Invited Commentary: Do Small Cause-of-Death Correlations Throw Into Question the Notion of a Collective "Deaths of Despair" Phenomenon?

Since the turn of the 21st century, during which White mortality has been rising, there has been a sharp increase in only 3 causes of death: drug use, alcohol use, and suicide. Because all 3 of these causes conjure notions of anguish and hopelessness, they have been conceptualized as a collective "deaths of despair" phenomenon. Simon and Masters (Am J Epidemiol. 2021;190(6)1169-1171) challenge this conceptualization by asking whether these 3 causes are empirically associated with each other. Their analyses produce small correlations, which lead them to call into question that the 3 causes are part of a unified phenomenon. We contest their work on several grounds. Their analyses suffer from several technical problems, including the fact that, for any given year and cause of death, 65.8%-97.6% of counties examined have death counts under 10. More fundamentally, it is unclear that we should expect these causes of death to rise and fall together, even if they are connected to a singular phenomenon. Instead, "despair" might manifest differently in different places (i.e., these causes might be substitutes for each other). We argue that the best answer to the authors' important question comes from assessing whether there is a common, despair-based causal mechanism underlying all 3 of them.