MENTALNO ZDRAVLJE MLADIH – RIZIK I ŠANSA · Ćurčić V. Mentalno zdravlje mladih – rizik i šansa 93 Predlog strategije za mentalno zdravlje mladih u Srbiji koji će predstavljati

Psihijat. dan., Suppl. /2005/37/1/87-96/ Ćurčić V. Mentalno zdravlje mladih – rizik i šansa

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UDK: 613.86 – 053.6

MENTALNO ZDRAVLJE MLADIH – RIZIK I ŠANSA

Vojislav Ćurčić

Klinika za psihijatriju Kliničko bolničkog centra „Dr Dragiša Mišović-Dedinje“, Beograd

Apstrakt: Adolescencija predstavlja specifičan razvojni period koji se karakteriše intenzivnim i dubokim transformacijama psihičkog aparata i psihosocijalnog funkcionisanja dotadašnje dece – budućih odraslih, ali i promenama odnosa adolescenata prema okolini. Kako se dinamika tih procesa dešava za relativno kratko vreme, adolescentni proces ima potencijal da destabilizuje psihološku ravnotežu i psihosocijalno funkcionisanja adolescenta, i time može da predstavlja rizik za mentalno zdravlje. Tenzija i konflikti izazvani ovim transformacijama ponekad ne mogu da se elaborišu u okviru psihičkog aparata, pa se šire u okolinu koja postaje neka vrsta „proširenog psihičkog prostora“ adolescenta. U tim okolnostima okolina dobija svoj značaj i znatan uticaj – pozitivan ili negativan. U našoj sredini, u poslednjih petnaest godina (1990-2004), u društvu su se dešavale izuzetno burne i nepovoljne promene. One su imale značajan uticaj na adolescente i uzrokovale intenziviranje ili promenu nekih oblika uobičajene psihopatologije, ili su doprinele pojavi nekih novih oblike psihopatologije ili poremećaja ponašanja. Rad je dokumentovan istraživanjima ili zvaničnim podacima koji to potvrđuju. Drugi deo rada predstavlja prezentaciju nalaza i predloga Ekspertske podgrupe za mentalno zdravlje i razvoj mladih koju je osnovalo Ministarstvo zdravlja Republike Srbije. Nalazi se odnose kako na istraživanje psihopatologije adolescenata na području cele Srbije, tako i na izveštaj nevladinih organizacija o stanju službi za zaštitu mentalnog zdravlja mladih u Srbiji. Izveštaj sadrži i predlog strategije za poboljšanje sistema za psihološku pomoć mladima i sistema zaštite mentalnog zdravlja. Na kraju se daju neke napomene koje određuju da adolescencija predstavlja ne samo rizik već i šansu za mlade osobe da kroz nju i tokom nje, spontano ili uz stručnu pomoć, mladi razreše neke svoje probleme i time uspešnije nastave put ka zrelosti, definitivnom određenju identiteta i sticanju nezavisnosti.

Ključne reči: adolescencija, psihopatologija, mentalno zdravlje, okolina


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UVOD – ADOLESCENCIJA KAO RIZIK ZA MENTALNO ZDRAVLJE Period mladalaštva je poseban razvojni period koji se karakteriše

transformacijama dotadašnje dece u odrasle osobe, odnosno, sazrevanjem psihičkog aparata i psihosocijalnog funkcionisanja, od infantilnog ka odraslom. Najveći broj adolescenata ovaj period prođe sasvim uspešno i lako, naravno, sa nekim kolebanjima u psihičkim stanjima, ponašanju i psihosocijalnom funkcionisanju.

Kako se očekivane i neminovne intrapsihičke transformacije dešavaju za relativno kratko vreme (nekoliko godina) i kako obuhvataju sve aspekte ličnosti i nivoe psihološkog funkcionisanja, one imaju potencijal da dezorganizuju biće mlade osobe. Zato adolescencija predstavlja koliko neminovan i progresivan razvojni period toliko, u izvesnoj meri i za neki broj adolescenata, i rizičan period koji može potencirati ili uzrokovati neke psihološke probleme i neku, za ovaj period, specifičnu psihopatologiju – kako po manifestacijama, tako i po psihodinamici njenog razvoja.

Burnost i intenzivnost adolescentnih transformacija nekada prevazilaze mogućnosti psihičkog aparata da ih obradi pa se konflikti i tenzija šire u okolinu čime ona postaje, na neki način, „proširen psihički prostor“ adolescenta (1). S druge strane, u adolescenciji se ne dešavaju samo intrapsihičke transformacije već i transformacije odnosa adolescenta prema osobama koje su bile značajne u periodu detinjstva, ali i prema aktuelnim osobama – od vršnjaka do značajnih osoba iz sveta odraslih. Zbog toga dešavanja u okolini u značajnoj meri utiču na psihička stanja i funkcionisanja adolescenata.

Okolina nije, naravno, neophodna adolescentima za stvaranje psihičkog aparata kao što je to deci, ali je od značaja za njegovu reorganizaciju. Razumevanjem, podrškom, razumnom tolerancijom i stabilnom i predvidivom strukturom okolina može odigrati uloge pomoćnog i spoljašnjeg Ja ili Nad Ja adolescenta i tako pomoći da na lakši i bolji način izađe na kraj sa adolescentnom burom i konfuzijom. I obrnuto, neadekvatan ili problematičan odgovor i reakcija okoline mogu dodatno omesti razvojne adolescentne procese ili intenzivirati nestabilnost i psihosocijalnu disfunkcionalnost adolescenta (2). A upravo se to desilo adolescentima Srbije u prethodnih petnaestak godina.

