HALF A MILLION DOWNLOADS REACHED - Helping Safeguard children from psychiatric drug harm due to possible severe toxic side effects. We need alternatives like psychological interventions, physical activity, or mindfulness training as a first course of action. Let's 'Enable not Label' kids to give them better futures - - - - - - - - -"There can be no keener examination of a society's soul than the way it chooses to treat its children." - - - - -
- Nelson Mandela
The British Psychological Society (BPS) is pleased that the 2018 NICE ADHD guideline has been amended following our comments during the consultation process.A number of additions relating to child safeguarding have been made, including:
- Environmental factors must be fully accounted for and appropriately adapted prior to a diagnosis of ADHD being made. - A behavioural baseline must be established. - Parents of children under five must have completed a recognised and accredited parent training course before a diagnosis of ADHD is considered. - In the case of under fives, the advice of another qualified tertiary professional should be considered before a diagnosis of ADHD is made. Dr Brian Apter, who led the Society's response, said:
"I am pleased that the consultation process has borne fruit and a number of safeguarding checks and balances have been added.
This new guidance will stand for 10 years before further revisions are considered, during this time it is vital that psychologists comply with this guidance to ensure the safeguarding of children and young people in the organisations that they work for and with."
Child psychologists are well placed to challenge medical practitioners when there is a Safeguarding concern due to a prescribed drug's side effects in a case where they are co-working.
You can read our full consultation response here.The Society produce responses to a number of consultations - for more information on these, including on how you can get involved, visit our consultations page.
A Reflective Checklist for Child Mental Health Professionals who Prescribe Psychotropic Medicines Endorsed by the Division of Educational and Child Psychology Division Committee of the BPS in June 2016 and subsequently by Professor Peter Kinderman, the then President of the British Psychological Society (See enclosed letter)
This year’s chairperson of the DECP, Brian Apter, as expressed in his ‘Chair’s Notes feels an article outlining the rationale underpinning the development of this Reflective Checklist by the Medicalisation Subcommittee of the Division of Educational and Child Psychology is needed at this stage to inform our members and all psychologists of its development so as to help them effectively challenge practice in cases where they have ethical and long term health concerns about the children with whom they co-work.
The idea for this Reflective Checklist for Mental Health practitioners is for prescribers of psychotropic medications to children in the U.K. to use as an aide-memoire on their desks to better safeguard the wellbeing of children they work with and came from Atul Gawande’s inspirational and practical work on checklists applied to the fields of surgery and neo-natal emergencies in the U.K. which have had profoundly beneficial outcomes on client survival rates. Atul Gawande is a Professor ofSurgery at Harvard Medical School and believes that incredibly complex processes and decisions can be improved and made safer by simple prompt questions and common sense practical procedures. His seminal book was 'The Checklist Manifesto.' 2009 which is an international bestseller and has provoked radical approaches in many fields.
The rapidly increasing prescription rates of psychotropic drugs for children by Child Psychiatrists and Paediatricians in the U.K. over the last two decades has alarmed many mental health practitioners and professional bodies alike such as the Division of Educational and Child Psychology and the Association of Educational Psychologists (AEP) as well as colleagues in America where the situation is even more extreme. In some States the prescription rate for Methylphenidate alone is 16% of the total school population which most professionals would want to avoid in the U.K.
As reflective practitioners and being ‘Ethically Mindful’ of the paramount principle of the Safeguarding Children in our shared care the DECP Medicalisation of Childhood Subcommittee has endeavoured to produce a positive contribution to this critical area of multi-professional debate and good practice. We hope that applying the much celebrated above approach of using simple and thought provoking question prompts could significantly improve the Safeguarding of vulnerable groups in society such as children.
The checklist went through many stages of generating suitable questions and consultation with colleagues about their suitability.The questions were then further refined to improve their face validity and effectiveness at making practitioners consider the importance of midfully making the decision to medicate a child in their often very busy working day. It is still our hope that child psychiatrists and paediatricians, themselves, through consideration by their professional bodies could then be distributed as a desk top aide-memoire which could be situated next to their prescription pad or indeed combined with it as one item. This would act as a significant additional safeguard we feel.
