Can a Ketogenic Diet Benefit Patients With Mental Health Disorders?

For more than 50 years, researchers have examined the effect of a ketogenic diet on patients with behavioral health disorders.¹ Despite this breadth of research, most of the studies have lacked depth, consisting mostly of case reports, animal studies, and small-sample open studies rather than controlled trials.¹ Although researchers remain cautious, a review of research reveals that the popular diet may hold some promise for individuals with mental health disorders.

How Does the Ketogenic Diet Affect the Brain?

The ketogenic diet is an established option for treatment-resistant epilepsy, as evidenced by a range of studies, including controlled trials.¹ The diet also has shown promise for managing other brain-based disorders, such as Parkinson disease, amyotrophic lateral sclerosis, traumatic brain injury, multiple sclerosis, and chronic headaches as well as for metabolic disorders such as obesity, cancer, and type 2 diabetes.²

Unfortunately, it is unclear how ketogenic diets work to control seizures, let alone how they may improve psychiatric symptoms.² It may pertain to the presence of ketones, reduction in blood sugar, reduction in insulin and other growth-promoting hormones, or the combination of all of these.² Other theories include altered neurotransmitter levels, changes in electrolyte gradients (lower intracellular sodium and calcium), reduction in markers of inflammation, and improved mitochondrial function.²

“The general consensus is that the brain functions more cleanly and efficiently when a significant portion of its energy comes from ketones, calming overactive and overly reactive brain cells,” Georgia Ede, MD, a board-certified psychiatrist specializing in nutrition-focused counseling, explained in Psychology Today.²

What the Research Reveals

A review of the literature reveals the following about the ketogenic diet’s reaction with diseases¹:

Anxiety: Exogenous ketone supplementation reduced anxiety-related behaviors in a rat model.
Attention-deficit/hyperactivity disorder: In a controlled trial of the ketogenic diet in dogs with comorbid epilepsy, both conditions significantly improved.
Autism-spectrum disorder: An open-label study in children reported no significant improvement, yet one case study reported “a pronounced and sustained response.” Further, in 4 controlled animal studies, the ketogenic diet significantly reduced autism-related behaviors in mice and rats.
Bipolar disorder: One case study reported a reduction in symptomatology whereas a second case study reported no improvement.
Depression: The ketogenic diet significantly reduced depression-like behaviors in rat and mice models in 2 controlled studies.
Schizophrenia: An open-label study in female patients found reduced symptoms after 2 weeks of the ketogenic diet whereas a single case study reported no improvement; however, 3 weeks of the ketogenic diet in a mouse study normalized pathological behaviors.

The Bostock review did not include studies regarding how the ketogenic diet affects dementia and Alzheimer disease. A 6-week study of a low-carbohydrate diet in persons with mild cognitive impairment saw improvement in verbal memory, with greater benefits for persons who achieved higher ketone levels.² The cognition and function of a man with Alzheimer disease “significantly improved” with the use of ketone supplements during a 20-month case study.²

A review of the effect of the ketogenic diet on patients with epilepsy concluded that³:

Subjective assessment of patients found cognitive improvements with the ketogenic diet treatment, particularly in the domains of alertness, attention, and global cognition;
Studies that used objective neuropsychological tests, however, confirmed benefits in alertness but found no improvement in global cognition;
The duration of the ketogenic diet treatment appears to have a positive effect on the degree of cognitive improvement; and
Because patient compliance with the ketogenic diet is generally low, this may lead to a bias in the research.

Researchers Urge Caution

According to researchers, there are several reasons why the effectiveness of the ketogenic diet in mental disorders is difficult to prove¹:

Low number of human studies
Low quality of the studies (sample sizes are small, no control for placebo effects, no consistent measurement of ketosis, lack of detail about the specifics of the diet and duration)
No enforced standards as to what constitutes the ketogenic diet in humans
Ketogenic diet monotherapy is largely unexamined in human studies
The ketogenic diet requires patients who may be ill to measure food portions
Diet compliance can be difficult, particularly for patients with mania, apathy, reduced appetite, food cravings, or binge eating issues

The ketogenic diet may also cause adverse effects, including^1,2:

Constipation
Elevated liver enzymes and/or abnormal liver function
Elevated serum cholesterol
Elevated triglycerides
Emesis
Gallstones
Hemolytic anemia
Hypoglycemia
Hypoproteinemia
Kidney stones
Leg cramps
Menstrual irregularities
Periorbital edema
Presacral edema
Renal tubular acidosis
Thrombocytopenia
Unwanted weight loss
Viral gastroenteritis

Dr Ede agreed that the research is not there — yet.

