Serious Mental Illness in Women

Marcela Almeida; Sun J. Fletcher


Curr Opin Psychiatry. 2022;35(3):157-164. 

In This Article

Most Common Serious Mental Illnesses in Women

Although it has been historically proposed that schizophrenia spectrum disorders (SSD) had a more benign course in women than in men, recent studies suggest that this concept should be revisited,[9] with female patients having similar number of hos-pitalizations and comparable functional outcomes.[10] Schizophrenia is a SMI with a lifetime prevalence of around 1% and is slightly more prevalent in men than women.[11] Even though it has a low prevalence, it is associated with significant burden of disease for both sexes.[12] The age distribution differs between men and women: women are typically older than men at symptom onset, first hospi-talization, and age at diagnosis (with men showing a peak around age 22 years and women having a more plateau-like distribution between ages 18 and 65 years and decreasing after that).[10]

One important dimorphism between genders is that women appear to have more depressive symptoms whereas men present with more negative symptoms. Comorbid use of substances is more common in men,[10,11,13] which may contribute to both earlier age of onset and higher severity in men compared with women. Suicide and mortality are lower in women.[10,14] Although women make suicide attempts more frequently, their completed suicide rates are lower than men's,[15] and although they experience less social impairment and fewer negative symptoms, they are at increased physical comorbidity risk compared with men.[16–18]

The fact that women tend to present for treatment at a later age may indicate missed opportunities at diagnosis, which may ultimately correlate with a poorer prognosis. Contrary to what has usually been reported, women have slightly more hospitalizations than men (with similar duration).[10] And, whereas women are more often prescribed antipsychotics, they receive lower doses of them and fewer prescriptions for long-acting injections, cloza-pine, and olanzapine, suggesting they may be undertreated or receive less effective treatment com pared with men.[19,20,10]

There are important differences between gen ders with regards to the pharmacological treatment of schizophrenia. In terms of pharmacokinetics, estrogen decreases glycoprotein levels, increases the free concentration of antipsychotics, and slows the transmission of dopamine. Estrogen also regulates the activity of specific cytochrome P450 enzymes, potentially increasing the levels of at least some antipsychotic drugs in women.[17] Slower absorption, metabolism, and excretion in women all lead to increased plasma concentrations of anti-psychotics, which may translate into more side effects and adverse reactions. Additionally, as women have more fat tissue than men and anti-psychotics are lipophilic, there is more drug accumulation in women. Notably, most research studies are performed in men, which may mean that women may be at times overmedicated, particularly during periods of higher hormonal levels, such as during ovulation and pregnancy. For most antipsy-chotics (with perhaps the exceptions of quetiapine and lurasidone), doses should be lowered for women compared with men.[9] Risperidone, in particular, may lead to hyperprolactinemia, which in turn can cause estrogen deficiency that can be associated with negative cardiovascular outcomes. The hormonal role in the pathogenesis of SSD has been a long standing research theme. Studies have found that levels of follicle-stimulating hormone, dehy-droepiandrosterone, and luteinizing hormone are closely associated with the severity of SSD symptoms.[15,19]

Affective disorders are more common in women than in men: the prevalence of major depression is twice as high in women, and men and women have similar rates of bipolar disorder.

The course of the illness can significantly vary between genders because of various factors including medication compliance, drug interactions, social, and cultural factors.

Women are more predisposed to mood episodes during periods of hormonal flux, such as in the perinatal, premenstrual, and perimenopause periods.[4] Recent research has highlighted the association between oral hormonal contraceptives and depression in adolescents, with adolescent women being more likely than adults to start taking psycho-tropic medications or to seek psychiatric help for symptoms of increased tearfulness, hypersomnia, and eating problems after initiation of oral contra ceptives, an association that seems to disappear once they enter adulthood.[21] A correlation between androgen levels and suicidality had been described in several small cross-sectional studies but a recent large study did support this link[22] or an association with worsening depression in women.[23]

Anxiety disorders are significantly more prevalent in women than in men (23.4 vs. 14.3%) ( Women are more likely to experience a traumatic event and develop PTSD after a traumatic event (20.4 vs. 8.1% for men) (, with sexual violence being the primary source of PTSD worldwide. Women also wait much longer (an average of 4 years) than men (1 year) after symptoms arise to seek professional help, possibly because of stigma and other cultural aspects.[24]

Eating disorders are SMI that affect 20 million women and 10 million men in the United States. They constitute anorexia nervosa, bulimia nervosa, binge eating disorder, orthorexia, avoidant restrictive food intake disorder (ARFID), among others, and may incur in important medical consequences including cardiovascular, gastrointestinal, neurological, and metabolic risks. The lifetime prevalence might be up to 4% among women and 0.3% among men for anorexia nervosa and up to 3% of women and more than 1% of men for bulimia[2] (Table 1).

Although the prevalence of substance use disorders is higher in men than in women, women experience important psychosocial factors that confer important differences regarding the presentation, course, impact, and outcomes. Women have a later onset of severe use and a more rapid decline compared with men and their use tends to affect their interpersonal relationships and functioning level to a greater degree than in men[25–27] (Table 2).