Higher Educational Attainment Protects Whites but Not Blacks against Future Suicide Attempts

Abstract

Purpose:

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 Emergency Department (ED), and (2) to compare this effect between non-Hispanic Black and non-Hispanic White ED patients.

Methods:

The current study analyzed data from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study, a quasi-experimental, 8-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.

Results:

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 to non-Hispanic Blacks. In race/ethnicity-specific models, completing college was associated with decreased future suicide risk for non-Hispanic Whites but not Blacks.

Conclusions:

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.

Although both longitudinal and cross-sectional studies have shown that socioeconomic status (SES) indicators such as education protect the physical and mental health of populations and individuals [1-6], these effects may differ for racial groups [7,8]. In addition to employment [9,10] and income [1,4,5], educational attainment is one of the most robust SES indicators that protect populations health [11]. Health effects of education are broad as they hold for both morbidity [12] and mortality [13-15]. Educational attainment has a robust effect on reducing individuals’ risk of depression [16-18], depressive symptoms [19] and suicide [20]. However, these studies examined risk across individuals, and not by socio-demographic subgroups (e.g., race/ethnicity).

Educational attainment does not universally protect all socio-demographic sub-groups [7,8,21], including racial and ethnic groups. Sub-populations do vary in how much they gain health benefits from the very same SES indicator, possibly because similar SES resources differently impact life conditions of various social groups [7,8]. One of the demographic factors that has repeatedly shown to alter the health gain associated with SES is race/ethnicity [17,22-24]. According to the Minorities’ Diminished Return theory, the protective effects of SES on health outcomes tend to be systemically smaller for minority (i.e., oppressed and disadvantaged) populations than the majority (i.e., dominant and advantaged) group [7,8,24]. This pattern is found to be robust across SES resources, outcomes, designs, and populations [7,8]. These patterns are shown for the effects of employment [18], income [25], and education [18] on a wide range of physical and mental health outcomes, however, suicide as an outcome is rarely tested [26]. Unfortunately, many of these effects are transgenerational and pass from parents to children [21,27,28].

The differential effect of educational attainment on mental health is in part because Blacks receive lower quality education [29] and have more challenges securing high rewarding low stress jobs [18]. In one study, White men gained most life expectancy from employment, however, this effect was non-significant for Black men [18]. The existing racism in the education system and labor market combined with job and residential segregation [30] limit Blacks’ employability compared to Whites [31-34]. Racial pay gap is a mechanism for racial differences in health gains from educational attainment [33,35]. The same amount of income provides more mental [36,40] and physical health [41,42,43] benefits for Whites than Blacks which may be due to residential segregation [30] and other structural factors that result in differential effects of income on the purchasing power of racial groups [7,8]. In a recent study, education was a more influential factor in helping White compared to Black families to escape poverty [44]. In another study, educational attainment of parents generated more economic return for White than Black families [45].

Another mechanism that may be involved is the degree to which SES impacts emotion regulation and impulse control [46]. SES is found to have a larger positive effect on impulse control of Whites than Blacks [27]. These mechanisms potentially result in a systemic diminished return of SES for Blacks and poor mental well-being of high-SES Blacks. In fact, studies have documented an increased risk of depression [17,47], depressive symptoms [22] and suicidal ideation [26] in high-SES Blacks and other ethnic groups of Blacks. For instance, in a nationally representative community survey of an ethnically diverse sample of Blacks in the United States, high educational attainment was a risk factor - not a protective factor - for lifetime suicidal ideation among Caribbean Black women, even after controlling for psychiatric disorders and religiosity [26]. As the results of community surveys may or may not replicate in clinical settings [48], there is a need to investigate the differential effect of educational attainment on suicide risk across racial and ethnic groups.

The current study was conducted with two aims: First, to assess the effects of baseline educational attainment (i.e., completing college) on risk of future suicide attempt/death over a 52-week follow-up period in emergency department (ED) patients. Second, to compare non-Hispanic White and non-Hispanic Black patients for this association.

Methods

Procedures.

