Wikipedia Deep Dive

Disease of despair

12 min read

In 2018, roughly 158,000 Americans died from drug overdoses, suicides, and alcoholic liver disease—nearly two and a half times the 65,000 who died from these same causes in 1995. This surge didn't happen because of some new virus or environmental toxin. It happened because millions of people lost hope.

Economists Anne Case and Angus Deaton, who won the Nobel Prize for their work on poverty and welfare, coined a term for this phenomenon: deaths of despair. It's a phrase that sounds almost literary, like something from a Victorian novel. But the reality behind it is grimly modern and distinctly American.

What Despair Actually Looks Like

Before we can understand how despair kills, we need to understand what despair actually is—and it's more complex than simple sadness.

Researchers have identified four distinct types. Cognitive despair lives in your thoughts: a persistent sense of defeat, guilt, and pessimism that makes you discount the value of anything that might happen years from now. Why save for retirement if you don't believe you'll make it there? Why study for a degree if you're convinced it won't matter?

Emotional despair is the feeling layer: sadness, irritability, loneliness, and that peculiar numbness called apathy. It corrodes your ability to form and maintain relationships, cutting you off from the very connections that might save you.

Then there's behavioral despair—the visible symptoms. Reckless driving. Unprotected sex with strangers. Self-harm. Drug use. These aren't random acts of self-destruction; they're the logical behavior of someone who has stopped believing in their own future.

Finally, biological despair: the body itself begins to malfunction. Stress hormones flood the system without relief. Sleep becomes impossible or inescapable. The body's regulatory systems, designed for occasional emergencies, get stuck in permanent crisis mode.

Live under these conditions long enough, and you develop what Case and Deaton call a "disease of despair"—meaning you become addicted to drugs or alcohol, or you begin contemplating suicide. And from disease, you progress to death.

An Epidemic Hidden in Plain Sight

For decades, the American mortality story was one of steady improvement. Between 1970 and 2013, death rates for middle-aged Americans fell by 44 percent. Cancer treatments improved. Heart disease became more manageable. The AIDS crisis, after devastating a generation, came under control. Even elderly Americans were living longer, healthier lives.

Then something strange happened to one particular group.

Starting around 1998, middle-aged white Americans without college degrees began dying at increasing rates. Not from cancer or heart disease—those continued declining. They were dying from overdoses, from suicide, from the slow self-destruction of alcoholic liver disease.

This was unprecedented. In every other wealthy country—Sweden, the United Kingdom, Australia, Japan, Germany—mortality rates for this age group continued falling by about two percent annually. African Americans and Hispanic Americans in the United States also continued their decades-long improvement in life expectancy.

But working-class white Americans started dying younger.

By 2015, white Americans aged 50 to 54 with only a high school diploma had a mortality rate of nearly 1,000 per 100,000—double the average for all white Americans regardless of education. The gap wasn't subtle. It was a chasm.

Geography of Despair

The deaths weren't evenly distributed across the map. They clustered in places like Appalachia—particularly Pennsylvania, West Virginia, and Delaware. They concentrated in rural areas, in small towns where the factory closed years ago and nothing replaced it, in communities where the mine shut down and the young people left.

Between 1999 and 2015, the rate of deaths of despair in rural areas among white Americans aged 30 to 44 increased at twice the rate of other causes of death. Rural death rates for all ethnicities among working-age adults rose six percent overall during this period.

These weren't just abstract statistics. They represented entire communities unraveling. Churches with shrinking congregations. Main streets with boarded-up storefronts. Schools consolidating because there weren't enough children left. A sense, pervading everything, that the best days were behind them and would never return.

The Racial Complexity

Early attention to deaths of despair focused almost exclusively on white Americans, but the full picture is more complicated—and more troubling.

In 2024, researchers Joseph Friedman and Helena Hansen at the University of California, Los Angeles, published findings that fundamentally challenged the narrative. African American deaths of despair, they argued, had been extensive for years but largely ignored by policymakers, the medical establishment, and the media.

