Research

JAMA Psychiatry | Original Investigation

Association of Obsessive-Compulsive Disorder

With Objective Indicators of Educational Attainment
A Nationwide Register-Based Sibling Control Study
Ana Pérez-Vigil, MD; Lorena Fernández de la Cruz, PhD; Gustaf Brander, MSc; Kayoko Isomura, MD, PhD; Andreas Jangmo, MSc;
Inna Feldman, PhD; Eva Hesselmark, BSc; Eva Serlachius, MD, PhD; Luisa Lázaro, MD, PhD; Christian Rück, MD, PhD; Ralf Kuja-Halkola, PhD;
Brian M. D’Onofrio, PhD; Henrik Larsson, PhD; David Mataix-Cols, PhD

Author Audio Interview

IMPORTANCE To our knowledge, the association of obsessive-compulsive disorder (OCD) and Supplemental content
academic performance has not been objectively quantified.

OBJECTIVE To investigate the association of OCD with objectively measured educational

outcomes in a nationwide cohort, adjusting for covariates and unmeasured factors shared
between siblings.

DESIGN, SETTING, AND PARTICIPANTS This population-based birth cohort study included
2 115 554 individuals who were born in Sweden between January 1, 1976, and December 31,
1998, and followed up through December 31, 2013. Using the Swedish National Patient
Register and previously validated International Statistical Classification of Diseases and
Related Health Problems, Tenth Revision (ICD-10) codes, we identified persons with OCD;
within the cohort, we identified 726 198 families with 2 or more full siblings, and identified
11 482 families with full siblings discordant for OCD. Data analyses were conducted from
October 1, 2016, to September 25, 2017.

MAIN OUTCOMES AND MEASURES The study evaluates the following educational milestones:
eligibility to access upper secondary school after compulsory education, finishing upper
secondary school, starting a university degree, finishing a university degree, and finishing
postgraduate education.

RESULTS Of the 2 115 554 individuals in the cohort, 15 120 were diagnosed with OCD (59%
females). Compared with unexposed individuals, those with OCD were significantly less likely
to pass all core and additional courses at the end of compulsory school (adjusted odds ratio
[aOR] range, 0.35-0.60) and to access a vocational or academic program in upper secondary
education (aOR, 0.47; 95% CI, 0.45-0.50 and aOR, 0.61; 95% CI, 0.58-0.63, for vocational
and academic programs, respectively). People with OCD were also less likely to finish upper
secondary education (aOR, 0.43; 95% CI, 0.41-0.44), start a university degree (aOR, 0.72;
95% CI, 0.69-0.75), finish a university degree (aOR, 0.59; 95% CI, 0.56-0.62), and finish
postgraduate education (aOR, 0.52; 95% CI, 0.36-0.77). The results were similar in the sibling
comparison models. Individuals diagnosed with OCD before age 18 years showed worse
educational attainment across all educational levels compared with those diagnosed at or
after age 18 years. Exclusion of patients with comorbid neuropsychiatric disorders, psychotic,
anxiety, mood, substance use, and other psychiatric disorders resulted in attenuated
estimates, but patients with OCD were still impaired across all educational outcomes.

Author Affiliations: Author

CONCLUSIONS AND RELEVANCE Obsessive-compulsive disorder, particularly when it has an affiliations are listed at the end of this
early onset, is associated with a pervasive and profound decrease in educational attainment, article.
spanning from compulsory school to postgraduate education. Corresponding Author: Ana Pérez-
Vigil, MD, Karolinska Institutet,
Department of Clinical Neuroscience,
Child and Adolescent Psychiatry
Research Center, Gävlegatan 22
(Entré B), Floor 8, SE-11330
JAMA Psychiatry. doi:10.1001/jamapsychiatry.2017.3523 Stockholm, Sweden
Published online November 15, 2017. (ana.perez.vigil@ki.se).

