Specialty team–based services for first-episode psychosis (FEP) have the potential to improve outcomes among patients with schizophrenia. In an article in Psychiatric Services, psychiatrists Maria Ferrara, M.D., and Vinod H. Srihari, M.D., of Yale University described several factors that may disadvantage women in terms of both access to and quality of care in FEP services.
Age of onset: Although many FEP services target young adults, research suggests the onset of psychosis may occur later in women. To meet the needs of women of all ages, the authors suggested that FEP programs consider increasing the maximum age at which a patient can receive FEP services. They acknowledged that designing psychosocial interventions to address the needs of younger adults and women across the lifespan may be challenging. Older women, some of whom may be pregnant or have children, might require “more intensive care planning, as well as sustained social worker support for childcare, involvement with child protective services, and consideration of economic needs.”
Clinical presentation: Compared with men experiencing FEP, women tend to present with more mood symptoms, which can lead to a misdiagnosis of psychosis due to a primary affective disorder—often a criterion for exclusion from FEP services. Women also tend to have better overall functioning at the onset of psychosis, which can lead to delays in services. To address this issue, the authors recommended FEP services support the needs of women with concomitant psychosis and mood symptoms, reevaluate their diagnoses, and refer women to other services only after preliminary treatment and several months of careful longitudinal assessment.
Pathways to care: Symptom-onset differences also result in women being less likely than men to be referred to FEP programs. “FEP services should be sensitive to these gender differences and target outpatient health facilities (for example, primary care and obstetric and gynecologic clinics) where women with underrecognized psychosis may be found,” they wrote. “To increase the likelihood that [women caring for children and/or elderly relatives] will access and accept care, services should integrate their outreach and engagement activities to settings where relevant services (for example, social services and child care) are co-located and readily available.”
Sexual and reproductive health: Psychosis symptoms often tend to first emerge during the period of greatest fertility for women. “FEP services should routinely provide education to help prevent sexually transmitted diseases and unintended pregnancies. Shared decision-making around family planning is also critical when medications with potential teratogenic risks are prescribed,” they wrote. Additionally, FEP services should consider collaborating with pediatric, primary care, and obstetric services to ensure patients who are pregnant or planning a pregnancy receive coordinated care during the peripartum period.
Preventive medicine: Research shows that women with schizophrenia are less likely to receive Pap test screenings for cervical cancer and mammograms for breast cancer compared with women without the disorder. “FEP services should consider providing education and care coordination to facilitate appropriate access to preventive measures (for example, human papillomavirus vaccination, breast self-examination, and diagnostic imaging),” they recommended.
“[W]omen with FEP have specific needs that can be proactively addressed to refine the current expansion of FEP services in the United States,” Ferrara and Srihari concluded.
For related information, see the Psychiatric Services article “Targeting Gender and Age in First-Episode Psychosis Services: A Commentary on Ferrara and Srihari.”