Brain Energy: New Hope – Treating Mental Health Disorders as Metabolic Disorders
A Conversation with Dr. Christopher Palmer
Christopher Palmer, MD is currently the Director of the Department of Postgraduate and Continuing Education at McLean Hospital and an Assistant Professor of Psychiatry at Harvard Medical School. His research interests have turned to the areas of metabolism, metabolic disorders, and their connection to mental disorders. He is focused on combining and understanding epidemiological data, basic science research, and clinical studies to better understand what role metabolism plays in mental illness. In November 2022, Dr. Palmer published the book, Brain Energy: A Revolutionary Breakthrough in Understanding Mental Health – and Improving Treatment for Anxiety, Depression, OCD, PTSD, and More, in which he argues that mental disorders are metabolic disorders of the brain.
Virginia Gleason: Thank you for agreeing to speak with the Harvard ALI Social Impact Review about this important area of your research. Could we begin at the beginning – what led you to recognize the relationship between mental illness and metabolic disease? How did you put all the pieces together to come up with this area of research?
Dr. Christopher Palmer: It began with my own personal story about 20 years ago. I have a long history of mental illness starting when I was a child. By the time I was in my twenties and doing my residency at Harvard, I was diagnosed with a metabolic disorder. My doctor told me diet and exercise were the treatment. I kept asking him “What diet. What exercise?” He replied “a low-fat diet. Do any exercise – go to the gym, run, bicycle, whatever. Lift weights.” I was doing these things year after year. Yet my blood pressure was going up. I was developing prediabetes. My cholesterol lipids were awful.
In a last-ditch effort, I tried a low carbohydrate diet – what ended up being a ketogenic diet.
Not only did I get rid of my metabolic syndrome within three months, but I noticed that my mood, energy, concentration, and sleep were improving. I felt like a different person. That led to friends and family making the same changes and they also noticed benefits.
Within a few years, I started using this treatment in patients with treatment-resistant depression and treatment-resistant personality and anxiety disorders. Lo and behold, in some of those patients I noticed significant improvement. At that point low carb diets were extraordinarily controversial; therefore, I wasn't ready to go out and talk about this or publish anything. I didn't want to get into trouble.
It was the example in 2016 that I mentioned in my book, Brain Energy, that completely upended everything that I had been taught as a psychiatrist. I had a patient with schizoaffective disorder who I had been treating for eight years. He had tried 17 different medications. None of them stopped his hallucinations or delusions. He had gained massive amounts of weight. He was tormented by his illness. I proposed he try the ketogenic diet. He lost a tremendous amount of weight, his psychiatric symptoms changed in profound ways, as did his ability to function in society.
That was my call to action. I recognized I could not sit on this. There are millions of people just like him who are desperate for a new treatment. Since that time, I've treated dozens of patients. I have helped patients with schizophrenia and bipolar disorder put their illnesses into remission and sometimes come off psychiatric medications. That’s what led me to go beyond the ketogenic diet as a treatment. Schizophrenia is not supposed to go into remission; we have not seen patients able to come off medications, and certainly not in response to a diet. That led me to take a deep dive into the science.
I did not set out to develop a unifying theory of mental illness. I simply set out to understand. I thought – how much science can I cobble together to try to get clinicians and researchers to take me seriously and see that the ketogenic diet is a powerful treatment for schizophrenia, bipolar and other serious disorders.
The great news is that we've got 100 years of science using the ketogenic diet for epilepsy, documenting what it's doing to the brain, how it's working, and how it stops seizures. Interestingly, we use epilepsy treatments in psychiatry every day in tens of millions of people. There is a close connection between a diet that can stop seizures and treating mental illness. Right away it was a no-brainer; it was obvious.
The more I dove into the science, the more I was led to connections that show that metabolism and mitochondria are related to mental illness. Once people understand the big picture and the detailed science which is based on decades of research, they will see that all of this has been hiding in plain sight.
