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Abstract

Midlife Mortality
ProceedingsoftheNationalAcademyofSciences This Issue
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(/) >CurrentIssue(/content/112/49.toc) >vol.112no.49 >AnneCase,1507815083,doi:10.1073/pnas.1518393112 Midlife Morbidity

Discussion

Materials and Methods

SI Data

SI Materials and Methods

Acknowledgments
Rising morbidity and mortality in midlife among white non- (/content/112/49.toc)
Footnotes December 8, 2015
Hispanic Americans in the 21st century vol. 112 no. 49
ReferencesMasthead (PDF)
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AnneCase(/search?author1=Anne+Case&sortspec=date&submit=Submit) and
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ContributedbyAngusDeaton,September17,2015(sentforreviewAugust22,2015reviewedbyDavidCutler,JonSkinner,
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Midlifeincreasesinsuicidesanddrugpoisoningshavebeenpreviouslynoted.However,thatthese
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upwardtrendswerepersistentandlargeenoughtodriveupallcausemidlifemortalityhas,toour content published
knowledge,beenoverlooked.Ifthewhitemortalityrateforages4554hadheldattheir1998value, in PNAS.

96,000deathswouldhavebeenavoidedfrom19992013,7,000in2013alone.Ifithadcontinuedto
declineatitsprevious(19791998)rate,halfamilliondeathswouldhavebeenavoidedintheperiod Article Tools
19992013,comparabletoliveslostintheUSAIDSepidemicthroughmid2015.Concurrent Article Alerts

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ThispaperdocumentsamarkedincreaseintheallcausemortalityofmiddleagedwhitenonHispanicmen (/external-ref?
and women in the United States between 1999 and 2013. This change reversed decades of progress in tag_url=http://www.pnas.org/cgi/content/short/11
mortalityandwasuniquetotheUnitedStatesnootherrichcountrysawasimilarturnaround.Themidlife Hispanic%20Americans%20in%20the%2021st%20
mortality reversal was confined to white nonHispanics black nonHispanics and Hispanics at midlife, and +PNAS&doi=10.1073/pnas.1518393112&link_type
those aged 65 and above in every racial and ethnic group, continued to see mortality rates fall. This
(/external-ref?
increaseforwhiteswaslargelyaccountedforbyincreasingdeathratesfromdrugandalcoholpoisonings,
tag_url=http://www.pnas.org/cgi/content/long/112
suicide,andchronic liver diseases and cirrhosis. Although all education groups saw increases in mortality
Hispanic%20Americans%20in%20the%2021st%20
fromsuicideandpoisonings,andanoverallincreaseinexternalcausemortality,thosewithlesseducation +PNAS&doi=10.1073/pnas.1518393112&link_type
saw the most marked increases. Rising midlife mortality rates of white nonHispanics were paralleled by
increasesinmidlifemorbidity.Selfreporteddeclinesinhealth,mentalhealth,andabilitytoconductactivities
of daily living, and increases in chronic pain and inability to work, as well as clinically measured (/external-ref?
deteriorations in liver function, all point to growing distress in this population. We comment on potential tag_url=http://www.pnas.org/cgi/content/long/112
economiccausesandconsequencesofthisdeterioration. Hispanic%20Americans%20in%20the%2021st%20
+PNAS&doi=10.1073/pnas.1518393112&link_type
midlifemortality(/search?fulltext=midlife+mortality&sortspec=date&submit=Submit&andorexactfulltext=phrase)
(/external-ref?
morbidity(/search?fulltext=morbidity&sortspec=date&submit=Submit&andorexactfulltext=phrase)
tag_url=http://www.pnas.org/cgi/content/long/112
USwhitenonHispanics(/search?fulltext=US+white+nonHispanics&sortspec=date&submit=Submit&andorexactfulltext=phrase)
Hispanic%20Americans%20in%20the%2021st%20
+PNAS&doi=10.1073/pnas.1518393112&link_type
There has been a remarkable longterm decline in mortality rates in the United States, a decline in which (/external-ref?
middleaged and older adults have fully participated (13). Between 1970 and 2013, a combination of tag_url=http://www.pnas.org/cgi/content/long/112
behavioralchange,prevention,andtreatment(4,5)broughtdownmortalityratesforthoseaged4554by Hispanic%20Americans%20in%20the%2021st%20
44%. Parallel improvements were seen in other rich countries (2). Improvements in health also brought +PNAS&doi=10.1073/pnas.1518393112&link_type
declinesinmorbidity,evenamongtheincreasinglylonglivedelderly(69).
Thesereductionsinmortalityandmorbidityhavemadeliveslongerandbetter,andthereisageneraland
(/external-ref?
wellbased presumption that these improvements will continue. This paper raises questions about that
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tag_url=http://www.pnas.org/cgi/content/short/11
presumption for white Americans in midlife, even as mortality and morbidity continue to fall among the
Hispanic%20Americans%20in%20the%2021st%20
elderly. Top
+PNAS&doi=10.1073/pnas.1518393112&link_type

