A psychotic episode associated with the Atkins Diet in a patient with bipolar disorder

Studies have suggested that a ketogenic diet is beneficial for epilepsy, both in adults (1) and in children (2). As antiseizure medications have proved to be effective treatment for bipolar disorder, the question has arisen whether the ketogenic diet, or other diets, may be effective in the treatment of bipolar disorder (3). Dietary omega-3 fatty acids have been found to lengthen remissions in bipolar disorder (4). But in one study that examined the effect of the ketogenic diet on bipolar disorder in valproate-resistant patients, no effect was found (5). We describe the case of a patient with bipolar disorder maintained on valproic acid, who developed mania shortly after initiating the Atkins diet. The patient is a 54-year-old veteran who first developed bipolar disorder in the mid-1990s. His most recent psychiatric admission was in October 2001. Discharge psychiatric medications were divalproex, 1.5 g total per day, clonazepam, 1 mg at HS, and quetiapine, total daily dose 700 mg. From October 2001 until June 2003, the patient had no psychiatric complaints recorded by his caseworker with the exception of mild anxiety. On June 12, 2003, the patient told his caseworker that he started the Atkins diet. On June 25, the patient reported that he was not sleeping well, and clonazepam was increased to 1.5 mg. On July 10, because of continued insomnia, his divalproex was increased to 2 g/day. On July 22, the patient’s family voiced concerns over his increasingly bizarre behavior and paranoia. On July 24, the patient had multiple somatic complaints, and on July 30, he complained of multiple odors and was hyperverbal. A total of 25 mg of diazepam/day was added to his medication regimen. On August 8, the caseworker noted that money was missing from the patient’s bank account. The patient continued to refuse hospital admission until August 12, when he was evicted after covering the entire apartment in talcum powder, and flooding the apartment with water from his bathtub, resulting in the collapse of the ceiling of the apartment downstairs. The time course of the patient’s diet and symptoms is outlined in Fig. 1. At presentation to the hospital, the patient’s weight was recorded as 189 pounds. Mood was irritable and expansive. Thought process was rambling and tangential. Thought content included somatic preoccupation and delusions with religious references. He was not oriented to day or date. He was placed on a regular diet, and treated with a continuation of his preadmission medications. His weight increased rapidly, his mood stabilized, and his delusions gradually improved until his discharge on September 8, 2003. One possible connection between diet and the development of mania in this patient is a relationship between ketosis and valproate metabolism.