Drew Ramsey: Food and food choice really do impact things like depression risk. They do impact things like inflammation, which we know directly correlate with things like depression and dementia, and to really help patients add this idea and this way of thinking as a way of empowering them.
Dr Rupy: Welcome to the Doctor's Kitchen podcast with me, your host, Dr Rupy, where we discuss the most important topics and concepts in the medicinal qualities of food and lifestyle. This podcast is the place to be for anything to do with nutritional medicine and how we can use both food and lifestyle to prevent and manage ill health, as well as maintaining your optimal well-being. My guest today is the wonderful Drew Ramsey, who is a leading innovator in mental health, combining clinical excellence, nutritional interventions, and creative media. He is an assistant clinical professor of psychiatry at Columbia University College of Physicians and Surgeons and in active clinical practice in New York City, which is where we had to do a Skype interview for our podcast today, because unfortunately he wasn't in the UK. As you can probably tell during the podcast, we really get on. I do see him as someone I, it feels like I've known him for many years, and when you get to the end of the podcast, you can see it kind of just disintegrates in us just having a back and forth and a bit of banter. His work has been featured by the New York Times, Wall Street Journal, The Lancet Psychiatry, The Today Show, BBC. He's been named the Kale Evangelist. He's given two TEDx talks, and the reason why, actually, to go back to kale, that he's the Kale Evangelist is that he actually was able to create a National Kale Day in America, which is quite some feat. His latest book, Eat Complete, talks about the 21 nutrients that fuel brain power and transform your mental health. His first book was called The Happiness Diet that he talks about. All of them are absolutely fantastic. I've currently got Eat Complete, which I'm making my way through at the moment. He's also got an e-course, Eat to Beat Depression, which helps people maximise their brain health with every bite. And he's on the advisory board at Men's Health and a couple of other psychiatry journals as well. He's a real powerhouse of knowledge and so, so humble with it as well. I mean, just reading his accolades, you know, if I didn't know him, I'd be pretty scared to interview him, but as you'll tell during this pod, he's just such a lovable, humble person. Today's topics, well, we talk about his background, what his clinical practice looks like, what nutritional psychiatry means to him and actually how he practises it with patients. And we go into some of the patient experiences that he's had as well. We touch briefly on omega-3 fatty acids and supplementation and his views on supplementation. The 21 nutrients of transformation, we didn't go through all of that, but it's all in his book. We do talk a little bit about inflammation as a causal part of depression and actually how we don't want to slip into the reductionist fallacy of depression being just a neurochemical imbalance. I think it's really, really important to recognise that this is a multimodal disease, and by that, I mean there are multiple different ways in which depression presents in different people, and the way we treat it can be vastly different. I also really like Drew's take on mental health being something that everybody deals with, which is why he is such an advocate for looking after your mental health before it becomes an issue. We all have to think about mental health in the same way we look at cardiovascular disease in preventative measures. Remember, you can find all of this information and more at thedoctorskitchen.com. Subscribe to the newsletter for weekly science-based recipes. Please give this podcast a five-star review if you found it helpful. It really does help spread the message. And we're going to be posting a discount code for Eat to Beat Depression, the e-course that Drew Ramsey has got on his website on thedoctorskitchen.com in the podcast show notes. So make sure you check those out.
Drew, thank you so much for making the time. I know we have to do this via Skype, and I would have loved to have had you in the kitchen and cook you something from one of your incredible recipes in your latest book, which I absolutely love. But until the next time I'm either in your part of the world or you're in the UK, we're going to have to reserve that for another time.
Drew Ramsey: Well, I'll take you up on your invitation to cook me some recipes from my book. I love that. That sounds like a lovely evening, and I look forward to getting in the kitchen with you. It's something I really like about you and admire about your work is how much time we get to see you in the kitchen. You definitely influenced how I cook, more spices, more chickpeas, stuff that I really just, I love what you bring to the table.
Dr Rupy: Thank you, man. And I did actually get the opportunity to cook for you when we first met for the first time. I've been following you for a while now, but we met at Chef Bouley's restaurant when I was doing an event, and we organised all the menu and stuff, and we were sat opposite each other drinking some delicious wine.
Drew Ramsey: That was a good night. It's, since we're both physicians and we're both deep in the food as medicine world and we both love to cook, it was really, that was a really nice treat because also, following you to really have that be a first night for us to get to know each other and hang out and I really enjoyed that. Chef Bouley creates great relationships and great synergies, so I'm looking forward to our next time we're there together too.
Dr Rupy: Yeah, definitely, man. And that sort of connection you have over food as well, and that's why I'm a massive fan. So, why don't you take us back? Because for my listening audience who may not be aware of you, even though you've got TED talks and a couple of books out and you've got, you're crushing it with the stuff that you're doing with the American Physicians Association, psychiatry association. Tell me about your journey toward food and your love of food, in particular, kale.
