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Clinical practice guidelines on assessment of needs among persons with mental illness and persons with substance use disorders with long stay in psychiatric institutions

2025; Medknow; Volume: 67; Issue: 1 Linguagem: Inglês

10.4103/indianjpsychiatry.indianjpsychiatry_687_24

1998-3794

Hareesh Angothu, Venkata Lakshmi Narasimha, Krishna Prasad Muliyala,

Mental Health Treatment and Access

INTRODUCTION The term long stay or extended stay or prolonged stay has been variously defined in the context of psychiatric hospitalization. While more than 1 year of stay in psychiatric hospitals has been considered as long stay, other definitions of long stay have been 5 years in medium secure and 10 years in high secure care settings.[1] However, persons with mental illness may rarely require more than 90 days of continuous hospitalization. Section 90 (8) of the Mental Health Care Act (MHCA) 2017 states that if more than 30 days of supported admission is required, the need for such admission should be limited to 90 days in the first instance.[2] We have used the term long stay to denote more than 90 days of hospitalization in psychiatric hospitals and when discharge is not possible due to deficiencies in support systems – absent family caregivers or unwilling family caregivers or lack of a safe place to live or challenges in independent living ability if they were to live alone in the community. "Need" is the requirement of the individual that enables them to achieve, maintain, or restore an acceptable level of social independence or quality of life.[3] "Need" is the discrepancy between the current and desired states.[4] While the needs of the long-stay patients are diverse, a broader goal is recovery. The needs of persons with mental illness and substance use disorders (SUDs), as well as the support they require, can vary significantly depending on their underlying mental health conditions, personality traits, and psychosocial circumstances. In this article, we have arranged the needs assessment of persons with severe mental disorders (SMD) like schizophrenia and related disorders and bipolar affective disorders (BPADs) separately from the needs assessment of persons with SUDs. However, such a distinction is artificial; often, there would be similarities rather than differences between needs, and SMD and SUD can co-occur. PROCESS OF DEVELOPMENT OF GUIDELINES A PubMed search using relevant terms of needs, long stay, severe mental illness, and substance use disorders was conducted – ("Health Services Needs and Demand"[MeSH] OR "Needs Assessment"[MeSH]) AND ("Long-Term Care"[MeSH] OR "Length of Stay"[MeSH]) AND ("Mental Disorders"[MeSH] OR "Psychotic Disorders"[MeSH] OR "Schizophrenia"[MeSH]) AND "Substance-Related Disorders"[MeSH]. A gray literature review of various government documents and independent documents from various NGOs and consultation with domain experts were done to develop the Clinical Practice Guideline. The purpose of the assessment of needs among persons with SMD or SUD in long stay can be for any one or more of the following: discharge from hospital and community reintegration, to provide least restrictive environment, and to provide a participatory, rights-based and recovery-oriented care that is holistic and person-centred care and with a focus on psychological, lifestyle, social, and economic interventions, not merely pharmacological interventions. NEEDS OF PERSONS WITH SMDS IN PSYCHIATRIC HOSPITALS The judiciary and the National Human Rights Commission (NHRC) have played a significant role in transforming psychiatric hospitals in India. The NIMHANS/NHRC report of 1999 noted violations of the rights of patients, deficiencies in infrastructure, lack of trained staff, and absence of psychosocial interventions.[5] Both governmental initiatives and the intervention of the NHRC resulted in a marked improvement in the infrastructure, hygiene, availability of drugs, and living conditions in many of the hospitals over the next decade. An in-depth analysis by NIMHANS for the National Commission of Women (NCW) in 2016 recommended that long stays of women must be discouraged in psychiatric hospitals.[6] The Hans Foundation study in 2019 involved a survey of 43 psychiatric hospitals across India and observed that 4935 patients stayed on average for more than 6 years in the closed wards. About one-third of them were admitted by their family members in the psychiatric hospitals. This report further stated significant variations in the number of patients across India. Maharashtra, Tamil Nadu, and West Bengal had over half of all long-stay patients. This report further stated that half of long-stay patients had schizophrenia, 22% had intellectual disability (ID), and 17% had psychosis, not otherwise specified.[7] A range of reasons can contribute to the extended stay of persons with SMDs in psychiatric hospitals. In many instances, family caregivers remain untraceable for a planned discharge and to ensure family reintegration.[8,9] Poor social functioning and independent living abilities have been observed in patients admitted for longer periods.