Personalized Psychiatry: Using Blood Tests to Find the Right Mental Health Treatment

Nicole: 
We’re healing a brain, I believe, with a ketogenic diet. And so it’s not simply about squashing or controlling symptoms. So, what ends up happening or what I see clinically is in the beginning, they still will get symptom. It’s not an immediate squashing of psychotic symptoms that kind of occurs.

They still occur, but they start to occur less frequently, less intensely, and less chronically until finally, for these people that recover, they just go away.

Bret: 
Welcome to the Metabolic Mind Podcast. I’m your host, Dr. Bret Scher. Metabolic Mind is a nonprofit 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.

Licensed mental health counselor, Nicole Laurent, and her colleagues just published a case series of individuals being treated with ketogenic therapy for schizoaffective disorder with dramatic life changes and benefits. So, let’s hear from Nicole. Let’s hear about how she worked with these clients in this case series and a lot of the details about what changed their lives.

Before we get into the interview, please remember our channels for informational purposes only. We’re not providing individual or group medical or healthcare advice or establishing a provider patient relationship. Many of the things we can discuss can be potentially very dangerous, if not done without proper clinical supervision, which you’ll hear in this interview.

So, please always consult with your provider before changing your medications or even changing your lifestyle to treat a medical condition. All right, let’s get on with the interview.

Nicole Laurent, welcome back to Metabolic Mind. Thank you for joining me again. 

Nicole: 
Thank you for having me, Bret. 

Bret: 
You have been active and prolific as usual, and have a new publication out about a two patient case series of using ketogenic therapy for schizoaffective and psychotic symptoms.

And it’s remarkable as so much of your work and I want to get into that and get into the details. But before we do, give us a little bit about your background in case it’s someone’s first time meeting you. Tell us who you are and how you got to here. 

Nicole: 
Sure. I’m a licensed mental health counselor in Washington State.

And I’ve been a licensed mental health counselor for, I believe, going on 18 years maybe now. And the last probably eight years, I’ve been using my psychotherapy skills to help people transition to a ketogenic diet as a treatment for mental illness. And I, of course, have some advanced training in how to do that, how to initiate and monitor the diet.

And, yeah, it’s just been my absolute joy to be helping people with this. 

Bret: 
Yeah. that’s wonderful. You’ve got a training course in ketogenic therapy for a therapist, and you’ve been so active on social media. We’ll link to all that at the end. But the other thing you’ve been really good about doing is actually writing up your clinical experience and case reports and having them published.

In the most recent one, published in Frontiers and Nutrition, Ketogenic Metabolic Therapy for Schizoaffective Disorder, a retrospective case series of psychotic symptom remission and mood recovery. Yeah, let’s go through these cases because they’re, or these patient experiences because they’re so dramatic.

And one of the things that I found that really jumped out at me when I read this was who these two individuals are. And they weren’t individuals who had symptoms, a couple weeks ago and you started them on ketogenic therapy and they got better. These were people who had struggled for years, if not more than a decade of with their mental illness, not able to go to school, not able to hold a job, and had really failed conventional therapy.

And I guess I just want to start there. When you see patients coming to you and they say they’ve tried everything and done so many things and still not improving, what goes through your mind about how to assess them and how to help them?

Nicole: 
Yeah. So, both of these individuals had been suffering over a decade with chronic mental illness. While they may not have gotten schizoaffective diagnosis right away, the level of disability and impairment that they were experiencing in distress had been going on for over a decade.

And so the first things that go through my head are, is this is worth trying for you? Let’s see what we can do. 

Bret: 
Yeah, and I’m curious with these individuals, they’ve been through so much and there is this sort of thought of I’ve heard people say this, oh, this treatment’s going to work.

Oh, just this next one, all you have to do is try this next one. This one’s going to help, and it doesn’t. And it doesn’t, and they get like treatment fatigue. And so here’s someone saying this diet is going to help. Do people kind of, or maybe these individuals or just in your clinic in general, is there some resistance to be like, oh, sure, here’s one more thing?

And this time it’s not even medicine, it’s only food. Like how’s that going to help? Is there some resistance and doubt? 

Nicole: 
Yes, absolutely. So not everybody, so the people who generally come to see me, often because of Metabolic Mind, have heard about this as a potential treatment and are actually very excited and very hopeful and optimistic about the recovery that they see is possible now that they didn’t see was possible prior.

