Mental Health Plartform.

Do I need help doing keto if I have a mental illness?

Advertisements

Changes in diet can be hard and challenging even for people who do not identify as having a mental illness. There are a lot of reasons you may benefit from professional help transitioning to a ketogenic diet and many different kinds of professionals that can help you. Some of these include ketogenic nutritionists, ketogenic dieticians, ketogenic informed mental health counselors, nutritional psychiatrists, functional psychiatrists, or other low carb diet informed prescribers who work in the mental health space.

Introduction

In this blog post, we will discuss some of the factors you might want to consider if you have a mental illness, and how they inform your decision about whether or not to use a ketogenic diet specialist. And, if you decide that a professional would be helpful, you can read on and learn about the different types of professionals you could work with as you use a ketogenic diet as a treatment for your mental illness.

Reasons you may want a ketogenic diet professional

A lot of people do the ketogenic diet on their own, often to lose weight or to improve their diabetes. They do all kinds of variations on the ketogenic diet with carbohydrate intakes varying from 20g total to 100g total per day. And as long as they are producing at least a little bit of ketones throughout the majority of their day, we call it a ketogenic diet.

Psychiatric symptoms need the right macros

But people using the ketogenic diet for mental illness (or neurological disorders) often need a slightly stricter version, at least in the beginning. Sometimes if we are not careful with the carbohydrate consumption we recommend for someone with mental illness, they may not have levels of ketones at high enough or for a long enough period of time to truly test the diet out as a treatment for their symptoms. We are changing the primary fuel source for the brain. And so it becomes very important to produce enough ketones through dietary fat to keep the brain happy and not exacerbate symptoms because of an energy deficit in the brain.

So if someone goes to any of the many excellent diet coaches out there, they may be told that 50g of total carbs a day is “doing keto” because they are focusing on your weight loss, and perhaps not on the diet it must be used for the treatment of mental illness. They may even recommend you restrict your dietary fat intake prematurely because they are focusing on that weight loss and trying to help you lose weight.

I wouldn’t want you to think you had tried a ketogenic diet to treat your psychiatric symptoms and that it was unsuccessful when all you may have needed was some help to find the right type of ketogenic diet to find relief. The ketogenic diet may not work for you. But it would be a shame to walk away prematurely without the benefit of the customization and support you both need and deserve.

It takes a good three weeks of very consistent therapeutic carbohydrate restriction, in the form of 20g (maybe 30g max), for you to get some idea of whether a ketogenic diet might be helpful for your individual psychiatric symptoms.

Keto and medications are a big deal

Another reason you may want to work directly with a ketogenic diet professional is if you are on psychiatric medications. This is a very important factor in your decision-making and should weigh heavily in your decision about whether to attempt keto on your own or with professional help. Ketogenic diets are such powerful mental health interventions, that your medications may need to be adjusted during the first few days or weeks of the diet. Keto and antidepressants; or keto and other medications for diabetes, blood pressure, and a few others need to be monitored carefully.

Sometimes you need to go down on a few medications simultaneously, and that’s complicated. And sometimes, if you are not working with a professional and you have a worsening of symptoms, you will not have anyone helping you watch out for side effect potentiation and you will give up early, thinking the diet is making you worse. There are some instances when it is in fact your ketogenic dietary therapy creating symptoms and you need some additional supportive bridge medications or supplements to support your healing journey.

So you can see, if you are on psychiatric medications, it is particularly wise to work with a ketogenic professional who is able to modify your medications or work with a prescriber who will, and has experience with the ketogenic diet and psychiatric medications. And if you cannot find a prescriber, you can find a ketogenic mental health professional to coordinate and work with a prescriber with whom you already receive care. This could be a ketogenic dietician or even a ketogenic informed mental health counselor (like me).

Lifestyle change is hard

You may also really benefit from working with a ketogenic informed mental health professional to assist you. They will be able to help you work through any issues that come up while making a big lifestyle change like the ketogenic diet. Sometimes big lifestyle changes bring up feelings of resistance and it can be good psychological work to explore those with someone who knows how to move you through those potential obstacles.

I have written some blog posts about some of the psychological aspects of the lifestyle change involved in ketogenic dietary therapy, and how mental health counseling can help. You can find those here:

If you have decided that it would be helpful to find a ketogenic dietary professional, then read on. I will go through the different types of mental health professionals you may find trained in ketogenic dietary therapies that could help you on your journey to better mental health.

Ketogenic diet professionals

Luckily there are a lot of different types of mental health professionals trained in ketogenic diets that can help you. We will go through and describe each one, and provide resources below that could help you find one to help you on your mental health journey.

Ketogenic nutritionist or dietician

A ketogenic nutritionist is a nutritionist that has been trained to use the ketogenic diet to treat neurological disorders. As you may have read before, the ketogenic diet has been used for over a century to treat epilepsy, and it is now used for diseases like Alzheimer’s disease, Parkinson’s disease, and ALS.

A ketogenic nutritionist may also go by the term ketogenic dietician. Many work in hospital settings, but many provide services outside those institutions. A ketogenic nutritionist or dietician cannot help you adjust your medication, but they can work closely with your prescriber. And they are often very clever at addressing any issues you might have in implementing your new diet (e.g, shopping, meal prep, budgeting). These professionals will be able to give you the correct macros that will ensure you have plenty of brain energy and the nutrient support you need to feel better.

If you choose to work with a nutritionist or a dietician, be sure to clarify with them that you are looking for someone with experience providing help with ketogenic diets specifically. Not all nutritionists and dieticians understand that ketogenic dietary therapy is being used outside of epilepsy treatment for mental illness. Find one that is not going to discourage your use of it because they are not keeping up with the research literature on this topic.

Nutritional psychiatrist

A nutritional psychiatrist is an MD or Licensed Psychiatric Nurse Practitioner, who is able to monitor your medications and adjust them as needed. Some focus on dietary interventions and medication, and others include psychotherapy work with patients. One of my favorite nutritional psychiatrists, Georgia Ede, MD has a great quote:

The most powerful way to change your brain chemistry is through food, because that’s where brain chemicals come from in the first place.

Georgia Ede, MD – https://www.diagnosisdiet.com/blog-parent/category/mental-health

This is how a nutritional psychiatrist will approach your ketogenic dietary treatment for mental health. There will be some baseline tests run, and there may be supplements, but there will not be a focus on supplements as the mechanism by which you will change your brain chemistry and function.

Functional psychiatrist

A functional psychiatrist may or may not be well-trained in the use of ketogenic diets, but many of them are. They may have a focus on tests and supplementation over dietary therapies and you will have to ask them if they are comfortable helping you try one for your mental illness. They work to evaluate and correct what is causing your mental illness and they will likely have some advanced and well-thought-out recommendations for supplementation, both as a primary treatment and to support your ketogenic diet. They are good at ferreting out underlying causes of mental illness that traditional psychiatry does not. Functional tests and supplementation can become expensive, as they are not usually covered by insurance in the US. If you want to explore using a ketogenic diet or just explore options to traditional psychiatry on your mental health journey, a functional psychiatrist is a great potential resource.

Mental Health Counselor

A mental health counselor (or therapist, they are called different things in different places) can be an excellent choice. A keto counselor of sorts!

Full disclosure, this is the kind of ketogenic professional I am (About Me).

A mental health counselor can see you bi-weekly or weekly, which will help you monitor your symptoms and help you overcome any practical or even psychological obstacles you are facing as you attempt a ketogenic diet for your mental health. A mental health counselor can practice both nutritional psychiatry and functional psychiatry (without the medication component; I know, because that’s what I do). They can coordinate your care directly with your prescriber regarding possible needs for medication adjustments and even preliminary medical testing that might be helpful in tracking your progress.

Using a ketogenic informed mental health professional like a mental health counselor or therapist means that you can get evidence-based psychotherapy while you are using your ketogenic dietary therapy for your mental illness. The two are very complimentary. You can read more about how they can work together here. Be sure to find a mental health therapist that understands ketogenic diets. There can be problems finding one that is current in their understanding of the use of ketogenic diets for mental illness. You can read more about why that would be a problem here.

Finding a Ketogenic Professional

  • Chris Palmer, MD’s website has a directory of ketogenic dieticians here
  • The Charlie Foundation has a list of ketogenic dieticians here.
  • Society of Metabolic Health Practitioners Provider Directory is a directory of all kinds of ketogenic informed healthcare practioners. If you want someone who can help with medication adjustment be sure to find someone who is a prescriber, such as an MD, DO, Licensed Physcians Assistant, or Licensed Medical Nurse Practioner. Bonus if you can find one near you or via telehealth that specializes in psychiatric or neurological conditions.
  • Find a Low-Carb Doctor at DietDoctor.com also is a directory of ketogenic informed healthcare practitioners. Just like the directory above, you will want someone who can either adjust your medications, or help you knowledgably monitor your symptoms with you and help you advocate with your current prescriber as needed.
  • You can search for a functional psychiatrist in your area or via telehealth at a great organization called Psychiatry Redefined.
  • If you want to see someone in person, you can type in the search term for what you are looking for and add “near me” next to it into your favorite search engine.
  • Don’t beccome discouraged if you cannot find someone near you! Lots of independent ketogenic practioners us telehealth. Just type in the search term for the type of professional you are looking for. You will find a variety of great telehealth professionals able to help you meet your goals.

Conclusion

Finding a ketogenic health professional like a nutritional or functional psychiatrist, ketogenic dietician or nutritionist, licensed mental health counselor, or another ally with training in mental health can be really helpful.

I want you to know all the ways you can feel better.

But more importantly, I want you to know that you deserve a higher level of support and encouragement as you try to make big changes to help treat big issues.

If you are curious about how a ketogenic diet might help treat the underlying mechanisms of specific disorders, I have written carefully researched individual posts on Depression, Anxiety, ADHD, Alcoholism, PTSD, OCD, GAD, Panic Disorder, Social Anxiety Disorder, and many more. I add new ones all the time. So if you do not see the disorder you are interested in, please search the bottom of the main page.

Please feel free to reach out to me if you have any questions or I can help you on your wellness journey. You can contact me here.

Like what you are reading on the blog? Want to learn about upcoming webinars, courses, and even offers around support and working with me towards your wellness goals? Sign up!

Free ebook

Can keto treat my depression without medication?

Advertisements

How can a ketogenic diet help treat Depression?

Ketogenic diets modify at least four of the underlying pathologies seen in people with depression. These include glucose hypometabolism, neurotransmitter imbalances, inflammation, and oxidative stress. A ketogenic diet is a powerful dietary therapy shown to directly impact these four underlying mechanisms (and others) involved with depression symptoms.

Please note, there is an exponentially shorter version of this article with much less detailed information available here.

3 Reasons you are depressed and why keto can fix them

Introduction

In this blog post, I am not going to outline the symptoms or prevalence rates of depression and/or treatment-resistant depression. This post is not designed to be diagnostic or educational in that way. Other than to say that there are several levels of severity and chronicity when it comes to depression. This blog post is not going to discuss bipolar depression or mood disorders with psychotic features.

That is not to say that the ketogenic diet cannot be used for psychotic disorders. There are in fact, at the time of this blog post, published case studies in the peer-reviewed literature showing profound benefits and RCTs underway. I will very likely do a blog post on this topic in the future. In this post, we will discuss unipolar depression and how a ketogenic diet may be useful in treatment.

If you suffer from unipolar depression you may benefit from reading this blog post. Your depression may be chronic and severe enough to meet the criteria for major depressive disorder, and if so, you will also find this blog potentially helpful. If you have found this blog post, you know what depression is and likely you or someone you love may already be suffering from it.

If you have found this blog post, you are looking for treatment options. You are trying to find ways to feel better and heal. You are wondering if you can treat your depression with a diet.

By the end of this blog post, you will be able to understand some of the underlying mechanisms going wrong in the brains of people suffering from depression and how a ketogenic diet can therapeutically treat each of them.

You will come away seeing a ketogenic diet as a possible treatment for your depressive symptoms or as a complementary modality to use with psychotherapy and/or in place of medications.

What is the standard of care in treating depression?

Not surprisingly, the standard of care for depression is medication, therapy, or a combination of the two.

Medications most commonly used to treat depression include:

  • Tricyclic antidepressants (TCAs)
  • Selective serotonin re-uptake inhibitors (SSRIs)
  • Selective serotonin noradrenaline re-uptake inhibitors (SNRIs)

Less common ones include:

  • Adrenergic alpha-2 receptor antagonists
  • Monoamine oxidase (MAO) inhibitors
  • Selective noradrenaline re-uptake inhibitors
  • Selective noradrenaline/dopamine re-uptake inhibitors
  • Melatonin receptor agonists and serotonin 5-HT2C receptor antagonists

When one medication does not work, other medications from the same or different drug classes are added into combinations that the prescriber believes will reduce symptoms. We can look up any of these medications to learn their side effects, and imagine what side effects may look like for someone taking three or more of these medications. More prescriptions are then given to deal with the side effects of medications themselves.

However, a very large meta-analysis published in a peer-reviewed journal found that there is a lack of efficacy for SSRIs and that they significantly can increase the risk of serious side effects.

“SSRIs might have statistically significant effects on depressive symptoms, but all trials were at high risk of bias and the clinical significance seems questionable. SSRIs significantly increase the risk of both serious and non-serious adverse events. The potential small beneficial effects seem to be outweighed by harmful effects.”

Jakobsen, J. C., Katakam, K. K., Schou, A., Hellmuth, S. G., Stallknecht, S. E., Leth-Møller, K., … & Gluud, C. (2017). https://doi.org/10.1186/s12888-016-1173-2

This is consistent with my experience of medications as a practitioner treating clients. You or a loved one may have similar experiences. They may have worked great for you or a loved one. Your experience may be that they not only saved your life but that you will need to take them continuously throughout the rest of your life. And you may feel completely ok with that option.

The people who have had great success using antidepressants or other psychopharmacology to treat their depression are not the people reading this blog.

This blog is for those people who are looking for alternative treatments likely to help where other interventions have failed, or who want to work to fix the root causes of unipolar depression. They want to explore if a ketogenic diet may be able to treat their depression without medications or reduced medications.

Psychotherapy is a key component of treatment for depression, whether with or without medications. According to updated treatment guidelines provided by the American Psychological Association (APA), some psychotherapies identified as being helpful to treat depression include the following:

  • Behavioral therapy
  • Cognitive therapy
  • Cognitive-behavioral therapy (CBT)
  • Mindfulness-based (includes ACT)
  • Interpersonal psychotherapy
  • Psychodynamic therapies
  • Supportive therapy

As a mental health counselor, I am partial to therapy. I use a combination of those top 4 and sometimes if depression is mild or more situational I will rely even on supportive therapy. I see it work great in most instances. But sometimes I get clients who are having a hard time responding to the therapy I am providing.

