|Year : 2014 | Volume
| Issue : 1 | Page : 45-55
Gender difference in affective and nonaffective psychosis
Maha ElTayebani1, Mamdoh ElGamal2, Reda Roshdy3, Sulaiman Al-Khadary4
1 Department of Psychiatry, Faculty of Medicine, Alexandria University, Alexandria, Egypt; Psychological Medicine Hospital, Kuwait University, Kuwait City, Kuwait
2 Department of Psychiatry, Faculty of Medicine, Cairo University, Cairo, Egypt; Psychological Medicine Hospital, Kuwait University, Kuwait City, Kuwait
3 Department of Psychiatry, Faculty of Medicine, Al Azhar University, Cairo, Egypt; Psychological Medicine Hospital; Department of Psychiatry, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
4 Psychological Medicine Hospital, Kuwait University, Kuwait City, Kuwait
|Date of Submission||20-Feb-2012|
|Date of Acceptance||25-Mar-2012|
|Date of Web Publication||18-Feb-2014|
Department of Psychiatry, Faculty of Medicine, Cairo University, Cairo, Egypt
Source of Support: None, Conflict of Interest: None
Recent studies have begun to examine sex differences in first-episode psychosis in an attempt to explain the heterogeneity of the illness. The aim of the current study was to examine sex differences with respect to sociodemographics and clinical presentations, including cognitive, affective, and psychotic aspects, in both nonaffective and affective groups at their first episode of psychosis.
Materials and methods
Sixty-one men and 29 women, 18 years of age or older, were recruited, admitted in the psychological medicine hospital, state of Kuwait, from January 2007 up to December 2009 for treatment of first-episode psychosis. All patients were divided according to the consensus clinical diagnoses on the basis of a structured clinical interview of DSM-IV into two groups: patients with nonaffective psychosis (n = 49, 39 men and 10 women) and patients with affective psychosis (n = 41, 22 men and 19 women). Psychometric assessment was carried out using Hamilton Depression Rating Scale, Young Mania Rating Scale, Positive and Negative Syndrome Scales, Wechsler Adult Intelligence Scale, and (Wechsler Memory Scale - 3rd ed.) subtests including measures for verbal, visual and working memory, attention, and executive functions as well as the trail-making test. Assessment of neurological side effects was carried out using the Simpson-Angus Scale. The assessment was carried out at baseline and after 2 years of follow-up.
Men in the nonaffective psychosis group (schizophrenia, schizoaffective, and delusional disorder) were significantly younger, had an early age at onset (3-5 years), higher level of education, and intact occupational function compared with women who had a more stable marital life. Men required a longer period for improvement in symptoms and were more sensitive to neurological side effects than women. Sociodemographics were comparable in both sexes in the affective psychosis group (bipolar psychosis and depressive psychosis). In terms of symptom presentation, there was no statistically significant impact of sex on different cognitive, affective, and psychotic aspects of presentation in both diagnostic groups at baseline and after 2 years of follow-up. Men had more severe affective symptoms, and more positive and low negative scores compared with women in the nonaffective psychosis group. Although nonsignificant, the affective group had higher cognitive functions and a faster rate of improvement compared with the nonaffective group.
Conclusion and recommendation
Study of sex differences in first-episode psychosis is still a challenging and a controversial issue in the short term, especially in clinical presentation. Longitudinal studies and long-term follow-up where biological and psychosocial variables are interacting are highly recommended.
Keywords: First-episode psychosis affective psychosis, gender difference, non-affective psychosis
|How to cite this article:|
ElTayebani M, ElGamal M, Roshdy R, Al-Khadary S. Gender difference in affective and nonaffective psychosis. Egypt J Psychiatr 2014;35:45-55
| Introduction|| |
Psychosis, irrespective of its nosological entity (e.g. schizophrenia, delusional disorder, organic psychosis) or phase (e.g. acute, chronic), is diagnosed in the same way using the same criteria in men and women. Gender difference is connected to psychosis in various ways (Cotton et al., 2009), as an epidemiological variable (e.g. male/female ratio in incidence or prevalence) (Hafner et al., 1998a, 1998b), age of onset (e.g. in schizophrenia or mood disorder) (Hafner et al., 1998a, 1998b; Howard et al., 2000). Other variables related to gender were help seeking behavior (e.g. in suicide prevention strategies) (Krakowski and Czobor, 2004), social support or social systems (e.g. deficit syndrome in schizophrenia) (Leucht et al., 2009), or special issues (e.g. pregnancy, birth, breast-feeding, menopause, motherhood) (McGrath, 2007). There are, however, other issues that influence clinical work with patients with acute psychosis, for example presentations of symptoms of acute psychosis that influence various domains of clinical and therapeutic work with acutely psychotic patients are related to sex differences. As men and women are different in many biological, psychological, sociological, and functional characteristics, it seems logical to believe that illness that markedly alters many of these domains should express itself differently in both sexes (Groleger and Novak-Grubic, 2010).
