Lifetime use of psychiatric medications and cognition at 43years of age in schizophrenia in the Northern Finland Birth Cohort 1966.

BACKGROUND: Higher lifetime antipsychotic exposure has been associated with poorer cognition in schizophrenia. The cognitive effects of adjunctive psychiatric medications and lifetime trends of antipsychotic use remain largely unclear. We aimed to study how lifetime and current benzodiazepine and antidepressant medications, lifetime trends of antipsychotic use and antipsychotic polypharmacy are associated with cognitive performance in midlife schizophrenia. METHODS: Sixty participants with DSM-IV schizophrenia from the Northern Finland Birth Cohort 1966 were examined at 43years of age with an extensive cognitive test battery. Cumulative lifetime and current use of psychiatric medications were collected from medical records and interviews. The associations between medication and principal component analysis-based cognitive composite score were analysed using linear regression. RESULTS: Lifetime cumulative DDD years of benzodiazepine and antidepressant medications were not significantly associated with global cognition. Being without antipsychotic medication (for minimum 11months) before the cognitive examination was associated with better cognitive performance (P=0.007) and higher lifetime cumulative DDD years of antipsychotics with poorer cognition (P=0.020), when adjusted for gender, onset age and lifetime hospital treatment days. Other lifetime trends of antipsychotic use, such as a long antipsychotic-free period earlier in the treatment history, and antipsychotic polypharmacy, were not significantly associated with cognition. CONCLUSIONS: Based on these naturalistic data, low exposure to adjunctive benzodiazepine and antidepressant medications does not seem to affect cognition nor explain the possible negative effects of high dose long-term antipsychotic medication on cognition in schizophrenia.

A comparison of the cumulative incidence and early risk factors for psychotic disorder in young adults in the Northern Finland Birth Cohorts 1966 and 1986.

AIMS: Few studies have compared time trends for the incidence of psychosis. To date, the results have been inconsistent, showing a decline, an increase or no significant change. As far as we know, no studies explored changes in prevalence of early risk factors. The aim of this study was to investigate differences in early risk factors and cumulative incidences of psychosis by type of psychosis in two comparable birth cohorts. METHODS: The Northern Finland Birth cohorts (NFBCs) 1966 (N = 12 058) and 1986 (N = 9432) are prospective general population-based cohorts with the children followed since mother's mid-pregnancy. The data for psychoses, i.e. schizophrenia (narrow, spectrum), bipolar disorder with psychotic features, major depressive episode with psychotic features, brief psychosis and other psychoses (ICD 8-10) were collected from nationwide registers including both inpatients and outpatients. The data on early risk factors including sex and place of birth of the offspring, parental age and psychosis, maternal education at birth were prospectively collected from the population registers. The follow-up reached until the age of 27 years. RESULTS: An increase in the cumulative incidence of all psychoses was seen (1.01% in NFBC 1966 v. 1.90% in NFBC 1986; p < 0.001), which was due to an increase in diagnosed affective and other psychoses. Earlier onset of cases and relatively more psychoses in women were observed in the NFBC 1986. Changes in prevalence of potential early risk factors were identified, but only parental psychosis was a significant predictor in both cohorts (hazard ratios ≥3.0; 95% CI 1.86-4.88). The difference in psychosis incidence was not dependent on changes in prevalence of studied early risk factors. CONCLUSIONS: Surprisingly, increase in the cumulative incidence of psychosis and also changes in the types of psychoses were found between two birth cohorts 20 years apart. The observed differences could be due to real changes in incidence or they can be attributable to changes in diagnostic practices, or to early psychosis detection and treatment.

Long-term antipsychotic use and its association with outcomes in schizophrenia - the Northern Finland Birth Cohort 1966.

BACKGROUND: Due to the paucity of previous studies, we wanted to elucidate the pharmacoepidemiology of antipsychotics in schizophrenia in a general population sample, and the association between long-term antipsychotic use and outcomes. METHODS: The sample included 53 schizophrenia subjects from the Northern Finland Birth Cohort 1966 with at least ten years of follow-up (mean 18.6 years since illness onset). Data on lifetime medication and outcomes (remission, Clinical Global Impression [CGI], Social and Occupational Functioning Assessment Scale [SOFAS]) were collected from medical records, interviews, and national registers. RESULTS: During the first two years 22 (42%), between two to five years 17 (32%), and between five to ten years 14 (26%) subjects had used antipsychotics less than half of the time. Drug-free periods became rarer during the follow-up. The mean lifetime daily dose of antipsychotics was 319mg in chlorpromazine equivalents. A high lifetime average and cumulative dose and antipsychotic polypharmacy were associated with a poorer outcome in all measures, whereas having no drug-free periods was associated with a better SOFAS score and a low proportion of time on antipsychotics with a better CGI score. CONCLUSIONS: In our population-based sample, the use of antipsychotics increased during the first five years of illness and was relatively stable after that. Our results suggest that both low dose and proportion of use, and having no drug-free periods, are associated with better outcomes, which concords with current treatment recommendations and algorithms. High long-term doses and polypharmacy may relate to poor outcomes.