But there definitely is a very large portion of individuals who come see me or their family members who reach out to me around this, that are just afraid to hope and they are like, okay, I’ll try this thing, but I’m not going to hope because, and I get it, because they’ve been so disappointed. And there’s been so many treatments that have been talked up to them that are going, that they’re told, we’ll potentially fix this, or this is going to fix this.

Or that’s communicated that really it’s interesting to watch because as they start to improve, they’ll say things like, I don’t think it’s the diet. We just have to wait and see. We just, they almost can’t believe what’s happening. And so you just give space for them to come to the determination about whether their recovery is ketogenic diet influenced or not. 

Bret: 
Yeah, and I want to talk about the structure a little bit, about starting these two individuals on a ketogenic diet, getting them into therapeutic ketosis because as you mentioned in the paper, not everybody was trained in ketosis. It’s not like the psychiatrist was trained or even a dietician that they were working with necessarily. They were working with you. You were the trained individual working with other clinicians who were not trained. So tell us about that interaction that you had with their other healthcare team members to make sure everybody’s on board and to make sure everybody agrees that this is the right thing to do and is going to follow the patient appropriately.

Nicole: 
So, what I’ve been finding is that it really, in my experience, and I think possibly the experience of some of the other people who do what I do that are not part of large medical systems, already is that we, it really only takes one well-informed ketogenic professional on a treatment team.

And because patients just do not want to wait for their local hospital to catch up, they don’t want to wait for the local clinic to catch up. And they just, they really want to the possibility of recovery as soon as possible because they’re suffering or their family sees that their loved one is suffering.

And so what I’ve found is that it really just takes one of us. And my capacity in both of these case studies was just private consultation. So, I was not even working under my role as a licensed mental health counselor. I was the dietician, so to speak, or the person managing the diet for the individual in both of these case studies.

And they had additional people on their treatment team. So, they had a therapist, they had a medical professional and also sometimes a psychiatrist, specifically. And so what is surprising is that, maybe not surprising, which is the medical professionals and the psychiatrists are very busy. And if I, or the person managing the diet, are not part of that treatment team within the electronic health record structure for communication, that sort of thing, sometimes it can be really difficult to coordinate with other professionals around it.

But what I’ve just had so much success with is teaching the patient to self-advocate and find the words around asking for what they want and need and articulating their questions. And I actually think that’s a bit more empowering, than if I just simply had a thought and communicated it directly to any of their providers. And it’s it’s just been working really well. I think part of the recovery process for people is self-empowerment and learning how to have these conversations with providers that may not be educated or may not even be on board, but they still need to ask for what they need from the treatment environment. 

Bret: 
Such an important point. The whole empowerment aspect because having a mental illness and being treated with medications that aren’t helping you the way you want them to help you is so disempowering. It couldn’t be less empowering.

And then you’re completely flipping that around and giving them control, showing they have control and they can be empowered to be proactive about their treatment, and something they can control with their nutrition. But also not just the nutrition, the relationship with their providers. I think that’s so important, and I can’t emphasize that enough. And I’m so glad you brought that up.

Before we continue, I want to take a brief moment to let our practitioners know about a couple of fantastic free CME courses developed in partnership with Baszucki Group by Dr. Georgia Ede and Dr. Chris Palmer. Both of these free CME sessions provide excellent insight on incorporating metabolic therapies for mental illness into your practice. They’re approved for a MA category one credits, CNE nursing credit hours and continuing education credits for psychologists. And they’re completely free of charge on mycme.com, there’s a link in the description. I highly recommend you check them both out. Now, back to the video.

So, when you’re getting started with somebody who has not responding to treatment, you’re going to start them on a ketogenic diet to put them in ketosis. You mentioned a number of different specifics in the case series, and one is the type of ketogenic diet or the ratios.

We’ve talked here at Metabolic Mind before of the old 4 to 1 ketogenic diet for epilepsy, which is, you could think of as an extreme ketogenic diet, and that’s the grams of fat ratio to the grams of carbs plus protein. And in your case series, you talked about starting the first patient on a 2.5 to 1.

And then later, transitioning to a 2 to 1 where the protein would go up a little bit. And the second one was a 1.75 to 1 transition to a 1.5 to 1. it’s very specific, but I just want to take a step back and say, how do you decide where to start? There’s just eat whatever you want to get into ketosis or there’s a more specific directive type of ketogenic diet to get you a ketosis?

