A chemical imbalance is not “The Cause” of depression. We have been systematically misinformed about what depression and anxiety are. This is the main idea behind Johann Hari’s bestselling book Lost Connections. In this post I summarize and respond to Hari’s claims.
Now, before you start throwing tomatoes at me as being a hater, let me back up. Depression is not your fault, and biology, including brain biology and brain chemistry, absolutely plays a role in depression.
Like, don’t stop taking your meds. Work with your healthcare professionals to find a really robust treatment plan for yourself. But in this video we’re going to explore a much more nuanced approach to the complex causes of depression than what the medication commercials taught us all back in the 90s.
Now, Johann Hari spent a decade writing articles on how depression was simply a chemical imbalance, a brain defect. He took an antidepressant for 13 years, and he praised its virtues, even when his therapist repeatedly suggested that he still seemed pretty depressed.
He says, “I had believed two stories about depression in my life. For the first 18 years of my life I had thought of it as all in my head, meaning it was not real, it was imaginary, fake, an indulgence, an embarrassment, a weakness. And then for the next 13 years I believed it was all in my head in a very different way, that it was due to a malfunctioning brain.
“But I was going to learn that neither of these stories is true. The primary cause of all this rising depression and anxiety is not in our heads. It is, I discovered, largely in the world and the way we are living in it. I learned that there are at least nine proven causes of depression and anxiety, although nobody had brought them together like this before, and many of them are rising all around us, causing us to feel radically worse.
“This wasn’t an easy journey for me. As you will see, I clung to my old story about my depression being caused by my brain being broken. I fought for it. I refused for a long time to see the evidence they were presenting to me. This wasn’t a warm slide into a different way of thinking; it was a fight.
“But as I pressed on through the journey I realized what was on the other side of it: the real solutions. When I finally understood what was happening to me and so many people like me, I learned there are real antidepressants waiting for us. They don’t look like the chemical antidepressants that have worked so poorly for so many of us. They aren’t something you buy or swallow. But they might hold the beginning of a true path out of our pain.”
So just to be clear: Johann Hari is not the first person to address this topic. This is a pretty well-known concept in the therapy world and among doctors now. But I don’t think it’s common among the general public. And really one of the reasons I’m summarizing his book is because he’s done such a good job laying out the explanation in a really clear, concise, step-by-step manner.
Where Does This Myth Come From?
So let’s lay out the bullet points.
Doctors, media, and drug companies, especially in the 90s and early 2000s, presented an overly simplistic message about what causes depression. They’d say it’s a chemical imbalance, or they’d say it’s when you don’t have enough serotonin in your brain.
This message was fed by the pharmaceutical companies’ advertising. And it was a message that was received so well because it seemed to provide an antidote to the stigma that previously plagued mental health conditions like depression, where people believed that depression was a character defect or a weakness.
Now, obviously, as we have come to understand the biology of depression, letting go of that stigma has been a positive step forward. Also, the published studies seemed to indicate that antidepressants like Prozac and Paxil were very effective at treating depression. But unfortunately, both the idea of a chemical imbalance and the effectiveness of antidepressants are not quite accurate.
So let’s start with the overly simplistic idea of a chemical imbalance. So let me be clear: brain chemistry is a part of every single thought and feeling that you have. Biology is essential for happiness or depression. And that’s because without your biology you don’t exist, you can’t think.
And I understand that for many of you the idea of a chemical imbalance has been very helpful, perhaps helping you seek treatment, helping you let go of shame or stigma or self-loathing. But neuroscientists will tell you that it’s not just a genetic chemical imbalance that causes depression. So this is an overly simplistic cultural myth.
So Johann spends four chapters building his case. And if you’re curious to see his incredulity lead to this surprising conclusion, then I just recommend you buy the book.
But here’s the basic idea: the serotonin hypothesis was started in 1952 when a drug given to TB patients caused patients to start dancing with joy in the halls. Then in 1965 a researcher hypothesized that it was increasing serotonin, and maybe serotonin could treat depression.
So to test this theory, in the 70s they gave a drug to lower the serotonin in people, and the result was there was no change in mood.
So the researchers looked into other neural chemicals and found that antidepressant drugs that increase serotonin in the brain have the same modest effect in in clinical trials as the drugs that decrease serotonin in the brain, and they have the same effect as drugs that increase another chemical, norepinephrine, and they have the same effect as drugs that increase another chemical, dopamine.
