Note: This is a transcript of an interview with Dr. Bret Scher, MD FACC, Dr. Georgia Ede, MD, and Matt Baszucki. Dr. Ede is a Harvard-trained, board-certified psychiatrist who specializes in nutritional and metabolic psychiatry. Matt Baszucki used nutritional ketosis in conjunction with other therapies to lower his medication dosage and improve his bipolar I symptoms.

If you start a ketogenic diet or begin therapeutic nutritional ketosis to treat bipolar disorder, depression, schizophrenia, anxiety, or another psychiatric illness, it’s important to consider how to manage your medications. We get asked about this frequently, and in this discussion, we hope to dive into the topic further to better understand how providers and patients think about tapering medications in general, and then, specifically how they think about it for people using nutritional ketosis to treat their psychiatric symptoms. 

That’s one of our goals at Metabolic Mind: to educate and inform people about all things relating to metabolic psychiatry. We’re not providing specific medical advice. 

But before we dive in, let’s clarify that we’re not advocating people stop or taper their medications. We want to stress the importance of working closely with a prescribing physician when discussing medication changes because every person is different, and tapering strategies must be tailored to each specific individual according to their goals, their response to adjustments in both lifestyle and medication levels, what medications they’re on, where they’re starting from, and a lot of different things. 

So let’s get into the details about managing psychiatric medications when on a ketogenic diet. One important point is that, whether you’re on a ketogenic diet or not, many psychiatrists will follow the principle that they want to use the least number and the lowest dose of medications required to manage symptoms. Psychiatrists, in that way, are all trained in tapering medications, as you’ll hear from Dr. Ede. 

Much of the information shared in this discussion is relevant to tapering strategies in general, not just specific to those employing nutritional ketosis as an intervention. But first, a reminder, Metabolic Mind is a nonprofit initiative of Baszucki Group. We explore the intersection of metabolic and mental health and metabolic therapies like nutritional ketosis as treatment for mental illness. Our channel is for informational purposes only. We’re not providing individual or group medical or healthcare advice or establishing a provider-patient relationship. Many of the interventions we discuss can have dramatic or even potentially dangerous effects if done without proper supervision. Consult your healthcare provider before changing your lifestyle or your medications. 

We know from individual and group case studies, including one study in France, that patients report being able to slowly reduce medications once they’re stable with nutritional ketosis. In the French study, 64% of the participants left the treatment on less medication. 

Now, we don’t have randomized controlled trials to guide us, but because tapering medications is always based on each individual and many factors that come into play, the same principles apply whether a person is in nutritional ketosis or not. 

Many individuals find that the side effects of psychiatric medications, especially at high doses, can be problematic, so one reason to try ketogenic therapy might be to see if, by stabilizing the brain with nutritional ketosis, individuals might be able to slowly reduce the number and dose of medications needed. 

But how do you know if it’s safe to try tapering? And how do you determine a specific tapering program? How can you tell the difference between a withdrawal effect and a symptom of your disorder? 

We are joined by two experts on this topic: Dr. Georgia Ede, a Harvard trained psychiatrist with decades of clinical experience, and Matt Baszucki, an individual with lived experience who knows firsthand what it’s like to work with his providers to slowly and safely taper his medications. Both Matt and Dr. Ede agree on a few important principles: 

1. Work closely with your medication prescriber.
2. Taper one medication at a time since it’s unsafe to go off a psychiatric medication cold turkey. 
3. Slower is better even if it takes weeks, months, or even years to reduce or eliminate a medication. 

First, let’s hear from Dr. Ede. 

(Interview segment with Dr. Ede begins)

Dr. Ede, when you hear someone say they want to get off their psychiatric medications, what do you think? What goes through your mind as a clinician?

Do you mean in the context of being on a ketogenic diet? That’s the reason why they want to try a ketogenic diet: to go off medications?

Yes, so someone says, “I’m going to start a ketogenic diet so that I can get off my medications for my mental illness,” whether it’s for bipolar disorder, severe depression, schizoaffective disorder, etc.

First of all, I think it’s a wonderful goal and it’s a wonderful goal to use the least amount of medication possible. I think that’s the goal, whether you’re on a ketogenic diet or not. Practicing psychiatry for so many years, even before I started using ketogenic diets in my practice, my goal was always to use the least amount of medication that a person needed to be well and stable. 

If you want to try a ketogenic diet in hopes of using less medication or perhaps even going completely off your medication, that is also a wonderful goal, and sometimes that is possible. Some people are able to eventually completely taper off all of their psychiatric medication, some people are able to reduce the number of medications they’re taking or the dosages of the medications they’re taking, and some people are able to use a ketogenic diet instead of medications. 

If you haven’t already started a medication, sometimes starting a ketogenic diet can allow you to avoid needing to take psychiatric medications in the first place. However, there are lots of people, including in my own practice, who start a ketogenic diet. They feel a lot better. They feel better physically and emotionally, but they are not able to taper off their psychiatric medications. It’s still a major victory for most of them because the diet itself is a really healthy metabolic intervention and can really help counteract a lot of the common side effects of psychiatric medication. 

