Journal of Racial and Ethnic Health Disparities

, Volume 6, Issue 5, pp 1001–1010 | Cite as

Higher Educational Attainment is Associated with Lower Risk of a Future Suicide Attempt Among Non-Hispanic Whites but not Non-Hispanic Blacks

  • Shervin AssariEmail author
  • Heather T. Schatten
  • Sarah A. Arias
  • Ivan W. Miller
  • Carlos A. Camargo
  • Edwin D. Boudreaux



In a sample of patients presenting to the emergency department (ED), the current study was conducted with two aims: (1) to investigate the protective effects of educational attainment (i.e., completing college) on subsequent risk of suicide attempt/death among patients presenting to the ED and (2) to compare this effect between non-Hispanic Black and non-Hispanic White ED patients.


The current study analyzed data from the Emergency Department Safety Assessment and Follow-Up Evaluation (ED-SAFE) study, a quasi-experimental, eight-center study of universal suicide screening and follow-up of ED patients presenting for suicidal ideation and behavior. Our sample included 937 non-Hispanic White and 211 non-Hispanic Blacks. The dependent variable was suicide attempt/death during the 52-week follow-up. The independent variable was completing college. Age, gender, lesbian/gay/bisexual status, psychiatric history, and previous suicide attempts at baseline were covariates. Race/ethnicity was the focal effect modifier. Logistic regression models were used to test the protective effects of educational attainment on suicide risk in the overall sample and by race/ethnicity.


In the overall sample, educational attainment was not associated with suicide risk over the follow-up period. A significant interaction was found between race/ethnicity and educational attainment on suicide risk, suggesting a larger protective effect for non-Hispanic Whites compared with non-Hispanic Blacks. In race/ethnicity-specific models, completing college was associated with decreased future suicide risk for non-Hispanic Whites but not Blacks.


Consistent with the Minorities’ Diminished Return theory, educational attainment better protected non-Hispanic White than non-Hispanic Blacks against future suicide attempt/death. While Whites who have not completed college may be at an increased risk of suicide, risk of suicide seems to be independent of educational attainment for non-Hispanic Blacks.


Socioeconomic status Ethnic health disparities Race Ethnicity Blacks Suicide 


Authors’ Contribution

SA analyzed the data and prepared the first draft of this paper. All other authors contributed to the interpretation of the findings and revision of the draft and approved the final paper.

Funding Information

This project was supported by Award Number U01MH088278 from the National Institute of Mental Health. Shervin Assari is partially supported by the Assari is supported by the Center for Medicare and Medicaid Services (CMS) Grant 1H0CMS331621 as well as the NIH Awards 54MD008149”, R25 MD007610, 2U54MD007598, and U54 TR001627. Heather Schatten is supported by Award Numbers R01MH112674, R01MH108610, and R01NR014540 from the National Institute of Mental Health.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.


The institutional review boards (IRBs) at each site approved the study protocol. All ED participants signed an informed written consent. As SOs in the intervention phase were only contacted via telephone, they gave verbal consent. The Data and Safety Monitoring Board (DSMB) of the National Institute of Mental Health (NIMH) conducted the overall study oversight and monitoring.


The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental Health or the National Institutes of Health.


