Book review: Lost Connections by Johann Hari

post by maia · 2021-10-20T02:40:09.443Z · LW · GW · 4 comments

Contents

  Why this book is interesting
  Summary of the book
  Critiques
    Broken signals
    Childhood trauma
    Down on pills for no good reason
  What I found most valuable
    Even non-"situational" depression usually involves having a depressing life
    Framing depression as a social problem
    … a social problem that is getting worse
    Social prescribing
    Economic reforms
  Overall takeaways
None
4 comments

Why this book is interesting

Well, it's about depression, which is generally interesting to LW readers. For instance, 34% of SSC readers said they were diagnosed or thought they had it in 2020 (source).

This book asserts that most of us are thinking about depression in a fundamentally wrong way, which would be very important if true. It also presents some interesting possible solutions for solving depression in one’s own life and solving depression as a social, collective-action problem. 

It’s not really fully fleshed out and supported, nor is it a good self-help guide. The book provides a vague model pointing towards how we should think about depression differently, and even some specific causes to look at, but there’s clearly some big gaps in the supporting evidence, and there’s not much concrete advice that a depressed person won’t have considered before (“maybe you would be less depressed if you made friends, or had more money”). Many of the claims made in the book seem to rely on anecdote and individual studies. The author seems to be taking a journalistic approach -- find one or two experts and one or two random individuals whose stories support his narrative, describe a couple of studies -- rather than a more rigorous “but why should we actually believe this over alternative models?”

Another major issue is that it conflates “biopsychosocial model of depression” with a more generalized position of “antidepressants bad, all other treatments good,” which really doesn’t help the author’s case. More on this in “Critiques”.

Nonetheless, I found the book useful because it provides a more social and practical lens on the problem of depression, which we really don’t talk about much because it doesn’t fit into the standard “treatment of illness” narrative. And some of the early results in e.g. social prescribing sound very promising.

Summary of the book

High-level claims:

• The biological model of depression is mostly wrong; instead, we should think of it as biopsychosocial, meaning that there are some biological and some social and some individual components. We should focus more on the psycho- and social- components, because right now we mostly treat it biologically.
• Depression is a signal in your brain that tells you something is wrong, like pain or nausea; you should listen to it and try to fix the underlying causes, rather than trying to just treat the symptom. If you suppress the signal, you might be missing something important.
• People are more depressed now than in the past because of society-wide trends towards people having more depressing lives. This requires societal solutions, not just individual solutions.

The author blames depression on “disconnection from” seven factors:

1. Meaningful work: Many people today feel that their work is “bullshit” or not important.
2. Social connection (loneliness): There are well-documented trends towards people having fewer friends, saying that they feel lonely more often in surveys, participating in fewer social events and clubs, etc., over time.
3. Meaningful values: Consumerism makes people focus on things that aren’t really meaningful to them, which makes them less happy.
4. Childhood trauma: People don’t talk about their trauma and it makes them sad. (I find this questionable as part of his overall argument, see “Critiques” for more detail.)
5. Status and respect: People don’t have control or status in the workplace, which makes them unhappy.
6. Natural world: People don’t see nature much and this makes them sad.
7. Hopeful/secure future: People have precarious lives, and can’t trust in the future of their jobs and lives. (I’m skeptical of this claim without evidence about how optimism about the future has changed over time vs. depression. The main supporting evidence here is some stuff about First Nations people becoming more depressed and suicidal as they lost control of their lands... which could be explained in several different ways, not just a lack of a secure future... and a study of depressed teenagers who were less able to predict the future of a character in a book than their non-depressed counterparts.)

And the author also devotes a chapter to the contributions of biology to depression:

• He thinks genes mainly affect things via genetic susceptibility to depression, not a genetic cause. In other words, if you are genetically susceptible but have a fun and non-depressing life, you won’t be depressed. If you aren’t susceptible, you won’t be depressed even if your life is depressing.
• Brain changes: you can get stuck in a depression feedback loop that’s counterproductive. Even if your depression was caused by something “real” in your life, your brain can undergo a feedback loop that gets out of control and out of proportion to the original cause.

He describes seven "reconnections" that he thinks could help people find their way to better, less depressing lives:

1. Other people
   1. The Amish are happy and they live around other people all the time
   2. Also if you’re depressed, try doing something nice for other people instead of yourself
2. Social prescribing
   1. Make people do group work for therapy. For example, one therapist prescribed a group of depressed city dwellers to make a community garden together; it helped them a lot because of the friendships they made.
3. Meaningful work
   1. Worker co-ops give you more control and meaning in your work.
4. Meaningful values
   1. Ban advertising?
   2. Teach people to reconnect with their values using workshops where they talk about money, what they spend money on vs what they find important, etc.
5. Sympathetic Joy, and Overcoming Addiction to the Self
   1. Loving-kindness meditation
   2. Maybe do CBT or something? But loving-kindness meditation is better because it connects us to others.
   3. Guided psychedelics therapy (psychedelics can cause brain changes like meditation)
      1. Caveat 1: Bad trips suck though.
      2. Caveat 2: Also for some people the effects don’t last long.
      3. (No mention of the possibility that the effects could be bad and long-lasting.)
6. Acknowledging and Overcoming Childhood Trauma
   1. Maybe your doctor should ask you about your trauma?
   2. Talking about childhood trauma is good.
7. Restoring the Future
   1. UBI is good, because it gives people a sense of stability which lets them do more long-term planning (going back to school, etc.).

