S1E59 / A Perfect Storm for Depression – Deaths of Despair Pt II / Anne Case & Roy Perlis

This is sort of a perfect storm where you have more forces pushing people towards a depression. You have that sort of chronic stress plus the acute stress of either getting sick or having a loss.

So their work life is fragile, their home life is fragile, their community life is fragile, so sort of a Turkheimian recipe for suicide.

You're listening to Epidemic, the podcast about the science, public health, and social impacts of the coronavirus pandemic. I'm your host, Dr. Celine Gounder. Anne Case grew up outside Binghamton, New York. It's a city upstate, not far from the Finger Lakes region.

There was a lot of industry there. There were really good jobs there.

IBM got its start there. Singer Link made flight simulators there. These were high-tech, well-paying jobs. Anne went to a big high school and says about half the students were college-bound. But most of those people didn't move back to Binghamton after college. IBM and a lot of big companies pulled out of town. And those great jobs went with them.

The people that I knew in high school who were not college-bound, who are very good people, somehow are trying to still keep body and soul together with jobs that are much less good jobs than they are capable of and much less good jobs than I think they deserve, given how hard they work.

Anne didn't move back either. She went on to become a professor of economics and public affairs at Princeton University. Back in 2014, Ann was studying suicide with her husband and research partner, Angus Deaton. They were looking for correlations between people's self-reported happiness and suicide.

Interestingly, they didn't correlate at all. But what we found was that suicide rates were rising, which surprised us.

They compared the suicide numbers against all-cause mortality. That's a kind of denominator for all the deaths in the US. In a given year. What they found was troubling.

For white non-Hispanics, all-cause mortality was rising and had been rising since the late 1990s and seemed to have been rising under the radar without anyone making note of it.

This turned a lot of traditional thinking about who dies by suicide upside down. It used to be thought that suicide was more common among well-educated, affluent people, not working-class folks. But that's not what the data showed.

So at first we thought we were wrong. I mean, we thought, well, we must have crunched the numbers wrong. So we went back, we did it again and again. We took it on the road. We took it to friends who teach and do research in medical schools. And it came as a surprise to everyone.

Every year, more and more white, middle-aged, working-class men and women were dying from things like opioid overdose, alcoholic liver disease, and suicide. Ann coined the phrase for this triad, the deaths of despair.

The media immediately picked it up and it hit a nerve so that those forms of death, which are not all suicide, but they are all death by one's own hand, they all show a fair amount of despair. That's what we've come to know as the deaths of despair.

The research quickly became personal for Anne. It reminded her of what happened to her hometown of Binghamton.

When I see what's happened to low-wage workers, I think in part, you know, I know these people. These people deserve better than this. And a lot of these people are really good people who rightly think the system is now rigged against them. What can we do to try to ring the bell to bring that more out in the open? So those are motivating factors for me.

This is the second in our two-part series on deaths of despair during the pandemic. In our previous episode, we looked at how the pandemic is affecting overdoses in the U.S. In today's episode, We're looking at how the pandemic is affecting rates of depression, anxiety, and even suicide. We'll look back at what was driving these deaths of despair before the pandemic.

It's a lack of hope that there will be something in the long run coming for me, helping me and my family.

How the pandemic is impacting people's mental health.

One of the things that has been most striking to me as a psychiatrist is realizing how much of the depression that we're seeing We're seeing is driven by economics.

And how the pandemic may change access to mental health services in the future.

There is an opportunity to think about real change, and that real change is going to mean unlocking health insurance from employers.

On this episode of Epidemic, the mental health costs of the pandemic. At the start of her research, Anne says the group they focused on ended up being white, working-class men and women. But over the years, as their research honed in on the problem, they found something else that more accurately predicts these deaths of despair: a bachelor's degree.

Unfortunately, life expectancy is still going up in the community that has a BA, but it started to fall in the community without a BA starting in about 2010 or so.

This is true across race and gender, Anne says.

Something stunning happened in the US. When I was in graduate school, for example, which was a while ago but not like ancient history, we learned that people with a college degree earned 40% more on average than people with a high school degree. And that was known as the college premium. But in the period between 1980 and 2018, That college premium went from being 40% to 80%. So the reward of going to college skyrocketed over that period.

But despite the benefits of a college education, there's not been a big increase in the number of Americans graduating with a bachelor's degree. And this is not a small group of people. Roughly two-thirds of adults in the United States don't have a four-year degree.

Take the state of Kentucky, which has one of the fewest percent percentages of their adult population who hold a 4-year college degree. So in Kentucky, deaths from all 3 of these causes have gone up year on year on year, but only among those who don't hold a BA.

Over the last several decades, those folks without a bachelor's degree have been hit harder and harder by outsourcing and automation.

The number of people employed relative to the population goes up in boom times, comes down in downtimes, and then as things get better, they go back into the labor force, but not as many of them go back into the labor force as had been there at the last boom. So we see this ratcheting downward of what we in economics would call the employment-to-population ratio, so that there's less and less attachment to the labor market among people without a BA. So what we've seen from 1980 through to 2019, before the pandemic started, is a long-term downward trend in wages for people without a bachelor's degree.