Obviously we do not want to unnecessarily duplicate procedures, such as the excellent NICE Guidelines for specific conditions for well trained and informed professionals but we do believe that a brief pause where they take stock with a period of reflection may in the long term benefit the client group we all serve. We hope as many colleagues in the field have already indicated that a few minutes well spent may enhance the decision making at the point of prescription and moderate unnecessary overprescribing to children who may well on reflection fall within the normal range of children experiencing higher levels of mental distress for whatever causal combination of environmental, social and biological factors.
The common-sense and reflective nature of the questions we have posed are, we feel, both practical and ethical in nature . Sadly despite our best efforts and success at drawing it to the attention of the appropriate professional bodies which initially showed a lot of promise at high levels within the organisations it seems that the inevitable committee considerations has not reached any positive conclusion at this stage. This in some way mirrors the consideration of new NICE Guidelines that we have also been involvedribers from potential complaint rather than better Safeguarding Children from what the President of the Royal College of Psychiatry, Sir Simon Wessely has refe in in the intervening period. The worrying trend seems to be a tendancy to protect prescrred to as, ‘over-zealous prescribing.’
We must persist with trying to influence good practice in this regard at both a personal interaction level with the medical colleagues we work with supporting children on our caseloads and at a professional collaboration level in setting up NICE’s preferred model of multi-agency pathways for child behaviour.
Some of the many endorsements received since it has received international coverage in articles include:
1)From the Psychiatric Times website - July 2015 - Professor Allen Frances, ex- editor in chief of DSM-IV states, "Overwhelmed teachers often recommend that parents take their kids to doctors for medicine when the problem may be more in the classroom than in the kid. Dave Traxson, a child and educational psychologist and his colleagues in the United Kingdom, have come up with a terrific suggestion to help contain the epidemic of careless medication in kids. They have developed a checklist of questions doctors should think about before prescribing psychoactive drugs to children."
Prof Allen Frances Psychiatrist 2018:This checklist is the best way to stop doctors from over-prescribing psych meds for kids.Forces them to do more thorough evaluation & to consider the many safer alternatives. LINK: https://t.co/unJicQf5r2 (https://twitter.com/AllenFrancesMD/status/978989855655931904?s=03)
Thanks Allen.
2)“ I saw the proposed checklist re: child psych medications in Psychiatric Times. It seems clear, thoughtful and feasible. Thank you.” Lloyd Sederer, MD. Medical Director, NYS Office of Mental Health, Adjunct Professor, Columbia/Mailman School of Public Health.Medical Editor for Mental Health, The Huffington Post.
3)"Thanks for the check list. I wonder how many children would really need medications after working through this check list? I am a child and adolescent psychiatrist , and as the years go by I find fewer and fewer children really need medications, and more and more do so much better without the meds that didn´t really help in the first place. But it is not popular talk around the block." Lisbeth Kortegaard - Consultant Child and Adolescent Psychiatrist at Child and Adolescent Psychiatry in Hoejbjerg, Central Region, Denmark.
4) Professor Peter Kinderman - President of the BPS 2016-17 stated -
I am happy personally to endorse the Reflective Checklist that the Division of Educational and Child Psychology approved for limited dissemination at their June Committee meeting, following their consultation with some interested partners and to thank you all for your work on this issue.
The Reflective Checklist having been duly endorsed by the DECP, as well as a range of significant external partners, including the General Secretary, Kate Fallon, of the Association for Educational Psychologists, means I am very happy to join with them in this regard. I agree with your hope and that of Professor Allen Frances (Editor in Chief of DSM-IV) expressed a couple of weeks ago on his blog that, were the Checklist to be used by the two main groups of prescribers for children and young people i.e. child and adolescent psychiatrists and specifically trained paediatricians, that the number of prescriptions of psychotropic medication would become more reasonable over time.
You mentioned that you would also be pleased to remain involved in this initiative and to liaise with me and the DECP Committee where appropriate and to start a conversation with the President of the Royal College of Psychiatrists, Sir Simon Wesseley who is already aware of this initiative, with a view to the RCP using it as a stimulus for meaningful discussion amongst their membership of the concept. 5) Caroline Martin, Chief of the ETB in the City of Dublin as feedback on this post: "This Reflective Checklist designed by Dave Traxson endorsed by the BPS Division of Educational & Child Psychology (amongst several notable others) is an excellent resource. It is targeted for use by those who prescribe psychotropic meds to children. However, I suggest it can also be used by educational & psychological professionals who are responsible for determining and/or implementing interventions for children. We need to stop assuming the source of the problem lies within the child and checklists like this challenge this assumption. Granted, this will make for some more uncomfortable conversations." AND NOW THE CHECKLIST - DISCUSS ITS BENEFITS
A Reflective Checklist for Child Mental Health Professionals who Prescribe Psychotropic Medicines Endorsed by the Division of Educational and Child Psychology Division Committee of the BPS in June 2016.
