PART ONE — Nurse Practitioner Julie Paul testifies at Lindsay Clancy's murder trial

[00:00:01] Speaker 1: Good afternoon. [00:00:02] Speaker 2: Good afternoon. [00:00:03] Speaker 1: Could you please tell the jury your first and last name? [00:00:05] Speaker 2: Julie Paul. [00:00:07] Speaker 1: And what do you do for work? [00:00:09] Speaker 2: I am a psychiatric mental health nurse practitioner, board certified. [00:00:13] Speaker 1: And can you tell us a little bit about your educational background? [00:00:16] Speaker 2: Sure. I graduated in 1991 from St. Anselm College with my nursing degree, worked as a labor and 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. [00:00:41] Speaker 1: Okay. Are you also a certified midwife? [00:00:45] Speaker 2: Yes, I am. [00:00:46] Speaker 1: And are you licensed in the state of Massachusetts to be a psychiatric nurse practitioner? Yes, I am. And what is required in order for you to become certified to be a psychiatric nurse practitioner? [00:00:58] Speaker 2: Yes, I attended a certified program, did two years additional training, and then took the certification exam through the ANCC. [00:01:08] Speaker 1: And can you tell us a little bit about your work history, your work background? [00:01:13] Speaker 2: 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 behavior health program at South Shore Hospital as a psychiatric nurse practitioner. [00:01:31] Speaker 1: And so the perinatal behavioral health clinic, explain to us a little bit about how that came about. [00:01:38] Speaker 2: Sure. There's a lack of resources on the South Shore for pregnant and postpartum people with mood disorders. So I really felt compelled because I had a couple 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 South Shore Hospital to establish the program. [00:02:02] Speaker 1: And where was the program actually located? [00:02:05] Speaker 2: It was located right in Weymouth, Massachusetts. [00:02:08] Speaker 1: And you said you worked with the South Shore Hospital? [00:02:11] Speaker 2: Correct. [00:02:12] Speaker 1: So the clinic is tied to South Shore Hospital in the South Shore Health System. Yes, it is. Now, when did you start that program specifically? When was it up and running? [00:02:22] Speaker 2: 2018 is when I started in October of 2018. [00:02:25] Speaker 1: And what, did you do that by yourself or did you have other practitioners that were doing that with you? [00:02:31] Speaker 2: 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. [00:02:38] Speaker 1: And what makes up this program other than you? [00:02:42] Speaker 2: 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 different 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 the Bridge Clinic on the other side and then we were on the other side of that program. [00:03:06] Speaker 1: And what's the Bridge Clinic? [00:03:08] Speaker 2: The Bridge Clinic works with people with substance use disorders. [00:03:12] Speaker 1: And all of this is kind of under that umbrella of what's classified as South Shore Behavioral Health, correct? [00:03:18] Speaker 2: That's correct. [00:03:19] Speaker 1: Now, as the clinic grew, did your role there change? [00:03:24] Speaker 2: I'm sorry, can you repeat that? [00:03:26] Speaker 1: As the clinic grew to what you described as having additional therapists and other prescribers on staff, did your role there change at all? [00:03:35] Speaker 2: I became the director of the program. [00:03:38] Speaker 1: And as director of the program, did you still see patients? [00:03:42] Speaker 2: Yes, I did. [00:03:43] Speaker 1: And was that at the same level as it had before or did it decrease because of your administrative roles? [00:03:49] Speaker 2: It actually increased because I increased my hours to five days a week. I did have a little bit of administrative time. Okay. [00:03:55] Speaker 1: 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? [00:04:13] Speaker 2: So I'd receive a referral and then the client would come in. They would do a 90-minute intake. And 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. [00:04:40] Speaker 1: 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? [00:04:51] Speaker 2: 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 like therapy focused on sleep hygiene. Really looked at the whole person, not just medication management. [00:05:09] Speaker 1: 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. That's correct. To address all these resources for patients. [00:05:21] Speaker 2: That's correct. [00:05:22] Speaker 1: So while you as the psychiatric nurse practitioner might have been a prescriber, were you also engaged in the therapy or psychotherapy? [00:05:31] Speaker 2: 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. [00:05:44] Speaker 