Adolescence is an important period for the development of mental health problems, with around 50% of all diagnosed mental disorders worldwide starting before the age of 18 years. Moreover, rates of depression, anxiety, and self-harm are rising in the UK and globally. Nonetheless, we have a limited understanding of what causes mental health problems. Finding modifiable risk factors is important to prevent the development of these mental health problems.
A potential factor that may play a role in adolescent mental health is academic pressure, and there are widespread concerns about the potential negative impact of academic pressure on adolescent mental health. However, the association has rarely been investigated.
In our study, which is part of a larger project, we will investigate the association between academic pressure and adolescent mental health, using electronic health record data. We will study how timing in the school year is associated with adolescent primary care and hospital visits for depression, anxiety, and self-harm. Based on conversations with students and teachers, we would expect clinical presentations to be highest around the time of exams and, especially, national ‘high-stakes’ exam times (i.e., May and June). This is because testing and national exam times are periods when adolescents tend to experience higher levels of academic pressure.
We will investigate the association between academic pressure and mental health problems in secondary-school adolescents. We will focus on 14- to 16-year-olds. Adolescents at this age typically take ‘high-stakes’ GCSE exams and tend to experience higher levels of academic pressure. Our objectives are to describe rates of clinical presentations for depression, anxiety, and self-harm for each calendar month, and to test for differences between calendar months. We hypothesise that clinical presentations will be highest in months of exams (May and June).
We will describe incidence of clinical presentations for depression, anxiety, and self-harm for each calendar month, based on CPRD diagnoses, symptoms, and prescriptions (depression, anxiety) and HES admissions (self-harm). We will then test our hypothesis that rates are highest in months of GCSE exams. First, we will test for differences in incidence rates between calendar months, using Poisson regression. Second, we will use the self-controlled case series method (Petersen et al., 2016) to test whether adolescents are more likely to have presented in months when they were exposed (May, June) than when they were unexposed (all other months). We will run interactions/sub-group analyses for sex, month of birth, country, and calendar year. We will also investigate ADHD diagnoses and prescriptions as secondary outcomes, as these may also be affected by academic pressure. We will investigate the impact of educational policies that may have affected academic pressure related to GCSE exams. Finally, we will investigate whether associations may be different for years when exams were cancelled due to the Covid-19 pandemic (2020, 2021).
Mental health problems are a public health priority. They often start in adolescence, and academic pressure may play a role. We are aiming to add evidence that could inform the prevention of mental health problems. Our findings could inform policies related to GCSE exams or school interventions.
Primary outcomes
- CPRD diagnoses and symptoms of depression and anxiety (focus on GAD)
- CPRD prescriptions for depression and anxiety (focus on SSRIs)
- HES admissions for self-harm
Secondary outcomes
- CPRD diagnoses of ADHD
- CPRD prescriptions for ADHD (focus on methylphenidates)
Negative control outcomes
- Physical health outcomes not associated with academic pressure (e.g., appendectomy)
Gemma Lewis - Chief Investigator - University College London ( UCL )
Marie Mueller - Corresponding Applicant - University College London ( UCL )
Alvin Richards-Belle - Collaborator - University College London ( UCL )
James Bailey - Collaborator - University College London ( UCL )
Joseph Hayes - Collaborator - University College London ( UCL )
Kenneth Man - Collaborator - University College London ( UCL )
Neil Davies - Collaborator - University College London ( UCL )
Victoria Yorke-Edwards - Collaborator - University College London ( UCL )
Neil Davies - Collaborator - University of Bristol
HES Admitted Patient Care;Patient Level Index of Multiple Deprivation;Practice Level Index of Multiple Deprivation