(Reprinted) E1
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 Research Original Investigation
E
ducational achievement is not only important from an
individual perspective, given its critical link to social and
economic success,1-3 but it is also relevant from a pub-
lic health and societal perspective. Education is one of the
strongest predictors of health4 and is associated with a coun-
try’s ability to increase its standard of living, compete in global
markets, and promote participation in civic affairs.5-7
The age at onset of a disorder is an important factor in pre-
dicting the course of illness and psychosocial outcomes, in-
cluding education;8,9 early-onset psychiatric disorders can lead
to truncated educational attainment.10-12 There is some evi-
dence from cross-sectional studies that children and adoles-
cents with psychiatric disorders are at increased risk for un-
derachieving in school or dropping out prematurely compared
with the general population.10,13 However, little is known about
the association of obsessive-compulsive disorder (OCD) with
educational attainment.
Obsessive-compulsive disorder is a relatively common psy-
chiatric disorder. It has a lifetime prevalence of 2.3%,14 which
is similar in both sexes;15 the disorder tends to follow a chronic
waxing and waning course.16 One-third of patients with OCD
develop the disorder before age 15 years, and about 50% re-
port onset in childhood and adolescence.17 Clinical experi-
ence suggests that OCD might be negatively associated with
the person’s education, not only in childhood and adoles-
cence, but also in early adulthood. However, this topic has
rarely been empirically investigated.
A handful of studies conducted in specialist pediatric OCD
clinics have found impairments in self-reported or parent-
reported educational outcomes.18-21 In addition, 2 cross-
sectional studies of 3570 individuals by the National Survey
of American Life found an association between OCD (n = 57)
and fewer self-reported years of education.20,21 A study using
data from the 2007 Australian National Survey of Mental Health
and Wellbeing retrospectively examined the association of
early-onset psychiatric disorders with the early termination of
secondary education in 2055 people aged 20 to 34 years.22 The
results showed that boys (but not girls) with early-onset OCD
(before age 16 years) had higher school dropout rates com-
pared with their unaffected counterparts (odds ratio [OR], 4.3).
However, these studies were limited by methodological is-
sues, including small sample sizes, recruitment mainly from spe-
cialist clinics, cross-sectional design, and retrospectively col-
lected self-reported or parent-reported data. Furthermore, none
of the previous studies could strictly adjust for important con-
founders, such as psychiatric comorbidity or familial factors (eg,
genetic or shared environmental factors), that might influence
both OCD and educational attainment. Finally, previous stud-
ies have been limited to the educational achievements in child-
hood and adolescence; thus, how OCD is associated with later
stages of education (eg, university studies) is unknown. It is plau-
sible that some individuals with OCD might be able to compen-
sate for their initial difficulties, find alternative routes to achieve
higher education, or return to the education system at a later
stage, but this has not been explored.
There is therefore a clear gap in the literature for studies
based on larger, prospectively collected samples and objec-
tively measured educational outcomes. This population-
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Association of Obsessive-Compulsive Disorder With Educational Attainment
Key Points
Question How is obsessive-compulsive disorder (OCD) associated
with objective indicators of educational attainment?
Findings This population-based cohort study included 2 115 554
individuals, of whom 15 120 were diagnosed with OCD, and found
that people with OCD were significantly more likely to fail all
courses in compulsory school and less likely to achieve each level
of education from primary to postgraduate education. The
association was greatest when OCD was first diagnosed before age
18 years.
Meaning Obsessive-compulsive disorder, particularly when it has
an early age at onset, has a pervasive and profound association
with decreased achievement across all educational levels.
based study aims to investigate the association of OCD with
educational attainment across the person’s lifespan—from com-
pulsory school through postgraduate education—taking into
account a number of measured covariates, such as parity and
parental age at the time that an individual was born. In addi-
tion, we used a sibling control design to control for unmea-
sured familial confounders shared by full siblings (such as ge-
netic factors, parental psychopathology, and socioeconomic
status). To ensure that the observed associations are not en-
tirely explained by comorbid conditions, we performed sen-
sitivity analyses in subgroups in which all individuals with co-
morbid conditions were excluded. We hypothesized that OCD
would be associated with academic underachievement across
all educational levels, particularly in individuals who experi-
enced pediatric or adolescent onset of the disorder.
Methods
The regional ethical review board of Stockholm approved the
study. The requirement for informed consent was waived be-
cause the study was based on existing registers, and the data
on the included individuals were deidentified.
Study Population and Design
The data were obtained by linking the following Swedish na-
tional population-based registers through the individuals’
unique personal identification numbers (after recoding these
for anonymity):23 (1) the National School Register, which holds
information on individual school performance from all mu-
nicipal and independent schools from December, 31, 1988;24
(2) the Longitudinal Integration Database for Health Insur-
ance and Labor Studies, acronymized LISA under its Swedish
name,25 which integrates annual data on the labor market, edu-
cation sector, and social sectors for all individuals living in Swe-
den; (3) the Swedish National Patient Register (NPR),26 which
covers inpatient hospital admissions since 1969 and outpa-
tient care since 2001, with International Statistical Classifica-
tion of Diseases and Related Health Problems, Tenth Revision
(ICD-10) codes in use from 1997 to the present; (4) the Multi-
Generation Register,27 which connects every person who was
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 Association of Obsessive-Compulsive Disorder With Educational Attainment
born in Sweden from 1932 to the present and who was regis-
tered at least once as living in Sweden between 1961 and the
present to their parents, enabling database users to obtain a
family genealogy for each participant; (5) the Migration
Register,28 which provides information about migration into
and out of Sweden; and (6) the Cause of Death Register,29 which
records information on dates and causes of all deaths since
1961.
The initial study cohort consisted of 2 328 201 individu-
als who were born in Sweden between January 1, 1976, and De-
cember 31, 1998, and followed up until December 31, 2013. Of
these, 1 195 489, or 51.3%, were male. Individuals diagnosed
with organic brain disorders (ICD-10 codes F00-F09) and/or
mental retardation (ICD-10 codes F70-F79) were excluded from
the cohort (n = 20 221). Additionally, individuals with 2 par-
ents born outside of Sweden and those who were missing data
on the origin of their parents were excluded (n = 192 426).30
The final study cohort therefore consisted of 2 115 554 indi-
viduals (of whom 1 085 445, or 51.0%, were male). For the sib-
ling-comparison analyses, we identified a subsample of 726 198
families with at least 2 singleton full siblings (ie, siblings of
either sex who shared the same biological mother and father)
during the same period.
Exposure
The exposure was defined as receiving a diagnosis of OCD
according to ICD-10 criteria (code F42), as recorded in the
NPR.31 Individuals with a lifetime diagnosis of OCD were
considered exposed and those without the disorder were
considered nonexposed.
Compulsory Education Outcomes
The National School Register contains information on each stu-
dent’s eligibility to access upper secondary education after suc-
cessful completion of compulsory education at age 15 or 16
years in Sweden. Because of different admission require-
ments before 1998 and after 2010, this study retrieved infor-
mation from the National School Register for a subcohort of
individuals with data between these years (n = 1 234 042). Eli-
gibility to access upper secondary education is based on the
school grades in the final year of compulsory school. The ad-
mission requirements vary depending on the student’s choice
for a vocational program or an academic program. Students
aiming to enter a vocational program were required to pass the
3 core courses (Swedish, English, and mathematics), and stu-
dents aiming to enter an academic program (which is prepa-
ration for higher education, such as a university degree) were
required to pass the 3 core courses and at least 9 additional
courses. The National School Register also includes informa-
tion on the individual school courses, which were coded as bi-
nary variables (passed vs failed). For the purposes of this study,
students are dichotomized as eligible or ineligible for access
to upper secondary education.
Educational Outcomes After Compulsory Education
Data on the following binary educational outcomes for the full
cohort (n = 2 115 554) were retrieved from the LISA database:25
finishing upper secondary school, starting a university de-
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Original Investigation Research
gree, finishing a university degree, and finishing postgradu-
ate education (ie, a master’s or doctoral degree). Each out-
come was dichotomized as achieved vs not achieved.
Statistical Methods
Logistic regression models were fitted to compare exposed and
nonexposed individuals on all binary outcomes (passing spe-
cific courses, eligibility to progress to secondary education, and
achievement of subsequent educational levels). First, crude
associations with OCD were modeled separately for each out-
come. Subsequently, models were adjusted for sex, year of
birth, maternal age and paternal age at the birth of the indi-
vidual participant, and parity. Results were expressed as OR
with 95% confidence intervals (CIs).
A fixed-effects model was implemented in the sub-
sample of clusters of all full siblings of individuals with OCD.
By design, these stratified logistic regression models control
for shared familial confounders32 and, in particular, for ge-
netic factors and unmeasured shared confounders, such as so-
cioeconomic status or unchanging parental traits. Further-
more, we adjusted for all measured confounders listed above,
which typically vary between siblings.
To examine whether individuals with a pediatric or ado-
lescent onset of the disorder had more profound educational
impairment than those with adult onset, we repeated our main
analyses, stratifying exposed persons into 2 groups: individu-
als first diagnosed with OCD before age 18 years (n = 4296) and
individuals first diagnosed at 18 years or older (n = 10 824).
Sensitivity analyses were performed in subgroups from
which all individuals with comorbid conditions were ex-
cluded. These conditions were organized in 7 groups: (1) at-
tention-deficit/hyperactivity disorder (ADHD) (ICD-10 code
F90); (2) other neuropsychiatric disorders (pervasive devel-
opmental disorders, Tourette syndrome and chronic tic dis-
orders, and learning disabilities; ICD-10 codes F84, F95, and
F81); (3) schizophrenia, schizotypal, and delusional disor-
ders (ICD-10 codes F20-F29); (4) phobic, anxiety, and reac-
tion to severe stress and adjustment disorders (ICD-10 codes
F40-F41 and F43); (5) affective disorders (ICD-10 codes F30-
F39); (6) substance use disorders (ICD-10 codes F10-F19); and
(7) other disorders (dissociative disorders, somatoform disor-
ders, other neurotic disorders, and eating disorders; ICD-10
codes F44, F45, F48, F50-F59). All disorders were defined as
at least 1 registered diagnosis in the NPR. These models also
adjusted for sex, year of birth, maternal and paternal age at the
birth of the individual participant, and parity.
All analyses were stratified by sex and were conducted
using SAS, version 9.4 (SAS Institute Inc). Data analyses were
conducted from October 1, 2016, to September 25, 2017.
Results
Descriptive Statistics
Descriptive characteristics of the study cohort are presented
in Table 1. Of the 2 115 554 individuals included, 15 120 re-
ceived a lifetime diagnosis of OCD. The proportion of females
in the OCD cohort (8996 of 15 120, or 59.5%) was significantly
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 Research Original Investigation Association of Obsessive-Compulsive Disorder With Educational Attainment

