How Understanding Deaths of Despair Can Change Psychiatry

In JAMA Psychiatry, researchers argue that a 'deaths of despair' framework requires a move beyond traditional psychiatric diagnosis.

Gavin Crowell-Williamson
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A pair of international researchers, Lilly Shanahan from the University of Zurich in Switzerland and William Copeland from the University of Vermont, recently released an opinion piece in JAMA Psychiatry on psychiatry’s understanding of ‘deaths of despair.’

The term ‘deaths of despair’ came from a 2015 paper hypothesized that the rising premature mortality rate in middle-aged, non-Hispanic, white individuals with low education due to suicide, drug poisoning, and alcoholic liver disease was a manifestation of hopelessness regarding challenging social and economic circumstances.

This framework has resulted in research in several different areas, which uncovered other findings: there is also rising premature mortality in other demographic populations; there are other causes of premature mortality such as hypertension or diabetes; causes of death implicated in deaths of despair did not always lead to premature mortality, and trends differ across region and sex. This has complicated the proposed framework.

There has been a dearth of research on deaths of despair within psychiatry, despite studying a number of adjacent phenomena within the field. The authors propose that ‘deaths of despair’ has become an increasingly ubiquitous catch-all for deaths related to economic stagnation, hopelessness, addiction, capitalism, and other related ailments.

They suggest psychiatry as an optimal discipline to study deaths of despair, though it would require moving beyond the traditional frameworks of psychiatric diagnosis. For example, they offer that irritability and suicidal behavior could be studied as not just symptoms of psychiatric disorders but as syndromes worthy of consideration on their own.

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To test the deaths of despair framework, they took data from the Great Smoky Mountains Study, which had a scale of despair. The scale was built on the DSM definitions of dysthymic disorder, major depression, and stand-alone symptoms of despair. There were low mortality rates in the study, so they measured suicidal thoughts and behaviors and drug/alcohol problems, which are hypothesized precursors of deaths of despair.

They found an association between despair and later suicidal thoughts and behaviors as well as illicit drug use, but not alcohol use disorder. More broadly, this and psychiatric research suggests a more complex, multilayered explanation of psychiatric mortality and morbidity. Meanwhile, deaths of despair is a very narrow, monocausal explanation for premature death, ignoring more complex pathways to more complex phenomena such as ACEs, physical health issues, neurobiological vulnerability, and maco-level policies regulating these processes.

To disentangle these processes would be time-consuming and expensive, requiring longitudinal studies and careful consideration of how cultural, sociological, and economic factors interact with biological factors. This will help move beyond reductionist approaches to deaths of despair that psychiatry seems eager to undertake. It will also help address the reality that psychiatric morbidity, disability, and mortality are sizably underestimated by affording psychiatry a more interdisciplinary collaboration and a better understanding the broad burden from psychiatric ailments.

“Deaths of despair have been important for shining the spotlight on the reversal in life expectancy gains,” conclude the authors.
“Psychiatry can sharpen this framework by defining and measuring the construct of despair, sorting out causal chains surrounding it, and infusing deaths of despair’s limited causal view with biological perspectives. In turn, psychiatry would benefit from increasing its focus on societal trends to identify risk groups and macro-level causes that could be targeted for intervention and from developing new methods to assess how psychiatric burden is accurately reflected in disability and mortality statistics. The integration of psychiatric and population models provides an opportunity to enrich psychiatry well beyond deaths of despair and highlights the need for conceptual models that capture the complex interplay of social and biological pathways to suicide and problematic drug and alcohol use.”

 

 

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Shanahan, L., Copeland, W.E. (2021). Psychiatry and Deaths of Despair. JAMA Psychiatry. Published online March 31, 2021. DOI: 10.1001/jamapsychiatry.2021.0256 (Link)

8 COMMENTS

  1. The most well known direct death associated with deaths of despair is opioid deaths.
    Opioids parallel psych drugs near perfectly.
    Opioid drug sellers lied and said the drugs were safe, effective, and non-addicting. None of those were true; long term studies show opioids do not improve pain and likely worsen pain. The drug manufactures coordinated with doctors to push and sell the drugs. Those who refused to get on board were said to be stigmatizing and hurting people with pain. Doctors salaries where linked to making sure they prescribed opioids for pain. Arguing with the science (short term studies designed by the drug sellers to make the drugs look good) resulted in getting insulted or worse.

