As a practicing psychiatrist in the heart of California’s Silicon Valley for more than two decades, I’ve seen growing numbers of patients struggling with depression, anxiety, and chronic pain, despite otherwise good health, loving families, robust social networks, financial privilege, and access to elite education … all the things we’ve come to associate with the ‘good life’.

My clinical experience broadly mirrors what is happening in the rest of the world. Global happiness surveys show that people today are less happy than they were 20 years ago. Rates of anxiety, depression, and chronic pain are increasing all over the planet but especially in rich nations.

How can we make sense of this?

Some argue that our despair is the result of a widening income gap. But the long view tells us that in fact the gap between rich and poor is smaller than it has been in centuries. Even the poorest of the poor living in rich nations today have more leisure time, more disposable income, and more access to luxury goods than at any point in recorded history. Some argue that trauma is the source of our suffering, but what kind of trauma are we talking about, beyond the trauma we create for ourselves? Can we honestly say that life today is more traumatic than it was thirty years ago?

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Twenty years ago the first thing I would have done for a patient presenting with anxiety or depression was prescribe an antidepressant or recommend psychotherapy. Today I’m more likely to suggest a dopamine fast: Abstaining from our drug of choice for four weeks

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I suggest to you that the primary cause of our unhappiness today is The Plenty Paradox. Abundance itself has become the source of our suffering. Wired for scarcity and a world of ever-present danger, the human brain is woefully mismatched for this world of dopamine overload, in which almost every human activity has become druggified in some way – made more reinforcing, more accessible, more potent, more novel, and nearly infinite in quantity. We also have drugs that didn’t exist before. Any child with access to the Internet can consume digital media, which lights up the same parts of our brains as drugs and alcohol. TikTok never runs out.

To understand how too much of a good thing becomes a bad thing, we need to understand how our brains process pleasure and pain. One of the most important discoveries in the field of neuroscience in the past 75 years is that pleasure and pain are co-located. That means the same parts of the brain that process pleasure also process pain, and they work like opposite sides of a balance: When we feel pleasure the balance tips one way; when we feel pain it tips the other.

There are several rules governing this balance, and the first and most important is that the balance wants to stay level, what neuroscientists call homeostasis, and our brains will work very hard to restore a level balance after any deviation from neutrality. I like to imagine that as these little neuroadaptive gremlins hopping on the pain side of the balance to bring it level again. But the gremlins like to stay on the balance, so they don’t hop off once it’s level. They stay on until it has tipped an equal and opposite amount to the side of pain. This is the hangover, the comedown, or in my case, that moment of wanting to eat one more piece of chocolate, read one more romance novel, watch one more episode of American Idol. If you haven’t met your drug of choice yet, it’s coming soon to a website near you.

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That means the same parts of the brain that process pleasure also process pain, and they work like opposite sides of a balance: When we feel pleasure the balance tips one way; when we feel pain it tips the other

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If I wait long enough, the gremlins hop off the balance, neutrality is restored, and craving passes. But what if I don’t wait? What if instead I watch another video, and another, and another, until hours later I’m watching Youtube videos of people watching Youtube videos late into the night. How did I get here?! Now I need to keep watching Youtube videos not to feel pleasure, but just to feel normal, and as soon as I stop watching, I experience the universal symptoms of withdrawal from any addictive substance: anxiety, irritability, insomnia, dysphoria, and mental preoccupation with using, otherwise known as craving. This is the hallmark of the addicted brain. I end up with enough gremlins on the pain side of my balance to fill a whole room. They’re camped out for the long haul, tents and barbecues in tow. I’ve changed my hedonic (joy) set-point. I’m in a dopamine-deficit state.

Despite increased access to all these feel-good drugs … or, as I hypothesize, because of it … we’re more miserable than ever.

According to the World Happiness Report, which ranks 156 countries by how happy their citizens perceive themselves to be, people living in the United States reported being less happy in 2018 than they were in 2008. Other countries with similar measures of wealth, social support, and life expectancy saw similar decreases in self-reported happiness scores, including Belgium, Canada, Denmark, France, Japan, New Zealand, and Italy.

