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The association between academic pressure and adolescent depressive symptoms and self-harm: a prospective longitudinal study in the UK

Ann John Orcid Logo, Xuchen Guo , Marie A. E. Mueller , Jessica M. Armitage , Prof Chris Bonell , Prof Tamsin J. Ford , Prof Glyn Lewis , Prof Simon Murphy , Prof George Ploubidis , Prof Frances Rice

The Lancet Child & Adolescent Health

Swansea University Author: Ann John Orcid Logo

Abstract

Background. Academic pressure could increase the risk of adolescent depression and self-harm. However, there are few longitudinal studies of this association, and those that exist have limitations. We used a large prospective cohort in England to investigate associations between academic pressure an...

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Published in: The Lancet Child & Adolescent Health
Published: Elsevier
URI: https://cronfa.swan.ac.uk/Record/cronfa70901
first_indexed 2025-11-14T16:01:59Z
last_indexed 2026-01-09T05:31:36Z
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fullrecord <?xml version="1.0"?><rfc1807><datestamp>2026-01-08T11:25:12.6707240</datestamp><bib-version>v2</bib-version><id>70901</id><entry>2025-11-14</entry><title>The association between academic pressure and adolescent depressive symptoms and self-harm: a prospective longitudinal study in the UK</title><swanseaauthors><author><sid>ed8a9c37bd7b7235b762d941ef18ee55</sid><ORCID>0000-0002-5657-6995</ORCID><firstname>Ann</firstname><surname>John</surname><name>Ann John</name><active>true</active><ethesisStudent>false</ethesisStudent></author></swanseaauthors><date>2025-11-14</date><deptcode>MEDS</deptcode><abstract>Background. Academic pressure could increase the risk of adolescent depression and self-harm. However, there are few longitudinal studies of this association, and those that exist have limitations. We used a large prospective cohort in England to investigate associations between academic pressure and subsequent depressive symptoms and self-harm.Methods: Our main exposure was academic pressure measured at age 15, using items from a school experiences questionnaire (total scores 0-9). Outcomes were depressive symptoms assessed with the short Mood and Feelings Questionnaire at five time-points between ages 16 and 22 (total scores 0-26), and a self-harm questionnaire at four time-points between ages 16 and 24. Analyses were linear (depressive symptoms) and logistic (self-harm in the previous year) multilevel models in samples with multiply imputed data, before and after adjustments. As secondary exposures, we investigated academic pressure at ages 11 and 14.Findings: We included 4714 adolescents (58.1% female; n= 2,725) born 1991-1992, from the Avon Longitudinal Study of Parents and Children. In fully adjusted models, a 1-point increase in academic pressure at age 15 was associated with a 0.43 (95% CI 0.36, 0.51) point increase in depressive symptoms. This association was largest when depressive symptoms were assessed at age 16 (0.53, 95% CI 0.42, 0.64), but remained at age 22 (0.35, 95% CI 0.23, 0.47). For self-harm, in fully adjusted models, each 1-point increase in academic pressure was associated with an 8% higher odds of self-harm (OR 1.08, 95% CI 1.01, 1.16) (no differences over time). For secondary exposures, we found similar associations with depressive symptoms. For self-harm, there was weak evidence of an association at age 11 but no evidence at age 14.Interpretation: Our findings support the hypothesis that academic pressure is a potential modifiable risk factor for adolescent depressive symptoms, and possibly self-harm. Interventions to reduce academic pressure could be developed and evaluated.Funding: Sir Henry Dale Fellowship awarded to Dr Gemma Lewis; Wellcome Trust and Royal Society (223248/Z/21/Z). &#x2003;Research in contextEvidence before this study: There is evidence that rates of adolescent depression and self-harm have been rising in many countries, including the UK. Identifying modifiable risk factors for these mental health challenges is required, to inform public health interventions to prevent them. Globally, academic pressure has been cited as a major source of stress for adolescents and one of the top adverse influences on their mental health. We searched MEDLINE and PsycInfo from database inception to Oct 7, 2025, for studies published in English describing the association between academic pressure and depression or self-harm in adolescents. We used the search terms &#x201C;academic pressure*&#x201D; OR &#x201C;academic stress*&#x201D; OR &#x201C;school pressure*&#x201D; OR &#x201C;school stress*&#x201D; OR &#x201C;exam stress*&#x201D; OR &#x201C;test anxiety*&#x201D;AND &#x201C;adolescen*&#x201D; OR &#x201C;student*&#x201D; AND &#x201C;depression&#x201D; OR &#x201C;self-harm&#x201D;, alongside searches in Google Scholar. A systematic review published in 2023 found evidence of associations between higher academic pressure or academic stress and increased risk of adolescent depression, anxiety, self-harm and suicide. However, the quality of studies was rated as low. Most were cross-sectional and could not rule out reverse causation. We only found five longitudinal studies with depressive symptoms as the outcome and no longitudinal studies of self-harm. Among the longitudinal studies of depressive symptoms, most had relatively small samples or did not adjust for potentially important confounders, including pre-existing mental health challenges and school grades. No studies had follow-up periods into adulthood. Findings were also inconsistent, with one study finding evidence of an association only in boys and another finding no difference in depressive symptoms at exam times compared with other times. Added value of this study: Higher levels of academic pressure at age 15 were associated with higher depressive symptoms at five follow-up time-points between ages 16 and 22. This association was largest for depressive symptoms measured at age 16, but remained up to age 22. Associations between academic pressure and depressive symptoms could therefore persist from secondary school to early adulthood. We also found evidence, albeit statistically weaker than for depressive symptoms, that higher levels of academic pressure at age 15 were associated with self-harm at four follow-up time-points between ages 16 and 24. This association did not vary according to follow-up time-point. Secondary analyses of academic pressure at ages 11 and 14 showed a similar pattern of associations with depressive symptoms. For self-harm, there was weak evidence of an association at age 11, but no evidence at age 14.Implications of all the available evidence: Whole-school interventions to reduce academic pressure might improve adolescent mental health and could be developed and evaluated. There is some evidence that exam stress can be reduced by interventions which enhance social and emotional learning and relaxation skills. There is also evidence that reducing the number of high-stakes tests reduces academic stress. Interventions which promote mastery-approach goals might also reduce academic pressure. Longer-term, academic pressure could be modified through changes in policy. Families and carers could also reduce academic pressure and encourage physical activity, socialising and sleep. Clinicians should be aware of academic pressure, assess for of it, and consider strategies to address it.</abstract><type>Journal Article</type><journal>The Lancet Child &amp; Adolescent Health</journal><volume/><journalNumber/><paginationStart/><paginationEnd/><publisher>Elsevier</publisher><placeOfPublication/><isbnPrint/><isbnElectronic/><issnPrint/><issnElectronic/><keywords/><publishedDay>0</publishedDay><publishedMonth>0</publishedMonth><publishedYear>0</publishedYear><publishedDate>0001-01-01</publishedDate><doi/><url/><notes/><college>COLLEGE NANME</college><department>Medical School</department><CollegeCode>COLLEGE CODE</CollegeCode><DepartmentCode>MEDS</DepartmentCode><institution>Swansea University</institution><apcterm/><funders>Funding: Sir Henry Dale Fellowship awarded to Dr Gemma Lewis; Wellcome Trust and Royal Society (223248/Z/21/Z).</funders><projectreference/><lastEdited>2026-01-08T11:25:12.6707240</lastEdited><Created>2025-11-14T09:56:23.4383365</Created><path><level id="1">Faculty of Medicine, Health and Life Sciences</level><level id="2">Swansea University Medical School - Health Data Science</level></path><authors><author><firstname>Ann</firstname><surname>John</surname><orcid>0000-0002-5657-6995</orcid><order>1</order></author><author><firstname>Xuchen Guo</firstname><surname/><order>2</order></author><author><firstname>Marie A. E. Mueller</firstname><surname/><order>3</order></author><author><firstname>Jessica M. Armitage</firstname><surname/><order>4</order></author><author><firstname>Prof Chris Bonell</firstname><surname/><order>5</order></author><author><firstname>Prof Tamsin J. Ford</firstname><surname/><order>6</order></author><author><firstname>Prof Glyn Lewis</firstname><surname/><order>7</order></author><author><firstname>Prof Simon Murphy</firstname><surname/><order>8</order></author><author><firstname>Prof George Ploubidis</firstname><surname/><order>9</order></author><author><firstname>Prof Frances Rice</firstname><surname/><order>10</order></author></authors><documents/><OutputDurs/></rfc1807>
