Review Open Access
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Psychiatr. Nov 9, 2018; 8(5): 125-136
Published online Nov 9, 2018. doi: 10.5498/wjp.v8.i5.125
Women who suffer from schizophrenia: Critical issues
Mary V Seeman
Mary V Seeman, Department of Psychiatry, University of Toronto, Institute of Medical Science, Toronto, ON M5P 3L6, Canada
ORCID number: Mary V Seeman (0000-0001-6797-3382).
Author contributions: Seeman MV is the sole author and responsible for every aspect of this paper; she received no assistance and no funding.
Conflict-of-interest statement: None.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Mary V Seeman, DSc, FRCP (C), MD, Emeritus Professor, Professor, Department of Psychiatry, University of Toronto, Institute of Medical Science, #605 260 Heath St. W., Toronto, ON M5P 3L6, Canada. mary.seeman@utoronto.ca
Telephone: +1-416-4863456
Received: July 18, 2018
Peer-review started: July 18, 2018
First decision: August 2, 2018
Revised: August 24, 2018
Accepted: October 11, 2018
Article in press: October 11, 2018
Published online: November 9, 2018

Abstract

Many brain diseases, including schizophrenia, affect men and women unequally - either more or less frequently, or at different times in the life cycle, or to varied degrees of severity. With updates from recent findings, this paper reviews the work of my research group over the last 40 years and underscores issues that remain critical to the optimal care of women with schizophrenia, issues that overlap with, but are not identical to, the cares and concerns of men with the same diagnosis. Clinicians need to be alert not only to the overarching needs of diagnostic groups, but also to the often unique needs of women and men.

Key Words: Schizophrenia, Women, Gender differences, Unmet needs

Core tip: Schizophrenia and related disorders are expressed differently in men and women. Causative factors may differ, as can the expression, timing and severity of symptoms. Prevention, course of illness, and treatment response are all intimately linked to gender.



INTRODUCTION

This review focuses on my experience dealing with clinical issues critical to women with schizophrenia. My work in this field began many years ago, and results are being continually updated as new information emerges. The paper is divided into the following main sections: Potential prevention strategies for women, the need for early and accurate diagnosis, the troubling complexities of the mental health system, effective treatment of schizophrenia and avoidance of adverse effects, the provision of access to vocational and avocational opportunities, attention to stigma, self-harm and suicide, the need for maintenance of physical, reproductive, and emotional health. Many of these issues are not specific to schizophrenia, nor are they all specific to women. But, directly or indirectly, they all bear on the health and well being of women with schizophrenia.

In each of the sections listed above, I reference my own work plus recent key papers from the PubMed database. Most of these topic areas continue to be the focus of intense research, and many questions await resolution. The paper ends by broadly outlining future directions for the field.

POTENTIAL PREVENTION STRATEGIES

Schizophrenia is defined by its symptoms, which are thought to arise from the interaction of inherited or de novo genetic polymorphisms with exposure to environmental stressors at critical periods of a person’s life. The details of specific gene mutations, the severity and identity of stressors, and critical chronology remain largely unknown. The strongest contributor to identifiable disease risk is a history of schizophrenia in close family members[1]. Knowledge of family history can now be combined with genetic risk scores from whole genome scans, which together, provide valuable information about a person’s vulnerability to schizophrenia[2]. Nevertheless, when it comes to prevention, even in the era of Clustered Regularly Interspaced Short Palindromic Repeats (commonly known as CRISPR)[3], it is not possible to edit out the hundreds of genes that potentially contribute to schizophrenia in any one individual. Even if in the future all suspicious genes could be eliminated, profound ethical concerns make this form of prevention doubtful[4,5].

Some investigators believe that prevention strategies for men and women need to differ. The genetic predisposition to schizophrenia may, for instance, be sexually dimorphic[6-8], although evidence for this is sparse. On the other hand, because male and female DNA is so often exposed to somewhat dissimilar environmental inputs, it may well transpire that the turning off and on of genes in particular sets of cells - the domain of epigenetics - is relatively sex-specific. Therefore, developments in epigenetics may one day enable the prevention of sex-specific expression of schizophrenia-inducing genes[9,10]. However, for the time being, genetic counseling for women and men[11] and individual contraception counseling[12] are the best ways to try to prevent the transmission of schizophrenia at the gene level.

Women with schizophrenia planning to be mothers and wanting to prevent schizophrenia in their offspring can be counseled (although this is, of course, impractical) to choose relatively young - but not too young - mates with no family history of psychosis[13] and to strategically plan the conception in order to avoid giving birth during late winter or early spring[14]. There is no direct evidence that this will work to prevent schizophrenia in the next generation, but there is an association (which does not imply causation) between season of birth and schizophrenia in offspring. The potential connection has been attributed either to fetal and/or neonatal exposure to infectious/immune factors or to the lack of sunlight and low levels of vitamin D. Associated preventive measures include adequate nutrition during pregnancy, and Vitamin D and folic acid supplements[15]. Other suggestions for mothers with schizophrenia to boost the health of their infants are: limits on maternal weight gain during pregnancy, appropriate immunization, low doses of antipsychotic (AP) drugs during pregnancy and lactation, abstention from tobacco, alcohol and other substances[16-18], and rapid treatment of infection and inflammation[19-21]. Nutritional deficiency, stress, and toxic substances in pregnant women have long been recognized to increase the risk for schizophrenia in offspring[22-24]. Infection, inflammation and immune reactivity have more recently been considered serious contributors to schizophrenia susceptibility[21,25].

Obstetric complications pose a potential risk to the infant brain. They are more common in the birth history of those who go on to develop schizophrenia than in their psychiatrically well peers, but it is not known whether obstetric complications arise from prior fetal problems or whether they result from substandard obstetric care[26,27]. Regardless, women with schizophrenia require exemplary care during pregnancy, labor, and delivery. The quality of maternal care of young children is also critical, as early physical and psychological trauma have been associated (again, this is an association that may not be contributory) with the later development of schizophrenia[26,28,29]. Such trauma is theoretically preventable through parent support and parent training groups, family health education, and child welfare monitoring, but interventions such as these require intensive collaborative work at the level of whole communities.

Further theoretical possibilities for prevention (based entirely on studies of association) are keeping children in their country of birth, since migration is a risk factor for schizophrenia[30,31], residing in rural rather than urban parts of the country[32,33], keeping children and adolescents away from alcohol and drugs[34] and teaching them emotion-regulating strategies (reappraising, accepting, and refocusing[35]) to prevent adversities such as discrimination and social defeat from culminating in paranoid delusions[36].

Given that fewer women than men are reported to develop schizophrenia (2/1 male/female ratio in the under-20 age bracket, although the discrepancy tends to even out with increasing age)[37], that the “female” hormone estrogen is known to be neuroprotective[38,39], and that women are especially vulnerable to psychosis during the postpartum period when estrogen levels precipitously drop[40], my research group predicted in the 1990s that, among women with schizophrenia, girls with early menarche (early pubertal rise in estrogen levels) would show a later onset of schizophrenia than girls who enter puberty at older ages[41]. This is precisely what we found in our clinic population, and this finding has been replicated by some groups, but not by all[42-44]. If accurate, this observation could lead to weight gain strategies[45] that bring menarche forward. This would, of course, not prevent schizophrenia, but might delay its onset in vulnerable women.

Knowing that low estrogen periods are times of special risk for psychotic episodes is especially useful for secondary prevention (prevention of recurrent episodes of psychosis) in women diagnosed with schizophrenia. Relapse can be prevented by increasing the dose of AP medication at low estrogen times in the menstrual month[46,47], during the postpartum period[48], after menopause[49,50], whenever therapeutic estrogen is stopped[51,52], or during therapy with anti-estrogen drugs[53,54]. These theoretical examples suggest that effective prevention of schizophrenia may, in the future, be possible in a sex-specific manner[55,56], though this is not the case presently.

EARLY ACCURATE DIAGNOSIS

It is well-established that delay in seeking treatment once psychotic symptoms have emerged is associated with impaired treatment response and a relatively poor prognosis[57]. Our group found that, on retrospective interview, the first sign of behavioral disturbance eventually leading to a diagnosis of schizophrenia occurred at approximately the same age in women and men, but that the pre-psychotic prodrome was almost twice as long for women[58]. The duration of untreated psychosis did not differ between the two sexes, but the interval between first behavioral sign and first treatment did - the lag was six years for men and nine years for women[58]. The corollary to this finding is that factors other than early diagnosis must determine prognosis because women’s outcome relative to men’s, despite a longer untreated interval, is generally superior, at least over the reproductive years[59,60]. Potential factors that favor women, besides estrogen levels, are premorbid functioning generally superior to that of premorbid men, more friendships, closer family relations, greater academic success, and a relative absence of substance abuse[61-63].

As important as the speed of diagnosis is its accuracy. Diagnosis leads, at least in theory, to disease-specific treatment, although this is not always true in psychiatry where illness categories often overlap and the same treatments are used for different diagnostic entities. Nevertheless, it is my clinical experience that women’s diagnoses frequently changes from depression to posttraumatic stress syndrome to eating disorder to schizophrenia to bipolar disorder (not necessarily in that order). This may be because it is more difficult to apply textbook schizophrenia criteria to women than to men. Women do not always exhibit the characteristic symptoms; they show few “negative” symptoms, few cognitive symptoms, and they rarely show flattened affect[64-66]. Prior to being diagnosed with a schizophrenia-related disorder, women with psychosis are often considered to be suffering from a mood disorder whereas, in men, a first tentative diagnosis is frequently alcohol or drug-induced psychosis[67]. Differential diagnoses sometimes missed in women include thyroid disease, autoimmune disorder, corticosteroid treatment, and anorexia-related starvation. All these conditions are much more prevalent in women than in men[68,69] and need to be ruled out before a diagnosis of schizophrenia is made.

