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The Observer
Is everything you think you know about depression wrong?
In this extract from his new book, Johann Hari, who took antidepressants
for 13 years, calls for a new approach


• Johann Hari Q&A: ‘I was afraid to dismantle the story about depression and anxiety’

Johann Hari

Sun 7 Jan 2018 04.00 EST Last modified on Thu 11 Jan 2018 05.49 EST
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Seroxat tablets on a page of words associated with depression
In the 1970s, a truth was accidentally discovered about depression – one
that was quickly swept aside, because its implications were too
inconvenient, and too explosive. American psychiatrists had produced a
book that would lay out, in detail, all the symptoms of different mental illnesses, so they could be identified and treated in the same way
across the United States. It was called the Diagnostic and Statistical
Manual. In the latest edition, they laid out nine symptoms that a
patient has to show to be diagnosed with depression – like, for example, decreased interest in pleasure or persistent low mood. For a doctor to
conclude you were depressed, you had to show five of these symptoms over several weeks.

The manual was sent out to doctors across the US and they began to use
it to diagnose people. However, after a while they came back to the
authors and pointed out something that was bothering them. If they
followed this guide, they had to diagnose every grieving person who came
to them as depressed and start giving them medical treatment. If you
lose someone, it turns out that these symptoms will come to you
automatically. So, the doctors wanted to know, are we supposed to start drugging all the bereaved people in America?

The authors conferred, and they decided that there would be a special
clause added to the list of symptoms of depression. None of this
applies, they said, if you have lost somebody you love in the past year.
In that situation, all these symptoms are natural, and not a disorder.
It was called “the grief exception”, and it seemed to resolve the problem.

Then, as the years and decades passed, doctors on the frontline started
to come back with another question. All over the world, they were being encouraged to tell patients that depression is, in fact, just the result
of a spontaneous chemical imbalance in your brain – it is produced by
low serotonin, or a natural lack of some other chemical. It’s not caused
by your life – it’s caused by your broken brain. Some of the doctors
began to ask how this fitted with the grief exception. If you agree that
the symptoms of depression are a logical and understandable response to
one set of life circumstances – losing a loved one – might they not be
an understandable response to other situations? What about if you lose
your job? What if you are stuck in a job that you hate for the next 40
years? What about if you are alone and friendless?

Drug companies would fund huge numbers of studies and then only
release the ones that showed success
The grief exception seemed to have blasted a hole in the claim that the
causes of depression are sealed away in your skull. It suggested that
there are causes out here, in the world, and they needed to be
investigated and solved there. This was a debate that mainstream
psychiatry (with some exceptions) did not want to have. So, they
responded in a simple way – by whittling away the grief exception. With
each new edition of the manual they reduced the period of grief that you
were allowed before being labelled mentally ill – down to a few months
and then, finally, to nothing at all. Now, if your baby dies at 10am,
your doctor can diagnose you with a mental illness at 10.01am and start drugging you straight away.

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Dr Joanne Cacciatore, of Arizona State University, became a leading
expert on the grief exception after her own baby, Cheyenne, died during childbirth. She had seen many grieving people being told that they were mentally ill for showing distress. She told me this debate reveals a key problem with how we talk about depression, anxiety and other forms of suffering: we don’t, she said, “consider context”. We act like human distress can be assessed solely on a checklist that can be separated out
from our lives, and labelled as brain diseases. If we started to take people’s actual lives into account when we treat depression and anxiety, Joanne explained, it would require “an entire system overhaul”. She told
me that when “you have a person with extreme human distress, [we need
to] stop treating the symptoms. The symptoms are a messenger of a deeper problem. Let’s get to the deeper problem.”

*****

I was a teenager when I swallowed my first antidepressant. I was
standing in the weak English sunshine, outside a pharmacy in a shopping
centre in London. The tablet was white and small, and as I swallowed, it
felt like a chemical kiss. That morning I had gone to see my doctor and
I had told him – crouched, embarrassed – that pain was leaking out of me uncontrollably, like a bad smell, and I had felt this way for several
years. In reply, he told me a story. There is a chemical called
serotonin that makes people feel good, he said, and some people are
naturally lacking it in their brains. You are clearly one of those
people. There are now, thankfully, new drugs that will restore your
serotonin level to that of a normal person. Take them, and you will be
well. At last, I understood what had been happening to me, and why.