spelling 2026-01-08T11:25:12.6707240 v2 70901 2025-11-14 The association between academic pressure and adolescent depressive symptoms and self-harm: a prospective longitudinal study in the UK ed8a9c37bd7b7235b762d941ef18ee55 0000-0002-5657-6995 Ann John Ann John true false 2025-11-14 MEDS Background. Academic pressure could increase the risk of adolescent depression and self-harm. However, there are few longitudinal studies of this association, and those that exist have limitations. We used a large prospective cohort in England to investigate associations between academic pressure and subsequent depressive symptoms and self-harm.Methods: Our main exposure was academic pressure measured at age 15, using items from a school experiences questionnaire (total scores 0-9). Outcomes were depressive symptoms assessed with the short Mood and Feelings Questionnaire at five time-points between ages 16 and 22 (total scores 0-26), and a self-harm questionnaire at four time-points between ages 16 and 24. Analyses were linear (depressive symptoms) and logistic (self-harm in the previous year) multilevel models in samples with multiply imputed data, before and after adjustments. As secondary exposures, we investigated academic pressure at ages 11 and 14.Findings: We included 4714 adolescents (58.1% female; n= 2,725) born 1991-1992, from the Avon Longitudinal Study of Parents and Children. In fully adjusted models, a 1-point increase in academic pressure at age 15 was associated with a 0.43 (95% CI 0.36, 0.51) point increase in depressive symptoms. This association was largest when depressive symptoms were assessed at age 16 (0.53, 95% CI 0.42, 0.64), but remained at age 22 (0.35, 95% CI 0.23, 0.47). For self-harm, in fully adjusted models, each 1-point increase in academic pressure was associated with an 8% higher odds of self-harm (OR 1.08, 95% CI 1.01, 1.16) (no differences over time). For secondary exposures, we found similar associations with depressive symptoms. For self-harm, there was weak evidence of an association at age 11 but no evidence at age 14.Interpretation: Our findings support the hypothesis that academic pressure is a potential modifiable risk factor for adolescent depressive symptoms, and possibly self-harm. Interventions to reduce academic pressure could be developed and evaluated.Funding: Sir Henry Dale Fellowship awarded to Dr Gemma Lewis; Wellcome Trust and Royal Society (223248/Z/21/Z).  Research in contextEvidence before this study: There is evidence that rates of adolescent depression and self-harm have been rising in many countries, including the UK. Identifying modifiable risk factors for these mental health challenges is required, to inform public health interventions to prevent them. Globally, academic pressure has been cited as a major source of stress for adolescents and one of the top adverse influences on their mental health. We searched MEDLINE and PsycInfo from database inception to Oct 7, 2025, for studies published in English describing the association between academic pressure and depression or self-harm in adolescents. We used the search terms “academic pressure*” OR “academic stress*” OR “school pressure*” OR “school stress*” OR “exam stress*” OR “test anxiety*”AND “adolescen*” OR “student*” AND “depression” OR “self-harm”, alongside searches in Google Scholar. A systematic review published in 2023 found evidence of associations between higher academic pressure or academic stress and increased risk of adolescent depression, anxiety, self-harm and suicide. However, the quality of studies was rated as low. Most were cross-sectional and could not rule out reverse causation. We only found five longitudinal studies with depressive symptoms as the outcome and no longitudinal studies of self-harm. Among the longitudinal studies of depressive symptoms, most had relatively small samples or did not adjust for potentially important confounders, including pre-existing mental health challenges and school grades. No studies had follow-up periods into adulthood. Findings were also inconsistent, with one study finding evidence of an association only in boys and another finding no difference in depressive symptoms at exam times compared with other times. Added value of this study: Higher levels of academic pressure at age 15 were associated with higher depressive symptoms at five follow-up time-points between ages 16 and 22. This association was largest for depressive symptoms measured at age 16, but remained up to age 22. Associations between academic pressure and depressive symptoms could therefore persist from secondary school to early adulthood. We also found evidence, albeit statistically weaker than for depressive symptoms, that higher levels of academic pressure at age 15 were associated with self-harm at four follow-up time-points between ages 16 and 24. This association did not vary