Raspad države, ratovi u okruženju, sankcije međunarodne zajednice, ekonomska kriza, kriza morala, haotičnost socijalnog, političkog i školskog sistema, dezorganizovanost i disfukcionalnost porodica su osnovne karakte-ristike prohujalih vremena. Ovakvo stanje u društvu je, u nekoj meri, pojačalo prirodnu konfuziju adolescenata, što se iskazalo kroz promenu i intenziviranje različitih mentalnih poremećaja, o čemu govore ne samo klinički utisci i iskustva već i neka istraživanja.


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Neka istraživanja i podaci o psihopatologiji adolescenata Istraživanje koje je organizovano 1995. godine na Odseku za

adolescentnu psihijatriju Klinike za psihijatriju KBC „Dr Dragiša Mišović-Dedinje“ u Beogradu rečito govori o udruženosti uticaja faktora unutrašnje i spoljašnje realnosti na psihopatologiju adolescenata (3). Istraživanje je obavljeno na populaciji adolescenata i postadolsecenata (15-24 godine) stacionarno lečenih na Odseku. Kao što se iz grafikona vidi (grafikon 1) u godinama najveće krize (posle raspada države) jako se smanjio broj adolescenata sa uobičajenom, adolescentnim problemima, označenim šifrom F90-98, po MKB-10. Tako je procenat adolescenata lečenih sa ovom dijagnozom 1990. godine bio 38.70%, da bi se u narednim godinama smanjivao do 1993., kada je registrovano samo 16.00%. Kliničkom slikom poremećaja iz ovog domena tih godina su dominirale depresivne manifestacije. Podatak bi se mogao tumačiti blokadom normalnih adolescentnih procesa (koji kod značajnog broja adolescenata generišu probleme) pod pretnjom značajnih egzistencijalnih, porodičnih i društvenih problema. Međutim, u istom periodu je rastao broj psihotično dezorganizovanih adolescenata (šifre F20-39) – od 32.25% registrovanih 1990. godine, sa nastavkom tendencije porasta u narednim godinama, do kulminacije 1993. godine, kada je registrovano 54.66%). To su bili adolescenti koji su manifestovali psihotičnu simptomatologiju, bilo tipa psihotičnih reakcija, bilo tipa dekompenzacijâ hroničnih psihotičnih procesa. Najčešće manifestovana klinička slika psihotičnih bi stanja mogla se označiti kao konfuzno-paranoidno-depresivna, što je i razumljivo s obzirom na specifičnosti okolnosti u kojima se živelo – destrukcija socijalnog miljea, podgrevanje kolektivne paranoidnosti („svi su protiv nas“), osećanje beznađa i besperspektivnosti. Grafikon 1. Psihopatologija adolescenata 1990-1994.


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U daljim godinama krize u našoj državi kod adolescenata su bile

izražene neke druge psihopatološke manifestacije i manifestacije poremećaja ponašanja, koje su, takođe, u znatnoj meri, pratile dešavanja u društvu.

Prema podacima Zavoda za statistiku Republike Srbije maloletnička delinkvencija je bila u porastu, posebno u vreme sankcija i ekonomske krize, i posebno se iskazivala kroz „dela protiv imovine“ (grafikon 2). Mladi su tada otimali odeću od svojih vršnjaka, obijali automobile i trafike, a kulminacija ovakvog ponašanja je zabeležena 1994-1995. godine, u vreme najvećeg siromaštva stanovništva. Posle tih godina je usledio pad ovog oblika delinkvencije, ali su poslednje godine obeležene novim vrstama delikata i po-rastom sve surovijeg nasilja. To se iskazuje kroz porast „dela protiv tela i života“ (grafikon 3). Ova vrsta delikata je porasla dvostruko (od 6% u 1991. godini do 12.8% u 2003). Međutim, uz porast nasilja i sve veću brutalnost adolescenata, zabrinjava podatak o porastu autodestruktivnosti adolescenata koji se iskazuje kroz porast broja samoubistava među mladima (grafikon 4). Prema podacima iz istog izvora, 1990. godine je registrovano 62 samoubistva mladih (15-24 godine), da bi taj broj rastao i dostigao kulminaciju 1997. godine (132), sa tendencijom pada do 2003. godine (80), ali nikada nije dostigao nivo pre društvene krize. Registrovane tendencije samoubilaštva mladih odgovaraju društvenim tendencijama. Tako je, na primer, 1997. godina, kada je registrovan najveći broj samoubistava, bila godina najvećih političkih i društvenih konflikata i nemira, ali i osećanja iscrpljenosti, depresivnosti i beznađa. Grafikon 2. Delinkvencija u Srbiji 1990-2003: dela protiv imovine

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Grafikon 3. Delinkvencija u Srbiji 1990-2003: dela protiv života i tela

Grafikon 4. Samoubistva mladih u Srbiji 1990-2003.

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Svi prikazani podaci govore o ranjivosti adolescentne populacije i značajnom uticaju okoline u kojoj žive na njihovo mentalno zdravlje. Prikazani porast i promene u psihopatologiji mogu se smatrati direktnom posledicom društvene krize kroz koju je prolazila naša zajednica poslednjih petnaest godina.

