Social Science & Medicine 66 (2008) 1334e1345

www.elsevier.com/locate/socscimed

Does a higher educational level protect against anxiety

and depression? The HUNT study*
Ingvar Bjelland a,*, Steinar Krokstad b, Arnstein Mykletun c, Alv A. Dahl d,
Grethe S. Tell e, K. Tambs f
a
Clinic for Child and Adolescent Mental Health Services, Haukeland University Hospital, Jonas Lies vei 65, N-5021 Bergen, Norway
b
Department of Community Medicine and General Practice, The Norwegian University of Science and Technology, Trondheim, Norway
c
Faculty of Psychology, University of Bergen, Bergen, Norway
d
Department of Clinical Cancer Research, Rikshospitalet, University of Oslo, Division The Norwegian Radiumhospital, Oslo, Norway
e
Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
f
Division of Mental Health, The Norwegian Institute of Public Health, Oslo, Norway
Available online 12 February 2008

Abstract

The relationship of education to the experience of anxiety and depression throughout adult life is unclear. Our knowledge of this
relationship is limited and inconclusive. The aim of this study was to examine (1) whether higher educational level protects against
anxiety and/or depression, (2) whether this protection accumulates or attenuates with age or time, and (3) whether such a relation-
ship appears to be mediated by other variables. In a sample from the Nord-Trøndelag Health Study 1995e1997 (HUNT 2)
(N ¼ 50,918) of adults, the cross-sectional associations between educational level and symptom levels of anxiety and depression
were examined, stratified by age. The long-term effects of educational level on anxiety/depression were studied in a cohort followed
up from HUNT 1 (1984e1986) to HUNT 2 (N ¼ 33,774). Low educational levels were significantly associated with both anxiety
and depression. The coefficients decreased with increasing age, except for the age group 65e74 years. In the longitudinal analysis,
however, the protective effect of education accumulated somewhat with time. The discrepancy between these two analyses may be
due to a cohort effect in the cross-sectional analysis. Among the mediators, somatic health exerted the strongest influence, followed
by health behaviors and socio-demographic factors. Higher educational level seems to have a protective effect against anxiety and
depression, which accumulates throughout life.
Ó 2007 Elsevier Ltd. All rights reserved.

Keywords: Norway; Cohort study; Educational level; Anxiety; Depression; Mediators; Adult; Mental health

*
The Nord-Trøndelag Health Study (The HUNT Study) is a collab-
oration between The HUNT Research Centre, Faculty of Medicine,
The Norwegian University of Science and Technology (NTNU),
Verdal, The Norwegian Institute of Public Health, The National
Health Screening Service of Norway and Nord-Trøndelag County
Council.
* Corresponding author. Tel.: þ47 90955893; fax: þ47 55586130.
E-mail address: ingvar.bjelland@uib.no (I. Bjelland).
Introduction
A recent meta-analysis (Lorant et al., 2003) found an
increased risk of depression in people belonging to the
lowest socioeconomic status (SES) compared to those
in the highest. However, SES is an ambiguous concept
and in this meta-analysis it was represented by various
characteristics such as education, income, occupation,