PAUSE - REFLECT - REVIEW
· Are the child’s behavioural differences pervasive, occurring in a wide range of social settings and observed by a range of different individuals in the community?
· Are the child’s difficulties severe, enduring, and significantly impairing?
· Have there been any stresses in the child’s relationships, social context, and recent history which might explain this pattern of behaviours?
· Does the child have presenting behaviours that closely conform to an approved usage for the particular medication being considered at this time?
· Is there research evidence on the efficacy and safety of this specific medication with children of the same age, gender, and social grouping?
· Are the child’s presenting behaviours significantly impairing in a range of settings to acceptably balance the possible impact on the child’s developing brain and body from the evidence based side effects of the specific medications being considered?
· Do the child’s parents and involved professionals see the child’s differences as significant enough to require this medication?
· Has a psychological intervention, such as a talking therapy (CBT etc.); a social intervention such as ‘Circle of Friends’ / ‘Buddy System’ or a physical intervention such as participation in sport been tried prior to prescribing this particular psychotropic medication being considered?
· Have there been any reported significant adverse side effects from this specific medication with children of the same age, gender and social grouping?
· Have you carefully weighed up the short and long-term risks and balanced them against possible benefits?
· Have you received valid consent from the parent and the child?
And perhaps the most searching question:
· If a child in your immediate family or circle of friends had the same presenting behaviours that are in front of you now, would you still be prepared to prescribe this drug?
Children in France are not be medicated as an early intervention for ADHD until the age of 7 years of age. The new ADHD Guidelines from NICE 2018 in the U.K. do significantly better Safeguard the under 5s but not children up to 7 years of age.
Professor Allen Frances, Duke University, gives a few clear reasons for why France has much lower #ADHD rates than US:
1)No Big#pharma unregulated advertising in France allowed to mislead/encourage parents & teachers.
2)MD's in France use more psychosocial approaches & less pill driven interventions.
3) School systems in France are less chaotic and children have very good diet/exercise routines in school.
4)French parents are more empowered & better at engaging and disciplining their own kids
5) French professionals/parents have more time for evaluation of the early interventions.
6) They adopt a more psychodynamic approach initially and encourage exercise, therapy etc. as a viable alternative to medication.
Why French Kids Don't Have ADHD?
French children don't need medications to control their behaviour.
Posted Mar 08, 2012
In the United States, at least 9 percent of school-aged children have been diagnosed with ADHD, and are taking pharmaceutical medications. In France, the percentage of kids diagnosed and medicated for ADHD is less than .5 percent. How has the epidemic of ADHD—firmly established in the U.S.—almost completely passed over children in France?
Is ADHD a biological-neurological disorder? Surprisingly, the answer to this question depends on whether you live in France or in the U.S. In the United States, child psychiatrists consider ADHD to be a biological disorder with biological causes. The preferred treatment is also biological—psycho stimulant medications such as Ritalin and Adderall.
French child psychiatrists, on the other hand, view ADHD as a medical condition that has psycho-social and situational causes. Instead of treating children's focusing and behavioral problems with drugs, French doctors prefer to look for the underlying issue that is causing the child distress—not in the child's brain but in the child's social context. They then choose to treat the underlying social context problem with psychotherapy or family counseling. This is a very different way of seeing things from the American tendency to attribute all symptoms to a biological dysfunction such as a chemical imbalance in the child's brain.
French child psychiatrists don't use the same system of classification of childhood emotional problems as American psychiatrists. They do not use the Diagnostic and Statistical Manual of Mental Disorders or DSM. According to Sociologist Manuel Vallee, the French Federation of Psychiatrydeveloped an alternative classification system as a resistance to the influence of the DSM-3. This alternative was the CFTMEA (Classification Française des Troubles Mentaux de L'Enfant et de L'Adolescent), first released in 1983, and updated in 1988 and 2000. The focus of CFTMEA is on identifying and addressing the underlying psychosocial causes of children's symptoms, not on finding the best pharmacological bandaids with which to mask symptoms.