[10] Persons with SMDs may have one or more medical conditions that require frequent medical supervision, or they may have patterns of behavior that pose significant challenges for living in supported living facilities.[11] Negative symptoms of schizophrenia have been observed to be associated with unmet rehabilitation needs.[12] SMD patients may have cognitive impairment with a range of medical problems that interfere with their ability to live independently in the community.[13] Lack of homes to live in and poor community living facilities for persons with SMDs could contribute to prolonged stays.[14] Apart from the individual characteristics like age at the time of admission and functional ability, intellectual disability, personality characteristics, socioeconomic issues, and institutional characteristics, such as whether the institute is an academic institution, appear to play a role in the extended stay of persons with SMDs.[15] Irrespective of a range of reasons contributing to the long stay in psychiatric hospitals, many persons with SMDs were observed to have the ability to live independently if a safe place to live was offered with an adequate range of required support.[16] The extended stay in psychiatric hospitals is multifactorial, ranging from patient characteristics that impact the ability to live a quality life post discharge to the availability of adequate and appropriate community mental health care facilities. Therefore, to understand the needs of long-stay persons with SMDs in psychiatric hospitals, we should examine it from a multidimensional perspective. Often, the needs of persons with SMDs during the initial period of psychiatric hospitalization are related to the control of symptoms irrespective of their clinical diagnosis. It includes improving the disturbances in biological functions and challenging behaviors, thoughts, or perceptual disturbances that may endanger their safety and others. The need to stay in psychiatric hospitals for a long time is often related to morbidities, strengths and deficits, socioeconomic situations, homelessness, family support, substance use, availability of community care facilities, and access to such facilities. Section 98 of MHCA 2017 has stated that the treating psychiatrist in any mental health establishment (MHE) should plan the continuity of mental health care after understanding the choices of persons with SMDs, discussing with relevant mental health professionals in the community where the person with SMD will reside, and the caregivers/family members/nominated representatives.[2] Following these steps for the discharge planning of persons with SMDs who do not have family caregivers can be challenging. Assessment of the needs of long-stay patients may be conceptualized as belonging to two categories. One category of evaluations would be related to the severity of mental illness, activities of daily living, meaningful engagement, and level of awareness about the need for mental health care and treatment. Another category is related to their ability to return to work, reality orientation, strengths and deficits that influence their ability to make choices, and support in the place where they will stay after discharge. However, assessment of needs only helps to understand the types of support and intensity of support needed for persons with SMDs. A range of community-based mental health care services will be essential for offering continued care. Often, such assessment should also include the readiness of persons with SMDs to go back into the community as prolonged stays in psychiatric hospitals may lead to the development of pessimistic attitudes toward living in the community.[9] A few other assumptions or even experiences of psychiatric hospital authorities that could prolong the stay are related to frequent and repeat hospitalizations, which further could be related to poor symptom control and personality trait-related challenges to adjust in the community. A slow transition through various community care facilities will likely enhance community reintegration.[17] The needs assessment should be person-centered as significant differences have been observed between the self-reported needs and those assessed by professionals.[16] The Hans Foundation survey, 2019, stated that about 80% of persons with mental illness staying in psychiatric hospitals for more than 1 year were likely to face mild to moderate challenges in leading a quality community life, and the remaining 20% were likely to face severe to profound difficulties if left alone. They all required some form of support of variable frequency and intensity. Based on our experience, we have formulated a model [Figure 1] in which the PMI can move to any standard living options, subject to the availability of a range of supports and services, personal preferences, and functional abilities. Persons with SMDs can move from one option to another as each option offers a range of freedom, restrictions, and scope for exercising their choices and autonomy.Figure 1: A model to describe the transition of Persons with Severe Mental Disorders (SMD) requiring continuous supportTo understand more about the suitability of long-stay patients to be transitioned, mental health professionals should know not only the strengths and deficits of the persons but also the availability of community mental health care facilities in a geographical location. A simple and generic approach that may be considered for comprehensive needs assessment is the World Health Organisation Community-based rehabilitation matrix, which includes health, education, livelihood, social, and empowerment components.