Does Gender Influence Outcome in Schizophrenia?

Gender differences in clinical and biochemical parameters among patients hospitalized for schizophrenia: towards precision medicine

BACKGROUND

The scientific literature shows some gender differences in the clinical course of schizophrenia. The aim of this study is to identify gender differences in clinical and biochemical parameters in subjects affected by schizophrenia. This would allow for the implementation of individualized treatment strategies.

METHODS

We examined a large set of clinical and biochemical parameters. Data were obtained from clinical charts and blood analyses from a sample of 555 schizophrenia patients consecutively admitted for exacerbation of symptoms to the inpatient clinic of Fondazione IRCCS Policlinico (Milan) or ASST Monza in Italy from 2008 to 2021. Univariate analyses, binary logistic regression, and a final logistic regression model were performed with gender as dependent variable.

RESULTS

The final logistic regression models showed that male patients (compared to females) were more prone to lifetime substance use disorders (p = 0.010). However, they also had higher GAF (global functioning) mean scores (p < 0.001) at the time of hospitalization. Univariate analyses showed that male patients (with respect to females) had an earlier age at onset (p < 0.001), a more frequent family history of multiple psychiatric disorders (p = 0.045), were more often smokers (p < 0.001), had a more frequent comorbidity with at least one psychiatric disorder (p = 0.001), and less often suffered from hypothyroidism (p = 0.011). In addition, men had higher levels of albumin (p < 0.001) and bilirubin (t = 2.139, p = 0.033), but lower levels of total cholesterol (t = 3.755, p < 0.001).

CONCLUSIONS

Our analyses indicate a less severe clinical profile in female patients. This is evident especially in the early years of the disorder, as suggested by less comorbidity with psychiatric disorders or later age at onset; this is consistent with the related literature. In contrast, female patients seem to be more vulnerable to metabolic alterations as demonstrated by more frequent hypercholesterolemia and thyroid dysfunction. Further studies are needed to confirm these results in the framework of precision medicine.

First episode psychoses in people over-35 years old: uncovering potential actionable targets for early intervention services

The traditional youth-oriented design of Early Intervention Services (EIS) may lead to the exclusion of patients who have their psychotic onset later in life. A retrospective study was conducted to compare first-episode psychosis (FEP) patients who accessed treatment when aged ≤ 35 years with those ≥36+. A total of 854 patients were identified among 46,222 individuals who had access to community psychiatric services from 1991 to 2021. FEP were aged 18-65, received care between 2012 and 2021 and had a diagnosis of affective or non-affective FEP. Two groups were identified (FEP diagnosed at age ≤ 35 vs ≥ 36) and compared for sociodemographic and clinical characteristics. Most patients were diagnosed when aged ≥ 36+ (61.8%). Compared to the ≤ 35 group, older patients were more likely to be women, married and diagnosed with affective psychosis, and they were less frequently hospitalized. Long-acting injectables antipsychotics (LAI) were less frequently prescribed in the ≥ 36+ group, whereas antidepressants were more frequently prescribed compared to those aged ≤ 35. In both age groups, women were less frequently prescribed LAIs compared to men. These findings highlight the need to reorient EIS to accommodate the needs of older FEP, especially women.

Effect of onset age on the long-term outcome of early-onset psychoses and other mental disorders: a register-based Northern Finland Birth Cohort 1986 study

Psychiatric illnesses can affect the social transitions of adolescence and young adulthood, such as completing education and entering working life and relationships. However, associations between earlier onset age and long-term outcomes among those with early-onset psychoses (EOP) are unclear, as are the long-term outcomes of EOP compared to non-psychotic disorders. We used national register data of the Northern Finland Birth Cohort 1986 to detect persons with EOP and other early-onset psychiatric disorders. The long-term clinical and work-family outcomes of persons with onset age before 18 years (n = 41 psychoses, n = 495 non-psychoses) or between 18-22 years (n = 61 psychoses, n = 377 non-psychoses) were compared. Individuals with the onset of psychosis between 18-22 years had significantly more unfavourable long-term outcomes when compared to those with psychosis onset before 18 years. Persons with psychosis onset before the age of 18 years had similar outcomes to those with non-psychotic psychiatric disorder onset before 18 years regarding educational level, marital status, having children, and substance use disorders. Individuals with EOP were more often on a disability pension compared to those with other early-onset mental disorders. Adjusting for sex, educational level and substance use only slightly diluted these results. Unexpectedly, later onset age of EOP was associated with worse outcomes. Those with psychosis onset between 18-22 years of age are in a critical period, which underlines the importance of investing on interventions in this age group. Further studies on the effect of the onset age on later outcomes in EOP are needed.

Sex-specific associations of plasma neutrophil gelatinase-associated lipocalin (NGAL) with cognition in patients with drug-naïve schizophrenia

This present study aimed to investigate the sex-specific association of plasma neutrophil gelatinase-associated lipocalin (NGAL) with cognition in drug-naïve schizophrenia patients for the first time. A total of 204 participants in this study, including 137 drug-naïve schizophrenia (DNS) patients and 67 healthy controls (HCs). All participants completed the Measurements and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery (MCCB), and were collected fasting venous blood for NGAL measurement. DNS patients also complete the Positive and Negative Syndrome Scale (PANSS). Partial correlation analysis and multiple linear regression were used to explore sex-specific associations between NGAL and cognition. All dimensions of MCCB scores were significantly lower in both male and female DNS patients than HCs. Sex differences were significant in cognitive performance in both DNS patients and HCs. Female DNS patients experienced poorer working memory and reason& problem solving than male patients. Female HCs performed a better attention/vigilance and visual learning, a poorer reason& problem solving than male HCs. In patients with DNS, NGAL levels were negatively associated with positive subscale of PANSS and positively associated with working memory and visual learning only in female. However, there was no significant correlation between NGAL levels and all cognitive tests in both male and female HCs. Regression model showed that higher level of NGAL was an independent protective factor for cognitive performance in female patients with DNS, whereas there was no such role in male patients. Our findings suggest sex specificity between NGAL levels and cognitive performance in DNS patients.

Durability of Effects of Cognitive Remediation on Cognition and Psychosocial Functioning in Schizophrenia: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

OBJECTIVE

Cognitive remediation provides substantial improvements in cognitive performance and real-world functioning for people living with schizophrenia, but the durability of these benefits needs to be reassessed and better defined. The aims of this study were to provide a comprehensive assessment of the durability of the benefits of cognitive remediation for cognition and functioning in people living with schizophrenia and evaluating potential moderators of effects.

METHODS

A systematic search was conducted in PubMed, Scopus, and PsycINFO, and reference lists of included articles and Google Scholar were inspected. Eligible studies were randomized clinical trials of cognitive remediation in patients diagnosed with schizophrenia spectrum disorders in which follow-up assessments were included. Screening and data extraction were performed by at least two independent reviewers. Cohen's d was used to measure outcomes. Primary outcomes were changes in cognition and functioning from baseline to conclusion of follow-up. Moderators of the durability of effects were assessed.

RESULTS

Of 2,840 identified reports, 281 full texts were assessed and 130 reports on 67 studies with 5,334 participants were included. Cognitive remediation produced statistically significant positive effects that persisted at the end of follow-up in global cognition (d=0.23) and in global functioning (d=0.26). Smaller study samples and single-center studies were associated with better cognitive outcomes; longer treatment and follow-up duration, techniques for transferring cognitive gains to the real world, integration with psychiatric rehabilitation, group format of delivery, and more female participants in the sample were associated with better functional outcomes.

CONCLUSIONS

Cognitive remediation provides durable improvements in cognition and functioning in schizophrenia. This finding corroborates the notion that cognitive remediation should be implemented more widely in clinical and rehabilitation practice.

Gender Differences in Prevalence and Associated Factors of Dyslipidemia in Initial-Treatment and Drug-Naïve Schizophrenia Patients

Background

Dyslipidemia is frequently comorbid with schizophrenia (SCZ), and both conditions often demonstrate significant gender differences in their clinical features. This study specifically focuses on investigating the prevalence of dyslipidemia and the factors that contribute to it in initial-treatment and drug-naïve (ITDN) SCZ patients, specifically focusing on gender differences.

Methods

A total of 224 male ITDN SCZ patients and 424 female ITDN SCZ patients were included in this study. Socio-demographic and general clinical data of the patients were collected, and routine biochemical parameters, such as lipid levels, fasting blood glucose, thyroid function, renal function, and blood cell counts, were measured. Patients were also assessed for psychopathology and disease severity using the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression Scale - Severity of Illness (CGI-SI), respectively. In addition, a lipids score was calculated for assessing the severity of dyslipidemia.

Results

The study revealed that the prevalence of dyslipidemia in male patients was 34.02% (83/224), whereas 33.25% (141/424) in females, indicating no statistically significant difference (χ2 = 0.04, p = 0.841). For males, the risk factors for dyslipidemia were high education levels and diastolic blood pressure (DBP), while red blood cell count (RBC) as a protective factor. Additionally, DBP was identified as a risk factor for dyslipidemia score. In females, systolic blood pressure (SBP) was identified as a risk factor for dyslipidemia, while being married and creatinine (CRE) levels were found to be protective factors. Moreover, SBP was revealed as a risk factor for dyslipidemia score.

