The educational burden of disease: a cohort study

Non-random Mating Patterns in Education, Mental, and Somatic Health: A Population Study on Within- and Cross-Trait Associations

Partners resemble each other on many traits, such as health and education. The traits are usually studied one by one in data from established couples and with potential participation bias. We studied all Norwegian parents who had their first child between 2016 and 2020 (N=187,926) and the siblings of these parents. We analysed grade point averages at age 16 (GPA), educational attainment (EA), and medical records with diagnostic data on 10 mental and 10 somatic health conditions measured 10 to 5 years before childbirth. We found stronger partner similarity in mental (median r=0.14) than in somatic health conditions (median r=0.04), with ubiquitous cross-trait correlations for mental health conditions (median r=0.13). GPA correlated 0.43 and EA 0.47 between partners. High GPA or EA was associated with better mental (median r=-0.16) and somatic (median r=-0.08) health in partners. Elevated correlations for mental health (median r=0.25) in established couples indicated convergence. Analyses of siblings and in-laws revealed deviations from direct assortment, suggesting instead indirect assortment based on related traits. Adjusting for GPA and EA reduced partner correlations in health with 30-40%. This has implications for the distribution of risk factors among children, for genetic studies, and for studies of intergenerational transmission.

Evaluating the causal relationship between educational attainment and mental health

We investigate the causal relationship between educational attainment (EA) and mental health using two research designs. First, we compare the relationship between EA and 18 psychiatric diagnoses within sibship in Dutch national registry data (N=1.7 million), thereby controlling for unmeasured familial factors. Second, we apply two-sample Mendelian Randomization, which uses genetic variants related to EA or psychiatric diagnosis as instrumental variables, to test whether there is a causal relation in either direction. Our results suggest that lower levels of EA causally increase the risk of MDD, ADHD, alcohol dependence, GAD and PTSD diagnoses. We also find evidence of a causal effect of ADHD on EA. For schizophrenia, anorexia nervosa, OCD, and bipolar disorder, results were inconsistent across the different approaches, highlighting the importance of using multiple research designs to understand complex relationships such as between EA and mental health.

Educational achievement among children with a disability: do parental resources compensate for disadvantage?

We examined the impact of child disability on Grade Points Average (GPA) using all children aged 15-16 years who completed their lower secondary education and registered with a GPA score in the period from 2016 to 2020 in Norway (n = 247 120). We use registry data that contain information on the child's main diagnosis, such as physical-, neurological- and neurodevelopmental conditions, and the severity of the condition, additional to the child's family characteristics. First, we examined whether the impact of the child's disability on the GPA scores varied by diagnosis and the severity of the child's condition. Second, we examined whether higher parental socioeconomic status (SES) buffers against the negative impact of child disability on GPA scores. Using longitudinal register data with the school fixed-effect model, the results showed that children with neurological and neurodevelopmental disabilities obtained lower GPA scores than their typically developing peers without chronic conditions, however children with asthma and diabetes had comparable GPA scores. These associations were most evident for neurodevelopmental conditions, such as ADHD and autism but also notable for neurological conditions such as epilepsy. In general, a severe condition impacts GPA scores more negatively than a less severe condition. Moreover, our analysis revealed that children of highly educated parents obtained higher GPA scores than children who had parents with short education. This applied to both disabled and typically developing peers, except children with autism and epilepsy, among whom buffering due to the parent's education did not seem to apply.

School achievement in adolescence and the risk of mental disorders in early adulthood: a Finnish nationwide register study

School grades in adolescence have been linked to later psychiatric outcomes, but large-scale nationwide studies across the spectrum of mental disorders are scarce. In the present study, we examined the risk of a wide array of mental disorders in adulthood, as well as the risk of comorbidity, associated with school achievement in adolescence. We used population-based cohort data comprising all individuals born in Finland over the period 1980-2000 (N = 1,070,880) who were followed from age 15 or 16 until a diagnosis of mental disorder, emigration, death, or December 2017, whichever came first. Final grade average from comprehensive school was the exposure, and the first diagnosed mental disorder in a secondary healthcare setting was the outcome. The risks were assessed with Cox proportional hazards models, stratified Cox proportional hazard models within strata of full-siblings, and multinomial regression models. The cumulative incidence of mental disorders was estimated using competing risks regression. Better school achievement was associated with a smaller risk of all subsequent mental disorders and comorbidity, except for eating disorders, where better school achievement was associated with a higher risk. The largest associations were observed between school achievement and substance use disorders. Overall, individuals with school achievement more than two standard deviations below average had an absolute risk of 39.6% of a later mental disorder diagnosis. By contrast, for individuals with school achievement more than two standard deviations above average, the absolute risk of a later mental disorder diagnosis was 15.7%. The results show that the largest mental health burden accumulates among those with the poorest school achievement in adolescence.