  1. 1.
    Dowd JB, Albright J, Raghunathan TE, Schoeni RF, Leclere F, Kaplan GA. Deeper and wider: income and mortality in the USA over three decades. Int J Epidemiol. 2011;40:183–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Marmot MG, Shipley MJ. Do socioeconomic differences in mortality persist after retirement? 25 year follow up of civil servants from the first Whitehall study. Br Med J. 1996;313:1170–80.CrossRefGoogle Scholar
  3. 3.
    Morris JK, Cook DG, Shaper AG. Loss of employment and mortality. Br Med J. 1994;308:1135–9.CrossRefGoogle Scholar
  4. 4.
    Van Groenou MIB, Deeg DJ, Penninx BW. Income differentials in functional disability in old age: relative risks of onset, recovery, decline, attrition and mortality. Aging Clin Exp Res. 2003;15:174–83.CrossRefGoogle Scholar
  5. 5.
    Berkman CS, Gurland BJ. The relationship among income, other socioeconomic indicators, and functional level in older persons. J Aging Health. 1998;10:81–98.CrossRefPubMedGoogle Scholar
  6. 6.
    Burgard SA, Elliott MR, Zivin K, House JS. Working conditions and depressive symptoms: a prospective study of US adults. J Occup Environ Med. 2013;55:1007–14.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Assari S. Health disparities due to diminished return among Black Americans: public policy solutions. Soc Issues Policy Rev. 2018;12:112–45.CrossRefGoogle Scholar
  8. 8.
    Assari S. Unequal gain of equal resources across racial groups. Int J Health Policy Manag. 2017;6:1–6. Scholar
  9. 9.
    Eliason M. Alcohol-related morbidity and mortality following involuntary job loss: evidence from Swedish register data. J Stud Alcohol Drugs. 2014;75:35–46.CrossRefPubMedGoogle Scholar
  10. 10.
    Noelke C, Beckfield J. Recessions, job loss, and mortality among older US adults. Am J Public Health. 2014;104:e126–34.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Baker DP, Leon J, Smith Greenaway EG, Collins J, Movit M. The education effect on population health: a reassessment. Popul Dev Rev. 2011;37:307–32.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Herd P, Goesling B, House JS. Socioeconomic position and health: the differential effects of education versus income on the onset versus progression of health problems. J Health Soc Behav. 2007;48:223–38.CrossRefPubMedGoogle Scholar
  13. 13.
    Hummer RA, Lariscy JT. Educational attainment and adult mortality. In: International handbook of adult mortality. Dordrecht: Springer; 2011. p. 241–61.CrossRefGoogle Scholar
  14. 14.
    Masters RK, Hummer RA, Powers DA. Educational differences in US adult mortality a cohort perspective. Am Soc Rev. 2012;77:548–72.CrossRefGoogle Scholar
  15. 15.
    Brown DC, Hayward MD, Montez JK, Hummer RA, Chiu CT, Hidajat MM. The significance of education for mortality compression in the United States. Demography. 2012;49:819–40.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Lorant V, Deliege D, Eaton W, Robert A, Philippot P, Ansseau M. Socioeconomic inequalities in depression: a meta-analysis. Am J Epidemiol. 2003;157:98–112.CrossRefPubMedGoogle Scholar
  17. 17.
    Assari S. Social determinants of depression: the intersections of race, gender, and socioeconomic status. Brain Sci. 2017;7.
  18. 18.
    Assari S. Life expectancy gain due to employment status depends on race, gender, education, and their intersections. J Racial Ethn Health Disparities. 2017;5:375–86. Scholar
  19. 19.
    Freeman A, Tyrovolas S, Koyanagi A, Chatterji S, Leonardi M, Ayuso-Mateos JL, et al. The role of socio-economic status in depression: results from the COURAGE (aging survey in Europe). BMC Public Health. 2016;16(1098).Google Scholar
  20. 20.
    Ki M, Seong Sohn E, An B, Lim J. Differentiation of direct and indirect socioeconomic effects on suicide attempts in South Korea. Medicine. 2017;96:e9331. Scholar
  21. 21.
    Assari S, Thomas A, Caldwell CH, Mincy RB. Blacks’ diminished health return of family structure and socioeconomic status; 15 years of follow-up of a national urban sample of youth. J Urban Health. 2017;95:21–35. Scholar
  22. 22.
    Assari S. Combined racial and gender differences in the long-term predictive role of education on depressive symptoms and chronic medical conditions. J Racial Ethn Health Disparities. 2016;4:385–96.CrossRefPubMedGoogle Scholar
  23. 23.
    Assari S, Lankarani MM. Race and urbanity alter the protective effect of education but not income on mortality. Front Public Health. 2016;4.
  24. 24.
    Assari S, Lankarani MM. Education and alcohol consumption among older Americans. Black-White differences. Front Public Health. 2016;4.
