Exercise as a Prescription for Depression with Dr. Nicholas Fabiano

Nick: 
You can’t just tell a patient, take this medication and expect them to know the dose, the route, the frequency and stuff like that. It would be crazy if we were physicians and said, take this. And they’re like, oh, like what do I do? But we do that with exercise so much. We say, you’re overweight, you should run. But then you just feel like, is that appropriate that they made that comment to me, like can I even do that sort of thing?

Like how do I go about that?

Bret: 
Welcome to the Metabolic Mind Podcast. I’m your host, Dr. Bret Scher. Metabolic Mind is a nonprofit initiative of Baszucki Group where we’re providing information about the intersection of metabolic health and mental health and metabolic therapies, such as new traditional ketosis as therapies for mental illness.

Thank you for joining us. Although our podcast is for informational purposes only and we aren’t giving medical advice, we hope you will learn from our content and it will help facilitate discussions with your healthcare providers to see if you could benefit from exploring the connection between metabolic and mental health.

Let’s face it, exercise is good for the brain, right? It can help you think better and think more clearly. It can help with dementia, and it can be a treatment for depression, but how do we go about exercise in a way that’s going to make it an effective treatment? How do we communicate that rather than just exercise more and being frustrated when it doesn’t work?

Dr. Nick Fabiano is here to discuss that and talk about his new paper about how to prescribe exercise for depression. Now, first a little warning though, is that we do have some discussions about suicidal thoughts and self-harm. So, if you are triggered by that, just be aware. All right, so let’s get on with this interview.

All right, Dr. Nick Fabiano, thank you so much for joining me today at the Metabolic Mind. 

Nick: 
Thank you for having me. 

Bret: 
Yeah, it’s a pleasure. So we connected over Twitter, over X where so many people seem to be connecting, I guess you could say. But I saw you post about a paper that you co-authored about how to prescribe exercise for the treatment of depression.

I thought it was really interesting take about the how to, but so I want to get into that, about the why to prescribe exercise, how to prescribe exercise, talk all about it. But first, before we dive in, tell us about you. Tell us about your background. 

Nick: 
Yeah, just a little bit about myself. So, currently, right now I’m based in Ottawa, which is in Canada, and I’m a third year psychiatry resident here at the Department of Psychiatry.

And I have a particular interest in looking at, my overarching theme is, the overlap between physical and mental health. But when you look a little bit more into it, I’m really interested in the lifestyle interventions and when, by that things like exercise, diet, sleep for mental disorders.

This paper’s about depression and a large amount of my research is more focused on that because it’s something that impacts a lot of people, but there are benefits across disorders. So that’s my main interest. So, yeah. 

Bret: 
Yeah, very good. I love that you’re talking about lifestyle to treat mental disorders because I think it’s something that is easy to overlook, but yet has so many potential benefits.

Your paper that caught my attention was the how to prescribe exercise for depression. But let’s take a step back and say, why are we prescribing exercise for depression? So, I think people intuitively get exercise usually makes you feel good. Maybe you’re outside breathing fresh air, you’re moving your body, you’re blood pumping, you can get endorphins. And there seems to be a body of literature that exercise is just good for the brain, whether it’s for cognitive function, depression, brain fog and others, and even dementia. So what do you see though as the strength of the evidence? And give us a little bit of the background evidence suggesting why exercise is good for depression. 

Nick: 
Yeah, so that’s a great question. So, in psychiatry, when we’re looking at tackling something like depression, most of the time the two conventional pathways that you can take are things like an antidepressant medication or therapy, and they’re not mutually exclusive.

But as it’s taught throughout medical school and even in residency, oftentimes those are really the only resources that are the first line sort of things. And oftentimes, we don’t look at lifestyle stuff, and lifestyle again, mentioning things like exercise. So, I became very interested in looking at kind of the exercise thing because it’s very unique where exercise can treat both the mental and physical side of things.

We know that people with depression, there’s a bidirectional association with physical ailments. For instance, someone that has depression has a higher chance of having something like a heart attack. And the same thing as someone that has a heart attack may have a higher chance of developing depression.

So from that basis alone, it really sparked that interest of, could we use exercise as a method to treat the depression but not from the same lens as we traditionally do in psychiatry? When we look at things like treating with the medication and assessing the outcome, and then same thing with therapy, but instead to do both at the same time.

The other thing with, that as well too, is with a lot of our treatments, so antidepressants and stuff, a lot of them have some metabolic burden to them as well, too. And by that, things like weight gain and glycemic control issues. And oftentimes, when we’re treating patients and we’re just seeing them in one instance, we don’t really address that with them.