'Gender differences are an ideal window through which to look at the interplay of biological and psychosocial factors' (Riecher-Rossler and Hafner, 2000).
The study of sex differences in the psychotic spectrum disorders has given rise to a number of models that have been grouped into two different dimensions: clinical/psychosocial and neurobiological (Leung and Chue, 2000; Koster et al., 2008). The first refers to the expression of symptoms and social behavior in schizophrenic patients; men show a higher frequency of negative psychotic symptoms (Goldstein and Link, 1988; McGlashan and Bardenstein, 1990), whereas women have a higher probability of showing affective symptoms. Usually, women with schizophrenia are more active and have a wider social network than affected men, who, in turn, are more passive and have social difficulties (Roy et al., 2001; Simonsen et al., 2007). The neurobiological dimension could include four hypotheses on sex differences in schizophrenia:
- The estrogen hypothesis postulates a protective effect by estrogens in the development of schizophrenia in women, which could explain certain sex differences in the manifestation of the disease (Seeman and Lang, 1990). In women, estrogens could retard development of schizophrenia up to menopause, which would explain its late onset (Hafner et al., 1989).
- Different subtypes of schizophrenia: This hypothesis postulates the existence of two distinct schizophrenias, masculine and feminine (Murray et al., 1985), corresponding to different forms of expression of specific psychotic symptoms according to the sex of the patient rather than the existence of two types of schizophrenic endophenotypes that are clearly differentiated. Castle et al. (1994) carried out a study on a sample of patients with a first-psychotic episode and identified three groups: a neurodevelopmental type (predominantly male), a schizoaffective type (almost entirely female), and a paranoid type (with an equal sex ratio).
- Early and late developmental models: both models postulate changes in the neurological development that predispose to the appearance of schizophrenia, but in accordance with the early neurodevelopmental model, these anomalies start at the prenatal and neonatal stages (Murray et al., 1992). However, the late neurodevelopmental model supports the hypothesis that these occur later in life, particularly during adolescence (Jerningan et al., 1991).
- Brain lateralization: this model attributes sex differences in schizophrenia to the differential hemispheric organization of the male and female brain as the latter is more symmetrically organized (less lateralized) than the male brain (Flor-Henry, 1978).
Schizophrenia and first-episode psychosis are disorders with considerable heterogeneity in several of its basic features. There is huge variability in the clinical presentation, disease course, and responses to both pharmacological and psychosocial treatment. Some aspects of this heterogeneity may be sex related. Study of the sex variable may help to explain the difference. The aim of this study is to examine the sex differences in first-episode psychotic patients in terms of cognition and different diagnostic outcomes both at baseline and after 2 years of follow-up.
| Patients and methods|| |
The current prospective study was carried out on first-contact, drug-naïve, Kuwaiti patients treated from their first-episode psychosis. Patients were newly admitted at the psychological medicine hospital state of Kuwait, the only and official hospital that provides psychiatric services at the tertiary level. Patients were enrolled in the study after they provided written consent. The research was approved by the research and ethics committee.
All patients with first-episode psychoses admitted between January 2008 and December 2009 were assessed by both clinical and psychometric studies on admission and were reassessed after 2 years. The study ended by the end of December 2011.
Kuwaiti patients of both sexes, 18 years of age or older, who had first-episode psychosis and who were free from any neurological or medical disorders, seizure, mental subnormality, substance abuse, or a history of head trauma with loss of consciousness for more than10 min were eligible for inclusion in the study.
At the end of recruitment, 176 patients were admitted for their first-episode psychoses; only 139 were Kuwaiti, 18 did not fulfill the inclusion criteria, and 11 refused to participate in the study. One hundred and ten patients completed the baseline study. On follow-up, 90 patients completed the entire study.
