About this transcript: This is a full AI-generated transcript of Lindsay Clancy FULL Trial: Psychiatrist Dr. Tufts & Nurse Testify on Mental Health Struggles — AB1E from DWS News and DRM News, published August 13, 2026. The transcript contains 27,906 words with timestamps and was generated using Whisper AI.
"trying to think of, or maybe it feels like, you know, maybe you're thinking of things a little 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. If we could..."
[00:00:00] Speaker 1: trying to think of, or maybe it feels like, you know, maybe you're thinking of things a little bit more slowly than you normally would.
[00:00:10] Speaker 2: And how often was she dwelling on suicide?
[00:00:16] Speaker 1: At what point?
[00:00:18] Speaker 2: At the point she told you that she had anxiety, insomnia, brain fog, crying inconsolably.
[00:00:28] Speaker 3: If we could have a date.
[00:00:30] Speaker 2: I think she's going to get to that. 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?
[00:00:56] Speaker 1: It was mentioned at some point.
[00:00:58] Speaker ?: Okay.
[00:00:58] Speaker 1: I don't see that on the 26th specifically.
[00:01:01] Speaker 2: All right. 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. 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? Yes. So what were the symptoms? 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 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?
[00:02:34] Speaker 3: Objection. If you could just have a date.
[00:02:35] Speaker 2: 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?
[00:02:42] Speaker 2: Because there were, I'm sorry. She already objected. He already said you can answer it. When did you increase her Ativan, and to what level?
[00:02:52] Speaker 1: 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?
[00:03:15] Speaker 1: Yes.
[00:03:16] Speaker 2: 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. I'm sorry.
[00:03:35] Speaker 2: How was she on the 31st? Halloween, how was she?
[00:03:39] Speaker 1: That's not my note. That's her therapy note.
[00:03:41] Speaker 2: Okay. So how about this November 2nd? Was that the next time you saw her?
[00:03:46] Speaker 1: I saw her on November 2nd.
[00:03:48] Speaker 2: And she told you that she was hesitant to use the medications, the buspar and the hydroxazine, right?
[00:03:56] Speaker 1: She said she was hesitant to try the buspar.
[00:03:58] Speaker 2: She was scared of the drugs, right?
[00:04:03] Speaker 1: She was afraid to take a medication.
[00:04:04] Speaker 2: 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 busparone.
[00:04:22] Speaker 2: Did you advise her or counsel her or give her therapy about that? Validations?
[00:04:28] Speaker 1: Yes.
[00:04:30] Speaker 2: And what did you tell her?
[00:04:32] Speaker 1: Well, I advised her of, you know, the risks.
[00:04:38] Speaker 2: What were the risks?
[00:04:40] Speaker 1: Well, the risks of medicine, like we had said, sedation or dizziness.
[00:04:47] Speaker 2: Okay. How about interfering with sleep?
[00:04:51] Speaker 1: Busparone doesn't usually interfere with sleep.
[00:04:53] Speaker 2: Not usually? Did you ask her about any thoughts of suicide or being close to having thoughts of suicide?
[00:05:00] Speaker 1: Yes.
[00:05:02] Speaker 2: Did she indicate to you that she had any thoughts of suicide at all?
[00:05:07] Speaker 1: Not at that date.
[00:05:08] Speaker 2: 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 yourself.
[00:05:21] Speaker 2: 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 suicide?
[00:05:44] Speaker 1: You mean in the, in the prior appointment?
[00:05:47] Speaker 2: I'm talking about a woman that's sitting in front of 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.
[00:05:59] Speaker 2: Okay. When was the next time that she told you that she was worried about or thinking about or suicidal ideation?
[00:06:17] Speaker 1: Um, that was the December 1st visit.
[00:06:20] Speaker 2: 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?
[00:06:41] Speaker 1: Um, I see the word alternatives, not safe for alternatives.
[00:06:49] Speaker 2: Do you remember talking to her about Remeron? Yes. Did you recommend that she take Remeron?
[00:06:55] Speaker 1: No.
[00:06:57] Speaker 2: 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. And you did not feel that that would be an appropriate medication for her to take at that time?
[00:07:16] Speaker 1: It was a very reasonable option, but we didn't decide to start it.
[00:07:20] Speaker 2: 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. And I'm not there to ensure that that is happening or not.
[00:07:47] Speaker 2: So, you had a November 22nd appointment, right? Yes. And it was at that time that she told you that she had been to see South Shore Perinatal Clinic, right?
[00:08:08] Speaker 1: Yes.
[00:08:08] Speaker 2: And did she tell you why she was seeing someone from the South Shore Perinatal Clinic?
[00:08:15] Speaker 1: I think she told me that it was because they were exclusively focused on treating perinatal conditions.
[00:08:25] Speaker 2: Yeah, but so were you, right?
[00:08:26] Speaker 1: Not exclusively, I'm a general psychiatrist. I see.
[00:08:31] Speaker 2: And did she mention the name of any doctor or nurse practitioner that she was seeing at the South Shore Perinatal Clinic?
[00:08:38] Speaker 1: Yes.
[00:08:38] Speaker 2: Who did she mention?
[00:08:41] Speaker 1: I think she said something about Julie.
[00:08:46] Speaker 2: Paul? Yes. Okay. And a woman by the name of Nurse Gelata?
[00:08:51] Speaker 1: Um, I heard her name a little bit later, but yes.
[00:08:56] Speaker 2: Um, did she advise that in fact, by script, she was using Ativan and Benadryl. Um, and you told her to taper off the Ativan at that appointment, right? Had she tapered off the Ativan?
[00:09:14] Speaker 1: Um, I, I think I told her to, I gave her a prescribed taper prior to that appointment.
[00:09:23] Speaker 2: What does that mean? What does that mean you gave her a prescribed taper?
[00:09:28] Speaker 1: So I, I told her that she should reduce her dose by 0.25 milligrams every two weeks until the medication was stopped.
[00:09:39] Speaker 2: Did she do that?
[00:09:41] Speaker 1: Um, I mean, I, I don't believe that she completely stopped it, no.
[00:09:45] Speaker 2: No? You don't believe or she didn't? Well... Trying to give the jury facts.
[00:09:50] Speaker 1: Yeah, she said she was taking Ativan, so, so no, she didn't completely stop it.
[00:09:55] Speaker 2: Had she tapered?
[00:09:57] Speaker 1: Um, I'm not sure how much she had reduced the dose, because I wasn't prescribing it again.
[00:10:03] Speaker 2: Right. So, 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?
[00:10:17] Speaker 1: I know she went to the ER, sorry ER, but I, I think it was after that.
[00:10:22] Speaker 2: Okay, which ER did she go to, do you know?
[00:10:25] Speaker 1: Um, I think she went to Mass General.
[00:10:29] Speaker 2: Do you know why she went to the ER?
[00:10:31] Speaker 1: Um, because of depression.
[00:10:35] Speaker 2: So, was she treated at the ER? Did they make any, to your knowledge, as her doctor, make any recommendations?
[00:10:42] Speaker 1: I'm not sure what they told her, but they ultimately, Go ahead.
[00:10:46] Speaker ?: Go ahead.
[00:10:46] Speaker 1: They ultimately discharged her. They didn't admit her.
[00:10:49] Speaker 2: Go ahead.
[00:10:50] Speaker ?: Go ahead.
[00:10:51] Speaker 1: Sorry.
[00:10:51] Speaker 2: I'm sorry. Um, was she put on any medication?
[00:10:57] Speaker 1: Not from the ER.
[00:10:58] Speaker 2: 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?
[00:11:12] Speaker 1: I didn't have access to those records.
[00:11:16] Speaker 2: You're going to keep your voice up so everybody can hear you. You're what?
[00:11:19] Speaker 1: I did not have access to those records. Why not? Because we're a completely separate clinic.
[00:11:27] Speaker 2: Seriously?
[00:11:28] Speaker ?: Objection.
[00:11:28] 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?
[00:11:36] Speaker 1: I did not have access to them, no.
[00:11:38] Speaker 2: Could she have signed a release, a HIPAA form?
[00:11:43] Speaker 1: Yes, she could have.
[00:11:44] Speaker 2: And you could have got the records?
[00:11:47] Speaker 1: Yes.
[00:11:48] Speaker 2: But you didn't?
[00:11:48] Speaker 1: I did not feel like it was necessary because she provided all the relevant information about her treatment there.
[00:11:56] Speaker 2: How do you know? She's got a mental disease and she's seeing you and she's on all this cocktail of drugs. How do you know that she is an accurate historian at this point in her life?
[00:12:11] Speaker 1: 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 was capable of doing that.
[00:12:29] Speaker 2: So when you talked to her husband, Pat, how many times did you talk to her husband, Pat? I think I was living with her.
[00:12:38] Speaker 1: I think it was once.
[00:12:39] Speaker 2: 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?
[00:12:52] Speaker 1: I think it was the December 16th visit.
[00:12:56] Speaker 4: So what's Reddington? Before we get to that, probably a good spot to stop. We're going to take the morning recess and then we'll come right back, okay?
[00:13:07] Speaker 2: Court, all rise. Sure. Here's the cold, here's the old boots facing on your chest. Next way, please.
[00:13:29] Speaker ?: Court, all rise.
[00:13:50] Speaker 2: Court, all rise. George Andrews. This court is now in session. Please be seated.
[00:14:22] Speaker 5: 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.
[00:14:31] Speaker 4: All right. Thank you. Mr. Regan.
[00:14:35] 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 . Where you have, I believe, interval history.
[00:14:50] Speaker ?: Can you repeat that?
[00:14:52] Speaker 2: Sure. October 20th? Sorry.
[00:14:59] Speaker ?: Okay.
[00:15:00] Speaker 2: So, looking at the interview history, that's when that you decided to start Zoloft. It says a week ago, right?
[00:15:07] Speaker 6: That's when the patient started, I guess.
[00:15:11] 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?
[00:15:26] Speaker ?: That she felt awful?
[00:15:30] Speaker 6: That she felt awful. She couldn't sleep.
[00:15:34] Speaker 1: 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.
[00:15:53] Speaker 6: She had some mental fog and was terrified to start something new.
[00:15:59] Speaker 2: Did she also tell you about her anxiety level?
[00:16:02] Speaker 6: 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.
[00:16:23] Speaker 2: That must have given you concern that you had a pretty sick patient on your hands at that point, right?
[00:16:29] Speaker 6: I was concerned, yes.
[00:16:32] Speaker 2: So you gave her some therapy, did you?
[00:16:36] Speaker 6: I gave her some therapy in conjunction with discussing all of her symptoms and assessing her and managing my patient.
[00:16:44] Speaker 2: 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 had just gone over? The symptoms?
[00:16:59] Speaker 1: There were a number of them to discuss in more detail. That's the summary of them.
[00:17:05] Speaker 2: Okay. So did she discuss it in detail?
[00:17:09] Speaker 1: Yes.
[00:17:10] Speaker 2: Did she tell you that her symptomology at this point on October 20th was so bad that she had to have her mother come and stay with her?
[00:17:21] Speaker 6: Her mom was coming to provide support, yes.
[00:17:24] Speaker 2: She wasn't coming to provide support. She was coming to stay with them, to live with them, wasn't she?
[00:17:33] Speaker 1: Yes. I don't know for how long, but yes.
[00:17:35] Speaker 2: Did you bother to ask her? Why is her mother having to stay with them?
[00:17:39] Speaker 6: Because she needed some help.
[00:17:43] Speaker 2: Do you know how long her mother stayed with her?
[00:17:45] Speaker 6: I don't.
[00:17:46] Speaker 2: Do you know that she ended up sleeping in the basement?
[00:17:49] Speaker 6: I don't.
[00:17:51] Speaker 2: Do you know that she ended up sleeping with her mother?
[00:17:55] Speaker 6: I don't.
[00:17:57] 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?
[00:18:04] Speaker 1: Well, I saw her the next day, so that's monitoring an example of monitoring closely.
[00:18:10] Speaker 2: So, this would be on October 21st that you saw her the next day, is that correct? Yes. Now, on the 20th, you made reference to the fact that you also recommended that she try fish oil and things of that nature, natural remedies? Yes.
[00:18:29] Speaker 6: Okay.
[00:18:30] Speaker 2: You also wanted to look into what's called Zulreso, Z-U-L-R-E-S-S-O? Yes. What's Zulreso?
[00:18:38] Speaker 1: It is a treatment for postpartum depression.
[00:18:43] 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?
[00:18:51] 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.
[00:19:08] Speaker 2: It's not a what?
[00:19:09] Speaker 1: I'm sorry. Sorry. It's not a medication I could start on my own. It's infused through an IV in a hospital, so it's a bit difficult to coordinate.
[00:19:22] Speaker 2: It's a 60-hour infusion, right?
[00:19:26] Speaker 1: It's a long infusion, that sounds right.
[00:19:28] Speaker 2: And it's about two and a half days of infusion and it has to be under hospital circumstances. The only hospital around here is in Rhode Island, right? Yes. And did you ever recommend that she do that?
[00:19:42] Speaker 1: It was something to consider. I couldn't make the official recommendation because that's not something I prescribed.
[00:19:50] Speaker 2: Why?
[00:19:51] Speaker 1: Because you can't make that up at the pharmacy. Well, no.
[00:19:57] Speaker 2: Obviously, you have to go to a hospital setting and basically have an infusion through your veins of 60 hours or 2.5 days, but why didn't you look into it or recommend that she do that?
[00:20:10] Speaker 1: Well, I did look into it.
[00:20:12] Speaker 2: So what happened?
[00:20:14] Speaker 1: She ended up actually going to a partial hospitalization program at the hospital that does it. I don't believe the program is completed, but she went. And I advised her to discuss it with them because they have access to that medicine. I don't have access to it.
[00:20:36] Speaker 2: Question. Is this Women and Infants Hospital in Rhode Island that you're talking about?
[00:20:41] Speaker ?: Yes.
[00:20:42] Speaker 2: Question. So when you looked at the medical records for Women and Infants Hospital, did they make reference to your inquiry for Zorosa?
[00:20:49] Speaker 6: I never received records from women and infants.
[00:20:53] Speaker 2: Question. Did you ever look at them or even online?
[00:20:56] Speaker 1: Online?
[00:20:57] Speaker 2: Yeah, online. Like you do when you talk to patients. No.
[00:21:01] Speaker 1: I never had access to them.
[00:21:03] Speaker 2: Why?
[00:21:04] Speaker 6: It's similar to South Shore. It's a completely separate hospital that I don't have access to. I don't work there. Well, of course you don't work there.
[00:21:13] Speaker 2: You're a doctor and you're treating a patient with medical records that you could access through a HIPAA release, right? Yes. Why didn't you do that?
[00:21:27] Speaker 1: Well, she didn't ultimately 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 Zorosa.
[00:21:38] Speaker ?: Can you? I don't exactly know how it works.
[00:21:38] Speaker 2: I don't exactly know how it works. Okay. And then again, on that date, which would be October 20 when the jurors are looking at the records. You check out the records. You checked off the, uh, the, uh, the, uh, the records.
[00:21:43] Speaker ?: And then again, on that date, which would be October 20 when the jurors are looking at the records.
[00:21:43] Speaker 2: You, you checked off the, uh, the, uh, the boxes. You checked off the, uh, the boxes. Again, you can't just walk into that place and say, hey, I'd like some Zorosa. Can you? I don't exactly know how it works.
[00:21:50] Speaker 1: And then again, on that date, which would be October 20 when the jurors are looking at the records.
[00:21:51] Speaker ?: You, you, you checked off the, uh, the boxes again on objective findings, mental status exam, appearance, speech, things of that nature.
[00:21:51] Speaker 1: Correct? Yes.
[00:21:53] Speaker 6: Okay.
[00:21:54] Speaker 2: And then again, on that date, which would be October 20 when the jurors are looking at the records. You, you checked off the, uh, the boxes again on objective findings, mental status exam, appearance, speech, things of that nature. Correct?
[00:22:21] Speaker ?: Yes. Excuse me for one minute. Do I have to do this? Do I have to do this? Okay. Okay. Okay. Okay. Okay. Okay. Okay. Okay.
[00:22:32] Speaker 2: Okay. So, when she was telling you on that date that she was parent in, in, in court, in your records, paranoid of getting suicidal thoughts and something bad happening, doesn't want to be alone. What did she mean by that?
[00:23:02] Speaker 6: Well, those were a lot of, a lot of her words.
[00:23:04] 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?
[00:23:11] Speaker 1: Because she was very anxious and had the feeling like something bad might happen.
[00:23:20] Speaker 2: Okay. Did her mother ultimately and dad come to stay with them? Yes. 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?
[00:23:37] Speaker 6: They never called my office, so I never spoke with them.
[00:23:42] Speaker 2: They, they never called your office?
[00:23:45] Speaker 1: They never called me or sent a message, so I did not have communication with them.
[00:23:51] Speaker 2: Well, it's their fault that they didn't call you, the doctor, or that's right. So, do you think maybe it would be reasonable if you're the doctor and you're investigating your patient's symptomology that you might, when you know that the parents are staying with her, that you would make a phone call yourself?
[00:24:10] Speaker 6: It's not typical when you have an adult who is able to advocate for themselves to speak with their parents.
[00:24:17] 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? Yes. Okay, on the television, on the computer.
[00:24:36] Speaker ?: Yes.
[00:24:37] Speaker 2: The next time you saw her was on October 26th, is that correct? And you can pull up your record. Yes. 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?
[00:25:08] Speaker ?: Yes.
[00:25:09] Speaker 2: And then you started her on Ativan, as we talked about, right? Yes. And then you started her on the Buspirone, right?
[00:25:18] Speaker 1: Well, she had already been served on the Ativan and then added the Buspirone.
[00:25:23] Speaker 2: So my question was, you started her on Buspirone, right? Yes. Okay. And also you added Hydroxylene as needed, right? Yes. And you continued the Ativan, correct? Yes. Did you discuss side effects with her at that point? Yes.
[00:25:43] Speaker 6: Yes.
[00:25:44] Speaker 2: Did you also discuss starting Remeron or Pregabalin? Yes. What did you tell her about Remeron and Pregabalin?
[00:25:55] Speaker 6: I don't think I went into any detail about those medicines, just that those might be things to consider in the future.
[00:26:06] Speaker 2: And then you saw her on October 31st, right?
[00:26:15] Speaker ?: That was her.
[00:26:17] Speaker 1: I think that was just a therapy appointment with a different provider.
[00:26:24] Speaker 2: Would that be Jennifer McAllister? Yes. So it's a different provider in the sense that she works for ASCA, right? Well, yes.
[00:26:34] Speaker 6: It just wasn't myself. Right.
[00:26:36] Speaker 2: So on October 31st, they did a suicide assessment, or she did, right, McAllister? I wasn't there. 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.
