Many people think depression is just a “chemical imbalance” in the brain: specifically, that it’s caused by low serotonin levels. However, that’s not the whole story: There’s more to depression than just biology.
Today, most experts use the biopsychosocial model to talk about depression, which recognizes three root causes of depression: biology, psychological history, and social factors. In Lost Connections, journalist Johann Hari investigates the psychological and social factors that contribute to depression (which he calls “disconnections”), as well as innovative social and environmental treatments for depression (or “reconnections”).
In this summary, we’ll explore seven types of disconnections that contribute to depression (including the real role of biology). We’ll also discuss the reason antidepressants don’t work for most people. Finally, we’ll explore seven reconnections that may help us to collectively heal depression.
Even if biology isn’t the primary cause of depression for most people, depression is a very real physical illness that can be triggered by external factors (just like how dust or dairy can trigger an allergic reaction). This section explores the social factors that contribute to depression.
One factor that can cause depression is disconnection from meaningful relationships with other people. The reason why this causes depression is rooted deep in human evolutionary history: Millions of years ago, the only way for early humans to avoid becoming a tasty snack for a predator was to band together into tribes. People who felt miserably depressed when they wandered off on their own were more motivated to stick with the tribe, so they were more likely than loners to survive long enough to pass on their genes.
Now, humans are more socially isolated than ever before. Studies show that most American adults have zero close confidants. Living with other people or in a big city doesn’t change that because solving loneliness isn’t just about gaining physical proximity to others: It’s about developing a mutually meaningful connection with someone else.
Some scientists think that human depression is a stress response from our evolutionary history, linked to a feeling of low social status. Researchers discovered this effect by studying the social hierarchies of baboons. For male baboons in particular, competition for the top spots is brutal. To avoid being ripped apart, low-status baboons make themselves as non-threatening as possible by lowering themselves physically as a way to say, “You win. Please don’t hurt me.” Their posture and behavior mimic those of severely depressed people.
Common life hardships like financial insecurity, lack of control over your daily life, and fractured relationships can inflict as much pain on a person as an alpha baboon inflicts on weaker male, and make us feel that we’re “worse” or lower-status than other people. So, we react with the same submission response.
It’s not just those with low social status who suffer from depression. People with high social status are also prone to depression because they’re constantly worried about threats to their position. Research shows that highly unequal societies (with a large gap between those at the bottom and those at the top) have higher rates of depression for everyone, regardless of their status, than countries with a smaller gap between the top and bottom rungs of the social ladder.
In addition to disconnections from other people, being disconnected from your own trauma history and from a sense of a hopeful future can both cause depression, too.
Childhood trauma is one of the most reliable predictors of adult depression according to the Adverse Childhood Experiences (ACE) Study. The study’s results show that people who had experienced ACEs were more likely to suffer health problems, including depression, and the more ACEs you have, the more likely you are to experience depression.
Losing the ability to imagine and plan for the future due to financial instability can contribute to depression. The rise of the “gig economy” means that stable, guaranteed employment is no longer the norm. More people than ever are working for hourly wages with no contract and no guarantee that they’ll still have a job next week, let alone next year. Without that security, it becomes impossible to picture the future—and easy to get depressed.
When everyday life feels meaningless, it’s easy to slip into a deep depression. For people living in cities, struggling to find stable work and surrounded by shallow advertisements, fighting back against that sense of meaninglessness is even more difficult.
In 2011 and 2012, a Gallup poll showed that only 13% of adults are “enthusiastic about and committed to” their work. The three main reasons for this are a lack of control over the job, low professional status, and a disconnect between effort and reward (for example, if working harder doesn’t translate to more money or status). At the same time, work hours are expanding—the “nine to five” is now more of a “seven to seven”—which means that many people spend the majority of their time working a job they don’t like.
Many people persevere in a depressing job because it pays well. That’s an example of extrinsic motivation—doing something just as a means to an end. On the other hand, intrinsic motivation is what drives you to do things purely for the joy of them. Studies show that achieving intrinsic goals increases happiness, but achieving extrinsic goals doesn’t. In fact, over time, it does the opposite: Dozens of studies from all over the world show that the more extrinsically motivated you are, the more likely you are to develop depression and anxiety.
Extrinsic motivation can manifest as materialism, which leads to depression for two reasons:
Many of us live in cities, far from the natural world. When we’re disconnected from the natural world in this way, we often become caught up in our own problems and lose sight of the greater sense of meaning in our lives. In a sense, humans living in dense cities are similar to unhappy wild animals in captivity, and we’re similarly distressed: Rates of all forms of mental illness are higher in cities than in rural areas, and people in urban areas with more green space (like parks) have better mental health than people in urban areas without access to green space. Scientists have three theories to explain this:
As we’ve seen, biology isn’t the sole cause of (or sole treatment for) depression, but there are still very real biological factors at play in the disease’s development and effects on the body: namely, neuroplasticity and genetics.
Neuroplasticity is your brain’s ability to change its structure in response to the environment. Each part of the brain works a bit like a muscle—the more you use it, the bigger and stronger it gets. For example, London taxi drivers who’ve memorized a map of the entire city have larger hippocampal regions (the part of the brain that controls memory) than people in other professions. Similarly, connecting to other people, your own experiences, and a meaningful life keeps the emotion centers of your brain in top shape. On the other hand, disconnecting from those things creates a steady stream of minor emotional upsets that, over time, weaken those parts of the brain and make it harder to maintain a sense of wellbeing.
This means that, for most people, depression creates changes in the brain—not the other way around. Social, psychological, and environmental disconnections deprive the emotion centers of the brain of the experiences they need to make us feel happy; if those disconnections persist, that unhappiness grows into depression, which makes it even more difficult to establish those beneficial connections and ultimately results in further changes in the emotion centers of the brain.
The good news is, neuroplasticity also means that depression isn’t a static state, because no one is born with a brain that is fundamentally, structurally depressed. If brains can change to become depressed, they can also change back to not being depressed.
Studies show that depression is roughly 37% inherited, meaning genetics are a big piece of the mental illness puzzle. However, they’re not the biggest piece: Roughly 63% of the basis for depression comes from somewhere outside of biology.
Even if you have genes that increase your vulnerability to depression, those genes alone aren’t enough to actually cause depression—the genes have to be “switched on” by the environment. In other words, if you have a perfect life with no major disconnections, you won’t become depressed, even with a genetic predisposition to the illness.
All of this evidence about the causes of depression points to one thing: If biology isn’t the only problem causing depression, then medication shouldn’t be the only solution to the illness. So why is medication so popular?
The placebo effect is partly to blame. The idea behind the effect is that every medical treatment actually has two parts: the treatment itself and the story that goes with it. For example, when you take medicine for a headache, you don’t just swallow a pill—you swallow a story about how that particular medicine can cure headaches. Your belief in that story can sometimes create the same physical results as the treatment itself.
For antidepressants, studies show that only 25% of their positive effects were due to the chemicals themselves. Natural recovery accounted for another 25%, and the additional 50% came down to the placebo effect. Most people have never heard those statistics because in the U.S., pharmaceutical companies control every step of the drug research and development process. Every drug they release brings in more money, so they continue to sell the idea that chemical antidepressants are the most effective treatment for depression.
So, what non-biological treatments could we use to tackle depression? The solutions—or “reconnections”—below are promising new ways to treat depression through reconnection to other people.
Depression creates an ego-centric worldview—you’re unhappy, you don’t feel good enough—so countering that narrative by focusing on the group and building relationships with people is more powerful than looking for a quick fix on your own. Focusing on other peoples forces your attention out of your own head and creates the mental breathing room you need to genuinely connect to others.
The idea that depression is a personal issue that should be dealt with alone is a symptom of Western individualist values. In the West, we see happiness as an individual thing, so we address it on an individual level. We engage in “self-care” and read books from the “self-help” section, but never ask for help or allow ourselves to be truly vulnerable around others. However, in Asian countries, if you set out to make yourself happy, you'll most likely engage in communal care because you see your happiness as intrinsically tied to the happiness of your community.
The power of connecting with others is evident in the example of Nuriye Cengiz, an elderly woman living in Kotti, a working-class neighborhood in Berlin. Nuriye was facing eviction because she couldn’t afford the most recent rent increase in her area. Distraught, she hung a note in her window explaining to her neighbors that she intended to kill herself before being forced out of her home. Neighbors from all different walks of life reached out and quickly recognized that their housing situation (and resulting depression) was a collective issue, not an individual one.
As a result of that realization, elderly Muslims, single mothers, teenage punks, and retired Communists banded together to call for justice for people like Nuriye in a makeshift protest camp—all under an umbrella donated by a local gay bar. Their individual experiences of depression were created by a force bigger than any one individual could fight alone, but taking action together created real change that improved everyone’s individual mental health, including Nuriye’s: She didn’t kill herself.
Depression has a way of shrinking your worldview down until all you can see is your own pain, so finding ways to step outside that narrow focus can be a powerful antidepressant. A type of meditation practice called “sympathetic joy” can relieve depression by breaking the grip of the ego. Sympathetic joy is the practice of intentionally feeling genuine happiness for other people. Over time, this trains your body to produce a rush of joy whenever you see someone else succeed, which connects you to an unlimited source of happiness (because at any given moment, someone, somewhere, is succeeding).
New research on the clinical effects of psychedelic drugs (like LSD) offers another way to let go of the ego. Early research from the 1950s showed that psychedelics could have all kinds of benefits for mental health, from helping people break lifelong addictions to healing chronic depression. More recent research shows that giving people psilocybin (the psychedelic chemical found in “magic” mushrooms) in a supervised, clinical environment can sometimes induce intense spiritual experiences in which people feel deeply connected to all living things. For some people, that sense of connection can permanently alleviate depression.
Reconnecting to other people can be difficult. Some doctors are trying a radical idea to help—what if, in addition to drugs, your doctor could prescribe social connection with a range of structured programs (like group volunteering) designed for that exact purpose?
This idea is called social prescribing, and it gives doctors back the power to fully care for their patients’ health on the biological, psychological, and social levels. Doctors who use social prescribing also prescribe antidepressants, but they see them as a temporary tool to ease the pain so people can make bigger lifestyle changes. This isn’t a solution anyone can necessarily take on alone, but you can advocate for it with your own doctor or as part of larger healthcare reforms.
In addition to connecting with others, recovering from depression requires acknowledging past trauma and reclaiming a hopeful future.
Talking openly about childhood trauma is painful, and it’s understandable to want to avoid that pain. However, research shows that it’s not just trauma itself that causes depression—it’s the experience of keeping that trauma buried inside for years. In a way, opening up about past trauma is like disinfecting a wound: It’s painful in the short-term, but it saves you from an infection that would continue to cause problems down the road.
The medical field can play an important role in addressing trauma on a community level. In one study, doctors expressed empathy for patients’ childhood trauma and asked if they’d like to talk about it. As a result, patients were 35% less likely to need follow-up care for any condition, mental or physical. Another study offered patients the option to discuss their trauma with a therapist—those patients were 50% less likely to need follow-up medical care from a doctor.
To restore a hopeful future, you need to advocate for a collective economic safety net that prevents anyone from falling through the cracks. That way, even if you work an unstable job without guaranteed hours, you’ll still have at least some control over your future because there’s a base level of support you can always count on.
