Psychiatry & Psychotherapy Podcast - Diet to Treat Depression and Anxiety

Episode Date: November 15, 2021

In this episode, we welcome back Dr. Drew Ramsey to discuss his new book, Eat to Beat Depression and Anxiety. Rather than writing a diet book, Dr. Ramsey has made healthy eating accessible for everyone by detailing the needed nutrients and the food items that can easily be added to our diet. We will discuss Dr. Ramsey's journey of finding ways to make healthy eating accessible and his insights into how the food we eat affects our mood and brain function. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com. Sign up, sign in, take the test, and the certification is emailed to you in seconds. All right, welcome back to the psychiatry and psychotherapy podcast. I am joined today with another

of the Dr. Drew Ramsey. He is a leading, I would say the leading nutritionist, nutritional psychiatrist, talking about lifestyle, talking about diet. He wrote a book recently called Eat to Beat Depression and Anxiety. And he is an assistant clinical professor

at Columbia University. And you recently moved to a beautiful part of America. I'm a little bit jealous. I've been living in a lot of beautiful parts of America, David. You've also moved to a beautiful part of America. But it's really nice to be back, David. So I love this podcast because it's just such a nice community in the sense of all of us caring about mental health, caring about psychiatry and psychotherapy. And so it's a treat to be back.

And I don't know, especially now, it means we've survived the pandemic this so far. So it's nice to be chatting with everybody. Yeah. Yeah. I think everyone is so used to Zoom now. We are Zooming. So tell me about your move. Where did you move and why?

I went to a group meeting of like regional local therapists here in Jackson. And they said, we went on the circle like talking about our needs from the group. And I just said, I'm in transition. I really have no idea what my needs are. And it felt like a very honest statement. Yeah. So I'm in a lot of transition. We've been living in really rural Indiana, which has been amazing for the past number of years on our

family farm and for a lot of different reasons, mostly around sort of kids and community and interest in climbing big mountain tops and starting another chapter in our life. We moved out to Jax in Wyoming where we're opening up another branch of the brain food clinic and it's, it's excited. We're just a couple months in, so it's been really exciting. But, you know, like everybody is experiencing all of you who've moved or had transitions or have losses, it's really a challenging time to transition in any way. I mean, you know, it's a different time in the sense than we've ever had before in mental health where, you know,

when you moved in the past, like, you know, you terminated with all your patients. Off you went. I didn't terminate with any patients really based on the move. You know, certainly have had some terminations since the move, but both to Indiana and to Wyoming. So it's been interesting that, you know, now we have a, in some ways, more security in our patients. doctor relationship than ever before. Oh, yeah. That's that's a nice yeah. When I moved here, I kept a lot of my private patients, cash-based patients, and picked up some new ones from the podcast, actually, a lot of people reaching out. So if you are interested in Drew being Dr. Drew being your psychiatrist, you could reach out to him. You have licenses all over, don't you?

I got licensed in, I guess, seven states now. And really over the last year, have tried to expand our clinical services to one just offer a more ranging from free cooking classes to coaching so people can really engage with the information and ideas around nutritional psychiatry and not necessarily have to see me a psychiatrist but but I'm also seeing uh you know I'm I'm mostly a psychotherapist who likes to talk about food occasionally as I probably and a handy handy psychiatrist but uh you know for me the the food kind of integrates in an overall, it's holistic approach,

and it's kind of one of the pieces of the puzzle I try and at least get right. Yeah, so reading your book was a very different experience. I can tell you're a therapist because you're imagining in your mind the hundreds of clients you've had and the conversations, hundreds, thousands of clients you've had and the conversations around food

and their defenses and their anxieties and how food is more than just what you eat, it's culture, it's family, it's comfort. And when I'm reading this book, it doesn't read like the average diet book. The average diet book starts with, you know, you've been thinking about it all wrong,

you've been lied to your whole life, and then progresses into, here's what the data really says. And I think you're accurate in saying a lot of us have diet fatigue almost at this point where we've read, you know, I don't know, like I think at one point I was like, I've read about 12 diet books,

like hardcore, like vegan diet, hardcore ketogenic diet, you know, intermittent fasting. So your book has a very different flavor. It's talking about mental health. It's talking about, you know, how these different things affect our brain categories of food. So I'm excited to kind of get into it today. Well, thank you.

It's nice to hear that feedback. I did to write it from clinical experience. and in my clinical experience, fear sucks and is a really, like, motivating intervention for some people in terms of medicine. And I think in terms of more, I don't know, the traditional fields of medicines, we think about, you know, smoking cessation or think about how we motivate people to change because of heart health, right? You're going to have a heart attack if you don't do this.

There's a lot of, I would say, fear mongering. And that also really happens in the wellness world, you know, but that creates just a lot of, I think, stigma around mental health. but just a lot of fear around something that should mostly be pleasurable. So my feeling is our clinic, and I've really been influenced by Samantha El Creef, who's been really helped develop these ideas, but also I think broaden them to be much more inclusive, but to really add joyfulness. I think the main thing Samantha did is really joyfulness is like the tip of the spear

in the sense that we're here to enjoy our lives. We're here to really enjoy the bounty of delicious food, Mother Nature, has given us. And people have gotten really disconnected from that. Like the biggest finding in the smile study, which was probably the best randomized trial around, not the best, but one of the first, around how food can be used to treat clinical depression. So there's a trial of about 60 people who are in clinical treatment. Most of them, the majority of the sample is in some type of psychotherapy you're taking an SSRI. And they added on a Mediterranean-style diet. You know, seven sessions with the nutritionist, emphasized Mediterranean diet, plus a little extra red meat. There was some data that

this research group had found that meat consumption has a kind of U-shaped curve relationship with depression. And they found that 32.3% of individuals went to full remission. So that's just like a remarkable number in terms of if that were a medication, blockbuster billion dollar drug, right? So taking that and then incorporating that data into clinical practice, it really like captivated us. And it does ask, you know, this chapter, Eat or Heel Myself, where I think part of it is I was, I don't know, I've been doing this for more than 10 years now. My first book, The Happiness Diet came out 2011. And I found myself, obviously, not in a joyful place, right? I'm either arguing the vegans about like whether there's B12 an algae or not or I'm, you know, having to be really like, I don't know, defend or or be scared of ketosis, right?

There's just like, it's really uncomfortable, I found. And it didn't feel true to me as a physician and as a psychiatrist where I really like a stance that your life is yours. My job is really to help you enjoy it and live it to its fullest. And there are a lot of different diets that humans have eaten and currently eat that are successful and feed our brain. And if we focus on the nutrients, focus on your values, focus on joy, I think we do a better job. of helping people. That's good. That's good, yeah.

Just to kind of look at that study, since we do have a kind of a lot of providers who listen to this, what did it do compared to what was the placebo group or what, can you tell me a little bit more? Yep, the placebo group. So this is a randomized double blind trial. Placebo group was a befriending protocol that's been shown to be, you know, gives people time, less people talk, does some crafts,

you know, does some stuff. The other group is, again, getting seven sessions. So you're getting equivalent number of sessions. The intervention, again, focuses on adapting Mediterranean-style diet. So an example, that is olive oil. Are you talking to patients about food? It's like, I never did this. No one taught me this in training.

Like, hey, what kind of oils do you cook with? But, like, that's such a fundamental piece of information as somebody interested in brain health and trying to help people, whether you're psychotherapist, psychiatrist, like you're trying to get the brain to grow and change. And we know that there are certain dietary patterns that make that easier and enhances that. And there are certain dietary patterns that just don't seem to help that and seem to promote depression and anxiety. And so in terms of the study, what was really interesting?

So the finding, what changed? What changed? People ate one fish meal more a week. People ate half a serving of fruit and a serving of vegetables more. I think it was half a serving of nuts and beans. You know, so as moderate changes, people added in a little bit of food. But what people really cut out was a 21 highly processed food meals a week. And that really kind of stands out as that feels like the big change is people really shifting off of this modern, highly processed food diet, which, you know, tends to be quite inflammatory, tends to not make us feel good.

