for children as a special organizational
unit within health institutions.
Strategy of protection and improvement of mental health comes from critical analysis of
the existing state and takes into the account modern strategy of protection and improvement
of health. It implies community work, with engagement of all its not only medical but also all
other formal and informal resources. Other basic principles are development and
implementation of measures and activities and primary, secondary and terciary prevention in
mental health protection, with strict division, but also interrelating the tasks and
responsibilities of the parties. Activity regarding permanent education of all shareholders
(professionals and laymen) for more and more efficient completion of tasks is very important
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for the implementation of the strategy. It is also necessary to evaluate activities, in particular
priority needs of different aspects of protection and improvement of mental health.
Continuing evaluation of effects that are planned will enable the use of new professional and
scientific achievements with the purpose of advancing the program. Strategy emphasizes the
importance of buildingpsychiatric institutions network and their integration into changes that
are envisaged by the reform of healthcare system.
6.2.
FRAMEWORK OF NATIONAL MENTAL HEALTH POLICY
Defining the national policy for mental health is one of the key segments of the
healthcare system reform in Montenegro. Bearing in mind the fact that until now there were
only individual attempts of defining certain segments of mental health and wording of the
policy for those, this documents will attempt to give an overall review and fundamental
guidelines which will serve as a base for drafting detailed plans and programs of activities
related to mental health protection and improvement. When defining wording of mental
health policies it is necessary to include beside the Ministry of health the Ministry for labour
and social care as well, because it is important to consider social and material conditions in
which people live although there seems not to be a direct link between mental health policy
and some other segments of a society, with the aim of increasing positive effects and results
of mental health improvement.
Defining the policy for mental health is complementary with activities carried out
within the project of the Stability Pact for South-Eastern Europe «Enhancing Social
Cohesion through Strenghtening Community Mental Health Service in South Eastern
Europe«. Mental health policy should also be interrelated directly with the Poverty reduction
strategy and other strategic documents in the field of health policy, social policy, employment
policy and prevention of disfunctional forms of behaviour.
National policy for mental health in Montenegro is designed in coordination with
accompanying documents and sources:
1. Study on Mental Health Policy and legislation Questionnaire for Serbia and
Montenegro, National Committee for Mental Health of Serbia and National
Committee for Mental Health of Montenegro, November 2003 , Belgrade
2. World Health Organization: World Health Report 2001, Mental Health: New
Understanding, New Hope. WHO 2001
3. World Health Organization: Mental Health Policy and Service Guidance Package:
MENTAL HEALTH POLICY, PLANS AND PROGRAMMES, World Health
Organization,20034. Data on the number of inhabitants derived from the estimation of the Federal
Statistical Office, which is based upon the results of the census in 1991 and data on
the newborn and deceased – Bulletin «Population 68».
5. Statistical yearbook of Montenegro, Republic Statistical Office, 2002.
6. D. Radevič i K. Beegle, ISSP – Podgorica, World Bank- Washington, DC.
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7. Republic secretariat for development, 2002 ”Development strategy and poverty
reduction in Montenegro”, first draft
8. D. Radević, K. Beegle: The standard of living and poverty in Montenegro in 2002.
9. Statistical yearbook on health and healthcare in Montenegro 2000, Office for
Health Care 2001
10. Report of the Centre for social medicine of the Public Health Institute, 2001
11. Report of the Centres for health information system and health registers of the Public
Health Institute (regular records on hospital and out-patient healthcare), 2001/02
12. Standards and norms of the staff and health services in Montenegro, Primary health
care, preventive medicine and diagnostics, Health Insurance Fund and Public Health
Institute,2002
Results that are anticipated from the impementation of the national policy for mental
health cannot be achieved without improvement of organizational aspect and quality of
services in the field of mental health, engagement of health care workers and orientation
toward community mental health.
6.3.
Values and principles of mental health policy
Value judgements and principles that are defined in this chapter are the key framework which
served as a basis for setting the goals in the national policy of mental health.
Improve and protect mental health of the population
VALUES
PRINCIPLES
Mental health care
 Mental health services should provide the best possible overall
treatment, which will involve family and community to the
maximum
 Mental health protection should be a constituent and inseparable
part of the primary health care. General practitioners should be
trained for responding to the needs from the field of protection of
mental disorders
 There must be inter-sectorial cooperation with other key holders
of society development
Community care
 Prior to hospitalization of the patient it is necessary to try to
provide alternative care within community or as near as possible
to the place the patient comes from
 Create opportunities for volunteer organizations to provide help
the families that take care of unhospitalized patients
 Mental patients should be cared for in the institutions with as little
restrictive forms of care as possible
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Education

Reform of the educational system should take into account mental
health of the population and influences that certain actual social
and health problems have on attitude of school children
(destigmatization of mental disorders, stereotypes, prejudices, ..)

Mental health promotion should be integrated in the area of social
care and in the educational system that trains that staff
Meeting the needs and expectations of the beneficiaries
VALUES
PRINCIPLES
Protection of
 There is a need for respective concrete strategies for mental health
vulnerable groups
protection of vulnerable groups, such as: children, adolescents, the
aged, disabled, refugees, IDPs, victims of violence
Cultural relativism
 Different cultural, social and ethnical groups should be included
in defining the policy of mental health in Montenegro so as to
respect differences and special needs that derive from those
differences.
