Gender differences in premorbid adjustment of patients with first episode psychosis

Sex comparisons on the beneficial effects of an early intervention program in a patients' cohort with first episode psychosis: what effectiveness in women?

PURPOSE

Males and females with First Episode Psychosis (FEP) usually tend to differ in psychopathology, clinical presentation and their longitudinal trajectory. This study aimed to examine the difference of effectiveness of specialized psychosocial and pharmacological treatments for FEP, focusing on various clinical and functioning outcomes across a 2-years follow-up period.

METHODS

The assessment included the CAARMS, the HoNOS, the PANSS and the GAF scale and was conducted at baseline and every 12 months.

RESULTS

490 FEP patients (age: 12-35 years) were recruited. Of them, 363 completed the follow-up (132 females and 231 males). At baseline, males showed a higher prevalence rate of schizophrenia diagnosis (56.1% VS 43.8%; p = .008), whereas females a higher prevalence rate of affective psychosis (36.2% VS 23.3%; p = .005). Male participants also showed a more consistent substance abuse (46.9% VS 24.3%; p = .0001), lower years of education (11.26 ± 2.94 VS 11.88 ± 2.68; p = .013), and more striking behavioral manifestations (4.06 ± 2.36 VS 3.39 ± 2.58; p = .003) compared to women. Our 2-year outcome parameter results showed a higher incidence of functional remission over time in females compared to males (49.2% VS 39.0%; p = .028), together with a decreasing trend in new hospitalization rates (17.8% VS 26.9%; p = .089). Independently from sex, our results also showed a statistically significant reduction in the prescription of psychotropic medications and through the increase of all psychosocial interventions, although more evident in males.

CONCLUSION

These results suggested that specialized interventions for FEP are overall effective in both treated subgroups. Additionally, FEP women specifically showed higher rates of improvement in functional outcome variables over time when compared to males.

Self-stigma and quality of life among people with psychosis: The protective role of religion

AIM

The quality of life in people with psychosis has been consistently demonstrated to be lower than those without, with self-stigma contributing greatly to this impairment. Hence, it is imperative to address this gap in order to facilitate recovery-oriented and other outcomes. This study investigates the potential of religiosity in moderating the effects of self-stigma on quality of life among those with psychosis.

METHODS

Adults with psychosis (n = 99) were recruited from the Early Psychosis Intervention Programme in Singapore from 2018 to 2021, and administered the self-report Religious Commitment Index, Internalized Stigma of Mental Illness scale, and Abbreviated World Health Organization Quality of Life instrument. Linear regression analyses were conducted and the interaction between self-stigma and religious commitment scores calculated to investigate the moderation effects of religiosity on the relationship between stigma and quality of life.

RESULTS

Preliminary regression analyses revealed a significant association between sex and psychological quality of life. After controlling for sex, religiosity was found to moderate the relationship between self-stigma and psychological quality of life.

CONCLUSIONS

The results of the study demonstrate the potential of religiosity in buffering the effects of self-stigma on quality of life. This reveals an area that can be easily targeted and addressed in treatment programs to improve outcomes beyond the clinical setting among people living with psychosis, to facilitate their recovery journey and beyond.

Sex, gender, and outcome in first-episode psychosis: The role of premorbid functioning

We examined the associations of sex (biological distinction) and gender (societal distinction) with psychopathology, depressive symptoms and social and occupational functioning over 24 months. We found that lower masculinity scores were associated with worse psychopathology outcomes, independent of sex and other neurodevelopmental factors. These effects were mediated by poor premorbid adjustment, which also mediated the relationship between childhood trauma and masculinity scores as predictors of disorganized symptom outcomes. Our findings highlight the importance of considering gender as a separate construct and the need for further research to understand the clinical implications of sex and gender differences in schizophrenia.

Two Neuroanatomical Signatures in Schizophrenia: Expression Strengths Over the First 2 Years of Treatment and Their Relationships to Neurodevelopmental Compromise and Antipsychotic Treatment

BACKGROUND AND HYPOTHESIS

Two machine learning derived neuroanatomical signatures were recently described. Signature 1 is associated with widespread grey matter volume reductions and signature 2 with larger basal ganglia and internal capsule volumes. We hypothesized that they represent the neurodevelopmental and treatment-responsive components of schizophrenia respectively.

STUDY DESIGN

We assessed the expression strength trajectories of these signatures and evaluated their relationships with indicators of neurodevelopmental compromise and with antipsychotic treatment effects in 83 previously minimally treated individuals with a first episode of a schizophrenia spectrum disorder who received standardized treatment and underwent comprehensive clinical, cognitive and neuroimaging assessments over 24 months. Ninety-six matched healthy case-controls were included.

STUDY RESULTS

Linear mixed effect repeated measures models indicated that the patients had stronger expression of signature 1 than controls that remained stable over time and was not related to treatment. Stronger signature 1 expression showed trend associations with lower educational attainment, poorer sensory integration, and worse cognitive performance for working memory, verbal learning and reasoning and problem solving. The most striking finding was that signature 2 expression was similar for patients and controls at baseline but increased significantly with treatment in the patients. Greater increase in signature 2 expression was associated with larger reductions in PANSS total score and increases in BMI and not associated with neurodevelopmental indices.

CONCLUSIONS

These findings provide supporting evidence for two distinct neuroanatomical signatures representing the neurodevelopmental and treatment-responsive components of schizophrenia.

