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Unknown: Thanks for joining the
Re-think and Re-tool podcast

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with Mehul Mankad MD where we
take a look at the people side

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of healthcare and new ideas
about enhancing overall well

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being so welcome. The doctor is
in the house.

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Welcome to Re-Think and Re-Tool
sponsored by Alliance Health.

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This is Mehul Mankad
psychiatrist and Chief Medical

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Officer for Alliance. No one is
more familiar with the topic of

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women's mental health than Dr.
Samantha Meltzer- Brody, the

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Assad Meymandi Distinguished
Professor and Chair of the

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psychiatry department at the
University of North Carolina,

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particularly when it comes to
the mental health of women

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during and after pregnancy. Dr.
Meltzer Brody is more

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knowledgeable than anyone else I
have ever met.

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We're also going to hear how Dr.
Meltzer Brody, a person who has

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worked at both Duke and UNC
handles things on game day.

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I can't wait to hear what she
has to say. Let's get started.

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Dr. Meltzer Brody.

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Well, hello, thanks for having
me. Thank you for joining us on

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rethinking retool. I will share
that our lives have been

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intertwined for a minute. And
you may not remember this, but

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I'll tell you what I remember.

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The year was 1997. And I was
interviewing for residencies

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all over the country, coming
from Chicago and really looking

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everywhere. And I came down and
the lady that ran the psychiatry

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residency at Duke, her name was
Tanah Grady. She said, There's

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someone I need you to meet.

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And it was you.

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How about that? Well, I remember
meeting you as a fellow in

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Northwestern Medical School, or
soon to be alum. And that was

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really fun. And I'm certainly
glad that you trained at Duke at

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that same time I was there so
that our paths have continued to

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cross ever since. Yeah, so our
paths have crossed, but they've

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certainly gone in different
directions. And one of the

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pieces I've just been in awe of
is your footprint in the world

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of women's mental health. And I
you know, is that space, does it

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have a different name? Is it
okay to call it women's mental

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health? Or is what is the best
term for that? Well, I think

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women's mental health will be
the most broad speaking. Okay.

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And that is a huge range.
Because if you're going to talk

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about women's mental health,
then you're literally talking

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about probably from the time of
adolescence, onward through

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lifespan. Great point versus
speaking about reproductive

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psychiatry, I see myself as a
reproductive psychiatrist, very

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much focused on in general, the
perinatal period, which is much

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more constrained in terms of
time, but you can use either it

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really just depends how
inclusive you're trying to be.

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Okay, so reproductive
psychiatry. And so I would love

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to know because this is a part
of, of your story that I'm

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unfamiliar with completely. How
did you get involved in

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reproductive psychiatry?

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So my initial introduction to
reproductive psychiatry,

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was as a research assistant, I
worked for three years between

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college and medical school as a
research coordinator at

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Massachusetts General Hospital
in Boston, I person had the

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opportunity to be with just a
really incredibly interesting

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and dynamic group of folks doing
studies and a lot of things and

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they had a new reproductive
psychiatry program, perinatal

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psychiatry program, the MGH
women's mental health program,

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which continues and so that was
my initial introduction to that

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and found it to be very, very
interesting. My next exposure to

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that was as a resident working
with Dr. Mimi Butterfield at the

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Durham VA where there was a
women's mental health clinic and

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that played a really formative

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role in my interest in women's
mental health specifically, but

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when I got

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to fellowship training at UNC
and then beyond, I realized that

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I was actually really interested
in focusing on the perinatal

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period, because I thought it was
and still do such a profound and

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transformative time for
families, for women's for women,

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and such an important time to
intervene.

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And so I continue to find
working with women and their

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families during that period of
time to be enormously rewarding.

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Because when someone has a
mental health condition during

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the perinatal period, pregnancy
or postpartum and you're able to

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help them through it, you are
changing the trajectory for for

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the mom's life and, and then for
their child across two

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generations. And so it continues
to be something that I am

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incredibly inspired by and
really love working with that

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patient population.

