Gender differences in sociodemographic and

clinical characteristic and the quality of life of

Chinese schizophrenia patients
Yu-Tao Xiang, Yong-Zhen Weng, Chi-Ming Leung, Wai-Kwong Tang,
Sandra S. M. Chan, Chuan-Yue Wang, Bai Han, Gabor S. Ungvari

Objective: The aim of the present study was to determine the sociodemographic and
clinical correlates of the gender of Chinese schizophrenia outpatients and their impact on
patients quality of life (QOL).
Methods: Two hundred and fifty-five clinically stable schizophrenia outpatients were randomly selected in Hong Kong. Counterparts matched according to gender, age, age at onset,
and length of illness were recruited in Beijing, China. All of the subjects at both sites were
interviewed by the same investigator using standardized assessment instruments.
Results: The combined BeijingHong Kong sample contained 251 male and 254 female
patients. On univariate analysis more male patients were employed, they had a significantly
higher monthly income, and took higher doses of antipsychotic drugs. No difference was
found, however, in any of the QOL domains between the genders. On multivariate analysis
being employed, taking a higher dose of antipsychotic drugs, having more severe extrapyramidal side-effects, and a higher score on the physical domain of QOL were independently
associated with male gender.
Conclusion: Female gender is independently associated with lower scores on the physical aspects of QOL, but there is no difference between the genders in the psychological,
social and environmental aspects.
Key words: China, gender, Hong Kong, quality of life, schizophrenia.
Australian and New Zealand Journal of Psychiatry 2010; 44:450455

Gender differences in schizophrenia have received

ample attention over recent decades. Consistently reported
Yu-Tao Xiang, Research Assistant Professor and Attending Psychiatrist
(Correspondence)
Department of Psychiatry, Chinese University of Hong Kong, Ground
Floor, Multicentre Building, Tai Po Hospital, Tai Po, NT, Hong
Kong (email: xyutly@cuhk.edu.hk); Beijing Anding Hospital, Capital
Medical University, Beijing, China
Yong-Zhen Weng, Professor; Chuan-Yue Wang, Professor
Beijing Anding Hospital, Capital Medical University, Beijing, China
Chi-Ming Leung, Consultant Psychiatrist; Wai-Kwong Tang, Professor;
Sandra S. M. Chan, Associate Professor; Gabor S. Ungvari, Professor
Department of Psychiatry, Chinese University of Hong Kong, Hong Kong
Bai Han, Associate Consultant Psychiatrist
Department of Psychiatry, First Hospital of Shanxi Medical University,
Taiguan City, Shanxi Province, China
Received 9 June 2009; accepted 12 October 2009.

2010 The Royal Australian and New Zealand College of Psychiatrists

gender differences in schizophrenia include age at onset,

clinical presentation, course, social functioning, therapeutic alliance, and treatment response [15]. It should
be noted, however, that evidence to support reported gender differences is still preliminary because schizophrenia
is a heterogenous disorder, possibly determined by a host
of biological and sociocultural factors [57]. As a result,
findings obtained in Caucasian patient populations may
not be applicable to other ethnic groups in different sociocultural settings.
In the past two decades, quality of life (QOL) has been
gaining attention as an important outcome measure in
psychiatric practice because it could give a comprehensive view of the effectiveness of pharmacotherapeutic and
psychosocial interventions [8]. A number of factors, including sociodemographic characteristics [9], psychotic and

