Stalked by depression for 20 years, Johann Hari couldn’t find the pharmaceutical relief doctors promised. He began asking why – and wrote a book about what he found.
The doctor told him about a chemical called serotonin that makes people feel good. Some people, he said, have a natural shortage of it in the brain, and Hari was clearly one. He offered him a drug to make him feel better.
At first, Hari did feel better: in a new book, Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions, he describes his first dose of a selective serotonin reuptake inhibitor (SSRI) as a “chemical kiss”. But as the months passed, the good feelings waned, so he kept returning to his GP to get higher-strength prescriptions.
“I loyally followed this medical advice for 13 years and I wanted to believe that I was feeling better. But when I finally looked at the evidence, I discovered that most people taking chemical antidepressants are very soon depressed again.”
Hari, who was by then a noted newspaper journalist, wanted to know why, if the drugs didn’t work very well, so many people were taking them. In the UK since 2006, antidepressant use has more than doubled; in the US, the increase was fourfold between the early 1990s and the late 2000s. In New Zealand, the picture is much the same, though the increase is not as extreme: figures reported in November by the Government’s drug-buying agency, Pharmac, showed the number of annual prescriptions for SSRI antidepressants rose 71% – from 700,000 to 1.2 million – between 2007 and 2016.
Hari wondered why no one had thought to ask if there was any other reason that he was feeling depressed: couldn’t his life, past and present, have been part of the explanation? Writing Lost Connections was his attempt to find the answer.
Hari’s book comes garlanded with an extraordinary collection of celebrity endorsements. The cover of the UK edition features Elton John (“If you have ever been down, or felt lost, this amazing book will change your life – read it now”); activist and author Naomi Klein; TV presenter Davina McCall; and erstwhile spin doctor for Tony Blair and now mental-health advocate Alastair Campbell. The US edition bears the view of Hillary Clinton that it “offers a wonderful and incisive analysis of the depression and alienation that are haunting American society”.
And judging by its success in the UK – published in January, it was reprinted after selling out almost immediately – these are questions that many other people also want answered.
Hari begins the book by picking apart old and new research into antidepressants, much of it under-reported, he says. He sides with Professor Irving Kirsch of the Harvard Medical School, who says that “beyond question … the traditional account of depression as a chemical imbalance in the brain is simply wrong”.
Kirsch, the associate director of the medical school’s programme in placebo studies, did his own research and analysed other studies – including data from unpublished trials of six antidepressants, obtained from the US Food and Drug Administration under the Freedom of Information Act, which had shown inconveniently unpromising results. He found that SSRIs’ effects were clinically meaningful (though still relatively small) only at the upper end of the very severely depressed category.
Hari says scientists have largely withdrawn their support for SSRIs, but that hasn’t stopped the prescription of such drugs. People continue to feel better taking them because they have been given a solution. In other words, it has a placebo effect.
“Research into chemical antidepressants is dominated by researchers who take money from the drug companies who profit from these drugs,” writes Hari. “They would fund huge numbers of studies, throw away all the ones that suggested the drugs had very limited effects, and release only the ones that showed success. 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.
“But it turns out that, overall, 65-80% of people on antidepressants are depressed again within a year.”
Scientists rate depression levels on a continuum called the Hamilton Rating Scale for Depression (named for the German-born English psychiatrist Max Hamilton, who published it in 1960).
“The scale ranges from 0 (where you’re skipping along merrily) to 51 (where you’re jumping in front of trains),” Hari writes. “To give you a yardstick: you can get a six-point leap in your Hamilton score if you improve your sleeping patterns.”
Hari reports that Kirsch’s Harvard research found antidepressants do cause an improvement in the Hamilton score. “They do make depressed people feel better. It’s an improvement of 1.8 points.”
This small improvement – less than a third of that conferred by better sleep – combined with SSRIs’ side effects (including weight gain and sexual dysfunction) underpinned Kirsch’s reconsideration of the clinical efficacy of antidepressant medication.
It is worth emphasising that the Hamilton scale has been criticised for placing more emphasis on insomnia than on feelings of hopelessness and self-destructive or suicidal thoughts, and for taking excessive account of medication’s side effects rather than primary effects. Hamilton himself urged against the use of his scale, which he revised three times in the 1960s and again in 1980, as a diagnostic tool.
