In Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions, Johann Hari takes a stand against the idea of biological causation of depression and anxiety. I expected going in that this book would annoy me, but at times it was just plain ridiculousness.
To start off, let me tell you the perspective I’m coming from. I support a biopsychosocial model that recognizes mental illness as complex and multifactorial. Every individual’s illness stems from a unique combination of factors, and for a treatment plan to work best it needs to effectively target whatever contributing factors can be identified. Sometimes that’s meds, sometimes that’s psychotherapy, and more often than not, it’s a combination of multiple different strategies. Meds aren’t a miracle cure, but they can get you well enough to do whatever you need to find true wellness. Ok, now that we’ve got that out of the way, let’s jump headfirst into the book.
First stop: Antidepressants will fix everything
Red flags were set off for me early on in the book when the author wrote that at age 18 he had an epiphany that he had the medical condition called depression, and from information in the media he knew that antidepressants were just what he needed to quickly make him all better. Initially, he was convinced that paroxetine made him feel even better than simply not depressed, and he spread the word to others that depression was solely about serotonin and antidepressants were the best thing since sliced bread.
Years later, his therapist pointed out to him that it seemed like he was still depressed; the author responded that no, he couldn’t possibly be depressed because paroxetine was keeping his serotonin levels up; but then changed his mind and decided to stop meds. “It was only when I stopped taking the [SSRI] and I started having more pleasurable sex again that I remembered regular sex is one of the best natural antidepressants in the world.” I guess I’m just a little (or a lot) judgmental, but Hari seemed like he was energetically leaping onto the train to out-there-ville.
Enter Irving Kirsch
Next stop on that train is with researcher Irving Kirsch. Kirsch criticized the typical design of drug trials, i.e. randomized placebo-controlled trials. You can find more about what those are in my post on research literacy. Kirsch argued that to truly understand the effect of a drug, there should be 3 arms to these kinds of studies: drug, placebo, and no-intervention, with the third arm capturing the number of people who get better with no treatment or placebo at all.
This sounds all well and good, except that it gives you zero new information about what the drug does. The people who would respond to no intervention are already captured in the placebo responders, so adding a do-nothing arm only gives you information about how much of the placebo effect is due to that sugar pill the researchers are giving the patients. Now, that information may be useful in examining the placebo effect, but it doesn’t in any way change what a study shows about the effect of drug response over placebo.
The serotonin hypothesis
Next stop on the train is holding up the old serotonin deficiency hypothesis for depression as evidence that the illness doesn’t have a biological basis. That hypothesis was originally developed to try to explain why drugs that blocked serotonin reuptake had an antidepressant effect, and at the time they didn’t have the scientific techniques available to test whether this was really accurate.
It has since become clear that depression is not related to a deficit in the absolute amount of serotonin, but that doesn’t mean we should throw the baby out with the bathwater. Just because the overly simplistic early explanation was wrong doesn’t mean that neurotransmitters have nothing to do with depression period, and it doesn’t mean that antidepressants that affect neurotransmission won’t work. It’s like saying that because the flat earth hypothesis was wrong there must be no earth at all.
Bereavement and depression
The author talked about bereavement being mislabelled as depression. A woman he interviewed said “So now if your baby dies and you go to the doctor the next day and you’re in extreme distress, you can be diagnosed immediately.” People have the right to be ignorant, but that doesn’t mean their ignorant comments should be thrown into a book as evidence.
This idea that the DSM diagnostic criteria are a checklist and if you tick enough boxes you must be labelled with the disorder, well, it’s just not correct, which is why only highly trained clinicians are qualified to diagnose. Admittedly, some clinicians are too quick to jump to a diagnosis, but that’s very much a separate problem.
In the DSM-IV, bereavement was listed as an exclusion criterion for diagnosing a major depressive episode; this was done in an attempt to avoid bereavement from being mistaken as depression. The author raised concerns that maybe depression wasn’t so sound an entity if a normal experience mimicked the symptoms. But then he does a 180 and questions the removal of that bereavement exclusion in the DSM-5 and the addition of only a “vague footnote”. That “vague footnote” is right there with the diagnostic criteria for a depressive episode, and says:
“Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.”
So yeah, no day-after-death diagnosis.
