Clara Faria: Hello and welcome to the Mind the Kids podcast. This podcast series is designed to inspire, educate, and foster a deeper understanding of the global landscape of mental health of children and young people. And our first guest is a very special one. I'm very, very happy to welcome Dr. Nicolas Fabiano. Dr. Fabiano is a psychiatry resident at the University of Ottawa, and you may have seen him on Twitter because he's also an avid science communicator. So welcome, Nick. Thank you so much for being here today. So today we will be talking about exercise and mental health, specifically how exercise can improve. Nicholas Fabiano: Thank you for having me. Clara Faria: Depression and other common mental health conditions and what's the evidence base that's out there for it. And Nick, I know you are very passionate about this topic. It's a topic you constantly tweet about and you also have lots of research on it. So what would be the message you really think is important to convey to Dr. Nicholas Fabiano: So I would say exercise is vital for both your physical and mental health. So I would group those both together. And I think that one line really brings stuff together where oftentimes in psychiatry or mental health, we view these conditions as separate entities. But I think it's really important that we start looking at interventions that could target both. So exercise just being one of them. And I think that's why it's been so interesting for me, because it's one of these interventions where we can help someone through their mental health, whether it's depression, whether it's anxiety, but also we know in a population that's so comorbid with other ailments, whether it's mental or physical, having an intervention that can do both and not just addressing those in isolation. So I think if that's the one line I could pick, I think that's one that I would go with right now. Clara Faria: And sorry to start off by being but recently you've tweeted something along the lines of physical health is mental health. And I saw that like generated lots of attention and also lots of interesting debate. And like, I'm totally on board with you that it's usually physical health and mental health are seeing a separate entities when they're like, severely intertwined. But can you expand a little bit more? Do you truly believe that mental health and physical health are actually the same thing? And if yes, like what are the implications on your clinical practice? Dr. Nicholas Fabiano: Yeah, so I think throughout medicine and particularly in psychiatry, we, as I mentioned before, create this divide between mental and physical health. And that divide that we've made is honestly quite a gray area. And oftentimes we see stuff, an example would be between neurology and psychiatry. When we find a quote unquote physical cause for something, sometimes we do this trade where a condition that was a psychiatric condition now becomes a neurological. And I think it's very hard to arbitrarily draw a line of where the divide between physical and mental health really lies, especially when in the literature we see so many different associations, not only between comorbid conditions, but with the severity of those conditions and impact on depressive symptoms or impact on anxiety. So an example from a metabolic perspective could even be something like diabetes. know that people with mental disorders across the board are at a higher risk of diabetes. And the same thing is the other way to, or people with diabetes are at a higher risk of depression, anxiety. An argument could be that some of that is due to medication side effects, but a lot of it too can also come from the underlying nature of what we say is the divide between the two. And I don't think it's necessarily helpful to look at them in isolation, which is why I kind of stand by the statement of mental and physical health are the same entity. Because when we look at them in isolation and we have specialists treating different ones, we ignore the others, you know, in the quote unquote physical health standpoint where you're seeing your doctor for a physical ailment, your mental health may not be fully regarded there. Maybe a treatment is done to improve your blood sugar or something without taking into context the mental health aspect to it and what impacts that might have. So an example could be a dietary intervention. Maybe that's not sustainable for someone. Maybe it changes that number on the scale and improves that outcome from the physical side, but we're not necessarily addressing the mental side of things too. So I think it's... helpful for no matter what kind of clinician you are or whatever kind of patient you're seeing that you look at it as one entity. Because as I mentioned before, those bi-directional relationships are endless and you can look in the literature and really see those associations between various conditions. And they really don't operate in isolation. So I don't think that it's helpful to treat them in isolation either. again, it adds a layer of complexity for the clinician treating the patient, but I do think it's to their benefit. So that's where that concept of physical and mental health being the same thing is, is almost an advocacy thing for the patient in front of you saying that, you know, these two things interact with one another and we should address both and both are very important. And when I say