Nalazi i predlozi Ekspertske podgrupe za mentalno zdravlje i

razvoj mladih Ministarstva zdravlja Republike Srbije Ovakvo stanje je zahtevalo odgovarajuću intervenciju društva, zbog

čega je Ministarstvo zdravlja Republike Srbije početkom 2003. godine, uz pomoć UNICEF-a, formiralo Ekspertsku grupu za razvoj i zdravlje mladih. Grupa se sastoji od nekoliko podgrupa, a jedna od njih je Podgrupa za mentalno zdravlje i razvoj mladih. Podgrupa je formirana tako da njen sastav čine kako predstavnici iz oblasti zaštite mentalnog zdravlja, tako i nevladinog sektora, iz svih regiona Republike. Po tim principima sastav grupe su činili: prim. dr sci Vojislav Ćurčić (predsednik, Beograd), prof. dr Aneta Lakić (Beograd), prof. dr Dragan Mitrović (Novi Sad), dr Ljubomir Milosavljević (Niš), prim. dr Ljiljana Pešić (Beograd), dr Gordana Inštitoris-Pribić (Subotica), dr Oliver Vidojević (Beograd), dr Branislava Stamatović-Gajić (Valjevo), dr Jovanka Cvetković (NVO IAN, Beograd), dr Zagorka Bradić (Beograd), Ivana Zaklan (NVO „Srce“, Novi Sad), Dragana Ćuk-Milankov (NVO „Studenti s hendikepom“, Beograd), Danijela Maljević (Ministarstvo prosvete, Beograd), Raša Sekulović (NVO „Save the Children“, Beograd), Vladimir Borovnica („Internet savetovalište za mlade“, Beograd), dr Silvia Koso i dr Jelena Zajeganović (UNICEF, Beograd).

Prvi zadatak Komisije je bio da, kroz organizovano istraživanje, pokuša da sagleda: 1. demografsku situaciju; 2. stanje mentalnog zdravlja mladih u Srbiji; 3. stanje i organizaciju službi za zaštitu mentalnog zdravlja namenjenih mladima, kao i stanje u nevladinim organizacijama koje se bave mladima. Na osnovu dobijenih podataka i njihove analize napravljen je

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Predlog strategije za mentalno zdravlje mladih u Srbiji koji će predstavljati deo dokumenta sveukupne Strategije za zdravlje i razvoj mladih.

U daljem tekstu će biti predstavljeni rezultati i predlozi ove Ekspertske podgrupe.

Demografski podaci Prema podacima iz popisa stanovništva 2002. godine (Republički

zavod za statistiku Republike Srbije) populaciju mladih (15-24 godine) čini 1.008.080 stanovnika (ili 13,44 % opšte populacije) i to u Centralnoj Srbiji 727.862 (ili 13,32 % opšte populacije), a u Vojvodini 280.218 (ili 13,79 % opšte populacije). Podaci ne obuhvataju stanovništvo Kosova i Metohije.

STANJE MENTALNOG ZDRAVLJA MLADIH SRBIJE Klinička zapažanja Podaci kojima raspolažu članovi grupe, kao stručnjaci koji imaju

značajno iskustvo u svakodnevnom kliničkom radu sa mladima sa mentalnim problemima, govore sledeće:

• iz godine u godinu sve je veći broj mladih koji imaju psihološke probleme ili manifestuju određenu, za ovaj uzrast, specifičnu psihopatologiju

• među psihološkim problemima najčešće su različite teškoće adolescentnog procesa, koncentrisane oko formiranja stabilnog i definitivnog identiteta

• najčešće psihopatološke manifestacije su depresivna stanja (uključujući samoubilaštvo) i poremećaji ponašanja, uključujući zloupotrebu psihoaktivnih supstanci i delinkventno ponašanje

Kako su ove kliničke opservacije, iako zajedničke, ipak samo zapažanja stručnjaka, grupa je organizovala istraživanje koje je trebalo da proveri kliničko iskustvo.

ISTRAŽIVANJE Istraživanje je urađeno u okviru aktivnosti Ekspertske grupe za

mentalno zdravlje mladih Ministarstva zdravlja, uz finansijsku i organizacionu pomoć Ministarstva prosvete Srbije.

Analiza mentalnog zdravlja mladih je rađena na osnovu prilagođene verzije upitnika za Samoprocenu ponašanja mladih u Srbiji (YSR, T. Achenbach).

Istraživanje je obavljeno na populaciji srednjoškolaca, u deset gimnazija i dvanaest srednjih stručnih škola u Srbiji, u jedanaest gradova (Beograd, Šabac, Niš, Novi Sad, Kraljevo, Vranje, Subotica, Kragujevac, Zaječar, Valjevo i Zrenjanin) – ukupno 1.126 ispitanika.


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Istraživanje je takođe obavljeno, istom metodologijom, i na populaciji studenata Beogradskog univerziteta (Studentska poliklinika) – ukupno 557 ispitanika.

Rezultati istraživanja ukazuju na sledeće činjenice: a) Srednjoškolska populacija

- prosečan uzrast: 16 godina (standardno odstupanje od pola godine)

- mladići: 549 (48,8%), devojke: 577 (51,2%) - gledano iz ugla koji razlikuje samo grupu graničnih i

rizičnih od grupe ostalih ispitanika, prvih je jedna trećina (34,0%) od ukupnog uzorka

- u grupi graničnih i rizičnih ima znatno više devojaka (39,2%) od mladića (28,6%)

- graničnih i rizičnih ispitanika je najviše u Beogradu (46,6%), zatim u užoj Srbiji (32,9%), a najmanje u Vojvodini (30,4%)

b) Studentska populacija

- prosečan uzrast: 21,5 godina - mladići: 39,14%, devojke: 60,86% - stepen psihološkog trpljenja i manifestovane patologije

studenata je nešto manji nego u grupi srednjoškolaca ipak, evidentan je visok prosečni rezultat na svim ispitivanim skalama

- devojke u odnosu na mladiće imaju viši procenat na svim skalama, a statistički značajno na skali anksioznost-depresivnost

- budući da se radi o samoproceni, evidentan je uticaj muško-ženskog stereotipa na poželjno-nepoželjne odgovore, a takođe u većoj meri kod devojaka, želja za promenom pola, što asocira na stav da je društveni kontekst pogodniji za muški pol

- kvalitativna analiza odgovora koji u grupi rizičnih značajno prelaze 10% daje sliku povučenog, sumnjičavog, zabrinutog i nervoznog mladog čoveka, koji ima imperativ da bude savršen, što ilustruje smernice preventivnog delovanja.

