The enduring gap in educational attainment in schizophrenia according to the past 50 years of published research: a systematic review and meta-analysis
Educational attainment is associated with wellbeing and health, but patients with schizophrenia achieve lower levels of education than people without. Several effective interventions can ameliorate this situation. However, the magnitude of the education gap in schizophrenia and its change over time...
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| Published in: | The Lancet. Psychiatry Vol. 9; no. 7; p. 565 |
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| Main Authors: | , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , |
| Format: | Journal Article |
| Language: | English |
| Published: |
England
01.07.2022
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| ISSN: | 2215-0374, 2215-0374 |
| Online Access: | Get more information |
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| Abstract | Educational attainment is associated with wellbeing and health, but patients with schizophrenia achieve lower levels of education than people without. Several effective interventions can ameliorate this situation. However, the magnitude of the education gap in schizophrenia and its change over time are unclear. We aimed to reconstruct the trajectories of educational attainment in patients with schizophrenia and, if reported, their healthy comparator controls.
We did a systematic review and meta-analysis including all studies reporting on patients with schizophrenia (of mean age ≥18 years) and describing the number of years of education of the participants, with or without healthy controls. There were no other design constraints on studies. We excluded studies that included only patients with other schizophrenia spectrum disorders and studies that did not specify the number of years of education of the participants. 22 reviewers participated in retrieving data from a search in PubMed and PsycINFO (Jan 1, 1970, to Nov 24, 2020). We estimated the birth date of participants from their mean age and publication date, and meta-analysed these data using random-effects models, focusing on educational attainment, the education gap, and changes over time. The primary outcome was years of education. The protocol was registered on PROSPERO (CRD42020220546).
From 32 593 initial references, we included 3321 studies reporting on 318 632 patients alongside 138 675 healthy controls (170 941 women and 275 821 men from studies describing sex or gender; data on ethnicity were not collected). Patients' educational attainment increased over time, mirroring that of controls. However, patients with schizophrenia in high-income countries had 19 months less education than controls (-1·59 years, 95% CI -1·66 to -1·53; p<0·0001), which is equivalent to a Cohen's d of -0·56 (95% CI -0·58 to -0·54) and implies an odds ratio of 2·58 for not completing 12 years of education (ie, not completing secondary education) for patients compared with controls. This gap remained stable throughout the decades; the rate of change in number of total years of education in time was not significant (annual change: 0·0047 years, 95% CI -0·0005 to 0·0099; p=0·078). For patients in low-income and middle-income countries, the education gap was significantly smaller than in high-income countries (smaller by 0·72 years, 0·85 to 0·59; p<0·0001), yet there was evidence that this gap was widening over the years, approaching that of high-income countries (annual change: -0·024 years, -0·037 to -0·011; p=0·0002).
Patients with schizophrenia have faced persistent inequality in educational attainment in the last century, despite advances in psychosocial and pharmacological treatment. Reducing this gap should become a priority to improve their functional outcomes.
