Clinical implications - Schizophrenia and Gender

Assessment
Textbook descriptions of schizophrenia are of male-type schizophrenia. When assessing women, clinicians may miss a first episode of schizophrenia, because the woman may seem too old for a first episode or may have too many affective symptoms. When assessing women, clinicians can also mistake the following for schizophrenia: posttraumatic stress, eating disorder with starvation, psychotic depression, or a short-lived psychosis in the context of a personality disorder. When assessing women, clinicians should ascertain the influence of hormones on symptoms (e.g., contraceptive pill use, time of the month, pregnancy, postpartum period, menopause).

Treatment
Effective antipsychotic drug doses in women are generally lower than those in men (in both genders, it is important to inquire about cigarette smoking, coffee drinking, and concomitant medication). Depot medications can be given at longer intervals in women.

Many women require relatively higher doses premenstrually and postmenopausally, and when pregnant may need only very small doses. Women are generally more emotionally involved with their friends and families than are men, and effective treatment must take interpersonal stressors into greater account. It is essential to inquire about the presence of children and to ensure that children under the care of women with schizophrenia are being cared for adequately. Comorbid depression is more prevalent in women than in men and usually needs to be treated.

Advocacy
There is an urgent need for family-centered services with therapeutic day care for mothers and children, including parent coaching and support services. Advocacy for individual patients is needed to convince child care agencies that it is generally preferable to provide support for the mother with schizophrenia at home than to take children away to foster care.

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KEY POINTS

• Differential diagnosis in women includes mood disorder, and posttraumatic stress disorder, and starvation secondary to anorexia; in men, substance use disorders need to be ruled out.
  
• Hormonal triggers are important in women with schizophrenia (e.g., premenstrual period, postpartum period, menopause, contraceptive use).
  
• Depending on the antipsychotic used, women often require lower doses than do men.
  
• Heavy smoking lowers antipsychotic drug levels in both sexes.
  
• Because antipsychotic drugs are stored in adipose tissue, sudden gain or loss of weight affects efficacy and side effects of these drugs. This is a special issue for women.
  
• Women are especially vulnerable to weight gain and to disturbances of glucose and lipid metabolism secondary to long-term use of antipsychotics.