[00:26:53] Speaker ?: Objection.
[00:26:54] Speaker 3: Objection. Is that a question?
[00:26:56] Speaker ?: No. Good.
[00:26:58] Speaker 2: Next question. McAllister did a suicide assessment, apparently, right?
[00:27:06] Speaker 6: I'm sure she assessed her suicide.
[00:27:07] Speaker 2: No, no, no. Look at the record, please.
[00:27:09] Speaker 6: Where do you see it? Sorry.
[00:27:11] 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.
[00:27:21] 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.
[00:27:31] 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? I wasn't there.
[00:27:54] Speaker 1: You would have to ask her.
[00:27:56] Speaker 2: Well, maybe I will if she comes in. Okay. Why don't you tell me what the record shows?
[00:28:02] Speaker ?: Did they do a suicide assessment? Did you check off the little boxes? I'm looking for that section.
[00:28:05] Speaker 6: It says a patient denies suicidal or homicidal ideation at this time. Okay.
[00:28:24] Speaker 2: So again, this is on October 31st, right? Yes. 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?
[00:28:41] Speaker 6: It's not my business to be this.
[00:28:44] Speaker 2: Has reported suicidal ideation and fear and dwelling about killing herself and afraid of those thoughts, right?
[00:28:53] Speaker ?: I just wanted the absolutely clear. So yes, you know what? Yes, the answer is yes. Yes, the answer is yes. Yes, the answer is yes. She had voiced those concerns. Right. So as a result of voicing those concerns, is it your understanding that McAllister did not
[00:29:04] Speaker 2: do any of the suicide assessment questions, because Lindsay reported that he did not do any of the suicide assessment questions?
[00:29:17] Speaker 6: Because Lindsay reported that she wasn't suicidal?
[00:29:18] Speaker ?: It appears that she asked about suicide.
[00:29:18] Speaker 6: Right.
[00:29:19] Speaker 2: You already told us that. Excuse me. Hold on. Thank you. Hold on.
[00:29:24] Speaker ?: Thank you.
[00:29:24] Speaker 2: I'm not asking you. You told us three times now that she said she was not suicidal when she spoke to McAllister. I'm asking you about the suicide assessment. I'm asking you about the suicide assessment. And I'm asking you about the suicide assessment, because Lindsay reported that she wasn't suicidal. It appears that she asked about suicide. You already told us that. I'm asking you about the suicide assessment.
[00:29:36] Speaker ?: Excuse me.
[00:29:37] Speaker 6: Hold on. Answer this question. Thank you.
[00:29:40] Speaker 2: I'm not asking you. You told us three times now that she said 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? Yes.
[00:30:00] Speaker ?: Okay.
[00:30:01] Speaker 2: 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.
[00:30:17] Speaker 1: I don't see anything written here.
[00:30:21] Speaker 2: So was there a suicide assessment?
[00:30:24] Speaker 6: I don't know, because it wasn't there. I don't know what the conversation was.
[00:30:28] Speaker 2: And you don't know from looking at the records, right?
[00:30:31] Speaker 1: From looking at the records, I don't see evidence of additional suicidal questions beyond asking if it was there or not.
[00:30:42] 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? The four pages, right? Yes. And there is not one notation indicating that that test was ever administered to her on October 31st. Correct?
[00:31:21] Speaker ?: It looks like it was asked in other ways.
[00:31:26] Speaker 2: Okay. November 2nd. Oh. It was asked in other ways? Is that what the little check box where it says, deny suicidal ideation? Can I read something that she said? You have indicated repeatedly that she denied suicidal ideation, right? Yes. Okay.
[00:31:43] Speaker ?: Okay.
[00:31:44] Speaker 2: The suicidal assessment was not administered according to the record that's in front of you by McAllister. Yes?
[00:31:52] Speaker 6: The additional suicidal assessment, yes. November 2nd.
[00:31:57] Speaker 2: By the way, as a psychiatrist, not a psychologist, you had the ability to prescribe medication obviously, right? Yes. And that's what we 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? Yes. 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. Okay. Keep your voice up. Okay. What does metabolism mean?
[00:32:41] Speaker 1: The body breaking down the medication.
[00:32:46] 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?
[00:33:05] Speaker 6: We don't typically have any specific testing that we do to understand that. How about a blood test?
[00:33:14] Speaker 2: It's not done for that. It's not done for that. Meaning a blood test is not done to determine the metabolism of your patient, of your medications? Are you referring to genetic testing?
[00:33:30] Speaker ?: No, I'm asking about the metabolism.
[00:33:31] Speaker 6: I'm not talking about genetics.
[00:33:32] Speaker 2: I'm talking about the metabolism of the SSRIs in our body.
[00:33:41] Speaker ?: Okay.
[00:33:42] Speaker 2: You can tell that metabolism rate through blood testing, right?
[00:33:46] Speaker 6: Not in the way that you're describing. Okay.
[00:33:49] Speaker 2: What way would it be?
[00:33:50] Speaker 1: There is genetic testing that can give information about metabolism. Like what? 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.
[00:34:29] Speaker 2: Okay. So it provides the enzymes that a person might have the genes for. Forgive me. I'm having difficulty with that. What does that mean?
[00:34:38] Speaker 6: It's a little complicated.
[00:34:39] Speaker 2: Yeah. You don't expect a patient that's going through what she was going through to understand that, would you? No. Did you guys do the enzyme test?
[00:34:48] Speaker 1: They are not typically done.
[00:34:50] Speaker 2: Why?
[00:34:51] Speaker 1: Because, again, it's genetics. Does insurance cover it?
[00:34:57] Speaker ?: It's just in the middle of answering. Okay.
[00:35:01] Speaker 4: You can say it's a lot of follow-up.
[00:35:03] Speaker 1: Okay. So it's not as simple as testing your 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.
[00:35:31] Speaker 2: What is the, sorry, what is the Cytopro P4-50 system?
[00:35:37] Speaker 6: That's one of the enzymes that I'm talking about.
[00:35:40] 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 is that it's a test. Again, what is that?
[00:35:56] Speaker 1: 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 not useful in that way.
[00:36:11] Speaker 2: So what's it useful for?
[00:36:13] Speaker 1: I mean, I don't find it terribly useful.
[00:36:18] Speaker 2: How long has the Cytopro P4-50 system been in use in your field?
[00:36:24] Speaker 6: Sorry?
[00:36:25] Speaker 2: How long has the Cytopro P4-50 system been in use in your field, psychiatry?
[00:36:31] Speaker 1: Well, it's an enzyme in the body.
[00:36:33] Speaker 2: Well, I know what it is. I'm asking you about the system, the testing. How long have they been using that?
[00:36:39] Speaker 6: The genetic testing? Yeah, whatever it is. It's very new. Very new.
[00:36:46] Speaker 2: Does insurance cover it?
[00:36:48] Speaker 6: Sometimes. Sometimes.
[00:36:50] Speaker 2: So it is, nevertheless, a legitimate test to determine the breakdown of psychiatric meds in a patient's blood. Correct?
[00:37:02] Speaker 6: It exists, yes.
[00:37:05] Speaker 2: It exists. Well, it exists, but you didn't use it, right?
[00:37:10] Speaker 1: It would not have made a difference.
[00:37:12] Speaker 2: In what? In your opinion? In her treatment. Because you go by the checks in the checkbox and what she self-reports, right? No.
[00:37:20] Speaker 6: Not just the checks and the checkbox. Oh. In any given. Tell me about the thyroid.
[00:37:24] Speaker 2: Tell me about the thyroid. It's an organ in the human body that regulates hormones. And what, if any, import and impact do thyroid levels have in your evaluation of your a woman who is in the thrones of postpartum depression? Good job. What is the purpose of a test to determine the thyroid levels? Well, you can test something like the TSH.
[00:38:03] Speaker ?: Well, I don't know what TSH is.
[00:38:03] Speaker 2: I'm sorry.
[00:38:04] Speaker ?: What is the TSH? Thyroid stimulating hormone.
[00:38:06] Speaker 6: Okay. Thank you. That's something that can be tested typically by maybe a PCP, primary care, or endocrinologist
[00:38:11] Speaker 2: if they have concerns about someone's thyroid function.
[00:38:15] Speaker 1: Were you aware of a study that was a major study that was peer reviewed?
[00:38:16] Speaker ?: What is peer reviewed like in your business?
[00:38:16] Speaker 1: What is peer reviewed like in your business?
[00:38:17] Speaker ?: That it was was reviewed by a doctor?
[00:38:17] Speaker 1: What is peer reviewed like in your business? That it was reviewed by a doctor? What is peer reviewed like in your business? That it was reviewed by other researchers in similar fields.
[00:38:24] Speaker ?: And the report?
[00:38:24] Speaker 1: What is peer reviewed like in your business? That it was reviewed by other researchers in similar fields.
[00:38:30] Speaker 6: And the report or the article or whatever it may be has to be approved by the peers.
[00:38:31] Speaker ?: So, I think that it was a major study that was a major study that was peer reviewed. What is peer reviewed like in your business? That it was reviewed by other researchers in similar fields.
[00:38:33] Speaker 2: And the report or the article or whatever it may be has to be approved by the peers? That it can be published, right? That it can be published, right? That it can be published, right? Right. And the report or the article or whatever it may be has to be approved by the peers that are reviewing it before it can be published, right?
[00:38:40] Speaker ?: Yes.
[00:38:41] Speaker 6: And you would agree with me that in the medical field it's a big deal to have publishing. articles on your resume, right?
[00:38:45] Speaker ?: Yes.
[00:38:45] Speaker 6: And you would agree with me that in the medical field it's a big deal to have publishing articles on your resume, right? Yes. articles on your resume, right?
[00:38:49] Speaker ?: Yes. And how many articles have you published about postpartum?
[00:38:49] Speaker 6: Yes.
[00:38:50] Speaker 2: And you would agree with me that in the medical field it's a big deal to have publishing articles on your resume, right? Yes.
[00:38:55] Speaker ?: And how many articles have you published about postpartum?
[00:38:55] Speaker 2: depression, postpartum psychosis, anything? Um, I have published about postpartum, postpartum, postpartum, postpartum, postpartum psychosis,
[00:38:57] Speaker ?: anything. Um, I have published about postpartum, postpartum, postpartum, postpartum psychosis,
[00:39:02] Speaker 2: postpartum, postpartum psychosis, anything.
[00:39:03] Speaker ?: Um, I have published something but it's not a full article, it's just a small thing.
[00:39:03] Speaker 2: Okay. Are you aware of the postpartum? I have published something but it's not a full article, it's just a small thing. Okay. Are you aware of the postpartum? I have published something.
[00:39:09] Speaker ?: I have published something but it's not a full article, it's just a small thing.
[00:39:09] Speaker 2: Okay. Are you aware of the postpartum psychosis?
[00:39:11] Speaker 1: I have published something, but it's not a full article. It's just a small thing. Okay.
[00:39:29] Speaker 2: Okay. Are you aware of the, uh, Psychiatry Magazine, uh, article dealing with, uh, in 2021 thyroid function and postpartum psychosis, an exploratory study. Have you ever heard of anything about that, let alone read an article about it?
[00:39:50] Speaker ?: No.
[00:39:51] Speaker 2: Are you aware that there are studies that have compared thyroid function between psychosis patients 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?
[00:40:24] Speaker 1: No, I'm not a researcher. I'm a clinician.
[00:40:27] Speaker 2: Have you read any of the articles such as thyroid function and postpartum psychosis? I've read many articles.
[00:40:33] Speaker 1: I've read many articles. There are thousands. I have not read that specific article.
[00:40:37] Speaker 2: Thousands? Thousands of articles on postpartum psychosis and the thyroid?
[00:40:44] Speaker 1: No, not on that specific topic.
[00:40:47] Speaker 2: So when the Aster doctors are treating a person like Lindsay, 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?
[00:41:12] Speaker 1: It does not yield information that would influence treatment. Really?
[00:41:19] Speaker 2: So if there was elevation in the thyroid, that wouldn't impact on your treatment at all, your evaluation, your investigation?
[00:41:27] Speaker 6: Sorry, I thought you had mentioned the cytochrome issue. Are we talking about that one or are we talking about the thyroid?
[00:41:34] Speaker 2: We're talking about the thyroid. Okay. So if there were tests that revealed elevation in the thyroid level, is it your testimony that you wouldn't care?
[00:41:48] Speaker 1: If I somehow found out that a patient had elevated thyroid levels, I would advise them
[00:41:56] Speaker 6: to talk to their primary care or maybe get an endocrinologist to discuss it.
[00:42:04] Speaker 2: Did you ever recommend that Lindsay get an endocrinologist?
[00:42:08] Speaker 6: No. She did not.
[00:42:10] Speaker 2: The answer is no. 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 did not do any blood tests.
[00:42:26] Speaker 6: There was no clinical reason to obtain a blood test. All right.
[00:42:36] Speaker 2: So you continue on with your meetings by the computer, correct? Yes.
[00:42:41] Speaker ?: November 2nd.
[00:42:42] Speaker 2: November 2nd. You can get November 2nd out. You get it? November 22nd?
[00:42:47] Speaker ?: No. It looks like November 2nd.
[00:42:49] Speaker 2: I apologize. That's what I'm looking at.
[00:42:51] Speaker ?: Tufts, Jennifer, MD. Clancy, Lindsay. Follow-up note.
[00:42:54] Speaker 6: November 2nd. Yes.
[00:42:56] Speaker ?: Okay. And you're still diagnosing her with generalized anxiety disorder, GAD, right? Yes.
[00:42:58] Speaker 2: You add in there an adjustment disorder with depressed mood, I guess because of what she had been telling you, right? Yes. Okay. Looking at the psychiatric condition, you note that it's improving. Yes. Okay. Okay. And you're still diagnosing her with generalized anxiety disorder, GAD, right?
[00:43:14] Speaker ?: Yes.
[00:43:15] Speaker 2: You add in there an adjustment disorder with depressed mood, I guess because of what she had been telling you, right?
[00:43:22] Speaker ?: Yes. Okay.
[00:43:24] Speaker 2: Looking at the psychiatric condition, you note that it's improving. Right? Yes. And then you determine that you will decrease the Ativan to 0.75 milligrams for two weeks and then decrease it to 0.5 milligrams for two weeks and consider alternatives for sleep anxiety. Is that correct? Yes. And then you know if she's having urges to harm herself or others, to go to the nearest emergency room and call 911 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 911 if you're feeling suicidal and things of that nature.
[00:44:20] Speaker 6: Well, that's advice that we provide for every single patient.
[00:44:27] Speaker 2: Okay. And then you note that half the encounter was on counseling or coordination of care on November 2nd, right? Yes.
[00:44:36] Speaker ?: That's a typical statement.
[00:44:37] Speaker 6: It's just a part of the documentation that doctors use.
[00:44:44] Speaker 2: Okay. All right. Now on November 2nd, you were suggesting the four drugs that she would stack would be Remeron, Trazodone, Pregavalin, and Hydroxazine, right?
[00:44:57] Speaker 6: Those are just things we were considering. Oh. It wasn't starting all of those medicines.
[00:45:04] Speaker 2: I see. On November 22nd, now that would be almost three weeks later, right? You saw her, right?
[00:45:10] Speaker ?: You saw her, right?
[00:45:10] Speaker 2: 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. And how do you know that? Because the box is checked?
[00:45:31] Speaker 1: It's written in my notes. What does it say? Patient denies SI.
[00:45:36] Speaker 2: Okay. What did you ask her about that?
[00:45:40] Speaker 6: I don't remember the exact words, but I know that I asked about that.
[00:45:44] Speaker 2: Did you ask her about how things were going at home with her mother and father staying there?
[00:45:49] Speaker ?: That, I don't remember.
[00:45:53] Speaker 1: I didn't document how her parents were doing. Okay.
[00:45:57] Speaker 2: 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.
[00:46:05] Speaker ?: If you did, fine.
[00:46:06] Speaker 2: If you didn't, that's fine too. I don't think that I did. Okay.
[00:46:09] Speaker 6: That's all. That's fine.
[00:46:11] Speaker 2: 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?
[00:46:18] Speaker ?: Yes. She disclosed to you that she had been seeing South Shore, right? 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. Right. I mean, what she was telling me.
[00:46:24] Speaker ?: Right.
[00:46:24] Speaker 2: Right. I mean, what she was telling me. Right. And she told you that she was doing the Ativan taper, right? Right. Right. And she told you that she was doing the Ativan taper, right? Right.
[00:46:32] Speaker ?: And she told you that she was doing the Ativan taper, right? Right.
[00:46:34] Speaker 2: And she told you that she was doing the Ativan taper, right? And she told you that she was doing the Ativan taper, right? Well, she said she had tried doing that, but that then she was having more sleep. And she told you that she was doing the Ativan taper, right? Well, she said she had tried doing that, but then she was having more sleep. 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
[00:47:01] Speaker 6: those meds, including Trazodone, right?
[00:47:05] Speaker 2: Well, she said she was 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?
[00:47:18] Speaker 6: Well, the Trazodone she didn't have a problem with. It just didn't seem like it was particularly helpful.
[00:47:25] Speaker 2: Right. Did you prescribe the Trazodone or somebody else?
[00:47:28] Speaker 6: I suppose somebody else.
[00:47:30] Speaker 2: So, do you know what the milligrams were that she was on?
[00:47:33] Speaker 6: It says she tried between 50 and 150 milligrams.
[00:47:37] Speaker 2: All right. Now, did she at some point try Remeron?
[00:47:47] Speaker 6: She said that she did.
[00:47:48] Speaker 2: Did you suggest in your discussions that she try Remeron?
[00:47:54] Speaker 6: No, I did not.
[00:47:56] Speaker 2: Did she indicate to you that she had rebound anxiety and intrusive thoughts, that she was going to die? Do you recall that?
[00:48:04] Speaker 6: Well, she said worse depression and intrusive thoughts. Okay.
[00:48:10] Speaker 2: Did she tell you what the intrusive thoughts were?
[00:48:13] Speaker 6: It was the feeling like I'm going to die.
[00:48:16] 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? Yes. Then she tried, she was on Klonopin, right? Yes. And what is Klonopin?
[00:48:38] Speaker 6: Depends what it has to be.
[00:48:40] Speaker 2: And on December 1st is when she told you, again, that she was close to having suicidal ideation, feeling hopeless. Do you 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, denies suicidal ideation, but, quote, yesterday, close to it, feeling hopeless. Did you give her therapy and validations after she told you that?
[00:49:34] Speaker ?: I did.
[00:49:35] Speaker 2: What did you do? You got a woman that's telling you that she, she's hopeless, she doesn't care if she dies, can't sleep. What did you do to validate on your therapy?
[00:49:47] Speaker 6: I told her that this was something that we could address, that there was hope, that there were treatments, and there are, you know, different types of treatment programs that are more supportive,
[00:50:04] Speaker 1: like partial hospitalization programs, so she knew that she still had options and a reason to hope.