Anne says these deaths of despair are more or less unique to the United States.

For most other wealthy countries, suicide rates have been falling. They didn't open themselves up to have a prescription opioid epidemic because they control their opioids. So we stand alone in terms of Seeing 158,000 Americans die in 2017 and again in 2018 from these deaths that no one should die from, that's just not happening in other countries. But of course, also in other countries, they fund their healthcare systems differently.

The history of tying health insurance to employment in the United States has led to a system that makes it prohibitively expensive to hire people with benefits. And it's hitting less educated people in low-wage jobs hardest.

These low-wage workers found themselves not employable because their health insurance premiums were so high for employers that the employers just decided, we can do without those workers, we'll just hire in from outsourcing companies.

Anne says the high cost of insuring workers in the US is an underappreciated driver behind the deaths of to spare.

The US is the last country to learn that lesson. And we think that unless it does that, it will continue to take a wrecking ball to the low-wage labor market.

The pandemic is only making these trends worse.

A much larger fraction of people with a BA are able to work from home, whereas people who find themselves at risk because they're working with the public— you know, they're driving a bus, or they're a checkout person at a grocery store, The people who are at highest risk of COVID healthcare workers aside, are going to be people with less education.

Looking back to the last time there was a huge disruption to the economy, Anne says deaths of despair continued to tick up before, during, and after the Great Recession of 2008. The numbers just kept going up. But Anne says the current economic crisis caused by the pandemic is different from past downturns.

This, like, self-induced recession when we locked down and we decided that that was a way to try to, you know, keep the lid on the virus, that's a really different kind of recession. So in a regular recession, people can go out, they can go to church, they can see their friends. And this recession where people are being asked to stay at home, the loss of social connection we think might be incredibly important. And we won't know that for a while.

We may not know yet how the pandemic will impact deaths of despair, but there is some national survey data available on depression, anxiety, and suicidal thinking. We'll find out what this may signal for deaths of despair during the pandemic after the break. Roy Perlis is a professor of psychiatry at Harvard Medical School. Roy says the pandemic has been very different from past crises when it comes to people's mental health.

This is not a one-time disaster. This is not like where something awful happens and then people try to put the pieces back together. This is a much more chronic stress It looks a lot more like what you'd expect to see in people who have lived through a war.

Since the spring, Roy has been one of the principal investigators of a national survey about the pandemic. It's called the COVID States Project.

It's an internet-based survey, and we generally survey around 20,000 people each month. We want to know things like how many people are wearing masks, who's more likely to wear a mask. Who's depressed? Who's anxious? What's driving that depression and that anxiety?

A quick note when we refer to depression.

You know, again, we have to make a distinction between feeling lousy, which I think many or most people do, and feeling sufficiently depressed, sufficiently impaired that people are having trouble sleeping and they're losing their appetite and they're having trouble functioning.

Roy says reports of depression, anxiety, and suicidal thoughts are all up since the beginning of the pandemic. And it's especially bad among young Americans.

At least in terms of thinking about suicide, the greatest risk is in this young adult, this 18- to 24-year-old group. And that is unfortunately also the group where the U.S. has struggled the most with increasing rates of suicide.

Roy says as many as one-third of young people surveyed said they've had some suicidal thoughts during the pandemic.

I would say the rates of suicidal thinking are as much as 10 times higher than would be normal in that group, 5 to 10 times higher than would be normal.

Clark County, Nevada, which includes Las Vegas, is one school district that's been struggling with this. The New York Times reported that 18 students there had taken their life between March and December of last year. The suicides have prompted the district to accelerate school reopenings despite stubbornly high coronavirus caseloads. This is affecting college students too.

With colleges closing and universities, a major source of access to mental health care is gone for students. Because for a lot of sort of late teens, early 20-somethings, their first contact with any sort of mental health care is wandering into student health and talking to someone. And that's a lot harder to do when you're going to school on Zoom.

Meanwhile, Roy says older Americans have not seen a similarly sharp increase in depression or suicidal thoughts.

COVID has been incredibly hard on older adults, but at least in terms of mental health, they've held up pretty well.

Roy says this spike in depression and suicidal thoughts is affecting everyone regardless of race, gender, and even political affiliation.

And I think that's because of the other thing that has crossed traditional lines, which are the economic consequences.

The economic drivers behind the stress, anxiety, and depression people report cannot be underestimated.

What jumped out at us was that rates of depression were way higher among people who had had one of these financial consequences of COVID You're about 20% more likely to have symptoms of depression if you tell us that you're behind on your rent. You're more than 20% more likely to have depressive symptoms if you tell us you've been evicted. About 10 to 15% more likely to tell us that you're depressed if you've had to cut down on your work because your hours were reduced or your, your wages were reduced. So there really was a pretty strong connection between having financial consequences of COVID and being depressed. And that was true even when we account for people's level of education, education and people's level of wealth or their socioeconomic status. It's really true across the board.

