This neglect has caused the 3lb organ inside our heads to become the most misunderstood part of the body. But in the last few decades, a revolution has been gradually changing the way we look at our minds.
Firebrand English author Johann Hari has a lot to say about this. Never one to shy away from storming controversy, in 2012 Hari authored his bestselling debut Chasing the Scream, about the war on drugs. Now he’s tightened his belt and taken aim at the mental health industrial complex, and the £65 billion pharmaceutical industry that for decades has kept us hooked on coloured pills with unpronounceable names.
In his new book Lost Connections, Hari, while exploring his own history of depression and anxiety, walks us through a new world where scientists, healthcare experts and psychologists are increasingly fed up with our inconsistent view of mental health. He wants us to start changing our minds about the mind.
"I remember the first time I swallowed an antidepressant and this huge sense of relief about having a story that made sense to me about why I felt this way."
I’m interested in the title Lost Connections; it implies that connection is something that we once had and perhaps some people still have, what was the idea around the title?
Well, there are several reasons why I wrote Lost Connections. There were these 2 mysteries that I couldn’t solve that were really haunting me: one was why was I still depressed? When I was a teenager I went to my doctor to explain this feeling I had that pain was just leaking out of me and I couldn’t control it. My doctor told me this story about a chemical in people’s brains that makes us feel good called serotonin and there are some people who naturally lack serotonin and I was clearly one of them. He told me the drugs he was giving me would boost my serotonin levels. I remember the first time I swallowed an antidepressant and I remember having this huge sense of relief about having a story that made sense to me about why I felt this way. I did feel a significant boost at first but within a few months this feeling of pain started to bleed back through, so I went back to the doctor and got a bigger dose. The exact same thing happened again and again until by the end I was taking 80mg a day, and I was on that, with a few breaks in between, for 13 years.
Depending on which story you look at, between 65-80% of people on antidepressants are still depressed. So the bigger question was not why am I still depressed but why are there so many people like me?
In Britain, there has been a 180% increase in antidepressant prescriptions alone since 2006. That’s a powerful figure if you think about going on the tube and 1 in 11 people is taking antidepressants just to get through the day.
So those were the 2 things I wanted to know and I ended up going to all these different places and interviewing leading social scientists all over the world as well as people who had experienced depression but had a very different perspective on it. I went to this crazy Amish village in Indiana, a city in Brazil that had banned advertising, a lab in Baltimore that was giving people psychedelics to see if that helped their depression, and it was really in these sorts of places that I gradually built up this different picture related to connection. The way it became clear to me was that there are lots of dissident psychologists from around the world who are arguing that we have misunderstood what depression and anxiety are: there’s no evidence that [depression and anxiety] are caused by spontaneous chemical imbalances in people’s brains.
What’s interesting about that then is why that view and those psychologists are considered on the fringe?
If you look at the balance of scientific papers then I don’t think that view is fringe. The UN, in their statement for World Health Day in 2007, said that this dominant biomedical model is based on a selective and inaccurate reading of the evidence, and there was a really powerful line saying we need to talk less about chemical imbalances and more about power imbalances.
The connecting thread underlying this different way of thinking about it is that everyone knows we have physical needs – food, water and shelter etc. But there is equally strong evidence that we have innate psychological needs; we need to feel like we belong; we need to have meaning and purpose; we need to feel like people see us and value us. As a culture, we are getting worse at meeting a lot of those psychological needs.
So what are we doing wrong? How can we reclaim some of that connection?
If we think about work: most people spend the majority of their lives doing paid work so this dominates our lives. There was a really interesting study by Gallup, the polling organisation, that looked at how people feel about their work: 13% of people enjoy their work and look forward to it; 63% neither like nor hate their work; they’re defined as ‘sleepwalking’ through their day; 24% of people hate and dread their work. So just over 1 in 10 people like their jobs and twice as many people hate their jobs than love their jobs.
We need to change the narrative so people realise that it is not a disorder to react to factors in your own environment. The philosopher Krishnamurti said, ‘it’s no sign of good health to be well-adjusted to a sick society.’ I don’t mean this as a glib point; a society that chose Donald Trump to be the most powerful person in it, a man who is obviously deeply unwell and unhappy is another symptom or manifestation of something that is very sick in our culture and needs to be cared for and tended to.
There are a lot of studies on social anxiety at the moment. For example, girls developing social anxiety because of the social media world and being constantly judged online by their peers. We’re sort of locked in this dominant narrative of disorder, aren’t we?
