Thursday, August 26, 2010

Ketogenic Diets and Bipolar Disorder 1

Bipolar disorder is a challenging illness, with various clinical presentations. In "type one" people struggle with alternating symptoms of mania and depression. In "type two," depression is the primary state, with the occasional rare bit of hypomania. By mania, I mean increased energy, increased sexuality, religion, insomnia, and spending money. It feels great right up until reality comes knocking on the door. Medication has been proven to be helpful in decreasing the number of manic and depressive episodes. Typically, the medications are anti- seizure medicines also, such as depakote, lamotrigine, and carbamazepine.

Most low-carb followers will know that ketogenic (extremely low carb) diets have been used to treat epilepsy for a hundred years. Would the same diets be useful in bipolar disorder (1)?

Now is the time to add a special disclaimer. No ketogenic diet has ever been systematically studied with respect to bipolar disorder. If you have bipolar disorder, please discuss any thoughts you might have from reading this article with your personal physician. The one case study I could find in the literature showed *no* benefit from a ketogenic diet. (4:1:1 fat:protein: carb) Bipolar disorder is an illness I wouldn't want to face alone.

In the literature for epilepsy, patients were encouraged to fast for 12-36 hours to promote ketosis, and then to follow a dietary plan with less than 20 g carbohydrate daily (or even lower, in most research ketogenic diets). In doing so their brains would be flooded with ketones, and most importantly, promote extracellular acidosis. There are several seizure medicines (such as gabapentin) that are no good for bipolar disorder. When scientists look closely, they find that only the seizure medicines that promote a reduced extracellular sodium concentration are helpful in bipolar disorder. Ketosis does exactly that.

It all looks great on paper, but as I mentioned earlier, when well- intentioned doctors tried to use a ketogenic diet to treat resistant bipolar symptoms, they came up with a big zero (2). And while ketogenic diets are definitely safe short term, when ever we begin to talk about treating epilepsy or bipolar disorder, we are talking about long-term strict compliance. No cookies. No bread. One would need to work with a knowledgeable nutritionist, and there are reports of patients on ketogenic diets for epilepsy dying of selenium deficiency (3). (my paleo perspective - you are eschewing your vegetables, eat your organ meats!).

In the next post I will review the case studies above more closely, and delve more deeply into the biochemistry of sodium ions and the NMDA receptor. I know you can hardly wait!  (It's here - be sure to check out Ketogenic Diets and Bipolar Disorder 2)


  1. Hi Emily,

    I just found this blog recently and am inhaling all the archives!

    I have recovered from depression using the paleo diet and supplement trial and error. I feel like I have woken up from a very long sleep for the first time in years. It's great to see a blog devoted to the mental side of things.

    Re: Selenium deficiency, what about the ketogenic diet makes it more deficient than the SAD would you say? I quickly googled sources of selenium and it seems to be all fish, organs and nuts that are the best sources. Do you think that the need for selenium goes up on a keto diet?

    I have also heard that thiamine deficiency is common on long-term keto diets that don't contain a lot of pork.

    Anyway, keep up the good work!


    1. I started a low carb diet a month ago with an incredible effect on my BPD. I can think more clearly, and have way less intense moods. I am still on Lamotrigine.

  2. I find it hard to believe that long term use of a ketogenic diet would not correct bipolar disorder. I'd be interested to take a look at the one clinical trial. Were they using real foods? Balanced n-6/n-3 PUFA ratio? In a lot of these studies, they'll say they're using "fat" but then they take some proctor and gamble 25% trans fat nonsense mix and then want to extrapolate to animal fats.

  3. SamAbroad and Geoff - thanks for the comments. I'll be looking more closely to see if some details of the actual diets used in those ketogenic epilespy studies were mentioned. I'm sure they were garbagey in some way! Never heard of the thiamine deficiency. Interesting.

  4. I haven't yet found a satisfactory answer to the selenium question, other than in several studies the writers spoke of ketosis as mimicking starvation, and that with the limited food choices of a ketogenic diet (4:1:1 fat:carb:protein) that the overall nutrient density of the diet was poor. Of course that is ridiculous or very realistic depending upon the source of the calories! I just wanted to comment on this as I plan to keep looking. But just in case I get distracted and move on to something else, which I am apt to do!

  5. Urf! I was driving myself crazy chasing reference after reference on pubmed, and then it occurred to me to try wikipedia - of course there is an excellent article:

  6. Speaking as food scientist it is utter nonsense to say that a proper meat-based ketogenic diets are nutrient deficient.

    A diet consisting only of muscle and organ meats supplemented with 30-40g of wild berries contains at least 2-10x the RDI of every essential nutrient. If you chew on the bones (or eat some sardines) you will get all the magnesium and calcium you need.

    How much meat do you need? About 1-1.5kg per day. The Lewis and Clark expedition members ate 3kg/day.

    Contrary to the widespread public belief most fruits and vegetables are extremely poor sources of nutrition. They consist of little more than water, small amounts of non-essential amino acids, potassium and carbohydrates.

    Liver contains far more of every vitamin and mineral (except vitamin C) than any known plant foods.

