Metabolic psychiatry, a new approach to mental healthcare, is based on the theory that symptoms of psychiatric conditions are caused by neurometabolic dysfunction. Research on the underlying mechanisms of malfunctioning brain metabolism is currently underway; there are a variety of hypotheses, but it likely involves impaired mitochondrial function leading to energy dysregulation. Metabolic psychiatry often employs a medical ketogenic diet as a cornerstone therapy to help repair mitochondria and restore brain energy. At Metabolic Mind, we emphasize that ketogenic therapy should be done with oversight from a clinician trained in metabolic therapies. Sometimes patients and their families voice frustration, lamenting the fact that metabolic psychiatry care is largely inaccessible and unaffordable. We know this is a challenging situation to navigate. Because metabolic psychiatry is an emerging field, trained clinicians are still scarce. While we would love a scenario where everyone has an interdisciplinary clinical care team trained in metabolic therapies, we know that this is not currently the case for most people. 

I understand firsthand how frustrating it is to be unable to access metabolic psychiatry care. When I started ketogenic therapy in the summer of 2021, despite an extensive search, I could not find a trained clinician to help me. When considering how to proceed with limited resources, it is important to understand that working with a trained clinician is highly recommended. 

Why do we recommend working with a metabolic psychiatrist? 

Medication management on a medical keto diet 

Ketogenic therapy is a physiological intervention that changes the body’s fuel source from glucose to ketones and has a profound impact on neurochemistry. From more than a century of research in epilepsy, we know that it is a safe, relatively low-risk intervention; however, it creates powerful changes in the brain and body that can very rarely induce symptoms of hypomania or even full-blown mania. 

As someone who has survived hypomanic and manic psychotic episodes, I know these states come with enormous risks. Not only are they inherently traumatizing and damaging, they often trigger reckless and dangerous behavior. Dr. Bret Scher, Metabolic Mind Director, delves into this risk, and how it can be avoided, in interviews with metabolic psychiatry experts Dr. Georgia Ede, and Nicole Laurent, a Licensed Mental Health Counselor (LMHC). They emphasize the importance of monitoring symptoms, and share that, while rare, some patients do end up needing to temporarily add back carbohydrates, or use a bridge medication to manage hypomanic or manic symptoms when adapting to a medical keto diet. Laurent highlights that it is not always easy to recognize hypomania when beginning ketogenic therapy because, “You do get an increase in energy, but not all increases in energy are signs of a pathological mechanism going awry.” 

To distinguish between healthy heightened energy and symptoms of hypomania, Laurent looks to sleep as an indicator, “As soon as sleep starts to become disrupted more than a night or so, maybe two, then it’s time to talk to the prescriber about whether it is time to use the bridge medication or not.” 

Another important reason to have clinical oversight is that ketogenic therapy can be such a powerful form of treatment that patients may experience potentiation effects. This happens when medical keto is so effective that a patient ends up requiring a lower dose of psychiatric medications. During this process, they may begin to feel increased side effects, such as lethargy and fatigue. To counter these effects, medication tapering is required. A patient attempting medical keto without help from a trained clinician may incorrectly assume that the negative symptoms they are experiencing are a result of their keto diet, rather than a potentiation effect. A trained metabolic prescriber, however, could recognize this and adjust their doses accordingly. Patients on injectable antipsychotics that can not be tapered on an inter-dose basis may have extreme difficulties and may wish to discuss alternative delivery systems. 

Another great resource on this important topic is this video, in which Dr. Bret Scher interviews Dr. Ede and Matt Baszucki, a patient advocate and host of the metabolic psychiatry podcast Bipolarcast, on the topic of medication tapering while on keto.  

Individual tailoring of medical keto  

As an evolving field, metabolic psychiatry still has a lot to uncover about the underlying mechanisms of ketogenic therapy, related biomarkers, and individual responses. A person’s diet may require substantial tailoring depending on their unique needs, as well as their personality and preferences. Trained metabolic clinicians can help because they have a broad knowledge base and are able to give more individualized guidance. 

What if a patient cannot access care? Can they still try medical keto? 

The honest answer is: It depends on the individual and their unique circumstances. Successfully implementing ketogenic therapy takes work, dedication, proactive research, and willingness to experiment and iterate. It is also important to note that ketogenic therapy is not a silver bullet. Other critical metabolic therapies are often integral to success; for example, cutting out substances like alcohol and drugs and managing sleep routines. 

Certain individuals may benefit from a structured approach: rather than researching, experimenting, and tweaking, they prefer to be given a plan to follow. For individuals who know that they thrive with guidance and like having step-by-step instructions, it would be best to attempt ketogenic therapy with regular ongoing support from a metabolic psychiatrist or other medical keto expert, like a counselor, keto coach or dietician. Unfortunately, most medical keto experts are not yet covered by insurance. 

For those with budget constraints, there are some structured group programs that are more affordable than one-on-one sessions. Nicole Laurent, LMHC, offers comprehensive group programs that include self-paced educational content as well as question and answer sessions twice a week, where individuals can get more tailored advice as needed. Erin Bellamy, PhD, recently started Integrative Ketogenic Research and Therapies. She currently offers one-on-one coaching, and will be launching a group program in July 2024. 

It is also important to acknowledge that for some, an out-of-pocket group program will be cost-prohibitive. For those who feel they require structure and guidance to be successful with medical keto but cannot afford to participate in a program, another approach to consider might be taking steps to improve metabolic health without attempting ketogenic therapy until clinical assistance becomes more accessible. This could mean starting to eat a lower-carb, whole foods diet, abstaining from alcohol and drugs, managing a consistent sleep routine, and implementing positive practices like meditation, journaling, and exercise. When I discovered ketogenic therapy, I had already spent a couple of years improving my metabolism and strengthening my willpower through these types of interventions, so I was in a great position to incorporate a medical keto diet. 

