Illustration: Erin Aniker

MIND

How do you treat a problem like depression?

Thirty years after Prozac arrived on the drug market, a new book, Lost Connections, has reignited debate – and stirred up controversy – about our complicated relationship with antidepressants. So, are we getting it right? Eleanor Morgan investigates

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By Eleanor Morgan on

Questions on the whys and hows of mental distress are among the most vital we can ask of ourselves as human beings. Anyone claiming to have a radical new approach is going to provoke interest, which is certainly what Johann Hari’s new book, Lost Connections: Uncovering the Real Causes of Depression – And the Unexpected Solutions, has done.

While not the main focus of the book, debate has centered on its message concerning a first-line treatment option for mental distress across the world: antidepressants. Hari says the ways we’re told they work is wrong and that, to some degree, this misinformation perpetuates the idea that there’s something inherently “wrong” inside the brains of those who have ever been mentally unwell.

Hari has been accused of feeding the already-ripe stigma surrounding antidepressant use. This is a major international release from a major publisher, with swathes of A-list celebrity endorsement. Lost Connections’ reach could be huge. So, professionals from various fields associated with mental health are taking its claims seriously, on social media and beyond. It seems reasonable at this point to pan out on the debate and make sense of what’s being said. First, let’s walk the elephant into the room.

Hari remains indelibly tarred by his past form as a journalist – the plagiarising, the character-smearing, the lying. The full tableau can be revealed with a quick Google search. It is understandable that, despite Hari’s efforts to show remorse, to make his working processes transparent, some people – even if intrigued by his ideas – will say, “No, thanks.” There are many who feel he should never have been allowed to write publicly and profitably again and that we should approach his claims, and all the data and sources therein, with extreme caution.

If we choose to approach, Lost Connections encourages us to move away from “faulty wiring” theories of mental distress and place greater focus on people’s life experiences, asking how societal structures help or hinder our needs along the way. I subscribe to the idea that people can learn to do better when they fuck up and am interested in people’s different experiences of mental distress. So, I was interested – if sceptical – to read the book, when I was sent an advance copy. The title’s proprietary language unsettled me. What could Hari be “uncovering” that hadn’t already been presented in research? The word “real” and its implied authority of causation made me wince. However, I found Hari’s candid story of his own mental-health issues affecting. I publicly said how important I thought its questions were. The problem is that Hari is selling the book as a tome of his radical discoveries. They are not.

Lost Connections presents various arguments about how our experiences and environment shape our mental health in vastly variable ways, alongside possible biological factors. This is not a revolutionary stance – the biopsychosocial model is widely accepted in most areas of human study and healthcare systems. Still, that our state of mind is “made” by factors both within and outside us isn’t always presented in an accessible, mainstream way. Enter the good-intentioned Lost Connections, with its timely exploration of the impact of disrupted social bonds, unmet human needs and the therapeutic power of human connection when we are in distress. Many have agreed that Hari makes several valid points. However, storm clouds rumble over his methods of challenging the focus on “chemical imbalance” (what we call the “biomedical model” of mental distress) and our over-reliance on antidepressants. A key statistic Hari is using in his marketing of the book has been thoroughly scrutinised, as has the overall quality of his research and practices. Some have called the marketing soundbites offensive and simplistic.

Hari has addressed many of the criticisms on his website. He tells me his position on depression and the various treatments available is that it is “an ongoing debate, with reputable scientists on both sides”. He recommends that “readers follow both sides of the argument before making decisions for themselves”. Currently, any nuanced analysis of the debate around antidepressants – where most of the controversy surrounding Lost Connections seems to lie – risks being swallowed by the heat surrounding the book’s very existence.

***

For a long time, we were told that an “imbalance” of certain chemicals in that big, wrinkly organ of ours was the cause of mental illness. Scientists first hypothesised this neat idea in the 1960s, after the apparent success of drugs thought to alter the levels of these chemicals. These drugs became known as antidepressants, “discovered” by accident in the 1950s.

