Note: This article is updated constantly. Disclaimer: I’m not a doctor, and this is not medical advice! This information is for educational purposes only, and is in no way intended to be personal medical advice. Please ask your physician about any health guidelines seen in this blog.
I was reluctant to write this article, because I’m not a doctor, and I have never tried a ketogenic diet myself (update: I now have), neither I have a mental disorder that I know of. The depression I had accumulated in the past 10 years because of IBS-D ruining my life, is already gone with the plain, less-restrictive Paleo/Primal diet.
As it happens, I kept researching about ketogenic diets as a way to lose more weight. But what I ended up finding instead, is a whole new way of fixing (== making asymptomatic) disorders that until very recently I’d thought to be “unfixable”. I always thought of mental disorders as this whole other thing, medically. It’s not like a broken arm, where you put it in a cast, and it gets fixed in a month or so. Or even like with my own problem, IBS-D, where you remove certain foods, while adding others, to fix this GI issue. Mental disorders are shrouded in this mystique of the unknown, which I always found fascinating, and scary as hell at the same time.
So while researching (some links: 1, 2, 3, 4, 5, 6, 7), I found that the known ketogenic diet for epileptics, actually has magical effects also to autistic/aspergers, bipolar, depressed, anxious, and even schizophrenic people (report). Other positive benefits of a very low-carb, high-fat diet was found during the treatment of Parkinson’s, Alzheimer’s, Lou Gehrig’s disease, and even brain cancer patients! Unfortunately, no research was ever done for adults to study the alleviating of these illnesses’ symptoms with a keto diet (Update: there’s such research for bipolar now, read the updates at the bottom of the article). The epileptic keto diet is mostly tested on children, who are not allowed to eat more than 10 grams of carbs daily. A number of children who have followed the diet, generally saw a reducing of the number of seizures within a few weeks, and in some cases, they got a complete loss of seizures within a few months. There are also a lot of autistic kids who got their ability to connect with others, and even speak, or go to normal school, just by following the similar to Paleo & Keto diets: the GAPS and SCD diets. A bipolar woman got so much better that she even managed to stop her medication within 6 months time of following a strict ketogenic diet (with the agreement of her doctor, one of the few doctors who suggests diet as a prescription). There are these who claim that most mental disorders are nothing but inflammation. A completely “physical” problem, that is.
A ketogenic diet is a diet that removes most sugars and starches from the diet. Adult patients are not allowed to eat more than 30-40 grams of net carbs a day, and it’s about 10-20 grams for children. After 2-3 weeks, the body stops burning glucose as its fuel, and instead runs on fat! While in this mode, the body then will produce a byproduct called ketones. There are sticks you can buy where you pee on them in the morning, that let you see if your body has gotten into a ketosis mode or not (also, bad breath, and stinky unine are other ways to know). These methods are good to know if you have reached ketosis in the first few weeks, but as your body adapts, ketones won’t be disposed by your body anymore (so detection won’t be possible anymore via sticks). The brain/body can also run on protein, but it prefers sugar or ketones/fat. By changing the fuel that floods the brain from glucose to ketones, the seizures get minimized or stop, because the whole dynamic/chemistry of the brain changes. Your mood will stabilize, you will focus better, and a whole new world will open up for you (hopefully — as with other reported illnesses, a minority doesn’t respond to dietary changes).
So, to start, follow the Paleo diet as described there (including bone broths, oysters, offal, seaweed, lactose-free home-made goat kefir, but not the suggested honey). Never put grains in your mouth again, not even in the form of a beer. You will have to avoid gluten the same way a celiac does — even if you’re not a celiac. You will have to measure your carbs to make sure you don’t go over your daily allowance number of grams!
For oils, go for any animal fat, grass-fed butter, and coconut oil for cooking, and extra virgin olive oil, raw, for salads. Avoid all vegetable oils and margarine, and make sure your olive oil is true olive oil (most olive oils these days are bastardized with cheaper oils, illegally). Coconut oil should be your main cooking oil, since it has strong brain effects.
