The Get Healthy Tampa Bay Podcast

E136: Dr. Gary Liu on Anxiety, Depression, ADHD & Evidence-Based Psychiatry in Tampa Bay

• Kerry Reller

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Welcome to the Get Healthy Tampa Bay Podcast with Dr. Kerry Reller! This week, I am joined by Dr. Gary Liu, an adult psychiatrist and physician-scientist who recently opened his private practice in South Tampa. In this episode, we explore the science of mental health, discussing anxiety, depression, ADHD, and how evidence-based psychiatry guides diagnosis and treatment. Dr. Liu explains exposure therapy (with his memorable “taco analogy”), the role of exercise in boosting mental health, and why finding meaning and connection is just as important as medication. Tune in to gain practical insights for managing anxiety and depression and to learn how small steps can build resilience and well-being.

Dr. Gary Liu is an adult psychiatrist dedicated towards providing affordable, evidence-based mental health care. He earned his MD/PhD from Baylor College of Medicine, where he was inducted into the Alpha Omega Alpha Honor Medical Society. As a McNair Scholar, his neuroscience research led to numerous peer-reviewed publications, including his thesis in Nature Communications. Dr. Liu then completed a research-track psychiatry residency at the University of Pennsylvania, where his work focused on the intersection of immune dysfunction and brain health. His research has been published in leading peer-reviewed journals across the fields of psychiatry, neuroscience, and developmental biology. 

Clinically, Dr. Liu has received specialized training in dedicated programs for a wide range of psychiatric conditions, including ADHD, bipolar disorder, depression, psychosis, anxiety, OCD, autism spectrum disorder, eating disorders, substance use disorders, and geriatric psychiatry. He is also trained in multiple therapy modalities, including Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), Exposure Therapy, and Psychodynamic Therapy. Dr. Liu founded Eve Psychiatry to offer personalized medication management rooted in science.

0:28 – Introducing Dr. Gary Liu and his journey from neuroscience research to psychiatry
2:19 – How research training shapes evidence-based psychiatric practice
7:52 – ADHD diagnosis: strict criteria, misconceptions, and real-life evaluation
13:32 – Beyond medication: therapy and behavioral approaches to anxiety and depression
14:47 – Exposure therapy explained with the fear hierarchy (and snakes 🐍)
20:12 – Dr. Liu’s taco analogy for how the brain adapts to repeated exposure
23:12 – Innate vs. learned fears: from mice and cat urine to PTSD in veterans
25:22 – “Whatever you avoid, persists”: how avoidance keeps anxiety alive
35:50 – Depression, meaning, and the “life buckets” that need to be filled
39:04 – Exercise as the ultimate antidepressant and motivation to get moving

Connect with Dr. Liu
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Connect with Dr. Reller
Podcast website: https://gethealthytbpodcast.buzzsprou... 
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Kerry:

All right. Hi everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller, and today we have a very special guest, Dr. Gary Liu. Welcome to the podcast. you are a little bit newer to the Tampa Bay area, so can you tell us a little bit about your journey of who you are and what you do?

Gary:

Yeah, so I am an adult private practice psychiatrist. I just started in South Tampa after moving here from Philadelphia, so a little bit about me. I did undergraduate at University of California San Diego, and then afterwards completed a combined MD PhD, which is basically a physician scientist training program at Baylor College of Medicine in Houston. There you basically train with the medical students and then at the same time, or rather at different times you complete a research under a mentor doing a PhD. So for me, I studied how different neurons in the brain help with sensory processing in various models. But so it's essentially a systems neuroscience PhD. Afterwards I completed a research track psychiatry residency at the University of Pennsylvania in Philadelphia. And that was four years. And then now I am fresh out of residency and loving South Tampa and the wonderful weather here.

Kerry:

Nice. Nice. So I don't think I've ever had like an MD PhD, so I'm really glad that you explained all that to, you know, the listeners here today. You, you did a lot of research, right? So how do you take what you learned, you know, in the research lab and apply it to kind of helping patients directly?

