Gender and outcomes

Male participants with schizophrenia had a poorer long-term prognosis than their female counterparts, which is consistent with

Table 2 Characteristics of participants alive in 2008 (n = 328)

	Men (n = 131)	Women (n = 197)	χ2 or t	d.f.	P
Living with offspring, n (%)	17 (13.0)	42 (21.3)	χ2 = 3.7	1	0.05
Previous physical illness, n (%)	52 (39.7)	61 (31.0)	χ2 = 2.6	1	0.10
Age, years: mean (s.d.)	53.4 (12.6)	57.8 (12.7)	t = 3.11	326	0.00
Education, years: mean (s.d.)	5.1 (3.2)	4.3 (3.2)	t = 2.28	308	0.02
Age at onset, years: mean (s.d.)	27.2 (11.1)	30.7 (10.6)	t = 2.93	326	< 0.0001
Number of family members: mean (s.d.)	2.8 (1.7)	3.5 (1.5)	t = 3.89	320	< 0.0001
Duration of illness, years: mean (s.d.)	24.7 (11.0)	25.9 (10.9)	t = 0.98	314	0.33
Assessment scores: mean (s.d.)
PANSS positive symptoms	11.8 (5.6)	12.4 (6.2)	t = 0.85	288	0.40
PANSS total score	15.8 (9.3)	15.2 (9.0)	t = 0.44	222	0.66
PANSS negative symptoms	54.8 (20.0)	56.9 (22.8)	t = 0.65	199	0.52
GAF	61.5 (24.5)	61.5 (24.9)	t = 0.01	307	0.99

GAF, Global Assessment of Functioning; PANSS, Positive and Negative Syndrome Scale.

previous studies in other countries. ^{Reference Leung and Chue5,Reference Tamminga15} The International Pilot Study in a few countries also found female gender to be the best predictor of a remittent (v. chronic) course of schizophrenia. ^{Reference Sartorius, Jablensky, Korten, Ernberg, Anker and Cooper16} The poor long-term prognosis for men in this study might be due to higher rates of suicide, homelessness, being single or divorced and without a caregiver, and to lower rates of survival and marriage. Given the high rate of violent and criminal behaviour in men with schizophrenia, ^{Reference Ran, Chen, Liao, Chan, Chen and Tang17} they may more likely to be abandoned or rejected by their families and local community.

There are a number of possible reasons for better outcomes in women. Even though significant discrimination against women still exists, ^{Reference Pearson18} women with schizophrenia may have better support and care from their family or community. This may relate to our findings that female participants had significantly more family members than male participants, suggesting that women’s deviant behaviour may be more readily tolerated than that of men in rural China, ^{Reference Mueser, Bellack, Morrison and Wade4,Reference Ran, Xiang, Li, Shan, Huang and Li9,Reference Ran, Chan, Chen, Mao, Hu and Tang19} and may be less likely to alienate their families. Many women with the disorder continue to be able to perform some family functions (e.g. cooking, cleaning, washing and child care), but men with schizophrenia contribute little to smooth family functioning; moreover, their levels of violence will also be harder for family members to manage. ^{Reference Ran, Chen, Liao, Chan, Chen and Tang17} Further, schizophrenia develops later in women, so their symptoms may not become apparent until after they are married; ^{Reference Pearson18} even if symptoms do appear women may still marry, given the high ratio of unmarried men to women