Brain structural changes in women and men during midlife.

Brain development during childhood and adolescence differs between boys and girls. Structural changes continue during adulthood and old age, particularly in terms of brain volume reductions that accelerate beyond age 35 years. We investigated whether brain structural change in mid-life differs between men and women. 43 men and 28 women from the Northern Finland 1966 Birth Cohort underwent MRI brain scans at age 33-35 (SD=0.67) and then again at age 42-44 (SD=0.41). We examined sex differences in total percentage brain volume change (PBVC) and regional brain change with FSL SIENA software. Women showed significant PBVC reduction compared with men between the ages of 33-35 and 42-44 years (Mean=-3.21% in men, Mean=-4.03% in women, F (1, 68)=6.37, p<0.05). In regional analyses, women exhibited greater brain reduction than men in widespread areas. After controlling for total percent brain volume change, men show greater relative regional brain reduction than women in bilateral precentral gyri, bilateral paracingulate gyri, and bilateral supplementary motor cortices. The results indicate sex differences in brain changes in mid-life. Women have more total brain reduction, and more reduction on the outer brain surface than men, whereas men exhibit more brain reduction on the mid-line surface than women after co-varying for total brain volume loss. These changes could contribute to sex differences in midlife behaviour and health.

Interaction between parental psychosis and early motor development and the risk of schizophrenia in a general population birth cohort.

BACKGROUND: Delayed motor development in infancy and family history of psychosis are both associated with increased risk of schizophrenia, but their interaction is largely unstudied. AIM: To investigate the association of the age of achieving motor milestones and parental psychosis and their interaction in respect to risk of schizophrenia. METHODS: We used data from the general population-based prospective Northern Finland Birth Cohort 1966 (n=10,283). Developmental information of the cohort members was gathered during regular visits to Finnish child welfare clinics. Several registers were used to determine the diagnosis of schizophrenia among the cohort members and psychosis among the parents. Altogether 152 (1.5%) individuals had schizophrenia by the age of 46 years, with 23 (15.1%) of them having a parent with psychosis. Cox regression analysis was used in analyses. RESULTS: Parental psychosis was associated (P<0.05) with later achievement of holding the head up, grabbing an object, and walking without support. In the parental psychosis group, the risk for schizophrenia was increased if holding the head up (hazard ratio [HR]: 2.46; degrees of freedom [df]=1; 95% confidence interval [95% CI]: 1.07-5.66) and touching the thumb with the index finger (HR: 1.84; df=1; 95% CI: 1.11-3.06) was later. In the group without parental psychosis, a delay in the following milestones increased the risk of schizophrenia: standing without support and walking without support. Parental psychosis had an interaction with delayed touching thumb with index finger (HR: 1.87; df=1; 95% CI: 1.08-3.25) when risk of schizophrenia was investigated. CONCLUSIONS: Parental psychosis was associated with achieving motor milestones later in infancy, particularly the milestones that appear early in a child's life. Parental psychosis and touching the thumb with the index finger had a significant interaction on risk of schizophrenia. Genetic risk for psychosis may interact with delayed development to raise future risk of schizophrenia, or delayed development may be a marker of other risk processes that interact with genetic liability to cause later schizophrenia.

Use of antiepileptic or benzodiazepine medication and suicidal ideation--The Northern Finland Birth Cohort 1966.

