Defeating the diseases of despair

The growth of the noninfectious diseases—mental illness, cancer, diabetes, heart disease—and the decline of the infectious diseases is a well-known, long-term, worldwide phenomenon related to economic development. Much less well-known is the more recent emergence of the “diseases of despair”—deaths due to suicide, alcohol liver cirrhosis, and opioid overdoses. Although small (40 deaths per 100,000 per year) in comparison with the overall U.S. death rate (725 deaths per 100,000 per year), death rates due to these diseases currently are growing. And opioid-related deaths actually are spiking in an epidemic that is now termed a crisis.

Two major causal mechanisms likely are involved.

• First, we already know that noninfectious diseases are linked closely with the social and physical determinants of health in developed countries, such as poverty, discrimination, poor education, social exclusion and dirty, dangerous environments. In fact, our current knowledge suggests that more than three-quarters of all behavioral health conditions are due to the trauma that arises from exposure to adverse social and physical determinants of health.
• Second, according to the World Health Organization, depression became the leading cause of disability in the world during 2010. Thus, it is quite reasonable to assume that underlying depression plays a huge role in the growth of deaths due to the diseases of despair.

A little reflection will suggest that depression and personal pessimism co-occur very frequently. Personal pessimism can arise from a broad range of factors depending upon the particular social determinants to which one has been exposed. These factors include our long-term wars in Iraq, Afghanistan, and Syria; the Great Recession and its sequelae; the growing inaccessibility of a college education due to cost escalation; deep-seated urban and rural problems; majority-minority conflicts; and the continuing slide of the middle class, among others.

Urgent need

A major question is what we can do to defeat the diseases of despair.

If we assume that the causal sequences outlined above are accurate, then an urgent need exists to address the adverse social and physical determinants of health that are causing the rise in the diseases of despair and the ensuing increases in death rates. Further, despite what some have observed, it also seems quite clear that the diseases of despair are not restricted only or primarily to white, middle-aged males but also affect most subgroups in the U.S. population.

To put a direct point on it: Improving the social and physical determinants of health in a person’s life is the vaccination needed to prevent the diseases of despair. Hence, such actions are fundamental to prevention. In a future commentary, I will discuss innovative work being undertaken to address the social and physical determinants of health that lead to the diseases of despair.

It won’t be possible, however, to address the underlying social and physical determinants in every circumstance. In such cases, it will be very important to increase resiliency. Building strong, engaging and reliable social support networks of neighbors, peers and mentors can do much to enhance resilience.

The diseases of despair are diseases of aloneness and isolation. Unfortunately, aloneness and isolation are growing phenomena in American society. Approximately 4 in 10 adults now live alone. Further, although our new urban communities bring people together, they frequently don’t foster ongoing relationships. Thus, it is not surprising that the diseases of despair are becoming more prevalent.

For those already in the grips of depression, good care can be made available. We do know that depression is eminently treatable, and that most people do recover when they receive good care.

Last Monday, the interim report of the president's opioid commission was released for comment. As you reflect on that report, please also examine the diseases of despair in your own community. Is the mortality rate in your community due to these diseases above or below the national average of 40 deaths per 100,000 per year? What are the sources of despair in your community?  What can you do to address them?