Diseases of Despair in Early Adulthood
Today, I use material from a single article on an important topic. Dupéré et al. (2024) published “Diseases of Despair in Early Adulthood: The complex role of social relationships” in Developmental Psychology. Here’s the highly edited article:
“Diseases of despair,” most prominently depressive and substance-related problems, diminish the prospects of many young adults, especially those with lower levels of education. Yet many young adults in that situation avoid these problems. Close relationships are thought to be a key factor underpinning risk and resilience among this group. To examine this premise, this study explored links, beyond potential confounders assessed in adolescence, between strengths and strains in the social domain and markers of despair in the early and mid-20s in a Canadian sample overrepresenting youth without postsecondary credentials (N = 543, 52% male, 23% non-White). Having a good general ability to maintain supportive relationships was associated with fewer depressive and substance-related symptoms. Furthermore, support and less strain in relationships with parents and friends were associated with fewer depressive symptoms in the early and mid-20s, while for romantic relationships, associations with depressive symptoms became more consistent and robust in the mid-20s. Therefore, support and strains in romantic relationships gradually gained prominence as a determinant of depressive symptoms as youth advanced in adulthood. For substance-related problems, significant associations emerged for strains in friendships only, in both the early and mid-20s. These results suggest that multiple aspects of relationships pose a risk for or protect from the development of diseases of despair in early adulthood and that their relative importance changes depending on outcomes and developmental timing. Thus, facilitating meaningful social connections and reducing the prevalence and impact of relationship strains might contribute to preventing diseases of despair among youth with lower educational attainment.
“Deaths of despair,” that is, mortality resulting from suicide, drug overdose, or alcohol-related liver disease, have caused reversals in long-standing trends toward improvement in life expectancy and have attracted considerable research and media attention in the United States and beyond. Although despair mortality primarily affects middle-aged adults, deaths of despair are typically preceded by symptoms of diseases of despair, that is, of mood or substance-related disorders. According to a recent meta-analysis, peak incidences for substance-related and mood disorders, respectively, occur at 19.5 and 20.5 years of age, with median ages of onset estimated at 25 and 30 years of age (Solmi et al., 2022). Early adulthood is thus a critical period for the emergence and crystallization of diseases of despair.
In addition to these mental health precursors, another key antecedent of deaths of despair also crystallizes in early adulthood: low educational attainment. Having no more than a high school education is the demographic factor most strongly associated with despair mortality, with similarly strong associations for diseases of despair in early adulthood. For instance, among 18- to 24-year-olds in the United States, the odds of attempting suicide and of being arrested for drug-related charges are about 2.5 times higher for those without a high school diploma than for those with one. As such, low educational attainment counts as a major social determinant of limited life expectancy and of poor health.
A priority for research on early adults with lower levels of education is the identification of risk and protective factors associated with diseases of despair that are amenable to prevention. Notably, support provided in close relationships by parents, friends, and romantic partners is thought to be important. Yet even as relationships are a key reservoir of support, they are also a major source of strain, and their potential impact on mental health is not always a net positive (Offer, 2021). This study’s goal is therefore to examine how social relationships might shape, for better or worse, symptoms of mood and substance-related problems in early adults with lower levels of education.
Many theories rely on the concept of social support for understanding the role of social relationships in health and well-being. Among them, a major theoretical approach is the relationship perspective (see Lakey & Cohen, 2000). This perspective stresses three aspects of relationships that must be considered to fully capture their impact on adjustment: (a) their positive side, which includes support, intimacy, and overall relationship quality; (b) their negative side, which refers to conflicts, demands, and disappointments; and, finally, (c) relatively stable individual differences in relational skills or abilities.
Among young adults, individual differences in relational ability should be mainly apparent in their involvement in functioning dyadic relationships across a variety of contexts. Previous research indeed suggests that such relationships are more important for young adults’ mental health than their status in larger networks. Individual differences in young adults’ general ability to form and maintain functioning dyadic relationships should be relatively stable, but also manifest a degree of change, given that personality traits continue to evolve during early adulthood, with correlations of about .50 across traits measured a few years apart during this period (Bleidorn & Hopwood, 2019).
Functioning as an adult requires the development of close dyadic relationships beyond one’s family of origin, most prominently with friends and romantic partners. As such, close relationships outside one’s family of origin gradually gain in perceived importance as youth advance in adulthood. Even as precedence shifts toward close peers, relationships with parents are likely to remain a relevant, if gradually receding, influence on young adults’ mental health.
