The Role of Food and Nutrition in Treating Bipolar Disorder: A Narrative Review for The Allied Health Professions
Main Article Content
Abstract
This narrative review analyzes the body of literature on known physiological mechanisms impacting bipolar disorder (BD) and how patient-centered nutrition in conjunction with prescribed medications may positively impact patient health outcomes. Additional topics include understanding the current state of research on nutrition and BD, impact of specific micronutrient imbalances on BD, dietary tendencies including current research on whole dietary patterns and potential applications for patients with BD. The totality of research included in this review indicate that inflammatory processes play a central role impacting health outcomes in patients with BD which can be addressed with not only medication, but also with targeted nutrition therapy.
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How to Cite
VELASCO-POPOV, Vida; COOPER, Christen Cupples.
The Role of Food and Nutrition in Treating Bipolar Disorder: A Narrative Review for The Allied Health Professions.
Medical Research Archives, [S.l.], v. 12, n. 6, june 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/5390>. Date accessed: 02 july 2024.
doi: https://doi.org/10.18103/mra.v12i6.5390.
Section
Review Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
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2. Rowland T, Marwaha S. Epidemiology and risk factors for BD. Therapeutic Advances in Psychopharmacology. 2018;8(9):251-269. Doi:https://doi.org/10.1177/2045125318769235
3. Simjanoski M, Patel S, Boni RD, et al. Lifestyle interventions for BDs: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews. 2023;152:105257. Doi:https://doi.org/10.1016/j.neubiorev.2023.105257
4. Smith DJ, Whitham EA, Ghaemi SN. Chapter 15 - BD. ScienceDirect. Published January 1, 2012. Accessed November 26, 2023. https://www.sciencedirect.com/science/article/abs/pii/B9780444520029000152?via=ihub
5. Solé B, Jiménez E, Torrent C, et al. Cognitive Impairment in BD: Treatment and Prevention Strategies. International Journal of Neuropsychopharmacology. 2017;20(8):670-680. Doi:https://doi.org/10.1093/ijnp/pyx032
6. Yatham LN, Kennedy SH, O’Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with BD: update 2007. BDs. 2006;8(6):721-739. Doi:https://doi.org/10.1111/j.1399-5618.2006.00432.x
7. Lee JG, Woo YS, Park SW, Seog DH, Seo MK, Bahk WM. Neuromolecular Etiology of BD: Possible Therapeutic Targets of Mood Stabilizers. Clinical Psychopharmacology and Neuroscience. 2022;20(2):228-239. Doi:https://doi.org/10.9758/cpn.2022.20.2.228
8. Harrison PJ, Geddes JR, Tunbridge EM. The Emerging Neurobiology of BD. Trends in Neurosciences. 2018;41(1):18-30. Doi:https://doi.org/10.1016/j.tins.2017.10.006
9. Jones GH, Vecera CM, Pinjari OF, Machado-Vieira R. Inflammatory signaling mechanisms in BD. Journal of Biomedical Science. 2021;28(1). Doi:https://doi.org/10.1186/s12929-021-00742-6
10. Luciano M, Sampogna G, Amore M, et al. Improving physical activity and diet in patients with severe mental disorders: Results from the LIFESTYLE multicentric, real-world randomized controlled trial. Psychiatry Research. 2022;317:114818. Doi:https://doi.org/10.1016/j.psychres.2022.114818
11. Johnson RJ, Wilson WL, Bland ST, Lanaspa MA. Fructose and uric acid as drivers of a hyperactive foraging response: A clue to behavioral disorders associated with impulsivity or mania? Evolution and Human Behavior. Published online October 1, 2020. Doi:https://doi.org/10.1016/j.evolhumbehav.2020.09.006
12. Łojko D, Stelmach-Mardas M, Suwalska A. Is diet important in BD? Psychiatria Polska. 2018;52(5):783-795. Doi:https://doi.org/10.12740/pp/onlinefirst/78703
13. Dorota Łojko, Stelmach-Mardas M, Aleksandra Suwalska. Diet quality and eating patterns in euthymic bipolar patients. PubMed. 2019;23(3):1221-1238. Doi:https://doi.org/10.26355/eurrev_201902_17016
14. Gabriel FC, Oliveira M, Martella BDM, et al. Nutrition and BD: a systematic review. Nutritional Neuroscience. Published online May 24, 2022:1-15. Doi:https://doi.org/10.1080/1028415X.2022.2077031
15. Madireddy S, Madireddy S. Therapeutic Interventions to Mitigate Mitochondrial Dysfunction and Oxidative Stress–Induced Damage in Patients with BD. International Journal of Molecular Sciences. 2022;23(3):1844. Doi:https://doi.org/10.3390/ijms23031844
16. Ashton MM, Dean OM, Marx W, et al. Diet quality, dietary inflammatory index and body mass index as predictors of response to adjunctiveN-acetylcysteine and mitochondrial agents in adults with BD: A sub-study of a randomised placebo-controlled trial. Australian & New Zealand Journal of Psychiatry. 2019;54(2):159-172. Doi:https://doi.org/10.1177/0004867419882497
