Keywords: addiction, alcoholism, suicide, mortality rates, middle-age
The Centers for Disease Control (CDC) publish mortality data (“Multiple Cause of Death” files) for all deaths in the U.S. (beginning with 1969) based on death certificates filed in each US county. Deaths of middle-aged White Americans (ages 45-64) steadily declined through the 1980’s. However, beginning in the 1990s there was a sharp up-surge in deaths from drug and alcohol poisoning, liver cirrhosis, and suicide among this demographic. These three causes of death together constitute the “deaths of despair” or DOD statistic.
In a 2015 publication, Case and Deaton identified an alarming trend in mortality rates for non-Hispanic White Americans in the 45-54 age group. Between 1978 and 1998, mortality rates declined by 2% per year on average for this group. After 1998, mortality for this group began rising by half a percent per year. This trend was surprising as it represented a reversal from the steadily declining mortality rate among all groups in the U.S. up to that point (1999). Further, the fact that this trend was not observed in other age groups or racial-ethnic minorities nor in other wealthy countries brought attention to this issue. Case and Deaton dubbed this trend “deaths of despair.” Since then, additional studies have been published examining potential explanations for the sudden change in mortality rates among this group.
Although this blog prefers to draw upon the findings of meta-analyses on a given topic, there simply aren’t any meta-analyses to date on the topic of “deaths of despair.” Current research is exploratory in nature, as researchers attempt to explain this growing trend.
In their 2015 publication, Case and Deaton found that education level was an important factor as the least educated in this group had the highest mortality rates. According to the authors, “this trend was largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis” (p. 15078). In addition to declines in mortality, the authors point to related declines in other health outcomes among this group including mental and physical health, ability to work, and chronic pain.
In a follow-up article, Case and Deaton (2017) explored various explanations for the DOD trend among mid-life White Americans. For example, they refuted a purely economic explanation for higher DOD among this group. Instead, they proposed that the cumulative disadvantage of declining labor market opportunities combined with increasing “social dysfunctions” fostered by “the decline of marriage, social isolation, and detachment from the labor force” (p. 22) are the likely cause.
Read below for other explanations of the DOD trend.
Citations: Case, A., & Deaton, A. (2015). Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proceedings of the National Academy of Sciences, 112(49), 15078-15083.
Case, A., & Deaton, A. (2017). Morality and morbidity in the 21st century. Brookings Papers on Economic Activity, 397-476.
Do declining economic conditions explain the rise in “deaths of despair”?
In three publications (2015, 2017, 2020), Case and Deaton identified the alarming trend in “deaths of despair” (DOD) among White middle-aged Americans with less education and proposed that declining economic conditions may have contributed to the high rates of DOD among this population.
Ruhm set out to address the question: can DOD be accounted for by declining economic conditions? This “working paper” (meaning it has not been subjected to peer review) measured deaths due to alcohol and drug poisoning, overdoses, and suicide. Demographic data was collected on county of residence, age, gender, race/ethnicity, education, year and weekday of death between 1999 and 2015. County-level data was used to identify economic conditions.
Economic conditions accounted for less than one-tenth of the rise in drug and opioid mortality rates. The disproportional rise in deaths of despair among Whites is not likely due to economic conditions as non-White groups face harsher economic challenges. Also, this pattern is not being seen in other countries. At the end of the Great Recession, there was a strong upsurge in opioid overdose deaths in spite of improving economic circumstances.
Ruhm concluded that changes in the drug environment played a bigger role in deaths of despair than did economic conditions. “Efforts to improve economic conditions in distressed locations, while desirable for other reasons, are not likely to yield significant reductions in drug mortality” (p. 1).
Citation: Ruhm, C. J. (2020). Death of despair of drug problems? (Working paper No. 24188). National Bureau of Economic Research. http://www.nber.org/papers/w24188.
Is the trend for “deaths of despair” really an exclusive phenomenon among White Americans?
The authors of this article proposed that DOD deaths are not exclusive to White Americans and are influenced by two primary factors: the rise in opioid-deaths and the Great Recession.
Non-hispanic White and non-hispanic Black Americans, ages 20-64, were compared for deaths from suicide, drug and alcohol use during the 1990-2017 period.