    The natural diet of our ancestors on the savannah was virtually nothing but meat and very small amounts of fruit and greens.

  7. I have been on the atkins for several months and am (very) bipolar. I've noticed an increased stability, better sleep and weight loss that counteracts the weight gain from common meds like zyprexa and seroquel.

    Do I believe a diet will cure me? No. Medication and psychotherapy, as well as an intense personal desire to be healthy and stable have brought me to remission. But I have determined that things like cereal, grain, bread, sugar, etc. were really disruptive to my mood.

    The low-carb diet has not been challenging for me to be on, because I feel a lot better day-to-day. This xmas was the first time in months I had high-carb stuff and sugar and I could really feel the effect it had on my body.

    I hope that helps.

  8. Poetic Terrorist - that is helpful. I've seen a number of anecdotes on various forums about low-carb or paleo diets helping to regulate mood, but of course there is only indirect scientific data, and the case studies in the literature are negative. Every anecdote is helpful.

  9. I have been struggling with staying on the PaNu version but the lapses are getting fewer and further between. I didn't notice, but my co workers noticed a large change in moods and commented on it without being asked.

  10. I was bipolar, along with having IBS and chronic fatigue. It was all diet related.

    I knew that ketosis cured me but couldn't sustain it due to cravings. I experimented for years.

    Finally I found a cheap little trick that works to kill all cravings.

    The secret is to eat a meal of ground beef with eggs, in a ratio of 250g beef to 1 egg, at least once daily. But limit the # of eggs per day to a low number.

    I eat this, with no salt or seasoning, and it finally cured my health problems, despite the built up long term damage to my digestive tract.

    Here's the link:

  11. I just finished reading “The Primal Blueprint” by Mark Sisson. I started the primal diet a couple of months back after my girlfriend convinced me that it would help my bipolar symptoms. Wow, was she right! I’m a believer in the primal way of life. It’s not a diet or a passing fad–it’s a life-change that makes so much sense for me. Along the path of learning about the primal way, I learned that depression is an inflammatory disorder. What causes inflammation in our bodies? Carbohydrates, of course! I was poisoning myself with every piece of bread or bowl of cereal; it made no difference that they were whole grains. Eating right isn’t the only change I made. Routine exercise, meditation and regular sleep patterns have become the norm making insomnia, fatigue and stress a thing of the past. This book really does offer the tools one needs to change your life! I highly recommend it!

  12. you know any thing is worth a try i know i eat alot of breads and things so im going try this diet it cant hurt thinking of just eating proteins with high fat in it and eating meat witch is good for me i lift weights but havent felt great so not really lifting but uh going give it a go see what happens and if ingested any carbs greens i would think be ok

  13. Emily,

    Have you seen this?

  14. i have struggled with ibs, low energy, general and social anxiety. i started in july and its made a big difference. my energy isnt as high as i had thought because i lost my job AS a dishwasher. im not sure why i cldmt,make the cut. my ibs has been kicking my butt lately. one thing im missing which helps ibs cers which is what i have problems with lately. is vitamin c has a lot of healing properties. im told in can be rough on people that have acid reflux like i have. supposedly you can get calcium ascorbate or ester c which can help if youre senstitive to ascorbic acid. anyone have luck with supplementing with vitamin c?

  15. Hello! First, I must say I LOVE this website! You come much closer to an understanding of Bipolar Disorder than my psychiatrist ever has! I was diagnosed bipolar II about a year ago, though have been suffering with symptoms for many years. I thought I had intermittent major depression, as every doctor I saw thought as well. Every time I was prescribed an antidepressant, and every time I went hypomanic. Now both my father and brother are also Bipolar, but they have Bipolar I. Because I have never thought the dog was talking to me like my father, or flew to France to join the French Foreign Legion because my brother thought he was Rambo (true story!), it never occurred to me I was bipolar as well. Every time I went to the doctor I went for deep, soul crushing depression and suicidal ideation. When they would ask me if I had ever had any manic type symptoms, I always denied it. Not consciously, but because I did not recognize my own hypomanic behavior. Even after I had lost my house to foreclosure and filed bankruptcy as a result of my out of control spending and my husband of 10 years left me because of my crazy, erratic and promiscuous behavior, I still did not see it. Eventually I stopped having hypomanic phases and only cycled rapidly between depression and horrible mixed states. I am currently on Lamotrigine and doing much better. Before I was prescribed a mood stabilizer I tried many various natural approaches to varying degrees of success. I quit drinking caffeine and cigarettes and reduced alcohol and sugar consumption, which has greatly improved my general stability but did not stop the actual cycling... I then tried a very high protein diet, consisting of protein shakes in the morning and grass fed beef for lunch and dinner. My thinking centered around protein is made up of amino acids and amino acids make neurotransmitters - I am just protein deficient and once I fix the deficiency, I'll be cured! Unfortunately 5 days in, I became full blown manic with delusions, which up and till then had never experienced before... I then stopped eating pretty much anything and the mania subsided. It may have been a coincidence but I wonder if I had been on a mood stabilizer, I wouldnt have become manic but instead cure my depression...? I would love to hear any theories you may have on the subject and sorry for such a long setup!


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