145. Dr. Dave Rabin: HRV, Vagal Tone, and the Science of Safety for Performance and Mental Health

Welcome to Extend with me, Dr. Darshan Shah, a podcast dedicated to cutting-edge science, research, tools, and protocols designed to help you extend your healthspan. Having become one of the youngest doctors in the country at the age of 21 and trained and board-certified at the Mayo Clinic, I've accumulated three decades of practice as a board-certified surgeon and longevity expert. Over that time, I've discovered that a mere 20% of health knowledge yields 80% of the results when it comes to your healthspan. We are living in a new era where we are creating a new healthcare system, no longer focused on disease management, but achieving optimal health and vitality. Join me as I interview world-renowned experts, offering you a step-by-step guide to proactively avoid disease and, most importantly, extend your health span. Most of us assume that if we feel anxious, overwhelmed, or constantly on edge, something is wrong with us. But what if your nervous system is actually responding exactly as it was designed to, just to threats it was never built to handle? In this episode of Extend, I'm joined by Dr. Dave Rabin. He's an MD, PhD, a board-certified psychiatrist, a neuroscientist, and executive director of the Board of Medicine. And he's a creator of the Apollo Wearable. For 15 years, he studied chronic stress, resilience, and how modern life is reshaping our brains and our bodies. His upcoming book, A Simple Guide to Being Alive, explores why being human feels harder than ever and what to do about it. We break down the difference between good stress and the kind that rewires your brain. Why so many mental health struggles are actually nervous system overload rather than personal failure. And the practical science-backed tools that help you shift from survival mode back into presence, safety, and connection. Hey, everyone. Before we dive into today's episode, I want to talk about something that you hear me talk a lot about, your biomarkers. And I want to tell you how I'm approaching this situation right now with all of the patients that are calling me from listening to this podcast. So what happens is every day patients are writing to me saying they feel exhausted, they can't lose weight, they're having brain fog, and they see their doctor and the doctor tells them all their blood work is normal. But the problem is this doctor usually is only checking about 10 to 15 biomarkers that only tell you if you have a disease developing. Meanwhile, your body has 160 different systems that are running. And all of these have blood tests that we can test on how effective they're working for you every single day. So if someone is not close to one of my clinics, one of my next health clinics, then I tell them go to their local laboratory and get on Function Health. Function Health gives you access to 160 different biomarkers. The same kind of comprehensive testing that we do at all of our next self clinics. And if you try to get this on your own through your regular doctor, it can cost you thousands of dollars. Hormones, inflammation, toxins, nutrient levels, they're all tracked over time in this one platform called Function Health. They can even help you get an MRI scan or a CT scan if you want one. So what I love most about this company is that they don't have a crazy incentive to do this. Function doesn't push supplements. They don't have pharmaceuticals they're trying to get you to take. you're just getting the data and you're getting insights from the data. And you can bring this data to a clinic like ours. And we then have the information that we need to tell you how to improve your health. Membership is now only $365 a year. Literally, it's just a dollar a day. And right now, if you're one of my listeners, you can get a $25 credit towards the membership. You just go to the link in the bio or go to functionhealth.com slash Dr. Shah and use the code Dr. Shah 25 for a $25 credit towards your membership. Dr. Rabin, I'm so happy to have you here. Thank you for joining us on Extend. Yeah, it's such a pleasure to be here. Yeah, I always love having these conversations with a fellow physician. Likewise. Who's also kind of bridged over into the world of just trying to help people feel better day to day, right? And so you've seen the entire spectrum of like serious disease, and then also people that are struggling with day-to-day life issues like stress and just the overwhelming amount of stuff we put on ourselves. Yeah. It's a lot. It's a lot. We were just talking about it. Yeah, we were just talking. Both of us have young kids and businesses. Clinics and patients. Yeah. I mean, we're responsible for a lot, which I think is interesting. And that's actually one of the things that fascinated me about this field and got me into it was not just setting people and helping people who are ill, but what are the high performers look like? Right. Right. Like the people who we model ourselves after, you know, to really excel at life. Like what are their lifestyles look like? What are their trauma backgrounds look like? What makes them superhuman? You know, and then when you start to look at the history, people are actually kind of similar things that make people sick versus superhuman. It's overcoming it's it's facing challenge. But when you overcome it and you grow from it, that's when you get to the next level. That's so interesting. Yeah. You know, I always think that when you are a high performer, you constantly keep pushing the limits, obviously, because you make it through the last thing. And then you're like, okay, I can take another risk and make it through the next thing. Let's see what happens. And I always wonder, like, how far are we from really breaking at some times? You know what I mean? Yeah. I mean, probably a lot of us are pretty close to the edge. You know, I think the but I don't think it's because I don't think it's because we're pushing ourselves to to take chances. I don't think like that is really the thing that's getting that's keeping us close to the edge. I think it's that we are not taught to adequately prioritize peak recovery as much as we prioritize peak performance. Yes. Right. So if we are taught, hey, all that matters is your production of stuff, ideas, money. success when you're healthy, then we save recovery for when we're not healthy. And when you're not healthy, recovery becomes a lot harder. It takes longer. You can burn out, right? And so a lot of people, I think, are doing what they're doing and doing it generally well, but really on the edge of burnout because we're burning the candle at both ends and we're not prioritizing recovery on the calendar, on the schedule with the same level of importance, literally just that's it, creating the boundaries and structure that recovery gets the same importance as work and performance. And if we keep performing without refueling the tank of our super high-performance vehicle that we are, the most high-performing technology we'll ever have is right here. And if we don't refill that fuel, if we don't do its regular repairs and take care of it, we're going to burn out. It's inevitable. But I think taking chances in healthy, safe situations, taking risks is critical to growth. And that can actually stave off burnout if we do it thoughtfully and make sure we have time to recover afterwards. That is true. That is true. So yeah, I guess what I was thinking more of is like I, in my day to day, I push myself to the limit every single day. And if the prior day, I got a lot done, like, let me see what else I can add. And, you know, I don't know. I think I suffer from this disease of like saying yes to everything, you know? And we're caregivers, right? Yes, yes. Kind of like our mindset. Exactly. It really is. There's no one that I don't want to help or can't help. I just want to see what I can do. And then eventually it just gets to a point where, like you said, you're almost at the edge. Right. So I think I'm a big fan of evolutionary biology. And I think about humans and the way we used to live. And so going all the way back to the caveman era, right, we always talk about, oh, your sympathetic nervous system is fight or flight, like running away from a saber-toothed tiger. But how many times a day, a month, or a week were we really running away from a saber-toothed diver, right? Yeah, not often. Not often, right? Exactly. I mean, I think about what life might have been like prior to technology and kind of the grind culture that we've created in modern day society. We probably spent a lot more time in our day in recovery mode. Absolutely. Do you think that too? Without a doubt. Yeah, and stress came in bursts most of the time, right? And if the burst was long, it was like days or weeks, not months or years of stress. And it was actual survival threat. Right. Right. Like we only have our nervous system. I also love evolutionary bio. You know, it's one of my passions. And I think it teaches us so much of how the body and the mind were designed to work. Right. How we evolved to be where we are. And I think the most humbling thing about it is that when you look at how our nervous system functions today, it's basically identical to the way it functioned 50,000 years ago. Yes. Right? And it's basically identical from Eric Kandel's Nobel Prize winning work in 2000 to see snails from 300 million years ago. Yes, yes. We respond to fear and safety stimulation the same way. Too much, too loud, too fast increases fight or flight survival responses. It tricks the brain. Right. Right? Because in the prairies, you know, going back prehistoric times, prehistoric humans, in the jungle in the prairies, if there was lots of all of a sudden loud, fast-moving stimulation coming at us, and we're giant sensory organs designed to perceive everything around us, all of a sudden you overwhelm the system with uncertainty, lots of things going on. That is, in the prairies, a signal that you are about to die. And our nervous system knows that. But we have it, and so it's designed and evolved to really tackle six major survival threats. Lack of air, in order of importance, lack of air, lack of water, lack of food, lack of shelter and physical safety, and lack of sleep and lack of connection to the community. We need those six things to survive. We can survive on our own. The community thing isn't the last one. We can survive on our own. It's just really unpleasant and we don't last very long. Exactly, yeah. So those are the six things that our system evolved to respond to, the survival response. In modern day society, most of us don't have to tackle those issues, thankfully. But our system is still in a state designed to tackle those issues. And so what happens instead is overstimulation, looking at your phone, too many screens, too many responsibilities, just adding things on and on and on. And before we know it, our system is completely overwhelmed and thinks it's under survival threat when it's actually not. So interesting. You're right. We've checked off a lot of these basic needs, right? Like Maslow's needs. We've checked off a lot of them. And I do want to go back to community because loneliness is a huge problem right now. For sure. And it's interesting to think of that activating our fight or flight sympathetic nervous system as well because I can see how that would happen, right? So that's one that we haven't really solved. But now that we've solved for those, we've added other stresses into our life that are more consistent and constant, like, for example, our phone