FULL HEATED CROSS-EXAM: Dr. Tufts Grilled Over Zoloft, Suicide Fears & Postpartum Treatment — AB1E

[00:00:00] Speaker 1: trying to think of, or maybe it feels like, you know, maybe you're thinking of things a little [00:00:06] Speaker 2: bit more slowly than you normally would. And how often was she dwelling on suicide? At what point? At the point she told you that she had anxiety, insomnia, brain fog, crying inconsolably. [00:00:27] Speaker 3: Doctor, if we could have a date. I think she's going to get to that. [00:00:33] Speaker 2: October 26th, heading into November 2nd. Do you recall, I'll rephrase it, do you recall going into the November month meeting with her and she told you that she had brain fog? [00:00:55] Speaker 1: It was mentioned at some point, I don't see that on the 26th specifically. [00:01:01] Speaker 2: Alright, so let's talk about brain fog. Did you ask her what that meant? Because when you say subjective, that means that's her interpretation, that's in her head, she's telling you, right? Yes. As opposed to objective, which would be what people in general would think, right? Yes. So when she's telling you, in addition to the anxiety, in addition to the crying, in addition to the stress that she was undergoing, she was worrying about suicide, she talked about brain fog. Brain fog. So you must have asked her, what does that mean? Subjectively, what does that mean? [00:01:34] Speaker 1: Subjectively means in the patient's, you know, own opinion. That's what their experience is. [00:01:40] Speaker 2: Okay, so she's the one that's inside her head, right? [00:01:43] Speaker 1: Yes. [00:01:44] Speaker 2: So what were the symptoms? What does it mean? When a patient tells you that they have brain fog, is that something you would consider as being a potential side effect of the medications that you would put her on? [00:01:57] Speaker 1: It depends. [00:01:58] Speaker 2: On what? [00:02:00] Speaker 1: I mean, sometimes it could be, and sometimes it could be unrelated. It's a symptom of depression as well. So sometimes it's hard to tell what it's attributed to. [00:02:12] Speaker 2: So at this point, heading into November, your answer was to prescribe more medication, three more drugs, right? You prescribed Ativan, or increased the Ativan. What was she, what was her load for Ativan at this point? Do you remember? Sorry? What was her milligrams, if that's right, or nanograms, whatever it is, on the Ativan, on the script that you had provided her? Objection, if we could just have a date. I think she said, if you could answer that, go ahead. [00:02:39] Speaker 1: Which date are we referring to for the Ativan? Because there were, I'm sorry. [00:02:43] Speaker 2: She already objected. He already said you can answer it. When did you increase her Ativan, [00:02:49] Speaker 1: and to what level? So she was prescribed Ativan 0.5 milligrams. Right. And then when I next saw her, she said it was a little bit helpful. So I said, you could increase it and see if one milligram is more helpful. [00:03:14] Speaker 2: Did she increase it? Yes. And when was the next time you saw her? To talk to her on the television or on the computer? [00:03:22] Speaker 1: Well, I saw her on the 26th, and then I saw her on the 31st. [00:03:33] Speaker 2: I'm sorry. Thanks. How was she on the 31st? Halloween, how was she? That's not my note, that's her therapy note. Okay. So how about this November 2nd? Was that the next time you saw her? I saw her on November 2nd. And she told you that she was hesitant to use the medications, [00:03:51] Speaker 1: the BuSpar and the hydroxyzine, right? She said she was hesitant to try the BuSpar. She was scared of the drugs, [00:04:01] Speaker 2: right? She was afraid to take a medication. She wasn't doctor shopping and asking you to give her drugs so she could get high. She was asking you for help. Isn't that right? Yes. And she was afraid to take the drugs and told you that she was afraid to take the drugs, right? [00:04:18] Speaker 1: She told me she was afraid to take the BuSpar. Did you advise her or counsel her or give her therapy about that? Validations? Yes. And what did you tell her? Well, I advised her of, you know, the risks. What were the risks? Well, the risks of medicine, like we had said, sedation or dizziness. Okay. How about interfering with sleep? BuSpar doesn't usually interfere with sleep. Not usually? [00:04:55] Speaker 2: Did you ask her about any thoughts of suicide or being close to having thoughts of suicide? Yes. Did she indicate to you that she had any thoughts of suicide at all? Not at that date. Did she use those words or is that a box that you checked off? [00:05:14] Speaker 1: I don't remember her exact words, but we talked about suicide or, you know, thoughts of hurting [00:05:21] Speaker 2: yourself. Right. And there's a distinction between, and your records in the notation, between suicidal ideation and, and I quote, worrying about thinking about suicide. Would you agree with that? Yes. And what did she mean when she told you, as her doctor, that she was worrying about thinking about [00:05:42] Speaker 1: suicide? You mean in the, in the prior appointment? I'm talking about a woman that's sitting in front of [00:05:49] Speaker 2: you on your television or your computer, telling you that she was worried about thinking about suicide. [00:05:57] Speaker 1: Well, on, on the second, she didn't say that. Okay. When was the next time that she told you that [00:06:04] Speaker 2: she was worried about, or thinking about, or suicidal ideation? That was the December 1st visit. Okay. So go back to the November 2nd visit. Would you agree with me that she, after you talked with her for that period, however long it was, that you then brought up four medications to her, recommending that they might be safer, and I quote, "safer alternatives"? Would you agree with that? [00:06:43] Speaker 1: Um, I, I see the word alternatives, not safer alternatives. Do you remember talking to her [00:06:50] Speaker 2: about Remeron? Yes. Did you recommend that she take Remeron? No. Did you ever prescribe Remeron? No. And is that Mirtazapine, as far as its generic name? Yes. And Remeron is an antidepressant, isn't that right? Yes. Um, and you did not feel that that would be an appropriate medication for her to take at that time? It was a very reasonable option, but we didn't decide to start it. So is this a collaboration? In other words, you and the patient, you would both make a decision as to when to start a drug, or is it your decision and advice to the patient? [00:07:31] Speaker 1: Well, it's ultimately my decision, but the patient's thoughts about the matter are very important. At the end of the day, the patient has to go home and take it themselves. I'm not, I'm not there to ensure that that is happening or not. So you had a November 22nd appointment, right? [00:07:55] Speaker 2: Yes. And it was at that time that she told you that she had been to see South Shore Perinatal Clinic, right? Yes. And did she tell you why she was seeing someone from the South Shore Perinatal Clinic? [00:08:13] Speaker 1: Um, I, I think she told me that it was because they were, uh, exclusively focused on treating perinatal conditions. Yeah, but so were you, right? Not exclusively. I'm a general psychiatrist. [00:08:28] Speaker 2: I see. Um, and did she mention the name of any doctor or nurse practitioner that she was seeing at the South Shore Perinatal Clinic? Um, yes. Who, who'd she mention? Um, I think she said [00:08:43] Speaker 1: something about, um, Julie. Paul? Yes. Okay. And a woman by the name of, uh, nurse, uh, Gelata? Um, I, I, I heard her name a little bit later, but yes. Okay. Um, did she advise that in fact [00:09:00] Speaker 2: by script she was using Ativan and Benadryl, um, and you told her to taper off the Ativan at that [00:09:07] Speaker 1: appointment, right? Had she tapered off the Ativan? Um, I, I think I told her to, I gave her a prescribed taper prior to that appointment. What does that mean? What does that mean you gave her a prescribed taper? So I, I told her that she should reduce her dose by 0.25 milligrams every two weeks. until the medication was stopped. Did she do that? Um, I mean, I, I don't believe that she completely [00:09:44] Speaker 2: stopped it. No. No? You don't believe or she didn't? Well. Trying to give the jury facts. Yeah, [00:09:51] Speaker 1: she said she was taking Ativan. So, so no, she didn't completely stop it. Had she tapered? Um, I'm not sure how much she had reduced the dose because I wasn't prescribing it again. Right. So, [00:10:05] Speaker 2: did you know that she had been or had she been to any emergency wards