Dr. Chris Palmer is the Director of the Department of Postgraduate and Continuing Education at McLean Hospital and an Assistant Professor of Psychiatry at Harvard Medical School, where, in addition to McLean Hospital and Massachusetts General Hospital, he completed his residency. Dr. Palmer’s work has focused on comprehensive treatment for people suffering from treatment-resistant mental illnesses, and he has been a pioneer in investigating and communicating the important link between metabolic and mental health. In his practice, Dr. Palmer has used the ketogenic diet as an effective treatment method for mental illness, while also facilitating promising research into its clinical potential for psychiatry as a whole.
Levels team member Ben Grynol spoke to Dr. Palmer for an episode of our podcast, A Whole New Level. Below is an edited version of that conversation.
Food as Medicine
Ben Grynol: You’ve got a new book coming out called Brain Energy, where you discuss the inextricable link between mental health and metabolic health. You concretize it down to this simple statement: “Mental disorders are metabolic disorders of the brain.” It’s something that you’ve been researching for many years prior to this one event, which involved a gentleman named Tom. Why don’t we kick it off there?
Dr. Chris Palmer: Tom’s story began in 2016. He had been my patient for about eight years. He was a 33-year-old man with schizoaffective disorder, which is a cross between schizophrenia and bipolar disorder. He had hallucinations and delusions every day of his life. He was really paranoid, and could barely leave home: it was horrible and uncomfortable for him because he was convinced everybody was out to get him; they were all part of this big conspiracy theory. He had trouble with hygiene. He was a classic person with schizophrenia, basically.
He had tried 17 different medications, but they failed to work. And they caused him to gain a lot of weight. Weighing 340 pounds, he asked for my help. We decided to try the ketogenic diet. Within two weeks, not only did he begin to lose weight, but I began to notice a dramatic antidepressant effect. He was making better eye contact, talking more, smiling more. I thought, “Well that’s really fascinating.” But he was still hallucinating and delusional.
The shocking thing to me was that at about six to eight weeks, he spontaneously reported that his long-standing hallucinations were going away, and that his paranoid delusions were, too. He began to realize that they weren’t true and probably never had been.
Tom went on to lose 160 pounds and has kept it off to this day. But he was able to do things that he had never been able to do since the time of his diagnosis. He was able to complete a certificate program, go out in public and not be terrified or paranoid, and he was able to perform improv in front of a live audience. He got better enough that he was able to move out of his father’s home for a period of time. That really upended everything I knew as a psychiatrist and started me on a journey.
Ben Grynol: As a medical professional, did you feel an internal dilemma of, “Do I say something? Or is it too wild of an idea?” It really is a novel idea to think about how diet, lifestyle choices, and metabolic health can mitigate serious mental illness.
Dr. Chris Palmer: I’d been using low-carb and keto diets for a long time, but mostly with patients with depression. I didn’t even know that the ketogenic diet was a treatment for epilepsy. I knew it as a weight-loss diet. I had first come across it as the Atkins diet. I also knew that it was really powerful for diabetes. I had used it with my parents, both of whom had Type 2 diabetes, and I had seen dramatic and remarkable improvement in their symptoms. With my father in particular, it was nothing short of miraculous for him.
But Tom had schizophrenia. And I thought, “Wait, this is impossible.” My first reaction was disbelief. I was completely in disbelief. The good news is that his father was involved, and there was actually another mental health professional, a psychologist, who had been seeing him. I actually had to go to both of them and say, “Are you guys seeing what I’m seeing? Because I can’t believe what I’m seeing. His schizophrenia symptoms are evaporating, and I’ve never seen anything like this. Even with the medication, I’ve never seen anything like this. I didn’t change his meds. He’s on the same meds. This is crazy. What’s happening?”
Sure enough, they confirmed it, and that’s when I started doing a deep dive. That’s when I learned that the ketogenic diet is an epilepsy treatment. Who knew? Why had I never been told that? As a psychiatrist, that, for me, was really important, because we use epilepsy treatments in psychiatry every day, in tens of millions of people. We use medications like Depakote, Tegretol, Lamictal, Topamax, Neurotin (or Gabapentin), Valium, Klonopin, Xanax. All of those are anti-seizure medicines. But most people who’ve heard of them actually have heard of them because of their use in mental health.
It turns out the ketogenic diet can stop seizures, even when those pills don’t stop seizures. That became very intriguing to me. I thought, “Wait, if this diet can actually stop seizures when all of those medicines fail to, maybe it’s doing something like that to Tom’s brain, and that’s why Tom is getting so much better.”
The great news is that I was able to call upon decades of neuroscience research to start to understand what the ketogenic diet does to the brain. It changes neurotransmitter systems, decreases brain inflammation, changes calcium signaling in the brain, changes gene expression, changes the gut microbiome. It does all sorts of things that we in psychiatry know are highly relevant in people with serious mental illness.
As soon as I started doing more research on the use of the ketogenic diet for epilepsy and neurological disorders, all of the puzzle pieces began to fit together.
Ben Grynol: There are certain things that objectively are going to lead to metabolic dysfunction and mitochondrial dysfunction. In the book, you explain how that ties into mental disorders. The conclusion is not to go eat keto and everything changes; it’s an input to get this other output.
You talked from this stance of vulnerability, where you shared how, when you started your career, you felt like a fraud, because you got the question, “What causes mental illness?” You start talking about all of these things. But in the field, instead of just saying, “We don’t really know,” people claimed they knew what the underlying factors were.
Your interactions with Tom seemed to be the first foray into thinking about how important diet, lifestyle, and metabolic health are to positive mental health. It was one of those moments where the link became very clear.
How many people globally are impacted by poor mental health, and what does this mean economically?
Dr. Chris Palmer: Mental illness is a growing crisis, in the same way that obesity and diabetes are growing crises. Mental illnesses are the leading cause of disability in the United States and on the planet. The disorder that tops the list of disabling diagnoses of all medical diagnoses is depression. It’s not because those people aren’t getting treatment. Those people are getting treatment: they are trying antidepressant after antidepressant. They are in psychotherapy for years or decades. They are trying shock therapy. They are trying transcranial magnetic stimulation. They’re getting ketamine injections. They are trying psychedelics. They are thinking happy, positive thoughts. They’re doing everything in their power to not be disabled and to not be miserable. And yet depression is the leading cause of disability on the planet.
