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Special Communication
February 2, 2022

Why Deaths of Despair Are Increasing in the US and Not Other Industrial Nations—Insights From Neuroscience and Anthropology

Author Affiliations
  • 1Department of Neuroscience, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 2Marketing Department, Wharton School of Business, University of Pennsylvania, Philadelphia
  • 3Department of Psychology, School of Arts and Sciences, University of Pennsylvania, Philadelphia
JAMA Psychiatry. 2022;79(4):368-374. doi:10.1001/jamapsychiatry.2021.4209

The US National Academy of Sciences reports rising mortality for US adults, most steeply for White adults with a secondary education or less. The rise is largely attributable to deaths of despair (suicide and poisoning by alcohol and drugs) with strong contributions from the cardiovascular effects of rising obesity. Although the report does acknowledge a crisis, it proposes mild measures to manage it, such as strengthening programs to support recovery, prevent relapse, increase resilience, and perform more research toward clinically useful definitions of despair. The US National Academy of Sciences report notes that mortality is decreasing in a control group of 16 wealthy nations (including countries in Western Europe, Canada, Australia, and Japan), but it does not ask what protects those nations from despair. It has been observed that human beings are constrained by evolutionary strategy (ie, huge brain, prolonged physical and emotional dependence, education beyond adolescence for professional skills, and extended adult learning) to require communal support at all stages of the life cycle. Without support, difficulties accumulate until there seems to be no way forward. The 16 wealthy nations provide communal assistance at every stage, thus facilitating diverse paths forward and protecting individuals and families from despair. The US could solve its health crisis by adopting the best practices of the 16-nation control group.

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4 Comments for this article
Dopamine makes the world go round - even before "sapiens"
Wolfgang Liedtke, MD, PhD | Duke University Dept of Neurology, Durham NC 27710, USA; New York University College of Dentistry, New York NY 10021, USA
Sterling and Platt's thoughtful article is a must-read way beyond psychiatry and medicine.
Here is one comment, extending on a key insight of the article.
Our ancestors as hunter-gatherers had lifestyles that integrated the reward of procuring for the group's needs. Our ancestors' behaviors and way-of-life were driven by brain circuits, running on dopamine, that powerfully evoked the seeking of food and mates. - Perhaps extend that to satisfaction of elementary homeostatic needs that subserve our species' survival, at the level of individual survival and of passing on our genes. Thus, these are instinctive needs, namely hunger for food,
thirst for water, sodium and mineral appetite [1], reproductive sex. Satisfaction of instinctive needs is linked to brain reward machinery, which runs on dopamine "dopamine makes the world go round", and then we can refer to their satisfaction as gratification. Gratification of instinctive needs via a dopamine neural organization is hardwired to ancestral lineages way before our own species ("sapiens" - ?) did emerge [2, 3].
The many ways we shovel our own graves in over-abundantly wealthy societies, now more than 2 decades into the 21st century, are linked to dopamine-reward neural organization [4]. This particular neural circuit mechanism, in turn, is ancestrally rooted in us having become more effective survivors and propagators of our own genetic material, namely by gratification of instinctive needs inherently coupled to dopamine reward.
To my estimate it is a helpful perspective to view addictions and addiction-related behaviors as "artificial instincts" [5-7], which provides explanatory context and also readily reconciles the real-life enormous challenges that we encounter when trying to treat these conditions.
- Back to now, and thanks to Sterling and Platt for opening our eyes to this mind bogglingly alarming dynamics affecting us in the US, this means that addictions and addiction-related detrimental behaviors, and all of their negative fall-out, are piggybacking on ancestral survival mechanisms, deeply rooted in our brains. It leaves me tremendously unsettled to see the impact this has on the US, side-by-side to data from other countries, with exclamation mark on the temporal dynamics.