[00:50:12] Speaker 2: Did you ever suggest to her that maybe you ought to come in and see me, rather than talk on the computer?
[00:50:18] Speaker 1: Discussing, talking with her over the video did not seem like an issue. It didn't seem like there was anything that I was missing or that there was any need to see her in person.
[00:50:34] Speaker 2: Now you'd agree with me that in December of 2022, COVID was all done, right?
[00:50:41] Speaker 6: It wasn't completely all done.
[00:50:43] Speaker 2: 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?
[00:50:51] Speaker 6: We were definitely feeling more comfortable about being face to face with people. But I think, you know, it was still something that we thought about.
[00:51:00] Speaker 2: You discussed trying Seraquel with her at that point, right?
[00:51:05] Speaker 6: I didn't really discuss it. She, well, she had told me that that was, that was something that she had discussed with her other provider.
[00:51:19] Speaker 2: So looking at your notes, does it say also discussed trying Seraquel alone tonight? Did your notes say that?
[00:51:33] Speaker 6: It says, yes.
[00:51:35] Speaker 2: What is that?
[00:51:36] Speaker 6: But I wasn't, I wasn't making a recommendation about the Seraquel. It was just a medicine I was providing her more information on.
[00:51:42] Speaker 2: So you were telling her about the Seraquel? Are you providing information?
[00:51:49] Speaker 6: Yes, we were talking about the Seraquel. Right.
[00:51:53] Speaker 2: Why? Because her other provider had recommended that she started. You also discussed with her the possibility of undiagnosed bipolar disorder. Did you not? 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?
[00:52:34] Speaker 1: Does your, excuse me, does your notes say, and I quote, also discussed possibility of undiagnosed bipolar disorder given extreme reaction to SSRIs and insomnia, period.
[00:52:53] Speaker 2: Does it say that? Yes. Those are your notes, right? Yes.
[00:52:58] Speaker 1: The way you were saying it made it sound a little bit different before, but that's exactly what I wrote.
[00:53:02] Speaker 2: I read it directly from your note, right? How did it make it sound different?
[00:53:06] Speaker 1: I don't know. It sounded different the first time you said it than the second.
[00:53:09] Speaker 2: So did she have bipolar? No. Did you make that decision that night? That day?
[00:53:15] Speaker 1: I assessed that with her pretty much every time that I saw her, and she never had mania.
[00:53:24] Speaker 2: What about mood stabilizer like Lamectol? Did you discuss that with her?
[00:53:29] Speaker ?: Yes.
[00:53:30] Speaker 2: What is Lamectol?
[00:53:32] Speaker 1: It's an anticonvulsant, but it's used in treating mood disorders.
[00:53:40] Speaker 2: So, what was the end result of your meeting with her on December 1st? What did you guys do? Were you given any recommendations, advice, anything?
[00:53:50] Speaker 1: Yeah, well, so at this time I was not concerned about her patients, but I was still concerned,
[00:53:57] Speaker 6: not concerned enough that she was in the risk of hurting herself or anybody else given what she said, but we had a plan for her to pursue a partial hospitalization. Where was that? Well, the one that I had recommended was HRI.
[00:54:11] Speaker 2: What is that, HRI?
[00:54:12] Speaker 6: It's a hospital in Brookline. And did she ultimately go to another hospital? She ultimately went to the women and infants hospital for one day.
[00:54:15] Speaker 2: And those are the records that you didn't get, right?
[00:54:16] Speaker 6: Correct. Okay.
[00:54:18] Speaker 2: And you decided that she did not have bipolar disorder because, in your opinion, she did not
[00:54:24] Speaker ?: meet, and I quote, the criteria, right?
[00:54:24] Speaker 1: And that would be the criteria in the DSM, right? Yes. And the DSM, of course, is the Diagnostic Statistical Manual.
[00:54:27] Speaker ?: Yes. And the DSM, of course, is the Diagnostic Statistical Manual.
[00:54:27] Speaker 1: Roman numeral five, I mean, test revision, right?
[00:54:28] Speaker 2: Yes. Is that what you were using back then? The Diagnostic Statistical Manual? Yes. And the DSM, of course, is the Diagnostic Statistical Manual. And the DSM, of course, is the Diagnostic Statistical Manual. Roman numeral five, I mean, test revision, right? Yes. Is that what you were using back then? This thing here, DSM-5, TR, this DSM, right? Yes. Yes. And you decided that she did not have bipolar disorder because, in your opinion, she did not meet, and I quote, the criteria, right? And that would be the criteria in the DSM, right? Yes. And the DSM, of course, is the Diagnostic Statistical Manual.
[00:54:51] Speaker 1: 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.
[00:55:22] Speaker 2: Right. Um, hypomanic bipolar disorder, how many days does that require under the DSM?
[00:55:34] Speaker 1: A hypomanic episode lasts for at least four days.
[00:55:37] Speaker 2: And is that per the DSM?
[00:55:40] Speaker 1: Yes.
[00:55:41] 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?
[00:55:54] Speaker 1: Well, mania is, is seven days. Hypomania is four. Yes.
[00:55:59] Speaker ?: In your records that she indicated that she was really struggling. And it was as a result of that that you recommended that hospital probing, right?
[00:55:59] Speaker 1: Do you agree that she had, in your opinion, a severe mental disturbance at that point that was
[00:56:00] Speaker ?: manifesting itself? Yes. Yes. Do you agree that she had, in your opinion, a severe mental disturbance at that point that was manifesting itself? She had a, in your opinion, a severe mental disturbance at that point that was manifesting itself. She had, in your opinion, a severe mental disturbance at that point that was manifesting itself. She had a, in your opinion, a severe mental disturbance at that point that was manifesting itself. Yes. She had a, in your opinion, a severe mental disturbance at that point that was manifesting itself? She had a, in your opinion, a severe mental disturbance at that point that was manifesting itself. She had a, in your opinion, a severe mental disturbance at that point that was manifesting itself. She had a, in your opinion, a severe mental disturbance at that point that was manifesting itself. She had a, in your opinion, a severe mental disturbance at that point that was manifesting itself. Yes.
[00:56:09] Speaker 2: She had a, in your opinion, a severe mental disturbance at that point that was manifesting itself.
[00:56:31] Speaker 1: She had a, maybe moderate, moderate heading towards severe.
[00:56:36] 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?
[00:56:52] Speaker 6: Um, well, she, she, she did. She said she did trauma. Okay.
[00:56:58] Speaker 2: So as you answered the rest, can you just answer yes or no?
[00:57:01] Speaker 6: I'm sorry. I was just trying to check the record. Okay.
[00:57:05] Speaker 2: You can check the record all you want. But if I ask you a question respectfully, can you just not go on and ramble? Answer yes or no. That's all.
[00:57:12] Speaker 6: It's sometimes impossible to do that.
[00:57:14] Speaker 2: All right. You tell them.
[00:57:16] Speaker ?: If you can't answer yes or no, just say you can't answer yes or no. If you can't answer yes or no, answer yes or no.
[00:57:22] Speaker 4: That's how we do it. All right. Fine.
[00:57:25] Speaker 2: Thank you. 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 date. Is that fair? She denied it. But she told you that she was worried about suicidal ideation and having suicidal thoughts, right? Well, this, yes.
[00:57:54] Speaker 6: 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?
[00:58:00] Speaker 2: Does that mean 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, close to suicidal ideation?
[00:58:08] Speaker 6: So I asked about that and that's when she said she described it further as using the word hopeless. Yes.
[00:58:20] Speaker 2: So did you prescribe the Lamontra gene on that occasion or no?
[00:58:30] Speaker 1: No.
[00:58:31] Speaker 2: On December 16th, that's the next appointment she had, right? Yes. That'd be two weeks later?
[00:58:43] Speaker ?: Right?
[00:58:44] Speaker 2: Yes. She was still not well, correct? She told you she was having a really rough time.
[00:58:55] Speaker 6: She was sleeping but she was still feeling very broken.
[00:58:58] Speaker 2: In your notes does it say that she was having a really rough time?
[00:59:02] Speaker ?: Yes.
[00:59:03] 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? It's an important detail. Yeah, I guess.
[00:59:14] Speaker ?: How about the rough time? What did that mean?
[00:59:16] Speaker 2: What were the symptoms of having a really rough time for this kid? Yeah, I'd like you to answer that.
[00:59:30] Speaker 6: So finally, Wirt, referring to the valine ocotriopine, 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 inpatient, feeling hopeless, no intent or plan, and feels like depression related to cerebral.
[01:00:00] Speaker 2: Okay. Now that's the question on Friday that will strike that. So what was the SI? Suicidal ideation? Yes.
[01:00:08] Speaker ?: Yes.
[01:00:09] Speaker 2: And can you read that back to me again? What did she say about SI?
[01:00:13] Speaker 6: So that when she went to the hospital, she went because she had no motivation, some SI.
[01:00:21] Speaker 2: Some SI meaning that she had some suicidal ideation, right?
[01:00:27] Speaker ?: Yes.
[01:00:28] Speaker 2: 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?
[01:00:44] Speaker 6: Yes or no? Now.
[01:00:48] Speaker 2: Well, it's in your notes that she said that, right? Yes?
[01:00:52] Speaker 6: What is in my notes?
[01:00:54] Speaker 2: Do you understand my question?
[01:00:58] Speaker 6: I don't want to get confused right now. Can you hear me where your question is? Sure, of course.
[01:01:04] Speaker 2: We spent some time talking about, thinking about suicidal ideation, worrying about suicidal ideation. Now, same, she had suicidal ideation, right?
[01:01:18] Speaker 6: She said it, yes.
[01:01:22] Speaker 2: Yes. Well, this is the only source of information that you're getting, apparently, is what she's telling you, right? Yes. So what suicidal ideation did she have? Was she thinking of cutting her throat? Was she thinking of throwing herself off a building, running out in front of a car, what?
[01:01:39] Speaker 6: No.
[01:01:40] Speaker 2: What was she thinking of?
[01:01:42] Speaker 6: So I asked her those important follow-up questions. Like what? So what do you mean when you say I'm feeling suicidal? Okay.
[01:01:51] Speaker 1: 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?
[01:02:03] Speaker 6: Do you have a plan for hurting yourself? And she denied those.
[01:02:08] Speaker 2: And that's where you left it?
[01:02:10] Speaker 6: I mean, I'm sure more was said, but that's the most important part of that clinical encounter.
[01:02:18] Speaker 2: And did you give a therapy by the computer on that day, too? Yes. What did you do for therapy about her suicidal ideation and saying she wanted to kill herself?
[01:02:29] Speaker 6: Well, you know, we explored what that meant and, you know, what to do if you're feeling that way.
[01:02:39] Speaker 2: To do what? Call 911?
[01:02:41] Speaker 6: To go to the emergency room.
[01:02:43] Speaker 2: Did you discuss prescribing Seroquel to her? Or was she getting Seroquel? Did Seroquel enter into your discussion at all?
[01:02:50] Speaker 6: We talked about it. I was not prescribing it for her.
[01:02:54] Speaker 2: What is Seroquel?
[01:02:56] Speaker ?: That's an antipsychotic.
[01:02:57] Speaker 2: 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, and then she, what, just moved on and went home?
[01:03:23] Speaker 6: Well, she was assessed in the emergency room, um, and was not admitted, and I assessed her on the day again, and while she was certainly struggling, she did not, um, require hospitalization at that moment. So, she was, um, she was planning on going to the infant program and I supported that.
[01:03:48] Speaker 2: Did you know that around that time she confessed to her husband that she was having now thoughts of harming the children?
[01:03:58] Speaker ?: No.
[01:03:59] Speaker 2: Would that have been something you were concerned about?
[01:04:01] Speaker 6: If I heard that, I would have been very concerned.
[01:04:04] Speaker 2: You would have called DCF, right?
[01:04:06] Speaker ?: I might have.
[01:04:07] 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? He never called me again.
[01:04:25] Speaker 1: He never called me again. Or, he never called at all. I never spoke with him again.
[01:04:28] 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. You never talked to her husband about what he observed? Because he didn't call you?
[01:04:48] Speaker 1: Well, we did speak on that visit.
[01:04:51] Speaker 2: Which visit?
[01:04:52] Speaker 1: The 16th. I think that that's the one that he was at.
[01:04:56] Speaker 2: You think it was? It's not noted in the record?
[01:04:58] 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.
[01:05:18] Speaker 2: December 16th, on your objective findings, you note that her mood was depressed, right? Yes. What does that mean? Did she just say, "I'm depressed," or did she give you symptoms? I mean, you checked the little box.
[01:05:37] Speaker 6: Yeah, she was saying that she was depressed.
[01:05:39] 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 worshipping at the Forcelain Guard? What was going on in her life?
[01:05:57] Speaker 6: She said she was having a really tough time.
[01:06:03] Speaker 2: Her affect was flat, right? Yes. And again, depressed, you check it off twice. One under mood and one under affect, right?
[01:06:17] Speaker ?: Yes.
[01:06:18] Speaker 2: 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?
[01:06:29] Speaker 6: We don't have a for our lab, no.
[01:06:34] Speaker 2: Well, why does it say "recent lab work" typed into your form where you check off the little boxes?
[01:06:40] Speaker 6: That's something that auto-populates.
[01:06:42] Speaker 1: It's a template. It's a what? It's a template. The whole note is something that psychiatrists or, you know, probably all across the country use. Probably.
[01:06:54] Speaker 2: You can't diagnose someone's illness by a template, can you? No.
[01:06:59] Speaker 1: No.
[01:07:00] Speaker 2: You filled in, no lab results were found, right?
[01:07:03] Speaker 1: There were none in the computer. Yes. I didn't type that in, though.
[01:07:07] Speaker 6: It just auto-populated.
[01:07:08] Speaker 2: So who typed it in?
[01:07:09] Speaker 6: It was auto-populated.
[01:07:10] Speaker 2: So on the next page, where it talks about symptom goals, treatment goals, I'm sorry, symptom reduction and improved functioning. What does that mean?
[01:07:25] Speaker 6: Symptom reduction is to have fewer mental health symptoms and improved functioning means improved day-to-day life functioning. You know, things like she's doing in her daily life.
[01:07:48] 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?
[01:08:12] Speaker 6: 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.
[01:08:29] Speaker 2: How long did that meeting take?
[01:08:32] Speaker 6: Probably about 30 minutes.
[01:08:34] Speaker 2: And was that the therapy that you provided, telling her to go to the emergency room?
[01:08:41] Speaker 6: I think that was probably a component.
[01:08:44] Speaker 2: So, the plan, excuse me, on December 16th was to follow up with women and infants, right?
[01:08:53] Speaker ?: Yes.
[01:08:54] Speaker 7: Did she?
[01:08:56] Speaker 2: Yes.
[01:08:57] Speaker ?: Do you know when?
[01:08:59] Speaker 2: Do you know when?
[01:09:00] Speaker ?: I don't know. I don't know.
[01:09:02] Speaker 2: What does that mean? I don't know. What does that mean?
[01:09:05] Speaker ?: Do you know? Do you know?
[01:09:08] Speaker 2: Then you were considering a brexaniline or brexanilone infusion, right?
[01:09:14] Speaker 6: That's the zylbrexaniline.
[01:09:16] Speaker 2: That's the same thing you wrote out of it? Yeah. Okay. And that didn't go anywhere, right? That was, that's the end of that. Yeah. It says, "Start Lamectol, 25 milligrams daily," right? Yes. Continue Seroquel, right? What was the milligram for the Seroquel up to at this point?
[01:09:34] Speaker ?: Well, she had told me it was 200.
[01:09:35] Speaker 2: Well, was it? I did not write that prescription. So that's what her provider had prescribed her. Okay.
[01:09:39] Speaker 6: 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?
[01:09:42] Speaker 2: I could.
[01:09:43] Speaker 6: Yeah. But you, anyway, she said that she was on Seroquel. And you said that she was on Seroquel. Okay. You said that she was on Seroquel.
[01:09:49] Speaker 2: What was the milligram for the Seroquel up to at this point? Well, she had told me it was 200. Was it? I did not write that prescription. So that's what her provider had prescribed her. Okay. So you can ask somebody to show me the bottle, the pill bottle. 200 milligrams, right? And had stopped with the valium, right?
[01:10:11] Speaker ?: Yes.
[01:10:12] Speaker 2: And then you go on with that form thing saying, if you have urges to harm yourself or others, you've 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?
[01:10:33] Speaker 6: I'm not sure.
[01:10:34] Speaker 2: Did you ever ask anybody other than her how she was doing?
[01:10:40] Speaker 6: I asked her husband when he was at that appointment.
[01:10:45] Speaker 2: Yeah, that's the other appointment though. How about now? We're talking December 16th into the month of December. Did you ever ask anyone how she was doing?
[01:10:53] Speaker 6: I think he was at that visit.
[01:10:56] Speaker 2: You think he was at the visit? How did he tell, what did he say to you about how she was doing?
[01:11:01] Speaker 6: He said she wasn't doing well. No.
[01:11:04] Speaker 2: She's got an objection. Objection.
[01:11:06] Speaker ?: Go ahead. He said she wasn't doing well. Anything else? No.
[01:11:10] Speaker 6: He felt that it might have been, his opinion was that it was related to when she started the
[01:11:14] Speaker 2: Saripa.
[01:11:15] Speaker ?: He basically said you guys are turning her into a zombie, right? Objection. Are those his words? I don't know how that went.
[01:11:18] Speaker 1: You may have said that. Does that kind of hit you though that you might remember that?
[01:11:20] Speaker ?: 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.
[01:11:20] Speaker 1: Yes. It's possible.
[01:11:22] Speaker ?: It's possible. It's very possible.
[01:11:22] Speaker 1: Okay. It's very possible. Okay. Excuse me.
[01:11:26] Speaker 2: Next meeting. Okay. Next meeting.
[01:11:29] Speaker ?: Okay.
[01:11:29] Speaker 6: Okay.
[01:11:30] Speaker 2: Next meeting. And how does this happen? Does the patient call?
[01:11:58] Speaker ?: I know you don't set up these appointments. Somebody has to deal with somebody.
[01:11:59] Speaker 2: In the next meeting. And how does this happen? Does the patient call?
[01:12:05] Speaker ?: I know you don't set up these appointments.
[01:12:09] Speaker 2: Somebody has to deal with somebody in the next meeting. 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 next meeting. 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?
[01:12:37] Speaker 1: So at the end of an appointment, I typically will schedule their next appointment.
[01:12:44] Speaker 2: So did you schedule January 6th?
[01:12:47] Speaker 6: I think that when she scheduled herself.
[01:12:51] Speaker 2: That was the day after she got out of McLean, right? Yeah.