Table 1. Distribution of Study Variables Among Study Cohort Members Born in Sweden Between 1976
and 1998, Stratified by Obsessive-Compulsive Disorder
Individuals With Obsessive-Compulsive Unaffected Individuals
Characteristic, No. (%) Disorder (n = 15 120) (n = 2 100 434 )
Female 8996 (59.5) 1 021 113 (48.6)
Age of mothers at birth of study participant, 28.4 (5.3) 28.0 (5.0)
mean (SD), ya
Age of fathers at birth of study participant, 31.2 (6.2) 30.7 (5.8)
mean (SD), ya
Missing 101 (0.7) 13 950 (0.7)
Paritya
1 6444 (42.6) 853 017 (40.6)
2 5227 (34.6) 766 216 (36.5)
3 2253 (14.9) 326 417 (15.5)
≥4 1000 (6.6) 125 379 (6.0)
Missing 196 (1.3) 29 403 (1.4)
a
Comorbidity Statistically significant
a
between-group difference
Attention-deficit/hyperactivity disorder 2644 (17.5) 53 215 (2.5) determined with a χ2 test or 2-tailed
Other neuropsychiatric disordersa,b 2718 (18.0) 27 020 (1.3) t test; all marked comparisons
Schizophrenia, schizotypal, or delusional 982 (6.5) 9133 (0.4) yielded P < .001.
disordersa b
Includes pervasive developmental
Phobic, anxiety, stress reaction, 8643 (57.2) 129 872 (6.2) disorders, Tourette syndrome and
and adjustment disordersa chronic tic disorders, and learning
Affective disordersa 7132 (47.2) 109 494 (5.2) disabilities.
c
Substance use disordersa 2343 (15.5) 88 730 (4.2) Includes dissociative, somatoform,
a,c other neurotic, and eating
Other disorders 2517 (16.7) 33 358 (1.6)
disorders.