Gary:

So a little bit more about the research training itself. So during your PhD the MD PhD really is designed for to receive training in basic science in some way. Of course, there's other different types of PhD, but a lot of people choose to do what's called basic science, so that's bench research. So what that typically entails and not always, but is using various animal models through genetics, through different types of beds bench techniques to explore the basic science of underlying any sort of genetic disorder. Or anything that involves studying specific populations of cells. For example, and I'm giving very just specific types, but there's many different types. For me in particular, what I was in a lab studying was essentially how, just very generally how specific populations of inhibitory, so basically neurons, atory, neurons, which inhibit parts of the brain and how those actually contribute to how the brain actually processes the sensory information. So given that training you really try to understand exactly what it is at the most fundamental level, how to conduct research. And so basically when you first start off in any sort of PhD you are mostly starting off as someone who is pretty naive. You may have a good, you know, fundamental in terms of I would say like undergraduate, you may have some medical school training. You may have taken classes, but now the key is can you then take what is not known within the scientific literature and then design experiments to further. Knowledge about that given problem though or unknown, and then come together with a cohesive story and by the end of that process. What you're hoping to do is to gain a level of expertise in which, for that specific thing that you're studying, you are one of the leading people you know, studying it to to understand, right? So basically a very in-depth understanding of whatever that topic is. Then knowing how to think and knowing how to analyze the given data that's out there, and then how to further it. And also poke holes, right? So you wanna know how to poke holes at any given scientific literature because during that process you're also reviewing other publications. And then, so there's always a difference between the data that is presented and then kind of what it's being sold as. So throughout that process, one of the things I I was able to do was to basically you read a lot, you read a lot of papers, actually. Because neuroscience is such a broad and longstanding field. So in that sense what I really took away from it, there were two things I took away from it. One, one is that. I really try to be evidence-based in my clinical practice. So what do I mean by that? Every single let's say FDA approved drug on the market requires it essentially to have gone through some sort of clinical trial in order to be approved. Now, the clinical trial itself has both strict inclusion exclusion criteria. So what that means is, is that this drug is only applicable in the FDA approved sense for whoever it was that it was intended for. Obviously there's off-label use. We can talk about that later. But in these cases, then that means. There has to be very strict diagnostic criteria for things to actually, for it to work. These are the criteria for it to work. And then also how do you monitor efficacy? What is the way in which clinical trials actually say this is efficacy for this. So meaning that in order for us to be evidence-based in some way, it requires us to basically have an understanding of these types of. Literature, not just the abstract, but actually understanding how things were analyzed and then who is it intended for, how to make the correct diagnoses in those cases. And then to monitor what exactly is the on average right treatment response and how to analyze that. So for me, I try to be very systematic in that way, in that I try to say, okay, all right. This is the evidence for this, any given medication for this type of diagnosable disease in mental health. So that means we make strict diagnostic criteria and then also we use medications that have been shown to be beneficial for that. And then of course those depend on the level of added evidence there is.

Kerry:

Why don't, why don't you give us an example of one of those diagnoses, like what criteria is required perhaps for anxiety or something like that, and then you decide to put the person on a medication or whatever. So what, what are the criteria? So you can give an example, and then how do you show that's actually, you know, helping or being what is the efficacy of it?

Gary:

Alright, so, in terms of, let's take a DHD for example, right? So A DHD is kind of one of these neurodevelopmental disorders in which there is typically something that has happened prior to the age of 12 that has either problems with attention concentration. Or the other domain of hyperactivity. So basically meaning that people are usually having problems focusing on certain aspects of, of life in some way, and then, and or being super hyperactive. So running around, right? Like so. And of course like the idea is, okay, all right, isn't that just kids, you know, kids being kids, things like that. But there are some signs in which that leads to deficits in. Abilities to function either in school, either in social settings, things like that. But in terms of A DHD, there's actually a very strict criteria, and I don't want to just name like DSM five diagnostic criteria, but one key thing right now is one, it's a neurodevelopmental disorder. So that means there should be some evidence prior in the earlier years itself. Then two, typically what happens with these patients is that then the, as life becomes more complicated, right? So for example, when you go to college or you have a significant other, or you have kids. So I have a one and a 3-year-old myself and I know how hectic life can get and careers and social situations. The, the symptoms that have been happening earlier on, get more and more complicated as time goes on. And then a lot of times when patients see me, that's really when those types of issues start becoming problematic. Now with the advent of social media, what's happening is kind of a little bit is like, oh, A DHD can present like this. ADHD can present like this. And then, so sometimes when patients come to me, they say, I have problems with attention and concentration and I think I have ADHD for example, right? So then the very, like the scientific way is to go, okay, so A DHD is a neurodevelopmental disorder. Anxiety and problems with concentration can literally present secondary meaning because of anything within the entire spectrum of psychiatric illnesses. I'm being a little bit, you know, like exaggerating a little bit. But truthfully speaking, there's a lot of things that can present with problems with attention and concentration. So what that means is, is that in order to first see if a medication that is approved for treating A DHD is intended for a patient. It's not just someone coming in and saying, I have problems with attention and concentration. It's actually going through and taking a very thorough history about how it is from a neurodevelopmental perspective, what exactly was happening back in their childhood, and then also how those symptoms progressed and then how it's actually impacting'em now. And then there are various ways in which to gauge how effective a medication is. So first there are certain scales. For example, there's a SRS, which is a scale that you can use to basically have the patient's own subjective assessment of how it is that they're doing once you put'em on a medication. But of course. Any subjective scale is not that great, right? There's always a lot of errors with those types of things. So in those cases, you know, I tend to ask a lot about how they're actually doing, like their performance. So for example, if these things are. Having problems. They're, they're having problems because of a DHD at school. Then I start asking about grades. Then I started asking about performances. If it was in impacting their abilities with their to be, let's say a good parent at home or to engage in a really defined as good parenting. I asked them about, well, how is it going at home? And then a lot of times patients will start bringing in their significant others and then they'll say something like, oh my gosh, you know, like all of these things that I had to tell them like a million times to do, and then now finally it's actually, you know, they're doing it. So that to me is actually the most important part of it is when you have external collateral for, for example, from family members saying, oh my gosh, I see the difference. This is really, really great. And I, I value that very highly as well. So not exactly sure if I answered fully your, your, your question, but that's typically my approach, meaning that for every single, diagnosis, what is the actual diagnostic criteria? What should, what is it, what is it not? If it's not ADHD, but someone is still presenting from anxie with anxiety and problems with concentration, then we go over the other likely things. For example, social anxiety, generalized anxiety, anything like that.

