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For more information about what to do to address many of
the issues outline in this report, visit and to get specific policy and
programmatic recommendations for advancing mental health and
addiction in this country, as one avenue to help decrease deaths of
despair in our country.


Stephen Petterson, PhD
Robert Graham Center
American Academy of Family Physicians
John M. Westfall, MD, MPH
Robert Graham Center
American Academy of Family Physicians
Benjamin F. Miller, PsyD
Well Being Trust

More Americans could lose their lives to deaths of despair,
deaths due to drug, alcohol, and suicide, if we do not do something
immediately. Deaths of despair have been on the rise for the last
decade, and in the context of COVID-19, deaths of despair should
be seen as the epidemic within the pandemic. The goal of this
report is to predict what deaths of despair we might see based
on three assumptions during COVID-19: economic recovery,
relationship between deaths of despair and unemployment, and
geography. Across nine different scenarios, additional deaths of
despair range from 27,644 (quick recovery, smallest impact of
unemployment on deaths of despair) to 154,037 (slow recovery,
greatest impact of unemployment on deaths of despair), with
somewhere in the middle being around 68,000. However, these
data are predictions. We can prevent these deaths by taking
meaningful and comprehensive action as a nation.

We used the quantifiable factors identified from prior economic downturns to
estimate the number of additional deaths of despair due to COVID-19 impact
on unemployment, isolation, and uncertainty. We shifted our interpretation
slightly as we predict social isolation will have an additional negative impact
on the lives of those suffering economic downturn. For the uncertainty, while
we predict it may have a negative impact, it is not included in our calculations
and is intended to be used to encourage social connection in the face of
physical distancing, and for policies that mitigate the economic loss and
unemployment we are witnessing. Ideally, local communities and even states
can implement measures to mitigate isolation, creating local solutions for
their neighbors and friends. While high unemployment may be a national fact,
social connection and the impact of uncertainty may be a local phenomenon,
amenable to community and local policy solutions. As science sheds light
on the novel COVID-19 virus, uncertainty may give rise to confidence and
rigorous education.


Policy solutions
This report is not a call to suddenly reopen the country. Some might use this report to argue that
this is why our economy needs to open up fast. But that’s NOT what we are saying. We need to
abide by good science, and make sure that testing and contact tracing is occurring at adequate
levels to assure that it is safe to open up. Even as of today parts of the country are opening, data
suggest that this is premature due to a lack of consistent testing, which allows local public health
authorities to trace, treat, and isolate to prevent further spread. A range of efforts at containing the
COVID-19 pandemic must be rigorously applied to minimize deaths from infection. Policies that
maintain infection control while addressing the mental health and addiction needs of the people
will balance the impact of COVID-19 across all sectors.
Deaths of despair were a problem before COVID-19, just as health disparities were also a problem
prior to COVID-19. What COVID-19 has done, is highlight yet again that the United States has not
addressed underlying structural flaws in our systems. Issues of disparities are perpetuated by not
addressing structural inequalities like employment, transportation, and income, making those at
highest risk for losing their job or being exposed to COVID-19 communities who were already at a
higher risk of a death of despair and now at even higher risk of dying to COVID-19.
To fully address the issues that surround deaths of despair, our policy solutions must
be comprehensive and attempt to tackle the social, economic, and health related
factors all at once. This begins with a recognition of the complex interplay between
employment status and our overall health and well-being. With the profound
uncertainty surrounding our economy from COVID-19, it is not clear the full extent
unemployment may have on our nation as well as other nations. This brief is not
intended to offer up all the solutions to each of these complex problems, but rather
draw attention to them so our government, at every level, can begin to realize the
connections. We offer a few examples of policies that may help stem the tide of
deaths of despair in the time of COVID-19.

Central to many of the problems in our communities will be the need to find
employment. The literature is clear that unemployment is a risk factor for suicide
and drug overdose as well as a decrease in overall health status. To this end, policy
solutions must focus on providing meaningful work to those who are unemployed.
Service can be a powerful antidote to isolation and despair, and COVID-19 offers
new and unique opportunities to employ a new workforce – whether that be
through contact tracing – helping local public health department track the virus
– or through community health services where a new corps of community
members are employed to provide help to those in the most need. Let us make
sure that we provide additional training to these front-line workers to assure that
they are capable of also addressing issues of mental health and addiction as they
will likely encounter them as well. In fact, this work may be identifying mental
health needs or connecting people to care when appropriate.

The pandemic has created the greatest forced isolation in our modern history. We
are physically distant but must socially connect (Bergman et al, 2020). Communities
have created innovative solutions for connecting with their neighbors like singing (or
howling) from their balconies and porches. Faith communities are reinventing how
their members can get together through online and virtual platforms; however, many
small organizations, civic clubs, and community groups do not have the resources
to build robust virtual platforms. Many communities may not have the bandwidth or
internet access to support video connections. Policies that support small non-profit
organizations, faith communities, and community solutions can provide opportunities
to get people connected to their neighbors (Felzien et al., 2018).

We must immediately engage all COVID-19 response and recovery efforts in mental
health screening and treatment. It is not just the job of mental health clinicians, or even
primary care, to find and treat all those suffering from the mental health impacts of
unemployment, social isolation, and the fear of uncertainty. As we create teams to test,
track and trace COVID-19 infections, we must also test, track, trace, and treat patients
suffering from mental health and substance use disorders.

Uncertainty leads to fear and fear may give way to dread. And dread negatively impacts
our health and well-being. People need science and calm facts. This is not a time
for partisan positioning; it is a time, as President George Bush said recently, to stand
together while apart. Every leader offering a briefing on the topic should provide
informative leadership on the topic of mental health by describing its impact, ways
people can get help, and what to expect from the pandemic.

COVID-19 opens up the door to offer a new vision for the future of health care in this
country. Mental health should be central to that vision. Care that is fragmented only
creates roadblocks for patients and families. Referrals, prior authorizations, and other
administrative barriers have historically led to frustration by all parties, including clinicians.
It is essential to bring mental health and addiction care into the fabric of a redesigned
vision of clinical care, as well as across community settings. This requires vision, alignment
with a framework, and a method for holding key stakeholders accountable for personcentered outcomes (Well Being Trust, 2020).
Any policy plan brought forward that does not consider ways to better integrate mental
health and addiction services will likely have a much less significant impact.

Care, especially primary and mental health care, has historically been fragmented.
Individuals have had to work harder to get the care they need, and often that care is not
delivered in a timely or evidence-based fashion. If COVID-19 has highlighted anything
about our current delivery system, it’s that asking people to come to a clinic or a hospital
is not always the best approach. Policies that support creative opportunities for care
delivered at home, virtually or in-person will provide comfort and safety. The idea of
a home visit or a house call is not new, and for professions like primary care, it can
be a major benefit for countless. The artificial walls we have created around who can
be seen where, by whom, and for what, have not been proven to work effectively for
mental health. Its time to consider policies that bring care to people as one avenue for
mitigating despair and providing help to those who need it most.


The models we have created rely on the way things happened before — when our
communities were faced with rising unemployment, social isolation, and individual
uncertainty the people suffered, to increased deaths of despair. But things could
be different. By taking stock of the current crisis, predicting potential loss of life,
and creatively deploying local community solutions, it may be possible to prevent
impending deaths of despair. We should not sit idly by, waiting for more deaths of
despair to occur but move aggressively towards solutions that bring mental health
into the center of all our discussions on COVID-19 response and recovery.


For more information about what to do to address many of
the issues outline in this report, visit and to get specific policy and
programmatic recommendations for advancing mental health and
addiction in this country, as one avenue to help decrease deaths of
despair in our country