larger than in the unexposed population (1 021 113 of 2 100 434,
or 48.6%). As expected, those with a diagnosis of OCD also had
more psychiatric comorbidity than those without OCD (12 234
of 15 120, or 80.9%, vs 284 905 of 2 100 434, or 13.6%)
(P < .001). Of the 726 198 families with at least 2 singleton chil-
dren, 11 482 (1.6%) included full siblings who were discordant
for OCD.
Compulsory Education
Individuals with OCD were less likely to be eligible to access a
vocational or an academic program in upper secondary school
compared with the general population (adjusted OR [aOR],
0.47; 95% CI, 0.45–0.50 and aOR, 0.61; 95% CI, 0.58-0.63, for
vocational and academic programs, respectively). The re-
sults remained largely unchanged in the sibling comparison
models (aOR, 0.53; 95% CI, 0.47-0.60 and aOR, 0.65; 95% CI,
0.58-0.71, for vocational and academic programs, respec-
tively). This pattern was similar across both sexes (Table 2).
Analyses of the specific school courses revealed that in-
dividuals with a lifetime diagnosis of OCD were significantly
less likely to pass all courses in the last year of compulsory edu-
cation (aOR range, 0.35-0.60). For example, students with OCD
were 43%, 40%, and 53% less likely to pass each of the core
courses (Swedish language, English language, and mathemat-
ics, respectively) (Table 3). A very similar pattern of results
emerged in the sibling comparison models (aOR range, 0.42-
0.60) (Table 3).
Overall, female students with OCD tended to experience
lower odds of success in various courses compared with males
with OCD, but these differences were not statistically signifi-
cant (in that their confidence intervals overlapped) in the full
sibling comparisons (eTable 1 in the Supplement).
Educational Attainment After Compulsory School
Compared with population controls, individuals with OCD were
significantly less likely to achieve each of the assessed edu-
cational levels during the 22-year study period. In the ad-
justed models, the individuals with OCD were 57% less likely
to complete upper secondary school, 28% less likely to start a
university degree, 41% less likely to finish a university de-
gree, and 48% less likely to complete postgraduate education
compared with those without OCD (Table 2). The results re-
mained similar in the sibling comparison model, although the
estimates for postgraduate studies had broader confidence in-
tervals and so were less precise. Female persons with OCD were
less likely to start a university degree and also less likely to fin-
ish a university degree compared with males with OCD, as in-
dicated by the OR’s non-overlapping CIs. However, these dif-
ferences were no longer significant in the full sibling
comparison.
Individuals Stratified by Age at First Diagnosis
Overall, individuals first diagnosed with OCD before age 18
years (n = 4296) had worse outcomes across all educational lev-
els, compared with individuals first diagnosed at age 18 years
or older (n = 10 824), both in the adjusted model and the sib-
ling comparison model (Table 4).
Psychiatric Comorbidity
When individuals with different groups of comorbidities
were excluded from the analyses, the results still showed
significantly worse educational outcomes for the OCD group
compared with the general population; however, in general,
the magnitude of these differences was smaller. For
example, after the exclusion of individuals with ADHD, the

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 Association of Obsessive-Compulsive Disorder With Educational Attainment Original Investigation Research

Table 2. Educational Attainment Among Individuals With Lifetime Obsessive-Compulsive Disorder, Compared With Unaffected Individuals
and Full Siblings of Affected Individuals, Stratified by Sex

No. (%) OR (95% CI)

Educational Attainment Level Individuals With OCD Individuals Without OCD Unadjusted Model Adjusted Modela Full Sibling Comparisona
Compulsory education 9415 1 224 627
Eligible for vocational program, 7962 (84.6) 1 118 459 (91.3) 0.52 (0.49-0.55) 0.47 (0.45-0.50) 0.53 (0.47-0.60)
all
Female 4855 (85.2) 552 635 (92.6) 0.46 (0.43-0.50) 0.45 (0.41-0.48) 0.48 (0.38-0.61)
Male 3107 (83.5) 565 824 (90.1) 0.56 (0.51-0.61) 0.51 (0.47-0.56) 0.53 (0.41-0.69)
Eligible for academic program, all 6413 (68.1) 943 458 (77.0) 0.64 (0.61-0.67) 0.61 (0.58-0.63) 0.65 (0.58-0.71)
Female 3959 (69.5) 466 435 (78.2) 0.64 (0.60-0.67) 0.62 (0.58-0.65) 0.63 (0.53-0.76)
Male 2454 (66.0) 477 023 (76.0) 0.61 (0.57-0.66) 0.59 (0.55-0.63) 0.61 (0.49-0.76)
Postcompulsory education 15 120 2 100 434
Finishing upper secondary school, 7995 (52.9) 1 395 993 (66.5) 0.57 (0.55-0.59) 0.43 (0.41-0.44) 0.45 (0.42-0.48)
all
Female 4961 (55.2) 700 405 (68.6) 0.56 (0.54-0.59) 0.41 (0.39-0.43) 0.45 (0.39-0.51)
Male 3034 (49.5) 695 588 (64.5) 0.54 (0.52-0.57) 0.44 (0.42-0.47) 0.44 (0.38-0.50)
Starting a university degree, all 3973 (26.3) 605 011 (28.8) 0.88 (0.85-0.91) 0.72 (0.69-0.75) 0.64 (0.59-0.69)
Female 2620 (29.1) 351 037 (34.4) 0.78 (0.75-0.82) 0.66 (0.63-0.70) 0.65 (0.57-0.73)
Male 1353 (22.1) 253 974 (23.5) 0.92 (0.87-0.98) 0.83 (0.78-0.89) 0.62 (0.52-0.73)
Finishing a university degree, all 1626 (10.8) 292 960 (14.0) 0.74 (0.71-0.78) 0.59 (0.56-0.62) 0.53 (0.48-0.59)
Female 1156 (12.9) 186 151 (18.2) 0.66 (0.62-0.70) 0.55 (0.52-0.59) 0.51 (0.43-0.60)
Male 470 (7.7) 106 809 (9.9.) 0.76 (0.69-0.83) 0.69 (0.62-0.76) 0.60 (0.47-0.75)
Finishing postgraduate 27 (0.2) 6876 (0.3) 0.55 (0.37-0.80) 0.52 (0.36-0.77) 0.57 (0.27-1.21)b
education, all
Female 15 (0.17) 3114 (0.30) 0.55 (0.33-0.91) 0.50 (0.29-0.84) 0.73 (0.14-3.85)b
Male 12 (0.20) 3762 (0.35) 0.56 (0.32-0.99) 0.56 (0.31-0.98) 0.18 (0.03-1.18)b
Abbreviations: OCD obsessive-compulsive disorder; OR odds ratio. stratification by sex.
a b
Adjusted by sex, year of birth, maternal and paternal age at the birth of the Nonsignificant findings. All other findings in this table are statistically
study participant, and parity. Sex was not included as a covariate in the significant.

