[HEARD] It’s never too early to start thinking about tax season. Heard is the financial back office built specifically for therapists in private practice. They combine smart software with real humans to help you manage your bookkeeping, taxes and payroll. Regardless of whether you’re a seasoned clinician or are in the first year of private practice, Heard will identify areas of growth and streamline best financial practices for your business. When you sign up with Heard, you’ll connect your bank accounts so your transactions will automatically be pulled in and categorized. My favorite thing about Heard is their allocation guide, what helps you decide how much to pay yourself each month and how much to set aside for taxes. You’ll also receive financial insights such as profit and loss statements and personalized monthly reports. You can say goodbye to pouring over spreadsheets and guessing your tax deductions or quarterly payments. Focus on your clients and Heard will take care of the rest. Heard always has transparent pricing with no hidden fees. Sign up for a free 15-minute consult call today at joinheard.com/partners/joe. Again, that’s joinheard, like I heard it, not like a herd of cattle, joinheard.com/partners/joe. [JOE SANOK] This is the Practice of the Practice Podcast with Joe Sanok, episode number 833. I’m Joe Sanok, your host and welcome to the Practice of the Practice Podcast. I am so glad you’re here. If this is your first time listening to the show, welcome, you’re in the right place. Well, hopefully, I mean, if you’re looking for private practice advice on starting, growing, scaling, or exiting your practice, you’re in the right place. If you’re looking for a plumbing podcast, I guess you’re in the wrong place, but maybe you’ll learn something as well. We are talking private practice, we’re talking marketing, we’re talking clinical things. We’re exploring topics that often aren’t covered in the general counseling world to make our private practices better, to make more access to mental health occur and you’re a part of that movement. You are a part of that by listening to this, by making an amazing practice. I am so excited about our guest today. Dr. Christopher M. Palmer is a Harvard psychiatrist and researcher working at the interface of metabolism and mental health. He’s the director of the Department of Postgraduate and Continuing Ed at McLean Hospital and an Assistant Professor of Psychiatry at Harvard Medical School. For over 25 years he’s held administrative, educational, research, and clinical roles in psychiatry at Harvard. He’s been pioneer in the use of medical ketogenic diets in the treatment of psychiatric disorders, conducting research in this area, treating patients, writing, and speaking around the world on this topic. Chris, welcome to the Practice of the Practice Podcast. [DR. CHRISTOPHER M. PALMER] Thank you for having me. [JOE] Oh, I am so excited to talk about this because I feel like, so I sold my practice in 2019, but anytime I helped an angry kid, it was mostly angry kids and their parents that I worked with, so angry teenagers, when they’d come in and be like, my son has an ADHD diagnosis, I’d be like, well, let’s talk diet. Let’s talk sleep. Inevitably they’d have tons of carbs, tons of sugar, they’re doing their iPad right before bed. To just see the changes, even in just small things in their diet just changed so much. So the fact that you’ve been researching this for so long and that you’re bringing it together and that you’re a Harvard researcher, I mean, we got to listen to you. So welcome to the show, [DR. PALMER] Thank you [JOE] How did you first get into how food and mental health combined? [DR. PALMER] I’ve been doing this work for probably about 20 years and the quick story is it started with my own health. I went on a low carb diet to try to reverse metabolic syndrome. I noticed dramatic changes in my energy level, mood, sleep and other things and I started recommending it to family and friends. A lot of people were also noticing improvement, so within a couple years I started using it in patients with treatment resistant depression and lo and behold, it actually worked really well for some people. I think everything changed dramatically though for me. In 2016, when one of my long-standing patients with schizoaffective disorder asked for help to lose weight, I decided let’s try the ketogenic diet really thinking it was just going to help him lose weight. I had no expectation that it was going to do anything for his schizoaffective disorder because that’s a very different disorder than depression. Lo and behold, within two weeks, not only is he losing weight, but I noticed this significant antidepressant effect in him, he’s making better eye contact, smiling more, talking more. Most astonishingly, at about six to eight weeks, he spontaneously tells me his longstanding hallucinations are going away, his longstanding paranoid delusions are going away. This man went on to lose 160 pounds and keep it off. He was able to do things he had never been able