Psychopathology in women and men: focus on female hormones

OBJECTIVE

The goal of this overview is to examine male/female differences in psychopathology in light of the known effects of gonadal steroids, especially estradiol, on neural function.

METHOD

The epidemiology of specific psychopathological syndromes is highlighted with respect to male/female differences and discussed against the backdrop of recent neuroendocrine findings.

RESULTS

A number of differences between the sexes in rates of illness and course of illness are documented, with Alzheimer's disease, schizophrenia, alcoholism, and mood and anxiety disorders each illustrating slightly different hormone-mediated risks and buffers.

CONCLUSIONS

Estrogens are neuroprotective with respect to neuronal degeneration, growth, and susceptibility to toxins. The cyclic fluctuations of estrogens and progesterone enhance the response to stress, which confers susceptibility to depression and anxiety.

The role of estrogens in schizophrenia gender differences

The male/female differences that have been described in schizophrenia are important because they may ultimately shed light on factors that mediate the expression of schizophrenic illness. The hypothesis of this article is that estrogens, either directly or indirectly, modify symptom expression and account for many of the observed gender differences. The role of sex hormones is divided into organizational and activational effects. Organizational effects take place during a critical period in fetal life and put a permanent stamp on the developing brain. Activational effects are the direct influences of circulating hormones that appear when hormonal levels rise, and wane when hormonal levels drop. Because levels of sex hormones in adult women fluctuate during the menstrual cycle, cyclic effects of high and low female hormones may induce specific responses by the adult female brain. All these effects have implications for genetic, environmental, pharmacological, neurocognitive, clinical, and epidemiological research in schizophrenia.

Gender differences in the prescribing of antipsychotic drugs

OBJECTIVE

The aim of this article is to offer recommendations and rationale for gender-specific antipsychotic treatment.

METHOD

The author summarizes reviews of recent literature in psychiatric clinical trials, pharmacology, drug safety, toxicology, obstetrics and gynecology, and pediatrics.

RESULTS

The pharmacokinetics and pharmacodynamics of antipsychotic drugs differ in women and men and are influenced by gender-specific factors such as body build, diet, smoking, concurrent medication, exercise, substance use, and hormonal transitions. In general, and for some drugs in particular, women require lower doses in order to stay well. Because preliminary drug testing is not done in pregnant women, the issue of effective dosing during pregnancy is unstudied, and safety for fetuses and nursing infants may not become evident until a drug is widely used. Specific adverse effects on issues crucial to women (e.g., parenting) have not been well studied, but some side effects, such as weight gain, passivity, hypotension, and hyperprolactinemia, are reported to be particularly problematic for women. Some serious side effects are more often seen among women than among men.

CONCLUSIONS

Optimal maintenance regimens of antipsychotics for women and men are not the same.

Gender differences in schizophrenia

men with schizophrenia have an earlier age of onset, a somewhat inferior response to treatment and a generally poorer prognosis than women. These findings can perhaps be explained by the existence of two distinct forms of the illness, one with early onset, primarily affecting men, and one with later onset, primarily affecting women. There is not much evidence for this first view. Alternatively, non-specific cumulative stress factors may impinge selectively on the male, reaching the threshold of demonstrable illness at an earlier age. A third possibility is the existence of specific biological protective factors in the female, such as relatively bilateral representation of left hemisphere functions or relative dopaminergic inhibition by estrogens.

Secondary effects of antipsychotics: women at greater risk than men

CONTEXT

The health burden of antipsychotic medication is well known, but the disproportionate effect on women as compared with men is underappreciated.

OBJECTIVE

The goal of this article is preventive--to better inform clinicians so that the risks to women and to their offspring can be diminished.

METHOD

All PubMed sources in which the search term gender (or sex) was linked to a side effect of antipsychotic medication were reviewed.