group with OCD was still 32% to 44% less likely to be eli-
gible for upper secondary school entry and 51% less likely to
finish upper secondary school than the group without OCD
(Table 5). Similar results were obtained when these analyses
were stratified by sex (Table 5) or age of first OCD diagnosis
(eTable 2 in the Supplement).
Discussion
To our knowledge, this is the first study examining the asso-
ciation of OCD with prospectively and objectively measured
educational outcomes at a nationwide level. The main find-
ing was that OCD is associated with pervasive academic un-
derachievement. The association was global rather than being
limited to a particular course; patients were more likely to fail
each of the core and additional courses in compulsory school
and less likely to achieve each level of education, from pri-
mary school to postgraduate education. As expected, the as-
sociation was greatest when OCD was diagnosed at an early age,
in childhood or adolescence. For example, patients first diag-
nosed with OCD before age 18 years were 55% to 62% less likely
to progress beyond compulsory education compared with
population controls. The corresponding figures for patients di-
agnosed at 18 years or older were 32% to 48%. The results were
not simply explained by the high rates of psychiatric comor-
bidity; when individuals with relevant comorbidities were ex-
cluded, the magnitude of the results was attenuated, but per-
sons with OCD were still significantly impaired across all
educational outcomes.
An interesting finding was that the impairment appeared
greatest up to the end of upper secondary school (since pa-
tients with OCD were 57% less likely to complete this educa-
tional level) and was somewhat improved during university
education (where persons with OCD were 28% less likely to
start and 41% less likely to finish a degree). We speculate that
some individuals with OCD might cope better with their symp-
toms as they age, perhaps because of the natural history of the
disorder or their receiving evidence-based treatment that al-
lows them to resume their education. These individuals might
be able to find alternative routes to access university, such as
the locally funded school system for adults who have failed
to complete primary or secondary school (known as komvux
in Sweden). Thus, early educational failure does not
necessarily condemn individuals to lifelong educational
ostracism.
The examination of the educational attainment of this
uniquely large cohort of patients with OCD greatly increases
our understanding of the burden and societal impact of this
disorder and its relationship to productivity impairment. Ac-
cording to the Organization for Economic Cooperation and De-
velopment (OECD), which is composed of 35 countries includ-

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 Research Original Investigation Association of Obsessive-Compulsive Disorder With Educational Attainment

Table 3. Odds of Individuals With Obsessive-Compulsive Disorder, Unaffected Individuals, and Full Siblings of Affected Individuals Passing Specific
Courses on Graduation From Compulsory Educationa,b

No. (%) OR (95% CI)

Individuals With OCD Individuals Without OCD
Courses (n = 9415) (n = 1 224 627) Unadjusted Model Adjusted Modelc Full Sibling Comparisonc
Core courses
Swedish language 8626 (94.1) 1 166 914 (96.2) 0.63 (0.58-0.69) 0.57 (0.52-0.62) 0.56 (0.46-0.68)
English language 8525 (92.8) 1 156 648 (95.2) 0.65 (0.60-0.71) 0.60 (0.56-0.66) 0.60 (0.51-0.72)
Mathematics 8173 (89.0) 1 144 845 (94.2) 0.50 (0.47-0.53) 0.47 (0.44-0.50) 0.52 (0.45-0.60)
Additional courses
Arts 8454 (92.1) 1 167 048 (96.1) 0.48 (0.44-0.52) 0.43 (0.40-0.47) 0.56 (0.47-0.66)
Biology 6389 (85.6) 930 711 (92.5) 0.48 (0.45-0.51) 0.43 (0.40-0.46) 0.46 (0.39-0.54)
Chemistry 6095 (81.7) 912 009 (90.7) 0.46 (0.43-0.49) 0.42 (0.39-0.44) 0.50 (0.43-0.57)
Geography 5516 (87.5) 782 701 (93.4) 0.49 (0.46-0.53) 0.45 (0.42-0.49) 0.52 (0.43-0.63)
Handcraft textile/wood 8384 (91.3) 1 173 369 (96.6) 0.37 (0.34-0.40) 0.35 (0.32-0.38) 0.49 (0.42-0.58)
History 5521 (87.6) 781 234 (93.3) 0.51 (0.47-0.55) 0.48 (0.44-0.52) 0.52 (0.43-0.62)
Home and consumer 6430 (89.9) 929 888 (95.8) 0.39 (0.36-0.43) 0.36 (0.34-0.39) 0.44 (0.37-0.54)
studies
Knowledge of society 5558 (88.2) 783 476 (93.5) 0.52 (0.48-0.56) 0.48 (0.44-0.52) 0.54 (0.45-0.65)
Music 8275 (90.1) 1 158 558 (95.4) 0.44 (0.41-0.48) 0.41 (0.38-0.44) 0.44 (0.37-0.52)
Physics 6141 (82.3) 917 154 (91.2) 0.45 (0.42-0.48) 0.41 (0.39-0.44) 0.48 (0.41-0.55)
Religion 5577 (88.5) 782 800 (93.5) 0.54 (0.50-0.58) 0.49 (0.45-0.53) 0.56 (0.46-0.68)
Sports and health 7630 (83.1) 1 131 457 (93.1) 0.36 (0.34-0.38) 0.36 (0.34-0.38) 0.42 (0.37-0.48)
Technology 8048 (87.6) 1 150 707 (94.7) 0.40 (0.37-0.42) 0.38 (0.36-0.40) 0.44 (0.38-0.51)
b
Abbreviations: OR odds ratio; OCD obsessive-compulsive disorder. All other findings in this table are statistically significant.
a c
Data from the subcohort of individuals who graduated compulsory school Adjusted by sex, year of birth, maternal and paternal age at the birth of the
between 1998 and 2010. study participant, and parity.