Sex and gender differences in symptoms of early psychosis: a systematic review and meta-analysis

First-episode psychosis (FEP) can be quite variable in clinical presentation, and both sex and gender may account for some of this variability. Prior literature on sex or gender differences in symptoms of psychosis have been inconclusive, and a comprehensive summary of evidence on the early course of illness is lacking. The objective of this study was to conduct a systematic review and meta-analysis of the literature to summarize prior evidence on the sex and gender differences in the symptoms of early psychosis. We conducted an electronic database search (MEDLINE, Scopus, PsycINFO, and CINAHL) from 1990 to present to identify quantitative studies focused on sex or gender differences in the symptoms of early psychosis. We used random effects models to compute pooled standardized mean differences (SMD) and risk ratios (RR), with 95% confidence intervals (CI), for a range of symptoms. Thirty-five studies met the inclusion criteria for the systematic review, and 30 studies were included in the meta-analysis. All studies examined sex differences. Men experienced more severe negative symptoms (SMD =  - 0.15, 95%CI =  - 0.21, - 0.09), whereas women experienced more severe depressive symptoms (SMD = 0.21, 95%CI = 0.14, 0.27) and had higher functioning (SMD = 0.16, 95%CI = 0.10, 0.23). Women also had a lower prevalence of substance use issues (RR = 0.65, 95%CI = 0.61, 0.69). Symptoms of early psychosis varied between men and women; however, we were limited in our ability to differentiate between biological sex and gender factors. These findings may help to inform early detection and intervention efforts to better account for sex and gender differences in early psychosis presentation.

Sex and gender associations with indicators of neurodevelopmental compromise in schizophrenia spectrum disorders

BACKGROUND

It has been proposed that sex and gender differences described in schizophrenia can be explained from a neurodevelopmental perspective.

AIM

In this study, we examined the associations of biological sex and gender role endorsement with putative indicators of neurodevelopmental compromise.

METHODS

We used the Bem Sex Role Inventory to calculate masculinity scores in 77 patients with a first episode of a schizophrenia spectrum disorder, and selected the following indicators of neurodevelopmental compromise: family history of schizophrenia, obstetric complications, premorbid functioning, neurological soft signs, and cognitive function. Secondary objectives included the moderating effects of age of onset of illness, substance use and negative symptoms on these associations.

RESULTS

There were no significant sex differences across any of the indicators of neurodevelopmental compromise. However, lower masculinity scores correlated significantly with poorer premorbid adjustment, sensory integration deficits and worse overall cognitive performance. Stepwise linear regression identified poorer premorbid adjustment in early adolescence and lower verbal learning scores as independent predictors of lower masculinity scores. In contrast to sex, gender showed several associations with indicators of neurodevelopmental compromise.

CONCLUSIONS

Lower masculinity scores may represent part of a phenotype for a neurodevelopmental anomaly that places some individuals on a pathway to schizophrenia.

Premorbid adjustment amongst outpatients with schizophrenia in a Nigerian psychiatric facility

BACKGROUND

Studies from developed countries have shown that poor premorbid adjustment in patients with schizophrenia is associated with poor outcome. However, similar studies in developing countries like Nigeria are few despite the stability of schizophrenia prevalence across cultures.

AIM

The aim of this study was to assess the prevalence and correlates of poor premorbid adjustment amongst outpatients with schizophrenia.

SETTING

The Neuropsychiatric Hospital, Abeokuta in Ogun State, Nigeria.

METHODS

The premorbid adjustment of 300 outpatients with schizophrenia was assessed using the premorbid adjustment scale. Pattern and severity of psychosis, overall illness severity, global assessment of functioning and socio-demographic factors were investigated as correlates of premorbid functioning.

RESULTS

About half (53.3%) of the respondents had poor premorbid adjustment and most of them were males (56.9%). Poor premorbid adjustment was associated with male gender (χ 2 = 7.81, p = 0.005) whilst good premorbid adjustment was associated with no or borderline illness severity (χ 2 = 8.26, p = 0.016) as well as no or mild impairment in functioning (χ 2 = 7.01, p = 0.029) amongst the respondents. Positive, negative and general symptomatology were predicted by premorbid adjustment at different developmental stages.

CONCLUSION

Consistent with existing literature, poor premorbid adjustment was prevalent amongst patients with schizophrenia in this study and was associated with male gender, poorer clinical outcomes and greater illness severity. Mental health promotion and other preventative approaches are recommended as possible early intervention strategies in dealing with schizophrenia.

Gender Differences in Clinical and Psychosocial Features Among Persons With Schizophrenia: A Mini Review

An extensive literature regarding gender differences relevant to several aspects of schizophrenia is nowadays available. It includes some robust findings as well as some inconsistencies. In the present review, we summarize the literature on gender differences in schizophrenia relevant to clinical and social outcome as well as their determinants, focusing on clinical variables, while gender differences on biological factors which may have an impact on the outcome of the disorder were not included herewith. Consistent findings include, in male with respect to female patients, an earlier age of illness onset limited to early- and middle-onset schizophrenia, a worse premorbid functioning, a greater severity of negative symptoms, a lower severity of affective symptoms and a higher rate of comorbid alcohol/substance abuse. Discrepant findings have been reported on gender differences in positive symptoms and in social and non-social cognition, as well as in functional outcome and rates of recovery. In fact, despite the overall finding of a more severe clinical picture in males, this does not seem to translate into a worse outcome. From the recent literature emerges that, although some findings on gender differences in schizophrenia are consistent, there are still aspects of clinical and functional outcome which need clarification by means of further studies taking into account several methodological issues.

Adolescent social functioning in offspring at high risk for schizophrenia spectrum disorders in the Finnish Adoptive Family Study of Schizophrenia

BACKGROUND

Children and adolescents with a genetic risk for schizophrenia are often found to have poorer social functioning compared to their controls. However, less is known about high-risk offspring who have not been reared by a biological parent with schizophrenia. The purpose of this study was to examine deficits in social functioning in adolescence as a possible factor related to genetic vulnerability to schizophrenia spectrum disorders, and also to examine possible gender differences in these associations.

