Research Paper - Archives of General Internal Medicine (2019) Volume 3, Issue 1

Subjective Financial Status and Suicidal Ideation among American College Students: Racial Differences

Shervin Assari^1,2*

¹Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA

²Center for Research on Ethnicity, Culture, and Health (CRECH), School of Public Health, University of Michigan, Ann Arbor, MI, USA

*Corresponding Author:

Shervin Assari
Department of Psychiatry
University of Michigan
Ann Arbor, MI, USA
Tel: +1 734-764-1817
E-mail: shervinassari@cdrewu.edu

Accepted date: March 20, 2019

Citation: Assari S. Subjective financial status and suicidal ideation among American college students: Racial differences. Arch Gen Intern Med. 2019;3(1):13-18. DOI: 10.4066/ 2591-7951.100068

Abstract

Purpose: The current study aimed to compare American Black and White college students for the protective effect of subjective socioeconomic status (SES) on suicidal ideation. Methods: This study used data from the Healthy Mind Study (HMS 2015-2017). This study included 2,983 undergraduate college students who were at least 18 years of old. These participants were either White (n=2,704) or Black (n=279). The dependent variable was suicidal ideation. The independent variable was subjective SES. Age, gender, transition status, first generation status, and social isolation were covariates. Race/ethnicity was the moderator. Logistic regressions were applied to test the effect of subjective SES on suicidal ideation in the overall sample and by race/ ethnicity. Results: In the overall sample, high subjective SES was associated with less suicidal ideation in the pooled sample of college students. A significant interaction was found between race and subjective SES on suicide risk, suggesting a larger protective effect of high subjective SES for Whites than Blacks. In race-stratified models, high subjective SES was associated with less suicidal ideation for White college students but not for Black college students. Conclusions: Consistent with the Minorities? Diminished Returns theory and in line with previous research that has documented worse mental health of high SES Blacks particularly Black men, this study showed that high SES protects White college students but not Black college students against suicidal ideation. While Whites with low SES are protected against risk of suicide, risk of suicidal ideation seems to be constant regardless of SES among Black college students.

Keywords

Socioeconomic status, Ethnic health disparities, Race, Ethnicity, Blacks, Suicide

Introduction

Although both longitudinal and cross-sectional studies have shown that socioeconomic status (SES) indicators are protective against both undesired physical and mental health outcomes of populations and individuals [1-6], these effects may not be equal across racial groups [7,8]. To give examples, education [9], employment [10], income [11], and marital status [12] generate more health for Whites than Blacks. However, very few studies have tested whether the effects of subjective SES on risk of suicidal ideation are also different by race/ethnicity.

Several SES indicators do not equally protect all demographic sub-groups [7,8,13], including racial and ethnic groups. Subpopulations widely vary in how much they gain health benefits from the very same SES indicator, possibly because SES resources differently impact life conditions across social groups [7,8] particularly based on race/ethnicity [14-16]. According to the Minorities’ Diminished Returns theory, the effects of several SES indicators on health outcomes are systemically smaller for the members of the race and ethnic minority group compared to the majority group [7,8,16]. This pattern is robust across SES resources, outcomes, designs, and populations [7,8]. Same patterns can be seen within and across generations [13,17,18]. Education [15], employment [10], income [19], and marital status [12] generate more health gain for Whites than Blacks. However, suicide as an outcome is rarely tested [20].

The diminished returns of SES on mental health in blacks can have many reasons. One is lower quality education is Blacks communities [21]. Second is that Blacks are more likely to be unemployed and work at low pay high stress jobs [10]. Racism that exists in the education system NS labor market combined with residential segregation [22] can limit return of SES for Blacks [23-25]. Racial pay gap is well-known phenomenon [24,26]. As a result, the very same SES will provide more mental [11,27] and physical [28-30] health benefits for Whites than Blacks. Given structural factors such as segregation, education and income have smaller real effects on the purchasing power of Blacks than Whites [7,8]. As a result, education better brings White families than Black families out of poverty [31]. This is because the very same educational attainment generates more economic return for White than Black families [32].

A major mechanism by which SES impacts mental health is through emotion regulation and impulse control [33]. However, SES has a larger effect on impulse control for Whites than Blacks [17]. As a result, the magnitudes of the effects of SES on health are systemic diminished for Blacks than Whites, thus high-SES Blacks still report poor outcomes. This is supported by studies that have documented higher risk of depression [14,34], depressive symptoms [15] and suicidal ideation [20] among high-SES Blacks.