Besides these reconfigurations in relative importance, the inherent quality of each type of relationship (with parents, close friends, and romantic partners) is also likely to change, although to varying degrees.
Most studies linking social relationships and mental health focus on the positive side of relationships, especially social support. Social support specifically refers to the accessibility of sympathy, encouragement, love, and care from significant others, such as family members (e.g., see Rueger et al., 2016). Apart from its emotional component, social support also includes instrumental assistance (e.g., financial, material). Due to the critical role played by support in coping with life’s difficulties and fulfilling basic human affiliation needs, the risk of distress and problematic behaviors is likely to increase when it is lacking.
Data were obtained from the Parcours project (Dupéré, Dion, Leventhal, et al., 2018), each phase of which was approved by the designated Institutional Review Board. Three cohorts of participants were recruited during as many consecutive school years (2012–2013 to 2014–2015) in 12 socioeconomically disadvantaged public high schools with high dropout rates (averaging 36% at the time of data collection) located in and around Montreal (Québec, Canada).
In each participating school, virtually all students at least 14 years of age (97%, Nscreening = 6,773) provided informed consent and filled in a screening questionnaire at the beginning of the school year (usually in October). In the months following the preliminary screening, a subset of screened adolescents was recruited to participate in a detailed interview. They belonged to one of three profiles, each representing about a third of the sample: (a) adolescents who had recently left high school before graduation (after the initial screening, but before the interview), (b) matched peers still in school at the time of the interview but at high risk of quitting before graduating according to the beginning-of-school-year risk index, or (c) students with a relatively low dropout risk, close to their school’s average, again according to the risk index. At the time of the first interview, participants were, on average, 16.3 years old (SD = 0.9). The sample was evenly split as a function of sex, with about a quarter comprising minority youth. Four years later, participants, now, on average, 20.9 years old (SD = 1.0), were invited for a second individual interview. In total, 71% of the original sample took part (n = 384), a high retention rate considering the nature of the sample (e.g., see Murray et al., 2021). Eight years after the initial interview, participants were recontacted to organize a third interview. In total, 56% of the original sample took part (n = 302). By that time, participants were, on average, 24.5 years old (SD = 1.1). In bivariate analyses comparing the adolescence control variables as a function of attrition, no significant differences were found, except an overrepresentation of males among those lost to attrition, F(1, 541) = 13.44, p ˂ .001. In terms of educational attainment, 33% of the reinterviewed participants did not yet have a high school diploma, 25% had a high school (or equivalent) diploma, 25% had a vocational degree, and 18% had a postsecondary credential. Participants’ occupations at the second interview were working only (64%), working and studying (21%), studying only (6%), and not in education or employment (9%). Finally, in terms of living arrangements, a third of the sample lived with their parents (35%), another third lived with a romantic partner (37%), about one in five lived either alone (10%) or with roommates (8%), with the remaining 10% living in varied arrangements (11% of whom were living with their children).
Seminal studies on deaths of despair have relied on data from death certificates, which informs about regional patterns and demographic groups most at risk but offers few clues as to underlying processes. Recent investigations have aimed at uncovering the developmental roots of diseases of despair. The present study adds to this literature by examining risk and resilience processes unfolding during a period of peak incidence and frequent onset for key diseases of despair, that is, early adulthood, in a demographic group particularly at risk, that is young adults with lower levels of education, with a focus on modifiable social factors amenable to intervention. The findings suggest that within this group, a limited ability to connect with others, a sparse access to supportive relationships, or entanglements in unsupportive or burdensome relationships apparently increase the risk of developing diseases of despair, with potentially dire consequences for long-term well-being and longevity. Conversely, strong relational ability and support in relationships with parents, friends, or romantic partners apparently help vulnerable youth avoid diseases of despair. These results underscore the need to create contexts that broadly sustain strong and positive social connections, for instance, by improving access to stable, satisfying jobs with living wages for youth who do not earn college degrees. Indeed, economic hardships and unsatisfying employment, which disproportionately affect youth without college degrees, disrupt close relationships and mental health. Providing these youth with opportunities to access decent employment is also critical, considering that marked socioeconomic inequalities apparently create the conditions under which diseases of despair become particularly likely to develop, including among youth (Benny et al., 2023; King et al., 2022).
I think it’s important to understand the consequences of low educational attainment, especially in a world where income inequality seems stable or growing. While therapists can’t help clients get further education or better-paying jobs, they can help young adults understand the importance of quality relationships. These findings also highlight the importance of tracking relationships during the transition from high school to the early 20s.