To the extent that French clinicians are successful at finding and repairing what has gone awry in the child's social context, fewer children qualify for the ADHD diagnosis. Moreover, the definition of ADHD is not as broad as in the American system, which, in my view, tends to "pathologize" much of what is normal childhood behavior. The DSM specifically does not consider underlying causes. It thus leads clinicians to give the ADHD diagnosis to a much larger number of symptomatic children, while also encouraging them to treat those children with pharmaceuticals.
The French holistic, psychosocial approach also allows for considering nutritional causes for ADHD-type symptoms—specifically the fact that the behavior of some children is worsened after eating foods with artificial colors, certain preservatives, and/or allergens. Clinicians who work with troubled children in this country—not to mention parents of many ADHD kids—are well aware that dietary interventions can sometimes help a child's problem. In the U.S., the strict focus on pharmaceutical treatment of ADHD, however, encourages clinicians to ignore the influence of dietary factors on children's behavior.
And then, of course, there are the vastly different philosophies of child-rearing in the U.S. and France. These divergent philosophies could account for why French children are generally better-behaved than their American counterparts. Pamela Druckerman highlights the divergent parenting styles in her recent book, Bringing up Bébé. I believe her insights are relevant to a discussion of why French children are not diagnosed with ADHD in anything like the numbers we are seeing in the U.S.
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Trop peu d’enfants souffrant de troubles déficit de l’attention ou d’hyperactivité bénéficient du traitement qu’ils devraient avoir. A l’inverse, trop d’étudiants l’utilisent mal, avec des conséquences importantes.
Depuis sa commercialisation en France en 1996, la Ritaline® et autres psychostimulants du même ordre (Concerta®, Quasym® et Medikinet®) ont permis à des centaines de milliers d’écoliers de suivre un cursus normal alors qu’ils étaient en situation scolaire périlleuse. On estime en effet que de 2 à 5 % des enfants d’âge scolaire souffrent de TDAH ( trouble déficit de l’attention/ hyperactivité), un syndrome d’origine inconnue et qui peut mélanger plusieurs symptômes.
Parfois l’hyperactivité et l’impulsivité prédominent, donnant des enfants incapables de tenir en place, d’attendre leur tour, impatients, ayant besoin d’agir mais le faisant de façon désordonnée et inefficace. D’autres fois, c’est le déficit de l’attention qui est au premier plan, avec une incapacité à terminer une tâche, l’évitement de celles qui nécessitent une attention soutenue et une distractibilité majeure. Et des formes mixtes sont possibles.
D’après les données de l’Assurance-maladie, fondées sur les bénéficiaires du régime général, 48.895 personnes étaient traitées par méthylphénidate en 2014 en France. Surtout des jeunes, puisque 20.000 étaient âgés de 6 à 11 ans et 20.000 autres de 12 à 17 ans. Il est habituel d’interrompre le traitement en périodes de vacances scolaires pour voir si celui-ci est toujours nécessaire.
Risques d’effets indésirables du traitement
Quoi qu’il en soit, 40.000 enfants traités, c’est insuffisant. Dans son dernier rapport sur les données d’utilisation et de sécurité d’emploi en France du méthylphénidate (avril 2017), l’Agence du médicament (ANSM) estime que «le nombre d’enfants souffrant de TDAH en France métropolitaine serait compris entre 190.000 et 480.000 ». Ainsi, plusieurs centaines de milliers d’enfants ne bénéficient pas du traitement qu’ils devraient avoir.
L’ANSM souligne pourtant que le TDAH «est à l’origine d’une altération importante des relations avec l’entourage et de l’apprentissage scolaire, et nécessite une prise en charge psychologique, éducative, sociale et familiale, en particulier quand les symptômes deviennent un handicap et sont une source de souffrance».
Il faut dire que la brochure de l’ANSM destinée aux parents fait frissonner tant elle insiste sur les risques d’effets indésirables du traitement. Sur le plan neuropsychiatrique: l’apparition de tics moteurs ou verbaux, d’agressivité, de manque d’appétit, voire d’hallucinations, de paranoïa ou de dépression. Sur le plan cardio et cérébro-vasculaire: palpitations, maux de tête, etc. La brochure rappelle aussi que «le méthylphénidate pourrait ralentir la croissance et la prise de poids».