both, they should almost be one. So maybe I shouldn't use the word both. Clara Faria: Definitely. Yeah, I think you touched on a really important point and like when you mentioned the bi-directional associations between physical health and mental health, like, like there's a really nice math analysis of Marcus Soumy, who I know you worked with published a few years ago in the Lancet showing that patients with severe mental illness, have much worse outcomes when it comes for cancer screening, for example. And I think that, and I mean, we know that are several other meta-analysis out there between like the associate showing us a really strong association between severe mental illness and worse physical health outcomes. so, yeah, so when you think about those associations, I think you're right to say that it is really important to consider both jointly as opposed to, oh, you know, I will leave the mental health issues to the psychiatrist, but the reason why I brought up the physical health and mental health duality is because we know that oftentimes there's actually lots of studies showing also like that usually patients that have severe depression, for example, are less likely to exercise and are less likely to engage in physical activity as well. So I just wanted to ask you, how do you see that relationship and like what role exercise can play? Is it that patients who have severe depression or severe anxiety are less likely to be physically active? And that's why we know exercise is good for health, so we should encourage them to do more exercise. Or there's really an exclusive benefit that exercise confers to those patients. And yeah, what is the evidence base of that for exercise and depression? Dr. Nicholas Fabiano: Yeah, so I would say with regards to that, it's both. would say you're right to say that someone who is currently depressed is less likely to be active. But at the same time too, there's studies to show that people that are more active, it has a preventative effect on depression. So I think it does go both ways. So it's hard to say that this one variable is causing someone to be depressed or something of that sort. And I think that's where the nuance is very important and how I view exercise and even other lifestyle measures like diet and proper sleep. I really frame that as the foundation for someone's health overall. So not necessarily that it needs to be a treatment. I think sometimes when we look at lifestyle interventions, whether it's exercise, diet or sleep, we often put them into separate camps where you're either in the lifestyle camp or you're in the traditional medication therapy sort of thing. And that's another dichotomy that I don't think is helpful. I think they should be used together. Because as I mentioned, some of these lifestyle interventions, whether it's for your physical or mental health, it really forms that foundation for your health overall. So it's important if you're experiencing depression, if you're experiencing anxiety, if you're experiencing trauma or something like that, surely therapy is important. Surely medications have a role too. But at the same time, I think you're doing a disservice to the patient in front of you. If you're not also talking about some of those foundational aspects, because even anecdotally being a resident doctor and doing a 24 hour shift, my mood and anxiety and everything after being sleep deprived just for one night and not being able to eat. I'm, my foundation has crumbled for that moment and I'm different in that moment too. And you can imagine if that pattern continues on for days, for weeks, for months, for years, how someone's foundation can become eroded from that. And it makes it harder to do things like engage in therapy. makes it maybe more prone to medication side effects and maybe not adhere as well too. So that's how I view the role of exercise and all of these other lifestyle measures in the treatment regimen where it is that foundation, but it's also not something that we necessarily need to force upon someone. If someone's saying, Hey, not ready to start exercising or something. And depending on the level of depression that they're experiencing, maybe it's also not appropriate to start in that moment. But I do think that it is a foundational aspect and it should be a treatment option offered to a patient. Just because our role as physician is not to make a patient do something, but to educate them on their options and make sure that they're able to make an informed decision from that. So I think in line with all of that, just making sure that we're having that role in education and allowing the patient to make a decision, making sure that they understand how important some of these lifestyle interventions can be from like that foundation perspective. So yeah, that would be my view on. Clara Faria: Yeah, I think that's super interesting and you mentioned this dichotomy often between like what is now being branded as lifestyle medicine and the more traditionalist view and I agree with you that it doesn't need to be like that. I'm a bit, to be completely honest, I'm a bit skeptical when I hear someone say, you know, you can cure your depression with only lifestyle measures. And I think we've seen some of that speech by some pseudo-scientists. However, that does not mean that exercise isn't super important. And I think, you said, there isn't a need to exist a dichotomy