Please consider participating in Dr Shebani Sethi Dalai’s clinical trial of ketogenic diet for bipolar disorder at Stanford University by clicking the link below:
Stanford Ketogenic Diet Bipolar Disorder Trial
Full BJPsychOpen Study here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6620566/
As a teenager when I was ill with Bipolar Disorder I often wished I could flip between the state of experience of a normal person and compare it to my own normal. How would it be? Would I feel a sudden rush of cool relief, a complete expulsion of all pain and a breath of calm permeate my being in a way never experienced before? Would it feel fundamentally different to be normal? How different would it be? Would it suddenly become apparent that I had been wearing a thousand-pound mental backpack while those running beside me in this marathon of life were comparatively unburdened?
What if someone could experience my reality? If they suddenly flipped into my normal state of being would they feel they had been cast into a sea of anguish and suddenly exclaim “Oh wow? This is what you feel like day to day? I had no idea.” Would they feel a sudden onset of the pressure of mental pain that gripped me like a vice daily? Would they feel this to be an intolerable emergency state requiring immediate medication, painkillers, or a hospital visit? Would they feel that we had been living in two different worlds?
Many of us with Bipolar have gone so deep into the dark that it’s hard to even remember what the light looks like. Without comparison, it’s hard to have any kind of objective evaluation of one's own experience.
One day in 2014 around 8.30am in the morning, for the first time in my life I experienced the transition from the bipolar state to a healthy normality. I had 3 or 4 days previously started a ketogenic diet to lose weight, I had no expectation whatsoever that this would have any effect on my mental health. However sitting on the bus I became aware that I was experiencing something fundamentally different in my mind-state. For the first time in over 15 years, I felt the lights in my brain switch back on.
I felt cool, peaceful, clear rivers of crystalline thought pouring unhindered through my mind washing out decades of mental junk gathered in every crevice. I wondered at first whether I was becoming manic but, no, this was something fundamentally different: I felt a calm, cool serenity wash through my body and a lightness pervade every cell. It was as if hundreds of pounds of dead-weight and accumulated trash were being liberated from my body and mind. I had never felt this light and free before and yet at the same time fully grounded and objective about my experience. Whole areas of my brain were coming back online and I could l feel it happening. Experiences of life I had lost completely were re-emerging from the dark: the feeling of … serenity? Is this what happiness used to feel like? What is this? These emotions were so foreign to me it took me weeks to even recognise them.
It reminded of the allegory of Plato’s Cave. People had been trapped in the cave so long only seeing dark shadows that they eventually they forgot what real objects in daylight looked like. Upon being released from the cave they marvelled at seeing the world in bright daylight. This is how I felt. Like I was emerging from a whole life observing shadows to finally experiencing what others experienced. The simple and gentle contentment of looking at nature returned to me for the first time in years as I enjoyed the daylight shining on leaves outside the bus window. I felt the beautiful calm of watching nature embrace my mind and I realised that these pleasures pervade the lives of most people in a way that I had completely forgotten.
I felt like I could feel the networks of neurons in my brain like the lights of a city grid clicking back online with a satisfying thump, sizzle, and radiant glow. Until this moment my brain had been like a city grid with the power offline, just a dark, chaotic mess gradually sliding into entropy. All that it needed was to have the power turned back on and the city would once again hum to life and re-organise itself into order. A thousand power-grids, traffic lights and necessary systems of repair would re-activate and restore the city to life automatically. This was happening in my brain for the first time in over 15 years, and I knew life would never be the same. But why was I experiencing this?
For some time now bipolar disorder (BD) and epilepsy treatment have centered around many of the same anti-convulsant medications. This is a curious situation, the conditions seem to be very different so why would the treatments for epilepsy show efficacy in Bipolar? Several researchers have suggested that since some key biomarkers are common to both conditions, perhaps there is a biological similarity in the mechanism of action of anticonvulsants on BD and epilepsy. The ketogenic diet was developed as an intervention for use in epilepsy with nearly 100 years of clinical use and trials attesting to its effectiveness. There are ketogenic diet services in most major hospitals in the UK for treating epilepsy and The Charlie Foundation support many people with epilepsy using the diet to manage their condition.
I had heard that the diet was very good for weight-loss but I had no idea it could have any effects on the brain. I started the diet in the days leading up to my major shift in mood described above and I have since had very significantly improved mood stability in the years I have stayed on the diet and live a normal life completing a PhD, starting a family with a wonderful wife and working a great job. Things I really thought may never be possible for me. Keto isn't a panacea but I can say with certainty that it saved my life.
Our bodies typically derive their energy from “burning” glucose as its main fuel source. Much of the food we eat is broken down into glucose and this fuels each cell in our body. However, there is an alternate fuel supply that is produced in the body when we don’t eat for a period of time and we start burning body fat instead of glucose. The molecules that make up this fat-derived fuel are known as “Ketones”. People naturally produce and burn ketones for fuel when there is no external source of food to provide the body with glucose. This is how body-fat is burned when losing weight. However, in our modern society with nearly unlimited access to food, we rarely reach this natural state of fat-burning and do not receive the many benefits it can provide for the brain.