1: 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? [00:06:09] Speaker 2: 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. [00:06:25] Speaker 1: 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 are either pregnant or after birth? [00:06:37] Speaker 2: Correct. [00:06:38] Speaker 1: 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? [00:06:49] Speaker 2: Correct. [00:06:50] Speaker 1: And so what encompasses a treatment plan generally? [00:06:53] Speaker 2: Generally, if there were a situation where we were referring them for therapy, then we would work with the therapist to kind of work, bring in the client to figure out what their needs are, and then really stress whatever. Well, the therapist works on certain aspects of the therapy that we kind of work together, but not in tandem. We talk, but not to the extent we are in our own disciplines. [00:07:18] Speaker 1: 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 encompassed with the social workers that you work with at the clinic? [00:07:37] Speaker 2: Our social workers primarily did cognitive behavioral therapy. We did group therapy for more social support. What I did mainly was just supportive therapy. [00:07:48] Speaker 1: Okay. And would you oftentimes, through the clinic, refer clients out to other local community providers? [00:07:55] Speaker 2: Yes, we would. [00:07:57] Speaker 1: 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? [00:08:09] Speaker 2: Yes, it does play a role. [00:08:10] Speaker 1: And how is it that you determine what's the appropriate medication track for any given patient? [00:08:16] Speaker 2: 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. [00:08:29] Speaker 1: When you say work as a team, does that include the patient themselves? [00:08:32] Speaker 2: Absolutely. The patient is the most important part of the team. [00:08:39] Speaker 1: And in your training and experience working with postpartum women, what is the acceptable period to determine postpartum? [00:08:49] Speaker 2: Anywhere within the first year. [00:08:55] Speaker 1: Did you know a nurse or do you know a nurse named Susan Clancy? I do. How do you know her? [00:09:00] Speaker 2: I worked with her off and on throughout my years as a nurse midwife. [00:09:04] Speaker 1: And what's the nature of your relationship with her other than the working with her? [00:09:11] Speaker 2: Essentially, we just worked together. We worked, when we did births together, we worked well as a team. Okay. [00:09:17] Speaker 1: And do you know where she worked? [00:09:19] Speaker 2: She worked at Seltzer Hospital. [00:09:21] Speaker 1: On November 20th of 2022, did you have a conversation or did you get a call from Sue Clancy? [00:09:29] Speaker 2: I did. She was referred to me through Nanette Landry, another midwife that I work with. Okay. [00:09:36] Speaker 1: 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? [00:09:47] Speaker 2: It was the same day. [00:09:48] Speaker 1: 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? [00:09:59] Speaker 2: 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. So did you initiate the call to Lindsay Clancy? With the permission. I asked Sue Clancy if Lindsay had given permission and she said she had. [00:10:18] Speaker 1: And in the conversation that you had with her, do you know approximately how long that phone conversation lasted? [00:10:24] Speaker 2: I don't recall. [00:10:25] Speaker 1: Okay. But were you able to get all the pertinent information from her during that phone call? [00:10:30] Speaker 2: I got enough data to determine that she would be a good candidate for the program. [00:10:34] Speaker 1: So she would have met criteria for a referral from any other resource? [00:10:39] Speaker 2: Correct. [00:10:40] Speaker 1: 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? [00:10:54] Speaker 2: Yes, I asked when the birth of Callan was and she said it was May 26, 2022. [00:11:06] Speaker 1: 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. [00:11:27] Speaker 2: 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. [00:11:37] Speaker 1: 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? [00:11:56] Speaker 2: It was very typical of what I'd hear. [00:12:01] Speaker 1: 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? [00:12:08] Speaker 2: 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. Okay. [00:12:16] Speaker 1: 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? [00:12:32] Speaker 2: 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 that she had any questions about Buspar. [00:12:49] Speaker 1: Okay. And did she mention anything about that combination of Ativan and Benadryl in her treatment history that was of concern to her? [00:12:59] Speaker 2: 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. [00:13:07] Speaker 1: And were you aware, did she tell you that she had been prescribed Trazodone after that? [00:13:13] Speaker 2: Yes, after she went to the emergency room, she was prescribed Trazodone. [00:13:17] Speaker 1: Did she indicate whether the Trazodone gave her any relief to her sleep issues? [00:13:21] Speaker 2: She said she was able to fall asleep, but was having difficulty staying asleep. [00:13:25] Speaker 1: 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. How about the immediate need for sleep? [00:13:48] Speaker 2: Did you address that with her in the phone call? 