Ciencia y Tecnología para el Desarrollo (CYTED) to the Latin American Network for the Study of Early Psychosis (ANDES). |
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| AbstractList | Educational attainment is associated with wellbeing and health, but patients with schizophrenia achieve lower levels of education than people without. Several effective interventions can ameliorate this situation. However, the magnitude of the education gap in schizophrenia and its change over time are unclear. We aimed to reconstruct the trajectories of educational attainment in patients with schizophrenia and, if reported, their healthy comparator controls.BACKGROUNDEducational attainment is associated with wellbeing and health, but patients with schizophrenia achieve lower levels of education than people without. Several effective interventions can ameliorate this situation. However, the magnitude of the education gap in schizophrenia and its change over time are unclear. We aimed to reconstruct the trajectories of educational attainment in patients with schizophrenia and, if reported, their healthy comparator controls.We did a systematic review and meta-analysis including all studies reporting on patients with schizophrenia (of mean age ≥18 years) and describing the number of years of education of the participants, with or without healthy controls. There were no other design constraints on studies. We excluded studies that included only patients with other schizophrenia spectrum disorders and studies that did not specify the number of years of education of the participants. 22 reviewers participated in retrieving data from a search in PubMed and PsycINFO (Jan 1, 1970, to Nov 24, 2020). We estimated the birth date of participants from their mean age and publication date, and meta-analysed these data using random-effects models, focusing on educational attainment, the education gap, and changes over time. The primary outcome was years of education. The protocol was registered on PROSPERO (CRD42020220546).METHODSWe did a systematic review and meta-analysis including all studies reporting on patients with schizophrenia (of mean age ≥18 years) and describing the number of years of education of the participants, with or without healthy controls. There were no other design constraints on studies. We excluded studies that included only patients with other schizophrenia spectrum disorders and studies that did not specify the number of years of education of the participants. 22 reviewers participated in retrieving data from a search in PubMed and PsycINFO (Jan 1, 1970, to Nov 24, 2020). We estimated the birth date of participants from their mean age and publication date, and meta-analysed these data using random-effects models, focusing on educational attainment, the education gap, and changes over time. The primary outcome was years of education. The protocol was registered on PROSPERO (CRD42020220546).From 32 593 initial references, we included 3321 studies reporting on 318 632 patients alongside 138 675 healthy controls (170 941 women and 275 821 men from studies describing sex or gender; data on ethnicity were not collected). Patients' educational attainment increased over time, mirroring that of controls. However, patients with schizophrenia in high-income countries had 19 months less education than controls (-1·59 years, 95% CI -1·66 to -1·53; p<0·0001), which is equivalent to a Cohen's d of -0·56 (95% CI -0·58 to -0·54) and implies an odds ratio of 2·58 for not completing 12 years of education (ie, not completing secondary education) for patients compared with controls. This gap remained stable throughout the decades; the rate of change in number of total years of education in time was not significant (annual change: 0·0047 years, 95% CI -0·0005 to 0·0099; p=0·078). For patients in low-income and middle-income countries, the education gap was significantly smaller than in high-income countries (smaller by 0·72 years, 0·85 to 0·59; p<0·0001), yet there was evidence that this gap was widening over the years, approaching that of high-income countries (annual change: -0·024 years, -0·037 to -0·011; p=0·0002).FINDINGSFrom 32 593 initial references, we included 3321 studies reporting on 318 632 patients alongside 138 675 healthy controls (170 941 women and 275 821 men from studies describing sex or gender; data on ethnicity were not collected). Patients' educational attainment increased over time, mirroring that of controls. However, patients with schizophrenia in high-income countries had 19 months less education than controls (-1·59 years, 95% CI -1·66 to -1·53; p<0·0001), which is equivalent to a Cohen's d of -0·56 (95% CI -0·58 to -0·54) and implies an odds ratio of 2·58 for not completing 12 years of education (ie, not completing secondary education) for patients compared with controls. This gap remained stable throughout the decades; the rate of change in number