Conclusion

No significant gender differences were observed in the prevalence of dyslipidemia among the ITDN SCZ patients. However, notable gender differences were identified in the factors influencing dyslipidemia and its severity within this group. These findings suggest the necessity of implementing gender-specific interventions to address the potential risk factors associated with dyslipidemia.

Gender differences in cognitive improvements after two months of atypical antipsychotic treatment in first episode schizophrenia

Aims

This study aims to explore the gender differences in cognitive improvements after two months of atypical antipsychotic treatment in first episode schizophrenia (FES).

Methods

82 patients with FES, including 50 male patients and 32 female patients, were enrolled in the present study. Positive and Negative Syndrome Scale (PANSS) and MATRICS Consensus Cognitive Battery (MCCB) were respectively conducted to evaluate the clinical symptoms and cognitive function of patients with FES at baseline and after treatment. Repeated measure ANOVA was performed to compare gender differences in cognitive domains scores between baseline and 2-month follow-up. Stepwise liner regression model was performed to explore the effect factors of cognitive improvements in patients.

Results

There was no significant difference in age of onset, education years, PANSS scores, duration of untreated psychosis and Olanzapine equivalent doses between male and female patients (all p > 0.05). In the comparisons of cognition function, male patients exhibited better performance in social cognition compared with female patients at baseline (t = 3.20, p < 0.05). After treatment, improvements of attention/vigilance and working memory were both found in male patients and female patients (attention/vigilance, F = 11.867, p < 0.05; working memory, F = 18.265, p < 0.05). In addition, improvement of speed of information processing was only found in female patients (F = 11.65, p < 0.01). Significant interaction between time and gender was found in speed information of processing (F = 4.140, p = 0.045). Stepwise liner regression model revealed that improvements of negative symptoms promote improvements of cognitive function in female patients (all p < 0.05).

Conclusions

Our findings revealed gender differences of cognitive improvements in patients with FES after 2-month treatment. It provides new evidence for gender differences in cognitive symptoms of schizophrenia, and also provides preliminary clues for further individualized cognitive intervention strategies.

Productivity costs of schizophrenia spectrum and other psychotic disorders by friction cost and human capital methods: The Northern Finland Birth Cohort 1966

PURPOSE

Psychotic disorders are associated with substantial productivity costs; however no previous studies have compared these between schizophrenia spectrum (SSD) and other psychotic disorders (OP). The human capital method (HCM) and the friction cost method (FCM) are the two most common approaches to assess productivity costs. The HCM focuses on employees' perspectives on the costs, whereas the FCM demonstrates employers' perspectives. Studies comparing these methods when estimating the productivity costs of psychoses are lacking.

METHODS

Utilizing the Northern Finland Birth Cohort 1966 with linkages to national registers, we compared the adjusted productivity costs of SSD (n = 216) and OP (n = 217). The productivity costs were estimated from ages 18 to 53 including projections to statutory retirement age using the FCM and HCM.

RESULTS

When estimated via the HCM, productivity losses were higher for SSD (€193,940) than for OP (€163,080). However, when assessed using the FCM, costs were significantly lower for SSD (€2,720) than for OP (€4,430). Productivity costs varied by sex and various clinical and occupational factors.

CONCLUSION

This study highlights how productivity costs vary by psychosis diagnosis. These differences should be noted when planning interventions. The low FCM estimates indicate the need of interventions before or during the early phases of psychoses. From a societal perspective, interventions are needed, particularly for those with highest HCM productivity losses, such as males with SSD. Besides psychiatric services, the roles of social services, employment agencies and occupational health care should be considered when helping individuals with psychoses to working life.

The 3-hit animal models of schizophrenia: Improving strategy to decipher and treat the disease?

Schizophrenia is a complex disease related to combination and interactions between genetic and environmental factors, with an epigenetic influence. After the development of the first mono-factorial animal models of schizophrenia (1-hit), that reproduced patterns of either positive, negative and/or cognitive symptoms, more complex models combining two factors (2-hit) have been developed to better fit with the multifactorial etiology of the disease. In the two past decades, a new way to design animal models of schizophrenia have emerged by adding a third hit (3-hit). This review aims to discuss the relevance of the risk factors chosen for the tuning of the 3-hit animal models, as well as the validities measurements and their contribution to schizophrenia understanding. We intended to establish a comprehensive overview to help in the choice of factors for the design of multiple-hit animal models of schizophrenia.

Sex differences in schizophrenia-spectrum diagnoses: results from a 30-year health record registry

This study investigated sociodemographic and clinical differences between the sexes in individuals affected by schizophrenia-spectrum disorders (SSD) who accessed outpatient mental health services. Within a retrospective cohort of 45,361 outpatients receiving care in Ferrara (Italy) from 1991 to 2021, those with a SSD diagnosis were compared between the sexes for sociodemographic and clinical characteristics before and after the index date (when the ICD-9: 295.*diagnosis was first recorded) to assess early trajectory, age and type of diagnosis, and severity of illness indicated by medication use, hospitalization, and duration of psychiatric care. Predictors of discharge were also investigated. Among 2439 patients, 1191 were women (48.8%). Compared to men, women were significantly older at first visit (43.7 vs. 36.8 years) and at index date (47.8 vs. 40.6) with peak frequency at age 48 (vs. 30). The most frequent last diagnosis recorded before the index date was delusional disorder (27.7%) or personality disorder (24.3%) in men and depression (24%) and delusional disorder (30.1%) in women. After the index date, long-acting antipsychotics and clozapine were more frequently prescribed to men (46.5% vs. 36.3%; 13.2% vs. 9.4%, p < 0.05) and mood stabilizers and antidepressants to women (24.3% vs. 21.1%; 50.1% vs. 35.5%; p < 0.05). Women had fewer involuntary admissions (10.1% vs. 13.6%) and were more likely to be discharged as the time under care increased (p = 0.009). After adjusting for covariates, sex was not a significant predictor of discharge. Our study confirmed that sex differences exist in clinical and sociodemographic characteristics of outpatients with SSD and that gender considerations might influence the rapidity of diagnosis and medications prescribed. These findings highlight the need to implement a women-tailored approach in specialist care programs for psychoses.

Practical solutions for including sex as a biological variable (SABV) in preclinical neuropsychopharmacological research

Recently, many funding agencies have released guidelines on the importance of considering sex as a biological variable (SABV) as an experimental factor, aiming to address sex differences and avoid possible sex biases to enhance the reproducibility and translational relevance of preclinical research. In neuroscience and pharmacology, the female sex is often omitted from experimental designs, with researchers generalizing male-driven outcomes to both sexes, risking a biased or limited understanding of disease mechanisms and thus potentially ineffective therapeutics. Herein, we describe key methodological aspects that should be considered when sex is factored into in vitro and in vivo experiments and provide practical knowledge for researchers to incorporate SABV into preclinical research. Both age and sex significantly influence biological and behavioral processes due to critical changes at different timepoints of development for males and females and due to hormonal fluctuations across the rodent lifespan. We show that including both sexes does not require larger sample sizes, and even if sex is included as an independent variable in the study design, a moderate increase in sample size is sufficient. Moreover, the importance of tracking hormone levels in both sexes and the differentiation between sex differences and sex-related strategy in behaviors are explained. Finally, the lack of robust data on how biological sex influences the pharmacokinetic (PK), pharmacodynamic (PD), or toxicological effects of various preclinically administered drugs to animals due to the exclusion of female animals is discussed, and methodological strategies to enhance the rigor and translational relevance of preclinical research are proposed.

No gender differences in the pharmacological emergency treatment of schizophrenia: results of a 21-year observation

Patients suffering from schizophrenia are at high risk for admission and treatment in locked units. This study investigated gender differences in the pharmacological emergency treatment of schizophrenia patients over a 21-year observation period. The current retrospective study was conducted at the Division of Psychiatry I of the Medical University Innsbruck. All adult patients (n = 845; 425 female) suffering from schizophrenia who were admitted involuntarily to one of the acute psychiatric units in the years 1997, 2002, 2007, 2012 and 2017 were included in the study. In the years mentioned above, 590 schizophrenia patients (297 men, 293 women) admitted to a locked unit received pharmacological emergency treatment. With the exception of clozapine which was more frequently administered to men no significant differences between men and women were found in terms of the choice, dosage, and type of application of medication (antipsychotics and benzodiazepines). Since most treatment guidelines for schizophrenia do not consider gender differences at all, it is not surprising that acute treatment is almost the same for men and women. However, in times when individualized therapies gain more and more importance, the consideration of sex differences should be part of new treatment concepts.

