Full testimony in Lindsay Clancy trial from mental health counselor Latiesha Dukes

[00:00:00] Speaker 1: Good morning. Hi. I'm going to ask you to keep your voice up and speak into that microphone. [00:00:06] Speaker 2: Okay. All right. Thank you. Yes, counsel. Thank you. Could you please tell the jury your first [00:00:11] D-U-K-E-S: and last name? My name is Leticia Dukes. And how do you spell your first name? L-A-T-I-E-S-H-A. How do you spell Dukes? D-U-K-E-S. What do you do for work? So I'm a licensed mental health counselor. I worked as a perinatal clinician at South Shore Hospital. And what kind of education did you receive in order to do that? So I have a bachelor's in psychology, a master's in mental health counseling, and a master's of education in mental health counseling. And you mentioned [00:00:46] Speaker 2: the South Shore Perinatal Clinic. Do you still work there? No, I do not currently still work [00:00:51] D-U-K-E-S: there. How long did you work there? I worked there for about five years. What did you do there? At the perinatal clinic, I worked as a perinatal clinician, which involves like short term therapy from prior to birth, birth to postpartum, and supported with connection to care, whether that be therapy or higher levels of care. So intensive outpatient therapy, partial hospitalization, [00:01:19] Speaker 2: or inpatient care. And do you often collaborate with patients and other clinicians at the clinic or nurses about treatment plans for patients? D-U-K-E-S. Yes. And do you help to manage the treatment plans with the patient? D-U-K-E-S. Yes. How do patients, or strike that, for your role at the clinic, doing the therapy, and being the clinician? Are you often referred patients by the nurse practitioners or somebody else who had seen the patient or did an intake with the patient? D-U-K-E-S. Yes. And do you work with that prescriber practitioner over the course of the treatment with that patient? D-U-K-E-S. Yes. D-U-K-E-S. And as far as your role and what you do with patients, is it fair to say that a large amount of your ability to work with the patient is based on your relationship and rapport that you develop with the patient? D-U-K-E-S. Yes. And do you rely heavily on things that they report to you when you're assessing them diagnostically and trying to help them come up with a treatment plan and offering therapy? D-U-K-E-S. Yes. And one of the things that might be important in that is to assess a patient's presentation each and every time you meet with them, right? D-U-K-E-S. Yes. D-U-K-E-S. So do you do that in each appointment or each interaction with a patient? Assess them for various things? D-U-K-E-S. Yes. And what kinds of assessments do you perform? [00:02:50] D-U-K-E-S: D-U-K-E-S. So I typically perform a psychosocial assessment, which is getting their behavioral health history, as well as their current presentation and reason for coming in for therapy. So whether that be a specific diagnosis or current concern or recent crisis or trauma, and also a risk assessment [00:03:11] Speaker 2: that assesses how they're doing in that moment. D-U-K-E-S. Okay. And as far as the therapy component of your interactions, is that largely based on the patient? D-U-K-E-S. Yes. And what kinds of therapy [00:03:24] D-U-K-E-S: can you offer in that short-term therapy? D-U-K-E-S. In that short-term therapy, we offer cognitive behavioral therapy, dialectical behavioral therapy. I also offer something called EMDR, eye movement, desensitization, and reprocessing therapy for patients that have gone through trauma, as well as it could be even short-term support, like a couple of weeks until they're transferred to the appropriate level of care. [00:03:51] Speaker 2: D-U-K-E-S. And in your sessions with patients, is there a minimum or a maximum time limit? [00:03:56] D-U-K-E-S: D-U-K-E-S. Typically our program would go from birth to postpartum, up to two years. If it did go a little bit over two years because of lack of connection to care, then it would go a little beyond that. But typically it's two years. [00:04:10] Speaker 2: D-U-K-E-S. Okay. And that's the duration of your treatment or your interaction with patients. But what about in each appointment that you have? Is there a minimum or maximum time set by the clinic of when you see a patient in a particular visit? D-U-K-E-S. Yes. [00:04:25] D-U-K-E-S: D-U-K-E-S. Yes. So do you mean as far as like weekly or like hour, half an hour? [00:04:31] Speaker 2: D-U-K-E-S. Well, I guess the question is if a patient's coming in to you because they've referred you're meeting with them on a regular basis, how long are the appointments and duration? D-U-K-E-S. Sure. D-U-K-E-S. An hour, half an hour? [00:04:43] D-U-K-E-S: D-U-K-E-S. So appointments could be anywhere from a half an hour to an hour based on the patient need at that time. [00:04:49] Speaker 2: D-U-K-E-S. And when you're interacting with a patient and you're making all those assessments, are there tools available to you if you feel or you experience that a patient needs a higher level of care or is heading or is in some sort of crisis? What tools are available to you for that? [00:05:08] D-U-K-E-S: D-U-K-E-S. So tools that are available to me is connection to my direct supervisor, as well as crisis coordination, as well as the crisis support numbers that are in that area. So I could either call with the patient or sit with the family, create a safety plan, and the patient could call later on if they feel like they're safe to go home and they have supports at home. [00:05:29] Speaker 2: D-U-K-E-S. Okay. And at some points, could it be that you would need to involve authorities like the police? [00:05:36] D-U-K-E-S: D-U-K-E-S. Yes. [00:05:37] Speaker 2: D-U-K-E-S. And you also are familiar with the Section 12? [00:05:40] D-U-K-E-S: D-U-K-E-S. Yes. [00:05:41] Speaker 2: D-U-K-E-S. And then that it's an involuntary procedure where the court gets involved? [00:05:46] D-U-K-E-S: D-U-K-E-S. Yes. [00:05:47] Speaker 2: D-U-K-E-S. Now, as far as when you do meet with patients on that regular basis, either for a follow-up or an intake, is it a telehealth situation, an in-person situation? [00:06:02] D-U-K-E-S: D-U-K-E-S. It depends on what the patient is comfortable with and what the patient is able to do as far as like access. So we offer both in-person and virtual appointments. [00:06:11] Speaker 2: D-U-K-E-S. Okay. As far as when you first meet with a patient, when they've been referred to you, that first intake procedure, is there a recommendation for whether that be in-person or telehealth? [00:06:21] D-U-K-E-S: D-U-K-E-S. All the perinatal behavioral health appointments for mental health counseling are in-person, that initial visit. [00:06:27] Speaker 2: D-U-K-E-S. And then the subsequent appointments are oftentimes directed by the patient? D-U-K-E-S. Correct. D-U-K-E-S. Would there be instances where you would insist or prefer that the patient actually come in-person if they've elected for telehealth? [00:06:43] D-U-K-E-S: D-U-K-E-S. Typically, you prefer someone to come in-person because they have either like fallen out of care or their concerns for their safety for some reason. [00:06:54] Speaker 2: D-U-K-E-S. Okay. And if you don't have those immediate concerns and it's the preference of the patient, do you often engage via telehealth? D-U-K-E-S. Yes. D-U-K-E-S. I'm going to draw your attention to a particular patient by the name of Lindsay Clancy. Do you remember when your first contact was with her? [00:07:10] D-U-K-E-S: D-U-K-E-S. I remember it was around late November, early December. [00:07:15] Speaker 2: D-U-K-E-S. Okay. And you're aware that she came to the perinatal clinic and was being initially treated by Julie Paul? [00:07:25] D-U-K-E-S: D-U-K-E-S. Yes. [00:07:26] Speaker 2: D-U-K-E-S. And by the time you engaged with her, her care had been transferred to Rebecca Gelata, correct? [00:07:33] D-U-K-E-S: D-U-K-E-S. Yes. [00:07:34] Speaker 2: D-U-K-E-S. So fair to say you had the most contact with Rebecca Gelata about this particular patient? D-U-K-E-S. Yes. D-U-K-E-S. And if I mentioned December 2nd, does that sound familiar as the first intake with Lindsay Clancy? D-U-K-E-S. Yes. [00:07:50] D-U-K-E-S: D-U-K-E-S. As I said, around late November, early December. So that sounds about right. D-U-K-E-S. Okay. [00:07:55] Speaker 2: D-U-K-E-S. And the intake appointment, was it in person with Lindsay Clancy? [00:08:00] D-U-K-E-S: D-U-K-E-S. Yes, it was in person. [00:08:02] Speaker 2: D-U-K-E-S. And what were the services that were being offered for her? D-U-K-E-S. Why was she referred to you? [00:08:09] D-U-K-E-S: D-U-K-E-S. So she was referred to me for postpartum anxiety and depression symptoms. D-U-K-E-S. She, yeah, that's what she was referred for. [00:08:18] Speaker 2: D-U-K-E-S. And in this first intake, did you go through that psychosocial history with Lindsay Clancy? D-U-K-E-S. Yes. D-U-K-E-S. And did you have some previous information from an intake with Rebecca, excuse me, with Julie Paul? D-U-K-E-S. Or did you do it fresh on your own? [00:08:35] D-U-K-E-S: D-U-K-E-S. Fresh on my own. D-U-K-E-S. Okay. [00:08:37] Speaker 2: D-U-K-E-S. And so again, this is information that the patient is reporting to you about their history? D-U-K-E-S. Yes. D-U-K-E-S. And so in this instance, you noted that the defendant told you or Lindsay Clancy told you that she had, she had been, had some prior contact with mental health, right? D-U-K-E-S. D-U-K-E-S. That she had engaged with a psychiatrist in nursing school and that she had been prescribed medication at that point, correct? D-U-K-E-S. D-U-K-E-S. Yes. D-U-K-E-S. And that she, prior to coming to the clinic, that she had been engaged with a psychiatrist? [00:09:17] D-U-K-E-S: D-U-K-E-S. Yes. [00:09:18] Speaker ?: D-U-K-E-S. [00:09:19] Speaker 2: D-U-K-E-S. Did she identify what her concerns were or what her presenting concerns were to you? D-U-K-E-S. Yes, she did. [00:09:26] D-U-K-E-S: D-U-K-E-S. And what were the concerns? D-U-K-E-S. Her