So how do you approach that? 

Nicole: 
It’s funny that you asked that because I believe the peer, some of the peer reviewers, were asking the same thing. What, how do you make this decision? And I think that my experience for so many years as a mental health counselor has actually been very helpful in this, in that I’m able to kind of contextualize what might work best for that particular person.

So, for example, in case study one, which was a 17-year-old female with schizoaffective disorder, that individual was coming directly from the hospital and had met with me prior, and was not, was feeling so destabilized that she really felt like she needed to go into the hospital and become stabilized.

But while she was in the hospital, she actually, she let her parents know, because they had met with me prior as a possibility that she, this was not the path she wanted. And she wanted to try a ketogenic diet when she got out. My thought with that, correct or incorrect, was that I really want to get her into a strong level of ketosis as soon as possible to see if she can feel some treatment effects because this person was a teenager and was in a place where I thought that the possibility of her getting discouraged very quickly. I didn’t feel like we had the, we didn’t have the room I felt like for me to fiddle around and try to get her macros just so over a month or, and I knew she had really good support at home with parents that were going to be helping her cook for the diet and making sure she had ketogenic diet food.

And so I didn’t feel like I needed that very careful behavioral ramp up. I often do with people where I need to make sure they have the recipes, and they know how to get the food and they’re not going to fall off the wagon because they didn’t plan their meals right. So it’s just kind of stuff like that I think about when I decide about what ratio to start someone on. 

Bret: 
Yeah, and I want to talk about the supplements, too, but I realize in a way, I’m, unintentionally burying the lead here because I also want to talk about the amazing results. At six weeks, complete remission of psychosis, dramatic improvement in mood that was sustained out to 24 weeks.

So tell me about how she and the family responded again at, with six weeks, a complete remission of her symptoms. What was their response to you? 

Nicole: 
I just love this family, so I just love this family. Just first disbelief, this can’t be working this quickly is, was things that the patient was saying, that the client was saying. But the family was just absolutely overjoyed just so much excitement.

I just, I can’t really, although I’m sure the people who watch Metabolic Mind understand, I can’t articulate well enough the level of distress these families experience watching their loved ones suffer. And I am, I’m not sure I can articulate well enough the level of distress it has on the family in general, in the system, to have these treatments that are just completely inadequate.

And yeah, inadequate. I was going to soften that a little bit, but I feel like I can’t because, this was a, this was an individual that family had been trying to keep them alive with, with really acute suicidal ideation for a very long time. And So, for this individual, the treatments were completely inadequate.

She was in great distress, her family along with her, of course, as, symptoms starting to go away and they’re starting to watch her capacity increase. That’s a word we hear a lot in ketogenic diet recoveries about capacity increasing, and people feeling more present.

And so as they started to, as they started to watch that, it’s just joy. It’s just really joy. 

Bret: 
Yeah. but interesting in the second case, it was mentioned that it was six months for symptom, complete symptom relief. So, I’m curious about that difference now that there was improvement, earlier it sounds like, but not complete relief until six months.

So do you see that often? Different timelines for different people and there’s not really one way people respond? 

Nicole: 
Yeah, so in case study two, and now I’m going to go back and look at that because it was, so six months in terms of I believe mood, but I believe she let me look again. Oh, significant reduction in psychotic symptoms within two weeks and then complete resolution within six months.

Yeah, so she, it varies, right? And just like in the epilepsy world where this is used as a treatment for seizure disorders, there can be periods of time when during the treatment they get seizures, right? So, we’re healing a brain, I believe, with a ketogenic diet. And so it’s not simply about squashing or controlling symptoms. So, what ends up happening or what I see clinically, is in the beginning, they still will get symptom. It’s not an immediate squashing of psychotic symptoms that kind of occurs. They still occur, but they start to occur less frequently, less intensely and less chronically until finally for these people that recover, they just go away.

And I think that’s what happens. But for case study two, they were just absolutely, I think gobsmacked about how quickly, what a huge reduction in psychotic symptoms this particular person got in just two weeks. But some people, it absolutely takes longer. 

Bret: 
And that’s okay. Yeah, it’s a good point.

I focused on the six months, but that was for complete resolution of symptoms, but quality of life dramatically changed at only two weeks with such reduction in her symptoms. So, really important concept there. Now, the other thing that was really interesting, was you talked about the supplementation. And there was some overlap that they both were supplemented with vitamin B, D, K2 an L-carnitine.