This paper documents a marked deterioration in the morbidity and mortality of middleaged white non Abstract
Published online before print
Hispanics in the United States after 1998. General deterioration in midlife morbidity among whites has November 2, 2015, doi:
Midlife Mortality
10.1073/pnas.1518393112
receivedlimitedcomment(10,11), but the increase in allcause midlife mortality that we describe has not
PNAS (Proceedings of the National
been previously highlighted. For example, it does not appear in the regular mortality and health reports Academy of Sciences)
Midlife MorbidityDecember
issued by the CDC (12), perhaps because its documentation requires disaggregation by age and race. 8, 2015 vol. 112 no. 49 15078-
Beyondthat,theextenttowhichtheepisodeisunusualrequireshistoricalcontext,aswellascomparison 15083
Discussion
withotherrichcountriesoverthesameperiod. Classications
Materials and Methods
Social Sciences
Increasing mortality in middleaged whites was matched by increasing morbidity. When seen side by side Social Sciences
SI Data
(/search?
with the mortality increase, declines in selfreported health and mental health, increased reports of pain,
tocsectionid=Social+Sciences&sortspec=date&submit=Subm
andgreaterdifficultieswithdailylivingshowincreasingdistressamongwhitesinmidlifeafterthelate1990s. SI Materials and Methods
Wecommentonpotentialeconomiccausesandconsequencesofthisdeterioration.
Acknowledgments

Figures
Footnotes
Midlife Mortality
References
Fig.1 shows age 4554 mortality rates for US white nonHispanics (USW, in red), US Hispanics (USH, in
blue),andsixrichindustrializedcomparisoncountries:France(FRA),Germany(GER),theUnitedKingdom
(UK),Canada(CAN),Australia(AUS),andSweden(SWE).ThecomparisonissimilarforotherOrganisation
forEconomicCooperationandDevelopmentcountries.

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Fig.1.

Allcausemortality,ages4554forUSWhitenonHispanics(USW),USHispanics(USH),andsix
comparisoncountries:France(FRA),Germany(GER),theUnitedKingdom(UK),Canada(CAN),
Australia(AUS),andSweden(SWE).

Fig.1 shows a cessation and reversal of the decline in midlife mortality for US white nonHispanics after
1998. From 1978 to 1998, the mortality rate for US whites aged 4554 fell by 2% per year on average,
which matched the average rate of decline in the six countries shown, and the average over all other
industrializedcountries.After1998,otherrichcountriesmortalityratescontinuedtodeclineby2%ayear.
In contrast, US white nonHispanic mortality rose by half a percent a year. No other rich country saw a
similar turnaround. The mortality reversal was confined to white nonHispanics Hispanic Americans had
mortality declines indistinguishable from the British (1.8% per year), and black nonHispanic mortality for
ages4554declinedby2.6%peryearovertheperiod.

For deaths before 1989, information on Hispanic origin is not available, but we can calculate lives lost
among all whites. For those aged 4554, if the white mortality rate had held at its 1998 value, 96,000
deathswouldhavebeenavoidedfrom1999to 2013, 7,000 in 2013 alone. If it had continued to fall at its
previous (19791998) rate of decline of 1.8% per year, 488,500 deaths would have been avoided in the
period19992013,54,000in2013.(SupportingInformationprovidesdetailsoncalculations.)

