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A ketogenic diet could end your mental illness

Reading time: 15 minutes
Ketogengic diet could end your mental illness

Celeste McGovern investigates how the high-fat ketogenic diet could put an end to some of psychiatry’s most stubborn illnesses.

Carrie Brown was handcuffed to a hospital gurney. She had been waiting for more than five hours, under the watch of a guard, for a specialist to determine if she should be committed involuntarily for psychiatric treatment. Her heart rate had normalized now, and she looked back on how this wretched day had completely unraveled. 

It had begun with the usual gloom of depression that had been with her for most of her 38 years, but a new sense of despair had also crept in recently that she just couldn’t shake.

 To make matters worse, she hadn’t slept for the past 48 hours. In fact, in a sort of driven frenzy, she’d made herself work for 36 of them. 

From her office at Microsoft where she was an executive assistant, she’d telephoned her therapist because her mental storm was unbearable. He’d returned her call, but it hadn’t helped. “I’m done,” she said finally, and then hung up. 

Carrie had seen numerous psychiatrists before. Her health care bills averaged $36,000 a year. Various medications over the years had not worked out for her. 

One particularly bad year, she’d been on five different prescriptions; a few had helped for a time, but also made her “zombie-like,” violent, restless or suicidal. One drug put her in a state of unrelenting panic attack for weeks. 

She left the medicines behind and stuck to talk therapy but was still stuck in her depression graveyard.

That evening, as Carrie drove home from her office, occupied with thoughts of ending her life, she saw a police SUV approaching as she neared her house. It was something she’d never seen in her exclusive suburban neighborhood. The officer in the driver’s seat glanced at her as they passed each other, and in her rearview mirror she saw the SUV do a U-turn and follow her. 

“He called the police!” she thought of her psychotherapist and, panicking, stepped on the gas to make it home and lock herself in. As her automatic garage door was descending, the police officer threw himself underneath it and it rose again. 

In the conversation that ensued, she knew she had become belligerent and irrational. He called for back-up. Six officers were on the scene, plus paramedics, and she eventually arrived at the hospital, handcuffed, in an ambulance.

Looking back on it seven years later, Carrie sees that “breakdown” as a sort of stepping stone to where she is now. Her depression diagnosis was changed to bipolar disorder to account for her despairing lows and frantically driven manic highs. 

She was given lamotrigine, an antiepilepsy drug, for treatment, and after taking it for just three days, she says, “It was like someone turned the lights on.” She felt joy for the first time in years, and she was productive and happy. 

Six months later, however, she woke up one day and the effect was gone. Her doctor doubled her dose and she lifted again, and then a few month later, descended. 

She stayed on lamotrigine, but, fed up with drugs and desperate, Carrie began searching for answers elsewhere, ordering a battery of genetic and food sensitivity tests. She saw a naturopath, started taking B vitamins and gave up grains and sugar. 

It helped, but she was still on a roller coaster of manic highs and depressive lows when she met Seattle-based physician Ted Naiman on a social platform where he mentioned that he thought bipolar disease could be helped with a ketogenic diet.

After consulting Naiman and converting her low-carb diet into a strict high-fat ketogenic one, Carrie says she improved dramatically in just weeks. Three months later she was weaning off her medication. 

“It’s been more than five years that I have not been depressed,” she says. “I’m not bipolar anymore and I’m off all medication.”

Once an award-winning professional baker who made pastries for the Queen of England, Carrie has turned her culinary talents to whipping up ketogenic recipes and cookbooks and teaching people how to cook keto on her website (www.carriebrown.com). “I don’t want people to die or live a depressed life just because they don’t know how to cook,” she says.

Carrie’s claim that a change of diet took her from of decades living a life of  “grays” to one of  “technicolor happiness” may sound like hyperbole or extraordinary at least, but there is a growing number of similarly incredible testimonies of people overcoming anxiety, lifting out of depression and ending panic attacks using a high-fat, low-carbohydrate ketogenic diet.  

A few astonishing cases have made their way into medical journals, where mounting evidence is laying out the case for keto as a serious treatment for brain disorders from epilepsy to psychosis, neurodegenerative diseases such as Alzheimer’s and Parkinson’s, and mood disorders.

How does it work?