17. Shah J, Sakshi Gurbani. Association of Vitamin D Deficiency and Mood Disorders.; 2019.
18. Boerman R, Cohen D, Schulte PFJ, Nugter A. Prevalence of Vitamin D Deficiency in Adult Outpatients With BD or Schizophrenia. Journal of clinical psychopharmacology. 2016;36(6): 588-592. Doi:https://doi.org/10.1097/JCP.0000000000000580
19. Higdon, Ph.D J. Coenzyme Q10 . Linus Pauling Institute: Micronutrient Information Center. Published 2003. 1. Coenzyme Q10. Linus Pauling Institute. Published April 28, 2014. https://lpi.oregonstate.edu/mic/dietary-factors/coenzyme-Q10
20. Jahangard L, Yasrebifar F, Haghighi M, Ranjbar A, Mehrpooya M. Influence of adjuvant Coenzyme Q10 on inflammatory and oxidative stress biomarkers in patients with BDs during the depressive episode. Molecular Biology Reports. Published online July 25, 2019. Doi:https://doi.org/10.1007/s11033-019-04989-z
21. Vasdev S, Singal P, Gill V. The antihypertensive effect of cysteine. International Journal of Angiology. 2009;18(01):07-21. Doi:https://doi.org/10.1055/s-0031-1278316
22. Nery FG, Tallman MJ, Cecil KM, et al. N ‐acetylcysteine for depression and glutamate changes in the left prefrontal cortex in adolescents and young adults at risk for BD: A pilot study. Early Intervention in Psychiatry. Published online April 2021. Doi:https://doi.org/10.1111/eip.13149
23. Wozniak J, DiSalvo M, Farrell A, et al. Findings from a pilot open-label trial of N-acetylcysteine for the treatment of pediatric mania and hypomania. BMC Psychiatry. 2022;22(1). Doi:https://doi.org/10.1186/s12888-022-03943-x
24. Campbell I, Campbell H. Mechanisms of insulin resistance, mitochondrial dysfunction and the action of the ketogenic diet in BD. Focus on the PI3K/AKT/HIF1-a pathway. Medical Hypotheses. 2020;145:110299. Doi:https://doi.org/10.1016/j.mehy.2020.110299
25. Porcu M, Urbano MR, Verri WA, et al. Effects of adjunctive N-acetylcysteine on depressive symptoms: Modulation by baseline high-sensitivity C-reactive protein. Psychiatry Research. 2018;263:268-274. Doi:https://doi.org/10.1016/j.psychres.2018.02.056
26. Whitbread D. Top 10 Foods Highest in Tryptophan. myfooddata. Published November 18, 2014. https://www.myfooddata.com/articles/high-tryptophan-foods.php
27. Davidson M, Rashidi N, Nurgali K, Apostolopoulos V. The Role of Tryptophan Metabolites in Neuropsychiatric Disorders. International Journal of Molecular Sciences. 2022;23(17):9968. Doi:https://doi.org/10.3390/ijms23179968
28. Huang Y, M.M. Wenxuan Zhao, Chen X, et al. Tryptophan Metabolism in Central Nervous System Diseases: Pathophysiology and Potential Therapeutic Strategies. Aging and Disease. 2023;14(3):858-858. Doi:https://doi.org/10.14336/ad.2022.0916
29. Generoso JS, Giridharan VV, Lee J, Macedo D, Barichello T. The role of the microbiota-gut-brain axis in neuropsychiatric disorders. Braz J Psychiatry. 2021;43:293-305. http://dx.doi.org/10.1590/1516-4446-2020-0987
30. Rudzki L, Stone TW, Maes M, Misiak B, Samochowiec J, Szulc A. Gut microbiota-derived vitamins - underrated powers of a multipotent ally in psychiatric health and disease. Progress in Neuro-Psychopharmacology & Biological Psychiatry. 2021;107:110240. Doi:https://doi.org/10.1016/j.pnpBD.2020.110240
31. Evans SJ, Bassis CM, Hein R, et al. The gut microbiome composition associates with BD and illness severity. Journal of Psychiatric Research. 2017;87:23-29. Doi:https://doi.org/10.1016/j.jpsychires.2016.12.007
