# Disease of despair

A disease of despair is one of three classes of behavior-related medical conditions that increase in groups of people who experience despair due to a sense that their long-term social and economic prospects are bleak. The three disease types are drug overdose (including alcohol overdose), suicide, and alcoholic liver disease.
Diseases of despair, and the resulting deaths of despair, are high in the Appalachian region of the United States, especially in Pennsylvania, West Virginia, and Delaware. The prevalence increased markedly during the first decades of the 21st century, especially among middle-aged and older working class White Americans starting in 2010, followed by an increase in mortality for Hispanic Americans in 2011 and African Americans in 2014. It gained media attention because of its connection to the opioid epidemic. For 2018, some 158,000 U.S. citizens died from these causes, compared to 65,000 in 1995.
Deaths of despair have increased sharply during the COVID-19 pandemic and associated recession, with a 10% to 60% increase above pre-pandemic levels. Life expectancy in the United States declined further to 76.4 years in 2021, with the main drivers being the COVID-19 pandemic along with deaths from drug overdoses, suicides and liver disease.

## Definitions

   Despair often breeds disease.
The concept of despair in any form can not only affect an individual person, but can also arise in and spread through social communities.
There are four basic types of despair. Cognitive despair denotes thoughts connected to defeat, guilt, hopelessness and pessimism. It may make a person perceive other people's actions as hostile and discount the value of long-term outcomes. Emotional despair refers to feelings of sadness, irritability, loneliness and apathy and may partly impede the process of creating and nourishing interpersonal relationships. The term behavioural despair describes risky, reckless and self-destructive acts reflecting little to no consideration of the future (such as self-harm, reckless driving, drug use, risky sexual behaviours and others). Lastly, biological despair relates to dysfunction or dysregulation of the body's stress reactive system and/or to hormonal instability.
Being under the influence of despair for an extended amount of time may lead to the development of one or more of the diseases of despair, such as suicidal thoughts or drug and alcohol abuse. If an individual has a disease of despair, there is an increased risk of death of despair, usually classified as a suicide, drug or alcohol overdose, or liver failure.

## Risk factors

Unstable mental health, depression, suicidal thoughts and addiction to drugs and alcohol affect people of every age, every ethnicity, and every demographic group in every country in the world. However, data show that in recent years these problems are on the rise, especially among the US White non-Hispanic men and women in midlife. Since the beginning of the millennium, this particular group of people is the single one in the world which experienced continual increase in mortality and morbidity while US Black non-Hispanics and US Hispanics, as well as all subgroups of populations in other rich countries (such as countries from the EU, Japan, Australia and others), show the exact opposite trend. Moreover, men and women having no more than high school education and those living in rural areas are more affected by this phenomenon than their peers who are college-educated and live in urban areas.