Data were analyzed on 1,148 adult (≥18 years old) participants from the Emergency Department Safety Assessment and Follow-Up Evaluation (ED-SAFE) study. ED-SAFE was an 8-center quasi-experimental study with three phases: treatment as usual (Phase 1), universal screening (Phase 2), and universal screening + intervention (Phase 3) (see Boudreaux et al., 2013, [49] for a complete study description). To account for any intervention effects, a dichotomous variable was created to indicate whether the intervention was present (Phase 3) or not (Phases 1 and 2). Enrolled participants completed a baseline assessment and follow-up assessments at 6, 12, 24, 36, and 52- weeks post-discharge. Reviews of medical records were completed at 6 and 12 months after the index ED visit. The analytical sample in this study was limited to non-Hispanic White (n = 937; 81.6%) and non-Hispanic Black (n = 211; 18.4%) participants.

Measures.

Race/ethnicity.

Race/ethnicity was the focal effect moderator, measured as self-identified race and ethnicity. Race/ethnicity was operationalized as a dichotomous variable (0 = non-Hispanic White, 1 = non-Hispanic Black).

Demographics.

During the baseline assessment, demographic variables that were collected included age (years) and gender (0 = male, 1 = female). The main independent variable of interest in this study was an SES indicator, educational attainment. A dichotomous variable was created for educational attainment to reflect completion of a college degree or greater versus no college degree (0 = no college degree, 1 = college degree or greater).

Lesbian/Gay/Bisexual (LGB) status.

Sexual orientation was asked using a single item. Participants were considered LGB if they responded positive to being 1) Gay or Lesbian, or 2) Bisexual. This variable was operationalized as a dichotomous variable (0 = non-LGB, 1 = LGB).

History of psychiatric disorders.

Data were collected at baseline on history of at least one psychiatric disorder. These data were collected using the following question: “Have you ever been diagnosed by a doctor or therapist with…depression, bipolar disorder, alcohol abuse, drug abuse, anxiety, ADHD, eating disorder, schizophrenia, or other psychiatric problems?”. This variable was also operationalized as a dichotomous variable (0 = no psychiatric disorder, 1 = psychiatric disorder).

History of suicide attempts.

Data collected during baseline included lifetime history of suicide attempts. Baseline suicidal ideation severity and suicide attempt severity were derived from the Columbia Suicide Severity Rating Scale (C-SSRS) [50]. The C-SSRS has been validated in the context of adults presenting to the ED for psychiatric reasons [51].

Suicide attempt/death over time.

Data on suicide attempts and suicide death during the 52-week follow-up were collected in multiple ways, including medical and administrative record review, and patient-reported follow-up assessments (which included responses to the C-SSRS). Total number of suicide attempts that occurred during the 52-week post-discharge follow-up period were also calculated. Participant deaths were identified by contacts with family and friends of the participant, medical record review, searches conducted through state-specific vital records, and results from a formal search of the National Death Index (NDI). Death by suicide was determined when the cause of death was clearly intentional.

Analytic plan.

Analyses were conducted using SPSS 22.0 for Windows (IBM Corp, Armonk, NY). For descriptive purposes, we reported mean (standard deviation (SD)) and relative frequencies (%). Bivariate analyses were conducted to compare non-Hispanic Whites and non-Hispanic Blacks, comprised of Pearson Chi-squared tests and independent samples t-tests in the pooled sample, and Spearman rank correlation tests in both the pooled sample and by race/ethnicity to estimate the degree of associations across study constructs. For multivariate analyses, we ran four logistic regression models (Models 1-4). In all logistic regression models, educational attainment (i.e., college graduation) was the independent variable, suicide attempt/death during the 52-week period was the dependent variable, and demographic factors (e.g., physical health and mental health characteristics) were covariates. Race/ethnicity was the focal effect modifier. The first two logistic regression models were estimated in the pooled sample that included both non-Hispanic Whites and non-Hispanic Blacks, and included race/ethnicity as a covariate. Model 1 only included the main effects but not the race/ethnicity by educational attainment interaction term. Model 2, however, did include the race/ethnicity by educational attainment interaction term. Subsequently, we estimated two race/ethnicity-specific logistic regression models, one in non-Hispanic Whites (Model 3) and one in non-Hispanic Blacks (Model 4). As the sample sizes of Whites and Blacks were not equal, we relied on the interaction term which is not sensitive to sample size. Adjusted odds ratios (OR) and 95% confidence intervals (CIs) were reported; p < .05 was considered statistically significant.