because actually those two things are linked and exercise has the potential to improve so many aspects regarding quality of life and actually act in synergy with medication and other types of interventions. Because if we think about someone who is severely depressed, they might not be able to exercise at that moment. But as you said, maybe on a second moment where the depression has improved a little bit, maybe by some pharmacological or psychotherapy intervention then, you know, exercise comes in helping that plus and maintain a more improved quality of life. I wanted to now that's going to become a bit of a more technical talk, but we have lots of academics in our audience. So we know that there have been some recently published math analysis looking at the effect size of exercise in improving depression and anxiety symptoms in adults. I think it was one in 2023 that was you've quoted before. yeah, and I just want to, can you comment a little bit on like, you know, effect sizes and, and like, and I know you've read a lot about it as well. And I know you recently published with Brendan Stubbs, a really nice editorial looking also at the benefits of exercise together with supplementation. then, yeah, can you tell us a little bit about that? Dr. Nicholas Fabiano: Yeah, so there's been a few different meta reviews, both meta-analyses, which is combining those individual studies and also umbrella reviews, which is a higher level where you're combining now systematic reviews and meta-analyses and that's your individual study level. Essentially what happened is for one of these umbrella reviews, it was in the British Journal of Sports Medicine, forgetting the first author's name, but this study compared different exercise interventions and compared it to medications and therapy across mental disorders, depression, I believe anxiety as well too. And originally when this came out, it was misquoted by the media and was, I don't know how the effect sizes were kind of misinterpreted. However, it was kind of taken as exercise was 1.5 times as effective as antidepressants and therapy. And that was widespread. was on news articles. It was on podcasts. It was disseminated widely. however, there's also been different, as I mentioned, meta analysis comparing some of those effect sizes. And when you actually look at the data. At best exercise is equivalent to CBT or therapy and antidepressant medications in terms of their antidepressant effect. There's not this 1.5 times benefit. So I think first off, just it's important when we're looking at the literature to reframe it as such, because as much as someone who's an advocate for exercise would love for it to be better, it's important that we communicate the science honestly from that front to both make sure that patients are making an educated decision but also making sure that we're not spreading blatant misinformation from an expectation perspective too. So that's kind of the literature is that with that. The caveat being too, when you're comparing these trials, it's not exactly comparing one to one. You can imagine a therapy trial or a medication trial or an exercise trial may be a lot different from one another in terms of how they're compared in a randomized control trial setting. One particular limitation for exercise interventions is the blinding. You can't really blind someone to... exercising, like if you literally blind them, it's still, they're still going to know they're exercising. And what you get from that is sometimes expectancy effects. Whereas with medications, like antidepressants, giving a placebo pill oftentimes is a good blinding strategy because there's not an acute effect of that antidepressant that someone can necessarily notice. whereas exercise, there's not exactly that parallel, which introduces the aspect of bias sometimes in some of these trials where patients are going in expecting to do better because of the intervention that they're randomized to, which can perhaps inflate some of those effect sizes. And it's hard to measure by how much. So that's one limitation there. And that's why I think it's important to really understand these limitations of the literature. And also when we compare them on a meta-analytical level, that we're being honest about what to expect. But then the other piece of that is these meta-analyses, often look at the antidepressant effect in isolation. And that's the outcome that matters. But we know for these interventions, there's more than just that for any intervention. There's side effects, there's ability to actually complete the intervention and like seeing what the discontinuation rate is. And what we see is when you compare exercise to antidepressants, the side effects are much lower in the exercise arm, which makes sense, right? Because exercise, maybe you get injured, et cetera, et cetera. But the dropouts are actually higher in exercise. So despite there being higher side effects in the medications, there's more adherence to the medications. And that to me, although it can seem concerning, I think that shows a gap for where physicians could maybe do better where in terms of when we prescribe exercise and different things, I know these are also in RCT settings and they are supervised in these trials, but perhaps there's different ways to go about it to make sure that the patient feels well supported to continue with these interventions and actually complete it