This week, we’re publishing two articles on the topic of schizophrenia. Dr. Seeman’s article addresses key differences in males and females afflicted by schizophrenia, while Ms. Iman’s article focuses on how physicians can better support the parents of people with schizophrenia.
Dr. Mary V. Seeman (biography and disclosures)
What care gap I’ve noticed
Most practice guidelines for the treatment of schizophrenia are written with men in mind, ignoring the expanding research base that points to several important differences between the experiences of men and women who suffer from this illness (1).
Data that should be considered
- Male/female differences in schizophrenia
Throughout the world, males begin their struggle with schizophrenia during adolescence, several years, on average, before women. This may be because men are exposed to more antecedents such as difficult pregnancies (male infants have more trouble in the womb than female infants), difficult deliveries (more obstetrical problems with male infants), early physical trauma (more rough and tumble play), more childhood psychiatric problems (autism spectrum, attention deficit disorder), more communication problems (speech defects, stuttering, slower language acquisition), more learning difficulties (2), more exposure to alcohol, drugs, and industrial solvents in their teens.
Consequent to an early illness start, males are frequently unable to complete their schooling or to experience romantic partnerships or to become independent of their parents before serious symptoms make all this impossible, or, at least, very difficult (3). Perhaps for these reasons, men respond less well to standard schizophrenia treatment than women, more often commit suicide during the first decade of illness, are more often aggressive and commit acts of lawlessness (4). Compared to women with schizophrenia, they are less often employed, less often enjoy an adequate social network, are less likely to look after their hygiene and health, and more likely to abuse alcohol and drugs.
However, there is improvement as men age. The aggression and denial of illness wane. They allow themselves to be cared for and, gradually, symptoms and quality of life improve. Paradoxically, women appear to do less well as they age. As their social supports decrease with the passage of time, adherence to medication also decreases and psychotic symptoms rise in severity, especially during and after menopause (5). Women previously free of illness develop psychotic symptoms for the first time at this age. Because women with a diagnosis of schizophrenia are not socially isolated, they can suffer the consequences of relatives and relationships – deaths, break ups, domestic violence, difficulties bringing up children, economic difficulties, frequent loss of child custody.
The trajectory of illness is, thus, different in women and men.
2. Problems for the clinician
Because textbooks and guidelines are written from the male perspective [schizophrenia is slightly more prevalent in men than in women (6)], clinicians screening for schizophrenia look for teenagers who are withdrawn, hostile, uncommunicative and who exhibit bizarre behaviour. But women with schizophrenia present differently. They tend to be older, to have retained many of their premorbid social skills, to show their emotions, and to be capable of forming a therapeutic relationship. Despite the presence of psychotic symptoms, clinicians are loath to ‘label’ the illness schizophrenia because of the stigma that continues to attach to this illness. Women tend to receive the diagnosis of depression (because depression is so common in women) and to be treated with antidepressants, which not only exacerbates their psychotic symptoms but also delays effective treatment. This is unfortunate because early treatment has been shown to improve prognosis (7).
Clinicians also struggle with issues of sexuality, contraception, pregnancy, and parenting in the context of schizophrenia and women. These crucial subjects are neglected even though they are vital to the health of future generations.
Clinicians fail to recognize that psychotic symptoms can increase in women at certain times of the month (8) and at the time of menopause. Response to antipsychotic treatment can decrease at this time (9).
Clinicians may also fail to recognize that the side effects of antipsychotics differ in men and women (10). In general, women require lower doses and develop more side effects. Weight gain, a common problem associated with antipsychotic medication, and its sequelae (diabetes and heart disease) are special problems for women.
What I recommend
- Screen for psychotic symptoms in men and women of any age and prescribe antipsychotics whether or not prominent disturbances of mood are also present.
- Take suicide precautions in schizophrenia, especially in younger men and older women (11).
- Plan on improved outcome in men with schizophrenia as they age.
- Discuss reproductive issues with both men and women and their families.
- Be prepared to raise the dose of antipsychotic medication in women at menopause or change to depot formulations.
- Antipsychotic medication can cause medically important side effects in both sexes (diabetes, cardiovascular disease and metabolic syndrome and these must be prevented or mitigated (12). Prevention can take the form of keeping doses low, selecting antipsychotics less prone to causing obesity, engaging patients in nutrition education and fitness programs, or adding medication that is safe in schizophrenia and that keeps weight down.