It's not like you eat fast food. And you're like, yeah, I'm taking care of my health. He's like, like, I needed that on this road trip, but like, oh, 12 chicken McNuggets in two and a half minutes. That's just never going to sit well. So it's, you know, in some ways a lot of this feels at times like common sense that's now backed up by good data. But those are some more details of the smile study for clinicians who are interested. Felice Jacka is really the mother of nutritional psychiatry when it comes to research. She and Michael Burke, along with a few other researchers have really.

have been the early champions of this. Al-NU, Almuda Sanchez-Vigas and her group at University of Las Palmas in Spain. We should have some of these people on the podcast together. Oh, you should. Alma is great. I did an interview with her for Medscape years ago at the international. There's an international, I mean, for people who are interested in this stuff. There are a few ways to get into nutritional psychiatry.

I'd mention our course just because our course is the only CME course for Nutrational. nutritional psychiatry is a 10.25 hour course. We recorded it at the Omega Institute. We had about 30 clinicians live there, and we've had hundreds of people go through the training. And then we have a small clinician group, about 30 to 50 clinicians. We get together monthly. But along with that course, there's great information at the Moody Food Center, which is in Australia and Felice Jacka, her group, and wonderful set of resource and just incredible data. All this great data coming out about it. microbiome and inflammation. Yeah, I want to get into it.

Let's get into it. Yeah. Let's get into the nuts and bolts. The nuts and bolts of it? Like, why does nutritional psychiatry work? Oh, so just for, for my sort of curiosity. So you had this control group, you had the actual group, and you're saying that the nutritional group in this smile study was 30%.

Yeah, 32.3% of those patients went into full remission. I don't remember. I want to say it was about 8% went into. emission and the other group. Okay. And then so there's a big, there's a big effect. That's, um, it, and if I'm sorry, so that's one trial that there's sort of the classic five nutritional psychiatry trials, which are randomized trial all of, from your idea, like,

what effect size are we looking at? Like, overall, if we're doing this. I think that's going to depend on the population. And so I think there's, you know, oftentimes we think about these interventions, wellness and lifestyle interventions is like, this is for adjustment. disorder. This is for mild depression. This isn't for anybody who's really got some challenges. And I think there's some data that really suggests that's incorrect. One is just the, I would say, personal data that all of us have been clinicians. I started in community mental health and working

with a great psychiatrist, Christina Mangarian, who's now, I think, vice chairman at UCSF. she got really interested in nutrition for individuals in our day program with severe mental illness, usually schizophrenia, schizoaffective disorder. Because they were in our day program, we were feeding them lunch every day. And Christina really saw this as an opportunity to, in some ways, do some food justice work of really helping this population do a better job. As everybody was getting on at that point years ago, it was like 2004. Everyone's kind of getting transitioned from typical anti-sicic, typical site.

antipsychotics onto atypical antipsychotics, and a lot of folks are gaining a lot of weight. And so we start adding more vegetables. It was really the first food intervention that I've been a part of. We started, I remember we had a patient, we switched to white rice, and he stood up in group meeting, and he was pissed. It was just like, what is this brown rice? He was like, this isn't my food, this isn't my culture. Remember we had this group meeting, and if you've been to community mental health, you know, these are wonderful, wonderful opportunities to really be with patients and hear more of patients' process. And the group kind of decided, you know, we're going to do 50-50 split. We're going to do half brown rice, half white rice. And Max said, okay, all right, that's fine.

And it was just little things like that that taught me these kind of small steps, right? We added in more plants. We people really were eating a lot of candies and sweets. We added in more fresh fruit. And one of those things, people are like, oh, fruit has sugar, who knows? It's like, well, for this population in that setting, getting people from candy to fruit, knitting people from, you know, really sweet fruit to kind of maybe a little bit, I don't know, mellow or fruit. That was something we saw happen in patients. So those are the personal experience, right?

Then in the data and kind of like what happens, there are a number of trials. A healthy med trial was a group intervention. So I was joking my talks, David, I always say, like, this would be great for. my depression. It was a group Mediterranean-style cooking class. I was like, that just makes me feel better thinking about it. Like, oh, what are you doing tonight, Drew? It's like, oh, it's Tuesday night. And I've got my mood is food, Mediterranean-style cooking class. We're sampling olive oils, like, cooking. So that was every two weeks. I'm trying to remember what their control group was. It was like a, it was a group where they, like, you know, got some, like, snacks and they hung out and did crafts and

picture books. So again, you know, an active control group. Yep. Yeah. And what was interesting about this trial, the reason I'm bringing up is 86.3% of the sample was extremely or severely depressed. It was in the sort of top 20% of depression. Yeah. So they're, they're, I can remember. I think this trial was a ham D. I don't think that's right. A ham, but their depression rating scores were quite high. Yeah. And, and what they found is a really significant rapid drop that then was maintained for six months. So they had, I think it was about a 40% drop. People didn't go into full remission, but they exited severe depression. And as you and I know, that, you know, going from really being severely, severely depressed to being mildly depressed,

that's life-saving and a big change. So that was another nutritional trial. And since we're talking trial since you just want to talk science. This was a really quick study. This study takes 21 minutes. And if I asked you, David, in 21 minutes of contact time, if I could reduce college depression in freshmen by 30 percent, would you give me those 21 minutes? Sure. Yeah. Besides that, I also need some boxes filled with olive oil, some nut butter, some nuts, like on. almonds, cashews, and some cinnamon and turmeric. Can you give me that plus 21 minutes? I don't know if we can afford that.

We don't know. Okay. Whoever's listening that could afford that or if you're heard about college depression or if you're on a college campus treating college kids, check out this great study by Heather Francis. It happened in Australia. They looked at, there were individuals in psychology sort of 101, and they had bad eating habits and they had depression.

they showed these kids a 13-minute video, these students. They're basically like, hey, depression and food are related. Actually, I haven't seen the video. So this is the summary in their study. I asked to see the video, and it's proprietary. They wouldn't let me see it yet. But essentially, like, eat more like a Mediterranean-style diet, eat more plants, eat less garbage.

Here's some nuts. Here's a box of olive oil nuts, like roast up veggies and olive oil, eat nuts for snacks, eat more fish. Here's some recipes. like a lot of resources. And then a week after they saw the video, they called them up for five minutes. Like, hey, David, how are you, man? How's the box of food?

What do you cook? Can you have any problems? Well, look, keep eating for your mental health, okay? Good job. And then a week later, they called back five minutes. Hey, David, it's been a couple weeks, right? That's the whole intervention. They drop anxiety, depression, and stress rating scales at three and I think six months by,

it's like more than 30 percent, like statistically significantly. can't drop. It is impressive. It is impressive. It's a small trial, again, dietary encouragement, which I find in younger people, they're much more kind of, I mean, everybody's sort of tuned into this now, but there's more awareness. And so those are some of the clinical trials, I think, that inform why talking about food and clinical practice, it's a good idea. It's a good idea right now. And it's also, I would say, you know, it's something we've been missing.

And it's just something we weren't talked to do. It's kind of obvious, right? Your brain runs on food. it's made of food, it dictates in some ways how much inflammation is in your body and in your brain. Why the hell wouldn't we really be interested in that if we care about brain health? Yeah, no, I think that begs the question. What are the major roadblocks you see for people trying to eat healthier? Well, we just dropped a new resource on our site for brain food on a budget because one that we hear is cost.

And so we kind of want to do the calculation. How much does it cost to eat? brain healthy diet a week. How much does it cost to go out and just stock your kitchen? You know, in the Smiles trial, individuals saved over $100 a month. So over $1,000 a year, almost $1,200 a year they saved by, because, you know, they're eating at home more. You're eating that process food seems cheap.

