Getting out of bed is incredibly difficult if you have depression and so the things that would heal you You can't do and so it's you know insult injury and then you also have an amplified sense of guilt And so you beat yourself up for not doing the thing you can't do and you know that makes you feel even more discouraged It's just this vicious cycle once you're in the spin.
It's hard to get out of by yourself But that said the key principle is whatever energy you've got if it's the ability to walk to the mailbox Or if it's the ability to run 10 miles like use it and the other thing to recognize is that sometimes that varies wildly It's a hard thing when you don't have the energy to do the thing to make you feel better So depression can be a brutal experience It can make you feel like there's just something fundamentally missing from your life some vital spark that has been extinguished leaving you feeling numb or joyless disconnected from who you know yourself to be and and More and more from those around you as well one of the toughest aspects is often the feeling that this feeling that you have it It'll never end and that you'll never feel alive and connected like yourself again And this has become a really pervasive experience for so many people and typical treatments have varying levels of effectiveness for different people and often they tilt towards Sumbling of therapy and medication and for many these can be godsens But they can also come with side effects and for still many others They either don't work at all or they only kind of work part way Which is why I was excited to talk to my guest today Dr.
David Carian So he's a psychiatrist on the leading edge of transforming how we understand and treat depression as a co-founder of Kasia mental health and Silicon Valley He has helped some of the most treatment resistant cases Achieve just remarkable turnarounds using groundbreaking brain stimulation technologies combined with ancient wisdom in his new book The opposite of depression what my work with suicidal patients has taught me about life hope and had a flourish He died as deep into the swilly purposeful territory and with the background that includes studying and teaching at Stanford We're here in his MD David brings a unique Sort of multi-dimensional lens to mental health his clinical work focuses not just on alleviating symptoms But on restoring the freedom to fully inhabit one's true self and live a life of profound meaning and purpose and yes Even joy So excited to share this conversation with you.
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I feel like depression is also become a bit of an umbrella term where people aren't necessarily entirely sure that they're Referencing the same thing when they use the word you know We're gonna dive into depression the opposite depression some all sorts of ideas around this What are we actually talking about when we're talking about depression?
It's a really a really great and profound question I mean this is something that goes back at least to Job, you know, you have a good number of the core Symptoms of depression described in the book of Job and then all through human history people are struggling with different names in different Constructs melancholia black bile and then more moderately there was the attempt to Systematize it.
We didn't have the biology worked out but at least we can agree on what we're calling the thing And so the the hope of the in a 1960s 1970s 1980s was maybe we can at least agree on which symptoms are called depression Which symptoms are called anxiety and so at least in the psychiatric profession?
Major depressive disorder was born and it's a five of a set of nine symptoms that you might have Want we have to have either Depressed mood or what's called an hedonia the inability to experience pleasure and so Within the profession that's what it is But I think you make a great point which is this is a term that goes well beyond some technical Dialogue between experts in a field that nobody cares about this is how we are beginning to frame our daily life It's sort of entered the vernacular in a way that is different than I got this news and I felt sad I felt that you know I got this news I felt disappointed.
No, I depressed is the words it's chosen and so I think that there's a pull towards Medicalization of the human experience and so part of my interest in psychiatry personally was Well, if this is how the world is being made sense of maybe understanding what it is within the profession So I could speak to what is or what is not every day depression This has been described and named although the name was not always depression but you know all going all the way back to Job and was it If we trace it all the way back as far as we can see this mentioned a reference and as you described You know like many of the sort of like the checkbox is like we're there and they've been written about in previous times in our history Was this described as something that was quote wrong with you to be fixed or just a state that we Experience that as part of the human condition that is okay Well, I think it's it's definitely Spanned the realm historically of what sorts of things have been said about it I think one of the things to note about a psychiatry at least within the discipline is that it's A theoretical that it is it's not even attempting to put forward a theory of why this is happening It's just a description and from a certain perspective.
That's how all science starts You know you look back at the early 1900s and the neurologists this particular physical fight went with that particular prognosis We give it this particular name, but yeah, there's definitely I don't know almost an unconscious or unspoken trust in say at the 1970s that depression was Biology and that this was you know, do you have a biological thing that's wrong with you and you need pills you over there That's just tragedy of life and you're sad and it's psychological and I'm not sure that was ever fully true But at least that's part of the the history handed down and you know different errors are putting emphasis on Perhaps spiritual forces or supernatural forces that are a factor you are or perhaps it is biological but with a pre-modern understanding of well There's too much block bio and not enough of the other kinds of bio or the other kinds of humors But yeah, I think the question of how we explain what's wrong with us is in what to do about it Yes, is this something that we accept and you know And we sometimes when I use the word grief I've seen this come up a little bit more recently people especially within Christianity like to use the word grief I'm grieving over X or I'm in grief about this or and again I think it's it's wanting to avoid the the term depression It's still say same sort of a thing that's a syndrome that's more acceptable than depression But what are the limits of grief versus depression versus normal ups and downs of human experience that need to be and I think what we're trying to say is important though Some things need to be accepted some things yes We are you know that in this in the state that we're in things are not as they should be there is sadness There is a an experience of life and then there's things that I deal with which are at least presumably things that are Pathological things that are wrong things that are diseased things that are excessive things that are not helpful and that's that's At least in my functional use of the word depression when I say somebody is depressed I'm thinking more the that they need that professional help of some kind maybe this is not a possible question to answer But you might you might make me the curiosity is where is that line?
And especially in people that get better and that are starting to then an emotion hits That's one of the hardest questions to answer for me is like yeah something bad happened and you feel sad again Is this the beginning stages?
You know is this the tumor that was cut out and the beginnings of another one that we need to really be aggressive about?
Or should we just let you be sad and it's like well?
You know, I don't want to miss call it, but it's difficult and you know It is a very difficult judgment call But we have to have and this sort of gets to another point norms of what our emotions and what are they for and there's a sense in which We can say something is excessive we can say that something but that's not something you could say with much precision That's a very difficult thing to say, but it is something that without it.
It's it's impossible to do the job that I do not that Is possible that anybody's job is possible for that matter, but it's a great question And I guess it's partly an open question and probably like very much dependent on the individual at any given moment and time But it is always a curiosity in mind sort of like when do you know?
When you're just really sad or you're really bummed or you're really upset or you're really frustrated You're grieving something that is worthy of your grief and when does that cross into?