GENDER DIFFERENCES IN SCHIZOPHRENIA

depressive symptoms [1012], drug-induced side-effects

[13], and length of illness [14] are all related to poor
QOL in schizophrenia. There is preliminary evidence of
cross-cultural or ethnic differences in the QOL of
psychiatric patients [15], and it is likely that findings
reported from Western countries do not apply to patients
with different ethnic and cultural backgrounds. To the
best of our knowledge, no study in China has addressed
gender in schizophrenia and its relationship with QOL
using standardized assessment methods.
The aim of the present study was therefore to examine
(i) gender differences with regard to sociodemographic
and clinical characteristics in schizophrenia outpatients
in two major Chinese cities, Beijing and Hong Kong; and
(ii) the association between gender and QOL in schizophrenia patients. In view of earlier findings [6,7,15], we
hypothesized that gender differences in one or more
sociodemographic or clinical characteristics would exist
in Chinese schizophrenia patients. We also expected that
female patients would have a better QOL than their male
counterparts.
Schizophrenia outpatients deserve special attention
because they account for  90% of the whole schizophrenia
patient population in China, comprising approximately 5
million outpatients [16].
Methods
Settings and subjects
The present study was part of a large-scale project on QOL in schizophrenia outpatients in China. A detailed description of the study design
and data collection has been reported elsewhere [17]. Briefly, subjects
in Hong Kong were randomly selected from the schizophrenia patients
who attended the outpatient department (OPD) of a university-affiliated
general hospital serving a population of approximately 800 000. Their
Beijing counterparts, matched according to gender, age, age at onset and
length of illness, were recruited from schizophrenia patients who
attended the Adult Psychiatric OPD at Beijing Anding Hospital,
a teaching psychiatric hospital serving a population of approximately
3 000 000 in Beijing.
Patients who met the following inclusion criteria were invited to
participate in the study: (i) diagnosis of schizophrenia according to
DSM-IV; (ii) age between 18 and 60 years; (iii) length of illness 5
years; and (iv) being outpatients who had been clinically stable for 3
months before recruitment [18]. The exclusion criteria were: (i) history
of or ongoing major chronic medical or neurological condition(s); and
(ii) past or current significant drug/alcohol abuse other than nicotine.
The course of recruitment was as follows: (i) at the Hong Kong site,
all schizophrenia patients meeting the study criteria were identified with
the computerized Chart Management System (CMS) by the principal
author before their attendance at the OPD; (ii) subjects were randomly
selected from the total number of eligible patients and invited to participate in the study; (iii) in Beijing, once schizophrenia patients registered

451

at the OPD of Anding Hospital, their medical records were screened to

establish eligibility for the study, and the first patient who matched a
previously unmatched Hong Kong counterpart was invited to participate;
and (iv) the principal author spent 2 months alternatively in Hong Kong
and Beijing selecting, recruiting, and assessing the subjects.
The study protocol was approved by the Joint Chinese University of
Hong Kong and New Territories East Cluster Clinical Research Ethics
Committee in Hong Kong and the Human Research and Ethics Committee of Beijing Anding Hospital. Written consent was obtained from
all subjects.

Data collection
The principal author assessed all subjects throughout the study and
conducted interviews on the day that the subjects attended the OPD.
Sociodemographic and clinical data were extracted from medical notes
and confirmed during the interview.

Assessment tools and procedures

Psychotic symptoms were measured with the Brief Psychiatric Rating
Scale [19]. The following three mean symptom scores of the scale were
used: (i) positive (conceptual disorganization, suspiciousness, hallucinatory behavior, and unusual thought content); (ii) negative (emotional
withdrawal, motor retardation, blunted affect, and disorientation) [20];
and (iii) anxiety and tension [10]. The 17-item Hamilton Depression
Rating Scale was used to assess the severity of depressive symptoms
[21]. Extrapyramidal side-effects (EPS) were evaluated with the
SimpsonAngus Scale of Extrapyramidal Symptoms [22] and the
Barnes Akathisia Rating Scale [23]. The sum scores of these scales
were entered into the statistical analysis [24].
QOL is defined as an individuals perception of ones position in
life in relation to goals, expectations, standards and concerns in the
context of the culture and value systems in which one lives [25].
It was assessed with the Hong Kong and mainland Chinese versions of
the World Health Organization Quality of Life ScheduleBrief [26] in
Hong Kong and Beijing, respectively. The two QOL schedules are
nearly identical, and both cover four domains: physical and psychological health, social relationships, and environmental factors. Doses
of antipsychotic drugs (AP) were converted to chlorpromazine equivalents [27]. A suicide attempt was defined as a self-destructive act carried out with at least some intent to end ones life [28].
To check the consistency of the principal authors ratings, before
the study an interrater reliability exercise of all rating instruments was
conducted involving another qualified psychiatrist on 20 randomly
selected schizophrenia patients. The intra-class correlation coefficients
(ICC) for all instruments tested were 0.75.