Human rights
 Human rights and dignity of a mental patient should be protected
protection
at all levels within the system of mental health
 Passing the legislation
 Mental health institutions need to have inbuilt systems for
monitoring in order to provide security of the rights and needs of
mental patients
Community
 Beneficiaries of the mental health protection system (individuals
participation
with mental disorders), their associations and families will be
included in the process of planning, organization and monitoring
of mental health care.
Create a comprehensive, functional and coherent system of mental health protection on
the whole territory of Montenegro
VALUES
PRINCIPLES
Network of services  Mental health protection must be accessible and available
 Unification of services and existence of a unique database for
registration of treatment and medication
 System has to be accesible to all, regardless of location,
ecopnomic status, education, or ethnical, cultural or religious
orientation
Quality of services
 Setting clear rules, procedures, standards of services and control
mechanisms for services for all mental health protection
institutions including the segments of primary health care that
comprise mental health protection
 Activities referring to collection and analysis of the data on
patients should also be an integral part of mental health protection
system.
 Psychotropic drugs should be available at all levels of treatment of
an individual with mental disorders, with provision of sufficient
quantity of drugs
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6.4.
GOALS OF THE MENTAL HEALTH POLICY
Goal 1 Improvement and protection of mental health of the population

Primary prevention of mental disorders (universal, selective and indicated) and
early detection of mental disorders
Goal 2 Meeting the needs and expectations of the beneficiaries
 Increase in quality of services and protection of the rights of mental patients
 Improvement of legislation related to protection of the rights of mental patients
and human rights protection
 Increase in inclusion of beneficiaries, families and community in the process of
planning, organization and monitoring of the services for mental health.
Goal 3 Provision of financial protection from expenditures related to illness

Establishing the mechanisms for provision of all necessary psychotropic drugs
free of charge.
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6.5.
PRIORITY AREAS OF ACTIVITIES
1. Financing
To implement national policy for mental health it is necessary to define the way in
which the implementation will be financed. It is necessary to set aside certain
percentage from the budget for the needs of mental health protection. Financing
priorities are mental health protection of vulnerable groups and areas of the republic
that have insufficiently developed services.
2. Legal framework and human rights
The existing legislation in the field of protection of individuals with mental disorders
is insufficient. Only some of the rights are defined in parts of different laws. It is
necessary to revise the existing laws and amned them in a way that provides an
adequate protection of the rights of the mentally ill (pass the Law on mental health
and Law on protection of the rights of the mentally ill).
3. Organization of services and institutions
It is necessary to reorganize the system of mental health so that treatment of patients
is shifted from large psychiatric institutions and clinics to out-patient psychiatric
services, mental health services are developed at the local level which will provide
overall, less restrictive mental health protection which is closer to community, and
mental health protection included in the primary health care.
4. Staff and training
It is necessary to fit the number and a kind of staff needed to the institutions for
mental health protection in accordance with present needs. There is a need for training
and further training for the staff in mental health protection and primary health care.
5. Promotion, prevention, treatment and rehabilitation
It is necessary to build a wide range of activities related to promotion, prevention,
treatment and rehabilitation, which will be an integral part of the national policy. This
plan can be designed after the data have been collected. These data will be collected
from a detailed analysis of the total population and some targeted samples on the
estimation of needs based on social, cultural, gender, age, and development
framework.
6. Procurement and distribution of basic drugs
It is necessary to set up a list of priority psychotropic drugs and other medications
needed for treatment of the mentally ill, make them accessible pursuant to
therapeutical effect and safe use at all levels of mental health protections.
7. Representation
Defining the policy and plan of inclusion of NGO sector, volunteers and families with
the purpose of improving the protection of rights in the field of mental health.
Defining the responsibilities and forms of action.
8. Quality improvement
Due to differencies in quality and level of services which are provided in different
services for mental health protection, national policy has to define and implement
Strategija za unaprijeđenja mentalnog zdravlja u Republici Crnoj Gori
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concrete instruments for maintenance, control and improvement of services in the
field of mental health protection. These instruments should include: accreditation of
individuals and organizations that provide mental health protection services, standards
of diagnostics and treatment in compliance with international standards, clinical
guidelines, indicators for measuring the results, etc.
9. Information system
When building up the information system in addition to unique database for
registration of treatments and medications, analysis of of data on patient, it is
necessary to include the data on institutions, staff and NGO sector which participates
in the system of mental health protection. The information system should be
accessible to all shareholders of the system, regardless of their geographical location
ot the territory of the republic.
10. Survey and evaluation of policies and services
Surveys should be defined in accordance with WHO recommendations and in
cooperation with academic institutions. Surveys should be used for evaluation of the
policy and quality of services in the field of mental health protection.
11. Inter-sectoral cooperation
Implementation of the mental health policy should involve as many parties as possible
who are either directly or indirectly linked to the policy - beneficiaries, their
associations and their families, service providers at the level of primary health care
and specialized mental health protection, both public and private institutions, as well
as their associations, government agencies and ministries (health, social care,
education, interior, employment), representatives of the local self-government,
academic institutions and NGO sector, especially NGOs that deal with humanitarian
aid, social protection, mental health protection and human rights protection.
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7.
7.1.
ACTION PLAN FOR MENTAL HEALTH
General strategy
Priority fields of activities
1 Financing
2 Legal framework and human
rights
Strategy
Earmarking part of the budget for financing
the mental health within general health financing
 Creating a special fund for development of
mental health component in the primary
health care
 Overview of the existing legal provisions and
procedures for protection of rights of the
mentally ill
 Making a draft bill on mental health and on
protection of mental patients
 Organizing public campaigns and debates on
the draft bill
 Building the mechanisms for implementation
of the law on mental health in the psychiatric
institutions
3 Organization of services and
institutions


4.Staff and training


Setting up the links between primary health
care and services for mental health and
strengthening community services
Supporting
the
process
of
deinstitutionalization
parallel
with
development of alternative forms of
community protection.
