Comparison of the long-term treatment outcomes of women and men diagnosed with schizophrenia over a period of 20 years. A prospective study☆
Introduction
Gender, alongside age of onset, marital status and education, is a demographic prognostic factor of schizophrenia that has seen a great interest of researchers. One of the first to indicate the significance of gender in the course of schizophrenia was Manfred Bleuler [1] who diagnosed a far higher incidence of ‘broken homes’ and loss of one parent, usually a father, in men, and consequently a negative impact of these phenomena on the subsequent course of illness. Researchers who found more favourable course of schizophrenia in women stressed that one of the decisive factors is their later age at onset [6,9,10,14], better premorbid social and cognitive functioning, as well as a higher educational and professional attainments being a result of a more successful socialization [[2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13]]. Moreover, most women before the onset of psychosis have left their family of origin, got married or have a long-term partner and children [16,17].
The most frequently cited argument concerning later age at onset of schizophrenia in women is one of ‘oestrogen protection’ and the ‘neuroleptic’ effect of this hormone that makes women less susceptible to develop psychosis than men, that may also explain more frequent onset and more severe course of illness in premenstrual, postpartum, and postmenopausal phases [11,14]. In case of women, heightened stress is more often observed in the year preceding onset of illness [16], while among men substance abuse is more common in the period before the onset [19]. It has been suggested that the change in the initially more favourable situation of women may be dependent on the protective role of oestrogens [20,21] and the influence of stress connected with the dual roles of professional work and running the household [22].
Another interesting research area is gender-differentiated psychopathology. Clinical experience indicates that psychotic symptoms in women differ in quality from those displayed by men in terms of their hallucinatory content. Their superficial rationality can be misleading causing clinicians to make errors in assessing schizophrenia in women. Moreover, calmer behaviour of women tends to arouse less unease in their immediate circle [15] and they have more favourable responses both to pharmacological treatment [23] and in compliance [2]. It has been observed that among women, irrespective of their age at onset, negative symptoms are less intense [4,15], hospitalizations briefer and less frequent, and the course of the illness less severe [14,24], whereas men are more likely to demonstrate prodromal symptoms, and their clinical presentation is dominated by negative symptoms such as flat affect, deficiency of activity or withdrawal from community [7,16,18].
In the past, it was believed that throughout years of illness, women maintain superior skills and social competences compared to men [2,6] and achieve more favourable treatment results [[25], [26], [27]]. More recent research Ochoa et al. [19] also confirmed longer and more stable remission periods and fewer relapses in women. However, long-term studies [4,31,34] displayed that the differences favouring women prior to onset and in the initial period of illness in terms of clinical and social functioning, due to later age at onset and higher level of social functioning [35], diminished in successive years. Angemeyer and Kühn [5] found that, irrespective of the assessing time period (5 years, between 5 and 10 years, and over 10 years from schizophrenia onset), the percentage spread of the results was similar for men and women, that was also confirmed in other studies [[28], [29], [30],33]. According to Marneros et al. [34] and Diaz-Caneja et al. [32] gender of the study subjects is of no prognostic value, and the more favourable course of illness in women could only be related to short- and medium-term assessments and be attributable to estrogen function.
In the Mannheim study [35] women, despite having similar long-term treatment outcomes to men, reported greater satisfaction with many aspects of their lives due to better cooperation in treatment and a greater capacity to accept a situation in which they found themselves.
Section snippets
Research objective
The objective of the study was to describe and compare the dynamics of the course of illness in the group of men and women suffering from schizophrenia, at the point of first hospitalization and in their long-term treatment outcomes. Three detailed research objectives were identified:
- 1.
Assessment and comparison of demographic, social and clinical indicators between women and men during their index psychiatric hospitalization.
- 2.
Assessment and comparison of the clinical and social outcomes of
Material and methods
The initial group of 80 people hospitalized for the first time at the Psychiatric Clinic of the University Hospital in Cracow and diagnosed with schizophrenia by clinical interview on a basis of DSM III (and re-diagnosed after 12 years in accordance to DSM-IV-R) was selected. Conditions for inclusion in the study were: minimum age of 18 years, lack of organic brain disorder and dependence on substances, exclusion of mental retardation, living in Cracow, lack of previous psychiatric
The study group at index hospitalization
Seven detailed indicators used in the demographic and social assessment are presented in the table below.
