Unknown: Thanks for joining the Re-think and Re-tool podcast
with Mehul Mankad MD where we take a look at the people side
of healthcare and new ideas about enhancing overall well
being so welcome. The doctor is in the house.
Welcome to Re-Think and Re-Tool sponsored by Alliance Health.
This is Mehul Mankad psychiatrist and Chief Medical
Officer for Alliance. No one is more familiar with the topic of
women's mental health than Dr. Samantha Meltzer- Brody, the
Assad Meymandi Distinguished Professor and Chair of the
psychiatry department at the University of North Carolina,
particularly when it comes to the mental health of women
during and after pregnancy. Dr. Meltzer Brody is more
knowledgeable than anyone else I have ever met.
We're also going to hear how Dr. Meltzer Brody, a person who has
worked at both Duke and UNC handles things on game day.
I can't wait to hear what she has to say. Let's get started.
Dr. Meltzer Brody.
Well, hello, thanks for having me. Thank you for joining us on
rethinking retool. I will share that our lives have been
intertwined for a minute. And you may not remember this, but
I'll tell you what I remember.
The year was 1997. And I was interviewing for residencies
all over the country, coming from Chicago and really looking
everywhere. And I came down and the lady that ran the psychiatry
residency at Duke, her name was Tanah Grady. She said, There's
someone I need you to meet.
And it was you.
How about that? Well, I remember meeting you as a fellow in
Northwestern Medical School, or soon to be alum. And that was
really fun. And I'm certainly glad that you trained at Duke at
that same time I was there so that our paths have continued to
cross ever since. Yeah, so our paths have crossed, but they've
certainly gone in different directions. And one of the
pieces I've just been in awe of is your footprint in the world
of women's mental health. And I you know, is that space, does it
have a different name? Is it okay to call it women's mental
health? Or is what is the best term for that? Well, I think
women's mental health will be the most broad speaking. Okay.
And that is a huge range. Because if you're going to talk
about women's mental health, then you're literally talking
about probably from the time of adolescence, onward through
lifespan. Great point versus speaking about reproductive
psychiatry, I see myself as a reproductive psychiatrist, very
much focused on in general, the perinatal period, which is much
more constrained in terms of time, but you can use either it
really just depends how inclusive you're trying to be.
Okay, so reproductive psychiatry. And so I would love
to know because this is a part of, of your story that I'm
unfamiliar with completely. How did you get involved in
reproductive psychiatry?
So my initial introduction to reproductive psychiatry,
was as a research assistant, I worked for three years between
college and medical school as a research coordinator at
Massachusetts General Hospital in Boston, I person had the
opportunity to be with just a really incredibly interesting
and dynamic group of folks doing studies and a lot of things and
they had a new reproductive psychiatry program, perinatal
psychiatry program, the MGH women's mental health program,
which continues and so that was my initial introduction to that
and found it to be very, very interesting. My next exposure to
that was as a resident working with Dr. Mimi Butterfield at the
Durham VA where there was a women's mental health clinic and
that played a really formative
role in my interest in women's mental health specifically, but
when I got
to fellowship training at UNC and then beyond, I realized that
I was actually really interested in focusing on the perinatal
period, because I thought it was and still do such a profound and
transformative time for families, for women's for women,
and such an important time to intervene.
And so I continue to find working with women and their
families during that period of time to be enormously rewarding.
Because when someone has a mental health condition during
the perinatal period, pregnancy or postpartum and you're able to
help them through it, you are changing the trajectory for for
the mom's life and, and then for their child across two
generations. And so it continues to be something that I am
incredibly inspired by and really love working with that
patient population.
Wow. So you mentioned impact and intervention in this perinatal
period. So So what do you mean, what are the different things
that are going on with women? I imagine, you know, kind of going
back to my own training,
this this kind of bio psychosocial model. And I wonder
if that's helpful as an explanation for what you're
describing?
Well, certainly, you have very complex biology, you have very
complex changes in most physiologic simple systems. So
if you think about pregnancy, your blood volume goes up five
times, right, you know, almost organ systems are impacted, you
know, immune system factors, HPA axis system factors, hormonal
factors, you name it, it's changing.
And then you have this rapid down escalation of everything,
if it goes well, postpartum. Meanwhile, you have the
transition from being pregnant to for women who choose to do so
lactating,
and, you know, suddenly,
you know, end up with this small infant, without a manual that
you know, it was handed to the mom.