Kerry:

Yeah, no, you answered the question. For sure. Like I, you know, I wanted to have everybody understand the, kind of like the evidence-based method, like your thought process and how we bring those, I guess the tools that have been used in research to help diagnose something and like those criteria, you mentioned, those DSM criteria, which is a tool that we use to diagnose, you know, mental health diagnoses, and then how do you evaluate it if you were to choose to be on a medicine or even other therapy. It doesn't always have to be medication, right?

Gary:

exactly, a hundred percent. And one thing is typical for me is, you know, you, you really want to use the lowest effective dose for.

Kerry:

Mm-hmm.

Gary:

Anything, any medication. And then at the same time, for example, for patients with anxiety and depression, a lot of my methods is really for helping the patient tolerate something in which they can behaviorally then start doing to make themselves feel better. For example, with therapy, so we, we go over anxiety, right? One of the really great parts about anxiety is it's really treatable through behavioral interventions. For example, if someone is really, really scared of something, right? One of the ways in which we can actually treat that with therapy is with what's called exposure therapy. So what you do is that. For example, let's say that you are, someone is scared of what's something that, that, for you personally, that you, you would have a lot of fear with snakes. Okay. Snakes. Snakes, right. So if someone is afraid of snakes and, I don't know how often you would see snakes and things like that, but let's say that

Kerry:

Easter time.

Gary:

So let's say that someone has a severe fear of, of, of snakes to the point where they are, in their head they say, okay, all right, there's a chance if I go outside today, I will see a snake. Right. And they're not leaving their home as a result of it. Right? Then we go, okay, all right. So this is now severely impacting your life in some way, right? So for that, those types of patients, one of the things that you may actually do, and this is taken from obsessive compulsive disorder research, which is you essentially build a fear hierarchy, which means okay. On a scale to from zero to a hundred. Tell me what is something that would give you the most amount of fear, right, that you, that is not dangerous for you to do, but for you would cause extreme stress and then like, it's like, and that's the a hundred, right? So it would be something like, okay, if a stake were, let's say, you know dead or something like that and has no chance of biting me, but me picking that snake up would basically be a hundred outta a hundred. It would be the most terrifying thing. It's like, okay, alright, so now we have that as like the high and then we say, okay, what about a toy snake? would you be willing, like if you were to pick up a toy snake, zero to a hundred, how fearful would it be? Right. And then they may say something like, oh, like, you know, like, like less, but it'll be like 50. Okay. And then you say, okay, instead of seeing a toy snake and picking it up, what if you are shown a picture of a snake and then zeros a hundred? Would it be, and then there'll be like, okay, alright. Maybe like 20 or so. Alright, so 20 meaning zero to a hundred. How anxious would it get you? Okay. So in that case you build up from zero to a hundred. What exactly are the things that they could do to be exposed to a fear-inducing situation? And then you say, okay, alright. And then I explain the principle, right? So the principle is this. So basically in, in a lot of cases, whatever stimulus meaning like whatever, like information that you give to the brain. If you present it with enough times, typically the response from your brain decreases, right? So one kind of easy example for patients to understand this is like what I call like the taco way of explaining it. So I ask them, okay, what's your favorite food? And they'll be say something like, okay, it's tacos or ramen, or something like that. I'm like, okay, alright. Imagine you basically are 2:00 AM really hungry and then you get your favorite taco shop delivered to you, right? If you were to say you were how much you enjoyed it, it would probably look like this kind of graph where the enjoyment. Starts increasing. Just thinking about it, thinking about it, and then the second that you start, take that first bite of taco, it's, it's at a hundred. It is the most wonderful thing you have, you know, tasted in a long time. And then you keep eating, eating, eating. And it comes down, it comes down, it comes down. And then at some point it's gonna be back to baseline. You're just trying to finish the last bit of that taco, right? If you order enough now, if you were to, then the next time you're hungry again, do your very next meal, you order tacos again. Do you think that enjoyment would reach the same amount? It doesn't. So it kind of goes up, but it won't. And so it looks like this graph where it goes up and down and then up, but not as high and down and up and down and up and down. And at some point you are gonna be sick of tacos, right? You are not gonna want to eat it anymore, and it's just gonna be at baseline. So in this case, it's very similar. This is a. Whatever it is that is giving someone a very anxiety inducing response, if we then take what they're willing to do in terms of homework and expose them to that situation over and over and again, and let the anxiety come down on its own. That is a way for them to gradually be exposed to increasing amount of, of that fear that they have so that they can then learn to tolerate it more and more. And the great thing about it is if you basically start off with showing the pat of the snake, actually what the research shows is that the rest of the anxiety at the other situations which give them anxiety about snakes actually also come down to as well. So in this case. Been my role for within and, and I've done these I therapies with patients before, but the case for medication is that, okay, this is really anxiety inducing. I am literally telling someone to face their fears, their worst fears. So what are the things that I can offer them for them to tolerate this type of exercise without sedating them, meaning making them. So tired that it doesn't really matter, like whether or not they're exposed to it anymore or not. So that's how I see my role.