So there are different outcomes. If someone comes to me and says, “Will I be able to come off my psychiatric medication?” I say, “Well, I don’t know. This will be a process of discovery, and we’ll find out what’s possible for you, but there are lots of wonderful possibilities.” In most cases, people are happy with the outcome, but it may not always be that it’s completely coming off every psychiatric medication.

I really like how you laid out that, first and foremost, no matter what approach, you are trying to get them on the least amount of medications for the effect that they need to have, whether that’s with a ketogenic diet or without. I really like how you laid that out from the start, and how you said, even if you can’t reduce your medications, it doesn’t mean that using nutritional ketosis is a failure or isn’t working because it can still help them with the side effects or help them even feel better even on the same amount of medications. 

But what about the timing of thinking about reducing medications? Because when we talk about mental illness, it’s not one thing. You could be hospitalized with psychosis, mania, or severe depression; you could be in a relatively stable period at home; or anything in between. So when you talk to somebody about the timing of when they might want to consider or when they might not want to consider reducing medications, what are some of the general guidelines that you advise?

Here is where things get pretty specific to the individual. Let me just say, generally speaking, if all is going well and the person has transitioned well to the ketogenic diet, has tolerated the diet well, they’re feeling good… And I haven’t seen any problems come up in terms of the combination of the diet plus the medication, which is something we can talk about later, but let’s say everything’s gone smoothly. The earliest time frame that I like to begin looking at potentially reducing one of the medications is 6-12 weeks after they have been on the ketogenic diet. The earliest, at least in the epilepsy literature, is usually four weeks in. I like to wait at least six weeks. Ideally, I like to wait twelve weeks. The reason for that is that, at twelve weeks, you are more likely to be looking at a new equilibrium for your body and your mind to really be in a solidly new place, different from where they were before, metabolically, chemically. So you’re not only more likely to be looking at a new, stable equilibrium, but you’re also more likely to be comfortable with the diet. You’ve gotten some practice with the diet and you’ve had a chance to decide whether it’s a diet that you want and that you think you want to stay with for a longer term. 

If you’re just experimenting with the diet and you’re going on and going off, once you start making medication changes, it’s really kind of a tricky situation. You want to be in a place where you’re feeling more committed to staying on the diet longer term because, otherwise, you’ll be going back and forth with your prescriber saying, “Oh, I went off the diet. Do I need to raise the medication again?” 

So I like to wait at least 12 weeks. That’s in an ideal and smooth situation, but there are lots of things that can come up as you’re going along that might make it reasonable and sometimes even necessary to reduce the medications earlier. That’s why it’s so important to work with your prescriber when you’re doing this because you can sometimes see medications can start to feel uncomfortable in combination with the diet, so they might need to be reduced or the level of the medication might change in combination with the diet. Side effects can come up, so sometimes, the medications need to be adjusted earlier than that, but if everything’s going smoothly, I personally like to wait 12 weeks.

I like the way you said that: that they should be stable and committed to it because, in a way, the ketogenic diet’s like another medication. If you just stop taking your medication, it’s the same as just stopping your diet because you come out of ketosis, which changes your body’s physiology. I don’t think it’s something people necessarily think of like, “Oh, I could just start a ketogenic diet and I can taper my medicines without really thinking it through” or, “Am I going to be on this long term to help me stay off or stay on lower doses of medication?” I think that was well said. 

You talk about how there are lots of specifics with the medications. Some you need to taper sooner. Some you need to be more concerned of. I know none of this is individual medical advice and none of this is meant for someone to take and do on their own.

Right.

But rather, individuals need to discuss this with their clinician, but are there medications where you think, “Okay, these are the first ones I want to get people off, and these are the ones I want to save for later or be the last ones to get them off”? On either end of their spectrum, are there medications that fit those buckets for you?

No, and here’s why: there are specific questions you can ask yourself and that you can work with your clinician to answer. There’s no one correct order in which to approach medication tapering, and the reason is that most people, unfortunately, for better or for worse, are taking more than one psychiatric medication. If there were just one involved, then, of course, that would be the one that you would start to taper when you felt ready to do so, but most people are taking more than one. 

That’s where this question comes in: where do we begin? And it really depends on several things that are specific to that individual. Let’s say that you, Bret, come to me, and you are taking an antidepressant, you are taking an antipsychotic, and you’re taking an anti-anxiety medication. Regardless of what the names of them are, I’m going to ask you some questions about those medications so that you and I can decide together which one we are going to start working on first. I’m going to ask you, “Which one of these medicines do you wish you could stop first? Is one of these bothering you a lot? Are you having a lot of side effects with one of these? What’s your wish list? If you could just pick one, which one would you want to stop?” 

