Women and schizophrenia: a review

Regulation of sex differences in risk-based decision making by gonadal hormones: Insights from rodent models

Men and women differ in their ability to evaluate options that vary in their rewards and the risks that are associated with these outcomes. Most studies have shown that women are more risk averse than men and that gonadal hormones significantly contribute to this sex difference. Gonadal hormones can influence risk-based decision making (i.e., risk taking) by modulating the neurobiological substrates underlying this cognitive process. Indeed, estradiol, progesterone and testosterone modulate activity in the prefrontal cortex, amygdala and nucleus accumbens associated with reward and risk-related information. The use of animal models of decision making has advanced our understanding of the intersection between the behavioral, neural and hormonal mechanisms underlying sex differences in risk taking. This review will outline the current state of this literature, identify the current gaps in knowledge and suggest the neurobiological mechanisms by which hormones regulate risky decision making. Collectively, this knowledge can be used to understand the potential consequences of significant hormonal changes, whether endogenously or exogenously induced, on risk-based decision making as well as the neuroendocrinological basis of neuropsychiatric diseases that are characterized by impaired risk taking, such as substance use disorder and schizophrenia.

Gender-associated role in patients with schizophrenia. Is there a connection with the resistance?

Schizophrenia is a chronic mental illness observed with equal prevalence in different cultures and ethnic groups. The clinical picture relates to behavior and social adaptation. A significant percentage of patients, despite the implementation of various therapeutic interventions, remain resistant to the ongoing treatment. Occupying a certain gender role depends both on biological belonging and on the way of self-perception characteristic of the given person. Self-perception reflects gender identification, which in social aspect is determined by the choice of social activities performed. Changes in behavior and social adaptation in patients with schizophrenia led us to conduct a study to analyze the perceived gender role in patients with schizophrenia, looking for differences between patients with treatment resistance and those in clinical remission.

MATERIALS AND METHODS

A total of 105 patients with schizophrenia were analyzed. Of them, 45 were with resistant symptoms and 60 in clinical remission. The clinical analysis of the patients was carried out using the PANSS and BPRS scales. The evaluation of the choice of social activity related to a particular gender was done with the Bem Sex-Role Inventory (BSRI).

RESULTS

Out of all 105 patients with schizophrenia, in 80/76.19%/we found a higher identification with the female role, 17/16.19%/made an association with the male role and in 8/7.61%/patients we found the same results, i.e., with both the male and female roles. Among the patients with treatment resistant schizophrenia (TRS)-45, 34/75.56%/identified more with the female gender role, 6/13.33/perceived the male gender role as active, and in 5/11.11%/the identification was equal both with the male and with the female roles. Among the patients in clinical remission (CR)-60, 46/76.67%/accepted the female role as active, 11/18.33/identified with the male one, and three/5%/accepted both roles equally. When assessing the relationship between biological sex and perceived gender role, it was found that among men/a total of 39/half identified with the female gender role and half with the male gender role. Among women/a total of 66/, 90% perceived the female gender role, 7%-the male and 3% equally the male and the female gender role. No relationship was found between the choice of a certain gender role and the onset of psychosis and its duration in the observed patients.

CONCLUSION

We found a higher percentage of schizophrenic patients who showed higher identification with the female gender role. Approximately half of the males identified with the female gender role. Resistance had no influence on the choice of sex-associated social activity. Factors related to the course of the schizophrenia process such as age of onset of psychosis and duration of psychosis was not associated with an influence on identification with sex-associated social activity. Our research suggests that identification with a particular sex associative social activity is most likely established earlier in the prodromal period.

Interactive effect of MTHFR C677T polymorphism and sex on symptoms and cognitive functions in Chinese patients with chronic schizophrenia

The etiology of schizophrenia is still unknown, and the MTHFR gene has been shown to be associated with SCZ. Previous studies have shown that patients with schizophrenia exhibit sex differences in symptoms and cognitive function. However, no study has been conducted to investigate the sex difference in the association between C677T polymorphism and symptoms and cognitive impairment in Chinese patients with schizophrenia. The C677T polymorphism was genotyped in 957 patients with schizophrenia and 576 controls. Patients were also rated on the Positive and Negative Syndrome Scale (PANSS) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The results showed that there were significant differences in MTHFR C677T genotype and allele distributions between male patients and male controls (both p<0.05), while there was no significant difference between female patients and female controls (both p>0.05). Further analysis showed that there were significant sex differences in the association between C677T genotype and negative symptoms, immediate memory or attention index score in schizophrenia (p<0.05). This study suggests that the complex interactive effect between MTHFR C677T polymorphism and sex plays an important role in some clinical characteristics of patients with schizophrenia.