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. [00:14:01] Speaker 1: 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? [00:14:13] Speaker 2: 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. [00:14:25] Speaker 1: And is this kind of a normal conversation you would have with somebody to screen them and determine whether the clinic, the SSRI perinatal clinic, was an appropriate fit? [00:14:35] Speaker 2: 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. [00:14:44] Speaker 1: 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? [00:14:56] Speaker 2: Yes, it did. [00:14:57] Speaker 1: 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? [00:15:09] Speaker 2: There was no immediate need. [00:15:11] Speaker 1: Now, as a result of this conversation, did you determine whether she was having any suicidal ideations? [00:15:23] Speaker 2: Yes, I asked her specifically if she felt like she wanted to harm herself or her children. And she said no. [00:15:28] Speaker 1: And how about asking her about homicidal ideations? 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? [00:15:43] Speaker 2: Not at the time, no. [00:15:44] Speaker 1: And did she indicate to you whether she had ever experienced any? [00:15:47] Speaker 2: No. [00:15:48] Speaker 1: How about visual hallucinations? Did you ask her about those? I did. And did she indicate that she had experienced any? No. And delusions? Did you ask her whether she had any delusions? [00:15:59] Speaker 2: I didn't ask specifically about delusions, I believe. [00:16:01] Speaker 1: 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, whether they're having any ideas of delusion? 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. Okay. 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. If I were to show you your note, would that refresh your memory? [00:16:44] Speaker 2: I have my notes right here, I could look at it. [00:16:47] Speaker 1: Okay. Draw your attention to the note from November 20th of 2022. [00:16:53] Speaker 2: Yes, I did ask her apparently. And she said no to illicit drug use, tobacco or marijuana or alcohol at that time. [00:17:05] Speaker ?: Okay. [00:17:06] Speaker 1: And she also indicated to you that at this time on November 20th that she had stopped breastfeeding. [00:17:12] Speaker 2: That's correct. [00:17:14] Speaker 1: 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? [00:17:34] Speaker 2: Generally speaking, we like to do the intake in person as long as it's feasible. And for her it was. [00:17:40] Speaker 1: Okay. 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? [00:18:01] Speaker 2: If somebody needs to do like a urine drug screen or laboratory work, we'll have them come in. If they seem to be not making sense or having more difficulties, we'll have them come in in person. [00:18:11] Speaker 1: 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? [00:18:22] Speaker 2: Yes. [00:18:23] Speaker 1: Okay. And that's just the normal course of business at the clinic? Correct. So 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? [00:18:45] Speaker 2: Yes. Generally, we do a full intake. The first thing they do is meet with the nurse who does all the screenings. [00:18:52] Speaker 1: Okay. 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. And so for this patient, for Lindsay Clancy, what did she identify as the reason for the visit? [00:19:13] Speaker 2: Would it be okay if I refer to my note? Sure. So she said pretty much I cannot sleep was her major concern. Okay. [00:19:20] Speaker 1: And is that something that you've seen in your experience with new moms that come through the clinic in our postpartum? [00:19:28] Speaker 2: It's very typical. [00:19:30] Speaker 1: Okay. 