Sex and schizophrenia

Evaluation of nonadherence to treatment among patients with schizophrenia attending psychosocial care centers in the south region of Brazil

Introduction

The treatment of schizophrenia aims to reduce symptoms, improve quality of life and promote recovery from debilitating effects. Nonadherence to treatment is related to several factors and may lead to persistence of symptoms and relapse. Worldwide, the rate of nonadherence to treatment in individuals with schizophrenia is around 50%.

Objectives

To compare the clinical profile of nonadherent and adherent patients among individuals diagnosed with schizophrenia receiving treatment at psychosocial care centers in a city in southern Brazil.

Method

The clinical-epidemiological profile of patients with schizophrenia was retrospectively analyzed based on medical records entered into the system between January and December 2016, evaluating data at one-year follow-up.

Results

112 patients were included. The disease was more prevalent in men; mean age was 40.5 years, being lower among men. Most of the sample had a low level of education, was unemployed/retired, did not have children and resided with relatives. The highest rate of diagnosis was among young adults. Psychotic symptoms were most frequently described, and the most commonly prescribed antipsychotic was haloperidol. The nonadherence rate was 15.2%; only one patient required admission to a psychiatric hospital. Among nonadherent patients, the mean time of attendance was 6 months; there were more nonadherent women than men. The most prevalent age range of nonadherence was 41-64 years. Psychosocial and clinical data were similar across the whole sample.

Conclusion

A nonadherence rate of 15.2% was found among individuals receiving treatment for schizophrenia, suggesting that psychosocial care centers were effective in treating and monitoring these patients.

The Sex Chromosome Hypothesis of Schizophrenia: Alive, Dead, or Forgotten? A Commentary and Review

The X chromosome has long been an intriguing site for harboring genes that have importance in brain development and function. It has received the most attention for having specific genes underlying the X-linked inherited intellectual disabilities, but has also been associated with schizophrenia in a number of early studies. An X chromosome hypothesis for a genetic predisposition for schizophrenia initially came from the X chromosome anomaly population data showing an excess of schizophrenia in Klinefelter's (XXY) males and triple X (XXX) females. Crow and colleagues later expanded the X chromosome hypothesis to include the possibility of a locus on the Y chromosome and, specifically, genes on X that escaped inactivation and are X-Y homologous loci. Some new information about possible risk loci on these chromosomes has come from the current large genetic consortia genome-wide association studies, suggesting that perhaps this hypothesis needs to be revisited for some schizophrenias. The following commentary reviews the early and more recent literature supporting or refuting this dormant hypothesis and emphasizes the possible candidate genes still of interest that could be explored in further studies.

Antipsychotic-induced alterations in CB1 receptor-mediated G-protein signaling and in vivo pharmacology in rats

Dysregulation of the endocannabinoid and dopamine systems has been implicated in schizophrenia. The purpose of this study was to examine the effects of sub-chronic treatment with two antipsychotics on CB1 receptor-mediated in vitro and in vivo effects. Adult and adolescent male and female rats were injected twice daily with haloperidol (0.3 mg/kg), clozapine (10 mg/kg), or saline for 10 days. Subsequently, CB1 receptor number and function were assessed by [3H]SR141716 and WIN55,212-2-stimulated [35S]GTPgammaS binding, respectively. The effects of sub-chronic antipsychotic treatment on the in vivo actions of Delta9-tetrahydrocannabinol (Delta9-THC) were also evaluated. In adult female rats, antipsychotic treatment attenuated maximal stimulation of CB1 receptor-mediated G-protein activity in the striatum (clozapine) and prefrontal cortex (both antipsychotics), but not in the ventral midbrain. Associated changes in CB1 receptor number were not observed, suggesting that this attenuation was not due to downregulation. In vivo, sub-chronic treatment with clozapine, but not haloperidol, attenuated Delta9-THC-induced suppression of activity in adult females, whereas neither drug altered hypothermia or catalepsy. In contrast, antipsychotic treatment did not change CB1 receptor-mediated G-protein activation in any brain region in adult male rats and in adolescents of either sex. In vivo, haloperidol, but not clozapine, enhanced Delta9-THC-mediated suppression of activity and hypothermia in adult male rats whereas neither antipsychotic affected Delta9-THC-induced in vivo effects in adolescent rats. These findings suggest that modulation of the endocannabinoid system might contribute in a sex- and age-selective manner to differences in motor side effects of clozapine versus haloperidol.