But that’s not the only important thing. That’s important, but not the only important thing. Another important thing is when you look at these medications, these three medications that you’re taking, can you tell me what those medications have done for you? Is there any one of these medicines that you view as particularly important to your wellbeing? Did one of these medicines help keep you out of the hospital? Did one of these medicines help keep you from harming yourself? Do you view one or more of these medicines as being particularly crucial to your well-being? That’s the one we’re going to taper last, if you see what I mean. 

The third consideration is: which one of these medicines is the easiest one to taper? Some, you can taper more quickly than others and some are more complicated. Let’s say that you don’t view any one of these medicines as particularly crucial to your well-being. They’ve all been somewhat helpful. You don’t have a favorite one that you want to stop first and you say to me, “Well, Dr. Ede, which one would you pick first?” I’m going to pick the one that’s easiest to taper first. For example, if your antidepressant is Wellbutrin, Wellbutrin is a lot easier to taper than say Paxil (paroxetine), which can take, in some cases, weeks or even months to taper off comfortably and safely. Why not go for the low-hanging fruit first if all of the things are created equal?

Yes, and you mentioned the timeline: weeks to months, depending on the medication. This brings up the concept of: how quickly can I get off my medications? Not just can I, but how quickly? 

What are some of your concerns of going too fast? And then, on the flip side, are there concerns with going too slow?

No concerns with going too slow, unless a medication is really giving you a lot of side effects. For example, if I’m working with somebody who’s taking a medication and they start the ketogenic diet and the medication starts to feel strong as though they’re having a lot of side effects from it, I’m going to target that medication first. I might even need to taper it a little bit more quickly than I otherwise would if I’m concerned about a serious side effect emerging. 

Again, that’s why it’s so important to work with somebody who really knows medications and who knows you. Sometimes, that’s necessary. That’s not very common, but it happens enough to be worth mentioning. 

The other thing about timing is that each medication’s a little bit different. Most psychiatric medications must be tapered slowly rather than stopped abruptly. A person should never, never stop any psychiatric medication abruptly and never stop a psychiatric medication without talking to the clinician who’s prescribing that medication for you. That’s not just some legal disclaimer that I’m just saying to be generically safe or legally protect myself. It’s for your safety because tapering medications, in some cases, if you go too fast, can cause either extremely uncomfortable, extremely uncomfortable side effects, or can even be medically dangerous if you stop them too quickly. 

Here are a couple of examples. If you’re tapering a serotonin reuptake inhibitor, these are really common medications prescribed for depression and anxiety. Say it’s a medication like Paxil or Zoloft. Those are both good examples of serotonin reuptake inhibitors. Lots and lots of people take medicines in that family (Lexapro, Zoloft, etc.). You would think, “Well, that’s just an antidepressant. That’s not a problem. I can just stop that.” 

The problem with the serotonin medications is that, if you stop them abruptly, you can have really uncomfortable and sometimes psychiatrically dangerous side effects if you do that. For example, you can experience things like dizziness, headaches, nausea, nightmares, and sleeplessness, but you can also experience agitation, depression, and anxiety. You can even experience these very strange symptoms that are referred to as brain zaps. People have all kinds of very strange physical and emotional side effects when they’re trying to stop a medication in the serotonin family too quickly. 

You might say, “Well, how quickly is too quickly?” It depends on the person. So some people can stop these medications within a few weeks. Others may take many months and they have to go down extremely slowly in tiny increments. It’s very individualized. If you stop those medications abruptly, it can cause a lot of psychiatric distress. 

There are other medications that also cause distress. A good example would be the benzodiazepines medications. These are medications like Xanax, Ativan, and Klonopin. These are medicines which are prescribed very commonly for anxiety and sleep. These medications, if you stop them too quickly, you can actually put yourself at risk of having withdrawal seizures, and all kinds of other really uncomfortable symptoms that can be life-threatening. If you have a seizure when you’re driving or you have a seizure when you’re climbing a ladder, this is a very dangerous situation, so it’s very important to taper these medicines slowly. In a lot of cases, the slower, the better. 

Again, as long as it’s not causing you any side effects where we need to go faster, slower is always better. Do it in small increments. Wait long periods of time between each dosage drop and really make sure that you’re feeling solid before you take the next dosage down. This is the kind of thing that, honestly, requires a lot of clinical experience with medications to be able to do comfortably with people. You really want to work with somebody who knows you and who knows medication as well.

Yes, it sounds like it takes experience from the clinician’s standpoint and patience from the patient’s standpoint.

Yes.

A person really cannot be in a rush to do this. The risks of going too fast seem far greater than the risks of going too slow. 

In our interview with Matt Baszucki, he talked about his difficulty weaning off his benzos and how it was very challenging. He had to go very slow. Now, interestingly, the other thing Matt brings up is the importance of monitoring his sleep. Since he’s specifically coming from a bipolar standpoint with a bipolar I diagnosis and he’s been prone to mania, monitoring his sleep was so important. If he noticed that he was getting less sleep, which he was tracking vigilantly, he would know, “Now is not the time to decrease more. Actually, I may need to go back.” 