Both antiepileptic drugs (AEDs) and benzodiazepines (BZDs) have previously been associated with an increased risk of suicidality. Our aim was to study the association between the use of conventional AEDs and BZDs and suicidal ideation in a large population-based cohort. Information on the medications used in the Northern Finland Birth Cohort 1966 was collected from the subjects at the age of 31 years, using a postal questionnaire (N=8211). The presence of suicidal ideation and other symptoms of depression and anxiety was assessed via the Hopkins Symptom Checklist - 25 questionnaire. The associations between medications and suicidal ideation were studied in different diagnostic groups and adjusted for symptoms of depression and anxiety. No difference was observed in suicidal ideation between AED users (n=54) and nonusers (n=8157). Subjects using BZDs (n=147) had greater suicidal ideation compared with nonusers (n=8064). Antiepileptic drug and benzodiazepine users more often exhibited other depression and anxiety symptoms. After adjustment for these symptoms, both AED and BZD users had less suicidal ideation compared with nonusers. In conclusion, in this population-based cohort, neither the use of AEDs nor that of BZDs was found to be associated with increased suicidal ideation when the symptoms of depression and anxiety were taken into account.

Brain morphometry of individuals with schizophrenia with and without antipsychotic medication ­ The Northern Finland Birth Cohort 1966 Study.

BACKGROUND: In schizophrenia, brain morphometric changes may be associated with antipsychotic medication. Only limited data is available concerning individuals with schizophrenia without antipsychotic medication. We aimed to study the associations of: use versus no use of antipsychotic medication; length of continuous time without antipsychotic medication; cumulative dose of lifetime antipsychotic medication; and type of antipsychotic medication; with brain morphometry in schizophrenia after an average of 10 years of illness. METHODS: Data of 63 individuals with schizophrenia (mean duration of illness 10.4 years) from the Northern Finland Birth Cohort 1966 were gathered by interview and from hospital and outpatient records. Structural MRI data at age 34 years were acquired and grey matter volume maps with voxel-based morphometry were analyzed using FSL tools. RESULTS: Of the individuals studied, 15 (24%) had taken no antipsychotic medication during the previous year. Individuals with antipsychotic medication had lower total grey matter (TGM) volume compared with non-medicated subjects, although this association was not statistically significant (Cohen's d=-0.51, P=0.078). Time without antipsychotic medication associated with increased TGM (P=0.028). Longer time without antipsychotic medication associated with increased regional volume in right precentral gyrus and right middle frontal gyrus. There were no associations between cumulative dose of lifetime antipsychotic medication or type of antipsychotic medication and brain morphometry. CONCLUSIONS: Unlike some previous investigators, we found no association between cumulative dose of lifetime antipsychotic medication and brain morphological changes in this population-based sample. However, longer continuous time without antipsychotic medication preceding the MRI scan associated with increased gray matter volume.

Neurocognition as a predictor of outcome in schizophrenia in the Northern Finland Birth Cohort 1966.

The purpose of this study was to study neurocognitive performance as a predictor of outcomes in midlife schizophrenia. There is a lack of studies with unselected samples and a long follow-up. The study is based on the prospective, unselected population-based Northern Finland Birth Cohort 1966. The study includes 43 individuals with schizophrenia and 73 controls, whose neurocognitive performance was assessed twice, at 34 and 43 years. At both time points we used identical neurocognitive tests to assess verbal and visual memory and executive functions. Our main aim was to analyse neurocognitive performance at 34 years as a predictor of clinical, vocational and global outcomes at 43 years. Additionally, the analysis addressed cross-sectional associations between cognitive performance and clinical, vocational and global measures at 43 years. The assessment of outcomes was performed in the schizophrenia group only. In the longitudinal analysis poorer visual memory predicted poorer vocational outcome and poorer long-term verbal memory predicted poorer global outcome. In the cross-sectional analysis poorer visual memory and lower composite score of neurocognition were associated with poorer global outcome. No individual neurocognitive test or the composite score of these predicted remission. These data indicate that neurocognition, especially memory function, is an important determinant of long-term functional outcome in midlife schizophrenia.

Associations between brain morphology and outcome in schizophrenia in a general population sample.

OBJECTIVE: To analyse associations between brain morphology and longitudinal and cross-sectional measures of outcomes in schizophrenia in a general population sample. METHODS: The sample was the Northern Finland 1966 Birth Cohort. In 1999-2001, structural brain MRI and measures of clinical and functional outcomes were analysed for 54 individuals with schizophrenia around the age of 34. Sex, total grey matter, duration of illness and the use of antipsychotic medication were used as covariates. RESULTS: After controlling for multiple covariates, increased density of the left limbic area was associated with less hospitalisations and increased total white matter volume with being in remission. Higher density of left frontal grey matter was associated with not being on a disability pension and higher density of the left frontal lobe and left limbic area were related to better functioning. Higher density of the left limbic area was associated with better longitudinal course of illness. CONCLUSIONS: This study, based on unselected general population data, long follow-up and an extensive database, confirms findings of previous studies, that morphological abnormalities in several brain structures are associated with outcome. The difference in brain morphology in patients with good and poor outcomes may reflect separable aetiologies and developmental trajectories in schizophrenia.

