Lost connections - part 1: A deeper understanding of depression
Johann Hari wrote a book titled “Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions”. I highly recommend reading it, but there’s a lot in there, so here I’ve extracted the key points and most fascinating discoveries he reveals in those pages (along with a few thoughts of my own here and there). This is incredibly useful and increasingly necessary information. While Hari’s focus is on clinical depression and anxiety, those are simply the most extreme ends of feeling a little unhappy or a little stressed. You don’t have to wait to be clinically depressed or anxious to begin to use this information to improve things and broaden your understanding of these important issues.
And depression and anxiety are not as different from one another as we’ve been led to believe. Everything that increases depression also increases anxiety and vice-versa.
One of the key ideas that Hari proposes is that our pain and suffering is a reasonable response to the circumstances in our lives. For example, if you have no friends, are poor, work in a meaningless job with a tyrannical boss and have nothing to look forward to, then it is a natural response to be depressed. It would be unnatural to feel joyful in those circumstances. While it is possible to grow from such challenging circumstances, it’s the exceptional among us who are able to do so.
Yet rather than looking at depression and anxiety as a symptom of something that is deeply wrong in the world and our lives, the common narrative we’re told is that it’s a chemistry imbalance in our brain that needs to be fixed with pills. Yet if we try to get rid of the message we’re receiving (ie: the feeling of depression or anxiety) by taking pills, we’re blinding ourselves to the true causes and thus the solutions.
Depression is not a small thing that only a few people experience. It is a significant and widespread problem. Hari writes:
“One in five U.S. adults is taking at least one drug for a psychiatric problem; nearly one in four middle-aged women in the United States is taking antidepressants at any given time; around one in ten boys at American high schools is being given a powerful stimulant to make them focus; and addictions to legal and illegal drugs are now so widespread that the life expectancy of white men is declining for the first time in the entire peacetime history of the United States.”
further on he writes:
“When scientists test the water supply of Western countries, they always find it is laced with antidepressants, because so many of us are taking them and excreting them that they simply can’t be filtered out of the water we drink every day. We are literally awash in these drugs.”
Keep in mind that this book was written in 2018. A lot has happened since then, so these numbers are probably higher.
How effective are antidepressant drugs anyway?
The effectiveness of the drugs being given to people for depression and anxiety is highly questionable. One study found that 25 percent of the effects of antidepressants were due to natural recovery, 50 percent due to the placebo effect, and only 25 percent due to the actual chemicals. On top of this, almost all drug trials are conducted by the companies selling those drugs to make a profit, and they only publish the trials which make their drugs look good (though fortunately there are ways to get your hands on the raw data and the trials they don’t want the public to know about.)
One study was done with an antidepressant drug called “Prozac”. It was given to 245 patients, but the drug company only published the results for 27 of those people. ie: it worked for those 27 people (who’s results were published) and didn’t work for the other 218 (who’s results were hidden). Furthermore, drug testing is not as professional as we tend to think it is. Companies only need to show some improvement in order to put a drug on the market. As Hari points out, this means that there can be 1,000 scientific trials in which 998 of them show the drug doesn’t work, but if just 2 of those trials show there is a tiny effect, that drug can be sold at your local pharmacist or prescribed by your doctor.
To measure how depressed or happy someone is, you can use what is known as the Hamilton scale. It ranges from 0 (where you’re skipping with joy), to 51 (where you try to commit suicide). If you just improve your sleeping patterns, you can improve your score by six points. Yet antidepressants (with all their side effects and high financial costs) often only improve someone’s score by about 1.8 points. Furthermore, it’s not easy to get participants on whom to test antidepressant drugs. Many of the participants volunteer because they’re in a rough place and need some money. Companies also provide added incentives for them such as free food, therapy, a warm place, a community of people who listen to them and more. And so it would be logical for those things (independent of any drug someone takes), to improve their feelings.
Despite drug companies knowing this, they still sell these drugs claiming that they work, and doctors are handing them out to patients.
Not only are the results for antidepressants depressing, but the theory behind how antidepressants work seems to be false. The story we’re told is that depression is caused by low levels of serotonin in the brain (or simply “a chemical imbalance in the brain”). You would think that there would be plenty of research and data to back this up. However, as mind boggling as it is, this was just a theory that someone came up with, but it was never actually verified! When you alter someone's brain chemistry, whether that’s increasing or decreasing serotonin, dopamine or norepinephrine, the results are the same. So you can decrease the levels of serotonin in the brain (the very thing that people with depression are supposed to have little of) and the effects are the same as if you increased it. This suggests that the results of antidepressants are largely based on the placebo effect. Some leaders in this area have concluded that the way we think of antidepressants is an accident that people have just run with. (This is the part where you say “holy shit!!!”)