Organizing training and further training for
the doctors and other health workers in the
institutions for mental health protection and
primary health care.
Revising
the
existing
professional
development curricula in the field of mental
health protection and adjusting to the
guidelines of community organization of
mental health.
5 Promotion, prevention, treatment  Give priority to programmes of mental health
and rehabilitation
prevention and improvement
Educational programs should include promotion
of mental health
6. Procurement and distribution of  Accessibility of the drugs to the mentally ill
basic drugs
 Modern psychopharmacies will be available
Strategija za unaprijeđenja mentalnog zdravlja u Republici Crnoj Gori
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7.Representation

8 Quality improvement

9.Information system
10. Survey and evaluation
policies and services
Developing standardized procedures (good
practice guide) for diagnostics and treatment
 Developing procedures of monitoring and
evaluation of services
Project of information system will include fully
all activities regarding mental health protection
of 

11.Inter-sectoral cooperation


7.2.
through adequate distribution
Establishing and supporting the associations
of beneficiaries and their families
Outcomes of the national policy will be
monitored in regular time intervals
Surveys on the quality of services will be
defined in cooperation with the academic
institutions
It is necessary to build up inter-sectoral
cooperation at all levels (ministries,
municipalities, mental health services... )
Supporting the inter-sectoral programmes for
mental health protection which are clearly
defined (action plan for the fights against
drug abuse, domestic violence, children with
special needs, care for the old, reduction of
poverty...)
Time frame and resources
Design and implementation of the Mental health strategy in Montenegro will be carried out in
a couple of phases. Here are presented only general deadlines and names of activities.
Detailed plan is expected to be done both during the preparatory and drafting period of the
strategy.
Strategy drawing up phase within six months
Implementation phase
harmonize with deadlines of the recommendations from the
Stability Pact for southeastern Europe.
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Appendix 1.
LEGISLATION IN THE FIELD OF MENTAL HEALTH
Recommendations of the STABILITY PACT FOR SOUTHEASTERN EUROPE,
HEALTH NETWORK OF SOUTHEASTERN EUROPE, that is “Action of health
development for South-Eastern Europe ”, were fully respected when drawing up the
QUESTIONAIRRE FOR APPRAISAL OF THE POLICY AND LEGISLATION IN
THE FIELD OF MENTAL HEALTH FOR SOUTH-EASTERN EUROPEAN
COUNTRIES, which contained the following questions and provided insight into legislation
related to mental health and its needs in Montenegro:
a) Does your country have access to international and regional initiatives and
documents related to the fight for human rights? If yes, please specify.
Our country is a member of the Council of Europe and it is included in the projects of
the Stability Pact for SEE, which refer to relations and protection of human rights.
b) Were there any recommendations to your country from other countries in
relation to the improvement of mental health policy and legislation?If yes, please
specify.
Yes, within the Project of the World Health Organization and Stability Pact for SouthEastern Europe “Improvement of social cohesion by strengthening community mental
health services”.
c) Does the legislation on mental health include a part that referrs to the protection
of the rights of the persons suffering from mental disorders?
Yes, in some provisions of the Law on health care, Law on out-of-court proceedings,
Law concerning domestic relations and the Law on carrying out of criminal sanctions.
In the health sector:
1) Does the national legislation require the use of the least restrictive alternative? All
the persons suffering from mental disorders should be provided a treatment in a
community except under the circumstances that involve risk of potential damage.
Involuntary admissions and treatments can be done only in exceptional circumstances
and for a short period.
Yes, partially the Law on health care and health insurance and the Law on out-of-court
proceedings (part that refers to involuntaryhospitalization).
2) Does the national legislation provide confidentiality?
Legislative protection ensures that all information and records, which pertain to
health, i.e. psychic problems of a person, remain confidential. The Law must prevent
explicit use of these without a prior permission that professionals have to ask for, and
all that has to be defined by the law.
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Confidentiality of the information pertaining to psychiatric patients is not specifically
defined in the legislation, only generally – in the Law on health care (art. 12) and the
Criminal Law there are provisions regarding professional secret – data on health
condition of a patient and causes, circumstances and consequences of that condition.
3) Does the national legislation deal with voluntary and involuntary admission?
Does that refer to involuntary treatment as well?
The Law on out-of-court proceedings defines voluntary and involuntary admission.
Forced treatment is not defined.
4) Does the national legislation define procedures that involve a ban on movement?
It refers to urgent procedures for acute episodes in mental disorders with a high
risk for health and safety.
It does not define that issue.
5) Does the national legislation define mechanisms for periodic revisions at all levels
that violate integrity or freedom of a person suffering from psychic disorders?
Yes, it is determined in the Law on out-of-court proceedings.
6) Does the national legislation define the issue of work ability?
Yes, the Law on marriage and domestic relations.
7) Does the national legislation define the problem of informed consent?
National legislation does not define the problem of informed consent.
Out of health sector:
1) Does the national legislation prohibit discrimination against psychiatric patients in
terms of housing, employment and social security?
National legislation, apart from the constitutional provisions that prohibit
discrimination on any grounds, does not define special provisions on discrimination
against psychiatric patients.
