00:00
Dr. Nicholas Fabiano
With depression itself, we actually don’t even know the mechanisms of what’s causing depression. Low serotonin equals depression and that’s why we treat with these antidepressants that restore serotonin levels. But we know it’s a lot more complicated than that.

00:11
JJ Virgin
Dr. Nicholas Fabiano is a third year resident in psychiatry and is like totally making waves in terms of using exercise therapeutically to treat depression. He is a psychiatry resident and researcher at the University of Ottawa. He has been doing a lot of research on the intersection between mental health and physical health, especially in terms psychiatry. And he’s got a beautiful way that he talks about how to dose all.

00:35
Dr. Nicholas Fabiano
Of this just challenging yourself. So whether it’s exercise, whether it’s signing up for a course that you think you can’t do, even though during these times it’s very difficult to get through, and even more so when you’re in a depressed state, the fact that you’re able to accomplish that and get through it, no matter how hard it is, it gives you this what we call locus of control.

00:56
JJ Virgin
Hey, I’m JJ. Virgin. PhD dropout. Sorry, Mom. Turned four time New York Times bestselling author. As a certified nutrition specialist, fitness hall of famer, and globally recognized leader in health, I’m driven to keep asking the tough questions and use my podcast to simplify the science of health into actionable strategies that help you thrive. I’d also love to hear your thoughts on the show. And here’s the fun part. When you send me your review, I’ll reply to you using my on demand virtual me. That’s right, my team and I created a virtual JJ packed with my books, speeches and wisdom so I can personally connect with you. Here’s how you do it. Subscribe and leave an honest review of the podcast. Take a screenshot of your review. Text it to 813-565-2627. That’s 813-565-2627.

01:55
JJ Virgin
My virtual JJ will reply directly and trust me, this will make your day. So subscribe now@subscribetoj.com and text me your review. Let’s keep thriving together. Dr. Nicholas Fabiano. What a great name. Welcome to the show.

02:14
Dr. Nicholas Fabiano
Thank you for having me.

02:15
JJ Virgin
I’m so happy you’re here. I stalked you a bit. So as I was telling you offline, I have a talk that is unusual for me because I’m talking about the mental health benefits of exercise and as I was digging into all the research about it and I love the fact that I’m now Going to medical conferences, talking about exercise, first of all, makes my heart sing. But I was like, you kept showing up, and then I found you on a podcast. Now all of a sudden, you’re on every podcast everywhere.

02:42
Dr. Nicholas Fabiano
Yeah, I’ve been busy lately.

02:44
JJ Virgin
It’s fantastic. Exercise is finally having its day out there. It makes me so excited. Let’s go back to how you studying psychiatry ended up with looking at exercise as a treatment modality.

02:57
Dr. Nicholas Fabiano
Yeah, so it’s a great question because it’s kind of in psychiatry, you don’t always see those two going hand in hand. But my swords are.

03:04
JJ Virgin
You never see them go.

03:05
Dr. Nicholas Fabiano
Yeah, you never do. And I think we’re seeing a tide shift now, but you don’t traditionally, as you mentioned, see them go hand in hand. So a little bit of my own background. I’ve always been into sports and different things like that. Like, I played soccer throughout my life and in medical school, tried to stay active and different things like that. And at first, I was actually interested in going into more of a sports medicine sort of career. But I found when I was doing some of the electives in sports medicine and working with some of the varsity players, a lot of the concerns were more so surrounding mental health. So that was something that piqued my interest.

03:35
Dr. Nicholas Fabiano
And then during medical school, unfortunately, I had my own little bit of an accident as well, too, where I was getting into the gym a little bit more. I started arm wrestling. Not professionally or anything like that. And I ended up actually breaking my arm in arm wrestling. So I have a big scar right here, a nice surgical scar.

03:52
JJ Virgin
Oh, man.

03:52
Dr. Nicholas Fabiano
Yeah.

03:53
JJ Virgin
For those of you who can’t see it, his whole forearm is like a scar.

03:57
Dr. Nicholas Fabiano
When I broke my arm, at first I didn’t think it was a huge thing, but I noticed the impact it had on my mental health, where I went from being able to do all these fun things, work out, and how important that was for my own mental clarity to now breaking my dominant arm, not being able to do a lot of the fitness stuff. Can’t even write my exams and stuff because that’s my. My hand. And top it off, after I had surgery on it, I ended up getting nerve damage, too. So my radial nerve was unfortunately damaged a little bit, so I couldn’t move my wrist properly either.

04:26
Dr. Nicholas Fabiano
So all these things came down and I realized how important exercise and how intertwined mental health and physical health were for my own experience on top of this, and how important it was for my own recovery from my prior experiences from my. My silly arm break. It really led me to have a passion for exercise and for exercise specifically in mental health. And the most applicable one, when I started looking into it, was more so through the lens of depression. So that’s kind of where some of my interests peak first. But, you know, since then, it’s expanded beyond that, even beyond exercise. And it’s more so applying, but emphasizing these lifestyle parameters to mental health. So at the forefront with psychiatrists, not just at a, you know, population level from a prevention standpoint, but also from a treatment standpoint.

05:13
Dr. Nicholas Fabiano
So I had my interest, I broke my arm, and here I am now.

05:16
JJ Virgin
Yeah. Well, I love that you are out there talking about this. It is such an incredible thing that you can use in depression. In, like, I have a son with a traumatic brain injury. We did a lot of exercise therapy to bring him back. Like, there’s so many different places I’d love to start, really high level of just what some of the mental benefits of exercise are before we get into kind of more treatments and the different types and all of that.