because ultimately, the best outcome you're going to have for any intervention is if you're adherent to it. If you're randomized to receiving intervention and you're not completing the intervention, you're not going to have the outcome, right? And in a real world setting. And I think that's one of the biggest caveats too, in these RCTs where we see a lot of dropouts and stuff from that front. We need to see that from how do we apply this in the real world? And how does that look? What does that look like if you're prescribing this to a patient? So I think in summary, for my long-winded thing is meta-analytically, the antidepressant effect size is at best the same across these different interventions, but we see increased side effects in things like antidepressants, but increased dropout in things such as exercise. Again, because it's likely harder to commit to an exercise regimen, especially if someone's not doing it all the time. Clara Faria: Yeah, also, I think there's a time investment, right? Doing exercise while like, for an antidepressant, you're actually taking that pill, which is much less time consuming. But it's interesting you've mentioned the side effects because I think one of the fantastic things about exercise and especially thinking about, you know, the current landscape in mental health services in the UK, like our services are heavily oversubscribed. I don't know, would love to hear from you how the situation is in Canada, but I think exercise really has the potential, obviously not to replace anything, but it has the potential to be a really scalable intervention with minimal side effects as you said, compared to more traditional interventions as antidepressants for someone who has mild depression, for example. And I think a testament of that is the fact that both NICE and CanMatch include exercise as a first line therapy for depression in adults. Dr. Nicholas Fabiano: Yeah, agree. And from our perspective too, it's, always hard to have an intervention where it's not as easy as just taking a pill sort of thing. Cause there's the time investment from both the patient side, but also the provider side and being able to provide the resources to set someone up to be successful in exercising. And I think sometimes it's important to reframe how we view exercise too, because sometimes it can be overwhelming for both provider and patient alike when thinking of prescribing exercise to someone, to someone that might look like. Okay, now they need to buy a gym membership. need to be off of work this much earlier. They need to do all of these things, but sometimes even reframing it to little things that you don't perceive to be exercise. So maybe an instance where you're taking the elevator where you could take the stairs or, that could happen at work. so little bouts of exercise and, we know based on the data to that antidepressant, in fact, at the beginning from going from no exercise to more, you see that drastic increase at the beginning. Cause can imagine if someone who's completely sedentary to someone who's now starting to move a little bit more, those benefits will be exponentially more than someone who's already an athlete and doing a ton of exercise from that front. So that's why I think sometimes reframing it and making it possible for the patient, because maybe it's not realistic to go to the gym five days a week for an hour or something. And that's not possible for a lot of people. But I think it is possible to reframe ways and help people to see that, to make it realistic for them to do. And again, maybe not as a monotherapy, monotherapy, but maybe something that they can do on top of some of other things that. Clara Faria: No, definitely. And just discussing a little bit more about the evidence that's out there. So you mentioned this meta-analysis that was published in the British Journal of Sports. I think despite the fact that, well, this meta-analysis specifically only looked at adults. And despite the fact that you have already commented that they only, like those trials are very different. So it's hard because they acknowledge that in the paper. They say there's lots of heterogeneity among the studies. The number necessary to treat of exercise, the NND was still two, which I mean, it's fantastic, right? It's a great NND if we stop to think about it. But looking at children and young people and the evidence of exercise for improving mental health conditions in children and young people, I know that there is a really good evidence base for ADHD, for example. There's even a really cool podcast I was hearing the other day, and A can learn about it, looking at the evidence base of prescribing exercise to neurodivergent kids, which is super interesting. But specifically for depression and anxiety, there is a, I mean, it's a bit outdated by now, but there is a conquering systematic review and meta-analysis from 2006 showing that actually the effect size for exercise in children and young people with depressive symptoms in terms of, as you saw, the outcome they were looking at was just the... depression scales as self-reported, but the effect size was minimal and it was marginally significant. So I was just wondering, what could explain that difference? Because we know that for adults, the evidence base is really solid. And I mean, there's only one meta-analysis and they've only included five studies in optimistic, and sorry, they've