Arwen Podesta MD (00:00) we don’t have a stethoscope in psychiatry. Our, our talking and the way we ask questions, but our listening and our watching is our, is our stethoscope and we don’t do a brain biopsy. Dr. Siri Chand Khalsa (00:16) to Roots of Healing, the podcast where we uncover the stories and insights of visionary leaders shaping the future of lifestyle and integrative medicine. I’m your host, Dr. Siri Chand-Khalsa, a physician and advocate for embodied living. Before we begin, please note that this podcast is for educational and informational purposes only. The views expressed by our guests are their own and do not constitute medical advice. Please consult with your healthcare provider for personal medical concerns. Each week, I have the absolute privilege of sitting down with trailblazers and thought leaders who are reimagining what it means to heal mind, body, and spirit. Together we’re exploring their journeys, innovative approaches, and the deeper roots of healing that inspire us all. This week, I have the absolute pleasure of introducing Dr. Arwen Podesta. She works in Louisiana with an office in New Orleans. She is a specialist in psychiatry, addiction medicine, forensic psychiatry, and holistic and integrative medicine. What an incredible combination. She’s authored a book on addiction called Hook. which is available online and on Amazon. She was recently awarded the honor of distinguished fellow of the American Psychiatry Association, as well as the American Society of Addiction Medicine, and is the immediate past president of the Louisiana Psychiatric Medical Association. She’s a national speaker. She teaches, consults, and is an advocate for integrative best practices for those with addiction and psychiatric needs. This is absolutely incredible background. And whenever I hear about ⁓ a clinician who has had both leadership roles and a deep dive into integrative and holistic medicine, I always want to know a little bit more, like, how do you bridge all of that innovation in one career? Tell us a little bit about how you came to have a relationship with holistic and integrative principles. Arwen Podesta MD (02:20) Yeah, I think it’s at my core, but I also think that my left brain needed the scientific aspect and that’s what landed me in the other parts such as forensic psychiatry. And I was thinking about that today in preparation for this podcast because I’m working on a devastating case of a patient at a ⁓ forensic correctional facility who ended up dying. And so I’m the expert witness on that as an expert psychiatrist and forensic psychiatrist and addictionologist. And so how does that link itself to my belief practice and personal practice and practice in my patients, for my patients into the holistic integrative lifestyle realm? What I like to actually call modifiable risk factors. I want to start adopting that, including the other arching umbrellas that we talked about. My background was kind of split between regular old ⁓ growing up in junior high school and high school and public schools in Houston, Texas, and Dundda, father lived on a commune, regenerative farming, involved in holism and living off the land. And it was not ⁓ a cult or it was not any sort of leadership. It was an egalitarian commune. And he of the people, several hundred people that I interfaced with over my entire upbringing really led me to understand living off the land, to understand the benefit of being centered. I learned things like yoga and cooking and some very interesting pieces that have continued to walking barefoot, waking up at the sunlight, all these things that have influenced my mental wellness. And when I went to medical school, well, let me back up, before medical school, I went, left Houston, went to California, became a massage therapist. So I studied massage therapy. I always say that was my first iteration was my massage therapy training. was excellent training, over two years of training. I worked really hard and I was a young, pretty exceptional massage therapist in the Bay Area for almost a decade. And while in training, body was invigorated, my brain was bored. My scientific thinking was not there. So I pursued undergraduate ⁓ degree in biology and ultimately got a degree in biochemistry and just loved that science, worked in R &D, but also maintained my massage therapy practice. straddling like this left brain, really scientific thinking. worked on the Human Genome Project. I was, you know, using all of these high powered ⁓ new fangled techniques back in that time of our scientific advancements. ⁓ And I was over here, you know, wanting to do like safe human touch that was healing and also mentally healing folks. And I worked with people in massage therapy ⁓ with chronic disease. so folks that had post polio, multiple sclerosis, repopulsey, and I became, as a scientist, scientifically minded, I only had an undergraduate degree, but scientifically minded massage therapist, I became someone who started accompanying some of these folks to their medical doctors visits and even traveled with some of them overseas and was like the safe person to help. demystify some of their disease issues and also think about how I could help them more wholly from left and right thinking. And then I was like, well, do I want to get a PhD in science and research or do I want to get an MD? And I ultimately went to University of Southern California, Kexical Medicine for my medical degree and found a couple of mentors that were involved in ⁓ the complementary and alternative medicine space. In fact, one of them that was, I think, the vice president or something of that at the time, did some research in that realm. While I was learning what you and I know very well is very biased ⁓ and reductionist, important stuff for all MDs to know, but still it misses the mind-body-spirit connection. And so I was able to do research on breast cancer and research on complementary healing strategies and shamanism and such while I was in medical school. And then I moved from medical school to residency. I landed in Louisiana out of just love and adoration for the culture and the space. It was right before Hurricane Katrina. So then I ended up being a resident during Hurricane Katrina in 2005. where I was learning with really seriously mentally ill folks that were evacuated from New Orleans, because New Orleans and the hospital didn’t exist anymore. And it was intense. And the person that I was ⁓ training, one of the five or six people I was training under or training with, was very holistically minded. and allowed me to pursue some studies outside of, were called doctors without hospitals. We were just making our own training programs, trying to learn everything we could. And so I started training in addiction medicine over here in kind of this holistic spa type of ⁓ mindfulness-based therapeutic tools over here and seriously mentally ill that were. evacuated from Katrina and we didn’t even