Mais ce qui inquiète surtout l’Agence, c’est le mésusage important observé dans de nombreux pays et, à un degré moindre en France. Par des toxicomanes, mais aussi par des étudiants sans TDAH qui espèrent ainsi augmenter leurs facultés de concentration. L’ANSM insiste sur le risque de dépendance et les effets secondaires possibles du médicament.
«Vigilance requise»
Le 12 janvier dernier, la commission des stupéfiants et des psychotropes de l’ANSM se penche sur le méthylphénidate. Ce jour-là, le Dr Samira Djezzar (Centre d’évaluation et d’information sur la pharmacodépendance de Paris), présente les résultats de l’enquête officielle d’addictovigilance. Elle souligne «une tendance générale à la hausse des cas de pharmacodépendance notifiés».
Mais le Dr Luc de Haro, médecin généraliste à Marseille, suivi par d’autres membres de la commission, met en garde: «La vigilance est requise pour ne pas priver du traitement les enfants qui en ont besoin tout en évitant les dérives», fait-il remarquer. Finalement, la commission propose à l’unanimité de rappeler aux médecins et pharmaciens «les conditions de prescription et de délivrance, précisant les différents risques notamment chez l’adulte liés à l’abus et au détournement du méthylphénidate». Prudent, mais sans doute insuffisant pour améliorer l’utilisation chez les enfants.
‘Drugs are having a positive effect for some people – but they clearly can’t be the main solution for the majority of us.’ Photograph: Alamy
In the 1970s, a truth was accidentally discovered about depression – one that was quickly swept aside, because its implications were too inconvenient, and too explosive. American psychiatrists had produced a book that would lay out, in detail, all the symptoms of different mental illnesses, so they could be identified and treated in the same way across the United States. It was called the Diagnostic and Statistical Manual. In the latest edition, they laid out nine symptoms that a patient has to show to be diagnosed with depression – like, for example, decreased interest in pleasure or persistent low mood. For a doctor to conclude you were depressed, you had to show five of these symptoms over several weeks.
The manual was sent out to doctors across the US and they began to use it to diagnose people. However, after a while they came back to the authors and pointed out something that was bothering them. If they followed this guide, they had to diagnose every grieving person who came to them as depressed and start giving them medical treatment. If you lose someone, it turns out that these symptoms will come to you automatically. So, the doctors wanted to know, are we supposed to start drugging all the bereaved people in America?
The authors conferred, and they decided that there would be a special clause added to the list of symptoms of depression. None of this applies, they said, if you have lost somebody you love in the past year. In that situation, all these symptoms are natural, and not a disorder. It was called “the grief exception”, and it seemed to resolve the problem.
Then, as the years and decades passed, doctors on the frontline started to come back with another question. All over the world, they were being encouraged to tell patients that depression is, in fact, just the result of a spontaneous chemical imbalance in your brain – it is produced by low serotonin, or a natural lack of some other chemical. It’s not caused by your life – it’s caused by your broken brain. Some of the doctors began to ask how this fitted with the grief exception. If you agree that the symptoms of depression are a logical and understandable response to one set of life circumstances – losing a loved one – might they not be an understandable response to other situations? What about if you lose your job? What if you are stuck in a job that you hate for the next 40 years? What about if you are alone and friendless?
The grief exception seemed to have blasted a hole in the claim that the causes of depression are sealed away in your skull. It suggested that there are causes out here, in the world, and they needed to be investigated and solved there. This was a debate that mainstream psychiatry (with some exceptions) did not want to have. So, they responded in a simple way – by whittling away the grief exception. With each new edition of the manual they reduced the period of grief that you were allowed before being labelled mentally ill – down to a few months and then, finally, to nothing at all. Now, if your baby dies at 10am, your doctor can diagnose you with a mental illness at 10.01am and start drugging you straight away.
Dr Joanne Cacciatore, of Arizona State University, became a leading expert on the grief exception after her own baby, Cheyenne, died during childbirth. She had seen many grieving people being told that they were mentally ill for showing distress. She told me this debate reveals a key problem with how we talk about depression, anxiety and other forms of suffering: we don’t, she said, “consider context”. We act like human distress can be assessed solely on a checklist that can be separated out from our lives, and labelled as brain diseases. If we started to take people’s actual lives into account when we treat depression and anxiety, Joanne explained, it would require “an entire system overhaul”. She told me that when “you have a person with extreme human distress, [we need to] stop treating the symptoms. The symptoms are a messenger of a deeper problem. Let’s get to the deeper problem.”