In those cases, my job is to send that client out for medication, as the research literature has found that in cases of moderate to severe depression outcomes are better when medication and psychotherapy are provided simultaneously. And sometimes this works well. But the client is often afraid to titrate down from the medication. Even though psychotherapy can change your brain chemistry and literally rewire your brain in healthier ways, there is almost always this idea that the pill did the trick.

Some of my clients believe they need the medication, even if it has side effects or may be difficult to titrate off of later. Yes, many clients do not receive adequate informed consent that withdrawal symptoms can be a part of taking psychiatric medications. There is an excellent article about it here.

Sometimes my clients come into therapy feeling numbed and having side effects that they are finding not tolerable. There have been times a psychiatrist will put them on so much medication I cannot do effective therapy with them.

Medications used to treat depression are designed to reduce the symptoms of depression. Medications for depression are not designed to fix whatever underlying process was going on that caused your depression in the first place, whether physiological, social, cognitive or some combination of all three.

Most psychiatrists are not going after the root cause of what is causing depression. The prescribing of medications is designed to help you continue your life as it was. To help you get back to work. Parent the kids more. Stay in that marriage. Deal with that difficult family member. Continue at that job. They are modulators of symptoms (hopefully, at their very best) but do not address the underlying pathologies that occurred to create the depressed state in the first place.

But medication and psychotherapy together are not always sufficient to eliminate symptoms, reduce symptoms, or keep them from recurring. You may be asking yourself if a ketogenic diet is able to treat depression without medication. For people who have decided to not use medications or even those who have, and are still suffering from depression, this is a legitimate question. People who are suffering from treatment-resistant depression are valid in their want to explore alternative therapies. You have the option to attempt to treat your depression using the ketogenic diet without medication or as a complement to psychotherapy. But first, you should learn more about why this might be a valid option on your wellness journey.

What are the neurobiological factors we see in depression?

A previous post went into detail about how a ketogenic diet can modify symptoms of anxiety. In this post we will see whether these same four areas of pathology are seen in depression:

  • Glucose Hypometabolism
  • Neurotransmitter Imbalances
  • Inflammation
  • Oxidative stress

In unipolar depression we see these same pathologies occurring. There are areas of the brain with hypometabolism (not using energy properly), distinct neurotransmitter imbalances affecting mood and cognition, and inflammation. The literature has identified oxidative stress as a component in exacerbating depression symptoms. Let’s review each of these. And consider how the ketogenic diet modulates all of these and may favorably improve symptoms.

In this blog post I will also discuss two other mechanisms by which a ketogenic diet may be helpful in the treatment of depression:

  • gut microbiome
  • brain-derived neurotrophic factor (BDNF)

Depression and Glucose Hypometabolism

Glucose hypometabolism is a prominent feature of depression. We see it in several areas of the brain. Hypometabolism means that for some reason, energy is not being used well. The term “metabolism” refers to how the cells are using, storing, or creating energy. This “hypo” (too low) metabolism in the brain can be caused by a variety of factors and are often the result of those factors causing inflammation and oxidative stress (which we will learn more about in this blog post).

Altered metabolism in insula, limbic system, basal ganglia, thalamus, and cerebellum and thus these regions are likely to play a key role in the pathophysiology of depression.

Su, L., Cai, Y., Xu, Y., Dutt, A., Shi, S., & Bramon, E. (2014). Cerebral metabolism in major depressive disorder: a voxel-based meta-analysis of positron emission tomography studies. https://doi.org/10.1186/s12888-014-0321-9

There are a lot of areas of hypometabolism involved in depression, and it is thought that these different areas of dysfunction reflect differences in subtypes of depression and different methods of study. For example, when we see decreased metabolism in the prefrontal cortex, particularly the dorsolateral prefrontal cortex, we see it associated with a reduction in problem-solving abilities and a higher likelihood for negative emotions to be acted upon.

Location of the dorsolateral prefrontal cortex

This tendency to be unable to solve problems and to react with negative emotions can put people with depression at risk for suicidality in those with Major Depressive Disorder (MDD).

Factors believed to contribute to the creation of hypometabolism in include the following:

  • aging
  • hypertension
  • diabetes
  • hypoxia/obstructive sleep apnea
  • obesity
  • vitamin B12/folate deficiency
  • depression
  • traumatic brain injury

Pay attention to that list. We will talk about it a bit more when we discuss ketogenic diets as a treatment for depression.

We are discussing brain hypometabolism as we focus in on brain dysfunction in depression. But me talking about hypometabolism must also be conceptualized as a metabolic disorder. Brain hypometabolism is a sign of metabolic dysregulation and disorder.

Three longitudinal studies among depressed patients found that a combination of multiple metabolic dysregulations contributes to the sustained chronicity of depression.

Penninx, B., & Lange, S. (2018). Metabolic syndrome in psychiatric patients: overview, mechanisms, and implications. . https://doi.org/10.31887/DCNS.2018.20.1/bpenninx

Remember this as we begin to discuss below how a ketogenic diet can treat this underlying pathological state in depressed brains.

How does a ketogenic diet treat hypometabolism in depression?

Now, let’s go back to the list we just reviewed showing the factors believed to contribute to the creation of hypometabolism in the brain. But this time, we will point out the conditions in which a ketogenic diet is used to treat and/or reverse those very factors.

  • aging
    • ketogenic diets are used to treat mild cognitive decline, Alzheimer’s disease, and other dementias (e.g., vascular)
  • hypertension
    • a ketogenic diet can get someone off hypertension medications in as little as 3 days
  • diabetes
    • ketogenic diets have been seen to reverse Type II Diabetes or put in remission to the point insulin is no longer needed
    • If you are surprised by this you may enjoy exploring Virta Health
  • hypoxia/obstructive sleep apnea
    • ketogenic diets help people lose weight, which can either reverse or reduce the severity of obstructive sleep apnea
  • obesity
    • there is a large research literature showing that the ketogenic diet can help reduce obesity and improve body composition
  • vitamin B12/folate deficiency
    • this can be due to genetic issues and may need special supplementation, however, a well-formulated ketogenic diet is high in these nutrients
  • depression
    • Why we are here reading about a ketogenic diet as a treatment for depression
  • traumatic brain injury
    • ketogenic diets are used as a therapy for traumatic brain injury

So before we even explore how a ketogenic diet helps reverse or improve brain hypometabolism, we can see that the ketogenic diet already has strong research and clinical base showing its use in conditions that are either associated with or create brain hypometabolism!

The ketogenic diet is, in fact, a treatment for metabolic disorders. Remember the quote from a few moments ago, from a research paper discussing how psychiatric illnesses are metabolic disorders? Ketogenic diets have the power to reverse metabolic disorders. Meaning they can reverse the mechanisms underlying metabolic disease. Even those that occur in the brain. We use ketogenic diets to improve the metabolic dysfunction in the brains of those suffering from Alzheimer’s Disease. Should we not be considering it to reverse the metabolic dysfunction we see in clinically depressed brains?

I would argue strongly that we in fact should.

But now we will talk about how a ketogenic diet can reverse or improve brain hypometabolism.

The most obvious way that a ketogenic diet improves hypometabolism is by providing an alternative fuel source for the brain. Sometimes, for a variety of reasons, the machinery used by brain cells to use glucose as fuel doesn’t work well anymore. Luckily, ketones, which are generated on a ketogenic diet, can bypass that faulty cell machinery and get right into those neurons to be burned as fuel. Ketogenic diets also upregulate the creation of something called mitochondria.

Mitochondria are the powerhouses of your neurons. They make energy. So your cells make more mitochondria and those mitochondria work really well when given ketones as fuel.

The other way that ketogenic diets help prevent and reverse hypometabolism is by helping cell membranes work better. Cell membranes working better mean healthy action potentials. Action potentials are what we call that moment when a cell fires. A firing cell, firing in a balanced way, without firing too much or too little, is an effect of ketogenic diets.

Ketogenic diets also upregulate (increase or make more of) important enzymatic activities (enzymes are essential in almost all things) needed to generate cellular energy.

The bottom line is that brains suffering from hypometabolism work better using a ketogenic diet. Got depression? You have hypometabolism. Need a treatment for that underlying pathology driving your depression? Ketones are a potential therapy.

Depression and Neurotransmitter Imbalances

It can be difficult to write about the effects of the ketogenic diet on mental illness, and on depression in particular, because each of the headings we will discuss influences the other. Here is a good example:

Thus, pro-inflammatory cytokines can interact virtually with all pathophysiological changes that characterise major depression and thereby influence neurotransmitter function, synaptic plasticity and ultimately neuronal structure.

Leonard, B. E., & Wegener, G. (2020). Inflammation, insulin resistance and neuroprogression in depression. https://pubmed.ncbi.nlm.nih.gov/31186075/

This section is not about inflammation. That comes later. But as you learn about how the ketogenic diet treats depression you will have to become a systems thinker. Keep in mind as we discuss neurotransmitter imbalances seen in depression, that the other categories of hypometabolism, inflammation, and oxidative stress influence the creation of those neurotransmitter imbalances. I will also do my best to wrap how these interact in the conclusion, but do your best to make these connections as you go.

The neurotransmitter imbalances we see in depression occur most likely because of neuroinflammation, often initiated by immune responses that create inflammatory cytokines. We will talk more about that later, but understand that when your brain is inflamed, it is an environment that is not in balance. And apparently, your brain needs to have a certain amount of stability in order to make neurotransmitters in the right amount and balance. To achieve neurotransmitter balance you need a brain that is not under a lot of excess stress, inflammation, or oxidative stress.

Neurotransmitters thought to be involved in major depressive disorder include serotonin, dopamine, norepinephrine, and GABA. Almost the entire psychiatric literature has been based on the idea that depression is a neurotransmitter imbalance, right? But let’s talk about how those neurotransmitters might be getting out of balance in the first place.

When your brain is suffering from inflammation (and yes, a high sugar diet can cause higher inflammation and immune system dysfunction that can lead to neuroinflammation), there is something called a tryptophan steal. This results in less serotonin, less melatonin, and less GABA being made. It also means more dopamine, which for some psychiatric disorders is not a good thing, as well as excitotoxic levels of glutamate. What does this mean to the depressed brain?

Tryptophan is an amino acid and gets made into neurotransmitters with a little help from cofactors such as important micronutrients. If your brain is inflamed at a time that neurotransmitters need to be made, this amino acid goes through a different pathway and makes more of an excitatory neurotransmitter called glutamate. Now, glutamate is not a bad neurotransmitter. you need glutamate. You just don’t need or want the 100x more glutamate that will be made when your brain is inflamed. That much extra glutamate is neurotoxic and ironically, creates even more inflammation through neurodegeneration.

Glutamate at these levels feels anxious. Or if inflammation levels get high enough probably feels depressed. Why? Because by going through the wrong pathway your brain has made much much less GABA than it was supposed to.

Was there some time in your life when you were feeling the opposite of overwhelmed? You felt chill and competent and exuded a sense of “I got this” as you thought about life and your future? That was your brain having the right amount of GABA. And that, my friend, is your natural state of being.

You are not your depression.

This tryptophan steal also reduces the amount of serotonin and melatonin you can make. So you get low, sad, depressed mood and terrible sleep. You start doing that thing where you don’t fall asleep at a reasonable time. And then you stay up late, possibly ruminating or feeling generally terrible, and then you have trouble getting up in the morning. So you call yourself a loser and reinforce the negative cognitive bias that develops and helps sustain depression. Which makes you sadder and worsens your symptoms causing more inflammation. Sound familiar?

You know what I am talking about. That is you living the consequences of an inflamed brain messing up your neurotransmitter balance. Depleting your micronutrients to upkeep your brain and make enzymes and neurotransmitters. And fixing this is actually more in your control than you would ever imagine.

Remember, medications do not help you make more serotonin. Only your brain can really do that. They just help what you can make hang out. And if you are not making enough because of this inflammatory neurotransmitter imbalance train-wreck and/or because of micronutrient deficiency (less likely on a well-formulated ketogenic diet), then those medications can only do so much.

How the ketogenic diet improves neurotransmitter imbalances seen in depression

Ketogenic diets significantly alter the neurotransmitters dopamine and serotonin but with a stable ratio, meaning it helps the brain make not too much and not too little. Something particularly useful in those with depression. Remember, you can be prescribed medication in the form of reuptake-inhibitors for both serotonin and dopamine. They will give you longer access to the neurotransmitters you have managed to produce and for a lot of people that will help to relieve symptoms.

What those medications will NOT do is ensure a balanced ratio, or be able to tell your complicated brain when it needs more or less. And that is why they often create side effects. Side effects can happen when a medication is trying to modulate something too far one way or the other, and it is affecting multiple systems. You do not get that with a ketogenic diet. There is just none of that nonsense going on.

And so a ketogenic diet, with its many pathways of intervention and its ability to regulate and balance neurotransmitter production and use, can make it an excellent treatment for depression. All by itself, or in addition to medications, under the care of your prescriber.

Depression and neuroinflammation

A lot of things can cause neuroinflammation. A high sugar or carbohydrate diet that your metabolism cannot deal with can cause inflammation. That high fructose drink you prefer? That can cause inflammation. No really, I am not making this up. Look here.

A leaky blood-brain barrier that lets toxins get up in the brain where they don’t belong can cause inflammation. A leaky gut that lets matter through for the immune system to freak out about can cause inflammation. An event that happens in your body, way far away from your brain, can trigger neuroinflammation, because the immune system in your body, talks to the one in your brain. A traumatic event can increase neuroinflammation, probably through mechanisms around cortisol. Having an immune response, whether viral or to injury, can cause neuroinflammation.

When we study depression and inflammation, we look for markers of inflammation. And the research literature is full of studies looking at these different types of markers for what are called cytokines. Cytokines are powerful and the way they play out in your brain is they control your behavior. Remember when you had a bad cold or flu, and you literally just laid down, and did not get up again for a very long time. You sat still. You had no motivation to go do anything or stimulate yourself overmuch with any sort of activity? That was your body’s immune system calling out to the separate immune system that is in your brain, to let it know to stay alert, that your body was under attack, and that you needed to rest. So that brain inflammation did just that, with inflammatory cytokines. So you rested.