have their medical records. We didn’t know who they were. We didn’t know where their families were. And so I did that for a couple of years, then came back to New Orleans. And once I finished my residency, I went into forensic psychiatry because I love the science and the expertise that’s there. And I love the vigorous nature of that. And I went into addiction medicine because I can make such an impact by being so compassionate. and helping my addiction patients get into a space where they can go beyond addiction and thrive in their life by using all the tools that you and I know can affect our life. And I’m just a regular old psychiatrist. Dr. Siri Chand Khalsa (09:10) What an incredible passage. And there’s so many pieces in there for us to jump off from, so many points of discussion. One of the things I’m really curious about, I think for the listeners, they’re probably well aware by now that we share so many similarities in our journey, in the sense that when I finished my undergrad degree, I’d been pre-med and then said, I’m gonna move to San Francisco and look at acupuncture schools. And this was in 1994. So we may in fact have been there at a similar overlap. And it took me about four or five years, made my way back, got a master’s degree because I thought I might enjoy research and had a very progressive, even for that time, because in my undergrad years, I’d had such a deep understanding being in Charlottesville and in the Shenandoah region about natural healing. And that was really the first place I’d ever been exposed to it. I’m curious if you remember the exact moment when you said, wow, massage therapy is amazing and I’m really having an impact, but I want to do more. Was there a particular case or situation that really woke up the commitment to say, I’m going to go get my either baccalaureate or I’m going to do all the pre-med requirements and take the MCAT. shadow someone and get recommendations and all the things it takes to get into such an exceptional school like the UC system. Arwen Podesta MD (10:42) Two things, an acupuncturist and an ⁓ MD primary care that I was taking one of my clients with post polio to some of her medical visits. The acupuncturist, Marcy Zellner in Northern California, amazing. And she noted my compassion and my understanding of the body and my understanding of the brain and definitely influenced me to seek further training, whether it be something beyond massage therapy, something that may be more in leadership and more ⁓ in some way to shape the future of medicine. within the next, that was, I was probably my maybe 22 years old and I was already taking some community level, know, in California, you can take community classes and they can apply to the UC systems if you do it right. And so I was already taking some community college classes in things like biology and other things I enjoyed. And then I went from that appointment with her to maybe a couple of weeks later, an appointment with a primary care. And he said something to me about, I’m trying to remember exactly, he was so influential and he ran triathlons, he had like two kids, he ran a practice, he was an amazing physician and he was very mind-body oriented and he said something about massage therapy being just the tip of the iceberg and that we could do so much more by not being, he wanted to be in higher leadership because he could influence more and make more change larger than one-on-one and although the one-on-one is so exceptional and so profound. And we don’t want to escape that, but being able to have what now I learn to call capacity building. So I took that on. I started pursuing that, ⁓ my undergraduate degree in the sciences, and then I continued to keep those people in mind and medicine fit. Dr. Siri Chand Khalsa (13:04) incredible. And I think that probably it was just really additive for you. You had a deep listening from your upbringing where you’d had your own, one could say somatic relationship to healing in lifestyle through food, through community, through love, through co-regulate, co-regulatory practices with the land, with people. Was that something when you first started your medical school training that felt like Arwen Podesta MD (13:05) Thank Dr. Siri Chand Khalsa (13:32) how to bridge my massage school, how to bridge my upbringing, especially in the eras we trained. Now I think it’s much more common. mean, there were no integrative medicine curricula in med school. There was no integrative medicine curricula in residency when we were training. And now that’s much more common. And we’re understanding, as you eloquently said, These are modifiable factors in any disease process that we have more agency over than really most clinicians realize or even most patients for sure realize. So when you first kind of came into the medical school environment, did you have any moments of like, dang, hard stop? I’m not sure this is gonna work or did you just kind of have a sense you’d be carried through? Arwen Podesta MD (14:23) Well, because of the biochemistry background and I was like doing pretty okay and those sorts of courseworks, that was fine. But some of the more ⁓ rote stuff that we definitely had to learn that we may never apply. I was just like, what is happening here? This is so archaic. It’s not really forward thinking. ⁓ And so it was definitely a challenge. know, we like, you know, muscling through gross anatomy, which was interesting, but how they do it a lot differently now. as you and I know, but there were a lot of courseworks and a lot of leaders that maybe were very mind, body ⁓ skeptics. those that were, even our psychiatrist was still a guy, one of our psychiatry professors was still a guy that wanted to go into a room and smoke cigarettes with a patient and talk. to him and not think about the whole inflammatory body and the lifestyle and the terrible things that are going on inside and outside that person’s and that patient’s body and existence. you know, there was a lot of joy that I had when I was doing some of the work with the professor that was part of the ⁓ complementary and alternative medicine from the NIH. That’s a very, very small. piece of NIH’s budget, but it was new at that time. And so it was kind of flourishing and they were doing some on ⁓ mental health and on mindfulness and on meditation. So that’s kind of a foray into the science of that for me. Dr. Siri Chand Khalsa (16:09) And it’s so interesting because my husband and I are currently here at Harvard. And we have a very dear friend who did chaplaincy training here, but then went on to ⁓ a master’s degree in divinity, MDiv, they call it, but is now doing his PhD in mindfulness for children in Minnesota. And I think we’re starting to really understand that. the neuroplasticity and the introduction of these techniques to the young mind really can have this lifelong, very positive impact. And ⁓ certainly the mindfulness research is not so much up for debate anymore, is