One with following the levels and increasing when the levels were low. So tell us about those supplements. Do those, are those common in the patients that you and the clients that you work with to make sure they’re supplemented? 

Nicole: 
So again, this is a clinical decision that kind of comes with experience.

Chris Palmer has been great about pointing out that there are some case studies where carnitine supplementation in non-ketogenic populations has caused, it’s been questioned, about whether that has ramped up mania or hypomania. There’s a couple of those, and so I would not encourage listeners to just willy-nilly start supplementing with carnitine, right?

If they aren’t being managed by someone with the diet, some people are sensitive to carnitine, but when I encounter someone who I suspect the quality of their diet is not that great coming into their ketogenic diet. So, I do a nutritional analysis before I implement the ketogenic diet and I can get a feel for the quality of amino acids that they’re taking, in the bioavailability, that sort of thing.

And if they’re eating a very low red meat diet, right? “Carna” means red meat, then I often will prophylactically supplement a very small amount of carnitine just to try to ensure that their ketones are available, or that they’re able to sustain ketosis. Because what I don’t want, if we’re finding that ketone level of ketones might have therapeutic benefit, right, so I don’t want someone’s ketones to be unnecessarily low or non-existent, if that is one of the treatment effects in these populations on a ketogenic diet.

So, also, sometimes it’s really hard for me to get a carnitine panel from the doctors. It’s really hard, especially the Canada people and the Australia people that I work with. And even the US, they’re not sure how to order it, even though it’s on, in the peer reviewed literature that adults on ketogenic diets, these are, this is the blood work they need, table five, it’s right there. So, sometimes I will do it prophylactically. Sometimes I will wait until I get a carnitine panel back and then adjust it accordingly.

But I think it might, I think it might be an important part of treatment with ketogenic diets. I’m still trying to decide, and I’m pretty sure that the research needs to figure that out for me. 

Bret: 
Yeah, and it’s a good point though about what their pre-diet was because if somebody does have severe mood disturbances and experiencing psychosis, those tend to not go along with very high-quality diets.

So, it’s usually to be stereotypical and generalized, but that people don’t really focus on food quality when they’re in that type of a mental state. So there are going to be deficiencies, most likely, and there are nutrient deficiencies and vitamin deficiencies and micronutrients and so forth, yeah.

So the, I think it is so important that you address those as you also dramatically increase the quality of their food intake. And then the next part I wanted to talk about those are medications because, as we know, there can be a lot of details you need to think about with medications.

Being in ketosis can potentiate the effect of some medications. It can lower the serum levels of some medications. So, there’s a lot to consider, especially when a prescribing physician may not know about ketosis. And you are the one who has the ketogenic experience, but you’re not the prescriber.

So, you have to communicate with the prescriber about approaching the medication. So, tell me first what happened with the medications in both of these clients that you were seeing. And then tell me about the specifics on how you worked out those logistics. 

Nicole: 
Yeah, so again, I bring it back down to client empowerment and education.

So, we definitely have conversations about the possibility of whether some new emerging symptoms are potentiation effects, and whether or not they need to have discussions with their prescribers about whether that needs to be titrated down slightly. it’s actually really interesting.

So, in case study two, that individual got potentiation effects very quickly where they got very sedated, and they just almost felt like they couldn’t even get out of bed. And that was after just a couple weeks, two and a half weeks or so. And if they had not been working with a ketogenic informed professional, there’s all kinds of things that could have happened as a result of that.

And one of them is they could have thought, oh my gosh, this ketogenic diet is making me exhausted. I just need to eat some carbs or I just don’t feel good on this ketogenic diet. And that was a helpful and important conversation. And being a non-prescriber, of course, I didn’t give any advice about how or how to do that or anything like that.

That’s not my place. But I was able to have a conversation with her about that possibility that she was then able to have a talk with her prescriber about, who was then open to reducing the medication and she felt almost immediate relief. And so that is a piece, so that’s an example of where I didn’t actually need to even talk to the prescriber directly, but just simply being able to communicate with my client about what we see and then them self-advocating, which I think is really helpful and really important.

And then with case study one, they were doing fantastic and continued to do fantastic, but there were just some very subtle things that were going on that really looked like potentiation effects. And they had a prescriber that was very nervous, understandably very nervous, about titrating down a little bit just to see if some of those symptoms went away.

