Part 2: Psychiatrist Jennifer Tufts' Cross-Exam In Lindsay Clancy's Trial

[00:00:00] Speaker 1: This course is down in session. Please be seated. [00:00:04] Speaker 2: Your Honor, for the purpose of the record, we return back to the trial of Commonwealth versus Lindsey Clancy. All parties are present, including the defendant [00:00:12] Speaker 3: and the 18 jurors. All right, thank you. Mr. Rennington. [00:00:16] Speaker 1: 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 auditorium where you have, I believe, interval history. [00:00:32] Speaker 4: I had trouble hearing the date. Can you repeat that? Sure. October 20th. [00:00:36] Speaker 1: Sorry. Okay. So, looking at the interview history, that's when you decided to start Zoloft. It says a week ago, right? That's when the patient started it, yes. Okay. And she then increased the dose, and it says last night, right? Yes. 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? [00:01:08] Speaker 4: Um, that she felt awful. She couldn't sleep. Um, had insomnia, um, which became worse when she increased the dose. She didn't want to eat. She was having diarrhea. Food, um, felt really unappealing. She was more depressed on it. Crying all day yesterday, um, which is not normal for her. She had some mental fog and was terrified to start something new. [00:01:42] Speaker 1: Did she also tell you about her anxiety level? [00:01:44] Speaker 4: Anxiety was really bad even before med. Now, hard to differentiate. Um, overnight racing thoughts. Paranoid of getting suicidal thoughts. Um, something bad happening. Doesn't want to be alone. [00:02:02] Speaker 1: That must have given you concern that you had a pretty sick patient on your hands at that point, right? [00:02:12] Speaker 4: I was concerned, yes. [00:02:14] Speaker 1: Um, so you gave her some therapy, did you? [00:02:16] Speaker 4: Um, I gave her some therapy in conjunction with discussing all of her symptoms and assessing her and managing the medication. [00:02:26] Speaker 1: Okay, and again, I apologize. You have to keep your voice up so people can hear you way down here. Um, so when you say you were talking about the symptoms and, um, what did you do? Just talk about the same thing that we had just gone over? The symptoms? [00:02:40] Speaker 4: Well, there were a number of them to discuss in more detail. That's, that's the summary of them. [00:02:48] Speaker 1: Okay. So, did she discuss it in detail? Yes. Did she tell you that her symptomology at this point, on October 20th, was so bad that she had to have her mother come and stay with her? [00:03:02] Speaker 4: Um, her mom was coming to provide support, yes. [00:03:06] Speaker 1: She wasn't coming to provide support, she was coming to stay with them, to live with them, wasn't she? [00:03:14] Speaker 4: Yes, I don't know for how long, but yes. [00:03:17] Speaker 1: Did you bother to ask her? Why is her mother having to stay with her? [00:03:21] Speaker 4: Because she needed some help. [00:03:24] Speaker 1: Do you know how long her mother stayed with her? [00:03:28] Speaker 4: I don't. [00:03:29] Speaker 1: Do you know that she ended up sleeping in the basement? [00:03:32] Speaker ?: I don't. [00:03:33] Speaker 1: Do you know that she ended up sleeping with her mother? [00:03:36] Speaker ?: I don't. [00:03:37] Speaker 1: So you decided that you'd stop the Zoloft and you would monitor closely, right? Yes. What does that mean, monitor closely? [00:03:47] Speaker 4: Well, I saw her the next day, so that's, that's monitoring, an example of monitoring closely. Okay. [00:03:54] Speaker 1: 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, you also recommended that she try fish oil and things of that nature, natural remedies? [00:04:11] Speaker 4: Yes. [00:04:12] Speaker ?: Okay. [00:04:13] Speaker 1: You also wanted to look into what's called Zulreso, Z-U-L-R-E-S-S-O? Yes. What's Zulreso? [00:04:20] Speaker 4: It is a treatment for postpartum depression. [00:04:25] Speaker 1: 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? [00:04:34] Speaker 4: 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 because… [00:04:50] Speaker 1: You know what? [00:04:51] Speaker 4: 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. [00:05:04] Speaker 1: It's a 60-hour infusion, right? [00:05:07] Speaker 4: It's a long infusion. That sounds right. [00:05:11] Speaker 1: And it's about two and a half days of infusion and it has to be under hospital circumstances and the only hospital around here is in Rhode Island, right? Yes. And did you ever recommend that she do that? [00:05:25] Speaker 4: It was something to consider. I couldn't make the official recommendation because that's not something I prescribe. [00:05:33] Speaker ?: Why? [00:05:34] Speaker 4: Because you can't pick that up at the pharmacy. [00:05:39] Speaker 1: Well, no. Obviously, you have to go to a hospital setting and basically have an infusion through your veins for 60 hours or 2.5 days, but why didn't you look into it or recommend that she do that? [00:05:53] Speaker 4: Well, I did look into it. [00:05:55] Speaker 1: So what happened? [00:05:56] Speaker 4: She ended up actually going to a partial hospitalization program at the hospital that does it. I don't believe the program was 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. Question. [00:06:19] Speaker 1: Is this Women and Infants Hospital in Rhode Island that you're talking about? [00:06:24] Speaker 4: Yes. [00:06:25] Speaker 1: So when you looked at the medical records for the Women and Infants Hospital, did they make reference to your inquiry for Zoressa? [00:06:32] Speaker 4: I never received records from women and infants. [00:06:36] Speaker 1: Did you ever look at them or even online? [00:06:39] Speaker 4: Online? [00:06:40] Speaker 1: Yeah, like online, like you do when you talk to patients. [00:06:44] Speaker 4: No, I never had access to them. [00:06:46] Speaker 1: Why? [00:06:48] Speaker 4: It's similar to South Shore. It's a completely separate hospital that I don't have access to. I don't work there. [00:06:55] Speaker 1: Well, of course you don't work there. But you're a doctor and you're treating a patient who's got medical records that you could access through a HIPAA release, right? [00:07:08] Speaker 4: Yes. [00:07:09] Speaker 1: Why didn't you do that? [00:07:12] Speaker 4: Well, she didn't ultimately end up having any treatment there. So it didn't seem necessary. [00:07:21] Speaker 1: She didn't end up having any treatment there, so it didn't seem necessary. You can't just walk into that place and say, "Hey, I'd like some Zoressa," can you? [00:07:33] Speaker 4: I don't exactly know how it works. [00:07:36] Speaker 1: And then again, on that date, which would be October 20, when the jurors are looking at the records, you checked off the boxes again on objective findings, mental status exam, appearance, speech, things of that nature, correct? Yes. [00:07:54] Speaker ?: Excuse me for one minute, Judge. Yes. [00:07:54] Speaker 1: Excuse me for one minute, Judge. Judge. [00:07:56] Speaker ?: Okay. [00:07:56] Speaker 1: Okay. Okay. Okay. Okay. Okay. speech, things of that nature, correct? Yes. Excuse me for one minute. So when she was telling you on that date that she was "paranoid" of getting suicidal thoughts and something bad happening, doesn't want to be alone, what did she [00:08:40] Speaker 4: mean by that? Well those were a lot of a lot of her words. Right, isn't that a [00:08:48] Speaker 1: concern? Your patient is telling you she doesn't want to be alone. Why didn't she [00:08:53] Speaker 4: want to be alone? Because she was very anxious and had the feeling like [00:08:58] Speaker 1: something bad might happen. 