METHOD

The present sample consisted of 88 genetic high-risk (HR) adoptees whose biological mothers were diagnosed with schizophrenia spectrum disorders and 83 genetic low-risk (LR) adoptees with biological mothers with non-schizophrenia spectrum disorders or no psychiatric disorders. Adoptees' social functioning at ages 16-20 was assessed using the UCLA Social Attainment Survey.

RESULTS

Compared to LR adoptees, HR adoptees displayed statistically significant deficits in their peer relationships, involvement in activities and overall social functioning during adolescence. HR males were distinguished from LR males by their significantly poorer overall social functioning. Compared to HR females, HR males showed significant deficits in their romantic relationships. Of marginal significance was that HR females displayed more social functioning deficits relative to LR females, mainly in the areas of peer relationships, involvement in activities and overall social functioning.

CONCLUSIONS

These results from the adoption and high-risk study design suggest that deficits in social functioning in adolescence may be related to genetic vulnerability to schizophrenia spectrum disorders and that some of these deficits may be gender-specific.

Factors limiting romantic relationship formation for individuals with early psychosis

BACKGROUND

Although many young adults with early psychosis (EP) desire to engage in a romantic relationship, many report having difficulties in engaging in such a relationship. However, almost no research has been conducted on factors potentially explaining impairments in their ability to form romantic relationships.

AIM

To compare an EP single young adult sample with single students or students in stable romantic relationships on factors that can cause difficulties in romantic relationship initiation processes METHODS: Cross-sectional study comparing these three groups (n = 83) on self-esteem, attachment, social functioning and perceived difficulties in dating.

RESULTS

No significant group differences were found on self-esteem, although lack of confidence was the second most frequent reason evoked by EP participants when asked why they were single. EP participants had greater attachment preoccupation than students involved in a relationship. Single EP individuals rated their social interaction abilities higher compared with single students, but did not engage in social interactions more often. Both single EP participants and single students had more negative perceptions of their intimacy abilities and fewer intimacy behaviours compared with participants involved in a relationship.

CONCLUSIONS

Potential interventions to improve EP young adult's capacity to engage in romantic relationships could target perception of their interaction skills, preoccupation about being loved, negative perception of their intimacy abilities, frequency of intimacy related behaviours and lack of confidence.

Career Decision-Making Processes of Young Adults With First-Episode Psychosis

The first episode of psychosis often emerges during young adulthood, when individuals are pursuing important educational and career goals that can become derailed because of the development of major impairments. Past research has neglected the developmental nature of employment and education decisions that young adults with first-episode psychosis make within the context of their lives. The purpose of this grounded theory study was to advance a model of the career decision-making processes of young adults with first-episode psychosis, and the influences that affect their career decision-making. The career decision-making of young adults with first-episode psychosis emerged as a multistaged, iterative process that unfolded over three phases of illness, and was affected by several internal and environmental influences. These findings suggest the phase of illness and career decision-making stage should be considered in future vocational programming for young adults with first-episode psychosis.

Cannabis use in male and female first episode of non-affective psychosis patients: Long-term clinical, neuropsychological and functional differences

BACKGROUND

Numerous studies show the existence of a high prevalence of cannabis use among patients with psychosis. However, the differences between men and women who debut with a first episode of psychosis (FEP) regarding cannabis use have not been largely explored. The aim of this study was to identify the specific sex factors and differences in clinical evolution associated with cannabis use.

METHOD

Sociodemographic characteristics at baseline were considered in our sample of FEP patients to find differences depending on sex and the use of cannabis. Clinical, functional and neurocognitive variables at baseline, 1-year, and 3-years follow-up were also explored.

RESULTS

A total of 549 patients, of whom 43% (N = 236) were cannabis users, 79% (N = 186) male and 21% (N = 50) female, were included in the study. There was a clear relationship between being male and being a user of cannabis (OR = 5.6). Cannabis users were younger at illness onset. Longitudinal analysis showed that women significantly improved in all three dimensions of psychotic symptoms, both in the subgroup of cannabis users and in the non-users subgroup. Conversely, subgroups of men did not show improvement in the negative dimension. In cognitive function, only men presented a significant time by group interaction in processing speed, showing a greater improvement in the subgroup of cannabis users.

CONCLUSION

Despite knowing that there is a relationship between cannabis use and psychosis, due to the high prevalence of cannabis use among male FEP patients, the results showed that there were very few differences in clinical and neurocognitive outcomes between men and women who used cannabis at the start of treatment compared to those who did not.

Gender differences in one-year outcomes of first-presentation psychosis patients in inner-city UK Early Intervention Services

AIM

Men and women have historically been shown to differ in their presentation and outcome of psychotic disorders and thus are likely to have different treatment needs. It is unclear whether Early Intervention Services (EIS) are able to provide equitable care for both men and women presenting for the first time with psychosis. The main aim of this study was to explore gender differences for first-presentation psychosis patients at the time of their referral to inner-city EIS and their outcomes 1 year later.

METHODS

Audit data were utilized from 1098 first-presentation psychosis patients from seven EIS across London, UK, collected via the computerized MiData package. Binary logistic regression was employed to detect potential associations between gender and (i) initial clinical presentation (including duration of untreated psychosis, pathways to care, risk behaviours); and (ii) 1-year clinical and functional outcomes.

RESULTS

At entry to EIS, male patients presented with more violent behaviour whereas female patients had more suicide attempts. Following 1 year of EIS care, men still presented as more violent towards others whereas women were more likely to have been admitted to a psychiatric ward.