Drew Ramsey: Kale and all leafy greens. I'm an equal representative now for the food category, leafy greens. Don't tell the kale mafia. So, hey everybody, it's a real treat to be speaking to you all and so yeah, I'm Drew. I'm a psychiatrist and I mean, the food story starts with me that when I was really young, I was about six, my parents got, in America we had this back-to-the-land movement. And this is kind of, it's happening now again as people are more interested in farms and farming, but kind of the extended version of the hippie movement in America had a lot of people who were thinking about homesteading again, the whole Rodale family had kind of come out with the notion of organic farming and getting back to our roots and putting up our food. And my parents really got swept up into that and moved from Long Island to really rural Indiana. And it's actually where I moved back in with them. My wife and our kids and I did about three years ago. But that's where I'm from, and they moved out there with a real intention to grow more of their food, to be closer to the natural cycle of the earth, to really live in a way that is, you know, now we're understanding really aligned with the values we're pushing in medicine and in lifestyle medicine, to sleep with the natural rhythm of nature and to swim in their pond in the front of their house and raise a lot of their food and have their kid race around outside a lot, which is what we did. And so I spent a lot of time as a young kid gardening and eating our own tomato sauce and and really on my personal life, food has always been very important. I was a vegetarian and when I became 20 as part of that, you know, kind of low-fat, low-cholesterol movement, and so I was really focused on what I was eating. And then during residency, as that omega-3 data was coming out, I did my psychiatry residency at Columbia University, a really amazing place to train, one would argue one of the top places in the world to really learn about psychiatry. And there wasn't, there wasn't really a focus at all on food, but it just kind of struck me. The omega-3 data started coming out. There was that big study that came out showing there was a correlation between fish intake and the national risk of bipolar disorder. There were a couple of initial trials of omega-3 fats being used to augment antidepressants. There's, you know, some epidemiological data that suggests omega-3 fats related to depression and dementia in some way. And I kind of got the question, like sometimes you get as a physician, I was like, where do those come from, those omega-3 fats? And I realised like, I didn't really know. I was like, fish oil. And like, well, what's in there? And you know, you look like, okay, it's made of EPA and DHA. And it's like, well, what do those do in the body? And it just kind of opened up my mind to several things. One, I was still a vegetarian at the time that I wasn't eating any seafood. And the other was just how little I knew about this aspect of my patients' lives. And that's really where my food journey in this form has taken off over the past, let's say, 10 years with my first book, The Happiness Diet, and then really working hard to just know my patients as eaters and to know them in a much more intimate way as an eater than I had really ever conceived of.
Dr Rupy: Yeah, it's amazing the omega-3 stuff that came out, actually, and it's still ongoing. I just had a lecture, actually, during my master's program in nutritional medicine where we had a psychiatrist who is definitely of your way of thinking who is certainly recommending to certain patients that omega-3 supplementation would be beneficial. And there's a whole bunch of evidence around why and what the mechanisms of action are for long-chain omega-3 fatty acids. And as you said, as a vegetarian, you know, unless you're taking algae supplementation, it would be quite hard to get it into your into your diet.
Drew Ramsey: Well, that's also as physicians and as researchers, how it begins to get approached, right? Of like, can we supplement it? That's where we're going to do the, the what we feel are higher quality trials because we can placebo control them and and you know, can we augment it and can we treat patients that way? And really what food has led me into is this realisation that in mental health, we've not, we've really let the public down and let ourselves down, that we haven't gotten involved with people before they're ill, ever. There is no prevention in psychiatry. You never want to meet me as a psychiatrist. You never want to tell anybody you see a psychiatrist, and you're going to wait until you're really, really ill. And what's really opened my mind and given me a lot of hope is a notion that by being involved with food and linking mental health to brain health, we can get involved with the public in a much more preventative way. And that's really where food, you know, I'm excited about the data and we'll talk about some of the data that's been really great science, but to me, the real promise is in getting the public thinking about their brain and their brain health and their emotional health and thinking that there are a set of tools. Food is obviously just one of those tools, but there's a set of tools that by making better decisions and different decisions every day, you can influence your mental health and emotional health and your brain health. And that to me just, that's gotten me really juiced up.
Dr Rupy: Absolutely. Yeah. And it's and the more you learn about it as a physician, the more you actually want to entertain giving, you know, open-minded, honest advice to patients who really need it. And on that note, I wanted to just ask you about what your current clinical practice looks like and the conditions that you see, because you work in both Indiana and in New York as well, and you're seeing like a really, a real array of different sort of clinical presentations.
Drew Ramsey: Yeah, well, so I began my work actually in community mental health, and one of the things that got me into food, maybe I should include this in my food story, is the atypical antipsychotics. These are medicines like aripiprazole and olanzapine, quetiapine. They're atypical, they were a new generation of medications used for psychotic disorders like schizophrenia. And they were very effective clinically and really devastating in terms of side effects that patients began to develop metabolic syndrome. So patients would gain 20, 30, 40 pounds, they'd be sedated, they'd get high blood sugar, dyslipidemia, high and begin to get, we first we called it syndrome X, but then we now call it metabolic syndrome. And that just really concerned me, this notion that I was giving patients something that helped them, but also in terms of their long-term health trajectory was just a tragedy. So today, I'm mostly in private practice in New York. We have a small team here. I have a wonderful health coach and therapist, psychotherapist and chef, all in one person, Samantha Elkrief, who has really expanded my practice and giving me that, you know, I'm a doc who likes food and I know some things about nutrition, but Samantha's a real, I call her the food fairy. She's really skilled in the application of, you know, you need a little za'atar spice in your life, or, you know, you're way too worried about chickpeas. Have you tried this other, just really wonderful ideas around food and around what's really become central to our practice. We're a general psychiatric practice, so we see patients mainly for with depressive and mood disorders, some bipolar disorder, and anxiety disorders. But what probably sets us apart and makes us a little odd is that we want to know about patients as an eater. When you meet us in an evaluation, you'll, we'll ask the question all shrinks ask, but we also want to hear about your relationship with food and particularly what I'm listening for as a psychiatrist is how you think about your own nourishment and how you derive joy from self-nourishment and nourishment of other people, and whether you do derive joy, because so many people have this very conflictual relationship with food. People have a lot of conflicts about food, and this is where I've really enjoyed marrying up my psychiatrist hat of thinking about conflicts and motivations and really the foundations of who we are and how we think about ourselves with this new nutritional knowledge that's coming out that that food and food choice really do impact things like depression risk, they do impact things like inflammation, which we know directly correlate with things like depression and dementia, and to really help patients add this idea and this way of thinking as a way of empowering them. Because, you know, psychiatric care in some ways is very disempowering. It's it's me, the expert who knows a lot about the deep workings of your unconscious, and over years, things will happen and you'll, you know, change. I love psychotherapy, I do a lot of it, I've been in a lot of it, but that's a long-term process that isn't in some ways empowering right away. Medications, very empowering in terms of they help patients with symptoms, but people generally tend not to like them, feel very stigmatised about taking them. So this idea that there's these things that you can do, that you own, your food, your exercise, your sleep hygiene practice, I really like that as a way of empowering patients.
