Ketogenic diet for mental health: Come for the weight loss, stay for the mental health benefits?
So the Oslo-based software technician, 28, combined the ketogenic diet with intermittent fasting. He cut out all sugar, fruit and refined or starchy carbs, eating primarily meat, fish, eggs, nuts and above ground vegetables. A favourite dish of his is a special Norwegian reindeer stew called Finnbiff.
Most days he eats during a three-hour window, usually a small afternoon snack like beef jerky and then his evening meal.
“It felt right. It was easy,” he says. Over the past year he has lost more than 63 kilos (140 pounds). He feels and looks great.
However, another welcome change occurred: his rapid cycling bipolar II disorder became much more stable and manageable. While he still had five “mood cycles” in 2017, all of them were easier for him to handle.
“My cycles are much milder now. My elevated moods are more predictable and I can still sleep properly and focus my extra energy when elevated. My depressions are less intense, and when depressed I can still be interested in my hobbies and friends. Everything is much more predictable and easy to deal with.”
In short, Hessen came to keto eating for the weight loss, but he is staying for its positive impact on his mental health.
He was diagnosed in 2014 with bipolar II disorder1 when he was working in Finland and suddenly began rapidly shifting between hypomania2 and depression almost weekly. He feels now that the condition has likely been with him for most of his life. “I have had depressions for as long as I can remember, down to the age of 3 or 4.”
He posts regularly now on ketogenic forums on Reddit, sharing his experience with others who are contemplating doing the diet for mental health reasons.
“I am always really careful not to raise any false expectations. The diet is by no means a cure for the chronic illness that bipolar is. However, the diet is a great tool to help manage it,” he says.
Hessen is not alone. Reddit and other social platforms have comment threads in which people on the LCHF or ketogenic diet report improvements for anxiety, depression, bipolar disorder and even schizophrenia.
Could the ketogenic diet help prevent, reduce or better manage some mental health conditions? While clinical research on real patients to date is slim, a growing body of basic science on ketones’ impact on brain function in animal and human models, and a large number of anecdotes, suggests that it just might.
Poor mental health: An increasing global issue
In Europe and in North America the impact of mental illness on the individual and society is enormous. Each year, one in five people will be impacted by a mental health condition and over the course of a lifetime, almost one in three (29%). Since 2005 the rate of depression alone has increased 18%, now impacting 322 million people globally and the number one cause of disability in the world.
Those with mental health conditions have higher rates of physical illness and premature mortality, with life spans shortened by 13 to 30 years. People with mental health conditions also have higher rates and worse outcomes for chronic conditions such as diabetes, cardiovascular disease, and cancer. Years lived with disability for mental and substance use disorders increased 45% from 1990 to 2013 worldwide – during the same time that the incidence of obesity and the diabetes exploded.
Dr. Georgia Ede, a US psychiatrist with a passion for food’s impact on brain health, feels there is a strong connection between rising rates of mental distress and the obesity and diabetes epidemics.
“Why should the brain be any different than the rest of the body?” says Dr. Ede, who has her own website Diagnosis Diet, blogs about nutritional psychiatry at the magazine Psychology Today and has popular videos at Diet Doctor on low-carb for mental health and Alzheimer’s.“I believe the decline in mental health around the world has a lot to do with the decline in the quality of our diet over the last 75 years.”
Dr. Ede believes the two main driving factors for brain distress are high consumption of refined carbohydrates like flours, baked goods, cereals, fruit juice and sugar and refined and processed vegetable and seed oils.
“What do we know about those ingredients? We actually know a lot,” says Dr. Ede. “Both those ingredients (refined carbohydrates and refined industrial oils) are very powerful promoters of inflammation and oxidation. Many mental health disorders are very strongly linked to inflammation and oxidation, just like many physical illnesses are.”
Other potential culprits, Dr. Ede notes, are grains and legumes, which not only interfere with absorption of brain-healthy nutrients but are also high in lectins and other factors that may pose risks to brain health. Cutting out refined carbohydrates, refined oils, grains and legumes through the low-carb high-fat (LCHF) or ketogenic diet may improve mental health, just as doing so can reverse diabetes and promote weight loss, she notes.
What has happened to individuals with diagnosed, serious mental health conditions who have adopted an LCHF or ketogenic diet? Some of the anecdotes are inspiring.
“I feel better than I can ever remember,” said Scheto, 34, diagnosed with schizophrenia in his late teens, who was amazed by the ketogenic diet’s impact on his brain. “My brain is firing better than it has in years, but astonishingly the symptoms (voices) have lessened by what must be 90%. My brain is silent again and I can concentrate.”described how his own obsessive compulsive disorder was resolved almost instantly — never returning — on a low-carb high-fat diet. Naiman over the years has seen dramatic mental health improvements in his patients who adopt low carb ketogenic diet. “Definitely bipolar, depression, anxiety, OCD, are all much, much better on a low-carb diet,” he says.