Maybe we speak to them about it very briefly. But I think it’s important to incorporate something else, again, as I mentioned, that can help deal with maybe some of these side effects. So that’s where some of that evidence is. And to get more into where is the evidence right now for treating depression?

How does it compare, as another question that often people ask, to antidepressants or therapy, which again, as I mentioned, are the first line. If we rewind years and years ago, people would be like, you’re crazy to try to treat depression with exercise. In the recent years, there’s been more and more studies looking at movement essentially as medicine for mental health.

And there’s been a lot of different meta-analyses, different umbrella reviews, which are essentially things that group studies together that show that exercise is actually very comparable to things like antidepressants and therapy. And when I say comparable, I mean from an effect on the depression. So, in these studies, they look at before and after treatment to see how these depression scores have decreased or if these patients have one into remission.

And when we take all these studies and put them together, we actually see that they’re quite similar so across the board. And the other thing to say is that doesn’t mean that these treatments are necessarily the same. Because as I mentioned before, a lot of the side effects that something like antidepressants might cause, can be treated with exercise.

And then the other important point to address, too, is that these treatments don’t have to be used in isolation. So, oftentimes, when people feel that you are in the exercise camp of stuff, sometimes they assume that means that now I can’t use medications or I can’t use therapy, but there’s evidence to show that there’s a synergistic effect.

So, you’re using all of them together to improve those outcomes, which is why I think it’s really important. And I think it’s also important to give the patient the option, because sometimes if you’re only given two options, so antidepressants or therapy, that might not be feasible for the patient. It might not be something that they’re motivated to do.

The side effects might be too much, even if it’s not something that everyone wants to do, that’s completely okay. But I think it’s important to expand the options that we have available to offer our patients so that at the end of the day, they can make an informed choice with regards to that treatment.

So I think, I hope, that’s a little bit of an overview of some of the antidepressants effects of exercise and stuff of that sort. 

Bret: 
Yeah, I think that’s a greater overview. And I think it’s also worth emphasizing that we’re not talking about studies that just observe people who exercise more, have less depression, and people who exercise less have more depression because then you don’t know cause and effect, chicken or the egg.

But these are actually interventional trials where they, half the group gets an antidepressant, half the group gets exercise, and they tend to do equally as well at the end of the observation period. Now, not maybe every study, but like you’re saying, the meta-analysis show, in the end, like on par that they do the same or better.

So would you agree that, without putting words in your mouth, that it is these interventional trials that we’re talking about? 

Nick: 
Yeah. So it’s at the, yeah, like you mentioned, the interventional or like otherwise known as like the RCTs or randomized control trials. And with those, the important point to notice too, oftentimes, it is stronger evidence than, like you mentioned, observational studies where you’re taking a third person view and seeing what’s happening in people that are more active. And they’re very vulnerable to confounders at that point, which is why these, this higher level of evidence is important, but at the same time, it doesn’t go without its limitations.

And if it’s okay, maybe we could talk a little bit about that with the evidence and limitations of using it and basing stuff based on RCTs? The first thing with RCTs, or randomized control trials, is that they’re often very small. It’s helpful when you bring them together and put it into meta-analysis, and you get these sample sizes that are now in the thousands, which is better than when you’re in the hundreds or even some of these trials are very small in the tens or twenties.

But the other times, it’s not always representative of the general population. So, sometimes these RCTs pre-select for populations that may be healthier or may be younger than the patient that you’re treating, which is important when you’re trying to apply those findings to the patient in front of you.

And then the one main critique of exercise research is the fact that it’s very hard to blind someone to the fact that they’re exercising. You can’t blindfold someone and make them run because they still know they’re running and stuff like that. So, it becomes very difficult because that does influence the expectancy effect, like knowing that you’re exercising, knowing that your body’s moving.

And it’s hard to compare that sometimes to trials, compared to like antidepressants where if you have a placebo pill, you don’t know if you’re getting the active drug or if you’re getting the antidepressant, and it’s easier to blind at that front. So, one of the largest critiques of exercise research right now is that inability to effectively blind.

And it’s a tough obstacle really to get around. But stuff that, it’s something that you need to acknowledge but doesn’t completely take away from how important the research is. 

Bret: 
Yeah, that’s a great point about the blinding. And I guess devil’s advocate would say, so what, who cares if the patient’s getting better?

Doesn’t matter, right? So there is that approach too, but you’re a hundred percent right that it does weaken the higher level of evidence for the RCT. And I guess the other thing that rolls into the randomized controlled trials or the interventional trials, like you said, the population selected.