0277-9536/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2007.12.019
 I. Bjelland et al. / Social Science & Medicine 66 (2008) 1334e1345
assets, and social class. As indicators of SES, such vari-
ables are not recommended as interchangeable (Geyer,
Hemström, Richard, & Vågerö, 2006). Unlike income,
education is quite stable after young adulthood and is
likely to result in good mental health rather than result
from it. Education is a resource that is part of a person,
rather than being external to the person (Ross & Mirow-
sky, 2006). Education precedes and influences other
SES indicators, such as occupation and income. In
addition, education, as a source of human capital, may
enable people to succeed more generally and may prove
effective in pursuing fundamental ends that include
emotional well-being (Mirowsky & Ross, 1998). Educa-
tion was also more frequently used than the other SES
variables in the studies included in the aforementioned
meta-analysis (35 out of 56) (Lorant, et al., 2003).
Furthermore, the majority (48 out of 56) of the stud-
ies (Lorant et al., 2003) had a cross-sectional design,
and thereby could not demonstrate whether differences
in SES were associated with increasing or decreasing
differences in depression with age or time. Such
changes would indicate whether the protective effect
of a high SES is stable, increases, or decreases during
life. Hence, the possible cumulative effect of educa-
tional level on mental health in principle can be demon-
strated, by longitudinal studies but not cross-sectional
ones. Four longitudinal studies that measured SES by
educational level were reported in the meta-analysis
(Bracke, 2000; Eaton, Muntaner, Bovasso, & Smith,
2001; Kaplan, Roberts, Camacho, & Coyne, 1987;
Sargeant, Bruce, Florio, & Weissman, 1990). The re-
sults of these studies were inconsistent, with only one
study (Kaplan et al., 1987) reporting a clear inverse
association between educational level and depression.
The only longitudinal study that addressed education
as the main predictor of depression reported that the as-
sociation was weakened and no longer statistically sig-
nificant when adjusted for earlier depressive symptoms
(Sargeant et al., 1990). These results imply no cumula-
tive effect of education on depression with age. A study
not included in the meta-analysis that followed adoles-
cents into early adulthood did not show an association
between educational attainment and depression at all
(Miech, Caspi, Moffitt, Wright, & Silva, 1999).
Despite the limitation of the cross-sectional design in
this respect, stratifying the sample by age makes it pos-
sible to study the effects of education on mental health
through life. Increasing associations between low edu-
cation and depression with age would imply that the
protective benefits of high education accumulate
through life. One study has shown that the difference
in depressive level between high and low educational
1335
levels increases with age (Miech & Shanahan, 2000).
Another study with a similar design has demonstrated
the cumulative advantage of high educational level on
physical health (Ross & Wu, 1996).
In contrast to the meta-analysis of Lorant et al.
(2003), a concurrent systematic review (Fryers, Melzer,
& Jenkins, 2003) addressed the relationship between
social inequalities and both depression and anxiety dis-
orders. The three relevant studies (Andrews, Hender-
son, & Hall, 2001; Bijl, Ravelli, & van Zessen, 1998;
Kessler et al., 1994), which were cross-sectional, all
found a significant negative association between educa-
tional level and anxiety disorders. In addition, we are
aware of only one longitudinal study addressing the as-
sociation between anxiety and education (Miech et al.,
1999). That study showed that the anxiety level was
negatively associated with both the educational level
of the respondent’s parents and their own educational
attainment.
Various studies have suggested that some mediators,
such as health behaviors (smoking, alcohol consump-
tion, and physical activity) and psycho-social status
(Kaplan et al., 1987), somatic health (Kaplan et al.,
1987; Miech & Shanahan, 2000), socio-demographic
(Bracke, 2000; Kaplan et al., 1987) and work character-
istics (Bracke, 2000; Kaplan et al., 1987; Ross &
Mirowsky, 2006; Zimmerman, Christakis, & Vander
Stoep, 2004) explain the association between educational
level and depression. However, the data are ambiguous.
Aims of the study
First, we used a cross-sectional design to examine
whether higher educational level protects against anxi-
ety and/or depression. Second, we examined whether
such a protection accumulates or attenuates with age
or time, partly by using an age stratification approach
in a cross-sectional design, and partly by examining
the course of anxiety and depression symptoms over
an 11-year period. Third, we aimed to identify possible
mediators in the relationship between education and
anxiety/depression.
Material and methods
Sample
All inhabitants of Nord-Trøndelag County of Norway
aged 20 years and above (N ¼ 85,100) were invited to
participate in the Nord-Trøndelag Health Study 1984e
1986 (HUNT 1) (Holmen, Midthjell, & Bjartveit,
1990; HUNT, 2007), of which 77,310 individuals
1336 I. Bjelland et al. / Social Science & Medicine 66 (2008) 1334e1345
(90.9%) participated 11 years later in the HUNT 2 study.
The HUNT 2 study consisted of all inhabitants aged 20
years and above in the same county (N ¼ 94,197) (Hol-
men et al., 2003), and this time 65,648 individuals
(69.7%) participated. Earlier studies have shown impor-
tant general health inequalities by educational level
(Krokstad, Kunst, & Westin, 2002). In both HUNT 1
and HUNT 2, data were obtained from three sources:
(1) a first questionnaire that was a part of the invitation
was mailed to all eligible participants and returned
when they attended the study site; (2) physical examina-
tion; and (3) a second questionnaire, handed out during
the examination and returned by mail (by approximately
80% of the participants in both studies).
The Norwegian Data Inspectorate and the Regional
Committee for Medical Research Ethics in Health re-
gion IV of Norway approved HUNT 2. These agencies
were not established in Norway when HUNT 1 was
conducted. Each participant in the HUNT 2 study was
asked to sign an informed consent, stating that his or
her data could be used for medical research (Holmen
et al., 2003).
A cross-sectional sample aged 25e84 years from
HUNT 2 (N ¼ 60,210) with valid information on educa-
tional level, anxiety and depression (N ¼ 50,918) was
used to examine age specific effects. Among these, par-
ticipants below 70 years with information on a variety of
somatic problems, health behaviors, socio-demograph-
ics, and work characteristics from the second question-
naire (N ¼ 41,819) were included in an examination of
mediator effects.
Longitudinal analyses were conducted on a cohort
from HUNT 1 (N ¼ 33,774) that was followed up at
HUNT 2 (Fig. 1), and was identified by valid informa-
tion on educational level and an indicator of symp-
toms of anxiety and depression, termed the Anxiety/
Depression Index (ADI). The participation rate was
decreased because some of the items were in a second
questionnaire in HUNT 1. There was no established
instrument tapping anxiety and depression in HUNT
1, so the ADI was created in order to have a common
anxiety/depression measure in HUNT 1 and HUNT 2
(described below).
Measures
Treating of missing data
When possible, information was replaced or pre-
dicted from a similar variable: Missing educational
level at HUNT 1 was replaced by educational level at
HUNT 2, while missing frequency of alcohol drinking
was predicted by alcohol consumption (and vice versa)
Was eligible for
HUNT 1
N=85,100
Did not attend N=7,790
Attended HUNT 1
N=77,310
Was not eligible for HUNT 2 N=17,177
Did not attend HUNT 2 N=12,809
Did attend both
HUNT 1 and 2
N=47,324
Invalid information on
education or Anxiety-Depression Index N=13,550a
Longitudinal sample
N=33,774
Fig. 1. The selection procedure for the longitudinal sample. aHigh attri-
tion rate because some of the anxiety and depression items were in a sec-
ond questionnaire handed out during attendance at the physical exam.
and missing frequency of light physical exercise by
heavy physical exercise (and vice versa) using linear re-
gression. The remaining missing data were substituted
by sample means. In the mediator analyses, the covari-
ates were supplemented with a corresponding set of
dummy variables that identified the subjects with a miss-
ing value (‘‘Mean imputation with a dummy’’) (Paul,
Mason, McCaffrey, & Fox, 2003). If the coefficient of
such a dummy is significant, then the data are not miss-
ing completely at random, thus, this procedure implies
testing for selection bias (Anderson, Basilevsky, &
Hum, 1983).
Anxiety and depression
In HUNT 2, information on symptoms of anxiety and
depression was partly obtained from the Hospital Anxi-
ety and Depression Scale (HADS), a self-administered
questionnaire consisting of 14 items, seven for anxiety
(HADS-A subscale) and seven for depression (HADS-
D subscale) (Zigmond & Snaith, 1983). Previous studies
have shown a two-dimensional covariance structure of
the HADS (Bjelland, Dahl, Haug, & Neckelmann,
2002; Mykletun, Stordal, & Dahl, 2001).
However, nearly all the HADS depression items tap
the absence of positive emotion. Therefore, we wanted
to supplement the HADS with some additional negative
emotion items to obtain a more comprehensive measure
and to achieve a better correlation between the HADS
and the ADI (described below), the latter which was
used in both HUNT 1 and HUNT 2. Six new items
 I. Bjelland et al. / Social Science & Medicine 66 (2008) 1334e1345
were added to the HADS, three for each subscale, and it
was re-termed the Expanded Hospital Anxiety and De-
pression Scale (EHADS) (Cronbach’s alpha 0.85).
These new items were not from a specific instrument,
but single questions assumed to tap elements of anxiety
or depression. The complete EHADS (EHADS-total)
was divided into anxiety (EHADS-A) (Cronbach’s
alpha 0.86) and depression (EHADS-D) (Cronbach’s
alpha 0.82) subscales. The reported number and per-
centages of the missing values are according to all par-
ticipants in HUNT 2 (N ¼ 60,210). On average, there
were 8.2% (N ¼ 4942) individuals with missing values
on each item of EHADS-A and 7.1% (N ¼ 4290) of
EHADS-D. However, substitution was performed only
when valid data already existed for at least half of the
items, resulting in replacement on average for only
1.1% (N ¼ 659) and 1.6% (N ¼ 941) (EHADS-A and
EHADS-D, respectively) of the subjects on each item.
To achieve close to normal distributions, all three scores
were ln-transformed after adding the constants 32
(EHADS-total), 13 (EHADS-A), and 12 (EHADS-D).
The logarithmic scores were then z-transformed in or-
der to facilitate the interpretation of the regression
coefficients.
Because no established measurement instruments for
anxiety or depression were used at HUNT 1, an Anxiety/
Depression Index (ADI) (Cronbach’s alpha 0.83) was
composed by selecting items that were identical (seven
items) or almost identical (two items) in HUNT 1 and
HUNT 2 (Data available on request from the authors).
These were assumed to tap global features of anxiety,
depression, and well-being. The reported number and
percentages of the missing values are according to the
individuals who participated with both questionnaires
in both HUNT 1 and HUNT 2 (N ¼ 35,766). On average,
there were 2.2% (N ¼ 780) individuals with missing
values on each item at HUNT 1 and 2.5% (N ¼ 910) at
HUNT 2. Again, substitution was performed only
when there already were valid data for at least half of
the items, resulting in replacement on average for only
0.8% (N ¼ 279) and 1.4% (N ¼ 507), of the subjects
on each item in HUNT 1 and HUNT 2. In order to
maximize the correlation between the two measures of
anxiety/depression, EHADS was regressed on each of
the ADI items and the regression coefficients were
used to weight each ADI item before summation in
HUNT 1 and HUNT 2 (Data available on request from
the authors). The correlation between the ADI and the
EHADS-total in HUNT 2 was 0.83, and the correlation
between ADI in HUNT 1 and HUNT 2 was 0.53. The in-
dex was z-transformed, with high values indicating high
anxiety/depression symptom level.
1337
Education
Education was classified into five levels: primary
school (<10 years), high school for 1 or 2 years (10e
11 years), complete high school (12 years), college or
university less than 4 years (13e15 years), and college
or university 4 years or more (16 years). Not all
participants in HUNT 1 had finished their education.
Therefore, we composed a common educational level
for HUNT 1 and HUNT 2 using the highest reported
level. When information on education was missing at
HUNT 1 (N ¼ 8100, the majority of which was due to
not returning the second questionnaire, in which educa-
tion was reported), information from HUNT 2
(N ¼ 7444) was used and vice versa (N ¼ 3830 and
N ¼ 2708). When data were missing in both HUNT 1
and HUNT 2 (N ¼ 656 in HUNT 1 and N ¼ 1122 in
HUNT 2), missing data were not substituted. In the
cross-sectional sample (HUNT 2), age was restricted
to 25 years and above to exclude most participants
with ongoing education. Mean educational level (1e5,
1 was the highest level) was 3.76 (standard deviation ¼
1.29). In the sample used for longitudinal analyses, the
youngest participants were 31 years old and were as-
sumed to have completed their education at HUNT 2.
Here, the mean educational level was 4.05 (standard
deviation ¼ 1.21).
Other covariates
These variables from HUNT 2 were included as pos-
sible mediators of the effect of education on anxiety and
depression, i.e. in the models they were assumed to be
a consequence of educational level and a cause of
anxiety and depression (intermediate variables). When
not otherwise specified the data were obtained by self
report. The covariates were grouped into four blocks.
The reported numbers and percentages of missing
data refer to the cross-sectional sample of HUNT 2
selected for the mediator analyses (N ¼ 41,819).
The covariate block ‘‘Somatic health’’ included mus-
culo-skeletal complaints (from neck, shoulders, elbows,
wrists/hands, chest/stomach, upper back, lower back,
hips, knees, ankles/feet, average missing data N ¼ 89
or 0.2%), cardiovascular disease (myocardial infarction,
angina pectoris, stroke, average missing data N ¼ 81 or
0.2%), diabetes (missing data N ¼ 69 or 0.2%), gastro-
intestinal symptoms (nausea, dyspepsia, diarrhea,
constipation, average missing data N ¼ 3481 or 8.3%),
and chronic impairment of daily functioning concerning
movements, vision, hearing, and somatic illness
(average missing data N ¼ 1334 or 3.2%).
The covariate block ‘‘Health behaviors’’ included
smoking (number of cigarettes per day), alcohol
1338 I. Bjelland et al. / Social Science & Medicine 66 (2008) 1334e1345
consumption, and physical activity. Cigarette smoking
had N ¼ 1781 missing values (4.3%). Alcohol con-
sumption was calculated as a sum of drinking episodes
during the last month (SD ¼ 3.1) and consumed units of
beer, wine, and liquor during the last 2 weeks
(SD ¼ 4.8). The variables were coded zero for individ-
uals who reported themselves as abstainers. In cases
where there was no information on the frequency vari-
able, this value was imputed using linear regression
analysis with the consumption variables as predictors.
Likewise, missing consumption values were predicted
using the existing alcohol information. Missing values
on both the frequency and consumption variables
(N ¼ 1033 or 2.5%) were substituted with sample
means. Physical activity was calculated as a sum of
graded responses (1e4) to questions about light and
hard physical activity outside job during the last year,
where the value of hard physical activity was weighted
by a factor of two. In cases where there was no informa-
tion on hard physical activity, this value was imputed
using linear regression analysis with light physical ac-
tivity as a predictor, and vice versa. When there were
missing data on both variables, the values were
substituted by sample means (N ¼ 2505 or 6.0%).
Height and weight were measured, and body mass index
(BMI) was calculated as kg/m2. There were no missing
data on BMI.
The covariate block ‘‘Work-related factors’’ in-
cluded variables such as whether the respondent had
lost his/her job, had considered changing jobs, re-
ported that his/her job was so physically strenuous
that he/she was often physically tired at the end of
the working day, reported that the work demanded so
much concentration and attention that he/she often
felt exhausted at the end of the working day, and
whether he/she was satisfied with his/her job. The re-
sponse categories of these questions were graded and
missing information (average N ¼ 8912 or 21.3%)
was substituted by sample means. Having lost his/her
job had no missing values.
The covariate block ‘‘Socio-demographic’’ factors
included whether the respondent was living alone and/
or was separated or divorced, his/her type of residence
according to an urbanerural gradient assigned to each
municipality (Statistics Norway, 1994), whether there
had been any economic hardship in the household the
last year, and whether the respondent felt that he/she
had enough friends. Information on the two former vari-
ables was obtained from public population registries, in
which there are practically no missing data. Missing
data on the two latter variables (average N ¼ 820 or
2.0%) was substituted by sample means.
Statistical analyses
We used linear regression analysis, adjusting for age
and sex, to examine main effects of educational level
(each level as dummy variables and highest level as
reference) on anxiety and depression (EHADS-A,
EHADS-D, and EHADS-total) in the cross-sectional
sample. By the same procedure, we evaluated whether
such effects were linear. Effect modifications were
tested by specifying interaction terms between educa-
tional level and both age and sex in analyses of variance
(UNIANOVA, SPSS). To examine the direction of the
possible effect modifications of age (10-year cate-
gories) and sex, linear regression analyses were strati-
fied by these variables.
For the longitudinal sample, linear regression
models were used to predict the ADI level in HUNT 2
by educational level, adjusting for age, sex, and the
ADI scores in HUNT 1. When entering the baseline
level of ADI (ADI at time 1) as a covariate, the effects
of the other covariates should be interpreted as effects
on change in ADI from time 1 to time 2.
In order to test the effects of the possible mediators,
pairs of regression models were specified with and with-
out certain covariates. The differences in the standard-
ized regression coefficients of educational level
(within the pair) are assumed to be due to the influence
of the covariate(s). To achieve such a difference, the co-
variate had to be associated with both educational level
and anxiety/depression. The linear regression models
included adjustments for age and sex and were run for
the EHADS-total, the EHADS-A, and the EHADS-D.
First, each covariate was included in a model separately
and consecutively. Then, each covariate block was in-
cluded separately, and finally all covariates were added
in the full model. All models were applied on the whole
sample as well as on each sex and age stratum.
Because the large number of statistical tests implies
a large risk of obtaining significant results at random,
a strict two-tailed p-value, p < 0.005, was chosen. The
statistical analyses were conducted using the software
package of SPSS 11.5.
Results
Characteristics of the study samples
Primary school was the most common level of educa-
tion attained in both samples (Table 1). However, educa-
tional level was characterized by a marked age gradient
(Fig. 2). Hence, in the cross-sectional sample the
proportion of individuals with only primary school
 I. Bjelland et al. / Social Science & Medicine 66 (2008) 1334e1345 1339