How is this relevant to depression? Think about it like this. Are you motivated to get up and do things? Does being on the couch and not feeling motivated to move sound familiar? Your brain is inflamed. This inflammation is part of what creates your symptoms of depression. Signs of neuroinflammation include brain fog, anxiety, depression, headaches, and poor mental stamina. Do those sound like some of your symptoms?

Depression is not just neurotransmitter imbalances as you were led to believe, and told could be fixed with medication. It is also inflammation that is driving your symptoms. And inflammation needs its own special attention in the treatment of depression.

Chronic low-grade inflammation has been observed in major depression and other major psychiatric disorders and has been implicated in metabolic changes that are commonly associated with these disorders.

Leonard, B. E., & Wegener, G. (2020). Inflammation, insulin resistance and neuroprogression in depression. HTTPS://PUBMED.NCBI.NLM.NIH.GOV/31186075/

Let me use this as an opportunity to help you make connections. Remember when we discussed the need for the brain to not be inflamed in order to make the right combo of neurotransmitters? Remember our talk of the tryptophan steal? This is what the below quote from the research literature is talking about:

Thus, as a consequence of immune activation, the changes in the tryptophan-kynurenine pathway play a major role in the dysfunctional neurotransmitter systems in the brain and, in addition, contribute to the changes in the brain structure and function which characterise depression.

Leonard, B. E., & Wegener, G. (2020). Inflammation, insulin resistance and neuroprogression in depression. https://pubmed.ncbi.nlm.nih.gov/31186075/

Neuroinflammation sets the stage for your brain to not work well, which then creates the perfect conditions for that tryptophan steal to occur. And this consistent state of inflammation and imbalanced neurotransmitters starts to change your brain structures and the connectivity of those brain structures.

So as you can imagine, a powerful intervention to reduce inflammation is warranted if we want to treat depression. And I think you obviously know where I am going with this.

How ketogenic diets reduce neuroinflammation in those with depression

There is an excellent and well-written article on how ketones work here and one specifically about inflammation here. They are much more biochemically in-depth than the level discussed in this blog post. If you like the neurochemistry and biochemistry pieces you should definitely deep dive there for a more in-depth understanding.

But for the rest of us, it is just important to know that ketogenic diets are VERY powerful anti-inflammatory therapies.

First, the reduction in carbohydrates significantly reduces inflammation, because your body isn’t desperately trying to get your ideal blood sugar levels back down to about a tsp worth of glucose in your entire bloodstream. If you are insulin resistant (and you likely are because of how our diets are in modern times) then every second you are swimming in higher blood sugar levels for longer than they should be you are contributing to cell damage and inflammation. So ketogenic diets, with their restriction to low carbohydrates, really help that.

Second, ketones, which are produced on a ketogenic diet, are signaling molecules. This means they turn genes on and off. And some of the genes they turn on and off are those that manage inflammation in the body. And if that wouldn’t make them an effective treatment for the neuroinflammation that we see is rampant in depression, I do not know what would be. Perhaps someday gene therapies will occur for depression, that does the work of ketones. And you can wait for those, but I am not sure why you would want to when you have the ability to instigate your own gene therapy through a free, effective dietary therapy with no significant side effects.

Depression and Oxidative Stress

Oxidative stress, in general, works like this:

  • Cells make energy using ATP
  • ATP goes through a process called oxidative phosphorylation
  • This causes reactive oxygen species (ROS); which are destructive by-products of this very normal process
  • ROS damages DNA, and this damage can be cumulative
  • Oxidative Stress is what we call the burden on our system to repair this damage

It is not about whether you have oxidative stress, it is about what your levels of oxidative stress are and the burden and damage that occurs in your body as a result.

The brains of people suffering from depression have higher levels of oxidative stress. The higher your oxidative stress, the poorer your outcomes when using anti-depressants. Why would that be? Well, anti-depressant medications do not address this problem. As we discussed, medications for depression are about alleviating symptoms. Not causes.

If your inflammation is too high, you create more ROS. And too much ROS depletes the systems designed to reduce inflammation. This increases your level of oxidative stress. Oxidative stress is higher in those with depression. So we need an intervention that can address both inflammation and oxidative stress.

How ketones treat Oxidative Stress in those with Depression

B-Hydroxybutyrate, one of 3 types of ketones made in the body reduces the production of reactive oxygen species (ROS) and thereby improves mitochondrial function, which you experience as energy and better working everything. It also stimulates your own antioxidant system that uses endogenous glutathione production. I promise you, there is no antioxidant therapy you can take that will be as powerful as your own endogenous glutathione system that is upregulated with ketone action and plenty of glutathione precursors coming from a well-formulated ketogenic diet. I don’t care how much Vitamin C you are downing, you are not going to get the same level of anti-oxidant support you would get from your own well-working endogenous (made in your body) anti-oxidant system.

You were, after all, made to deal with reactive oxygen species. Seriously, you get them just by breathing. Do you think evolution didn’t think about that?

I am not saying our modern world with its pollutants, chemicals, current ways of eating, and the resulting chronic diseases, do not warrant some extra anti-oxidants or detoxification strategies. But I am saying that if you use ketogenic dietary therapy and upregulate your ketones you are going to treat the neuroinflammation in your brain that is contributing to, or more likely causing, your depressive symptoms. And it’s going to do it at a level you are just not going to get eating as you have and popping a lot of vitamin C and turmeric.

Glutathione aside, reducing your carbohydrate intake helps (immensely) to not deplete the glutathione you already make. Oxidative stress is a result of creating more reactive oxygen species than your current antioxidant systems (whether those you make or those you eat) can handle. And then we get cell damage, inflammatory cytokines, and quite frankly, serious DNA damage. And that DNA damage can never be fixed if you are constantly slamming your defenses with a diet (or environment) that creates a constant source of inflammation.

Usually, I stop with the above four mechanisms of action. But in depression, I thought it would be helpful to discuss two other ways that a ketogenic diet may be helpful in treating depression without medication (or with meds if you find a knowledgeable prescriber or mental health counselor).

Effects of ketogenic diets on gut microbiome and depression

There is a lot of research that I will not go into here about the gut microbiome and depression. There are some important nutrients involved in this (e.g., Vitamin D is HUGE) and it really warrants its own blog post. Also, what we know about the microbiome is very much in its infancy. There are a lot of educated assumptions going on as researchers are trying to figure things out.

But what I can tell you is that a well-formulated ketogenic diet makes for a happy and healthy microbiome. Beta-hydroxybutyrate is one of three types of ketones. The “butyrate” portion of this type of ketone is immensely helpful for gut healing and health.

Butyrate along with other fermentation-derived SCFAs (e.g. acetate, propionate) and the structurally related ketone bodies (e.g. acetoacetate and d-β-hydroxybutyrate) show promising effects in various diseases including obesity, diabetes, inflammatory (bowel) diseases, and colorectal cancer as well as neurological disorders. Indeed, it is clear that host energy metabolism and immune functions critically depend on butyrate as a potent regulator, highlighting butyrate as a key mediator of host-microbe crosstalk. 

Stilling, R. M., van de Wouw, M., Clarke, G., Stanton, C., Dinan, T. G., & Cryan, J. F. (2016). https://doi.org/10.1016/j.neuint.2016.06.011

I know what you are thinking. The benefits of the ketogenic diet just go on and on and on. It sounds like a scam. Like a too-good-to-be-true sort of thing. And I would understand if you were skeptical. But I promise I am not making this stuff up.

Do you know what food has the highest butyrate levels? Butter. That’s right. Your gut loves butter. Possibly more than it loves all the prebiotic fiber you are worried about getting. But don’t be concerned. A well-formulated ketogenic diet is full of that also in all those low-carb veggies you would be enjoying.

So don’t let people tell you the ketogenic diet is bad for your gut microbiome or it is going to “mess it up” or something like that. That is just not the case. If anything it can improve your gut health, help repair leaky gut, and as a result calm down that immune system activity that is contributing to inflammation, which then can cause neuroinflammation, and directly contribute to the imbalances in your neurotransmitters.

The gut microbiome is not my area of expertise at all. I am not up on my understanding of all those little bacteria and the effects they have on the body, or the metabolic pathways they may influence. But if you are way into that stuff and want to learn more about what kind of specific changes in the gut microbiome we see with ketogenic diets you can find a great blog post here.

Brain-Derived Neurotrophic Factor (BDNF)

Brain-derived neurotrophic factor (BDNF) is a protein encoded by a specific gene. It’s that important. It does some really important things:

  • enhance neurogenesis (new brain cells and parts)
  • brain cell proliferation and survival
  • an important role in learning and memory

It is required for a healthy brain. It is needed to grow, to heal, to make new connections, and to learn. Why does this matter if you have depression?

When you have a depressed brain the damage is progressive in nature and includes changes in brain structure and function. You are going to need nice high levels of BDNF to help restructure those pathways and to get the most out of any psychotherapy you use as an adjunctive treatment. When I sit down with a client using cognitive-behavioral therapy, I am there to help them restructure thought patterns. That is going to mean they need to make new connections of thought and memory.

Problems with BDNF have been identified as a factor in depression.

The maladaptive neuroplastic in depression may be related to alterations in the levels of neurotrophic factors, which play a central role in plasticity. Enhancement of neurotrophic factors signaling has great potential in therapy for depression.

Yang, T., et al. (2020). The role of BDNF on neural plasticity in depression. https://doi.org/10.3389/fncel.2020.00082

BDNF is this mysterious factor that is absolutely crucial for brain health and fixing broken connections, and it just happens to be upregulated quite nicely on a ketogenic diet. Seen, by the way, in both animal and human studies. The science on this is legit. Anyone saying the ketogenic diet as a treatment for depression is fringe just doesn’t know the research literature on its benefits. Because if they did, they would nod their head and say “yeah, I can totally see how that would work.”

Conclusion

So the reduction in carbohydrates that happens with a ketogenic diet is helpful because it reduces inflammation and it allows our bodies to make ketones. And as we have learned, ketones are a direct and powerful intervention for inflammation. Ketones, which are generated by employing a ketogenic diet, help you make more of your own anti-oxidants (glutathione). Ketones can help repair leaky brain and gut membranes to keep inflammation down from immune system over-activation.

There is even important research about how ketogenic diets improve immune function, but I had to have some limits on this post or it would go on forever.

Less inflammation helps your body hold on to more of its important micronutrients. These micronutrient levels could be boosted further in the choice to eat a well-formulated, whole foods ketogenic diet. These micronutrients would be used to repair damaged DNA, help cell membranes work better, and make neurotransmitters in sufficient and balanced quantities. The boost in cellular energy and power that you get with ketones helps your neurons repair themselves from the damage that has happened. That fuel helps them to do basic housekeeping and upkeep those cells and cell membranes.

I don’t know of a single medication that can do all of these things. And I do not believe a cocktail of medications could achieve these things without an awful lot of side effects. And it is for this reason that I really wanted you to know that a ketogenic diet might be used instead of medications for depression. I want you to know that many of the mechanisms by which ketogenic diets work are well-documented in research. As are their stellar effects. And I believe you need this information in order to make good treatment decisions, so you can live your very best life.

I want to encourage you to learn more about your treatment options from any of the following blog posts. I write about different mechanisms in varying degrees of detail that you may find helpful to learn on your wellness journey. You may enjoy the Ketogenic Case Studies page to learn how others have used the ketogenic diet to treat mental illness in my practice. And you may benefit from understanding how working with a mental health counselor while transitioning to a ketogenic diet can be helpful here.

Share this or other blog posts I have written with friends and family suffering from mental illness. Let people know there is hope!

You can learn more about me here. If you would like to contact me you may do so here. If you just have a simple question please do not hesitate to reach out. Or let me know in a comment if you have found this blog post to be helpful on your wellness journey.

I truly believe you have the right to know all of the ways you can feel better.

Like what you are reading on the blog? Want to learn about upcoming webinars, courses, and even offers around support and working with me towards your wellness goals? Sign up!

Free ebook

References

Bajpai, A., Verma, A. K., Srivastava, M., & Srivastava, R. (2014). Oxidative Stress and Major Depression. Journal of Clinical and Diagnostic Research : JCDR, 8(12), CC04. https://doi.org/10.7860/JCDR/2014/10258.5292

Bedford, A., & Gong, J. (2018). Implications of butyrate and its derivatives for gut health and animal production. Animal Nutrition (Zhongguo Xu Mu Shou Yi Xue Hui), 4(2), 151–159. https://doi.org/10.1016/j.aninu.2017.08.010

Binder, D. K., & Scharfman, H. E. (2004). Brain-derived Neurotrophic Factor. Growth Factors (Chur, Switzerland), 22(3), 123. https://doi.org/10.1080/08977190410001723308

Black, C. N., Bot, M., Scheffer, P. G., Cuijpers, P., & Penninx, B. W. J. H. (2015). Is depression associated with increased oxidative stress? A systematic review and meta-analysis. Psychoneuroendocrinology, 51, 164–175. https://doi.org/10.1016/j.psyneuen.2014.09.025

Brietzke, E., Mansur, R. B., Subramaniapillai, M., Balanzá-Martínez, V., Vinberg, M., González-Pinto, A., Rosenblat, J. D., Ho, R., & McIntyre, R. S. (2018). Ketogenic diet as a metabolic therapy for mood disorders: Evidence and developments. Neuroscience & Biobehavioral Reviews, 94, 11–16. https://doi.org/10.1016/j.neubiorev.2018.07.020

Daulatzai, M. A. (2017). Cerebral hypoperfusion and glucose hypometabolism: Key pathophysiological modulators promote neurodegeneration, cognitive impairment, and Alzheimer’s disease. Journal of Neuroscience Research, 95(4), 943–972. https://doi.org/10.1002/jnr.23777

Delva, N. C., & Stanwood, G. D. (2021). Dysregulation of brain dopamine systems in major depressive disorder. Experimental Biology and Medicine, 246(9), 1084–1093. https://doi.org/10.1177/1535370221991830

Diener, C., Kuehner, C., Brusniak, W., Ubl, B., Wessa, M., & Flor, H. (2012). A meta-analysis of neurofunctional imaging studies of emotion and cognition in major depression. NeuroImage, 61(3), 677–685. https://doi.org/10.1016/j.neuroimage.2012.04.005

Gaynes, B. N., Lux, L., Gartlehner, G., Asher, G., Forman-Hoffman, V., Green, J., Boland, E., Weber, R. P., Randolph, C., Bann, C., Coker-Schwimmer, E., Viswanathan, M., & Lohr, K. N. (2020). Defining treatment-resistant depression. Depression and Anxiety, 37(2), 134–145. https://doi.org/10.1002/da.22968