Thisturnaround,asof2014,isspecifictomidlife.AllcausemortalityratesforwhitenonHispanicsaged65
74 continued to fall at 2% per year from 1999 to 2013 there were similar declines in all other racial and
ethnicgroupsaged6574.However,themortalitydeclineforwhitenonHispanicsaged5559alsoslowed,
 decliningonly0.5%peryearoverthisperiod.

There was a pause in midlife mortality decline in the 1960s, largely explicable by historical patterns of Navigate This Article
smoking(13).Otherwise,thepost1999episodeinmidlifemortalityintheUnitedStatesisbothhistorically
Top
and geographically unique, at least since 1950. The turnaround is not a simple cohort effect Americans
bornbetween1945and1965didnothaveparticularlyhighmortalityratesbeforemidlife. Abstract

Fig. 2 presents the three causes of death that account for the mortality reversal among white non Midlife Mortality
Hispanics, namely suicide, drug and alcohol poisoning (accidental and intent undetermined), and chronic
Midlife Morbidity
liverdiseasesandcirrhosis.Allthreeincreasedyearonyear after 1998. Midlife increases in suicides and
drugpoisoningshavebeenpreviouslynoted(1416).However,thattheseupwardtrendswerepersistent Discussion
and large enough to drive up allcause midlife mortality has, to our knowledge, been overlooked. For
context,Fig.2 also presents mortality from lung cancer and diabetes. The obesity epidemic has (rightly) Materials and Methods

made diabetes a major concern for midlife Americans yet, in recent history, death from diabetes has not
SI Data
beenanincreasingthreat.Poisoningsovertooklungcancerasacauseofdeathin2011inthisagegroup
suicideappearspoisedtodoso. SI Materials and Methods

Acknowledgments

Footnotes

References

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Fig.2.

Mortalitybycause,whitenonHispanicsages4554.

Table1showschangesinmortalityratesfrom1999to2013forwhitenonHispanicmenandwomenages
4554 and, for comparison, changes for black nonHispanics and for Hispanics. The table also presents
changes in mortality rates for white nonHispanics by three broad education groups: those with a high
school degree or less (37% of this subpopulation over this period), those with some college, but no
bachelors(BA)degree(31%),andthosewithaBAormore(32%).Thefractionof45to54yoldsinthe
threeeducationgroupswasstableoverthisperiod.Eachcellshowsthechangeinthemortalityratefrom
1999to2013,aswellasitslevel(deathsper100,000)in2013.

Table1.

In this window (15078/T1.expansion.html) Changesinmortalityrates20131999,ages4554

In a new window (15078/T1.expansion.html) (2013mortalityrates)

Overthe15yperiod,midlifeallcausemortalityfellbymorethan200per100,000forblacknonHispanics,
andbymorethan60 per 100,000 for Hispanics. By contrast, white nonHispanic mortality rose by 34 per
100,000.TheratioofblacknonHispanictowhitenonHispanicmortalityratesforages4554fellfrom2.09
in 1999 to 1.40 in 2013. CDC reports have highlighted the narrowing of the blackwhite gap in life
expectancy (12). However, for ages 4554, the narrowing of the mortality rate ratio in this period was
largelydrivenbyincreasedwhitemortalityifwhitenonHispanicmortalityhadcontinuedtodeclineat1.8%
peryear,theratioin2013wouldhavebeen1.97.Theroleplayedbychangingwhitemortalityratesinthe
narrowingoftheblackwhitelifeexpectancygap(20032008)hasbeenpreviouslynoted(17).Itisfarfrom
clearthatprogressinblacklongevityshouldbebenchmarkedagainstUSwhites.

