Mayor Pete Doesn't Understand 'Deaths of Despair'

The problem's bigger than mental health

South Bend, Indiana, mayor Pete Buttigieg / Getty Images
August 27, 2019

There is, as Democratic presidential contender Pete Buttigieg correctly noted, a surging wave of suicides, drug overdoses, and alcohol deaths. These have been collectively labeled "deaths of despair," first in academic literature and then in the popular press.

On Friday, Buttigieg's presidential campaign released a plan to "improve mental health care and combat addiction," with the explicit purpose of reducing "deaths of despair." The plan calls for massive federal investment in mental health care, including a drive to increase the number and geographic diversity of psychiatric and drug treatment services. It also includes several liberalizing reforms to the prison and drug treatment systems.

There are several things to like about the South Bend mayor's plan. Expanded pre-conviction diversion for people with a history of mental illness and substance use would benefit not only individuals who need treatment, but the prison wardens and police officers forced, over their own objections, to play mental health counselors. Increasing the availability of naloxone, a medicine used to reverse opioid overdoses, almost certainly would be beneficial, as would the removal of federal limits on syringe exchange programs.

In general, there is nothing per se objectionable about expanding access to mental health and drug abuse treatment. How Buttigieg would actually effect this expansion is often left unclear. The plan is heavy on imperatives, light on details.

If the "deaths of despair" crisis were predominantly caused by a dearth of mental health resources, then perhaps Buttigieg's plan would be meatier. But the vagueness of the proposal and its focus on mental health indicate that Mayor Pete does not understand the true nature of "deaths of despair."

Economists Anne Case and Angus Deaton coined the term to describe a particular series of comorbidities that collectively explained the unprecedented increase in all-cause mortality among white Americans in their 40s and 50s. The term does not describe an underlying causal theory. The fundamental force driving these increases is not an amorphous "despair" that suddenly emerged ex nihilo. Nor, for that matter, is there much evidence that most Americans are more lonely or mentally ill than they used to be (except for teenagers). Rather, as I've written previously, the three distinct crises that compose the "deaths of despair" phenomenon each became prominent around the same time, but have distinct underlying etiologies linkable to particular social and policy decisions over the past 20 years.

For example, there is good reason to believe that U.S. trade policy, and specifically permanent normal trade relations with China, sparked increases in drug use and suicide, as well as contributing to decaying marriage and family formation rates which in turn promote "despair." Similarly, Buttigieg is right that rates of depression and anxiety have risen among teens and young adults. But, while there is no consensus as to why, there are multiple valid competing theories which link the trend to the rise of the internet, changes in our educational structure, and a decline in teen socialization, all linked to both family and state decision-making.

At their heart the "deaths of despair" crises are not about mental health. They are about political economy. How we have chosen to structure our society, and to whose benefit—the old versus the young, the beneficiaries of trade versus those harmed—is more fundamental than increasing the number of psychiatrists per capita.

The Buttigieg plan obliquely acknowledges non-mental-health causes, alluding to "parents being laid off," or "teenagers coping with childhood trauma," or "older people whose aging friends don't stop by as often." It also includes the standard grab-bag of social issues: racism, poverty, etc. All of these are timeless social problems, not particular causes that, for example, initiated an unexplained and unrelenting increase in the suicide rate beginning two decades ago. Something—or more than one thing—initiated an explosion in deaths.

Some might object that even if there are more "root" causes, mental health treatment is a more readily available solution. But while there are undoubtedly more mental health resources—including for at-risk groups—today than there were 20 years ago, the suicide rate is 30 percent higher. This does not mean treatment causes suicide, but it does mean that the fundamental problem is not a lack of mental health resources—it is deeper, structural issues. It also means that additional mental health resources are not going to meaningfully reduce total death rates.

In a sense, the Buttigieg plan offers a band-aid. Yes, people's lives will be harmed by their jobs getting shipped to China, but at least they will be able to talk to a psychiatrist about it. There is something fundamentally sinister about this band-aid.

When asked why his plan was not targeting "root issues," the Buttigieg campaign told the Washington Free Beacon, "Simply spending more on current programs will get us the same results, which is why we are proposing forward-thinking ways to bring mental health care into schools, primary care offices, and communities."

"Our approach to mental health and addiction assistance is grounded in ensuring that every American has a place to receive support and care," the campaign spokesperson continued. "It puts resources directly in the hands of communities, allowing them to address social factors as well as health care factors to dramatically improve mental health treatment and ultimately save one million lives over the next decade."

This answer simply doubles down on the focus on mental health. Buttigieg emphasizes a desire to destigmatize mental illness—a common line in similar plans. But the emphasis on mental health, instead of political economy, necessarily focalizes the source of people's despair on themselves. The problem, our former McKinsey consultant tells us, is not that we have shipped your job to China, or mortgaged your future to pay for the Boomers' retirement, or allowed China and Mexico to flood your town with fentanyl. The problem is that you are not taking the right anti-depressant, and you do not talk enough to your psychologist.

The problem, in other words, is not us. It is you.