32. Dickerson F, Adamos M, Katsafanas E, et al. Adjunctive probiotic microorganisms to prevent rehospitalization in patients with acute mania: A randomized controlled trial. BDs. 2018;20(7):614-621. Doi:https://doi.org/10.1111/bdi.12652
33. Douglas LC, Sanders ME. Probiotics and Prebiotics in Dietetics Practice. Journal of the American Dietetic Association. 2008; 108(3):510-521. Doi:https://doi.org/10.1016/j.jada.2007.12.009
34. Siwek M, Sowa-Kućma M, Styczeń K, et al. Decreased serum zinc concentration during depressive episodes in patients with BD. Journal of Affective Disorders. 2016;190:272-277. Doi:https://doi.org/10.1016/j.jad.2015.10.026
35. Jonsson BH, Orhan F, Bruno S, et al. Serum concentration of zinc is elevated in clinically stable BD patients. Brain and Behavior. 2021;12(1). Doi:https://doi.org/10.1002/brb3.2472
36. Cheng WW, Zhu Q, Zhang HY. Mineral Nutrition and the Risk of Chronic Diseases: A Mendelian Randomization Study. Nutrients. 2019;11(2):378. Doi:https://doi.org/10.3390/nu11020378
37. Ciappolino V, DelVecchio G, Prunas C, et al. The Effect of DHA Supplementation on Cognition in Patients with BD: An Exploratory Randomized Control Trial. Nutrients. 2020;12(3):708. Doi:https://doi.org/10.3390/nu12030708
38. Saunders EFH, Mukherjee D, Myers T, et al. Adjunctive dietary intervention for BD: a randomized, controlled, parallel‐group, modified double‐blinded trial of a high n‐3 plus low n‐6 diet. BDs. Published online August 2, 2021. Doi:https://doi.org/10.1111/bdi.13112
39. Harvard T.H. Chan School of Public Health. Omega-3 Fatty Acids: An Essential Contribution. The Nutrition Source. Published May 22, 2019. https://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/fats-and-cholesterol/types-of-fat/omega-3-fats/
40. Mitchell ES, Conus N, Kaput J. B vitamin polymorphisms and behavior: Evidence of associations with neurodevelopment, depression, schizophrenia, BD and cognitive decline. Neuroscience & Biobehavioral Reviews. 2014;47:307-320. Doi:https://doi.org/10.1016/j.neubiorev.2014.08.006
41. Harvard School of Public Health. B Vitamins. The Nutrition Source. Published June 4, 2019. https://www.hsph.harvard.edu/nutritionsource/vitamins/vitamin-b/
42. Chmiel I. Ketogenic diet in therapy of bipolar affective disorder - case report and literature review. Psychiatria Polska. Published online July 19, 2021:1-19. Doi:https://doi.org/10.12740/pp/onlinefirst/136356
43. Kuang H, Duong A, Jeong H, Zachos K, Andreazza AC. Lactate in BD: A systematic review and meta‐analysis. Psychiatry and Clinical Neurosciences. 2018;72(8):546-555. Doi:https://doi.org/10.1111/pcn.12671
44. Li X, Yang Y, Zhang B, et al. Lactate metabolism in human health and disease. Signal Transduction and Targeted Therapy. 2022;7(1):1-22. Doi:https://doi.org/10.1038/s41392-022-01151-3
45. Dietch DM, Kerr-Gaffney J, Hockey M, et al. Efficacy of low carbohydrate and ketogenic diets in treating mood and anxiety disorders: systematic review and implications for clinical practice. BJPsych Open. 2023;9(3):e70. Doi:https://doi.org/10.1192/bjo.2023.36
46. Danan A, Westman EC, Saslow LR, Ede G. The Ketogenic Diet for Refractory Mental Illness: A Retrospective Analysis of 31 Inpatients. Frontiers in Psychiatry. 2022;13. Doi:https://doi.org/10.3389/fpsyt.2022.951376a
