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Metabolic Psychiatry and Ketogenic Therapy for Serious Mental Illness with Dr. Matthew Bernstein
Dr. Ben Weitz interviews psychiatrist Dr. Matthew Bernstein about metabolic psychiatry, proposing that some mental illnesses relate to brain energy metabolism, insulin resistance, and mitochondrial dysfunction rather than primarily neurotransmitter imbalance. Bernstein describes limits and side effects of conventional psychopharmacology and explains how brain insulin resistance can occur even with normal blood markers, especially in regions like the amygdala, hippocampus, and hypothalamus that use insulin-dependent GLUT4 transporters. He outlines how medical ketogenic diets may “rescue” brain energy by supplying ketones that cross the blood-brain barrier without insulin, reduce oxidative stress and inflammation, influence mitochondrial biogenesis, and shift GABA/glutamate balance. He discusses diet ratios, ketone monitoring, gradual transition and electrolyte support, conditions that may benefit, contraindications, medication reduction, lab testing (including carnitine), select supplements, and lifestyle factors such as exercise, mind-body practices, circadian rhythms, sleep, and gut health.
00:00 Show Intro and Mission
00:59 Metabolic Psychiatry Preview
02:40 Why He Shifted Beyond Meds
30:06 Low Carb vs Full Keto
33:42 Transition Tips and Keto Flu
36:00 Lasting Effects and Relapse Risk
39:32 When Keto Is Not Fit
41:12 Reducing Psych Meds
42:34 Lab Workup Essentials
43:24 Iron Mitochondria Link
44:28 Carnitine Troubleshooting
46:38 Supplements That Help
47:33 Creatine And NAC Dosing
53:32 Mind Body Stress Tools
55:39 Gut Microbiome And Fiber
57:49 Sleep Circadian Reset
58:54 Resources And Wrap Up
Dr. Matthew Bernstein is a psychiatrist and a leading voice in the emerging field of metabolic psychiatry. He’s the founder of Accord, a residential program designed around metabolic approaches to mental health and the website is Accordmh.com. He also serves as chief medical officer of Ellenhorn, and lectures in psychiatry at Harvard Medical School.
Dr. Ben Weitz is available for Functional Nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure. Dr. Weitz has also successfully helped many patients with managing their weight and improving their athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111.
Dr. Weitz: If you’re looking for clinically useful insights, not wellness hype, then this is the place for you. Welcome to the Rational Wellness Podcast, the podcast for functional and integrative practitioners who wanna practice with greater clarity and precision. I’m Dr. Ben Weitz, and each week, I sit down with the leading clinicians, researchers, and lab innovators to explore the science, lab testing, and clinical reasoning behind modern root cause medicine. This is a show focused on practical, evidence-informed insights that you can actually use in patient care. Please subscribe to the Rational Wellness Podcast on Apple, Spotify, or YouTube. Please tell your friends and colleagues, and if you could give us a ratings and review on Apple or Spotify, we would certainly appreciate it. Finally, to access the show notes and the full transcript, please go to my website, drweitz.com.
Today, we’re going to challenge an emerging area of psychiatry that challenges us to think about mental illness, not only in terms of neurotransmitters, the dominant theory today, but also in terms of metabolism, energy production, insulin resistance, and brain energy.
My guest is Dr. Matthew Bernstein, a psychiatrist and a leading voice in the field, the emerging field of metabolic psychiatry. Dr. Bernstein has more than two decades of experience in clinical psychiatry, and has spent the past several years focusing specifically on the relationship between, um, metabolic health and psychiatric illness. He’s the founder of Accord, a residential program designed around metabolic approaches to mental health. He also serves as chief medical officer of Ellenhorn, and lectures in psychiatry at Harvard Medical School. His interest in the field was influenced in part by the work of Dr. Christopher Palmer, and by seeing remarkable changes in patients with serious mental illness using ketogenic metabolic therapy.
The idea we’re going to explore today is fascinating. Could some psychiatric disorders be manifestations of how the brain produces and utilizes energy? And if that is true, could changing metabolism through a ketogenic diet change psychiatric symptoms? Dr. Bernstein, welcome to Rational Wellness Podcast.
Dr. Bernstein: Thanks for having me. Yeah.
Dr. Weitz: Excellent. So how did you move from conventional psychiatry into metabolic psychiatry?
Dr. Bernstein: Yeah. So I mean, I’ve, you know, been doing conventional work for a long time, but, you know, probably about 15 years ago started noticing that [00:03:00] even though these medications would often stabilize people with serious illnesses and, you know, I would prescribe them frequently, you know, I used to be an inpatient doctor, meaning, you know, dealing with the people with an acute crisis, and I saw these medications really help stabilize psychosis and mania and suicidal depression and-
Dr. Weitz: Let, let me just point out for those who aren’t following that conventional psychiatry revolves largely around the use of medications for treatment
Dr. Bernstein: Yes, especially for serious illnesses, I would say. You know, so conventional psychiatry might recommend a course of psychotherapy for someone with some mild to moderate depression or a grief reaction from losing someone or a job change. Um, more and more these days we are, we are reaching for our prescription pads, uh, even for those situations. But, you know the evidence shows that something like psychotherapy could be just as effective as [00:04:00] medications for those conditions.
But once we get to the more serious illnesses like schizophrenia, schizoaffective disorder, bipolar disorder, severe major depression, OCD, a severe case of OCD, and even things like PTSD and ADHD, we’re reaching for our prescription pads more and more and more in the last, you know, twenty years. It’s even changed since I did my training, you know, twenty-six years ago or so, I finished my training.
And so that’s the conventional approach. It’s we think about these things as imbalances in neurotransmitters, and we’re gonna use a medication that will, you know, block certain neurotransmitters or boost certain other neurotransmitters as the mainstay of treatment. Um, but what I started noticing is that, you know, even though those medications would stabilize people with some of these more serious conditions, they would then become very stuck in this very chronic sort of [00:05:00] state, where they weren’t needing to be hospitalized, but they also weren’t getting back to their full level of functioning.
They weren’t working. They weren’t living independently. They weren’t having relationships. They really weren’t living a full life, and that, you know, even reducing the medications would improve their functionality quite a bit, um, even without adding anything else, just re- just reducing medication. Um, and then, you know, I learned about this metabolic connection, metabolic approach probably about seven or eight years ago now, and I was very open-minded ’cause I had, uh, two of my kids had these sort of, uh, unusual, um, conditions they, they came down with, even though they were very healthy, and then all of a sudden they got what looked like very ill from a psychiatric perspective, but it really turned out to be an autoimmune encephalitis.
Their immune system was attacking their brain. So we were already deep in the functional medicine world and learning about these [00:06:00] mind-body connections and how much, you know, the immune system and hormones and the gut are affecting the brain. So then when I heard about these ketogenic diets and how they could treat Uh, people with treatment-resistant, medication-resistant epilepsy, that’s been known for 100 years now.
Um, and then, you know, the work on serious mental illness has been going on, you know, for a while now too, maybe about 10 years or so. I started, you know, hearing about this and, and I was very open-minded, thinking, oh, you know, this makes sense. There’s a lot about this mechanistically that is really deep and powerful, and the science there is actually, to me, much more compelling than the science around the neurotransmitter theories, which is not very compelling science, um, if you really look into it.
Dr. Weitz: Maybe you could talk a little bit more about the science of neurotransmitters. I’ve been pretty skeptical of that theory for a while, especially when you consider that there’s a [00:07:00] whole plethora of neurotransmitters that play varying roles in our mental health, and we often whittle it down to low serotonin or low dopamine or something like that. And then when you also consider that there’s medications that increase serotonin production, and then there’s a medication that lowers serotonin production that has essentially the same efficacy.