ThechangeinallcausemortalityforwhitenonHispanics4554islargelyaccountedforbyanincreasing
deathratefromexternalcauses,mostlyincreasesindrugandalcoholpoisoningsandinsuicide.(Patterns
are similar for men and women when analyzed separately.) In contrast to earlier years, drug overdoses
werenotconcentratedamongminorities.In1999,poisoningmortalityforages4554was10.2per100,000
higherforblacknonHispanicsthanwhitenonHispanicsby2013,poisoningmortalitywas8.4per100,000
higher for whites. Death from cirrhosis and chronic liver diseases fell for blacks and rose for whites. After
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2006,deathratesfromalcoholanddruginducedcausesforwhitenonHispanicsexceededthoseforblack
nonHispanics in 2013, rates for white nonHispanic exceeded those for black nonHispanics by 19 per Top
100,000.
Abstract
The three numbered rows of Table 1 show that the turnaround in mortality for white nonHispanics was
Midlife Mortality
drivenprimarilybyincreasingdeathratesforthosewithahighschooldegreeorless.Allcausemortalityfor
thisgroupincreasedby134per100,000between1999and2013.Thosewithcollegeeducationlessthana Midlife Morbidity
BA saw little change in allcause mortality over this period those with a BA or more education saw death
ratesfallby57per100,000.Althoughallthreeeducationalgroupssawincreasesinmortalityfromsuicide Discussion
andpoisonings, and an overall increase in external cause mortality, increases were largest for those with
Materials and Methods
theleasteducation.Themortalityratefrompoisoningsrosemorethanfourfoldforthisgroup,from13.7to
58.0, and mortality from chronic liver diseases and cirrhosis rose by 50%. The final two rows of the table SI Data
show increasing educational gradients from 1999 and 2013 the ratio of midlife allcause mortality of the
lowesttothehighesteducationalgrouprosefrom2.6in1999to4.1in2013. SI Materials and Methods

Acknowledgments
Fig. 3 shows the temporal and spatial joint evolution of suicide and poisoning mortality for white non
Hispanicsaged4554,foreveryotheryearfrom1999to2013,foreachofthefourcensusregionsofthe Footnotes
United States. Death rates from these causes increased in parallel in all four regions between 1999 and
2013.SuiciderateswerehigherintheSouth(markedinblack)andtheWest(green)thanintheMidwest References
(red)orNortheast(blue)atthebeginningofthisperiod,butineachregion,anincreaseinsuicidemortality
of1per100,000wasmatchedbya2per100,000increaseinpoisoningmortality.

(15078/F3.expansion.html)

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Fig.3.

Censusregionlevelsuicideandpoisoningmortalityrates19992013.CensusregionsareNortheast
(blue),Midwest(red),South(black),andWest(green).

Thefocusofthispaperisonchangesinmortalityandmorbidityforthoseaged4554.However,asFig.4
makesclear,all5yagegroupsbetween3034and6064havewitnessedmarkedandsimilarincreasesin
mortalityfromthesumofdrugandalcoholpoisoning,suicide,andchronicliverdiseaseandcirrhosisover
the period 19992013 the midlife group is different only in that the sum of these deaths is large enough
thatthecommongrowthratechangesthedirectionofallcausemortality.
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Top

Abstract

Midlife Mortality

Midlife Morbidity

Discussion

(15078/F4.expansion.html) Materials and Methods

SI Data

SI Materials and Methods

Acknowledgments

Footnotes

References

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Fig.4.

Mortalitybypoisoning,suicide,chronicliverdisease,andcirrhosis,whitenonHispanicsby5yage
group.

Midlife Morbidity
Increasesinmidlifemortalityareparalleledbyincreasesinselfreportedmidlifemorbidity.Table2presents
measuresofselfassessedhealthstatus,pain,psychologicaldistress,difficultieswithactivitiesofdailyliving
(ADLs),andalcoholuse.EachrowpresentstheaveragefractionofwhitenonHispanicsages4554who
reported a given health condition in surveys over 20112013, followed by the change in the fraction
reporting that condition between survey years 19971999 and 20112013, together with the 95%
confidenceinterval(CI)onthesizeofthatchange.

Table2.

