Can Ketogenic Therapy Help Depression & Anxiety? Real-World Evidence from Clinical Practice

Erin: 
This kind of real world research does have a place. The randomized control trials are extremely important, but we also need to know how does this work or does it work in the real world? But when you talk to the individuals and you hear the changes in their life, it’s phenomenal.

Bret:
Welcome to the Metabolic Mind Podcast. I’m your host, Dr. Bret Scher. Metabolic Mind is a non-profit initiative of Baszucki Group where we’re providing information about the intersection of metabolic health and mental health and metabolic therapies, such as nutritional ketosis as therapies for mental illness.

Thank you for joining us. Although our podcast is for informational purposes only and we aren’t giving medical advice, we hope you will learn from our content and it will help facilitate discussions with your healthcare providers to see if you could benefit from exploring the connection between metabolic and mental health.

A new publication from Dr. Erin Bellamy shows some pretty impressive results using ketogenic medical therapy to intervene on depression and anxiety symptoms. Now, it’s not a randomized controlled trial. It’s the results of her practice, but still really impactful on the lives of these individuals. So, we talk about the results, and we talk about the difference between this level of evidence and randomized controlled trials or other studies.

Now, if you don’t know Dr. Erin Bellamy, she’s been on our channel before. She has a PhD in psychology, and she is a mental health professional who has her own program at IKRT.org, where she helps people institute ketogenic therapies with support structures in a group setting and helps treat depression and anxiety.

She’s based in the UK. But as you hear, she sees patients from all over. And she also is the award recipient of the Metabolic Psychiatry Scholar Award, which is now allowing her to launch another study, which we’re going to hear about as well. So, I hope you enjoy this interview with Dr. Erin Bellamy.

Many of the interventions we discuss can have potentially dangerous effects if done without proper supervision. Consult your healthcare provider before changing your lifestyle or medications. In addition, it’s important to note that people may respond differently to ketosis, and there isn’t one recognized universal response.

Dr. Erin Bellamy, welcome back to Metabolic Mind. It’s a pleasure to see you again. 

Erin: 
Thank you so much for having me, Bret. It’s an absolute pleasure to be back on Metabolic Mind. 

Bret: 
Yeah, and I’m excited to talk about this paper you recently published and your new upcoming study. But first, I want to start with a question. Tell me, in your own mind, what is the thing that sort of the mental health profession really gets wrong or has a misconception about that you wish were different? 

Erin:
This is a great question to start off with. I think over the past couple of years, there’s been a constant kind of undertone of, and comments of people who struggle with their mental health or they have different diagnosis, perhaps they’re not able to make meaningful changes to their diet and lifestyle.

Maybe it’s too difficult for them? Or it’s too hard? Or they won’t be able to stick to it? And I think that’s the biggest misconception that we have because, I think, as we’re about to discuss now, really, I see the opposite to be true. People are able to make meaningful changes, especially if it helps them to feel better.

So yeah, I would say, it would be. 

Bret: 
Yeah. That’s a great answer, and does tee us up perfectly for this discussion of your paper because this paper you published is a review of your practice. So, you’ve got a clinical practice where you are helping people institute ketogenic medical therapy for various psychiatric diagnoses or symptoms. And you published some pretty impressive results that you are having.

To set the stage, not a randomized control trial, not a trial. It’s a self-selected group, and we’ll talk about that because some people might say it weakens it. Some people might say this strengthens the paper. But so, tell us about, a little bit about the background of what you did in your practice and what you found.

Erin: 
Yeah, absolutely. So, first of all, I’m just so excited about this because if we think back to my previous research, my PhD, it was seeing if the ketogenic diet could improve depression and psychological well-being for people. And my biggest limitation there was that there was no group support.

There wasn’t really the correct education in place for something like ketogenic therapy. And fast-forward pretty much a decade, and here I am in practice. And I took the first couple of cohorts that I had coming through into my group program. And we had 19 people all together, and the program is a combination of psychoeducation about the science of ketogenic therapy and why it’s important for these individuals.