Guilloteau, P., Martin, L., Eeckhaut, V., Ducatelle, R., Zabielski, R., & Immerseel, F. V. (2010). From the gut to the peripheral tissues: The multiple effects of butyrate. Nutrition Research Reviews, 23(2), 366–384. https://doi.org/10.1017/S0954422410000247

Hirono, N., Mori, E., Ishii, K., Ikejiri, Y., Imamura, T., Shimomura, T., Hashimoto, M., Yamashita, H., & Sasaki, M. (1998). Frontal lobe hypometabolism and depression in Alzheimer’s disease. Neurology, 50(2), 380–383. https://doi.org/10.1212/wnl.50.2.380

Information, N. C. for B., Pike, U. S. N. L. of M. 8600 R., MD, B., & Usa, 20894. (2020). Depression: How effective are antidepressants? In InformedHealth.org [Internet]. Institute for Quality and Efficiency in Health Care (IQWiG). https://www.ncbi.nlm.nih.gov/books/NBK361016/

Jacob, Y., Morris, L. S., Huang, K.-H., Schneider, M., Rutter, S., Verma, G., Murrough, J. W., & Balchandani, P. (2020). Neural correlates of rumination in major depressive disorder: A brain network analysis. NeuroImage: Clinical, 25, 102142. https://doi.org/10.1016/j.nicl.2019.102142

Jakobsen, J. C., Katakam, K. K., Schou, A., Hellmuth, S. G., Stallknecht, S. E., Leth-Møller, K., Iversen, M., Banke, M. B., Petersen, I. J., Klingenberg, S. L., Krogh, J., Ebert, S. E., Timm, A., Lindschou, J., & Gluud, C. (2017). Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis. BMC Psychiatry, 17(1), 58. https://doi.org/10.1186/s12888-016-1173-2

Koenigs, M., & Grafman, J. (2009). The functional neuroanatomy of depression: Distinct roles for ventromedial and dorsolateral prefrontal cortex. Behavioural Brain Research, 201(2), 239–243. https://doi.org/10.1016/j.bbr.2009.03.004

Koh, S., Dupuis, N., & Auvin, S. (2020). Ketogenic diet and Neuroinflammation. Epilepsy Research, 167, 106454. https://doi.org/10.1016/j.eplepsyres.2020.106454

Koo, J. W., Chaudhury, D., Han, M.-H., & Nestler, E. J. (2019). Role of Mesolimbic Brain-Derived Neurotrophic Factor in Depression. Biological Psychiatry, 86(10), 738–748. https://doi.org/10.1016/j.biopsych.2019.05.020

Leonard, B. E., & Wegener, G. (2020). Inflammation, insulin resistance and neuroprogression in depression. Acta Neuropsychiatrica, 32(1), 1–9. https://doi.org/10.1017/neu.2019.17

Lindqvist, D., Dhabhar, F. S., James, S. J., Hough, C. M., Jain, F. A., Bersani, F. S., Reus, V. I., Verhoeven, J. E., Epel, E. S., Mahan, L., Rosser, R., Wolkowitz, O. M., & Mellon, S. H. (2017). Oxidative stress, inflammation and treatment response in major depression. Psychoneuroendocrinology, 76, 197–205. https://doi.org/10.1016/j.psyneuen.2016.11.031

Liu, H., Wang, J., He, T., Becker, S., Zhang, G., Li, D., & Ma, X. (2018). Butyrate: A Double-Edged Sword for Health? Advances in Nutrition (Bethesda, Md.), 9(1), 21–29. https://doi.org/10.1093/advances/nmx009

Maletic, V., Robinson, M., Oakes, T., Iyengar, S., Ball, S. G., & Russell, J. (2007). Neurobiology of depression: An integrated view of key findings. International Journal of Clinical Practice, 61(12), 2030–2040. https://doi.org/10.1111/j.1742-1241.2007.01602.x

Masino, S. A., & Rho, J. M. (2012). Mechanisms of Ketogenic Diet Action. In J. L. Noebels, M. Avoli, M. A. Rogawski, R. W. Olsen, & A. V. Delgado-Escueta (Eds.), Jasper’s Basic Mechanisms of the Epilepsies (4th ed.). National Center for Biotechnology Information (US). http://www.ncbi.nlm.nih.gov/books/NBK98219/

Myette-Côté, É., Soto-Mota, A., & Cunnane, S. C. (2021). Ketones: Potential to achieve brain energy rescue and sustain cognitive health during ageing. British Journal of Nutrition, 1–17. https://doi.org/10.1017/S0007114521003883

Newman, J. C., & Verdin, E. (2017). β-Hydroxybutyrate: A Signaling Metabolite. Annual Review of Nutrition, 37, 51. https://doi.org/10.1146/annurev-nutr-071816-064916

Norwitz, N. G., Dalai, Sethi, & Palmer, C. M. (2020). Ketogenic diet as a metabolic treatment for mental illness. Current Opinion in Endocrinology, Diabetes and Obesity, 27(5), 269–274. https://doi.org/10.1097/MED.0000000000000564

Nutt, D. J. (n.d.). Relationship of Neurotransmitters to the Symptoms of Major Depressive Disorder. J Clin Psychiatry, 4.

Offermanns, S., & Schwaninger, M. (2015). Nutritional or pharmacological activation of HCA2 ameliorates neuroinflammation. Trends in Molecular Medicine, 21(4), 245–255. https://doi.org/10.1016/j.molmed.2015.02.002

Penninx, B. W. J. H., & Lange, S. M. M. (2018). Metabolic syndrome in psychiatric patients: Overview, mechanisms, and implications. Dialogues in Clinical Neuroscience, 20(1), 63–73.

Pinto, A., Bonucci, A., Maggi, E., Corsi, M., & Businaro, R. (2018). Anti-Oxidant and Anti-Inflammatory Activity of Ketogenic Diet: New Perspectives for Neuroprotection in Alzheimer’s Disease. Antioxidants, 7(5). https://doi.org/10.3390/antiox7050063

Richard F. Mollica, M. D. (2021). Moving Beyond the Enormity Problem: Tackling the Global Refugee Crisis. https://www.psychiatrictimes.com/view/integrating-psychotherapy-and-psychopharmacology-treatment-major-depressive-disorder

Rogers, M. A., Bradshaw, J. L., Pantelis, C., & Phillips, J. G. (1998). Frontostriatal deficits in unipolar major depression. Brain Research Bulletin, 47(4), 297–310. https://doi.org/10.1016/S0361-9230(98)00126-9

Shippy, D. C., Wilhelm, C., Viharkumar, P. A., Raife, T. J., & Ulland, T. K. (2020). β-Hydroxybutyrate inhibits inflammasome activation to attenuate Alzheimer’s disease pathology. Journal of Neuroinflammation, 17(1), 280. https://doi.org/10.1186/s12974-020-01948-5

Simons, P. (2017, February 27). New Data Show Lack of Efficacy for Antidepressants. Mad In America. https://www.madinamerica.com/2017/02/new-data-showslack-efficacy-antidepressants/

Su, L., Cai, Y., Xu, Y., Dutt, A., Shi, S., & Bramon, E. (2014). Cerebral metabolism in major depressive disorder: A voxel-based meta-analysis of positron emission tomography studies. BMC Psychiatry, 14(1), 321. https://doi.org/10.1186/s12888-014-0321-9

Taylor, R. W., Marwood, L., Oprea, E., DeAngel, V., Mather, S., Valentini, B., Zahn, R., Young, A. H., & Cleare, A. J. (2020). Pharmacological Augmentation in Unipolar Depression: A Guide to the Guidelines. International Journal of Neuropsychopharmacology, 23(9), 587–625. https://doi.org/10.1093/ijnp/pyaa033

Yang, T., Nie, Z., Shu, H., Kuang, Y., Chen, X., Cheng, J., Yu, S., & Liu, H. (2020). The Role of BDNF on Neural Plasticity in Depression. Frontiers in Cellular Neuroscience, 14, 82. https://doi.org/10.3389/fncel.2020.00082

Yudkoff, M., Daikhin, Y., Melø, T. M., Nissim, I., Sonnewald, U., & Nissim, I. (2007). The ketogenic diet and brain metabolism of amino acids: Relationship to the anticonvulsant effect. Annual Review of Nutrition, 27, 415–430. https://doi.org/10.1146/annurev.nutr.27.061406.093722

Social Anxiety Disorder (SAD)

Advertisements

How could a ketogenic diet help treat the symptoms of Social Anxiety Disorder (SAD)?

Ketogenic diets are able to modify at least four of the pathologies we see in people suffering from Social Anxiety Disorder. These include glucose hypometabolism, neurotransmitter imbalances, inflammation, and oxidative stress. A ketogenic diet is a powerful dietary therapy that has been shown to directly impact these four underlying mechanisms that have been identified to be involved with the symptomatology of Social Anxiety Disorder.

Introduction

In this blog post, I will not be listing the symptoms or prevalence rates of Social Anxiety Disorder (SAD). This post is not designed to be diagnostic or educational in that way. If you have found this blog post, you probably know what Social Anxiety Disorder is and it is possible or likely that you or someone you love may already be suffering from it.

If you have found this blog post, you are looking for treatment options. You are trying to find ways to reduce symptoms and increase your functioning in social situations.

By the end of this blog post, you will be able to understand some of the underlying mechanisms going wrong in the brains of people suffering from social anxiety and how a ketogenic diet can therapeutically treat each of them.

You will come away seeing a ketogenic diet as a possible treatment for your social anxiety or as a complementary modality to use with psychotherapy and/or in place of medications.

Clinical experience and limited systematic data suggest that augmentation with benzodiazepines or gabapentin, or switching to monoamine oxidase inhibitors, benzodiazepines or gabapentin can be useful in treatment-resistant cases. Cognitive-behavioral treatment can also be a helpful adjunct or alternative in non-responders to pharmacological treatment of SAD.

https://doi.org/10.1016/B978-0-12-394427-6.00022-4

The current standard of treatment for Social Anxiety Disorder is the use of pharmacology and/or psychotherapy in the form of Cognitive-Behavioral Therapy (CBT). CBT helps clients look at their thoughts and beliefs around social situations which can be quite helpful There is also a significant behavioral component of exposure therapy, in which clients would create a list of social anxiety-provoking situations and rate the subjective level of anxiety they felt at the idea of doing those activities. They would then actually do the things on the list, exposing themselves to the behaviors until they felt zero anxiety doing so.

But when you look at the list of medication types above, that are considered standard of care psychopharmacology, you have some real potential problems.

  1. These medications often have side-effects that are really unpleasant. Some can even create physical dependance.
  2. Use of fast acting medications can create a psychological dependance on their use in stressful situations.
  3. Access to faster acting anxiety medications can become a barrier for people to learn to reach for other tools of coping (e.g., mindfulness or CBT techniques).
  4. These medications all potentially get in the way of effective behavioral therapy for social anxiety. If you are medicated while doing behavior therapy you cannot habituate and expose effectively. The anxiety will come back when you stop your medication.

What are the neurobiological changes seen in Social Anxiety Disorder? Where are possible pathways of intervention?

A previous post went into detail about how a ketogenic diet can modify symptoms of anxiety by affecting four areas of pathology seen in these types of disorders.

  • Glucose Hypometabolism
  • Neurotransmitter Imbalances
  • Inflammation
  • Oxidative stress

In Social Anxiety Disorder (SAD) we see these same underlying mechanisms. There are areas of the brain with hypometabolism (not using energy properly) and we see overexcitability in others. Also seen in Social Anxiety Disorder (SAD) are neurotransmitter imbalances, neuroinflammation, and oxidative stress as part of the underlying disease process. Let’s review each of these as they are seen in the development and/or perpetuation of Social Anxiety Disorder (SAD).

Social Anxiety and Hypometabolism

“hypometabolism”

noun

  1. The physiological state of having an decreased rate of metabolic activity

When we compare whole-brain analysis using functional MRI (fMRI) of people with Social Anxiety Disorder there is significantly lower activation (hypometabolism) in the left anterior cingulate gyrus. This part of the brain is responsible for attention control.

Hypometabolism of the cingulate gyrus has a strong role in the creation of anxiety in social situations. Those with Social Anxiety Disorder show lower activation in the cingulate gyrus, which is responsible for the process of attention control.

What does this mean for those experiencing symptoms?

Anyone who has ever experienced social anxiety knows what this feels like. When you are socially anxious, you cannot be fully present with whomever you are talking to or even enjoy the environment you are in. Why? You cannot focus your attention exclusively on the interaction. And as a result, a huge part of your attention is being used to fuel your anxiety.

Instead of being able to have a simple conversation, your attention is focused on what to say next so you don’t feel stupid, evaluating what you think the other person thinks of you and possibly imagining worst-case social scenarios that are not even happening.

Successful treatment of Social Anxiety Disorder using behavioral exposure therapy will show positive changes in activation of the cingulate gyrus. Reflecting the person’s improving ability to utilize this part of the brain better and thereby holding attention on primarily the conversation they are having. This better brain activation results in more positive thoughts regarding the self in social situations and less tendency to ruminate on actual or perceived negative social moments.

How does a ketogenic diet treat hypometabolism in Social Anxiety Disorder (SAD)?

We know from past posts discussing ketogenic diets for mental illness (here, here, and here) that it is a powerful metabolic therapy for the brain. Sometimes brains stop using glucose effectively as a form of fuel in many structures. There are many theories about why this happens. It can develop in response to high carbohydrate diets. We can begin to to see impaired utilization of glucose as fuel in our 30s, and possibly sooner. The brain’s ability to take in and use glucose depends on insulin sensitivity. The higher carbohydrate laden our diets, the more insulin our body must produce. And over time that increase in insulin actually reduces the ability of our cells use glucose as fuel. While I could not find any specific studies suggesting insulin resistance was directly responsible for areas of brain hypometabolism seen in those with Social Anxiety Disorder, it does not seem an unlikely culpruit. Regardless of the causation, if a brain cannot utilize glucose as well, it needs an alternate fuel. Implementing a low carbohydrate dietary therapy can reduce levels of insulin and allow ketones to be generated by the body and used in the brain for energy.

Ketones themselves are an energy source for the brain that have powerful effects as signaling molecules. These signaling molecules help increase the number and health of important cellular energy structures known as mitochondria. These mitochondria are the power plants of your cells. Brains need and want a lot of them and they need and want them in good repair! Ketones provide this for the impaired brain. And they can most certainly theoretically provide it for the struggling cingulate gyrus we see prominent in Social Anxiety Disorder.