Dr. Bernstein: Yeah, and it’s not as simple as just like, you know, the medication increases production. I mean, what these SSRIs do is they block the reuptake of serotonin- Right … into the presynaptic neuron, so that the signal that serotonin is out there in that synaptic cleft is just a little bit longer. You know, it’s instead of, you know, 200 milliseconds, it might be 250 milliseconds. You know, and but then the, you know, if that’s happening immediately, the, the be- medications don’t usually have a benefit until- you know, three, four [00:08:00] weeks if they are going to have a benefit at all. But, you know, the benefits are really not very strong in major depressive disorder at all. The effect sizes are very weak compared to placebo. Um, but, you know, is it that there’s some postsynaptic changes in it? We’ve never really answered those questions about how these medications even work.
And we also know that they’re really– they’re not very effective, and they have a lot of side effects. And whenever there’s a treatment that isn’t very effective and has a lot of side effects, we’re not really at the root cause of the condition itself. If we were, it would be, you know, we’d have a lot of benefit and very few side effects. That’s how you know you’re getting at really what’s the cause of an illness. And we, and it, and, and, you know, we just have hypothesized that these illnesses have to do with these neurotransmitters because we, we accidentally found these medications work. They really were discovered by accident. Almost all the classes of psychopharmacology [00:09:00] were being studied for other things, and then eventually we learned that they work for some of these conditions.
They have some benefits. So for example, the original antipsychotic medication, Thorazine, was being studied as a surgical anesthetic, and then they realized that it had some benefits in psychosis. Um, similarly with antidepressants, the first tricyclic antidepressant was being studied as an anti-tuberculosis medication, and they noticed that people’s mood got a little better. Um, and then so then we’ve sort of reversed, uh, you know, engineered the hypothesis about these illnesses based on the fact that, well, the medications work on these neurotransmitters, so that must be what’s causing these illnesses. But there’s a whole set of research that existed even before the medications ever came online about metabolism and mental, mental health conditions.
We knew about glucose dysregulation in schizophrenia in the nineteen thirties, and we knew about problems with glutathione and lactate in these serious mental illnesses also in the nineteen thirties and [00:10:00] nineteen forties. And, and we, we’ve now reopened those hypotheses with this metabolic approach, and it turns out that people were on the right track back then before the medications ever came along. And we kind of got derailed, is the way I look at it, from really looking at what the root causes of these conditions are because we got enamored with these medications. And it’s unfortunate because the medications don’t typically ever fully solve the problem. Um, you ask any honest psychiatrist, and they will tell you the same thing.
Dr. Weitz: So explain how impaired metabolism contributes to psychiatric symptoms.
Dr. Bernstein: So, okay, so the brain is the most energy-intensive organ in the body. It’s, weighs about 2% of the weight of the body, and at any one time it’s using 20 to 25% of total energy in the body. And in addition, the brain has no energy storage at all. You know, we store our energy for our body in our fat cells, and then [00:11:00] in the form of glycogen in our muscles and in our liver. And so the brain is needing all this energy, and it’s, uh, also not storing it. It has no, like, local source of energy. So energy production becomes a real limiting factor in the brain functioning the way it should.
Um, and we have seen evidence of things like insulin resistance in all these major psychiatric conditions. We’ve seen evidence of mitochondrial dysfunction, which are energy factories in the cells, but they do a lot more in all these mental health conditions. And then we’ve seen epidemiologic evidence too, showing that, you know, kids with metabolic issues in childhood have a much higher rate of psychiatric disorders when they get to their 20s.
If you develop in your adulthood a, a metabolic disorder, you’re much more likely to end up with a psychiatric diagnosis, and it’s vice versa as well. If you start with a psychiatric diagnosis, you’re much more likely to get a m- metabolic diagnosis as well. So these are intricately related processes. [00:12:00] Um, and The other key thing to know is that someone can look metabolically fairly healthy on the outside, um, on, in their bloodstream, they might not have any signs of insulin resistance, but there still could be metabolic issues going on in their brain.
And so these areas in the brain that are really important for mental health conditions are the most vulnerable ones to things like brain insulin resistance, which can develop from stress. It doesn’t have to be just developing from a metabolic condition in the rest of the body. Um, so it all adds up to the idea that if we can improve metabolic function in the brain, um, we can have remarkably dramatic benefits in brain health and mental health.
Dr. Weitz: So how do we, how do we understand, and is there a way to measure brain insulin resistance as compared to whole body insulin resistance, which we measure by looking at glucose and insulin and hemoglobin A1C and- [00:13:00] Yeah … and HBI.
Dr. Bernstein: I wish. Yeah, we’re not there yet in the clinic. We don’t have a clinical test for brain insulin resistance, just like we don’t have a really good clinical test of what’s going on in the mitochondria in the brain either. And so we’re really left to hypothesize that when someone presents with a mental health problem, they’re just coming in with, you know, severe anxiety or depression or mania or psychosis, that there is a metabolic problem going on in their brain. And then if we think of it that way and we start targeting those levers, we get a lot of benefits. And, and that’s what I’ve been seeing clinically for, for years now. I mean, it’s really dramatically beneficial to do the things that will improve brain energy metabolism.
Dr. Weitz: How should we really understand this? How can it be that there’s insulin resistance in the brain and the rest of the body doesn’t have it?
Dr. Bernstein: Yeah. I mean it, the reality is that insulin resistance is not a universal phenomenon, that each organ can develop insulin resistance at its own rate, just like each organ can age at its own rate. You know, your heart can be sort of like a 50-year-old heart, your kidneys could be a 70-year-old kidney, you know?
Dr. Weitz: Right. You can get fatty liver and maybe some, the other organs can get fatty and, and the other organs aren’t.
Dr. Bernstein: Exactly. Exactly. And so, yeah, there, you know, there’s these insulin-dependent, insulin-dependent glucose transporters in certain areas of the brain that happen to be very, very important for mental health. So the hypothalamus, the hippocampus, and the amygdala, very important for everything that I do in my clinical work. Those use these GLUT4 transporters, which are insulin-dependent, and so when those areas are under stress, um, and, you know, the brain, the whole organism’s under stress, you know, which is true from adverse childhood [00:15:00] events, chronic stress from your job or your relationships, poor sleep, um, poor diet, like, you know, the, you know, you’re under stress, that’s going to lead to that insulin resistance in those specific areas of the brain, and you could have a perfectly normal, you know, hemoglobin A1c can be 5.0, and your fasting insulin could be four. You know, you could look just pristine in your blood work and still be, you know, very severely depressed, which means, you know you’re likely having, you know, severe brain insulin resistance in your amygdala, your hypothalamus, your hippocampus, and we need to focus on that. That if we can focus on that, we’re getting at more at the root cause of what’s causing that severe depression.
Dr. Weitz: So explain why the hypothalamus, the amygdala, the hippocampus, which are parts of the midbrain, why are those so important for understanding the psychiatric conditions?
Dr. Bernstein: Yeah. So I mean, if you think about, let’s just look at the amygdala. So the [00:16:00] amygdala is our area of the brain that is focused on fear, you know, and fear response. We need this part of our brain. We n- you know, when we were evolving, if we weren’t afraid of the things we should be afraid of, we would get killed, right? So it’s a very important part of the brain, but it gets overactive.