Then the professional guidance, the implementation of the diet in the correct way for each person. And then the ongoing weekly support over six months, week in, week out. Meeting with them. Troubleshooting what they’re doing. Tweaking things with them. And then letting them support one another so they’re on the journey together.

And then, bring that all together, and we were able to see some really meaningful changes and clinically significant changes in both depression and anxiety. So yeah, it’s very different to the research that I did. But I think that kind of led me to where I am now, and I know what’s important to individuals in order to get this level of change.

Bret: 
Yeah. So, I guess let’s jump to the results. And then back up and talk about sort of the support and the, maybe the, struggles and challenges and how you overcame those and what you learned about it. So, with the results, looking at the paper, it’s really remarkable with the two main criteria used, the PHQ-9 and the GAD-7. So, for depression and anxiety, going from a 13 to a five on average for the PHQ-9, and the GAD-7 going from a 13 to a seven.

What does that mean? So for the person who’s not familiar with this, what does that mean? What kind of change is that? 

Erin: 
Yeah. it’s a pretty great change, I’ll tell you. So, with the PHQ-9, so coming from 13 to five on average, that means that on average, people were starting out with kind of moderate levels of depression, and coming down to almost what the scale would call a normal levels of depression.

Now, this is average, right? So, there were some people who started way up in the severe, up at 27 on this PHQ-9 scale, and they were able to drop significantly as well. And if the scores drop by five points or more, then what you have is a clinically meaningful improvement. In other words, it points to or suggests that intervention or that medication is working for some people.

And so, that’s what we’ve seen here. We’ve seen, there were 19 people together that were included here. The mean score, the average score, went from 13 to five. So, it came down eight points, which is more than five. So, we have a clinically meaningful improvement in 12 of those people.

They came down by more than five points. And we even had eight of those people together reaching a point of what we call remission. So, remission being their numbers came down to between zero and four. The quote, unquote “normal range.” And really what that means is they no longer met the criteria for having depression.

And take from that what you like, but really clinically significant changes there. 

Bret: 
And you found the same for anxiety as well. Like almost exactly the same, basically. 

Erin: 
Exactly. And so, with the depression, about 80, 88% experienced some improvement. At some point over those 12 weeks, they experienced an improvement.

Not everyone. So 88% with anxiety, everybody experienced improvement at some point over those 12 weeks. And with the GAD-7, so this is the scale that we use to measure anxiety. We’re looking for a decrease of four points or more. And the average went again from 13, so moderate levels of anxiety, down to seven.

So, this was a decrease of six points. Again, just like with the depression, we are looking then at a clinically meaningful improvement in those people that dropped more than four points. And so 80% of those people saw and experienced that clinically meaningful improvement. So again, had it been an antidepressant or another intervention, something like that, we would say, “Yes, this seems to be working for these individuals.”

Bret: 
And I like how in your paper, of course, every study like this is going to report the average, but you also had those graphs that show all the individual lines. You can see how some people had these dramatic improvements. Some less, but pretty much like you were saying, the vast majority improved by both scales.

Setting the stage of the study, though, people will say, “Oh, this was a self-selected group. They wanted to be part of this. It wasn’t randomized.” And in the scheme of research hierarchy, you say it’s a lower level. But in the scheme of saying, “Look, I have this program.

Am I helping people? Can I document people are getting better so I know I’m doing the right thing?” It’s pretty powerful. So, how do you see that, those two types of studies and where this fits? 

Erin: 
Yeah. I love this because, I think, anybody watching this, if they know how to read research or they want to critique things, that’s going to be the first thing they say.

“What’s the comparator? You didn’t have a control group. They were self-selected. They wanted to do this.” Yes, they did, and I think this kind of real world research does have a place. The randomized control trials are extremely important, but we also need to know, how does this work? Or does it work in the real world outside of randomized control trial con- conditions?

Yes, there’s no control. Yes, all of these individuals came and said, “Hi, I want to take part in your program. I want to see if it’s going to work with me.” But if anything, the people that came to me are the ones that have tried everything already. As you can see from the paper, I think five of them were not on medication. Fourteen of them were on medications. Some of them up to five medications.

