| Abstract|| |
Women's mental health is closely linked to their status in society. This paper outlines the clinical features of women with schizophrenia and highlights the interpersonal and social ramifications on their lives. There is no significant gender difference in the incidence and prevalence of schizophrenia. There is no clear trend in mortality, although suicides seem to be more in women with schizophrenia. In India, women face a lot of problems, especially in relation to marriage, pregnancy, childbirth, and menopause. Most studies have shown better premorbid functioning, and social adjustment for women compared with men. There is a great need to plan for gender-sensitive mental health services targeting the special needs of these women. Women caregivers also deserve due attention.
Keywords: Childbirth rehabilitation, marriage, pregnancy, schizophrenia, severe mental illness, women
|How to cite this article:|
Thara R, Kamath S. Women and schizophrenia. Indian J Psychiatry 2015;57, Suppl S2:246-51
| Introduction|| |
The 1998 World Health report states that "women's mental health is inextricably linked to their status in society. It benefits from equality and suffers from discrimination.  Many women with severe mental illness stay outside treatment settings, especially in low income countries with poor and inadequate mental health facilities. Those who do enter treatment settings have varied experiences ranging from humane care to indifference and stigmatization. More reports on human rights violations of mentally ill women are emerging. Women caregivers of the mentally ill seem to outnumber the male caregivers and also face unique problems. One of the major disorders which impact the life of women patients, caregivers and family members is schizophrenia.
The World Health Organization (WHO) described schizophrenia as a disease of young men. It is also observed that mental illnesses in women are different from those in men.  The clinical picture of early onset, poor premorbid development, emotional blunting, social withdrawal, and poor outcome occurred more frequently in males compared to females. This paper outlines the clinical features of women with schizophrenia and highlights the interpersonal and social ramifications on their lives.
| Epidemiology|| |
The incidence of schizophrenia seems to be fairly stable in both genders across reported studies. The diagnostic definitions (broad versus restrictive) used have, however, determined differences as in the case of Determinants of Outcome of Severe Mental Disorders (DOSMED) study. 
The review of 55 core incidence studies by McGrath et al. reported higher incidence rates in males, the male:female rate ratio median was 1.4 (0.9:2.4).  Nine studies which reported higher rates in women were examined in detail, but showed no features distinguishable from the other studies.
The Madras study on a population of 100,000 did not show any gender differences.  However, Dube and Kumar  in Agra reported a greater incidence in males (1.5:1). In the Chandigarh study, the incidence rate of broadly defined schizophrenia was the highest among rural women (0.47/1000) and lowest in urban males (0.37/1000).
It is therefore not quite clear if there are significant gender differences in the incidence schizophrenia.
The same holds good for prevalence, with rates for genders varying greatly across studies. This could be partly explained by variations in methodology, and sample sizes preventing any definitive conclusions to be drawn. A review of prevalence studies in schizophrenia by Saha et al.  did not find any striking sex differences.
Morbidity risk for schizophrenia over the life spans seems to be around 1% in both genders. In the 25 years follow-up of the Madras longitudinal study of 90 first episode schizophrenia patients, 24 patients died, of whom males were 14. More males had physical illnesses, while, more women committed suicide.  The suicides in women were largely in response to symptoms as in the case of one woman who had the delusion that she appeared nude to others and the resultant social embarrassment. Higher suicide risk in women with schizophrenia was also reported by Mortensen and Juel. 
A recent study in rural China by Ran et al.  found much more mortality and suicide in men than in women and ascribed the higher prevalence of schizophrenia in women to this.
A systematic review of mortality in schizophrenia revealed no sex differences.  Auquier et al.,  however, report more suicides in young males with schizophrenia.
As in the case of incidence and prevalence, there is no clear trend in mortality, although suicides seem to be more in women with schizophrenia.
| Course and Outcome|| |
Women have a better outcome than men. It is unclear whether this is due to the later age of onset, protective nature of hormones such as estrogens or better drug response.