[01:12:55] Speaker 6: Usually the hospital coordinates the discharge appointment.
[01:12:59] Speaker 2: Well, if I tell you that, in fact, the hospital told her to set up the appointment. And that within an hour, she set up the appointment. Is that in your notes? It's not in my notes.
[01:13:11] Speaker 6: It's not in my notes.
[01:13:12] Speaker 2: Do you remember that? That was a pretty big deal when she was in McLean, walked wards for four and a half years, right? Yes. Well, she's your patient and she's really gone downhill bad, right? She wasn't doing well. And she admitted herself to the wards at McLean, right? Yes. And what was the diagnosis at McLean?
[01:13:40] Speaker 6: I believe they diagnosed her with major depression.
[01:13:44] Speaker 2: Did they recommend any medication?
[01:13:47] Speaker 6: They took her off of the seropel.
[01:13:50] Speaker 2: They took her? Off of it. Off. Okay. So, did you look at the McLean records?
[01:13:58] Speaker 6: Yes, definitely.
[01:14:00] Speaker 2: And those were imported easily because you're part of the same structure or whatever?
[01:14:05] Speaker 6: No, but after someone is hospitalized, the hospital usually faxes it to their doctor.
[01:14:11] Speaker 2: All right, so if I tell you that the McLean records are really pretty baloonless, that's not what they faxed. They faxed you with a two-page discharge signs, right? Yes. You didn't get that by faxed, right? No. So what did McLean tell you? Look in your notes.
[01:14:34] Speaker ?: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:15:07] Speaker 6: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:15:10] Speaker 2: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:15:26] Speaker 6: You didn't get that by faxed. You didn't get that by faxed.
[01:15:28] Speaker 2: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:15:33] Speaker ?: You didn't get that by faxed.
[01:15:34] Speaker 1: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:15:37] Speaker 2: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:15:41] Speaker 6: You didn't get that by faxed. You didn't get that by faxed.
[01:15:43] Speaker 2: You didn't get that by faxed.
[01:15:44] Speaker 6: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:15:52] Speaker 2: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:16:07] Speaker ?: You didn't get that by faxed.
[01:16:08] Speaker 6: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:16:13] Speaker 2: You didn't get that by faxed. You didn't get that by faxed.
[01:16:15] Speaker 6: You didn't get that by faxed. You didn't get that by faxed.
[01:16:17] Speaker 2: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:16:20] Speaker 6: You didn't get that by faxed.
[01:16:21] Speaker 2: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:16:26] Speaker ?: You didn't get that by faxed.
[01:16:27] Speaker 2: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:16:34] Speaker ?: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:16:41] Speaker 2: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:16:44] Speaker ?: You didn't get that by faxed.
[01:16:45] Speaker 6: You didn't get that by faxed. You didn't get that by faxed.
[01:16:47] Speaker 2: You didn't get that by faxed. You didn't get that by faxed.
[01:16:49] Speaker 6: You didn't get that by faxed.
[01:16:50] Speaker 2: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:16:54] Speaker ?: You didn't get that by faxed.
[01:16:55] Speaker 6: You didn't get that by faxed.
[01:16:56] Speaker 2: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:17:01] Speaker 6: You didn't get that by faxed. You didn't get that by faxed.
[01:17:03] Speaker 2: You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed. You didn't get that by faxed.
[01:17:07] Speaker ?: You didn't get that by faxed. You didn't get that by faxed.
[01:17:09] Speaker 2: You didn't get that by faxed. You didn't get that by faxed.
[01:17:11] Speaker ?: You didn't get that by faxed.
[01:17:12] Speaker 6: You didn't get that by faxed. You didn't get that by faxed.
[01:17:14] Speaker ?: You didn't get that by faxed. You didn't get that by faxed.
[01:17:16] Speaker 6: You didn't get that by faxed. That's not entirely true.
[01:17:18] 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 Valium. What does that mean?
[01:17:34] Speaker 6: Well, I think she was having trouble sleeping. It wasn't that she wasn't sleeping.
[01:17:38] Speaker 2: Ah, I see. Okay. So was the Trazodone increased at that point? Yes. How about on January 9th, did you see her through the computer or whatever then? Yes. And did you prescribe medication to her on that date? Yes.
[01:18:14] Speaker ?: And was that diazepam? Yes. Fourteen count, one milligram? No, I'm sorry. Fourteen count, five milligrams.
[01:18:19] Speaker 2: That sounds right. Okay. Did you also, on January 12th, three days after January 9th meeting, prescribe additional medication to her? I'm not sure.
[01:18:26] Speaker ?: I'm not sure. I don't have a record of January 12th. I'm not sure. I don't have a record of January 12th.
[01:18:26] Speaker 2: Do you recall on January 12th that, in fact, you prescribed Trazodone 150 milligrams, 30 count? Yes.
[01:18:29] Speaker ?: Yes.
[01:18:30] Speaker 2: Yes. Yes. Three days later. Three days later, a couple of days later. January 16th. Do you recall, January 16th. Do you recall, January 9th meeting, prescribed additional medication to her? I'm not sure.
[01:18:39] Speaker ?: I don't have a record of January 12th.
[01:18:40] Speaker 2: Do you recall on January 12th that, in fact, you prescribed Trazodone 150 milligrams, 30 days later?
[01:18:55] Speaker ?: Yes.
[01:18:56] Speaker 2: Three days later, or a couple of days later, January 16th, do you recall prescribing amitriptyline? Yes. What is amitriptyline? Tricyclic antidepressant. What does a tricyclic antidepressant mean?
[01:19:20] Speaker 6: Well, it's an older antidepressant.
[01:19:25] Speaker 1: It's called a tricyclic because it has three rings. You look at the chemical itself like a tricycle. But it's an older but efficacious medicine for depression and anxiety as well as insomnia.
[01:19:41] Speaker 2: On January 16th, look at your interval history. Does she indicate to you that her mood was very low, no motivation? Yes.
[01:19:55] Speaker 5: Numb?
[01:19:56] Speaker 2: Yes. 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 computer, right? Yes. What did that tell you? Were you concerned about this woman postpartum, well within the year from the CDC at that point with these symptoms that she's telling you about?
[01:20:30] Speaker 6: I was concerned that she was depressed.
[01:20:33] Speaker 2: And in all of the times that you spoke to her, you could agree with me that she appeared to be honest and forthright telling you what she felt, right?
[01:20:42] Speaker 6: That's what I thought she was, yes.
[01:20:45] Speaker 2: Do you have any reason to think that she was lying to you?
[01:20:48] Speaker 1: No.
[01:20:50] Speaker ?: Yeah.
[01:20:51] Speaker 2: Yeah. 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 express that she was still having concerns about side effects from medications? Not at that point. So what does ROS mean under interval history that we're looking at?
[01:21:21] Speaker ?: A view of symptoms.
[01:21:22] Speaker 6: Okay.
[01:21:23] Speaker 2: And then it says patient denies SIHI, that'd be suicidal ideation, homicidal ideation, correct? Yes. Denies other questions or concerns, and you recommend a low dose of amitriptyline for depression, correct? Yes. The patient agrees with the treatment, and you guys were also going to explore ketamine treatment, ketamine treatment, is that right? Eskaketamine.
[01:21:54] Speaker ?: Yes.
[01:21:55] Speaker 2: Now, did you know that she was on her computer looking up medication after medication after medication after medication, treatments, ketamine treatments, and all that, did you know that? No. Did you ever ask her whether or not she was looking up the symptomology of pharmacology and having interactions between drugs? No.
[01:22:23] Speaker ?: No. No.
[01:22:25] Speaker 2: No. January 23rd. Um, you had that meeting, correct, with her? Yes.
[01:22:32] Speaker ?: Yes.
[01:22:33] Speaker 2: And this is after, obviously, excuse me, the January 16th appointment. And in the January 16th appointment, she told you that her mood was very low, and that's the worst that she ever reported her mood to you. Is that right?
[01:22:48] Speaker ?: On the 16th? Yeah.
[01:22:50] Speaker 6: I don't know if that was the worst that was ever reported, but it was certainly active.
[01:23:02] Speaker 2: And you didn't recommend that she have a hospital evaluation, did you? This is the day before she killed the kids, right? The 23rd? Yeah. It was the day before.
[01:23:09] Speaker 6: Yes. You didn't recommend a hospital evaluation, did you?
[01:23:12] Speaker ?: No. There were no, um...
[01:23:14] Speaker 2: The answer's no? No. They'll ask you all the questions they want.
[01:23:17] Speaker 6: Your answer's no. January 23rd.
[01:23:19] Speaker 2: Friday, you testified that she said her mood was depressed. And you noted that her affect was depressed and flat, right?
[01:23:24] Speaker ?: Yes.
[01:23:25] Speaker 2: She also reported that her heart was racing, right? Yes. She also reported that her heart was racing, right? Yes.
[01:23:34] Speaker ?: She also reported that her heart was racing, right? Yes.
[01:23:38] Speaker 2: She had no motivation, is what she told you, right? Yes. She told you that she had been feeling numb and no emotion for 17 days straight, is what she told you, right?
[01:23:59] Speaker 6: I'm not sure about 17 days straight, but that's how she was feeling.
[01:24:04] Speaker 2: You didn't reach out to her mother and father at that point? They didn't call you, I guess, right? No. And Patrick didn't call you at that point, right?
[01:24:15] Speaker 6: No.
[01:24:16] Speaker 2: So she's sitting in front of her computer, getting help from her doctor on January 23rd. And what did you do? Well, I thought about how I could best help her with the medicines that she tried and what
[01:24:38] Speaker 6: her current symptoms were.
[01:24:40] Speaker 1: And it made sense to slowly titrate the amitriptyline so that we could get her to a dose that reduced
[01:24:51] Speaker 6: her depression so that she would feel better.
[01:24:54] Speaker 2: It increased the amitriptyline. Yes. And it pushed her over the edge, didn't it?
[01:25:02] Speaker ?: I don't think so.
[01:25:02] Speaker 2: That's all I have.
[01:25:03] Speaker ?: That's all I have.
[01:25:04] Speaker 6: I don't think so.
[01:25:34] Speaker ?: Thank you.
[01:26:04] Speaker 3: On cross-examination about your residency, at that point you were already a doctor, correct? Yes. And during your residency, that was a four-year period, correct? Yes. And you were saying that you treated patients during that time, is that correct? Yes. Was there someone with you while you treated these patients telling you what to do and how to handle them? No. Were you alone responsible for the evaluation, diagnosis, and treatment of your patients?
[01:26:51] Speaker 1: For the most part, but if I had questions or needed to talk it through, I had help.
[01:26:57] Speaker 3: And approximately how many patients did you treat during those four years? Thousands. And those were all psychiatric patients, correct? Yes. You said approximately 50 of those patients were patients dealing with postpartum depression or some postpartum issues. Is that correct?
[01:27:16] Speaker ?: Yes.
[01:27:17] Speaker 3: You also said you had some specialized or specific training in that area. Can you describe that for us?
[01:27:22] Speaker 1: Yes. I did a specialized elective with a specifically perinatal psychiatrist where I worked in an obstetrics clinic. And I saw patients who were pregnant and postpartum.
[01:27:35] Speaker 3: And how long was that clinic for?
[01:27:38] Speaker 1: It was for about a year.
[01:27:39] Speaker 3: And so for a year, you were evaluating and diagnosing and treating women with postpartum issues? Yes. And that's separate and apart from your residency?
[01:27:50] Speaker 1: It's a part of the residency. It's an elective.
[01:27:53] Speaker 3: So for one year out of the four, that was specifically designated to postpartum issues?
[01:28:00] Speaker 1: Yes. It wasn't every single day, but it was continuing the same patients for about a year.
[01:28:05] Speaker 3: So you would follow those same patients throughout the year? Is that what you're saying? Yes. And you were asked about postpartum psychosis and you said it was rare. How rare is it?
[01:28:18] Speaker 1: I'm not sure of the statistic, but low.
[01:28:21] Speaker 3: Low. Have you dealt with patients in your four years of residency that had other types of psychosis?
[01:28:30] Speaker 1: Yes, many.
[01:28:31] Speaker 3: And psychosis, whether it's from postpartum or some other mental illness, does it present the same or does it matter what the underlying illness is?
[01:28:42] Speaker 1: I mean, it can present different based on the individual, but it's the same general disorder.
[01:28:49] Speaker 3: And so what are the symptoms or signs that you look for to determine whether someone has psychosis?
[01:28:55] Speaker 1: So you look at them, you assess their appearance, are they disheveled? And then you look at how cooperative they are, how they're engaging in your interview. Are they answering your questions or maybe refusing to answer your questions? Maybe being, um, very, uh, aggressive. Um, you look at their speech, whether they're speaking very fast, very loud, or, uh, the opposite, like maybe not really even speaking much at all. Um, you look at what their thoughts are like. And, um, we assess thoughts by, uh, what they're saying. That's how we know what people are thinking and, um, whether what they say, um, makes sense, um, linearly, um, or whether someone's jumping around and you can't follow them. Um, we also assess the thoughts for their content. If someone is speaking about things that are very bizarre, things that are very paranoid, um, if someone is, uh, talking or making noises, or it seems like they're communicating with somebody that's not in the room. Um, those are all things, behaviors that we assess for.
[01:30:07] Speaker 3: So although you'd never treated someone with postpartum psychosis, you had evaluated, diagnosed, and treated people with other types of psychosis. Is that correct? Yes. Did you see any signs of psychosis in any of your interactions with Lindsay Clancy?
[01:30:20] Speaker 1: No.
[01:30:22] Speaker 3: Defense counsel mentioned that part of your residency was during COVID. Did mental health issues just stop during COVID?
[01:30:29] Speaker 1: Of course not. They, they often got worse.
[01:30:31] Speaker 3: And so you, it's fair to say you still kept busy seeing patients, uh, on a daily basis? Yes. You also mentioned that, um, some of the patients you saw, um, in your residency, it was, um, outpatient care. Is that correct? Yes. Is that similar to the care you were providing to Lindsay Clancy? Yes. And, um, was that all four years you were providing outpatient care to psychiatric patients?
[01:30:56] Speaker 1: Um, for three of the four. Three of the four.
[01:31:00] Speaker 3: Uh, you were also asked about telehealth. Is telehealth, um, appointments in psychiatric care, um, standard in the industry? Yes. And how long has that been standard? Since COVID. And, um, is, is it a fairly common and accepted practice at this point? Yes. Most of the, um, the session, for a psychiatric session, you're talking to someone, right? Yes. Does looking at someone through a computer screen, um, somehow inhibit how you hear the answers? No, it does not. Or inhibit the way you ask your questions?
[01:31:33] Speaker 1: No.
[01:31:34] Speaker 3: And defense counsel asked you about, you know, not being able to see below the waist someone's shaking or moving, but if someone's sitting and they're, they're, they're bouncing, can you see it elsewhere? Can you see other movement?
[01:31:46] Speaker 1: Yeah. Sometimes it can reverberate in different parts of the body.
[01:31:52] Speaker 3: You were also asked about the Edinburgh scale. Um, you said you don't use it, right? Yes. You said you use the PHQ-9. Uh, why do you use that instead of the Edinburgh scale?
[01:32:02] Speaker 1: It's not my choice. That's the, the practice at ASTAR of what we use.
[01:32:07] Speaker 3: And the PHQ-9, what does that look for?
[01:32:11] Speaker 1: It assesses, uh, various symptoms of depression.
[01:32:15] Speaker 3: And postpartum depression, um, are there questions on the PHQ-9 that look for the signs and symptoms of postpartum depression?
[01:32:24] Speaker 1: Not specifically postpartum depression, but, but the symptoms of postpartum depression are symptoms of depression that occur during postpartum. It's, it's the same symptoms.
[01:32:35] Speaker 3: So the PHQ-9 is asking the patient questions, um, that would reveal whether or not they might be depressed, but not whether or not they just had a baby. Correct. And then with your interaction with the patient, you're able to know whether or not they, um, are in the postpartum phase. Yes. And so would it be fair to say that you take the PHQ-9 plus the information you learned from the patient, put it together and come up with a diagnosis? Yes. When you take a history from a patient, you were asked about taking history from Ms. Clancy. Um, how important is it that, um, the patient give you accurate information?
[01:33:14] Speaker 1: That's very important. And why is that? Um, well, that's, that information is, is being used to make, um, treatment decisions. Um, and, uh, a lot of things can be assessed. You know, the, the things that I described before, um, that's, that's very helpful, but we, we can't see what someone else's thoughts exactly are. So the person does have to tell them to us.
[01:33:41] Speaker 3: And would you agree that people in the medical field, such as nurses, are acutely aware of the, the necessity of an accurate medical history and symptom presentation?
[01:33:50] Speaker 1: Yes.
[01:33:52] Speaker 3: You mentioned that the defendant was able to advocate for herself. In what ways did she show you that?
[01:33:59] Speaker 1: In scheduling her own appointments, in presenting herself to the emergency room when things were
[01:34:07] Speaker 8: really not going well. She said, okay, she's going to be able to advocate for herself.
[01:34:24] Speaker ?: She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself.
[01:34:27] Speaker 8: She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself.
[01:34:29] Speaker ?: She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself.
[01:34:36] Speaker 8: She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself.
[01:35:17] Speaker 3: She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself.
[01:35:39] Speaker 1: She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself. She said, okay, she's going to be able to advocate for herself.
[01:35:45] Speaker 3: Now, is it accurate to state that in every one of your sessions with Ms. Clancy, you told her about individual therapy and encouraged her to attend individual therapy?
[01:36:00] Speaker 1: That was the treatment recommendation each time. I'm not sure if I explicitly mentioned it each time, but I did many times.
[01:36:08] Speaker 3: And you, in fact, wrote it on the work form that we talked about previously. On page 104 of the records, it lists, was the patient referred to other healthcare providers for evaluation or treatment? And it says, yes, if yes, state the nature of such treatments and expected duration of treatment. And it says individual weekly therapy, correct? Yes. And this is the form that the defendant asked you to fill out, correct? Yes. And you sent it back to her. And the first version, she wanted you to make some corrections on, correct? Yes. But she didn't ask you to change that portion, correct? No. And in fact, on the second version, on page 107 of the record, it still says individual weekly therapy recommended, correct, for follow-up?
[01:36:56] Speaker 1: Yes.
[01:36:57] Speaker 3: Would it be accurate to state that the defendant only saw Jennifer McAllister twice the entire time that she was with your practice for therapy? Yes. You were asked about Zoloft being used for general anxiety disorder. Yes. And why is that?
[01:37:20] Speaker 1: Because it's effective and it's safe.
[01:37:22] Speaker 3: You were also asked about the suicide warning on it, that there is a suicide warning. Is that for all ages? No. What ages or groups is that suicide warning for?
[01:37:33] Speaker 1: It's really for children and adolescents, they do say up to 24 years. But it's really children and adolescents.