Table 1
Characteristics of the study samples and non-attendeesa
Cross-sectional sample Longitudinal sample Non-attendeesa
(N ¼ 50,918) (HUNT 2) (N ¼ 33,774) (HUNT 1/2) (N ¼ 8565) (HUNT 2)
Mean ageb (SD) 49.2 (14.0) 45.1 (20.4) 49.5 (18.7)
Men [N (percent)] 24,753 (48.6) 15,620 (46.2) 4479 (52.3)
Educational level [N (percent)]
Primary school 18,069 (35.5) 15,991 (47.3) 5356 (62.5)
High school <3 years 17,882 (35.1) 10,833 (32.1) 2165 (25.3)
High school 4202 (8.3) 1739 (5.1) 445 (5.2)
College/university <4 years 6407 (12.6) 3089 (9.1) 370 (4.3)
College/university 4 years 4358 (8.6) 2122 (6.3) 229 (2.7)
Mean (SD) Anxiety/Depression Index 0.00 (1.00) 0.10 (1.12)
(z-standardized)
The HUNT study.
a
Participated in HUNT 1 (with valid data on educational level and the Anxiety/Depression Index [ADI] in HUNT 1) and were invited to HUNT 2,
without participating.
b
At HUNT 2 in the cross-sectional sample; at HUNT 1 in the longitudinal sample.