Aim

Current study compared White and Black college students for the effects of subjective SES on suicidal ideation.

Methods

Design and setting

Healthy Mind Study (HMS 2015-2017) is an online mental health survey of American college students in the US. The HMS is a web-based survey that assesses mental health and wellbeing of students in colleges and Universities, mental health, stigma, and service use. Since 2007, HMS has collected data on more than 175,000 respondents from 150 college campuses.

Ethics

The HMS protocol received Institutional Review Board (IRB) approval from the University of Michigan (U of M). The study also increased the confidentiality of its participants through a Certificate of Confidentiality that was received from the National Institutes of Health (NIH). All participants signed consent.

Sampling and participants

Colleges that participated in the HMS provided the HMS study with a random sample of their enrolled adult (age 18+ years) students. While large colleges provided 4000 enrolled students, smaller colleges provided all of their enrolled students.

Analytical sample

Current analysis only included undergraduate, White or Black, domestic students who had not identified as sexual minority (LGBT). Although HMS has sampled both undergraduates and graduate students, this analysis only included undergraduates but not graduate students. The study included 2,983 undergraduate college students who were either White (n=2,704) or Black (n=279).

Data collection

The HMS variables in this analysis included: race, ethnicity, gender, age, subjective SES, years in the program, transfer status, social isolation, and suicidal ideation.

Race

Race was self-identified as Black/African American versus White [referent group].

Ethnicity

Ethnicity was self-identified as Hispanics/Latino non-Hispanic.

Suicidality

Suicidal ideation was measured using the following three items: 1) “In the past year, did you ever seriously think about committing suicide?”, 2) “In the past year, did you make a plan for committing suicide?”, and 3) “In the past year, did you attempt suicide?” The questions two and third were only asked from responses who answered yes to the first question. These items measured suicidal ideation, suicidal plan, and suicidal attempt in the National Comorbidity Survey (NCS). These items were on a yes/no response scale [35].

Data analysis

We used the Stata 13.0 (Stata Corp., College Station, TX, USA) was used for data analysis. For descriptive purposes, we reported proportions (%) and means. For multivariable analysis, we ran a four logistic regression models. In all these models, suicidal ideation was the dependent variable, subjective SES was the independent variable, and age, gender, ethnicity, years in the program, transfer status, and social isolation were the covariates. In the first model, only main effects of subjective SES, race, and covariates were entered. The second model included race × subjective SES interaction term. The third and fourth models were stratified models in White and Black college students, respectively. Odds Ratio (OR), 95% Confidence Interval (CI), and p were reported.

Results

This analysis included 2,983 undergraduate college students who were at least 18 years of old. These participants were either White (n=2,704) or Black (n=279). The sample was predominantly female. Table 1 shows the summary of the descriptive statistics overall and also by race. Compared to White students, Black students were older, had lower subjective SES, and had lower perceived social isolation. Black students had slightly lower odds of suicidal ideation.

Table 1. Descriptive statistics overall and by race.

Table 2 shows the results of the two logistic regression models in the overall sample. Model 1 did not have the interaction, and Model 2 had race by subjective SES interaction. Model 1 showed that in the pooled sample, high subjective SES had a significant association with lower odds of suicidal ideation (OR=0.64, p=0.034). Model 2 showed a significant interaction between race and subjective SES on suicidal ideation (OR=2.18, p=0.023), suggesting a weaker negative effect between subjective SES and suicidal ideation for Black compared to White college students.

Table 2: Logistic regressions overall.

Discussion

In line with Minorities’ Diminished Return theory [7,8], I found support for racial differences in the association between subjective SES and suicidal ideation. Black students were found to be at a relative disadvantage compared to White students regarding receiving mental health gain from their subjective SES.

This is not the first study to document racial differences in the mental health effects of SES indicators [15,36-39]. It is, however, one of the first studies documenting the same pattern for suicidal ideation as the outcome [40-44]. While we know more about diminished returns of SES for physical health outcomes [40-44] as well as anxiety [12] and depression [7,8], less is known about these processes for suicide [20], particularly for college students. Most papers on the Minorities’ Diminished Return theory is written on general population in the community setting. The consistency and robustness of these findings are shown as the very same patterns hold regardless of resource, outcome, setting, and population [7,8].

