Are 'deaths of despair' really more common for white Americans? A UCLA report says no

For the record:
11:57 a.m. May 21, 2024: An earlier version of this article said social worker Nakeya Fields is 32 years old. Fields is 44.

Nakeya Fields has seen how the stresses that come with being Black — racial injustice, financial strain, social isolation — can leave people feeling hopeless and push some into substance abuse.

It's one of the reasons the Pasadena social worker started offering "therapeutic play" gatherings for Black mothers like herself and children.

"I'm trying to host more safe spaces for us to come and share that we're suffering," the 44-year-old said. "And honestly, the adults need play more than kids."

Yet while Black and brown mental health practitioners such as Fields have labored to address these issues within their communities, a very different conversation has been occurring in the nation at large.

For years, discussions about America's substance-abuse crisis have focused almost exclusively on the narrative that it is white, middle-age adults who face the greatest risk of dying from drug overdoses, alcoholic liver disease and suicide.

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The theory, which was presented by two Princeton economists in 2015 and based on data from 1999 to 2013, argued that despair was behind rising premature mortality rates among white Americans, especially those who were less educated.

Virtually overnight, the "deaths of despair" concept began to drive the national discourse over populist far-right politics; the rise of Donald Trump; and deepening political polarization over such topics as addiction treatment, law enforcement and immigration.

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But after roughly a decade, researchers at UCLA and elsewhere have begun to dismantle this idea.

In a study published recently in the journal JAMA Psychiatry, authors found that rates of deaths of despair for middle-age Black and Native Americans have surged past those of white Americans as the overdose crisis moves from being driven by prescription opioids to illegal drugs such as fentanyl and heroin.

While the opioid crisis did raise drug overdose deaths among white Americans for a time, it was an anomaly, said Joseph Friedman, a social medicine expert at UCLA's David Geffen School of Medicine who was the lead author of the journal analysis. In fact, by 2022, the rate for white Americans had started to dip.

"What's really important is that now, with these three causes of death, the gap has closed, and it's moving in the other direction," Friedman said.

The analysis found that deaths of despair for Black Americans hit a rate of 103.81 per 100,000 people in 2022, compared with 102.63 for white Americans. The rate for Native American and Alaska Native populations was even higher at 241.7 per 100,000 people in 2022.

The UCLA analysis doesn't specify the midlife personal issues that might have led to addiction or suicide.

But the authors say that flaws in the methodology of the 2015 report skewed its conclusions about who was most at risk of deaths of despair. Specifically, Friedman said that it failed to give enough consideration to long-standing racial inequities that Black Americans experience in income, educational attainment, incarceration and access to quality medical care, all of which can contribute to drug use and poor mental health outcomes. And statistics for Native Americans weren't factored in at all.

"It was burned into the American psyche that it was white people in the rural U.S.," Friedman said. "It was just a very small piece of the truth that was very interesting but was widely sold as something it wasn't."

Another recent worrying sign, Friedman said: Deaths of despair among Latinos are starting to catch up to those among Black and Native Americans.

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Princeton professors Anne Case and her husband, Angus Deaton, winner of the 2015 Nobel Prize in economic sciences, were thrust into the media spotlight when their findings on deaths of despaire were first published. Deaton told NPR that during a visit to the White House, even President Obama asked him about the phenomenon.

Their 2020 book, "Deaths of Despair and the Future of Capitalism," was described by publisher Princeton University Press as "a troubling portrait of the American dream in decline."

"For the white working class, today’s America has become a land of broken families and few prospects. As the college educated become healthier and wealthier, adults without a degree are literally dying from pain and despair," the publisher said.

Fields, who employs yoga and pottery in her therapy, said this framing was misleading and racially biased.

"I'm actually flabbergasted that somebody has a term called 'deaths of despair,'" Fields said. "It's 'despair' when white people experience this suffering. But when we experience it, it's just what we have to deal with."

Both Friedman and Fields said their critiques are not intended to minimize deaths among white Americans.

Still, Friedman wonders: "How do we empower Black and Native American communities in a way that enables them to treat these problems?"

Racism must be considered when trying to make sense of the crisis in premature deaths, said Dr. Helena Hansen, head of UCLA's Department of Psychiatry and a senior author on Friedman's analysis. Hansen, who is Black and specializes in addiction psychiatry, also co-wrote the book "Whiteout: How Racial Capitalism Changed the Color of Opioids in America."

For years, pharmaceutical companies steered expensive prescription pain medications, such as the opioid OxyContin, as well as the most effective medications for opioid-use disorder, to white Americans with good access to healthcare, she said.

But at the same time, Black and brown Americans were unfairly subjected to law enforcement policies that prioritized incarceration for illegal drug use over increasing access to more humane medical strategies to help them, further harming already vulnerable communities, Hansen said.

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"In our society, people with access to the new technologies and pharmaceuticals are more likely to be white," Hansen said. "None of this is by accident. All of this is the direct result of careful racially and class-segmented marketing strategies by pharmaceutical companies."

This two-tiered system arose because drug manufacturers, doctors and policymakers have for too long failed to see people from historically marginalized communities who live with addiction and mental health crises as worthy of the same sympathy and treatments that many white Americans receive, Hansen said.

Joseph Gone, a professor of anthropology at Harvard who has spent 25 years studying the intersection of colonialism, culture and mental health in Indigenous communities, agreed.

"Deaths of despair have been a reality for Indigenous communities since conquest and dispossession," he said.

"It's amazing how much grief our people contend with from early deaths — there are not that many communities in America that bear it quite the way we do," said Gone, who is a member of the Aaniiih-Gros Ventre tribal nation of north-central Montana. "Until we acknowledge and take responsibility for the casualties of colonization, which endure to this day through deaths of despair, it's going to be very hard to turn this around."

Gone, who has collaborated with Friedman on previous research, said the mental health crisis in tribal nations is aggravated by widespread joblessness and generational poverty, and a lack of healthcare resources to treat people in need of immediate or long-term treatment.

Just one traveling psychiatrist serves reservations spread across both Montana and Wyoming — a region covering more than 243,300 square miles — mostly to manage patients' prescriptions, he said.

And "for all of Indian country, we're talking about a very small number of in-patient psychiatric facilities," Gone said.

General practitioners can serve as a first line of defense, but they are not necessarily equipped to address the ongoing life crises that can lead to excessive drug and alcohol use, Gone said.

Fields said it's important to address mental wellness issues early, before people reach a crisis point and become another statistic.

While her focus remains on Black women, she's developed additional programming for adults, families and children, such as developmental screenings that measure for high stress levels. In June, Fields will co-present "Rap 4 Peace," a conference and gala featuring hip-hop artists talking about mental health and reducing gun violence.

"This 'tragedy of despair' lives in us," Fields said. "We breathe it. We go outside hoping that nobody will harm us or our children because they feel threatened by us. This is truly harmful to our bodies."

This story originally appeared in Los Angeles Times.