Deaths of Despair among Former Military Service Members, Massachusetts (2014-2021) and Minnesota (2014-2022)

People who served in the U.S. armed forces-former service members (FSMs)-may be at increased risk of deaths of despair: alcohol-related, drug-related, and suicide deaths. We linked 2014-2021 Massachusetts and 2014-2022 Minnesota death certificates for decedents aged 18-64 years with military personnel files to describe deaths of despair in FSM and non-military populations. We calculated age- and sex-standardized proportionate mortality ratios (PMR) for all FSMs and three-year rolling average age-standardized mortality rates for FSMs with active duty experience. We mapped the geographic distribution of these deaths and describe patterns by service history. Of 176,719 decedents, 9.5% were FSMs. FSMs were more likely to die from a death of despair than non-military populations (PMR (95% Confidence Interval), MA: 111.9 (107.0, 117.0), MN: 106.7 (101.4, 112.2)), specifically suicide deaths (MA, MN) and drug-related deaths (MA). Mortality rates displayed similar trends. FSM deaths of despair occurred a median of 20-30 years after military separation and were most common among those with Coast Guard, Marine, or Army service and Bad Conduct/Dishonorable or Uncharacterized separations. FSMs have higher burden of deaths of despair than non-military populations with patterns that vary by service history, warranting further investigation into contributing military, individual, and community factors.