[01:37:41] Speaker 3: Would it be accurate to state that the defendant was 32 years old when she saw you? That sounds right.
[01:37:47] Speaker 1: I can check. That sounds right.
[01:37:49] Speaker 3: Well, if you want to check the record. I can check. I can check.
[01:37:52] Speaker ?: Yes.
[01:37:53] Speaker 1: Yes.
[01:37:54] Speaker ?: Yes. Is that correct?
[01:37:56] Speaker 3: Yes. Okay. So, 32 years old is not three to four years older than 24, correct? No. Why didn't you have to titrate the 50 milligrams of Zoloft?
[01:38:11] Speaker 1: You mean to stop it? Yes. Because it's still a very low dose, so it can be stopped right away.
[01:38:19] Speaker 3: So, was it necessary?
[01:38:21] Speaker 1: Not necessary.
[01:38:22] Speaker 3: The defendant waited about a month after receiving the prescription before taking the medication, correct? Yes. And she only took the medication when she decided she was ready to take it, correct?
[01:38:39] Speaker 1: Yes.
[01:38:40] Speaker 3: So, she was taking in the information you gave her, correct?
[01:38:44] Speaker 1: Yes.
[01:38:45] Speaker 3: She was making her own decisions, correct? Yes. She actually had an appointment in between when you first prescribed it and when she started taking it, where she was still discussing with you whether or not she wanted to take it. Is that correct? Yes. Is that part of the advocating for herself that you were talking about? Yes. Is that part of the medical sophistication that she possessed that you were talking about? Yes.
[01:39:11] Speaker 2: Your Honor, at some point in light of the fact this is direct, I have to object.
[01:39:16] Speaker 4: Sure. Yeah, if you could just not ask the leading question. Sure.
[01:39:20] Speaker 3: I want to direct your attention to the September 12, 2022 form that the defendant filled out. On page 16 of the record. Oh, we have different page numbers, right? We do.
[01:39:35] Speaker 1: But if you just tell me what you're looking at, I can find it. The past psychiatric history.
[01:39:54] Speaker 3: Okay. What did she tell you, Ms. Clancy, tell you about the, where it says if yes, list the reason and dates. What did she tell you?
[01:40:02] Speaker 1: Um, she said anxiety, September 2013 to September 2014, postpartum anxiety, May 2020.
[01:40:14] Speaker 3: And on the following page, under the past or current psychiatric medications, which ones did she list?
[01:40:22] Speaker 1: Um, Prozac, 50 milligrams and Welbutrin, 100 milligrams.
[01:40:30] Speaker 3: Is there a column there that says effective yes or no?
[01:40:34] Speaker 1: Yes.
[01:40:35] Speaker 3: What was the defendant's answer with whether or not Prozac was effective? Yes. What was her answer as to whether or not Welbutrin was effective?
[01:40:44] Speaker 1: Yes.
[01:40:45] Speaker 3: Is there another column there that said experienced side effects? Yes. Did she check off any side effects experience for Prozac? No. Did she check off any side effects experience for Welbutrin? No. Going to the October 20th, 2022 appointment. 2022 appointment. You were asked about this on cross-examination about documenting side effects in your notes. Did you document the side effects that the defendant reported from the Zoloft on October 20, 2022? Yes. And what did you document?
[01:41:52] Speaker 1: Well, I checked the box for GI, but I also talked about the side effects and the interval history. And so what does GI mean?
[01:42:02] Speaker 3: Gastrointestinal. So what that means, stomach issues? Yeah. And what did you put in your notes?
[01:42:11] Speaker 1: Couldn't sleep, insomnia, worse on grease dose, doesn't want to eat, diarrhea, food really unappealing, was more depressed on it, crying all day, yesterday, not normal, mental fog, terrified to start something new.
[01:42:29] Speaker 3: And so you did document the side effects that she reported to you, correct? Yes. You also documented in the interval history, paranoid of getting suicidal thoughts. Was that the defendant's phrasing? Yes. And is there a difference between someone being worried about having suicidal thoughts and someone actually having suicidal thoughts? Yes. And what's the difference in terms of how a psychiatrist sees it?
[01:43:00] Speaker 1: So that's the difference between what someone, what a patient might answer and then what the psychiatrist actually assesses. So say a patient might say they're having suicidal thoughts, but when they describe them, they're not actual suicidal thoughts, they're fears of suicidal thoughts. So that's, that's the difference there. And I'm sorry, I think I forgot exactly what your question was.
[01:43:29] Speaker 3: What's the difference in your training and experience between someone having fears of suicidal thoughts and actually having suicidal thoughts?
[01:43:38] Speaker 1: Well, so if it's, if it's a fear, then it means that they're not actually having suicidal thoughts. It's a negative.
[01:43:46] Speaker 3: And does that affect the way you proceed with treatment?
[01:43:50] Speaker 1: Yes, in some ways, yes. How? Well, you, you still proceed with treatment. It's still concerning, but it is a level of concern that can be managed on an outpatient basis, not requiring hospitalization.
[01:44:07] Speaker 3: And so according to the defendant, she was not yet having suicidal thoughts at that time. Yes. So when defense counsel asked you repeatedly why you didn't document how many times she had those thoughts, she hadn't had those actual thoughts yet, correct?
[01:44:23] Speaker 1: Correct.
[01:44:25] Speaker 3: That was later in December. Is that right? Yes. Now, she also told you that she was worried about something, that something bad might happen. So she arranged for her mother to stay. Is that correct?
[01:44:39] Speaker 1: Well, she arranged for her mother to stay. I'm not sure if that was because she was afraid something bad was happening, or it just seemed like they needed more help. Okay.
[01:44:51] Speaker 3: So you don't recall the two being together as a thought? Correct. And the fact that she was struggling and arranged to have her mother stay, got support, advocated for herself. Would those be protective factors?
[01:45:07] Speaker 1: Yes. How so? So if someone demonstrates that they can advocate for themselves, that they can seek help if symptoms worsen, then that shows that they have good judgment, they can be trusted to present for care if serious safety concerns were to arise.
[01:45:35] Speaker 3: So based on your training experience with Ms. Clancy, where she says she's worried about getting suicidal thoughts, and she has her mom come stay with her, do you see that as a positive decision? Yes. You were asked about not asking the defendant if she had called the suicide hotline. If a patient denies suicidal ideation, would you typically ask them if they had called a suicide hotline?
[01:46:05] Speaker 1: No.
[01:46:06] Speaker 3: And why not?
[01:46:08] Speaker 1: Because I, you know, I wouldn't think that they would have, you know, if, if a patient were to call a suicide hotline, I would think that they would be telling me they're having suicidal thoughts as well.
[01:46:26] Speaker 3: You were asked about prescribing hydroxyzine, Ativan and Buspar. Did you tell the defendant how to take those medications? Yes. What were your instructions?
[01:46:40] Speaker 1: So the Ativan was to take as needed for severe anxiety. The Buspar was to be an everyday medicine. And the hydroxyzine, we had started that to see if she could use that as an alternative to the Ativan. So to take it instead of the Ativan. But if the Ativan wasn't, or sorry, if the hydroxyzine wasn't working, she still had the Ativan to use, which is, it's stronger.
[01:47:12] Speaker 3: So there was never, was there ever an instruction for her to take all three at the same time? No. And you were asked about the contraindications of Ativan and Benadryl. Do you recall that? Yes. Are there contraindications for taking the two together?
[01:47:26] Speaker 1: It's not an absolute contraindication. You have to be careful that the person is not excessively sedated, you know, meaning like they're so sleepy that it's hard for them to, you know, engage in normal activities because they're so sleepy or maybe they might feel a little bit dizzy, but it's not an absolute contraindication. You just have to monitor them.
[01:47:53] Speaker 3: And is that one of the reasons that you prescribed the hydroxyzine?
[01:47:57] Speaker 1: Sorry, is what one of the reasons?
[01:47:59] Speaker 3: It's the fact that the two of them together, Ativan and Benadryl. Well, let me strike that question. Why did you prescribe the hydroxyzine?
[01:48:10] Speaker 1: So she had been taking Benadryl, which is not a prescription medication. It's not classically within the scope of psychiatry, but it's very similar to hydroxyzine. So I thought that, you know, hydroxyzine might be a better alternative than the Benadryl.
[01:48:29] Speaker 3: Okay. And I'm just going to direct you to your November 2nd, 2022 interval history. Now, would it be fair to say that on the November 2nd date, the defendant reported she was fine all day, evenings, bedtime, get anxious, Ativan helps, sleeping great on it, afraid to try something else, but knows it's not a long-term solution. Is that correct? Yes. And what part of that did the defendant tell you was not a long-term solution?
[01:49:17] Speaker 1: Taking the Ativan.
[01:49:18] Speaker 3: And why is that?
[01:49:20] Speaker 1: Because it was indicated for short-term use only. People can struggle more with dependence if they're taking it for a very long period of time.
[01:49:30] Speaker 3: And was there a plan developed based on that concern?
[01:49:35] Speaker 1: Yes, there was. What was the plan? To reduce the dose by 0.25 milligrams every two weeks until she was off it.
[01:49:42] Speaker 3: So the defendant was able to express to you a concern she had about the medication. You had a conversation about it and you addressed that with her and came up with a plan. Is that right?
[01:49:51] Speaker 1: Yes.
[01:49:55] Speaker 3: She also told you that day that she was in therapy and exercising daily, correct?
[01:50:00] Speaker 1: Yes.
[01:50:04] Speaker 3: Did the defendant ever tell you that she went to the South Shore Hospital Emergency Department on November 16, 2022?
[01:50:11] Speaker 1: I don't recall that.
[01:50:12] Speaker 3: Did she tell you that they had prescribed trazodone to her at that time?
[01:50:16] Speaker 1: I don't recall that.
[01:50:18] Speaker 3: Did she ever tell you that she was trying some alternative methods like weed gummies?
[01:50:22] Speaker ?: No.
[01:50:25] Speaker 3: Do you have any way of knowing these things if the patient doesn't tell you?
[01:50:29] Speaker 1: No.
[01:50:33] Speaker 3: Now, on December 1, 2022, defense asked you about that date. That's the date that she again said she had the fear of thoughts of suicide. Is that correct?
[01:50:44] Speaker 1: Yes.
[01:50:45] Speaker 3: Up until that point, had she consistently denied suicidal ideation or intent or a plan? Yes. Had she consistently denied homicidal ideation, intent or a plan? Yes. What's the difference? Well, let me ask you this. When you talk to a patient, do you ask them, do you have suicidal ideation?
[01:51:06] Speaker 1: Not usually.
[01:51:06] Speaker 3: Not in that way. How do you get that information from them? What types of questions do you ask?
[01:51:11] Speaker 1: It depends how the course of the conversation is going. I might ask if they're having thoughts of hurting themselves, if they sometimes wish that they weren't alive. It can be a lot of different words, and sometimes I use, you know, the patient's own words, but things like that.
[01:51:32] Speaker 3: And is there a difference between having thoughts of suicide versus having the intent and a plan to do it? Yes. And are there different types of treatment or things that you would do if someone has intent or plan to do it?
[01:51:50] Speaker 1: Yes. That would generally require hospitalization.
[01:51:53] Speaker 3: And so if Ms. Clancy had told you she had thoughts of hurting herself, or actually, sorry about that, if she told you that she had a plan to hurt herself or a plan to hurt her children, would you have moved to commit her? Yes. And that would be a section 12? Yes. Yes. You were asked about the October 31st therapy session with Jennifer McAllister, and I know you weren't present from that. You're just going from the records. But you did say that in that session, the defendant denied suicidal ideation and homicidal ideation, correct?
[01:52:35] Speaker 1: Yeah, that's what's documented.
[01:52:36] Speaker 3: Would there be any reason, based on your training experience, to do that further suicidal intent assessment?
[01:52:43] Speaker 1: No.
[01:52:44] Speaker 3: Why not?
[01:52:45] Speaker 1: Because if someone is denying suicidal ideation, they're just going to deny every other detail about suicide.
[01:52:56] Speaker 3: But that further evaluation, is that very specific questions about planning for suicide, how you do it, all of those things? Yes. You were also asked about evaluating the defendant for bipolar, and you said that she, based on your conversations with her, there were no signs of mania, correct?
[01:53:17] Speaker 1: Correct.
[01:53:18] Speaker 3: What are the types of questions you ask a patient to determine if they've experienced an episode of mania?
[01:53:26] Speaker 1: Well, a lot of it is what I can see in the session. I might also ask about some of those symptoms, like decreased need for sleep, or racing thoughts, or increased risk-taking activities. But even if they're reporting those things, I would have to really see it for myself to diagnose that.
[01:53:50] Speaker 3: And what would you see physically?
[01:53:53] Speaker 1: So I might see that the person is talking very fast, and it's almost impossible to interrupt their rate of speech. And it might also be very loud. They might be hyperactive, not able to sit still. They might be yelling and jumping from one thought to another without any linear connection between the thoughts. They might, yeah, I guess that's probably what I would observe in terms of behaviors.
[01:54:30] Speaker 3: Did you observe any of those behaviors with Lindsay Clancy?
[01:54:33] Speaker 1: No, it was the opposite.
[01:54:35] Speaker 3: What do you mean it was the opposite?
[01:54:37] Speaker 1: So, you know, the opposite of euphoria is dysphoria or depression. The opposite of hyperactivity is tiredness and fatigue. So, you know, in a way, it was the opposite of mania that I observed.
[01:54:55] Speaker 3: And in terms of the questions you asked about her past behavior, were any of the answers that she gave indicative of mania?
[01:55:02] Speaker ?: No.
[01:55:03] Speaker 3: You were asked about discussing Seroquel with the defendant, even though you weren't the prescriber. Why did you discuss that medication with her?
[01:55:15] Speaker 1: Because the patient was asking about it, and her husband was also asking me about it. They really wanted my opinions about it. It wasn't necessarily that I was prompting this line of conversation.
[01:55:31] Speaker 3: And what did you tell them about it?
[01:55:33] Speaker 1: Well, I shared that it has very good evidence for treating depression. And I may have shared that Seroquel does different things at different doses, right? So sometimes people are concerned that it is called an antipsychotic, but it actually doesn't function as an antipsychotic until you get up to really high doses, like 800 milligrams. So in low doses, it's more of a sleep medicine or an antidepressant. So I think that I explained that to them. It's obviously a very important part of it, but they were also concerned about that causing the depression that she was experiencing. So we talked a bit about how you would tell. You know, it kind of can be hard to tell whether a medicine is causing that or it's just occurring because of depression.
[01:56:33] Speaker 3: What did you tell them in terms of how to tell?
[01:56:36] Speaker 1: That it's really based on the timing, if you were to notice a significant decline after starting or increasing the medication.
[01:56:45] Speaker 3: And prior to Ms. Clancy taking the Seroquel, had you noticed signs of depression in her? Yes. And after she was off of the Seroquel in January, did you see signs of depression in her? Yes. So that was completely off the Seroquel, both before and after, still showing signs of depression? Yes. During January, the defendant told you she had trouble getting out of bed?
[01:57:18] Speaker 1: Is there a specific visit?
[01:57:20] Speaker 3: I think it was right after she got out of the hospital. Maybe your first or second visit with her.
[01:57:40] Speaker 1: I see that on the 16th she did say that she was able to force herself out of bed and take care of basics, so on and so forth.
[01:57:51] Speaker 3: Were you aware that she had gone to the Museum of Science with her family on January 8th and spent a few hours there interacting with the exhibits and the children?
[01:57:59] Speaker 1: No.
[01:58:00] Speaker 3: Were you aware on January 15th, the day before that session, she had been to the Cape Codder down in Hyannis with the family, interacting with the kids and going down little water slides and all of that?
[01:58:12] Speaker ?: No.
[01:58:13] Speaker 3: Were you aware that on January 14th, she watched all three kids while Pat went to a brunch and was fine?
[01:58:20] Speaker ?: No.
[01:58:21] Speaker 3: Were you aware that on January 16th, her husband took Cora skiing and she was alone with the boys all day and had no issues?
[01:58:29] Speaker ?: No.
[01:58:31] Speaker 3: You were asked about the thyroid and how that can affect mental health and postpartum. Were you aware that at both South Shore Hospital and Brigham and Women's Hospital, her thyroid limits were in normal range?
[01:58:49] Speaker 1: No, I was not.
[01:58:51] Speaker 3: You received a discharge summary from McLean Hospital? Yes. What's contained in the discharge summary?
[01:58:58] Speaker 1: So it includes information about how the patient initially presented, what they said when they first came to the hospital, and their initial assessment from the psychiatrist that they spoke with. It talks a bit about their course, their treatment course, how things progressed, any changes that were made. And then it talks about how the patient appears on the day of discharge.
[01:59:28] Speaker 3: Does it also include what medications they were prescribed and what the diagnosis might have been? Yes. And was that sufficient in terms of your review of the information that you needed to know about your patient at that time?
[01:59:44] Speaker 1: Yes, that was a very helpful amount of information that I would typically review that amount of information for a patient after the hospital.
[01:59:58] Speaker 3: Now, you were asked about your January 23rd, 2023 session with the defendant. Defense counsel asked if you had, you know, recommended a hospital evaluation for her on that day. And you said, no, why not?
[02:00:15] Speaker 1: Because she was completely denying any suicidal ideation or homicidal ideation. There were no signs of psychosis or mania. So there were no serious signs that her safety or that anyone else's safety was at risk.
[02:00:42] Speaker 3: And during that session, did she ever tell you that she planned to harm herself or the children?
[02:00:47] Speaker 1: No.
[02:00:47] Speaker 3: If she had done that, what would you have done?
[02:00:49] Speaker 1: I would have. It depends exactly how it would have played out. You know, it would definitely include hospitalization. If the children were in immediate harm, it might include enlisting help from my staff so that they could call the police while I'm on the phone with her. You know, I think it depends. But I would address it promptly.
[02:01:16] Speaker 3: You were asked by defense counsel about the amitriptyline that you prescribed on January 16th, 2023. That initial prescription was for 10 milligrams, correct?
[02:01:27] Speaker 1: Yes.
[02:01:35] Speaker 3: And out of this pill bottle here, there were 30 pills in this prescription, correct? Yes. And there are only eight, there are eight pills missing from this bottle. So filled on January 16th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd, 23rd would be eight days, correct? And on the 23rd is when you said she could raise it to 20 milligrams? Yes. So if there are only eight pills missing, she never took that additional dose, correct?
[02:02:26] Speaker 1: That's what I would think based on what you just said.
[02:02:30] Speaker 3: So the amitriptyline, increasing it from 10 milligrams to 20 milligrams, wouldn't have pushed her over the edge, correct?
[02:02:38] Speaker 1: Well, if she didn't take 20 milligrams, then that's correct. Okay.
