depression Archives - Chris Palmer, MD

Low Carb MD podcast with Drs. Tro and Brian Lenzkes – Treating schizophrenia with a ketogenic diet

Christie Barnett, APN — Sun, 08 Sep 2019 14:05:05 +0000

Show notes for Low Carb MD Podcast Episode 49

00:00 Welcome to the Low Carb MD podcast with Dr. Chris Palmer. He is a Harvard psychiatrist who has case reports and case studies on mental health and the ketogenic diet.
01:23 Nutritional approaches to psychiatric disorders.

Dr. Chris Palmer’s personal health history and metabolic recovery

02:19 Dr. Palmer’s story, 20-25 years ago, “I was one of those skinny, metabolically-disordered people.”
03:19 Chris’s low fat diet.
03:33 Dr. Palmer’s health: “I was pre-diabetic. I definitely had hypertension and I had horrible cholesterol.”
05:36 The effect of low-carb diet intervention, “Everything was better. My LDL plummeted. My HDL doubled. And my triglycerides plummeted into a normal healthy range. I was no longer pre-diabetic. My blood pressure was down to a really good, healthy level.”
06:02 Twenty+ years on a low-carb ketogenic diet.

Lifestyle intervention

09:01 “When I speak to other physicians I often ask how lifestyle interventions are going for their patients? Almost all of them roll their eyes and give a deep sigh of hopelessness and futility. ‘There’s no point. It never works.’ Their perception is that the patients are lazy slackers.”

Change is hard

10:01 “Bad advice doesn’t work. Low-carb, high-fat eating goes against everything that we have believed for decades. Everything that we’ve been taught. Change is hard.”

Global metabolic and mental disorder epidemic

11:44 “In the United States, and around the world, there is something profoundly wrong… Obesity rates are skyrocketing. Diabetes rates are skyrocketing, and my passion, mental disorders, are skyrocketing.”
12:30 Other mental disorders are also skyrocketing at the exact same time that we’re seeing these exploding rates of metabolic disorders.

Ketogenic diet as intervention for treatment-resistant depression and weight loss

13:40 “I’ve been using it with patients for treatment-resistant depression. And, I’ve been using with a lot of people for weight loss and just for general health improvement.”

Speaking out

14:04 Also, I knew I was going against the medical establishment.
14:54 “I can’t stay quiet anymore.”
15:21 “A schizophrenic patient was on every medication. He suffered every day every day.”
16:19 “On psychiatric medication, he gained 150 – 200 lb, he was sedated. He couldn’t function. He couldn’t live alone.”
17:03 “I had worked with him for 10 years. We had tried numerous medications.”

Sometimes medication is not enough when treating schizophrenia

17:22 “And we couldn’t help him. We’re doing our best. The medications are required. They’re essential.”
18:12 “But these medications also made him morbidly obese. These medications are sedating him so that he sleeps 16 hours a day. And these medications are not working for him.”
18:45 “Unfortunately, there are literally tens of millions of people just like him all around the world, and this is what the medical field has to offer them.”

Weight loss and psychosis

19:02 The patient wants to lose some weight.
19:09 “Getting a person with schizophrenia to do a diet though. Everybody thinks that’s impossible.”
20:34 But, at the 3-week mark of doing a ketogenic diet, I noticed something distinctly different about him. He’s losing weight. But he is now starting to be more alert. I haven’t changed his meds at all.”
21:26 At about 6 weeks, “He spontaneously reports to me: ‘Dr. Palmer, you know those voices that I tell you I hear all the time? I think they’re kind of getting quieter and I’m not hearing them as much, they’re not talking as much anymore…’”

Ketogenic dietary intervention takes time to work when treating schizophrenia.

22:01 Another 4 weeks go by, this treatment takes time, he says “Dr. Palmer, you know, I had these delusions? I think maybe that’s not really happening, I think maybe I have schizophrenia and it’s getting better.”

100 pound weight loss and psychiatric symptoms improve

23:48 He loses over a hundred pounds at the one-year mark. He is improved psychiatrically, functionally, and socially.

