Daniel George, MSc, PhD Associate Professor, Department of Humanities Associate Professor, Department of Public Health Sciences Penn State

Diseases of Despair: Rural and Urban Sufferers See Same Structural Problems

This story explores suicide and conditions leading to despair. If you are at risk, please stop here and contact the National Suicide Prevention Lifeline for support. 800-273-8255

MedicalResearch.com Interview with:

Daniel George, MSc, PhD Associate Professor, Department of Humanities Associate Professor, Department of Public Health Sciences Penn State

Dr. George

Daniel George, MSc, PhD
Associate Professor, Department of Humanities
Associate Professor, Department of Public Health Sciences
Penn State

MedicalResearch.com: What is the background for this study? What are the common diseases of despair? 

Response: Last decade, two Princeton economists, Anne Case and Angus Deaton, noted a precipitous rise in self-harming deaths (suicide, alcoholism, accidental poisonings, i.e., overdose) especially among poor whites in midlife with low educational attainment since the 1990s. These deaths were intimately linked with economic changes over the past several decades that have created more despairing conditions for the working class, made people more susceptible to seeking escape, numbness, and relief from physical, mental, and emotional pain. In recent years, the crisis has broadened, and we’ve seen rising excess mortality in other groups of working-class Americans as overall life expectancy has consistently fallen.

Our team at Penn State College of Medicine and Highmark Inc. has previously examined “diseases of despair”, these being patients who are experiencing suicidal ideation or substance use issues and seeking out clinical care before they convert to “deaths of despair”. We published a study in BMJ in 2020 showing a marked rise in these clinical diseases of despair across a sample of 12 million insurance carriers in Appalachia and the Rust Belt, again spanning across demographic boundaries. For this study, we honed in on high prevalence census blocks we had identified in our hospital’s service area in central Pennsylvania and organized 4 focus groups in both rural and urban areas. We wanted to learn more about what people felt was driving despair in their communities, and what solutions might look like 

MedicalResearch.com: What are the main findings? 

Response: When we evaluated our data, perhaps the most interesting finding was that, for all the culture war splitting of rural and urban America, participants in our study largely converged around similar themes. In terms of causes, people identified financial stress at the heart of the crisis–the difficulty getting jobs with full benefits, the need to work multiple jobs, etc–and linked this to domestic policies that did not favor working-class Americans but did favor the ruling class. People talked about being forced to choose groceries over medical and mental health care, and how it was simply cheaper to buy beer to calm their nerves than pay for anti-depressants.

Participants also talked about how the lack of infrastructure worsened peoples’ lives. In rural communities, people spoke of the difficulties of finding public transportation to jobs or medical care (especially given the rash of rural hospital closures in recent decades). In urban focus groups, people talked about how underfunded, understaffed schools are failing to prepare kids with trades or skills to be competitive in a 21st century economy. All groups spoke about a general sense of decline in community–things like greater loneliness and alienation, loss of trust, people escaping into social media, a breakdown in nuclear family structures, loss of neighborliness, and so forth. All of this is downstream from economic transitions in a globalized world that has outsourced jobs, stagnated wages, and generally diminished peoples’ way of living.

In terms of solutions, people felt there had to be action at both the local/community and state levels to build greater resilience to despair. Locally, things like initiatives from non-profits and religious groups to build community and reach the most vulnerable, ride-sharing to jobs, and other types of mutual support were desired. However, participants were pretty firm in stating that the despair crisis is a structural problem and that there needs to be larger-scale investment in creating living wage jobs and job training centers, better safety nets for people who are struggling, better transport infrastructure, more accessible mental health care, and so on. There was also significant anger at local politicians for failing to serve the people in their communities and for failing to regulate the pharmaceutical industry in ways that had allowed prescription opioids to flood economically vulnerable communities. Again, lots of convergence from rural and urban participants on these themes.

MedicalResearch.com: What should readers take away from your report?

Response: Certainly, that this crisis is intimately linked with political-economic decisions that have been made over the past several decades, most of which have ramified in ways that make peoples’ lives more precarious and distressing. This is not about individual moral failures, or the moral decadence of particular communities. The fact that participants in rural and urban areas are seeing the same structural problems and identifying similar solutions means there might be ways to mobilize seemingly disparate communities around political initiatives that address underlying drivers of despair. In the meantime, hospitals can do their part to develop better processes for identifying and tracking despair in patients and connecting them with helpful resources that mitigate acute distress. That may mean working more intentionally with social workers and community health workers, and developing relationships with community organizations to provide integrated care for those most at risk, especially those who do not interface with the healthcare system.

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: Since most work on deaths of despair has been epidemiologic, it would be helpful to deepen qualitative inquiry and continue building an understanding of the pathways of distress in peoples’ lives–especially those who have been affected by despair-related illnesses or deaths of friends and family members. That said, there does seem to be a role for big data in studying high-prevalence areas and identifying socio-economic patterns over time to see what is most predictive of despair-related illness. And obviously it would be good for hospitals to implement better screening approaches and referral patterns and evaluate their effectiveness and scalability. This is a relatively newly identified crisis, so much work to be done.

No disclosures, but I just want to reaffirm that I speak for myself here and not necessarily on behalf of Penn State College of Medicine or my collaborators. 


George DR, Snyder B, Van Scoy LJ, et al. Perceptions of Diseases of Despair by Members of Rural and Urban High-Prevalence CommunitiesA Qualitative StudyJAMA Netw Open. 2021;4(7):e2118134. doi:10.1001/jamanetworkopen.2021.18134


Jul 23, 2021 @ 8:44 pm

The information on MedicalResearch.com is provided for educational purposes only, and is in no way intended to diagnose, cure, or treat any medical or other condition. Always seek the advice of your physician or other qualified health and ask your doctor any questions you may have regarding a medical condition. In addition to all other limitations and disclaimers in this agreement, service provider and its third party providers disclaim any liability or loss in connection with the content provided on this website.


This story explores suicide and conditions leading to despair. If you are at risk, please stop here and contact the National Suicide Prevention Lifeline for support. 800-273-8255