notifications, everything that we're doing and adding to our plate every single day. Yeah, absolutely. So how does an individual know if they have too much on their plate or not? Because it is something that I always say this to all my patients, like, if you wait for the symptoms, you're waiting way too long to figure this out. And you're talking about like the health symptoms, right? Yeah, but the time that they're like, oh, it's time to see Dr. Shaw. Yeah, exactly. Agreed. Yeah, same with me. I think with mental health symptoms, I think there are earlier signs, right? We talk about symptoms, which are like the clinical presentation. There's also signs that come along before, right? And I think that we're not taught often to listen to the signs. We're taught to like, oh, like shut them down, just keep doing your work, right? But ultimately, those signs are really important because they are the first signal that the body is dysfunctioning towards what we would call distress. So I like to think about stress in two ways. And I talk about this in A Simple Guide to Being Alive because I don't think that people really are taught this well. I wasn't taught this well. There's two kinds of stress. There's eustress, from Latin, E-U means good. E-U stress is good stress. It's stress that facilitates growth and personal development, development, growth, moving up and better, faster. stronger, right? Then there is distress. Distress is stress that is overwhelming. We feel bad when we're experiencing it. It doesn't feel good. It feels unsafe. And it causes, when left unchecked, disease. Eustress, when you train it, is like a hormetic stress. So hormetic meaning like you're slowly stressing the body in healthy, safe ways, but the body grows from it. And that increases ease because you get better at life from learning to cope with eustress. So life gets easier. If you have too much distress, you get initial signs, irritability, sleep dysregulation, harder to fall asleep, harder to stay asleep, less empathy, right, less ability to feel connected to other people, which is where the perception of loneliness comes from. But generally speaking, we're not actually lonely. We're not disconnected from the community. It's very much perception, which I think is very, very interesting. And then the last other things that happen are like fatigue, low energy, like recovery slows down, increased rates of likelihood of getting a cold or illness, brain fog. Those are the early signs. But sleep and irritability, feeling like you're really struggling for creative, like get your creative juices going, all of those little signs are the signs that you're putting too much on yourself and probably could use a little more break. Right, a little more recovery time. And I mean, I think a lot of people feel all of those, but we're taught to push them away, right? We're taught to like bury them and sweep them under the rug and just keep getting through life. And to your point, those are all indicators that it's time to actually put some recovery. Change course. Change course. Yeah, it's just like, hey, it's like if you're sailing or you're, you know, it's like there's a storm coming, right? All right, keep going. We got to get to the other side. Well, maybe you won't make it, right? Exactly. That storm's bad enough. You don't know. Maybe it's time to stop or reverse course or go another direction. Just go pull into harbor over here. Look, there's a dock right there. Let's go pull in. Let's wait for the storm to pass. Let's take a little nap. Have a snack. We'll go back out again. Right. But if you don't make it to going back out again, you're not going back out again. Right. Life is a brief thing that we're here to enjoy, but it's also long when we treat it right. We have so much to appreciate in life that comes with time and patience. And if we try to rush to get to the end all the time, then we miss a lot of it because we spend all of it rushing and not actually taking the time to enjoy what we're here to do. I have this longevity conversation all the time, and people ask me, like, oh, how many years am I going to live? And I'm like, it really doesn't matter, right? Because it doesn't matter because you can expand and contract time depending on what you're doing in that time. So if you're constantly running, you're trying to get to the end of something, you're constantly trying to get to the next thing, you've contracted time a lot. And so a year can go by in a flash. However, if you spend more time being mindful, spend more time being in the present situation, that year can last a very, very long time. So rather than keep trying to add years at the end when you probably lost some health as well, doing it at that current moment is going to pay off, first of all, massive dividends to your health, but also you'll feel like you've got more time on this planet. Absolutely. No. Yeah. That's a big thing also that I talk about in the book that people aren't taught. We're taught that like Einstein discovered this over 100 years ago. Exactly. Time is linear. time is also relative with respect to the perspective of the observer the motion and the gravity of the observer right and it's like this was known einstein knew it yeah pretty sure tesla knew it like people have known richard feinman like this has been known for 100 years why i and this goes back to like why i went into translational neuroscience which people also most people don't know what that is but translational neuroscience is how do you take how do we actually make use of the greatest discoveries of our time, right? Not just how do we discover more stuff and then let it sit on a shelf in a lab. That's what most of these things do, right? But how do we actually understand what Einstein was saying, right? Which is that time is linear and time is relative at the same time. So if that's the case, then we have, to your point, exquisite control through something as simple as breath to bring ourselves back into the present, soothing touch, Practice this like gratitude, forgiveness, compassion, compassion being like patience, right? Like we have control over those things and how often we do them and when and why we do them. And that dilates time. It expands time. And it pulls us out of the constant rush of fast breathing, contracted productivity-based time. And so if you have control over that, then, and you understand how to do that, and you understand that concept of like, yes, one second follows the next second, which follows the next second. at the same time we can shift the way we feel and perceive that to get more or less done during that time or to get more out of that then we should probably be spending more more effort on on that but we're not you know we're not quite there yet as a as a society we're still caught in the caught in the rush yeah absolutely maybe we were there in the past i mean i remember certainly being a kid you know you just kind of there's nothing to do sometimes you were bored you just looked out the window or you read a book or you just kind of just sat there and people ask you, like, what are you doing? You're like, I'm daydreaming. Right. No kids do that anymore. Like, that is gone from the normal speak. Yeah. And I have two young kids, like, you have one kid or two? One. One, yeah. And you have a one-year-old, right? Yeah. Yeah. And, you know, we always say, like, we wish these devices never really existed because they are just like us, you know, like, they model our behavior. Yeah. is the minute there's a moment that something is not going on to stimulate their brain, they go for the device. And that's where time just becomes smushed. Yep. Right? And that leads to these heightened arousal states. So there's a lot of negative consequences to that behavior. For sure. And I think also to your point, part of what we also forget that stifles our health span longevity and our general health as a whole is that we are actually, like our inner children, that child self that you described from when we were kids, that had imagination, that daydreamed, that just took joy and wonder and awe from the present moment of just sitting and watching something like a cloud pass by, like something we would consider totally mundane. That part of ourselves is still very much alive inside of us. like science show we like we do this work with people all the time in trauma therapy where you actually have to work with that that childhood part but that part is alive in all of us that we are like my wife has this funny saying she's like we're all just big babies you know we just think ourselves adults and so we deny our child baby selves all the needs that they have but we still need awe and wonder and imagination and joy and play right and and so to your point yes We haven't lost it as a species. We've lost it as adults that we have forgotten how to play. We've forgotten how to take joy in the present without thinking about your phone or looking at your phone or whatever. But the devices are a problem because, like drugs, they are highly addictive in the dopamine circuitry and the way they activate dopamine circuitry. And they're designed to do so. Social media companies talk about how they design for that kind of behavior. So it's even more important that we as adults take responsibility for our intention, our actions, and don't give away our time or our attention freely to technology or to anyone else that's not serving our greater good. Right, right, exactly. And I think also in this, you know, achievement culture, you feel as though taking any time away from a computer screen or device, you're maybe not going as fast as the other people are going. but what I keep trying to remind my own self and tell other people is in those moments where you're off a device and you give your brain a minute to kind of take in the universe and the outside environment and everything going on is when you sometimes have the best ideas you'll ever have and that's why a lot of people say I was in the shower this morning I figured out a way to completely revamp my company or like the story of Archimedes you remember? that's my favorite story I'm not going to get it exactly right But he was trying to figure out buoyancy, the mathematical equation for buoyancy and the proof. And he was like, he's been sitting in his library for days, unshowered, smelly and dirty and starting to get really wrapped up in his thoughts and couldn't figure it out. He just couldn't figure it out. And his wife kept coming in and being like, Archimedes, you have to take a shower. He smells so bad. And he would just take a break, take a shower. And he's like, no, no, I refuse. Or I guess it wasn't a shower, maybe it was a bath. But I think it was a bath. So finally, she gets him. I don't remember how long it was, maybe it was a week or something in there. And she gets him to take a bath. And he goes in the bath, and he sees something float by him in the bath. And he's like, Eureka! I got it! Exactly. Yeah, Einstein, too, when he couldn't figure something out, he'd go and play the violin. And that's when he would get his best thinking. I think he even said he discovered the theory of relativity and three other theories that he won Nobel Prizes for while he was playing a musical instrument is when he had the thoughts that got him to that point. So it's super important. Let me ask you something else now. So we are in this modern society of wearables and devices and data. And there are symptoms, obviously, that we talked about earlier, irritability, lack of sleep. But there are also now metrics that can even tell us a