Diseases of despair

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The diseases of despair are 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 outlook is 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 Appalachia region of the United States. 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.[1] It gained media attention because of its connection to the opioid epidemic.[2] For 2018, some 158,000 U.S. citizens died from these causes, compared to 65,000 in 1995.[3] The economists Anne Case and Angus Deaton attribute this rising mortality to the flaws in contemporary capitalism.[4]

Deaths of despair have increased sharply during the COVID-19 pandemic and associated recession, with a 10% to 60% increase above pre-pandemic levels.[5]


Despair often breeds disease.


The word despair derives from the Latin word desperare, which means "down from hope". 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.[6] 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.[7]

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 suffers from 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.[7][8]

Risk factors[edit]

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 college educated and in-urban-areas-living peers.[8][9][10]

Recent trends in numbers[edit]

Mortality and morbidity rates in the United States have been decreasing for decades. Between 1970 and 2013, mortality rates 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.[9] The infamous AIDS epidemic 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.[11] Cardiovascular disease and cancer, the two biggest killers in middle age, are also on a decline,[8] even though the still growing problem with obesity is not getting under control yet. 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 unpleasant 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. If compared to US Black non-Hispanics, the mortality and morbidity rates are still lower; nevertheless the gap between these groups is narrowing very quickly and, for example, for people aged 30–34 the difference between these two ethnicities has almost completely diminished. Another interesting fact is that White non-Hispanics aged 50–54 with no more than a high school diploma reached almost 1000 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 most 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).[8]

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 increasing. 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.[10]


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.

Anne Case and Angus Deaton, Deaths of Despair and the Future of Capitalism (2020)[12]

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[13][14] 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.[15] 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.[16][17]

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.[8] However, some experts claim the correlation between income and mortality/morbidity rate is only coincidental. 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.[8][18]

Economists Anne Case and Angus Deaton 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.[8] But why are the African Americans and Hispanics “immune” to the diseases of despair? Probably because their situation, despite the fact that economically is still generally worse, seems much more positive from their own point of view. These people grow up in their own solid social groups, which are usually very interconnected and thus provide a relatively stable base of social contacts. This factor may significantly decrease the risk of feeling lonely, lost or unwanted, even though segregation is still present de facto everywhere in the USA. They are also much more likely to be better off than their parents regardless of their achieved education.[10]

Ultimately, recent data show that diseases of despair pose a complex threat to the 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 suffer from diseases of despair or not.[19] 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."[20]

Contrasted with diseases of poverty[edit]

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.[16] 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.[16] 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.[8]


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).[8] By 2014, the increasing number of deaths of despair had resulted in a drop in overall life expectancy.[8] 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.[8] The number of deaths of despair in the United States has been estimated at 150,000 per year in 2017.[21]

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.[22] 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.[23] As stated above, diseases of despair and an increase in drug and alcohol overdoses and suicides have much in common. Therefore, should this trend continue to spread, the U.S. society will have to pay for it, both psychologically and economically.


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.[24] While the disease model of addiction has a strong body of empirical support,[25] there is weak evidence for biological markers of suicidal thoughts and behaviors and no evidence that suicide fits a disease model.[26][27] 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.


