Mortality Myths?: Testing the Claims of the Theory of Deaths of Despair (2024)

2024 Theses Doctoral

Segura, Luis Esteban

A groundbreaking narrative, which would come to be known as the theory of “deaths of despair”, emerged in 2015 from a study by Case and Deaton analyzing mortality rates in the United States between 1999 and 2013. They found an increasing trend in all-cause mortality rates due to drug poisonings, alcohol-related liver disease, and suicides, which they called “deaths of despair”, among non-Hispanic (NH) white Americans aged 45 to 54—this age group was called the midlife. Case and Deaton’s findings and their narrative about the hypothetical causes of their findings garnered significant attention. The authors of this narrative hypothesized that the observed increases in mortality rates were due to white individuals in midlife increasingly suffering from “despair” and proposed a causal link between increasing “despair” rates and increased mortality rates only among white Americans in midlife. Case and Deaton did not provide a clear definition of “despair”; they presumed that white Americans in midlife were hopeless about their prospects for the future compared to what their parents had attained.

This provocative narrative persisted and gained momentum because it functioned as an explanation of recent events like the 2016 U.S. presidential election, rise in white nationalism, and far right extremism. These white-related events were thought to be expressions of an agonizing, poor, under-educated generation of white Americans increasingly suffering from hypothetical feelings of "despair”, which have led them to self-destructive behaviors and premature death.

However, no study has investigated the central claim of this theory: whether there is evidence of an association between increased “despair” rates and increased mortality rates only among white individuals in midlife, particularly for those with low education. Moreover, there is little evidence of their hypothesis of an increasing epidemic of “despair” affecting only white Americans in midlife, particularly those with low education.

The theory of “deaths of despair” can be understood through Geoffrey Rose’s framework of causes of incidence and causes of cases, which highlights the difference between between-population and inter-individual causes of disease. Rose’s argues that causes of incidence explain the changes in outcome rates between populations, and may be uniform and imperceptible within populations. On the other hand, the causes of cases explain why some individuals within a population are susceptible or at high risk of the outcome. Like Rose’s causes of incidence, the authors of the theory of “deaths of despair” argue that “despair” increased between the midlife white American population in 1999 and in 2014, which led to increased mortality rates. Conversely, this theory does not claim that some individuals are at higher risk of death due to “despair”, which would be analogous to causes of cases. Therefore, the contrast of interest to test the central claim of Case and Deaton’s theory of “deaths of despair” is a between-population contrast (causes of incidence). As such, this dissertation aims to test the claims of the theory of “deaths of despair” proposed by Case and Deaton at the right level (causes of incidence).

I began by conducting a scoping review of the current literature providing empirical support to the different elements of this theory: 1) socioeconomic causes as causes of “despair”, “diseases of despair”, “deaths of despair”, and all-cause mortality, and 2) “despair” as the cause of “diseases of despair”, “deaths of despair”, and all-cause mortality. I found 43 studies that I organized and displayed in two graphs according to Rose’s causes of cases (individual-level causes of “deaths of despair”) and causes of incidence (between-population level causes of “deaths of despair” rates). In each graph, I showed the number of studies that provided evidence for the individual- or population-level elements of the theory of “deaths of despair”.

Of these 43 studies, I found that only 13 studies explicitly stated that they tested this theory. Three studies provided different definitions of “despair”, which did not align with the previous vague definition provided by Case and Deaton about white individuals’ hopeless about their prospects for the future. Most studies provided individual-level evidence for “despair” increasing the likelihood of death and despair-related outcomes, which is analogous to a type III error—a mismatch between the research question and the level at which the studies’ design and analyses were conducted to answer that question. Further, no study addressed at the right level—between populations—the central claim of the theory of “deaths of despair”. This led me to review the literature around concepts similar to “despair” and propose a suitable indicator to test the claims of the theory of “deaths of despair”.

I leveraged data from the National Health Interview Survey and the Centers for Disease Control mortality data to test whether increases in the prevalence of “despair” were associated with increases in all-cause mortality rates only among white individuals in midlife and whether this effect was bigger among low educated white individuals. To obtain a valid estimate of this association, I adapted econometric methods to develop a valid estimator of the association between increasing “despair” prevalence and increased all-cause mortality rates. After adjusting for potential confounders at the between-population level, I found that the trends in the prevalence of “despair” were negligible across all race and ethnic groups and that an increasing trend could not be identified. Further, I found no evidence that increasing prevalences of “despair” were associated with increased all-cause mortality rates among NH white individuals in midlife, or that this association was more pronounced for those with low education.

Lastly, I conducted a similar analysis looking at the association between increased prevalences of “despair” and increased rates of “deaths of despair”. I replicated Case and Deaton’s observed increased rates of “deaths of despair” among white individuals in midlife. However, I found no evidence that increased prevalences of “despair” were associated with increased “deaths of despair” rates among white individuals in midlife or that this association was higher for those with low education.

Together, these findings suggest that the claims about the causes of increased mortality rates among white Americans in midlife are at best, questionable, and at worst, false. My aim with this work is to challenge and provide a critical examination of the theory of "deaths of despair", which has fueled the narrative of a suffering white generation and justified recent problematic events as white individuals lashing out for being forgotten to despair and die. While Case and Deaton’s observed rise in mortality rates among whites is a reproducible fact, their narrative ignores other evidence of white racial resentment as the cause of rise in mortality among white individuals. With this work, I intend to help stopping the perpetuation of narratives that favor structural whiteness by promoting an unsubstantiated narrative of psychosocial harm experienced by white Americans. Ultimately, I hope this work helps shift the focus in public health away from Case and Deaton's findings, which may overshadow and detract from the stark reality that mortality rates for Black individuals significantly exceed those for white individuals.