to do since the time of his diagnosis. He could go out in public and not be afraid anymore. He was able to perform certificate programs, he was able to perform Improv in front of a live audience. [JOE] Yes, I love Improv like that, my love language or something. [DR. PALMER] That’s awesome. I was dumbfounded and ended up going on a journey to understand what on earth just happened. [JOE] Take us through the research of like, what is happening in the brain? I know you have this new book, Brain Energy, what’s happening in the brain when people go on this type of diet? Maybe share with us first, I guess, what is this type of diet? Because we see keto put on everything now. It’s like the new, like gluten-free. I even saw a local oil change place that said keto gluten-free oil changes, just like, they’re just like, they’re just being silly but it’s like you throw the buzzer on and now all of a sudden all the hippies get their oil change there. First, what is the keto diet? How do you explain that to patients in just regular person language? Then I do want to dive into the brain research of what’s actually happening that you’ve discovered here. [DR. PALMER] It’s a great question. As you say, although most people have heard of it as a fad diet, and some people even think of it as a dangerous diet, the ketogenic diet was actually developed a hundred years ago by a physician for one and only one purpose and that was to stop seizures. So this is an evidence-based treatment for epilepsy. We have a number of randomized controlled trials, we have two Cochrane reviews, which are the gold standard in the medical field showing that the ketogenic diet is highly effective for treatment resistant epilepsy. Now for those all of you in the mental health field, you already know we use epilepsy treatments in psychiatry every day in tens of millions of people. For any of you non prescribers, these include things like Depakote, Lamictal, Topamax, Neurontin, Valium, Klonopin, Xanax. All of these are anti-seizure treatments. So this diet is an anti-seizure treatment. In fact, we’ve got decades of neuroscience research showing us how and why this can stop seizures and those same mechanisms of action are highly relevant to patients with mental illness. [JOE] Dang, so what’s the actual diet look like? Or do you even like the word diet? I know some people don’t like that word. What’s the way people look like when they’re on the keto diet? [DR. PALMER] That’s the thing. It’s called the ketogenic diet and I really think about it more as like a metabolic therapy or a metabolic intervention. Because what we’re trying to do is profoundly change brain function and brain metabolism to improve brain health. So what it looks like is it’s a diet that is low in carbohydrate, moderate in protein, and high in fat. There are lots of variations of it and depending on the person that’s using it, if the person is already overweight or obese, they may not need to add that much fat to the diet. They may just get by on a low carb diet because they have a lot of fat stores that they can tap into as a fat source. For thin people though, they do need to add a lot of fat, because you want the diet to result in your body burning fat and ketones as a fuel source. [JOE] Okay, so it really sounds like it needs to be more individualized rather than just have this many grams of carbs in a day. I mean you, we’ve all seen the like really probably unhealthy version where the guy eats bacon all day every day as his like quote keto diet. Well, as a starting point for people, are there certain like blood tests or ways of thinking about if they’re just doing it individually, maybe they’re not even talking to their patients or their clients about it right now and they say, yes, I’d like to take a step into this type of diet, are there certain things you would say, just try to eliminate a few more of these things or add a few more of these things? What would be just a couple things that people could add so that they can conceptualize what we’re talking about in regards to the ketogenic diet? [DR. PALMER] It’s a great question. I think the easiest way to ease your way into a low carb or ketogenic diet is probably going to be more about eliminating certain things. So you’re going to want to eliminate junk food and sweets. What that means is you’re going to try to get rid of as many carbohydrates as you can. Some people start with sugar and grains, meaning no bread, no baked goods, and nothing with added sugar. For some people that’s enough. So they might still be eating fruit and vegetables, which definitely have carbohydrates, and some fruits actually have a fair amount of carbohydrates, but maybe eliminating added sugar and grains could be a good start in that direction. [JOE] Awesome. So what’s actually happening in the brain with people that have these really tough disorders that they’re dealing with when they move over to a ketogenic diet? [DR. PALMER] As I said, we’ve got decades of neuroscience research and basic research on this, so we know that the ketogenic