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. [00:19:51] Speaker 2: 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. [00:20:02] Speaker 1: 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? [00:20:26] Speaker 2: I did. [00:20:27] Speaker 1: 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? [00:20:42] Speaker 2: I did. [00:20:43] Speaker 1: 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? [00:20:53] Speaker 2: At every visit, those are standard questions that I ask if they have any type of suicidal, homicidal ideation or auditory or visual hallucinations. [00:21:00] Speaker 1: Do you ask the same questions each time or is it kind of fluid based on your rapport and conversation with the patient? [00:21:08] Speaker 2: 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. [00:21:15] Speaker 1: 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? [00:21:45] Speaker 2: She was feeling overwhelmed. [00:21:47] Speaker 1: 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? [00:22:11] Speaker 2: As far as what I was told, yes. [00:22:14] Speaker 1: 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. [00:22:40] Speaker 2: Correct. [00:22:41] Speaker 1: And you also learned about any prior psychiatric medications she had been on? [00:22:46] Speaker 2: Yes. She had been on the Zoloft, the Ativan. She had been prescribed Buspar, but she hadn't, she didn't indicate whether she had taken that or not. [00:22:55] Speaker 1: Okay. And so that was her report of her most recent course of treatment. But did she talk about having anxiety issues? Yes. Further back in her history? Yes. [00:23:05] Speaker 2: In college she had trialed Prozac, Propanolol, and Wellbutrin. [00:23:09] Speaker 1: And fair to say she indicated that to you that she did well on those medications in nursing school. [00:23:15] Speaker 2: Correct. With the only side effect being sexual side effects. [00:23:19] Speaker ?: Okay. [00:23:20] Speaker 1: Um, did you talk to her at this point in November 20, uh, on November 21, excuse me, 2022, about whether she had a plan to go back to work? [00:23:31] Speaker 2: Um, I don't know if that was a specific day. I know that we talked about work at a different date. [00:23:40] Speaker 1: Okay. Um, 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. [00:23:49] Speaker 2: Oh, I'm sorry. And you're talking about the day of the intake? Yes. Sorry. I thought you said the 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. Okay. [00:24:06] Speaker 1: And, um, during the course of this intake, again, you did those same, um, mental status screens for any concerns, right? Correct. Did you know any in this face to face in person meeting with her? [00:24:19] Speaker 2: No, she was goal directed linear. She was a great historian, actively participated in the care plan. Okay. [00:24:27] Speaker 1: And as far as, um, some of the screenings that you do during these visits, um, for a, uh, person who is in that postpartum period, are there any specific screenings that you do? [00:24:39] Speaker 2: Yes, we do the postnatal, the Edinburgh 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 5 Ps, which assesses for substance use disorders and pregnancy and postpartum. [00:24:55] Speaker 1: And so, as far as in each one of those screens, um, what did you find as it pertained to this particular patient? [00:25:01] Speaker 2: She was significantly high in the GAD-7, which is for generalized anxiety. She scored 21 out of 21, which isn't, 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. [00:25:24] Speaker 1: Okay, um, and so why is it that you look at that one in particular, or why do you consider that most? [00:25:31] Speaker 2: Because that shows significant depression, especially if they have lots of harming themselves. [00:25:36] Speaker 1: Is it fair to say that that Edinburgh's, um, scale, it also could fluctuate with a postpartum mom, depending on their situation? [00:25:43] Speaker 2: Yes. [00:25:44] Speaker 1: And, um, and the other screens that you performed, did you identify whether there is any substance use issues? [00:25:50] Speaker 2: No, there wasn't. [00:25:52] Speaker ?: Okay. [00:25:53] Speaker 1: 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, um, an assessment and a plan for, um, how to, uh, help her? [00:26:04] Speaker 2: Yes. She... [00:26:06] Speaker 1: And what was going to be the plan with Ms. Clancy? [00:26:09] Speaker 2: So, we had discussed starting Prozac. Okay. [00:26:13] Speaker 1: And is that, uh, or why, why Prozac? Why start there? [00:26:16] Speaker 2: 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. Okay. [00:26:35] Speaker 1: And what about some of the medications that she had already, um, that she was already on? The Ativan and Benadryl and the Trazodone. Did you have a plan for those? I did. [00:26:43] Speaker 2: 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. [00:27:00] Speaker 1: And as far as Prozac goes, what kind, what class of medication is it? [00:27:05] Speaker 2: It's an SSRI, a Selective Serotonin Reuptake Intimator. [00:27:08] Speaker 1: Is it commonly