Table 4. Educational Attainment Among Individuals With Obsessive-Compulsive Disorder, Compared With Unaffected Individuals
and Full Siblings of Affected Individuals, Stratified by Age at First Diagnosis

No. (%) OR (95% CI)

Level of Education Individuals With OCD Individuals Without OCD Unadjusted Model Adjusted Modela Full Sibling Comparisona
Diagnosed With OCD Before Age 18 Years
Compulsory education 2512 1 224 627 NA NA NA
Vocational program 2059 (82.0) 1 118 459 (91.3) 0.43 (0.39-0.48) 0.38 (0.34-0.42) 0.38 (0.30-0.49)
Academic program 1482 (59.0) 943 458 (77.0) 0.43 (0.40-0.46) 0.45 (0.42-0.49) 0.46 (0.38-0.56)
Postcompulsory education 4296 1 224 627 NA NA NA
Finishing upper secondary school 1435 (33.4) 1 395 993 (66.5) 0.25 (0.24-0.27) 0.46 (0.43-0.49) 0.43 (0.38-0.49)
Starting a university degree 479 (11.2) 605 011 (28.8) 0.31 (0.28-0.34) 0.59 (0.54-0.65) 0.52 (0.44-0.62)
Finishing a university degree 92 (2.1) 292 960 (14.0) 0.14 (0.11-0.17) 0.43 (0.35-0.53) 0.49 (0.35-0.68)
Finishing postgraduate education 1 (0.0) 6876 (0.3) NA NA NA
Diagnosed With OCD at or After Age 18 Years
Compulsory education 6903 2 100 434 NA NA NA
Vocational program 5903 (85.5) 1 118 459 (91.3) 0.56 (0.52-0.60) 0.52 (0.48-0.56) 0.60 (0.52-0.70)
Academic program 4931 (71.4) 943 458 (77.0) 0.75 (0.71-0.79) 0.68 (0.65-0.72) 0.74 (0.66-0.83)
Postcompulsory education 10 824 1 224 627 NA NA NA
Finishing upper secondary school 6560 (60.6) 1 395 993 (66.5) 0.78 (0.75-0.81) 0.41 (0.40-0.43) 0.45 (0.42-0.49)
Starting a university degree 3494 (32.3) 605 011 (28.8) 1.18 (1.13-1.23) 0.75 (0.72-0.78) 0.67 (0.62-0.73)
Finishing a university degree 1534 (14.2) 292 960 (14.0) 1.02 (0.97-1.08)b 0.61 (0.57-0.64) 0.54 (0.48-0.60)
Finishing postgraduate education 26 (0.2) 6876 (0.3) 0.73 (0.45-1.08)b 0.51 (0.35-0.76) 0.52 (0.24-1.14)b
Abbreviations: OCD, obsessive-compulsive disorder; NA, not applicable; study participant, and parity.
OR, odds ratio. b
Nonsignificant findings. All other findings in this table are statistically
a
Adjusted by sex, year of birth, maternal and paternal age at the birth of the significant.

ing Sweden, national unemployment rates among 25- to 64- 2015, unemployment rates were 4.8% for those with tertiary
year-olds are directly proportional to educational levels; in education (ie, university studies), 7.3% for those with upper

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 Association of Obsessive-Compulsive Disorder With Educational Attainment Original Investigation Research

Table 5. Educational Attainment Among Individuals With Lifetime Obsessive-Compulsive Disorder Compared With Unaffected Individuals, Excluding
Comorbidities and Stratified by Sexa