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? They never called my office, so I never spoke with them. They never called your office? They never [00:09:29] Speaker 4: called me or sent a message, so I did not have communication with them. So it's their [00:09:34] Speaker 1: fault, but they didn't call you the doctor. Sustained. Next question. 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 [00:09:50] Speaker 4: with them, that you would make a phone call yourself? It's not typical when you have an adult who is able to advocate for themselves to speak with their parents. So [00:10:00] Speaker 1: 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? Yes. 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? Yes. And then you started her on Ativan, as we talked about, right? Yes. And then you started her on the Buspirone, right? Well, she had [00:11:02] Speaker 4: already been started on the Ativan, and then we added the Buspirone. So my [00:11:06] Speaker 1: 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. Did you also discuss the studying Remeron or Pregabalin? Yes. What did you tell her about Remeron and Pregabalin? I don't think I [00:11:40] Speaker 4: went into any detail about those medicines. Just that those might be things to consider in the future. And then you saw her on October 31st, right? That was her... I think that was just a therapy appointment with a different provider. Would that be Jennifer McAllister? Yes. So it's a [00:12:13] Speaker 1: different provider in the sense that she works for Aston, right? Well, yes. It just wasn't myself. Right. 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. Objection. Is that a question? No, go ahead. Next question. McAllister did a suicide assessment, apparently, right? I'm sure she assessed her suicide. No, no, no. Let me get the record, please. Mm-hm. Where do you see it? Sorry. Where it says suicide assessment. [00:12:55] Speaker 4: There's only four pages for October 31st. Yeah. Well, actually, there would be eight because it's two sides. So that is the assessment that you go through. If somebody reports any thoughts of suicide, then you ask those questions, which go into a lot more detail about them. [00:13:15] Speaker 1: Okay. So here you have a patient who's already reported to you as a psychiatrist that she's got suicidal ideation, worried about suicide, worried about killing herself days before October 31st, and a suicide assessment was done by McAllister, right? [00:13:36] Speaker 4: I wasn't there. You would have to ask her. Well, maybe I will if she comes in. Okay. Okay. Why don't you tell me what the record shows? [00:13:44] Speaker 1: Okay. Did they do a suicide assessment? Did you check off the little boxes? I'm looking for that section. [00:13:59] Speaker 4: It says that patient denies suicidal or homicidal ideation at this time. Okay. So again, this is on October 31st, right? Yes. [00:14:13] Speaker 1: She's a patient within a period of a couple of days and meetings with you that McAllister has access to because the records are within your business, right? It's not my business, but yes. Has reported suicidal ideation and fear and dwelling about killing herself and afraid of those thoughts, right? [00:14:38] Speaker 4: She -- I just want to be absolutely clear. So, yes. You know, a little while earlier she had voiced those concerns. [00:15:00] Speaker 1: Right. So as a result of voicing those concerns, is it your understanding that McAllister did not do any of the suicide assessment questions because Lindsay reported that she wasn't suicidal? [00:15:18] Speaker 4: I -- it appears that she asked about suicidality. [00:15:23] Speaker 1: You already told us that. I'm asking you about -- excuse me. Hold on. Ask the next question. Go ahead. Thank you. I'm not asking you -- you've 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. Okay. Can you tell me, did Lindsay answer any of the questions that were asked over the two pages, possibly three, of the suicide assessment -- yeah, three -- done by McAllister? [00:16:00] Speaker 4: I don't see anything written here. [00:16:04] Speaker 1: So was there a suicide assessment? [00:16:07] Speaker 4: I don't know because I wasn't there. I don't know what the conversation was. [00:16:11] Speaker 1: You don't know from looking at the records, right? [00:16:14] Speaker 4: From looking at the records, I don't see evidence of additional suicidal questions beyond asking if it was there or not. [00:16:23] Speaker 1: So, a 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? For four pages, right? [00:16:52] Speaker ?: Yes. [00:16:53] Speaker 1: And there is not one notation indicating that that test was ever administered to her on October 31st, correct? [00:17:03] Speaker 4: Correct. But it was -- it looks like it was asked in other ways. [00:17:09] Speaker 1: Okay. November 2nd. Oh, it was asked in other ways? Is that what the little check box where it says "deny suicidal ideation"? [00:17:17] Speaker 4: Can I read something that she wrote in the note? [00:17:20] Speaker 1: You had indicated repeatedly that she denied suicidal ideation, right? Yes. Okay. The suicidal assessment was not administered according to the record that's in front of you by McAllister, yes? [00:17:37] Speaker 4: The additional suicidal assessment, yes. [00:17:43] Speaker 1: November 2nd. By the way, as a psychiatrist, not a psychologist, you have the ability to prescribe medication, obviously, right? Yes. And I think you talked about the DEA number and all of that, correct, which you had for about a month, other than when you were a resident, right? Yes. So you're prescribing these SSRIs and antipsychotics and antitropics or whatever they are. Okay. And it's important as to the metabolism of your patient with those drugs, isn't it? [00:18:18] Speaker 4: Yes. [00:18:19] Speaker 1: Okay. Keep your voice up. What does metabolism mean? [00:18:24] Speaker 4: The body breaking down the medication. [00:18:29] Speaker 1: 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? [00:18:48] Speaker 4: We don't typically have any specific testing that we do to understand that. [00:18:55] Speaker 1: How about a blood test? [00:19:01] Speaker 4: It's not done for that. [00:19:04] Speaker 1: It's not done for that, meaning a blood test is not done to determine the metabolism of your patient, of your medications? [00:19:13] Speaker ?: Okay. [00:19:14] Speaker 4: Are you referring to genetic testing? [00:19:17] Speaker 1: No, I'm asking about the metabolism. Okay. I'm not talking about genetics. I'm talking about the metabolism of the SSRIs in our body. Okay. You can