I’m using that as an example, so what advice do you give to people on what they should be monitoring in their own life? Some side effects are going to be very obvious and some are going to be a little more subtle. To pick up on the subtle hints that may imply something is creeping up, what kind of advice can you give?

So again, and I hate to sound repetitive, but it really depends on the individual because… The question you’re asking is very, very important because it brings up two questions: When you’re tapering a medication, how do you tell the difference between your old symptoms coming back because the medication dosage is now too low for you, so you need to back up and stay on a certain amount of medication? And how do you tell when it’s because you’re going too fast you’re getting withdrawal effects? 

Let’s say, for example, you had mentioned that Matt followed his sleep really closely. When his sleep started to feel a little rougher, he knew that was a sign that he might be going too quickly with the medication or that it might not be a good time to make another change. That’s a great example. 

When you’re trying to taper medication, one of the most challenging things to do as a psychiatrist, whether your patient is on the ketogenic diet or not, is to figure out, “Okay, we’ve just made a change in the medication. The person is feeling a little worse in some way. Is that because we’ve gone too fast with the taper and we need to slow it down? Are they having withdrawal symptoms from the medication? Or are their symptoms coming back and this is a sign that they actually need to go back to that previous dose because that’s the amount they’re going to need to feel well?” 

This is why all of this is so personalized and individualized. Having a lot of experience can help you figure that out. It’s not foolproof, but having a lot of experience can help you tell the difference between what a withdrawal symptom is and what is a sign that the medication may need to be continued. 

The bottom line is, if you’re going very slowly and you’re using small increments and you’re lowering the medication by small amounts and you’re really, really patient, it’s a lot easier to tell the difference. First of all, if you’re going very, very slowly, it’s a lot less likely that you’re suddenly going to see all your symptoms come back. It’s much more likely, if it’s within two or three days of lowering that dose, it’s almost always a withdrawal side effect. These are the kinds of things you notice. 

You asked: which types of things should you monitor? For example, Matt was monitoring his sleep. That, again, depends on the person. What withdrawal symptoms do we know about that particular medication? For example, a lot of seizure or anticonvulsant medications are used in psychiatry, and the benzodiazepines we talked about are often used in psychiatry. If you’re tapering a medicine like that, you’re going to watch for withdrawal symptoms from those medications, which are very different from withdrawal symptoms from antidepressants. 

We’re going to monitor for specific withdrawal symptoms that are characteristic of each medication and we’re also going to watch for the types of symptoms that have been problematic for you in the past. So we’re watching for two things: we’re not only watching for withdrawal symptoms on the medication, but we’re also watching for signs that your condition is worsening and that some of the old symptoms that used to bother you before you started taking medication are starting to come back. This is why a personalized approach is so important.

Yes, I think you’ve done a very good job of explaining why this is a difficult process. A doable, but difficult and careful process that needs to be individualized, and there isn’t a cookbook way to do it.

That brings up the question: will physicians and/or psychiatrists be able to do this with their patients? Now, I’m sure there are some psychiatrists who would rather take the approach of, “Nope, You’re stable on your medications. I don’t want you to reduce any doses. It’s not worth the risk.” Have you encountered psychiatrists or physicians like that? And what kind of advice could you give if someone experiences that with their clinician?

It’s a really common concern and I can see both sides of it, honestly. I can see the patient’s perspective where they’re feeling better on a ketogenic diet and they really want to begin tapering their medications. Of course I understand that and want to support them in that goal, but I can also see the psychiatrist point of view, where tapering a medication has some risk involved. As I was just describing, it’s time-consuming. It’s going to take more visits. It’s going to take more time and energy. Psychiatrists, most of them are really busy. While you’re tapering a medication, they might need to see you once a week for a while. They might hear from you on a messaging system or they might call you or send you messages a lot more frequently. If you’re a busy clinician, that becomes something that’s tricky. Why would you want to take the extra time to do that? 

So I do understand both sides of it, but all psychiatrists have experienced tapering psychiatric medications. It’s part of what we do, mostly because, unfortunately, even in 2023, prescribing psychiatric medications is almost entirely a trial-and-error process. 

When we’re trying to find a medication that works for somebody, we are trying, hopefully, one at a time, very slowly and patiently, to find something that helps. Every time we stumble upon something that doesn’t help, which happens a lot, we have to taper that medicine off and start a new one, so we have a lot of experience tapering psychiatric medications. 

One of the things I like to do is have a conversation with the psychiatrist and say, based on my working with this particular person, I think they are in a really different place now. I think they’re a lot healthier. Their symptoms seem to have decreased, physically and emotionally. I think this person’s in a much better place. I think they’re ready to try this, and so I think it’s really worth the time and energy.  

I try to come at it from that point of view of being encouraging and supportive, but I also remind the patient that the ultimate decision about what you decide to do really does rest with you. You need to have your psychiatrist or your nurse practitioners, your prescribing clinician. You need to be working with somebody who wants to support you. 

