CLINICAL HANDBOOK OF SCHIZOPHRENIA

56. Gender 579accounted for by women smoking less than men), to the fact that women are generallymore compliant with prescribed medications, and to their greater fat stores, which extendthe half-life of lipophilic drugs. It may also result from estrogen action at receptor targetsites, such as brain dopamine receptors. Women’s relatively superior response appears tobe lost after menopause.AssessmentCLINICAL IMPLICATIONSTextbook descriptions of schizophrenia are of male-type schizophrenia. When assessingwomen, clinicians may miss a first episode of schizophrenia, because the woman mayseem too old for a first episode or may have too many affective symptoms. When assessingwomen, clinicians can also mistake the following for schizophrenia: posttraumaticstress, eating disorder with starvation, psychotic depression, or a short-lived psychosis inthe context of a personality disorder. When assessing women, clinicians should ascertainthe influence of hormones on symptoms (e.g., contraceptive pill use, time of the month,pregnancy, postpartum period, menopause).TreatmentEffective antipsychotic drug doses in women are generally lower than those in men (inboth genders, it is important to inquire about cigarette smoking, coffee drinking, andconcomitant medication). Depot medications can be given at longer intervals in women.Many women require relatively higher doses premenstrually and postmenopausally, andwhen pregnant may need only very small doses. Women are generally more emotionallyinvolved with their friends and families than are men, and effective treatment must takeinterpersonal stressors into greater account. It is essential to inquire about the presence ofchildren and to ensure that children under the care of women with schizophrenia are beingcared for adequately. Comorbid depression is more prevalent in women than in menand usually needs to be treated.AdvocacyThere is an urgent need for family-centered services with therapeutic day care for mothersand children, including parent coaching and support services. Advocacy for individual patientsis needed to convince child care agencies that it is generally preferable to provide supportfor the mother with schizophrenia at home than to take children away to foster care.KEY POINTS• Differential diagnosis in women includes mood disorder, and posttraumatic stress disorder,and starvation secondary to anorexia; in men, substance use disorders need to be ruledout.• Hormonal triggers are important in women with schizophrenia (e.g., premenstrual period,postpartum period, menopause, contraceptive use).• Depending on the antipsychotic used, women often require lower doses than do men.• Heavy smoking lowers antipsychotic drug levels in both sexes.