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

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“This is not like a lot of the other disasters that people have studied. It looks a lot more like what you’d expect to see in people who have lived through a war. ” -Roy Perlis

This is the second in our two-part series about deaths of despair during the pandemic. We speak with experts and review the latest data on how the pandemic is affecting rates of depression, anxiety, and even suicide in the United States. We’ll look back at what was driving these deaths before the pandemic, the impact of the economic fallout on depression, and how this crisis may change access to mental health services in the future.

This podcast was created by Just Human Productions. We’re powered and distributed by Simplecast. We’re supported, in part, by listeners like you.

S1E59: A Perfect Storm for Depression – Deaths of Despair Part II / Anne Case and Roy Perlis

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

Anne Case: So their work-life is fragile. Their home life is fragile. Their community life is fragile. So sort of a Durkheimian recipe for suicide.

Céline Gounder: 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 of Binghamton, New York. It’s a city upstate, not far from the Finger Lakes region.

Anne Case: There was a lot of industry there, there were really good jobs there.

Céline Gounder: 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 the big companies pulled out of town. And those great jobs went with them.

Anne Case: The people that I knew in high school who are 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.

Céline Gounder: Anne didn’t move back either. She went on to become a Professor of Economics and Public Affairs at Princeton University. Back in 2014, Anne was studying suicide with her husband and research partner, Angus Deaton. They were looking for correlations between people’s self-reported happiness and suicide.

Anne Case: Interestingly, they didn’t correlate at all but what we found was that suicide rates were rising, which surprised us.

Céline Gounder: They compared the suicide numbers against all-cause mortality. That’s a kind of denominator for all the deaths in the U.S. in a given year. What they found was troubling.

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

Céline Gounder: This turned a lot 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.

Anne Case: 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, um, friends who teach and do research and medical schools, and it came as a surprise to everyone.

Céline Gounder: 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. Anne coined the phrase for this triad — the deaths of despair.

Anne Case: 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.

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

Anne Case: When I see what’s happened to low wage workers, I think in part, you know, I know these people, um, 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.

Céline Gounder: 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.

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

Céline Gounder: How the pandemic is impacting people’s mental health…

Roy Perlis: 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 is driven by economics.

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

Anne Case: There is an opportunity to think about real change. And that real change is going to mean unlocking health insurance from employers.

Céline Gounder: 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.

Anne Case: 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.

Céline Gounder: This is true across race and gender, Anne says.

Anne Case: Something stunning happened in the U.S. 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.

Céline Gounder: But despite the benefits of a college education, there has 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 ⅔ of adults in the United States do not have a four-year degree.

Anne Case: Take the state of Kentucky, which has one of the fewest, uh, percentages of their adult population who hold a four-year college degree. So in Kentucky deaths from all three of these causes have gone up year on year on year, but only among those who don’t hold a BA.

Céline Gounder: Over the last several decades, these folks without a bachelor’s degree have been hit harder and harder by outsourcing and automation.

Anne Case: 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 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 and wages for people without a bachelor’s degree.

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

Anne Case: For most other wealthy countries, suicide rates have been falling. They didn’t, um, 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.

Céline Gounder: 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.

Anne Case: 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.

Céline Gounder: Anne says the high cost of insuring workers in the U.S. is an underappreciated driver behind the deaths of despair.

Anne Case: The U.S. 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.

Céline Gounder: The pandemic is only making these trends worse.

Anne Case: A much larger fraction of people with a BA are able to work from home. Whereas people who have to work. Um, 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 are going to have to be, healthcare workers aside, are going to be people with less education.

Céline Gounder: 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.

Anne Case: This like, self-induced the recession when we locked down and we decided that that was a way to try to 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 in this 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.

Céline Gounder: 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.

* * *

Céline Gounder: 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.

Roy Perlis: 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.

Céline Gounder: 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.

Roy Perlis: 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.

Céline Gounder: A quick note when we refer to depression:

Roy Perlis: 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.

Céline Gounder: 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.

Roy Perlis: 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 US has struggled the most with increasing rates of suicide.

Céline Gounder: Roy says as many as one third of young people surveyed said they’ve had some suicidal thoughts during the pandemic.

Roy Perlis: I would say the rates of suicidal thinking are as much as ten times higher than would be normal in that group, five to ten times higher than would be normal.

Céline Gounder: 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 case loads. This is affecting college students too.

Roy Perlis: With colleges closing and universities, a major source of access to mental health care is gone for students, because for a lot 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 a lot harder to do when you’re going to school on Zoom.

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

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

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

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

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

Roy Perlis: 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 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, or people’s level of wealth or socioeconomic status. It’s really true across the board.

Céline Gounder: 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.

Anne Case: 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, so, but we know the numbers must be literally in the millions.

Céline Gounder: 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.

Roy Perlis: 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. So 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.

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

Roy Perlis: 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.

Céline Gounder: 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.

Roy Perlis: Our data from, from our survey and others suggest 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 contributed suicide risk.

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

Anne Case: 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.

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

Anne Case: 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.

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

Roy Perlis: 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.


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I’m Dr. Celine Gounder. Thanks for listening to EPIDEMIC.


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