Some of you may remember that I served on the Biden-Harris Transition COVID Advisory Board. Biden gets it. He understands that people need help to get through this pandemic, that it's about having a roof over your head and food on the table, but that it's also about mental wellness too. Biden's America Rescue Plan would provide financial assistance to households, paid sick and family medical leave, unemployment benefits, extension of the federal moratorium on evictions and food stamps, a national $15 per hour minimum wage, and more. Here's Anne Case again.

You would think 30 million people lose their jobs overnight, and, you know, some fraction of them lose their health insurance at the same time. Now, we don't have good numbers on this yet, but we know the numbers must be literally in the millions.

When people get sick and need help, they may not be able to afford it, especially if their health insurance is tied to their job. And that's why Biden's America Rescue Plan also seeks to expand health coverage by extending COBRA, extending Affordable Care Act premium subsidies, and supporting the VA. But even people who had insurance before the pandemic were struggling to access mental health services. Both Roy and I have seen firsthand how hard it can be to get a patient an appointment.

I mean, I've talked to people who call 20, 25 different therapists and they never get a call back. You know, we might think that we have access. We don't really have access. That's even true for people with fancy commercial insurance. In terms of what we do, it's really doing things that we needed to be doing before COVID COVID just, as in so many other aspects of our society, COVID just laid bare where the cracks were in our system. And the big crack in mental health is access. The big crack in mental health is How do we make sure that when people are struggling that they get assessed and that they can get ongoing treatment?

One of the strange twists of the pandemic is that telemedicine may have made it easier to access mental health services.

COVID has forced us to move to telemedicine much more quickly than I think we would have otherwise, and what we've learned is telemedicine really works. Patients embrace it. Clinicians, including psychiatrists, really find it pretty effective. One of the amazing things is since my hospital's psychiatry outpatient programs moved over to telemedicine, our no-show rates have gone down dramatically because it's much easier for patients to dial in on Zoom.

Roy is hopeful that when the final data comes in, we won't see twin epidemics of COVID and suicide. But the survey data is, so far, reason for concern.

Our data from, from our survey and others suggests there's a substantial increase in suicidal thinking. And we know that suicidal thinking is a major risk factor for suicide itself. So I think we do have to respond as if we recognize that there's an increase in risk and do the things that we know can reduce that risk, namely treat the depression, treat the anxiety, and try to treat the underlying contributors to desperation that contribute to suicide risk.

Anne Case hopes that the pandemic will be an opportunity to hit the reset button on many things, especially the cost of healthcare.

We really do have to get a handle on prices in the healthcare industry. And if we don't do that, then it's still going to be this cancer on the U.S. economy and on low-wage people that's going to continue to grow. So I think that given the COVID crisis, there is an opportunity to think about real change, and that real change is going to mean unlocking health insurance from employers.

And unfortunately, the reason Anne may be right is that, unlike prior epidemics or economic crises, the pandemic is affecting everyone.

It's suddenly not going to look like just the far left is thinking about healthcare reform. I think suddenly people well up the distribution are going to understand, wait a minute, this is also affecting me and my family. And there may be a real push for change.

Lastly, Roy says, if you or someone you know seems like they may be depressed or thinking of hurting themself, reach out. Say something.

I think the most important intervention is to say something. The most important intervention is to ask. That in itself is therapeutic. If someone's thinking, am I depressed? Is this something that needs to be treated? It is worth figuring that out.

If you or someone you know is thinking of hurting themselves, please call the National Suicide Prevention Lifeline at 1-800-273-8255. It's 24/7, free, and confidential. That's 1-800-273-8255. Epidemic is brought to you by Just Human Productions. We're funded in part by listeners like you. We're powered and distributed by Simplecast. Today's episode was produced by Zach Dyer and me. Our music is by The Blue Dot Sessions. Our interns are Annabel Chen, Brian Chen, and Julie Levy. Special thanks this week to Jessica Ribeiro. If you enjoy the show, please tell a friend about it today. And if you haven't already done so, leave us a review on Apple Podcasts. It helps more people find out about the show. Follow Epidemic on Twitter and Just Human Productions on Instagram to learn more about the characters and big ideas you hear on the podcast. We love providing this and our other podcasts to the public for free. But producing a podcast costs money, and we've got to pay our staff. So please make a donation to help us keep this going. Just Human Productions is a 501(c)(3) nonprofit organization, so your donations to support our podcasts are tax deductible. Go to epidemic.fm to make a donation. That's epidemic.fm. And if you like the storytelling you hear on Epidemic, check out our sister podcast, American Diagnosis. On American Diagnosis, we cover some of the biggest public health challenges affecting the nation today. Past seasons covered topics like youth and mental health, the opioid overdose crisis, and gun violence in America. I'm Dr. Celine Gounder. Thanks for listening to Epidemic.