Time to think of sex and gender differences in mental health services for psychosis
By Maria Ferrara, MD
If you ask ordinary physicians whether they provide care differently to women and men affected by psychosis they will likely be horrified at the thought of discriminating based on sex; all individuals have the same rights when it comes to mental health care, they will reassure patients and family members. This might sound like the right answer, but is it really the best approach?
Does providing care without distinction based on sex and gender mean we are providing equal care? Are men and women equal when it comes to accessing mental health care for psychosis? Do men and women with psychosis have the same care needs?
As the WHO reminds us, sex and gender are critical determinants of health, including mental health. Psychosis is a mental health condition characterized by hallucinations (seeing or hearing things that are not there), delusions (believing in something that is not true, and most of the time impossible), disorganized thoughts and speech patterns. It affects 3 in 100 people worldwide, and it typically develops around the age of 21. It includes diagnoses such as those of the schizophrenia spectrum and affective disorders (depression with psychotic features and bipolar disorder).
Sex and gender differences in the clinical characteristics of the psychosis spectrum have been well documented: men and women differ for incidence and age at onset, for symptoms at care presentation and course of illness. Compared to men, women also carry more risk factors for psychosis, including hormonal and psychosocial factors. What is still unknown, and maybe overlooked, is that women who are experiencing their first episode psychosis (FEP) might experience potential gender-based disparities in accessing and receiving care.
Factors That Can Affect Access to Care for Women With FEP
Age at onset: Many FEP programs accept only individuals aged 15 to 35, an age range that might cut-off women who have their first episode later in life. In fact, a large European study including 2774 individuals with FEP, reported not only that women were older at first contact with FEP services (age 34 vs. age 28 for men) but also that they had a second peak of new onset of psychosis in their 50s’.
Clinical presentation of psychosis and pathways to care also differ by gender. Women tend to present with prevalent mood symptoms associated to psychosis instead of the classic bizarre behavior and thoughts, therefore they are more likely to receive a diagnosis of affective psychosis (often an exclusion criterion from FEP programs). By contrast, men frequently manifest their psychosis through aggressive and disorganized/dangerous behaviors, often complicated or triggered by a comorbid substance abuse problem (which is also more common in men than women), leading them to hospitalization. While the acute access to inpatient psychiatric units is often dramatic and considered an aversive entry to mental health care, it still represents one of the main doors to access FEP programs.
Gender stereotypes and societal norms can also affect access to care and the provision of a correct diagnosis: women’s call for help can be labelled as being overdramatic or acting out to gain attention. When gender stereotypes are intertwined with gender norms, access to care can become problematic: women are often the designated caregivers for infants and elderly relatives, so their necessity to prioritize care of others over their own needs could further delay their own access to treatment. Moreover, women are more often than men employed in precarious jobs, with lower salaries, and worse benefits (shorter OPT, less flexible schedule), thus challenging a smooth access to care.
Factors That Can Affect Quality of Care for Women With FEP
Sexual and reproductive health monitoring should also be considered as an integral part of FEP services, considering that FEP usually manifests during adolescence years, and most importantly, in fertile age. Women, by definition, carry a unique risk factor for new onset or relapse of psychosis: pregnancy. 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 post-partum period.
Physical health. Both men and women can develop metabolic side effects due to the pharmacological treatment for psychosis, which contributes to increase the cardiovascular risk in these population (individuals diagnosed with a severe mental illness die on average 15-20 years younger than their peers). The choice of pharmacological treatment for women with FEP should be especially sensitive to those side effects which are more heavily stigmatized in women, such as weight gain and hair loss.
Preventive medicine. Women with schizophrenia, compared to those without a severe mental illness, are less likely to receive a Pap test screening for cervical cancer and half as likely than the general population to receive a mammography screening. FEP service 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 victimization. Moreover, there is a strong association between exposure to traumatic events in childhood and increased risk of psychosis. Thus, 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.
It is time for a gender-sensitive FEP service: being a woman is a key determinant in the pathway to and through mental health care for psychosis. The gender specific issues highlighted here might unveil blind spots in the care delivered by FEP programs, and might provide clinical guidance in tailoring such services.
A close consideration should be undertaken by stakeholders, care providers, and policy makers on the gender specific needs of this subpopulation to access FEP specialized care as well as receive appropriate treatment. By creating the infrastructure and a comprehensive service tailored to the women’s needs we are paving the way to facilitate access and providing a high quality FEP service.
Main image courtesy of freepik.com