Dr. Weitz: Yeah, or you would climb mountains without ropes like-
Dr. Bernstein: Right. You’d, you’d climb without enough food and get, you know, starve at the top, right? Like you, you need to have a healthy amount of fear and anxiety to survive. But, you know, if it gets overactive, you know, if it’s, it’s enlarged, you know, because of so much stress, trauma, you know, problems that you’ve had, then you start thinking that everything is a threat, you know, that, you know, the person walking down the street is a threat to you even though they may not be.
And that’s the world that, you know, the people who come to see me are living in. They’ve got these overactive amygdala, um, and that’s leading to these symptoms that people have. You know, similar you think about, um, you know, the hippocampus. It’s [00:17:00] all about learning and memory. Well, if your brain is not easily learning new things, it’s gonna be, uh, you’re not gonna be flexible in those situations.
So, you know, if in your job, you know, all of a sudden everything’s changing and you feel like you can’t change along with it, do you think of how much stress you’re gonna feel, right? Um, y- and then you’re not sleeping well, and then you c- you are afraid to go to work, and then you get in trouble, and then you’re even more depressed.
And so th- these are the areas that lead to people having these, these mental health challenges. Um, and, and those are, again, those are the areas that are really susceptible to insulin resistance because they rely on these GLUT4 transporters, unlike other areas of the brain which, you know, don’t… They use other types of, uh, glucose transporters that don’t rely on an insulin signal
Dr. Weitz: So talk a little more about the GLUT4 transporter and why it’s so significant for what you do.
Dr. Bernstein: Yeah, so I mean again, so when most of the time our brain is running on [00:18:00] glucose. This is the main source of fuel for the brain. Fatty acids, which, you know, muscles are using all the time at rest. We’re both sitting here. Arm- when I’m moving my arm, my muscle’s using fatty acids for fuel, not even glucose. You know, it’s the, it’s the baseline fuel source. But fatty acids are too big to get into the brain. They won’t cross the blood-brain barrier, which is our filter to keep dangerous things out of the brain, and they keep large molecules out of the brain like a, like a full fatty acid. Um, and so, you know, our brain’s running on glucose, you know, most of the time.
Um, and you know, generally again, we need that insulin signal to get glucose into the neuron to be used as fuel. And so what ends up happening is those areas of the brain, if there’s resistance to that insulin signal, um, because of all the things we talked about, the stress most- mostly, um, but it could be metabolic issues as well.
You know, too much insulin all the time leads eventually to insulin resistance. Um, so for some people it has to do [00:19:00] with, you know, they’ve had diabetes or pre-diabetes for years, and eventually those areas get insulin resistant as well. Um, e- eventually those areas, they could be literally bathed in glucose, but that neuron could still be starving for energy because the insulin signal’s not allowing the glucose to get in.
Uh, this is where the, the treatment part comes in. You know, w- I’m recommending for people to use medical ketogenic diets, which means that we’re gonna send a bunch of these small fat molecules, ketones, that can cross the blood-brain barrier into the brain, and that same neuron in the, in the amygdala that was otherwise starving, all of a sudden it can use those ketones, and ketones do not require an insulin signal to get into those neurons. So that’s the really key point of what’s the difference between a ketone and glucose when it comes to rescuing these areas from a brain energy crisis.
Dr. Weitz: So what is your ketogenic diet look like? There have been [00:20:00] various propositions for what a ketogenic diet should look like, anywhere from 90% fat to 70% fat. Yeah. Um, they, seeing how m- h- how much protein is okay. Too much protein could even cause glucose release. You have Bredesen recommending a mildly ketogenic diet or what he calls a keto flex diet. Some people advocate being able to flex back and forth a little bit from using different fuel sources. What, what do you think is the optimal ketogenic diet for mental health?
Dr. Bernstein: Well, it, again, it depends a little bit on what condition we’re using it for. Okay. So if someone’s coming to me with a real serious mental health issue, they’ve got schizophrenia or, you know, bipolar disorder or severe treatment-resistant major depression, we are trying to get their ketone levels up pretty high. And so we don’t, you know, we can, you know, use a ratio, like you’re talking about 90% or [00:21:00] 70%. We tend to use these numbers like a 4:1 ratio or a 3:1 ratio, 2:1 ratio, and that’s grams of fat compared to grams of protein and carbohydrates combined. Typically I can get people’s ketones up in the program.
We have a dietician and, you know, we’re really looking over what’s going on. We can get their ketone levels above, you know, two millimolar of beta-hydroxybutyrate or even three with a 2:1 diet. We don’t tend to need to go above that ever. And some people, if they’re exercising a lot-
Dr. Weitz: So that’s 2:1 fats versus proteins and carbs.
Dr. Bernstein: Yeah, grams of fat versus grams of protein and carbs combined. Yeah.
Dr. Bernstein: Yeah. So yeah, so if you think about it, it would be like, you know, 150 grams of fat per day, 75 grams of protein and fat combi- protein and carbs combined. So maybe, you know, you would get, you know, 70 grams of protein and five grams of carbs.[00:22:00] That’s, that’s a low-calorie version of it. You know, that’s for a small person. You know, a bigger person, we want them to get more protein than that. And sometimes we can get away, like I said, with a 1.5 to 1 ratio, so, you know, even less fat and you can get a little more carbs and, and protein in there.
Um, but typically, you know, for most people, we can keep their protein levels up around 1.5 or 1.6 grams per kilogram per day because it’s also, uh, very important for overall health to, you know, feed the muscle protein that it needs and, and we, we want people to be building muscle while they’re doing this program as much as possible, ’cause that also has its own overall health benefits, but also mental health benefits. Muscle sends signals to the brain, these myokines, that are really good for mental health. And so exercise and building muscle is also a big part of this program. Um- So, so any, you know, so it depends on people’s preferences. You know, they may like, uh, [00:23:00] you know, and we generally like people to get some veggies, some non-starchy veggies in there. You can even have a little, you know, occasionally some berries and, you know, some fruits. Nuts and seeds can be part of this, avocados, olive oil.
Dr. Weitz: Does it matter what, what type of fats they’re getting when we’re talking about fats?
Dr. Bernstein: In terms of making ketones, it doesn’t matter that much. Um, in terms of, you know, to, you know, when we’re worried about looking at someone’s cholesterol numbers, that’s a whole other topic. Uh, but in general, you know, we are almost always exceeding this, you know, 10% saturated fat limit that the government still has. You know, I don’t see saturated fat as inherently dangerous at all, especially when someone’s not eating sugar and carbohydrates along with their saturated fat. I find that their blood work looks usually very good even with a high amount of saturated fat.
And so for a lot of people, if they tolerate dairy well, dairy fat ends up being a really big part of a ketogenic diet. If they don’t tolerate [00:24:00] dairy, you know, we’re looking at things like olive oil, avocados, nuts and seeds, things like that, coconut. Um, but again, we’re back, with coconut we’re back to a saturated fat.
Um, and you know, there are some very ketogenic fats. There’s one called MCT oil, which is derived from coconuts that’s often an, an, an additional thing that we add in so that it allows people to have a lower ratio of, uh, their diet, so it could be more like a 1.5 to 1 diet. Otherwise, looks more like a normal plate of food.
Um, but if you add in the MCT oil, we can keep those ketone levels up pretty high
Dr. Weitz: Is it beneficial to add exogenous ketones?
Dr. Bernstein: Generally, we’re not finding that that’s a, a strategy that, that often is necessary or that makes sense for most people. Um, occasionally, like if there’s certain situations, I mean, if people are wanting to see what, uh, you know, being in ketosis feels like as a test, you know, taking some exo- exogenous [00:25:00] ketones gives you a little bit of a sense of it.