No sugar, not even artificial one (except, rarely, maybe, some Stevia). A small piece of 85+% dark chocolate is ok. A bit of raw, local honey is ok after you’ve transitioned away from Paleo-keto to plain Paleo later on.
From nuts and seeds, you can have all of them in moderation, except peanuts that are out completely (they’re not nuts, botanically-speaking they’re legumes, hence all these allergies people have with them!). All these details are explained better in the Paleo diet link above, make sure you read that article, and its links.
For protein, give priority to wild fish (esp. wild salmon, mackerel, sardines) and shellfish (esp. oysters) over meat. Wild seafood has a lot of omega-3, which has mental stabilizating benefits. Prefer pastured eggs for the same reason. For meat, go for pastured/grass-fed if possible, but it’s ok to go for regular meat if you don’t have the budget for it. Eating pastured offal (e.g. grass-fed liver, heart, duck gizzards) is paramount though. I usually buy lamb/goat liver/heart, since most of these animals are pastured in the US (as opposed to cows). Duck gizzards look healthier than chicken offal, since ducks are less industrialized.
If you can tolerate dairy, you should make your own home-made probiotic lactose-free goat kefir, which has strong healing properties. You can also eat goat/sheep cheeses (avoid cow cheese/milk). For plain milk, you go for unsweetened almond or coconut milk.
For fruits, you can chop two small strawberries in your yogurt, or 4-5 of the smaller berries per day (that’s overall about 3-5 grams of carbs). The rest of the fruits are pretty much out, unless you’re ok eating very small pieces of them, pieces that overall don’t have more than 5 grams of carbs (e.g. 1/4 of a small peach).
For soy sauce, go for the wheat-free “tamari” soy sauce, or coconut aminos (you can take these with you at a sushi restaurant too — order sashimi). Garlic, and gluten-free herbs (always confirm!) are ok! Fermented foods (e.g. live kimchi, sauerkraut etc) are very beneficial and they must be consumed.
Look above for a list of the kind of carbs allowed. Start at 30-35 net carbs per day for 6 months, and then add 10 gr of net carbs every 2-3 months, until you reach up to 100 gr of net carbs per day, sometime 1.5 to 2 years after you’ve started the diet. You then stabilize there, for life (plain Paleo). Remember, gluten will have to go 100%, forever.
A tip: While you’re calculating carbs, you can remove the fiber from the calculation, so that allows for more vegetables to eat. For example, if a veggie has 10 grams of carbs for 100 grams of its weight, but 4 of these grams are fiber, then in reality that’s 6 grams of “net” carbs. So add more than 100gr of the vegetable in your plate! Yum, more to eat! Here’s how to calculate “net” carbs. Create a free account with Cron-o-meter web site, and setup your profile with the right diet information (there’s a ketogenic option). Then, click “Profile”, “Carbohydrates” (from the tabs at the bottom of the page), check the “visible” checkbox for the “net carbs” (it’s not visible by default). Now, every time you add some food on the list, it will also show you the net carbs consumed, in addition to other nutritional information.
Regarding supplementation, if you’re not out in the sun a lot, get 2000 IU of D3 daily (but make sure you check your levels via a blood test every year, you don’t want to reach toxic levels). Also, the “fermented cod liver/butter oil” can stabilize the mood (google for it). Other interesting vitamins is Magnesium (and K2 Mk-4, if you don’t do the cod liver oil). For people specifically on a keto diet, it could be useful to get L-Carnitine (at least in the beginning), a substance that helps the body metabolize fat into fuel. Also, make absolutely sure that you cook mostly with pure coconut oil (MCT oils are imperative for mental health). Make sure your sea salt has added iodine in it, and that you do eat salt. Also, have sea-vegetables for their iodine (seaweed). Beet *greens* and swiss chard can keep a good level of potassium too (you can also occasionally use potassium salt). It’s paramount that you drink enough water on a ketogenic diet, or you can get horribly constipated with it.
