National mental health policy and Australia’s ‘ Deaths of despair ’

First coined in the United States, ‘Deaths of despair’ refer to mortality due to suicides, alcohol-related mortality and drug overdoses (Case and Deaton, 2017). Deaths from these combined conditions are approximately double the suicide rate alone and may represent a more comprehensive picture of adverse outcomes from psychological morbidity (Figure 1). In contrast to the declining rates of all-cause mortality in high-income countries, those from ‘Deaths of despair’ have remained steady or even increased, particularly in the United States. For instance, recent US data revealed that the age-standardised rates for Deaths of despair have increased by 56%, from 28.3 per 100,000 in 2006 to 44.1 per 100,000 in 2017 (US Congress Joint Economic Committee, Social Capital Project, 2019). Total US ‘Deaths of despair’ between 2006 and 2017 increased for males and females by 51% and 65%, respectively. Most of this increase was attributable to drug overdose related deaths, which doubled from 10.3 to 20.5 per 100,000 in that period. Other explanations included increasing economic insecurity, a lack of a universal health care system and the widespread availability of opioids (Case and Deaton, 2017). For white, middle-aged, non-Hispanic US residents, the lack of a college education was a further risk factor (Case and Deaton, 2017).

Figure 1.

AIHW* Australian Deaths of Despair 2006–2018. Persons | Age-standardised rate (per 100,000).

Although Australian data show a less clear trend, there may be grounds for concern. For instance, while all-cause mortality for those aged 50–54 decreased by 1% each year from 1999 and 2015, ‘Deaths of despair’ had increased by 2.5% annually (third worst out of the 14 wealthy countries analysed) (Case and Deaton, 2017). Data from the Australian Institute of Health and Welfare (without providing breakdowns by age and race) show a mixed picture between 1997 and 2018 (https://www.aihw.gov.au/suicide-self-harm-monitoring/data/behaviours-risk-factors/deaths-of-despair). While rates at the start and the end of two decades of data were similar at 23–24 deaths per 100,000 population, this disguises a trough of 18.8 deaths per 100,000 in 2006 and subsequent rise in the following years (Figure 1). For instance, from 2006 to 2018, Australian ‘Deaths of despair’ increased by 21% (males by 20% and females by 24%). Since 2006, suicide rates have increased by 19%, alcoholic liver disease deaths have increased by 4% and accidental poisoning deaths have increased by 54% (Figure 1). These data are for the overall population and further analysis is required to identify Deaths of despair within specific age cohorts (youth, middle-aged and older adult), ethnic cohorts (e.g. Indigenous, Asian and European) and disadvantaged socioeconomic groups.

There have been criticisms of the concept of Deaths of despair as a marker of disadvantage when applied to the United States (Muennig et al., 2018). For instance, a major contributor to the increasing rates of Deaths of despair in middle-aged non-Hispanic whites are overdoses of prescription opiates. This might actually reflect relative advantage compared to other groups such as African-Americans in that they have better access to insurance, drug plans and health care in general. However, these criticisms may be less applicable to Australia.

Thus, at best, rates for ‘Deaths of despair’ have remained steady over the last decade and possibly worsened since 2006. These disappointing results have occurred despite the national suicide prevention strategy (Jorm, 2019); rising prescription rates of antidepressants; the introduction of the Better Access Programme (2006); introduction of Headspace (2006); increased availability of numerous online mental health resources; the Fourth National Mental Health Plan (2009); and policy advice from the National Mental Health Commission (2012).

In this context, it is essential to better understand why Australia’s numerous national mental health plans and major investment in primary mental health care since 2006 have not reduced the population prevalence of mental illness, or drug and alcohol morbidity/mortality. Instead, there have been significant rises in emergency department mental health attendances and rising Deaths of despair. We advocate ongoing monitoring and analysis of Australian Deaths of despair data (in addition to monitoring suicide rates) to more comprehensively measure whether national mental health policy, drug and alcohol policy and care delivery systems are having positive impacts at the population level.

Further investment in individual therapy approaches (psychotherapy and antidepressants) may not reduce Australia’s rising Deaths of despair, or indeed reduce the prevalence of mental illness. Increases in Deaths of despair (Case and Deaton, 2017) may relate to sociological factors (age, race, gender, economic insecurity, education, social integration and social capital) and possibly increased access to prescription opioids, which may require a multidimensional approach encompassing individual, family and public health elements (Caine et al., 2018).

Australia urgently needs to review its population mental health, and alcohol and other drug strategies in view of the burgeoning Deaths of despair. With Australia currently experiencing an unprecedented and likely protracted economic downturn due to the COVID-19 pandemic, significantly affecting government budgets, we need to invest in targeted evidence-based and cost-effective approaches towards high-risk populations.