3 January 2020

Dear Interested Readers,

 

What Is Our Role In Addressing The Diseases of Despair?

 

In 2015 we were all shocked to learn from the Nobel prize winning work of Angus Deaton of Princeton University and his wife Anne Case, who is also a professor at Princeton, that in our country over recent years the life expectancy of white men without a college education has been falling. We now have data that shows despite spending more money per capita on healthcare than any other nation in the world we have had at least three consecutive years of falling life expectancy. This is a new trend that begs an answer to the question, “Why?” Deaton and Case postulated that the falling life expectancy of white men without a college education was an increase in “deaths of despair,” and speculated that alcohol abuse, drug abuse, and suicide were the vectors of the deaths.. 

 

I have already placed my order for the new book by Deaton and Case that will be coming out in late March, Deaths of Despair and the Future of Capitalism.  My expectation is that the book will be an expanded answer to the “Why” question. The title suggests that they will present data that connects alcoholism, drug abuse, and an increasing suicide rate to a failing capatolistic system of economics.  

 

In the interim since 2015 there have been several articles that have attempted to expound on the “Why?” that explained the data Deaton and Case brought to our attention. The Atlantic offered us an excellent description of “deaths of despair” in a 2015 article by Olga Khazan.  In Lean thinking we learn to ask “why” at least five times. So if the answer to the “first why” is alcohol, drugs, and suicide, why are we seeing an increase in those fatal problems? Even in 2015 Deaton and Case were suggesting that the answer to the “second why” was a decline in personal economic prospects. Economic despair among vulnerable populations did seem like a plausible explanation for the observed increase in the number of people who were vulnerable to alcohol abuse, drug use, and suicide. After talking to Deaton and Case, Khazan wrote:

 

So, what’s eating less-educated Boomers?

One persuasive explanation, and one the researchers put forth, is financial strain. Jobs in fields like manufacturing and construction, which were historically filled by people without college degrees, have been evaporating quickly over the past 15 years. As I’ve written previously, less-educated people are more likely to be unemployed and to make less, so they struggle to afford things like therapy, gym memberships, and recreation that isn’t drugs. Without jobs, they may lack the social networks and sense of purpose that have shown to reduce mortality.

Nearly half of Americans in their 40s and 50s don’t have enough money saved for retirement to live as they’re accustomed to, even if they work until they’re 65. All of this is crashing down on Boomers, who were raised on the promise of the American Dream.

 

I am sure that there were many white males and females with graduate degrees and secure employment in business, academics or the professions, who read about or heard of the work of Deaton and Case and shook their heads in sad acknowledgement of the plight of their less educated peers, and congratulated themselves on having had the stamina and foresight to get the education that apparently had immunized them against death by a disease of despair. 

 

There was even speculation that it was our “benefit structure” for retirement that was a root cause of the problem.  “Defined contribution programs” and 401Ks had replaced pensions in the 70s and 80s and left many baby boomers with a bleak outlook on retirement.

 

Khazan finished her piece with a recitation of this theory:

 

Deaton and Case note that middle-aged people in other countries also faced dire financial straits, especially during the 2009 recession. Yet they’re not dying like American 50-somethings are. One difference is that in those countries, comfortable pensions for retirees are guaranteed, so the prospect of an impoverished retirement might not loom as large in Europe as it does here.

“The U.S. has moved primarily to defined-contribution pension plans with associated stock market risk, whereas, in Europe, defined-benefit pensions are still the norm,” Deaton and Case write. “Future financial insecurity may weigh more heavily on U.S. workers.”

Tragically, that weight seems to be crushing these Americans before they can even retire.

 

In 2017, The Atlantic  gave us a followup article, “Is Economic Despair What’s Killing Middle-Aged White Americans?: Two Princeton economists elaborate on their work exploring rising mortality rates among certain demographics” by Alana Semuels. The Atlantic article appeared after Deaton and Case wrote a paper for a Brookings conference that offered further speculation on the “second why.” Semuels also suggested that the same despair that was killing many less educated baby boomers was also at least a partial explanation for the election of Donald Trump.  Semuels asked a “third why”:

 

The paper caused a stir in academic circles and in the media, and has remained in the public discourse following Donald Trump’s win partly on the strength of his support from these same middle-aged white Americans (the alive ones, to be clear). The paper, however, couldn’t answer the question everyone had: Why was this demographic in particular struggling?  It couldn’t be purely the economic pain they faced in the wake of globalization; after all, European countries are also affected by globalization, and their residents are getting healthier and living longer. And non-whites in the U.S. are living longer than they used to as well, and they are subject to the same economic forces as middle-age whites and are struggling, at least in economic terms, even more.