increased monotonously from 9.3% in the youngest age with an increased level of all three anxiety/depression
group to 75.7% in the oldest. The anxiety level de- measures (Table 2). Compared to the highest
creased monotonously with increasing age, while the educational level, the lowest level was associated with
depression level showed an exact opposite pattern (Re- mixed anxiety and depression of an effect size (ES) of
sults not shown). Non-attendees (participants of HUNT 0.26 (95% confidence interval 0.23e0.29), which corre-
1 who were invited, but did not attend in HUNT 2) were sponds to a quarter of the standard deviation of the total
characterized by older age, lower educational level, pre- EHADS. The interaction terms between educational
dominance of males, and a higher level of anxiety/de- level and age and between educational level and sex
pression (Table 1). were all significant (p < 0.005). All the effects of
education on anxiety and depression decreased with in-
Cross-sectional analyses: associations between creasing age, with the exception of the age group 65e74
educational level and anxiety/depression years (Fig. 3). The figure shows standardized regression
coefficients with educational level entered as a continu-
Compared to the highest educational level, the three ous variable. In men, educational level was somewhat
lowest levels were significantly (p < 0.001) associated more strongly associated with depression, with and
without anxiety, and somewhat more strongly associ-
Primary school ated with anxiety in women (results not shown). The as-
High school < 3 years
sociation was most pronounced in the youngest and
High school 3 years
College/university < 4 years oldest age groups (results not shown).
College/university > 4 years
80
Percent within each age group

