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March 31, 2021

Psychiatry and Deaths of Despair

Author Affiliations
  • 1Jacobs Center for Productive Youth Development, University of Zurich, Zurich, Switzerland
  • 2Department of Psychology, University of Zurich, Zurich, Switzerland
  • 3The Vermont Center for Children, Youth, and Families, Department of Psychiatry, University of Vermont, Burlington
JAMA Psychiatry. 2021;78(7):695-696. doi:10.1001/jamapsychiatry.2021.0256

In 2015, economists Case and Deaton1 reported that decades-long gains in US life expectancy had stalled and reversed and that rates of premature mortality had risen among middle-aged non-Hispanic White individuals with low education. They hypothesized that this premature mortality was due to increases in cause-specific mortality from suicides, drug poisonings, and alcoholic liver disease, which, in turn, they hypothesized to be due to hopelessness spawned by adverse social and economic circumstances. The now widespread narrative of deaths of despair was born.2,3

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    2 Comments for this article
    "Psychiatry and Depths of Despair": Others Have Despaired Before
    Edward Shorter, PhD, FRSC | Jason A Hannah Chair in the History of Medicine, Professor of Psychiatry, Faculty of Medicine, University of Toronto
    The helpful article by Shanahan and Copeland in the current JAMA argues that psychiatry is in need of “despair” as an independent diagnosis, and expresses surprise that this has not already happened. The problem is that in the rich diagnostic history of the mental sciences, despair has indeed been noted as a diagnosis. Yet as with so much of psychiatry’s nosological past, despair has simply been forgotten.

    In 1892 D Hack Tuke, examiner in mental physiology in the University of London, wrote of “despair” as a diagnostic term, “A condition of distressful and terrible
    hopelessness.” Three years later, in 1895, Sigmund Freud toyed with the diagnosis “hysterical despair” (hysterische Verzweiflung) before deciding not to include it in his diagnostic system. And in 1950, psychologist Erik Erikson notably described “despair” as belonging to the eighth, or final, stage of life. “Despair expresses the feeling that the time is now short, too short for the attempt to start another life.”

    What happened that much of the field is unaware of this nosological tradition? The issue is the flatness of the historical horizon in among many of the members of the Task Force of DSM-III in 1980. They seem to have had little awareness of psychiatry’s disease-definition past. Rather than building on the groundwork of disease classification dating back two centuries, they simply invented many diagnoses (eg “major depression”) because they seemed like a good idea. So, by all means, let’s give despair another trip around the block.
    Testing Causality in Economics and Psychiatry for Deaths of Despair in a COVID-19 World
    Michael McAleer, PhD(Econometrics),Queen's | Asia University, Taiwan
    In economics, the simple univariate analysis of reductions in gains of life expectancy based on deaths of despair, has focused on middle-aged ethnic minorities with low education.

    The direction of presumed univariate causality has also relied on cause-specific mortality and hopelessness arising from adverse socio-economic conditions.

    Updated empirical findings have broadened the narrative to include age, gender, geographic regions, racial and ethnic minorities, organ system diseases, alcohol abuse, and drug poisoning, among others.

    These factors would be expanded further during COVID-19 because of substantial losses in income during lockdowns, which have been absorbed in part by government
    payments, and further psychiatric illness that has been exacerbated by social distancing and quarantining, which have not necessarily been mitigated by appropriate counselling.

    Psychiatry can define despair more clearly as a syndrome rather than as a symptom of psychiatric disorders, and measure it more accurately by focusing on the causal pathways, or multivariate causality, based on economic and financial factors, feelings of hopelessness, suicide attempts, and deaths.

    Creating a novel scale (or index) of despair based on symptoms of mental disorders to examine the precursors of deaths of despair is a helpful start, although arbitrary scales inevitably suffer from selection biases and measurement errors that lead to biased estimates of the influence of the causal factors and associated statistical inferences.

    Ideally, such a despair scale would involve dynamic longitudinal panel data that incorporate intertemporal variations in biological, socio-economic, financial, and psychiatric factors in a multivariate setting to enable a detailed and rigorous interactive analysis of the causal pathways among the variables.

     A multivariate analysis that includes physical healthcare, neurological, bio-neurological, psychiatric, socio-economic, and financial issues, should lead to more informative outcomes regarding deaths of despair that provide prescriptions on the causal effects than what is presently known based on restrictive empirical findings from univariate models in economics and biology.