Going off the diet and symptoms return

24:57 If he does not follow the diet, he can become acutely psychotic again within 24-48 hours. Just like stopping medication. When he resumes the diet, symptoms abate.

Keto diet is not a stand-alone treatment

25:57 Psychosocial and psychoeducational intervention, and sometimes medications, are still necessary. Keto is not a cure-all.

Psychiatric medications

27:43 Medications interfere with metabolism, cause weight gain, diabetes, and increases in blood sugar and insulin.

70 year old woman with schizophrenia improves on keto

28:25 One of Dr. Eric Westman’s patients had chronic paranoid schizophrenic for 53 years. She couldn’t function in life.

Dr. Eric Westman at Duke University

29:24 She had debilitating, disabling schizophrenia and she gained weight up to 330 pounds. Eric Westman, MD treated her at the low-carb weight-loss clinic at Duke University.
30:24 Within 2 months her psychotic symptoms were improved.
30:32 “She has been off of medications now for 12 years, fast forward 12 years. That’s today. She’s lost 150 lb.”
31:14 The patient is symptom-free.
31:16 She’s off all medications.
31:36 “She is so excited to share her message of recovery using the ketogenic diet.”

Compliance

32:21 Compliance is a huge issue.

Food as medicine?

35:00 Food can act as medicine?
36:11 It’s not a conclusion. It’s a question.

Quackery?

36:42 Quackery… skepticism.
37:54 “We have more basic science research and knowledge and understanding of the effects of this [ketogenic] diet on the human brain than we do any other dietary intervention and than we do for most psychiatric medication.”
38:14 “Thousands and thousands of studies published in some of the best medical journals neurology journals.”

Keto for epilepsy

39:14 Twenty to 30% of treatment resistant people treated with the ketogenic diet are seizure-free. “These are the worst of the worst. They’ve tried everything they suffered for years or decades and nothing is working for them. And this diet can make 20 to 30% of them seizure-free.” But, some can’t stay on the diet.

Cochrane review

39:50 “The Cochrane review on the ketogenic diet for pediatric epilepsy in particular, and it is unequivocal in its conclusion: The ketogenic diet is an effective treatment for epilepsy.”

“Off-label” treatment

40:59 A ketogenic diet is shown to work for epilepsy. Every anti-epileptic medication is used in psychiatry. “We use benzodiazepines, Depakote, Lamotrigine and Tegretol. We use all of it. Every anticonvulsant medication is used in psychiatry sometimes on label, sometimes off label.”
42:45 “When we combine two psychiatric medications, that’s off-label.”
43:41 “We use every epilepsy treatment in psychiatry. We often treat patients off-label in psychiatry… why should I even consider using the ketogenic diet today in a patient with a treatment-resistant mental illness? [It is] because it’s a proven treatment for treatment-resistant epilepsy and you’re going to use it off label. So the way I look at it is, I am using an off-label established treatment for epilepsy in psychiatric disorders.”

Time with patients

47:15 “…one of the great things about being a psychiatrist is that we are probably the last of the medical professionals who still get to have a relationship with our patients. Who still get to talk about whatever we think is important to their health.”

The mental-metabolic connection

51:24 “We have hardcore epidemiologic data… obesity affects diabetes and diabetes control affects cardiovascular disease.”
51:59 Sleep and metabolism.
53:59 Bipolar disorder.
54:43 Treatment-resistant depression. “Dramatic Improvement in mood disorders and anxiety symptoms…”
55:23 Caveats: Keto adaptation-keto flu is a serious medical risk. People may get worse initially, before they get better.
56:13 Transition from utilizing glucose for fuel to using fat for fuel takes time and the process initially deprives cells of energy.
57:48 Metabolic disorders and energy deprivation.
58:56 Medical monitoring necessary for people with serious disorders.
59:52 Medical risk, powerful intervention.
1:02:47 “Mental health and metabolic disease are intimately related.”

Can a ketogenic diet successfully treat Bipolar Disorder?

Dr. Chris Palmer — Thu, 10 Jan 2019 18:18:05 +0000

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.

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