Anabolic Steroid Use in Psychiatric Disorders

[00:00:00] I have friends who have gone in and their test levels have been 700, 800, 900, and they're still given kind of this cookie cutter dose of 200 milligrams per week. Some physicians will go up to 300 milligrams, and when I'm referencing all of this stuff, this is typically per week

And welcome back to How to Be Patient. This is the start of season four, and I am flying solo right now, with the exception of Robert, who is not Rob the producer, if you've seen him before. Hello, Robert, and welcome to the pod. Hey, what's up? Thanks for having me, guys. So today, we are talking about a topic near and dear to my heart, because it's related to exercise, not that I have any personal experience with anabolic steroids.

But this actually goes way back to when Rob and I were both fourth-year med students and we were rotating on our addition [00:01:00] rotation and as, like, a part of the sub-I thing, you're supposed to give a presentation. And- ... I remember Rob did his on anabolic steroid use in psychiatry, and I was like, "Wow, this is so interesting."

So this has been a pet project or, just a topic of interest for you for a long time. Yeah. Yeah. Preston's being nice, too, because he says I gave my presentation on anabolic androgenic steroid use disorder. and it was in the context of, like, it needs to be, you know, psychiatric related, and it was 'cause it was a use disorder, but I probably went way too much on a tangent of the actual steroid use itself and some of the per- you know, repercussions of doing that.

But gosh, it's crazy to think that was, like, four years ago already. Yeah. Well, so I, mean, it stuck with me. I thought it was really useful because anyone can look up a use disorder in the DSM, but I didn't know the difference between Trenbolone or an Anavar or, like, basic t- vanilla [00:02:00] testosterone, I guess I would say, and, like, it gave me a lot more insight into, like, the menu of options that people have because- You know, we're not orthopedic surgeon psychiatrists.

We exercise. I think we're more of a Pilates crowd or a Dungeons- ... and Dragons group. But it's, rare, I would say, to, have psychiatrists that lift pretty heavily or, like, in this space. So I think that was, like, pretty useful. Yeah, and Rob's given the vi- Both, both Rob and I lift, so we're talking about, like, "Oh yeah, psychiatrists don't lift that much," but, maybe we just see ourselves as the exception.

So, I guess I, I'm curious, Rob, where did... A- and I know you've, intertwined this with your, you know, interest in medicine and, probably your practice, at some point in the future. Where did this come from? Like, when did this start? Yeah. So like you had mentioned, spent 10 years of my life in Las Vegas.

I kinda consider that home now. and the Mr. Olympia every year for-- And for [00:03:00] those who don't know, that is, like, the, you know, the Super Bowl of bodybuilding shows, the Mr. Olympia. It's huge. it's the biggest show. It's always at the end of the year. And, right, so some people might know, like, Chris Bumstead.

he participates in that show, and that's in Las Vegas. and I was a, I was a- So, so people come from all over the world for, like, to the mecca of bodybuilding for this show, and that's where you're living. Yeah, quite literally the epicenter of bodybuilding. So, like, all these folks that you guys see on, you know, TikTok, Instagram, Twitter, if, they have any kind of fitness connection, they are at this, expo and, you know, they're making sure to cover it.

So I, I kinda had an up close, you know, view of this going on. And then the gym scene in Las Vegas, I always compare it to a little bit of, like, a Miami vibe because people are showing up to the gym, you know, [00:04:00] It's, almost like a fashion show in some sense, right? They're wearing their best gym apparel.

You know, sometimes you'll see women, you know, full makeup going in. There's valet service at some gyms. So it is, like, the, you know, kinda the mecca, even if you're just trying to, like, go in and hit bis and tris and, like, get some cardio in, right? So I think that was kinda my first introduction. And then, you know, in undergrad, You know, you learn a little bit more of the biochemistry part of, you know, the steroid use disorders or just steroid use in general, and surprisingly how many folks use these performance-enhancing substances.

And, gosh, you said something earlier like, "Oh, people just think of these as steroids." There's like 1,000 flavors of steroids, right? There's... It's so broad and it's probably even like- It's like the cereal aisle in a grocery store. Y- [00:05:00] exactly. Yeah. Yeah, exactly. Okay. But we just try to clump it all up into one, and that just, pr- you know, adds this other layer of complexity to it.

One thing I noticed on the... I was in the Instagram fitness scene for a little bit and go back and forth there. There's, this huge complaint or, kind of a commentary on, you know, being natty or not. And a- as you're describing this almost cultural phenomenon of going to the gym and maybe I guess, putting your best self forward.

It's, not just health maintenance and it's, an experience that you're, taking a valet here. So did people talk about their steroid use at all, or was it kind of taboo? Like, h- how did these things come up in conversation when you were in Vegas? Yeah. it was taboo until it wasn't, right?

It was taboo until it wasn't. And, you know, you talk about the culture of steroid re- use, you know. Y- you know, nowadays, if you... And 'cause there's specific gyms where you can tell, like, there's a larger percentage of the [00:06:00] folks who are on gear. You know, gear is sometimes referred to as steroids. And, you know, if, you're hearing things like, "Hey, bro, I'm just trying to get, you know, hotter than the sand, bigger than the ocean," right?

"Just trying to get jacked and tanned," things like that. So it's a little bit more synonymous and, you know, it's, You talk about, like, gosh, how do these conversations come up? You know, once you kind of start to realize, you know, it's relatively easy to get big, it's rela- and I'm saying relatively easy, kind of, you know, some air quotes, but it's relatively easy to get big.

It's relatively easy to get lean and, like, shredded. But when you have folks who are both lean and shredded, and then you kind of put some contextual to- cues to it, you know, the bacne, the stuff, it's pretty easy to spot. Okay. So it's taboo. People aren't talking about it a ton, but once you've kind of broken the glass with a couple people, you start to see it [00:07:00] a lot more.

That almost makes me think of, like, certain cosmetic procedures, like lip filler. I think I used to not be able to spot lip filler anywhere until, you know, like, the girls I was with would be like, "Oh, you know, she got, you know, 20 cc's there, 10 cc's there." And then you're like, "Oh, was that lip filler?" Or like, "Oh, was this, Botox?"

'Cause I had no idea what this was before, but now it's, brought to my mind, and I can spot it. y- you already pointed out that it sounds like, you know, someone who, is extremely lean and also very muscular, like, that's a, warning sign And backne can be another one. What are other signs-- And I guess even coming back here as a, physician who's looking at patients coming to the clinic, like, what are other signs that make you concerned that someone might have, anabolic steroid use?