[02:02:45] Speaker 3: I have nothing further. Thank you.
[02:02:53] Speaker 4: All right. Can we cross briefly?
[02:02:57] Speaker 2: Briefly. So one of the questions that the prosecutor asked you pertained to whether or not you could reach out to a third party. Do you recall that question? Like mother, father, husband?
[02:03:15] Speaker 1: Yes.
[02:03:17] Speaker 2: And we already on cross talked about that, that you didn't, and they didn't call you, but then the DA also raised that, and you said you didn't have HIPAA permission. Do you recall just telling that to the jury?
[02:03:31] Speaker 1: Yes. That was an additional detail.
[02:03:34] Speaker 2: All right. What does that mean?
[02:03:38] Speaker 1: Well, HIPAA is the privacy law for patients, which we have to respect and honor very diligently. So we are not allowed to talk about a patient's treatment to anyone. We're not even allowed to say that they are a patient at our clinic unless they were to waive those HIPAA rights.
[02:04:04] Speaker 2: And she was very cooperative, would have been more than willing to have to talk to her mother, father, and her husband, right? Conjection. Sustained. Well, did you ever tell her, ask her to sign a HIPAA?
[02:04:17] Speaker 1: So that was not the main reason why it wasn't done. It wasn't...
[02:04:20] Speaker 2: Did you ever ask her to sign a HIPAA?
[02:04:25] Speaker 1: A release, you mean? Yeah. Yes. No, I did not ask her to sign a release.
[02:04:32] Speaker 2: And if she did sign a release, even though her mother, her father, her husband didn't call you, you could have then reached out to them, right?
[02:04:43] Speaker 1: I could have, but it is not typically something that is done when you have an adult patient who is able to speak for themselves.
[02:04:50] Speaker 2: What is that? It's not typically done when?
[02:04:53] Speaker 1: When you have an adult patient who is able to speak for themselves.
[02:04:57] Speaker 2: My God, you don't call the parents that she's living with because they're helping her or her husband?
[02:05:03] Speaker 1: No.
[02:05:05] Speaker 2: Because why? She's able to advocate for herself?
[02:05:10] Speaker 1: Yes.
[02:05:13] Speaker 2: The prosecutor yet again raises the issue of the marijuana. Do you recall that question?
[02:05:24] Speaker 1: Yes.
[02:05:26] Speaker 2: She wasn't smoking marijuana, was she?
[02:05:28] Speaker 1: She did not tell me she was smoking marijuana.
[02:05:31] Speaker 2: Did she tell you that she was using marijuana?
[02:05:34] Speaker ?: No.
[02:05:35] Speaker 2: Did she tell you that she was using gummies?
[02:05:39] Speaker 1: No.
[02:05:40] Speaker 2: Did she, because gummies in plural is what the DA asked you, right? She was using gummies? Yes. Now, I asked you about getting access to the woman and infant's hospital records, which you did not. Which you did not, right? I did not. And we already went over that. You could have, if you asked for them with a HIPAA form, right?
[02:06:03] Speaker 3: Objection. You didn't ask about those records.
[02:06:06] Speaker 2: I don't care if she asked about the records. It's overruled. You can ask that question. She asked you about marijuana gummies, right? Yes. Okay. Your Honor, I would offer the woman and infant's hospital records from Rhode Island, dealing with Lindsay Clancy.
[02:06:28] Speaker 3: No objection.
[02:06:29] Speaker 2: Okay. They may be admitted.
[02:06:33] Speaker 3: I just want to look at them at some point to make sure it's a clean copy.
[02:06:36] Speaker 4: Sure, yeah. Before it goes to the jury, you can review it.
[02:06:47] Speaker 2: And it's important for a patient to be forthright when asked questions by their provider, right?
[02:06:59] Speaker 5: Yes.
[02:06:59] Speaker 2: And you always, in your opinion, found her to be forthright, right?
[02:07:03] Speaker 1: Yes.
[02:07:03] Speaker 2: If you, if I could, approach you with, was it in 220, excuse me, and, uh, see the second paragraph? It begins in the middle of November. Could you read that for a sentence?
[02:07:21] Speaker 1: In the middle of November, she tried taking a marijuana edible to help her sleep, which caused her to have increased anxiety and palpitations.
[02:07:31] Speaker 2: So, the records that you had obtained them, you would have seen that it was not marijuana, it was not gummies, plural. It was one gummy that she tried, and it wouldn't work out, right?
[02:07:45] Speaker 1: Based on what I just read. Yes. Yes.
[02:07:47] Speaker 2: Then you told us that there's a difference between a thought of suicide versus a plan of suicide, one of which would result, in your words, were a commit, a commitment, right? Yes. What does that mean? Thought versus plan equals commit.
[02:08:12] Speaker 1: A suicidal plan means that they, uh, are, you know, they, they know exactly what they're going to do to end their life, you know, what they're going to use, maybe when they're going to do it. They've researched it. And that presents an immediate threat, and that is something that would require hospitalization.
[02:08:39] Speaker 2: District Attorney had asked you also about the thyroid levels, and you indicated, or she indicated that, um, they were in the low range at Mass General Hospital, Reed, is that correct?
[02:08:50] Speaker 1: I thought she said they were normal.
[02:08:52] Speaker 2: Oh, I thought she said low, but normal or low, um, MGH, Mass General Hospital, right? Sorry, what's the question? District Attorney asked you whether or not they were thyroid reads. Do you remember that question?
[02:09:07] Speaker 1: She said her thyroid had been tested.
[02:09:09] Speaker 2: The question now is, do you remember that question that she asked you that you answered with no problem? Yes. Okay, and your response was that, my memory, because the juror's accounts, that it was low reads, MGH, and South Shore Hospital, is that right?
[02:09:32] Speaker 1: Um, I, I thought she said that it was normal, or within normal limits.
[02:09:37] Speaker 2: Almost fine, we'll go with normal. So, your memory is that there were thyroid blood level reads of Lindsay Clancy from two healthcare providers, is that correct? Yes. One would be Mass General Hospital, right?
[02:09:55] Speaker 1: Um, I, I don't remember, I, exactly, I think, I think she said yes, I think she said Mass General.
[02:10:00] Speaker 2: Okay, do you remember where the other hospital healthcare provider was?
[02:10:05] Speaker 1: It might have been South Shore.
[02:10:05] Speaker 2: Do you know what date those were?
[02:10:09] Speaker 1: No.
[02:10:10] Speaker 2: Those are old reads, weren't they? I don't know. One of the things that the district attorney asked you about on a number of occasions that seems to be important is if the person that you're treating has, I guess, what do they call it, pressured speech? Yes. And you told us repeatedly that you never detected that Lindsay had pressured speech, right?
[02:10:32] Speaker 6: Correct.
[02:10:33] Speaker 2: I'm sorry?
[02:10:34] Speaker 6: Correct.
[02:10:36] Speaker 2: Looking at the record from October 21st, would you?
[02:10:47] Speaker 3: Any objection is writing on this?
[02:10:49] Speaker 2: Oh, all right, you know what, I'll just, I'll ask her to just look at it.
[02:10:53] Speaker 4: Might take a look at it, and if you want to get the actual exhibit, we could do that.
[02:10:59] Speaker 2: All right, so forget all about my sloppy writing. I'm looking here on October 21st of 22, is that correct, right up there? Okay. Yes. Ann, can you just read this paragraph here for us?
[02:11:13] Speaker 1: No, sorry. No sleep last night. Falls asleep after 40 minutes, heart racing, severe anxiety, worrying about kids, baby, sleep, yawns but not drowsy, not hyper-pressured speech.
[02:11:28] Speaker 2: What was that?
[02:11:29] Speaker 1: Not hyper what? Not hyper, not pressured speech is what I meant. I know it doesn't say not, but that is exactly what I meant.
[02:11:36] Speaker 2: When did you see this, that you noticed that it did not say not?
[02:11:40] Speaker 1: I don't care what it says, I know what I meant.
[02:11:43] Speaker 2: Well, when you wrote this, you did not say not pressured speech, you said in the medical record, pressured speech, right? No. Does it say that?
[02:11:57] Speaker 1: Yeah, the word is, the word not is right before not hyper, comma, pressured speech, the two are following the not.
[02:12:05] Speaker 2: Do you, when you put down in a medical record, heart racing, comma, severe anxiety, comma, worried about kids, comma, baby, comma, sleep, comma, yawns but not drowsy, period. Not hyper, comma, pressured speech. That's what you wrote, right?
[02:12:24] Speaker 1: She did not have pressured speech, she did not have pressured speech, I wrote that but you're misinterpreting my note.
[02:12:29] Speaker 2: Am I reading this correctly, and the jury will be able to look at it, that you put not hyper, comma, pressured speech. Did you, did I read that right?
[02:12:43] Speaker 1: Yes, but your interpretation is incorrect.
[02:12:47] Speaker 2: As opposed to yours? Go ahead.
[02:12:53] Speaker 4: Just in regards to what was raised there.
[02:12:56] Speaker 3: Yes, just two brief issues. Approaching you with your records from October 21st, 2022, the section labeled speech, where there are all the boxes where you can put pressure, word salad, all of the different things. What do you check off for speech on October 21st, 2022?
[02:13:14] Speaker 1: Appropriate.
[02:13:16] Speaker 3: And defense asked you about the thyroid levels, was it, would it be accurate to state that I asked you if you were aware that her levels were normal at Seltzer Hospital and Brigham and Woman's Hospital?
[02:13:31] Speaker 1: Yes.
[02:13:32] Speaker 3: And your answer was no, correct?
[02:13:34] Speaker 1: No, I was not aware.
[02:13:36] Speaker 3: Because you don't have those records, correct?
[02:13:37] Speaker 1: Correct.
[02:13:38] Speaker 3: Thank you.
[02:13:40] Speaker 2: Do we have any clue as to how old they were?
[02:13:44] Speaker 1: I don't know. You're asking me about something I never saw.
[02:13:49] Speaker 4: All right.
[02:13:50] Speaker 2: Nothing further.
[02:13:51] Speaker 4: All right. Anything further? All right. Thank you, Doctor. Let me step down. Thank you.
[02:14:05] Speaker 3: Your Honor, the Commonwealth would move to submit the certified copy of the Spalding Rehabilitation Records. No objection.
[02:14:10] Speaker 2: That's by agreement.
[02:14:11] Speaker 4: Okay. By agreement of council, the Spalding Rehabilitation Records will be introduced.
[02:14:17] Speaker 5: Get the 221.
[02:14:25] Speaker 7: Can I call the next witness?
[02:14:27] Speaker 4: Yeah. Please, council.
[02:14:28] Speaker 7: I'm also called Julie Paul. Okay.
[02:14:30] Speaker ?: Okay. Good afternoon.
[02:14:54] Speaker 9: All right.
[02:15:11] Speaker 4: Good afternoon. Good afternoon.
[02:15:12] Speaker 7: Good afternoon.
[02:15:13] Speaker 4: All right. Yes. Trini Buckhamp, please.
[02:15:16] Speaker 7: Thank you. Good afternoon.
[02:15:18] Speaker 9: Good afternoon.
[02:15:19] Speaker 7: Could you please call the jury your first and last name?
[02:15:22] Speaker 9: Julie Paul.
[02:15:23] Speaker 7: And what do you do for work?
[02:15:26] Speaker 9: I am a psychiatric mental health nurse practitioner, board certified.
[02:15:30] Speaker 7: And can you tell us a little bit about your educational background?
[02:15:33] Speaker 9: Sure. I graduated in 1991 from St. Anselm College with my nursing degree, worked as a labor delivery nurse for 17 years, and then graduated in 2006 from Frontier Nursing University with my midwifery degree. And then in 2018, I graduated from Frontier Nursing University with my psychiatric nurse practitioner degree. I also have a perinatal mental health certification from Postpartum Support International from 2018.
[02:15:58] Speaker 7: Okay. Are you also a certified midwife?
[02:16:02] Speaker 9: Yes, I am.
[02:16:03] Speaker 7: And are you licensed in the state of Massachusetts to be a psychiatric nurse practitioner?
[02:16:09] Speaker 9: Yes, I am.
[02:16:10] Speaker 7: And what is required in order for you to become certified to be a psychiatric nurse practitioner in Massachusetts?
[02:16:17] Speaker 9: I attended a certified program, did two years additional training, and then took the certification exam through the ANCC.
[02:16:25] Speaker 7: And can you tell us a little bit about your work history, your work background?
[02:16:30] Speaker 9: Sure. Like I said, in New Hampshire, I worked as a labor and delivery nurse before transferring to Massachusetts in 2006 to work as a certified nurse midwife. And then in 2018, I started the Perinatal Behavioral Health Program at Celtshire Hospital as a psychiatric nurse practitioner.
[02:16:47] Speaker 7: And so the Perinatal Behavioral Health Clinic, explain to us a little bit about how that came about.
[02:16:55] Speaker 9: Sure. There's a lack of resources on the Celtshire for pregnant and postpartum people with mood disorders. So I really felt compelled because I had a couple of clients that really struggled with mental health issues as a nurse midwife and really wanted additional education and be able to prescribe for them and take care of them in a proper way. So I went back, got my psych NP, and then worked with Celtshire Hospital to establish the program.
[02:17:19] Speaker 7: And where was the program actually located?
[02:17:22] Speaker 9: It was located right in Weymouth, Massachusetts.
[02:17:25] Speaker 7: And you said you worked with the Celtshire Hospital?
[02:17:28] Speaker 9: Correct.
[02:17:29] Speaker 7: So the clinic is tied to Celtshire Hospital in the Celtshire Health System. Yes, it is. Now, when did you start that program specifically? When was it up and running?
[02:17:39] Speaker 9: 2018 is when I started in October of 2018.
[02:17:42] Speaker 7: And what, did you do that by yourself or did you have other practitioners that were doing that with you?
[02:17:48] Speaker 9: Initially, it was just me. I started doing it two days a week and then grew the program gradually over the next year or two.
[02:17:55] Speaker 7: And what makes up this program other than you?
[02:17:59] Speaker 9: So at the time, when it was just me, I just saw patients two days a week and then gradually built up to five days a week. And we included a therapist and the team, two diffusional prescribers. We also worked with women with substance use disorders as well. So we had additional support that way. And then when the building grew, we also had substance, the bridge clinic on the other side. And then we were on the other side of that program.
[02:18:23] Speaker 7: And what's the bridge clinic?
[02:18:24] Speaker 9: The bridge clinic works with people with substance use disorders.
[02:18:28] Speaker 7: And all of this is kind of under that umbrella of what's classified as South Shore Behavioral Health, correct?
[02:18:35] Speaker 9: That's correct.
[02:18:37] Speaker 7: Now, as the clinic grew, did your role there change?
[02:18:41] Speaker 9: I'm sorry, can you repeat that?
[02:18:42] Speaker 7: As the clinic grew to what you described as having additional therapists and other prescribers on staff, did your role there change at all?
[02:18:52] Speaker 9: I became the director of the program.
[02:18:54] Speaker 7: And as director of the program, did you still see patients?
[02:18:59] Speaker 9: Yes, I did.
[02:19:00] Speaker 7: And was that at the same level as it had before? Or did it decrease because of your administrative roles?
[02:19:06] Speaker 9: It actually increased because I increased my hours to five days a week. I did have a little bit of administrative time.
[02:19:12] Speaker 7: And can you tell us a little bit about how the clinic would work for a woman who is coming in either during the birth period or prior to birth and after birth? What kinds of things would they be offered at the clinic?
[02:19:29] Speaker 9: So I'd receive a referral and then the client would come in. We would do a 90-minute intake. When they left, when it was just me, I was using outside therapists, that sort of thing. But as the program grew, we had moms groups run by doulas. We had therapists that we brought in that was brought in from Aspire, but part of our program embedded within our program. And I brought in two additional prescribers as well as nursing staff.
[02:19:57] Speaker 7: And when you talk about people as prescribers and your role as a psychiatric nurse practitioner who could prescribe, what were you offering to patients as part of this clinic as a prescriber?
[02:20:08] Speaker 9: We were offering the proper medication for anxiety, depression, mood disorders, really any psychiatric disorder that came in, mostly for pregnant and postpartum people up to two years postpartum. We also offered therapy focused on sleep hygiene, really looked at the whole person, not just medication management.
[02:20:26] Speaker 7: And fair to say that the medication is one piece and the therapy is another piece, and this is part of a team approach that you had at the clinic.
[02:20:34] Speaker 9: That's correct.
[02:20:35] Speaker 7: To address all these resources for patients.
[02:20:38] Speaker 9: That's correct.
[02:20:38] Speaker 7: So while you, as the psychiatric nurse practitioner, might have been a prescriber, were you also engaged in the therapy or psychotherapy?
[02:20:48] Speaker 9: I would do supportive therapy, but I'm not a therapist. I mainly am responsible for assessing, diagnosing, prescribing, but I also really understand the importance of sleep, nutrition, and exercise.
[02:21:05] Speaker 7: And so being that you had a history of working as a midwife and working as a nurse in labor and delivery, do you have a lot of experience with moms or women who are in that postpartum period? Yes. And how about your experiences with diagnosing and prescribing for women in that period? Do you have experience in that?
[02:21:25] Speaker 9: In the labor and delivery realm, as a nurse midwife, yes, I diagnosed like labor and that sort of thing, and even depression, anxiety, not to the extent of higher acuity psychiatric conditions, but as a psychiatric nurse practitioner, I did.
[02:21:41] Speaker 7: Okay. And as far as your role at the perinatal behavioral health clinic, fair to say that your primary patient base was all going to be women who were either pregnant or after birth?
[02:21:53] Speaker 9: Correct.
[02:21:54] Speaker ?: Correct.
[02:21:55] Speaker 7: And a part of this team approach at the clinic, is it also to work on developing a treatment plan for patients when they come in?
[02:22:05] Speaker 9: Correct.
[02:22:06] Speaker 7: And so what encompasses a treatment plan generally?
[02:22:09] Speaker 9: Generally, if it were a situation where we were referring them for therapy, then we would work with the therapist to kind of bring in the client to figure out what their needs are, and then really stress whatever. The therapist works on certain aspects of the therapy that we kind of work together, but in, not in tandem, kind of, we talk, but not to the extent we rejury in our own disciplines.
[02:22:34] Speaker 7: Okay. And as far as the resources that the clinic had available to you, is it fair to say that there are certain types of therapy, for instance, cognitive behavioral therapy or dialectic behavioral therapy that are not necessarily encompassing with the social workers that you work with at the clinic?
[02:22:54] Speaker 9: Our social workers primarily did cognitive behavioral therapy. We did group therapy for more social support. What I did mainly was just supportive therapy.
[02:23:04] Speaker 7: Okay. And would you oftentimes, through the clinic, refer clients out to other local community providers? Yes, we would.