Gleason: Can you give us the high-level, non-medical explanation of the relationship between metabolic health and mental health?
Palmer: Most people think of metabolic health disorders as confined to obesity, being overweight, type 2 diabetes and cardiovascular disease. Those are largely accepted as metabolic disorders, and we know that they are largely related to lifestyle. Most people think if you follow a good diet, if you exercise enough, don't smoke, and you won't have any of these problems.
There's a burgeoning field called nutritional psychiatry that suggests that maybe diet can play a role in mental health. Most people in that field focus on how diet might help depression and anxiety but believe that it doesn't help with other things. They doubt that it helps with real brain disorders like ADHD, or autism spectrum disorder, schizophrenia or bipolar disorder.
What I have argued in Brain Energy is that if you do an in-depth review of all the clinical, epidemiological, neuroscience, genetic, and metabolic research that has been done over the last 200 years, this has been hiding in plain sight. We have centuries of observations as far back as 1800 that diabetes and serious mental illness such as schizophrenia and bipolar disorder run in the same families. We have decades of basic science research, neuroimaging research documenting metabolic abnormalities in the brains and bodies of people with a wide range of mental disorders.
The easiest way to summarize what occurs is to look at metabolism from three perspectives: the production of energy inside your cells; turning food into energy or building blocks for growing and maintaining cells; and efficient management of all the waste products of that process. Energy, building blocks, waste management – that is metabolism. It is fundamental to all organisms. When there's a problem with metabolism, there will be a problem in the way cells develop or function. What I’m arguing is that metabolism is the only way that we can understand the brain dysfunction that occurs when people have mental disorders.
Sally Bloomberg: What are the challenges to widespread adoption of this approach and how do you think they can be overcome?
Palmer: I think that the first challenge to widespread adoption is just understanding the science and really seeing the big picture. If you say to most people, including psychiatric researchers and clinicians, that diet can play a role in an illness like schizophrenia, they won't believe you. The first step is to present and disseminate the science in an understandable way to make the case and to help people understand the science. Once they understand, I truly believe they will see that the solution has been hiding in plain sight.
Another challenge is that our current health care system focuses on 15-minute appointments with your doctor. The doctor is not given time to do much more than assign a label, measure a biomarker, and deliver a pill. That is a very efficient health care system. If that model worked well, I would be all for it. I wouldn't be here. I wouldn't be trying to disrupt the paradigm. The pharmaceutical companies love that model, it works for them, and they have no incentive to see anybody, or anything disrupt their very lucrative industry. That doesn't make them evil; it makes them capitalists; they have invested in their products. I give them the benefit of the doubt.
Numerous research reports show that the U.S. spends more on health care than other Western countries and has some of the poorest outcomes. We have to take an objective stance and ask, “How are we doing?” But we are not doing that; the U.S. population is not doing well at all. Physical and mental health is rapidly declining. That’s a call to action.
Bloomberg: How do you overcome the resistance in the medical community to challenging the status quo and why is it so hard to change behavior in the medical community?
Palmer: My sense is there are two primary strategies we can employ to try to change the understanding between the link between metabolic disease and mental health. The first strategy is to set up pilot trials or pilot clinics where clinicians use a comprehensive treatment approach. Some people refer to this as holistic, but I want to avoid this term because the medical community tends to think of holistic as including extra things that are not considered real medical care. That’s why I prefer the term comprehensive and effective. We need comprehensive and effective treatment approaches to restore people's health, put illnesses into remission, and allow them to function as humans in society. Not only does this reduce suffering, but it also restores dignity and self-respect, and saves a lot of money in the long run. If we take somebody off disability and they are able to maintain a job, they are no longer considered by society to be a “drain to the system as a disabled person.” Instead, they are productive, taxpaying citizens. The stereotype is that people on disability are lazy slackers. I'm here to tell you they are not. The overwhelming majority of those people are suffering human beings who desperately want to be better, who want to function, who want to contribute to society, who want to hold their heads high, and we need to enable them to do that.