Social Anxiety and Neurotransmitter Imbalances

Treating Social Anxiety Disorder with psychopharmacology includes medications that act on GABA, glutamate, and other neurotransmitter systems.

We know from a past blog post (here) that a ketogenic diet improves the environment in which your brain makes neurotransmitters and it creates an environment in which they function better. Ketogenic diets increase the neurotransmitter GABA which has a natural soothing of anxiety. It is the neurotransmitter that makes you feel like you can handle life and that there is no reason to be overwhelmed. It is the neurotransmitter that psychopharmacology attempts to alter with benzodiazepines and gabapentin. Except when they do, it usually comes with side effects like being sleepy or feeling out of it. How nice would it be to increase your GABA without having to check out for the night? Ketogenic diets do that. They naturally increase your GABA in a balanced way that doesn’t cause these types of issues. You are just more chill. Not sleepy.

Brains that have stressful internal environments like inflammation and oxidative stress (spoiler alert: the Social Anxiety Disorder brain has this happening) influence the creation of different neurotransmitter ratios being made. A brain under the duress of trying to perform in a constantly hostile internal biological environment is not going to make more GABA. It is going to make the excitatory neurotransmitter Glutamate, and possibly 100x more than it would normally. The pathway in which this happens also depletes important resources needed to ensure balanced levels of other important neurotransmitters.

The neurotransmitter glutamate in too high of levels is neurotoxic and does a lot of damage. It also makes you feel terribly anxious and overwhelmed. Ketogenic diets keep the excitatory neurotransmitter Glutamate in check by improving the biological environment in which your brain is trying to function.

Additionally, recent research has shown that the interaction between dopamine and serotonin transport is a distinct type of neurotransmitter imbalance seen in Social Anxiety Disorder.

“We see that there is a different balance between serotonin and dopamine transport in people with social anxiety disorder compared with control subjects. The interaction between serotonin and dopamine transport explained more of the difference between the groups than each carrier individually. This suggests one should not focus exclusively on one signal substance at a time, the balance between different systems may be more important”

Olof Hjorth, Ph.D. student at the Department of Psychology at Uppsala University, Sweden. (https://neurosciencenews.com/serotonin-dopamine-anxiety-15558/)

You just might not need a medication like an MAOI if your cell membranes were working in top form. Ketogenic diets greatly improve cell membrane function through any number of mechanisms, including reduced inflammation and oxidative stress (I promise we will get there), the signaling powers of the ketones themselves, or their use as an efficient and preferred fuel source. And because a well-functioning cell membrane directly enhances your brains’ ability to balance neurotransmitters, I include it here for your consideration.

How does the ketogenic diet help treat neurotransmitter imbalances seen in Social Anxiety Dsiorder?

SAD is associated with mainly increased expression in the transporters for serotonin and dopamine seen in fear and reward-related brain regions. It just so happens that ketogenic diets have been seen to increase serotonin and decrease excessive levels of dopamine.  It was already known that there are differences in serotonin reuptake (how long the neurotransmitter hangs out to be used) in those with Social Anxiety, but this understanding of dopamine’s role is new and exciting.

The rationale for the use of the ketogenic diet is based on the potential mood stabilizing effects through level modifications of metabolites such as dopamine and serotonin and the regulation of GABA/glutamatergic neurotransmission, mitochondrial function and oxidative stress.

https://www.frontiersin.org/articles/10.3389/fphar.2020.578396/full?utm_source=F-AAE&utm_medium=EMLF&utm_campaign=MRK_1498129_62_Pharma_20201203_arts_A

It would not be thorough to leave this section just at neurotransmitter function. When they discuss psychopharmacology for Social Anxiety Disorder, and they discuss the role of monoamine oxidase inhibitors (MAOI), they are attempting to control an enzymatic reaction to modify levels of the neurotransmitters norepinephrine, serotonin, and dopamine in the brain. They block the removal of these neurotransmitters. They do not balance these neurotransmitters. They do not make these neurotransmitters work together in a beautifully balanced symphony in any way. Also, these drugs have side effects which I will not go into here, but you can easily Google.

So, we have to talk about how ketogenic diets improve cell membrane function. I wrote briefly about it here but let me get you up to speed. Ketogenic diets optimize your neuronal functioning. So this means that these neuronal membranes can better accomplish all of these VERY important tasks:

  • accumulate nutrients
  • reject harmful substances
  • catalyze enzymatic reactions
  • create electrical potential
  • conduct nerve impulses
  • remain sensitive to neurotransmitters and modulators
  • decreased hyperexcitability

The well-documented neurotransmitter balancing effects of ketogenic diets, in particular, seen with GABA, glutamate, serotonin, dopamine, and norepinephrine, clearly provide support as a potential treatment modality for those suffering from Social Anxiety Disorder.

Social Anxiety and Inflammation/Oxidative Stress

I have included oxidative stress and inflammation together under the same heading because one condition perpetuates the other and vice versa. One marker of inflammation that is often studied is an immune-mediated response known as inflammatory cytokines.

Studies conducted over the past few years suggest that anxiety disorders may be characterised by lowered antioxidant defences

HTTPS://PUBMED.NCBI.NLM.NIH.GOV/29742940/

The easiest way to talk about it these two mechanisms is to think that our environment and experiences increase inflammation, and when inflammation can no longer be controlled, it results in oxidative stress.

Inflammation can come from many things. Pollution, substances, diets higher in carbohydrates than our body can currently metabolize, traumatic events, terrible relationships, being sick with a virus, or other lifestyle factors like not getting enough movement.

Oxidative stress is well-established as having a role in anxiety disorders. When it comes to fear and anxiety, there is some debate going on around whether having fearful experiences increases inflammation and thereby oxidative stress, or whether unchecked inflammation increases oxidative stress and then creates symptoms of fear and anxiety. I believe the etiology (how it starts) could be either. Regardless of what comes first, we want to reduce inflammation and oxidative stress as much as possible, by whatever means we can.

Perhaps unsurprisingly, we see a reduction in oxidative stress when we use Cognitive-Behavioral Therapy for Social Anxiety Disorder (SAD). This makes sense because we have reduced the level of stress involved in social situations by changing how we think about them or habituating our nervous system to them. This reduction in both perceived and actual stress would of course reduce inflammation and the body’s response to what was once determined to be scary or dangerous.

Your brain is going to have some level of oxidative stress that naturally occurs. We already have a great antioxidant system in the body and brain, using the most powerful antioxidant there is called glutathione. But when we are exposed to particularly stressful situations (i.e., experiencing trauma, unhealthy relationships, etc) or doing things that add more stress (i.e., inflammatory diets with sugar and highly processed foods, insufficient physical activity, smoking, etc.) then our body cannot make enough glutathione. Your body becomes depleted of micronutrients dealing with those stressors and it needs them to make enough antioxidants to reduce inflammation and combat oxidative stress.

And it’s great if you take antioxidants. In fact, taking antioxidants can help modulate symptoms of anxiety and other psychiatric issues. But you cannot outrun poor lifestyle and behavioral choices or events by ingesting a lot of antioxidants. There are plenty of people trying this with a lot of expensive supplements and it is my understanding the results are equivocal.

Also, this ignores the fact that we are behaving in a way that causes damage to our body. It would be like putting a hole in your wall every day and just making sure that you have enough spackle, sand paper, paint and dry time before the next hole happens. How long do you think it will be before your house is in very bad shape? With some holes only partially repaired and some not at all. At what point or how long will it take for the structural integrity of the walls to really not work well anymore? Probably sooner than you imagine. This would be a silly way to handle damage. But this is what we do when we try to outrun inflammation, whether through diet or lifestyle, by only increasing our antioxidants and/or popping a multivitamin. Much better to stop the behavior that puts holes in the walls. Much better to stop the conditions that cause excess inflammation and metabolic stress.

But I digress.

Oxidative stress depletes your micronutrient stores and glutathione. It puts cells in a constant state of stress and inhibits the number and functioning of important cell structures, like mitochondria. Eat all the food you want, but if your mitochondria are impaired your energy is going to be low, both to enjoy life and to repair your body. Insufficient and poorly functioning cell mitochondria mean that there is less energy to maintain cell functioning and do all the things that need to happen to combat inflammation.

Oxidative stress also decreases Brain-Derived Neurotrophic Factor (BDNF), which you need to help heal your brain after the damage is done, or even just to learn new things. Is it any surprise that we cannot learn easily when we are stressed?

Depletion of the brains most important antioxidants, like glutathione, allow significant damage to occur in the form of neuroinflammation and a faster aging brain. Oxidative stress, which is basically the brain’s inability to deal with the level of neuroinflammation going on, will create an environment that will influence your neurotransmitter balance. A high-stress environment in the brain essentially leads to uncomfortable and unfavorable neurotransmitter imbalances. We just learned about this above when we mentioned glutamate in the neurotransmitter imbalance section. But because inflammation and the subsequent oxidative stress have direct effects on neurotransmitters let’s revisit by naming a pathway involved.

When your brain tries to make neurotransmitters in an environment of oxidative stress, the kynurenine pathway will sneak tryptophan away from the making of other neurotransmitters. It then takes that precious tryptophan and makes more glutamate, increasing your anxiety.

Tryptophan is a building block (precursor) for serotonin, and when there is less available this means you get to experience less serotonin, and all the anxiety-producing and behavioral effects involved in that.

Oxidative stress also gets in the way of you making and effectively using these and other neurotransmitters in the balanced and magical ratios you need to live your life with less social anxiety.

For all these reasons we need to find an effective way to reduce oxidative stress when we think about treating social anxiety.

You just might not need a medication like an MAOI if your cell membranes were working in top form. Ketogenic diets greatly improve cell membrane function through any number of mechanisms, including reduced inflammation and oxidative stress (I promise we will get there), the signaling powers of the ketones themselves, or their use as an efficient and preferred fuel source. And because a well-functioning cell membrane directly enhances your brains’ ability to balance neurotransmitters, I include it here for your consideration.

How does the ketogenic diet help treat inflammation and oxidative stress in those with Social Anxiety Dsiorder?

An inflamed brain is not one that can function properly. For example, inflammatory cytokines trigger the activation of an enzyme that degrades serotonin and the amino acid precursor tryptophan. It is believed this is one of the many mechanisms involved between inflammation and the neurotransmitter imbalances seen in anxiety disorders. Ketogenic diets are very effective at reducing inflammation.

Ketones, which are what we produce on a ketogenic diet, happen to influence all of these relevant mechanisms and pathways needed to reduce oxidative stress.

Conclusion

Ketogenic diets are metabolic therapies, that improve metabolism in the brain. Metabolism is just a word referring to how well your cells make and burn energy. This has the potential to directly treat areas of hypometabolism (hypo=low, metabolism=energy use) seen in the neuronal structures of people experiencing social anxiety.

A reduction in the excitatory neurotransmitter glutamate and an increase in GABA and serotonin can only help social anxiety. And it will do it in a way that does not cause problematic side-effects. Ketones also increase the number and health of mitochondria in cells while improving cellular functioning at the level of the cell membrane. They reduce inflammation as signaling molecules that are able to turn down the expression of inflammatory pathways and turn up other important antioxidant functions, like glutathione production.

Improved cell membrane function helps increase micronutrient stores, cell communication, and allows those neurotransmitters to hang out for just the right amount of time before your body makes more in just the right amounts. Thereby, potentially alleviating your anxiety symptoms in a multifunctional way I am not sure any developed current psychopharmacology can duplicate with the same absence of side-effects.

It is my hope that after reading this post you will have a better understanding of not only the biological mechanisms involved in the pathology and symptoms experienced by those suffering from Social Anxiety Disorder (SAD), but also the understanding of how the ketogenic diet has direct influences on the multiple factors associated with healing and symptom reduction.

So ask yourself why would you NOT consider a ketogenic diet for the treatment of Social Anxiety Disorder (SAD)?

It’s OK if you don’t want to use a ketogenic diet, or other nutritional therapies to treat Social Anxiety Disorder (SAD). Convincing you to use the ketogenic diet to treat mental illness is not the purpose of my blog. The purpose of this post, and all the others, is to communicate that it is a viable option.

Because you have the right to know all of the ways that you can feel better.

You can learn more about me here. And if I can be of help on your wellness journey, please do not hesitate to contact me.

Like what you are reading on the blog? Want to learn about upcoming webinars, courses, and even offers around support and working with me towards your wellness goals? Sign up!

Free ebook

References

Fedoce, A., Ferreira, F., Bota, R. G., Bonet-Costa, V., Sun, P. Y., & Davies, K. (2018). The role of oxidative stress in anxiety disorder: cause or consequence?. Free radical research52(7), 737–750. https://doi.org/10.1080/10715762.2018.1475733

Bandelow B. (2020) Current and Novel Psychopharmacological Drugs for Anxiety Disorders. In: Kim YK. (eds) Anxiety Disorders. Advances in Experimental Medicine and Biology, vol 1191. Springer, Singapore. https://doi.org/10.1007/978-981-32-9705-0_19

Blanco, C., Bragdon, L., Schneier, F. R., & Liebowitz, M. R. (2014). Psychopharmacology for social anxiety disorder. In Social Anxiety (pp. 625-659). Academic Press. https://doi.org/10.1016/B978-0-12-394427-6.00022-4.

Dąbek, A., Wojtala, M., Pirola, L., & Balcerczyk, A. (2020). Modulation of cellular biochemistry, epigenetics and metabolomics by ketone bodies. Implications of the ketogenic diet in the physiology of the organism and pathological states. Nutrients12(3), 788.