05:42
Dr. Nicholas Fabiano
Yeah. So in a general sense, there’s a lot of different benefits for exercise. So even if we’re not looking at it necessarily from a mental health perspective, we know that there are associations with variety of different types of exercise and cognitive benefits. So whether you have depression, whether you don’t, whether you’re deemed to be a quote, unquote, healthy individual, exercising regularly will lead to improvements in your cognition. So that means your ability to think through stuff, your memory, and all these different factors which are so important. The other obvious thing that we don’t often think of in the realm of brain health is just your overall body health and how that goes hand in hand with your mental health and with your brain health. So moving regularly is so important for the health of your body. It also helps regulate things like your sleep.

06:24
Dr. Nicholas Fabiano
Staying active and being active throughout the day and in a regular interval is so important to regulate your sleep, which, you know, moving forward also improves your mood and cognition and all these different things. And we know with exercise as well, there are different structural changes to your brain. So with exercise, an area of your brain called the hippocampus, which is very important for memory, has actually shown increases in size. And this is particularly relevant as we’re getting older because we know some of these brain regions will actually shrink. So exercise can have a protective effect against some of this. And, you know, the topic of this podcast is mental health benefits. So diving into that with exercise, we see most of the literature is behind depression. So some of these antidepressant effects. But there’s also benefits for anxiety.

07:06
Dr. Nicholas Fabiano
There’s even benefits for more of the severe mental illness, like schizophrenia from a symptom perspective or even cognition perspective. So, you know, we could probably go all day speaking about all the different mental benefits of exercise, but just to show that it’s very important in a quote unquote, healthy population. But there’s also so many applications in the field of psychiatry.

07:25
JJ Virgin
So I think back 30, 40 years ago, I’m totally dating myself, but back then we all thought the mental benefits of exercise were endorphins. And everything was about cardio back then. So it was all about running to get endorphins. But I think the key point here is it goes way past that and through a variety of different types of mechanisms. Right.

07:48
Dr. Nicholas Fabiano
I think there’s a large focus on the biological basis of exercise and the antidepressant effects. One of the things that I like to bring up is with depression itself, we actually don’t even know the mechanisms of what’s causing depression. It’s previously been this theory or the serotonin theory, where low serotonin equals depression. And that’s why we treat with these antidepressants that, you know, restore serotonin levels. But we know it’s a lot more complicated than that. I like to break it down into what’s called like a biopsychosocial model, so we can speak about the biological things that exercise does from antidepressant perspective. So we know that exercise increases some of those myokines, so how your muscles essentially communicate with your brain. And one of the important ones is brain derived neurotrophic factor, or bdnf, which is otherwise termed as miracle growth for the brain.

08:29
Dr. Nicholas Fabiano
So that’s a very important one that we think is implicated in depression. And that’s what leads to some of those brain changes that we’ve seen. We know that exercise also can reduce inflammations, whether that’s peripherally or that’s centrally in the brain, which again is important because there are a lot of different inflammatory hypotheses for depression. So we think that may be another mechanism. Exercise can lead to some of these brain changes. Where we see increases in the hippocampus, which in depression, sometimes we actually see shrinking shrinkage of these brain areas. So those are some of the biological realms of what exercise is doing. But oftentimes we stop there, we stop it biological and say, okay, that’s what exercise is doing. But I like to open it up a little bit further Than that.

09:11
Dr. Nicholas Fabiano
One thing is the social aspect that I mentioned, and it’s particularly important for people that are maybe rather isolated. Exercise may be an activity or the only thing that they’re doing during the week where they’re doing it with someone else. So whether it’s a fitness class, whether it is being on a team sport, whether it’s even just going to the gym and speaking to other people that are there, it’s such an important part of exercise that often goes under recognized. But it’s hard to really separate the two unless you’re doing an exercise that’s completely in isolation. There’s probably an element of being social that’s contributing to the antidepressant effects, because we know how toxic loneliness can be to your body. Not even just mental health, but also the physical perspective.

09:51
Dr. Nicholas Fabiano
And then the other thing that I like to bring up too, is through the psychological lens, we know that immediately after exercise, you have that almost boost in mood, and that can give you that motivational push to start doing other different things and to tackle your next goal. Those are some of the antidepressant mechanisms beyond just the biological basis. But I think they’re so important to be aware of because we get so stuck in the biological sense, because it’s the fancy one, very interesting to talk about. But there’s also the other realms that are so important too.

10:17
JJ Virgin
You know, I heard you talking about social on a podcast, and I thought that actually may be the most important one. When you really look at this. It was kind of a running joke back when I was a personal trainer paying my way through grad school was I’d take clients and start working out with them, and they would literally vomit up their whole life stories. Like, all the stuff. Like, I knew everything going on more way. I was like, don’t need to know all this. Like, everyone’s relationship problems, like, all of it. And I kept thinking, gosh, should I just go become a therapist? Should I become like the, you know, exercise therapist? Because it’s. It. It does. There’s something about movement that just gets people to start letting things go. Think about how. How effective that could be. Maybe that’s a new.

11:01
JJ Virgin
A new form of specialty therapy. The challenge, though, that I see is, you know, and I think back, so I. As I told you, I had a son who had a traumatic brain injury. One of the first things I started getting him to do was to move and just kind of reconnect things. But some of the times now, as we’ve been working through it, is getting him to do it when he’s not motivated. And I have a friend right now who’s in the big lower part of a bipolar stage, and I was like, could we just get out and walk up the stairs? Like, you know, it’s someone who is listening to this, who’s like, yeah, but I don’t want to get off the couch.

11:40
JJ Virgin
I mean, how would we move them from being completely sedentary to starting to do some of these things that are going to help?

11:46
Dr. Nicholas Fabiano
That’s a great question. I think there’s not a clear consensus in research of what is the smallest amount of exercise to have antidepressant benefit. But there is literature, and when you look at meta analyses, which is when you bring the studies together to suggest that going from sedentary to even moving just a little bit. So, like you mentioned, whether that’s just going for a walk, whether that’s while you’re at work instead of taking the elevator, going up the stairs, and hopefully it’s not too high up, but just these little steps are so important because I think sometimes we get lost in what is optimal for exercise.

