In addition to today’s resource, please review:
Linking To And Excerpting From “The ketogenic diet is not for everyone: contraindications, side effects, and drug interactions”
Posted on February 18, 2026 by Tom Wade MD
Today, I link to and excerpt from Frontiers In Nutrition‘s Awareness and best practices in using ketogenic therapy to treat serious mental illness: a modified Delphi consensus. [Full-Text HTML] [Download PDF]. ORIGINAL RESEARCH article: Front. Nutr., 23 February 2026. Sec. Nutrition and Metabolism. Volume 13 – 2026 | https://doi.org/10.3389/fnut.2026.1749406
All that follows is from the above resource.
Abstract
Background:
Metabolic dysfunction is emerging as an important contributor to the pathophysiology of major depressive disorder, bipolar disorder, and schizophrenia, fueling interest in ketogenic metabolic therapy (KMT) as a potentially beneficial intervention for serious mental illness. KMT has been used successfully for decades in treating epilepsy, but evidence for treating mental illness has yet to mature.
Aims:
This study aimed to produce expert-informed guidance for the implementation of KMT in adults with serious mood and psychotic disorders.
Method:
A modified Delphi methodology was used to examine the opinions of KMT-experienced mental health experts. A steering group of eight such experts convened to develop an online survey comprising 33 statements regarding 1) the definition of KMT in the context of serious mood and psychotic illness; 2) identification of eligible candidates; 3) monitoring and measurement standards; and 4) best practices in employing KMT. This survey was distributed to clinician peers to examine opinions. The threshold for consensus agreement was set a priori at 75%.
Result:
Consensus was reached for all 33 statements (100%); therefore, the steering group approved the complete series of recommendations.
Conclusions:
This consensus provides expert-informed guidance to support the use of KMT in adults with major depressive disorder, bipolar disorder, and schizophrenia.
1 Introduction
Schizophrenia, bipolar disorder, and major depressive disorder afflict hundreds of millions of people globally (1) and are associated with poor quality of life, reduced life expectancy, and high socioeconomic burden (2).
Despite decades of prescription drug treatments designed to remediate underlying dysfunction in neurotransmitter systems, this approach continues to leave many individuals without meaningful relief (3). Those who do benefit from psychotropic drugs often suffer serious side effects that negatively impact quality of life, cause metabolic dysfunction, and can even be life-threatening (1, 2, 4, 5). Pharmaceutical innovation in psychotropic medication has essentially stalled, with few drugs with novel mechanisms of action approved in recent years (6). This lack of new and effective treatment options is particularly challenging for individuals whose conditions have not responded to multiple psychotropic drugs and are therefore considered treatment-resistant (3, 7–10).
For these reasons, the search for modifiable factors underlying serious mental illnesses has expanded beyond neurotransmitter system dysfunction to include neuroinflammation and excessive oxidative stress (both of which disrupt neurotransmitter production pathways), and insulin resistance—a common driver and marker of general metabolic dysfunction (11, 12). Serious mood and psychotic disorders are strongly correlated with metabolic disorders (13, 14). For example, people with glucose levels in the prediabetes range are 2.7 times more likely to develop major depression (15), those with newly diagnosed bipolar disorder are 3.5 times more likely to have metabolic syndrome (16); and individuals with newly diagnosed schizophrenia are 3.7 times more likely to have insulin resistance (17, 18). Insulin resistance is linked to cerebral glucose hypometabolism, which has been observed in schizophrenia, bipolar disorder, and treatment-resistant major depressive disorder (19). It has been demonstrated in a carefully controlled clinical trial that reversing insulin resistance with medication (metformin) may substantially improve depression symptoms in adults with treatment-resistant bipolar disorder (20), suggesting that addressing metabolic dysfunction by other means such as with lifestyle changes may also offer clinical benefits.
Ketogenic metabolic therapy (KMT), an intervention that leads to potentially therapeutic levels of ketone bodies in the blood, can improve metabolic health (18). While it is possible to lower insulin levels enough to initiate ketogenesis through fasting or significant caloric restriction (21), or raise circulating ketone levels using exogenous ketone (beta-hydroxybutyrate) supplements (11), the safest way to maintain ketosis long-term is with a ketogenic diet.
KMT has been shown to decrease neuroinflammation, regulate neurotransmitter systems, reduce hyperexcitability of the neural network, stabilize neuronal firing rates, and improve brain energy metabolism (11). Indeed, mitochondrial dysfunction is increasingly implicated in the pathogenesis of many neuropsychiatric disorders (22) including schizophrenia (23), bipolar disorder (24), and major depressive disorder (25). KMT improves brain bioenergetics by bolstering antioxidant defenses, which protects the health of existing mitochondria, and by promoting mitochondrial biogenesis, the creation of new mitochondria (26).
The clinical utility of KMT has been demonstrated in epilepsy for many decades (27), and a growing body of evidence that includes preclinical research and human case reports suggests a similar approach could improve both metabolic dysfunction and serious psychiatric symptoms, even supporting remission of treatment-resistant mood and psychotic illnesses in some cases (28, 29).
Although data from larger, more rigorous human clinical trials of KMT in serious mood and psychotic illnesses are not yet available, a growing number of clinicians have been turning to KMT in an effort to improve outcomes for patients living with these challenging conditions.
Our objective was to engage KMT-experienced mental health experts in a modified Delphi study to develop clear clinical guidance for the safe and appropriate implementation of KMT in the treatment of serious mood and psychotic illnesses.