CONCLUSION

Gender differences in clinical outcome, service use and risk behaviours were apparent within the first year of specialist psychosis care. This may be partly due to the different pathways to care taken by men and women and differences in clinical presentation. Greater focus on the specific needs of each gender by EIS in detection and intervention is required to improve equality of outcome.

Investigating trajectories of social recovery in individuals with first-episode psychosis: a latent class growth analysis

BACKGROUND

Social disability is a hallmark of severe mental illness yet individual differences and factors predicting outcome are largely unknown.

AIM

To explore trajectories and predictors of social recovery following a first episode of psychosis (FEP).

METHOD

A sample of 764 individuals with FEP were assessed on entry into early intervention in psychosis (EIP) services and followed up over 12 months. Social recovery profiles were examined using latent class growth analysis.

RESULTS

Three types of social recovery profile were identified: Low Stable (66%), Moderate-Increasing (27%), and High-Decreasing (7%). Poor social recovery was predicted by male gender, ethnic minority status, younger age at onset of psychosis, increased negative symptoms, and poor premorbid adjustment.

CONCLUSIONS

Social disability is prevalent in FEP, although distinct recovery profiles are evident. Where social disability is present on entry into EIP services it can remain stable, highlighting a need for targeted intervention.

Gender differences in suicidal behaviour in patients with first-episode psychosis

AIM

Prior research shows contradictory gender patterns in suicidal behaviour among patients with first-episode psychosis. The aim of this study was to investigate gender differences in the prevalence of suicidal behaviour (suicidal ideation, suicide plans and suicide attempts) and to delineate risk factors for suicidal behaviour among consecutively included male and female patients with first-episode psychosis in the TIPS II early detection study.

METHODS

Patients with first-episode psychosis (n = 246) from a hospital catchment area with a system for early detection were assessed and compared on baseline sociodemographical and clinical variables according to gender. Current (past 1 month) and lifetime prevalence of suicidal behaviour were assessed.

RESULTS

Current and lifetime rates of suicidal behaviour were high (50.8% and 65.9%, respectively) and higher among females (lifetime: 78.3 %, past month: 64.2 %) versus males (lifetime: 56.4 %, past month: 40.7 %). Depressive symptoms and female gender were associated with both lifetime and current risk for suicidal behaviour. Lifetime prevalence was also associated with a longer duration of untreated psychosis and young age after controlling for other risk factors.

CONCLUSIONS

Suicidal behaviour was frequent among patients with first-episode psychosis, with a higher prevalence of suicidal behaviour in females. Depressive symptoms and female gender were significantly associated with suicidal behaviour.

The subjective experience of youths at clinically high risk of psychosis: a qualitative study

OBJECTIVE

Understanding the experience of individuals across stages of schizophrenia is important for development of services to promote recovery. As yet, little is known about the experience of individuals who exhibit prodromal symptoms of schizophrenia.

METHODS

Audiotaped interviews were conducted with 27 participants of diverse racial-ethnic backgrounds who were at clinically high risk of psychosis (15 males and 12 females; mean age 21). Phenomenological qualitative research techniques of coding, consensus, and comparison were used.

RESULTS

Emergent themes differed by gender. Themes for males were feeling abnormal or "broken," focus on going "crazy," fantasy and escapism, and alienation and despair, with a desire for relationships. Themes for females were psychotic illness among family members, personal trauma, struggle with intimate relationships, and career and personal development.

CONCLUSIONS

The finding of relative social engagement and future orientation of females identified as at risk for psychosis is novel and has implications for outreach and treatment.

Short-term functional outcome and premorbid adjustment in clinical high-risk patients. Results of the EPOS project

PURPOSE

In patients with schizophrenia, premorbid psychosocial adjustment is an important predictor of functional outcome. We studied functional outcome in young clinical high-risk (CHR) patients and how this was predicted by their childhood to adolescence premorbid adjustment.

METHODS

In all, 245 young help-seeking CHR patients were assessed with the Premorbid Adjustment Scale, the Structured Interview for Prodromal Syndromes (SIPS) and the Schizophrenia Proneness Instrument (SPI-A). The SIPS assesses positive, negative, disorganised, general symptoms, and the Global Assessment of Functioning (GAF), the SPI-A self-experienced basic symptoms; they were carried out at baseline, at 9-month and 18-month follow-up. Transitions to psychosis were identified. In the hierarchical linear model, associations between premorbid adjustment, background data, symptoms, transitions to psychosis and GAF scores were analysed.

RESULTS

During the 18-month follow-up, GAF scores improved significantly, and the proportion of patients with poor functioning decreased from 74% to 37%. Poor premorbid adjustment, single marital status, poor work status, and symptoms were associated with low baseline GAF scores. Low GAF scores were predicted by poor premorbid adjustment, negative, positive and basic symptoms, and poor baseline work status. The association between premorbid adjustment and follow-up GAF scores remained significant, even when baseline GAF and transition to psychosis were included in the model.

CONCLUSION

A great majority of help-seeking CHR patients suffer from deficits in their functioning. In CHR patients, premorbid psychosocial adjustment, baseline positive, negative, basic symptoms and poor working/schooling situation predict poor short-term functional outcome. These aspects should be taken into account when acute intervention and long-term rehabilitation for improving outcome in CHR patients are carried out.

Premorbid adjustment and schizophrenia in individuals with 22q11.2 deletion syndrome

The literature on idiopathic schizophrenia has consistently reported that poor premorbid functioning precedes onset of psychosis. Individuals with 22q11.2 deletion syndrome (22q11.2DS) are at heightened risk of developing schizophrenia. The present study examined the relationship between adult-onset schizophrenia and social and academic functioning across childhood and early adolescent development in 22q11.2DS.