Dr Rupy: Wow, there's so much that I want to pick up on there. Like, first of all, your practice sounds incredibly utopian. I mean, it's brilliant that you have a collection of both the physician, but also chefs and psychotherapists that can really give that overview, that real holistic treatment package. But also the last point about giving patients that control back, because I think, particularly in medicine, when things are outside your locus of control, it really degrades at your identity as being able to do anything for yourself, and you are completely reliant on external factors to better yourself. And that is really like, it's, it gives you a lot of embarrassment. I mean, I know of this from personal experience when I had my heart issues, and I was reliant on anti-arrhythmic medication, I was reliant on my cardiologist to perform electrophysiology studies to find out what the heck was going on. And it's, it's embarrassing as being a patient, and it's incredibly vulnerable as well. You feel incredibly disempowered to do anything about it. And lifestyle in and of itself, I mean, it's not a cure-all, it's not a panacea, but it offers that real, genuine attempt for a patient to actually do something for themselves.
Drew Ramsey: One of the things that we hope for in health care, I mean, we hope to be empowering for patients. You know, your cardiologist wants you to be empowered by the electrophysiology findings to, you know, which you were in a lot of ways, right? You changed your lifestyle. Part of your journey is, you know, it was you got empowered, but you know, it's like we don't quite get it right because we're a very disempowering industry where there's a lot of shaming of patients, especially, you know, in mental health. Patients go and talk to mental health providers say, well, I'm changing my diet to improve my mental health. It's almost our default stance is like, well, that's not going to be enough. You know, like you need some meds, you need some therapy. And you know, like I like what you said, it's not a panacea, but there's this weird disconnect that in medicine, we know that food choice underlies the majority of pathology that we see, but we don't actually help anybody with their food choice. It's like it doesn't make any sense. And I think part of that and what's really changing, I hope it's changing, is that as there's more awareness of how things like food impact our health and mental health, patients have gotten much more proactive in terms of really asking for that information, really changing their lifestyle. And you know, it doesn't take a lot of examples clinically of seeing how people can really take control of their food to, you know, to become a convert as a physician that this is really powerful medicine.
Dr Rupy: Absolutely. Yeah. And I'm glad to see that psychiatrists across the world are actually engaging in this discussion a lot more. I know you know Professor Felice Jacka, and she's been pivotal with some of her studies looking at nutritional psychiatry and how we can use that as an adjunct. I just wanted to go back on to something that you mentioned about inflammation because I think inflammation is like a really hot, sexy topic in both medicine and food and nutrition in general.
Drew Ramsey: It's like we had to say it like 10 times this podcast, right? If we didn't say inflammation, people were like, why don't they talk about, don't Rupy and Ramsey know about inflammation? We have to say that, we have to say microbiome. Like we're not going to leave. And coconut oil. I'm going to say coconut oil and avocado. We've got to say that. We definitely have to say avocado. Keto, don't forget this. Oh yeah, yeah, we're going to talk about keto. And we have to talk about, I mean, we've already mentioned dark leafy greens, but yeah. But anyway, inflammation, as you're saying, such a buzzword these days.
Dr Rupy: Really is. But I find it absolutely fascinating, particularly like, you know, how inflammation is, yes, one of the mechanisms by which we see a lot of different lifestyle-related illnesses, cardiovascular disease, the issues associated with obesity and metabolic dysregulation. But I know you talk about it a lot in your books. How does that relate to depression?
Drew Ramsey: Well, if you think about your brain is, you know, really the most special part of your body. I mean, one of the reasons I want, I look forward and I hope everybody listening is really going to reconsider your mental health. What I've been asking people is to think about your mental health 2.0, right? Like what's that next level for you of better mental health and all the ways that you could think about that. We want you to think about your brain as these very specialised cells. They're really doing more work than kind of any other cells in your body. And anytime cells are, you know, they're like any engine, you're running at a high metabolic rate, you're creating a lot of waste products, you're needing a lot of inputs. Inflammation is is is simply the alarm settings of our body, right? It's the natural forces that we create in our body to deal with injury. And so as we have all kinds of things that are quote-unquote injurious, right? Whether that's stress and lots of cortisol, whether that's eating a diet that tilts our cell membranes to be more pro-inflammatory, the notion is that inflammation and kind of is having excess inflammation, well, it's like having it anywhere in your body. If you sprain your ankle, walking around on rounds in the hospital becomes a much more difficult and arduous task. You can still do it. Rupy will still finish rounds with a sprain. If we give him two sprain ankles, he'd hobble along on crutches, but his experience of it, his patient's experience of it, it wouldn't be the best day. He'd get home and his ankles would be hurting, he'd be grumpy. And that's kind of a good example of that's just because of inflammation in his ankles. So we want to kind of make that analogy and translate that into thinking about both your brain cells and also that way that it's not as simple as when you're upset, you have inflammation in your brain. But in some ways it is. When you look at things like some of the interleukin treatment for hepatitis, I think over half of those patients get depressed. Think about what happens when you get the flu. You get, you know, that day where you have the flu, you're like, oh my gosh, I just am so depressed and I don't have any energy and I'm kind of tearful and I feel achy and it feels a lot like clinical depression feels like because those inflammatory signals in the body naturally cause some of the feelings that we see in clinical depression. So that's kind of how we think about inflammation is related to the brain and related to depression. There are lots of biomarkers that support this. Patients with depression have higher CRP, they have higher homocysteine. There's just a big meta-analysis that two of them that have come out looking at the use of anti-inflammatories, any anti-inflammatory, whether it's a statin or an NSAID or a COX-2 inhibitor, and finding a much greater response rate to antidepressants. And so it turns out that, you know, when you think that anti-inflammatories have a big data signal that they're antidepressants, you know, it at least it leads us right now in the data to know that something about inflammation and depression are very interrelated that we're going to unravel.
Dr Rupy: Absolutely. And you know what, I have loved watching this sort of realisation where we've known about the associations between inflammatory disorders and depression, and now we're actually beginning to see links of causal mechanisms between inflammation and depression and a whole suite of other mental health illnesses. Some of the stuff that's come out regarding the mechanisms is it reduces the reuptake of neurotransmitters, it lowers your serotonin and diverts it toward actually neurotoxic chemicals in some cases via the kynurenine pathway, I always forget how to say it.