Yeah. So, right now we're talking about, like, the phys- the physical cues, right? You know, folks who have, like, really low body fat. They may have, like, increased muscle mass. We [00:08:00] talked about some of the acne things. If you're prone to male pat-pattern baldness, it'll accelerate that. but surely there is this psychological side of things too, right?

you know, Trenbolone, which is, you know, kind of a, you know, part of the steroid meme community. You know, that's, a compound that is known to cause, like, extreme aggression in folks. So I always think to myself, right, 'cause I consume, like, this type of media. It's all over social media, right?

People running different cycles. And I always see, like, these people who are- And what is running a cycle for those who aren't familiar? Yeah. Yeah, great question. So, so running a cycle is like, "Oh, hey, I'm gonna, you know, I'm gonna run a 12-week cycle of, you know, testosterone, Deca, Trenbolone, Winstrol," things like that.

And Deca, Winstrol, those are-- are those other types of [00:09:00] anabolic steroids? Yeah. Yeah. So these are the, these different flavors. And, like we were talking about earlier, we clump all of these different substances kind of into just one category. And I, would even go as far to say, like, going down the slippery slope now is like you hear about all these folks using peptides, right?

And, technically, right, they're not steroids. They don't have the, you know, four-ring structure, but they're performance-enhancing nonetheless, right? and that kinda gets lumped into, things as well. But you'll see just, like, this erratic behavior. You know, you hear, like, the roid rage. And, everybody can handle these substances differently.

Obviously, like, dosages depend on things as well. something we were talking about earlier that, that I was gonna just circle back to was, you know, we kinda talked about this culture, right? And, it, very much does feel like this in crowd versus out crowd when you talk to folks who are using, right?

You'll, see, [00:10:00] right, they typically work out together. They might have their niche in the gym. And if, you know, a random person comes up, they maybe, will stop talking about it. So there, there very much is this I don't wanna use the word cult 'cause I'm gonna get in trouble online, but there very much is this tight-knit community So you feel like they would, push back against you describing it as a cult?

I think so, because, you know, you had mentioned something like, y- and I'm sure we'll talk about it at some point, but there is a large percentage of folks who use anabolic or androgenic steroids, and they might also just, like, look like normal people, right? And you might not even know they're using the gear.

So it also becomes this conversation of, you know, are you just like, "Oh, hey, I go to a TRT, testosterone replacement therapy clinic, and my doctor prescribes me my, you know, 200 milligrams a week," or are you the gym [00:11:00] bro who's buying gear from some friend who's, you know, telling you to dose it at five, six, 700 milligrams a week?

so there's definitely kind of sub-communities within this, larger community, for sure. Yeah. That, is really interesting. And, thank you for th- this primer. So we're gonna take a quick break, and then when we come back, I actually want to get more into the granular stuff in the culture.

So, hopefully we, can discuss the different types of anabolic steroids, maybe where they came from, and also if, is there, like, a time when this actually is medically indicated? Because like you brought up, there are these TRT clinics, and I, see the men's health clinics all around. I've always kind of balked at them.

I never learned anything in med school that told me I should be prescribing testosterone, but there are physicians out there who do. So right after these messages, we will get into that

Here's my question to you, [00:12:00] and, I've done some, like, peripheral research on this. Is there a time when testosterone replacement therapy is medically indicated? Yeah, I think, there's a couple different ways to answer that, right? And I think part of that is, you know, are you experiencing symptoms of low testosterone and, you know, based on a conversation with your primary care doc or, you know, whoever's prescribing this, medication, 'cause it is just that.

you know, surely as men age, right, they produce less testosterone, right? Less endogenous testosterone. And I do think that there are medical indications, right, hypogonadism, in which TRT could be appropriate. I think the-- in my opinion, the real question is, okay, if someone is appropriate to start these hor-hormones, how do they then [00:13:00] mitigate any potential side effects?

'Cause not a lot of people talk about that, right? Especially on the social media side. Maybe it's-- maybe they're not getting it through a, you know, a, medical professional, and the side effect portion of things kinda gets pushed to the side. Okay. Yeah. So, so hypogonadism, I mean, certainly if someone, has, like a bilateral orchidectomy, so they have both their testicles removed, maybe if they have testicular cancer or something, or have some kind of injury, be necessary to take, testosterone.

And then I guess the other example I'm thinking of is, someone who's transgender or transitioning. And I guess the part that I'm on the fence with-- So, so those I think are in one category of like very clear, indications for testosterone replacement. But then- We have this other group which is, I would say the 40-year-old guy or fift- the 50-year-old male patient who's kind of in the low normal testosterone range.

And [00:14:00] 'cause the range of testosterone, if, I remember right, it's like 200 to 800 milligrams per deciliter or like micrograms per d- per deciliter or something like that. So, so it's a, decently sized range and so you maybe used to be at 600 but now you're at 300, and they also have these symptoms of low testosterone.

And j- I guess just to recap, what, are some of the symptoms of low testosterone? Yeah. the big few that, you know, you hear most about, most people talk about online is like the low energy, right? the low libido, that's another one, right? and then some folks, you know, say like, you know, maybe there's also some increased body fat, too.

so, so I think those are the big ones but, you know, one thing that I wish, you know, more people would maybe focusing on is before they jump to substances like this, you know, what are you doing... And [00:15:00] gosh, this, could probably be a whole another conver- podcast in and of itself, but like what are you doing right now to optimize your own natural, testosterone production, right?

So like are you getting enough sleep, right? And I know that sounds so basic and slow c- so cliché, right? We probably talk about that a lot in psychiatry, like how sleep can impact your mood. Well, s- adequate sleep can also affect your hormone levels, right? Diet surely plays a role in this, right?

Are you eating processed foods? Are you eating high-fat diets, high sugar content? That affects your hormone levels as well. And then obviously alcohol, substances, really big. So, you know, if, there's... And I'm kinda just thinking off the top of my head here, but if there's one thing that I would hope folks get out of listening to this podcast is to do those things first before putting an exogenous hormone in your body, right?

Like, because [00:16:00] even if you're taking these substances, it's not a magic pill, right? You still need to be, you know, taking care of yourself, eating correctly, sleeping, not eating garbage, right? So optimizing these peripheral things before just kinda going to the quote unquote "quick fix" that's sometimes glamor- glamorized on social media.

Yeah. Yeah, exactly. So, people don't realize that men's hormone cycles I think fluctuate, on a daily and even monthly basis. And I guess to, to furnish kinda some of your examples, you know, ad- adherence to the Mediterranean diet, can promote testosterone syn- synthesis, getting enough omega-3 fatty acids.

