Recent social research suggests that the next generation of older adults may be more troubled than the current and previous generations. This, of course, is counterintuitive. 70 is the new 50, we say; 80 the new 60. We are living longer, and we are healthier, right?
Yes, but will the next generation be like this generation?
Anne Case and Angus Deaton1,2—sociologists at Princeton University—and others writing about “deaths of despair” are predicting a significant increase in illness and disability in the next generation. Pursuing a totally different line of research, Julie Phillips3—a sociologist at Rutgers University—is predicting a rise in suicide rates among future elder boomers.
Deaths of Despair
Case and Deaton’s research focuses on the fact that life expectancy in the United States has declined in the past few years, reversing a trend of longer life over several decades. This change is particularly surprising because death rates among older adults have continued to decline and because there have been particularly dramatic reductions in death rates due to cancer and heart disease. Why, then is life expectancy decreasing?
According to Case and Deaton declining life expectancy is due to a vast increase in deaths due to drug overdoses, suicide, and alcohol-related disease among working age, white, non-Hispanic people who have a high school education or less. Taken together these “deaths of despair,” as they have come to be called, are now the 5th leading cause of death in the United States.
It is tempting to believe that this is an historical blip due to the recession of 2007 and the years it has taken for economic recovery. But, Case and Deaton note, increasing death rates are unique to the United States. Other developed countries, which also were deeply affected by the recession, have continued to see death rates decline.
What is Different in the United States?
Case and Deaton’s analysis focuses on “cumulative disadvantage” including the decline of job opportunities and stability for people with low education, declining rates of marriage due both to cultural changes and struggles with the economics of family life, declining connections with religion as a source of meaning, and more. In short, Case and Deaton see a kind of Durkheimian connection between rates of death and a lost sense of hopeful connection that white*, working class people have historically had with the American society.**
Issues for The Next Generation of Older Adults
But what does a rise in death rates among working age whites have to do with projections of increased illness and disability in the next generation of older adults? After all, those who have died will not become older.
Case and Deaton cite data that indicate that illness and disability (“morbidity”) are also on the rise in the working age population with high mortality. Self-reports on health surveys indicate that they perceive themselves as in poorer health, in more pain, with more limits on activities of daily living, and with more emotional distress than in the past.
In addition, deaths due to overdoses, suicides, and alcohol related diseases are almost certainly just the tip of the iceberg. Many more people are addicted to drugs than who die from accidental overdoses. Many more people attempt suicide than complete it. And alcohol related diseases can persist well into old age. Epidemiological data already indicate increasing use, misuse, and abuse of alcohol and drugs among older adults.
In general, suicide rates have been increasing in the United States since the end of the 20th century. But there has been a significant change in the population most at risk of suicide. Early in this century it was adults over 65. Now it is working age adults.
In her remarkable work, Julie Phillips has tracked suicide rates by age, historical period, and generation from 1940 on. Her work indicates that the elder boom generation is at higher risk for suicide than previous generations and that the risk is greater among the younger members of the elder boom generation than among those who are already old. Her conclusion is that the cohort of working age adults who will become old in 10 to 20 years is likely to have higher suicide rates than those who are currently old.
Why? Like Case and Deaton, Phillips uses a Durkheimian perspective to try to understand rising suicide rates. There are, she believes, weaker connections between individuals and their society due to such factors as increased mobility and separation from extended family, increased divorce rates, increased loneliness, decreased civic participation, unstable employment, decreased religiosity, and more.***
Has there also been an increase in mental illness? Given the close connection between mental illness and suicide, that seems likely.
Implications for Geriatric Mental Health Policy
It has been clear for many years that the projected growth of people 65 and older4 both in absolute numbers (they will double) and as a proportion of the American population (they will outnumber children) will create very tough challenges for the mental health system. The research on “deaths of despair” suggests that the challenges will be even greater than anticipated because the prevalence of emotional distress for older adults may be higher than it has been in the past.