Gzieło, K., Janeczko, K., Węglarz, W. et al. MRI spectroscopic and tractography studies indicate consequences of long-term ketogenic diet. Brain Struct Funct 225, 2077–2089 (2020). https://doi.org/10.1007/s00429-020-02111-9

Hjorth, O.R., Frick, A., Gingnell, M. et al. Expression and co-expression of serotonin and dopamine transporters in social anxiety disorder: a multitracer positron emission tomography study. Mol Psychiatry 26, 3970–3979 (2021). https://doi.org/10.1038/s41380-019-0618-7

Hur J., et al. (2021). Virtual Reality–Based Psychotherapy in Social Anxiety Disorder: fMRI Study Using a Self-Referential Task. In JMIR Ment Health 2021;8(4):e25731. URL: https://mental.jmir.org/2021/4/e25731
DOI: 10.2196/25731

Imbalance between serotonin and dopamine in social anxiety disorder. Neuroscience News (2021). URL: https://neurosciencenews.com/serotonin-dopamine-anxiety-15558/

Jensen, N. J., Wodschow, H. Z., Nilsson, M., & Rungby, J. (2020). Effects of Ketone Bodies on Brain Metabolism and Function in Neurodegenerative Diseases. International journal of molecular sciences21(22), 8767. https://doi.org/10.3390/ijms21228767

Kerahrodi, J. G., & Michal, M. (2020). The fear-defense system, emotions, and oxidative stress. Redox Biology, 101588. https://www.sciencedirect.com/science/article/pii/S2213231720302615

Martin, E. I., Ressler, K. J., Binder, E., & Nemeroff, C. B. (2009). The neurobiology of anxiety disorders: brain imaging, genetics, and psychoneuroendocrinology. The Psychiatric clinics of North America32(3), 549–575. https://doi.org/10.1016/j.psc.2009.05.004

Mental health medications. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml#part_149856.

Miller, A. H., Haroon, E., Raison, C. L., & Felger, J. C. (2013). Cytokine targets in the brain: impact on neurotransmitters and neurocircuits. Depression and anxiety30(4), 297–306. https://doi.org/10.1002/da.22084

Miller, A. H., Haroon, E., Raison, C. L., & Felger, J. C. (2013). Cytokine targets in the brain: impact on neurotransmitters and neurocircuits. Depression and anxiety30(4), 297–306. https://doi.org/10.1002/da.22084

Nuss P. (2015). Anxiety disorders and GABA neurotransmission: a disturbance of modulation. Neuropsychiatric disease and treatment11, 165–175. https://doi.org/10.2147/NDT.S58841

Operto, F. F., Matricardi, S., Pastorino, G. M. G., Verrotti, A., & Coppola, G. (2020). The ketogenic diet for the treatment of mood disorders in comorbidity with epilepsy in children and adolescents. Frontiers in Pharmacology11, 1847.

Rebelos, E., Bucci, M., Karjalainen, T., Oikonen, V., Bertoldo, A., Hannukainen, J. C., … & Nuutila, P. (2021). Insulin resistance is associated with enhanced brain glucose uptake during euglycemic hyperinsulinemia: A large-scale PET cohort. Diabetes care44(3), 788-794.

Santos, P., Herrmann, A. P., Elisabetsky, E., & Piato, A. (2018). Anxiolytic properties of compounds that counteract oxidative stress, neuroinflammation, and glutamatergic dysfunction: a review. Brazilian Journal of Psychiatry41, 168-178.

Yu X, Ruan Y, Zhang Y, Wang J, Liu Y, Zhang J, Zhang L. Cognitive Neural Mechanism of Social Anxiety Disorder: A Meta-Analysis Based on fMRI Studies. International Journal of Environmental Research and Public Health. 2021; 18(11):5556. https://doi.org/10.3390/ijerph18115556

How do ketogenic diets help anxiety disorders?

Advertisements

How could a ketogenic diet help my anxiety? Or improve my symptoms of Generalized Anxiety Disorder (GAD), Panic Disorder (PD), Social Anxiety Disorder (SAD), Obsessive-Compulsive Disorder (OCD), and or Post-Traumatic Stress Disorder (PTSD)?

Ketogenic diets help anxiety disorders by mediating the underlying pathologies of mental illness that are primarily metabolic in nature. These include glucose hypometabolism, neurotransmitter imbalances, oxidative stress, and inflammation.

Introduction

In this post, I will go into what the biological mechanisms of symptom reduction are when using a ketogenic diet for mental illness. My goal is to do so in a way that is easy to understand. Few people benefit from overcomplicated biochemistry explanations using words and processes they do not understand. My goal is for you to be able to read this blog post and then be able to explain how a ketogenic diet helps treat mental illness, and anxiety disorders in particular, to friends and family.

This blog post is an introduction to ketogenic diets for anxiety disorders in general. In this post, we describe the mechanisms involved in mental illness in general, in which anxiety is obviously a category, and discuss the therapeutic effects of the ketogenic diet on those mechanisms.

You may also want to read the posts I have written applying the ketogenic diet to the underlying pathologies seen in specific populations. There are more in-depth blog posts about using the ketogenic diet as a treatment for anxiety disorders.

This is a different way to evaluate the literature about whether or not a particular therapy can be helpful for a particular diagnosis. Usually, we wait (sometimes for decades or longer) for randomized-controlled trials looking at a very specific therapy paired with a very specific diagnosis and/or population. But that is not the only way to evaluate whether or not therapy might be useful.

It can make perfect sense to explore whether we can modify those mechanisms with substances or interventions that have an effect on those same pathways. And while I am always excited about RCTs, there are plenty of people suffering from anxiety disorders right now at this moment. Today. They may not be getting adequate symptom control from the standard of care or be looking for an actual cure as opposed to symptom reduction models. These individuals may want to better understand the ketogenic diet as a treatment for anxiety disorders.

It is my hope that by the end of this post you will have a better understanding of the current evidence base for its use in anxiety disorders and why it can have benefits beyond what is offered by current psychopharmacological treatments.

What is happening in my brain that is causing my mental illness?

In a review of biological mechanisms, this current (2020) review discussed the four key underlying pathologies that are seen in mental illnesses and discusses how a ketogenic diet can influence mental health symptoms.

  • Glucose Hypometabolism
  • Neurotransmitter Imbalances
  • Oxidative Stress
  • Inflammation

Let’s go over each of these in a little more detail.

Glucose Hypometabolism

Glucose Hypometabolism is a metabolic disorder in the brain. It basically means that your neurons are not using glucose well as fuel in certain parts of your brain. A brain that does not have adequate fuel, even if you are eating plenty of food, is a starving brain. A starving brain is stressed and it calls the alarm in many different ways. These ways can include the other factors of inflammation, neurotransmitter imbalance, and oxidative stress that we will be discussing. When brain cells do not get adequate fuel they die. If enough brain cells in a particular area die we see brain structures shrink. Memory and cognition begin to become impaired.

A ketogenic diet, by definition, generates an alternative brain fuel known as ketones. Ketones can get into neuronal cells in the brain easily and bypass the broken cell machinery not allowing other fuels like glucose to enter. The brain shifts from attempting to use a primarily glucose-based metabolism to a fat and ketone-based metabolism. As you can imagine, a brain that can access fuel is a better working brain.

But the role of ketones as a fuel source is just the beginning of what they can do for an ailing or distressed brain. The ketones themselves have some of their own very positive effects. It is not just that the brain is being fed energy. The ketones themselves do not just maintain metabolic functioning, but they act as something called a signaling molecule. And a signaling molecule is basically like a little messenger running around, giving your cells updates about what is happening in the body, so that your cell can then manage its machinery to do the best thing at that moment. The information that these signaling molecules give is powerful enough to turn your genes on and off even! Ketones as signaling molecules have the power to help your cells do things to help you burn more fat for fuel or other purposes, reduce oxidative stress and increase the protection of your brain.

β-HB (a kind of ketone) is currently considered not solely an energy substrate for maintaining metabolic homeostasis but also acts as a signaling molecule of modulating lipolysis, oxidative stress, and neuroprotection.

Wang, L., Chen, P., & Xiao, W. (2021)

It is easy to see that a ketogenic diet, which acts as a signaling molecule that tends to make more of those important things happen, could be very beneficial in treating those underlying pathological mechanisms of mental illness (which includes anxiety disorders) that were introduced at the beginning of this post.

Neurotransmitter Imbalances

Hyperglycemia is a term used to describe blood sugar levels getting too high for the body to manage. If your body cannot manage glucose levels it cannot stop it from causing damage to tissues. Even people without a diagnosis of diabetes struggle with hyperglycemia. Many without even knowing it. It has been long established in the literature that hyperglycemia or the body’s inability to handle the amount of glucose (sugar) in the blood, creates inflammation. Oxidative stress is what happens when you don’t have enough antioxidants to offset the damage trying to occur from all the inflammation happening.

But wait a minute you say, this section is about neurotransmitter imbalances. Inflammation and oxidative stress are supposed to come later. And I would agree with you. Except for inflammation and the resulting oxidative stress that occurs because of inflammation sets the stage for severe neurotransmitter imbalances.

There are many different pathways that affect neurotransmitter creation, balance, how long they hang around in the synapses to be enjoyed and used, and how they get broken down. But the best example for neurotransmitter imbalance when inflammation is high has to do with something we call the tryptophan steal. Tryptophan is an amino acid that comes from the protein you eat. That part isn’t the important part of our example. What is important is for us to illustrate what happens to tryptophan when it is in an inflammatory environment. An inflammatory environment is often, and I would argue most commonly caused, by eating more dietary carbohydrates than your particular body can handle.

And what do we restrict in a ketogenic diet? Carbohydrates. And what does that do? Reduce inflammation. And what magical signaling properties do some ketones have? Reduction of inflammation. And a well-formulated ketogenic diet increases the pool of nutrients available to make the most powerful antioxidant ever, that your own body can make with the right metabolic environment and that will deal will oxidative stress? Ok, sorry. Now I am jumping ahead too far. I got a little excited.

But I know you are getting the idea!

So let’s say your brain is wanting to make neurotransmitters out of the tryptophan you ate. If your inflammation is high, your body will take that tryptophan and make MORE of a neurotransmitter called Glutamate. Up to 100x more than it normally would if that tryptophan had encountered a less inflamed and stressed internal environment. Glutamate is an excitatory neurotransmitter. And you obviously need some because it is part of a well-balanced brain. But the amount made while the body is inflamed or under oxidative stress creates a lot more than is needed. Glutamate at too high of levels CREATES ANXIETY.

In excess, glutamate is the neurotransmitter of being overwhelmed and freaked out. It is a particularly unpleasant neurotransmitter imbalance that too many people live with and think is just a part of their daily lives every single day. And it may just very likely be that their carbohydrate dominant diet is perpetuating this unpleasant neurotransmitter imbalance. This same pathway that makes too much glutamate in a high inflammation and oxidative stress environment negatively affects the balance in other neurotransmitters like dopamine, serotonin, and GABA. It reduces the creation of something called Brain-Derived Neurotrophic Factor (BDNF) which is what your brain needs (and plenty of it!) to help you learn, remember, and heal the effects of all that inflammation and oxidative stress that is happening (for whatever reason).

This next piece is just my opinion and even possibly a hypothesis I picked up from people I have followed and learned from along the way. But if so, I agree with them. It seems to me that it is almost as if because your brain knows it is being “attacked” or is in “danger” with all that high inflammation. It is trying to tell you it cannot handle what you are doing. It wants to tell you to be on alert! Anxious. It needs to sound the alarm that it is not ok! And it has no other way to tell you. But it is not a very efficient way, is it? Because you don’t make the connection. You think you are anxious because of traffic, or your kids, or your job, or that making dinner is just too overwhelming. We are human beings constantly trying to make sense of our experiences so we make connections between things that seem the most obvious. We start to avoid anything that we think stresses us out. Never knowing that a possible source of the stress we feel is happening internally as a direct result of our lifestyle choices.

But what happens to tryptophan if you do not have excessive amounts of inflammation or are suffering from oxidative stress? Tryptophan can then be used to “upregulate” or make more of the neurotransmitter GABA. GABA also needs to be balanced in the brain, but a little too much of it does not create an environment of excitability. In fact, many people would like more GABA.

Ever heard of Gabapentin? Often used as a mood stabilizer in psychiatric disorders? You guessed it. It works to increase GABA. Except in its attempts to increase GABA, it often causes side effects for people. Like sleepiness and brain fog. Increasing GABA with a ketogenic diet does not produce the same side effects of medications trying to accomplish the same thing.

GABA is the neurotransmitter of feeling “chill” and “I got this” and of not feeling overwhelmed with the ups and downs of life or the idea of new challenges. Who couldn’t use more GABA? Particularly those suffering from Post-Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder (GAD), Panic Disorder, and Obsessive-Compulsive Disorder (OCD)?

Are there other neurotransmitter imbalances involved in anxiety disorders? Of course, there is! That was just one very important and easily illustrated example. Some happen just from nutrient imbalances alone, which can cause inflammation and oxidative stress in their own right. As I have said in other blog posts. You may not need a full ketogenic diet to improve symptoms of anxiety. But it is important to note that the majority of Americans are not metabolically healthy and are very likely eating a much larger amount of dietary carbohydrates than their body (and brain) can handle. And that this alone can cause and contribute to the development of anxiety symptoms. So in that respect, it is an important and relevant example for the majority of individuals reading this blog today, trying to discover how the ketogenic diet could work for them or those they love.

Doesn’t it make sense to treat a fundamentally metabolic set of pathologies, which mental illnesses are, with a complimentary metabolic approach?

Nicholas G. Norowitz, Department of Physiology, Anatomy and Genetics, Oxford University (link)

Oxidative Stress

As I explained above, oxidative stress is what happens when you do not have enough anti-oxidants to protect you from all the biological fallout of just being alive. The job of antioxidants is big and important. Most people believe that this means they need to consume foods that have been identified as antioxidant-rich and take supplements like Vitamin E and C in order to protect themselves from this particular type of biological damage. But the reality is that you could not take enough supplementation or eat enough antioxidant-rich food to match the power of an antioxidant you could be making yourself, from inside your body, known as glutathione. And your internal production of glutathione skyrockets on a ketogenic diet. Remember how ketones act as signaling molecules? They tell your body to make more glutathione. And as long as you are eating a well-formulated ketogenic diet that has an abundance of what you need to make more glutathione, your body will do just that!

You came equipped with your own antioxidant system. I am sure the supplement industry does not want you to know that but it’s true.

If you think about it, this makes sense. We did not have grocery stores or year-long access to a variety of fruits and vegetables full of antioxidants throughout our history. Were there some? Well yes of course! Regionally there were likely many different dietary sources of increased antioxidants. But also, you came with your own machinery and that machinery makes an antioxidant more powerful than anything else you can put in your mouth for that purpose. So what is happening that our own endogenous antioxidant power-house known as glutathione is not able to keep all that oxidative stress in check?

You guessed it. Diets that contain levels of carbohydrates our bodies cannot manage increase inflammation. To deal with that inflammation we have to use a LOT of nutrients as cofactors to try to keep the damage in check. And those cofactors are also needed to make our glutathione. And if we are using them up with a highly processed carbohydrate diet full of things industrial oils (that will likely be another blog post) we become depleted, and we are not available to make the glutathione levels we need. Also, if we don’t make sufficient amounts of ketones because our diets are too high in carbohydrates for us, how can those ketones signal to our cells to make some extra to help us out?