tell that metabolism rate through blood testing, right? [00:19:29] Speaker 4: Not in the way that you're describing. Okay. [00:19:32] Speaker 1: What way would it be? [00:19:34] Speaker 4: There is genetic testing that can give information about metabolism. [00:19:41] Speaker 1: Like what? [00:19:44] Speaker 4: 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. [00:20:11] Speaker 1: 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? [00:20:20] Speaker 4: It's a little complicated. [00:20:22] Speaker 1: Yeah. You don't expect a patient that's going through what she was going through to understand that, would you? Yeah. Did you guys do the enzyme test? [00:20:31] Speaker 4: They are not typically done. [00:20:33] Speaker 1: Why? [00:20:34] Speaker 4: Because, again, it's genetics. [00:20:38] Speaker 1: Are you sure it's covered? I'm just in the middle of the answer. [00:20:43] Speaker 5: Good. Finish that answer and allow a follow-up. Go ahead, Doctor. [00:20:47] Speaker 4: So it's not as simple as testing for an 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 is not commonly done. [00:21:11] Speaker 1: What is the, sorry, what is the Cytopro P4-50 system? [00:21:20] Speaker 4: That's one of the enzymes that I'm talking about. [00:21:23] Speaker 1: So the Cytopro P4-50 system talks about and tests for the breakdown of psychiatric meds in the blood, right? [00:21:31] Speaker 4: It's not in the way that you're describing. It doesn't tell you what medicines to take. [00:21:38] Speaker 5: Again, finish the answer and then you can ask follow-up. Go ahead, Doctor. [00:21:43] Speaker 4: 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. So what's it useful for? I mean, I don't find it terribly useful. [00:22:00] Speaker 1: How long has the Cytopro P4-50 system been in use in your field? I'm sorry? How long has the Cytopro P4-50 system been in use in your field, psychiatry? [00:22:14] Speaker 4: Well, it's an enzyme in the body. Well, I know what it is. [00:22:17] Speaker 1: I'm asking you about the system, the testing. How long have they been using that? [00:22:22] Speaker 4: The genetic testing, maybe a few years. Yeah, whatever it is. It's very new. Very new. [00:22:29] Speaker 1: Does insurance cover it? Sometimes. [00:22:32] Speaker 4: Sometimes. [00:22:33] Speaker 1: Sometimes. So, it is nevertheless a legitimate test to determine the breakdown of psychiatric meds in a patient's blood, correct? [00:22:46] Speaker 4: It exists, yes. It exists. [00:22:49] Speaker 1: Well, it exists, but you didn't use it, right? [00:22:53] Speaker 4: It would not have made a difference. [00:22:55] Speaker 1: In what? In your opinion? In her treatment. Because you go by the checks in the checkbox and what she self-reports, right? [00:23:03] Speaker 4: No. No. Not just the checks in the checkbox. Oh. [00:23:07] Speaker 1: In any event. Tell me about the thyroid. The thyroid? Tell me about the thyroid. [00:23:11] Speaker 4: The thyroid? The thyroid. It's an organ in the human body that regulates hormones. [00:23:18] Speaker 1: And what, if any, import and impact do thyroid levels have on your evaluation of a woman who is in the throes of postpartum depression? They don't. They don't. What is the purpose of a test to determine the thyroid levels? [00:23:49] Speaker 4: Well, you can test something like the TSH. Well, I don't know what a TSH is. [00:23:54] Speaker 1: I'm sorry. What is a TSH? [00:23:56] Speaker 4: A thyroid stimulating hormone. [00:23:59] Speaker 1: Okay. Thank you. [00:24:01] Speaker 4: That's something that can be tested typically by maybe a PCP, primary care, or endocrinologist if they have concerns about someone's thyroid function. [00:24:16] Speaker 1: Were you aware of a study that was a major study that was peer-reviewed? What does peer-reviewed mean in your business? [00:24:24] Speaker 4: That it was reviewed by other researchers in a similar field. [00:24:33] Speaker 1: 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? Yes. And you'd agree with me that in the medical field it's a big deal to have publishing articles on your resume, right? Yes. And how many articles have you published about postpartum depression, postpartum psychosis, anything? [00:25:05] Speaker 4: I have published something, but it's not a full article. It's just a small thing. Okay. [00:25:13] Speaker 1: Are you aware of the Psychiatry Magazine article dealing with, in 2021, thyroid function in postpartum psychosis, an exploratory study. Have you ever heard of anything about that, let alone read an article about it? [00:25:33] Speaker ?: No. [00:25:34] Speaker 1: Are you aware that there are studies that have compared thyroid function between psychosis with postpartum onset, PPO, psychosis without postpartum onset, PWPO, and normal postpartum? Are you aware of that? No. Well, you're supposed to be an expert, or you specialize, or you have an interest in treating women that have suffered from postpartum, correct? Yes. Have you written any articles at all about postpartum depression, anxiety, psychosis? No. [00:26:08] Speaker 4: I'm not a researcher. I'm a clinician. [00:26:10] Speaker 1: Have you read any of the articles, such as thyroid function and postpartum psychosis? I've read many articles. [00:26:17] Speaker 4: There are thousands. I have not read that specific article. Thousands? [00:26:21] Speaker 1: Thousands of articles on postpartum psychosis and the thyroid? [00:26:27] Speaker 4: No, not on that specific topic. [00:26:30] Speaker ?: No. [00:26:31] Speaker 1: 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 cytochrome P4 testing, is not necessary because Jennifer Tufts doesn't think it's necessary, right? [00:26:55] Speaker 4: It does not yield information. That would influence treatment. Really? [00:27:02] Speaker 1: So, if there was elevation in the thyroid, that wouldn't impact on your treatment at all, your evaluation, your investigation? [00:27:08] Speaker 4: Sorry, I thought you had mentioned the cytochrome issue. Are we talking about that one or are we talking about the thyroid? [00:27:18] Speaker ?: I'm talking about the thyroid. Okay. Yeah. [00:27:21] Speaker 1: So, if there were tests that revealed elevation in the thyroid level, is it your testimony that you wouldn't care? [00:27:31] Speaker 4: If I somehow found out that a patient had elevated thyroid levels, I would advise them to talk to their primary care or maybe get an endocrinologist to discuss it. [00:27:47] Speaker 1: Did you ever recommend that Lindsay get an endocrinologist? No. [00:27:52] Speaker 4: She did not. The answer is no. [00:27:54] Speaker 1: And you basically did not have any information that you could use to even realize that there might have been a thyroid issue with this woman that was postpartum, right? Because you didn't do any blood tests. [00:28:15] Speaker 4: There was no clinical reason to obtain a blood test. [00:28:19] Speaker 1: All right. So, you continue on with your meetings by the computer, correct? Yes. November 2nd. You can get November 2nd out. You get it? [00:28:34] Speaker 4: November 22nd? No. [00:28:39] Speaker 1: It looks like November 2nd. I apologize. That's what I'm