Longitudinal analyses: associations between

educational level and the ADI
60

The non-standardized regression coefficient of edu-

40 cational level predicting z-transformed ADI in HUNT
2, adjusting for age and sex, was 0.054 (p < 0.001)
(Table 3). After adjusting for ADI in HUNT 1, the coef-
20
ficient was reduced to 0.031, but was still highly signif-
icant (p < 0.001). Interaction terms between educational
0 level and (1) sex, (2) age and (3) age and sex were all sig-
25-34 35-44 45-54 55-64 65-74 75-84 nificant (p < 0.001). Stratified regression analyses re-
Age groups (years) vealed clear group differences regarding age, but not
Fig. 2. Distribution of educational level in the various age groups of sex. The oldest age group (three groups: <45 years;
the cross-sectional sample (N ¼ 50,918). The HUNT 2 study. 45e56 years; >65 years) had coefficients twice as large
1340 I. Bjelland et al. / Social Science & Medicine 66 (2008) 1334e1345

Table 2
Mean differences in symptoms of anxiety and depression between groups with high and low education, adjusted by age and sex in HUNT 2
(N ¼ 50,918)
Mixed anxiety and depression Anxiety Depression
Effect size 95 % CI Effect size 95 % CI Effect size 95 % CI
College/university 4 years reference level reference level reference level
College/university <4 years 0.04 0.00e0.08 0.02 0.02e0.05 0.05* 0.01e0.09
High school 0.12** 0.08e0.17 0.08** 0.04e0.12 0.15** 0.11e0.19
High school <3 years 0.16** 0.13e0.19 0.10** 0.07e0.13 0.18** 0.15e0.22
Primary school 0.26** 0.23e0.29 0.18** 0.14e0.21 0.28** 0.24e0.31
*p < 0.010.
**p < 0.001.
Note: Effect sizes were calculated using non-standardized regression coefficients calculated for the normalized dependent variables, which gives
adjusted mean differences divided by standard deviations.