And I guess that’s where depression really deserves some discussion because depression is a diagnosis by itself. But if you’re talking mild, moderate, or, severe depression, major depressive disorder, the etiology and the effect of an intervention may be different, but also depression could be a symptom of so many other DSM-5 illnesses, whether it’s OCD or anxiety or even bipolar disorder, schizophrenia. Like depression can fit into all of those. So, does that complicate things in your mind when you say, how are we treating depression and what depression are we even talking about? 

Nick: 
No, that’s a really good point you bring up, and I think that applies across different psychiatric diagnoses.

Because where we are in psychiatry, as you mentioned, is a lot of times, and we’ll keep it to depression, it’s a cluster of symptoms. And oftentimes, as you mentioned, they can be present in a variety of disorders and disorders that aren’t even what we would deem to be a mental or psychiatric disorder.

So, it does cloud that picture a little bit. But sometimes it’s helpful, rather than treating based on the DSM definition or anything of that sort, you look at the symptoms you have, see how you can treat that and improve that patient’s quality of life. Otherwise, the overarching picture becomes very, as you mentioned, confusing and very kind of all these gray areas of what is depression at the end of the day.

It’s just symptoms that we put together that we said, you need to meet this criteria for X period of time, these number of symptoms. But say you’re missing, your one off of having a major depressive disorder diagnosis. I would be in the camp that doesn’t take away from the experience that person is having.

And still, there could be benefits to things like exercise, but you’re right that it clouds that picture a bit. And you mentioned something as well, too. So grouping depression into the mild, moderate, and severe, and that’s a very important point as well too, because sometimes where people get stuck on is that a lot of the depression research is mostly focused on the mild and moderate depression.

So those are people that have these symptoms, they’re still able to function oftentimes in their daily life, but it’s not easy. They feel very fatigued. They can’t concentrate. Maybe their appetites change, but they’re still able to go to work, and do these sorts of things.

But when you’re looking at a more severe depression, someone that’s bedbound, they’re not eating, they’re not drinking, they’re completely shut down, the concept of exercise in that instance, it may not be fair to apply that to that person. And not indefinitely, that person, I would hope isn’t going to be severely depressed for their entire life, but perhaps there’s a time period where it’s appropriate to introduce exercise.

And again, going back to it, the research that I discussed before, almost all of it is exclusively on that mild to moderate depression. Where you see that the patient is maybe able to engage a little bit more or maybe exercise is appropriate, but also to say that it isn’t appropriate for everyone, not only for kind of a motivation perspective, but also there can be physical ailments.

If someone has an injury, or if they have a pre-existing medical condition, that doesn’t mean that they can’t do any exercise at all. But it becomes important to apply a unique exercise prescription to that person whereby you don’t just apply, this is what the guidelines say. This is what you should do.

If you can’t do that, then I don’t know, sort of thing. It’s important to very much personalize it from that sense. And I think it’s a great point that you brought up, the mild, moderate, and severe. 

Bret: 
Yeah, and, to harp a little bit more on this. Why are we using exercise for depression or for mental health or for brain-based disorders?

A lot of times, medicine wants to know the one mechanism, right? The GLP-1 drugs, they work because they’re an agonist for this GLP-1. Although we have to admit there are some drugs that we have no idea how they work, and some drugs we say have one of one mechanism, but really can have multiple mechanisms.

But with exercise it’s a lot more complicated. You, it’s hard to say. There’s one mechanism, and you already brought up the metabolic health part of it. And in Metabolic Mind, we talk a lot about this connection between metabolic health and mental health. So, anything that’s going to improve metabolic health is likely going to improve mental health.

So, that certainly could be one of the mechanisms. Is that the only mechanisms, or are there others that have been proposed and studied about how exercise helps brain-based disorders, how it helps symptoms of depression? 

Nick: 
Yeah, so I think with regards to that, it’s almost important to take one step back from that question first.

So to first ask, do we even know the mechanism for depression? And the answer to that would actually be no. We oftentimes look at it, and the longstanding thing was the serotonin hypothesis and saying that there’s just a deficiency in serotonin. And that was the rationale for some of our medications that we use right now.

But the reality is it’s much more complex than that. Depression as itself, we don’t even know the mechanisms behind that. We do know that there are changes in neurotransmitters, so things like serotonin, norepinephrine, dopamine, but we don’t know if that’s necessarily causative. And by that, I mean we don’t know if those neurotransmitter changes is what cause the depression or if that was a result of the depression.

And then there’s a million other factors that can go into the biological side of depression. So, we know that inflammation can contribute to it. We know that a bunch of other different factors from that side. And one thing that exercise is known to improve, beyond the metabolic side of things, is there’s something called the brain-derived neurotrophic factor or BDNF, and exercise essentially is able to increase that.