presenting concerns were anxiety, lack of sleep, depression symptoms, frequent passive suicidal ideation, thoughts of wanting to die and no longer be here. [00:09:43] Speaker 2: D-U-K-E-S. And had she reported to you that she had been on a number of different medications? D-U-K-E-S. Yes. D-U-K-E-S. And you're aware that she was, those medications were being managed by the nurse practitioners in the clinic? [00:09:55] D-U-K-E-S: D-U-K-E-S. Yes. [00:09:56] Speaker 2: D-U-K-E-S. And as far as your role as a social worker, do you often kind of get into the weeds with patients about their medication? [00:10:02] D-U-K-E-S: D-U-K-E-S. So I'm not a social worker. I'm a mental health counselor. D-U-K-E-S. I'm sorry. D-U-K-E-S. Yeah, no problem. D-U-K-E-S. But I typically have an overview of medications, but I don't particularly get into prescribing or how to take medications. [00:10:17] Speaker 2: D-U-K-E-S. Okay. And so what's the focus of your role in offering counseling services to women with postpartum anxiety and depression at the clinic? [00:10:25] D-U-K-E-S: D-U-K-E-S. So my role would be to create a treatment plan to address the concerns, which would be like the anxiety and depression symptoms and work on coping skills and building community supports around that. D-U-K-E-S. Or if she needed a referral to a higher level of care, I would do that. [00:10:43] Speaker 2: D-U-K-E-S. As far as diagnosis goes based on your interaction with the patient? D-U-K-E-S. Yes. D-U-K-E-S. And in this first interaction with Ms. Clancy, you got her history. You also did some of those assessments, correct? D-U-K-E-S. And so as far as assessing her present condition, kind of how she presented to you, did you make observations of her mood? D-U-K-E-S. Yes. D-U-K-E-S. And do you recall her mood being low, that she was felt numb and unable to laugh? [00:11:15] Speaker 4: D-U-K-E-S. I apologize. If it's medical record, I don't have any objection, but I'd prefer not the leading. I have no problem if she reads from the record, though. [00:11:21] Speaker 1: D-U-K-E-S. All right. If you could just -- there's an objection, in fact, leading question sustained, but is there any -- so there's no objection at this witness. D-U-K-E-S. If you want to look at your notes, I don't know if you have your notes with you. [00:11:33] D-U-K-E-S: D-U-K-E-S. I do not. Do they have a copy? [00:11:34] Speaker 1: D-U-K-E-S. I don't know if the parties have a copy that she could look at. [00:11:39] Speaker 4: D-U-K-E-S. I do. I could -- D-U-K-E-S. Do you have a blank copy? D-U-K-E-S. Well, I mean, it has like a date on it. It doesn't have a lot of notes on it. D-U-K-E-S. I can approach page by page. [00:11:53] Speaker 1: D-U-K-E-S. Sure. That's fine. D-U-K-E-S. If you need or want to look at the record, just let us know and we'll do that. D-U-K-E-S. Sure thing. Thank you. [00:12:04] Speaker 2: D-U-K-E-S. Sure. D-U-K-E-S. Sure. Yeah. D-U-K-E-S. So, Ms. Dukes, on this particular visit on 12-2, what was her mood? [00:12:18] D-U-K-E-S: D-U-K-E-S. So, she reported having low mood and feeling numb. [00:12:24] Speaker 2: D-U-K-E-S. Okay. And so, you said she reported. So, in the note that you're reviewing, these particular questions or these observations that you noted, are they based on her reports to you about these areas? [00:12:39] D-U-K-E-S: D-U-K-E-S. Yes. And as well as my observation of her. [00:12:43] Speaker 2: D-U-K-E-S. Okay. So, did it appear that her mood was consistent with what she was reporting to you based on your observations? [00:12:50] D-U-K-E-S: D-U-K-E-S. She appeared to have, if you can say, like, normal mood. There was no, like, tears or sadness or, like, there was no blunted interaction. She was able to make eye contact. [00:13:03] Speaker 2: D-U-K-E-S. Okay. And, kind of moving to what's identified in your record as mental status exam. D-U-K-E-S. Yes. D-U-K-E-S. What is a mental status exam? [00:13:16] D-U-K-E-S: D-U-K-E-S. So, a mental status exam is an exam that's assessing how the patient is appearing, what she is reporting, as well as any concerns about safety, which would be any suicidal ideation, homicidal ideation, D-U-K-E-S. As well as any intrusive thoughts or worry, any hallucinations or delusions. [00:13:39] Speaker 2: D-U-K-E-S. Okay. And so, in this exam, is it a mixture of what the patient tells you and what you're observing? D-U-K-E-S. Correct. D-U-K-E-S. Okay. And if I can approach you with another page. D-U-K-E-S. Thank you. D-U-K-E-S. In regards to, on this particular first encounter on December 2nd, when it comes to the mental status exam, were you able to observe her facial expressions? D-U-K-E-S. Yes. D-U-K-E-S. And what were your observations over facial expressions? [00:14:21] D-U-K-E-S: D-U-K-E-S. She was tearful when discussing her anxiety symptoms. [00:14:24] Speaker 2: D-U-K-E-S. Okay. And were you, did you also ask those questions about thought, thought content? D-U-K-E-S- You just have to answer out loud. D-U-K-E-S. Yes. [00:14:39] D-U-K-E-S: D-U-K-E-S. Okay. And so, what did you say about thought content? D-U-K-E-S. So, thought content, worry about her infant and that she had an addiction to Ativan. [00:14:49] Speaker 2: D-U-K-E-S. And you said you also, in this assessment, assessed suicidal thoughts, correct? D-U-K-E-S. Correct. D-U-K-E-S. And so, did you ask her anything more about those passive thoughts that you indicated she reported? [00:15:01] D-U-K-E-S: D-U-K-E-S. And what she reported, as far as like passive thoughts, were thoughts of not wanting to be here or no longer wanting to live, but no plan. [00:15:10] Speaker 2: D-U-K-E-S. And is that significant to you, the fact that she identified there was no plan? [00:15:15] D-U-K-E-S: D-U-K-E-S. Yes. [00:15:16] Speaker 2: D-U-K-E-S. And why is it significant? [00:15:18] D-U-K-E-S: D-U-K-E-S. Because if she identified that she, in fact, had a plan, then that would escalate me to see it as a crisis. D-U-K-E-S. And request higher level of support at that time. [00:15:27] Speaker 2: D-U-K-E-S. As far as your observations of her thought process, were those within normal limits? D-U-K-E-S. Yes. D-U-K-E-S. And her intellectual functioning, were those within normal limits? D-U-K-E-S. Yes. D-U-K-E-S. Did she report to you any past attempts to harm herself or others? D-U-K-E-S. No. [00:15:51] Speaker ?: D-U-K-E-S. Yes. [00:15:52] Speaker 2: D-U-K-E-S. Yes. [00:15:53] Speaker ?: D-U-K-E-S. Yes. [00:15:54] Speaker 2: D-U-K-E-S. And other than what you indicated as the anxiety and sleep, did she identify any concerns for around substance abuse issues? [00:16:16] D-U-K-E-S: D-U-K-E-S. Yes. D-U-K-E-S. So she did identify concerns about, not in her history, but in that visit, about misuse of Ativan. [00:16:26] Speaker 2: D-U-K-E-S. And if somebody expresses concern about that substance use, do you have a tool available to you to assess whether they have substance use issues? [00:16:41] D-U-K-E-S: D-U-K-E-S. Yes. So there is an assessment within the initial intake appointment that has a specific section to further assess substance use disorder. [00:16:51] Speaker 2: D-U-K-E-S. And did you identify whether she presented with any substance use disorder issues? [00:16:56] D-U-K-E-S: D-U-K-E-S. I did assess that she did not present with any substance use disorder issues. [00:17:01] Speaker 2: D-U-K-E-S. And as far as her expressed concern to you, fair to say it was focused on one particular medication, the medication Ativan, correct? D-U-K-E-S. And why did you not find that that to be an issue based on your assessment? [00:17:22] D-U-K-E-S: D-U-K-E-S. Based on my assessment and how she stated she was supposed to be using it, it was used correctly to remedy the anxiety symptoms. [00:17:34] Speaker 2: D-U-K-E-S. And after this initial intake, I guess the first question is approximately how long is this initial intake appointment? [00:17:42] D-U-K-E-S: D-U-K-E-S. The initial intake appointment is typically an hour. [00:17:45] Speaker 2: D-U-K-E-S. And after having spent the hour, gone through these assessments, spoken to her about her history, were you able to come up with or give an opinion about diagnosis? D-U-K-E-S. Yes. D-U-K-E-S. And based on her presentation to you, what was your opinion about diagnosis? [00:18:00] D-U-K-E-S: D-U-K-E-S. At the time, my opinion about her diagnosis was postpartum anxiety because she had a lot of anxiety about most things. [00:18:09] Speaker 2: D-U-K-E-S. Okay. And so what were your recommendations as far as a treatment plan for her? [00:18:14] D-U-K-E-S: D-U-K-E-S. My recommendations at that visit was outpatient therapy, continued medication, and weekly visits with me. [00:18:24] Speaker 2: D-U-K-E-S. Okay. And why would you, why did you recommend outpatient therapy on top of therapy with you? [00:18:29] D-U-K-E-S: D-U-K-E-S. So outpatient therapy was kind of like a blanket therapy, but more so like intensive outpatient therapy, partial hospitalization therapy. [00:18:38] Speaker 2: D-U-K-E-S. And was your role in offering her weekly sessions an attempt to kind of bridge services and make sure she was getting everything she needed or something different to bridge services? D-U-K-E-S. And so after that meeting with the recommendation for weekly visits, did you begin to schedule additional visits with her? D-U-K-E-S. Yes. D-U-K-E-S. And after that particular visit on December 12th, did you send her any particular information? D-U-K-E-S. Yes. D-U-K-E-S. And how do you do that? How do you send patients information if you, if they're not able to, you're not able to give it to them? [00:19:17] D-U-K-E-S: D-U-K-E-S. I can send it through my chart messaging. [00:19:19] Speaker 2: D-U-K-E-S. And on this particular day, after your meeting with her, you sent her some resources about cognitive behavioral, cognitive behavioral therapy, did you not? D-U-K-E-S. Yes. D-U-K-E-S. Your next contact with her was December 5th. Why December 5th, if you had just met with her on the 2nd? [00:19:37] D-U-K-E-S: D-U-K-E-S. That may have been the soonest available