  25. 25.
    Assari S. The benefits of higher income in protecting against chronic medical conditions are smaller for African Americans than whites. Healthcare. 2018;6.
  26. 26.
    Assari S. Ethnic and gender differences in additive effects of socio-economics, psychiatric disorders, and subjective religiosity on suicidal ideation among blacks. Int J Prev Med. 2015;6:53. Scholar
  27. 27.
    Assari S, Caldwell CH, Mincy R. Family socioeconomic status at birth and youth impulsivity at age 15; blacks’ diminished return. Children. 2018;5:58. Scholar
  28. 28.
    Assari S, Caldwell CH, Mincy RB. Maternal educational attainment at birth promotes future self-rated health of white but not Black youth: a 15-year cohort of a national sample. J Clin Med. 2018;7:93. Scholar
  29. 29.
    DeCuir JT, Dixson AD. “So when it comes out, they aren’t that surprised that it is there”: using critical race theory as a tool of analysis of race and racism in education. Educ Res. 2004;33:26–31.CrossRefGoogle Scholar
  30. 30.
    Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep. 2001;116:404–16.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Oliver ML, Shapiro TM. Black wealth, White wealth: a new perspective on racial inequality; Taylor & Francis: Abingdon, UK, 2006.Google Scholar
  32. 32.
    Williams DR, Mohammed SA, Leavell J, Collins C. Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities. Ann N Y Acad Sci. 2010;1186:69–101.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Assari S, Caldwell CH. Social determinants of perceived discrimination among Black youth: intersection of ethnicity and gender. Children. 2018;5.
  34. 34.
    Wilson KB, Thorpe RJ, LaVeist TA. Dollar for dollar: racial and ethnic inequalities in health and health-related outcomes among persons with very high income. Prev Med. 2017;96:149–53.CrossRefPubMedGoogle Scholar
  35. 35.
    Assari S. High income protects whites but not African Americans against risk of depression. Healthcare. 2018;6:E37. Scholar
  36. 36.
    Assari S, Caldwell CH. Family income at birth and risk of attention deficit hyperactivity disorder at age 15: racial differences. Children. 2019;6:10.CrossRefPubMedCentralGoogle Scholar
  37. 37.
    Assari S, Moghani Lankarani M. Poverty status and childhood asthma in white and Black families: national survey of children’s health. Healthcare. 2018;6:62.CrossRefPubMedCentralGoogle Scholar
  38. 38.
    Assari S. Family income reduces risk of obesity for white but not Black children. Children. 2018;5:73.CrossRefPubMedCentralGoogle Scholar
  39. 39.
    Assari S. Blacks’ diminished return of education attainment on subjective health; mediating effect of income. Brain Sci. 2018;8:176.CrossRefPubMedCentralGoogle Scholar
  40. 40.
    Assari S. Parental education better helps white than Black families escape poverty: national survey of children’s health. Economies. 2018. In Press.Google Scholar
  41. 41.
    Assari S. Diminished economic return of socioeconomic status at birth among Black than white youth. Soc Sci. 2018;7:74. Scholar
  42. 42.
    John OP, Gross JJ. Healthy and unhealthy emotion regulation: personality processes, individual differences, and life span development. J Pers. 2004;72:1301–34.CrossRefPubMedGoogle Scholar
  43. 43.
    Assari S, Caldwell CH. High risk of depression in high-income African American boys. J Racial Ethn Health Disparities. 2017;5:1–12. Scholar
  44. 44.
    Kukull WA, Ganguli M. Generalizability: the trees, the forest, and the low-hanging fruit. Neurology. 2012;78:1886–91. Scholar
  45. 45.
    Boudreaux ED, Miller I, Goldstein AB, Sullivan AF, Allen MH, Manton AP, et al. The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE): methods and design considerations. Contemporary Clinical Trials. 2013;36:14–24.CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Posner K, Brent D, Lucas C, Gould M, Stanley B, Brown G, et al. Columbia-suicide severity rating scale (C-SSRS). Columbia University Medical Center. 2008.Google Scholar
  47. 47.
    Posner KP, Brown GK, Stanley B, Brent DA, Yershova KV, Oquendo MA, et al. The Columbia-Suicide Severity Rating Scale: initial validity and interval consistency findings from three multisite studies with adolescent and adults. Am J Psychiatr. 2011;168:1266–77.CrossRefPubMedGoogle Scholar
  48. 48.
    Chen E, Martin AD, Matthews KA. Understanding health disparities: the role of race and socioeconomic status in children’s health. Am J Public Health. 2006;96:702–8.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Assari S, Preiser B, Lankarani MM, Caldwell CH. Subjective socioeconomic status moderates the association between discrimination and depression in African American youth. Brain Sci. 2018;8:E71. Scholar