The Australian Study of Low Prevalence (Psychotic) Disorders  looked at gender differences among 1090 cases of psychosis (schizophrenia, schizoaffective disorder, affective psychoses, and other psychoses). Results within diagnostic groupings confirmed differences in how men and women experience and express their illness. Within each diagnostic group, women reported better premorbid functioning, a more benign illness course, lower levels of disability and better integration into the community than men. They were also less likely to have a chronic course of illness. There were no significant differences in age at onset. Differences between women across the diagnostic groups were more pronounced than differences between women and men within a diagnostic group. In particular, women with schizophrenia were severely disabled compared to women with other diagnoses.
The Madras longitudinal study found the better outcome in women after 5 years of follow-up, but this did not sustain through the rest of the 15 years of follow-up.  It is likely that several mechanisms are needed to explain the differences. Greater social integration and functioning in women across diagnostic groups may well reflect culturally and socially determined gender differences. In contrast, variability and attenuated findings with respect to symptom profiles beg the question of biological mechanisms with some degree of specificity. 
| Clinical Features|| |
Women seem to have more affective symptoms, fewer negative symptoms and more of a diagnosis of schizoaffective disorder.  It has been documented that women with schizophrenia tend to be more overtly hostile, physically active and dominating, with more of sexual delusions, and more emotional than men.  They also experience affective and paranoid symptoms, more of anxiety symptoms and less of negative symptoms.  The meaning of symptoms seems to differ for men and women. While expression of isolation, withdrawal and dependency may reflect a depression syndrome in women, it may reflect a negative syndrome in men.
A large sample of Chinese patients with schizophrenia had more paranoid subtype of schizophrenia in females who also showed a different pattern of ongoing symptoms and severity, more severe positive and affective symptoms, and a greater number of suicide attempts, whereas male patients were more likely to show severe deterioration over time. 
Müller  studied gender-specific differences in the association of depression in persons with schizophrenia. In females, depression was independently associated with higher negative symptom scores (P < 0.01) and younger age (P < 0.05), whereas in males positive symptoms (P < 0.05) and short hospitalization (P < 0.05) were the main factors associated with depression.
The role of estrogen levels in the symptomatology in women is ambiguous. Both late onset schizophrenia, which is more common in women , and the worsening of symptoms as women get older are not correlated with estrogen levels.  The adverse effect of estrogen withdrawal on the postmenopausal brain has been noted by Murray. 
Age at onset
A higher mean age at onset of schizophrenia for women has been one of the very consistent findings in the last 20 years. Several independent reviews of many studies have shown that the disorder appears later in women. Since the time between onset of symptoms and first hospitalization were the same in both genders, it was evident that women did have a later onset. There have been, however, a few reports not replicating this finding. Some studies from India have not found a gender difference in the age of onset and have questioned the universality of the traditional view of earlier onset in men.  The Madras longitudinal study of almost equal numbers of men and women in a sample of 90 cases also did not find a gender difference in onset. 
The WHO study on DOSMED  examined individuals with first onset schizophrenia and found a preponderance of males in the younger age group and females in the older age group 45-54 years. Gangadhar et al. opined that the higher age at onset in women may be a function of perinatal complications. In Indian states with low infant mortality rate (IMR), age at onset did not differ between the two sexes. However, men had an older age at onset than women in states where IMR was 5 times higher.  Similarly a study from a community sample did not find gender differences in the age of onset and the authors have suggested that there is a need to revise the description of schizophrenia in the classificatory system keeping in view the regional variation in the age of onset. 
Response to treatment
It has long been observed that men and women seem to require different dosages of antipsychotics and have different responses to them. The Schizophrenia Outpatient Health Outcomes study was a 3-year, prospective, observational study of health outcomes associated with antipsychotic treatment in 10 European countries that included over 10,000 outpatients initiating or changing their antipsychotic medication in 4529 men (56.68%) and 3461 women (43.32%). Findings showed that gender was a significant predictor for response based on the Clinical Global Impression scale and for improvement in quality of life. The highest gender differences were found in typical antipsychotics and clozapine. Olanzapine only showed differences in quality of life, and no differences were found for risperidone. 