Callosal misconnectivity and the sex difference in psychosis

The sex difference in age of onset in schizophrenia is paradoxical in the sense that the brain is developing faster in females but onsets are earlier in males. Therefore if schizophrenia, as widely believed, is a disorder of development, the difference is in the wrong direction. Here we attempt to resolve the paradox with the hypothesis that psychosis is an anomaly of development of cerebral asymmetry and the following assumptions: (1) asymmetry (the torque) confers directionality on the 'language circuit'--failure to develop asymmetry leads to the risk of reverse transmission, a putative mechanism of psychotic symptoms; (2) the corpus callosum goes on developing in an antero-posterior direction into the third and fourth decades of life; (3) a sex difference in structure and development of the corpus callosum (with some anterior components greater in males and posterior components greater in females) reflects stronger, faster lateralization in females; (4) because of the inverse relationship between asymmetry and interhemispheric connections, females, by developing faster, avoid the misconnectivity phenomena in the frontal lobes that males, developing more slowly, may encounter at a younger age with particular risk of negative symptoms.

Sex differences in neurochemical effects of dopaminergic drugs in rat striatum

Previous data indicate that dopamine neurotransmission is differently regulated in male and female rats. The purpose of the present study was to investigate the dopamine transporter and autoreceptor as potential loci responsible for this sex difference. Fast cyclic voltammetry at carbon-fiber microelectrodes was used to monitor changes in electrically evoked levels of extracellular dopamine in the striata of anesthetized male and female rats before and after administration of an uptake inhibitor, a dopamine D2 antagonist, or a D3/D2 agonist. Administration of 40 mg/kg cocaine ip increased electrically-evoked extracellular dopamine concentrations in both sexes, but to a significantly greater extent in female striatum at the higher stimulation frequencies. The typical antipsychotic, haloperidol, increased dopamine efflux in both sexes but the effect was twice as large in the female striatum. The D3/D2 agonist quinpirole induced an unexpected, transient increase in dopamine efflux following high-frequency stimulation only in females, and evoked dopamine was higher in females across this entire time course. More detailed analysis of cocaine effects revealed no fundamental sex differences in the interaction of cocaine with DAT in vivo or in synaptosomes. These results indicate that nigrostriatal dopamine neurotransmission in the female rat is more tightly regulated by autoreceptor and transporter mechanisms, perhaps related by greater autoreceptor control of DAT activity. Thus, baseline sex differences in striatal dopamine regulation induce different pharmacologic responses. These results contribute to understanding sex differences in stimulant-induced locomotor activity in rats and may have broader implications for neurologic disorders and their pharmacotherapies in humans.

Estrogen as an adjuvant therapy to antipsychotics does not prevent relapse in women suffering from schizophrenia: results of a placebo-controlled double-blind study

The expected therapeutic effect of estrogen as an adjunct treatment to antipsychotics in women suffering from schizophrenia for relapse prevention was to be tested under real-life conditions. A multicenter, randomized, placebo-controlled, double-blind, cross-over study based on an A-B-A-B (and/or B-A-B-A) design was applied. Forty-six hypoestrogenic women with schizophrenia hospitalized for the first time or repeatedly were included in the study. Their average age was 37.9 and they had been suffering from schizophrenia for 8.4 years. During the drug treatment phases, they received a three-phase estrogen-gestagen combination drug (17beta-estradiol+norethisterone acetate) in addition to an antipsychotic drug. Significant effects of the adjuvant hormone replacement therapy on the estradiol levels could be observed, and high and low levels of estradiol prevailed in the active drug and placebo phases, respectively. We did not find any difference either in defined relapse events or in the psychopathology between estradiol replacement and placebo phases. Neither did the required antipsychotic doses or the tolerance data differ between the two phases. Thus, the results of our study do not confirm the hypothesis that a combined estradiol/antipsychotic therapy is superior to an antipsychotic monotherapy for relapse prevention.