[18] A comprehensive assessment might require several interactions with the person and other important stakeholders. The following tools [Table 1] can be helpful to mental health professionals/trainees to have a broader understanding of the multidimensional needs of persons with SMDs staying in psychiatric hospitals for a prolonged period. However, these tools cannot replace the subjective judgment established collaboratively through an understanding of the pragmatic needs and rights.Table 1: List of tools for assessment of support needs before dischargeAssessment of capacity to make treatment choices and decisions Simple open-ended screening questions such as 'why might it be difficult for you to manage safely at home?' for decisions regarding placement and 'what is this treatment about?' for decisions about treatment may be used.[19] Capacity Assessment Guidance Document for patients admitted in the psychiatric hospital prepared by the Expert Committee as per Section 81 of the Mental Healthcare Act, 2017 can be used for treatment decisions.[20] Capacity being decision-specific, in general, the ability to understand information for decision making, the ability to retain the information and then weigh the information for decision making, and the ability to communicate the decision should be assessed. To facilitate greater involvement of service users, a shared decision making and more recently the supported decision-making frameworks are increasingly being recommended.[21] Psychosocial assessment A comprehensive psychosocial assessment that covers the domains of income, place of residence, social support, citizenship status, access to social protection measures, and welfare schemes will be necessary to support community integration. Income: Below Poverty Line (BPL) card and/or an income certificate will provide access to welfare schemes of the Government. Social support: The primary, secondary, and tertiary sources of social support should be mapped. Citizenship status: Aadhar card, Passport, and Voter identity cards will be important to exercise the civil, political, and social rights as a citizen. Bank accounts and PAN card will be important to exercise economic rights. Social protection measures: The availability of a Unique Disability Identity (UDID) card for benchmark disability will ensure that social protection measures such as disability pension become accessible. Assessment of activities of daily living (ADL) Basic activities of daily living include procedural skills to manage basic physical needs. An assessment of these skills will assist in determining the degree of daily assistance required. Katz Index of Independence in ADL[22] has six items – bathing, dressing, toileting, transferring, continence, and feeding, which are scored from 0 to 1 for each item. Barthel Index of Daily Living[23] has ten items that measure a person's daily functioning, specifically the activities of daily living and mobility. The items include feeding, moving from wheelchair to bed and return, grooming, transferring to and from a toilet, bathing, walking on a level surface, going up and down stairs, dressing, and continence of bowels and bladder. The Everyday Abilities Scale for India is an 11-item informant-based scale and includes items that cover eating, personal hygiene, dressing, social interaction, and cognitive functioning with a 2-point scale. Instrumental activities of daily living (IADL) Instrumental activities of daily living include predominantly cognitively driven activities focusing on household chores, financial management, medication management, and social activities. The Lawton Instrumental Activities of Daily Living (IADL) scale measures independent living skills across eight function domains: food preparation, housekeeping, laundering, ability to use the telephone, transportation, responsibility for one's own medications, shopping, and the ability to handle finances. Individuals are scored according to their highest level of functioning in that category.