During the period of admission, consensus diagnoses were determined by members from the clinical and research team using the structured clinical interview of DSM-IV (First et al., 1996); as well as all available collateral information from families and or previous caregivers, medical records, and information provided by the clinical and research team. This information generally included initial symptoms and information obtained by direct and ancillary information over the course of 6-8 weeks of initial treatment. Repeated assessments on clinical bases were carried out every 6 months or at the time of rehospitalization.
Sixty-one men and 29 women were recruited. All patients were divided according to the consensus clinical diagnoses into two groups: the nonaffective psychosis group (n = 49, 39 men and 10 women) and the affective psychosis group (n = 41, 22 men and 19 women).
All patients were subjected to the following:
The Positive and Negative Syndrome Scale (Kay et al., 1987)
Positive and Negative Syndrome Scale (PANSS) items are scored along a continuum of severity between 1 (asymptomatic) and 7 (extreme symptom severity).
Analysis was carried out both on the total scales and subscales (positive, negative, and general psychopathology).
Hamilton Depression Rating Scale (Hamilton, 1960, 1967)
The original version had 17 items [Hamilton Depression Rating Scale (HDRS 17)] pertaining to symptoms of depression experienced over the past week. A score of 0-7 is generally accepted to be within the normal range (or in clinical remission), 8-13 as indicating mild severity of depression, 19-22 as moderate severity, and more than 23 as very severe degree of depression.
Young Mania Rating Scale (Young et al., 1978)
Young Mania Rating Scale (YMRS) is an 11-item clinician-rated scale designed to assess the severity of manic symptoms over the previous 48 h both for baseline assessment and for follow-up of treatment response.
Four of the YMRS items were scored on a 0-8 scale, with the remaining five items rated on a 0-4 scale. A score of 12 or less indicates remission of symptoms.
A standardized cognitive battery was completed by all participants, both at baseline assessment and at the end of 2 years. Cognitive ability was examined by dividing various neuropsychological tests into six cognitive domains as recommended by the National Institute of Mental Health - Measurement and Treatment Research to Improve Cognition in Schizophrenia (Neuchterlein et al., 2004; Kern et al., 2004, 2008).
The following domains were derived:
Working memory: from spatial span subtests of the Wechsler Memory Scale - 3rd ed. (WMS-III) (Wechsler, 1997), and the digit span subtests of Wechsler Adult Intelligence Scale - 3rd ed. (WAIS-III) (Wechsler, 1997).
Verbal learning and memory: from the logical memory subtest of WMS-III.
Visual learning and memory: from the visual reproduction subtests of WMS-III.
Speed and processing: from the trial-making test A (completion time; Reitan, 1992) and the digit symbol subtest of WAIS-III.
Reasoning and problem solving: from the trial-making B and block design subtest of WAIS-III.
Attention: from spatial span and digit span forward subtest of WAIS-III.
Intellectual ability: using Wechsler Adult Intelligence Scale
Using the two subtests of WAIS (verbal and performance subtest). It was measured both at baseline and at the end of 2 years.
Simpson-Angus Extrapyramidal Side Effect Scale (Simpson and Angus, 1970)
A score less than or equal to 3 is normal without Parkinsonism More Details features. It includes 10 items scored from 0 to 4. The patient is examined on walking at a normal rhythm and each side of the body is examined separately.
The duration of untreated psychosis (DUP) is defined as the number of weeks between the first expression of psychosis and study recruitment, and duration of untreated illness (DUI) is defined as the number of weeks between the start of any behavioral changes and/or psychological change and start of study recruitment.
Data were collected and coded, and then entered into an IBM compatible computer using SPSS version 17 for windows (SPSS Inc., Chicago, Illinois, USA). Entered data were checked for accuracy, and then for normality using the Kolmogorov-Smirnov test.
Qualitative variables were expressed as numbers and percentages, whereas qualitative variables were expressed as measures (X) and SD. The arithmetic mean (X) was used as a measure of central tendency whereas the SD was used as a measure of dispersion.
The following statistical tests were used.
- Independent-samples t-test was used as a parametric test of significance for comparison between two sample means after carrying out Levene's test for equality variances.
Independent-samples Mann-Whitney's U-test (or Z-test) was used as a nonparametric test of significance for comparison between two sample medians.
- The χ2 test (or log likelihood ratio) was used as a nonparametric test of significance for comparison of the distribution of two qualitative variables.
- The Kruskal-Wallis test (χ2 value) was used as a nonparametric test of significance for one-way comparison between more than two sample means, when the one-way analysis of variance test was not appropriate.
