Introduction
Most people have heard of the high-fat, low-carb “keto” diet for weight loss and blood sugar control, but a therapeutic ketogenic diet (TKD) is different (read more here). A therapeutic ketogenic diet is a type of medical nutrition therapy used as adjunct treatment for specific physical or mental health conditions that is either prescribed by a Physician (doctor) and implemented by a Dietitian, or implemented by a Dietitian under Physician oversight.
In a therapeutic ketogenic diet, the amount of protein, carbohydrates, and fat is carefully controlled to keep ketone levels steady throughout the day, and both glucose and ketone levels must be monitored so that a specific therapeutic level called the Glucose to Ketone Index (GKI) is achieved.
Therapeutic ketogenic diets have been used for over 100 years for epilepsy and diabetes, and more recently, in the treatment of various mental health disorders, including depression, bipolar disorder, and schizophrenia.
Therapeutic Ketogenic Diet for Mental Health
A 2022 study in Frontiers in Psychiatry included 31 adults with treatment-resistant depression, bipolar disorder, or schizoaffective disorder in a psychiatric hospital in Toulouse, France. They followed a therapeutic ketogenic diet that restricted carbohydrates to 20g per day. Of the 28 individuals who stayed on the diet for more than two weeks, all showed symptom improvements within three weeks. Forty-three percent achieved full remission, and 64% were discharged on less psychiatric medication [1].
Other pilot studies show similar results in bipolar disorder and schizophrenia [2][3].
“Brain Energy” and Mitochondrial Health
The release of the book Brain Energy by Harvard Psychiatrist Dr. Chris Palmer in 2022 brought public attention to the role of therapeutic ketogenic diets in mental health [4], which has led to an increase in inquiries about using them. But what is a therapeutic ketogenic diet?
Types of Therapeutic Ketogenic Diets
Therapeutic ketogenic diets are a form of medical nutrition therapy using a specific ratio of fat to protein plus carbohydrate.
Classic Ketogenic Diet (KD) – 4 : 1
The Classic Ketogenic Diet has a 4:1 ratio, which means 4g of fat is provided for every 1g of protein plus carbohydrate. This diet is 80% fat. Protein may be set at 15% of calories with a maximum of 5% of calories coming from carbohydrate, or protein may be set lower at 10%, and carbohydrate as high as 10%. This type of diet is used when the need to achieve and maintain high levels of ketones is necessary.
Modified Ketogenic Diet (MKD) – 3 : 1
The Modified Ketogenic Diet (MKD) has a 3:1 ratio, which means 3 parts fat for every 1 part protein and carbohydrate. This diet is 75% of calories from fat, and 25% from a combination of protein and carbohydrate. Protein may be set at 15% of calories, with a maximum of 10% of calories coming from carbohydrate.
Modified Atkins Diet (MAD) – 2 : 1
The Modified Atkins Diet has a 2:1 ratio and is only 60-65% fat. It is used in specific mental health conditions that do not require the higher levels of ketones produced by a 3:1 ratio. Many Psychiatrists transition stable patients from a 3:1 to a 2:1 ratio for easier long-term maintenance.
Calculating Ratios Based on Caloric Density
As a Dietitian, the first step is to determine the individual’s energy needs (kcal). Then, I calculate the specific grams of fat, protein, and carbohydrate required. Meals in therapeutic ketogenic diets are much smaller than conventional meals because fat is much more calorically dense, providing 9 kcal/g, whereas protein and carbohydrate provide only 4 kcal/g.
The Importance of Medical Oversight
Following a ketogenic diet must be done with the knowledge and oversight of one’s doctor—especially when taking specific types of medication such as:
- Insulin (or insulin analogues)
- SGLT2 inhibitors (Invokana, Jardiance, etc.)
- Blood pressure medications (ACE inhibitors, Beta-blockers)
- Psychiatric medications (Lithium, Antidepressants, etc.)
Dr. Palmer suggests that individuals should trial a therapeutic ketogenic diet for a period of three months [4]. If the doctor finds that the diet is helping, they may begin to gradually discontinue some medications. Changing dosages of medication is not something people should do on their own. Taking “cheat days” is not an option in a therapeutic context; breaking the diet can cause symptoms to reappear dramatically as ketosis is lost [8].
Steps to Getting Started
Learn about me and the types of therapeutic ketogenic diets that I design as adjunct therapy for mental health conditions, and which are implemented under a doctor’s oversight. View my Therapeutic Diet Services page.
If you are thinking of adopting a therapeutic ketogenic diet for improved mental health, discuss it with your doctor first. If your doctor is willing to oversee your health and medications while you adopt the diet, they can complete and return a Request for Medical Supervision Form to our office, available at the link directly above.
To your good health!
Joy
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References
- Danan, A., Westman, E. C., Saslow, L. R., & Ede, G. (2022). The Ketogenic Diet for Refractory Mental Illness: A Retrospective Analysis of 31 Inpatients. Frontiers in Psychiatry, 13. [https://doi.org/10.3389/fpsyt.2022.951376]
- Sethi, S., et al. (2024). Ketogenic Diet Intervention on Metabolic and Psychiatric Health in Bipolar and Schizophrenia: A Pilot Trial. Psychiatry Research, 335, 115866. [https://doi.org/10.1016/j.psychres.2024.115866]
- Campbell, I. H., et al. (2023). A Pilot Study of a Ketogenic Diet in Bipolar Disorder: Clinical, Metabolomic and Magnetic Resonance Spectroscopy Outcomes. medRxiv. [https://doi.org/10.1101/2023.10.23.23297391]
- Palmer, C. M. (2022). Brain Energy: A Revolutionary Breakthrough in Understanding Mental Health—and Improving Treatment for Anxiety, Depression, ADHD, PTSD, and More. BenBella Books. [https://brainenergy.com/]
- Sarnyai, Z., & Palmer, C. M. (2020). Ketogenic Therapy in Serious Mental Illness: Emerging Evidence. International Journal of Neuropsychopharmacology, 23(7), 434–439. [https://doi.org/10.1093/ijnp/pyaa036]
- Norwitz, N. G., Sethi, S., & 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]
- Kossoff, E. H., et al. (2020). Ketogenic Diet Therapies for Epilepsy and Other Conditions: Seventh Edition. Springer Publishing. [https://www.springerpub.com/ketogenic-diet-therapies-for-epilepsy-and-other-conditions-9780826149589.html]
- Puder, D. (2022). Episode 163: Dr. Chris Palmer: Ketogenic Diet for Mental Health. Psychiatry & Psychotherapy Podcast. [https://www.psychiatrypodcast.com/psychiatry-psychotherapy-podcast/163-treating-mental-health-disorders-with-a-ketogenic-diet]
© 2025 BetterByDesign Nutrition Ltd.
Joy is a Registered Dietitian Nutritionist and owner of BetterByDesign Nutrition Ltd. She has a postgraduate degree in Human Nutrition, is a published mental health nutrition researcher, and has been supporting clients’ needs since 2008. Joy is licensed in BC, Alberta, and Ontario, and her areas of expertise range from routine health, chronic disease management, and digestive health to therapeutic diets. Joy is passionate about helping people feel better and believes that Nutrition is BetterByDesign©.