METHOD

Premorbid adjustment in social and academic domains during childhood (ages 5-11 years) and early adolescence (ages 12-15 years) of 103 adults with 22q11.2DS was assessed using the Premorbid Adjustment Scale (PAS). Linear mixed-models were used to compare PAS scores between the 43 subjects who later developed schizophrenia and the 60 subjects who did not.

RESULTS

Social functioning and academic functioning deteriorated from childhood to early adolescence among those who later developed schizophrenia compared to stable functioning, on average, in those who did not later develop a psychotic disorder. Those who developed schizophrenia had significantly higher PAS scores (indicating poorer functioning) in social (β=0.118, 95% CI: 0.046-0.189) and academic (β=0.072, 95% CI: 0.015-0.129) domains between childhood and early adolescence, independent of the presence of intellectual disability. The two groups had similar PAS scores during childhood.

CONCLUSION

Consistent with the literature on idiopathic schizophrenia, deterioration in social and academic functioning between childhood and early adolescence preceded onset of schizophrenia in this cohort of 22q11.2DS patients, regardless of functioning at baseline. These findings suggest that monitoring for changes in functioning, in addition to emergence of typical symptoms, may help to prevent delays in diagnosis and treatment of major psychotic illness in 22q11.2DS.

The relationship of early premorbid adjustment with negative symptoms and cognitive functions in first-episode schizophrenia: a prospective three-year follow-up study

Premorbid adjustment is an important prognostic factor of schizophrenia. The relationships between sub-components of premorbid adjustment and outcomes on symptoms and cognition in first-episode schizophrenia were under-studied. In the current study, we prospectively followed up 93 patients aged 18-55 years presenting with first-episode schizophrenia-spectrum disorder. Psychopathological and cognitive assessments were conducted at baseline, clinical stabilization, 12, 24 and 36 months. Premorbid adjustment was sub-divided into discrete functional domains, developmental stages and premorbid-course types based on ratings of the Premorbid Adjustment Scale (PAS). The study focused on early developmental stages to minimize contamination by prodromal symptoms. Results indicated that gender differences in premorbid functioning were primarily related to early-adolescence adjustment and academic domain. Social domain was more strongly related to negative symptoms, while academic domain was more consistently linked to cognitive outcome (Wisconsin Card Sorting test and verbal fluency). Patients with stable-poor premorbid course had more severe negative symptoms and cognitive impairment. In conclusion, in a Chinese cohort of first-episode schizophrenia-spectrum disorder, sub-components of early premorbid adjustment were shown to be differentially related to clinical and cognitive measures. The results highlighted the importance of applying a more refined delineation of premorbid functioning in studying illness outcome.

The influence of gender on clinical and social characteristics of patients at psychosis onset: A report from the Psychosis Incident Cohort Outcome Study (PICOS)

BACKGROUND. This paper examined the hypothesis that males with first-episode psychosis (FEP) experience lower pre-morbid adjustment, greater social disability and more self-perceived needs at illness onset than females(by controlling for duration of untreated psychosis, diagnosis, age and symptoms at onset). Results disconfirming this hypothesis were thought to suggest the potentially mediating role of social context in determining the impact of symptoms and disability on the everyday lives of male patients in the early phase of psychosis. METHOD. A large epidemiologically representative cohort of FEP patients (n=517) was assessed within the Psychosis Incident Cohort Outcome Study (PICOS) framework – a multi-site research project examining incident cases of psychosis in Italy's Veneto region. RESULTS. Despite poorer pre-morbid functioning and higher social disability at illness onset, males reported fewer unmet needs in the functioning domain than females did. An analysis of help provided by informal care givers showed that males received more help from their families than females did. This finding led us to disconfirm the second part of the hypothesis and suggest that the impact of poorer social performance and unmet needs on everyday life observed in male patients might be hampered by higher tolerance and more support within the family context.CONCLUSIONS. These findings shed new light on rarely investigated sociocultural and contextual factors that may account for the observed discrepancy between social disability and needs for care in FEP patients. They also point to a need for further research on gender differences, with the ultimate aim of delivering gender-sensitive effective mental health care.

Similarities in early course among men and women with a first episode of schizophrenia and schizophreniform disorder

The aims of this study were to analyze the presence of gender differences in the phenotypic expression of schizophrenia at the onset of illness and to explore whether these differences determine clinical and functional outcome 2 years after the initiation of treatment. Data from 231 first-episode-psychosis non-substance-dependent patients (156 men and 75 women) participating in a large-scale naturalistic open-label trial with risperidone were recorded at inclusion and months 1, 6, 12, and 24. Men presented a significant earlier age of onset (24.89 years vs. 29.01 years in women), poorer premorbid functioning, and a higher presence of prodromal and baseline negative symptoms. Women were more frequently married or lived with their partner and children and more frequently presented acute stress during the year previous to onset than men. No other significant clinical or functional differences were detected at baseline. The mean dose of antipsychotic treatment was similar for both genders during the study, and no significant differences in UKU scores were found. The number of hospitalizations was similar between groups, and adherence was more frequent among women. At the 2-year follow-up, both groups obtained significant improvements in outcome measures: PANSS, CGI severity, and GAF scores. Significant gender * time interactions were detected for negative and general PANSS subscales, with the improvement being more pronounced for men. However, no differences were detected for the mean scores obtained during the study in any outcome measure, and the final profile was similar for men and women. Our results suggest that although the initial presentation of schizophrenia can differ according to gender, these differences are not sufficient enough to determine differentiated outcome 2 years after the initiation of treatment in non-substance-dependent patients. The influence of gender on the early course of schizophrenia does not seem to be clinically or functionally decisive in this population.

