Geography of Despair

"Deaths of despair"–or deaths from stress-related conditions, such as suicide and drug overdose–are highest among rural counties and counties experiencing economic distress.

map depicting the probability of deaths of despair by county

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“Deaths of despair” – the term captures death rates from stress-related conditions like suicide, drug overdose, and alcohol-related diseases that seem to trend together.

The increase in U.S. midlife mortality that occurred from 1999-2013 was attributed to such deaths. But the worsening mortality figures were largely isolated to White Americans, who in surveys were reporting greater mental pain.

These conditions appeared most often in persons with low levels of education, perhaps due to worsening labor and economic prospects. As a result, additional research has explored underlying factors that may impact the larger mortality trend, such as economic insecurity at the county level.

Jong Hyung Lee and colleagues analyzed social determinants of health at the county-level. The authors compiled population and mortality data from the National Center for Health Statistics, mapped county-level changes from 2004-2016, and identified counties with higher risk of deaths of despair than the U.S. national average.

The figure above identifies hotspots of deaths of despair clustered in parts of Appalachia, California, Florida, the Southwest, Oklahoma, and the Pacific Northwest.

Rural counties and counties experiencing more economic distress (i.e., lower rates of health insurance access, educational attainment, and employment) demonstrated higher risk of death. Conversely, counties with greater populations of Hispanic and Black individuals and more educational attainment had lower risk.

The authors note prior work suggesting that communal and social support (such as health care, education, etc.) may act as a buffer against the effects of stress. They also note the importance of understanding substance use as a method to cope with stress. Critics of the “deaths of despair” framing argue that grouping drug mortality with other deaths minimizes the role of the drug environment (i.e., the availability and cost of substances).

Lee and colleague’s research is an important step in addressing the complexity of suicides and drug-related deaths. By focusing on county-level characteristics, prevention and intervention programs can target specific localities more efficiently.

Databyte via Jong Hyung Lee, David C. Wheeler, Emily B. Zimmerman, et al. Urban–Rural Disparities in Deaths of Despair: A County-Level Analysis 2004–2016 in the U.S. American Journal of Preventive Medicine, 2023.