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 Table of Contents  
INVITED PERSPECTIVE/VIEWPOINT
Year : 2021  |  Volume : 37  |  Issue : 4  |  Page : 352-359

Psychiatric rehabilitation in indian general hospital psychiatry unit settings


1 Department of Psychiatry, Psychiatric Rehabilitation Services, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
2 Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
3 Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
4 Nursing, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Submission06-Nov-2021
Date of Acceptance07-Nov-2021
Date of Web Publication25-Nov-2021

Correspondence Address:
Dr. Thanapal Sivakumar
Department of Psychiatry, Psychiatric Rehabilitation Services, National Institute of Mental Health and Neuro Sciences, Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_318_21

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  Abstract 


In India, General Hospital Psychiatry Units (GHPUs) are the backbone for mental health care. GHPUs have less stigma, facilitate inter-specialty collaboration, and provide integrated mental and physical healthcare. GHPUs offer a predominantly medical model of care and face multiple challenges in offering psychiatric rehabilitation, including a severe crunch of human resources. This article summarizes the basic concepts of psychiatric rehabilitation, possible rehabilitation interventions in resource-constrained settings, and interventions that can be delivered with the help of caregivers and frontline mental health workers. The article concludes with some of the pragmatic indigenous models of psychiatric rehabilitation at GHPUs.

Keywords: Caregivers, general hospital psychiatry units, liaison, psychiatric rehabilitation


How to cite this article:
Sivakumar T, Roy A, Reddy K S, Angothu H, Jagannathan A, Muliyala KP, Bhola P, Gandhi S, Kumar D. Psychiatric rehabilitation in indian general hospital psychiatry unit settings. Indian J Soc Psychiatry 2021;37:352-9

How to cite this URL:
Sivakumar T, Roy A, Reddy K S, Angothu H, Jagannathan A, Muliyala KP, Bhola P, Gandhi S, Kumar D. Psychiatric rehabilitation in indian general hospital psychiatry unit settings. Indian J Soc Psychiatry [serial online] 2021 [cited 2021 Nov 30];37:352-9. Available from: https://www.indjsp.org/text.asp?2021/37/4/352/331127




  Introduction Top


A General Hospital Psychiatry Unit (GHPU) is the psychiatric wing in a general hospital or medical school.[1] GHPUs are currently the face of psychiatric care in India and have taken psychiatric care to the population. GHPU is the leading source of mental health care, training, and research.[2] GHPU has less stigma, facilitates inter-specialty collaboration, and is a predominant model of providing integrated mental and physical healthcare.[3] GHPU delivers one or a combination of clinical services, including outpatient, inpatient, emergency services, specialty clinics, consultation-liaison psychiatric services, and community outreach. GHPU services are offered within public, private, corporate, charitable trust-run general hospital settings, and medical colleges.

There is considerable heterogeneity in the conceptualization of what constitutes psychiatric rehabilitation. Many people equate rehabilitation with long-term residential care facilities, day-care, skills training, or job placement. In simplest terms, rehabilitation enables disabled people to achieve their life goals. Life goals are unique to a person's life situation and aspirations, including having friends, getting a job, learning to sing, being respected by others, or being independent. The World Health Organization Community-Based Rehabilitation matrix[4] conceptualizes a multi-dimensional rehabilitation model comprising five key domains: Health, Education, Livelihood, Social, and Empowerment [Figure 1]. Psychiatric rehabilitation comprises “coordinated and comprehensive behavioral services that enable the person with psychiatric disabilities to perform those cognitive, emotional, social, intellectual, and physical skills needed to live, learn, work, and function in the community as normally and independently as possible.”[5]
Figure 1: World Health Organization Community based rehabilitation Matrix

Click here to view


It is unequivocally proven that patients with psychiatric disorders have better outcomes with rehabilitation inputs.[6],[7] Therefore, psychiatric rehabilitation needs to be a part of the patient's management plan right from the first contact. In this background, GHPUs must offer psychiatric rehabilitation assessments and interventions regularly.