diet changes neurotransmitter activity, it changes calcium channel regulation, it decreases brain inflammation, changes the gut microbiome, improves insulin signaling, it does all of these things. The way that I think about it more broadly is that it improves brain metabolism, and I actually believe that is fundamental to reducing symptoms or sometimes even putting into remission the symptoms of mental illness. [JOE] So you’ve written this book, Brain Energy. Walk us through some of the research or case studies that you found in putting together the book. [DR. PALMER] The book in many ways, although it presents a bold and audacious theory of mental illness that a lot of people will probably say is a new theory, that mental disorders are metabolic disorders. In fact, it really just takes all of the existing research that we have had for decades and it puts it together in one coherent way. So we have known since the 1800s that mental disorders and metabolic disorders are linked, and that includes disorders like diabetes and cardiovascular disease. For any mental health clinicians who don’t know this, you should know this, people with mental illness die early deaths. On average men lose 10 years of life, women lose seven years of life, and most of the people are dying of heart attacks. They’re dying of metabolic illnesses. So we have evidence since the 1940s that people with mental illness have metabolic abnormalities in their brains and bodies. Since the 1990s we’ve had functional imaging studies like functional MRI or PET scans or Spec scans, and all of those are actually measuring brain metabolism. That’s what they are measuring. So in many ways, this evidence has been right in front of our eyes all along, but when you get down to the cellular level to try to understand, well, what does it mean? What does it mean to have a metabolic disorder? You land on these tiny little things in most of our cells called mitochondria. Most people know mitochondria as the powerhouse of the cell, but in fact, they play a key role in all of the factors known to play a role in mental illness. They play a role in regulating neurotransmitters, important hormones like cortisol, estrogen, testosterone. They play a role in inflammation and actually epigenetics, they are a major regulator of epigenetics, which means they control which genes get expressed in which cells. So when you do a deep dive into the science of all of that, it’s actually the only way that we can connect the dots of mental illness but once you have that broad perspective and you can see the big picture, it opens up entirely new ways to think about treating mental illness. [JOE] Now it sounds like you’re saying that it’s more people have these things in their brains and then eating, maybe the typical American diet is amplifying it and you’re not saying, and this is more for my own clarification, it doesn’t sound like you’re saying that the food choices are causing it as much as it’s amplifying something that’s already going on in the brain. Is that correct? [DR. PALMER] Absolutely correct. And it’s not just biological things. It’s psychological and social things. So believe it or not, we have very strong good evidence that trauma, stress, adverse childhood events all impact mitochondria and their function, and they result in changes in brain metabolism. So this theory actually connects the biopsy psychosocial model of mental illness. By no means am I saying a bad diet is the cause of all mental illness. The causes of mental illness are all of the things that mental health clinicians already know; trauma, stress genetics and epigenetics, hormonal imbalances. Looking at it from the view of metabolism, mitochondria is the way to connect all of it. [RECEPTIONIST] When I had my group of practice, I was so sick of running to the lobby to see if my next appointment had arrived, or even more awkwardly to have a bunch of therapists run to the lobby when we heard the door open. Maybe you want a more discreet, stress-free way for your clients to check in. Take a deep breath. The Receptionist for iPad empowers your practice to create a zen-like check-in experience. This episode sponsored by The Receptionist for iPad, it’s the highest rated digital check-in software for therapy offices and behavioral health clinics used by thousands of practitioners across the country, including many who are just getting started. The Receptionist for iPad is super simple. It’s an inexpensive way to allow your clients to discreetly check in, to notify providers of a patient’s arrival and to ensure your front lobby is stress free. The software sends an immediate notification to the therapist when a client checks in and can even ask if a patient information has changed since their last visit. Start a 14-day free trial of The Receptionist for iPad by going to the receptionist.com/practice. Again, that’s the receptionist.com/practice and when you do, you’ll also get your first month free when you sign up. [JOE SANOK] So when we look at what’s really going on, do we know how it’s