In this window (15078/T2.expansion.html) Changesinmorbidity,whitenonHispanics4554

In a new window (15078/T2.expansion.html)

ThefirsttworowsofTable2presentthefractionofrespondentswhoreportedexcellentorverygoodhealth
and fair or poor health. There was a large and statistically significant decline in the fraction reporting
excellent or very good health (6.7%), and a corresponding increase in the fraction reporting fair or poor
health(4.3%).ThisdeteriorationinselfassessedhealthisobservedineachUSstateanalyzedseparately
(resultsomittedforreasonsofspace).Onaverage,respondentsinthelaterperiodreportedan additional
fulldayinthepast30whenphysicalhealthwasnotgood.

The increase in reports of poor health among those in midlife was matched by increased reports of pain.
Rows 47 of Table2 present the fraction reporting neck pain, facial pain, chronic joint pain, and sciatica.
OneinthreewhitenonHispanicsaged4554reportedchronicjointpaininthe20112013periodonein
five reported neck pain and one in seven reported sciatica. Reports of all four types of pain increased
significantly between 19971999 and 20112013: An additional 2.6% of respondents reported sciatica or
chronicjointpain,anadditional2.3%reportedneckpain,andanadditional1.3%reportedfacialpain.

The fraction of respondents in serious psychological distress also increased significantly. Results from the
Kessler six (K6) questionnaire show that the fraction of people who were scored in the range of serious
mentalillnessrosefrom3.9%to4.8%overthisperiod.Comparedwith199799,respondentsin20112013
reportedanadditionaldayinthepastmonthwhentheirmentalhealthwasnotgood.

Table2 also reports the fraction of people who respond that they have more than a little difficulty with
ADLs.Overthisperiod,therewassignificantmidlifedeterioration,ontheorderof23percentagepoints,in
walkingaquartermile,climbing10steps,standingorsittingfor2h,shopping,andsocializingwithfriends.
Thefractionofrespondentsreportingdifficultyinsocializing,ariskfactorforsuicide(18,19),increasedby
2.4 percentage points. Respondents reporting that their activities are limited by physical or mental health
increased by 3.2 percentage points. The fraction reporting being unable to work doubled for white non
Hispanicsaged4554inthis15yperiod.
Increasing obesity played only a part in this deterioration of midlife selfassessed health, mental health,
reportedpain,and difficulties with ADLs. Respondents with body mass indices above 30 reported greater
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morbidityalongallofthesedimensions.However,deteriorationinmidlifemorbidityoccurredforbothobese
andnonobeserespondents,andincreasedprevalenceofobesity accounts for only a small fraction of the Top
overalldeterioration.
Abstract
Risk for heavy drinkingmore than one (two) drinks daily for women (men)also increased significantly.
Midlife Mortality
Bloodtestsshowincreasesinthefractionofparticipantswithelevatedlevelsofaspartateaminotransferase
(AST)andalanineaminotransferase(ALT)enzymes,indicatorsforpotentialinflammationof,ordamageto, Midlife Morbidity
theliver.NonalcoholicfattyliverdiseasecanalsoelevateASTandALTenzymesforthisreason,weshow
the fractions with elevated enzymes among all respondents, and separately for nonobese respondents Discussion
(thosewithbodymassindex<30).
Materials and Methods

As was true in comparisons of mortality rate changes, where midlife groups fared worse than the elderly,
SI Data
most of these morbidity indicators either held constant or improved among older populations over this
period.Withtheexceptionofneckpainandfacial pain, and enzyme test results (for which census region SI Materials and Methods
markers are not available), the temporal evolution of each morbidity marker presented in Table 2 is
Acknowledgments
significantly associated with the temporal evolution of suicide and poisonings within census region.
(SupportingInformationprovidesdetails.) Footnotes

References
Discussion
The increase in midlife morbidity and mortality among US white nonHispanics is only partly understood.
The increased availability of opioid prescriptions for pain that began in the late 1990s has been widely
noted,ashastheassociatedmortality(14,2022).TheCDCestimatesthatforeachprescriptionpainkiller
deathin2008,therewere10treatmentadmissionsforabuse,32emergencydepartmentvisitsformisuse
orabuse,130peoplewhowereabusersordependent,and825nonmedicalusers(23).Tightercontrolson
opioidprescriptionbroughtsomesubstitutionintoheroinand,inthisperiod,theUSsawfallingpricesand
rising quality of heroin, as well as availability in areas where heroin had been previously largely unknown
(14,24,25).