Istraživanje je potvrdilo klinička iskustva i pokazalo da 1/3 srednjoškolske populacije pripada grupi graničnih i rizičnih, tj. manifestuje znake psihološkog trpljenja i mentalnih problema i poremećaja. Slični su rezultati i na studentskoj populaciji. Ugroženije su devojke i adolescenti u urbanim sredinama.


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ANALIZA POSTOJEĆE MREŽE ZDRAVSTVENIH SLUŽBI I NEVLADINIH ORGANIZACIJA NAMENJENIH REŠAVANJU PSIHOLOŠKIH PROBLEMA I ZAŠTITI MENTALNOG ZDRAVLJA MLADIH U SRBIJI

Podaci koji su prikupljeni s područja cele Srbije ukazuju na sledeće: Službe za mentalno zdravlje mladih a. stacionarne jedinice namenjene adolescentima postoje samo u

Beogradu (Institut za mentalno zdravlje – namenjen deci i mladima do 18. godine, Klinika za neurologiju i psihijatriju za decu i omladinu – namenjena deci i mladima do 18 godina, Odsek za adolescentnu psihijatriju Klinike za psihijatriju KBC „Dr Dragiša Mišović-Dedinje“ – namenjen adolescentima i postadolescentima od 15-24 godine); Novom Sadu (Centar za dečju i adolescentnu psihijatriju) i Nišu (Odeljenje za neurologiju i psihijatriju raz-vojnog doba – za decu i mlade do 18 godina) i Boru (Odsek za dečju psihijatriju i razvojnu psihologiju). Zapažanje: postojeće stacionarne jedinice tretiraju uglavnom zajedno decu i mlade (do 18 godina), često zajedno one sa neurološkim kao i one sa mentalnim poremećajima. Samo jedna ustanova se bavi isključivo adolescentima i postadolescentima (do 24 godine). Ukupan broj postelja za decu i adolescente: oko 70

b. dnevne bolnice za decu i adolescente (2) postoje samo u Beogradu i Novom Sadu

c. službe za vanbolničku pomoć adolescentima postoje takođe samo u najvećim centrima-gradovima, bilo u okviru psihijatrijskih odeljenja bilo u okviru domova zdravlja.

d. u najvećem broju regiona Srbije ne postoje nikakve službe namenjene zaštiti mentalnog zdravlja mladih, a retko postoje i edukovani profesionalci koji se ciljano bave mentalnim problemima ove populacije.


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NEVLADINE ORGANIZACIJE Prema podacima do kojih je bilo teško doći i koji su verovatno

nepotpuni ima jako malo nevladinih organizacija koje ciljano, organizovano i kontinuirano imaju programe i projekte namenjene mladima sa psihološkim problemima ili mentalnim poremećajima.

Analizom je utvrđeno da je postojeći broj i nivo zdravstvenih službi, kao i nevladinih organizacija namenjenih mentalnim problemima mladih apsolutno nedovoljan i/ili nefunkcionalan da bi mogao da odgovori potrebama ove populacije.

PREDLOG STRATEGIJE Na osnovu svih iznetih elemenata i analiza, Ekspertska podgrupa za

mentalno zdravlje i razvoj mladih je predložila sledeće mere i strategiju za unapređenje službi i programa za pomoć i lečenje adolescenata sa psihološkim problemima i mentalnim poremećajima:

1. Podrška naporima i aktivnostima Nacionalne komisije za mentalno zdravlje Ministarstva zdravlja Republike Srbije, posebno u delu otvaranja Centara za mentalno zdravlje, jer će oni sadržati i timove stručnjaka i organizacionu jedinicu namenjenu deci i mladima;

2. Povećanje preventivnog i terapijskog potencijala primarne zdravstvene zaštite kroz dodatnu edukaciju postojećih kadrova u domovima zdravlja (lekara opšte prakse, pedijatara i saradnika) za mentalne probleme mladih;

3. U većim centrima, u okviru domova zdravlja, formiranje i edukovanje timova za zaštitu mentalnog zdravlja mladih, ili razvojnih savetovališta sa mogućnošću pružanja psihološko-psihijatrijske podrške ili pomoći;

4. Osnaživanje i pomoć (kadrovska, organizaciona i prostorna) postojećim stacionarnim jednicama za mentalne probleme mladih i razdvajanje od jedinica za decu, kao i od jedinica za decu i mlade sa neurološkim poremećajima;

5. Otvaranje novih stacionarnih jedinica za lečenje mladih (15-24 godine) u svim medicinskim centrima-opštim bolnicama većih gradova, kapaciteta 4-6 kreveta;

6. Stručna pomoć i podrška programima i projektima nevladinih organizacija za psihološku podršku i pomoć mladima;

7. Rad na borbi protiv stigmatizacije mentalnih poremećaja mladih; 8. Stvaranje mogućnosti mladima za psihološku podršku i pomoć

izvan zdravstvenih i psihijatrijskih ustanova – u školama, studentskim domovima i internatima, ali i kroz otvaranje savetovališta u gradovima – izvan bilo kakvih institucija;

9. Obučavanje vršnjaka i razvijanje sistema vršnjačke pomoći mladima sa psihološkim dilemama i problemima;


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10. Rad na primarnoj prevenciji mentalnih poremećaja mladih kroz školski sistem (dodatno informisanje i edukovanje profesora, školskih psihologa, pedagoga i roditelja) i sve oblike masovnih komunikacija (informisanjem javnosti o specifičnostima adole-scencije kao razvojnog perioda i potrebama i mogućnostima adolescenata za psihološku pomoć).