It was found that the women on average experienced onset of schizophrenia three and a half year later than the men (p = 0.027), and that their overall social functioning was better than that of the men (p = 0.009). Prior to the index psychiatric hospitalization the women had more satisfying extra-familial social relations (p = 0.008) and half of them had started a family, compared to only
Results
Evaluation of the results was presented in three separate areas: 1) clinical, 2) social and familial, and 3) regarding subjective quality of life (QoL), for the men and the women separately and including comparisons of the two groups.
Discussion
The obtained results confirm previous findings [[2], [3], [4], [5], [6], [7], [8], [9], [10],32,36,38,39] regarding differences between women and men prior to and at the onset of schizophrenia. In our study gender differences in favour of women observed at the index hospitalization were attributed to later age at onset, a less frequent personality disorder, lower symptom severity, and, above all, better social and professional competencies being a result of a more successful socialization and
Conclusions
- 1.
The initial differences between men and women in terms of symptom severity in favour of women fade out in 20-year course of illness.
- 2.
No significant differences between men and women in clinical outcomes were found in long-term observations.
- 3.
Over the years of illness, differences between men and women in terms of social functioning, employment and subjective quality of life are not statistically significant, but a trend towards more favourable outcome in women is observed.
- 4.
Over the course of the
Study limitations
There are circumstances which may have influenced the obtained results and their representativeness for a wider population. Those eligible to participate in the study were adults – aged over 18 – which may have limited the population of men, who tend to experience onset of schizophrenia at an earlier age [10]. The study was conducted in Cracow, a large academic city with extensive educational and employment opportunities, and this may also have influenced the representativeness of the study
Acknowledgment
The research presented in the attached manuscript was founded from the research grant no. KBN 501/G/573 (2006–2009) an internal grant of the Chair of Psychiatry, Collegium Medicum, Jagiellonian University in Cracow, Poland.
References (45)
- et al.
Estrogen inhibits the dopamaminergic supersensitivity induced by neuroleptics
Life Sci
(1982) - et al.
Long-term clinical course and outcome of schizophrenia in rural Ethiopia: 10-year follow-up of a population based cohort
Schizophr Res
(2015) - et al.
Premorbid asocial adjustment and prognosis in schizophrenia
J Psychiatr Res
(1969) Die schizophrenen Geistesstoerungen im Lichte langjähriger Kranken- und Familiengeschichten
(1972)- et al.
Trial of maintenance therapy in schizophrenia
Br Med J
(1971) One-year follow-up. The Scottish Schizophrenia Research Group
Br J Psychiatry
(1988)- et al.
Gender, premorbid social functioning and long-term outcome in DSM III schizophrenia
Schizophr Bull
(1990) - et al.
Gender and course of schizophrenia: differences in treated outcome
Schizophr Bull
(1990) The significance of age of onset for schizophrenia
Schizophr Bull
(1992)- et al.
Gender differences in social functioning
Causes and consequences of the gender difference in age at onset of schizophrenia
Schizophr Bull
Women and schizophrenia
Age of onset of schizophrenia: perspectives from structural neuroimaging studies
Schizophr Bull
Psychopathological long-term outcome of schizophrenia – a review
Acta Psychiatr Scand
Odrębność schizofrenii u mężczyzn i kobiet
Psychiatr Pol
Women and schizophrenia: clinical aspects
Similarities in early course among men and women with a first episode of schizophrenia and schizophreniform disorder
Eur Arch Psychiatry Clin Neurosci
Różnice w czynnikach rokowniczych między mężczyznami i kobietami hospitalizowanymi po raz pierwszy z rozpoznaniem schizofrenii
Psychiatr Pol
Psychiatric illness in women
Gender differences in schizophrenia and first-episode psychosis: a comprehensive literature review
Schizophr Res Treat
The role of estrogens in schizophrenia gender differences
Schizophr Bull
The role of estrogen in schizophrenia
J Psychiatry Neurosci
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Paper researched and written by the Cracow Schizophrenia Research Group.