The Book in a Nutshell
As a child and young adult, Johann Hari believed what the prevailing pharmaceutical narrative told him: that his longstanding depression and anxiety were the result of a chemical imbalance, and that this chemical imbalance was best fixed through chemical antidepressants. In Lost Connections, Hari recounts the research that changed his view on depression and anxiety entirely. Through interviews with over 200 experts and review of extensive scientific research, Hari arrives at the conclusion that the fast rise in depression and anxiety is not a result of chemical imbalances, but of nine or more rising factors around us in the world.
Book Summary: The Key Ideas
#1: The myth of the “chemical imbalance“. The claim that depression is caused by a chemical imbalance is widely exaggerated. Research shows that a significant portion of purported efficacy for antidepressants is in fact a placebo effect. In part due to perverse incentives in the pharmaceutical industry, medicine tends to ignore the social and environmental causes of depression, instead favouring prescriptions with a wide range of adverse physical and mental side effects.
#2: Nine causes of depression and anxiety. The real causes of depression are in our increased disconnection from many aspects of the world. These range from disconnection from meaningful work, other people and nature, to disconnection from meaningful values and a secure future.
#3: How to reconnect. Our approach to treating depression and anxiety needs to focus on reconnecting. We can achieve this through novel approaches such as social prescribing and democratic work structures, as well as returning to important practices from the past such as meditation and immersion in nature.
Book Notes: The Key Ideas in Detail
The below are more detailed notes on the key ideas from Lost Connections by Johann Hari, along with some quotations that caught my eye. These notes do not by any means cover the full breadth of ideas within the book. They are instead intended to serve as an introduction to some of the key ideas, from which to decide whether the book is worth further attention.
Key Idea #1: The myth of the “chemical imbalance”
Prescriptions of chemical antidepressants are based largely on the idea that we need to correct so-called “chemical imbalances” to treat depression and anxiety. This notion suits pharmaceutical companies but doesn’t reflect the anecdotal and empirical reality.
Hari points to seminal research by Irving Kirsch on the role of placebo effects in antidepressant studies. Kirsch found that across a wide range of antidepressant studies, the true efficacy of antidepressants was negligible and less, for example, than sleep.
Another problem with these studies, Hari suggests, is that pharmaceutical companies who tend to fund them exhibit publication bias for financial gain. In the past, these studies were also guilty of paying insufficient attention to placebo effects from antidepressants.
One of the major problems here is that antidepressants such as SSRIs come with a range of worrying side effects. Studies show increased risk of suicide, violent criminal behaviour, weight gain, miscarriages, strokes, and all cause death. The approach is also blinding practitioners to the reality that depression is mainly environmental and social.
For example, one major longitudinal study in the 1970s found that major negative life events had a significant correlation with depression. The gap between those that didn’t have a negative event with depression and those that did was substantial. Subsequent studies have thrown further weight behind the idea that environmental and social factors are the leading causes of depression.
The official medical literature in the United States also even briefly recognized this reality. According to the Diagnostic and Statistical Manual (DSM), you have to show at least 5 out of 9 listed symptoms to be depressed. Interestingly, the DSM briefly made an exception for grief, which openly recognized the obvious conclusion that depression may be circumstance related. But in 2015, they removed this exception.
Key Idea #2: The Nine Causes of Depression and Anxiety
Hari identifies 9 causes of depression and anxiety, 7 of which are environmental and social factors:
“They are all forms of disconnection. They are all ways in which we have been cut off from something we innately need but seem to have lost along the way.”
Cause 1: Disconnection from Meaningful Work
“Derealization” is a common symptom of depression – where you feel like nothing you are doing is authentic or real – and it is close connections to our working lives.
Studies have shown that within the same organization, higher-level jobs with more autonomy and control over outcomes are correlated with lower levels of depression and higher levels of social activity. In other words, those in lower-level jobs with less autonomy tend to be so exhausted by the deadening effect of their work that they spend less time socializing.
Cause 2: Disconnection from Other People
Studies have shown that feeling lonely can cause cortisol levels (the hormone linked to stress) to increase as much as in a physical attack. As Hari puts it:
“Being lonely seems to cause as much stress as being punched in the face.”
Other studies are increasingly demonstrating that loneliness raises mortality risk, weakens the immune systems, and has other debilitating physical health impacts. There seems to be an underlying evolutionary cause for the physiological responses to loneliness. As Hari argues:
“Every human instinct is honed not for life on your own, but for life in a tribe. Humans need tribes as much as bees need a hive.”
Over the last 50 years, this problem has only got worse. The western world has experienced what Hari calls a “social crash”, with people spending less time together than ever before in history. One of the key challenges here is that this loneliness can cause a “snowball effect” as disconnection spirals into more disconnection.
[For more on the physiological impacts of loneliness, check out the book summary of Together by Vivek Murthy.]
Cause 3: Disconnection from Meaningful Values
Materialistic values also strongly correlate with overall worse experiences of life. Studies show that achieving extrinsic goals (e.g. a job promotion, a bigger house, etc.) has no lasting effect on depression. Conversely, intrinsic goal attainment does.
Our problem in countering this value system is that the world promotes extrinsic motivators at the expense of intrinsic goals – a problem Hari labels as “junk values”.
“Materialism is KFC for the soul.”
Adverts, TV, news and social media all tend to promote the notion that an extrinsic value system will make you happier than an intrinsic value system.