prescribed to treat people with depression? [00:27:12] Speaker 2: Yes, it's a first-line treatment. [00:27:14] Speaker 1: You said first-line treatment? Correct. And, um, the idea of pairing, um, a particular, uh, medication like an SSRI with another medication, is that a fairly common practice, um, with psychiatric medications? Yes. As far as, um, the, you mentioned, um, that sometimes symptoms could get worse before they get better. Is that also common with SSRIs? Yes, it is. Does it take a while for a medication to, um, get into a person's system and, um, stabilize them? [00:27:45] Speaker 2: Generally, side effects are the first week or two, but to get to a therapeutic level, it's about four to six weeks. [00:27:52] Speaker 1: And was this something that you discussed with her about the timetable it would take to reach a therapeutic level? Yes. 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. Right. Now, um, 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, um, did you indicate that, um, there would be a plan to taper that or reduce that? [00:28:26] Speaker 2: Yes. Once the activating symptoms dissipate, went away, then we would look at reducing that and act moving away from the Ativan and moving more towards like abuse bar. Okay. [00:28:39] Speaker 1: And as far as, um, talking about that plan and what the risks and benefits of that plan were, um, did she appear to understand and engage in conversation with you about that? [00:28:49] Speaker 2: Yes. She verbally understood and said that she understood the instructions. [00:28:53] Speaker 1: Did she ask the appropriate questions or follow up? [00:28:56] Speaker 2: Yes, she did. [00:28:58] Speaker 1: And as far as, um, 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? [00:29:09] Speaker 2: 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 can act, who is trained in this. Okay. And so you mentioned Leticia Dukes? Correct. She was the clinician in our program at the time. [00:29:32] Speaker 1: And, um, when you make this recommendation and this intake visit, do you work with the patient to, um, schedule something before they leave or is it up to them to schedule the time with the social worker? [00:29:43] Speaker 2: It was set up with her before she left, I believe. [00:29:45] Speaker 1: Okay. And, um, you're aware that the first appointment, scheduled appointment with Leticia was for December 2nd? Correct. [00:29:52] Speaker 2: I believe because it was a holiday week that week. [00:29:54] Speaker 1: Okay. Um, now this time that you were with, um, Ms. Clancy during this initial intake, fair to say it was approximately 60 minutes? Yeah. [00:30:04] Speaker 2: She spent 30 minutes with my nurse and 60 minutes with myself. So she was there for an hour and a half. [00:30:08] Speaker 1: And is that normal time period that you allot for people coming in for intakes? Yes. Okay. And, um, as far as follow up with you as a clinic, as the, um, clinician and prescriber, was there a plan set for when she was going to return? [00:30:28] Speaker 2: Yes. We had established a return in two weeks. [00:30:31] Speaker 1: 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? [00:30:38] Speaker 2: This was going to be a short-term arrangement. I was already in the process of leaving the program at the time. [00:30:44] Speaker 1: Had that been communicated to her? [00:30:47] Speaker 2: I don't recall. [00:30:48] Speaker 1: Okay. Um, and, um, as far as what your plan was, um, how long were you remaining at the practice? [00:30:55] Speaker 2: I was at the practice until mid-December. So this was like a pre-planned, um... I was moving back to New Hampshire, yes. [00:31:07] Speaker 1: But as far as, um, the preliminary care, did you continue on, um, with Lindsay as a patient? No. [00:31:20] Speaker 2: I transferred her care on November 30th. And I communicated with that to Lindsay. Okay. [00:31:30] Speaker 1: So, um, as far as after the intake, um, she was provided with that, um, December 2nd video, uh, excuse me, intake or, um, meeting with Leticia Dukes, the social worker. And then the next scheduled event would have been, um, December 7th. Right? [00:31:51] Speaker 2: For a follow-up? 