Part 3 of my Lost Connections review. Back to part 1
Right in the title of Lost Connections is a clue as to what it is supposed to be about: “Uncovering the real causes of depression”. That’s nice, but unfortunately, the book does nothing of the kind.
Throughout the text the same problem that I identified in my reading of the extract is present: dozens of things are being conflated with depression, to the end that depression isn’t really the subject of the text at all.
The problems begin right at the introduction. If you’re writing a book on anything, you need to start with a working definition of the thing you’re discussing. It’s really important to get this right. Hari doesn’t, and this part of the book is one of the most sparsely-footnoted sections, setting the tone for the rest of our journey.
Hari states that depression and anxiety are the same thing. We’re treated to an academic saying that “the diagnoses, particularly depression and anxiety, overlap.” Hari then claims that studies which present depression and anxiety as different diagnoses are no longer funded by the National Institutes of Health. The reference for this? An article by Thomas Insel on NIMH’s website which introduces a new project for looking at symptom clusters in a different way, with no mention of funding any other types of project, and literally no mention of anxiety.
It’s true that depression and anxiety often happen in the same patient. I myself have experienced both: sometimes one, sometimes the other, sometimes both at the same time. And this bears out at a population level, with some 50% of patients visiting a doctor with one of the problems also experiencing the other. This does not equate to the two being the same thing.
However, let’s pretend that it’s an established scientific consensus that depression and anxiety are the same thing, or at least, two parts of the same whole. That still renders vast swathes of the book not about depression.
There are two things most frequently conflated with depression. The first is stress, which I mentioned in the review of the extract, but I’ll quote again here, so I don’t have to say it again.
Towards the latter end of the extract, Hari discusses environmental factors, and places a lot of emphasis on stress. While stress is acknowledged to be a contributor to depression, it’s a different kettle of fish entirely and isn’t thought to be the root cause of all depression by anyone. Stress is physical changes to the body caused by your “fight-or-flight” responses going on the alert in response to an external stimulus and just keeping on going. Stress isn’t a medical condition, per se, and it’s often advised that it’s managed by relaxation or just taking a break once in a while. There’s different neurotransmitters involved: depression itself doesn’t tend to have increased levels of cortisol, which is the dangerous thing about stress, and the killer. Because it’s different, stress has different symptoms to depression, though there may be some overlap.
The other thing frequently conflated with depression is something called “negative affect”. Negative affect is not depression. It’s pretty much a fancy way of saying “bad feels”. It covers feelings like anxiety, guilt, shame, fear, sadness, anger, irritability. It’s not a diagnosis, or a sickness, it’s a broad name for the bad feelings. When something is causing negative affect, that is not the same thing as causing depression. Likewise, when something is alleviating negative affect, it is not alleviating depression. Negative affect itself is not clinical: it’s just sometimes a useful thing that psychologists need to measure, although it can be measured and present in depression.
Also mentioned occasionally within the text are grief and substance abuse. Again, neither of these are the same things as depression.
Interestingly, though, what is barely mentioned in the book–indeed, a quick search reveals the word is only used twice–is bipolar. Bipolar features depressive episodes. You can make a better argument for bipolar being a type of depression than, say, stress. However, where bipolar (and its physical component) is mentioned, all we get is “They are a very small proportion of depressed people.” With up to 2% of the population screening positive for bipolar, it seems to me like this ought to be discussed a little more than being mentioned literally twice in a book about depression. Perhaps it’s because there’s stronger evidence for genetics and brain chemistry in bipolar, which is a little uncomfortable when you’re writing a book about how Actually, These Factors Aren’t As Important.
Which brings me to my other quibble with how depression and its treatments are constructed throughout Lost Connections: a false dichotomy.
The way Lost Connections presents it is that there are two routes: an exclusively chemical approach, favoured by scientists, which isn’t right, so that’s taken apart in Part 1; and the real cause (his word, not mine: I remind you the second half of the title is “Uncovering the real causes of depression”) which is largely social and environmental.