Like those, all those things contribute. even exercise can help- I guess, regulate your hormones. this is a lot of kind of like, like in the air wellness talk. but on, on the other end, and one thing that I think about often is that when someone has all these symptoms of low testosterone, so you're [00:17:00] describing, you know, like fatigue, decreased energy, maybe less libido, probably, I think poor sleep is another s- symptom, low mood.

Th- those are all pretty transdiagnostic symptoms of depression. So I think like one, often frustrating, topic is that, you know, s- male patients will come in and they have all the symptoms of depression, but before considering treatment with depression, they wanna target testosterone that's in the normal to low normal range.

What are your thoughts on, and I think there are some of these men's health clinics that will, you know- push testosterone before considering depression first. what's your thought about that kind of phenomena? You hit the nail on the head, right? A lot of times there is this underlying mood component, and this is the way that I like to think about it.

in some ways, maybe folks who also [00:18:00] have some type of depression component, maybe they're coping with those depressive or low mood or anxiety-like symptoms with exercise, right? And we say, "Hey, there's this strong correlation," right? We, probably preach this to our patients all the time, like, "You gotta move more," right?

We- we're all-- We all sit in front of computers all day. Like, you gotta get out, you gotta move, whether it's, you know, lifting weights, going for a run, going for a walk, right? So there's this, you know, popular belief that, like, exercise can help my mood. But where it becomes dangerous and this slippery slope is, okay, now I'm gonna treat some of my mood symptoms with some type of anabolic steroid, right?

they're coping with these mood symptoms with this exogenous thing. And super, super, super interesting, or at least I think it's interesting, is there is a comorbidity between folks who use testosterone [00:19:00] specifically and other substances, right? So if you use substances like cannabis, weed, right, marijuana, you're more likely to use substances like testosterone and kind of vice versa.

So, so I think you said something super, super important that people should really hear is we need to treat the underlying thing that's going on, right, whether that's the mood side of things or maybe in some shape, way, or form it is a hypogonadism thing. But, I would anecdotally think that, like, there's probably other peripheral stuff going on, right?

We talked about the mood. Most people sleep like crap. They eat like crap. So I think there's other things going on there for sure. Yeah. And, you, can sample someone's testosterone at different months, different times, and, it will fluctuate on its own. The other thing that I, guess as a doctor, and so I've-- I personally have never prescribed exogenous testosterone.

I, don't really plan on getting into [00:20:00] that space. But I-- what I would be concerned about is if someone's not making those lifestyle modifications and we're also not treating their depression, we're giving them a substance that kind of, makes them dependent because the s- the second you start taking anabolic steroids, you're now disrupting your gonadal axis.

And so your, own production of testosterone's gonna get reduced. So if you were to discontinue it at some point, now you, you have almost like iatrogenic hypogonadism. Yeah. And that's a real thing too, right? Like we are-- Are we- f- you know, folks who take these, you know, compounds, are we giving them this crutch that's gonna hurt them later down the road?

And then you, kinda opened, that conversation of like, yeah, there's a lot of downstream side effects of introducing exogenous testosterone, right? We are stopping or we're severely suppressing the body, [00:21:00] the, our own body's ability to produce, you know, gonadotropin-releasing hormone, FSH, LH. And these are hormones that are systemic throughout our body, right?

Like, obviously they act on the testes, and there's different receptors in our brain, but there's also downstream effects of that, right? wh- whether it's mood or whether, you know, it's increased heart size, 'cause right, there's, receptors on our hearts. It's not just skeletal muscle. So there, th- you really do, in a lot of ways, you're opening Pandora's box by kind of going down this road.

And I think we, kind of both agree that, like, yes, there are probably specific scenarios where hormones may be indicated under, you know, a physician or a provider's, kind of watch. But I think that is probably few and far between compared to the number of folks who are using the substances, you know, from some guy at [00:22:00] the gym or, how many underground websites are, you know, out there selling this type of stuff.

Or, like, or even in Mexico. Like, I was in- Yeah ... Tulum a couple years ago, and there's just, like, pharmacies or almost grocery stores where they're like, "You anabolic steroids here," and it just has a picture of like Larry Wheels on the front- ... or Cbum. Like, "You wanna look like this guy? Like, come in here, you know, and buy this."

so I, a survey, this is from tr- I think Medicine and Sports Journal. So a survey of over the 500 male anabolic steroid users age 29 reported that 70% of them used it for recreational exercise. and these are, amateurs, so only 12% of those that even report anabolic steroid use were actually competitive bodybuilders, even less were competitive weightlifters or competitive athlete in other sports.

So the, vast majority of people that are using anabolic steroids are just [00:23:00] kind of like your normal civilian going to the gym. And, the primary reason cited for this, cosmetic steroid use is to handle muscle dys- to treat muscle dysphoria or I guess cope with muscle dysphoria or, megarexia.

So y- we have talked about these like medical scenarios, and I agree those are few and far between. And then when we actually survey people that do take these, exogenous steroids, it's, like it's far and away the, recreational users. I, think I saw... I actually... This might have been from your PowerPoint back a couple years ago, but a- about 10% of men between ages like 18 and 35 have tried an anabolic steroid at some point in their life.

So, so this, it's extremely prolific, and yet When we've alluded to this several times, we don't-- we clump them all into a little box. So I wanna take a second and maybe I, wanna take class in, the sense of like I wanna learn a little bit about what are these like different [00:24:00] compounds and, like what are the doses that people take them at?

And so here's one that I think I know a little bit about, which is testosterone, so that's where I'll start. So- Yeah ... exogenous testosterone, I was just looking this up. So if you're taking it for, like gender dysphoria or you're transitioning, or you go- wanna become a, if you're a trans man, the initial dose is around 50 to 100 milligrams of testosterone, and you take that about one every two weeks, and then you reach a maintenance dose of about 100 to 200 milligrams every one to two weeks.

So that's like the common transitioning dose, and I th- I think that's actually a very similar dose to the amount people take when they're, like they no longer have testes. So You mentioned that some people for recreational use will take 600 milligrams. what's kind of the range you'll see of people for just taking testosterone?

Yeah. Yeah. And it's, it is... The, [00:25:00] range is wild, right? So if you were to go to a doctor right now and you were to, you know, get your testosterone levels checked, right, you'd go in the morning when your testosterone levels are higher. They'd take your blood. Okay. Then they'd look at that range that you mentioned earlier, like, right, 200 to 8 or 900, some- depends on the lab.