But let’s say you are working with a psychiatrist or a nurse practitioner who doesn’t have the time to help you taper the medication or doesn’t think it’s a good idea. You do have the option of looking for somebody else to work with who would support you, although that can be really challenging. It can be really challenging to find somebody who takes your insurance, who has openings in their practice, or who is willing to work with somebody who’s on a ketogenic diet. 

This is why I’m so delighted that the Metabolic Mind organization exists because one of the things we’re all working on together is to help more people learn about these strategies and train clinicians. I train clinicians how to work with ketogenic diets and medication management in hopes to get information out to more people so that there’ll be more and more clinicians who feel comfortable working with these strategies. 

Also, we have a small, but growing clinician directory where people can look for prescribing professionals as well as other types of professionals who are keto savvy and willing to work with you on these things. We need many more clinicians who do this, but I would say what’s most important is to try to convince the clinician you are already working with of the reasons why you want to do this for your health. You’re willing to work with them, to be patient, to follow their instructions about how to taper the medications, and that you really are trying, as I think all psychiatrists would agree is the best idea, to use the least amount of medication necessary. Hopefully, they’ll share that goal with you.

I think it is really commendable that you have your CME course and that you are training clinicians how to use a ketogenic diet within metabolic psychiatry.

At the same time, a physician to help you taper your medications does not have to know about the ketogenic diet and how to use a ketogenic diet. I like how you said every psychiatrist has experience with tapering medication, so every psychiatrist can help you. Going to diagnosisdiet.com/directory to find someone who’s taking your training course is a great place to find clinicians, but not necessary. There are other clinicians who should be able to help with the tapering.

That’s right. If you’re already stable on a ketogenic diet and you’ve already gone through the transition phase (or the keto adaptation phase) and you’ve come to your new metabolic equilibrium and you’re feeling well, any psychiatrist can help you taper your medications. They don’t need to know anything about the ketogenic diet to do that. That’s a really good point.

Nevertheless, that’s not the response that I usually get from psychiatrists. I think there is a lot of hesitance about working with somebody who is on a ketogenic diet because there’s not a lot of familiarity, so it can feel uncomfortable, if you’re a clinician who doesn’t have any experience or knowledge about these diets, to work with somebody who might know something more about ketogenic diets than the clinician themselves do. 

I think that’s a fair point, but as you said, if the person is already stable on a ketogenic diet, you don’t need any special knowledge about a ketogenic diet to taper a psychiatric medication.

Very good. I really appreciate you taking the time and sharing this information because this is such an important topic. I can understand people wanting to get off their medications, but it really could be a risky situation. It’s measured, authoritative, and educated voices like yours that are so necessary for people to understand that there is a safe way to do this and it needs to be done in conjunction with an experienced clinician. People should not be doing this on their own. There are real risks involved, so thank you so much for taking the time and giving us your knowledge and your experience.

You’re very welcome. Thanks for the great questions and I hope people found it helpful.

(End of Dr. Ede’s interview segment)

You can hear from Dr. Ede’s answers how this approach needs to be individualized. That’s one of many reasons we don’t want you to think that, just by reading this discussion, you’re able to reduce your medications. Hopefully, her answers impressed upon you the importance of working with your prescribing physician and how just about every psychiatrist should have some level of comfort in helping their patients reduce medications safely when appropriate. I really appreciate her providing that realization. 

Next, let’s hear from Matt Baszucki about his personal and ongoing journey with his medication tapering. 

(Interview segment with Matt Baszucki begins)

Matt, we hear a lot of people who are taking medications, whether it’s for depression, bipolar disorder, or schizophrenia, hope they can find a way to get off those medications or at least to reduce the dose. You have personally gone through this. 

First, I want to thank you for taking the time to share your personal story and your personal journey with us. I want you to go back to the point where you first thought, “Maybe I can start to taper my medications.” What was that like? What was the motivation? What was the thought process like when you go back to that point?

I remember the point when I realized I might be able to taper these was, I would say, about 2018 when I had a moment of insight and I started to establish some healthy habits, like exercising regularly and taking better care of my sleep. Not perfect, but better. 

What I realized was that some of those habits could serve as buffers, where if they were in place and they were consistent, I might not need as much medication. I was able to start to come off an antipsychotic and the benzodiazepine I was on, Ativan. I ended up doing a cross-taper over to Valium, and then coming off that. That was very challenging for me.

I still needed medications. I still needed Zyprexa, the antipsychotic, to keep me from going manic, especially in March. That was a pretty consistent thing. I still depended on medications, especially Zyprexa, to bring me back whenever I would start to go into some sort of hypomanic episode. I would start to sleep less and less every night for a period of consecutive nights, three or four. Then, I would take extra Zyprexa and I would have a long sleep. This was happening consistently throughout 2018 and 2019 and into and even 2020. 

So I was coming off some of them and my parents and I, with the help of the psychiatrist, were playing around with different medications. We just couldn’t find the right balance. I wasn’t on keto at the time. I didn’t go on keto until 2021. I just depended on the antipsychotics and the mood stabilizers to keep me from going into a hypomanic episode consistently, especially in March, but throughout the entire year. 