[24] Assessment of recovery The personal process of living with mental illness constitutes personal recovery. The personal recovery framework includes connectedness, hope and optimism, identity, meaning in life, and empowerment. While traditionally clinicians are oriented to measure clinical recovery, contemporary recovery-oriented services focus on personal recovery. Personal recovery has been understood to be complementary to clinical recovery. Assessment of personal recovery is about processes rather than outcomes. Recovery Assessment Scale (RAS)[25]: The RAS measures recovery across five domains of personal confidence and hope, reliance on others, goal success and orientation, and willingness to ask for help. RAS has 24 items that are self-reported. It is also used in the evaluation of recovery-oriented practice. The Recovery Star has been designed for adults managing their mental health and recovering from mental illness. It was developed by Triangle in collaboration with the Mental Health Providers Forum. It assesses ten life domains. Each domain is measured on the ladder of change based on the five-stage journey of change model: stuck, accepting help, believing, earning, and self-reliance.[26] The service user and the service provider rate the Recovery Star collaboratively. Discharge planning and readiness to discharge Discharge planning has been operationally defined as "comprehensively assessing biopsychosocial needs, determining available resources, coordinating care and services, and developing an individualized discharge plan to ensure the most optimal patient clinical outcomes, functional status, and integration in the community."[27] It becomes important to emphasize that discharge planning involves resource availability management and service coordination. The role of the discharge planner may be assumed by a social worker or nurse. While discharge planning has been conceptually defined as collaborative, the readiness to discharge has been clinically determined. Readiness for Discharge Questionnaire (RDQ)[28] has six items assessing suicidality/homicidality, control of aggression/impulsivity, activities of daily living, medication-taking, delusions/hallucinations interfering with functioning, and global status. It has been used in inpatients with schizophrenia. Overall functioning and disability The International Functioning, Disability and Health classifies three levels of human functioning: functioning at the level of body or body part, the whole person, and the whole person in a social context. Disability is therefore dysfunction in one or more of these levels – impairments, activity limitations, and participation restrictions. Some tools to measure functioning and disability include the following: Global Assessment of Functioning (GAF) Scale[29]: This scale measures global functionality on a linear scale of 1–100. The higher the score, the greater the functionality Social Occupational Functioning Scale (SOFS)[30]: A brief yet comprehensive, easy-to-administer measure of social functioning in persons with schizophrenia. It measures adaptive living skills, social appropriateness, and interpersonal skills. Indian Disability Evaluation Assessment Scale (IDEAS)[31]: IDEAS measures disability by assessing self-care, interpersonal relationships, communication and understanding, and work domains and calculating the duration spent in mental illness over the preceding 2 years. IDEAS is the tool to be used for purposes of disability assessment and certification under the RPWD Act, 2016. World Health Organisation Disability Assessment Schedule (WHODAS) 2.0[32]: WHO DAS 2.0 measures six domains: cognition, mobility, self-care, getting along with people, life activities, and participation. There is a longer 36-item and a shorter 12-item version. Assessment tools for social living skills and community support The following tools can aid in the assessment of community support and social living skills: The Social Network Map[33]: This measure helps to map the social supports in individual care. It can assist in identifying areas in which the social support of service users can be improved. Social support is assessed through the active involvement of both the service user and provider. Camberwell Assessment of Needs (CANSAS)[34]: This instrument has been used to assess the needs of persons with severe mental illness. It assesses both health and social needs and can be used to track changes. Life Skills Profile[35]: A 20-item questionnaire that is available to assess the community living needs of persons with schizophrenia. Social Functioning Scale[36]: It has been used in persons with schizophrenia and contains 79 items. It measures social engagement, interpersonal behavior, prosocial activities, independence, and participation in recreational and employment activities. SCARF Social Functioning Index[37]: It rates the individual's social functioning in the areas of self-concern, occupational performance, role in the family, and other social role performances. Vocational potential assessment in PMI The Vocational Potential Assessment Tool has been designed to assess the potential for employment in persons with severe mental illness.