Association Between Age at Onset of Schizophrenia and Age at Menarche

INTRODUCTION

Increasing evidence from clinical practice, as well as from epidemiological and basic research shows that there are gender differences in clinical features of schizophrenia, and this may be related to estrogens. There may be a relationship between earlier puberty and later onset of the disease, because of the protective effects of estrogens in women with schizophrenia. In this study, our aim was to analyze the correlation between age of menarche and age of onset of schizophrenia and to investigate the protective effects of estrogens in schizophrenia.

METHOD

In this study, we included 289 patients who were diagnosed with schizophrenia. Those with mental deficiency or organic brain disorders were excluded from the study. All subjects were given a socio-demographic form to determine their personal information, age at menarche, age at first odd behavior, age at onset of the disease and first hospitalization. Data on factors which may affect the association between age at onset of schizophrenia and age at menarche such as family history, head or birth trauma etc. were recorded on the information form.

RESULTS

We found out that age at menarche was negatively associated with age at first odd behavior and age at first psychotic symptoms.

CONCLUSION

Our study verifies the protective effects of estrogens and shows that the earlier puberty may be the cause of later onset of schizophrenia. A gender-sensitive approach in psychiatry improves our understanding of mental illness and our therapeutic strategies.

The role of estrogen in the treatment of men with schizophrenia

Schizophrenia is a debilitating and pervasive mental illness with devastating effects on many aspects of psychological, cognitive and social wellbeing. Epidemiological and life-cycle data point to significant differences in the incidence and course of schizophrenia between men and women, suggesting that estrogen plays a "protective" role . Adjunctive estrogen therapy has been shown to be effective in enhancing the treatment of schizophrenia in women. In men, consideration of estrogen therapy has been impacted by concerns of feminisation, however, clinical trials using estrogen to treat prostate cancer, bone density loss and even aggression in men with dementia or traumatic brain injury, show estrogen to be a safe and effective therapy. Findings do, however, suggest that further exploration of a therapeutic role for adjunctive estradiol treatment in men with schizophrenia is warranted. The development of the new estrogen compounds - Selective Estrogen Receptor Modulators (SERMs) which do not cause feminisation - opens up the possibility of using a different type of estrogen for a longer period of time at higher doses. Estrogen could therefore prove to be an important component in the treatment of psychotic symptoms in men with schizophrenia. This review explains the scientific rationale behind the estrogen hypothesis and how it can be clinically utilised to address concerns unique to the care of men with schizophrenia.

Hinduism, marriage and mental illness

For Hindus, marriage is a sacrosanct union. It is also an important social institution. Marriages in India are between two families, rather two individuals, arranged marriages and dowry are customary. The society as well as the Indian legislation attempt to protect marriage. Indian society is predominantly patriarchal. There are stringent gender roles, with women having a passive role and husband an active dominating role. Marriage and motherhood are the primary status roles for women. When afflicted mental illness married women are discriminated against married men. In the setting of mental illness many of the social values take their ugly forms in the form of domestic violence, dowry harassment, abuse of dowry law, dowry death, separation, and divorce. Societal norms are powerful and often override the legislative provisions in real life situations.

Hormones and schizophrenia

PURPOSE OF REVIEW

It is a well established fact that many serious mental illnesses, in particular psychoses such as schizophrenia, may have a significant hormonal aetiological component. This study aims to discuss the oestrogen protection hypothesis of schizophrenia in particular, with an emphasis on findings from the recent literature in support of this theory.

RECENT FINDINGS

Epidemiological and life-cycle data point to significant differences in the incidence and course of schizophrenia between men and women, suggesting a protective role of oestrogen. In-vitro and in-vivo preclinical research has confirmed oestradiol's interactions with central neurotransmitter systems implicated in the pathogenesis of schizophrenia, whereas results from randomized controlled trials investigating the antipsychotic potential of oestrogen have been promising. Research into other neuroactive hormones with possible effects on mental state is a field still in its infancy but is evolving rapidly.

