To Örebro University

Background: Social Anxiety Disorder (SAD) is a relatively frequent psychiatric disorder, with a lifetime prevalence of about 4% [1], which usually starts in adolescence [2]. As in the case of other mental disorders, [3] SAD has also been linked to academic impairment and school drop-out [4,5], but this previous research has a number of methodological limitations, mainly the use of modest sample sizes, retrospective designs, self-reported measures, and focusing in a single educational level.

Aim: We aim to investigate the association between SAD and educational outcomes at all levels using objectively collected measures, controlling for a number of covariates and unmeasured factors shared between siblings.

Method: Using the Swedish nationwide registers, we designed this population-based birth cohort study, which included 2,244,191 individuals born in Sweden between 1973 and 1997, who were followed up from 1991 until 2013. A total of 15,765 individuals had a record of SAD in the Swedish National Patient Register, according to the International Classification of Diseases, 10th edition. Logistic regression models tested the association between SAD and the prospectively-collected and objectively measured educational outcomes. These educational milestones included: the year grades in the final year of compulsory school, the eligibility to access upper secondary school after compulsory education (for both, vocational and academical programs), finishing upper secondary school, starting university, finishing a university degree, and completing post-graduate education. In order to reduce the impact of possible confounders, we took into account a number of covariates such as age, sex, maternal and paternal age at birth and year of birth. The impact of common psychiatric comorbidities of SAD was also taken into account. In order to control for unmeasured shared familial factors, we performed a sibling comparison analysis. We identified 786,766 families with 2 or more siblings, and identified 11,950 families with full siblings discordant for SAD.

Results: Compared to the unexposed individuals, individuals with SAD were less likely to pass all subjects in the last year of compulsory school (adjusted odds ratios [aOR] ranging from 0.19 to 0.44). They were also less likely to access a vocational program or an academic program in upper secondary education (aOR=0.31 [95% CI, 0.30–0.33] and aOR=0.52 [95% CI, 0.51–0.55], respectively). SAD cases also had 81% lower odds of finishing upper secondary education (aOR=0.19 [95% CI, 0.19–0.20]), 53% lower odds of starting a university degree (aOR=0.47 [95% CI, 0.45–0.49]), 65% lower odds of finishing a university degree (aOR=0.35 [95% CI, 0.33–0.37]), and 42% lower odds of finishing postgraduate education (aOR=0.58 [95% CI, 0.43-0.80]). Results were attenuated but remained significant in fully adjusted sibling comparison models. When comorbidities were taken into account, results were maintained.

Conclusion: SAD has an adverse impact on educational attainment throughout the life-span, even after controlling for confounders and factors shared between siblings.