  Psychiatric Rehabilitation in India Top


In India, psychiatric rehabilitation is still in its infancy. There are negligible institutional-based rehabilitation facilities in the country, and they are predominantly centered in mental hospitals and Nongovernmental Organizations (NGOs) in South India[8] and select GHPUs. On the other hand, the Mental Health Care Act, 2017 mandates that the government makes provisions for offering hospital-based and home-based rehabilitation services for persons with mental illness.[9] The other rehabilitation services are half-way homes, sheltered accommodation, supported accommodation, and community-based rehabilitation.[9]

Though rehabilitation is an essential component of psychiatric management, it is often misconstrued as a last resort for patients who do not get better with treatment and/or are treatment failures in India. The primary reason for such a dismal scenario is poor awareness about psychiatric rehabilitation among patients, caregivers, and even Mental Health Professionals (MHPs). It is often neglected in routine clinical practice due to multiple challenges, including lack of clarity on the concept of rehabilitation, lack of training, lack of resources, and pessimism regarding the impact of rehabilitation interventions.


  Psychiatric Rehabilitation Assessment and Interventions Top


Unlike diagnostic assessments that focus on eliciting symptoms and deficits, rehabilitation assessment aims to understand the person's overall needs. Both the patient and family members are enquired about the perceived rehabilitation needs. For this, additional history on the patient's aspirations, life goals, available opportunities, efforts made, challenges encountered, and lessons learned are collected. The strengths of the person, family, environment, community support systems, socio-cultural norms, and social networks are assessed. The nature of rehabilitation inputs varies as per the strengths and priorities of the patient.

The MHP helps the patient prioritize the goals and prepare an action plan in discussion with the family based on the assessment. The MHP plays a facilitatory role in accomplishing those goals. Execution of plan requires effective coordination between different stakeholders such as family, friends, neighbors, teachers, employers, NGOs, colleagues at the workplace, and various MHPs. For example, for a patient who wants a job, details of work history, reasons (if any) for discontinuation or job change, and challenges faced at the workplace are collected. Based on the findings, the patient may be recommended vocational skills, or social skills assessment and training (for those who have never worked before), or efforts can be directed towards sheltered or supported employment (for those who worked before, however, currently not working). Similarly, a patient who could not complete a college education may need help in joining a course according to interest, ability, and availability. Likewise, a homeless patient will need a safe shelter, treatment, and reintegration with family.

Before delving into various aspects of rehabilitation interventions, a few things warrant a mention: (a) The agency of change for rehabilitation lies with the patient. She/he cannot be rehabilitated against her/his wishes. Thus, a pre-requisite for success in rehabilitation is the “perceived need for change” on the patient's part. Unless the patient is “rehabilitation ready,” the interventions are unlikely to succeed[10] (b) rehabilitation is a slow process of building upon incremental benefits. One needs to be persistent, innovative, and flexible in the recovery journey. Optimism and the ability to learn from failure are essential.


  Psychiatric Rehabilitation Interventions at General Hospital Psychiatry Units Top


Many psychiatric rehabilitation interventions have been deemed possible in a GHPU setting. These interventions can be individual-, family-, or community-centered. Examples of individual-centered interventions are motivational interviewing, functional assessment, skills training (social, daily living, vocational), and recreational therapy. Family-centered interventions include family therapy, family training programs, formulating self-help groups, and networking with various agencies to strengthen the family support system. Community-based interventions include community awareness programs, community mobilization and resource utilization, and home-based rehabilitation.[11],[12],[13]

The question is, which of these interventions are feasible in a GHPU setting? The following are some, rather pragmatic, suggestions to offer psychiatric rehabilitation in GHPU settings. We have started with easier interventions that are possible with a limited number of MHPs and ascended to interventions that might need multi-disciplinary MHPs or leveraging other human resources or liaison and networking. Any MHP can carry out these interventions.

Single session rehabilitation counseling

Single-session rehabilitation counseling can be considered in busy centers without enough human resources.[14] The objectives of single session rehabilitation counseling are to understand the awareness among caregivers about rehabilitation, provide information about rehabilitation services, assess their available resources, assess the patients' abilities, and generate a rehabilitation plan. It is not a solution for all the issues related to rehabilitation. Still, it ensures that patients and caregivers are provided with important information which would be helpful in the recovery process.