2) Does the national legislation provide for the following special circumstances:
o housing, including halfway houses and assisted-living homes;
o employment, including protection from discrimination and exploitation in
the opportunities for getting an employment and rehabilitation programs
for preparation for work.
o social security: health insurance and diability allowances at the similar
amounts guaranteed to other people.
National legislation provides social security: health insurance and disability
allowances for psychiatric patients at the similar amounts guaranteed to other people.
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3) Does the criminal legislation include the part pertaining to psychically deviated
criminal offenders (their accountability to stand the trial, criminal responsibility, legal
representation, testimony)?
Yes, in the General Criminal Law, Criminal Law of the Republic of Montenegro, and
the Law on Criminal Proceedings.
4) Does the civil legislation provide regulation pertaining to marriage, divorce and
parental rights, testator ability and the ability to make a contract and guardianship
conditions?
Yes, the Law on marriage and domestic relations, the Law of inheritance and the
Obligations Law.
5) Does the Law on health care ensure that persons suffering from mental illnesses have
equal access to all kinds of health care and equal quality as other patients?
The Law on health care and health insurance classify as a group, by providing care in
relation to prevention, eradication and early detection and treatment of illnesses of
greater socio-medical importance, the persons suffering from mental illnesses and
disorders, who have the right to health care, which comprises preventive diagnostical,
thrapeutical and rehabilitation health services in the health institution including the
transport in emergency cases, medications and additional material.
6) Does the country have the legislation that involves components of mental health
improvement and prevention of psychic illnesses?
o in the health sector – legislation that strengthens introduction of psychiatric
interventions to the primary health care, prevention of the negative influence of
children mistreatment, prevention of the negative influence of mistreatment of
children, women and the aged.
o out of the health sector: legislation that should unable access to alcohol and drugs
and protect vulnerable groups.
No.
Previous responses showed clearly that it is necessary to start drafting and adjusting the
legislation within the field of mental patients’ rights protection, and with that aim we set up a
working group of the Committee for mental health, which will work on drawing up the
legislation.
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Appendix 2.
Results of the field survey
Overview of the results of the field survey of facilities and human resources in the field
of mental health which is the basis for drawing up the STRATEGY OF MENTAL
HEALTH PROTECTION AND IMPROVEMENT in Montenegro
According to the census from 2003, Montenegro has 616.258 inhabitants. Health care
of the population is provided in 18 dom zdravlja and 3 health stations which provide outpatient health care, in 7 general hospitals 5 dispensaries of dom zdravlja facilities, Clinical
Centre and 3 special hospitals where hospital care is provided.
In Montenegro there are several public health institutions for mental health protection
and improvement (out-patient and hospital institutions): Special psychiatric hospital Dobrota,
one development reference centre, one psychiatric ward in the General hospital, one
Psychiatric clinic in Podgorica one psychiatric ambulanta, one private psychiatric practice,
one ambulanta, 13 dom zdravlja facilities provide the services in the mental health protection.
Dispensaries that deal with mental health protection and improvement dispose of the
following bed capacities:
 Special hospital for treatment of psychiatric patients Dobrota has 252 beds,
 Clinical Centre Podgorica – Psychiatric clinic has 40 beds,
 General hospital Nikšić – Psychiatric hospital has 30 beds,
 ZIKS (prison ward, planned) – Psychiatric ward with 50 beds
TOTAL------------------------------------------------------373 beds
Listed data was collected in a field survey – data was obtained directly from the hospital
services, and the survey was conducted in 2003.
Public health institutions that deal with mental health protection and improvement
dispose of the following staff:









32 neuropsychiatrists,
12 psychiatrists,
4 medical psychologists,
10 psychologists
2 special education teachers,
7 who attend specialization,
7 social workers,
5 superior nurses,
100 nurses (plus 3 nurses who attended additional training for leading sociotherapeutical community).
Out of the total number of the employed in the public health institutions that work in the
field of mental health protection, almost half of the staff works in the Special psychiatric
hospital Dobrota. Therefore, staff that provide services in the field of mental health protection
and improvement at the primary level, does not meet the needs. However, it is the fact that
mental health policy is undergoing significant changes in terms of redirecting the
Strategija za unaprijeđenja mentalnog zdravlja u Republici Crnoj Gori
35
beneficiaries to the out-patient care, and it is expected to have redistribution of the staff from
the secondary to the primary level of health care.
Pursuant to the official norms in the primary and preventive health care per 15000
inhabitants there should be a team consisted of 1 specialist (neuropsychiatrist or psychiatrist),
1 nurse, 0,30 clinical psychologist and 0,25 social workers. For the whole territory of
Montenegro it is necessary to provide at the primary level: 41 specialists, 41 nurses, 12
clinical psychologists and 10 social workers.
Experiences from the countries that provide mental health protection primarily in the outpatient institutions, with engagement of experts from hospital institutions on the occasional
basis (whose potentials, according to the new initiative in Montenegro, are being gradually
reduced) show that staff norms (per number of inhabitants) should be the following:




1 specialist (neuropsychiatrist or psychiatrist) per 20000-30000 inhabitants.
1 clinical psychologist per 20000-30000 inhabitants.
1 social worker per 20000-30000 inhabitants.
1 nurse per 15000 inhabitants.
