Artículo de revista: Piñeiro, Bárbara; Spijker, Jeroen; Trias-Llimós, Sergi; Blanes, Amand; Permanyer, Iñaki (2023). “Trends in cause-specific mortality: deaths of despair in Spain, 1980–2019”. Journal of Public Health, fdad133. (ISSN 1741- 3850) https://doi.org/10.1093/pubmed/fdad133 Journal of Public Health | pp. 1–9 | https://doi.org/10.1093/pubmed/fdad133 Trends in cause-specific mortality: deaths of despair in Spain, 1980–2019 Bárbara Piñeiro1 , Jeroen J. A. Spijker1 , Sergi Trias-Llimós1 , Amand Blanes Llorens1 , Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdad133/7231018 by guest on 10 October 2023 Iñaki Permanyer1,2 1 Centre d’Estudis Demogràfics, Centres de Recerca de Catalunya (CERCA), Universitat Autònoma de Barcelona, 08193 Bellaterra/Barcelona, Spain 2 ICREA, 08010 Barcelona, Spain Address correspondence to Bárbara Piñeiro, E-mail: bpineiro@ced.uab.es ABSTRACT Background Research from various countries has shown increases in alcohol- and drug-related deaths and suicide, known as ‘deaths of despair’ over recent decades, particularly among low-educated middle-aged individuals. However, little is known about trends in death-of-despair causes in Spain. Therefore, we aim to descriptively examine this among 25–64-year-olds from 1980 to 2019 and by educational attainment for the years 2017–19. Methods We obtained mortality and population data from the National Institute of Statistics to estimate age-standardized mortality rates and assess educational inequalities using the relative index of inequality (RII). Results Deaths of despair as a share of total mortality slightly increased from 2000 onwards, particularly among 25–64-year-old men (from 9 to 10%). Only alcohol-related mortality declined relatively more since 1980 compared with all-cause mortality. Regarding educational differences, low-educated men presented higher mortality rates in all death-of-despair causes (alcohol-related: RII 3.54 (95% CI: 2.21–5.66); drug-related: RII 3.49 (95% CI: 1.80–6.77); suicide: RII 1.97 (95% CI: 1.49–2.61)). Women noteworthy differences were only observed for alcohol-related (RII 3.50 (95% CI: 2.13–5.75)). Conclusions Findings suggest an increasing proportion of deaths of despair among 25–64-year-olds since 2000, particularly among men. Public health policies are needed to reduce and prevent these premature and preventable causes of mortality. Keywords alcohol, cause mortality, deaths of despair, drugs, educational attainment, premature mortality, suicide, trends Introduction of attention and interest, the deaths of despair literature has received strong criticisms.10 Life expectancy gains have slowed in many high-income and Outside the USA, studies on trends in deaths of despair are low-mortality countries, including Spain, since 2010,1–4 lead- limited. One Scottish study11 found drug-related deaths and ing to debates on possible causes. In the USA, the increases in suicides to be the leading causes of death of despair between mortality rates in drug overdoses, alcohol-related diseases and 1980 and 2018 among men aged 15–44, with mortality suicide observed among low-educated working-aged whites from drugs being the biggest contributor to socioeconomic over recent decades have spurred a great deal of interest inequalities in mortality. The authors emphasize marginaliza- and attention among scientists, policymakers and media.5–7 tion, lack of opportunities and social support structures as These causes of death known to be associated with self- likely contributors to the high rates. Another study compared destructive behaviors reflect a kind of despair or loss of deaths of despair mortality rates among birth cohorts in hope or expectations, reason why some researchers refer to them as ‘deaths of despair.’6,7 These deaths of despair B. Piñeiro, Researcher are linked to low educational attainment, deteriorating labor J.J.A. Spijker, Researcher market opportunities and economic resources, living in rural S. Trias-Llimós, Researcher A.B. Llorens, Researcher and deprived areas, widespread availability of opioids, and I. Permanyer, ICREA Research Professor cultural and social factors.6–9 However, despite this high level © The Author(s) 2023. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com This is an Open Access article distributed under the terms of the Creative Commons Attribution NonCommercial-NoDerivs licence 1 (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 2 JOURNAL OF PUBLIC HEALTH Scotland, England and Wales and found similarities in the the deaths according to educational attainment through mul- peak ages at death across cohorts, suggesting similar root tiple data linkages, including municipal population registers causes.12 (Padrón), the 2001 and 2011 censuses, or data on official In Spain, life expectancy gains slowed down among adults degrees issued by the Ministry of Education.16 INE also already before COVID-19,2 despite being one of the world’s provided the required sex-, age- and education-specific popu- leading countries in life expectancy.4 Since the economic lation data for the denominators of our mortality indicators. Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdad133/7231018 by guest on 10 October 2023 crisis of 2008–14, mortality improvements have decelerated. We examined cause-specific mortality trends separately for Among young men, this has especially been due to external deaths from alcohol use, drug use and suicide. These causes causes, and among 60–79-year-old men and women due to were initially selected based on Case and Deaton6,7 and Allik circulatory and respiratory system diseases.13 In a study that et al .11 but adapted to fit our purposes (Table 1). In line with analyzed changes in drug- and alcohol-related mortality dur- previous studies,10,17 we also analyzed the cumulative rate ing the early stage of the economic crisis in Spain (2008– of the three death-of-despair causes together, as well as the 11), an upward trend in drug and alcohol-related mortality remaining natural and external causes (Fig. 1). Causes of death was found.14 Another study conducted in Spain that analyzed were coded according to the International Classification of the gender gap in life expectancy at three time points (1980, Diseases (ICD). Despite the switch from the ninth (ICD-9) 1995 and 2012) according to causes of death found that to the tenth revision (ICD-10) in 1999, there is no indication improvements in male mortality from HIV/AIDS, cardiovas- of trend breaks regarding these causes of death in Spain.18 cular diseases and traffic accidents contributed to narrow the The exact codes used for the causes of death are shown in gender gap. However, male excess mortality from substance Table 1. abuse (alcohol and drugs) had little impact (0.035 years in 1980 and 0.020 years in 2012).15 As sex differences vary across Data analyses health dimensions and historical time, analyzing demographic Analyses were carried out separately for men and women. and socioeconomic characteristics of cause-specific mortality Mortality rates were standardized for age and sex using the patterns can provide insight into where the current burden 2013 European Standard population. Ninety-five percent of deaths lies, which may facilitate policy responses. Given confidence intervals (CI) were also calculated to compare the known socioeconomic differences in death of despair different periods and education categories. Educational mortality in the USA6,7 and UK,11,12 similar studies should inequalities in cause-specific mortality were estimated using be conducted for Spain in the hope of preventing premature the relative index of inequality (RII). The RII assumes and preventable deaths in the future. the relative position of each educational group within the In this context, this study aims to descriptively examine the population. It can be interpreted as the mortality rate ratio mortality trends of the deaths-of-despair causes, drug- and comparing the low- with the high-educated population alcohol-related mortality and suicide, among Spanish men and groups. The RII was estimated from a multiplicative Poisson women aged 25–64 for the years 1980–2019, as well as by regression model adjusted by age.19 educational attainment for the years 2017–19. To visualize the age-specific mortality rates of the different cause-of-death categories across the studied time period, heat maps were created in Excel 2019. Methods We obtained sex-specific data on all-cause and cause-specific Results mortality for the years 1980–2019 from the mortality registry of the Spanish National Statistics Institute (INE) database Long-term trends (www.ine.es). We analyzed deaths among ages 25–64, includ- All-cause mortality rates decreased for men and women aged ing age-specific patterns. In addition, for the years 2017–19 25–64 from 1980 to 2019 (Fig. 1). All-cause standardized (pooled), we explored differences according to educational mortality rates (SMRs) were higher among men than women attainment (reliable cause-specific mortality data according throughout the period and declined among both sexes (the to education is not available for an earlier period). We dis- SMR almost halved between 1980–82 and 2017–19), with the tinguished between three educational levels: low (less than decline among men becoming more pronounced since the secondary education), middle (completed secondary educa- early 1990s. tion and intermediate vocational training) and high (post- Men also have