2. Rowland T, Marwaha S. Epidemiology and risk factors for BD. Therapeutic Advances in Psychopharmacology. 2018;8(9):251-269. Doi:https://doi.org/10.1177/2045125318769235
3. Simjanoski M, Patel S, Boni RD, et al. Lifestyle interventions for BDs: A systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews. 2023;152:105257. Doi:https://doi.org/10.1016/j.neubiorev.2023.105257
4. Smith DJ, Whitham EA, Ghaemi SN. Chapter 15 - BD. ScienceDirect. Published January 1, 2012. Accessed November 26, 2023. https://www.sciencedirect.com/science/article/abs/pii/B9780444520029000152?via=ihub
5. Solé B, Jiménez E, Torrent C, et al. Cognitive Impairment in BD: Treatment and Prevention Strategies. International Journal of Neuropsychopharmacology. 2017;20(8):670-680. Doi:https://doi.org/10.1093/ijnp/pyx032
6. Yatham LN, Kennedy SH, O’Donovan C, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of patients with BD: update 2007. BDs. 2006;8(6):721-739. Doi:https://doi.org/10.1111/j.1399-5618.2006.00432.x
7. Lee JG, Woo YS, Park SW, Seog DH, Seo MK, Bahk WM. Neuromolecular Etiology of BD: Possible Therapeutic Targets of Mood Stabilizers. Clinical Psychopharmacology and Neuroscience. 2022;20(2):228-239. Doi:https://doi.org/10.9758/cpn.2022.20.2.228
8. Harrison PJ, Geddes JR, Tunbridge EM. The Emerging Neurobiology of BD. Trends in Neurosciences. 2018;41(1):18-30. Doi:https://doi.org/10.1016/j.tins.2017.10.006
9. Jones GH, Vecera CM, Pinjari OF, Machado-Vieira R. Inflammatory signaling mechanisms in BD. Journal of Biomedical Science. 2021;28(1). Doi:https://doi.org/10.1186/s12929-021-00742-6
10. Luciano M, Sampogna G, Amore M, et al. Improving physical activity and diet in patients with severe mental disorders: Results from the LIFESTYLE multicentric, real-world randomized controlled trial. Psychiatry Research. 2022;317:114818. Doi:https://doi.org/10.1016/j.psychres.2022.114818
11. Johnson RJ, Wilson WL, Bland ST, Lanaspa MA. Fructose and uric acid as drivers of a hyperactive foraging response: A clue to behavioral disorders associated with impulsivity or mania? Evolution and Human Behavior. Published online October 1, 2020. Doi:https://doi.org/10.1016/j.evolhumbehav.2020.09.006
12. Łojko D, Stelmach-Mardas M, Suwalska A. Is diet important in BD? Psychiatria Polska. 2018;52(5):783-795. Doi:https://doi.org/10.12740/pp/onlinefirst/78703
13. Dorota Łojko, Stelmach-Mardas M, Aleksandra Suwalska. Diet quality and eating patterns in euthymic bipolar patients. PubMed. 2019;23(3):1221-1238. Doi:https://doi.org/10.26355/eurrev_201902_17016
14. Gabriel FC, Oliveira M, Martella BDM, et al. Nutrition and BD: a systematic review. Nutritional Neuroscience. Published online May 24, 2022:1-15. Doi:https://doi.org/10.1080/1028415X.2022.2077031
15. Madireddy S, Madireddy S. Therapeutic Interventions to Mitigate Mitochondrial Dysfunction and Oxidative Stress–Induced Damage in Patients with BD. International Journal of Molecular Sciences. 2022;23(3):1844. Doi:https://doi.org/10.3390/ijms23031844
16. Ashton MM, Dean OM, Marx W, et al. Diet quality, dietary inflammatory index and body mass index as predictors of response to adjunctiveN-acetylcysteine and mitochondrial agents in adults with BD: A sub-study of a randomised placebo-controlled trial. Australian & New Zealand Journal of Psychiatry. 2019;54(2):159-172. Doi:https://doi.org/10.1177/0004867419882497
