Passion, Persistence and Serendipity

Serendipity and science often go together. Examples abound of fortuitous accidents in the lab or “failures” like the adhesive that spawned the success of 3M’s Post-It Notes.

Here’s another. UNC-Chapel Hill’s Perinatal Psychiatry Program—an outpatient and research program that also includes the first and only free-standing inpatient postpartum depression unit in the nation–may not have existed, but for a failure and several serendipitous moments in the life and career of Samantha Meltzer-Brody, M.D., M.P.H.

The new unit is so important because 10-15 percent of new mothers experience postpartum depression (PPD). Of those, about 5 percent require hospitalization, which equates to 20,000-30,000 women per year in the United States. Women with severe perinatal psychiatric illness need a place designed to care for the mother-infant dyad that can provide specialized treatment services at this vulnerable time.

The UNC unit has up to five beds and has attracted patients from the Southeast and as far away as Iowa. So, it is a small, yet significant start. According to Meltzer-Brody, however, there have been inpatient “mother-baby units” in Europe for the last 40-50 years.

The adverse consequences of untreated postpartum depression include impaired mother-infant attachment, which can lead to a lifetime of problems for the children. Mothers with depression also are not able to be as attentive in general to their children as they want to be. In the most serious cases, the safety of the mother and baby are at risk.

Research continues to search for the exact causes of PPD. Physicians know that the intense hormonal fluctuations of pregnancy and delivery are a precipitating factor. Women who have a history of more intense mood changes during their menstrual cycles are more at risk, as are women with trauma or sexual abuse histories. Some women also may be genetically predisposed, or more “hard-wired,” to get PPD. The biggest predictor is a prior case of PPD, which makes it difficult to guess which first-time mothers will have it, or a prior major depression. Investigating the underlying pathophysiology and genetic influences of PPD is a major focus of Meltzer-Brody’s research. It is funded on a NIH K23 Career Development Award and she is mentored and collaborates with Patrick Sullivan, M.D., in psychiatric genetics at UNC.

How Meltzer-Brody got involved

Born into a family that for several generations had owned a retail business in Ohio, Meltzer-Brody learned early the value of giving back to the community. For her, that meant going into medicine, specifically psychiatry. Undergraduate work at Simmons, a women’s college in the heart of Boston, gave her confidence and an interest in women’s health. Medical school at Northwestern, psychiatric residency at Duke, followed by a Robert Wood Johnson Clinical Scholars fellowship at UNC, all foretold a successful career in clinical research. Yet, she is quick to note candidly that there is more to the story.

“People who don’t know me will say it looks like the trajectory was more smooth sailing than it was. I actually gave a talk to some of the younger [medical scholars],” she said. “Whenever you get to hear someone’s real story there are always successes and failures and, really, if you don’t have the resilience to pick yourself up and say ‘let’s move on and try something different,’ you’d bomb out.”

She spent four years in her first faculty position at UNC working 80 percent of the time as a clinician and trying to carve out a research program in the other 20 percent. At the time, her focus was women’s mental health, pelvic pain and sexual trauma. She was also raising her two very young children with her husband, an OB/GYN affiliated with the UNC School of Medicine.

Simultaneously, seeing an unmet need through her clinical work as a consultation-liaison psychiatrist in the hospital, she had begun a small out-patient postpartum depression clinic in 2004 along with a senior colleague, Cort Pedersen, M.D. At first, she and some psychiatry residents saw patients one morning a week, but the need was greater than that, and it took off.

“When we were planning for the opening of the clinic, we were hopeful that the patients would come. However, once it opened, the response was overwhelmingly positive and we were soon scrambling to keep up with patient referrals. We quickly realized that we had tapped into a huge and unmet need for specialized mental health treatment during the vulnerable perinatal period,” she said.

Recognizing also that she needed more protected research time, she applied for a career development grant for her work in women’s mental health and pelvic pain, but did not get it.