Minorities’ Diminished Returns theory has provided more than enough evidence on smaller health returns of SES resources for Blacks and other minority populations than Whites [7,8]. Although most of the literature on Minorities’ Diminished Returns theory is on physical health outcomes [9,10,16,19], a growing literature is showing the same patterns for mental health outcomes [11,21,45,46]. These diminished returns are not only seen for economic resources, but also for psychological assets [47-57]. Similarly, studies have shown smaller effects of SES on drinking and smoking for Blacks compared to Whites [16,46]. These patterns are shown for Blacks [16,46] as Hispanics [58] and even homosexual individuals [59]. So, it seems that any social identity that stigmatizes people may reduce the health gains of SES indicators.

Our finding that high SES has a protective effect against suicide among White but not Black college students, does not suggest that Blacks and Whites are innately different in their abilities to use their economic and SES resources. The results also do not suggest that Whites are innately more efficient than Blacks in using their SES resources. These differences are not innate but socially shaped. In the US context, Black families higher social and psychological costs for their upward social mobility than White families [34,60-78]. Upward social mobility, being more taxing for Blacks, increases mental health risk of high SES [11,15,45,36-39,79-96].

Conclusion

In conclusion, race alters the association between subjective SES and suicidal ideation in a national sample of college students in the US. The effect of race on suicide is not only a result of SES but also due to the differential mental health gains that follow SES. This may be due to society’s differential treatment of people due to their race and skin color. In US, race is a proxy of people’s access to the opportunity structure and what they can realistically gain from their SES.

Conflict of Interest

The authors declare no conflict of interest.

Authors’ Contribution

The paper has one author.

Acknowledgements

Shervin Assari is partially supported by grants 4P60MD006923-05 (National Institute on Minority Health and Health Disparities; NIMHD; PI=Vickie Mays), D084526-03 (National Institute of Child Health and Human Development; NICHD), DA035811-05 (National Institute on Drug Abuse; NIDA; PI=Marc Zimmerman), and CA201415 02 (the National Cancer Institute; NCI; Co-PI=Ritesh Mistry). Thanks to Hamid Helmi for his contribution to this paper.