Ketones are a more energy-efficient fuel source for the brain and result in many biologically advantageous conditions for neurons. These include increased energy supply (ATP), beneficial changes in neurotransmitter release (decreased glutamate and increased GABA), and reduced levels of reactive oxygen species to name but a few.
The other way that a state of "Ketosis" -where we generate Ketones for energy- can be achieved is to adhere to a ketogenic diet. On the ketogenic diet, fat becomes the primary source of calories instead of protein and carbohydrates. When high levels of fat are present in the diet with minimal carbohydrates the body enters ketosis without needing to fast. The body simply burns the fat consumed in the diet instead of just burning existing body fat, either way, the process produces Ketones.
But isn’t such a high level of fat unhealthy? The modern understanding of the role of dietary fat has changed significantly in the past 20 years and the fat-phobia of the 1980s is gradually subsiding. It turns out that healthy fats can be highly beneficial for the brain; a recent meta-analysis shows that consumption of dietary saturated fat is not the significant cardiovascular risk factor it was thought to be [2].
The ketogenic diet has not been widely considered for use in bipolar disorder despite its widespread use amongst epilepsy patients. One small trial was carried out with two patients who both achieved significant mood stabilisation on the diet. One participant reported that “being in ketosis has been life-changing for me”. But there is little research beyond this trial except for one other case study in which the patient did not achieve a state of ketosis. [3]
To find out if other people with bipolar disorder have experienced benefits in mood stabilisation on a ketogenic diet, I collaborated with a Professor of Genetic Epidemiology on a study which analysed all posts from the largest online bipolar disorder forums which mention the ketogenic diet. This was recently published in The British Journal of Psychiatry Open journal. [4]
The study returned a surprising number of posts from online bipolar disorder forums considering that this is not a well-recognized intervention for bipolar disorder. Among the popular bipolar disorder forums there were a total of 165 posts mentioning the ketogenic diet (multiple posts by the same user were excluded).
What is more striking is that 141(85.5%) of the posts on ketogenic diets reported a positive impact on mood stabilisation. 20 (12.1%) of these reports mentioned a complete remission of symptoms; in some cases, years of continuous mood stability were reported after previous severe illness. 73 posts (44%) reported a much higher level of mood stabilisation to that experienced before adopting the diet.
Of course, there could be some bias here in that those who experienced benefit from the diet may well be more likely to post about this. For this reason, we also examined forum posts related to other dietary interventions which people in the bipolar disorder community adopt, and compared these to our data of the ketogenic diet. For this analysis, we searched for all posts on the same forums related to either Omega 3 supplementation or a vegetarian diet, which were the two other main dietary conditions we found the community talking about.
In this analysis, reports of mood stabilisation were substantially higher for a ketogenic diet than for both the other diets combined. We found 94 reports of people following omega 3 enriched or vegetarian diets, with only 14 (14.9%) reports of significant mood stabilisation or remission of symptoms. This in contrast to 93 (56.4%) reports for these outcomes out of 165 total for the ketogenic diet.
Many of the forum posts contained detailed reports of the improvements experienced, several lasting for extended periods (months to years). Other than mood stabilization, people also reported improved clarity of thought and speech, increased energy, and weight loss.
Having said this, these reports are solely drawn from subjective experience and should therefore be interpreted with caution until a trial can be carried out. It is at least interesting to note that the diet is often considered an effective therapy by many in bipolar forums.
If further investigation reveals the effect reported by some members of the online bipolar disorder community to be a real phenomenon, then what could be the reason for this?
The latest research on bipolar disorder provides mounting evidence that the root problem causing bipolar disorder is a dysfunction of mitochondria in the brain due to their inability to effectively use glucose as a fuel source. Mitochondria essentially act as engines generating energy within each cell of the body - including neurons. The brain consumes a large amount of the body’s energy and is very sensitive to any change in energy supply. When mitochondria are not functioning correctly and producing stable levels of energy for the brain, this may diminish the brain’s ability to regulate neurochemistry and keep the brain in a stable state.
Ketones act as an alternate backup fuel supply for the mitochondria in neurons and bypass many of the problematic biological pathways glucose encounters. This means that if mitochondria have trouble using glucose for fuel they can still operate at full capacity in the presence of ketones.
It is quite clear from the results of epilepsy research that this diet needs to be adhered to with the supervision of a medical professional who understands its effects. While people with epilepsy who go on the diet can have significant seizure reduction, those who do not adhere to it correctly can have a backlash of seizures. Under proper supervision such complications can usually be avoided and methods for this are quite well understood. Additionally, certain anti-convulsants affect metabolism and may be problematic in combination with the ketogenic diet so a psychiatrist must be consulted to adequately manage this.
Full study results: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6620566/
For information on use of the Ketogenic Diet in Epilepsy: https://charliefoundation.org/
For information on use of the Ketogenic Diet in Bipolar Disorder:
https://www.chrispalmermd.com/tag/bipolar/
References:
1. https://www.ncbi.nlm.nih.gov/pubmed/29588983
2. https://www.ncbi.nlm.nih.gov/pubmed/24723079