In theory, there are several mechanisms that can explain why a ketogenic diet could be a valid therapy for mental illness. A 2020 review outlines four major issues in brain metabolism that using fat as an alternative fuel to the brain could help correct: 

• glucose hypometabolism

• neurotransmitter imbalances

• oxidative stress

• inflammation.1 

“These four foundational metabolic diseases warrant a metabolic approach to therapy,” writes lead author Nicholas Norwitz, an Oxford-trained physiologist and Harvard University medical student whose research focuses on the ketogenic diet for neurological diseases.

“This shift from a glucose-dependent brain metabolism to a fat- and ketone-based metabolism allows for the circumvention of glucose hypometabolism, it rebalances neurotransmitters, it reduces oxidation and it reduces inflammation,” explains Norwitz.

Epilepsy treatment

Harvard professor of psychiatry Dr Christopher Palmer is a frontrunner in the field of using nutrition to treat psychiatric illness. His interest in the ketogenic diet stems from its use for nearly a century as a well-documented treatment for epilepsy. It had been discovered that many patients’ epileptic seizures stopped when they fasted for periods as long as 18 to 25 days. 

Fasting—as well as a high fat/ low carbohydrate diet, it turns out—produces ketone bodies that are an alternate fuel for the body and brain. In 1921, the Mayo Clinic’s Dr Russell Wilder developed the high-fat/low carb ketone-producing “ketogenic” diet for epileptic patients, which has a similar effect to an extended fast.

The diet fell out of fashion with the advent of antiepileptic drugs but regained popularity with those who experienced their side-effects or didn’t respond to drug therapy. Now, it’s accepted as an “evidence-based” treatment for epilepsy when all else fails.1 

“We know from the abundant epilepsy evidence that sometimes people with severe epilepsy—people who are having 20 seizures a day that haven’t responded to drugs and  sometimes even surgery and nothing has worked for them—then find the keto diet works for them,” says Palmer. “It doesn’t work for everybody, but about 55 percent of people with refractory epilepsy respond to some degree. I hesitate to say ‘cure,’ but some have complete remission of seizures.” In some cases, people with severe epilepsy have even remained seizure-free after they stop eating keto. 

Psychiatry’s most staple drugs are in fact antiepileptic drugs, Dr Palmer points out. Many anti-anxiety drugs and antipsychotics, drugs used to treat eating disorders, substance abuse and sleep disorders as well as being used as mood stabilizers, were first used in neurology to stop seizures in epilepsy. 

Palmer reasons that if a diet has the power to stop seizures in their tracks where drugs like gabapentin, Valium and Xanax fail, then perhaps it could also work for other brain disorders those drugs  are used to treat, especially when they don’t work or cause intolerable side-effects.

All metabolic

Most psychiatric diseases are still explained in the mainstream as “chemical imbalances” where neurotransmitter signals go awry. But  if that’s the case, Palmer wonders, “Why do the symptoms come and go then? Why do people hallucinate some days and other days they don’t?”

Brain metabolism is a different way to think of brain disorders, he says. 

Recent research has pointed to aberrations of metabolism in the brains of people with neurodegenerative diseases like Alzheimer’s and mental illnesses like schizophrenia, as in epilepsy. It’s been known for decades that people with some mental illnesses have metabolic issues with their brains as well. 

The ketogenic diet is understood to dramatically alter brain metabolism, which is how it works in epilepsy. Like an engine switching from regular fuel to diesel, when the brain switches to running on its default of burning glucose to burning ketones from fat, it bypasses problems with the default setting.

The ketogenic diet has become very popular for its weight loss effects, but Palmer insists its effects are potent beyond the body. “This is not a fad diet,” he says. “This is a metabolic intervention that profoundly changes brain metabolism to affect a metabolic brain disorder.”

Profound or not, it’s still an idea that is foreign to most mainstream psychiatrists. “Some people think there’s no way that a diet can treat a hard-core brain disorder like schizophrenia,” Palmer says. “But epilepsy is a hard-core brain disorder too, and we use diet to treat that and sometimes it works.”

Case reports

In his 2019 paper published in the journal Schizophrenia Research, Palmer describes two patients with long-standing, severe mental illness who made astonishing recoveries when they began to eat a ketogenic diet. 

“Patient A”  is a woman with a 53-year history of unremitting schizophrenia. She was diagnosed at age 17 when she developed chronic paranoia and began seeing skeletons and hearing voices on a daily basis. 

Over the following decades, she was hospitalized on multiple occasions for psychosis and suicide attempts and was medicated over the years with at least nine different antipsychotic and mood stabilizing drugs. 

