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 I would disagree with what Hari had to say, but it surpassed my expectations.
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 then again, nothing is.
Now that we’ve got that out of the way, let’s jump headfirst into the book.
Antidepressants will fix everything?
This book set off red flags for me early on. The author wrote that, at age 18, he had an epiphany—he had this medical condition called depression. From information in the media, he knew that antidepressants were just the thing to quickly fix everything. Initially, he believed that paroxetine made him feel even better than simply not being depressed. He even spread the word to others that depression was all about serotonin and antidepressants were the best thing since sliced bread.
Years later, his therapist pointed out to him that he still seemed depressed; the author insisted that he couldn’t possibly be, because paroxetine was keeping his serotonin levels up. After that, he 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.”
If whatever is going on with you is fixed by sex, let me suggest that it’s probably not depression.
Enter Irving Kirsch
Part of Hari’s information-gathering in preparing this book was speaking to researcher Irving Kirsch. Kirsch criticized the typical design of drug trials, i.e. randomized placebo-controlled trials. 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, making it rather irrelevant.
The serotonin hypothesis
Hari presented the inaccurate serotonin deficiency hypothesis for depression as a reason to believe 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’s 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 is wrong, there must be no earth at all.
Bereavement and depression
The author raised concerns about bereavement being mislabelled as depression. He interviewed a woman who 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.” That’s simply untrue, but presumably, it was included anyway for emotional impact.
In the DSM-IV, someone couldn’t be diagnosed with a major depressive episode if they were also going through bereavement. Hari raised concerns that maybe depression wasn’t so sound an entity if a normal experience mimicked the symptoms, but then turned around and questioned the removal of that bereavement exclusion in the DSM-5 and the addition of only a “vague footnote”.
That “vague footnote” doesn’t look vague to me, and it’s not a footnote. The relevant section in the DSM-5 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 lost connections of the book’s title. The identified causes for depression 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 explores ways for people to reestablish those needed connections. This starts off with 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 she had 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 called to mind 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.”
Hari concluded that “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 doesn’t recognize the privilege of that stance. He talked to a woman who was anxious because of her negative work situation. She then decided to join her husband and others in creating a cooperative bike repair business, and things became 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, angst, and unhappiness in society at large, this would be 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. He says it’s all disconnect. 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 severe mental illness.
So what can I conclude personally from this book? Apparently, 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. I’m not alone in that experience of depression, and by laying out nine little boxes, Hari has effectively disconnected from those of us whose experiences of depression don’t fit those boxes.
Lost Connections is available on Amazon (affiliate link).