- Spearman's rank correlation coefficient was used as a nonparametric measure of the mutual relationship between two non-normally distributed qualitative or ordinal variables.
- A 5% level was chosen as a level of significance in all statistical significance tests used.
| Results|| |
Recent studies have begun to examine sex differences in schizophrenia (nonaffective psychosis) and other affective psychosis in first-episode patients in an attempt to explain the heterogeneity of the illness. However, a number of uncertainties remain.
Sociodemographics and clinical characteristics
Group comparison of demographics [Table 1], [Figure 1] and [Figure 2] showed a significant sex difference between the diagnostic groups. Men were mainly presented with nonaffective psychosis (79.59%; n = 39) while (53.65%, n = 22) had affective psychosis. However, there were more women in the affective group (46.34%, n = 19) compared with the nonaffective group (20.41%, n = 10) [χ2 = 8.74, d.f. = 3 (P < 0.05)].
|Table 1: Demographics and clinical characteristics of men and women in nonaffective and affective first-episode psychosis|
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Significantly more men were single and divorced than women in the nonaffective group, but not in the affective group.
Male patients had higher educational levels in both groups compared with women.
Occupation did not show any significant sex difference in both groups.
[Table 1] also shows that men had a more negative family history of psychosis compared with women, but this was significant in the nonaffective psychosis group but not in the affective group (P = 0.03 and 0.87, respectively).
There was clear gender differences regarding age and age at onset. Age at onset of symptoms were 3-5 years earlier in men than in women among both groups (nonaffective and affective psychosis), but this difference in age was statistically significant in the nonaffective group (P < 0.05).
Among nonaffective patients, men had a significantly longer DUP, whereas women showed a longer DUI (P < 0.05). This tendency was observed in affective patients, but was not statistically significant [Table 1].
In nonaffective psychosis, in terms of treatment characteristics, male patients required significantly longer duration for stability on treatment, with greater neurological side effects compared with women (P = 0.02 and 0.01). Lower dosage range of psychotropics with higher rehospitalization rates were found in men than women, but these tendencies were not statistically significant (P > 0.05).
The above pattern of treatment characteristics in both sexes was also observed in affective patients, but it was not statistically significant.
Generally, the mean scores of cognitive function tests for both male and female patients in affective psychoses were higher than those of non affective psychoses (working memory, verbal memory, visual memory, attention, executive functions). Differences between groups and within each group of patients did not reach statistical significance [Table 2] and [Table 3].
|Table 2: Cognitive functions in both sexes for nonaffective and affective psychosis at baseline assessment of first-episode psychosis|
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|Table 3: Percent change of cognitive functions after 2 years of treatment in both sexes for nonaffective and affective psychoses|
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Baseline intellectual functions (WAIS) were matched for both sexes in each group and even in comparison with each other [Table 2].
In [Table 3], the rate of improvement in working, verbal, and visual memory after treatment was higher in affective psychotic patients than nonaffective ones.
In contrast, the nonaffective group had higher percent change in relation to attention and executive function. The effect of sex in both groups and within groups was not statistically significant in terms of baseline, intellectual function, and all other cognitive tests.
[Table 4] shows that although statistically nonsignificant, men had severe depressive and bipolar symptoms than women in each group of patients. As expected, the higher mean scores of HDRS and YMRS were clear in the affective group.
|Table 4: Sex differences in the percent change of scores of Hamilton Depression Rating Scale, Young Mania Rating Scale, and Positive and Negative Syndrome Scales in both nonaffective and affective psychosis|
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The rate of improvement of affective symptoms in men after 2 years was higher compared with women with either affective or nonaffective psychoses. This was not statistically significant, except for (HDRS scores) in men of the affective group (P = 0.02).
The mean total and subscores of PANSS (positive, negative, and general psychopathology) were comparable for male and female patients in nonaffective and affective psychotic groups. This was also true for the rate of improvement after 2 years of treatment [Table 4].
Despite lacking statistical significance, there was an impact of sex on symptom presentation for patients with first-episode psychoses in both nonaffective and affective groups. Men had marginally lower negative scores, and higher positive and psychopathology scores of PANSS compared with women. However, the rate of improvement and response to treatment was better in men in the nonaffective psychosis group on PANSS scores and subscores whereas women were more responsive in the affective group after 2 years.
| Discussion|| |
Gender differences with respect to psychotic disorders are an important factor in the understanding of the manifestations and development of the disease. Even though in the last decades this was an intensively studied subject, controversial results were obtained from the different studies carried out.