Okay, this is something which actually needs to be dealt with in a different way It is now worthy of some kind of intervention Yeah, for the average person there's a couple things.
There's the example of counting the experiment of can you count how many marbles are in a big jar?
So you have a big jar and it's like, you know, I don't know something to proximity to five out of marbles And yes, somebody how many marbles and they're gonna say I don't know and they're gonna throw out a guess One person is very bad at that task like the chance you're gonna guess the exact right number of marbles It's about zero or is like one or a thousand or so But you get a bunch of people to make that same estimate and it it Converges very precisely on the right number.
We're all seeing something We're all having our own heuristics and guesses about what what it is or what it isn't And so in a sense I think that an individual's depression being problematic You can identify that better in a group or better with help than alone It's very difficult to look in within yourself and say this is perfectly appropriate amounts of sadness and grief Now there's some flags which I would say especially from my philosophical perspective are are pretty clear flags I think that suicidal thinking is never a good or healthy thing Now is it an acceptable thing is an understandable thing is a thing that I'd like to help with of course But is that a thing that it's like oh well I'm just feeling a bit suicidal today.
No, that's a sign that yeah She's talked to somebody and that said it's like a surprisingly high number people have that experience But nonetheless that's something that is like yes I do think you know it is appropriate to dosy kelp if that's ever happening with any amount of regularity and The other thing that is kind of a cop out answer from the professional side is it's causing Disabilities interfering with your ability to function in your social or Occupational roles and like okay, that's fair But it's a tragedy of you know someone dying who is a loved one Yeah, you're not gonna be as productive at work and that's okay It's appropriate and again, I think it gets back to that you know if it's the next day.
That's fine if it's 10 years Okay, that you might want to get some help with that and so somewhere between that is like yeah What is excess of them?
What is not we try to put these arbitrary lines on it?
But I think a community particularly a spiritual community or people that are that know you well Might be able to help with that distinction.
Hmm. It also brings up Needs somebody at one point who was Politically diagnosed with something that I don't know if this was actually what was shared with them But that was named as functional depression.
This was somebody who was going on with their life Like going through all the motions like doing the work and yet there was this pervasive thing That was always like just sitting with them the whole time for years until finally they felt like Let me see if this is actually just the way I am just the way that life is for everybody or if there's something going on here In fact there was something going on and and it was something that was Goat processable.
So the disability part of that.
Yeah, I kind of raised an eyebrow with that also because I wonder how many people are just They're doing that they're checking the boxes of what would be considered okay, so like I'm functioning in daily life And yet they're suffering at the same time.
Yeah, it's a great point I think that again with the sort of odd definition of five of nine That means that you can have two people with the same label that have one similar symptom in common at least in theory and so Yes, some people have all of the you know psychological and You know low energy and ability to be productive suicidal thinking and then other people have none of those symptoms are also you know, but don't have pleasure and Have problems with appetite problems asleep You know, and there's these kind of two clusters sometimes and these people have the same label Is that even the same condition?
But yeah, it's it's it is definitely for the time being until we get better biology and better neuroscience Yeah, so often also we especially I think when we struggle to really clearly define a term or a state Looking at the opposite helps us understand it and this is this is kind of interesting because this is this is what you To a certain extent done like the name of your your recent book the opposite of depression is really saying okay So if this is X What is Y and I think a lot of people if they hear what's the opposite of depression the word that pops into their mind immediately is oh happiness Not so fast It's one of the things that I saw with my patient So you know, I I focus on the most treatment resistant patients who have depression Possibly in the world and I'm sort of certainly on the short list people flying from around the world to To get the treatments we provide and so I see some really depressed people and There are some conditions that like disable a part of you, you know, but broken arm You can't move your arm and if you can't move your arm then well, of course you're you're you're not functioning to your full capacity and Depending on what you do for work that really is either inconvenient to incapacitating for what your job is But the depression is this this unique way of kind of disabling the whole of you or like getting to the soul or the core or You know something deep inside and it's is kind of across the spectrum these nine symptoms represent some of the deepest and most core parts of a person kind of broadly speaking and so When I see patients recover it's incredible to see them like Become themselves and that's actually one of my favorite things that people say I feel like myself again that there's this Identifiable state of like myself that's the opposite of depression that that depression removes the self-ness as it were Of a person and so when it's restored they can feel it they could see it and so the function of the person is Taken from depression and so yeah, you can see when people are flourishing Yeah, they very much have not happiness all the time but properly functioning emotions when things are sad They feel sad when things when happy things happen they feel happy and yeah, maybe that baseline is high is elevated Is you know things are going well, but sometimes it isn't that there are plenty of people that are doing well in life that aren't Smiling as they walk down the street.
That's not necessarily how it works, but that the Omni-present sadness or the somnipresent you know single-tone life is not what they have There's a very ability and I think that's part of our design is to have that variability and when that's absent in a condition like depression It isn't a disorder an illness.
It is so interesting right?
You know like returning somebody to the flourishing or feeling more like themselves and not necessarily like perpetually skipping them the road with a smile on their face That's not the sort of like the everyday state for a lot of people even when they're feeling like you're like how are you?
I'm like I'm genuinely good.
I'm not giddy. I'm not like just constantly happy I wonder if this goes back to some of the study that that from my understanding it was done on twins Also, which really sort of teased out this notion of when you look at happiness, you know like that Fabulous self-help latitude like happiness is a choice It gets kind of squishy because in part yes, but in part, you know, there is a certain genetic point or set point and See an argument about whether it's movable or not, but a certain amount of your happiness is kind of like Genetically determined.
Yes, there's a whole bunch of environment and behavior and stuff like that that can really make a difference But also it's not a hundred percent with an art of control And if we set this aside a standard that says okay, the goal is you've got to be up here like 93.4% Happiness every part of the day and if you're missing that there's something wrong Then we're like piling shame on top of not being able to meet that magic and imagine that's even worse It is definitely important to think about the genetic contributions to the to both sides of it and yeah most traits are Something between you know 30 to 70% hair couple almost anything you could think up from you know Lifetime income like how much you make in your life whether or not you're gonna be a violent criminal Whether or not you're gonna get depression whether or not you're gonna be an alcoholic all these things have a huge genetic component And that's from one perspective concerning But what does that mean to have a genetic component?
