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Aims: This study examined the association between educational attainment and the risk of deaths of despair among individuals assessed for substance use severity at municipal social services in Sweden. It aimed to determine whether the protective association between education and despair-related mortality risk, commonly observed in broader population studies, also applies to this high-risk, treatment-seeking population.

Methods: We linked data from municipal Addiction Severity Index (ASI) assessments to various population registers. The study population included adults aged 25 years or older who were assessed for substance use severity between 1999 and 2019. Fine–Gray competing risk regression models were employed to examine the association between educational attainment and despair-related mortality, both overall and by subtype (alcohol-related, drug use-related, suicide).

Results: Tertiary education was unexpectedly associated with increased risks of overall despair-related mortality, alcohol-related and drug use-related mortality, after controlling for demographic characteristics, ASI composite scores and substance use onset age. No significant associations were found between education and suicide.

Conclusions: The counterintuitive finding that tertiary education is linked to a greater risk of despair-related mortality among social service users may be attributed to differences between the treatment-seeking population and the general population. Highly educated individuals who seek treatment from municipal social services might have severe substance use and complex psychosocial problems and/or contact social services after exhausting other treatment options. Further research is necessary to understand how educational and socioeconomic factors influence treatment pathways for individuals with severe substance use problems in Sweden and how these different pathways impact health-related outcomes.

Background: A recent review of research on the association between school-related stress and internalizing problems found growing scholarly interest in the topic, but also raised questions concerning the quality and reliability of the existing knowledge base. The aim of this study was to investigate how robust the association between school-related stress and internalizing problems is to differences in model specifications.

Methods: Longitudinal survey data from between 2,991 and 4,845 Swedish adolescent students aged 13–16 years were used. A total of 57,322 different models were estimated, varying the choice of sample, measure of internalizing problems, functional form, statistical method, and combinations of included control variables. The results were summarized using specification curve analysis.

Results: Most estimates of the association between school-related stress and internalizing problems were statistically significant at the 5% level. The choice of sample, outcome, functional form, and control variables had a limited influence on the size and significance of the estimates, but the estimates were markedly smaller and mostly non-significant in models investigating lagged effects.

Conclusions: This study showed that school-related stress is a robust predictor of internalizing problems as long as the association is assumed to be contemporaneous, while evidence for lagged effects was weaker. A key conclusion is that the choice of whether to estimate lagged or contemporaneous effects may be the most consequential in studies on school-related stress and internalizing problems or similar topics.

Bakground: Growing educational disparities in mortality due to suicide, drug overdose, or alcohol-related liver disease – or “deaths of despair” (DoD) – have received increased attention in research and public debate. However, no study has investigated educational differences in despair-related mortality outside of North America. Thus, the aim this study was to investigate changes in the association between academic achievement in compulsory school and subsequent all-cause mortality (ACM) and DoD between 1990 and 2018 in Swedish youths.

Data and methods: Register data on all students graduating from compulsory school in Sweden between 1990 and 2010 were used (N = 2 252 938). Students were followed for a maximum of 8 years using discrete time proportional hazard models. Academic achievement was measured by grades at the end of compulsory school.

Results: ACM declined for medium/high achieving but not for low-achieving youths, while DoD increased slightly for medium/high achieving and markedly for low-achieving youths, resulting in growing achievement-related disparities in both types of mortality. The trends were primarily driven by native-born youth and girls.

Conclusions: The trends in Swedish youths resemble the trends in the American working-age population, but partly contrasts with corresponding trends in other European countries. Future research should investigate if the underlying causes that have been emphasized in the American context – socio-economic transformations and a greater supply of drugs – have also contributed to the Swedish trends.

Rising rates of "deaths of despair" – mortality from suicide, drug overdose, and alcohol-related causes – have contributed to widening educational disparities in mortality. It is not known to what extent the trends are due to selection effects (health causing education, or a third factor causing both) or social causation (education affecting health). This study investigated the relative contribution of selection and causation for these trends, focusing on the recently documented widening achievement-based disparities in mortality among Swedish youths.

To this end, two cohorts of Swedish compulsory school graduates (graduating in 1992–1993 and 2009–2010, respectively) were followed for eight years after graduation using comprehensive administrative data (n = 424,715). Logistic regression models were used to assess the role of pre-graduation selection, while inverse odds ratio-weighting was used to assess mediation by post-graduation socioeconomic disadvantages.

Roughly half of the association between low achievement and all-cause and despair-related mortality within cohorts was due to selection. However, selection effects did not explain the widening disparities over time. Socioeconomic mediators accounted for most of the remaining disparities within cohorts as well as of for most of the increase in these disparities over time. Overall, social causation was more important than selection in explaining the widening educational disparities in all-cause and despair-related mortality.

We conclude that low academic achievement increasingly constrains life-course prospects of Swedish youths, amplifying its adverse health consequences. These findings highlight the need for lower barriers in the education system and for viable educational and employment pathways for low-achieving students in an increasingly knowledge-intensive labor market. 

Higher academic performance is almost universally considered a good thing, and most quantitative studies show that performance is positively, although weakly, related to mental health. Simultaneously, however, qualitative studies consistently find that high-performing students and students attending high-performing schools report high levels of stress and other mental health problems. This study investigates a simple explanation for this puzzle – that the relationship between performance and mental health is not linear and is conditional on the performance culture of the school. Data on almost 5000 Swedish students from the Programme for International Student Assessment were used. The results show that the relationship between performance and mental health is generally not linear and that intermediate-performing boys have the best mental health, while both low- and high-performing girls and boys alike have poorer mental health. Although inconclusive, the results also suggest that low-performing students may be vulnerable to a strong school performance culture.