The gender differences in our sample were clear in terms of the incidence of nonaffective psychosis, where men predominantly had nonaffective psychosis whereas women had a tendency to have affective disorder. These results are in agreement with the studies of Castle et al. (1993), Lewine et al. (1984), and Aleman et al. (2003) of male predominance in nonaffective psychosis and with Haahr et al. (2008), who showed that female sex was one of the predictors for affective psychosis.
Traditionally, it was accepted that the incidence and prevalence of nonaffective psychosis was the same in men and women (Wyatt et al., 1988). More recent studies on the prevalence of schizophrenia in the general population did not find sex differences (Perala et al., 2007; McGrath et al., 2008).
One possible explanation for the disparity between incidence (centered on clinical data) and prevalence (centered on epidemiological resources) may be the rate of compliance with treatment and higher rates of suicide completion in men than women (Test et al., 1990).
Similarly, female sex was a significant predictor of conversion to affective psychosis 2 years after ascertainment in an ultra-high-risk group, and young male adults had a four-fold risk of having schizophrenia 1 year after enrollment compared with women (Nordentoft et al., 2006).
In terms of premorbid functioning, both males and females with affective psychosis showed comperable adjustment for academic domain, social domain (marital status), and occupational functions. Whereas in the nonaffective group, men were more adjusted in educational and occupational life compared to women. These results are in agreement with those of McGlashan and Bardenstein (1990), but not Norman et al. (2005).
Also, good premorbid functioning in men was not consistent with Shtasel et al. (1992), Morgan et al. (2008), and Childers and Harding (1990).
One explanation for this difference may be cultural impact, where generally, in Arab culture, men receive more support in education and occupational function whereas women have more social support in marital life.
Men have less familial tendency of psychosis than women in nonaffective psychosis. This result was also reported in Goldstein et al. (1990), Pulver and Liang (1991), and Maier et al. (1993), where women had more relatives with psychosis than men.
In contrast, Kendler and Walsh (1995) found no sex differences in the familial risk of schizophrenia, except age younger than 17 years, where males have a significantly higher familial risk of psychosis. Other studies have found no interaction between age of onset, sex, and familial risk (Godstein et al., 1992).
Difference in age and age at onset are the most replicated findings in studies on sex differences, especially in schizophrenia and nonaffective psychosis. Men usually develop the illness 3-5 years earlier. This is consistent with the current results and has been reported in the studies of Goldstein et al. (1989) and Gureje (1991).
However, a number of studies have found no sex differences in the age at onset (Folnegovic and Folnegovic-Smalc, 1994; Addington et al., 1996; Naqvi et al., 2005).
The most common explanation for this sex difference in age at onset is the estrogen theory for women older than 40 years of age (Riecher-Rossler et al., 1994), and a link with a high risk of psychosis in families of male patients (Albus et al., 1994; Hafner et al., 1998a, 1998b).
The previous two theories are not applicable in our sample, where women were younger than 40 years of age and the negative familial risk was the greatest in men. We assumed that such difference is complex and occurred as a result of an interaction of multiple factors such as premorbid adjustment, neurodevelopmental deficits, and genetic and cultural factors.
Male patients with nonaffective psychosis/schizophrenia was strongly associated with longer DUP. This association is important as a predictor for schizophrenia differentiation in males (Haas et al., 1998; Blcak et al., 2001). Other studies have questioned these findings (Barnes et al., 2000; Craig et al., 2000).
The shorter DUP and longer DUI in women could be attributed to more social adjustment and cultural impact, where stigma determined the illness behavior of patients and families. Women in Arab culture are more socially supported leading to longer time for seeking help, but if the female started to exhibit odd or eccentric psychotic behavior; families under effect of stigma will seek medical help.
The current study was in agreement with that of Uggerby et al. (2011) and Usall et al. (2003). Studies have reported a higher rate of hospitalization and longer stay in hospital until stability in men than women among schizophrenia patients of first-contact psychosis. Other studies have reported the reverse pattern in women (Usall et al., 2001; Haro et al., 2008).
The greater sensitivity to neuroleptics among men in our study was not consistent with Seeman (1990), who reported that Parkinsonian symptoms with atypical neuroleptics were more frequent in women. This may be attributed to the longer and frequent hospitalization for men with more exposure to antipsychotic than women.