Adolescencija kao šansa za mentalno zdravlje mladih Adolescencija je razvojni period sa značajnim potencijalom za

promene, kako one koje su prirodne i uobičajene u adolescentnom procesu, tako i one koje predstavljaju poremećaje i patologiju. Neke se dešavaju spontano ili uz pomoć najbliže okoline adolescenata, a neke se mogu obezbediti kroz različite oblike stručnih intervencija. Izvesna psihosocijalna disfkcionalnost adolescenata ili manifestacije psihopatologije se mogu redukovati, ali se neke mogu trajnije i radikalnije korigovati. Zato je, za većinu adolescenata sa problemima, poželjno da se stručnjaci ne zadovolje samo redukcijom ili povlačenjem simptoma i aktuelnog trpljenja već i da pokušaju, kroz psihoterapijski rad ili proces, da omoguće adolescentu korekcije intrapsihičke dinamike i dinamike psihološkog funkcionisanja koje su prethodile problemu ili ga uzrokovale (4).

Medikamentna terapija može, naravno, da se koristi u cilju redukcije simptoma i obezbeđenja bolje funkcionalnosti. Druge profesionalne inter-vencije (usmerene na školu, radnu sredinu i slično) takođe mogu da pomognu adolescentu u prevazilaženju nekih problema, a pre svega situacija. Međutim, psihoterapija ima potencijal, posebno analitički orijentisana, da razjasni i proradi neke razvojne teškoće, neke strukturne neusklađenosti i neku nesvesnu psihodinamiku koji su uzrokovali probleme adolescenata. Tako mogu da se koriguju i/ili otklone faktori koji su ometali normalne razvojne procese i na taj način da se omogući dalji put adolescenta ka zrelosti, nezavisnosti i odrasloj funkcionalnosti. U tom smislu, adolescencija se može shvatiti i kao šansa, ne samo za prevazilaženje aktuelnih psiholoških problema i psihopatologije, već i za buduće dobro psihosocijalno funkci-onisanje i dobro mentalno zdravlje.

Psych. Today, Suppl. /2005/37/1/97-107/ Curcic V. Mental health of adolescents – risk and chance

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UDK: 613.86 – 053.6

MENTAL HEALTH OF ADOLESCENTS – RISK AND CHANCE

Vojislav Curcic

Psychiatric clinic “Dr Dragisa Misovic - Dedinje“

Clinical Hospital Center, Belgrade

Abstract: Adolescence is a specific developmental period characterized by inten-

sive and deep transformations of the psychic apparatus and psychosocial functioning of the former children – future adults, but also by changes of the adolescents’ attitude to their en-vironment. Since the dynamics of these processes occur in a relatively short time, the ado-lescent process has the potential to destabilize psychological balance and psychosocial func-tioning of the adolescent, thus presenting the risk to mental health. Tension and conflicts caused by the transformations sometimes cannot be elaborated within the psychic apparatus, and they spread in the surroundings which becomes a kind of “broad psychic space” of the adolescent. In such circumstances, the environment has more importance and considerable influence – good or bad. In the last fifteen years (1990–2004), our society has experienced tremendously intensive and negative changes. They have considerably influenced the ado-lescents and caused escalation or alteration of certain types of common psychopathology, or contributed to the onset of new types of psychopathology and behavioral disorders. The ar-ticle is documented and confirmed by research results and official information. The second part of the article presents findings and proposals of the Expert subcommittee for mental health and development of adolescents, established by the Republic of Serbia Ministry of Health. The findings refer to the study of adolescent psychopathology in the entire territory of Serbia, as well as to the report of non-governmental organizations on the state of mental health care services for adolescents in Serbia. The report contains the proposed strategy for improving the system for psychological assistance to adolescents and the mental health care system. The concluding notes state that adolescence presents not only a risk, but also a chance for the young people to, either spontaneously or with professional help, solve some of their problems and continue down the path of maturity, definite identity and independ-ence.

Key words: adolescence, psychopathology, mental health, environment


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INTRODUCTION - ADOLESCENCE AS A RISK TO MENTAL HEALTH The period of adolescence is a special developmental period charac-

terized by the transformation of children into adults, with their psychological apparatus and psychosocial functioning maturing from the infantile to the adult. The majority of adolescents get through this period quite successfully and easily, with some oscillations in psychological states, behavior and psy-chosocial functioning.

Since the expected and inevitable intrapsychic transformations occur in a relatively short time (a few years), involving all aspects of personality and levels of psychological functioning, they have the potential to disorgan-ize the being of a young person. Therefore, as much as adolescence is an in-evitable and progressive developmental period, it is also, to a certain level and in a certain number of adolescents, a dangerous time that can enhance and cause psychological problems and psychopathology specific for this pe-riod, both by its manifestations and by the psychodynamics of its develop-ment.

Force and intensity of adolescent transformations sometimes over-power the capacity of the psychic apparatus to process them, so that conflicts and tension spread into the surroundings, making it in a way the adolescent’s “broader psychic space” (1). On the other hand, the period of adolescence includes not only intrapsychic transformations, but also the changes of the adolescents’ attitude toward the persons who were important in their child-hood, and also toward persons with current significance – from peers to im-portant adults. This is why the events in the surroundings have considerable influence on the psychic condition and functioning of adolescents.

The environment, of course, does not have the same impact on the creation of psychic apparatus in adolescents as in children, but it is important for its reorganization. By understanding, support, reasonable tolerance and stable and predictable structure, the environment can play the role of addi-tional and external Ego or Super Ego of the adolescents, thus helping them cope with the adolescent turmoil and confusion. And vice versa, inadequate or problematic response and reaction of the surroundings can additionally disturb the adolescent developmental processes or intensify their instability and psychosocial dysfunctionality (2). This is exactly what happened to ado-lescents in Serbia in the last fifteen years.