as the middle age group, and the youngest group approx-
imately 50% larger than the middle age group.
To obtain the estimate of the increased difference be-
tween the highest and the lowest educational levels
(coded 1e5) in anxiety/depression through 11 years,
the coefficient should be multiplied by a factor of four
(0.31 SD  4 ¼ 0.124 SD). Thus, people with a low
education on average moved towards higher anxiety
and depression scores during the 11-year follow-up
period, whereas people with a high education changed
in a favorable direction. In other words, a moderate
protective effect of higher educational levels increased
somewhat during this period.
Cross-sectional analyses: influence of possible
mediators on the educationeanxiety/depression
associations
Table 4 shows the standardized regression co-
efficients for educational level predicting anxiety/
depression scores in models including various types
of covariates. In the first analyses, single covariates
were entered one by one. Then blocks of covariates,
including variables pertaining to somatic health, health
behavior, work-related factors, and socio-demographic
factors were entered consecutively. Finally, all covari-
ates were entered simultaneously. Among the covari-
ate blocks, somatic health exerted the strongest
influence in terms of reducing the observed effect of
education; considerably so not only for anxiety (58%
reduction of the standardized beta coefficient), but
also for mixed anxiety and depression (43% reduction
of beta), and for depression (34% reduction of beta).
Adjusting for health behaviors and socio-demographic
factors resulted in a moderate reduction of the betas,
for mixed anxiety and depression 25% and 23%, for
anxiety 19% and 32%, and for depression 28% and
17%. Work-related factors reduced the associations
more modestly with 13% for mixed anxiety and depres-
sion, 2% for anxiety, and 17% for depression. Among
individual covariates, however, one of the work-related
factors, ‘‘Being physically tired at the end of the day’’,

Table 3
Educational levela predicting the level of anxiety/depression (ADI Anxiety/Depression Index) during an 11-year period by linear regression (adjust-
ing for sex and age)
N Without adjustment for ADI at HUNT 1 After adjustment for ADI at HUNT 1
Bb 95% CI Bb 95% CI
All 33,774 0.054* 0.045e0.063 0.031* 0.024e0.039
Sex (educational level  sex*)
Men 15,621 0.051* 0.038e0.063 0.035* 0.024e0.046
Women 18,153 0.053* 0.040e0.066 0.025* 0.014e0.037
Age (educational level  age*)
<44 years 8214 0.061* 0.042e0.079 0.036* 0.019e0.053
45e64 years 14,930 0.043* 0.030e0.055 0.025* 0.014e0.036
>64 years 10,630 0.085* 0.065e0.106 0.058* 0.041e0.076
*p < 0.001. The HUNT study.
a
Ranked 1e5 (1 is highest level), mean ¼ 4.05, standard deviation ¼ 1.21.
b
Non-standardized regression coefficient.
 I. Bjelland et al. / Social Science & Medicine 66 (2008) 1334e1345
0.14
Anxiety and depression
0.12 Anxiety
Depression
0.10
Beta
0.08
0.06
0.04
0.02
25-34 35-44 45-54 55-64 65-74 75-84
Age groups (years)
Fig. 3. Associations (linear regression analysis, adjusted for sex)
between educational level and anxiety (EHADS anxiety subscale,
ln-transformed), depression (EHADS depression subscale, ln-
transformed), and mixed anxiety and depression (EHADS total scale,
ln-transformed) in the various age groups (N ¼ 50,918). The HUNT 2
study.
caused the largest reduction in the effect of education
(for mixed anxiety and depression 58%, for anxiety
75%, and for depression 49%). What may appear to
be contradictory, that one work-related covariate re-
duces the effect of education more than the whole block
of work-related covariates, is due to the fact that adjust-
ing for other work-related variables, like ‘‘exhausted
due to concentration’’, actually increases the effect.
Among other single variables that substantially reduced
the observed effect of education on mixed anxiety and
depression, anxiety, and depression were economic
hardship (38%, 53%, and 31%), musculo-skeletal com-
plaints (26%, 35%, and 21%), and gastro-intestinal
symptoms (24%, 32% and 17%).
The significance level of the dummy variables for
mean substituted missing values revealed that not all
missing data were completely at random. All the
dummies of work-related variables (except ‘‘lost
job’’) were highly significant (p < 0.001). Compared
to the corresponding models that did not include
dummies for missing values, the betas for work-related
predictors of educational level in the models with
dummies were on average reduced by 13%. Dummies
for some other variables also reached significance level
(diabetes, angina, two gastro-intestinal symptoms, re-
duced vision, and cigarette smoking) in some of the
models. However, in general, here the p-values were
higher and there were no or only minor differences
(on average 1.7%) in betas between the models with
dummies and the corresponding models without
dummies.
1341
Discussion
Main findings
We found highly significant, though moderate, as-
sociations between low educational level and anxiety
and depression in the cross-sectional as well as the
longitudinal samples. The results from the cross-sec-
tional data showed decreasing effects of education on
anxiety/depression with increasing age/older cohorts.
If we assume no cohort effects, this could suggest
a declining protective effect over time of a higher ed-
ucational level. However, there was an opposite trend
in the longitudinal analysis, that is, the differences
between low and high education for anxiety and de-
pression increased with time. The non-standardized
regression coefficient was 0.031 (for one unit in-
crease in educational level), which should be multi-
plied by a factor of four (¼ 0.124) to obtain the
estimate of the increased difference between the
highest and the lowest educational level (coded 1e
5) in standardized anxiety/depression scores through
11 years. The accumulated protection through the
11-year period is the average effect across persons
highly different in age. Assuming an adult life span
from age 25 to 80 and a linear increase in protective
effect of education throughout life, the lifelong accu-
mulated protective effect could be around five times
the 11 year increase, or in the order of 0.124
SD  5 ¼ 0.62 SD. Though somewhat theoretical,
this calculation gives at least a clue about the true
lifelong accumulated protection. Combined with the
results from the cross-sectional analysis, showing
a difference between the highest and lowest education
group of 0.26 (Table 2, averaged across all ages),
these results indicate that there is a relatively weak
protective effect from high education in early adult
life. However, the effect late in life may be far
from trivial.
In the models that included covariates that were
assumed to mediate the effect of education on mental
health, the most influential variable block was somatic
health, reducing the effect with approximately 45%.
However, both health behavior and socio-demographic
factors reduced the effect with approximately 25%.
‘‘Being physically tired at the end of the day’’ (app-
roximately 60% reduction), ‘‘economic hardship’’
(approximately 40% reduction), ‘‘musculo-skeletal
complaints’’ (approximately 25% reduction), and
‘‘gastro-intestinal complaints’’ (approximately 25%
reduction) were the single covariates that weakened
the associations most.
1342 I. Bjelland et al. / Social Science & Medicine 66 (2008) 1334e1345