Drew Ramsey: You've been, yeah, you've been boning up. Yeah, I mean there are all these, and I like what you're saying that, you know, it's that we as we understand more mechanism, you know, there's a kind of, I would say academic parts of medicine and for all of us as physicians that we love to geek out on that stuff. And then I do think there's that farm boy in me that says, okay, like how are we going to change somebody's life today with this information? And where, you know, how does this idea of everybody listening that you can change the, in some way, let's say make your diet somewhat more anti-inflammatory. And we'd all kind of convince that sounds good. Who wants inflammation in the brain? I don't want a sprained ankle in my brain. And like, well, what are you going to eat differently at dinner tonight? Because that's really where the rubber hits the road, right? How is that going to directly inform your choices? And and that's where I get so excited about your work, Rupy, is that I really feel more than just about any other doctor, you really give people the tools for that of really, you know, we could all talk about like, oh, more spices, spices are anti-inflammatory. It's like, okay, I can put a spicy recipe in my cookbook, but like you really show people the use of a lot of these really ancient, really anti-inflammatory spices. So it's, it's just great work.
Dr Rupy: That's great, man. Yeah, and same to you. And one of the things I love about medics as well, in general, and scientists is that we love a mechanism, we love a pathway. And once it's like, it's binary like that, okay, inflammation bad, we can block inflammation using, yes, food, but you know, certain pharmaceutical targets, then I can understand that. But one thing, and this is going to your point, I wanted to talk about is, do you think we use the reductionist methodology in the way we approach something that is quite systemic in too much of a way? In the same way we treat, you know, individual symptoms with one pharmaceutical, one pharmacological target at a time. And in reality, is depression not actually a suite of different conditions that in some cases, yes, may have a chemical imbalance, but in other cases is and exactly what you're doing with your with your clinic, have deep psychological roots.
Drew Ramsey: Yeah, I mean, I think we get overly reductionistic. One of the things that I really love about psychiatry and I really love about Columbia psychiatry is a kind of constant pressure to be on your toes clinically and be thinking about deep psychological causes and really appreciating those in our patients. It's one of the reasons I went into psychiatry. I mean, I'm seeing you, it's 10:30 in the morning here and I've been seeing, I've been listening for four hours. I have four and a half. I started this morning at 6:00 a.m. and really listening as carefully and in a different way than in a way that really has gotten lost in a lot of medicine just because people don't have time. And so I think one of the reasons we've gotten reductionistic is that Prozac is very effective for a lot of people. And Prozac costs $5 a month and you can prescribe it in a primary care doctor's office visit that takes 10 minutes. And that's a very efficient way to treat depression and anxiety. It doesn't address the root causes, be that inflammation or, let's say, you know, polymorphisms in your serotonin receptor or your BDNF gene, or the deeper psychological causes. So often informing depression, things like trauma. So much trauma that so many of us have experienced, whether that's being bullied or being, it doesn't have to be sort of sexual assault or a trauma on that level. It can be a trauma of neglect or a trauma of just not being understood during development. You know, I was like the nerdy kid who got teased. And those things sit with us. So, you know, I think we both want to reduce mental health because it's scary, right? And we want to live in some denial and in a lot of ways perpetuating the stigma that those are the conditions of other people. I've got the slide in my slide deck that, you know, one in five people have a mental illness. And I'm like, I hate this slide because like five out of five of us have mental health and it's fragile and it could go at any minute. And if you're not working on it, I think you're at increased risk of, you know, becoming one of the one in five Americans who have a mental illness. It's just, it frames the argument as this notion of other. And then you look at, okay, lifetime rates in men of a substance use disorder, half of us, right? Lifetime rates of depression in women, I mean, just majority, right? It's just, it's, it gets reductionistic because in many ways the challenges that medicine has faced and how do we wrap our arms around mental health? How do we even diagnose these disorders? We don't have any biomarkers. So let's describe them. Well, now, you know, medicine, we're in trouble with that, right? We have this somewhat unreliable diagnostic system and, you know, everyone's angry at antidepressants because they don't work. I think when you sit with hundreds and hundreds of patients that have depression, you see that that what you're saying, that there are a variety of different ways to get into those illnesses and not just depression, also anxiety disorders for sure, and substance abuse disorders. And that that people respond really differently. It's very humbling as a physician. You give a patient Zoloft or you prescribe them the Mediterranean diet or you do a course of CBT with them and you see some people, it just totally works. I mean, their lives, you see Prozac kick in in a month and people come in and it's like, oh my gosh, you were a vibrant living human being. You give that same medicine to a patient who has kind of the same symptoms and they come in and they're like, this is the worst thing I've ever taken. I hate it. I feel awful. I feel jittery. This is, it's humbling and you realise that, you know, it's where it's, it's, you realise quite quickly that to respect without any judgment that there are lots of different ways that people get better and there are lots of different values that people bring into treatment and that we have to do a better job respecting those values and engaging with people because they're, you know, I can give you an antidepressant that's an herb, that's a diet, that's a pharmaceutical, that's an interpretation about your development, that's a prescription for better sleep and exercise. Like there's lots of antidepressants that we have.
Dr Rupy: Absolutely. And I'm so glad we're like having a genuine conversation about this being, you know, your anecdote about five out of five people have mental health and we are all fragile. And it just takes some people who have a lower threshold to tip into what would be classically defined as a mental health condition.
Drew Ramsey: Or something that could take your own experience, right? During your episode with a heart arrhythmia, like how was your mental health? I mean, it must have been a mess.
Dr Rupy: Yeah, totally. I mean, one of the things, I can't remember if we talked about this, but one of the things was that, you know, as a physician, I mean, you know, you went to Columbia, one of the best universities in the world, medical schools in the world. You're meant to be indestructible as a medic. You know, you're meant to do your residency or your foundation jobs without really thinking about, you know, the fact that you haven't slept for three days straight and you're stressed out your mind, but you're a medic, you can deal with this. This is what your job details, you know, you're meant to be an absolute warrior at all times of the day. And for you to suddenly realise that your threshold for a poor lifestyle is so low that you tip yourself into, you know, episodes of where your heart beats like 200 beats a minute. I mean, it's, it really degrades at your your central identity, whether I could even do this job. And after studying for six years, that was a, that was a big realisation.
