Ketogenic diet: reductions in auditory hallucinations and delusions, better mood and energy, and weight loss

Two schizoaffective patients of Dr. Chris Palmer, a psychiatrist from Harvard’s McLean Hospital in Belmont, Massachusetts, tried a ketogenic diet for weight loss. As well as losing weight, they experienced reductions in auditory hallucinations and delusions, had a better mood and had more energy.

Here is additional information about these remarkable results, published late last year in this letter to the editor – Ketogenic diet in the treatment of schizoaffective disorder: Two case studies.

The male patient: lost weight, reductions in auditory hallucinations and delusions, better mood and energy

The male patient, diagnosed with schizoaffective disorder, with a prior psychiatric history of attention deficit hyperactivity disorder and major depression, experienced “dramatic” reductions in auditory hallucinations and delusions, as well as better mood and energy on the ketogenic diet. He also lost weight, losing 104 pounds over the course of a year.

He weighed 322 lb and wanted to lose weight by following a ketogenic diet, typically consisting of coffee with medium chain triglyceride (MCT) oil and butter (“bulletproof coffee”), eggs, meat, fish, poultry, spinach, kale, and olive oil. Within 3 weeks, he had lost 15 lb, but also noted a dramatic reduction in his auditory hallucinations and delusions, and improvement in his mood, energy, and ability to concentrate. For the past year, he has largely remained on this ketogenic diet and has lost 104 lb.

His functioning has improved and he has become more independent:

He completed a certification course, successfully participates in an online college program, has friends, began dating, and moved from his father’s home into an independent apartment.

The female patient: lost weight, resolution of her delusions

After four weeks on the ketogenic diet, the female patient, also diagnosed with schizoaffective disorder, and with a prior psychiatric history of major depression and anorexia nervosa, had resolution of her delusions and lost ten pounds:

she wanted to lose weight, and went on a ketogenic diet, consisting mostly of coffee, eggs, poultry, and lettuce. Within 4 weeks, she lost 10 lb and noted that her delusions were no longer present, and that her mood and energy were much better. After 4 months, she lost a total of 30 lb and her PANSS score decreased to 70 [down from 107]

In both instances their symptoms returned when they stopped the diet, but then improved again when back on the ketogenic diet.

In case you’re not familiar with the ketogenic diet here is a quick summary:

The ketogenic diet is a high-fat / low carbohydrate [and low protein] diet that has been used since the 1920’s to treat childhood epilepsy, with some studies suggesting that over 50% of patients experience significant reductions in seizure frequency. The ketogenic diet results in ketone bodies, instead of glucose, being used as the primary energy source in the brain.

There simply is no psychiatric medication available with the power to accomplish these results

I had the pleasure of meeting Dr. Georgia Ede, MD  last year at the ISNPR conference. She is a Harvard-trained psychiatrist and nutrition consultant practicing at Smith College, and writes about these two schizoaffective cases in her article – Low-Carbohydrate Diet Superior to Antipsychotic Medications:

These outcomes are truly remarkable: improvement by dozens of points on the PANSS, significant weight loss, and better quality of life. There simply is no psychiatric medication available with the power to accomplish these results.

I agree with Dr. Ede especially when we look at the medications these patients had trialed. These medication trials for the male patient: methylphenidate, amphetamine salts, dextroamphetamine, bupropion, sertraline, paroxetine, buspirone, lamotrigine, lorazepam, clonazepam, gabapentin, haloperidol, perphenazine, aripiprazole, olanzapine, quetiapine, and clozapine. The female patient had a similarly long list of medication trials and she also received 23 electroconvulsive therapy treatments. For both of them, positive and negative symptoms persisted.

I do still have questions about the ketogenic diet

The research in epilepsy is extensive and the research in mental health is growing. I am really impressed with the results, but I do still have questions about the ketogenic diet. Perhaps you have some similar questions and concerns. Here goes…

1. If this particular nutritional psychiatry approach works so well for severe mental health disorders such as schizophrenia and psychosis, how will it work for less severe conditions like anxiety and panic attacks? Are these severe cases like the “canaries in the coal-mine” paving the way and teaching us about the benefits of this way of eating?
2. Should you use a ketogenic dietary approach as the first approach or consider it as a last resort once the other dietary approaches have been implemented and you’re not seeing full symptom resolution? In other words, should you start with a real whole foods diet, then implement a gluten-free diet, then a grain-free diet, then remove dairy (if it’s an issue), then incorporate low FODMAPs if needed and only then implement a ketogenic diet? (low oxalate, low salicylate and low histamine would be incorporated as needed earlier in the process, based on each person’s unique needs).  If we look only at schizoaffective disorder,  there is growing evidence of the role of gluten  in some individuals with this paper “suggesting that an antigliadin IgG positive population of schizophrenia could be a distinct subgroup.” This 2 person pilot study reports the benefits of a gluten-free diet: “this potential mechanism is exciting and may provide improvement for up to one-fourth of patients (antibody-positive) who suffer from this devastating disorder.”
3. How do we clearly define a ketogenic diet and communicate this definition to practitioners and to those who choose to implement this way of eating on their own? I’ve had feedback from many people who tell me they have been on a ketogenic diet (and it’s worked well for them or maybe it hasn’t worked so well for them), only to discover they are not really eating a true ketogenic diet. How do we simplify this way of eating and make it easy for individuals to understand and then stay in ketosis?
4. How do we create a ketogenic diet that is nutrient dense and also offers the benefits seen in this research. I have major concerns about long-term nutritional deficiencies with a diet of coffee, eggs, poultry, and lettuce (as eaten by the female patient in this case study). It should ideally include plenty of leafy greens, non-starchy vegetables like broccoli, cauliflower, asparagus etc. and healthy fats like avocado, grass-fed butter and coconut oil, together with fermented vegetables and bone broths. I’m also not convinced that coffee should be part of the ketogenic diet, especially if coffee increases your anxiety and affects your sleep.

5. How do we help individuals make the switch to this way of low carb eating and help them maintain so they don’t feel deprived and are not relying on willpower alone? As you can see from these 2 cases, the diet can be challenging to sustain and slip ups are common. If you are eating enough health fats (and it’s a lot more than you’re used to eating), this typically helps with cravings. If you still have cravings and feel you are deprived and missing out on treats, the targeted individual amino acids offer powerful results: tryptophan (for afternoon cravings), GABA (for stress eating), DPA (for comfort eating), tyrosine (when there is low motivation) and glutamine (for low blood sugar cravings).
6. Is the ketogenic diet the next big fad or weight-loss trend as we’re hearing in the media? Based on the above research it truly does have impressive therapeutic benefits beyond only weight-loss. So can we see similar benefits with a modified ketogenic diet, using intermittent fasting and/or cycling in and out of ketosis, and even adding in a ‘feasting day’ of carbs?
7. Who shouldn’t adopt a ketogenic diet? For example: those with the APOE4 gene, women with adrenal and hormone issues, and individuals with thyroid issues and no gallbladder? The question then becomes this: of those suffering with anxiety and depression or another mental health disorder, who doesn’t have one of these issues? And how do we address the keto rash, constipation, fat malabsorption, fatigue, mineral deficiencies and other issues some people experience on a ketogenic diet?

Right now, this is my thinking: as with any nutritional or functional medicine approach, I would say there is no one-size-fits all for who should implement a ketogenic diet (we need to consider the unique biochemistry of each person) and there is no one set ketogenic diet (it will need to be customized for each person).

Please do share if you’ve adopted a ketogenic diet and the benefits you have experienced, and if you experienced any issues. Be sure to share what a typical day’s diet looks like for you.