So in other words, no matter what chemical you tinker with, you get the same outcome.
Dr. David Healey, the man who has written the most detailed history of antidepressants we have, told Johann that when it comes to the idea of the imbalanced brain, there never was any basis for it ever. It was just marketing copy. And Professor Andrew Skull of Princeton has said that attributing depression to low serotonin is deeply misleading and unscientific.
Now, Johann couldn’t believe what he was learning, so he started interviewing as many experts as he could.
Professor Joanna Moncrieff, one of the leading experts on this question, said, “The term doesn’t really make any sense. We don’t know what a chemically balanced brain would look like. People are told that drugs restore a natural balance to your brain,” she said, “but it’s not true. They create an artificial state. The whole idea of mental distress being caused by a chemical imbalance is a myth sold to us by the drug companies.”
Now, from my perspective, the field of depression treatment is moving away from the serotonin hypothesis toward a much more nuanced approach to depression, with contributing factors including inflammation, allergies, nutrient deficiencies, and, of course, how you think and the experiences you’ve had.
What’s the Truth?
So right now some of you might be feeling really upset or really angry or really confused. Maybe you’re also thinking about throwing your meds out the window or you’re feeling ashamed or blamed or like I’m a crazy non-believer in science.
So I hope that’s not the case. But if it is, take a deep breath. I’m not saying you should quit your meds. I’m not saying depression is your fault. I’m not saying that it has anything to do with your worth or goodness as a person. I’m saying that if you want to learn to treat depression, we have to move past an overly simplistic explanation of the cause of depression.
So what if the causes of depression are much more complicated than we thought? What if it’s not a chemical imbalance but it’s this combination of factors, and especially what’s going on around us and also inside of us?
So for some people who have a limited understanding of the causes of depression, moving away from the simple chemical imbalance theory sounds like heresy. But before I recorded this video I shared the script with three professionals I trust: a doctor, a psychiatric nurse practitioner, and a psychiatrist, and all three of them basically said, “Isn’t this basically the biopsychosocial model?”
The biopsychosocial model is a well-understood and commonly accepted approach to mental health that conceptualizes the causes of mental illness as being an interplay of biology, psychology (how you think), and society (your experiences, your environment). But I’m making this video because many members of the public have never heard of it.
I think the author was pretty mind-blown over the realization that he had been misled. So in his pendulum swing away from the chemical imbalance hypothesis he swings way over here to the social causes of depression, and he leaves out a pretty significant and well-rounded approach to the biological causes of depression and that interactive nature of the body and the mind with depression.
These are things like sleep, vitamin D, your thyroid, nutrition, exercise, light therapy. All of these are evidence-based treatments that have shown to be effective at treating depression. He just kind of ignores all the other biological contributing factors. And I go into a lot more detail about these other treatments in my course Change Your Brain. So if you want to learn more about that, check out the link in the description.
And anyway, I’m rambling, but I’m going to make another video on my perspective of this well-rounded approach to the causes of depression.
And to be honest, there’s so much we don’t know about depression. Like right now we don’t have a diagnostic test to determine what is causing your depression. When you get a depression diagnosis the doctor or the psychologist or the therapist has absolutely no way of telling you what is causing it. They’re just telling you that you fit this cluster of symptoms, and we call this group of symptoms depression. But there is no chemical imbalance test.
So we’re actually a lot better at identifying and diagnosing these social and psychological causes of depression — so these are things like abuse or stress — then we are at diagnosing how biology is contributing to depression. But still a lot of people believe that depression is simply a chemical imbalance. And that’s due to the advertising from the pharmaceutical companies.
Now, we can tell you statistical probabilities, but we don’t know who are the people who have something biological going on and who are the people who are struggling with environmental or psychological factors. And the reality is it’s probably a combination of a lot of factors for most people.
So before we go into some of the more accurate causes of depression, let’s just quickly address Johann’s point number two.
How Effective Are Antidepressants?
Point number two is that we’ve been misled about the effectiveness of antidepressant medications. So 50 to 65% of people who take an antidepressant will see positive effects. And I know that antidepressant medications have probably been life-saving for many of you out there.
But he quotes a scientist here. He says, “To find out the chemical effects of the drug you do two things. So first you subtract all of the people who would have just gotten better anyway. This is called natural recovery. Then you subtract all of the people who got better when they were given a sugar pill or a placebo. What’s left is the real effect of the drug.”
But when these researchers added up the figures from all of the publicly available scientific studies on antidepressants, what they found baffled them.