The numbers for Native Americans and Alaska Natives were even more stark. In 2022, their midlife death rate from despair was 241.70 per 100,000 people—more than twice the rate among white Americans. Their drug overdose rate hit 104.95 per 100,000, compared to 84.80 for Black Americans and 59.26 for white Americans. Most striking of all: their rate of alcoholic liver disease was 108.83 per 100,000, more than six times the white rate of 17.92.

These disparities had been hiding in plain sight for decades. The pattern among white Americans only became newsworthy because it represented a reversal—things getting worse for a group accustomed to things getting better. For Native Americans, devastation had been the baseline for generations.

By 2022, Hispanic Americans were also catching up to the elevated rates seen among white and Black populations. The epidemic was spreading.

Why America?

Here's the puzzle that haunted Case and Deaton: globalization and technological change affected every wealthy country. Factory jobs disappeared in Germany and France just as they did in Ohio and Pennsylvania. Automation replaced workers in Japan and Australia just as it did in Michigan and West Virginia.

But the deaths of despair remained overwhelmingly American.

In 2015, drug, alcohol, and suicide mortality among white Americans was more than double the rate seen in the United Kingdom, Sweden, or Australia. Other rich countries faced similar economic disruptions, yet their citizens weren't dying of hopelessness at anywhere near the same rate.

Case and Deaton's explanation comes down to a fundamental difference in how America organizes its society. In the United States, they argue, globalization and technological change shifted power dramatically toward capital and away from labor. Corporations grew stronger. Labor unions grew weaker. Wages stagnated for decades while corporate profits soared.

European countries, facing similar pressures, maintained stronger social safety nets. Universal healthcare meant a job loss didn't mean losing access to doctors. Unemployment insurance was more generous and lasted longer. Labor unions retained political power. The welfare state, while fraying at the edges, still provided a floor beneath which citizens couldn't fall.

In America, that floor had holes—and people fell through them.

The Meaning Problem

But economic security alone doesn't explain everything. Case and Deaton point to something deeper: a crisis of meaning.

African Americans with college degrees experienced even steeper percentage declines in income after 1999 than white Americans with similar education. Yet Black mortality rates continued falling steadily, by two to three percent annually across all age groups. Economic hardship alone couldn't explain who was dying and who wasn't.

The difference, Case and Deaton suggest, lies in expectations and trajectory. Working-class white Americans in the late twentieth century could reasonably expect their lives to follow a certain script: graduate high school, get a job at the plant or the mine, marry, buy a house, raise kids, retire with a pension. Their parents had lived this life. Their grandparents had lived this life.

When that script stopped working—when the plant closed, when the pension disappeared, when the marriage fell apart under financial stress—they experienced not just hardship but betrayal. The rules they'd followed had stopped applying.

African Americans and other minority groups, by contrast, had never been promised that script in the first place. Their relationship to American institutions had always been more complicated, more skeptical. When conditions worsened, they weren't falling from an expected height; they were facing familiar obstacles. Studies suggested they were also more likely to perceive themselves as doing better than their parents, even in objectively similar economic circumstances.

This may explain why diseases of despair differ from diseases of poverty. Impoverished people who believe their lives or their children's lives will improve don't succumb to despair at the same rates. It's not the hardship itself that kills. It's the hopelessness.

The Opioid Accelerant

Deaths of despair might have remained a slow-burning crisis if not for a catastrophic accelerant: synthetic opioids.

The opioid crisis has its own complex history, beginning with aggressive marketing of prescription painkillers like OxyContin in the 1990s, continuing through a wave of heroin use as prescriptions became harder to obtain, and culminating in the flood of synthetic fentanyl that began around 2013.

Between 2010 and 2019, annual overdose deaths in the United States doubled. Fentanyl, roughly 50 to 100 times more potent than morphine, made every dose a game of Russian roulette. Users couldn't know how much they were taking. Dealers couldn't precisely measure what they were selling. The margin between getting high and dying narrowed to almost nothing.

