In a rational world, the real needs of the mentally ill would be identified and addressed in an efficient and cost effective way. Those who need care would receive it. Those who don’t, wouldn’t. The national research portfolio would prudently balance studies aimed at practical solutions to urgent, current problems with those that promise home runs, but only in the remote future.

Unfortunately, policy in the United States is based mostly on profit, political power, and ideology — thus producing terrible outcomes that are anything but rational.

Here is a summary of the power players and the aggregate mess they cause:

1) The over-treatment of the worried well is promoted by Pharma, insurance companies, mental health professionals, primary care doctors, patients, and politicians.

Pharma by massive misleading marketing. Insurance companies by requiring premature diagnosis as a requirement of reimbursement. Mental health professionals by cherry picking the easy patients. Primary care docs by careless and excessive prescription of 80 percent of all psychiatric drugs. Patients by wanting a quick medication fix for the problems of everyday life. And politicians by pandering to all of the above in an effort to gain money and votes.

2) The neglect of the really sick is promoted by state governments, federal agencies, mental health professionals and anti-psychiatry patient advocacy groups.

State governments by attempting to cut costs by underfunding and privatizing appropriate community treatment and housing. Meanwhile, they foolishly overspend much more money on prison beds for the 350,000 mentally ill who wind up getting locked up inappropriately for nuisance crimes, avoidable had treatment been available. Federal agencies by shirking their responsibility to the really sick and instead diverting scarce funding and attention to appealing but ineffective prevention and wellness programs. Mental health professionals and associations by preferring to cater to the large group of the nearly well and avoiding advocacy for the small group of the really ill. Consumer advocacy groups dominated by former patients understandably resentful of psychiatric treatment they found harmful or unhelpful by fighting against all use of psychiatric medicine and involuntary treatment — even for those much sicker than they who desperately require such help lest they wind up in prison, homeless, or harming themselves or others.

3) Research efforts provide no help for the currently ill because they are funded either by the NIMH or Pharma — neither which has much interest in their welfare.

The NIMH research agenda is a triumph of hope over experience — virtually the entire investment has been bet on the long shot, long term gamble that future basic science triumphs will someday be easily translated into effective prevention and treatment breakthroughs. Why bother with bandaids for mental illness suffering now if we can use magic technology to altogether eradicate mental illness in the future. There is minimal NIMH investment in research that might promote current advances in clinical care, service delivery, and policy making and instead a doubling down on previously failed bets on future breakthroughs via neuroscience, molecular biology, and genetics. This despite 40 years of ever more fascinating neuroscience discovery that so far has not helped a single suffering patient. Pharma sponsored “research” does not come close to deserving the name, since it is no more than a tool of marketing aimed at higher profits, not patient benefit.

So much for the powerful. How about the powerless? These are the more than 600,000 people whose severe mental illness has been neglected. The homeless guy begging on the street because there is no housing for him; the guy stuck in jail, brought there only because the cop knew there was no appropriate treatment option; the woman with severe depression who has no insurance and cant afford medication; the psychotic teenager who winds up in juvenile detention; the mother who kills her child because of untreated command hallucinations; the avoidable suicide; the guy shot by a cop; some of our mass murderers; the 200,000 raped in prison every year, many of whom are made vulnerable by mental illness… and it goes on and on. We are the richest nation in the history of the world and yet we provide the worst care ever conceived for the severely ill who most need it.

Paradoxically, the strongest advocates for reform are the cops, the judges, and the prison officials who have to deal with the fallout caused by our disastrously dysfunctional and disorganized mental health nonsystem. Cops are scared silly by the unpredictability of the untreated patients they are untrained to deal with. Judges know firsthand that diversion to treatment is a more humane and cost effective alternative to imprisonment. And jailers know that many of their prisoners belong in treatment, not custody. The National Rifle Association has also become a paradoxical supporter of increased funding for mental health, but for all the wrong reasons — to divert blame for gun violence away from guns and onto the very few mentally ill who actually use them.

The natural advocates of the severely ill — the professional associations and patient advocacy groups — have so far done little or nothing to help them. And a very useful, bipartisan mental health reform bill has been blocked in Congress — the victim of special interest lobbying and political posturing.

Is there any hope? The best news is that helping the severely ill is not that hard to do. Other countries provide wonderful services using many fewer dollars — because they allocate them rationally rather than based on politics and ideology. This isn’t rocket science and the U.S. did a much better job 30 years ago before community mental health centers were privatized.

It is also promising that the media are picking up the story, although unfortunately that this occurs mostly when someone with a mental illness commits or becomes victim of a violent act. This is unfairly stigmatizing — most of the mentally ill are never violent and most violence is not committed by the mentally ill. But if this is the only way to call attention to the plight of the severely ill and to get funding for adequate services, and housing, perhaps the tradeoff is worth it. The current impasse is a blight on our nation and a catastrophe for our most vulnerable.

Allen Frances is a professor emeritus at Duke University and was the chairman of the DSM-IV task force.

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