higher mortality rates than women in secondary vocational training and university). INE obtained each of the three specific causes of death of despair. DEATHS OF DESPAIR IN SPAIN 3 Table 1 International Classification of Diseases (ICD) codes for alcohol- and drug-related causes of death and suicide ICD-9 codes ICD-10 codes Alcohol 291, 303, 305.0, 357.5, 425.5, 535.3, 571 (excluding F10, K70, K73, X45, G31.2, G62.1, I42.6, K29.2, K74.0, K74.2, K74.6, 571.6), E860 K86.0 Drugs 292, 304, 305.2–305.9, E850–E858 F11–F16, F18–F19, X40–X44 Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdad133/7231018 by guest on 10 October 2023 Suicide E950–E959, E980–E989 X60–X84, Y10–Y34, Y87.0, Y87.2 Note: Despite the switch from the ninth (ICD-9) to the 10th revision (ICD-10) in 1999, there is no indication of trend breaks regarding these causes of death in Spain (Ruiz et al.18 ). While Case and Deaton7 considered alcoholic liver diseases and cirrhosis (ICD10 K70, K73–74) and drug and alcohol poisoning (X40–45, Y10–15, Y45, Y47, Y49) separately, we combined chronic liver disease and cirrhosis with alcohol poisoning and other alcohol-related disorders to create the category ‘alcohol-related deaths’ following Allik et al.11 We also combined mental and behavioral disorders due to use of drugs (excluding tobacco and alcohol) and accidental poisoning by exposure to drugs (excluding alcohol) to create the category ‘drug-related’ deaths. The final death-of-despair category is suicide, which includes events of undetermined intent because we know from the literature that suicide is a sensitive issue that may not always be correctly coded. The categories are also mutually exclusive: suicides (including undetermined intent) due to drugs are only included among suicides but are also analyzed together as deaths of despair. Fig. 1 Age-standardized mortality rates (per 10 000) from specific causes of death for Spanish men and women aged 25–64, 1980–2019. Note: The left axis presents the age-standardized mortality rates (per 10 000) from deaths of despair (suicide, alcohol- and drug-related) and other causes of death (natural and external), according to sex for the years 1980–2019. The sum of the rate of the specific cause-of-death categories equals the all-cause mortality rate. The right axis refers to the sum of the age-standardized mortality rates of the three death-of-despair causes as a percentage of the total age-standardized mortality rate. The downward trend is particularly visible for alcohol- despair peaked at 11% for men and 7% for women in the early related mortality (declining 3–5% annually), while drug- 1980s, and decreased until the late 1990s before stabilizing at related mortality initially rose sharply (30% among men and around 5–6% for women. In the 2010s, the relative share 13% among women between 1980–82 and 1993–95), before increased again to 9–10% for men. Supplementary Tables S1 declining. As a proportion of all-cause mortality, deaths of and S2 offer more detail on increasing and decreasing 4 JOURNAL OF PUBLIC HEALTH mortality rates, including confidence intervals and annual Discussion changes. Supplementary Figures S1 and S2 also summarize Main finding of this study sex- and cause-specific results for age groups 25–44 and Our findings show overall declines in mortality since 1980, 45–64 for the three causes of death and as a proportion of all particularly in alcohol- and drug-related mortality, which con- causes. The most noteworthy finding is the continual increase trasts with the increasing trends observed in the USA.6 How- in percentage of deaths of despair among the younger age ever, as a proportion of total mortality, the share of deaths of Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdad133/7231018 by guest on 10 October 2023 group since 1980. despair only increased slightly in the case of men aged 25–64 Due to the lag time between prolonged intake and chronic from 2000 onwards (from 9 to 10%). health effects, some deaths of despair have clear age patterns, Sex differences are also noteworthy; men’s all-cause mortal- especially alcohol-related death. Figure 2 shows a heatmap of ity rates were much higher than women’s rates throughout the 5-year age-specific rates. period. This result lends support to those who advocated sex- Throughout the 1980s, alcohol-related mortality was high specific analysis in response to the initial study by Case and among 50–64-year-old men, but gradually declined among Deaton,6 where this was not contemplated.10,17 One possible younger ages. This trend has continued to the present. explanation for our findings is that men are more vulnerable Regarding drug-related deaths, however, deaths were scarce to socioeconomic factors such as low