interacting or is the research too new to really know like why it’s impacting the mitochondria? [DR. PALMER] This research actually isn’t new at all, and that’s the surprising thing. I mean, I guess it’s relatively new. The research on mitochondria and metabolism over the last 20 years has exploded. There has been a working hypothesis of the mitochondrial theory of autism since the 1980s. The mitochondrial theory of depression, bipolar disorder and schizophrenia has been around since 2000. So for 22 years, leading researchers have been hot on this trail of mitochondria and mitochondrial dysfunction as playing a central role in major serious psychiatric disorders. The challenge has been so much of this research is recent and new, but also that a lot of this research is taking place in other fields. It’s taking place in the field of obesity medicine or it’s taking place in the field of diabetes and nobody to date has done a broad exhaustive review of all of the different fields and all of the different research and been able to put it together in one coherent way. That’s what I have attempted to do in Brain Energy and the good news is that some leading world renowned psychiatrists and neuroscientists have publicly endorsed my book saying they think I’ve done it. So it’s groundbreaking in many ways. [JOE] So in the last third of the interview I’d love to just focus in on your book and dig deeper in. How would you, we already covered some of it, but what do we need to make sure we hit on in the next 10 minutes or so to let listeners have a good working understanding of brain energy and what you’ve discovered? [DR. PALMER] Given that your audience is mental health clinicians, first and foremost, I want to say that this theory does two things that are going to be highly relevant to each and every one of you. One, it gives you new treatment strategies and new treatment tools so that when medications aren’t working for your patients or when psychotherapy isn’t working for your patients. It’s not that those treatments don’t work for anyone, we all know that they work for some people and some people live happily ever after with those treatments, but we also all have patients that those treatments are just, they’re helping a little bit or even maybe even moderately. But the people are still suffering, they are still struggling, and we are looking for new answers, better answers, add on treatments. This theory gives you a lot of obvious common sense strategies that you can use, such as diet, exercise, other lifestyle interventions to help improve the mental health of the patient’s right in front of you. But additionally, number two is this theory integrates metabolic health and mental health. One of the take home points for me is that patients who are struggling with obesity or diabetes or cardiovascular disease, they deserve and need appropriate mental health treatment and that might mean psychotherapy and other mental health treatment strategies to improve their outcomes. I know that I’m preaching to the choir here with that message, but I am really hoping to get the rest of the medical field to take mental health much more seriously based on this scientific theory. [JOE] What are some of the risks or threats, like if people hear this and then they, I know most folks that are listeners will do lots of research before they do this, but if someone just says, oh, I’m going to go start telling my clients or patients to get on the keto diet, what would be the smart way for them? Obviously, read your book understand it from that perspective, but are there certain partners, like a nutritionist that they should partner with? Are there psychiatrists that think a certain way that they should partner with? Are there people that should be on a team so that we mitigate the risk of a therapist just saying, go on the keto diet, it’s going to help? [DR. PALMER] That is an outstanding question. Thank you for asking it. Everything you just suggested is absolutely appropriate. The keto diet for weight loss, people can wing it if they want. The worst that’s going to happen is they’re not going to lose weight. Big deal. If you are treating a patient with a serious mental disorder, you know these are serious disorders. They are not do-it-yourself projects for us to just tell patients, oh, go ahead and wing it, just try something. Like we don’t give them pills and say, well just wing it, just do whatever you want with these pills and try it out and see how it works out for you. We don’t even do that with psychotherapy. We don’t say just wing it, just do whatever you want and let me know how it works out. The ketogenic diet that I’m using is a medical intervention that stops seizures. So you can work with a dietician. If you’re a clinician and you want to consider this, I really do want you to learn a little more about the medical version of the ketogenic diet because it does come with some risks for nutritional things and the other types of risks. So I want you to understand what you’re doing and then ideally partner with a ketogenic