They tried multiple different interventions, both standard and alternative. In terms of how many times people had been admitted to in-patient psychiatric units, one person, up to 10 times in their life. So, this is not just people who are, “Oh, I have kind of low-grade depression. Can you help me?” These are people who had tried and exhausted everything.

They came across this, and really put all their eggs in one basket, though I tell them not to do that. But put all their eggs in one basket and just gave it their all because the other things either had not helped or had only had a limited effect. And so, when you take that group, that’s the group that people say, “They can’t do it, or it’s going to be too difficult for them.”

They’ve got all their other things. Like they’ve got to live their life. They’ve got to go to psychiatry appointments. They’ve got to do all the rest of it because it’s a real world environment. And so if anything, you would argue that, or I would argue, these guys have it harder.

They’ve been through more, and they’ve struggled, likely more than others, too. So, they’re very, they’re two separate things. The randomized control trial and then this kind of real world intervention. And yes, there’s no control. But at the same time, Bret, when you see the improvements, even outside of depression and anxiety, we know the improvements that people can experience when implementing ketogenic therapy.

It’s worth getting out of bed for every day. 

Bret: 
Yeah. So, you started off this discussion by answering my question by saying the mi- biggest misconception is that people can’t make these meaningful changes. But yet, you saw that they could. But as we know with any lifestyle change, it’s rarely a straight line and it’s rarely perfect.

What were some of the challenges you saw and how did you and the community as a whole, the group as a whole, help people overcome those challenges? 

Erin: 
Yeah. So the one thing that I always do with everyone, and I think anybody who knows me listening who has worked with me will be laughing because I always show them this kind of expectation slide as soon as we start working together.

You’ve got all eggs in one basket coming in. And you expect that it’s going to go from down here on the left, a straight line to the top right corner, and you’re going to be in ketosis. All your symptoms are magically going to disappear, and you’re going to go off and live your life. Whereas actually, the next part of the slide is this, start in the bottom left-hand corner and you’ve got this very squiggly line all the way up to the top right. And that’s absolutely the journey that people go on.

They start off all guns blazing. They might be a little hesitant, but all guns blazing. They’re very excited. Within two weeks, the novelty wears off because like with any diet, they’ve got that kind of mindset. They’re trying to learn things, track their food, trying to do things a little differently, navigate parents and in-laws and all the rest of it, and then reality hits.

So, that’s the dip in the curve. The dip in the squiggly line. And that’s the importance of having those weekly check-ins and the support because it’s up, down, round and round. But when you take a step back and if you look at the trend over time, you see the improvements, like you see in the chart.

Over from baseline to week four, pretty spectacular improvements and drop in symptoms. And then, it levels out for some people or maybe some symptoms creep back in. And then, you’ll see another drop or stabilization. So, each kind of month as you go through, each month is very different, and you need different levels of support throughout.

If you were just to say, “Go and do this,” it would be very tricky. I think you’d give up at the two-week mark. 

Bret: 
Yeah, so it seems like there’s sort of two interventions. There’s the support aspect and then there’s the dietary intervention. So, with the dietary intervention, did you shoot for a specific macro or a specific ketone level?

Because there isn’t just one ketogenic diet. It’s any diet that lowers your carbohydrates enough to be in nutritional ketosis, which can fit thousands of different, specific versions. So, how did you address that with your clients? 

Erin: 
Yeah. So, everybody that comes to me, we start off working from a food list, ketogenic food list that I’ve used for many years, just to get them used to creating the meals.

I give them a structure. Two from the fat section, one from the protein, one from the carb fiber, and work with that for a few weeks until they’re in a little bit of a groove. And then, I provide each person with individual personalized macronutrients based on height, weight, medication status, and all the rest of it.

Working from a 1.5-to-1 ketogenic ratio up to about a 2-to-1 ketogenic ratio. But keeping an eye on the ketones as we go because, like you’ve mentioned, not everybody needs the same approach. I like to try and get people away with as many carbs as they can. So, if they can have a 1.5-to-1 ratio, have some more carbohydrates, and have ketone levels where their symptoms are reducing, we’ll stay there.