Drew Ramsey: Well, I mean, there's all kinds of layers of that for you. I mean, not to make this a session for you, but I think just to think that, you know, how many clinicians ask you about your mood or whether you were depressed, right? And if you were anxious, you got maybe a little Ativan because you don't want to trigger an arrhythmia, so it's better to take a little Ativan just to calm it down. And and all the ways that sat with you that, you know, what, you're no longer a warrior. I mean, you're, you know, you're, you're also, I mean, you're a special guy because, you know, you're not, you're not just sort of proving it as a physician, but you're, you know, you're also bringing a a real cultural element to the workplace. I don't know what it, I don't know what it means in to be British and of, as you're, are you from Indian descent? Indian, yeah, Indian background, yeah. Right, but there's a, you know, there's a whole complicated layer in that of, you know, not just being a man who's struggling with his health, but, you know, being, I'm sure there's a lot of pressure on you to prove things in all kinds of different ways. And so the idea that you're struggling not just with a heart arrhythmia, but probably also with your mood and with your anxiety, like those are words that, you know, we can't, you know, male physicians, we shouldn't use, right? We never get depressed and we don't have anxiety. And, you know, that's probably one of the reasons that at least in America, and I suspect it's similar in the UK, physicians are the top group for suicide. I mean, we are at the number one risk group and, and it just I think goes to speak of that, um, I guess one of the things that's nice about the world getting a little more woke is this idea that it's not going to work for us as physicians to die in droves like this and it doesn't work for our patients if we don't walk the walk. And if we don't understand that, you know, it's five out of five of us. You're working on your mental health just like I am, just like my patients are. You're working on your physical health just like we all are, because then we're in this together, which I feel is more cosy to me.
Dr Rupy: Yeah, 100%. And I feel like a lot more of us are getting more attuned to the idea of self-care and how important that is. And I think it probably took me a few years after to actually recognise how much of an impact it may have had on my self-esteem and my mental well-being. And it wasn't until like, you know, having open and honest conversations with other people about it who have been in similar circumstances, albeit with different pathologies, that I came to realise, you know, this is something we just need to be a lot more honest about. And I don't know about the US, but certainly in the UK, there's definitely a lot more efforts from our employers in the National Health Service to to actually give a little bit more advice and actually a bit more leeway for for self-care and lifestyle.
Drew Ramsey: Yeah, it's, we're seeing more of that in the US. There are more wellness programs, but I still think it's a big cultural shift for us as physicians that that, you know, it's finding that that balance between, yeah, we can still be warriors, we can still pull all-night shifts and and, you know, more than that, maybe just sit and hold space with illness and death and that it's, we're trained, it's not going to rattle us in a certain way, but also acknowledge that that rattles all of us and that, you know, you got to, you got to feed the machine so to speak of taking time to really nourish the self and and make sure that we are in tip-top shape for doing this job.
Dr Rupy: You touched on something earlier regarding, you know, the varying effects of pharmaceuticals or lifestyle interventions from patient to patient. How do you process what you're going to start a patient with based on their history, based on their presentation? Like, how do you actually approach a new patient when they arrive in your clinic? Like, what's the thinking behind everything?
Drew Ramsey: Well, I really look at the history. So it's a big difference somebody who's never been treated with depression or anxiety and somebody who's come in and they've tried a number of different either psychotherapies or medicines. You know, I kind of start from an acuity standpoint of really making sure that there aren't safety issues of just often having to contend with really frightening symptoms like suicidality and so I really kind of look at, um, a symptoms-based approach. What are the primary symptoms that I'm dealing with? What are the primary barriers to function? Is there what I think of as low-hanging fruit in terms of someone's psychology that they either ideas they haven't explored? Let's say someone who tells me that they were sexually molested as a child and they've never talked about it. You know, while that's a very traumatic thing to hear about, to me, again, that's low-hanging fruit. That's something that's really important and a core piece of your identity that talking about that with a skilled professional and getting into it and understanding it is going to lead somewhere. I don't know where, but it's going to lead somewhere that's critically important for that person's psychological development and human potential. If I hear something like, you know, someone's been trying a million different diets to treat their anxiety and they've never had Zoloft or, you know, sertraline, that's going to go on my list of things. So I kind of, in an initial consult, I'm looking for symptoms, what's been tried, and like what's my, what's in my bag of tricks? What are the list of interventions that are evidence-based? Someone who, you know, comes in and they're eating garbage, they're eating the standard American diet. They wake up and they have a muffin and a, you know, giant soy Frappuccino latte, you know, just a giant processed food sugar bomb. And then they have, you know, they tell me they have a healthy lunch of some iceberg lettuce with a chicken breast and some, you know, ranch salad dressing. And then they tell me they feel guilty in the middle of the day, but they have to have their pick me up, so they have a giant bag of white chocolate pretzels. Right, I'm starting, I don't have to hear much more to think that goes on my list. Like, all right, this is a person who thinks they're making some healthy choices, so that's good, they're interested in that, but is not eating any of the foods that I would want them to think about as really being at the top of their list given that they have a lot of anxiety and depression. Um, and I kind of think about the next steps in terms of somebody who's coming to me and is in a really bad depression, not sleeping, there needs to be medical interventions to really turn things around or the person will end up in the hospital potentially. Um, versus, you know, someone who through the conversation feels a little more settled down, symptoms aren't as severe, and what are some of the more either natural things, ranging from some supplements to getting into a supportive relationship, psychotherapy relationship that's going to help them. And often times, you know, what's nice about my job and our clinic is that you don't know sometimes after sitting with somebody for an hour. And and that's why we meet with people frequently and people come right back. I would say usually it's a couple of sessions, two or three sessions to really have a feel of who someone is and then, um, and then that leads to our interventions. Um, sometimes we see folks with much more severe concerns, things like ketamine addiction, um, and substance use and various types of struggles. Um, but I mean, I think that gives you a little notion of how we think, which is, you know, what's our best guess of a reasonable diagnosis? What are all the treatments for that? And then who is this person? How can we fit something together that feels really good to them? If you come and see me and you're like, you hate big pharma, okay, like I'm not going to think that I'm going to give you Prozac until we get to know each other really well. And I want to have a lot of other tools. I'm going to talk to you about, you know, foods and lifestyle changes. I'm going to talk to you about some herbs and supplements that might be helpful based on the data. And then, you know, I tell patients a lot, I think about that we're in the service industry and I'd like to give you a menu. And here are the things that would be reasonable to try that people have tried that I've seen work, that evidence tells us work. How do those sound to you? What questions do you have about them? Which one do you think we could get started on the fastest because unfortunately, I can't, you know, right now I can't predict whether you're going to respond to Zoloft or psychotherapy or lifestyle changes. And so let's get started on a trial. And what you see then is, you know, after a month or six weeks, people are better or they aren't. And I'm real like, I don't know, I wouldn't say quick to judge, but like I'm, like when something doesn't work, I'm really like, that's great news. As I tell patients, the next step, best step is the next step. Once we know what's not working, then we're on to, then we're looking for the next thing that will.