between that period of time that you last saw her and when you were seeing her on this meeting? Um, I know she went to the ER, [00:10:19] Speaker 1: sorry, ER, but I, I think it was after that. Okay. Which ER did she go to? Do you know? Um, I think she went to Mass General. Do you know why she went to the ER? [00:10:31] Speaker 2: Um, because of depression. So, was she treated at the ER? Did they make any, to your knowledge, as her doctor, make any recommendations? I'm not sure what they told her, but they ultimately, [00:10:46] Speaker 1: go ahead. They ultimately discharged her. They didn't admit her. Go ahead. Sorry. Sorry. Um, [00:10:54] Speaker 2: was she put on any medication? Not from the ER. Um, when you looked at the records from South Shore Perinatal Clinic, what did they indicate about suicidal ideation, worrying about suicide, close to suicide, anything? I didn't have access to those records. You're going to keep your voice up so everybody can hear you. You what? I did not have [00:11:21] Speaker 1: access to those records. Why not? Because we're a completely separate clinic. Seriously? Objection. [00:11:29] Speaker 2: She's visiting with you as a patient, and you can't access her medical records? Is what you're telling this, Jerry? I did not have access to them, no. Could she have signed a release? A HIPAA form? Yes, she could have. And you could have got the records? Yes. But you didn't? I did not feel like it was [00:11:50] Speaker 1: necessary because she provided all the relevant information about her treatment there. How do you know? [00:12:00] Speaker 2: She's got mental disease and she's on all this cocktail of drugs. How do you know that she is an [00:12:07] Speaker 1: accurate historian at this point in her life? It felt very accurate when she was able to recall the names of the medicines, doses of the medicines, specific days. She provided a lot of incredibly detailed information. So it showed me she was capable of doing that. So when you talked to her husband, [00:12:32] Speaker 2: Pat, how many times did you talk to her husband, Pat? I think I was living with her. I think it was once. And he came to your office, right? No, he didn't. He got on the television or the computer screen, right? Yes. And when was that? [00:12:50] Speaker 1: Uh, I think it was the December 16th visit. [00:12:55] Speaker 4: So, before we get to that, it's probably a good spot to stop. We're going to take the morning recess and then we'll come right back. Okay? Court, all rise. [00:13:08] Speaker 2: Court, all rise. Sure. Here's the polls and all votes facing on your chest. [00:13:21] Speaker 4: Y'all sit for the jury? Yes. [00:13:31] Speaker 2: Court, all rise. George Andrews. Court, all rise. Thank you. This court is now in session. Please be seated. [00:14:03] Speaker 3: Your Honor, for the purpose of the record, we return back to the trial of Commonwealth versus Lindsay Clancy. All parties are present, including the defendant and the 18 jurors. [00:14:12] Speaker 4: All right. Thank you. Mr. Rennington. [00:14:16] Speaker 2: If you would just please look at your medical records that you have in front of you, I believe, and just go back to the document where you have, I believe, interval history. Can you repeat that? Sure. October 20th? Sorry. So, looking at the interview history, that's when that you decided to start Zoloft. It says a week ago, right? [00:14:48] Speaker 1: That's when the patient started, I guess. [00:14:52] Speaker 2: Okay. And she then increased the dose, and it says last night, right? And what was she telling you on the computer screen when you were talking to her? What did she say about increasing the dose of the Zoloft? [00:15:11] Speaker 1: That she felt awful. She couldn't sleep. Had insomnia, which became worse when she increased the dose. She didn't want to eat. She was having diarrhea. Food felt really unappealing. She was more depressed on it. Crying all day yesterday, which is not normal for her. She had some mental fog and was terrified to start something new. [00:15:41] Speaker 2: Did she also tell you about her anxiety level? [00:15:44] Speaker 1: Anxiety was really bad even before men. Now, hard to differentiate. Overnight, racing thoughts. Paranoid of getting suicidal thoughts. Something bad happening. Doesn't want to be alone. [00:16:04] Speaker 2: That must have given you concern that you had a pretty sick patient on your hands at that point, [00:16:09] Speaker 3: right? I was concerned, yes. [00:16:13] Speaker 2: So you gave her some therapy, did you? [00:16:17] Speaker 1: I gave her some therapy in conjunction with discussing all of her symptoms and assessing [00:16:22] Speaker 2: her and managing the medication. Okay. And again, I apologize. You have to keep your voice up so people can hear you way down here. So when you say that you were talking about the symptoms, and what did you do? Just talk about the same thing that we've just gone over? The symptoms? [00:16:40] Speaker 1: There were a number of them to discuss in more detail. That's the summary of them. [00:16:46] Speaker 2: Okay. So did she discuss it in detail? Yes. Did she tell you that her symptomology at this point on October 20th was so bad that she had to [00:16:59] Speaker 1: have her mother come and stay with her? Her mom was coming to provide support, yes. [00:17:05] Speaker 2: She wasn't coming to provide support. She was coming to stay with them, to live with them, wasn't she? [00:17:14] Speaker 1: Yes. I don't know for how long, but yes. [00:17:16] Speaker 2: Did you bother to ask her? Why is her mother having to stay with her? [00:17:21] Speaker 1: Because she needed some help. [00:17:25] Speaker 2: Do you know how long a mother stayed with her? I don't. Do you know that she ended up sleeping in the basement? I don't. Do you know that she ended up sleeping with a mother? [00:17:36] Speaker 1: I don't. [00:17:38] Speaker 2: So you decided that you'd stop the Zoloft and you would monitor closely, right? Yes. What does that mean, you'd monitor closely? [00:17:46] Speaker 1: Well, I saw her the next day, so that's, that's monitoring, an example of monitoring closely. [00:17:51] Speaker ?: Okay. [00:17:51] Speaker 2: Okay. So this would be on October 21st that you saw her the next day, is that correct? [00:17:58] Speaker ?: Yes. [00:17:59] Speaker 2: Now, on the 20th, you made reference to the fact, you also recommended that she try fish oil and things of that nature, natural remedies. [00:18:10] Speaker ?: Yes. [00:18:12] Speaker 2: You also wanted to look into what's called Zulresso, Z-U-L-R-E-S-S-O? [00:18:18] Speaker 1: Yes. [00:18:18] Speaker 2: What's Zulresso? [00:18:20] Speaker 1: It is a treatment for postpartum depression. [00:18:25] Speaker 2: And when you say that you were looking into it, what did you do? Did you find out if it was available and if she could participate in the program? [00:18:34] Speaker 1: I did some digging online to see where it is done and how to do it. I hadn't officially recommended it, so I had not started that for her. It's not really an easy medicine that I could just start. [00:18:49] Speaker 2: It's not a what? I'm sorry. [00:18:49] Speaker 1: Sorry. It's, it's not a medication I could start on my own. It is, it's infused through an IV in a hospital. So it's a bit difficult to coordinate. [00:19:03] Speaker 2: It's a 60-hour infusion, right? [00:19:07] Speaker 1: It's a long infusion. That, that sounds right. [00:19:10] Speaker 2: And, um, it's about two and a half days of infusion and it has to be under hospital circumstance. And the only hospital around here is in Rhode Island, right? Yes. And did you ever recommend that she do that? [00:19:24] Speaker 1: It was something to consider. I couldn't make the official recommendation because that's not something I prescribed. Why? Because, um, because you can't make that up at the pharmacy. [00:19:37] Speaker 2: Well, no, obviously you have to go to a hospital setting and basically have an infusion through your veins for 60 hours or 2.5 days, but why didn't you look into it or recommend that she do that? [00:19:52] Speaker 1: Well, I, I did look into it. [00:19:54] Speaker 2: So what happened? [00:19:54] Speaker 1: She ended up, um, actually going to a partial hospitalization program at the hospital that, that does it. Um, I don't believe the program is completed, but, but she went. And, um, I advised her to discuss it with them because they have access to that medicine. I, I don't have access to it. [00:20:17] Speaker 2: Of course not. Is this Women and Infants Hospital in Rhode Island that you're talking about? [00:20:23] Speaker ?: Yes. [00:20:24] Speaker 2: So