And with a, you know, best wishes.
Good luck. And it goes better or worse, depending on lots of
things, but the psychosocial contributions, the support
system, the history of childhood adversity, and that how that may
impact someone's hypothalamic pituitary stress axis, and how
that responds well or does it during a time when you're doing
sort of HPA Axis gymnastics, whether someone will find out
that they actually don't do well with sleep deprivation, or they
find out they do find without sleep deprivation, whether they
have the social supports, they need to make this all work, or
they don't. And so I think that it's a time of such profound
change. That, on one hand is very universal, because people
have children all over the world every day, and on the other
hand, is exceptionally unique to that particular individual in
that time and place,
unique arrangement of do they have, you know, three
generations of family all living on the same block to help or
they're literally by themselves somewhere with no one else to
help them because their partner, you know, left when they found
that they were pregnant? And it's just them? Do they have
maternity leave? You know, do they have adequate finances? So
there's so many different things that come into play both what's
biologic genetic predisposition, and then what's the
psychosocial. So it's no wonder that, at least conservatively,
10 to 15% of women will have some sort of postpartum mood or
anxiety episode, higher in women who have more adversity, or
higher risk for some reason. And it is always an exceptionally
meaningful time to be able to have the privilege to be part of
someone's life as a health care professional and to try and
intervene in a positive way for people who are struggling.
That's remarkable, you know, as you've kind of described the
situation, instead of thinking of it as kind of biological
factors, psychological factors and social factors is three
maybe independent buckets. It sounds like they really are
interconnected, and things that happen in one of these domains
really impacts some of the other domains.
Well, certainl y we know that you have your genetic
risks. So perhaps you have a family history of depression,
but we know whether any gene is expressed or turned on or not,
or off is very dependent on any number of factors, but certainly
epi genetics. We know that adverse life events cause
epigenetic modification. And so it is so complex in the studies
we've done at UNC looking with diverse populations of women.
It's really not about your race or ethnicity, ethnicity, that's
going to increase your risk, it's going to be about
underlying genetic risk and adversity. In studies, you know,
that have been done around the world increases risk and
powerful ways. Why is that? Well, likely, because of
epigenetic modification, likely because of trauma, and the
impact that has on psychological functioning on HPA axis
functioning. And during the perinatal period, the HPA axis
is on overdrive. And so when you need your HPA axis to work
really well, if it's going to be wonky, which is obviously not a
technical term, because of, you know, early life adversity, or
life adversity that has caused it to act in a way that's
dysregulated. It increases risk. But there's so many different
permutations of what we see as, for example, perinatal
depression on set during pregnancy versus people that
said, I felt great during pregnancy and postpartum it was
like, a switch was flipped.
And clearly, there's people for whom a huge amount is
biologically driven.
There are then people who have all sorts of psychosocial
stressors, including a traumatic birth experience or a child
that, you know, a premature birth and you end up in the
NICU. We know that moms of preemies and parents of babies
in the neonatal intensive care units have much higher risk. So
there's so many different factors that will ultimately
decide which way the postpartum period goes for an individual
mom and her family.
So Dr. Meltzer, birdie, what I'd love to do after we come back
from the break is take this kind of to the next level in
understanding, you know, if someone is struggling, what are
their options in terms of treatment, because I imagine if
there are multiple things that could be contributing to someone
struggling, there are probably multiple options. And so, really
want to hear more about that in a moment. But want to also let
people know that we're going to ask Dr. Meltzer-Brody, a very
important question, which will probably impact our friendship
for forever. All right, so we will be back in a minute. At
Alliance, we see health care differently than some. Every day
we walk alongside the people we serve on their chosen path to
recovery and self determination. We believe in health care that
concentrates on the whole person, including support that
promotes physical, social, emotional, and financial well
being and housing security, helping people live healthier,
more satisfying lives. That's the Alliance way.
All right. So we're back with Dr. Samantha Meltzer Brody,
chair of the UNC psychiatry department. And I mentioned that
because that is one place where Dr. Meltzer Brody, pledges
allegiance but as I think we heard a few minutes ago, she and
I actually met further up the road at the darker believes blue
school at Duke in another century as my my children like
to say.