But you’re not getting all the benefits of a ketogenic diet by taking exogenous ketones. People really need to understand that. Um, it is not the same thing. You’re not getting that insulin-lowering benefit. You’re not getting the glucose stabilization. You’re not getting a full 24 hours of elevated ketones ’cause exogenous ketones generally last about two or three hours at the longest, and so you can’t dose them in such a way that you’re having your ketones stay up throughout the day.
And most likely, there’s gonna be s- you know, I, I think, I predict there’s gonna be research that shows us that the, um, the level of ketones is gonna correlate with the brain health benefits, you know, especially not just a single test per day, but if once we get these continuous ketone monitors which are, you know, just got approved and we’ll get access to them very soon, um, we’re gonna see that probably the area under the curve for the whole day is the important thing to be looking at in terms of your ketones ’cause they really [00:26:00] fluctuate a lot throughout the day.
Um, they may start in the morning at .4, .5 and in the middle of the night they might get all the way up to 5 in the same day for the same person. Mm. Um, so they, you know, they, they vary by a factor of tenfold throughout the day for some people.
Dr. Weitz: And do you measure ketones in your patients?
Dr. Bernstein: We do, yeah. We measure it with blood a blood meter. Usually we use the Keto-Mojo, which is very accurate and gives us the best number. And we generally test like mid-afternoon or late-afternoon as a time, which is sort of a middle number for where it’s gonna be throughout the 24-hour period. Like I said, it’s kind of lowest in the morning with the cortisol surge in the, in the morning that kind of suppresses ketones a little bit.
And then in the middle of the night when cortisol’s really low, the ketones like just drift up higher and higher and higher generally.
Dr. Weitz: And is this new continuous ketone monitor, is this gonna be similar to a glucose monitor?
Dr. Bernstein: It’s, it’s gonna be very similar. Yeah, yeah. It’s like a, you know, thing that you can, uh, uh, you know, apply to the [00:27:00] back of your arm just like you do a continuous glucose monitor, which we also use, by the way, in the program.
They’re, they’re useful for, for multiple reasons. Um, but the ketone monitor is gonna be very, very useful for people doing a medical ketogenic diet, for sure.
Dr. Weitz: So how does the brain work differently when it’s using ketones rather than glucose?
Dr. Bernstein: So yeah, so I mean, number one, we’re solving that, that energy problem in the certain areas of the brain.
So that’s a huge part of this, which is that if a neuron’s running out of fuel, it’s not gonna perform its function, which is essentially neurons, you know, the, the– those are the, the brain cells that I talk about the most, um, you know, that are– they’re the ones that are transmitting information. You know, they’re taking a signal from one neuron, and then they’re transmitting that signal if they– to a, to multiple different neurons, and they make up these networks, which is essentially how our brain does all the things that it does, which is, you know, an incr- most incredible, [00:28:00] uh, you know, thing in the universe in many ways is the human brain.
You know, it’s so complicated. We have no se– you know, we really don’t understand the depths of how it works. I mean, what I’m talking about, you know, is what we understand, but there’s so much more to it, obviously, that we, we haven’t figured out yet. Um, and so that’s one way in which ketones are gonna be super important.
The, i- the other thing that we know about is, you know, the signal that ketones give to cells to, uh, to make more mitochondria and also to recycle old, damaged mitochondria. So there is research that shows, it’s mostly animal research, but still very important, that ketones give a signal to the system called PGC1alpha, and that turns on mitochondrial biogenesis and mitophagy, which is that recycling process.
And mitochondria are also these– they’re these energy factories, but they’re way more than that. They’re a collective going around the cells to perform all kinds of vital functions in the [00:29:00] cell. And for example, in neurons, mitochondria go from the nucleus to the end of the axon, this long projection. At the end of it, it’s releasing these neurotransmitters.
The mitochondria huddle around these vesicles of neurotransmitters to help the neuron release those neurotransmitters. Um, and so they’re involved even in that neurotransmitter system. Um, they’re involved in transcription of DNA in the nucleus of the cell. They’re involved in– They can even decide if the cell lives or dies.
Um, th- they’re involved in initiating and resolving inflammation, uh, in the body, which we all know is very important for overall health, but it’s very important for mental health. All these mental health disorders are, uh, associated with excess inflammation in the brain So ketogenic diets help with that brain inflammation.
It actually helps with brain oxidative stress. When we’re burning ketones in the brain, that’s a less dirty fuel than burning glucose and so less oxidative stress. Um, and then, you know, we also know that [00:30:00] ketones do change some neurotransmitters directly. So from the epilepsy literature, we know that ketogenic diets increase GABA and reduce glutamate in the brain.
So GABA is like this universal brake pedal. So unlike things like serotonin, dopamine, norepinephrine, which are very localized neurotransmitter systems, just certain areas of the brain have, you know, the serotonin system, other areas have the dopamine system. GABA is universal all throughout the brain and, um, it’s constantly just sort of slowing things down when it needs to be slowed down.
And if we don’t have enough GABA, um, you know, our brain becomes too excitable, uh, which can lead to all kinds of problems. Um, and, uh, so we see that as one of the main– you know, one of the mechanisms by which these diets are helping with a lot of these mental health conditions. Um, same with glutamate. So glutamate’s this excitatory neurotransmitter that’s all over the brain.
It’s like the universal gas pedal. Um, and that gets reduced, um, in ketogenic [00:31:00] diets. There was, uh, one study that showed, you know, they were actually measuring glutamate in the brain with people with bipolar and on a ketogenic diet, and it significantly reduced glutamate in these important areas of the brain.
Um, and it actually reduced glutamate more than some of the medications can reduce glutamate that we use for bipolar disorder. So very interesting research that’s coming out about, you know, some of these mechanisms.
Dr. Weitz: Is there a response not as beneficial but somewhat beneficial for somebody who follows a lower carb approach that’s not necessarily ketogenic?
Dr. Bernstein: Yeah, absolutely. Yeah, you don’t need to go all the way to that ketogenic appro- approach, which, you know, I was saying, you know, that’s the approach I would recommend for someone with a serious mental health condition. If we have someone with a little bit of mild depression that’s episodic, a little mild anxiety, maybe some sleep issues, they don’t have quite the energy that they used to have, they feel like they, their brain isn’t thinking as [00:32:00] quickly or as clearly as it used to be, we don’t have to necessarily get a high level of ketones.
You know, we can do a much lower, uh, ratio, maybe a one-to-one ratio, which looks much more like a normal plate of food, just you’re avoiding the, you know, sugars and really starchy, uh, foods like bread and rice and pasta. Um, but you can eat a lot more liberally, you know, let’s say protein. You don’t have to eat as much fat.
That could produce a low level of ketosis. Maybe in like the afternoon it might be around .5, you know, instead of up to the two or three range. Uh, and then you combine that with some exercise and you can solve many, many, many, many of the world’s, uh, mental health problems with that approach. Um, and it’s not that hard to do actually.
Dr. Weitz: Actually, for the full ketogenic approach, can you just give us an idea of what a plate of food would look like? Let’s say you take somebody who’s eating 1,800, [00:33:00] 2,000 calories a day. Yeah. Give us just a sample of what three meals might look like.
Dr. Bernstein: Sure. Sure. So someone in, for breakfast might have, you know, three eggs cooked in a good amount of butter or olive oil, and they may have a half of an avocado sliced up on the side, and then they may have a little bit of MCT oil and heavy cream in their coffee.
So, you know, they’re getting some protein, they’re getting some fiber and, and, you know, vitamins and minerals from that avocado, but they’re, you know, the vast majority of the calories in that breakfast is from, uh, a fat source essentially.
Dr. Bernstein: Um, and then lunch could, you know, something simple might be, again, they could have like a, a tuna bowl.
