Psychosis Onset Age and Employment Over 40 Years

Key Takeaways

• Among Finnish birth-cohort participants with psychosis, the proportion of time in registered employment increased significantly with later psychosis onset.
• Employment before psychosis was more common when the first recorded diagnosis of any psychiatric illness occurred later.
• Later psychosis onset was not significantly associated with employment five years afterward following adjustment, or with employment at age 57.
• Pre-onset employment remained significantly associated with employment five years after psychosis onset and at age 57 in adjusted analyses.
• Having children was associated with employment at all three assessed time points.

For people who develop psychosis, employment before the first psychotic diagnosis provides context for interpreting subsequent work across adulthood. Their work histories before and after illness onset allow investigators to examine how onset age relates to later employment.

In Kujanperä and colleagues’ Social Psychiatry and Psychiatric Epidemiology cohort study, investigators analyzed 225 people with psychosis in the Northern Finland Birth Cohort 1966 (excluding acute and transient, other nonorganic, and unspecified psychotic disorders) and used 6,835 people without a psychiatric diagnosis as a descriptive comparison. Linked national health and pension records covered 1983–2023, or ages 17–57; people who died or emigrated before 2023 were excluded from the complete-work-history analysis. Daily pension-accruing work informed each person’s mean annual proportion of days employed. Employment at specific time points meant any registered work in the relevant year: two years before psychosis onset, five years afterward or at age 57. Pre-onset regression used age at first recorded diagnosis of any psychiatric illness; post-onset regression used age at first psychotic-disorder diagnosis. Regression compared onset after age 21 with onset before age 21, while the descriptive onset groups had an upper boundary of 42.2 years. Investigators used Kruskal–Wallis tests with Bonferroni-adjusted pairwise comparisons and staged logistic models accounting for sex/gender, education, children and substance use; later-outcome models also accounted for earlier employment.

Across 1983–2023, mean proportions of time in registered employment were 0.10, 0.24 and 0.39 in ascending psychosis-onset-age groups. The overall difference and every pairwise comparison were statistically significant. At the assessed time points, the youngest-onset group consistently had little registered employment, whereas the oldest-onset group had more work before and after onset. Employment at age 57 was higher in the comparison group than among participants with psychosis. These descriptive trajectories should be distinguished from adjusted associations at individual time points.

Later onset of any psychiatric illness was associated with employment before psychosis onset after adjustment. Psychosis onset after age 21 was associated with employment five years afterward before adjustment (crude odds ratio [OR], 3.72), but not significantly after staged adjustment; it was not significantly associated with age-57 employment even before adjustment. Employment before psychosis onset was associated with employment five years afterward (adjusted OR, 11.12; 95% confidence interval [CI], 4.41–28.01) and remained significantly associated with employment at age 57. Having children was associated with employment at all three time points; secondary or tertiary education was associated with age-57 employment in the second adjusted model.

Registered pension-accruing work does not capture supported or voluntary work, education, training or employment outside Finland. Missing symptom-severity and treatment histories leave room for residual confounding. Excluding people who died or emigrated before 2023 could make observed work trajectories appear more favorable. The relatively homogeneous Finnish cohort and small diagnostic subgroups limit applicability to more diverse populations. The authors also cautioned that including premorbid employment might overadjust onset-age models, without establishing that overadjustment occurred.

The authors linked later psychosis onset to more time in registered work, while pre-onset employment remained associated with later work even though the adjusted onset-age association at five years did not persist.

Clinician Questions

Can employment findings for early-onset affective psychosis be compared with those for schizophrenia?

In the Northern Finland Birth Cohort 1966, the schizophrenia subgroup showed broadly similar associations to the overall psychosis sample. Only three people with affective psychosis developed psychosis before age 21, so investigators could not estimate post-onset employment associations by onset age for that subgroup.

Could early outpatient-only psychosis diagnoses have been missed in the Finnish birth-cohort registers?

For psychosis-onset ascertainment in the Northern Finland Birth Cohort 1966, specialized outpatient registers begin in 1998 and primary-care registers in 2011, leaving a theoretical gap for earlier outpatient-only diagnoses. The authors judged substantial missed ascertainment unlikely because initial psychosis presentations were generally assessed in inpatient settings in Finland during the relevant decades; insurance, pension and reimbursed-medication records could also capture cases.

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