It's some people are gregarious, you know, if both of their parents are extroverts Then they're probably gonna be an extrovert and you know that that's you know Even if they happen not to have the influence the parents, you know They you know raised by someone else like of course there's gonna be some sort of genetic influence and from another perspective Extroverts who are out with a bunch of people all the time more likely to fall into alcoholism than people that never go out Yeah, probably it's gonna be something like that where it's some it's probably some trait that we can identify that's connected to something else But to your point the people who and you know again It's the sort of old philosophical question of you know when I look at something and see red It's that the same thing that you see as when you see red.
It's like yeah Probably but it's an interesting philosophical question Especially when we get to happiness like how do you know if somebody's happy ask on a scale is you're to tend how happy are you and they put like Seven you put five it's like am I really happier than you or me?
There is no other way for us to like quantify it and so yeah There are in fact some people that will put sevens more than fives on these surveys and yeah I guess that kind of tracks with you know how much they're smiling or whatever But I'm eager to get more have the research show more More objective ways of of quantifying these things and just from a scientific standpoint But from a life standpoint, it's much more important are you fulfillment satisfaction meaning purpose and maybe fulfilling your role or doing what you're You're called to do is maybe even more important than not maybe I believe it strongly to be more important than Whether you happen to be happy more often.
Yeah, that makes so much sense I may be asked that same person you know like broadly are you living a good life?
Many of those people would say yeah, even though if you said you like how happy you in the last seven days They may not check a lot of boxes there There's an interesting distinction also and this is you mentioned the word pleasure before and that is certainly one of the indicators The inability to feel pleasure and this is one of the things that you write about and there's also this distinction that often happens between pleasure and Happiness and often Pleasure is looked at as oh, that's the bastard child of happiness Yeah, like it's not the real thing and yet we all want it so often and Take me a little bit deeper into the concept of pleasure here One of I think that the most important insights that I I think I believed before doing this work and that I really double down on Sense it which is a lot of these experiences that we have are a lot closer to Seeing than they are to believing or calculating something with pleasure.
I believe I like Chocolate I believe I like ice cream or whatever it is It's like sure it's a belief but the more important part of it is the experience itself of Enjoying the thing and and that's either president or it's not and it's just like sight like some people are blind or some people temporarily are blind But it's much closer to the to a direct Experiencing of something than it is to other types of human cognition Pleasure is one of those things and so yes, and depression We see in Hedonia where people can't do that and yeah That's really hard when you just don't get any pleasure out of anything and also it's a guide You know we use our eyes to to see we avoid obstacles We go where we want we're able to see the world around us and sort of construct a almost a 3d universe a Topography of where we're going to walk, you know avoid that curb go up that hill whatever it is So to with pleasure with our ability to sense pleasure We also can create this topography if I were to do this thing That would be an elevate that would be a hill that would feel great if I write this book I'm going to feel good.
It's going to take a lot of work It's gonna be a uphill climb But if I do it will feel good at the end of it.
That's great That's something that I I was able to see because I didn't have an idonia and then pursue it because I knew that there would be minor You know minor points long a step where I feel minor pleasure and a lot of pleasure once I finish the thing So pleasure is something that is good to pursue it I think that this old idea that these senses of pleasure for example should be linked to something deeper something broader So when we think about the other other other senses other things that we can also see My there they're two categories that I think this is this goes back to it like old Greek stuff the good the true and the beautiful And so being able to see that this is also in line with the truth This is also in line with the good my values my moral values I'm writing a book.
I'm not going some heinous crime No, if it's in line with actually good values That's when things are really going well going right and so yes pleasure can be good But when pleasure is disconnected from a larger set of values when it's disconnected from what we believe to be true or what say What's a truth that we're living in then it becomes problematic when you're pursuing it for the sort of spike and crash Well, that's again if you think about the long term it's not going to be more pleasure It's gonna be less, you know The drugs are a great example they feel apparently I have been told they feel great in the short term and then terrible if you continue to do them And so you know there's there's a good story about the people called the dopamine system That's a little oversimplifying we can get into that if we want to but but yeah, that you you know you you you know Blot your dopamine system or you know probably your pleasure system which is a different neurotransmitter The endorphin system and yeah, you're not able to experience that same degree of enjoyment or pleasures You did before because you kind of overused it and so what's a good long-term strategy for maximizing pleasure and We'll be right back after word from our sponsors Your life project is brought to you by Sarna the soothing solution for your skin So I am actually a bug bite magnet if there's a bug anywhere nearby I'm getting bitten my wife and I actually joke about this but it can be a real pain I mean literally Sarna can help it's the number one dermatologist recommended topical anti-itch brand It's kind of like a multi-tool for skin irritations providing really from bug bites sunburns and more Sarna comp and cool with its quick absorbing formula packed with skin soothing ingredients It provides immediate relief so you can get back to enjoying your day and for bug bites Sarna bug bite patches are easy to apply and mess free I love these I carry them with me in my pack now whenever I go hike or go to the beach or just I'm outside in the evening with friends So whether you're dealing with problematic plants bug bites or sunburns Sarna offers soothing relief try Sarna and Experience the difference shop for Sarna bug bite patches on Amazon or just click the link in the show notes Good life project is sponsored by care dot com so you know my daughter is all grown up in head of the house now But I remember those days when juggling work and parenting was just a real challenge And it was something like care dot com had been around back then It's a lifesaver for so many families Connecting them with sinners nannies and senior caregivers who can help with everything from after school care to Mail prep for aging loved ones.