In the 1970s, a small town in Canada experimented with a groundbreaking economic policy called universal basic income, in which the government directly paid every citizen the bare minimum they needed to survive (in today’s money, roughly $19,000 U.S. each), no strings attached. The hope was that public health would improve when people no longer had to worry about having enough to eat or a roof over their heads. It worked: After three years, school retention and performance improved, parents took longer parental leave, and gender gaps evened out as personal income allowed women to afford higher education.
The experiment also had a powerful impact on community mental health, including a 9% drop in hospitalizations for depression and anxiety during that time. Other communities around the world have replicated this experiment with similar positive results: For example, a Native American tribe saw a 40% decrease in childhood behavioral and mental health problems after implementing a universal basic income. Parents in the tribe had more time to focus on their children as a guaranteed income removed the need to be constantly working.
Objections to Universal Basic Income
Despite this promising research, many people see universal basic income as a radical, amoral, and completely unfeasible idea. Here’s how experts in the field respond to the three most common objections to universal basic income:
In addition to reconnecting to your past, your future, and others, to heal from depression, you also need to reconnect to a sense of meaning and purpose in everyday life.
Being forced to work at a job you hate just to pay the bills is a surefire recipe for depression—but when job prospects are limited and rent is due, quitting a soul-sucking job isn’t an option for most people, nor is it necessary for this reconnection. Instead, as a society, we need to reexamine our approach to work so that fewer people hate their jobs in the first place.
One way to do this is through democratic cooperatives like Baltimore Bicycle Works. This bike shop is collectively owned by a group of friends and works like any democracy: Employees elect leaders, make decisions, and share profits as a group. The lack of hierarchy means that anyone can propose an idea, and everyone’s opinion counts—providing reconnections to meaningful work and to positive social status. That equal footing means that everyone has at least some control of their work, leading to happier employees.
Reconnecting to meaningful and enjoyable work is important, but when you’re inundated with harmful, materialistic messages the moment you step outside, it’s hard for those positive effects to carry over. For that reason, we need to curb materialism.
The biggest culprit in the rise of materialism is advertising. Advertisers manipulate consumers by selling them a story that there’s something “wrong” with them that only the newest product can fix. This creates a cycle of misery: You get the message that you’re not good enough as you are, so you buy whatever the ad is selling, but it doesn’t make you happy (because there was nothing wrong with you in the first place), and that misery primes you to be more susceptible to harmful advertising messages.
One approach to stop this cycle is to ban advertising altogether. It may seem like a radical step, but several countries have banned different types of advertising with encouraging results. In Brazil, the city of São Paulo banned all forms of outdoor advertising in 2007 with the widely popular “Clean City Law”—now, 70% of residents believe it’s made the city a better place to live.
Another way to curb materialism is to refocus on intrinsic motivations. For example, in Minneapolis, an experimental group of sixty parents, their teenage children, and a professional financial advisor met regularly for three months to discuss their relationship to money and materialism. The advisor guided them through a series of exercises designed to help them reconnect to their values. Participants discussed their spending habits, listed their intrinsic motivations, and held each other accountable to only spend discretionary cash on things that actually made them happy (instead of just more “stuff”).
At the end of the study, the group who dug into their money habits and refocused on their values had significantly lower levels of materialism and significantly higher self-esteem than the control group.
As we’ve seen, depression is a societal issue, not an individual one—so we can’t expect to conquer it individually. Even if you could cure depression on your own, if you’re working endless hours at a dead-end job just to make rent, you’re unlikely to have the time or energy to do so!
Instead, to tackle depression, we need large-scale societal changes, including a fundamental restructuring of personal, cultural, and economic priorities. That’s a daunting task—but so was marriage equality, not to mention women’s suffrage, the Americans with Disabilities Act, and the election of a Black president. With enough momentum, big changes are absolutely possible.
(Shortform note: We’ve reordered the book’s material in this summary to add clarity.)
When Lost Connections author Johann Hari first started taking antidepressants, his doctor explained depression the way the medical community sees it: Depression is a brain disease caused by low levels of a chemical called serotonin in the brain, and antidepressants treat depression by increasing the level of serotonin in the brain. Millions of people have heard this same explanation from doctors when they sought medical treatment for depression—in 2014, one out of every five adults in the United States was taking some form of psychiatric medication.
But the sheer number of people taking medications for mental health hints at a deeper issue: If depression is a purely biological illness caused by a random malfunction in the brain, how is it that so many people’s brains are going biologically haywire at the same time? As it turns out, depression is not just about your biology. Brain chemicals (called neurotransmitters) and genetics do play a role, but even if you’re genetically predisposed to depression, your genes alone won’t make you depressed—something in the environment outside the brain has to go wrong to trigger them.
Today, most scientists talk about depression and other mental illnesses using the arguably more accurate biopsychosocial model, or the idea that mental illness is caused by a combination of three factors: biology (“bio”), psychological history (“psycho”), and social environment (“social”). In other words, biology is only part of the problem—which means a drug that treats biological factors can only be part of the solution.
This isn’t to say that Hari is against antidepressants in general (nor are most of the doctors and scientists he interviewed). As we’ll see, antidepressants do have some effect on symptoms of depression and anxiety: but it’s a small effect, on a small percentage of people, that lasts for a short time.
In Lost Connections, Johann Hari investigates the psychological and social factors that contribute to depression (which he calls “disconnections”), as well as innovative social and environmental treatments for depression (or “reconnections”).
In Part 1 of this summary, you’ll learn how the medical field views depression and why many psychiatrists now use the biopsychosocial model to talk about mental illness. Then, we’ll discuss the history of antidepressants, the shaky science behind them, and why biological treatments alone can’t cure depression. Part 2 will cover the seven social disconnections that lead to depression as well as the real role of biology in mental illness. In Part 3, you’ll learn about innovative solutions for each of the seven disconnections and why treating depression is a cultural, political, and economic issue.
The “medical model” of mental illness is the idea that a serotonin imbalance in the brain causes symptoms of depression and anxiety, with no influence from the outside environment. Serotonin is one of several chemicals in the brain called neurotransmitters, which are chemical messengers that relay information from one cell to another. In the medical model, serotonin is the chemical that makes us feel happy, and people get depressed when their brains don’t produce enough serotonin on their own. Through this lens, depression is a medical disease that pops up randomly, much like cancer.
This explanation is a relief for many depressed people who are often accused of being lazy or just not trying hard enough to be happy or even to function. The model gives these people a biological process to point to: Depression comes from a chemical imbalance in the brain, not a lack of willpower or a choice to be lazy, so it’s not their fault. However, that story is only half-true: Depression isn’t about willpower or laziness (and is certainly not a choice), but the debilitating effects of depression are not the result of a simple “chemical imbalance.”
The false idea that low serotonin levels in the brain cause depression symptoms originated in a tuberculosis ward in 1952 with an experimental new drug containing serotonin. The treatment was a flop in terms of treating tuberculosis, but it induced a state of euphoria in the patients that left them dancing in their rooms. There could be any number of explanations for that unexpected effect, but the technology required to test them didn’t exist yet, so all scientists could do was speculate that serotonin was responsible for the mood-lifting effects—and that’s exactly how “the serotonin story” started.
When scientists proposed that the failed tuberculosis drug was creating a sense of euphoria in patients by raising their serotonin levels, and that, therefore, low serotonin levels must lead to depression, it was a hypothesis based on pure guesswork. If raising serotonin levels increased patients’ happiness, then maybe low serotonin levels were causing their depression. At the time, there was no evidence to support (or refute) that theory, but it persisted.
In contrast to the cultural idea of depression as a brain disease, most experts today look at depression through the lens of the biopsychosocial model. As previously noted, this view recognizes three root causes of depression: biology, psychological history, and social factors.
One of the first proponents of looking at depression through the biopsychosocial model was an anthropologist named George Brown. In the 1970s, Brown and his team conducted one of the first longitudinal studies looking at the psychological and social predictors of depression. They repeatedly interviewed hundreds of women in their homes (114 of whom had a formal diagnosis of depression, and 344 of whom had no diagnosis and served as a control group). These interviews looked for three things: severe losses or traumatic events in the previous year; chronic stressors (like an unsatisfying marriage or living in a violent neighborhood); and “stabilizers,” or positive relationships that counterbalance those negative events.
The idea was that if depression was truly a random brain malfunction that could strike anyone at any time, there should be no correlation between life experience and a diagnosis of depression; in other words, the women with depression would be just as likely as women without depression to have experienced trauma or chronic stress in the last year. To illustrate this, think of depression as a meteor falling from the sky—whether or not someone experienced trauma in the year before being hit by a meteor wouldn’t make any difference to the chances of the meteor strike occurring, because the event is truly random.
But Brown’s study showed that depression is nothing like a meteor. The results showed a clear distinction between the women with depression and the control group: Only 20% of the women in the control group had experienced a traumatic event in the previous year, compared to 68% of the depressed group. Women with depression were also three times more likely to have chronic stressors in their lives compared to women who weren’t depressed. However, stabilizers can make all the difference: Having a supportive partner and a tight network of close friends significantly reduces the risk of depression, even after serious trauma or stress.
These effects are both cumulative and exponential: If you experience a negative event or a chronic stressor, it increases your likelihood of becoming depressed a little bit; but if you experience both, your risk of depression skyrockets (unless you have a strong network of social support). Other researchers have replicated this study in different cultures and locations with similar results.
Before these studies, psychiatrists classified depression as either “reactive” (developing in response to a traumatic event) or “endogenous” (developing without any obvious trauma). Brown’s study included women with both these diagnoses, but the results showed that in reality, none of the women in the study had truly endogenous depression—they all had some sort of stressful life event that preceded their diagnosis. Today, most psychiatrists agree that endogenous depression is a myth, and even those who believe it exists are quick to say that truly endogenous depression is exceedingly rare (estimated anywhere from 1% to 5% of all depression cases).
There’s a lot of misinformation about depression out there. Use this exercise as a chance to reflect on your exposure to those myths.
Think back: When was the first time you remember hearing about depression explicitly? What was the context? (For example, in a school health class, on television, or talking to a parent about their own experience with depression.)
Which “story” about depression did you hear? (For example, you may have been told that depression comes from a chemical imbalance, that it happens when someone goes through trauma, or even that it’s just an excuse for laziness.)
How did that story shape the way you view people with depression? If you’ve dealt with depression yourself, how did that story influence the way you thought of your own struggles?
Does the biopsychosocial model (the idea that depression comes from a combination of biology, personal psychology, and environment) change those views at all? Why or why not?
Now that we’ve explored the history of the medical and biopsychosocial models, let’s examine the arguments against antidepressants: the golden standard of treatment in the medical model.
Before you dive into this chapter, remember that Hari’s goal is not to talk anyone into or out of taking antidepressants—it’s to make us question the way we think about depression and the societal conditions that contribute to it. Chemical antidepressants do work for a small minority of people, and Hari stresses that the information in Lost Connections is not medical advice. Going off these medications can cause severe physical withdrawal symptoms, so if you do decide to stop taking antidepressants, talk to your doctor first. They can help you create a plan to reduce your dosage gradually and minimize withdrawal symptoms.
In this section, we’ll discuss the lack of evidence for the “chemical imbalance” that forms the foundation of the medical model of depression and see how psychiatry itself undermined that idea with the former “grief exception” in the DSM. Then, we’ll discuss why pharmaceutical antidepressants continue to be so popular (and can still be legally sold at all) despite the evidence that most people feel relief from a placebo effect, not the drug itself.
