An evaluation of the variation and underuse of clozapine in the United Kingdom.

BACKGROUND: Clozapine is the only licensed treatment for treatment refractory schizophrenia. Despite this, it remains grossly underused relative to the prevalence of refractory schizophrenia. The extent of underuse and the degree of regional variation in prescribing in the United Kingdom is unknown. It is also unclear, how the UK compares with other European countries in rates of clozapine prescribing. METHODS: We obtained data relating to all clozapine prescribing in the UK from the relevant clozapine registries. We examined regional variation in clozapine use across England, corrected for the known prevalence of severe mental illness (SMI). We also compared the UK rate of clozapine use per 100,000 population to that described in other European countries. FINDINGS: There is substantial variation in clozapine prescribing across different regions of England and only about a third of potentially eligible patients were prescribed the drug in the UK. Clozapine prescribing rate in the UK was lower than in several European countries. INTERPRETATION: There is clear regional inequity in access to the most effective treatment in refractory schizophrenia in England. Strategies to increase clozapine use, by overcoming both real and perceived barriers, are urgently necessary to reduce treatment inequity for patients with refractory schizophrenia.

Myths of Mental Health: Revelations from the French System for the United States.

Drawing on an analysis of the French mental health system, this essay examines four presumptions about mental health care dominant in the United States: (1) the required abolition of the hospital for psychiatric deinstitutionalization; (2) the substitutability of public and private financing; (3) the importance of a "dangerousness" criterion for involuntary commitment procedures; and (4) the need for an ever-expanding scope of care. These claims hold little weight when subjected to comparative scrutiny, and the essay closes by discussing the implications of these revelations for US mental health care policy and ethics.

Insights from California on Involuntary Commitment for Substance Use.

Involuntary commitment (IC) for the treatment of substance use disorders is a highly controversial and poorly understood practice, with California offering a striking example. The state's involuntary commitment laws, known collectively as Lanterman-Petris-Short, authorized IC for grave disability related to chronic alcoholism. These provisions remain shrouded in obscurity, and data on their usage are lacking. Amid the ongoing debate over the utility of IC as a tool to treat severe substance use disorders and legislation expanding IC for substance use disorders (SUDs) in California and other states, this article highlights the need to better study the use and effectiveness of existing legislation as well as to consider upstream interventions, such as expansion of community-based treatment models.

Making the City "Second Nature": Freegan "Dumpster Divers" and the Materiality of Morality.

How do people maintain deeply held moral identities in a seemingly immoral social environment? Cultural sociologists and social psychologists have focused on how individuals cope with contexts that make acting on moral motivations difficult by building supportive networks and embedding themselves in communities of like-minded people. In this article, however, the author argues that actors can achieve a moral "sense of one's place" through a habitus that leverages the material dimensions of place itself. In particular, he shows how one community of radical environmental activists make affirming moral identities centered on living "naturally" seem like "second nature," even in a seemingly unnatural and immoral urban environment, by reconfiguring their physical world. The author shows how nonhuman objects serve as proofs of moral labor, markers of moral boundaries, and reminders of moral values, playing both a facilitating and constraining role in moral life.