Independent Risk Factors for 'Deaths of Despair' Identified

TOPLINE:

Income inequality and lack of social mobility are independently associated with so-called "deaths of despair" among working-age Americans, with exposure to both risk factors linked to additional risks for such deaths.

METHODOLOGY:

Increasing mortality from suicide, drug overdose, and alcohol-related liver disease — collectively referred to as deaths of despair — is a critical public health crisis.

Researchers obtained 2000-2019 data on county-level, cause-specific and race- and ethnicity-specific deaths from the Centers for Disease Control and Prevention, information on sociodemographic characteristics from the US Census Bureau, and indicators of intergenerational social mobility from the Opportunity Atlas data library.

The outcome was deaths of despair (avoidable and preventable deaths from suicide, drug/alcohol poisoning, and alcohol-related liver diseases and cirrhosis) among working-age individuals in the US from 2000 to 2019.

The interaction between income inequality and social mobility was tested on both additive and multiplicative scales.

TAKEAWAY:

The sample included 788 counties for Hispanic, 1050 counties for Black, and 2942 counties for white populations, representing 95.5%, 96.5%, and 99.8% of the population for each racial and ethnic group, respectively.

Over the study period, 149,589, 152,350, and 1,250,156 deaths of despair were recorded for working-age Black, Hispanic, and white populations, respectively.

Compared with counties with low income inequality, risk for deaths of despair were higher in counties with greater income inequality (high inequality: risk ratio (RR), 1.18 [95% CI, 1.15 - 1.20] for Blacks; RR, 1.26 [95% CI, 1.24 - 1.29] for Hispanics; and RR, 1.22 [95% CI, 1.21 - 1.23] for whites).

Compared with counties with high social mobility, mortality risks were higher where there was less social mobility (low mobility: RR, 1.64 [95% CI, 1.61 - 1.67] for Blacks; RR, 1.79 [95% CI, 1.76 - 1.82] for Hispanics; and RR, 1.38 [95% CI, 1.38 - 1.39] for whites).

The highest RRs were in counties with high income inequality and low social mobility for Hispanics and whites and with medium income inequality and low social mobility for Blacks.

IN PRACTICE:

"The findings of this study suggest that policy responses to the epidemic of deaths of despair must address the underlying social and economic conditions associated with these deaths," the investigators note.

SOURCE:

The study was conducted by Chun-Tung Kuo, PhD, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, and the Institute of Health Behaviors and Community Sciences, National Taiwan University, Taipei, and a colleague. It was published online July 2 in JAMA Network Open.

LIMITATIONS:

The study could not establish causality or account for the dynamic nature and temporal variations in deaths of despair, which, for example, may have been affected by changes in opioid-related overdose deaths. The study also could not account for the association of social and health policies — such as Medicaid Expansion, prescription drug monitoring programs, state policies on alcohol sales, and state-level gun laws — with deaths of despair.

DISCLOSURES:

The study was supported by the Postdoctoral Research Abroad Program, National Science and Technology Council, Taiwan. The authors have disclosed no relevant financial relationships.

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