17. Shah J, Sakshi Gurbani. Association of Vitamin D Deficiency and Mood Disorders.; 2019.
18. Boerman R, Cohen D, Schulte PFJ, Nugter A. Prevalence of Vitamin D Deficiency in Adult Outpatients With BD or Schizophrenia. Journal of clinical psychopharmacology. 2016;36(6): 588-592. Doi:https://doi.org/10.1097/JCP.0000000000000580
19. Higdon, Ph.D J. Coenzyme Q10 . Linus Pauling Institute: Micronutrient Information Center. Published 2003. 1. Coenzyme Q10. Linus Pauling Institute. Published April 28, 2014. https://lpi.oregonstate.edu/mic/dietary-factors/coenzyme-Q10
20. Jahangard L, Yasrebifar F, Haghighi M, Ranjbar A, Mehrpooya M. Influence of adjuvant Coenzyme Q10 on inflammatory and oxidative stress biomarkers in patients with BDs during the depressive episode. Molecular Biology Reports. Published online July 25, 2019. Doi:https://doi.org/10.1007/s11033-019-04989-z
21. Vasdev S, Singal P, Gill V. The antihypertensive effect of cysteine. International Journal of Angiology. 2009;18(01):07-21. Doi:https://doi.org/10.1055/s-0031-1278316
22. Nery FG, Tallman MJ, Cecil KM, et al. N ‐acetylcysteine for depression and glutamate changes in the left prefrontal cortex in adolescents and young adults at risk for BD: A pilot study. Early Intervention in Psychiatry. Published online April 2021. Doi:https://doi.org/10.1111/eip.13149
23. Wozniak J, DiSalvo M, Farrell A, et al. Findings from a pilot open-label trial of N-acetylcysteine for the treatment of pediatric mania and hypomania. BMC Psychiatry. 2022;22(1). Doi:https://doi.org/10.1186/s12888-022-03943-x
24. Campbell I, Campbell H. Mechanisms of insulin resistance, mitochondrial dysfunction and the action of the ketogenic diet in BD. Focus on the PI3K/AKT/HIF1-a pathway. Medical Hypotheses. 2020;145:110299. Doi:https://doi.org/10.1016/j.mehy.2020.110299
25. Porcu M, Urbano MR, Verri WA, et al. Effects of adjunctive N-acetylcysteine on depressive symptoms: Modulation by baseline high-sensitivity C-reactive protein. Psychiatry Research. 2018;263:268-274. Doi:https://doi.org/10.1016/j.psychres.2018.02.056
26. Whitbread D. Top 10 Foods Highest in Tryptophan. myfooddata. Published November 18, 2014. https://www.myfooddata.com/articles/high-tryptophan-foods.php
27. Davidson M, Rashidi N, Nurgali K, Apostolopoulos V. The Role of Tryptophan Metabolites in Neuropsychiatric Disorders. International Journal of Molecular Sciences. 2022;23(17):9968. Doi:https://doi.org/10.3390/ijms23179968
28. Huang Y, M.M. Wenxuan Zhao, Chen X, et al. Tryptophan Metabolism in Central Nervous System Diseases: Pathophysiology and Potential Therapeutic Strategies. Aging and Disease. 2023;14(3):858-858. Doi:https://doi.org/10.14336/ad.2022.0916
29. Generoso JS, Giridharan VV, Lee J, Macedo D, Barichello T. The role of the microbiota-gut-brain axis in neuropsychiatric disorders. Braz J Psychiatry. 2021;43:293-305. http://dx.doi.org/10.1590/1516-4446-2020-0987
30. Rudzki L, Stone TW, Maes M, Misiak B, Samochowiec J, Szulc A. Gut microbiota-derived vitamins - underrated powers of a multipotent ally in psychiatric health and disease. Progress in Neuro-Psychopharmacology & Biological Psychiatry. 2021;107:110240. Doi:https://doi.org/10.1016/j.pnpBD.2020.110240
31. Evans SJ, Bassis CM, Hein R, et al. The gut microbiome composition associates with BD and illness severity. Journal of Psychiatric Research. 2017;87:23-29. Doi:https://doi.org/10.1016/j.jpsychires.2016.12.007