Brain-derived neurotrophic factor, sex hormones and cognitive decline in male patients with schizophrenia receiving continuous antipsychotic therapy

BACKGROUND

There are systematic differences in clinical features between women and men with schizophrenia (SCZ). The regulation of sex hormones may play a potential role in abnormal neurodevelopment in SCZ. Brain-derived neurotrophic factor (BDNF) and sex hormones have complex interacting actions that contribute to the etiology of SCZ.

AIM

To investigate the influence of BDNF and sex hormones on cognition and clinical symptomatology in chronic antipsychotic-treated male SCZ patients.

METHODS

The serum levels of follicle-stimulating hormone, luteinizing hormone (LH), estradiol (E2), progesterone, testosterone (T), prolactin (PRL) and BDNF were compared between chronic antipsychotic-treated male (CATM) patients with SCZ (n = 120) and healthy controls (n = 120). The Positive and Negative Syndrome Scale was used to quantify SCZ symptoms, while neuropsychological tests were used to assess cognition. Neuropsychological tests, such as the Digit Cancellation Test (DCT), Semantic Verbal Fluency (SVF), Spatial Span Test (SS), Paced Auditory Serial Addition Test (PASAT), Trail Making Task (TMT-A), and Block Design Test (BDT), were used to assess executive functions (BDT), attention (DCT, TMT-A), memory (SS, PASAT), and verbal proficiency (SVF).

RESULTS

Although E2 levels were significantly lower in the patient group compared to the healthy controls, T, PRL, and LH levels were all significantly higher. Additionally, the analysis revealed that across the entire sample, there were positive correlations between E2 Levels and BDNF levels as well as BDNF levels and the digital cancellation time. In CATM patients with SCZ, a significant correlation between the negative symptoms score and PRL levels was observed.

CONCLUSION

Sex hormones and BDNF levels may also be linked to cognitive function in patients with chronic SCZ.

Exploring the relationship between baseline health-related quality of life (AQoL-4D utility values) and mortality during long-term follow-up for people living with a psychotic disorder

Holistic summary measures of health-related quality of life (HRQoL) could provide useful information for screening and/or monitoring high-risk individuals. This study explores the association of baseline HRQoL (AQoL-4D values) with death from natural and external causes (such as suicide, overdose, or accident) in a prevalent cohort over a mean follow-up of 6.9-years. Baseline data were obtained from the 2010 National Survey of High Impact Psychosis (SHIP) and its 2012 sister survey, the North-Metro Survey of High Impact Psychosis. Follow-up data were obtained from the National Deaths Index (to January 18, 2018). Associations between baseline HRQoL (and the 12 individual items of the AQoL-4D) and deaths by cause, stratified by sex were investigated using multivariable Cox Proportional Hazards models, with age used as the time scale. Overall, 7.6 % of the cohort (137 of 1805 people meeting ICD-10 criteria for a psychotic disorder and agreeing to linkage) died, 4.2 % from natural causes (primarily heart disease and cancer) and 3.4 % from external causes. There was an association between low HRQoL (AQoL-4D ≤ 0.20) and mortality due to natural causes, primarily driven by difficulties with mobility and vision in men, and difficulty with household tasks in women. No significant associations were obtained between AQoL-4D utilities and death from external causes. Sleep problems were associated with death from external causes for men only. As people with psychotic disorders experience multiple causes of death with complex associations which are difficult to quantify, monitoring for low HRQoL using the AQoL-4D could be a useful indicator of increased mortality risk in this population. TWITTER: Monitoring for low HRQoL (AQoL-4D ≤ 0.20) could be a useful indicator of increased mortality risk from natural causes in people living with psychotic disorders, with differing but specific items of relevance to men and women.

Negative symptoms and sex differences in first episode schizophrenia: What's their role in the functional outcome? A longitudinal study

INTRODUCTION

Negative symptoms (NS) include asociality, avolition, anhedonia, alogia, and blunted affect and are linked to poor prognosis. It has been suggested that they reflect two different factors: diminished expression (EXP) (blunted affect and alogia) and amotivation/pleasure (MAP) (anhedonia, avolition, asociality). The aim of this article was to examine potential sex differences among first-episode schizophrenia (FES) patients and analyze sex-related predictors of two NS symptoms factors (EXP and MAP) and functional outcome.

MATERIAL AND METHODS

Two hundred and twenty-three FES (71 females and 152 males) were included and evaluated at baseline, six-months and one-year. Repeated measures ANOVA was used to examine the effects of time and sex on NS and a multiple linear regression backward elimination was performed to predict NS factors (MAP-EXP) and functioning.

RESULTS

Females showed fewer NS (p=0.031; Cohen's d=-0.312), especially those related to EXP (p=0.024; Cohen's d=-0.326) rather than MAP (p=0.086), than males. In both male and female group, worse premorbid adjustment and higher depressive symptoms made a significant contribution to the presence of higher deficits in EXP at one-year follow-up, while positive and depressive symptoms predicted alterations in MAP. Finally, in females, lower deficits in MAP and better premorbid adjustment predicted better functioning at one-year follow-up (R2=0.494; p<0.001), while only higher deficits in MAP predicted worse functioning in males (R2=0.088; p=0.012).

CONCLUSIONS

Slightly sex differences have been found in this study. Our results lead us to consider that early interventions of NS, especially those focusing on motivation and pleasure symptoms, could improve functional outcomes.

Decrease in cognitive performance and increase of the neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios with higher doses of antipsychotics in women with schizophrenia: a cross-sectional study

BACKGROUND

We explored the relationship between symptoms, cognitive performance, neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) (three markers of inflammation), and antipsychotic dose (in chlorpromazine units) in male and female patients with schizophrenia.

METHODS

We conducted a cross-sectional analysis in patients with schizophrenia of the complete blood count and the results of neuropsychological testing, using the Welch t-test to compare groups and the Pearson test for correlations.

RESULTS

We found that the NLR and the PLR are higher among women with schizophrenia when compared with men. In women, the NLR and the PLR correlate positively with antipsychotic drug dose and inversely with a working memory test (Direct Digit Span). Higher doses of antipsychotics are associated with worse working and semantic memory and mental flexibility in the women in our sample.

CONCLUSION

Higher doses of antipsychotics were associated with worse working and semantic memory and mental flexibility in women with schizophrenia. No such correlations were present in men, suggesting that, in female patients, cognitive performance deteriorates as the antipsychotic dose is increased, a finding that could be mediated by inflammatory mechanisms, given the demonstrated relationship to biomarkers of inflammation - e.g., the NLR and the PLR.

TRIAL REGISTRATION

NCT03788759 (ClinicalTrials.gov).

Gender differences in outcomes of early intervention services for first episode psychosis

AIMS

There is growing interest in early intervention in psychotic disorders. However, gender differences in the outcomes of such treatment have not been studied in a randomized clinical trial.

METHODS

Patients diagnosed with schizophrenia spectrum disorders with less than 6 months antipsychotic exposure entered a cluster randomized trial of early intervention services compared to usual care in the Recovery After an Initial Schizophrenia Episode Early Treatment Program (RAISE-ETP) study. Masked evaluators assessed the Quality of Life Scale (QLS) and the Positive and Negative Syndrome Scale (PANSS) every 6 months. Our secondary analyses examined gender differences in baseline characteristics, 2-year gender outcomes, and intervention responses.

RESULTS

Altogether 404 individuals aged 15-40 entered the study: 111 (27.4%) women and 293 (72.5%) men. At baseline, women were significantly more likely to have been married (p = .007) and to be living independently (p = .012) than men. Women were also more likely to be diagnosed with schizoaffective disorder, bipolar type (p = .006) and scored higher on the depression subscale of the PANSS (p = .0004) but not the CDSS. Women were less likely to use or abuse cannabis (p = .0004), though no less likely to abuse alcohol. Controlling for these differences, there were no significant gender differences in the QLS or PANSS outcomes.

CONCLUSION

Baseline gender differences in comorbid substance use and prevalence of mood symptoms in women with first episode psychosis are consistent with previous studies. The absence of significant gender differences in outcomes with early intervention has not been previously reported in a multi-site randomized US clinical trial.

Sex difference in association between tardive dyskinesia and cognitive deficits in patients with chronic schizophrenia

BACKGROUND

Tardive dyskinesia (TD), a side effect due to long-term use of antipsychotic medication, is associated with cognitive impairment. Several studies have found sex differences in cognitive impairment in schizophrenia patients, while whether there are sex differences in cognitive performance in schizophrenia patients with TD has not been reported.

METHODS

A total of 496 schizophrenia inpatients and 362 healthy controls were recruited for this study. We used the Positive and Negative Syndrome Scale (PANSS) to assess patients' psychopathological symptoms and the Abnormal Involuntary Movement Scale (AIMS) to assess the severity of TD. Cognitive function was measured in 313 of these inpatients and 310 of healthy controls using the Repeatable Battery for Assessment of Neuropsychological Status (RBANS).