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It is so specific to your needs literally down to your DNA It's personalized health care to help you thrive my wild health coach is just incredibly insightful and takes into account my lifestyle My history genetics and blood work to help create movement and nutrition plans tailored to accommodate me on the most granular level And I was able to have this conversation with him about some very detailed concerns I was just incredibly impressed by the depth of his knowledge and then I got my health report Which is this 44 page report with the most incredible information and insights in it It explains so many things about my health and well-being as well as why certain lifestyle choices like nutrition and exercise Either do or don't work for me the nutrition part for me was actually so validating and also gave me new strategies to consider And being able to review that in detail with my wild health physician and ask questions and get answers that I had never heard before Was just incredibly eye-opening and empowering I felt like I had insights that were so tailored to me that I had the ability to make choices like never before and really take control of all aspects of my health Wild health gives you smart, sustainable, lifestyle tweaks tailored to your biology So whether you want to lose weight, prevent disease or just boost overall wellness They guide you every step of the way Wild health is generously extending good life project listeners 20% off the cost of membership with the code good life So head on over to wildhealth.com slash good life and use the code good life at checkout Make this commitment to yourself and start taking control of your health today at wildhealth.com slash good life Or just click the link in the show notes and use the code good life Which brings up another interesting question around pleasure at end its linked to depression Like if one of the things is okay like the the absence of or the inability to feel it How do we distinguish between that and what has sort of emerged and literature and been popularized as Hedonic adaptation that thing where like there's a thing we love to do and we get the high and we feel awesome But if we do it over and over and over and over again We are like we we are habituating beings that over time We don't get the same hit like you know, it's a little lower low It until it just doesn't give us the same thing How do we know when We're just adapting we're habituating to something and that's quote normal versus Oh, actually there's something going on here where I literally have lost the capacity to feel something I think this gets back to what I was saying about Community and maybe even like community over over time that these are really hard questions And you know, it's it's very easy to fool one self that I really arrived and it's like okay Well, that's great two people do that how about ten how about a million if we think about if we want everyone to flirt Now again, maybe that's a good question of values.
Do we want everyone to flirt?
Do we have that obligation or should it just be us?
But what is a game? What is a system?
What is a way that we can work together where many people are Moving towards flourishing and this is United States the the founders having this idea of life liberty and the pursuit of happiness That we want a government that allows us to pursue happiness because it's kind of hard That's a really hard question.
How do we all and again? I think they meant happiness and the more flourishing sense than the you know Pondonic spike sense, but yeah, these are deep questions How do you know if you're just habituating?
I think that is a good sign that maybe you know Maybe try to pursue something something more and this is also something with with the community with other people like And I just being lazy have I gotten to a plateau, but not the mountaintop and I think this idea that in a almost religious idea That like well, are you a maximally in this state of enjoyment and maybe enjoyment in this deeper sense?
If not then keep working keep looking keep realizing what of myself is inadequate?
What of my habits are insufficient to achieve this level and you know a lot of what I talk about is sort of Ways that we can with more secular approaches experience goods like exercise You know turning around negative thoughts pursuing beauty in the in the world around us and that could get you pretty high if people did nothing other than that The world would be a dramatically more flourishing place However, there are some people that seem to be able to transcend this Despite all terrible circumstances they might be in saints or heroes or lies people through the ages are able to get into these modes Where yeah, it doesn't matter what you do to me that they just transcend it and they experience these states of like literal joy Like smiles on their faces as terrible things are happening because they've transcended the mundane So yeah, I mean I'd say parallel paths like there This there seems to be something to human's are capable of of the transcendence and at the same time the day-by-day work I've seen this in AA too There's some people that work the program they work the program they go to their meetings They're just continuing to go into meetings They you know they relapse they go back to me they relapse they go back to me It is a slog and after five years They're sober and it's like amazing and they have to just keep going to meetings and keep gritting their teeth and they Yeah, it's hard work, but they're sober and it's worth it and it's great their life is so much better than it was before But it's a lot of work and then there's others who just have a transformation and they're better and it's gone Um If you should then you know, it's just like yeah, I uh you know turn my life over to my hair power and like yeah I don't have any desire at all for alcohol anymore.
That's not fair Like these people are working and you just trigger it.
It's like it's gone It's like yeah, and but then he relapsed and then that didn't happen again He you know in this particular case he had this one-time experience of like Complete I don't know super nice like radical healing without any additional work But then the second time he really had to work at it So again that the world is a complex and a mysterious place that there are these pathways and um being open to I guess grace when it comes but also like it often doesn't or at least in the uh, you know work a day world We just have to you know do the best thing we know how to do and not get lazy I think that's the other thing now if you're depressed and listening to this like you're not lazy You think you're lazy you're brainy telling you're lazy.
That's not on site You probably need to treat yourself less harsh and this gets maybe to another topic on guilt What's an appropriate way to judge oneself and answer a suburb between you know Really depends on the circumstance and are you over-judging yourself?
Which almost every depressed person does or is it that yeah?
I kind of gotten complacent and uh, I climbed the hedonic treadmill and I'm kind of bored Yeah, and you do make you make this really interesting distinction between constructive and destructive guilt Effectively and like how are you gonna I look at it almost from like this seed is saying okay So here's an experience that has an energy to it Yeah, there's an activation energy to it.
What is it going in what direction is it going to activate you and you contrast that with what you were just sharing Like a lot of what you've been describing.
There's an element of seeking You know, there's an aspirational like I there's something out there that I want to move toward but my sense has always been that In the experience of depression even though you may see that thing that you want to move toward The movement toward it is the thing that is really hard to access like how do I actually go from being here feeling the way I'm feeling looking out there and saying I want that But I can't there's something inside of me that is not allowing me to do all the things that would get me from where I am to that place out there Yeah, several of the symptoms are in this direction.
So one idea is pleasure I anticipate if I do this thing like a workout for example.
I will feel good about it if you're depressed You're not gonna feel good about it.
It doesn't feel you don't feel anything you don't feel pleasure anymore So like the idea that hey, maybe I can motivate myself for the you know the intrinsic reward of the thing That's not gonna work.
You also have you know psychomotor slowing so like physically slower I mean, I remember one patient in particular I literally thought he had a movement disorder like Parkinson's because he walked so slow We cheated him with the intensive magnetic treatments.
We acted it to the part of the brain and uh, you know I asked my my team like who's the new patient?
This is no that's that's mr.
Smith It's like I recognized him by his gate and his gate changed so radically between you know days that I saw him That he looked like a different person So you've got that symptom that makes it harder to move And then you've got this sort of more squishy idea of energy or lethargy and like getting out of bed is Incredibly difficult if you have depression and so the things that would heal you you can't do and so it's you know insult Injury on this and so then and then you also have an amplified sense of guilt And so you beat yourself up for not doing the thing you can't do and you know that makes you feel even more discouraged So it's just this vicious cycle that's um, you know once you're in the spin.
It's hard to get out of by yourself But that said whatever amount of energy you've got like the key and the other thing that is um the key principle of my practice in book is Whatever energy you've got if it's the ability to walk to the mailbox or if it's the ability to run 10 miles Like use it and there really is a okay Maybe you can have a little bit more energy the next day if you do use the energy you do have and the other thing to recognize Is that sometimes that varies wildly some days you might have energy and others you other days you don't and so if you set like a fixed Standard I'm gonna do this much every day.