“Nutrition studies are hard. Blinding is nearly impossible, funding is hard to come by, compliance is challenging, and controls are difficult to design,” Dr Ede explained.² “Fear, bias, and nutrition miseducation limit the number of scientists interested in and willing to conduct studies of low-carbohydrate, high-fat diets. We clearly need high-quality human studies exploring the effects of ketogenic diets on mental health disorders, as many clinicians and patients will be afraid to utilize this diet without stronger evidence.”²

Most researchers agree that low-carbohydrate diets can help stabilize brain chemistry, particularly for patients who are not responding to other treatments. Psychiatrists interested in recommending the ketogenic diet to a patient may benefit from consulting with a dietitian or primary care provider with expertise in ketogenic diets.²

References

Bostock EC, Kirkby KC, Taylor BV. The current status of the ketogenic diet in psychiatry. Front Psychiatry. 2017;8:43.
Ede, G. (2017). Ketogenic diets for psychiatric disorders: a new 2017 review. Psychology Today. [Accessed 9 Aug. 2019].
van Berkel AA, Ijff DM, Verkuyl JM. Cognitive benefits of the ketogenic diet in patients with epilepsy: a systematic overview. Epilepsy Behav. 2018;87:69-77.

Ketogenic Diets for Psychiatric Disorders: A New Review

Ketogenic Diets Yesterday, Today and Tomorrow

Source: Freepik

If you have a brain, you need to know about ketogenic diets. The fact that these specially-formulated low-carbohydrate diets have the power to stop seizures in their tracks is concrete evidence that food has a tremendous impact on brain chemistry and should inspire curiosity about how they work. I first became interested in ketogenic diets as a potential treatment for bipolar mood disorders, given the many similarities between epilepsy and bipolar disorder.

Ketogenic diets have been around for about 100 years, and have proved to be invaluable tools in the treatment of stubborn neurological conditions, most notably epilepsy. They have also shown promise in the management of other brain-based disorders such as Parkinson’s Disease, ALS, Traumatic Brain Injury, Multiple Sclerosis, and chronic headaches, as well as in metabolic disorders like obesity, cancer, and type 2 diabetes.

But where does the science currently stand on the ketogenic diet and psychiatric disorders like bipolar disorder, schizophrenia, and Alzheimer’s Disease? How many human studies do we have, and what do they tell us? If you are struggling with mood, attention, or memory problems, should you try a ketogenic diet? If you are a clinician, should you recommend a ketogenic diet to your patients?

A recent review article “The Current Status of the Ketogenic Diet in Psychiatry” by researchers at the University of Tasmania in Australia [Bostock et al 2017 Front Psychiatry 20(8)] brings us nicely up to date on all things ketogenic and mental health. I summarize the paper below and offer some thoughts and suggestions of my own. [Full disclosure: I am a psychiatrist who studies nutrition and eats a ketogenic diet.]

First, some basics for those of you who are unfamiliar with these special diets.

What are Ketogenic Diets?

Definitions vary, but what all ketogenic diets have in common is that they are very low in carbohydrate (typically 20 grams per day or less) and relatively high in fat. The goal is to lower blood sugar and insulin levels; when these are nice and low, the body naturally turns to fat (instead of sugar) as its primary source of energy. Most ketogenic diets also limit protein (to no more than the body requires), because excess protein can raise blood sugar and insulin levels to some extent. Body fat and fat from the diet then break down into ketones, which travel through the bloodstream and can be burned by various cells throughout the body, including most brain cells. Ketone levels rise in the blood, urine and breath within days, and can be measured using various home test methods, but it can take weeks for the body to become efficient at burning fat for energy, and for full benefits to be realized.

When a person is “in ketosis”, fasting morning blood glucose levels tend to average between 60 and 85 (mg/dl), and blood ketone levels rise to at least 0.5 mM (with much higher levels recommended for certain conditions). These parameters distinguish ketogenic diets from other low-carbohydrate diets, which may contain too much protein and/or carbohydrate to produce these metabolic effects.

