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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