appointment that week for her. [00:19:41] Speaker 2: D-U-K-E-S. Okay. And it was shy of the one week, right? [00:19:45] D-U-K-E-S: D-U-K-E-S. Mm-hmm. [00:19:46] Speaker 2: D-U-K-E-S. Did you, was there anything in your meeting with her on the 2nd that made it necessary to have a shorter appointment? D-U-K-E-S. No. D-U-K-E-S. This next contact on the 5th, was that in person or telehealth? D-U-K-E-S. Telehealth. D-U-K-E-S. And on this day on the 5th, when you met with her, did she report some additional information or report how things had gone over the weekend to you? [00:20:14] D-U-K-E-S: D-U-K-E-S. May I see my notes? D-U-K-E-S. Sure. [00:20:33] Speaker 2: D-U-K-E-S. If it's okay, I'm just going to give her all the pages from that note? D-U-K-E-S. That's fine. [00:20:37] Speaker 5: D-U-K-E-S. Thank you. D-U-K-E-S. Thank you. D-U-K-E-S. Okay. [00:20:45] D-U-K-E-S: D-U-K-E-S. I'm just reviewing the note. D-U-K-E-S. Sure. Take your time. [00:20:50] Speaker 2: D-U-K-E-S. Can you repeat the question? D-U-K-E-S. Sure. In that visit on December 5th, did she indicate to you or did she report to you how the weekend went for her? D-U-K-E-S. Yes, she did. [00:21:16] D-U-K-E-S: D-U-K-E-S. And what did she say about the weekend? D-U-K-E-S. She reported that over the weekend, she had a difficult weekend having intrusive thoughts about wanting to die and that she had contacted Aspire Crisis Support. D-U-K-E-S. She met with the clinician virtually and was told that she did not meet the criteria for inpatient treatment due to having no SI plan, suicidal ideation plan. [00:21:39] Speaker 2: D-U-K-E-S. And so when she reported the intrusive thoughts and having a tough weekend, did you follow up with her and begin to kind of talk with her about that? D-U-K-E-S. Yes. D-U-K-E-S. And what did she tell you about what she was feeling and those intrusive thoughts? D-U-K-E-S. So in those times, what she reported was that it was continuous intrusive thoughts of not wanting to be there, but no plan. D-U-K-E-S. Okay. D-U-K-E-S. Kind of like the same report that she gave to Crisis. D-U-K-E-S. Okay. And as far as kind of the difficulty of the weekend and how she was feeling, did she tell you how she was feeling? D-U-K-E-S. No. D-U-K-E-S. In that particular meeting, when she had talked about wanting to die, or not wanting to be there anymore, did you kind of follow up with her about those statements and whether she had any sort of intent or plan? D-U-K-E-S. Yes. D-U-K-E-S. And did you ask her additional information and complete that full mental status exam? D-U-K-E-S. Yes. D-U-K-E-S. On that meeting? D-U-K-E-S. And were there any signs of psychosis or signs of mania or homicidal ideation? D-U-K-E-S. No. D-U-K-E-S. And at the time that you met with her on the 5th, was she currently having those thoughts about wanting to die, if you know? [00:22:58] D-U-K-E-S: D-U-K-E-S. Just reviewing my notes. D-U-K-E-S. Sure. [00:23:00] Speaker 2: D-U-K-E-S. In that visit, she had no suicidal ideation. D-U-K-E-S. And on this particular visit on the 5th via telehealth, did somebody else participate in the visit as well? D-U-K-E-S. I can direct you to page 45. D-U-K-E-S. 45? D-U-K-E-S. Okay. D-U-K-E-S. Yes, her husband joined the visit. D-U-K-E-S. And this visit, approximately how long was it, if you recall? [00:24:13] D-U-K-E-S: D-U-K-E-S. This visit was approximately 30 minutes. [00:24:17] Speaker 2: D-U-K-E-S. And the focus of the visit was to kind of deal with that bad weekend and calling the crisis center. D-U-K-E-S. Yes. D-U-K-E-S. So what did you offer her as far as recommendations or assessments or assistance during this meeting? [00:24:33] D-U-K-E-S: D-U-K-E-S. So support during this meeting, I offered her support in connecting to, it seemed like she needed a higher level of care. D-U-K-E-S. So intensive outpatient therapy, partial hospitalization therapy, as well as we reviewed, one of her main concerns was also issues with sleeping. D-U-K-E-S. So we reviewed sleep hygiene and how to support better sleep to see if that would help with some of the intrusive thoughts. [00:24:55] Speaker 2: D-U-K-E-S. And as far as the recommendation for intensive outpatient or partial hospitalization, did she want to connect with those programs at that time? [00:25:08] D-U-K-E-S: D-U-K-E-S. At that time, she didn't decline services, but she was interested in the information. D-U-K-E-S. And so did you agree to send her some information? D-U-K-E-S. At that time, I did not agree to send her information. [00:25:20] Speaker 2: D-U-K-E-S. Did she ask for any other information in that meeting? [00:25:25] D-U-K-E-S: D-U-K-E-S. She did ask for information and support connecting to psychological testing. [00:25:30] Speaker 2: D-U-K-E-S. And is that something that you do at your clinic, do psychological testing? [00:25:35] D-U-K-E-S: D-U-K-E-S. Yes. [00:25:36] Speaker 2: D-U-K-E-S. Okay. And so did you make a referral for her to see somebody else in the clinic or did you provide her other information? [00:25:43] D-U-K-E-S: D-U-K-E-S. So I discussed this information with a provider at the time, which was the psychiatrist and medication provider at the time. [00:25:52] Speaker 2: D-U-K-E-S. And would that have been Rebecca Gelata? D-U-K-E-S. Yes. D-U-K-E-S. And so did you subsequently send Lindsay Clancy some information about psychological testing? D-U-K-E-S. Yes. D-U-K-E-S. But there was no recommendation for it to be done at the clinic? D-U-K-E-S. No. [00:26:09] D-U-K-E-S: D-U-K-E-S. Do you know why? D-U-K-E-S. At the time, it sounded like she wanted extra support or like outside opinion as far as like diagnosis and medication. D-U-K-E-S. Okay. [00:26:20] Speaker 2: D-U-K-E-S. And was the testing something that she brought up or did it come out naturally in your conversations with her? D-U-K-E-S. That's something she brought up. D-U-K-E-S. In your meetings, did she discuss medication side effects with you? D-U-K-E-S. Yes. D-U-K-E-S. Okay. D-U-K-E-S. And what were your observations of her demeanor during this visit on the 5th? [00:26:42] D-U-K-E-S: D-U-K-E-S. One second. [00:26:48] Speaker ?: So, let's go. [00:27:18] D-U-K-E-S: Her presentation overall was within normal limits. She didn't appear like anxious or different than in any other visit I had with her. [00:27:36] Speaker 2: And this is kind of your second meeting with her, right? And how many meetings did you have overall with her during the time she's at the clinic, if you know? [00:27:46] D-U-K-E-S: Four. [00:27:46] Speaker 2: Four. So, but you had spent an hour with her on that intake where there's a lot of information exchange, right? Yes. So, was there anything different about how she presented, how she spoke to you or answered questions during this follow-up on the 5th? No. And as far as the conversations about the bad weekend and calling crisis, did you have any concern that she was in crisis? [00:28:14] D-U-K-E-S: No. [00:28:15] Speaker 2: And you made those recommendations for a higher level of care, correct? [00:28:19] D-U-K-E-S: Yes. [00:28:20] Speaker 2: But nothing that would have prompted you for those other interventions that you've previously described to us, right? [00:28:25] D-U-K-E-S: Right. [00:28:30] Speaker 2: Did you ever, in this visit, see signs of mania? [00:28:35] D-U-K-E-S: No. [00:28:35] Speaker 2: And is that something you look for? [00:28:37] D-U-K-E-S: Yes. [00:28:38] Speaker 2: And did you ever see signs of delusions or paranoia? [00:28:42] D-U-K-E-S: No. [00:28:42] Speaker 2: How about psychosis? [00:28:43] D-U-K-E-S: No. [00:28:45] Speaker 2: Now, your next contact with her was December 12th, correct? Yes. And was that in-person or telehealth, if you recall? Telehealth. And on the 12th, did you have further conversation with her about your previous recommendations about partial hospitalization programs? [00:29:17] D-U-K-E-S: May I repeat? [00:29:18] Speaker 2: Yes. [00:29:20] D-U-K-E-S: May I approve? [00:29:21] Speaker ?: Thank you. [00:29:30] D-U-K-E-S: Yes, we did have further conversation about recommendations. [00:29:44] Speaker ?: Okay. [00:29:44] Speaker 2: And did she indicate to you that she would be starting a program soon? [00:29:49] D-U-K-E-S: Yes. She indicated that she would be starting a partial hospitalization program in Norwell on December 20th, 2022. [00:29:56] Speaker 2: Did she provide you any details about that program? Do you know? [00:30:05] D-U-K-E-S: No, just that she would be starting a program in Norwell. [00:30:08] Speaker 2: Was that, had you referred her to any programs in Norwell? [00:30:13] D-U-K-E-S: No. [00:30:14] Speaker 2: And in this meeting with her, did you continue to talk about her need for higher level of care? [00:30:21] D-U-K-E-S: Yes. [00:30:21] Speaker 2: And did you make recommendations on a different program? [00:30:29] Speaker ?: Yes. [00:30:30] D-U-K-E-S: I did make a recommendation on women and infants. [00:30:42] Speaker 2: And why did you recommend women and infants, or why were you recommending this higher level of care? [00:30:50] D-U-K-E-S: I was recommending this higher level of care because of continued passive suicidal ideation, even with crisis intervention, as well as women and infants was more so for postpartum women, and the infant would be able to come to the program with her. [00:31:09] Speaker 2: And so the program at women and infants is something that you're familiar with working through your clinic, correct? Yes. And you often make referrals over there? [00:31:16] D-U-K-E-S: Yes. [00:31:16] Speaker 2: Do you require the patient's consent to make a referral? [00:31:19] Speaker ?: Yes. [00:31:20] Speaker 2: Did Lindsay Clancy consent to the referral at that time? [00:31:35] D-U-K-E-S: Yes. [00:31:37] Speaker 2: And so did you work to make that referral after that visit? Yes. Now, you mentioned that she had continued passive suicidal ideation. In this meeting that you had with her, did you assess that, her suicidal ideation? [00:31:54] D-U-K-E-S: In this visit particularly, did she have passive suicidal