As I wrote yesterday, the poor health of middle-aged white Americans is having an impact on the labor force. Men aren’t working or looking for jobs because they’re sick, on pain pills, or abusing alcohol or drugs, research suggests. Just why they’re so sick was not something that Case and Deaton elaborated on in their 2015 paper.

Now, in a new paper, the economists explore why this demographic is so unhealthy. They conclude it has something to do with a lifetime of eroding economic opportunities. This may seem like a circular argument, when put together with previous work: Middle-aged Americans aren’t working because they’re sick, and middle-aged Americans are sick because they’re not working. But Case and Deaton argue that it’s not just poor job opportunities that are affecting this demographic, but rather, that these economic misfortunes build up and bleed into other segments of people’s lives, like marriage and mental health. This drives them to alcoholism, drug abuse, and even suicide, they say, in a new paper released Thursday in advance of a conference, the Brookings Panel on Economic Activity.

“As the labor market turns against them, and the kinds of jobs they find get worse and worse for people without a college degree, that affects them in other ways too,” Deaton told me.

What differentiates Case and Deaton’s paper is this idea that as people get older and their fates deviate more and more from those of their parents, they struggle to keep their lives together. The very act of doing worse than their parents’ generation—what Case and Deaton call “cumulative disadvantage”—is killing them.

As my colleague Olga Khazan has written, there are other convincing theories about why this demographic may not be doing well health-wise. A study from the Commonwealth Fund released last year suggested that while suicide and substance abuse contributed to deaths of middle-aged white people, factors such as heart disease, diabetes, and respiratory disease also played a big role. These factors may themselves have causes, such as diet and lifestyle, that are independent of macro-economic changes.

Case and Deaton agree that deaths from those factors are important, but emphasize that they see a large uptick in deaths from suicides, poisonings, and alcoholic liver disease among whites with lowest levels of educational attainment. This is in contrast to Europe, where people of all educational backgrounds are living longer, which suggests that there’s something unique among middle-aged Americans without a college education that’s making them sicker. It’s also in contrast to other Americans. For instance, whites aged 50-54 with a high-school degree or less had been dying at a rate 30 percent lower than that of that of all blacks in the same age group in 1999, but by 2015, their mortality rate was 30 percent higher than that of all blacks in that age group. Between 1998 and 2013, death rates for Hispanics fell as well.

What makes this group unique? It’s not just that they don’t have the guarantee of good jobs that they once did, Deaton said. Life doesn’t turn out as this age group hopes it would, creating a sense of hopelessness, and as a result, they turn to risky behaviors such as overeating, alcohol abuse, or drug use, the economists say. They divorce or have trouble finding a marriage partner because of their poor economic prospects. They no longer turn to social organizations like churches, which can provide important social support, the economists write. They don’t have structure in their lives, which in some cases makes them turn to suicide, the authors say.