Alma Sörberg Wallin

Background: Previous studies suggest a protective effect of parenthood on suicide, but little is known about how the association may change across the lifespan, or in relation to sex, marital status or occurrence of psychiatric disorders. Methods: We followed a cohort of over 5 million Swedish women and men, from 1991 to 2011, up to max. age 75, for death by suicide using national registers. Information on childbirths/adoptions, potential confounders and modifying factors were obtained from national registers. We assessed the associations between parenthood and suicide across adulthood using within time-stratified Cox regression models, with parenthood as a time-dependent exposure. Results: Parents had a lower risk of suicide than non-parents across the lifespan, after adjusting for sociodemographic factors. The association was most pronounced in young adults, especially young women, but attenuated with increasing age and converged between sexes in older age groups. The lower risk of suicide over the life course was similar whether parents were married, unmarried or divorced, apart from married men; among them, parents only had a lower risk above age 55. The lower risk in parents was also evident in people with a history of psychiatric hospitalizations, but disappeared from age 55 in this population. Conclusion: The lower risk of suicide was present in both parents, was most pronounced in young adulthood and weakened with increasing age. Our results are consistent with a plausible mechanism where feelings of responsibility and connectedness are protective against suicide in parents.

Objective To investigate whether patients with clozapine treatment are at an increased risk of a more severe COVID-19 infection as compared with patients on other antipsychotic drugs. Methods In this register-based cohort study, all residents (age 18 or older) in the Stockholm Region with a psychotic disorder diagnosis and antipsychotic treatment were included (N = 8 233) and followed from March 1, 2020 to January 14, 2021. The exposure was defined as clozapine treatment and the outcome measures (indicating a more severe COVID-19 infection) were: inpatient care, care within intensive care unit or death due to COVID-19 infection. Differences in outcome rates between exposed (n = 966) and unexposed (other antipsychotics; n = 7 267) were examined using Cox proportional hazards models and expressed as hazard ratios (HR) with 95% confidence intervals (CI). Results No statistically significant differences in outcome rates were found between the two groups of patients after adjusting for age, sex, and residence in retirement homes. The adjusted HR for the exposed compared to the unexposed was 0.96 (95% CI: 0.54, 1.70) for inpatient care; 1.69 (0.48, 5.93) for care in intensive care unit (ICU); and 0.86 (0.26, 2.80) for death. Regarding inpatient care, additional adjusting for country of birth, living in socioeconomically vulnerable areas, number of care visits during the previous year, and comorbid medical illnesses did not alter the results. Conclusions Our results may add support to the present guidelines, recommending sustained clozapine treatment during the current COVID-19 pandemic with careful monitoring and readiness to alter drug doses as needed.

Objective: To determine whether parenthood among 25‐ to 44‐year‐olds is associated with a lower suicide rate in men and women in Sweden, and whether this is explained by selection into parenthood.Methods: In total, 1,582,360 Swedish women and men, born between 1967 and 1985, and childless at their 25^th birthday, were followed from 1992 to 2011. All data originated from linkage to national Swedish registers. Cox regression models were used with time‐varying parenthood status to estimate adjusted hazard ratios and 95% confidence intervals (aHR;CI) for suicide.Results: Having one, two, three or more children was associated with 64%, 79% and 78% lower suicide rate, respectively, compared with having no children, in models with basic adjustments. When a wide range of indicators of selection into parenthood were taken into account, the suicide rate was 58% lower in parents with one child and 70% lower in parents with two or more children compared with childless individuals (aHR 0.42 [95% CI 0.36‐0.48]; 0.30 [95% CI 0.25‐0.35]; 0.30 [95% CI 0.21‐0.42]). In fathers with one, two, three or more children suicide rate was 54%, 64% and 59% lower, respectively, compared with non‐fathers whereas in mothers was 70%, 83% and 93% lower, respectively, compared with non‐mothers.Conclusion: Parenthood among 25‐to 44‐year‐olds is associated with a lower suicide risk in both men and women but to a larger extent among women, and particularly in parents with two or more children. Although selection into parenthood is possible, a protective effect of parenthood on suicide is likely in both men and women.