OR (95% CI)
Whole Cohort Excluding Other Excluding Excluding Excluding Excluding Excluding Other
(Adjusted Excluding Neuropsychiatric Psychotic Anxiety Affective Substance use Psychiatric
Model) ADHD Disordersb Disorders Disordersc Disorders Disorders Disorders
Compulsory Education
Eligible for 0.47 0.56 0.54 0.48 0.54 0.50 0.49 0.46
vocational (0.45-0.50) (0.53-0.61) (0.51-0.58) (0.45-0.51) (0.49-0.60) (0.46-0.54) (0.45-0.52) (0.43-0.49)
program, all
Female 0.45 0.53 0.49 0.45 0.53 0.45 0.46 0.42
(0.41-0.48) (0.49-0.58) (0.45-0.54) (0.41-0.48) (0.46-0.61) (0.40-0.50) (0.42-0.50) (0.38-0.46)
Male 0.51 0.61 0.63 0.52 0.55 0.55 0.52 0.51
(0.47-0.56) (0.54-0.68) (0.56-0.70) (0.48-0.58) (0.48-0.62) (0.49-0.62) (0.47-0.57) (0.47-0.56)
Eligible for 0.61 0.68 0.67 0.61 0.71 0.64 0.63 0.61
academic (0.58-0.63) (0.65-0.72) (0.63-0.70) (0.59-0.64) (0.66-0.76) (0.61-0.69) (0.60-0.67) (0.58-0.64)
program, all
Female 0.62 0.69 0.67 0.62 0.78 0.66 0.65 0.62
(0.58-0.65) (0.65-0.74) (0.63-0.71) (0.58-0.66) (0.71-0.87) (0.61-0.72) (0.61-0.70) (0.58-0.66)
Male 0.59 0.66 0.66 0.60 0.64 0.62 0.60 0.59
(0.55-0.63) (0.61-0.71) (0.61-0.72) (0.56-0.64) (0.58-0.71) (0.57-0.68) (0.56-0.65) (0.55-0.63)
Postcompulsory Education
Finishing upper 0.43 0.49 0.48 0.45 0.57 0.51 0.47 0.44
secondary (0.41-0.44) (0.47-0.51) (0.46-0.50) (0.43-0.47) (0.54-0.61) (0.48-0.53) (0.45-0.49) (0.43-0.46)
school, all
Female 0.41 0.47 0.45 0.43 0.62 0.51 0.46 0.43
(0.39-0.43) (0.44-0.49) (0.43-0.47) (0.41-0.45) (0.57-0.67) (0.48-0.55) (0.44-0.49) (0.40-0.45)
Male 0.44 0.51 0.52 0.47 0.53 0.49 0.47 0.45
(0.42-0.47) (0.48-0.54) (0.49-0.56) (0.44-0.50) (0.49-0.57) (0.45-0.52) (0.45-0.50) (0.43-0.48)
Starting a 0.72 0.82 0.80 0.75 0.86 0.80 0.79 0.73
university (0.69-0.75) (0.78-0.85) (0.77-0.84) (0.72-0.78) (0.81-0.91) (0.76-0.85) (0.75-0.82) (0.70-0.77)
degree, all
Female 0.66 0.75 0.72 0.68 0.85 0.77 0.72 (0.69-0.76)0.66
(0.63-0.70) (0.71-0.79) (0.68-0.76) (0.65-0.72) (0.79-0.92) (0.71-0.82) (0.63-0.70)
Male 0.83 0.94 0.99 0.87 0.86 0.85 0.90 0.84
(0.78-0.89) (0.88-1.01) (0.92-1.06) (0.82-0.94) (0.78-0.95) (0.78-0.92) (0.84-0.97) (0.79-0.90)
Finishing a 0.59 0.66 0.65 0.62 0.73 0.68 0.65 0.61
university (0.56-0.62) (0.63-0.71) (0.61-0.69) (0.58-0.66) (0.67-0.80) (0.63-0.73) (0.62-0.69) (0.58-0.65)
degree, all
Female 0.55 0.62 0.59 0.57 0.72 0.63 0.61 0.56
(0.52-0.59) (0.58-0.66) (0.55-0.64) (0.54-0.61) (0.65-0.80) (0.57-0.69) (0.57-0.65) (0.52-0.61)
Male 0.69 0.79 0.81 0.75 0.75 0.78 0.78 0.72
(0.62-0.76) (0.71-0.87) (0.73-0.90) (0.67-0.83) (0.65-0.86) (0.68-0.89) (0.70-0.86) (0.65-0.80)
Finishing 0.52 0.59 0.55 0.57 0.65 0.69 0.61 0.56
postgraduate (0.36-0.77) (0.40-0.87) (0.37-0.83) (0.39-0.85) (0.38-1.13)d (0.43-1.11)d (0.41-0.89) (0.38-0.84)
education, all
Female 0.50 0.55 0.50 0.53 0.77 0.60 0.56 0.57
(0.29-0.84) (0.33-0.94) (0.29-0.87) (0.31-0.90) (0.39-1.56)d (0.30-1.21)d (0.33-0.96) (0.33-0.98)
Male 0.56 0.64 0.63 0.64 0.52 0.79 0.67 0.55
(0.31-0.98) (0.36-1.13)d (0.35-1.14)d (0.36-1.13)d (0.22-1.25)d (0.41-1.53)d (0.38-1.18)d (0.31-1.01)d
Abbreviations: ADHD attention deficit/hyperactivity disorder; OR odds ratio. tic disorders, and learning disabilities.
a c
Adjusted by sex, year of birth, maternal and paternal age at the birth of the Includes dissociative, somatoform, other neurotic, and eating disorders.
study participant, and parity. Sex was not included as a covariate in the d
Nonsignificant findings. All other findings in this table are statistically
stratification by sex. significant.
b
Includes pervasive developmental disorders, Tourette syndrome and chronic

secondary education, and 12.5% for those with only primary
education.33 Additionally, individuals with tertiary educa-
tion earned on average 55% more than those with upper sec-
ondary education,34 and the difference in salaries continues
to increase with further education beyond the tertiary level.35
Hence, it is likely that the profound educational underachieve-
ment observed in this study has a direct effect on the socio-
economic status of the affected individuals and, indirectly, on
the wealth of society at large.
Intuitively, our results highlight the need to detect and treat
OCD at an early stage to increase the chances that affected in-
dividuals fulfill their educational potential. Whether access to
and receipt of evidence-based treatment for OCD is associ-
ated with a higher likelihood of progressing to higher educa-
tional levels, as has been recently suggested in ADHD,36 is an
important question for future research. School-based strate-
gies aimed at reducing scholastic underachievement in this
group seem to be warranted; these might include educating
school staff to identify early signs of OCD or creating guide-
lines for schools and higher education institutes. This ap-
proach has been used in other childhood-onset disorders, such
as ADHD.37 These strategies may require unprecedented col-

