A new expert consensus published in Frontiers in Nutrition marks a significant milestone in the field of metabolic psychiatry. Developed through a rigorous Delphi process, this document offers practical, experience-based recommendations for clinicians interested in using ketogenic metabolic therapy (KMT) as an adjunctive approach to support individuals living with serious mental illnesses (SMIs), including schizophrenia, bipolar disorder, and major depressive disorder.
To unpack the significance of this work, Dr. Bret Scher, Metabolic Mind’s Medical Director, sat down with two contributors to the expert committee: Dr. Matt Bernstein, a Harvard-trained psychiatrist and Medical Director at Ellenhorn and Accord Mental Health, and Dr. Georgia Ede, a Harvard-trained psychiatrist and pioneer in nutritional psychiatry. Together, they clarify what this consensus means, how it was developed, and how it can serve clinicians and patients seeking safe, thoughtful therapeutic options.
What Is a Delphi Consensus and Why Is It Important?
A Delphi process is a structured method to assess consensus in fields where research is still evolving. It’s perfect for ketogenic therapy, “a field where the clinical research isn’t yet robust enough for people to be able to draw conclusions about how they should apply [it] in clinical practice,” Dr. Ede explains.
Dr. Bernstein adds, “Sometimes clinical practice moves faster than research. So this is the perfect setting for this type of document, where clinical practice and demand from patients are outpacing the research.”
Who Was Involved?
The panel consisted of eight experts representing psychiatry, psychology, nutrition, and metabolic science:
- Georgia Ede, MD
- Matt Bernstein, MD
- Lori Calabrese, MD
- Iain Campbell, PhD
- Nicole Laurent, LMHC
- Chris Palmer, MD
- Shebani Sethi, MD
- Beth Zupec-Kania, RDN
Despite working independently, the group reached agreement on 33 core statements that help inform how KMT can be used safely and in which patient populations. These recommendations were then surveyed by a larger group of experienced clinicians to assess broader consensus, which resulted in all 33 statements meeting the consensus threshold.
The 33 consensus statements were then further distilled into 10 high-level clinical recommendations.
What the Consensus Statement Offers
Importantly, this document is not a formal treatment guideline. Rather, it provides consensus-based insights to inform clinical decision-making and research priorities.
Dr. Bernstein highlights this distinction: “We’re not saying everyone needs to do this, but I think we’re providing guidance for people who want to do this. We help identify the types of people who would most benefit from KMT, along with the most critical things that need to be measured, monitored, and thought about throughout the process.”
Key Clinical Takeaways:
Among the 10 recommendations, three stand out:
- Adjunctive Use: KMT may be considered as an adjunct to first-line treatments (e.g., medications and psychotherapy) for individuals with bipolar disorder, schizophrenia, and major depressive disorder.
- Alternative for Non-Responders: KMT may be appropriate for individuals who decline, do not tolerate, cannot access, or do not benefit from standard treatments.
- Metabolic Status Not a Barrier: Observable signs of metabolic dysfunction are not required to consider a trial of KMT.
The panel also identified contraindications, primarily rare inborn errors of metabolism, and outlined straightforward monitoring protocols. These include baseline lab tests such as complete blood count (CBC), complete metabolic panel (CMP), vitamin D, B12, and a carnitine panel.
Real-World Relevance and Flexibility
Dr. Ede notes that the consensus reflects real-world experience: “In almost all cases, we are adding ketogenic metabolic therapy to existing care, to people already in psychotherapy, already taking medications.”
When asked what clinicians need to know most, Dr. Bernstein compares the recommendations to a recipe: “Let’s think of a clinician who has some experience as a really, really good cook… But we know that a really good cook is going to individualize the recipe to their kitchen, their style, the ingredients that are most fresh that they have, and a really good clinician will do the same. They’re going to take these recommendations and apply them to the clinical situation that they’re in and be creative and work together with that individual to really come up with the best plan for that person.”
While many topics received unanimous agreement, some areas required more conversation to reach a consensus, including:
- How long to trial KMT before assessing efficacy: Three months was the agreed upon baseline.
- Whether ketone levels must remain within a specific range: It was established that many patients will require levels to be consistently maintained at 1.0 mM or higher for optimal outcomes.
- Whether a nutrition professional is required or if other qualified professionals may suffice: It was ultimately agreed that, at a minimum, a nutrition professional and a prescribing clinician with training and experience in KMT should be involved.
Ultimately, these recommendations are meant to provide a framework, not rigidly dictate care. Clinicians are encouraged to take these principles and thoughtfully apply them to the clinical situation they’re in, working creatively and collaboratively with each individual to develop the best plan for that person.
Why This Consensus Matters Now
As research and clinical interest in ketogenic metabolic therapy (KMT) continue to expand, clinicians need a thoughtful framework for safe implementation. While KMT is not yet part of standard psychiatric training, it represents a relatively low-risk metabolic intervention that may be appropriate to consider within comprehensive care. Developing consensus-based guidance is an important first step in helping practitioners apply these approaches responsibly while we await results from ongoing randomized controlled trials.
Dr. Bernstein reflects on the value of this work: “I would have loved to have read this six years ago when I was starting to implement these types of practices. It would have given me the confidence to move forward even more quickly and with greater clarity.”
Where to Learn More And How to Help
If you’re a clinician interested in learning more about metabolic approaches in psychiatry, we encourage you to explore the full publication here. Please feel free to share it with your peers, and we invite you to share your thoughts on social media and tag us @metabolicmind.
If you’re a patient or family member, consider sharing this paper with your care team to start an informed discussion about whether metabolic strategies may be appropriate in your individual case.
Clinicians can also explore Dr. Georgia Ede’s Ketogenic Metabolic Therapy Training Program to gain practical skills for integrating KMT into psychiatric care. By spreading awareness and sharing these resources, you can help bring metabolic therapies to the individuals and professionals who need them most.