And the side effects of all these drugs include weight gain, sexual disfunction, increase risk of violent criminal behaviour, increase death from all causes, increase risk of stroke, type 2 diabetes, miscarriage, giving birth to children with deformities and giving birth to children on the autism spectrum. We don’t even know what the long term effects are, and for many people, antidepressants only provide relief for a short time. They then need to gradually increase the dosage or they simply don’t work anymore. On top of that, people can recover from depression or anxiety very naturally, just like if someone has a cold they get better after some time even if you don’t give them any medicine. And if you are on antidepressants and ever decide to stop, you get to experience withdrawal symptoms.
While it is not the narrative that is being heard, most scientists now agree that depression is not simply caused by a chemical imbalance in the brain. And in spite of all the evidence above, there is still debate on the effectiveness of antidepressants.
The problem with how depression is diagnosed
How is depression diagnosed? Well, in America and much of the world, doctors use what is known as the DSM (which has gone through several iterations). It’s essentially the bible for diagnosing mental illness and is written by a panel of psychiatrists. In order to be diagnosed with depression you have to show 5 of 9 symptoms every day. Some of these are things like: a depressed mood, a decreased interest in pleasure or feelings of worthlessness.
The thing is, almost everyone who is grieving the loss of a loved one fulfils the criteria for clinical depression. Said differently, if your 2 year old baby is horribly murdered, and you don’t feel quite as chipper as you used to, or you’re not as interested in pleasant things in life any more etc, you’re considered to have a mental illness according to what is in the DSM.
This does not hold up under logic, so the authors of the DSM created a loophole called “the grief exception”. They said that if you’re grieving the loss of a loved one, you can show the signs of depression and not be considered mentally ill. Sounds OK, however, initially they said that you could show the signs for one year, and that if after that one year you were still showing signs of depression, you were then considered mentally ill. This time period has been shortened throughout the revisions for the DSM, until it was completely removed. In other words, the people who are supposed to be the brightest minds in mental health have concluded that if your baby has just died and you’re feeling down, it’s time to pop a pill because something is wrong with you that needs fixing.
As one of the people Hari interviewed said: giving an arbitrary date to how long we should grieve denies our very humanity. To love and grieve the loss of that love is to be human, is to be alive.
To me, the way of thinking that is depicted in the DSM is eerily similar to the society depicted in “a brave new world”, where people just take a pill to feel better, no matter what just happened. It’s worth questioning whether we even should get over the pain of loss. If you met someone who said “My family was brutally murdered, but now I’m over it and I don’t feel any bad feelings about it at all”, to me that would be when I start to question if someone is mentally and emotionally sane, if someone is connected to their emotions. It’s possible to overcome such things, but from what I’ve seen, it takes a great dedication to internal work to make that happen. A dedication that is very rare. Feeling the pain can make you feel connected in a world gone crazy, it can make you a more compassionate person, and gives you a perspective that few others have. That shouldn't be a thing to be medicated away.
The grief exception forced the psychiatric thinking to admit that it is reasonable to show signs of depression in such a circumstance. But then the question has to be asked, why is death the only exception? In other words, the context of our lives matter. Sometimes depression is a normal response to the conditions of our lives. Our brain and emotions are not disconnected from everything else that happens to us and around us. Taking this view, diagnosing depression can no longer simply be check boxes to tick. You have to take into account the complexity of life. And that doesn’t fit into the old model that Western medicine has been using for so long.
Many people who have been going to their doctors for years and taking antidepressants were never asked if there was anything in their life that might be causing (or at least affecting) their mood. A different approach is to listen to the pain and see what it is telling us. Even calling something a mental health condition isn’t very accurate, because what we’re really talking about with depression is an emotion, is a full human being. It’s not just in the head. Medicating depression is addressing the symptom (poorly), and not the cause.
A new perspective
What if depression is a form of grief. Grief for our lives not being as they should? A grief for the connection we have lost, yet still need?
We used to think that depression was a random occurrence, like someone getting hit by a meteor. It’s just bad luck and there’s nothing much different between people who do get hit by a meteor and people who don’t. But some investigations into people who were depressed showed that 68% of them had experienced a significantly negative event in the year prior to the depression setting in. They were also 3 times more likely to have faced serious long-term stressors in their lives in the year before they developed depression than people who weren’t depressed.
Further research found that if people didn’t have any friends, didn’t have a supportive partner and experienced a severely negative event, they had a 75% chance of being depressed. It turns out that the likelihood of developing depression grows exponentially as your conditions get poorer. Just like if you put fungus in a dark and damp place, it doesn’t just grow faster, the growth becomes exponentially faster than if it is in a dry and light place. The good news is that the opposite of this is also true.
So if you have positive, stabilising things in your life, that can significantly reduce the chances of developing depression.
Depression is not just a problem in your brain, it’s a problem in your life. It is not irrational. It is a rational response to adversity. A more complete look at depression looks at what is happening biologically, psychologically and socially.
Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions by Johann Hari