Regional and selective effects of oestradiol and progesterone on NMDA and AMPA receptors in the rat brain

We investigated the effect of 10 months ovariectomy and a correction therapy, 2 weeks before the rats were killed, of oestradiol, progesterone or their combination on NMDA and AMPA receptor binding in the hippocampus, dentate gyrus, striatum, nucleus accumbens and frontal cortex of the rat brain as well as on amino acid levels in frontal cortex. NMDA and AMPA binding densities were assayed by autoradiography using, respectively, L-[3H]glutamate and [3H]AMPA; amino acid concentrations were measured by high performance liquid chromatograhy (HPLC) coupled with UV detection. Ovariectomy was without effect on NMDA and AMPA binding density in all brain regions assayed except in the hippocampal CA1 region and dentate gyrus where it decreased NMDA binding density compared to intact rats values. Oestradiol restored and increased NMDA binding density in the CA1 subfield and the dentate gyrus of ovariectomized rats but, by contrast, it decreased binding density in the striatum and in the frontal cortex while having no effect in the CA2/3 subfield of the hippocampus and in the nucleus accumbens. Oestradiol was without effect on AMPA binding density in the hippocampus and the dentate gyrus but it reduced AMPA binding density in the striatum, the frontal cortex and the nucleus accumbens. Progesterone, and oestradiol combined with progesterone, decreased NMDA but not AMPA binding density in the frontal cortex of ovariectomized rats, and they were without effect on these receptors in the other brain regions assayed. Amino acid concentrations in the frontal cortex were unchanged after ovariectomy or steroid treatments. The effect of oestradiol in the hippocampus confirmed in the present study and our novel findings in the frontal cortex, striatum and nucleus accumbens may have functional significance for schizophrenia and neurodegenerative diseases.

Gender differences in treatment and outcome in a therapeutic community ward, with special reference to schizophrenic patients

This study examines gender differences in treatment and institutional outcome in a closed mixed-psychiatric ward functioning as a therapeutic community. Its first-time male (n = 784) and female (n = 741) patients were classified into five diagnostic categories according to criteria from the third revised edition of the Diagnostic and Statistical Manual of Mental Disorders: schizophrenia, schizophreniform/schizoaffective disorder, other psychoses, mood disorders, and nonpsychotic disorders. There were no statistically significant gender differences in sociodemographic variables either in the length of stay or in the number of treatment episodes in this ward in any diagnostic group. Differences in male and female participation in psychosocial therapies (individual, group, and milieu therapy) and in institutional outcome were minimal, with a slight trend in favor of the females. These minimal gender differences indicate an achievement of the treatment goals, and of achieving intergender equality. These goals are especially important for schizophrenic males due to their more severe clinical profile and poorer prognosis. With its greater degree of interaction and positive experiences, the therapeutic community model may help psychotic male patients in facing their age- and gender-specific life-span challenges.

Differences in distribution of ages of onset in males and females with schizophrenia

An earlier age at onset of schizophrenia in men as opposed to women, has been widely reported, but hitherto, insufficient account has been taken of parameters that might confound this finding. Furthermore, few explanatory models have accounted for the differences in shape of the age-at-onset distributions in males and females with schizophrenia. A catchment area sample of 477 first contact cases with schizophrenia or related disorders was ascertained through a case register. Differences in age at onset distributions between males and females were determined, and adjustment made for potential confounding factors. The most powerful predictors of early illness-onset were poor premorbid occupational functioning, single marital status, and male sex. The earlier onset in males was robust to controlling for other parameters. The shape of the onset distribution also differed between the sexes: SKUMIX analysis revealed a two-peak distribution for males, and a three-peak distribution for females. The mean age at onset for schizophrenia is earlier in males, and the onset distribution differs between the sexes. Psychosocial variables cannot explain these findings. Possible explanations for these gender differences include males and females being differentially susceptible to subtypes of illness with different mean ages at onset; precipitating and/or ameliorating factors operating at different stages of life in males and females; and/or an X-linked susceptibility locus that determines the age at onset.

