Ketogenic therapy can be a powerful tool for mental health stability, with some individuals reporting significant symptom reduction, improved functioning, and, in some cases, sustained remission. But even when someone is doing everything right, an acute mental health crisis can still happen.
“This is a powerful treatment, but it doesn’t make us bulletproof from all eventualities in life,” explains psychiatrist Dr. Matthew Bernstein.
Planning ahead can make a meaningful difference. A written crisis care plan helps individuals, loved ones, and clinicians recognize early warning signs, protect important treatment preferences, and respond more effectively when symptoms escalate.
In this article, Dr. Georgia Ede, a Harvard-trained psychiatrist and expert in ketogenic therapy; Nicole Laurent, LMHC, a mental health counselor specializing in ketogenic therapy; and Dr. Matthew Bernstein, a Harvard-trained psychiatrist and Chief Medical Officer at Ellenhorn, share practical guidance for preparing for and navigating a mental health crisis.
Why Symptoms Can Return During Ketogenic Therapy
A return of psychiatric symptoms doesn’t necessarily mean ketogenic therapy has stopped working. Even when someone remains in ketosis and follows their treatment plan closely, there are other factors that can affect stability.
Dr. Georgia Ede has seen this in people who had been doing well enough during ketogenic therapy to work with their clinicians on reducing psychiatric medication before symptoms began to return. “There are other factors besides the ketones that can change what the person is experiencing,” she explains.
Food sensitivities, inflammation, disrupted routines, stress, sleep changes, exercise patterns, or medication changes may also contribute, even when ketone levels remain in the usual range.
With that said, ketone levels are often the first place to look. A downward trend may suggest that the person has less of the metabolic support that has been part of their stability.
One important consideration is whether the change seems like a temporary dip or the beginning of a more serious crisis. A brief period of anxiety, low mood, poor sleep, or irritability may improve once the trigger is addressed. A developing crisis is more likely to involve symptoms that intensify, interfere with daily functioning, or resemble warning signs that have preceded past episodes.
Because these patterns are highly individual, recognizing them early can help the person and their care team respond before symptoms escalate.
Create a Mental Health Crisis Plan Before You Need It
The middle of a mental health crisis can be the hardest time to decide what should happen next. Symptoms may affect judgment, communication, or trust, while loved ones and clinicians may be trying to help without knowing how the person typically experiences a crisis.
Planning during a period of stability creates an opportunity to identify those patterns before they become urgent. What do the earliest warning signs look like? Who usually notices them first? How should concerns be raised? Which responses feel supportive, and which have caused harm in the past?
At Ellenhorn, a community-based psychiatric recovery program where Dr. Matthew Bernstein serves as Chief Medical Officer, clinicians use the Shared Agreement for Collaborative Treatment, or SACT, to guide these conversations. The framework explores a person’s past experiences with care, the signs that symptoms are worsening, when additional support may be needed, and how clinicians can respond most effectively.
These conversations help the individual, their loved ones, and their care team develop a shared understanding of what a crisis looks like for that person. Rather than waiting until symptoms escalate, everyone has clearer signals for when to step in and how to offer help.
What to Include in a Mental Health Crisis Plan
A crisis care plan should clearly explain what has helped the person stay well and what they want preserved if their symptoms worsen. That includes the full treatment approach, such as ketogenic therapy, psychiatric medications, sleep routines, exercise, stress-management practices, and any other supports that have contributed to stability.
The plan should also document medication preferences in detail. Dr. Matthew Bernstein recommends noting which medications have been helpful in the past, which have caused difficult side effects, and which options the person might consider using temporarily during an acute episode. These details can help the care team make more informed decisions when time is limited.
Bernstein compares a crisis plan to a birth plan. It may not control every outcome, but it gives everyone involved a clearer roadmap and helps keep the person’s wishes visible during a stressful situation.
The document should also identify a trusted healthcare proxy who can speak on the person’s behalf if needed. Copies should be shared with the clinical team, close family members, and anyone else likely to play a role during a crisis.
The goal is to make the person’s preferences easier to understand, access, and act on when they may be unable to communicate them clearly.
Navigating a Hospital Stay on a Ketogenic Diet
Hospitalization can make it difficult to maintain a ketogenic diet, especially when meals, medications, and IV fluids are controlled by the hospital. When a stay is planned, such as for surgery, contacting the hospital in advance can help clarify what accommodations are available and whether outside food, refrigeration, or food delivery will be permitted.
Patients and caregivers can also speak with the care team about:
- Ketogenic-friendly meal options: Review the hospital menu and identify foods that fit the person’s usual protocol, such as eggs, meat, or non-starchy vegetables.
- Additional fat sources: Request extra butter when appropriate, or bring preferred options such as olive oil, coconut oil, or sugar-free dressings if the hospital allows them.
- IV fluids: Ask whether glucose- or dextrose-free fluids can be used when medically appropriate.