ideation? [00:31:59] Speaker 2: Well, do you ask if they still have that? Yes. Or if they currently have thoughts of suicide? Yes. And in this instance, did she have thoughts of suicide or wanting to die? [00:32:11] D-U-K-E-S: Just reviewing. Hold on. So, yes, she reported, like, continued suicidal ideation at the time. [00:32:31] Speaker 2: And, but did she ever indicate a plan? [00:32:34] D-U-K-E-S: No. [00:32:34] Speaker 2: Having met with her on the 12th, did she ever articulate to you that she had made any attempts? [00:32:47] D-U-K-E-S: No. [00:32:51] Speaker 2: And in your conversation with her on the 12th, were you able to identify any protective factors based on everything that you knew about her at this time? Now, this is your third time with her, right? Yes. So, what were you able to identify as protective factors for this particular patient? [00:33:09] D-U-K-E-S: At this time, she had supports, which were her husband and her mother-in-law. At this time, she was able to, from the past visit I had with her, able to contact crisis when she felt like she needed extra support. So, she was able to follow through with suggestions that I had given her in the previous visit. [00:33:30] Speaker ?: Okay. [00:33:30] Speaker 2: And, based on your visit with her on the 12th, she accepted a willingness to go to one of those programs, right? Yes. Or at least be referred? Yes. So, was there anything about your interaction with her on December 12th that warranted any of those higher levels of intervention from you? [00:33:49] D-U-K-E-S: No. [00:33:50] Speaker 2: Now, the next time you met with her was on December 19th, correct? Yes. And, was that the final time that you met with her? [00:33:58] D-U-K-E-S: Yes. [00:33:59] Speaker 2: On that day of December 19th, was that an in-person or a telehealth? [00:34:06] D-U-K-E-S: May I review the note? Sure. [00:34:07] Speaker ?: Sure. Thank you. [00:34:29] D-U-K-E-S: That visit was virtual? And, what was the question? [00:34:33] Speaker 2: That was the question. Thank you. So, on this particular visit on the December 19th, did she report any further issues or anything that had happened between the 12th and the 19th that were of concern? [00:34:49] D-U-K-E-S: So, she was continuing to have low mood and numbness. She did not have any SI and had no need for crisis intervention over that weekend. [00:34:59] Speaker ?: Okay. [00:35:00] Speaker 2: And, did she indicate to you that she had been doing things at home to try to help with her mood? [00:35:06] D-U-K-E-S: Yes. [00:35:07] Speaker 2: And, what was she doing? [00:35:09] D-U-K-E-S: Let's see. She was spending time with family and her children and exercising. [00:35:18] Speaker 2: Now, at this point, as the December 19th rolled around, had you already put in that referral to women and infants? Yes. And, did you know if she engaged with women and infants by that point? [00:35:29] D-U-K-E-S: By that point, women and infants had reached out to her, but she had missed the call, but said she would contact them back. [00:35:38] Speaker ?: Okay. [00:35:38] Speaker 2: Now, one of the concerns that you often talked about in your meetings with her was sleep, right? Yes. And, in this meeting with her on December 19th, did she report any improvements in her sleep? No. Well, if I direct your attention to page 13, at the top of the page where it says risk assessment, there's a category for neurovegetive disturbances. Do you see that? Yes. [00:36:28] Speaker 4: Can you show me what you mean by page 13? [00:36:31] Speaker 5: I'm looking at prior ones. I don't know. Those don't have page numbers. But the one I gave her has. It's December 19th. Okay. That's the last page. [00:36:43] Speaker 4: I don't know. This is one of the other, right? [00:36:45] Speaker 5: Yeah. [00:36:46] Speaker 4: Okay. [00:36:47] Speaker 5: There should be three pages. I only got one. [00:36:50] Speaker ?: Sorry. [00:36:50] Speaker 2: What did you note under neurovegetative disturbances? I reported that sleep has improved. And that would be information that's reported to you, correct? Yes. You can't make observations of whether somebody's sleep has improved, can you? [00:37:06] D-U-K-E-S: No. [00:37:07] Speaker ?: Okay. [00:37:08] Speaker 2: So, in this instance, she told you she was going to follow up with the referral, that she was waiting for a callback, that she had improved sleep, but that her mood kind of had remained the same, low mood, numbness, right? [00:37:22] D-U-K-E-S: Yes. [00:37:23] Speaker ?: Okay. [00:37:24] Speaker 2: Anything about your interaction with her that day that was different from the prior interactions? [00:37:29] D-U-K-E-S: That day, she seemed to be more engaged. She was able to smile. She was able to laugh. And she was enjoying time with family. [00:37:42] Speaker 2: And so, did you look at that as something positive? [00:37:46] D-U-K-E-S: Yes. [00:37:47] Speaker 2: Was there anything about your interaction with her on this day, on December 19th, that made you think that you needed to invoke a higher level of care? [00:37:56] D-U-K-E-S: No. [00:38:04] Speaker 2: As far as in-person visits, did you have any other in-person visits with Lindsay Clancy after the 19th? [00:38:11] D-U-K-E-S: No. [00:38:12] Speaker 2: Fair to say your contact with her was very limited after that point? [00:38:16] D-U-K-E-S: Yes. [00:38:16] Speaker 2: And on December 27th, did you have some interaction with her and her husband? Yes. And why did you have interaction with them? [00:38:27] D-U-K-E-S: May I see the note? Sure. Sure. [00:38:32] Speaker 5: Thank you. [00:38:51] Speaker 4: Thank you. Thank you. [00:38:59] D-U-K-E-S: Can you repeat the question? [00:39:06] Speaker 2: On December 27th, why did you have contact with her? Why did you make contact with Lindsay? [00:39:16] D-U-K-E-S: I was calling her to inform her that her referral had been completed. [00:39:20] Speaker 2: Okay. And so, you had a call with her at 10.23, 10.17, going back 9.44. Do you see that in the records that you have? The four notes that you have in front of you? They kind of go in a reverse order. Yes. But prior to the contact about the referral being completed and just reaching out to her and letting her know, did you have a conversation with her husband? [00:39:58] D-U-K-E-S: Yes. [00:39:58] Speaker 2: And was that at Lindsay's request? Did she give consent for that? [00:40:04] D-U-K-E-S: She did give consent for that. Okay. [00:40:07] Speaker 2: And first, he was reporting concerns of prescriptions, right? [00:40:12] D-U-K-E-S: Yes. [00:40:12] Speaker 2: And that's not your area in the clinic, is it? [00:40:16] D-U-K-E-S: No. [00:40:16] Speaker 2: So, did you refer him to the prescriber? [00:40:21] D-U-K-E-S: At this time, yes. I redirected him to speak to the prescriber. [00:40:24] Speaker 2: Okay. And again, in each and every encounter that you've had, did you further recommend that she engage with a higher level of care, either a partial hospitalization program or an outpatient program? [00:40:36] D-U-K-E-S: Yes. [00:40:41] Speaker 2: Now, at any point that you were interacting with her between December 2nd and the last contact with December 27th, albeit limited, did you ever have any concerns about her physical well-being? [00:40:56] D-U-K-E-S: No. [00:40:56] Speaker 2: Did you ever have any concerns about the physical well-being of others in her presence? [00:41:01] D-U-K-E-S: No. [00:41:02] Speaker 2: Did you ever see or observe any signs of mania, delusion, or paranoia? [00:41:07] D-U-K-E-S: No. [00:41:07] Speaker 2: Any signs of psychosis observed by you? [00:41:10] D-U-K-E-S: No. [00:41:10] Speaker 2: Did you ever have any difficulty understanding what she was saying or notice any differences in her speech patterns? [00:41:16] D-U-K-E-S: No. [00:41:17] Speaker 2: Did you ever have any concerns that she wasn't accurately reporting things to you? [00:41:22] D-U-K-E-S: No. [00:41:24] Speaker 2: And did you ever feel the need to collaborate with your provider for a higher level of care or an additional intervention? [00:41:36] D-U-K-E-S: When I did, yes. [00:41:37] Speaker 2: And so would that be for the calling the police section 12 or safety? [00:41:45] Speaker 1: Hold on. Go ahead. Last second. [00:41:48] Speaker 2: My question was, in any of the times that you engaged with her, did you ever engage with your provider to come up with a plan for safety planning, section 12, or any other of those interventions you discussed before? [00:42:03] D-U-K-E-S: No safety or section 12. No. [00:42:05] Speaker 2: So as far as recommendations, would you agree that those were the recommendations for higher level of care? [00:42:12] D-U-K-E-S: Yes, for IOP or PHP services. Okay. [00:42:19] Speaker 2: And on that last visit that you had with her, she reported doing things outside of the home, right? Yes. And that stood out to you? [00:42:28] D-U-K-E-S: Yes. [00:42:29] Speaker 2: As what? [00:42:29] D-U-K-E-S: As an improvement in mood and ability to connect with others. Okay. Thank you. [00:42:36] Speaker 2: If I may have a moment to put these back together. [00:42:39] Speaker 4: Is it four times that you yourself actually met with Lindsay or more? Can you repeat that? I'm sorry. Was it four times that you actually met with Lindsay or more? And that would include telehealth? Four. Four times. Okay. You met with her on the 2nd of December, right? Yes. And you met with her on the 12th of December. Is that right? Yes. You met with her on the 19th of December, right? Yes. And is it the 27th as well? Was there another one? Do you remember when that was? That was by phone. By phone. And would that be the 27th? Yes. Okay. So what I'm going to do is give you the documents that the district attorney is questioning you from. Thank you. And you can slide up and just. Yeah. And if I get confused or something, just let me know that you're on a different page than me. A couple of background questions. When you met with Lindsay, for example, on the 2nd of December, you were at least able to look at the