It's like you might have the capacity that some days and not others And that's discouraging but setting sort of tiered goals of like I'm at least gonna walk to the mailbox every day And if I feel good I might go for a walk kind of I feel great.
I might go for a run Great up, but not getting not getting too discouraged It's a hard thing when you don't have the energy to do the thing to make you feel better Yeah, I do want to drop into some of the body based things that you you actually just referenced earlier But before we get there you also just reference um some of the work you're doing with TMS For the Sonoma is this shorthand for trends if I'm getting a right transgranial magnetic stimulation Which is fascinating fascinating work take me into this more because I think it's really interesting And I'm so curious sort of like what are you seeing in this work right now?
Transgranial magnetic stimulation was an approach that was invented in 1985 Where you are able to activate a part of the brain or depending on how you tune the machine deactivate it And so the idea is we are able to put this magnet It's kind of about the size of a palm of your hand as the face of the magnet is over the part of the brain that we want to activate And this very powerful electromagnet is absurd you know depolarizes about a cubic centimeter of brain And you know you do that in a particular pattern you can sort of send signals down the wires of the brain starting at that location This was shown in the late 90s and early 2000s to be a very effective Or I at least at that time an effective antidepressant and from 2008 to about 2018 They sort of grew an acceptance grew and availability and even grew an insurance coverage And some more and more people are able to get access to this treatment for the treatment of depression And we sort of realized um, okay, well if you tune the machine in this way if you increase a number of pulses If you increase it we're able to optimize the parameters and then in 2018 Dr.
Williams, Dr. Williams of Stanford developed an approach called saint where he did a high dose To a personalized Target so he did a brain scan Located exactly the right place to stimulate and then did a lot of stimulation over five days And in the first study got 90% remission Absolutely astonishing remission rates and people who had really tried everything was this long term did it last?
They're doing long-term studies now, but yeah, I mean in my clinical experience it often does And the numbers ended up being closer to You know 50% 50 60% in the at the one-month time point and most of those people end up Staying better roughly speaking for for at least a year and then retreatment works great But the idea being this is the first time in the history of psychiatry that we had a treatment That could be potentially scalable where we started with the brain We use the brain the individual person's brain to direct the treatment now You know it's 2024 it shouldn't just be how we do psychiatry like the question is being in my head I'm like why is this not like the frontline treatment?
Yeah, and I mean that's the question in my head too, which is and part of the answer is inertia The powers that being systems that be are rather resistant to change You know for various good and bad reasons But yeah, it's astonishingly effective.
It's very fast It's currently expensive and that's part of the reason why it's you know prozac's three bucks a month and it's hard to It's hard to beat prozac so prozac you know on a cost basis Yeah, you know, but that comes with all kinds of side effects So the TMS We believe to be less have less long-term side effects than having to be on an any depressing long term But the more important that there is hope for depression is one major takeaway But the other takeaway is wait a minute we can modify any arbitrary circuit in the brain up or down That's wild.
There's a lot of stuff in the brain that's good that goes wrong beside depression and so sure enough So there's some studies on obsessive compulsive disorder.
So that also is FDA clear.
There's a studies in addiction And that's also FDA cleared and there's probably about a dozen other conditions from Parkinson's to Chronic pain to a variety of other things that live in the brain that are Treatable with this new approach and with these newer methods of targeting we're getting better and better at treating it I think that we're at the beginning of a revolution a pivot point in the history of psychiatry and neurology where it's no longer These general sort of bathed the whole brain and serotonin approaches It's like no this is the circuit that's wrong.
This one needs to go up We don't need to increase the whole temperature of the serotonin system to to affect us We just want to hit this one and so more targeted more personalized treatments are becoming available every day And so I think that it's incredibly exciting time in psychiatry even when I was going I'm not that old And when even I was going into psychiatry it's like, ah well, I really like talking to people And I like the deep questions and so maybe you know, this is the field for me and it's like wait wait a minute Wait a minute we're actually having breakthroughs in this thing This is isn't exciting time to be a psychiatrist and particularly in the neurosciences Yeah, I mean it's so fascinating to me because on the one hand you can talk to some folks in the field And they'll say like there's really nothing new that's been happening for 40 years now and then talk to you and you're like no wait a minute There's there's really groundbreaking stuff happen you talk to folks who are Um researching psychedelics MDMA and things like this and they're like okay, so really early days a lot of studies It's still needed, but there's some stunning things happening there too and Like these interventions they also strike me as So part of me out on you know a long time entrepreneur Part of my curiosity is how to improve the human condition part of my curiosity is like how does this become a sustainable model that like Everyone can access you know when you have some sort of pharmaceutical or something like that where basically It's like you take this thing often for years sometimes for life.
There's a great quote business model around it When you're talking about something where it's oh, this is a one time or like a one-week intervention and maybe it lasts forever And maybe once a year you come in for a tune up generally a much poorer business model behind that So like the entity is that support you know the quote industry of well-being It's much harder for them to get behind it.
So I would imagine there's a certain tension that you're navigating every day when you're doing this work Yeah, no, it is a very difficult set of questions and yeah, I think that there are understanding the financial incentives of the You know the medical system is is an incredibly important thing and It's watching a senate subcommittee hearing as one does And it's taking the years as the CEO of the company and trying to think about the business strategy of how do we get this out to more people And how do we develop the scientifically but how do we also make this more accessible and scalable understanding how money works in healthcare and it is dirty it is I thought it was dirty like starting out And I was like, oh, yeah, you know, you know greedy fat cats and all But it's like no it is like it's become this like frankenstein nightmare monster of wealth extraction That is you know consuming ever more of everybody's paychecks every month as it continues to just Doble at more and more and it's like It's incredibly efficient and frankly I used to think that it was like some you know that the CEOs of these companies were just sort of like you know Ringing their hands and thinking ah, yes, we're exactly going plant nobody knows it's going on It's so complicated, but all that diatribe to say yes, it's complicated to figure out how How to make this thing that really is potentially going to change has the scientific potential to change flourishing affect mental illness affect neurological illness in ways that have not been thought of before But it's much harder to extract profit from if you're a payer now that said the people who have been paying the money for healthcare Are largely the fortune 500 and they're getting sick and tired of getting taken advantage of by these these healthcare companies So so we're the beginnings of a sea change.