So what does Oxidative Stress mean in mental illness and in anxiety in particular? There is a very strong association between levels of oxidative stress and anxiety disorders, although the direct causal factors are still being teased out. It is a strong enough association that the use of antioxidants is discussed in the research literature as a treatment for anxiety disorders.

Well there you go, you may say to yourself. I don’t need a ketogenic diet. I can just take more antioxidants. And I suppose that is an option. But do tell me when you have determined just the right dose of antioxidants, in the perfect form and combination, that reduces the damage that comes from oxidative stress in the brain to such a degree that you can eat all the sugar, processed carbohydrates, and inflammatory seed oils you want and not suffer from anxiety symptoms. As you can see, theoretically, using antioxidants you eat or take as supplements as a way to reduce anxiety sounds like a great treatment option. And it may certainly help your symptoms, especially if you stop some of the other major metabolic stressors of sugar, refined carbohydrates, and other highly inflammatory industrial food products.

As I said, we do not always have to attempt a ketogenic diet to treat anxiety disorders. But eliminating unnecessary metabolic stressors AND rocketing your internal glutathione levels up using a ketogenic diet sounds like a level of intervention that you not only should know about but deserve to know is an option. Anxiety symptoms are awful. And you deserve to feel well and be without those symptoms as soon as possible. I don’t want to see you experimenting constantly with vitamin C dosages, taking a bunch of expensive anti-oxidant supplements, and continuing to suffer over years when you could feel the benefits of reduced oxidative stress with the ketogenic diet in as little as a few weeks or months.

In mental illness, and specifically in anxiety, there is increased oxidative stress. Ketogenic diets reduce that pathology by allowing the body to make more of the powerful antioxidant known as glutathione. The level of glutathione your body makes seems to be well equipped to deal with much of the oxidative stress that comes with being alive. When you remove unnecessary internal metabolic stressors and improve the nutrition availability in your diet, this directly improves your internal antioxidant mechanisms and reduces oxidative stress in your brain, quite possibly leading to a reduction in anxiety symptoms.

Inflammation

Inflammatory cytokines are a cause of neuronal inflammation. These inflammatory cytokines are actually a part of the brain’s own immune system. The immune system in the body and the one in the brain stay physically separate but they are able to talk to one another. For example, when you are acutely ill your body’s immune system will communicate with your brain’s immune system. The inflammatory cytokines then make you want to lie down, stay still, and rest. I give this example because I need you to understand that these inflammatory substances in the brain are powerful. And can literally control your behavior.

Anxious and overwhelmed and can’t get off the couch? It could be that unloading the dishwasher is just too much. It could also be that neuronal inflammation is telling you to stay still and not move. Do you have high neuronal inflammation because you are stressed about the dishwasher? Likely not. It likely is due to something else. It could be coming from a huge variety of things. But one of the causes could be your diet.

But wait a minute, you say! How can my food choices influence my immune system? That makes no sense!

Remember the term hyperglycemia? Meaning too much blood sugar or a level of blood sugar that is higher than your body can handle is occurring? This state influences your immune system in a negative way. It has been shown that hyperglycemia promotes the creation of proinflammatory cytokines (aka inflammation) and it makes it harder for your immune system to deal with threats. An immune system that is impaired by high blood sugars cannot knock out a threat in a quick and decisive manner. And the entire time that your immune system is fighting off some low-grade infection or virus, those inflammatory cytokines are hanging out in your brain just that much longer. And we know from what we have learned before how brain inflammation will then affect our neurotransmitter balance and our levels of oxidative stress. For example, inflammatory cytokines trigger the activation of an enzyme that degrades serotonin and the amino acid precursor tryptophan. It is believed this is one of the many mechanisms involved between inflammation and the neurotransmitter imbalances seen in anxiety disorders.

Because you have made it this far into this blog post, you know what that means for your anxiety! And if we have cerebral hypo-metabolism as well, we know how that lack of fuel stresses the brain and perpetuates your symptom cycle. You have learned that it is all connected.

So fine you say, I will reduce my sugar and my refined carbohydrates and that should do the trick! I will have a better immune system. And you absolutely would! That may be all you need to do and if that is the case I am super happy for you! A whole foods diet is a powerful intervention for many people. So why would you still maybe want to try a ketogenic diet for your anxiety disorder?

Because ketones have special properties. Not only are they important signaling molecules as described above, they are also powerful in reducing inflammation. We think that they reduce inflammation by blocking some of the inflammatory pathways. And while we have mostly been discussing metabolic stressors that increase inflammation, dietary influences are not the only source.

We are bombarded with chemicals. We have leaky guts causing autoimmune reactions (which also are mirrored in the brain). We have gut microbiomes that are not ideal and could be causing inflammation in our brain. We don’t prioritize sleep which can increase inflammation. We encounter normal and not so normal psychological stressors that induce inflammation. Heck, even just being under fluorescent lights has been shown to increase inflammation.

You can change your diet, which I absolutely think you should! That will definitely help. But there are so many places you will be potentially getting brain inflammation from that it makes sense to increase the production of ketones. Ketones can help you fight the neuronal inflammation that is just going to be a part of our modern environment.

And the less inflammation you have as a result of employing ketones to work for you, the fewer micronutrients you are going to use up fighting inflammation.

And the more micronutrients you have available, the more glutathione you can produce to help with oxidative stress.

And the lower your oxidative stress and neuronal inflammation, the better you will be able to balance your neurotransmitters.

And are you loving as much as I am how this is all connected?!! And how your knowledge of the underlying mechanisms involved in your anxiety symptoms are coming together?!

Sharing this with you in a way you can understand is an absolute joy for me!

Conclusion

The ketogenic diet is a powerful intervention that has benefits and may correct one or more of the four pathological underlying mechanisms underlying mental illness and your anxiety disorder.

You can choose to use it as first-line therapy for your anxiety disorder.

You can attempt to use it in place of medications.

You can use it as a powerful complementary therapy with mental health counseling (my personal favorite).

And if you decide to use it in conjunction with your medications that you are already on, do let your prescriber know. As the ketogenic diet modulates all of those pathways that have been influencing your anxiety disorder, it will change how you respond to your medications, both in what symptoms you might get, and their effectiveness. If you are on medications please work with a qualified mental health professional and prescriber that is knowledgeable regarding ketogenic and medication adjustment.

You may have anxiety and depression, and some other co-occurring disorders such as ADHD, Alcoholism or PTSD and may find those posts helpful in making your decision about whether a ketogenic diet is something you want to try for symptom relief.

As always, please feel free to contact me if you have any questions or if i can help you on your mental health journey.

Like what you are reading on the blog? Want to learn about upcoming webinars, courses, and even offers around support and working with me towards your wellness goals? Sign up!


References

Alessandra das Graças Fedoce, Frederico Ferreira, Robert G. Bota, Vicent Bonet-Costa, Patrick Y. Sun & Kelvin J. A. Davies (2018) The role of oxidative stress in anxiety disorder: cause or consequence?, Free Radical Research, 52:7, 737-750, DOI: 10.1080/10715762.2018.1475733

Ask the Scientists: What is Cell Signalling. https://askthescientists.com/qa/what-is-cell-signaling/

Betteridge D. J. (2000). What is oxidative stress?. Metabolism: clinical and experimental49(2 Suppl 1), 3–8. https://doi.org/10.1016/s0026-0495(00)80077-3

Bouayed, J., Rammal, H., & Soulimani, R. (2009). Oxidative stress and anxiety: relationship and cellular pathways. Oxidative medicine and cellular longevity2(2), 63–67. https://doi.org/10.4161/oxim.2.2.7944

Hu, R., Xia, C. Q., Butfiloski, E., & Clare-Salzler, M. (2018). Effect of high glucose on cytokine production by human peripheral blood immune cells and type I interferon signaling in monocytes: Implications for the role of hyperglycemia in the diabetes inflammatory process and host defense against infection. Clinical immunology (Orlando, Fla.)195, 139–148. https://doi.org/10.1016/j.clim.2018.06.003

Jeong EA, Jeon BT, Shin HJ, Kim N, Lee DH, Kim HJ, et al. Ketogenic diet-induced peroxisome proliferator-activated receptor-gamma activation decreases neuroinflammation in the mouse hippocampus after kainic acid-induced seizures. Exp Neurol. 2011;232(2):195–202.

Maalouf, M., Sullivan, P.G., David, L., Kim D.Y. & Rho, J.M. (2007). Ketones inhibit mitochondrial production of reactive oxygen species production following glutamate excitotoxicity by increasing NADH oxidation. Neuroscience, 145(1), 256-264. https://doi.org/10.1016/j.neuroscience.2006.11.065.

Inflammation. National Institute of Environmental and Health Sciences. https://www.niehs.nih.gov/health/topics/conditions/inflammation/index.cfm

Paige Niepoetter and Chaya Gopalan. (2019). The Effects of Ketogenic Diets on Psychiatric Disorders Involving Mitochondrial Dysfunction: A Literature Review of the Influence of Dieting on Autism, Depression, Anxiety, and Schizophrenia. HAPS Educator, v23 n2 p426-431. https://files.eric.ed.gov/fulltext/EJ1233662.pdf

Paoli, A., Gorini, S. & Caprio, M. The dark side of the spoon – glucose, ketones and COVID-19: a possible role for ketogenic diet?. J Transl Med 18, 441 (2020). https://doi.org/10.1186/s12967-020-02600-9

Norwitz, N. G., Dalai, Sethi, & Palmer, C. M. (2020). Ketogenic diet as a metabolic treatment for mental illness. Current opinion in endocrinology, diabetes, and obesity27(5), 269–274. https://doi.org/10.1097/MED.0000000000000564

Samina, S., Gaurav, C., and Asghar, M. (2012). Advances in Protein Chemistry and Structural Biology – Chapter One – Inflammation in Anxiety.
https://doi.org/10.1016/B978-0-12-398314-5.00001-5.
(https://www.sciencedirect.com/science/article/pii/B9780123983145000015)

Vincent, A. M., McLean, L. L., Backus, C., & Feldman, E. L. (2005). Short-term hyperglycemia produces oxidative damage and apoptosis in neurons. FASEB journal : official publication of the Federation of American Societies for Experimental Biology19(6), 638–640. https://doi.org/10.1096/fj.04-2513fje

Volpe, C.M.O., Villar-Delfino, P.H., dos Anjos, P.M.F. et al. Cellular death, reactive oxygen species (ROS) and diabetic complications. Cell Death Dis 9, 119 (2018). https://doi.org/10.1038/s41419-017-0135-z

Wang, L., Chen, P., & Xiao, W. (2021). β-hydroxybutyrate as an Anti-Aging Metabolite. Nutrients13(10), 3420. https://doi.org/10.3390/nu13103420

White, H., Venkatesh, B. Clinical review: Ketones and brain injury. Crit Care 15, 219 (2011). https://doi.org/10.1186/cc10020

Do you have to use a keto diet to improve your symptoms of depression and anxiety?

Advertisements

Do you have to use a keto diet to improve your symptoms of depression and anxiety?

Often no. There are a lot of different levels of dietary and nutritional intervention that can be tried before implementing a ketogenic diet. If you want relief from symptoms of anxiety and depression but are hesitant to use a ketogenic diet, you can work with a professional to work on fixing nutrient insufficiencies and learn what a healthy brain diet looks like (it is probably not what you think).

So as with most things, the answer is “it depends”. How severe are your symptoms and how long have they been going on? What level of functional impairment exists? In this post, we will explore the varying levels of dietary intervention that I have seen improve symptoms of depression and anxiety in my practice.

Introduction

There are published case studies of people with some of the most severe and debilitating psychiatric illnesses recovering using a ketogenic diet. But your severity of symptoms may not be to that degree. Does that mean you may not have to go on a ketogenic diet to see improvements in your anxiety and depression? I get it. You may be afraid to contact me because you are worried that I would automatically recommend you use a ketogenic diet to treat your anxiety and depression. I mean, my entire site is kind of devoted to that. And you may in fact need a ketogenic diet to feel better.

But you also may not. You may be able to use supplementation and learn to make better food choices that support your mental health. You may be able to stop using ultra-processed foods as an emotional comfort because you feel terrible and begin to heal and recover from the debilitating symptoms that are a part of anxiety and depression. Professionals don’t implement ketogenic diets just willy-nilly to anybody. Individuals need to be screened and evaluated to determine if a ketogenic diet is appropriate for them.

Sometimes I meet people excited to try the ketogenic diet because they want to know what all those documented brain benefits feel like! But much of the time people contact me wanting to know about less restrictive nutrition and dietary measures. So, let’s talk about some of the ways I help people in my practice with diet and nutrition to treat mental illness. There are varying degrees of nutritional intervention that can be done, and there can be a lot we try before you decide on whether a ketogenic diet is a good option for treating your mental illness.

What are the different ways anxiety and depression can be treated with nutrition?

One of my favorite ways to get started is to do a nutritional analysis of what you have eaten over a few days in a typical week. This can give me a good idea of the quality of your diet and what micronutrients and macronutrients you may be under or overeating. This gives us a jumping-off point to determine what level of nutritional or dietary intervention might be right for you.

Nutritional Supplements to Treat Anxiety and Depression

With the information gathered from your dietary analysis, I may recommend supplementation. How powerful can supplements be? Pretty powerful. The most common nutrients I suggest clients supplement with are magnesium, zinc, B vitamins, vitamin D, and vitamin K2. Sometimes I will supplement with DHA and EPA (brains LOVE these!). I have had people who presented as severely clinically depressed and ready to do intensive therapy but their symptoms went away before we could really get started because we supplemented with the right amount and type of Magnesium. Even though their serum magnesium levels were deemed normal by their doctor during prior visits.

