Defining despair: Assessing the multidimensionality of despair and its association with suicidality and substance use in early to middle adulthood

Are employment and social integration more strongly associated with deaths of despair than psychological or economic distress?

The label "deaths of despair" for rising US mortality related to drugs/alcohol/suicide seems to implicate emotional distress as the cause. However, a Durkheimian approach would argue that underlying structural factors shape individuals' behavior and emotions. Despite a growing literature on deaths of despair, no study has directly compared the effects of distress and structural factors on deaths of despair versus other causes of mortality. Using data from the Midlife in the United States study with approximately 26 years of mortality follow-up, we evaluated whether psychological or economic distress, employment status, and social integration were more strongly associated with drug/alcohol/suicide mortality than with other causes. Cox hazard models, adjusted for potential confounders, showed little evidence that psychological or economic distress were more strongly associated with mortality related to drugs/alcohol/suicide than mortality from other causes. While distress measures were modestly, but significantly associated with these deaths, the associations were similar in magnitude for many other types of mortality. In contrast, detachment from the labor force and lower social integration were both strongly associated with drug/alcohol/suicide mortality, more than for many other types of mortality. Differences in the estimated percentage dying of despair between age 25 and 65 were larger for employment status (2.0% for individuals who were neither employed nor retired versus only 0.6% for currently employed) and for social integration (1.9% for low versus 0.7% for high integration) than for negative affect (1.2% for high versus 0.8% for no negative affect). Most of the association between distress and drug/alcohol/suicide mortality appeared to result from confounding with structural factors and with pre-existing health conditions that may influence both the perception of distress and mortality risk. While deaths of despair result from self-destructive behavior, our results suggest that structural factors may be more important determinants than subjective distress.

The World of Women's Despair: An Unfolding Unitary Conceptual Journey

In looking back over 3 decades since the development of his interest in developing a unitary conceptualization of despair, nurse scholar W. Richard Cowling, III, had new insights and revelations. The purpose of this dialogue article is to re-envision this journey as one of unfolding, seen with the gift of new eyes. Revisiting this journey allowed him to understand and appreciate it anew. Horizons of possibilities of this conceptual journey are explained in terms of conceptual-theoretical development, inquiry, and the advancement of discipline-specific knowledge, and improving the lives of women in despair. It is his sincere hope, as with all meaningful scholarly endeavors, that a wider discourse occurs with the persistent inclusion of women's voices and experiences.

Trends in Suicides and Homicides in 21st Century America

BACKGROUND

Violent deaths, including suicides and homicides, pose a significant public health challenge in the United States. Understanding the trends and identifying associated risk factors is crucial for targeted intervention strategies.

AIM

To examine the trends in suicides and homicides over the past two decades and identify demographic and contextual predictors using the Center for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System online database.

METHODS

A retrospective analysis of mortality records from 2000 to 2020 was conducted, utilizing multivariate regression analyses. Covariates included age, race, sex, education, mental health conditions, and time period. Age-adjusted rates were employed to assess trends.

RESULTS

Over the 20 years, there was an upward trajectory in suicide rates, increasing from approximately 10/100,000 to over 14/100,000 individuals, which is a notable increase among American Indians (100.8% increase) and individuals aged 25 years and younger (45.3% increase). Homicide rates, while relatively stable, exhibited a significant increase in 2019-2020, with African Americans consistently having the highest rates and a significant increase among American Indians (73.2% increase). In the multivariate regression analysis, Individuals with advanced education (OR= 1.74, 95% CI= 1.70 - 1.78), depression (OR = 13.47, 95% CI = 13.04 - 13.91), and bipolar disorder (OR = 2.65, 95% CI = 2.44 - 2.88) had higher odds of suicide. Risk factors for homicide include African Americans (OR = 4.15, 95% CI = 4.08 - 4.23), Latinx (OR = 2.31, 95% CI = 2.26 - 2.37), people aged 25 years and younger, and those with lower educational attainment.

CONCLUSION

This study highlights the changing demographic pattern in suicides and homicides in the United States and the need for targeted public health responses. Means restriction, universal suicide screening, addressing mental health stigma, and implementing broad interventions that modify societal attitudes toward suicide and homicides are essential components of a comprehensive strategy.

