The present study provides a cross-sectional picture of a cohort of typical chronic psychotic patients attending a community mental health service in Italy. The patient sample was made up largely of middle aged, low income subjects with a long psychiatric history who lived in the community. As expected, a number of gender differences were revealed in the sample described here. Sociodemographic conditions of women were somewhat better than those of males, as shown by the higher frequency of female patients who were married with children, a finding that is substantially congruent with data present in the literature [8
], probably reflecting the later onset of schizophrenia, a better premorbid adjustment [10
] and less severe symptoms at onset among females [17
]. In the sample studied, a higher proportion of schizoaffective disorders was found among females, a finding partially congruent with literature data reporting a higher frequency of affective symptoms in women [6
]. Although statistical significance was not reached, likely due to the limited number of subjects investigated, the younger age at onset of the disorder and the consequent early start of treatment in males observed in this study is fully in agreement with previous findings [2
]. The more frequent prevalence of male offenders found in our study, together with a higher rate of disturbing and aggressive behaviors as evaluated by means of PSP, tend to confirm data from the literature reporting a stronger association of violent crimes in mental disorders with the male gender [49
]. No substantial gender differences were detected with regard to duration of untreated psychosis, a result which is partly congruent with literature data reporting on first-onset psychoses [51
], and in contrast with others showing a longer DUI among males [52
]. In accordance with literature findings (2) no gender differences were detected in the sample studied in symptom course pattern, although there was a considerable lack of literature studies reporting on clinical course according to DSM-IV criteria.
The absence of gender differences in current pharmacological treatment may indicate that, in spite of a series of literature reports demonstrating substantial differences between the genders in terms of response to and tolerability of treatments, in clinical practice males and females are treated in a comparable manner, thus reflecting the lack of gender-specific treatment guidelines [4
]. In this study, female patients more frequently underwent individual psychotherapy, a finding which might be interpreted as the consequence of a higher propensity compared to males to resort to psychological interventions rather than to actual differences in therapeutic needs. Interestingly, no differences were detected in the frequency of rehabilitation activities between genders, with the sole exception of art therapies, which were more frequent among female patients. These findings are partly in contrast with literature data, underlining how women are less involved in rehabilitation activities, probably due to the lower degree of disability generally attributed to the female sex, and to lower needs of clinical and psychosocial care [53
]. Moreover, women are reportedly less involved in job placement or educational programs [8
], although no significant gender differences were observed in the present sample with regard to these interventions. The data obtained in this study showed substantially similar levels and quality of psychopathology, as revealed by PANSS and CGI-SCH, in males and females; these findings are in contrast with data present in the literature, generally reporting a higher incidence of negative symptoms in males, and affective symptoms in females [6
]. However, in the present study the more frequent observation of schizoaffective disorders in women may reflect a higher frequency of mood symptoms in females throughout the longitudinal course of the illness.
Following application of Andreasen's et al. [30
] criteria, higher rates of clinical remission were detected for women than for men, although differences were not statistically significant; likewise, similar results emerged when other criteria were used. However, as expected rates of remission progressively decreased when more restrictive sets of criteria were considered. Moreover, a higher albeit not significant percentage of women showed an adequate functioning and were considered in “functional remission”. Furthermore, compared to males, women more frequently report a condition of subjective wellbeing on SWN scale, with statistically significant differences in the “self-control” subscale. Recent studies utilizing operational criteria to define clinical and functional remission show contrasting results. A study by Galderisi et al. [31
] failed to find a statistically significant difference in rates of clinical remission between genders and higher rates of functional remission in females, a difference at the limits of statistical significance; Brugnoli et al. [55
] found a higher frequency of clinical remission among females, while no difference between the sexes was found by Karow et al. [56
When taking into account the main criteria adopted in the present study, that is, a state of clinical remission together with an adequate functioning and a true subjective wellbeing, “recovery” was significantly more frequent among female patients; similar results were obtained when recovery was only based on clinical remission and functional status. These results are fundamentally congruent with evidence from the literature. Indeed, in a longitudinal prospective study lasting 20 years Grossman et al. [32
] revealed a trend for a better overall outcome and higher rates of recovery among women with schizophrenia and other psychotic disorders, thus disconfirming the hypothesis advanced by some authors that in women with schizophrenia outcome worsened over time, largely resembling that observed in men [33
]. The SOHO study [30
] reported a higher frequency of full recovery among females, presenting a lower global severity, less negative symptoms, and better social functioning at baseline. Similarly, Albert et al. [37
] found that recovery was predicted, among other factors, by female sex.
Prior to the drawing of any conclusion from the data collected in the present study, a series of limitations should be taken into account, including the cross-sectional nature of the study, the limited number of cases included, the exclusion of cases of mental retardation and organic brain disorders, the exclusion of duration criteria in defining clinical remission. On the other hand, the use of structured interviews to define diagnoses and of standardized methods in the evaluation of clinical and psychosocial variables, thus allowing remission and recovery to be assessed in a reliable manner should be considered strengths of the study. The overall data provided by this study of a cohort of chronic outpatients who were highly representative of typical psychotic patients attending community mental health centers in Italy, tend to confirm a best prognosis and lower overall severity of schizophrenic spectrum disorders in women than in men [2
]. In particular, our data appear to demonstrate a better outcome not only in the short and middle term, but likewise in the long term in schizophrenic and schizoaffective women. This improved outcome is likely the result of both an intrinsic, less severe nature of the disorder and to a series of other positive factors related to treatment (i.e., better response, higher compliance) and psychosocial environment (i.e., higher social support) among women.