Abstract
Although entitled Women and Schizophrenia this book provides an excellent and learned update on the neurobiological, epidemiological, clinical, hormonal and reproductive factors influencing the impact of the illness in both sexes. In fact, as the editors point out, it is important to compare males and females with the illness so that ultimately they may ‘illuminate causal mechanisms’ of schizophrenia (p.1). It is also important to examine biological and psychosocial differences associated with gender which will have a bearing on the treatment of schizophrenia for men and women.
The book provides comprehensive reviews covering the medical (neurobiological and hormonal) aspects of gender differences in schizophrenia. There are, however, social and psychological issues underlying the aetiology and treatment of schizophrenia. It is unfortunate that such issues have not been subjected to the thoroughgoing scrutiny in the research literature that the medical aspects have. This is not a criticism of this book, simply a reflection of the state of available research.
This important book raises a number of interesting issues. Men experience a significantly higher incidence of schizophrenia despite the fact that there is a higher incidence among women over 45. This has become more apparent recently where more stringent criteria for diagnosis have been implemented: excluding affective psychoses for which women predominate. However, the difference dissipates when we consider prevalence rates, which suggests that maybe men have shorter duration of illness. Research has not clarified whether this is due to higher successful suicide rates in males or to other psychosocial or physiological gender differences. As pointed out by the authors, considerations of mean age of onset are somewhat spurious because distributions are not particularly unimodal nor normally distributed (chapter 3).
Neurobiological evidence as discussed in chapter 2 suggests that boys have a greater vulnerability to neurodevelopmental disorders such as ADHD and autism and this is likely due to the slower development of parts of the male brain leaving it vulnerable for longer to physical and chemical insult. There is also evidence to support the notion of the protective effect of oestrogen against the early onset of acute schizophrenia (chapter 5). This would explain the later onset of symptoms in women and the reduced amount of oestrogen around menopause also may explain the increased incidence of schizophrenia among menopausal women which is not seen at the same age for men.
Among the many interesting issues raised throughout the book is that the prevalence of the illness remains relatively stable despite evidence of a genetic influence in its transmission and the fact that schizophrenic males and females have fewer children than the general population. Under these circumstances we would expect prevalence to decline. Various explanations have been explored but nothing has gained empirical support (such as higher birth rates among near relatives, chapter 7). Also the issue of a stable rate of schizophrenia across time is muddied by changes in definition over the years and the range of rates found throughout the world. It could be that rates are more influenced by rates of brain insult at birth (or later on in development) more so than genetic predisposition. (Refer Warner [1] for a review of the likely impact of obstetric complications in schizophrenia.)
The chapters on pregnancy and motherhood highlight a significant gap in service needs for schizophrenic women. This is clearly a highly disabled segment of the community for whom special programmes are needed to inform and assist them with these issues. Reference is made to research which demonstrates poor communication between mental health services, primary care and child welfare services as well as legal and financial services (chapter 7), which places inordinate pressure on the mother who, like most, wishes to retain the guardianship of her children. The authors argue cogently that apart from humanitarian issues it is also cost-effective to retain the family unit intact with extra care provided at times of crisis. These chapters also highlight a significant gap in research with few studies identifying best practice to combine the efforts of the various services involved. Given the inordinate gap between need and service provision in mental health services (as distinct from physical health services), let's hope this important book reaches the desks of the policy-makers who decide where the dollar will go.