[02:23:12] Speaker 9: Yes, we would.
[02:23:13] Speaker 7: Now, as the psychiatric nurse practitioner, does medication play an important role when you are dealing with a particular patient that came into the clinic?
[02:23:26] Speaker 9: Yes, it does play a role.
[02:23:27] Speaker 7: Okay. And how is it that you determine what's the appropriate medication track for any given patient?
[02:23:33] Speaker 9: We do proper screening, and then we do a complete interview with the client. And then based on what their responses are, together we work as a team to develop the best medication options or treatment options for that client.
[02:23:46] Speaker 7: When you say work as a team, does that include the patient themselves?
[02:23:49] Speaker 9: Yes. Absolutely. The patient is the most important part of the team.
[02:23:56] Speaker 7: And in your training and experience working with postpartum women, what is the acceptable period to determine postpartum?
[02:24:06] Speaker 9: Anywhere within the first year.
[02:24:12] Speaker 7: Did you know a nurse, or do you know a nurse named Susan Clancy?
[02:24:15] Speaker 9: I do.
[02:24:16] Speaker 7: How do you know her?
[02:24:17] Speaker 9: Yes, I worked with her off and on throughout my years as a nurse midwife.
[02:24:22] Speaker 7: And what's the nature of your relationship with her, other than working with her?
[02:24:28] Speaker 9: Essentially, we just worked together. We worked, when we did births together, we worked well as a team.
[02:24:34] Speaker 7: Okay. And do you know where she worked?
[02:24:36] Speaker 9: She worked at Seltzer Hospital.
[02:24:40] Speaker 7: On November 20th of 2022, did you have a conversation, or did you get a call from Sue Clancy?
[02:24:46] Speaker 9: I did. She was referred to me through Nanette Landry, another midwife that I work with. Okay.
[02:24:52] Speaker 7: Okay. And so as a result of the phone call that you had with her, did you get in contact with a woman by the name of Lindsay Clancy? Yes, I did. Was that the same day or a different day?
[02:25:03] Speaker 9: It was the same day.
[02:25:04] Speaker 7: And your contact with Lindsay Clancy, was it by phone or virtual or in person? It was by phone. And so what was the purpose of calling Lindsay Clancy?
[02:25:15] Speaker 9: I just wanted to get her side of what had been going on with her history. Sue had alluded that she was struggling in the postpartum period, so I wanted to know exactly what she was struggling with to see if she'd be a good candidate for our program.
[02:25:28] Speaker 7: So did you initiate the call to Lindsay Clancy?
[02:25:30] Speaker 9: With the permission. I asked Sue Clancy if Lindsay had given permission and she said she had.
[02:25:35] Speaker 7: Okay. And in the conversation that you had with her, do you know approximately how long that phone conversation lasted?
[02:25:40] Speaker 9: I don't recall. Okay.
[02:25:42] Speaker 7: But were you able to get all the pertinent information from her during that phone call?
[02:25:46] Speaker 9: I got enough data to determine that she would be a good candidate for the program.
[02:25:51] Speaker 7: So she would have met criteria for a referral from any other resource?
[02:25:55] Speaker 9: Correct.
[02:25:56] Speaker 7: Now, is it fair to say that in this conversation, in order to determine whether she qualified, you had to ask her some background questions? I did. And so were you able to identify whether she was in that postpartum period? Yes.
[02:26:10] Speaker 9: I asked when the birth of Callan was, and she said it was May 26, 2022.
[02:26:19] Speaker 7: And so after determining that she was in fact postpartum with a baby at home, did you ask any questions or did you learn any information about how the experience was earlier in the postpartum, right after birth? I did.
[02:26:43] Speaker 9: She said she did really well for the first 12 weeks. She was excited, really happy. And then when Patrick went back to work, she said she started to struggle with some anxiety.
[02:26:53] Speaker 7: And you knew Patrick to be her husband, Patrick Clancy? Correct. And do you recall her indicating that she was having difficulty leaving the baby, that she was feeling overwhelmed and having racing thoughts? Yes. And so in your training and experience, are those things that you would hear from new moms? It was very typical of what I'd hear.
[02:27:12] Speaker 9: It was very typical of what I'd hear.
[02:27:17] Speaker 7: Did you learn from her whether she had engaged with any other treatment prior to contacting or prior to you having this conversation with her?
[02:27:24] Speaker 9: She did say that she had met with a psychiatrist. She didn't give the name. And then she'd also said that she had been in the emergency room a few days prior to.
[02:27:32] Speaker 7: Okay. And were you able to determine that was actually the South Shore emergency room? Yes, it was. And that would have been on November 16th of 2022? Correct. Now, in addition to seeing a psychiatrist, did she identify to use some medications that she had been taking up to that point?
[02:27:48] Speaker 9: She did. She said she had trialed Zoloft for one week. She also said that she'd been trialing Ativan and Benadryl, which worked the best to help her sleep. She identified. She had questions about Buspar. Didn't say specifically whether she had been prescribed that or not, but she had any questions about Buspar.
[02:28:05] Speaker 7: Okay. And did she mention anything about that combination of Ativan and Benadryl in her treatment history that was of concern to her?
[02:28:15] Speaker 9: Just that she had been taking it for two weeks. It worked really well. But then she was getting concerned about dependence. So she self-weaned herself off of that.
[02:28:23] Speaker 7: And were you aware, did she tell you that she had been prescribed Trazodone after that? Yes.
[02:28:30] Speaker 9: After she went to the emergency room, she was prescribed Trazodone.
[02:28:33] Speaker 7: Did she indicate whether the Trazodone gave her any relief to her sleep issues?
[02:28:37] Speaker 9: She said she was able to fall asleep, but was having difficulty staying asleep.
[02:28:42] Speaker 7: Did she also indicate to you that one of her goals was not to be on long-term medications? Yes, she did. And based on this initial phone conversation, did you recommend that she come in for an intake appointment? I did. Okay. Okay. How about the immediate need for sleep? Did you address that with her in the phone call?
[02:29:06] Speaker 9: I just encouraged her to take the medication that she already had on hand. That if the Benadryl and the Ativan were working, she should take that to help her sleep that night. And we talked the next morning about different options.
[02:29:17] Speaker 7: And also in this initial phone call, did you have a conversation with her about options and risks of various types of SSRIs or continued use of benzodiazepines?
[02:29:29] Speaker 9: Yes, we viewed that being on SSRI most of the time is preferable than being on benzodiazepines for long periods of time, especially to address her concern about addiction or dependency on the medication.
[02:29:41] Speaker 7: Okay. And is this kind of a normal conversation you would have with somebody to screen them and determine whether the clinic, the South Shore perinatal clinic, was an appropriate fit?
[02:29:51] Speaker 9: Yes, it's more to establish rapport and get a basic understanding and make sure that she was safe. Okay. And she didn't indicate that she was safe.
[02:30:00] Speaker 7: And so that's kind of my follow-up to that. So in the course of that phone call, you were able to communicate with her, correct? Correct. And what she was telling you about her reported history, did that seem to make sense to you?
[02:30:12] Speaker 9: Yes, it did.
[02:30:13] Speaker 7: And did you identify or were you addressing or assessing during the whole course of this conversation, whether there was any immediate safety risk or need for her? Yes, I was. And did you find that there was any?
[02:30:25] Speaker 9: There was no immediate need.
[02:30:28] Speaker 7: Now, as a result of this conversation, did you determine whether she was having any suicidal ideations?
[02:30:39] Speaker 9: Yes, I asked her specifically if she felt like she wanted to harm herself or her children, and she said no.
[02:30:44] Speaker 7: And how about asking her about homicidal ideations? Yes. Yes. And did she indicate whether she had any? She did not. Did you also ask her whether she had experienced any auditory hallucinations? I did. And did she experience any?
[02:30:59] Speaker 9: Not at the time, no.
[02:31:00] Speaker 7: And did she indicate to you whether she'd ever experienced any?
[02:31:03] Speaker 9: No.
[02:31:04] Speaker 7: How about visual hallucinations? Did you ask her about those? I did. And did she indicate that she had experienced any?
[02:31:11] Speaker 9: No.
[02:31:12] Speaker 7: And delusions. Did you ask her whether she had any delusions?
[02:31:15] Speaker 9: I didn't ask specifically about delusions, I believe.
[02:31:17] Speaker 7: Okay. And in the course of talking with an individual, do you kind of constantly keep that in mind with what they're telling you? Are they telling you whether they're having any ideas of delusions? Yes, I do. In the conversation you had with her on November 20th, did you identify, based on your conversation with her, whether she was experiencing delusions? No, I did not. And fair to say, a standard set of questions that you also ask have to do with drug use or tobacco or alcohol, did you ask those questions as well? I don't recall.
[02:31:50] Speaker 9: If I were to show you your note, would that refresh your memory? I have my notes right here, I could look at it.
[02:32:03] Speaker 7: Okay, draw your attention to the note from November 20th of 2022.
[02:32:12] Speaker 9: Yes, I did ask her apparently. And she said no to illicit drug use, tobacco or marijuana or alcohol at that time.
[02:32:22] Speaker 7: And she also indicated to you that at this time on November 20th, that she had stopped breastfeeding. That's correct. Now, did she schedule or did you schedule with her an intake for the next day, November 21st? We did. And at the clinic, what generally is the practice for whether a person appears in person or on a telehealth visit or virtually?
[02:32:50] Speaker 9: Generally speaking, we like to do the intake in person as long as it's feasible. And for her it was. Okay.
[02:32:56] Speaker 7: And just kind of while we're on that topic, going forward with a patient who's being seen at the clinic, what are the criteria to determine an in-person visit or a telehealth visit? They're given the option about what works best for them. And are there instances where you as a provider might insist a person comes in in person?
[02:33:16] Speaker 9: If somebody needs to do like a urine drug screen or laboratory work, we'll have them come in. Or if they seem to be not making sense or having more difficulties, we'll have them come in in person.
[02:33:26] Speaker 7: And if a person is scheduled for an in-person visit and there are no observed issues on your end, can they opt to change it to a virtual appointment at any point? Yes. And that's just the normal course of business at the clinic? Correct. Now, in this particular instance, you said the intake was in person, right? Yes. And during the course of the intake, are there particular types of questions that are asked of the person to get to know them and get to know their situation?
[02:34:01] Speaker 9: Yes. Generally, we do a full intake. The first thing they do is meet with the nurse who does all the screenings.
[02:34:09] Speaker 7: And one of the things that is asked of an individual when they come in is to tell you why they are there, right? Correct. What their complaint is. Yes. And so for this patient, for Lindsay Clancy, what did she identify as the reason for the visit?
[02:34:29] Speaker 9: Would it be okay if I refer to my note? Sure. So she said, "Pretty much, I cannot sleep," was her major concern. Okay.
[02:34:36] Speaker 7: Okay. And is that something that you've seen in your experience with new moms that come through the clinic in our postpartum?
[02:34:44] Speaker 9: It's very typical. Okay.
[02:34:46] Speaker 7: Now, even with that report or that reason, do you do a full history to try to identify kind of what's going on in the present and what has happened in the past? Yes, I do. And generally, is it fair to say that that's kind of the goal of an intake, right? I do that with every client.
[02:35:07] Speaker 9: I have a standard set of questions. Is that just for the intake or any follow-up? Any follow-up. I have a basic kind of script, but I always adjust it based on what they're saying. Okay.
[02:35:18] Speaker 7: But fair to say, once a person gives kind of that history of their background, especially if they've had prior births before, prior experiences with mental health professionals or psychiatric history, that that kind of follows the patient as they go through with their subsequent visits. Yes. So in this instance, you had some background information from the phone call you had with her, but did you go back through those standard questions that you'd ask in an intake? I did. And did you learn a little bit more about her current mental status? Did you ask her some questions about currently how she was in this November 21st meeting?
[02:35:58] Speaker 9: I did.
[02:35:59] Speaker 7: And so, again, do you kind of go through in each and every instance whether the person has any thoughts of suicide or harming themselves or others?
[02:36:09] Speaker 9: At every visit, those are standard questions that I ask if they have any type of suicidal homicide ideation or auditory or visual hallucinations.
[02:36:16] Speaker 7: Do you ask the same questions each time or is it kind of fluid based on your rapport and conversation with the patient?
[02:36:24] Speaker 9: Generally, I try and touch upon the topic. Sometimes we get to that answer indirectly just by the line of questioning that we're using.
[02:36:31] Speaker 7: Okay. And where it had been reported to you that she had been on the Zoloft and stopped you insomnia, that she was overwhelmed and her mind was racing, did you talk with her about intrusive thoughts? I did. And did she indicate whether at that point she was having any intrusive thoughts of harming herself or her babies? She was not. Did she report to you how she was feeling at home with having now three children to take care of?
[02:37:00] Speaker 9: She was feeling overwhelmed.
[02:37:02] Speaker 7: And that, again, reiterating that around 12 weeks when Patrick went back to work, that she was having increased anxiety? Correct. And did she indicate to you that that was something that she had experienced to some extent with her other two children? At least with her second pregnancy. And was she able to manage that with her second pregnancy without medication? As far as what I was told, yes. And fair to say she indicated that she would use breathing, meditation and yoga to work through it. Correct. And so on this November 21st intake date, you again ask about drug use, right? Correct. And at this point, she had told you that she did trial one CBD gummy at some point, but that did not help? Correct. And you also learned about any prior psychiatric medications she had been on?
[02:38:02] Speaker 9: Yes. She had been on the Zoloft, the Ativan. She had been prescribed Buspar, but she didn't indicate whether she had taken that or not.
[02:38:11] Speaker 7: Okay. And so that was her report of her most recent course of treatment. But did she talk about having anxiety issues? Oh, yes. Further back in her history?
[02:38:21] Speaker 9: Yes. In college, she had trialed Prozac, Propanolol, and Wellbutrin.
[02:38:25] Speaker 7: And fair to say she indicated that to you that she did well on those medications in nursing school?
[02:38:31] Speaker 9: Correct. With the only side effect being sexual side effects.
[02:38:37] Speaker 7: Did you talk to her at this point in November 21, excuse me, 2022, about whether she had a plan to go back to work?
[02:38:49] Speaker 9: I don't know if that was a specific day. I know that we talked about work at a different date. Okay.
[02:38:57] Speaker 7: If you have your note in front of you, I'd just draw your attention to maybe the last paragraph of the history of present illness.
[02:39:06] Speaker 9: Oh, I'm sorry. And you're talking about the day of the intake? Yes. Sorry. 22nd so Yeah, she had planned to go back to work in October, but it got delayed. She pushed it forward to November because she was having anxiety
[02:39:27] Speaker 8: The same
[02:39:41] Speaker 7: In that postpartum period, are there any specific screenings that you do?
[02:39:56] Speaker 9: Yes, we do the Postnatal Depression Scale. We did the GAD, which is the Generalized Anxiety Depression Scale. We did the Mood Disorders Questionnaire Scale, the Columbian Suicidal Scale, as well as the 5Ps, which assesses for substance use disorders and pregnancy and postpartum.
[02:40:12] Speaker 7: And so as far as in each one of those screens, what did you find as it pertained to this particular patient?
[02:40:18] Speaker 9: She was significantly high in the GAD-7, which is for generalized anxiety. She scored 21 out of 21, which is, they're just screening, so it's not diagnostic, but it did indicate that she was experiencing extreme anxiety. And then with the Edinburgh Postnatal Depression Scale, she scored a 23 out of 30. But the one that I look for the most in that scale is number 10, and she was negative, and that's for suicidality.
[02:40:41] Speaker ?: Okay.
[02:40:41] Speaker 7: And so why is it that you look at that one in particular, or why do you consider that most?
[02:40:47] Speaker 9: Because that shows significant depression, especially if they have thoughts of harming themselves.
[02:40:52] Speaker 7: Is it fair to say that that Edinburgh scale, it also could fluctuate with postpartum mom, depending on their situation?
[02:40:59] Speaker 9: Yes.
[02:41:00] Speaker 7: And the other screens that you performed, did you identify whether there is any substance use issues?
[02:41:07] Speaker 9: No, there wasn't.
[02:41:08] Speaker 7: Now, once you were able to kind of gather all this information from her and do these screenings, were you able to come up with an assessment and a plan for how to help her? Yes.
[02:41:21] Speaker 9: She --
[02:41:22] Speaker 7: And what was going to be the plan with Ms. Clancy?
[02:41:26] Speaker 9: So we had discussed starting Prozac. Okay.
[02:41:29] Speaker 7: And is that -- or why Prozac? Why start there?
[02:41:33] Speaker 9: Because she'd had a history of being successful on it in the past. And that's a good indicator that instead of trying multiple medications, to start with the ones that actually work. So I gave her 10 milligrams for the first four days to make sure there were no adverse reactions. And then I gave her -- I was going to increase her to 20 milligrams if she tolerated that well.
[02:41:51] Speaker 7: Okay. And what about some of the medications that she had already -- that she was already on, the Ativan and Benadryl and the Trazodone? Did you have a plan for those?
[02:42:00] Speaker 9: I did. So I encouraged her to take the Ativan. So when Prozac can sometimes be very activating, it can make the anxiety worse before it gets better when you first start it. So I wanted to pair it with the Ativan just in the beginning, just to help her be more comfortable with the anxiety and to make sure that it didn't interfere with her sleep.
[02:42:17] Speaker 7: And as far as Prozac goes, what kind -- what class of medication is it?
[02:42:22] Speaker 9: It's an SSRI, a selective serotonin reuptake inhibitor.
[02:42:25] Speaker 7: Is it commonly prescribed to treat people with depression?
[02:42:29] Speaker 9: Yes, it's a first-line treatment.
[02:42:31] Speaker 7: You said first-line treatment?
[02:42:32] Speaker 9: Correct.
[02:42:33] Speaker 7: And the idea of pairing a particular medication like an SSRI with another medication, is that a fairly common practice with psychiatric medications? Yes. As far as the -- you mentioned that sometimes symptoms could get worse before they get better. Is that also common with SSRIs?
[02:42:54] Speaker 9: Yes, it is.
[02:42:54] Speaker 7: Does it take a while for a medication to get into a person's system and stabilize them?
[02:43:01] Speaker 9: Generally, side effects are the first week or two, but to get to a therapeutic level, it's about four to six weeks.
[02:43:08] Speaker 7: And was this something that you discussed with her about the timetable it would take to reach a therapeutic level?
[02:43:15] Speaker 9: Yes.
[02:43:15] Speaker 7: And when we say therapeutic level, what's the goal of reaching therapeutic level? Is remission and symptoms. People start to feel better then, right? Correct. Now, even though you were advising that she continue with the Ativan and she had told you that there -- she had concerns about continuing with the benzodiazepine, did you indicate that there would be a plan to taper that or reduce that? Yes.