How do Ketogenic Diets Work?

It remains unclear how ketogenic diets work to control seizures, let alone how they may improve psychiatric symptoms. On a fundamental level, we are not even sure whether it is the presence of ketones, the reduction in blood sugar, the reduction in insulin and other growth-promoting hormones, or the combination of all of these which are responsible for the brain-stabilizing effects of these diets. Theories abound, and include altered neurotransmitter levels, changes in electrolyte gradients (lower intracellular sodium and calcium), reduction in markers of inflammation, and improved mitochondrial function. The general consensus is that the brain functions more cleanly and efficiently when a significant portion of its energy comes from ketones, calming overactive and overly-reactive brain cells.

What about Ketone Supplements?

You can raise your blood ketone levels without changing your diet, by either taking expensive ketone supplements or by ingesting fats high in medium chain triglycerides (MCTs), which the liver rapidly transforms into ketones. Purified MCTs are available for purchase, or you can simply take coconut oil, which is naturally rich in MCTs. You’ll see below that these approaches can be effective short-term, but my opinion is that they simply mask the underlying disease, which continues to worsen due to ongoing high insulin and/or blood glucose levels.

SUMMARY OF THE SCIENCE

I’ve listed all relevant studies covered in the 2017 Bostock review below, paying special attention to the human studies, and supplementing with original source material where helpful, as there were some minor errors in the text of the review.

Ketogenic Diets and Bipolar Disorder

2002: A one-month case study of a woman with unspecified, treatment-resistant bipolar disorder noted no improvement after two weeks on a ketogenic diet followed by two weeks of MCT oil supplementation. Urine testing found ketosis was never achieved.

2012: A case study of two women with bipolar II disorder who ate a ketogenic diet (one for two years, the other for three years) found that the diet was superior to the anticonvulsant/mood stabilizer lamotrigine (Lamictal) in management of symptoms. Ketosis was documented using urine test strips.

Ketogenic Diets and Schizophrenia

A 3-week mouse study showed that a ketogenic diet normalized pathological behaviors.

1965: A 2-week study of 10 women with treatment-refractory schizophrenia found a significant decrease in symptoms when a ketogenic diet was added to their ongoing standard treatments (medications + ECT). Ketone monitoring was not reported.

2009: A 12-month case study details the experience of a 70-year old overweight woman with chronic schizophrenia who was prescribed a diet limited to 20 grams of carbohydrate per day. She noted significant improvement in severe symptoms beginning only eight days after starting the diet, which consisted of “beef, poultry, ham, fish, green beans, tomatoes, diet drinks, and water.” [ Kraft and Westman 2009 Nutrition & Metabolism 6:10.] She reported complete resolution of auditory and visual hallucinations–with which she’d suffered since age seven. Ketone levels were not monitored.

Comment: This diet is best characterized as a low-carbohydrate, primarily whole foods diet. As protein wasn’t limited and fat intake wasn’t manipulated, this may or may not have been a truly ketogenic diet.

Ketogenic Diets and Anxiety

A rat study found that adding ketone supplements to a standard high-carbohydrate diet reduced anxious behavior.

Ketogenic Diets and Depression

A rat study found that a ketogenic diet reduced depressive behaviors.

A mouse study found that feeding pregnant animals a ketogenic diet reduced offspring susceptibility to depressed (and anxious) behaviors.

Ketogenic Diets and Autism Spectrum Disorder (ASD)

A 70-day mouse study found that a ketogenic diet improved behavior.

A 10-14 day rat study found that a ketogenic diet improved complex social behaviors and mitochondrial function.

A 3-4 week mouse study found that a ketogenic diet improved behaviors in ways that were different for males than females.

2003: A 6-month inpatient study evaluated the effects of a cyclical ketogenic diet (4 wks on, 2 wks off) on 30 children with ASD. Of the 18 children who completed the study, eight showed moderate improvement, and two showed “significant” improvement. Benefits appeared to persist even during the 2-week “diet-free” periods. Urine and blood ketone monitoring confirmed that all children were in ketosis.

Comment: blood ketone levels ranged from 1.8 to 2.2 mMol during ketogenic phases and from 0.8 to 1.5 mMol during “diet-free” periods, meaning that the children actually spent the entire 6-month study period in ketosis.