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However, a few months into my drugging, something odd happened. The pain started to seep through again. Before long, I felt as bad as I had at
the start. I went back to my doctor, and he told me that I was clearly
on too low a dose. And so, 20 milligrams became 30 milligrams; the white
pill became blue. I felt better for several months. And then the pain
came back through once more. My dose kept being jacked up, until I was
on 80mg, where it stayed for many years, with only a few short breaks.
And still the pain broke back through.

I started to research my book, Lost Connections: Uncovering The Real
Causes of Depression – and the Unexpected Solutions, because I was
puzzled by two mysteries. Why was I still depressed when I was doing
everything I had been told to do? I had identified the low serotonin in
my brain, and I was boosting my serotonin levels – yet I still felt
awful. But there was a deeper mystery still. Why were so many other
people across the western world feeling like me? Around one in five US
adults are taking at least one drug for a psychiatric problem. In
Britain, antidepressant prescriptions have doubled in a decade, to the
point where now one in 11 of us drug ourselves to deal with these
feelings. What has been causing depression and its twin, anxiety, to
spiral in this way? I began to ask myself: could it really be that in
our separate heads, all of us had brain chemistries that were
spontaneously malfunctioning at the same time?

To find the answers, I ended up going on a 40,000-mile journey across
the world and back. I talked to the leading social scientists
investigating these questions, and to people who have been overcoming depression in unexpected ways – from an Amish village in Indiana, to a Brazilian city that banned advertising and a laboratory in Baltimore
conducting a startling wave of experiments. From these people, I learned
the best scientific evidence about what really causes depression and
anxiety. They taught me that it is not what we have been told it is up
to now. I found there is evidence that seven specific factors in the way
we are living today are causing depression and anxiety to rise –
alongside two real biological factors (such as your genes) that can
combine with these forces to make it worse.

Once I learned this, I was able to see that a very different set of
solutions to my depression – and to our depression – had been waiting
for me all along.

To understand this different way of thinking, though, I had to first investigate the old story, the one that had given me so much relief at
first. Professor Irving Kirsch at Harvard University is the Sherlock
Holmes of chemical antidepressants – the man who has scrutinised the
evidence about giving drugs to depressed and anxious people most closely
in the world. In the 1990s, he prescribed chemical antidepressants to
his patients with confidence. He knew the published scientific evidence,
and it was clear: it showed that 70% of people who took them got
significantly better. He began to investigate this further, and put in a freedom of information request to get the data that the drug companies
had been privately gathering into these drugs. He was confident that he
would find all sorts of other positive effects – but then he bumped into something peculiar.

Illustration by Michael Driver of a man trying to block out anxieties. Facebook Twitter Pinterest
Illustration by Michael Driver.
We all know that when you take selfies, you take 30 pictures, throw away
the 29 where you look bleary-eyed or double-chinned, and pick out the
best one to be your Tinder profile picture. It turned out that the drug companies – who fund almost all the research into these drugs – were
taking this approach to studying chemical antidepressants. They would
fund huge numbers of studies, throw away all the ones that suggested the
drugs had very limited effects, and then only release the ones that
showed success. To give one example: in one trial, the drug was given to
245 patients, but the drug company published the results for only 27 of
them. Those 27 patients happened to be the ones the drug seemed to work
for. Suddenly, Professor Kirsch realised that the 70% figure couldn’t be right.

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It turns out that between 65 and 80% of people on antidepressants are
depressed again within a year. I had thought that I was freakish for
remaining depressed while on these drugs. In fact, Kirsch explained to
me in Massachusetts, I was totally typical. These drugs are having a
positive effect for some people – but they clearly can’t be the main solution for the majority of us, because we’re still depressed even when
we take them. At the moment, we offer depressed people a menu with only
one option on it. I certainly don’t want to take anything off the menu – but I realised, as I spent time with him, that we would have to expand
the menu.

This led Professor Kirsch to ask a more basic question, one he was
surprised to be asking. How do we know depression is even caused by low serotonin at all? When he began to dig, it turned out that the evidence
was strikingly shaky. Professor Andrew Scull of Princeton, writing in
the Lancet, explained that attributing depression to spontaneously low serotonin is “deeply misleading and unscientific”. Dr David Healy told
me: “There was never any basis for it, ever. It was just marketing copy.”