I think everybody knows schizophrenia is much, much worse than depression. Bipolar disorder also is. Substance use disorders can be. Obsessive compulsive disorder can be. The global statistics are really hard to measure right now because of the pandemic. The pandemic poured gasoline on an already burning inferno.
Prior to the pandemic, in about 2017, the World Health Organization estimated there were about one billion people on the planet currently suffering from a mental or substance use disorder, and that’s about 13% of the population or so. In the United States, the rates are higher, and they’ve been higher for many, many decades. In the United States, the rate is about one in five people: 20% of the population in any given year will be affected by a mental or substance use disorder. If you look at lifetime prevalence rates, they’re actually much higher. About 50% of all people in the United States will meet criteria for a mental disorder at some point or another in their life.
But the pandemic has actually made everything worse. The CDC was actively and aggressively tracking rates of mental disorders during the pandemic. During the peak, in 2020, they were doing representative household surveys of 1,000 or 2,000 people, just trying to get a sense for what was happening in the population. At one point, about 40% of a representative sample of all Americans reported that they were currently suffering from symptoms of depression, anxiety, PTSD, or a substance use disorder. I think the more alarming statistic was that they asked participants, “In the last 30 days, have you seriously considered killing yourself?” 11% of respondents said yes.
The youngest age group was 18 to 24. Among that group, that statistic was 25%: one in four young adults said they had seriously considered killing themselves in the last 30 days. The rates have come down a little bit from that peak, but they are not back to the baseline rates. What we know is that mental disorders are an escalating and persistent crisis. They are crises right now.
In terms of dollars, it’s hard to estimate — again, due to the pandemic. The Biden administration just pledged billions more dollars toward mental health, so I’m sure that will change the statistics. In a couple of years, we’ll look back and have better data. But prior to the pandemic, the estimates were that, by 2030, mental disorders would cost the global economy about $6 trillion a year. Those costs include direct care services, disability, productivity loss, losses at work, and other societal costs.
Ben Grynol: It’s alarming, especially the statistics on children and young adults. Children are developing, and that’s where it starts to become clear that there are many inputs contributing to declining mental health. It’s not just things like technology. It’s not just environmental.
You start to think, “What is happening at a societal level? What are we doing that is causing these increased rates of mental illness?” The only other thing that’s also increasing at an alarmingly rapid rate is the metabolic health crisis.
Connections and Complexities
Ben Grynol: Let’s get into how mental health is an output of many different inputs. In 1977, Dr. George Engel developed the biopsychosocial model. What exactly is the model?
Dr. Chris Palmer: Right now, if you ask the best neuroscientists and psychiatrists what actually causes mental illness — schizophrenia, major depression, anxiety disorders, alcoholism — the real answer is that no one knows. All we know are risk factors. The risk factors get lumped into what we call this biopsychosocial model, which says that there are biological, psychological, and social factors that come together and result in different mental disorders in different people.
There is an endless combination of factors. We know that genetics, neurotransmitters, and hormones play a role. Those are some of the biological factors. Psychological factors include poor parenting, or getting bullied and developing a low self-esteem. Bullying and teasing might be more social factors. Other social factors can be poverty, homelessness, abuse, neglect—those types of issues.
It turns out that biopsychosocial risk factors confer risk for all mental disorders, pretty much across the board. The only exceptions would be the neurodevelopmental disorders that begin in infancy or at a very young age. With those disorders, everybody knows that the person was born that way; that’s not due to bullying and teasing. They’d never even had an opportunity to be bullied and teased.
But when you see trauma and neglect in childhood, most people think that leads to PTSD. But guess what else? Depression — that makes sense. Anxiety — that makes sense. Alcoholism — I can see that. It can also trigger bipolar disorder and schizophrenia. Trauma and neglect confer risk for psychotic disorders, which include bipolar disorder and schizophrenia.
Even when we get really granular with a specific set of genes, it turns out there’s not one gene that confers risk for any one disorder. There’s not a schizophrenia gene or a depression gene or a bipolar gene. Even though everybody thinks there are, we actually know with certainty those don’t exist.
We’ve had the human genome mapped for over 20 years. Artificial intelligence has been on the job. Artificial intelligence and the best scientists tell us there aren’t schizophrenia genes. There are genes that increase risk for mental disorders, but they increase risk for schizophrenia and bipolar and depression and epilepsy and obesity and mental retardation. They increase risk for lots of things, not just schizophrenia.
When we look at any of the risk factors, they confer risk for a wide variety of disorders, if not all of the disorders. That’s where we’re at in the field. It’s this big, complicated mess, a complicated puzzle nobody can figure out.
Ben Grynol: Why do you think lifestyle factors like diet, sleep, exercise, and overall metabolic health have been overlooked for so long? Why has there been so much focus on the biopsychosocial model, and on always trying to find that correlation?
Dr. Chris Palmer: We’ve been looking at the complexity of the brain to try to understand what causes these disorders. Researchers, for very good and obvious reasons, have assumed that schizophrenia must be a disorder of the brain, that depression has to be a disorder of the brain. With bipolar disorder and even alcoholism, that’s the only organ researchers are studying. They’re not studying the pancreas. They’re not looking at fat cells. The gut microbiome is the hot topic lately, and they’ve started looking at the gut, but that’s in its infancy, in terms of the gut-brain connection. For the most part, researchers have focused on the brain and the complexity of the brain to try to understand mental illness. Again, it made sense. It was logical. It was the obvious place to look.
But the shocking thing to most people is that mental disorders are all over the map. If we look at a group of people with major depression, and we scan their brains, there are no consistent findings. If we look at a group of people with schizophrenia and we scan their brains, there are no consistent findings. The findings are all over the place. What we call this is heterogeneity: they’re heterogeneous findings. Some people can have abnormalities in metabolism in some regions, but this person with the exact same diagnosis might have abnormalities in metabolism in a different brain region compared to healthy controls. That’s part of it.