looking at. Tufts, Jennifer, MD. Clancy, Lindsay. Follow up? No. November 2nd? Yes. Okay. And you're still diagnosing her with generalized anxiety disorder, GAD, right? [00:28:58] Speaker 4: Yes. [00:28:59] Speaker 1: You add in there an adjustment disorder with depressed mood, I guess because of what she had been telling you, right? [00:29:06] Speaker ?: Yes. [00:29:07] Speaker 4: Okay. [00:29:08] Speaker 1: Looking at the psychiatric condition, you note that it's improving. Right? [00:29:15] Speaker ?: Yes. [00:29:16] Speaker 1: 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 note if she's having urges to harm herself or others to go to the nearest emergency room and call 9-1-1 and things of that nature, correct? [00:29:51] Speaker ?: Yes. [00:29:52] Speaker 1: So is that a form that you basically press a button in because it seems to be kind of like a generic advice, call 9-1-1 if you're feeling suicidal and things of that nature. [00:30:05] Speaker 4: Well, that's advice that we provide for every single patient. [00:30:10] Speaker 1: Okay. And then you note that half the encounter was on counseling or coordination of care on November 2nd, right? [00:30:20] Speaker 4: Yes. That's a typical statement. It's just a part of documentation that doctors use. All right. [00:30:29] Speaker 1: Now, on November 2nd, you were suggesting the four drugs that you would start would be Remeron, Trazodone, Fragabalin, and Hydroxazine, right? [00:30:41] Speaker 4: Those were just things we were considering. Oh. I wasn't starting all of those medicines. I see. [00:30:48] Speaker 1: Okay. On November 22nd, now that would be almost three weeks later, right? You saw her, right? And did you ask her about whether or not she was still having suicidal thoughts or worrying about suicidal thoughts, for example? Did you ask her that? Yes. And how do you know that? [00:31:11] Speaker 4: Because the box is checked? [00:31:12] Speaker 1: It's written in my note. What does it say? Patient denies as I. [00:31:15] Speaker 4: Okay. What did you ask her about that? I don't remember the exact words, but I know that I asked about that. [00:31:28] Speaker 1: Did you ask her about how things were going at home with the mother and father staying there? [00:31:33] Speaker 4: That, I don't remember. I didn't document how her parents were doing. [00:31:40] Speaker 1: Okay. Well, I don't really care about how her parents were doing. I'm asking about whether or not you asked her how it was working out while her parents were there helping out. If you did, fine. If you didn't, that's fine, too. [00:31:52] Speaker 4: Yeah, I don't think that I did. In this appointment, she... [00:31:55] Speaker 1: Okay. That's all. [00:31:57] Speaker ?: Okay. [00:31:58] Speaker 1: 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 Soshore? Yes. She disclosed to you that she had been seeing Soshore, right? Yes. We already talked about the fact that you never got the records from Soshore, so you don't know, other than what Lindsay reported to you, what medications she was on, right? [00:32:32] Speaker ?: Right. [00:32:33] Speaker 4: I knew what she was telling me. [00:32:36] Speaker 1: Right. And she told you that she was doing the Ativan taper, right? [00:32:41] Speaker 4: Well, she said she had tried doing that, but that then she was having worse sleep. [00:32:50] Speaker 1: 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? [00:33:03] Speaker 4: Well, the Trazodone she didn't have a problem with. It just didn't seem like it was particularly helpful. [00:33:09] Speaker 1: Okay. Did you prescribe the Trazodone or somebody else? [00:33:12] Speaker 4: This was somebody else. [00:33:14] Speaker 1: So, do you know what the milligrams were that she was on? [00:33:17] Speaker 4: It says she tried between 50 and 150 milligrams. [00:33:21] Speaker 1: All right. Now, did she at some point try Remeron? [00:33:31] Speaker 4: She said that she did. [00:33:33] Speaker 1: Did you suggest in your discussions that she try Remeron? [00:33:38] Speaker 4: No, I did not. [00:33:39] Speaker 1: Did she indicate to you that she had rebound anxiety and intrusive thoughts that she was going to die? Do you recall that? [00:33:49] Speaker 4: Well, she said worse depression and intrusive thoughts. [00:33:54] Speaker 1: Okay. Did she tell you what the intrusive thoughts were? [00:33:57] Speaker 4: It was the feeling like I'm going to die. [00:34:03] Speaker 1: Did she then have a script for Prozac, 10 milligrams? [00:34:07] Speaker ?: Yes. [00:34:08] Speaker 4: That's what she said. [00:34:09] Speaker 1: And she said that she couldn't sleep and had worse sleep so that had to be stopped, right? Yes. Then she was on Klonopin, right? [00:34:20] Speaker 4: Yes. [00:34:21] Speaker 1: And what is Klonopin? [00:34:22] Speaker 4: It's a benzodiazepine. [00:34:25] Speaker 1: 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. 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? I believe that I did. [00:35:18] Speaker 4: What did you do? [00:35:19] Speaker 1: What did you do? You've got a woman that's telling you that she's hopeless, she doesn't care if she dies, can't sleep. You can't sleep. [00:35:27] Speaker ?: What did you do? [00:35:27] Speaker 1: What did you do to validate on your therapy? [00:35:31] Speaker 4: Well, 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, like partial hospitalization programs. So she knew that she still had options and a reason to hope. [00:35:58] Speaker 1: Did you ever suggest to her that maybe come in and see me, rather than talk on the computer? [00:36:04] Speaker 4: I think, um, discussing, uh, talking with her over the video did not seem like an issue. Um, it didn't seem like there was anything that I was missing or that there was any need to see her in person. [00:36:17] Speaker 1: Now, you'd agree with me that in December of 2022, COVID was all done, right? [00:36:24] Speaker 4: It wasn't completely all done. [00:36:26] Speaker 1: 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? [00:36:33] Speaker 4: 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. [00:36:44] Speaker 1: You discussed trying Seroquel with her at that point, right? [00:36:49] Speaker 4: Um, I didn't really discuss it. She, um, well, she had told me that that was, um, that was something that she had discussed with her other provider. [00:37:03] Speaker 1: So, looking at your notes, does it say "also discussed" trying Seroquel alone tonight? Did your notes say that? [00:37:17] Speaker 4: It says, yes. Um, but I wasn't, I wasn't making a recommendation about the Seroquel. It was just a medicine I was providing her more information on. [00:37:26] Speaker 1: So, so you were telling her about the Seroquel? You're providing information? [00:37:33] Speaker 4: Yes, we were talking about the Seroquel. Right. [00:37:37] Speaker 1: Why? [00:37:38] Speaker 4: Because her other provider had recommended that she started it. [00:37:44] Speaker 1: What is Seroquel? [00:37:46] Speaker 4: It's an anti-psychotic. [00:37:49] Speaker 1: You also discussed with her the possibility of undiagnosed bipolar disorder, did you not? [00:38:03] Speaker 4: It was