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osprey_archer) wrote2018-04-05 09:37 am
osprey_archer) wrote2018-04-05 09:37 am
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Book Review: Lost Connections
I liked Johann Hari’s Chasing the Scream so much that I went right on to his new book, Lost Connections: Uncovering the Real Causes of Depression - And the Unexpected Solutions. In this book, Hari argues that, although most people in the field of psychology would agree that depression has biological, psychological, and social/environmental components (he’s following the World Health Organization in this argument), in actual practice the medical establishment has focused a lot of attention to fixing the biological causes (through antidepressants), some attention to fixing psychological causes (through therapy), and attempted sporadically at best to address the social causes.
Why not try to tackle those social causes? That’s Hari’s driving question in this book.
There seems to be widespread agreement within the various branches of the psychological profession that poverty, childhood trauma, adverse life events (deaths in the family, break-ups, job loss, etc.), and long-term loneliness are factors that contribute to depression. Now, some of these things are unavoidable - death, for instance - but some of these factors can be addressed, like loneliness. Admittedly addressing it would require reconceptualizing our understanding of medical treatment (“I’m prescribing you a therapeutic gardening club! Stop laughing, I’m serious”), but then so did germ theory.
Hari’s got some fascinating case studies here, and I think it would be great if the public discussion of Hari’s work went something like, say, “Now that we know that loneliness is as bad for human health as obesity and smoking, how can we make it a public health priority to help isolated individuals to find human connection and increase the general sense of meaningful belonging? Should we (I'm picking just one of his many suggestions here) try wider-ranging experiments with universal income?”
But no. I suspect everything else in the book is going to be buried alive in arguments about the efficacy or lack thereof of antidepressants.
Hari’s arguments largely follow Irving Kirsch’s (you can read Irving Kirsch’s summary of his own work here: Antidepressants and the Placebo Effect) in arguing that the actual drug effect of antidepressants is real but, on average, fairly small. According to Kirsch, on the 53-point Hamilton depression scale, which is the scale the FDA requires researchers to use when they are testing antidepressants for FDA approval, the mean difference in effect between antidepressants and placebo treatments was 1.8.
If you want more details I urge you to read Kirsch’s own paper. If you want a rebuttal to Kirsch, Peter Kramer - who wrote Listening to Prozac: The Landmark Book about Antidepressant Drugs and the Remaking of the Self in the early nineties - later wrote Ordinarily Well: The Case for Antidepressants in part as a response to Kirsch. If all these dueling statistics give you a headache, then join the club. What I got out of this in the end is “Sometimes antidepressants help and sometimes they don’t (or don’t help enough), and sometimes the side effects are worth it and sometimes they aren’t.”
Hari himself took antidepressants for thirteen years, starting when he was eighteen, and stopped because he found that they gave him short-term relief but had little long-term effect. This is apparently fairly common, although given the general inability of scientists to agree about anything about antidepressants you will be unsurprised to hear that estimates as to just how common vary widely.
I can see why Hari brought his own life story into it, but ultimately I think it adds an emotional weight that makes him come across as more negative toward antidepressants than he intends. When he was diagnosed with depression at eighteen, he bought hook, line, and sinker into the explanation offered by his doctor (and antidepressant ads at the time), that depression is caused by a chemical imbalance in the brain and nothing else contributes - and in the book there’s a certain raw feeling of if only I could have accepted sooner that there are other factors, maybe I wouldn’t have suffered so much.
But all the same it’s frustrating to see this debate overshadowing everything else in the book, because even if Hari turns out to be quite wrong about antidepressants, his other arguments still stand. Even if Peter Kramer’s stance is one day utterly vindicated, it would still make sense to try to fix the social causes of depression, because then fewer people would get depressed in the first place.
And also a world with less loneliness and childhood trauma and glaring inequality would be a nicer place for everyone to live in.
Why not try to tackle those social causes? That’s Hari’s driving question in this book.
There seems to be widespread agreement within the various branches of the psychological profession that poverty, childhood trauma, adverse life events (deaths in the family, break-ups, job loss, etc.), and long-term loneliness are factors that contribute to depression. Now, some of these things are unavoidable - death, for instance - but some of these factors can be addressed, like loneliness. Admittedly addressing it would require reconceptualizing our understanding of medical treatment (“I’m prescribing you a therapeutic gardening club! Stop laughing, I’m serious”), but then so did germ theory.
Hari’s got some fascinating case studies here, and I think it would be great if the public discussion of Hari’s work went something like, say, “Now that we know that loneliness is as bad for human health as obesity and smoking, how can we make it a public health priority to help isolated individuals to find human connection and increase the general sense of meaningful belonging? Should we (I'm picking just one of his many suggestions here) try wider-ranging experiments with universal income?”
But no. I suspect everything else in the book is going to be buried alive in arguments about the efficacy or lack thereof of antidepressants.
Hari’s arguments largely follow Irving Kirsch’s (you can read Irving Kirsch’s summary of his own work here: Antidepressants and the Placebo Effect) in arguing that the actual drug effect of antidepressants is real but, on average, fairly small. According to Kirsch, on the 53-point Hamilton depression scale, which is the scale the FDA requires researchers to use when they are testing antidepressants for FDA approval, the mean difference in effect between antidepressants and placebo treatments was 1.8.
If you want more details I urge you to read Kirsch’s own paper. If you want a rebuttal to Kirsch, Peter Kramer - who wrote Listening to Prozac: The Landmark Book about Antidepressant Drugs and the Remaking of the Self in the early nineties - later wrote Ordinarily Well: The Case for Antidepressants in part as a response to Kirsch. If all these dueling statistics give you a headache, then join the club. What I got out of this in the end is “Sometimes antidepressants help and sometimes they don’t (or don’t help enough), and sometimes the side effects are worth it and sometimes they aren’t.”
Hari himself took antidepressants for thirteen years, starting when he was eighteen, and stopped because he found that they gave him short-term relief but had little long-term effect. This is apparently fairly common, although given the general inability of scientists to agree about anything about antidepressants you will be unsurprised to hear that estimates as to just how common vary widely.
I can see why Hari brought his own life story into it, but ultimately I think it adds an emotional weight that makes him come across as more negative toward antidepressants than he intends. When he was diagnosed with depression at eighteen, he bought hook, line, and sinker into the explanation offered by his doctor (and antidepressant ads at the time), that depression is caused by a chemical imbalance in the brain and nothing else contributes - and in the book there’s a certain raw feeling of if only I could have accepted sooner that there are other factors, maybe I wouldn’t have suffered so much.
But all the same it’s frustrating to see this debate overshadowing everything else in the book, because even if Hari turns out to be quite wrong about antidepressants, his other arguments still stand. Even if Peter Kramer’s stance is one day utterly vindicated, it would still make sense to try to fix the social causes of depression, because then fewer people would get depressed in the first place.
And also a world with less loneliness and childhood trauma and glaring inequality would be a nicer place for everyone to live in.
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Humanity has a basket of intractable problems we have to deal with, and it's interesting to me to see how whatever our obsessions du era are, those are the ones we use to conceptualize and tackle the problems. Medicine and disease are so big with us now--everything is seen in terms of disease! Even fundamental problems like depression and loneliness.
I don't think that's a bad thing; I think our fundamental problems can probably do with tackling from any number of different perspectives or disciplines. It's just weird/interesting to see it happen.
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(I see that as an argument for paying more attention to social factors, though. In that case, the social factors influencing doctors' perceptions.)
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