Professional Documents
Culture Documents
Short communication
Age-at-onset and schizophrenia:
reversed gender eect
B. N. Gangadhar, C. Panner Selvan, D. K. Subbakrishna, B. N. Gangadhar1, C. Panner
N. Janakiramaiah. Age-at-onset and schizophrenia: Selvan1, D. K. Subbakrishna2,
reversed gender eect N. Janakiramaiah1
Acta Psychiatr Scand 2002: 105: 317±319. ã Munksgaard 2002. 1
Department of Psychiatry and 2Department of
Biostatistics, NIMHANS, Bangalore 560 029, India
Objective: This study seeks an explanation for reversed gender eect
on age-at-onset (AAO) in schizophrenia. The hypothesis is older AAO
in males would be detected in a sample where higher infant mortality
(IMR) prevailed.
Method: Case records of International Classi®cation of Diseases-10
(ICD-10) schizophrenia patients from two states (n 70 each) with an
IMR of 13 and 67 per thousand were reviewed and AAO was obtained
by using the recorded age and duration of illness.
Results: In the sample from the state with lower IMR, AAO did not
dier between the two sexes. However, men had older AAO than
women in the state with ®vefold higher IMR.
Conclusion: Gender dierences in AAO may be a function of perinatal B. N. Gangadhar, Additional Professor, Department of
complications. In places where infants with perinatal complications are Psychiatry, NIMHANS, Bangalore 560 029, India.
less likely to survive, hence high IMR, a small group of potentially E-mail: bng@nimhans.kar.nic.in
youngest AAO schizophrenic males may be eliminated thus changing
the gender eect on AAO. Accepted for publication 12 November, 2001
317
Gangadhar et al.
Table 1. Patient characteristics and AAO of the two samples in the lower IMR state's sample and needs
Samples from
explanation. The IMR in Germany is only one-
third (3.5/1000) (11), as that of Kerala. This may
Variables Kerala (n 70) Karnataka (n 70) explain why the younger AAO for males in
Age (years) 29.8 9.0 29.6 8.9
Germany (2) is not seen in the Kerala sample of
Male : Female1 37 : 33 38 : 32 this study. The limitations of record-based data
AAO (years)2 23.5 8.3 25.4 8.5 have to be considered in accepting these results.
Age (years) at first Consultation3 24.8 7.8 27.9 8.8 For example, it is dicult to relate AAO from the
AAO (years)**
Male 23.5 8.5 27.4 8.6 case ®les to onset of psychosis reliably. The role of
Female 23.5 8.2 23.2 8.0 familial loading was not examined in this record-
Age (years) at first Consultation*** based study. This is yet another limitation consid-
Male 25.1 7.9 29.5 8.5
ering that females have higher incidence of familial
Female 24.4 7.8 25.9 9.0
morbidity (12).
1
Figures in cells are mean SD in all except one cell that has number of subjects. Kerala being the most literate state in the
Kerala±Karnataka difference: 2P 0.181; 3P 0.028. country, the patients may have sought medical
Sex difference: Kerala; **P 0.99, ***P 0.68; Karnataka; **P 0.045,
***P 0.091. help earlier. While the AAO was only 2 years
younger in Kerala sample, the mean age at ®rst
consultation was 3 years earlier than in Karnataka
sample (Table 1). However, the sex dierence was
Results absent in the Kerala sample. The social status of
Samples from Kerala and Karnataka were not women in the two states is not dierent. Social
dierent with respect to age and sex distribution. factors may have a less likely role aecting AAO.
The mean AAO and age at ®rst consultation of In summary, perinatal complications may in¯uence
Kerala sample were lesser than Karnataka; the the sex dierence in AAO. Future studies on sex
dierence being signi®cant only for the latter dierences in AAO of schizophrenia may have to
measure. Sex dierence was absent in the Kerala control for perinatal complications and perhaps
sample, whereas in the Karnataka sample the mean familial loading.
AAO and age at ®rst consultation were older in
males (Table 1). References
1. WORLD HEALTH ORGANIZATION. International classi®ca-
Discussion tion of diseases, 10th edn. Geneva: WHO, 1992.
2. KONNECKE R, HAFNER H, MAURER K, LOFFLER W,
The mean AAO in this (record-based) sample was HEIDEN W. Main risk factors for schizophrenia. increase
similar to an earlier prospective sample from the familial loading and pre- and peri-natal complications
same center (3) or from another Indian sample antagonize the protective eect of estrogen in women.
Schizophr Res 2000;44:81±93.
(10). This validates partially the AAO information 3. MURTHY GVS, JANAKIRAMAIAH N, GANGADHAR BN,
obtained from the records. Sex and age distribu- SUBBAKRISHNA DK. Sex dierence in age at onset: a dis-
tion in the samples of the two states too was crepant ®nding from India. Acta Psychiatr Scand
similar. A ®vefold dierence in the IMR in the 1998;97:321±325.
two states brought out a dierential sex-eect on 4. SUBBAKRISHNA DK, MURALI N, GANGADHAR BNN,
JANAKIRAMAIAH N. Younger age at onset of schizophrenia
measures of AAO. Sex dierence was absent in in females: a replicative study. In: SUBBAKRISHNA DK,
the lower-IMR Kerala state sample. In the sample KALIAPERUMAL VG, eds. Statistical methods and appli-
from the state with higher IMR, Karnataka, cation in biology and medicine. Bangalore, India:
males had older AAO than females. The age at NIMHANS, 2001:253±260.
®rst consultation too was older (trend) in this 5. BYRNE M, BROWNE R, MULRYAN N et al. Labor and
delivery complications and schizophrenia, case control
sample. study using contemporaneous labor ward records. Br J
With higher IMR in Karnataka, more infants Psychiatry, 2000;176:531±536.
with perinatal complications (more in males) may 6. KIROV G, JONES PB, HARVEY I et al. Do obstetric com-
have succumbed. This may have reduced the size of plications cause the earlier age at onset in male than female
the population at risk contributing to lower AAO. schizophrenics? Schizophr Res 2000;20:117±124.
7. ALDA M, AHREUS B, LIT W et al. Age of onset in familial
As perinatal complications being thrice more and sporadic schizophrenia. Acta Psychiatr Scand
common in males (9), this dierential IMR would 1996;93:447±450.
confound the sex-eect. Higher IMR may explain 8. PARK K. Park's textbook of preventive and social medi-
why older AAO was detected in males. Younger cine, 15th edn, Jabalpur, India: Banaresidas Bharat Pub-
AAO in males as in literature (2) was not detected lishers, 1997:342±391.
318
Age at onset of schizophrenia
9. PRETI A, CARDASCIA L, ZEN T, MARCHETTI M, FAVARETTO 11. NOLTE E, BRAND A, KOUPILOVA I, MCKEE M. Neonatal
G, MIOTTO P. Risk for obstetric complications and schi- and postneonatal mortality in Germany since uni®cation.
zophrenia. Psychiatry Res 2000;96:127±139. J Epidemiol Community Health 2000;54:84±90.
10. HAMBRECHT M, MAURER K, HAFNER H, SARTORIUS N. 12. WOLYNIEK PS, PULVER AE, MCGRATH JA, TAM D,
Transnational stability of gender dierences in schizophre- SCHIZOPHRENIA. Gender and familial risk, J Psych
nia? Eur Arch Psychiatry Clin Neurosci 1992;242:6±12. Research 1992;26:17±27.
319