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Wow. So you mentioned impact and
intervention in this perinatal

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period. So So what do you mean,
what are the different things

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that are going on with women? I
imagine, you know, kind of going

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back to my own training,

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this this kind of bio
psychosocial model. And I wonder

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if that's helpful as an
explanation for what you're

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describing?

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Well, certainly, you have very
complex biology, you have very

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complex changes in most
physiologic simple systems. So

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if you think about pregnancy,
your blood volume goes up five

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times, right, you know, almost
organ systems are impacted, you

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know, immune system factors, HPA
axis system factors, hormonal

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factors, you name it, it's
changing.

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And then you have this rapid
down escalation of everything,

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if it goes well, postpartum.
Meanwhile, you have the

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transition from being pregnant
to for women who choose to do so

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lactating,

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and, you know, suddenly,

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you know, end up with this small
infant, without a manual that

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you know, it was handed to the
mom.

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And with a, you know, best
wishes.

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Good luck. And it goes better or
worse, depending on lots of

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things, but the psychosocial
contributions, the support

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system, the history of childhood
adversity, and that how that may

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impact someone's hypothalamic
pituitary stress axis, and how

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that responds well or does it
during a time when you're doing

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sort of HPA Axis gymnastics,
whether someone will find out

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that they actually don't do well
with sleep deprivation, or they

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find out they do find without
sleep deprivation, whether they

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have the social supports, they
need to make this all work, or

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they don't. And so I think that
it's a time of such profound

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change. That, on one hand is
very universal, because people

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have children all over the world
every day, and on the other

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hand, is exceptionally unique to
that particular individual in

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that time and place,

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unique arrangement of do they
have, you know, three

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generations of family all living
on the same block to help or

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they're literally by themselves
somewhere with no one else to

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help them because their partner,
you know, left when they found

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that they were pregnant? And
it's just them? Do they have

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maternity leave? You know, do
they have adequate finances? So

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there's so many different things
that come into play both what's

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biologic genetic predisposition,
and then what's the

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psychosocial. So it's no wonder
that, at least conservatively,

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10 to 15% of women will have
some sort of postpartum mood or

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anxiety episode, higher in women
who have more adversity, or

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higher risk for some reason. And
it is always an exceptionally

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meaningful time to be able to
have the privilege to be part of

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someone's life as a health care
professional and to try and

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intervene in a positive way for
people who are struggling.

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That's remarkable, you know, as
you've kind of described the

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situation, instead of thinking
of it as kind of biological

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factors, psychological factors
and social factors is three

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maybe independent buckets. It
sounds like they really are

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interconnected, and things that
happen in one of these domains

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really impacts some of the other
domains.

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Well, certainl y we know that
you have your genetic

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risks. So perhaps you have a
family history of depression,

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but we know whether any gene is
expressed or turned on or not,

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or off is very dependent on any
number of factors, but certainly

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epi genetics. We know that
adverse life events cause

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epigenetic modification. And so
it is so complex in the studies

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we've done at UNC looking with
diverse populations of women.

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It's really not about your race
or ethnicity, ethnicity, that's

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going to increase your risk,
it's going to be about

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underlying genetic risk and
adversity. In studies, you know,

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that have been done around the
world increases risk and

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powerful ways. Why is that?
Well, likely, because of

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epigenetic modification, likely
because of trauma, and the

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impact that has on psychological
functioning on HPA axis

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functioning. And during the
perinatal period, the HPA axis

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is on overdrive. And so when you
need your HPA axis to work

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really well, if it's going to be
wonky, which is obviously not a

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technical term, because of, you
know, early life adversity, or

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life adversity that has caused
it to act in a way that's

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dysregulated. It increases risk.
But there's so many different

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permutations of what we see as,
for example, perinatal

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depression on set during
pregnancy versus people that

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said, I felt great during
pregnancy and postpartum it was

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like, a switch was flipped.

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And clearly, there's people for
whom a huge amount is

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biologically driven.