This goes to the core point, which is that the vast majority of depression and anxiety is an understandable response to deep unmet needs. A lot of depressed people would say, ‘Well I have nothing to be unhappy about but I still feel terrible.’ It always reminds me the 1950s and 1960s where very often you would have women going to their doctor to say that there was something terribly wrong with their ‘nerves’, which was what they called it then. They would explain that they’ve got everything they could possibly want: a nice husband who doesn’t beat me, a car, children and a house, but they feel terrible so there must be something physically wrong. What we would now say if we could go back and talk to these women is that yes they have everything they could possibly want by the standards of the culture, but the standards of the culture are mistaken about what women need.
In the same way people will often say to me that they have everything they need to be happy: expensive consumer goods, a job that they work hard at and pays them well etc. But then you ask them about their social connections or how meaningful they find their work, some of these deeper things. You find that those things are lacking.
One of the cruellest things about this situation is that we have been deprived of a vocabulary to describe our own distress. In fact, we’ve been given an alternative vocabulary that doesn’t match our distress. It disconnects you from your own distress and if you are disconnected from it then you can’t find solutions and nor can other people.
I wonder if that’s one of the reasons why it is so popular to think about mental health like this because it’s so much harder to root around for the real causes of sadness?
One of the reasons that this biomedical model has dominated public debate is that it fits with the consumerist mode of the times; we live in a consumer culture where we want solutions we can swallow. It also fits with this very individualistic way of thinking. Another thing I should point out is that it was extremely profitable to tell this story and it has made tens of billions of dollars for the pharmaceutical industry.
It’s not that I’m against chemical antidepressants, it’s just that for something as complex as human depression there should be lots of options on the menu. One of the things on the menu should absolutely be chemical antidepressants but it can’t be the only option because 65-80% of people taking them are still depressed.
One thing that helped me to think about that was a story told to me by my friend and the psychiatrist Derek Summerfield. Derek went to Cambodia in the early 21st century, just as antidepressants were being introduced to the country so he was there to study how they thought about them. When he started talking to Cambodian doctors about them they said to him, ‘we don’t need them, we’ve already got antidepressants.’ He thought they were talking about some herbal treatment or something but they gave him an example of this guy who worked in the rice paddies and accidentally stepped on a landmine so his leg was blown off. They gave him an artificial leg and he went back to work in the fields but he was in a lot of pain and he was working in the field where it happened so you can imagine that it was quite traumatic. He started to cry a lot and didn’t want to get out of bed, which seemed like depression so the doctors sat with him to listen about what was going on and they realised that it was working in the field that was the difficulty.
They decided that if he were to be a dairy farmer instead he wouldn’t have all the bad memories and the pain, so they bought him a cow. The doctors told Derek that the cow was the antidepressant in this case because after they bought him the cow he stopped crying and actually wanted to get out of bed in the morning. These doctors absolutely intuitively saw the thing that we have been educated out of seeing, which is when someone is exhibiting signs of extreme distress you need to sit with them and listen to them in order to solve what is actually causing them distress.
"There’s no evidence that [depression and anxiety] are caused by spontaneous chemical imbalances in people’s brains."
How do you feel when you think back to how you were treated when you were first presented with your mental health problems?
I feel really angry about it. One of the people who really helped me to think about this was a professor called Joanne Cacciatore. Joanne’s baby Cheyenne died in childbirth and Joanne was really appalled that loads of the grieving people she got to know were just being told that they had a brain disorder and given drugs as soon as their child died. She learned all about this really interesting controversy in the 1970s when psychiatrists laid out for the first time in the DSM (Diagnostic and Statistical Manual), which is like the bible for psychiatry, 10 symptoms as a way to diagnose depression. The symptoms included things like ‘persistent low mood’, and they said that if you had 6 of these over a period of a few weeks then you should be counted as depressed. So doctors started using these symptoms but they found a problem with the guideline; it meant that every grieving patient would be classified as mentally ill and should be given drugs. The doctors wanted to know if their position now should be to drug every grieving person in the US? The psychiatrists said they would add in a clause to the guideline saying that if a person has lost someone in the last year then it doesn’t count as depression; it’s just a natural response.
The year marker is such a preposterous time limit, this idea that one day you are still allowed to be grieving and then the next you are considered to be mentally ill.
It’s true because this then begged the question why this is the only piece of context that is salient to this diagnosis? Why not if you’ve lost your home or your job? Why not if you’re stuck in a job you hate for the next 40 years? It blasted a hole in the whole way of thinking about depression as a checklist that describes a brain disease. What this said is that actually depression is a response to things that happen in your life, and so we have to start looking at it in a much broader context.
They eventually just got rid of the grief exception because it was so inconvenient. So now you can have someone you know die at 10 am, and if by 10:01 you are showing all symptoms they you can be diagnosed with a mental illness. I think most people know intuitively why that’s crazy, right?