included 11 studies, but it was a population of around 9,000 people, something like that. I'll double check while you answer, but it's just that I was just wondering like what could explain the difference and maybe, I don't know, maybe it's just the fact that we're looking at the wrong outcomes because we know exercise is super important developmentally for kids. I don't know. Dr. Nicholas Fabiano: And when was that meta-analysis from again? Like you said 2006. Clara Faria: 2006, yeah, was from, it was the title if anyone that's listening wants to look up, it's called Exercise in Prevention and Treatment of Anxiety and Depression Among Children and Young People. It was published in July 2006, it's in the Cochrane database. And yeah, they basically looked at the vigorous exercise versus no intervention at all. And yeah, to be fair, they looked at the general population of children. Dr. Nicholas Fabiano (20:03) Yeah. Yeah. Interesting. Okay. So I don't, can't speak to that specific meta analysis because I haven't read that one specifically, but I have seen newer ones and I can't cite specific ones, but in children, I had a lesson since then that have updated some of these meta analysis and there is surely less research than the adult population. That's without a doubt in terms of the antidepressant effect and stuff. And from what I recall, and I don't want to misquote anything, I think the effect size had increased a little bit in some of the more recent studies and how I would interpret that trend would be this is we know that in children and adolescents, there's an association between sedentary behavior and depressive symptoms. And a lot of the sedentary behavior for these kids, they're spending on their phones, their iPads, increasingly amounts with TikTok and all the different apps we have today. So it wouldn't surprise me to say in 2006, when kids maybe didn't have phones as often, didn't have TikTok, didn't have all these things, perhaps their baseline level of activity was a little bit higher than we would see now. So there may be a stronger effect in current days with exercise targeted interventions, because now we're starting with a population that's less mobile and that has more sedentary time than perhaps in the past. So there may be more utility and there may be this almost inflated in fact size because of rather than it just being the exercise intervention, it's more of a anti sedentary behavior intervention. So you're getting these kids to move, which goes to the point that I made about adults too, where we see those initial antidepressant benefits when someone is moving the least. If you take, if you can take someone from the lowest amount of physical activity and move them up even just a little bit. That's where you'll see the greatest benefits at the beginning. And I wonder, and I am not as well versed in the child and adolescent realm of things. However, I wonder if that's what we're seeing from the trend when we look at the Cochrane meta-analysis from 2006 and then the more recent trials in, I want to say 2018. I think it was one in the, one of the ACAM journals as well too. Seeing that change in effect size with more recent studies, that would be my thought around that in terms of why we see a difference with, with kids. because perhaps that change in baseline physical activity. But I would be open to discussion around that as well too, because again, it's not my area per se of expertise, but I'm open to chat about that. Clara Faria: No, that's actually a really interesting point you just made. I think, yeah, you're right. Exercise is not my area of expertise either. But so it's interesting because I think we complement each other. no, the thing you just mentioned about like the fact that today kids are way less active than 10 years ago, 15 years ago even, because as you said, like there's much more screen time and lifestyle changed because of that the baseline they're coming from is much lower in terms of physical activity than before. That's actually an interesting take. It would be interesting to test that somehow. What I wanted to ask you is, you've touched on the fact that one of the limitations of meta-analysis and also studies looking at exercises and intervention is the fact that oftentimes we are, in those studies, the exercise is done in very, very controlled conditions in a clinical trial for example, while that in real life people have other challenges and time pressures and constraints. In your paper that you've published recently, I think you make a really interesting distinction between exercise and physical activity. And as you said before today, like if you're prescribing exercise to a person that's completely sedentary and has never done anything and you go to them and say, you know, now you're going to go to the gym five times a week, am I not? So I just wanted to ask you, how do you approach that in your clinical practice? And what do you think are evidence-informed ways we can actually prescribe or at least encourage our patients to exercise more as an intervention, per se? Dr. Nicholas Fabiano: Yeah, so I think the first point is just feeling it out to see if this is an intervention that the person in front of you might even be interested in hearing about. And I say that because I think a lot of people have had a lot of negative experiences, even outside of psychiatry, with being in front of a medical professional for whatever ailment they may have. And as you know, exercise, diet, these things can be beneficial across the board. However, you know, in the past, if they've been exposed to that, maybe it was for diabetes, maybe it was for weight loss or something of that sort. And being told by a physician in front of you, just exercise, just go diet. You automatically have that negative connotation attached to it. And now when you're in a vulnerable setting, speaking to your psychiatrist and they're saying the same thing as maybe another doctor that you've spoken to in the past, that can be very, very off putting. so I think first kind of feeling it out to see if that's something that the patient seems interested in and having that curiosity to talk about and presenting it as a way of.