[02:43:43] Speaker 9: Once the activating symptoms went away, then we would look at reducing that and moving away from the Ativan and moving more towards like abuse bar. Okay.
[02:43:55] Speaker 7: And as far as talking about that plan and what the risks and benefits of that plan were, did she appear to understand and engage in conversation with you about that?
[02:44:06] Speaker 9: Yes, she verbally understood and said that she understood the instructions.
[02:44:10] Speaker 7: Did she ask the appropriate questions or follow-up?
[02:44:13] Speaker 9: Yes, she did.
[02:44:16] Speaker 7: And as far as kind of overall what the plan was moving forward, was medication the only recommendation that you were making or did you have other recommendations for her?
[02:44:25] Speaker 9: No, I set her up with talk therapy with Leticia Dukes as well. Sorry, when you say talk therapy, what do you mean by that? So coming in and actually doing cognitive behavioral therapy with a clinician, someone who is trained in this. And so you mentioned Leticia Dukes? Correct. She was the clinician in our program at the time.
[02:44:49] Speaker 7: And when you make this recommendation and this intake visit, do you work with the patient to schedule something before they leave or is it up to them to schedule the time with the social worker?
[02:44:59] Speaker 9: It was set up with her before she left, I believe.
[02:45:02] Speaker 7: And you're aware that the first appointment, scheduled appointment with Leticia was for December 2nd?
[02:45:08] Speaker 9: Correct. I believe because it was a holiday week that week.
[02:45:12] Speaker ?: Okay.
[02:45:13] Speaker 7: Now this time that you were with Ms. Clancy during this initial intake, fair to say, it was approximately 60 minutes.
[02:45:20] Speaker 9: Yeah, she spent 30 minutes with my nurse and 60 minutes with myself. So she was there for an hour and a half?
[02:45:27] Speaker 7: Correct. And is that normal time period that you allot for people coming in for intakes?
[02:45:35] Speaker 9: Yes.
[02:45:37] Speaker 7: And as far as follow-up with you as the clinician and prescriber, was there a plan set for when she was going to return?
[02:45:45] Speaker 9: Yes, we had established a return in two weeks.
[02:45:48] Speaker 7: Now at this point, because you had made that initial contact with her and you had done this intake, was she going to be assigned to you as a patient?
[02:45:55] Speaker 9: This was going to be a short-term arrangement. I was already in the process of leaving the program at the time.
[02:46:01] Speaker 7: Had that been communicated to her?
[02:46:03] Speaker 9: I don't recall. Okay.
[02:46:06] Speaker 7: And as far as what your plan was, how long were you remaining at the practice?
[02:46:13] Speaker 9: I was at the practice until mid-December. So this was like a pre-planned? I was moving back to New Hampshire, yes.
[02:46:28] Speaker 7: But as far as the preliminary care, did you continue on with Lindsay as a patient?
[02:46:37] Speaker 9: No, I transferred her care on November 30th. And I communicated with that to Lindsay.
[02:46:45] Speaker 7: Okay, so as far as after the intake, she was provided with that December 2nd video, excuse me, intake or meeting with Letitia Dukes, the social worker, and then the next scheduled event would have been December 7th, right? For a follow-up?
[02:47:11] Speaker 9: She had a, I believe, I don't recall the actual what her next follow-up with me was. I don't recall that date, but she did have a follow-up with Rebecca Gelata.
[02:47:20] Speaker 7: Okay. Prior to you communicating on November 30th that you were transferring her care, did you have further contact with Lindsay Clancy?
[02:47:30] Speaker 9: Yeah, we had a few phone calls and MyChart messages going back and forth.
[02:47:35] Speaker 7: Can you just explain to the jury what the MyChart messaging system is in your practice?
[02:47:40] Speaker 9: It's kind of a chat feature between the client. They can reach out directly to the provider, it goes right to our inbox, and we can talk back and forth between visits.
[02:47:48] Speaker 7: And do you encourage patients when they come in in that first meeting to utilize the MyChart messaging system?
[02:47:55] Speaker 9: I do often. It's the quickest way to get a hold of me if they're experiencing any major issues.
[02:47:59] Speaker 7: And fair to say it's just an easy way in between visits to communicate particular points of information or concerns or symptoms. Yes. Do you, in your practice, often use MyChart messages if you're not available to meet with the patient to make changes to their treatment plan? Occasionally, yes. Now, prior to your first MyChart message with Lindsay Clancy, did you get a text message from her on your personal phone? I do. I don't recall. Okay. Do you recall whether Sue Clancy provided your number to Lindsay?
[02:48:47] Speaker 9: I know I did. So she must have, she had my number because I called her from my direct, my personal phone call because it was on a Sunday when I reached out to her initially.
[02:48:55] Speaker 7: So that November 20th phone conversation was a communication between you and her on your personal phone?
[02:49:01] Speaker 9: Correct.
[02:49:02] Speaker 7: And so do you recall on November 22nd getting a message from her saying, "Hi, Julie, this is Lindsay Clancy. I'm sorry to contact you like this, but when you have a minute, can you please call?"
[02:49:11] Speaker 9: I can't recall whether that was in MyChart message or if that was on my personal phone. I apologize.
[02:49:17] Speaker 7: That's okay. As a result of some way her contacting you, did you then have a, or send her a message or have a conversation with her on November 23rd?
[02:49:31] Speaker 9: I know we communicated on the 22nd. I sent a message saying that was the day she was getting nervous about starting the Prozac, so we encouraged her to go ahead and start the Prozac. I know we communicated on the 23rd either by phone or by MyChart message that indicated that she had taken the medication. She had started it on the 22nd. Okay.
[02:49:53] Speaker 7: And were you aware at this time period that she was currently already a patient in the South Shore Health System Network with a primary care physician named Margaret Anastasia?
[02:50:04] Speaker 9: Yes.
[02:50:05] Speaker 7: And she's a nurse practitioner, right? Correct. Now, as far as these concerns that she relayed to you about starting the Prozac,
[02:50:22] Speaker 9: do you know whether she did start the Prozac? Yes, she stated that she started the Prozac on the 22nd of November.
[02:50:29] Speaker 7: And by November 25th of 2022, did you start having some MyChart communications with Lindsay Clancy?
[02:50:39] Speaker 9: I did.
[02:50:40] Speaker 7: And so just referring first to November 25th of 2022, fair to say that you gave her or sent her a MyChart message encouraging to kind of stick with the plan, right? Correct. Prior to that, yes. At that point, had you prescribed her something to help her sleep outside what you had previously provided or outside what she had? Before November 25th, I did not. Okay. So on November 25th, did you prescribe her some additional medications?
[02:51:11] Speaker ?: I did.
[02:51:11] Speaker 9: So she wasn't tolerating the Prozac, so we had a conversation about stopping the Prozac. I gave her, she was really having a hard time sleeping, so I gave her a one-time dose of Ambien. And then I also prescribed Mirtazapine, which is another antidepressant, but it works really good for sedation and anxiety. So started that at 7.5 milligrams, told her to stop the Prozac. And I also paired it with Klonopin, but I told her explicitly not to take the Ativan, just to take the Klonopin to help its longer-acting benzodiazepine, to help her with sleep and longer-acting anxiety support while we got this new medication up and running.
[02:51:49] Speaker 7: And so in your conversations with her about her concerns about the Prozac, fair to say she reported to you that she was feeling disconnected out of it, a little bit spacey. Does that sound right?
[02:52:01] Speaker 9: Yes, that's correct.
[02:52:02] Speaker 7: And so you said your recommendation at that point was to discontinue the Prozac. Correct. And as far as the Prozac went, she hadn't taken it for very long, had she? She took it for three days. Three days? Correct. And again, you had that conversation with her about kind of waiting it out for the four to six weeks. But based on what she was reporting to you, did you have any concerns about her stopping the Prozac after only three days?
[02:52:30] Speaker 9: She, when a client doesn't have buy-in to the medication, it's awful. It doesn't work as well. So I was working with Lindsay to try and find a medication that would make her feel more comfortable. She was feeling very uncomfortable, very anxious. And the Prozac, she just wasn't tolerating the activation from the Prozac. Butazapine is a little bit more calming, which I thought she would resonate with better. Okay.
[02:52:51] Speaker 7: And so again, this is not one of those follow-up visits on a telehealth or a face-to-face. So were you relying heavily on what she was reporting to you?
[02:53:02] Speaker 9: Yes.
[02:53:05] Speaker 7: And again, in that MyChart message, you did indicate to stop the Prozac, Benadryl, and Atifan, and don't take while taking Klonopin, right? Correct. And in your practice as a psychiatric nurse practitioner who prescribes medication, is it common that you have to kind of trial different medications to find the right one to work for any given patient?
[02:53:31] Speaker 9: Yes, it's pretty common practice in psychiatry.
[02:53:34] Speaker 7: And fair to say, there's no way to anticipate how a particular patient is going to respond to any particular treatment, medication treatment? Correct. So after prescribing the Klonopin, the Mirtazapine, and giving her that single dose of Ambien, did you do anything or set anything up to follow up with her after changing those prescriptions?
[02:54:06] Speaker 9: I just told her to keep, she can, MyChart messaged me over the weekend. It was the holiday weekend, so I made sure she knew I was available to answer her questions.
[02:54:15] Speaker 7: And fair to say she did, in fact, MyChart. You sent me MyChart messages over the course of that weekend, correct? She did, yes. And so starting at 7:51 on November 26th, she reported to you kind of how that night went, didn't she?
[02:54:30] Speaker 9: Yes.
[02:54:30] Speaker 7: Where she said, I did better last night. I took 7.5 Mirtazapine and 0.5 Klonopin at bedtime, slept fairly well on and off until 3:45. And then she asked, do you think increasing the Mirtazapine will help me stay asleep longer? I can survive like this, but it would be helpful to get to sleep until at least 5. Thoughts? Thank you, Lindsay. Yes. Did you respond to that message? I did. And what did you advise her to do when she asked about increasing the Mirtazapine and wanting to stay asleep longer?
[02:55:00] Speaker 9: I said she could trial the 15 milligrams.
[02:55:03] Speaker 7: And again, is that something that is common for you to do in prescribing, that maybe you have to adjust the dosage? Yes. Did you have any concerns that increasing the Mirtazapine up to 15 would have had any issues or problems? No. And then again, on November 27th, you had a correspondence with her starting at 9:59 a.m. Where she again reports to you how she did that night. Is that something you encourage her to do, to just give you a nightly or like a follow-up the next day, check-in to let you know how she was or what she was experiencing by way of symptoms?
[02:55:39] Speaker 9: I do that with a lot of clients that are really anxious. I like to make myself available to them so that they have that reassurance. Okay.
[02:55:47] Speaker 7: Um, so this wasn't, this wasn't kind of unexpected?
[02:55:50] Speaker 9: It wasn't out of the ordinary for me.
[02:55:53] Speaker 7: And so on the 27th, she, um, indicated she slept well, taking the 15 Mirtazapine and the 0.5 Klonopin, feel rested but super disconnected with myself in reality, and describes it was a scary feeling, thinking of stopping Klonopin tonight and just taking the Mirtazapine. Do you recall that? I do. Communication? And, um, she acknowledges that I've only taken it two nights so that it should, so that should be right, okay? Or, sorry, I've only taken it two nights so that should be okay, right?
[02:56:23] Speaker 9: Do you recall her asking that? She's referring to the Klonopin, and yes, she did. She was really anxious about being dependent on benzodiazepines. So I think her goal was to not be on them. And if she was gonna, she, the disorientation might have been because of all the sedation from the Mirtazapine, which is a common side effect, which is why we chose that and she knew that. Um, and adding the Klonopin, maybe removing that might have helped with some of the sedative factors for it.
[02:56:48] Speaker 7: So did you find there to be any issues with, um, stopping the Klonopin or, or her deciding not to take it after two days?
[02:56:55] Speaker 9: No, I did not. No, I did not.
[02:56:57] Speaker 7: And in fact, you indicated and told her that would, that should help with the disorientation, right? Yes, it might. Okay. Um, and so that was on November 27th. And fair to say that there was another communication via my chart on November 28th with Lindsay Clancy. Yes, there was. And, um, at this point she was asking for, um, or there was some back and forth about needing a note for work, correct? Correct. And is, um, that something that you had talked about with her about, um, getting another note for work?
[02:57:37] Speaker 9: Yes, that's what I do that often.
[02:57:40] Speaker 7: And in fact, um, you kind of went back and forth with her and ultimately she said never mind that she didn't qualify for short-term disability anymore and she's just going to be on personal leave. Correct. So on the 28th, um, there was no back and forth about her, um, taking the medicine and the effects or how she was feeling?
[02:57:59] Speaker 9: She actually had a panic attack earlier in the day, before there was communications about work, and I recommended she take 0.5 of Ativan and go for a run, and I also recommended that she consider doing the partial hospitalization program at women and infants.
[02:58:13] Speaker 7: And, um, what was her response to the recommendation for the partial hospitalization program?
[02:58:18] Speaker 9: At that time, she felt it wasn't going to work logistically for her or her family. And why did you, um, recommend maybe going for a run? To get rid of some of the adrenaline from the anxiety. And running has been a really good thing for her in the past, and I thought it would help calm her down.
[02:58:35] Speaker 7: Um, now on November 29th of 2022, that was the first day that she actually met with Rebecca Gelata, but you had some conversation with her or she sent you a message, I should say, earlier in the day, correct?
[02:58:50] Speaker 9: She sent me a message earlier in the day and at that time I wasn't working that day and Rebecca had an opening. So, I offered the appointment with Rebecca for her. So, I didn't actually communicate with her that day.
[02:59:01] Speaker 7: Okay, but you did receive her message at 6:05 a.m. Um, where she reported that at that point she took 15 Remeron and CBD and it only worked slightly.
[02:59:10] Speaker 9: Correct.
[02:59:11] Speaker 7: So, how did you get from, um, what you have told us now was the, um, mirtazapine, or is that, that's Remeron, right? Correct. Um, how do we get from just the mirtazapine with not the other, the Klonopin, without the Klonopin or without some other?
[02:59:27] Speaker 9: The Klonopin was an as-needed medication. Okay. So, I honored her choice to be able to decide whether she wanted to take that or not.
[02:59:35] Speaker 7: Okay. So, after this panic attack, after the communication about, um, the work form, she reports the next morning that she took the 15 of the mirtazapine or Remeron, um, and then she was having some sleep issues, right? Correct. And that she tried breathing, meditation, and muscle relaxation, um, but then she ended up having to take the Ativan. Correct. Now, um, had you had any conversation with her in this back and forth in these MyChart messages about whether Ativan was something that she should continue to take?
[03:00:07] Speaker 9: It was understood that she wouldn't take it unless, until I had that conversation with her. I was under this understanding that she wouldn't be taking it while taking the Klonopin.
[03:00:17] Speaker 7: But she had told you she wanted to discontinue the Klonopin? Correct. And so, you said as of November 30th that, um, you had then fully transferred care.
[03:00:32] Speaker 9: I let her know that I would be leaving the clinic and I thought it would be best if she saw a clinician that was working five days a week.
[03:00:38] Speaker 7: And Rebecca Gelata, is she a clinician that works at the clinic? Correct. And, um, had you worked with her, um, for quite some time?
[03:00:45] Speaker 9: She'd been in the clinic, I think, for two years, I believe, at the time.
[03:00:50] Speaker 7: And you said that, um, you had, um, recommended on the day before, on the 29th, that she set up that meeting with Rebecca because she was available? Correct. So, it just was kind of happenstance that she ended up with Rebecca, or?
[03:01:03] Speaker 9: I was in the process of transferring all of my patients between Rebecca and our new hire. And Rebecca was an experienced clinician, so I felt she'd be a better match for Lindsay. Okay.
[03:01:14] Speaker 7: And, um, as far as when you sent or communicated to Ms. Clancy that you were transferring her care, um, that was via my chart message, right? Correct. And, um, Lindsay then responded to you. Or do you recall if she responded to you? I'm sorry.
[03:01:31] Speaker 9: She did respond to me saying thank you for the care that I provided. She appreciated it and wished me luck. Okay.
[03:01:38] Speaker 7: Did you have any other contact with Lindsay Clancy, um, after that point?
[03:01:42] Speaker 9: No, I did not.
[03:01:52] Speaker 7: And just to, um, be clear, so when we were talking about, um, moving from November 28th to the 29th in time, um, did you have a phone call with her outside the MyChart messages about that panic attack? Or do you recall having, um, entering a progress note about that?
[03:02:21] Speaker 9: I do remember entering a progress note about that. And that's when I told her to go for the run. I made the recommendation for the PHP.
[03:02:37] Speaker 7: Um, did you ever have any, um, further contact with Sue Clancy about Lindsay Clancy's care after that first, um, contact on November 20th, 2022?
[03:02:47] Speaker 9: I don't recall that.
[03:02:51] Speaker ?: I have no further questions at this time.
[03:02:58] Speaker 7: I have no further questions at this time. Councilor, can you see it sadly?
[03:03:02] Speaker ?: I have no further questions at this time. Councilor, can you see it sadly? I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time.
[03:04:04] Speaker 8: I have no further questions at this time. I have no further questions at this time. I have no further questions at this time.
[03:04:07] Speaker ?: I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time. I have no further questions at this time.
[03:04:16] Speaker 4: I have no further questions at this time. I have no further questions at this time. We are going to start with the cross-examination of this witness. We are going to start that tomorrow. Alright. So we are going to break until tomorrow. Remember my instructions. Don't talk about this case. Don't read about this case. Even similar cases in regards to this. Don't read anything. Don't take any field trips. Don't do any research. You kind of know what the instructions are. I am going to ask you those questions. I will come in. We might start. I would ask you to be here ready to go at 9:00. There may be an issue. I have to talk to the council. It might cause a little bit of a delay. But we will try and keep that minimized. We will get you in here tomorrow. Okay. Great. Thank you for all your work. And I hope you have a nice evening. We will see you tomorrow. Alright.
[03:05:05] Speaker 2: Alright. Good.
[03:05:07] Speaker ?: So do not close but follow me. Alright. Good. So do not close but follow me. Good. So do not close but follow me. Good. So do not close but follow me. Good. Good. So do not close but follow me. Good. Good. So do not close but follow me. Good. So do not close but follow me. Good. So do not close but follow me. Good. So do not close but follow me. Good. So do not close but follow me. Good. So do not close but follow me. Good. So do not close but follow me.
[03:05:34] Speaker 2: Jurisdivak, 7th of the court on this court's session. Please be seated.
[03:05:46] Speaker 4: All right. Anything else we need to address the court? Thank you. So the plan will be to start tomorrow. Before we bring the jury back in, my plan would be to address the defendant's motion for that additional witness. We could maybe do that first thing, and then after I do that, go right back into the presentation evidence. All right. All right. Thank you, everyone. Thank you. Board, all rise.