Table 3 Outcomes of surviving participants in 1994, 2004 and 2008

	1994 (n = 510)		2004 (n = 367)		2008 (n = 328)
	Men (n = 237) n (%)	Women (n = 273) n (%)	Men (n = 156) n (%)	Women (n = 211) n (%)	Men (n = 131) n (%)	Women (n = 197) n (%)
Marital status
Married	105 (44.3)	222 (81.3)Footnote **	71 (45.5)	167 (79.1)Footnote ***	59 (45.0)	150 (76.1)Footnote ***
Single	93 (39.2)	16 (5.9)Footnote **	51 (32.7)	6 (2.8)Footnote ***	42 (32.1)	4 (2.0)Footnote ***
Divorced	29 (12.2)	5 (1.8)Footnote **	19 (12.2)	7 (3.3)Footnote **	19 (14.5)	8 (4.1)Footnote **
Bereaved	10 (4.2)	30 (11.0)Footnote *	15 (9.6)	31 (14.7)	11 (8.4)	35 (17.8)Footnote *
Family economic status <mean	143 (60.3)	135 (49.5)Footnote *	97 (62.2)	108 (51.2)Footnote *	96 (73.3)	137 (69.5)
Living alone	51 (21.5)	13 (4.8)Footnote **	44 (28.2)	21 (10.0)Footnote ***	35 (26.7)	14 (7.1)Footnote ***
Without caregiver	65 (27.4)	25 (9.2)Footnote **	25 (16.0)	11 (5.2)Footnote **	15 (11.5)	5 (2.5)Footnote **
Violent or criminal behaviour	7 (3.0)	11 (4.0)	NR	NR	26 (19.8)	30 (15.2)
Previous suicide attempt	14 (5.9)	23 (8.4)	26 (16.7)	35 (16.6)	28 (21.4)	41 (20.8)
Never treated	81 (34.2)	75 (27.5)	37 (23.7)	52 (24.6)	29 (22.1)	38 (19.3)
Previous hospital admission	56 (23.6)	54 (19.8)	59 (37.8)	61 (28.9)	50 (38.2)	70 (35.5)
Inability to work	51 (21.5)	46 (16.8)	34 (21.8)	50 (23.7)	37 (28.2)	57 (28.9)

* P < 0.05

** P < 0.01

*** P < 0.001 (differences between genders within each year).

NR, not reported.

in rural China (over 1.9). Also, given the lower social expectations for women, their domestic survival skills in the community are likely to be higher than those of men. ^{Reference Pearson18} Evidence indicates that oestrogen may facilitate the effects of antipsychotic medication, causing women to have a better treatment response than men and thus a better course of illness, ^{Reference Goldstein, Cohen, Horton, Lee, Andersen and Tohen21} and women have better premorbid functioning. ^{Reference Mueser, Bellack, Morrison and Wade4,Reference Leung and Chue5,Reference Pearson18} However, more research is necessary in order to understand fully the relative contribution of gonadal hormones and other gender-specific developmental influences towards symptoms and functioning in psychosis. ^{Reference Willhite, Niendam, Bearden, Zinberg, O'Brien and Cannon2}

The rate of mortality (death, suicide) among men with schizophrenia is alarming. The high rate of suicide in male participants in this study is consistent with previous studies in developed countries. ^{Reference Lester22} Homelessness is a serious problem among people with schizophrenia, especially men, which is also consistent with previous studies. ^{Reference Ran, Chen, Conwell, Chan, Yip and Xiang10,Reference Ran, Chan, Chen, Mao, Hu and Tang19,Reference Folsom, Hawthorne, Lindamer, Gilmer, Bailey and Golshan23} Schizophrenia, which is diagnosed at roughly equal rates for men and women in Western countries, ^{Reference Sartorius, Jablensky, Korten, Ernberg, Anker and Cooper16,Reference Pearson18} is diagnosed more frequently in women in China. ^{Reference Ran, Xiang, Li, Shan, Huang and Li9,Reference Phillips, Yang, Li and Li24} We suggest that higher rates of mortality, suicide and homelessness in men with schizophrenia compared with women may contribute to the higher prevalence of the disorder in women in China. ^{Reference Ran, Xiang, Li, Shan, Huang and Li9,Reference Phillips, Yang, Li and Li24}

Compared with the cohort in 1994, even though more participants were treated in 2008 their status in this study worsened. For example, participants in 2008 had significantly higher rates of violent or criminal behaviour and previous suicide attempts than in 1994. Female participants had a significantly higher rate of inability to work in 2008 than in 1994. Although the average net income of each farmer in Xinjin County had increased from 1994 to 2008, all participants’ family economic status had relatively worsened in 2008 compared with that in 1994. Evidence from higher-income countries indicates that people with schizophrenia may decline to less favourable socioeconomic status over the course of the illness, ^{Reference Hudson25} and this is confirmed by our study. Such socioeconomic factors may have an important role in influencing long-term outcomes of people with schizophrenia. Further studies should be conducted to explore the impact of socioeconomic development on the outcomes of this group.