It’s like what we call the miracle growth for the brain, and that’s one of the supposed mechanisms. But I like to discuss a few others because oftentimes we get very entrenched in the biological side of things, but I think it’s important to look at the bio-psychosocial. So a three-pronged approach of how exercise might help.

So we spoke about biological, and there’s much more to speak about beyond that, but I think for all intents and purposes, before we get down a specific pathway and all that, I think that’s it’s a good start when we look at exercise from a social perspective as well, too. Oftentimes when you exercise, you may be on a sports team, you may be going to the gym, you may be exercising with friends, and this is often an overlooked part of exercise as well, too. The social aspect, particularly in older populations too, where you have during the COVID pandemic, where people are isolated, they live alone, maybe they’re widowed and going out to exercise might be the only social interaction that they have for the next, for the whole week or something of that sort.

So, that part is very important to consider. And that goes into the psychological side, too, as we briefly touched on in the beginning, too, with the immediate benefits on your mood, your self-esteem, your ability to tolerate stress. I think all of these come together for the antidepressant effects of exercise.

It’s a very complex picture, and oftentimes in medicine, we try to simplify stuff to make it easy to understand, which makes sense from a teaching perspective. But I think we’re such early days in not only exercise mechanism, but also depression mechanism or defining what depression is, that it’s impossible right now to say what the mechanism or single mechanism for exercise may be or even depression.

But I think all is to show that we see these benefits. We know that there are some things happening, and we’re only building our knowledge day after day. So, we’ll continue to see growth from that area. But for right now, there’s not a clear answer. 

Bret: 
Yeah, so that’s a good point about the mechanism of depression. And taking that step back and, how we do like to simplify things?

Oh, okay, an SSRI might help. So, it must be serotonin, case closed. Why dig any further? Yeah, so not doing ourselves any favors by being so simplistic. No yeah, and then like I said before, again devil’s advocate, or just oversimplifying things like who cares why it works, if it works?

And I think a lot of the times, searching for the mechanism is so we can create a pill that does the same thing as opposed to just doing the thing. And I guess part of that is because clinicians and have maybe become jaded about, I could talk to this person about exercise, but they’re not going to do it.

Nobody sticks to it. So why be, like they’ve just been jaded over time, but maybe they’re just not doing it right themselves? Maybe they’re not given the right coaching? Or maybe there needs to be more accountability and support and so forth? So that’s when we get into this, how do you prescribe exercise? How do you discuss exercise so that someone’s going to use it, stick with it, and see the benefits? And there’s a lot to consider. What exercise, how much, how intense, how often? So how did you start to synthesize all this for your paper? 

Nick: 
So that’s, it’s a great point with regards to the medication. Because in medical school as a physician, we learn to prescribe medications oftentimes.

With medications, you can’t just tell a patient, take this medication and expect them to know the dose, the route, the frequency and stuff like that. It would be crazy if we were physicians and said, take this. And they’re like, oh, like what do I do? But we do that with exercise so much. We say, like you’re overweight, you should run.

But then you just feel like, is that appropriate that they made that comment to me like? Can I even do that sort of thing? Like how do I go about that? It’s very similar, the two. So prescribing both a medication or exercise, and I think speaking from my own experience and speaking to other people that have been through medical school and are residents or physicians, now we’re oftentimes taught that exercise is so beneficial in mental health, but also in physical health and that whole thing.

But it’s oftentimes just exercise. It’s not anything beyond that. We don’t learn which types, we don’t learn how to prescribe that for a different population, and I think that’s where this paper came in to hopefully provide somewhat of a framework that clinicians could use to have a conversation with their patients.

Because oftentimes, there’s previous research to show that if a physician themself isn’t active, they’re less likely to talk to their patient about things like this because that probably represents a lack of knowledge in the area, and that’s okay. Like I don’t expect every physician to have to exercise and do this thing, but I do hope that they would be able to have a discussion with their patient if they were interested in it.

So, that’s what brings up kind of the framework for this paper, which was the FITT principle. And this is something, not that I came up with myself, it was from a previous literature from the FITT. But it breaks down a similar prescription to how you dose the medication. So the F being the frequency.

So, that’s how often you exercise. The I being the intensity of the exercise. And that’s separated into the low intensity, moderate intensity, and the more kind of vigorous intensity. And then you get into the type of exercise. So that’s something like, is it aerobic? So, something like running. Is it resistance?

So, that would be like weight training. Or is it something that’s mind-body? Something like yoga. And the last part of it would be the timing of it. So how often are you, or sorry, timing of it would be, how long are these sessions? Like how long do you want these sessions to be? And maybe we can talk about going through that framework now and with the recommendations of this paper and then discussing from there?