Results

Descriptive statistics.

Table 1 provides the descriptive statistics for the pooled sample and also by race/ethnicity. For the pooled sample (N = 1148), the mean age was 37.5 years (SD = 13.3), 81.6% (n = 937) non-Hispanic White, and 18.4% (n = 211) non-Hispanic Black. Non-Hispanic Blacks had lower educational attainment compared to non-Hispanic Whites. During the follow-up period, 251 individuals (21.9%) had at least one suicide attempt, and there were 5 suicide deaths (0.4%). Together, 22.3% of our sample had a suicide attempt/death over the follow-up period.

Table 1.

Descriptive statistics in the pooled sample and by race/ethnicity

Characteristics	All (N= 1148)		Non-Hispanic Whites (n = 937)		Non-Hispanic Blacks (n = 211)
	%	95% CI	%	95% CI	%	95% CI
Age (M, SD) *,b	37.46	13.32	37.99	13.63	35.12	11.59
Gender
Male	518	45.12	434	46.32	84	39.81
Female	630	54.88	503	53.68	127	60.19
Education (College Graduate or Higher) *,a
No	920	80.14	731	78.01	189	89.57
Yes	228	19.86	206	21.99	22	10.43
ED-SAFE Intervention a
No	724	63.07	587	62.65	137	64.93
Yes	424	36.93	350	37.35	74	35.07
Psychiatric History (baseline) *, a
No	136	11.85	102	10.89	34	16.11
Yes	1012	88.15	835	89.11	177	83.89
Suicide attempt History (baseline) (M, SD) b	0.86	1.44	0.89	1.46	0.73	1.32
Lesbian/Gay/Bisexual (LGB) *,a
No	998	86.93	815	86.98	183	86.73
Yes	150	13.07	122	13.02	28	13.27
Suicide Attempt/Death Over the Follow-Up *,a
No	892	77.70	720	76.84	172	81.52
Yes	256	22.30	217	23.16	39	18.48

^*p < 0.05 for comparisons of non-Hispanic Whites and non-Hispanic Blacks.

^aPearson Chi-square.

^bIndependent samples t-test.

Bivariate correlations.

Table 2 summarizes the results of bivariate correlations in the pooled sample and also for non-Hispanic Whites and non-Hispanic Blacks. Race/ethnicity (non-Hispanic Blacks) was negatively correlated with age, education, and psychiatric history but not with history of suicide, LGB, and subsequent suicide attempt/death over the follow up period. Education did not show a correlation with the suicide outcome in the pooled sample, non-Hispanic Whites, or non-Hispanic Blacks.

Table 2.

Correlation matrices in the pooled sample and by race/ethnicity.

Characteristics	1	2	3	4	5	6	7	8	9
All (N = 1148)
1 Race/Ethnicity (non-Hispanic Blacks)	1.00	−0.02	0.05	−0.07*	−0.11**	0.00	−0.06*	−0.04	−0.04
2 ED-SAFE Intervention		1.00	−0.03	−0.02	−0.01	0.02	−0.02	−0.01	−0.02
3 Gender (Female)			1.00	−0.12**	0.06	0.04	0.11**	0.05	0.04
4 Age				1.00	0.19**	−0.14**	0.13**	0.05	0.03
5 Education (College Graduate or Higher)					1.00	0.09**	0.03	−0.03	−0.03
6 Lesbian/Gay/Bisexual (LGB)						1.00	0.01	0.02	0.02
7 Psychiatric History (Baseline)							1.00	0.10**	0.13**
8 Suicide Attempt History (Baseline)								1.00	0.10**
9 Suicide Attempt/Death Over the Follow-Up									1.00
Non-Hispanic Whites (n937 = 937)
2 ED-SAFE Intervention		1.00	−0.04	0.00	−0.01	0.04	0.02	−0.00	−0.02
3 Gender (Female)			1.00	−0.12**	0.06	0.02	0.14**	0.04	0.04
4 Age				1.00	0.19**	−0.16**	0.11**	0.03	0.02
5 Education (College Graduate or Higher)					1.00	.09**	0.05	−0.04	−0.05
6 Lesbian/Gay/Bisexual (LGB)						1.00	0.00	0.01	0.01
7 Psychiatric History (Baseline)							1.00	0.09**	0.13**
8 Suicide Attempt History (Baseline)								1.00	0.11**
9 Suicide Attempt/Death Over the Follow-Up									1.00
Non-Hispanic Blacks (n = 211)
2 ED-SAFE Intervention		1.00	0.03	−0.14*	−0.06	−0.05	−0.16*	−0.04	−0.07
3 Gender (Female)			1.00	−0.10	0.09	0.12	0.04	0.09	0.06
4 Age				1.00	0.14*	−0.03	0.19**	0.14*	0.09
5 Education (College Graduate or Higher)					1.000	0.10	−0.10	0.02	0.12
6 Lesbian/Gay/Bisexual (LGB)						1.00	0.06	0.08	0.03
7 Psychiatric History (Baseline)							1.00	0.14*	0.14*
8 Suicide Attempt History (Baseline)								1.00	0.05
9 Suicide Attempt/Death Over the Follow-Up									1.00