In 2008, at the age of 70, she was taking six different drugs, receiving Social Security, and had a visiting mental health team and a court-appointed guardian. Weighing 330 pounds, she began eating a ketogenic diet to lose weight. Within two weeks, according to the paper, “she noted a marked reduction in her psychotic symptoms.” 

Over the next several months, the woman took it upon herself to stop all of her medications. Her mood improved dramatically, and she no longer had suicidal thoughts. Her hallucinations and paranoia remitted completely. 

In 2019, at the age of 82, she had remained on the ketogenic diet for 12 years, had lost a total of 150 pounds, took no medications, was free of psychotic symptoms, no longer required a care team and no longer had a guardian.  The study adds, “She lives independently, and reports that she is happy to be alive.”

“Patient B” is  a 39-year-old woman with a history of depression, anxiety, anorexia, hallucinations and paranoia that began in 1993, who was eventually diagnosed with schizophrenia. Despite having tried more than a dozen different psychiatric medications over the years, her symptoms persisted.  

In 2013, she started on a ketogenic diet when she visited a functional medicine practitioner for symptoms of chronic gastrointestinal distress. Shortly after starting the diet, she abruptly stopped the 14 medications she was taking and became severely psychotic. Although hospitalized and started on the antipsychotic drug haloperidol (Haldol), she continued the ketogenic diet. 

Within a month of starting the diet, she reported complete resolution of her psychotic symptoms for the first time in 20 years, despite having tried Haldol in the past without a response. 

She was tapered off Haldol over the following year, and has remained free of psychotic symptoms for the past five years while off all antipsychotic medications. She continues the ketogenic diet, and since her symptoms have remitted, she has finished graduate school and now works full time.2

Some studies have reported benefits in a small number of autistic children eating a strict keto diet.3 Other research has reported positive results using the ketogenic diet with binge-eating disorder,4 schizo-affective disorder and major depression.5 

In one case reported by Palmer and colleagues in 2017, a 33-year-old man with a history of attention deficit hyperactivity disorder and major depression was diagnosed with schizoaffective disorder in 2003. He’d been put on trials of 17 different psychiatric medications with varying effects. 

He weighed 322 pounds and went on a ketogenic diet to lose weight. Within three weeks, he had lost 15 pounds but also noticed that we wasn’t hearing voices as often, while his mood, energy and focus had all improved. 

Over the following year he lost a total of 104 pounds and gradually tapered his drugs. On five occasions when he stopped the diet, he noticed his symptoms worsened for two days until his body started burning ketones again as measured by urine ketone strips. His life improved dramatically, and eventually he was able to complete courses online, make friends, begin dating and move out of his father’s home into his own apartment.5

Diabetes of the brain

The problem of glucose hypometabolism—the brain’s inability to efficiently burn glucose for fuel—has been noted in Alzheimer’s disease as well. Alzheimer’s brains show an altered glucose metabolism and impaired insulin regulation in tandem with the cognitive decline and deterioration of the

brain size and structure that are the hallmarks of the disease.1 

The discovery has led some researchers to call Alzheimer’s “type 3 diabetes” because blood sugar and the effects of insulin in the brains of Alzheimer’s patients are akin to those of a person with diabetes, but specific to the brain.

The original diabetic diet before the discovery of insulin was the ketogenic diet. This is also the diet that is increasingly being used to curb type 2 diabetes and obesity.2 

Likewise, the ketogenic diet is emerging as a promising new therapy for Alzheimer’s and other neurodegenerative disorders like Parkinson’s disease because it targets underlying metabolic problems and gut and brain inflammation.3 

“Low carb and ketogenic diet are the best way to prevent cognitive decline and neurodegenerative diseases bar none,” says brain researcher Nicholas Norwitz.

Clinical trials needed

Keto skeptics may be unimpressed by case reports, however. Despite many people claiming on the internet that they put their anxiety or depression into remission, the only studies for these conditions have been in rats and mice. The rest of the research is limited by small sample sizes, lack of controls, insufficient testing to confirm ketosis and variation in ketogenic diets. 

However, there is enough information to have inspired a growing number of doctors to try the diet in practice, and scientists to want to investigate. Research in mice has shown that a keto diet can reduce tremor in animals withdrawing from alcohol, so a major clinical trial sponsored by the US National Institute of Alcohol Abuse and Alcoholism is underway to see if the diet can lessen symptoms of alcohol withdrawal in alcoholics, for example.