Dr Rupy: We're getting more attuned to just how rife mental health issues are just generally in society. What do you think we don't know about? Do you think we're, we're literally just looking at the tip of the iceberg? Do you think we're, we're, we're
Drew Ramsey: I think we're looking at the tip of the iceberg because we don't, you know, unlike the rest of medicine, you know, I'll, when if you have a bad depression or anxiety, I'm going to test your thyroid. I'm going to look, make sure you have your B12 normal and your iron's normal. But you know, but besides some of those basic labs, I'm going to make sure you're, you know, you don't have drugs in your urine, but you know, in some ways, if I'm a good psychiatrist, you'll tell me about that, right? That if you think about a test that really is going to direct my treatment or an imaging scan, there isn't much. And so that's going to completely change in the next 10 to 15 years in psychiatry. Um, for sure. We're going to get more biomarkers, we're going to do a better job of matching up probably genotypes with different treatments. We're not close to that yet, but we're getting there. Um, and I look forward to seeing that because it's very frustrating. Patients say, all right, well, like why'd you pick that medicine? It's like, because I like it, I've seen it work, you know. And because like, well, why not this other one that's evidence-based? It's like, you know, and that that's how a lot of us practice and, um, you know, I think I want to do better than that for my patients. My patients want me to do better than that. So, um, then there's this whole new layer of data coming out about neuroplasticity. There's this whole new kind of way that we're learning about how the body kind of speaks to itself. There's all the microbiome data that's just blowing up in terms of the different types of organisms in our gut and how they dictates, you know, beyond the sound bites that like, oh, the bacteria in your gut makes serotonin. It's like, whoop-dee-doo. Like, the bottom line is your gut really regulates your inflammatory processes and is absolutely central to having a healthy brain. So, so for example, you know, that just, if I would have told you four years ago, five years ago, that the gut is going and and giving probiotics and fermented foods is actually going to become something that people think about in mental health. I mean, 10 years ago, people would have just laughed at that idea. And now that is like, I was just talking to my colleague, Jeff Miller, who's the head of neuroimaging at Columbia psychiatry. And, you know, they are right now in the process of scanning brains for inflammation and correlating it to patient microbiome for patients with depression who are in the hospital, right? So it's, it's, cool things are happening.
Dr Rupy: I mean, I, I was just in a lecture the other day, um, looking at different methods in which, is this some banging? That's, that's my New York, this is how people know it's an authentic New York City interview. That's my heater.
Drew Ramsey: That's your heater. I thought it was a builder like just going at it at the radio.
Dr Rupy: It's the heater. It's just, it's, it's actually the little tiny water molecules that get caught and then they bang around and it's, I guess, such force that it sounds like a hammer, but it's just a drop of water. Like, that's New York for you.
Drew Ramsey: That's, that's New York for you. Yeah. No, I, um, like the microbiome and the microbiota and all these different methods of communication with our brain just absolutely fascinate me. You know, we like to, again, with the reductionist hat on, we like to think, okay, well, these, these metabolites of microbial activity include short-chain fatty acids, but also neurotransmitters like serotonin. That's clearly going to have an effect. Well, actually, serotonin is having an impact on your brain via indirect mechanisms. It's quite unlikely that it's going to be crossing the blood-brain barrier, although there's some people that postulate that, but more likely, it's going to be having an impact on the motility of your gut and then also interacting with your vagal nerve afferents that will take information directly to your brain and actually change inflammation pathways centrally. So, and that's just a tip, that is the tip of the iceberg, you know, it impacts.
Dr Rupy: Yeah, but I do think that describes the mechanism. To me, in enough detail that it catches our interest and it makes sense. The idea that this vagus nerve is sitting down there and it is taking in tremendous amount of information from the gut. Um, the idea that these, um, uh, these signals directly influence the brain through the vagus, uh, that's, you know, that that's increasingly, you know, supported with good science, but also, you know, makes, it makes sense to us. You know, especially if we begin to think about serotonin not as like the happiness molecule, but as the homeostasis molecule that it regulates sleep, sex. I mean, I fiddle with serotonin a lot in people's brains, not fiddle, but you know, it's part of what we do and, you know, it has tremendous effects on cognition, on creativity, on sex drive. Um, people think, yeah, it's, it's really, uh, it's a very, very, you know, the model is ubiquitous in our systems. And so, um, it does a lot more than just making us happy.
Drew Ramsey: Totally. Yeah. And like, to go on your point about, um, choosing different treatments based on data that we currently lack, it is exactly the same here in the NHS that what we know about through our own personal research, through communicating with like, you know, within the functional medicine community, within the nutritional psychiatry community, it can be quite frustrating for a physician on the front line where you know there is a way in which you can match certain interventions to certain people, and there will be a way of actually making that a much more educated guess. But currently now, it's kind of like, what's the flavour of the month? What have you seen anecdotally? What is within your sort of locus of practice that you've seen that could potentially work and it's going to cause the less, the least harm based on clinical.