Outpatient rehabilitation counseling for caregivers of persons with developmental disabilities

An outpatient-based rehabilitation counseling can be helpful for caregivers having persons with developmental disabilities covered under the National Trust Act, 1999 (viz., intellectual disability, autism, cerebral palsy, and multiple disabilities). Information on various rehabilitation services and facilities available can be discussed with the caregivers. Some of these are:

  • The National Trust website[15] offers details of NGOs registered under the act at the state and district levels. Persons with developmental disabilities can be referred to the nearest National Trust registered organization
  • The MHP can educate caregivers to access various welfare schemes, including the Niramaya health insurance scheme[16]
  • Caregivers can be encouraged to be part of a parent's association – “Parivaar“ (www.parivaarnfpa.org). This will facilitate awareness and peer learning for the caregivers[17]
  • Patients coming from rural areas can be referred to District Disability Rehabilitation Centre to facilitate comprehensive rehabilitation services
  • Caregivers can be guided to access resources of various central government institutes, including the National Institute for the Empowerment of Persons with Intellectual Disabilities (divyangjan) and NIEPMD National Institute for Empowerment of Persons with Multiple Disabilities available at their website
  • The resource materials developed by psychiatric rehabilitation services (on welfare benefits, what after me? Issues and guardianship) and the mental health education department of NIMHANS can be accessed at https://nimhans.ac.in/psychiatric-rehabilitation-2/resource-materials-psychiatric-rehabilitation/and https://mentalhealtheducationnimhans.org/respectively. The resources are free to download and use.


Disability certification and unique disability ID card

Unique Disability ID (UDID) is a digitally generated disability certificate. A disability certificate is needed to avail various welfare benefits for persons with benchmark disabilities. In India, awareness about disability certification/UDID and welfare benefits among patients and MHPs is low. Although government GHPUs cater to a reasonably good number of patients,[3] the number of disability certificates issued is relatively meager compared to mental hospitals.[18],[19]

Most government GHPU may be authorized to issue disability certificates. Others need to liaison with nearby government hospitals which issue disability certificates.[20] The MHP can initiate the certification process for eligible patients. Information about getting the UDID online can be displayed on notice boards for the patients visiting the outpatient services at GHPU.

Welfare benefits for persons with benchmark disabilities

The central and state government offers welfare benefits for persons with benchmark disabilities (40% and above disability), including disability and unemployment allowance, travel benefits (concessional bus pass and train concession), income tax deduction, and pension transfer. These welfare benefits vary state-wise. MHP must counsel the patient and caregivers about the welfare benefits available in respective states. A poster with details about the welfare benefits available in the respective state can be exhibited in the outpatient complex. Patients with good family income can benefit from the income tax deduction, whereas patients with low family income can benefit from a disability pension and an unemployment allowance. An MHP can guide eligible patients to avail the disability pension.

Keep a record of patients requiring rehabilitation inputs

A list of patient details requiring additional rehabilitation inputs can be maintained. This will help plan for offering interventions. Such a list can initially be maintained for inpatients and later be expanded for outpatients depending on available resources.

Use goodwill to help needy patients

Every MHP would have encountered situations where the family of a recovered patient wants to do something as they received help at a critical juncture. Such patients and family members can be suggested to help needy patients (e.g., providing free medication, employing a recovered patient, sponsoring education or training).

Involve caregivers

Caregivers are a crucial asset for the rehabilitation field as they have the lived experiences of caring for persons with psychiatric disabilities. The caregivers can be helpful in the rehabilitation process in two ways: (a) Assisting the MHP team in designing, developing, and implementing various rehabilitation programs as they have first-hand experience of helping the patient in solving their problems on an everyday basis, and (b) delivering some of the interventions with their assistance. The first requirement is periodic caregiver education and support programs to seek assistance in designing, developing, and implementing various rehabilitation programs. It will help them understand the need for a systematic rehabilitation process and motivate to get involved in rehabilitation-focused activities. For example, the caregivers can be encouraged to start NGOs[21] that help in rehabilitation initiatives of the GHPU. As mentioned, due to their lived experience, they are likely to know what works well under what circumstances. Willing caregivers can also be hired and trained on-job as vocational trainers, job coaches, or administrative staff. An MHP can formulate caregiver advocacy groups to share their practical experiences and mentor various awareness and empowerment programs. The aim should be to ensure inclusion, equity, respect, and a rights-based approach for patients in society.