it? I don’t know, what do you think? Arwen Podesta MD (16:51) was not, you know, what’s so interesting now that we have all these biomarkers that we can do in actual tests. Like I always used to say at my beginning in my psychiatry and now when I teach psychiatry to residents, even medical students, I’m like, you know, we, we don’t have a stethoscope in psychiatry. Our, our talking and the way we ask questions, but our listening and our watching is our, is our stethoscope and we don’t do a brain biopsy. So we don’t know what are disrupted or what the cause is. And so frequently in, you know, ⁓ in Western typical medicine, you know, when we say this in functional medicine, that Western typical medicine says, ⁓ name it, blame it, tame it. And so we have these ICD-10 or DSM codes and then we call it that and then we use a medicine that’s FDA approved for that. ⁓ And then we end up not getting to the root, to the whole underneath. And so when we don’t have a brain biopsy or a way of understanding, the analogy is a fever. So a fever can be caused by many, many different things. We want to treat the thing that’s causing the fever. Yes, give an aspirin. Yes, ice. Yes, do other things to modify the seizure. I mean, the fever so that you don’t end up having a seizure from the fever. But you also want it to get to the cause. Is it bacterial? it viral? So in medicine, in psychiatry, we don’t really have that. as much, but now we do have biomarkers. We can test, you know, it’s a controversial thing to look at salivary serotonin, but people do it. We can test certain genes, certain markers like BDMF, certain other immune markers. And so what we know is that meditation, and I use a lot of intentional breath work, ⁓ that it actually has some neural feedback, but that the markers are testable. And so when we do pre and post of, know, and in psychiatry, we just, use so much pre and post like Madras scale, Ham D, like all of these scales that really don’t get into a cause. But we can use heart rate and we can use blood pressure and we can use coronary artery scans, know, pre and post with the only intervention being mindfulness techniques or breath work or other things. We can test BDNF, although it’s an experimental test, it’s very expensive. We can do EEGs. We can look at all these different pieces. And so now science is catching up with what we’ve known for centuries. I love it. I think it’s such a fantastic time to be in my field, in your field, in our field. I just love it. Dr. Siri Chand Khalsa (19:46) It really is a time of great innovation and integration, think we’re embracing ⁓ for for myself, I spent nearly two decades now studying our Aveda, which is a whole person healing system that understood very intricately the interconnectedness of the spirit, the body, the mind and emotions that the things aren’t just rooted supertentorially, that there’s this ⁓ whole system process. One thing that I think people might be interested in that would seem very foundational to you and I, and then we can go into things that may be ⁓ perhaps a little more esoteric, but still evidence-based, I’m sure in their own way, is ⁓ we’ve come to understand that metabolic diseases and changes in insulin resistance are sort of the linchpin of what we think of classically as ⁓ diabetes, hypertension, stroke, some preventable cancers, we don’t often make that jump to ⁓ psychiatric changes. And I think that’s a real disservice to people that in fact, inflammation may be at a very interesting route. ⁓ Again, what causes the inflammation is even still further a very interesting question, but Many people don’t appreciate that when they make these modifiable lifestyle changes for their hypertension, their diabetes, their pre-diabetes, that their mood starts to shift. And I wondered if you could, we could start with something so basic as reducing inflammation and the positive impact to mental, spiritual, emotional wellbeing. Arwen Podesta MD (21:36) It’s so great that you asked that. I have a couple of things that ⁓ are in the hopper in my future right now. ⁓ I just finished recording a video on modifiable ⁓ risk factors for Alzheimer’s disease. And there’s some great work by Cat Tubes, Dale Bredesen, and others that really look at those modifiable risk factors. And they have tested them in combination with each other. you know, it metabolic breathing, interleukins, general inflammation, and then other things that can cause inflammation, like people getting stuck with like mold, you know, harboring mold and yeast and things like that, or other parasites, ⁓ toxins, all these things that cause this, what looks like an amorphous disease in the brain, but we need to just get down to some of the causation. But what we know is that there are and a lot of the newer medicines are steroid in nature, which is decreasing inflammation. And that brings me to another thing, like the newest, some of the newest medications in psychiatry are steroid in nature. The ⁓ postpartum IV, that’s just a wildly successful, very quick treatment for someone with postpartum depression, it’s a steroid. And so what we know is that by decreasing inflammation, your mood can get better if inflammation is the cause. Inflammation isn’t always the cause. Sometimes it can be related to a neurotransmitter deficiency, a micronutrient deficiency, know, trauma constantly in your face, and it might not respond to that. But the studies look so good for these neuro steroids to help improve mood. help improve just general mentality for many, but not for all. And then, you know, when you think, so the other thing that I’m launching, you said metabolic overall, and ⁓ I’m wearing a CGM right now for fun. I’m doing it just because I’m getting ready to launch a metabolic mind base. So metabolic mind is a leader group in metabolics for mental health. And so I’m doing a metabolic month with my patients. ⁓ in a couple of months and so I’m developing the coursework now. And I’m so excited because watching your glucose getting into using ketones for your brain is so much more valuable. Glucose is very toxic at high levels and at unchecked levels. so eating things that cause your glucose to spike even if you don’t have diabetes or even if your pancreas is working. eating things that makes your diabetes spike, or make, I’m sorry, wait. eating things that make your glucose spike, even in the light of not having diabetes, we definitely have a lot of mental health disparities. And so we’re actually looking at that a lot. ⁓ It’s just in its nascent stages though. And I’ve had so many people tell me, friends and family members and patients, like if one more doctor tells me what I put in my body is gonna affect the way I feel or how long I live, you know, we’ve been tricked. by the ⁓ food industry. we know that not all food that we buy at the grocery store is actually good for us. It’s good for their bottom line. It’s good for their rank. But we’ve succumbed to that. And