But over time, it's not very satiating. People buy a lot of it. It leads to eating out, eating a lot more, you know, kind of expensive food. supposed to, you know, simple food, cooking at home most of the time saves you money. So we have that source on our site, brain food on a budget, because we've got all these questions. And so we put on our most value budget-friendly recipes from my books, along with some kind of calculations and information about how to really save money and do brain food well.

So that's one barrier, is accessibility. Another barrier, people say time, and I think this just speaks to the overall mental health problem, that if we're living a lifestyle where we don't have time to take care of ourselves, or we have this fantasy that someone else is going to take really good care of us, right? That thing that you pull out of the, you know, the freezer, like, look, some pre-processed and pre-prepressed food, that's great. I don't, you know, I don't want people to stress out that everything needs to be from scratch.

But it just feeds into an overall lifestyle where we're not active in taking care of our mental health, right? We're too busy to exercise. We're too busy to sleep well. We're too busy to eat well. And I think it's where you, I think you and I often meet people where the, you know, the, you know, big switch that folks make as they take care of their mental health and kind of get on a journey to recovery as they get more active often in those areas. That's good. That's really good. What about you talk about like omega-3s? Well, before we talk omega-3s, can we talk another barrier?

Sorry. Yeah, let's go. Let's go for it. At least something else we tried to do this year. So another barrier we found is people, you know, you don't know how to do this stuff. And I'm a parent, it's kind of scary. You're cooking dinner. You want everybody to eat it. You want it to go down nice and easy. You want to clean up, right? This is, this is probably my main barrier. Yeah, you don't want to like, hey, kids, let's try sardine toast. And they're like, blah. Right. And then you're like, you've got two hungry kids and no backup plan. Right. So that, that, you know, there are lots of challenges. I would say one is around skills and, and knowledge of these foods and the many experience of cooking them together. So we started the

mental fitness kitchen. We have a wonderful new member of our team at the brain food clinic, Emily Burner. She's been in charge of the culinary garden and cooking classes at New York Presbyterian Hospital. And she's brought this wonderful kind of virtual cooking school to our clinic. We've been doing classes every month. And it's a time to, like, I don't know, have you ever used, like, canned salmon, David? Can salmon. Oh, my gosh. No, not often, but I use, it's okay. I do like, we get frozen salmon. Okay.

That's the easiest at this point. That's super easy. I'd not use canned salmon much either, but as we started getting a lot of questions over the years, you know, just about, look, you know, I don't have a fishmonger. I live in a food desert. Like, I'd love to eat wild salmon, but I can't afford it. So canned fish, incredible value. You can get a half a pound of salmon for three bucks. And then what do you do with it, right?

First is you've got to get used to it. You got to open it up and look. It's kind of like opening a jar of a can of cat food the first time. Then you look at it and you're like, is it cooked? You know, so many people have, I wasn't raised with fish. You know, so many people have fears of new foods, understandably. So just getting that experience kind of together in a cooking class, we made wild salmon burgers from the book.

I've got this great recipe for canned wild salmon burgers. Pretty intentionally with the idea of, I mean, I love a burger, good grass food burgers, I think pretty tasty brain food. But of just giving us a little. away, especially during the pandemic, to make sure I had like a good stock of them, I get three fats and seafood. And then my kids liked them. I started making them instead of burgers, little croquettes. And it was like the first time my daughter had asked for a repeat from a recipe book. She was like, Dad, will you make those wild salmon burgers again?

And I just started, I started to cry right on the spot there. I was like, oh, every phone. Every night. I'm going to start crying nothing about it. Oh, man. It just touches your soul, right? The other day, okay, this was that one of those moments for me. I was, we were downtown at the farmer's market.

I just got in some, some microgreens. Microgreens, knowing you, right? Which I'm like, microgreens for me are the new kale. It's like. Well, they are. They're the veal of the kale world. I mean, just so you know, it's like we're babies. Like, are you eating the real veal of the plant world?

Do you eating the sunflower sprouts? I'm eating, like, there were basal microgreens. That's like the whole. I just, I mean, it's fine, but like, that's, that's like pounds of pesto that you're just feasting on, you know? Could be. It's babies, David. Those are baby plants. Oh, my gosh.

Okay, so they grow them to kill them as babies, though. Is that, does that make a better? They do better? I mean, yeah. So I'm sitting there eating this in front of my kids. And my kids had some and then kept eating it. And I was just like, this is, this is beautiful. Because my kids are very picky eaters.

They're like they have the sensory processing issues, probably from two very sensitive parents. You know, my son in particular, pretty, you know, somewhat picky eater. And I think it's one of those, again, kind of challenges as parents. You're asking like the barriers to this. And, you know, especially for folks thinking about family and feeding kids, right, a lot of these foods, like at the top of the antidepressant food scale, right? Things like oysters, things like greens. They're not things that kids naturally eat or often have been introduced to. So, for example, my kids are okay with kale, but they really love kale chips.

And I really love my kale mac and cheese. I don't sneak it in. I just kind of like it's like a green kale mac and cheese. But there's like, I don't know, half a pound of kale in there. Oh, wow. I think there's a lot of pressure on parents. And I think it's also where there's a, you know, our culture has always been in love with the idea that, boy, who knows, maybe they're.

there's some nutrient not getting, you should take a multivitamin. Like, that's nutrition. Oh, yeah, and you're hesitant to, you're a little bit critical of that sort of multivitamin. Yeah, I'm full on critical of the multivitamin. I just think it's a bad public health policy to think that there's insurance, an insurance policy for not eating well. This idea like, oh, it's an insurance policy. It's like an insurance policy for what?

Like, and I appreciate it. Look, there are times we need multivitory. If you're in a situation you can't eat well, you're in a food desert, you're, you know, really struggling and you really have food insecurity. You're in a refugee, like, sure, like multivitamin all the way. You're recovering from addiction. You know, there are a lot of times that supplementation is appropriate. I just find the way that I see it used in my practice is really not intentional.

It's people taking a lot of things out of fear and often really bad recommendations. And very expensive. there's there's some psychiatrists who prescribe them and it's like it's a couple hundred dollars a month yeah i mean you know the oftentimes there's a real significant markup in specialty supplements and i think it's a real concerning part of bias in the industry that people don't talk enough about where you know i have no financial kickback if i give you prozac or zoloft or or or omega-3 fats or whatever right that doesn't change my bottom line as opposed to if i'm selling supplement line or selling that in my office, you know, that becomes for some practices,

25, 30 percent of their revenue. And they're very much marked up. I mean, you should always, if you're getting a specialty supplement, just compare it to Amazon and see what, you know, I've seen vitamin D for like $65 a month, whereas vitamin D, I mean, $65 a month, that gets you more than a year supply. So it is a concerning thing that happens. I also think it's where people go kind of willy-nilly and they treat their body. body like this, I don't know, everything you put in your mouth, your body has to process,

right? It's not like you take all this extra iron, like iron is an oxidant, right? It, it, it, it, it oxidizes things. So you're taking lots and lots and lots and lots of iron. That's one of the reasons high iron intake is linked to colon cancer. It, it's, your body has to do something with it, you know, for any nutrient. And, and I just always like to think about that is really trying to work in harmony with my body, not to overtax it. And yeah, for sure, not to under nourish it and just to be really intentional. Yeah, I think this is a part where I have some respect for you because I think you could make so much money promoting a supplement.

But it doesn't even seem to have my sort of natural barometer is like, okay, that's how that person could make money, but you're not making money that way because you don't believe in it. I appreciate that. Well, you know, who knows what will happen. I haven't done any supplements yet. sometimes I feel like I don't know which ones to recommend to patients and it would be nice to do a really low-cost basic line. But then, you know, then it feels, well, then it feels also like I'm getting a little spoonful of my own medicine, right?