Kerry:

I really like your taco analogy. It, I, it actually reminds me of sometimes how we think about just. Eating in general. Like it's, you've got that suspense of the food that dopamine actually comes prior to the actually eating it. Right. And then it kinda drops off kinda So I've, I've discussed that kind of pattern in the past with some of my weight management patients. Like once you're not interested in this great big dessert that you were desiring so much. Yeah. Stop eating it. Like, I mean, it's hard to do, right? Because you

Gary:

Yeah. Yeah.

Kerry:

it's a thought if you really listen in to, you know, what's going on, you can make those decisions. But yeah, I think, I mean I've definitely heard of exposure therapy and, you know, my fear of snakes. It kind of makes sense to do it the way that you're, you know, responding to it. And a really good way to overcome it. So I think my husband had fear of heights and we'd like to go hiking and stuff like that, and he's definitely got better. As you know, you went on and exposed yourself to it and it makes a lot of sense too. Yeah.

Gary:

and it doesn't have to be as drastic as right snakes, right, because. What we're trying to do in psychiatry is not take away people's emotions. Your fear of things makes sense, right? Like people are supposed to be scared, fear, fearful of certain things. If a bear is running at me, I am not trying to get a patient to medicate them, to the point where I don't care if a bear is running at me. No, you should be very fearful and that could motivate you to run as fast as you can or do whatever it is that you know, it's hard to run away from bear. But yes. So the point though is that those systems in our brain were developed for a long time in which. We had for the majority of the time, like Hunter gather sages where there were those types of dangers around. Right? And not saying that there aren't any more, but currently within, you know, this more developed society, we kind of hijacked that system to perceive things that are actually. When you look at, you know, evidence, they're not really that dangerous or harmful for you, but in our head we've hijacked that same system in order to basically say, oh no, that is really important to to, to, to avoid that is really important for me to get away from. And that is so dangerous. And, and I'm not talking about states anymore. I'm talking about more things like, for example when patients have fear of going to the elevator for it falling right, of course elevators can fall, and I cannot guarantee you that an elevator won't fall. But really it's the exaggeration of the likelihood of how catastrophic something could be. That then leads to a lot of avoidance behaviors and problems with their own life.

Kerry:

So is fear, is it always a learned. I guess response, or is it something that could also be innate?

Gary:

That's a great question. So we know for sure that there are innate fears and that's conserved throughout various animal models. For example, if you give a mouse who has never seen. A cat before and you give them cat urine, like you just put that urine there, the mouth will run away. So yeah. So a lot of these things that are definitely innate fears that are very, very true. Impossible. So one of the things that happens though is it could be generalized as well and learned, and then generalized meaning, for example. Back in Philly, we trained at the VA a lot serving veterans. And there what you see is a lot of post-traumatic stress disorder, PTSD. So in those cases, somebody had a life-threatening or witnessed a life-threatening thing happen, and then obviously that can induce a lot of fear, right? However, once that happens and then they learn it, they come home where they're not really surrounded by those types, that environment anymore. However, that heightened arousal state is still present and that can lead to a lot of issues such as avoidance or always being on the edge, and then a lot of other things such as nightmares and then. Mood problems with their mood as well. So in these cases, right, so I guess what I'm saying is, of course you have innate fears and then you have learned fears. And then really one of the things that we're trying to do is really assess how much the fear is actually impacting your life in a way that you want to manage in some way.

