Invited Commentary: Stop Analyzing Suicides, Drug-Related Deaths, and Alcohol-Related Deaths Together

Abstract

This article is linked to "Are We Undercounting the True Burden of Mortality Related to Suicide, Alcohol Use, or Drug Use? An Analysis Using Death Certificate Data From Colorado Veterans" and "Adams et al. Respond to “Stop Analyzing ‘Despair’ Deaths Together”" (https://doi.org/10.1093/aje/kwac194 and https://doi.org/10.1093/aje/kwad004).

Editor’s note: The opinions expressed in this article are those of the author and do not necessarily reflect the views of the American Journal of Epidemiology.

There is a notable phrase missing from the accompanying article by Spark et al. (1): “deaths of despair.” With data on Colorado veterans, the authors demonstrated that analyzing underlying causes of death, rather than multiple (or contributing) causes of death, undercounts the full burden of mortality related to suicide, alcohol use, or drug use. They further argued that “a lack of consensus remains regarding which causes of death should be included when looking at these 3 types of deaths together” (1, p. 721) and that “developing a case definition for suicide, alcohol-related, and drug-related deaths is required to improve the quality and validity of emerging research” (1, p. 729). However, the authors do not adequately account for the historical context of these analyses, in which these causes have often been analyzed collectively within the umbrella term “deaths of despair.” Several critiques of “deaths of despair” have pointed out important reasons why the 3 causes should not be analyzed collectively.

“Deaths of despair” garnered mass public attention when Case and Deaton (2) argued that rising middle-aged mortality among White Americans was largely due to suicide and drug- and alcohol-related mortality. Case and Deaton argued that these trends were the result of growing social and economic distress in this population. Their conclusions and analytical approach have been critiqued, with some disputing the term “deaths of despair” and the strategy of analyzing these causes of death together (e.g., see Masters et al. (3)). Subsequent research has consistently found different patterns for each of the 3 causes of death, calling into question the presence of a common underlying driver.

One important cause is the opioid epidemic that Spark et al. mentioned (1), an epidemic comprised of 3 waves: 1) the widespread availability and marketing of prescription painkillers over the last several decades and the subsequent waves of 2) heroin and 3) fentanyl use (4). Drug-related mortality increased steeply beginning in the late 1990s, continuing to rise to the highest rates ever observed in 2021 (4). In contrast, suicide mortality, also highlighted by Spark et al. (1), increased slowly across the late 1990s and early 2000s, with more rapid increases beginning in 2006 (5). Finally, alcohol-related mortality has also been slowly increasing since 1999, but has been concentrated in persons aged 25–64 years (6), albeit less so for younger cohorts (7). Simon and Masters (8) provide explicit evidence that suicides and drug- and alcohol-related deaths do not move together temporally or spatially in US counties. This is supported by research showing distinct period and cohort trends for the 3 causes of death (7). The spatiotemporal differences for each of the 3 causes indicate different underlying drivers and mechanisms for each.

Despite evidence that these 3 causes of death do not trend together, research in both the United States and worldwide continues to analyze these causes together (e.g., see King et al. (9)). While Spark et al. (1) do not explicitly use the term “deaths of despair,” their work perpetuates the concept by analyzing the 3 underlying causes of death together and arguing for an expanded and consistent case definition for the 3 causes combined. While this is perhaps unintentional, their analysis highlights a need to move beyond a crude conceptualization of these causes of death as representing the same underlying phenomenon with the same underlying drivers.

I am not disputing the existence of despair; there is plenty of research showing rising rates of mental health duress in the United States (10, 11). What I am disputing is the persistent and problematic linear relationship that is often theorized as existing between despair and “deaths of despair.” Analyzing these 3 causes in tandem and labeling them as “deaths of despair” contributes to the inference that these causes of death are inextricably linked to one another and to despair. The association that ensues when the phrases “despair mortality” and “deaths of despair” are used is that of individual suffering that results in death. This does occur in some instances, but it is not the only reason for the rising numbers of deaths from drug and alcohol use and suicide.

To that end, I urge all researchers to stop analyzing suicide, drug-related mortality, and alcohol-related mortality as a joint outcome.

ACKNOWLEDGMENTS

Author affiliations: Leverhulme Centre for Demographic Science; Department of Sociology, Social Sciences Division; and Nuffield College, University of Oxford, Oxford, Oxfordshire, United Kingdom (Andrea M. Tilstra).

This work was funded by the Leverhulme Trust and the European Research Council (Leverhulme Trust Large Centre Grant ERC-2021-CoG-101002587).

I thank Antonino Polizzi, Prof. Dr. Jennifer Beam Dowd, and Prof. Dr. Ridhi Kashyap for their comments on an earlier version of this article.

Conflict of interest: none declared.

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