Like you can open up a can of tuna and use a really generous amount of, uh, mayonnaise in there, and you might put some nuts in there, um, and some herbs. Um, and then, you know, maybe, uh, some [00:34:00] celery along with that, you know, to get in, again, getting some fiber and some, and some vegetable content in there. Um, but you know, again, you get- it’s- you get some protein, but, but again, if we put enough fat in there, you know, um, you know, it’s gonna, it’s gonna meet the criteria for being ketogenic.
And then dinner, again, could be like a piece of salmon or, you know, a piece of pork tenderloin and maybe some broccoli or asparagus on the side. And then it needs to have a, a fatty sauce. And if you wanna make a sauce, great. If you want to, you know how to cook and, um, all of that, um, excellent. But if you don’t, um, ha- you know, wanna be fancy about it, you can just pour a bunch of olive oil on your food.
You know, if you really wanna be simple, you know, just, you know, pour olive oil or some butter o- on there and, you know, again, you gotta get in a good amount of fat along with the, the, the rest of the food. Um, and you know, that can do it. Um, so that’s like sort of an [00:35:00] omnivore simple version of a ketogenic diet.
There’s many different versions, and people do it fancy, they do it carnivore style. Some people do it vegetarian or, and even vegan, although that’s very hard to do it vegan. Um, yeah
Dr. Weitz: And when people follow a full-on ketogenic diet, do you recommend going into gradually, hardcore? What are some of the, uh, problems people have when they try to get their body, which is m- mostly used to breaking down, uh, carbohydrates and proteins, and now all of a sudden has to break down a lot of fat?
Dr. Bernstein: Yeah, it’s gotta use a whole new fuel source. Right. So you gotta ch- you know, the cells have to learn how to burn fat much more preferentially than burning glucose for fuel. The liver’s got a whole different job to do now, you know, uh- And the
Dr. Weitz: gut enzyme structure has to change …
Dr. Bernstein: mi- microbiome’s gonna change.
Your, your pancreas is making different enzymes to break down fats. Yeah, [00:36:00] lots and lots of physiological changes that need to be made. And so if there’s no hurry, um, and someone’s doing this on their own, it’s much better to do this gradually than to do it, you know, to slam yourself into this whole new paradigm.
And when you are making this transition, it’s very, very important too to drink lots of water and take in some electrolytes because the, the process of changing the metabolic, um, you know, fuel source, we’re gonna get rid of a lot of this glycogen storage. So, you know, generally if you’re eating carbohydrates, you’re storing, you know, about a day’s worth of carbohydrates in your muscles and, and in your liver as glycogen, and mostly that’s gonna get used up in, in the beginning when you start reducing your carbohydrate intake, and, and then you’re not replacing it.
So when the glycogen’s coming out and, and getting used, it’s bringing with it a lot of water, and so you’re losing, you know, a few pounds of water in that transition. And so when people, you know, f- let’s say people fast and they go into [00:37:00] ketosis in two or three days, um, or they just, you know, stop eating carbohydrates completely if they do it and, you know, they’ll g- might get into ketosis in, again, two or three days, um, they’re at risk of this f- situation called keto flu, which is losing water, losing electrolytes.
People feel really awful. You feel very sick. Um, and so we… But we generally can avoid that either by doing it gradually, or if you’re, even if you’re doing it, um, all at once, you just have to drink a lot of water and take in a lot of electrolytes, a lot of salt, potassium, and magnesium, and, and you don’t necessarily have to have any keto flu symptoms.
Most of the people in our program never get any keto flu symptoms at all, and we put people into ketosis very quickly usually.
Dr. Weitz: And when somebody’s on a ketogenic diet, is it, are there permanent changes that happen to the brain, or is it only beneficial as long as they stay on it?
Dr. Bernstein: Well, we do definitely think there’s permanent changes.
Um, you know, there’s, there’s gonna be, for example, that, that brain insulin [00:38:00] resistance is going to reverse. Um, w- because we’re giving that signal to the mi- the cells to make more mitochondria, those cells are getting healthier. They’re having, you know, better and more and healthier mitochondria. Um, and then, you know, as people are doing that, we’re creating this, um, opening for neuroplasticity for the brain to change along with whatever new experiences people have.
Um, and so a period of recovery using a ketogenic diet, you know, we’re, we are making brain changes. The brain is changing all the time. Um, but can we completely reverse one of these conditions? That research really we don’t have a lot of science to answer that question. I can just give you anecdote. Um, there are s- a few people, adults I know with serious mental health conditions, who have been able to be on a ketogenic diet for a few years and then transition off of it and retain those benefits.
But that is not something that I promise to people, ’cause it’s not the most common story that you hear. The more common thing you’ll hear is that I feel way better doing a [00:39:00] ketogenic diet, exercising, doing these other aspects of metabolic treatment, which we can get into. Um, and then, you know, if I go off my diet, if I eat a bunch of carbohydrates because, you know, I just felt like it or I was in a, I was traveling, it wasn’t easy to find my foods, uh, the people feel worse, um, sometimes, sometimes dramatically and quickly.
Um, but the, my sense is that the longer someone stays on a ketogenic diet, the more resilient their brain would be to not being in a state of ketosis, but it depends on a lot of factors. You know, it depends on how long they were sick in the first place and how many medications they’re on and how many they’re still taking.
And so i- i- and everyone’s individual. So we w- we’re, we just don’t have enough science to fully answer that question. Um, but generally I say, you know, most likely you’re gonna feel so good you’re gonna wanna stay on this. Um, and you’re gonna, you’re gonna see it as a small, uh, the inconvenience of doing it as a very [00:40:00] small part of your life compared to how much better you’re feeling and how much problems it’s solving for you.
Dr. Weitz: Which psychiatric conditions do you think benefit the most from a ketogenic diet?
Dr. Bernstein: I don’t think we know the answer to that yet. We’re, w- you know, whenever we’re studying new ones, we’re seeing benefits, and clinically I’m seeing benefits in many, many different conditions. Like every one that I’ve named today on this podcast I’ve seen benefits in.
Um, and we probably have the most research in bipolar disorder. Uh, that’s one that, you know, people are very excited about. But I would not say at all that this is only for bipolar disorder. You know, again, I see- I’ve seen benefits in psychosis, severe major depression, OCD, uh, PTSD, even in anorexia there’s, there’s a new study that came out this year in weight restored anorexia, uh, that the ketogenic diet was extremely beneficial for all the continued depression and other, uh, thinking about body image, thinking about food, all [00:41:00] that responded beautifully well to, to women who were weight restored with their anorexia but still were having lots of symptoms.
Um, so you know, that would be counterintuitive to the eating disorder clinicians out there, but-
Dr. Weitz: For sure. You’re worried about putting somebody on a restrictive diet who- Yeah … already is… Yeah.
Dr. Bernstein: Yeah, but it, it’s, it’s really, it’s really seems to be helpful, um, in eating disorders. Uh, not just anorexia, but binge eating disorder as well.
We see it as very, very helpful in binge eating disorder.
Dr. Weitz: Are there certain patients where you would say you should not follow a ketogenic diet?
Dr. Bernstein: Yeah. I mean, I think, uh, certainly people who are gonna struggle with, you know, following the program, following the rules, I mean, that’s probably the biggest contraindication in my population is that, you know, people are either not motivated or, or not capable, um, of, you know, following all of this ’cause it- there’s a lot to it.