Gender differences in remission and recovery of schizophrenic and schizoaffective patients: preliminary results of a prospective cohort study

The aim of the paper was to evaluate rates of clinical remission and recovery according to gender in a cohort of chronic outpatients attending a university community mental health center who had been diagnosed with schizophrenia and schizoaffective disorder according to DSM-IV-TR. A sample of 100 consecutive outpatients (70 males and 30 females) underwent comprehensive psychiatric evaluation using the Structured Clinical Interview for Diagnosis of Axis I and II DSM-IV (SCID-I and SCID-II, Version R) and an assessment of psychopathology, social functioning, clinical severity, subjective wellbeing, and quality of life, respectively by means of PANSS (Positive and Negative Syndrome Scale), PSP (Personal and Social Performance), CGI-SCH (Clinical Global Impression-Schizophrenia scale), SWN-S (Subjective Well-being under Neuroleptics-scale), and WHOQOL (WHO Quality of Life). Rates of clinical remission and recovery according to different criteria were calculated by gender. Higher rates of clinical remission and recovery were generally observed in females than males, a result consistent with literature data. Overall findings from the paper support the hypothesis of a better outcome of the disorders in women, even in the very long term.

Neurodevelopmental liability to schizophrenia: the complex mediating role of age at onset and premorbid adjustment

Large individual variation in the clinical presentation of schizophrenia-spectrum disorders raises key questions regarding their aetiological underpinnings. In this respect, age at onset of the disorder is a particularly interesting marker of liability, as it has been reported to be associated with other signs of developmental compromise, such as male gender, increased presence of familial history of psychosis and poor premorbid adjustment, as well as a more severe clinical outcome in terms of cognition and symptomatology. The association between these variables has encouraged a neurodevelopmental perspective of the aetiological mechanisms involved in the pathophysiology of schizophrenia. However, the complex relationships within neurobiological liability markers, and between these markers and clinical outcome, remain to be understood. In the present study, we used a path-analytic approach to explore: i) the fit of the model to observed data; and both ii) direct and iii) indirect associations between the variables. In a sample of 106 patients with schizophrenia-spectrum disorders, we found a good fit of the model to the observed data, providing further evidence that supports a neurodevelopmental pathway to the disease in a subgroup of patients. However, the most parsimonious model showed complex relationships, where age at onset and premorbid functioning acted as mediators between gender, familial history of psychosis and clinical outcome. These findings refine earlier explanations of the neurobiological basis of schizophrenia, with potential applications in genetic studies based on more homogeneous forms of the disease. We further discuss the putative implications of our results in clinical practice and prevention policies.

The genetics of sex differences in brain and behavior

Biological differences between men and women contribute to many sex-specific illnesses and disorders. Historically, it was argued that such differences were largely, if not exclusively, due to gonadal hormone secretions. However, emerging research has shown that some differences are mediated by mechanisms other than the action of these hormone secretions and in particular by products of genes located on the X and Y chromosomes, which we refer to as direct genetic effects. This paper reviews the evidence for direct genetic effects in behavioral and brain sex differences. We highlight the 'four core genotypes' model and sex differences in the midbrain dopaminergic system, specifically focusing on the role of Sry. We also discuss novel research being done on unique populations including people attracted to the same sex and people with a cross-gender identity. As science continues to advance our understanding of biological sex differences, a new field is emerging that is aimed at better addressing the needs of both sexes: gender-based biology and medicine. Ultimately, the study of the biological basis for sex differences will improve healthcare for both men and women.

Gender differences in patients presenting with first-episode psychosis in Hong Kong: a three-year follow up study

OBJECTIVE

The aim of the current study was to investigate gender differences with respect to pre-treatment characteristics, clinical presentation, service utilization and functional outcome in patients presenting with first-episode psychosis.

METHODS

A total of 700 participants (men, n = 360; women, n = 340) aged 15 to 25 years consecutively enrolled in a territory-wide first-episode psychosis treatment programme in Hong Kong from July 2001 to August 2003 were studied. Baseline and three-year follow up variables were collected via systematic medical file review.

RESULTS

At service entry, men had significantly lower educational attainment (p < 0.01), longer median duration of untreated psychosis (p < 0.001), fewer past suicidal attempts (p < 0.01), more severe negative symptoms (p < 0.05) and fewer affective symptoms (p < 0.01) than women. There was no significant gender difference in age of onset. In three-year follow up, men had more prominent negative symptoms (p < 0.001), fewer affective symptoms (p < 0.01), more violent behaviour and forensic records (p < 0.01), and higher rate of substance abuse (p < 0.01). Women achieved higher levels of functioning than men (Social Occupational Functioning Assessment Scale (SOFAS), p < 0.001) and a significantly higher proportion of women than men engaged in full-time employment or study for at least 12 consecutive months (p < 0.001) in the initial three years after psychiatric treatment.

CONCLUSION

Notable gender differences in clinical profiles, illness trajectory and functional outcome were demonstrated in Chinese young people suffering from first-episode psychosis. Differential needs between men and women and hence gender-specific therapeutic strategies should be considered in early intervention service.