12:17
Dr. Nicholas Fabiano
What is the optimal intensity, what is the optimal amount, what is the optimal timing that can become very overwhelming for, as you mentioned, like your friend, that’s at a lower point right now that can seem overwhelming to the point where you’re like, I’m. I’m not even gonna try this. So I think the emphasis needs to be placed on just doing any little amounts of exercise and using that as motivation to build to the next stage and really shaping in a way that is something that you like to do. Because similar to diets, you can have a perfect diet that, you know, calorically macro and micronutrients, everything’s perfect. But if you don’t like it and it’s not sustainable to make, it’s very expensive, you’re not going to do it.

12:55
Dr. Nicholas Fabiano
And the same principles apply for exercise, and even more so when you’re in a state where you’re feeling more down or depressed, Any amount of exercise is better than none. And starting low and going slow will always be the best approach with something that you like.

13:08
JJ Virgin
And it all counts is the good news.

13:09
Dr. Nicholas Fabiano
Mm.

13:10
JJ Virgin
Now, even though it does all count, and I’ve. I’ve looked at some of this literature, and it seems to be skewing more on the cardio side. I think it’s important to look at it because exercise is as broad a category as nutrition, where you’ve got vegan and paleo and carnivore you know, and then you look at exercise and you’ve got everything from walking to sprinting to powerlifting and everything in between. So you have all these different modes. Are there different things that are really stand out in the field of mental health?

13:39
Dr. Nicholas Fabiano
Most of the literature is based on aerobic exercise. So things like walking, running. I think that’s the case because it’s easier to conduct studies and safer oftentimes to conduct studies versus putting someone in a weight training class or something where there is, you know, maybe a higher likelihood of injury. And it does happen with running, weightlifting sort of thing. But when you look at again, the meta analysis which put all these studies together, there’s not necessarily a clear winner in terms of aerobic or mind body. And let me, I guess I should describe the different classes and research based first before I kind of go into that. We alluded to one already. There is aerobics. So that’s things like running. Then we have resistance, which are things like weight training. Then we also have mind body, which are things like yoga.

14:17
Dr. Nicholas Fabiano
And to circle back to, what I was saying is there’s not a clear winner amongst those. The most important thing is adherence. So in the literature it’s dominated more by these aerobic studies, but it doesn’t necessarily mean that they’re better when we’re starting to put these studies together. So with a patient in front of you, or if you’re just even listening and wanting to get into something, think about what you want to do and what would be interesting and whether that’s something you’ve done in the past and you would want to pick it back up, or whether it’s something you’ve just seen online and you’re like, hey, that would be cool to try. I would say go for it because ultimately you want to have that curiosity and passion to learn more about it and get into it.

14:53
Dr. Nicholas Fabiano
And that’s what will build as you start to learn more rather than saying, you know, going to your doctor and saying you have to run this many miles at this pace, maybe won’t yield as many results.

15:04
JJ Virgin
I will tell you, when I was in grad school, all of the research was done on cardio. Like I actually went and did strength research and I was, it was hard to even find an advisor. Everything was based on cardio and it is a lot easier. You have class Monday, Wednesday, Friday, do three 30 minute training sessions and cardio so easy to control. You know, you do wonder, because I think Andrew Huberman was talking about this on his podcast Cast of one of the things that happens with exercise. And you could do this with cardio, but it wouldn’t be so much steady state. It’s more like the hit or the resistance training of what happens to your brain when you do these hard things. Can you talk about that?

15:42
Dr. Nicholas Fabiano
Yeah. So I think even though it’s out of the realm of mental health, just challenging yourself, so whether it’s exercise, whether it’s signing up for a course that you think you can’t do, even though during these times it’s very difficult to get through, and even more so when you’re in a depressed state, the fact that you’re able to accomplish that and get through it, no matter how hard it is, it gives you this what we call locus of control. Oftentimes with medications, you are prescribed a medication. And there is a role for medications in depression and a variety of other mental disorders. But I’ve had a lot of patients say to me that, you know, I feel that this is almost external to me and I’m reliant on this thing that I don’t control.

16:19
Dr. Nicholas Fabiano
Whereas when you’re getting into something difficult, like whether it’s exercise, you’re. You’re training for just running a short distance or a marathon, or whether you’re weight training and you’re setting a goal there, even if it takes a long time to get there, the fact that you can look from where you started and look back and say, wow, like I really did that gives you that sense of control. And sometimes you won’t even notice the mood benefits that happened along that journey. Again, that goes to say, you know, you were able to accomplish whatever your objective is, but also almost get yourself out of that depression. And, and I’m always careful when I discuss this point too, because it’s not to say that people’s depression are caused by lack thereof of exercise. Depression is a disease. Like any other disease.

16:59
Dr. Nicholas Fabiano
It could, it can happen, like diabetes. There’s risk factors for family history. Sometimes it just happens out of the blue. So I think it’s very important as a physician when discussing with your patient, not to have the tone that you currently are depressed due to lack of exercise. But more so, hey, this is a treatment option and maybe, let’s talk about it. But doing these hard tasks are so important because it gives you that sense of control and for the future, then you know that you’re able to do something again that maybe is even.

17:25
JJ Virgin
More difficult just between the social side of it and that feeling of accomplishment knowing you can do Hard things, those two things alone, if there weren’t the actual biological things going on, those alone are huge. So are you actually in the place where you’re diagnosing and prescribing at this point?

17:45
Dr. Nicholas Fabiano
Yeah, so right now I’m in my third year of residency, so I’ve been doing clinical rotations since mid medical school. So two years of medical school, then three years of residency and I’m switching to my fourth year in just one month actually. So I’ve been doing it for a fair bit. Not as much as obviously staff and stuff that have been doing it for a long time. But I think in this time, and even as my experience as a medical student, I’ve been able to see how important this is for a lot of patients and also how it’s not for everyone. I think that’s where there’s a soft spot sometimes where you try to promote exercise for absolutely everyone. And that’s okay. If it’s not something you don’t want to do, then there’s a lot of other options.

