**3. Diseases of despair (DoD)**

Not all individuals start from suicidal actions stemming from the feelings of depression, anxiety, and hopelessness, some may develop dependence on noxious substances first in the hope to improve their situations [20, 21]. However, in reality, these behaviors worsen the situations and sets up a vicious cycle to contribute to subsequent depression and suicidal behaviors [21]. This points to the fact that the death of despair is a common pathway to suicides and substance abuse [22]. In a recent survey conducted among nearly 1500 individuals, young adults were twice likely to engage in the substance abuse behaviors and the prevalence of despair among young adults was 20 percent [22]. Reportedly, suicidal ideation increased by over 200% between 2009 and 2018 among young adults aged 18–34 years [23]. This is a complex problem with a multifactorial origin, which stem from the change in social structure and social media [19, 20, 23]. Cyberbullying and sleep problems are also contributing to the adverse mental health outcomes, including psychological distress and suicidal thoughts [19]. Three behaviors, including drug overdose, suicides, and alcoholic liver disease collectively called diseases of despair [19–25], which contribute to the deaths of despair.

#### **3.1 Sociodemographic determinants of DoD**

Just like other events, gender and race/ethnic disparities do exist in the prevalence of diseases or deaths of despair [22, 23, 26]. As compared to females, males are nearly twice likely to be diagnosed with alcohol and substance abuse related despair diagnoses [26]. However, females have had higher odds of exhibiting suicidal ideations than their male counterparts [26]. These differences in the suicidal attempts can be partially explained by differences in perception, natural coping mechanism,

and social expectations among males and females [27]. Females tend to have safety seeking behaviors and are less likely to resort to self-destructive behaviors, such as suicidal attempts [27, 28]. Age was also a significant predictor of DoD, with 18–35 years old being at the highest risk [21, 25, 26]. African Americans, people with lower socio-economic status and less education attainment had the higher rates of despair [22]. Type of insurance was also associated with the higher risk of diseases of despair [26]. People with public insurance and Affordable Care Act (ACA) were significantly more likely to exhibit any diseases of despair diagnoses compared to those with commercial insurance plans [26]. These disparate effects highlight the need of deciphering potential mechanisms of risk based on theoretical frameworks [28].