Palmer’s group is running a pilot study of the ketogenic diet for opioid addiction. He has launched a fundraiser for the $350,000 needed to conduct a randomized, controlled, 8- to 12-week study of the ketogenic diet in people with psychosis, which he is confident would produce the results needed to get the approach mainstream attention. “We need the gold standard of research for this approach,” he says.

Personal experience

A frequent collaborator of Dr Palmer’s is physiologist Nicholas Norwitz, an expert in ketogenesis and brain aging who completed his doctorate at Oxford and is now a medical student at Harvard. Norwitz first learned the power of the keto diet from experience. 

Growing up, he ate a low-fat Standard American Diet loaded with carbohydrates from cereals, breads, pastas, pizzas and fruit. “If I was skinny, I was healthy,” Norwitz figured, and as a rail-thin kid who could run a half-marathon in under 75 minutes, he thought he was
very healthy. 

At 18, however, he developed severe osteoporosis. “My bones were, biologically, four times my chronological age.” He had fractures in his feet, shins, femurs and spine, and his marathon days looked to be behind him.

That was not Norwitz’s worst affliction, however. His gut started cramping and bleeding, and by his early 20s he was diagnosed with ulcerative colitis, an inflammatory disorder of the gut that can severely hamper normal life.  

In one particularly bad flare of the disease while he was studying at Oxford, he lost 20 pounds and his heart rate dropped below 30 beats per minute. He wound up housed in a palliative care unit in England for three days until he stabilized.

Back home in Boston, he says, he was “a little bit desperate.” None of the drugs he’d been prescribed nor the many diet modifications he’d tried had worked. His calprotectin test, a measure of inflammation, was
150 µg/mg on a scale where a normal reading is below 50 µg/mg.  

“Either I’m going to figure this out or I’m going to die,” he recalls thinking. He’d read about the ketogenic diet and decided he had nothing to lose in trying it. To his amazement, “One week after starting, all of my symptoms were gone.”  

He convinced his GI specialist, who was skeptical that a retest of inflammation would show any changes in just a week, to repeat the calprotectin test anyway, because he was returning to Oxford. One week after starting the ketogenic diet it had plummeted from 150 µg/mg to
20 µg/mg.

“Weirdly, I also felt incredible,” recalls Dr Norwitz. He had more energy and eventually came off all of his medications. One year into the ketogenic diet, he checked his bone density and was shocked to find that he no longer had osteoporosis. 

“It’s not an exaggeration to say that addressing my metabolic health through nutrition may have saved my life,” he says. His own health transformation changed Norwitz’s career path; he focused his doctoral research on the ketogenic diet. 

“The most remarkable thing about thing about my story is that it’s not at all unique,” says Norwitz, who discovered a whole “keto community” of people who had put their health ailments behind them using a ketogenic diet. 

He’s teamed up with keto cook Martina Slajerova (whose healed her own thyroid condition with a keto diet) and others for a forthcoming “keto-friendly” cookbook (The New Mediterranean Cookbook, Quarto Publishing Group, 2021).

“Psychobiotic” psychiatry of the future?

In their landmark 2017 study, researchers from McMaster University in Canada transplanted stool from patients with irritable bowel syndrome (IBS) and anxiety, a common co-occurrence of the condition, into “germ-free” mice lacking their own microbiota. Remarkably, the mice not only developed quicker bowel transit time, indicating they had developed irritable bowels, but they also showed clear signs of becoming anxious too.

The experiment demonstrated how bacteria or bacterial products from the microbiome may not only affect gastrointestinal function but also mediate gut-brain interactions and alter behavior.

“It showed you could ‘catch’ mental illness,” says Valerie Taylor, chief of psychiatry at the University of Calgary in Canada. “Now we’re trying to see if we can do the reverse.”

Taylor’s research group has been conducting fecal transplant experiments at Women’s College Hospital in Toronto to see if “poop pills”—capsules filled with stool from the healthiest donors they could find—can positively alter the mental health picture of bipolar and depressed patients who swallow them. 

GI issues are a common complaint among patients with mental illnesses, and while mainstream psychiatry tends to refer these to a different specialist in the hospital, the “gut-brain axis”—a two-way-street between the central nervous system and the gut nervous system mediated by bacteria—is one of the hottest research topics going. 

At this stage, researchers don’t even know what  a “normal” human microbiome should look like or what microbes, if any, are missing or over-represented in various mental illnesses.