As we were talking about, a lot of details here, um, [00:42:00] which we’ve gotten into a little bit of. But, you know, to really do a healthy ketogenic diet, you know, you gotta, you know, you gotta be able to shop and cook and, and, you know, understand macronutrients and, you know, measurements and all of this stuff. Um, so that’s a, a big contraindication.
Um, you know, for, for, for medical contraindications, there’s not that many actually. You know, I wouldn’t induce ketosis in someone who’s pregnant. Um, you know, that’s not probably a wise thing. We don’t have a lot of research on that. Um, it’s done in kids all the time for epilepsy. And so I’m not a child psychiatrist, but people ask me all the time, “Is this safe for kids?”
Well, there’s, you know, many decades worth of, of literature on doing this safely in kids and, and it is more effective than antiepileptic drugs in pediatric epilepsy. Um, there’s a couple medications that are contraindicated, uh, SGLT2 inhibitors in particular. We have to stop those when we do a ketogenic diet.
And then, you know, blood pressure medications, um, diabetes medications, [00:43:00] we’re gonna need to lower the doses of those medications early on in the process because as metabolism improves, you know, we don’t need the same amount of blood pressure medication or diabetes medication, and we can overshoot with those medications once someone’s getting metabolically healthier, which happens very quickly actually in, in practice.
Dr. Weitz: And what percentage of your patients who follow a ketogenic diet are they, um, able to reduce their psychiatric meds?
Dr. Bernstein: Many of them, yeah. I mean, in many people that is the goal. You know, they, they come to me saying, “I’d like to be on less medication if I can. I still wanna be stable. I don’t wanna get ill. I don’t ever go, wanna go back to a hospital, but I’d really like to live on less medication.”
Um, and many of them can reduce medication. Um, and then there’s some people who don’t wanna reduce their medication. They say, you know, they say like, “I’m comfortable on this medication. I’ve been on ones, I’ve been off of ones, and I wanna stay on this.” And that’s okay too for people to choose to wanna stay on medication.
Um, [00:44:00] some people find though once they’re in ketosis for a while they are more susceptible, they’re more sensitive to the side effects of their medication, and then even if they started off saying, “I’m not sure I wanna reduce my medication,” they realize at a certain point, they say, “Well, now I’m feeling more side effects.
Let’s see if I can do well on less.” And, and the art of reducing medication without inducing a withdrawal syndrome is, is also a very, very important topic. Um, and I think my field has gotten that wrong for many years where we just reduce medication, you know, by half and then by half again, you know, in a week and then another week and then we stop and we say that’s a taper, you know, one or two weeks.
Uh, for many people that’s gonna induce a withdrawal syndrome, uh, for many people on many medications. Yeah.
Dr. Weitz: Um, when you see a new patient what is your lab testing look like?
Dr. Bernstein: So at the program we do a pretty thorough lab panel. We’re doing, um, you know, the advanced, uh, lipid profile [00:45:00] which is, you know, the NMR fractionation of all the different lipids.
Dr. Bernstein: Uh, we do the HOMA-IR test, hemoglobin A1C obviously. We’re getting s- um, you know, obviously like a CBC. We get a homocysteine, HSCRP, iron levels, vitamin D levels, copper, ceruloplasmin. We do a celiac screen on everyone. A- any psychiatric patient who’s not had a celiac screen should get one for sure.
We do all the thyroid tests that you can get. Um, we find a lot of abnormalities there. I’m seeing a lot of abnormalities in, in iron too interestingly in psychiatric populations even in, in men where you wouldn’t necessarily expect to find it, but-
Dr. Weitz: What, what kind of pattern are you seeing?
Dr. Bernstein: I mean, often it’s low ferritin, like people just have low iron storage.
Sometimes they’re at frankly low in their iron in their blood as well. Um, th- that’s very common. Um- What,
Dr. Weitz: what do you make of a patient who has say normal serum iron but low ferritin?
Dr. Bernstein: I mean, [00:46:00] it’s just l- I mean, t- usually that’s just low iron storage, so, uh, you know, they, they can’t deal with a stressor that’s going to, uh, s- you know, take up more, you know, use up more iron.
And we, we think about iron as only part of, you know, red blood cells, but the mitochondria have iron as part of those, um, those proteins on the electron transport chain. Iron are part of those complexes. And so our mitochondria can’t function and make energy if we don’t have enough iron. And so it ends up being, I think, very, very important in this whole story of metabolism and mental health.
Dr. Weitz: So in that case, you’re adding more iron supplements?
Dr. Bernstein: Exactly. Yeah, I mean, sometimes, uh, di- if it’s just, you know, slightly low ferritin, you know, the, the good diet where we’re adding back in some, you know, red meat that they weren’t getting before will solve that. Um, oh, the other test that we get, too, I forgot to mention, is carnitine.
Very important test to get when someone’s doing a ketogenic diet. So, uh, the mitochondria need carnitine to get the fuel across the inner [00:47:00] mitochondrial membrane, and we use up a lot more carnitine when someone’s on a ketogenic diet, and there are some medications that we use in psychiatry that deplete carnitine as well.
So sometimes I’m seeing low carnitine in the beginning, but r- usually it’s showing up, when it does, a couple months into the ketogenic diet. And what you see the pattern of is that even though someone’s strictly doing the diet, they’re not getting the benefits, and they’re not making as many ketones as you think they would make, uh, from how strictly they’re doing it.
Sometimes that’s caused by low carnitine. So if you don’t have access- Interesting … to a carnitine blood test, which in, you know, most people can get access to, but if f- for whatever reason, if you don’t have access to that, you can just empirically try some carnitine supplementation in that kind of situation, and sometimes you’ll get a nice benefit.
Um, there’s some warnings- White, white, white man- … about carnitine indu- inducing- Yeah … mania, too. I just wanna put that out there that- Okay … some people are worried about just, you know, everyone taking carnitine. You might induce some excitability, insomnia, even some [00:48:00] hypomania in some people, but I, I tend to think it’s pretty safe, actually.
Um, and it’s, the, the medication that it lowers carnitine most is, uh, valproic acid or also known as Depakote, which is very- Yeah … commonly prescribed to people with bipolar disorder as well as people with seizures, but you see it in bipolar all the time, and that really depletes carnitine.
Dr. Weitz: Uh, recently in the cardiovascular world, they’ve put some warnings about carnitine increasing TMAO levels
Dr. Bernstein: Oh, interesting.
Dr. Weitz: which I’m pretty skeptical about. But Stanley Hazen of, uh, Cleveland Clinic has recommended, um, avoiding red meat and avoiding, um, uh, d- both, uh, L-carnitine and, uh, choline, which is another essential uh, nutrient for the brain.
Dr. Bernstein: I’m, I’m extremely skeptical as well. I mean, I mean, again, you know, if you’re mostly suffering with a, a mental health condition, these kind of warnings are really unfortunate and je- you know, [00:49:00] potentially, like, you know, scaring people away from the very things that are going, that they need to feed their brain.
Dr. Weitz: So let’s talk about some of the nutritional supplements that you find some of the patients can benefit from with psychiatric- Yeah … disorders.
Dr. Bernstein: Yeah. So, you know, as we were saying, you know, testing for iron, vitamin D, we were gonna replete those. Uh,
Dr. Weitz: when- You test for omega-3?
Dr. Bernstein: I, I haven’t been. I’m, I’m considering it, adding, adding it to my panel.
I mean, people are gonna get a lot of good omega-3s in the diet, uh, once we get them into this diet. Um, but you know, there’s could be a lot to, uh, make up for, so s- you know, supplementation is, is often very helpful, um, you know, omega-3 supplementation. Um, so we’re gonna, you know, we’re, we’re gonna look at homocysteine too, and when that’s elevated, you know, I tend to think, you know, th- a lot of people are doing genetic tests.