When general practitioners encounter young adults who are unable to concentrate, who have difficulty making themselves understood, who appear to be preoccupied with extraneous stimuli, who are isolated from friends and alienated from family, they should recommend psychiatric assessment for early psychosis. Mood disturbance with psychotic features may turn out to be the more accurate diagnosis but low dose antipsychotic medication will, whatever the diagnosis, calm the patient, ease the distress, and allow for the development of a therapeutic relationship. The focus of this article is to point out that men and women, regardless of diagnosis, usually have different service needs (13).
References (Note: Article requests might require a login ID with CPSBC or UBC)
- Abel KM, Drake R, Goldstein JM.: Sex differences in schizophrenia. Int. Rev Psychiatry. 22(5), 417-428 (2010). (View with CPSBC or UBC)
- Kirchengast S, Hartmann B.: The male disadvantage hypothesis reconsidered: is there really a weaker sex? An analysis of gender differences in newborn somatometrics and vital parameters. J. Life Sci. 1(1), 63-71 (2009). (View article)
- Rabinowitz J, Levine SZ, Häfner H.: A population based elaboration of the role of age of onset on the course of schizophrenia. Schizophr. Res. 88(1-3), 96-101 (2006). (View with CPSBC or UBC)
- Kao YC, Liu YP.: Effects of age of onset on clinical characteristics in schizophrenia spectrum disorders. BMC Psychiatry. 10:63 (2010). (View article)
- Seeman M.V.: Treating schizophrenia at the time of menopause. Maturitas. 72 (I2), 117-120 (2012 ). (View article with CPSBC)
- McGrath J, Saha S, Chant D, Welham J.: Schizophrenia: A concise overview of incidence, prevalence, and mortality. Epidemiol Rev. 30(1), 67-76 (2008). (View article)
- Riecher-Rossler A.: Early detection of schizophrenia psychoses in men and women. Ther. Umsch. 64(6), 337-343 (2007).
- Bergemann N, Parzer P, Runnebaum B, Resch F, Mundt C.: Estrogen, menstrual cycle phases, and psychopathology in women suffering from schizophrenia. Psychol. Med. 37,1427-1436 (2007). (Request from CPSBC)
- Seeman MV.: Parenting issues in mothers with schizophrenia. Curr. Women’s Health Rev. 6(1), 51-57 (2010).
- Seeman MV.: Secondary effects of antipsychotics: Women at greater risk than men. Schizophr. Bull. 35(5), 937-948 (2009). (View article)
- Hor K, Taylor M.: Suicide and schizophrenia: a systematic review of rates and risk factors. J. Psychopharmacology. 24(4 Suppl), 81–90 (2010). (View article)
- De Hert M, Correll CU, Cohen D.: Do antipsychotic medications reduce or increase mortality in schizophrenia? A critical appraisal of the FIN-11 study. Schizophr. Res. 117(1), 68-74 (2010). (View with CPSBC)
- Scheyett AM, McCarthy E.: Women and men with mental illnesses: Voicing different service needs. Affilia. 21(4), 407-418 (2006). (Request from CPSBC)
How to Offer Better Support to Parents of People with Schizophrenia
by Susan Inman, BA, MA (biography)
What has been happening
Because too little accurate information about schizophrenia is available in popular culture and elsewhere, parents of people who develop this disorder experience enormous distress and are confused about what they should do. Many programs training mental health professionals do not provide science based curriculum about psychotic disorders and parents’ early interactions with various kinds of therapists can actually be harmful both to their child and to them. When therapists have only been trained in psychodynamic theories, not only can they fail to make appropriate referrals to early psychosis intervention programs, but they can lead families to believe that these neurobiological disorders have been caused by poor parenting.
What can change the lives of these parents
Providing accurate information about the state of knowledge about these disorders can help parents recover from the unjustified and demoralizing guilt they may have developed. When physicians become familiar with the kinds of help parents need, they can assist them in developing the behaviours that will lead to the best outcome for their child.
Five Tips for Helping Parents of persons with schizophrenia or psychotic disorders:
- Assure them that they did not cause these disorders and let them know that research demonstrates that their ongoing involvement helps achieve the best possible recovery. Surprisingly, parents are sometimes told that their involvement limits the independence of a still ill son or daughter.