little bit earlier than some of those symptoms potentially, but also kind of serve as an indicator of if you improving or going in the wrong direction right So one of those I love is HRV I know you talk a lot about HRV but what are some of those metrics and how do you think about using these I mean the metrics we had for a long time are heart rate resting heart rate blood pressure, to some extent blood glucose, hemoglobin A1C, which is a measure of your blood glucose over the last three months, and blood glucose stability. And then since the 1960s, we've had heart rate variability, which came from the field of biofeedback. and heart rate variability is fascinating new biomarker because i think it's arguably the most impactful current like biomarker evidence-based biomarker we have because you can measure it through the skin it doesn't any anybody can now measure it with a wearable at home not as accurately as you can in a lab but you can get pretty good metrics over time and it predicts vagus nerve activity. And it's like a proxy for vagus nerve activity. And the vagus nerve is the most important nerve of the parasympathetic rest and digest recovery nervous system that basically tells the stress response fight or flight system and the amygdala that governs that system to say, hey, quiet down. You're not actually in danger right now. It's like if the amygdala is the gas, like the gas of the fear center that's getting stepped on to make the car go, the vagus nerve is the brake. And the car maybe shouldn't go right now because maybe there's a cliff in front of you and maybe you want to turn around and go a different direction. But if you only have gas and you can't easily change course. So the vagus nerve is what gets activated during breaks. It's activated when we do slow deep breathing. It's when we do biofeedback, neurofeedback. When you get a hug from a loved one or hear your favorite song come on by surprise on a bad day and you instantly feel better, that is a vagal nerve response. and it turns out that that nerve, and everything about the body is blood flow regulated, right? You know this, you're a surgeon. So when you are in fight or flight mode, your body only has so much blood to go around to all the organs. It'll make sure everything gets enough blood to stay alive, but in the short term, what happens is almost all the blood flow to reproduction, immunity, digestion, empathy, everything that's in sleep, everything that's not important for survival, squeeze tight. It shuts down blood flow, nutrients, delivery, and waste removal. And then where does that blood go? To heart, lungs, skeletal muscles, motor cortex, fear center, get you out of that situation safely. Again, as you said, that's historically, prehistorically, that was supposed to come in small bursts. Day, maybe a week if you are in a giant storm or something you're trying to get out of. And then you go back to a vagal recovery state when you get back to safety. Safety triggers the vagus nerve, and then blood vessels to reproduction, digestion, immunity, sleep, rest, creativity, empathy. They dilate. And the blood vessels squeeze to muscles and to the other systems so that you can now feed all the systems that you want to be activated when you're at rest and heal the body. Recover from the stress. Thrive. Enjoy your life. So HRV is amazing because it's the rate of change of the heartbeat over time. It's a very simple metric, but what it predicts is everything from longevity and health span now, from what we can tell, to whether or not you're going to perform consistently in a cognitive or physical pursuit, or how likely you are to get sick, or how likely you are to recover if you are sick, and a number of other things that are very interesting. So it's incredibly important. It's so great to hear a fellow physician say that, and you're in PhD as well, because I think in the medical community, HRV is really not really even talked about, noted as a vital sign. None of it, right? Only cardiology. Cardiology is now using HRV. They've been using it for a while. They were the first medical field to use HRV, not for the reasons that we're talking about, but for post-cardiac, post-MI patients, post-heart attack. Because if you have a low heart, I mean, this is no surprise to you, I'm sure, Now we know what we know. But back 20 or 30 years ago, we didn't know all the stuff about HRV that we know as well now. And if you had low heart rate variability after a heart attack or a cardiovascular surgical procedure, like a bypass, if your HRV was low and stayed low, your chances of sudden cardiac death thereafter and not surviving a year out were extremely high. Oh, so interesting. So they would use it as a predictor to try to understand how to help people recover faster and make it past that one-year mark. And I think in large part, HRV became an important part of spurring cardiac rehab practices, which extend life dramatically. They reduce post-cardiac episode mortality by 80%, 90% when people do them and extend the one-year survival rates tremendously. And one of the best predictors of whether someone's going to succeed and that is how much your HRV increases over time. That's an important data point because it's like, you know, like everything in medicine, we use incredible information too late sometimes, like after a heart attack. Usually. So it's so great to like bring it to your day-to-day life now. Even, you know, I think it's even valuable for if you have a high school student, you know, let's get them starting to look at their own HRV because you can get the number instantly with a wearable and it can give you a lot of indicator, a lot of indication about like kind of what your status is right now and what you need to work on. So I'm a big fan of tracking HRV. I've been tracking, and obviously I myself, since all these wearables came out. I'm wearing three different wearables right now. And I think that it's, for me, I am also getting my head wrapped around this being kind of the most important vital sign that we have. Resting heart rate is another one as well, but that takes so long to change, whereas HRV can be changed in the moment. Right. Yeah, HRV does change every moment. right every time you take a breath we have respiratory sinus arrhythmia right it changes the pressure in your lungs changes the amount of work your heart has to do to get the blood through through your lungs to get oxidated your hrv just changed right every time you are stressed your hrv goes down every time you do a recovery practice you're a properly and you take the time to do it you're present your hrv goes up right so it's not it's so the real-time stuff is is really interesting but that's actually what makes hrv complicated to measure because real-time HRV isn't that useful. We already know when it's supposed to go up and down. I think what's really interesting about it is the predictive piece, which is how do you predict resilience and recovery in someone? So if you're, and this is where we have to be thoughtful, really thoughtful the way we teach kids about it, because you don't want to give them data anxiety. Right, that's true as well. This is also a real thing. So it's really about tracking, getting a baseline, right? So your HRV baseline is going to be slightly different than mine. Kids are probably going to be different than ours. so you have them wear an ORA ring or an Apple Watch and don't look at the data for like a month. And just get a month of baseline data and particularly important when they're asleep. I think there's a lot of my patients actually as well. I'm like, just wear the ring, don't open the app. Or just open the app to sync it, but don't pay attention to the data, it doesn't matter, it's just calibrating to you. And it takes about two to four weeks for all the best wearable trackers to calibrate to you because they are filled with all the variability of your day-to-day life that confuses it because it doesn't know what you're doing that's contributing to your HRV going up or down. So it's going to give you an accurate data in the short term. So you get about a month of baseline. And then at a month, what you have is this beautiful metric that says in the last month, your HRV typically fluctuated between this number and this number and here's your average, right? And so then you go into the next week of the first, the first week of the next month and say for a kid in school or something like that. And their HRV first day for Monday of the next week is like 20% lower than it was the month before. So what does that tell you? It tells you that they're probably going to be 20% more likely to make mistakes, 20% less likely to pay attention well. They're going to have not exactly 20%, but it's like that proportionate amount of difference. They're going to be 20% less recovered. They're going to perform 20% less well because they're 20% less recovered, roughly. so I think that kind of so you wouldn't want to put them under extreme stress that day you wouldn't want to push their limits a little bit further that day, you probably want to take it easy that day save the pushing limits when they're back at baseline right otherwise they're going to get frustrated and quit and that's not burnout exactly, that's a really great way of looking at the data for your child as well teaching them how to use it appropriately I think a lot of times too a lot of people really worry about that number if it's too low, right? So I live around 30, actually, 30 to 40, you know? And there's certain people that live in the 80s and 90s and 100s. Like, do those people have a superpower or is it just their individual number? So, you know, I think it's not necessarily, it's not that they have a superpower. It's that in all likelihood, whatever combination of things they have that have happened to them, that they have done, that they are doing, is resulting in, generally speaking, more healthier vagus nerve activity at baseline. So when your body is, and it's a relatively simple equation, right? Like if you think about what happens when you experience stress, or when you're stressed about something that happened in the past, right, or you're worried about the future, your heart rate goes up. When your heart rate goes up, your HRV goes down, because the amount of time between each beat shrinks. You have more beats in a minute. That means there's less time between each beat, less variability. Right. It's that simple. Very simple. So if your heart rate variability is lower than you want it to be, it means you likely have two or three things happening. You're taking a beta blocker. Yeah. Right? Or some kind of cardiac regulator, like heart rhythm regulator. Right. HRV is not going to work well, not going to be a good measure. Or you're taking a sedative, like a benzo or something like that. Or you have too little vagal tone too much of the time. So then what we do in the clinic is we use tools like Apollo, and we teach breathing techniques, and we basically say, if this is how the system works, let's inundate you with things around the clock that boost vagus nerve activity. And then let's track your HRV and see what happens. And ultimately, as long as they're not taking one of those drugs that prevents heart rate variability from changing, their HRV gets better. Got it. And it can take, usually when people actually do the work, It's usually within months that they start to see a steady trend, and you get like 10 or 20% improvement in HRV month over month. If it doesn't improve, then it's usually related to, from what we can tell right now, usually some kind of