## Recent trends in numbers

Mortality and morbidity rates in the United States have been decreasing for decades. Between 1970 and 2013, mortality rates for middle-aged Americans fell by 44% and morbidity was on a decline even among the elderly. After 1998, mortality rates in other rich countries have been declining by 2% a year; midlife mortality fell by more than 200 per 100,000 for Black non-Hispanics and by more than 60 per 100,000 for Hispanics during the 1998–2013 period. The AIDS epidemic in the US was brought under control; in 2018, only 37,968 people received an HIV diagnosis in the USA and its 6 dependent areas, which is an overall 7% decrease compared with the year 2014. Cardiovascular disease and cancer, the two biggest killers in middle age, are also on a decline, even though the still growing problem with obesity remains uncontrolled. Despite all of these satisfactory numbers, White non-Hispanic population exhibits an increase in premature deaths, especially in those caused by suicide, drug overdose and alcoholic liver disease.
There are two main factors driving this trend. Firstly, the data show the US White non-Hispanic population significantly differs from populations in other countries. For example, in 2015, drug, alcohol and suicide mortality was more than two times higher among US White non-Hispanics in comparison to people from the United Kingdom, Sweden or Australia. In comparison to US Black non-Hispanics, the mortality and morbidity rates are still lower; nevertheless the gap between these groups is narrowing quickly and, for example, for people aged 30–34 the difference between these two ethnicities has almost completely diminished. Also, White non-Hispanics aged 50–54 with no more than a high school diploma reached almost 1,000 premature deaths per 100,000 in the year 2015, whereas the average for all White non-Hispanics regardless of their education was only around 500 deaths per 100,000. Therefore, the factor of education probably negatively correlates with the probability of developing a disease of despair (that means higher education correlates with lower probability of developing a disease of despair).
Secondly, the excess premature deaths are, as stated above, caused primarily by suicide, poisonings or drug overdoses and other causes connected especially to alcoholism such as chronic liver diseases. The proportion of these causes of death (in comparison to deaths caused by assaults, cancer, cardiovascular diseases, HIV and motor vehicle crashes) in population white non-Hispanic people aged 25–44 is increased by 210%. It is also worth noting that the highest rates are to be discovered among people living in rural areas. For example, during the years 1999–2015, the rate of deaths of despair increased twice as much as the rate of other causes of deaths in the population of White non-Hispanics aged 30–44 living in rural areas. In total, death rates in rural subpopulations for all ethnicities increased among those aged 25–64 years by 6%. As a result of these findings, it is possible to assume that living in rural areas is also connected to the diseases and deaths of despair.
Suicides reached record levels in the United States in 2022, with 49,369 suicide deaths. Since 2011, roughly 540,000 people have died by suicide in the United States.
Life expectancy for working class Americans without a college degree peaked in 2010 and has been declining since, with adult life expectancy after the age of 25 being 49.8 years, down from 51.6 in 1992. Anne Case and Angus Deaton attribute this trend in part to rising deaths of despair.

## Causes

   Our account echoes the account of suicide by Emile Durkheim, the founder of sociology, of how suicide happens when society fails to provide some of its members with the framework within which they can live dignified and meaningful lives.
The factors that seem to exacerbate diseases of despair are not fully known, but they are generally recognized as including a worsening of economic inequality and feeling of hopelessness about personal financial success. This can take many forms and appear in different situations. For example, people feel inadequate and disadvantaged when products are marketed to them as being important, but these products repeatedly prove to be unaffordable for them. This increase in rates of mental distress and diseases of despair have been attributed to the flaws in contemporary capitalism and policies associated with the ideology of neoliberalism, which seeks to release markets from all restrictions and reduce or eliminate government assistance programs. The overall loss of employment in affected geographic regions, and stagnant wages and deteriorating working conditions along with the decline of labor unions and the welfare state, are widely hypothesized factors. As such, some scholars have characterized deaths of despair as driven by austerity policies and privatization as "social murder".
The changes in the labor market also affect social connections that might otherwise provide protection, as people at risk for this problem are less likely to get married, more likely to get divorced, and more likely to experience social isolation. However, some experts claim the correlation between income and mortality/morbidity rate is only coincidental and may not be associated with deaths for all groups. Anne Case and Angus Deaton argue that "after 1999, blacks with a college education experienced even more severe percentage declines in income than did whites in the same education group. Yet black mortality rates have fallen steadily, at rates between 2 and 3 percent per year for all age groups." Many other examples from Europe also show that decreased incomes and/or increased unemployment do not, in general, correlate with increased mortality rates. They argue that the ultimate cause is the sense that life is meaningless, unsatisfying, or unfulfilling, rather than strictly the basic economic security that makes these higher order feelings more likely. In a later work Case and Deaton assert that in the United States, much more so than in peer countries such as those of Western Europe, globalization and technological advancement dramatically shifted political power towards capital and away from labor by empowering corporations and weakening labor unions. As such, other rich countries, while facing challenges associated with globalization and technological change, did not experience a "long-term stagnation of wages, nor an epidemic of deaths of despair."
Recent data show that diseases of despair pose a complex threat to modern society and that they are not correlated only to the economic strength of an individual. Social connections, level of education, place of residence, medical condition, mental health, working opportunities, subjective perception of one's own future – all of these play a role in determining whether the individual will develop diseases of despair or not. Additionally, the younger generations are more and more influenced by social media and other modern technologies, which may have unexpected and unfavourable effects on their lives as well. For example, according to a study from 2016, the use of social media "was significantly associated with increased depression."