When I realized I could really taper these was when I went on keto, which was in the beginning of 2021. I went through that March on a much lower dose of Zyprexa, five milligrams a day, which was about 25% of what I had been taking previously. I realized that this might be possible. I was able to accelerate the benzo taper. I was able to get off the benzos that fall, which was in October of 2021. It was really challenging, but I managed to get off them. 

I’ve no doubt that keto played a major part in my ability to get off them. It was challenging. I’m on a little cocktail of a few meds, but the doses are really low and the side effects are minimal. A recent challenge has been getting off lithium, which has been going very well down from 1,500 to 600.

To answer your question, I think when I really started to put the sleep hygiene, the exercise, and some of the other organic mood stabilizers in place and really take them seriously was when I realized I might be able to get off some of these.

But it sounds like it wasn’t until the dietary approach really kicked in and you were a nutritional ketosis that you were able to speed it up to a degree. It is a super interesting journey, how that happened. 

But I want to go back to what you said when you were starting to come off the antipsychotic, the Zyprexa. It sounds like you needed to be very aware if you were starting to become hypomanic. You had to have great insight to that to say, “I need to go back on.” How did that come about? Was that from your psychiatrist? Was that from your family? What was the way you could really stay connected to say, “Okay, something’s happening here,” or, “I think I need to go back up on the medication”?

That’s a great question, Bret. I’ve been tracking my sleep for years. I track it every night. I have an Oura ring, which is very good. Before I had the Oura ring, I would just track when I fell asleep and when I woke up, and I would look at the time I spent asleep. Particularly, I think for people with bipolar I disorder, this might be especially useful: I would look at whether or not I had slept less than the night before. If I saw two, three, or four consecutive nights where I had slept less each night, I knew something was up. 

Because I was so meticulous about tracking my sleep, I was able to catch these types of manic episodes before they really escalated and before I lost insights. For those couple years when I wasn’t on keto and I was relying on the medications to keep me stable, I was still able to catch all of these episodes before they took me away. I was very fortunate, and it was only because I kept track of my sleep in writing and I looked at that log consistently. I knew that the only way I would be able to stay stable at the time – because I didn’t have keto, I didn’t have that resource – was to just watch for less and less sleep over consecutive nights.

Such an important message. I think a lot of people probably think in their brains, “Oh, these people have come off their medications. I can do it, too. All I have to do is be smart about how I taper, and that’s it.”

But no, it’s so much more involved. You had that meticulous nature. You had that commitment to measuring your sleep, which was really so important. It’s such an important lesson that you still have to be vigilant, and it’s not a straight line. You go down a little. You go up a little. You go down a little. You go up a little. As long as the trend is overall down, you’re progressing, but it’s not a straight line. It sounds like your journey was like that as well.

Then, once you were in nutritional ketosis, you were able to taper the doses a little bit more effectively. Give us a timeframe. You said you went down in lithium. You went down in Zyprexa. But over what timeframe did you reduce 50% of the dose or 75% of the dose? Because I want to get that concept of how long that took.

It’s a long process. It took me a long time. I had been coming off the benzos for a couple of years at that point, and I was able to get off them. In about nine months, I was down to a low dose of benzos. I tapered them very, very slowly with a compound pharmacy tapering 0.1 milligram of diazepam per week or a couple times a week. Whatever it was, it was really, really slow.

So 0.1 milligram.

I think I was doing 0.1 every week or 0.1 twice a week towards the end, so I decelerated the rate of the taper towards the end of the taper. I was able to drop a milligram towards the beginning when I was on a high dose, but if you take a milligram off 50 milligrams, that’s 2%. If you take a milligram off 10 milligrams, that’s 10%. Suddenly, you’re tapering effectively five times as much. The rate of the deceleration needs to be less. 

So I did it. I slowly slowed, slowed, slowed, slowed, and I was eventually able to get off them. 

The point is this was a long, long journey. The Zyprexa was 5 milligrams a day at the time, and it was my mission to come off of the 5, down to 2.5. That took a long time as well. I think that took about… I want to say it took about seven or eight months to get from 5 to 2.5 milligrams. Again, using a compound pharmacy, 0.1 milligram a week over six months. I’m on 2.5 now. 

I did the Zyprexa from 5 to 2.5 in 2022. Then, in 2022 again, I started the lithium taper about six months ago, five months ago. I’ve gone from 1,500 down to 600 milligrams of lithium, which is kind of crazy. It’s remarkable how few manic symptoms I’ve had. This is March right now, and I haven’t seen any symptoms. I’m watching very carefully, but I haven’t seen any yet. 

It’s a really, really slow, careful process of doing one medication at a time, changing one variable at a time, doing them with the help of a psychiatrist as well as keto, obviously. 