Cut off most cigarettes, and completely cut off recreational drugs. Limit alcohol (you could still have a bit of dry wine or cider every now and then), and definitely get off caffeine. Caffeine has some good effects itself, but it can send some people with mental disorders into a manic state. Chamomile and Greek Mountain herbal teas should be in your tea pot. If you’re an alcoholic, you must cut off alcohol slowly, so you don’t get ketoacidosis. If you have to cut down all these substances, then it makes sense to go for the plain Paleo diet in the first month, and only after you’re free from addiction to go for the Paleo-keto version of the diet. This way, not everything comes at you overwhelmingly at once.
Try to sleep 8 hours at night, no later than 11 PM. Sleep has a very important therapeutic role while you’re healing. Some basic exercise will help too, nothing too strenuous. Yoga and meditation are good too.
If after a few months on this diet you saw no mental rebound, consider checking yourself for parasites, viruses, tumors etc. You might have to see a good specialist about all that.
To recap, this Paleo-ketogenic diet for mental disorders is a bit tweaked compared to plain Paleo, or plain Keto diets, in order to support the brain as much as possible. To recap, these tweaks are:
- In the first month, while you could be battling addiction to carbs/sugar, alcohol, or too much caffeine, go with the less-restrictive, plain Paleo diet (up to 100-150 gr of net carbs per day — it allows for raw honey as a sweetener, tubers, more fruits). When you feel comfortable at that diet, only then go Paleo-ketogenic.
- You’ll need a cooking weight scale, and to use cronometer.com, to weight/calculate the “net” carbs of what you eat. That’s 40 gr of “net” carbs per day for 6 months in the Paleo-ketogenic diet, and then add 10 gr per day every 3 months, until you reach 100 gr. At that point, try to stabilize on a diet that goes up to 100 gr of net carbs per day for the rest of your life. The ketogenic phase in the first few months is hard, but it only gets easier!
- Eat much more wild fish and shellfish than meat. Your brain needs as much DHA as possible. Have pork belly with some of your breakfasts, beef for Sunday lunch, poultry or game on Friday dinner, and offal on Wednesday. The rest of the time should mostly be wild fish (particularly low-mercury oily fish, e.g. salmon, mackerel, trout etc), and shellfish (particularly oysters or mussels).
- Coconut oil is your main cooking oil. Ketone production will get stimulated by coconut oil.
- Home-made non-chicken bone broth, slow-cooked for 24 hours (cook with some of it, or heat up and drink a cup daily).
- Home-made goat kefir, fermented for ~24 hours. Add a few chopped nuts and berries in it and eat it at lunch time, or at breakfast time along 1-2 fried eggs (or in omelette) and occasionally, a bit of fried pork belly/patties.
- These crackers are your only “bread” from now on. Have no more than 4-5 pieces a day. Avoid insane amounts of almond/coconut flour for baking.
- Small amounts of various sea vegetable species, almost daily. Avoid eating your seaweed/fish with any of the cabbage family of vegetables (including broccoli, Brussels sprouts), because they block iodine absorption.
- Have beet greens almost weekly (they have lots of potassium). Slow-fry them in butter, garlic, 1 cup of bone broth. Sprinkle potassium salt instead of sea salt on some of your non-fish dishes.
- Eat enough high quality sea salt too. Ketogenic diets are diuretic, so you’ll be losing lots of water/salt/potassium.
- Live/unpasteurized sauerkraut/kimchi, and Greek Mountain Tea, if you can find it on your local Mediterranean store. Greek Mountain Tea (herbal) will help you sleep well if you drink it an hour before bed. Use chamomile if you can’t find the specific herbal tea suggested.
- Not too much coffee. You must establish your regular circadian rhythm back, and get enough sleep. Without enough sleep, this diet won’t reach high potency. Sleep from 10 PM until 6-7 AM. People who work at night: they’re screwed.
- Walk or do some yoga, almost daily. Your skin must “see” the sun daily. Consider some meditation too.