References

1. Dowd JB, Albright J, Raghunathan TE, et al. Income and mortality in the USA over three decades. Int J Epidemiol. 2011;40:183-8.
2. Marmot MG, Shipley MJ. Do socioeconomic differences in mortality persist after retirement? 25 year follow up of civil servants from the first Whitehall study. Br Med J. 1996;313:1170-80.
3. Morris JK, Cook DG, Shaper AG. Loss of employment and mortality. Br Med J. 1994;308:1135-39.
4. Van Groenou MIB, Deeg DJ, Penninx BW. Income differentials in functional disability in old age: Relative risks of onset, recovery, decline, attrition and mortality. Aging Clin Exp Res 2003;15:174-83.
5. Berkman CS, Gurland BJ. The relationship among income, other socioeconomic indicators, and functional level in older persons. J Aging Health. 1998;10:81-98.
6. Burgard SA, Elliott MR, Zivin K, et al. Working conditions and depressive symptoms: A prospective study of US adults. J Occup Environ Med. 2013;55:1007-14.
7. Assari S. Health disparities due to diminished return among Black Americans: Public policy solutions. Soc Issues Policy Rev. 2018:12:112-145.
8. Assari S. Unequal gain of equal resources across racial groups. Int J Health Policy Manag 2017;6:1-6.
9. Assari S, Lankarani MM. Race and urbanity alter the protective effect of education but not income on mortality. Front Public Health. 2016;p:4.
10. Assari S. Life expectancy gain due to employment status depends on race, gender, education, and their intersections. J Racial Ethn Health Disparities. 2017.
11. Assari S. High income protects whites but not African Americans against risk of depression. Healthcare. 2018;6:E37.
12. Assari S, Caldwell CH, Zimmerman MA. Family structure and subsequent anxiety symptoms: Minorities' diminished return. Brain Sci. 2018;8:E97.
13. Assari S, Thomas A, Caldwell CH, et al. Blacks’ diminished health return of family structure and socioeconomic status: 15 Years of follow-up of a national urban sample of youth. J Urban Health. 2017.
14. Assari S. Social determinants of depression: The intersections of race, gender and socioeconomic status. Brain Sci. 2017; 7.
15. Assari S. Combined racial and gender differences in the long-term predictive role of education on depressive symptoms and chronic medical conditions.J Racial Ethn Health Disparities. 2016;4:385-96.
16. Assari S, Lankarani MM. Education and alcohol consumption among older Americans. Black-White Differences. Front Public Health. 2016;p:4.
17. Assari S, Caldwell CH, Mincy R. Family socioeconomic status at birth and youth impulsivity at age 15; Blacks’ Diminished Return. Children. 2018;5:58.
18. Assari S, Caldwell CH, Mincy RB. Maternal educational attainment at birth promotes future self-rated health of White but Not Black Youth: A 15-Year Cohort of a National Sample. J Clin Med. 2018;7:93.
19. Assari S. The benefits of higher income in protecting against chronic medical conditions are smaller for African Americans than Whites. Healthcare. 2018;p:6.
20. Assari S. Ethnic and gender differences in additive effects of socio-economics, psychiatric disorders, and subjective religiosity on suicidal ideation among blacks. Int J Prev Med. 2015;6:53.
21. DeCuir JT, Dixson AD. “So when it comes out, they aren’t that surprised that it is there”: Using critical race theory as a tool of analysis of race and racism in education. Educational Researcher. 2004;33:26-31.
22. Williams DR, Collins C. Racial residential segregation: A fundamental cause of racial disparities in health. Public Health Reports. 2001;116:404.
23. Oliver ML, Shapiro TM. Black Wealth, white wealth: A new perspective on racial inequality. Taylor & Francis: Abingdon, UK, 2006.
24. Williams DR, Mohammed SA, Leavell J, et al. Race, socioeconomic status, and health: Complexities, ongoing challenges and research opportunities. Ann NY Acad Sci. 2010;1186:69-101.
25. Assari S, Caldwell CH. Social determinants of perceived discrimination among Black Youth: Intersection of ethnicity and gender. Children. 2018;p:5.
26. Wilson KB, Thorpe RJ, LaVeist TA. Dollar for dollar: Racial and ethnic inequalities in health and health-related outcomes among persons with very high income. Prev Med. 2017;96:149-53.
27. Assari S, Caldwell CH. Family income at birth and risk of attention deficit hyperactivity disorder at age 15: Racial differences. Children. 2019;6:10.
28. Assari S, Moghani-Lankarani M. Poverty status and childhood asthma in white and black families: National survey of children’s health. Healthcare. 2018;6:62.
29. Assari S. Family income reduces risk of obesity for white but not black children. Children. 2018;5:73.
30. Assari S. Blacks’ diminished return of education attainment on subjective health: Mediating effect of income. Brain Sci. 2018;8:176.
31. Assari S. Parental education better helps white than black families escape poverty: National survey of children’s health. Economies. 2018;In Press.
32. Assari S. Diminished economic return of socioeconomic status at birth among black than white youth. Soc Sci. 2018;7:74.
33. John OP, Gross JJ. Healthy and unhealthy emotion regulation: Personality processes, individual differences and life span development. Journal of Personality. 2004;72:1301-34.