Disconnection as cause for depression
The author announced that based on his information gathering (and no training whatsoever in psychiatry/psychology), he has identified 9 causes of depression. He adds that depression is a form of grief over these various forms of disconnection. The identified causes are:
- Disconnection from meaningful work
- Disconnection from other people
- Disconnection from meaningful values: The author talked about “junk values”, and particularly materialism, as being problematic and something he had struggled with. It was around this point that it really started to sound like the author was referring to depression and anxiety as negative emotional states and existential malaise and not necessarily appreciating the difference between these emotion states and mood/anxiety disorders.
- Disconnection from childhood trauma
- Disconnection from status and respect
- Disconnection from the natural world
- Disconnection from a hopeful or secure future
- The real role of genes and brain changes: The author saw 2 potential roles for biology: circumstances can cause brain changes that accelerate the problem, OR
- genetic variations may contribute to depression but only in specific environmental circumstances; they can’t cause depression without an environmental trigger
Part II of the book, “Reconnection: A new kind of antidepressant”, looks at ways in which people can reestablish those needed connections. This starts off with what to me seemed to be a rather rambling story about an apartment block in Berlin slated for demolition. An older woman had posted a note saying she was going to kill herself because she’d be losing her housing and she had no other options (there’s no indication that this was a woman with any history of mental illness).
This sparked community activism that positively impacted all of those involved. And lo and behold, the woman’s suicidal thinking disappeared – so that’s what I must have been missing those times I tried to kill myself! It made me think of a line from a medical historian interviewed in the documentary The Age of Anxiety: “If your problem can be corrected by a new boyfriend or a cheque for $5000, you probably don’t have a psychiatric disorder.”
The author came to the conclusion from this and other examples that “if you want to stop being depressed, don’t be you. Don’t be yourself. Don’t fixate on how you’re worth it. It’s thinking about you, you, you that’s helped to make you feel so lousy. Don’t be you. Be us. Be we. Be part of the group. Make the group worth it… So part of overcoming our depression and anxiety—the first step, and one of the most crucial—is coming together.”
The author says that “work is essential”, which made me wonder why he has his head up his privileged ass. He talked to a woman who was anxious because of her negative work situation. She then decided to join with her husband and others in creating a cooperative bike repair business, and then things were hunky dory. The author describes this “recipe for mental health” as “Elect Your Boss”. So that’s what we’re all doing wrong…
Hari wrote that if he could speak to his younger self, he would say: “You are not suffering from a chemical imbalance in your brain. You are suffering from a social and spiritual imbalance in how we live. Much more than you’ve been told up to now, it’s not serotonin; it’s society. It’s not your brain; it’s your pain… Because you are being told depression and anxiety are misfirings of brain chemicals, you will stop looking for answers in your life and your psyche and your environment and how you might change them. You will become sealed off in a serotonin story.” I suspect there may be some funky paint fumes going on up in that serotonin story.
Some concluding thoughts
If this had been a book about general dissatisfaction and unhappiness in society at large, this would be quite a different review. I suspect that Hillary Clinton and some of the other well-known people who have commented positively on the book may have been looking at it from that perspective. If the book had talked about some people having mental illness that is heavily influenced by social/environmental factors, or the need to take social/environmental factors into account in approaching the treatment for mental illness, then I would have far more positive things to say.
But that’s not the case. Hari is saying that mental illness is not biologically caused and medication is not a valid treatment for depression. Full stop. I think that’s just as bad as the purely biomedical stance that he criticizes. Such a reductionistic approach really isn’t useful to anybody. Beyond that, it’s insulting to those of us living with the complexity of mental illness.
So what can I conclude personally from this book? Apparently, to get better I’m supposed to engage in local activism, participate in a community garden, start a co-op, hang out in nature, and get laid. Forget meds, give me a little penis therapy instead. Why would anyone be suicidal when they could bond over community activism?
Of the various disconnects that he believes cause depression, I had a whopping none for my first two depressive episodes. Screw pain, I was generally happy and optimistic. I had no childhood trauma, a supportive social circle, a job I liked, a strong preference for the value of travelling the world rather than accumulating possessions, a home in an urban oasis right with a forest just steps away… and yet there I was, depressed, psychotic, suicidal.
Meds are certainly not the only tool in my toolbox, but without them, I probably wouldn’t be alive today. So rather than go postal on the author’s ass for presuming to tell me what’s going on with my illness, I’ll just wave as he goes by on the train to out-there-ville. Enjoy the ride!
Lost Connections is available on Amazon.
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