I hope, by the time I’m 30, 31, I’ll be off all of them, which will be 4-5 years from now. We’ll see. I’m not in a rush because the side effects are relatively minimal now. I’m also on a low dose of Equetro and isradipine. They’re very low, so it’s a little cocktail, but the doses are low and side effects are minimal at this point.

It’s really impressive to hear how slow it is. I think that’ll surprise a lot of people.

And I like what you’re saying: there’s no rush. What’s the rush? Because you got to the point where the side effects are minimal. I want to ask you about that, but, first, I want to go back to what you said about tapering by percentage, rather than dose. I think that is so important because we frequently say, “You’re on 50, go to 25. You’re on 25, go to 12. You’re on 12, you can stop.” But that’s just too simplistic of a concept because the percentages probably make more of a difference, but not everybody’s on board with that. Is it difficult to work with your psychiatrist to get that concept of going by percentage, rather than by dose? Or how’d that come about?

My dad and I are very math-oriented thinkers, so we really planned this out. I understood that, just thinking about this logically. My experience informed me as well, especially with the benzos, which caused me horrific side effects when I was tapering off them and was actually quite terrible. 

I was able to take one milligram off of a 50 milligram dose of diazepam when I was on that, but taking one milligram off of four or five milligrams is just impossible because you’re basically taking out 10 times as much relative to what you’re on. So we were tapering by percentage, rather than absolute amount of the medication. Rather than taper one milligram per week for one year to get off 50 milligrams, maybe I would taper 3% per week or 2% per week, and then just do the math and calculate how much that would equate to. 

My experience, having tapered quite a few medications, is that the body responds to tapering a consistent percentage of the medication, or at least I’ll say my body responds to it as though the taper is consistent. If I taper one milligram, one milligram, one milligram for six months, my body doesn’t feel that’s a consistent withdrawal of the medication or a consistent taper. But if I taper 1%, it feels like the same amount of meds or the effect of the med on my system is lessening by the same amount every week. I think it was so important for me to do that.

So what’s an example of a time that maybe you went a little too fast and your body let you know? Give us an example of that.

The Valium towards the end. I just remember there were a couple weeks where, maybe I’m on 10 milligrams of diazepam, and I said, “Okay, I think we could try to drop it to 9 mg this week or we could drop it to 9.5 mg,” and I would just have a really, really, really terrible withdrawal. I had to learn the rate at which my body could handle these tapers, especially the benzo and the Zyprexa, which also caused me withdrawal. The lithium has not, but those two did. 

I gradually learned, through trial and error, how much or what percent of these meds I could taper on a weekly basis and still be okay. It was impossible to prevent the withdrawals entirely, but there were many times where I just did a little too much. I would feel it and I would say, rather than go up – which I never did, I actually never went back up – I would just say, “Okay, for the next dose, we’re either going to decrease the amount or we’re going to wait a little longer to do it. Maybe we’re going to wait two weeks instead of one week, or we’re going to taper 0.5 mg instead of 1 mg.” Those are the two mechanisms by which I could effectively decrease the rate of the taper. 

It was just very slow progress and trial and error. These are really challenging meds to taper. Benzos are very, very challenging to get off. This is a tangent, but it’s very sad that the psychiatrists tend to put people on these like candy, especially the diazepam (Valium). I was humbled and I had to be very careful, but I eventually got off it, and I think keto can make it easier to taper some of these.

So how’s your quality of life changed since you’ve been able to taper your medications?

It’s night-and-day. I remember this summer in 2016, when I was on 10 or 15 milligrams of Zyprexa, 20 milligrams, something very high. I was on 20 milligrams or more when I was in the psych ward. It’s just not… it’s not a life worth living. The weight gain, the lethargy, the fatigue, the brain fog, I really couldn’t live. I couldn’t function. I couldn’t do any of the things I liked to do. I had no motivation to get outside, get active. It was just a flywheel of frustration because I couldn’t improve in those elements. 

But my experience of life now, having gotten off some of these – not all the way off, but off them enough to the point where I can more or less live – it’s just next level. I’m so excited to see what’s going to happen when I eventually get off them because maybe I am still sedated to a certain extent and I don’t realize it. It’s been so long since I was entirely off medications. So relative to the high doses I was on – 20 mg of Zyprexa, 1,500 mg lithium, and all the other meds I’ve been on – this is an amazing experience of life.

I would encourage people out there to really give this a shot. I did it under the supervision of a psychiatrist, very slowly. I think this is such an important point. I’m glad I was working with intelligent people. I didn’t just go on keto in 2021 at the beginning of the year and, three weeks later, expect to just drop all these medications. I didn’t do that. It’s still been a very, very slow process, but I’ve been able to get off them.

It sounds like you really hit the right level because you improved your quality of life by diminishing the side effects without going so far that you wound up back in the hospital, manic, psychotic, or severely depressed as can happen if you go too fast. You did that by being very meticulous about it and working with your doctors. I like the advice that you give: that it has to be a team approach. 