educational attainment, until the mid-1980s (and still are among women). It then unemployment and financial strain that might conduce to increased among 25–39-year-old men, peaked in the late declines in mental health.20,21 Women, on the other hand, are 1990s and declined among young adult men over the next better able to cope with stressful situations, at least regarding decade. Among middle-aged men, a reverse trend can be the adoption of unhealthy lifestyles.20 observed since 2010. Lastly, suicide mortality was higher Educational inequalities in deaths of despair were analyzed among men of all ages compared with women, with peaks for the period 2017–19. Our findings show a pattern of gen- during the 1990s among men aged 25–45 and during the erally higher mortality rates among the low educated for the mid-1980s among men aged 45–64 (Supplementary Figs S1 three specific death-of-despair causes analyzed (alcohol, sui- and S2). As comparison, the heatmap for remaining natural cide and drugs), with higher levels in men than among women. and external causes shows clear annual declines and age Our findings are consistent with previous studies,6,7,21–25 gradients in the former and declining mortality after peaks including a pooled study of 27 European countries that found in the 1980s and early 1990s in the latter (mainly due to trends consistently higher all-cause mortality among the lower edu- in traffic accidents; results not shown). cated.26 It is well established that low-educated individu- als are more likely to experience higher rates of mortality Deaths of despair by educational attainment and sex as a result of poorer access to healthcare, financial strains, unemployment, low income, smoking, and use and abuse of Overall, educational differences in deaths of despair-related substances.27 Regarding the observed sex differences in the mortality among women are much less pronounced than men analyzed deaths of despair, men’s higher mortality rates across (Fig. 3). Results have shown a pattern of generally higher all educational levels may be due to their higher prevalence mortality rates among the low educated for the three specific in hazardous drinking and drug consumption. Concurrently, death-of-despair causes analyzed (alcohol, suicide and drugs), women’s smaller educational inequalities in mortality may with higher levels in men than among women. Among men, be due to the effect of the later socioeconomic modern- the highest educational differences are found for alcohol ization, which led to a delay in the adoption of smoking, and suicide. In the case of alcohol-related mortality, 2.08 especially among less educated women.28,29 Accordingly, the (95% CI: 1.95–2.22) low-educated men per population of relationship between men and women mortality rates is heav- 10 000 died during the period under study compared with ily influenced by epidemiological and social circumstances and 0.54 (95% CI: 0.50–0.59) high-educated men. Among women, behavioral differences.30 a marked educational gradient in mortality is observed only for alcohol-related diseases where low-educated women have the highest levels of mortality (0.51 (95% CI: 0.45–0.58) What is already known on this topic deaths per 10 000 compared with 0.14 (95% CI: 0.12–0.16) Before COVID-19, life expectancy improvement had slowed among high-educated women). For comparative purposes, in many high-income and low-mortality countries.1–4 This Supplementary Fig. S3 shows the results according to educa- has been attributed, at least partly, to increasing mortality rates tional attainment for the remaining natural and external causes from drug- and alcohol-related diseases and suicide, especially of death categories. among low-educated middle-aged men.6,7 These so-called DEATHS OF DESPAIR IN SPAIN 5 Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdad133/7231018 by guest on 10 October 2023 Fig. 2 Heat map of age- and cause-specific mortality rates per 10 000. Spanish men and women aged 25–64, 1980–2019. Note: The columns represent years (1980–2019) and rows age (25–64). The cells for each specific cause of death were colored differently using a gradient palette. Lighter colors represent lower mortality rates while darker colors represent higher mortality rates. 