Critiques

Broken signals

Hari says depression is a “signal” that we need to improve things in our life-- just like pain is a signal that something is wrong, or nausea, or whatever. I wonder how often he takes Tylenol for a headache.

These biological signals can go wrong. And it’s often necessary to give people medication to remove their pain or nausea, because A) everyone involved is already aware there is a problem and working on it, and B) pain and nausea make it harder to cope with your problems mentally. Depression has the same problem. A little can motivate you to fix what’s going wrong in your life, but too much can be disabling. That’s a great motivating case for antidepressants, even in cases where the “real problem” is something in your life-- giving you breathing room to actually solve those problems, instead of not being able to get out of bed every morning.

Hari gives some lip service to the idea of “feedback loops” in your brain that make things worse, but that doesn’t address the idea that the signal can simply be unhelpful even without that. As far as I know, no one talks about “pain feedback loops” for an ordinary headache, or “nausea feedback loops” in pregnancy; it’s just known that sometimes you have had enough pain or nausea, actually, and your body doesn’t always get that right.

Childhood trauma

Part of the whole thesis of this book is that people are more depressed now than in the past, and we need to look at why. But childhood trauma doesn’t fit this story at all.

In general, people had way more childhood trauma in the past. For example, attitudes on corporal punishment have only turned around in the past couple decades; people have only started talking about the later impacts of childhood sexual abuse in about the same interval; and if you go back further, violence was simply a more normal part of life for people, including children, in the past. And historically, people didn’t cope with childhood trauma openly the way we do now-- treating it as a disorder, bringing it up in therapy, or even having therapy at all. It was just a thing that happened to you. How can this explain an increase in depression, when people treat their children dramatically more nicely now than they used to and talk about their trauma more?

I’d agree that talking about childhood trauma in therapy can be helpful-- I’ve found it helpful myself!-- but I think you’d have to do a lot more work to prove that this is a societal problem, or that it’s worse now compared to before.
 

Down on pills for no good reason

I originally heard about this book on Econtalk (episode link). Hari comes across very reasonably on the episode. He says people tar him as wanting to “break into their house and take away their Prozac,” and claims that this is not at all his position; he says antidepressants can be useful for many people, it’s just that we should encourage people to investigate other solutions. And not just therapy, either-- structural and social solutions to people’s problems. I found this position intriguing and very reasonable; surely more possible solutions is better than fewer.

Unfortunately, the book is not nearly as reasonable as he sounded in the podcast; in the book, he spends a lot of time basically talking about how antidepressants don’t work in the vast majority of cases, and have terrible side effects, and never worked for him at all even when he thought they did and told everyone they did, and the cases where they’re useful are (his words) “very rare”; can’t imagine why that would make people think you want to take away their antidepressants!

And there’s something else that makes me skeptical about his position on medication. He spends a chapter or so talking about CBT, meditation, and psychedelics. But here’s the thing: If antidepressants don’t work because depression is an honest signal of things that are going wrong in people’s lives, then meditation, CBT, and psychedelics shouldn’t work either. And for that matter, psychedelics are biological, too.

Meditating doesn’t fix your problems. CBT doesn’t fix your problems. David Burns, author of one of the most famous DIY CBT books, Feeling Good, often says on his podcast that people who are depressed don’t need to change anything in their life to be happy; all they need to do is change their thoughts.[1] That’s the exact opposite of Hari’s primary thesis, which is that depression is a signal that you need to change something concrete in your life, and that it would be bad to just “turn it off” because you’d be missing signals about something important. And yet, he argues for meditation and CBT as solutions to depression! I think this betrays an unfounded bias against medication on his part. It basically comes off as a naturalistic fallacy or, in the case of psychedelics, a “hippie” bias.

A final note: He spends a while in the book going through his own experience with antidepressants, which was not good, and uses that as support for his claim that they mostly don’t work. But frankly, the treatment algorithm his doctors used was wildly bad. They kept giving him higher and higher doses of the same antidepressant, despite the fact that it was causing side effects that harmed him increasing amounts, without trying a single alternative. (Nothing at all like the treatment algorithm described here.) I’m not saying antidepressants would necessarily have worked for him if they did a better job, but it was pretty predictable that they weren’t going to work given what his doctors were actually doing.