- Medications: Liquid medications often contain added sugar, so a tablet or capsule alternative may be preferable when available.
- Outside food: Family members may be able to bring prepared meals, shelf-stable options, or enough food to store in a small hospital refrigerator.
When suitable food is unavailable, eating less frequently may be a temporary option for some people, but only when medically appropriate, discussed with the care team, and not a risk for someone who is underweight or at risk of becoming underweight.
Nicole Laurent, LMHC, also points to hospitalization resources from Matthew’s Friends and blender meal recipes from The Charlie Foundation for people who cannot eat orally.
Family support can be especially valuable during a hospital stay. Nicole Laurent describes loved ones preparing and delivering meals as “such a huge act of love,” helping the person maintain an important part of their treatment while the clinical team manages the immediate crisis.
The Caregiver’s Role During a Mental Health Crisis
Family members and caregivers can play an important role during a mental health crisis, but the most effective support often begins long before the crisis itself. Understanding the person’s care plan, early warning signs, treatment preferences, and healthcare proxy arrangements in advance can reduce confusion when symptoms escalate.
In the moment, support may involve helping to communicate the person’s wishes, sharing relevant history with clinicians, or ensuring the care team has access to the written crisis plan. Caregivers may also notice changes before the individual does, which makes it helpful to agree in advance on how concerns should be raised.
During a hospitalization, practical dietary support can be especially valuable. Depending on hospital policies, loved ones may be able to:
- Bring ketogenic-friendly meals or shelf-stable foods
- Coordinate food deliveries
- Provide preferred fat sources
- Help review menus and medication ingredients
- Bring blender meals if the person cannot eat orally
At the same time, caregivers don’t have to manage the crisis alone. When safety is at risk or symptoms require urgent treatment, the clinical team should lead medical decisions. The caregiver’s role is to provide context, advocate for the person’s documented preferences, and support the plan wherever possible.
Final Thoughts
Even with a strong treatment plan, consistent nutritional ketosis, and the right support, a mental health crisis can still happen. That does not undo the progress someone has made or mean that ketogenic therapy is no longer helping. It simply means that long-term stability may sometimes require additional support.
Planning ahead can make those moments easier to navigate. A thoughtful crisis care plan gives the individual, their loved ones, and their clinicians a shared understanding of what to watch for, what has helped in the past, and how to respond if symptoms begin to escalate.
No plan can prepare for every possibility, but it can make a difficult situation feel less chaotic and help protect the person’s preferences when they may not be able to communicate them clearly.
For more support, explore Metabolic Mind’s THINK+SMART framework, connect with others through the Metabolic Collective, or use Diagnosis Diet’s Clinician Directory to find a clinician familiar with metabolic approaches to mental health.
Frequently Asked Questions
Can a mental health crisis happen even if someone is still in ketosis?
Yes. Ketogenic therapy can support significant and lasting mental health stability, but it cannot prevent every possible crisis. Stress, illness, injury, disrupted sleep, seasonal changes, medication adjustments, and other biological or environmental factors can still affect symptoms, even when ketone levels remain within a person’s usual therapeutic range.
Does a return of psychiatric symptoms mean ketogenic therapy has stopped working?
No, a temporary increase in symptoms may be related to falling ketone levels, poor sleep, illness, stress, food sensitivities, medication changes, or a disruption in routine. The severity, duration, and progression of symptoms can help determine whether someone is experiencing a temporary dip or the beginning of a more serious mental health crisis.
What should be included in a mental health crisis care plan?
A mental health crisis care plan should outline the person’s early warning signs, current treatment approach, medication preferences, dietary needs, and past experiences with helpful or harmful care. It should also explain when additional support may be needed, identify a trusted healthcare proxy, and describe how the person would like family members and clinicians to respond if symptoms escalate.
What should someone do if ketone levels drop and psychiatric symptoms begin to return?
The first step is often to review recent ketone trends with the person’s healthcare team and identify potential causes of the change. Adjusting the ketogenic protocol may help restore the person’s usual therapeutic ketone range. Sleep, stress, illness, food changes, exercise, and medication adjustments should also be reviewed because ketone levels are only one factor that can affect mental health stability.
How can someone maintain a ketogenic diet during a hospital stay?
Maintaining a ketogenic diet in the hospital may involve reviewing the menu for compatible foods, requesting additional fat sources, bringing prepared meals, or arranging food delivery when hospital policies allow it. Patients and caregivers can also ask about added sugar in liquid medications and discuss glucose- or dextrose-free IV fluids with the medical team when clinically appropriate.
How can family members support someone during an acute mental health crisis?
Family members can prepare by learning the person’s early warning signs, treatment preferences, medication history, and dietary needs before a crisis occurs. During an acute episode, they may help by sharing this information with clinicians, communicating the person’s documented wishes, and coordinating ketogenic-friendly meals during hospitalization. When symptoms are severe or safety is at risk, the clinical team should lead medical decisions.