- Learn to eat more types of veggies: turnip, rutabaga, spaghetti squash, kale, amaranth greens, radishes, jicama etc. Without adding more variety to your diet compared to the few “standard” vegetables most people eat, you won’t make it in this diet. You need the variety and adventure that comes with it. Same goes for game meats, and lesser known types of fish.
- Try to increase your raw food/recipes a bit after a while. I have many Paleo recipes for you here (avoid the tuber-based ones and most desserts, as these are higher carb).
- A single Brazil Nut, 3-4 times a week. This will be enough to keep your selenium levels up! Don’t overdo it! Both selenium and iodine are needed for good thyroid function, but they’re also antagonists!
- Your dairy (kefir, yogurt, cheese) should always be fermented, and from goat/sheep/buffalo. From cows, only do grass-fed/pastured butter, and European style probiotic cream (or crème fraîche). If you can tolerate it, occasionally go for “European style” cow yogurt (unfortunately, most goat yogurt in the US has tapioca and other additives in it).
- Drink a lot of water. If your tap water has added fluoride, you’ll need to hunt for the right bottled water.
- If you’re looking for the extra mile, here’s my recipe for home-made non-fluoride toothpaste too.
- Supplement almost daily with 2000 IU D3 (morning), 1 pill of Fermented cod liver / butter oil mix (lunch), and Magnesium Malate (20 mins before sleep). Supplement at dinner time (not daily, rotate them) with the specific forms of CoQ10 Ubiquinol, Folate (not folic acid), and Acetyl-L-Carnitine. Replenish only D3 and Magnesium when they’re out. Don’t use multi-vitamins, they often use the wrong forms, or they’re missing key nutrients, while they over-do it on others.
- Once a year check your iron, B12, D3, folate, potassium, calcium, CRP, thyroid T3 etc. status via a blood test, and tweak your diet/supplementation according to the results. Every individual is different, so further tweaks might be needed.
- Finally, and most importantly: AVOID GLUTEN AT ALL COSTS. Read food labels!
Having said all that, be careful with such a diet, and always ask the permission of your doctor. Of course, most doctors don’t believe that a diet works for mental illnesses, because the research for it is brand new and most don’t even know about it. The main danger is ketoacidosis: avoid alcohol, and definitely ask your doctor first, if you’re a Type 1 diabetic, or such a diet can become fatal!
Other reported problems are kidney stones and constipation, so make sure you drink enough water. If your eyes are starting to get dry, add a few more carbs. Also, if you are exercising or working physically a lot, you need to add more carbs too than the suggested amounts.
Finally, you will feel headaches, brain fog, cramps, moodiness, and fatigue in the first 30 days of the diet, this is normal and to be expected (“carb flu”). Try to not eat more carbs to combat all this, your body will adjust to the new fuel eventually, as long as you eat enough fat. IF your body can’t adjust within 30 days, then you will have to add carbs back, gradually add up to 100-150 gr of net carbs daily (eat fruits, sweet potatoes), and after a few months try to stabilize down to about 100 gr of net carbs. This is explained here, and it’s mostly true for people who over-produce rT3 (thyroid problems), have malabsorption, high lipids, high cortisol, and maybe who are insulin-resistant. For these people (a minority), going very low carb is actually a bad idea, and they’ll have to do with the fewer benefits of just going plain Paleo (mental benefits will still happen even with plain Paleo, just not as much). You might also want to check out your genes, to see if you’re APoE e4/e4. 3% of the world’s population have this gene, and they can’t digest fats properly.
Also note, that most people who got out of the diet had their symptoms eventually returned. A Paleo diet is not a panacea, but it’s a way to manage your problems, and eventually & hopefully (with your doctor’s approval), to stop taking these drugs that usually have so horrible side-effects, and most often than not, they just don’t work. But no matter what, always keep your doctor(s) in the loop!
Here’s how a sample menu looks like in a Paleo-ketogenic diet:
* Breakfast: 2 eggs (or in omelette with greens/mushrooms/cheese), fried in coconut oil. Fried pork belly pieces with lemon, or half an avocado. Drink a cup of your home-made goat kefir, served with 4-5 berries, nuts, and seeds, all chopped. That’s about 10 gr of net carbs for breakfast. It’s best to eat within 30-40 minutes of waking up.