Table 1 shows that DOD was highest in the 50-64 age group for White and Black men and women in 2017 compared to earlier time periods. When DOD causes are broken down by category, there were more deaths by alcohol among the oldest group of White women compared to other age groups and other causes. Since sustained liver damage takes time to occur, this may explain why deaths from alcohol use tend to be lower for younger age groups. A similar trend was found for White men, although deaths by suicide were the same for the 35-49 and 50-64 age groups. Their findings revealed that mortality from DOD increased for all age groups during this period, except for Black men and women aged 35-49 who experienced declines over time. This was driven by declines in deaths from alcohol use. Death by suicide declined among Black men and was stable for Black women in the oldest age group. The authors concluded: “Increases in drug-related deaths account for the overwhelming share of increases in “deaths of despair” mortality among both US Black and White populations” (p. 1753).
In summary, even though DOD increased for all age groups between 1990 and 2017, drug-related deaths accounted for the largest proportion of deaths from these three causes. Alcohol-related death for all groups and suicide deaths among Whites point to the role of the Great Recession in deaths of despair. By breaking down data by race, gender, and age-group, nuances were identified that point to different drivers of changes in DOD for these groups.
Citation: Tilstra, A. M., Simon, D. H., & Masters, R. K. (2021). Trends in “deaths of despair” among working-aged White and Black Americans, 1990-2017. American Journal of Epidemiology, 190(9), 1751-1759.
Did COVID-19 lead to a spike in “deaths of despair”?
Two recent studies considered the impact of COVID-19 on deaths of despair. Did fears over the epidemic and resulting lockdowns lead to more deaths by suicide, overdose, and diseases of the liver?
During the COVID-19 pandemic, concerns were raised about potential spikes in suicide and drug abuse rates due to social isolation, job loss, economic insecurity, and inaccessibility of services. The authors of this study used pandemic data to address questions regarding the effect of the pandemic on DOD in the U.S. and the U.K. Mortality data was gathered for England, Wales, Northern Ireland, Scotland, and the U.S. Surprisingly, suicide rates were relatively stable during the first two years of the pandemic (2020 and 2021). However, England, Wales, and the U.S. saw an increase in alcohol-specific deaths, with higher death rates among women than men. In the U.S., drug-related deaths accelerated during the pandemic for both men and women, with a 54% increase for men between 2019-2021. Age-specific data were inconsistent: compared to the U.K., the U.S. had the sharpest increase in alcohol and drug deaths across almost all age groups during the pandemic.
In summary, suicide concerns during the pandemic were unfounded. However, almost all countries saw a pandemic-related spike in alcohol deaths, and the U.S. experienced an unmatched spike in drug deaths. Although DOD is purported to be higher among lower-income residents, this study did not incorporate socioeconomic data. “The increases in alcohol and drug misuse deaths in the United States are particularly stark and suggest that policy action is urgently required…Whether these increases in mortality will return to pre-pandemic levels in the coming years represents a major public health concern” (p. 95).
Citation: Angus, C. Buckley, C., Tilstra, A. M., & Dowd, J. B. (2023). Increases in ‘deaths of despair’ during the COVID-19 pandemic in the United States and the United Kingdom. Public Health, 218, 92-96.
Another study took a broader look at the impact of COVID-19 on DOD in the U.S. and in 16 other countries. This article compared suicides, drug poisonings, and alcoholic liver disease deaths for the pre-pandemic period with those during the pandemic. Seventy articles were reviewed, 80% of which were published in 2021.
Issues with low-quality studies and research using different methods make it difficult to draw comparative conclusions about DOD in the 17 included countries during the pandemic. Studies of drug poisonings found an increase between pre- and post-pandemic periods. In contrast, suicide deaths in developed countries showed no change or even a decline in suicides during the pandemic, with a few exceptions. Two studies that focused on alcohol-related liver disease/cirrhosis deaths in the U.S. found an increase during the pandemic. A substantial upswing in liver disease deaths were observed in a U.K. study.
By comparison to the Angus et al. study (see above), suicides in Japan and Korea increased significantly during the pandemic among women and younger age groups. In China, there was a spike in suicides among the youngest and oldest population segments, even though the overall suicide rate declined during the pandemic.