What do individuals with schizophrenia need to increase their well-being

The aim of this qualitative study was to deepen the knowledge of how individuals with schizophrenia themselves describe what they need in order to increase their well-being in everyday life. Seven patients were interviewed. An open explorative approach was applied and grounded theory was used for the analysis resulting in five categories illustrating how patients with schizophrenia handle their struggle for a normal life. The patients stressed first the importance of receiving information about the disease: for themselves, for society, and for their families. Taking part in social contacts such as attending meeting places and receiving home visits were identified as important as well as having meaningful employment. They also pointed out the importance of taking part in secure professional relationships. Mainly they expressed the need for continuity in the relationships and the wish to be heard and seen by the professionals. Finally, interviewees addressed the need for support for sustaining independent living through practical housekeeping and financial help. To conclude, the participants in the present study described their need for help as mainly linked to activities in their overall life situation rather than just their psychosis.

Gender differences in premorbid, entry, treatment, and outcome characteristics in a treated epidemiological sample of 661 patients with first episode psychosis

OBJECTIVES

Gender differences in psychotic disorder have been observed in terms of illness onset and course; however, past research has been limited by inconsistencies between studies and the lack of epidemiological representative of samples assessed. Thus, the aim of this study was to elucidate gender differences in a treated epidemiological sample of patients with first episode psychosis (FEP).

METHODS

A medical file audit was used to collect data on premorbid, entry, treatment and 18-month outcome characteristics of 661 FEP consecutive patients treated at the Early Psychosis Prevention and Intervention Centre (EPPIC), Melbourne, Australia.

RESULTS

Prior to onset of psychosis, females were more likely to have a history of suicide attempts (p=.011) and depression (p=.001). At service entry, females were more likely to have depressive symptoms (p=.007). Conversely, males had marked substance use problems that were evident prior to admission (p<.001) and persisted through treatment (p<.001). At service entry, males also experienced more severe psychopathology (p<.001) and lower levels of functioning (GAF, p=.008; unemployment/not studying p=.004; living with family, p=.003). Treatment non-compliance (p<.001) and frequent hospitalisations (p=.047) were also common for males with FEP. At service discharge males had significantly lower levels of functioning (GAF, p=.008; unemployment/not studying p=.040; living with family, p=.001) compared to females with FEP.

CONCLUSIONS

Gender differences are evident in illness course of patients with FEP, particularly with respect to past history of psychopathology and functioning at presentation and at service discharge. Strategies to deal with these gender differences need to be considered in early intervention programs.

Gender differences in first episode psychosis

BACKGROUND

In the description of 1 episode schizophrenia patients, female gender is associated with better social function and a higher degree of compliance, while males exhibit more negative symptoms and a higher degree of abuse. The question is raised whether gender specific differences exist which should be taken into consideration in order to provide optimal treatment for the patients.

METHODS AND MATERIAL

Data from 269 persons (181 men and 88 women), included in the Danish national schizophrenia project (DNS), were registered at inclusion and year 2, and were analyzed according to gender, social functioning, psychopathology, drug consumption and abuse during the course of 2 years treatment.

RESULTS

Women had longer duration of illness before treatment and exhibited more affective symptoms while men were more socially isolated and had more negative symptoms. Alcohol and drug abuse appeared significantly more among men. Women were comparatively more heavily medicated than men. Social function, PANSS negative, drug consumption, affective symptomatology and abuse improved significantly after 2 years follow-up.

CONCLUSION

The gender differences demonstrated in the study suggest gender specific treatment interventions in order to provide optimal treatment for both male and female patients.

Body mass index (BMI) of drug-naïve psychotic adolescents based on a population of adolescent psychiatric inpatients

OBJECTIVE

To investigate the connection between overweight and first-episode schizophrenia spectrum as well as non-schizophrenia spectrum psychiatric disorders in adolescent male and female drug-naïve psychiatric inpatients, whose illness was early onset.

METHOD

Three hundred twenty-three adolescents with no past or present psychiatric medication, 12-17 years of age, admitted to the psychiatric inpatient care (Oulu University Hospital, Northern Finland) between April 2001 and March 2006. DSM-IV diagnoses were based on the "Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime" (K-SADS-PL). An adolescent was defined as overweight if his or her BMI was greater than or equal to the 85th percentile.

RESULTS

Overweight values were highest in drug-naïve adolescent boys with first-episode schizophrenia spectrum (RR: 2.5, 95%CI: 1.08-4.29) and non-schizophrenia spectrum (RR: 2.80, 95%CI: 2.20-3.45) disorders. The RR in girls with non-schizophrenia spectrum disorders was 1.73 (95%CI: 1.31-2.23), but in those with first-episode schizophrenia spectrum disorders RR did not differ from general population.

CONCLUSIONS

In our study sample of first-episode schizophrenia spectrum drug-naïve adolescents, overweight was shown to be prevalent in all diagnostic groups other than first-episode schizophrenia spectrum psychotic girls. To the best of our knowledge, this is the first study in which overweight was analyzed and verified among drug-naïve adolescent boys, suffering from first-episode schizophrenia spectrum disorder. To what extent our results are applicable to other regions and study groups, remains to be seen.

Premorbid adjustment, symptom development and quality of life in first episode psychosis: a systematic review and critical reappraisal

OBJECTIVE

To systematically review the relationship of premorbid adjustment to symptomatology in first episode psychosis (FEP), taking into account the influence of duration of untreated psychosis (DUP).

METHOD

Electronic databases were searched to identify relevant studies.

RESULTS

A variety of approaches to the reporting of premorbid adjustment were identified. There was no significant association between premorbid adjustment and DUP, supporting the proposition that they are independent constructs. The effect of premorbid adjustment upon positive symptomatology was negligible. Premorbid adjustment had a modest effect upon negative symptoms and quality of life, increasing over duration of follow-up.

CONCLUSION

Premorbid adjustment remains a valid construct in the study of FEP. Both premorbid adjustment and DUP confer independent effects on aspects of symptomatology in FEP. Results for premorbid adjustment are similar to previous findings in more chronic samples. The potential for conceptualizing premorbid functioning by developmental, academic/social and typological approaches is currently underexploited.