[38] The tool includes daily functioning, job-related social and cognitive skills, work behavior, job readiness, job-related details, and family and client factors in the vocational potential assessment. Health-related Quality of Life Generic and condition specific scales can be used to assess health-related quality of life in persons with mental illness. Disorder-specific quality-of-life instruments will likely be representative of the priorities of people with lived experience. A QOL scale that provides an overall picture of the patient's QOL considers the cost and time constraints in clinical care and captures issues surrounding multimorbidity and is overall useful in clinical decision making for the respective setting should be considered for use. World Health Organisation Quality of Life (WHO-QOL, WHO-QOL BREF)[39]: WHO-QOL and the WHO-QOL BREF measure "individuals' perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns". WHOQOL-BREF is a cross-culturally validated instrument with 26 questions, an abbreviated version of the WHOQOL-100 quality-of-life assessment. Euro-QOL 5D-5L measures health status across five dimensions – mobility, self-care, usual activities, pain/discomfort, and anxiety/depression.[40] Each dimension has five levels. The individual's health is also self-rated on a vertical visual analog scale. Disorder-specific scales can be used for schizophrenia (e.g. Schizophrenia quality of life scale) or bipolar disorder (e.g. Quality of Life in Bipolar Disorder questionnaire).[41,42] Tools to assess wellbeing While mental wellbeing and mental illness are independent constructs, they may be correlated aspects of mental health. Mental wellbeing is important in recovery and has been associated with functional status in SMDs.[43] WHO-5 wellbeing index[44]: WHO-5 is a brief measure of subjective wellbeing over a 2-week period. The WHO-5 consists of five noninvasive questions rated using a 6-point Likert scale. Warwick-Edinburgh Mental Wellbeing Scale has 14 items with five response categories that can be summed to provide a single score.[45] A shorter 7-item scale is also available. Assessment of physical health Often physical health conditions are ignored in mental health settings. Persons with SMD have been observed to have premature mortality compared to the general population. Several physical health conditions co-occur with severe mental illness (e.g., diabetes mellitus, hypertension, cardiovascular disease). Multimorbidity is the co-occurrence of multiple diseases or conditions. While disease counts and composite measures have been used to measure multimorbidity in research, in clinical settings, a thorough history, physical examination, and relevant investigations are recommended for long-stay patients as it is often seen that mental health symptoms may overshadow physical symptoms and health conditions. The multimorbidity burden in SMD is primarily attributed to noncommunicable diseases (NCDs). Hence, the risk factors for NCDs, such as tobacco use, poor diet, and low physical activity, should be assessed. The WHO STEPS manual comprehensively covers the risk factors and may be used as a guide. The Lester tool (NHS) is an example of guidance for the assessment of cardiometabolic health of people with severe mental illness and tools to enable staff to deliver safe and effective care to improve the physical health of persons with severe mental illness.[46] Long-term rehabilitation for persons with SUDs SUDs are chronic relapsing-remitting illnesses that require long-term care. Whether it is outpatient or inpatient-based care, evidence suggests that long-term treatment for SUDs has better outcomes compared to short-term treatment.[47] The history of long-term rehabilitation or long-term residential programs started in the 1950s as therapeutic communities (TCs) and drug-free residential programs. There was a paradigm shift in looking at addiction recovery from a treatment perspective. Therapeutic communities is a generic term in some countries for long-term and short-term residential programs. Long-term treatments worldwide are known by various names: extended intervention, continued care, stepped care, recovery management, or aftercare. These treatments have different approaches. Therefore, there are no standardized definitions in terms of the model of care. In USA, the duration of long-term rehabilitation of SUDs is around 3 months, and short-term rehabilitation is around 3 weeks.[48] A majority of people received short-term care compared to long-term care. While such data are lacking from India, published data from private rehabilitation centers suggest a 4–6 weeks stay.[49,50] In NIMHANS, the duration of inpatient care is around 3 weeks.[51] In India, data from government-run integrated rehabilitation centers for addicts (IRCAs) suggest that the duration of stay is around 3 months.[52] The camp approach followed in different places across India, and the duration of stay has varied. For example, in camps at Chandigarh, patients were admitted for 10 days, and in Manjakuudi, Tamil Nadu, they were admitted for 15 days.[53,54] In Karnataka, the camp duration was 8 days.[55] NEEDS OF LONG-STAY PERSONS WITH SUD Before we understand the needs of a person seeking addiction treatment, it is crucial to understand what recovery means in persons with SUDs. Addiction recovery is a gradual, complex, long-term process, different for every individual (personalized).