What is the bare minimum someone needs to do medical keto without a trained metabolic clinician? 

People who are committed to a comprehensive metabolic therapies plan including ketogenic therapy should always be monitored by their clinical care team. When I began ketogenic therapy, I saw a Licensed Clinical Social Worker (LCSW) every week and, while she had no training in ketogenic therapy, she offered invaluable emotional support and encouragement, and also monitored me for symptoms of hypomania or mania. As a counselor, she had wonderful insights into behavior change strategies that helped me implement ketogenic therapy successfully. A care team could include someone to monitor symptoms and a prescribing physician to help with medications adjustments. My general practice doctor was willing to do this and also ordered any labs that I requested. It is highly advisable that patients get labs done periodically throughout their ketogenic therapy journeys. Dr. Bret Scher goes over recommended labs in this video. Patients can print this form and take it to their provider – or even order the labs themselves through Own Your Labs. 

For those who like to do research and experiment, participating in group sessions or having one-on-one consultations with an expert could be beneficial.. However, if this is cost-prohibitive, another option would be saving up to see an expert for occasional consultations focused on troubleshooting or optimizing. I did not have access to care and created a plan that I implemented on my own. By the time I did have access to care, I no longer required general guidance, but did have specific, targeted questions to help me refine my metabolic therapy protocol. Even a 30-minute session with a keto coach or dietician every quarter can help patients to achieve great metabolic health outcomes. Because this is typically an out-of-pocket expense, doing it occasionally with well thought-out questions can be more affordable and provide great return on investment in terms of metabolic health impact. 

What if my current care team is not supportive of ketogenic therapy? 

Because metabolic psychiatry is a nascent field, some providers may not have heard of ketogenic therapy, and may respond with skepticism or confusion. Patients can take this summary handout from Dr. Ede to their providers. It details the scientific rationale for ketogenic therapy and refers to some of the studies that have been completed so far. Patients can also share our website, and direct clinicians to the up-to-date research page that provides information on completed studies and current trials, including the gold standard Randomized Controlled Trials (RCTs) that are currently underway. 

Ideally, all providers would be supportive of their patients’ goals, but, unfortunately, this is not always the case. If an individual’s care team is unsupportive, they may need to get a second opinion, or consider finding a new care team. We understand that many providers have challenging schedules and time constraints, making it hard to pursue additional training, formally or informally. At a bare minimum, a patient’s care team should be willing to learn about the basic premise of ketogenic therapy, provide emotional support, and help patients to the best of their abilities.

What else can a patient do to have success with ketogenic therapy without having a clinician trained in metabolic psychiatry?

Ketogenic therapy is a powerful medical intervention that entails some risk, particularly if a patient is taking psychiatric medications, and it should be undertaken with caution. Implementing medical keto without expert guidance is not ideal and requires the patient, family, or other personal contact to put in quite a bit of work in terms of researching, figuring out a plan, experimenting, and iterating. If individuals are unable to access metabolic psychiatry care but feel dedicated to implementing ketogenic therapy, there are many available resources that can help them succeed. 

Lauren Kennedy has been documenting her journey implementing metabolic therapies, including a medical keto diet, in real-time on her YouTube channel, Living Well With Schizophrenia. Her Keto and Metabolic Health Project 2024 playlist is a treasure trove for anyone looking to navigate this form of treatment with limited resources. Many of her videos provide great examples of how a patient can successfully implement medical keto while working with their care team, and supplementing with a keto coach who can provide expert guidance. For example, this video documents Lauren’s experience of potentiation effects and her tapering process. Witnessing Lauren’s life-changing results from metabolic therapies is incredibly inspiring. As of May 2024, she has reduced her medications by 60%, and put symptoms of her schizoaffective disorder into remission.

Metabolic Mind also has an extensive array of resources that is expanding all the time. This page is an ideal place for patients and families to begin. It includes a number of links to fantastic books, articles, intro videos, and provider directories to search for metabolic psychiatrists, coaches, dieticians and more. 

Another invaluable strategy for anyone looking to implement metabolic therapies, with or without a trained clinician, is connecting with community and finding peer support. Having interacted with many individuals with lived-experience, I am in awe of the kindness I witness on a daily basis as people go out of their way to support, uplift, and encourage each other. Individuals often swap strategies and resources. X has a very active community of people sharing experiences with ketogenic therapy. You can connect with them and discover many others by following accounts like: @ChrisPalmerMD, @GeorgiaEdeMD, @IainCampbellPhD, @KetoCounselor, and our account, @Metabolic_Mind. Peer support groups also provide a wonderful platform to connect, learn from others, and find inspiration and encouragement. This group is a great place to find peers who are implementing ketogenic therapy for psychiatric conditions. 

A brighter future for metabolic psychiatry is ahead.

I understand firsthand the frustration people feel around the inaccessibility of metabolic psychiatry care. At Metabolic Mind we are dedicated to the long term vision of creating systemic change. This is one of the reasons Baszucki Group, our parent organization, is especially focused on metabolic psychiatry research. If rigorous scientific studies including Randomized Controlled Trials prove the safety and efficacy of ketogenic therapy as a treatment for psychiatric conditions, it will drive patient demand and more clinicians will pursue training. This will help make metabolic therapies more accessible in the future. Metabolic Mind is in the process of collaborating with experts to make free Continued Medical Education (CME) courses available to clinicians who would like training to help patients implement metabolic therapies. We are providing as much information as possible–articles, videos, databases of relevant information–so people can more easily access the resources that are available. Seeing the incredible success stories makes it all worthwhile!