Caregiver-assisted cognitive remediation

So far as delivering some of the interventions with the help of caregivers is concerned, the issue of resource crunch (both in terms of trained workforce and money) can be tackled in a major way if such focused intervention modules are developed that can be delivered through the caregivers with the minimal supervision of the MHPs. Delivery of a caregiver-assisted home-based cognitive remediation program is one such example. It is unequivocally proven that individuals with severe mental illnesses, especially schizophrenia, have widespread cognitive deficits that create significant hurdles in their everyday functioning and employability.[22],[23],[24] Thus, it has a direct adverse impact on the rehabilitation process. It is also proven that systematic cognitive remediation activities reduce the cognitive deficits and help the patients develop compensatory approaches to the deficits if needed.[25],[26] However, cognitive remediation programs are resource-consuming as the patients need to visit the clinicians several times a week for many weeks. Thus, neither many patients can afford this intervention, nor an MHP can offer this service to many patients. Therefore, given its importance, of late, there is an emphasis on developing such cognitive remediation modules which can be delivered with the help of caregivers.[27],[28] Our pilot study[28] found that the caregiver-assisted cognitive remediation is as effective as clinic-based cognitive remediation program. It is worth highlighting here that while developing any caregiver-assisted interventions, it is imperative to keep in mind that it is not too taxing and time-consuming for the caregivers. If it compromises their everyday activities (e.g., going to work) in a significant way, they are less likely to get involved in such activities.

Patient and caregiver-led livelihood initiatives

At many rehabilitation centers, patients and caregivers run café or canteens. While at many other centers, patients sell beverages and snacks at the outpatient complex.[29],[30] Similar initiatives can be adopted at GHPU, wherein recovered patients can be encouraged to start a small venture, such as having a coffee vending machine in outpatient premises. A patient can be trained in simple activities such as preparing paper bags for dispensing medications or gift items. Nearby pharmacies or gift centers can be requested to procure these paper bags made by the patient. Vocational sections such as bakery, tailoring, carpentry, and printing can be initiated to meet hospital demands and involve patients in work. MHP can also help meet the livelihood needs of patients by facilitating self-employment or supported employment as per the patient's ability and requirement.

Referrals to utilize government schemes

“Pradhan Mantri Kaushal Vikas Yojana (PMKVY)” is an initiative under the Ministry of Skill Development and Entrepreneurship for free training of any unemployed Indian citizen aged 18–35 years. The PMKVY website provides details of centers and vocational courses.[31],[32] MHP can liaise with nearby PMKVY centers for eligible patients. Initially, high-functioning patients can be referred to avoid organizational resistance. Regular follow-ups must monitor the patients' progress and any challenges the patient or the organization face. Once the arrangements are in place, other patients can be referred gradually.

Start a day-care center

In general, the stay of inpatients in GHPUs is limited till symptomatic control. It is difficult for GHPU settings to carry out all the rehabilitation interventions within this limited time frame. Thus, having a day-care will spare additional time to deliver structured rehabilitation services. Day-care programs are not expensive and can benefit many patients/family members in gaining psychosocial skills and empowerment. It is desirable to have sections that teach market-relevant skills. This boosts the chances of patients securing jobs in the open market. The type of sections chosen may depend on the local job market. A profitably run vocational therapy unit ensures regular work, positive word of mouth publicity, and teaches good work ethic to the patients. Shihabuddeen and Mehar[33] have emphasized that starting a day-care “may not require huge funds but rather require additional effort and zeal.” Exposure to day-care settings can lead to many direct and indirect benefits, such as day-structuring, improvement in socio-occupational behavior, and a family's positive attitude towards illness.[34],[35]

Utilizing corporate social responsibility funds

Many Indian corporates have come forward to address issues related to mental health. corporate social responsibility funds can be utilized in multiple ways to promote the psychiatric rehabilitation of patients. These funds can be used to set up a day-care and half-way homes, conduct awareness and community outreach programs, sponsor medications or skills training, and conduct other programs or interventions. Other strategies to ensure funding for rehabilitation services include seeking donations and funds to develop resources/services.

Home-based rehabilitation

A plan of activity can be made by MHP to keep the patient productively engaged at home. The day-structuring activities must be planned based on the patient's interests and capabilities. The activities can be a combination of skills training, informational, and recreational activities.

Liaison and networking with stakeholders

A resource map of facilities available in the locality, including details of organizations working for patients with psychiatric disabilities, special schools, training centers, socially conscious entrepreneurs, and influential people (including district health officer/Taluk Health officer, disability welfare officer) can be prepared. Periodic meetings and constant communication with all concerned stakeholders are helpful and must be encouraged. Recognizing the vital role of different stakeholders and treating them as equal partners is quintessential for the psychiatric rehabilitation field. Networking with multiple stakeholders translates to awareness, cooperation, and a strengthened support system for patients and their families in the community. Liaison and networking with various stakeholders can comprise the following:

  • Liaison with community volunteers who offer their services (including arranging free medications, offering food, helping with needs like paying a bill, arranging a job etc.) to the needy and less fortunate in their community
  • Liaison with local employers and corporate chains to employ recovered patients
  • Liaison with existing organizations like Lion's club/Rotary club to involve them in mental health-related activities
  • Liaison with local government officials, religious organizations, and not-for-profit clubs/organizations opens many options and resources for patients.