32. Dickerson F, Adamos M, Katsafanas E, et al. Adjunctive probiotic microorganisms to prevent rehospitalization in patients with acute mania: A randomized controlled trial. BDs. 2018;20(7):614-621. Doi:https://doi.org/10.1111/bdi.12652
33. Douglas LC, Sanders ME. Probiotics and Prebiotics in Dietetics Practice. Journal of the American Dietetic Association. 2008; 108(3):510-521. Doi:https://doi.org/10.1016/j.jada.2007.12.009
34. Siwek M, Sowa-Kućma M, Styczeń K, et al. Decreased serum zinc concentration during depressive episodes in patients with BD. Journal of Affective Disorders. 2016;190:272-277. Doi:https://doi.org/10.1016/j.jad.2015.10.026
35. Jonsson BH, Orhan F, Bruno S, et al. Serum concentration of zinc is elevated in clinically stable BD patients. Brain and Behavior. 2021;12(1). Doi:https://doi.org/10.1002/brb3.2472
36. Cheng WW, Zhu Q, Zhang HY. Mineral Nutrition and the Risk of Chronic Diseases: A Mendelian Randomization Study. Nutrients. 2019;11(2):378. Doi:https://doi.org/10.3390/nu11020378
37. Ciappolino V, DelVecchio G, Prunas C, et al. The Effect of DHA Supplementation on Cognition in Patients with BD: An Exploratory Randomized Control Trial. Nutrients. 2020;12(3):708. Doi:https://doi.org/10.3390/nu12030708
38. Saunders EFH, Mukherjee D, Myers T, et al. Adjunctive dietary intervention for BD: a randomized, controlled, parallel‐group, modified double‐blinded trial of a high n‐3 plus low n‐6 diet. BDs. Published online August 2, 2021. Doi:https://doi.org/10.1111/bdi.13112
39. Harvard T.H. Chan School of Public Health. Omega-3 Fatty Acids: An Essential Contribution. The Nutrition Source. Published May 22, 2019. https://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/fats-and-cholesterol/types-of-fat/omega-3-fats/
40. Mitchell ES, Conus N, Kaput J. B vitamin polymorphisms and behavior: Evidence of associations with neurodevelopment, depression, schizophrenia, BD and cognitive decline. Neuroscience & Biobehavioral Reviews. 2014;47:307-320. Doi:https://doi.org/10.1016/j.neubiorev.2014.08.006
41. Harvard School of Public Health. B Vitamins. The Nutrition Source. Published June 4, 2019. https://www.hsph.harvard.edu/nutritionsource/vitamins/vitamin-b/
42. Chmiel I. Ketogenic diet in therapy of bipolar affective disorder - case report and literature review. Psychiatria Polska. Published online July 19, 2021:1-19. Doi:https://doi.org/10.12740/pp/onlinefirst/136356
43. Kuang H, Duong A, Jeong H, Zachos K, Andreazza AC. Lactate in BD: A systematic review and meta‐analysis. Psychiatry and Clinical Neurosciences. 2018;72(8):546-555. Doi:https://doi.org/10.1111/pcn.12671
44. Li X, Yang Y, Zhang B, et al. Lactate metabolism in human health and disease. Signal Transduction and Targeted Therapy. 2022;7(1):1-22. Doi:https://doi.org/10.1038/s41392-022-01151-3
45. Dietch DM, Kerr-Gaffney J, Hockey M, et al. Efficacy of low carbohydrate and ketogenic diets in treating mood and anxiety disorders: systematic review and implications for clinical practice. BJPsych Open. 2023;9(3):e70. Doi:https://doi.org/10.1192/bjo.2023.36
46. Danan A, Westman EC, Saslow LR, Ede G. The Ketogenic Diet for Refractory Mental Illness: A Retrospective Analysis of 31 Inpatients. Frontiers in Psychiatry. 2022;13. Doi:https://doi.org/10.3389/fpsyt.2022.951376a