The opioid crisis and deaths of despair aren't identical phenomena, but they're deeply intertwined. Despair creates the demand—the need to escape, to numb, to feel something other than hopelessness. The drug supply, increasingly saturated with fentanyl, makes meeting that demand increasingly lethal.

Social Disintegration

Despair doesn't just affect individuals. It unravels the social fabric that might otherwise protect them.

People at risk for deaths of despair are less likely to get married and more likely to get divorced. They experience higher rates of social isolation. The very connections that might provide meaning, support, and reasons to keep going dissolve under the pressure of economic stress and psychological distress.

This creates a vicious cycle. Economic displacement leads to social disconnection. Social disconnection removes the buffers against despair. Despair leads to addiction, self-harm, or suicide. Each death ripples outward, traumatizing survivors, breaking up families, removing role models from communities already short on hope.

The decline of labor unions removed not just economic protections but social ones. Unions were gathering places, sources of identity and solidarity. The local lodge, the union hall, the company softball team—these institutions gave working people places to belong. When they disappeared, nothing replaced them.

Churches, once the backbone of community life in many affected areas, also declined. Some scholars point to the rise of social media and digital entertainment as contributing factors, replacing in-person connection with the thin gruel of online interaction. A 2016 study found that social media use was significantly associated with increased depression.

The Pandemic's Toll

Then came COVID-19.

The pandemic functioned as a stress test for American society, and the results were grim. Deaths of despair increased sharply, rising between 10 and 60 percent above pre-pandemic levels depending on the measure and location.

The mechanisms were painfully clear. Lockdowns and social distancing requirements intensified isolation. Job losses mounted. Housing and food insecurity spiked. The biopsychosocial risk factors that researchers associate with despair—financial stress, housing precarity, social disconnection—all surged simultaneously.

Life expectancy in the United States fell to 76.4 years in 2021, with drug overdoses, suicides, and liver disease driving the decline alongside COVID-19 itself. A preliminary review of 70 studies across 17 countries found that women, ethnic minorities, and younger age groups may have suffered disproportionately.

In Milwaukee County, Wisconsin, researchers documented a remarkable acceleration of the opioid crisis during the pandemic. Monthly overdose deaths increased by 12, with the worst impacts concentrated in poor, urban, Black and Latino neighborhoods. Even wealthy white suburbs saw increases, though smaller ones.

Drug overdose deaths in both Canada and the United States had been climbing before COVID-19, but the pandemic accelerated the trajectory. In Canada, where overdose deaths had begun to stabilize, they shot upward again after March 2020. In the United States, an already-rising curve bent further upward.

The Path Forward

By 2022, American suicides reached record levels, with 49,369 deaths. Since 2011, roughly 540,000 people had died by suicide in the United States alone. Life expectancy for working-class Americans without college degrees peaked in 2010 and has been declining ever since—adult life expectancy after age 25 falling from 51.6 additional years in 1992 to 49.8 years today.

Some scholars have characterized deaths of despair as "social murder"—the predictable result of austerity policies, privatization, and the systematic dismantling of institutions that once provided security and meaning to working people. Others resist this framing, pointing to the complexity of the phenomenon and the difficulty of isolating any single cause.

What seems clear is that the crisis won't be solved by any single intervention. Better addiction treatment helps. Expanded access to mental healthcare helps. Economic policies that raise wages and strengthen labor protections might help. But addressing deaths of despair ultimately requires rebuilding something harder to quantify: a sense that the future holds something worth living for.

Case and Deaton argue that contemporary capitalism, at least in its American form, has fundamental flaws that produce despair as a byproduct. The ideology of neoliberalism—the belief that markets should be freed from all restrictions and government assistance programs reduced or eliminated—has created winners and losers. The winners are doing spectacularly well. The losers are dying.

The question facing American society is whether it can muster the political will to address this crisis before more generations succumb to it. The answer remains unclear. What's certain is that the deaths continue, quietly, in towns and neighborhoods across the country—each one a human being who ran out of reasons to believe tomorrow might be better than today.