The landscape of metabolic psychiatry is shifting rapidly–with a focus on ketogenic therapy for serious mental illness, with the first wave of modern clinical trials now published in major peer-reviewed journals. This growing body of evidence, including pioneering pilot studies, a Delphi consensus, and the first randomized controlled trials, points toward the safety and therapeutic potential of ketogenic therapy for bipolar disorder, schizophrenia, major depression and anorexia. With several pivotal studies recently completed and preparing for publication, the field has begun a transition from foundational research to evidence-informed clinical application.