18:21
Dr. Nicholas Fabiano
But I think my own clinical experience has been a lot of people value it and rank it as one of their most important features of their lifestyle.

18:27
JJ Virgin
So you’ve been. Because you’re kind of a, like, you’re sort of a renegade here doing this, right? I mean, you know, so you’re now seeing patients and offering this as a treatment modality. What are you like, how are you doing that and what are some of the things you’re seeing by using this?

18:45
Dr. Nicholas Fabiano
So my approach to that, and we actually wrote a paper about this, is to kind of prescribe exercise in a similar manner that you would a medication. So when you’re going to your doctor and speaking about a medication, you would expect to know what the medication is, the frequency that you’re taking it, the dose you would expect to have, follow up to see how the antidepressant response is happening. And what I found was there was a disconnect with exercise where a lot of patients would say, their doctor would say, you know, just go exercise or just go run. And that is obviously very condescending to a patient because they know that they don’t need to hear it again from someone speaking that to them, right?

19:22
JJ Virgin
What they want to know healthy.

19:26
Dr. Nicholas Fabiano
And that can make you like not want to go back to the doctor. So what I thought was it would be helpful to have a framework to prescribe exercise similar to medication, not to medicalize exercise, but to make it in a way that you could speak to your patients similar to Medication. So the framework for that is called the FIT framework. It’s called F I T T, so that stands for frequency. So that’s how often are you exercising per week? There’s intensity. So that goes from low, moderate or vigorous intensity. And a simple way to measure that is something called the talk test. If you’re able to have a full conversation, sing and everything when you’re exercising, that’s probably near low intensity.

20:03
Dr. Nicholas Fabiano
If you’re able to talk but it’s getting a little bit more difficult, you can’t maybe sing, you don’t have that lung capacity, it’s probably getting more near to a moderate. But if you’re not even able to speak to the person beside you, that’s probably closer to a vigorous intensity. Then there’s the timing of exercise. So how long are your sessions? Are they quick, 10 minute sessions? Are they an hour long, are they longer than that? And then the last T is. The type of exercise which we’ve spoken about is whether it’s aerobic, is it resistance, is it mind, body, or is it a mix of them? Because a lot of different exercise types kind of are jumbled up and there’s not a clear fit for different ones.

20:34
Dr. Nicholas Fabiano
So using the fit framework, you can speak to your patient, you can essentially prescribe exercise in a similar manner that you would for medication. But what’s important is you can also follow up, you can chart this in your notes, you can see what the patient has agreed to exercise, see how that’s working for them from both antidepressant perspective, but also feasibility is three times per week too much, is one times, two week too little, and adjusting based on that. And that really allows you to have a conversation more than just exercise. And I found that to be very helpful in the clinical practice.

21:06
JJ Virgin
Don’t you think that part of the issue, like, you know, we hear all the time and so my background is nutrition and exercise and you know, you hear all the time, well, doctors get an hour of nutrition. I’m like, well, that’s interesting. They get zero hours of exercise. And honestly, I mean, how much can you throw at one person to learn, right? I mean, you know, like exercise physiology is a whole separate subject. So I mean, don’t you think part of this is that a doctor has had no training in this now all of a sudden? And that might be part of why they’re not using it as a modality in order to heal. What’s interesting for me with my son was one of Dr. Daniel Amen’s, one of his docs.

21:46
JJ Virgin
And he was like, let’s have him do ping pong, because that’s going to help, you know, connect the dots. It’ll help his brain. And then we also did hit training and all sorts of other things. Because I was reading the research, I’m like, oh, this will make sense. But I think for so many people, they didn’t have any background whatsoever, so how would they be able to put it in as a treatment protocol?

22:07
Dr. Nicholas Fabiano
Yeah, that’s a great point you make because based on the literature, what we see is people or physicians that are active themselves are more likely to prescribe exercise. So that applies to primary care, but that also applies to psychiatry, which speaks exactly to the point that you were making, where people that are not doing those behaviors themselves probably don’t have the expertise nor feel comfortable speaking about that to a patient. I think there is an issue at the educational level because, you know, repeatedly throughout medical school residency, we’re told how important exercises for mental and physical health, but we’re not told how to prescribe it. So I think there’s a big gap there. And yes, I think there’s a lot that we’re learning in medical school and different things like that, but I do see how important it is to learn.

22:48
Dr. Nicholas Fabiano
And do I expect physicians to have the whole physiology of exercise down and all these different mechanisms? Maybe not. But I do think it’s important at least to be able to speak to your patient about prescribing exercise. Because when we look at exercise as a treatment for depression, it has similar effects to medications or therapy. And it’s actually first line in a lot of different guidelines with that. I think it would be expected that a physician would be able to provide a first line treatment to their patient. And that’s where we’re doing a disservice in training or for different physicians. Because there is this first line option. We have the evidence to back it, but we don’t have the training to allow providers to speak to their patients about it. So I think the first step is education.

23:29
Dr. Nicholas Fabiano
I think the second step is, at least in Canada I can speak to. We don’t have a lot of streamlined methods to refer to allied health. So whether that’s physiotherapy, whether that is a personal trainer or something like that, we don’t have a streamlined process to give someone a prescription to go to the gym, as easy it is to enter it into our computer for a medication. Another problem as well is the incentive structure too. A lot of times in primary care, people are strapped for time. They don’t have a lot of time to be speaking to their patients about different things like this. And even in psychiatry there’s not incentive for the physician, which you hate to speak about it from that lens. But we know that financial incentive result in change.