It should be emphasized that specialists who would work in the Centres for mental health
protection and improvement spend a part of the working hours in a dispensary located in their
area, in order to monitor their patients and take an active part in their complete therapeutical
treatment. According to the data, number of specialists who work in mental health protection
and improvement could meet the need of the montenegrin population, if there is a better
territorial distribution of the staff and if the role of trained psychiatrists, psychologists and
social workers, who could engage a lot more in preventive and therapeutical field, is
strengthened.
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36
OVERVIEW OF FACILITIES AND HUMAN RESOURCES IN MENTAL HEALTH
PROTECTION BY MUNICIPALITIES IN MONTENEGRO
In the municipality of Andrijevica there live 5697 inhabitants. In Dom zdravlja Andrijevica
there are 34 employed health workers, 6 of which are doctors, and one of them is a specialist.
There is no specialist that deals with mental health protection and improvement. Population
of Andrijevica will receive service in the field of mental health in the Mental Health Centre
Berane.
Municipality of Bar has 39688 inhabitants. Health care services to the population of this
municipality are provided in the following public health institutions: out-patient care in Dom
zdravlja, with 182 workers, 42 of which are doctors (32 specialists) and hospital care in the
General hospital Bar, with 220 health workers, 35 of which are doctors. It disposes of 2
specialists (neuropsychiatrists) and 2 medical technicians (nurses), that work in the field of
mental health protection, and are employed in Dom zdravlja.
Protection and improvement of mental health to the population in this municipality will be
provided in the Mental Health Centre Bar.
Municipality of Berane with 34791 inhabitants provides out-patient health care in Dom
zdravlja which has 158 employed health workers, 33 of which are doctors (25 specialists).
Hospital health care is provided in the General hospital, which has 211 health workers, 35 of
which are doctors. It disposes of one specialist-psychiatrist, one psychologist, and one social
worker as well as two medical technicians and one specially trained medical worker for
leading socio Th and TH community, and all of them deal with the mental health protection
and improvement in Dom zdravlja Berane.
Mental health protection will be provided in the Mental Health Centre Berane.
Municipality of Bijelo Polje has 49773 inhabitants. It has Dom zdravlja with (204 health
workers, 43 of which are doctors) and General hospital with 134 health workers, 24 of which
are doctors. It disposes of two specialists-neuropsychiatrists, one psychiatrist, one
psychologist, a medical technician and two workers trained for leading socio Th and TH
community, in the field of mental health protection.
Planned Mental Health Centre in Bijelo Polje will provide better quality realization of the
services in the field of mental health protection and improvement.
Municipality of Budva has 15671 inhabitants. Out-patient care is provided in Dom zdravlja
(80 health workers, 25 of which are doctors) and mental health will be provided in the Mental
Health Centre Kotor and Dom zdravlja Budva, which disposes of one specialistneuropsychiatrist (who is a visiting doctor in Dom zdravlja Cetinje, on certain days) and a
medical technician, who works in the field of mental health protection and improvement.
Municipality of Danilovgrad has 16270 inhabitants. Out-patient care is provided in Dom
zdravlja on its territory (72 health workers, 11 of which are doctors), and mental health will
be provided in the Mental Health Centre Podgorica. On certain days to Dom zdravlja
Danilovgrad come a visiting neuropsychiatrist and a psychologist.
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Municipality of Žabljak has 4181 inhabitants. Out-patient care is provided in the Health
station (23 health care workers, 4 of which are doctors), which is linked to Dom zdravlja
Pljevlja, and the Mental Health Centre Pljevlja will provide mental health care and
improvement services to the population of this municipality. In Dom zdravlja Žabljak there
works one specialist in neuropsychiatry.
Municipality of Kolašin (9871 inhabitants) has on its territory Dom zdravlja, which provides
out-patient care (61 employed health care workers, 10 of which are doctors) In Dom zdravlja
there works one doctor who attends spacialization in psychiatry. Mental health care services
for the population of this municipality will be provided in the Mental Health Centre
Podgorica.
Municipality of Kotor (22640 inhabitants) has out-patient care provided in Dom zdravlja
(100 health care workers, 19 of which are doctors), hospital care provided in the general
hospital (114 health workers, 28 of which are doctors), and it is planned to set up the Mental
Health Centre, which will provide mental health care services. In this municipality (Special
psychiatric hospital) there work 9 neuropsychiatrists and 4 psychiatrists, 2 doctors that attend
specialization, 2 psychologists, a medical psychologist, 2 special education teachers, 3 social
workers, 2 medical technicians with higher education and 62 of them with high school
education.
Municipality of Mojkovac has 10007 inhabitants. Dom zdravlja (65 health care workers, 13
of which are doctors) provides services in out-patient care, and mental health care services
for the population of this municipality will be provided in the Mental Health Centre Bijelo
Polje. In Dom zdravlja Mojkovac there works one neuropsychiatrist and a nurse, in the field
of mental health care.
Municipality of Nikšić for its 75076 inhabitants has out-patient care provided in Dom
zdravlja (276 health care workers, 58 of which are doctors), hospital care in the General
hospital (205 health care workers, 51 of which are doctors). It is planned to set up the Mental
Health Centre.
Nikšić disposes of (in Dom zdravlja and General hospital) 5 neuropsychiatrists, a psychiatrist,
2 doctors who attend specialization, 2 psychologists, a medical psychologist, one nurse with
higher education and 10 nurses with high school education, from the field of mental health
protection and improvement.