Kerry:

Would you say that the exposure therapy is how you would like, I guess get over that avoidance cycle?

Gary:

Yeah, so like I I think I wrote this down. Whatever you resist, persist, whatever you avoid, persist, right? One of the things that kind of happens, is that in that taco analogy again, right? Let's say instead of the talk analogy, it's like to talking to somebody who you really are afraid of talking to, right? And if you talk to them every single day, your, your anxiety would talk to'em, is gonna decrease. But let's say the first time you're supposed to chat with'em, you go, oh. Maybe I'm just not feeling that good. I, you know, I, I just didn't really sleep that well. You know, kind of like giving yourself a pass and then, and, and some of those may be after real in terms of rooted in, you know, reality. However, if you just really ask this person, what is the primary reason I, you know, I, I'm just super anxious to talk to, so if you avoid Yeah. Momentarily, just at the beginning, your anxiety comes down. However, what happens is, right, like, just like when we put off homework right back in, you know, the, the day it starts creeping up on you and then you go, Ugh. Believe I have to do that thing. Oh my gosh, oh my gosh, oh my gosh. And then so your anxiety starts going up, up, blah, blah, blah, and you're not actually even allowing yourself that ability to come down on its own, through being exposed, continuously exposed to that stressor. So that's really one of the things that I, I try to get patients see, is that their overall anxiety actually increases. If you look at the overall long-term picture, when there's avoidance involved.

Kerry:

Yeah, I mean, it definitely, definitely makes sense. So not to totally change the topic, but

Gary:

However you want.

Kerry:

immune dysfunction, is that correct?

Gary:

Yes. Yeah, yeah, yeah,

Kerry:

What kind of role might inflammation or immunity immune health play in anxiety

Gary:

