Peri- and Post-Menopausal Women with Schizophrenia and Related Disorders Are a Population with Specific Needs: A Narrative Review of Current Theories

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.

Women with Schizophrenia-Spectrum Disorders After Menopause: A Vulnerable Group for Relapse

BACKGROUND AND HYPOTHESIS

Throughout the life stages of women with schizophrenia-spectrum disorders (SSD), lower estrogen levels are associated with more severe disease course. At perimenopause in the mid-forties, estrogen levels decline to remain persistently low after menopause. This period is hypothesized to increase relapse risk and reduce antipsychotic effectiveness in preventing relapse.

STUDY DESIGN

The cohort of persons with schizophrenia/schizoaffective disorder was identified from Finnish nationwide registers (N = 61 889) and stratified by sex and age <45 vs. ≥45 years. Hospitalizations for psychosis were defined per 5-year age group during the follow-up 1996-2017. Risk of psychosis hospitalization (Adjusted Hazard Ratio, aHR) was assessed using within-individual design, by comparing antipsychotic monotherapy use to nonuse periods in the same individuals for seven dose categories in defined daily doses (DDDs/day).

RESULTS

Starting at age 45-50, women were consistently more often hospitalized for psychosis than their male peers. Women ≥45 had significantly higher aHRs than women <45 at antipsychotic monotherapy >0.6 DDDs/day, and than men at >1.1 DDDs/day. This female-specific age-dependent decrease in effectiveness was present for clozapine doses >0.6 DDDs/day, olanzapine doses >1.4 DDDs/day, and for specific doses of quetiapine (0.9-1.1 DDDs/day) and risperidone (0.6-0.9 DDDs/day).

CONCLUSIONS

While younger women have a lower risk of relapse and generally need a lower antipsychotic dose to prevent rehospitalization than men, antipsychotic effectiveness declines in women after the age of 45. Starting in mid-forties, older women with SSD should be regarded as a vulnerable group that deserve special attention.

Serious mental illness in women

PURPOSE OF REVIEW

Psychiatric illnesses are very prevalent in the United States and impact women and men differently. In this review, we will explore some gender differences in the expression of psychopathology, discuss the most common serious mental illnesses (SMI) affecting women, and review treatment options according to specific life stages. We hope to raise awareness of these issues and consequently improve outcomes for women with serious mental illness.

RECENT FINDINGS

SMI have different rates and are manifested differently in women and men because of biological, psychological, social, and cultural factors. Some SMI are more prevalent in women whereas others uniquely affect them during particular life stages. Even in disorders that have a similar prevalence in men and women or are more prevalent in men, the presentation, course, management, and repercussions can vary significantly between the two genders. Medical and psychiatric comorbidities, which directly influence treatment, prognosis, and disability, are more common in women.

SUMMARY

Several differences in the gender expression of SMI have not yet been fully described. It is important to become familiar with important characteristics of SMI in women, including biological determinants, treatment differences, and psychosocial aspects. Recognizing gender biases, cultural considerations, and adaptive responses can help identify women at risk, promote early recognition of symptoms, and prompt interventions that may lead to improved outcomes.

Disentangling early and late onset of psychosis in women: identifying new targets for treatment

Women present a second peak of incidence of psychosis during the menopausal transition, partially explained by the loss of estrogen protection conferred during the reproductive years. In view of the lack of studies comparing sociodemographic, biological, and clinical variables and neurocognitive performance between women with early onset of psychosis (EOP) and those with late onset of psychosis (LOP), our aim was to characterize both groups in a large sample of 294 first-episode psychosis (FEP) patients and 85 healthy controls (HC). In this cross-sectional study, the participants were interviewed to gather information on sociodemographic variables. We assessed laboratory features of interest and conducted a clinical assessment of psychopathological symptoms and neurocognitive abilities. From the latter, we derived a global cognitive functioning score. Analysis of covariance (ANCOVA) was used to compare EOP and LOP groups, and each group with age-comparable HC. EOP women were more frequently single and unemployed than HC age peers. While cholesterol levels in LOP women were higher than those in EOP women, no statistically significant differences were found in leptin levels. Women with LOP presented with less severe negative symptoms and higher cognitive processing speed scores than women with EOP. Cannabis and alcohol use was greater in EOP than in LOP women. Within the total FEP group, there was a history of significantly more recent traumatic events than in the HC group. Women with EOP and LOP show several sociodemographic and clinical differences, which may be valuable for planning personalized treatment.

Antipsychotic Polypharmacy-Related Cardiovascular Morbidity and Mortality: A Comprehensive Review

Schizophrenia is a psychotic disorder that exists at the more extreme end of a spectrum of diseases, and significantly affects daily functioning. Cardiovascular adverse effects of antipsychotic medications are well known, and include changes in blood pressure and arrhythmias. Sudden cardiac death is the leading cause of death worldwide, and antipsychotic medications are associated with numerous cardiac side effects. A possible link exists between antipsychotic medications and sudden cardiac death. Common prescribing patterns that may influence cardiovascular events include the use of multiple antipsychotics and/or additional drugs commonly prescribed to patients on antipsychotics. The results of this review reflect an association between antipsychotic drugs and increased risk of ventricular arrhythmias and sudden cardiac death by iatrogenic prolongation of the QTc interval. QTc prolongation and sudden cardiac death exist in patients taking antipsychotic monotherapy. The risk increases for the concomitant use of specific drugs that prolong the QTc interval, such as opioids, antibiotics, and illicit drugs. However, evidence suggests that QTc intervals may not adequately predict sudden cardiac death. In considering the findings of this narrative review, we conclude that it is unclear whether there is a precise association between antipsychotic polypharmacy and sudden cardiac death with QTc interval changes. The present narrative review warrants further research on this important potential association.

Gynecological Health Concerns in Women with Schizophrenia and Related Disorders: A Narrative Review of Recent Studies

Sex and age are important factors influencing physical and mental health in schizophrenia. Our goal was to review the recent literature for associations between gynecological conditions and psychotic illness and to propose integrated strategies for their management in order to improve overall health outcomes in women. We addressed the following questions: What are the prevalence and risk factors of gynecological disorders in women with schizophrenia or delusional disorder (DD)? What are the rates of uptake of gynecological cancer screening and mortality in this population? What role does menopause play? We found an increased incidence of breast cancer in women with schizophrenia. Other gynecological comorbidities were less frequent, but the field has been understudied. Low rates of breast and cervical cancer screening characterize women with schizophrenia. Menopause, because of endocrine changes, aging effects, and resultant comorbidity is associated with high rates of aggressive breast cancer in this population. Uterine and ovarian cancers have been less investigated. Psychosocial determinants of health play an important role in cancer survival. The findings lead to the recommendation that primary care, psychiatry, gynecology, oncology, and endocrinology collaborate in early case finding, in research into etiological links, and in improvement of prevention and treatment.