Some go to 1,100. Okay, you're subtherapeutic, right? And that's so subjective, right? Oh, your levels were 500, which is like a normal range, but let- let's get you up to s- you know, more of an optimal subtherapeutic range, that upper end of range. So if you go to a doctor- So it's a, it's kind of hand-wavy how they look at these, levels because of that generous range.

Super hand-wavy. I have friends in Las Vegas who-- 'cause these TRT clinics are popping up all over the place, right? I have friends who have gone in and their test levels have been 7, 8, 900, and they're still given kinda this cookie cutter [00:26:00] dose of 200 milligrams per week. So if you go to the doctor, 200 is kind of the standard dose.

Some physicians will go up to 300 milligrams. And when I'm referencing all of this stuff, this is typically per week, right? So most folks are injecting these substances once a week. Wow. So, so this is, a cisgendered man looking to exercise who has maybe a moderate to moderately high level of endogenous testosterone, and they're getting what could be twice what a trans man would take for-- to transition.

Oh, that's, just the, kinda tip of the spear because- Oh my gosh ... we're talking about medical, the medical side of things. There are gym bros, right, in Gold's Gym right now who are running over 1,000 milligrams of testosterone per week. So, right, you, you-- and then you think about some of these bodybuilders, right?

The C Bums, the Jay Cutlers, the [00:27:00] Larry Wheels. These guys are running 1,500 to 2,000 milligrams just of- Oh, God. yeah. Wow. So, so we're not talking about milligrams at this point. We're talking about grams, right? These folks are rocking a gram of test. but here's the wild thing. We're talking about testosterone, right?

We're typically talking about-- sometimes you hear folks refer to it as Test E or test cip, cypionate. That's just the ester that's attached to the testosterone. Well, folks who are running that high of gear, is steroids, they're not just running that base testosterone with a half-life of a couple days.

They're also using shorter acting forms of testosterone with no esters right before the gym In addition to taking, you know, Trenbolone a couple hundred milligrams every other day, Winstrol, Accopoise, right? There's all these other things going on S- so, so let me get this straight. If, l- like I'm gonna use A- [00:28:00] like ADHD as the analogy here.

People take like their Adderall XR in the morning, or they got their, long-acting injectable antipsychotic, and then they're taking their booster right before the gym. So they've got their, weekly injection, which is, which you're describing as five to 10 times what is like medically prescribed, and then they're also taking it like additional, like minor doses throughout the day.

I guess before we get into to Trenbolone, 'cause a- and, Anavar, Decadron, like the other things, 'cause I'm really curious about those, what are the, risks of someone running, I'm not g- I'm using the lingo now, running a cycle of 1,500 to 2,000 milligrams a week of testosterone? Yeah. I think the...

There, so there's, a handful, right? And everybody responds to gear a little bit differently. But the one that always scares me a- and right, you've probably heard like all of these bodybuilders who, it's really sad [00:29:00] actually, they're dying in their 30s, 40s, 50s, and a lot of times it's the cardiac complications.

Specifically, it's this left ventricular hypertrophy. So, so like what is that in kind of layman's terms, right? There's, the left side of your heart, it, right, your heart's a muscle. and yes, most folks take steroids because they want their skeletal muscle to increase, but these are a lot of times non-specific substances that don't bind specifically just to skeletal muscle, right?

So you have these increased heart, sizes. And, you know, I remember when I heard about this, like forever ago, I was like, "Oh, wouldn't that be good?" Like, don't I want my heart to be strong, right? I want a big heart. But right, no, because it has way more oxygen requirements than as well, and right then that can lead to, you know, cardiac cell death.

So, so the big one's cardiac [00:30:00] related, right? You can also have high blood pressure, high cholesterol. those are the main ones. What I was thinking is that i- if it causes increased blood pressure, and I think part of this too is that the, anabolic steroids help induce expression of alpha-1 receptors on your blood vessels.

So even when you do get activated, like you're like they're constricting a lot more and your blood pressure in tender- in general is tighter, and then cholesterol, so obviously the viscosity of your blood's going up. So all these things are contributing to your high levels of bl- blood pressure. I was almost picturing that being the thing that causes the ventricular hypertrophy.

but, I guess what you're saying is that the steroids themselves directly bind to a- and mediate the, cardiac myocyte hypertrophy. Yeah, I think, the, way that I think of it is it's, all the above, right? it's really all the above. And, you know, unfortunately, we are not, [00:31:00] this is not in a vacuum, right?

Because at the same time, right, most folks just don't go to the gym. They're slamming two, three scoops of pre-workout, right? They're taking, high caffeine loads, a ton of stimulants. And not to mention, you know, gosh, don't get me started on this, all of these supplements, they're not FDA approved, right?

You have no idea what's in this just because the label says one thing, right? We all remember the, the old school, gosh, the name is escaping me, but it was in, in essence meth in the pre-workout before it got banned. so, so you're combining, you know, steroid use with high stimulant use.

We talked about earlier how folks who use steroids- Nicotine too, yeah nicotine, that's a big one, right? H- hitting a couple Zyns, a couple Upper Deck Pillows, Oh my God ... while they're lifting. Upper Deck Pillow, never heard of that. That's funny. And then, the other thing [00:32:00] too is y- you know, we're talking about, you know, vasoconstriction, vasodilation.

A lot of folks take Viagra before they go to the gym because it's a vasodilator, right? So, so that's really dangerous in and of itself because there's these huge swings in your blood pressure throughout the day, right? You're taking these stimulants, the steroids themselves can cause, like you said, alpha-1 expression and vasoconstriction, and then we're taking vasodilators on top.

It is a, a lot of unsafe bro science, right? 'Cause unfortunately nobody's getting this stuff from their doctors, which, gosh, guys, you-- just go see your physician and, like, make sure you're doing... If, you're-- if this is something you think you're a candidate for, like, this has gotta be done in a safe way, right?

Yeah, it's the Wild West out there. and we're only talking about testosterone right now. Like the, wild- yeah ... stuff is the trenbolone and- Oh, God. okay, so I'm, j- I'm trying to [00:33:00] picture this medically. I haven't thought too much about cardiac physiology in a while, but you're...

So Viagra as a vasodilator, it, increases, nitrous oxide expression, right? so that's actually gonna probably, it's, gonna increase your veins, like the dilation of your veins, which I think people take for cosmetic purposes to make their pump look bigger. But at the same time, that's gonna decrease the preload on your heart, so you're getting less oxygen generation into your heart.