By the 1970s, new pharmaceutical technology allowed scientists to test the idea that serotonin was the specific cause of euphoria in patients given the failed tuberculosis drug. They tested this theory using a drug designed to lower serotonin levels in the brain. If healthy serotonin levels are the true key to happiness, then lowering the level of serotonin in someone’s brain should cause them to become depressed. However, in the study, this didn’t happen. For the vast majority of people in the experiment, the serotonin-lowering drug didn’t alter their mood at all. Further studies showed that decreasing serotonin has the same, tiny effect on the brain as increasing serotonin. Scientists moved on to do similar tests on other neurotransmitters (like norepinephrine and dopamine), only to get the exact same results.
The chemical imbalance theory as a whole started to fall apart. If depression is truly caused by an imbalance in the brain, then either resolving or increasing that imbalance should have created different results; either decreasing or increasing depression levels. However, it didn’t, suggesting the whole hypothesis is false. In spite of this, most modern antidepressants are still designed to address imbalances by raising serotonin.
Another piece of evidence that calls the medical model into question is the former existence of the “grief exception,” which prohibited psychiatrists from giving someone an official diagnosis of depression if they were grieving the loss of a loved one. The exception (sometimes called the “bereavement exclusion”) was a caveat to the official diagnostic criteria for depression, which are laid out in the official manual for diagnosing mental health conditions known as the Diagnostic and Statistical Manual (DSM).
The grief exception existed because grief and depression have nearly identical symptoms, to the point that people who are grieving a recent loss usually meet the official diagnostic criteria for depression in the DSM. Without context about a person’s life or recent losses, even a skilled psychiatrist might not be able to tell grief and depression apart based on symptoms alone. The exception gave psychiatrists a way to officially recognize that grief is a normal response to loss, not a biological illness, and that the symptoms of grief are situational—even when they’re indistinguishable from the symptoms of depression. In other words, the official medical rulebook of the psychiatric profession acknowledged that external life events—not just biology—can cause all the symptoms of clinical depression.
There was a time limit on this “normal” grief—in the original version, you could grieve for one year without being considered depressed, but after that you were subject to a diagnosis that there was something medically “wrong” with you. Later editions slashed that time limit down gradually until 2013, when the newly-released DSM 5 eliminated the grief exception entirely.
Psychiatrists decided to remove the grief exception because its existence raised uncomfortable questions about the biological model of depression. By including the exception, psychiatrists were admitting that something that looks a lot like depression, having exactly the same symptoms as it, could be caused by a person's life circumstances—not just by their brain chemistry.
This opened up discussions about the causes of depression as a whole. If, in the case of grief, we can acknowledge that a person's situation, not their biology, triggers depression symptoms, couldn’t this be the case for all depressed people who’ve experienced a terrible event? Consider depressed people who've gone through traumatic breakups or financial struggles: Could their depression symptoms have been triggered by their awful circumstances, too, rather than their brain chemistry?
Removing the grief exception allowed psychiatrists to simply ignore these questions and continue to promote the biological model of depression. The elimination of the exception means that if someone loses their spouse or sibling or child on Tuesday, they can be diagnosed with (and prescribed medication for) a mental health disorder on Wednesday. The only remaining evidence of the grief exception is a footnote encouraging providers to use “clinical judgment” based on an individual's circumstances.
The widespread belief that antidepressant drugs are a cure-all is partly due to the placebo effect. The idea behind the placebo effect is that every medical treatment actually has two parts: the treatment itself and the story that goes with it. For example, when you take medicine for a headache, you don’t just swallow a pill—you swallow a story about how that particular medicine can cure headaches. Your belief in the power of the treatment can sometimes create the same physical results as the treatment itself. So even if that headache medicine is actually an inert sugar pill, your headache may very well disappear.
When someone’s symptoms improve as a result of a placebo, the improvement isn’t “all in their head”—placebos can create real, measurable changes in the body, like reducing inflammation or curing stomach ulcers. During World War II, an American doctor even used the placebo effect to operate on wounded soldiers without painkillers. The overwhelmed clinic had run out of morphine, so the doctor improvised and gave patients a saltwater drip that he told them was morphine. He then successfully performed surgery without the soldiers howling in pain or going into physical shock—which should be impossible without painkillers.
In the 1990s, Dr. Irving Kirsch and his research team set out to unravel just how big a role the placebo effect plays in antidepressant success rates. They conducted a meta-analysis of every published study of antidepressants, comparing the results of three groups across every study: a treatment group (that got the real medication), a placebo group (that got a sugar pill), and a control group (that got no pill at all). The control group was critical—it made it possible to calculate what percentage of people would get better on their own, with no drug and no story.
By accounting for natural healing and the placebo effect, Kirsch and his team were able to calculate exactly how much the actual chemicals in antidepressants were affecting people. The results were shocking: only 25% of the positive effects of antidepressants were due to the chemicals themselves. Natural recovery accounted for another 25%, and the additional 50% came down to the placebo effect. Researchers tested and retested this data and got the same answer every time: most of the relief people feel when taking antidepressants doesn’t come from the actual drug.
Some people argue that the fact the placebo effect is responsible for most of the positive effects of antidepressants doesn’t mean that antidepressants aren’t useful or that the relief they provide isn’t real. It just means that the brain is providing most of that relief all by itself simply thanks to a person’s belief in the drug’s impact, without requiring the chemical boost of the drug. Therefore, they argue, what’s the harm in continuing to prescribe anti-depressants if they do give people relief—even if that relief doesn’t occur for the reason we’d expect?
Arguably, the harm in continuing to prescribe these drugs comes from their side effects. The side effects of antidepressant drugs are very real and come from the chemicals themselves, not a placebo effect. In general, these effects include weight gain, sexual dysfunction, and an increased risk of type 2 diabetes. Certain groups are even more at risk: For young people, antidepressants increase the risk of suicide; for older people, they increase the risk of stroke; for pregnant people, they increase the risk of miscarriage and birth defects. That’s a very serious set of risks for a drug that only really provides a placebo effect.
Another argument against chemical antidepressants is that even when they create an initial boost in mood, those effects don’t last more than a few months (and may be due to the placebo effects of trying a promising new medicine). Researchers have studied this in many ways, always with similar results.
For example, the Star-D Trial in the 1990s tracked people who visited their doctor and were prescribed an antidepressant. Within the first few months, a promising 67% of patients felt relief from their depression symptoms. But after a year on the drugs, half the people who felt initial relief were depressed again, while only 33% of patients made a full recovery while taking antidepressants. However, without a control group, it’s impossible to say how many of those patients would have recovered on their own—so the real number who found lasting relief from antidepressants is likely even lower.
One final argument against chemical antidepressants is that they may not be as effective as pharmaceutical companies claim they are. The reason for this is that in the United States, pharmaceutical companies control every step of the drug research and development process.
In order to get a drug on the market in the United States, pharmaceutical companies have to produce two separate trials that show some positive effects—no matter how small. These trials are run by the companies themselves (or by scientists whose research they fund), not by independent researchers, which means the people conducting the research have a vested interest in the drugs appearing to work (even when that’s not exactly true).
Furthermore, companies can run as many trials as they like in order to get those two positive results. So if a company runs 500 trials of a drug and finds no positive effects in 498 of those tests, that drug can still go into production based on the two trials where it showed even a tiny positive result.
On top of this, drug companies aren’t required to publish the results from those failed trials. This creates a serious publication bias. When independent researchers want to look at the data about a drug for themselves, they only see a fraction of the real picture—just the times the drug was successful, not the times that it wasn’t. Even the most objective evaluator is going to come to the conclusion that these drugs work if that’s the only data available to her.
Eventually, the results of drug trials are evaluated by a group of regulators, who decide whether the drug is safe enough to be released. This should mean that independent eyes—who have no vested interest in the outcome—objectively evaluate the data and decide whether the drug is safe and effective enough to release. The catch? In the United States, drug companies pay 40% of the regulators’ salaries; in the United Kingdom, they pay 100%. In other words, every single link in the drug production chain is controlled by someone who stands to make a profit if the drug is released. Even if a drug only works for a small percentage of people, there is always incentive to push that drug through anyway because it will bring in more profit.
Most pharmacology researchers accept the conclusion that antidepressants don’t work for most people in the long term and that short term results are often due to placebo effects. However, some scientists still strongly believe that antidepressants work the way they’re supposed to (providing long term relief for the majority of people who take them).
One of the most notable proponents of antidepressants is Dr. Peter Kramer, whose book Listening to Prozac is one of the best-selling books on antidepressants ever written. Kramer disagrees with Dr. Irving Kirsch’s idea that antidepressants aren’t helpful for most people. Kramer has three main arguments against the evidence, all of which were refuted by Dr. Kirsch after further research.
1) The clinical trials that the research is based on weren’t long enough. This is a valid critique—most clinical trials lasted four to eight weeks, but antidepressants don’t work that quickly. It takes time for the chemicals to build up in the body and start taking effect, which is why most people taking antidepressants don’t feel the full effects of the medication for at least eight weeks. To see the true effectiveness of the drug, we need long term data.
Kirsch’s team agreed with this point and went back to the data to isolate only those trials that lasted more than eight weeks. There were only two, which isn’t enough to make a definitive conclusion, but the antidepressants were no more effective than the placebos in those trials (in one, the placebo did even better than the drug). More long term studies need to be done to confirm this, but so far, the conclusion still holds.
2) Kirsch’s data analysis combined studies on both moderately and severely depressed people. As a practicing psychiatrist, Kramer has personally witnessed severely depressed people make incredible recoveries on antidepressants. He concedes that the effects might not be as strong for moderately depressed people—so when the two groups are lumped together, the moderately depressed people’s results are obscuring the true effects of the drug.
When Kirsch reanalyzed his data, he found that only one of the studies he originally included looked at people with moderate depression. Every single other study looked exclusively at severely depressed people. Removing the one study on moderate depression didn’t change the results.
3) Clinical trials are invalid by default because people self-select into them. This is Kramer’s biggest argument and is based on his personal experience of supervising drug trials. To be part of a drug trial, participants need to have a diagnosis of only depression (with no comorbid conditions) and be willing to take experimental medication for very little pay—usually between $40 and $75. People who agree to that arrangement are essentially volunteering to sacrifice their time and potentially their safety for free medical care and a small monetary reward. These are people who probably have few other options to get the care they need, and who are willing to say whatever they think researchers want to hear in order to keep getting care.
This is a crucial point, and one that Kirsch fully agrees with, although he comes to a different conclusion. Kramer argues that the reliance on self-selection makes all clinical trials fundamentally invalid and claims this means Kirsch’s arguments are based on data from bad science. But this point is self-defeating: If all the studies Kirsch analyzed were fundamentally flawed, that must include the studies that drug companies used to satisfy safety regulations. If we have no valid scientific evidence that these drugs are safe, they aren’t actually legal to sell and therefore shouldn’t be used.
We’ve seen that biology isn’t the primary cause of depression for most people. In this part, we’ll cover what does cause depression: the social, psychological, and environmental factors in our daily lives.
Hari calls these factors “disconnections” because they represent a fundamental disconnect between the realities of modern life and the healthy practices we need in order to stave off depression. Disconnections fall into three broad categories: disconnections from others, disconnections from your past and future, and disconnections from a meaningful life.
In this chapter, we’ll begin by exploring forms of disconnections to others: namely disconnection from meaningful relationships and from positive social status.