  1. ^ Achenbach J (November 26, 2019). "'There's something terribly wrong': Americans are dying young at alarming rates". The Washington Post. Archived from the original on 2 December 2019. Retrieved December 18, 2019.
  2. ^ Cunningham PW (October 30, 2017). "Appalachian death from drug overdoses far outpace nation's". The Washington Post.
  3. ^ Case A, Deaton A (April 14, 2020). "American capitalism is failing Trump's base as white working-class 'deaths of despair' rise". NBC News. Retrieved April 15, 2020.
  4. ^ Case A, Deaton A (2020). Deaths of Despair and the Future of Capitalism. Princeton University Press. ISBN 978-0691190785.
  5. ^ Fottrell Q (January 5, 2021). "'Deaths of despair' during COVID-19 have risen significantly in 2020, new research says". MarketWatch. Retrieved January 5, 2021.
  6. ^ Pulcu E, Trotter PD, Thomas EJ, McFarquhar M, Juhasz G, Sahakian BJ, et al. (July 2014). "Temporal discounting in major depressive disorder". Psychological Medicine. 44 (9): 1825–34. doi:10.1017/S0033291713002584. PMC 4035754. PMID 24176142.
  7. ^ a b Shanahan L, Hill SN, Gaydosh LM, Steinhoff A, Costello EJ, Dodge KA, et al. (June 2019). "Does Despair Really Kill? A Roadmap for an Evidence-Based Answer". American Journal of Public Health. 109 (6): 854–858. doi:10.2105/AJPH.2019.305016. PMC 6506367. PMID 30998413.
  8. ^ a b c d e f g h i j k Case A, Deaton A (2017). "Mortality and morbidity in the 21st century". Brookings Papers on Economic Activity. 2017 (1): 397–476. doi:10.1353/eca.2017.0005. PMC 5640267. PMID 29033460.
  9. ^ a b Case A, Deaton A (December 2015). "Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century". Proceedings of the National Academy of Sciences of the United States of America. 112 (49): 15078–83. Bibcode:2015PNAS..11215078C. doi:10.1073/pnas.1518393112. PMC 4679063. PMID 26575631.
  10. ^ a b c Stein EM, Gennuso KP, Ugboaja DC, Remington PL (October 2017). "The Epidemic of Despair Among White Americans: Trends in the Leading Causes of Premature Death, 1999-2015". American Journal of Public Health. 107 (10): 1541–1547. doi:10.2105/AJPH.2017.303941. PMC 5607670. PMID 28817333.
  11. ^ March 17, Content Source: HIV govDate last updated; 2021 (2021-03-17). "U.S. Statistics". HIV.gov. Retrieved 2021-04-14.{{cite web}}: CS1 maint: numeric names: authors list (link)
  12. ^ Case A, Deaton A (2020). Deaths of Despair and the Future of Capitalism. Princeton University Press. p. 8. ISBN 978-0691190785.
  13. ^ Woodward A (November 30, 2019). "Life expectancy in the US keeps going down, and a new study says America's worsening inequality could be to blame". Business Insider. Retrieved December 18, 2019.
  14. ^ Coughlan S, Brown D (May 14, 2019). "Inequality driving 'deaths of despair'". BBC. Retrieved December 18, 2019.
  15. ^ Danny D (June 3, 2015). Injustice (revised edition): Why social inequality still persists. Policy Press. ISBN 9781447320777. Part of the mechanism behind the worldwide rise in diseases of despair is suggested, with evidence provided below, to be the anxiety caused when particular forms of competition are enhanced....The effects of the advertising industry in making both adults, and especially children, feel inadequate, are also documented here
  16. ^ a b c McGreal C (November 13, 2018). American overdose: The opioid tragedy in three acts (1st ed.). New York, NY. pp. 109–112. ISBN 978-1-61039-861-9. OCLC 1039238075.
  17. ^ ""Diseases of Despair" Have Soared in the US Over the Past Decade". SciTechDaily. May 19, 2021. Retrieved May 20, 2021. Such 'deaths of despair' have coincided with decades of economic decline for workers, particularly those with low levels of educational attainment; loss of social safety nets; and stagnant or falling wages and family incomes in the US, all of which are thought to have contributed to growing feelings of despair.
  18. ^ Chetty R, Stepner M, Abraham S, Lin S, Scuderi B, Turner N, et al. (April 2016). "The Association Between Income and Life Expectancy in the United States, 2001-2014". JAMA. 315 (16): 1750–66. doi:10.1001/jama.2016.4226. PMC 4866586. PMID 27063997.
  19. ^ Brignone E, George DR, Sinoway L, Katz C, Sauder C, Murray A, et al. (November 2020). "Trends in the diagnosis of diseases of despair in the United States, 2009-2018: a retrospective cohort study". BMJ Open. 10 (10): e037679. doi:10.1136/bmjopen-2020-037679. PMC 7654125. PMID 33168586.
  20. ^ Lin LY, Sidani JE, Shensa A, Radovic A, Miller E, Colditz JB, et al. (April 2016). "Association Between Social Media Use and Depression Among u.s. Young Adults". Depression and Anxiety. 33 (4): 323–31. doi:10.1002/da.22466. PMC 4853817. PMID 26783723.
  21. ^ Hassan A (March 7, 2019). "'Deaths From Drugs and Suicide Reach a Record in the U.S." The New York Times.
  22. ^ U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016
  23. ^ "Economic Cost of Substance Abuse in the United States, 2016". Recovery Centers of America.{{cite web}}: CS1 maint: url-status (link)
  24. ^ Brignone E, George DR, Sinoway L, Katz C, Sauder C, Murray A, et al. (November 2020). "Trends in the diagnosis of diseases of despair in the United States, 2009-2018: a retrospective cohort study". BMJ Open. 10 (10): e037679. doi:10.1136/bmjopen-2020-037679. PMC 7654125. PMID 33168586. S2CID 226296925.
  25. ^ Volkow ND, Koob GF, McLellan AT (January 2016). "Neurobiologic Advances from the Brain Disease Model of Addiction". The New England Journal of Medicine. 374 (4): 363–71. doi:10.1056/nejmra1511480. PMC 6135257. PMID 26816013.
  26. ^ Oquendo MA, Sullivan GM, Sudol K, Baca-Garcia E, Stanley BH, Sublette ME, Mann JJ (December 2014). "Toward a biosignature for suicide". The American Journal of Psychiatry. 171 (12): 1259–77. doi:10.1176/appi.ajp.2014.14020194. PMC 4356635. PMID 25263730.
  27. ^ Chang BP, Franklin JC, Ribeiro JD, Fox KR, Bentley KH, Kleiman EM, Nock MK (September 2016). "Biological risk factors for suicidal behaviors: a meta-analysis". Translational Psychiatry. 6 (9): e887. doi:10.1038/tp.2016.165. PMC 5048204. PMID 27622931.

Further reading[edit]

External links[edit]

External video
video icon Krystal and Saagar: New Study Shows Deaths Of Despair Hitting Poor Working Class Of ALL Races on YouTube