Then we’ve had these signals for decades — literally 80 years — and we’ve had the clinical evidence for 200 years, at least, that there are these connections between what we call metabolic problems and mental disorders. We’ve known since the 1800s that diabetes and mental illness have strong connections and are bidirectional, meaning people with diabetes are more likely to develop mental illnesses, serious ones: bipolar and schizophrenia and depression. But people with those disorders are more likely to develop diabetes. That’s been known since the 1800s. That research continues to show that those connections persist. That’s fairly well-documented and established as fact.
At the beginning of the 1940s, we had all this metabolic research. Researchers studying schizophrenia actually took blood from people’s veins and found that they had abnormalities in lactate metabolism. Lactate is a marker of metabolic stress. If you really exercise and push yourself, you’re going to have higher levels of lactate.
Schizophrenics who are just resting can have higher levels of lactate. That was discovered in the 1940s. In fact, in the 1980s, researchers were injecting lactate into people who have panic disorder. Lo and behold, when they did that, it would induce a panic attack in most of the patients. It wasn’t just the needle injection, because when they injected saline, nothing happened. Injecting lactate into a vein of somebody with panic disorder can precipitate a panic attack.
What does lactate have to do with a mental disorder? Mental disorders are chemical imbalances in your brain. Neurotransmitters don’t have anything to do with lactate. Again, in many ways, my theory is nothing new. My theory builds on decades of research, but metabolism is really complicated. We’re still trying to figure it out. The brain is even more complicated, some would say. And there’s so much we still don’t know about the brain.
You put those two fields together, and it’s just a mess. It’s overwhelming. There’s no way anybody can figure this out. Lots of researchers are just waiting on better computers, because better computers will have the computing power to figure this puzzle out. And that’s where the field has been. I am really hoping that my book will change all of that and bring a big-picture clarity to these issues.
Ben Grynol: You highlighted the one statistic about how the brain is roughly 2% of our body mass, but takes up about 20% of our energy use in a resting state. I’m thinking, “How much fuel does the brain need?”
We’ll get into mitochondria, the energy factories of the body. If they’re not working well, what do you think is happening in the brain? There are some really interesting things you brought up around the bidirectional relationships between diabetes and certain conditions like depression and schizophrenia. One doesn’t cause the other, but which came first? We don’t know.
Dr. Chris Palmer: The really important take-home point about a bidirectional relationship is that when we see correlations between two variables, A and B, most people assume it’s cause and effect. People get overly simplistic. For instance, children who have a lot of screen time are more likely to have ADHD. People think, “Does screen time cause ADHD, or does ADHD cause kids to sit around and look at screens all day?” That’s an example of correlations, and people are thinking cause and effect. That’s usually where people stop.
If I look at a group of people with depression, they’re more likely to have a substance use disorder like alcoholism. But if I look at a group of alcoholics, they’re more likely to have depression.
People get into ridiculous debates. They assert that depression must cause alcoholism. That’s the prominent self-medication hypothesis out there: people become alcoholic because they’re self-medicating. They were probably depressed their whole life, and alcohol is the only thing that made them feel better and that’s why they drank. Other people go in the other direction: “No, it’s the alcohol. Alcohol’s making them depressed. Alcoholism comes first, and then depression. That’s the way it goes.”
But there’s another possibility we need to consider, that there is something downstream or upstream that actually increases the risk of a person developing both. It’s important to think that through, because that can help us see the bigger picture about cause and effect. It turns out that all mental disorders have strong bidirectional relationships with all of the other mental disorders, but it doesn’t stop there. They also have strong bidirectional relationships with all the metabolic disorders—obesity, diabetes, cardiovascular disease—plus neurological disorders like epilepsy and Alzheimer’s disease.
It sounds crazy and overwhelming, and that’s why I really take my time in the book to step people through, one by one, in what I hope is a measured way, to help them really get it. A variety of studies, epidemiological studies and others, and even some basic science studies all support the same conclusions. When we see these strong bidirectional relationships, it suggests that there is some common factor or pathway upstream from all of these different disorders that might be playing a role in their etiology.
Ben Grynol: Some of the metrics are shocking to read. People with schizophrenia are three times more likely to develop diabetes. People with diabetes are two to three times more likely to develop depression. People with depression are 60% more likely to develop diabetes.
Mitochondria: Beyond the Powerhouses of the Cell
Ben Grynol: How did we get to the point where we have poor metabolic health? You talk a lot about mitochondrial dysfunction. What exactly are mitochondria, and why is it so important to have great mitochondrial function in the body?
Dr. Chris Palmer: That was the epiphany, and it was quite mind blowing. Most people who’ve heard of mitochondria know them as the powerhouses of the cell. That’s what most people learn in school biology, whether it’s middle school, high school, or even college. That means they take food and oxygen and turn it into ATP, which is the energy currency of the cell. There is no doubt that mitochondria are the powerhouses of the cell. They make the majority of energy in the human body, a critically important task. If you poison mitochondria, people can die very quickly.
But one of the things that allowed me to develop this theory is that over the last 20 years, groundbreaking research has taken place on exactly what mitochondria are, and they are so much more than powerhouses of the cell. Yes, they are powerhouses; we would be dead without them. But they actually do much more than that.
One mitochondrial researcher used the analogy of a human cell as a computer. Most people think of mitochondria as the power cord to that computer, because they’re providing the energy. That’s true. But in fact, mitochondria are actually more like the motherboard of that computer. They are distributing and allocating resources throughout the cell and throughout the human body. They play a powerful role in numerous functions.
