PlasmaBitcoin

A lot of people tell me to read Christopher Palmer's (@ChrisPalmerMD) Brain Energy. I've tried a few times over the years and would keep putting it down, annoyed. The premise is directionally correct: mental health is downstream of cellular energy availability. But Palmer's answer to it is always the same: Biogenesis and mitophagy. More mitochondria, cleaner mitochondria — that's the mechanism he credits for keto, fasting, exercise, electroconvulsive therapy (ECT), thyroid, and even SSRIs. A mechanism that explains diet, movement, and induced seizures equally well isn't explaining much. Worse, biogenesis isn't automatically evidence of improved metabolism. It can be compensatory. If each mitochondrion produces less ATP, the cell may build more of them to hold total output steady. More mitochondria can mean the cell is struggling, not healing. So it skips the real question: not how many mitochondria you have, but whether they can simply do their job and burn glucose. Palmer has the evidence and walks right past it: Brain insulin resistance preceding psychosis by fifteen years. Induced hyperglycemia degrading memory and mood. Alzheimer's as brain glucose hypometabolism. Alcoholic brains starved when sober. His own case for keto gives it away: ketones are a rescue fuel for cells that can't use glucose. He champions the workaround and never asks why the primary pathway failed. The analysis stays frustratingly surface-level throughout. Palmer works almost entirely at the level of the organelle—ATP-to-ADP ratios, ROS, calcium handling, fusion and fission—and never gets down to the enzymes. Pyruvate dehydrogenase, the irreversible committed gate into oxidative metabolism, appears nowhere in the book. B vitamins show up three or four times each, all in passing. Thyroid gets a few pages at the end of the hormone chapter, framed as an augmentation strategy for refractory depression rather than something to check first. Keto gets over twenty mentions, none of them in Chapters 5 through 14—the entire theoretical core. It shows up only once he starts prescribing. The epilepsy evidence is strong. But his own mechanism for it is the same one he credits to fasting, exercise, and ECT. If that's the active ingredient, ketosis is one route among several, and he never asks what else gets there. It's the closest he comes to nutritional biochemistry, and he stops at the one diet that made his career. The serotonin chapter is where I lose patience entirely. Palmer introduces low serotonin as one of the best-known single-cause theories (come on…), raises five sharp questions it can't answer—and never turns any of them on the drugs. Chapter 11 opens by conceding the ground outright: he isn't challenging the trials, isn't challenging the imbalance observations, isn't challenging the people who say the drugs saved them. Instead he replaces a dead rationale with a live one: SSRIs work, he concludes, by driving mitochondrial biogenesis, which conveniently also explains the two-to-six-week delay he raised earlier in the book. The biogenesis claim rests on a single 2019 rodent study. And it runs precisely opposite to the evidence that SSRIs inhibit electron transport chain complexes and reduce ATP production—evidence he never mentions. Which is the strange part, because he built the category himself. He devotes pages to psychiatric drugs that impair mitochondrial function, names antipsychotics and valproate, and warns that suppressing mitochondria may block recovery and can itself cause symptoms. SSRIs are simply exempt. In fact, "SSRI" appears three times in a nearly 90,000-word book. Moncrieff, Kirsch, and Healy appear zero times. Akathisia and sexual dysfunction appear zero times; "blunting" appears once, describing facial expression in schizophrenia. "Placebo" appears only as trial design, never as efficacy. He never once reports a drug–placebo difference. He gets within one paragraph of the activation literature—claiming that antidepressants raise brain energy and can trigger anxiety, mania, or psychosis in metabolically compromised people—and stops. That’s also exactly backwards: akathisia doesn't look like a surplus of brain energy; it looks like a brain that can't afford the cost of holding itself still. I understand this is a book written for a lay audience, and things have to be kept simple. I appreciate what it attempts, directionally. But I can't help being frustrated by how many opportunities are missed, and how much time goes to throat-clearing (a car-and-traffic analogy that could have been a paragraph runs across four chapters). I hope more researchers and clinicians take up the brain energy model. It's correct—Palmer just fails to explain why. This book feels like one tentative step in a 100-meter sprint.