Augarde, Gunnell, and colleagues examine in Social Psychiatry and Psychiatric Epidemiology temporal trends in ‘deaths of despair’ in England and Wales [1]. Their findings, using data from 2001–2018, do not support the apparent concordance of mortality patterns involving drug and alcohol poisonings, suicides, and longer-term systemic alcohol-related fatalities described for white men and women in the United States (US) by Case and Deaton in their recent book and prior work [2,3,4].

In this new report, data for England and Wales were drawn from WHO (2001–2016) to calculate age standardized, sex-specific trends in mortality from alcohol-related disorders, suicide, and drug poisoning. Augarde, Gunnell, and colleagues also averaged mortality rates from local governmental authorities in England (2016–2018) to assess whether temporal trends co-varied with one another. Case and Deaton had found that mortality for these conditions had risen nearly in lockstep in the US, while demonstrating associations with a variety of factors that could contribute to psychosocial distress—i.e., social determinants that can contribute to distressed psychological states, which in turn may lead to drug and alcohol misuse—and despair—and set the stage for premature deaths. In contrast to the results from the US, Augarde et al. detected “limited tracking” of mortality trends from 2001–2016. While alcohol associated conditions accounted for the largest proportion of deaths (men = 44.0%; women = 56.5%), their rates rose in a relatively modest fashion for men (10.8%) and women (7.4%), in contrast to substantial increases in drug-related deaths for both sexes (men = 104.9%; women = 61.9%). During this same time, suicide increased to a much lower degree (men = 2.8%; women = 6.9%). For the years 2016–2018, the authors found considerable variation in mortality outcomes across local governmental authorities in England. At most, correlations among rates were modest.

These results do not imply that social factors are not important influences on different forms of premature mortality or that these deaths may share common antecedent exposures and risk factors. They do underscore, however, that what may be true for mortality patterns in the US may not be true for patterns of death in other countries.

“Deaths of Despair”: what are they?

When I first read the paper by economists Anne Case and Angus Deaton in December 2015, I wondered: Aren’t nearly all suicides ‘deaths of despair’? Their terminology quickly caught public notice with its attention to social factors associated with decreasing life expectancy in the US. The latter apparently was driven by increased mortality rates among white men and women, particularly those in the middle years of life who had no post-secondary education—specifically related to fatal drug use and alcohol consumption, and suicide. While the aggregate of these deaths had been rising steadily for more than two decades, the impact had been obscured largely by decreasing deaths due to vascular diseases. Case and Deaton also demonstrated that their finding was more than a cohort effect; increased mortality rates also were apparent in younger generations of less educated individuals. Of note, early consideration of their findings roused considerable debate, as they focused exclusively on whites—it was their mortality trends that had contributed to the decrease in US life expectancy. Subsequent reports using additional data from later years described decreasing life-expectancy that cut across ethnic and racial categories [5], as opioid-related deaths spread from more rural areas to urban centers.

It is important to understand the nature of Case and Deaton’s approach, which Augarde et al. followed to assess whether findings from the US were replicable in England and Wales. The authors undertook broadly based population analyses where it is possible to study patterns and associations, but gain only inferential insight into causes or mechanisms. A careful scrutiny of the choice of conditions reveals its implicit challenges and limitations. Case and Deaton combined data involving acute causes of death—fatal drug/alcohol poisoning and suicide—and fatalities arising from longer term exposure to alcohol. In one instance, persons die of a “chronic” disease; for the others, their demise reflects immediate instrumental actions on the day of death.

Such an approach is challenged by data derived from longitudinal studies of persons presenting to emergency care for both self-harm [6] and opioid overdose [7], which revealed high levels of premature deaths following index contact, whether measured by years of life lost [6] or by standardized mortality ratios [7]. While the rates of subsequent substance-related fatalities and suicide were greatly elevated, the majority of decedents suffered common medical conditions (e.g., vascular diseases, cancers, infections), apparently reflecting the effects of adverse health behaviors, including drinking, drug use, and smoking. With these results in mind, it is not possible to draw a clear distinction between ‘deaths of despair,’ as denoted by Case and Deaton, and the diverse array of conditions associated with premature mortality among substance using and suicidal populations. ‘Deaths of despair’ have few precise clinical boundaries! Indeed, Neeleman and colleagues described more than two decades ago a continuum of premature mortality including “natural” causes as well as suicide (an example of multi-finality) among persons experiencing psychosocial distress and among those bearing risk factors typically associated with suicide [8, 9].

Common roots, diverse outcomes

Standing back from the work of Case and Deaton, and considering the results from Augarde, Gunnell et al. it is not so surprising that findings from England and Wales do not replicate those from the US. After all, these authors together are studying mortality outcomes that reflect what now are labeled as “social determinants” of disease. And one would expect that such factors will differ greatly from country to country; for example, including measures of income/wealth inequality, access to medical care and treatment for addictions, housing support, education, and unemployment insurance. Throughout the twenty-first century, England and Wales have implemented and evaluated initiatives to prevent suicide that have demonstrably saved lives [10]. Moreover, the US has experienced a more than two-decade, ceaseless rise of opioid-related fatalities that has no comparison internationally.

Mortality diversity and diverging trends of premature deaths do not mean that there are no strategies that can be deployed to ameliorate common risk factors. Suicide prevention initiatives worldwide tend to focus on suicidal and “high risk” persons; few, however, utilize upstream strategies to prevent persons from becoming suicidal [11]. Such approaches necessarily must address social and community factors, as well as family and individual level risks such as substance misuse. In the process they have the potential to prevent a diverse array of outcomes. Further downstream, it is evident that we need to deploy efforts that more specifically meet the needs of individuals on a path to imminent death. Without a combination of such approaches, it is unlikely that we can fundamentally alter the burdens of non-communicable conditions that have become ever more present during the past 75 years.