education. So presenting it along with some of the other treatment options that you spoke about antidepressants therapy, exercise, kind of lumping it within and not forcing it in someone's face. The other thing, as well too, is with that, you want to be able to have like a productive discussion with them about it. So if that is something they're interested in talking about again, sticking to the evidence and maybe how they might be able to do that. And that kind of bridges into the, do you prescribe exercise sort of thing? Because as I mentioned before, for medications, if you're starting someone on an antidepressant, you wouldn't just say, start antidepressant and then leave your clinic. And they'd be like, what is going on? But that happens with exercise, right? You say, just exercise. so with a medication, you prescribe the type of medication you prescribe, the dose of medication you prescribe, how they take that medication. So orally injection, you prescribe, you know, how often they're taking it, all of these different parameters. So the same thing you can apply to exercise too, to make it actionable for the patient. So. what I recommended using is something called the fit principle. So it's F I T T. So that stands for frequency. So how often someone is exercising per week intensity. that's split up between the low, moderate or vigorous intensity. and then there is the type of exercise. So we broadly divide, that up into aerobic, which is things like running, strength training, which is things like, resistance or weights. and then we also have mind body, which are things like yoga. And then the last T is just timing. So how long are those exercise sessions? Is it 10 minutes? Is it an hour? And what that helps you to do is to break that down into something actionable for the patient so that they can actually do, and you can work together towards a goal. So you can look at someone's schedule and say, you know, how much time first do I have to even exercise? If I want to make this its own sort of entity and do something, go for a walk. And then you can talk about your, your provider, like I have this much time. Let's do this and kind of make that something actionable. And when you start engaging in that exercise, that can also be something where at your next appointment, you can say, this was too, too long of session. Maybe we should go down and you can also track, you know, as you would in any other appointment using scales like depression scales and correlate it to what the current exercise prescription was as well. So having that measurement based care with the exercise prescription versus just saying, you know, I went for a run and you know, I'm feeling the exact same sort of thing. It's hard to really do anything with that, right? You might just cross it off and say, Kate, we tried to exercise the same thing as you would with a medication. If you started too low of a dose and you didn't see an effect because you didn't expect to the fact sort of thing. So I think it's a nice way to communicate with the patient in a similar way that you would with the medication and be able to prescribe something that's actionable to them versus something where you as a provider are just saying, just exercise. And it's not something that they can necessarily do if they don't have that background or feel comfortable too. So it provides that framework and I think it's been helpful so far in facilitating some of those discussions. Clara Faria: That's super interesting and I think the Fitch framework is a really useful tool for clinicians as you said to kind of, you know, prescribe it realistically and track the effect of exercise over time. And I have a question for you because you were an exercise expert and in the name of all the gym phobics out there. like, for instance, if we look at the WHO recommendations for exercise, they recommend 30 to 50 minutes. The minimum is 150 minutes a week, if I'm not mistaken. And yeah, it's split into either five, 30 minutes or three, 50 minute sessions. I think some people do even more than that. But I think for some people, to start with that. mean, obviously that's the goal, right? But for some people to start with that is a lot. you've mentioned, especially I think for young people, you've mentioned, you know, how screen time has increased. And we know that like fitness influencers are a thing. And I think sometimes some young people might think, but if I can't go to the gym and you know, and if I don't have a six pack, like exercise is not for me because, you know, but like, what's the evidence on like, even if you do a little bit, helps. you said, obviously