Wouldn't that be the really the ultimate way to like, if you really are going to complain about an industry and how corrupt it is? Like, I don't know. One thought I've had is like, it's kind of the opposite. Like I should join it and do a line of really low-cost, really effective, really clean things to but yeah i haven't gone that path in part because it just feels that it makes you biased and i'm always a little skeptical i mean i just i've always been that way i think part of that is being a psychiatrist i see a lot of things work and i see a lot of things don't work including the things i prescribe and i think it just adds a humility to how i think about these things where you know there's

often a lot of well i i think it's good that you're preaching this and i i wouldn't put it you know i wouldn't think less of you if you created a good line eventually. But the thought that there's some people who will do a lot of questionnaires and maybe even like some very expensive imaging and then they'll say that you need this vitamin. And it's like, I don't think that that is evidence based to recommend vitamins based off of, you know, this kind of stuff. I mean, what we're talking about today is like eating real food. It's like eating real food. By the way, by the way, way, first vitamin, I was surprised. First vitamin discovered in 1912, right? So just a little over a hundred years ago that we actually could say like, oh, wow, this is a vitamin, vitamin B1,

first one. We didn't really know what these things were. We really couldn't isolate them. We never took them. And, you know, we'd take stuff. We'd take like desiccated liver. We'd take, you know, people would eat placenta. I mean, there was a way that we engaged in certain types of, you know, supplementation. But yeah, it's, I had a Korean friend who told me that after childbirth, women were encouraged to eat seaweed soup, which kind of makes sense because the number one cause of mental disability in the planet is low iodine. It's cretanism from low iodine. And so, you know, there are all these ways that humans have gotten proper nourishment, that we've co-evolved with food. And so that's why I tend to look there as the first solution.

Also, I would say the other reason and where I think supplements and kind of medicine is really missed something is now waking up to it is this whole new notion of the microbiome. And so the idea that, you know, I'm just going to drop things down into my colon and, like, not really care how it affects my microbiome, that's totally changed now, where, you know, anytime you're eating more plants, more fermented foods, you're in general. general trending your microbiome, all the bugs that live in our gut, towards a less inflammatory, more diverse profile, which is looking like it's really tied to a lot of quite good health outcomes. Yeah. And you talk about the, what is it, the rat or mouse study where they took all

of the bacteria out of the mouse and they didn't handle stress as well. Yeah. The reason that we think, and this is really evolving, if clinicians are interested in this, um, I've got some information up on my site and a blog about it, but there's this great study by a Washtick and Gardner that came out of Stanford really kind of advanced, like all the omics, the genomics, the protomics, the metabolomics, really advanced study looking at a group, you know, some issue in the sample, the sample was mostly women. I think it was like 83% women, mostly white and mostly affluent. So they're already in some ways kind of a demographic with reasonably healthy eating,

But they did a 17-week protocol of eating more plants. They took people from about 21 grams a day of fiber to about 45 grams a day of fiber versus eating more fermented foods where they took individuals in their intervention group from 0.4 servings of fermented food a day to six servings of fermented perminton per day. It's plus or minus two. So, you know, like four to eight. I've been emulating that recently as I stopped drinking and I'm drinking a ton of kombucha instead. and it's,

what was remarkable about the study, though, besides all the kombucha, was the plant folks, they didn't change their microbiome. Yeah. They didn't change the diversity of the microbiome, and they didn't change their immune status. What they changed is in the microbiome,

the number of enzymes that digest plant walls went up. So eating more plants like meh. Okay. The folks who ate more fermented foods, their immune systems were much, much improved for these researchers' metrics. Their microbiome diversity by all measures of diversity went way up. They had a number of biomarkers that improved. So there was this notion, the more of the first, then how's that working?

Another interesting part of the study is not necessarily working that we eat the good bugs, as I call them and eat to be depression and anxiety, and then they go down there and populate. What's interesting is what changes in diversity, at least in this trial, was all these other bacteria. And so it's almost like the bacteria we eat,

you know, one thought it had almost like from basketball, I was like they kind of like box out some bacteria and allow these other species that are already inside of us grow. It's one of the ways that you can really, I think, get so deep into the science now. And oftentimes it gets reduced to like, like take a probiotic.

And again, when you talk about like waste of money, there are a few besides the soda aisle. I mean, there are few places I would say that more people waste money than the probiotic aisle. It's just really, it's just there's a kind of shotgun approach and there tend to be like a good quality of probiotics. It's 50, 60 bucks for a month.

I mean, it's or more. And so, and especially when you think, you know, at least in our clinic, like what you want to beat all the probiotics on the shelf, like drink kaffir, in the morning.

We make a little kaffir. All of the eat to be depression and anxiety, smoothies have a kaffir base. And if you're non-dairy, you can do a coconut kaffir. Kaffir has more colony-forming units than anything else I've been able to find. And if folks listening know something more, you know,

I'd love to maybe nato, but in terms of stuff that, you know, Americans will eat, Kaffir, it's a liquidy yogurt if you don't know what it is. I would recommend you get plain so you don't get a bunch of sugar. And then where do you get that? Is that how the yogurt? You'll see it.

It's like on a little caraff by the yogurt. Okay. Yeah. If you're on the West Coast. How does it compare to yogurt? Because I usually do yogurt. It's more liquidy and it's a little tart, sure, a little more tart, but not to. I like I like it.

You know, when I put yogurt in my smoothie, I feel like I'm drinking a yogurt smoothie. And I'm like, meh, when I put kaffir in the smoothie, I feel like I'm drinking something special. My favorite spooleys was Koeh. I want you to get some, David, and try it. Okay, okay. You're going to love this. Oh, man. I want you to come, like, be my chef for a week.

How much would that cost? We do my rowing coach for a week? Oh, heck yeah. Come out to Orlando. I'll take you out 100%. I haven't gotten a squat racket. I'm kind of scared to get that belt on. I feel like I'm going to pop something in there.

No, no, no, no. You put the belt rack below the ribs, you know? I just feel it's all going to squirt out somewhere all that way. No, no, you put, it's the vasava, it creates the vasava. And you don't need a squat. You don't need a belt until you. you get above maybe the mid-200s. Okay, that's good.

I probably might not get there at my age. Dude, let's get you squatting, man. Let's go back to your smoothie. So I want to get some kaffir, especially, I think your kids like this. And I get them involved. The other thing I like about smoothies, you get kids involved. I tend to sweeten all my smoothies with, like, bananas. Sometimes people like them smoothie, you can drop some dates in there.

But banana, I find one banana does a great job. And then there's a couple of DVA, there are two that I'm viving with right now. Besides, like, the wild blueberry and whatever else you put in there, my general smoothie rules, is put in some nuts, right? Because you're going to get a fiber, you can get some healthy fats, right? So some almond butter. And then I like going either kind of,

I've got this peanut butter, chocolate peanut butter cup smoothie recipe where it's cacao powder, almond or peanut butter, a banana, some Brazil nuts. You can throw anything in there of pistachios. You even toss your microgreens in there. I don't think it's the best use of your plant feel,

but if you love the microgreens, you can drop them in a nice smoothie. Another one that would be good for the microgreens. I like a kind of banana with a... I just do like a cinnamon, cinnamon, banana, and cashew and then drop your microgreens in there. So the idea is you're getting tons of colony forming units.

You're getting all the fibers they need to grow. And just value-wise, you know, a jug of kaffir is like four bucks. Cheap, okay. It's pretty cheap. And there are a bunch of there's national brand life weight that's great. If you're out on the West Coast, I love these folks, Kiefer Labs, a little small producer. I don't have any affiliation with either. I just, those are the two that I tend to see and like.

Yeah, that's, okay, that's something I can change. That's something I can change. That's good. I like that. Especially if your kids are having some, I feel like the banana cinnamon cashew is real, kind of just really mild and delicious and light. And he's like a high speed bender to like whip it all up real nice. like a Vitamix or something like that?

I imagine some people, psychiatrists are listening to it's thinking, like, probiotics, like really? Like, what's the data on that? I haven't heard about that. Well, you know, I mean, a lot of people haven't heard of the data on that. I think a lot of folks having clinical practice, I think, you know, I think we're always in mental health hesitant about new ideas in a certain way. There's a bias we have because we get good at something.