Statistical analysis
The data were analysed using SPSS 13.0 for Windows (SPSS,
Chicago, IL, USA). The comparison between the two genders with
respect to sociodemographic and clinical characteristics was performed
using independent sample t-test, MannWhitney U-test, and 2 test as
appropriate. Multiple logistic regression analysis was used to adjust for
relevant covariates and to determine the independent correlates of gender. Gender was the dependent variable, and the independent variables

Y.-T. XIANG, Y.-Z. WENG, C.-M. LEUNG ET AL.

452

included age, marital and employment status, education level, monthly

income, age at onset, length of illness, number of admissions, lifetime
suicide attempts, severity of psychopathology, drug-induced EPS, and
depressive symptoms, taking typical APs only, atypical APs only, doses
of APs, and each domain of QOL. The one-sample Kolmogorov
Smirnov test was used to check the normality of distribution for
the continuous variables. The level of significance was set at 0.05
(two-tailed).

a significantly higher monthly income and took higher doses of

antipsychotic drugs than the female patients.
On multiple logistic regression analysis, being employed, a higher
dose of antipsychotic drugs, more severe EPS, and a higher score on
the physical QOL were independently associated with male gender
(Table 2).

Results

To the best of our knowledge, this was the first study

to investigate the association of gender and QOL in
Chinese schizophrenia patients.
The first hypothesis was supported by the results.
There were differences between the two sexes in terms
of employment status, monthly income, doses of APs and
severity of EPS. Over recent decades it has been consistently reported that men with schizophrenia have an earlier age at onset than women [3,2931]. Several biological
mechanisms for this gender difference have been proposed, including sex-linked genetic mechanisms [32], the
neuroprotective effect of estrogens [33], and the increased
vulnerability of the male brain due to slower maturation
[34]. In the present study male patients had an earlier age

Two hundred and ninety-eight patients in Hong Kong and 288

patients in Beijing were invited to participate in the study. Forty-three
patients in Hong Kong and 38 in Beijing declined to take part. There
was no significant difference between those who participated and those
who declined to take part in the study in terms of age, gender, age at
onset, or length of illness. The two samples in Hong Kong and Beijing
were combined because they were both drawn from a population of
clinically stable outpatients and were matched according to basic sociodemographic and clinical variables. There were 251 male and 254 female
patients in the combined sample.
Table 1 lists the sociodemographic and clinical characteristics of the
whole sample and those for men and women separately, providing a
comparison between the genders with regard to sociodemographic and
clinical data and QOL. More male patients were employed and they had

Discussion

Table 1. Subject characteristics

Whole sample

Married/cohabitating
Employed
Suicide attempt
On typical AP(s) only
On atypical AP(s) only

Women

228
165
135
244
219

45.1
32.7
26.7
48.3
43.4

104
101
73
117
115

41.4
40.2
29.1
46.6
45.8

124
64
62
127
104

Mean
Age (years)
Educational level
(years)
Monthly income (HK$)
Age at onset (years)
Length of illness (years)
No. admissions
CPZeq (mg)
BPRS positive score
BPRS negative score
BPRS anxiety score
EPS sum score
HAMD score
Physical QOL
Psychological QOL
Social QOL
Environmental QOL

Men (n  251)

