Long-term outcome studies of schizophrenia: do females continue to display better outcome as expected?

Short-term studies of schizophrenia have uniformly found overall outcome better for females. The question is: 'Do females continue across time to exceed male levels of functioning?' If so, what are the possible buffers and protective mechanisms? If not, then why did females lose their advantage? Seven recent long-term studies of schizophrenia are reviewed. Outcome across all investigations was much better than expected, but the strong advantage for females seemed to have diminished across time to the trend level with males appearing to gain in strength. The long-term studies have suggested differences in genetic loadings, premorbid adjustment, age of onset, symptom presentation, social skills, structural brain anomalies and mortality causes and rates. The discussion revolves around normal and psychopathological biological differences (e.g. differential brain organization, hormonal effects, genetic sex linkages, and preferred cognitive mode), as well as social development which work for and against improvement. Several suggestions are made about research strategies to assess the complexities found in the long-term perspective.