A realistic conversation
It’s the antidepressant section of the book that has attracted most news coverage in the UK, but when we meet in London shortly before its publication, Hari is much more interested in talking about the many causes of depression – and anxiety: he believes the two are linked, “like cover versions of the same song by different bands” – and the ways of dealing with it.
He is keen to emphasise that the book is “not an attack on chemical antidepressants but an attempt to have a more realistic conversation about them”.
As he told Kim Hill on RNZ National, “I say unequivocally in the book that if people are taking chemical antidepressants and they’re experiencing more benefits than side effects, just to carry on taking the drugs.”
The fact that a big proportion of people taking them are still depressed doesn’t mean that they don’t get some relief from them, he says. “It doesn’t mean they should stop. But we need to expand the menu of what they can be offered.”
There are, he says, three causes of depression: biological (your genes can make you more vulnerable); social factors (such as poverty); and psychological factors, relating to the way you think about yourself in the world.
Hari’s view is that the medical establishment’s overwhelmingly pharmacological response treats patients reporting depressive symptoms as machines that need only a few damaged components repaired to function well again.
But it’s the psychological element of depression that particularly interests him.
“If you are depressed, you’re not a machine with broken parts; you’re a person with unmet needs. Depression is simply a sign that something is wrong.”
Hari argues that, rather than resorting to prescription medicine, we should be looking at what is lacking in our lives. He details a selection of different areas that he believes have some part in causing depression and anxiety. They include a sense of not having meaningful work, loneliness and alienation from others, a lack of meaningful values, a struggle to be respected and a lack of easy access to the natural world.
His assessment has its share of critics. Psychiatrist Carmine Pariante, writing in the Independent, expressed concern at the “machine with broken parts” analogy, pointing out that people with depression showed measurable changes in the brain: it became smaller and production of new brain cells was reduced. Their bodies also changed, Pariante wrote, because activation of the stress response leads to raised levels of inflammation and stress hormones. Antidepressants reverse some of the physical effects.
“Use of [antidepressant] drugs certainly shouldn’t go unquestioned,” Pariante says. “We still do not know exactly how they work; they work differently on different people and there is much scope for the development of better medication. But they certainly have relevant, positive effects on the brain and the body.”
Research, some of which was publicly funded, not underwritten by pharmaceutical companies, used “the most rigorous approaches” to show that antidepressants “lift the pervasive sadness at the core of clinical depression, albeit with varying effects on other symptoms such as sleep or appetite problems”.
Pariante said that he and “vast” numbers of other medical professionals strongly endorsed Hari’s view that helping people to connect with the things that really matter in life is essential to improving our mental health.
“This is no revelation, but it is useful that Hari spells it out. But suggesting that prescribing antidepressants to a patient who suffers from clinical depression is the equivalent of treating them as a ‘machine with malfunctioning parts’ is wrong, unhelpful and even dangerous.
“Contrary to the claim that too many people are prescribed antidepressants, only one in five people with depression in high-income countries receives help, either psychological or pharmacological.”
Flawed ways of living
The pages of Lost Connections are jammed with details of research and interviews with social scientists highlighting our flawed ways of working, living and relating to each other and the way they lead to stress, isolation and physical and mental illness.
“I was interested in the way work caused depression and anxiety,” Hari says. “A detailed Gallup poll showed that 13% of people love their jobs, 63% sleepwalk through their work and 24% hate and fear their jobs.
“You and I love what we do, but we are very fortunate: most people – 87% – are not happy at work.”
Our response to work is affected by many factors: the idea of “work hours” is disappearing, so the pressure to perform is never-ending; job security is virtually unknown and whole areas of employment are now under threat from technological disruption. Hari unearthed a 1970s study by epidemiologist Michael Marmot, who wanted to be able to predict who in an organisation – he used the British civil service – was most likely to have a stress-related heart attack.
“You’d think, wouldn’t you, that the most senior people were most at risk, but that simply wasn’t true. The lower down [the seniority scale] you went, by a big margin, the more likely they were to have a heart attack. And the same figure was true of depression.”
There are two reasons for this, he suggests: “If you have no control over your work, you are stressed, and if there is an imbalance between effort and reward, you feel irrelevant.” Mentally and physically, such work is crushing you.