The first factor that can cause depression is disconnection from meaningful relationships with other people. Social isolation can create loneliness, which impacts us on more than just an emotional level: It creates real, measurable change in the body. In one study, researchers found that acute loneliness raises your levels of the stress hormone cortisol as much as being physically attacked.
(Loneliness also lowers your immune response. One study found that lonely people are three times more likely to catch the common cold than socially connected people; another study found that when people get sick with cancer or heart disease, lonely people are two to three times more likely to die from that illness than connected people are. These health effects will become an even bigger concern as technology starts to replace all types of in-person connections.)
The link between loneliness and depression is deceiving because it could reasonably go both ways: Loneliness could trigger the onset of depression, or being depressed could lead to social withdrawal and ultimately trigger loneliness. Researchers tested the direction of this effect using the power of hypnosis. They administered a battery of personality tests (including a test of depression symptoms) to participants and divided them into two groups. A psychiatrist who specializes in the clinical use of hypnosis then prompted one group to remember experiences of profound loneliness and the other group to remember feeling profoundly socially connected.
After coming out of hypnosis, the participants completed the personality tests a second time. The results were conclusive: People who remembered feeling lonely were significantly more depressed than they had been before undergoing hypnosis, and people who remembered feeling connected were significantly less depressed. In other words, this study showed that loneliness is a cause of depression, not just a result, because making people feel more lonely also made them feel more depressed.
If you think about loneliness in the context of evolutionary history, it makes sense that being isolated from other people would lead to depression. Millions of years ago, humans were much further down the food chain than we are now. The only way for early humans to avoid becoming a tasty snack for a predator was to band together into tribes. People who felt miserably depressed when they wandered off on their own were more motivated to stick with the tribe, and so they were more likely than loners to survive long enough to pass on their genes. In other words, the inability to tolerate loneliness due to the depression it triggered is what kept our ancestors alive.
What does this mean for modern humans? Essentially, we are the descendants of the people who had the strongest negative reactions to social isolation (because the more it hurts to be alone, the more motivated you are to stay with the group). On a deep, instinctual level, our entire species evolved to be especially sensitive to loneliness and to interpret feeling lonely as a powerful signal meaning “I am not safe, and I need to get back to the group now”—and for modern humans, that powerful unease translates to depression.
That evolutionary sensitivity to loneliness makes chronic loneliness a self-perpetuating problem. Profound loneliness triggers depression, which makes people withdraw and isolate themselves. On top of that, they become highly anxious because, as previously mentioned, the most primitive part of their brains perceives isolation as a threat. That anxiety makes them even more suspicious and afraid of strangers, making it even harder to form the genuine connections they need. It’s easy to justify this with the Western emphasis on independence and self-sufficiency, but in reality, humans were not built for isolation. We have a deep evolutionary need for community.
Today, loneliness is hard to avoid, as nearly every form of social connection (like sports leagues or regular dinners with friends) is becoming less and less frequent. This trend is particularly obvious in individualist cultures: For example, a 1980s study showed that the average American had three close friends; by 2004, that number dropped to zero. That’s not because people are spending more time with family and less with friends—all forms of family togetherness have dropped in popularity as quickly as other social connections.
Today, many people report feeling disconnected and lonely even in densely populated cities where it is nearly impossible to ever be truly alone. There’s a common, paradoxical sense of homesickness, even when we’re already home. That’s because overcoming loneliness isn’t just about gaining physical proximity to others, but also about feeling a mutually meaningful connection with someone else. It’s not enough to be around people, or even to be around someone you care about—you need to feel that they care about you in return, and that you’re both connected to something you’re equally passionate about.
It may seem ironic that the explosion of chronic loneliness across the world coincided with the birth of easily-accessible social media—now that we have constant access to everyone we know, shouldn’t we feel more connected, not less? Psychologists who specialize in internet addiction disagree because social media facilitates communication, not real connection.
Online communication scratches the connection itch temporarily, and can be a valuable tool, but it doesn’t provide the long-term sense of well-being that comes from connecting with someone in the same physical space as you. When you connect with someone face-to-face, all of your senses are engaged, satisfying your brain’s primal urge to connect. But when the interaction is mediated through a screen, that multisensory experience shrivels down to a series of pixels—a very new form of communication that your brain’s very old evolutionary patterns can’t quite process.
Not all forms of in-person connections are helpful—if your social status is low or threatened, interaction with others can actually make depression worse. Surprisingly, the first researchers to study this effect weren’t psychologists or sociologists—they were primatologists studying the social hierarchies of baboons in Kenya. Monkeys and apes are humankind’s closest evolutionary cousins, and like us, they live in social communities. Studying those groups gives researchers a chance to watch social relationships play out in a much more concentrated way than they can when studying human communities.
For baboons in particular, there is a strict hierarchy within the group. Female baboons inherit their place in the hierarchy from their mothers, but male baboons are constantly competing with each other for the top spots. Even the alpha male baboon’s position can be challenged by younger, stronger males. The competition is brutal—researchers can often identify low-status males instantly because they’re covered in so many bite marks from higher-status males asserting their dominance.
What does this have to do with human depression? The key is the way those low-status males cope with the constant abuse from high-status baboons. To avoid being ripped apart, low-status baboons make themselves as non-threatening as possible by lowering themselves physically. They bow their heads and keep their bodies low to the ground whenever other apes are around as a way of communicating, “You win. Please don’t hurt me. I’m not a threat.” Their posture, behavior, and energy levels mimic those of a severely depressed human.
The similarity between stressed baboons and depressed humans goes even further—both have elevated levels of the stress hormone cortisol in their blood, and both show the same changes in the brain, pituitary gland, and adrenal gland compared to their unstressed counterparts.
Because of these similarities, some scientists think that human depression is a submission response from deep in our evolutionary history. On a primal level, your brain can’t tell the difference between being savagely attacked by a competitive baboon and working a thankless job, being compared to unrealistic body ideals, or struggling financially—all of which make you feel “not good enough,” or like your status is low relative to people who are successful, thin, or rich. As a result, your brain reacts in the same way it would if you were being attacked. Whatever the cause, depression is the body’s way of saying, “You win. I give up. Just stop the pain.”
This stress response shows up in different situations depending on a baboon’s place in the social hierarchy: Low-status baboons are stressed almost constantly, and high-status baboons are acutely stressed when their status is threatened.
Generally, human depression works the same way: When people are at the bottom of their social hierarchy, they’re more likely to be depressed. That makes intuitive sense—when life is harder, there’s more to be depressed about—but being at the top of the hierarchy can also trigger depression for humans if that status is threatened.
Sometimes, even having a social hierarchy at all can constitute a status threat because everyone feels the stress of needing to avoid falling to a lower rung of the social ladder. Research shows that highly unequal societies (with a large gap between those at the bottom and those at the top) have higher rates of depression for everyone, regardless of their spot in the hierarchy, than countries with more equal social structures. This is part of why countries like the United States (with the most unequal distribution of wealth of any advanced economy) have higher rates of all mental illnesses, including depression, than countries with more social equality (like Norway).
Between advances in technology and the rise of social media, many forms of communication that once took place face-to-face have moved online. Reflect on the differences between in-person and online interactions.
Interacting online and interacting face-to-face are very different experiences. Aside from not being in the same physical space, what differences do you notice in how you see these experiences? (For example, maybe you feel more anxious when communicating in person, or maybe you get distracted easier when communicating online.)
Hari argues that online interactions can’t fulfill the instinctual human need to connect. Do you agree? Why or why not?
In your ideal world, what types of interactions would take place online, and what types would take place in person? (For example, maybe you think all banking should happen online, or all job interviews should be in person.)
In addition to disconnections from other people, being disconnected from your own trauma history and from a sense of a hopeful future can both cause depression, too.
It may seem counterintuitive that being disconnected from past trauma could cause depression: If you’re not thinking about the terrible things that happened to you, shouldn’t you be happy? However, trauma affects us in powerful ways, many of which operate subconsciously—in other words, just because you’re not thinking or talking about the trauma doesn’t mean it’s not still impacting your life and contributing to depression, even decades later. Childhood trauma is one of the most reliable predictors of adult depression, and fully processing that trauma by facing it head-on is a powerful way to begin healing depression.
Scientists still don’t know exactly how childhood trauma causes adult depression, but Hari has his own theory based on the fact that people who experienced trauma as a child often irrationally blame themselves for what happened. He argues that this impulse starts out as a coping mechanism—when kids experience trauma, blaming themselves is a way of taking back control. In the short term, that sense of control is a relief—especially when the alternative is feeling totally powerless in a big, scary world—but in the long run, the false idea that the trauma was their fault and that they deserved what happened creates a deep emotional wound.
Researchers didn’t discover the link between childhood trauma and adult outcomes until the 1980s. The discovery itself was the accidental product of a completely unrelated study on obesity. In that study, Dr. Vincent Felitti put people who were dangerously overweight on a medically supervised extreme diet. Most people did lose weight, but there was a catch: Those who lost the most weight also started experiencing intense anxiety and depression. Many of them dropped out of the program and quickly put all the weight back on.
Instead of simply moving on without these participants, Felitti reached out to them to ask what happened—why would they suddenly run away when they’d already achieved so much? In a series of interviews, he discovered that almost all of these participants first began to put on weight after experiencing abuse as a child. They’d gained weight as a subconscious attempt to protect themselves from feeling that vulnerable again. The extra weight provided a sense of security in three ways:
Almost everyone who had abandoned the program and regained the weight fell into one of these categories. They’d successfully lost the weight—but when the weight was suddenly gone, so was the sense of safety that came with it.
Ultimately, Felitti realized that obesity—much like depression—doesn’t pop up randomly; it’s a symptom of a much deeper, hidden issue. In other words, treating obesity by focusing on weight loss—or treating depression without addressing childhood trauma—is like trying to put out a house fire by focusing on blowing away the smoke.
Another study that demonstrates the link between trauma and depression is the Adverse Childhood Experiences (ACE) Study, a landmark piece of research in the connection between childhood trauma and adult outcomes (like depression, obesity, cancer, and missed work days). The original study surveyed seventeen thousand people on their experience with 10 categories of childhood trauma:
The ACE Study has been replicated all over the world, and the results are always the same: There is a strong positive correlation between adverse childhood experiences and adult health issues. In other words, people who had experienced ACEs were more likely to suffer from all kinds of physical, mental, and behavioral problems than people who had no ACEs. For depression and suicidality outcomes specifically, the data from the ACE study is shocking: people with seven ACEs are 3,100% more likely to attempt suicide than people with no ACEs.
Moreover, the relationship between ACEs and health problems shows a dose-response effect—the more ACEs someone had, the more likely they were to experience negative health outcomes as an adult. For example, a person with five categories of ACEs is more likely to experience depression as an adult than someone with two categories of ACEs, just like someone who smokes two packs of cigarettes a day is more likely to develop lung cancer than someone who only smokes occasionally.
The dose-response relationship implies that ACEs are at least partly causing these outcomes. In other words, experiencing ACEs causes depression; and the more ACEs you experience, the higher your risk of being depressed as an adult. Think of it this way: If one sleeping pill makes you feel drowsy, but two sleeping pills knock you out for hours, that’s a good sign that the pills actually work the way they’re supposed to. If they were a placebo, there might be a small difference in the effects of taking one pill versus two, but not nearly to the same degree.