24:05
Dr. Nicholas Fabiano
So I think at a policy level it would be great to see changes where if you’re having a discussion with a patient, that there are incentives to do so. So there are now incentives to learn this, there are incentives to implement this in your practice. So I think these are just a few of the changes that need to happen to see a change. I think it will probably take a while. I think the evidence is starting to build to say how important exercise is from a mental health realm and even common sense. Someone would say that too. But I think it’s going to take some time. And really we need an educational reform to really highlight the benefits but also implement it into practice.

24:40
JJ Virgin
What is some of the evidence you’ve kind of. I’d love you to go a little deep on a couple of the studies to show how important this is.

24:49
Dr. Nicholas Fabiano
So what on a large scale, and this is not the exciting one because it’s the meta analysis data where we bring together a lot of the studies. They brought together. I’m forgetting how many studies now, I want to say over 50 in a meta analysis. And what they did was they compared exercise to medications and therapy and they brought all of these studies together, saw what their effects were, and they found in mild to moderate depression. There’s really no difference amongst the different treatments for exercise. One of the more interesting individual trials though is there was a trial in the Journal of Affective Disorders, I believe in 2024 and I’m forgetting the first author now, but essentially what they did was they compared running therapy to antidepressants.

25:25
Dr. Nicholas Fabiano
So a head to head trial and again they found a very similar anti anxiety response for running therapy as compared to medications. But the other interesting finding in this trial is that there were so many physical health benefits that antidepressants sometimes do the opposite do so in the running therapy groups. There was benefits to weight, there was benefits to blood pressure, there was benefits to waist circumference, there was benefits to your heart rate variability. These are things that we often overlook in psychiatry, at least in our traditional sense of training. We monitor for some of these things, but we’re not proactive enough because we know that antidepressants, we know that antipsychotics, they contain these metabolic side effects.

26:03
Dr. Nicholas Fabiano
I think there is a responsibility to do something proactively to prevent these, but also if there’s a treatment option like exercise that not only prevents them, but does the opposite of making some of these parameters better. I think it’s so important. So in summary, we see very equivalent effects for mild to moderate depression, but we also see multi system benefits of exercise that even go beyond what I mentioned in that one trial. But we see changes to insulin resistance, we see changes to all these different parameters that are so important for our health. So yeah, I think these are things that are often overlooked but are important to discuss.

26:35
JJ Virgin
And it is. I mean, when you think of something like antipsychotic, which the side effect is going to be insulin resistance and all the blood sugar instability, which then can sometimes create more problems in terms of psychosis when you’ve got blood sugar. Just seems like a natural to have at least have exercise on board alongside it. And I know it must be hard. There’s no way to do a blinded study with exercise and drugs to be able to look at both of them. Any other places that you’ve seen besides using it in depression? Like you talked about schizophrenia and anxiety. But what other studies have come up that really are mind blowing?

27:16
Dr. Nicholas Fabiano
One of the studies or two that we’ve conducted was looking at an important parameter which is suicide. So we’re looking at exercise and we brought together the studies looking at what effect does exercise have on suicide, because we know within depression, but across all mental disorders, people have an elevated risk of suicide. So it’s very important to see kind of what’s going on. And we did two different meta analyses, so one looking at randomized controlled trial data, one looking at population based data. And we found a very similar trend where exercise led to a reduction in suicide attempts, but there actually wasn’t a noticeable change in suicide deaths or the thoughts of suicide, which is interesting. It doesn’t really necessarily make sense on first view.

27:54
Dr. Nicholas Fabiano
And what we thought from that was, you know, maybe the numbers were luckily too low to detect a change in suicide deaths. However, the alternative interpretation is that exercise is known to reduce emotional impulsivity. And we know that a lot of suicide attempts are not these necessarily well thought out or planned attempts, but they’re more so these impulsive reactions to a stimuli or something very horrible that happened in your life. And the thought is that exercise may reduce this emotional impulsivity and thereby reduce the amount of suicide attempts that one would have. So I think it’s an important lens beyond depression because we see again such a high risk of suicide across different mental disorders, that it’s important that we proactively address this as well, too.

28:38
JJ Virgin
So I’ve also heard you speaking on creatine, which I’m a huge fan of, like, when I look at especially how to use exercise for this. I don’t know if you’ve had to deal with the perimenopausal menopausal woman with all the mood swings yet. Have you had that pleasure?

28:55
Dr. Nicholas Fabiano
Yeah, I’ve had a few, for sure, yeah.

28:59
JJ Virgin
Yep. You know, when you look at exercise is such a key thing there because you’ve got insulin resistance starting to happen, cortisol going up, you’ve got them starting to store more visceral fat. But the other thing I’ve been really gung ho there on is creatine. And there was that study that came out, I think, with creatine and creatine, with SSRIs I think they were using versus just SR alone for depression. Are you familiar with that study I’m talking about?

29:25
Dr. Nicholas Fabiano
Yeah. The study you’re referring to is probably Liu et al. It’s in the American Journal of Psychiatry. It was back actually in 2011, but it’s had a resurgence of interest. As you mentioned, creatine, it’s more traditionally viewed through this muscle lens of improved performance, whether it’s weightlifting, whether it’s running. But because we know creatine also has cognitive benefits, there’s been a resurgence of interest from a mental health perspective. So with Liu et al, what they did was they, as you mentioned, paired creatine with antidepressant and compared it to antidepressant alone. And this trial was eight weeks long. And what they found was that at the marker of two weeks, there was an improved antidepressant response. And that went onwards to eight weeks, where they continued to see antidepressant benefits.

30:04
Dr. Nicholas Fabiano
And in that point, they only used 5 grams of creatine, which is impressive because we’re starting to see literature that we may actually need higher doses of creatine to have some of these brain benefits. And I’m actually writing a paper with Darren Kando right now. I just was finished writing it yesterday about why we may need higher doses from a cognition but also mental health perspective. One other thing that’s relevant in this area too is we spoke about creatine plus antidepressants, but there was also a recent trial in 2025 in the European Neuropsychopharmacology that compared creatine plus cognitive behavioral therapy, which is one of the first line Treatments for depression versus just therapy alone.

