Adams et al. Respond to “Stop Analyzing ‘Despair’ Deaths Together”

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 "Invited Commentary: Stop Analyzing Suicides, Drug-Related Deaths, and Alcohol-Related Deaths Together" (https://doi.org/10.1093/aje/kwac194 and https://doi.org/10.1093/aje/kwad002).

We appreciate Dr. Tilstra’s invited commentary (1) on our article (2). However, Dr. Tilstra incorrectly asserts that our advocating for standardized case definitions for suicide, alcohol-related, and drug-related mortality “implies that they should be analyzed together”’ as a “joint outcome” (1, p. 732). Our main aims were to examine how using a restrictive definition to capture deaths due to suicide, alcohol use, or drug use (i.e., the death certificate, underlying cause of death only) may be undercounting the burden of such deaths. Thus, we compared an underlying-cause-of-death–only definition with a more inclusive definition (i.e., multiple-cause-of-death indicators), with the goal of providing empirical findings to guide future research. Because of evidence-related challenges regarding the concept of “deaths of despair,” we intentionally omitted this term from our study, as Tilstra correctly noted (1). Nonetheless, this does not diminish the importance of examining how these types of mortality may be intertwined.

Tilstra described alarming trends of increasing suicide, drug-related, and alcohol-related deaths, yet noted that “research has consistently found different patterns for each of the 3 causes of death, calling into question the presence of a common underlying driver” (1, p. 732). We concur that the existence of one common driver (e.g., despair) for deaths related to these causes is highly unlikely. It is well established that suicide, alcohol-related, and drug-related mortality have multifaceted risk and protective factors, and “despair” is likely one of many potential drivers. Moreover, even though trends in suicide and alcohol- and drug-related deaths do not always co-occur within the same time periods and/or geographic regions, long-term temporal overlap in trends for the three is certain (3). Additionally, we suggested that given differential latency periods between initiation of drug and alcohol use and negative health outcomes (e.g., opioid overdose, alcoholic liver disease), risk for these types of mortality may overlap even if time to a specific type of mortality may differ (2).

We also asserted that to explore whether there are at-risk groups who share common underlying drivers of suicide-, alcohol-, and drug-related mortality, appropriate and valid case definitions should be considered for nuanced analyses. Mortality risk for some individuals may accumulate based on overlapping factors (e.g., alcohol and drug use increasing risk for suicide). Studies have shown that approximately 25% of suicide deaths and 15% of drug overdose deaths involve alcohol (4–7). Further, in 2017 alone, over 40% of overdose and suicide deaths involved an opioid, demonstrating how these types of mortality are often interrelated (8, 9). Recently, the directors of the National Institute of Mental Health (NIMH), the National Institute on Drug Abuse (NIDA), and the National Institute on Alcohol Abuse and Alcoholism discussed these types of mortality as being intertwined (4, 10). The NIMH and NIDA directors highlighted challenges associated with determining intent for death and stated, “Concealed in the alarming number of overdose deaths is a significant number of people who have decided to take their own life” (10). This is also likely true among some people whose deaths are determined to be alcohol-related (11). Thus, conducting research that considers how these types of mortality may be intertwined is imperative.

Our study aims were conceptualized as a preliminary but important step in identifying approaches to aggregating and disaggregating populations who died by suicide, alcohol-related causes, or drug-related causes. Indeed, we found that alcohol-related mortality doubled when using a more inclusive case definition. Studies that examine these types of mortality and consider multiple-cause-of-death indicators may ultimately 1) allow researchers focused on an individual cause of death to more comprehensively capture information regarding the outcome of interest; 2) increase understanding regarding how these types of death are intertwined (e.g., potential shared risk and protective factors); and 3) inform the development of public health and clinical interventions to reverse troubling mortality trends.

ACKNOWLEDGMENTS

Author affiliations: Author affiliations: Rocky Mountain Mental Illness Research Education and Clinical Center (MIRECC) for Veteran Suicide Prevention, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, United States (Rachel Sayko Adams, Talia L. Spark, Claire A. Hoffmire, Jeri E. Foster, Lisa A. Brenner); Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Boston, Massachusetts, United States (Rachel Sayko Adams); Department of Physical Medicine and Rehabilitation, Anschutz School of Medicine, University of Colorado, Aurora, Colorado, United States (Talia L. Spark, Claire A. Hoffmire, Jeri E. Foster, Lisa A. Brenner); Injury and Violence Prevention Center, Colorado School of Public Health, University of Colorado, Aurora, Colorado, United States (Talia L. Spark, Lisa A. Brenner); Department of Psychiatry, Anschutz School of Medicine, University of Colorado, Aurora, Colorado, United States (Lisa A. Brenner); and Department of Neurology, Anschutz School of Medicine, University of Colorado, Aurora, Colorado, United States (Lisa A. Brenner). R.S.A. is now affiliated with the Department of Health Law, Policy, and Management at Boston University School of Public Health, Boston, Massachusetts, United States.

This work was supported by the US Department of Veterans Affairs, Rocky Mountain MIRECC for Veteran Suicide Prevention.

The views expressed in this article are those of the authors and do not necessarily represent the views or policy of the Department of Veterans Affairs or the US government.

T.A.S. reports employment with Westat, Inc. (Rockville, Maryland). R.S.A. reports receiving grants from the National Institutes of Health and the Henry M. Jackson Foundation for the Advancement of Military Medicine (Bethesda, Maryland) on behalf of the Uniformed Services University of the Health Sciences. She consults for The Informatics Applications Group (TIAG; Reston, Virginia) in support of the National Intrepid Center of Excellence at Walter Reed National Military Medical Center. C.A.H., J.E.F., and L.A.B. report receiving grants from the Department of Veterans Affairs, the US Department of Defense, and the National Institutes of Health. J.E.F. and L.A.B. additionally report receiving grants from the state of Colorado. L.A.B. reports receiving editorial renumeration from Wolters Kluwer N.V. (Alphen aan den Rijn, the Netherlands) and the RAND Corporation (Santa Monica, California) and royalties from the American Psychological Association (Washington, DC) and Oxford University Press (Oxford, United Kingdom). In addition, she consults with sports leagues via her university affiliation.

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