 

The paper that Deaton and Case presented at the Brookings Institute is a long one, and unless you are an economist, you might adopt my approach and peruse the graphs that seem to suggest that there is some regional variation with “red states” seeming to suffer more deaths when normalized for population. Semuels reported:

 

…Just why they’re so sick was not something that Case and Deaton elaborated on in their 2015 paper.

Now, in a new paper, the economists explore why this demographic is so unhealthy. They conclude it has something to do with a lifetime of eroding economic opportunities. This may seem like a circular argument, when put together with previous work: Middle-aged Americans aren’t working because they’re sick, and middle-aged Americans are sick because they’re not working. But Case and Deaton argue that it’s not just poor job opportunities that are affecting this demographic, but rather, that these economic misfortunes build up and bleed into other segments of people’s lives, like marriage and mental health. This drives them to alcoholism, drug abuse, and even suicide…

 

I added the bolding because I am impressed by the possibility that what we are seeing now is the result of a very long term process that may stretch back to the eighties or earlier. I would also speculate that when the new book comes out in March Deaton and Case may have even more to teach us, or new insights that will further startle us.

 

We are still in a period of speculation. I wonder if our inherent biases may be causing us to overlook factors that we should be considering. Deaton and Case keep suggesting that the vulnerable group is blue collar middle aged white men. Could it be that there are factors we have not considered and that blue collar middle aged white men are just the leading edge of a process to which they are more vulnerable that will eventually impact other demographic groups? 

 

All of the articles continue to speculate why this is an American phenomena that is not seen in Europe, although there have been some who suggest that in the UK life expectancy in some places and among some groups has flattened even if it is not falling.  Again Semuels writes:

 

This [falling life expectancy in the USA] is in contrast to Europe, where people of all educational backgrounds are living longer, which suggests that there’s something unique among middle-aged Americans without a college education that’s making them sicker. It’s also in contrast to other Americans. For instance, whites aged 50-54 with a high-school degree or less had been dying at a rate 30 percent lower than that of that of all blacks in the same age group in 1999, but by 2015, their mortality rate was 30 percent higher than that of all blacks in that age group. Between 1998 and 2013, death rates for Hispanics fell as well.

 

The bottom line for the difference seen between Europe, with its plethora of social safety nets, and America, with its culture of self reliance, maybe that hopelessness is less likely in Europe and other countries that have granted their citizens more protection from the ups and downs of the economy. 

 

What makes this group unique? It’s not just that they don’t have the guarantee of good jobs that they once did, Deaton said. Life doesn’t turn out as this age group hopes it would, creating a sense of hopelessness, and as a result, they turn to risky behaviors such as overeating, alcohol abuse, or drug use…

 

Hopelessness as the explanation for despair, perhaps the “fourth why” is the subject of a recent post on the blog of the American Philosophical Association entitled “The Humanitarian Crisis of Deaths of Despair” written by David V. Johnson of Stanford. He begins with a good question:

 

Case and Deaton’s research raises important questions for the US political economy and the legacy of neoliberalism. But I am more interested in the framing of the mortality statistics as “deaths of despair.” Assume for the sake of argument that a large segment of the US population—non-Hispanic white Americans without college degrees—are suffering despair. What does it mean to say this?

 

He grabbed me with his next paragraph. I have bolded what drew me in:

 

We can gain some insight by contrasting its opposite, hope, which has received a lot of philosophical attention for the puzzles it raises about rationality and agency. Hope is a forward-looking emotion with cognitive and desiderative elements. We hope for things that are possible in the future (we don’t hope for the impossible or the certain), which means we make a judgement about their possibility. And when we hope for them, we desire for them to come about, and this desire can motivate our action if we think our acting can help bring it about. Is it rational to hope for something that has a miniscule chance of happening, and if so, under what circumstances? And when is it rational to act based on hope? Much ink has been spilt on these questions.

 

Further along he writes:

 

We can see why despair, as a condition opposed to hope and hopefulness, can be such a debilitating state of mind. Despair undermines agency. The despairing person may conceive of plans and goals but feel that he is so unlikely to achieve them that they are not worth the investment of time and energy, or that even if he does achieve them, it won’t make a substantive difference to his life. 