A need for purpose
In his research for the book, Hari travelled the world to find solutions to the “disconnects” that are making us unwell. Perhaps predictably, he found people learning to meditate or seeing a therapist. But he discovered more inventive approaches, too: community-based work models that allowed greater connection with others; countering depression by helping others, rather than looking for help from them; a rejection of social media that traded in and nurtured envy; a resistance to the blandishments of advertising that fuelled the urge to seek solace in consumption.
He found answers in Pennsylvania and in London’s East End, in Berlin and Baltimore: what they had in common was that they offered a purposeful, hopeful future, in which people have a sense of autonomy and do not constantly try to compare themselves with others.
At an Amish community in Indiana, he was impressed by “a big interconnected tribe of about 150 people – all Amish, all within walking distance of each other”. Their religion is fundamentalist Christian, their economy is self-supporting and their life is very insular. But at 16, all Amish men are allowed into the non-Amish world for a couple of years, after which they make the decision whether to stay or return. Hari concedes that women are treated as unequal, gay rights are unknown and children are beaten for misbehaving, but points out that the community elements of their life are inspiring – and depression is at much lower levels among the Amish.
Meanwhile, a treatment practice known as social prescribing pushes depressive patients towards social initiatives that will break them out of isolation and increase their sense of connectedness with the society around them.
Hari cites the case of a mental health nurse in East London, Lisa Robinson, who spent seven years off work with depression, taking Prozac and putting on weight until she was more than 100kg. She felt she had lost herself and told Hari she was “completely disabled by depression”.
Then, instead of being given another prescription, she was offered an activity. She joined a group of 20 volunteer patients, who were given a plot of wasteland to turn into a garden. They didn’t have to talk about anything; they had to get their hands dirty and figure out how to work together.
“It felt to Lisa that, as the garden came to life, the members of the group came to life,” Hari writes.
A couple of years later, Lisa had stopped taking Prozac, lost 28kg, fallen in love with a gardener and moved to Wales. “She is still in touch with some of the people from the gardening group. They saved each other, she told me. Them and the soil.”
Hari says humans have an innate need to feel that what they do is purposeful. “Of all the causes of depression, I found this most personally challenging: not just that we have the absence of meaning but we have the presence of bullshit. Junk values, such as who has the most likes on Instagram, are like junk food – there is no nutritional benefit.”
Hari blazed in the London media firmament in the early years of the century. He was Young Journalist of the Year in 2003 and became a star columnist with the Independent. But he suffered a catastrophic fall from grace in 2011 when he was discovered to have used quotes from other journalists’ work as if the words had been said to him in interviews. Worse, it later emerged that he had anonymously edited the Wikipedia pages of some of his critics so as to present them in a negative light. As his own Wikipedia entry now says, “these behaviours resulted in significant damage to Hari’s reputation: he was required to return the prestigious Orwell Prize [for political writing], which he had won in 2008, and he lost his position as a columnist for the Independent”.
Even before the era of fake news, this was a massive blow to Hari’s credibility. He publicly apologised but never returned to professional newspaper journalism. Instead, he spent time in the US and has re-emerged as a non-fiction author, first with bestseller Chasing the Scream: The First and Last Days of the War on Drugs about drug addiction and now with Lost Connections.
The public and professional opprobrium cannot have been easy to endure, but he took it on the chin. He has apologised to the individuals whose Wikipedia pages he doctored. And he has also stopped taking antidepressants.
Anoosh Chakelian from political weekly the New Statesman (where Hari worked in his early twenties) reports him as saying, “I don’t want to get into reconstructing my mental state around the time of the controversy I was involved in.” But he tells her he was “addicted to working all the time”, taking the narcolepsy drug Provigil to “prop up” this condition, “which, like all addictions, was really about an underlying source of pain”.
So, how is Hari’s mental health now? “Really good, actually!” says the writer, who is 39 but looks 10 years younger and buzzes with a puppyish energy. We’d never met, but he hugged before and after our talk and was keen to leave me with his email address so I could contact his interviewees.
“I learnt a huge number of insights from these people who have helped me reorient my life. I feel the best I’ve ever felt. But I don’t want to say, ‘Well, I did this and you can too.’
“I am privileged and I have the means to make changes to my life, but I am in a minority. Most people can’t make these changes alone; they need there to be societal changes because there are factors causing anxiety and depression in the deeper society. We can make it better, but we have to do it together.”
Former Guardian journalist Louise Chunn is the founder of therapy platform welldoing.org
This article was first published in the March 3, 2018 issue of the New Zealand Listener.