6 JOURNAL OF PUBLIC HEALTH Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdad133/7231018 by guest on 10 October 2023 Fig. 3 Age-standardized mortality rates (per 10 000) for alcohol-related, drug-related and suicide deaths according to educational attainment and sex. Ages 25–64, 2017–2019. Note: RII for alcohol-related mortality: 3.54 (95% CI: 2.21–5.66) men, 3.50 (95% CI: 2.13–5.75) women; drug-related mortality: 3.49 (95% CI: 1.80–6.77) men, 3.74 (95% CI: 1.68–8.33) women; suicide: 1.97 (95% CI, 1.49–2.61) men, 1.30 (95% CI, 1.02–1.66) women. deaths of despair may stem from societal factors such as young adult men, although admissions for treatment of abuse unemployment, financial insecurity and housing wealth.6–8,31 or dependency of non-social-recreational sedative-hypnotic However, the multifaceted underlying drivers of deaths of drugs (e.g. to deal with anxiety and distress) increased sharply despair are not yet fully understood. A recent literature review from about 300 during the late 1990s to 1192 in 2014, par- on deaths of despair and social determinants suggests a lack ticularly among middle-aged men.34,35 Preventive measures of consensus on the determinants, prompting a need for were established to raise awareness of the risks associated of further research on the structural and intermediate social substance use, such as with cannabis, which did not peak until determinants and mechanisms to better understand inequali- 2004.35 Another explanation for the decline in drug-related ties and their association with deaths of despair.32 mortality since the 1990s could be generational shifts in drug consumption, as the use of hard drugs, especially heroin, has What this study adds been declining almost uninterruptedly since 1995.34 This paper offers for the first time a comprehensive descrip- Our results on alcohol-related mortality align with other tive analysis of trends in alcohol- and drug-related deaths and Spanish studies that found very low alcohol-related mortality suicide since 1980 in Spain for 25–64-year-olds by sex, age and rates among women and declining rates among men between educational attainment. The share of these deaths of despair the early 1990s and late 2000s in Barcelona, Madrid and increased slightly since 2000, particularly for males aged 25– the Basque Country as well as similar educational differences 44. Drug-related deaths were rare until the mid-1980s (and still in the late 2000s36 and 2016–1837 as we found for 2017– are among women) but quickly increased among 25–39-year- 19. Given the very sharp decline in alcohol-related mortality old men due to the intravenous heroin epidemic and access since the 1980s despite alcohol consumption having remained to other drugs such as opioids and cocaine. One plausible stable since 1997,34 we also checked for age displacements explanation for the increase in consumed drugs is that illicit in deaths that could be due to improved medical treatment. drugs had become readily available after Spain transitioned to However, also for age groups 65–74 and 75–84, there were democracy in the late 1970s and became more prosperous, continual declines in alcohol-related mortality in both sexes and unemployment rose steadily. Moreover, coastlines and (results available upon request). borders were rarely controlled, facilitating the entry of drugs Regarding suicide, the higher rates observed among men into the country, while the possession of illicit drugs was compared with women and the lower educated compared no longer punishable.33 After reaching its peak in the late with the higher educated are in line with an earlier study con- 1990s, mortality from illicit drugs drastically declined among ducted in Spain.38 One possible explanation for these findings DEATHS OF DESPAIR IN SPAIN 7 is that men, and especially low educated, tend to be more although causes of death for violent deaths with judiciary vulnerable to socioeconomic factors such as unemployment intervention have been more accurately assigned since 2011, and financial strain, recession and economic crises as well as causing a notable increase during the period 2011–2013.45 more likely to engage in abuse of substances.20,21,24,25,27 The less precise classification of deaths due to suicide prior to Overall, our findings highlight that low educational attain- 2011 could explain the heterogeneous results in Spanish stud- ment is a strong determinant of premature mortality from ies on suicide during the economic crisis,45 although it should Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdad133/7231018 by guest on 10 October 2023 deaths of despair. Therefore, health policies should prioritize not affect our results on educational differences during 2017– interventions targeting primary drivers of premature mor- 19. Third, we used education as a proxy of socioeconomic tality. Policies should address alcohol use in young adults status. Although it is known to be less context dependent and low socioeconomic settings, with community-based pro- than income or occupation,23 there are yet no cause-specific grams focusing on prevention and promotion of safe nightlife data available for other socioeconomic indicators. Moreover, environments. As