 

After an interesting analysis of despair, Johnson writes, and I add bolding:

 

This kind of despair [the kind that Deaton and Case postulate as the cause of their finding] is not forward looking, per se, but rather focused narrowly on the present. It sees the present as dark, dreary, painful, and uninteresting, and anticipates this state of consciousness to extend indefinitely into the future. It’s the feeling of unrelenting misery and ennui. No one wants to feel like this, but the person who despairs in this way does not form the desire to avoid it, or is not motivated by such a desire, because he does not see a means of escape or because the present sense of pain and dreariness is so overwhelming that it disrupts his ability to imagine such means. This form of despair is what Case and Deaton have in mind: people who have not only lost the will to live—i.e. to direct their lives, make plans, pursue them—but are so miserable and distressed that they either die by suicide or self-medicate with drugs and binge drinking to lessen their immediate pain, and do so as a way of slowly dying by suicide. It is the constant feeling associated with present consciousness that life is bad, and that it will continue to be bad indefinitely into the future. A sizable portion of the American public feels this way.

 

We talk a lot about the social determinants of health. It’s interesting to me that we don’t talk much about the “social destroyers of health.” We are easily overwhelmed by the enormous complexities of inequality. Some of us, not me, feel relieved by scripture, both in the “Old Testament” (Deuteronomy 15:14) and in the “New Testament” (Matthew 26:11 and Mark 14:7). Since the Bible says: “You will always have the poor with you…,” many people express the feeling that the plight of those in need is the result of their own poor choices and not their concern. I should add that the scriptures doesn’t go on to say “…therefore, you are relieved of any concern about them, and you might as well go on to exploit them…” I would argue that understanding the origin of the diseases of despair is as important for anyone in healthcare, as it is to understand the role of genetics in inherited illnesses. 

 

In November JAMA published data that showed the decline in life expectancy for the last three years, up to 2017, that have been measured. The data suggests that the problem may be expanding beyond the blue collar white population that Deaton and Case originally identified. Is hopelessness an infectious disease? CNN picked up the JAMA report and published a review of this data in late November. Jen Christensen, the CNN writer, asked the question what are we to do? She quoted from the editorial by Howard Koh, of the T.H. Chan Harvard School of Public Health, that was written to accompany the report in JAMA:

 

“It is a whole constellation of conditions they have shown impacts life expectancy. It is not just medical conditions, but also the social drivers that appear to be at play, like income inequality and mental distress,” Koh said. He believes there is a greater awareness of these issues, that your health is much more than what happens in your doctor’s office.

Koh said he has seen some signs of hope. He’s noted more business leaders have added workplace health programs and there’s more awareness in the housing and transportation sectors about the impact both have on human health. Collaboration across all sectors will be key, he said.

“Health starts with where you live, labor, learn, play and pray,” Koh said. “What that means is that we need to embed a culture of health through all sectors of society.”

 

Everything that Koh said is true, but I have trouble with his statement because it feeds into a concept that I have picked up on in conversation with many healthcare providers and have heard debated at conferences and in board meetings that the social determinants of health and environmental issues are not the domain of practice. Koh seems to divide the causative factors for the decline in life expectancy into two groups, those that can be addressed in the office and the hospital and those which arise in society outside the reach of practice, the social determinants of health.  He calls for a culture of health, and I applaud the idea. I do not know if he really meant to say that in the office we should just focus on treating disease and leave the rest of the problem to employers and those in the government who manage policies on housing and transportation. He did call for “collaboration” across all sectors, but I wish that he had explicitly called for healthcare to take a leadership role in addressing or at least emphasizing the importance to the health of the nation of addressing the root cause problems that create disease and death though the vector of despair. 

 

I noted last January in a piece entitled “Poverty And The Care of The Patient” that Dr. Francis Peabody’s had advised us nearly a century ago that “the secret of the care of the patient is caring for the patient.” I feel certain that Dr. Peabody would advocate being aware of the social stresses that diminish the health of our patients, and would do more than hand his patients a prescription for an antidepressant. I do believe from my own experience of more than forty years of practice that there are things that can be said and done in the office that can address hopelessness even as we try to treat the diseases that arise from despair through collective political and social action. 

 

Earlier this week I read an opinion piece in the New York Times entitled “Why Is America So Depressed?” written by cultural critic Lee Siegel. That may be our fifth “why.” In his piece, Mr. Siegel addresses despair and hopelessness in his own life, and tries to understand the origin of our national problem with depression. He begins by reminding us of the depressing realities of our current state.