The epidemic of pain which the opioids were designed to treat is real enough, although the data here
cannot establish whether the increase in opioid use or the increase in pain came first. Both increased
rapidlyafterthemid1990s.Painprevalencemighthavebeenevenhigherwithoutthedrugs,althoughlong
termopioidusemayexacerbatepainforsome(26),andconsensusontheeffectivenessandrisksoflong
termopioidusehasbeenhamperedbylackofresearchevidence(27).Painisalsoariskfactorforsuicide
(28).Increasedalcoholabuseandsuicidesarelikelysymptomsofthesameunderlyingepidemic(18, 19,
29),andhaveincreasedalongsideit,bothtemporallyandspatially.

Althoughtheepidemicofpain,suicide,anddrugoverdosesprecededthefinancialcrisis,tiestoeconomic
insecurity are possible. After the productivity slowdown in the early 1970s, and with widening income
inequality,manyofthebabyboomgenerationarethefirsttofind,inmidlife,thattheywillnotbebetteroff
thanweretheirparents.Growthinrealmedianearningshasbeenslowforthisgroup,especiallythosewith
onlyahighschooleducation.However,theproductivityslowdowniscommontomanyrichcountries,some
ofwhichhaveseenevenslowergrowthinmedianearningsthantheUnitedStates,yetnonehavehadthe
same mortality experience (lanekenworthy.net/sharedprosperity (http://lanekenworthy.net/shared
prosperity)andref.30).TheUnitedStateshasmovedprimarilytodefinedcontributionpensionplanswith
associated stock market risk, whereas, in Europe, definedbenefit pensions are still the norm. Future
financial insecurity may weigh more heavily on US workers, if they perceive stock market risk harder to
managethanearningsrisk,oriftheyhavecontributedinadequatelytodefinedcontributionplans(31).

OurfindingsmayalsohelpusunderstandrecentlargeincreasesinAmericansondisability.Thegrowthin
SocialSecurityDisabilityInsuranceinthisagegroup(32)isnotquitetheneardoublingshowninTable2for
theBehavioralRiskFactorSurveillanceSystem(BRFSS)measureofworklimitation,butthescaleissimilar
in levels and trends. This has been interpreted as a response to the generosity of payments (33), but
careful work based on Social Security records shows that most of the increase can be attributed to
compositional effects, with the remainder falling in the category of (hard to ascertain) increases in
musculoskeletalandmentalhealthdisabilities(34)ourmorbidityresultssuggestthatdisabilityfromthese
causeshasindeedincreased.Increasedmorbiditymayalsoexplainsomeoftherecentotherwisepuzzling
decreaseinlaborforceparticipationintheUnitedStates,particularlyamongwomen(35).

Themortalityreversalobservedinthisperiodbearsaresemblancetothemortalitydeclineslowdowninthe
UnitedStatesduringtheheightoftheAIDSepidemic,whichtookthelivesof650,000Americans(1981to
mid2015). A combination of behavioral change and drug therapy brought the US AIDS epidemic under
control ageadjusted deaths per 100,000 fell from 10.2 in 1990 to 2.1 in 2013 (12). However, public
awarenessoftheenormityoftheAIDScrisiswasfargreaterthanfortheepidemicdescribedhere.

AseriousconcernisthatthosecurrentlyinmidlifewillageintoMedicareinworsehealththanthecurrently
elderly.Thisisnotautomaticiftheepidemicisbroughtundercontrol,itssurvivorsmayhaveahealthyold
age.However,addictionsarehardtotreatandpainishardtocontrol,sothosecurrentlyinmidlifemaybea
lostgeneration(36)whosefutureislessbrightthanthosewhoprecededthem.