And so that was a very, I had to have a very kind of, I’m trying to find the right word, I had to really help them find the language that they needed to use with their prescriber in such a way that the prescriber felt comfortable enough to attempt a slight titration down to see if that improved symptoms.

And in that circumstance, it definitely did. And their recovery was not off track, but it started to improve even better after that. So you can’t, I really think that what I see clinically is in my experience, usually people who are on ketogenic diets for several months, sometimes when their prescribers are very nervous about titrating down the medication, even in the face of this person doing beautifully and wonderfully and then sometimes problems can happen because of that.

The answer is not always just stay on your medication at exactly the same dose as you did before your ketogenic diet. We just want to use it to be safe, right? I think that prescribers really need to think about the ketogenic diet almost as though it’s its own powerful medication that’s now on board with these other medications and then evaluate the medications from that standpoint. 

Bret: 
Yeah, that’s a great, that’s a great point because, and the flip side is, the answer is also, okay, now you can just stop all your medications.

That’s also not the answer. 

Nicole: 
Oh my goodness yeah. Yeah, we should talk about that. So one of the concerns that I have as a clinician is that I’m seeing beautiful ketogenic recoveries in schizoaffective disorder and other diagnoses, where people are stable and doing beautifully and clearly are not in need of medication anymore.

They’re just thriving, and they get to the point where they’re like, I think I would like to go down off of this medication. And as you’ve had on Metabolic Mind, tapering experts talk about how psychiatrists are not necessarily up to date with things like hyperbolic tapering practices. I’m seeing people get into trouble by not being self-educated about different hyperbolic tapering practices when they come into those conversations with prescribers.

So I just, that’s something that we, you’ve asked me about how I coordinate with prescribers directly. What I find to be more effective is to send people to Metabolic Mind, to watch some of those conversations with the tapering psychiatrist, to buy their own copy of the Maudsley Deprescribing Guidelines because what I don’t want to see is, I don’t want to see a beautiful ketogenic recovery where someone is thriving, be inadvertently thwarted by poor tapering practices by psychiatrists and prescribers. 

Bret: 
So just for those who, it’s the first time they’ve heard it briefly, describe what hyperbolic tapering is. 

Nicole: 
I’m not a prescriber, but it’s a little bit, it’s about adjusting medications down in small percentages as opposed to milligrams or appropriate units. Many prescribers believe that going down, last 5 or 10 milligrams of something is no big whoop, right? No big deal. You’re not going to have any problems, but people have problems. And so really hyperbolic tapering is about helping patients figure out how to get smaller and smaller doses so that they can gradually, carefully, and thoughtfully come down off these medications in a way that does not put their recovery at risk because that’s what’s happening now. 

Bret: 
Great point. So instead of 40 to 20 to 10 to off. It’s 40 to 20 to 17.5 to 15, to 14 to 13 to 12. So it’s much more slower at the lower doses because the percentages can be higher. Yeah. Okay. So before we wrap though, I want to hear what happened to these wonderful individuals, right?

They’re having these incredible changes in their lives. So what did you notice? What change that you can give us an update on them. 

Nicole: 
Yeah, case study one actually got to go off to college where before that wasn’t even a remote option for her. I found that to be very exciting.

And the other individual, is living symptom free, and I would say not just living symptom free. I got to do an extended follow-up on her, which I think is another real strength of the case studies is the longer follow-up that was available for one of the individuals.

So not only did they use a ketogenic diet as a treatment for a serious mental illness, they continue to maintain the diet for a very extended period of time, and they are thriving. And they have not had any kind of relapse or any kind of issue. So, I think that’s a very strong piece.

So, they are living their best life, I think would be the best way to say, that outcome. 

Bret: 
Ah, just wonderful updates. Such amazing work that you’re doing and so thankful that you are publishing it so everybody can see it. So psychiatrists can see it, therapists can see it, dieticians can see it, people can see it in the literature and know that this is an approach they should be considering.

So if people want to find out more about you and all the work you’re doing, where would you suggest they go? 

Nicole: 
They could go to my website. It’s called mentalhealthketo.com. And there’s a contact form, and they can use that to contact me. 

Bret: 
Very good. All right. thank you again for joining me, and I look forward to having you back in the future and hearing more about the work you’re doing.

Nicole: 
Yeah. Thank you, Brent. 

Bret: 
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