43.0
10.4
2022
26.8
16.2
2.3
273
1.4
1.4
1.4
0.6
4.4
14.2
13.6
13.1
13.6

SD
8.4
3.4
2511
7.6
8.3
2.2
188
0.7
0.5
0.6
1.6
4.0
2.4
2.6
2.6
2.2

(n  254)
%
48.8
25.2
24.4
50.0
40.9

Mean

SD

Mean

40.0
10.6

8.8
3.5

43.1
10.1

8.2
3.3

1699
27.2
15.8
2.3
247
1.5
1.5
1.4
0.5
4.4
14.1
14.1
13.3
13.7

2241
7.9
8.4
2.1
183
0.7
0.7
0.6
1.2
3.8
2.5
2.5
2.4
2.3

2347
26.5
16.6
2.4
299
1.4
1.4
1.5
0.9
4.4
14.3
13.5
13.0
13.6

2723
7.4
8.3
2.3
191
0.7
0.5
0.7
2.0
4.2
2.4
2.6
2.9
2.2

SD

Statistics
2

df

2.8
13.0
1.4
0.6
1.2

1
1
1
1
1

0.1
0.001
0.2
0.4
0.3

T/Z

df

0.1
1.5

503
503

0.9
0.1

3.1
1.1
1.1
0.3
3.5
0.6
0.06
1.3
1.7
0.6
0.7
1.1
1.2
0.5

503
503

503
503
503

503
503
503
503

0.002
0.3
0.3
0.8
0.001
0.6
0.9
0.2
0.09
0.6
0.5
0.3
0.2
0.6

AP, antipsychotic drug; BPRS, Brief Psychiatric Rating Scale; CPZeq, chlorpromazine equivalent; EPS, extrapyramidal side-effects;
HAMD, Hamilton Depression Rating Scale; QOL, quality of life. Men vs women; MannWhitney U-test.

GENDER DIFFERENCES IN SCHIZOPHRENIA

Table 2. Factors associated with gender on multiple

logistic regression

Married/cohabitating
Being employed
Suicide attempt
On typical AP(s) only
On atypical AP(s) only
Age (years)
Educational level (years)
Monthly income (HK$)
Age at onset (years)
Length of illness (years)
No. admissions
CPZeq (mg)
BPRS positive score
BPRS negative score
BPRS anxiety score
EPS sum score
HAMD score
Physical QOL
Psychological QOL
Social QOL
Environmental QOL

OR

95% CI

0.5
0.028
0.5
0.4
0.1
0.96
0.2
0.3
0.8
0.6
0.5
0.001
0.1
0.8
0.2
0.005
0.4
0.017
0.2
0.4
0.5

0.9
1.7
1.1
1.4
1.8
1.002
1.03
0.9
1.01
1.02
0.96
1.002
0.7
0.9
1.3
1.2
0.9
1.1
0.9
0.9
0.9

0.61.3
1.12.8
0.71.8
0.72.9
0.913.8
0.91.1
0.91.1
0.91.01
0.91.1
0.91.1
0.91.1
1.0011.003
0.61.1
0.71.4
0. 92.0
1.11.4
0.91.04
1.031.3
0.81.04
0.91.1
0.81.1

AP, antipsychotic drug; BPRS, Brief Psychiatric Rating Scale;

CI, confidence interval; CPZeq, chlorpromazine equivalent;
EPS, extrapyramidal side-effects; HAMD, Hamilton Depression
Rating Scale; OR, odds ratio; QOL, quality of life. Female
gender used as the reference group.

at onset than female patients, but the difference did not

reach a statistically significant level. The discrepancy
between our results and those of the mainstream literature could be due to the following reasons. First, the age
at onset of schizophrenia is likely to be influenced by both
biological and social factors [5,35]. Consequently,
differences in the sociocultural environment between
Caucasian and Chinese populations could explain the
difference in findings. Second, there is evidence that men
have an earlier age at onset only in the 1525 year age
group, whereas equal numbers of men and women fall ill
between the ages of 25 and 35. After the age of 35 more
women are diagnosed with schizophrenia [36]. In the
present sample the mean age at onset was 26.5 years in
men and 27.2 years in women in the age range of 2535
years, supporting Castles findings [36]. The relationship
between gender and age at onset needs to be further
explored in different ethnic groups and sociocultural
contexts.
The ratio of the lifetime suicide attempts an important risk factor for completed suicide [37,38] between
women and men in the present study was 0.8, considerably lower than the figure of 2.7 found in the general
Chinese population [39]. This discrepancy is compatible