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 Research Original Investigation Association of Obsessive-Compulsive Disorder With Educational Attainment

laborative efforts between mental health services, education
authorities, and policy makers.
Strengths of the study include the use of a large, nationally
representative cohort with data collected from records kept by
government agencies or other organizations, which ensured mini-
mal risk of selection, recall, and report biases. Second, the study
benefited from a long-term follow-up period, which allowed the
examination of educational levels from childhood (compulsory
school) to adulthood (up to postgraduate education). Third, the
use of sibling comparison models allowed strict control of un-
measured confounders, such as genetic and environmental fac-
tors, that are shared by siblings. Finally, this study used ICD-10
codes for OCD, which have been shown to have excellent inter-
rater reliability and validity in the Swedish NPR, with positive pre-
dictive values ranging from 0.91 to 0.96.38
Limitations
Several limitations of the study need to be considered. First,
patients included in the NPR might not be representative of
all people with OCD in the population, as the register was only
amended to include outpatient care in 2001 (and therefore only
includes inpatient admissions between 1997 and 2000). In ad-
dition, it only includes specialist care visits and not patients
seen by general practitioners. Similarly, the NPR does not in-
clude patients diagnosed by professionals other than special-
ist physicians, which means that only a fraction of all Swed-
ish patients with OCD could be included in our analyses.39
These limitations also apply to the identification of the co-
morbid psychiatric conditions.
Second, we used the date of first OCD diagnosis as a proxy
for the age at onset of the disorder to identify individuals with
a pediatric or adolescent onset. However, the date of first di-
agnosis does not necessarily correspond to the age at disor-
der onset, because many individuals with OCD do not seek help
when they first experience symptoms.40-42 Thus, many indi-
viduals in the adult-onset group probably had undiagnosed
OCD before age 18 years.43 An additional limitation is that the
NPR does not include measures of symptom severity, which
may have a clear association with the eventual educational at-
tainment of an individual.
Finally, we were not able to investigate other interesting
outcomes, such as absenteeism from school. This would have
added valuable information on the association of OCD with
education.
Conclusions
Obsessive-compulsive disorder, particularly when it has an
early age at onset, is associated with pervasive and profound
decreases in educational attainment across all levels, span-
ning from compulsory school to postgraduate education.

ARTICLE INFORMATION
Accepted for Publication: September 29, 2017.
Published Online: November 15, 2017.
doi:10.1001/jamapsychiatry.2017.3523
Author Affiliations: Centre for Psychiatry
Research, Department of Clinical Neuroscience,
Karolinska Institutet, Stockholm, Sweden
(Pérez-Vigil, Fernández de la Cruz, Brander,
Isomura, Hesselmark, Serlachius, Rück,
Mataix-Cols); Department of Child and Adolescent
Psychiatry and Psychology, Institute of
Neuroscience, Hospital Clínic de Barcelona,
Barcelona, Spain (Pérez-Vigil, Lázaro); Stockholm
Health Care Services, Stockholm County Council,
Stockholm, Sweden (Isomura, Rück, Mataix-Cols);
Department of Medical Epidemiology and
Biostatistics, Karolinska Institutet, Stockholm,
Sweden (Jangmo, Kuja-Halkola, D’Onofrio,
Larsson); Department of Public Health and Caring
Sciences, Uppsala University, Uppsala, Sweden
(Feldman); Department of Medicine, University of
Barcelona, Barcelona, Spain (Lázaro); Institut
d'Investigacions Biomèdiques August Pi i Sunyer,
Barcelona, Spain (Lázaro); Centro de Investigación
Biomédica en Red de Salud Mental, Barcelona,
Spain (Lázaro); Department of Psychological and
Brain Sciences, Indiana University, Bloomington
(D’Onofrio); School of Medical Sciences, Örebro
University, Örebro, Sweden (Larsson).
Author Contributions: Dr Pérez-Vigil had full
access to all the data in the study and takes
responsibility for the integrity of the data and the
accuracy of the data analyses.
Study concept and design: Pérez-Vigil, Fernández
de la Cruz, Brander, Isomura, Jangmo, Larsson,
Mataix-Cols.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Pérez-Vigil, Fernández
de la Cruz, Mataix-Cols.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Pérez-Vigil.
Obtained funding: Pérez-Vigil, Fernández de la Cruz,
Mataix-Cols.
Administrative, technical, or material support:
Larsson, Mataix-Cols.
Study supervision: Fernández de la Cruz,
Mataix-Cols.
Conflict of Interest Disclosures: Dr Mataix-Cols
and Dr Fernández de la Cruz receive royalties for
contributing articles to UpToDate, a part of Wolters
Kluwer Health. Dr Larsson has served as a speaker
for Eli-Lilly and Shire and has received a research
grant from Shire Pharmaceuticals (all outside the
submitted work). No other disclosures are
reported.
Funding/Support: This work was supported by a
research grant from the International OCD
Foundation awarded to Dr Fernández de la Cruz.
Ms Pérez-Vigil is supported by a grant from the
Alicia Koplowitz Foundation. Dr Fernández
de la Cruz is supported by a Junior Researcher grant
from the Swedish Research Council for Health,
Working Life, and Welfare (FORTE grant
2015-00569). Mr Brander is supported by a
Karolinska Institutet PhD stipend (KID-funding).
Dr Rück is supported by grant K2013-61P-22168
from the Swedish Research Council.
Role of the Funder/Sponsor: The funders had no
role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review,
or approval of the manuscript; and decision to
submit the manuscript for publication.
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