Partnership with nongovernmental organizations

Partnership with NGOs working in the disability sector is beneficial for facilitating psychiatric rehabilitation interventions and community integration of patients.[36] Liaison with organizations that work for people with physical disabilities helps build links with the disability sector and facilitates patients benefit from the best practices. This is a potential opportunity whose true potential has not yet been realized.

Partnership with NGOs can be considered to offer rehabilitation services, including day-care, special schools, long-term residential facilities, and vocational sections. Many such organizations get Income tax exemption certificates for donations. An MHP can do a heath camp or workshop at various mental health NGOs and invite them to discuss their services and schemes. Many NGOs are also involved in manufacturing various products as a part of vocational training or sheltered work. Certain items required for organizing conferences and functions can be procured from these NGOs, such as notepads, pens, gift items, and snacks. Partnering with an NGO with business acumen can also be considered to design work programs for patients.[37] The collaboration helps to bank on the technical expertise of the NGO in choosing and preparing a marketable product and using marketing strategies to reach out to the public. NGOs can also help to provide funding assistance for initiating such work programs.

When adequate human resources are available, more resource-intensive rehabilitation interventions including supported employment,[38] supported education,[39] social skills training,[40] self-help groups,[41] half-way home, and long-stay residential facilities[42] can be offered.


  Challenges in Offering Psychiatric Rehabilitation in General Hospital Psychiatry Units Top


Most GHPUs are run only by psychiatrists and nurses. They do not have the luxury of a multidisciplinary team comprising MHP from the field of clinical psychology, psychiatric social work, psychiatric nursing, or other associates such as occupational therapists (OT) and vocational trainers. Consequently, GHPU predominantly follows a medical model, and psychiatric rehabilitation interventions are often overlooked or considered the last resort in management.[2],[3] Other documented challenges in offering psychiatric rehabilitation are lack of standard practice guidelines, minimal or informal training in psychiatric rehabilitation, lack of awareness, and poor utilization of existing services.[3],[11]

Human resource constraints, including the dearth of trained psychiatric rehabilitation professionals, an inadequate number of rehabilitation practitioners, and lack of coordination among team members, are the primary causes of ignoring and disregarding psychiatric rehabilitation at GHPUs.[2],[11]


  Additional Human Resources for Rehabilitation in General Hospital Psychiatry Units Top


As is evident from the above discussion, offering rehabilitation requires additional human resources. To begin with, GHPUs run exclusively by psychiatrists may consider recruiting a psychiatric social worker or a trained medical social worker proportionate to the number of psychiatrists to offer various community-based rehabilitation interventions, liaisons, and networking with stakeholders/organizations. Over a period, other team members can be recruited. The government needs to come up with norms for human resources at GHPUs for delivering rehabilitation services.

Most postgraduate students (especially psychiatrists) are usually not exposed to psychiatric rehabilitation practices during their training resulting in them not including rehabilitation as part of their clinical practice when they become practitioners. Adequate exposure to rehabilitation practices by encouraging a posting to rehabilitation centers (sometimes in the same city) is an opportunity to inculcate a rehabilitation orientation and practice rehabilitation interventions during training. While many GHPUs in medical colleges offer postgraduate psychiatry courses,[2] some GHPU centers of excellence have recently started postgraduate courses in clinical psychology, psychiatric social work, and psychiatric nursing. This will increase human resources to offer psychiatric rehabilitation interventions in the country.

OT is generally underutilized in the Indian psychiatric rehabilitation setting apart from some exceptions like Christian Medical College, Vellore. OT students can be posted in psychiatry wards as part of their internship and can help inpatients with activity scheduling and advice regarding vocational rehabilitation. Vocational instructors can be recruited when daycare centers are opened.