discussed. [00:38:05] Speaker 1: And undiagnosed bipolar disorder was, in your opinion, as a result of, not a reaction, but extreme reaction to the SSRIs, right? Right? [00:38:19] Speaker 4: Not, so not as a result of the SSRIs, but that reaction. [00:38:24] Speaker 1: Does your, excuse me, does your note say, and I quote, "also discussed possibility of undiagnosed bipolar disorder given extreme reaction to SSRIs and insomnia." Period. Does it say that? Yes. Those are your notes, right? [00:38:42] Speaker 4: Yes. The way you were saying it made it sound a little bit different before, but that's exactly what I wrote. [00:38:47] Speaker 1: I read it directly from your note, right? That time. How did it make it sound different? [00:38:50] Speaker 4: I don't know. It sounded different the first time you said it than the second. [00:38:53] Speaker 1: So did she have bipolar? No. Did you make that decision that night? That day? [00:38:59] Speaker 4: I assessed that with her pretty much every time that I saw her, and she never had mania. [00:39:08] Speaker 1: What about mood stabilizer like Lamictol? Did you discuss that with her? Yes. What is Lamictol? [00:39:16] Speaker 4: It's an anticonvulsant, but it's used in treating mood disorders. [00:39:24] Speaker 1: 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? [00:39:34] Speaker 4: Yeah. Well, so at this time I was not prescribing her medications, but I was still concerned, not concerned enough that she was at imminent risk of hurting herself or anybody else given what she said. But we had a plan for her to pursue a partial hospitalization program. [00:39:55] Speaker 1: And where was that? [00:39:56] Speaker 4: Well, the one that I had recommended was HRI. [00:39:59] Speaker 1: What is that, HRI? [00:40:00] Speaker 4: It's a hospital in Brookline. [00:40:02] Speaker 1: And did she ultimately go to another hospital? [00:40:06] Speaker 4: She ultimately went to the Women and Infants Hospital for one day. [00:40:12] Speaker 1: And those are the records that you didn't get, right? Correct. [00:40:16] Speaker 4: Okay. [00:40:17] Speaker 1: And you decided that she did not have bipolar disorder because, in your opinion, she did not meet, and I call it the criteria, right? And that would be the criteria in the DSM, right? Yes. And the DSM, of course, is the Diagnostic Statistical Meaningful. Roman numeral 5, R, meaning text revision, right? Yes. Is that what you were using back then? It would be this thing here? DSM-5, TR? This is the DSM, right? Yes. [00:40:45] Speaker ?: It's like a cookbook, right? [00:40:46] Speaker 1: Yes. It's like a cookbook, right? [00:40:49] Speaker 4: It's more of a guideline that we use to, you know, to help us in our treatment. But it's not the psychiatry bible that people sometimes think that it is. [00:41:07] Speaker 1: Right. Hypomanic bipolar disorder, how many days does that require under the DSM? [00:41:17] Speaker 4: A hypomanic episode lasts for at least four days. [00:41:22] Speaker 1: And is that per the DSM? [00:41:24] Speaker 4: Yes. [00:41:25] Speaker 1: Remember on Friday you said that the most important criteria is seven days with continued high energy levels? Yes. So is it seven days or is it four days? And who says? [00:41:38] Speaker 4: Well, mania is seven days. Hypomania is four. [00:41:44] Speaker ?: Yes. You know in your records that she indicated that she was really struggling. [00:41:58] Speaker 1: And it was as a result of that that you recommended that hospital program, right? Yes. Do you agree that she had a severe mental disturbance at that point that was manifesting itself? [00:42:13] Speaker 4: She had a maybe moderate and moderate heading towards severe. [00:42:20] Speaker 1: Moderate heading towards severe mental issue. Okay. Do you agree with me that she had increased anxiety, right? Yes. She had very, very increased depression, right? Well, she did. [00:42:37] Speaker ?: Just answer yes or no. [00:42:37] Speaker 4: I'm sorry. I was just trying to check the record. Okay. 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. [00:42:43] Speaker 1: That's all. It's sometimes impossible to do that. [00:42:45] Speaker ?: I'm just here. [00:42:46] Speaker 4: If you can't answer yes or no, just say you can't answer yes or no. [00:42:51] Speaker 1: If you can't answer yes or no. [00:42:52] Speaker ?: If you can answer yes or no, answer yes or no. That's how we do it. [00:42:52] Speaker 1: All right? Okay. Thank you. Thank you. [00:42:56] Speaker 4: Now, mental issues like anxiety that was diagnosed, the depression that was diagnosed, and the [00:43:01] Speaker 3: fact that she indicated yet again that she was close to suicidal ideation, quote, worried about suicidal thoughts. Um, but you indicated that she wasn't suffering from suicidal ideation on that day. [00:43:09] Speaker 1: Is that fair? She denied it. But she told you that she was worried about suicidal ideation and having suicide. All right? All right? Okay. 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 day. Is that fair? [00:43:33] Speaker 4: She denied it. [00:43:34] Speaker 1: But she told you that she was worried about suicidal ideation and having suicidal thoughts, [00:43:39] Speaker 4: right? Well, yes, this was the time she said she was worried that she was close to having suicidal thoughts. [00:43:46] Speaker 1: All right. So did you ask her what does that mean? Does that mean 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? [00:43:56] Speaker 4: So I asked about that, and that's when she said, she described it further as using the word "God bless." [00:44:04] Speaker 1: So, did you prescribe the Lamarco gene on that occasion, or no? No. [00:44:14] Speaker 4: On December 16th, that's the next appointment she had, right? [00:44:16] Speaker ?: Yes. Like two weeks later? Right? Yes. Yes. She was still not well, correct? Yes. [00:44:21] Speaker 1: She told you she was having a really rough time. She was sleeping, but she was still feeling very poorly. [00:44:36] Speaker ?: In your notes, does it say that she was having a really rough time? [00:44:36] Speaker 1: Yes. Yes. [00:44:38] Speaker ?: 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? No. [00:44:39] Speaker 4: No. No. No. No. [00:44:43] Speaker 1: No. No. [00:44:45] Speaker ?: It's an important detail. [00:44:45] Speaker 1: Yeah, I guess. [00:44:46] Speaker ?: How about the rough time? [00:44:46] Speaker 1: Yes. So when I asked you, if your notes reflected that she said she was having a really rough time, why do you feel compelled to say she was sleeping? [00:44:57] Speaker ?: Attention. [00:44:58] Speaker 4: Overall. It's an important detail. [00:45:02] Speaker 1: Yeah, I guess. How about the rough time? What did that mean? What were the symptoms of having a really rough time for this kid? [00:45:11] Speaker 4: Do you want me to... [00:45:12] Speaker 1: Yeah, I'd like you to answer that. [00:45:16] Speaker 4: Okay. So finally works, referring to the valium and quetiapine, but very depressed during the day. No motivation, some SI. Do you want me to continue? [00:45:31] Speaker 1: Sure. [00:45:32] Speaker 4: Went to MGH emergency room for SI. Declined