453

with the fact that the prevalence of and gender ratio in

suicidal behavior and completed suicide are different
between the general population and schizophrenia patients
[3840]. In a retrospective survey, 9156 schizophrenia
patients were followed up for 17 years after their first
admission in Denmark [40]. The female/male suicide
ratio was 0.7, very similar to the ratio of suicide attempts
found in the present study.
Women with schizophrenia have been found to have
better social functioning and more post-hospitalization
employment than their male counterparts [1,2,41]. In the
present study, however, more men were found to be
employed. The attitudes of Chinese society towards women
with psychiatric disorders might be behind this surprising
finding. In China, men are traditionally regarded as the
pillar of the family. Their role is to take full responsibility
to support the whole family. Most women with schizophrenia, even if they are clinically stable and have better
social functioning than male patients, are expected to
stay at home as housewives. In addition, Chinese women
with psychiatric disorders suffer from more severe discrimination when applying for jobs than men [42]. All of
these factors could lead to a lower rate of employment
and lower monthly income in women with schizophrenia.
The male patients in the present study took higher
doses of antipsychotic drugs and experienced more
severe EPS than the female patients, confirming most
[4345] but not all [46] previous findings. In addition to
the variables controlled in the present study, other factors
that could play a role in determining antipsychotic doses,
treatment responses, and side-effects such as genetics,
height, weight, lean musclefat ratio, diet, exercise, smoking,
alcohol abuse, and use of concomitant medication [1]
were not included. Therefore, the relationships between
gender with antipsychotic doses and side-effects need to
be further explored.
Women with schizophrenia have been reported to have
better social functioning, more employment, less severe
psychopathology, fewer and shorter hospitalizations, more
benign courses of the disease, more favourable outcomes,
and fewer criminal records [1,2,41,47,48]. Consequently,
we hypothesized that female schizophrenia patients
would have a better QOL than their male counterparts.
The results, however, did not support this hypothesis.
There was no significant difference between the two genders in any of the QOL domains on univariate analysis,
but female patients had a lower score in the physical
domain after adjusting for sociodemographic and clinical
variables. This result suggests that there might be an
independent association between gender and QOL in
schizophrenia, although female gender has never been
reported as an independent negative factor in any of the
theoretical models of QOL in psychiatry [4954].

454

Y.-T. XIANG, Y.-Z. WENG, C.-M. LEUNG ET AL.

According to the distress/protection QOL model [54],

QOL is the outcome of an interaction between protective
and distressing factors. Although most illness-related
factors are more favourable to female schizophrenia
patients than their male counterparts [1,2,41,47,48], their
QOL was worse in the present study, suggesting that
distressing factors must be negatively influencing it: this
unexpected finding needs confirmation. We speculate
that relatively more severe discrimination towards women
with schizophrenia in Chinese society might contribute
to their lower QOL.
The strengths of the present study were its large, random, and diagnostically homogeneous sample. The results
should be interpreted with caution, however, because of
the following methodological limitations. First, only
chronic and clinically stable schizophrenia patients were
included and those with a history of or ongoing major
medical or neurological conditions, and past or current
drug/alcohol abuse were excluded. Therefore the results
may not be applicable to patients in different stages of the
disorder. Second, some factors might have led to selection
bias using the current recruitment strategy. For example,
in Hong Kong schizophrenia patients in better economic
condition are more likely to attend private psychiatrists
for more convenient service provision, while the stigma
attached to schizophrenia might have prevented some
patients from attending outpatient clinics in both sites.
Third, previous studies in the West indicated that some
more variables such as premorbid functioning and family
support had significant influence on QOL [5557], therefore more relevant factors should be investigated in
future studies. Finally, the severity of psychotic symptoms of patients who refused to participate in the study
could not be assessed because they did not sign the consent form. Therefore, the possibility cannot be excluded
that the participants represented a less or more severely
disabled subgroup of schizophrenia patients.
In conclusion, gender differences with regard to
sociodemographic and clinical characteristics in Chinese
schizophrenia patients are not entirely consistent with the
results reported in Western settings. In contrast to the
generally held view based on Western studies, Chinese
female schizophrenia patients do not seem to have a better QOL, and, even in the physical aspect of QOL, they
fare worse than their male counterparts.
Acknowledgements
This study was supported by grants from the National
Natural Science Foundation of China (No. 30800367),
the Beijing Nova Program of the Beijing Municipal
Science and Technology Commission (No. 2008B59),

and a Direct Grant for Research from the Chinese University of Hong Kong (Project No. 2041454).
Declaration of interest: The authors report no conflicts
of interest. The authors alone are responsible for the content and writing of the paper.

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