I’m not as convinced about that. I tend to just move right to just giving people a good methylated B complex at that point- Yeah … and that usually brings [00:50:00] their homocysteine down, and I, I don’t worry as much about, um, MTHFR as a lot of people do. Um- And let’s see, um, uh, creatine I think is really useful. Um, you know, obviously it’s gonna help people in the gym, which is again, a big part of this metabolic approach.
Dr. Weitz: there’s- So the dosage for the gym is like five grams. What do you find for psychiatric, uh, patients?
Dr. Bernstein: Yeah, tend to, tend to go higher, uh, for brain health. Uh, what they-
Dr. Bernstein: 10 minimum, yeah. And then some people, if they’re tolerating that, they may try higher and prefer even 15 or 20. Um, but you know, minimum 10, so like 10 to 20 would be the range for brain health, I would say.
Dr. Weitz: And when it comes to L-carnitine, uh- Yeah … L-carnitine versus acetyl-L-carnitine and dosage?
Dr. Bernstein: I generally use acetyl-L-carnitine, yeah. I, I’m not as aware of the nuances, I think, between acetyl-L-carnitine and L-carnitine.
Dr. Bernstein: Um, [00:51:00] but I generally am using acetyl-L-carnitine. Start with like 500 twice a day, and then we’ll retest and see if they’re repleted.
If not, we may end up going higher than that, yeah.
Dr. Weitz: Um, what about other supplements, vitamin D,
Dr. Bernstein: anything? Yeah, vitamin D if it’s low especially, and you know, we’re try- we’re shooting for more in like the 50 to 80 range for vitamin D- Okay … at least. Um, so that, that can be very useful. I’m, I try to be a bit of a supplement minimalist.
If people ask me for more, I’ve got plenty more I can talk about. Um, you know, especially- There’s
Dr. Weitz: been some interesting research with NAC, with various psychiatric disorders.
Dr. Bernstein: NAC, high-dose NAC for OCD, definitely. Yeah, there’s really good research, but you gotta get the dose up. So I think people on- sometimes try, you know, 1,000 of NAC and they say, “Oh, it didn’t work.”
But the research actually shows you gotta get up to more like 2,500, 3,000 of NAC-
Dr. Weitz: Oh, interesting. That’s a clinical pearl- Per day … right there.
Dr. Bernstein: [00:52:00] Yeah, that’s important For things like, for sleep, there’s all kinds of interesting things we can try. I mean, uh, magnesium in general, y- a lot of people benefit from, especially at nighttime.
I, I prefer for brain health the magnesium threonate ’cause it gets into the brain. Um, I like L-theanine a lot for an- anxious people. If their brain can’t shut down, that can be really useful at night. Um, glycine also, a big dose of glycine at night sometimes really helps people fall asleep. Um, so those are some, some go-to favorites.
And, uh, but there’s, you know, lots of herbs out there. I mean, lion’s mane, you know? People can, you can, you can end up taking, you know, 40 supplements a day- … uh, easy.
Dr. Weitz: Which, which I do.
Dr. Bernstein: Yeah, yeah. And you know, I think it’s, a lot of people find it so burdensome, right? Sure. And so, you know, I am often seeing people coming in on 30 supplements, and they say, well…
And I ask them, “Are these helping you?” And they say, “Well, that one for sure seemed to help. The rest of them, I never could tell,” you [00:53:00] know? “I don’t know.” Um, and so it depends. Some of these things you, you might wanna keep taking for your overall health. Like, some of these things are just protective, uh, for your health.
Sure. You know? And, and I do take a good number myself, but I try to tailor it to the individual’s, you know, sort of taste and preference and their needs, you know? And, and not just say, you know, everyone needs the same, you know, 10 supplements and- Sure … you know, and then t- 10 more if you’re willing, you know?
It’s like, it, it’s a lot for people.
Dr. Weitz: I, I get it. Um-
Dr. Weitz: another supplement I’ve, I’ve talked to other practitioners, uh- Yeah … who are in a similar space like is low-dose lithium.
Dr. Bernstein: Yeah, low-dose lithium Interesting. Yeah, very interesting one. Um, so, you know, we’ve been using it, um, you know, in the mental health world for a long time.
You know, the- Dr. James Greenblatt has been writing about this for a couple of decades, actually.
Dr. Weitz: Yeah, I had him on the podcast.
Dr. Bernstein: Yeah. He- and he, he’s great. I, I, I took his [00:54:00] fellowship and learned all the research there. The research is super interesting about, you know, the, the, the amount of lithium in the water, and that there really should be a recommended daily allowance of lithium, but it’s more like about a milligram probably is what people really need.
Once you’re getting above that, you’re using it more as a therapeutic, not just a, a, a, a, a mineral that your body absolutely needs. Um- There’s
Dr. Weitz: even data showing it reduces amyloid plaque in the brain.
Dr. Bernstein: Yeah, yeah. I mean, that’s recent. So, so- Yeah … so, you know, so for- if you’re using it for, for mood, you know, great.
Five milligrams, 10 milligrams, it’s a therapeutic dose for some people. Right.
Dr. Bernstein: Um, and, you know, and it’s certainly a lot safer than taking, you know, full-dose lithium carbonate. Sure. And for a lot of people, it works as well. I’ve definitely been able to transition people with bipolar disorder who are lithium responsive from lithium carbonate full dose to li- you know, low amounts of lithium orotate, which I think is much, much safer for them.
Um, [00:55:00] but then the research came out, you know, not too long ago, like, really showing that there’s- this has a preventative benefit for the brain. Um, you know, and so many people who are worried about dementia, which we all should be, um, you know, it’s not unreasonable at all to take, you know, five milligrams of lithium orotate just as a preventative, you know, just to add it in there.
And it’s, and very, very low risk, very easy to take. Uh, you know,
Dr. Weitz: I think- You can take it at night. It helps a little bit with sleep.
Dr. Bernstein: Yeah, yeah. You, you c- exactly. And, you know, you know, I know Dr. Greenblatt recommends, like, once a year, you know, get a lithium level and get a creatinine level, um, just to make sure that you’re, you know, not…
And, and a thyroid test. But, you know, people should be getting a creatinine and a thyroid every year anyway, so, um-
Dr. Weitz: Well, thyroid is not often done necessarily, but creatinine is part of your typical chem screen metabolic- Yes … metabolic panel.
Dr. Bernstein: Yeah, yeah. Yes. But, you know, people should be getting a thyroid screen.
Dr. Weitz: Oh, absolutely. And a, and a full thyroid [00:56:00] panel, not just TSH, but-
Dr. Weitz: typically they have this way of trying to reduce the testing, so you get a- Yeah … TSH, and only if the TSH is abnormal, then you get a T3. Right. And only if T3, uh, uh, T4 is abnormal, maybe you’ll get a T3 or maybe you won’t.
Dr. Bernstein: Yeah. Right, but exactly.
Why not get, you know, why not see the full picture? Let’s look at the antibodies. Let’s look at the reverse
Dr. Weitz: T3. Right. Absolutely.
Dr. Bernstein: You know? Absolutely. Yeah, I agree with you. Yes. Yeah.
Dr. Weitz: All right. Um, uh, any things we haven’t covered that you’d like to talk about?
Dr. Bernstein: Yeah. I mean, part of the approach too is not just diet, not just exercise.
We’re also h- strongly recommending, you know, other things. So one would be mind-body practices. So very important and instrumental to, um, our whole hormonal system that eventually affects metabolism, if we can just think about the hormone cortisol being elevated all the time, and a mind-body practice that [00:57:00] will bring that down.