Cause 4: Disconnection from Childhood Trauma
Studies have highlighted that childhood trauma significantly increases the probability of depression in later life, particularly emotional abuse. By failing to acknowledge this trauma we are exacerbating the problem.
Cause 5: Disconnection from Status and Respect
Robert Sapolsky conducted seminal work on the study of status in baboons. One of the conclusions was that baboons are most stressed (as measured by cortisol levels and some other indicators) when status is threatened and status is low.
Humans exhibit the same physiological changes when depressed. The psychologist Paul Gilbert argues that this is a kind of “submission response” .
The idea that status anxiety causes depression has some support in the socio-demographic data and economic data, too. Studies have found that the higher the inequality, the higher the depression and anxiety in countries. Of course, controlling for other causative factors here is tricky.
Cause 6: Disconnection from the Natural World
There is a strong association between living in green areas and lower depression levels. Even when accounting for other potential causes, nature seems remarkably correlated with levels of reported wellbeing and mental health.
One idea propagated by E.O. Wilson is called “biophilia”: an innate love of nature that all humans have. The positive effects are simply a result of restoring this natural balance.
Being out in nature also gets us away from our ego, inducing a feeling of awe. The grandness of the world can put our individual problems in some perspective.
[For more on the physical and mental health benefits of nature, check out the book summary of The Nature Fix by Florence Williams.]
Cause 7: Disconnection from a Hopeful or Secure Future
A lack of security in our futures is also a causative factor. Hari points to the rise of the “gig economy” and zero hours contracts as an erosion of this certainty from one period to the next.
Cause 8: Brain Changes
The real nature of the “brain chemistry” argument is underscored in a phenomenon known as neuroplasticity (more on that here). In short, this is where the brain constantly changes in response to the environment, pruning synapses it doesn’t need and growing synapses it does.
“The brain changes as you become depressed and anxious, and it changes again when you stop being depressed and anxious. It’s always changing in response to signals from the world.”
The key point here is that Causes 1-7 (see above) have the capacity to physically influence our brain chemistry in response.
Cause 9: Genes
Genetic studies of depression are far from conclusive, but the usual way of studying this is through comparison of identical twins vs. non-identical twins. Studies suggest both depression and anxiety are between 30-40% inherited. More specifically, a variant of a gene called 5-HTT has been linked to depression, but importantly, it only elevates the risk of depression in certain environments.
Key Idea #3: How to reconnect
Reconnection 1: To Other People
The search for individual solutions to depression is part of the problem.
“We have become imprisoned inside our own egos, walled off where true connection cannot reach us.”
The accumulating evidence suggests that happiness (when a clearly stated goal) is harder to obtain in countries considered to have more individualistic cultures. Hari also cites the example of the Amish community as one which embraces the collectivist community, with research pointing to lower rates of depression among the Amish community.
We therefore need to seek out reconnection to others.
Reconnection 2: Social Prescribing
“Social prescribing” is a means of enabling doctors and healthcare professionals to refer people to a range of local activities and services (typically group activities that offer reconnection to others), instead of or in conjunction with medicine. Research is increasingly showing that this is a more effective way of treating some depression and anxiety than chemical antidepressants.
Reconnection 3: To Meaningful Work
Hari mentions democratic work structures, such as cooperatives, as a tool to reconnect people with their work, status and futures.
“Work wouldn’t be an ordeal that’s done to you, something to endure. It’d be a democratic tribe that you are part of, and that you control as much as anyone else.”
Reconnection 4: To Meaningful Values
Hari discusses two potential approaches:
- Defensive: This would involve banning certain advertising (e.g. to children and in cities). As an example of how this might work in practice, Hari points to Sao Paolo’s Clean City Law.
- Proactive: Set up groups to explore intrinsic values and set intrinsic goals.
Reconnection 5: Sympathetic Joy and Overcoming Addiction to the Self
“Sympathetic joy” is a method for cultivating a feeling of happiness for others. The process first involves thinking of something good happening to yourself and feeling the joy of it. Then you imagine something good happening to a loved one – again, feeling joy. Then you do the same for someone you don’t like and for someone you really don’t like. Repeat this meditation practice for 15 minutes every day.
More broadly, a wide range of studies have pointed to the benefits of meditation for depression and anxiety. There is also a growing pool of evidence on the neurological benefits of meditation.
Interestingly, the “mystical experience” invoked in experienced deep meditators has parallels with the psychedelic experience. A newly revived field of study, psychedelics, such as psilocybin, appear to offer valuable experiences for users in controlled set and setting, with studies reporting effectiveness for depression, anxiety and addiction.
The key parallel between deep meditation and these psychedelic experiences, Hari suggests, is the dissolving of our ego.
[For more on the psychedelic experience, check out this book summary of How to Change Your Mind by Michael Pollan.]
Reconnection 6: Acknowledging and Overcoming Childhood Trauma
By openly recognising and acknowledging childhood trauma, studies show that we stand a better chance of reducing rates of depression.
Reconnection 7: Restoring the Future
Hari discusses the role of Universal Basic Income (UBI), citing regional trials that showed some efficacy for rates of depression. The problem here, however, is that Hari doesn’t explore the economics of rolling out UBI across whole countries. In practice, there are clear inflationary implications that risk undermining the benefits reporting in regional studies.