And then before that, Dr. Meltzer Brody was at
Northwestern University. And so I have some of that connection
as well. And so my question is, of those three storied
institutions. If they were playing each other,
which one would you root for? It's a piece of cake. So Mehul I
was a Michael Jordan fan for a very long time and rooted for
Carolina long before I had the honor of working here but I've
been at UNC for the summer will be 22 years. So it is a easy,
easy win. And clearly, at least this year, we are far superior
I certainly Duke or Northwestern, so easy, easy
choice. It's yeah. Well, it's easy to be better than
Northwestern in athletics on on any given Sunday
or Saturday or Friday.
Anyway, well, well, well, thank you for that. Dr. Meltzer Brody.
So and I think that's the right answer that a lot of people were
expecting for you. So. So you were telling us, you know, just
very clearly all of the components that kind of go into
maternal well being, and when when people are not feeling so
well. And so then I imagine if we kind of turn the tables a bit
and think about well, okay, we've identified here is a woman
and a family system that is struggling. Now what, you know,
what are our options? And it's probably not a one size fits
all?
No, certainly, I think we should all be humbled by anything in
medicine, that is not a one size fits all and certainly in in, in
something as complex as psychiatry or mental health.
If we look at practice guidelines, and if we look at
the literature,
for first line treatment, and has been continues to be for
mild moderate symptoms, psychotherapy, okay?
interpersonal psychotherapy, or IPT, has the largest evidence
base. Certainly, there are other studies that have looked at
different forms of cognitive behavioral therapy, behavioral
activation therapy, there are multiple different types of
psychotherapy, but certainly, interpersonal psychotherapy has
a very large evidence base. And I think part of its
effectiveness is because it's looking at the interpersonal
issues, which certainly during the perinatal period, are front
and center, the relationship with a partner, or the father of
the baby, or whoever happens to be in the partner role,
relationships with other family members with the mother's own
parents, or in laws, or siblings, or whoever's in the,
the village, if you will. And then the transformative role of
becoming a parent and the relationship
and how relationships shift in the role of becoming a mother
and parenting that way. Or, you know, to be most inclusive,
whoever it is, is, you know, welcoming a baby into their
life, whether that's a woman man or or someone who doesn't
identify with a specific gender, but it is a very transformative
time. So I think that for that reason, IPT has been very
effective.
So psychotherapy, it's often the first line treatment. And that's
great as long as you're someplace where you can access
it. And so, access is an issue in terms of there's not enough
mental health professionals, for people to easily access them,
let alone
you know, people with specialty training in perinatal mental
health. Now certainly virtual care has been quite helpful, and
expanding access broadly. And that's something that we
certainly are providing care of much more broadly across North
Carolina with virtual care than we were before. And for a lot of
mothers, as you can imagine. Pregnant women and postpartum
women, if they have the option for a virtual appointment,
they're going to often choose that versus all the
inconveniences of having to travel and take the baby or get
childcare or all of those things. So I think it's much
more accessible than it was there's still way to go if we
think about pharmacologic treatment. The
selective serotonin reuptake inhibitors, the SSRIs have a
very robust evidence base both in pregnancy and lactation. They
probably do like a medicine like flu OXA teen brand name Prozac
or sertraline, brand name Zoloft, those kinds of
medicines. Exactly. And it's probably been more heavily
scrutinized the SSRIs than any other drug ever during pregnancy
and postpartum. Looking for associations, better outcomes
worse outcomes. By and large, if you look at all the data in
maths, it's largely extremely reassuring. We know that
depression, untreated depression during pregnancy, increases risk
of preterm birth.
We also know that SSRI use may also increase risk of preterm
birth. We also know that a lot of people are prescribed less
than therapeutic doses of SSRIs. So they both have continued to
have depression and they're taking an SSRI. So it gets very
murky. When you're looking at these studies to try and figure
out was depression adequately treated? Or were they just
taking an antidepressant and still continued to struggle with
depression, but sorry to interrupt, I just want to mark
that you
And I know we're talking about treatments, but just want to
call this out. If I understand correctly, what you're saying is
that a woman having depression during the, let's say, the last
trimester of her pregnancy, that is what some scientists such as
yourself would call an independent risk factor for
preterm birth. Did I hear that correctly? Yes, that women who
have untreated depression during pregnancy have an increased risk
for preterm birth. That's remarkable. We also see a risk
with SSRIs. That has been documented as well. So the
literature trying to do the chicken egg what's causing what
gets very tricky because of that.