That’s simply not true, and has never been true, and isn’t true of the general academic understanding of depression, or its treatment approaches, or… well, anything in particular.
As much as I loathe to use analogies, particularly those comparing a mental health issue with a physical health issue, I’m going to crack one out here, because the public understanding of mental illness isn’t great to begin with, and certainly isn’t going to get any better with books like Hari’s floating around.
Consider the common cold, a virus which we’ve probably all experienced. There’s lots of different things that scientists can do when studying and treating the common cold. A virologist will be most interested in the structure of the virus, and how it affects the body. A pharmacologist will be most interested in developing drugs that treat the symptoms. An epidemiologist would be most interested in how the cold is spread, and developing solutions to stop it spreading. A health psychologist is most interested in seeing how people feel about their colds. An occupational psychologist wants to work on getting people back to work when they have a cold. An immunologist will be thinking about how the cold is fought by the body. A geneticist would be interested in determining if some people are more susceptible to catching colds. They’re all looking at different things, but this doesn’t mean any of the approaches are incorrect, and that there’s a real cause of the common cold. It means that there are many ways of skinning a cat.
It’s the same for depression. When medications for depression are developed, that does not mean that the social, environmental and cognitive factors in depression don’t exist. It means that researchers in a particular field of research are looking at things from their angle.
Returning to Insel’s article, cited at the beginning, the one which doesn’t say that NIH are not funding any research that doesn’t treat anxiety and depression as the same thing, what we actually see is this approach in action. The article is launching the Research Domain Criteria, which brings together various disciplines to “transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information”.
The joined-up thinking is also present in the current pathway of care in the UK. The way you’d think of it if you’d only read Hari’s book, you roll into the doctor with your depression, and they drug you up. And I don’t know, perhaps that truly happened to him, and if so, I feel sorry for him, because that’s not good medical care. If you’re diagnosed with depression, you have options on your table: medication is one, there’s also talking therapy, group-based recovery colleges where you learn skills for coping with your depression and support and receive support from others who have experienced depression, doing a low-level CBT course online… And yes, we can talk about problems with waiting lists to access this care; indeed, I could talk about it till the cows come home, because it’s appalling that this care is gatekept by GPs and the waiting lists are terrifyingly long, and so you’re often prescribed medication without other support while you wait. Honestly, don’t get me started on this. But this is not something discussed in Lost Connections. Instead, we’re saddled with a false dichotomy of Just Medical and Actual Things That Work.
Interestingly, psychological interventions are almost entirely neglected in Hari’s work, so the false dichotomy is entirely between organic and social/environmental remedies. Cognitive behavioural therapy, one of the most common talking therapies for depression, is mentioned precisely once in the book, and very near the end, in a paragraph also covering psychotherapy. The rest of the chapter (chapter 20) is devoted to sympathetic joy meditation as psychological change. There’s a lot of evidence for sympathetic joy meditation presented, including an fMRI study of its effect on empathy, its ability to reduce intergroup bias, its effect on altruism. These are all cited in a footnote for a paragraph claiming that 58% of people who don’t have this treatment become depressed again, compared to 38% of people trained in meditation. I think that particular statistic might feature in the other footnoted study, which is from a self-help book called The Buddha Pill, which I cannot access to check its scientific rigour.
There is meanwhile a vast bulk of evidence for the talking therapies which barely even receive lip service–CBT is so well-studied, there’s even a meta-analysis of meta-analyses!
To those with an interest in treating it, “biopsychosocial” is a word which is often used to describe the relationships between the well-documented causes and treatments of depression. In Hari’s book on depression, this word appears precisely twice, and both to bolster claims that doctors are getting it all wrong.
The false dichotomy set up makes things easier for a slightly weaselly author to pull a fast one on us, the readers. And it also helps us hide the fact that actually much of the book isn’t teaching us anything new…