Researchers interviewed nearly 150,000 people in twenty-six countries to determine the prevalence of generalized anxiety disorder, defined as excessive and uncontrollable worry that adversely affected their life. They found that richer countries had higher rates of anxiety than poor ones. The number of new cases of depression worldwide increased 50 percent between 1990 and 2017. The highest increases in new cases were seen in regions with the highest sociodemographic index (income), especially North America.

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Twenty years ago the first thing I would have done for a patient presenting with anxiety or depression was prescribe an antidepressant or recommend psychotherapy. Today I’m more likely to suggest a dopamine fast: Abstaining from our drug of choice for four weeks

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We are literally consuming ourselves to death. Seventy percent of world global deaths are attributable to disease caused by modifiable behavioral risk factors like smoking, physical inactivity, and diet. The leading global risks for mortality are high blood pressure (13 percent), tobacco use (9 percent), high blood sugar (6 percent), physical inactivity (6 percent), and obesity (5 percent). In 2013, an estimated 2.1 billion adults were overweight, compared with 857 million in 1980. There are now more people worldwide who are obese than who are underweight, except in parts of sub-Saharan Africa and Asia.

The poor and undereducated, especially those living in rich nations, are most susceptible to the problem of compulsive overconsumption. They have easy access to high-reward, high-potency, high-novelty drugs at the same time that they lack access to meaningful work, safe housing, quality education, affordable health care, and race and class equity before the law. This creates a dangerous nexus of addiction risk.

Our compulsive overconsumption further threatens our planet. The world’s natural resources are rapidly diminishing. Economists estimate that in 2040 the world’s natural capital (land, forests, fisheries, fuels) will be 21 percent less in high-income countries and 17 percent less in poorer countries than today. Meanwhile, carbon emissions will grow by 7 percent in high-income countries and 44 percent in the rest of the world.

What to do?

Twenty years ago the first thing I would have done for a patient presenting with anxiety or depression was prescribe an antidepressant or recommend psychotherapy. Today I’m more likely to suggest a dopamine fast: Abstaining from our drug of choice for four weeks. Why four weeks? Because that’s the average amount of time it takes for those neuroadaptation gremlins to hop off the pain side of the balance and for homeostasis to be restored. About 80% of my patients feel better with this intervention alone, consistent with the idea that consumption of high reward substances and behaviors feels good in the short term but contributes to depression and anxiety in the long term.

I also recommend that my patients intentionally do things that are hard, because the gremlins are agnostic to the initial stimulus. If we first press on the pleasure side of the balance, they’ll hop on the pain side and stay on until we’re tipped an equal and opposite amount to the side of pleasure. By paying for our dopamine up front, we can reset joy to the side of pleasure. Examples include physically and/or psychologically effortful activity in moderate doses, like exercise, ice cold water plunges, intermittent fasting, meditation, prayer, etc.

How about you? What is your drug of choice, the thing that once you start you have trouble stopping? Or the thing that makes you feel good in the moment but worse afterward. Consider the smartphone itself as a possible culprit. Whatever your drug of choice, I challenge you to give it up for a month, or a week, or even a single day.

When you do, notice how at first your pleasure pain balance tilts to the side of pain and you feel restless, cranky, and most of all preoccupied with using your drug … your brain telling you all the reasons why you should use even though you planned not to. But if you wait long enough, the gremlins hop off, and balance is restored. You’ll find you’re free then. Your mind is less preoccupied with using, you’re more able to be present in the moment, and life’s little, unexpected joys are rewarding again. If and when you decide to go back to using, remember to create literal and metacognitive barriers (self-binding) between yourself and your drug of choice, so you don’t go to war with your gremlins. Get your dopamine indirectly by pressing on the pain side of the balance.

Bottom line: To reset your dopamine brain, first abstain, self-bind to maintain, then seek out pain.

| Anna Lembke is professor of psychiatry at Stanford University School of Medicine and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic.