The First Expert Consensus on Ketogenic Therapy for Serious Mental Illness

Something significant happened in our field this month, and I want to make sure you know about it.

On 24 February 2026, Frontiers in Nutrition published a paper that represents a meaningful turning point for ketogenic metabolic therapy (KMT) in psychiatry: "Awareness and Best Practices in Using Ketogenic Therapy to Treat Serious Mental Illness: A Modified Delphi Consensus", authored by Dr Georgia Ede and colleagues including Dr Chris Palmer, Dr Shebani Sethi, and a distinguished group of clinicians and researchers from the United States and the United Kingdom. You can read the full paper here.

This is the first formally structured expert consensus on the clinical application of KMT for major depressive disorder, bipolar disorder, and schizophrenia. In a field that has long operated on the frontier of evidence, with passionate clinicians sharing case reports and hard-won practical knowledge in lieu of large randomised controlled trials, this paper matters enormously.

What Is a Delphi Consensus and Why Does It Matter?

A modified Delphi methodology is a well-established process in medicine for building structured expert agreement on topics where randomised trial evidence is not yet available or feasible. A steering group develops a series of statements, those statements are then distributed anonymously to a broader panel of qualified peers, and consensus is defined when a pre-specified threshold of agreement is reached. In this study, that threshold was set at 75%.

The steering group comprised eight KMT-experienced clinicians spanning psychiatry, dietetics, mental health counselling, and metabolic psychiatry research. Their 33 consensus statements were distributed to 47 respondents, all of whom were actively working in the mental health field with direct knowledge or clinical experience of KMT. All 33 statements reached consensus, with the majority achieving agreement levels well above 91%.

It is worth understanding what a Delphi consensus is and what it is not, because this shapes how we should read and use the paper. The methodology is explicitly designed to capture the structured opinion of experienced specialists in a clinical area where the randomised controlled trial evidence has not yet matured. The respondent panel in this study was drawn from the professional networks of the steering group, meaning that participants already had clinical familiarity with KMT. The authors are transparent about this, acknowledging that gathering opinions from those without any awareness of this treatment modality would add little clinical value at this stage of the field's development. The extraordinarily high agreement levels across all 33 statements reflect the coherence of this specialist community's experience rather than a claim that KMT has achieved broad mainstream acceptance. That distinction is important, and the authors make it honestly. What the paper offers is the formally documented, peer-reviewed position of the clinicians who have been doing this work most carefully and for longest, and that is precisely what the field needs right now.

What Does the Paper Actually Say?

The consensus is organised around four core clinical domains, and together they provide the most comprehensive clinical roadmap for KMT in psychiatry that has ever been published.

Defining KMT in the context of serious mental illness

The panel agreed that KMT is ideally achieved through dietary modification that produces endogenous ketone bodies, with clinically relevant nutritional ketosis defined as a serum beta-hydroxybutyrate (BHB) concentration of at least 0.5 mmol/L. Importantly, many individuals may require levels consistently at or above 1.0 mmol/L for the greatest psychiatric benefit. The panel also agreed that the time to clinical response is highly variable, and that a minimum of three to four months of sustained ketosis is likely required before drawing conclusions about effectiveness. This aligns closely with what experienced clinicians in this space, including our team at Metabolic Psychology, observe in practice.

The paper firmly situates KMT within its well-established historical context: it is an intervention with over a century of use in epilepsy, supported by six randomised controlled trials in adults with that condition. Applying it to serious mental illness is an extension of proven neurological science, grounded in overlapping mechanisms of neuroinflammation, oxidative stress, mitochondrial dysfunction, and cerebral glucose hypometabolism.

Who is an appropriate candidate?

The consensus is clear that KMT should be considered for the vast majority of adults with major depressive disorder, bipolar disorder, and schizophrenia, provided there are no absolute contraindications. The paper provides a comprehensive table of absolute and relative medical contraindications drawn from three recent authoritative reviews, which will be invaluable for clinicians navigating treatment planning conversations.

