Book Club: Lost Connections by Johann Hari
When I started reading Johann Hari’s Lost Connections, I was already a convert. I knew depression and anxiety weren’t solely caused by chemistry or biology, despite growing up in the age of Prozac. While it was clear to me that antidepressants could be effective for people with moderate to severe depression, I suspected that for many people they weren’t solving the problem per se, but instead giving a boost that might be helpful in putting into place other changes that provide more lasting relief. I had a hunch that the mechanism by which antidepressants worked was more complicated than their action on neurotransmitters and that our apparent widespread deficits in serotonin were caused by something more complex. In short, I had become disenchanted by the explanations medicine has to offer about anxiety and depression and the tendency in some quarters to look at antidepressants as first line treatment rather than one piece of a much bigger puzzle.
Lost Connections is a book about those other causes of depression and anxiety. The author is an investigative journalist whose own story of depression, from his teens through adulthood, provides the framework for a journey through current research and what it tells us about what we get wrong, and right, about depression and anxiety.
When Hari was first diagnosed with depression at age 18, his doctor prescribed him antidepressants. He found them helpful at first, but years later in therapy came to realize that the medicine was no longer doing the trick for him - and hadn’t been for a long time. Hari set out to understand why this was, speaking with psychologists, psychiatrists, counselors, community organizers, researchers, and people struggling with depression and anxiety. What he found was that the scientific evidence for medication’s effectiveness is conflicting and controversial but the evidence for other causes, and treatments, is abundant.
I want to pause here for a moment to strongly emphasize that I am NOT recommending that anyone taking an antidepressant or other psychotropic medication stop taking it (and neither is Hari, so far as I can tell). That decision can only be made by you in consultation with your doctor, therapist, and support network. In my practice, I never advise clients to stop taking medication unless they can clearly articulate their goals for doing so and, most importantly, have had a thorough conversation with their prescriber to ensure that any changes they make are closely monitored by a medical professional. Abruptly discontinuing SSRIs or other psychotropic medication can be dangerous and should never be done without medical supervision.
Having said that, I believe Hari makes a compelling, thoughtful, and deeply researched case for why we must broaden the way we think about treating depression and anxiety as a society. The research he cites, in conscientious detail, is an enormous body of evidence saying that depression and anxiety are not predominately caused by low serotonin levels but rather by the way we live today. Nothing in this was particularly new or surprising to me, nor I expect will it be to many other people (especially therapists), but Hari makes his case in a particularly comprehensive and organized way that covers a lot of ground.
Any therapist or psychiatrist worth their salt will recognize that other factors besides chemistry play a major role in the development of depression. The work we do with our clients does not make a difference by raising serotonin levels. It makes a difference by helping clients to change the way they live in the world. We experience so many kinds of emotional pain - grief and loss, difficulty in relationships, feeling alienated or excluded from our communities, domestic violence, trauma, living in the shadow of prejudice or poverty - and all of these play a role in our mental health. One of the reasons therapy is an effective treatment for depression and anxiety is that it gives us an opportunity to share these painful experiences, process them, and find a way forward through our pain.
Where I believe Hari errs is in his seeming assumption that so much of the medical field is still invested in the all-or-nothing approach of SSRIs as a cure-all. While I have occasionally run into mental health professionals who are particularly “prescription-happy,” none of the therapists or psychiatrists I work with think this way, and the ones I refer to and learn from all have nuanced views of the many factors in play in depression and anxiety. Hari exhibits the zeal of the newly converted here, and while this enthusiasm helps him to make an important argument, I worry that it paints a misleadingly black and white picture.
Living as we so often do with the constraints of health insurance regulations, not enough time, lack of access to comprehensive care, etc., we rely on what we can to get by in a difficult world. This is especially true for those whose economic or other circumstances limit their access to opportunity and their ability to make big changes in their lives. Antidepressants are a viable option for many people, one that allows them to live happier, more fulfilling lives. Crucially, they may be one of the only accessible forms of treatment for many. Antidepressants are only one tool in an enormous tool kit for treating depression, however, and thorough help should always include as many tools as appropriate for the client’s situation.
If nothing else, I hope that Hari’s book drives home the point that mental health care and public policy must be holistic in their approach. Whenever we think in all-or-nothing terms, we miss the potential for helping people make profound changes in their lives. While we’ve gotten pretty good at bringing access to antidepressants and anti-anxiety medication to more people, we have a lot of work to do on making holistic treatment accessible and feasible. Hari shares examples of several community-level treatment programs with promising results, which hopefully will inspire us to create more and better options available to a greater number of people - and maybe even to change the way we live to make a world where depression and anxiety are not so prevalent.
TL;DR: A controversial book that lacks some nuance but offers a vision of changes we can make on a personal and community level to help treat anxiety and depression more effectively.
by Johann Hari
For more reading:
Neither this essay nor the book reviewed constitute psychological, medical, or pharmacological advice. Always consult with your doctor before making any changes to medication routines. Discontinuing medication abruptly can be dangerous to your health.