RESULT

There is general agreement in the literature on women's increased susceptibility to weight gain, diabetes, and specific cardiovascular risks of antipsychotics, with less consensus on malignancy risks and risks to the fetus. Cardiovascular death, to which men are more susceptible than women, is disproportionately increased in women by the use of antipsychotics. Sedating antipsychotics raise the risk of embolic phenomena during pregnancy, and postpartum. Prolactin-elevating drugs suppress gonadal hormone secretion and may enhance autoimmune proclivity.

CONCLUSIONS

Clinicians need to be aware of the differential harm that women (and their offspring) can incur from the side effects of antipsychotics.

Current outcome in schizophrenia: women vs men

This article reviews the 1980's literature on gender differences in schizophrenia outcome. Neuroleptic response, long-term course, and housing, appear to be superior in women. Mortality ratios are advantageous to schizophrenic men. After menopause, women may require higher neuroleptic doses than men and are more at risk for severe tardive dyskinesia. The antidopaminergic effects of estrogens appear to be responsible for some of the outcome differences.

Does Gender Influence Outcome in Schizophrenia?

Good outcome of schizophrenia has several meanings and most of these meanings carry both positive and negative undertones depending on perspective. Currently, a person's subjective sense that illness has been partly overcome and that life is meaningful has come to be viewed as the most valid signpost of a good outcome. A review of the literature shows that women have certain advantages over men in that their illness starts at a later age and that their symptoms respond more quickly and more completely to available treatments. These advantages serve women well at the outset of illness but benefits appear to dissipate over time. Gender differences in outcome thus vary depending on the age of the patient. They also vary with the social and cultural background of the study population. Neither sex, therefore, has a monopoly on good outcome. The hope is that studying gender differences will uncover critical elements of good outcome that lead to interventions that will benefit both women and men.

Men and women respond differently to antipsychotic drugs

BACKGROUND

Because women are often perceived as having better outcomes than men in psychotic illnesses such as schizophrenia - women are less often in hospital, have a lower suicide rate, are less often involved with the law, enjoy better relationships with family and friends - the question arises as to whether or not this apparent advantage is attributable to a gender difference in antipsychotic response.

OBJECTIVE

The aim of this paper is to critically review the quantitative and qualitative literature on gender difference in antipsychotic response sourced mainly from medical databases of the last ten years.

FINDINGS

There are theoretical reasons why women's effective doses of antipsychotics might need to be lower than guidelines recommend for men, especially as regards olanzapine and clozapine, but, because there are so many variables that impinge on antipsychotic response, it is difficult to provide definitive guidance. What is evident is that some antipsychotic side effects, weight gain for instance, are more worrisome for women than for men. It is also evident that, after menopause, women need an increase in their antipsychotic dose; other reproductive stages in women's lives require special prescribing considerations as well.

CONCLUSION

There is a science, and an art, to prescribing antipsychotics, which needs to take gender into account. This article is part of the issue entitled 'Special Issue on Antipsychotics'.

Is schizophrenia a dopamine supersensitivity psychotic reaction?

Adolf Meyer (1866-1950) did not see schizophrenia as a discrete disorder with a specific etiology but, rather, as a reaction to a wide variety of biopsychosocial factors. He may have been right. Today, we have evidence that gene mutations, brain injury, drug use (cocaine, amphetamine, marijuana, phencyclidine, and steroids), prenatal infection and malnutrition, social isolation and marginalization, can all result in the signs and symptoms of schizophrenia. This clinical picture is generally associated with supersensitivity to dopamine, and activates dopamine neurotransmission that is usually alleviated or blocked by drugs that block dopamine D2 receptors. While the dopamine neural pathway may be a final common route to many of the clinical symptoms, the components of this pathway, such as dopamine release and number of D2 receptors, are approximately normal in schizophrenia patients who are in remission. Postmortem findings, however, reveal more dimers of D1D2 and D2D2 receptors in both human schizophrenia brains and in animal models of schizophrenia. Another finding in animal models is an elevation of high-affinity state D2High receptors, but no radioactive ligand is yet available to selectively label D2High receptors in humans. It is suggested that synaptic dopamine supersensitivity in schizophrenia is an attempt at compensation for the original damage by heightening dopamine neurotransmission pathways (preparing the organism for fight or flight). The dopamine overactivity is experienced subjectively as overstimulation, which accounts for some of the clinical symptoms, with attempts at dampening down the stimulation leading to still other symptoms. Reaction and counter-reaction may explain the symptoms of schizophrenia.

