Pathways Out of Depression: A Book Review of Lost Connections: Uncovering the Real Causes of Depression – And Unexpected Solutions

In the book, Lost Connections, journalist Johann Hari takes aim at the antidepressant industry and the story it sells – namely, that depression is a physical ailment, a chemical imbalance in the brain, correctable with medication.  Hari begins by relating how, as a severely depressed teenager, his doctor told him his depression was a physical problem that could be corrected with a pill.  The antidepressant helped at first, despite an array of unpleasant side effects, but a year later, Hari found himself as depressed as he was before.  The writing of Lost Connections became Hari’s quest to come to terms with his own experience, and to investigate why it is our modern understanding of depression is failing to mitigate what has become a societal epidemic.

Part I of the book examines the evidence for the biochemical model of depression and the efficacy of antidepressants. Most damningly, Hari spotlights a huge National Institute of Mental Health study which found that 65 – 80 % of antidepressant users experience an initial alleviation of depression symptoms, but within a year are depressed again.  Only a quarter to a third of the depression sufferers fully recovered, and the researchers were unable to say whether these patients might have recovered spontaneously, without the medication.  Hari went on to gather interviews with a range of researchers: some were concerned the pharmaceutical companies have only reported the results of the trials they fund that found a benefit from the pills; others who believe in the medications question whether they are appropriate for long-term use.  He was unable to find a single study to support the theory that depression is caused by a chemical imbalance in the brain.  

Having exposed serious fault-lines in the neurochemical imbalance theory of depression, Hari goes on to examine what other factors could be likely to cause depression.  He begins the exploration by describing the genesis of the “bio-psycho-social model” of depression: the idea that multiple factors, including psychological and life circumstances, such as severe stress, poverty, and a lack of a social support system all contribute to depression.  Hari concludes with the statement, somewhat misleadingly, that up until now, “these truer insights remained private, sealed off from a public that could have been helped by them, they didn’t shape the treatment that was offered to them.” Perhaps Hari was taking poetic license, but this claim is my only serious issue with the book.  In fact, the biopsychosocial model has been at the foundation of Clinical Psychology for decades

Part II of Lost Connections explores psychological and social causes at the root of the depression epidemic.  Six chapters are devoted to the key social factors Hari believes are the root causes of depression, including meaningless work, lacking in any sense of autonomy; poverty and income inequality, especially a gig economy in which people are uncertain of their next paycheck; rampant materialism; loneliness and loss of community, exacerbated by the internet, which essentially provides a “junk food” facsimile of our genuine need for connection; and isolation from nature and the outdoors. 

Hari’s bias as a sociologist is evident in the book: only approximately 15 pages are devoted to the psychological aspect of the biopsychosocial model.  Regardless, the 15 pages are devastating.  In a survey of 17,000 Kaiser Permanente patients, individuals who could list six or more adverse childhood experiences (ACE’s) such as emotional or sexual abuse were five times more likely to suffer depression than someone who didn’t have any.  Individuals who had seven ACE’s were 3,100 times more likely to attempt suicide as an adult. Emotional abuse in particular showed a strong causal link to later developing depression.  Dr. Robert Anda, a co-author of the study, was shocked by the magnitude of his findings.  He concluded, “When people have these kinds of problems, it’s time to stop asking what’s wrong with them, and time to start asking what happened to them.” 

In Part III, Hari explores alternate, non-pharmaceutical, solutions to depression.  Some of his proposed solutions, such as physical exercise and mindfulness meditation, have been widely prescribed as part of a non-pharmaceutical program for depression for at least a decade.  As well, he describes a promising pilot follow-up to the Kaiser Permanente study which found a significant reduction in symptoms simply by telling one’s story of trauma to a sympathetic listener (although again this has been the foundation of Clinical Psychology for decades) and admits a huge benefit to having spoken to a therapist about his own trauma.  

Perhaps where Hari’s sociological perspective most shines is in his discussion of the role of poverty in depression.  It is well-established that individuals with an income of $20,000 or less are twice as likely to become depressed as those with an income of over $70,000. Playing a role in the link between poverty and depression is the sense of short- and long-term financial insecurity, and the lack of means to maneuver out of stressful life circumstances. As a possible solution, Hari advocates legislated guaranteed minimum income.  Pilot studies of guaranteed basic income support the notion that it could have a measurable impact on public mental health.  In one experiment measuring the benefits of guaranteed income in a small Native American community, for example, childhood ADHD and depression fell by 40%.  In Canada, at least, the idea has some bipartisan support.  

Failing the political will to do that, two projects Hari describes could point in a promising direction.  The first is an innovative mental health program in the UK, which for a fraction of the cost of putting people on expensive medication instead assigns patients to volunteer groups.  One such project set a group to work constructing a community garden and park out of a junk-filled alley. The participants deemed it wildly successful – it seems the act of getting outdoors, and interacting with others, slowly leading to friendships and a social support system simply by working shoulder to shoulder, was sufficient to lift most of the participants out of depression and to increase their life satisfaction.   

The second project Hari describes involved the formation of a community group in a poor section of Berlin that came together to combat gentrification and skyrocketing rents, and in the end formed deep ties and healthy, flourishing community.  Hari might also have included the Beacon Project – a community based effort that lifted a small town out near ghetto-ized levels of poverty and saw dramatically positive outcomes in crime reduction, improvement of standard of living, and mental health outcomes.        

Lost Connections is an important and timely re-examination of our understanding of depression.  In his book, Hari suggests sweeping changes to our culture and system of government to address this epidemic. But even without these radical changes, Hari’s core message is empowering. The neurochemical imbalance model of depression conveys the message that there’s nothing we can do besides taking a pill to feel better.  Hari provides overwhelming evidence to the contrary.  Armed with a better understanding of the root causes of our depression, and the tools to move out of it, Hari shows us that tapping into our innate resilience will lead us to a happier, more meaningful life.  Speaking to his former self, Hari concludes: 

[…]“[Y]ou aren’t a machine with broken parts. You are an animal whose needs are not being met…I know how deep your suffering cuts. But this pain isn’t your enemy however much it hurts…It’s your ally – leading you away from a wasted life and pointing the way to a more fulfilling one.  

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