adverse health effects accumulate over the while we were able to calculate education-specific mortality life course, these programs could have long-term (mental) rates for 2017–19, it was not possible to stratify cause-specific health benefits. The combined analysis of trends in alcohol, mortality by educational level for the earlier part of the studied drugs and suicide since 1980 should be interpreted with cau- period, preventing us from analyzing time trends. tion as the age- and sex-specific trends of the specific causes Despite these limitations, one of the major strengths of our differ and it is unlikely that they share the same etiology. Doing study is having analyzed deaths-of-despair mortality trends so would ignore alternative explanations of the recent trends over a four-decade period and educational differences for a in drug-related deaths and growing educational inequity.10,39 recent period (2017–19). In addition, by analyzing sex sep- In contrast to the USA, one noteworthy difference is that arately we overcame the possibility of masking important ‘deaths of despair’ mortality in Spain is primarily attributable sex-based differences in mortality trends.10,17 Our findings to alcohol- rather than drug-related diseases, although such support evidence that inequalities in these premature and deaths have not decreased recently in Spain, except possibly in preventable specific causes of death also exist in Spain. Public the case of opioids.34 Spain’s stronger safety nets, particularly health policies are therefore needed to prevent these prema- the role of the family, including the fact that young Spanish ture and preventable deaths among vulnerable populations, adults are more likely to live with their parents, may also especially now in a post-COVID-19 era.46 contribute to having lower absolute and relative levels of deaths of despair, particularly in recent decades.4,40 However, Administrative permissions further research is needed to better understand the determi- No administrative permissions were required to access the raw nants of suicide, drugs and alcohol consumption among low- data used in our study. educated middle-aged adults. Moreover, the opioid epidemic, a longstanding public health issue in the USA characterized by Research involving human participants, human the misuse and addiction to opioids including the prescription material or human data of pain relievers, heroin and synthetic opioids7,41 is not yet prevalent in Spain, and could be another reason for the higher This research does not involve human participants, human rates of deaths of despair in the USA. material or human data. Limitations of this study Supplementary data Our study did have several limitations. First, alcohol- and Supplementary data are available at the Journal of Public Health drug-related deaths and suicides may be undercounted on online. death certificates as deaths may be misclassified and/or the certificate may list as primary the proximate cause rather than the underlying cause.42 Therefore, our underlying causes of Conflict of interest death approach may underestimate the absolute impact of The authors declare that they have no competing interests. alcohol and drugs, as shown for alcohol in Spain37 and for drugs in the USA.43 However, as this would mainly affect Funding absolute levels, we believe that the effect on time trends and educational differences will be minimal. Second, there are also This work was supported by the European Research Coun- limitations in using death certificate data. For instance, suicide cil (ERC-2019-COG agreement No 864616, HEALIN; PI: may not always be correctly coded due to it sensitive nature,44 I. Permanyer)—a project on healthy lifespan inequality; the 8 JOURNAL OF PUBLIC HEALTH Ramón y Cajal program of the Spanish Ministry of Science 3. World Population Prospects. The 2019 Revision http://esa.un.org/ and Innovation (RYC2021-033123-I); the National R&D Plan wpp (15 March 2023, date last accessed). (Grant no PID2020-113934RB-I00; PI: J. Spijker)—a project 4. Foreman KJ, Marquez N, Dolgert A et al. Forecasting life expectancy, on gender and SE inequalities in co-morbidity & multiple years of life lost, and all-cause and cause-specific mortality for 250 causes of death: reference and alternative scenarios for 2016–40 for causes of death; and the Catalan Government under the 195 countries and territories. Lancet 2018;392(10159):2052–90. CERCA program. The study sponsors had no role in the 5. Auerbach J, Miller BF. Deaths of despair and building a National Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdad133/7231018 by guest on 10 October 2023 design or conduction of the study; the collection, manage- Resilience