30:39
Dr. Nicholas Fabiano
And they found a very similar trend where adding creatine to therapy resulted in improved antidepressant benefits at week eight, which both of those are very exciting for me because creatine has such a favorable risk benefit ratio. It’s very cheap, it’s very accessible by a lot of people. So it’s very promising to see these early signals. One thing that I will say, and I’ve written about this before in some papers, is the evidence is missing for creatine plus exercise for depression, which makes the most sense because most people that take creation are doing it for exercise. So the question that I would like to see answered is what happens if you combine creatine plus exercise for depression? We’re actually. We’ve submitted some grants to do a trial adding creatine plus resistance training, so hopefully we’ll be able to get that up and running soon.

31:22
Dr. Nicholas Fabiano
But that is just to say creatine is a very promising supplement from the mental health realm. And I’m excited to see more and more research come out. Even beyond depression.

31:30
JJ Virgin
I’d love to see resistance training versus cardio to see if there’s any kind of difference there or if it’s just movement matters. I just wonder if the intensity matters, the duration matters. Like what matters here. I understand from an exercise prescription standpoint, telling someone just to go walk is the easiest possible. They’re not likely to get hurt. It’s easy to do. Anyone can. Almost anyone can do it. So that piece is exciting. But I do wonder if there’s something about both the doing hard things and the intensity that may have a bigger impact. And you wonder if some of that, as we age, losing fast twitch muscle fibers might be contributing to some of the issues with cognition. So there’s that. Then on the creatine side, I use a different form of creatine and I met the person who actually discovered it.

32:23
JJ Virgin
And so I’m using much lower doses to have the same to get the bioavailability. So I use hcl, which is really interesting. Ends up being about the same price point, but because you can use a seventh of the dose. But I have a feeling I was listening to what you were saying in terms of timing, I think, yeah, that would be about when it would take, because preferentially you would think if 95% of your creatine’s in your muscle and 5% in your brain, that you would probably get into your muscles before your brain, you know, even though it seems like it should go to Your brain first, it’s more important. It probably goes to your muscles first and foremost.

32:53
JJ Virgin
And then you think about, like, especially in the women, their tissue stores likely were lower to begin with because they’re not getting what they need from animal products as much. They’re probably not even a pound of raw beef. So, you know, you just wonder if some of that, like, I wish there was a way we could really measure creatine levels in the body. That would be amazing. But I don’t think we’ve figured out how to do it. All I can think of is somehow overloading and then seeing some creatinine spillover. But I don’t know how you would be able to tell. It does make sense. Like, it’d be great to know, does intensity matter? Is there a certain point of duration to hit a certain thing?

33:33
JJ Virgin
And do you need to have kind of supra physiologic doses, like to make ensure you’re getting more to the brain? Is it in time of depression or stress that your brain might need more? These are the questions I would love to have found out.

33:47
Dr. Nicholas Fabiano
Yeah, and I can speak to a few of those, actually. So let’s talk about intensity first. In terms of exercise, the general trend, and again, referring to the meta analytic data which is bringing the studies together, says that higher intensity, so the closer you are to vigorous, has greater antidepressant benefits. The caveat to that though is as we get older, it’s actually more near the mild or moderate because you can imagine if you’re 80 or 90 years old and you’re trying to do a vigorous intensity exercise, you’re more susceptible to have injuries or to have more medical complications as result of that. So we see that in general the trend is higher intensity, greater antidepressant effect. But the caveat again is as we age, we start to go more near the mild or moderate range, which is important.

34:29
JJ Virgin
Is that just because we have to, or is it like when you say as we age we go towards that? Is that just because we’ve lost those fast twitch muscle fibers and we’ve slowed down and we’re trouble getting that intensity?

34:40
Dr. Nicholas Fabiano
It’s, it’s hard to say because a lot of this data is based on randomized control trials. So they preset what people’s intensity levels are working at. And of course you can’t force someone to go to an intensity level that they’re not capable of. So I think there’s a little bit of bias There. So I think it’s probably both of what are we capable of doing as we age? But also I think it is a matter of if you’re pushing your body too far. It goes back to the curve that I mentioned, where that curve is not the same for everyone. That is a general curve, but that shifts based on your age, based on any medical conditions you may have. That’s why I’m always very careful to say that vigorous intensity exercise is always better, because that’s the general trend.

35:19
Dr. Nicholas Fabiano
But there are lots of caveats to that. So I think whether it’s, again, medical conditions, age, so many different things, and that’s why it’s so important to have an individual exercise prescription for someone and not just throwing the book at them and saying, this is what the literature says, this is what you have to do. The other thing is creatine. What dose do we need for depression? And as I mentioned before, most of the studies have just used 5 grams. The problem with that is that’s the dose for muscles. We know that some people will have their loading phase of creatine. Well, they’ll take 20 grams for about a week or so, then they’ll go down to three or five. And this is referring to creatine monohydrate. But does that work for the brain? And right now there’s not a clear answer.

35:58
Dr. Nicholas Fabiano
But what I can say mechanistically is your muscles have a lot more of those creatine transporters express to be able to essentially suck up that creatine and store it as phosphocreatine, whereas your brain has a lot less. So that’s why we see the numbers of 95% going to the muscles and only about 5% going to the brain, because your muscles want it so much more. So the thought is that we need higher doses. We also need longer dosing durations because, as I mentioned, a lot of these trials only go for eight weeks. Is that enough for the brain? I don’t know, maybe not. So we need higher doses, longer trials to see kind of what’s happening at the brain level.