We help people a certain way. And so it's hard to sort of think that, like, like, and in some ways maybe it's a creep of like people don't think it's within the scope of their practice. But I really think with the current data that's changed. And so the data on the microbiome is really evolving. It's not conclusive in any way. I would say the two, the study that I liked the most about probiotics comes from a study in

bipolar disorder at Johns Hopkins. Really interesting trial to 40 person arms, so 80 people in the trial admitted for acute mania, all treated given treatment is useful, lithium, depicode, or an atypical antipsychotic. Then half the group gets a probiotic. Half the group gets placebo. So over the next, and they do a couple of measurements. One, they measure something. I had not seen this in a mental health trial before, we're going to see more of it.

They measured an inflammatory index. So they looked at a number of kind of antibody levels to some weird viruses that gave them a sense of someone's, you know, a measure of inflammation. Okay. They found the individuals who got the probiotic who had high on the inflammatory index. They over six months had a 90% reduction in their re-hospitalization rate. And when they did get hospitalized, it was for something like two and a half days

versus seven days. So that study just blew my mind in terms of well-controlled. What was the other side of the arm? Like what was the re-hospitalization rate of the other? Half. I don't remember. But it was considerably different? It was much higher.

It was like 60 to 70%. I don't want to get quoted here, but it was much higher. It was significant. The 90% stood out also. It's just like, that's a pretty good number in bipolar disorder for any medicine. Okay. So that's supporting this idea that the microbiome is important for people with a variety of mental health issues. The idea, I think, that's new if people haven't heard about this kind of stuff.

and it sounds like weird juju. The idea that I think resonates is that if we think about inflammation in the immune system, those are really largely regulated by the gut, the majority of your immune systems in your gut. When we think that the type of bacteria in your gut, in part, it's dictated by a lot of things where you breastfed, did you have a vaginal birth, did you have antibiotics? But your microbiome is, in terms of things you do in your life,

really dictated by how many plants you eat, the diversity of plant fibers you eat and the amount of fermented foods that you eat. So microbiome is determined that diet and inflammation and inflammatory status in part is determined by microbiome and diet. So that relates now as we think that, you know, studies are saying up to a third of our patients with depression and anxiety have significant level, you know, elevated levels of inflammation. Really interesting, I think data coming out, looking at the genes that regular

inflammation and how that also relates to our mental health. And then just some big meta-analyses that have come out looking at, if you look at people with depression who get an antidepressant plus any anti-inflammatory. And a lot of medicines like statins, powerful anti-inflammatories. I learned in the study, Providual is an anti-inflammatory. Some of the anti-hypertensives are also anti-inflammatories. Many of the diabetes medications are anti-inflammatories. So SSRI plus any anti-inflammatory. And you have a almost a double of the response rate in these meta-analyses. There are two really large ones.

So that's the kind of data that I think supports this idea. Then we just have the concrete data. So depression is a really nice study looking at how the Mediterranean diet buffers inflammation and depression. And it's maybe one of the ways that it helps. So if you look at, there's a study that looked at the Kianti dataset. And it saw that individuals, anyone who gets depression, your interleukin six levels go up.

It's an interleukin six, just like one of the interleukins, kind of a generic marker. An inflammatory marker, yeah. Yeah, generic marker. So everybody's depression. Part of depression is your markers of inflammation, IL-6, go up. But this study over six years looked at individuals in the Kianti study and looked at their analukin six levels.

And individuals who adhered to the Mediterranean diet, their IL-6 levels didn't go up. They still went up, but they didn't go up as much. You know, it was like 1.5 versus like two and a half. And so one of the ideas is that our lifestyle choices like diet, movement, things we do to kind of reduce inflammation and stress in our life, is one of the ways that these dietary choices help, one, prevent depression, right? And then also when individuals are depressed,

help reduce the impact of the repressive episodes. So. Yeah. Yeah. And I would also add. the omega-3s go on to make anti-inflammatory mediators, like resolving E1, protectin D-1. EPA, and dries all these acosinoids. Right, whereas the omega-6s go on to make like the more like pro-inflammatory mediators.

Yeah, these arachidonic acid pathways. This is actually a really kind of controversial part of the nutrition world. I think it makes sense. Okay, well, what's the, am I right or right? wrong is the controversy shown something else there. General idea is that omega, so omega-3 and omega-6 fats, they're both long chains with poofas, polyunsaturated fatty acids, the longest, some of the longest fats in our body. So, for example, when you, you know, eat a steak, right, and you have saturated fat, those are like 12, 14 carbons long.

These long-chained fats, EPA and DHA are like 22, 24 carbons long. Omega-6 fats are also essential. And I kind of in the, when I talk to people, I can compare them often. Like, it's, you know, the difference between like a SWAT team and like a really good community-oriented police officer. Like, they're both really necessary, right? If someone takes hostages of the bank, you want a great SWAT team. But, you know, you also need folks out there really, you know, keeping peace in the community.

And so I think about the community-oriented police officer. is really the omega-3 fats and the SWAT team like the omega-6 fats. And so you wouldn't want too much SWAT team in your body, right? It's just going to like, you don't want the SWAT team to respond to like when there's a traffic accident, right? It's going to be too much inflammation. It's sort of the analogy we're making. And so there's some controversy in this data. The cardiologists, you know, they're big on omega-6 fats in the sense that they think

polyunsaturated fat acids in their data or their data suggests are just better than saturated fat. So you replace butter with corn oil and soybean oil that's, you know, that's decreasing heart disease risk. There's not a lot of data about this in mental health. There's one study showing a real strong correlation between omega-6 and omega-3 fat ratio and the risk of depression and anxiety as a teen. So if you're 12 or 13 and you've got more omega-6 fats coming on board than omega-3s, the ratio, by the way, is about 10 to 1 and paleolithic diet. and in our modern American diet, we've kind of doubled that. So what does this all mean?

It just means if you're eating a lot of fried food, a lot of soybean oil, a lot of corn oil, if you use vegetable oil in your house, one simple thing to do is to kind of eliminate fried foods or use things that are more, I would say, like pan-fried in something like an avocado oil. But to switch over to olive oil, right? Instead of fried foods, start, you know, we have a lot of French fries in our house. but they're olive oil oven-roasted potatoes that are delicious, full of iodine and vitamin C and kids gobbled them up.

A good example of that's a really different beast than a French fry. It just, you know, so, yeah, the omega-6, omega-3 idea also is what kind of supports where we come on seafood, which is just there's a lot of data about fish oil in our field and mental health, but not a ton of data about fish, some. And the date about fish is pretty positive. So if you look at things like you want to prevent peripartime depression, six months prior to pregnancy, a really great idea is to get women to eat more seafood, more sardines, more anchovies, more small fish, more wild salmon, and avoid fish with a lot of mercury that are avoiding swordfish, old tuna, mackerel, and tilefish of the worst.

But it's just a good example. That's a way we're going to build omega-3 stores, which that's what we're going to build. what baby's brain is made of. So it's generally a good idea. And then there's a real, really kind of strong protective effect in the data, like a significant reduction, I think six times reduced risk or something like this, of high omega-3 fat intake in terms of preventing postpartum depression. So, you know, there's a lot of, yeah, there's a lot of controversy, but I think the bottom

line where I come down is omega-3 fats seem to be quite helpful in some data. the meta-analysis of omega-3 fats and depression basically show clinical insignificance, but statistical significance. So you get about a one-point reduction on the Hamilton-D scale, at least in the most recent meta-analysis I've seen. And so, you know, the challenge with that is like, well, if you're battling depression, like anything that drops Ham D, I'm down with. If you look at the studies, there are like one to two grams of fish oil. And that's where, you know, eating a nice piece of wild salmon has, like, like,

3,000 to 4,000 milligrams of launching omega-3 fats. So you end up with a lot more omega-3 fats often out of seafood than you will out of fish oil pills. Right. So I want to show you this. I've been working on this question of EPA versus DHA, you know, how much?