Particularly important is the statement that the absence of peripheral signs of metabolic dysfunction should not preclude a trial of KMT. This reflects growing understanding that central metabolic dysfunction, including cerebral glucose hypometabolism, can be present even when standard metabolic markers appear normal. The panel highlighted that individuals with treatment-refractory illness, those who cannot tolerate or decline pharmaceutical treatments, and those with signs of metabolic dysfunction such as elevated fasting insulin, elevated triglyceride-to-HDL ratio, raised fasting glucose, or central adiposity are especially appropriate candidates.

Motivation and social support are identified as factors that increase the likelihood of success, though the paper also acknowledges that individuals with lower motivation or less social support may still benefit in structured environments such as intensive outpatient, residential, or inpatient settings.

Monitoring and measurement standards

This section of the paper is particularly valuable for clinicians. The consensus recommends a baseline assessment that includes a full blood count, comprehensive metabolic panel, fasting lipid profile, fasting insulin, vitamin B12, vitamin D3, and a carnitine panel. These same parameters should be monitored regularly throughout the course of KMT, with any identified nutrient deficiencies addressed through supplementation. The paper gives specific attention to carnitine, noting that secondary carnitine deficiency is not uncommon in adults following ketogenic diets, particularly those taking valproate, those with liver or kidney disease, or those following low-meat diets. If free plasma carnitine falls below 25 µmol/L, acetyl-L-carnitine supplementation in divided doses of up to 100 mg/kg per day may be appropriate.

For ketone monitoring, blood BHB measurement is recommended as the gold standard during the initiation phase, ideally at approximately the same time each day to allow meaningful trend tracking. Where blood monitoring is not feasible, urine or breath ketone measurement is an acceptable alternative.

Best practices in employing KMT

The consensus strongly affirms the multidisciplinary model. At minimum, KMT for serious mental illness should be supervised by a prescribing clinician and a nutrition professional, both of whom have specific training and experience in KMT. The team may also include a therapist, nurse, or health coach. The paper explicitly states that education in KMT for psychiatrists, dietitians, nutritionists, and health coaches should be a priority for the mental health field, something Metabolic Psychology has been working toward since our inception.

Medication management receives important attention. Physiological adaptations to ketosis can meaningfully affect blood pressure, blood glucose levels, electrolyte balance, fluid status, and the pharmacokinetics and pharmacodynamics of existing medications. Antihypertensive agents, glucose-lowering medications, diuretics, and carbonic anhydrase inhibitors may all require earlier and more frequent adjustment than would ordinarily be expected. This must be managed actively by the prescribing clinician.

The paper also addresses the possibility that psychiatric symptoms may transiently worsen during keto-adaptation and recommends that patients and caregivers be educated to recognise this possibility and instructed to notify the clinical team promptly. A gradual rather than abrupt transition into ketosis is suggested as one approach to reducing the likelihood and severity of these transient effects. Importantly, the authors recommend that KMT not be used as a standalone intervention for acute, unstable, or potentially dangerous psychiatric presentations, including acute mania, active psychosis, or active suicidal ideation.

Why This Paper Matters So Much

Those of us working in metabolic psychiatry and metabolic psychology have long operated in a space where the science was ahead of the formal guidance. We have been practising carefully, sharing knowledge within our community, and advocating for our clients on the basis of compelling mechanistic evidence, growing case report literature, and emerging pilot trial data. We have lacked a formal consensus document that other clinicians could reference and that could begin to shift institutional and professional norms.

This paper addresses that gap in a meaningful way.

It legitimises the clinical framework that experienced practitioners have been using. It provides a defensible roadmap for clinicians who want to offer KMT but have not known where to start. It acknowledges explicitly that metabolic dysfunction is deeply implicated in the pathophysiology of schizophrenia, bipolar disorder, and major depressive disorder, and that addressing that dysfunction through dietary metabolic therapy is a rational and potentially transformative clinical strategy.

The epidemiological data cited in the paper is striking and worth pausing on. Individuals with prediabetic glucose levels are 2.7 times more likely to develop major depression. Those newly diagnosed with bipolar disorder are 3.5 times more likely to have metabolic syndrome. Those newly diagnosed with schizophrenia are 3.7 times more likely to have insulin resistance. Insulin resistance is linked to cerebral glucose hypometabolism, which has been observed across all three of these conditions. A clinical intervention that directly addresses insulin resistance and provides the brain with an alternative fuel source is a direct therapeutic response to a core feature of these illnesses.

The paper also matters because of who wrote it. Dr Georgia Ede, who trained me in ketogenic therapy for mental health, is the lead author, and I could not be more proud to see her work and her collaborative spirit produce something of this magnitude. Dr Chris Palmer, who I had the pleasure to meet in 2023 at a Harvard Medical School psychiatry conference, is also among the authors. His book Brain Energy has reached hundreds of thousands of readers and clinicians worldwide. Dr Shebani Sethi, who has led some of the most important pilot trial work in this area, contributed alongside a team of genuinely committed and expert clinicians. This is peer-reviewed work, published in a respected journal, and authored by people who have been doing this clinical work carefully and for years.

Reading This Paper With Clear Eyes

Any thoughtful clinician reading this paper will notice that the respondent panel was relatively small at 47 participants, recruited through the professional networks of a steering group that was itself composed of KMT advocates. The conflict of interest disclosures are extensive, as one would expect from the leading figures in any emerging clinical movement who have built programs, written books, and developed training around their area of expertise. And the absence of patient perspectives is a notable limitation that the authors themselves address directly.

These observations do not diminish the paper's contribution; they contextualise it appropriately. The Delphi methodology is designed for exactly this kind of clinical community, where the practitioners with the deepest experience are necessarily those who have committed to the approach. The alternative, surveying clinicians with no KMT experience, would produce uninformative noise rather than actionable guidance. What we gain from this paper is the carefully considered, formally documented clinical wisdom of the people best placed to provide it, at this particular moment in the evidence cycle.

The honest framing is that this paper represents a rigorous first step: the consolidation of specialist expert opinion as a scaffold for the randomised trials that must follow. The authors themselves commit to repeating the Delphi process in five years, incorporating patient perspectives, and acknowledging how opinions may have shifted as the evidence base matures. That is exactly the right scientific posture, and it is one of the things that makes this paper credible rather than merely promotional.

What This Means for Our Clients

If you are someone living with major depressive disorder, bipolar disorder, or schizophrenia, this paper matters because it strengthens the case you can make to your treating team for a properly supervised trial of KMT. It provides language and a framework. It names the monitoring standards, the contraindications, the expected timeline for response, and the kind of multidisciplinary support that best practice looks like.

It also makes clear that you do not need to have obvious metabolic problems to potentially benefit. The absence of elevated blood sugar or a large waist circumference does not mean your brain is metabolising fuel optimally. Central metabolic dysfunction can exist quietly, and KMT may address it.

If medications have not provided the relief you hoped for, or side effects have been intolerable, or symptoms have persisted despite doing everything right, this paper affirms that KMT is a legitimate adjunctive or alternative therapeutic pathway worth exploring with the right clinical team.

What This Means for Our Field

The call to action is clear: clinicians working in psychiatry, psychology, dietetics, and general practice need education in KMT. At Metabolic Psychology, supporting that education, both for our own team and for the broader clinical community through peer supervision and professional development, is central to what we do.

This paper is a foundation. The field will build on it, the evidence base will mature, and the individuals whose lives can be transformed by ketogenic metabolic therapy will ultimately be better served because a group of dedicated clinicians took the time to formally document how to do this safely and well.

At Metabolic Psychology, we provide individually tailored, medically supervised ketogenic metabolic therapy as part of comprehensive mental health care. Our team includes clinical psychologists, a consultant psychiatrist, and dietitians trained in therapeutic carbohydrate restriction. If you would like to explore whether KMT may be appropriate for your situation, we invite you to contact us to arrange a consultation.

Reference: Ede G, Bernstein M, Calabrese L, Campbell IH, Laurent N, Palmer CM, Sethi S, Zupec-Kania B. Awareness and best practices in using ketogenic therapy to treat serious mental illness: a modified Delphi consensus. Front Nutr. 2026;13:1749406. doi: 10.3389/fnut.2026.1749406