2013: A 14-month detailed case study of one child with ASD, epilepsy, and obesity who was placed on a ketogenic diet in combination with anti-epileptic medications, noted numerous improvements. “In addition to improvement in seizures, there was a 60-pound weight loss…as well as improved cognitive and language function, marked improvement in social skills, increased calmness, and complete resolution of stereotypies.” [Herbert and Buckley 2013 J Child Neurol 28(8)]. Ketosis was confirmed (presumably by urine testing).

Ketogenic Diets and ADHD (Attention Deficit Hyperactivity Disorder)

A 6-month study of dogs with ADHD and epilepsy found significant improvement in ADHD behaviors on a ketogenic diet.

Ketogenic Diets and Alzheimer’s disease

2009: A 90-day randomized, double-blind, placebo-controlled, parallel study of 152 people with mild to moderate Alzheimer’s Disease tested the effects of a daily MCT supplement (previously marketed under the name Axona) on cognitive test performance. People continued their usual diets and took either the MCT supplement or a safflower oil placebo. Regular medications were continued throughout the study. At 45 and 90 days, patients taking MCTs showed significant improvement on a cognitive test known as the ADAS-Cog scale, unless they carried a gene called ApoE4, which is associated with higher risk for Alzheimer’s disease. Cognitive benefits did not persist after MCTs were discontinued.

Not mentioned in the Bostock review are the following two studies:

1) A 6-week study of a simple low-carbohydrate diet (protein and fat unrestricted) in people with mild cognitive impairment (MCI, aka “pre-Alzheimer’s” disease) demonstrating improvement in verbal memory, with greater benefits seen in those who achieved higher ketone levels [Krikorian R et al 2012 Neurobiol Aging 33(2):425].

2) A 20-month case study of a man with Alzheimer’s Disease whose cognition and function significantly improved with the use of ketone supplements [Newport MT et al 2015 Alzheimer’s & Dementia 11] .

Please also see my Psychology Today article Preventing Alzheimer’s Is Easier Than You Think.

Limitations of the Research

If you are a ketogenic diet skeptic, you will find the above summary unimpressive. I can’t blame you—there is precious little human data about ketogenic diets and psychiatric disorders, and what is there is flawed: small sample sizes, no controls, ketosis unconfirmed in some cases, diet composition and length of treatment variable between studies, etc. However, as a low-carbohydrate diet enthusiast, I find much to be excited about in this ragtag fugitive fleet of papers.

Nutrition studies are hard. Blinding is nearly impossible, funding is hard to come by, compliance is challenging, and controls are difficult to design. Fear, bias, and nutrition miseducation limit the number of scientists interested in and willing to conduct studies of low-carbohydrate, high-fat diets. We clearly need high-quality human studies exploring the effects of ketogenic diets on mental health disorders, as many clinicians and patients will be afraid to utilize this diet without stronger evidence. If only more people held the USDA Dietary Guidelines to the same scientific standard and eyed it with the same healthy skepticism…

Ketogenic Diets in the Real World

Nevertheless, I believe in the therapeutic potential of low-carbohydrate diets to stabilize brain chemistry, and feel strongly that people should be made aware of dietary strategies as an option. For people who don’t want to take medication, haven’t responded to medication, can’t tolerate medication or can’t afford medication, nutritional intervention can offer real hope and empowerment. I personally noticed an overall improvement in concentration, mood, energy, and productivity when I changed my own diet years ago, and have witnessed people in my own practice whose mood stabilized by switching to a low-carbohydrate, high-fat, whole foods diet. My philosophy regarding the dietary treatment of mental health problems is as follows:

Everyone should eat real, whole foods and minimize refined carbohydrates like sugar and flour. Most view this as common sense advice (with the notable exception of the USDA). I personally recommend a pre-agricultural dietary pattern (which includes animal protein/fat and eliminates grains/legumes).
Those with insulin resistance (including those with type 2 diabetes) would be wise to make lifestyle changes that can help to normalize insulin and blood sugar levels. Strategies with the potential to accomplish this include simple low-carbohydrate diets, intermittent fasting, strength training, and caloric restriction. Education, professional guidance, support and medical monitoring are important to have in place before trying dietary changes, particularly if you have any health problems or take any medications.
Individuals who have not benefited from the above changes or who simply want to try a different approach may wish to consider a ketogenic diet.