When I began to do this deep dive into the science of mitochondria, knowing what I know as a psychiatrist and as a neuroscientist, that’s when my mind blew up. I thought, “Oh, my God. This is connecting all of the dots of the mental health field.” Mitochondria play powerful and direct roles in neurotransmitter production and regulation. They play a direct role in the production and regulation of critical hormones like cortisol, estrogen, testosterone, and progesterone. They turn inflammation on and off in the human body. Mitochondria are the single most powerful factor that controls epigenetics. Some researchers suggest that they probably control at least 60% of the human genome. They play a powerful role in metabolism and they actually sense glucose. They control whether or not insulin gets released from the pancreatic beta cells. Mitochondria and their reactive oxygen species are the determining factor of the release of insulin.
A lot of people in the metabolic health community love to focus on sugar and insulin. Mitochondria play powerful and very direct roles in all of these things, and once we understand that, we not only understand mental health but all mental disorders. It helps us answer the question of why there are these strong relationships between mental disorders and Type 2 diabetes. Why are there strong relationships between mental disorders and cardiovascular disease, and premature aging, and premature mortality? As soon as you understand the metabolic and mitochondrial connections, everything makes sense.
Ben Grynol: Why are mitophagy and autophagy also important to have well-functioning mitochondria in the body?
Dr. Chris Palmer: There are a few processes. The two big ones that some people have heard of are autophagy and apoptosis. Autophagy is not necessarily the death of an entire cell. Instead, it is taking old, damaged cell parts, proteins, misfolded proteins, old proteins, and other waste molecules, and recycling them, and managing those recycled products. Some of those products get reused for energy or as building blocks to create new proteins. But some of them need to be managed appropriately. The easiest way to think of autophagy is a hoarder’s house. Autophagy is cleaning up that house, getting rid of stuff. And it’s not indiscriminate cleaning. It’s not just burning the whole house down and starting fresh. It’s not throwing away all of the useful furniture in that hoarder’s house. We’re going to keep what the person actually needs and requires, but we’re going to get rid of all the junk. Things will actually be healthier and more efficient if we do that.
Apoptosis is a different process, where cells become old, dysfunctional, and pass a point of no return. They need to be killed. Mitochondria play a direct role in both processes, autophagy and apoptosis. They are the central regulators of apoptosis. For a long time, researchers thought it was the human genome, but in fact that signal comes from mitochondria.
Autophagy is a process that gets stimulated, especially during fasting states, or if somebody’s on a ketogenic diet, which mimics the fasting state. There’s always baseline autophagy going on, because otherwise we would just accumulate waste products and pass away. But you can really put autophagy into hyperdrive through fasting and fasting-mimicking diets. Mitochondria play a direct role in creating the signals that start that process.
Medication, Metabolic Health, and a Holistic Approach to Mental Health
Ben Grynol: There is a time and a place, which you state, for prescribing medication. There are things like seizures, which medication can help. That is true. If a person seizes for too long, they’ll pass away. But the challenge is that medication can lead to, in some cases, mitochondrial impairment. I imagine that, as a medical professional, you must always think about the costs and the benefits of prescribing medication, especially regarding metabolic health.
Dr. Chris Palmer: Stimulants have been used for decades for weight loss, and they actually speed up metabolism. They increase mitochondrial function. They increase the production of energy and heat, and that helps people burn calories. There aren’t any universal themes for psychiatric medications, but there are classes of psychiatric medications—in particular the antipsychotics and some of the mood stabilizers, but also some of the antidepressants and other types of meds—that we know with certainty impair metabolism and mitochondrial function. For the most part, these were just thought to be side effects, the price we pay. Because psychiatric disorders are sometimes dangerous and life-threatening, these are the pills that seem to work.
I don’t know any clinicians who feel good about the fact that we’re causing metabolic harm. I don’t think anybody does. I have met a couple of what I would call clueless clinicians, who think, “Well, if they just ate less and exercised more, they wouldn’t be gaining so much weight.” And I think, “That is really heartless and cruel and naive and stupid of you to say.” Anybody who takes these pills gains weight, essentially. It is an extraordinarily rare human being who can take some of those pills and not gain weight. It’s unfair to put all the blame on the patient. But we’ve known this since the 1800s.
Again, it has just been assumed these are side effects, that metabolism has nothing to do with mental illness: “Well, it has nothing to do with the actual effect of the medication on the brain because the brain isn’t where diabetes is. Diabetes is in the pancreas.”
Anybody who actually knows metabolism actually knows that no, it’s not all located in the pancreas. The brain is playing a role in sensing and controlling glucose levels, in the secretion of insulin from the pancreas. Believe it or not, the human body is really interconnected, and that includes the brain. The brain is integral to that interconnection.
The really profound revelations of the brain-energy theory are that these metabolic connections are, in fact, not at all side effects. They represent the direct impact of these medications on the brain and the body. It is directly related to their ability to suppress symptoms.
The challenge is that, although some of these medications can suppress symptoms in the short run, they may very well be making matters worse in the long run. I know how controversial that will be.
And also, if anyone is taking a psychiatric medication, please do not stop your medication on your own. Do not try to taper yourself off of your medication on your own. I have seen patients manic, psychotic, suicidal, severely depressed, hospitalized, arrested, and even dead because they took it upon themselves to stop their medications. Once you’ve been on these medications, you are now in a difficult position and cannot just easily get off them. Please do not stop them on your own. Please, don’t try to taper them on your own. Please work with a competent healthcare provider who knows what they’re doing and can help you safely get off them if you decide that might be something you want.
You also have to have a treatment plan in place, because simply getting off medications may not be an effective treatment plan. If somebody gained a hundred pounds from the medication, simply getting them off the meds doesn’t automatically make them lose that weight. They have to put other treatments or strategies in place. Although I can help people lose tremendous amounts of weight, I’m interested in brain function and brain symptoms that impair and disable people. It needs to be done safely, and it needs to be done responsibly.
The terrifying thing is that we may in fact be prescribing medications that are keeping people chronically ill. As a psychiatrist who has prescribed these medicines for 27 years, it’s heartbreaking. It’s heartbreaking to do a deep dive into the science and come to that conclusion. I always knew that the medications were causing metabolic harm, but again, for a long time I just bought the paradigm hook, line, and sinker that these are just side effects. They’re just the price we pay to treat serious disorders. These are serious life-threatening disorders. I thought I was saving people’s lives by prescribing these medicines.