  50. 50.
    Hudson DL, Neighbors HW, Geronimus AT, Jackson JS. Racial discrimination, John Henryism, and depression among African Americans. J Black Psychol. 2016;42:221–43.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Hudson DL, Neighbors HW, Geronimus AT, Jackson JS. The relationship between socioeconomic position and depression among a US nationally representative sample of African Americans. Soc Psychiatry Psychiatr Epidemiol. 2012;47:373–81. Scholar
  52. 52.
    Hayward MD, Hummer RA, Sasson I. Trends and group differences in the association between educational attainment and U.S. adult mortality: implications for understanding education’s causal influence. Soc Sci Med. 2015;127:8–18.CrossRefPubMedGoogle Scholar
  53. 53.
    Backlund E, Sorlie PD, Johnson NJ. A comparison of the relationships of education and income with mortality: the national longitudinal mortality study. Soc Sci Med. 1999;49:1373–84.CrossRefPubMedGoogle Scholar
  54. 54.
    Everett BG, Rehkopf DH, Rogers RG. The nonlinear relationship between education and mortality: an examination of cohort, race/ethnic, and gender differences. Popul Res Policy Rev. 2013;32:893–917.CrossRefGoogle Scholar
  55. 55.
    Cutler DM, Lleras-Muney A Education and health: evaluating theories and evidence. National Bureau of Economic Research. Available online: (accessed on 9 September 2017).
  56. 56.
    Holmes CJ, Zajacova A. Education as “the great equalizer”: health benefits for black and white adults. Soc Sci Q. 2014;95:1064–85.Google Scholar
  57. 57.
    Assari S, Lankarani MM, Caldwell CH. Does discrimination explain high risk of depression among high-income African American men? Behav Sci. 2018;8:E40. Scholar
  58. 58.
    Assari S, Mistry R. Educational attainment and smoking status in a national sample of American adults; evidence for the blacks’ diminished return. Int J Environ Res Public Health. 2018;15:763.CrossRefPubMedCentralGoogle Scholar
  59. 59.
    Lampe FC, Walker M, Lennon LT, Whincup PH, Ebrahim S. Validity of a self-reported history of doctor-diagnosed angina. J Clin Epidemiol. 1999;52:73–81.CrossRefPubMedGoogle Scholar
  60. 60.
    Assari S, Lankarani MM, Burgard S. Black-white difference in long-term predictive power of self-rated health on all-cause mortality in United States. Ann Epidemiol. 2016;26:106–14.CrossRefPubMedGoogle Scholar
  61. 61.
    Assari S, Burgard S, Zivin K. Long-term reciprocal associations between depressive symptoms and number of chronic medical conditions: longitudinal support for black-white health paradox. J Racial Ethn Health Disparities. 2015;2:589–97.CrossRefPubMedGoogle Scholar
  62. 62.
    Assari S, Moazen-Zadeh E, Lankarani MM, Micol-Foster V. Race, depressive symptoms, and all-cause mortality in the United States. Front Public Health. 2016;4:40. Scholar
  63. 63.
    Assari S, Lankarani MM. Depressive symptoms are associated with more hopelessness among white than black older adults. Front Public Health. 2016;4:82. Scholar
  64. 64.
    Assari S, Burgard S. Black-White differences in the effect of baseline depressive symptoms on deaths due to renal diseases: 25 year follow up of a nationally representative community sample. J Ren Inj Prev. 2015;4:127–34.PubMedGoogle Scholar
  65. 65.
    Assari S. Hostility, anger, and cardiovascular mortality among Blacks and Whites. Res Cardiovasc Med. 2016;6:2. Scholar
  66. 66.
    Assari S. Race, sense of control over life, and short-term risk of mortality among older adults in the United States. Arch Med Sci. 2016;5:1233–40. Scholar
  67. 67.
    Assari S, Lankarani MM. Association between stressful life events and depression; intersection of race and gender. J Racial Ethn Health Disparities. 2016;3:349–56.CrossRefPubMedGoogle Scholar
  68. 68.
    Assari S, Sonnega A, Pepin R, Leggett A. Residual effects of restless sleep over depressive symptoms on chronic medical conditions: race by gender differences. J Racial Ethn Health Disparities. 2016;4:59–69. Scholar
  69. 69.
    Assari S. Perceived neighborhood safety better predicts 25-year mortality risk among Whites than Blacks. J Racial Ethn Health Disparities. 2016;4:937–48. Scholar
  70. 70.
    Adam EK, Heissel JA, Zeiders KH, Richeson JA, Ross EC, Ehrlich KB, et al. Developmental histories of perceived racial discrimination and diurnal cortisol profiles in adulthood: a 20-year prospective study. Psychoneuroendocrinology. 2015;62:279–91. Scholar
