Ketogenic metabolic therapy as a candidate adjunct for CBTp delivery in schizophrenia spectrum disorders

Schizophrenia spectrum disorders (SSDs) are managed with pharmacotherapy alongside psychosocial interventions, including cognitive-behavioral therapy for psychosis (CBTp). In routine services, uptake and completion of CBTp remain limited, and participation barriers disrupt initiation, retention, and between-session follow-through. Ketogenic metabolic therapy (KMT) is a dietary intervention intended to induce and maintain nutritional ketosis through carbohydrate restriction and a higher fat dietary pattern, with education, monitoring, and safety management integrated into care. Early reports utilizing KMT in SSDs describe improvements in domains that limit CBTp delivery, including sleep disruption, arousal and distress reactivity, mood instability, cognitive burden, and day to day functioning, while effects on positive symptoms remain uncertain and evidence is methodologically heterogeneous. This perspective article situates KMT within CBTp engagement frameworks and reframes an actionable question for clinical psychologists: whether KMT can reduce participation limiting factors enough to increase CBTp initiation, retention, and completion when psychotherapy is truncated by instability, cognitive burden, distress, or practical barriers. A care pathway model is outlined that organizes participation barriers across entry into therapy and continuity across transitions back to community care, with CBTp indicators proposed for evaluating adjunct impact. If future trials support this adjunct role, KMT may represent a practical strategy for increasing CBTp dose and strengthening access to recovery-oriented gains in coping, stability, and functional outcomes, even when positive symptoms persist or fluctuate. These elements form a clinically grounded conceptual model that specifies measurable indicators and testable decision points for evaluating KMT as an adjunct to CBTp delivery in routine care.