It may be selection bias but when I did community service in coal country WV there seemed to be only two kinds of people in those forsaken towns. Depressed or self destructive. No opportunity and no escape is a hell of a combo. They weren’t starving, but they didn’t have money for much of anything else so their house was decaying around them (our job was fixing up the houses) along with the rest of their lives. This was back in the 90’s. I suspect those towns have been lost to opioids and meth now.