Targeting Gender and Age in First-Episode Psychosis Services: A Commentary on Ferrara and Srihari

Abstract

Ferrara and Srihari argue in this issue of Psychiatric Services (1) that women are disadvantaged relative to men in early intervention services for first-episode psychosis in the United States. According to a recent report, 23 is the mean age of participants in such services (2), probably because many early intervention programs set an age limit on entry. Most patients in these intervention services are men (2). It has been acknowledged that in many countries, current early intervention programs are gender and age inequitable (3). Relatively few women receive these services, and those who do constitute an underserved minority, both with respect to the number of individuals receiving services and to their stage in life at which they receive services. For men, first episodes of psychosis occur predominantly among young individuals, whereas they can occur among women at all ages (4). Whatever the precise diagnosis, the emergence of psychosis is brought to clinical attention earlier for men than for women, perhaps because men are more likely to abuse substances that precipitate or unmask psychotic symptoms or because police involvement and involuntary hospitalization are more prevalent among men (4).As a result of the young age of first-episode service participants, current mental health care programming primarily addresses the challenges of the early twenties, namely independence from parents, completion of education, vocational training, expansion of social networks, substance abuse prevention, and development of intimate relationships. Even if there are no age limits to service entry, the needs of older individuals, both men and women, remain relatively neglected (3). Individuals who develop psychotic illness at older ages face problems with employment, finances, housing, marriage, pregnancy and postpartum challenges, worsening health, parenting dilemmas, the burden of care for aging parents, and bereavement-themes that lend themselves to therapy but do not, at present, form a regular part of first-episode psychosis programming.This lack of programming for older adults is understandable. The emphasis on early intervention originated in the hope that "catching" (and halting) a disease in the young when it first begins, or even before it begins, prevents what used to be called

Sex differences in schizophrenia-spectrum diagnoses: results from a 30-year health record registry

“…In the last 20 years, a lot of resources have been devoted to the prompt identification of young individuals with a first episode of psychosis (Patel et al 2007 ). What is still missing though is a strategy for the rapid identification of early signs of SSD that may differ by sex and gender (Seeman 2020 ;Ferrara and Srihari 2021 ). This could for example involve more training for professionals about the specific presentation of SSD in women (less adherent to the conventional representation of SSD), more attention to female-specific risk factors such as the peripartum period, or the vulnerability conferred by a history of violence or abuse (Seeman 2018 ), and major hormonal changes (Sommer et al 2023 ).…”

“…A sex- and gender-oriented approach is thus needed to reduce chronicity, especially for conditions like SSD that cause great disability and suffering for affected individuals and their families, as well as premature death, and result in high direct and indirect health care costs (Christensen et al 2020 ). Despite this evidence, guidelines for the comprehensive treatment of schizophrenia in women are lacking (Fernando et al 2020 ; Seeman 2020 ; Ferrara and Srihari 2021 ).…”

Baseline benzodiazepine exposure is associated with greater risk of transition in clinical high-risk for psychosis (CHR-P): a meta-analysis

“…More investigation of gender differences in the early stage of psychosis is warranted, both because women remain an underserved minority in early intervention services (Ferrara & Srihari, 2021), and because of their known sensitivity to drugs' adverse effects and additional specificity in care issues, such as domestic abuse, and reproductive and parenting issues (Seeman, 2021).…”

Psychosis in Women: Time for Personalized Treatment

“…Taken together, these studies point to differential characteristics of male and female brains right from the beginning of psychosis [14], thus to differential response to pharmacotherapy [15]. Therefore, reconsidering the evidence, the need for personalized, gender-related care emerges; this is stressed by recent studies [16][17][18].…”