COMPLEXITY OF THE MENTAL HEALTH SYSTEM

The mental health system in most countries is very complex and leaves individuals who experience mental distress not knowing whether to turn to physicians or social workers or psychologists or spiritual counselors. Family doctors may or may not recognize symptoms of early psychosis and, even when they do, may not know where to refer their patients. Waiting lists for the various mental health professionals are often long. Visits may or may not be covered by available insurance. Navigation services that help patients identify financial, linguistic, cultural, logistical and educational barriers to mental health care and provide guidance to access are badly needed by both women and men[70]. The routes to care differ in the two sexes, obstetricians and midwives sometimes serving as intermediaries for women, and guidance counselors and police more often paving care routes for men.

EFFECTIVE TREATMENT

Treatment is known to be most effective when it is individualized to meet the specific needs of the person being treated. Gender, age, family situation, place of residence, state of health, and personal preferences all play a part in determining optimal intervention. One example is the decision-making process around drug dosing. In women of reproductive age, effective drug doses can usually be lower than doses recommended for men[71-75]. Women’s ability to respond at lower doses has been attributed to the effects of female hormones on the absorption and metabolism of AP drugs and also to women’s relatively increased blood flow to the brain, carrying with it more drug to cell receptor targets[76]. The presence of estrogen at the dopamine receptor site helps to slow the transmission of dopamine[77], an excess of which is thought responsible for psychotic symptoms.

In addition, because AP drugs are lipophilic and women’s reserves of adipose tissue are on average larger than men’s, women store these drugs in their bodies for comparatively longer periods. This means that psychotic relapse after drug discontinuation is not as rapid in women[78-80]. It also means that, in theory, the intervals between women’s intramuscular depot AP injections can be longer than those in men, but the sex-specific spacing of AP depot drugs has not yet been researched.

Another reason why AP drug doses can generally be lower in women than in men is because many women take more concomitant drugs than men do, notably antidepressants, mood stabilizers, analgesics, and contraceptives or hormone replacements, all of which can interact with and influence the blood level of AP medication[78,81].

An important aspect of pharmacotherapy for women is that levels of female hormones change over the course of a monthly cycle and also over reproductive phases such as pregnancy, lactation, and menopause. This affects the dosage requirement of AP medication, i.e., there will be a need for higher doses during low estrogen phases[47-50,82,83]. Adjunctive estrogen or selective estrogen receptor modulators can make treatment more effective and can reduce AP doses and, thus, help to prevent side effects. This applies to both sexes, but is especially applicable to women[84-90].

Besides pharmacotherapy, other aspects of schizophrenia treatment need to be differentiated according to the patient’s gender, e.g., substance abuse treatment, cancer screening (breast, prostate, cervix)[91-96], interventions for sexual dysfunction[97-99], contraceptive prescribing[12], treatment of comorbidities (osteoporosis and cardiovascular care for instance[100,101]), safeguards against domestic abuse and victimization[102-108], screening for proclivity to violence[109], provision of parenting support and child custody issues[110-112].

DRUG SIDE EFFECTS

Effective treatment means the removal of symptoms and improvement of function; ideally, it also means freedom from adverse side effects. Side effects cause distress, stop patients from regularly taking the medicines they need, and often cause serious harm to health, perhaps even contributing to the high mortality rate among individuals with schizophrenia[113]. Unfortunately, AP medications have many side effects[114] and on average, women suffer more negative effects than men[115,116]. Women may be more vulnerable than men to adverse drug reactions because the doses recommended when a drug goes on the market are calculated on the basis of a 70 kg man.

There are well-known gender differences in drug reactions. In a recent study of over a thousand patients with psychosis, twice as many women as men described their side effect burden as severe. In this study[117], the effects that women complained of (more than men) included: Concentration difficulties, sedation, blurred vision, nausea, constipation, dizziness on rising, heart palpitations, pruritus, photosensitivity, increased pigmentation, weight change, galactorrhoea and headache.

Women have unique risk factors for some adverse effects of APs, such as Torsade de Pointes[118], which is a form of ventricular tachycardia that occurs in patients whose QT interval is relatively long. The QT interval is a measure of the time between the start of the Q wave and the end of the T wave on the electrocardiogram; it is the time it takes for the heart to come back to normal after depolarization, which, on average, is longer in postpubertal women than it is in men. For this reason, two-thirds of Torsade de Pointes occur in women[118]. That being said, more men with schizophrenia than women die of heart disease. Much remains unknown about gender differences in cardiovascular function and cardiac response to therapeutic drugs.

The hypercoagulability state induced by APs raises the risk for venous thromboembolism, pulmonary embolism, and cerebrovascular accident. The use of oral contraceptives, as well as hormone replacement therapies, pregnancy, the immediate postpartum state, and obstetrical complications are all risk factors for these complications[119]. There are many such factors, however, including ethnicity[120]. Despite the many contributing factors, pregnant women on APs have been shown to be at significantly higher risk for venous thromboembolism than pregnant women in the general population[121,122].

With respect to the potential for AP to heighten the risk of breast cancer via weight gain and prolactinemia, the jury is still out[94] on this important concern. What is known, however, is that the cancer death rate of women with schizophrenia is high relative to women in the general population[95], although this cannot be attributed to AP drugs. Many side effects of APs, e.g., weight gain, skin blemishes, and hair loss[123], negatively affect appearance (Table 1)[124]. Women are more sensitive to such effects than men are.

Table 1 Side effects of antipsychotics that negatively affect appearance[124].
Weight gain
Bad teeth
Hirsutism
Acne
Hair loss
Salivation
Slurred speech
Blepharospasm
Parkinsonian gait
Dyskinesias
Urinary incontinence

APs also have negative reproductive effects. They can disrupt menstrual cycles[125], interfere with a woman’s ability to conceive[126], increase the risk for gestational diabetes[127], increase the risk of premature labor[127] and, by entering breast milk, can make breastfeeding a risk for infants of mothers with schizophrenia[128]. The secondary effect of hyperprolactinemia can lead to hirsutism, amenorrhea, galactorrhea, pseudocyesis[129], and osteoporosis[125].

In addition, older women may be more susceptible than older men to tardive dyskinesia (TD)[114]. It is known that TD prevalence is influenced not only by age and sex, but also by many confounding factors, such as individual genetics[130], the specific AP used, its dose, treatment duration, alcohol, tobacco, and marijuana usage, ethnicity, the precise definition of TD, the rating scale used to assess TD, the predominant symptoms (positive or negative) and the presence or absence of prior brain damage. Because estrogen modulates dopamine-mediated behaviors and protects against oxidative stress-induced cell damage caused by long-term exposure to AP medication, one hypothesis is that when all the confounding factors are controlled, TD prevalence is equal in women and men prior to menopause and becomes subsequently higher in women[131].

Because of sex differences in immunity, women are also more susceptible to the agranulocytosis inducible by clozapine[132]. In general, older individuals, men as well as women, are at relatively increased risk of adverse effects of all drugs[133].

VOCATIONAL AND AVOCATIONAL OPPORTUNITIES

Women with schizophrenia want meaning in their lives, as do men. Meaning comes in several forms: hope in the future, the belief that one is needed, interest in what one is doing, earning money, engaging in artistic endeavors, pursuing a goal. In our study of clinic members with longstanding schizophrenia, more women than men were working outside the home[134], probably because “women’s” jobs were more plentiful at the time in our region. Job availability always depends on time, place, and economic conditions. When homeless, or living in room and board homes or with parents, the housewife role is not readily available to women with schizophrenia. Many prefer self-employment opportunities[135] and appreciate assistance in the form of supported employment, individual placement, and job buddies. They welcome opportunities to learn, to volunteer and to be of help to others. Like men, women need creative channels to enable self-expression as they seek ways to be meaningfully occupied[136].

FREEDOM FROM STIGMA

Stigma (being devalued and discriminated against, with consequent loss of self-respect) is a significant problem in schizophrenia[137]. The diagnostic label of schizophrenia is itself frightening to many people, conjuring up fears of dangerousness, unprovoked and uncontrollable violence, irrationality, and incurability. The population at large does not always appreciate the fact that those who suffer from schizophrenia, and this is especially true for women, are more often victims than perpetrators of violence[138]. Different studies have used different definitions of both violence and of victimization, making these terms difficult to quantify across studies. Within a one-year period, it has been estimated that between 11% and 52% of persons with serious mental illness (SMI) exhibit violence at a 2-8 higher rate than that found in the general population[139]. The same study found rates of victimization in persons with SMI to be between 20% and 42%, 23 times that of the general population. Perpetration of violence and victimization are risk factors for each other and often overlap in the same person. Interestingly, Desmarais et al[139] reported higher rates of perpetration of violence among women with SMI than among men. They speculate that this is due to the fact that violence in this population most often occurs in the context of close relatives, and women with SMI are more likely than men to be living with family; consequently, they have more opportunity to vent their rage at domestic targets such as husbands and parents.

Women with schizophrenia are too often victims of sexual exploitation, domestic abuse, and random violence[106-108]. Risk factors are age, place of residence, and degree of psychopathology, in addition to personality and behavioral factors[140]. The factors that contribute to the perpetration of violence have been described by the same research team as substance abuse, young age, homelessness, unemployment, low educational attainment, low socioeconomic status, membership in an ethnic minority, past hospitalization for psychosis, past conviction for violent crime, personality factors, and residence in disorganized neighborhoods[140]. These are risk factors for both women and men, but they occur more frequently in men.

In general, schizophrenia is a heavily stigmatized illness, men perhaps suffering more than women because of the perception that they are prone to act out violently and indiscriminately. Women, however, suffer from a specific form of stigma - the frequent conviction of health workers that individuals with schizophrenia should not bear children, and, in the event of pregnancy, should seek abortion. Women with this illness are widely considered incapable of being good mothers, making prenatal care more problematic, as women fear disclosing that they are pregnant, afraid that their infants will be apprehended at birth[141,142]. Healthcare professionals may not be aware of their own discriminatory attitudes, often communicated inadvertently by words and gestures[143]. Finding effective ways of combating biased attitudes both in oneself and in others is a critical issue for all care providers treating patients with stigmatized illnesses.

RELIEF FROM THOUGHTS OF SELF-HARM AND SUICIDE

In the context of schizophrenia, triggers for male suicidal activity (ideation, attempts, and completed suicide) have been described as being: (1) psychotic symptoms and (2) the prospect of chronic disability, while triggers for suicidal activity in women have been mainly attributed to depression. Male suicides in this population decline with age, whereas this is not the case for women. In a longitudinal study, a 10.5% rate of suicide in the first two years after hospital discharge in men dropped to 0% twenty years later, while women’s rate of suicide (6%) was spread more evenly over the twenty years[144].