Background Poor academic performance in childhood is associated with suicide attempt in adulthood, but the mechanisms are not known. We investigated educational attainment as a possible pathway. Methods We followed two sets of cohorts, born around 1950/1970, respectively, in the Swedish population-representative ‘Evaluation Through Follow-up’ study for a first suicide attempt in national records up to 2013. Data on grade point average (GPA) at age 13/16 and educational attainment (years of schooling) in adulthood were used. The path models included linear and Cox proportional hazards regressions. A model with matched age range during follow-up was used to compare the cohorts. Results In the 1970 cohort, the association between GPA and suicide attempt between age 26 and 46 was partly mediated by attained education (total association, β=−0.82; via education: −0.29, per SD increase in GPA), but GPA also had a direct path to suicide attempt (β=−0.53). There was no evidence of such a pathway in the 1950 cohort between age 41 and 65. In the age-matched analysis, at age 26–46, the association between GPA and suicide attempt was stronger in the 1970 cohort compared to the 1950 cohort (β=−0.72 and −0.24, respectively). Conclusions Differences in attained education seem to partly explain the associations of academic performance with suicide attempt up to middle age. Furthermore, there is some indication that academic performance may have become more important for young people’s mental health than it was in previous generations.

Background: Both low intelligence and low emotional control have previously been linked to a higher risk of suicide, but it is unknown whether the associations apply consistently over the life course.Methods: The study was based on data on intelligence and emotional control, collected from 48 738 Swedish men conscripted in 1969–1970, at ages 18–20 years. The data were linked to national registers giving information on subsequent suicidal behavior (completed and attempted suicide) up to the age of 59 years. The associations were investigated using logistic regression and Cox proportional hazards regression models, with adjustment for childhood socioeconomic status.Results: Intelligence and emotional control assessed in late adolescence both showed robust inverse associations with suicidal behavior over the 38-year follow-up. However, while the association between lower intelligence and higher rate of suicidal behavior remained the same throughout (~40% increased hazard per unit on a five-level scale), the association between lower emotional control and suicidal behavior was substantially stronger in early adulthood (~100% increased hazard per unit) than in late middle age (~30% increased hazard per unit).Conclusions: The study adds to previous research by showing that the association between poor emotional control and subsequent suicide risk in men becomes weaker over the life course, while the association between low intelligence and suicide risk seems to be constant. The particularly high suicide risk of young men with poor emotional control may motivate targeted prevention efforts.

The incidence of major depression among adults has been shown to be socially differentiated, and there are reasons to seek explanations for this before adulthood. In this cohort study, we examined whether academic performance in adolescence predicts depression in adulthood, and the extent to which externalizing disorders explain this association.

Objective: Academic performance in youth, measured by grade point average (GPA), predicts suicide attempt, but the mechanisms are not known. It has been suggested that general intelligence might underlie the association.Methods: We followed 26 315 Swedish girls and boys in population‐representative cohorts, up to maximum 46 years of age, for the first suicide attempt in hospital records. Associations between GPA at age 16, IQ measured in school at age 13 and suicide attempt were investigated in Cox regressions and mediation analyses.Results: There was a clear graded association between lower GPA and subsequent suicide attempt. With control for potential confounders, those in the lowest GPA quartile had a near five‐fold risk (HR 4.9, 95% CI 3.7–6.7) compared to those in the highest quartile. In a mediation analysis, the association between GPA and suicide attempt was robust, while the association between IQ and suicide attempt was fully mediated by GPA.Conclusions: Poor academic performance in compulsory school, at age 16, was a robust predictor of suicide attempt past young adulthood and seemed to account for the association between lower childhood IQ and suicide attempt.