so I think we’re climbing out of that right now, which I’m so excited for so many reasons to be practicing medicine like this at this time. But that’s one of the major components. Dr. Siri Chand Khalsa (25:29) That’s really, I mean, we have so much to think about this. And I think that the CDC has some really intense statistics ⁓ surrounding pre-diabetes. And I think I saw a study that said 98 million adults have pre-diabetes. And if we think about that, that’s telling just what you’re saying, which is that the body’s ability to utilize insulin, well, insulin and glucose effectively has now been impaired. And so there are these probably neuroinflammatory processes that are happening as well. ⁓ Small aside, but anecdotally, have you seen the GLP-1’s improved mood for people? Arwen Podesta MD (26:16) So there’s some research that I’m actually privy to that is looking at ⁓ another specialty of is addiction medicine. And so first, because of the high note of improvement with people and cravings, because first, the GLP ones, they do a lot for your glucose metabolism. They do a lot for your pancreas and for your gut health. And then they also have this ancillary effect that people noticed early on that it decreases food chatter. And so food chatter. also kind of titrates into decreasing alcohol chatter. So for folks that crave that drink at the end of the day, they were saying, huh, I’m not really, along with that, I’m decreasing my drinking. Part of it’s that they’re full and their stomachs are upset. And so they’re getting like, alcohol just sits right here and causes heartburn. And so part of it’s discomfort for some. But I’ve talked to many patients that just say, oh. one or two but I used to have six or eight like pretty heavy drinkers and they’re just decreasing it not all not everybody but when it’s the right mechanism for the patient it’s a vast improvement and because of the decrease in inflammation we’re noticing ⁓ increased improvement in cognition and Alzheimer’s early Alzheimer’s disease increase in ⁓ mood for some not all and on also some anxiety components. Because think about when you have somatic anxiety, physical anxiety, muscles are prickly, they’re kind of twitchy. And so if you can just calm that down by having decreased inflammation, by processing sugar better, by getting it through your system, then you have less somatic anxiety. And when you have less somatic anxiety, it sends signals to your thinking brain. that makes it so that you have less mental anxiety. So it has an upward. So there are studies going on. There are a few that are ready for prime time and maybe have come out really recently, but it looks really good. Again, not for all. No medication is correct for every person on the planet. We have to do as doctors and scientists, we have to be scientists and detectives and figure out why one medicine would be good for one. versus another, and a lot of that is ⁓ what we can do with listening and good workups. Dr. Siri Chand Khalsa (28:45) Yeah, my health journey, which I’ve been pretty transparent about, has included a post-COVID small fiber neuropathy that includes damage to the parasympathetic nervous system. And that has created ⁓ delayed gastric emptying and all the delays through the GI tract and so on. And so the GLP ones may not be good for me because part of their mechanism is to delay gastric emptying Arwen Podesta MD (29:13) strength. Dr. Siri Chand Khalsa (29:14) And so there’ve been some people in the long COVID community that do better and some that don’t, but one place where that mechanism doesn’t work well is when you have some already impact to the parasympathetic, connective connection. And that’s been really fascinating for me. we’re both obviously scientists. love when modern medicine can serve a function, but we also have a broader sense One of the big conflicts that I came into, it’s sort of in my, it’s my interior world, was that people would come for wanting a deep change, wanting something different, but then they would find themselves without community support, without friends and family that could cheer them along. They would take these measures into their native environment and they would come back and say, I just don’t think I can do it. And of course, Arwen Podesta MD (29:54) Bye. Dr. Siri Chand Khalsa (30:13) The beautiful thing about being an MD is you can say, then we have these other mechanisms that are going to prevent the, perhaps the sequela of untreated hypertension, untreated diabetes, untreated ⁓ cardiovascular disease and such. But I’m curious in your work, are you finding a real value for group visits and building community where there’s sort of, you mentioned you’re going to do it with your practice. And I would imagine in psychiatric, it’s a little different than primary care. People might be more guarded or have more significant disease and not be interested in group work. from what I recall, the first time I ever encountered group work was in my psychiatry rotation as a medical student. So I’m curious if you could just comment on that continuum of agency and community and maybe even the way some clinicians blame people who can’t make change, but it’s really Arwen Podesta MD (30:59) Yeah. Dr. Siri Chand Khalsa (31:11) more a factor of the world that’s surrounding them that’s a little bit out of their control. Arwen Podesta MD (31:15) Yeah. Well, I want to, first of all, my dog agrees with you. That was him barking. So he said, hi, his name is Teddy little rescue baby. What? We both have Teddy. Okay. Well, maybe they should have their own podcast. So I want to mention something that I think is left out in our training. And I was just talking about it with a physician friend last night. And when you have. Dr. Siri Chand Khalsa (31:20) My dog is Teddy too! ⁓ Yes. Arwen Podesta MD (31:43) When you’re a physician, when you’re a physician in training, that’s your time to look into your counter-transference. Because what is it about your personal belief system, your personal judgment, your personal ⁓ ability to handle a difficult patient or a difficult disease that makes it uncomfortable for you? And it’s not the same for everybody. Not everyone responds the same. And actually, this person I was speaking to is an emergency physician, very ⁓ very well seasoned and he teaches the same thing in emergency, that that’s part of your ability to diagnose. Not just diagnose a psychiatric disease, but diagnose based on when you understand your countertransference and how something makes you feel. If your grandmother died of diabetes and this looks like the flavor of diabetes and you’re very mad at it and subconsciously you get prickly because of it, you may have just diagnosed someone with diabetes subconsciously. So it’s so important as a trainee and as any physician and definitely psychiatry to really tap into understanding your own countertransference and not applying it to judgment of the patient, but applying it to