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School grades, parental education and suicide—a national register-based cohort study
  1. Charlotte Björkenstam1,2,
  2. Gunilla Ringbäck Weitoft2,3,
  3. Anders Hjern2,4,6,
  4. Peter Nordström3,
  5. Johan Hallqvist1,5,
  6. Rickard Ljung1,2
  1. 1Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
  2. 2National Board of Health and Welfare, Stockholm, Sweden
  3. 3Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
  4. 4Centre for Health Equity Studies (CHESS), Stockholm University/Karolinska Institutet, Stockholm, Sweden
  5. 5Department of Public Health and Caring Sciences, Uppsala University, Sweden
  6. 6Department of Children's and Women's Health, Uppsala University, Uppsala, Sweden
  1. Correspondence to Charlotte Björkenstam, National Board of Health and Welfare, S-106 30 Stockholm, Sweden; charlotte.bjorkenstam{at}


Background To investigate whether school performance is a risk factor for suicide death later in life and, if so, to what extent this is explained by intergenerational effects of parental education.

Methods This population-based cohort study comprises national birth cohorts between 1972 and 1981 in Sweden. We followed 898 342 students, graduating between 1988 and 1997 from the 9 years of compulsory school, equivalent to junior high school, until 31 December 2006, generating 11 148 758 person-years and 1490 suicides. Final school grades, in six categories, and risk of suicide were analysed with Poisson regression.

Results The incidence rate ratio (RR) for suicide death for students with the lowest grades was 4.57 (95% CI 2.82 to 7.40) for men and 2.67 (1.42 to 5.01) for women compared to those with highest grades after adjustment for a number of sociodemographic and parental morbidity variables, such as year of graduation, parental education, lone parenthood, household receiving social welfare or disability pension, place of schooling, adoption, maternal age and parent's mental illness. Students with grades in the middle categories had RRs in between. These relationships were not modified by parental education.

Conclusions The strong association between low school grades and suicide in youth and young adulthood emphasises the importance of both primary and secondary prevention in schools.

  • Suicide
  • school performance
  • adolescence
  • register
  • Sweden

Statistics from


  • Funding The Swedish Council for Working Life and Social Research financially contributed to part of the correspondent author's salary.

  • Competing interests None.

  • Ethics approval This study is approved by the ethical committee dnr: 60-5075/2007 at Karolinska Institute, Stockholm, Sweden.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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