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Consumer Profile Most individuals with Severe and Persistent Mental Illnesses (SPMI) can function effectively in community-based service systems with access to general hospital psychiatric units. However, several authors have identified patient characteristics that interfere with placement in community settings and may indicate a need for tertiary care (1-3). The most common behaviours are aggressiveness, noncompliance with medication, danger to selfand/or others, or inappropriate sexual behaviour. Other problems include incontinence, fire risk, suicidal risk, substance abuse, stealing, urinating or defecating in public, begging, bulimia or polydipsia, and poor orientation or absconding. Aviram and others identified characteristics of patients not ready for discharge from New Jersey state psychiatric hospitals (4). These patients were severely disabled in comparison to a discharge-ready group and required special precautions with regard to danger to others. The proportion of those completely or frequently dependent on others for personal care was substantially higher in the not-ready group. A seminal article on deinstitutionalization was published by Gudeman and Shore in 1984 (3). These authors identified 5 subgroups whose needs cannot be met by the primary and secondary mental health care system. These groups include: 1) elderly patients suffering from dementia, psychosis, and medical illness; 2) developmentally handicapped patients with psychiatric disorders, often with assaultive behaviour; 3) brain-damaged patients with loss ofimpulse control; 4) patients with schizophrenia who are chronically psychotic, assaultive, or suicidal; and 5) chronic schizophrenia patients with severely regressed behaviour. There are other subgroups (for example individuals with eating disorders, first-episode schizophrenia, or personality disorders) with specialized needs generally treated by secondary care services. Because they present significant treatment challenges, academic health science centres have an important role to play. While these subgroups may be treated appropriately in tertiary-level programs, they most often are served at the secondary-level and so are not discussed further in this review.

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