School performance and risk of suicide in early adulthood: Follow-up of two national cohorts of Swedish schoolchildren

doi:10.1016/j.jad.2011.01.002

Journal of Affective Disorders

Volume 131, Issues 1–3, June 2011, Pages 104-112

https://doi.org/10.1016/j.jad.2011.01.002 Get rights and content

Abstract

Background

Poor school performance and low IQ are associated with an increased risk of suicide in males; it is uncertain whether cognitive performance is a risk factor for suicide in females and whether severe mental illness influences these associations.

Method

Record linkage study of Swedish education, population and census data with mortality and inpatient registers. Data were available for 95,497 males and 91,311 females born in 1972 and 1977 and followed up until 31 December 2005.

Results

230 males and 90 females died from suicide over the follow-up period. There were strong inverse associations between school performance at age 16 and subsequent suicide risk in males (fully adjusted hazard ratio (HR) per SD increase in school performance score: 0.6 (95% CI 0.6 to 0.7; p < 0.001)) but not females: adjusted HR. 1.1 (CI 0.9 to 1.4 p = 0.50). In males there were almost four fold differences in suicide risk between children in the top and bottom fifths of the range of school grade scores. Similar associations were seen with upper secondary school performance (age 18/19 years). There was no strong evidence that deterioration in school performance between ages 16 and 18 was associated with increased suicide risk. Amongst men who developed severe psychiatric illness school performance was not associated with suicide risk.

Limitations

We had limited information on the prevalence of minor psychiatric disorder in cohort members and no data on IQ for the cohort as a whole.

Conclusions

Good performance in secondary (age 16) and upper secondary (age 18) school is associated with a reduced risk of suicide in men but not women. This protective effect is not seen amongst those who develop severe psychiatric illness. These differences indicate that the aetiology of suicide differs in males and females and in those with and without severe mental illness.

Introduction

Cohort studies carried out in Sweden (Andersson et al., 2008, Gunnell et al., 2005), Australia (O'Toole and Stankov, 1992, O'Toole and Cantor, 1995), Denmark (Osler et al., 2008), Norway (Gravseth et al., 2010) and Finland (Alaraisanen et al., 2006) suggest that low IQ and poor school performance are associated with an increased risk of suicide in males. The associations are strong, with over two-fold differences in risk between high and low scorers.

Mechanisms underlying these associations are unclear. It is possible that deterioration in cognitive function or interruption of schooling as a result of mental illness may contribute to the observed patterns of risk. Alternatively, the more limited job opportunities available to people who perform less well at school may impact on adult socioeconomic position and job security, which in turn influence suicide risk. Lastly, cognitive function may impact on problem solving skills; it is possible that people with limited problem solving ability may be more likely to see suicide as the only solution to their problems. Previous studies have not investigated changes in cognitive function in relation to subsequent suicide risk, nor have they comprehensively assessed the possible confounding (or mediating) effects of socioeconomic position.

Furthermore, recent studies of the association of cognitive function with suicide have generated unexpected findings. In a study of 21,809 Swedish schoolchildren, born in 1948 and 1953 and assessed at age 13, IQ was inversely associated with suicide in males but not females (Andersson et al., 2008). No other studies have investigated gender-specific associations of cognitive test performance with suicide. Two studies have reported that associations differ in people with and without mental illness, with a positive association between test performance and suicide in people with previous hospital admissions for psychosis (Alaraisanen et al., 2006, Andersson et al., 2008). Similar findings have been reported in relation to attempted suicide (Batty et al., 2010). Likewise, in a study of former psychiatric inpatients in Denmark, there was an inverse association between the highest level of education completed and suicide risk (Agerbo, 2007).