Population of the municipality of Plav (14042) receives services of out-patient care in Dom
zdravlja (83 health workers, 23 of which are doctors), and mental health protection will be
provided in the Mental Health Centre Berane. In Dom zdravlja Berane there work one
neuropsychiatrist and a nurse, who deal with mental health protection and improvement.
Municipality of Plužine has 4269 inhabitants for which out-patient care is provided in the
Health station (13 health workers, 2 of which are doctors), which is linked according to
location to Dom zdravlja Nikšić, and mental health protection will be provided in the Mental
Health Centre Nikšić.
Population of the municipality of Pljevlja (total 35724) has out-patient care services provided
in Dom zdravlja (143 employed health workers, 33 of which are doctors), hospital care in the
General hospital (104 health workers, 20 of which are doctors). It is also planned to establish
Strategija za unaprijeđenja mentalnog zdravlja u Republici Crnoj Gori
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the Mental Health Centre, which will provide mental health care services. In Dom zdravlja
Pljevlja there work one specialist-neuropsychiatrist, one psychologist, one social worker, and
one nurse/medical technician in the field of mental health protection and improvement.
The largest municipality of Podgorica with 168600 inhabitants has on its territory Dom
zdravlja with several health points with the total of 470 employed workers, 128 of which are
doctors. In the Clinical centre, which provides health services for the whole population of
Montenegro, there work the total of 1190 health care workers, 252 of which are doctors.
Mental Health Centre will provide services of mental health care for both the local residents
and patients from other municipalities. In Podgorica (Dom zdravlja and the Clinical centre
there work 7 neuropsychiatrists, 4 psychiatrists and 3 doctors who attend specialization, 2
medical psychologists, 1 psychologist, 17 nurses/medical technicians, who work in the field
of mental health protection and improvement.
Municipality of Rožaje ima 22341 inhabitants. It has Dom zdravlja, which provides the
services at the level of primary health care (98 employed workers, 28 of which are doctors),
and the Mental Health Centre Berane will provide the services of mental health protection. It
disposes of one specialist (neuropsychiatrist) that deals with mental health protection and
improvement.
Municipality of Tivat (13404 inhabitants) has Dom zdravlja (62 employed workers, 19 of
which are doctors, 1 of which is a neuropsychiatrist), and in the Mental Health Centre Kotor
the population of Tivat will receive services in the field of mental health care.
Municipality of Ulcinj (20003 inhabitants) has on its territory Dom zdravlja, which provides
out-patient health care to its population (85 employed workers, 19 of which are doctors),
while mental health care is provided in the Mental Health Centre Bar.
Municipality of Herceg Novi (32889 inhabitants) on its territory has Dom zdravlja, which
provides out-patient health care, while mental health care is provided in Kotor. There work
one neuropsychiatrist, one psychologist and one nurse/medical technician in the field of
mental health care and improvement.
Municipality of Cetinje has 18380 inhabitants. It has on its territory Dom zdravlja, which
provides out-patient health care (108 employed workers, 20 of which are doctors), General
hospital for meeting the needs for hospital care (116 employed workers, 26 of which are
doctors). In Dom zdravlja Cetinje there work one specialist – neuropsychiatrist, one
psychologist, and one nurse/medical technician who work in the field of mental health
protection and improvement. Population of Cetinje will receive mental health services in the
Mental Health Centre Podgorica.
The smallest municipality in the Republic is Šavnik with 2941 inhabitants. It has out-patient
health care provided in the Health station (13 workers, 2 of which are doctors), which is
linked to Dom zdravlja Nikšić, so mental health protection for the population of this
municipality is going to be provided in the Mental Health Centre Nikšić.
Human resources employed in the mental health institutions have attended a set of
additional trainings from the area of psychotherapy, short seminars for acquiring skills in
dealing with certain categories of patients, etc. By reviewing the achieved scientific
vocations, one gets impression that in this segment as well they attempt to compensate for the
Strategija za unaprijeđenja mentalnog zdravlja u Republici Crnoj Gori
39
problems in this segment of functioning, and so we have 2 PhD, 5 chiefs of staff. It can also
be concluded that an indicative number of staff, regardless of their formal education, have
knowledge of a foreign language (English, Russian, French, German), and also a significant
number of the employed is ready to pursue further professional development and education.
In the past period listed data was supported by the fact that the employed in the
mental health institutions were not only participants, but also initiators of many projects
related to protection of mental health of the vulnerable groups, such as: children. women, the
aged, persons with special needs, that were supported by: UNICEF, UNHCR, SAVE THE
CHILDREN,DANISH COUNCIL, COUNCIL OF EUROPE, SOROSH,SCF,WHO and
others.
Strategija za unaprijeđenja mentalnog zdravlja u Republici Crnoj Gori
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Non-governmental organizations as a model of communal psychiatry
Pluralization of the Montenegrin society resulted in a large number of NGOs. Awareness
of that fact, as well as of the values they should present, such spontaneously organized
groups, i.e. perception of the place and role of NGOs in the concept of development of
communal model of mental health care will be partly brought to light through the
presentation of the results of CRNVO from 2001, and partly through the survey from 2003.
The citizens acquired the right to form NGOs and initiative goes from non-governmental
creative professional and semi-professional groups and associations providing supportive and
original activism for some health or social needs. Segment of NGOs that deal with sociohumanitarian issues, and there are 103 such NGOs in Montenegro, can be divided into the
following areas: improvement and promotion of mental health, mental health protection and
prevention of maladapted forms of behaviour (alcoholism, drug abuse) and those that carry
out their activities through interventions in crisis and stressful situations by providing
psychosocial aid to the individuals and families.