when you looked at the medical records for Women and Infants Hospital, did they make reference to your inquiry for Zola Russell? [00:20:31] Speaker 1: I've never received records from Women and Infants. [00:20:35] Speaker 2: Did you ever look at them or even online? [00:20:38] Speaker 1: Online? [00:20:39] Speaker 2: Yeah, like online, like you do when you talk to patients. [00:20:43] Speaker 1: No, I, I never had access to them. Why? Like, it's similar to, to South Shore. It's a completely separate hospital that I don't have access to. I don't work there. [00:20:54] Speaker 2: Well, of course you don't work there, but you're a doctor and you're treating a patient that medical records that you could access through a HIPAA release, right? [00:21:07] Speaker ?: Yes. [00:21:07] Speaker 2: Why didn't you do that? [00:21:11] Speaker 1: Well, she didn't ultimately end up having any treatment there. So it didn't seem necessary. [00:21:19] Speaker 2: She didn't end up having any treatment there. So it didn't seem necessary. You can't just walk into that place and say, hey, I'd like some Zaresa, can you? And then again, on that date, which would be October 20, when the jurors are looking at the records, you checked off the boxes again on objective findings, mental status exam, appearance, speech, things of that nature, correct? [00:22:03] Speaker ?: Yes. [00:22:14] Speaker 2: Excuse me for one minute. Did I have some tears? So when she was telling you on that date that she was, in quoting your records, paranoid of getting suicidal thoughts and something bad happening, doesn't want to be alone. What did she mean by that? [00:22:43] Speaker 1: Well, those were a lot of hard words. [00:22:45] Speaker 2: Right. Isn't that a concern? Your patient is telling you she doesn't want to be alone. Why didn't she want to be alone? [00:22:53] Speaker 1: Because she was very anxious and had the feeling like something bad might happen. [00:23:01] Speaker 2: Okay. Did her mother ultimately and dad come to stay with them? [00:23:06] Speaker ?: Yes. [00:23:07] Speaker 2: How long did they stay with them? I don't know. When you talked to the mother and the father, did you say to them, what is she doing? How does she appear? Is she in bed all day? What did they tell you? [00:23:20] Speaker 1: They never called my office, so I never spoke with them. [00:23:24] Speaker 2: They never called your office? [00:23:27] Speaker 1: They never called me or sent a message, so I did not have communication with them. [00:23:32] Speaker 2: Well, it's their fault that they didn't call you the doctor. So, do you think maybe it would be reasonable if you're the doctor and you're investigating your patient's entomology that you might, when you know that the parents are staying with it, that you would make a phone call yourself? [00:23:53] Speaker 1: It's not typical when you have an adult who is able to advocate for themselves to speak with their parents. [00:23:58] Speaker 2: So, while she is telling you about her symptomology and tearfulness and crying and unable to get up and anxiety and the medications and the mental illness that she had, you felt that she could advocate for herself? [00:24:14] Speaker ?: Yes. [00:24:15] Speaker 2: Okay, on the television, on the computer? Yes. The next time you saw her was on October 26th, is that correct? And you can pull up your record. Now, and if you look again at the interval history where you put down what's going on in the patient's life that time, this is when she indicated that she's back to where she felt that she was before Zoloft, which was not great, and that you guys were considering a new medication, is that right? Yes. And then you started her on Ativan, as we talked about, right? [00:24:55] Speaker ?: Yes. [00:24:56] Speaker 2: And then you started her on the Buspirone, right? [00:24:59] Speaker 1: Well, she had already been served on the Ativan and then added the Buspirone. [00:25:04] Speaker 2: So my question was, you started her on Buspirone, right? Yes. Okay. And also, you added Hydroxylene as needed, right? [00:25:14] Speaker ?: Yes. [00:25:16] Speaker 2: And you continued the Ativan, correct? [00:25:20] Speaker ?: Yes. [00:25:20] Speaker 2: Did you discuss side effects with her at that point? Yes. Um, did you also discuss the studying Remeron or Pregabalin? Pregabalin? Pregabalin. Yes. What did you tell her about Remeron and Pregabalin? [00:25:37] Speaker 1: I don't think I went into any detail about those medicines, just that those might be things to consider in the future. [00:25:48] Speaker 2: And then you saw her on October 31st, right? [00:25:56] Speaker ?: That was her. [00:26:01] Speaker 1: I think that was just a therapy appointment with a different provider. [00:26:06] Speaker 2: Would that be Jennifer McAllister? [00:26:10] Speaker ?: Yes. [00:26:11] Speaker 2: So it's a different provider in the sense that she works for ASCA, right? [00:26:15] Speaker 1: Well, yes. It just wasn't myself. [00:26:17] Speaker 2: Right. So on October 31st, they did a suicide assessment, or she did, right? McAllister? [00:26:26] Speaker ?: I wasn't there. [00:26:28] Speaker 2: Well, I know you weren't there, but these are medical records that have been introduced into evidence that the jury's going to have in the jury room. [00:26:35] Speaker 4: Jackson, is that a question? No, good. [00:26:38] Speaker ?: Yes, sir. [00:26:39] Speaker 2: McAllister did a suicide assessment, apparently, right? [00:26:47] Speaker 1: I'm sure she assessed her suicide. [00:26:48] Speaker 2: No, no, no. Look at the record, please. [00:26:51] Speaker 1: Where do you see it? Sorry. [00:26:52] Speaker 2: Where it says suicide assessment. There's only four pages for October 31st. Well, actually, there would be eight because it's two sides. [00:27:03] Speaker 1: So that is the assessment that you go through. If somebody reports any thoughts of suicide, then you ask those questions, but you go into a lot more detail about them. [00:27:13] Speaker 2: So here you have a patient who's already reported to you as a psychiatrist that she's got suicidal ideation worried about suicide, worried about killing herself days before October 31st, and a suicide assessment was done by McAllister, right? [00:27:35] Speaker 1: I wasn't there. You would have to ask her. [00:27:38] Speaker 2: Well, maybe I will if she comes in. [00:27:40] Speaker ?: Okay. [00:27:40] Speaker 2: Why don't you tell me what the record shows? Did they do a suicide assessment? Did you check off the little boxes? [00:27:51] Speaker 1: I'm looking for that section. It says the patient denies suicidal or homicidal ideation at this time. [00:28:05] Speaker 2: Okay. So again, this is on October 31st, right? [00:28:10] Speaker ?: Yes. [00:28:11] Speaker 2: The patient, within a period of a couple of days in meetings with you, that McAllister has access to because the records are within your business, right? [00:28:23] Speaker 1: It's not my business to make this. [00:28:25] Speaker 2: Has reported suicidal ideation and fear and dwelling about killing herself and afraid of those thoughts, right? [00:28:39] Speaker ?: I just wanted the absolutely, um, aware. [00:28:47] Speaker 1: So, um, so yes, uh, you know, what a little while earlier she had, she had voiced those concerns. [00:29:00] Speaker 2: Right. So, as a result of voicing those concerns, is it your understanding that McAllister did not do any of the suicide assessment questions because Lindsay reported that she wasn't suiciding? [00:29:17] Speaker 1: It appears that she asked about suicide. [00:29:22] Speaker 2: Right. You already told us that. I'm asking you about, excuse me. Hold on. Thank you. I'm not asking you. You've told us three times now that she says she was not suicidal when she spoke to McAllister. I'm asking you about the suicide assessment for the third time. You see it in front of you? [00:29:43] Speaker ?: Yes. [00:29:43] Speaker 2: Okay. Can you tell me, did Lindsay answer any of the questions that were asked over the two pages, possibly three, of the suicide assessment? Yeah, three. Done by McAllister. [00:30:00] Speaker 1: I don't see anything written here. [00:30:03] Speaker 2: So, was there a suicide assessment? [00:30:06] Speaker 1: I don't know because it wasn't there. I don't know what the conversation was. [00:30:09] Speaker 2: And you don't know from looking at the records, right? [00:30:14] Speaker 1: From looking at the records, I don't see evidence of additional suicidal questions beyond asking if it was there or not. [00:30:21] Speaker 2: So, the suicidal assessment doctor is in the medical records. It consumes almost four pages, does it