sometimes someone is going to go for a run and it's going to be a one off thing and they're not going to see an effect. like if someone is a little exercise, I think my question is, is little exercise better than no exercise at all? Even if that's not reaching the recommendations imposed by WHO or like by other guidelines. Dr. Nicholas Fabiano: Yeah, no, no, I think, back to the point that I said before, the less active you are and being able to do any amount of exercise, you're going to see significant amount of benefits at the very beginning. And those benefits, as you optimize it more, are actually going to start tapering off sort of thing where, you know, I think sometimes it's very off putting for patients. And that's why I'm very careful when I discuss these different thresholds or what we're aiming for. It's more so rather than aiming for specific time or a specific intensity, it's really building that momentum and making it something that the patient wants to do. Because the same thing with diet, you can have a perfect diet that tastes horrible, it's not working, you stick to it for one week and your body's the healthiest it's ever been for that one week, but you're miserable and you stop it after that one week. The same thing is with exercise. You can start right at the recommendations and do it for one week and you're like, I hate this. And then you stop, right? So the biggest thing for any treatment, again, is adherence. So my goal when I'm... speaking with someone is not necessarily to meet these thresholds because again, these thresholds as well are based on RCT data and people are not RCTs, right? If you actually look at the individual data points of RCTs, you have these hyper responders to exercise from both a physical standpoint and a mental standpoint. You also have people that don't really respond to it. So you don't know where that person necessarily in front of you is going to fall. It's helpful to have these accumulated averages of where someone might fall based on these trials. And it's very helpful. And we need that for the research and evidence to move forward. But I think my overarching thing is you want to make it feasible and something that they want to do. So the biggest part of the fit principle that I see is the type of exercise you want to talk about them about something that maybe they've done in the past that they liked and try to adapt it to that. And then from there, you can kind of fit it in their schedule in terms of how much time they have to do it at what level of intensity is comfortable. Because although generally the rule is from an antidepressant effect perspective, we see higher benefits, the higher the intensity. It's not very realistic to just go from no exercise to just doing a full marathon or something like that. So I think number one, tailoring the expectations, but also just helping as a physician foster that interest and passion towards it. Because a lot of patients say, once they get into it, it feels like it's a treatment that they're in control of. Whereas sometimes the medication, they can feel that the medication is in control of them, that they need this medication to be okay. Whereas exercise can be something that they're doing. It gives them this locus of control. So even if that's lower than the recommendations, that's totally okay. Because if that's working for them, or if that's working to a spot that is increasingly helping them, that's totally okay too. And that's why I'm always, as I mentioned, hesitant to say, you you need to hit this many minutes at this intensity of this specific exercise. Because that's a common question that's asked is what's the best exercise. And the same thing applies for diet. What's the best diet for X, Y, It's the one that you can stick to. and that is what I see my role as. in these consultations or speaking with patients is to find what works for them and hopefully set them up for success from that end. But yeah, that would be my approach. Clara Faria: That's fantastic. And I think it's useful advice for clinicians out there who want to incorporate exercise in their prescribing routines. So to wrap up our talk and our discussion about exercise and mental health, I just wanted to end with a takeaway from you. if you could considering where the evidence base stands today.

around exercise and the effects on it on mental health. What do you think should be the main change that should happen in clinical practice? Because as we were discussing before, like exercise already is on some of the guidelines as for slight interventions like CanMath, which you guys use in Canada, and NICE, which we use here in the UK. So what do you think should be the main change moving forward? What do you think? Dr. Nicholas Fabiano Yeah, so I think it's a great point you make. no, sorry. It's a great point that you make with regards to it being present on the guidelines. I think that's a very important first step. But the surprising point with that is a lot of people that I've spoken to that are either psychiatrists, psychiatry residents, they're actually not even aware that it is some of these first line options. So I think we need a bottom up approach from an educational perspective, because I can only reflect reflect on my own medical school experience and own residency experience. But although we're often taught the benefits of exercise across physical, mental, whatever condition, my