This disconnection is an especially difficult one for people who have believed the serotonin story their whole lives. It’s much easier to say, “I have a chemical imbalance in my brain that I treat with medication” than it is to say, “Terrible things happened to me as a child, and I’m really struggling because of them.” Moreover, in the serotonin story, there is always the gleaming hope that the right combination of medications will take the pain away entirely—and abandoning that story means abandoning the hope that there is a simple, painless solution.
Facing childhood trauma takes immense courage. It requires not only acknowledging what happened, but rewriting the story to reflect the truth: If adults in your life failed to keep you safe, that is not your fault, and you did not deserve what happened. Childhood trauma leaves powerful wounds that you may have spent a lifetime covering up, and facing that trauma can be terrifying—but finding the courage to address those old wounds is the only way to truly heal this disconnection and the depression it causes.
While disconnection from childhood trauma is a form of disconnection from the past, this section focuses on disconnection from the future: specifically, being unable to picture a hopeful future for yourself—or even any future at all.
You might assume that a lost sense of the future is just another symptom of depression—people get depressed, so they stop planning ahead because there doesn’t seem to be a point—but a lost sense of the future can also cause depression. Researchers confirmed this by studying indigenous First Nations groups in Canada. For generations, indigenous Canadians have suffered the same state-sanctioned abuses as Native Americans in the United States, including being forced off their ancestral land and into reservations. As a result, suicide rates were higher among First Nations people than any other group in Canada—but those suicides were clustered in only half of the 196 indigenous nations. The other half had zero suicides.
The reason for that stark difference had to do with control. Until recently, the Canadian government took over control of nearly every aspect of life in indigenous communities, including schools, elected officials, and even the local language. In the last few decades, some indigenous nations have successfully reclaimed control of some of their rights; others are still completely at the mercy of the federal government. That split in nations’ degree of control maps perfectly onto the suicide data: Nations with the most control of their own lives had the lowest suicide rates, while nations with the least control had the highest suicide rates.
Feeling in control of your life is so important to avoiding depression because when you don’t control your life, you can’t control your future; and when you have no way to influence the future, it’s hard to picture a happy one that feels remotely attainable. If your present reality is brutal and you can’t picture a hopeful future, depression is a pretty logical response.
For people outside First Nations communities, the loss of control that leads to no hope for the future and ultimately depression takes the form of unstable work, which is far less traumatic but can still have a powerful impact on mental health. The rise of the “gig economy” means that stable, guaranteed employment is no longer the norm. More people than ever are working for hourly wages with no contract and no guarantee that they’ll still have a job next week, let alone next year. Without that security, it becomes impossible to picture the future, and depression sets in.
The way we think about work has changed radically over the years. Think about how these changes might impact your own mental health.
If you have experience with both stable, contracted work and unstable, gig-based or freelance work: How did each of them impact your mental health? Which did you prefer and why?
Did you identify with the description of a “lost sense of the future” in this chapter? Why or why not?
Think about your parents and others of their generation. How did their work structure differ from yours? (For example, maybe your parent was a lifelong member of a labor union and always had job security, or maybe they were self-employed and only worked sporadically.)
Do you think you’d prefer that work structure over your own? Why or why not?
The final group of disconnections we’ll look at are disconnections from meaning and purpose. For many people, the loss of hope for the future hinges on an unsatisfying and seemingly meaningless work life. Being low on your organization’s totem pole and having little control over the day-to-day responsibilities of your work can lead to depression. That feeling of being an unimportant cog in the machine can also spill over into your personal life and prevent you from doing the things you truly enjoy doing for their own sake.
Furthermore, for people living in cities, those work and life struggles are coupled with a disconnection from the natural world. This makes it much harder to see how small many problems really are in the grand scheme of things.
We’ll look at each of these factors below.
For many people, an unfulfilling and unhappy work life leads to depression. Most people sleepwalk through their work day or actively dread going to work, often because they feel they have little control over their responsibilities and thus disengage from their work. In 2011 and 2012, a Gallup poll surveyed millions of people all over the world. Only 13% said they are “enthusiastic about and committed to” their work. The rest were “not engaged” (63%) or “actively disengaged” (24%). At the same time, work hours are expanding—the “nine to five” is now more of a “seven to seven”—which means that many people spend more time working than doing things they actually enjoy.
It might seem obvious that spending most of your life in a job where you have little control and aren’t actively engaged could make you depressed, but scientists resisted that idea for many years. The tide began to change after a landmark study of British civil servants showed that the higher your status at work, the lower your risk of heart attacks and depression.
This finding contradicted the popular assumption that people at the top of the ladder would have more health problems because they made more important decisions and therefore had more stress. In fact, a second study of the British civil service showed that people who have more control over their work are far less likely to be depressed than people who have less control, even when they work in the same office and have the same salary. In other words, the degree of control you have over your job is a better predictor of depression than where you work, how much status you have, or even how much money you make.
This lack of control affects people even after they clock out. People who feel they have a sense of control over their work tend to feel more fulfilled at the end of a work day, so they have the energy to spend time with friends and family. On the other hand, people who have very little control over their work lives tend to be so drained by the end of a work day that they have no energy to invest in their relationships. Over time, that lack of investment creates disconnections with other people that only worsen depression.
Another control-related factor that determines how much work contributes to depression is the balance between effort and reward. In some jobs, the harder you work, the more money and status you gain; in others, your performance and dedication don’t matter, and the only time anyone even notices your work is if you do something wrong. If your efforts have a meaningful impact on your rewards, as in the former case, you have some degree of control over how rewarding your work is, and a lower risk of developing depression; but if your efforts go unnoticed and you have no control over your rewards, your risk for depression increases.
How much you enjoy your work life also depends on whether you’re intrinsically or extrinsically motivated to do the work itself. Intrinsic motivation is what drives you to do things purely for the joy of them. If you love running and spend all your free time doing it, you’re acting on intrinsic motivation. On the other hand, extrinsic motivation is a means to an end: If you hate running but keep doing it because you’re trying to lose weight, that’s extrinsic motivation. You’re not doing it for the joy of the activity itself—you’re doing it for the payoff.
Today’s culture emphasizes extrinsic motivation because we base our definition of success on external milestones—like climbing the corporate ladder, getting married, buying a house, and so on. The logic is that meeting those milestones is the only way to be successful, and being successful is the only way to be happy. You may not love the actual day-to-day routine of your job, but you stick with it because it pays well, carries a fancy title, and makes it possible to buy that nice house. The job itself is just the means to achieve that goal.
Extrinsic motivation isn’t necessarily a bad thing—you’re probably not intrinsically motivated to go to the dentist for yearly checkups, but it’s still a good thing to do. But when the majority of your time is spent pursuing extrinsic motives, it’s a recipe for misery. Studies show that achieving intrinsic goals increases happiness, but achieving extrinsic goals doesn’t. Whether it’s a promotion, a bigger house, the newest gadgets—they might give you a fleeting burst of joy, but it wears off quickly, and doesn’t make you happier overall. In fact, over time, it does the opposite: Dozens of studies from all over the world show that the more extrinsically motivated you are, the more likely you are to develop depression and anxiety.
Extrinsic motivation often manifests as materialism because modern society uses money and material objects as status indicators. If your extrinsic goal is to be seen as successful, you’re more likely to focus on having expensive clothes or a fancy car because most people associate wealth with success. Hari calls these superficial, materialistic extrinsic values “junk values”—like “junk food,” they may be satisfying in the moment, but too much of them can make you sick. Over time, these junk values lead to depression for four main reasons:
1) Extrinsically motivated, materialistic people have shorter, lower-quality relationships with others. We’ve seen how important authentic connections are for preventing depression, but if you’re laser-focused on climbing the corporate ladder so you can afford to live a lavish lifestyle, you’re more likely to seek out connections with people because of what they can do for you, not who they are. On top of that, if your relationships are based on status symbols and perceived wealth, they’re more likely to crumble if that wealth someday disappears.
2) People experience fewer flow states when they’re focused on materialistic, extrinsic goals. Flow states are times when you’re so absorbed in an activity that you lose all sense of time. In flow, you lose yourself in the joy of what you’re doing instead of focusing on ego-driven questions about what other people will think or how much money you’ll make for doing it. Studies show that getting into a flow state frequently is an important part of overall happiness—but it’s almost impossible to be in flow when you spend most of your time focused on making enough money to buy the next exciting gadget or expensive sneakers. Constantly feeling the pull of “stuff” makes it difficult to fully sink into an activity purely for the joy of it.
3) Materialistic people have a less secure sense of self-worth. If you’re driven by money or status, you’ll always be worrying about what other people think of you and calculating whether you’re impressive enough to earn external rewards. Over time, constantly questioning whether you’re “good enough” chips away at your self-esteem.
4) Junk values don’t meet our fundamental social needs. When you spend all your time chasing the status and material stuff you think you need to be happy, you inevitably neglect your real need for connection. For example, if you work late because you think the resulting money and status will make you happy, you’ll be disappointed. But if you go home and genuinely connect with your loved ones during that time instead, you’ll actually achieve that happiness.
Despite these harmful effects of junk values, it’s easy to get distracted by them because we’re all steeped in materialism from a young age. Studies show that kids as young as three can recognize one hundred brand logos. A separate study showed that after watching just two commercials for a certain toy, most four- and five-year-olds would rather play with a “mean boy” who owns that toy than with a “really nice boy” who doesn’t own the toy. Conversely, most kids who weren’t exposed to the two commercials chose to play with the nice boy, even though he didn’t own the toy. Essentially, it only took two commercials to persuade kids to choose a material object over a human connection.
This effect doesn’t lose power as kids grow up—in fact, it gets even stronger. Advertisers prey on typical teenage insecurities to sell everything from clothing to cologne. The link between a certain product and increased social status then spills over into kids’ social circles and reinforces the message even further—if the ad itself didn’t sell them on the product, the fact that all the cool kids are buying it might do the trick.
Thankfully, the social environment can also be a good influence: If the people in your social circle have healthy, anti-materialist values, you’re more likely to focus on those healthy values too. However, there’s a limit to how much any individual can escape the materialist vortex—it will take policy changes at the societal level to truly put an end to the problem (like advertising bans, which we’ll explore in more detail in Chapter 9).
The final disconnection we’ll explore is a disconnection from nature. Humans evolved to live in the wild—in evolutionary terms, living inside buildings is a very new development. When we lose touch with the natural world, we often become caught up in our own problems and lose sight of the greater sense of meaning in our lives. We’re also more likely to become depressed: Rates of all forms of mental illness are higher in cities than in rural areas, and people in urban areas with more green space (like parks) have better mental health than people in urban areas without access to green space.
Some of the first scientific studies on how being disconnected from nature can make people sick weren’t about people at all. Researchers comparing bonobos in captivity to bonobos in the wild discovered that both groups show the same type of fierce social competition as baboons, with the same constant stress for the low-status animals.
However, the effects of this stress differed in severity between captive and wild bonobos. In the wild, the low-status bonobos showed signs of that distress by scratching compulsively, refusing grooming, and isolating themselves—but only up to a certain point. In captivity, the low-status bonobos sank lower than their wild counterparts, often developing tics, howling, or scratching until they bled. Other animals show the same extreme distress in captivity by injuring themselves, rocking compulsively, and refusing to mate—behaviors researchers have never seen in the wild.
In a sense, humans living in dense cities are similar to animals in captivity, living in concrete boxes far from the natural habitat that evolution prepared them for. And like all animals, living in captivity can make us deeply depressed.