Survey confirmed that institutional psychiatric segment of health care and NGOs can
exist in a parallel manner and complement each other giving better effects with the purpose
of improving the quality of life of mental patients. Linking and inter-sectorial cooperation
(institutional and out-of-institution) contribute to the development of alternative communal
orientation in psychiatry. The final goal is humanization of the surroundings of the mental
patients, improvement and rationalization of of the services to the patients and
destigmatization of mental illnesses.
Strategija za unaprijeđenja mentalnog zdravlja u Republici Crnoj Gori
41
Appendix 3.
7.2.1. Profile of the country
Montenegro, according to the census in 2003, has 616,258 inhabitants. According to the
census in 1991 there were 615 035 inhabitants, which means that the total number of
inhabitants rose by the rate of 0.6% at the annual level. Pursuant to the projection for
population in the next 20 years it is envisaged that the growth rate will decrease slowly, and
in the year 2020 it would reach the growth level of 0,2%.
Process of demographic transition, which started in Montenegro later than in the
western and northern European countries, and some of the ex-Yugoslav republics, is
conditioned by social, economic and political situation and in the past decades it was slowed
down by political and economic crisis and war surroundings. Birthrate is in the constant
process of decline in the last seven decades, with controlled fertility in marriages. There is a
decrease in death rate, especially in death rate of infants, and changes in the age structure of
the population as a result of demographic process of aging, changes in economic and social
structure of population. According to the latest available data of the national statistics in 2001
the birthrate was 13,3 , death rate 8,2 and the population growth rate was 5,1.
Under the influence of demographic transition the structure of population is being
changed with a slow tendency of aging, especially in rural areas, and seven municipalities
registered negative population growth. Participation of persons over 65 exceeds 11% of total
population and average age of population is estimated at over 35 years - 34 for men and 36,6
for women, and thus the population can be considered old. In the northern, economically
undeveloped region, and in some of the municipalities the situation is a lot worse than the
situation at the republic level.
Total number of the employed in Montenegro in 2002 was 113 827. On the list of the
unemployed in the Employment Agency in 2002 there were 80 584 people. Ratio of the
employed and unemployed according to the official record is 1:1,4. Employment rate in the
period 1990 – 2002 was decreasing on average by 2,9% per year.
Unemployment rate (calculated according to the methodology of ILO) in Montenegro
in the same period, according to the official data, viewed through the ratio of the unemployed
and active population was 30,4% (20,6% men and 40,4% women).
Basic characteristics of unemployment in Montenegro are the following: unfavourable
ratio of the employed and unemployed, more unfavourable position of the women regarding
getting an employment, long years of waiting for a job, unbalanced opportunities for finding
an employment by regions, high percentage of people active in the informal economy, on
which there are no valid data, and high percentage of so-called techno-economic surpluses
(redundancies).
In 2000, public institutions for children and youth housed 567 proteges. In the public
institutions for children without parental care there were 151 proteges. In the public
institutions for children and youth with psychophysical disorders there were 390 proteges
while in the public institutions for neglected children and youth there were 26 proteges. At
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the end of 2001, 9.639 children from the families who are beneficiaries of MOP (family
allowance) received children allowance.
Lack of official data on the number of children in the street, homeless and number of
trafficked children, does not mean that there are no such cases, but it is very hard to monitor
and evaluate this segment.
Number of people in prisons on various grounds in Montenegro, according to the data
of the Ministry of Justice, is cca. 450. During 2001, 2004 adults were convicted of crimes,
8,1% of which were women, and 101 juveniles, 3,0% of which were women.
According to the data of the Commissariat for displaced persons in Montenegro there
are 43 116 IDPs and refugees, which makes around 6,5% out of total number of domicile
population or 6,1% of the total population. In Podgorica there live around 28% of the total
number of IDPs and refugees.
7.3.
Short review of the present state of mental health institutions in Montenegro
7.3.1. Capacities for treatment of mental illnesses
Treatment of the patients with mental and behavioural disorders, as an compulsory aspect of
health protection, is provided in public health institutions of Montenegro. Out-patient
protection is provided in referral centres, mental health centres which are in the process of
establishing or are incomplete, psychiatric ambulantas, within Dom zdravlja and private
psychiatric practice.
Dispensary units (Special psychiatric hospital, Psychiatric Clinic, Psychiatric hospital,
Psychiatric Ward) for psychiatric patients are located in:
 Special hospital for treatment of psychiatric patients Dobrota which has 252 beds,
 Clinical centre of Montenegro – Psychiatric Clinic with 40 beds,
 General hospital Niksic – Psychiatric hospital with 30 beds,
TOTAL------------------------------------------------------323 beds
The above-mentioned data are collected in the survey - the data were obtained directly from
hospital services, and the survey was conducted in 2003.
7.3.2. Staff coverage indicators in mental health treatment units
According to collected data, per 100.000 inhabitants there are 1,66 specialists in
psychiatry, 4,7 specialists in neuropsychiatry, 1,5 psychologists, 0,6 medical psychologists,
1,05 social workers and 0,3 special education teachers.
Staff norms, as determined standard in this field of health protection, are the
following: in the primary healthcare protection per 15 000 inhabitants there should be mental
health protection team consisting of 1 specialist doctor, 1 nurse, 0,30 clinical psychologist (or
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1 clinical psychologist per 50 000 inhabitants) and 0,25 social worker (or 1 social worker per
60 000 inhabitants).