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. Okay. [00:32:04] Speaker 1: Um, prior to you communicating, um, November 30th that you were, um, transferring her care, did you have further contact with, um, Lindsay Clancy? [00:32:13] Speaker 2: Yeah, we had a few phone calls and MyChart messages going back and forth. [00:32:18] Speaker 1: Can you just explain to the jury what the MyChart messaging system is in your practice? [00:32:23] Speaker 2: 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. [00:32:32] Speaker 1: And do you encourage patients when they come in at that first meeting to utilize the MyChart messaging system? [00:32:38] Speaker 2: I do, often it's the quickest way to get a hold of me if they're experiencing any major issues. [00:32:43] Speaker 1: And fair to say it's just an easy way in between visits to communicate, um, particular points of information or concerns or symptoms? Yes. Um, do you, in your practice, often use MyChart messages, um, if you're not available to meet with the patient to make changes to their treatment plan? Occasionally, yes. Now, um, prior to your first MyChart message with, um, Lindsay Clancy, did you get a, um, text message from her on your, uh, personal phone? I do. I don't recall. [00:33:21] Speaker ?: Okay. [00:33:22] Speaker 1: Do you recall, um, whether, um, Sue Clancy provided your number to Lindsay? [00:33:30] Speaker 2: 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. [00:33:39] Speaker 1: So that November 20th phone conversation was a communication between you and her on your personal phone? [00:33:44] Speaker 2: Correct. [00:33:45] Speaker 1: And so do you recall on November 22nd getting a message, um, 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?" [00:33:56] Speaker 2: I can't recall whether that was in MyChart message or if that was on my personal phone. I apologize. [00:34:01] Speaker 1: That's okay. Um, as a result of, um, some way her contacting you, did you then have a, um, or send her a message or have a conversation with her on November 23rd? [00:34:12] Speaker 2: I, 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, um, that indicated that she had taken the medication. She had started it on the 22nd. Okay. [00:34:36] Speaker 1: And were you aware at this time period that she was, um, currently already a patient in the South Shore Health System Network, um, with a primary care physician named Margaret Anastasia? [00:34:47] Speaker 2: Yes. [00:34:48] Speaker 1: Okay. And she's a nurse practitioner, right? Correct. Um, now, as far as, um, these concerns that she relayed to you about starting the Prozac, um, do you know whether she did start the Prozac? [00:35:08] Speaker 2: Yes, she stated that she started the Prozac on the 22nd of November. Okay. [00:35:13] Speaker 1: And, um, by November 25th of, um, 2022, um, did you start having some MyChart communications with, um, Lindsay Clancy? I did. And so, just referring first to November 25th of 2022, um, fair to say that you gave her, or sent her a MyChart message, um, encouraging to kind of stick with the plan, right? Correct. Prior to that, yes. Um, at that point, had you prescribed her something to help her sleep, um, outside what you had previously provided, or outside what she had? [00:35:45] Speaker 2: Before November 25th, I did not. Okay. [00:35:49] Speaker 1: So, on November 25th, did you, um, prescribe her some additional medications? [00:35:54] Speaker 2: I did. So, she wasn't tolerating the Prozac, so we had a conversation about stopping the Prozac. Um, 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. [00:36:33] Speaker 1: And so, um, in your conversations with her about her concerns about the Prozac, um, fair to say she reported to you that she was feeling disconnected out of it a little bit spacey? Does that sound right? [00:36:45] Speaker 2: Yes, that's correct. [00:36:46] Speaker 1: And so, you said your recommendation at that point was to discontinue the Prozac? Correct. And, as far as the Prozac went, um, she hadn't taken it for very long, had she? She took it for three days. Three days? Correct. And, um, 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? [00:37:13] Speaker 2: 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. So, mitazapine is a little bit more calming, which I thought she would resonate with better. Okay. [00:37:35] Speaker 1: And, um, so, again, this is not one of those follow-up visits on a telehealth or, um, a face-to-face. So, um, were you relying heavily on what she was reporting to you? Yes. And, um, 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, um, 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? [00:38:14] Speaker 2: Yes, it's pretty common practice in psychiatry. [00:38:17] Speaker 1: And, Fred, you say there's no way to anticipate how a particular patient is going to respond to any particular treatment, medication treatment? Correct. So, after, um, prescribing the Klonopin, Klonopin, the mitazapine, and giving her that single dose of Ambien, um, did you do anything or, or, um, set anything up to follow up with her after, um, changing those prescriptions? [00:38:49] Speaker 2: 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. [00:38:58] Speaker 1: And fair to say she did, in fact, um, MyChart, you send you MyChart messages over the course of that weekend, correct? She did, yes. And so, um, starting at 7:51 on November 26th, um, she reported to you, kind of, how that night went, didn't she? Yes. Where she said, I did better last night, I took 7.5 mirtazapine and .