Whereas, some people might struggle to get their ketones up. Or their ketones will be up, but they’re not experiencing benefits yet. So, we’ll move then towards a 2-to-1 or maybe even a little bit higher in order to see if that person will get some symptom relief at the higher ratio. So, we start off small so as to not overwhelm everyone. And then move into the personal macros, and then adjust those over time.

Bret: 
Yeah. So, that makes sense. Very personalized and adjusting because there isn’t just one-size-fits-all. I think that’s an important point to make, for sure. And that’s where support can be so helpful. And it’s clear your program has a great deal of support to really help people through.

Now, so we talked a lot about the quantitative. The PHQ-9 went from X to Y, and the GAD-7 and so forth, but what about the qualitative? What do you hear from your patients, your clients about how things changed for them? 

Erin: 
You know that’s my favorite part. 

Bret: 
Yeah. 

Erin: 
The quantitative and the numbers, I’m like, “Okay, fine.” 

But sometimes, numbers are difficult to really understand. You know, what does that mean? But when you talk to the individuals and you hear the changes in their life, it’s phenomenal. If I think about a couple people from this group, one person had struggled with depression for four decades, and she didn’t really know what to do.

She didn’t really know how to kind of show up in life without depression being part of her every day. Other people that I think of, just being able to go out into social situations and communicate with other people and, communicate with their friends and family without feeling like everybody’s looking at them.

That morning dread. Waking up in the morning and having that dread, that not being there. Feeling like their head is not ready to explode. Just having a kind of sense of calmness about it. These things don’t get captured on forms. They don’t get captured when we talk about percentages or point drops.

But when you have people coming each week and sharing their win like we do, and they’ll say, “I was able to actually travel for the first time in 12 or 13 years. I was able to enjoy myself with my family. I was able to go outside. I was able to walk with my family and friends and, not excuse myself for the day.” These are life-changing.

Bret: 
Yeah, that really is the best part, isn’t it? just looking at the numbers, you have no idea how it changes somebody’s life. But to hear those stories, see that feedback, that really just is inspiring to see how people’s lives are changing. And like you said, not just people who have felt depressed for a couple weeks, but these are people who’ve had been living this way for years with medication after medication.

And with your program and ketogenic medical therapy, it really changed everything. That is just so inspiring, and you’re so great about relaying those stories and sharing that. So, I really appreciate that. This has been awesome just reading about the paper and hearing you talk about it, but it doesn’t end there.

So, not only do you have your ongoing clinical practice, but now you’re also a Metabolic Psychiatry Scholar Award winner and are starting in a new study. So, why don’t we transition here, and tell us about this new study you’re doing. 

Erin: 
Yeah, absolutely. Thank you. So, this is one of the most exciting things I think to come out of the last year.

Being given this award to me, just it just showed me how far I can take this. Because for so long, I had felt like I can’t reach the people I want to reach or I can’t do the studies I want to do because I was doing it part-time and all the rest of it. But having this award means that now I have registered the protocol for a six-month trial.

We are going to be taking this foundations program. So, the same one we’ve just been discussing. We’re going to take this, and we are going to run it with 40 people, so 40 participants. We are going to be looking at all sorts, so depression. It’s going to be focused on depression and anxiety, but we’ll also be measuring things like binge eating disorder and psychological well-being and stress and many other different symptoms.

And we’ll be trying it to see, first of all, is it as effective as we’ve seen here in this paper we’ve just been discussing? Do we see the same results? Are they better, are they worse? And also, if it comes out that the results are positive, what we have is a program, an online program, that can be scaled.

And it can reach people who, you know, up until this point may not be able to go and see a professional face-to-face. So, whether that be that they are geographically located in the mountains in Finland, of which I have some people who are, or whether it’s that they physically are feeling so unwell that they can’t leave the house, and they really could benefit from taking part in something from the comfort of their own home. And therefore, they can make progress until they start to feel better. And they can get out and work with people face-to-face.

Bret: 
Yeah. So for people to be in this trial, can they be anywhere since it’s online? 

Erin: 
So, they can be anywhere, but they have to be in the United Kingdom just because of the way the ethics is. So, 40 people from the United Kingdom. But you can be anywhere in the United Kingdom as long as you’ve got a good internet connection.