*****
I was a teenager when I swallowed my first antidepressant. I was standing in the weak English sunshine, outside a pharmacy in a shopping centre in London. The tablet was white and small, and as I swallowed, it felt like a chemical kiss. That morning I had gone to see my doctor and I had told him – crouched, embarrassed – that pain was leaking out of me uncontrollably, like a bad smell, and I had felt this way for several years. In reply, he told me a story. There is a chemical called serotonin that makes people feel good, he said, and some people are naturally lacking it in their brains. You are clearly one of those people. There are now, thankfully, new drugs that will restore your serotonin level to that of a normal person. Take them, and you will be well. At last, I understood what had been happening to me, and why.
However, a few months into my drugging, something odd happened. The pain started to seep through again. Before long, I felt as bad as I had at the start. I went back to my doctor, and he told me that I was clearly on too low a dose. And so, 20 milligrams became 30 milligrams; the white pill became blue. I felt better for several months. And then the pain came back through once more. My dose kept being jacked up, until I was on 80mg, where it stayed for many years, with only a few short breaks. And still the pain broke back through.
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I started to research my book, Lost Connections: Uncovering The Real Causes of Depression – and the Unexpected Solutions, because I was puzzled by two mysteries. Why was I still depressed when I was doing everything I had been told to do? I had identified the low serotonin in my brain, and I was boosting my serotonin levels – yet I still felt awful. But there was a deeper mystery still. Why were so many other people across the western world feeling like me? Around one in five US adults are taking at least one drug for a psychiatric problem. In Britain, antidepressant prescriptions have doubled in a decade, to the point where now one in 11 of us drug ourselves to deal with these feelings. What has been causing depression and its twin, anxiety, to spiral in this way? I began to ask myself: could it really be that in our separate heads, all of us had brain chemistries that were spontaneously malfunctioning at the same time?
To find the answers, I ended up going on a 40,000-mile journey across the world and back. I talked to the leading social scientists investigating these questions, and to people who have been overcoming depression in unexpected ways – from an Amish village in Indiana, to a Brazilian city that banned advertising and a laboratory in Baltimore conducting a startling wave of experiments. From these people, I learned the best scientific evidence about what really causes depression and anxiety. They taught me that it is not what we have been told it is up to now. I found there is evidence that seven specific factors in the way we are living today are causing depression and anxiety to rise – alongside two real biological factors (such as your genes) that can combine with these forces to make it worse.
Once I learned this, I was able to see that a very different set of solutions to my depression – and to our depression – had been waiting for me all along.
To understand this different way of thinking, though, I had to first investigate the old story, the one that had given me so much relief at first. Professor Irving Kirsch at Harvard University is the Sherlock Holmes of chemical antidepressants – the man who has scrutinised the evidence about giving drugs to depressed and anxious people most closely in the world. In the 1990s, he prescribed chemical antidepressants to his patients with confidence. He knew the published scientific evidence, and it was clear: it showed that 70% of people who took them got significantly better. He began to investigate this further, and put in a freedom of information request to get the data that the drug companies had been privately gathering into these drugs. He was confident that he would find all sorts of other positive effects – but then he bumped into something peculiar.
We all know that when you take selfies, you take 30 pictures, throw away the 29 where you look bleary-eyed or double-chinned, and pick out the best one to be your Tinder profile picture. It turned out that the drug companies – who fund almost all the research into these drugs – were taking this approach to studying chemical antidepressants. They would fund huge numbers of studies, throw away all the ones that suggested the drugs had very limited effects, and then only release the ones that showed success. To give one example: in one trial, the drug was given to 245 patients, but the drug company published the results for only 27 of them. Those 27 patients happened to be the ones the drug seemed to work for. Suddenly, Professor Kirsch realised that the 70% figure couldn’t be right.
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It turns out that between 65 and 80% of people on antidepressants are depressed again within a year. I had thought that I was freakish for remaining depressed while on these drugs. In fact, Kirsch explained to me in Massachusetts, I was totally typical. These drugs are having a positive effect for some people – but they clearly can’t be the main solution for the majority of us, because we’re still depressed even when we take them. At the moment, we offer depressed people a menu with only one option on it. I certainly don’t want to take anything off the menu – but I realised, as I spent time with him, that we would have to expand the menu.