We’ve made some recommendations in this piece in terms of how, what would be quote unquote optimal. But at the same time, it’s as I mentioned before, not fair to apply across different patients and different things like that because everyone’s unique. So it’s a reminder that this is a guideline. It’s a framework, but it’s not something to be followed to a T.

It’s a great goal to set, but it’s not necessarily necessary. And it’s based on the evidence in terms of where we’ve seen benefit from depression based on these intervals. To start with F again, to go through for frequency, we found the most benefit for three to five sessions per week. The intensity of the exercise was usually more in the moderate to vigorous. So, the higher the intensity of the exercise, the greater the antidepressant effects.

But there are caveats of this as well, too. So, particularly in older populations, we actually find that the low moderate is actually more effective in treating depression. So, it’s important to keep in mind these nuances as well, too. And the other question you’re probably asking is like, what separates these intensities?

Like how do I know? Do I wear a watch that tells me I’m at this specific rate? And if you want to get really into it, you can look at heart rate and different things like that, comparing it to your max heart rate. But the simple thing that I tell to patients is to do the talk test. So, if you’re able to have a full conversation, you’re able to even sing while you’re exercising, you’re probably at a low intensity.

If you’ve upped the intensity a little bit, and you are able to now, they’ll talk, you couldn’t sing a whole song or something. You’re putting in some work, you’re probably at a moderate intensity. But if you’re going so hard that you can’t even have a conversation with someone, that’s probably more in the vigorous intensity, and that’s a good mental way.

It’s not perfect, but it’s probably more feasible than having to track your heart rate. And all these VO2 max and all these different stats. And then the other thing is the time of the sessions. So, oftentimes we recommend sessions that are 45 minutes to 60 minutes. But at the beginning, maybe that’s not feasible.

Maybe not doing that much is realistic. So, doing shorter sessions or any exercise is better than none, is what we say. And then the last part I mentioned was the type of exercise. As I mentioned, that can be aerobic-strength. It can be mind-body. The literature’s a little bit all over the place in terms of which one is the best.

Sometimes aerobic comes out a little bit on top and then strength. Mind-body, sometimes they flip flop depending on how they synthesize the evidence. So, what I would recommend there is that whatever one you want to do because the biggest factor beyond the fit principle is adherence. The same thing goes with diet.

You can have this diet that you can follow for a week, but you absolutely hate it and you’re going to just drop off, and stop it after a month or a few weeks, and you’re not going to see the benefits. So, the biggest principles beyond these overarching principles is any exercise is better than none.

And you want to do something that you want to do, not something that you’re necessarily forced to do. And it might not be fun right away. Like it might take some time to get into and find that you enjoy it, but it’s important to work with your doctor, or whoever you’re working with, to really find what works for you as a patient.

Bret: 
Yeah, such a good description and bringing in the analogy of nutrition and so much more complicated than take this pill twice a day and see you in six months. So much more complicated. But that doesn’t mean we shouldn’t be talking about it and shouldn’t be doing it. And I love how you brought up that if the doctor themselves does not exercise, they’re less likely to recommend it.

I think everybody in medical school should be required to become a certified personal trainer, too. I took the personal training course. I know some other physicians who’ve become certified personal trainers. And not that I work as a personal little trainer, but I can speak the language, and I know how to recommend it to patients. I think everybody should do that, but that’s my little soapbox aside.

Before we continue, I want to take a brief moment to let our practitioners know about a couple of fantastic free CME courses developed in partnership with Baszucki Group by Dr. Georgia Ede and Dr. Chris Palmer. Both of these free CME sessions provide excellent insight on incorporating metabolic therapies for mental illness into your practice.

They’re approved for a MA category one credits, CNE nursing credit hours, and continuing education credits for psychologists, and they’re completely free of charge on mycme.com. There’s a link in the description. I highly recommend you check them both out. Now, back to the video.

But so you’re talking about what the recommendations are, and you mentioned the word optimal. What’s optimal? And I think a lot of people are like, okay, but what’s like the minimum to do to get some benefit, right? Everybody wants to know what’s the least amount I can put in to get some benefit? And you made the comment that some is better than none. And then, there’s the optimal level.

But is there like a threshold, ah, if you’re not doing it for 15 minutes, don’t even bother, or even getting up and five minutes of walking, like even that’s going to do something.? Like where do you stand on that? 

Nick: 
Yeah, so there is some research into this and again, falling onto the meta-analysis, bringing stuff together sort of thing.

And it’s based on RCTs and different data from that side. It still stands by that principle of any exercise is better than none. So, when you look at the curve in terms of, and I don’t have the exact numbers off my head right now, but when you look at that curve, even little bits of exercise are so beneficial. And it’s those little bits that help so much at the beginning, and then you start getting a diminishing return when you’re doing more and more sort of thing.