Clinical interventions for women with schizophrenia: pregnancy

OBJECTIVE

A comprehensive treatment program for schizophrenia needs to include services to women of childbearing age that address contraception, pregnancy, and postpartum issues, as well as safe and effective parenting. To update knowledge in these areas, a summary of the recent qualitative and quantitative literature was undertaken.

METHOD

The search terms 'sexuality,''contraception,''pregnancy,''postpartum,''custody,' and 'parenting' were entered into PubMed, PsycINFO, and SOCINDEX along with the terms 'schizophrenia' and 'antipsychotic.' Publications in English for all years subsequent to 2000 were retrieved and their reference lists further searched in an attempt to arrive at a distillation of useful clinical recommendations.

RESULTS

The main recommendations to care providers are as follows: take a sexual history and initiate discussion about intimate relationships and contraception with all women diagnosed with schizophrenia. During pregnancy, adjust antipsychotic dose to clinical status, link the patient with prenatal care services, and help her prepare for childbirth. There are pros and cons to breastfeeding while on medication, and these need thorough discussion. During the postpartum period, mental health home visits should be provided. Parenting support is critical.

CONCLUSION

The comprehensive treatment of schizophrenia in women means remembering that all women of childbearing age are potential new mothers.

Menstrual exacerbation of schizophrenia symptoms

OBJECTIVE

To better understand premenstrual exacerbations of schizophrenia in women and weigh treatment options.

METHOD

A PubMed literature search was conducted, using the search terms 'schizophrenia', 'psychosis', 'menstrual exacerbation', 'hormones' and assessing relevance to premenstrual exacerbation of schizophrenia symptoms.

RESULTS

Exacerbations are usually distinguishable from periodic or menstrual psychosis, a relatively rare condition. Controversy continues about whether low estrogen periods of the month lead to an increase in schizophrenia symptoms among women of reproductive age or whether some women suffer from both schizophrenia and premenstrual dysphoric disorder (PMDD). No treatment trials of specific interventions have been conducted so that physicians must decide on a case-by-case basis whether to raise antipsychotic doses premenstrually, try estrogens or estrogen/progesterone combinations or selective estrogen receptor modulators, or target PMDD symptoms.

CONCLUSION

Clinicians need to be aware of premenstrual symptom aggravation in a large minority of women with schizophrenia. Treatment strategies will depend on the nature of the symptoms that are exacerbated. Optimal treatment needs to be adjusted to the individual woman.

Sex differences in schizophrenia relevant to clinical care

Introduction: Most medical diagnoses present somewhat differently in men and women, more so at specific periods of life. Treatment effects may also differ. This is true for schizophrenia, where premorbid effects are experienced earlier in life in boys than in girls, and where symptoms and outcomes differ.Areas covered: This review does not cover all the differences that have been reported between men and women but, instead, focuses on the ones that carry important implications for clinical care: effective antipsychotic doses, medication side effects, symptom fluctuation due to hormonal levels, comorbidities, and women's requirements for prenatal, obstetric, postpartum, and parenting support.Expert opinion: Of consequence to schizophrenia, sex-biased genes, epigenetic modifications, and sex steroids all impact the structure and function of the brain. Furthermore, life experiences and social roles exert major sex-specific influences. The co-morbidities that accompany schizophrenia also affect men and women to different degrees. This review offers several examples of sex-specific intervention and concludes that gold standard treatment must look beyond symptoms and address all the physiologic, psychologic, and social role needs of men and women suffering from this psychiatric disorder.