In the Chinese study by Tang et al.,  males received higher daily doses of antipsychotics and demonstrated a different pattern of antipsychotic usage, being less likely to be treated with second-generation antipsychotics. The clozapine blood level was 35% higher in women than in men.
In general, premenopausal women seem to require lower doses. The role of estrogens in neuromodulation seems to account for this difference. It has to be kept in mind that the bulk of patients taking part in drug trials are men, and much of the knowledge about dosing is, therefore, more applicable to men.
Side effects of medication
Neuroendocrine effects of antipsychotics, especially those secondary to hyperprolactinemia can cause a lot of distress to women patients. This is true with all FGAs and to an extent with risperidone and ziprasidone. Clozapine, olanzapine, and quetiapine seem to spare prolactin, but result in weight gain. Amenorrhea, galactorrhea, decreased sexual interest, and functioning and changes in bone density are the side effects of increased prolactin levels.
Obesity also seems to be commoner among women and has its own psychological and medical effects.
| Mentally Ill Women and Marriage|| |
The process and dynamics of courtship, dating and marriage vary widely between different nations and cultures and impact the rates of marriage. In developed countries, where finding a partner involves social skills, persons with schizophrenia have low rates of marriage. However, in developing countries, where many marriages are arranged by the families, the rates of marriage are as high as 70.5% in Ethopia  and around 65% in Chennai, India.  While getting married did not probably involve too many social skills, staying married certainly did. Hence, separation and divorce were fairly common and much higher than seen in general populations.
Even in urban areas, the misconception that marriage cures mental illness is still widely prevalent. As a consequence, many families secretly arrange marriages of their wards and professional care givers know of it much later. While fewer men get married, their marriages seem to be quite stable. On the other hand, breakdown and separation were seen more in female patients, especially if they are symptomatic or childless. Patients with a relapsing course were less likely to get married, and the system of arranged marriages accounted for higher rates of marriage in India compared to the West. 
An ethnographic, qualitative study of 75 women with schizophrenia who were either divorced or separated revealed that 95% of the marriages were arranged by the families and the separated women lived in their parental homes with the onus of care on elderly caregivers. The stigma of being separated was more often felt by patients and families. They continued to wear the traditional symbols of marriage (for example the mangalsutra) as it gave them a sense of security and status in a society where marriages are revered.
This study also highlighted the need for community-based resources like half way homes, Day Care Centers and Rehabilitation Centers in both the government and private sectors. The need for Comprehensive Care Centers for this group of patients where these chronic mentally ill women could learn some skills and get some employment to support their children is imminent. ,
| Pregnancy and Motherhood|| |
Women with schizophrenia have a higher rate of unplanned and unwanted pregnancies. Miller  has opined that psychosis may contribute to the denial of pregnancy, misinterpretation of somatic changes and even lack of recognition of labor. Seeman and Cohen  describe a comprehensive service for women with schizophrenia in Canada to address various requirements under one roof. There is a need for specialized services and the need to encourage these women to make birth control decisions whenever necessary to preserve their own health and that of future children. Issues related to medication during pregnancy and the postpartum periods are of special concern. The risk of congenital abnormalities is low following prenatal exposure to most psychotropic medication; the highest risk to the fetus is 4-10 weeks after conception. Several comprehensive reviews have appeared on this subject. ,, The outcome of pregnancy in women with schizophrenia suggests a lower mean birth weight, increased incidence of intrauterine growth retardation, preterm birth, and premature death as compared to healthy pregnant women.  Through education and support pregnant women with schizophrenia can be protected from the risk factors.
| Homelessness|| |
Homelessness is probably the most visible of all the social sequelae of psychotic disorders in women. It has been estimated that 20-40% of homeless women suffer from psychotic disorders. In many developing countries, family support notwithstanding, the numbers of mentally ill women who become homeless seems to be on the increase. This may well be due to breaking up of joint and extended families, and better transport facilities resulting in such women migrating from one part of the country to the other. In many countries, services for such women are either absent or totally fragmented and inadequate. Homeless mentally ill women have more pregnancy and childbirth-related complications.
