Shannon M. Monnat

Highlights: Jointly modeling state and county contexts reveals synergistic, not independent, mortality associations. Lowest mortality is observed in economically secure counties within liberal-policy states. For males, extreme county economic insecurity yields high mortality regardless of state policy. For males, high labor force participation raises mortality in conservative state contexts. For females, liberal state policies buffer both county economic and labor disadvantages.

Rising drug-and alcohol-related mortality among working-age adults in the United States underscores the critical need to identify factors that increase the risk of illicit drug use and prescription drug misuse. 1-2 Adolescents and young adults with ADHD are more likely than their peers without ADHD to use illicit drugs and misuse prescription drugs. 3-4 Neurocognitive mechanisms, such as heightened reward sensitivity, deficits in response inhibition, and executive function impairments, contribute to the higher risk of drug use among adults with ADHD. 5

Objective: To estimate differences by self-reported lifetime ADHD diagnosis status in the percentage of U.S. working-age (18- to 64-year-old) adults in 2023 who report lifetime and past-year use or misuse of 11 different categories of illicit drugs and prescription medications, overall and among those without a self-reported drug use disorder (DUD). Method: We analyze data from the 2023 National Wellbeing Survey (total sample unweighted N = 7,044; no DUD sample unweighted N = 6,484) to estimate lifetime and past-year use of seven illicit drugs (marijuana, powder cocaine, crack cocaine, methamphetamine, heroin, fentanyl, and hallucinogens) and misuse of four prescription medications (opioids, tranquilizers, sedatives, and stimulants) among working-age adults, by self-reported lifetime ADHD diagnosis status, sex, age, race/ethnicity, nativity, education, and rural-urban residence. Weighted descriptive and multivariable logistic regression model estimates are obtained for the total population and for the subpopulation without a self-reported DUD. Results: In 2023, lifetime and past-year use or misuse of all 11 categories of drugs and medications was significantly higher among working-age adults with ADHD than among those without ADHD. Statistically significant differences by self-reported ADHD status persisted in multivariable models that controlled for demographic characteristics, with adjusted odds ratios (AORs) ranging from 1.77 for lifetime misuse of prescription sedatives to 3.08 for lifetime misuse of prescription stimulants, and from 1.63 for past-year use of crack cocaine to 3.33 for past-year misuse of prescription stimulants. Among those with no DUD, results indicated significantly higher lifetime use or misuse among persons with ADHD than among persons without ADHD for all 11 categories of drugs and mediations, with AORs ranging from 1.69 for misuse of prescription opioids to 2.87 for prescription stimulants. Past-year use or misuse among working-age adults never diagnosed with a DUD was significantly higher for 7 of 11 categories of drugs and medications among persons with ADHD relative to persons without ADHD, with statistically significant AORs ranging from 1.54 for use of heroin to 3.48 for misuse of prescription stimulants. Conclusion: Results suggest that ADHD is a risk factor for higher illicit drug use and prescription medication misuse among U.S. working-age adults, even in the absence of a DUD. Clinicians working with adults with ADHD should assess use and misuse of a broad range of drugs and medications regardless of whether the person with ADHD has a co-occurring DUD diagnosis, and engage in therapeutic interventions when appropriate. Future national data collection efforts that include measures of drug use and medication misuse (e.g., NSDUH, NHIS, and BRFSS) should include measures of lifetime and current ADHD diagnosis, symptoms, and treatment history.

Despite expectations that suicide rates would surge during the pandemic, the national suicide rate declined in the United States in 2020 before returning to pre-pandemic levels in 2021. Explanations of the decline in suicides at the national level include a “pulling-together effect” in the face of a crisis and a shorter than expected pandemic recession. However, suicide rates and the change over time in suicide rates vary substantially across US states. At various times during the pandemic states enacted physical-distancing and economic support policies that may have affected suicide rates. We examined the association between state-level physical-distancing and economic support policy contexts and suicide rates among US adults ages 25–64 years during the COVID-19 pandemic. We found that a 1-SD increase in the stringency of a state's physical-distancing policies was associated with a 5.3% reduction in male suicide rates but was not associated with female suicide rates. Economic support policies were not associated with suicide rates for the period as a whole. The results support the growing evidence that COVID-19 policies had indirect and unintended consequences beyond their direct effect on COVID-19 transmission and death, in this case to reduce suicides among working-age males.

One in five Americans lives in rural areas, and many urban residents hail from rural backgrounds. Rural America is home to most of the nation’s natural resources and natural amenities, supplies a significant portion of the nation’s food and energy, and plays a crucial role in elections. Thus, the wellbeing of rural America is essential for the wellbeing of the country. Rural America faces three converging demographic trends that have critical implications for wellbeing and sustainability. These trends are (1) rapid population aging, (2) declines in health and longevity among working-age adults, and (3) population loss. This article describes these trends, discusses the implications for rural America, and proposes policies to address them. Throughout, it is important to remember that these trends represent averages. The rural United States is diverse, and although some areas are facing significant health and aging challenges, others are thriving.

Objective: To estimate the percentage of U.S. working-age (18- to 64-year-old) adults in 2023 who self-reported ever being diagnosed with ADHD by a health care professional. Method: We analyze data from the 2023 National Wellbeing Survey ( N = 7,053) to estimate self-reported lifetime ADHD diagnosis status among working-age adults, overall and by sex, age, race/ethnicity, nativity, education, and rural-urban residence. Results: Among U.S. working-age adults in 2023, we estimate that 13.9% (95% confidence interval [13.0%, 15.0%]) self-reported ever being diagnosed with ADHD by a health care professional. We find statistically significant variation by each of the demographic variables analyzed, with higher rates among working-age adults who are female, younger, non-Hispanic White, U.S.-born, less well-educated, and residing in metro areas with 250,000 to 1 million people (relative to those living in metro areas with 1+ million population). Conclusion: The percentage of U.S. working-age adults who self-report in 2023 that they have ever been diagnosed with ADHD by a health care professional (13.9%) is substantially higher than estimates from 2012 (4.25%) and a 2023 estimate of 7.8% among adults of all ages (18+ years). The increase over time may reflect changes in diagnostic criteria for children and adults, greater acceptance of adult diagnosis, over- and mis-diagnosis, and methodological issues. The difference between the 2023 estimates likely reflects study-specific differences in the constructs measured, the age range of the samples, and methodological differences in the online panels used for sampling, in quality control approaches, and in post-survey weight construction. Additional data collection and empirical research is needed to validate or refine provisional estimates based on samples drawn from online panels, and to determine explanations for the observed increase over time.

The contextual predictors of mortality in the United States are well documented, but the COVID-19 pandemic may have upended those associations. Informed by the social history of disease framework (SHDF), this study examined how the importance of county contexts on adult deaths from all causes, drug poisonings, and COVID-19-related causes fluctuated during the pandemic. Using 2018 to 2021 vital statistics data, for each quarter, we estimated associations between county-level deaths among adults ages 25 to 64 and prepandemic county-level contexts (economic conditions, racial-ethnic composition, population health profile, and physician supply). The pandemic significantly elevated the importance of county contexts—particularly median household income and counties’ preexisting health profile—on all-cause and drug poisoning deaths. The elevated importance of household income may be long-lasting. Contextual inequalities in COVID-19-related deaths rose and then fell, as the SHDF predicts, but rose again along with socio-political disruptions. The findings support and extend the SHDF.