not? Yes? Yes. Okay. And all of the questions, like asking have you felt life is not worth living? Is death something you've thought about recently? Are you dwelling on that? What leads up to the thoughts? What are the thoughts? All those questions, right? But four pages, right? [00:30:51] Speaker ?: Yes. [00:30:52] Speaker 2: And there is not one notation indicated that that test was ever administered to her on October 31st, correct? [00:31:04] Speaker ?: Correct. But it was, it looks like it was asked in other ways. [00:31:07] Speaker 2: Okay. November 2nd. It was asked in other ways? Is that what the little check box where it says, denies suicidal ideation? [00:31:17] Speaker 1: Can I read something that she- [00:31:18] Speaker 2: You have indicated repeatedly that she denied suicidal ideation, right? [00:31:24] Speaker ?: Yes. Okay. [00:31:26] Speaker 2: The suicidal assessment was not administered according to the record that's in front of you by McAllister. Yes? [00:31:35] Speaker 1: The additional suicidal assessment, yes. [00:31:41] Speaker 2: November 2nd. By the way, as a psychiatrist, not a psychologist, you have the ability to prescribe medication, obviously, right? [00:31:52] Speaker ?: Yes. [00:31:53] Speaker 2: And that's when you talked about the DEA number and all of that, correct? Which you had for about a month other than when you were a resident, right? So you're prescribing these SSRIs and antipsychotics and antitropics or whatever they are. And it's important as to the metabolism of your patient with those drugs, isn't it? Yes. What does metabolism mean? [00:32:21] Speaker 1: The body breaking down the medication. [00:32:28] Speaker 2: So how is it that you can determine how the body of your patient is breaking down the medication that is in their brain and they're complaining about all of these symptoms? How, as a doctor, do you determine how the body is breaking it down? [00:32:46] Speaker 1: We don't typically have any specific testing that we do to understand that. [00:32:53] Speaker 2: How about a blood test? [00:33:01] Speaker ?: It's not done for that. [00:33:03] Speaker 2: It's not done for that. Meaning a blood test is not done to determine the metabolism of your patient, of your medications. [00:33:13] Speaker 1: Are you referring to genetic testing? [00:33:15] Speaker 2: No, I'm asking about the metabolism. I'm not talking about genetics. I'm talking about the metabolism of the SSRIs in our body. You can tell that metabolism rate through blood testing, right? [00:33:28] Speaker 1: Not in the way that you're describing. [00:33:30] Speaker 2: Okay, what way would it be? [00:33:33] Speaker 1: There is genetic testing that can give information about metabolism. [00:33:39] Speaker 2: Like what? [00:33:43] Speaker 1: It can talk about different enzymes that a person might have to suggest. It provides information about the enzymes that a person might have the genes for. [00:34:09] Speaker 2: Forgive me, I'm having difficulty with that. What does that mean? [00:34:18] Speaker 1: It's a little complicated. [00:34:20] Speaker 2: Yeah, you don't expect a patient that's going through what she was going through to understand that, would you? [00:34:25] Speaker 1: No. [00:34:26] Speaker 2: Did you guys do the enzyme test? [00:34:29] Speaker 1: They are not typically done. [00:34:31] Speaker 2: Why? [00:34:33] Speaker 1: Because, again, it's genetics. [00:34:36] Speaker 2: Does insurance cover it? [00:34:37] Speaker ?: It's just in the middle of answering. [00:34:46] Speaker 1: So it's not as simple as testing sperm enzyme or not. You can test someone's genome. Like we have the ability to test the entire human genome now, which is great. But the clinical use of that is not there yet. So while we can test these things, it does not yield meaningful clinical information. So it's not commonly done. [00:35:12] Speaker 2: What is the, sorry, what is the Cytopro P4-50 system? [00:35:19] Speaker 1: That's one of the enzymes that I'm talking about. [00:35:20] Speaker 2: So the Cytopro P4-50 system talks about and tests for the breakdown of psychiatric meds in the blood, right? It's not in the way that you're describing it. All I'm describing it is that it's a test. [00:35:36] Speaker 1: Again, what is that? [00:35:37] Speaker 4: Do you see it or do you ask for it? [00:35:39] Speaker 1: Um, it just, yes, this is a test that is done, but it doesn't tell you what medications a patient will do better on. It's, it's not useful in that way. [00:35:53] Speaker 2: So what's it useful for? [00:35:55] Speaker 1: I mean, I, I don't find it terribly useful. [00:36:00] Speaker 2: How long has the Cytopro P4-50 system been in use in your field? [00:36:06] Speaker 1: Sorry? [00:36:07] Speaker 2: How long has the Cytopro P4-50 system been in use in your field, psychiatry? [00:36:12] Speaker 1: Well, it's an enzyme in the body. [00:36:15] Speaker 2: Well, I know what it is. I'm asking you about the system, the testing. How long have they been using that? [00:36:21] Speaker 1: The genetic testing, um, maybe a few years. Whatever it is. It's, it's very new. [00:36:27] Speaker 2: Very new. Does insurance cover it? [00:36:30] Speaker 1: Sometimes. [00:36:31] Speaker 2: Sometimes. So, it is nevertheless a legitimate test to determine the breakdown of psychiatric meds in a patient's blood, correct? [00:36:45] Speaker 1: It exists, yes. [00:36:46] Speaker 2: It exists. Well, it exists, but you didn't use it, right? [00:36:52] Speaker 1: It would not have made a difference. [00:36:53] Speaker 2: In what? In your opinion? [00:36:56] Speaker 1: In her treatment. [00:36:57] Speaker 2: Because you go by the checks in the checkbox and what she self-reports, right? [00:37:01] Speaker 1: No, not, not, not just the checks in the checkbox. [00:37:04] Speaker 2: Oh, in any event. [00:37:07] Speaker 1: Tell me about the thyroid. [00:37:09] Speaker 2: The thyroid. Tell me about the thyroid. [00:37:14] Speaker 1: It's an organ in the human body that regulates hormones. [00:37:19] Speaker 2: And what, if any, import and impact do thyroid levels have in your evaluation of a woman who is in the throes of postpartum depression? [00:37:37] Speaker ?: Thank you, John. [00:37:38] Speaker 2: What is the purpose of a test to determine the thyroid levels? [00:37:47] Speaker 1: Well, you can, you can test something like the TSH. Well, I don't know what TSH is, I'm sorry. [00:37:53] Speaker 2: What is the TSH? [00:37:55] Speaker 1: Thyroid stimulating hormone. Okay, thank you. That's something that can be tested typically by maybe a PCP, primary care, or endocrinologist if they have concerns about someone's thyroid function. [00:38:14] Speaker 2: Were you aware of a study that was a major study that was peer-reviewed? What is peer-reviewed like in your business? [00:38:23] Speaker 1: That it was, was reviewed by, um, other researchers in, in similar fields? [00:38:30] Speaker 2: And, and, and the report, or the, the article, or whatever it may be, has to be approved by the peers that are reviewing it before it can be published, right? Yes. And you'd agree with me that in the medical field it's a big deal to have publishing articles on your resume, right? Right? Yes. And, and how many articles have you published about postpartum? Depression, postpartum psychosis, anything? [00:39:04] Speaker 1: Um, I have published something, but it's not a full article, it's just a, a, a small thing. [00:39:11] Speaker 2: Okay. Are you aware of the, uh, psychiatry, uh, psychiatry, um, magazine, uh, article dealing with, uh, in 2021, thyroid function in postpartum psychosis, an exploratory study. Have you ever heard of anything about that, let alone read an article about it? [00:39:32] Speaker ?: No. [00:39:32] Speaker 2: Are you aware that there are studies that have compared thyroid function between psychosis with postpartum onset, PPO, psychosis without postpartum onset, PWPO, and normal postpartum? Are you aware of that? No. Well, you're supposed to be an expert, or you specialize, or you have an interest in treating women that have suffered from postpartum, correct? Yes. Have you written any articles at all about postpartum depression, anxiety, psychosis? [00:40:06] Speaker 1: No, I'm not a researcher. I'm a clinician. [00:40:08] Speaker 2: Have you read any of the articles such as thyroid function and postpartum psychosis? [00:40:14] Speaker 1: I've read many articles. There are thousands. I have not read that specific article. [00:40:19] Speaker 2: Thousands? Thousands of articles on postpartum psychosis and the thyroid? [00:40:26] Speaker 1: No, not on that specific topic. [00:40:29] Speaker 2: So when the Aster doctors