RESULTS

Patients with schizophrenia performed worse in all cognitive domains than healthy controls(all p < 0.001). Compared to patients without TD, patients with TD had higher PANSS total, PANSS negative symptom subscale and AIMS scores (all p < 0.001), while RBANS total, visuospatial/constructional and attention subscale scores were significantly lower (all p < 0.05). In addition, the visuospatial/constructional and attention indices remained significantly lower in male patients with TD than those without TD (both p < 0.05), but these results were not observed in female patients. Moreover, visuospatial/constructional and attention indices were negatively correlated with total AIMS scores only in male patients (both p < 0.05).

CONCLUSION

Our results suggest that there may be sex differences in cognitive impairment in schizophrenia patients with comorbid TD, indicating that female gender may have a protective effect on cognitive impairment in schizophrenia patients caused by TD.

Intelligence quotient changes over 10 years: Diversity of cognitive profiles in first episode of psychosis and healthy controls

OBJECTIVE

This study aimed to analyse whether intelligence quotient (IQ) improves, declines, or remains stable over 10 years among FEP patients and healthy subjects.

METHODS

A group of FEP patients enrolled in a Program of First Episode Psychosis in Spain called PAFIP, and a sample of Healthy Controls (HC) completed the same neuropsychological battery at baseline and approximately 10 years later, which included the WAIS vocabulary subtest to estimate premorbid IQ and 10-year IQ. Cluster analysis was performed separately in the patient group and the HC group to determine their profiles of intellectual change.

RESULTS

One hundred and thirty-seven FEP patients were grouped into five clusters: "Improved low IQ" (9.49 % of patients), "Improved average IQ" (14.6 %), "Preserved low IQ" (17.52 %), "Preserved average IQ" (43.06 %), and "Preserved high IQ" (15.33 %). Ninety HC were grouped into three clusters: "Preserved low IQ" (32.22 % of the HC), "Preserved average IQ" (44.44 %), and "Preserved high IQ" (23.33 %). The first two clusters of FEP patients, characterized by a low IQ, earlier age at illness onset, and lower educational attainment, showed a substantial cognitive improvement. The remaining clusters demonstrated cognitive stability.

CONCLUSIONS

The FEP patients showed intellectual improvement or stability, but no decline post-onset of psychosis. However, their profiles of intellectual change are more heterogeneous than that of HC over 10 years. Particularly, there is a subgroup of FEP patients with a significant potential for long-term cognitive enhancement.

Risk Factors for Psychotic Relapse After Dose Reduction or Discontinuation of Antipsychotics in Patients With Chronic Schizophrenia. A Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND HYPOTHESIS

Although maintenance treatment with antipsychotics protects against psychotic relapse, high doses may hamper recovery. Therefore, dose reduction or discontinuation may be considered in patients with chronic schizophrenia. Here, we identified risk factors for psychotic relapse when doses are reduced.

STUDY DESIGN

We systematically searched MEDLINE, EMBASE, and PsycINFO from January 1950 through January 2021 and reviewed randomized controlled trials (RCTs) that reported relapse rates after antipsychotic dose reduction or discontinuation in patients with chronic schizophrenia. We calculated relative risks (RRs) with 95% confidence intervals (CIs) per person-year and sought to identify potential risk factors for relapse. The study is registered with PROSPERO (CRD42017058296).

STUDY RESULTS

Forty-seven RCTs (54 patient cohorts, 1746 person-years) were included. The RR for psychotic relapse with dose reduction/discontinuation versus maintenance treatment was 2.3 per person-year (95% CI: 1.9 to 2.8). The RR was higher with antipsychotic discontinuation, dose reduction to less than 3-5 mg haloperidol equivalent (HE), or relatively rapid dose reduction (<10 weeks). The RR was lower with long-acting injectable agents versus oral antipsychotic dose reduction. Other factors that increased the risk of psychotic relapse were younger age and short follow-up time.

CONCLUSIONS

Clinicians should take several risk factors for psychotic relapse into account when considering dose reduction in patients with chronic schizophrenia. Studies of a relatively fast reduction in antipsychotic dose support a minimum dose of 3-5 mg HE. However, if the dose is tapered more gradually, relapses related to medication withdrawal might be avoided, possibly enabling lower-end doses to be achieved.

Employment trajectories until midlife in schizophrenia and other psychoses: the Northern Finland Birth Cohort 1966

PURPOSE

Psychoses are associated with poor labour market attachment, but few studies have compared schizophrenia (SZ) and other psychoses (OP). Moreover, studies on long-term employment trajectories over individuals' working life courses are lacking. We compared 30 year employment trajectory patterns in a general population sample among individuals with SZ, OP, and those with no psychosis (NP).

METHODS

Utilising the Northern Finland Birth Cohort 1966, we collected survey data on employment from ages 16 to 45 and detected individuals with register-based history of SZ (n = 62), OP (n = 87), or NP (n = 6464) until age 46. Through gender-specific latent class analyses on annual employment roles, we identified traditional, highly educated, self-employed, delayed and floundering employment trajectories with distinct socioeconomic characteristics. We addressed attrition by conducting weighted analyses.

RESULTS

Floundering trajectories were common among individuals with SZ (79% of men, 73% of women) and OP (52% of men, 51% of women). In NP, a traditional employee trajectory was most common in men (31%), and a highly educated trajectory in women (28%). A history of psychosis was associated with heightened odds ratios (ORs; 95% confidence intervals (CIs)) for floundering trajectories in both men (SZ: 32.9 (13.3-81.4); OP: 7.4 (4.0-13.9)) and women (SZ: 9.9 (4.6-21.5); OP: 3.9 (2.1-7.1)) compared to NP. Weighted analyses produced similar results.

CONCLUSION

Most individuals with SZ or OP have floundering employee trajectories reflecting an elevated risk of unemployment and part-time work until midlife. These results indicate the importance of improving labour market attachment during the early phases of psychoses.

[Socio-demographic and clinical-psychological characteristics of patients with residual schizophrenia and directions of their psychosocial rehabilitation]

OBJECTIVE

To analyze the socio-demographic, clinical and psychological characteristics of patients with residual schizophrenia, to identify variants of residual states and to determine measures for psychosocial rehabilitation on this basis.

MATERIAL AND METHODS

At the time of investigation, 91 patients with the diagnosis of residual schizophrenia (F20.5xx according to ICD-10) were under dispensary supervision in the psychoneurological dispensary No. 18 of Moscow. A study of the medical records of all these patients was carried out. Twenty-three patients consented to face-to-face examination. The Positive and negative syndrome scale (PANSS), the Symptom Checklist-90-Revised (SCL-90-R), the Brief Assessment of Cognitive Functions in Schizophrenia (BACS) and the author's questionnaire concerning the opinion of psychiatrists on the clinical and social characteristics of patients with residual schizophrenia were used. Mathematical and statistical methods implemented in the STATISTICA 12.1 software and the Excel office suite were used. The method of stochastic nesting of neighbors («T-distributed Stochastic Neighbor Embedding», t-SNE) implemented in the Python program to cluster cases and identify variants of residual states was used.

RESULTS

The patients with residual schizophrenia belonged to the cohort of elderly patients (mean age 66.3±13.28 years) with a predominance of females (62.22%). At the time of examination, the course of the schizophrenic process had a negative impact on the social life and professional activities of patients, which led to disability of 74.72% patients and 91.55% of them had disability due to a mental disorder. The analysis showed that patients with residual schizophrenia was a heterogeneous group with a predominant presence of negative symptoms in the clinical picture (the composite score on the PANSS negative subscale was17.79±6.67). Three variants of residual states were identified using clustering by the t-SNE method of individual PANSS indicators. Deficiency symptoms with features of pseudoorganic syndrome prevailed in the first variant. In the second variant, patients had mild positive symptoms, mainly in the form of paranoia and residual delirium, as well as a psychopathic syndrome. The third, small group, included patients with the most favorable variant of remission, having a fairly high level of social adaptation, mainly with personality changes.

CONCLUSION

The obtained data were correlated with the results of a psychological examination. It was revealed that patients with residual schizophrenia were not sufficiently included in the process of psychosocial treatment and rehabilitation. Taking into account the identified variants of residual states, the directions of possible psychosocial interventions were determined.

Real-life functioning in women with schizophrenia living in residential facilities: Gender-based comparison

Introduction

Despite many patients with schizophrenia being able to achieve good functional outcomes, the number of patients with poor functional outcome estimates at over 25 percent. One of the wider constructs, reflecting functional outcomes in schizophrenia, is real-life functioning, whose key domains include ability to live relatively autonomously, productive activity and social interaction. Negative symptoms are seen among independent predictors of real-life functioning. As most researchers agree that schizophrenia is a disease with gender differences in terms of both clinical and functional outcomes, the goal of our observational study was to examine real-life functioning of women with schizophrenia, living in residential care facilities, and study the relationship between daily functioning and negative symptoms.

Methods

Using the Standardized Protocol of Clinical Interview and observation for 1 or more weeks, we examined 46 females with schizophrenia, living in psychiatric residential facilities and compared them with 54 males with schizophrenia, living in the same facilities. In a pilot study 21 subjects with schizophrenia (13 females and 8 males), were evaluated by the Russian version of the Brief Negative Symptom Scale (BNSS).