It could be many years before we see high-quality studies of ketogenic diets in the treatment of psychiatric disorders. For those of you who don’t want to wait that long—what do you need to know?

Ketogenic Diet Safety and Side Effects

The ketogenic diet is safe for most people, but there are clear exceptions to consider that go beyond the scope of this post, so please do not embark on a ketogenic diet yourself nor recommend it to someone else without first reading my detailed article Ketogenic Diets and Psychiatric Medications, my short post Is the Ketogenic Diet Safe for Everyone? and seeking additional guidance and resources to educate yourself about the diet. Two of the best books on the subject are The Art and Science of Low Carbohydrate Living by Drs. Phinney and Volek, and The New Atkins for a New You by Dr. Eric Westman.

Some studies report side effects such as constipation, leg cramps, and increased risk of kidney stones. There are very real shifts in salt and fluid balance that occur in the early stages of the diet that may explain some of these side effects, but most people tolerate the diet well, including myself. My opinion is that the majority of side effects are not due to the low-carbohydrate, high-fat nature of the diet, but rather due to food choices. Unfortunately, most ketogenic diets, particularly those prescribed to children with epilepsy, are high in processed/artificial ingredients, and foods that many people are sensitive to, such as nuts, dairy, eggs, and biogenic amines.

If you are a psychiatric clinician interested in recommending the ketogenic diet to a patient, I highly recommend collaborating with a dietitian, primary care provider, or specialist with expertise in ketogenic diets. If there isn’t such an individual in your area, there are other options, including specialty dietitians and medical centers offering on-line consultation.

https://youtu.be/UR7H9xeMYME?t=1

The Carnivore Diet for Mental Health?

How plant-free diets affect the brain

arnivore Curious?

Last month, I had the pleasure of participating in the Boulder Carnivore Conference, the world’s first meeting dedicated to the potential benefits of plant-free diets. For this special event, I created a new presentation exploring the nutritional differences between plant and animal foods, and summarizing the scientific arguments in support of all-meat diets for optimal brain health. Skeptical? You should be. This seemingly strange and extreme way of eating flies in the face of every piece of conventional nutrition advice we’ve been given, yet a growing number of people report remarkable benefits, including resolution of serious, chronic psychiatricsymptoms. If you are curious about how this diet might help to correct chemical imbalances in the brain, please watch this video to learn more.

If you are completely new to the idea of all-meat diets, allow me to provide a bit of context, along with some additional links and resources should you care to dive a little deeper.

*An update in response to concerns expressed in the comments section: No, I am not funded by the meat industry. My nutrition work is >95% self-funded. I have no financial conflicts of interest that might bias me towards animal foods. I do acknowledge intellectual bias towards animal foods, as I’m convinced by the science (see video and resource following this article), my clinical experience, and my own personal experience (see below) that they are important to human health.

Interest in Plant-free Diets Takes Root

Have you heard? The so-called “carnivore” diet—a diet completely free of plant foods—has become something of a hot new micro-trend, thanks in part to several high-profile adopters who report that switching to an all-meat diet significantly improved their mental and physical health.

One of these ambassadors of carnivory is Mikhaila Peterson, a 27-year old Canadian woman who credits a meat-only diet not only for putting her juvenile rheumatoid arthritis into remission (no small feat, as JRA, is a serious and destructive autoimmune disease), but also for her complete recovery from the severe depression and anxiety she’d suffered with since the fifth grade.

Mikhaila first became aware of the carnivore diet after hearing Dr. Shawn Baker talk about the benefits of his all-beef diet on the Joe Rogan Experience podcast. Dr. Baker is a California-based orthopedic surgeon and multi-sport elite athlete who actively promotes the carnivore diet on social media and explores its theory and practice on his popular Human Performance Outliers podcast.

Mikhaila’s experience inspired her father, well-known University of Toronto psychologist Professor Jordan Peterson, to try the diet in an attempt to alleviate his own depression. He has since reported alleviation of not only depression and anxiety but also of a number of bodily ailments including psoriasis and gastric reflux, as detailed in this article in The Atlantic.

The Boulder Carnivore Conference was the brainchild of Colorado-based Amber O’Hearn, a data scientist, nutrition science writer and public speaker who has adhered to a carnivore diet since 2009. She produces thoughtful, meticulously-researched articles about the science of animal-based nutrition on her website Empirica and is writing a book dedicated to this topic. In interviews such as this one, she explains how her unusual way of eating seemed to resolve her symptoms of bipolar depression, including suicidalideation, which psychiatric medications had failed to accomplish.