I didn’t want to hear this. Once you settle into a story about your
pain, you are extremely reluctant to challenge it. It was like a leash I
had put on my distress to keep it under some control. I feared that if I
messed with the story I had lived with for so long, the pain would run
wild, like an unchained animal. Yet the scientific evidence was showing
me something clear, and I couldn’t ignore it.

*****

So, what is really going on? When I interviewed social scientists all
over the world – from São Paulo to Sydney, from Los Angeles to London –
I started to see an unexpected picture emerge. We all know that every
human being has basic physical needs: for food, for water, for shelter,
for clean air. It turns out that, in the same way, all humans have
certain basic psychological needs. We need to feel we belong. We need to
feel valued. We need to feel we’re good at something. We need to feel we
have a secure future. And there is growing evidence that our culture
isn’t meeting those psychological needs for many – perhaps most –
people. I kept learning that, in very different ways, we have become disconnected from things we really need, and this deep disconnection is
driving this epidemic of depression and anxiety all around us.

Let’s look at one of those causes, and one of the solutions we can begin
to see if we understand it differently. There is strong evidence that
human beings need to feel their lives are meaningful – that they are
doing something with purpose that makes a difference. It’s a natural psychological need. But between 2011 and 2012, the polling company
Gallup conducted the most detailed study ever carried out of how people
feel about the thing we spend most of our waking lives doing – our paid
work. They found that 13% of people say they are “engaged” in their work – they find it meaningful and look forward to it. Some 63% say they are “not engaged”, which is defined as “sleepwalking through their workday”.
And 24% are “actively disengaged”: they hate it.

A doctor writing a prescription
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Antidepressant prescriptions have doubled over the last decade.
Photograph: Anthony Devlin/PA
Most of the depressed and anxious people I know, I realised, are in the
87% who don’t like their work. I started to dig around to see if there
is any evidence that this might be related to depression. It turned out
that a breakthrough had been made in answering this question in the
1970s, by an Australian scientist called Michael Marmot. He wanted to investigate what causes stress in the workplace and believed he’d found
the perfect lab in which to discover the answer: the British civil
service, based in Whitehall. This small army of bureaucrats was divided
into 19 different layers, from the permanent secretary at the top, down
to the typists. What he wanted to know, at first, was: who’s more likely
to have a stress-related heart attack – the big boss at the top, or
somebody below him?

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Everybody told him: you’re wasting your time. Obviously, the boss is
going to be more stressed because he’s got more responsibility. But when Marmot published his results, he revealed the truth to be the exact
opposite. The lower an employee ranked in the hierarchy, the higher
their stress levels and likelihood of having a heart attack. Now he
wanted to know: why?

And that’s when, after two more years studying civil servants, he
discovered the biggest factor. It turns out if you have no control over
your work, you are far more likely to become stressed – and, crucially, depressed. Humans have an innate need to feel that what we are doing, day-to-day, is meaningful. When you are controlled, you can’t create
meaning out of your work.

Suddenly, the depression of many of my friends, even those in fancy jobs
– who spend most of their waking hours feeling controlled and
unappreciated – started to look not like a problem with their brains,
but a problem with their environments. There are, I discovered, many
causes of depression like this. However, my journey was not simply about finding the reasons why we feel so bad. The core was about finding out
how we can feel better – how we can find real and lasting
antidepressants that work for most of us, beyond only the packs of pills
we have been offered as often the sole item on the menu for the
depressed and anxious. I kept thinking about what Dr Cacciatore had
taught me – we have to deal with the deeper problems that are causing
all this distress.

I found the beginnings of an answer to the epidemic of meaningless work
– in Baltimore. Meredith Mitchell used to wake up every morning with her heart racing with anxiety. She dreaded her office job. So she took a
bold step – one that lots of people thought was crazy. Her husband,
Josh, and their friends had worked for years in a bike store, where they
were ordered around and constantly felt insecure, Most of them were
depressed. One day, they decided to set up their own bike store, but
they wanted to run it differently. Instead of having one guy at the top
giving orders, they would run it as a democratic co-operative. This
meant they would make decisions collectively, they would share out the
best and worst jobs and they would all, together, be the boss. It would
be like a busy democratic tribe. When I went to their store – Baltimore Bicycle Works – the staff explained how, in this different environment,
their persistent depression and anxiety had largely lifted.