Suicide in women with schizophrenia is not as rare (relative to men) as it is in the general population[145]. The clinical implications are that both depression and substance abuse need to be vigorously treated in patients with schizophrenia because both contribute to impulsive acts of self-harm. In treatment settings, suicidal ideas are often “contagious”[146], with one completed suicide sometimes sparking a series of further self-harm attempts[147]. The index of suspicion needs to be high and suicidal ideation needs to be taken seriously[148].

PHYSICAL HEALTH

The life expectancy of individuals with schizophrenia is significantly shorter than that of the general population, with 90% of deaths attributable to physical illness. The assumption is that early mortality in schizophrenia is secondary, if not to suicide, then to lifestyle factors such as heavy smoking, alcohol abuse, and lack of physical activity[149-151]. More recently, a new understanding of the brain-gut connection[152] has implicated nutritional factors. In addition, there is the probability of shared susceptibility genes between schizophrenia and physical diseases that can decrease health-related quality of life and hasten death, auto-immune disease (e.g., Crohn’s disease, multiple sclerosis, systemic lupus erythematosus, type 1 diabetes, and ulcerative colitis) being one such category of illness[153].

Social precipitants of early death are critical in this population: Poverty[154], homelessness[155], social isolation[156], poor hygiene[157], malnourishment[158], exposure to toxic substances[159] and adverse treatment effects[114]. High mortality from diabetes, cardiovascular disease and malignancies can, in part, be due to a relative lack of screening, delays in diagnosis, and suboptimal treatment[94,95,160-162]. Javatilleke et al[163] conclude their list of causes of lost life expectancy in severe mental illness by pointing out that the range of causes is very broad, with many putative causes varying according to gender.

REPRODUCTIVE HEALTH

Reproductive health includes sexual health (libido, sexual function, the ability to establish and maintain sexual relationships)[99,164,165], menstrual health[47,125,166], the preservation of fertility[167,168], contraception[12], prenatal care[122], pregnancy[18,169], postpartum care[170] and lactation support[171], parenting support and training groups, home visiting, peer support, respite care[111,112,172,173], and menopausal care[49,50,83,174].

Clinicians may not realize that during pregnancy, physiological changes such as delay in gastric emptying and increase in gastric pH prolong the time it takes for AP drugs to reach peak levels. Increased cardiac output steps up blood flow to the liver and may boost the speed of drug elimination. There is an overall increase in body water, which only affects hydrophilic drugs such as lithium, and there is also an increase in the lipid compartment, which provides extra storage space for lipophilic drugs (including APs). The blood flow to the kidneys is increased, as is the glomerular filtration rate, which means a greater degree of renal clearance. The plasma albumin concentration is reduced so that more free drug is available to the brain. Enzyme activity is affected by the increase in pregnancy hormones; some enzymes are affected more than others. For most APs, the net serum concentration in the third trimester is significantly decreased from what it was at the beginning of pregnancy. The exceptions are olanzapine and clozapine, both of which are inactivated by Cytochrome P450 enzyme 1A2, whose activity decreases during the 2nd and 3rd trimester of pregnancy because of rising estrogen levels. This enzyme is also highly inducible by smoking and, since women tend to reduce their cigarette smoking during pregnancy, the activity of this enzyme is further reduced. Therefore, the serum levels of olanzapine and clozapine rise during pregnancy[175-177].

FURTHER AREAS OF CONCERN

There are other areas of concern to women with schizophrenia. Some of these are the availability of crisis support[178], the achievement of nightmare-free restorative sleep[179-182], the safety of treatment settings[104,183], the safety and affordability of housing[184], access to skills training in new technologies[185] and assistance with existential concerns[186,187]. Whereas existential issues such as free will, personal identity, fears for the future, contemplation of mortality, justice concerns, finding meaning in life, and relating to others are all similar in men and women, as women age, they express more security fears, while aging men are more likely to report not being valued and fearing that they are a burden to others. Physical appearance may be more central to identity for women than for men[188] (Table 2).

Table 2 Existential concerns[179,180].
Meaning
Fear
Justice
Mortality
Identity
Relatedness
Freedom of choice
FUTURE DIRECTIONS

Many of the issues that are critical to the care provision of women diagnosed with schizophrenia stem from a failure to recognize male/female differences in this illness. Sex differences are based in dimorphic brain structure and function, particularly evident in the dopaminergic system that is so crucial to the development of schizophrenia[189]. They are driven by sex hormones, but also depend, to an extent not yet fully understood, on non-gonadal functions of the X and Y chromosomes because genes on sex chromosomes influence brain development disproportionally to their relatively small number. The number of sex chromosomes, X chromosome inactivation patterns, X-linked imprinting effects, and the indirect effects of sex chromosomes on the expression of autosomal genes all contribute to sex differences in neuropsychiatric disease[190].

Future research into sex differences in brain disorders such as schizophrenia will benefit from a fuller understanding of the causes of sex differences and their effects not only on brain and behavior but also on metabolic, cardiovascular, inflammatory and immune parameters. The field also needs to better understand the timing of the emergence of sex differences. Longitudinal studies that track developmental processes over time are needed. The effect of puberty with its influx of sex-specific hormones on brain maturation needs to be better understood. Biological sex differences need to be disentangled from environmental influences, an important issue for all psychiatric diseases. Sex differences in the brain, whether innate or secondary to exposure and learning, confer differential risk or resilience that fosters or inhibits the expression of specific symptoms, psychiatric diagnoses, and their outcomes.

Footnotes

Manuscript source: Unsolicited manuscript

Specialty type: Psychiatry

Country of origin: Canada

Peer-review report classification

Grade A (Excellent): A, A

Grade B (Very good): 0

Grade C (Good): 0

Grade D (Fair): D

Grade E (Poor): 0

P- Reviewer: Hicks PB, Rajkowska G, Sobanski T S- Editor: Ji FF L- Editor: Filipodia E- Editor: Wu YXJ