I think in healthcare payment because Again to be a little cynical is a little bit more a little cynical You can steal from poor people all you want nothing's going to change you start seeing them from rich people Well, things are going to change real quick and I think that we're at the point where the people who are stockholders and stakeholders and leaders at some of these bigger companies are seeing come on you know Big healthcare groups like this is absurd.
This is going to need to change But so there's an appetite for change, but the system is so complicated many now have tried and failed to do anything of utility In this incredibly complex system where lives are in the balance like you don't want to mess this one up Yeah, it must be interesting on like you know sitting where you sit on the one hand You know what you know you have tools technology and like ways to intervene that you see are just really helpful and really effective And to feel at the same time a bit hamstrung like how do we scale this out to millions and tens and millions hundreds of millions of people How do we make it affordable for everybody and Everybody wants it, but there's sort of you know, there's the level of friction Um in the middle is kind of stunning.
I hope you're right. I hope there is you know We are in this early moment of at least the early days of change, you know While we're quote waiting for that, you know while this you have these these ideas, you know like There are still things that we can do medication is certainly one of the options a lot of people pursue But you also brought up you know like these fairly straightforward accessible to everybody things You know, you mentioned exercise and we've certainly seen a ton of research on the effect of exercise And and mood and state mind and affect sleep.
I think everybody has sort of like heard you know recently how just profoundly important this is to not just your physical functioning but your psychological functioning Food is an interesting category and these are all three things that you write about you know in the body section of your book I feel like there it's emerging now as like oh wait a minute.
This is a better psychology too Yeah, turns out we're embodied creatures and that the uh, you know That the that the brain is connected to the body and uh, you know what goes on in your tummy affects your brain So yeah eat garbage and you don't feel good and as things like you know your mom could have told you that But like no, but really like and like understanding the starting to understand more and more about the physiology of like how exactly does that happen and You know having the appropriate nutrients and even some of these more carefully controlled studies and so there's Um, Mediterranean diet is uh, probably the best tested diet, but you know What exactly is that is it you know?
What are the aspects of it that make it magical lots of open questions But like it's not a bunch of junk food and fast food and ultra processed food um or it's at least less of that But yeah, you've got less mental illness.
You've got less depression You've got faster recovery from depression.
You've got less like you become depressed It's it's kind of and less likely to like physically die like eating good food is good for you And there's a sense in which we've always known that but I think that especially in a world that is Busy this is something else that I've I've I don't quite know how to I don't quantify This the sense that we're always rushing the sense that we're always busy The sense we don't have time for anything and like you look at the studies of like number of hours worked or you know How we're using our time.
It's like it's not obvious that we have less time now than we did 40 years ago But there seems to be something in our daily experience where I just don't have time to cook It's like yeah, I feel that like you know as much as this is good, you know Dr.
Heal myself like how often do I make a nice you know a nice bedded training and meal last night I did so I can brag about that But it's not as often as I'd like that I have the time or that you know We as a family have the time to sit down to a nice, uh, you know prepared meal because we're too busy You know maybe social media maybe the pace of life But it seems like there's a the sense that we just don't have enough time anymore and we once did Hmm.
I think that makes a lot of sense, you know I think a lot of people say like well, okay, so I get that food is gonna help I get that sleep's gonna help I get that exercise gonna help But but just like you're saying on like life's moving too fast.
How am I where am I gonna fit it?
How am I gonna fit it in um And I get that I completely understand that I think we've we've all lived that and felt it maybe like if you're listening right now You're living and feeling that in this moment you can't conceive of saying Well, I'm working two jobs and I've got a family support and a single parent and like there's like where where and how is this going to happen And I feel like that is one of the major frustration from so many people It's like they look at some of the basic things to say yes I get that this will help But how like in my life the way it is right now like I don't see the margins for this Yeah, and I'd say the few things Number one is If you're working two jobs then this might not be true of you, but many of my patients in Silicon Valley Could create the margin had they prioritized it It's not a financial thing if they just chose this particular lifestyle So ask the question is this necessary the answer may well be yes Of course I literally cannot afford rent unless I work two jobs And this is just how it has to be but like if you like many of my patients The answer is yeah no you could make some changes there and don't assume that you can't I think that's another thing you people sort of fall into this trap of like oh, I could never tell my boss And I've got to be home at six p.m.
Or whatever. It's like you know you might be able to the other thing is A little goes a long way in reviewing the research for the book the difference between Zero minutes of exercise and then they had a category of you know one to a few minutes per week It's like the difference between zero and one minute of exercise per week is like drastic Now they get probably it's the you know one minute not that different than zero But like 10 minutes a week or 30 minutes a week is like that is a big difference And so Trying to take the stairs when you're at work instead of an elevator or spending two minutes in the morning doing calisthenics or something or that There's the you know five minute workout from some years back that showed similar effect I had a patient who was not able to walk and so she got one of those under desk She you know she had lost he was a hundred pounds in a year I did she traveled and came back and then you know I saw him she like look like she lost a lot of weight.
I was concerned like I'm you know with the symptom of depression Like you must be feeling terrible.
No, doctor. I'm feeling great.
It's like what happened And oh, I just got this under and so she was kind of going like this She's kind of rocking back and forth during the interview I'm like when I was on zoom with her.
There was middle of COVID She said as it was oh, I got this under desk little bicycle like micro bicycle and she just does that all day long And she's just on this little bicycle under desk all day long And that's what she does.
She's off the hundred pounds in a year And it's like it you can't walk this lady can't walk because of a problem in her back That's not gonna ever get better.
So yeah, I did not in fact have my own You know under desk treadmill that she was able to lose a hundred pounds on despite not being able to walk So all to say these changes a little goes a long way and there was another study I can't quite remember the details But it was people who worked as housekeeping at a hotel.