Breakdown of the state, wars in the region, international community sanctions, economic crisis, deterioration of moral principles, chaotic social, political and educational system, disorganized and dysfunctional families were the basic characteristics of recent past. Such condition of the society has to a certain extent intensified the adolescents’ natural confusion, and caused the alteration and increase of different mental disorders, which is manifest not only in our clinical impressions and experiences, but in several studies as well.


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Studies and data on adolescent psychopathology The study organized in 1995 by the Psychiatric clinic Section for

adolescent psychiatry at the “Dr Dragisa Misovic – Dedinje“ CHC in Bel-grade, has clearly demonstrated the combined influence of internal and ex-ternal reality factors on the psychopathology of adolescents (3). The study was conducted on the population of adolescents and post-adolescents (15-24 years of age) hospitalized at the Section. As can be seen in the graph (graph 1), the number of adolescents with typical adolescent problems, marked by the ICD-10 code F90-98, has reduced significantly in the years of deepest crisis (following the breakdown of the state). In 1990, the percentage of ado-lescents treated for these disorders was 38.70%, in the following years the percentage was steadily decreasing, and in 1993 only 16.00% were regis-tered. At the time, clinical picture of this type of disorders was dominated by depressive manifestations. The fact can be explained by the obstruction of normal adolescent processes (generating problems in a significant number of adolescents), under threat of crucial existential, familial and societal prob-lems. In the same period, however, the number of psychotically disorganized adolescents (codes F20-39) has increased – from 32.25% registered in 1990, with the continued tendency of rise in the following years, to the 1993 cul-mination, when 54.66% were registered. The adolescents manifested psy-chotic symptomatology, either the psychotic reactions, or the decompensa-tion of chronic psychotic processes. The most frequently manifested clinical picture of psychotic conditions can be marked as confused-paranoid-depressive, which is understandable considering the specific circumstances – destruction of the social milieu, instigation of collective paranoia (“everybody is against us”), the feeling of hopelessness and lack of prospect. Graph 1 Psychopathology of adolescents 1990-1994.

38,70

30,00

26,26

16,00

39,13 32,25

34,77

46,71

54,66

42,02

0

10

20

30

40

50

60

1990 1991 1992 1993 1994

year

F90-98 F20-39

percent


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In further years of the crisis in our country, other psychopathological manifestations and manifestations of behavioral disorders, which have also to a certain extent followed the events in the society, were also registered in the adolescents.

According to the data obtained by the Statistical Office of the Repub-lic of Serbia, juvenile delinquency was on the rise, especially in times of sanctions and economic crisis, mostly manifested as “acts against property” (graph 2). Adolescents have been grabbing the clothes away from their peers, breaking into cars and shops, and the culmination of this type of behavior was registered in 1994-1995, along with the extreme poverty of the popula-tion. The decrease of this type of delinquent behavior has ensued, but the fol-lowing years have been marked with new types of criminal acts and increase of the constantly more ferocious violence, manifested in the increase of “acts against body and life” (graph 3). This type of criminal acts has doubled in number (from 6% in 1991 to 12.8% in 2003). However, beside the increase of violence and the growing brutality of adolescents, there are also alarming statistics on the growing auto-destructiveness of adolescents, manifested by the increase of suicides among young people (graph 4). According to the same source, 62 suicides of adolescents (15-24 years of age) were registered in 1990, the number has increased and peaked in 1997 (132), with the ten-dency of decline to 2003 (80), but it never reached the level before the social crisis. Registered suicidal tendencies in adolescents correspond with the so-cial tendencies. For example, 1997, the year of the highest registered suicide rate, was also the year of the strongest political and social conflicts and tur-moil, as well as the feelings of exhaustion, depression and hopelessness.

Graph 2 Delinquency in Serbia 1990-2003: acts against property

81,8

78,4

83,3

84,485,5

82,8

79,779,2

81,8

77,7

81,5

80

73,3

66 68 70 72 74

78

82 84 86 88

1990. 1991. 1992. 1993. 1994. 1995. 1996. 1997. 1998. 1999. 2000. 2001. 2002. 2003.

Percent


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Graph 3 Delinquency in Serbia 1990-2003: acts against body and life

Graph 4 Suicides of adolescents in Serbia 1990-2003

All the presented data illustrate the vulnerability of adolescent popu-

lation and the significant impact of surroundings to their mental health. The presented increase and changes in psychopathology can be considered as di-rect consequence of the social crisis that afflicted our community in the last fifteen years.

Findings and proposals of the Expert subcommittee for mental

health and development of adolescents of the Republic of Serbia Minis-try of Health

The situation called for adequate intervention of the society; in the beginning of 2003, the Republic of Serbia Ministry of Health, with the sup-port of UNICEF, has formed the Expert subcommittee for development and

62 79

8892

98

112118

132

89

114

107

83

96

80

0

20 40

60

80

100

120

140

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Year

Number 15-19 20-24 Total

6 6 6

4,6

5,75,4

6,7 6,7

9

8,2 8,47,8

9,5

12,8

0

2

4

6

8

10

12

14

1990. 1991. 1992. 1993. 1994. 1995. 1996. 1997. 1998. 1999. 2000. 2001. 2002. 2003. Year