Longitudinal associations between academic achievement and depressive symptoms in adolescence: Methodological considerations and analytical approaches for identifying temporal priority

Failure to meet educational expectations in adolescence can derail an individual's potential, leading to hardship in adulthood. Lower academic achievement is also associated with poorer mental health, and both share common pathways to adult functional outcomes like employment status and economic security. Although linked in adolescence, and predictive of similar outcomes in adulthood, methodological and analytical limitations of the literature do not permit the assessment of the temporal priority between academic achievement and mental health. This omission of directionality hampers intervention and prevention efforts. In this narrative review, we summarize the literature on the temporal ordering between academic achievement and depressive symptoms in adolescence, a particularly vulnerable developmental period. We propose methodological and analytical strategies to guide future research to disentangle the chronological ordering between academic achievement and depressive symptoms-recommendations that can be used to examine other sets of correlated variables over time. Specifically, we highlight methodological issues that require attention such as the need to understand reciprocal and cascading influences over time by attending to repeated measures and timing, measurement consistency, reporter effects, examination of processes and mechanisms, and missing data. Finally, we discuss the need to embrace analytical methods that separate within-person from between-person effects; account for heterogeneity in associations using person-centered approaches; and use the two approaches as complementary, rather than competing, for a more holistic examination of temporality.

The COVID-19 pandemic's impact on mental health care use among Norwegian students in higher education: a nation-wide register-based pre-post cohort study

BACKGROUND

The COVID-19 pandemic, and its associated social distancing measures, gave profound changes to the everyday and academic life of students in higher education. The current study is the first to use nation-wide data to evaluate the long-term effect of the pandemic and its countermeasures on university students' mental health care use.

METHODS

Using nation-wide individual-level data, we studied mental health consultations in primary care (data available from January 2017 to February 2022) and dispensed prescription drugs used to treat anxiety, depression, and sleep disturbances (data available from October 2018 to February 2021) for first-year undergraduate university students. We compared changes over time in mental health care use in a pandemic cohort (12,501 first-year students enrolled in 2019) to the same change in a pre-pandemic cohort (25,990 first-year students enrolled in 2017 and 2018). Event study and difference-in-difference models allowed us to separate the impact of the pandemic, experienced by the pandemic cohort only, from secular and seasonal changes experienced by all cohorts.

RESULTS

The percentage of students with a mental health consultation temporarily decreased during the first period of strict social distancing measures in March 2020. At the end of the second round with strict measures in April 2021, the level of mental health consultations increased by 73% (95% CI 40-106.3). There was also a 42% (95% CI 5.7-79.5) increase in mental health consultations in November 2021. No similar increases were observed for dispensed prescription drugs between March 2020 and February 2021.

CONCLUSIONS

The COVID-19 pandemic was associated with increases in mental health consultations in primary care among students, especially during/after longer periods of strict social distancing measures. The benefits of social distancing measures in future pandemic preparedness should be weighed against the cost of potentially worsening mental health in vulnerable groups.

Educational inequalities and premature mortality: the Cuba Prospective Study

BACKGROUND

Although socioeconomic status is a major determinant of premature mortality in many populations, the impact of social inequalities on premature mortality in Cuba, a country with universal education and health care, remains unclear. We aimed to assess the association between educational level and premature adult mortality in Cuba.

METHODS

The Cuba Prospective Study (a cohort study) enrolled 146 556 adults aged 30 years and older from the general population in five provinces from Jan 1, 1996, to Nov 24, 2002. Participants were followed up until Jan 1, 2017, for cause-specific mortality. Deaths were identified through linkage to the Cuban Public Health Ministry's national mortality records. Cox regression models yielded rate ratios (RRs) for the effect of educational level (a commonly used measure for social status) on mortality at ages 35-74 years, with assessment for the mediating effects of smoking, alcohol consumption, and BMI.

FINDINGS

A total of 127 273 participants aged 35-74 years were included in the analyses. There was a strong inverse association between educational level and premature mortality. Compared with a university education, men who did not complete primary education had an approximately 60% higher risk of premature mortality (RR 1·55, 95% CI 1·40-1·72), while the risk was approximately doubled in women (1·96, 1·81-2·13). Overall, 28% of premature deaths could be attributed to lower education levels. Excess mortality in women was primarily due to vascular disease, while vascular disease and cancer were equally important in men. 31% of the association with education in men and 18% in women could be explained by common modifiable risk factors, with smoking having the largest effect.

INTERPRETATION

This study highlights the value of understanding the determinants of health inequalities in different populations. Although many major determinants lie outside the health system in Cuba, this study has identified the diseases and risk factors that require targeted public health interventions, particularly smoking.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK, CDC Foundation (with support from Amgen).