Monday, February 26, 2018

Book Review: Lost Connections: Uncovering the Real Causes of Depression—and the Unexpected Solutions by Johann Hari

Johann Hari’s new book on depression has received a considerable amount of attention, much of which has focused on the first fifty pages or so of the book which criticizes the chemical imbalance theory of depression and casts doubt about the efficacy of and the reliance on antidepressant drugs. In fact, despite the pharmaceutical advertising implying that depression is caused by too little serotonin in the brain, there is no evidence of that. To the extent that selective serotonin reuptake inhibitors work, there is something else going on. Moreover, they don’t alleviate depression for everyone, and, in many cases, they do not work much better, if at all, than a placebo.
The debate about antidepressants is fierce. Irving Kirsch, a psychologist who is currently the Associate Director of the Program in Placebo Studies and a lecturer in medicine at the Harvard Medical School and Beth Israel Deaconess Medical Center, ignited the debate in a 2009 book, The Emperor's New Drugs: Exploding the Antidepressant Myth. Marcia Angell, a former editor-in-chief of the New England Journal of Medicine and is also currently affiliated with Harvard Medical School, promoted Irving Kirsch’s book in two long 2011 articles for the New York Review of Books. (I wrote about this here.) 
The debate has recently been reignited on the other side by a recent study in The Lancet which argues that antidepressants are effective, some more than others. Andrea Cipriani, a psychiatrist who led the study, told the BBC: “This study is the final answer to a long-standing controversy about whether anti-depressants work for depression.” Of course, that is wishful thinking on his part. The controversy will continue. (For example, see this, this, and this.)
Moreover, what is not known is the effect of long-term use of antidepressants. The studies that have been done focus on what happens after eight weeks; most people who use these drugs use them for much longer than that.
To focus solely on Hari’s chapters on antidepressants though is to miss his main point; the prevalence of depression in modern societies is due to how we live, not to chemical imbalances. He lists nine causes of depression and anxiety in modern life. The first seven are “disconnection from meaningful work,” “disconnection from other people,” “disconnection from meaningful values,” “disconnection from childhood trauma,” “disconnection from status and respect,” “disconnection from the natural world,” and “disconnection from a hopeful or secure future.” Each of these rates a chapter. Causes eight and nine, “the real role of genes and brain changes,” are consigned to a short and not very informative single chapter.
Hari argues persuasively about the travails of modern life. But there is a confusion in the book between what individuals should do about their individual circumstances and what we should be trying to do to change society. As a result, the book is neither a self-help book nor a guide on how to effectuate societal change.
For example, Hari does not address what a mental health professional is supposed to do when a patient walks in desperately unhappy. It is not in the professional’s power to change society or working conditions. In many cases, if there are no clear solutions about the objective conditions that patients face which are causing distress, I would guess in many cases mental health professionals will likely focus on helping patients to adapt better to the environment in which they find themselves. Hence, the temptation to prescribe antidepressants, tranquilizers, and other drugs. 
Another problem with the book is that it is unclear what we mean by depression. There is a difference between people who are chronically unhappy because of unsatisfying jobs or unsatisfactory personal relationships (or lack thereof) but who can still function on a day-to-day basis and people who spend most of their time in bed and can barely function and need help in meeting their daily needs. The author thinks this is a continuum, but it is not clear that they are the same thing, only differing by severity. 
Furthermore, when it comes to troubling, exogenous factors impacting daily life, why do some people manage to cope while other become mildly or severely depressed? No one really knows, though Hari does say there is a genetic component. There probably is in some or many cases, but the solution for the individual is not obvious. Saying that society is sick does not help the individual.
The problem for the medical profession in treating depression is that there is nothing to see except an unhappy individual. There are no blood tests or x-rays doctors can order to help them diagnose the condition. They can ask questions or ask patients to fill out a questionnaire, but this is all in the realm of subjectivity. Some lucky patients may benefit from drugs; others may find that talk therapy works; others may in time get over their distress; and others may have to suffer. Various forms and severity of what we call depression may more accurately be described as symptoms that are the result of various factors, depending on the individual and circumstances.
Apparently, no new antidepressants are likely to come to market anytime soon. There is some promising research in using psychedelic drugs to treat some forms of depression, but as Hari mentions, this does not work for everyone and there are risks. Those who remember the sixties will likely recall that some people had “bad trips” when taking LSD. That apparently is still a problem.
Another therapy which is currently used for severely depressed patients who have been “treatment-resistant” is electroconvulsive therapy (“ECT”), which is an attempt at a non-alarming way to refer to shock therapy. Currently, ECT is practiced in a way that is less painful to patients than the horror stories one remembers from Ken Kesey’s novel (or the movie), One Flew Over the Cuckoo's Nest. It apparently often has good results, but how it works does not seem to be that clearly understood. The tradeoff of long-term costs and benefits are not clear. It appears to make permanent, physical changes to the brain. Hari, though, does not discuss ECT. 
I wanted to like this book more than I did. Hari, though, is a good writer and an engaging speaker. His criticisms of modern society are worth pondering, even if many will not fully agree with them. His criticisms of antidepressant drugs are especially cogent and convincing, and, it needs to be noted, that Hari does indicate that they are helpful to some people. 
Note: I was motivated to read this book by an event I attended at Washington, DC’s premier independent bookstore, Politics and Prose. At this book talk, Andrew Sullivan interviewed Johann Hari. The video of this event can be found here.
Probably because of a plagiarism episode in his past, Hari has provided extensive endnotes to the book and additional information on a website. At that website, one can listen to the audio of interviews Hari conducted in researching the book.