We know that cortisol’s very disruptive to metabolic health, and it’s gonna raise blood sugar, it’s gonna reduce our ability to make ketones. And so in my population, everyone needs to be doing a mind-body practice. So we’re giving people many options. There’s so many options of things people can do. It’s not just, you know, meditation is the only option.
You know, we can do Tai Chi, we can do yoga, we can do breathing practices. There’s walking meditations. There’s so many different things people can do. Very, very important. Wh-
Dr. Weitz: what’s, what’s your favorite?
Dr. Bernstein: Well, it de- I’m talking for me or for my patients? Well- Yeah …
Dr. Weitz: which ones do you like to recommend to the patients?
Dr. Bernstein: Yeah, so well, what we often try to introduce people to is this, uh, the HeartMath device, which has been around- Okay … for a long time, but it’s, you know, clips to your ear, and it gives you, um, HRV in real time, very accurate, and you breathe along with it, and you can see your HRV getting more coherent. You see your coherence scores going up.
Um, and that’s a really great device ’cause it gives a little [00:58:00] biofeedback, and I think people really who are learning how to do this in the beginning really benefit from a little bit of feedback in real time to their practice. So I, I tend to really like that one. But some people don’t gravitate towards that.
They’d rather do something else, and it’s the, it’s the one that someone’s gonna do is the most im- is the best one.
Dr. Weitz: What do you think- By far … about vagal nerve therapies?
Dr. Bernstein: I don’t have that much experience. I mean, th- they’ve had vagal nerve stimulators, you know, that, you know, medical versions for decades, but the research has never been that strong for mental health.
Um, you know, little bit of research benefit for that. So, you know, I think it’s, you know, it’s interesting. I just haven’t done my research to really be able to, you know, uh, have much experience with them. Um-
Dr. Weitz: Right. Do you deal with gut health as a factor?
Dr. Bernstein: Absolutely. Gut health is very crucial. And, and again, you know, a lot of that gets solved.
You know, people think you have to do a lot of fancy testing and supplements, and [00:59:00] for some people you do, but really truly cleaning up the diet, um, you know, from processed food, from the foods that are triggering that person, um, you know, usually solves most gut health issues in my-
Dr. Weitz: One challenge of the ketogenic diet is it tends to be lower in fiber.
Dr. Bernstein: Yeah, and for some people, that’s actually exactly what they need. Um- Right … you know? And so- Yeah, sure … some people, you know, the
Dr. Weitz: fiber- For patients who have bacterial overgrowth, yeah.
Dr. Bernstein: Exactly. Too much fiber i- and so l- you know, low fiber is good. Other people, you know, they need the fiber. But
Dr. Weitz: it does tend to negatively impact the microbiome.
Dr. Bernstein: Not necessarily. It changes the microbiome. Okay. But then again, I don’t think we know exactly what’s, what, uh, the optimal microbiome is. I, I think the research, especially for the brain, we don’t know the answer to that. And actually, one of the mechanisms by which the ketogenic diet helps in epilepsy based on lots of good science is through a microbiome mechanism, that [01:00:00] actually you’re making more akkermansia muciniphila with a ketogenic diet.
In addition, r- y- it’s really important to remember that beta-hydroxybutyrate- feeds those epithelial cells on the gut lining, um, similar to the butyrate that you’re producing from, you know, from the gut, the gut microbiome. Um, and
Dr. Weitz: so- And there’s, and there’s supplements on the market using Akkermansia to help control blood sugar.
Dr. Bernstein: That’s right. Yeah. Akkermansia is a big part of this. Um, but again, these are… We just have little clues on the microbiome, and the whole story is so much bigger than what we know so far. Um, but, but I definitely would not assume that the ketogenic diet’s negative for the microbiome. Um, it’s just gonna change it for sure.
Um, we need different bacteria to break down all these fats and, and work with these fats. Um, and for some people, again, you know, lower, lower fiber is good. You can eat a very high amount of fiber on a ketogenic diet if you’re trying to. Um, you know, and [01:01:00] so some people will, will make sure they’re getting lots of fiber and maybe even supplement their fiber if they need it.
Dr. Weitz: Right. What other lifestyle factors? Sleep obviously is very important. There’s…
Dr. Bernstein: Yeah, so the other part I was gonna talk about is, um, you know, circadian rhythms and sleep. Incredibly powerful in terms of mental health and the brain, and light exposure at the right times, getting up and seeing morning sunlight, being outside multiple times during the day to set that, uh, circadian clock, which is sitting right on top of our optic nerves where they cross.
The suprachiasmatic nucleus is there for a reason, because the light is what is giving it that signal, and we evolved outdoors. Um, we did not evolve to be sitting indoors all day. And so getting people to go outside multiple times during the day and then really doing their best to avoid blue light at night is so powerful.
Um, going to bed at the same time, waking up at the same time, even more important than going to bed at the same time. Um, these things end up becoming incredibly important and [01:02:00] powerful levers and, and we kind of just, you know, think of them as afterthoughts. But if we don’t get that locked in, we’re not gonna get all the benefits.
Dr. Weitz: That’s great. Excellent- Yeah … discussion, Doc.
Dr. Bernstein: Yeah, my pleasure. Yeah.
Dr. Weitz: How can viewers find out more about you, get in touch with you, find out about your programs?
Dr. Bernstein: So if they want to find out about the program, there’s a website for the program called, it’s called Accord, A-C-C-O-R-D. The website is accordmh.com, so accordmh.com. And then if they want to get in touch with me directly, I’m on LinkedIn, so I’m not on a bunch of other social media. That’s sort of, I think, just the nature of being a psychiatrist. When I trained, we were all suspicious of social media, and I just have never gotten into it. Okay … but I am on LinkedIn. If people want to find me there, they can, and I will always answer any, like, individual reaching out to me for, for help or support, absolutely.
Dr. Weitz: And do you have any programs for [01:03:00] practitioners?
Dr. Bernstein: I don’t. I am on, um, I am doing a lot of conferences, you know, lectures there, and I’m, you know, grand rounds at hospitals, so I’m really trying to spread the word to other clinicians. And if clinicians wanna learn more about this approach, there’s a great website called Metabolic Mind, where there’s lots of teaching content. There’s links to CMEs that I’ve done and other f- doctors have done, and there’s a whole training program that they’re releasing, uh, run by Dr. Georgia Ede, who’s one of the leaders in this field and wrote a great book, uh, called Change Your Diet, Change Your Mind. She has a whole clinician training program that they’re gonna be offering for free through Metabolic Mind. Um, and that’s- Wow. That’s,
Dr. Weitz: that’s awesome
Dr. Bernstein: … that’s the training program. Yeah. So if people really wanna know how to use these metabolic approaches, ketogenic diets for mental health conditions, and how to combine it with medications and what you need to do, there’s a ton of information there that, that people can learn.
Dr. Weitz: That’s great. Thank you so much, Doc.
Dr. Bernstein: Yeah, my pleasure. [01:04:00]
Dr. Weitz: Thank you for making it all the way through this episode of the Rational Wellness Podcast. For those of you who enjoy listening to the Rational Wellness Podcast, I would very much appreciate it if you could go to Apple Podcasts or Spotify and give us a five-star ratings and review. As you may know, I continue to accept a limited number of new patients per month for functional medicine. If you would like help overcoming a gut or other chronic health condition and want to prevent chronic problems and want to promote longevity, please call my Santa Monica Weitz Sports Chiropractic and Nutrition office at 310-395-3111, and we can set you up for a consultation for functional medicine. And I will talk to everybody next week.
