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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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Nicolás A. Crossley, Luz María Alliende, Leticia S. Czepielewski, David Aceituno, Carmen Paz Castañeda, Camila Diaz, Barbara Iruretagoyena, Carlos Mena, Cristian Mena, Juan Pablo Ramirez-Mahaluf, Angeles Tepper, Javiera Vasquez, Lais Fonseca, Viviane Machado, Camilo E. Hernández, Cristian Vargas-Upegui, Gladys Gomez-Cruz, Luis F. Kobayashi-Romero, Tomas Moncada-Habib, Celso Arango & 14 more Deanna M. Barch, Cameron Carter, Christoph U. Correll, Nelson B. Freimer, Philip McGuire, Sara Evans-Lacko, Eduardo Undurraga, Rodrigo Bressan, Clarissa S. Gama, Carlos Lopez-Jaramillo, Camilo de la Fuente-Sandoval, Alfonso Gonzalez-Valderrama, Juan Undurraga, Ary Gadelha

Original languageEnglish
Pages (from-to)565-573
Number of pages9
JournalThe Lancet Psychiatry
Issue number7
Published1 Jul 2022

Bibliographical note

Funding Information: This collaborative project was possible thanks to the Programa Iberoamericano de Ciencia y Tecnología para el Desarrollo (CYTED), through a grant to the Latin American Network for the Study of Early Psychosis (ANDES) as part of the CYTED's Redes programme (grant number 218RT0547). CdlF-S was supported by the Consejo Nacional de Ciencia y Tecnología—Sistema Nacional de Investigadores, Mexico (CONACyT—SNI); and the US National Institutes of Health, grant numbers R21 MH117434 and R01 MH110270. NAC and JU were supported by Agencia Nacional de Investigación y Desarrollo (ANID) in Chile, through the following grants: PIA-ACT192064, FONDECYT 1180358 and FONDECYT 1200601. JPR-M was supported by ANID-FONDECYT post-doctorate funding 3190311. CA was supported by the Spanish Ministry of Science and Innovation, Instituto de Salud Carlos III (grants number SAM16PE07CP1, PI16/02012, PI19/024), co-financed by ERDF Funds from the European Commission, “A way of making Europe”, CIBERSAM; Madrid Regional Government (B2017/BMD-3740 AGES-CM-2); European Union H2020 Program under the Innovative Medicines Initiative 2 Joint Undertaking (grant agreement No 115916, Project PRISM, and grant agreement No 777394, Project AIMS-2-TRIALS); Fundación Familia Alonso; and Fundación Alicia Koplowitz. Publisher Copyright: © 2022 Elsevier Ltd

King's Authors


Background: 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. Methods: 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). Findings: 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). Interpretation: 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. Funding: Ciencia y Tecnología para el Desarrollo (CYTED) to the Latin American Network for the Study of Early Psychosis (ANDES).

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