inpatient. Feeling hopeless. No intent for plan. And feels like depression related to Seroquel. [00:45:44] Speaker 1: Okay. Now that's the question on Friday that... I'll strike that. So what was the SI? Suicidal ideation? [00:45:53] Speaker 4: Yes. [00:45:54] Speaker 1: And can you read that back to me again? What did she say about SI? [00:45:58] Speaker 4: So that when she went to the hospital, she went because she had no motivation, some SI. [00:46:07] Speaker 1: Some SI meaning that she had some suicidal ideation, right? [00:46:13] Speaker 4: Yes. In her words, yes. [00:46:14] Speaker 1: 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? [00:46:30] Speaker 4: I can't answer that as a yes or no. [00:46:33] Speaker 1: Well, it's in your notes that she said that, right? Yes? [00:46:38] Speaker 4: What is in my note? [00:46:41] Speaker 1: Do you understand my question? [00:46:44] Speaker 4: I'm a little bit confused right now. Can you repeat what your question is? [00:46:46] Speaker 1: Sure, of course. We've spent some time talking about thinking about suicidal ideation, worrying about suicidal ideation. Now, same. She had suicidal ideation, right? [00:47:05] Speaker 4: She said it, yes. [00:47:07] Speaker 1: Well, this is the only source of information that you're getting, apparently, is what she's telling you, right? [00:47:13] Speaker ?: Yes. [00:47:16] Speaker 1: So what suicidal ideation did she have? Is she thinking of cutting her throat? Is she thinking of throwing herself off a building or running out in front of a car? What? [00:47:24] Speaker 4: No. [00:47:25] Speaker 1: What was she thinking of? [00:47:27] Speaker 4: So I asked her those important follow-up questions. What was it? So what do you mean when you say I'm feeling suicidal? [00:47:36] Speaker 1: Okay. [00:47:36] Speaker 4: And that's when she said, it means I'm feeling hopeless. And then I asked, do you have intention of hurting yourself? Do you have a plan for hurting yourself? And she denied those. [00:47:53] Speaker 1: And that's where you left it? [00:47:56] Speaker 4: I mean, I'm sure more was said, but that's the most important point of that clinical encounter. [00:48:02] Speaker 1: And did you give a therapy by the computer on that date, too? [00:48:08] Speaker 4: Yes. [00:48:08] Speaker 1: What did you do for therapy about her suicidal ideation and saying she wanted to kill herself? [00:48:14] Speaker 4: Well, we explored what that meant and what to do if you're feeling that way. [00:48:24] Speaker 1: To do what? [00:48:25] Speaker 4: To go to the emergency room. [00:48:28] Speaker 1: Did you discuss prescribing Seroquel to her? Or was she getting Seroquel? Did Seroquel enter into your discussion at all? [00:48:35] Speaker 4: We talked about it. I was not prescribing it for her. [00:48:39] Speaker 1: What is Seroquel? [00:48:41] Speaker 4: That's an antipsychotic. [00:48:49] Speaker 1: So at the conclusion of your meeting on December 16th, basically what you took away is that she had now increased the suicidal ideation, was feeling hopeless, all the rest of the things that we've talked about, and then she, what, just moved on, went home? [00:49:09] Speaker 4: Well, she was assessed in the emergency room and was not admitted. And I assessed her on that day again, and while she was certainly struggling, she did not require hospitalization at that moment. So she was planning on going to the women infants program, and I supported that. [00:49:34] Speaker 1: Did you know that around that time, she confessed to her husband that she was having now thoughts of harming the children? [00:49:44] Speaker 4: No. [00:49:44] Speaker 1: Would that have been something you were concerned about? [00:49:47] Speaker 4: If I heard that, I would have been very concerned. [00:49:49] Speaker 1: You would have called DCF, right? [00:49:51] Speaker 4: I might have. [00:49:53] Speaker 1: And 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? [00:50:10] Speaker 4: He never called me again. Or he never called at all. I never spoke with him again. [00:50:14] Speaker 1: 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 to 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? [00:50:34] Speaker 4: Well, we did speak on that visit. [00:50:36] Speaker 1: Which visit? [00:50:37] Speaker 4: The 16th. Or I think that that's the one that he was at. [00:50:41] Speaker 1: You think it was? It's not noted in your record? [00:50:43] Speaker 4: 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. [00:50:52] Speaker 1: December 16th, on your objective findings, you note that her mood was depressed, right? [00:51:13] Speaker 4: Yes. [00:51:14] Speaker 1: And what does that mean? Did she just say, I'm depressed, or did she give you the symptoms? I mean, you checked the little box. [00:51:21] Speaker 4: Yeah, it means she's saying that she's depressed. [00:51:24] Speaker 1: 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 date? Was she crying? Was she able to get out of bed? Was she worshiping at the Forcelain Guard? What was going on in her life? [00:51:43] Speaker 4: She said she was having a really tough time. [00:51:49] Speaker 1: Her affect was flat, right? [00:51:54] Speaker ?: Yes. [00:51:56] Speaker 1: And again, depressed, you check it off twice. One on the mood and one on the affect, right? Yes. And then at the next page, it says recent lab work. That wouldn't be blood testing, would it? I mean, Asta, does Asta do blood testing? [00:52:16] Speaker 4: We don't have a phlebotomist or a lab, no. [00:52:20] Speaker 1: Well, why does it say recent lab work typed into your form where you check off the little boxes? [00:52:26] Speaker 4: That's something that auto-populates. It's a template that, you know, many different... It's a template. The whole node is something that psychiatrists or, you know, probably all across the country use. [00:52:39] Speaker 1: Probably. You can't diagnose someone's illness by a template, can you? [00:52:44] Speaker 4: No. [00:52:45] Speaker 1: You filled in. No lab results were found, right? [00:52:49] Speaker 4: There were none in the computer, yes. I didn't type that in, though. It just auto-populated. It was auto-populated. [00:52:58] Speaker 1: 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? [00:53:12] Speaker 4: Symptom reduction is to have fewer mental health symptoms and improved functioning means, you know, improved, you know, day-to-day life functioning, you know, things that she's doing in her daily life. [00:53:33] Speaker 1: Really? Did you tell her all that? Yes. You have 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? [00:53:58] Speaker 4: I told her to go to the partial hospitalization program, and if she was having more suicidal thoughts again, or felt like she was at risk of hurting herself or anybody else, that she should go immediately to the emergency room. [00:54:15] Speaker 1: How long did that meeting take? [00:54:17] Speaker 4: Probably about 30 minutes. [00:54:20] Speaker 1: And was that the therapy that you provided, telling her to go to the emergency room? [00:54:26] Speaker 4: I mean, that was probably a component. [00:54:29] Speaker 1: So, the