understanding how that helps your diagnosis. So that is something that a lot of people don’t really tap into and it can be very valuable. So transference is how the patient feels about me, about their provider. Counter-transference is how the provider feels about the patient. And sometimes that can make it so that you guys are not a good fit. And if that’s the truth, then step away as a provider and… let the patient find someone or help the patient find someone that might be a better fit. But sometimes you can use it to your advantage for diagnosing certain psychiatric diseases. I used to work with ⁓ another psychiatrist and we did in tandem interviews right after Katrina where we would just go out to houseless populations and we’d have to in order for them to get housing from a particular agency, they had to have a psychiatric ⁓ evaluation diagnosis. And so we would go together to make it and I would write and she would ask and vice versa. And she found that she was much more able to identify, she had countertransference like this with someone that had borderline and bipolar, not necessarily both, but borderline and bipolar. And I was much more quick to get the hair packling on the back of my neck for someone who had ⁓ antisocial personality, psychopathy. and things like that. We both were able to just like this pick up on, know, panic attacks, agoraphobia. Obviously we were both quick to pick up like major depressive disorder and both of us to pick up on malingering on kind of faking the disorders. But it, but just, was so interesting to see how we do it differently. And so that was an awesome, interesting and weird time because that was where we were doing, we were doing group psychiatric checks. not with multiple patients at a time, but with two psychiatrists. So flip that over to group psychiatry or group visits or group, and I do it in addiction medicine mostly. ⁓ It’s pretty common to have counseling groups and counselors and therapists that do it in psychiatry and addiction medicine, but it’s not that common to have medication groups or to have like, you know, a group visit. And I’m telling you, the ones where I’m the one seeing the patients during, and I have a therapist that works with me on this. So we do it together. And like when I’m writing notes or writing prescriptions, she’s doing like real therapy. ⁓ But together we’re very therapeutic and these guys play golf together now. Some of them are in mom’s groups together now. They are, know, some of these, I’ve been seeing some of these people since 2012 and they’re still in the groups and they’re, many of them are patients that are on buprenorphine. And so they have to see us frequently and we need, you know, all of the checks, but it’s life saving and it’s life altering and they all are thriving. So I think the group component, I would say the opposite of addiction is connection. And I think that’s a really important way to think about if we can get people, if we can get everybody connected, then we can have. a ⁓ less deep hit on our patient population. Dr. Siri Chand Khalsa (36:31) I’m curious, and now we sort of blend in our arc into things that maybe aren’t as traditional. And I know that you’ve had a long standing relationship with yoga and breath work or pranayamas, it’s called, and different styles of breath work. Do you use that in these group visits? Is this something the group does together? Is there humming together like Polly vagal theory? Tell us little bit about maybe the more esoteric components and then bridge us into what some of modern neuroscience might be telling us about chanting together, singing together, humming together, and breath work in general. Arwen Podesta MD (37:12) Yeah, well, I personally don’t do and I have been involved with ⁓ chanting and humming and different yoga practices myself. And I think it’s a very valuable and very centering tool. And I remember trying to, when I was in Los Angeles in medical school, trying to get some friends to come, stressed out medical students to come to yoga with me. And they were just like, and it was the type of yoga I was doing and had a mirror in the front window, in the front of the wall. So you had to stare at yourself. And they’re like, I don’t want to look at myself. You know, I can’t do that. And so I was like, just come on, like, and just notice, like, you might find that you hate yourself at the beginning, but your serotonin literally comes on board and increases and your glutamate increases to tone within the first three to five minutes of yoga practice. And most yoga practices start with breath work. And so I’ve been doing yoga since probably high school, more intensely in college and undergraduate, and know that yoga has pranayama, which is the breathwork aspect, which is almost 90 % of the things that we know about the ancient traditions of yoga, only a small part is what Western folks practice, which is the asana, is the physical portion. But when my medical student colleagues felt good, They had that reinforcement and they knew the science that serotonin and this was 20 something years ago, 25 years ago, that serotonin was boosting because of the breathing, because of the physicality, because of the silence. I like to call it dynamic stillness. It was so beautiful. And so guess what? They came back and they came back and they made it through the hell of medical school that we all are experiencing in our lives at some point. ⁓ But it’s really, really valuable. I practice with some of my groups. We do some breath work interventions, but what I’ve done is I do a breath work course where I have, ⁓ it’s online and it’s 21 days of 21 minutes a day of breathing. And I introduce them to the science and I introduce them to, and many of my patients have taken this coursework and I want to share some results from it too. ⁓ But I introduce them to the science at first, some of the basics, and what we do is we practice alternative nostril breathing every day for several minutes, just to do that. And I do heart rate before we start and heart rate at the end, and I have them submit it to me. And so alternative ⁓ nasal breathing, you have, you know, multiple kinds, left, right, right, left. Right, right, et cetera. So you can do it all different ways. It all has different influence on your energy and on your mood and certain ones you want to do at night to sleep and certain ones you want to do to energize in the morning. But it’s all healthy and healthful because it’s intentional. You know, we go through our day forgetting, even me, just like talking, talking. I’m like, I’m just breathing shallowly. And the more shallow you breathe, the more acidified and the more prickly and the more discomforted your muscle and nerve ⁓ connections are. And so what deep breath work and intentional breath work, one of the many things it does is it cleans out. It helps, know, your lungs and kidney are connected. That was a very difficult concept for me in