When schizophrenia is diagnosed in Vermont, patients can expect a community clinic to step in and help them find state-sponsored housing, job training and emergency care.

With the same diagnosis in Hawaii, patients are more likely to be on their own.

Overall, according to a new study of the nation's services for the severely mentally ill, care is at a modern-day low, rivaling the extreme lack of care provided around 1820.

The study was done by the Public Citizen Health Research Group and the National Alliance for the Mentally Ill, consumer and mental health advocacy groups. The study ranked Vermont first and Hawaii last in the quality of services the states provide to people with schizophrenia and manic-depressive disorder, the two most common major psychoses.

"If you happen to be mentally ill and your boss offers you a transfer from Honolulu to Burlington, take it," said E. Fuller Torrey, a St. Elizabeths Hospital psychiatrist who was the report's chief author. "You're much more likely to get decent care in Burlington."

Overall, the report calls the nation's mental health care system "a disaster" and says more than 250,000 people with schizophrenia and manic-depressive psychosis live in homeless shelters, on the streets, or in prisons and jails -- almost four times the number who live in state psychiatric hospitals. Not since the 1820s, the report says, have so many seriously mentally ill people gone untreated.

The authors said much of the situation is due to a shortage of mental health professionals working in public clinics and hospitals and a lack of communication between psychiatric hospitals and public clinics. Torrey said the reason for this shortage is not a decrease in the number of psychiatrists or a lack of pay in the public sector, but the declining prestige associated with such work.

"It's not a question of numbers. We've got plenty of psychiatrists falling all over each other on Connecticut Avenue," he said. "And in most states these {public sector} jobs don't pay poorly. But to say, 'I am a first-class psychiatrist and I specialize in the treatment of schizophrenia' is a contradiction in terms."

Melvin Sabshin, medical director of the American Psychiatric Association, said that while his group agrees with many of the report's findings, Torrey's statement that psychiatrists have abandoned working for public clinics and hospitals is incorrect.

"Such allegations are not true and will not help to resolve the complex problems of financial support and public commitment needed to bring quality care to persons with severe mental illnesses," he said.

The report gives acceptable scores to only six states -- Vermont, New Hampshire, Rhode Island, Connecticut, Ohio and Colorado. It gives seven states -- Hawaii, Wyoming, Idaho, Mississippi, Montana, Texas and Nevada -- extremely low ratings.

The District, Maryland and Virginia placed in the middle of the list, with Virginia ranked 11th, Maryland 16th and the District 31st. These are improvements over the report the groups released two years ago, in which Virginia ranked 22nd, Maryland 24th and the District 49th.

The authors said they based their scoring system on quality of hospital services, availability of vocational and other training programs, availability of housing for seriously mentally ill people, and services for emotionally disturbed children.

In Hawaii, they said, Justice Department officials inspecting the state psychiatric hospital found pools of urine on the floor, a cockroach-infested kitchen and patients sharing toothbrushes because of lack of funds.

Although the Hawaii health department confirmed these findings, Barbara Hastings, spokeswoman for the department, said the report was not entirely fair. She said the state is expanding the number of hospital beds and community programs for the mentally ill. "We're not perfect, but we've made incredible strides," she said.

Locally, Torrey said, the strongest programs in Virginia and Maryland are located far from the District, such as in southern Virginia and Baltimore.

"There are some good things going on in Virginia, but not in the Washington area, and there are in Maryland, but not in the Washington area," he said. "The reason is because Washington tends to be a bastion for psychotherapy and counseling and this town, both on the Maryland side and the Virginia side, is full of psychiatric social workers and psychologists and psychiatrists who want to talk to you about your early childhood problems and how they relate to your current problems in life.

"Unfortunately, these have nothing to do with schizophrenia or with manic-depressive illness, which we now know are brain diseases," he added.

However, James P. Stratoudakis, director of mental health services for the Fairfax-Falls Church community services board, which runs the state-sponsored psychiatric programs, disputed this. "We have a lot going on now in Fairfax and we're directly engaging the people that he {Torrey} talks about -- meaning consumers and family members -- to improve the system," he said.

Torrey said care in the District has improved because St. Elizabeths Hospital has worked more closely with public psychiatric clinics since control of the hospital was transferred to the District in 1987.

The report, however, said conditions at St. Elizabeths had deteriorated and that patient seclusion and restraints and medication errors had increased since the last report was issued.

Robert A. Washington, commissioner of mental health services in the District, said his agency is proud of moving up from 49th to 31st on the list but denied that continuing problems were the fault of poor management. At fault, he said, were nationwide shortages of nurses and doctors and a lack of low-cost housing.