^*p < 0.05.

Logistic regression models in the overall sample.

Table 3 presents the results of two logistic regression models in the pooled sample. Both models have educational attainment (i.e., college graduate or higher) as the independent variable, and suicide attempt/death over the follow-up as the dependent variable. Model 1 did not show an association between educational attainment and odds of future suicide attempt/behavior above and beyond covariates. Model 2 showed a significant interaction between race/ethnicity and educational attainment, suggesting that the protective effect of educational attainment against suicide is greater for non-Hispanic Whites than for non-Hispanic Blacks.

Table 3.

Summary of logistic regressions between educational attainment and suicide attempt/death in the pooled sample

Characteristics	Model 1 Main Effects		Model 2 Model 1 + Interactions
	B	95% CI	B	95% CI
ED-SAFE Intervention	0.90 (0.15)	0.67-1.20	0.90 (0.15)	0.67-1.21
Race/Ethnicity (Non-Hispanic Blacks)	0.77 (0.20)	0.52-1.14	0.66 (0.22)*	0.43-1.00
Gender (Female)	1.17 (0.15)	0.88-1.57	1.16 (0.15)	0.87-1.56
Age	1.00 (0.01)	0.99-1.01	1.00 (0.01)	0.99-1.01
Education (College Graduate or Higher)	0.78 (0.19)	0.54-1.13	0.68 (0.20) *	0.46-1.00
Lesbian/Gay/Bisexual (LGB)	1.15 (0.21)	0.76-1.74	1.13 (0.21)	0.74-1.72
Psychiatric History (baseline)	3.62 (0.34)***	1.86-7.06	3.76 (0.34) ***	1.93-7.35
Suicide Attempt History (baseline)	1.13 (0.05) **	1.03-1.24	1.13 (0.05) *	1.03-1.24
Education × Race/Ethnicity	-		3.57 (0.56) *	1.20-10.62
Intercept	0.07 (0.40) ***		0.07 (0.40) ***

^*p < 0.05,

^**p < 0.01,

^***p < 0.001.

Logistic Regression Models by Race/Ethnicity.

Table 4 summarizes the results of two other logistic regression models, one in non-Hispanic Whites only and one in non-Hispanic Blacks only. Model 3 showed that high educational attainment was associated with lower odds of future suicide attempt/death in non-Hispanic Whites. Model 4, however, did not show an effect of educational attainment on odds of future suicide attempt/death for non-Hispanic Blacks.

Table 4.