* Lunch: A small cup of a veggie soup made with bone broth and sour cream. 120 gr of left-over roasted chicken, re-fried in coconut oil. Serve with a cup of greens (mostly from the cabbage family), 1/2 cup fried mushrooms or other veggies. Have some goat of sheep cheese with it and 2 cheese crackers. Overall, that’s 10-15 net carbs.
* Dinner: Green salad with olive oil vinaigrette. 250 gr of wild fish fried in coconut oil, or shellfish. Serve with 1/2 cup of mashed cauliflower, or a cup of other veggies, bathed in cream or butter. Have some goat of sheep cheese with it and 2 cheese crackers. That’s overall another 10-15 grams of net carbs.
* Snacking: a few seeds/nuts (don’t overdo it with these, they’re too high in O-6), heated bone broth, unsweetened almond/coconut milk (or prepared as cereal), wheat-free jerky, canned wild sardines and lemon, aged non-processed cheese, a square of 85%+ dark chocolate. Herbal tea/chamomile 1-3 times a day.
Overall for the day, rounding up on error, that’s about 30-40 grams of carbs, which is low-enough to keep most adults under ketosis, and high-enough to not be completely unmanageable. A considerable amount of fat should be consumed, since that’s what’s running the body now. Don’t be afraid about cholesterol, as with the Paleo diet, the diet itself will balance everything out. There are a lot of myths about cholesterol out there, but there’s also rebuttal (1, 2, 3).
The most difficult part of the Paleo-Ketogenic diet is of course to keep it up. Most people can’t keep it up for long. But if you can keep it up for 2-3 months, and then you see the benefits of the diet in both your body & mind, it’s up to you if you want to continue getting drugs for the rest of your life, or get with the program and find your inner peace. When after a while you transition to plain Paleo from the Paleo-ketogenic diet it’ll be easier to do maintenance for the condition for life. Think about it, and do your own research online. As importantly, start a blog about it, and share your progress while on such a diet! Spread the word if it worked for you!
Update Dec 20 2011: A new article, at NPR, about dieting and mental health.
Update Jan 6 2012: Coconut oil fixes Alzheimer’s.
Update Jan 20 2012: Positive effects of the ketogenic diet on behavior and cognition.
Update Mar 8 2012: Results from my own experiment with the Paleo-ketogenic diet.
Update Apr 26 2012: More Clues to Systemic Inflammation in Mood Disorders
Update Oct 10 2012: Research on Bipolar and ketogenic diet
Update Oct 13 2012: Two accounts about keto for bipolar, one successful, one less so (although I’d bet that the second person didn’t try the Paleo-ketogenic diet in particular, which is more effective than plain keto or plain Paleo).
Update 16 Dec 2012: One more great article about Bipolar from Dr Deans.
Update 27 Jan 2013: Is Schizophrenia an Autoimmune Disease? Article.
Update 31 Jan 2013: The actress who played Lois Lane in the ’70s Superman movies had massive bipolar issues that halted her career. For many years now she’s free of episodes, after going on a gluten-free, sugar-free diet in the ’90s.
Update 31 Jan 2013: Blog of a woman with bipolar who has managed a portion of her condition with the Paleo diet (not Paleo-ketogenic though).
Update 3 Mar 2013: The account of a Paleo-ketogenic dieter with Bipolar I and agoraphobia, and her success. Three more Reddit reports: 1, 2, 3.
Update 7 Mar 2013: Exclusive interview with DreaV, who successfully combated bipolar and agoraphobia with the Paleo-ketogenic diet!
Update 12 May 2013: More discussions on Reddit about keto and mental clarity: 1, 2, 3, 4, 5, 6, 7. While these are not published research papers, but rather anecdotal reports, they are numerous, and they are consistent, making them difficult to dismiss the positive effects of a very low carb diet for mental disorders.