 

Everyone has his or her own definition of a political crisis. Mine is when our collective mental health starts having a profound effect on our politics — and vice versa.

It cannot be a simple coincidence that the two have declined in tandem. The American Psychiatric Association reported that from 2016 to 2017, the number of adults who described themselves as more anxious than the previous year rose 36 percent. In 2017, more than 17 million American adults had a new diagnosis of a major depressive disorder, as well as three million adolescents ages 12 to 17. Forty million adults now suffer from an anxiety disorder — nearly 20 percent of the adult population. (These are the known cases of depression and anxiety. The actual numbers must be dumbfounding.)

The really sorrowful reports concern suicide. Among all Americans, the suicide rate increased by 33 percent between 1999 and 2017.

All of this mental carnage is occurring at a time when decades of social and political division have set against each other black and white, men and women, old and young. Beyond bitter social antagonisms, the country is racked by mass shootings, the mind-bending perils of the internet, revelations of widespread sexual predation, the worsening effects of climate change, virulent competition, the specter of antibiotic-resistant bacteria, grinding student debt and crises in housing, health care and higher education. The frightening environment helps cause depression, depression causes catastrophic thinking, and catastrophic thinking makes the environment seem even more terrifying than it is.

 

Siegel joins other critics and analysts in postulating that the election of Donald Trump was evidence of dissatisfaction with the current state.

 

Out of this dark cast of mind arose the hunger for a strong, avenging figure whose arrival has sent even more mentally harrowing shock waves through society. If President Trump is indeed mentally ill, as so many of his critics claim, he may well be the most representative leader we have ever had.

 

After revealing his own challenging mental health concerns that have included his drug dependency and suicidal thoughts borne of his pain and despair, he speaks to what he calls the “real divide” in America. I have bolded his reference to the issues that create a sense of hopelessness.

 

The real national division is between people who have the resources, inner and outer, to survive their mental illness and those who don’t...Freud famously said that depression was anger turned inward. We know now that depression is a result of numerous factors: social environment, economic pressure, cognitive misreading, a random event, trauma, neurobiology and genes.

Like anyone who has confronted depression, I know that this is, first and foremost, my challenge, unique to my life. And yet the line between the self and all the external forces that continually shape and reshape the self is blurrier than we like to believe. There are very particular external factors that make their way into my head and impel me toward thoughts of taking my own life.

 

He brings individual identity and life to the abstract distant collective image postulated by Deaton and Case that they generated from reams of “big data” of a generation of baby boomers who despair in the midst of their hopeless plight, and succumb to the relief of drugs, booze, and suicide.

 

There is the constant, relentless, unremitting financial triage as our financial obligations slowly overwhelm our means of meeting them…It’s not just the money. To say that there is less use for a 62-year-old white male (unless you happen to be running for president) these days is not to devalue the social transformations that are rapidly occurring in the age of Trump. You can hail necessary social change and complain about being, to some degree, a casualty of it, both at the same time.

In this way, I view myself — and imagine others — caught in a double bind. My depression springs from my biology, my biography, my choices. But it occurs within a far broader context that could bring just about anyone down, and apparently does. The fact is that the country is not red and blue. It is almost entirely blue.

 

He then restates the point he wants us to take away from his piece, and that I believe is a root cause of what Deaton and Case have identified through their use of the “big data” on life expectancy.

 

The real national division, as I see it, is between people who have the resources, inner and outer, to survive their mental illness and those who don’t.

 

His next point is a challenge that I frequently encountered as I tried to get help beyond my own skills for some of my patients. Finding the right help is a challenge. A lack of access to care is an enormous barrier. The fall back creates pressure on primary care providers who are often not prepared for the challenge. 

 

Affording a therapist and finding the right therapist — it is rare: wisdom, empathy and kindness cannot be taught — they are the first obstacles to overcome. Then you might have to find the right and affordable psychiatrist, who will help you make an informed decision about whether to take psychiatric drugs that will or will not help, perhaps even saving your life.

Even more people never receive an actual psychiatric diagnosis. A 2014 study found that 80 percent of all prescriptions for antidepressants were being issued by primary care physicians who had no psychological, psychiatric or psychopharmacological training at all.

