Heartache in the Heartland: Unraveling the Social Roots of Deaths of Despair in Kentucky.

Introduction: Deaths of despair (DoD), encompassing suicides, drug overdoses, and alcohol-related liver diseases, have emerged as a critical public health crisis in the United States, with their rise particularly pronounced from 1995 to 2013 and exacerbated by the COVID-19 pandemic. Kentucky, grappling with high rates of substance use disorder, poor mental health, and economic hardship, is at the forefront of this issue, particularly in its rural and Appalachian regions. Purpose: This study explores the social determinants contributing to DoD in Kentucky, focusing on economic and social factors that influence rising rates of suicide, drug overdose, and alcohol-related liver disease. The goal is to provide evidence to guide policy and intervention strategies. Methods: An ecological study was conducted across 120 Kentucky counties from 2011 - 2020. DoD mortality data were sourced from the CDC WONDER database, and socioeconomic variables from the American Community Survey. Principal Component Analysis (PCA) reduced 10 county-level socioeconomic variables. Poisson regression estimated associations between socioeconomic principal component scores and DoD mortality, adjusting for confounders like age, and racial demographics. Results: The median DoD mortality rate was 59.7 per 100,000 people, with geographic variation. Three principal components explained 78.4% of the variance in socioeconomic factors. Counties with extreme socioeconomic disadvantages (low education, high poverty, high disability, high unemployment) were strongly associated with higher DoD rates (RR=1.07; 95% CI=1.02-1.12). Implications: Extreme socioeconomic disadvantage is a key predictor of DoD rates in Kentucky. These findings can inform public health interventions and policy changes targeting high-risk areas, especially rural and Appalachian regions.