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School achievement as a predictor of depression and self-harm in adolescence: linked education and health record study

  • Muhammad A Rahman (a1), Charlotte Todd (a1), Ann John (a1), Jacinta Tan (a2), Michael Kerr (a3), Robert Potter (a4), Jonathan Kennedy (a1), Frances Rice (a3) and Sinead Brophy (a1)...

Mental disorders in children and adolescents have an impact on educational attainment.


To examine the temporal association between attainment in education and subsequent diagnosis of depression or self-harm in the teenage years.


General practitioner, hospital and education records of young people in Wales between 1999 and 2014 were linked and analysed using Cox regression.


Linked records were available for 652 903 young people and of these 33 498 (5.1%) developed depression and 15 946 (2.4%) self-harmed after the age of 12 but before the age of 20. Young people who developed depression over the study period were more likely to have achieved key stage 1 (age 7 years) but not key stage 2 (age 11) (hazard ratio (HR) = 0.79, 95% CI 0.74–0.84) milestones, indicating that they were declining in academic attainment during primary school. Conversely, those who self-harmed were achieving as well as those who did not self-harm in primary school, but showed a severe decline in their attainment during secondary school (HR = 0.72, 95% CI 0.68–0.78).


Long-term declining educational attainment in primary and secondary school was associated with development of depression in the teenage years. Self-harm was associated with declining educational attainment during secondary school only. Incorporating information on academic decline with other known risk factors for depression/self-harm (for example stressful life events, parental mental health problems) may improve risk profiling methods.

Declaration of interest


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This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Corresponding author
Correspondence: Sinead Brophy, FARR Institute, School of Medicine, Swansea University SA2 8PP. Email:
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School achievement as a predictor of depression and self-harm in adolescence: linked education and health record study

  • Muhammad A Rahman (a1), Charlotte Todd (a1), Ann John (a1), Jacinta Tan (a2), Michael Kerr (a3), Robert Potter (a4), Jonathan Kennedy (a1), Frances Rice (a3) and Sinead Brophy (a1)...
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School achievement and adolescent self-harm: methodological issues may have led to misleading conclusions in a highly powered national study

Sophie Epstein, NIHR Maudsley Biomedical Research Centre, South London and Maudsley NHS Foundation Trust
Thomas Stephenson, South London and Maudsley NHS Foundation Trust
Rina Dutta, Academic Department of Psychological Medicine, IoPPN, King’s College London
Johnny Downs, Academic Department of Child and Adolescent Psychiatry, IoPPN, King’s College London
15 August 2018

We welcome the work of Rahman and colleagues(1) whose study on school achievement, depression and self-harm using routinely collected data contributes to the limited evidence base on educational risk factors for adolescent mental health problems. Although they found little evidence for an association between early school achievement and later self-harm, due to a number of methodological issues we found their findings hard to interpret.

First, the exposure variable, school achievement, is dichotomised into two broad groups, meaning that within-group changes in achievement that do affect later mental health outcomes may be masked.

Second, the authors adjust for a range of poorly defined potential confounders. For example, the terms intellectual ‘disability’ and ‘difficulties’ are used interchangeably. Particularly with the latter, there is a risk of co-linearity with the exposure. How ‘conduct disorder’ is defined is also unclear as it appears to comprise a heterogeneous group of problems including eating disorders, autism and speech and language disorders, even reading disorder.

Third, the authors do not comment on whether high-risk subgroups, such as those with special educational needs, have been included in the analysis. These individuals may not be expected to follow the national curriculum and would therefore be omitted from the study. Similarly, linkage of health and education data is less likely to be possible for more mobile, socio-economically deprived populations.(2) Exclusion of such groups would create a biased sample and the possibility of underestimating the association.

Finally, the absence of key demographic, social and mental health variables within the routinely-collected education and health datasets raises the question of whether the study’s findings could be explained by residual confounding. Ethnicity, adverse childhood experiences, bullying and substance misuse could each act as confounders.(3) We would also recommend controlling for absence and exclusion from school given their association with poor outcomes.(4) Most pertinently, it is not clear whether depression has been considered a potential confounder of the association between achievement and self-harm.(3)

In addition to these methodological issues, two further points are worth raising. The results show that low achievement at age 7, but not age 11, is associated with adolescent self-harm. The authors state that ‘among those who self-harm there was no evidence of a decline in attainment in primary school.’ However, the authors provide no analysis in support of this interpretation, as they did not report the effect of within-individual changes in attainment between age 7 and 11.

The authors have hypothesised that there is a more acute relationship between achievement and self-harm in adolescence but this rich longitudinal data has not been used to disentangle the nature and direction of this acute relationship. This huge linked dataset offers a wealth of opportunities to better understand the relationship between school achievement and self-harm and we look forward to seeing further analyses, the results of which have the potential to make an important contribution to health and education policy.

1. Rahman MA, Todd C, John A, Tan J, Kerr M, Potter R, et al. School achievement as a predictor of depression and self-harm in adolescence: linked education and health record study. The British Journal of Psychiatry. 2018; 212(4): 215-21.

2. Gilbert R, Lafferty R, Hagger-Johnson G, Harron K, Zhang L-C, Smith P, et al. GUILD: GUidance for Information about Linking Data sets†. Journal of Public Health. 2018; 40(1): 191-8.

3. Hawton K, Saunders KE, O'Connor RC. Self-harm and suicide in adolescents. Lancet (London, England). 2012; 379(9834): 2373-82.

4. Fergusson DM, Beautrais AL, Horwood LJ. Vulnerability and resiliency to suicidal behaviours in young people. Psychol Med. 2003; 33(1): 61-73.
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Conflict of interest: None declared

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