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There are then people who have
all sorts of psychosocial

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stressors, including a traumatic
birth experience or a child

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that, you know, a premature
birth and you end up in the

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NICU. We know that moms of
preemies and parents of babies

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in the neonatal intensive care
units have much higher risk. So

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there's so many different
factors that will ultimately

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decide which way the postpartum
period goes for an individual

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mom and her family.

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So Dr. Meltzer, birdie, what I'd
love to do after we come back

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from the break is take this kind
of to the next level in

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understanding, you know, if
someone is struggling, what are

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their options in terms of
treatment, because I imagine if

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there are multiple things that
could be contributing to someone

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struggling, there are probably
multiple options. And so, really

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want to hear more about that in
a moment. But want to also let

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people know that we're going to
ask Dr. Meltzer-Brody, a very

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important question, which will
probably impact our friendship

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for forever. All right, so we
will be back in a minute. At

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Alliance, we see health care
differently than some. Every day

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we walk alongside the people we
serve on their chosen path to

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recovery and self determination.
We believe in health care that

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concentrates on the whole
person, including support that

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promotes physical, social,
emotional, and financial well

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being and housing security,
helping people live healthier,

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more satisfying lives. That's
the Alliance way.

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All right. So we're back with
Dr. Samantha Meltzer Brody,

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chair of the UNC psychiatry
department. And I mentioned that

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because that is one place where
Dr. Meltzer Brody, pledges

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allegiance but as I think we
heard a few minutes ago, she and

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I actually met further up the
road at the darker believes blue

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school at Duke in another
century as my my children like

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to say.

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And then before that, Dr.
Meltzer Brody was at

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Northwestern University. And so
I have some of that connection

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as well. And so my question is,
of those three storied

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institutions. If they were
playing each other,

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which one would you root for?
It's a piece of cake. So Mehul I

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was a Michael Jordan fan for a
very long time and rooted for

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Carolina long before I had the
honor of working here but I've

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been at UNC for the summer will
be 22 years. So it is a easy,

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easy win. And clearly, at least
this year, we are far superior

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I certainly Duke or
Northwestern, so easy, easy

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choice. It's yeah. Well, it's
easy to be better than

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Northwestern in athletics on on
any given Sunday

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or Saturday or Friday.

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Anyway, well, well, well, thank
you for that. Dr. Meltzer Brody.

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So and I think that's the right
answer that a lot of people were

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expecting for you. So. So you
were telling us, you know, just

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very clearly all of the
components that kind of go into

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maternal well being, and when
when people are not feeling so

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well. And so then I imagine if
we kind of turn the tables a bit

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and think about well, okay,
we've identified here is a woman

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and a family system that is
struggling. Now what, you know,

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what are our options? And it's
probably not a one size fits

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all?

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No, certainly, I think we should
all be humbled by anything in

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medicine, that is not a one size
fits all and certainly in in, in

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something as complex as
psychiatry or mental health.

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If we look at practice
guidelines, and if we look at

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the literature,

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for first line treatment, and
has been continues to be for

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mild moderate symptoms,
psychotherapy, okay?

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interpersonal psychotherapy, or
IPT, has the largest evidence

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base. Certainly, there are other
studies that have looked at

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different forms of cognitive
behavioral therapy, behavioral

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activation therapy, there are
multiple different types of

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psychotherapy, but certainly,
interpersonal psychotherapy has

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a very large evidence base. And
I think part of its

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effectiveness is because it's
looking at the interpersonal

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issues, which certainly during
the perinatal period, are front

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and center, the relationship
with a partner, or the father of

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the baby, or whoever happens to
be in the partner role,

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relationships with other family
members with the mother's own

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parents, or in laws, or
siblings, or whoever's in the,

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the village, if you will. And
then the transformative role of

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becoming a parent and the
relationship

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and how relationships shift in
the role of becoming a mother

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and parenting that way. Or, you
know, to be most inclusive,

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whoever it is, is, you know,
welcoming a baby into their

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life, whether that's a woman man
or or someone who doesn't

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identify with a specific gender,
but it is a very transformative

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time. So I think that for that
reason, IPT has been very

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effective.