Dr Rupy: And also the part that's frustrating is we hear that we have a huge mental health crisis, which we do. But I have to tell you, when I meet someone with depression, I'm just, maybe this sounds cocky, but I'm not worried about whether I can get them better or not. I'm not going to say our cure rate is like 100%, but our getting people better and into a better space is pretty high. And that's not because our clinic is, you know, better than other. It's just, I think most mental health clinicians, if you give them some runway and allow them time and space to work, we have tools to get people better, lots of them. And most patients do get a lot better. I feel like we all so often it's sort of, you know, with meds, we hear about the bad reactions and the horrible side effects people have, but we don't hear about, you know, the 16-year-old who was hearing voices and wanted to kill themselves and, you know, four days later on medicine was feeling better and didn't have any voices or, maybe that's an extreme example, but you don't hear those, you know, things I hear in my office all the time. And I don't mean to sound all pro-med, everyone's listened in to hear all about the food. We got to tell, we got to tell people what to eat for mental health here, but the, um, but just that that, you know, when when treatments get called like a miracle or I feel so much better or I understand that about myself now. And so, you know, I think that's one of the reasons that that also in mental health, we're hesitant to innovate is that there's been so much kind of quote-unquote innovation or hope for the future that hasn't worked out. And when we then have some of these workhorse medications and workhorse therapies that like do work out, it's we've had a hard time innovating. Um, and then you think about the innovations that's happening, right? It's like all drugs, like psilocybin, microdosing LSD, ketamine, you know, and it begins to feel that as much as I'm excited about a lot of, I'm really excited about a lot of those things and how they could change my practice. Um, it still feels to me that there's some things going on with people's mental health and how we approach and and develop mental health that that we're not getting right in our in our cultures. Um, and that there has been this kind of breakdown of institutions and values that traditionally have protected our mental health and give us orientation around ourselves. So, but I feel like we got to talk to people about, everyone's still listening, we got to talk about what foods we think people should eat for their mental health.
Drew Ramsey: I'm really glad that you touched on the acute side and the more severe side of mental health and how pharmaceuticals 100% have a role because I think there is an assumption that when we talk about food as medicine or we talk about nutritional psychiatry, we're talking about either or. It's not a combination approach. And like you said, very eloquently, there are people that have had miraculous improvements with the use of pharmaceuticals, and I don't think that should be forgotten.
Dr Rupy: Oh, it's so stigmatised, Rupy. Like imagine you're a mom with a suicidal depression and you're better on Zoloft. Like, you're going to bring that up in mommy's group? Like, hey, just so you ladies know, like I'm, I'm I wanted to like totally die last week, but I'm feeling great and I think it's a Zoloft. No one's going to say that, right? They're going to, even though that's like, what a miracle, you feel better. Like, but that's like the most stigmatised, right? You know, when you were struggling with your afib, if somebody would have put you on a little antidepressant, even to walk in and be like, God, you know, guys, thanks for all the support the last few months. I've really been struggling, but I got on a little medicine and man, I'm just feeling so much better. Everybody be like, oh, wow, are you going to be on that for a long time, Rupy? Or like, ooh, is that bad you needed medicine? Where you'd never be like, wow, you're, you know, hypertension was so bad you need medicine. You'd be like, wow, I'm really glad you're treating your hypertension. So there's that huge amount of stigma we have. Um, and I think people do forget the acute. You know, I think that's part of where the mental health community gets a little jaded is that, you know, you spend months in a psych ER and and really seeing the crisis that we have and people in acute mental health crises and and it gets frustrating when, you know, people want to, I don't know, really speak with authority. I really try not to speak with too much authority and with much more humility that comes from like, um, a respect for patients and individuals' experiences that are very different from my own and and that we really often are in a stance of judgment, right? I'm feeling bad. Hey, don't feel so bad, man. I'm anxious. Hey, you shouldn't worry so much. As opposed to that really more empathic and true space of like, what's bringing you down? And like, what's getting you worried? And really being with people in those mental states as opposed to dismissing them.
Drew Ramsey: I love the vibe, love your humour, love the humility that you bring to the profession, but also this crazy world of being in the media and juggling that with a proper clinical career and, you know, talking about food, which is very niche and actually, you know, being a champion for change in in terms of the appreciation of nutrition and lifestyle in conventional medicine, which I don't like, I don't like the word conventional medicine, it's just medicine. It's just, it's, it's, it's just medicine. And you know, I think the more that we can, you know, as you do a good job, kind of bring it under one house, realise that we have a lot of partners in this who aren't necessarily physicians, um, who are other advocates in health care, you know, our colleagues in nursing and in dietetics and in coaching and that that, you know, we have a, the UK and the US has a massive mental health care problem and and that, you know, we both don't want to hold out for some Hail Mary microbiome, ketamine, psilocybin, crazy whatever that that, you know, that that cures everyone from everything, um, when we know that there are lots of interventions that we can help people with to feel better and we have those now and and that food's one of those. So, absolutely. I'd love to, if you have any thoughts on any of the new developments in psychiatry, namely intermittent fasting, psychedelic treatments, um, anything wacky and wonderful to do with microbial and psychobiotics and stuff, um, let me know, man. I'm sure the listeners would love to hear about it and we'll jump on the pod again.
Dr Rupy: I think we'll, we should, we should, we should schedule a follow-up podcast for a few months from now and we can talk about that. But I think that that, you know, we we definitely are going to learn a lot about ketamine. That is a very exciting treatment, but also a treatment that has a lot of limitations to it. Um, but you know, at least exciting news that when people are acutely suicidal, there are medicines that look like can take those suicidal thoughts away, that do take those suicidal thoughts away for some patients within hours. I mean, that's just, you know, that's a radical concept. When you think about something like psilocybin just got granted, um, a special status by the FDA as an emergent treatment, something that's going into, I think phase two trials now. Um, there's a lot to learn, um, and a lot we are learning, but you know, the good news for people, especially anyone listening who's struggling with their mental health, is, you know, there's both the core workhouse stuff that that should work, right? Of of better lifestyle, responsible pharmacology, good psychotherapy. And then it's the human brain. Like we don't understand it yet. And there's, it's the tip of the iceberg, but we are rapidly, rapidly gaining, um, ground and, you know, new exciting things are going to come out of that for all of us to to benefit ourselves and and humanity's mental health. And that's, that's a very, you know, that's in some ways why I became a psychiatrist is like you realise, okay, it's going to be a, it's going to be going off here for the next like 20 to 50 years when it comes to understanding brain health and, uh, um, and it's, and we'll, we'll keep up as long as we can. I want to know what brain foods that you're going to eat today, Rupy. That's what I want to know. I want you to leave, I want you to leave your listeners with a brain food prescription.