Results

To the results, more females with schizophrenia, compared to males with schizophrenia, remained active and took initiative in their physical care, vocational activities, involvement in cultural events, and maintained friendly relationships with other inmates. We have identified a group of inmates, in which females prevailed, with less pronounced negative symptoms and a higher level of social functioning, who did not need residential social care in the institutions.

Discussion

Limitations of residential social care in the institutions for psychiatric patients are discussed.

Sex and gender differences in clinical and functional indices in subjects with schizophrenia and healthy controls: Data from the baseline and 4-year follow-up studies of the Italian Network for Research on Psychoses

Gender differences in clinical and psychosocial aspects of schizophrenia have been widely reported. Findings have not always been consistent, and some of them need further research. In a large sample of community dwelling persons with schizophrenia, we investigated gender differences in clinical, cognitive and functional indices, as well as their changes over a 4-year follow-up and their impact on real-life functioning. Gender differences in personal resources, cognitive and functional indices were explored also in a sample of healthy controls. Men with respect to women had an earlier age of illness onset, a worse premorbid adjustment in the academic domain, more severe avolition, expressive deficit and positive symptoms, lower prevalence of comorbidity for affective disorders, less frequent use of two coping strategies ('religion' and 'use of emotional support') and more frequent positive history of substance and alcohol abuse. In addition, men were more impaired in verbal learning, while women in reasoning/problem solving. Some patterns of gender differences observed in healthy controls were not confirmed in patients. Men's disadvantages in the clinical picture did not translate into a worse outcome. This finding may be related to the complex interplay of several factors acting as predictors or mediators of outcome.

Gender impact on the outcome of rehabilitation programs in psychiatry: Brief report from a metropolitan residential rehabilitative service

Background

Differences based on gender in the presentation and outcome of many psychiatric conditions have been highlighted in the past years. Moreover, women are often underrepresented in research samples, thus leading to a poorer understanding and addressing of their needs. As regards psychiatric rehabilitation, few studies have focused on the influence of gender on the outcomes of rehabilitation programs.

Objectives

This study aimed to analyze the impact of gender on socio-demographic and clinical characteristics, as well as on main rehabilitation outcomes, in a sample of subjects undergoing rehabilitation programs in a metropolitan residential service.

Methods

We collected socio-demographic, clinical variables and rehabilitation outcomes of all subjects discharged from the metropolitan residential rehabilitative service of the Luigi Sacco Hospital in Milan, Italy, from January 2015 to December 2021. Gender differences were analyzed through t-test and chi-square for continuous and categorical variables, respectively.

Results

In a total sample of 129 subjects equally distributed for gender (50.4% women), all subjects improved after their rehabilitation program, as measured through specific psychometric scales. However, women had a higher proportion of discharges to their own household (52.3% vs. 25% of men). They also showed higher educational status (53.8% completed high school vs. 31.3% of men). Clinically, they showed longer duration of untreated illness (3.6 ± 7.31 vs. 1.06 ± 2.35 years) and lower frequency of substance use disorders compared to men (6.4% vs. 35.9%).

Conclusion

The main result of this study shows, in light of an equal improvement in psychopathological and psychosocial functioning after the rehabilitation program, better outcomes in women compared to men, with a higher frequency of return to their own household after the completion of a rehabilitation program compared to men.

Face pareidolia in male schizophrenia

Faces are valuable signals for efficient social interaction. Yet, social cognition including the sensitivity to a coarse face scheme may be deviant in schizophrenia (SZ). Tuning to faces in non-face images such as shadows, grilled toasts, or ink blots is termed face pareidolia. This phenomenon is poorly investigated in SZ. Here face tuning was assessed in 44 male participants with SZ and person-by-person matched controls by using recently created Face-n-Thing images (photographs of non-face objects to a varying degree resembling a face). The advantage of these images is that single components do not automatically trigger face processing. Participants were administered a set of images with upright and inverted (180° in the image plane) orientation. In a two-alternative forced-choice paradigm, they had to indicate whether an image resembled a face. The findings showed that: (i) With upright orientation, SZ patients exhibited deficits in face tuning: they provided much fewer face responses than controls. (ii) Inversion generally hindered face pareidolia. However, while in neurotypical males, inversion led to a drastic drop in face impression, in SZ, the impact of orientation was reduced. (iii) Finally, in accord with the signal detection theory analysis, the sensitivity index (d-prime) was lower in SZ, whereas no difference occurred in decision criterion. The outcome suggests altered face pareidolia in SZ is caused by lower face sensitivity rather than by alterations in cognitive bias. Comparison of these findings with earlier evidence confirms that tuning to social signals is lower in SZ, and warrants tailored brain imaging research.

Sex differences in symptomatology in people with schizophrenia and other psychotic disorders: protocol for a systematic review and pairwise meta-analysis of observational studies

Sex differences in symptomatology in people with psychosis have been studied extensively in recent decades. Although studies have pointed to such differences, to date there is no review that has performed a systematic search and quantitative synthesis. In this paper, we describe the protocol for a pairwise meta-analysis comparing a range of symptom outcome measures between men and women diagnosed with a psychotic spectrum disorder at different stages of the disorder (PROSPERO registration number CRD42021264942). In August 2021 we conducted systematic searches of PsychInfo, PubMed, Web of Science, Scopus and Dialnet to identify observational studies that report data on symptoms for males and females separately. Two independent reviewers will conduct literature searches, select studies, extract data, assess the risk of bias and assess outcome quality. To assess the effect size of all outcome measures, we will conduct pairwise meta-analysis using random-effects models. The quality of studies will be evaluated using a National Heart, Lung and Blood Institute's quality assessment tool and the confidence in the results will be evaluated using the GRADE tool. Meta-regression and sensitivity analyses will be conducted to assess the robustness of the findings. No ethical problems are foreseen. Results from this study will be published in peer-reviewed journals and presented at relevant conferences.

Violence in relation to cognitive deficits and symptom severity in a sample of Egyptian patients with schizophrenia

BACKGROUND

Patient with schizophrenia are significantly more likely to be violent than general population; and the consequences of this violence risk are often very serious for the patients, their caregivers, and the entire community.

AIM

To assess the risk of violence in patients with schizophrenia and its correlation with severity of symptoms and cognitive functions.

METHODS

A cross-sectional comparative study conducted in Okasha institute of psychiatry including 50 patients with schizophrenia compared to 50 healthy control group regarding violence risk as assessed by Historical, Clinical, and Risk Management-20 (HCR-20), case group was assessed using Structured Clinical Interview for DSM-IV (SCID-I), Positive and Negative Syndrome Scale (PANSS), cognitive functions were assessed by Wechsler Adult Intelligence Scale (WAIS), Trail Making Test (TMT) Part A and B, the Wisconsin Card Sorting Test (WCST), and the Wechsler Memory Scale (WMS).

RESULTS

There was a statistically significant difference between case and control groups regarding risk of violence where 58% of the case group were found to have risk of violence compared to only 18% in the control group. There was a significant correlation between this risk of violence and period of untreated psychosis, no of episodes, and history of substance use; also was significantly correlated with PANSS and Wisconsin card sorting test subscales. Regarding logistic regression analysis for factors affecting violence risk; total PANSS score and history of substance use were significant independent factors that increase violence risk.

CONCLUSION

Violence risk in patient with schizophrenia is a cardinal factor that may affect life of the patients, their family, and society; this risk can be affected by different factors including severity of symptoms, no of episodes, history of substance use, and cognitive function of the patients.

The Effect of Menopause on Antipsychotic Response

Background: It has been hypothesized that, whenever estrogen levels decline, psychosis symptoms in women increase. At menopause, this can happen in two main ways: (a) the loss of estrogen (mainly estradiol) can directly affect central neurotransmission, leading to increase in schizophrenia-related symptoms, and (b) the loss of estrogen can decrease the synthesis of enzymes that metabolize antipsychotic drugs, thus weakening their efficacy. Aims and Methods: The aim of this narrative review was to investigate the second possibility by searching PubMed and ClinicalTrials.gov for studies over the last two decades that investigated the metabolism of antipsychotics and their efficacy before and after menopause in women or that studied systemic and local estrogen level effects on the pharmacokinetics and pharmacodynamics of individual antipsychotic drugs. Results: The evidence suggests that symptom level in women with schizophrenia rises after menopause for many reasons beyond hormones but, importantly, there is an estrogen-dependent loss of efficacy related to antipsychotic treatment. Conclusion: Effective clinical intervention is challenging; nevertheless, several promising routes forward are suggested.

