2022ECNP: Schizophrenia in perimenopausal women requires additional attention

Although patient-centered treatment is a hot topic in psychiatry right now, there is not enough discussion about the fact that
men and women may have important differences in their treatment needs.
Women receiving antipsychotic medications during childbearing age face either the challenge of effective contraception or the challenge
of anticipatory pregnancy.
In addition, antipsychotic-related hyperprolactinemia can also affect the patient's health
.

Dr.
Heidi Taipale, Senior Research Fellow at the Karolinska Institutet in Stockholm, Sweden, presented his findings
at the 35th ECNP Congress.

Throughout the life stages of female schizophrenia spectrum disorder (SSD), lower estrogen levels are associated
with a more severe course of the disease.
During perimenopause in your 40s, estrogen levels decline and remain low after menopause
.
It is assumed that this period increases the risk of relapse and reduces the effectiveness of
antipsychotics in preventing relapse.

The cohort of people with schizophrenia/schizoaffective disorder studied was from the Finnish National Register (N = 61,689) and was stratified
by sex, age, and < 45 versus ≥ 45 years.
During the follow-up period 1996-2017, psychiatric hospitalization rates were defined
by the 5-year age group.
The risk of psychiatric hospitalization was assessed using an individual design (adjusted risk ratio, aHR) by comparing
the use of antipsychotic monotherapy in seven dose classes in a defined daily dose (DDDs/day) with the time of non-use.

From the age of 45-50, women are consistently hospitalized for mental illness more frequently than men
.
Women over 45 years of age had significantly higher aHRs than women with antipsychotic monotherapy of 0.
6 DDDs/day and significantly higher aHRs than men at 1.
1 DDDs/day of antipsychotic monotherapy
.

Figure 1.
Effectiveness of antipsychotic monotherapy in preventing relapse by dose in women and men under 45 years of age and over 45 years of age

Fig.
2.
The effect of oral antipsychotics (clozapine, olanzapine, quetiapine and risperidone) in preventing relapse, divided into women under 45 years of age and women and men over 45 years of age

For clozapine doses of 0.
6 DDDs/day, olanzapine doses of 1.
4 DDDs/day, as well as specific doses of quetiapine (0.
9-1.
1 DDDs/day) and risperidone (0.
6 - 0.
9 DDDs/day), this female-specific age-dependent decrease in effectiveness exists
.

Younger women have a lower risk of relapse compared with men and usually require lower antipsychotic doses to prevent rehospitalization, but after age 45, the effectiveness of antipsychotics decreases
in women.
Starting in their 40s, SSDs for older women should be seen as a vulnerable group
that deserves special attention.

Overall, women with SSD age 45 and older need more hospitalizations for mental illness than men of the same age
.
Among women over the age of 45, antipsychotics were far less effective at preventing rehospitalization for psychiatric illness than women under the age of 45, but also lower than men
of the same age.
Clozapine, high-dose olanzapine, and optimal doses of quetiapine and risperidone had the most significant
sex-specific effects on age.

Perimenopause is a critical period during which symptoms increase, while the decreased effectiveness of antipsychotics is a consequence of
estrogen deficiency.
These processes may reinforce each other and together lead to a substantial increase
in the risk of recurrence.
Increasing the dose is a reasonable clinical response to worsening symptoms, but may not be the best strategy, as the effectiveness of antipsychotics in the higher dose range is very low
in women over 45 years of age.
Early studies have shown that estrogen therapy (HRT or raloxifene) reduces symptoms and increases the effectiveness of antipsychotics, but also protects
against cognitive decline, cardiovascular comorbidities, and osteoporosis in postmenopausal women with SSD.
Since the decline in estrogen and the exacerbation of the clinical course already begin in the mid-40s, this is the best age
to consider taking such precautions.

Original source

1.
#!abstractdetails/0000490220.

2.
Sommer IE, Brand BA, Gangadin S, Tanskanen A, Tiihonen J, Taipale H.
Women with Schizophrenia-Spectrum Disorders After Menopause: A Vulnerable Group for Relapse.
Schizophr Bull.
2022 Oct 5:sbac139.
doi: 10.
1093/schbul/sbac139.
Epub ahead of print.
PMID: 36198044.