Lost Connections: Uncovering the Real Causes of Depression—and the Unexpected Solutions



 

by Johann Hari

Review by Igor Sapozhnikov, MD1

Perm J 2019;23:18-231 [Full Citation]

https://doi.org/10.7812/TPP/18-231
E-pub: 05/15/2019

18 231I was originally recommended Lost Connections: Uncovering the Real Causes of Depression—and the Unexpected Solutions, by Johann Hari, primarily because it had a section on Vincent Felitti, MD, and his Adverse Childhood Experiences Study. The Adverse Childhood Experiences Study was initially published in 1998 and drew a direct correlation between childhood trauma and depression.1 It also revealed a correlation to obesity, a subject I have been researching through work in the Bariatric Clinic. Up to 40% of patients in my obesity clinic were victims of child abuse or neglect, and up to 57% of those had depression. Indeed, the section in Lost Connections detailing the effects of trauma on depression reinforced my findings. The rest of the book proved to be just as revelatory and important for primary care providers, who are responsible for 79% of prescriptions for psychotropic medications in the US.2

In addition to a chapter on childhood trauma, Hari explores 6 other reasons people are depressed. Some of these include: Lost connections to family, friends, and community; lost connections to a sense of hope for the future; and lost intrinsic values such as love. He does this while discrediting the old “chemical imbalance” theory as something the drug companies pushed to sell their products. The book highlights concrete evidence from scientific studies and could have come from a medical journal as a meta-analysis, providing scientific validity to support his ideas. The commentary from scientists who carried out the research adds an important discussion piece to paint a fuller picture of depression.

Throughout the book, Hari uses his training as a sociologist to explore how the Western world has changed to a point where more and more people are depressed, left behind, and disconnected. To add even more power and purpose to the book, Lost Connections is a self-exploration of Hari’s personal struggle with depression, including his experience with the aftermath of inadequate treatment by physicians and adverse effects from the selective serotonin reuptake inhibitors he was prescribed.

Hari mentions on multiple occasions that the physicians who prescribed the antidepressants to him never asked why he was depressed. They never looked for context to his depression. If they had asked, they would have found several contributing factors, including a painful heartbreak that was agonizing, albeit temporary, but also hidden scars from physical abuse sustained as a child. Hari explains further that by not asking about context, his physicians failed to offer meaningful changes to his life, such as therapy, support groups, and so on. Like the vast majority of patients, all he was given were selective serotonin reuptake inhibitors on the basis of the serotonin model of depression—a chemical deficiency in the brain fixed by more chemicals.

To his credit, Hari does not advocate for the complete cessation of prescribing antidepressants. In fact, he again uses science in an evidence-based approach, showing a benefit to the medications to “take someone from a ledge” and as a bridge to effectively address the underlying problems. He also does not challenge the empirical evidence of many patients who have been helped by the medications without experiencing disturbing adverse effects.

Perhaps the most important part of Lost Connections is his recipe for how to truly overcome depression. Hari reinforces finding meaning in work, community, environment, and in oneself. He does this almost as a well-researched, easily assimilated chapter-structured guide. However, the book should never be intended for the “Self-Help” section of the bookstore. With so many interwoven scientific citations, it is on par with medical literature to be integrated into training not only for psychiatry residents but also for primary care residents.

I have used the lessons from Lost Connections to help my patients deal with loneliness, hopelessness, and disconnection. I have started to uncover why my patients are depressed by digging under the surface (and I do not  have to dig deep). I have prescribed activities such as “church” and “volunteering at a shelter” and “1-moment meditation.”  This may seem simplistic, but it can help patients understand that it is not their brains that are broken, but rather depression is a sign that something is not going well in their lives. As Hari stipulates, with the guidance of their physician, patients can be taught to seek out changes to lead to a happier existence.

Depression and obesity can be considered diseases. They are objective diagnoses with concrete criteria as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition and the International Statistical Classification of Diseases and Related Health Problems 10th Edition, Clinical Modification code books. However, both depression and obesity are signs of an embattled body and mind. As I have learned in the primary care and obesity clinics, childhood trauma is an important causal predecessor that leads to either or both of the maladies discussed above. The subsequent neurochemical changes are real, and therapeutically useful, but they are intermediary mechanisms, not primary causes.

Hari’s book discusses the lost connections that can lead to a state of depression and anxiety. I would like to posit a connection that he does not discuss. I believe we are losing the connection to patients as primary care physicians. Our days are filled with maintaining a packed schedule, a packed electronic medical record system, and a packed message box. At best, a patient encounter lasts 10 minutes. The types of conversations that are worthwhile and therapeutic to patients often get skipped in lieu of a quick drug fix. Perhaps we need to look at re-establishing this vital patient-physician connection as we understand the best way to treat depression. To that end, Hari’s book is quite useful.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

How to Cite this Article

Sapozhnikov I. Lost connections: Uncovering the real causes of depression—and the unexpected solutions by Johann Hari. Perm J 2019;23:18-231. DOI: https://doi.org/10.7812/TPP/18-231

Author Affiliations

1 Department of Family Medicine, Panorama City Hospital, CA

Corresponding Author

Igor Sapozhnikov, MD (igor.x.sapozhnikov@kp.org)

References
1. Felitti VJ, Anda RF, Nordenburg D, et al.  Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998 May;14(4):245-58. DOI: https://doi.org/10.1016/S0749-3797(98)00017-8.

 2. Barkil-Oteo A. Collaborative care for depression in primary care: How psychiatry could “trouble shoot” current treatments and practices. Yale J Biol Med 2013 Jun 13;86(2):139-46.

Keywords: antidepressants, depression, lost connections

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