In-depth investigations of the molecular basis underlying sex differences among middle-aged and elderly schizophrenia populations

Sex can influence almost all aspects of schizophrenia. However, the molecular mechanisms underlying sex differences in schizophrenia remain poorly understood. In this project, the dataset GSE107638 containing neuronal RNA-seq data and age/sex information of individuals with or without schizophrenia were retrieved. Schizophrenia samples were divided into young male (M-1), young female (F-1), middle-aged and elderly male (M-2) and middle-aged and elderly female (F-2) groups. Next, green/yellow/turquoise modules related to the M-2 trait and turquoise module correlated with the F-2 trait were identified by weighted correlation network analysis (WGCNA) analysis (soft thresholding power: 13; min module size: 200). Crucial genes in the M-2 green, M-2 turquoise and F-2 turquoise modules were identified by WGCNA, gene significance/module membership, and protein-protein interaction (PPI) analysis. Moreover, 2067 and 934 differentially expressed genes (|log2 fold-change| ≥0.58 and P-value < 0.05) in M-2 and F-2 schizophrenia subgroups versus same-age and same-sex counterparts were identified, respectively. Additionally, 82 core genes in the M-2 turquoise module and 4 hub genes in the F-2 turquoise module were differentially expressed in M-2 and F-2 schizophrenia subgroups versus their counterparts, respectively. Among the 82 hub genes, 15 genes were found to be correlated with neuronal development by the Kyoto Encyclopedia of Genes and Genomes enrichment analysis. Also, 2 potential PPI networks related to neuronal development were identified. Taken together, multiple potential hub genes and 2 potential neurobiological networks related to schizophrenia sex differences and disease progression were identified among middle-aged and elderly schizophrenia populations.

Sex/Gender differences in schizophrenia: Thinking back and thinking forward

This commentary summarizes my view of my life's work in psychiatry, which has mainly been devoted to my obsessive interest in sex and gender differences in schizophrenia. I summarize the influences that guided my research and I take the opportunity to make some personal recommendations to future researchers.

Assessment of risk factors of treatment discontinuation among patients on paliperidone palmitate and risperidone microspheres in France, Germany and Belgium

BACKGROUND

Long-acting antipsychotics (e.g. 1-monthly (PP1M) / 3-monthly (PP3M) injection forms of paliperidone palmitate) have been developed to improve treatment continuation in schizophrenia patients. We aim to assess risk factors of treatment discontinuation of patients on paliperidone palmitate and risperidone microsphere. Additionally, treatment discontinuation between patients with PP1M and PP3M was compared.

METHODS

The IQVIA Longitudinal Prescription databases were used. Risk factors of treatment discontinuation were identified by a multilevel survival regression using Cox proportional hazards model. Kaplan Meier analyses were performed by identified significant risk factors.

RESULTS

Twenty-five thousand three hundred sixty-one patients (France: 9,720; Germany: 14,461; Belgium: 1,180) were included. Over a one-year follow-up period, a significant lower treatment discontinuation was observed for patients newly initiated on paliperidone palmitate (53.8%) than those on risperidone microspheres (85.4%). Additionally, a significantly lower treatment discontinuation was found for 'stable' PP3M patients (19.2%) than 'stable' PP1M patients (37.1%). Patients were more likely to discontinue when drugs were prescribed by GP only (HR = 1.68, p < 0.001 vs. psychiatrist only) or if they were female (HR = 1.07, p < 0.001), whereas discontinuation decreased with age (31-50 years: HR = 0.95, p = 0.006 and > 50 years: HR = 0.91, p < 0.001 vs. 18-30 years).

CONCLUSIONS

This study demonstrates that patients stay significantly longer on treatment when initiated on paliperidone palmitate as compared to risperidone microspheres. It also indicated a higher treatment continuation of PP3M over PP1M. Treatment continuation is likely to be improved by empowering GPs with mental health knowledge and managing patients by a collaborative primary care-mental health model. Further research is needed to understand why females and younger patients have more treatment discontinuation.

Multi-spatial-scale dynamic interactions between functional sources reveal sex-specific changes in schizophrenia

We introduce an extension of independent component analysis (ICA), called multiscale ICA, and design an approach to capture dynamic functional source interactions within and between multiple spatial scales. Multiscale ICA estimates functional sources at multiple spatial scales without imposing direct constraints on the size of functional sources, overcomes the limitation of using fixed anatomical locations, and eliminates the need for model-order selection in ICA analysis. We leveraged this approach to study sex-specific and sex-common connectivity patterns in schizophrenia. Results show dynamic reconfiguration and interaction within and between multi-spatial scales. Sex-specific differences occur (a) within the subcortical domain, (b) between the somatomotor and cerebellum domains, and (c) between the temporal domain and several others, including the subcortical, visual, and default mode domains. Most of the sex-specific differences belong to between-spatial-scale functional interactions and are associated with a dynamic state with strong functional interactions between the visual, somatomotor, and temporal domains and their anticorrelation patterns with the rest of the brain. We observed significant correlations between multi-spatial-scale functional interactions and symptom scores, highlighting the importance of multiscale analyses to identify potential biomarkers for schizophrenia. As such, we recommend such analyses as an important option for future functional connectivity studies.

Analysis of the early mother-child relationship in schizophrenic patients

BACKGROUND AND AIM

The mother as the first caregiver plays a significant role in the formation of the child's behavior, growth, and communication. The present study aimed to analyze the early mother-child relationship in schizophrenic patients.

MATERIALS AND METHODS

This qualitative study employed a descriptive phenomenological approach. The participants were male patients with schizophrenia who were hospitalized in Qazvin Bahman Psychiatric Hospital from March to September 2020 with an age range of over 18 years. Given the objective of the study, the data were collected using semi-structured interviews. The participants were selected using purposive sampling and the sampling procedure continued until data saturation as the point when no new information is observed in the data. Accordingly, the data were saturated after interviewing 15 participants. The data were analyzed using Colaizzi's seven-step method.

RESULTS

The analysis of the data revealed four main themes including ambivalent attachment to the mother, feelings of constant fear and worry, a sense of constant care for the mother, and a cold and emotionless relationship with the child.

CONCLUSION

The present study suggested that schizophrenia is a disorder that affects the mother-child relationship, and does the term "schizophrenic mothers" need to be reconsidered? However, the result of this research has been done according to the nature and cultural context of Iranian society.

Sex Differences in Social Cognition and Association of Social Cognition and Neurocognition in Early Course Schizophrenia

Background

Both impairment and sex differences in social cognition and neurocognition have been documented in schizophrenia. However, whether sex differences exist in the association between social cognition and neurocognition are not known. We aimed to investigate the contribution of areas of neurocognition to theory of mind (ToM) and hostility bias, representing social cognition, according to sex in early course schizophrenia.

Methods

In this cross-sectional study, we assessed neurocognition using the Japanese version of the Brief Assessment of Cognition in Schizophrenia (BACS) and assessed the ToM and hostility bias subdomains of social cognition using the Social Cognition Screening Questionnaire (SCSQ) in 131 participants (65 female, 66 male) diagnosed with schizophrenia within 5 years of onset. Sex differences were analyzed using t-tests. The associations of neurocognitive subdomains with ToM and hostility bias according to sex were analyzed using multiple regression analysis. Results were adjusted by age, estimated premorbid intelligence quotient, and symptomatology.

Results

No sex differences were found in ToM (p = 0.071) or hostility bias (p = 0.057). Higher verbal fluency was significantly associated with higher ToM in females (p < 0.01), whereas higher executive function was significantly associated with higher ToM in males (p < 0.05). Higher verbal fluency was significantly associated with lower hostility bias in females (p < 0.05), whereas neurocognition and hostility bias were not significantly associated in males.

Conclusion

The results suggest that neurocognition associated with social cognition differ according to sex. These differences should be considered for more effective treatment of social cognition.

Antipsychotic medication for women with schizophrenia spectrum disorders

There are significant differences between men and women in the efficacy and tolerability of antipsychotic drugs. Here, we provide a comprehensive overview of what is currently known about the pharmacokinetics and pharmacodynamics of antipsychotics in women with schizophrenia spectrum disorders (SSDs) and translate these insights into considerations for clinical practice. Slower drug absorption, metabolism and excretion in women all lead to higher plasma levels, which increase the risk for side-effects. Moreover, women reach higher dopamine receptor occupancy compared to men at similar serum levels, since oestrogens increase dopamine sensitivity. As current treatment guidelines are based on studies predominantly conducted in men, women are likely to be overmedicated by default. The risk of overmedicating generally increases when sex hormone levels are high (e.g. during ovulation and gestation), whereas higher doses may be required during low-hormonal phases (e.g. during menstruation and menopause). For premenopausal women, with the exceptions of quetiapine and lurasidone, doses of antipsychotics should be lower with largest adjustments required for olanzapine. Clinicians should be wary of side-effects that are particularly harmful in women, such as hyperprolactinaemia which can cause oestrogen deficiency and metabolic symptoms that may cause cardiovascular diseases. Given the protective effects of oestrogens on the course of SSD, oestrogen replacement therapy should be considered for postmenopausal patients, who are more vulnerable to side-effects and yet require higher dosages of most antipsychotics to reach similar efficacy. In conclusion, there is a need for tailored, female-specific prescription guidelines, which take into account adjustments required across different phases of life.

