Can a ketogenic diet successfully treat Bipolar Disorder?

bipolar disorder schizoaffective disorderThe 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.

Challenges for the ketogenic diet for bipolar disorder

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.

Where can I learn more?

In response to your requests we’ve put together the following resources:

Sources:

This article is based on portions of Chris Palmer, MD‘s presentation at Low Carb USA’s West Palm Beach 2019 conference.  My thanks to Nurse Christie‘s medical review and extensive edits.

  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
DISCLAIMER

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

Cecile Seth

Cecile Seth, MBA. Journalist. Co-Founder. Harvard Business School. Wellesley College. Bain & Company. Ms. Seth's award-winning blog, STEMshoots, helps her suburb with community planning and strengthening its schools.

12 Responses

  1. Patty says:

    I have been following the ketogenic diet to treat my bipolar disorder for 2 years. I have spent a lot of time researching it. I have Bipolar 1. I worked with my psychiatrist to wean off of all my medications. At the time I was taking Ativan, Vistaril, and Lithium. I can tell you from my personal experience the keto diet has helped me more than any medications I have taken. It does require some discipline but it helps with anxiety and bipolar. I really hope that more doctors start considering this as an option. Right now there just isn’t enough research on it. But, I can say for me it has worked very well.

    • Cecile Seth says:

      Patty,
      Thanks for sharing! Great to hear that you are finding keto and exercise to be useful parts of your tool kit on your path to better brain health! We’ve got more exciting insights in the pipeline. You may want to subscribe to our email list as well. I look forward to perusing your website in greater detail.

      Great thanks your doctor partnered with you. We would love to help move the needle on the research!

      Cecile

  2. Mary says:

    I would love to be a part of any clinical studies that might be upcoming. I’m dx’d with Bipolar Depression. I’ve been low carb for about 18 months now, mostly being in a low ketosis state. To be able to get rid of my meds would be exciting.

  3. Mary says:

    I would love to be a part of any clinical studies that might be upcoming. I’m dx’d with Bipolar Depression. I’ve been low carb for about 18 months now, mostly being in a low ketosis state. To be able to get rid of my meds would be exciting.

  4. Dorothy Krause says:

    I am 70. Been on Lithium fot 25 years.
    On Ketogenic diet for 3 years. Have reversed T2D, goal weight 2 yrs ago.
    I had a GP for 15 years who knew nothing about Keto. When I first started Keto he reduced my Lithium because I was toxic.
    My brain is a lot healthier but I feel the Lithium and Keto are too much together. In the last 3 months ive had several TIAs. My blood panel is all normal, I’m healthy, walk 20 km a week. I just feel that I need my Lithium reduced or removed.
    I’m really scared but don’t know where to turn.
    Even change from Lithium Carbonate to Lithium Orotate.
    Have changed doctors but they are reluctant to change because of good levels.

    • Cecile Seth says:

      Dorothy, I’m so glad to hear that your brain is feeling healthier and that you’ve been able to reverse your T2D and reach your goal weight! Congratulations!

      The TIA’s must have been frightening. Luckily, on our Ketogenic Clinicians Page we have 5 MD’s who are willing to see Keto-for-Psych patients. Four are psychiatrists and three are based in the US. Several see patients remotely or could consult with your existing prescribers. You’ll need to scroll down to the middle of the page.

      The literature reports that reducing psychiatric medications is tricking so I’m glad that you are looking for a doctor to help rather than trying to do it on your own. Please be careful and stay safe.

  5. T says:

    What else ya got to sell?

    “They each did the ketogenic diet..”

    “did?”

    • Cecile Seth says:

      “Did” refers to the time period which the case report describes. It does not try to cover what happened after publication.

      Many individuals report symptoms returning within 24-48 hours of eating carbohydrates again. That’s part of the reason we refer to symptoms being in remission rather than a cure. Perhaps carbohydrate addiction is similar to alcohol or opioid addictions. Currently there are clinical trials underway investigating just this fact.

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