## COVID-19 pandemic

Preliminary studies indicate an aggravation of depression, anxiety, drug overdoses, and suicidal ideation following the beginning of the COVID-19 pandemic. Though certain health aspects like stress can be concurrent with the crisis, other biopsychosocial risk factors such as job loss, housing precarity, and food insecurity can manifest over time. This range of social determinants, commonly experienced during an economic downturn, can induce and aggravate a sense of despair. Loneliness, which is associated with despair, was also aggravated by social isolation practices put in place during the COVID-19 pandemic, which may contribute to a rise in diseases of despair.
A preliminary review of 70 published studies conducted in 17 countries concerning the potential impacts of COVID-19 on deaths of despair indicates that women, ethnic minorities and younger age groups, may have suffered disproportionately more than other groups.

### Drug overdoses

Preliminary indications in Canada and the United States demonstrate that the trajectory of drug overdose-related deaths was exacerbated by the Covid-19 pandemic. In Canada, drug overdose-related deaths stabilized prior to the onset of COVID-19, but increased after the onset of COVID-19. In the United States, drug overdose-related deaths increased prior to and accelerated after the onset of COVID-19.
More specifically, the opioid overdose crisis worsened within the three years, from 2017 to 2020, in Wisconsin. Particularly in Milwaukee County, Wisconsin, it was found that the pandemic had remarkably escalated the number of monthly overdose deaths, due to opioids. In addition, it was found that the worst of these drug impacts seemed to primarily occur in poor and urban neighborhoods, especially affecting Black and Hispanic communities. Despite this, even wealthy and prosperous, White communities within the suburbs, also faced an increase in the number of overdose deaths.

### Impact on Wisconsin opioid crisis

The rise in the use of opioids for recreational use or self-medicating purposes has given way to the idea of an opioid crisis, which started emerging in the 1990s, but has significantly risen to the point of an opioid epidemic within the last two decades, especially since 2010. This is primarily due to the introduction of synthetic opioids, which has led to number of annual overdose deaths doubling between 2010 (38,329 deaths) and 2019 (70,360 deaths) within the USA. In order to observe the results in relation to the opioid epidemic, following the COVID-19 crisis, the number of monthly OODs (opioid overdose deaths) were examined from January 1st, 2017, until December 31st, 2020. As a result of the rising COVID-19 pandemic, an order to stay home was issued on March 23, 2020. This date is used to distinguish between the two scenarios within the experiment, with the pre-pandemic scenario ranging from January 1, 2017, until March 23, 2020, whereas the post-pandemic scenario ranges from March 23, 2020, until December 31, 2020.
According to the results of the study, the peak monthly overdose death total was 37 within the pre-pandemic timeline. After the COVID-19 pandemic hit, and following the stay-at-home order issued on March 23, 2020, the peak monthly overdose death total rose to 57, during the post-pandemic scenario. However, in addition to this, the minimum monthly OODs was 23. Overall, the number of average monthly OODs increased by around 12, which implies that, even on average, the rise in the number of OODs was significantly impacted by the conditions of COVID-19.
The Milwaukee County Medical Examiners' Office provided detailed death certificates of OODs, which included information on the drugs involved in the overdose. This information was utilized in order to isolate and extract data specifically related to opioid overdose deaths. The data included the addresses where the overdoses occurred, which was matched to the administrative boundaries of census tracts using ArcGIS Desktop 10.7 and the TIGER/Line database from the Census Bureau. The researchers also collected demographic data at the census tract level from the U.S. Census Bureau's 2010 Census data platform.
On one perspective, only 3% of census tracts consistently had low rates of opioid overdose deaths. These tracts were located in suburban areas and had a predominantly White population (83%) with a higher median household income ($87,079) and educational attainment (34% had a bachelor's degree or higher). These areas also had better access to health resources with 99% of residents having access to health insurance and care. Additionally, they had other positive indicators of social well-being such as a high rate of internet subscriptions (85%) and a low incarceration rate (3%).
However, when looking at pre-pandemic opioid overdose death patterns in Milwaukee County (2017-2019), it becomes evident that the opioid crisis has had a disproportionate impact on historically marginalized Black and Hispanic communities in central Milwaukee neighborhoods. This corresponds with our previous study's findings that policies, resources, and interventions aimed at addressing the opioid crisis in Milwaukee County have primarily benefited White communities rather than communities of color. This lack of impact on Black and Hispanic communities has further exacerbated existing health inequalities.
To analyze changes in opioid overdose deaths (OOD) during the pandemic, OOD increment percentages were calculated for all census tracts, comparing post-pandemic OOD rates to the 5-year average. The results revealed two areas where OOD rates were significantly impacted: (1) predominantly poor, Black neighborhoods in the inner city and (2) predominantly affluent White suburban census tracts. There were also areas where OOD rates remained stable, including tracts with high OOD rates prior to the pandemic. However, it's important to note that some suburban tracts saw large percent increases in OODs due to the relatively low pre-pandemic OOD frequency, which doesn't necessarily reflect a large increase in the total number of OODs.
The urban tracts that experienced a 10,280% increment in OODs suffer from racial and economic segregation, concentrated poverty, and a lack of educational and employment opportunities. The population in these tracts is predominantly Black (72.46%), with a low median household income ($31,192), high unemployment rate (34%), and low educational attainment (only 5% hold a bachelor's degree or higher). They also have a high incarceration rate (7%) and low internet subscription rate (69%). The pandemic has further exacerbated existing socioeconomic disparities in these areas.
In contrast, the suburban census tracts that experienced an 11,600% increment in OODs are affluent and well-educated. The population is predominantly White (83.63%), with a higher median household income ($75,959), lower unemployment rate (11%), and higher educational attainment (45% hold a bachelor's degree or higher). These tracts also have high rates of internet subscription (90%) and low incarceration rates (2%). Despite their high economic and social well-being, suburban tracts have still been affected by pandemic-related stress, which likely contributed to the increase in OODs.