according to follow-up time-point. Secondary analyses of academic pressure at ages 11 and 14 showed a similar pattern of associations with depressive symptoms. For self-harm, there was weak evidence of an association at age 11, but no evidence at age 14.Implications of all the available evidence: Whole-school interventions to reduce academic pressure might improve adolescent mental health and could be developed and evaluated. There is some evidence that exam stress can be reduced by interventions which enhance social and emotional learning and relaxation skills. There is also evidence that reducing the number of high-stakes tests reduces academic stress. Interventions which promote mastery-approach goals might also reduce academic pressure. Longer-term, academic pressure could be modified through changes in policy. Families and carers could also reduce academic pressure and encourage physical activity, socialising and sleep. Clinicians should be aware of academic pressure, assess for of it, and consider strategies to address it. Journal Article The Lancet Child & Adolescent Health Elsevier 0 0 0 0001-01-01 COLLEGE NANME Medical School COLLEGE CODE MEDS Swansea University Funding: Sir Henry Dale Fellowship awarded to Dr Gemma Lewis; Wellcome Trust and Royal Society (223248/Z/21/Z). 2026-01-08T11:25:12.6707240 2025-11-14T09:56:23.4383365 Faculty of Medicine, Health and Life Sciences Swansea University Medical School - Health Data Science Ann John 0000-0002-5657-6995 1 Xuchen Guo 2 Marie A. E. Mueller 3 Jessica M. Armitage 4 Prof Chris Bonell 5 Prof Tamsin J. Ford 6 Prof Glyn Lewis 7 Prof Simon Murphy 8 Prof George Ploubidis 9 Prof Frances Rice 10
title The association between academic pressure and adolescent depressive symptoms and self-harm: a prospective longitudinal study in the UK
spellingShingle The association between academic pressure and adolescent depressive symptoms and self-harm: a prospective longitudinal study in the UK
Ann John
title_short The association between academic pressure and adolescent depressive symptoms and self-harm: a prospective longitudinal study in the UK
title_full The association between academic pressure and adolescent depressive symptoms and self-harm: a prospective longitudinal study in the UK
title_fullStr The association between academic pressure and adolescent depressive symptoms and self-harm: a prospective longitudinal study in the UK
title_full_unstemmed The association between academic pressure and adolescent depressive symptoms and self-harm: a prospective longitudinal study in the UK
title_sort The association between academic pressure and adolescent depressive symptoms and self-harm: a prospective longitudinal study in the UK
author_id_str_mv ed8a9c37bd7b7235b762d941ef18ee55
author_id_fullname_str_mv ed8a9c37bd7b7235b762d941ef18ee55_***_Ann John
author Ann John
author2 Ann John
Xuchen Guo
Marie A. E. Mueller
Jessica M. Armitage
Prof Chris Bonell
Prof Tamsin J. Ford
Prof Glyn Lewis
Prof Simon Murphy
Prof George Ploubidis
Prof Frances Rice
format Journal article
container_title The Lancet Child & Adolescent Health
institution Swansea University
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college_str Faculty of Medicine, Health and Life Sciences
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hierarchy_top_id facultyofmedicinehealthandlifesciences
hierarchy_top_title Faculty of Medicine, Health and Life Sciences
hierarchy_parent_id facultyofmedicinehealthandlifesciences
hierarchy_parent_title Faculty of Medicine, Health and Life Sciences
department_str Swansea University Medical School - Health Data Science{{{_:::_}}}Faculty of Medicine, Health and Life Sciences{{{_:::_}}}Swansea University Medical School - Health Data Science
document_store_str 0
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description Background. Academic pressure could increase the risk of adolescent depression and self-harm. However, there are few longitudinal studies of this association, and those that exist have limitations. We used a large prospective cohort in England to investigate associations between academic pressure and subsequent depressive symptoms and self-harm.Methods: Our main exposure was academic pressure measured at age 15, using items from a school experiences questionnaire (total scores 0-9). Outcomes were depressive symptoms assessed with the short Mood and Feelings Questionnaire at five time-points between ages 16 and 22 (total scores 0-26), and a self-harm questionnaire at four time-points between ages 16 and 24. Analyses were linear (depressive symptoms) and logistic (self-harm in the previous year) multilevel models in samples with multiply imputed data, before and after adjustments. As secondary exposures, we investigated academic pressure