The numbers showed that 25% of the effects of antidepressants were due to natural recovery, 50% were due to the story they had been told about the medication — so this is the placebo effect — and only 25% of the effectiveness of the drugs was due to the actual chemicals. The researchers said, “This surprised the hell out of me.”
Now, drug companies also systematically made their medications look more effective than they were. So they’d run a bunch of studies, and then they would only publish the results that made their medication look good.
For example, in one trial for Prozac, the drug was given to 245 patients, but the drug company published the results for only 27 of them. So those 27 patients were the ones that the drugs seemed to work very well for. And this is called publication bias.
So when a researcher, Irving Kirsch, used the freedom of information act to gain access to all of the studies, not just the ones that the pharmaceutical companies wanted you to see, he learned something that was a little bit surprising. He learned right away that the drug companies had for years been selectively publishing research, and to a greater degree than he expected.
So scientists measure the depth of someone’s depression using something named the Hamilton scale, which was invented by a scientist named Max Hamilton in 1959. The Hamilton scale ranges from zero, where you’re skipping merrily along, you’re happy, to 51, where you’re suicidal.
So to give you a yardstick, you can get a six-point leap in your Hamilton score if you improve your sleeping patterns. What Irving found is that in the real data that hadn’t been run through a PR filter, antidepressants do cause an improvement in the Hamilton score. They do make depressed people feel better. It’s an improvement of 1.8 points on average across all the people they tested.
When Irving published these figures in a scientific journal, he expected a big fight-back from the scientists who had produced all this data. But in fact, in the months that followed he found there was, if anything, a feeling of shame-faced relief from many of them.
One group of the researchers wrote that it had been a dirty little secret in the field for a long time that the effects of these drugs on depression itself were in reality tiny.
Now, this was personal for Johann. Some pharmaceutical companies misled the public about the effectiveness of their medication. So for example, Paxil, the medication Johann started taking at 17 years old, lied in advertising about the effectiveness of Paxil for teenagers, and they later lost a case in court over the matter.
In his book The Body Keeps the Score, Bessel van der Kolk both praises the advent of psychopharmacology and he also mourns that it has been seen as a replacement for addressing the deeper causes of depression and trauma.
He says, “Consider the case of antidepressants. If they were indeed as effective as we have been led to believe, depression should by now have become a minor issue in our society. Instead, even as antidepressant use continues to increase, it has not made a dent in hospital admissions for depression. The number of people treated for depression has tripled over the past two decades, and 1 in 10 Americans now take antidepressants.”
Should I Take Medication for Depression?
So again, let me just be clear. I believe antidepressant medication to be an effective, research-backed treatment option for some people, and I know it has been life-saving for many of you out there. I’m absolutely not saying that you should stop or change your meds.
It’s just that I also believe that when it comes to a complex disorder like depression, people deserve as many effective, research-backed treatment options as possible. There should be no shame in educating yourself in the options and choosing any treatment you believe may be effective for you.
So I’m not saying it’s bad to take meds. I’m saying that if you want to treat your depression, you should try multiple approaches.
Among all the many treatments I recommend for my clients, I frequently encourage them to work with a doctor to explore their medication options and make an informed decision. And as I discuss this book, the point I seek to make is that the messaging that depression is simply a chemical imbalance is far too simplified an explanation to be of robust help to those who seek effective treatment options.
So if you look at heart disease and diabetes, if a 20-year-old man who is overweight, doesn’t exercise, eats a high-fat, high-salt, high-carb diet, if he goes into the doctor and he’s diagnosed with high cholesterol and pre-diabetes, the doctor is perhaps going to prescribe him a medication to help him, but he would also most likely encourage the patient to create lifestyle changes. So without changing his diet and exercise, the medication won’t be enough on its own.
Depression is a complex disorder. Its causes are far more complicated and intertwined than simply genes and brain chemistry. Depression is this complex interaction of biology, psychology, and our socio-cultural environment. And in my opinion, it involves some choice too. So we must seek effective treatments that incorporate as many of these aspects as possible.
So in the next video we’ll talk about what Johann Hari describes as the nine ways that society causes depression. You may be surprised to learn about some of the other factors that influence your mental health. And the best part of all of this is the more you know, the more options you have for actually treating your depression — the more tools you’ll have in your tool belt.
I hope this was helpful. Thank you for reading, and take care.
Check out my course, Change Your Brain, for more ways to help with Depression.