It’s not that their individual tasks had changed much. They fixed bikes before; they fix bikes now. But they had dealt with the unmet
psychological needs that were making them feel so bad – by giving
themselves autonomy and control over their work. Josh had seen for
himself that depressions are very often, as he put it, “rational
reactions to the situation, not some kind of biological break”. He told
me there is no need to run businesses anywhere in the old humiliating, depressing way – we could move together, as a culture, to workers
controlling their own workplaces.

*****

With each of the nine causes of depression and anxiety I learned about,
I kept being taught startling facts and arguments like this that forced
me to think differently. Professor John Cacioppo of Chicago University
taught me that being acutely lonely is as stressful as being punched in
the face by a stranger – and massively increases your risk of
depression. Dr Vincent Felitti in San Diego showed me that surviving
severe childhood trauma makes you 3,100% more likely to attempt suicide
as an adult. Professor Michael Chandler in Vancouver explained to me
that if a community feels it has no control over the big decisions
affecting it, the suicide rate will shoot up.

This new evidence forces us to seek out a very different kind of
solution to our despair crisis. One person in particular helped me to
unlock how to think about this. In the early days of the 21st century, a
South African psychiatrist named Derek Summerfeld went to Cambodia, at a
time when antidepressants were first being introduced there. He began to explain the concept to the doctors he met. They listened patiently and
then told him they didn’t need these new antidepressants, because they already had anti-depressants that work. He assumed they were talking
about some kind of herbal remedy.


Is everything Johann Hari knows about depression wrong?
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He asked them to explain, and they told him about a rice farmer they
knew whose left leg was blown off by a landmine. He was fitted with a
new limb, but he felt constantly anxious about the future, and was
filled with despair. The doctors sat with him, and talked through his
troubles. They realised that even with his new artificial limb, his old job—working in the rice paddies—was leaving him constantly stressed and
in physical pain, and that was making him want to just stop living. So
they had an idea. They believed that if he became a dairy farmer, he
could live differently. So they bought him a cow. In the months and
years that followed, his life changed. His depression—which had been profound—went away. “You see, doctor,” they told him, the cow was an “antidepressant”.

To them, finding an antidepressant didn’t mean finding a way to change
your brain chemistry. It meant finding a way to solve the problem that
was causing the depression in the first place. We can do the same. Some
of these solutions are things we can do as individuals, in our private
lives. Some require bigger social shifts, which we can only achieve
together, as citizens. But all of them require us to change our
understanding of what depression and anxiety really are.

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This is radical, but it is not, I discovered, a maverick position. In
its official statement for World Health Day in 2017, the United Nations reviewed the best evidence and concluded that “the dominant biomedical narrative of depression” is based on “biased and selective use of
research outcomes” that “must be abandoned”. We need to move from “focusing on ‘chemical imbalances’”, they said, to focusing more on “power imbalances”.

After I learned all this, and what it means for us all, I started to
long for the power to go back in time and speak to my teenage self on
the day he was told a story about his depression that was going to send
him off in the wrong direction for so many years. I wanted to tell him:
“This pain you are feeling is not a pathology. It’s not crazy. It is a signal that your natural psychological needs are not being met. It is a
form of grief – for yourself, and for the culture you live in going so
wrong. I know how much it hurts. I know how deeply it cuts you. But you
need to listen to this signal. We all need to listen to the people
around us sending out this signal. It is telling you what is going
wrong. It is telling you that you need to be connected in so many deep
and stirring ways that you aren’t yet – but you can be, one day.”

If you are depressed and anxious, you are not a machine with
malfunctioning parts. You are a human being with unmet needs. The only
real way out of our epidemic of despair is for all of us, together, to
begin to meet those human needs – for deep connection, to the things
that really matter in life.

• This is an edited extract from Lost Connections: Uncovering the Real
Causes of Depression – and the Unexpected Solutions by Johann Hari,
published by Bloomsbury on 11 January (£16.99). To order a copy for
£14.44 go to guardianbookshop.com or call 0330 333 6846. Free UK p&p
over £10, online orders only. Phone orders min p&p of £1.99. It will be available in audio at audible.co.uk

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