You could meet some of the most practised Buddhists who would say that actually it’s how you think about grief that defines how you respond to it rather than the fact of someone passing away. Are you convinced by that at all?
I don’t really agree with that; I think the part of Buddhism that is quite like stoicism, which is about detaching from life, some of that is helpful and good but I think you can go too far.
If you think of the Buddhist tradition, it is obviously part of the Western tradition now and the start of CBT (cognitive behavioural therapy): CBT has based on a version of the insight that it’s not your environment it’s how you think about your environment. But CBT just doesn’t work very well – it has modestly good effects for a short period of time. To be fair, Richard Layard who is the main champion of CBT in Britain does say that it works well when paired with a change in your environment as well.
This is not to say that there aren’t tools within the Buddhist tradition that are super useful; I have a whole chapter about loving-kindness meditation and all the evidence about that, which is quite different to all the individualist meditation that you see at the moment.
There’s been a massive reawakening of research into psychedelics and there is some early evidence that psychedelics are effective in the treatment of depression, but I think the more interesting thing is why it works. When I went to Johns Hopkins I met people who had taken part in a smoking cessation study. They were given 3 doses of psilocybin, which is the active component in magic mushrooms, and 80% of them stopped smoking. Most people when they take psilocybin will have some sort of spiritual experience, but the positive outcomes like reduction of depression or addiction to smoking correlate exactly with the intensity of the spiritual experience – if you have a really intense spiritual experience you get more of the positive outcomes whereas if you don’t have any spiritual experience then you have none of the positive outcomes. I think that tells us something really profound. It’s not like psychedelics are viewed in the same way that we saw antidepressants in the 1990s, as if they reset your brain chemistry etc. But what it does give you is an insight into what people feel is an intense connection to the world around them, and that is a really good way to be as a human being.
The psychedelics debate is really important but the likelihood is that most people are not going to be taking psychedelics in the near future. But it tells us something important about how we can change our lives to find that deep connection. There’s a veteran researcher of psychedelics from the 1960s who says that it is all a learning experience; you can choose to hold on to that learning or let it go. I think that’s the best way to think about it.
In terms of how this relates to the Buddhist experience, one of the most interesting studies I’ve seen found that deep meditators and people using psychedelic drugs seem to come to very similar insights. Someone put it to me in a great skiing analogy: meditation is like being on the beginners’ course while psychedelics is like going down the black slope, but you all end up at the same pile of snow at the bottom. I do think that some of the Buddhist insights about how the self is a fiction and ego can be a prison are really useful in telling us how we can get out of depression.
"I do think that some of the Buddhist insights about how the self is a fiction and ego can be a prison are really useful in telling us how we can get out of depression."
Studies on meditation do actually show physical changes in the brains of people meditating, especially in depressed and anxious people. So how does that relate to your environmental/psychosocial view of mental health?
It’s important to understand that everything we do changes our brains. London taxi drivers have to memorise the map of London in order to pass ‘the knowledge’, a famously hard test, and if you look at brain scans of cab drivers the part of the brain that relates to spatial awareness is much larger than it would be in you or I. That doesn’t mean that being a London taxi driver is a brain disease. Neuroplasticity is the tendency of the brain to change over time based on experience, and that’s an essential part of being a living human being. The fact that the brains of depressed and anxious people look different doesn’t mean that their brains are inherently different it just means that their brains have been used differently. That’s very different to talking about a chemical imbalance, for which there is no evidence.
There’s something called ‘synaptic pruning’, and the best way to explain it is if you take a baby and put it in complete darkness for an extended period of time it will go blind because the brain will shed the synapses related to sight. In a similar way, if you are consistently unhappy for a long period of time your brain will shed some of the synapses that might give some relief. That means you need more love, compassion and support to be able to get out of the depression.
I think the way we have talked about the neuroscience of this has been profoundly dangerous. Describing someone’s depression solely by looking at what is going on inside their skull is missing the point of what is happening.
It’s optimistic in a way to think that you can look at someone’s brain again in a year’s time and it will look very different if they take certain steps.
I’m super optimistic about change. One of the things that most encouraged me about the book is that there are solutions that work. The solution we’ve been offered for so long as the sole thing on the menu is not working well for most of us. But to get to the solutions that do work well we have to reframe the problem. It’s a bit like one of those ‘magic eye’ pictures; you have to reframe your focus in order to see things you didn’t see before.
There is always going to be distress and unhappiness among human beings but there is a huge range of causes of depression and anxiety around us that simply don’t have to be there. The more we reframe the problem the more solutions we will find because we are thinking about it differently.
*This interview has been condensed and edited for clarity
Original images by Stefan Jakubowski