own experience was that I wasn't necessarily taught how to prescribe it or how to talk to someone about it for different conditions. So I think it's great that it's on guidelines, but I think we need to take more of an educational perspective in teaching people to be comfortable about talking about these things. So how I would see an ideal clinical scenario would be someone comes in with depression like symptoms. When you're having a discussion about medications, therapy, I think things like exercise and diet should also happen at the same time. And again, not in this dichotomy where you're offering this side or that, but you're offering all of these treatment options and you're allowing the patient the option to make a choice in what works for them. And again, if they make a choice of medications or therapy, that doesn't mean that they have to stick to that one and that one alone. At future follow-ups, should still be something that's a discussion being had if that is appropriate. And I think that's where the education piece comes in again, because previous research has shown that people that are comfortable speaking about exercise often have a background in exercise from a personal interest standpoint. Like they're more physically active as a physician. But I also don't think it's fair to have that expectation on all physicians have to all be physically active sort of thing. It should be part of our education because it is a valid treatment option. So we should be able to speak to our patients about it. Again, not necessarily as a monotherapy, but as an option for someone that in front of you may be interested. Otherwise we're kind of stuck on this dichotomy of medications therapy. again, that's an oversimplification, but I do think that for all of these lifestyle measures, it should be something where we can facilitate that discussion and have it. And how that happens is through education, starting at medical school and maybe even before, and then throughout residency to make sure that people feel comfortable as they go through their training. That would be my overall approach to that. Clara Faria (Thank you so much for that. Yeah, I think you hit a nerve when you just said that we are not really taught on how to prescribe exercise, not as medical students. And I mean, I'm still beginning residency in chat and bus and psychiatry, but it's not something that is on the curriculum, right? And as you said, like usually the people who are more comfortable and more physically active are the ones who kind of push it more with the patients, but there should be some sort of like...universal approach as you said that includes exercise and not portrays it as this false dichotomy. Yeah, 100%. I'm really curious in the future to see, because we didn't talk a lot about that. We talked more about the evidence base for exercise, which we know it exists, but we didn't talk much about how do we motivate people to do it? Because I think that's the hardest thing in psychiatry and in life, right, is to promote behavioral change. I mean, I would be really interested to know more about. What's the motivation of people to do it and to sustain it at that high level? Like people who were previously sedentary and yeah, I know I said that the last one would be the last question, but can you comment on that as well? do you know? Yeah, in the current exercise research for it, which I know is your word, like, you know, what is on the pipeline? Dr. Nicholas Fabiano: Yeah. So for that, think a big component of it is timing of when you're having these discussions too, because that's what I mentioned before for people that have had poor experiences in the past or people that depending on the severity of their depression, maybe it's not appropriate to recommend it. So even in the moderate to severe range, that's probably where, you know, maybe that discussion isn't appropriate. Like moderate could be mild is where a lot of the research has been done in terms of depression severity standpoint. I think the first thing as a clinician that you are in control of is assessing that level of severity and seeing when it's appropriate to have that discussion because patients may see, you know, if that was presented as an option and they turned it down initially, maybe in their mind, this is now not an option to bring up again, because you've turned it down as the patient, which is not true, but that could be something that's kind of going on. But then the other piece is even in mild depression within depression itself, there's that a motivation there's there's in the diagnostic criteria. Right. So I think finding ways to tackle that and really get someone engaged in it starts from that stepped approach. So rather than necessarily throwing the book at them and saying, okay, you need to go full out exercise and everything like that, starting with low things. And as I mentioned, things that don't seem like exercise even, and seeing how that helps the patient and you might notice these changes. so I think taking that stepped approach and also having appropriate timing in terms of when to have that discussion is where you'll have the best, the most success. Clara Faria: Fantastic! Well, thank you so much for that, Nick, and thank you so much for being here today, sharing all your exercise expertise. And thank you, that's listening, for the lesson, and yeah, do leave your review, comments, or feedback.