But the afterload is also increased, so you have a situation where you have decreased preload and increased afterload. And then, the other thing is that y- you're working out pretty strenuously. So if you're doing a leg press at the gym or bench pressing, and these are pretty heavy weights, your blood pressure, like systolic, can go over 200 or sometimes even up to like mid-200s for, transient periods.

But that's a lot of consistent strain on, your entire [00:34:00] cardiovascular distributory system. And, these, are for, I guess athletes or recreational exercisers that are working out somewhere between, you know, three to six times per week. Yeah. Yeah. W- wild. And that's just the cardio, that's cardiovascular stuff.

what are some of the other, effects? So I guess, I know we talked about hypogonadism and maybe disrupting our own exogenous testosterone, but are there other hormonal effects? Yeah, sure- surely there's a lot of downstream effects. One thing I was gonna mention, you know, you're talking about the, you know, preload, afterload, all that stuff.

We've all seen the video, right, of some guy squatting or doing a, you know, finishing a bench press. He stands up too quick, and then he falls down, right? 'Cause, you know, blood's not getting to his head. It's pooling in the rest of his body. that was me yesterday. We were deadlifting, and I finished a deadlift, and I was like, "Whoa," like legs are coming down and, I'm not even taking- Whoa

2,000 milligrams of testosterone. I j- I just got what my body's making. Oh. Yeah, [00:35:00] so, so I mean, that's dangerous in and of itself, right? so yeah. So we're talking about, you know, skeletal muscle stuff. We're talking about cardiac stuff, some blood pressure stuff. You know, one of the things that I find super fascinating and, maybe, right, maybe this is 'cause I'm, a psychiatrist, right?

But, you know, surely there is a mood component to this, right? a- and is that a increase in risk-taking behavior? Is this, hey, we're, there's this underlying, you know, mood component, whether it's depression, anxiety, whatever, and now we're inappropriately coping with this substances, with this substance, which, yeah, might work in the short term, but, like, we're not- Mm-hmm

building good, strong coping, skills for, like, when life gets tough, right? So, so that's one thing, and then, you know, a lot of these steroids are [00:36:00] lipophilic, right? And they can cross the blood-brain barrier, right? Trenbolone is, kind of notorious of this, right? So I, that's the one thing that- And what's, the difference between trenbolone and testosterone?

Yeah. Yeah. So let's, dive into that a little bit. Testosterone is, it- it's kind of the where everybody starts, right? So if someone's gonna, you know, start taking steroids, typically they start with testosterone, right? You know, so if, you, know anyone who's on testos- or excuse me, on steroids, like, "Oh, yeah, I'm, taking testosterone cypionate or enanthate or Halotest or, whatever."

and that's typically people's first cycle or two, and then they, kind of, y- you know, "Oh, hey, I got this really good response from this. if, a little is good, more must be better," right? So let me- So testosterone's like a gateway drug to some of these more intense versions. and I guess chemically, is trenbolone very similar to testosterone?

Is there [00:37:00] something different about it? Yeah. It's, it is similar. I, c- you know, the exact molecular structure is, you know, I don't know it off the top of my head, but it is, this is really important, it is significantly, 'cause all of this, they can quantify this, trenbolone is significantly more anabolic and androgenic than testosterone itself, right?

So that's, why, you know, people claim these, you know, really, intense strength gains while taking, you know, substances like trenbolone. but again, there's all of these, down- downstream effects. The, other thing I wanted to comment on, you're like, you know, testosterone is this gateway drug, and I agree with you, but the thing that scares me is these peptides are becoming a gateway drug, right?

All these folks are-- You know, it's all over social media, "Oh yeah, I'm [00:38:00] using, you know, clomiphene," or all these other things. And if you're gonna take peptides that you're buying off some random Chinese, you know, underground website, you have no idea where this stuff is sourced, it, kind of puts you down the rabbit hole, which is, dangerous.

Okay. So just while you were talking, I, was looking this up really quick, and trenbolone, looks like it's roughly about five times more anabolic, in binding to, to, I guess the, receptors are... I think these steroids often bind to DNA components, than testosterone. And, actually it was invented to improve the feed efficiency of livestock.

So the-- Like these were-- This was a compound made that you would give to cows so that they would produce more meat faster And, we and bodybuilders were like, "Let me get some of that, over here." And, so you're saying, you know, this, [00:39:00] substance, and chemically looks very similar to testosterone.

I think it has a couple other, like, hydrogenated groups or acetyl groups on It, it's lipophilic. It crosses the blood-brain barrier. what are some of the, I guess, neurobiological effects that you're getting at? Yeah. the number, one thing is, like, the, aggression component, right?

Like, that's- Mm-hmm ... typically the way that a lot of folks present specifically with trenbolone. So you'll hear all these gym bros say, like, "Oh yeah, you know, I, hander- I handled, you know, 500, 600, 700 milligrams of testosterone, like, you know, didn't have too many side effects. I'm gonna... If I handled that, I can surely handle this substance that's five times as anabolic as testosterone," right?

And meant for farm animals. Yeah, let- And meant for farm animals ... let me get some of that. And the aggression is, w- is, there is no comparison, right? [00:40:00] this substance is in a league of its own as far as, like, side effects go. So it, the aggression's, you know, the, number one, but also that mood lability that we're talking about, right?

Because pe- there are, there's a ton of... Gosh, Reddit is a dangerous place to go sometimes, but there is a, there's a popular YouTuber, his name's Derek. I think he goes by, like, More Plates More Dates is his YouTube name, and he's done entire series on people abusing trenbolone, and the side effects that they get are wild.

One, one of which, and gosh, I don't... stop me if I'm going on too much of a tangent, but one of these, you know, we talked about this increased aggression, but another side effect is this hypersexuality, right? a- and how that can open up a- Almost like a second puberty kinda Yes. Yeah. This second puberty and these risk-taking behaviors when [00:41:00] they use substances like trenbolone, and the aftermath of some of these stories are just wild.

Like anybody who's hearing, you know, th- this and they're thinking like, "Oh gosh, that sounds like kind of a cool substance, like I'm gonna use it, I'm gonna get really strong," well, like I would recommend that people also look into the horrible side effects that go along with these because right there are two sides to, to every coin with this kind of stuff.

Yeah. I... One thing I've seen on social media is the Tren Twins. I think the- these are a group that they bodybuild and they make their whole identity that they use trenbolone. Wild. And the comments are interesting because I think people downplay the negative effects and they're like, "Look at how jacked they are."

You know, they'll, make memes like, "One cycle can't hurt if I c- if I can achieve this physique," almost like the, muscle dysphoria is talking. the, neurobiology of this is really fascinating to me. So I was actually looking a little bit into why steroids cause this rage and, where it comes from.