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So psychotherapy, it's often the
first line treatment. And that's

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great as long as you're
someplace where you can access

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it. And so, access is an issue
in terms of there's not enough

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mental health professionals, for
people to easily access them,

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let alone

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you know, people with specialty
training in perinatal mental

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health. Now certainly virtual
care has been quite helpful, and

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expanding access broadly. And
that's something that we

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certainly are providing care of
much more broadly across North

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Carolina with virtual care than
we were before. And for a lot of

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mothers, as you can imagine.
Pregnant women and postpartum

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women, if they have the option
for a virtual appointment,

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they're going to often choose
that versus all the

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inconveniences of having to
travel and take the baby or get

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childcare or all of those
things. So I think it's much

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more accessible than it was
there's still way to go if we

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think about pharmacologic
treatment. The

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selective serotonin reuptake
inhibitors, the SSRIs have a

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very robust evidence base both
in pregnancy and lactation. They

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probably do like a medicine like
flu OXA teen brand name Prozac

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or sertraline, brand name
Zoloft, those kinds of

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medicines. Exactly. And it's
probably been more heavily

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scrutinized the SSRIs than any
other drug ever during pregnancy

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and postpartum. Looking for
associations, better outcomes

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worse outcomes. By and large, if
you look at all the data in

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maths, it's largely extremely
reassuring. We know that

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depression, untreated depression
during pregnancy, increases risk

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of preterm birth.

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We also know that SSRI use may
also increase risk of preterm

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birth. We also know that a lot
of people are prescribed less

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than therapeutic doses of SSRIs.
So they both have continued to

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have depression and they're
taking an SSRI. So it gets very

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murky. When you're looking at
these studies to try and figure

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out was depression adequately
treated? Or were they just

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taking an antidepressant and
still continued to struggle with

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depression, but sorry to
interrupt, I just want to mark

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that you

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And I know we're talking about
treatments, but just want to

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call this out. If I understand
correctly, what you're saying is

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that a woman having depression
during the, let's say, the last

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trimester of her pregnancy, that
is what some scientists such as

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yourself would call an
independent risk factor for

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preterm birth. Did I hear that
correctly? Yes, that women who

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have untreated depression during
pregnancy have an increased risk

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for preterm birth. That's
remarkable. We also see a risk

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with SSRIs. That has been
documented as well. So the

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literature trying to do the
chicken egg what's causing what

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gets very tricky because of
that.

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Nonetheless, SSRIs are commonly
used during pregnancy and for

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postpartum depression. Okay.

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And,

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you know, often then you'll have
a combination approach of

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antidepressant medication and
psychotherapy.

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That can be very helpful
depending on the specific issues

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an individual person is
encountering in general,

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antidepressants would be used
for more moderate to severe

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depression. Okay, I'm most
recently and UNC served as the

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initial site. And I served as
the academic PI for the clinical

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trials investigating

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Brexanolone an IV infusion,
which is a proprietary

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formulation of allopregnanolone,
which is the neuro active

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metabolite of progesterone

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alone, is the first FDA approved
drug for postpartum depression.

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So marketed as by the company
that makes it sage therapeutics

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as zulresso. It is a rapidly
acting antidepressant. It's a 60

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hour IV infusion, and that's was
approved for severe postpartum

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depression. So because you have
to be in a medical setting.

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And people are quite sick. It is
really for people who have much

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more severe forms of postpartum
depression. But it's worth

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mentioning that maternal suicide
is one of the greatest causes of

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00:22:16,260 --> 00:22:20,430
maternal mortality, oh, my
goodness. So when women have

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postpartum depression, it can
take their lives because of

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suicide. So when it's that
severe and you know, certainly

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postpartum psychosis, which is
different but but devastating

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when it when you have postpartum
psychiatric illness that severe,

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it's just horrendous associated
with suicide or infanticide, and

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its worst forms. Thankfully,
those cases are much more rare.