So, the argument would actually be that if you’re able to do a little bit, the more and more that you can do, you’re really going up, and having that antidepressant effect. So, if you compare someone with no exercise to just a little bit, there’s a big change even. And then just a little bit more than that, there’s a big change. And then it keeps going up from there.

So, when we’re chasing these like optimal levels, sure it does improve it and improve, but you can imagine that if you’re feeling depressed, you’re sitting down all day. You’re not doing anything, per se. And not because you don’t want to because you just can’t. You don’t have that motivation.

If you’re able to get into things and maybe just go for a walk and maybe even things like, just get up, leave your apartment, go up and down the elevator, come back up. That movement is so important compared to none, and it leads to those further changes. It leads to that motivation that you can do more.

It leads to the motivation to want to do more, or that things aren’t that scary. And that you maybe want to look into this or have that conversation. I don’t have an exact cutoff in terms of how much is meaningless, per se, but anything from that curve is helpful. And it only gets better and better as you’re doing more.

Bret: 
Yeah, I think that’s a really good perspective. And just starting with some, doesn’t mean you stop at whatever level you’re at, but you build it from there and having sort of short obtainable goals that, the stepping stones to get you to a larger goal, are so important. But you mentioned the point of diminishing returns. So at some point, putting in more time and more intensity may not have the same level of psychological benefits, I guess you could say. But yet there are some people who find extreme amounts of exercise is what they need, so there’s definitely outliers. So how do you, what does the evidence say about that?

The ultra marathon runners? The people who are doing far more than what would be considered normal? But yet for them, that’s what they need to scratch their itch or that’s what helps them from their mental health. 

Nick: 
Yeah, that’s a great point. Like again, with these things, everything is just a guideline from that front.

So, as you mentioned, there are people that maybe they do better with a lot more, and there isn’t that kind of point of diminishing returns. And I think it’s really on that patient by patient basis and having that open conversation with them. But I think that leads into an interesting point as well too where, and something that I’ve written about recently about sometimes exercise may be perceived as a form of self-harm.

So, to explain the situations, we’ve done two previous systematic reviews on this topic. Looking at exercise, not the effect on depression, but the effect on suicidal ideation. So, that means thoughts of suicide, suicide attempts, and then also deaths by suicide. And what we found in both of those studies was that exercise led to a modest reduction in suicide attempts.

Didn’t change the actual deaths by suicide or the ideation part, just the attempts, which is interesting. There’s a lot of nuances, might be because of sample sizes, et cetera, et cetera. And originally, we hypothesized that it reduces attempts because it, exercise is able to tailor or dampen one’s emotional impulsivity because we know that a lot of suicide attempts are actually characterized by impulsivity rather than something that’s well planned out and someone that has a plan that they’re going to do.

So, that’s what we went with. And then I was thinking like, what if there’s something else going on? And that brought up the concept of can exercise also be a form of self-harm? And not all the time, but to explain it, self-harm isn’t always with suicidal intent. Sometimes, people feel very emotionally overwhelmed so they can resort to things like cutting or burning.

And those are more of the traditional self-harm things that you’ve probably heard about. But there becomes the concept of people that may use exercise as a maladaptive coping skill where they’re exercising to feel that pain or to cause an injury even. And that’s where sometimes you see these people that are exercising a lot and a lot. And it seems like it’s working for them at a surface level because from a societal perspective, we see that as sublimation, or someone has positive coping skills to a stressful stimuli, which may be true.

At the same time, I think it’s important that if we’re seeing someone that’s having so much exercise that they need to sustain themselves to have these antidepressant effects, perhaps opening that discussion to seeing, is this a form of self-harm? Is there an underlying depression that isn’t necessarily being treated but it’s being successfully coped with through exercise? Perhaps is a method of self-harm, and I think that’s an area that’s very new.

There’s not a lot of research behind it, but when I did write that piece, it resonated with a lot of people, which was very interesting to see. So I’m hoping to see more research in that area. But for now, I think it’s an important concept for clinicians also to be aware of exercise, not only as a form of self-harm, but also exercise dependence where people need to exercise, which has a lot of comorbidity with different mental disorders such as depression.

Bret: 
Yeah, I was going to ask you about the response that you got in writing that because I could see how it could be very controversial. And people could be very critical of it, and even calling it self-harm, but in a way it’s almost like adaptive so that you’re not doing other forms of self-harm.

So, the term self-harm is misleading because it sounds so negative when it actually could be fulfilling almost a positive role. Yeah, tell me more about the feedback and the response you got from people after you wrote that. 