are treating it's your testimony to this jury that testing, whether it's blood testing or whether it's the Cytopro P4 testing, is not necessary because Jennifer Tufts doesn't think it's necessary, right? [00:40:55] Speaker 1: It does not yield information that would influence this treatment. [00:41:00] Speaker 2: Really? So if there was elevation in the thyroid, that wouldn't impact on your treatment at all, your evaluation, your investigation? [00:41:08] Speaker 1: I'm sorry. I thought you had mentioned the cytochrome issue. Are we talking about that one, or are we talking about the thyroid? [00:41:15] Speaker 2: We're talking about the thyroid. Okay. Yeah. So if there were tests that revealed elevation in the thyroid level, is it your testimony that you wouldn't care? [00:41:32] Speaker 1: If I somehow found out that a patient had elevated thyroid levels, I would advise them to talk to their primary care or maybe get an endocrinologist to discuss it. [00:41:45] Speaker 2: Did you ever recommend that Lindsay get an endocrinologist? No. [00:41:50] Speaker 1: She did not. And the reason, the answer is no. [00:41:53] Speaker 2: And you basically did not have any information that you could use to even realize that there might have been a thyroid issue with this woman that was postpartum, right? Because you didn't do any blood tests. [00:42:13] Speaker 1: There was no clinical reason to obtain a blood test. [00:42:17] Speaker 2: All right. So you continue on with your meetings by the computer, correct? [00:42:23] Speaker ?: Yes. [00:42:24] Speaker 2: November 2nd. You can get November 2nd out. You get it? [00:42:35] Speaker 1: November 22nd? [00:42:39] Speaker 2: No. It looks like November 2nd. I apologize. That's what I'm looking at. Tufts, Jennifer, MD, Clancy, Lindsay. Follow-up note, November 2nd. Yes. Okay. And you're still diagnosing her with generalized anxiety disorder, GAD, right? Yes. You add in there an adjustment disorder with depressed mood, I guess, because of what she had been telling you, right? [00:43:05] Speaker ?: Yes. [00:43:07] Speaker 2: Okay. Looking at the psychiatric condition, you know that it's improving. Right? [00:43:18] Speaker ?: Yes. [00:43:20] Speaker 2: And then you determine that you will decrease the Ativan to 0.75 milligrams for two weeks, and consider alternatives for sleep anxiety, is that correct? [00:43:38] Speaker 1: Yes. [00:43:39] Speaker 2: And then you know if she's having urges to harm herself or others, to go to the nearest emergency room and call 9-1-1 and things of that nature, correct? Yes. So is that a form that you basically press a button? Because it seems to be kind of like a generic advice. Call 9-1-1 if you're feeling suicidal and things of that nature. [00:44:02] Speaker 1: Well, that's advice that we provide for every single patient. [00:44:08] Speaker 2: Okay. And then you note that half the encounter was on counseling or coordination of care on November 2nd, right? [00:44:18] Speaker 1: Yes, that's a typical statement. That's -- it's just a part of documentation that doctors use. [00:44:26] Speaker 2: All right. Now, on November 2nd, you were suggesting the four drugs that she would stack would be Remeron, Trazodone, Pregavalin, and Hydroxazine, right? [00:44:39] Speaker 1: Those are just things we were considering. Oh. It wasn't starting all of those medicines. [00:44:44] Speaker 2: I see. On November 22nd -- now, that would be almost three weeks later, right? You saw her, right? And did you ask her about whether or not she was still having suicidal thoughts or worrying about suicidal thoughts, for example? Did you ask her that? Yes. How do you know that? Because the box is checked? [00:45:13] Speaker 1: It's written in my notes. [00:45:14] Speaker 2: What does it say? [00:45:15] Speaker 1: Patient denies SI. [00:45:17] Speaker 2: Okay. What did you ask her about that? [00:45:20] Speaker 1: I don't remember the exact words, but I know that I asked about that. [00:45:25] Speaker 2: Did you ask her about how things were going at home? Were the mother and father staying there? [00:45:32] Speaker ?: That I don't remember. [00:45:35] Speaker 1: I didn't document how her parents were doing. [00:45:38] Speaker 2: Okay. Well, I don't really care about how her parents were doing. I'm asking about whether or not you asked her how it was working out while her parents were there helping out. If you did, fine. If you didn't, that's fine, too. [00:45:50] Speaker 1: I don't think that I did. [00:45:53] Speaker 2: Okay. That's all. That's fine. December 1st was the next appointment, correct? And you can look at the interval history. Yes. Now, on that December 1st appointment, this is after she had transferred to South Shore? [00:46:15] Speaker ?: Yes. [00:46:15] Speaker 2: She disclosed to you that she had been seeing South Shore, right? [00:46:19] Speaker 1: Yes. [00:46:19] Speaker 2: We already talked about the fact that you never got the records from South Shore, so you don't know, other than what Lindsay reported to you, what medications she was on, right? Right. I mean, what she was telling me. Right. And she told you that she was doing the Ativan taper, right? [00:46:41] Speaker 1: Well, she said she had tried doing that, but that then she was having more sleep. [00:46:48] Speaker 2: Having difficulty sleeping is what she indicated to you, right? Yes. And she tried other meds that you had suggested, but stated that she was having difficulty with those meds, including Trazodone, right? [00:46:58] Speaker 1: Well, the Trazodone she didn't have a problem with. It just didn't seem like it was particularly helpful. Right. [00:47:07] Speaker 2: Did you prescribe the Trazodone or somebody else? [00:47:09] Speaker 1: I suppose somebody else. [00:47:11] Speaker 2: So, do you know what the milligrams were that she was on? [00:47:14] Speaker 1: It says she tried between 50 and 150 milligrams. [00:47:18] Speaker 2: All right. Now, did she at some point try Remeron? [00:47:28] Speaker 1: She said that she did. [00:47:31] Speaker 2: Did you suggest in your discussions that she try Remeron? [00:47:36] Speaker 1: No, I did not. [00:47:38] Speaker 2: Did she indicate to you that she had rebound anxiety and intrusive thoughts, that she was going to die? Recall that? [00:47:47] Speaker 1: Well, she said worse depression and intrusive thoughts. [00:47:51] Speaker 2: Okay. Did she tell you what the intrusive thoughts were? [00:47:55] Speaker 1: It was the feeling like I'm going to die. [00:48:00] Speaker 2: Did she then have a script for Prozac, 10 milligrams? That's what she said. And she said that she couldn't sleep and had worse sleep, so that had to be stopped, right? [00:48:11] Speaker 1: Yes. [00:48:15] Speaker 2: She was on Klonopin, right? [00:48:18] Speaker 1: Yes. [00:48:18] Speaker 2: And what is Klonopin? [00:48:19] Speaker 3: It's a benzodiazepine. [00:48:22] Speaker 2: And on December 1st is when she told you, again, that she was close to having suicidal ideation, feeling hopeless. Recall that? Yes. Now, on the interval history on that date, you indicated that she can't sleep, she's panicking, she had worse depression, intrusive thoughts, she was numb, nothing mattered, I feel like I'm going to die, deny suicidal ideation, but, quote, yesterday, close to it, feeling hopeless. Did you give her therapy and validations after she told you that? What did you do, what did you do? You've got a woman that's telling you that she's hopeless, she doesn't care if she dies, can't sleep. What did you do to validate on your therapy? [00:49:28] Speaker 1: I told her that this was something that we could address, that there was hope, that there were treatments, and there are, um, you know, different types of treatment programs that are more, uh, more supportive, like partial hospitalization programs. So she knew that she still had, had options, and a reason to help. Did you ever suggest to her that maybe, uh, come in to see me, rather than talk on the computer? Um, discussing, uh, talking with her over the video did not seem like an issue. Um, it didn't seem like there was anything that I was missing, or that there was any need to see [00:50:13] Speaker 2: her in person. Now, you'd agree with me that in December of 2022, COVID was all done, right? It wasn't completely all done. Were you still nervous about dealing with people and wearing masks and stuff, or were you able to sit down and talk to somebody face-to-face? We were definitely feeling [00:50:34] Speaker 1: more comfortable about being face-to-face with people, but I think, you know, it was still something [00:50:40] Speaker 2: that we thought about. You discussed trying Sarah Cole