    The pain was often blamed for negative effects opioids, and more drug prescriptions followed. When negative effects of the drugs were subtly admitted the resulted was another drug to instead of removing the causative agent. Those taken off the drugs went through withdrawal and either needed to go through loads of suffering or keeping taking the drugs falsely labeled as safe. The major difference between psych drugs and opioids is psych drugs don’t get people high with pleasure before addiction kicks in.
    It might be effective to bring up the similarities between opioids and psych drugs when trying to inform people.

  2. I honestly can’t think of a more ill-fated task for psychiatry than to be charged with researching public health outcomes. Psychiatry has been shown to repeatedly ignore evidence in favor of protecting its guild interests and profit center – drugs. What makes anyone think this will change?

    “There has been a dearth of research on deaths of despair within psychiatry”

    That’s because the main function of Psychiatry has been to medicalize normal human suffering and place the “disease” within the individual. This article shows a clear misunderstanding of the role Psychiatry serves in society!

    “there are other causes of premature mortality such as hypertension or diabetes”

    These are also very closely associated with the same environemental conditions that lead to deaths of despair – i.e., poverty, ACEs, etc. It’s hard to comprehend how a thinking person could view them as a confounding factor.

    • They have not researched “deaths of despair” because they don’t recognize despair as a legitimate complaint. There should BE no despair, as far as their model is concerned. Despair is indicative of “illness,” even if it’s caused by being hung upside down in a dungeon and tortured by people who have promised you will never escape. The tortured person should apparently have a better attitude, or else the reason they’re so upset is because their brain chemistry is messed up. If they were “normal,” it would not bother them much to be tortured. They’d just accept it as another one of those crazy things that happen in life!

      • In the HAM D depression and PANSS psychotic scales psychiatry uses to measure mental illness complaining about your health, or physical symptoms is a sign of mental illness. The solution of course is more psych drugs. If the SSRI gives you headaches/stomach problems/physical symptoms it means you are mentally ill and need more psych drugs. Also if someone is concerned about their health and goes out of their way to be healthy it is also a sign of mental illness.

        In the PANSS psychotic scale you can be labeled psychotic simply for disagreeing with psychiatry strongly enough with hostile tones in your disagreement.

      • Psychiatry doesn’t give a rat’s ass about what is actually wrong with someone, whether it’s trauma or poverty or chronic illness. The entire playbook is individual brain disorders and manipulating brain chemistry or neural pathways.

        Let’s have medical interventions where they are warranted – and I mean truly addressing the etiology of illness, not just throwing more drugs at people to shut them up – as well as psychotherapeutic interventions where warranted and desired. A general approach of healing and empowerment would be leagues better than the rotten mess we have now.

  3. Psychiatry can sharpen this framework by defining and measuring the construct of despair, sorting out causal chains surrounding it, and infusing deaths of despair’s limited causal view with biological perspectives. In turn, psychiatry would benefit from increasing its focus on societal trends to identify risk groups and macro-level causes that could be targeted for intervention

    Ah yes, what we need to address despair is for psychiatry to ‘sharpen’ our understanding of its causes with biological perspectives that dispense with all those messy, blunt notions that it could be caused by factors other than defects in the sufferer. But we should still look at societal correlates of despair to better target people with non-societal interventions grounded in psychiatry’s biological perspectives (i.e. drug the despair out of them).

    Nothing beats psychiatry when it comes to despair, eh?

    • Why would we want to “infuse” the view of despair with “biological perspectives?” Sounds like what they already do, and with horrible results. How about they let the actual sufferers “infuse” psychiatrists’ views with human and compassionate perspectives?

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