Percent


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health of adolescents. The committee consists of several subcommittees, one of which is the Subcommittee for mental health and development of adoles-cents. The subcommittee includes representatives from both the field of men-tal health care and the non-governmental sector, from all regions of the re-public. In accordance with these principles, the group included the following members: Prim. Vojislav Curcic (president, Belgrade), Prof. Aneta Lakic (Belgrade), Prof. Dragan Mitrovic (Novi Sad), Ljubomir Milosavljevic, MD (Nis), Prim. Ljiljana Pesic (Belgrade), Gordana Institoris-Pribic, MD (Subotica), Oliver Vidojevic, MD (Belgrade), Branislava Stamatovic-Gajic, MD (Valjevo), Jovanka Cvetkovic, MD (NGO IAN, Belgrade), Zagorka Bradic, MD (Belgrade), Ivana Zaklan (NGO “Heart“, Novi Sad), Dragana Cuk-Milankov (NGO “Students with disability“, Belgrade), Danijela Mal-jevic (the Ministry of Education, Belgrade), Rasa Sekulovic (NGO “Save the Children“ – Belgrade), Vladimir Borovnica (“Internet counseling for adoles-cents“, Belgrade), Silvia Koso, MD and Jelena Zajeganovic (UNICEF, Bel-grade).

The first task of the Committee was to organize a study with the aim to explore: 1. demographic situation; 2. mental health state of adolescents in Serbia; 3. condition and organization of mental health care services for ado-lescents, as well as the condition of non-governmental organizations dealing with adolescents. Based on the obtained and analyzed information, the Pro-posal of strategy for mental health of adolescents in Serbia was prepared, as a part of the future comprehensive Strategy for health and development of ado-lescents.

Results and proposals of the Expert subcommittee will be presented in the following text.

Demographic data According to the results of the Population Census 2002 (the Statisti-

cal Office of the Republic of Serbia) 1,008,080 inhabitants (or 13.44 % of total population) belong to the adolescent population (15-24 years of age), out of which 727,862 (or 13.32 % of total population) in Central Serbia, and 280.218 (or 13.79 % of total population) in Vojvodina. The results do not include the population of Kosovo and Metohija.

MENTAL HEALTH STATE OF ADOLESCENTS IN SERBIA Clinical observations Data available to the group members as experts with substantial ex-

perience in everyday clinical work with adolescents suffering from mental health problems indicate the following:

• The number of adolescents with psychological problems or mani-festing certain age-specific psychopathology is increasing year after year


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• The most frequent psychological problems are various difficulties in the adolescent process, focused around the formation of defi-nite and stable identity

• The most common psychopathological manifestations are depres-sive states (including suicidality) and behavioral disorders, in-cluding abuse of psychoactive substances and delinquent behav-ior

Since these clinical observations, although shared by experts, are nevertheless just observations, the group has organized research with the aim to corroborate clinical experience.

RESEARCH The research was conducted within the framework of the activities of

the Expert group for mental health of adolescents of the Ministry of Health, with financial and organizational support of the Serbian Ministry of Educa-tion.

Analysis of the mental health state of adolescents in Serbia was based on the adjusted version of the Youth Self-Report questionnaire (YSR, T. Achenbach).

The research was conducted on the population of high school chil-dren in ten high schools and twelve vocational schools in eleven towns in Serbia (Belgrade, Sabac, Nis, Novi Sad, Kraljevo, Vranje, Subotica, Kragu-jevac, Zajecar, Valjevo and Zrenjanin) – the total of 1.126 subjects.

Using the same methodology, the study was also conducted among the student population of the Belgrade University (Students’ polyclinic) – the total of 557 subjects.

Results of the study point to the following facts: a) High school population

- mean age: 16 (standard half-year deviation) - boys: 549 (48.8%), girls: 577 (51.2%) - distinguishing only between the borderline and risk group and

the group of other subjects, the first group contains one third (34.0%) of the total sample

- there are significantly more girls (39.2%) than boys (28.6%) in the borderline and risk group

- the percentage of subjects in the borderline and risk group is the highest in Belgrade (46.6%), next in Central Serbia (32.9%), and the lowest in Vojvodina (30.4%)

b) Student population - mean age: 21.5 - boys: 39.14%, girls: 60.86%


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- level of psychological suffering and manifested pathology in the students is slightly lower than in the high school group, however, high average scores in all the tested scales are evident

- girls have higher percentage in all scales as compared to boys, with statistical significance in the anxiety-depression scale

- as this was a self-report, the influence of male-female stereo-type on the desirable – non-desirable responses was evident, as well as the wish to be of different gender that was more present in girls, indicating the attitude that the social context is more favorable for males

- qualitative analysis of responses significantly over 10% in the group of subjects at risk presents the picture of a restrained, distrustful, worried and nervous adolescent, with the im-perative to be perfect, which illustrates the guidelines for pre-ventive actions.

The study has confirmed clinical experiences and demonstrated that 1/3 of high school population belong to the borderline and risk group, i.e. manifest the signs of psychological suffering and mental problems and disor-ders. Similar results were obtained in the student population. Girls and ado-lescents in urban environment are more vulnerable.