And so [00:42:00] Anabolic steroids, when evaluated through MRI have shown, changes in amygdalar and frontal connectivity. And actually, long-term studies of, anabolic steroid users show enlarged right amygdala volumes and reduced resting state functional connectivity between the amygdala and frontal, you know, anterior cingulate, striatal, limbic, and hippocampal regions, which are really important for emotional connectivity.

So in essence, the, amygdala, which mediates a lot of our not only fear but rage, is getting hypertrophied and its ability to be mediated by our prefrontal cortex, which helps control our impulsivity, it, its interconnectivity, functional interconnectivity is, kind of reduced. So, so there's like a biological basis for why people are more likely to kind of engage in, or be vulnerable to this roid rage.

The, other thing I was seeing was that it changes, it [00:43:00] disrupts our dopaminergic, glutaminergic, and serotonergic pathways. So it can actually, increase 5-HIA concentrations, which, it, it reduces downstream serotonin receptor density and can contribute to, you know, possible, mania. And the increased, dopamine in the, I believe in the HPT axis can also affect our immediate psychosis.

So o-outside of the roid rage or out- outside of kind of the increased aggression, there, there are pretty significant or, you know, severe mental illnesses that can come out of this. Absolutely, right. You're talking about increased amygdalar activity. I like to think of the gas pedal, right? We are stepping, we're putting our foot on the gas pedal and then disruptions to the frontal cortex.

I kind of like to think of that as like the brake pedal. Like, hey, help me regulate some emotions, some personality stuff, some executive function. So [00:44:00] we're in some ways stepping on the gas, taking our foot off the brake, right? And it can lead to these kind of, wild behaviors, right? I always think of the, Me third year med school.

I'm, you know, at a hospital during my third year and someone jumped off a roof because they thought a helicopter was chasing them, and it was found out later they were using high dose, like grams of testosterone and high doses of trenbolone, right? So the, the neurobio stuff is super, super interesting.

I know you mentioned the Trend twins. I've actually met, them in Las Vegas. They are- Really? Wow. Yeah. at some of these bodybuilding shows. They're... And they're super popular, right? they are, as-- The, personality that they have is just as big as you would think they are. [00:45:00] they are wider than you'd think they are.

They are like really stocky guys. but yeah, that, that whole persona, s- you know, something you touched on earlier, the, you know, kinda fun, wild side y- of using the substance, that's glorified and personified and kind of put in the spotlight. But unfortunately, you know, these, downside, effects are, really not given the, spotlight that they need.

And I know I kept probably... You know, people might be thinking like, "Gosh, you know, Robert keeps going back to this, keep going back to this," but I've, seen it firsthand in close friends and I really think that is something that needs to be explored more before folks just start taking random, substances.

Yeah. Yeah, absolutely. And I guess just, I know we talked about the psych effects, the cardiovascular effects, but just to kind of summarize some of the other ones. So, when you have too [00:46:00] much testosterone in your body, there's this enzyme called aromatase, and that converts the testosterone into estrogen.

So people can also have high levels of estrogen, which can lead to things like, gynecomastia, and that can be a, pretty significant, like, side effect for someone who already suffers from body dysmorphia. So that, that can almost be like, I guess, it coming back around and causing more harm to the initial psychiatric disorder that was trying to be treated.

And then also, I think you mentioned acne at the very beginning. So I, If I remember right, these, steroids, they, cause hypertrophy of oil glands in, skin cells, and that, that can also contribute to acne. And we have, you know, certain hor- hormonal patches, of our skin, I think like around your jawline is one and your back.

Those can be more vulnerable to, cystic acne. And then I think the one, the last ones is, the effects of, like, [00:47:00] collagen in your fibroblasts. So I, don't remember exactly how this works, so I'll have, to look into this, but, it can also increase your vulnerability to, like tearing tendons or, You know, ripping your pectoral, pectoralis muscle.

I think part of it might just be that when your muscles hypertrophy so fast, the rest of your, like, bone and tendon structures don't have time to catch up. But I think it also directly weas- weakens it, yeah. You see that q- quite, often, a- and for the reasons, the exact reasons that you said, right?

Taking these substances, they work on skeletal muscle, but right, you're doing these compound lifts, right? Bench squat, deadlift, right? You're using these tendons, these different ligaments, and there's no receptors for, you know, for these substances, testosterone, you know, trenbolone, yeah, whatever, to strengthen those things, right?

To some of those support structures. So, so you know, you... We've all seen the video, right? Someone's benching, [00:48:00] the pec muscle snaps, right, specifically where it connects. and then, gosh, yeah, the, estrogen side of things are f- are fascinating f- in, in so many different ways, right? You know, folks are taking this exogenous testosterone.

I like to think of aromatase as, like, this, teeter-totter, right? We're, increasing exogenous testosterone, and aromatase is converting some of that to estrogen, right? And, yeah, that leads to increased prolactin, right? Prolactin really disinhibits, libido, right? So, so you got these folks who are, "Oh, hey, you know, I wanna start HRT, TRT, 'cause maybe I have low libido," and you're not taking anti-aromatizing or anti-estrogen medications with it a- and now you have the opposite of the thing that you were trying to treat, right?

Or more of it rather. you, also see like [00:49:00] increased, breast tissue, right? increased adipose around the breasts. So, y- you know, I hate this term, but sometimes you'll see it referred to online and excuse my language, but like bitch tits, right? You see guys walking around- I think man boobs is the other one I've, heard.

Yeah. That's probably the more, that's probably the more appropriate one. Yeah, the gynecomastia. Yeah. So, so you're saying people will... They'll take the exogenous testosterone, and then they'll take anti-aromatase medication. So if I remember right from, the sketches in med school, aromatase inhibitors, those were for like breast cancer, right?

So if... Or if someone ha- if someone has like a receptor positive breast cancer, they'll take an aromatase inhibitor to, to keep from like growing that tissue or I think maybe in some, possible like prostate cancers. I, don't know. I don't know if I'm looking at the right ones here. But these are partly almost like chemotherapy medications or medications used in cancer [00:50:00] patients and, it's being diverted to treat the side effects of these, exogenous hormones.

The br- the bro science rabbit hole goes further, right? You know, it's like, okay, we're taking, you know, exogenous steroids or exogenous hormones, and now we're sourcing peripheral medications to deal with some of these side effects. Yeah, some of which are used to treat cancer, right? So a- and, the tough thing is, and we talked a little bit about this in the beginning, is a lot of folks are using these substances, and they're not prescribed.