medical school, but the way that the respiration and alkalosis and acidosis and alkalosis work is very complicated and breath work helps fix it naturally. It’s amazing. So all your stress of every day is washed away. If you do about five to 15 minutes, everyone says something different, but the studies look good for, you know, average of 10 minutes of breath work daily to help with a lot of these things that are because of our cortisol levels, our heightened ⁓ acidosis, our decreased, ⁓ decreased ⁓ BDNF, brain-derived neurotrophic protein, all of these are advanced with intentional breath work. So in this 21-day coursework, which I’ve done a couple of times, many of my patients come, sometimes patient, non-patients come, and it’s open, and it’s synchronous in that it’s live, but people are not witnessing each other. Some of them know each other, but people aren’t in video together, because sometimes being on video with breath work is disconcerting for many. ⁓ They might feel judged or looked at or something. But the point of it is to train, get people who involve themselves in a habit of daily breath work, and then also reduce what we know the studies show, stress, anxiety, depression, improve cognition. And it’s all based on the alkalization and vagal tone. And so polyvagal theory, you’ve brought up. I love it. And we’ve had some really interesting outcomes with this particular type of breathwork workshop that I do. And I’m not an expert. haven’t, I mean, I’m an expert in my own writing that I’ve studied and I’ve read and I’ve practiced for multiple decades, but I’m not the scientist for all of this, but I am the clinician that does it. if anyone wants to come. So any of my workshops, just follow me and I’ll have something up probably in the fall. usually do it after Mardi Gras being that I’m in New Orleans. Dr. Siri Chand Khalsa (42:50) Yeah, that seems like the perfect time. So one of the things that I really appreciate is that as clinicians, know, we have our own internal stopgap of what’s the standard of care. And often right now in this particular era, there are clinicians that are saying, I know this isn’t what we would call the standard of care, but I know it to be true. There’s enough emerging research. There’s enough. lived experience, you’ve been in medicine 20 years, like there’s this courage I think it takes to sort of sit in it without being, you know, the premier researcher or the yogi from India who, you know, the family lineage is such that breath is, you know, expertise. And I love that because I think that that, that courage that clinicians are bringing to that, like yourself, helps speed innovation along in spaces that sort of deeply need innovation in the sense that we’re dealing with unprecedented, I believe, levels of mental health concerns, higher levels of self-harm, death by suicide, anxiety, depression. Also, we’re probably seeing expansion of other types of diseases in the mental, emotional, spiritual realm. I like to say that existential dread is at its own particular ⁓ know, peak as well, which really doesn’t respond so well to classic Western, I think you call it the typical treatment plans, meaning existential dread is a really particular space that brings in spirituality and care of the spirit, care of the soul without necessarily imposing a religious paradigm. I’m curious what what you’re finding in your work around sort of existential dread or existential pain that people are feeling the advent of AI, the geopolitical landscapes, the gun violence, the aspects of harder to find food, harder to pay for housing, especially in this generations younger than us that don’t ever imagine being able to own a home. Like, what are you seeing in terms of that that’s not per se a classic, you know, it doesn’t fit neatly into a book. Arwen Podesta MD (45:08) Yeah, don’t have, right, we don’t have a Hamilton rating scale for existential dread and it’s not even included on any of the rating scales, you know, so yeah, I nailed it. is, mean, psychiatric illness, psychiatric symptoms are rampant worldwide. It’s not just in the US where we have certain things going on, but worldwide. Same with addiction worldwide. And it’s massive. And it’s, you know, the peak is not we have not reached the peak. And it’s really tragic in our young people, in our teenagers, and even underneath teenagers, you know, in our elementary school kiddos. And it’s just, and we have to do more. So I’m never suggesting as an MD to not do what we know is the standard of care. I’m never suggesting that. And as someone that does risk evaluation, as a forensic psychiatrist that reads notes all over the country of people who. didn’t abide by the standard of care and got in trouble for it, please abide by the standard of care first, document your medical decision making, and add the things that you know in your heart and your soul and from the science and evidence that make a difference, that are modifiable changes. Because existential dread, it’s a hard one to treat. And I think group is a great way to both commiserate and kind of bitch about things. but also to support each other. And I think that some of my psychologists that I work with and therapists that I work with, they have some life skill coping groups. And that’s what can be, it doesn’t have to be ⁓ sanctioned algorithmic dialectical behavioral therapy. It can just be a life skill coping group that basically is a support network for stress, for shit in life. Because it’s not. it’s not lost on us as providers that things are hard for many people, for most people. Yeah. Dr. Siri Chand Khalsa (47:09) Yeah. Walk us through, I appreciate that answer because I think it’s ⁓ for those that are listening that are maybe in primary care may not recognize that bringing in our friends and colleagues that are therapists can be ⁓ life changing in terms of freeing up, I don’t know the right word per se, but internal bandwidth to make the lifestyle changes. Because some people just come in. sort of like what’s the point? And I think giving people space to kind of commiserate, but also do a little bit of healing and then develop some perhaps even coaching skills, life coaching skills or basic skill sets that help them reframe how they’re positioning a certain thought, I think can be so valuable. Arwen Podesta MD (47:56) When we as prescribers have this limited amount of time, even myself in my private practice, I’m fortunate to have a decent amount of time, but I need, I call it care extenders. And that’s what insurance calls it. And insurance covers, private and public insurance tends to cover some of these care extenders. And that means that I can spend more time doing the science-y part and the chemical stabilization part. and then get support and have extension for longer discussions with, you know, it can be a coach, can be a therapist, a social worker, a psychologist, a group. There’s so many options and now they’re asynchronous online and