Background: Rising rates of internalizing disorders and rising rates of school failure among adolescents are growing concerns. Despite the strong association between academic achievement and internalizing disorders, possible links between these two trends have not been investigated. Thus, the aim of this study was to investigate the development of the cross-sectional associations between academic achievement and internalizing disorders in Swedish students aged 16 years between 1990 and 2018.

Methods: Register data on specialist psychiatric care and prescriptions of psycholeptic and psychotropic drugs were linked to data on students’ school grades in the last year of compulsory school. The total sample size was 3,089,674 students. Logistic regression models with internalizing disorders as the dependent variable, and graduation year and academic achievement as independent variables, were estimated.

Results: Throughout the period, there was a strong negative association between academic achievement and internalizing disorders. Low-achieving students had by far the highest risks of internalizing disorders. In absolute terms, the increase in internalizing disorders was clearly largest for low-achieving students. The relative risks for low-achieving compared to higher achieving students increased between 1990 and 2010 and declined after 2010.

Conclusions: This study found consistently large, and at least until 2010 growing, achievement-related inequalities in internalizing disorders among Swedish adolescents between 1990 and 2018, with the lowest achieving students having disproportionally high risks. The increasingly pronounced concentration of internalizing disorders in the lowest rungs of the achievement distribution suggests that preventive interventions should focus on supporting this doubly disadvantaged group of students.

Background: Low academic achievement and low educational attainment in adolescence is associated with higher risks of internalizing disorders later in life. However, less is known regarding if these associations vary over time across cohorts. The aim of this study was to investigate temporal changes in the association between academic achievement or educational attainment and subsequent inpatient treatment for internalizing disorders among Swedish youths.

Methods: Register data on all students graduating from compulsory school in Sweden between 1990 and 2010 (N = 2 252 703) were used. Students were followed for a maximum of 8 years using discrete time proportional hazard models. Internalized disorders were measured by specialized inpatient psychiatric care for depression or anxiety disorders. Academic achievement was measured by grades at the end of compulsory school, and educational attainment by completion of upper secondary school.

Results: The positive association between inpatient treatment for internalizing disorders and both low compulsory school achievement and non-completion of upper secondary school became stronger in more recent cohorts. The results were completely driven by girls and native-born youth.

Conclusions: Low compulsory school achievements and failure to complete upper secondary school has become more important risk factors for inpatient treatment for internalizing disorders, particularly in native-born youth and girls. More research is needed to establish whether youth with internalizing disorders increasingly fail in school or whether low achievement has become more harmful for mental health.

This study examines the consequences of parental job displacement for birth outcomes and investigates how the effects vary with regional unemployment rates. We use Swedish register data and exploit plausibly exogenous variation caused by workplace closure to reduce the bias related to reverse causality and confounding. The differences in birth outcomes between children of parents who experienced job displacement and children of parents who were not displaced turn out to be quite modest. Even in the most disadvantaged regions, with the highest unemployment rates, parental job displacement is not harmful for health at birth. We relate these findings to the institutional setting in Sweden and discuss policy implications for the United States.

Background: This study investigated the possible mediating role of fear-of-failure between educational expectations and adolescent stress-related complaints with a specific focus on gender differences among Swedishadolescents, and related these findings more broadly to school-related demands and stress-related complaints.

Methods: A total of N¼ 5504 Swedish adolescents (Mage¼ 15 years, SD ¼ 0.0 years, 50.2% girls) were drawn from the2018 Swedish Programme for International Student Assessment study for our investigation. We used structural equation models to explore if fear-of-failure mediates the relationship between educational expectations and negativeaffect, with a specific focus on gender differences. Educational expectations were utilized in the measurement model.Fear-of-failure was constructed as a latent mediating variable. Negative affect was constructed as a latent variableand utilized as an outcome variable. We subsequently undertook bootstrapping tests of indirect effects and nonlinear comparisons of indirect effects to assess the reliability of the results.

Results: Fear-of-failure partially mediatedthe association between educational expectations and negative affect (39%). Our gender-specific structural equation model demonstrated that this relationship was more pronounced for girls, suggesting girls are more vulnerable to negative affect as a result of experiencing higher levels of fear of failing.

Conclusions: The findingssuggest that fear-of-failure partially explains the association between educational expectations and negativeaffect and that this association is more pronounced for girls. This study provides insights into better understanding adolescent stress-related complaints, and the differential role fear of failing has in regards to gender.

Academic stress among adolescents can undermine academic achievement and harm mental health. Levels of academic stress vary considerably across countries and education systems, but little is known regarding the causes of this variation. In this paper, I develop a theoretical framework positing that stress will be lower in education systems that reduce the stakes attached to academic achievements, temper competition and high aspirations, and weaken the link between achievements and self-worth. I test observable implications of the framework by analysing if stress is influenced by the degree of external differentiation and vocational orientation of education systems, using harmonised survey data on pupils in more than 30 countries. The empirical analyses largely support the implications of the framework: pupils in more differentiated and vocationally orientated systems report significantly lower levels of stress, also in models adjusting for country fixed effects. Moreover, academic achievement is a less important predictor of stress in differentiated or vocational systems, possibly due to lower stakes attached to achievements. I end by proposing further predictions of the framework that can be tested in future research, and by discussing implications of the results with regard to possible trade-offs between different goals of education policy.