They're, like kind of amateur users, right? They're not prescribed- Mm-hmm ... by a doctor. They're just like your, you know, guy who lifts as a hobby, and they may be getting these substances from a friend, some website, and they may not know that, oh, there's other medications that I have to take [00:51:00] in addition.

And it's, really-- it really is a, you know, you know, a dangerous, slippery slope and, gosh, you know, you could, make this argument, a- and I, have no idea what side I stand on, but it's like, do we make this more mainstream so that medical professionals can, help kind of put some guardrails on?

or do we do that and we just kind of promote unsafe behavior? and I don't know what the answer to that is, but it's, surely, it's kind of gas on the fire when you see all this stuff on social media and all the, wild stuff people do. Yeah. So, I think it's, a great conundrum to end this section on.

let's take a quick break, and when we come back, we'll talk about what, do you do when you suspect that one of your patients is taking anabolic steroids, or they even disclose it to you? like you said, do you, just ignore it? Do [00:52:00] you, practice harm reduction, which could be promoting it?

do you convince them to stop? Like, how do you approach that? So we'll take a quick break, and when we come back, we'll, discuss that.

I've probably had a handful of patients in residency so far disclose to me that they are taking, anabolic steroids, and it's always been for low T. That's, what I've been told. And I have-- I've honestly just kind of said, "Okay, Who's prescribing that to you? Like, that's been my follow-up question.

They'll say it's some doctor there, and I... And then they'll be like, "I was wondering if you could take it over." And I'm like, "I don't think this is necessarily indicated for your depression, but I'll, happily kind of continue with that." And, the farthest I've gone is to, I guess, discussing with them is, like, I'm not gonna give anyone stimulants.

Like, the last thing I would give someone who's already taking, like, exogenous testosterone is a, stimulant. I'll, continue to prescribe their antidepressants [00:53:00] and, get them to psychotherapy. But I'll ask them, you know, like, what are you trying to, get out of this, steroid use?

And then most of the time it's, all the things they're hoping to have their depression treated for. They want their energy back. They want their libido to return. They want their focus to come back, and a lot of those things can, you know, Wellbutrin does that. Try to- Yeah. Yeah ... sometimes. But I, guess what's, your experience been in residency with both, you know, identifying it, exogenous steroid use and also, like, counseling patients on it?

I, literally had this week at one of my clinics. Someone mentioned that they were prescribed it, and I think my first ap- approach with that is setting an environment and a stage where folks feel comfortable disclosing these things to you, right? we ask patients all the time about, you know, kind of some personal stuff, right?

Like, you know, what [00:54:00] are your drinking habits like? What substances are you using? and kind of normalizing or feeling more comfortable. You know, there's, a set of questions I, tell myself that, like, I need to get better at asking folks, and, like, eating disorder stuff is one, and, s- like, steroid use or any performance-enhancing substances, even if it's stuff you can buy over the counter, like, really implementing more of that in my interview.

so the f- the first thing is just, like, normalizing it, right? 'Cause we can't, you know, we can't help treat or- And, by normalizing it, you mean just by bringing it up in conversation? Yes. Specifically, from a medical standpoint, having those open and hon- honest conversations, right?

Kind of that, some of that trust-building between, you know, the physician-patient relationship. because you're right. It surely, it can impact medications that us as psychiatrists prescribe, right? [00:55:00] the last thing that we would want to do is to, Y- you know, you talked about, like, y- you know, stimulants a- and how maybe that could exacerbate some symptoms.

A- and I love that you brought that up, 'cause I kind of thought of maybe a different aspect. Like, that wasn't even on my radar, but if someone were to tell me that, and th- this was the case, this week is- I thought to myself like, "Okay, well maybe we need to maximize or increase your SSRI, right?

Maybe there's some untreated things going on. and how can I as your physician better treat those such that you're not reaching for these other things that may not be as safe?" And I'm not saying like, you know... I'm not saying, "Hey, none of our medications have side effects," right? But surely they are...

There's so much more research behind these, right? Versus, you know, jumping on TRT. [00:56:00] so- Yeah ... so having that conversation and then like how can I kind of help augment their current regiment so that they're not needing to use these other things? Right. Because people don't seek out hormone replacement therapy, ci- cisgendered, recreational exercising men don't, seek out hormone replacement therapy just for fun.

There, there is usually a problem that they are trying to solve in one way or another. and you're saying, "Let me try to, help solve that problem so they're not looking at other ways, looking at other places." And I think that's sometimes a, box we put ourselves in where if someone's already using a substance, the last thing we wanna do is, give them anything that, could exacerbate it.

I know we had didactics last week and we were talking about, stimulant use disorders and in a lot of these patients that use methamphetamine, many psychiatrists are like, "The last thing I'd ever give you is a stimulant," but there's these studies coming out about trying to use methylphenidate [00:57:00] as, as almost like a replacement, in patients that have untreated ADHD that's comorbid with their, stimulant use disorder.

So it- it's unintuitive to, to give, methylphenidate to someone who's taking methamphetamine, but that actually may reduce their use of it. and I feel like this, the same kind of logic may apply with, someone who's, you know, trying these different extracurriculars and hormone therapies. Yeah, and, and, I'm curious too, like, you know, what other things can we do Maybe even outside of medications, and we talked about them earlier, like maybe really maximizing your sleep, your diet, your social interactions, right?

One thing that we didn't talk about, and obviously this is pivotal to, our practice, is like more folks probably need to be in therapy, right? And help unpack whatever they're going through, right? so like what other tools or [00:58:00] levers can we use to kinda make sure the patient is, the trajectory of the patient is, you know, more in line with their goals, so we're not having to do those things.

The methylphenidate thing is also fascinating, right? kind of this anecdotal, maybe, anecdotal approach. I'm interested to see where that goes and, maybe, you know, y- you know, this is kind of the pie in the sky, but, you know, maybe y- you know, folks, we, implement this into the healthcare system, you know, some more, preventative stuff.

so, so folks don't, you know, aren't hopping on random gear and, you know, peptide stuff they see on social media. Yeah. I, think the therapy point is, probably the most important one, which targets the, underlying issue in what I mentioned earlier, you know, 70, 80% of these men is, muscle dysphoria.

it's a body dysmorphic disorder that is not being addressed by any of these other treatments or coping mechanisms. Just like how someone [00:59:00] with body dysmorphia may seek plastic surgery, plas- plastic surgery will never solve a true body dysmorphia disorder. Just like how getting bigger won't... or, you know, getting-- acquire more muscle mass won't address the underlying cause.