In general, all humans feel better with regular exposure to the natural environment. But for people with depression, that effect is up to five times greater—even after just a short nature walk. So why is nature such a powerful mood-booster, and why are we so miserable without it? Scientists have three theories:
1) Modern, sedentary lifestyles don’t meet our evolutionary needs. Humans are animals, and like all animals, we spent most of our evolutionary history outside, doing the hard physical work of hunting, building shelter, and fighting off threats in order to survive. Today, we value intellectual and technical skills more than physical ones, so we spend our time being sedentary and indoors, neglecting the purpose our bodies evolved for—and it’s making us miserable.
2) We have an innate preference for natural landscapes. Like the need for movement, the need to be in nature is rooted deep in human evolutionary history. Scientists call this “biophilia,” and it explains why even the smallest exposure to nature can have such profound effects (for example, one experiment in a prison showed that prisoners in cells that had a view of nature were 24% less likely to need medical care than prisoners without a view).
3) Connecting to nature breaks the grip of the ego. Depression can be so painful and consuming that people unintentionally sink into themselves and lose any sense of connection to the grander scheme of things. Their world shrinks down to their own experiences. But out in nature, that pain no longer seems like the biggest or most important thing in the world because it’s so small compared to the expansive landscape. Being in nature grants a new perspective—the pain is still there, but it’s far from the whole story of your life, because you are part of something much bigger than yourself.
Now that we’ve explored the many social and environmental factors that contribute to depression, it’s time to explore the real role of biology in this illness. The fact that biology isn’t the sole cause of (or sole treatment for) depression doesn’t mean there aren’t very real biological factors at play in the disease. The two most important biological factors that influence depression are neuroplasticity and genetics.
Your brain is made up of different parts that control every aspect of your life, from the most basic functions (like remembering to breathe) to the most advanced (like doing calculus or building Swedish flatpack furniture). Neuroplasticity is your brain’s ability to change that structure in response to the environment. It does this by adding and subtracting synapses, which are connections between brain cells. When you learn new information or practice a skill, new synapses form; if you don’t use that skill for decades afterward, the brain prunes those synapses to save energy to power the skills you do use.
The way your brain adds and subtracts synapses depends on how you use it. Essentially, each part of the brain works a bit like a muscle—the more you use it, the bigger and stronger it gets. For example, to pass the licensing test to become a taxi driver in London, you have to navigate between any two points in the city—from memory. Aspiring drivers memorize the entire city map to prepare for the test, and as a result, the part of their brains that handles spatial reasoning literally grows in size. If you took scans of their brains and compared them to other people in different professions, you’d be able to see a physical difference.
Neuroplasticity never stops—your brain keeps changing throughout your entire life. That has two major implications for how we understand depression:
1) For most people, depression creates changes in the brain—not the other way around. Social, psychological, and environmental disconnections deprive the emotion centers of the brain of the happy experiences they need in order to stay in good working order. If those disconnections persist, that unhappiness grows into depression, which makes it even more difficult to establish those connections and ultimately results in further changes in the emotion centers of the brain.
2) The good news is, neuroplasticity also means that depression isn’t a static state, so it’s possible to stop the brain changes depression makes from snowballing out of control. No one is born with a brain that is fundamentally, structurally depressed. Life and environmentally-based changes to your brain may have knocked it into that state, but the right combination of treatments can knock it back out, because changes to the brain aren’t necessarily permanent.
The other major player in the biology of depression is genetics. There is no single “depression gene,” but there is a particular variant of a gene called 5-HTT that significantly increases your vulnerability to depression. However, just having that gene alone is not enough to make you depressed—it has to be switched on by the environment. A baby born and raised in a perfect environment (with no trauma and all the right connections) wouldn’t spontaneously become depressed, no matter what their genetic makeup. But if a baby with the 5-HTT gene variant and a baby without it are exposed to the same trauma, the former is much more likely to develop depression as a result.
To figure out how big that impact is, scientists compared rates of depression in identical twins against rates of depression in fraternal twins. Fraternal twins share as many genes as any full siblings, but identical twins share all of their genes. This means that if depression is genetic, and one identical twin has depression, the other identical twin is highly likely to have depression too, since they have exactly the same genes. Meanwhile, fraternal twins might be expected to both have depression less frequently, since, while they do share some genes, they don’t necessarily share the gene variant that causes depression.
Scientists can use large data sets of fraternal and identical twins and measure how frequently both twins experience depression. If genetics had no influence on depression, then the identical twins would be no more likely to both be depressed than the fraternal twins. But if there are more sets of identical twins with depression than sets of fraternal twins, that points to at least some genetic component to the disease. By measuring the difference between depression rates in both types of twins, scientists can calculate just how big a role genetics play in depression. This isn’t a perfect method (since even twins can have different life events that can trigger depression differently in each person), but it gives a reliable best estimate for how much your genes contribute to depression.
As it turns out, depression is roughly 37% inherited, while severe anxiety is 30-40% inherited. That means that roughly 63% of the basis for depression comes from somewhere outside of biology. So genes are a big piece of the mental illness puzzle, but they’re not the biggest piece.
The relatively small role that genes play in depression doesn’t necessarily mean that “endogenous” depression (depression with a purely biological cause) doesn’t exist. However, even scientists who argue that endogenous depression does exist say that it probably only describes a tiny fraction of people with depression. It’s hard to answer this question definitively because endogenous depression is almost impossible to tease out from “‘reactive” depression—especially since, as we’ve seen, the structure of society itself is a major trigger for depression, so almost everyone has a circumstantial reason to be depressed.
If biology only accounts for a small portion of depression causes, why do we cling to the “biologically broken brain” model of the disease? There are four reasons for this.
1) Sometimes depressed people don’t appear to have “anything to be depressed about.” For example, depression was an epidemic among housewives in the 1950s, even though they “should'' have been happy by the standards of their culture. This would suggest to those in that culture that their depression must have been biological, since it didn’t seem to have any other cause.
But looking back now, there were social and environmental causes for this depression that were simply ignored: It’s clear how ridiculous it was to expect women to be happy without the options to have a fulfilling career, opt out of parenthood, pursue higher education, or prioritize anything other than having a piping hot meal on the table the moment their husbands walked in the door.
2) Mental health stigma is still a widespread problem. People dealing with depression and anxiety are often told that mental illness doesn’t exist and that they’re just choosing to be lazy or self-indulgent. As a result, many people cling to the “broken brain” model to defend themselves from these kinds of attacks—because if depression is a disease, then its symptoms are no more a choice than the symptoms of cancer or AIDS.
Unfortunately, this defense doesn’t seem to work in the long run: People are often just as hostile to the idea that depression is biological. In one study, the researchers told participants they were testing different learning styles and asked them to wait a few minutes while they set up the equipment. In the waiting room, an actor posing as another participant would strike up a conversation and make a passing reference to his mental illness, which, on different occasions, he said was either a biological “disease” or the result of a traumatic childhood.
After this conversation, researchers brought the participants to a different room and told them they’d be teaching a “learner” (the actor) how to push a set of buttons in a particular pattern. When the learner got the pattern wrong, researchers told participants to administer a small electric shock by pressing a certain button for as long as they thought was necessary (in reality, the shocks were fake, but the actor would react as though they were real—and painful).
The results of the study were surprising—people who were told the person they were shocking had a “biological disease” were more likely to hurt him than people who were told his depression was caused by life events. In other words, believing that depression is a “brain disease” doesn’t actually reduce stigma or hostility toward people with depression.
3) Acknowledging that our hierarchical society is making people sick is a threat to the people in power. Roughly one out of every five adults in the United States takes some type of psychiatric medication. If all of those people recognized the institutional structures that are making them miserable and demanded a change, it would be a serious threat to the people who benefit from those same structures. Keeping the focus on biology ensures we see depression as an individual problem needing individual solutions rather than seeking collective solutions that might force those people to give up some degree of power and privilege.
4) The idea that our brains are chemically broken is the underpinning of the multi-billion dollar pharmaceutical industry. As a result, we are constantly bombarded with advertisements for the newest antidepressants that promise to boost our serotonin levels, because the “broken brain” idea keeps people coming back for more and more new drugs. Pharmaceutical companies can’t make a profit off of treatments like “spend more time in nature,” so they have a strong motivation to push the idea of a chemically imbalanced brain in order to keep their profits flowing.
As we’ve seen, there is strong scientific evidence for social and environmental causes of depression, like Adverse Childhood Events, separation from nature, and a lack of control over your working life. All of this evidence points to one thing: If biology isn’t the only problem causing depression, then medication shouldn’t be the only solution to it.
Part 3 of this summary uses examples from all over the world to illustrate non-pharmaceutical forms of antidepressants. Hari calls these ideas “reconnections” because they can help us bridge the disconnections that contribute to depression. Many of these ideas seem radically new, but for the most part, they are actually a return to the way people lived their lives for most of human history.
As you read these sections, keep in mind that many of these strategies aren’t designed to be implemented individually. There are some remedies you can try on your own (like getting to know your neighbors or practicing loving-kindness meditation), but many more involve widespread social changes that require banding together with others and demanding policy changes that will improve everyone’s mental health on a societal level.
Furthermore, these reconnections are only the beginning of a new wave of innovative treatments for depression. Research on most of these ideas is still in the early stages, and there are probably many more ways to improve our collective mental health than are mentioned here. But these strategies offer a hopeful bridge across the disconnections that are making us so miserable—so they’re a pretty good place to start.
In this section, we’ll explore ways to reconnect with others, with your own past and future, and to a meaningful life. We’ll begin with three concrete strategies for reconnecting to others—building genuine relationships, letting go of the ego, and social prescribing.
In an increasingly digital world, many of our connections are superficial and don’t allow for meaningful connection, leading to loneliness and, ultimately, depression. To heal that depression, we need to build genuine relationships based on vulnerability and mutual support that restore us to our natural, healthy state as social animals living in close-knit communities.
One way to build such relationships and benefit from the healing power of connection is to engage in communal care: helping others around us, and receiving help ourselves in turn. Right now, the fatal flaw in depression treatment is that, as a society, we think of it as an individual endeavor. If you’re sick, you go to a doctor who gives you pills that make you better—nobody else needs to be involved. But as we’ve seen, depression is not just an individual issue. The societal structures that got us into this mess weren’t created by one person, and it will take a communal effort to reshape them into something new and soothe our collective depression.
The idea that depression is a personal issue that should be dealt with alone is a symptom of Western individualist values. Western culture values individual liberty over collective health—if you’re struggling, it’s your own fault; if you want to get better, it’s your own responsibility. We see happiness as an individual thing, so we address it on an individual level. We engage in “self-care” and read books from the “self-help” section—and we’re still miserable.
That’s a direct contrast to Asian collectivist cultures that value the wellbeing of the community over the wellbeing of particular individuals. Success and failure are shared with the group—when one person struggles, everyone struggles, and when the group succeeds, everyone succeeds. That’s why, in Asian countries, if you set out to make yourself happy, you'll most likely engage in communal care because you see your happiness as intrinsically tied to the happiness of your community. You’ll focus on making life better for other people, knowing that increasing their happiness will ultimately increase your own.
Collectivist approaches to depression actually work. Focusing on others forces your attention out of your own head and creates the mental breathing room you need to genuinely connect with a community. Depression creates an ego-centric worldview—you’re unhappy, you don’t feel good enough, you’re not getting what you need—so countering that narrative by focusing on the group is more powerful than looking for a quick fix on your own.