As I noted earlier, this is counterintuitive because people seem to be living longer and better. However, this research reveals that, while people with more than a high school education are doing better, the 40% of the American population that does not go beyond high school is not. That population may have growing needs for medical, behavioral, and social services as they become old.
What can be done? In part the answer is more and better services****, especially for people of lower socio-economic status and especially in localities that have had relatively high death rates. In part the answer is a comprehensive public health campaign to reduce drug and alcohol abuse. In part, the answer is more effective interventions to reduce the incidence of suicide and suicide attempts, including meaningful gun control. And for older adults, plans are needed that anticipate not just a growth in numbers but a growth of morbidity among those who will become old in 10 or 20 years.
Much of this is already on the behavioral health agenda to some extent. Not nearly enough, of course, but at least it’s on the radar screen.
But if Case and Deaton, Phillips, and others are right that deaths of despair reflect widespread disconnection between individuals and their societies, we need to think much more broadly and address the dimensions of the American society that contribute to growing division and alienation. Inequality; job insecurity; social isolation and loneliness; racial, gender, and class divisions; lost sources of meaning and hope—it is these trends that need to be addressed.
Is this too much for the physical and behavioral health systems? Probably. Perhaps the best we can hope for is continuing to chip away at problems of behavioral health, which sadly are unlikely to diminish and may in fact increase in a nation that appears to have abandoned what progressives at the beginning of the 20th century called the “promise of American life”.7
But perhaps health and behavioral health policy makers can begin to think big, not just about ingenious ways to manage care and cost, but also about alienation and division in America today. I’m skeptical, but still hopeful.
Michael B. Friedman, LMSW is an Adjunct Associate Professor at Columbia University School of Social Work and Chair of the Geriatric Mental Health Alliance of New York. He can be reached at firstname.lastname@example.org.
- Case A. and Deaton, A (2015). “Rising Morbidity and Mortality in Midlife Among White Non-Hispanic Americans in the 21st Century” in PNAS, December 8, 2015.
- Case A. and Deaton, A (2017). “Mortality and Morbidity in the 21st Century” in Brookings Papers on Economic Activity, Spring 2017.
- Phillips, J. (2014). “A Changing Epidemiology of Suicide? The Influence of Birth Cohorts On Suicide Rates in the United States” in Social Science and Medicine, May 2014.
- Friedman, M et al (2018). Geriatric Mental Health: Demographic and Epidemiological Data. The Geriatric Mental Health Alliance.
- Dwyer-Lindgren, L et al (2018). “Trends and Patterns of Geographic Variation in Mortality From Substance Use Disorders and Intentional Injuries Among US Counties, 1980-2014” in JAMA, March 13, 2018.
- Segal, L et al (2017). Pain in the Nation: The Drug, Alcohol And Suicide Crises And the Need For A National Resilience Strategy. The Trust for America’s Health and The Well-Being Trust.
- Croly, H. (1909). The Promise of American Life.
* Case and Deaton speculate why death rates have continued to decline for black and Hispanic populations despite the ongoing travails of life as a minority and the entrenched racial divide in America. Perhaps people of color have always had lower expectations and less hope than whites. Perhaps they have lost less than working class whites because they had less to begin with. Just speculation, Case and Deaton tell us.
** President Carter referred to this as an American “malaise” and paid a great political price when running against President Reagan’s vision of a great America. President Trump appears to have understood the profound desire of the white working class for a return to the heyday of blue collar jobs that paid a living wage.
*** A very recent study shows enormous differences in deaths due to overdoses, suicides, homicides and alcohol related illnesses from county-to-county in the United States. The authors say that this indicates that so-called “deaths of despair” may be more related to local circumstances than to broad social changes.5
**** A good example of advocacy for improvements in America’s health and behavioral health systems is a report calling for a “national resilience strategy” to address deaths of despair recently released by The Trust for America’s Health.6 It emphasizes the need for more and better mental health and substance abuse services, more preventive efforts, improved pain management, etc.