Gender and other characteristics

What factors are important in influencing the long-term outcomes of people with schizophrenia? Evidence indicates that never-treated individuals with schizophrenia might have a poorer outcome (e.g. higher mortality) than those accepting treatment with antipsychotic drugs. ^{Reference Ran, Chan, Chen, Mao, Hu and Tang19,Reference Tiihonen, Lonnqvist, Wahlbeck, Klaukka, Niskanen and Tanskanen26} In a 15-year and 25-year international follow-up study a significant proportion of treated incident cases of schizophrenia achieved a favourable long-term outcome. ^{Reference Harrison, Hopper, Craig, Laska, Siegel and Wanderling27} Our study showed no significant difference between men and women in the proportion who never received treatment for their illness in 1994, 2004 or 2008. There was also no significant difference between male and female participants in the proportion who had one or more previous hospital admissions, consistent with studies in higher-income countries. ^{Reference McAlpine and Mechanic28}

Evidence indicates that later age at onset may be also associated with better outcome in schizophrenia and other psychoses. ^{Reference Rabinowitz, Levine and Hafner29} Consistent with published research, ^{Reference Leung and Chue5,Reference Kohler, van, Werf, Hart, Morrison, McCreadie and Kirkpatrick30} we found female participants who survived through 14 years of follow-up to have a later age at onset (women 30.7 years, men 27.2 years) and better outcomes than male participants at that point in follow-up. An early onset of schizophrenia might arrest social development, resulting in greater social impairment in boys than in girls. ^{Reference Mueser, Bellack, Morrison and Wade4,Reference Pearson18} However, even though women had a more favourable outcome profile in cases of young or middle-age onset, they tended to have a poorer outcome in the very late-onset cases, particularly in terms of course, longest episode and remission. ^{Reference Kohler, van, Werf, Hart, Morrison, McCreadie and Kirkpatrick30} The ‘oestrogen hypothesis’ suggests that the disorder only becomes apparent after menopause for a proportion of women who have a psychosis liability. ^{Reference Seeman and Lang31} Consequently, men with lower levels of vulnerability develop psychotic disorders in old age and may display better outcomes than their female counterparts. ^{Reference Kohler, van, Werf, Hart, Morrison, McCreadie and Kirkpatrick30} Further studies will be needed to examine the effect of gender-age interactions.

The link between negative symptoms and functioning has been well established in research studies examining outcomes in patients with chronic schizophrenia. ^{Reference Breier, Schreiber, Dyer and Pickar32,Reference Bottlender, Strauss and Moller33} Differences in negative symptoms were found to mediate differences in functioning between men and women. ^{Reference Willhite, Niendam, Bearden, Zinberg, O'Brien and Cannon2} Although women with schizophrenia might have fewer negative symptoms than men, ^{Reference Leung and Chue5} we found no significant difference in positive and negative symptoms between men and women who completed 14 years follow-up, which is consistent with a previous study. ^{Reference Mueser, Bellack, Morrison and Wade4} It may be that men with severe positive and negative symptoms are more likely to die earlier or be lost to follow-up. Further studies need to be conducted on gender and long-term symptoms.

Previous studies in high-income countries indicate that women with schizophrenia may have better psychosocial functioning or be more skilled and less disabled than men. ^{Reference Mueser, Bellack, Morrison and Wade4,Reference Leung and Chue5,Reference Grossman, Harrow, Rosen and Faull34} However, the results of our study indicated that there was no difference in long-term social functioning (e.g. GAF score, inability to work) between the genders. Our results also showed that significantly more female participants were unable to work after 14 years (2008 v. 1994), which indicates higher rates of disability and poor long-term social functioning. Our study indicates that the trend of social functioning in people with schizophrenia, especially women, may be on a downhill path. ^{Reference Ganev35} Given the higher rates of suicide and mortality in men with schizophrenia in this study, women with more severe illness might survive longer into the follow-up period which might also result in different mixes of illness severity over time. Further investigations should explore the factors that influence the course of social disability, which is meaningful for planning rehabilitation interventions.