records of Nurse Paul as well as Nurse Gelata, right? No. Oh. I mean, you guys work in the same place though, right? Yes. Okay. So when a woman is in postpartum and comes to Social Health for help, when you're trying to help them, you can't see the medical records from what the other people like Nurse Paul and Nurse Gelata have written down? You can see the records, yes. You can? Yes. Okay. So you did look at the records? I did not look at the records. Okay. [00:44:40] Speaker ?: Okay. [00:44:40] Speaker 4: On the 2nd of December, you can look along with it if you wish. Looking under what would be referred to as behavioral health intake. Your pages are numbered, mine are not. So if you can find that one page, behavioral health intake on December 2nd. And the jurors will have this as an exhibit, but just going through the pages. You have it? [00:45:03] D-U-K-E-S: One second. [00:45:13] Speaker 4: Yes, I have it. Okay. Now, one of the things that you would be interested in when you're interacting with a patient that comes to your facility for help is how honest they are, right? Yes. Especially in psychiatry, you want to make sure that the person is not lying to you or hiding something. You want them to be honest, right? Yes. And, for example, Lindsay disclosed to you and to the others that back in 2012, while she was in nursing school, she actually had Prozac because she was very nervous, actually, about public speaking. But she was on Prozac, right? One second. Sure. I think it's right under behavioral health history, first paragraph. Yes. Yes. Okay. And she also told you that she had been prescribed Ativan, for example, by a psychiatrist, Jennifer Tufts, right? [00:46:24] D-U-K-E-S: Just reviewing. [00:46:25] Speaker 4: Second paragraph. [00:46:40] D-U-K-E-S: So, no. That's not what I see here. [00:46:43] Speaker 4: Okay. Do you see what it says prior to attending the Shure program? Sentence. Second paragraph. Yes. Patient was prescribed Ativan by psychiatrist Jennifer Tufts. [00:46:52] D-U-K-E-S: It says he or she was prescribed Zoloft. [00:46:56] Speaker 4: Well, I must be misreading something. I apologize. Let me approach you. So, this is what I have here. History and current functioning, right? History and current, okay. And then behavioral health history, paragraph one, right? References to Prozac, right? Yes. Okay. But it doesn't say... [00:47:22] D-U-K-E-S: She said Dr. Tufts. [00:47:23] Speaker 4: No, I was saying the second paragraph, prior to attending Shure program, she disclosed to you that she was prescribed Ativan, right? So, which one are you on? Second paragraph, right here. [00:47:35] D-U-K-E-S: Okay. [00:47:36] Speaker 4: Prior to attending Shure program, patient was prescribed Ativan, right? Yes. Okay. And that was by Dr. Tufts, right? Yes. So, she told you that she was prescribed Benzodiazepine by her treating psychiatrist. And further on into your interaction with her, she told you that she was very concerned about taking medication, right? Yes. And she was really concerned about becoming addicted to medication, such as a Benzo, like Ativan, right? She was concerned about becoming addicted to medication, yes. She had weight loss, right? Yes. No appetite, right? Correct. Panic attacks, right? Right. Couldn't sleep, right? Yes. Next page, December 2nd, office visit, the same visit. First paragraph. She was prescribed Remeron and Seroquel in the past four days, right? [00:48:38] D-U-K-E-S: I'm sorry. This is a different date on this one. What date do you have? Okay. [00:48:47] Speaker 4: So, the next page. [00:48:52] D-U-K-E-S: I find it goes to 12-5. [00:48:54] Speaker 4: Okay. All right. Let's look at this one, then. Is this, would you agree that this is a record from South Shore Health that talks about continuing your appointment December 2nd? Yes. Okay. If you can find it. I think they were just out of order. Okay. Okay. Let's find it. Don't worry. It's not your fault. So, are you with me on that? That she was prescribed Remeron and Seroquel? [00:49:17] D-U-K-E-S: Yes. [00:49:18] Speaker 4: Okay. And that was within the past four days. Is that right? Yes. So, when you saw her on December 2nd, after telling you about the Ativan and telling you about her weight loss and her anxiety and everything else, she told you that she had been prescribed Remeron and Seroquel. And I understand you don't do the drugs, so you don't really have... No, I don't do medication. It's very difficult to get the brand names and the other names, but we have a chat for that. So, she started Remeron and Seroquel, and then she told you that since starting the medication, she's had thoughts that she no longer wants to be here, meaning, I guess, what, on the earth? [00:50:03] D-U-K-E-S: No longer wanting to be here could mean anything, but in that instance, when assessing for suicidal ideation, no longer want to be here qualifies as passive suicidal ideation. Okay. [00:50:16] Speaker 4: And then she indicates further that this week, that she was seeing you, feels like she's going to die. That's what the DA read to you, right? Yes. But then it goes on and says, but she doesn't care if she dies, basically. She feels like she's going to die, but she doesn't care. She said that, right? Yes. She then talked about how the Remeron and Seroquel were not helping her sleep. Yesterday, she took Ativan, she told you, right? Yes. Due to intrusive SI, suicidal ideation thoughts, right? Yes. Did she indicate what the intrusive suicidal ideation thoughts were yesterday, which would be December 1st? Did she tell you what that meant? Did you ask her what she meant by that? [00:51:02] D-U-K-E-S: I did ask her what she meant, and that would mean that she had the thoughts that she told me about, about no longer wanting to be here. [00:51:10] Speaker 4: Okay. And you then told her that she could go to the ER and that you then sent her local crisis contact information. Is that right? Yes. And then talks about onset, says three months after the baby was born, she had unmanageable anxiety, correct? Correct. And what did she tell you the anxiety was about? One second. Yep. It's under onset. [00:51:39] D-U-K-E-S: And what was the question? [00:51:59] Speaker 4: Under onset, she indicated three months after the baby was born, she had unmanageable anxiety, is what the district attorney asked you. And then it continued on with a sentence. What was her anxiety about? About her children, especially the baby. And what does that mean, that she was having unmanageable anxiety? What does unmanageable mean? [00:52:31] D-U-K-E-S: So constantly worried that something was going to happen to her children or something bad was going to happen to the baby. [00:52:37] Speaker 4: And at that time, the children were four, three, and six months, right? Correct. Under social, the notes indicate that she reported she talks about her anxiety all the time with her mom, husband, and mother-in-law, correct? Correct. And one of the questions the DA asked you is about her support, family supports or collateral contacts, and you indicated the mother-in-law. She also had her mother and father as family support as well, right? Correct. And you knew that her mother and father had actually lived in Connecticut, but moved up or came up and stayed with her for at least a week, if not longer, during December, right? If you know. And I know it's difficult if it's not in the notes for you to remember. I'm just asking, do you remember at all that she said that her mother and father came up and stayed with her to help out? [00:53:27] D-U-K-E-S: I don't remember that. Okay. [00:53:30] Speaker 4: She further went on and said that she's uninterested in other topics from friends. What did that mean? She just didn't want to talk to her friends about anything? She just had a lack of interest in conversation with friends. And that would be her social circle. She just didn't care, right? Right. She said that she felt numb, right? Yes. She had a lack of attention, right? Right. Confusion, right? Right. Under mood, it says, well, of course, you have disturbed sleep. She's only sleeping two to four hours a night is what she told you, right? Correct. And then it says supports. Mother and father have been staying with her for the past week. Does that refresh your memory that you did get that info, that they were staying with her for the past week? Yes. That's fine. I just saw that, too, so no problem. You took her history, that she was a nurse, that she had been on leave, and she told you that she lost 10 pounds in the past month, right? Correct. Now, can you flip to the next page and make sure we're both on the same page? And the substance use assessment, do you have that? One second. Yep. Yes. Okay. So one of the things that you're concerned about is whether or not your patient has a substance abuse problem, like drugs or alcohol or something like that, right? Correct. And you've already told us that your opinion was that Lindsay did not have any substance abuse problems other than her fear about the prescribed Ativan, right? Correct. So did you ask her about alcohol? Yes. Can you tell me what she said about alcohol? [00:55:16] D-U-K-E-S: She said the last time she drank alcohol was in October of 2019. Go ahead. Yeah. Did she tell you how much, what it is that her alcohol of choice was? She said her alcohol of choice was wine. She would have one to two glasses. [00:55:32] Speaker 4: Did she say why she would do that? To cope with anxiety. Okay. And this is back in 2019, right? Correct. That would be three years before you actually met with her in December of 22, right? Correct. Cannabis. Yes. The weed. The devil's lettuce. How about that? Did she confess that she was using marijuana? [00:55:56] D-U-K-E-S: Yes, she said she did use marijuana. When? Last use was November 15, 2022. [00:56:03] Speaker 4: Why? I'm sorry? Why did she say that she used it? It's under comments? Yes, I'm taking a look. That's okay. [00:56:14] D-U-K-E-S: She said she tried a marijuana gummy to help with