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2. Denton, D.A., M.J. McKinley, M. Farrell, and G.F. Egan, The role of primordial emotions in the evolutionary origin of consciousness. Conscious Cogn, 2009. 18(2): p. 500-14.
3. Liedtke, W., A Classic Innate Behavior, Sodium Appetite, Is Driven by Hypothalamic Gene-Regulatory Programs Previously Linked to Addiction and Reward, in Neurobiology of Body Fluid Homeostasis: Transduction and Integration, L.A. De Luca, J.V. Menani, and A.K. Johnson, Editors. 2014: Boca Raton (FL).
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6. Anonymus, Addiction - an artificially
CONFLICT OF INTEREST: WL is a full-time employee of Regeneron Pharmaceuticals, Tarrytown NY 10591; WL co-founded TRPblue Inc. (Durham NC) in 2017
Death and despair
Jawahar Mehta, MD, PhD | University of Arkansas for Medical Sciences, Little Rock, AR
We read with great interest the commentary on the US National Academy of Sciences report on deaths of desperation in the United States compared to other wealthy countries (1). We have recently highlighted the impact of despair on cardiovascular health in “Heart Disease: It Is All in Your Head.” (2). We agree that psychosocial distress, especially loneliness, is dangerous and needs community and government intervention. We suggest here three possible approaches to government intervention for improving psychosocial well-being, creating economic safety nets, reducing loneliness, and promoting the pursuit of happiness.
First, the government can legislate social welfare and mental
health programs to improve the mental and physical health of their populations. In the Scandinavian countries, such programs have resulted in a decline in suicide rates and improvement in lifespan. Sweden had one of the highest suicide rates in the developed world prior to the 1980s. After the 1980s, the government-mandated changes in employee rights included a requirement for 25-day paid vacation leave to all employees, paid parental leave for up to 16 months after the birth of a child, tax credits for childcare, and access to subsidized daycare facilities. These mandates reduced suicide rates significantly and improved lifespan. Similar legislation was launched in Italy through an Equitable and Sustainable Well Being initiative which started in 2011. This initiative promoted legislation for environmental preservation, economic justice, and promotion of culture and personal well-being. These mandates reduced cardiovascular mortality since that time.
Second, the government can prioritize happiness as a national goal. In Bhutan, the gross happiness index has now replaced the gross national product as a measure of individual well-being, happiness being prioritized over economic wealth. This has resulted in improved monitoring of psychosocial parameters and has enabled the government to improve quality of life and longevity.
Third, the government can establish and fund a national Department of Loneliness. In the UK, one study showed that more than 200,000 people had not even spoken to another pers within the last month, and this led then Prime Minister Theresa May to form a Ministry of Loneliness charged with monitoring loneliness and developing anti-loneliness programs, including fully-funded clubs, groups, activities and promoting legislation to engage the population to stay socially connected. This has led to improved psychosocial health and a decrease in deaths of desperation.
Government matters! In this time of psychosocial crisis with rising rates of desperation, the government can develop and fund psychosocial economic programs, mandate protections, prioritize psychosocial well-being. It can promote the pursuit of happiness as a national goal as our forefathers envisioned when they wrote the constitution. As physicians, we can lead the way by advocating for these programs not just to reduce deaths of desperation but to improve happiness and health for all

Jawahar L Mehta, MD, PhD
Paulette Mehta, MD, MPH
University of Arkansas for Medical Sciences,
Little Rock, AR

1. Sterling P, Platt ML. Why deaths of despair are increasing in the US and not other industrial nations-insights from neuroscience and anthropology. JAMA Psychiatry. 2022 Feb 2. doi: 10.1001.
2. https://www.amazon.com/dp/B09NRD8JGV/ref=sr_1_1?crid=2G4ZW38HUMPX7&keywords= heart+disease%3B+it+is+all&qid=1640333428&s=books&sprefix=heart+disease+it+is+all%2Cstripbooks%2C75&sr=1-1
Causes or symptoms?
Paul O'Brien | Corporate
My two cents

* Suburban sprawl keeping us further apart

* Urban isolation in apartments or anti-social behavior

* Families too distant because the size of the U.S. makes it possible

* Social media replacing in-person friendship

* The shift of childhood from being outdoors to being indoors at home

* Local social groups (Kiwanis, Rotary, church, etc.) replaced by social network groups

* Culture shifting from compassion and responsibility to entitlement and denial

* Work from Home rather than work from somewhere

Certainly, quarantine
didn't help.

Who can say if my observations are valid, the point is that it's the variety of communities in which we socialize and can seek help, which saves us from ourselves. The real crisis in America might not be any of what we perceive, but rather that we're sheltered from one another, and we're sheltering future generations from the variety of close connections necessary for their health.
Get Rid of the GUNS
eugene breen, MRCPI,MRCPsych, DGM, DCh | Mater Misericordiae University Hospital, Dublin
Sterling and Platt try to explain the awful reality of the culture of death in US by comparison with Hunter-Gatherer society, the EU welfare states, and the dopamine rush. You could say the elephant in the room is the enormous difference in EU and US to access to lethal weapons. This obsession and almost genetic link to firearms is not seen in other countries. Without removing weapons of mass destruction you are ignoring a root cause of excess mortality.

The hunter-gatherer era may not be the best comparator. The Golden era in Europe for example, or the monastic
settlements in Europe that supported surrounding communities and developed the hospitals and universities - and beer making - were extraordinary human achievements and humanly bonding and supportive. In our own day third world countries boast of vibrant human capital and strong family bonding with inter-generational and community sharing. These are examples of human transcendence and echo Abraham Maslows "Theory Z" where pines "perhaps human nature has been sold short"1.

My last observation of this assessment of where we are at - the US is at - is that unlike Sterling and Platt I consider we are more than animals (apologies if this seems harsh or unfair). The overarching driver of mankind is not at a reductionist level of accommodating our needs and dopamine requirements (given these are important players) but that of giving and receiving love. May sound hackneyed but it certainly gets your dopamine going, and you get all that good bonding stuff and accommodation as well! People need to see and experience small (and big) acts of kindness at all levels and especially in leaders. This should be evident in all the measures Sterling and Platt point out - welfare payments, holiday entitlements, maternal care, family support, youth protection and so on. Without kindness/love shown in deeds of fairness, finance, job opportunities, support for the needy and vulnerable it is a sham.