Summary of logistic regressions between educational attainment and suicide attempt/death in Whites and Blacks

	Model 3		Model 4
Characteristics	Non-Hispanic Whites (n = 937)		Non-Hispanic Blacks (n = 211)
	B	95% CI	B	95% CI
Intervention	0.92(0.16)	0.67-1.26	0.81(0.40)	0.37-1.78
Gender (Female)	1.15(0.16)	0.84-1.57	1.29(0.39)	0.61-2.76
Age	1.00(0.01)	0.99-1.01	1.01(0.02)	0.98-1.04
Education (College Graduate or Higher)	0.68(0.20)*	0.46-1.00	2.39(0.54)	0.82-6.95
Lesbian/Gay/Bisexual (LGB)	1.15(0.24)	0.73-1.83	1.00(0.53)	0.36-2.80
Psychiatric History (baseline)	3.65(0.38) ***	1.73-7.70	4.15(0.78)	0.90-19.17
Suicide Attempt History (baseline)	1.14(0.05) **	1.03-1.26	1.03(0.13)	0.79-1.33
Intercept	0.08(0.44) ***		0.04(0.95) ***

^*p < 0.05,

^**p < 0.01,

^***p < 0.001.

Discussion

Supporting the Minorities’ Diminished Return theory [7,8], this study found evidence for racial differences in the association between educational attainment (i.e., having a college degree) and future risk of suicide attempt/death with non-Hispanic Blacks being at a disadvantage compared to non-Hispanic Whites in receiving mental health gain from their educational attainment.

Although this is not the first study to show that race/ethnicity alters the mental health effects of SES indicators [22,52-55], it is one of the first studies that document this pattern for the effect of educational attainment on future risk of suicide attempt/death in clinical settings [56-60]. Compared to physical health outcomes [56-60], less is known on the diminished returns of SES on depression [7,8], and even less is known about the effect on suicide [26], particularly for patient populations. Most previous studies on Minorities’ Diminished Return theory have been conducted in community settings. The consistency and robustness of these findings suggest that the diminished return of SES hold for various resources, outcomes, settings, and populations [7,8], including an ED patient population.

Minorities’ Diminished Return theory has provided considerable evidence on diminished mental and physical health returns of educational attainment, employment, and income for Blacks and other minority populations compared to Whites [7,8]. Although most of the literature on Minorities’ Diminished Return theory is on physical health outcomes [18,23-25], the same pattern is also shown for mental health outcomes [29,36,37,61]. Not only economic resources, but psychological assets such as affect, coping, sleep, and self-efficacy, better promote the health and well-being of Whites in comparison to Blacks [62-72]. Similarly, studies have also shown smaller effects of education on health risk behaviors such as drinking and smoking for Blacks compared to Whites [24,61].

Potential mechanisms of diminished returns.

Our finding that educational attainment has a protective effect against future suicide attempt/death among Whites, but not Blacks, does not suggest that Blacks are unable to use their economic resources such as educational attainment, or that Whites are innately more efficient in using their resources. Contextually, in the US, Black families pay extra social, psychological, and physiological costs for their upward social mobility, compared to Whites [47,73-76]. Currently, upward social mobility is more challenging for Blacks than Whites which increases mental health risk of highly educated minority families [22,36,37,52,53,54,55]. These experiences may explain some of the differential effects of educational attainment on future suicide attempt/death for Whites versus Blacks in our patient population.

Minorities’ Diminished Return theory attributes the diminished return of Blacks and other minorities to the structural racism that is embedded in the fabric of American society. American society maximizes the benefits of Whites, to the unintended cost for non-White groups such as Blacks, Latinos, and Native Americans [7,8,18]. At the same time, discrimination operates at the inter-individual level, and limits health gains that follow SES (e.g., education) [77]. Discrimination is more common for high SES minority individuals [34,37,54,55,77] and for Blacks who live in predominantly White areas [78]. Such discrimination reduces the health gain of SES for racial minority populations [34,53,77].

Implications for policy and practice.

Our findings – that educational attainment is a protective factor for future suicide attempt/death for Whites, but not Blacks – may have some policy and public health implications. Policies and programs should address barriers that hinder Blacks from mobilizing their SES resources such as educational attainment. Job training programs may be an important part of these strategies. Such programs may reduce the diminished returns of Blacks and may contribute to elimination of racial health disparities [7,8]. Policies that address health disparities should go beyond equalizing SES and reduce barriers in the daily lives of minority populations including ED patients [7,8].