with her at that point, right? Um, I didn't really [00:50:49] Speaker 1: discuss it. She, um, well, she had told me that that was, um, that was something that she had [00:50:58] Speaker 2: discussed with her other provider. So looking at your notes, does it say also discussed [00:51:07] Speaker 1: trying Sarah Cole alone tonight? Do you want to say that? It says, yes, but I wasn't, I wasn't making a recommendation about the Sarah Cole. It was just a medicine I was providing her more information on. [00:51:25] Speaker 2: So, so you were telling her about the Sarah Cole. Are you providing information? [00:51:32] Speaker 1: Yes, we were talking about the Sarah Cole. Right. Why? [00:51:37] Speaker ?: You also discussed with her the possibility of undiagnosed bipolar disorder. Did you not? [00:51:46] Speaker 2: It was discussed. And undiagnosed bipolar disorder was, in your opinion, as a result of not a reaction, but extreme reaction to the SSRIs, right? [00:52:16] Speaker 1: Not, so not as a result of the SSRIs, but that react, does your, excuse me, does your note say, [00:52:23] Speaker 2: and I quote, also discussed possibility of undiagnosed bipolar disorder given extreme reaction to SSRIs and insomnia, period. Does it say that? Yes. Those are your notes, right? [00:52:39] Speaker 1: Yes. The way you were saying it made it sound a little bit different before, [00:52:42] Speaker 2: but that's exactly what I wrote. I read it directly from your note, right? How did I make it sound different? I don't know. It sounded different [00:52:48] Speaker 1: the first time you said it than the second. So, did she have bipolar? No. Did you make that decision that night, that day? I assessed that with her pretty much every time that I saw her and she never had mania. What about mood stabilizer like Lamectal? Did you discuss that with her? Yes. What is Lamectal? It's an anti-convulsant, um, but it's, it's used, um, [00:53:20] Speaker 2: in treating mood disorders. So what was the, uh, the end result of your meeting with her on December 1st? [00:53:27] Speaker 1: What did you guys do? Were you given any recommendations, advice, anything? Yeah, well, so at, at this time I was not concerned with my patients, um, but I was, I was still concerned, not, not concerned enough that she was at any risk of hurting herself or anybody else, given what she said. Um, but, uh, we had a plan for her to pursue a partial hospitalization program. Where was that? Well, the one that I had recommended was HRI. What, what is that HRI? It's a hospital in Brooklyn. And did she ultimately go to, uh, another hospital? Um, she ultimately went to the women and infants hospital for one day. And those are [00:54:11] Speaker 2: the records that you didn't get, right? Correct. Okay. Um, and you decided that she did not have bipolar disorder because, in your opinion, she did not meet, and I call it the criteria, right? And that would be the criteria in the DSM, right? Yes. And the DSM, of course, is the diagnostic statistical manual. You know, to help us in our, in our treatment, but it's not, it's not the psychiatry bible. That people sometimes think that it is. [00:54:50] Speaker 1: Right. Um, it's, it's, it's more of a guideline that we use to, um, you know, to help us in our, in our treatment, but it's not, it's not the psychiatry bible that, that people sometimes think that it is. [00:55:03] Speaker 2: Right. Um, hypomanic bipolar disorder. How many days does that require? [00:55:13] Speaker 1: Um, under the DSM? A hypomanic episode lasts for at least four days. And is that per the, uh, DSM? Yes. [00:55:25] Speaker 2: Remember on Friday, you said that the most important criteria is seven days with continued high energy levels? Yes. So is it, is it seven days or is it four days? And who says? Well, mania is, is seven days. [00:55:38] Speaker 1: Hypomania is four. We discussed again. We're talking about with her. [00:55:49] Speaker ?: Yes. And do you know in your records that she [00:55:53] Speaker 2: indicated that she was really struggling? And it was as a result of that, and you recommended that hospital probing, right? In your opinion, a severe mental disturbance at that point that was manifesting itself. [00:56:08] Speaker 1: She had a, maybe moderate and moderate heading towards severe. [00:56:18] Speaker 2: Moderate heading towards severe mental issue. Okay. Um, you'd agree with me that she had increased anxiety, right? Yes. She had very, very, uh, increased depression, right? Um, well she, she, she, she did. She said. Okay. So as you answered, can you just answer a yes or no? [00:56:43] Speaker 1: I'm sorry. I was just trying to check the record. Okay. You can check the record all you want, [00:56:47] Speaker 2: but if I ask you a question respectfully, can you just not go on and ramble? Answer yes and no, that's all. [00:56:53] Speaker 1: It's sometimes impossible to do that. [00:56:55] Speaker 4: All right. All right. Thank you. [00:57:07] Speaker 2: Now, mental issues like anxiety that was diagnosed, the depression that was diagnosed, and the fact that she indicated yet again that she was close to suicidal ideation, quote, worried about suicidal thoughts. Um, but you indicated that she wasn't suffering from suicidal ideation on that day. Is that fair? She denied it. But she told you that she was worried about suicidal ideation and [00:57:34] Speaker 1: having suicidal thoughts, right? Well, this, yes, this was the time she said she was worried that she was close to having suicidal thoughts. Ah, so did you ask her what does that mean? Does that mean [00:57:45] Speaker 2: that she's standing at the edge of the stairs and she's thinking about falling down the stairs or what? What does that mean? A close to suicidal ideation? So I asked about that and that's, that's when she said, [00:57:57] Speaker 1: she described it further as, was using the word hopeless. [00:58:07] Speaker 2: So did you prescribe the Lamontra gene on that occasion or no? No. On December 16th, that's the next appointment she had, right? Yes. Would that be two weeks later? Right? Yes. She was still not well, correct? She told you she was having a really rough time. [00:58:36] Speaker 1: She was sleeping, but she was still feeling very broken. [00:58:40] Speaker 2: In your notes, does it say that she was having a really rough time? [00:58:44] Speaker ?: Yes. [00:58:44] Speaker 2: So when I ask you, if your notes reflected that she said she was having a really rough time, why do you feel compelled to say she was sleeping? [00:58:54] Speaker 4: Objection. [00:58:57] Speaker ?: It's an important detail. [00:58:59] Speaker 2: Yeah, I guess. How about the rough time? What did that mean? What was, what were the symptoms of having a really rough time for this kid? Yeah, I'd like you to answer that. [00:59:16] Speaker 1: So finally, Wirt, referring to the valine ocotriapine, but very depressed during the day, no motivation, some SI. Do you want me to continue? Sure. Went to MGH emergency room for SI, declined to inpatient, feeling hopeless, no intent or plan, and feels like depression related to cerebral. [00:59:41] Speaker 2: Okay. Now that's the question on Friday that will strike that. So what was the SI? Suicidal ideation? [00:59:49] Speaker ?: Yes. [00:59:50] Speaker 2: And can you read that back to me again? What did she say about SI? [00:59:55] Speaker 1: So that when she went to the hospital, she went because she had no motivation, some SI. [01:00:03] Speaker 2: Some SI meaning that she had some suicidal ideation, right? Yes. In her words, yes. Yeah, in her words. As opposed to thinking about having suicidal ideation or worrying about suicidal ideation. She actually indicated that she had suicidal ideation, right? Yes or no. Well, it's in your notes that she said that, right? Yes. [01:00:34] Speaker 1: What is in my notes? [01:00:38] Speaker 2: Do you understand my question? [01:00:40] Speaker 1: I don't want to get confused right now. Can you hear me where your question is? Sure, of course. [01:00:46] Speaker 2: We spent some time talking about, thinking about suicidal ideation, worrying about suicidal ideation. Now, same. She had suicidal ideation, right? [01:01:02] Speaker 1: She said it, yes. [01:01:04] Speaker 2: Well, this is the only source of information that you're getting, apparently, is what she's telling you, right? [01:01:10] Speaker ?: Yes. [01:01:12] Speaker 2: So what suicidal ideation did she have? Was she thinking of cutting her throat? Was she thinking of throwing herself off a building? Or running out in front of a car? What? [01:01:21] Speaker 1: No. [01:01:22] Speaker 2: What was she thinking of? [01:01:23] Speaker 