Materials and Methods

Mortality Data. We assembled data on allcause and causespecific mortality from the CDC Wonder
Mortality Data. We assembled data on allcause and causespecific mortality from the CDC Wonder
Compressed and Detailed Mortality files as well as from individual death records from 1989 to 2013. For
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populationbyethnicityandeducationalstatus,weextracteddatafromAmericanCommunitySurveysand,
before2000,fromCurrentPopulationSurveys.InternationaldataonmortalityweretakenfromtheHuman Top
Mortality Database www.mortality.org (http://www.mortality.org/) these are not separated by race and
Abstract
ethnicity. Specific causes of death are constructed for 19992013 using International Statistical
th
Classification of Diseases and Related Health Problems 10 Revision (ICD10) codes: alcoholic liver Midlife Mortality
diseases and cirrhosis (ICD10 K70, K7374), suicide (X6084, Y87.0), and poisonings (X4045, Y1015,
Y45, 47, 49). Poisonings are accidental and intentundetermined deaths from alcohol poisoning and Midlife Morbidity
overdosesofprescriptionandillegaldrugs.
Discussion

Morbidity Data. Data are drawn from multiple years of publicly available US national surveys: the
Materials and Methods
National Health Interview Surveys (NHIS, 19972013) www.cdc.gov/nchs/nhis.htm
(http://www.cdc.gov/nchs/nhis.htm), BRFSS (19972013) www.cdc.gov/brfss/index.html SI Data
(http://www.cdc.gov/brfss/index.html),andtheNationalHealthandNutritionExaminationSurveys(NHANES,
SI Materials and Methods
19992011) www.cdc.gov/nchs/nhanes.htm (http://www.cdc.gov/nchs/nhanes.htm). Details on morbidity
variablecodingareprovidedinSupportingInformation. Acknowledgments

Methods.Mortalityratesarepresentedasdeathsper100,000.Thesearenotageadjustedwithinthe10 Footnotes
y4554agegroup.Informationoneducationwasmissingfor5%ofdeathrecordsfrom1999to2013for
white nonHispanics aged 4554. For allcause mortality, deaths with missing education information were References

assigned an education category based on the distribution of education for deaths with education
information,bysexandyear(37).Forcausespecificmortality,educationwasassignedbasedonsex,year,
andcauseofdeath.

All morbidity averages are calculated using surveyprovided population sampling weights, and are
presentedwithoutfurtherstatisticaladjustments.Weuse3yofdatatocalculateaverages(19971999and
20112013),toensurethemeansreportedarenotanaberrationinanyoneyear.Exceptionsarenoted.

SI Data
TheNHISandBRFSSbothaskwhetherhealthingeneralisexcellent,verygood,good,fairorpoor,
andwereportbothpositive(excellent/very good) and negative (fair/poor) responses. Table2 reports
responses to this question from the BRFSS means from the NHIS are not statistically different from
thosereported.TheNHISasksquestionsonpain,whichvarybytypeofpain.Wescoreanswersthata
respondenthadanacheorpaininajointinthepast30d,withsymptomsfirstappearingmorethan3
moago,aschronicjointpain,andanswerstowhethertherespondenthadpaininthepast3molasting
awholedayormoreintheneck,face,orlowerbackpainthatspreaddowneitherlegbelowtheknee
as neck pain, facial pain, and sciatica. The NHIS administers the Kessler six (K6) questionnaire,
www.hcp.med.harvard.edu/ncs/k6_scales.php (http://www.hcp.med.harvard.edu/ncs/k6_scales.php),
scoredtodiscriminatecasesofseriouspsychologicaldistress(38).WeuseathresholdofK6greater
thanorequalto13asanindicatorofseriouspsychologicaldistress/seriousmentalillness.TheBRFSS
asks for the number of days in the past 30 mental (physical) health was not good. The NHIS asks
about respondents ability to go about daily living: walking, climbing, standing, sitting, shopping, and
participatinginsocialactivities.Answersonafivepointscalerangefromnotatalldifficulttocantdo
atall,towhichweadddonotdo.Wereportthefractionofpeoplewhorespondthattheyhavemore
than a little difficulty with each of these activities. The BRFSS asks respondents about current
employment. Answers are coded as used for wages, out of work (less than/more than 1 y),
homemaker, retired, student, or unable to work. We report the fraction responding that they are
unabletowork.TheBRFSScalculatesscoresofheavydrinking,definedasmorethanone(two)drinks
daily for women (men). NHANES provides results of enzyme tests, and we report the fraction with
elevatedenzymereadings:ASTaboveareferencelevelof48U/L(unitsperliter)formenand43U/L
forwomen,andALTaboveareferencelevelof55U/Lformenand45U/Lforwomen.WeuseMayo
Clinicreferencelevels(39).

