High Income, Employment, Postgraduate Education, and Marriage

CONTEXT: Studies dating back over 100 years have shown that the risk of suicide in the general population is associated with low income, unemployment, educational underachievement, and singleness. However, little is known about the association between suicide risk and these factors in psychiatric patients. OBJECTIVE: To estimate the association between suicide risk, socioeconomic position, and marital status in psychiatric patients. DESIGN, SETTING, AND PATIENTS: Population-based cohort study of all first-ever psychiatric patients aged 16 to 65 years admitted from 1981 to 1998, with administrative longitudinal data on income, labor market affiliation, educational attainment, and marital and cohabitational status (96,369 patients, 256,619 admissions, and 2727 suicides). MAIN OUTCOME MEASURES: Suicide risks after hospital discharge were depicted using Kaplan-Meier product-limit methods. Hazard ratios (HRs) for suicide from Cox proportional hazards regression and case-crossover/individually stratified analyses were calculated while adjusting for overall social drift. RESULTS: Using Cox proportional hazards regression, compared with patients in the highest income quartile, the suicide HR decreased from 0.90 (95% confidence interval CI, 0.79-1.02) in the third lowest to 0.83 (95% CI, 0.73-0.93) in the second lowest and to 0.68 (95% CI, 0.61-0.76) in the lowest income group. Compared with the fully employed, the HR for unemployed patients was 0.85 (95% CI, 0.77-0.93); for social benefits' recipients, 0.58 (95% CI, 0.48-0.70); and for disability or age pensioners, 0.63 (95% CI, 0.55-0.71). Compared with postgraduate education, HRs (95% CIs) associated with a bachelor's degree, vocational school, or primary school education were 0.82 (0.67-1.02), 0.66 (0.55-0.80), and 0.54 (0.44-0.65), respectively. The HRs (95% CIs) for widowed, divorced, and never-married patients were 1.07 (0.89-1.30), 0.74 (0.66-0.84), and 0.88 (0.79-0.98), respectively. Using individually stratified analyses, HRs (95% CIs) for transition into the third lowest, the second lowest, and the lowest income quartile were 1.19 (0.76-1.86), 1.47 (0.92-2.34), and 1.84 (1.14-2.97), respectively. The HRs (95% CIs) for patients who became unemployed, social benefits' recipients, disability or age pensioners, widowed patients, and divorced patients were 1.41 (1.01-1.95), 1.73 (1.06-2.80), 1.45 (0.91-2.30), 2.59 (0.76-8.89), and 1.86 (1.07-3.21), respectively. CONCLUSIONS: Suicide risk is generally associated with low income, unemployment, educational underachievement, and singleness, but this study suggests that the opposite is true among psychiatric patients. However, loss of income, labor market status, and marriage increase the suicide risk.