plan, excuse me, on December 16th, was to follow up with women and infants, right? [00:54:39] Speaker 4: Yes. [00:54:41] Speaker 1: Did she? [00:54:43] Speaker 4: Yes. [00:54:44] Speaker 1: Do you know when? [00:54:47] Speaker 4: I don't know exactly the day, shortly after. [00:54:53] Speaker 1: Then you were considering a brexaniline, brexanilone infusion, right? [00:55:00] Speaker 4: That's the Zolraso. [00:55:02] Speaker 1: That's the same thing in Rhode Island? [00:55:04] Speaker 4: Yeah. [00:55:05] Speaker 1: Okay. And that didn't go anywhere, right? That was... No. It says Stark Lamectol, 25 milligrams daily, right? Yes. Continued Seroquel, right? What was the milligram for the Seroquel up to at this point? [00:55:24] Speaker 4: Well, she had told me it was 200. That was... I did not write that prescription, so that's what her provider had prescribed her. [00:55:34] Speaker 1: Okay, so you can ask somebody to show me the bottle, pill bottle. You can ask somebody to show me the CVS receipt. You can ask somebody, you can call to verify, right? [00:55:45] Speaker 4: I could. [00:55:46] Speaker 1: But you... Anyway, she said that she was on Seroquel, 200 milligrams, right? And had stopped with the valinine, right? [00:55:57] Speaker 4: Yes. [00:55:57] Speaker 1: 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? [00:56:09] Speaker 4: Yes. [00:56:13] Speaker 1: Was her mother and father still staying with her on December 16th, if you know, with Pat and the kids? [00:56:18] Speaker 4: I'm not sure. [00:56:19] Speaker 1: Did you ever ask anybody other than her how she was doing? [00:56:27] Speaker 4: I asked her husband when he was at the appointment. [00:56:30] Speaker 1: Yeah, that's the other appointment. How about now, talking December 16th into the month of December, did you ever ask anyone how she was doing? [00:56:39] Speaker 4: Well, I think he was at that visit. [00:56:42] Speaker 1: You think he was at the visit? How did he tell... What did he say to you about how she was doing? [00:56:47] Speaker 4: He said she wasn't doing well. [00:56:49] Speaker 1: She's got an objection, great. Great. Objection. No rule. Go ahead. [00:56:56] Speaker 4: He said she wasn't doing well. [00:56:59] Speaker 1: Anything else? [00:57:00] Speaker 4: Yeah. He felt that it might have been, his opinion was that it was related to when she started the Cerequil. [00:57:11] Speaker 1: He basically said you guys are turning her into a zombie, right? That's it. Those are the words? Overruled. [00:57:19] Speaker 4: I don't have that written. He may have said that. [00:57:23] Speaker 1: Does that kind of hit me, though, that you might remember that? You might have been, as some people, worried about suicide. You might be thinking in your brain that he did say you're turning her into a zombie. It's possible. [00:57:34] Speaker 4: It's very possible. Okay. [00:57:35] Speaker 1: Okay. [00:57:38] Speaker ?: Excuse me. [00:57:40] Speaker 1: Next meeting. After the... December 16th, was it? Yes. December 16th? Is that what we were just on in? Yes. Okay. The next meeting was January 6th? [00:58:00] Speaker 4: Yes. [00:58:01] Speaker 1: Okay. And how does this happen? Does the patient call? I know you don't set up these appointments. Somebody has to deal with somebody in the administration or whatever. But do you like, on December 16th, say to Lindsay, call me or set up an appointment for January 6th? Or do they have to do it themselves? [00:58:24] Speaker 4: So, at the end of an appointment, I typically will schedule their next appointment. [00:58:31] Speaker 1: So, did you schedule January 6th? [00:58:34] Speaker 4: I think that one she scheduled herself. [00:58:38] Speaker 1: That was the day after she got out of McLean, right? [00:58:41] Speaker 4: Yeah. Usually, the hospital coordinates the discharge appointment. [00:58:45] Speaker 1: Well, if I tell you that, in fact, the hospital told her to set up the appointment, that within an hour, she set up the appointment. Is that in your notes? [00:58:56] Speaker 4: It's not in my notes, no. [00:58:58] Speaker 1: Do you remember that? That was a pretty big deal. She was in McLean Wads for four and a half days, right? [00:59:08] Speaker 4: Yes. [00:59:09] Speaker 1: I mean, she's your patient, and she's really gone downhill bad, right? [00:59:14] Speaker 4: No, she wasn't doing well. [00:59:18] Speaker 1: And she admitted herself to the lock wards at McLean, right? [00:59:22] Speaker 4: Yes. [00:59:23] Speaker 1: And what was the diagnosis at McLean? [00:59:26] Speaker 4: I believe they diagnosed her with major depression. [00:59:30] Speaker 1: Did they recommend any medication? [00:59:33] Speaker 4: They took her off of the Seroquel. [00:59:36] Speaker 1: They took her? Off of it. Off. [00:59:39] Speaker ?: Okay. [00:59:41] Speaker 1: So, did you look at the McLean records? [00:59:44] Speaker 4: Yes, definitely. [00:59:46] Speaker 1: And those were imported easily because you're part of the same structure or whatever? [00:59:51] Speaker 4: No, but after someone is hospitalized, the hospital usually faxes it to their doctor. [00:59:57] Speaker 1: All right. So, if I tell you that the McLean records are really pretty well-known with us, that's not what they fax. They fax you like a two-page dispatch on it, right? [01:00:10] Speaker ?: Yes. [01:00:12] Speaker 1: You didn't get that by fax, right? [01:00:14] Speaker ?: No. [01:00:16] Speaker 1: So, what did McLean tell you? What did you notice? [01:00:27] Speaker 4: Which part do you want me to read? [01:00:55] Speaker 1: Did you ever have her sign a release for McLean? Did you ever get access to the McLean records? [01:01:02] Speaker 4: I had access to the discharge summary. [01:01:04] Speaker ?: Okay. [01:01:05] Speaker 1: So, put the discharge summary aside because that's what they faxed you a couple of pages. What about the records? [01:01:12] Speaker 4: No, but that's typically not done. [01:01:14] Speaker 1: No, never mind typically. The answer is no. You never get the records, right? [01:01:20] Speaker 4: A discharge summary is a record. [01:01:22] Speaker 1: Did you talk to the doctor that discharged her? [01:01:26] Speaker 4: No. No one called me. [01:01:28] Speaker 1: No what? [01:01:30] Speaker 4: No. No one called me. I wasn't notified about the hospitalization until she was discharged. [01:01:37] Speaker 1: So, you just sit there behind your computer and wait for people, Patrick, wait for the doctor from McLean, wait for the sick person who's the patient to call you, and if these people don't call you, it doesn't exist apparently, right? [01:01:54] Speaker 4: No, not exactly. I had no way of knowing she was even at McLean. [01:01:58] Speaker 1: Well, you did once she got discharged, right? [01:02:00] Speaker 4: Yeah, but that was after the fact. [01:02:03] Speaker 1: Right. So, did you care why she was at McLean? [01:02:06] Speaker 4: Of course. [01:02:07] Speaker 1: And why was she in McLean? [01:02:08] Speaker 4: Because she was depressed. [01:02:10] Speaker 1: And what was the, uh, does your record indicate that she was discharged yesterday? Under interval history? [01:02:26] Speaker 4: Yes. [01:02:27] Speaker 1: And discharged from where? [01:02:30] Speaker 4: Um, well, I said MGH. [01:02:33] Speaker 1: Is that Mass General Hospital? [01:02:35] Speaker 4: Yes. [01:02:37] Speaker 1: And she was currently on Trazodome? [01:02:41] Speaker 4: Yes. [01:02:42] Speaker 1: Um, and she indicated that the goal was to come off Seroquel? [01:02:47] Speaker 4: Yes. [01:02:48] Speaker 1: And she described herself as still being very numb? [01:02:54] Speaker 4: Yes. [01:02:55] Speaker 1: She couldn't sleep, right? [01:02:58] Speaker 4: Um, that's not entirely true. [01:03:05] Speaker 1: Am I lying? I'm reading the medical records here. Sleep, taking Ativan and Trazodone, slept five hours broken, wondering about increasing Trazodone and switching to valentine. What does that mean? [01:03:21] Speaker 4: Well, it means she was having trouble sleeping. It wasn't that she wasn't sleeping at all. [01:03:24] Speaker 1: I see. [01:03:25] Speaker ?: Okay. [01:03:30] Speaker 1: So, was the Trazodone increased at that point? [01:03:34] Speaker 4: Yes. [01:03:34] Speaker 1: How about on January 9th, did you see her through the computer or whatever then? [01:03:55] Speaker ?: Yes. [01:03:56] Speaker 1: Ann, did you prescribe medication to her on that date? [01:04:04] Speaker 4: Yes. [01:04:05] Speaker 1: And was that diazepam? Yes. 14 count, one milligram? No, I'm sorry. 14 count, five milligrams. [01:04:15] Speaker 4: That sounds right. [01:04:16] Speaker 1: Okay. Did you also, on January 12th, three days after January 9th meeting, prescribe additional medication to her? [01:04:25] Speaker 4: Um, I'm not sure. I don't have a record from January 12th. [01:04:31] Speaker 1: Do you recall on January 12th that, in fact, you prescribed Trazodone 150 milligrams, 30 count? [01:04:41] Speaker 2: Yes. [01:04:45] Speaker 1: Three days later, or a couple of days later, January 16th, do you recall prescribing amitriptyline? [01:04:56] Speaker 4: Yes. [01:04:57] Speaker 1: What is amitriptyline? [01:04:59] Speaker 4: It's a tricyclic antidepressant. [01:05:01] Speaker 1: What does a tricyclic antidepressant mean? [01:05:08] Speaker 4: Um, well, it's, it's an older antidepressant. It, it's called a tricyclic because it has three rings. Uh, if you look at the chemical itself, like a tricycle. Um, but it's, it's a, an older but efficacious medicine for depression and anxiety, as well as insomnia. [01:05:28] Speaker 1: On January 16th, look at your interval history. Did she indicate to you that her mood was very low, no motivation? [01:05:41] Speaker ?: Yes. [01:05:42] Speaker 1: Numb? [01:05:44] Speaker ?: Yes. [01:05:46] Speaker 1: Able to force herself out of bed, taking care of basics, eating, concentration, fine. And caring for baby, bonding feels forced. That what she told you? Yes. Through the, through the computer, right? Yes. What, what did that tell you? Were you concerned about this woman, postpartum, well within the year from the CDC at that point with these symptoms that she's telling you about? [01:06:16] Speaker 4: I was concerned that she was depressed. [01:06:19] Speaker 1: And, in all of the times that you spoke to her, you'd agree with me that she appeared to be honest and forthright, telling you what she felt, right? [01:06:28] Speaker 4: That's what I thought she was, yes. [01:06:31] Speaker 1: Do you have any reason to think that she was lying to you? [01:06:34] Speaker 4: No. [01:06:38] Speaker 1: Not at that point. So, what does ROS mean under interval history that we're looking at? [01:07:08] Speaker 4: Review of symptoms. Okay. [01:07:11] Speaker 1: 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? [01:07:25] Speaker 4: Yes. [01:07:29] Speaker 1: Patient agrees with the treatment, and you guys were also going to explore ketamine treatment, ketamine treatment, is that right? Escaketamine. Yes. 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? [01:07:56] Speaker 4: No. [01:07:57] Speaker 1: Did you ever ask her whether or not she was looking up the symptomology of pharmacology and having interactions between drugs? [01:08:09] Speaker ?: No. [01:08:11] Speaker 1: January 23rd, you had that meeting, correct, with her? Yes. And this is after, obviously, 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. Isn't that right? [01:08:38] Speaker 4: On the 16th? [01:08:40] Speaker 1: Yeah. [01:08:44] Speaker 4: I don't know if that was the worst it was ever reported, but it was certainly bad. [01:08:49] Speaker 1: And you didn't recommend that she had a hospital evaluation, did you? This is the day before she killed the kids, right? [01:08:56] Speaker 4: The 23rd? [01:08:57] Speaker 1: Yeah. [01:08:58] Speaker 4: It was the day before. [01:09:00] Speaker 1: You didn't recommend a hospital evaluation, did you? [01:09:04] Speaker 4: No, there were no... [01:09:05] Speaker 1: The answer is no? [01:09:06] Speaker 4: No. [01:09:07] Speaker 1: They'll ask you all the questions they want. Okay. Your answer is no. January 23rd, Friday, you testified, and she said her mood was depressed, and you noted that her affect was depressed and flat, right? [01:09:24] Speaker 4: Yes. [01:09:25] Speaker 1: She also reported that her heart was racing, right? Yes. 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? [01:09:46] Speaker 4: I'm not sure about 17 days straight, but that's how she was feeling. [01:09:52] Speaker 1: You didn't reach out to her mother and father at that point? They didn't call you, I guess, right? [01:09:58] Speaker ?: No. [01:09:59] Speaker 1: And Patrick didn't call you at that point, right? [01:10:01] Speaker 4: No. [01:10:02] Speaker 1: So she's sitting in front of her computer, getting help from her doctor on January 23rd, and [01:10:09] Speaker 4: I thought about how I could best help her, the medicines that she'd tried and what her current symptoms were, and it made sense to slowly titrate the amitriptyline so that we could get her to a dose that reduced her depression, so that she would feel better. [01:10:40] Speaker 1: It increased the amitriptyline. [01:10:46] Speaker 4: Yes. [01:10:47] Speaker 1: That pushed her over the edge, didn't it? [01:10:50] Speaker 4: I don't think so. [01:11:05] Speaker 5: That's all I have to do. [01:11:06] Speaker ?: All right. [01:11:07] Speaker 5: All right. Members of the jury, we're going to take the afternoon recess at this time, all right? [01:11:14] Speaker 1: Court, all rise. [01:11:17] Speaker ?: The jury, can you find and close the notebook? This way. The jury, we're going to take the afternoon. The jury, we're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. [01:11:57] Speaker 1: We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. [01:12:00] Speaker 5: We're going to take the afternoon. [01:12:01] Speaker ?: We're going to take the afternoon. We're going to take the afternoon. [01:12:03] Speaker 5: We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. [01:12:08] Speaker 1: We're going to take the afternoon. We're going to take the afternoon. [01:12:10] Speaker 5: We're going to take the afternoon. [01:12:18] Speaker ?: We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon. We're going to take the afternoon.