New clinic offers alternative options for treatment-resistant depression
Stephen Manlove, M.D., has been a psychiatrist for decades, but some years ago, he almost stepped away from the profession for good.
He’d seen too many people struggle to find an effective treatment for their clinical depression. While commonly available antidepressants helped a percentage of his patients, there were many others who did not seem to benefit from the classic pharmacological approach. It felt frustrating to not be able to help the very people who so desperately needed his support.
“Around 2013 or 2014, I was thinking I should do something different, maybe wrap it up,” Manlove said. “I thought seriously about retiring at that point, of going in a different direction.”
But, as he talked through his frustrations with trusted friends and colleagues, Manlove came to a realization: “I concluded that what I really like to do is to treat people I haven’t been able to treat before. Psychiatry has gotten so limited to medication treatment, and I thought there has to be different things we could do.”
Instead of stepping away from psychiatry, Manlove instead decided to reinvigorate his Rapid City, South Dakota-based practice, offering patients the option of treating their mental illness with promising new therapies, including transcranial magnetic stimulation (TMS), a noninvasive procedure using magnetic fields to stimulate brain cells to improve symptoms of depression.
“At that point TMS was just coming out,” Manlove said. “I thought, ‘Maybe this is a way to help patients with treatment-resistant depression.’” He started offering TMS to his patients, and the results were overwhelmingly positive.
“It was one of the most incredibly satisfying things to see people who have been depressed for a long time get better. It is like magic.” When TMS works, he said, “It is as dramatic a change that you’ll see in the whole psychiatric world. It is incredibly rewarding.”
As he began to see his patients respond positively to TMS, Manlove decided to further expand his approach to depression treatment. He’d long known about the connection between physical and mental health, so he began encouraging his patients to make gradual lifestyle changes that could further support their recovery. He also trained his technicians to coach patients during treatment sessions.
“We found that when we addressed lifestyle plus medical issues that were somewhat normal and did TMS we got a better response than other places,” Manlove said. “Our recidivism rate was really low.”
Manlove’s interest in alternative therapies for depression eventually led him to research highlighting the promise of ketamine, a commonly used anesthetic and sometime party drug that has shown promise in treating severe depression. When administered under the guidance of a medical professional, ketamine was shown to significantly reduce depressive symptoms and suicidal ideation in patients. Like TMS, ketamine, when administered correctly, has few negative side effects, an issue that often plagued individuals treated with classic antidepressant or antipsychotic medications.
This felt like a promising new approach. Ketamine, Manlove explained, “added another tool. For years, the problem really had been the limited number of people who respond to medications for depression. I was interested in expanding my treatment options.”
A little over a year ago, Manlove was attending a meeting for mental health providers in Minneapolis when he struck up a conversation with a fellow attendee. When he told her about his interest in taking a new approach to depression treatment, her eyes lit up.
“She said,” Manlove recalled, “‘You should meet my husband. He thinks differently than other psychiatrists.’”
The woman’s husband was Brian Johns, M.D., a psychiatrist based at North Memorial Hospital in Robbinsdale. Johns had been using ketamine to treat patients with severe depression at North Memorial and at the Minneapolis VA, and had even co-authored a study on the approach.
Manlove called Johns and the two began discussing the possibility of a partnership, of opening a Twin Cities-based clinic that would bring Manlove’s approach to depression treatment to a wider audience in a larger metropolitan area.
Finding another psychiatrist interested in taking an alternative approach to the treatment of severe depression felt promising, Manlove said. The possibility of offering those treatments to a larger number of patients was exciting.
“I’ve practiced for a long time,” Manlove said. “I used the standard treatments. The people you remember at the end of the day are the ones who don’t get better. That’s frustrating and discouraging and makes you want to do better.”
He’d seen the positive impact that TMS and ketamine had on patients who had all but given up hope of ever recovering from their depression, and he wanted to offer that option to more people than he’d been able to reach in South Dakota. Maybe this new partnership would help him do that, he said: “There are few things more fun in my life than seeing a depressed person come alive and feel good again.”
Pandemic pause, then moving forward
Before Manlove and Johns could get their clinic off the ground, their plans were thrown off course by the emergence of a global pandemic. “That was a big hurdle,” Manlove said. “The world was vibrating in a funny way, so we decided to put the project on pause.”
The two potential business partners weren’t sure how they could operate a mental health clinic during a global shutdown, but then, as states and insurers began to loosen regulations around the practice of telepsychiatry, the pair realized that this might actually be the perfect time to launch a new practice.
“One of the things that happened with this pandemic was we all got better at communicating by televideo,” Manlove said. With remote meeting technology, he continued: “We thought it would be easier to do a clinic that straddled Rapid City and the Twin Cities. We realized that there are a lot of people in the Twin Cities who would be willing to do telemedicine for their regular appointments and then come in person to do TMS.”