Abstract
BackgroundDespite an overall reduction in suicide, educational disparities in suicide have not decreased over the last decade. The mechanisms behind educational disparities in suicide, however, remain unclear: low educational status may increase the risk of suicide (“causation”) or low educational status and suicide may share confounders. This paper assesses whether educational disparities in suicide (EDS) are more likely to be due to causation.MethodThe DEMETRIQ study collected and harmonized register-based data on mortality follow-up from forty population censuses from twelve European populations. More than 102,000 suicides were registered over 392 million person-years. Three analyses were carried out. First, we applied an instrumental variable approach that exploits changes in the legislation on compulsory educational age to instrument educational status. Second, we analyzed EDS by age under the hypothesis that increasing EDS over the life cycle supports causation. Finally, we compared EDS in men and women under the assumption that greater EDS in women would support causation.FindingsThe instrumental variable analysis showed no evidence for causation between higher education and suicide, for men or women. The life-cycle analysis showed that the decrease of educational inequalities in suicide between the baseline 1991 period and the 2001 follow-up period was more pronounced and statistically significant in the first three younger age groups. The gender analysis indicated that EDS were systematic and greater in men than in women: the rate ratio of suicide for men with low level of education (RR = 2.51; 95%CI:2.44–2.58) was higher than the rate ratio in women (RR = 1.32; 95CI%:1.26–1.38).InterpretationOverall, there was little support for the causation hypothesis, suggesting that the association between education and suicide is confounded. Educational inequalities in suicide should be addressed in early life by early targeting of groups who struggle to complete their education and display higher risk of mental disorder or of mental health vulnerabilities.
Highlights
Worldwide, suicide accounts for 1.5% of all deaths and ranks as the fourth leading cause of death in high-income countries [1]
The research question precluded an experimental method and so we looked into observational data for effective signatures of the two hypotheses mentioned above: do the data plead for causation or for confounding? We first used a quasi-experimental approach and performed two additional robustness analyses in order to investigate the causal link between education and suicide
The higher risk of suicide in less educated individuals may be due to early-life factors reducing educational opportunities and increasing mental health vulnerabilities
Summary
Suicide accounts for 1.5% of all deaths and ranks as the fourth leading cause of death in high-income countries [1]. The difference in suicide rates between socioeconomic groups (hereafter, socioeconomic disparities in suicide) is an important topic of research for two reasons. Despite an overall reduction in suicide, these disparities have not decreased over the last decade either in North America [5,6] or in Europe [7,8]. A Danish case-control study found that suicide risk increased as income decreased (but the same was not true of wealth) and this relationship disappeared once psychiatric history was factored in [18]. There is a need to see how the risk of suicide is related to low socioeconomic status, controlling for key confounding factors. This paper assesses whether educational disparities in suicide (EDS) are more likely to be due to causation
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