past traumatic event that the person is not even aware of that is keeping them in kind of a perpetually feeling unsafe or stressed state. The body remembers. Got it. So if the body remembers the trauma or what happened and doesn't feel safe, but you're like, oh, I don't know, nothing ever happened to me, your body still is going to keep your heart rate slightly elevated, ready to escape or react whenever because it's still not safe. So that's kind of like how we think about it in kind of the mind-body mental health model. This is great. I mean, this is like such a fantastic beginning of like almost a protocol that people can use. Exactly. Using data on their own body. I'm a big believer in end of one medicine. Like you have to know what's working for you and no one's going to track this as frequently or as carefully as you are on your on yourself because you're the one wearing the wearable. You're the one that has the data and you can make adjustments and changes and see what result it comes up with. Right. So back just one more question. I want to start talking about what are the methods people can use to improve their HRV? I do a couple more questions. So one is, do you think that people with like a higher HRV, let's say two 40-year-olds, one has an HRV of 30, one has an HRV of 80. Do you think that high number of 80 is because of a lifetime of not having too much sympathetic tone in their body and also being better able to regulate their parasympathetic sympathetic nervous system? And so there's a cumulative effect over time? Or do you think that's just what they're born with? No, I don't think it's what people are born with. Okay. I mean, there's a predisposition that we're born with, right? It's not a prediction. It's not a guarantee. It's a, the predisposition that we're born with is like a likelihood that if we are faced with extreme adversity and we don't have the proper support and don't deal with it in the best way, that we will be more likely to manifest symptoms of an illness. Got it. but it's not a guarantee. And so I think that the most powerful information we can take from the work of people like Eric Handel and B.F. Skinner and the people who did behavioral neuroscience back in the day is with rats, with snails, and humans. This is not unique to us. This is learned behavior. Probably like 95% of it is learned behavior. So that doesn't mean it's our fault. it means somebody taught us how to think and feel and be. Usually our parents are a role model or teachers or whatever. Or we figured out our own because we didn't have guidance, right? But we figured it out at an age where we were just doing what we could. And then those techniques of coping don't serve us when we're older anymore and they wind up causing more stress. And so I think the way to think about it is if we look at the distress and eustress model, right? Distress results in increased fight or flight sympathetic activity. Eustress over time, as you, you know, eustress is stress that forces growth or causes growth. Right. So if you're growing from stress, then your vagal tone is actually strengthening over time. Your HRV will increase over time. It's like going for a 15-minute walk every day or pushing your heart rate up a little bit every day doing exercise, we know, is a eustress. It boosts heart rate variability and vagal tone. Same with deep breathing, meditation, yoga, regular mindfulness practices, stretching, sauna cold plunge in the right time of the month, right? Like those kinds of things are gently stressing the body in a safe environment. And then the nervous system's like, oh, I feel uncomfortable, but I'm safe to be uncomfortable. Let's keep going a little more, right? Let's push a little further. And then you're like, okay, all right, let's take a break, you know? And then you come back and you're stronger the next time. So I think it's all training. And that, I mean, to me, that is the most hopeful thing. That's so hopeful. Right, exactly. Right, for everybody. For everybody. To think that, and it unlocks this concept of that we have potentially unlimited human potential that's untapped. Right, right. And HRV is also an amazing metaphor for that because HRV in human performance has no cap. There's no upper limit. So interesting. Right? We don't want HRV to go too low. We know that that predicts illness. There's no actually known upper limit in healthy people for heart rate variability. Interesting, okay. You think about heart rate variability as a proxy for adaptability and resilience, how quickly we bounce back. That is the most important feature of our potential and how we access it. So that's where all of our growth and human ability comes from, is that adaptation process. So HRV having no cap is really interesting because it suggests that human potential is far beyond, far beyond what we know it to be. And we haven't even begun to push the limits. Maybe Michael Jordan has started to push the limits. But I mean, the rest of us, you know, like, I mean, we are a little bit, because we're like, you know, so doing all the things we're doing as, you know, multi-faceted parts of life. But in general, as a species, we're not even close to seeing what we can do. There's so much more that we can do. So much more that we can do. Yeah, it's really an incredible thought that you can train it as well. So you're not just stuck with this HRV number. And so it's so important to make this a part of your day-to-day, your week-to-week routine is to add activities, mindset into your routine that can train your HRV. Yeah. And it brings up the importance of ambiance, which I think is really interesting. Talk about ambiance. Your environment, your setting. Like what kind of music is playing in the background? What kind of lighting is in the background? Is it white fluorescent hospital lighting or cubicles or like, is it, you know, loud construction noises? Is it, what is it, right? Like what are you spending most of your time surrounded by? And the more fast, loud, like overstimulating or like in the case of fluorescent light, right, like not pleasant to the body stimulation you are surrounded by in your day, the less well you're going to feel for that percentage of your day. And there's a certain amount of carryover because we're resonating with those frequencies. That's why when there's construction jackhammers going on the side, you start to notice your thoughts start to get fast and more self-critical. It's not, it's not surprise. It's we resonate with the energies around us. Yes. So, so that, that, so I think like when you think about that, you can actually train HRV simply to start by curating a nice soothing place for yourself at home where you spend most of your time. Right. Or making your workspace a little more comfy. That's why I love walking into your practice today. It was so calming in there. You can feel the HIV getting going up, right? Yeah, you just feel, yeah. And when you feel that, when you walk into a really nice environment and you just feel like a little bit of a, like, settling, a whoosh down, right? Or it says, your body says as soon as you walk into a new environment, like, I'm going to take a breath right now, right? That is a signal that your vagus nerve activity just went up and your HRV went up. So part of the protocol for increasing HRV is the ambiance of where you spend the most time in your day. So it's your home and then your office environment. I also think reducing clutter is a big part of this. I struggle with that personally. Yeah, it can be hard. There's so many things. Just reducing the amount of physical things in your life in general can be a real boost to your HRV and your overall relaxation response. Okay, so we can modify our environment. And then let's talk about breath work. And I think here, it's really good to talk a little bit more about the vagus nerve. As you know, I used to do surgery for years. And one of the surgeries that I did in general surgery, I can't believe we would do this as a vagotomy for someone that had ulcers, right? Because we just in medicine, we had no respect for this nerve. We just didn't really know what it did. It's like, what's this weird rope structure here causing ulcers, right? And so a vagotomy, for people that don't know what that is, is cutting the vagus nerve when someone comes in with a ruptured ulcer of the stomach. And before we had PPIs, this is a surgery I would do almost every single week. We'd have someone with a ruptured ulcer. We'd go in there. We'd fix the rupture. And then we'd cut the vagus nerve so it didn't happen again. And I wonder if anyone's ever studied all those people that a vagotomy has done, right? Because it really is the information superhighway between your internal organs and your brain. And when it's cut, there's a massive lack of communication. Even your microbiome is communicating with your brain through the vagus nerve. And the other anatomical feature of this nerve that's incredibly important is it runs right by your heart and through your diaphragm. And so diaphragmatic movement affects your vagal tone, right? And I think that's really important. Breathwork isn't just a mental activity. It's a physical, mechanical activity that is changing your vagal tone through an actual mechanical stimulation of the nerve, right? And so I just wanted to lay that groundwork, and maybe you can give us more color around this. Yeah, absolutely. And what you said is 100% correct. And then there's also the psychological piece of breathing, which is really interesting, where I like to take the work part out of the breath because people get put off by feeling like breath is work. And there is breath work, but you can also just choose to breathe right now. And breathing can be in response to the environment, which is what it's doing most of the time automatically, like we were taught in medical school. Don't worry about it. It's going to do its thing. And when that happens, what do we see in our patients? 12 to 24 breaths per minute is the expected in your office. 