The authors noted that DOD rates may have been impacted by the economic levels and resources available in the countries under study: most of the studies have been conducted in high-income countries where welfare safety nets and, in particular, vaccination access were often greater in comparison with low-income or lower-middle-income countries” (p. 7). In evaluating this evidence, it is important to note that long-term impacts of the pandemic on DOD may yet still emerge.
Citation: Rahimi-Ardabili, H., Feng, X., Nguyen, P-Y., & Astell-Burt, T. (2022). Have deaths of despair risen during the COVID-19 pandemic? A systematic review. International Journal of Environmental Research and Public Health, 19, 12835.
Does type of occupation relate to “deaths of despair”?
Deaths of despair (DOD) are highest among less-educated White Americans. Educational level is highly correlated with type of occupation such that many “working class” jobs involve higher risk of injury. In this paper, the authors focused on a logical question about connections between deaths of despair and occupational hazards. Are people in occupations prone to on-the-job injury more likely to die from DOD because of opioid overdose?
The authors pulled death certificates in Massachusetts from 2005-2015 for people aged 16-64. The death certificates identified cause of death as well as occupation of the deceased. The occupational categories were coded for analysis based on rates of injury or illness, perceived job insecurity, and the temporary nature of work. Note: the authors could not determine whether the deceased had experienced on-the-job injury based on the death certificates! Instead, the authors were looking at associations between DOD rates and occupations known to be hazardous (and therefore likely to cause injury/illness).
Their results (no surprise!) found that the highest number of DOD occurred among people in occupations with higher injury rates. Specifically, opioid overdose deaths were higher than alcohol and suicide deaths for these occupations. Further, there were also more DOD for occupations that had perceived job insecurity and non-standard (temporary) work arrangements. This study could not determine if overdose deaths were due to on-the-job injuries or some other factor.
These results are fraught with limitations and potentially confounding inter-correlations. Future research needs to directly assess occupational category, illness and injury rates for people who die from drug and alcohol overdose and suicide.
Citation: Hawkins, D., Punnett, L., Davis, L. & Kriebel, D. (2021). The contribution of occupation-specific factors to the deaths of despair, Massachusetts, 2005-2015. Annals of Work Exposures and Health, 65(7), 819-832, https://doi.org/10.1093/annweh/wxab017.
Does declining religious participation affect DOD?
In this “working paper” (which means it has not been subjected to peer review), the authors propose an interesting hypothesis: “Deaths of despair” (DOD) are connected to reduced religious participation which may have resulted from the repeal of “blue laws.” They point to the fact that the rise in DOD happened earlier than 1999, beginning in the early 1990s. Using survey data from the 1970s forward, the authors document the religious decline that began before the 1990s, especially for white, middle-aged Americans. Other researchers have focused on drug availability, such as OxyContin, as the driver of opioid overdose deaths (part of DOD). However, prior to OxyContin introduction in 1996, there were already 15% more excess deaths compared to earlier trends. The authors point to the role of religious participation (versus religious belief) in overall health.
Following a Supreme Court ruling in 1961, many states began repealing “blue laws” (laws which restrict commerce on Sundays). “Upon the repeal of blue laws, there was an increase in the opportunity cost of attending religious services on Sundays” (p. 14). In order words, people could replace church attendance with shopping on Sundays.
They found that repeal of blue laws coincided with reduced levels of religious participation, particularly for middle-aged adults. “States that experienced larger decreases in religiosity have had the largest gains in the rate of deaths of despair” (p. 31) and the decline is due to reduced religious participation rather than changes in beliefs or activities like prayer. In terms of DOD, they found these deaths coincided with repeals of blue laws.
Takeaway: keep in mind that they are correlating one thing with another. This study did not directly assess the religious participation of people who eventually died from DOD.
Citation: Giles, T., Hungerman, D. M., & Oostrom, T. (2023, January). Opiates of the masses? Deaths of despair and the decline of American religion. (Working paper No. 30840). National Bureau of Economic Research. http://www.nber.org/papers/w30840.
Reviews authored by Jennie Dilworth, Ph.D
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