References
1.  Murray RM, Lewis SW, Reveley AM. Towards an aetiological classification of schizophrenia. Lancet. 1985;1:1023-1026.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 196]  [Cited by in F6Publishing: 203]  [Article Influence: 5.2]  [Reference Citation Analysis (0)]
2.  Lu Y, Pouget JG, Andreassen OA, Djurovic S, Esko T, Hultman CM, Metspalu A, Milani L, Werge T, Sullivan PF. Genetic risk scores and family history as predictors of schizophrenia in Nordic registers. Psychol Med. 2018;48:1201-1208.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 23]  [Cited by in F6Publishing: 21]  [Article Influence: 3.8]  [Reference Citation Analysis (0)]
3.  Sander JD, Joung JK. CRISPR-Cas systems for editing, regulating and targeting genomes. Nat Biotechnol. 2014;32:347-355.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2175]  [Cited by in F6Publishing: 2244]  [Article Influence: 241.7]  [Reference Citation Analysis (0)]
4.  Brokowski C, Pollack M, Pollack R. Cutting eugenics out of CRISPR-Cas9. Ethics Biol Eng Med. 2015;6:263-279.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 9]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
5.  Sugarman J. Ethics and germline gene editing. EMBO Rep. 2015;16:879-880.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 36]  [Cited by in F6Publishing: 38]  [Article Influence: 4.5]  [Reference Citation Analysis (0)]
6.  Bergen SE, O’Dushlaine CT, Lee PH, Fanous AH, Ruderfer DM, Ripke S; International Schizophrenia Consortium, Swedish Schizophrenia Consortium, Sullivan PF, Smoller JW, Purcell SM, Corvin A. Genetic modifiers and subtypes in schizophrenia: investigations of age at onset, severity, sex and family history. Schizophr Res. 2014;154:48-53.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 44]  [Cited by in F6Publishing: 56]  [Article Influence: 4.9]  [Reference Citation Analysis (0)]
7.  Goldstein JM, Cherkerzian S, Tsuang MT, Petryshen TL. Sex differences in the genetic risk for schizophrenia: history of the evidence for sex-specific and sex-dependent effects. Am J Med Genet B Neuropsychiatr Genet. 2013;162B:698-710.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 67]  [Cited by in F6Publishing: 72]  [Article Influence: 7.4]  [Reference Citation Analysis (0)]
8.  Magi R, Lindgren CM, Morris AP. Meta-analysis of sex-specific genome-wide association studies. Genet Epidemiol. 2010;34:846-853.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 75]  [Cited by in F6Publishing: 75]  [Article Influence: 6.3]  [Reference Citation Analysis (0)]
9.  Kundakovic M. Sex-specific epigenetics: Implications for environmental studies of brain and behavior. Curr Environ Health Rep. 2017;4:385-391.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 10]  [Cited by in F6Publishing: 9]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
10.  Ratnu VS, Emami MR, Bredy TW. Genetic and epigenetic factors underlying sex differences in the regulation of gene expression in the brain. J Neurosci Res. 2017;95:301-310.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 78]  [Cited by in F6Publishing: 80]  [Article Influence: 13.0]  [Reference Citation Analysis (0)]
11.  Costain G, Bassett AS. Clinical applications of schizophrenia genetics: genetic diagnosis, risk, and counseling in the molecular era. Appl Clin Genet. 2012;5:1-18.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 27]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
12.  Seeman MV, Ross R. Prescribing contraceptives for women with schizophrenia. J Psychiatr Pract. 2011;17:258-269.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 37]  [Cited by in F6Publishing: 26]  [Article Influence: 3.4]  [Reference Citation Analysis (0)]
13.  Frans E, MacCabe JH, Reichenberg A. Advancing paternal age and psychiatric disorders. World Psychiatry. 2015;14:91-93.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 14]  [Cited by in F6Publishing: 14]  [Article Influence: 1.8]  [Reference Citation Analysis (0)]
14.  Escott-Price V, Smith DJ, Kendall K, Ward J, Kirov G, Owen MJ, Walters J, O’Donovan MC. Polygenic risk for schizophrenia and season of birth within the UK Biobank cohort. Psychol Med. 2018;1-6.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 17]  [Cited by in F6Publishing: 18]  [Article Influence: 3.4]  [Reference Citation Analysis (0)]
15.  Hollis BW, Johnson D, Hulsey TC, Ebeling M, Wagner CL. Vitamin D supplementation during pregnancy: double-blind, randomized clinical trial of safety and effectiveness. J Bone Miner Res. 2011;26:2341-2357.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 497]  [Cited by in F6Publishing: 537]  [Article Influence: 45.2]  [Reference Citation Analysis (0)]
16.  Seeman MV, Cohen R. A service for women with schizophrenia. Psychiatr Serv. 1998;49:674-677.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 28]  [Cited by in F6Publishing: 29]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
17.  Seeman MV. Prevention inherent in services for women with schizophrenia. Can J Psychiatry. 2008;53:332-341.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 16]  [Cited by in F6Publishing: 16]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
18.  Seeman MV. Clinical interventions for women with schizophrenia: pregnancy. Acta Psychiatr Scand. 2013;127:12-22.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 53]  [Cited by in F6Publishing: 55]  [Article Influence: 5.3]  [Reference Citation Analysis (0)]
19.  Brown AS, Patterson PH. Maternal infection and schizophrenia: implications for prevention. Schizophr Bull. 2011;37:284-290.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 140]  [Cited by in F6Publishing: 155]  [Article Influence: 10.8]  [Reference Citation Analysis (0)]
20.  Meyer U. Developmental neuroinflammation and schizophrenia. Prog Neuropsychopharmacol Biol Psychiatry. 2013;42:20-34.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 200]  [Cited by in F6Publishing: 214]  [Article Influence: 16.7]  [Reference Citation Analysis (0)]
21.  Solek CM, Farooqi N, Verly M, Lim TK, Ruthazer ES. Maternal immune activation in neurodevelopmental disorders. Dev Dyn. 2018;247:588-619.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 72]  [Cited by in F6Publishing: 75]  [Article Influence: 12.0]  [Reference Citation Analysis (0)]
22.  Brown AS, Susser ES. Prenatal nutritional deficiency and risk of adult schizophrenia. Schizophr Bull. 2008;34:1054-1063.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 202]  [Cited by in F6Publishing: 209]  [Article Influence: 13.5]  [Reference Citation Analysis (0)]
23.  Jablensky AV, Morgan V, Zubrick SR, Bower C, Yellachich LA. Pregnancy, delivery, and neonatal complications in a population cohort of women with schizophrenia and major affective disorders. Am J Psychiatry. 2005;162:79-91.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 331]  [Cited by in F6Publishing: 343]  [Article Influence: 18.4]  [Reference Citation Analysis (0)]
24.  van Os J, Selten JP. Prenatal exposure to maternal stress and subsequent schizophrenia. The May 1940 invasion of The Netherlands. Br J Psychiatry. 1998;172:324-326.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 345]  [Cited by in F6Publishing: 374]  [Article Influence: 13.8]  [Reference Citation Analysis (0)]
25.  Müller N. Inflammation in schizophrenia: Pathogenic aspects and therapeutic considerations. Schizophr Bull. 2018;44:973-982.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 240]  [Cited by in F6Publishing: 254]  [Article Influence: 60.0]  [Reference Citation Analysis (0)]
26.  Belbasis L, Köhler CA, Stefanis N, Stubbs B, van Os J, Vieta E, Seeman MV, Arango C, Carvalho AF, Evangelou E. Risk factors and peripheral biomarkers for schizophrenia spectrum disorders: an umbrella review of meta-analyses. Acta Psychiatr Scand. 2018;137:88-97.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 83]  [Cited by in F6Publishing: 88]  [Article Influence: 16.6]  [Reference Citation Analysis (0)]
27.  Buoli M, Bertino V, Caldiroli A, Dobrea C, Serati M, Ciappolino V, Altamura AC. Are obstetrical complications really involved in the etiology and course of schizophrenia and mood disorders? Psychiatry Res. 2016;241:297-301.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 20]  [Cited by in F6Publishing: 20]  [Article Influence: 2.9]  [Reference Citation Analysis (0)]
28.  Abajobir AA, Kisely S, Scott JG, Williams G, Clavarino A, Strathearn L, Najman JM. Childhood maltreatment and young adulthood hallucinations, delusional experiences, and psychosis: A longitudinal study. Schizophr Bull. 2017;43:1045-1055.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 30]  [Cited by in F6Publishing: 30]  [Article Influence: 6.0]  [Reference Citation Analysis (0)]
29.  Morgan C, Fisher H. Environment and schizophrenia: environmental factors in schizophrenia: childhood trauma--a critical review. Schizophr Bull. 2007;33:3-10.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 378]  [Cited by in F6Publishing: 393]  [Article Influence: 22.2]  [Reference Citation Analysis (0)]
30.  Alegría M, Álvarez K, DiMarzio K. Immigration and mental health. Curr Epidemiol Rep. 2017;4:145-155.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 107]  [Cited by in F6Publishing: 86]  [Article Influence: 17.8]  [Reference Citation Analysis (0)]
31.  Hogerzeil SJ, van Hemert AM, Veling W, Hoek HW. Incidence of schizophrenia among migrants in the Netherlands: a direct comparison of first contact and longitudinal register approaches. Soc Psychiatry Psychiatr Epidemiol. 2017;52:147-154.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 10]  [Article Influence: 1.7]  [Reference Citation Analysis (0)]
32.  DeVylder JE, Kelleher I, Lalane M, Oh H, Link BG, Koyanagi A. Association of urbanicity with psychosis in low-andmiddle-inclome countries. JAMA Psychiatry. 2018;75:678-686.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 72]  [Cited by in F6Publishing: 100]  [Article Influence: 18.0]  [Reference Citation Analysis (0)]
33.  Plana-Ripoll O, Pedersen CB, McGrath JJ. Urbanicity and risk of schizophrenia - new studies and old hypotheses. JAMA Psychiatry. 2018;75:687-688.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 10]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
34.  Nielsen SM, Toftdahl NG, Nordentoft M, Hjorthøj C. Association between alcohol, cannabis, and other illicit substance abuse and risk of developing schizophrenia: a nationwide population based register study. Psychol Med. 2017;47:1668-1677.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 47]  [Cited by in F6Publishing: 49]  [Article Influence: 7.8]  [Reference Citation Analysis (0)]
35.  Lincoln TM, Sundag J, Schlier B, Karow A. The relevance of emotion regulation in explaining why social exclusion triggers paranoia in individuals at clinical high risk of psychosis. Schizophr Bull. 2018;44:757-767.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 30]  [Cited by in F6Publishing: 31]  [Article Influence: 7.5]  [Reference Citation Analysis (0)]
36.  Selten JP, Booij J, Buwalda B, Meyer-Lindenberg A. Biological mechanisms whereby social exclusion may contribute to the etiology of psychosis: A narrative review. Schizophr Bull 2017. 43:287-292.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9]  [Cited by in F6Publishing: 21]  [Article Influence: 1.5]  [Reference Citation Analysis (0)]