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And it's much more common that
people are going to have more

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mild moderate symptoms for which
the treatments are, again are

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00:22:54,510 --> 00:22:59,190
going to initially be
psychotherapy and or first line

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anti depressant therapy, it's
really great to hear that there

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are a range of treatments, and
then some of the forms of

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psychotherapy both look inwards,
in the individual and also into

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their support system.

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Right. And I And I'm certainly
not even getting into all the

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other types of therapy too,
right. So there are studies that

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have looked at our TMS there's
certainly lots of studies

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00:23:28,217 --> 00:23:31,978
looking at exercise or
meditation. In the same way, if

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you look at depression writ
large, the power of social

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connection, I do think that
people are not meant to go

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through the perinatal period
alone, I don't think people are

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meant to certainly be parents in
a vacuum. And I do think that

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social connection, community
support systems are really just

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00:23:52,595 --> 00:23:56,774
paramount during this time,
which is one reason why over the

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course of the pandemic, we've
seen rates of maternal mental

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health just markedly worsen
because all the normal ways

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people get support, often from
grandparents and siblings coming

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00:24:09,381 --> 00:24:13,490
to visit helping them all of
that was profoundly disrupted,

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and people were left feeling
extremely lonely and isolated,

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and scared, none of which
helped, you know, anxiety or

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mood symptoms. So I think, a
terribly difficult time. And I

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think the stressors just in the
world now and where people are,

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we need social connection and
supports more than ever. And I

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think that's one of our
challenges moving forward is how

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we do that well. So I think the
world first of all needs more

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Dr. Meltzer Brody's. And the
piece that I'm curious about,

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although I have a sense as to
what your answer is going to be.

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But what I'd love for us to know
as we end our time together

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What gets Dr. Meltzer Brody
going? You know, why do you do

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what you do? Because you you
have choices you could be doing

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anything as a physician, why do
you do this?

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Well, I will have to blame what
I do largely on my family of

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origin, right? Shouldn't don't
we blame everything on our

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00:25:21,720 --> 00:25:23,940
family of origin and our
parents. But

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I think that, ultimately, I've
always been very curious about

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why people do what they do have
parents that were big advocates

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in the mental health arena.

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I love hearing people's stories.
And people's narratives and have

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00:25:46,830 --> 00:25:51,420
always been fascinated about,
you know, why any individual's,

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00:25:51,570 --> 00:25:54,930
you know, life story and
narrative and the factors add up

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00:25:54,930 --> 00:25:56,700
to a particular path.

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And I just have always found it
such a privilege to be able to

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work with people to hear their
life story and to talk about

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their mental health and to talk
about psychiatric symptoms and

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do our best as a field, however
limited, it has been to date, to

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try and make it better. And I
think now, maybe we'll now that

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we're old, getting older by the
day.

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I think my frustration now. And
what drives me now is we got to

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do better than we're doing.

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It's not okay, that mental
health still has the stigma it

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has. So I think we have a lot of
work to do.

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That's what drives me now.
There's just a huge amount to do

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to make things better for so
many people that suffer and

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00:26:50,700 --> 00:26:54,270
there's a real opportunity, I
think, to to do things that will

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improve the mental health.

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If we look at our children, if
we look at mothers if we look at

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other populations, and we just
need to roll up our sleeves and

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get to work.

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Dr. Meltzer Brody, thank you so
much for joining us. Thank you

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00:27:10,560 --> 00:27:12,120
for the opportunity to talk with
you.

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The rethink and retool
healthcare in the new era

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00:27:16,830 --> 00:27:20,670
podcast is produced by Alliance
health a North Carolina public

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00:27:20,670 --> 00:27:23,730
managed care organization. This
show was produced by Brandon

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00:27:23,730 --> 00:27:27,330
Alexander our associate producer
is Denise Dirks and executive

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00:27:27,330 --> 00:27:30,360
producer is Doug fuller. View
our show notes and hear other

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00:27:30,360 --> 00:27:34,530
episodes at Alliance health
plan.org forward slash podcast

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00:27:34,590 --> 00:27:35,850
thanks for tuning in.