Yeah, they just told them About hey look you know the thing that you do every day that actually counts as exercise and The education that this exercise presumably made them like scrub faster or harder or maybe take the stairs or something And they like lost substantial amounts of weight and were we're healthier afterwards So there's this sense of like even the things that you're doing physically to move move a little bit faster or have it in mind The hey it is counts and even that mindset shift can help in people that are that are feeling rushed and one more thing I'll say is an old word that which is Sabbath or rest So you know ancient tradition going back to certainly most as 10 commandments early pre-roots of Western civilization He got this idea that it's not just yeah, I don't murder people and I remember when I was when I was in college Engineering pre-med and so like I did not have time in college to take rest everybody studied all the time because you know For both engineering and pre-med let alone both so I was studying all the time and Then I was you know reading my Bible as I as I do and I came across the 10 commandments and I was like okay Yeah, not murdering anybody, you know I'm done doing pretty good on this one and you know So you know going down the list and you know not stealing and You know honoring God and all that so and then it was keep the Sabbath.
It's like don't work Don't work one day and seven.
That's got to be like one of the minor commandments And it's like no, this is like right next to murder like don't murder people Take a Sabbath I wasn't even trying to do that when I didn't even know that was like a moral duty Yes, I'm working on Sundays and it was the most magical amazing thing ever this this experience You know that that experience you get when it's the first day of summer and you just can't think of a responsibility It's not even you know that nagging list of stuff you got the mac your mind of like, yeah, I should be Whatever it's like that list is gone that list is is prohibited from on high I cannot work on that list This is for other stuff.
This is for spending time with people for going churches for throwing a frisbee It was great.
It was the most restorative thing and if I've I've kept that I've kept doing that practice and for a for me and throughout my medical training It's been absolutely transformative to have some time that yeah as busy as I am It's not gonna encroach on a you know on on at least this day this day is set up part for that So yeah, I mean we should be doing that with you know eight hours a night of sleep as almost a metaphor We should be doing that for sleep.
We should be doing that perhaps even in cycles in our life with sabbaticals periods where we're you know we've got vacations and that sort of built into our year But sometimes perhaps even longer periods where you just change the pace and I guess this gets back to the head on accept point You don't want to fall into these old traditions And if you're working the same thing every day, it's easy to just single track mind and if you stop it's like okay Who am I who am I when I'm not working who am I when I'm not busy?
It really gives time and space to consider One's identity and if you are defining yourself by your work.
Yeah, that's a problem.
That's real hard Yeah, and also it gets after to what you were talking about earlier Which is a sense of you know when you're working with patients and they start to like they start to lift and like What have they described that feeling I'm more like myself like But like you actually have to remember who that self is You know to be able to actually recall what it feels like and it's like and and the more you create space to step into that Oh like this is me This is me when I'm like at my best when I'm at peace when like I'm when my essence gets to show through I think we lose track of that so much out of that what you described is like that sense of busyness And we'll be right back after a word from our sponsors Hey, it's Nikola from side hustle pro from a local business to a global corporation Partnering with Bank of America gives your operation access to exclusive digital tools award winning insights and business solutions So powerful you'll make every move matter visit Bank of America dot com slash bank you for business to learn more What would you like the power to do Bank of America and eight copyright 2024 want to teach your kids financial literacy But not sure where to start green light can help with green light parents can keep an eye on kids spending and saving While kids and teens use a card of their own to build money confidence as a parent you can send instant money transfers Set up chores automate allowance and more.
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Yeah, there's a limit that you could get to you know Everything is going well with your body Everything is going well with your mind.
You're not believing false things about yourself You know the negative chatter is is died down.
You know, maybe you've controlled yourself in a sense the perfect stoic You've disciplined yourself.
You've organized your life and yet How high could the stoics rise?
The least don't let the gods see you you know cry like yeah, I mean that's kind of vindictive and you know Screw you gods.
It's like that's as high as you could rise is you know not not letting it show that Yeah, you're gonna die that no you can control a lot of things you can't control everything And that's not like happy that's minimizing the consequences of the negative and that's great And again if that's if that's the limit that we can go that is so much human suffering to be eliminated if everybody lived like that But that's not as high as humans can rise Yeah, I tell story or I recount the story of a woman who was in a convalescent home and she just you know end of her life Riddled with cancer alone blind unable to walk and Man came to visit her a pastor and he thought he was doing a good deed He was going to you know visit the poor people in the convalescent home as a you know as was his duty and You know was going to minister to these poor souls that were in such misery and he gets to her and she realizes that this person is Living a life of joy.
She can't see she can't walk She's being fed whatever the state can afford to feed her like every one of the things I say she should be doing She's not doing because she can't because she's in this you know terrible physical state He asked her like what do you think about all day in the blind in the dark with no ability to talk to people Lonely for you know not having friends for you know a decade.
It's like prison. It's like worse than prison And she said I think about my Jesus and how good he's been to me and she starts singing in him And it's like that's a state of blessedness of joy of of life that Even with all of the things and maybe even because of all of the things that I have and the most people have you know we don't often get to and this is um in the Possibly the most famous sermon ever given Jesus Blessed are those who mourn for they shall be comforted and so there's this sense of when you go into You there's this sort of topsy-turvy world when you when you go to the very limit of that direction You are lifted up and so in her case and in I suppose anybody's case there is this pathway that that's somewhat To some degree mysterious where you give up your life to gain it and in her case turning to Jesus turning to That's supposed following the example of someone who had everything at least according to the Christian story was God was the king of the universe and came down to live as a you know as a a a poor oppressed citizen of wrong not even citizen Poor oppressed then is in a realm and lived his life in this um, you know obscure village for for many decades And that's how you overcome to a greater degree and achieve the state which I call blessedness Yeah, I mean, so it's so interesting and I've seen some of the research on You know that measures Again, it will use us where loosely happiness or flourishing and Religacity and as a general rule all the research that I've seen is the more religious you are The more satisfied you are with your life the happier you are the more you feel like you're flourishing Even if you're living under really very constrained conditions I think people have tried to tease out well what's happening there and they look at well Your part of the community like a very well-defined tight-knit community And then we all know relationships are really important and you Have a set of beliefs that basically help you identify like if x then y like if this happens in your life in the family's life in culture Here is the answer here's the behavior that you do here's the practice So to a certain extent it minimizes sense of uncertainty and so okay Yes, I can I not along with that that that makes sense to me So we're looking at all these sort of like you like research-based things and then But is there something bigger going on that is literally like not quantifiable now?
And it will never be quantifiable.
It is a sense That it just is and I'm fascinated by that question Yeah, I mean, I think a lot of people will you know show me the evidence or are I'm pragmatic I follow the evidence where it leads and it's like well There's this one mode of being that seems to be better on most measurable domains of Flourishing of the good life of whatever we want to call it and you ask them and and they ask them You know, what is all about and they they point up or they point to god?
