Are "Deaths of Despair" Really Caused by Despair?

Americans, we are often told, are existentially unhappy. Increases in American despair have been blamed for the state of our family life, our politics, and, perhaps most prominently, for declining life expectancy. In an influential 2015 paper—and numerous follow-up works, including a full-length book—economists Anne Case and Angus Deaton argued that working-age whites were dying at historic rates from drugs, alcohol, and suicide, causes they famously labeled “deaths of despair.”

But since Case and Deaton first advanced their argument, researchers have challenged the usefulness of the “deaths of despair” idea. Now, in a recently released working paper with the National Bureau of Economic Research, University of Virginia economist Christopher Ruhm asks a question uninterrogated in Case and Deaton’s work: Is declining mortality actually driven by increases in measured despair?

If the answer is not ‘no,’ it is certainly more complicated than Case and Deaton’s famous work implies, according to Ruhm. He finds that worsening mental health has real but small effects on a variety of mortality outcomes, including but not limited to drug, alcohol, and suicide deaths. And worsening mental health explains some, but far from all, of the increase in mortality among working-age whites.

How do we measure despair? Ruhm’s preferred measure comes from the Behavior Risk Factor Surveillance System, a large, federally administered survey of Americans’ mental health. Specifically, the explanatory variable is the number of days Americans report poor mental health over the past month. They have become more likely to do so over the past three decades: the average number of past-month poor mental health days grew 53% between 1993 and 2019.

The paper then investigates the state-level associations between mental health and mortality, controlling for a variety of other factors. It finds relatively small effects overall. A one standard-deviation increase in poor mental health yields a 1% to 1.3% increase in mortality rates, an effect that becomes smaller with the addition of statistical controls.

Poor mental health effects some causes of death more than others, though. Investigating the traditional “deaths of despair,” Ruhm finds that a one standard deviation increase in poor mental health increases drug deaths by about 2.5% and alcohol deaths by 3.4%; suicide deaths, surprisingly, increase by only about 0.6%. But Ruhm also finds large predicted increases in other causes: heart disease, lower respiratory disease, and homicides.

What about the particular group that Case and Deaton focused on—working-age whites? The rise in deaths among this population has been identified as, among other things, a cause of President Donald Trump’s electoral success.

Again, though, the picture is more complicated. Ruhm estimates that worsening mental health explains between 16% and 29% of working-age whites’ increasing mortality. That falls to between 9% and 15% for working-age whites who never attended college—the group whom Case and Deaton identified as most at risk of a “death of despair.”

Similarly, the causes most affected by worsening mental health are not just those in the traditional “DoD” formulation. Worsening mental health acting through drug overdose, suicide, or alcohol deaths account for between 2% and 6% of mortality changes among whites, almost all through drugs. Other causes are also contributors.

What all this implies is that the causes of declining white mortality are more complicated than the “deaths of despair” narrative would imply. Yes, working-age white Americans are more prone to despair. But that rising despair does not explain the lion’s share of the increase in mortality. And to the extent that it does, it acts through a variety of causes—not just alcohol addiction, drug overdose, and suicide.

That suggests in trying to diagnose declining life expectancy, we should look elsewhere, such as at the causes of stalled progress on heart disease and the dramatic changes in the drug supply. Just as importantly, we should not be so quick to infer that phenomena like rising suicide or drug overdose are the results of rising despair, as opposed to some other factors, such as increased access to addictive drugs or methods of suicide.

Such nuance, of course, is often beyond the reach of politics. But readers should beware of anyone who reaches for “deaths of despair” as a convenient political cudgel. The reality, as we now know, is far more complicated.