Drew Ramsey: Well, mine's all about fibre right now, man. Um, so the mechanisms behind nurturing your microbiota with different types of fibres, um, I find absolutely astounding. The way your microbes can create different chemicals, they can create them, you know, changes in how you digest food and how that actually communicates with your cognitive functioning. Um, so trying a different type of bean, pulse, or lentil, just getting into the habit of actually introducing that into your diet, maybe once a week, if you already do that, maybe twice a week. I personally have one of those things on a daily basis. Like I already had my lentils in the morning because I had leftovers this morning. So for me, like it's all about the microbiota and trying to use what we have right now to, um, to to to nurture and encourage it. And then the advent for psychobiotics, I think is, um, it's strong, uh, to the point where I'm going to start taking a regular kefir drink in the morning, um, just because A, I can, and B, it's actually very affordable, particularly if you.
Dr Rupy: Oh, and from a probiotic standpoint, it's better than anything else. So all of the smoothies in Eat Complete use kefir. If you look at the, I mean, there's not a ton of science of how much colony forming units are in yogurt and in kefir, a few studies, but kefir both has more types of bacteria, live bacteria in there, but you know, some of these has up to a trillion CFUs in a serving of kefir, which when you complain like, you know, a good probiotic is what, 50 billion. So you're talking like 10 to 20 times more and it just to me, it feels a little more, um, less space-agey and more like real traditional diet that no one's ever taken probiotics before. We didn't, we didn't even have a vitamin identified until 1912, right? This is all new stuff, supplements. But people have been, you know, if you look at, I love when you look at the kefirs and the yogurts, you know, one of the, a lot of the, you know, fancier ones, they have this like Bulgarian, like ancient, you know, it's like ancient bacteria from Bulgaria is the key. And it's like, yeah, it kind of is the key. It's been around forever. So,
Drew Ramsey: Honestly, there was an episode of Rick Stein where he travels from Venice to Istanbul, and I think he goes through, it's either Turkey or it might be Bulgaria, and he basically goes and visits like some goat herders and they serve him a cheese that's made in the intestines of a goat. And it's like, it sounds disgusting and it didn't look great, but this is how this ancient tribe of people have been living for hundreds of hundreds of years. And this is their, this is their probiotic, man.
Dr Rupy: It was one of my favourite moments on our farm. So we're three years ago, we leased some lactating goats. And so like these are like pregnant goats basically, or goats that have just given birth that we took them to our farm and milked them every morning and made goat cheese. And and it's how, like with all the anti-dairy movement, I was just, I don't know, I got curious and boy, it's hard when you like spend time with goats and milk them and see like their udders kind of fit perfectly in our hands and that, you know, making goat cheese literally is like taking milk, squirting in some rennet juice, letting it curdle and then running it through a cheesecloth and that's it. And it's like the most delicious stuff, you know, cheese that you've had. It's just, um, it's really, uh, to me very fulfilling and kind of fascinating, but also feels just very like anciently human, right? Of of, but that that fermentation has always been a part of of human existence. It's, you know, the original way that we stored food. And so, so but, you know, I ask you for your brain food prescription for your audience. So, um, Dr. Rupy's audience, what I hear him saying, and I suspect you know this is lentils, which is like that is if we're going to be a brain food that Rupy's going to represent in the animated film brain food, it's going to be the lentil because you're lentil game is seriously strong. Your lentil and chickpea and bean game is really strong. And that's a huge food category, especially, you know, we think about complication, time and money, super simple, super inexpensive, right? And small red beans are the red beans with the most antioxidants according to the USDA. So if you need some special, you know, sound bite about your meal, you can make small red beans. Um, and then I hear you pulling out the kefir. And I think everybody's listening today, you should make a commitment right now, come hell or high water, or if it's late at night tomorrow, you're going to have some lentils and you're going to have some kefir and you're going to dedicate them to Dr. Rupy and the Doctor's Kitchen, all his good work.
Drew Ramsey: Okay, so if you're going to start with a spice, a singular spice, I would say fennel seed. A spice mix? Oh, a spice mix. Yeah, so spice, so singular spice, I would say fennel. Uh, spice mix, I would say baharat. Um, baharat spelled B-H-A-R-A-T. It's almost like a, a mix between ras el hanout and garam masala. It's like a beautiful spice mix with like cinnamon, clove, cumin, but there's something quite distinct about it. It's not quite ras el hanout and it's not quite garam masala. There's something else going on about it. And, um, I find it delicious. And that, that will change your brain. It will change the way you think about spices because you can, you can put that on white fish, you can do it lentils in it, you can make a broth with it. It's, it's very, very versatile.
Dr Rupy: We say that's the, the rule of kale. All my, we launched now at National Kale Day here in America about seven years ago, all my kale shenanigans. And it led to, I wrote 50 Shades of Kale. They rejected my, my subtitle, don't get rough, get roughage. But, but the, the basic rules of brain food are that you pick foods with nutrient density, which we've talked a lot about on this show. You pick foods with culinary versatility. What you're talking about, you put it on your white fish, you put it on lentils, and you pick foods that are locally available, either because, you know, you're growing it locally or there's, that's part of like the local food community, but, um, but I like, I like your brain food prescription and I really look forward to maybe we can cook some of that up next time we get together and it's been a real treat being with you, my brother, and I will look forward to our next conversation.
Drew Ramsey: 100%, man. Can't wait. Can't wait.