The modulation of brain dopamine and GABAA receptors by estradiol: a clue for CNS changes occurring at menopause

1. Tardive dyskinesia is more important in postmenopausal women than men of comparable age and a peak of first episodes of schizophrenia is observed in postmenopausal women. The effect of ovariectomy (2 weeks or 3 months) in rats was investigated as a model of decreased gonadal function associated with menopause. 2. Frontal cortex D1 receptor density and affinity were similar in intact male compared to intact female rats and progressively decreased in density with time after ovariectomy, with no change of affinity. Striatal D1 and D2 receptors also decreased in density after ovariectomy for both receptor subtypes, with no change of affinity. Striatal D1 receptor density and affinity were similar in intact male and female rats, whereas the density of D2 receptors was higher in females. Treatment with estradiol for 2 weeks restored the D2 but not the D1 receptor changes. 3. In the substantia nigra pars reticulata, striatum, nucleus accumbens, and entopeduncular nucleus, a progressive increase in [3H]flunitrazepam specific binding associated with GABAA receptors was observed as a function of time following ovariectomy; this was corrected with estradiol treatment. In contrast, the opposite was observed for [3H] flunitrazepam binding in the globus pallidus, where ovariectomy decreased binding, which was corrected with estradiol replacement therapy. 4. Low prefrontal cortex dopamine activity with implications of D1 receptors in negative symptoms of schizophrenia is hypothesized. Furthermore, GABAergic overactivity in the internal globus pallidus-substantia nigra pars reticulata complex is hypothesized in tardive dyskinesia. 5. The present data suggest that gonadal hormone withdrawal by reducing brain dopamine receptors and producing an imbalance of GABAA receptors in the output pathways of the striatum may predispose to schizophrenia and dyskinesia.

A prospective 1-5 year outcome study in first-admitted and readmitted schizophrenic patients; relationship to heredity, premorbid adjustment, duration of disease and education level at index admission and neuroleptic treatment

In a prospective outcome study, 120 DSM-III-R schizophrenic patients were followed for up to 5 years after index admission, when a comprehensive clinical and demographical examination was undertaken with the aim to find early prognostic factors for outcome. They were 86 males (72%) and 34 females (28%), and 66 (55%) were first-admitted and never before treated at index admission from a geographically defined area. Outcome was evaluated 1, 3 and 5 years after index admission by use of a Strauss-Carpenter outcome scale. At year five, 101 patients could be evaluated. Seven (7%) patients had committed suicide during the 5 years' follow-up period. 30% of the patients was considered to have a good, 14% a poor and 56% an intermediate outcome. It was found that 58% had not been in hospital during the last year, 27% were employed on the open market, 25% met friends regularly and 38% had no or only mild symptoms at the five years' follow-up evaluation. Females had a significantly better outcome than males. High education level and absence of premorbid deviant behaviour at index admission predicted a good outcome whereas problems in school (with friends and/or teachers) reported by relatives predicted poor outcome. No relationship was found between outcome and age at onset of the disorder and no gender difference in age at onset of the disorder. Patients with a family history of schizophrenia improved more between year one and five as compared with those without a family history, but heredity in itself was not an important factor for outcome. At 5 years after index admission, 40% of patients were on classical neuroleptics and 33% on clozapine whereas 19% were without medication. Of the total sample of 101 patients, 10% were drug-free and had a very good outcome at the 5 years' evaluation. The data indicate that there is a substantial subgroup of schizophrenic patients with a good prognosis and they can be characterized by female sex (even in a group without gender difference in age at onset), absence of premorbid deviant behaviour and a high education level at index admission.

Gender and schizophrenia. Results of an epidemiologically-based family study

BACKGROUND

Gender may have a significant impact on the prevalence, age at onset, symptoms, course and outcome of schizophrenia, as well as on the pattern of psychopathology in relatives.