Oh my gosh. Okay. So that is a really, so let me, let me talk a little bit first about my role within the and, and I might not fully really answer this question just so within so when I first got to UPenn did a research track, psychiatry residency. So what that basically means is, okay, you've done a lot of research in the past why don't you both do psychiatry, residency and then also do some sort of research, right? So. In this case I, I thought, okay, what are the different types of research that I'm really interested in? And so for me it actually was still neuroscience. So I, I joined a lab who's the principal investigator, basically the boss of the lab. It's called Chris Bennett. And he studies microglia within the brain. So microglia are these resonant immune cells within the brain that are essentially kind of like macrophages, which are essentially immune cells inside your blood. So anyways, these are basically immune cells from your brain. And then what he was really interested in was that how it is that different types of alterations within this microglia, this immune cell population may actually contribute to problems within the brain. So. In basic science research, what you typically do is you do very drastic changes within any given cell population, and then you try to see as best as you can what the function of that is. So in the these cases we were actually studying a neurodevelopmental dis disease called rabe disease. And essentially not to go into specifics, but rabe disease involves problems with processing various types of fats or lipids within any given, given cell type. And then you have a whole host of developmental problems that actually happen within the brain. and usually patients who have this disease, especially the childhood onset type, actually don't live past two years old. So we're taking a very drastic immune disorder and then trying to understand basic cell function and basic cell biology within this thing. So now how that is applicable to psychiatry itself, right? How what I specifically did within here is applicable to psychiatry. It's difficult for me to make that jump because as someone who does, you know, basic science research, right? Anything that comes out of it usually takes a very long time. Now, one of the issues that, you know, inflammation is kind of one of these things where we kind of wave a big hand and say, okay, alright, inflammation is likely doing something right, however, right. And then usually for, for you, I'm sure like a broad sites in inflammatory state, you have certain. Blood markers basically meaning things within if you were to draw blood and then look at their levels, maybe it would be higher and things like that. Okay. All right. Yeah, that's true. And then also if you alter immune dis immune function in various ways, very drastically. For example, if you were to give somebody a high dose of corticosteroids, right? There are cases in which then. It can lead to, you know, problems with mood or even problems with understanding reality in some way. Right? So steroid induced psychosis, so that higher drastic alteration, we kind of see. Okay, all right. It has some sort of impact. However, if we were to get to the, the, I would say like the minute details about the reason why someone is experiencing depression and things like that, and to understand a biological phenomenon for that, and then how it precisely relates to immune function. I would say, I don't really have a good answer for you. So throughout my training, what I kind of started realizing was these gaps and, and, and, and instead of solely focusing on neuroscience, what I started to do was looking at other ways in which I can help patients maybe a little bit more than more immediately. So I'll give you one example. There's this. Book called from Viktor Frankl, A Man's Search for Meaning? Yeah. So this is a psychiatrist who according to him, went to four different Natzi concentration camps. He was Jewish, and then essentially what he saw was that some prisoners fear better than others under those horrible conditions. And what he was trying to hypothesize was what is the reason by which they were able to still maintain their spirits and energy and things like that. And after reading this book, one of the things that I came to realize was that, you know, one gap that we have within this medicalized model in psychiatry is where is meaning, right? What do we talk about for meaning for a patient? So and, and now I'm, I'm gonna like, kind of, you know poo on my, what I said before, right? Is that, you know, there are the DSM five strict diagnostic criteria, but if you were to tell me, right, what are the buckets that give someone actual meaning in their life, and then you say, okay, all right, family, friends, community. Religion or spirituality, significant other finances, all of those buckets, right? That if you were to put in effort and time for each individual, one of those, someone could say, okay, all right, you have a, you're living like, according to at least my interpretation of Viktor Frankl's work. You're, you know, you're living what, what, what some people would describe, or a lot of people would, would see and describe as a a meaningful life. Right. So if someone comes to me and they're saying, Hey, doc, I'm feeling really depressed. I don't know what's going on. One of the things I do too is to assess in each one of these buckets, what exactly is it, like, how fill are these buckets for. Right. If you, if someone comes to me and all of these things are generally stable and well maintained and then still coming, arriving with the problems I described before for depression, and they meet this criteria for depression, it's like, okay, all right. So why don't we, why don't we still have you go to therapy? Okay. And then. I think it's reasonable, right? For us to, to try have a trial of an antidepressant, things like that. However, if somebody is coming to me and very few, if any of these buckets filled right, and they're saying they're depressed, well. One of the things is that could be really leading to this is a, a lack of meaning that they find in their life and then their depression is almost like a symptom of their understanding of that. And so while medication may be something that would be. Kind of like a bump for them to go out and actually explore, you know, their life such so that they can, you know, fill these buckets of meaning. I would say that their effort into gaining more meaning inside their life is, is, is, is really, really important, if not the most important part of, part of the treatment process. So medication, being primary or secondary, you know, it's, it's kind of like, to me it's, it's, it's really dependent on what are the external life circumstances that patients really present to me with.

Kerry:

So you're saying treating them with medication, if they have none of the buckets filled, can help them go out and attempt to fill the buckets?

Gary:

Well, so let's say that someone is severely depressed and not able to get out of bed sleeping all the time, things like that. First thing is okay, right? Well, first thing you access is. Like risk, like meaning, like how safe the patient is, right? So these are just various levels, and then once you deemed, okay, all right, this patient is safe, but at the same time, not having the energy to get out of bed, not having the ability to even concentrate to hold a job or things like that, or not even enjoying any aspects of life itself. Okay. Then there's the possibility that an antidepressant may help with some of that. Right. And then so once, and it's a tool, right? So once we give them a little bit of a tool, it's not sufficient to just say, okay, alright, so now we've done the, the, the, the medicalized model of giving you antidepressants and that's gonna cure everything. No, by no means. It's more so that, okay, we're doing this so that we give you a little, we, we, we, we give you a little bit more of the tools to then go out and then continue that increase by saying, okay, so what is the minimum thing that you. Can do and are willing to do to fill one of these buckets, and it doesn't have to be so high. Right. The name is escaping me, but there's a general who wrote a book where I think it was make Your Bed, right. So the first thing is like he talked about, like, the little things really matter. Right. And then, so just making your bed in the morning. Right. Okay. All right. So you're cleaning your home. Okay. And then what's something else? What, what about who? Who is one person in your life that you have connected with in the previously who you believe that you had a genuine connection with in some way? And then you all lost touch, right? For a variety of reasons. Okay. Are you willing to reach out to that person again? Right. And then, so these are the things, so slowly. Increasing those types of connections, strengthening their bond with the community. I think that is, is, is the ultimate goal for filling these buckets. And then if along the way, it's like, Hey, doc, like I'm actually doing pretty well. I, I, I, I really, I, I'm really having the energy for doing these types of things. And then you know, the medication may have been helpful in the beginning, and then it's like. Okay. I, I want to safely come off of them and I say, okay, all right. So let's find a way to get you off of it. Okay. And then let me tell you about the risk benefit, you know, analysis for that. So to me it's medication is rarely the magic bullet that we kind of think about in terms of anything. And, and really, quite frankly, there is no magic bullet within psychiatry.