dietician, a licensed dietician who, they are trained and how to do all of this. They’ll actually work with mental health providers and tell you it’s time to check these labs. Could you check these labs please and let me know what they are and then I will take it from there, I will prescribe supplements or I’ll tweak the person’s diet based on the results of these labs? So they can make outstanding medical partners with clinicians. And it’s important to do, to try this intervention in a controlled way just like we would try a medication trial or a trial of psychotherapy. We’re going to give it a certain amount of time, usually I tell people, try it for three months and then let’s assess it at the three month mark, whether this has helped you or not, just like we would do with an antipsychotic or an antidepressant medication. [JOE] You mentioned labs, what are some labs that just would be good for people to have a working knowledge of? I know most therapists aren’t going to be telling a doctor, here’s the labs that you should do, or telling their patients that, but just so that they understand here’s the handful of labs that are important if you’re going to be doing this work. [DR. PALMER] So there are, if you go to the Charlie Foundation website it will, there are guidelines. I’d rather not just spout a few off, off the top of my head because I really do want people to take this seriously but we want to check a variety of general health and wellness labs, so liver function, kidney function, those types of things. I would want to know where the person’s glucose and insulin levels are so I can measure whether they’re pre-diabetic or diabetic. I really want to look at other prescription medications that might impact this diet. There are some rare nutritional things like carnitine levels or selenium levels that clinicians never have probably even heard of checking in a lab value, but become really important when you’re using the medical ketogenic diet. [JOE] Okay, I mean, that’s smart to just say, hey, we don’t want to just throw out a couple labs. There’s best practices out there. The last question that I always ask is, if every private practitioner in the world were listening right now, what would you want them to know? [DR. PALMER] I would want you to know that you are desperately, desperately needed right now in the world. So thank you for doing the work you’re doing. As you all know, we have a crisis in the health, not the mental health of the world, but also the metabolic health of the world. Skyrocketing rates of obesity, diabetes and mental disorders, and its mental disorders across the board, depression, anxiety, burnout, but also suicides and deaths of despair and also autism. The rates have tripled. What I am here to say is these are not coincidences. These are all interrelated, and you are needed more than ever before. [JOE] So awesome. If people want to get your book where’s the best place for them to order it? [DR. PALMER] They can order it anywhere books are sold. So it’s on Amazon, Barnes and Noble, you can just Google Brain Energy Cris Palmer and you will find it. You can get it from wherever you like. [JOE] Ah, so awesome. Chris, thank you so much for being on the Practice of the Practice Podcast. [DR. PALMER] Thank you, Joe for hosting me. [JOE] As many of you know I have late onset Type 1 diabetes. I was diagnosed in my early thirties. My pancreas just gave me the middle finger and said, I’m not going to help out anymore. So it’s interesting to have gone through different phases of trying different diets, different lower carb diets. I would say that something close to what Chris is talking about is something that I tend to live. So I’m really excited to just dig in even more, read Chris’s book and just learn about this subject for myself personally but also just for the world of such good information that Chris brought us today and research that needs to be brought together and just great for our patients as well. We couldn’t do this show without our amazing sponsors. The Receptionist is such an amazing thing that I wish I had had in my practice. The Receptionist for iPad is a simple, inexpensive way to allow your clients to discreetly check in, notify the providers that the patients arrived, and to ensure your lobby isn’t full of a bunch of stress. You can start your 14-day free trial of The Receptionist for iPad by going to the receptionist.com/practice. When you do, you’ll get your first month free when you sign up. Again, that’s thereceptionist.com/practice. Thank you so much for letting me into your ears and into your brain. Have an amazing day. I’ll talk to you soon. Special thanks to the band Silence is Sexy for your intro music. This podcast is designed to provide accurate and authoritative information in regard to the subject matter covered. This is given with the understanding that neither the host, the producers, the publishers, or the guests are rendering legal, accounting, clinical, or other professional information. If you want a professional, you should find one.