This led Professor Kirsch to ask a more basic question, one he was surprised to be asking. How do we know depression is even caused by low serotonin at all? When he began to dig, it turned out that the evidence was strikingly shaky. Professor Andrew Scull of Princeton, writing in the Lancet, explained that attributing depression to spontaneously low serotonin is “deeply misleading and unscientific”. Dr David Healy told me: “There was never any basis for it, ever. It was just marketing copy.”
I didn’t want to hear this. Once you settle into a story about your pain, you are extremely reluctant to challenge it. It was like a leash I had put on my distress to keep it under some control. I feared that if I messed with the story I had lived with for so long, the pain would run wild, like an unchained animal. Yet the scientific evidence was showing me something clear, and I couldn’t ignore it.
*****
So, what is really going on? When I interviewed social scientists all over the world – from São Paulo to Sydney, from Los Angeles to London – I started to see an unexpected picture emerge. We all know that every human being has basic physical needs: for food, for water, for shelter, for clean air. It turns out that, in the same way, all humans have certain basic psychological needs. We need to feel we belong. We need to feel valued. We need to feel we’re good at something. We need to feel we have a secure future. And there is growing evidence that our culture isn’t meeting those psychological needs for many – perhaps most – people. I kept learning that, in very different ways, we have become disconnected from things we really need, and this deep disconnection is driving this epidemic of depression and anxiety all around us.
Let’s look at one of those causes, and one of the solutions we can begin to see if we understand it differently. There is strong evidence that human beings need to feel their lives are meaningful – that they are doing something with purpose that makes a difference. It’s a natural psychological need. But between 2011 and 2012, the polling company Gallup conducted the most detailed study ever carried out of how people feel about the thing we spend most of our waking lives doing – our paid work. They found that 13% of people say they are “engaged” in their work – they find it meaningful and look forward to it. Some 63% say they are “not engaged”, which is defined as “sleepwalking through their workday”. And 24% are “actively disengaged”: they hate it.
Antidepressant prescriptions have doubled over the last decade. Photograph: Anthony Devlin/PA
Most of the depressed and anxious people I know, I realised, are in the 87% who don’t like their work. I started to dig around to see if there is any evidence that this might be related to depression. It turned out that a breakthrough had been made in answering this question in the 1970s, by an Australian scientist called Michael Marmot. He wanted to investigate what causes stress in the workplace and believed he’d found the perfect lab in which to discover the answer: the British civil service, based in Whitehall. This small army of bureaucrats was divided into 19 different layers, from the permanent secretary at the top, down to the typists. What he wanted to know, at first, was: who’s more likely to have a stress-related heart attack – the big boss at the top, or somebody below him?
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Everybody told him: you’re wasting your time. Obviously, the boss is going to be more stressed because he’s got more responsibility. But when Marmot published his results, he revealed the truth to be the exact opposite. The lower an employee ranked in the hierarchy, the higher their stress levels and likelihood of having a heart attack. Now he wanted to know: why?
And that’s when, after two more years studying civil servants, he discovered the biggest factor. It turns out if you have no control over your work, you are far more likely to become stressed – and, crucially, depressed. Humans have an innate need to feel that what we are doing, day-to-day, is meaningful. When you are controlled, you can’t create meaning out of your work.
Suddenly, the depression of many of my friends, even those in fancy jobs – who spend most of their waking hours feeling controlled and unappreciated – started to look not like a problem with their brains, but a problem with their environments. There are, I discovered, many causes of depression like this. However, my journey was not simply about finding the reasons why we feel so bad. The core was about finding out how we can feel better – how we can find real and lasting antidepressants that work for most of us, beyond only the packs of pills we have been offered as often the sole item on the menu for the depressed and anxious. I kept thinking about what Dr Cacciatore had taught me – we have to deal with the deeper problems that are causing all this distress.
I found the beginnings of an answer to the epidemic of meaningless work – in Baltimore. Meredith Mitchell used to wake up every morning with her heart racing with anxiety. She dreaded her office job. So she took a bold step – one that lots of people thought was crazy. Her husband, Josh, and their friends had worked for years in a bike store, where they were ordered around and constantly felt insecure, Most of them were depressed. One day, they decided to set up their own bike store, but they wanted to run it differently. Instead of having one guy at the top giving orders, they would run it as a democratic co-operative. This meant they would make decisions collectively, they would share out the best and worst jobs and they would all, together, be the boss. It would be like a busy democratic tribe. When I went to their store – Baltimore Bicycle Works – the staff explained how, in this different environment, their persistent depression and anxiety had largely lifted.