And also there’s this concept of a compounding pharmacy. I’m sure a lot of people haven’t even heard of a compounding pharmacy before because they’re not all that common. And to be able to get off of 0.1 milligram, or even 1 milligram, of a medication is not all that common. Was it challenging to find a pharmacy to do that? Or what advice would you give for somebody to be able to take such small tapers?

I worked with my parents on this pretty extensively and I think, towards the beginning and the middle of a taper, it can be possible to just taper the minimal dose that a normal pharmacy will prescribe. It’s possible to just taper that dose for me, but especially towards the very end, like I said, coming off that last 1-2 milligrams of the benzo, I knew that if I just dropped the last milligram in its entirety and tried to go on, the withdrawals were going to be terrible. They were going to be terrible. I remember even tapering the last couple milligrams going by 0.1 milligrams. Maybe I did 0.1 milligrams for five months, or four months, or whatever it was for those last two. 

I think there’s something to be said for the psychological effect of having to taper more slowly as you reach the end of the taper. The first few weeks can be very fast because you’re going 50, 49, 48, 47. Before you know it, you’re at 45 and 40 milligrams. It’s very encouraging, but those last 2-3 milligrams of the benzo for me were so difficult and took a long time. I had to be patient but I would say that the compound pharmacy and prescribing the pills of 0.1-milligram increments were crucial for the last few months of the tapers. 

That was also helpful for me to map the trajectory of my taper on a spreadsheet so that I knew roughly where I was going to be at certain weeks. I knew how much to ask for from the compound pharmacy, whether that was a collection of 0.5 milligram pills and a collection of 0.1 milligram pills that would allow me to take the proper amount for successive weeks. Those were some of the things I did that made it easier, although both Zyprexa and the diazepam were not easy.

Yes, it’s a great point though. Maybe, in the beginning, you don’t need to work with a compound pharmacy, but as you’re getting closer to the smaller doses, that’s when it’s much more crucial. I appreciate that message.

Now, what about someone who says, “Look, I can do this with lifestyle. Medications are evil. It’s big pharma, and nobody should need those medications. It can all be done with lifestyle.” What kind of advice do you give for someone who’s approaching it that way?

For someone who’s already taking medications, I know that the effect of coming off medications too quickly can just be really dangerous. It can be really dangerous. 

Unfortunately, I have to offer some advice here, but I was on meds and I think I was stuck. It was like, “I’m on meds. There’s no way I can really come off of these rapidly without danger to my health and a risk of having a manic episode, so I just have to come off them slowly.” 

Now, if you have maybe an undiagnosed permutation of the illness where you’re not on meds and then you’re starting keto, I can’t really speak to that because I haven’t done that myself. But what I will say is that, in my opinion, the effects of coming off a medication rapidly and the risk is far more dangerous than taking it for a few months and just coming off it at a normal pace and watching for any psychiatric symptoms that might come up. I really do believe you just got to bite the bullet and do this a little bit slowly.

I think that’s great. Did you have anything else you wanted to share that we didn’t touch on?

Yeah. I just encourage people to have hope and keep pushing. This is really not an easy thing to do. Getting off some of these meds is a really, really challenging thing to do. Even in my experience, doing keto, doing everything right, getting off them is hard work. To get off a medication and avoid the symptoms along the way and then come out healthy and robust is an accomplishment that a lot of people without a diagnosis or people who’ve not taken these probably wouldn’t understand, but keep on pushing, guys.

All right, thank you. 

(Matt Baszucki interview segment ends)

There you have it: two very detailed, thoughtful approaches to reducing psychiatric medications after being in nutritional ketosis. 

Can you reduce your psychiatric medications after starting therapeutic nutritional ketosis? Possibly, but please don’t do it on your own. Instead, work with your provider. If they’re hesitant, send them this interview. Sometimes, doctors just need a little push to try something outside of their comfort zone. 

For even more helpful resources, Dr. Ede wrote a guide in Psychology Today titled “Ketogenic Diets and Psychiatric Medications.” Consider printing it out and sharing it with your clinician as well. 

And remember, as Dr. Ede mentioned, all psychiatrists are trained in tapering medications. If you can approach it with the patience and the vigilance like Matt Baszucki does, that could go a long way in helping your provider feel comfortable working with you on tapering and adjusting your medications. I would suggest not seeing medication reduction as an automatic guarantee after starting nutritional ketosis, but rather as something that you may be able to achieve once you’re stable in ketosis and once you put in the effort and have the teamwork. 

We hope to return to this topic with more perspectives soon, so stay tuned because this is an ongoing and very popular topic. 

Thank you and we hope this was helpful. Have a wonderful, healthy day. I’m Dr. Bret Scher, and we’ll see you here next time at Metabolic Mind.

• Danan, Albert, et al. “The Ketogenic Diet for Refractory Mental Illness: A Retrospective Analysis of 31 Inpatients.” Frontiers in Psychiatry. (2022).
• Ede, Georgia. “Ketogenic Diets and Psychiatric Medications.” Psychology Today. (2018).