There's just one study that looked at a really nice plot here that showed if the EPA was greater than 60% of the fish oil Sublet study? Elizabeth Sublet? This is Sublet, yeah. Yeah, this is Elizabeth Sublet is at Columbia. She's a great researcher. She and Jeff Miller are doing some really exciting work.

If you're interested in research and mental health, Jeff and Elizabeth are awesome. They're doing cool imaging, inflammation. They've got some studies that are going to... I got a little preview, and I can't say, but it's going to... I can't wait to talk about it with you next time. just super cool microbiome research.

But yeah, the critique of the study, I think, is these are all of the positive trials. Oh, really? That, if I remember, that was the rumor that I really like this trial. This is the trial that kind of had a shift to emphasizing more EPA, more than 60% EPA in your fish oil pill. It complicates things for vegans because it's hard to find vegan EPA. and vegan DHA is an algal DHA because the fishies, they concentrate the algae for us, these fats and algae. And even those, those have like 100, 200, 300 milligrams of DHA, like minuscule amounts.

It's like when they put it in milk, it's like, you know, it's like 17 milligrams of DHA and your kid's milk. And I think, yeah, anyway, I guess the sum's better than none. But David, you brought this up. Tell me your thoughts on those. So basically it showed that. a high EPA fish oil was probably better than the DHA. Anyways, that's how fish is, by the way. What do you mean how fish is?

Fish generally has more EPA than DHA. It's like when you eat a piece of salmon, it's more EPA than DHA, if I recall correctly. Well, I think part of the problem that I've seen in a lot of these studies that I look at is it's not really shifting the diet very much. So for a while, what I did was I made an Excel sheet with all the food, that I was eating and the amount of omega-3s and omega-6s in each of the foods, like I went through and found that, created an Excel sheet, and I was measuring how much my ratio was of omega-3 to

omega-6. How do you do? You want to see the data? I'll pull it up here. I would. You're such a good patient. It's like, no. Even I don't know. I just try and eat wild salmon, anchovy, sardines, and muscles. Those are just so everybody knows my, but. Well, I was, I was fascinated by this idea of the ratio. Yeah. And so what I did was I was looking at like the omega-3 to omega-6 ratio. And per day, I would write down like what I was actually doing.

So you could see some days my omega-6 to omega-3 ratio was like a seven. But some days I was able to get the three down to like a 0.38. So a lot more omega-3s to omega-6s. So I was trying to hit certain points of the ratio and move the ratio down. And just trying to see, like, how hard was this? Like, because there was this idea. What did you find helps you do that?

I mean, was it hard to do? I think if you eat flaxseed, chia seed, and fish, salmon, salmon specifically. It was pretty easy to move it down. You were counting A-L-A? that's yeah that's true that that counts that counts i just hadn't really thought about that a a la what do you mean a la a la a so the chi and the flax is a la it's it's an 18 carbon um omega three fat yeah yeah i was counting that which it's i mean it's an omega three fat it's not you know in the book in a nutritional

psychiatry i tend to emphasize just the lawn chains there's good data that shorter chains help you know we certainly convert them to EPA and dHA uh i think some of the nutrition Sometimes people kind of confuse or, you know, they're really excited about their flaxseed oil and TSEs and those things. And there really is no data that those help with mental health. Okay. That's helpful to know. They help with the ratio. And in terms of actually depression risk, there is a study of olive oil of mono unsaturated fat intake, decreasing depression risk over 10 years.

So that's super cool. Mono unsaturated fat is higher in nuts, higher in olive oil, right? That's what makes lard is 50% monocetriated fat, but people don't recommend that anymore. But olive oil and nuts, you know, I think about like nuts, because nuts also have omega-6 fats. You know, the thing about nuts is just really trying to, you know, the omega, I'm sorry, the monocetorated fats. And some of the like almonds are just one of the best sources of vitamin E. Vitamin E is really highly correlated. Low vitamin E is highly correlated with depression.

It kind of makes sense because vitamin E is a fat-soluble antioxidant. So it kind of wedges in our neuron membranes and is, you know, kind of in some ways make intuitive sense like, all right, more of that firefighter up in my brain is probably good for my mental health. So the high mufus, that's what you really want, right? Yeah, if I were going to think about the fatty acid intake that's sort of ideal according to the data, like what is the Mediterranean? You know, you're going to mostly be eating mono-uncaturated fatty acids, probably from, you know,

your plants, your nuts, and your... Okay, I'm getting confused. Were we just talking about poofas or muffas just a minute ago? Mufus. I thought you said Mufus. I thought you said the Mediterranean job would be Mufus. But the Mediterranean diet is the mono-insaturated, right? Yeah, well, Mediterranean...

Nuts are mono-unsaturated. They're going to have more... You know, the olive oil is mono-unsaturated fats. Right. The nuts are mostly monot saturated fats. Yep. And then you're going to add in your omega-3s with the seafoods. And where I kind of think people should focus, where I tend to focus,

is really just trying to increase the intake of mind. mono-un saturated fats, increase the intake of long-chained omega-3 fats. Because the omega-6 is going to take care of themselves. They're in a lot of different things. And so I appreciate that. So you really focus in on getting the long chain omega-3s. That's what you're really pushing. And then you're focusing on nuts and olive oil to get those high mufa.

Yeah. And the nuts and the others, you know, I throw those, the chia, the flexi, those things. I'm thinking about those mostly for their fiber, you know, where I'm throwing in, you know, I'll throw in flex meal into my oatmeal, you know, just to really bump up the fiber. Or I'll throw some cheeseies into a smoothie again, just to be bumping up some nutrients and fats and fiber. Yeah. What I think about fiber, greens, salads, oatmeal has some good fiber, right?

Oatmeal's, yeah, one of the best breakfast, great source of fiber. fiber, lots of really interesting data that oatmeal actually kind of decreases inflammation and really, really good for the gut, really good prebiotic fiber. You know, one of the swaps, I see people eating breakfast cereal or sweeten breakfast cereal, swap them over to oatmeal, where, you know, if you want it sweet, sure, but you control the sweetness, drop in some honey, drop in some maple syrup, drop in some brown sugar if you want, right? But also maybe drop in some fruits, some berries, some nuts. So again, you're getting a lot of fiber, but not just, you know, getting usually just big blast of sugar that is most processed cereal.

Really, really cool, yeah. And some of you may ask, like, what was my finding from my personal study of doing this? What was your finding for me? You ate a paleolithic ratio of omega-3 to omega-6 fads. Let me show you my data, my hard data right here. My resting heart rate was one of the things I was looking at. And you can see there's a lot of resting heart rates that I was wearing, like, a Fitbit. it was around 70, 60, 67, and by the end of it, and I was exercising and stuff as well, I was in the 50s.

Wow. Isn't that cool? How did you measure V-O-2 max? This was a formula that I found online where you could look at resting heart rate, maximum heart rate. So I created the equation in my Excel sheet. I'm kind of a nerd like that. So I was trying to look at age and the different variables. I love your Excel spreadsheet here.

Oh, you should see my budget one. It's like next level. In my coaching with physicians, I'll sometimes pull out like my budget exposure. Because people have a lot of anxiety, like, leaving, you know, whatever practice they're in to go to, like, private practice. And I'll pull out my spreadsheet and just show them some numbers, you know, of like what. Is it scared them more that you have such an organization? a spreadsheet or does it reassure them? It takes away anxiety immediately.

And it gives them courage to spread their wings a little bit, realizing what their value is on the free market, and how often, you know, if you're working for a big employer, they take 70% of what you're billing. I didn't know those numbers. That's definitely much higher than the share we give our clinicians in our clinic. So, yeah, I do think most, I think it's hard to step out. I mean, I've been in private practice, I guess this is my 17th year.

