It’s Time to Think of Women: Mental Health Services for First-Episode Psychosis

SPECIAL REPORT: PSYCHOSIS PART 2

As the World Health Organization reminds us,¹ gender is a critical determinant of health, including mental health. Psychosis affects 3 in 100 individuals worldwide and typically develops around age 21 years.² It includes diagnoses such as those of the schizophrenia spectrum and affective disorders. Early intervention services hold the promise of changing the trajectory of psychosis by providing specialized, coordinated care to individuals experiencing their first episode of psychosis (FEP).³ Evidence shows that FEP services can improve short-term and long-term outcomes for the individual^4,5 (eg, employment) and for their community⁶ (eg, reduced disruptive public behavior, legal charges). What remains unknown, and maybe overlooked, is that women experiencing FEP might encounter gender-based disparities in accessing and receiving specialized care.⁷

Crucial questions arise: Are men and women equal when it comes to accessing mental health care for FEP? Do men and women with psychosis have the same care needs?^8,9 How can we tailor FEP services to accommodate women’s needs?

Gender differences regarding the clinical characteristics of the psychosis spectrum have been extensively described^8,10: Men and women differ in incidence and age at onset,¹¹ in symptoms at care presentation, and in course of illness. Compared with men, women also carry different risk factors for psychosis,¹² including hormonal and psychosocial influence.

Several factors have been identified that could affect access to and quality of care received by women with FEP. Potential suggestions for overcoming clinical and structural challenges also will be provided.

Factors Affecting Access to Care for Women With FEP

Age at onset: Many FEP programs accept only individuals aged 15 to 35 years, which is consistent with the design of a service providing specific psychosocial interventions to address a set of needs for education and employment targeted to younger individuals. However, this age range might exclude women who have their first episodes later in life. The multinational EU-GEI study including 2774 individuals with FEP reported not only that women were older at first contact with FEP services (age 34 years vs 28 years for men) but also that they had a second peak of new onset of psychosis in their 50s (post menopause).¹³

In the United Kingdom, a solid attempt has been made to expand access to specialized FEP services to individuals up to age 65 years. A preliminary report suggested that, compared with individuals younger than 35, a higher proportion of referrals and accepted patients over 35 were female, providing further evidence of possible unmet care needs in women over 35 with FEP.¹⁴ The challenge exists in how to design FEP services for this older age group with higher care complexity, such as systematic involvement of family social care services and greater economic needs.

Clinical presentation of psychosis and pathways to care: These also differ by gender.¹⁵ Women tend to present with prevalent mood symptoms associated with psychosis instead of the classic bizarre behavior and thoughts; therefore, they are more likely to receive a diagnosis of affective psychosis (which is often a criterion for exclusion from FEP programs). Moreover, women are less likely to manifest psychosis through aggressive and disorganized/dangerous behaviors that often lead to hospitalization. As a result, paradoxically, women with acute psychosis are less likely to be identified by means of an admission to the inpatient psychiatric units. Hospitalization is often dramatic and considered an aversive entry to mental health care,¹⁶ but it still represents one of the main doors through which to access FEP programs.¹⁷ Given these premises on clinical presentation, FEP services might consider accepting women with concomitant mood symptoms into treatment, reserving some time to conduct an in-depth differential diagnosis evaluation to clarify the diagnosis, and then referring women to the appropriate service.

Gender stereotypes and societal norms: These also can affect access to care and establishing the correct diagnosis. A woman’s call for help can be labeled as being overdramatic or acting out to gain attention.¹⁷ When gender stereotypes are intertwined with gender norms, access to care can be very problematic: Women are often the designated caregivers for infants and elderly relatives, so prioritizing the care of others could further delay their own access to treatment.^18,19 Women, more often than men, are employed in precarious jobs with lower salaries and worse benefits (eg, less paid time off, more rigid schedules), challenging smooth access to care.^1,20 FEP services should be sensitive to these gender differences and implement gender- targeted, early-detection interventions in outpatient health facilities, such as primary care, obstetric, and gynecologic clinics, where women with underrecognized psychosis may be found.

Factors Affecting Quality of Care for Women With FEP

Sexual and reproductive health: Monitoring for this should be considered an integral part of FEP services, considering that FEP usually manifests during adolescence and most importantly in the reproductive years. Women, by definition, carry a unique risk factor for new onset or relapse of psychosis: pregnancy.²¹ Quality of care for FEP is also measured by the attention to mental health monitoring when a woman with a past or current history of psychosis is pregnant and in the postpartum period.²² FEP services may facilitate ad hoc consultations with other services (eg, pediatrics, primary care, or obstetrics). A more systematic interagency collaboration is also suggested. For example, patients with FEP might receive best-practice reproductive care during the peripartum period for themselves and simultaneously access to pediatric care for their infants.

Physical health: Both genders can develop metabolic adverse effects due to the pharmacological treatment for psychosis, which contributes to an increase in cardiovascular risk within these populations.^23,24 The choice of pharmacological treatment for women with FEP should be especially sensitive to those adverse effects, such as weight gain and hair loss, which are more heavily stigmatized in women.