METHOD

We examined these questions in the Roscommon Family Study, in which the probands were epidemiologically sampled from a case registry and followed up an average of 15 years after onset. Face-to-face interviews were conducted with 86% of traceable living relatives.

RESULTS

The treated lifetime prevalence of DSM-III-R schizophrenia was 0.54 +/- 0.06% in men and 0.28 +/- 0.04% in women. No significant differences were seen in the age at onset, symptoms, course or outcome of schizophrenia. The risks for schizophrenia, schizophrenia spectrum disorders, affective illness and alcoholism were similar in relatives of male and female schizophrenic probands.

CONCLUSIONS

Gender has little impact on the presentation and course of schizophrenia in the west of Ireland. The familial liability to schizophrenia did not differ in affected men and women. No evidence was found that schizophrenia in women, compared to men, is, from a symptomatic or familial perspective, more closely related to affective illness. The substantial gender difference in the prevalence rate of schizophrenia in Ireland cannot be explained by women having a greater resistance to the familial predisposition to illness.

Puberty and the onset of psychosis

According to the neurodevelopmental hypothesis of schizophrenia, maturational events in the brain at puberty interact with congenital defects to produce psychotic symptoms. As girls reach puberty at a younger age than boys, we predicted that (i) females would show earlier onset of psychotic illness arising around puberty, and (ii) onset of psychosis in females would be related to menarche. Analysis of epidemiological data regarding admission to psychiatric units in (a) England over the period 1973-1986, (b) France over the period 1975-1980, as well as examination of 97 psychotic adolescents referred to an adolescent unit over a 14 year period, supported both these propositions.

Sex differences in the age of onset of affective disorders

Studies of sex differences in first admission age for inpatients in Missouri public psychiatric hospitals were examined for the incidence of major affective illness and dysthymia. Patients diagnosed as schizophrenic were also studied to check for diagnostic comparability. Those males diagnosed as having major affective illness were admitted 3.82 years earlier than females; the differential held up regardless of fifth-digit coding for psychosis. Males diagnosed as dysthymic were admitted 0.98 years earlier than females. Male schizophrenic patients were admitted an average of 7.75 years earlier than females, and the distribution was similar to that reported in a variety of cross-cultural studies.

[Schizophrenia: difference between the sexes]

This literature review focuses on the main differences in schizophrenia according to gender. The data are presented as follows: epidemiological data (incidence and age at onset of the illness); data on evolution of the illness; and mortality. Clear conclusions can be drawn and directions for future research are suggested.

Schizophrenia: gender and familial risk

The morbid risks for schizophrenia and any nonaffective psychosis in the first degree relatives of male and female schizophrenic probands were compared utilizing Cox proportional hazards models. The schizophrenic probands (275 male; 106 female) were drawn from a larger sample of hospitalized patients obtained by systematically screening all psychiatric admissions to 15 facilities over a six-year period. Proband diagnoses (DSM-III) were based on a direct assessment of the patient and a review of medical records. The family history method was used to obtain information about the first degree relatives of the probands. Cox proportional hazards models were adjusted for duration of illness of the proband and gender of the relatives. First degree relatives of female probands had significantly higher morbid risks for schizophrenia and nonaffective psychosis than relatives of male probands. The differential risk for schizophrenia in the relatives of male and female probands demonstrated in this study, as well as others, suggests that males and females may be at different risk for subtypes of the disorder.

Gender differences in the incidence of definite schizophrenia and atypical psychosis--focus on negative symptoms of schizophrenia

In a catchment area study of 101 first inceptions of schizophrenia, mania and atypical psychoses, women were significantly more likely to have atypical psychosis and men were more likely to have definite schizophrenia. Negative symptoms such as affective flattening and poverty of speech were already present in many cases, and were significantly increased in patients with definite schizophrenia (geometric mean 5.6) compared with those with atypical psychosis (geometric mean 3.2) and mania (geometric mean 1.5). Negative symptoms were also twice as severe in men (geometric mean 5.5) than women (geometric mean 2.6). There was a significant increase in negative symptom severity with longer illness and greater depression, but the diagnosis and the sex effects were not caused by these factors. We suggest that our findings are further support for the hypothesis that men have a greater biological vulnerability to negative symptoms and consequent social disability in the face of psychosis, particularly a schizophrenic psychosis, and that this may be one explanation for the apparently greater risk of definite schizophrenia and its poorer prognosis in men.