Nonetheless, SSRIs are commonly used during pregnancy and for
postpartum depression. Okay.
And,
you know, often then you'll have a combination approach of
antidepressant medication and psychotherapy.
That can be very helpful depending on the specific issues
an individual person is encountering in general,
antidepressants would be used for more moderate to severe
depression. Okay, I'm most recently and UNC served as the
initial site. And I served as the academic PI for the clinical
trials investigating
Brexanolone an IV infusion, which is a proprietary
formulation of allopregnanolone, which is the neuro active
metabolite of progesterone
alone, is the first FDA approved drug for postpartum depression.
So marketed as by the company that makes it sage therapeutics
as zulresso. It is a rapidly acting antidepressant. It's a 60
hour IV infusion, and that's was approved for severe postpartum
depression. So because you have to be in a medical setting.
And people are quite sick. It is really for people who have much
more severe forms of postpartum depression. But it's worth
mentioning that maternal suicide is one of the greatest causes of
maternal mortality, oh, my goodness. So when women have
postpartum depression, it can take their lives because of
suicide. So when it's that severe and you know, certainly
postpartum psychosis, which is different but but devastating
when it when you have postpartum psychiatric illness that severe,
it's just horrendous associated with suicide or infanticide, and
its worst forms. Thankfully, those cases are much more rare.
And it's much more common that people are going to have more
mild moderate symptoms for which the treatments are, again are
going to initially be psychotherapy and or first line
anti depressant therapy, it's really great to hear that there
are a range of treatments, and then some of the forms of
psychotherapy both look inwards, in the individual and also into
their support system.
Right. And I And I'm certainly not even getting into all the
other types of therapy too, right. So there are studies that
have looked at our TMS there's certainly lots of studies
looking at exercise or meditation. In the same way, if
you look at depression writ large, the power of social
connection, I do think that people are not meant to go
through the perinatal period alone, I don't think people are
meant to certainly be parents in a vacuum. And I do think that
social connection, community support systems are really just
paramount during this time, which is one reason why over the
course of the pandemic, we've seen rates of maternal mental
health just markedly worsen because all the normal ways
people get support, often from grandparents and siblings coming
to visit helping them all of that was profoundly disrupted,
and people were left feeling extremely lonely and isolated,
and scared, none of which helped, you know, anxiety or
mood symptoms. So I think, a terribly difficult time. And I
think the stressors just in the world now and where people are,
we need social connection and supports more than ever. And I
think that's one of our challenges moving forward is how
we do that well. So I think the world first of all needs more
Dr. Meltzer Brody's. And the piece that I'm curious about,
although I have a sense as to what your answer is going to be.
But what I'd love for us to know as we end our time together
What gets Dr. Meltzer Brody going? You know, why do you do
what you do? Because you you have choices you could be doing
anything as a physician, why do you do this?
Well, I will have to blame what I do largely on my family of
origin, right? Shouldn't don't we blame everything on our
family of origin and our parents. But
I think that, ultimately, I've always been very curious about
why people do what they do have parents that were big advocates
in the mental health arena.
I love hearing people's stories. And people's narratives and have
always been fascinated about, you know, why any individual's,
you know, life story and narrative and the factors add up
to a particular path.
And I just have always found it such a privilege to be able to
work with people to hear their life story and to talk about
their mental health and to talk about psychiatric symptoms and
do our best as a field, however limited, it has been to date, to
try and make it better. And I think now, maybe we'll now that
we're old, getting older by the day.
I think my frustration now. And what drives me now is we got to
do better than we're doing.
It's not okay, that mental health still has the stigma it
has. So I think we have a lot of work to do.
That's what drives me now. There's just a huge amount to do
to make things better for so many people that suffer and
there's a real opportunity, I think, to to do things that will
improve the mental health.
If we look at our children, if we look at mothers if we look at
other populations, and we just need to roll up our sleeves and
get to work.
Dr. Meltzer Brody, thank you so much for joining us. Thank you
for the opportunity to talk with you.
The rethink and retool healthcare in the new era
podcast is produced by Alliance health a North Carolina public
managed care organization. This show was produced by Brandon
Alexander our associate producer is Denise Dirks and executive
producer is Doug fuller. View our show notes and hear other
episodes at Alliance health plan.org forward slash podcast
thanks for tuning in.