SUMMARY

Schizophrenia and related psychoses are pervasive and debilitating conditions, for which currently available treatments are often only partially effective and entail a high risk of serious side effects. Thus, new therapeutic strategies are needed, and the literature reviewed here suggests that hormones such as oestrogen could be a viable option. It is hoped that, with further research and larger trials, the oestrogen hypothesis can be translated into effective clinical practice.

The role of oestrogen and other hormones in the pathophysiology and treatment of schizophrenia

The theory that many serious mental illnesses, in particular psychoses such as schizophrenia, may have a significant hormonal aetiological component is fast gaining popularity and the support of scientific evidence. Oestrogen in particular has been substantially investigated as a potential mediator of brain function in schizophrenia. Epidemiological and life-cycle data point to significant differences in the incidence and course of schizophrenia between men and women suggests a protective role of oestrogen. In vitro and in vivo preclinical research confirms oestradiol's interactions with central neurotransmitter systems implicated in the pathogenesis of schizophrenia, while results from randomised controlled trials investigating the antipsychotic potential of oestrogen have been positive. Research into other neuroactive hormones with possible effects on mental state is a rapidly evolving field that may hold new promise. Given that schizophrenia and related psychoses are pervasive and debilitating conditions for which currently available treatments are often only partially effective and entail a high risk of serious side-effects, novel therapeutic strategies are needed. The literature reviewed in this paper suggests that hormones such as oestrogen could be a viable option, and it is hoped that with further research and larger trials, the oestrogen hypothesis can be translated into effective clinical practice.

Spontaneous gamma coherence as a possible trait marker of schizophrenia-An explorative study

OBJECTIVES

Integration of sensory information by cortical network binding appears to be crucially involved in sensory processing activity. Studies in schizophrenia using functional neuroimaging, event-related potentials and EEG coherence indicate an impairment of cortical network coupling in this disorder. Previous electrophysiological investigations in animals and humans suggested that gamma activity (oscillations at around 30-100Hz) is essential for cortical network binding. This is the first investigation of spontaneous gamma activity in schizophrenics and their first degree relatives as compared to normal controls.

METHOD

Resting EEG was recorded in 20 drug naïve/drug free male schizophrenic patients, their pair matched male first degree relatives and 20 age-, sex-, education- and handedness-matched normal controls. Power spectrum and coherence of gamma band activity was analysed using MATLAB 6.5.

RESULTS

Schizophrenic patients had significantly less interhemispheric spontaneous gamma coherence and increased gamma power compared to normal controls. But there was no significant difference in gamma coherence between patients and their first degree relatives. Spontaneous gamma coherence had significant correlation with few PANSS subscale scores.

CONCLUSIONS

There is cortical hyperactivation and a reduced spontaneous and induced gamma coherence abnormality in schizophrenia. The abnormal gamma coherence appears explaining the psychopathology and poor performance on cognitive task in schizophrenia. This study has also generated hypotheses that the gamma band abnormality may be a trait abnormality in schizophrenics as seen by the similarity between the patient and their clinically asymptomatic first degree relatives.

Importance of animal models in schizophrenia research

OBJECTIVE

This review aims to summarize the importance of animal models for research on psychiatric illnesses, particularly schizophrenia.

METHOD AND RESULTS

Several aspects of animal models are addressed, including animal experimentation ethics and theoretical considerations of different aspects of validity of animal models. A more specific discussion is included on two of the most widely used behavioural models, psychotropic drug-induced locomotor hyperactivity and prepulse inhibition, followed by comments on the difficulty of modelling negative symptoms of schizophrenia. Furthermore, we emphasize the impact of new developments in molecular biology and the generation of genetically modified mice, which have generated the concept of behavioural phenotyping.

CONCLUSIONS

Complex psychiatric illnesses, such as schizophrenia, cannot be exactly reproduced in species such as rats and mice. Nevertheless, by providing new information on the role of neurotransmitter systems and genes in behavioural function, animal 'models' can be an important tool in unravelling mechanisms involved in the symptoms and development of such illnesses, alongside approaches such as post-mortem studies, cognitive and psychophysiological studies, imaging and epidemiology.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

BACKGROUND

The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge.

METHOD

A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process.

TREATMENT RECOMMENDATIONS

This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no specialist involvement, while very common, is not regarded as an acceptable standard of care. Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.