The characteristics and outcomes of hospitalised and outpatient-treated first-onset schizophrenia patients: a 5-year register linkage study.

AIM: We compared the course and outcome of schizophrenia in two groups: (i) hospitalised patients (HP) (n = 5980) who were identified based on their first hospital admission for schizophrenia and (ii) outpatient-treated patients (OTP) who received disability pension because of schizophrenia but who had no hospital admissions for schizophrenia or other psychotic disorder before having been granted a disability pension for schizophrenia (n = 1220). Outcomes were compared using data on mortality, psychiatric hospital utilisation, relapse rate and occupational functioning. METHODS: A nationwide register-based 5-year follow-up study of all first-onset schizophrenia cases between 1998 and 2003 in Finland. The data were linked with the register information of hospital admissions, disability pensions and National Causes of Death Registers. RESULTS: When outcome of treatment was evaluated using mortality rate, relapses, hospital treatment and involuntary admissions as outcome measures, results indicated that OTP group had got along better with their illnesses than HP group. The mortality rates, number of psychiatric treatment days and relapse rate during the 5-year follow up were significantly lower in OTP group. Within the OTP group, there was a notable subgroup of never HP (n = 737, 60.4%), who did not require any psychiatric hospitalisation during the 5-year follow up. CONCLUSIONS: Patients first identified as outpatients had better outcomes than patients first identified following a hospitalisation. Future studies are required to establish whether outpatient treatment is associated with more favourable prognosis, even after fully adjusting for severity of initial symptoms. The higher suicide mortality of hospital-treated patients suggests that hospital treatment of first-onset patients does not protect from suicide.

Interaction between parental psychosis and risk factors during pregnancy and birth for schizophrenia - the Northern Finland 1966 Birth Cohort study.

Our aim was to investigate the association between parental psychosis and potential risk factors for schizophrenia and their interaction. We evaluated whether the factors during pregnancy and birth have a different effect among subjects with and without a history of parental psychosis and whether parental psychosis may even explain their effects on the risk of schizophrenia. The sample comprised 10,526 individuals from the Northern Finland 1966 Birth Cohort. A total of 150 (1.4%) cohort members had schizophrenia by the age of 44 years, of them 18 (12.0%) had a parent with a history of psychosis. In non-psychotic cohort members, this figure was 495 (4.8%). In the parental psychosis group, significant early biological risk factors for schizophrenia included high birth weight (hazard ratio, HR 11.4; 95% confidence interval 3.3-39.7) and length (HR 4.1; 1.3-12.5), high birth weight in relation to gestational age (HR 3.2; 1.1-9.0), and high maternal age (HR 2.6.; 1.0-6.7). High birth weight and length and high maternal education had a significant interaction with parental psychosis. The presence of any biological risk factor increased the risk of schizophrenia significantly only among the parental psychosis group (HR 4.0; 1.5-10.5), whereas the presence of any psychosocial risk factor had no interaction with parental psychosis. Parental psychosis can act as an effect modifier on early risk factors for schizophrenia. Evaluation of the mechanisms behind the risk factors should, therefore, include consideration of the parental history of psychosis.

Characteristics of subjects with schizophrenia spectrum disorder with and without antipsychotic medication - a 10-year follow-up of the Northern Finland 1966 Birth Cohort study.

OBJECTIVE: To estimate the prevalence of non-medicated subjects having schizophrenia spectrum disorder and to study how they differ from medicated subjects in terms of sociodemographic and illness-related variables. We also aim to find the predictors for successful antipsychotic withdrawal. METHODS: Data of 70 subjects with schizophrenic psychoses (mean duration of illness 10.4 years) from the Northern Finland 1966 Birth Cohort were gathered by interview at the age of 34 and from hospital records. The stability of remission was assessed by comparing hospitalization rates between non-medicated and medicated subjects over an 8.7-year additional follow-up period. RESULTS: Twenty-four (34%) subjects were currently not receiving medication. They were more often males, less often on a disability pension, more often in remission, and had better clinical outcomes. Relapses during the follow-up were equally frequent between non-medicated and medicated subjects (47% vs. 56%). Not having been hospitalised during previous 5 years before the interview predicted long-term successful antipsychotic withdrawal without relapse. CONCLUSIONS: Despite a lack of precise predictors, there might be subgroup of schizophrenia spectrum subjects who do not need permanent antipsychotic medication, and a fewer previous psychiatric treatments may indicate such a subgroup.

Predictors of short- and long-term clinical outcome in schizophrenic psychosis--the Northern Finland 1966 Birth Cohort study.

OBJECTIVE: Since the outcome in schizophrenia is heterogeneous and often poor, identification of specific predictors of outcome would be useful in clinical practice. METHODS: Subjects with schizophrenic psychoses (n=103) included in the Northern Finland 1966 Birth Cohort (n=12,058), representing the general population, were followed-up for an average of 16.4 years. Predictor and outcome data were collected from the nationwide Finnish Hospital Discharge Register, hospital records and interviews. RESULTS: Insidious onset of illness predicted a rehospitalization due to psychosis in the 2 years after the initial discharge. Being single, having an early onset, insidious onset, suicidal ideations upon the first admission, a rehospitalization and a high number of treatment days due to psychosis in the early stages of the illness all predicted a poorer clinical outcome in the longer term, after a minimum follow-up of 10 years. CONCLUSIONS: This population-based study indicates that clinical and sociodemographic factors around the onset of illness have significance for the long-term outcome in schizophrenia. These prognostic factors should be taken into account in clinical practice.

The influence of temperament on symptoms and functional outcome in people with psychosis in the Northern Finland 1966 Birth Cohort.

OBJECTIVE: To describe symptom expression and functional outcome in psychotic disorders in relation with temperament traits assessed with the Temperament and Character Inventory (TCI) in a population-based sample. METHOD: As part of the 31-year follow-up survey of the Northern Finland 1966 Birth Cohort, TCI temperament items were filled in by 4349 members of the cohort. In individuals with psychotic disorders, also positive and negative symptoms and outcome variables were assessed in a 35-year follow-up. Information of TCI and outcomes were available for altogether 41 individuals with psychosis. RESULT: Reward dependence (RD) (rho=-0.45) and Persistence (P) (rho=-0.52) were significantly correlated with Positive and Negative Syndrome Scale (PANSS) negative symptoms. Higher P scores predicted higher social and occupational functioning (as measured by Social and Occupational Functioning Assessment Scale [SOFAS]), and higher Harm avoidance (HA) predicted a higher likelihood of being on a disability pension. CONCLUSION: Results indicate that understanding of personality dimensions support better understanding of outcome and symptom expressions in psychotic disorders.

Prevalence of alcohol use disorders in schizophrenia--a systematic review and meta-analysis.

OBJECTIVE: Our aim was to present recent studies of alcohol use disorders (AUDs) in patients with schizophrenia, estimate overall prevalence and characteristics affecting the prevalence of AUDs. METHOD: We conducted a search using three literature databases and a manual search on articles published in 1996-2008. Meta-regression was used to study how prevalence is affected by different study characteristics. Articles that reported diagnoses according to DSM or ICD diagnostic systems were included. RESULTS: Altogether 60 studies met our criteria. The median of current AUD prevalence was 9.4% (inter-quartile range, IQR 4.6-19.0, 18 studies) and median of lifetime AUD prevalence 20.6% (IQR 12.0-34.5, 47 studies). In studies using DSM-III-R median prevalence was higher than that in studies using DSM-IV, ICD-9 or ICD-10 (32/17/11/6%). CONCLUSION: Approximately every fifth patient with schizophrenia had lifetime AUD diagnosis. When contrasted with the most recent review, there might be a descending trend in AUD prevalence in patients with schizophrenia.

Negative symptoms in schizophrenia: a review.

Negative symptoms refer to the weakening or lack of normal thoughts, emotions or behaviour in schizophrenia patients. Their prevalence in first-episode psychosis is high, 50-90%, and 20-40% of schizophrenia patients have persisting negative symptoms. Severe negative symptoms during the early stages of treatment predict poor prognosis. The aim of the study was to review the current literature on the negative symptoms of schizophrenia. In June 2007, the following databases were searched: Web of Science, PubMed, PsycINFO, Medline (Ovid) and Scopus. The search included articles written in English and no time limit was determined. The studies were manually screened by one of the authors according to the title and abstract. About one in three schizophrenia patients suffer from significant negative symptoms. In these patients, negative symptoms constitute a key element of overall symptoms, weakening their ability to cope with everyday activities, affecting their quality of life and their ability to manage without significant outside help. About one in three schizophrenia patients suffer from significant negative symptoms. Attention should be focused on negative symptoms during the early phase of treatment, because they cause significant impairment to patients' quality of life. So far, no treatment appears to substantially improve negative symptoms narrowly defined. However, according to clinical experience, when treating negative symptoms, the best effect is achieved by optimizing the dose of medication and by complementing it with psychosocial therapies.

