Age- and cause-specific contributions of deaths of despair to changes in life expectancy across European countries, 2001-2021

Technical Summary: Age- and Cause-Specific Contributions of Deaths of Despair to Changes in Life Expectancy Across European Countries, 2001–2021

Problem Statement
While "deaths of despair" (DoD)—comprising suicide, drug-related, and alcohol-related deaths—have been extensively linked to life expectancy (LE) stagnation in the United States, comparative cross-national evidence regarding their specific contributions to LE changes across Europe remains limited. Existing European literature has largely focused on mortality rate trends or cross-sectional estimates, with a notable gap in quantifying the age- and cause-specific contributions of DoD to LE changes over time. This study addresses this gap by estimating these contributions across 25 European countries from the turn of the 21st century through the early pandemic period.

Methodology
This descriptive observational study utilized mortality data from the WHO Mortality Database and population data from the Human Mortality Database.

• Data Scope: The analysis covered 25 European countries (including UK constituent nations) across three reference periods: 2001–2003 (early 21st century), 2017–2019 (pre-pandemic), and 2020–2021 (pandemic).
• Cause Classification: Underlying causes of death were classified into four mutually exclusive categories based on ICD-10 codes: drug-related deaths, suicide, alcohol-related deaths, and all other causes. The first three categories constituted DoD.
• Analytical Approach: Abridged life tables were constructed for each period and country. Changes in LE at birth across the pre-pandemic (2001–2003 to 2017–2019) and pandemic (2017–2019 to 2020–2021) intervals were decomposed by age and cause using the continuous-change model proposed by Horiuchi et al. All analyses were conducted separately by sex and country using the "DemoDecomp" package in RStudio.

Key Contributions

• Quantification of Contributions: The study provides the first comprehensive quantification of how specific DoD causes (drug, alcohol, suicide) and age groups contributed to LE gains and losses across a broad sample of European countries over two distinct historical intervals.
• Temporal Reversal Analysis: It documents a critical reversal in the impact of DoD on LE, shifting from a net positive contribution in the pre-pandemic era to a net negative contribution during the pandemic.
• Heterogeneity Mapping: The research highlights significant cross-country, cross-sex, and cross-cause heterogeneity, challenging the notion of a unified "deaths of despair" phenomenon that moves in tandem across all causes.

Results

• Overall Trends: During the pre-pandemic interval, LE increased in all countries, with DoD causes generally contributing to these gains (median contribution: +1.2 months for females, +3.8 months for males). Conversely, during the pandemic interval, LE declined in most countries, with DoD causes contributing to these losses (median contribution: -0.1 months for both sexes).
• Cause-Specific Dynamics:
  • Alcohol-Related Deaths: This was the primary driver of the reversal. Contributions shifted from predominantly positive in the pre-pandemic interval to predominantly negative during the pandemic.
  • Suicide: Generally contributed positively to LE gains in both intervals, though the number of countries with negative contributions increased among females during the pandemic.
  • Drug-Related Deaths: Predominantly contributed to LE declines in both intervals and sexes, with the notable exception of Scotland, where drug-related deaths were the leading negative contributor in both periods.
• Age-Specific Patterns: In the pre-pandemic interval, the 40–59 age groups accounted for the largest absolute contributions. During the pandemic, a shift toward younger age groups emerged, particularly among males (20–29 age group).
• Regional Variations:
  • UK Constituent Countries: Uniquely exhibited negative DoD contributions in both sexes for both intervals, closely resembling US patterns. Scotland recorded the largest LE losses from drug-related deaths.
  • Central/Eastern Europe & Baltics: Generally showed the largest LE gains from DoD in the pre-pandemic interval (driven by declines in alcohol and suicide mortality), but many, particularly Estonia, experienced significant LE losses during the pandemic. Estonia notably shifted from having the second/third highest gains pre-pandemic to the second/third highest losses during the pandemic.
  • Nordic Exception: Unlike the UK, most Nordic countries maintained positive DoD contributions pre-pandemic, though Iceland and Sweden showed some divergence.

Significance and Claims
The paper claims that the observed heterogeneity in DoD contributions challenges the unified "deaths of despair" framework, which posits that these mortality causes move in tandem as a collective phenomenon. Instead, the findings support the necessity of analyzing these causes separately to understand their distinct drivers and impacts.

The study concludes that policy responses must be cause-specific and nationally tailored rather than adopting a "one-size-fits-all" approach. Specifically, it highlights the need for targeted strategies to address drug-related mortality among younger and middle-aged adults, while acknowledging that alcohol-related mortality requires distinct interventions given its dramatic shift from a contributor to LE gains to a driver of LE losses during the pandemic. The authors explicitly state that their ecological and descriptive design precludes causal attribution of these changes to the pandemic itself, noting that the observed shifts should be regarded as speculative regarding specific causal mechanisms.