sleep. [00:56:19] Speaker 4: And that was on November 15, 2022, right? Yes. Go to the next page, assessment and recommendation. If you have that, make sure we have it. Let's see. And I think the district attorney had asked you about the mental status exam facial expression, and you indicated that her facial expression showed anxiety, right? Correct. Fear, right? Yes. Do you know what the fear was? [00:57:05] D-U-K-E-S: Just going back to that part of the assessment. Sure, yep. [00:57:08] Speaker 4: It's under facial expression. [00:57:22] D-U-K-E-S: And you said facial expressions, right? Yes, please. Yeah. Anxiety, fear, apprehension, sadness. [00:57:29] Speaker 4: Okay, so if I can, I apologize. If you just keep your voice, you're very soft-spoken. Yes, I'll walk. Voice up so the jurors can hear you. Yeah. Thank you. And you said that your facial expression exported to you anxiety, right? Correct. Fear of something, right? Yes. Apprehension, right? Yes. Sadness? Yes. Depression? Yes. And she expressed that she was having anxiety and numbness, right? Yes. And she was crying when she was telling you this, right? Yes. And again, indicated that her thoughts were worried about her baby, the new baby she had, the infant, as well as if she's being addicted to Ativan, is what she told you, right? Yes. And again, thoughts of wanting to die, but there was no plan. Correct. Next page, risk assessment. There's a whole lot of stuff on it, these pages. I'm just trying to cut to the chase here. So you see where it says risk assessment? I am trying to find it. One second. Yep. [00:58:31] Speaker ?: Okay. [00:58:48] Speaker 4: Under a current medic, I'm sorry, it's under a risk assessment. I'm taking a look. Okay. [00:59:03] D-U-K-E-S: I see protective factors, but I don't see risk assessment. [00:59:07] Speaker 4: Okay. Let me ask you, under risk assessment on December 2nd, when you asked me about that, at that point, as you can see here, she again admitted to suicidal ideation, right? Yes. It was passive. [00:59:23] D-U-K-E-S: Yes. [00:59:24] Speaker 4: It says to go to ER if she feels unsafe or has a plan, right? [00:59:29] D-U-K-E-S: Yes. [00:59:30] Speaker 4: And then farther down, you have current medications, and she was on quatapine or Seroquel, right? Yes. Floxetine or Prozac, right? [00:59:39] Speaker 1: Correct. [00:59:40] Speaker 4: Lorazepam or Ativan, right? [00:59:42] D-U-K-E-S: Yes. [00:59:43] Speaker 4: Ritazepine or Remeron, right? [00:59:45] D-U-K-E-S: Yes. [00:59:45] Speaker 4: And they were all, that was all active prescriptions that she had on December 2nd, right? Yes. She told you that she is seeking counseling for postpartum anxiety, right? Yes. Do you have on December 2nd, continuing on with your evaluation, where it says clinical notes, do you have the clinical notes? One second. What I could do is read what I have rather than stand next to you. And if you trust me, then I'm not misrepresenting it. I mean, I'm just reading off of this to make it quicker for you. It refreshes your memory. If it doesn't, I can walk up and show it to you, okay? Okay. On that date, your notes say patient requested addiction support services. Do you recall that? Yes. And that you indicated that you would be sending patient addiction support resources by MyChart, or the message thing, right? Correct. You then indicate that, based on history reported, patient meets the criteria for postpartum anxiety, right? Yes. That she would benefit from OP therapy. What does that mean? Yes, from outpatient therapy services. PHP? Yes, partial hospitalization program. IOP? Intensive outpatient program. And that you then helped her out by bridging the therapy services, right? Yes. You then noted again postpartum anxiety on December 2nd, according to your notes, right? Yes. Okay. Now, did you know that she had been seeking and receiving therapy? I don't know if that's therapy or counseling or that type of thing. Like, there's a woman that works in your business that provides therapy, right? Yes. So that person would be me. So did she come to see you for therapy? Yes. How many times? Four. So is it fair to say that she was more than willing to accept help from somebody like you? [01:02:07] D-U-K-E-S: Yes. [01:02:08] Speaker 4: She didn't appear to be avoiding any therapy when recommended, right? If you could, Ms. Dukes, please look at, I think it was December 12th was the next time perhaps that you saw her? [01:02:20] Speaker ?: Okay. [01:02:24] Speaker 4: Unless it's, there's another intervening period. [01:02:30] D-U-K-E-S: So there's December 12th and then there's December 5th. [01:02:34] Speaker 4: Oh, okay. So if you could, for December 5th. Yes. And if I can come up and look at it. [01:02:41] Speaker ?: Yeah. Thanks. Yep. [01:02:47] Speaker 4: All right. So on December 5th, again, you were meeting with her for therapeutic intervention, right? Yes. And on this occasion, she reported she had a difficult weekend, right? [01:03:01] D-U-K-E-S: Yes. [01:03:01] Speaker 4: Intrusive thoughts of wanting to die, right? [01:03:04] D-U-K-E-S: Yes. [01:03:04] Speaker 4: That she contacted Aspire Crisis Support, right? Yes. She met with an Aspire clinician, right? Yes. And what happened when she met with the Aspire clinician? [01:03:17] D-U-K-E-S: She met with the clinician virtually and was told that she did not meet the criteria for inpatient treatment due to not having any suicidal ideation plan. [01:03:27] Speaker 4: So if she said, in addition to the fact that she's been in counseling and therapy and seeing psychiatrists and on medications for the past three months or whatever the period ultimately would be, and that she wanted to kill herself, didn't want to be here, couldn't care if she died, they told her because she didn't have a plan that they couldn't help her? [01:03:48] D-U-K-E-S: Correct. [01:03:50] Speaker 4: Did they, to your knowledge, make any recommendations? Did they suggest, recommended that she attend a day program? Yes. All right. And that person from Aspire then said he would send her patient resources, right? [01:04:05] D-U-K-E-S: Correct. [01:04:05] Speaker 4: But nothing ever happened. He never sent her any, you did, but he never sent her any patient resources, right? If you know. [01:04:12] D-U-K-E-S: Not to my knowledge. [01:04:13] Speaker 4: Okay. All right. So she had you at least to talk to and counsel and advise her. You continued on to make your observations. Fair to say that pretty much things stayed the same as far as her appearance, appearing anxious, appearing sad, unable to relate to people, that type of thing. [01:04:35] D-U-K-E-S: Correct. [01:04:36] Speaker 4: Okay. Then you have, as a chief complaint of present illness, and again, that was, oh, wait a minute. That's not my note. That's not you. Okay. All right. So you can hold on to that again. [01:04:52] D-U-K-E-S: Yep. Thank you. [01:04:59] Speaker 4: Next time you saw her, it would be December 12th. Is that correct? Correct. All right. Now, on December 12th, that was a teleconference that she had called by an appointment with you? Yes. And at that point, this is, she reported that she had a difficult weekend and was experiencing intrusive thoughts of wanting to, do you have it in front of you? I don't want to take advantage of it. [01:05:21] D-U-K-E-S: Hold on one second. Yep. I don't see the 12th in here. Okay. [01:05:53] Speaker ?: Page 28. [01:05:54] D-U-K-E-S: Page 28. Page 28. [01:06:07] Speaker 4: And just for the record, I think, Your Honor, that she's looking at the actual exhibit. Am I right? That's the exhibit? That's in evidence? No, it's not at all. Okay. Can it be in evidence? Can I offer that? Yeah. Okay. Can I offer that? Any objection? [01:06:23] Speaker 5: Can you put so much on the issue? [01:06:24] Speaker 4: Sure. Yeah. [01:06:28] Speaker 1: Yeah, if I could just add that. [01:06:29] Speaker 4: Yes. Again, I could do what I did before. She probably had it before. Right, yeah. It references providers' interventions, and that would be, would that be you, provider? Correct. Okay. And you're talking about symptom management, and yet again, she's reporting she had a difficult weekend, experienced intrusive thoughts, wanted to die. Didn't have a plan for suicidal plan, but she contacted crisis over the weekend, and that would be, again, a spire, apparently, right? Because there were two times she contacted a spire, not once. Correct. Twice. Both times they told her that there's nothing they could do for her, right? Correct. And she told you that she was going to start a PHP in Norwell on December 20th, right? Correct. But in fact, you were able to, knowing people that you may have and pull strings, you were able to try to get her into the Rhode Island Women and Infants program, right? Correct. Which is a really pretty good program. Correct. And did you know that she did, in fact, go to Women and Infants on December 20th? She didn't go to the Norwell program. She went to Women and Infants program. And that she was there for the day, and that they basically turned her away. [01:07:53] D-U-K-E-S: I did know that she went to the Women and Infants program. I was not sure of the date. [01:07:58] Speaker 4: Okay. So if I suggest to you, it was the same date that she had told you that she was going to go to the program in Norwell on December 20th, and then that you and Nicole Hardin-Francis reviewed various options, one of which was that, which made sense, to attend the Women and Infants program, IOP or PHP program, right? Correct. And that she, patient, provided you with verbal consent. Correct. To sign whatever had to be signed and get her into that program, right? Correct. So you know that she did on December 20th, after not getting anywhere with Aspire times two, and after dealing with Gelata for all those times that she dealt with, I'm sorry, the other one, Tufts, you were trying to get her into this program, which would be pretty good for a woman that had postpartum problems, right? Correct. And you made your referral, you opened the door