Preventive medicine: Women with schizophrenia are less likely than those without a severe mental illness to receive Papanicolaou test screening for cervical cancer²⁵ and half as likely as the general population to receive screening mammography.²⁶ FEP services can act by providing education and facilitating the appropriate access to women-specific preventive programs.

Trauma-oriented care: Women, more than men, are victims of intimate partner violence that is linked to an increase in risk of manifesting psychotic experiences, especially in cases of multiple victimizations.²⁷ Moreover, there is a strong association between exposure to traumatic events in childhood and increased risk of psychosis.^28-31 It is recommended that FEP programs screen for past traumatic events and assess the current risk of trauma for the patient and potential children in the household.³²

Concluding Thoughts

It is time for gender-sensitive FEP services.^8,33,34 Being a woman is a key determinant in the pathway to and through mental health care for psychosis. The recent COVID-19 pandemic has further deepened the gender inequality³⁵ with severe job losses in women-prevalent professions (eg, manufacturing, domestic aid); heavier burdens for care of infants and older adults, creating an imbalanced personal-professional life; a rise in domestic violence³⁶; and a rise in distress related to increased risks for women’s health and that of the fetus in cases of pregnancy.³⁷ All these factors could trigger a preexisting vulnerability to psychosis or further challenge access to specialized care.

Extant FEP services should take into consideration logistic and clinical adjustments. Scientific initiatives such as the Women’s Brain Project are becoming central for promoting strategies to leverage discoveries and implement gender-sensitive practices in brain and mental disorders.³⁸

The gender-specific perspective presented here might unveil blind spots in the care delivered by FEP programs and may provide clinical guidance in tailoring such services³⁹ to meet women’s needs. Closer consideration should be undertaken by stakeholders, care providers, and policy makers regarding the gender-specific needs of this subpopulation to access FEP-specialized care, as well as to receive appropriate treatment. By creating the infrastructure to support a comprehensive service tailored to women’s needs, we are paving the way to facilitate access and provide high-quality FEP services to women.

Dr Ferrara is an assistant professor at the Institute of Psychiatry at the University of Ferrara in Italy and an adjunct assistant professor of psychiatry at the Yale School of Medicine in New Haven, Connecticut.

References

1. Social determinants of mental health. World Health Organization. 2014. Accessed May 20, 2022. https://apps.who.int/iris/bitstream/handle/10665/112828/9789241506809_eng.pdf

2. Bhugra D. The global prevalence of schizophrenia. PLoS Med. 2005;2(5):e151; quiz e175.

3. Correll CU, Galling B, Pawar A, et al. Comparison of early intervention services vs treatment as usual for early-phase psychosis: a systematic review, meta-analysis, and meta-regression. JAMA Psychiatry. 2018;75(6):555-565.

4. Larsen TK, Melle I, Auestad B, et al. Early detection of psychosis: positive effects on 5-year outcome. Psychol Med. 2011;41(7):1461-1469.

5. Ten Velden Hegelstad W, Haahr U, Larsen TK, et al. Early detection, early symptom progression and symptomatic remission after ten years in a first episode of psychosis study. Schizophr Res. 2013;143(2-3):337-343.

6. Pollard JM, Ferrara M, Lin IH, et al. Analysis of early intervention services on adult judicial outcomes. JAMA Psychiatry. 2020;77(8):871-872.

7. Mendrek A, Stip E. Sexual dimorphism in schizophrenia: is there a need for gender-based protocols? Expert Rev Neurother. 2011;11(7):951-959.

8. Ferrara M, Srihari VH. Early intervention for psychosis in the United States: tailoring services to improve care for women. Psychiatr Serv. 2021;72(1):5-6.

9. Seeman MV. Targeting gender and age in first-episode psychosis services: a commentary on Ferrara and Srihari. Psychiatr Serv. 2021;72(1):94-95.

10. Pence AY, Pries LK, Ferrara M, et al. Gender differences in the association between environment and psychosis. Schizophr Res. 2022;243:120-137.

11. Leung A, Chue P. Sex differences in schizophrenia, a review of the literature. Acta Psychiatr Scand Suppl. 2000;401:3-38.

12. Seeman MV. Women and psychosis. Womens Health (Lond). 2012;8(2):215-224.

13. Jongsma HE, Gayer-Anderson C, Lasalvia A, et al; European Network of National Schizophrenia Networks Studying Gene-Environment Interactions Work Package 2 (EU-GEI WP2) Group. Treated incidence of psychotic disorders in the multinational EU-GEI study. JAMA Psychiatry. 2018;75(1):36-46.

14. Clay F, Allan S, Lai S, et al. The over-35s: early intervention in psychosis services entering uncharted territory. BJPsych Bull. 2018;42(4):137-140.

15. Riecher-Rössler A, Butler S, Kulkarni J. Sex and gender differences in schizophrenic psychoses-a critical review. Arch Womens Ment Health. 2018;21(6):627-648.