of total years of education in time was not significant (annual change: 0·0047 years, 95% CI -0·0005 to 0·0099; p=0·078). For patients in low-income and middle-income countries, the education gap was significantly smaller than in high-income countries (smaller by 0·72 years, 0·85 to 0·59; p<0·0001), yet there was evidence that this gap was widening over the years, approaching that of high-income countries (annual change: -0·024 years, -0·037 to -0·011; p=0·0002).Patients with schizophrenia have faced persistent inequality in educational attainment in the last century, despite advances in psychosocial and pharmacological treatment. Reducing this gap should become a priority to improve their functional outcomes.INTERPRETATIONPatients with schizophrenia have faced persistent inequality in educational attainment in the last century, despite advances in psychosocial and pharmacological treatment. Reducing this gap should become a priority to improve their functional outcomes.Ciencia y Tecnología para el Desarrollo (CYTED) to the Latin American Network for the Study of Early Psychosis (ANDES).FUNDINGCiencia y Tecnología para el Desarrollo (CYTED) to the Latin American Network for the Study of Early Psychosis (ANDES). Educational attainment is associated with wellbeing and health, but patients with schizophrenia achieve lower levels of education than people without. Several effective interventions can ameliorate this situation. However, the magnitude of the education gap in schizophrenia and its change over time are unclear. We aimed to reconstruct the trajectories of educational attainment in patients with schizophrenia and, if reported, their healthy comparator controls. We did a systematic review and meta-analysis including all studies reporting on patients with schizophrenia (of mean age ≥18 years) and describing the number of years of education of the participants, with or without healthy controls. There were no other design constraints on studies. We excluded studies that included only patients with other schizophrenia spectrum disorders and studies that did not specify the number of years of education of the participants. 22 reviewers participated in retrieving data from a search in PubMed and PsycINFO (Jan 1, 1970, to Nov 24, 2020). We estimated the birth date of participants from their mean age and publication date, and meta-analysed these data using random-effects models, focusing on educational attainment, the education gap, and changes over time. The primary outcome was years of education. The protocol was registered on PROSPERO (CRD42020220546). From 32 593 initial references, we included 3321 studies reporting on 318 632 patients alongside 138 675 healthy controls (170 941 women and 275 821 men from studies describing sex or gender; data on ethnicity were not collected). Patients' educational attainment increased over time, mirroring that of controls. However, patients with schizophrenia in high-income countries had 19 months less education than controls (-1·59 years, 95% CI -1·66 to -1·53; p<0·0001), which is equivalent to a Cohen's d of -0·56 (95% CI -0·58 to -0·54) and implies an odds ratio of 2·58 for not completing 12 years of education (ie, not completing secondary education) for patients compared with controls. This gap remained stable throughout the decades; the rate of change in number of total years of education in time was not significant (annual change: 0·0047 years, 95% CI -0·0005 to 0·0099; p=0·078). For patients in low-income and middle-income countries, the education gap was significantly smaller than in high-income countries (smaller by 0·72 years, 0·85 to 0·59; p<0·0001), yet there was evidence that this gap was widening over the years, approaching that of high-income countries (annual change: -0·024 years, -0·037 to -0·011; p=0·0002). Patients with schizophrenia have faced persistent inequality in educational attainment in the last century, despite advances in psychosocial and pharmacological treatment. Reducing this gap should become a priority to improve their functional outcomes. Ciencia y Tecnología para el Desarrollo (CYTED) to the Latin American Network for the Study of Early Psychosis (ANDES). |
| Author | Mena, Cristian Correll, Christoph U Freimer, Nelson B de la Fuente-Sandoval, Camilo Hernández, Camilo E Moncada-Habib, Tomas Barch, Deanna M Iruretagoyena, Barbara Machado, Viviane Gama, Clarissa S McGuire, Philip Alliende, Luz María Evans-Lacko, Sara Undurraga, Eduardo Crossley, Nicolás A Fonseca, Lais Gonzalez-Valderrama, Alfonso Castañeda, Carmen Paz Kobayashi-Romero, Luis F Arango, Celso Aceituno, David Diaz, Camila Carter, Cameron Vasquez, Javiera Lopez-Jaramillo, Carlos Bressan, Rodrigo Ramirez-Mahaluf, Juan Pablo Undurraga, Juan Gadelha, Ary Gomez-Cruz, Gladys Czepielewski, Leticia S Mena, Carlos Tepper, Angeles Vargas-Upegui, Cristian |