some insurances cover those too. So I think it’s so important to know all of the pieces that you can get to help collaborate in your practice to outside or inside your practice to help you Do your best by the patient. Dr. Siri Chand Khalsa (48:58) Tell us a little bit about, as we’re starting to wind down, I wanna be mindful of your time. Tell us a little bit about the first time someone comes to see you. I imagine it’s never the same, dipping your foot in the same river twice, but are there some core principles that you maybe have a rhythm within those visits that there’s no way to really… extensively share the model that you’re using, but to give someone who might be curious or in a psychiatric learning pathway, like what might you be doing that’s in addition to what was part of your training that they people might be curious about? Arwen Podesta MD (49:43) think we have a lot of medications that are available. We have a lot of patients, whether they come to me for addiction treatment or they’re someone like you and me that doesn’t have addiction, but maybe someone, some of our friends have experimented on lots of things and they know what their experience with one drug versus another drug versus another experience was, whether it good, bad, ugly, et cetera. So it’s so valuable to know, and I call it the like phenomena, ⁓ know what medications do, know the mechanism of action of the medicines, especially in the brain where we don’t do a brain biopsy. And we’re not going to do an EEG on a patient prior to a psychiatric visit. And we’re not going to get a VDNF level and a CSF tap. No, we’re not doing that. So know what the mechanism of the medicine is and why it might work for the patient. And then know some of the analogs of character, of experience, and of… causation of certain pathways being disrupted and know some of the tools ⁓ that you can ask about in their history such as for someone who never used the say cocaine in college, they’re not coming to me for cocaine use now, they’re an attorney or whatever and they’re coming to me for just ⁓ general wellness. Know what mechanism cocaine has on the brain and why they liked it was because they’re pathway was susceptible to liking it and then know what medicines and what lifestyle factors and what vitamins and what nutrients support and what other things can affect that particular system. So I call it the like for like paradigm. It’s really simple. I have a master’s class in addiction plus. So in integrative strategies, well, neurobiology, regular and integrative strategies for addiction treatment. And I talk about it pretty deeply. And I think it’s very valuable for all people that work with anything brain oriented, which is everybody, every clinician works with brain oriented stuff, because you work with a patient. Dr. Siri Chand Khalsa (51:50) And if someone was ⁓ moving through an assessment and then moving into treatments, you have your care extenders. Do you utilize ⁓ mindfulness, yoga, supplements, therapists, movement, food, nutritionists? Could someone leave your visit ostensibly and be almost like they visited a primary care doctor for their mental health? Arwen Podesta MD (52:16) Well, yes. I have a nutritionist and several in my practice. She’s a functional medicine nutritionist, is a leader in the field in our area. ⁓ And ⁓ she also has other people that she’s mentored and that I can refer to when she’s not available. ⁓ And I have psychotherapists ⁓ in my practice. And then I have a referral spreadsheet that’s probably 15 pages long of an Excel document of ⁓ who needs what, but the key characteristic, just like finding the right medication for a patient, is finding the right care team for a patient. I have many patients that have sexual trauma and have never, are in their 30s as females and have never had a gynecological visit ever. that, I refer to one or two very wonderful specialists that are incredibly trauma-informed that are just wonderful with them. And now they have, their gynecological care. I think of head to toe, I think of using cancer testing, know, screening, I make sure that I get a battery of labs for patients, a pretty significant functional medicine battery of labs for patients. I don’t start with saliva work, I don’t start with gut health work, I just do basics, and then I have integrative providers that do the deeper work if I need them to. And I also do use A lot of things, I try and make things accessible to patients so that they’re not expensive. I have supplements that I use ⁓ that I can teach people how to use, ⁓ especially in addiction medicine. That’s in some of my coursework as well. I pretty much have anyone that’s on certain medicines like antipsychotics. have almost everyone on magnesium glycinate and anyone with anxieties on L-theanine and lots of other basics, but then there’s a whole like another like layer and level. and I’ve been trained in that. yes, ⁓ patients come to me seeking wellness, even if they’re at their depths. I actually had a patient yesterday who I haven’t seen in 10 years to the week, ⁓ young eating disorder 10 years ago, just out of college, and ⁓ cocaine and alcohol. And ⁓ she has gone through her journey for 10 years, master’s level, working full time, and then. relapsing and kind of spiraling back down, living with her parents now and now she’s back to see me. And we are, you know, putting one foot in front of the other and looking under the hood and I’m the detective seeing her and her family. I’m seeing her family too, because as you know, families are a huge part of the problem and the solution. So that’s my story. That’s kind of how I look at it. I want to put one more plug in for measurement based care as well. And I talked about the Modres and about biomarkers, but just looking at a little bit of quality of life pre and post an intervention is really valuable. So whether it’s a WHO five question quality of life scale, I like to look at the hero scale, which is happiness, enthusiasm, resilience, optimism, and just mental wellness in general. ⁓ super easy and you can get just bumps with even one intervention. Dr. Siri Chand Khalsa (55:33) And the way that charting works now, it’s possible for people to follow their progress and to see sometimes they forget what it felt like to not feel good. And then they are a little less incentivized to maintain the things that we know are keeping the quality of life up. And so they can see, wow, when I started, before I was really paying attention to movement and sleep, connection, self-care, my sense of wellbeing was here and now it’s here. And then they forget, like, I’ve got to keep doing all these things. So you can see those movements. And I think it gives a really important feedback to people. Yeah. Arwen Podesta MD (56:15) It’s neurofeedback and that’s you know kind of the beauty of these continuous monitors like the glucose monitor and other things they’re neurofeedback and so you’re doing neurofeedback