Sex differences, gamma activity and schizophrenia

This study explores the possibility that the more favourable clinical prognosis in females with schizophrenia may be associated with their greater network interconnectedness, which is possibly reflected in enhanced "Gamma" (40 Hz) electrical brain activity. An auditory "oddball" task was administered to 35 patients with schizophrenia and 35 age and sex matched controls (25 males and 10 females). Peak Gamma amplitude (from a time series of Gamma activity averaged for 40 target stimuli, as well as the immediately preceding 40 background tones) was examined across 19 sites. Peak Gamma activity occurred 250 to 450 ms in targets and 350 to 550 ms in backgrounds. Multiple within and between group MANOVAs were undertaken analysing both Peak Gamma amplitude (microvolts) and latency (milliseconds). Within-group, the control males showed a pattern of earlier Gamma latency in the right compared with the left hemisphere (F(1, 33)=3.70, p<.06), while control females exhibited delayed latency frontally compared with the posterior region (F(1, 33)=6.25, p<.04). This male lateralization finding and the anterior/posterior gradient in females is consistent with Goldberg's model. The patient group however, failed to show this male lateralized and female frontal-posterior pattern of Gamma activity, suggesting suboptimal network integration in the patient group, in both males and females.

Ziprasidone and the pharmacokinetics of a combined oral contraceptive

AIMS

To determine whether multiple doses of ziprasidone alter the steady-state pharmacokinetics of the component steroids, ethinyloestradiol and levonorgestrel, of an oral contraceptive; to evaluate the tolerability of a co-administered combined oral contraceptive and ziprasidone; and to compare plasma concentrations of prolactin in subjects taking a combined oral contraceptive with placebo or ziprasidone.

METHODS

Nineteen women taking a combined oral contraceptive (ethinyloestradiol 30 microg day(-1) and levonorgestrel 150 microg day(-1)) were enrolled into a double-blind, placebo-controlled, two-way crossover study. They received ziprasidone 40 mg day- 1 in two divided daily doses or placebo for 8 days (days 8-15) in one of two 21 day treatment periods separated by a 7 day washout period. Venous blood samples were collected immediately before and up to 24 h after the morning dose of oral contraceptive and ziprasidone or placebo on day 15 of each 21 day treatment period. These were assayed for ethinyloestradiol and levonorgestrel and the resulting data used to derive pharmacokinetic data for these steroids. Additional samples were collected immediately before and 4 h after the morning dose of oral contraceptive and ziprasidone or placebo on day 15 of each 21 day treatment period for prolactin assay. All observed and volunteered adverse events were recorded throughout the study.

RESULTS

The mean AUC(0,24 h), Cmax and tmax for ethinyloestradiol and the mean AUC(0, 24 h) and Cmax for levonorgestrel during ziprasidone co-administration were not statistically significantly different from corresponding values occurring during placebo co-administration. The tmax for levonorgestrel was approximately 0.5 h longer. Concomitant therapy with a combined oral contraceptive and ziprasidone did not result in adverse events not previously seen with either preparation alone.

CONCLUSIONS

The findings of this study suggest that, based on pharmacokinetic and tolerability data, ziprasidone may be co-administered with ethinyloestradiol and levonorgestrel without loss of contraceptive efficacy or increased risk of adverse events.

Psychiatric illness in women: a review of the function of a specialist mother-baby unit

OBJECTIVE

The aim of this paper is to describe a specialist program in a psychiatric mother-baby unit and to review the characteristics (including mothering skills) and outcomes on discharge of 36 women consecutively admitted to the unit over an intensive 6-month observation period. Changes in admissions to the same unit over 10 years were also compared.

METHOD

Consecutive admissions were studied in terms of demographics, ethnicity, diagnosis, psychiatric history, psychiatric information and mother-infant data.

RESULTS

The majority of women admitted suffered from schizophrenia or other psychotic disorders, with the second largest diagnostic criteria being depression. For 20 mothers, this was the first psychiatric admission and most admissions were voluntary. The mean length of stay was 21.7 days, representing a highly significant decrease in stay when compared to the past 10 years in the same unit. Mothering skills were found to be incompetent or only passable in 57% of women. A small improvement occurred by discharge, and the majority of women were not separated from their infants.

CONCLUSIONS

The critical need to support these women and their infants in the long term was highlighted, with recommendations of outpatient and day programs, as well as supported accommodation.