37.  McGrath J, Saha S, Chant D, Welham J. Schizophrenia: a concise overview of incidence, prevalence, and mortality. Epidemiol Rev. 2008;30:67-76.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 1256]  [Cited by in F6Publishing: 1328]  [Article Influence: 83.7]  [Reference Citation Analysis (0)]
38.  Agius M, Hockings H, Wilson C, Lane D. Is oestrogen neuroprotective? Psychiatr Danub. 2009;21 Suppl 1:120-127.  [PubMed]  [DOI]  [Cited in This Article: ]
39.  Brann DW, Dhandapani K, Wakade C, Mahesh VB, Khan MM. Neurotrophic and neuroprotective actions of estrogen: basic mechanisms and clinical implications. Steroids. 2007;72:381-405.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 375]  [Cited by in F6Publishing: 363]  [Article Influence: 23.4]  [Reference Citation Analysis (0)]
40.  Jones I, Chandra PS, Dazzan P, Howard LM. Bipolar disorder, affective psychosis, and schizophrenia in pregnancy and the post-partum period. Lancet. 2014;384:1789-1799.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 309]  [Cited by in F6Publishing: 372]  [Article Influence: 34.3]  [Reference Citation Analysis (0)]
41.  Cohen RZ, Seeman MV, Gotowiec A, Kopala L. Earlier puberty as a predictor of later onset of schizophrenia in women. Am J Psychiatry. 1999;156:1059-1064.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 4]  [Cited by in F6Publishing: 25]  [Article Influence: 0.2]  [Reference Citation Analysis (0)]
42.  Kiliçaslan EE, Erol A, Zengin B, Çetinay Aydin P, Mete L. Association between age at onset of schizophrenia and age at menarche. Noro Psikiyatr Ars. 2014;51:211-215.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3]  [Cited by in F6Publishing: 4]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
43.  Ullsperger JM, Nikolas MA. A meta-analytic review of the association between pubertal timing and psychopathology in adolescence: Are there sex differences in risk? Psychol Bull. 2017;143:903-938.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 93]  [Cited by in F6Publishing: 99]  [Article Influence: 15.5]  [Reference Citation Analysis (0)]
44.  Ruiz A, Blanco R, Santander J, Miranda E. Relationship between sex differences in onset of schizophrenia and puberty. J Psychiatr Res. 2000;34:349-353.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 13]  [Cited by in F6Publishing: 14]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
45.  Nwankwo M, Danborno B, Hamman WO. Relationship between body mass index and timing of maturation. J Exp Clin Anat. 2015;14:95-100.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 4]  [Cited by in F6Publishing: 4]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]
46.  Hallonquist JD, Seeman MV, Lang M, Rector NA. Variation in symptom severity over the menstrual cycle of schizophrenics. Biol Psychiatry. 1993;33:207-209.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 102]  [Cited by in F6Publishing: 103]  [Article Influence: 3.4]  [Reference Citation Analysis (0)]
47.  Seeman MV. Menstrual exacerbation of schizophrenia symptoms. Acta Psychiatr Scand. 2012;125:363-371.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 34]  [Cited by in F6Publishing: 36]  [Article Influence: 3.1]  [Reference Citation Analysis (0)]
48.  Seeman MV, Gupta R. Selective review of age-related needs of women with schizophrenia. Clin Schizophr Relat Psychoses. 2015;9:21-29.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 6]  [Cited by in F6Publishing: 6]  [Article Influence: 0.9]  [Reference Citation Analysis (0)]
49.  Brzezinski A, Brzezinski-Sinai NA, Seeman MV. Treating schizophrenia during menopause. Menopause. 2017;24:582-588.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 24]  [Cited by in F6Publishing: 25]  [Article Influence: 4.8]  [Reference Citation Analysis (0)]
50.  Seeman MV. Treating schizophrenia at the time of menopause. Maturitas. 2012;72:117-120.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 28]  [Cited by in F6Publishing: 20]  [Article Influence: 2.5]  [Reference Citation Analysis (0)]
51.  Chandra PS. Post-ovariectomy and oestrogen therapy related recurrence of oestrogen withdrawal associated psychosis. Acta Psychiatr Scand. 2002;106:76; author reply 76-76; author reply 77.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9]  [Cited by in F6Publishing: 10]  [Article Influence: 0.4]  [Reference Citation Analysis (0)]
52.  Moffitt O, Findley JC. A case of first-onset psychosis and repeated relapses secondary to discontinuation of non-prescription estrogen replacement therapy in a transgendered female. Gynecol Endocrinol. 2016;32:796-798.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 3]  [Cited by in F6Publishing: 2]  [Article Influence: 0.4]  [Reference Citation Analysis (0)]
53.  Seeman MV. Transient psychosis in women on clomiphene, bromocriptine, domperidone and related endocrine drugs. Gynecol Endocrinol. 2015;31:751-754.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 13]  [Cited by in F6Publishing: 13]  [Article Influence: 1.6]  [Reference Citation Analysis (0)]
54.  Holka-Pokorska J, Piróg-Balcerzak A, Stefanowicz A. [“Mid-stimulation psychosis” in the course of in vitro fertilization procedure with the use of clomiphene citrate and bromocriptine - case study]. Psychiatr Pol. 2014;48:901-916.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 8]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
55.  Grigoriadis S, Seeman MV. The role of estrogen in schizophrenia: implications for schizophrenia practice guidelines for women. Can J Psychiatry. 2002;47:437-442.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 93]  [Cited by in F6Publishing: 96]  [Article Influence: 4.7]  [Reference Citation Analysis (0)]
56.  Mendrek A, Stip E. Sexual dimorphism in schizophrenia: is there a need for gender-based protocols? Expert Rev Neurother. 2011;11:951-959.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 46]  [Cited by in F6Publishing: 48]  [Article Influence: 3.8]  [Reference Citation Analysis (0)]
57.  Millan MJ, Andrieux A, Bartzokis G, Cadenhead K, Dazzan P, Fusar-Poli P, Gallinat J, Giedd J, Grayson DR, Heinrichs M. Altering the course of schizophrenia: progress and perspectives. Nat Rev Drug Discov. 2016;15:485-515.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 314]  [Cited by in F6Publishing: 324]  [Article Influence: 44.9]  [Reference Citation Analysis (0)]
58.  Cohen RZ, Gotowiec A, Seeman MV. Duration of pretreatment phases in schizophrenia: women and men. Can J Psychiatry. 2000;45:544-547.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 17]  [Cited by in F6Publishing: 16]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
59.  Ran MS, Mao WJ, Chan CL, Chen EY, Conwell Y. Gender differences in outcomes in people with schizophrenia in rural China: 14-year follow-up study. Br J Psychiatry. 2015;206:283-288.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 36]  [Cited by in F6Publishing: 40]  [Article Influence: 4.5]  [Reference Citation Analysis (0)]
60.  Seeman MV. Current outcome in schizophrenia: women vs men. Acta Psychiatr Scand. 1986;73:609-617.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 137]  [Cited by in F6Publishing: 142]  [Article Influence: 3.7]  [Reference Citation Analysis (0)]
61.  Childers SE, Harding CM. Gender, premorbid social functioning, and long-term outcome in DSM-III schizophrenia. Schizophr Bull. 1990;16:309-318.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 89]  [Cited by in F6Publishing: 91]  [Article Influence: 2.7]  [Reference Citation Analysis (0)]
62.  Hanlon MC, Campbell LE, Single N, Coleman C, Morgan VA, Cotton SM, Stain HJ, Castle DJ. Men and women with psychosis and the impact of illness-duration on sex-differences: The second Australian national survey of psychosis. Psychiatry Res. 2017;256:130-143.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9]  [Cited by in F6Publishing: 8]  [Article Influence: 1.5]  [Reference Citation Analysis (0)]
63.  Remington G, Seeman MV. Schizophrenia and the influence of male gender. Clin Pharmacol Ther. 2015;98:578-581.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9]  [Cited by in F6Publishing: 9]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
64.  Heitz U, Studerus E, Menghini-Müller S, Papmeyer M, Egloff L, Ittig S, Navarra A, Andreou C, Riecher-Rössler A. Gender differences in first self-perceived signs and symptoms in patients with an at-risk mental state and first-episode psychosis. Early Interv Psychiatry. 2017;.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 14]  [Cited by in F6Publishing: 14]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]
65.  Seeman MV. Gendering psychosis: the illness of Zelda Fitzgerald. Med Humanit. 2016;42:65-69.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 8]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
66.  Thorup A, Petersen L, Jeppesen P, Ohlenschlaeger J, Christensen T, Krarup G, Jorgensen P, Nordentoft M. Gender differences in young adults with first-episode schizophrenia spectrum disorders at baseline in the Danish OPUS study. J Nerv Ment Dis. 2007;195:396-405.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 134]  [Cited by in F6Publishing: 145]  [Article Influence: 8.4]  [Reference Citation Analysis (0)]
67.  Fiorentini A, Volonteri LS, Dragogna F, Rovera C, Maffini M, Mauri MC, Altamura CA. Substance-induced psychoses: a critical review of the literature. Curr Drug Abuse Rev. 2011;4:228-240.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 59]  [Cited by in F6Publishing: 61]  [Article Influence: 5.4]  [Reference Citation Analysis (0)]
68.  Seeman MV. All psychosis is not schizophrenia, especially not in women. Clin Schizophr Related Psychoses. 2007;1:77-82.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 2]  [Article Influence: 0.1]  [Reference Citation Analysis (0)]
69.  Seeman MV. Psychosis in women: Consider midlife medical and psychological triggers. Curr Psychiatry. 2010;9:64-68, 75-76.  [PubMed]  [DOI]  [Cited in This Article: ]
70.  Anderson JE, Larke SC. Navigating the mental health and addictions maze: a community-based pilot project of a new role in primary mental health care. Ment Health Fam Med. 2009;6:15-19.  [PubMed]  [DOI]  [Cited in This Article: ]
71.  Crawford MB, DeLisi LE. Issues related to sex differences in antipsychotic treatment. Curr Opin Psychiatry. 2016;29:211-217.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 36]  [Cited by in F6Publishing: 38]  [Article Influence: 5.1]  [Reference Citation Analysis (0)]
72.  Lange B, Mueller JK, Leweke FM, Bumb JM. How gender affects the pharmacotherapeutic approach to treating psychosis - a systematic review. Expert Opin Pharmacother. 2017;18:351-362.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 33]  [Cited by in F6Publishing: 30]  [Article Influence: 5.5]  [Reference Citation Analysis (0)]
73.  Rabinowitz J, Werbeloff N, Caers I, Mandel FS, Stauffer V, Ménard F, Kinon BJ, Kapur S. Determinants of antipsychotic response in schizophrenia: implications for practice and future clinical trials. J Clin Psychiatry. 2014;75:e308-e316.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 42]  [Cited by in F6Publishing: 36]  [Article Influence: 4.7]  [Reference Citation Analysis (0)]
