Does Despair Really Kill? A Roadmap for an Evidence-Based Answer

Lilly Shanahan, PhD; Sherika N. Hill, PhD; Lauren M. Gaydosh, PhD; Annekatrin Steinhoff, PhD; E. Jane Costello, PhD; Kenneth A. Dodge, PhD; Kathleen Mullan Harris, PhD; William E. Copeland, PhD

Disclosures

Am J Public Health. 2019;109(6):854-858. 

In This Article

Abstract and Introduction

Abstract

Two seemingly associated demographic trends have generated considerable interest: income stagnation and rising premature mortality from suicides, drug poisoning, and alcoholic liver disease among US non-Hispanic Whites with low education. Economists interpret these population-level trends to indicate that despair induced by financial stressors is a shared pathway to these causes of death.

Although we now have the catchy term "deaths of despair," we have yet to study its central empirical claim: that conceptually defined and empirically assessed "despair" is indeed a common pathway to several causes of death. At the level of the person, despair consists of cognitive, emotional, behavioral, and biological domains. Despair can also permeate social relationships, networks, institutions, and communities.

Extant longitudinal data sets feature repeated measures of despair—before, during, and after the Great Recession—offering resources to test the role that despair induced by economic decline plays in premature morbidity and mortality. Such tests must also focus on protective factors that could shield individuals. Deaths of despair is more than a phrase; it constitutes a hypothesis that deserves conceptual mapping and empirical study with longitudinal, multilevel data.

Introduction

After decades of improvement, premature mortality (i.e., unfulfilled life expectancy) is on the rise among US non-Hispanic White adults with a high school degree or less.[1,2] Common causes of mortality in midlife—motor vehicle crashes, cancer, cardiovascular disease, HIV—are not to blame. Rather, suicide, drug poisoning (particularly from opiates), and alcoholic liver disease are among the main culprits, and their prevalence has especially risen in geographic regions hit hardest by economic decline (e.g., the Rust Belt, parts of Appalachia).[3]

At the population level, recent increases in premature mortality have coincided with decades of economic decline for less educated and unskilled workers, accompanied by declining family incomes and marriage rates, an increase in single-parent households, disengagement from the labor force, and community decline.[1,2] These trends were further exacerbated by the Great Recession. Some economists have interpreted these recent population-level trends to indicate that despair rising from economic stagnation is a shared pathway to suicide, drug poisoning, and death from alcoholic liver disease. Accordingly, they coined the term deaths of despair,[1,2] which quickly captured the attention of scientists,[4–7] policymakers,[8] and popular media but also drew criticism from addiction researchers,[9]racial disparities researchers,[10–12] family sociologists,[13] and demographers.[14]

Despite this high level of interest, the deaths of despair literature has neither defined nor empirically assessed its central concept, despair. This is concerning because deaths of despair constitutes an empirical hypothesis—that despair is a critically important mediator in a complex causal field that links economic troubles with diverse forms of morbidity and mortality. Deaths of despair research holds promise for delivery of a shared cause in an otherwise complex web of causality and, by extension, a basis for reversing several increases in premature mortality. Presently, however, the gap between deaths of despair as a claim and deaths of despair as a rigorously tested scientific concept is wide.

We propose that despair, and its hypothesized role in rising premature mortality, deserves empirical study and thus requires multidimensional conceptual mapping. We also urge the study of protective factors that moderate the putative effects of financial stressors on despair and deaths of despair so that preventions and interventions might have an empirical basis. Such studies would also illuminate additional consequences of despair on the pathway to premature death, such as poor physical (e.g., cardiometabolic) health, and insights into whether, why, and how some at-risk populations (e.g., poor African Americans in the United States) have seemingly escaped recent increases in premature mortality (although this finding is under debate[12]), and others have not (e.g., American Indians[11,12]).

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