In this video presentation, Dr. Palmer shares research and his use of ketogenic medical therapy to treat mental illness. The presentation was given to fellow medical professionals as “Grand Rounds.” McLean Hospital is an affiliated teaching hospital of Harvard Medical School.

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National Public Radio podcast examines the connection between a ketogenic diet and mental health. Psychiatrist Chris Palmer and his patient, Dan, are interviewed by host Karen Weintraub. Dan, who has schizophrenia, has been on a ketogenic diet for three years. During this time Dan’s quality of life was greatly improved.

“The good news in all of this is that these things (metabolic disturbances) are reversible. Metabolism can be changed by exercise and what we eat. That is a really exciting area of research.”

Chris Palmer, MD

https://dcs.megaphone.fm/BUR8345063909.mp3?key=812bcd5d8b9493d4a3f6d45474739e49

Podcast show notes

• 0:04 Introduction. The ketogenic diet contains large amounts of healthy fat, moderate amounts of protein, and very few carbohydrates. It has been used since the 1920’s to treat epilepsy.  Now it is also being tested as a treatment for depression, bipolar disorder and schizophrenia.
• 0:35 Karen introduces Dan, Chris Palmer’s patient. Dan talks briefly about his history as a young patient struggling with schizophrenia.
• 1:14 Karen and Dan talk about Dan’s recovery and the medical ketogenic diet he adheres to.
• 1:47 Karen introduces Chris. Chris and Karen talk about the connection between metabolism, diet and mental illness. Mental illness is closely linked with diet and metabolic issues. Metabolism can be positively changed by a ketogenic diet and exercise.
• 3:10 Karen talks about a study being done at Northeastern University: how individual nutrients and chemicals affect the brain. She introduces a computer scientist, Albert-Laszlo Barabasi, and he further explains the study.
• 4:13 Karen and Dan talk about Dan’s recovery again. Dan has been on the ketogenic diet for 3 years. He talks about the positive changes that have occurred in his life. He lost 140 lbs, is on half the medication he used to be on, has an active lifestyle and says he feels great.
• 4:55 – Closing.

Other case reports on schizophrenia and ketogenic therapies

Bibliography – Medical ketogenic diet for metabolic and mental health research

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Episode 10 “Nutritional Psychiatry, Metabolic Disorders, and Using the Ketogenic Diet as a Medical Intervention for Schizophrenia and Bipolar Disorder with Chris Palmer, M.D.”

Mental Horizons Podcast with Virgil Stucker & Associates’s Stephanie McMahon put together great show notes here.

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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.”

Other articles you might find useful

Start here

• Medical ketogenic diet bears burden of popularity despite being a useful therapy
• Keto resources for mental health and psychiatry
• Ketogenic providers

Information about specific diagnoses

• The relationship between the ketogenic diet and psychiatry
• Schizophrenia – Ketogenic diet brings new hope for the treatment resistant
• Might the ketogenic diet help fight Alzheimer’s Disease?
• Can a ketogenic diet successfully treat Bipolar Disorder?

Success Stories

• Doris’s chronic schizophrenia put into remission bringing hope to many
• Ketogenic diet helps young Ecuadorian twins improve their schizophrenic symptoms

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What can we learn from this study?

A central focus of this study was to assess how the ketogenic diet would affect these patients’ schizophrenic symptoms.

This pilot study employed a 6 week intervention of the ketogenic diet for these two people with schizophrenia. (A pilot study is a small study used to test whether the study question warrants a full-scale investigation. It is a building block for future medical research.) After allowing them to adapt to ketosis for 15 days, the twins’ psychiatric symptoms were evaluated. This evaluation was conducted by a psychiatrist who was unaware of the dietary intervention.

How did 15 days on the ketogenic diet affect the twins’ symptoms?

First off, they both lost weight. An effect well known for the ketogenic diet.

A second, and more important outcome was an improvement in their schizophrenic symptoms.

How were their schizophrenic symptoms measured?

The measure used in this study was the Positive and Negative Syndrome Scale (PANSS). The PANSS is an assessment used to evaluate the positive and negative symptoms of schizophrenia. It is often used in patient care in psychiatry.  It is also used in studies done to evaluate the efficacy of new medications. Therefore, it was an appropriate tool to use to evaluate this dietary psychiatric intervention.

Positive and negative symptoms of schizophrenia?

Yes, schizophrenia has symptoms which are both positive and negative.

Positive symptoms are the presence of abnormal characteristics. One group of positive symptoms is hallucinations (false sensory experiences that feel real). Delusions (false beliefs that persist despite a contradicting reality) are another set of positive symptoms. Negative symptoms are the absence of characteristics that would be present in a typical person. These include a lack of motivation, diminished thought content, lack of social interaction, diminished emotional responsiveness and expression, and loss of pleasure. Together the positive and negative symptoms form the bulk of some of the basic dysfunctions in schizophrenia.

The case study results

It is important that a tool that can measure both positive and negative symptoms was used in this study.  Despite not being able to maintain high levels of ketosis for long periods of the experiment, the PANSS scores improved for both twins, that is, their schizophrenic symptoms got better. This improvement lasted only as long as the patients stayed on the diet. At the end of the study the participants went back to their normal diet and their symptoms returned. The exacerbation of symptoms while off the diet is a further vote of confidence that it was the diet that spurred the improvement.

What does this case study mean about keto and schizophrenia?

Because this was a small, pilot study, it does not demonstrate anything conclusively. It does provide another bit of evidence to support the idea that more research is called for to explore the efficacy of the ketogenic diet for the treatment of schizophrenic symptoms.

Another case study about the efficacy of the ketogenic diet might also be of interest to you, see Dr. Palmer’s case study. The ketogenic diet and remission of psychotic symptoms in schizophrenia: Two case studies.

See the Ecuadorian twin study for yourself.

More on the ketogenic diet – mental health – and metabolic connections

• Our research and how to participate
• Continuing education for professionals

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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

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