By conducting research with pilot treatment programs, we can demonstrate superior efficacy to the status quo and cost savings. We need to demonstrate both. We need to look at cost comprehensively, because an intensive lifestyle treatment program may cost more money during the first six months. But if the comprehensive treatment program restores someone's health and wellness and avoids expensive prescription medications for the rest of their life, and allows that person to go back to work, we are saving a tremendous amount of money as a system.
We need to look beyond the cost of the status-quo treatments which include 15-minute doctor visits and the cost of the pills. That’s not a fair comparison of the current costs. We need to show that reducing human suffering saves money to the overall system. Ultimately, that will get insurance companies, government programs, school systems and other people interested in this approach. We'll start looking at it at scale, and either it will work or it won't. Obviously, I’m a believer that it will work.
The second strategy for changing the system is to educate consumers, which will lead to increased demand for these services. Patients are frustrated because they are not benefiting from the diagnostic labels and pills. They are tired of suffering; and they are willing to try a different approach.
The goal is to get a critical mass of consumers to start demanding these treatments and that will push clinicians and clinics to offer these options to the private-pay market. If the private pay market is achieving superior outcomes, the poor or middle-class people who need to use insurance for their services will get enraged that they are not being offered these treatments. It will become a grassroots movement with people saying, “Enough is enough. The system needs to change.”
The medical field has, for better or worse, required some grassroots movements at times to make significant progress. For example, look at HIV/AIDS and breast cancer. We never would have made much progress for people with these conditions without grassroots movements. We had breast cancer marches and ribbons and women saying “Enough is enough. We are sick of dying. You can develop better treatments. This needs to be a priority.” Similarly, I think that if we really want to see significant system changes, we're going to need at least some component of a grassroots movement.
Bloomberg: You reference a comprehensive and effective approach. In addition to diet, what are the other components of the Brain Energy approach?
Palmer: My research builds on and integrates biological, psychological and social research and provides a comprehensive and integrative approach to explain and treat mental illness.
As part of the comprehensive treatment program, I also think about exercise, sleep, and encouraging young people to get off their screens for a while each day and engage with another human being. You may be wondering: “How are we going to get them to do all that because they're not suffering currently?” I think there are a few strategies that are well established to increase the likelihood that we can get these high-risk youth to engage and it revolves around community.
First and foremost, it is important for the families to engage in interventions together. This is not a child-specific intervention. It’s no longer about little Johnny who has been identified as being at risk; he is a little bit overweight, so we need to put him on a diet. If the family loves little Johnny and wants to prevent health problems and or a serious mental health problem, the whole family needs to step up. This requires a kitchen stocked with food that is healthy for little Johnny and is also eaten by the entire family – without temptations for him or the other family members.
Another community-based strategy involves implementing the approach at schools – so that all the kids, or at least a cohort of children, are doing this together. With a supportive environment, they're all working together, and they can be the source of solutions for each other. Within the community, it will be safe for people to talk about what’s working and their challenges. Humans are social animals. We are influenced by what we see others doing. When people feel like they are doing something as part of the larger community, there is a greater likelihood that the new, desired behaviors will become natural.
Gleason: When will we start to see pilots to test the efficacy of the comprehensive Brain Energy model of treatment for large numbers of people?
Palmer: Research pilots are already being developed. I'm being approached by telehealth companies, individual clinicians, and functional medicine practitioners, who are all extraordinarily enthusiastic about the Brain Energy model of treatment, taking a comprehensive approach to mental health, and applying the metabolic health approach. The beauty of this approach is that while we are using diet, exercise, and other lifestyle strategies to treat someone's mental illness, we are also helping to address or prevent prediabetes or diabetes, premature cardiovascular disease, and other conditions. I'm getting thousands of emails from people who are quite upset that they cannot get these treatments already. The more that we can drive demand, the more that clinicians will step up and then the more we will see who can deliver these treatments and who can get people to comply with these treatments.