It is heartbreaking to think that maybe I was keeping people ill as a result of those treatment strategies. I really do feel like the brain-energy theory delivers clear, testable hypotheses, largely supported by the existing evidence. This is not a speculative theory. This is a theory that takes all of the existing research and puts it together in the only logical way possible.
Do we need more research to fully test this theory? Yeah, we do. Do we need more research to fully test what treatment strategies will help people fully recover and remain recovered for life? Yeah, we do. But the path to those clinical trials, those research studies, is obvious now. The path to helping people heal and recover from depression and anxiety—OCD, schizophrenia, and bipolar disorder—becomes clear now. I genuinely believe we can put those illnesses into remission and help people recover.
Ben Grynol: You brought up how this marriage of signs and symptoms makes it difficult to diagnose mental disorders. A syndrome is made up of signs and symptoms. Signs are objective measures. At Levels, that’s very much what we’re focused on: when you see data, you can start to make meaningful change. The challenge is that in any healthcare field, especially in the psychiatric field, you diagnose based on symptoms, which are subjective.
We end up having to treat these symptoms, but we don’t necessarily have clear signs all the time. The more that healthcare can start to see patterns proactively, to look at the signs, the better we can treat things. But without that, it becomes very challenging.
Dr. Chris Palmer: The metabolic theory of mental illness, based on existing studies, gives us so many opportunities to intervene and prevent chronic mental disorders. One longitudinal study followed thousands of kids from the ages of one to 24. The kids with the highest levels of insulin resistance, beginning age nine, were five times more likely—that’s 500% more likely—to be at risk for a psychotic disorder by the time they turned 24. They were three times more likely to already be diagnosed with bipolar disorder or schizophrenia. Insulin resistance beginning at age nine confers a highly elevated risk for the development of a chronic psychotic disorder.
Insulin resistance is something we can measure. Levels measures insulin resistance. You’ve got your continuous glucose monitors on. You’re tracking insulin levels. You’re tracking all sorts of stuff. You know what it is. We could slap one of these on a kid sometime and see what level of insulin resistance this child has. And we could intervene. We can do things with diet, exercise, and other lifestyle strategies to address insulin resistance.
Insulin resistance is a biomarker of extraordinarily complicated metabolic and mitochondrial things happening in the human body. Some people think that if you eat too much sugar, you have insulin resistance. It’s not such a simple construct. Yes, if somebody gorges on sugar all the time, they probably will develop some insulin resistance, but that’s not the only cause. Trauma can cause insulin resistance. If your mother was starving or grossly underweight while she was pregnant with you, you are at risk for insulin resistance. You didn’t do anything wrong. It has nothing to do with your diet; it has to do with your fetal programming by your mother, based on her environmental circumstances.
The only way the brain-energy theory works is that we have to think more completely and in a more complex way about what metabolism is and what it means to have a metabolic problem. Only then can we start to understand mental disorders. This theory is extraordinarily useful to people who want to lose weight. It is going to be extraordinarily powerful to people who want to prevent a heart attack, or to people who want to better control their diabetes.
I am a low-carb enthusiast, a keto enthusiast. Some might even call me a keto quack. But I know that low-carb and keto are not the cure-all for everything in the human species. They just are not. We need to be more sophisticated than that. We need to be clear that trauma, neglect, and epigenetic and genetic factors are playing a role. Hormonal factors are playing a role. Inflammation from things that you cannot control is playing a role. You might have gotten an infection. You might have chronic Lyme disease. You might have long COVID, which the latest research suggests is a chronic infection for some people. Their bodies are not clearing the virus.
That is not diet. That doesn’t have anything to do with carbohydrates. But it will cause insulin resistance, and it will cause mental problems, potentially. It will cause metabolic health problems. When we think more comprehensively in those ways, we can fully address human health in more effective ways.
Ben Grynol: There’s a section of the book where you bring up ACE (Adverse Childhood Experiences) scores. Kids with high ACE scores also have a higher probability of being obese or having diabetes.
There’s one story you share in the book, about a boy named Caleb, that was relatable for many reasons. Could you retell that story for us?
Dr. Chris Palmer: Caleb was a young boy growing up in an upper middle-class family. He had a reasonably good life, but he also had a strong family history of all sorts of mental disorders: bipolar disorder, depression, substance use disorders, psychotic disorders, suicide attempts.
At a young age, he was diagnosed with ADHD. His parents initially wanted to try to avoid medication, so he got psychotherapy. The parents were working with the school. They tried all sorts of strategies to try to help him, but none of those worked.
At some point, they decided to try stimulant medication, which is the standard treatment for ADHD. For a few days, it actually worked great; Caleb was able to focus better and everybody noticed an improvement.
But within a week or two, he couldn’t sleep. They tried different stimulant preparations: long-acting, short-acting, lower and higher doses, different times of the day. Nothing was working.
Then the psychiatrist said, “Let’s put you on a sleep medicine on top of your stimulant, to make sure that you sleep.” That’s when the parents said they’d already been tinkering with this stimulant, and that nothing was working. In some ways, he was able to focus, but in other ways things were getting worse because of the insomnia. He was getting more irritable and having some tantrums and other problems. His parents told the psychiatrist, “No, we’re not interested in adding more pills. We will stop the offending pill and figure out what to do.”
Caleb did not get better by just stopping that stimulant; his symptoms persisted and evolved. He started developing mood symptoms. He grew depressed. He threw tantrums in school. He got disciplined frequently and started threatening suicide. He threatened to kill people at school. I don’t think anybody took it seriously, but you can’t say you’re going to kill somebody at school. That doesn’t go over well with anyone. He would jab himself with a pencil sometimes, not necessarily breaking his skin, but people were alarmed and appropriately concerned.
At some point, the psychiatrist working with them and the school began insisting that Caleb take a mood stabilizer. They didn’t even suggest an antidepressant; they went right to a mood stabilizer, because of Caleb’s family history. The parents said, “No way,” and instead wanted to try a metabolic treatment strategy.