Prescribing contraceptives for women with schizophrenia

Although women with serious mental illness have high rates of lifetime sexual partners, they infrequently use contraception. Consequently, the prevalence of sexually transmitted infections is high in this population. In addition, while the overall rate of pregnancy in women with schizophrenia of child-bearing age is lower than in the general population, the percentage of pregnancies that are unwanted is higher than that in the general population. The objective of this paper is to help clinicians explore knowledge of appropriate methods of contraception for women who suffer from schizophrenia. The authors reviewed recent literature on the use of contraceptive methods by women with schizophrenia treated with antipsychotic and adjunctive medications. Contraceptive counseling to women and their partners is an important part of comprehensive care for women with serious and persistent mental illness. Women with schizophrenia who smoke, are overweight, or have diabetes, migraine, cardiovascular disease, or a family history of breast cancer should be offered non-hormonal contraception. Women with more than one sexual partner should be advised on barrier methods in addition to any other contraceptive measures they are using. Clinicians should be alert for potential interactions among oral hormonal contraceptives, smoking, and therapeutic drugs. Long-lasting contraceptive methods, such as intrauterine devices, progesterone depot injections, or tubal ligation are reasonable options for women having no wish to further expand their families.

Eating disorders and psychosis: Seven hypotheses

Psychotic disorders and eating disorders sometimes occur in the same person, and sometimes, but not always, at the same time. This can cause diagnostic confusion and uncertainty about treatment. This paper examines seven ways in which symptoms of both conditions can co-exist. The literature on this topic consists to a large extent of case reports, so that firm conclusions cannot be drawn from their examination. There is no consistent sequence in the co-occurrence of the two conditions-eating disorders sometimes precede, and sometimes follow the onset of psychosis. The advent of the psychosis, and sometimes the treatment of the psychosis can cure the eating disorder, but it can sometimes aggravate it. Psychosis is not necessarily a mark of severity in the course of an eating disorder, and food refusal can occur independent of severity in psychotic illness, but it can be a cause of death. There is some genetic association and some overlap of physiologic, cognitive and brain structure deficits in the two types of disorder. The connection between the two, however, remains speculative. The area of comorbidity and overlapping symptoms in psychiatry requires more research. Clinical recommendations include attention to the different individual ways in which these two disparate conditions often overlap.

Sex and schizophrenia

This paper summarizes male/female contrasts and speculates on how they may influence onset age and outcome differences in schizophrenia.

A service for women with schizophrenia

A program for women with schizophrenia that combines inpatient, outpatient, and outreach services is described. The program was established at the Clarke Institute of Psychiatry at the University of Toronto in 1995. Services include a comprehensive patient and family assessment, with subsequent recommendations to the treating clinician about differential diagnosis, psychopharmacologic and psychosocial treatments, and patient management during pregnancy and early parenthood. Other components of the program are home-based outreach services, substance abuse counseling, instruction of new mothers and parenting training, sex education, relationship-focused groups, and self-protection in an urban environment to prevent victimization. The clinic has established liaisons with pediatricians and gynecologists in the community to provide care to clinic patients. Linkages have also been established with agencies and facilities to fill gaps in the service spectrum, such as fitness programs and leisure activities and children's aid and protection.

Delusional loving

Erotomania is reexamined by an in-depth study of eight patients. There appear to be two main varieties: the phantom lover syndrome, or fixed delusion elaborated around a person who does not exist, and erotomania proper, a recurrent tendency to believe that one is loved by a powerful, prominent man.

Pathological jealousy

Five women with excessive and irrational jealousy of their spouses have long defied my therapeutic efforts and have prompted me to explore the sources and the ramifications of conjugal jealousy. This paper presents my experiences and the formulations that have emerged from them.

Schizophrenia: women bear a disproportionate toll of antipsychotic side effects

BACKGROUND

Men and women with schizophrenia suffer not only from their illness but also from the side effects of their medications.

OBJECTIVE

To review the toll of antipsychotic side effects specifically on women.

STUDY DESIGN

A review of the literature in the PubMed database since 1990 using search terms: sex difference, antipsychotics, schizophrenia, pharmacokinetics, pharmacodynamics, and pharmacogenomics and retrieving additional publications from the reference lists of the original articles.