Data on the existing staff show that the coverage of specialists in psychiatry is
significantly above the envisaged norms.
7.3.3. Indicators of morbidity of mental disorders and behavioural disorders
7.3.3.1.
Alcoholism
The problem of over-consumption of alcohol is particularly related to young
population of both sexes, with the more intensive growth among girls. According to the most
recent available data, alcohol is being consumed constantly or occasionally by 55% of the
young who are 15 to 30. Several times a year 11% of the young between 12 and 18 years,
60% of the young men and 14% of the girls between 19 and 30 get drunk. It is very worrying
that 4,3% of the young between 12 and 18 already show the signs of alcohol addiction.
In Montenegro during 2001 in the hospital institutions there were treated disorders
caused by alcohol consumption (F10 according to MKB-10) of 240 male patients during
6212 hospital days and 25 female patients during 1354 hospital days (in Podgorica 30/476
men and 3/34 women).
7.3.3.2.
Morbidity as a result of the use of psychoactive substances
In 2001 in Montenegro there were registered 69 cases of psychoactive substances
poisoning in outpatient and 7 in hospital morbidity. Some indicators show that there is an
increase in number of persons addicted to psychoactive substances, with a tendency of
decreasing the age limit.
In addition to the ones that were listed, during 2001 the following rates of mental disorders
and behavioural disorders were reported:
7.3.3.3. Morbidity of mental disorders in hospital institutions
In hospital services of Montenegro there have been registered 1800 cases of mental
disorders and behavioural disorders, and morbidity rate was 2692,2 per 100 000 inhabitants
of Montenegro. The most common disease in this group was schizophrenia, schizo-pathic
disorders, madness, which participated in the general structure of all mental disorders at
45,9%, then mood disorders at 16,1% and on the third place there are mental disorders caused
by alcohol 14,7%, and mental disorders caused by drugs. Out of the total number of patients
treated in hospitals there were 61,2% of men. The patients belong mainly to the 40 – 49 age
group (27,3%), then to 30 - 39 age group (22,1%), 20 - 29 age group (18,2%) and 50 - 59 age
group (17,9%), which shows that the greatest number of hospitalized patients, due to mental
and behavioural disorders, were capable of work (over 80%).
Mental disorder trends in the period from 1997 to 2003 show that were no statistically
significant changes in number of patients treated for mental disorders and behavioural
disorders in dispensaries of Montenegro for the given period, which can be seen in the graph.
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Total number of realized hospital days for treatment of mental diseases was 58028 or
on the average per a disease it was 32,2 days, which shows that the length of hospitalization
in such cases is pretty long. The longest treatments are the ones for schizophrenia, schizopathic disorders and madness, on the average it is 41,7 days. Mental disorders caused by
alcohol have been treated for on the average 28,5 days, mood disorders 27,5 days, while
mental disorders caused by drugs and neurotic disorders were treated for 13,2 days on the
average. Compared to all other diseases which are treated in dispensaries mental disorders
and behavioural disorders require the greatest length of hospitalization.
Bed occupancy for treatment of mental disorders and behavioural disorders was 122,7 days
during the year, which shows that beds were free for a relatively long period. Number of
beds, according to the reports from the services for dispensary treatment of this group of
diseases, shows that occupancy was 155,6 days during 2001.
7.3.3.4.Morbidity of mental disorders in out-patient institutions
In out-patient services there are 9739 reported cases of mental disorders with
morbidity rate of 1456,7 per 100 000 inhabitants of Montenegro.
The most frequent illnesses from this group were neurotic, stressogenic and
somatoform disorders with morbidity rate of 542,6, followed by schizophrenia, schizopathic
disorders, insanity (morbidity rate 399,0) and on the third place there are mood disorders with
morbidity rate of 288,4. The biggest number of registered cases of mental disorders and mood
disorders was in the general medicine service 63,1%, followed by occupational medicine
services with 32%. In the service for health protection of preschool and school children there
were 463 treated children and most frequent illnesses were other mental disorders and mood
disorders.
Changes in the number of treated mental patients and patients with mood disorders
from 1997 to 2003 are shown in the Graph 2.
In the illustrated graph you can see there is a visible tendency of growth of the
number of treated patients with mental and behavioural disorders in the primary health care
units, with 2000 as a critical period, when the number of treated patients was significantly
less compared to the previous period, as well as to the year that followed, i.e. 2001.
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Data is obtained from the registered hospital morbidity
Graph 3. Tendency of mental disorders in out-patient
morbidity from 1997 to 2003
number of treated
12000
y = 659x + 5476,6
10000
8000
6000
4000
2000
0
1997
1998
1999
2000
2001
year
Table 2 shows total morbidity of mental disorders and mood disorders in Montenegro
(both out-patient and hospital), as well as by the structure of most frequent conditions from
this group. In addition to that, there are morbidity rates, percentage of participation of mental
disorders and behavioural disorders in total morbidity of Montenegro, as well as participation
in percentage of certain components of this group of conditions in the structure of the same
group.
Table 2. Total morbidity (out-patient and hospital) in Montenegro related to mental disorders
and behavioural disorders in 2001
CONDITION
NUMBER OF
MORBIDITY RATE
PERCENTAGE
CASES
MENTAL
DISORDERS
11539
1725,9
18,8%
AND MOOD
DISORDERS
Neurotic,
stressogenic
3730
557,9
32,3%*
disorders
Schizophrenia
3494
522,6
30,3%*
Mood disorders
2217
331,6
19,2%*
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