74.  Seeman MV. Gender differences in the prescribing of antipsychotic drugs. Am J Psychiatry. 2004;161:1324-1333.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 141]  [Cited by in F6Publishing: 148]  [Article Influence: 7.4]  [Reference Citation Analysis (0)]
75.  Seeman MV. Gender differences in schizophrenia. Can J Psychiatry. 1982;27:107-112.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 120]  [Cited by in F6Publishing: 122]  [Article Influence: 2.9]  [Reference Citation Analysis (0)]
76.  Gur RE, Gur RC. Gender differences in regional cerebral blood flow. Schizophr Bull. 1990;16:247-254.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 80]  [Cited by in F6Publishing: 80]  [Article Influence: 2.4]  [Reference Citation Analysis (0)]
77.  Gordon JH, Gorski RA, Borison RL, Diamond BI. Postsynaptic efficacy of dopamine: possible suppression by estrogen. Pharmacol Biochem Behav. 1980;12:515-518.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 56]  [Cited by in F6Publishing: 56]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
78.  Franconi F, Campesi I. Pharmacogenomics, pharmacokinetics and pharmacodynamics: interaction with biological differences between men and women. Br J Pharmacol. 2014;171:580-594.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 138]  [Cited by in F6Publishing: 143]  [Article Influence: 15.3]  [Reference Citation Analysis (0)]
79.  Seeman MV. Women and psychosis. Womens Health (Lond). 2012;8:215-224.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 14]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
80.  Smith S. Gender differences in antipsychotic prescribing. Int Rev Psychiatry. 2010;22:472-484.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 46]  [Cited by in F6Publishing: 48]  [Article Influence: 3.8]  [Reference Citation Analysis (0)]
81.  Marazziti D, Baroni S, Picchetti M, Piccinni A, Carlini M, Vatteroni E, Falaschi V, Lombardi A, Dell’Osso L. Pharmacokinetics and pharmacodynamics of psychotropic drugs: effect of sex. CNS Spectr. 2013;18:118-127.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 46]  [Cited by in F6Publishing: 49]  [Article Influence: 4.6]  [Reference Citation Analysis (0)]
82.  González-Rodríguez A, Catalán R, Penadés R, Ruiz Cortés V, Torra M, Seeman MV, Bernardo M. Antipsychotic response worsens with postmenopausal duration in women with schizophrenia. J Clin Psychopharmacol. 2016;36:580-587.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 29]  [Cited by in F6Publishing: 31]  [Article Influence: 4.8]  [Reference Citation Analysis (0)]
83.  González-Rodríguez A, Seeman MV. Pharmacotherapy for schizophrenia in postmenopausal women. Expert Opin Pharmacother. 2018;19:809-821.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 20]  [Cited by in F6Publishing: 15]  [Article Influence: 4.0]  [Reference Citation Analysis (0)]
84.  Kulkarni J, Gavrilidis E, Worsley R, Hayes E. Role of estrogen treatment in the management of schizophrenia. CNS Drugs. 2012;26:549-557.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 36]  [Cited by in F6Publishing: 37]  [Article Influence: 3.3]  [Reference Citation Analysis (0)]
85.  Kulkarni J, Gavrilidis E, Worsley R, Van Rheenen T, Hayes E. The role of estrogen in the treatment of men with schizophrenia. Int J Endocrinol Metab. 2013;11:129-136.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 34]  [Cited by in F6Publishing: 35]  [Article Influence: 3.4]  [Reference Citation Analysis (0)]
86.  Labad J, Martorell L, Huerta-Ramos E, Cobo J, Vilella E, Rubio-Abadal E, Garcia-Pares G, Creus M, Núñez C, Ortega L. Pharmacogenetic study of the effects of raloxifene on negative symptoms of postmenopausal women with schizophrenia: A double-blind, randomized, placebo-controlled trial. Eur Neuropsychopharmacol. 2016;26:1683-1689.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 16]  [Cited by in F6Publishing: 18]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]
87.  Usall J, Huerta-Ramos E, Labad J, Cobo J, Núñez C, Creus M, Parés GG, Cuadras D, Franco J, Miquel E. Raloxifene as an adjunctive treatment for postmenopausal women with schizophrenia: A 24-week double-blind, randomized, parallel, placebo-controlled trial. Schizophr Bull. 2016;42:309-317.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 40]  [Cited by in F6Publishing: 42]  [Article Influence: 5.0]  [Reference Citation Analysis (0)]
88.  Weickert TW, Weickert CS. Raloxifene improves cognition in schizophrenia: Spurious result or valid effect? Front Psychiatry. 2017;8:202.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 13]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
89.  Weiser M, Levi L, Burshtein S, Hagin M, Matei VP, Podea D, Micluția I, Tiugan A, Păcală B, Grecu IG. Raloxifene plus antipsychotics versus placebo plus antipsychotics in severely ill decompensated postmenopausal women with schizophrenia or schizoaffective disorder: A randomized controlled trial. J Clin Psychiatry. 2017;78:e758-e765.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 31]  [Cited by in F6Publishing: 27]  [Article Influence: 5.2]  [Reference Citation Analysis (0)]
90.  Wong J, Seeman MV, Shapiro H. Case report: Raloxifene in postmenopausal women with psychosis: preliminary findings. Am J Geriatr Psychiatry. 2003;11:697-698.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 4]  [Cited by in F6Publishing: 7]  [Article Influence: 0.2]  [Reference Citation Analysis (0)]
91.  Caton CL, Xie H, Drake RE, McHugo G. Gender differences in psychotic disorders with concurrent substance use. J Dual Diagn. 2014;10:177-186.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 20]  [Cited by in F6Publishing: 18]  [Article Influence: 2.5]  [Reference Citation Analysis (0)]
92.  Martens PJ, Chochinov HM, Prior HJ, Fransoo R, Burland E; Need To Know Team. Are cervical cancer screening rates different for women with schizophrenia? A Manitoba population-based study. Schizophr Res. 2009;113:101-106.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 50]  [Cited by in F6Publishing: 50]  [Article Influence: 3.6]  [Reference Citation Analysis (0)]
93.  Seeman MV. Preventing breast cancer in women with schizophrenia. Acta Psychiatr Scand. 2011;123:107-117.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 15]  [Cited by in F6Publishing: 15]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
94.  Seeman MV. Breast cancer prevention and treatment in women with severe mental illness. Int J Womens Health Wellness. 2017;3:064.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 2]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
95.  Seeman MV. Schizophrenia and cancer: low incidence, high mortality. Res J Oncol. 2017;1:6.  [PubMed]  [DOI]  [Cited in This Article: ]
96.  Torrey EF. Prostate cancer and schizophrenia. Urology. 2006;68:1280-1283.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 25]  [Cited by in F6Publishing: 26]  [Article Influence: 1.5]  [Reference Citation Analysis (0)]
97.  Basson R, Gilks T. Women’s sexual dysfunction associated with psychiatric disorders and their treatment. Womens Health (Lond). 2018;14:1745506518762664.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 44]  [Cited by in F6Publishing: 54]  [Article Influence: 11.0]  [Reference Citation Analysis (0)]
98.  Seeman MV. Spotlight on sibling involvement in schizophrenia treatment. Psychiatry. 2013;76:311-322.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 14]  [Cited by in F6Publishing: 16]  [Article Influence: 1.6]  [Reference Citation Analysis (0)]
99.  Seeman MV, Benes C. Sexual problems in a women’s clinic for schizophrenia. Sexologies. 2000;34:12-15.  [PubMed]  [DOI]  [Cited in This Article: ]
100.  Cauley JA. Screening for Osteoporosis. JAMA. 2018;319:2483-2485.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 11]  [Cited by in F6Publishing: 11]  [Article Influence: 2.2]  [Reference Citation Analysis (0)]
101.  Hung OY, Titterington JS, Wenger NK. Evolving cardiovascular care for women: a decade of progress. Future Cardiol. 2015;11:275-279.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 2]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
102.  de Vries B, van Busschbach JT, van der Stouwe ECD, Aleman A, van Dijk JJM, Lysaker PH, Arends J, Nijman SA, Pijnenborg GHM. Prevalence rate and risk factors of victimization in adult patients with a psychotic disorder: A systematic review and meta-analysis. Schizophr Bull. 2018;.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 41]  [Cited by in F6Publishing: 43]  [Article Influence: 10.3]  [Reference Citation Analysis (0)]
103.  Kulkarni J, Galletly C. Improving safety for women in psychiatry wards. Aust N Z J Psychiatry. 2017;51:192-194.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 8]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
104.  Seeman MV. Single-sex psychiatric services to protect women. Medscape Womens Health. 2002;7:4.  [PubMed]  [DOI]  [Cited in This Article: ]
105.  Seeman MV. Bad, burdened or ill? Characterizing the spouses of women with schizophrenia. Int J Soc Psychiatry. 2013;59:805-810.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 7]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
106.  Seeman MV. Sexual exploitation of women with schizophrenia. Am Res J Addict Rehab. 2018;2:1-8.  [PubMed]  [DOI]  [Cited in This Article: ]
107.  Seeman MV. Sexual exploitation of a woman with schizophrenia. J Clin Cases. 2018;1:1-6.  [PubMed]  [DOI]  [Cited in This Article: ]
108.  Van Deinse TB, Macy RJ, Cuddeback GS, Allman AJ. Intimate partner violence and sexual assault among women with serious mental illness: A review of prevalence and risk factors. J Soc Work. 2018;146801731876642.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 10]  [Cited by in F6Publishing: 11]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
109.  Rund BR. The association between schizophrenia and violence. Schizophr Res. 2018;pii:S0920-9964(18)30123-3.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 13]  [Article Influence: 2.4]  [Reference Citation Analysis (0)]
110.  Lau AS. Making the case for selective and directed cultural adaptations of evidence-based treatments: examples from parent training. Clin Psychol Sci Pract. 2006;13:295-310.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 234]  [Cited by in F6Publishing: 240]  [Article Influence: 13.8]  [Reference Citation Analysis (0)]
111.  Seeman MV. Parenting issues in mothers with schizophrenia. Curr Womens Health Rev. 2010;6:51-57.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 18]  [Cited by in F6Publishing: 18]  [Article Influence: 1.4]  [Reference Citation Analysis (0)]
112.  Seeman MV. Intervention to prevent child custody loss in mothers with schizophrenia. Schizophr Res Treatment. 2012;2012:796-763.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 36]  [Cited by in F6Publishing: 39]  [Article Influence: 3.0]  [Reference Citation Analysis (0)]
113.  Ralph SJ, Espinet A. Increased all-cause mortality by antipsychotic drugs: updated review and meta-analysis in dementia and general mental health care. J Alzheimers Dis Rep. 2017;1:1–25.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 68]  [Cited by in F6Publishing: 71]  [Article Influence: 13.6]  [Reference Citation Analysis (0)]