[56,57] While clinical recovery is staying abstinent from drugs, a broader definition of addiction recovery is associated with various life domains beyond abstinence.[57] These include health, work, education, housing, legal, social, and economic wellbeing. Overtime control over substance use, along with abstinence, is included in the definition. Support to individuals and families generally helps in the recovery process. Individual, family, and treatment perspectives on the meaning of recovery might differ. Stages of Addiction Recovery Early ( 5 years) The recovery duration is associated with reduced crimes and better occupational and housing outcomes.[57] Retention in treatment, engagement in meaningful activities, and availability of support and resources are common factors that support addiction recovery. Needs vary based on the acuity of the problem, chronicity, and complexity [Figure 2].[58] A needs assessment can be based on an individualized approach or using tools to understand the needs.Figure 2: Needs of long-stay patients with SUDs (MHCA, Mental Health Care Act; RPwD, Rights of Persons with Disability; SUDs, substance use disorders)Recovery-oriented treatment at an institutional level A minimum infrastructure and functional services are necessary for the long-term care of patients with SUDs. The National Action Plan on Drug Demand Reduction (NAPDDR) recommends guidelines followed by the Integrated Rehabilitation Centre for Addicts (IRCAs), which include minimum infrastructure and the standard of care that needs to be provided.[59] It is mandatory for the institutions providing care for people with SUDs to register with the state mental health establishments and follow the Mental Health Care Act (MHCA) of 2017.[59] These institutions need to be periodically assessed by state mental health review boards. A breach of ethical principles is commonly observed during long-term care for people with SUDs across many settings.[60] For example, if a patient with cirrhosis of the liver continues to drink alcohol, can he be admitted to a rehabilitation center if he is not willing for admission? If forcefully admitted, there is a breach of autonomy. Although certain situations result in a clinical dilemma for treating physicians, it is important to adhere to the ethical principles of autonomy, beneficence, nonmaleficence, and justice in treating people with SUDs. Community as a "method" – learnings from Therapeutic Communities (TCs) TCs is the first program to see addiction from a treatment perspective. The program follows the principle of "community as a method." The key components of the program model are its social organization (structure), peer and staff roles, group and individual counseling, community enhancement meetings, community management elements, and program stages. The original treatment was for 24 months; now, it has been shortened. The social structure emphasizes mutual responsibility at various levels and peer-based learning. TCs focus on providing a safe physical and psychological environment to the population. Community enhancement meetings occur daily, with multiple scheduled meetings. The focus of these meetings is to instil the spirit of community. Therapeutic, educational activities involve group and individual counseling. While TCs are modified for special populations (comorbidity) and settings (prisons), most services in India are "TC-oriented services." TC-oriented services incorporate select elements of the TC (community meetings, peer support groups) but mainly utilize services and practices that are not specific to the TC. Post-treatment aftercare is a part of traditional TC services. At an individual level A recent study examined treatment-related needs identified from a patient's perspective. The needs included individual, family, treatment, and community-related needs.[61] Among individual needs, medication-related, psychological, and occupational were prominent. Addressing family conflict and supporting the family were the significant subthemes for family-related needs. The behavior of the treating team, environmental needs, and diverse services were the significant hospital-related needs. Awareness, accessibility, availability, and affordability of treatment services were the major community-related needs. The sociocultural needs can be different for men, women, and the LGBT community.[62] While the needs assessed from short-term care suggest the quality of therapeutic relationships, stigma and discrimination from the health care system, support needs, and informational needs were the prominent needs of women with SUDs, the long-term needs of women not been well understood. In India, very few women-only centers provide care. Gender-sensitive services like addressing sexual abuse, domestic violence, child care, and protection become important during the treatment.[63] Recovery capital An inter-related concept is to look at the strengths of individuals in the recovery process, "recovery capital." It is defined as "the breadth and depth of internal and external resources that can be drawn upon to initiate and sustain recovery from substance use problems."