16. Anderson KK, Fuhrer R, Schmitz N, Malla AK. Determinants of negative pathways to care and their impact on service disengagement in first-episode psychosis. Soc Psychiatry Psychiatr Epidemiol. 2013;48(1):125-136.

17. Nossel I, Wall MM, Scodes J, et al. Results of a coordinated specialty care program for early psychosis and predictors of outcomes. Psychiatr Serv. 2018;69(8):863-870.

18. Ferrari M, Flora N, Anderson KK, et al. Gender differences in pathways to care for early psychosis. Early Interv Psychiatry. 2018;12(3):355-361.

19. Slaunwhite AK. The role of gender and income in predicting barriers to mental health care in Canada. Community Ment Health J. 2015;51(5):621-627.

20. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. World Health Organization. 2008. Accessed May 20, 2022. https://apps.who.int/iris/bitstream/handle/10665/ 43943/9789241563703_eng.pdf

21. González-Rodríguez A, Guàrdia A, Álvarez Pedrero A, et al. Women with schizophrenia over the life span: health promotion, treatment and outcomes. Int J Environ Res Public Health. 2020;17(15):5594.

22. Harlow BL, Vitonis AF, Sparen P, et al. Incidence of hospitalization for postpartum psychotic and bipolar episodes in women with and without prior prepregnancy or prenatal psychiatric hospitalizations. Arch Gen Psychiatry. 2007;64(1):42-48.

23. Nordentoft M, Wahlbeck K, Hällgren J, et al. Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden. PLoS One. 2013;8(1):e55176.

24. Wildgust HJ, Hodgson R, Beary M. The paradox of premature mortality in schizophrenia: new research questions. J Psychopharmacol. 2010;24(suppl 4):9-15.

25. Tilbrook D, Polsky J, Lofters A. Are women with psychosis receiving adequate cervical cancer screening? Can Fam Physician. 2010;56(4):358-363.

26. Hwong A, Wang K, Bent S, Mangurian C. Breast cancer screening in women with schizophrenia: a systematic review and meta-analysis. Psychiatr Serv. 2020;71(3):263-268.

27. Shevlin M, O’Neill T, Houston JE, et al. Patterns of lifetime female victimisation and psychotic experiences: a study based on the UK Adult Psychiatric Morbidity Survey 2007. Soc Psychiatry Psychiatr Epidemiol. 2013;48(1):15-24.

28. Garcia M, Montalvo I, Creus M, et al. Sex differences in the effect of childhood trauma on the clinical expression of early psychosis. Compr Psychiatry. 2016;68:86-96.

29. van den Berg D, de Bont PAJM, van der Vleugel BM, et al. Long-term outcomes of trauma-focused treatment in psychosis. Br J Psychiatry. 2018;212(3):180-182.

30. Read J, van Os J, Morrison AP, Ross CA. Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatr Scand. 2005;112(5):330-350.

31. Yates K, Lång U, Peters EM, et al. Sexual assault and psychosis in two large general population samples: is childhood and adolescence a developmental window of sensitivity? Schizophr Res. 2022;241:78-82.

32. Vila-Badia R, Butjosa A, Del Cacho N, et al. Types, prevalence and gender differences of childhood trauma in first-episode psychosis. What is the evidence that childhood trauma is related to symptoms and functional outcomes in first episode psychosis? A systematic review. Schizophr Res. 2021;228:159-179.

33. Ministero della Salute, Italia. Piano per l’applicazione e la diffusione della Medicina di Genere. June 21, 2019. Accessed May 20, 2022. https://www.salute.gov.it/portale/donna/dettaglioPubblicazioniDonna.jsp?id=2860&lingua=italiano

34. Grisold W, Moro E, Teresa Ferretti M, et al; EAN Gender, Diversity Issues Task Force. Gender issues during the times of COVID-19 pandemic. Eur J Neurol. 2021;28(10):e73-e77.

35. Brand BA, de Boer JN, Dazzan P, Sommer IE. Towards better care for women with schizophrenia-spectrum disorders. Lancet Psychiatry. 2022;9(4):330-336.

36. Taub A. A new Covid-19 crisis: domestic abuse rises worldwide. The New York Times. April 6, 2020. Accessed May 20, 2022. https://www.nytimes.com/2020/04/06/world/coronavirus-domestic-violence.html

37. Rasmussen SA, Lyerly AD, Jamieson DJ. Delaying pregnancy during a public health crisis - examining public health recommendations for Covid-19 and beyond. N Engl J Med. 2020;383(22):2097-2099.

38. Schumacher Dimech A, Ferretti MT, Sandset EC, Santuccione Chadha A. The role of sex and gender differences in precision medicine: the work of the Women’s Brain Project. Eur Heart J. 2021;42(34):3215-3217.

39. Snow RC. Sex, gender, and vulnerability. Glob Public Health. 2008;3(suppl 1):58-74. ❒