This is the first point where her persistence met with serendipity. Patricia Byrns, M.D., now retired, but former program director for the Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Scholar program, advised her to set aside pelvic pain research and focus on her passion and success with treating postpartum depression. She did and began the application process for a three-year BIRCWH grant. The BIRCWH is a career development program that provides 75 percent protected research time (almost a complete reversal of her faculty position at the time) to clinician-scholars and is administered by the N.C. Translational and Clinical (NC TraCS) Institute, home of UNC’s NIH Clinical and Translational Sciences Awards (CTSA).

Enter serendipity again. In late 2005, the UNC School of Medicine announced that the new chair of the department of psychiatry was going to be David Rubinow, M.D., who had spent 25 years studying women’s reproductive mood disorders at the NIH.

“I am 100 percent certain that he is the only chair of psychiatry in the United States who is an expert in women’s mood disorders. It is just not a big area,” said Meltzer-Brody.

“He came to interview and I was part of a small group that took him to dinner as a chair candidate. David Rubinow is an international expert and is also a highly engaging person and effective mentor. As a junior faculty member who had started this postpartum depression clinic, I was trying to segue my research from everything I had done in sexual trauma, abuse and pelvic pain to developing the clinical infrastructure and the patient flow necessary to sustain a research program that could study postpartum depression and lead to a successful grant application. Therefore, I was incredibly excited about the possibility of David Rubinow coming to UNC,” she explained in rapid-fire succession.

Before taking his post at UNC officially, he worked with Meltzer-Brody through the BIRCWH application process and agreed to serve as her mentor. He started as chair at the first of January 2006, the same day she began as a BIRCWH Scholar.

“The BIRCWH really saved me in terms of my career trajectory,” she said. “I think for a lot of junior faculty members it is a peak time when they are trying to balance the demands of launching a career in academic medicine with the demands of raising young children. Had I not gotten the protected time of the BIRCWH I am a 100 percent positive that I would have said, ‘You know, this has all been really nice, but I can’t keep running on this academic treadmill without protected time for research.’” That would have meant she would have set aside her years of training and skills in clinical research and simply continued on treating patients in psychiatry. While she admits that is an important and worthy goal in itself, it would have not fulfilled her personal career aspirations, nor allowed her to help move the science forward.

Looking ahead

Meltzer-Brody said that without the leadership of Rubinow, it is clear that they would not be where they are now in terms of the extent of the UNC Perinatal Psychiatry Program—a comprehensive outpatient and research program that also includes the new perinatal inpatient unit. Recently, Rubinow was elected to the Institute of Medicine, one of the nation’s highest honors in medicine. The process of developing the UNC Perinatal Psychiatry Program has been lengthy and has only succeeded because of the collaboration with many other faculty and staff at UNC, including Christena Raines, N.P., Elizabeth Bullard, M.D., Susan Killenberg, M.D., and the support of UNC Hospitals nursing leadership including Mary Tonges, R.N., Ph.D., and Eileen Spahl.

“I do think that Samantha's organizational skills, her limitless enthusiasm, her clinical talents and her passion for her chosen field of research converged to permit the success that she has rapidly achieved,” said Rubinow. “Equally central to that success, however, has been her wonderful sense of humor, which goes a long way toward sustaining one (and one's collaborators) during the otherwise difficult periods that characterize academic medicine.”

Meltzer-Brody credits the interdisciplinary culture at UNC for the success. She continues to collaborate on research projects with investigators across UNC. For example, she described the receptivity of the OB/GYN department in working with psychiatry so that women have access to a mental health professional within that setting rather than having to go to a place labeled “mental health.”

“If you have the flu, it’s not a secret. But if you have depression, it’s often seen as embarrassing and is kept a secret. That permeates all mental health issues,” she said.

“I would like postpartum depression to be something that people no longer feel reluctant talking about, that they see it as a common complication of pregnancy, that they speak up, that families are educated, that they get diagnosis and treatment. Postpartum depression should be part of routine screening in every obstetrical setting in the United States.”