36:35
Dr. Nicholas Fabiano
And another point that you brought up that was important is in a metabolically demanding state, such as sleep deprivation or depression, it seems that the brain is more likely to soak up some of that creatine. Based on some of the trials that we’ve seen, when you’re in one of these metabolically demanding states, like depression, your brain is not working as it usually should. Usually the body makes energy through this fancy process called oxidative phosphorylation. Where you make energy or ATP, but your body’s not as effective as doing that when it’s sleep deprived or depressed. So what creatine is able to do is it is this essential backup system where it can replete that ATP or energy at a faster rate, but it eventually runs out because your brain only has so much creatine in it.

37:16
Dr. Nicholas Fabiano
So that’s where I think that we reach those mental blocks or some of the fatigue symptoms associated with depression. So not to say that depression is creatine deficiency, but creatine may be able to help with some of those symptoms and may help even facilitate getting into exercise or dietary patterns and things like that. So I don’t think it’ll necessarily be a cure for depression, but I do think it has a significant role in helping people gain that momentum and may even have a role in more of a mild depression where all you need is that little push or that extra energy boost.

37:47
JJ Virgin
You know, it’s not crazy, though, what you just said, like, it’s not a creatine deficiency. However, think about it. We are in this crazy time where sleep deprivation is the norm because of having all the blue lights and a lot of mental stress. And then, okay, we’re exercising. Then you wonder if there’s only so much creatine in your system and you’re not getting. So, you know, we’re making that gram a day that we can from arginine, glycine, methionine, then we need to get the rest from food. But come on, who’s eating, you know, rare meat and fish? So then they’re eating it cooked, and then some of it’s going, getting denatured to creatinine. So then you’re working out hard, so that’s gonna increase your needs for your muscles.

38:32
JJ Virgin
And if your brain’s kind of getting at last, but now you’re sleep deprived, under stress, focusing a lot. What if some of it was just. Maybe your brain’s low in omega 3s and it’s low in creatine. And, you know, what if, I mean, you know, the research on omega 3s in depression and brain health is pretty amazing. Like, what if some of this just was nutrient deficiencies?

38:52
Dr. Nicholas Fabiano
It’s important to say, too, depression is a very broad term. It’s one term, but it can be diagnosed in so many different ways, and not only in symptom clusters that are used to make the diagnosis, but you can have two people with the same number of symptoms, but their symptoms are so different. So you can have sleeping problems in depression, which is an inherent feature of that. But what does that look like in person A versus person B? You can have low energy. That can be so different in person A versus Person B. I think where we go wrong in medicine is our broad definition of depression. And then we try to treat it all exactly the same.

39:30
Dr. Nicholas Fabiano
We say you’ve met the criteria for depression and sometimes they don’t even necessarily meet the criteria for the depression, but they just have one feature which maybe is more of just kind of a mild sort of presentation. But then you’re given a medication or started on something that may be a lifelong therapy. So I think we’re very quick to make these changes, but I think we need to first redefine or re look at how we conceptualize depression before we can look at how to treat it. And again, that’s what circles back to the individualized care. Yeah, maybe creatine or exercise is not for everyone, but as you mentioned, a lot of people are sleep deprived. A lot of people are pretty sedentary in their life and would benefit from being able to move more or have a little bit of that extra energy.

40:12
Dr. Nicholas Fabiano
So I think we need to work on personalizing our care more. But they’re in doing so, we also need to expand our treatment options, which are, you know, in simplistic terms, limited to antidepressants or therapy.

40:22
JJ Virgin
Right now I would love to imagine a world where these things like moving more and eating a more well rounded whole foods diet and having creatine and fish oil and things like that are foundational so that we’re pleading any deficiencies. And then you would have your genetics and epigenetics and your lifestyle and you’d look at all of it and be able to pinpoint. That would be like, amazing. I know it’s coming. I know it’s very different than I remember. My, my son with the brain injury has had rapid cycling bipolar disorder as a child. Right. We take him to a psychiatrist. Literally, this will drive you crazy. In five minutes this guy goes, oh, now he is my son. Just sitting there five minutes. He’s got ocd, odd, ADHD and rapid cycling bipolar disorder. And I’m like, you like, what are you talking about?

41:15
JJ Virgin
You know, in this cocktail of things that he was going to go on. I’m like, yeah, that’s what I was like, sought out. Dr. Amen. I’m like, nope, we will not be doing this.

41:25
Dr. Nicholas Fabiano
You know, and I think that’s an issue in the medical system as a Whole is just this time crunch where we’re making very quick judgments based on very limited information. And, and that’s where you run into problems where then you’re started on a slew of treatments that may or may not be appropriate because there wasn’t the appropriate looking into what are these symptoms or beyond what are these symptoms, what is a unifying feature of these symptoms? So an example would be, we spoke about sleep deprivation and isolation or sleeping issues. So stuff like obstructive sleep apnea, where people require CPAP machines to sleep because their airways are closing when they’re sleeping, these sleeping concerns can actually cause depression or cause anxiety.

42:09
Dr. Nicholas Fabiano
And if you’re to look at it just from a symptoms based perspective of what are your current symptoms, oh, I have low energy, I’m not sleeping well, I, my mood is very low. You may diagnose that person with depression, but if you don’t look into what is causing it, you’re not doing that person proper care. Because maybe fixing their sleep would do a whole lot better than prescribing antidepressant or even therapy in that instance, because they have a reason for feeling depressed or having a medical workup. For someone who comes in with depression, their thyroid hormones maybe are just low. So I think these are things that are often overlooked and it’s a testament to how stressed the medical system is. Because the quickest thing is, here’s your prescription. But I think there are a lot of factors that go into depression.

42:49
Dr. Nicholas Fabiano
Sometimes the answer is medication, but I think too often it is right now. Whereas we need to explore other avenues for treatment and also causative factors for the presentation.

42:59
JJ Virgin
Well, I hope you’ll be out there teaching as well.

43:02
Dr. Nicholas Fabiano
Yeah, I try my best in residency.