Do women express and experience psychosis differently from men? Epidemiological evidence from the Australian National Study of Low Prevalence (Psychotic) Disorders

OBJECTIVE

To examine how women differ from men in their expression and experience of psychosis.

METHOD

Using an epidemiological sampling frame, 1090 cases of psychosis (schizophrenia, schizoaffective disorder, affective psychoses, and other psychoses) were randomly selected from a catchment of 1.1 million people as part of the Australian Study of Low Prevalence (Psychotic) Disorders. Women and men were compared with respect to their premorbid functioning, onset and course of illness, symptomatology, levels of disability and service utilization.

RESULTS

Results within diagnostic groupings confirm differences in how men and women experience and express their illness. Within each diagnostic group, women reported better premorbid functioning, a more benign illness course, lower levels of disability and better integration into the community than men. They were also less likely to have a chronic course of illness. There were no significant differences in age at onset. Differences between women across the diagnostic groups were more pronounced than differences between women and men within a diagnostic group. In particular, women with schizophrenia were severely disabled compared to other women.

CONCLUSIONS

These comparisons across diagnostic groupings are among the most systematic and comprehensive in the literature. It is likely that several mechanisms are needed to explain the differences. Greater social integration and functioning in women across diagnostic groups may well reflect culturally and socially determined gender differences. In contrast, variability and attenuated findings with respect to symptom profiles beg the question of biological mechanisms with some degree of specificity.

Gender differences in young adults with first-episode schizophrenia spectrum disorders at baseline in the Danish OPUS study

Gender differences in age at first onset, duration of untreated psychosis, psychopathology, social functioning, and self-esteem were investigated in a group of 578 young adults with a first-episode schizophrenia spectrum disorder. The mean age at first-onset of symptoms, age at first contact, and duration of untreated psychosis were similar for men and women. Men had more severe negative symptoms, poorer premorbid functioning, and poorer social networks, whereas women had more severe hallucinations. More men than women were substance abusers, were unemployed, and lived alone. Women had poorer self-esteem than men, in spite of better scores in functioning. Premorbid social adjustment was significantly related to the level of negative symptoms and number of friends. Conclusion is that men and women with first-episode psychosis showed different psychopathological characteristics and different social functioning, which cannot be explained by older age of onset for women. Women make more suicide attempts and experience lower self-esteem in spite of better social functioning.

Gender differences in the prediction of 5-year outcome in first episode psychosis

OBJECTIVE

To examine gender differences in prediction of long-term outcome in first episode psychosis (FEP).

METHOD

Eighty-one male and 72 female FEP patients were compared regarding the sensitivity and specificity of the Predictive Rating Scale (PRS). The contributions of pre-admission clinical and socio-demographic characteristics to a poor 5-year outcome were analysed for males and females separately. Gender differences in the relations between predictors and outcome were examined using the equality of correlation comparing correlation coefficients.

RESULTS

The sensitivity of the PRS was significantly better for males than for females. The following items: 'the highest Global Assessment of Functioning (GAF) the year before first admission < or =70' and 'GAF at first admission < or =30' explained most of the variance of a poor 5-year outcome for males, whereas for females the corresponding items were 'the highest educational level is compulsory school', 'living with parents' and 'contact with friends < or =2-3 times/month'. When the PRS was adapted assigning a weight of two to the item 'the highest educational level is compulsory school' for females, the sensitivity increased.

CONCLUSION

This study revealed that the predictors for poor outcome differ between male and female patients with FEP.

Differential patterns of premorbid academic and social deterioration in patients with schizophrenia

Schizophrenia is a neurodevelopmental disorder that is characterized by a number of behavioral abnormalities that are present prior to onset. These premorbid abnormalities may serve as unique markers for the disorder. The current study examines academic and social functioning prior to schizophrenia onset in a group of 58 males diagnosed with schizophrenia. The pattern of deterioration for social and academic functioning was examined across three age periods including childhood, early adolescence, and late adolescence, using the retrospective Premorbid Adjustment Scale (PAS). Results indicated that while increasing deterioration was present for both social and academic adjustment across age periods, there was a significant difference in deterioration between academic and social functioning (p<.05) during late adolescence, with greater deterioration in academic functioning. Results of the current study suggest that premorbid academic functioning is particularly susceptible to deterioration during late adolescence, with accelerating deterioration as schizophrenia onset becomes imminent. When considered together with results from other studies, the present findings suggest that deterioration in premorbid academic functioning from early to late adolescence may be a unique premorbid marker for schizophrenia.

Pharmacogenomics of multigenic diseases: sex-specific differences in disease and treatment outcome

Numerous genetic variations have been shown to affect disease susceptibility and drug response. Pharmacogenomics aims at improving therapy on the basis of genetic information for each individual patient. Furthermore, sex chromosomes broadly determine biological differences between males and females. Consequently, substantial sex differences exist in phenotypic manifestation of disease and treatment response. This review discusses the role of sex in coronary artery disease, schizophrenia, and depression--complex multigenic disorders with considerable sex differences in frequency and presentation. Moreover, genetic factors underlying disease and drug response appear to differ between male and female patients. This appears to result at least in part from different physiological effects exerted by sex hormones such that polymorphisms in susceptibility genes may have physiological relevance only in males or females. However, few examples have been discovered to play a role in complex multigenic diseases, and the mechanistic basis of genetic variants as sex-dependent susceptibility factors has yet to be explored. Therefore, pharmacogenomic studies must consider sex differences in an effort to optimize individual drug therapy.