1: So I asked her those important follow-up questions. Like what? So what do you mean when you say I'm feeling suicidal? Okay. And that's when she said, it means I'm feeling hopeless. And then I asked you, you know, do you have intention of hurting yourself? Do you have a plan for hurting yourself? And she denied those. [01:01:49] Speaker 2: And that's where you left it? [01:01:52] Speaker 1: I mean, I'm sure more was said, but that's the most important part of that clinical encounter. [01:01:59] Speaker 2: And did you give a therapy by the computer on that date, too? [01:02:04] Speaker 1: Yes. [01:02:04] Speaker 2: What did you do for therapy about her suicidal ideation and saying she wanted to kill herself? [01:02:10] Speaker 1: Well, we, you know, we explored what that meant and, you know, what to do if you're feeling that way. [01:02:20] Speaker 2: To do what, call 911? [01:02:22] Speaker 1: To go to the emergency room. [01:02:25] Speaker 2: Did you discuss prescribing Seroquel to her or was she getting Seroquel? Did Seroquel enter into your discussion at all? [01:02:31] Speaker 1: So, at the conclusion of your meeting on December 16th, basically what you took away is that she had now increased the suicidal ideation, was feeling hopeless, all the rest of the things that we've talked about. [01:02:46] Speaker 2: And then she, what, just moved on or went home? [01:03:03] Speaker 1: Well, she was assessed in the emergency room and was not admitted and I assessed her on the day again and while she was certainly struggling, she did not require her hospitalization at that moment. So, she was, she was planning on going to the infant program and I supported that. [01:03:31] Speaker 2: Did you know that around that time, she confessed to her husband that she was having now thoughts of harming the children? [01:03:40] Speaker 1: No. [01:03:41] Speaker 2: Would that have been something you were concerned about? [01:03:43] Speaker 1: If I heard that, I would have been very concerned. [01:03:45] Speaker 2: You would have called DCF, right? [01:03:48] Speaker ?: I might have. [01:03:49] Speaker 2: And did, when you spoke to Pat, did you ever ask him what his observations were of her spiraling into November and December? Not that one time that he stuck his face on the computer and talked to you. Did you ever talk to him? [01:04:06] Speaker 1: He never called me again. Or he never called at all. I never spoke with him again. [01:04:10] Speaker 2: So, he is a husband of a woman who just had a baby. He was postpartum with all of these symptoms that we talked about. All of the drugs that you were prescribing and that. She was dealing with, trying to get help. He never talked to her husband about what he observed. Because he didn't call you? [01:04:30] Speaker 1: Well, we did speak on that visit. [01:04:32] Speaker 2: Which visit? [01:04:33] Speaker 1: The 16th. I think that that's the one that he was at. [01:04:37] Speaker 2: You think it was? It's not noted in the record? [01:04:39] Speaker 1: It's not noted, but I remember some of what we talked about. And so, in reading that record, it seems like that's the likely one that he was at. [01:04:59] Speaker 2: December 16th, on your objective findings, you note that her mood was depressed, right? [01:05:09] Speaker ?: Yes. [01:05:10] Speaker 2: What does that mean? Did she just say, "I'm depressed," or did she give you symptoms? I mean, you checked the little box. [01:05:18] Speaker 1: Yeah, she's saying that she's depressed. [01:05:20] Speaker 2: Okay, so you're the doctor. You checked the little box. What did your patient tell you about her symptoms? That she was depressed on that day. Was she crying? Was she able to get out of bed? Was she worshiping at the Postal of God? What was going on in her life? [01:05:39] Speaker 1: She said she was having a really tough time. [01:05:45] Speaker 2: Her affect was flat, right? [01:05:51] Speaker ?: Yes. [01:05:52] Speaker 2: And again, depressed. You check it off twice. One under mood and one under affect, right? Yes. And then at the next page, it says, "Recent lab work." That wouldn't be blood testing, would it? I mean, Aster, does Aster do blood testing? [01:06:12] Speaker 1: We don't have a verbotimist or a lab, no. [01:06:16] Speaker 2: Well, why does it say "recent lab work" typed into your form when you check off the little boxes? [01:06:22] Speaker 1: That's something that auto-populates, it's a template. It's a what? It's a template. The whole note is something that psychiatrists or probably all across the country use. [01:06:35] Speaker 2: Probably. You can't diagnose someone's illness by a template, can you? No. You filled in, no lab results were found, right? [01:06:44] Speaker 1: There were none in the computer, yes. I didn't type that in though, it just auto-populated. [01:06:49] Speaker 2: So who typed it in? [01:06:50] Speaker 1: It was auto-populated. [01:06:54] Speaker 2: So on the next page, where it talks about symptom goals, treatment goals, I'm sorry. Symptom reduction in improved functioning, what does that mean? [01:07:08] Speaker 1: Symptom reduction is to have fewer mental health symptoms and improved functioning means improved day-to-day life functioning. Things that she's doing in her daily life. [01:07:29] Speaker 2: Really? Did you tell her all that? You get a young woman that's obviously mentally ill, very sick. She's deteriorating, whether you like that word or it's automatically imported. What on that date did you do? Never mind all those words you just said. What did you tell her on the television or the computer? [01:07:54] Speaker 1: I told her to go to the partial hospitalization program and if she was having more suicidal thoughts again or if it felt like she was at risk of letting herself or anybody else that she should go immediately to the emergency room. [01:08:11] Speaker 2: How long did that meeting take? [01:08:14] Speaker 1: Probably about 30 minutes. [01:08:17] Speaker 2: Was that the therapy that you provided telling her to go to the emergency room? [01:08:23] Speaker 1: That was probably a component. [01:08:25] Speaker 2: So the plan, excuse me, on December 16th was to follow up with women and infants, right? [01:08:35] Speaker ?: Yes. [01:08:37] Speaker 2: Did she? [01:08:39] Speaker ?: Yes. [01:08:40] Speaker 2: Do you know when? I don't know. What is that? I don't know. Then you were considering a brexaniline or brexanilone infusion, right? That's the same thing you wrote out of it? [01:09:00] Speaker ?: Yeah. [01:09:01] Speaker 2: Okay. And that didn't go anywhere, right? That was, that's the end of that. It says start Lamectol, 25 milligrams daily, right? [01:09:12] Speaker ?: Yes. [01:09:12] Speaker 2: Continue Seroquel, right? What was the milligram for the Seroquel up to at this point? [01:09:21] Speaker 1: Well, she had told me it was 200. [01:09:23] Speaker 2: What was it? [01:09:24] Speaker 1: That was, I did not write that prescription. So that's what her provider had prescribed her. [01:09:30] Speaker 2: Okay. So you can ask somebody to show me the bottle, pill bottle. You can ask somebody to show me the CVS receipt. You can ask somebody, you can call to verify, right? But you, anyway, she said that she was on Seroquel, 200 milligrams, right? And had stopped with the valium, right? [01:09:53] Speaker ?: Yes. [01:09:53] Speaker 2: And then you go on with that form thing saying, if you have urges to harm yourself or others, you got to call 911, crisis hotlines, and everything else, right? That's the next two paragraphs that are in that report, right? Yes. Was her mother and father still staying with her on December 16th, if you know, with Pat and the kids? [01:10:13] Speaker 1: I'm not sure. [01:10:15] Speaker 2: Did you ever ask anybody other than her how she was doing? [01:10:23] Speaker 1: I asked her husband when he was at that point then. [01:10:26] Speaker 2: Yeah, that's the other point. How about now, we're talking December 16th into the month of December. Did you ever ask anyone how she was doing? [01:10:35] Speaker 1: I think he was at that visit. [01:10:38] Speaker 2: You think he was at the visit? How did he tell, what did he say to you about how she was doing? [01:10:43] Speaker 1: He said she wasn't doing well. [01:10:45] Speaker 2: She's got an objection. [01:10:48] Speaker ?: Objection. [01:10:52] Speaker 2: Go ahead. [01:10:52] Speaker ?: He said she wasn't doing well. [01:10:55] Speaker 2: Anything else? [01:10:56] Speaker 1: Yeah, he felt that it, what might have been, his opinion was that it was related to when she started the Sarefa. [01:11:07] Speaker 2: And he basically said you guys are turning her