| Author_xml | – sequence: 1 givenname: Nicolás A surname: Crossley fullname: Crossley, Nicolás A email: ncrossley@uc.cl organization: Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK. Electronic address: ncrossley@uc.cl – sequence: 2 givenname: Luz María surname: Alliende fullname: Alliende, Luz María organization: Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Department of Psychiatry and Behavioral Neuroscience, School of Medicine, The University of Chicago, Chicago, IL, USA – sequence: 3 givenname: Leticia S surname: Czepielewski fullname: Czepielewski, Leticia S organization: Laboratory of Molecular Psychiatry, Centro de Pesquisa Clínica, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil; Programa de Pós-Graduação em Psicologia, Instituto Psicologia, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil – sequence: 4 givenname: David surname: Aceituno fullname: Aceituno, David organization: Psychiatry and Mental Health Service, Complejo Asistencial Dr Sótero del Río, Puente Alto, Chile – sequence: 5 givenname: Carmen Paz surname: Castañeda fullname: Castañeda, Carmen Paz organization: Early Intervention Program, Instituto Psiquiátrico Dr. J. Horwitz Barak, Santiago, Chile – sequence: 6 givenname: Camila surname: Diaz fullname: Diaz, Camila organization: Pharmacovigilance Program, Instituto Psiquiátrico Dr. J. Horwitz Barak, Santiago, Chile – sequence: 7 givenname: Barbara surname: Iruretagoyena fullname: Iruretagoyena, Barbara organization: Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Department of Neurology and Psychiatry, Faculty of Medicine, Clínica Alemana Universidad del Desarrollo, Vitacura, Chile – sequence: 8 givenname: Carlos surname: Mena fullname: Mena, Carlos organization: Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; Institute of Cognitive Neuroscience, University College London, London, UK – sequence: 9 givenname: Cristian surname: Mena fullname: Mena, Cristian organization: Early Intervention Program, Instituto Psiquiátrico Dr. J. Horwitz Barak, Santiago, Chile; School of Medicine, Universidad Finis Terrae, Santiago, Chile – sequence: 10 givenname: Juan Pablo surname: Ramirez-Mahaluf fullname: Ramirez-Mahaluf, Juan Pablo organization: Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile – sequence: 11 givenname: Angeles surname: Tepper fullname: Tepper, Angeles organization: Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile – sequence: 12 givenname: Javiera surname: Vasquez fullname: Vasquez, Javiera organization: Department of Psychiatry, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile – sequence: 13 givenname: Lais surname: Fonseca fullname: Fonseca, Lais organization: Schizophrenia Program (PROESQ), Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil – sequence: 14 givenname: Viviane surname: Machado fullname: Machado, Viviane organization: Schizophrenia Program (PROESQ), Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil; Interdisciplinary Laboratory in Clinical Neuroscience (LiNC), Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil – sequence: 15 givenname: Camilo E surname: Hernández fullname: Hernández, Camilo E organization: Department of Psychiatry, Faculty of Medicine, University of Antioquia, Medellín, Colombia – sequence: 16 givenname: Cristian surname: Vargas-Upegui fullname: Vargas-Upegui, Cristian organization: Department of Psychiatry, Faculty of Medicine, University of Antioquia, Medellín, Colombia – sequence: 17 givenname: Gladys surname: Gomez-Cruz fullname: Gomez-Cruz, Gladys organization: Laboratory of Experimental Psychiatry, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico – sequence: 18 givenname: Luis F surname: Kobayashi-Romero fullname: Kobayashi-Romero, Luis F organization: Laboratory of Experimental Psychiatry, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico – sequence: 19 givenname: Tomas surname: Moncada-Habib fullname: Moncada-Habib, Tomas organization: Laboratory of Experimental Psychiatry, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico – sequence: 20 givenname: Celso surname: Arango fullname: Arango, Celso organization: Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, CIBERSAM, Madrid, Spain – sequence: 21 givenname: Deanna M surname: Barch fullname: Barch, Deanna M organization: School of Medicine, University of Washington in St Louis, St Louis, MO, USA – sequence: 22 givenname: Cameron surname: Carter fullname: Carter, Cameron organization: Department of Psychiatry and Behavioral Sciences, University of California Davis, Davis, CA, USA – sequence: 23 givenname: Christoph U surname: Correll fullname: Correll, Christoph U organization: Department of Psychiatry, The Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY, USA; 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| Title | The enduring gap in educational attainment in schizophrenia according to the past 50 years of published research: a systematic review and meta-analysis |
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