Diminished health returns and differential effects of SES indicators should be regarded as a major contributor of racial health disparities in the US [79-82]. Policies that only address unequal access to SES and ignore population differences in distribution of barriers will have sub-optimal effects on closing the racial health gap. Policy makers and program planners who are committed to eliminating the persisting racial health disparities in the US should close the gap in gains from equal resources. Equalizing gain and equalizing access to resources are inseparable components of eliminating health disparities. Programs evaluation should specifically address barriers that are common in the lives of Blacks and hinder them from gaining full benefit from their resources. Program programmers should be aware of the possibility that programs that enhance population access to SES resources have the potential to widen the existing gaps through providing a larger benefit for the demographic group which is already in a relative advantage compared to other social groups.

Implications for theory.

This study contributes to the current theoretical knowledge on racial and economic health disparities. Theories such as Double Jeopardy [47,83], Triple Jeopardy [35], Multiple Jeopardy [84], and Multiple Disadvantage [85] have traditionally conceptualized Blacks and other minority groups as vulnerable groups, meaning that their health is more strongly impacted by the presence or absence of social risk and protective factors [84]. Our findings show that Whites’ mental health is more closely linked to economic resources than Blacks’ in a suicidal ED patient population.

Minorities’ Diminished Return theory argues that the disparities are both due to differential effects as well as differential exposures [7,8]. Differential effects, however, are historically overlooked [23,24]. Without a simplistic assumption that SES indicators universally protect all social groups, systemic interactions between the effects of race/ethnicity and SES resources on health should be always explored [7,8]. Opposite to the above theories, it is not Blacks but Whites whose mental health closely links to educational attainment.

Race/ethnicity limits how much mental health benefit can be gained from an SES resources such as educational attainment [15,16]. These patterns will explain the observed poor health status of high SES minority groups [35,86]. The interactions between race/ethnicity and class [22,24,56,57,87] suggest that the effects of SES and race/ethnicity are multiplicative rather than additive [86]. As SES effects are conditional by race/ethnicity [88,89], it is not “race/ethnicity or SES” but “race/ethnicity and SES” that shape health disparities [7,8]. If it was race/ethnicity or SES, equalizing SES across racial groups would be enough for elimination of racial gap in health. As SES and race/ethnicity are jointly involved, only addressing SES would not be the most efficient way of reducing health disparities. To eliminate racial disparities in health, merely closing the SES differences by race/ethnicity would be result in sub-optimal outcomes for minorities [7,8]. The most effective policies would be probably those that concurrently tackle processes related to race/ethnicity and SES.

This study does not claim that education as the sole cause of suicide. However, it conceptualized educational attainment as a protective factor against risk of suicidality. It is still unknown whether low education causes suicide, or low education is a proxy of a wide range of social and behavioral risk factors that increase risk of suicide. Regardless whether the association between education and suicidal ideation is due to causation or selection, they differ between non-Hispanic Black and non-Hispanic White.

Limitations.

Our study had few methodological limitations. Given the observational nature of this study, no causal association can be concluded. SES and mental health have bidirectional effects, and the possibility of reverse causality should not be overlooked. While low SES increases risk of undesired mental health outcomes such as suicide, poor mental health also interferes with economic productivity that results in downward social mobility. Another limiting factor of the current study is the omitted confounders such as marital status, wealth, and employment. Future research should replicate the same hypothesis for other SES indicators. In addition, future research should go beyond individual characteristics and include characteristics of communities, families, and providers. Higher-level SES indicators, availability of resources in the community, and density of racial groups in the area may have some effects on mental health. Research may also explore the role of medications, health care encounters, and stigma in explaining diminished return of Blacks. In addition, there is a significant difference between the number of White participants and AA. This issue may have resulted in differential statistical power based on race. Furthermore, additional research may wish to add other protective and risk factors such as stress, trauma, social support, and religion involvement. Finally, any study that includes racial and ethnic diverse sample is prone to measurement bias due to differential validity of the constructs across diverse groups [90].

Conclusions.

In conclusion, race/ethnicity moderates the association between educational attainment and future suicide attempt/death in a sample of individuals presenting to the ED for suicidal ideation or behavior in the US. The effect of race/ethnicity on suicide is not only a result of less education or increased exposure to risk factors, but also due to the health gains that follow economic resources such as educational attainment. This may be due to society’s differential treatment due to skin color; thus, race/ethnicity becomes a proxy of people’s access to the opportunity structure and what they can realistically do with their available resources.