In a recent article published in the Proceedings of the National Academy of Sciences (USA), Anne Case and Angus Deaton describe a disturbing trend involving middle-aged white men and women in the U.S. Based on analyses of data from national and international surveys and databases, they report that the rates of mortality and morbidity in 45- to 54-year-old non-Hispanic white men and women have increased significantly over the last 15 years. These trends are in stark contrast to the declining mortality rates seen in African Americans and Hispanic Americans in this age group, as well as in populations in other industrialized countries like France, the United Kingdom, Canada, and Australia. Between 1999 and 2013, the mortality rates in these groups have been decreasing by about 2% per year, while the mortality rates for 45- to 54-year-old non-Hispanic white Americans have been increasing by about 0.5% a year. Prior to 1999, the mortality rate for American non-Hispanic whites had been decreasing in parallel to the other groups.
What is causing the reversal of mortality rates in this age group? It turns out that the majority of the increase can be attributed to increases in the number of deaths resulting from suicide, poisonings (for example, overdosing on pain medications), and chronic liver diseases (often related to alcohol). In other words, the lion’s share of factors contributing to the increasing mortality rates involves psychiatric illnesses and their complications.
This increase in mortality rates was seen for both non-Hispanic white men and women. Lower levels of educational achievement were associated with higher mortality rates.
The investigators found that increased levels of self-reported poor physical health, i.e., higher morbidity rates, paralleled the increase in mortality rates during this time period. There was a significant increase in reports of chronic pain conditions in this age group between 1997–1999 and 2011–2013. Risk for heavy drinking also increased as well as the number of people who reported serious psychological distress.
The two disorders most often associated with completed suicides are depression and alcoholism. Substance use disorders are associated with accidental self-poisoning, especially with opiates including prescription drugs and heroin, although a percentage of these deaths are likely suicides that are misclassified as “accidents.”
The increase in suicides in the middle-aged white population helps explain the recent rise in the overall suicide rate in the U.S. According to the Centers for Disease Control and Prevention (CDC) over 40,000 Americans committed suicide in 2013, resulting in a rate of 12.6 deaths by suicide per 100,000 people. This represents a significant increase from less than 30,000 suicides in the year 2000 at which time the rate was 10.4 deaths by suicide per 100,000.
Psychiatric illnesses, including substance use disorders, are having profound effects on the health of our country. Individuals who are 45 to 54 years old should be in their prime in terms of productivity. Exactly what societal changes have occurred during the last 15 years that, interacting with psychiatric disorders and chronic pain states, have led to a marked increase in mortality and morbidity in non-Hispanic white Americans in this age group have yet to be determined.
These trends are likely to continue unless increased efforts are made to help prevent and treat depressive disorders, alcohol use disorders, opiate use disorders, and other substance use disorders. There is a shortage of mental health professionals to adequately deal with the need and an even greater shortage of mental health professionals with expertise in treating substance use disorders. Treatment is also hampered by disparities in coverage and reimbursement of care for psychiatric disorders. The current over-prescription of opiate pain relievers also must be addressed. More work must be directed toward studying the underlying mechanisms of these illnesses and determining more effective and efficient treatments, but research is handicapped by limited federal funding. At the same time, it will be important to elucidate the societal trends (including economic factors) over the last 15 years that are contributing to the deteriorating mental and physical health of these individuals.
This column was written by Eugene Rubin MD, PhD and Charles Zorumski MD.