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The mind-to-gut connection is getting an entirely new spotlight with the rise of metabolic psychiatry interventions as a new modality for treating serious mental illnesses (SMIs).
The ketogenic diet, in particular – defined by low-carb, high-fat, moderate-protein eating that induces a ketosis state, burning fat instead of glucose – has yielded positive outcomes for patients with bipolar disorder and schizophrenia. It has also helped patients with major depressive disorder and a range of other SMI conditions.
Throughout the last few years, a slew of research and clinical trials on the impact of ketogenic diets for patients with these conditions, and new practices offering metabolic psychiatry as a component of treatment plans have popped up.
Providers who offer the service are still few and far between, but universities are also starting to launch training programs for clinicians, signaling this modality could be a mainstay in the future.
New metabolic service lines represent an opportunity to diversify revenue streams and improve integrated care delivery. Still, reimbursement pathways continue to be a major challenge.
The beginnings of metabolic psychiatry
Dr. Shebani Sethi, founder and director of Stanford’s Metabolic Psychiatry Clinical Program, is credited with coining the term “metabolic psychiatry” and establishing it as a field for treating mental health conditions by addressing underlying metabolic dysfunction.
Typically, for a patient population experiencing SMI conditions, these individuals also have higher rates of metabolic syndrome, inflammation, obesity, or insulin resistance as well, Sethi told Behavioral Health Business.
As a board-certified physician in both obesity medicine and psychiatry, seeing that physical intersection with their mental health conditions prompted her to find treatment options that addressed both and led to improvement.
“I looked at these two things, and I realized that the folks who are harder to treat and not getting the best outcomes despite medication are the ones that have this comorbid association between these two conditions,” Sethi told BHB. “The idea was, can we use metabolic interventions, whether it’s obesity treatment or reversing its resistance or other interventions, to address this population with SMI and see if there’s an improvement? It largely gets ignored a lot of times because they don’t have access to primary care, or they don’t have access to obesity treatment or metabolic medicine expertise.”
To track improvements, Sethi and the team at Stanford’s metabolic psychiatry clinic look for metabolic and psychiatric changes in the brain both centrally and peripherally, as well as in blood markers.
Sethi also founded Metabolic Psychiatry Labs, which creates treatment plans for patients with SMIs that center around metabolic solutions. The company has both a patient-facing app and a provider solution to help other practitioners adopt this new modality and bring it to their practice.
“We’re not trying to take psychiatrists’ patients away from each other, but really just augment the care to provide wraparound support where we do remote monitoring, and we do also look at metabolic treatments that we supplement, we tweak psychiatric medications accordingly, based on what’s appropriate, and then we monitor their labs as well,” Sethi said. “We are also using AI tools to provide recommendations that make sense for metabolic psychiatry.”
Metabolic psychiatry is complex and incorporating it goes beyond hiring a dietician to consult on nutrition at a specific practice. That’s where Metabolic Psychiatry Labs comes in, to bring ease and insight for those who are interested in applying the modality at their own practice.
“Getting dietitians is complicated, because not all dietitians have the expertise of ketogenic therapies,” she said. “The format of the nutritional pieces for mental health are unique, so the protocols that we have are very specific for mental health conditions based on clinical experience, and based on research and the latest data.
In practice
Close in proximity to Sethi’s work of paving the way in the new modality of metabolic psychiatry, leaders at San Francisco-based Amae Health have been some of its early adopters.
Amae Health is a behavioral health service provider focused on treating individuals with SMIs. The company has been focused on integrating components of holistic wellness and physical health with mental health treatment since its founding in 2022, but began a trial treating patients with ketogenic diets in 2024 and has since expanded these trials to include more than 100 patients.
“If you think about SMI, one of the unfortunate components of different diseases like schizophrenia is self-neglect, and you’re generally doing harmful activities that could be substance use, smoking, very unhealthy diets,” Stas Sokolin, co-founder and CEO of Amae Health, told BHB. “So the fact that you’re actually able to eat well and eat in a way that is healthy for you is a very big step. That is a very complex component of it all, and it’s difficult. It requires intervention.”