Nick: 
Yeah. I think it surprisingly had a lot of positive feedback because I think a lot of people, although as you mentioned, the more traditional methods of self-harm or again, someone might be cutting or burning themselves and leading to visually damaged parts on their body or something. That is more what we conceive to be self-harm.

It resonated with people that may not be doing those acts, but maybe using exercise again as that coping mechanism, which again, it can be a good thing if it’s replacing those. But at the same time, it received that response because people were realizing like, hey, maybe I am having a hard time? Maybe on a societal level, people are saying, you’re going to the gym and going so hard all the time that you’re passing out.

You’re like, wow, that’s a hard worker sort of thing. And it reinforces, and it almost leads to this hidden subgroup of people that are suffering. But from a societal perspective, it looks like everything’s okay because they’re using, as you mentioned, these positive coping skills, which I do think it’s good to use things like exercise and use this as a coping, but also to be realistic with yourself.

And sometimes coping skills don’t get to the root of the problem. As we’ve been speaking about this whole time, like exercise can be helpful in treating depression. It’s not always perfect. Sometimes you do need other things to help as well, too. So, I think it really resonated with the people that kind of had that moment where they took a step back and said, am I doing this to cope or is this something that’s helping me?

And it opened that discussion, and hopefully, led to further discussions, and the help that they needed. 

Bret: 
Yeah, super interesting. And I want to circle back then to something you said about maybe it’s not, they need more than that and it’s not all they need, and it’s not always a solitary treatment.

So, when we talk about nutrition a lot, which we do at Metabolic Mind, there are sort of two ways to look at it. Nutrition instead of medical therapy, which is how a lot of people look at it, but by no means is that really what the majority should be. It could be synergistic and working together.

And you mentioned that word earlier that exercise plus medications is often synergistic, but at the same time, some people may choose to use it as a solitary treatment without medication. So. How do you help people understand where exercise fits in terms of using it by itself? Using it with medications? Can it help taper medications, et cetera? Like tell us a little bit about that. 

Nick: 
Yeah, so with that, I think the principle that I follow the most is as a physician, my role is to educate the patient in front of me in terms of their treatment options. So, in this, in the case of depression, whether it’s exercise, medications, therapy, and what that looks like.

So, commitment-wise, side effect-wise, time-wise, and really working with the patient so that I feel that they understand all of the options and going the route that makes the most sense for them or their schedule or what they’re hoping for. And I think that’s where you’ll get the most success, too, because exercise, although it seems positive, can be quite a polarizing topic sometimes.

And it can be very off-putting for patients that have had bad experiences before where they go, for instance, maybe to their primary care doctor, and they’re just repeatedly told to exercise, exercise, and they’re not doing it because they weren’t given the instructions.

So, that term exercise now being said by their psychiatrist. It can be so off putting because maybe they felt like it was a safe space, and mental health has nothing to do with that sort of thing, or that’s the notion that they had. So, I think the best approach is to make sure that you’re giving that educated opinion.

So, describing the things that we spoke about that exercise, antidepressants and therapy have very similar efficacy, independently and then together can be used, and be very helpful. Because you can imagine something like a complex trauma or something that led to a depression, exercise alone might not solve that.

Exercise might help stuff be easier. You might be able to deal with those stressful situations easier, but therapy might be needed to be able to talk about those things because you can exercise as much as you want, but if you’re not really unwinding those memories or what happened. It’s important to get all of those modalities together.

And same thing with medications, too. If somebody is open to having that and having that synergist effect, but is also aware of maybe some of the side effects that are associated with antidepressant medications. It’s important to have that informed discussion. So I think in summary, each of those treatments has their utility, both alone and together.

It’s ultimately up to myself as the clinician to educate them, for them to make that decision and for me to do my best to guide them through that. And the other thing is, too, I think oftentimes patients think like, when I make this decision, I have to stick on this one and just this one alone. But say you decide to do antidepressants first, that doesn’t take exercise off the table.

It doesn’t take therapy off the table. You can do a stepped approach as well, too. And I don’t think that there’s any correct order, per se, too. Even though I’m a big advocate for exercise, I am, I’m well aware that it’s not for everyone. Maybe they don’t want to do it.

And the timing part comes in, too. So as I mentioned with regards to severity of depression, if someone’s severely depressed, maybe it’s not even correct to offer exercise as an option, right? In this instance, until we’re able to get them to a point where they’re feeling a little bit better, and maybe that’s something they’re considering.

But again, the overarching thing is just informing the patient and allowing them to make that informed decision. 