114.  Solmi M, Murru A, Pacchiarotti I, Undurraga J, Veronese N, Fornaro M, Stubbs B, Monaco F, Vieta E, Seeman MV. Safety, tolerability, and risks associated with first- and second-generation antipsychotics: a state-of-the-art clinical review. Ther Clin Risk Manag. 2017;13:757-777.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 219]  [Cited by in F6Publishing: 230]  [Article Influence: 36.5]  [Reference Citation Analysis (0)]
115.  Seeman MV. Secondary effects of antipsychotics: women at greater risk than men. Schizophr Bull. 2009;35:937-948.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 108]  [Cited by in F6Publishing: 116]  [Article Influence: 7.2]  [Reference Citation Analysis (0)]
116.  Seeman MV. Schizophrenia: women bear a disproportionate toll of antipsychotic side effects. J Am Psychiatr Nurses Assoc. 2010;16:21-29.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 25]  [Cited by in F6Publishing: 26]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]
117.  Iversen TSJ, Steen NE, Dieset I, Hope S, Mørch R, Gardsjord ES, Jørgensen KN, Melle I, Andreassen OA, Molden E. Side effect burden of antipsychotic drugs in real life - Impact of gender and polypharmacy. Prog Neuropsychopharmacol Biol Psychiatry. 2018;82:263-271.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 58]  [Cited by in F6Publishing: 60]  [Article Influence: 11.6]  [Reference Citation Analysis (0)]
118.  Johannesen L, Garnett C, Luo M, Targum S, Sørensen JS, Mehrotra N. Quantitative understanding of QTc prolongation and gender as risk factors for torsade de pointes. Clin Pharmacol Ther. 2018;103:304-309.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 14]  [Cited by in F6Publishing: 14]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]
119.  Chow V, Reddel C, Pennings G, Scott E, Pasqualon T, Ng AC, Yeoh T, Curnow J, Kritharides L. Global hypercoagulability in patients with schizophrenia receiving long-term antipsychotic therapy. Schizophr Res. 2015;162:175-182.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 26]  [Cited by in F6Publishing: 27]  [Article Influence: 3.3]  [Reference Citation Analysis (0)]
120.  Lazo-Langner A, Liu K, Shariff S, Garg AX, Ray JG. Immigration, region of origin, and the epidemiology of venous thromboembolism: A population-based study. Res Pract Thromb Haemost. 2018;2:469-480.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 4]  [Cited by in F6Publishing: 4]  [Article Influence: 0.8]  [Reference Citation Analysis (0)]
121.  Jönsson AK, Schill J, Olsson H, Spigset O, Hägg S. Venous thromboembolism during treatment with antipsychotics: A review of current evidence. CNS Drugs. 2018;32:47-64.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 34]  [Cited by in F6Publishing: 36]  [Article Influence: 8.5]  [Reference Citation Analysis (0)]
122.  Vigod SN, Kurdyak PA, Dennis CL, Gruneir A, Newman A, Seeman MV, Rochon PA, Anderson GM, Grigoriadis S, Ray JG. Maternal and newborn outcomes among women with schizophrenia: a retrospective population-based cohort study. BJOG. 2014;121:566-574.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 87]  [Cited by in F6Publishing: 90]  [Article Influence: 9.7]  [Reference Citation Analysis (0)]
123.  Seeman MV. Skin and hair conditions in women with schizophrenia or related disorders. Womens Health Res. 2018;2:14-28.  [PubMed]  [DOI]  [Cited in This Article: ]
124.  Seeman MV. Antipsychotics and physical attractiveness. Clin Schizophr Relat Psychoses. 2011;5:142-146.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 24]  [Cited by in F6Publishing: 25]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
125.  Zhang-Wong JH, Seeman MV. Antipsychotic drugs, menstrual regularity and osteoporosis risk. Arch Womens Ment Health. 2002;5:93-98.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 22]  [Cited by in F6Publishing: 15]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
126.  Currier GW, Simpson GM. Antipsychotic medications and fertility. Psychiatr Serv. 1998;49:175-176.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 22]  [Cited by in F6Publishing: 20]  [Article Influence: 0.9]  [Reference Citation Analysis (0)]
127.  Galbally M, Snellen M, Power J. Antipsychotic drugs in pregnancy: a review of their maternal and fetal effects. Ther Adv Drug Saf. 2014;5:100-109.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 55]  [Cited by in F6Publishing: 57]  [Article Influence: 6.1]  [Reference Citation Analysis (0)]
128.  Gentile S. Infant safety with antipsychotic therapy in breast-feeding: a systematic review. J Clin Psychiatry. 2008;69:666-673.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 53]  [Cited by in F6Publishing: 32]  [Article Influence: 3.5]  [Reference Citation Analysis (0)]
129.  Seeman MV. Pseudocyesis, delusional pregnancy, and psychosis: The birth of a delusion. World J Clin Cases. 2014;2:338-344.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 21]  [Cited by in F6Publishing: 21]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]
130.  Zai CC, Maes MS, Tiwari AK, Zai GC, Remington G, Kennedy JL. Genetics of tardive dyskinesia: Promising leads and ways forward. J Neurol Sci. 2018;389:28-34.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 28]  [Cited by in F6Publishing: 31]  [Article Influence: 5.6]  [Reference Citation Analysis (0)]
131.  Turrone P, Seeman MV, Silvestri S. Estrogen receptor activation and tardive dyskinesia. Can J Psychiatry. 2000;45:288-290.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 20]  [Cited by in F6Publishing: 22]  [Article Influence: 0.9]  [Reference Citation Analysis (0)]
132.  Hollingworth SA, Winckel K, Saiepour N, Wheeler AJ, Myles N, Siskind D. Clozapine-related neutropenia, myocarditis and cardiomyopathy adverse event reports in Australia 1993-2014. Psychopharmacology (Berl). 2018;235:1915-1921.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 12]  [Article Influence: 2.4]  [Reference Citation Analysis (0)]
133.  Seeman MV. Prevention of antipsychotic side effects in elderly populations. J Ment Health Aging. 2018;2:24-28.  [PubMed]  [DOI]  [Cited in This Article: ]
134.  Seeman MV. Bilingualism and schizophrenia. World J Psychiatry. 2016;6:192-198.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 9]  [Cited by in F6Publishing: 9]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
135.  Ostrow L, Nemec PB, Smith C. Self-employment for people with psychiatric disabilities: Advantages and strategies. J Behav Health Serv Res. 2018;.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9]  [Cited by in F6Publishing: 8]  [Article Influence: 3.0]  [Reference Citation Analysis (0)]
136.  Hammell KW. Dimensions of meaning in the occupations of daily life. Can J Occup Ther. 2004;71:296-305.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 302]  [Cited by in F6Publishing: 304]  [Article Influence: 43.1]  [Reference Citation Analysis (0)]
137.  Link BG, Phelan JC. Conceptualizing stigma. Ann Rev Sociol. 2001;27:363-385.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 4255]  [Cited by in F6Publishing: 4379]  [Article Influence: 193.4]  [Reference Citation Analysis (0)]
138.  Khalifeh H, Johnson S, Howard LM, Borschmann R, Osborn D, Dean K, Hart C, Hogg J, Moran P. Violent and non-violent crime against adults with severe mental illness. Br J Psychiatry. 2015;206:275-282.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 55]  [Cited by in F6Publishing: 57]  [Article Influence: 6.9]  [Reference Citation Analysis (0)]
139.  Desmarais SL, Van Dorn RA, Johnson KL, Grimm KJ, Douglas KS, Swartz MS. Community violence perpetration and victimization among adults with mental illnesses. Am J Public Health. 2014;104:2342-2349.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 73]  [Cited by in F6Publishing: 106]  [Article Influence: 8.1]  [Reference Citation Analysis (0)]
140.  Lamsma J, Harte JM. Violence in psychosis: Conceptualizing its causal relationship with risk factors. Aggress Violent Behav. 2015;24:75-82.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 22]  [Cited by in F6Publishing: 22]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
141.  Krumm S, Checchia C, Badura-Lotter G, Kilian R, Becker T. The attitudes of mental health professionals towards patients’ desire for children. BMC Med Ethics. 2014;15:18.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9]  [Cited by in F6Publishing: 10]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
142.  Jeffery D, Clement S, Corker E, Howard LM, Murray J, Thornicroft G. Discrimination in relation to parenthood reported by community psychiatric service users in the UK: a framework analysis. BMC Psychiatry. 2013;13:120.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 34]  [Cited by in F6Publishing: 36]  [Article Influence: 3.4]  [Reference Citation Analysis (0)]
143.  Topor A, Bøe TD, Larsen IB. Small things, micro-affirmations and helpful professionals everyday recovery-orientated practices according to persons with mental health problems. Community Ment Health J. 2018;.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 40]  [Cited by in F6Publishing: 73]  [Article Influence: 8.0]  [Reference Citation Analysis (0)]
144.  Kaplan KJ, Harrow M, Clews K. The twenty-year trajectory of suicidal activity among post-hospital psychiatric men and women with mood disorders and schizophrenia. Arch Suicide Res. 2016;20:336-348.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 8]  [Article Influence: 1.7]  [Reference Citation Analysis (0)]
145.  Seeman MV. Suicide among women with schizophrenia spectrum disorders. J Psychiatr Pract. 2009;15:235-242.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 6]  [Cited by in F6Publishing: 6]  [Article Influence: 0.4]  [Reference Citation Analysis (0)]
146.  Seeman MV. The marilyn monroe group and the werther effect. Case Rep J. 2017;1:4.  [PubMed]  [DOI]  [Cited in This Article: ]
147.  Seeman MV. The impact of suicide on co-patients. Psychiatr Q. 2015;86:449-457.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9]  [Cited by in F6Publishing: 9]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
148.  Brodsky BS, Spruch-Feiner A, Stanley B. The zero suicide model: applying evidence-based suicide prevention practices to clinical Care. Front Psychiatry. 2018;9:33.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 80]  [Cited by in F6Publishing: 84]  [Article Influence: 16.0]  [Reference Citation Analysis (0)]
149.  Brown S, Birtwistle J, Roe L, Thompson C. The unhealthy lifestyle of people with schizophrenia. Psychol Med. 1999;29:697-701.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 624]  [Cited by in F6Publishing: 639]  [Article Influence: 26.0]  [Reference Citation Analysis (0)]
150.  Moradi H, Harvey PD, Helldin L. Correlates of risk factors for reduced life expectancy in schizophrenia: Is it possible to develop a predictor profile? Schizophr Res. 2018;.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 9]  [Article Influence: 1.6]  [Reference Citation Analysis (0)]
151.  Seeman MV. An outcome measure in schizophrenia: mortality. Can J Psychiatry. 2007;52:55-60.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 20]  [Cited by in F6Publishing: 22]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