like on a regular basis by watching like I’ve got to redo this scale I’ve got to do this that’s why some app-based care is so useful too as an extender and so able to track things it’s very valuable for especially people that like get so far away from themselves they don’t they don’t connect and they Dr. Siri Chand Khalsa (56:32) Mm-hmm. Yeah. Arwen Podesta MD (56:43) have some significant problems remembering based on lots of things ⁓ or really detaching from their bodies. And so it’s really nice to have that data. Dr. Siri Chand Khalsa (56:55) I think there’s so much more we could talk about. I we didn’t even dive into sort of the newest buzzwords of trauma and trauma-informed care or therapeutic models that help with internal self-talk or the sympathetic, the vagus nerve health. I mean, we know that all these things can play such an important role, but I think you offer a lot of resources for people to learn from. Can you tell us just a little bit about how someone either maybe from a clinical side and from just the general public layperson side, how could someone learn from you? And from this treasure trove of what is very apparent to me is not just clinical experience, but it’s lifelong learning and curiosity that continues to drive your desire to help innovate in a model that we know needs innovation because as we’ve said and shared, some of the things we’re doing are not I don’t want to be so bold as to say they’re not working, but they’re maybe not staying even with whatever the degree of stressors that people are experiencing are so that we’re seeing these really painful shifts in how people are experiencing themselves in their lives. Arwen Podesta MD (58:09) Right, I mean, you’re right. The level of psychiatric intervention and the level of awareness of psychiatric needs has increased drastically. And guess what? We haven’t caught up with it. It’s a Sisyphusian task. We’re going uphill still. We’re driving up the mountain without chains on a snowy mountain. We’re just slipping down and down and down. And it’s because the lift is so hard, but also because we’re not using all the tools. That’s why we need the plus. The traditional treatment works. 35 to 60 percent of the time what’s wrong with those other 40 to 65 percent of people is it’s not their disease is stronger than what they’re being offered. It’s not them it’s their disease and so we need to offer them more. So I have my book hooked it’s on Amazon on my and easy to find but don’t look up hooked on phonics. I hooked my name Arwen Podesta or you can go to my website drarwin.com and I have a master’s course for clinicians ⁓ that want to learn more about addiction. And it’s a pretty straightforward, very, very ⁓ deep course. And I haven’t had the time slated yet to do the group ⁓ discussion about that course yet, but I will be doing that. So if you just go to drarwen.com, you’ll find a way to link to that. And then you can find me on socials at Dr. Arwin, etc. and check that out. And then as far as general psychiatry, ⁓ I’m doing some really great talks right around the corner in San Diego in early, in mid September at Psych Congress. ⁓ Really fun talks and that’s a great conference to attend. You can go live or virtual. And then I want to put in a plug for a smaller conference that is called Integrative Medicine for Mental Health. That’s also in San Diego in just a few weeks. So it might be hard to get away, but thinking about that for next year, it’s a really, both of those conferences are really ⁓ neat, great forums for so, so much deep learning. Dr. Siri Chand Khalsa (1:00:20) I think that collaborative spirit really helps maintain ⁓ professional buoyancy. This is heavy work, it’s hard work, it’s isolating in its own ways. There’s silos that happen for innovators in the integrative field. And I can’t help but want to highlight the fact that the conferences and spaces where we feel seen and supported. is so important as well, especially for our younger listeners in their career. ⁓ Find a peer group that, I’m really loving mirror neurons right now. So find that peer group that celebrates you, that gets excited about what you’re thinking about and pour your heart, open your soul to them. And so these conference rep and ⁓ group-based cohorts where you can learn with leaders in the field, where you can experience ⁓ connectivity are such important spaces. And I want to just say thank you. Arwen Podesta MD (1:01:18) Yeah, I want to mention the live version of it because what we know, we can do everything virtually and then we’re back in a silo. And so is our patient and so is our colleague and so is our peer. It’s great to have the text message threads, but what we know is that doesn’t give you the same oxytocin that a live visit, that a hug that standing next to somebody does. And that is good for serotonin, that’s good for cortisol, that’s good for GABA, that’s good for so many things. For us, as we’re treating patients, we need to also think about how we’re treating ourselves, just like you said. So thank you for that plug. Dr. Siri Chand Khalsa (1:01:55) Yeah, thank you so much for our time together, Dr. Arwen Podesta and your website. Again, just tell us one last time, is podestawelness.com. Arwen Podesta MD (1:02:07) Head us to Podestawellness.com is my general practice website and you can find other things there. But my coursework website is drarwen.com. ⁓ Dr. Siri Chand Khalsa (1:02:20) And are you taking new patients? Because there’s surely someone that’s going to write in and ask. Arwen Podesta MD (1:02:25) Feel free to reach out on the Podesta Wellness website. There’s an email address admin at podestawitness.com. Feel free to reach out. Right now I have a bit of a waiting list because of my travel for these conferences, but I certainly am taking new patients. And if what we do, we actually answer the phone and we get back with every single person that reaches out and we try to navigate the territories for them to find the right fit for them. even if they aren’t the right fit for us, depending on the need, location. I’m only board certified in North Carolina and Louisiana, so I can only take new patients from those locations. So that’s something to think about. But yes, I am. I just want to make sure that we have a caveat carve out for that. Dr. Siri Chand Khalsa (1:03:14) Wonderful. Well, thank you so much for your time. And I’m sure that we’re going to have questions and ⁓ ongoing conversations with so much overlap in our interests. And I look forward to meeting you in person someday. Arwen Podesta MD (1:03:28) We’ll have to have that oxytocin boost from an in-person meeting. I can’t wait for that. And thank you so much for what you do. The podcast, all of your work, everything you’re doing, amazing. I commend you so much. And it’s so great to work with you in this aspect. Dr. Siri Chand Khalsa (1:03:45) Thanks everyone for joining us for this week’s episode of Roots of Healing. Take care everyone.