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It’s not that their individual tasks had changed much. They fixed bikes before; they fix bikes now. But they had dealt with the unmet psychological needs that were making them feel so bad – by giving themselves autonomy and control over their work. Josh had seen for himself that depressions are very often, as he put it, “rational reactions to the situation, not some kind of biological break”. He told me there is no need to run businesses anywhere in the old humiliating, depressing way – we could move together, as a culture, to workers controlling their own workplaces.
*****
With each of the nine causes of depression and anxiety I learned about, I kept being taught startling facts and arguments like this that forced me to think differently. Professor John Cacioppo of Chicago University taught me that being acutely lonely is as stressful as being punched in the face by a stranger – and massively increases your risk of depression. Dr Vincent Felitti in San Diego showed me that surviving severe childhood trauma makes you 3,100% more likely to attempt suicide as an adult. Professor Michael Chandler in Vancouver explained to me that if a community feels it has no control over the big decisions affecting it, the suicide rate will shoot up.
This new evidence forces us to seek out a very different kind of solution to our despair crisis. One person in particular helped me to unlock how to think about this. In the early days of the 21st century, a South African psychiatrist named Derek Summerfeld went to Cambodia, at a time when antidepressants were first being introduced there. He began to explain the concept to the doctors he met. They listened patiently and then told him they didn’t need these new antidepressants, because they already had anti-depressants that work. He assumed they were talking about some kind of herbal remedy.
He asked them to explain, and they told him about a rice farmer they knew whose left leg was blown off by a landmine. He was fitted with a new limb, but he felt constantly anxious about the future, and was filled with despair. The doctors sat with him, and talked through his troubles. They realised that even with his new artificial limb, his old job—working in the rice paddies—was leaving him constantly stressed and in physical pain, and that was making him want to just stop living. So they had an idea. They believed that if he became a dairy farmer, he could live differently. So they bought him a cow. In the months and years that followed, his life changed. His depression—which had been profound—went away. “You see, doctor,” they told him, the cow was an “antidepressant”.
To them, finding an antidepressant didn’t mean finding a way to change your brain chemistry. It meant finding a way to solve the problem that was causing the depression in the first place. We can do the same. Some of these solutions are things we can do as individuals, in our private lives. Some require bigger social shifts, which we can only achieve together, as citizens. But all of them require us to change our understanding of what depression and anxiety really are.
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This is radical, but it is not, I discovered, a maverick position. In its official statement for World Health Day in 2017, the United Nations reviewed the best evidence and concluded that “the dominant biomedical narrative of depression” is based on “biased and selective use of research outcomes” that “must be abandoned”. We need to move from “focusing on ‘chemical imbalances’”, they said, to focusing more on “power imbalances”.
After I learned all this, and what it means for us all, I started to long for the power to go back in time and speak to my teenage self on the day he was told a story about his depression that was going to send him off in the wrong direction for so many years. I wanted to tell him: “This pain you are feeling is not a pathology. It’s not crazy. It is a signal that your natural psychological needs are not being met. It is a form of grief – for yourself, and for the culture you live in going so wrong. I know how much it hurts. I know how deeply it cuts you. But you need to listen to this signal. We all need to listen to the people around us sending out this signal. It is telling you what is going wrong. It is telling you that you need to be connected in so many deep and stirring ways that you aren’t yet – but you can be, one day.”
If you are depressed and anxious, you are not a machine with malfunctioning parts. You are a human being with unmet needs. The only real way out of our epidemic of despair is for all of us, together, to begin to meet those human needs – for deep connection, to the things that really matter in life.
• This is an edited extract from Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions by Johann Hari, published by Bloomsbury on 11 January (£16.99). To order a copy for £14.44 go to guardianbookshop.com or call 0330 333 6846. Free UK p&p over £10, online orders only. Phone orders min p&p of £1.99. It will be available in audio at audible.co.uk
If you are affected by depression or suicidal thoughts, there are places you can turn to. In the UK, Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Other international suicide helplines can be found at www.befrienders.org.