for her, and she got in there to at least be interviewed, right? Correct. And they didn't take her, right? Correct. You know why? I am not aware as to why. Would you be surprised if I told you that they indicated that they could not help her out because their diagnosis or secondary diagnosis was that she was over-medicated? [01:09:16] D-U-K-E-S: Repeat the question. [01:09:18] Speaker 4: Would it surprise you to know that they indicated that they couldn't treat her as a woman with postpartum psychosis or postpartum depression or postpartum anxiety or any of that because their opinion was that she was suffering from an over-medication? [01:09:36] D-U-K-E-S: It would surprise me, yes. [01:09:38] Speaker 4: But you don't know? I do not know. Okay. Did you know that the records from women and infants indicate that, in fact, on that very same day they reached out to Nurse Gelata and asked her to call them so that they could discuss the medication and Gelata never got back to her? [01:09:59] D-U-K-E-S: I was not aware of that. [01:10:01] Speaker 4: I'm sorry? [01:10:02] D-U-K-E-S: I was not aware of that. [01:10:04] Speaker 4: Okay. I think the district attorney had asked you a question about the last time that you saw her or had any activity with her. It was on December 19th. Is that right? Correct. Okay. And I may have misunderstood. Did she ask you, like, did you call Lindsay four times and she never got back to you that day? Or is that just a list of different things that you did for her? That's a list of different things that I did for her that day. Okay. So you were calling other contacts, you were talking to Patrick, you would contact her. I mean, she certainly was not avoiding you. Yes, we were in communication. All right. You're familiar with, maybe you are, what's called the Edenburg scale? I'm aware of it, yes. And did she have the Edenburg scale administered to her, to your knowledge? To my knowledge, no. Okay. What is polypharmacy? What does that mean? Polypharmacy? Yeah. You ever heard of that, polypharmacy? I've heard of it, but not sure of the exact definition. Is it something to do with having too much medications thrown at you all at once? If you know. No, I'm not sure. Not sure. Okay. Excuse me for one minute. I apologize. I just had something pulled up, and it just went back to default on me, so I just need a second. I apologize. Okay. I get it. And how long have you been working in your particular field? [01:12:30] D-U-K-E-S: Since 2011. [01:12:32] Speaker 4: Okay. And you have, obviously, a very impressive background as far as your educational background and your experience. Do you continue to, like, with continuing education? Yes. Have you ever been aware, are you aware of the Mass General Hospital Center for Women's Mental Health? [01:12:55] D-U-K-E-S: I am aware of it, yes. [01:12:56] Speaker 4: Do they offer seminars and programs as well as research articles? [01:13:03] D-U-K-E-S: I believe they do. [01:13:03] Speaker 4: Do you know that Mass General Center for Women's Mental Health, about a year ago, issued a fairly major study and various recommendations for people that are dealing with women that have postpartum periods and how they break up the periods? Are you familiar with that? No, I'm not familiar with that. So, if I suggest to you that, in that particular Mass General Hospital article, it goes on about postpartum period, and do you agree that the postpartum period, 85% of women that are pregnant, or after pregnancy, experience some type of mood disturbance? Would you agree with that? No, I wouldn't agree with that. All right. Would you agree that 10% to 15% of women develop more significant symptoms of depression or anxiety? I agree. Okay. And then postpartum psychiatric illness is then divided into three categories. One sounds like something out of the 50s, postpartum blues. Would you agree with that? Yes. You've heard that expression before, right? Correct. And that's, it can be bothersome, it can be aggravating, it can be intrusive, but it's not threatening the life of the mother or baby or anybody else, right? Correct. And it's fairly common, right? Correct. Number two would be postpartum depression. That's a different issue, correct? Yes. And number three would be postpartum psychosis. Is that right? Yes. All right. Now, postpartum depression, prior to morphing, if you will, into postpartum psychosis, consists of a number of symptoms, symptomology, right? For you to diagnose a woman, whether she's pregnant, has the baby, or after having the baby with postpartum depression, there are certain things that are symptoms that you look for, right? Correct. One of which would be depressed or sad mood, right? Yes. Lindsay had that, right? Yes. Next would be tearfulness, right? Yes. Lindsay had that, right? Correct. Next one would be loss of interest in social activities or usual activities or her friends. She had that, right? Correct. Feelings of guilt. She had that, right? She didn't express feelings of guilt. Okay. Feelings of worthlessness? Did she express that she felt worthless? She did not express that. How about fatigue? Did she have that? She did not express fatigue, but lack of sleep. I know, lack of sleep, were you aware that, in fact, that she had indicated that she was so wiped out that she couldn't even get out of bed, couldn't put her feet on the ground, and if she did, she felt heavy? I did not hear that from her. Okay. How about, you mentioned it, you got it, sleep disturbance is another issue, correct? Correct. She had that, right? Yes. Change in appetite, she had that, lost 10, 15 pounds, right? Yes. Poor concentration, she had that, right? She said she was numb. She could not focus. Suicidal thoughts? Yes. We know she didn't have a plan, but she had suicidal thoughts, right? Correct. So under the Mass General Hospital Research Project for women that are suffering from postpartum issues, she pretty much hit every one of the postpartum depression symptoms, correct? Correct. And then it talks about if it increases in severity, significant anxiety symptoms may occur. Not generalized anxiety, significant anxiety symptoms can occur, is that right? Correct. And one of the ways that you determine that is by the test, that it can be administered to a person who is in a postpartum status, and that would be what we talked about, the Edenberg test, right? Correct. And you're aware that she was given the Edenberg test and had a 23 out of 30, I think it was. I was not aware. Okay. And some women develop panic attacks referred to as hypochondriasis. You'd agree with that, right? Agree with that in reference to. Lindsay, she had panic attacks and complained of having panic attacks. Yes. Okay. And then you can get into the various diagnoses of which on a postpartum person in that time frame, obsessive compulsive disorder, OCD, right? Correct. Or bipolar 1 or bipolar 2, right? Are you using them interchangeably or could develop? Trust me. Let's say bipolar 1. Yeah. Okay. So that would be one mental disease, correct? Correct. And it's pretty serious stuff, right? Yes. And if a person is diagnosed as bipolar, one of the things that you shouldn't, if you know, is prescribed SSRIs, such as Prozac or Zoloft, right? If you know. I'm not sure of that. Okay. Would you agree that with various cases dealing with postpartum depression, all of the symptoms that we talked about, they utilize the Edinburgh postnatal depression scale, which is a 10-item questionnaire that can identify women that have postpartum depression and the severity that they have. And on the scale, the score of 12 or greater raises concern and indicates a need for more thorough evaluation, right? Correct. Do you know whether she was thoroughly evaluated by anybody other than Tufts and Gelata? I'm only aware of Tufts and Gelata. Okay. I mean, you were trying to do the best you could with what you had to work with, right? Correct. Okay. Now we get to postpartum psychosis. That's the third category, right? Postpartum psychosis, you'd agree, is the most severe form of postpartum psychiatric illness. Is that right? Correct. Would you agree that it occurs in averages about two out of a thousand women, right? Correct. And its presentation can be very dramatic with onset of symptoms, and that can be within a year, according to the CDC, Center for Disease Control, right? Okay. And when it hits you, it just hits you. Bang. Quick. Right? Correct. And when you think about two out of a thousand people, it seems like a daunting number, but if I tell you that Fenway Park, when they're full, when they're playing the Yankees, they have 37,700 people. If you take the 37,000 people and you multiply it by two, that would mean as you're sitting there behind first base, 74 women possibly have postpartum psychosis, right? Not sure of that number, but... Well, if you agree that it's two out of a thousand, according to the studies and the statistics, and if Fenway Park has 37,000 seats, times two would be 74. Okay. That's a pretty large number of people, right? 