What I found most valuable

Even non-"situational" depression usually involves having a depressing life

There are some very interesting studies cited in the book showing that there wasn’t much difference between “situational” (aka “reactive” depression) and the other kind. They asked a bunch of people who were diagnosed with “situational” vs normal depression a lot of questions about things in their life -- their financial situation, romantic situation, other relationships and support system -- and found that even the people with “non-situational” depression had many of the same life problems. This is definitely suggestive. I don’t think it quite supports the author’s belief that antidepressants don’t help-- that’s a different proposition-- but it does strongly suggest that biology isn’t the sole underlying cause of depression.

Framing depression as a social problem

I appreciated the point that, if people’s lives are depressing, we should probably work on that problem, and not just making them less depressed via other methods like pills and therapy. And in particular, that this might require help, rather than being something someone can always do by themselves.

The book makes the very good point that the biological-only method of treating depression is often oriented towards “just get this person to survive in their current life without making changes,” which, in many cases, benefits other people more than the patient. They take drugs to help them get through their shitty job and pretend their shitty personal life isn’t so bad. It’s rather nightmarish. In theory, the best use of drugs is to get people enough breathing room that they can make their lives better, but in practice it doesn’t always work that way.

Another study he mentioned was one where they took people from the United States and from Russia, Japan, and Taiwan, and tracked A) whether they were trying to become happier deliberately, and B) whether they did actually become happier. Of those who actively tried to become happier, those from the US did not, but the others did become happier. The study authors attribute this to the fact that most of the Asian people chose to focus on improving their family or group, rather than focusing on their happiness in an individualistic way (e.g. by treating themselves). I found this interesting because I hadn’t considered that taking that kind of totally different frame on the problem could help. (Though, I believe it only weakly; it’s one study, and I’m not all that convinced they’ve ruled out alternative explanations like “people in different countries interpret the survey questions differently.”)

… a social problem that is getting worse

I think it’s also useful to look at societal trends in depression over time and try to track why they’re happening. It does seem true that depression has been increasing recently, and it’s also quite clearly true that people are becoming lonelier and less connected to other people in their lives. The most striking statistic in the book to me was the modal number of friends that Americans now report having: zero. And to be clear, this didn’t used to be the case.

I suspect it’s also true that more people now feel they are working bullshit jobs, and that this probably makes people more depressed (from my own experience, if nothing else).

Social prescribing

Social prescribing is particularly interesting now because, at least in theory, it’s something that one person or a small group of people can implement without the need for huge society-wide coordination (unlike, say, UBI), and the initial results are promising.

The basic idea is that a psychiatrist or mental health professional tells a group of patients to work together in some social way, which will hopefully result in social bonds forming that help them become happier and/or help them in other areas of their life. I almost wonder whether there’s some catch or problem that explains why I haven’t heard of this before, since it seems like such an obviously good idea. If it consistently works, why aren’t more people doing it?

Economic reforms

When it comes to economic reforms to help people be less depressed, I mostly agree with Hari’s proposals, but he doesn’t have that much evidence that they would actually work.

In the case of UBI, his argument is mostly “Look at all these studies showing that UBI improved people’s lives,” which is fair. I’m not entirely convinced of the impact on depression specifically (as opposed to generic life-improvement), or that this impact is mediated the way he says it should be (via having a sense of a more secure future). But the theory that “if people are less likely to become homeless or starve, they will be less depressed” seems basically sound.

Then there’s worker co-ops. He admits there is no research on whether coops improve the mental health of workers. I agree that such research would be very helpful! I don’t know how realistic it is to remold a significant fraction of our economy on a co-op model, but maybe if the evidence piled up that employee ownership was important to wellbeing, more people would start buying stock in the companies they work for (or more companies would start offering ownership shares to employees).

Overall takeaways

This book is about depression, which might make you think that the target audience is depressed people or perhaps psychiatrists. But it’s really neither. If depression is a social problem that needs to be solved by society as a whole, then you can’t just talk to those people; you need to talk to everyone. So it’s really aimed at more of a general audience, and many of the solutions proposed can’t be implemented by just one depressed person trying to have a better life. It makes sense in that context to think of it as more of a pop-science book with a political agenda.

I spent more of my time on this book hatereading than regular reading. I still think it was worth going through, for the valuable frame and points that it makes, but I wouldn’t necessarily recommend going through it in its entirety, unless you find random anecdotes about depressed people and whatnot interesting. There’s a lot of filler.

I didn’t have time to do epistemic spot checks of the claims made in the book; I’ve done my best here to represent my guess at how reliable they are. If anyone has stronger data on claims I’ve made here or that the book made, I’d be happy to hear about it.

 

[1] Personally, I think this is partly true; thoughts are the ultimate mediator of feelings, but in some circumstances it’s just not reasonable to have certain thoughts! Also, there’s “distorted” vs “nondistorted” sadness/pain in his ontology, which still leaves a lot of room for human suffering.

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