Kerry:

No, I mean there's no magic bullet really with anything. But you do mention one thing that can help and I think that was exercise. Size. Did you wanna comment on that

Gary:

Yeah, my view is this so physical health is super important, right? And, if you were to take the benefits from exercise, right, and we're just talking broadly speaking, exercise, there's a lot of different ways to do exercises, and if you were to take the benefits of that and put it into a, let's say a pill, right, it would be by far the highest grossing medication of all time. So in terms of exercise itself. Right. There's many different buckets for it, and, and I, I really, really believe that, you know, physical mobility and ability to do something active is so important to mental health because every single patient that I have that is able to do, perform some sort of exercise, I ask'em about it, and then I see if there are other things that we can do to basically support that. for example, right. One of the things that has been looked at for longevity is essentially what's called aerobic capacity. Meaning how much oxygen can somebody utilize? Right in any given amount of time. So I'm, I'm so, so at the high extreme ends of it, we're talking about like, you know, professional cyclists or marathon runners or things like that. So basically, how much oxygen can they extract from the environment? Now for that, what they found is that as you go up. In terms of numbers or ability to maintain to, to heighten your ability to do aerobic exercise. So think running, swimming, things like that. Then there's. A decrease in all cause mortality for somebody. And intuitively, if you think about it, it really makes sense. For example, you need a certain amount of ability to breathe and to maintain your oxygenation in order to just simply be independent, meaning walking up and down stairs if you have them walking around your home, things like that. At any point, if, let's say you're teetering on that edge of being independent, not independent, and then some sort of stress comes in, whether through infection or something else and then that would, then, if you're not able to maintain that, then what ends up happening is the oxygenation drops and then you have to go into the hospital. Right? So that's hypoxia. So that's, that could be a problem. So. The more that you give yourself that barrier, a capacity for you to maintain that state of independence, the better it seems to be for your overall long-term benefits. And so that's one. So for that case, we're talking about, you know, aerobic, well strength too, right? So for example. There's various ways that have been analyzed for how well somebody, for example now we're talking about the more elderly from sit to stand, right? So basically that's one test that you can do, so that those are hip strength tests. So in those cases, right, having reserves and your hip strength. And of course, and we know that muscles tend to atrophy with age. So earlier training in terms of muscular strength is also really important for functional mobility later on in life. Because if you don't have the hip strength in which to stand. And then risk of falls, risk of fractures, things like that tend to increase as well. So training and, and there's just, and, and, and anyone who has ran or done any kind of aerobic, anaerobic, I don't care what it is, like right afterwards, oh my gosh, I feel so much better. I sleep better, I feel better. I'm just happier. Then, so, you know, I, I think intuitively and also from experientially, like, like most people would say, yeah, if I do something physical, physically active, I just feel better that day. And so that's also a another wonderful thing for exercise. Yeah, so, so I think it's so important. I think it's so.

Kerry:

Oh, I guess the question that always is, is how do you get'em to do it in the first place?

Gary:

Right, right, right. So now we're talking about motivation, right? So what is the reason why somebody wants to do something like that? So let's, let's talk about a few things. There's obviously a desire to look better, right? For losing weight in some way, right? Look at Ozempic. If there is no desire for, you know, some sort of physical change, then ozempic would not be what it is. And then same with, let's say plastic surgery or things like that. The, it wouldn't be the mark, there wouldn't be the market for what. What it is. So I think that that is one of the ways to tell that people do have a desire to basically lose weight or improve their appearance in some way. And it, and, and, and it's one of those things that we can tap into, right? The problem, one of the problems is that. This is not a immediate gratification thing in the sense that you don't look at your body and see the change right away. If I don't go to the gym for one day, no, there's likely no measurable change. If I go to the gym for one day, there's likely no measurable change. But if I go consistently for six months, there likely is one, and if I don't go for six months, there likely is one. So it's kind of like. A longer term thing. So then the question is, okay, what are the ways that we can get somebody to actually think about or, or to do things that are, that can maybe lead to more a visible changes, right. Well, quicker. So this leads to a misconception is that exercise and I is, is the primary way in which we. Exchange body shape, right? And that then gets to diet. So diet, diet, diet. So let's just very simply break it down. One mile burns about roughly a hundred kilo calories. There's 3,500 kilo calories, 3,500 within a pound of fat. So you can run about, you know, maybe like 30, 35 miles, maybe 25 to 35, depending on your body weight, things like that to burn one pound of fat. Okay? One of those really nice cookies, those large cookies that you can get at any convenience store. Something like 300 or 500 calories depending on how big it is, right? So. if you read the kind of the weight loss literature, like, like what, what people recommend in terms of decreases in calorie consumption while still maintaining their musculature because people also want, like we talked about, people wanna look good, so they don't want to just be a smaller version of themselves. They still wanna maintain muscle. So in those cases, right I think diet is also so important in this realm. And then, so for example, a 300 calorie deficit. Meaning like this is the amount of calories, like let's say 2000 calories, right? To maintain your your, your current bo body weight decreased by 300 every single day. So in those cases, right, you have a slow, steady in 10 days, that's one pound of fat. So I think that one thing is pairing diet and exercise along with it, and then also 1 thing that gives people motivation in these cases, especially when I see them, is that a if a patient is depressed, they're tired of being home alone by themselves, things like that, and then giving them a plan for how to be more active. Then to physically engage with their body and to also make them healthier in some ways, in many ways is a very the, the good idea to to, to start because they both have that desire for appearance. But also at the same time, what I find is that there is a. Pain from being inactive from being home, that is also driving them forward. So those are two things that can, can possibly use as motivation to drive a patient to, to be more active. So that is something that I definitely try to emphasize.