Bret: 
Yeah, and it is interesting how you brought up the specific example of the trauma and needing therapy. And I could see some patients reacting like, wait a second, I thought my depression was because of my chemical imbalance and my genetics. And now you’re telling me it’s my fault because I didn’t exercise.

I can see that type of reaction. Have you come across that response? 

Nick: 
Yeah, no. For sure, and I think that’s a very common thing and why there’s sometimes that immediate pushback to exercise. And I think for both exercise and diet, it’s important to frame it in a specific way to the patient.

So, to avoid that kind of response, because it can be very off-putting for a patient where it feels that when you’re a physician, and you’re in that position of authority. You’re almost, sometimes patients can be, feel that they’re being spoken down to, or that, as you mentioned, that they cause their depression.

But when this happens, it’s important to look at depression or any mental ailment to be similar to a physical disorder. So, someone that has asthma, per se, you didn’t ask for it. You didn’t want that to happen. You didn’t necessarily cause that. But then to say that, hey, these are some treatment options that would help.

You don’t have to take them. It’s not something that you caused or anything, but I want to be here as your physician to help guide you through that, provide you with the support, the education, and follow you along the way to make sure that you’re as successful as possible with that. And if the patient says, hey, I’m not open to that right now and leaving the discussion there, but just letting them know that the door is always open to have that conversation again.

I think is the best approach to avoid that accusatory or overwhelming stance, of kind of shoving exercise down someone’s throat and if they don’t want to. 

Bret: 
Yeah, the other important part about knowing human behavior and behavioral change, and that it’s hard and that not everybody responds the same way and how to go about it in an individualized fashion.

But before we wrap here, the other point is, which you brought up earlier about the metabolic consequences of both having depression and the medications for depression, or if you’re talking about medications for schizophrenia or bipolar disorder, they are just ripe with metabolic complications, with insulin resistance, with weight gain. So, of course, you want to use exercise as part of a treatment for that. And oh, by the way, may also help the underlying mental disorder as well. That’s how we look at nutrition and ketogenic therapy and metabolic therapies like it can help with the metabolic consequences.

And oh, by the way, might help with the psychiatric consequences as well. So it’s a twofer. So, why wouldn’t you like, and so it’s such an, it’s like such an obvious approach. As we’ve talked throughout this interview, it’s not easy. It’s not straightforward and not as easy as the pill. So, that’s why I’m so thankful that you wrote that paper about how to discuss it so it’s not just beating somebody over the head.

Exercise more, and it becomes this self-fulfilling failed prophecy, but giving some advice and giving some direction. Yeah, so thank you for writing that. I appreciate that. Hopefully, more people will see it and learn from it, clinicians and individuals, because you can apply it to yourself or you can apply it to your patients.

So, what’s next for you? What else do you have in the pipeline that we might see from you in the future? And then finish that up by telling us where we can find more about you. 

Nick: 
Yeah. I think, thank you again for all the compliments with regards to the article. I’m glad that you found it helpful.

And in terms of what’s next, like I mentioned, I’m still very much interested in the space of exercise, diet and sleep. And as I mentioned, I’m still just a third year resident now. So, I’m still working on kind of building those skills. I’d say right now my higher knowledge base is in the exercise realm, but I’m working on building my knowledge in the diet and sleep realm as well, too.

Because as I go on with my career, I’d like to have those three main pillars and work on those and incorporate those in different ways. In terms of next, I think I’ll have a lot of different studies on exercise coming out. We’re going to be, we’re looking more into, as I mentioned, the exercise as a self-harm piece and more so than the opinion, but looking into more of the evidence and if the evidence isn’t there, getting that evidence.

So, that’s some of the next steps. And again, building upon my knowledge from the diet standpoint and the sleep standpoint to really put all these together. Because how I envision what my practice will look like in the future is going to be putting these things all together to be able to help the patient that’s in front of me.

And that will require some learning and different things, but maybe in the future I’ll have a paper of how to prescribe diet for depression or something of that. It’s not in the works right now, but something I can certainly see across disorders as well, too, because there are nuances that are important to discuss.

So again, thank you for having me. Right now, if you want to find me on any platforms, I’m pretty much just active on Twitter or X and that’s at NTFabiano. And I usually post kind of scientific articles there. It’s not always exercise related, but I usually just break down articles into, I try for about 10 tweets, so that the convoluted knowledge of science can be in a way to understand a little bit easier. But yeah. Thank you for having me. 

Bret: 
Yeah, my pleasure. Thanks for listening to the Metabolic Mind Podcast. If you found this episode helpful, please leave a rating and comment as we’d love to hear from you. And please click the subscribe button so you won’t miss any of our future episodes. And you can see full video episodes on our YouTube page at Metabolic Mind.

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