And so it's really struck me how, I don't know, I think our field is really changing and probably revolutionizing and how we think about the structure and kind of communities that support us in mental health. I think there have been just, you know, oftentimes really kind of pretty traditional path. And I think that's shifting so much with it's really exciting time. to be in mental health. Okay, so anyways, from my working out, from all the stuff I was doing, my heart weight went down about 10 beats per minute. Do you think that was some of the fat ratio? Do you think that was like healthier diet that like going after that fat ratio, fatty acid

ratio kind of helped clean up the diet? I was losing some weight during it as well. Is that also when you moved and you were like rowing like a? No, this was this was actually a study I did on myself back in 2017. Gotcha. So let's see, but my weight had decreased roughly 15 pounds over that period. So I do this with some people when we want to look at measurables. You know, you have a person who's like burned out, stressed out.

It's like what measurables can you look at for how your body is handling chronic stress, right? Because I think what happens is a lot of physicians when they start, when they start out in residency are actually a ton more resilient than the general population. The suicide rate is about four per 100,000, whereas the general population is about 12, 13. So residents are a whole lot less likely to kill themselves than the general population. So we start out very resilient, and then something happens in our 50s and 60s where... I think it happens in residences, don't you? You just get like squashed. You may feel burned out, and you will score higher on the burnout scale because you're more

tired. But overall, compared to the general population, suicide rate is lower. We're much more, we're, you know, we're, I mean, you're talking about like the Navy SEALs of intellectual elites, you know, who get into medicine, who are, are fighting this battle, right? But my argument is, what I've seen is that suicide rates go up in the older population of physicians in the 50s, 60s, and it's, so what it is, is the 20 years of that chronic stress, which leads to, people being unhappy, people being exhausted. And so what I've seen in the clients that I've treated is like looking at things like diet,

looking at things like exercise, you know, there's so much room to vary there that people haven't exploited, right? I think particularly for positions. You know, we have a culture that really, you know, hospitals don't serve healthy food, right? That's where we train. I think that's when I say, you know,

I think we set it up in residency that I think, you know, we do start resilient, like you say. I didn't know that the suicide rate was lower, I think, with a number of the resident physician and resident psychiatrist physician suicides. It's good to hear that number and reassuring. The burnout rate is higher among physicians, but you have to understand how they measure burnout. They split the mass law burnout inventory, which is used, is measured in the general population, and they create a bell curve.

And then they say the top third people who are scoring, the highest in burnout. We create a line straight down there. And for now on, anyone who scores above that score is burned out. It sounds like it's like three, right? Two-thirds, one-third. Well, I would say it's actually not like how we look at depression. Because what they're doing is there's no reason why they put one-third is burned out, that bottom one-third or the top one-third scores, right, in the burnout inventory. And so you put someone a little bit sleep-deprived in that scale and you're going to score around 50% of the population is burned out. Now, is that clinically relevant?

No, it's the people who are who you look at their scores and you're like, okay, they're every day showing up to work emotionally exhausted. You know, those are the people are two to three times a week, right? Those are the people you're very concerned about. They're probably depressed. They say they're burned out because it's like a socially condonable word. Anyways, my point in all this is having looked at medical education, research and having thought about this, it's like what variables can we actually change in

physicians who are stressed out, who feel burned out, who feel depressed, especially in their 30s and 40s and 50s. And diet is one of those things. I think that is one. I think the piece that's missing for many people is community. I think especially as you go into private practice. Absolutely. I think is a colleague told me recently this, you know, a great quote by someone. some chairman somewhere has said, just remember the university doesn't love you back. Okay. Let me state this for the, for completeness here.

Diet is not the first thing I think about. I think about busyness and I think about the environment. In burnout studies, they found that 80% of the reason why physicians are burned out is the environment. And so the studies where they actually try to change the environment, not the physician, have the best, effect size. But nevertheless, when you have a client come into your room, they're stuck in an

environment. So it's like, okay, how much can you manipulate your environment? Like, yeah, no, I felt that especially now for those of us in mental health, I'm sure a lot of people, health, a lot of people felt that have just like, as I've struggled with my mood during the pandemic, like, my Zoom cage is not changing. My patient population, my client need is not changing. And actually, if I don't step up to my job, no matter how I'm feeling, I'm going to feel worse. And so I think it's a real conundrum that physicians end up in, besides, you know, along with poor diet, we don't live in a field or work in a field that has valued,

um, the modern value of health, i.e. it's not healthy to work yourself to death. It's not healthy to be aggressive. It's not healthy to be condescending and, and arrogant, you know, it's, it's not healthy to not eat well. It, uh,

like, those are, or it's, it's not healthy to be chronically busy noise in our head at all times, often negative noise. And then, Yeah, and I think what physicians are up against, I mean, I'm quite insulated from this. So I speak from a position of, you know, a type of physicianally privilege that I,

but, you know, the, I think very toxic environment of reimbursement and documentation where physicians are spending a couple of hours a day documenting, it's a way that their work is, you know, critiqued off and along a set of guidelines that aren't applicable to the current clinical situation and they kind of undermine physician self-esteem. And on top of that, it just, you know, it gets, there's just a lot of, I would say, unfulfillment, especially right now with COVID, you know, the number of physicians and nurses and healthcare professionals who are taking a second look at the field, those have been on the front lines, you know, the numbers are quite high and also gets a lot of sense, right?

There's been a shift, the number of stories I hear about healthcare professionals being kind of accosted. It's just really, you know, the kind of things that makes people leave the field. Yep. Yeah, I was looking at a study on like the mental health influence of COVID. Depression scores up maybe three times since it started. And then subsequently they looked at in this one new study that's coming out, Lancet, from like about a month after COVID started to a year after COVID. And people who had kind of ongoing stresses, whether it be financial stresses or, you know, all these kind of unique stresses that. that we have, the people with the most stresses, their depression rates just went way up. So it's like sometimes it's the, that chronicity of the stress that's hitting people. Yeah, I felt that. I'm sure everyone listening has felt a piece of that where, you know, like, I don't know, there was a part going into it. I think anybody who's in healthcare and the helping

professions, right, kind of like, I don't know, you kind of steal yourself that you're going to help people get through this. And, you know, I think that got us all through six months, eight months, then I think as people begin to feel in their own personal lives, more of the cost of things, you know, the cost and the challenge of everybody, I was a homeschooler before that, but, you know, everybody suddenly being a homeschooler of not socializing, of not exercising, right? I think that our ability, everyone's ability to kind of tolerate grief, stress, pressure, it just, you know, where you can handle three or four or five stressors, suddenly you could handle three. And they had a bigger impact of just, and I think that's still ongoing. I saw that

statistic come out in the New York Times that 120,000 kids have lost a primary caregiver, a parent or primary caregiver in America. I mean, it's just, you know, that when you think about the effect, the mental health trajectory effect on that, it's just incredibly sad. Yeah. So it's been, it's been a tough time. It's good to talk with you. It's good for a face-to-face with a friend. here. It's nice to see you, David. It's nice to talk a little about nutrition. I appreciate you highlighting my my most recent book and our e-course for clinicians and just your interest in nutritional psychiatry. I mean, you yourself are a nutritional psychiatrist in your own way. Just, you know, your interest in tracking your diet and diets effect on mental health. So I really like

thinking of you as a colleague out here trying to spread the good word about, well, about all the cool stuff that you're doing in modeling. And I would even say the healthy stuff on social, you know, I love seeing you drawing and rowing and growing microgreens will be your next. You'll be slaughtering your own baby plants at home. Man, I can't wait. That's going to be great. Yeah, I mean, just a note on my social media, like, if you go visit my Instagram, you can see a, you can see a lot of energy I used to put into it. I think during COVID, I just lost any, like, motivation for social media. I do my own social media. And so I just post like pictures of me rowing or just enjoying life. I mean, Instagram has kind of become the main platform I operate in both at a

sort of interest and curiosity and just, I don't know, it's the, it's the color palette that fits me. But, you know, I think it's best Instagram is just that, David. I think it's people posting pictures from their life, things that interest them. That's really that's still where I hope I don't know, my content goes in terms of, you know, really trying to share something. And, you know, while it's a curated platform, that's reasonably authentic. But, yeah, also, you have the podcast, which, you know, is just this podcast is so cool. You're like, a hundred and, what, 27 episodes in. You talk about all aspects of mental health.