Strategy. J Public Health Manag Pract 2018;24(4):297–300. ment, analysis and interpretation of the data; or the prepara- 6. Case A, Deaton A. Rising morbidity and mortality in midlife among tion, review or approval of the manuscript. white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A 2015;112(49):15078–83. Authors’ contributions 7. Case A, Deaton A. Mortality and morbidity in the 21(st) century. Brookings Pap Econ Act 2017;397–476. BP wrote the first draft of the manuscript. JS, STL and IP 8. Stein EM, Gennuso KP, Ugboaja DC et al. The epidemic of despair contributed to the writing of the paper and provided vital among white Americans: trends in the leading causes of premature feedback. JS, AB and STL contributed to data acquisition. AB death, 1999–2015. Am J Public Health 2017;107(10):1541–7. ran the analyses with input from BP, JS, ST and IP. All authors 9. Knapp EA, Bilal U, Dean LT et al. Economic insecurity and deaths of contributed to the study design and interpretation of analyses. despair in US counties. Am J Epidemiol 2019;188(12):2131–9. All authors critically reviewed and revised the manuscript and 10. Masters RK, Tilstra AM, Simon DH. Mortality from suicide, chronic approved the final version. liver disease, and drug poisonings among middle-aged U.S. white men and women, 1980–2013. Biodemography Soc Biol 2017;63(1):31–7. Data availability 11. Allik M, Brown D, Dundas R et al. Deaths of despair: cause-specific mortality and socioeconomic inequalities in cause-specific mortality All data relevant to the study are included in the article or among young men in Scotland. Int J Equity Health 2020;19(1):215. uploaded as supplemental information. 12. Walsh D, McCartney G, Minton J et al. Deaths from ‘diseases of despair’ in Britain: comparing suicide, alcohol-related and drug- related mortality for birth cohorts in Scotland, England and Note Wales, and selected cities. J Epidemiol Community Health 2021;75(12): The content is solely the responsibility of the authors and 1195–201. does not necessarily represent the official views of the 13. Marquez-Calderon S, Perez Velasco L, Viciana-Fernandez F et al. Trends in age-sex-specific mortality in Spain (1981–2016). National Institute of Statistics of Spain (INE). Changes associated with the economic crisis. Gac Sanit 2020;34(3): 230–7. Consent for publication 14. Mateo-Urdiales A, Barrio Anta G, Jose Belza M et al. Changes in drug and alcohol-related mortality by educational status during the 2008– Patients and or public were not involved in this research. Thus, 2011 economic crisis: results from a Spanish longitudinal study. Addict patient consent for publication was not required. Behav 2020;104:106255. 15. García González JM, Grande R. The changing sex differences in life Ethical approval and consent to partici- expectancy in Spain (1980–2012): decomposition by age and cause. pate Gac Sanit 2018;32:151–7. 16. INE. Asignación de nivel educativo, relación con la actividad laboral y ocupación The results presented in this paper are based on the analysis a ficheros de Movimiento Natural de la Población (MNP). Método de obtención y of secondary data provided by the Spanish National Statistics advertencias a usuarios. Madrid, Spain: INE (Spanish National Statistics Institute (INE), which has been properly anonymized. Thus, Institute), 2020. ethical approval was not required. Patients and or public 17. Masters RK, Tilstra AM, Simon DH. Explaining recent mortality were not involved in the design, or conduct, or reporting, or trends among younger and middle-aged white Americans. Int J Epi- dissemination plans of this research. demiol 2018;47(1):81–8. 18. Ruiz M, Cirera Suarez L, Perez G et al. Comparability between the ninth and tenth revisions of the international classification References of diseases applied to coding causes of death in Spain. Gac Sanit 1. Ho JY, Hendi AS. Recent trends in life expectancy across high income 2002;16(6):526–32. countries: retrospective observational study. BMJ 2018;362:k2562. 19. Moreno-Betancur M, Latouche A, Menvielle G et al. Relative index 2. OECD/European Union. Health at a Glance: Europe 2020. Paris: of inequality and slope index of inequality: a structured regression OECD Publishing, 2020. framework for estimation. Epidemiology 2015;26(4):518–27. DEATHS OF DESPAIR IN SPAIN 9 20. Lopez-Contreras N, Rodriguez-Sanz M, Novoa A et al. Socioe- 34. Observatorio Español de las Drogas y las Adicciones (OEDA). Alco- conomic inequalities in suicide mortality in Barcelona during hol, tabaco y drogas ilegales en España. Informe 2020. [Alcohol, tobacco and the economic crisis (2006-2016): a time trend study. BMJ Open illegal drugs in Spain. 2020 report]. Madrid: Ministerio de Sanidad, 2019;9(8):e028267. Consumo y Bienestar Social, 2020. 