I subscribe to the idea that people can learn to do better when they fuck up and am interested in people’s different experiences of mental distress

Scientists at an asylum in Switzerland were seeking a treatment for schizophrenia and found that a drug modifying the brain’s balance of chemicals involved in controlling mood, pain and emotions caused episodes of euphoria in patients. This was not beneficial for those with schizophrenia. It was, however, helpful for those with depression. In initial trials, patients reported increased energy and sociability. The drug, imipramine, was called a “miracle cure”. Pharmaceutical companies rushed to develop rivals. These were all known as tricyclic antidepressants, named after their three-ring chemical structure.

We know that our psychological constitution is affected by trauma in our early lives, that our bodies remember emotional pain and remain chronically inflamed

 

Many people reported a relief of symptoms, but side effects were rife: exhaustion, weight gain and, sometimes, fatal overdose. Scientists produced a new alternative: the selective serotonin reuptake inhibitor (SSRI), said to hone in on the neurotransmitter serotonin. Neurotransmitters are chemicals that help relay signals from one part of the brain to another. Serotonin is believed to influence mood, libido, appetite, memory, sleep, social behaviours and learning. It was posited that those with depression or anxiety disorders may not have enough going around.

This new class of antidepressant was led by Prozac, entering the US market in 1987. Patients reported the same kind of relief as with the first kind of antidepressants, only with fewer side effects. Far easier to prescribe, SSRIs made their parent companies billions in the coming decades. Of course, the very notion of a drug so transformative had its detractors. Over the years, critics said antidepressants were prescribed too often, that their function was still empirically unproven and their long-term effects unknown. Still, sales remained robust. In 1994, Newsweek said, “Prozac has attained the familiarity of Kleenex and the social status of spring water.”

It is curious that the popular theory of chemical imbalance continued – and continues – to saturate public understanding of mental distress like depression and anxiety, because no robust evidence of it has ever materialised.

Historically, psychiatry has shifted focus in its quest to understand the mind and determine what is or isn’t “normal”. A recent Quartz article details how, through the first half of the 20th century – owing largely to Freud’s influence – organic brain function almost vanished from psychiatry. Prozac repainted the landscape. The chemical-imbalance theory continues to grab us because taking a drug to “correct” faulty chemistry seems instinctive. It’s a politically attractive idea, too. Social scientists argue that those who perceive themselves to be ill are easier to manage than those who feel their distress is a result of societal injustice. But while the “depression is just like any other illness” narrative may be helpful for some, for others it reinforces the idea that they’re different to those who are “well”. This leads us to question the diagnosis of mental “disorders” altogether.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) still holds considerable influence in psychiatry, yet categories like bipolar disorder, schizophrenia, anxiety and depression cannot be “confirmed” with tests, like diabetes – often used as a comparator for depression – can. The borders between diagnoses are fuzzy. People who are depressed or have a diagnosis of bipolar disorder also have many symptoms of anxiety, for example. As the psychologist Dr Jay Watts writes in The Guardian, the pharmaceutical industry has a “direct interest in shaping behaviours and emotions into various symptoms, to be sold back to consumers as disorders requiring medication”.

***

Today, robust evidence shows poverty and inequality to be the biggest cause of suffering on earth. We know that our psychological constitution is affected by trauma in our early lives, that our bodies remember emotional pain and remain chronically inflamed. However, governments appear to remain selectively dismissive of such findings. Funding bodies like the Medical Research Council (MRC) continue to throw millions at identifying biological causes of mental distress. There has been some success in identifying genes that increase susceptibility to certain problems, but far more research on environmental factors is needed.

Being aware of this imbalance in the very mechanisms by which we understand mental distress is important because the tacit suggestion is that mental illness must be viewed as interchangeable with physical illness to earn interest and funding. The idea that mental distress is “real” because it’s lurking in our brain chemistry and our genes can reinforce stigma around what it means to become mentally unwell – that when we suffer, we are inherently broken or wrong. The tendrils of stigma extend to those who choose to take antidepressants as part of their mental-health management. I’ve written about this before. How a person chooses to conceptualise their distress should only be judged by how useful it is for them at any given time. Stigmatising the use of antidepressants (as some perceive Hari to be doing, indirectly or otherwise) is grossly unkind and unhelpful.