Gender Differences in Psychiatric Symptoms and the Social Functioning of 610 Patients with Schizophrenia in Urban China: A 10-Year Follow-Up Study

PURPOSE

To explore the different outcomes between male and female patients with schizophrenia after long-term follow-up.

PATIENTS AND METHODS

Schizophrenia patients were participants in our study. First, two senior psychiatrists collected data on the demographic characteristics and clinical symptoms of patients from the Hospital Information System between February 2009 and January 2010. Second, two other senior psychiatrists called the patients and their guardians between February 2019 and January 2020 to get general information on the patients and assess their psychiatric symptoms and social functioning using the Positive and Negative Syndrome Scale (PANSS) and the Personal and Social Performance (PSP) scale.

RESULTS

Of the 610 participants, the 306 female participants were younger (48.32 ± 12.99 vs 49.84 ± 12.60) and had received more education (8.08 ± 3.76 vs 7.94 ±3 0.73). After 10 years, women were found to have more outpatient visits than men (20.86 ± 22.21 vs 16.11 ± 16.87, P < 0.05). However, there was no significant gender difference in number of hospitalizations (3.12 ± 5.34 vs 2.77 ± 5.84, P > 0.05). The PANSS scores were lower for both groups at the 10-year follow-up. Women had significantly lower scores than men after the 10-year period (P < 0.05). With regard to social functioning, there was a significant difference in social functioning between baseline scores and 10-year follow-up scores indicating an improvement in social functioning. PSP scores had significantly increased in women (P < 0.01) but not in men (P > 0.05).

CONCLUSION

Female patients had significantly lower levels of psychiatric symptoms and higher levels of social functioning at 10-year follow-up than male patients. They also reported more outpatient visits, which may have contributed to the gender differences in outcomes. Family members and doctors of patients should urge patients to make regular outpatient visits for better outcomes after hospitalization.

Sex Difference in Comorbid Depression in First-Episode and Drug-Naive Patients With Schizophrenia: Baseline Results From the Depression in Schizophrenia in China Study

OBJECTIVE

Comorbid depression is common in schizophrenia, and sex differences are prominent in many aspects of schizophrenia. However, few studies have investigated sex difference in comorbid depression in schizophrenia. This large sample study aimed to investigate sex differences in first-episode drug-naive (FEDN) patients with schizophrenia comorbid major depressive episode (SZ-MDE).

METHODS

A total of 996 FEDN patients with schizophrenia (472 males/524 females) were recruited. The 17-item Hamilton Depression Rating Scale and Positive and Negative Syndrome Scale (PANSS) were applied.

RESULTS

There was no difference in the prevalence of comorbid MDE between male and female patients with schizophrenia. Among SZ-MDE patients, men had more severe psychotic symptoms (scores of PANSS total scale, negative scale, and general psychopathology scale), more severe depressive symptoms, and higher proportion of severe depression than women (all p < .001). The early onset age of schizophrenia, smoking, and PANSS positive score were the risk factors for comorbid MDE only in female patients with schizophrenia (all p < .05). Furthermore, in female patients with SZ-MDE, smoking was associated with the severity category of depression (p = .001, odds ratio = 2.70). Multiple variable regression demonstrated that the Hamilton Depression Rating Scale score correlated with PANSS general psychopathology (p = .01) and total scores (p = .04) in female SZ-MDE.

CONCLUSIONS

Our results indicate sex differences in proportion of severe depression, clinical symptoms, and factors of comorbid MDE in FEDN patients with schizophrenia. These sex differences have clinical implications for the treatment of depression as related to the nature and severity of psychopathological symptoms in patients with schizophrenia.

Stratification by Sex and Hormone Level When Contrasting Men and Women in Schizophrenia Trials Will Improve Personalized Treatment

BACKGROUND

Sex and gender differences have been reported in the prevalence, expression, treatment response, and outcome of schizophrenia, but most reports are based on relatively small samples that have not been stratified for the impact of sex hormone levels. This literature review aims to show how women's hormone levels can impact the results of male/female comparisons.

METHODS

This is a narrative review of data from publications of the last decade.

RESULTS

Epidemiologic evidence, reports of the impact of hormones on cognition, results of sexually dimorphic responses to treatment, and male/female trajectories of illness over time all suggest that female hormone fluctuations exert major effects on male/female differences in schizophrenia.

CONCLUSIONS

Information on hormonal status in women participants is rarely available in clinical studies in schizophrenia, which makes male/female comparisons largely uninterpretable. These are the current challenges. Opportunities for individualized treatment are growing, however, and will undoubtedly result in improved outcomes for both women and men in the future.

Sex difference in the interrelationship between TNF-α and oxidative stress status in first-episode drug-naïve schizophrenia

Background

Increasing evidence indicates that dysregulated TNF-α and oxidative stress (OxS) contribute to the pathophysiology of schizophrenia. Additionally, previous evidence has demonstrated sex differences in many aspects of schizophrenia including clinical characteristics, cytokines, and OxS markers. However, to the best of our knowledge, there is no study investigating sex differences in the association between TNF-α, the OxS system, and their interaction with clinical symptoms in schizophrenia patients, especially in first-episode drug-naïve (FEDN) patients.

Methods

A total of 119 FEDN schizophrenia patients and 135 healthy controls were recruited for this study. Serum TNF-α, superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), catalase (CAT), and malondialdehyde (MDA) were measured. The Positive and Negative Syndrome Scale (PANSS) was applied to evaluate psychotic symptoms. Two-way ANOVA, partial correlation analysis, and multivariate regression analysis were performed.

Results

A sex difference in MDA levels was demonstrated only in healthy controls (F = 7.06, p_Bonferroni = 0.045) and not seen in patients. Furthermore, only male patients had higher MDA levels than male controls (F = 8.19, p_Bonferroni = 0.03). Additionally, sex differences were observed in the association of TNF-α and MDA levels with psychotic symptoms (all p_Bonferroni < 0.05). The interaction of TNF-α and MDA was only associated with general psychopathology symptom in male patients (B = − 0.07, p = 0.02).

Conclusion

Our results demonstrate the sex difference in the relationship between TNF-α, MDA, and their interaction with psychopathological symptoms of patients with schizophrenia.

A Review of the Potential Use of Pinene and Linalool as Terpene-Based Medicines for Brain Health: Discovering Novel Therapeutics in the Flavours and Fragrances of Cannabis

"Medicinal cannabis" is defined as the use of cannabis-based products for the treatment of an illness. Investigations of cannabis compounds in psychiatric and neurological illnesses primarily focus on the major cannabinoids, cannabidiol (CBD) and Δ9-tetrahydrocannabinol (Δ9-THC), which are hypothesised to benefit multiple illnesses manifesting cognitive impairment, neurodegeneration and neuro-inflammation, as well as chronic pain, epilepsy and post-traumatic stress disorder, respectively. The cannabis plant contains >500 compounds, including terpenes responsible for the flavour and fragrance profiles of plants. Recently, research has begun providing evidence on the potential use of certain plant-derived terpenes in modern medicine, demonstrating anti-oxidant, anti-inflammatory, and neuroprotective effects of these compounds. This review examined the effects of two key terpenes, pinene and linalool, on parameters relevant to neurological and psychiatric disorders, highlighting gaps in the literature and recommendations for future research into terpene therapeutics. Overall, evidence is mostly limited to preclinical studies and well-designed clinical trials are lacking. Nevertheless, existing data suggests that pinene and linalool are relevant candidates for further investigation as novel medicines for illnesses, including stroke, ischemia, inflammatory and neuropathic pain (including migraine), cognitive impairment (relevant to Alzheimer's disease and ageing), insomnia, anxiety, and depression. Linalool and pinene influence multiple neurotransmitter, inflammatory and neurotrophic signals as well as behaviour, demonstrating psycho-activity (albeit non-intoxicating). Optimising the phytochemical profile of cannabis chemovars to yield therapeutic levels of beneficial terpenes and cannabinoids, such as linalool, pinene and CBD, could present a unique opportunity to discover novel medicines to treat psychiatric and neurological illnesses; however, further research is needed.

Gender Differences in the Attitudes of Parents Living with Adult Children with Schizophrenia

BACKGROUND

This paper explored the gender differences in the attitudes of parents toward taking care of their adult daughters or sons with schizophrenia, and focused on how parents define and think about the roles of their children, and how they cope with fulfilling the expected roles.

METHODS

Qualitative research design and purpose sampling were used to enroll parents who had adult patients with schizophrenia at a medical center in central Taiwan. Semi-structured in-depth interviews were conducted and content analysis was used to analyze the data.

RESULTS

Seven main themes emerged from the data provided by ten parents living with adult children with schizophrenia. Three themes that focused on gender difference are listed: parents continue to expect their sons with schizophrenia to carry on the family name; society as a whole expects males to be the "head of the family"; male family members are supposed to assume the responsibility of caring for siblings with schizophrenia.

CONCLUSIONS

The results of the study could help clinical professionals to understand and have greater empathy with regard to the difficulties for families and the concerns of parents taking care of their children with schizophrenia in the specific context of Chinese culture, and to provide more efficient and responsive assistance.

