Caring for Women with First Episode Psychosis

Writer's note: This piece was written with the support of Maria Ferrara, MD PhD; Psychiatrist | First Episode Psychosis Program, Ferrara, Italy; Assistant Professor | University of Ferrara, Italy

First Episode Psychosis (FEP) refers to the first experience of psychotic symptoms, such as hallucinations or delusions. FEP affects 2–3% of young people and marks a critical turning point in mental health care, as early identification and treatment strongly influence long-term outcomes. About 25% of patients recover fully, 50% recover but experience relapses or develop chronic conditions, and 25% do not fully recover, especially when treatment is delayed. Such delayed care can lead to persistent social, academic, and functional difficulties. Early intervention (within weeks to months), on the other hand, greatly improves chances of recovery, school or work reintegration, and reduced relapses.

I am a final-year psychiatry trainee with a long-standing interest in both FEP and gender-specific medicine, now working in a specialised early intervention service in Northern Italy. What first drew me to this field was the chance to intervene early, when recovery is most possible, and to help young people make sense of their experience and regain hope for the future.  As a woman and a doctor, I’m also very interested in gender specific medicine. This blog explores the challenges faced by women experiencing FEP at different phases of their life course.

Image source: Anda Lupulet on Unsplash

Is psychosis different in women?

Women typically develop FEP later in life than men. While men most commonly experience it between 18 and 25 years old, women and people who menstruate tend to develop it in their late twenties or early thirties, with a second peak around menopause. This temporal difference underscores the need for sex-specific approaches in early intervention that take into account the very different life phases in which women and men may experience FEP. Women experiencing FEP around menopause may be managing established careers and family responsibilities. For these women, recovery involves not only overcoming symptoms but also protecting and maintaining what they have built.

The psychotic experience can be especially complex for women, as it often intersects with pregnancy, motherhood, and menopause. As healthcare providers, it is essential to be sensitive to these unique challenges and to adopt proactive, tailored strategies that support women’s recovery in the context of their lives.

The Menstrual Cycle

The menstrual cycle adds a further layer of complexity to the psychotic experience in women. Some of the medications that are prescribed in FEP can disrupt or even stop the menstrual cycle. This might seem like a minor issue compared to severe hallucinations or thought disorders, but it matters to women, and their reproductive health should matter to us as providers. Patients rarely bring this problem up spontaneously, perhaps out of embarrassment or because they don’t see the connection between the drug and their menstrual cycle. Given that the menstrual cycle is being increasingly recognised as a vital sign of health, it is up to providers to ask the question and to figure out different treatment options.

Image source: Alice Guardado on Unsplash

Pregnancy and Motherhood

Few situations are as delicate as psychosis in the context of pregnancy. In rare cases women can experience their FEP immediately after birth (namely, post-partum psychosis which affects 0.1-0.2% of mothers). If left untreated, postpartum psychosis risks serious harm for both mother and baby, ranging from difficulty caring for the infant to maternal self-harm, suicide, and infanticide in the most severe cases. Other women can develop symptoms during pregnancy itself, which is equally risky and is associated with pre-term birth, stillbirth, increased rates of C-section, poor foetal development, and maternal self-harm and suicide.  

Intriguingly, some women experience a psychotic denial of pregnancy, whereby they genuinely do not recognise that they are pregnant. We have seen patients in our service who have entered the service in psychosis and received ongoing clinical evaluations and anti-psychotic medication but have been unable to acknowledge that they are indeed pregnant. These patients are a reminder of how reproductive health should be routinely part of our psychiatric care, as patients with severe mental illness may miss or misinterpret signs of pregnancy. Engaging patients in conversations about reproductive healthcare is essential.

Then there are women in treatment for psychosis who express the wish to become mothers. These conversations require openness and appropriate clinical preparation; we need to talk about potential health risks, responsibilities, and preventative strategies to ensure healthy pregnancies and births for both mother and baby.

Menopause

The second spike in presentation of FEP in women is seen at the onset of menopause. The cause of this association is not entirely clear. Some studies suggest that the hormone oestrogen, which is present in higher amounts during a woman’s reproductive years, may help to protect the brain against psychosis. During menopause, oestrogen levels drop dramatically, diminishing this potentially protective effect. This may be what causes some women to become more vulnerable to developing psychotic symptoms for the first time and helps to explain why FEP frequently occurs in middle-aged women, while men, who never have the protective level of oestrogen, are more likely to present with psychosis at a younger age. Of course, this is not the only mechanism at work, as only ~1% of women experience FEP at menopause.

At times, symptoms of FEP during menopause can be overlooked due to their subtle nature and overlap with perimenopausal symptoms such as sleep disruption, anxiety, and cognitive changes. This can lead to delays in recognising FEP and therefore treating it, and minimising the impact on the patient’s life and wellbeing. Psychosocial stressors at midlife – including work and caring responsibilities – may further increase vulnerability in perimenopausal women. Clinician awareness, careful and specialised assessment in this high-risk period is essential to distinguish menopausal symptoms from the early signs of FEP.

Why sex and gender matter in psychiatry

For a long time, psychiatry paid little attention to sex and gender differences. As in many other medical fields, symptoms were described, treatments tested, and protocols written as if men and women experienced illness in the same way (Samrina Sangha previously wrote about the Invisibility of Women in Healthcare for ITM). But as research has grown, it has become clearer that sex and gender shape when and how psychosis appears and the patient’s experience of the disorder.

We have all heard of the infamous belief that women are natural “multi-taskers”. Because of that, they often need to juggle multiple responsibilities as professionals, partners, and caregivers. Psychosis can disrupt all of these at once, leading to widespread impacts in a woman’s life and recovery. Ignoring the clinical relevance of the complexity of the multiple roles culturally assigned to women (for more on this read the Mental Load of Motherhood on ITM by Professor Jodi Pawluski) means providing care that is technically correct but delivers incomplete results in recovery.

As clinicians, our role is not only to prescribe medication or deliver therapy, but also to protect our patients’ self-identities, relationships, and futures. Supporting recovery from psychosis means much more than reducing symptoms. It is about helping women to reclaim their place in the world, in all their complexities. And perhaps that is the most poignant lesson I have learnt while working in early psychosis: that mental illness may bend a life’s path, but with timely, thoughtful care, it doesn’t have to break it.