Carnivore Diets and Psychiatric Disorders

As a psychiatrist specializing in nutrition, I work with people to help troubleshoot, customize and optimize their diets to improve their mental health, with the goal of reducing or in some cases even eliminating the need for psychiatric medications. There are many different dietary strategies that can help people achieve this goal—removing processed foods, carefully supplementing whole food plant-based diets, ketogenic diets, etc. It’s important to emphasize that most people probably don’t need to go to the extreme of removing all plants from their diet in order to experience relief, and of course, no diet, including a carnivore diet, will work for everyone.

All that being said, I have consulted with many people who report significant mental health benefits on low-plant and plant-free diets. While I am not at liberty to share the details of these confidential cases, numerous compelling, public first-hand personal accounts of psychiatric conditions resolving on all-meat diets exist, including this interview with 58-year-old West Virginia-born musician Brett Lloyd and this conversation with Andrew Graf, a young entomologist in Texas, both conducted by Boston-based host Scott Myslinski on his CarnivoreCast podcast. Dr. Baker curates a wonderful collection of mental health testimonials at meatheals.com, which contains 110 entries to date.

I count myself among the believers [I use the word “believers” intentionally to underscore the fact that clinical trials of the carnivore diet do not yet exist.] In 2008 I reversed symptoms of fibromyalgia, chronic fatigue, migraines, and IBS by gradually removing most plant food from my diet. As a psychiatrist, I was fascinated to observe that my mood, energy, sleep, and concentration improved significantly as well. I share more about my story in this video interview with Ivor Cummins. [I switched from a very low-plant ketogenic diet to a pure carnivore diet in June 2018, long after this conversation took place]. It was that extraordinary experience that called me to question conventional beliefs about food and health, gave birth to my passion for the study of nutrition science, and led eventually to my first public presentation in 2012 Little Shop of Horrors: the Risks and Benefits of Eating Plants.

As surprising and powerful as these stories are, they are just anecdotes…they do not constitute formal scientific evidence. Perhaps all of these alleged improvements could be chalked up to exaggeration, wishful thinking, or coincidence. It is up to you whether you choose to dismiss them, become genuinely curious about them, or feel inspired by them. I lay out the scientific arguments supporting this way of eating in my video but clinical trials do not yet exist.

If remarkable stories of chronic mental illness being put into remission through all-meat diets are to be believed, we have to ask why. Why might a diet completely devoid of the plant foods we are told to be so healthy for us be—at least in some cases— ostensibly healthier for the brain than one containing plants?

Look Before You Leap

If you are inspired to try a carnivore diet for mental health purposes, and you currently take psychiatric medications (or medications of any kind), please read my article Ketogenic Diets and Psychiatric Medications first. Just as with a standard low-carbohydrate or ketogenic diet, carnivore diets cause profound shifts in brain and body chemistry rather quickly. These changes are almost always positive and healthy, but they can have a major impact on medication levels, dosages, and side effects that require close medical supervision, particularly in the first month or two while your metabolism adjusts to your new healthy way of eating. It is very important to consult with your prescribing clinician before embarking on any low-carbohydrate diet. article continues after advertisement

For More Information

If you prefer written arguments (fully referenced) to videos or would like to learn more about the arguments outlined in the video, you may find the following articles of interest:

Your Brain on Plants: Micronutrients and Mental Health

The Brain Needs Animal Fat

Do You Have Arachiphobia?

Which Diet Is Healthiest for the Brain?

The Antioxidant Myth

Low Brain Cholesterol—Separating Fact from Fiction

Do We Really Need to Eat Our Vegetables?

Ketogenic Diets for Psychiatric Disorders: A New 2017 Review

Little Shop of Horrors? The Risks and Benefits of Eating Plants

What is the Carnivore Diet? Potential Benefits and Concerns (by nutrition therapist Amy Berger)

The Ultimate Guide to the Carnivore Diet (by Raphael Sirtoli and Amber O’Hearn)

Original Source: https://www.psychiatryadvisor.com/home/topics/general-psychiatry/can-a-ketogenic-diet-benefit-patients-with-mental-health-disorders/