Table 4
The influencea of the covariates (linear regression analyses) on the association between educational level and anxiety/depression
Covariates in the models Mixed anxiety-depression Anxiety Depression
Betab 95 % CI Betab 95 % CI Betab 95 % CI
Unadjusted 0.092 0.082e0.103 0.033 0.023e0.043 0.125 0.115e0.135
Age and sex 0.084 0.073e0.094 0.057 0.047e0.068 0.088 0.078e0.099
Somatic health
Musculo-skeletal complaints 0.062 0.051e0.072 0.037 0.026e0.047 0.070 0.060e0.080
Cardio-vascular disease 0.083 0.072e0.093 0.057 0.046e0.067 0.088 0.077e0.098
Diabetes 0.083 0.073e0.094 0.057 0.047e0.068 0.088 0.078e0.099
Gastro-intestinal complaints 0.064 0.054e0.075 0.039 0.029e0.049 0.073 0.063e0.083
Impairment of daily functioning 0.076 0.066e0.087 0.051 0.041e0.062 0.082 0.072e0.092
All somatic 0.048 0.038e0.058 0.024 0.014e0.034 0.058 0.048e0.068
Health behavior
Smoking 0.072 0.061e0.082 0.046 0.035e0.056 0.079 0.069e0.089
Alcohol consumption 0.086 0.075e0.096 0.062 0.052e0.073 0.087 0.077e0.098
Body mass index (kg/m2) 0.082 0.072e0.093 0.059 0.048e0.070 0.085 0.074e0.095
Physical activity 0.074 0.063e0.085 0.053 0.042e0.063 0.075 0.065e0.086
All health behaviors 0.063 0.053e0.074 0.046 0.035e0.057 0.063 0.053e0.074
Work-related factors
Lost job 0.067 0.056e0.077 0.043 0.032e0.053 0.101 0.090e0.111
Considered to change job 0.091 0.080e0.101 0.065 0.054e0.075 0.053 0.042e0.064
Physically tired 0.035 0.024e0.045 0.014* 0.003e0.025 0.045 0.034e0.056
Exhausted due to concentration 0.106 0.096e0.116 0.081 0.070e0.091 0.105 0.095e0.116
Satisfied with job 0.067 0.057e0.078 0.043 0.033e0.054 0.073 0.063e0.083
All work related factors 0.073 0.062e0.084 0.056 0.045e0.067 0.073 0.062e0.083
Socio-demographic factors
Economic hardship 0.052 0.041e0.062 0.027 0.016e0.037 0.061 0.051e0.071
Enough friends 0.095 0.085e0.105 0.067 0.057e0.077 0.099 0.089e0.109
Marital status 0.083 0.072e0.094 0.057 0.046e0.067 0.088 0.078e0.099
Urban-rural gradient 0.081 0.071e0.092 0.057 0.046e0.067 0.085 0.075e0.095
All socio-demographic factors 0.065 0.054e0.075 0.039 0.028e0.049 0.073 0.064e0.083

All covariates 0.045 0.034e0.055 0.034 0.023e0.045 0.044 0.034e0.055

The HUNT 2 study (N ¼ 49,048).
* p ¼ 0.015. p-values for all other betas were <0.001.
a
The influence of the covariate(s) should be read as the difference in the standardized regression coefficients of educational level between the
model adjusted for age and sex only, and the model including the covariate(s).
b
All the standardized regression coefficients (betas) are for the association between educational level and the anxiety/depression measure
(ln-transformed), adjusted for the covariate in question.