at ages 11 and 14.Findings: We included 4714 adolescents (58.1% female; n= 2,725) born 1991-1992, from the Avon Longitudinal Study of Parents and Children. In fully adjusted models, a 1-point increase in academic pressure at age 15 was associated with a 0.43 (95% CI 0.36, 0.51) point increase in depressive symptoms. This association was largest when depressive symptoms were assessed at age 16 (0.53, 95% CI 0.42, 0.64), but remained at age 22 (0.35, 95% CI 0.23, 0.47). For self-harm, in fully adjusted models, each 1-point increase in academic pressure was associated with an 8% higher odds of self-harm (OR 1.08, 95% CI 1.01, 1.16) (no differences over time). For secondary exposures, we found similar associations with depressive symptoms. For self-harm, there was weak evidence of an association at age 11 but no evidence at age 14.Interpretation: Our findings support the hypothesis that academic pressure is a potential modifiable risk factor for adolescent depressive symptoms, and possibly self-harm. Interventions to reduce academic pressure could be developed and evaluated.Funding: Sir Henry Dale Fellowship awarded to Dr Gemma Lewis; Wellcome Trust and Royal Society (223248/Z/21/Z).  Research in contextEvidence before this study: There is evidence that rates of adolescent depression and self-harm have been rising in many countries, including the UK. Identifying modifiable risk factors for these mental health challenges is required, to inform public health interventions to prevent them. Globally, academic pressure has been cited as a major source of stress for adolescents and one of the top adverse influences on their mental health. We searched MEDLINE and PsycInfo from database inception to Oct 7, 2025, for studies published in English describing the association between academic pressure and depression or self-harm in adolescents. We used the search terms “academic pressure*” OR “academic stress*” OR “school pressure*” OR “school stress*” OR “exam stress*” OR “test anxiety*”AND “adolescen*” OR “student*” AND “depression” OR “self-harm”, alongside searches in Google Scholar. A systematic review published in 2023 found evidence of associations between higher academic pressure or academic stress and increased risk of adolescent depression, anxiety, self-harm and suicide. However, the quality of studies was rated as low. Most were cross-sectional and could not rule out reverse causation. We only found five longitudinal studies with depressive symptoms as the outcome and no longitudinal studies of self-harm. Among the longitudinal studies of depressive symptoms, most had relatively small samples or did not adjust for potentially important confounders, including pre-existing mental health challenges and school grades. No studies had follow-up periods into adulthood. Findings were also inconsistent, with one study finding evidence of an association only in boys and another finding no difference in depressive symptoms at exam times compared with other times. Added value of this study: Higher levels of academic pressure at age 15 were associated with higher depressive symptoms at five follow-up time-points between ages 16 and 22. This association was largest for depressive symptoms measured at age 16, but remained up to age 22. Associations between academic pressure and depressive symptoms could therefore persist from secondary school to early adulthood. We also found evidence, albeit statistically weaker than for depressive symptoms, that higher levels of academic pressure at age 15 were associated with self-harm at four follow-up time-points between ages 16 and 24. This association did not vary according to follow-up time-point. Secondary analyses of academic pressure at ages 11 and 14 showed a similar pattern of associations with depressive symptoms. For self-harm, there was weak evidence of an association at age 11, but no evidence at age 14.Implications of all the available evidence: Whole-school interventions to reduce academic pressure might improve adolescent mental health and could be developed and evaluated. There is some evidence that exam stress can be reduced by interventions which enhance social and emotional learning and relaxation skills. There is also evidence that reducing the number of high-stakes tests reduces academic stress. Interventions which promote mastery-approach goals might also reduce academic pressure. Longer-term, academic pressure could be modified through changes in policy. Families and carers could also reduce academic pressure and encourage physical activity, socialising and sleep. Clinicians should be aware of academic pressure, assess for of it, and consider strategies to address it.
published_date 0001-01-01T05:33:54Z
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