 

The remainder of his piece is a review of our inability to address the challenges of providing adequate mental health resources to the nation. He applauds the small residual gains that were the result of Jimmy Carter’s 1977  President’s Commission on Mental Health which lead to positive legislation, the Mental Health Act of 1980 that was largely reversed by Ronald Reagan. He calls for a national leader who will return to the sort of emphasis that Carter tried to place on our mental health issues. He clearly states that Donald Trump is not a leader that has the capacity to lead us anywhere but into deeper realms of hopelessness. 

 

Trump appeals only to our meanest selves, unconcerned with the impact that has on our overall sense of self…We need a national leader who will, as President Carter tried to do, address the urgent issue of mental illness, not with piecemeal legislation but with a national crusade. We need a leader who will elevate this crisis to the same level of national urgency as gun control and climate change. I know what I rationally expect in a president: reason, character, dignity. But I will not feel hopeful about anyone who does not respond to my turbulent unconscious, to my brute, irrational need to be the object of empathetic concern as an individual and to be affirmed as a person….Sadly, Mr. Trump has known how to make that appeal better than anyone on the national stage so far. He addresses himself to the meanest, basest sources of emotion, and this has the effect of making everyone who is indifferent to his appeal feel imperiled and unnerved.

 

The title of this rather long musing is a question, “What is our role in addressing the diseases of despair?” “Our” is intentionally ambiguous. It refers to all Americans, and it also refers to healthcare professionals. As voters we can endeavor to put leaders in place who feel that their responsibilities include not only defending us from hostile external threats and keeping the stock market moving to higher and higher levels, but also accept the responsibility of providing all Americans with access to adequate affordable care that provides an effective approach to our growing problem with the “diseases of despair.” As citizens, we can also promote a dialog that endeavors to find common ground and shuns behaviors that worsen what divides us. 

 

As healthcare providers there are many things, large and small, that we can do to address the distress that so many of our patients feel. As I say that, I realize that “burnout” impares the ability of many clinicians and support staff to respond to patients with empathy. Mr. Siegel suggests that many clinicians can’t meet his needs. He is right. If we can’t provide access to mental health professionals, we need to enhance those abilities within primary care perhaps by reengineering our deployment of some of our mental health resources from direct care to broader support of primary care.

 

We need innovative changes in the structure of practice and the deployment of clinical resources that bring people closer to their providers. Those providers need training that gives them the competence to address the complex issues that burden their patients. Those clinicians also need the time it takes to provide the care that will dispel a sense of hopelessness. Cell phone apps and Skype are wonderful tools, but we need innovations in clinical design that offer many more people the opportunity to be in the presence of a caring provider who can see them as a whole person and who understands the connection between their hopelessness and despair and the diseases that challenge them. The actions I describe need to be part of our stalled process of healthcare reform. We are in trouble, and we must collectively decide that it is wise to invest in solutions that move us toward the Triple Aim while we also chose to make the investments necessary to improve the environment, education, job training, and housing that have been delayed for too long. The solution to what ails us is not  to elect a bigger bully. We should elect an individual as our president who demonstrates empathy and has an understanding of the issues that affect the “least of us.”

 

While we wait for the slow political process to move forward there are many things to be done closer to where we work. We need to reduce barriers to getting care for those who do have coverage. Some patients in despair don’t even have the strength and focus to get through our phone systems, or the energy to navigate their way from our parking garages through our enormous physical plants, to our offices. We should spend time looking at the barriers we have constructed for our own protection. What we can’t do is to say that the social determinants of care and the issues that lie at the root of the diseases of despair lie outside of the sphere of our professional responsibilities. 

 

There Is Something Beautiful Around Every Corner

 

I am looking forward to my walk this afternoon with a couple of my friends. We are going to be walking the 5.65 miles around Pleasant Lake, the other lake in my little town that lies at the foot of Mount Kearsarge. “Strawberry Fields” is part of a lakeside farm that offers “pick it yourself strawberries” in the summer. It lies at one turn of the road in the walk around the lake. The picturesque old barn across the road that serves the farm is beautiful in all seasons, but I think that I notice it most in winter when the fields it serves lie under a regenerative blanket of snow.

 

We are now into the “heart of winter.” The holidays are behind us, and there are almost four months more of frozen lakes and cold weather between us and the first buds of spring. One has choices. We can hunker down, leave town and head south, or get out each day to see the beauty in the ordinary things that we often overlook in other seasons. I think that I will try them all.

 

Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,

 

Gene