Comparisons with other studies
Our findings concerning depression and anxiety are
in accordance with the meta-analysis of Lorant et al.
(2003), and the systematic review of Fryers, Melzer, &
Jenkins (2003), which both included mainly cross-
sectional studies. Contrary to the findings from our
cross-sectional analyses, (but in line with our longi-
tudinal results) one of the included studies (Miech &
Shanahan, 2000) reported increasing associations be-
tween depression and educational level with increasing
age. Among the longitudinal studies, only Kaplan et al.
(1987) (N ¼ 4864 and follow-up time 9 years), in con-
trast to Eaton et al. (2001) (N ¼ 693 and follow-up
time 15 years), Bracke (2000) (N ¼ 2223 and follow-
up time 3 years), Sargeant et al. (1990) (N ¼ 423 and
follow-up time 1 year), Miech et al. (1999) (N ¼ 939
and follow-up time 6 years), and Nærde, Tambs, &
Mathiesen (2002) (N ¼ 682 and follow-up time 3 years)
found an accumulating effect of educational level on
depression. The discrepancies between most of these
studies and our longitudinal results might be due to their
much smaller sample sizes and/or shorter follow-up
time. If the true accumulated protective effect of
a high educational level on anxiety and depression is
quite moderate, as is implied by our results, it could
be difficult to observe in such studies.
Miech & Shanahan (2000) found that somatic
health problems accounted for most of the age-dependent
differences in depression between educational levels. In
our models, somatic health problems seemed to be the
most important mediator as well, though to a lesser
 I. Bjelland et al. / Social Science & Medicine 66 (2008) 1334e1345
degree. Yet, physical disease is seldom considered in
such studies (Lorant et al., 2003).
Possible explanations for the observed relationships
between education and anxiety/depression
The protective effect of educational level on mental
health that attenuated, rather than accumulated with age
in the cross-sectional analyses, might reflect relation-
ships that differ from those reflected by the longitudinal
results. Fig. 2 reveals the dramatic development in edu-
cational level from the oldest through the youngest age
groups, illustrating the profound changes that have
taken place during the latter decades in Norwegian so-
ciety. For the oldest part of the sample, family SES
was probably the deciding factor in whether they would
attain a lower or a higher education. With the develop-
ment of the Norwegian welfare state, a higher educa-
tional level became more available regardless of
economic ability, and, therefore, characteristics such
as intelligence or specific abilities now play a greater
role in educational choices. Heath et al. (1985) demon-
strated in a large Norwegian twin sample that family en-
vironment was much more important, and genetic effect
less important for educational level among people born
in 1915 than among people born in 1960. It is likely that
the correlation between mental resources and educa-
tional level is higher among the younger than among
the older age groups. Perhaps such mental resources
also give higher resilience in regards to strain or
stresses, hence protecting against anxiety and depres-
sion. This cohort effect may have accounted for the
weakening of the association between educational level
and anxiety/depression with increasing age in the cross-
sectional study.
The stronger associations between educational level
and the anxiety/depression measures in the age group of
65e75 years than in their adjacent age groups could be
related to World War II, when Norway was occupied by
Germany. Belonging to a higher social stratum,
associated with taking a higher education, might have
been protective to the general strain and hardship
most people experienced during those years (Grzywacz,
Almeida, Neupert & Ettner, 2004). In the years 1940e
1945 individuals in this age group were between 8 and
24 years old.
The stepwise analyses including different sets of
covariates indicated that somatic health problems, in
particular musculo-skeletal and gastro-intestinal com-
plaints, and having a job that includes physically hard
labor, might mediate some of the observed effect of
education on anxiety and depression. A low educational
1343
level most often restricts an individual’s occupational
options to various forms of manual work. After some
years of one-sided physical strain, there is a risk of
developing musculo-skeletal problems and general
fatigue.
Strengths and limitations of the study
The very large samples were population-based and
covered a wide age range. Information regarding both
somatic and mental health as well as health behaviors
and work-related and socio-demographic factors was
available, and the follow-up period was relatively long.
Educational level, as the main ‘‘exposure’’ variable
was established for most individuals as approximately
constant before the measure of possible mediators and
outcome variables.
Unlike previous studies, the use of the EHADS en-
abled us to study the effect of education not only on
symptoms of depression, but on anxiety as well. Though
there was no established measure of anxiety and depres-
sion in HUNT 1, the ADI should qualify as a satisfactory
substitute due to the high correlation with EHADS.
A possible selection bias in the longitudinal sample
indicated by lower education and poorer mental health
among non-attendees could have somewhat attenuated
the true association between education and anxiety/
depression.
The most extensive substitutions of missing data
were performed for the work-related variables. On aver-
age 21.3% of the values were missing on each of the
four items. This proportion corresponds well with the
proportion of people in Norway in the age 25e69 years
that do not take part of the labor market due to old-age
pension, disability pension, or unemployment. The
highly significant regression coefficients of the dummy
variables identifying the missing values of these vari-
ables indicate that the role of these variables as media-
tors should be interpreted with some caution. Most
likely, the reduced variance for the predictor (mediator)
variables after mean substitution of missing data would
shrink the effect of these predictors, and hence, artifi-
cially reduce the observed mediator effect. However, in-
troducing the dummy variables for missing data besides
of the original mediator variables will probably produce
mediator effects (in terms of reduced effect of education
after adjusting for these variables) closer to what would
be expected in a complete data set. The other dummy
variables for missing data that were significant in the
models did not notably change the coefficients of edu-
cational level in the models. In addition, the substitu-
tions for these variables were not very extensive.
1344 I. Bjelland et al. / Social Science & Medicine 66 (2008) 1334e1345
The possibility that the educational level was af-
fected by preceding symptoms of anxiety or depression
(the selection theory, social mobility) cannot be ruled
out in the cross-sectional analyses. However, the down-
ward age restriction makes it probable that the partici-
pants had completed their education when the data
were recorded. Further, the results from the analyses
of the longitudinal sample indicate a separate effect of
educational level on anxiety/depression symptoms that
increases with age. The cross-sectional design also de-
limits the interpretability of the examination of media-
tor effects because the causal directions are assumed
rather than empirically established. Still, the single me-
diators that showed the strongest influence, i.e. eco-
nomic hardship, musculo-skeletal and gastro-intestinal
complaints, and work-related physical tiredness, were
plausible indirect consequences, or successors, of edu-
cational level. Somatic complaints are often regarded
as consequences of both anxiety and depression, but
in our models such a pathway would not influence the
association between educational level and anxiety
and/or depression.
Our study supports the notion that higher educational
level, or the factors that are reflected by higher educa-
tion, may protect against anxiety and depression, and
the protective effect seems to accumulate throughout
life. The mechanisms of the protective effect may in-
volve factors such as personal characteristics related
to various levels of resilience to stress and to differences
in occupational restrictions, which may be associated
with level of stress exposure and somatic health.
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