12 to 24 breaths per minute is stress breathing. We're supposed to be breathing at rest 5 to 7 breaths per minute. That's less than half of what most of us are breathing at. so to to your point you know you're getting that on for most of us on a day-to-day who are not conscious or aware of how how we're breathing we're actually breathing at a rate that is known to induce stress it's known to signal to the vagus nerve through that biomechanical system that you just described to turn down yeah that's not what we want no right no i mean especially if just sitting there. Yeah, right. I mean, most of the time when we're not like doing a, we're not escaping a survival threat or not in like a high, super high performance sporting event, you want your vagus nerve to be activated and significantly activated because you want the body to recover and heal. So when something comes, you can be ready for you to the next, have all your resources. And the psychological piece is really interesting because there's this, there's this thing that happens when you just choose to breathe rather than letting the environment tell you when to breathe. And when you decide, hey, I'm going to take a breath right now, there's this interesting subconscious loop that we're not necessarily aware of, some of us are, that opens up, which is the amygdala, the fear center, and the prefrontal cortex, the part that says, I'm deciding to. The amygdala is the fear center, and then the insulate cortex is the emotional memory system of the limbic system that governs empathy, interoception, body awareness, and introspection, self-reflection, self-reflective behavior. So those three are in a loop together. They're very tightly connected. And when we say, when we let the environment drive our breath speed, the amygdala tells the insula the emotional cortex and the prefrontal cortex how to act When I say I choosing to breathe right now my prefrontal cortex is telling my amygdala So it goes opposite direction It literally taking control of the system The amygdala, right. And when we do that, the amygdala, rather than just responding de facto to the speed and the rate of stimulation of the environment, which is what it's doing most of the time, it's like, oh, there's fast, loud stuff, breathe faster, breathe, breathe more. rather than just doing that the prefrontal cortex is stepping in and saying nope i'm taking and taking the wheel i'm going to choose to breathe right now and that sends a signal to the insulate the emotional cortex the insula which is the interoceptive part right that says posterior insula that says oh i'm aware of my body right now i just chose take a breath automatically you're aware of your body automatically you can start to become aware of the feeling of air coming into your nose, mouth, windpipes, lungs, and then slowly leaving. And then that sends this very, very powerful signal to the amygdala that says, hey, amygdala, if I have the ability to take time to focus on the feeling of air coming into my body right now, there is no freaking way you can be running from a lion in this moment. It is impossible. Because we all know that if we're running from a lion, you'd be running the show. right I would never say in allowing you to feel your body right now and it's like a dialogue between these parts of the brain and then all of a sudden you've created a positive feedback loop where you realize oh every time I decide I want to take a breath right now and just pay attention to that even just for a few moments I've broken the fear cycle like I've broken the cycle of the environment controlling me now I'm controlling me and now I have reinstated safety in my body and increased vagus nerve tone immediately and HRV immediately because I'm in control of the system. Yeah, I love that. Okay, so taking breath work back to its absolute basics, just even doing the breath work and taking control of that usually automatic activity is telling your amygdala it's no longer in control. Right. And that creates this feeling of safety. It creates more parasympathetic tone, which then improves, obviously, HRV, but you just feel great as well. Yeah. Who does not feel great when they're sitting there just taking a nice breath, right? Yeah, it feels good for a reason. And I think the slight nuance is that actually it's the safety piece that you reaffirm by saying, I choose to take a breath right now. That leads to the safety first. Then the safety signals from the insula to the amygdala that says we're safe because we have time to choose to do this. You're not under threat. Shut the F up. Take a nap. Take a breath. Take a smoke break. show right now, right? Exactly. Okay, but like, you know, I think about my day to day, and you know, I'm in the car driving, and then I'm getting out of my computer. And then, you know, I'm like working away. And your day just gets down this path of trying to get everything accomplished, right? So how do you practically make breath work part of your day? And like, how do you make this something that you can bring into your conscious more often? And what are some tools there? So you're going to laugh because I'm going to say it again. But the first thing I do is I don't call breath work because the last thing that all of us busy people want to do is more work. It creates a psychological barrier. It really does. And so I just take the work out of it and I just say, I'm going to breathe. So that's where it starts. It's the neurocognitive. time to breathe. Yeah, it's a neurocognitive understanding of this isn't about work. This isn't about forcing myself to do something that I, like work has this weird connotation. It's like everybody knows it is the place they spend most of their time and they don't want to be, right, to make money. It's so funny because I went to this thing last weekend. It was like a breathwork seminar. And you literally, you know, you go there 45 minutes long and you're working, right? It's like do a four-by-four breath and then a four-seven-eight breath. And now we're going to do the, you know, the tiger breathing. It's like one thing after the other. It's a lot. It's a lot, right? Exactly. It's 45 minutes. I'm doing a lot of stuff. But I'm like, did I really get a lot out of that? I don't know. Is that something that I need to be doing daily? Or to your point, breath should be something that is throughout your day. Yeah. Yeah, and I think that's – I like the thing that works best for me that I think a lot of people like us who are busy resonate with is just like taking five minutes, two minutes here and there. you know like i think the other problem with calling it breath work is that people think oh it has to be done a certain way do you know what i mean from a lot of those courses like the one you're talking about people leave my patients leave i leave those all the time and i'm like oh well if i don't have the 15 minutes to do this full breathing exercise or this full meditation practice what's the point i'm not going to get what i want out of it and that's not true there are micro moments of wellness that can be achievable in an instant because the moment itself is wellness, right? Like the present moment is what we're trying to get back to. That's what breath and, and, and all of these techniques are trying to get us back to. And so I tell people, look, like, don't worry about counting your breaths. Don't worry about spending a bunch of time trying to plan out what you're going to fit into your day. You have, you were just working on something in the head in front of a screen. You're like feeling like you're like trying to figure something out. You're not sure where it's going. You just like need 30 seconds, breathe. 60 seconds, breathe. Two minutes between now and the next meeting, go pee and then breathe, right? And just choose to do it until you have to go do something else. And you will feel that clarity start to, and the vagal toning start to build up because it's not about, it's not, it's not really about having your vagus nerve activated all the time in a high level. It's about the rapid switching that matters. And our bodies are always switching between stress and not stress states so it's that's what adaptation is as a skill right and that's what hrv predicts is how quickly you switch on and then switch off and the more practice you get that i'm switching throughout the day right the better your hrv is going to be and that's and i think that's where breath really helps to start to tune and acclimate the body because you can do it anytime anywhere you don't you don't have to do a specific practice all you need to do and this is what i tell every all of my patients is like don't worry about doing a specific practice just take all of that stuff out of it and say, that's advanced stuff for later. For now, let's start by just taking a breath by choice and then start filling your lungs on the next time you take a breath by choice. Just fill your lungs as much as you can and then empty them as much as you can. It doesn't have to be complicated. And I think when we break it down into that simple, that very, very simple approach, people are like, oh, anybody can do this. And I'm silly if I can't find five minutes a day to start to do this. Everybody has five minutes a day. Everyone. You can't tell me you don't. That's simple and profound because it really makes it so much more accessible to people rather than adding another thing to their day. Yeah. That is work, right? Yeah, exactly. I mean, that's a lot of the psychology, or what I call the modern approach to mental health and psychiatry is this. And this is where technology and psychedelic medicines become really powerful tools to help us because it's not about adding more. onto your plate. It's about helping you sort through the clutter and then figure out that, oh, there's actually a lot more space on this plate than I thought, but I was spending like 50% of it thinking about this future that I can't control or all the things about the past that I regret, and that was just making me feel like my plate's full all the time. Guess what? I actually just got 50% of it back, right? Absolutely, absolutely. So there's all these tricks that we can use to do that, and Apollo psychedelic medicines use properly, breath work, you know, again, these yoga practices, soothing touch, intimacy, incredibly underappreciated ways to get back to the present moment, to get back to health and well-being and vagus nerve activity, high HRV states, hugs, soothing touch, faster than anything we can do in any other way. Wow. It's amazing. Right? It's the language that existed between our moms and us before words. Yes. There's so many techniques out there. people do not need to be suffering no i think also you know one of the things that i like to do now and i've changed my practice on this is i love doing sauna i actually like doing cold plunge and cryotherapy but using those stressful situations as a moment to kind of train my nervous system so as i'm going into a cold plunge doing some breaths and just become becoming like acutely aware oh yeah this fight or flight and then taking it down to where it's like i'm doing this because I'm choosing to do this. And then when you're in, there's going to be that initial rush, but then there's also another opportunity to control that feeling in your brain that you need to run away. And same with the heat, like being in the heat as well. And I think those are also great opportunities to do some of this training and making that also part of a routine. 