SI Materials and Methods

Calculationsofdeathsthatwouldhavebeenaverted(19992013)useactualmortalityratesobserved
eachyearcomparedwiththeratesthatwouldhaveheldineachyearifthemortalityratehadcontinued
to fall at the speed observed for the period 19791998 (1.8% per year). We allow those who would
havesurvivedtofacesubsequentmortalityrisk,andweaccountforpeopleagingoutofthe4554age
group. Define mt as the mortality rate observed for whites aged 4554 in year t. Define m
t as the

mortalityratethatwouldhaveoccurredifthemortalityratehadcontinuedtofallat1.8%peryear.In
1999, lives saved (LS99 ) are calculated using the white population aged 4554 in 1999 ( 99 ):
LS99 = (m 99 m 99
) 99 .In2000,livessavedarecalculatedbasedonthepopulationthatwould

havebeenobservedifliveshadbeensavedin1999,netofthosewhowouldhavediedofothercauses
in1999,whohadnotagedoutofthegroup4554,

LS00 = (m 00 m
00
)
00

[S1]

= + 0.9 (1 )
 where
00 = 00 + 0.9 LS99 (1 m
99
) . For year t, we construct the population from which lives
would have been saved if the mortality rate had continued to fall at 1.8% per year,
Navigate This Article

t = t + 0.9LSt1 (1 m t1

) + 0.8LSt2 (1 m t2

) (1 m t1
) + ... and calculate lives

+ 0.1LSt9 (1 m
) (1 m
) (1 m ) Top
t9 t8 t1

savedinyeartasinEq.S1.
Abstract

The temporal associations between suicide and poisoning mortality and morbidity are established for Midlife Mortality
each of our morbidity markers using least squares regressions with census region fixed effects. For
census region i in year t, we ran least squares regressions of suicide and poisoning mortality Midlife Morbidity
combined,
Discussion

ln(mortality)
it
= morbidityit + i + u it . Materials and Methods

SI Data
Withtheexceptionofneckpainandfacialpain,wefindasignificantassociation betweensuicideand
poisoningmortalityandmorbidityforeachmorbiditymarkerpresentedinTable2. SI Materials and Methods

Acknowledgments

Acknowledgments Footnotes

References
We thank David Cutler, Jonathan Skinner, and David Weir for helpful comments and discussions. A.C.
acknowledgessupportfromtheNationalInstituteonAgingunderGrantP30AG024361.A.D.acknowledges
funding support from the National Institute on Aging through the National Bureau of Economic Research
(Grants5R01AG04062902andP01AG0584214)andthroughPrincetonsRoybalCenterforTranslational
ResearchonAging(GrantP30AG024928).

Footnotes
1
Towhomcorrespondencemaybeaddressed.Email:accase@princeton.edu(mailto:accase@princeton.edu)or
Deaton@princeton.edu(mailto:Deaton@princeton.edu).

Authorcontributions:A.C.andA.D.designedresearch,performedresearch,analyzeddata,andwrotethepaper.

Reviewers:D.C.,HarvardUniversityJ.S.,DartmouthCollegeandD.W.,InstituteforSocialResearch.

Theauthorsdeclarenoconflictofinterest.

SeeCommentaryonpage15006(/lookup/doi/10.1073/pnas.1519763112).

Thisarticlecontainssupportinginformationonlineat
www.pnas.org/lookup/suppl/doi:10.1073/pnas.1518393112//DCSupplemental
(/lookup/suppl/doi:10.1073/pnas.1518393112//DCSupplemental).

FreelyavailableonlinethroughthePNASopenaccessoption.

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