Another option is Broad Spectrum Micronutrient Therapy. People have different genetic differences that make them need more of certain nutrients, even with an already healthy diet (and especially if they do not have a healthy diet because poor diets use up existing nutrients at a faster rate as your body attempts to deal with excess sugar and increased inflammation. There exists a very solid research base for using Broad Spectrum Micronutrient Therapy with a variety of diagnoses and populations, including children and adolescents. These are not the Flintstone Vitamins you took as a kid and they are definitely not those gummy vitamins everyone is giving their children. They are powerful interventions and if you (or your child or adolescent) are already on medications you may need to have them adjusted in the first week because these nutrients are allowing pathways to work better. An example of this effect, known as potentiation, is that prescribers monitoring stimulant medication of ADHD patients implementing Broad-Spectrum Micronutrient Therapy will often have to reduce stimulant dosage in the first week. You can learn more about this specific type of nutrient therapy for mental health at these websites here and here . It is of note that researchers who study the effects of these treatments do not take funding from the companies that create these supplements, other than the companies providing the supplements to participants of the study so they can be studied. There are no “kickbacks” going on that create unwarranted conflicts of interest in evaluating the data. The sites provided will provide case studies, links to the research, and information regarding dosage. But again, if you are already on medications proceed with caution and work with your prescriber.

The point is, people need different levels of these nutrients for their brain to function. We have recommended daily intakes for these vitamins and minerals, but sometimes the research used to determine the amounts was not well done. The levels are set in an attempt to avoid a level of deficiency that would lead to an acute medical disorder. The RDIs are not about our optimal function. I am about your optimal functioning. And so even if you go to your doctor and they test some of your nutrients and they come back normal, it does not automatically rule out that you are not suffering from its insufficiency. Nutrient testing is complicated and often requires specialized functional nutrition tests. And even then to some degree, we are guessing at levels for some of them. So yes, you may just need supplementation.

Your treatment-resistant depression and anxiety really could just be an unidentified nutrient insufficiency. This is a low-risk, zero side effect avenue of exploration for individuals suffering from mental illness.

Nicole Laurent, LMHC

On a side note, if you are interested in learning more about nutrition and brain health I highly recommend Chris Masterjohn PhD’s free Vitamins and Minerals Course which you can find here. The lessons are short, easy to understand, and provide high-quality and accurate information.

Elimination of Ultra-Processed Foods to Treat Anxiety and Depression

If your dietary analysis has come back and I see your quality of diet is not good we may discuss what percentage of your diet is highly processed foods. I often provide nutrition and psychoeducation around what highly processed food is, and how it hijacks your neurotransmitters and hunger cues. Clients are often very surprised to learn how the neurotransmitter system and the dopamine neurotransmitter balance specifically is influenced by these “foods” (actually they are more like psychoactive substances than food).

Are you depressed and having a hard time finding joy in anything? Is the only thing you look forward to a particularly tasty ultra-processed food tasting sweet or salty? Believe it or not, these “foods” impair our neurotransmitter activity to such a degree that normally pleasant activities, such as going for a walk or visiting with a friend become less joyful. There is an entire medical textbook written about the neurobiological and treatment implications of processed food addictions (see Joan Ifland’s textbook here). And it is being taught now in medical schools. So this is not a fringe idea. This is science. Processed foods are not benign and directly influence your symptoms of anxiety and depression. And we can talk about this and potentially use this knowledge even if you currently have or have had a previous diagnosis of Binge Eating Disorder or Bulimia Nervosa. But don’t worry. Because I am a licensed mental health counselor, we would be doing psychotherapy to help you successfully make these and any other changes you might need to reduce or eliminate your symptoms of depression and anxiety.

Paleo Diets to Treat Depression and Anxiety

Often times I and other professionals that practice nutritional psychiatry will transition people to what is known as a paleo diet. The paleo diet as a treatment for mental health is often effective because it eliminates some problematic foods that block absorption of very important brain nutrients. Paleo diets also tip the diet toward more bioavailable and nutrient-dense foods. I have seen first-hand many clients not only see significant symptom reduction in their anxiety and depression but begin to thrive using just a paleo diet. There is a wonderful blog post about paleo diets for mental health by nutritional psychiatrist Georgie Ede, MD that I would recommend you read here if you are curious.

Elimination Diets to Treat Depression and Anxiety

Sometimes with clients, the best course of action is an elimination diet. These are not fun, and the only clients I have ever seen be excited about them are those that were very excited at the possibility of feeling better! These types of diets restrict down to a few highly nutrient-dense foods that generally have a lower risk of reactivity. Then we watch to see if symptoms improve. One great way to measure this is using assessment tools that measure levels of self-reported and observed symptoms of anxiety and depression. Elimination diets are not forever, because people carefully and methodically add one whole food back at a time, paying attention to how they feel. Common elimination diets work with excluding grains, legumes, dairy, nightshades, and/or sugar/fruits (fructose). But can also include foods that we would normally consider quite healthy like vegetables. Essentially, we are looking for autoimmune responses or whether the elimination of certain anti-nutrients found in some foods reduces symptoms of anxiety and depression for clients.

And of course there is the very powerful ketogenic diet!

The ketogenic diet targets several different pathways considered causal or associational in the development and progression of depression and anxiety. But you can read about those in my blog posts here, here, and here and learn about other people’s outcomes from my Case Studies and from other nutritional psychiatry practitioners and researchers by following the links on my resource page. (I highly recommend the podcasts!)

Where do I begin if I am wanting to use nutrition or dietary therapy to help treat my symptoms of depression and anxiety?

Photo by cottonbro on Pexels.com

If you are on any medications at all you should let your doctor know if you are planning to take supplements or make a significant dietary change. Even sometimes what we would consider benign supplements like fish oil or vitamin K2 can influence medications. If you are on psychiatric medications or any medications used to treat metabolic issues (e.g., hypertension, Type I or II diabetes, diuretics) you really need to have the support of a prescriber to work with you on adjusting medications during your diet change.

Especially if the diet change involves any type of therapeutic carbohydrate restriction as would be the case with a low-carb or ketogenic diet. Your current prescriber may not have experience with dietary therapies so you may benefit from finding a psychiatrist or prescriber that does. Or you can have someone experienced on your treatment team. For example, when I coordinate care with prescribers, we discuss what medications may need adjustments as you progress with your dietary and nutritional therapy for depression and anxiety. You deserve a treatment team that works together for your health whenever and however possible. It is worth the time to develop your treatment team from the very beginning.

There are some useful drug interaction checkers online here and here. But this does not replace the care of a doctor or prescriber evaluating your medications and being an active participant on your treatment team.

Conclusion

Dietary therapies for mental health symptoms like we see in depression and anxiety are powerful interventions. There is a strong evidence base in the literature, going back decades, showing the effects of nutritional deficiencies and insufficiencies in mental health disorders. Including clinically significant anxiety and depression. Ketogenic diets have been used for over a century to treat epilepsy and there are now case studies and some RCTs looking at its use in other brain disorders classified as neurological disorders and mental illness. Evidence-based treatments such as CBT, DBT, Behavioral Therapy, and EMDR for depression and anxiety are powerful. Imagine a treatment plan in which you have access to and are implementing both. This is what I get to do with people every day and I get to see how powerful this combination can be. And that is why I am excited about the possibility of you reducing your symptoms of anxiety and depression.

Feel free to learn about me and what I do. Contact me and ask questions. I will do my best to become a resource on your treatment team or I am happy to help you find resources on your journey towards wellness.

Like what you are reading on the blog? Want to learn about upcoming webinars, courses, and even offers around support and working with me towards your wellness goals? Sign up!

What level of nutritional or dietary therapy would YOU be willing to try to reduce symptoms of anxiety and depression?

How is a ketogenic diet complementary to psychotherapy?

Advertisements

The standard of care for mental disorders is medication and therapy. Even in what are considered to be primarily neurological conditions that are generally treated with medication, psychotherapy is always considered an excellent adjunct that improves outcomes for the patient.

For example, the American Psychological Association lists cognitive-behavioral therapy (CBT) as an evidence-based treatment for a variety of clinically significant disorders such as depression, anxiety, and substance use disorders. For primarily medication-based psychiatric disorders such as some eating disorders and psychotic disorders, CBT is used to assist with treatment and medication compliance. It is also recommended for normal life stressors people encounter that can become difficult to manage, such as issues in parenting, relationships, or life transitions.

In moderate to severe cases of psychiatric illness, medication with psychotherapy is the standard of care.

But what if you have tried medications. Possibly lots of them. And you didn’t respond well or the side effects made you more miserable than the disorder you came to get treatment for? What if you found that you had to take other medications to deal with the side effects of the medications you were already taking?

What if you found that your psychiatric medications were causing additional health problems, such as higher running blood sugars, weight gain, hormonal imbalances, and metabolic issues?

What if the medication only worked for a short period of time? And you made some progress in therapy but then you felt like you got stuck, and didn’t progress past a certain point of symptom relief you were hoping for?

What if you found it was really hard to make progress in psychotherapy because of some of the side effects of your psychiatric medications made it more difficult to think, concentrate, or practice mindfulness?

In moderate to severe cases of mental illness, we use medications adjunctively, in part, to make it easier to participate in psychotherapy. If medication is not working for you, and you are in psychotherapy, you may not be getting the full benefits of either.

As someone who practices psychotherapy AND helps people transition to ketogenic diets, for all the reasons above, I can tell you the work of psychotherapy is exponentially easier when your neurotransmitters are better balanced, you have less brain fog because of less brain inflammation, and your energy is up because you are burning ketones for fuel.

Evidence-based psychotherapy often has homework. Some of the best evidence-based treatments, such as CBT, require worksheets. There are behavioral homework assignments, such as taking walks or implementing sleep protocols. Psychotherapy is work! At least the psychotherapy I do. And as with all evidence-based psychotherapy treatments, outcomes can be better with prescription treatment. Or I would argue nutritional treatments that work as well or better than psychiatric medications available that clients have tried and found unhelpful.

How is this possible? Ketogenic diets affect multiple pathways found to be causal in the creation and maintenance of different brain-based disorders, whereas medications often are only able to influence one or two. You can learn about some of the ways ketogenic diets affect the brain here in prior blog posts (part 1, part 2 and part 3)

Your practitioner should always make available to you the standard of care for your disorder. Always. But it is not ok for your practitioner to not discuss alternative therapies and provide real informed consent regarding your options for treating mental illness and neurological disorders. Sometimes your treatment team does not know about therapies like the ketogenic diet, or they have a belief it will not help, or that you will not be able to sustain it. Sometimes they believe you just wouldn’t be interested in trying it, or changing your diet to feel better.

But it is not good practice for them to make these assumptions. Good care means a conversation with you about ALL the options that are showing benefit in the scientific literature. And the ketogenic diet for mental illness and neurological disorders is very much a treatment showing great promise, both in the study of underlying mechanisms and in published case studies. RCT’s using ketogenic diets for epilepsy are well established, and many RCTs for other disorders are in progress, for a variety of mental illnesses and neurological issues.

Do we have RCT’s showing that pairing psychotherapy with the ketogenic diet is as good or better than pairing psychotherapy with medication? Of course not! I am not sure who would pay for those studies, as implementing a ketogenic diet is not a profitable endeavor in our current healthcare model. I would love to see those studies be done, and I have great hope and optimism that they will be. But I see no reason for you to needlessly suffer waiting for the perfectly conducted and funded RCT before you can advocate for your treatment.

I can use my own clinical experiences and those of others who specifically use the ketogenic diet with populations with mental illness and neurological issues. And these clinical experiences report, that for those who adhere to the diet for at least 6 weeks there can be a remarkable improvement in a variety of symptoms.

You can also use your own logic. You may be struggling right now with depression and anxiety, but that does not mean that you are unable to make informed decisions regarding your care.

If we pay attention to the literature that is now suggesting that a ketogenic diet is a powerful intervention for many mental and neurological disorders, then why would we not use it with psychotherapy when attempts with medication have proven ineffective?

If you do not want to use psychiatric medications for whatever reason, or have not had positive experiences using medications, consider a ketogenic diet as a treatment for your illness or as an effective potential adjunct to evidence-based psychotherapy.

Are you already on medications? If you are on any medication at all, psychiatric or otherwise as you read this, please do not attempt a ketogenic diet or reduce or change your medications without the help of a prescriber.

In an ideal world, your treatment team would include a mental health professional and/or a nutritionist or health coach who is trained in ketogenic diets specifically and understand their effects on medications and psychiatric symptoms. They would provide the emotional and behavioral strategy support you deserve when making important lifestyle changes.

Like what you are reading on the blog? Want to learn about upcoming webinars, courses, and even offers around support and working with me towards your wellness goals? Sign up!

References

https://www.apa.org/ptsd-guideline/patients-and-families/medication-or-therapy

https://pubmed.ncbi.nlm.nih.gov/30760936/

https://www.jwatch.org/wh200305200000003/2003/05/20/hormonal-side-effects-antipsychotics

https://www.frontiersin.org/articles/10.3389/fphar.2020.578396/full

https://journals.lww.com/co-endocrinology/Abstract/2020/10000/Ketogenic_diet_as_a_metabolic_treatment_for_mental.5.aspx

https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC7387764/

Ketogenic diets treat mental illness – Part 3

Advertisements

Keto for mental health

BHB (a ketone type) promotes neurotransmitter balance which has neuroprotective effects. A diet low in carbohydrates resolves hyperglycemia, which is known to produce inflammatory cytokines. Ketogenic diets are amazing for mental health and neurological disorders because of their ability to reduce chronic inflammation and oxidative stress.

Neuroprotective effects of the ketogenic diet will lead to:

  • reduced advanced glycation end products (AGEs)
  • reduction of inflammatory cytokines
  • reduction of free radicals in the brain
  • reduced damage to blood brain barrier
    • major structure offering protection for the brain
  • reduced atrophy of the hippocampus
    • critical for learning, emotional responses, memory formation and storage
  • Upregulation of endogenous glutathione production
    • POWERFUL antioxidant!

You have to give your brain what it needs to work better if you want to treat mental illness and neurological disorders. Ketogenic diets are powerful mental health interventions.

Check out Part 1 and Part 2 of this same blog series to learn more about how ketogenic diets can treat mental illness and neurological disorders! Lots more information at the Mental Health Keto blog, where you can discover more benefits of the keto diet for mental health.

Like what you are reading on the blog? Want to learn about upcoming webinars, courses, and even offers around support and working with me towards your wellness goals? Sign up!

Free ebook

References

https://pubs.acs.org/doi/10.1021/acschemneuro.7b00410

https://www.psychologytoday.com/us/blog/diagnosis-diet/201712/the-antioxidant-myth

https://onlinelibrary.wiley.com/doi/full/10.1111/j.1471-4159.2008.05460.x

https://www.psychologytoday.com/us/blog/diagnosis-diet/201712/cooling-brain-inflammation-naturally-food

https://pubs.acs.org/doi/10.1021/acschemneuro.7b00410

Please ensure Javascript is enabled for purposes of website accessibility
Exit mobile version
%%footer%%