34. Assari S, Caldwell CH. High risk of depression in high-income African American Boys. J Racial Ethn Health Disparities. 2017;pp:1-12.
35. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry. 2005;62:593-602.
36. Chen E, Martin AD, Matthews KA. Understanding health disparities: The role of race and socioeconomic status in children’s health. Am J Public Health. 2006;96:702-8.
37. Assari S, Preiser B, Lankarani MM, et al. Subjective socioeconomic status moderates the association between discrimination and depression in African American Youth. Brain Sci. 2018;8:E71.
38. Hudson DL, Neighbors HW, Geronimus AT, et al. Racial discrimination, john henryism, and depression Among African Americans. J Black Psychol. 2016;42:221-243.
39. Hudson DL, Neighbors HW, Geronimus AT, et al. The relationship between socioeconomic position and depression among a US nationally representative sample of African Americans. Soc Psychiatry Psychiatr Epidemiol. 2012;47:373-81.
40. Hayward MD, Hummer RA, Sasson I. Trends and group differences in the association between educational attainment and U.S. adult mortality: Implications for understanding education’s causal influence. Soc Sci Med. 2015;127:8-18.
41. Backlund E, Sorlie PD, Johnson NJ. A comparison of the relationships of education and income with mortality: The national longitudinal mortality study. Soc Sci Med. 1999;49:1373-84.
42. Everett BG, Rehkopf DH, Rogers RG. The nonlinear relationship between education and mortality: An examination of cohort, race/ethnic, and gender differences. Popul Res Policy Rev. 2013;32:893-917.
43. Cutler DM, Lleras-Muney A. Education and health: Evaluating theories and evidence. National Bureau of Economic Research.
44. Holmes CJ, Zajacova A. Education as “the great equalizer”: Health benefits for black and white adults. Soc Sci Q. 2014;95:1064-85.
45. Assari S, Lankarani MM, Caldwell CH. Does discrimination explain high risk of depression among high-income African American Men?. Behav Sci. 2018;8:E40.
46. Assari S, Mistry R. Educational attainment and smoking status in a national sample of American adults: Evidence for the Blacks’ diminished return. Int J Environ Res Public Health. 2018;15:763.
47. Lampe FC, Walker M, Lennon LT, et al. Validity of a self-reported history of doctor-diagnosed angina. J Clin Epidemiol. 1999;52:73-81.
48. Assari S, Lankarani MM, Burgard S. Black-white difference in long-term predictive power of self-rated health on all-cause mortality in United States. Ann Epidemiol. 2016;26:106-14.
49. Assari S, Burgard S, Zivin K. Long-term reciprocal associations between depressive symptoms and number of chronic medical conditions: Longitudinal support for black-white health paradox. J Racial Ethn. Health Disparities. 2015;2:589-97.
50. Assari S, Moazen-Zadeh E, Lankarani MM, et al. Race, depressive symptoms, and all-cause mortality in the United States. Front Public Health. 2016;4:40.
51. Assari S, Lankarani MM. Depressive symptoms are associated with more hopelessness among white than black older adults. Front Public Health. 2016;4:82.
52. Assari S, Burgard S. Black-White differences in the effect of baseline depressive symptoms on deaths due to renal diseases: 25 year follow up of a nationally representative community sample. J Ren Inj Prev. 2015;4:127-134.
53. Assari S. Hostility, anger, and cardiovascular mortality among Blacks and Whites. Res Cardiovasc Med. 2016.
54. Assari S. Race, sense of control over life, and short-term risk of mortality among older adults in the United States. Arch Med Sci. 2016.
55. Assari S, Lankarani MM. Association between stressful life events and depression; intersection of race and gender. J Racial Ethn Health Disparities. 2016;3:349-56.
56. Assari S, Sonnega A, Pepin R, et al. Residual effects of restless sleep over depressive symptoms on chronic medical conditions: Race by gender differences. J RacialEthn Health Disparities. 2016.
57. Assari S. Perceived neighborhood safety better predicts 25-year mortality risk among Whites than Blacks. J Racial Ethn Health Disparities. 2016.
58. Assari S, Farokhnia M, Mistry R. Education attainment and alcohol binge drinking: diminished returns of hispanics in Los Angeles. Behav Sci (Basel). 2019;14:E9.
59. Assari, S. Education attainment and obesity: Differential returns based on sexual orientation. Behav Sci. 2019;9:16.
60. Adam EK, Heissel JA, Zeiders KH, et al. (2015) Developmental histories of perceived racial discrimination and diurnal cortisol profiles in adulthood: A 20-year prospective study. Psychoneuroendocrinology. 2015;62:279-91.
61. Fuller-Rowell TE, Curtis DS, Doan SN, et al. Racial disparities in the health benefits of educational attainment: a study of inflammatory trajectories among African American and white adults. Psychosom Med. 2016;77:33-40.
62. Fuller-Rowell TE, Doan SN, Eccles JS. Differential effects of perceived discrimination on the diurnal cortisol rhythm of African Americans and Whites. Psychoneuroendocrinology. 2012;37:107-18.
63. Fuller-Rowell TE, Doan SN. The social costs of academic success across ethnic groups. Child Dev. 2010;81:696-713.
64. Eliason M. Alcohol-related morbidity and mortality following involuntary job loss: Evidence from Swedish register data. J Stud Alcohol Drugs. 2014;75:35-46.