Bloomberg: It seems that there are opportunities to conduct pilots with people who have symptoms and are already participating in residential treatment programs and living in prisons.
Palmer: I am being approached by people in prison systems. I'm being approached by people who are really interested in youth mental health. Can we get some pilot trials in school systems? I think there are countless opportunities to start to deliver these treatments. Clinicians and clinics are going to need to develop the tools and skills to implement these comprehensive treatments involving diet, exercise and sleep within a supportive community. We need to educate providers. We need to develop toolkits and protocols when possible, and we need to empower clinicians to implement these treatments effectively.
Bloomberg: Do you anticipate that the comprehensive treatments will be provided to people on an outpatient basis or as part of an inpatient or residential program?
Palmer: That depends on the patient. The majority of the patients will be treated on an outpatient basis. However, there are patients with schizophrenia for instance, who currently live in group homes, or live in State hospitals or prison systems. Since they are not outpatient right now, it would not be realistic to assume these individuals could receive outpatient comprehensive services, at least to start. I hope that we will see residential and inpatient programs that will begin to utilize these strategies for the people who need them.
Bloomberg: Personal change is difficult. What are your thoughts about how to encourage people to adopt and sustain the behavioral changes required?
Palmer: That’s a question that I am asked frequently. I work with treatment-resistant serious mental disorders – I don't see patients with mild or moderate depression or anxiety. I’m working with people with schizophrenia and bipolar disorder and cognitive impairment and dangerous behaviors. People often ask me; “How do you get them to follow and stick with a diet? We can't get normal, everyday educated people to go on a diet and stick with it.” And the quick answer is that the people that I work with are desperate for a better life.
If I talk with “a normal, otherwise healthy, educated person” who might stand to lose 20 pounds about weight loss, there's no urgency. The extra 20 pounds isn’t typically causing tremendous suffering and torment in that person. The patients I work with are tormented by their symptoms. They are desperate to make them stop, and they are highly motivated to at least give it a try.
Here's where I win. I get them to do it for a month. They're dramatically improved. Then, like everyone else, they say “Now I can have my pizza and ice cream. I'm so much better now. I don't need this diet anymore and I deserve a treat. I've been so good for the whole month.” They do all the usual things that everyone else does. But when my patients cheat on their diet, their symptoms come back with a vengeance.
Bloomberg: When symptoms return are they worse or just the same as before treatment began?
Palmer: Their symptoms return about the same. But to them it's more tormenting because they've been having relief for a month and now it's coming back. They were starting to think “I'm getting better. Wow! It's really nice to not have those symptoms, the voices, or the depression, or the suicidality, or whatever else they were experiencing.” When the symptoms return within 24 to 48 hours, there is a quick negative reinforcing event. At that point, they fully understand that pizza and ice cream caused them to hallucinate, etc. Then, they think “That pizza and ice cream …. Yes, it tastes good, but it's not worth what I’m going through right now.”
Gleason: What are your plans for gaining support for comprehensive treatment programs?
Palmer: I've been approached by some philanthropists who want to support this work. I’m hoping to start what will be called the Brain Energy Foundation which will develop professional education for the clinicians who want to start using these treatments. We will offer professional education and address topics such as: How to implement programs for your patients recognizing real-life constraints; Here are things you should be looking out for, etc. We would love to develop patient and family resources, including patient community support groups – they could be Metabolic Mental Health Groups, Brain Energy Groups or whatever we want to call them. They would be peer-led groups that are free where we offer a sense of community, support and encouragement and education – sort of like Weight Watchers groups or Alcoholics Anonymous (AA).
I have already been approached by several people who want to conduct pilot programs in schools, in prisons with homeless population, with LGBTQ youth, with racial minority groups.
