Deaths of despair before and during the COVID-19 pandemic: a comparative analysis of 27 European countries and the United States

Background: The phenomenon of "deaths of despair" has been frequently described in the context of the United States but has rarely been analyzed across multiple countries. The onset of the coronavirus disease 2019 (COVID-19) pandemic, accompanied by the imposition of substantial restrictions by public authorities, may have worsened mental health at the individual level, thereby potentially increasing the number of despair-related deaths. Objective: This study investigates trends and differences in despair-related deaths across 27 European countries and the United States before and during the COVID-19 pandemic. Methods: Using official cause-of-death statistics, we estimated standardized death rates (SDRs) by country and sex from 2011-2021 for despair-related deaths and five sub-categories based on a harmonized classification. To quantify the relative change during the two pandemic years (2020-2021) compared to the five preceding years (2015-2019), we calculated standardized mortality ratios (SMRs). Results: In most European countries, the number of despair-related deaths remained stable or declined over the past decade. However, this downward trend did not continue during the pandemic. Increases were observed in Eastern European countries and Ireland, but remained well below those in the United States. Contribution: This study is the first to explore recent trends in deaths of despair across wide parts of Europe in comparison with the United States based on a harmonized classification. The underlying causes of these deaths, which are considered preventable, are multifaceted and necessitate the implementation of targeted public health strategies.