Though ill males are at greater risk of becoming homeless, homeless women seem to be sicker than their male counterparts , spoke of the demoralization of the female homeless who wanted their rights respected and autonomy maintained.
A comparative study found substance abuse to be less in homeless women than in men. Symptom severity in homeless individuals with schizophrenia appears as an interaction of symptom profiles and risk behaviors that are gender specific. 
There has been a dearth of systematic research in homelessness, especially in developing countries. As pointed out by Bhugra,  the impact of risk factors such as poverty and poor environmental conditions and their association with ill health needs to be studied in various sociocultural settings. In large countries like India, where the homeless travel long distances across the length and breadth of the country, the challenge is relocating them into their families. While some families are keen to receive them, others tend to be distinctly hostile or indifferent to them when they are sent back. Planning of care facilities for this group of persons with severe mental illness is hardly a priority in many countries.
| Disabilities in Women|| |
The 1992 National Health Interview Survey data from the USA is a comprehensive published data set that contains domains of disabilities associated with health conditions. The survey assessed three domains of disabilities: Limitations in activities, work, and self-care. A minimally greater proportion of women were more disabled than men in all three domains. However, women who were mentally disabled were younger than their physically disabled counterparts. This was especially notable in limitations in personal care. It was pointed out by the authors that policymakers need to be aware of the special needs of service development and configuration for women disabled by mental disorders. Appropriate coverage for the care of disorders and disabilities would result in the better short-term and long-term outcomes. 
In the Madras longitudinal study, there were no differences in disabilities between genders at 5 years follow-up. However, work in the case of men and daily activities in the case of women seemed critical to address and intervention. 
| Psychosocial Rehabilitation in Women|| |
It has been observed that psychosocial rehabilitation (PSR) programs, by and large, have not paid much attention to the special needs of women. Kennedy et al.  points out that only 3% of the 127 articles published in the Psychiatric Rehabilitation Journal from 1999 to 2001 were on women. For women, relationship and basic survival skills take precedence over substance abuse related skills. In many countries in Asia where women live in joint and extended families, there is a constant need to adjust to various emotions, critical comments, and expectations of the family members. Married women in the west are often exposed to PSR programs with specific focus on motherhood and care of children. While the focus of PSR in the west is on independent living, it is on managing dependent relationships in large families in many Asian countries. Marriage and motherhood are also issues that need to be addressed during rehabilitation.
Burden and stigma
The stigma faced by patients and families has also evinced a lot of international research interest and efforts are underway to plan major stigma reduction programs. The WHO's dare to care campaign and the World Psychiatric Association's global anti-stigma programs are foremost among these. Knowledge of mental illness in the relative, the need to seek psychiatric treatment which is still not looked upon very favorably in many traditional societies, the need for social restraints on account of behavior problems and above all issues of employment and marriage contribute to the experience of stigma in families. Thara and Srinivasan.  found that many caregivers felt depression and sorrow, which was more if the patient was a woman. Women caregivers reported more stigma than male caregivers. These feelings probably become even more severe when they have to deal with their daughters with uncertain futures and broken marriages and lack of social support.
| Conclusion|| |
Schizophrenia is a neurodevelopmental disorder, in which both biological and psychosocial events play an important role. Men and women are more or less equally prone to develop the disorder, but an earlier onset is seen in men, especially in Western countries. There is not a noted gender difference in the incidence and prevalence of schizophrenia. Females are reported to have better clinical outcome than males in the short-term, whereas gender differences tend to disappear over longer periods. Most of the studies have shown a better social adjustment for females compared to males, and they also have better premorbid functioning than males.
There is a great need to plan for gender-sensitive mental health services. In India, women face a lot of problems especially in relation to marriage, pregnancy childbirth, and menopause. There is an urgent need to understand the community care needs of these women given the differential roles and differential family response and community tolerance. Women caregivers also require a lot of information about the disorder and ways of handling various symptoms.
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Schizophrenia Research Foundation, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None