Keto has staying power. The concept of the ketogenic diet dates back to the 1920s, when Mayo Clinic doctors developed it as a treatment for epilepsy. The (almost) carb-free diet re-emerged as a weight-loss regimen in the early ’70s, but it didn’t go fully mainstream until the 2010s. “Keto” has since become one of the most popular diets in the US, and legions of fans promise it works — not only for weight loss, but also beating brain fog and improving mental health. On social media and in articles online, people share stories of keto curing their depression and anxiety, and sending their bipolar disorder into remission. Their claims aren’t completely out of left field; emerging science suggests the diet might help those living with a variety of mental health conditions.
What’s behind the psychological improvements linked to keto? We’re not sure. A keto diet is thought to be an effective weight-loss regimen because it induces ketosis, a metabolic state in which low glucose availability forces the body to burn fat reserves for energy. Various theories offer explanations for how ketosis might support mental health. One says ketosis might reduce oxidative stress, inflammation and mitochondrial dysfunction, which are processes seen in schizophrenia, bipolar disorder and major depressive disorder. Another suggests ketosis corrects neurotransmitter imbalances observed in some of these conditions. But most of the current evidence supporting the benefits of ketosis for mental health comes from animal studies and individual case reports; we don’t know if the same results would bear out in a large group of humans. At this point, we need more research to understand how keto affects the mind and whether it’s a viable treatment for any specific diagnoses.
But research takes time, and many people aren’t willing to wait. Compared to treatment options such as medication and behavioral therapy, simply changing the way you eat might seem like a low-risk, low-cost way to manage a mental health condition on your own. But experts caution against such a DIY approach.
Dietary changes “can be used as adjudicative treatment to everything else a person is doing,” says nutritional psychiatrist Dr. Uma Naidoo, author of This Is Your Brain on Food and director of nutritional and lifestyle psychiatry at Massachusetts General Hospital. “But if you have a diagnosis, you really should speak to a professional.”
Nutritional counseling in psychiatry
Healthcare providers might “prescribe” dietary changes to help treat a variety of medical issues, including mental health conditions. As the relatively new field of nutritional psychiatry (also called nutritional psychology) continues to grow, it’s likely that more mental health professionals will talk to patients about their eating habits. Still, those trained to see food as part of treatment say it needs to be incorporated carefully.
“In psychiatry, there are a lot of gray areas. It can be really tough,” says Adrienne DiRaddo Feehan, a board-certified psychiatric mental health nurse practitioner with Presence Wellness in Austin, Texas. For example, depression and anxiety can swing between two extremes. Both issues can kill someone’s appetite to the point where even thinking about food is physically uncomfortable. But they can also prompt someone to seek out food to cope with difficult emotions. And, just as with medication, everyone responds differently to diet changes, Feehan adds. “What we put in our bodies can affect the way we feel, but we don’t have robust studies on which diet is recommended for which person.”
Rather than suggest a specific eating plan, Feehan aims to meet each patient where they are. “If you don’t have the energy to get out of bed and microwave a frozen burrito, how will you follow a really strict, regimented diet? Or have the energy and forethought to make yourself nutritious foods?” she says.
Naidoo prescribes medication and works on individualized nutritional strategies. Before she does anything, she assesses their medical history, ability to follow a treatment plan, and motivation.
After all, a new diet can only help if someone commits to it.
The slippery slope of self-treating through diet
Although they believe food can play a part in managing psychological conditions, Feehan and Naidoo both say patients should consult their providers first. There might be risks associated with self-treating a diagnosed disorder.
For starters, a change in diet could interfere with prescribed medications. Suddenly cutting out sodium or coffee can increase or decrease levels and therefore the effectiveness of lithium, a common medication for bipolar disorder. Lurasidone for schizophrenia needs to be taken with about 350 calories worth of food. Intermittent fasting may reduce absorption of medication and make it less effective, Feehan says. Doctors and dietitians sometimes work together to make sure medication and diet don’t work against each other.
For that reason, Naidoo works with doctors who refer patients to her for dietary consultations. “The nutritionist needs to understand what medications someone is on and the side effects of those medications so they can advise on what foods to eat or avoid,” she says. If nobody knows a patient changed their diet, the provider doesn’t know to check to see if they should change the dosage of any medications.
Another possible consequence of self-treating is the “magic bullet” effect. “There is a large concern that in the first weeks of a change in lifestyle, you might feel really great and motivated,” Feehan says. If that happens, the patient might skip out on therapy or decrease or stop medication or other interventions without consulting their providers. Or, with the ketogenic diet, they may experience the “keto flu” and have brain fog, fatigue or irritability but not know why. In that case, “someone might come in saying, ‘I’m not sleeping well. I’m feeling tired and flu-like,’ and that could lead to us changing medications or adding medications if we don’t know what’s going on behind the scenes,” Feehan says.
Then there’s the possibility of a restrictive or rigid diet exacerbating symptoms of certain conditions, such as anxiety, OCD and eating disorders. “When there is so much focus on numbers or you have to eat certain things with no moderation, wanting to get everything just right can lead to increased anxiety,” Feehan says. Similarly, when a healthcare provider doesn’t know someone has a history of disordered eating or excessive exercise, “it can be a really slippery slope if a nutrition plan is restrictive in any way, cuts out food groups, counts anything, or promotes fasting,” Feehan says.
Another big stressor is the cost of certain diets. “While there are benefits to cutting out processed foods and sugar and adding more vegetables and fruit, those foods can spoil really easily,” Feehan says. “It’s important to keep in mind where a patient is coming from and if it’s a possibility for them to make those choices every day.”
Finally, there’s the risk of a boomerang: “Diets that offer extremes are hard to sustain,” Naidoo says. A patient could see great improvement in the first month or so but then start to crave forbidden foods. Managing those cravings might take the right coping tools and professional support
“They can end up with worse mental health symptoms,” Naidoo says. “Or they may gain back weight and then become depressed or anxious about that.”
Experts don’t want to discourage patients from making lifestyle improvements. Quite the opposite; they want to support patients in their pursuit of health. But if you want to try out a new diet for the express purpose of treating a diagnosed mental condition, loop in your provider first. They’ll help you come up with a plan that makes sense for you. “We want to keep everything balanced and even-keeled mood-wise, anxiety-wise and psychosis-wise, so it’s important we know what is going on so we don’t make extreme changes,” Feehan says.