So I, I would say that, you know, the takeaways that I'm getting from this conversation is that you need to screen for it because it's a lot more common than you think. 10% of men between, you know, 18 and 35, and it- it's not in our templates. In all the, pre-written intake forms that I have, it's, you know, smoking, drinking, different illicit drug use, but there's nothing specific about, you know, do you use hormone replacement therapy, anabolic steroids?

Like, how much do you work out? Like, that's, not really in our, screening vernacular, and a lot of psychiatrists aren't thinking about it. And then the, next one being, okay, what, h- what do we do to get more men in therapy? Because that's the... That's a lot easier said than done, but that- that's [01:00:00] how you target the, kind of driving pathology in a lot of this.

100%, and, this could be an, a-whole-nother podcast that I'd love to explore in more, in a little bit more detail. But, you know, men who are listening to this, you know... I- I'll just use myself as an example. You know, 10 years ago, if you were to say, hey, Robert, you know, you should consider therapy for XYZ," I would be like, "Bro, I don't need...

I'm just gonna go s- slam, do some more cardio. I'm just gonna go to the gym. Like, that, the gym is my therapy." And I can tell you right now, a lot of folks in my experience maybe have a preconceived notion of what therapy is. "Oh, I'm gonna go lay down on some couch and someone's gonna analyze me?" It's, not like that at all, right?

A lot of times it's more conversational, right? It's getting another perspective from things and, you know, without going, without getting too far off topic, right? You know, we say like, medications are great, therapy's great, but, like, medication and [01:01:00] therapy's synergistic. It's, like, really good. So that, gosh, that's a nugget that hopefully people take out of this is, like, therapy is super underrated, specifically when we're talking about, you know, bigorexia, these, you know, body dysmorphia issues and how that could be just low-hanging fruit to, to kind of address some of these problems.

Yeah. Yeah. There's... It's, a treadmill, you know. If, you think you're gonna solve your muscle dysmorphia by getting bigger, there's always gonna be someone's bigger, who's bigger. You're never gonna feel big enough and then, you know, before you know it, you end up in a, pretty dangerous place. this guy, I'm thinking of that comes to mind when we were talking about all these cardiovascular effects is, Jo Aesthetic.

Oh, so sad. His name is, like, Joe Linden. Yeah. Yeah, so, so this guy, he's a 30-year-old bodybuilder, Instagram famous, like very popular guy, and I think he had an aneurysm- Yep ... in his, I don't know if it was his brain or in his carotid artery, but related to [01:02:00] chronic hypertension and accelerated atherosclerosis from his steroid use and these fitness influencers that look really young or they're young to start off with and they look healthy, but they're, you know, kind of destroying their body to, to get that physique.

So it, you know, it's dangerous and I'm kinda sad because I feel like social media's response, especially on things like TikTok and Instagram, is just to hate on this community. You know, these, gym bros or people are exercising because they're trying to treat something, they're trying to better themselves.

They wanna feel better about who they are, and everyone's like, "Bro, you just need to just go to therapy. Like, what's your problem?" And that's... It's just, like, a pretty negative approach to it, and I think, you know, it'd be nice to have empathy for them and say like, "Hey, you know, we're, all chasing our own demons, and, this is, you know, a way that we can get better."

Surely, you know, that aspect of the gym community is [01:03:00] misunderstood, right? It is, you know, there's that gym bro persona, right? and there's kinda some automatic thinking associated with that for sure. I like to think of it as, you know, like, gosh, these people who may be, abusing these steroids, I'd like to think of it, not that I'm generalizing, but I'd like to think of it as just like any other substance use disorder.

Like, this person needs help, you know, and, how can we kinda help facilitate that in, in a way where the patient's on board, you know, we're not overreaching, and, all that stuff. Yeah, absolutely. Well, thanks Rob for being here. this is a fun pod. I appreciate learning everything you had to teach me and kinda just getting to discuss more about these, these hormones.

bef- before we kinda close up, is there anything you want us to plug on your side? So if someone wants to follow you on socials, or they wanna get to connect with you [01:04:00] more, where they... where can they find you? Yeah. Yeah, just wanna say awesome conversation. Really appreciate you having me on. So glad we did this.

This is, you know, kinda a couple years in the making. but yeah, if you guys, I, It's so funny, I, was having this conversation with my wife a couple days ago. I think, I'm thinking about making my Instagram public again. but I'm just @undercoverdoc. you know, I post all types of things, lifestyle stuff.

Preston inspired me to train for a half-marathon. So I'm gonna start posting some running content over there. So, @undercoverdoc. Okay. Well, thank you undercover doc. He's, over-covered today, getting us of the public eye, and we'll both be running plenty. to the audience, thanks, y'all for listening.

You stuck with us through se- three seasons, so here's a good start to season four. How's the show? Let us know, what you wanna hear, what you think. I know this was kind of our, probably our bro-iest episode ever because w- we are talking about steroids, and also Margaret isn't here. So [01:05:00] we've really leaned into the gym stuff today.

But Marg- Margaret, she does, Rob, if you're not familiar, my, my co-host, Margaret Duncan does- She's a Pilates teacher. She also takes creatine. She, has her own fitness space that she makes comments on, social media, but I don't think she's too familiar with, the folks running Trend Malone.

So this is, this will be very, informative. shout out again to, to all of our listeners that are leaving kind feedback and, awesome reviews. on Patreon, we are gonna be announcing the, winners of the shirt contest. I said, I made a post, I said, "Like this post if you want one of our free farm, merch shirts."

I'm gonna go do a, random name generator later today, and I'll, message you guys and ship those shirts out. thanks again for listening. I'm your host, Preston Roche. Margaret Duncan will be joining us soon later in season four. Our executive producers are me, Preston Roche, Margaret Duncan, Will Flanary, Kristin Flanary, Aron Korney, Rob [01:06:00] Goldman, and Shahnti Brooke.

Our editor and engineer is Jason Portizo. Our music is by Omer Ben-Zvi. To see more from our episodes, you can find them on YouTube at It's Presro or at howtobepatientpod.com. To learn more about our program disclaimer and ethics policies, submission verification, and licensing terms, and our HIPAA release terms, go to howtobepatientpod.com or reach out to us at howtobepatient@human-content.com with any questions or concerns.

How to Be Patient is a Human content production.

Thank you for watching. If you wanna see more of us or if you wanna see... This is Lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac, point to the other episodes. Lilac doesn't know what the internet [01:07:00] is, but I swear they're there. They pr- they probably exist for real.

But in the meantime, I'm just gonna pet Lilac, and then I'm gonna go dance in the background