43:04
JJ Virgin
You know, you’ve got some really great information and you’re just, I mean, you’re in residency and you’re already with all of this information. So hopefully you will be one of those people that changes the way we think about treating mental health. That’s, that’s my hope over here. What are you working on now? What’s, what’s the latest?

43:25
Dr. Nicholas Fabiano
Yeah, so research wise, my main interest has been pivoting a little bit to the creatine sort of realm because I’ve had a big interest in that. I’m of course always doing exercise things, but I’ve written a few papers for creatine for depression, but we’re working on mechanistic papers for other disorders. I haven’t had a chance to actually Dive into them. As I mentioned, just yesterday I finished writing up a paper on a rationale for higher doses needed for creatine from.

43:47
JJ Virgin
I gotta connect you with my creatine researcher because yeah, probably fund some stuff but B, give you another one to look at with different pharmakinetics because sometimes the higher doses cause other problems and people won’t stick with it.

44:01
Dr. Nicholas Fabiano
You know, I would love to be able to be connected there because I think it’s an emerging area that I’m really passionate about. And as I mentioned, we’re trying to set up a few trials for creatine right now too. So the first one that I mentioned was pairing it with resistance training for depression. The second that we’re trying to get funding for is using it as a monotherapy for mild depression. So taking a population that’s been diagnosed with depression, giving them 10 grams of creatine and seeing what happens versus a placebo and I honestly wouldn’t be surprised if we see benefits. Right now. I can’t say anything evidence based to say creatine monotherapy is necessarily an appropriate treatment for mild depression. But I think this trial will be very important to say is this something that’s feasible?

44:38
Dr. Nicholas Fabiano
Because a lot of the population suffers from this mild or low grade depression. And like I mentioned, people are very quick to be on antidepressant which are hard to come off of sometimes. So I’m very interested to see the results of this to see what that shows because that could be a paradigm shift in terms of how we go about treating some of the milder cases.

44:57
JJ Virgin
Of depression that could be. And again, I still go back to, I think, you know, as I started to unpack this, I went, I think women are mildly creatine deficient, you know, and especially as they’re heading into like you think of perimenopause. I’m tired, I can’t sleep. I’m like, you know, I’m depleted, depressed, I’m losing muscle, I can’t perform. Like, you know, like so could be interesting. Yeah, I will connect you up with my buddy because he might be able to do some funding here.

45:27
Dr. Nicholas Fabiano
That’d be great.

45:27
JJ Virgin
I know it’s always the thing. I’m going to put all of your information, I’ve got all of your social media sites. I’ll put it all@jjvirgin.com forward slash. Happy workout is what the team decided to call it. Where are you most active? Which platforms?

45:41
Dr. Nicholas Fabiano
So I’d say I’m most active on my Twitter or X. I try to post a study or breakdown there every single day. And I try my best to interact with people. I’m trying to be more active on my Instagram too with different form content. As I’ve been doing more podcasts, I’ve.

45:53
JJ Virgin
Been trying to post a lot.

45:54
Dr. Nicholas Fabiano
Isn’t it clips there? Yeah. I would say if you want to follow me anywhere, it would be the most beneficial at either X or Twitter and Instagram and slowly I’ll build other platforms. But for now I’m busy from the research front. But yeah, it was a pleasure to be here and thank you for having me.

46:11
JJ Virgin
I appreciate it. Thank you. So, a little fun story. Back when Grant was in the hospital, I, as you can imagine, had some serious anxiety going on. And what I would do to manage that anxiety was I found a gym close by and I also found the hospital stairs. And I was just doing what I needed to do every single day because I found that if I didn’t, I wanted to crawl out of my skin. It like just saved me from being able to just handle all that was going on. It was like kind of animal shaking off all the stress. So this can be enormously helpful for you if you are depressed, if you’re anxious. It’s amazing what exercise can do.

46:53
JJ Virgin
And in fact, if you listen to my other podcast interview with Eric and Meaties where he talks about the Hadza and lessons from them, he talks about the fact that they don’t really know what depression and sadness is. They said, oh yeah, if we’re sad for more than a couple days, we end up getting hungry and we have to go out to, you know, hunt animals and then the depression’s over. So meaning the movement solves that. So it’s amazing how many things exercise can help, like, don’t really hear about, you know, the things that it doesn’t do well. So yet another reason to make sure that you’re moving more throughout the day. And remember, it all counts, even if all it is just doing a couple exercise snacks, which we created. I’ll have to just tell you this.

47:36
JJ Virgin
We have a little snack challenge@jjvirgin.com snack challenge that literally just takes you through. If you have, you know, a couple minutes a day, what you can do, we call it 10 minutes to win it to, you know, shift your physiology. So there you go. Hope you enjoyed this episode. The big takeaway from here is to just make sure you’re doing a little something every day. Just get moving and then build on that. Be sure to join me next time for more tools, tips and techniques you can use to look and feel your best and be built to last. Also, I’d love to connect with you and hear your thoughts on the podcast. Here’s how. First, subscribe to the podcast and leave an honest review. Second, take a screenshot of your review and third, text to 813-564-2627. That’s 813-565-2627.

48:39
JJ Virgin
When you do, I’ll reply using my brand new Virtual JJ. It’s my on demand virtual self built from my books, talks and years of experience so I can interact with you directly. You’ll make my day and I can’t wait to hear from you. Thanks for tuning in and I’ll catch you on the next episode. Hey JJ here. And just a reminder that the well Beyond 40 podcast offers health, wellness, fitness and nutritional information that’s designed for educational and entertainment purposes only. You should not rely on this information as a substitute for, nor does it replace professional medical advice, diagnosis or treatment. If you have any concerns or questions about your health, you should always consult with a physician or other healthcare professional.

49:24
JJ Virgin
Make sure that you do not disregard, avoid or delay obtaining medical or health related advice from your healthcare professional because of something you may have heard on the show or read in our show notes. The use of any information provided on the show is solely at your own risk.

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