Perhaps, as researchers found in another recent study of IBS, there will be psychiatrically sound “super donors” able to transplant in a pill the mental health microbes that those suffering from mental illnesses lack.1 

While Taylor does not want to disclose any details of her team’s findings before publication this year, she does say the results are “really, very intriguing.”

High fat is healthy

Dr Palmer at Harvard warns that the medical ketogenic diet he uses to treat epilepsy and serious mental illness is much stricter than a lot of popularized variations that allow higher ratios of carbohydrates to fats. 

Though many people with less severe illnesses report improvement on less intense versions of keto, the classic medical ketogenic diet is a ratio of four grams of fat for every one gram of protein and carbohydrate combined. 

For serious chronic disease, “it needs to be medically managed,” says Palmer. He is no longer taking new patients, but he encourages people who are struggling with serious mental illness to visit his website
(www.chrispalmermd.com) for resources and to seek out a doctor who can monitor ketosis to ensure it’s done accurately and adjust medications as necessary.

“I am pragmatic enough to know that there are risks with it,” says Palmer. Selenium deficiency and high calcium levels have been reported with keto, for example. Most mainstream doctors worry that a high-fat diet could lead to weight gain and cardiovascular risks, and that’s a concern that needs to be investigated, even though the diet is widely known for its weight loss effect.

However, there are risks associated with psychiatric drug treatments, too. Obesity is a frequent side-effect of psychiatric drugs, and recent research has found that people with a serious, chronic mental illness had an average of 14.5 years shaved from their lives, with cardiovascular disease the leading cause of death.6 

The ketogenic diet directly opposes the American Heart Association-approved “low fat” diet that’s been ingrained in the public health consciousness for decades. It rids the diet of processed junk, however, and includes all whole foods like bacon and eggs, avocados, fish, steak, chicken, shrimp, nuts, low carbohydrate vegetables such as broccoli and asparagus plus a lot of healthy fats like olive oil added in. 

“Eat as much oil as you can tolerate and as much fat in whatever way you find palatable,” Palmer advises. High-fat cheese and yogurt, whipped cream and butter are all in. Low-fat foods, sugar, including sugars from fruit, and inflammatory oils containing trans fats or too many omega-6 fats are out. 

Dr Palmer isn’t convinced that the ketogenic diet is the answer for every mental health patient. He doesn’t know if some patients will be permanently healed enough to be able to eat a common high-carb diet (though he knows some who have made remarkable recoveries and will occasionally indulge in a piece of cake or pizza). What it does offer is a new way of viewing mental illness that is not as hopeless as it often seems.

“I very much hope that this will be a help to some of the many people who are tormented and disabled by their mental illness, when they’ve tried everything and nothing works.” 

Fundamentals of a keto diet

The ketogenic diet is a high-fat, low-carbohydrate diet in which the body is in a state of ‘ketosis,’ burning fat instead of carbs for fuel. There are many variations, but essentially the basis of it is the following:

• Avoid all sugar, grains and processed foods that include grains

• Eat good-quality plant or animal protein 

• Have substantial amounts of stable saturated ‘good’ fats:  olive, hemp and rapeseed oils, animal fats (beef fat, butter, duck fat) and coconut oil

• Eat copious amounts of green and rainbow vegetables

• Keep starchy vegetables to a minimum.

For a simple guide, consult Dr Sarah Myhill’s book, The PK Cookbook (Hammersmith Books, 2018). To find out if your body is in a state of ketosis, use urine strips or purchase a ketometer, which determines your state of ketosis from your breath. 

 

References

How does it work?

1 

Curr Opin Endocrinol Diabetes Obes, 2020; 27: 269–74

 

Diabetes of the brain

References

1 

Lancet Neurol, 2020; 19: 758–66

2 

Expert Rev Endocrinol Metab, 2018; 13: 263–72; J Nutr, 2018; 148: 1253–60.

3 

Mol Neurobiol, 2020; 57: 4961–77; Int Rev Neurobiol, 2020; 155: 141–68

 

“Psychobiotic” psychiatry of the future?

References

1 

Gut, 2020; 69: 859–67

 
Main Article

References

1 

Cochrane Database Syst Rev, 2020; 6: CD001903

2 

Schizophr Res, 2019; 208: 439–40

3 

Front Pediatr, 2014; 2: 69

4 

J Eat Disord, 2020; 8: 2

5 

Schizophr Res, 2017; 189: 208–9

6 

Psychiatr Serv, 2010; 61: 663–8

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