Gleason: I believe poor metabolic health is driving behavioral issues that lead many people into poverty. As a society, we spend a lot of money on the back end and we are not achieving the desired quality of life in many cases. We really need to be focusing on reducing suffering early on – agreed?
Palmer: We have people at all levels within society recognizing that what we're doing today isn't working. We need some new solutions.
The rates of serious mental illness in youth have doubled over the last about 12 years – that’s appalling. And it's not a coincidence. Science shows it is not a coincidence that youth are developing skyrocketing rates of overweight, obesity, non-alcoholic fatty liver disease, and diabetes. They are also developing skyrocketing rates of mental health problems.
I am also interested in prevention strategies. For example, high levels of insulin resistance in youth put them at a five-fold increased risk for developing a psychosis at-risk mental state by the time they turn 24. That means they are at high risk of developing schizophrenia or bipolar disorder. I would love to see programs in which we work with the youth BEFORE that diagnosis ever starts – we measure insulin resistance, and start using dietary and lifestyle strategies.
Gleason: What has the response been from the medical community?
Palmer: We have a group of researchers now – well over 50 people located in the top 10 cities, some of them world-renowned psychiatrists, neuroscientists, psychiatric researchers and metabolic psychiatric researchers pursuing this work. Dr. Nora Volkow serves as the Director of the National Institute on Drug Abuse (NIDA). She has been passionate about this work for decades. We've got decades of research to support all of this and a large group of researchers continuing to explore this area.
I am mindful of the systemic challenges – even if we get randomized controlled trials that show a benefit, on average, even for a medication trial, it takes about 17 years for a trial that shows a benefit to actually be implemented in clinical practice. Medications are quicker to be implemented because you've got the marketing power of Pharma, and they've got money to be made, so they come at it with a vengeance. As soon as they get a positive trial, you've got a multi-million dollar advertising campaign. Nobody is going to fund a multi-million dollar advertising campaign for diet and exercise to treat your mental health.
I'm interested in raising awareness, and that's ultimately why I decided to write the book. I wanted the book to be accessible to a lay audience. I've heard from some people that it's too complex for some people. It's too much science, too much mitochondria. I know it's not for everyone. I had to walk the line. I had to include enough science, enough evidence, enough rigor so that people would take it seriously. I did my best to make it as understandable as possible to as large of an audience as I could.
I'm hopeful that if enough people read it, understand it, or just learn about it they will want to take action. Maybe they've got a child suffering from chronic anxiety and depression and suicidality. And they're saying the current system isn't working for them. I want people to stand up and say “Enough – we need new solutions, and there's enough science here. Let's pursue this.”
Bloomberg/Gleason: Thank you Dr. Palmer for your time today. You offer us hope in this area of advancing science, health, and importantly mental health.
About the Authors:
Sally Bloomberg was a member of the 2021 Harvard Advanced Leadership Initiative Leadership cohort. Sally is passionate about the human side of change. She works with individuals and organizations to enhance performance through coaching, facilitating, and organizational strategy and change consulting. She was a founding board member of Compass, a provider of pro bono consulting services to nonprofits and served as the Chair of The Tuck School at Business Washington, DC area alumni club for many years. She mentors underrepresented and first-generation undergraduate students as they prepare to pursue professional careers.
Virginia Gleason was a member of the 2022 Harvard Advanced Leadership Initiative Leadership cohort. Virginia applies wide industry experience to helping public entities create solutions to help alleviate suffering and promote public safety and wellness. A graduate of University of Oregon Law School, she began her career as a lawyer in private practice but moved to pursue her passion in public service, serving at four different law enforcement agencies. Virginia now focuses on organizational compliance with laws, regulations, professional standards and ethical practices; utilization of data to increase the value and credibility of public services; practices that support inclusion; and risk management. She is an adjunct professor at the Seattle University Department of Criminal Justice and Forensics and an instructor for FBI-LEEDA. She is an avid soccer fan and long-time player in adult soccer leagues.
This interview has been edited for length and clarity.