100%. Yeah, you nailed it. And it's the same concept you just brought up of, I'm choosing to do this, so I'm safe to do it, right? If you feel like you're not able to choose to do something or not, it takes some of the safety element out of it. It feels like you're being forced or coerced or whatever. But no, you're choosing. I'm choosing to take this breath. I'm choosing to sit in this freezing cold water, right? And just acknowledging that is regulating. Yes, exactly. And thank you so much, by the way, for giving me one of these Apollo Neuro devices. I'd love for you to talk about how this adds to someone's day-to-day routine in this topic. Sure. Yeah. Yeah, so let me start. Have you ever had a time where you had a bad day or a hard day and somebody just came up and gave you a hug and you instantly feel better? Yeah, all the time. What about a time where you were having a tough day and you walk in somewhere and one of your favorite songs is randomly playing and you instantly feel better? Yes. Did you know why that happens? No. We haven't known why, the full explanation of why that, like, that effect on the body, which is instantaneous and nearly universal across all humans. Yeah. We've all, basically every human has had these experiences that we just described. And we haven't known the neuroscience behind it up until about 20 or 30 years ago. Mm-hmm. And what's really interesting is that the reason those techniques work, or the techniques, the reason those random experiences make us feel better, even though we could be having the worst day of our lives, is because they create feelings of safety in the body through the vagus nerve. And in the case of music, it's rhythmic vibrational resonance and the familiarity of a song that you like that makes you feel safe because familiarity is safety to the evolved human body, right? Newness can be scary when we're stressed, but familiarity, that feels great. That is right. I can trust this. They don't have to worry. Same with getting a hug from somebody you like. So you get soothing touch, powerful vagus nerve, amplifying behavior, and it's familiar because it's with somebody you like. Same thing for somebody unfamiliar or who you don't like. Eh, not the same response. Maybe the opposite response. So we were studying these responses for years, and I was trying to figure out, mostly at the University of Pittsburgh Medical Center, I was working with veterans who had severe PTSD, often substance use issues and many other issues. And we were trying to figure out better ways to help them because over 70% of these people were not responding to treatment with all the best treatments we had available, medication therapy, all of it. So I started to ask them what worked when they were feeling good and then started reading more about it. And I realized very quickly that it was these vagus nerve techniques, the soothing touch, service animals, the listening to their listening to songs they like that were familiar, made them feel safe and help them reduce their symptoms more than any medication that we gave them could. I was like, this is really interesting. So then I went in 2016. I got my training in MDMA assisted therapy. And that was fascinating because I was studying how MDMA was working on the brain, and I was really interested in how this medicine, when combined with 43 doses only, combined with 42 hours of psychotherapy with two therapists over 12 weeks, induces a 67% complete remission rate at one year out from people who have never responded to any treatment. Crazy. 67%. 67%. That was in the phase two trial. Yeah. But what's even more interesting is that right after the treatment ended, it was 55%. And then with no additional treatment for the year, it went up, not down. We've never seen that in the history of psychiatry before. And this is for PTSD? For PTSD. Wow. We've never seen this in the history of psychiatry before. In three MDMA sessions. Three MDMA sessions, 12 weeks, 42 hours of therapy. And people continue to get better afterwards, right? So even when the treatment has stopped, this is paradigm shifting for mental health. because every study shows when you stop taking your math, you get worse. When did you do this study? That study was the MAPS study. Oh, okay. So that study was done and completed prior to my training. I think it was like 2014. Right. And that study really piqued my interest because it's the same patient population I was working with, and these people are getting dramatically better. So I was like, I have to get trained in this. So I ended up getting my training, and during the training, the core theme of the entire training we talked about every single day, multiple times a day, was safety. I was like oh my god everything's pointing to this I have to go and investigate this more so I went back to the lab after the training and we started to look at and map out what are the pathways being activated by MDMA what are the nervous system pathways guess what then we look at soothing touch what is that activating your favorite song soothing smells that your favorite food your parents made when you were a kid or tasting amazing food or any of those things, hugging service animals or any animal. It's the same thing. Insula, amygdala, prefrontal cortex. Saw these patterns and I'm like, holy cow, this network is conserved, right? It's like the same for everybody. And when you do that, vagus nerve activity goes up. So I thought, all right, well, if all of these healing techniques work by activating this network, why don't we use technology to activate this network better? music can do it so what if we deliver music to your body like that feels like touch so we started exploring that and we figured out between 2016 and 2018 how to compose very specific sound wave vibrations that you can feel you felt earlier you're feeling through your device i'm wearing on my chest right that are slow bass rhythms like the same bass frequency that comes out of subwoofer right or that comes out of a stand-up double bass somebody's playing on stage and they're so low volume that we can't hear them, but they're at the frequency level that our touch receptors are sensitive to. Oh, that's so interesting. So we composed for the touch receptors instead of the skin. It's literally music that I composed based on the neuroscience of how touch affects that insula, amygdala, prefrontal loop to induce vagus nerve activity. And it worked. And then we did double-blind randomized placebo-controlled trials, and we continue to see time and time again that vagus nerve activity goes up within minutes, and cognitive performance goes up, physical performance, recovery metrics, blood pressure goes down, resting heart rate goes down, people sleep 30 more minutes a night. I mean, we have 17 trials now. So we're continuing to see the same consistent results in both healthy people and patient populations. But what was so interesting about Apollo is that originally we built it for veterans. We built it for patients. It wasn't for everyone because we didn't know that everybody needed it. Then we started prototyping the wearables. And when we started making our first wearable prototypes, my wife and I are wearing it. We just gave them to everybody. We gave them to our friends, family, colleagues. And personally for us, it changed our lives. I mean, we slept better. We focused better. We doubled our productivity with maintaining calm because we were just so much more present throughout the day having this gentle, it feels like an ocean wave kind of washing over you, right? And it's barely noticeable, but that was enough. That little boost in vagus nerve activity was enough throughout the day and night to just transform our lives in terms of the amount of calm and productivity we're able to get. And from there, we realized this has to be a consumer product. Like we can't keep us behind a prescription paywall. So we released it in 2020 as a consumer wearable and here it is. Right, exactly. So I'm wearing it on my wrist right now, but you can also wear it on your chest and your ankle, right? And you wear it throughout the day on your ankle. generally and um sleep definitely on the ankle yes sleep definitely on the ankle okay i mean this is fantastic i can't wait to you know have this on for a few weeks and see how i feel i'm always struggling with my hrv and trying to get it up and also just you know throughout the day just having a reminder a gentle reminder to take breaths so yeah i'm really hopeful that this will help so i'm excited about it yeah and we'll pair it to your aura ring too so then because it Because it takes your aura data and then customizes vibration patterns for you based on your data. So if you want to boost HRV, like you were talking about, you want to pair it because then it can understand, oh, Darshan's HRV is a little low, so we need to send him vibration patterns that are specifically for boosting HRV. Got it. Because Apollo, contrary to what most people understand, it's a vagus nerve modulator, not a stimulator. So vagus nerve stimulators just increase. They don't decrease. They don't adjust. We need adjustment. When you're tired, sometimes tired means I'm super fatigued and drained, I have no energy. That means you need stimulation, coffee, or you need more fast, more loud for a short time to give you more energy. But if you are under-recovered significantly, you need recovery before you start providing stimulation to the body. You need more vagus nerve activity. So there's a balance. And that's one of the things that's missing from the way that we address mental health is autonomic balance, right? A flow state, which is one of our most desirable states to exist in as humans, comes from having high vagus nerve activity and also high sympathetic fight or flight activity at the same time. That's what flow is. That's what flow is. Yeah, it's peak presence. Peak presence with peak acuity, right? So you're not peaking on either. But you're fully present in a state where you can do stuff functionally. Yes. Right? Yes. So you're not just sitting there listening in a dominant vagal state. You're actually doing stuff. So I think that's a state that we all know and love that we want to get back to more often. And using tools like Apollo, we can facilitate access to what we call autonomic balance or flow more often. So cool. you know one of the things that you mentioned earlier that I wanted to get back to was this notion that if you have unresolved traumas in your life you might have a hard time with modifying your HRV and just kind of you know and could this be a good tool for that and what are some other tools that people can use in that in those cases yeah I mean I think Apollo was built for that like we literally designed it for people with unresolved trauma and PTSD who were not getting results from anything else and needed that vagal boost just to get out of bed in the morning, just to go to work, have a conversation with their families. People were really struggling. And it worked. It was amazing. And you know, you're a doctor, how many things do we do research on that actually work? This is the first one for me. Right, exactly. First one of my entire career that actually turned into something that worked. So I think that's a tool that is really important. It's just the first of what's going to be many similar tools that help us get there when we don't know how. And when we don't know what it feels like to get there. We've forgotten what it feels like to feel calm and present in times of stress and overwhelm. So that's one tool. I think when it comes to people who have a known past history of trauma or unknown, it's a funny question because we all have had trauma. Exactly. So a big part of it starts with not denying yourself that, not saying, I am too good to have experienced trauma. I am too, you know, I'm too human. No, you're human. You've experienced trauma, right? Like we all have, whether you consider it like a giant trauma, like an actual abuse situation or not, is a different story. but even just having like like your when you start if you are a kid and you're singing at home I think this is Gabor Mate's reference that I really love because it's so true you're a little kid you're one two years old you just found your voice you're just starting to sing and you're you're singing and you're bothering your mom because she's trying to do something that requires a lot of focused attention so she yells at you and tells you to shut up and you start to learn hey there's something wrong with my voice and then you develop fear of public speaking and you develop like you know fear of singing and fear of expressing yourself, right? And it controls your entire life. That is not what most people would call a big T trauma. That's a parent, a loving parent making a very normal conscious common mistake, right? And so I think that all of that impacts us in a big way. Like feeling like your voice is unwelcome when our voice is so important to everything we do in human society is an immediate kick in the dick. Right. Right? Exactly. That is just not, that's something you're going to have to deal with for years until you do enough things that teach you that your voice is powerful