  71. 71.
    Fuller-Rowell TE, Curtis DS, Doan SN, Coe CL. Racial disparities in the health benefits of educational attainment: a study of inflammatory trajectories among African American and white adults. Psychosom Med. 2015;77:33–40. Scholar
  72. 72.
    Fuller-Rowell TE, Doan SN, Eccles JS. Differential effects of perceived discrimination on the diurnal cortisol rhythm of African Americans and Whites. Psychoneuroendocrinology. 2012;37:107–18. Scholar
  73. 73.
    Fuller-Rowell TE, Doan SN. The social costs of academic success across ethnic groups. Child Dev. 2010;81:1696–713. Scholar
  74. 74.
    Hudson DL, Bullard KM, Neighbors HW, Geronimus AT, Yang J, Jackson JS. Are benefits conferred with greater socioeconomic position undermined by racial discrimination among African American men? J Mens Health. 2012;9:127–36.CrossRefPubMedPubMedCentralGoogle Scholar
  75. 75.
    Assari S, Gibbons FX, Simons RL. Perceived discrimination among Black youth: an 18-year longitudinal study. Behav Sci. 2018;8:44.CrossRefGoogle Scholar
  76. 76.
    Navarro V. Race or class, or race and class. Int J Health Serv. 1989;19:311–4.CrossRefPubMedGoogle Scholar
  77. 77.
    Mehta N, Preston S. Are major behavioral and sociodemographic risk factors for mortality additive or multiplicative in their effects? Soc Sci Med. 2016;154:93–9.CrossRefPubMedPubMedCentralGoogle Scholar
  78. 78.
    Williams DR, Collins C. U. S. socioeconomic and racial differences in health: patterns and explanations. Ann Rev Sociol. 1995;21:349–86.CrossRefGoogle Scholar
  79. 79.
    Farmer MM, Ferraro KF. Are racial disparities in health conditional on socioeconomic status? Soc Sci Med. 2005;60:191–204.CrossRefPubMedGoogle Scholar
  80. 80.
    Dowd JJ, Bengtson VL. Aging in minority populations an examination of the double jeopardy hypothesis. J Gerontol. 1978;33:427–36.CrossRefPubMedGoogle Scholar
  81. 81.
    Bowleg L, Huang J, Brooks K, Black A, Burkholder G. Triple jeopardy and beyond: multiple minority stress and resilience among Black lesbians. J Lesbian Stud. 2003;7:87–108.CrossRefPubMedGoogle Scholar
  82. 82.
    King DK. Multiple jeopardy, multiple consciousness: the context of a Black feminist ideology. Signs J Women Cult Soc. 1988;14:42–72.CrossRefGoogle Scholar
  83. 83.
    Assari S. Number of chronic medical conditions fully mediates the effects of race on mortality; 25-year follow-up of a nationally representative sample of Americans. J Racial Ethn Health Disparities. 2017;4:623–31.CrossRefPubMedGoogle Scholar
  84. 84.
    Steenland K, Henley J, Thun M. All-cause and cause-specific death rates by educational status for two million people in two American Cancer Society cohorts, 1959–1996. Am J Epidemiol. 2002;156:11–21.CrossRefPubMedGoogle Scholar
  85. 85.
    Assari S, Nikahd A, Malekahmadi MR, Lankarani MM, Zamanian H. Race by gender group differences in the protective effects of socioeconomic factors against sustained health problems across five domains. J Racial Ethn Health Disparities. 2017;4:884–94.CrossRefGoogle Scholar
  86. 86.
    Montez JK, Hayward MD, Brown DC, Hummer RA. Why is the educational gradient of mortality steeper for men? J Gerontol Ser B Psychol Sci Soc Sci. 2009;64:625–34.CrossRefGoogle Scholar
  87. 87.
    Assari S, Moazen-Zadeh E. Ethnic variation in the cross-sectional association between domains of depressive symptoms and clinical depression. Front Psychiatry. 2016;7:53. Scholar
  88. 88.
    Assari S, Preiser B, Kelly M. Education and income predict future emotional well-being of whites but not blacks: a ten-year cohort. Brain Sci. 2018;8:122.CrossRefPubMedCentralGoogle Scholar
  89. 89.
    Assari S, Farokhnia M, Mistry R. Education attainment and alcohol binge drinking: diminished returns of Hispanics in Los Angeles. Behav Sci. 2019;9:9.CrossRefGoogle Scholar

Copyright information

© W. Montague Cobb-NMA Health Institute 2019

Authors and Affiliations

  1. 1.Department of Family MedicineCharles R. Drew University of Medicine and ScienceLos AngelesUSA
  2. 2.Department of Psychiatry and Human Behavior, Alpert Medical SchoolBrown UniversityProvidenceUSA
  3. 3.Butler HospitalProvidenceUSA
  4. 4.Department of Emergency Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  5. 5.Department of Emergency MedicineUniversity of Massachusetts Medical SchoolWorcesterUSA
  6. 6.Department of PsychiatryUniversity of Massachusetts Medical SchoolWorcesterUSA
  7. 7.Department of Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterUSA

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