152.  Martin CR, Osadchiy V, Kalani A, Mayer EA. The brain-gut-microbiome axis. Cell Mol Gastroenterol Hepatol. 2018;6:133-148.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 492]  [Cited by in F6Publishing: 483]  [Article Influence: 98.4]  [Reference Citation Analysis (0)]
153.  Severance EG, Dickerson FB, Yolken RH. Autoimmune phenotypes in schizophrenia reveal novel treatment targets. Pharmacol Ther. 2018;189:184-198.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 22]  [Cited by in F6Publishing: 20]  [Article Influence: 4.4]  [Reference Citation Analysis (0)]
154.  Bosworth B. Increasing disparities in mortality by socioeconomic status. Annu Rev Public Health. 2018;39:237-251.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 52]  [Cited by in F6Publishing: 55]  [Article Influence: 13.0]  [Reference Citation Analysis (0)]
155.  LePage JP, Bradshaw LD, Cipher DJ, Crawford AM, Hoosyhar D. The effects of homelessness on Veterans’ health care service use: an evaluation of independence from comorbidities. Public Health. 2014;128:985-992.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 20]  [Cited by in F6Publishing: 21]  [Article Influence: 2.2]  [Reference Citation Analysis (0)]
156.  Cohen S. Social relationships and health. Am Psychol. 2004;59:676-684.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2357]  [Cited by in F6Publishing: 2586]  [Article Influence: 130.9]  [Reference Citation Analysis (0)]
157.  Butler-Jones D, Wong T. Infectious disease, social determinants and the need for intersectoral action. Can Commun Dis Rep. 2016;42:S118-S120.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 16]  [Cited by in F6Publishing: 16]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]
158.  Teasdale SB, Samaras K, Wade T, Jarman R, Ward PB. A review of the nutritional challenges experienced by people living with severe mental illness: a role for dietitians in addressing physical health gaps. J Hum Nutr Diet. 2017;30:545-553.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 33]  [Cited by in F6Publishing: 34]  [Article Influence: 5.5]  [Reference Citation Analysis (0)]
159.  Dickey B, Normand SL, Weiss RD, Drake RE, Azeni H. Medical morbidity, mental illness, and substance use disorders. Psychiatr Serv. 2002;53:861-867.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 219]  [Cited by in F6Publishing: 261]  [Article Influence: 10.4]  [Reference Citation Analysis (0)]
160.  Attar R, Berg Johansen M, Valentin JB, Aagaard J, Jensen SE. Treatment following myocardial infarction in patients with schizophrenia. PLoS One. 2017;12:e0189289.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 21]  [Cited by in F6Publishing: 21]  [Article Influence: 3.5]  [Reference Citation Analysis (0)]
161.  Holt RI, Mitchell AJ. Diabetes mellitus and severe mental illness: mechanisms and clinical implications. Nat Rev Endocrinol. 2015;11:79-89.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 88]  [Cited by in F6Publishing: 92]  [Article Influence: 9.8]  [Reference Citation Analysis (0)]
162.  Lawrence D, Kisely S. Inequalities in healthcare provision for people with severe mental illness. J Psychopharmacol. 2010;24:61-68.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 363]  [Cited by in F6Publishing: 389]  [Article Influence: 30.3]  [Reference Citation Analysis (0)]
163.  Jayatilleke N, Hayes RD, Dutta R, Shetty H, Hotopf M, Chang CK, Stewart R. Contributions of specific causes of death to lost life expectancy in severe mental illness. Eur Psychiatry. 2017;43:109-115.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 49]  [Cited by in F6Publishing: 45]  [Article Influence: 8.2]  [Reference Citation Analysis (0)]
164.  de Boer MK, Castelein S, Wiersma D, Schoevers RA, Knegtering H. The facts about sexual (Dys) function in schizophrenia: an overview of clinically relevant findings. Schizophr Bull. 2015;41:674-686.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 97]  [Cited by in F6Publishing: 101]  [Article Influence: 12.1]  [Reference Citation Analysis (0)]
165.  Seeman MV. Loss of libido in a woman with schizophrenia. Am J Psychiatry. 2013;170:471-475.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 10]  [Article Influence: 0.8]  [Reference Citation Analysis (0)]
166.  Wong J, Seeman MV. Prolactin, menstrual irregularities, quality of life. Schizophr Res. 2007;91:270-271.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 10]  [Cited by in F6Publishing: 9]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
167.  Seeman MV. Antipsychotic-induced amenorrhea. J Ment Health. 2011;20:484-491.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 21]  [Cited by in F6Publishing: 20]  [Article Influence: 1.9]  [Reference Citation Analysis (0)]
168.  Vigod SN, Seeman MV, Ray JG, Anderson GM, Dennis CL, Grigoriadis S, Gruneir A, Kurdyak PA, Rochon PA. Temporal trends in general and age-specific fertility rates among women with schizophrenia (1996-2009): a population-based study in Ontario, Canada. Schizophr Res. 2012;139:169-175.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 62]  [Cited by in F6Publishing: 52]  [Article Influence: 5.6]  [Reference Citation Analysis (0)]
169.  Miller LJ. Sexuality, reproduction, and family planning in women with schizophrenia. Schizophr Bull. 1997;23:623-635.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 118]  [Cited by in F6Publishing: 120]  [Article Influence: 4.5]  [Reference Citation Analysis (0)]
170.  Vigod SN, Rochon-Terry G, Fung K, Gruneir A, Dennis CL, Grigoriadis S, Kurdyak PA, Ray JG, Rochon P, Seeman MV. Factors associated with postpartum psychiatric admission in a population-based cohort of women with schizophrenia. Acta Psychiatr Scand. 2016;134:305-313.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 11]  [Cited by in F6Publishing: 12]  [Article Influence: 1.6]  [Reference Citation Analysis (0)]
171.  Whitworth AB. Psychopharmacological treatment of schizophrenia during pregnancy and lactation. Curr Opin Psychiatry. 2017;30:184-190.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 11]  [Cited by in F6Publishing: 11]  [Article Influence: 1.8]  [Reference Citation Analysis (0)]
172.  Seeman MV. Women with schizophrenia as parents. Primary Psychiatry. 2002;9:39-42.  [PubMed]  [DOI]  [Cited in This Article: ]
173.  Seeman MV. Assessing the effects of antipsychotics on parenting. Womens Health Bull. 2018;5:e13409.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 2]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
174.  Seeman MV, González-Rodríguez A. Use of psychotropic medication in women with psychotic disorders at menopause and beyond. Curr Opin Psychiatry. 2018;31:183-192.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 9]  [Cited by in F6Publishing: 9]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]
175.  Costantine MM. Physiologic and pharmacokinetic changes in pregnancy. Front Pharmacol. 2014;5:65.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 214]  [Cited by in F6Publishing: 222]  [Article Influence: 23.8]  [Reference Citation Analysis (0)]
176.  Pariente G, Leibson T, Carls A, Adams-Webber T, Ito S, Koren G. Pregnancy-associated changes in pharmacokinetics: A systematic review. PLoS Med. 2016;13:e1002160.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 139]  [Cited by in F6Publishing: 145]  [Article Influence: 19.9]  [Reference Citation Analysis (0)]
177.  Westin AA, Brekke M, Molden E, Skogvoll E, Castberg I, Spigset O. Treatment with antipsychotics in pregnancy: Changes in drug disposition. Clin Pharmacol Ther. 2018;103:477-484.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 40]  [Cited by in F6Publishing: 44]  [Article Influence: 6.7]  [Reference Citation Analysis (0)]
178.  Murphy SM, Irving CB, Adams CE, Waqar M. Crisis intervention for people with severe mental illnesses. Cochrane Database Syst Rev. 2015;CD001087.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 31]  [Cited by in F6Publishing: 47]  [Article Influence: 3.9]  [Reference Citation Analysis (0)]
179.  Seeman MV. Sleepwalking, a possible side effect of antipsychotic medication. Psychiatr Q. 2011;82:59-67.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 21]  [Cited by in F6Publishing: 19]  [Article Influence: 1.8]  [Reference Citation Analysis (0)]
180.  Seeman MV. Diagnosis and treatment of sleep apnoea in women with schizophrenia. J Ment Health. 2014;23:191-196.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 10]  [Cited by in F6Publishing: 12]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
181.  Seeman MV. Sleep, nightmares and schizophrenia. J Sleep Disord Manag. 2017;3:1-7.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 4]  [Cited by in F6Publishing: 4]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
182.  Seeman MV. Antipsychotic-induced somnolence in mothers with schizophrenia. Psychiatr Q. 2012;83:83-89.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 18]  [Cited by in F6Publishing: 8]  [Article Influence: 1.6]  [Reference Citation Analysis (0)]
183.  Waddell A, Ross L, Ladd L, Seeman MV. Safe Minds - Perceptions of safety in a rehabilitation clinic for serious persistent mental illness. Int J Psychosocial Rehab. 2006;11:4-10.  [PubMed]  [DOI]  [Cited in This Article: ]
184.  Goering PN, Streiner DL, Adair C, Aubry T, Barker J, Distasio J, Hwang SW, Komaroff J, Latimer E, Somers J. The At Home/Chez Soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities. BMJ Open. 2011;1:e000323.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 187]  [Cited by in F6Publishing: 203]  [Article Influence: 15.6]  [Reference Citation Analysis (0)]
185.  Piva M, Santarelli E, Vivarelli M. The skill bias effect of technological and organisational change: Evidence and policy implications. Res Policy. 2005;34:141-157.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 137]  [Cited by in F6Publishing: 131]  [Article Influence: 7.6]  [Reference Citation Analysis (0)]
186.  Vos J, Craig M, Cooper M. Existential therapies: a meta-analysis of their effects on psychological outcomes. J Consult Clin Psychol. 2015;83:115-128.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 85]  [Cited by in F6Publishing: 86]  [Article Influence: 9.4]  [Reference Citation Analysis (0)]
187.  Mushkin P, Band-Winterstein T, Avieli H. “Like every normal person?!” The paradoxical effect of aging with schizophrenia. Qual Health Res. 2018;28:977-986.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 5]  [Cited by in F6Publishing: 5]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
188.  Chochinov HM, Hassard T, McClement S, Hack T, Kristjanson LJ, Harlos M, Sinclair S, Murray A. The landscape of distress in the terminally ill. J Pain Symptom Manage. 2009;38:641-649.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 101]  [Cited by in F6Publishing: 108]  [Article Influence: 7.2]  [Reference Citation Analysis (0)]
189.  Kaczkurkin AN, Raznahan A, Satterthwaite TD. Sex differences in the developing brain: insights from multimodal neuroimaging. Neuropsychopharmacology. 2018;.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 125]  [Cited by in F6Publishing: 136]  [Article Influence: 25.0]  [Reference Citation Analysis (0)]
190.  Arnold AP. A general theory of sexual differentiation. J Neurosci Res. 2017;95:291-300.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 148]  [Cited by in F6Publishing: 161]  [Article Influence: 24.7]  [Reference Citation Analysis (0)]