Can a ketogenic diet successfully treat Bipolar Disorder?

ketogenic diet Bipolar Disorder schizoaffective

The exact causes of bipolar disorder (formerly known as manic depressive illness) are unknown. Most people believe it is related to a chemical imbalance, referring to neurotransmitter imbalances in the brain. Current treatments are mainly medications, which supposedly correct these imbalances. When medications fail to work, treatments can also include transcranial magnetic stimulation (TMS) and electroconvulsive therapy (ECT). Unfortunately, for some people, current treatments don’t work well enough, leaving them with unstable moods, chronic depression, and even disability.

The Epilepsy Connection

Many treatments that are approved for the treatment of epilepsy also work for bipolar disorder and other psychiatric disorders, including medications like Depakote (valproic acid), Tegretol (carbamazepine), and Lamictal (lamotrigine). Other anticonvulsant medications are used off label very commonly in the treatment of bipolar disorder. This includes medications such as Neurontin (gabapentin), Topamax (topiramate), and all of the benzodiazepines, such as Klonopin, Ativan, and Xanax. Given the overlap in effective treatments, it is not unreasonable to question if the evidence-based ketogenic diet might play a role in the treatment of bipolar disorder, at least for some people.

Energy Metabolism in Brain Cells

In support of this possibility, recent research suggests that disturbances in energy metabolism play a role in bipolar disorder, meaning the brain or certain parts of the brain may not be getting enough energy, at least from glucose. (1) This is often described as mitochondrial dysfunction. There appears to be a correlation between bipolar disorder and the body’s impaired ability to process glucose/sugar for energy. The ketogenic diet forces the body and brain to begin using ketones for energy instead of glucose, possibly bypassing some of these abnormalities. The ketogenic diet also has numerous other 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.

Is there evidence that the ketogenic diet can work in bipolar disorder?

There are case reports, which should be considered preliminary evidence (definitive evidence would be a blinded, randomized, controlled trial).

In 2013, Phelps et al (2) described two women diagnosed with bipolar disorder, type II, whoeach did the ketogenic diet for over 2 years, were able to get off all of their psychiatric medications, and reportedly did much better on the diet alone than they had ever done on medication. [As a caution… getting off of psychiatric medication is a complicated process that requires slow tapering and medical supervision! Please don’t stop psychiatric medications on your own!]

For those who suffer from a more serious form of bipolar disorder, including those with psychotic symptoms, in 2017, I published two case studies (3) of patients with schizoaffective disorder, bipolar type, that improved dramatically on the ketogenic diet. Improvement occurred in both mood and psychotic symptoms. Although these people were diagnosed with schizoaffective disorder, the medications used to treat bipolar disorder and schizoaffective disorder are often then same. If anything, schizoaffective disorder is more treatment-refractory, so given that the ketogenic diet worked for these two patients, it should at least be considered for those with treatment-resistant bipolar disorder.

I would be remiss to exclude a 2002 report from Israel (4) that described a 49 year old woman with bipolar disorder who 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 (a common “side effect” early on), which tells me that she was never in ketosis, so was not doing the diet correctly. The authors concluded that she had tried it and it just didn’t work for her, which again speaks to the lack of understanding of the different versions of the ketogenic diet, appropriate monitoring for compliance, and most importantly, appropriate education on how to do this diet. It’s not easy to do. 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, and that is the presence and levels of ketones in urine and blood.

So… should people just try this diet 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 (2:1 up to a 4:1 ratio diet), the same one used in treating epilepsy. This version of the diet should be medically prescribed and monitored, as it is very difficult to do and has risks, as well as potential benefits. Levels of ketones, glucose, and body weight all impact the effectiveness of the diet. Additionally, medications often need to be adjusted, as new side effects can emerge when people are in ketosis, and 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, and should only be done with medication supervision and monitoring. 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.

Sources:

  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

Dr. Chris Palmer

Psychiatrist with a clinical practice at McLean Hospital in Belmont, Massachusetts. Director of Department of Postgraduate and Continuing Education, and Assistant Professor of Psychiatry at Harvard Medical School.  He has been using the ketogenic diet to treat his patients for more than 15 years.

16 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.

  6. Earle Barker says:

    I am bipolar 1. I have struggled with alcohol and abusing prescription medication for about 25 years. I always end up quitting my meds because I cannot stand the way I feel on them and turning to alcohol, pain killers and benzos.
    A few years ago I began another one of my many health kicks and started experimenting with intermittent fasting staying in ketosis constantly. Those several months I stayed on a fasting focused routine while working out hard with weights is the best I’ve felt and looked since I was in high school. I eventually fell victim to myself and the old habits that are so familiar and going down a bad path.

    I’ve now been sober 3 weeks and am on my first 72 hour fast. I’ve been feeling really bad lately, down, no energy, sad, anxiety and obsessing over things.
    This morning I woke up feeling great! I’m in an awesome mood!
    I checked my keto strip and it was significantly pink and this made me wonder and worry if fasting might bring on a bout of mania and I came across this great article.
    I hope to abstain from alcohol indefinitely and remain on a fasting focused lifestyle.

    From the short history I have with ketosis, I can say for sure, it seems to make a huge difference in my energy levels and mood.

    • Volunteer Journalist #1 says:

      Thanks for your note! Great to hear that you are feeling so much better!

      Please stay safe! I strongly encourage you to include your medical team, especially during the fat adaptation period, because symptoms can get worse before they get better. This journal article gives you a sense for both how effective ketosis can be and the minority of folks who self-reported adverse symptoms along the way. In this article 8 out of 165 individuals reported “mood destabilization.” Campbell, I. H., & Campbell, H. (2019). Ketosis and bipolar disorder: Controlled analytic study of online reports. BJPsych Open, 5(4), e58. https://doi.org/10.1192/bjo.2019.49 You can download a full pdf of the article for free.

      In addition to fasting, you might want to consider the version of the medical ketogenic diet used in pediatric epilepsy. The 3 dietitians on this list are very experienced and can work with you remotely.

      Please consider working with your healthcare provider to have your results published as a case study! That is the best way to change the medical establishment and help them to adopt this therapy and keep patients safe! Here’s an overview of the process. Why write medical case reports about unique cases? While there are many anecdotes of fasting helping bipolar, it would be great to have case studies in peer-reviewed literature. I (Cecile) can help support your healthcare provider if they have questions. They will be more likely to be comfortable writing a case study if you involve them along the way.

      Sounds like you are successfully figuring out how to make fasting work for you! If you have questions, then The Fasting Method is a quality source of information.

      Keep up the great work!

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