When it comes to resisting the pull of individualism and embracing collective living, we can learn a lot from the Amish. In Amish communities, everything is shared. Unrelated neighbors consider each other “family,” and every adult takes responsibility for helping to raise children in the community. People don’t see their family’s house as “home” because the entire community is “home.” That’s the main reason the Amish eschew modern transportation—not using cars means they are always “at home,” or close to it, because home is an entire community contained within the circle of how far you can travel by horse and buggy.
What makes Amish people especially unique is that they have freely and consciously chosen to give up modern convenience in order to focus on their community. All Amish young people leave the community for two years to go on Rumspringa, where they live in modern cities and are free to use technology, drink alcohol, and fully experience the wider world. At the end of this period, they can choose whether to rejoin their home community. Those who decide to maintain the Amish lifestyle do so because to them, the novelty of the modern world is a distraction from what really matters—a fully connected community.
Obviously, the Amish way of life is an extreme approach, and not one that can or should be used on a grand scale. It also has serious downsides, like the entrenched sexism and homophobia in Amish communities. However, studying Amish collectivism still offers valuable lessons—lessons that can be applied in communities that look nothing like Amish farmland, like the Kotti neighborhood in Germany.
The Kotti neighborhood was once a West Berlin peninsula bordered on three sides by the Berlin Wall. Being nearly surrounded by Soviet-controlled East Berlin terrified local residents and led to a mass exodus from the area. By 2011, Kotti was almost solely populated by people who faced ostracism in other parts of Berlin—Turkish immigrants, left-wing activists, and gay people. These radically different groups made uneasy neighbors and were deeply distrustful of one another.
Hari jokingly refers to Kotti as “Berlin’s Bronx” because of the proliferation of housing projects. But after the Berlin Wall came down and the threat of Soviet invasion passed, the rock bottom property values in Kotti began to skyrocket as developers snatched up the now-safe available real estate. The cost of rent rose dramatically until most residents were spending more than half their monthly income on rent alone.
In the midst of this chaos, an elderly Turkish-German woman (Nuriye Cengiz) living in Kotti was facing eviction because she couldn’t afford the most recent rent increase. As an elderly, disabled immigrant with no close family nearby, Nuriye had nowhere else to go and felt that suicide was her only option. She hung a note in her window explaining to her neighbors that she intended to kill herself before the police arrived to forcibly remove her.
For the first time, her neighbors began to reach out. They empathized with Nuriye’s despair—the endless rent increases were slowly pushing them to their limits, too. No one recommended that Nuriye see a psychiatrist because they understood that despair was a reasonable reaction to the circumstances they were all facing. That part is crucial: Kotti residents recognized that their shared depression was a collective issue, not an individual one.
In response to Nuriye’s announcement, her neighbors reached across the ideological divide between them and decided to fight back against the rent hikes and evictions. They formed a makeshift protest camp and blocked a major street. The residents each took shifts guarding the camp to prevent the police from tearing it down overnight, working in randomly-assigned pairs. Elderly Muslims teamed up with single mothers in mini skirts while teenage punks paired with retired Communists—all under an umbrella donated by a local gay bar. Nuriye became the center of a strong community of people who genuinely cared for one another. She no longer felt that she had to face her problems alone, and her depression and suicidality began to heal.
After decades of living just steps away from each other but never interacting, the residents of Kotti reconnected under a common purpose. When they welcomed a homeless protester named Tuncai into the community, residents brought him food and clothing—in return, Tuncai kept the camp spotless and gave out encouraging hugs.
Eventually, the owner of the gay bar hired Tuncai in a paid position. Unfortunately, this stability didn’t last. Tuncai’s go-to solution for anyone who seemed unhappy was to hug them—so when police officers showed up to the camp and appeared to get angry, Tuncai tried to hug an officer and was immediately arrested.
The Kotti protesters immediately rallied to find Tuncai and bring him back. When the police refused to give them any information, the residents tracked Tuncai down on their own. They discovered that he’d been locked up in a psychiatric institution, and that he’d spent much of his life in similar institutions before escaping and becoming part of the Kotti community.
For eight solid weeks, huge groups of residents consistently stormed the offices of the facility holding Tuncai to demand his release while others put together official petitions and gathered signatures. The Berlin authorities had never seen that kind of dedication—most people in the facility didn’t have a strong social network to fight for them.
Eventually, the authorities agreed to release Tuncai on the condition that he had a job and a place to live. The community signed off on these demands easily, but they saw them as only the first, tiny step: What Tuncai needed most was the type of community the Kotti residents had found through their protests. He needed a group of people who genuinely cared about him to act as a safety net.
The Kotti protesters’ efforts to free Tuncai are a model for the type of social connections we all need in order to thrive. Before the protests, Tuncai was homeless both physically and emotionally: He had no safe place to live, and no one to make meaningful connections with. Like Nuriye, his situation was a pressure cooker for depression, but what he needed wasn’t a prescription: Instead, he needed basic shelter, a secure source of food, and a place to belong. If every depressed person had those basic necessities, our cultural approach to chemical antidepressants would change drastically.
The second strategy for reconnection to others is letting go of your ego and focusing on others rather than your own struggles. This is especially hard because individualist Western culture operates on the assumption of scarcity: There is not enough to go around, so the only way to succeed is to focus on your own needs and compete with other people—even for clearly unlimited resources like intelligence. This constant egocentric competition and self-interest fuels depression, but there is an antidote to it: a technique called “sympathetic joy.”
As the name implies, sympathetic joy is the practice of feeling genuine, untainted happiness for other people. You won’t master the skill overnight, but if you’re willing to practice it, it can significantly improve your life. To try it for yourself, follow the steps below, spending at least 15 minutes following them each day:
Studies show that this kind of meditation has all kinds of mental health benefits, including reducing jealousy and increasing compassion in practical ways (which makes it easier to make the social connections everyone needs). Even better, training your body to produce a rush of joy whenever you see someone else succeed connects you to an unlimited source of happiness. At any given moment, someone, somewhere, is feeling profoundly happy. If you seek out those people and allow yourself to share their joy, you can conjure a genuine sense of happiness even when your own life feels especially dark.
As we’ve just noted, deep, sustained meditation practice similar to that outlined above can be a powerful treatment for depression. The downside to meditation, however, is that it can take months or even years of practice to become skilled enough to reap those benefits. So, in the 1950s, scientists started the search for a faster way than meditation to dissolve the ego and reconnect to other people. They started the first official research into the clinical effects of psychedelic drugs like LSD (which was legal at that time) with extremely promising results. Those early studies showed that psychedelics could have all kinds of benefits for mental health, from helping people break lifelong addictions to healing chronic depression.
Unfortunately, a wave of anti-drug hysteria in the United States led to a total ban on LSD in the late 1960s, shutting down psychedelic research programs before they could follow up on those promising early results. Research on the mental health benefits of psychedelics didn’t pick up again until a single study in the 1990s, this time using psilocybin (the psychedelic chemical found in “magic” mushrooms). Modern medical research involves much stricter controls than in the 60s, so researchers spent months preparing participants before administering the drug in a series of guided, graded exposures. After taking the drug, many participants had deep revelations about long-suppressed trauma and described it as a “spiritual experience.”
Once again, the results were almost universally positive—nearly 80% of participants said the experiment was one of the five most important events in their lives. That study opened the door for a modern wave of psychedelics research. It’s still in the early stages, but preliminary studies show that psilocybin is remarkably effective at treating depression and anxiety. It’s also more consistently effective for helping people quit smoking than any other treatment on the market. These results are correlated with the intensity of the spiritual experience a person has: Somehow, a powerful, mystical experience dissolves the ego as effectively as deep meditation.
In addition to building genuine relationships and practicing sympathetic joy, social prescribing can be a powerful way to reconnect with other people. Social prescribing is a practice in the medical field in which doctors can prescribe a range of structured social connections as a treatment for depression in addition to psychiatric drugs. To make this possible, doctors and medical facilities join forces with social workers, volunteer programs, and behavioral health programs that provide opportunities for people to form social connections in a supported, low-pressure environment.
Social prescribing has the potential to revolutionize mental healthcare by integrating social treatments for depression directly into patients’ medical treatment plans. To illustrate this, imagine you visit your doctor because you’ve been struggling with depression. Traditionally, she would only be able to prescribe medication and possibly recommend seeing a therapist. In terms of the biopsychosocial model, she’d only have the power to directly address part of the problem—the biological aspect. The rest, you’re left to tackle on your own.
In contrast, social prescribing would give doctors back the power to fully care for their patients’ health by prescribing treatments that work on the biological, psychological, and social levels. If your doctor practices social prescribing, you’d leave the appointment with prescriptions for two antidepressants: one in the form of a pill, and one in the form of, for example, an invitation to join a volunteer project focused on turning an empty lot into a community garden.
Anecdotal data suggests that social prescribing can be a powerful remedy for depression, but there is little formal research that specifically analyzes these programs—most likely because research requires funding, and pharmaceutical companies are the largest source of funding for research on mental illness. These companies have no interest in funding research on social prescribing because it is a major threat to the medical model that they rely on to make a profit.
Social prescribing threatens drug company profits because it addresses all the causes of depression. If you treat the underlying causes of mental illness, the need for drugs to act as a bandaid eventually goes away, and the number of people taking psychiatric medication as a long-term solution would drop dramatically. But if you only treat the biological component of depression, most people won’t get better, so they’ll keep buying newer and more powerful versions of the drugs.
To see what social prescribing looks like in action, Hari visited the Bromley-by-Bow Center in East London. The doctors at Bromley-by-Bow fully embrace social prescribing. They don’t claim to be “experts” in treating depression because they understand that the causes of depression are deeply personal, and that the biological aspect that they were trained to treat is only one piece of the puzzle. These doctors take the time to really get to know their patients—to ask “What matters to you?” instead of “What’s the matter with you?” That relationship informs every aspect of their treatment plan.
The doctors at Bromley-by-Bow can and do prescribe pharmaceutical antidepressants, but they think of them as only a first step—if depression is a bullet wound, then antidepressants are just the bandage that stops the bleeding. Once the patient’s immediate pain is addressed, doctors can treat the underlying issues contributing to their depression by prescribing one of over one hundred different structured social programs. These programs are deliberately designed to help depressed people connect to others, primarily through group volunteering.
You may wonder: Why volunteering, rather than, say, a support group, or maybe a sports team? There are two reasons for this. First, while support groups have their place, they require people to talk about the traumatic experiences that are making them miserable, which can feel impossible for people in the middle of a deep depression. The volunteer programs at Bromley-by-Bow avoid that hurdle while still providing the type of structured support that a support group would provide.
Second, volunteering with a group provides more than just social reconnection. Doing something to help others also provides a reconnection with meaningful work. Furthermore, caring for others can increase a person’s sense of status and respect, and some forms of volunteering (like urban gardening) can provide reconnection with the natural world.
Depression can make us hyperfocus on ourselves and our own pain. Refocusing on people around us can help break that habit.
When you feel particularly depressed, what things do you usually do for yourself to lift your spirits?
How much do those things usually help?
What are three small, easy things that you can do for someone else the next time you feel especially low? (For example, you could send a nice text to a friend or bring food to a neighbor.)
In addition to connecting with others, recovering from depression requires acknowledging past trauma, reclaiming a hopeful future. Likewise, it requires reconnecting to a sense of meaning and purpose in everyday life. Collectively changing the way we think about work is a major part of this: For most people, work takes up more waking hours than any other activity, so if work feels meaningless, it’s easy for everything to feel meaningless. On top of that, we need to reconnect to deeper, meaningful values, rather than being sucked into the materialistic worldview we discussed in Chapter 5.