and good and great just the way it is. And you train it. Right? So I think like, like the ultimate end goal is, is not just to identify trauma or to do things that make the past trauma, of the effects of the past trauma on our body go away. That is just a temporary solution. It's like a band-aid or bandage, right? What actually solves it is the surgery, or the psychosurgery in our case which is like going back and understanding what happened that made you feel bad about yourself Do you remember a time where you used to think about yourself nicely What was that When was that Do you remember when that changed Right And then when you start to understand the events, you can start to retrain the brain to remake meaning around those events and then heal from those events. And so that so so the the day to day stuff that we were talking about is the same stuff. It's the deep breathing. It's the self-care techniques. It's good hygiene, emotional, mental sleep hygiene, physical hygiene. It's exercising a little bit every day, even if it's just a 10, 15-minute walk. It's taking five minutes a day to breathe. Take one minute a day to find things you're grateful for about yourself. It's stretch a little bit before bed. It's all of that stuff that we all know. But the stuff that we don't know is that we all have to accept that we all have had some traumatic event in our lives and denying that is self-deception. Self-deception creates uncertainty and fear in the body, lowers your HRV. So the first step is accept. We've all had trauma. Second step is start doing things that actually help the body feel safe enough to heal from it. That's true. Yeah. I know you're a kind of a pioneer as well in kind of this new world of psychedelic therapy too. And in the next few minutes we have left, I'd love to kind of get an update on ketamine, MDMA-assisted therapy, and what else you're seeing out there that could be potentially helpful and any words of caution you have for people. Yeah. I'd love to talk about that. I think ketamine is actually the only legal psychedelic therapy we have available today. Ketamine is extremely powerful medicine. We use it for anesthesia in the emergency room. Exactly. And that's how it was used first, was for anesthesia and surgery, and because it's a very well-tolerated anesthetic agent, and it was used to evacuate wounded soldiers from battle so they didn't go into shock. It was not originally used for animal tranquilizers, which is the way we talk about it. It was used for humans, and it still is used for humans all the time as a gentle anesthetic. It has very interesting properties at low doses. So we're talking like one-tenth to one-twentieth of what you use in anesthesia. and we use it at that dose to induce a slightly, what we call a non-ordinary state of consciousness, like almost like a waking dream. Right. And to preserve the memory of the experience. In surgery, you don't want people to remember anything. So you give high doses. We call it a dissociative anesthesia. Exactly. Where the person's like awake and looking around, but you're doing surgery on them because they are not asleep, but they're completely disassociated from their body. It works great for kids especially. Yes. because you don't have to intubate them. They don't stop breathing, and they can easily get through a small procedure like putting stitches in. Yeah, it doesn't last very long. Yeah, so ketamine is an extremely safe medicine. It's been around for over 70 years, and I think it has some very interesting properties in mental health that started to be discovered around the late 90s, early 2000s, starting with John Crystal's work at Yale. And one of the things that was discovered is that ketamine is acutely antidepressant. So unlike our SSRIs and other antidepressants that can take four to 12 weeks to work, this can work in a single session. Very interesting. Very interesting. It's also acutely anti-suicidal. It acutely relieves in the immediate timeframe and it relieves suicidal thoughts. We don't really have anything that does that. No. That's safe, that's well-tested. So those are two very interesting properties of ketamine. Very, yeah. And we use it in psychotherapy to get very similar kinds of outcomes that we see with the MDMA and psilocybin studies, but you have to dose it more frequently. So if psilocybin is one to three doses, MDMA is three doses over 12 weeks, in 12 weeks we'll do six to nine doses of ketamine. So it's shorter sessions, but you have to do it a little more frequently to get that same level of symptom remission from the illness. But it works in almost the same way. And it's legal in every state, right? So it's somewhat easier to obtain and to find a place that's going to do ketamine-assisted therapy on you. Legal, regulated, you're getting 100% ketamine every time you get it. Not going to a shaman. Yeah, it's not concerning. There's no concerns about the, like, are you getting the actual drug? Or is this person treating me trained or supervised in any way, right? And so that adds some safety to the experience. But the problem with ketamine is that there's still debate in the field for what reasons we can talk about later. But there's still debate in the field between the anesthesiologists and the ER docs who prescribe ketamine in the in the clinical setting without any therapy that the psychedelic effects of ketamine are an unintended side effect that is not related to healing. and I can tell you that that is completely false except for the acutely antidepressant benefits of ketamine which are neurochemical a big part of that is the chemical action but the psychological impact of people actually getting better is not just due to the drug because if you just give people the medicine and don't do the therapy they relapse over 50% of the time and they become dependent on the medicine That's a clear sign that the medicine is not taking them to the other side of the hill. So we need to, so what we do is in psychedelic work, we combine psychotherapy, preparatory sessions, sessions with the medicine, with providers there, usually too, and then integration afterwards where you unpack and figure out how is all the stuff I learned from the session, it get reintegrated into my life. and that it actually has long-lasting benefit. So this is a big challenge in the field right now where 90% of clinics are just giving you ketamine in a chair. We are trying to help people understand that even if you're going to do that, connect your patient with a therapist. Have a holistic approach so that people have a chance at getting better long-term. Yeah, ketamine clinics are popping up all over the place and they're money-making machines for people. And like you said, people do get that acute elimination of depression. But none of it that I see is a pain clinic. Yeah, exactly. It's like a pain clinic. And a lot of pain clinics offer ketamine infusion. And so just because it's safe and you can do it doesn't mean you're doing it in the right way to have long-lasting benefits. So going beyond ketamine, what about some of the other therapies that are in plant medicine now? I'm hearing a lot about ayahuasca, ibogaine. How do you feel about those? I mean, they're incredible tools. I think we have a lot more understanding to do. I think that what has always fascinated me about these medicines is that even though they're molecularly different, they all are used to heal people from mental illness in the same way. They're all trauma-informed care techniques, amplifiers of trauma-informed care. That's what they do. And they help create a state in the body where people can literally, and again, this is regardless of the medicine. So, you know, Ibogaine, ayahuasca, LSD, psilocybin, MDMA, you name it, basically. Almost every known studied psychedelic in clinical care so far for mental illness is working in this way where it helps people feel safe enough. because the medicine is an amplifier of awareness. So you curate a safe environment, ambiance, right? Curate a safe ambiance where the environment's super soothing and nice with people the person trusts, guiding them. They take the medicine, and then the medicine is molecularly amplifying the information. It's already in that amygdala, insula, prefrontal loop, which now is not fear or threat. It's safety, right? Because you've already set the stage for that. So the medicine amplifies that, And then all of a sudden people feel safe enough to go back and remake meeting around past traumatic events from the perspective of not fear. Right. And when you're afraid or stressed, like you don't want to go back and relive that stuff. Like why? It's so painful. But when you feel so safe that you know nothing can hurt you from your past because your past is gone, it's the past, it's over, you're empowered to go back and then remake meaning around it. And the safety is critical because vulnerability is hard. Right. And if we don't feel safe, we're not going to be vulnerable. We're not going to be our full selves. so the medicines are working with therapy even though they have slightly different molecular actions they're working together with therapy to amplify the therapeutic access to that safe healing state that allows meaning making to be reshaped and what's so cool is more is going to come out about this all of this is pretty much 5-HT2A receptor dependent serotonin receptor dependent you block 5-HT2A there's some studies have shown meaning making from psychedelics disappears Really? That's so interesting. Right? Yeah, so interesting. It seems like it's going to be an incredible world now that we are studying psychedelics again. We had a huge pause due to all the things that happened. But it seems like a lot of these can be potentially, I hate to say this word, but curative for a lot of mental disorders. and I can see a lot of pushback from the pharmaceutical industry that is relying on these prescriptions that are subscriptions for the rest of someone's life. And so I'm so excited about this, again, gaining momentum. I mean, you're at the forefront of making this happen as well, so we thank you for that. And yeah, the world of psychiatry is just in a whole different place right now. Yeah, I mean, I think it's funny to talk about because when I went into psychiatry, and probably when you were doing your rotations, psychiatry was kind of made fun of. It was the butt of medicine. People thought, no idea what we were doing. It was guessing, right? Like when I went into psychiatry, people were like, are you sure? You sure you want to do that? Like, we don't respect you, you know? And it was tough decision. But when I realized, of course, that I could study what I wanted to study and see the people I want to see, there's no question. But I think that it goes without saying that this generation for psychiatry, the generation, the time we're in right now, is easily the most exciting time in the history of our field because of psychedelic medicine. Not in spite of it. It's because we went, we had a psychoanalytic model with Freud and Carl Jung and all these people that worked kind of well, but it was a very interesting way to view the mind. It wasn't great at treating illness particularly efficiently. Then we went to the biological model for 50 years. We eliminated almost all psychoanalysis, and that's not really working any better. And now we're finally, through psychedelics, going back to therapy and medicine together is better. Right? It's not one or the other. It's like this is a holistic approach. We need to set the therapeutic frame, set the safety frame, set the