Family history and brain morphology in schizophrenia: an MRI study

This study examined neuroanatomical differences between male schizophrenic patients with a family history of psychosis (n = 16) and those without such a history (n = 15). Intracranial area, cerebral area, ventricular size, and cortical atrophy were assessed using magnetic resonance imaging (MRI). Third ventricular enlargement was more prevalent in patients than controls (n = 15). Familial and nonfamilial patients differed significantly. Reduced cranial and cerebral areas without ventricular enlargement characterized familial patients, whereas nonfamilial patients showed marked lateral ventricular enlargement without a reduction in cranial/cerebral size.

Sex differences in the familial transmission of schizophrenia

The hypothesis that schizophrenic men have a lower familial risk for schizophrenia than schizophrenic women was tested using the DSM-III-diagnosed samples of the Iowa 500 and non-500 family studies. Survival analyses were used to test for differences in the risk for schizophrenia and spectrum disorders, for sex of proband and sex of relative, controlled for fertility effects and ascertainment bias. Male and female relatives of schizophrenic men had a significantly lower risk for schizophrenia, schizophreniform, and schizoaffective disorders than relatives of schizophrenic women. However, the effect was not significant for the full spectrum nor when analysed by sex of relative. Sex differences in the risk for other psychiatric disorders among relatives of schizophrenic probands were not significant.

Gender differences in the brain: are they relevant to the pathogenesis of schizophrenia?

Gender differences are present in the clinical expression of schizophrenia, age of onset, course of illness, and response to pharmacologic treatment. These differences are not surprising in view of the normal gender differences in brain growth, differentiation, adult brain structure, and neurochemistry. The present review examines what is presently known about brain gender differences, and whether this information is consistent with the published reports of brain functional and morphological abnormalities in schizophrenia. Whether gender differences in the brain can explain the gender differences in clinical aspects of the disorder remains unknown.

Gender differences in schizophrenia: rehospitalization and community survival

This study tested the hypothesis that schizophrenic men experience a poorer course than schizophrenic women. A representative sample from Hannover, FRG, including 278 first admission DSM-III schizophrenics, were followed for three years. Findings demonstrated that schizophrenic women experience fewer rehospitalizations, shorter lengths of stay, and survive longer in the community than schizophrenic men. Implications of the role of gender for schizophrenia are discussed.

Sex differences in the phenomenology of schizophrenic disorder

The content and structure of delusions were compared in 30 women and 30 age-matched men with Schizophrenic Disorder. Men showed an excess of homosexual persecutory delusions and of grandiose delusions involving social status and personal power. Women showed an excess of delusions of fertility and of jealousy, and were more often than men objects rather than subjects in their grandiose delusions. There was an excess of women who reported co-objects of persecution, and who personally knew their persecutors, nearly always men. These differences mirrored aspects of the social environment, especially with regard to sex-role stereotyping.

Gender and the expression of schizophrenia

The expression of schizophrenia was examined in 169 DSM-III diagnosed schizophrenics. Restricted maximum likelihood factor analysis was used to test the invariance of the hypothesized symptom model across gender. Findings indicated that schizophrenic women not only expressed more impulsivity and affective symptomatology than did men, but their psychotic symptoms covaried consistently with the expression of impulsivity, anger and other affective symptomatology. Men's expression of schizophrenia covaried positively with withdrawal/isolation and an inability to function, suggesting a possible negative symptom pattern. Gender differences were not attributable to misclassification, differences in diagnostic subtypes, nor to selection. Results are discussed in light of their implications for understanding the heterogeneity of schizophrenia.

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.