Note that these are all examples of the type of collective action to fight depression that we mentioned at the beginning of Chapter 7. They aren’t just individual solutions—they involve steps we can all take to help everyone reconnect to their full self.
To heal depression, we need to reconnect to our childhood trauma by talking about it. Talking openly about childhood trauma is painful, and it’s understandable to want to avoid that pain. However, research shows that it’s not just trauma itself that causes depression—it’s the experience of keeping that trauma buried inside for years, too. In a way, opening up about past trauma is like disinfecting a wound: It’s painful in the short-term, but it saves you from an infection that would continue to cause problems down the road.
Acknowledging and working through childhood trauma can also benefit your physical health. In one study, doctors expressed empathy for patients’ childhood trauma and asked if they’d like to talk about it. As a result, patients were 35% less likely to need follow-up care for any condition. Another study offered patients the option to discuss their trauma with a therapist—those patients were 50% less likely to need follow-up medical care from a doctor.
This research is only a first step, but it builds on a history of medical research showing that bottling things up because of internalized shame can make people physically ill. For example, at the height of the AIDS crisis, openly gay men lived an average of two to three years longer than closeted gay men, even when they got the same quality of medical care.
Another important takeaway from this research is that there are ways to change the healthcare system to help everyone overcome their trauma. If all doctors asked their patients about their trauma history and gave them the chance to talk about it (as they did in the study above), it could drastically improve the mental and physical health of their entire communities.
To heal depression, we can’t just deal with the past—we also have to restore hope for a meaningful future. When your personal trauma history is making you depressed, that’s an individual problem with a mostly individual solution. On the other hand, the loss of a hopeful future is a collective problem caused by systemic economic inequality, so solving it requires a structural societal overhaul. Specifically, restoring a hopeful future for everyone requires creating a social and economic safety net. That way, even if you work an unstable job without guaranteed hours, you’ll still have at least some control over your future because there’s a base level of support that you can always count on.
In the 1970s, a small town in Canada experimented with a way to break the cycle of depression caused by financial instability and give people the breathing room to think about the future. They implemented a groundbreaking economic policy called universal basic income, in which the government directly paid every citizen the bare minimum they needed to survive (in today’s money, roughly $19,000 U.S. each). The money was guaranteed, with no hoops to jump through and no strings attached. The government hoped that removing the burden of constantly worrying about having enough money to survive would translate to improved community health.
After three years, a new conservative government took office and immediately shut down the experiment, and the results weren’t calculated for another 35 years. As it turned out, the experiment had been a huge success even in its short run. School retention and performance improved, parents took longer parental leaves to care for their newborns, and those babies had significantly healthier birth weights.
The effects were especially powerful for women. Before universal income, women faced enormous barriers to higher education—they were expected to be full-time family caregivers, which left little time to pursue schooling. However, with guaranteed income, not only could they pay tuition, but they could afford the cost of childcare for their children while they were in school. Armed with a degree, those women were then able to secure higher-paying jobs and ultimately create generational wealth for their families.
The experiment also had a powerful impact on community mental health, including a 9% drop in hospitalizations for depression and anxiety during that time. That result makes sense given that universal basic income attacks multiple causes of depression simultaneously. When you’re not constantly worried about money, you not only regain a sense of the future—the financial security of a basic income also gives you the freedom to turn down jobs that make you miserable and seek out meaningful work.
Other communities around the world have replicated this experiment with similar positive results. For example, a Native American tribe saw a 40% decrease in childhood behavioral and mental health problems after implementing a universal basic income because parents had more time to focus on their children. A guaranteed income removed the need to be constantly working. The results of that study are especially impressive because the universal income was only $6000 to $9000 per year—not enough to live on, but enough to take some pressure off of working families.
These early results are promising in terms of improving public mental health. They also suggest something about the nature of mental illness: If depression and anxiety were truly biological brain disorders that strike randomly and indiscriminately, they wouldn’t be so closely correlated with poverty levels, and financial security wouldn’t do anything to alleviate them. Clearly, social and environmental factors hold a huge influence over the development of these diseases.
Despite this promising research, many people see universal basic income as a radical, amoral, and completely unfeasible idea. Here’s how experts in the field respond to the three most common objections to universal basic income:
As well as reconnecting with your past and future, healing from depression requires you to reconnect with meaning and purpose in your present: in particular, to reconnect to meaningful work. Being forced to work at a job you hate just to pay the bills is a surefire recipe for depression—but when job prospects are limited and rent is due, quitting a soul-sucking job isn’t an option for most people. For that reason, this reconnection isn’t an individual suggestion, since individual action isn’t always possible: Instead, it’s a call to reexamine the way we think about work as a society so that everyone can make a living without becoming depressed.
One way to do this is through democratic cooperatives like Baltimore Bicycle Works. This bike shop is collectively owned by a group of friends whose mission was to break out of the typical boss-as-dictator business model and find a way to reclaim control of their livelihoods.
The actual, day-to-day work of the business isn’t too different from that of a “traditional” bike shop—mechanics still fix bikes, office workers still handle paperwork. The key difference is that the shop’s co-op model works like any democracy: Employees elect leaders, make decisions, and share profits as a group. The lack of hierarchy means that anyone can propose an idea without worrying about stepping on anyone’s toes, and everyone’s opinion counts. This kind of work model provides reconnections to meaningful work (because everyone has control over their jobs) and to positive social status (because everyone’s opinion matters).
Starting an innovative new business is risky, but the Baltimore Bicycle Works is a success, both financially and as proof that the co-op model creates a more meaningful work experience. Having a sense of control over the shop makes all the difference to the employees’ mental health. Everyone working in the shop is happier and less anxious overall than in their previous, traditional jobs: They no longer feel like work is something “done to” them, and they don’t have to worry about their livelihood depending on the whims of whoever’s in charge. The sense of control also restores a balance between effort and reward: Everyone shares in the shop’s profits equally, so everyone is motivated to work hard and make the business succeed.
The Baltimore Bicycle Works model doesn’t just improve employees’ mental health: The business is more successful overall than similar shops with traditional top-down models of leadership. Nothing is siloed—if one person encounters a problem, the entire team can help solve it instead of letting that person flounder alone. Like any workplace, they have occasional arguments or off days, but overall, the co-op model could be the solution to work-induced misery.
Reconnecting to meaningful work is important, but when we’re inundated with harmful, materialist messages the moment we step outside of the office, it’s hard for those positive effects to carry over. For this reason, the second thing we must do to reconnect to a meaningful life is to curb materialism and reduce its impact on our lives.
While we all know that materialist culture is contributing to the rise in depression rates, most of us don’t have the individual freedom to completely shut out commercial culture by moving to the countryside and ignoring all advertising. Instead, to tackle materialism, we need to take collective action to reframe how, on a societal level, we think about “stuff.”
As we discussed in Chapter 5, the biggest culprit in the rise of materialism is advertising, which tells us that we “need” certain products in order to be successful, fit in, and be happy. One approach to stop this cycle of depression is to ban advertising altogether. It may seem like a radical step, but several countries have banned different types of advertising with encouraging results. In Brazil, the city of São Paulo banned all forms of outdoor advertising in 2007 with the widely popular “Clean City Law”—now, 70% of residents believe it’s made the city a better place to live.
Advertising bans can create a healthier environment for future generations, but they can take years to implement. In the meantime, a focused, collective effort to spend time and money on the things that actually make us happy can boost self-esteem and fight off materialism-induced depression.
One experiment in Minneapolis paved the way for this type of intervention. A group of sixty parents and their teenage children met regularly with a financial advisor to discuss their family’s relationship to money and materialism (a separate group of parents and their children served as a control group and didn’t participate in discussions). Over the course of three months, the advisor guided them through a series of exercises designed to help them reconnect to their values:
Social scientists tested the participants’ materialism and self-esteem at the start of the study and then again after the three-month intervention. The results were groundbreaking: The group who dug into their money habits and refocused on their values (rather on spending for status or emotional reasons) had significantly lower levels of materialism and significantly higher self-esteem than the control group. This suggests that, with group support, it’s possible to resist the barrage of depressing messages from a materialistic culture.
Universal basic income is an extremely divisive idea—some people think it could cure a whole host of societal ills, while others think it would be a moral and economic failure. Take a moment to reflect on where you stand.
Had you heard of Universal Basic Income before reading this chapter? When you first encountered the idea (here or elsewhere), what were your first reactions?
If the government implemented Universal Basic Income tomorrow, how would your life change? (For example, you might choose to go back to school or start a new business.)
How would your neighborhood or city change? (For example, would there be more businesses? Less? Would people be happier? Would it affect other social inequalities?)
Overall, what do you think of the idea of Universal Basic Income? Is there anything you’d change about it if you could?
Making financial decisions based on your core values (things that you consider most important for living a good life) and intrinsic motivations (things you love to do just for the joy of it) can help alleviate depression. Use this exercise as a chance to take inventory of those values and how they affect your decisions.
Other than necessities like food and rent, what things do you typically spend money on? (For example, a daily coffee shop visit, vacations, gadgets, and so on.)
Now, try to list three values that are most important to you (things like sustainability, family time, integrity, and so on).
Next, list three of your intrinsic motivations—things you love to do and would happily do for free (for example, playing an instrument, reading, gardening, and so on).
Do the things you spend extra money on line up with your values and intrinsic motivations? Do they make it easier to do the things you really love to do? Why or why not?
What concrete change could you make to better align your spending habits with your values and intrinsic motivations? (For example, if you lease an expensive car just to impress other people, you might consider downgrading to a less expensive car and putting the money you save toward something you really value, like a trip to spend time with relatives in another country).
As we’ve seen, depression is more than just an individual issue, and we can’t expect to conquer it individually. Even if it were possible to cure depression on your own, if you’re working endless hours at a dead-end job just to make rent, you’re unlikely to have the time or energy! Instead, as previously noted, to truly tackle depression, we need large-scale societal changes, including a fundamental restructuring of personal, cultural, and economic priorities. The way depression has become nearly universal should be a wake-up call: The old ways of doing things are not working.
This may seem like a daunting task. Fundamentally changing the systems that cause depression is undeniably a massive undertaking. However, so were social changes such as introducing marriage equality, women’s suffrage, and the Americans with Disabilities Act, and electing a Black president—and these changes still came to pass.
As evidence that even seemingly impossible social change can happen, Hari offers the story of his friend, journalist Andrew Sullivan. In 1993, after watching the AIDS crisis unfold and claim the lives of his friends, Sullivan received his own devastating HIV-positive diagnosis (at the time, there were no reliable treatments for HIV, so the diagnosis was often a death sentence). With little to lose, Sullivan quit his job and poured his energy into writing the first book to propose legalizing same-sex marriage. He knew the idea would sound like an absurd pipe dream, but he hoped it would at least make things a bit better for the next generation after his death.
Except, to his own surprise, Sullivan survived. The book, Virtually Normal, attracted serious backlash, but it also started a conversation that evolved into a full-blown civil rights movement. Twenty-five years later, the majority opinion for the Supreme Court ruling that legalized gay marriage quoted the book directly as part of the rationale for writing marriage equality into federal law.
Andrew Sullivan’s absurd, not-quite-deathbed dream became a reality for the entire United States. Perhaps one day, the dream of restructuring society to address the way it causes depression can become a reality, too.