We ended up trying two things. One, Caleb was eating a ton of sugar. School sucked for him. When he came home, he was almost in tears. His parents felt terrible about this. They said, “It’s heartbreaking to see our son struggle and suffer so much.”
He would want a treat at the end of the school day. The parents said, “Okay, go ahead. Have ice cream, cookies, whatever. We’ll stock the kitchen with treats for you.” Then he would have dinner, and would want dessert after dinner: another ice cream or another cookie or candy bar. Caleb’s parents went along with it because it just seemed like the nice thing to do. Caleb was so much.
We looked at that pattern. I talked with them about insulin resistance and how it might be playing a role in bipolar disorder and depression in some kids, and that there’s really low hanging fruit. I didn’t go right for the ketogenic diet. Could we get rid of the sugar at least during the school week? I didn’t want to be heartless. I didn’t want to say all the time. On weekends, he can still have dessert. But could we get rid of the sugar during the school week? Let’s just try that and see.
Caleb was not thrilled about it, but he recognized that he was not doing well. He knew he was suffering. He knew he was struggling in school. He also knew all these people were trying to make him go on more pills. He was very reluctant to go on pills because he remembered the stimulants and how they made him not sleep, and he didn’t want to be in that situation again. He was very invested: “If there’s a way to control this without pills, I’m open to that,” he thought.
That was the hard sell. The easy sell was that I also introduced a light box, for light therapy. I’m just operating under the assumption that he has bipolar disorder. Clearly he has depression. Clearly he has ADHD. That is the perfect setup for what we call bipolar disorder. He’s also got this strong family history of bipolar. I treated him as though he had bipolar disorder, but used metabolic approaches. We’ve got really good data that sleep regulation is critical for the control of mood disorders, and bipolar disorder in particular. Llight exposure first thing in the morning is a really powerful way to control circadian rhythms and sleep.
We ended up introducing a light box first thing in the morning. He was on video games anyway, and I had the parents put the light box right in front of the video games he was playing. Within two months, Caleb was clearly turning a corner: no more tantrums at school. He actually said, “I feel better.” He didn’t miss the sweets during the school week anymore. And he actually noticed, “I’m better. I feel it. I feel better.” He became his own advocate: “I need to do my light box. I can’t have sweets during the week.” He really began to own this treatment as part of his lifestyle and something that he needed to do to control his mood and ability to concentrate.
By the next year, Caleb got straight As. Then in 2020, he started high school, right in the middle of the pandemic. All the other kids were struggling. All the other kids were stressed and lonely. But Caleb was thriving, and ended up getting straight A+’s, actually. The school even took him off of his Individual Education Plan (IEP). He continues to thrive and follows essentially the same treatment plan to this day.
On Biology, Honesty, and a Sustainable Approach to Healing
Ben Grynol: We give highly processed food to kids because we think they should have treats. It doesn’t mean we should be so prescriptive that kids have a difficult relationship with food. They’re learning, too. We want them to understand what whole food is, what processed food is, so they can make these decisions.
But there’s one thing that’s for sure: if you give your kid only highly processed food, the outcome is going to be long-term metabolic dysfunction, which has a direct link to mental health. We’re not doing our children any favors by surrounding them with conditions they aren’t in control of.
Dr. Chris Palmer: We’re not. Most people, even clinicians, don’t understand or appreciate these connections with mental health. Most people think that processed food and sugar is all about weight. We’re a fat-shaming society. We’re getting beyond that, and we don’t want to be fat shaming people. People think, “Kids have a high metabolism anyway; they can eat that stuff and burn it off. I’ll just have them run around the house a little bit, or play baseball, and that’ll help them burn off those calories. It’s a win-win.” Parents think about how much their kids like them when they give them treats.
Our current food supply is a lot of non-food. It’s a lot of chemicals and highly-processed food things that are formulated to be addictive. Even though the American Psychiatric Association doesn’t recognize food addiction, the Director of the National Institute of Drug Abuse has done a lot of research studies that have found that some highly-processed foods are in fact addictive and use the exact same reward pathways as cocaine addiction and nicotine addiction.
But the food companies kind of admit it. You can’t eat just one. I mean, come on—what is that? It means they are making highly palatable foods, and when you give a highly palatable food to any human being, they are going to be more likely to eat it. If you give a highly palatable food to a human being who is stressed, there is a direct connection there.
The reason the parents wanted to give Caleb that food is because they knew it would decrease his stress response in the moment. And it did. When people are highly stressed, they have intense cravings for that food. If his parents had just decided to deprive him of it, without a clear rationale, without a clear plan, without clear objectives, Caleb would’ve experienced that as cruelty or deprivation. When any of us are stressed, we crave highly palatable and high-calorie foods. That is in our biology. It’s probably an evolutionary adaptive strategy for when humans were stressed in other ways. Stress can be starvation or war or famine or abuse. If you’re in any of those situations and you see some food around, you should probably take the opportunity to eat it, because you might not have another opportunity in the next few days.
When animals are highly stressed and food is right in front of them, they are going to eat it. As much as we shame people for that, we need to recognize and respect our biology. Our biology is driving us to do that. There’s nothing wrong with our biology, but there are things wrong with the foods we’re eating.
People can become trapped in a vicious cycle. Once they’re addicted to it, they start getting stressed because their blood sugars are on a roller coaster, and now they need to eat that food in response to the stress. But the cause of the stress is actually the food they’re eating. It’s just a mess. That’s how people go into metabolic and mental problems.
Ben Grynol: We’re creatures of the dopamine factory that exists inside of us. We keep hitting that button and just keep going, because it feels really good. Those reward pathways feel good in the moment. And we hyperbolically discount long-term outcomes with short-term gains.
As you’ve said, there is not a motivation problem; there’s a metabolic one. From a productivity standpoint, people want to get to work. People want to live average lives. People want to feel well. How do you think about long-term behavior change, knowing that we hit that dopamine button over and over again?