They tell you a story about something profound and I think that for a lot of a lot of folks It's like you know, what do you do with that like you shrug and listening to a um another podcast even this morning And it was the podcaster talked about how you know faith was a gift that I haven't yet been given And it's like yeah, this is great, but like what do I do just go to church and there's some really interesting research on that question Which is so there's a researcher at Stanford Uh, Tonya Lureman who studies various anthropologists, you know are famous for going to you know obscure villages and strange customs and traditions and peoples and So she went to a very strange tribe of she got famous for visiting psychiatrists So she went to a psychiatrist residency and studied us very strange tribe indeed very strange very strange tribe And then she went to um and so she also wrote a book a few years back called when when god talks back where she You know lived in you know works of Stanford and palo Alto in northern california and she Traveled all the way to the other side of palo Alto to visit this group of charismatic Christians And so she visited the church and then lived with them and went to the bible studies with them and tried to understand And how they saw the world and one of the things that she Emphasizes and this is a line with other sorts of cognitive science work is that the default state of a human Is not like we start a fiest and then somebody teaches us to be a fiest It's something different.
It's not that we start like christian or you know islamic that those are things that very clearly have to be taught It's a belief in god or gods belief in their being a spiritual realm And then we sort of shape that sort of prewiring into our civilization shapes it either into secularism or into Christianity or islam or whatever it is And so her point was that or what she discovered was that it was a repetition that every Sunday these people would come together They would sing songs they would hear a sermon they would move together They would sing together they would speak in tongues You know all of these sort of practices and rituals help them reinforce this particular way of belief And so in a sense Yeah, we can say that faith is a gift that just sort of strikes us like lightning and sometimes that happens But most often it's just like everything we've been talking about it's embodied embodied in a human physical community That people meet together every weekend this particular place if you go and learn their ways and see their customs and go visit You know most of them are more than happy to have you to explore But it's also something that's really difficult to do outside of a community It's almost like it's this emergent phenomenon Again, there are very important exceptions to this of the hermits or of of individual monks that will go off into the wilderness And like have these experiences, but almost everybody has to experience that in a community And yeah, and that the community imbued with the set of all beliefs and strange practices But all of that goes together and it's almost like you can't separate it's like that That you know the drug companies big pharma likes to figure out like oh well, you know Here's this plant that does this thing what if we extract out this one Compound and then we can sell that for a bunch of money.
It's like well Okay, you can't like extract out the theology of Christianity or the praying five times of Islam and like inject that into a Atheist and think that's gonna do anything like it's a system You kind of got to take it at least mostly as it is and find your place in it and you know these are big tents There's a lot of you know whether you're going to be a you know a ecstatic person who's experiencing the ecstasy of prayer or whether you're going to be a you know An dusty phyologian reading books like those are within the same Community but it is a community but all that to say it it's something that people can do and should explore I think and I think that um Seeing that more and more even in people that you know I would never have thought would explore that side of things.
I think that we're seeing the And of what pure and maybe hardcore atheism can do.
Yeah, I mean it is really interesting I think we you know we've seen all the data You know the growth of the quote nuns the people who who consider themselves spiritual but non-affiliated And then the question I think for a lot of them that they're asking now is you know like how am I doing?
And if I actually do want to feel like I'm part of something bigger what does that look like for me?
You know like maybe I don't want to go back to the way that it was taught to me or the community that I left But have the sense that I want to be a part of something that there is something bigger whatever that may be in it I do see a lot of questioning now and a lot of so like reimagining like what is this in the context of my life And the way that I want to be in the world and it's it's an interesting moment just this sort of like Those questions drop Yeah, I think that's exactly right and and this is um and I think even the uh the spiritual but not religious category itself Is that a wave and is declining that and you know when we look at the research too.
It's it's Believe in God matters much less than was your butt in a pew somewhere last Sunday That question seems to be much more important than you know what you happen to believe about God And so again like you're right.
It's it's the community.
It's the whole apparatus of experience of being connected to this thing that exists And the Bibles were too or too or too or gathered Okay, maybe it's and then I think there's a quorum um in Judaism for a synagogue So you know that there's this appreciation that it's not just an individual could have it But an individual isn't the thing but but yeah like that's that's certainly where it can start but how You know, is it the traditional ways that can be plugged back into is it something new?
Is it a new variant within this is it's some different religion?
I think these are important things we need to start wrestling with in a more Aggressive way particularly because to that point of of was your religious participation The the strongest protective factor for suicide of all the things I've ever heard of is Going weekly to mass 50 fold reduction 50 fold reduction in suicide completion There is nothing more powerful the that particular thing if I knew nothing else about a person beside They went to mass that is the most protective thing they could say more protective than I've never attempted suicide or I've never You know, I know it's like this is a huge thing And so if we would we're thinking about what is flourishing?
What is the opposite of depression?
You know, how do we prevent suicide?
Like if we see something that reduces it by 50 fold If we want to at least think about hey, maybe that's got something to it or maybe there's components of that If we want to try to separate it we shouldn't be Ignoring that effect as that says something profound about our human experience when it is that big You know that big a difference Yeah, that's it's so fascinating Um, so curious to see where all all this goes over the next decade or two as well Yeah, she's like a good place for us to come full circle as well So in this container of good life project If I offer up the phrase to live a good life what comes up?
I think I'll go back to Westminster to glorify God and enjoy in forever Hmm, thank you Hey, before you leave you'd love this episode safe But you'll also love the conversation we had with best old vandal called about trauma You can find a link to his episode in the show notes This episode of good life project was produced by executive producers Lindsay Fox and me Jonathan Fields Editing help by Alejandro Ramirez Christopher Carter crafted our theme music and special thanks to Shelley Del for her research on this episode And of course if you haven't already done so please go ahead and follow good life project in your favorite listening app And if you found this conversation interesting or inspiring or valuable and chances are you did since you're still listening here Would you do me a personal favor a seven second favor and share it maybe on social or by text or by email Even just with one person just copy the link from the app you're using and tell those you know those you love those you want to help Navigate this thing called life a little better So we can all do it better together with more ease and more joy Tell them to listen then even invite them to talk about what you've both discovered because when podcasts become Conversations and conversations become action.
That's how we all come alive together Until next time I'm Jonathan Fields signing off for good life project You