- Acknowledge the life changing situations they are facing. Caring for a son or daughter with a psychotic disorder can impact many aspects of parents’ lives including their physical and psychological health, their financial situations, and the well-being of their other children.
- Help parents connect to local educational and support programs which are often available through provincial schizophrenia societies. Emphasize the value of connecting with other families facing similar problems. Parents need to learn about the necessary legal and financial tools available, like Representation Agreements, that can help them plan for the future.
- Help parents understand anosognosia, the neurological condition impacting 40 – 50% of psychotic people that prevents them from understanding that they are ill. Understanding this aspect of their child’s disorder helps parents know that arranging for treatment, even when the person thinks nothing is wrong with them, is the responsible choice to make. People rarely recover from a psychotic disorder by just patiently waiting for things to improve. Despite the obstacles they will encounter in trying to get treatment, parents need to know they should persist.
- Encourage parents to learn all they can about programs and services for their child. Having a parent, for example, advocate for a fragile child or young adult to receive all the disability services to which they are entitled can make it possible to return to an interrupted education.
Developing a positive working alliance with the parents of patients with schizophrenia helps the whole family adjust to the extraordinary challenges of living with a psychotic disorder.
National Post Jul 29, 2011 – 7:30 AM ET | Last Updated: Jul 28, 2011 4:07 PM ET By Susan Inman
Susan Inman: The right to be sane
Many mental illnesses make it impossible for the victim to realize they’re sick. Forced medication is the only humane option.
Our daughter doesn’t want you to protect her “right” to be mentally ill. Through no fault of hers, or ours, she has spent the past 11 years experiencing the extraordinary challenges of learning to live with a schizoaffective disorder. This illness, a combination of schizophrenia and bipolar disorder, has at various times thrown her into the horrors of prolonged psychotic episodes. Perhaps the most dangerous part of her illness is the fact that, when in the grips of a psychotic episode, my well-educated daughter is not capable of realizing that she’s ill.
Psychotic disorders present a unique challenge to the people who live with them and to the safety of the public. While people with these disorders who are being treated pose no greater threat than the rest of the population, research has clearly shown that people who are not being treated do have a higher rate of violent behaviour. Many of these victims of mental illness end up committing crimes and are relegated to the penal system, where they become further damaged and isolated while making no progress towards a healthy, normal life.
We are currently hearing a lot of justified criticism in the media about the pathologizing of normal human experiences both by psychiatry, with its revision of the already problematic Diagnostic and Statistical Manual, and by pharmaceutical companies who want the public to take ever-increasing amounts of unneeded medication. These are legitimate problems. But psychiatry and medication are still badly needed by some, those who suffer from genuine mental illnesses and would benefit from any of a number of readily available anti-psychotic medications.
There are many reasons that some people may be unable to obtain anti-psychotic medication. But there is also anosognosia. This well-researched neurological phenomenon means that 40-50% of psychotic people, due to their mental illness, are simply not able to understand that they are in fact sick. In these tragic cases, the only effective way to treat the illness is to force people to take medication. Many are uncomfortable with this approach, but when a symptom of the illness is a literal inability to realize that one is sick, there are no other logical options.
Forty four U.S. states have recognized that the only humane option in these cases is to force patients to be medicated, and have developed some form of mandated treatment. The Mental Health Commission of Canada, however, appears to be headed in a different direction. It currently is partnering with the Canadian Mental Health Association (CMHA) on a research project looking at human-rights issues related to mental illnesses. The CMHA has a long-standing position, published on their website, opposing involuntary treatment. They believe that people must have the choice to reject treatment. They don’t discuss the indisputable research demonstrating how many people experiencing psychosis aren’t able to freely choose the option that could liberate them from the chaos of psychosis.
My daughter is the fortunate beneficiary of several excellent psychoeducation programs that exist in Vancouver for people with severe mental illnesses. These programs, which need to be better funded, help people learn to accept their mental disorders and better manage them. Despite our daughter’s very healthy acceptance of her quirky brain and her extensive knowledge about these disorders, during relapses her understanding of her illness vanishes; she counts on us to take care of her during these episodes and ensure that she isn’t left to deteriorate in an untreated psychosis. Current trends among people who want to protect her “human rights” will make it even more difficult than it already is to protect her genuine human right to be sane.