Dr. Chris Palmer: It’s a question I get asked a lot. Other researchers, clinicians, and patients will often say, “We get the science. I listened to your lecture. I saw you give a talk. The science is compelling. You make a really good case. But how the hell are you going to get somebody to go on a diet? We have an obesity epidemic. Nobody can stick to a diet. And you’re working with mentally ill people who are further impaired, and they’re also impaired in terms of motivation. They’re taking medications that increase their appetite. It’s a double whammy for them, because we’re giving them medications that are making them crave sweets even more than they probably had before.” Most people get hopeless or pessimistic about this. Humans like the dopamine reward, and they think we’re never going to get them to overcome it.
One of the reasons I have been successful at getting people to make healthy changes may in fact be because I do work with people who are suffering. Suffering is a powerful motivator. If somebody’s just a little bit overweight, it doesn’t physically hurt them. It may not even emotionally or psychologically hurt them. It might: there’s fat-shaming. Or maybe you really want to go out with that hot boy or girl, and they don’t look at you because you’re a little overweight.
Some will say that’s suffering. But that’s not the kind of suffering I deal with. I deal with people who are tortured by their symptoms, who are depressed, who have no self-esteem regardless of what they look like. I deal with people who are tormented by hallucinations, delusions, or addiction. Those people desperately want to make those symptoms stop.
When I talk with them about metabolic treatments, it’s more than diet. For some, it’s exercise. For some, it is diet. For some it’s, sleep regulation. For others, it’s getting off substances that are harming their metabolism. There are lots of different metabolic treatments. When I talk with them about a comprehensive metabolic treatment strategy, I give them accurate and actionable information, which includes all of the downsides.
Even when I’ve talked to other low-carb or keto clinicians, sometimes they sugarcoat keto adaptation a little too much. They say, “You can do it.” That’s not at all what I say to patients. That’s not even what I say to friends or family who just want to try keto for a diet. I say, “It’s going to be a living hell for two weeks. Get ready for it. Let’s prepare for a living hell. You’re going to feel weak and dizzy and lightheaded. And you’re going to have intense cravings. It’s going to feel unbearable. But I will help you get through it. We will come up with strategies. I have gotten schizophrenic patients to do it. You can do it, too.”
That’s my approach, almost across the board. Every person comes back to me and says, “It wasn’t nearly as bad as you made it out to be.” But setting that expectation makes all the difference in the world. If you tell them, “This is a really easy diet to do. You can do it. I feel great on keto,” and you fail to tell them about what keto adaptation was like for you, as soon as they experience discomfort or dizziness or weakness or intense cravings, they freak out and they think something horrible has gone wrong, and that they’re not getting this euphoria you spoke of. Instead, they’re having a serious, bad reaction. They think that all those vegans who were saying that keto is dangerous were right. They think, “Oh, my God, you’re killing me. You’re killing me with this keto diet.”
I set the stage for this. I say, “This is how you’re going to do it. This is what’s going to happen. These are the strategies you’re going to use to get through it.” Then if they fall off the wagon, I’m right there. I’m not frustrated. I’m not exasperated. I actually am expecting it. Nobody is perfect, and certainly not the patients I work with. They’re going to give it a shot and probably fall off the wagon at some point. They’re going to go out with friends, and those friends are going to push all sorts of food in front of them. They’re not going to have the willpower. They’re not going to have the strategies. They’re not going to have the assertiveness they need to be able to resist. They’re going to give in and eat it, and then they’re going to come back in and they’re not going to be in ketosis.
Then we’ll talk about what was going on. I say, “You’re not in ketosis and I thought you were onto this plan. Are you still wanting to do the plan?” I always give them the out: “You don’t have to do this if you don’t want to, but I really believe it might help you feel better and change your life. Are you still interested in that? I am. You’ve tried 30 pills already. You really think number 31 is going to be the magic pill? Because I don’t. I’m a psychiatrist, I prescribe these all the time. I don’t think 31 is going to be the magic pill for you. Instead, we need a whole new approach.”
That provides a flavor of how you overcome that dopamine addiction, those societal pressures—human nature. I usually paint a picture. I almost always tell people, especially if they’re doing a low-carb or keto diet, and they really like sweets, “You have to give me three months of really sticking to it. Only then will we assess two things: is this diet working for the symptoms we outlined, and is it sustainable for at least a couple years?” Usually we’re trying to treat mental symptoms like depression, anxiety, bipolar, schizophrenia.
I always let them know that I don’t want them to answer either of those questions prior to three months. Some patients, at the six week mark, will experience dramatic improvement in their mental symptoms, but they will still be having intense cravings for bread or ice cream or other sweets that they can’t have on the diet. They will still be thinking that life is going to be really miserable without those foods: “What’s the point in living if I can’t socialize with people, if I can’t celebrate holidays with people? I’m going to be like this social outcast who has to eat a weird diet, and I’m craving those foods.”
The shocking thing is that for the majority of people, if they can get through three months, that goes away. All of it goes away. They start to realize, “Wow, I feel so good. And now that I see people eating that ice cream, it reminds me of how shitty I used to feel. I don’t think I need them anymore. I don’t want to eat that.”
The more likely scenario is they go ahead and hit the four month mark. They try pizza and ice cream because they’re feeling so great. They figure, “Well, I’m good now. I don’t need this diet anymore.” They eat those foods and then they wake up the next morning feeling like crap. The patients I deal with might wake up hallucinating again, or they might wake up feeling severely depressed and suicidal again. That is one of the most powerful motivators for the people I work with, because they see a clear and direct effect of food on their mental health.
Hope, Support, and the Capacity for Change
Ben Grynol: Long-term behavior change takes commitment. One thing humans are very good at is giving up on things. We’re good at giving up on ourselves. We’re also really good at giving up on others. There’s no better example than the story about Mildred you highlight in the book. It’s one of the most eye-opening parts of the book I read.
Dr. Chris Palmer: This woman’s story is particularly powerful because most people think schizophrenia is a lifelong disorder. A lot of people, even neuroscientists, think that if you’ve had schizophrenia for decades, it’s too late.