In 2009, Drs. Eric Westman and Bryan Kraft published a case study and a review of the literature for a 70-year-old woman with life-long schizophrenia. Diagnosed at age 17, she had experienced daily visual and auditory hallucinations (skeletons that urged her to hurt herself) since the age of 7. She also had obesity, sleep apnea, hypertension, and gastro-esophageal reflux disease (GERD) among a number of other health issues. After only 8 days on the ketogenic diet, the voices and hallucinations stopped. At the time of publication she had continued the ketogenic diet for more than a year, with no return of hallucinations, and had lost more than 10 kilograms (22 lbs).
None of these testimonies surprise Dr. Georgia Ede. Not only was her own anxiety and depression alleviated on a ketogenic diet, she constantly gets comments on her blog from individuals with similar experiences.
Her 2014 column about low-carb diets and bipolar disorder now has 100 comments, and climbing, from a number of people with diagnosed conditions, particularly bipolar disorder, whose symptoms improved on the low-carb ketogenic diet.
A March 2018 column by Dr. Ede, about managing psychiatric medications while eating a ketogenic diet, elicited this comment from Vicky French: “Since starting keto almost 5 months ago I’ve had some major improvements in depression & anxiety. I was on 5 psychiatric medications. With the help of my psychiatrist I am off 3 medications.”
“These sorts of personal stories shed light on the relationship between food and mood that research studies cannot,” said Dr. Ede. “If we wait for science to properly test these theories we will be waiting for years. You have nothing to lose by doing your own individual experiments,” she says.
The brain can use two fuels
Our brains are very energy hungry. While weighing only 2% of our body weight, our brain consumes 20% of our daily energy. Studies show that two thirds of the brain’s energy budget is used to help nerve cells “fire” or send signals. The remaining third is for “housekeeping,” or cell health maintenance.
As was described in a recent Diet Doctor post on using ketones for Alzheimer’s Disease, it has long been known that the brain can use two fuels for its energy needs: 1) glucose or 2) ketones. Glucose is the product of the breakdown of carbohydrates that we eat or is made via our liver by a process called gluconeogenesis (literally “new glucose making.”) Ketones are the product of the breakdown of fat to fatty acids, either from fat in our diet or fat stored in our adipose tissue.Diet Doctor has a number of videos and posts about positive impacts of the ketogenic diet for migraines, brain cancer, and traumatic brain injury. Recently, two psychiatrists reviewed the research base for psychiatric issues and noted that while promising, it is slim. Dr. Ede takes a more hopeful view. “My mantra is that the most powerful way to change your brain chemistry is by food, because that’s where brain chemicals come from in the first place,” she says.
While the exact mechanisms of ketones on brain health are still unclear, a 2017 paper in the journal Neurochemistry summarized what is known: ketones as fuel in the brain have been shown to enhance mitochondrial respiration, increase neuronal growth factors, strengthen the signal sent between synapses, reduce brain inflammation, and reduce oxidative stress. These effects, the paper noted, then seem to have downstream implications for a wide range of brain functional pathways.
Clinical trials slim; basic science promising
Clinical trials that compare various diets’ outcomes among patients with mental health conditions are sorely lacking. For example, while currently there are 2822 clinical trials registered at Clincaltrials.gov for schizophrenia, none of them are examining the ketogenic diet’s impact on this debilitating chronic condition (three however, are examining gluten-free diets.) Likewise, there are NO ketogenic interventions among 1180 clinical trials for bipolar disorder and 5370 for depression. (Although there are still a number of trials for these conditions that are looking at “low-fat healthy diets” or “Mediterranean diets” with plenty of fruits, grains and vegetables.)
One notable clinical trial of the ketogenic diet for schizophrenia occurred in 1965. Back then, one of the authors noted that in some of his schizophrenic patients a carbohydrate binge preceded eruption of their hallucinations and paranoia. The study put 10 women with schizophrenia on a ketogenic diet for two weeks. The diet was added to their standard treatment of medication and ECT (electroconvulsive therapy) and resulted in a significant decrease in symptoms. A week after the women resumed a standard diet, symptoms returned. Despite this preliminary, positive outcome, few researchers in the intervening 50 years have investigated the promising potential of the ketogenic diet in schizophrenia.
The lack of clinical trials, however, does not mean there is a dearth of evidence that the ketogenic diet could have a powerful impact on brain health. Evidence that certain impaired brain functions can improve by increasing the use of ketones for brain fuel has existed for almost a century for epilepsy.
Epilepsy and bipolar disorder share features
It has been known for more than a decade that bipolar disorder shares a number of clinical, biochemical and physiologic features with epilepsy and that a similar neurobiology may underpin both disorders. Both conditions cycle, both are risk factors for each other, and anticonvulsant drugs used in epilepsy have been found to be effective in helping manage bipolar illness.
A growing body of research is finding that behind many psychiatric and neurological issues — such as bipolar disorder, epilepsy, migraine — are malfunctions in the work of sodium, potassium and calcium ion channels in brain neurons, which pass the electric charge between nerve cells. As noted above, two thirds of the brain’s energy is used to help nerve cells “fire,” or send signals between cells. Another nerve cell signaling chemical (neurotransmitter), called GABA (Gamma-aminobutyric acid) has also been found to be disordered in bipolar, epilepsy and schizophrenia. A 2017 genetic study also found common genetic and biochemical pathways between bipolar disorder and epilepsy that create “excessive circuit sensitivity” in the neurons of both conditions.