Kerry:

Yeah, I definitely think, you know, finding their reasons why is very important in motivation and everything, and obviously you made a good point. Exercise is, you know, a delayed gratification for body composition change, but not as much for, you know, the immediate, you feel better after exercising kind of thing. Right. That can be still delayed'cause you gotta get through it, but a little more immediate to make you feel better too. Well, I, I feel like we've gone long here. I've taken so much of your time. Is there anything else that you'd like to share with the listeners today? And maybe we can have you back for more of your scientific expertise on another episode, but.

Gary:

Well I so much for this opportunity. I. Never been on a podcast before. So and I really appreciate you giving me the time to talk, even if I just ramble. At least it feels like to me that I'm just rambling and to speak about and I yeah, I, I, I, I just wanna say that, you know one of the things that I, I really want you know. Listeners to, we, we did talk about anxiety, but I, I wanna talk a little bit, just, just slightly about depression. You know, it's, it's, right now we, we talked about, a problem in meaning a as a contributor factor. One of the things that I, I do want listeners to take away from is that, you know a lot of times in depression, we do the opposite of what it is that would make us feel better. For example, we self isolate a lot. And, and one of the reasons why I went into psychiatry was from personal experience. So we, we self isolate, we think, okay, no you know, it's, it's not really worth interacting with people because we, we catastrophy meaning we, we basically overly magnify, how bad things are with other people. So we don't reach out, we don't go out to other places. We don't try to connect and the more that we isolate, the worse the symptoms actually end up getting. So my, my plea to anybody is that if you feel like you know, you, you're not feeling good and are persistently sad, I think that it's really, really important to, to do the opposite of what you know, that voice is telling you to stay alone, which is to reach out to friends, to family, to whoever it is. And I think that just, and, and just from your own experience every single time, no matter what that interaction is, usually, usually you feel better afterwards. And so reaching out to others not feeling alone, not feeling like you're isolated is such an important thing. And I really hope that like, you know for, for, for anyone who's listening,

Kerry:

No, I think that is excellent advice. And I think it even shows, you know, like you mentioned longevity and we know that the sense of community is very important in that. Right. So I think those are very good. Good, important comments to, to make. Like where can people find you if they wanna work with you?

Gary:

Oh right. Yeah. So the easiest way is to just go to eve psychiatry.com. Eve psychiatry.com. I, I chose the name Eve mostly, well first because it's just easily Typeable, EVE. And a lot of people can actually ask me, you know, like, why Eve? Like, who's Eve? And then so for me I thought, oh, new Year's Eve, like the beginning of something like the Don of something. And then also it's, you know, Adam and Eve. First woman more of a nurturing feel as well. So that's kind of how I picked the name. I don't really have anyone close to me whose name Eve. That's just Eve's Psychiatry was just, it was just something that, you know came. Yeah.

Kerry:

I was gonna ask you why eve psychiatry, so thank you for answering. Think that's a really cool name the way.

Gary:

Thank you. I, I, I, I now say it just like, kind of like right when anyone asks, just because I like, that's usually the next question. Oh, why eve?

Kerry:

Well, you should share why, obviously. So I think that's

Gary:

Yeah,

Kerry:

Yeah, very nice. Okay, so eve psychiatry.com and we can put all that information in the show notes and anything, anything else that you shared. So thank you Dr. Liu, so much for your time today. This was, you know, I learned definitely a lot. As I said, I always learned something and I think our listeners will have had a great experience as well. So thank you so much and stay tuned next week everybody for next week's episode.

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Dr. Kerry Reller

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