Engaging with an SMI patient population is inherently complex and sometimes getting them to adhere even to prescribed medications can be a battle for clinicians.
Even though Amae Health has tested and seen the results metabolic psychiatry interventions can achieve, implementing diet changes for anyone can be hard — for SMI patients, diet adherence can be even more challenging in some ways than medications, Sokolin said.
“This is a simple yet hard intervention,” Sonia Garcia, co-founder and Chief Growth Officer at Amae Health, said. “By being really judicious and intentional about wrapping the multi-disciplinary team around someone and working diligently day after day to structure their behavior change until the habit can form, I think is really important. That’s where the in-person component really makes a difference.”
Garcia said at Amae, the patients they work with on ketogenic diet implementation as a component of their treatment are assigned a team that works in tandem to treat them. The psychiatrist looks at the metabolic side effects and monitors medication, nutritionists help make adjustments with food and answer questions and the therapist is in the loop to share any helpful anecdotes that may come up from a session. That collaboration is where the “transformation” of patients stems from, Garcia explained.
Your Behavioral Health, a behavioral health care provider based in Torrance, California, also offers metabolic psychiatry services and has been doing so in some capacity for about 10 years, Dr. Martha Koo, the company’s chief medical officer, told BHB.
Mostly, the service has been offered in conjunction with Transcranial Magnetic Stimulation (TMS), which many patients with mental health conditions find appealing due to the absence of pharmaceutical medications. A natural-based way to further improve mental health through a healthy diet is usually well-received in these instances, Koo said.
“For a decade, we’ve been really focusing on this concept of diet, your gut health and helping people understand how that plays into mental health,” Koo said. “When you do transcranial magnetic stimulation, patients come in every day, five days a week, for six weeks, and there’s a lot of opportunity to talk to them. We’ve always taken the time during those visits to look at all these other things. We more formally had a lot of metabolic psychiatry when we were offering our IV nutritional services. That focused a lot on the oxidative stress issue, inflammation, mitochondrial health and other areas.”
Moving forward, she said, Your Behavioral Health is looking to have several of its clinicians become board-certified in related dietary areas, ranging from obesity medicine, lifestyle medicine to hormone replacement therapy. GLP-1 weight loss medications and their intersection with mental health conditions are also a key area of focus for the team.
“There’s a big comorbidity, obviously, with metabolic syndrome and mental health, as well as metabolic syndromes that we actually cause from our medications,” Koo said. “People gain weight on SSRIs. They gain weight on antipsychotics. So, incorporating an opportunity to collaborate with their internist and really make sure that we’re advocating for the patients to get the GLP-1s is key, because we know it has a huge impact in terms of how they feel about themselves and their mood, which is important.”
Even though outcomes from metabolic psychiatry interventions have proven their weight in gold for the clinicians who offer the modality, reimbursement pathways are a major barrier to adoption for most.
Some reimbursement options do exist, Sethi explained, but it will require more research, data and scale of these programs to make the case to payers on the industry side.
“In general, because we manage medications and nutrition and do remote monitoring via telehealth, there are reimbursement models that exist,” Sethi said. “They’re not the best, but they do exist. We’re optimistic that over time, through the remote monitoring and other pieces that this will improve on the digital health side over the next couple of years.”
In the meantime, providers like Amae Health and Your Behavioral Health may have to eat the cost it takes to offer metabolic psychiatry services to patients.
“It’s generally not reimbursed by insurance, so we’re able to do it via grant funding,” Sokolin said. “That is a little bit of an issue, and we’ll see if that changes. We’ve long understood the gut-brain connection. I just don’t think we as a clinical community, have changed the way we take care of patients despite that understanding. We’ve seen with the patients that we have in our clinic, remarkable results. I really think that it should be a kind of frontline intervention for some individuals.”
Companies featured in this article:
Amae Health, Stanford's Metabolic Psychiatry Clinical Program, Your Behavioral Health