[64] These strengths are commonly assessed in individual, interpersonal (social), and community-related domains (environmental). This helps in understanding the unmet needs of a person's duration of long-term care.[65] Recovery capital has been primarily studied in the context of SUD; however, there is emerging research in the context of severe mental illness. Assessing recovery capital for long-stay patients may aid the promotion of personal recovery. Disability in SUD Because of harm sustained due to alcohol, a number of individuals develop disability, for example, patients who develop dementia secondary to alcohol, like alcohol-related dementia or due to Wernicke Korsakoff syndrome.[66] These individuals require disability assessment and certification as per the Rights of Persons with Disability (RPwD) Act 2016. Memory rehabilitation measures are effective if delivered interventions are focused, individualized, and cohesively integrated into comprehensive learning methods.[67] Various interventions, encompassing compensatory memory-enhancement techniques, including traditional aids like agendas, memory cards, and digital tools such as smartphones and smartwatches, show significant promise. Needs assessment tools in persons with SUD Although there are direct needs assessment tools focused on people with SUDs, there are some indirect ways. To gain insight into someone's needs, it is essential to understand their strengths and difficulties. A commonly used tool to assess the strengths of individuals with SUDs is Addiction Recovery Capital. In the Indian context, a Hindi version of the tool has been validated.[68] A widely used tool to determine the severity of addiction is the Addiction Severity Index (ASI).[69] A similar Indian tool developed recently, Assessment of Severity of Substance use for Outcomes Research and Treatment (ASSORT), can help understand the severity of addiction. This substance use severity scale was developed and validated across six tertiary care centers in India. It is simple to administer, and scoring is brief and culturally sensitive.[70] WHODAS 2.0 and WHO Quality of Life (WHO-QOL) assessment are other commonly used tools for assessment of disability and quality of life that can assist in understanding the needs.[32,39] Another important tool that can help during the stay is understanding the motivation based on the transtheoretical model of change (precontemplation, contemplation, preparation, action, maintenance). The readiness to change questionnaire, a 12-item tool, assists in allocating and predicting outcomes.[71] Further, the Treatment Readiness Tool (TReaT) helps understand the motivation (precontemplation, contemplation, and preparation) to seek treatment.[72] The Government of India empowers state mental health authorities to frame guidelines for a minimum standard of care in deaddiction centers, considering recommendations from the Ministry of Social Justice and Empowerment.[73] These guidelines are updated regularly. Institutions should follow the previous recommendations until the updated version is released.[74,75] Barriers to assessment of needs in long stay of SMDs and SUDs A significant proportion of persons admitted to psychiatric hospitals may have comorbid intellectual disability and speech and language deficits. Understanding their preferences and choices can be challenging. Several psychiatric hospitals may not have multidisciplinary professionals to assess the postdischarge needs of long-stay patients, and a limited number of mental health professionals are often overwhelmed with persons having acute mental health problems. A major barrier to needs assessment for long-term rehabilitation of persons with SUDs is high variability in terms of definition (duration), settings (government vs private), regional variations of substance use problems (opioids in North India vs alcohol in southern India), and, last, lack of structured validated scales. Pragmatic needs assessment is less likely to be covered by any of the structured tools. The tools mentioned above may capture the information related to strengths, deficits, and choices. However, the tools may not be able to assess several other complex needs. When patients are homeless and are admitted to psychiatric hospitals for years or even for decades, they may not have documents which entitle them to several social protection measures for community living. CONCLUSION Assessment of the needs of long-stay patients in psychiatric hospitals is a complex, multidimensional, and continuous process as needs can change over time. We should strive toward assessments and services becoming recovery-oriented, rights-based, and person-centred. A structured multimodal approach is essential at the individual, social, and institutional levels. Professionals caring for the long-stay patients with SMD and SUD should be aware of various community care facilities as they transition to facilities that could cater to their needs. Identifying and strengthening the recovery capital assists the recovery process for persons with SMD and SUD. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.