Sex differences in cognition have been another controversial issue; a number of authors have reported that there is no impact of sex on cognitive function (Salokangas, 1983; Goldberg et al., 1995; Moriarty et al., 2001). This was consistent with our results indicating no differences between men and women statistically in terms of cognitive functions in both affective and nonaffective psychosis at baseline and confirmed after a 2-year follow-up treatment with antipsychotics.
Besides statistical significance, men had marginally higher mean scores on working, visual memory subtests and also speed and processing in the nonaffective psychotic group of patients with first-episode psychosis, whereas women performed better on working memory, attention, and speed and processing subtests. The rest of cognitive functions tested in the current study yielded mixed results in both groups of psychotic patients for both sexes. The above results may confirm this controversial and sometimes contradictory impact of sex on cognition for patients of first-episode psychosis.
Karilampi et al. (2011) concluded that there may be slight differences between women and men in the domains related to cognitive function that need to be taken into account. Bilder et al. (1992) found that men performed better in the information subset of WAIS whereas women performed better in the digit symbol subtest. Other studies have shown cognitive functions to be worse in women with schizophrenia (nonaffective psychosis) than in men (Perlick et al., 1992; Lewine et al., 1996).
Vaskinn et al. (2011) suggest better functioning in neuropsychological performance in women than men, except in the category of attention. Bozikas et al. (2010) found that women perform better than men in verbal learning and memory. Also, a number of authors have reported that men score worse in attention, language, and executive function than women (Goldstein et al., 1994; Seidman et al., 1997; Goldstein et al., 1998; Hoff et al., 1998).
In summary, gender differences in cognitive function for patients with first-episode psychosis are a subject of controversy, yielding mixed complex and sometimes contradictory results, indicating the heterogeneity of the clinical presentation at early stages of illness and even after being treated the picture at baseline and short-term outcomes.
The study of sex differences in symptoms of patients with first-episode psychosis has been one of the most explored issues. However, the results of these subjects are inconclusive.
The absence of a significant impact of sex on symptom presentations of patients with first-contact psychosis in our results is in agreement with Addington et al. (1996), Lindstrom and Von Knorring (1994), Larsen et al. (1996), and Szymanski et al. (1995), who reported either no impact or inconclusive results on symptom presentation for sex.
Nevertheless, marginally higher positive and psychopathology scores with lower negative scores for men compared with women were not consistent with Galderisi et al. (2012), Shtasel et al. (1992), Cowell et al. (1996), Riecher-Rossler and Hafner (2000), and Morgan et al. (2008), who reported that men have more negative symptoms among patients with a diagnosis of schizophrenia on the first episode.
Also, many studies have found higher affective and anxiety symptoms in women than men (Walker et al., 1985; Cotton et al., 2009). These conclusions were in contrast to our results, where men had more severe depressive and bipolar symptoms among both affective and nonaffective psychotic patients.
The discrepancy between the current results and previous studies regarding gender impact on psychosis can be attributed to the fact that, for the impact of gender to be high and significant more time is needed. This time needed may extend up to 10 years to allow the stability of the diagnosis Bromet et al. (2005). The diagnostic stability of schizophrenia from baseline assessment has been less well studied and the positive predictive value exceeds 90%, and preliminary findings from the 10-year follow-up of the Suffolk Country Mental Health Project Cohort have shown that the agreement across time increased from K = 0.52 (baseline to 10 years) to K = 0.76 (6-24 months to 10 years) (Bromet and Fennig, 1999). This means that the impact of sex may become more clear with time but not at onset of illness or at short-term outcome, indicating the need for long-term follow-up.
| Conclusion|| |
Study of the impact of sex in first-episode psychosis is considered as an important attempt to clarify the heterogeneity of the illness.
As the extent of sex differences in first-episode psychosis and most results have been controversial, differentiation of the clinical picture of patients with psychosis may require long-term follow-up, where the picture at baseline or short term may be unclear, with sex differences.
| Recommendations|| |
A long-term follow-up study for patients with first-episode psychosis may help clarify sex differences
Study of premorbid adjustment, biological, and genetic differences between men and women may be helpful to test the neurodevelopment theory of schizophrenia and nonaffective psychosis.
Novel sex-specific treatment could be developed to better meet the needs of patients with psychosis on the basis of clinical, biological differentiation, and long-term assessments.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]