intentions, medicine as an amplifier. Right? The medicine gets sprinkled on to amplify, and to your point you made earlier, the reason why this is so exciting in psychiatry is because we are starting to see evidence that we can cure mental illness like PTSD. And we have never, ever been able to do that before. We've been taught to not even use the C word. We treat. And if you stop taking the medicine that we prescribed you... I was nervous to say it. It seems like we're headed towards that. No, we are. We absolutely are. And part of the reason why I'm so excited about the work that we're doing, why I'm so excited about the book and about Apollo and all of this that's connected to the way – it all comes from information we've learned thanks to what psychedelic medicines have taught us, the psychedelic science of the mind and the body and how they're connected. And we will be curing mental illness in 10 years. Within the next 10 years, we will cure at least one mental illness. That's incredible. It doesn't mean it won't exist. It means that people will come into the office and they will get a prescription to remission like they get a treatment for infection with antibiotics. It's going to be no different. And nothing could be more exciting to me than that. Exactly. Yeah. And, you know, going way back to the beginning of our talk, you had mentioned hemoglobin A1c and as a measure of three months average of your glucose level. And so I had Andrew Palmer on here as well. And we talked a lot about brain energy and just really tying in the metabolic effects of having high sugar and dysregulated metabolism on the brain as well. And that piece also being brought in, especially through the lens of GLP-1 medications as well, being part of an overall algorithm, just make the brain metabolically healthier as well. So that's another piece that we can also bring to the puzzle. And all of this together, it's a really bright future for mental illness. Yeah, it's extremely hopeful, extremely promising. And I think that's what people really need to hear. you know like we there's so much doom and gloom everywhere every social media time you open social media right but the truth of the matter is that like we are on the cusp of something truly tremendous in mental health and it's going to affect the world it's not it's not going to be isolated just a few people like the hep c medication that just came out that cost eighty thousand dollars for one dose like that is not what we're talking about here we're talking about broadly, widely accessible, scalable mental health care that comes from a new understanding of how the mind-body works. Right. That can be potentially curative and much cheaper. And much cheaper. Right. Yeah. Much cheaper, like actually curative. Yeah. Actually helping people get back to themselves. So incredible. So incredible. Well, I applaud you for all the work you're doing in this. And thank you so much for coming on the podcast and making people aware of all of these things. I think, you know, we learned so much from how to fix your HRV, how to breathe, how to even think about mental illness and depression and kind of the bright future we have there. And I'm just so excited that you're writing a book now to teach more of us about this and go deeper. What's that book? It's called A Simple Guide to Being Alive. I love that. I've been working on it for a long time. I mean, I've been probably working on it for about 10 years, but actually writing it really in the last year or two. It's a labor of love about basically, and I think you'll really appreciate this, it's like we went to so much medical training, so much medical training. How many things were left out of that training? Nutrition pretty much on the whole, right? Just to give one example. Psychedelic drugs, not included. No therapeutic benefits of those. And there's some breathing, being able to choose, the importance of choosing to breathe. Another thing, there were so many other pieces, meditation, mindfulness, yoga. We weren't taught about any of this stuff. But I learned a ton. I learned, you learned, I'm sure, we learned so much about all the intricacies of how the body works in ways that most other people do not get the honor of understanding in that depth, we know it because we have to know how every single drug affects it. And we have to know how every single disease dysfunctions under the pressure. And so I basically did all this training and realized that when I went into my regular day-to-day life, how much was new. How much I had been left out. And then as I started to treat my patients starting in 2012, the veterans, they're not getting better. and so I started researching eastern and tribal medicine and psychedelic therapy and we're not taught about any of this so I start broadening my window of awareness to oh there's other disciplines out here and then there's my own life experience and the things I learned from that and when I said oh maybe I should meditate myself and I believe in that and see if that works because it seems to have existed for thousands of years so I gave it a shot and then there's some of that that came through and basically I realized is like we never had a guide about how to be human, you know? And like it's so much easier than we were told without a guide. It's like part of the – and I realize like as I see thousands of patients like you, right, there's certain – there's some things that everybody's doing that if we could just in the education system explain, right, when kids are young, don't do that, right? Don't swallow air. It gives you gas. It's like simple things. Simple things, right? Like we would prevent tons of illness. You stress, distress thing, right? Like if we teach people how to do that, that creating distress is simply by asking, why me when something hard happens? Creating you stress is asking, taking that same question and saying, oh, I'm not going to ask that. I'm going to ask, what can I learn from this experience today? That's it. Yeah. So when you think about how simple the changes that we could make or the things that we could be doing could make us, like help us live and achieve everything we could ever want and more because we haven't even conceived of what else is out there because we're so stuck in the stress loop, then that is actually not represented in any of these fields independently. It's actually at the intersection of Eastern, Western, and tribal medicine disciplines. And when we look at them all as opposed, we miss the beauty of where they all complement each other. And so from working with these really hard patients and living my life, I realized, oh, wait, this is the opportunity to, in a simple manual, give people something that you can read, even you can understand, even if you just graduated from high school and you don't have an advanced medical degree. And you can understand that if you do these things, even in a time of crisis, even if crisis feels like it's all the time, you can come back to yourself in a healthy, happy, long life. And it's not hard. There's nothing wrong with you that you're in the situation you're in like this. We can break this down. So that's the guide. I cannot wait to read this. I totally resonate with everything you've said. And, you know, I spend a lot of my time with patients that are struggling with medical problems like autoimmune disease, you know, cardiovascular disease, a lot of things, all the things that you see as well. And I remember like 20 years ago, not having any of the tools that I have now, you know, HRV being a big one of them, you know, and just how much that accelerates someone's path to not just covering the symptoms, but actually reversing chronic disease, right? And so, and I always tell everyone this is like the opposite of having a chronic disease is feeling awesome. Yeah. We should all feel awesome every single day. It's not just being not sick. Yes, exactly. The big difference between feeling awesome and being not sick. Yeah, that's up on every wall here at Next Health. You know, it's like the definition of health is not the absence of illness. It's the abundance of vitality, right? And so how do you feel vital every single day? And everyone should learn this stuff, you know? And I think it's really an important message. And I can't wait to read your book. Thank you. I'm excited to share with you. I can't wait to get it. So we're going to have you back on because I want to dive deeper into that topic once the book is out, too. Let's do it. Let's do that. And Apollo Neuro, you can buy this online, I assume? Yep, at ApolloNeuro.com. Or you can go to WearableHugs.com. WearableHugs.com. That's what the kids call it. Oh, very cool. I love that. And then where can people learn more about you and follow your work? Find me on socials at DrDavidRaven. And then on my personal website and professional website is DrDave.io. And that has pretty much everything you'd want to find out about me. Amazing. And you have a clinical practice in San Francisco and New York? San Francisco and New York. We see patients throughout California and New York. We also train clinicians to do advanced psychotherapy techniques like ketamine and how to work with psychedelics in delicate situations. Teaching is a passion of mine. I love it. Dr. Rabin, you are amazing and I'm so honored that you joined me today. Thank you. It's such a pleasure to be with you. Thanks for having me. here are my top five takeaways from that episode with dr rabin number one not all stress is bad but chronic stress is you stress which is good stress asks what did i learn from this experience distress asks why is this happening to me one builds growth and resilience the other signals overwhelm and perceive threats number two modern life keeps us in survival mode our nervous systems evolve for short bursts of threat, not nonstop digital stimulation. The brain can now feel under attack and overstimulated all day long, even when we're physically safe. Number three, HRV is a longevity and resilience super metric. Heart rate variability reflects vagus nerve function, your body's brake pedal. Track your monthly baseline. When HRV drops, prioritize recovery. The good news, there's no upper limit. It's trainable to reach higher levels. Number four, take the work out of breath work. You don't need perfection. Simply choosing to slow your breath to five to six breaths a minute, even just for two minutes, signals safety to your brain. Conscious breathing shifts you from reacting to your environment to your regular body. Number five, the future of mental health is nervous system medicine. From vagus nerve stimulation and wearables to guided psychedelic therapy, psychiatry is shifting towards treating root nervous system dysregulation, not just managing the symptoms. We're on the cusp of mental health care becoming more curative, not just coping based. Thank you so much for listening to the podcast today. Please remember to subscribe if you like this episode and give us a good review and share a link with your friends. It really helps to support all of our efforts. I also want to remind you that the information shared on this podcast is for educational purposes only and is not intended to replace professional medical advice, diagnosis, or treatment. Please consult with your healthcare provider or physician before making any decisions or taking any action based on what you hear today, especially if you have any underlying health conditions or on any medications. Your doctor knows your personal health situation the best and it's always important to seek their guidance. Thank you.