RESULTS

Findings suggest that, because of differing pharmacokinetics, women are more vulnerable than men to weight gain secondary to antipsychotics and to the consequences (metabolic, cardiovascular, reproductive) of weight gain. They are also more vulnerable to hyperprolactinemia and QTc prolongation.

CONCLUSIONS

Dosing guidelines need to be critically appraised. The greater toll of side effects in women may undermine adherence to prescribed treatments, add to the stigma that attaches to mental illness, and diminish the quality of women's lives. Side effects increase the cost of mental illness and heighten the burden experienced by caregivers. They exacerbate morbidity and raise mortality rates. They affect the children of women treated with antipsychotic medication.

The Pharmacodynamics of Antipsychotic Drugs in Women and Men

Background: Animal and human experiments have confirmed sex differences in the expression of hepatic enzymes that metabolize antipsychotic drugs and that may, in this way, be partly responsible for the clinical sex/gender differences observed in the efficacy and tolerability of antipsychotic treatment. Aim: The aim of this mini review is to synthesize the literature on the pharmacodynamics of male/female differential response to antipsychotic drugs. Method: Relevant search terms were used to search for pre-clinical and human trials and analysis of antipsychotic differential drug response and occurrence/severity of adverse effects in women and men. Results: The search found that sex influences drug response via the amount of a given drug that enters the brain and the number of neurotransmitter receptors to which it can bind. Consequently, sex partly determines the efficacy of a specific drug and its liability to induce unwanted effects. There are other factors that can overshadow or enhance the dimorphic effect of sex, for instance, the host's age, hormonal status, diet and life style as well as the molecular structure of the drug and its dose, and the method of its administration. Most of all, the host's individual genetics affects each step of a drug's pharmacodynamics. Conclusion: On average, women's psychotic symptoms respond to antipsychotic drugs at doses lower than men's. This means that many women may be de facto overdosed and, thus, experience unnecessary adverse effects. That being said, factors such as genetics and age probably determine drug response and tolerability to a greater degree than do biological sex or gender social roles.

Psychiatry in the Nazi era

OBJECTIVES

To update Canadian psychiatrists on recent information from newly discovered Berlin archives about the actions of physicians, especially psychiatrists, during the era of National Socialism in Germany and to encourage introspection about the role of the medical profession, its relationship with government, and its vulnerability to manipulation by ideology and economic pressures.

METHOD

This is a selective review of the literature on the collaboration of physicians, especially psychiatrists, in the sterilization, experimentation, and annihilation of patients with mental illness before and during World War II.

RESULTS

Directed to value the health of the nation over the care of individual patients and convinced that a hierarchy of worth distinguished one person from another, German psychiatrists were enlisted to commit atrocities during the Nazi period.

CONCLUSIONS

The values of care and compassion can be eroded; this knowledge demands constant vigilance.

Antipsychotics and physical attractiveness

BACKGROUND

Antipsychotics are effective in treating the symptoms of schizophrenia, but they may induce adverse effects, some of which-those that impact negatively on physical appearance-have not been sufficiently discussed in the psychiatric literature.

AIM

Through a narrative review, to catalog antipsychotic side effects that interfere with physical attractiveness and to suggest ways of addressing them.

METHOD

PubMed databases were searched for information on the association between "antipsychotic side effects" and "attractiveness" using those two search phrases plus the following terms: "weight," "teeth," "skin," "hair," "eyes," "gait," "voice," "odor." Data from relevant qualitative and quantitative articles were considered, contextualized, and summarized.

RESULTS

Antipsychotics, as a group, increase weight and may lead to dry mouth and bad breath, cataracts, hirsutism, acne, and voice changes; they may disturb symmetry of gait and heighten the risk for tics and spasms and incontinence, potentially undermining a person's attractiveness.

CONCLUSIONS

Clinicians need to be aware of the impact of therapeutic drugs on appearance and how important this issue is to patients. Early in treatment, they need to plan preventive and therapeutic strategies.