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 would be helpful to get, to sleep until at least 5. Thoughts? Thank you, Lindsay. [00:39:36] Speaker 2: Yes. [00:39:37] Speaker 1: Did you respond to that message? I did. And what did you advise her to do, uh, when she asked about increasing the mirtazapine and wanting to stay asleep longer? [00:39:45] Speaker 2: I said she could trial the 15 milligrams. [00:39:48] Speaker 1: And again, is that something that is common for you to do in prescribing, that maybe you have to adjust the dosage? [00:39:54] Speaker 2: Yes. [00:39:55] Speaker 1: Did you have any concerns that, um, increasing the mirtazapine up to 15 would have, um, had any issues or problems? [00:40:03] Speaker 2: No. [00:40:04] Speaker 1: And then again, on, on November 27th, you had a correspondence with her starting at 9:59 AM, 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? [00:40:23] Speaker 2: 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. [00:40:30] Speaker 1: Um, so this wasn't, this wasn't kind of unexpected? [00:40:33] Speaker 2: It wasn't out of the ordinary for me. [00:40:35] Speaker 1: And so, on the 27th, she, um, indicated she slept well, taking the 15 of 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 communication? I do. 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? Do you recall her asking that? [00:41:07] Speaker 2: She's referring to the Klonopin, and yes, she did. No. 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. [00:41:31] Speaker 1: 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? No, I did not. 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. 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? [00:42:15] Speaker 2: Correct. [00:42:16] Speaker 1: And is, um, that something that you had talked about with her, about, um, getting another note for work? [00:42:21] Speaker 2: Yes. That's what I do that often. [00:42:24] Speaker 1: 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. [00:42:35] Speaker 2: Correct. [00:42:36] Speaker 1: 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? [00:42:44] Speaker 2: 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. [00:42:58] Speaker 1: And, um, what was her response to the recommendation for the partial hospitalization program? [00:43:03] Speaker 2: At that time, she felt it wasn't going to work logistically for her or her family. Okay. And why did you recommend maybe going for a run? Um, you know, 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. Okay. [00:43:18] Speaker 1: Um, now on November 29th of 2022, that was the first days 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? [00:43:33] Speaker 2: 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. Okay. [00:43:45] Speaker 1: 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. [00:43:54] Speaker 2: Correct. [00:43:55] Speaker 1: 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 Klonop, without the Klonopin or without some other? [00:44:11] Speaker 2: 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. [00:44:19] Speaker 1: 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. 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? [00:44:50] Speaker 2: 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. Okay. [00:45:01] Speaker 1: 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. [00:45:15] Speaker 2: 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. [00:45:22] Speaker 1: 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? [00:45:29] Speaker 2: She had been in the clinic, I think, for two years, I believe, at the time. [00:45:33] Speaker 1: 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...? [00:45:47] Speaker 2: 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 would be a better match for Lindsay. Okay. [00:45:58] Speaker 1: 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? [00:46:14] Speaker 2: I'm sorry. She did respond to me saying thank you for the care that I provided. She appreciated it and wished me luck. [00:46:20] Speaker ?: Okay. [00:46:21] Speaker 1: Did you have any other contact with Lindsay Clancy, um, after that point? [00:46:26] Speaker 2: No, I did not. [00:46:28] Speaker 1: 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? [00:47:05] Speaker 2: 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. 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? [00:47:18] Speaker 1: I don't recall that. [00:47:31] Speaker 2: I don't recall that. [00:47:42] Speaker 1: I have no further questions at this time. I see it.