The exact causes of bipolar disorder (formerly known as Manic-Depressive Illness) are unknown. Current treatments are mainly medications. But they also include transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT). Unfortunately, for some patients, current treatments don’t work well. This is particularly so for bipolar depression. Interestingly, many treatments that are approved for treating epilepsy also work for bipolar disorder and other psychiatric disorders. This includes medications like Depakote (valproic acid), Tegretol (carbamazepine), Lamictal (lamotrigine), and Neurontin (gabapentin), among others.
Does energy metabolism play a role?
Given the overlap in effective treatments, it is not unreasonable to question if the medical version of the ketogenic diet, an intervention long used to treat epilepsy, might have a role in the treatment of bipolar disorder. In support of this possibility, recent research suggests that mitochondrial dysfunction and disturbances in energy metabolism play a role in bipolar disorder. This means the brain or certain parts of the brain may not be getting enough energy, at least from glucose.1
Both bipolar disorder and schizophrenia appear to be correlated with bodily dysfunction in the utilization of glucose for energy. The ketogenic diet allows the body and brain to begin using ketones for energy instead of glucose. Using ketones as an energy source may possibly bypass some of these abnormalities. This alternate energy source allows brain cells to be adequately fueled and therefore made more functional. The ketogenic diet also has numerous other beneficial effects on the body and brain, such as changes in neurotransmitter systems and decreased inflammation, that may also play a role in a therapeutic effect.
Does a medical ketogenic protocol work in bipolar disorder?
Yes. There are case reports, which should be considered only as preliminary evidence. Definitive evidence would be a positive outcome in a blinded, randomized, controlled trial.
In 2013, Phelps et al2 described two women diagnosed with bipolar disorder, type II. They each did the ketogenic diet for over 2 years and were able to get off all of their psychiatric medications. Reportedly they both did much better on the diet alone than they had ever done on medication. (A strong warning… getting off of psychiatric medication is a complicated process. It that requires slow tapering and medical supervision! Please don’t stop psychiatric medications on your own!)
What about Schizoaffective disorder?
Schizoaffective disorder is an even more devastating condition in which people experience both psychotic symptoms along with mania or depression. In 2017 our own Chris Palmer, MD published two studies3 of patients with this disorder, and both of them improved dramatically on the ketogenic diet. Both their psychotic and mood symptoms got better. Although they were diagnosed with schizoaffective disorder, the medications used to treat them were the same ones that are used to treat people with bipolar disorder. Schizoaffective disorder tends to be more treatment-refractory than bipolar disorder, so it is harder to successfully treat. The effectiveness of the ketogenic diet for the treatment of these two patients is an early indication that it could also be considered for treatment of bipolar disorder.
Apparent exception was not in ketosis
I would be remiss to exclude a 2002 report from Israel.4 It described a 49 year old woman with bipolar disorder. She reportedly tried the ketogenic diet for one month without any effect on her bipolar disorder symptoms. Of note, however, is that she NEVER had urine ketones and didn’t lose any weight. Weight loss is a common “side effect” of the diet early on. The lack of urine ketones and weight loss tells me that she was never in ketosis, so she was not doing the diet correctly. The authors concluded that she had tried it and it just didn’t work for her.
I believe this example speaks to the
- lack of understanding of the different versions of the ketogenic diet,
- need for appropriate monitoring for compliance, and
- most importantly, appropriate education for providers on how to do this diet, as it’s not easy to start.
Even when people think they are doing everything correctly, they may not be. The good news is that there is an objective test to tell us if a person is doing everything right. That is the presence and levels of ketones in urine and blood.
So… should people just try this medical keto protocol on their own?
As much as I wish it were that simple, it’s not. First of all, the version of the diet that appears to work for serious psychiatric disorders is the strict medical version using a 3:1 or 4:1 ratio. The ratios are grams of fat: grams of combined protein and carbohydrate. This is the same version used in treating pediatric epilepsy. This version of the diet should be medically prescribed and monitored. That’s because it is very difficult to do and has serious risks, as well as potential benefits. Levels of ketones, glucose, and body weight all impact the effectiveness of the diet.
Medical supervision is mandatory because…
- medications often need to be adjusted.
- new side effects can emerge when people are in ketosis. Some medications can interfere with the effectiveness of the ketogenic diet by increasing blood glucose levels and preventing ketosis, so they may need to be safely reduced or stopped.
- adjusting psychiatric medications can sometimes be very dangerous
- Finally, when starting the ketogenic diet, people can experience hypoglycemia, low blood pressure, weakness, dizziness, and other worrisome symptoms, which all need to be monitored and safely managed by a skilled medical team.
Nothing in this article or on this site is intended as medical advice. Anyone contemplating fasting, the ketogenic diet, a particular form of exercise, or any intervention as a treatment for an illness is urged to seek medical help from a competent medical provider trained in treatment of the underlying condition as well as the specifics of the proposed treatment or intervention. No healthcare provider-patient relationship is created by this article or website, or by any responses to comments posted in this forum by Chris Palmer, M.D or Christie Barnett, APN
1. Clay, H.B., Sillivan, S., Konradi, C., 2011. Mitochondrial dysfunction and pathology in bipolar disorder and schizophrenia. Int. J. Dev. Neurosci. 29, 311–324.
2. Phelps et al, The ketogenic diet for type II bipolar disorder. Neurocase. 2013;19(5):423-6
3. Palmer, CM. Ketogenic diet in the treatment of schizoaffective disorder: Two case studies. Schizophrenia Research , Volume 189 , 208 – 209
4. Yaroslovsky et al, Ketogenic Diet in Bipolar Illness. Bipolar Disorders 2002: 4: 75