There is a need for a close liaison with personnel working to rehabilitate physical disabilities (like physiotherapists who are likely to be present in most GHPUs). In addition, MHPs can also liaison with social workers under district mental health program, personnel from the government disability sector (including village rehabilitation workers and multipurpose rehabilitation workers), other existing government services such as Rashtriya Bal Swasthya Karyakram[43] and Rashtriya Kishor Swasthya Karyakram.[44]


  Pragmatic Indigenous General Hospital Psychiatry Units Rehabilitation Models Top


The Disability Assessment, Rehabilitation and Triage (DART) services (Government Medical College and Hospital [GMCH], Chandigarh) and “Hombelaku“-a residential rehabilitation center (Kasturba Medical College, Manipal) are examples of indigenous GHPU based rehabilitation models.

DART, a part of GMCH, Chandigarh, is a daycare-based rehabilitation setting that runs various clinics such as crisis resolution and home-based treatment, neurocognitive rehabilitation clinic, vocational rehabilitation clinic, placement cell, social skills clinic, disability clinic, and occupational health services.[45] Many rehabilitation services are offered in collaboration with NGOs “Parivartan“, “Umeed“ and “Prayatan“. Project “Umeed“ (the brainchild of Late Professor Bir Singh Chavan, Director-Principal, Professor and Head, Department of Psychiatry, GMCH) is an innovative and sustainable model of facilitating livelihood, wherein ice-cream kiosks were set up across the city. A patient-caregiver pair run the kiosks, and they are remunerated monthly, based on profits. A mobile catering van – “Umeed food express” operated by 3–4 patients offers fast food within the city.

Hombelaku (meaning “light with golden hue” in Kannada) is a medium to long-term residential-based rehabilitation setting for persons with chronic mental illness.[46] The center has separate residential wings for men and women. Individualized rehabilitation programs are planned and administered by a team of psychiatrists, psychiatric social workers, clinical psychologists, psychiatric nurses, OT, and case managers. The patients follow a daily routine of activities. They are trained in daily living skills and vocational skills (tailoring, baking, crafts) and are involved in recreational and outdoor activities (games, gardening, picnics). They are also involved in individual and group therapies. Community integration and work placement are facilitated.

In the state of Karnataka, some GHPUs (Bangalore Medical College and Research Institute, Bengaluru; Jawaharlal Nehru Medical College, Belagavi) run day-care centers as part of “Manasadhara” initiative (one community mental health day-care center for each district, run by NGOs, and funded by the Ministry of Health and Family Welfare, Government of Karnataka).


  Need for Leadership and Collaboration Top


An understanding that a proportion of patients cannot be helped with medical interventions alone has motivated psychiatrists to envision and develop the services mentioned above beyond the traditional medical model of care offered in GHPUs. Besides, their wisdom in recognizing the invaluable role played by different stakeholders and treating them as equal partners is noteworthy. Having a committed and dedicated team is critical. The quality and synchronization of team efforts influence the rehabilitation outcomes. This necessitates that the team leader ensures the best utilization of available human resources and coordinated team services.

Principled leadership is needed to instill mutual trust and respect among team members. Clear role demarcation helps streamline efforts and utilize resources better. Intelligent human/financial resource management and public relation relationship skills are necessary. Transparency, equality, honesty, differential reinforcement for efficiency, and effective grievance redressal help keep up the team morale. Periodic meetings, work reviews, openness to criticism, and willingness to apply corrective measures will help improve the team's efficiency.


  Conclusion Top


There is a need to transform mental health services from the current focus on treating symptoms and crisis intervention to helping people lead meaningful lives in their communities. GHPUs have a crucial role to play in this transformation. It is not the resource constraints but the attitudinal barriers and hesitation that often hinder the adoption of rehabilitation outlook and execution. Once started on a positive note, resources often fall in place.

Considering challenges faced in practicing evidence-based psychiatric rehabilitation interventions and the dearth of trained professionals to deliver such interventions, there is a need to develop and document innovative, socio-culturally appropriate psychiatric rehabilitation models, including challenges faced and solutions to handle. Documenting the real-world experiences helps to build “practice-based evidence.” The examples of Chandigarh, Manipal, Bengaluru, and Belagavi provide models to follow. MHPs in GHPUs may adopt some of the practices mentioned above that they think are feasible in their setting and document the outcomes.

A journey of thousand miles starts with a single step. Rehabilitation is a series of small steps with long pauses in between. Every small step for psychiatric rehabilitation is expected to improve outcomes for our patients.

Acknowledgments

The authors would like to acknowledge valuable inputs from Prof. Jagadisha Thirthalli to improve the draft.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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