21. Blakely TA, Collings SC, Atkinson J. Unemployment and suicide. 35. Colell E, Sanchez-Niubo A, Delclos GL et al. Economic crisis and Evidence for a causal association? J Epidemiol Community Health changes in drug use in the Spanish economically active population. 2003;57(8):594–600. Addiction 2015;110(7):1129–37. Downloaded from https://academic.oup.com/jpubhealth/advance-article/doi/10.1093/pubmed/fdad133/7231018 by guest on 10 October 2023 22. Fishman SH, Gutin I. Debts of despair: education, financial losses, 36. Mackenbach JP, Kulhanova I, Bopp M et al. Inequalities in alcohol- and precursors of deaths of despair. SSM Popul Health 2021; related mortality in 17 European countries: a retrospective analysis of 14:100759. mortality registers. PLoS Med 2015;12(12):e1001909. 23. Huisman M, Kunst AE, Bopp M et al. Educational inequalities in 37. Trias-Llimos S, Spijker JJA. Educational differences in alcohol-related cause-specific mortality in middle-aged and older men and women in mortality and their impact on life expectancy and lifespan variation in eight western European populations. Lancet 2005;365(9458):493–500. Spain (2016–2018): a cross-sectional analysis using multiple causes of 24. Li Z, Page A, Martin G et al. Attributable risk of psychiatric and socio- death. BMJ Open 2022;12(1):e053205. economic factors for suicide from individual-level, population-based 38. Borrell C, Mari-Dell’Olmo M, Gotsens M et al. Socioeconomic studies: a systematic review. Soc Sci Med 2011;72(4):608–16. inequalities in suicide mortality before and after the economic reces- 25. Lorant V, Kunst AE, Huisman M et al. Socio-economic inequalities in sion in Spain. BMC Public Health 2017;17(1):772. suicide: a European comparative study. Br J Psychiatry 2005;187:49–54. 39. Geronimus AT, Bound J, Waidmann TA et al. Weathering, drugs, 26. Mackenbach JP, Valverde JR, Artnik B et al. Trends in health inequal- and whack-a-mole: fundamental and proximate causes of widening ities in 27 European countries. Proc Natl Acad Sci U S A 2018; educational inequity in U.S. life expectancy by sex and race, 1990– 115(25):6440–5. 2015. J Health Soc Behav 2019;60(2):222–39. 27. Mackenbach JP, Valverde JR, Bopp M et al. Determinants of inequali- 40. Fingerman KL, Cheng Y-P, Tighe L et al. Relationships between ties in life expectancy: an international comparative study of eight risk young adults and their parents. In: Booth A, Brown SL, Landale NS factors. Lancet Public Health 2019;4(10):e529–e37. et al. (eds). Early Adulthood in a Family Context. New York: Springer, 2012, 59–85. 28. Piñeiro B, Trias-Llimos S, Spijker JJA et al. Estimation of smoking- related mortality and its contribution to educational inequalities in life 41. National Institute of Drug Abuse. Opioid Overdose Crisis. National expectancy in Spain: an observational study, 2016–2019. BMJ Open Institute of Drug Abuse Website. drugabuse.gov/drug-topics/opioi 2022;12(8):e059370. ds/opioid-overdose-crisis (15 March 2023, date last accessed). 29. Kulhanova I, Bacigalupe A, Eikemo TA et al. Why does Spain have 42. Shiels MS, Tatalovich Z, Chen Y et al. Trends in mortality smaller inequalities in mortality? An exploration of potential explana- from drug poisonings, suicide, and alcohol-induced deaths in the tions. Eur J Public Health 2014;24(3):370–7. United States from 2000 to 2017. JAMA Netw Open 2020;3(9): e2016217. 30. Crimmins EM, Shim H, Zhang YS et al. Differences between men and women in mortality and the health dimensions of the morbidity 43. Glei DA, Preston SH. Estimating the impact of drug use on US process. Clin Chem 2019;65(1):135–45. mortality, 1999–2016. PloS One 2020;15(1):e0226732. 31. Jou A, Mas N, Vergara-Alert C. Housing wealth, health and deaths of 44. Alicandro G, Malvezzi M, Gallus S et al. Worldwide trends in suicide despair. J Real Estate Finan Econ 2023;66(3):569–602. mortality from 1990 to 2015 with a focus on the global recession time frame. Int J Public Health 2019;64(5):785–95. 32. Beseran E, Pericas JM, Cash-Gibson L et al. Deaths of despair: a scoping review on the social determinants of drug overdose, 45. Moreno-Lostao A, Barrio G, Sordo L et al. Mortality in working-age alcohol-related liver disease and suicide. Int J Environ Res Public Health population during the great recession and austerity in Spain. PloS One 2022;19(19):12395. 2019;14(6):e0218410. 33. Reeg AR. Drugs and the law in post-Franco Spain. In: Traver H, 46. Muntaner C, Gunn V, Prins SJ. On Case and Deaton’s deaths of Gaylord M (eds). Drugs, Law and the State. Hong Kong: Hong Kong despair: implications for health inequalities research in the post- University Press, 1992, 49–63. COVID-19 era. Gac Sanit 2021;35(5):409–10.