What if you do, I have to buy a coffee mug, right? I don't have the coffee mug. That's what I want. I can't send you one of those. I can't buy it on your website. If you become a Patreon supporter, you can get shipped one. It's like $5 a month, I think. We'll ship one out.

I think, I mean, if anybody listening, he isn't a Patreon supporter, I think you should certainly sign up and support David for just the simple reason. It's a lot of time and energy that he could be seeing patients or doing other things that he dedicates to educating all of us. Thanks to that plug, man. I appreciate that. Well, it's a true point. This stuff takes a lot of time.

Oh, you know. You know it does. Tell me, I want to hear next. Diet steps for you and next clinical practice steps for you as we conclude our podcast episode. You know, I'm doing everything by Zoom right now. And I do, I started a nonprofit to do coaching. So it's like a separate, it's a separate business. And the practice, I'm thinking about getting a local place just so I can see people in person.

I'm looking forward to that again. I've licensed in Florida, Texas, California. to see patients. So I continue to have people who reach out who like are listeners of the podcast, which are truly the best patients because they know how I think. They know what to expect kind of.

They're the best patients. It's a way of almost like people by the time they get to you via the podcast, they have a sense of you and kind of how you maybe fit into their health care and mental health journey. That's really it's fun because often they like, they're suffering in some way. Like I had one patient reach out like

TBI and like on all the wrong meds that affects sensorium they listened to my sensorium episode and they were like oh wow there are actually tons of things that we can do to optimize our total brain function and so they reached out and we're doing that and it's it's good so i don't know practice wise i think just continuing to do a lot of what i'm doing sounds like returned to in person which i think a lot of us are um some in person i'll always do video now i just will yeah i was about a third video and then our clinic you know our group of clinicians is now really all over the country. We're serving about, I think, our clinicians are licensed in about 12 states. And if anybody's listening is looking for a clinical community

to join, we're definitely expanding. But we decided at least for right now to go all digital, in part, my practice had been two days a week in person in New York and one day, one and a half days, maybe two days a week, video. And, you know, the pan, so I felt prepared for the pandemic, but I keep trying to go back to New York once a month, and it's just not, but the, it just hasn't been feasible. And at some point, I also, as I think about it, we've been forced into this model that for years, we thought it was kind of like, you know, the bastard stepchild of real mental health, right? That insurance pays less for telepsychiatry, that, you know, it must, must be less potent. And I have this experience, both with my, with my patients and in your tonic clinicians, that it's been like a master class that we've all had to get really good at it. And there's some stuff that really wasn't obvious to me.

How do you run a good dynamic treatment? And, you know, somewhat obvious. Like, I've been working on it for a while, but now just really having to meditate on the meaning of telepsychiatry, what is the power of it? What are the challenges in it? You know, I feel better at it than I've ever been. And we're planning to stay 100% digital for right now. And then wondering, is there going to be a new model that evolves?

Like, that's what I'm kind of, is it a model where, like, we're digital. But like, I don't know, once a year, we get to see each other, check in, have a kind of annual, like, you know, just to remind, remember that we're 3D, or is that not necessary? I've had this experience, too, where I've had a good groove going in video and then I've seen people in person. So, do you want to hear something? And it kind of disrupts a frame. So we measure the effect size in this IOP that I've been running in California.

And we went all digital. So we watched, like, the effect size change. And we actually had a slightly increased effect size after going all digital. And it kind of blew my mind. I always thought, you know, telepsychiatry, like not in person would not be as valuable. But our effect size actually went from like 2.5 to 3. That was surprising. The second thing I would add is I think the microexpression training that I offer is really, really effective at helping people do telepsychiatry better.

Because sometimes in telepsychiatry, you don't feel the emotions to the same intensity you might if you're in person. But with reading the small moments of emotion, it does really help. I kind of bridge that. It's such a, I think, really cool idea for exploration, which is, how do you assess and value transference for feelings

in a digital space? This happened to me a number of times where like, I'll almost feel like, I'm like super, like, I'm feeling really, you know, kind of, like, there must be something going on with me because I'm feeling so, like, discombobulated or upset or like,

God, this page's really angry or whatever, right? like a powerful transferential feeling, but because I'm sitting here in my room, it takes a minute to like recognize it as that, as opposed to when I'm in the office, it's like, well, for sure there's transference, you know, it's like, does you and me in this room?

And so I have found that, and I do think the micro expression, one is a great way to think about that because in some ways that's what we have. And I would also say, that's what I like about Zoom, right? Because I'll be out here sometimes hanging out, and I'll come move in a little bit.

And then if I have like a good interpretation or something, or you're really struggling. I noticed, like, I'll end up. And I find patients to that, too. Or one of the things I noticed is that I'm closer to my patient's faces than they ever would be in person. Oh, that's interesting. Yeah. Yeah, I see that.

When your face is big on the screen, it's like, we are like, it would be like our noses are almost touching. And so it's super intimate in a certain way that has really, I don't know, it's just been. Wow. I like that. struck me over the last, I don't know, six months or so. Well, I'm going to wrap it up here. We're going to wrap it up. We're going to wrap it up.

You're going to eat your own microgreens. That's your goal? That's your treatment goal until our next episode. Oh, for the diet stuff? Oh, you know, gosh, I still need, I still need to lose about 20 pounds probably. So that's- I lost. I hit my maximum ever weight of December last year, the middle of the pandemic.

I never I never weighed this much. Yeah. Okay. That makes you feel better. Yeah, just so you know. Yeah. I, and I'm not sure what happened, but then I can say I'm sure what happened. Things sort of shifted for me in a variety of ways.

And I got into a healthier groove. Okay, so I'm going to get some of that yogurt drink. K-K-F-I-R. K-F-R. K-F-R. K-F-R. I'm going to get some of that. K-F-E-F-R.

Make some smoothies. for you and your kids. You're going to do a little smoothie lab. You're going to try some canned salmon burgers maybe. And you're going to keep making great podcasts for us in rowing. So I look for it. I am going to be near you at some point. I think I'm going to come compete on my horse in Okala in February.

And I think it was last time we didn't connect. But this time, I mean, I think I'll be there for a few weeks. So you can meet Cinco. We didn't talk equine therapy, but that's going to know what I'm going to my mind. horse so just made me cry. David, thank you for a great conversation. Everybody has been listening and thank you so much. I look forward to seeing you sometime in the future. Yeah, I look forward to seeing you. And we should, I would really appreciate thinking out who are the three top researchers in this field and then let's interview them together and talk about their studies. That would be a lot

of fun for me. Oh, that would be awesome. I'd love to do that. We'd do, I'd love to do that. We could do, I mean, for sure, we'd interview Felice and ideally Felice and Michael. Yep. I think it would be really cool to interview Elizabeth Sublette and Jeff Miller at Columbia. Yep, okay. Because they're like, you know, they're sticklers for the data and they create some of the data. And I think it would be, yeah, you didn't ask for the list now. Let's do that because I feel like no one is coming to people's office with, you know, eat more healthy food.

you know and so there's this natural pressure of psychiatrists to sort of uh you know prescribe medications because there's just a lot of money and energy behind that so let's be that for um it's exciting when you get it right it's like wow like it's just going on right up there because of that medicine like i mean it's just it's great i i know that some very thought out interpretations they resonate but you know when you get a good meta effect and it works like one of the reasons we like it is it feels very powerful to us it's very relying on us and and and at times, often, you know, it's super life-changing for patients. So more healthy food.

I look forward to spreading the word with you on that, my friend. We'll talk more soon. We'll talk soon. Okay. All right. We'll leave it there.