Outcome and its predictors in schizophrenia within the Northern Finland 1966 Birth Cohort.

PURPOSE: We report clinical and social outcomes of schizophrenia in the longitudinal, population-based Northern Finland 1966 Birth Cohort, and describe associated demographic, developmental and illness-related factors. SUBJECTS AND METHODS: Subjects with DSM-III-R schizophrenia (n=59) were followed prospectively from mid-gestation up to age 35 years. Outcome measures included positive and negative symptoms, psychiatric hospitalisations, social and occupational functioning. Several definitions of good and poor outcome were explored, and developmental, socio-demographic and clinical predictors of outcomes were analysed. RESULTS: Good clinical outcome varied from 10% to 59%, and good social outcome 15-46%, depending on definition. Poor clinical outcome varied 41-77% and poor social 37-54%. Lack of friends in childhood, father's high social class, lower school performance and earlier age of illness onset predicted poor outcomes. DISCUSSION: The outcomes of schizophrenia in this study depended on definitions used but were relatively poor. The age of illness onset, father's social class, school performance and poor social contacts in childhood were only statistically significant predictors. CONCLUSION: Definitions of outcome have a major effect on estimates for proportions of good and bad outcomes and on the predictors of outcomes. However, regardless of which definitions were used, the outcome of schizophrenia in this population-based sample was generally bleak.

Hope and schizophrenia: an integrative review.

The purpose of this article is to describe the current status of research on hope and schizophrenia. The CINAHL database was used to identify the articles that met the criteria. The searches were conducted using the terms 'hope', 'hope instillation (IOWA NIC)', 'hope (IOWA NOC)', 'schizophrenia' and their combinations. The findings were limited to research articles. In addition, Pub Medical database was used by searching the words 'hope' and 'schizophrenia' from the fields 'title' or 'abstract'. Four new articles were found. The data consist of 17 articles on hope and schizophrenia published in peer-reviewed journals, which were analysed using content analysis. Existing research has focused on people with schizophrenia (n = 8), significant others (n = 4), staff (n = 2), hope-engendering interventions (n = 2) and treatment evaluation related to hope (n = 2) in the care of people with schizophrenia. Different data collection methods have been used in these studies. The most common method was interview (n = 9), followed by questionnaires (n = 8) and observation (n = 1). Most studies used quantitative methods (n = 9). Hope is considered a positive factor in the life of a person living with schizophrenia, in significant others as well as in staff members. Existing research provides evidence of the following themes: factors associated with hope and factors contributing to hope in people with schizophrenia; hope from the perspective of significant others of people with schizophrenia; staff hopefulness and factors contributing to their hope, hope-engendering interventions and treatment evaluation in regard to hope. Based on this review, research evidence of hope in the context of schizophrenia is quite scant and limited, even though the importance of hope in schizophrenia has been underlined in research reports and the literature. It is clear that hope is important to people with schizophrenia, their significant others and the healthcare personnel caring for them. It is therefore also important to study hope among these people.

Good school performance is a risk factor of suicide in psychoses: a 35-year follow up of the Northern Finland 1966 Birth Cohort.

OBJECTIVE: Our aim was to analyse the relationship between good school performance and risk of suicide in the Northern Finland 1966 Birth Cohort, especially in psychoses. METHOD: A total of 11,017 cohort members who were alive at the age of 16 years were followed up to the age of 35 years. School performance was measured by the school marks given at age 16 at the end of comprehensive school. School, diagnostic and mortality data were based on national registers. RESULTS: For psychotic persons having good school performance (highest 20%), the adjusted hazard ratio (HR) for suicide was 3.56 (0.97-13.05) compared with the remaining 80%. In the non-psychotic population (97% without psychiatric hospitalization), accordingly, adjusted HR was 0.28 (0.07-1.16). Interaction (school performance x psychiatric diagnosis) was significant (P = 0.01) even when adjusted with gender, social class and age of onset of illness. CONCLUSION: Good school performance at age 16 years is associated with increased risk of suicide (before age 35 years) in persons who develop psychosis, whereas in persons who do not develop psychosis, it is associated with lower suicide risk.