In our recent study of Swedish schoolchildren, assessed at age 13, we found that associations of IQ with suicide disappeared in models controlling for mean school grade, indicating it was IQ-related school performance, rather IQ per se that influenced suicide risk (Andersson et al., 2008). To further investigate the link between school performance and suicide we have studied a cohort of over 180,000 Swedish males and females with measures of school performance at ages 16 and 18/19 years. This study has considerably more statistical power than our previous analysis, more detailed information on socioeconomic position and measures of educational performance at two time points in adolescence. We have investigated whether associations between school performance and suicide a) differ in males and females; b) differ in those with and without a record of psychiatric illness and c) are influenced by deterioration in school performance between ages 16 and 18.

Section snippets

Study population

This analysis is based on all Swedish males and females who were born in 1972 (n = 113,646) and 1977 (n = 99,749) and who completed their compulsory education in Swedish schools at age 16. Complete follow-up and baseline data were available for 186,808 subjects (88%) — the main reasons for exclusion were incomplete compulsory school performance data (n = 7058) and immigration to Sweden in the two years before completing compulsory school (n = 7712) (see below).

The following databases were linked to

Results

Altogether 95,497 males and 91,311 females fulfilled the inclusion criteria for the analyses, their characteristics are given in Table 1. There were 320 suicides (230 male and 90 female) over the 12–17 year follow-up: the overall suicide rate was 7.8 per 100,000 person years in males and 3.2 per 100,000 in females.

In total 6465 (3.5%) subjects were admitted to a psychiatric hospital and 3027 (1.6%) were admitted to a hospital following episodes of self-harm over the follow-up period. The most

Main findings

We found that school performance at ages 16 and 18/19 was strongly inversely associated with suicide risk in males, but not females. Amongst males there was a fourfold higher risk among those with the lowest 20% of school grades at age 16 compared to those with the highest 20%. In the subgroup (47%) of females who studied theoretical (more academic) courses in secondary school there was weak evidence (p = 0.09) that those with better school performance had an increased risk of suicide.

The

Conclusion

Educational performance is strongly associated with suicide risk in males and this association does not appear to be confounded by socioeconomic background or severe mental illness. Further studies are needed to elucidate the mechanism(s) through which education influences risk and reasons for the gender specificity of this association. Our findings add to the literature showing that risk factors for suicide differ in men and women (Qin et al., 2000). Similarly, risk factors for suicide appear

Role of funding source

The funder was not involved in the analysis, interpretation or write up of the results presented in this paper.

Conflict of interest

No conflict declared.

Acknowledgements

This project was funded by the Swedish Council for Working Life and Social Research. The UGU (education) database is funded by the Swedish Research Council. The project was approved by the Stockholm Regional Ethical Review Board. David Gunnell is a National Institute for Health Research (NIHR) Senior Investigator.

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Research reportSchool performance and risk of suicide in early adulthood: Follow-up of two national cohorts of Swedish schoolchildren

Abstract

Background

Method

Results

Limitations

Conclusions

Introduction

Section snippets

Study population

Results

Main findings

Conclusion

Role of funding source

Conflict of interest

Acknowledgements

Person. Individ. Diff.

Soc. Sci. Med.

High income, employment, postgraduate education, and marriage: a suicidal cocktail among psychiatric patients

Arch. Gen. Psychiatry

Risk of suicide in relation to income level in people admitted to hospital with mental illness: nested case–control study

BMJ

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

Acta Psychiatr. Scand.

Causes of death in a cohort of 50, 465 young men—validity of recorded suicide as underlying cause of death

Scand. J. Soc. Med.

Association of IQ scores and school achievement with suicide in a 40-year follow-up of a Swedish cohort

Acta Psychiatr. Scand.

Psychosis alters association between IQ and future risk of attempted suicide: cohort study of 1, 109, 475 Swedish men

BMJ

Show me the child at seven II: Childhood intelligence and later outcomes in adolescence and young adulthood

J. Child Psychol. Psychiatry

Research report
School performance and risk of suicide in early adulthood: Follow-up of two national cohorts of Swedish schoolchildren