65. Noelke C, Beckfield J. Recessions, job loss, and mortality among older US adults. Am J Public Health.  2014;104:e126-34.
66. Baker DP, Leon J, Smith Greenaway EG, et al. The education effect on population health: A reassessment. Popul Dev Rev. 2011;37:307-32.
67. Herd P, Goesling B, House JS. Socioeconomic position and health: The differential effects of education versus income on the onset versus progression of health problems. J Health Soc Behav. 2007;48:223-38.
68. Hummer RA, Lariscy JT. Educational attainment and adult mortality. In International Handbook of Adult Mortality; Springer: Dordrecht, The Netherlands. 2011;pp:241-61.
69. Masters RK, Hummer RA, Powers DA. Educational differences in US adult mortality a cohort perspective. Am Soc Rev. 2012;77:548-72.
70. Brown DC, Hayward MD, Montez JK. The significance of education for mortality compression in the United States. Demography. 2012;49:819-40.
71. Lorant V, Deliege D, Eaton W. Socioeconomic inequalities in depression: A meta-analysis. Am J Epidemiol. 2003;157:98-112.
72. Freeman A, Tyrovolas S, Koyanagi A, et al. The role of socio-economic status in depression: results from the COURAGE (aging survey in Europe). BMC Public Health. 2016;6:1098.
73. Ki M, Seong Sohn E, An B, et al. Differentiation of direct and indirect socioeconomic effects on suicide attempts in South Korea. Medicine.  2017;96:e9331.
74. Assari S, Preiser B, Kelly M. Education and income predict future emotional well-being of whites but not blacks: A ten-year cohort. Brain Sci. 2018;29:E122
75. Kukull WA, Ganguli M. Generalizability: the trees, the forest, and the low-hanging fruit. Neurology. 2012;78:1886-91.
76. Boudreaux ED, Miller I, Goldstein AB, et al. The emergency department safety assessment and follow-up evaluation (ED-SAFE): Methods and design considerations. Contemporary Clinical Trials. 2013;36:14-24.
77. Posner K, Brent D, Lucas C, et al. Columbia-Suicide Severity Rating Scale (C-SSRS). Columbia University Medical Center. 2008.
78. Posner KP, Brown GK, Stanley B, et al. The Columbia-Suicide Severity Rating Scale: Initial validity and interval consistency findings from three multisite studies with adolescent and adults. American Journal of Psychiatry. 2011;168:1266-77.
79. Hudson DL, Bullard KM, Neighbors HW, et al. Are benefits conferred with greater socioeconomic position undermined by racial discrimination among African American men? J Mens Health. 2012;9:127-36.
80. Assari S, Gibbons FX, Simons RL. Perceived discrimination among black youth: An 18-year longitudinal study. Behav Sci. 2018;8:44.
81. Navarro V. Race or class, or race and class. Int J Health Serv. 1989:19:311-4.
82. Mehta N, Preston S. Are major behavioral and sociodemographic risk factors for mortality additive or multiplicative in their effects? Soc Sci Med. 2016;154:93-9.
83. Williams DR, Collins CUS. Socioeconomic and racial differences in health: Patterns and explanations. Ann Rev Sociol. 1995;21:349-86.
84. Farmer MM, Ferraro KF. Are racial disparities in health conditional on socioeconomic status? Soc Sci Med. 2005;60:191-204.
85. Dowd JJ, Bengtson VL. Aging in minority populations an examination of the double jeopardy hypothesis. J Gerontol. 1978;33:427-36.
86. Bowleg L, Huang J, Brooks K. Triple jeopardy and beyond: Multiple minority stress and resilience among Black lesbians. J Lesbian Stud. 2003;7:87-108.
87. King DK. Multiple jeopardy, multiple consciousnesses: The context of a Black feminist ideology. Signs J Women Cult Soc. 1988;14:42-72.
88. Assari S. Number of chronic medical conditions fully mediates the effects of race on mortality; 25-year follow-up of a nationally representative sample of Americans. J Racial Ethn. Health Disparities. 2017;4:623-31.
89. Steenland K, Henley J, Thun M. All-cause and cause-specific death rates by educational status for two million people in two American Cancer Society cohorts, 1959-1996. Am J Epidemiol. 2002;156:11-21.
90. Assari S, Nikahd A, Malekahmadi MR, et al. Race by gender group differences in the protective effects of socioeconomic factors against sustained health problems across five domains. Journal of racial and ethnic health disparities. 2017;4:884-94.
91. Montez JK, Hayward MD, Brown DC, et al. Why is the educational gradient of mortality steeper for men? J Gerontol Ser B Psychol Sci Soc Sci. 2009;64:625-34.
92. Assari S, Moazen-Zadeh E. Ethnic variation in the cross-sectional association between domains of depressive symptoms and clinical depression. Front Psychiatry. 2016;7:53.
93. Assari S. Parental educational attainment and mental well-being of college students; diminished returns of blacks. Brain Sci. 2018;8:E193.
94. Assari S. Multiplicative effects of social and psychological risk factors on college students' suicidal behaviors. Brain Sci. 2018;8:E91.
95. Assari S, Lankarani M. Violence exposure and mental health of college  students in the United States. Behav Sci (Basel). 2018;24:E53.
96. Lipson SK, Lattie EG, Eisenberg D. Increased rates of mental health service utilization by U.S. college students: 10-year population-level trends (2007-2017). Psychiatr Serv. 2018;5:appips201800332.