A quick search on the internet can uncover many highly positive anecdotal reports of people who have improved their symptoms using the ketogenic diet. Interview any nutritional psychiatry practitioner, and they will likely tell you their experiences treating patients with this dietary intervention. But anecdotal evidence is not sufficient for many people to try a dietary therapy for such a serious mental illness.
However, the evidence pointing to the ketogenic diet being a possible effective treatment for bipolar disorder (BD) does not stop there. Some published case studies show some profound improvements in people suffering from bipolar disorder. And a current pilot study is recruiting participants at Stanford University Department of Psychiatry & Behavioral Sciences by Shebani Sethi Dalai, M.D. and Diane E Wakeham, Ph.D.
What is Bipolar Disorder?
Bipolar disorder is a mental illness characterized by episodes of mania or hypomania (periods of abnormally elevated, extreme changes in mood, behavior, activity, and energy level) that cycle into sometimes severe depressive episodes. Manic and hypomanic episodes are generally considered well-controlled for most patients using combinations of psychiatric medication options. However, depressive episodes and prodromal symptoms are still very common and difficult to live with even when medicated. This poor control of prodromal symptoms by the current standard of care leads to dangerous depressive episodes that increase suicide risk and fails to stop the progression of neurodegeneration and loss of function we see in these patients.
How Does the Ketogenic Diet Help Bipolar Disorder?
Several biological mechanisms have been proposed as potential underlying causes of BD. These include mitochondrial dysfunction, oxidative stress, and neurotransmitter disruption. Increasing numbers of genetic, biological, and neuroimaging studies have begun to address these hypotheses in recent years. When there is a dysfunctional biological mechanism, energy metabolism, cellular signaling, and circadian rhythms are some of the major processes shown to be impacted.
Biological mechanisms that have been proposed as underlying the disease process in bipolar disorder include mitochondrial dysfunction, oxidative stress and neurotransmitter disruption. Ketogenic diets have been found to exert effects in improving all these areas. Ketones upregulate the number and functioning of mitochondria (the powerhouses of nerve cells) which improves energy metabolism in the brain. Ketones have also been found to improve the health of cell membranes which improve neuronal firing, the storing of nutrients needed to make important enzymes and provide precursors for neurotransmitter production. This increased mitochondrial function allows neurons to upkeep general cell health and functioning.
Ketones also increase the function of endogenous antioxidant systems, such as the glutathione production. Glutathione upregulation, as seen on a ketogenic diet, helps reduce oxidative stress. And there are several documented enhancements in neurotransmitter balance and production that occur with ketogenic diets. Some of those include those neurotransmitter systems implicated in bipolar disorder pathology and include the dopamine, serotonin and norepinephrine pathways as well as glutamate and GABA production.
Why do neuroinflammation and oxidative stress matter in the bipolar brain? Because they cause levels of neuronal damage that an already energy-starved brain (hypometabolism) cannot deal with. They change the environment in which neurotransmitters are made. A brain with high levels of inflammation and oxidative stress cannot maintain cell membrane health, which impairs all the things a neuron needs to do to stay healthy and work right. One of those is having enough nutrients to be able to make important enzymes required to make neurotransmitters in the first place. Poor membrane function and high inflammation contribute to this nutrient depletion, causing a worsening of disease processes and contributing to bipolar disorder.
In Summary, Why is Ketosis Beneficial in Treating Bipolar Disorder?
We don’t know exactly, but we have some good guesses coming from research on the effects of ketones on the brain.
Ketones appear to improve cell membrane function and health. The improved energy brain cells get from burning ketones as fuel may be providing more energy for this outcome. It could also be ketones’ ability to reduce levels of inflammation as a signaling body and its ability to disrupt inflammatory pathways on the molecular level. Ketones have also been shown to increase the amount of an important substance called Brain-Derived Neurotrophic Factor (BDNF) which can promote cellular repair and even help improve memory function through its effects on the hippocampus. This may help reduce some of the effects of neurodegenerative processes that are seen in bipolar disorder.
And if all that is not enough, there is evidence to suggest that ketogenic diets upregulate the production of glutathione, which is our own bodies’ powerful antioxidant system, having a direct and favorable impact on levels of oxidative stress in the bipolar brain.
What I See in My Practice
As a mental health counselor who helps patients use ketogenic diets to treat mental illnesses like bipolar disorder, I only have anecdotal information on what my clients report to experience, coupled with what I observe as a clinician. What I see in people who use ketogenic diets consistently is an improvement in symptoms and functioning that they report they were unable to get from psychopharmacology alone.
I have bipolar patients who use the ketogenic diet consistently and exclusively to manage their bipolar disorder, and I have bipolar patients who use the ketogenic diet for mood stability and choose to stay on medications that include lithium. Often, but not always, my bipolar patients are able to titrate down their dosages of all medications with the help of their prescriber. But regardless of whether they are able to go down or off their medications, what I always see with consistent use is improved mood and functioning than they had prior to attempting ketogenic dietary therapy.
A Word of Caution
First, if you want to do a ketogenic diet for bipolar disorder and you are currently on medications, you really MUST have a prescriber available for medication management. Please do not attempt to do it alone. You deserve medical care. And ketogenic diets are powerful metabolic therapies that affect your medications. You can get serious side effects or a temporary worsening of symptoms that needs to be monitored by a healthcare team that includes a prescriber.
Why Ketone Levels Matter
When doing a ketogenic diet, ketones are your source of brain energy. People with psychiatric disorders are exquisitely sensitive to deficits in brain energy and it can cause a worsening of symptoms. So regular testing with a blood ketone monitor can be very helpful.
It can help patients begin to make connections between their ketone level and their mood and functioning. Ketone testing can help patients decide if they need to eat more healthy fats or supplement with MCT oil. A diabetic patient will test blood glucose and ketones in order to monitor and hopefully treat their illness. Testing is just as important for the bipolar individual using ketogenic dietary therapy to treat their symptoms.
About Nicole Laurent, LMHC
Nicole is a seasoned psychotherapist based in Vancouver, Washington who is passionate about reducing psychiatric and neurological symptoms with powerful dietary interventions. She completed her B.A. in Psychology and Master of Arts in Clinical Psychology from Argosy University (formally Washington School of Professional Psychology). She has additional post-graduate level education in functional nutrition and specifically in therapeutic carbohydrate restriction as a mental health intervention.
Learn more about Nicole here: www.mentalhealthketo.com