It’s focused on depression and anxiety. So, need a formal diagnosis of that. And obviously, the other usual eligibility criteria you’d need to match. I think one of your recent videos, Bret, about who should do a ketogenic diet, who can’t, the contraindications, absolute and so on.

Some of those will apply, but if people are interested in this and they haven’t yet experimented or trialed a ketogenic diet to improve their mental health, they’re the people that I’m looking for. And it will be run just like the study we’ve been discussing. 

Bret: 
Yeah, and as we discussed, so important to get this real world data to see the impact.

And at the same time, the randomized controlled trials are being done as well. So, it’s getting both lines of data are going to be so important. And the key is, how are we changing people’s lives, and how is your program changing people’s lives? So, that’s fantastic. So enrolling now, or is it open?

Erin: 
Yeah. We are enrolling right now. So, recruitment’s underway. We are moving quickly. So, if anybody is hesitating, please don’t hesitate. Just get in contact, and we can see if you’re eligible. You can go to, I know you’ll probably add it to the show notes, but you can go to ikrt.org/trial, and you can put your information in there. And then, we’ll get in contact with you to see if you’re eligible and take you through the usual checks.

And also, if you’re not eligible, you can still come and work with me at IKRT. It’s not, oh, because you’re not eligible, you can’t get the support that you need. We are still very much functioning, as usual, and I’m doing this study on the side. 

Bret: 
So, for the study, you’ve got to be in the UK. But to work with you, you can be in the mountains of Finland, right?

Erin: 
Exactly. 

Bret: 
Which sounds awesome. 

Erin: 
Exactly. 

Bret: 
I want to be in the mountains of Finland. That sounds amazing but anyway. 

Erin: 
Yeah. 

Bret: 
Outstanding. Thank you so much for taking the time to talk about your paper and your upcoming study. You told us where to go to enroll in the study, but what about for you?

If we just want to learn more about you and the work you’re doing, where can people go? 

Erin: 
Yeah, absolutely. So, you can pop my name into Google, and I should jump up at you. But if you don’t find me there, you can go to ikrt.org. So, it’s Integrative Ketogenic Research and Therapies, a little bit of a tongue twister, (dot) org.

That’s my practice. You can contact me there. And I think the most important thing is not everybody knows if ketogenic therapy is right for them. Often, they have a lot of hesitations. And sometimes, I think that gets in the way of them asking for help. So, I would say just get in contact. We can decide whether or not it’s suitable for you at this time.

And if not, I can point you over to some of the other colleagues that I have. But yeah, don’t, be scared to reach out, is what I would say. 

Bret: 
Great, great. Thanks again. I look forward to hearing more about your upcoming study, too, and that wraps up. 

Erin: 
Yeah. Thank you so much, Bret. It’s been a pleasure to chat. And thank you for letting me share everything.

Bret: 
I really like Erin’s perspective about the different types of evidence. And I really wanted to ask her about that because it is quick for people to say, “Ah, it’s not a randomized controlled trial. It doesn’t mean anything.” It does mean something because these are real people, real lives, improving their lives.

And when she talked about how much people were improving, I think that’s just what really gets you. It’s almost like, who cares what the intervention is? And it’s not quite like that. But the flip side, can we say it is the ketosis that did it? No, on a study like this it doesn’t, quote-unquote, prove it’s the ketosis.

Was it the support and the community and just working with Erin or the ketosis? For the patient, it probably doesn’t matter if they’re feeling better. So, combining this research with the other lines of research, the mechanistic, the randomized controlled trials and so forth, that’s how we bring everything together.

But at its core, Erin wants to help people improve their lives, and that’s what she’s doing. And her new study from the Metabolic Psychiatry Scholar Award will just expand that and see about scaling that even further. So, I hope you enjoyed this. I thought it was inspiring to hear what she’s doing and the work she’s doing and that there’s hope, right?

Again, there is hope. These people have tried medication after medication and were not improving their lives the way they wanted to. They were able to do with this program, and we hope those results continue. So, thank you for joining me, and we’ll see you here next time at Metabolic Mind.

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