into a zombie, right? [01:11:10] Speaker 1: Objection. [01:11:12] Speaker 2: Are those his words? [01:11:16] Speaker ?: I don't know how that went in. You may have said that. [01:11:19] Speaker 2: Does that kind of hit you though? You might remember that. You might have been, as some people worry about suicide, you might be thinking in your brain that he did say you're turning her into a zombie. It's possible. [01:11:30] Speaker 1: It's very possible. Okay. [01:11:36] Speaker 2: Next meeting, after the December 16th, was it? Is it December 16th? Is that what we were just on end? Yes. Okay. The next meeting was January 6th? [01:11:56] Speaker ?: Yes. [01:11:57] Speaker 2: Okay. And how does this happen? Does the patient call? I know you don't set up these appointments. Somebody has to deal with somebody in the administration or whatever. But do you like on December 16th say to Lindsay, call me or set up an appointment for January 6th? Or do they have to do it themselves? [01:12:20] Speaker 1: So at the end of an appointment, I typically will schedule their next appointment. [01:12:27] Speaker 2: So did you schedule January 6th? [01:12:30] Speaker 1: I think that when she scheduled herself. [01:12:33] Speaker 2: That was the day after she got out of McLean, right? [01:12:36] Speaker 1: Yeah. Usually the hospital coordinates the discharge appointment. [01:12:40] Speaker 2: Well, if I tell you that, in fact, the hospital told her to set up the appointment. Within an hour, she set up the appointment. Is that in your notes? [01:12:52] Speaker 1: It's not in my notes. [01:12:54] Speaker 2: Do you remember that? That was a pretty big deal when she was in McLean Rock's Woods for four and a half years, right? Yes. And she's your patient and she's really gone downhill bad, right? She wasn't doing well. And she admitted herself to the White Woods at McLean, right? Yes. And what was the diagnosis at McLean? [01:13:23] Speaker 1: I believe they diagnosed her with major depression. [01:13:26] Speaker 2: Did they recommend any medication? [01:13:29] Speaker 1: They took her off of the Seraphil. [01:13:32] Speaker 2: They took her? All of it. Off. [01:13:35] Speaker ?: Okay. [01:13:37] Speaker 2: So did you look at the McLean records? [01:13:40] Speaker 1: Yes, definitely. [01:13:41] Speaker 2: And those were imported easily because you're part of the same structure or whatever? [01:13:47] Speaker 1: No, but after someone is hospitalized, the hospital usually faxes it to their doctor. [01:13:53] Speaker 2: All right, so if I tell you that the McLean records are really pretty baloneless, that's not what they faxed. They faxed you with a two-page discharge on it, right? You didn't get that by faxed, right? So what did the McLean tell you? Look in your notes. [01:14:22] Speaker ?: Which part do you want me to read? [01:14:49] Speaker 1: Which part do you want me to read? [01:14:52] Speaker 2: Did you ever have her sign a release for McLean? Did you ever get access to the McLean records? I got access to the discharge summary. Okay, so put the discharge summary aside because that's what they faxed you a couple of pages. What about the records? [01:15:08] Speaker 1: No, but that's typically not. [01:15:10] Speaker 2: No, never mind typically. The answer is no. You never got the records, right? [01:15:15] Speaker 1: A discharge summary is a record. [01:15:17] Speaker 2: Did you talk to the doctor that discharged her? [01:15:21] Speaker 1: No, no one called me. [01:15:23] Speaker 2: No what? [01:15:25] Speaker 1: No, no one called me. I wasn't notified about the hospitalization until she was discharged. [01:15:33] Speaker 2: So you just sit there behind your computer and wait for people. Patrick, wait for the doctor from McLean. Wait for the sick person who's the patient to call you and if these people don't call you, it doesn't exist apparently, right? [01:15:50] Speaker 1: No, not exactly. I had no way of knowing she was even at McLean. [01:15:54] Speaker 2: Well, you did once she got discharged, right? [01:15:56] Speaker 1: Yeah, but that was after the fact. [01:15:58] Speaker 2: Right. So did you care why she was in McLean? [01:16:01] Speaker 1: Of course. [01:16:02] Speaker 2: And why was she in McLean? [01:16:04] Speaker 1: Because she was depressed. [01:16:06] Speaker 2: And what was the, uh, does your record indicate that she was discharged yesterday under interval history? [01:16:16] Speaker ?: Yes. [01:16:23] Speaker 2: And discharged from where? [01:16:26] Speaker 1: Well, I said NGH. [01:16:28] Speaker 2: Is that Mass General Hospital? [01:16:30] Speaker 1: Yes. [01:16:32] Speaker 2: And she was currently on Trazodone? [01:16:36] Speaker 1: Yes. [01:16:38] Speaker 2: And she indicated that the goal was to come off Seroquel? [01:16:43] Speaker 1: Yes. [01:16:44] Speaker 2: And she described herself as still being very numb? [01:16:50] Speaker ?: Yes. [01:16:50] Speaker 2: She couldn't sleep, right? [01:16:58] Speaker 1: That's not entirely true. [01:17:00] Speaker 2: Am I lying? I'm reading the medical records here. Sleep, taking Ativan and Trazodone, slept five hours broken, wondering about increasing Trazodone and switching to valentine. What does that mean? [01:17:16] Speaker 1: Well, I think she was having trouble sleeping. It wasn't that she wasn't sleeping. [01:17:19] Speaker 2: Ah, I see. So was the Trazodone increased at that point? [01:17:41] Speaker ?: Yes. [01:17:43] Speaker 2: How about, uh, on January 9th? Did you see her, uh, through the computer or whatever then? Yes. And did you prescribe medication to her on that date? [01:17:59] Speaker ?: Yes. [01:18:00] Speaker 2: And was that Diazepam? [01:18:03] Speaker ?: Yes. [01:18:04] Speaker 2: Fourteen count, one milligram? No, I'm sorry. Fourteen count, five milligram. [01:18:11] Speaker ?: That sounds right. [01:18:11] Speaker 2: Okay. Did you also on, uh, January 12th, three days after January 9th meeting, prescribe additional medication to her? [01:18:19] Speaker 1: I'm not sure. I don't have a record in January 12th. [01:18:26] Speaker 2: Do you recall on January 12th that, in fact, you, uh, prescribed Trazodone 150 milligrams, 30 count? [01:18:37] Speaker ?: Yes. [01:18:41] Speaker 2: Three days later, or a couple of days later, January 16th, do you recall prescribing amitriptyline? [01:18:52] Speaker ?: Yes. [01:18:53] Speaker 2: What is amitriptyline? [01:18:55] Speaker 1: Tricyclic antidepressant. [01:18:57] Speaker 2: What does a tricyclic antidepressant mean? [01:19:03] Speaker 1: Um, well, it's, it's an older antidepressant, it, it's called a tricyclic because it has three rings. If you look at the chemical itself, like a tricycle, um, but it's, it's a, an older but efficacious medicine for depression and anxiety, as well as insomnia. [01:19:24] Speaker 2: On January 16th, look at your interval history. Does she indicate to you that her mood was very low, no motivation? [01:19:37] Speaker 3: Yes. [01:19:37] Speaker 2: Numb? [01:19:39] Speaker ?: Yes. [01:19:41] Speaker 2: Able to force herself out of bed, taking care of basics, eating, concentration fine, caring for baby, bonding feels forced. Is that what she told you? Yes. Through the, through the computer, right? Yes. What, what did that tell you? Were you concerned about this woman, postpartum, while within the year from the CDC at that point with these symptoms that she's telling you about? [01:20:11] Speaker 1: I was concerned that she was depressed. [01:20:14] Speaker 2: And, in all of the times that you spoke to her, you can agree with me that she appeared to be honest and forthright, telling you what she felt, right? [01:20:23] Speaker 1: That's what I thought she was, yes. [01:20:26] Speaker 2: Do you have any reason to think that she was lying to you? No. Diazepam taper on January 16th, five milligrams, last two nights, slept for four hours, and then a light sleep, maybe two hours, stretches. Did she, did she express that she was still having concerns about side effects from medications? [01:20:56] Speaker 1: Not at that point. [01:20:57] Speaker 2: So, what does ROS mean under interval history that we're looking at? [01:21:03] Speaker 1: A few of symptoms. Okay. [01:21:06] Speaker 2: And then it says, patient denies SIHI, that'd be suicidal ideation, homicidal ideation, correct? [01:21:13] Speaker ?: Yes. [01:21:14] Speaker 2: Denies other questions or concerns, and you recommend a low dose of amitriptyline for depression, correct? Yes. Patient agrees with the treatment, and you guys were also going to explore ketamine treatment, ketamine treatment. Is that right? Esca ketamine. [01:21:37] Speaker ?: Yes. [01:21:38] Speaker 2: Now, do you,