Although our previous study in China showed that male participants had significantly higher rates of all forms of criminal behaviour (13.8%) than female participants (6.8%) (P<0.05), ^{Reference Ran, Chen, Liao, Chan, Chen and Tang17} in 2008 we found no significant gender difference in rates of violent and criminal behaviour, which is consistent with some previous international studies. ^{Reference Swanson, Swartz, Van Dorn, Elbogen, Wagner and Rosenheck36,Reference Walsh, Gilvarry, Samele, Harvey, Manley and Tattan37} This study showed that violent behaviour was also common among female participants in rural China. Previous violent behaviour was found to be a predictor of criminal behaviour in people with schizophrenia. ^{Reference Ran, Chen, Liao, Chan, Chen and Tang17}

Sociocultural conditions appear to modify the long-term course of schizophrenia. ^{Reference Harrison, Hopper, Craig, Laska, Siegel and Wanderling27} In rural China we found that men with the disorder had higher rates of divorce and living alone, lower family economic level and fewer caregivers. Compared with men, women with schizophrenia might be more likely to be accepted by families and communities in this setting, which is vital to patients’ survival and integration in the community. Stronger social and familial acceptance for women may serve to reduce their stress more effectively. Poor family and social support for men may be risk factors for their poor long-term prognosis. This is consistent with a previous study in which men reported less positive social support than their female counterparts and felt they received marginally more criticism than women. ^{Reference Willhite, Niendam, Bearden, Zinberg, O'Brien and Cannon2} Although people with mental illness generally are not confined to institutions in high-income countries, this does not guarantee that they will be fully integrated into their communities owing to the disabilities produced by their illness and also to stigmatising and discriminatory public attitudes. ^{Reference Leff and Warner38} The quality of social networks around an individual patient has been shown to correlate with that person’s level of functioning. ^{Reference Erickson, Beiser and Iacono39} Family involvement, support and warmth may predict improvement in negative symptoms and social functioning. ^{Reference O'Brien, Gordan, Bearden, Lopez, Kopelowicz and Cannon40} In general, China developed rapidly between 1994 and 2008. However, in our study no improvement was apparent in family or social support for the participants or in family economic status in rural Xinjin County. Further studies should be conducted to explore the relationship between social development and mental healthcare (e.g. family, community and social care) for people with schizophrenia in the community.

Limitations of the study

The limitations of this study include possible recall bias for interviews with participants and informants at long-term follow-up intervals, but such bias may be minimised by the use of multiple follow-up data sources. The death and suicide rates may be underestimated because most homeless individuals were lost to follow-up. Over the 14 years much has changed in China, including access to and the nature of the treatments received, access to other services and quality of life more generally. Findings here may not apply to other settings in which such changes have not been observed. Given the diversity of sociocultural, economic and care provision characteristics, results from rural China may not generalise to high-income countries.

Implications for services

Even though significant discrimination against women still exists in rural China, women with schizophrenia have better support and care from family or community, which contributes to their better long-term outcomes. Men with the disorder have higher rates of mortality, suicide and homelessness than women, which contribute partly to the higher prevalence of schizophrenia in women than in men in China. Our results have implications for improving long-term prognosis of patients with schizophrenia in China and elsewhere. The characteristics of both men and women with schizophrenia should be taken into account when developing interventions to enhance their long-term prognosis. Compared with female patients, male patients in rural China comprise a highly vulnerable subgroup of individuals who, in addition to psychiatric care, need more support from family, community and society on a long-term basis. We suggest that early treatment (e.g. antipsychotic medication and other interventions) and community-based care and support (e.g. family, community and social level) are crucial for improving the long-term outcomes of both men and women with schizophrenia. ^{Reference Harrison, Hopper, Craig, Laska, Siegel and Wanderling27,Reference Ran, Xiang, Chan, Leff, Simpson and Huang41} Given that few programmes address psychosis in rural China from the standpoint of gender, gender-specific interventions should be provided for patients with schizophrenia. ^{Reference Koster, Lajer, Lindhardt and Rosenbaum42} For example, for men care should focus on medication, preventing suicide and violent behaviour and providing family and social support. For women, improving medication and social functioning should have greater emphasis. In the Chinese context, support for the patient’s family should also be strengthened.

Given the representative sample used in this study, we are confident that our findings are generalisable to the population of people with schizophrenia in rural areas, and even to other low- and middle-income countries that have a similar social environment. Overall long-term outcomes of schizophrenia are a major concern in psychiatry. It is crucial to supply comprehensive community mental health services and medication to these people in rural China. The impact of socioeconomic development on outcomes for men and women with schizophrenia living in the community should be investigated further.