Antidepressant prescriptions continue to rise in part because threadbare services cannot match demand. GPs often have no other immediate options for people when waiting lists for talking therapies are so long

Clinical trials are not always reliable. Studies with questionable methodology and small numbers of participants continue to generate clickable headlines and affect public consciousness. But although we don’t know exactly how antidepressants work, we know they do work for many people, helping to reduce catastrophic thinking patterns, increase energy and improve mood. They can save lives at points of crisis. We can say this while also acknowledging what else was going on when a person decided to take medication; for example, how someone began to accept themselves during talking therapy or felt empowered with increased social activity will also affect a change in thinking. However, given that we have no tests for what is helping most for an individual, isn’t what we attribute our improved state of mind to up to us?

***

I have taken a low-dose SSRI for six years, after a decade of untreated anxiety took me to a place of full-body, chemical grenade despair. I take it knowing everything I have written here and don’t feel inclined to flush my Citalopram down the toilet after reading Hari’s book. However, I also have to acknowledge my position as a reader. I am not a qualified professional (yet), but I am informed. I wrote a research-heavy book on anxiety and am now retraining as a psychologist. I did an MSc in psychology recently and am reasonably confident in my ability to compare and analyse literature and data (handy, as I begin writing another book to do with mental health). From the first statistics seminar on the MSc, I learnt how easily figures can be manipulated to protect vested interests – be it those of pharmaceutical companies, scientists from different fields or, indeed, authors.

Any much-needed shift in thinking about mental illness cannot happen if only those with letters after their name challenge our beliefs and the systems that help form them. The subject needs broad curiosity. Journalists and authors. But, if we are making big claims, we must root them in well-sourced, accurate information. Given Hari’s past and how bold the promotional thrusts of Lost Connections are, not to mention its potential reach, Hari has real responsibility. It has been argued that, in taking such a authoritative position on this complex, sensitive subject, selling his book as a solution to something like trauma-related suicide, he isn’t fulfilling that responsibility. People are entitled to their opinions towards Hari and to rigorously examine Lost Connections’ components. Hopefully, the debate surrounding the book will encourage people to expand their knowledge, assumptions and stigmas about mental health and the variability of the human mind.

On my social-media feeds, I have seen people claiming that chemical-imbalance theories are washing away; that “everyone knows” mental illness has many complex factors. I’m not sure I agree. Many mental-health professionals, particularly the “critical” kind (those who analyse the ways politics and culture underpin mainstream theories and practice, questioning the absolutes of empirical research), believe that it’s stuck. Dr Joanna Moncrieff is a critical psychiatrist who writes compellingly on how chemical-imbalance theories still affect how we perceive our distress. She tells me that, although she does not usually initiate prescribing antidepressants, she “sees no benefit” in telling her patients to stop taking them. She does, however, ensure they are fully informed – something she calls a “drug-centered approach”. On Hari’s book (for which she gave an interview but hasn’t yet read), she says he is “making some points that are obvious,” but that it’s “no bad thing” to “highlight the things about modern life that make us unhappy and ask more complex questions about what we believe depression is”.

What is happening under our current government is a naked illustration of what happens when people are lonely and isolated. As welfare and public services are decimated, people are becoming more distressed. Antidepressant prescriptions continue to rise in part because threadbare services cannot match demand. GPs often have no other immediate options for people when waiting lists for talking therapies are so long. In turn, increased demands on NHS therapists has lead to them reporting increasing levels of distress. Hari’s arguments on broken social bonds reflect this picture. Should they have been given a platform in the first place? That is a matter of opinion and, at this point, it remains to be seen whether any potentially valid input will be eclipsed by public perception of his practices.

 

@eleanormorgan

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Illustration: Erin Aniker
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depression
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