74 people out of that crowd? Okay. It's not that horribly unusual. I mean, it's something that perhaps you've dealt with in your practice, right? Yes. And when you're dealing with people with postpartum psychosis, do you agree that generally they present with an episode of bipolar illness? If you know. No. No, they don't? Or no, you don't know? No, I don't know. Okay. Bottom line is, from your dealing with Lindsay, she appeared to be sincere, right? Correct. She appeared to be looking for help, right? Correct. She appeared to be hurting, right? Yes. Turning in every direction she could for help, right? Correct. And the last time you saw her was when? December 19th. Okay. Thank you very much. [01:21:56] Speaker 1: 3D Bucky. [01:21:57] Speaker 2: Briefly, please. Ms. Dukes, you indicated that you didn't review the records of Nurse Paul or Nurse Gelata. Correct. Why? [01:22:13] D-U-K-E-S: I wanted to have a fresh set of eyes to look at the situation and to assess it when she came in for her visit. That's typical practice. [01:22:21] Speaker 2: And that's why you do an entirely new process, right? Where you do your own intake, you assess diagnostics for determining whether there's any sort of mental illness, right? Correct. And while you can collaborate or speak with the providers about an overall treatment for the patient, your therapy is your therapy. Correct. And as far as your role, you don't have any role in medication management, do you? [01:22:51] D-U-K-E-S: No, I don't. Okay. [01:22:53] Speaker 2: And so when the note read current medications, is that just based on what pre-fills for the patient, based on their historical records for the clinic? [01:23:04] D-U-K-E-S: Yes. [01:23:04] Speaker 2: And so you don't know what she was prescribed and when and if all of those prescriptions were active. You just know what's in the computer. Correct. And as far as the timeline here for the recommendations for partial hospitalization, I just want to make sure that we're clear. You had been, for some time, recommending some sort of partial hospitalization program, correct? Correct. And on December 12th, you had already talked to Lindsay Clancy about the Women and Infants program, had you not? Correct. And so when she told you on the 12th that she was starting that program in Norwell, that wasn't from your referral, right? [01:23:51] D-U-K-E-S: No. [01:23:52] Speaker 2: And you still recommended Women and Infants? Correct. And you got her consent on that visit, right? [01:23:58] D-U-K-E-S: Yes. [01:23:59] Speaker 2: And on the 19th, when you saw her, were you aware that she had been at the Mass General ER on December 15th for evaluation? [01:24:07] D-U-K-E-S: No. [01:24:07] Speaker 2: And that she had reported then to them that she opted for an outpatient program at Women and Infants as opposed to going inpatient to McLean? Did you know that? [01:24:16] D-U-K-E-S: I wasn't aware of that. [01:24:18] Speaker 2: And when you met with her on the 19th, after the visit to the ER, she still hadn't engaged with Women and Infants, had she? [01:24:26] D-U-K-E-S: No. [01:24:26] Speaker 2: And so you had to re-refer her? Yes. But you weren't aware that she had already gotten a referral from Mass General? [01:24:34] D-U-K-E-S: No. [01:24:34] Speaker 2: And so you did later learn she went on December 20th, correct? Correct. Were you able to review those records about this visit to the 20th? So you don't know that the ultimate plan and assessment for her was that they didn't think she qualified for the program, but they provided her with several options for other inpatient treatments for medication management, partial hospitalization, and general mental health. Did you know that? [01:25:11] D-U-K-E-S: No. [01:25:14] Speaker 2: And as of your last meeting with her on December 19th, ultimately, what were your impressions of how she was doing? [01:25:25] D-U-K-E-S: My impression was that her symptoms were improving because of the social aspects, spending time with family and friends and able to exercise when before it was difficult for her to engage or pay attention. [01:25:40] Speaker 2: And your observations of her while you were interacting with her, were they more positive than on previous occasions? [01:25:47] D-U-K-E-S: Yes. She was able to smile and laugh. Okay. [01:25:50] Speaker 2: Thank you. [01:25:52] Speaker 4: What were you laughing about? When was it she was laughing with you? I believe that was the last visit, the 19th. So on the 19th, it was on television or was it in person? It was a virtual visit, a video visit. A virtual visit. Yes. And on the 19th, on the virtual visit, what was the purpose of that visit? [01:26:13] D-U-K-E-S: The purpose of that visit was to see if she was able to connect with care. [01:26:17] Speaker 4: Okay. So you would have, I guess, in your notes or a reference to the fact that on the 19th of December, that she was laughing. Not that she was laughing, but that she was able to laugh. Able to laugh. Okay, because I'm looking here on December 19th, telemedicine, Latisha, I apologize, Dukes, perinatal behavior health program. And you talk in that form about the date of the service, December 19th, psychotherapy, PCP, Margaret, that would be the primary care, Margaret Anastasi. Perinatal behavioral health program, you talk with the quote, if this is telehealth visit, please dot the phrase, video visit, whatever. Therapeutic intervention, she's 32 years old, married female, presents for postpartum anxiety. Symptom management, patient continues to have low mood and numbness. Numbness? Was she laughing when she had numbness? What date are you looking at? December 19th, the last day you saw her, or the last time you had any contact with her. She didn't appear to have that, no. She didn't appear to have what, laughing or numbness? Numbness. Well, it says right in the notes, does it not, that patient continues to have low mood and numbness? Yes. Okay. I don't want you to say yes unless I'm sure I want you to be so. Patient continues to have low mood and numbness, right? Correct. Patient has not had suicidal ideation and did not need crisis intervention over the weekend. In other words, she didn't kill herself, right? Correct. To help with the mood, patient has been spending time with her husband, children, and exercising, right? [01:28:08] D-U-K-E-S: Yes. [01:28:09] Speaker 4: And exercise is one of the things that you would generally, your people would generally recommend that the mother do, right? Correct. That's a good thing to try to do is to exercise, right? Correct. So if the fact that the government has records that show that she would take her kids or her husband would take her kids or they would go to a local gym and exercise or swim, that's consistent with what she was advised, right? [01:28:34] D-U-K-E-S: Correct. [01:28:34] Speaker 4: It doesn't mean that she's just out there having a good time exercising, right? Objection. She was told that that's a good thing to do, right? [01:28:47] D-U-K-E-S: She was told that that was a good thing to do, but the fact that she's able to follow through and do it shows improvement. [01:28:53] Speaker 4: Oh, okay. So when did she go to the gym? [01:28:56] D-U-K-E-S: She didn't give me exact dates. These are things that she told me she did. [01:29:00] Speaker 4: Did you ever ask her? If you're telling me that this is showing improvement, is it in the records? Does it indicate that you asked her if she was exercising? And if so, where and when? [01:29:09] D-U-K-E-S: So we don't write down everything that we talk about in the meeting. It's particularly a summary of that visit. [01:29:16] Speaker 4: Okay. And all I did was ask you about the patient was spending time with her husband, children, and exercising, and then you said that that's an indication that she's improving. [01:29:27] D-U-K-E-S: Correct. [01:29:28] Speaker ?: Okay. [01:29:29] Speaker 4: And then I asked you if she's going to a gym. That's not a bad thing, is it? [01:29:33] D-U-K-E-S: No, it's not. [01:29:33] Speaker 4: Okay. And then it says that she received a call, and counsel asked you about this. She received a call from women and infants but missed the call. Do you remember that? Remember the DA asking you that question? You said that she missed the call? Yes. She didn't continue to read that the reason she missed the call is that she was at another medical appointment, right? [01:30:00] D-U-K-E-S: Correct. [01:30:00] Speaker 4: And she called you back, right? Yeah. Okay. Clinician, that'd be you, provided contact information for women and infants. Patient reported that she would contact them today, being December 19th, but in fact, she did, and you did with, she, back it up. She did with your help, and she then went the following day on the 20th, right? Correct. [01:30:24] Speaker ?: Okay. [01:30:25] Speaker 4: And finally, fair to say that nowhere in here does it say that she was laughing? [01:30:33] D-U-K-E-S: You would have to go to the assessment, the risk assessment. [01:30:38] Speaker 4: Okay. Let's do that. You got it? [01:30:43] Speaker ?: Yes. [01:30:43] Speaker 4: Let me see, please. Okay. Now, what's a mental status exam? [01:30:56] D-U-K-E-S: So, a mental status exam is to assess how the person is appearing that day, their mood, and their interaction with you in that visit, and how you perceive them. [01:31:07] Speaker 4: Okay. So, with the help from the DA, we have December 19th, the telemedicine form, clinical notes, right? Yes. The laughing wouldn't be in that area, would it? [01:31:27] D-U-K-E-S: No, it would be more so in this area. Okay. [01:31:29] Speaker 4: Yes. Mental status exam, right? Appearance, hygiene, WNL. [01:31:33] D-U-K-E-S: Within normal limits. [01:31:35] Speaker 4: Okay. Clothing normal, eye contact normal, build normal, posture normal, body movement normal, right? Yes. Behavior is cooperative, right? [01:31:45] D-U-K-E-S: Yes. [01:31:46] Speaker 4: And speech is within normal limits, is that correct? [01:31:48] D-U-K-E-S: Correct. [01:31:50] Speaker 4: Emotional state, affect, patient reports feeling numb and having low mood for most of the day, right? [01:31:58] D-U-K-E-S: Yes. [01:31:59] Speaker 4: Facial expression, other, facial expression, calm, was able to laugh and smile, right? [01:32:06] D-U-K-E-S: Yes. [01:32:07] Speaker 4: Would that be in response to you saying something funny, or why was she laughing? [01:32:11] D-U-K-E-S: That would be in response to me saying something funny. [01:32:13] Speaker 4: So you guys were kind of bonding a little bit. Yes. All right. But she basically still continued to report that she was numb, having low mood, and basically the symptomology that she had already reported, right? [01:32:25] D-U-K-E-S: Correct. [01:32:28] Speaker 4: Okay. Thank you, ma'am. I appreciate it. [01:32:31] Speaker 1: All right. Comal? [01:32:32] Speaker ?: Nothing's right. [01:32:32] Speaker 1: Thank you. All right. Thank you. Thank you. You may step down. Thank you. [01:32:35] Speaker ?: Thank you. Thank you.