Institutional Failures as Structural Determinants of Suicide: The Opioid Epidemic and the Great Recession in the United States

We investigate recent trends in U.S. suicide mortality using a "structural determinants of health" framework. We access restricted-use multiple cause of death files to track suicide rates among U.S. Black, White, American Indian/Alaska Native, and Latino/a men and women between 1990 and 2017. We examine suicide deaths separately by poisonings and nonpoisonings to illustrate that (1) women's suicide rates from poisonings track strongly with increases in prescription drug availability and (2) nonpoisoning suicide rates among all adult Americans track strongly with worsening economic conditions coinciding with the financial crash and Great Recession. These findings suggest that institutional failures elevated U.S. suicide risk between 1990 and 2017 by increasing access to more lethal means of self-harm and by increasing both exposure and vulnerability to economic downturns. Together, these results support calls to scale up to focus on the structural determinants of U.S. suicide.

Child and Adolescent Psychopathology and Subsequent Harmful Behaviors Associated with Premature Mortality: A Selective Review and Future Directions

In the United States (U.S.), premature mortality in adulthood from suicide, alcohol-related disease, and substance overdoses has increased steadily over the past two decades. To better understand these trends, it is necessary to first examine the harmful behaviors that often precede these preventable deaths (i.e., suicidal ideation and attempts, and harmful alcohol and substance use). Representing critical developmental periods in which psychopathology is most likely to emerge, childhood and adolescence provide an informative lens through which to investigate susceptibility to harmful behaviors. This article synthesizes current evidence describing these rising U.S. mortality rates and the prevalence rates of harmful behaviors linked to these types of mortality. A brief selective review of longitudinal research on harmful behaviors in relation to the most relevant categories of child and adolescent psychopathology is then provided. Finally, recommendations for future research and implications for prevention are discussed.

Association between diseases of despair and atherosclerotic cardiovascular disease among insured adults in the USA: a retrospective cohort study from 2017 to 2021

OBJECTIVES

To assess associations between diseases of despair (DoD) and incident atherosclerotic cardiovascular disease (ASCVD) among insured adults in the USA.

DESIGN

Retrospective cohort study.

SETTING

Highmark insurance claims data in the USA from 2017 to 2021.

PARTICIPANTS

Adults with at least 10 months of continuous insurance enrolment, no record of ASCVD in the 2016 baseline year and no missing data on study variables.

PRIMARY AND SECONDARY OUTCOME MEASURES

Cox proportional hazard regression was used to calculate crude and adjusted hazard ratios (HR) and 95% confidence intervals (CI) to assess risk of ASCVD (composite of ischaemic cardiomyopathy, non-fatal ischaemic stroke, peripheral arterial disease or non-fatal acute myocardial infarction) by baseline DoD overall, and by the component conditions comprising DoD (alcohol-related disorders, substance-related disorders, suicidality) individually and in combination.

RESULTS

The DoD-exposed group had an age-adjusted rate of 20.5 ASCVD events per 1000 person-years, compared with 11.7 among the unexposed. In adjusted models, overall DoD was associated with increased risk of incident ASCVD (HR 1.42, 95% CI 1.36 to 1.47). Individually and in combination, component conditions of DoD were associated with higher risk for ASCVD relative to no DoD. Substance-related disorders were associated with 50% higher risk of incident ASCVD (HR 1.5, 95% CI 1.41 to 1.59), alcohol-related disorders and suicidality/intentional self-harm were associated with 33% and 30% higher risk, respectively (HR 1.33, 95% CI 1.26 to 1.41; HR 1.30, 95% CI 1.11 to 1.52). Co-occurring DoD components conferred higher risk still. The highest risk combination was substance-related disorders+suicidality (HR 2.01, 95% CI 1.44 to 2.82).

CONCLUSIONS

Among this cohort of insured adults, documented DoD was associated with increased ASCVD risk. Further research to understand and address cardiovascular disease prevention in those with DoD could reduce costs, morbidity and mortality. Further examination of overlapping structural factors that may be contributing to concurrent rises in ASCVD and DoD in the USA is needed.