Sex Selection Bias in Schizophrenia Antipsychotic Trials—An Update Systematic Review

The lack of female participation in antipsychotic trials for schizophrenia poses an important issue regarding its applicability, with direct and real-life repercussions to clinical practice. Here, our aim is to systematically review the sampling sex bias among randomized clinical trials (RCTs) of second-generation antipsychotics—namely risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole—as an update to a previous 2005 review. We searched MEDLINE and the Cochrane database for studies published through 7 September 2020 that assessed adult samples of at least 50 subjects with a diagnosis of schizophrenia, schizophrenia spectrum disorder, or broad psychosis, in order to investigate the percentage of women recruited and associated factors. Our review included 148 RCTs, published from 1993 to 2020, encompassing 43,961 subjects. Overall, the mean proportion of women was 34%, but only 17 trials included 50% or more females. Younger samples, studies conducted in North America, pharmaceutical funding and presence of specific exclusion criteria for women (i.e., pregnancy, breast-feeding or lack of reliable contraceptive) were associated with a lower prevalence of women in the trials. Considering the possible different effects of antipsychotics in both sexes, and our lack of knowledge on the subject due to sampling bias, it is imperative to expand actions aimed at bridging this gap.

Estrogens in schizophrenia: progress, current challenges and opportunities

PURPOSE OF REVIEW

Schizophrenia is a heterogeneous psychiatric disorder with a different, but not necessarily milder clinical presentation in women as compared to men. These sex differences have largely been attributed to the protective role of estrogens. This article reviews the current state of estrogen research in schizophrenia.

RECENT FINDINGS

Estrogens regulate important pathophysiological pathways in schizophrenia, including dopamine activity, mitochondrial function, and the stress system. Estrogen deficiency is common in both sexes and is associated with increases in psychotic symptoms. Hyperprolactinemia causes secondary estrogen deficiency and can be a reaction to stress, or secondary to prolactin-raising antipsychotics. Therefore, prolactin-sparing antipsychotics should be preferred especially in premenopausal women, who are more prone to hyperprolactinemia. Premenopausal women furthermore require lower doses of antipsychotics than men, since estrogens raise the availability and efficacy of antipsychotics.

SUMMARY

The past years have established the importance of estrogens in the pathophysiology of schizophrenia and have shown its relevance to clinical practice through its influence on antipsychotic drug efficacy. Future research should focus on the neurobiological and clinical effect of contraceptives in premenopausal women with schizophrenia. Furthermore, the potential of estrogen-like augmentation with raloxifene and phytoestrogens in schizophrenia should be established in the coming years.

Ageing with schizophrenia: an update

PURPOSE OF REVIEW

The aim of this review was to summarize the recent literature on the clinical symptoms, functioning, outcomes and treatments for older adults with chronic schizophrenia.

RECENT FINDINGS

The number and proportion of older adults with schizophrenia is rapidly increasing. Schizophrenia is a heterogeneous disorder and older adults with schizophrenia display significant variability in symptom severity, quality of life and overall outcomes. Many achieve stable disease remission, some display persistent nonremission and others experience fluctuating symptoms. Depression is commonly reported, and although rates of suicide are higher when compared with age-matched peers, the excess mortality seen in this population is mainly attributed to natural causes of death. Cognitive decline and reduced illness awareness have important implications for functional status and quality of life. Antipsychotics remain essential in the treatment regimen, although elderly patients with chronic disease may be good candidates for gradual dose reduction. Interdisciplinary treatment approaches as well as nonpharmacologic psychosocial interventions play a critical adjunctive role in the treatment of older adults with schizophrenia.

SUMMARY

Research focusing on schizophrenia in late life is sparse. Too often, older patients are eliminated from research studies or averaged in with all age groups. Thus, there continues to be gaps in our understanding of modifiable predictors of remission and recovery, and the most efficacious and safest treatment approaches for this age group.

Gender role endorsement in first-episode schizophrenia spectrum disorders

Sex (a biological distinction) and gender (a social construct) are inter-related, but semi-independent measures. The aim of our research was to compare gender role endorsement between first-episode schizophrenia spectrum disorder patients (n=77) and matched controls (n=64). The Bem Sex Role Inventory (BSRI) was used to assess masculinity and femininity scores as separate linear measures. This well-known research instrument also allowed us to examine gender as a categorical measure based on sex-specific cut-off scores calculated for controls as our normative reference sample using a median-split technique. First, we found that both masculinity and femininity scores differed between patients and controls. The distribution of gender as a categorical measure also differed between the two groups. Post-hoc testing with correction for multiple comparisons identified masculinity scores in particular as being lower in both male and female patients compared to controls of the corresponding sex. In conclusion, lower masculinity scores reported for chronic schizophrenia also affects first-episode patients with minimal prior treatment exposure irrespective of their biological sex. Future studies would do well to examine the associations of sex and gender with clinical and treatment outcomes from the perspective of the neurodevelopmental model of schizophrenia as a proposed "disorder of the self".

Sex differences in association between cognitive impairment and clinical correlates in Chinese patients with first-episode drug-naïve schizophrenia

BACKGROUND

Schizophrenia is a complex mental illness with significant sex differences. Cognitive impairment is common in patients with schizophrenia, even in remission. This study was designed to examine the sex differences in the relationship between cognitive impairment and clinical correlations with first-episode drug-naïve (FEDN) schizophrenia.

METHODS

93 FEDN patients (male/female = 45/48) and 160 controls (male/female = 74/86) were enrolled to compare the sex differences in cognitive functions measured by the MATRICS Consensus Cognitive Battery (MCCB). Positive and Negative Syndrome Scale (PANSS) and Hamilton Depression Scale (HAMD) were used to evaluate patients' clinical symptoms. We compared cognitive impairment with sociodemographic characteristics and measures of different genders, as well as group-by-sex interactions.

RESULTS

Our results showed that male patients had significantly lower scores for symbol coding, digital sequence, and verbal learning than female patients, while the healthy controls showed similar sex differences. In female patients, multiple linear regression analysis confirmed that PANSS negative symptoms and general psychopathology scores, HAMD total score, and education level were independent contributors to MCCB total score. In male patients, only education was an independent contributor to MCCB total score.

CONCLUSIONS

These findings revealed significant sex differences in cognitive impairments and clinical symptoms in FEDN, which will be worthy of a follow-up study of schizophrenia in the future.

Clozapine tolerability in Treatment Resistant Schizophrenia: exploring the role of sex

Clozapine is the only evidence-based drug indicated for Treatment Resistant Schizophrenia but it is largely underprescribed, partially due to its life-threatening adverse effects (AEs). However, clozapine treatment is burdened by other common AEs as constipation, hypersalivation, postural hypotension, tachycardia and metabolic abnormalities. Few studies have investigated sex-related differences in clozapine's tolerability, reporting women to experience more frequently weight gain, hyperglycemia and constipation, while men hypertension and dyslipidemia. Based on these premises, we investigated clinical, psychopathological and metabolic sex-related differences among 147 treatment-resistant patients treated with clozapine, with a specific focus on non-life-threatening AEs. We observed significant higher prevalence of tachycardia in men, and of orthostatic hypotension and constipation in women. Concerning metabolic alterations, we observed significant lower levels of HDL-cholesterol and higher prevalence of hypertriglyceridemia among men, whereas females showed higher prevalence of abdominal obesity. Consistently with previous studies, our data confirm the presence of sex-related differences in clozapine tolerability, with a main effect of sex especially for tachycardia, postural hypotension and constipation. Although non-life-threatening, these common AEs significantly affect patients' quality of life, undermine compliance and cause treatment discontinuation. A better understanding of this topic could contribute to tailor therapeutic approaches, thus improving tolerability, compliance and clinical stability.

Sex-specific Association of Antipsychotic-induced Weight Gain and Treatment Response for Antipsychotic-Naive First Episode Schizophrenia Patients: A Prospective 8-week Longitudinal Study

BACKGROUND

Patients with antipsychotic-naïve first-episode (ANFE) schizophrenia (SZ) can help clarify many confounding factors in determining sex differences in antipsychotic drug induced weight gain and its association with symptom improvement.

METHODS

This 8-week longitudinal trial of ANFE patients with SZ enrolled 526 patients and 313 healthy controls. We evaluated bodyweight and the efficacy of antipsychotics on the Positive and Negative Syndrome Scale (PANSS) at baseline and at the end of week 8.

RESULTS

Males and females after treatment showed no sex difference in weight gain, BMI increase, and percentage of weight gain. However, at baseline, male patients had more positive symptoms than female patients, and decreases in positive symptoms, general psychopathology, and total PANSS scores were less in male than female patients. Adjusting for confounding factors using multiple linear regression confirmed that weight gain was significantly associated with these decreases in PANSS symptoms only in men not women.

CONCLUSIONS

The relationship between weight gain and symptom reduction after 8 weeks of antipsychotic treatment exists only in male patients with ANFE SZ and not in female patients.