While the science of nerve signaling and genetic mutations is incredibly complex, it makes sense that a therapy, the ketogenic diet, that has been used successfully in epilepsy for 100 years might be helpful in conditions that share some similar features. Could changing the brain’s fuel, help change the malfunctions in its nerve cell firings and neuron excitability?
In 2013, researchers published a case study of two women with bipolar II who ate long-term ketogenic diets, one for two years and the other for three years. The authors reported that both “experienced mood stabilization that exceeded that achieved with medication; experienced a significant subjective improvement that was distinctly related to ketosis; and tolerated the diet well.” They noted, too, that “there were no significant adverse effects in either case” and that the two cases “demonstrate that the ketogenic diet is a potentially sustainable option for mood stabilization in type II bipolar illness.” .
A word about wheatOf all the high-carbohydrate foods that are eliminated in the low-carb ketogenic diet cutting out wheat products — bread, cereals, baked goods, pasta — may be the most significant for mental health disorders. It has been known for more than 50 years that an associate appears to exist between wheat consumption and symptoms for some people with schizophrenia.
Celiac disease is another condition with a very well established link to psychiatric and neurologic conditions. It is estimated that one to two of every 100 people has celiac disease, an immune disorder in which the ingestion of gluten in wheat, rye and barley destroys the lining of the small intestine, leading to a wide array of health problems. Another six out of every 100 people may have non-celiac gluten sensitivity, which while not having evidence of damage to the lining of their small intestine nevertheless can experience a wide range of health issues, including mental health issues.
In a comprehensive 2016 paper, Bread and Other Edible Agents of Mental Disease, the authors note that “the evidence is overpowering” for an association between wheat products and mental illness. While not everyone will see their mental health symptoms resolve, they recommend a wheat-free diet as a trial for anyone with mental health issues. The popular book Wheat Belly by Dr. William Davis, makes similar recommendations.
Fortunately, the ketogenic diet is wheat- and gluten-free.
Managing medications while going ketogenic
Are you thinking of trying the ketogenic diet for your mental health? If you are not on any psychiatric medications you can begin right away.
If you are on medication, Dr. Ede recommends you work closely with your psychiatrist or mental health care provider. “Ketogenic diets cause profound shifts in brain and body chemistry rather quickly. These changes are almost always positive and healthy, but they can have a major impact on medication levels, dosages and side effects that require close medical supervision,” she says.
In a March 2018 blog post, Dr. Ede provides a range of very helpful tips for anyone already on mood-altering or psychiatric medications who want to try a ketogenic diet, such as how to talk with your psychiatrist or mental-health provider and what laboratory metabolic tests the doctor should order to help monitor your response to the diet. Most importantly, she provides details about some specific medications — notably specific antipsychotic medications, anticonvulsant medications, and lithium — that should be carefully monitored.“The bottom line: if you take psychiatric medications, it is critically important to educate yourself, plan ahead, and work closely with your mental health providers before embarking on a ketogenic diet,” she says.
Originally Ole Jørgen took little to no medication for his bipolar illness, now he only carries medication as a safety precaution, in consultation with his doctors. Now he finds that with his ketogenic diet, exercise and good sleep his moods are predictable and stable. In short, life is good. He is reaching out to friends more. “I even met a girlfriend and we have started a good relationship.” He plans to run the New York City Marathon in the fall of 2018, another first for him.
“This diet is a great tool that you can adapt. I highly recommend that people try it and give it three to five months before drawing any conclusions,” he says.
If you have tried the ketogenic diet or a low-carb high-fat diet for your mental health concerns, we’d love to hear about your experience.
Below you’ll find a few interesting references, see links in the text above for more.
Amann B and Grunze H. “Neurochemical underpinnings in bipolar disorder and epilepsy.” Epilepsia 2005; 46 (suppl 4): 26-30. Link.
Ede, Georgia. “The Ketogenic Diet for Psychiatric Disorders: A New 2017 Review.” Psychology Today, June 2017. Link.
Ede, Georgia. “The Ketogenic Diet and Psychiatric Medications” Psychology Today, March 2018. Link.
Jackson, Jessica R. et al. “Neurologic and Psychiatric Manifestations of Celiac Disease and Gluten Sensitivity.” The Psychiatric Quarterly 83.1 (2012): 91–102. Link.
Scott J. Koppel, Russell H. Swerdlow. “Neuroketotherapeutics: A modern review of a century-old therapy.” Neurochemistry International, 2017. Link.
Stafstrom CE and Rho JM. “The ketogenic diet as a treatment paradigm for diverse neurological disorders.” Frontiers in Pharmacology 2012; 3(59).-30. Link.
Kraft, BD and Westman, EC. “Schizophrenia, Gluten, and Low-Carbohydrate, Ketogenic Diets: A Case Report and Review of the Literature.” Nutrition & Metabolism 6 (2009): 10. Link.