ANALYSIS OF THE EXISTING NETWORK OF HEALTH CARE SERVICES

AND NON-GOVERNMENTAL ORGANIZATIONS AIMED AT THE SOLUTION OF PSYCHOLOGICAL PROBLEMS AND MENTAL HEALTH CARE OF ADOLESCENTS IN SERBIA

Data obtained from the entire territory of Serbia indicate the follow-

ing: MENTAL HEALTH CARE SERVICES FOR ADOLESENTS a. Hospital units for adolescents exist only in Belgrade (Institute of

mental health – intended for children and adolescents under 18, Clinic for child and adolescent neurology and psychiatry – for children and adolescents under 18, Section for adolescent psy-chiatry of the CHC “Dr Dragisa Misovic-Dedinje“ Psychiatric clinic – for adolescents and post-adolescents, age 15-24), Novi Sad (Center for child and adolescent psychiatry), Nis (Depart-ment of neurology and psychiatry of developmental age – for children and adolescents under 18) and Bor (Section for child psychiatry and developmental psychology). Observation: existing hospital units mostly treat children and adolescents (under 18) jointly, frequently both those with neuro-logical and with mental disorders together. Only one institution


105

deals exclusively with adolescents and post-adolescents (under 24). The total number of beds for children and adolescents: about 70.

b. Day hospitals for children and adolescents (2) exist only in Bel-grade and Novi Sad

c. Outpatient services for adolescents also exist only in the largest centers – cities, whether in psychiatric departments, or within health centers.

d. The majority of regions in Serbia lack in mental health care ser-vices for adolescents, as well as in trained mental health profes-sionals dealing exclusively with this population.

NON-GOVERNMENTAL ORGANIZATIONS According to the data that were hard to attain and that are probably

incomplete, very few non-governmental organizations have specific, organ-ized and continual programs and projects intended for adolescents with psy-chological problems or mental disorders.

Analysis has proved that the present number and level of health care services, as well as non-governmental organizations dealing with mental health problems of adolescents is absolutely insufficient and/or impractical to meet the needs of this population.

Based on all the presented elements and analyses, the Expert sub-committee for mental health and development of adolescents has proposed the following measures and the strategy for promotion of services and pro-grams providing help and treatment of adolescents with psychological prob-lems and mental disorders.

1. Supporting efforts and activities of the National Committee for Mental Health of the Republic of Serbia Ministry of Health, particularly in the area of establishing Mental health centers, since they will also include teams of professionals and organizational units intended for children and adolescents;

2. Increasing preventive and therapeutic potential of the primary health care by providing the health center personnel (general practitioners, pediatrists and coworkers) with additional training related to mental problems of adolescents;

3. Creating and training adolescent mental health care teams or counseling units within larger health centers, with the possibilities of providing psychological-psychiatric support or assisstance;

4. Empowerment and assisstance (regarding personnel, organization and space) to the existing hospital units for mental health problems of adolescents and their separation from the children’s units, as well as from children and adolescents with neurological disorders;


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5. Opening new hospital units for the treatment of adolescents (age 15-24) in all medical centers/general hospitals in larger towns, with the capacity of 4-6 beds;

6. Professional assisstance and support to non-governmental organizations and their programs and projects for the provision of psychological help and support to adolescents;

7. Campaigns against stigmatization of mental health disorders in adolescents;

8. Creating the possibility for young people to obtain psychological support and assistance outside health care and psychiatric institutions – in schools, students’ dorms and boarding schools, and also through the establishment of counseling units in towns – outside any kind of institutions;

9. Peer training and the development of peer support system for adolescents with psychological dillemmas and problems;

10. Working on the primary prevention of mental disorders in adolescents through the educational system (additional information and education of teachers, school psychologists, pedagogues and parents) and all types of mass communication (informing the public on the specific traits of adolescence as a developmental period and the adolescents’ needs and options regarding psychological help).

Adolescence as the chance for mental health Adolescence is a developmental period with considerable potential for

changes, both the natural ones, common for the adolescent process, and the changes that imply disorders and pathology. Some changes occur spontaneously or with assisstance of the adolescent’s immediate surroundings, and some can be provided by different types of professional interventions. Certain psychosocial dysfunctionalities in adolescents or psychopathological manifestations can be reduced, but some can be corrected more radically and lastingly. For that reason, it would be benefitial for most adolescents with problems if the professionals would not focus on mere reduction or withdrawal of symptoms and suffering, but instead try, through psychotherapeutic work or process, to enable the adolescents to correct their intrapsychic dynamics and the dynamics of psychological functioning that preceded or caused the problem (4).

Pharmacological therapy can, of course, be used to reduce the symptoms and ensure better functionality. Other professional interventions (aimed at school, work environment, etc.) can also help the adolescent in overcoming certain problems and, most of all, situations. Psychotherapy, however, especially analytically oriented, has the potential to clear and work through some of the developmental difficulties, certain structural discords and unconscious psychodynamics that caused the problems of adolescents.


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This is the way to correct and/or eliminate the factors that disturbed normal developmental processes of adolescents and clear their path to maturity, independence and adult functionality. With this in mind, adolescence can be seen as the chance not only for overcoming the current psychological problems and psychopathology, but also for the future good psychosocial functioning and good mental health.

______________________

Prim. dr Vojislav ĆURČIĆ, dr sci med, psihijatar – psihoanalitičar, direktor Klinike za psihijatriju Kliničko-bolničkog centra „Dr Dragiša Mišović-Dedinje“, Beograd

Prim. Vojislav CURCIC, MD, PhD, psychiatrist – psychoanalyst, director of the Psychiatric Clinic, at the “Dr Dragisa Misovic-Dedinje“ Clinical Hospi-tal, Belgrade e-mail: [email protected]

References 1. Jeammet P. Adolescence et processus de changement. In: Widlöcher

D. Traité de psychopathologie. Paris: Presses Universitaires de France; 1994. p. 687-726.

2. Jacobson E. The Self and the Object World. New York: Interna-tional Universities Press; 1964.

3. Ćurčić V. Adolescencija u posebnim okolnostima: dvostruka konfuzija. In: Erić Lj, Ćurčić V (eds). Adolescencija: identitet –psihopatologija – psihoterapija, Beograd: IP Žarko Albulj; 1997.p.189-193.

4. Ćurčić V. Adolescenti između svemoći, nemoći i lekova. In: Ćo-rić B (ed). Čovek i lek. Beograd: Institut za mentalno zdravlje; 2004. p. 171-180

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