## Contrasted with diseases of poverty

Diseases of despair differ from diseases of poverty because poverty itself is not the central factor. Groups of impoverished people with a sense that their lives or their children's lives will improve are not affected as much by diseases of despair. Instead, this affects people who have little reason to believe that the future will be better. As a result, this problem is distributed unevenly, for example by affecting working-class people in the United States more than working-class people in Europe, even when the European economy was weaker. It also affects White people more than racially disadvantaged groups, possibly because working-class White people are more likely to believe that they are not doing better than their parents did, while non-White people in similar economic situations are more likely to believe that they are better off than their parents.

## Effects

Starting in 1998, a rise in deaths of despair has resulted in an unexpected increase in the number of middle-aged White Americans dying (the age-specific mortality rate). By 2014, the increasing number of deaths of despair had resulted in a drop in overall life expectancy. Anne Case and Angus Deaton propose that the increase in mid-life mortality is the result of cumulative disadvantages that have occurred over decades, and that solving it will require patience and perseverance for many years, rather than a quick fix that produces immediate results. The number of deaths of despair in the United States has been estimated at 150,000 per year in 2017.
Even though the main cause of diseases of despair may not be purely economical, the consequences of this phenomenon are, in terms of money, expensive. According to a report from 2016, alcohol misuse, misuse of illegal drugs and non-prescribed medications, treatment of associated disorders and lost productivity cost the U.S. more than $400 billion every year. About 40 percent of those costs were paid by government, which implies a huge cost of alcohol and drug misuse to taxpayers. Another study claims even higher costs of around $1.5 trillion in economic loss, loss of productivity, and societal harm.

## Terminology

The phrase diseases of despair has been criticized for medicalizing problems that are primarily social and economic, and for underplaying the role of specific drugs, such as OxyContin, in increasing deaths. While the disease model of addiction has a strong body of empirical support, there is weak evidence for biological markers of suicidal thoughts and behaviors and no evidence that suicide fits a disease model. The use of the phrase diseases of despair to describe suicide in medical literature is more reflective of the medical model than suicidal thoughts and behaviors.