This woman was diagnosed with schizophrenia when she was 17, and she had daily hallucinations and delusions. Over the ensuing decades, she tried numerous antipsychotic and mood-stabilizing medications, but they did not stop her symptoms. She was gaining tons of weight. She had a guardian and a PAC team—the people who came into her home to help her with grocery shopping, paying her bills, and other things. This woman was miserable.
Between the ages of 68 and 70, she tried to kill herself at least six times, and was hospitalized for those suicide attempts. At 70, after having lived with schizophrenia for 53 years, she’s referred to Duke University, where Dr. Eric Westman was using the ketogenic diet as a weight-loss tool. She was referred solely for weight loss, and that’s all Dr. Westman was treating.
Within a couple of weeks, not only did she start losing weight, but her hallucinations pretty much went away. With a lot of other patients I work with, it takes a little longer, but she had a powerful effect. Within months, all her symptoms of schizophrenia were in remission. Within a few more months, she was off all her psychiatric medications and remained in remission. This woman went on to live for another 15 years—symptom-free, medication free, no more mental health professionals, no more suicide attempts, no more psychiatric hospitalizations. She had an entirely new life.
When I last spoke with her, she was really happy and asked me, almost pleaded with me, to please tell her story to as many people as I could, because she hoped that if her story could even spare one other human being the living hell she had to endure for 53 years, it would be worthwhile. Sadly, this had not happened at the time I wrote the book, and tragically, this woman passed away this past January, of COVID pneumonia, at the age of 85, which is actually a longer-than-average lifespan for a person with schizophrenia.
Ben Grynol: It’s such a powerful story, and it’s a reminder that she lived for a prolonged period of time after making this change. Once we get to an older age, we might not know how many years we have left, because things can change. She lived for 15 more years. Things are more in our control than we think, especially when we consider metabolic health and how we can make changes that lead to positive mental health changes.
There are macro conditions: government, academia, the medical field. But what’s the biggest challenge when it comes to implementing something like the brain-health model? It still feels like there’s more of a movement that needs to be done. When you think through these challenges, what is the largest one we face?
Dr. Chris Palmer: The biggest challenge in the mental health field is the stigma of mental illness. For centuries society has wanted to just discard the mentally ill. They are considered subhuman by many. They are considered criminals. In fact, the US prison system is the largest provider of mental health services in the United States. Homeless shelters are filled with the mentally ill. Lots of mentally ill people are disabled or living less than optimal lives. They stay at home. They don’t go out. They don’t have as many friends as other people. That stigma makes people not really care about them, not really care about providing resources or treatment for them.
The tragedy is that when we parrot the gross ineffectiveness of the current mental health treatments, that just further shames and stigmatizes and humiliates the mentally ill. We put them on pills that are not effective long-term, and we know that based on all of the controlled trials that we have. There are no trials showing that we can put even 50% of patients, with any diagnosis, into full and lasting remission. Not one study shows us that.
Our treatments, if we really do a hard and realistic assessment, are failing these people. It’s hard to get worked up about ineffective treatments that make people feel like crap and make them fat and diabetic, and then they don’t work. Who wants to march in the streets for that? Back to the stigma: people think, “It’s just the mentally ill. They’re defective. They’re weak.”
Those are the biggest barriers we have. I am 100% convinced that nothing will change if we do not get a grassroots movement. If people don’t join myself and others demanding change—demanding treatment programs that use metabolic strategies to help people fully heal and recover from their mental disorders—if we don’t get insurance companies to start paying for this, if we don’t get government and others to start funding research for this, nothing’s going to change. The status quo will remain, and mental disorders will continue to skyrocket and will probably take on a larger and larger portion of disability throughout the world.
I am aware of that pessimism, and I am begging people to join us. I’ve devoted my career to this work. I know these people deserve respect. I know these people deserve better lives, and I desperately want people to join this movement.
Ben Grynol: If people want to make change, what tactical things can they do? What are small things that they can do to make this positive impact?
Dr. Chris Palmer: I am hoping to create a home base at brainenergy.com. I’m going to encourage people to go to that website. There’s a free self-assessment to help people assess their mental health and their metabolic health with some objective markers. I’m not giving you a treatment plan. I cannot treat the world’s population based on some small computer algorithm. But it will help inform people about some areas you might think about changing, or might help you determine whether you’ve got insulin resistance or not. It might help you think about blood pressure, your weight, and other things, but also your mental health.
It will give you some ideas about some things you might want to work on. If you’re struggling, or if you know somebody who’s struggling, it can help encourage positive changes. Take that, and listen to friends, family, other metabolic or mental health podcasts. Listen for strategies: How can I improve my insulin resistance? How can I improve my blood pressure? What can I do to get stronger, fitter? What can I do to add some meaning and purpose in my life? You could take that assessment to your healthcare provider, whether it’s your general practitioner, or a mental health provider.
At brainenergy.com, I am also hoping to start the grassroots movement. I really want change. The first step is that we need numbers. We need people. That means I want you to tell other people. If you are persuaded by the metabolic theory of mental illness, if you see even a tiny sliver of the hope that I see in this for the masses of people who are suffering, I need you to spread the word.
Whether they buy the book or not, I really don’t care. My publisher will kill me for saying that. But my goal is not to sell books. My goal is to sell a theory that can transform human health—mental health—for millions of people. And that means people need to have this knowledge. They need to know why and how so they can talk with healthcare providers in a competent, knowledgeable way. But also, what are some strategies they can use? What are some problem areas they might identify?
Then I want to advocate for change. I want insurance companies covering this. I want the government funding this. That means we need numbers. For the people who believe me, trust me, nobody else is going to do this. Nobody’s going to do it for you. If you know somebody with a mental illness, I’m not asking you to do it for me. I’m asking you to do it for that person. I’m asking you to do it for the people you know with mental illness who deserve better lives.
That’s why you’re going to get involved. You’re going to stand up for those people. You’re going to stand up for your sons, your daughters, your spouses, your parents, your siblings, your friends, your coworkers, or just the little kid down the block who you see is tormented. You’re going to stand up for that person, and you’re going to get involved.