Trial Day 10

... the case. So first let me ask the questions. Has any member of the jury read, seen, heard, or overheard anything from any source about any aspect of this case that would affect your ability to be a fair and impartial juror?

No.

All right. Next, is there any other serious matter or concern bearing on your service as a juror in this case that anybody needs to bring to my attention? All right. Thank you for following those instructions. And then in regards to today's schedule, we've got a number of witnesses. I'm not quite sure how long it may go. So we may break a little bit early today, just kind of depending on the way the case comes in. And then, in regards to where we are right now, we're going to, if you remember, when we broke on Friday, there was a witness, a Dr. Tufts. The Commonwealth had finished their direct examination. We're now going to have that witness return to the stand and the cross-examination by the defendant will begin. All right. And so with that, if we could recall that witness.

Good Morning.

Good morning.

Stop right there and raise your right hand for the clerk, please.

Good morning. Do you solemnly swear that the testimony and the evidence you shall give to the court and the jury in the matter now pending between the Commonwealth and the defendant shall be the truth, the whole truth, and nothing but the truth, so help you God?

Yes.

You may have a seat.

Just watch your step, please.

All right. Good morning, doctor.

Good morning.

All right. Mr. Reddington?

Thank you. Good morning, doctor.

Good morning.

Do you have your record in front of you? Your notes or-

I do.

... record? Great. Thank you. And you can look at that anytime you want, just to refresh your memory with what's what.

Thank you.

Dr. Tufts, you are presently a psychiatrist, correct?

Correct.

And can you tell me where you went to med school?

University of Vermont.

And what were the years that you were at the University of Vermont?

2014 to 2018.

Beautiful country out there. Great place to go to school, right?

It is. It's beautiful.

And when you graduated from med school, you then did your residency?

Correct.

And where was the residency?

Boston Medical Center.

And can you tell me, what is it exactly that you do as a psychiatric resident or a psychiatrist resident? What do you do?

Well, you do a lot. A lot of different things. You rotate in all the different aspects of psychiatry as well as internal medicine so that you have a foundational knowledge of broad medical topics. You admit patients into the inpatient hospital. You manage emergencies in the hospital and in the emergency room. Decide whether patients need to be admitted psychiatrically or not, and also carry a panel of outpatients.

And is this a hospital that you're working in or is it Boston University? Is it a medical center?

So yes, it's the Boston University program located at the hospital, Boston Medical Center, with also a lot of time spent at the various Boston VA locations.

Okay. And what were the years? I'm sorry, that you did your residency?

2018 to 2022.

So you basically were working as either a person studying to be a doctor, graduating, and then becoming a resident through the entire pandemic?

For the first part of the pandemic, yes.

Well, the pandemic ended when Joe Biden said it ended. I think it was July of 2022, right?

I'm not sure exactly when he said that.

Would you agree with me that when the pandemic started around 2019, when you began your residency, 2020, '21 into '22, it was a, if you will, of the pandemic timeframe? So, when you finished, do you graduate from a residency or is it like you get a certificate or something?

Yes, there is a certificate for completing it.

And then at that point, you are now a licensed doctor. Is that how it works?

Well, you're actually a licensed doctor the entire time that you're in residency, but upon the completion of that, you can obtain a full unrestricted Massachusetts license and also become board certified.

And the board certification, for example, you have a board certification in general psychiatry. Is that correct?

Yes, sir.

And when was it that you got that certification?

When was it?

Yes.

It was September 12th, 2022.

When was it that you actually started working as a physician, as a psychiatrist?

I started working as a physician and as a psychiatrist during the residency training program, but I started practicing completely independently at Aster Mental Health in August of 2022.

August of 2022?

Yes.

Now prior to working with or at Aster, is that A-S-T-O-R or E-R?

A-S-T-E-R, like the flower.

And what is Aster? Is it like a group of doctors? Is it a medical center? What is it?

It is a outpatient practice that is owned by a psychiatrist. It has a number of psychiatrists as well as therapists.

And where is it located? Is it a brick and mortar type place where you have offices?

Yes. The original offices were in Braintree, Massachusetts, and now there's an office in Peabody as well.

Where was your office? Where do you work?

So at the time I saw the patient, I was working in the Braintree office. I currently work in Peabody.

Where? I'm sorry.

Currently, in Peabody, Massachusetts.

Okay. So when you start working at Aster, obviously like anybody else, you submit a resume, an application perhaps, and then they hired you, right?

It's a fairly lengthy process and a number of interviews with different staff at the practice and some recommendations, letters of reference, verification of credentials, all of that. But yes, it can be comparable to another profession in that process.

Now in August of '22, when you... Congratulations, obviously you were hired by Aster. How many women had you treated in your residency regularly postpartum?

With postpartum depression? Or just in the postpartum period?

How many women that were in the postpartum period did you treat prior to August of '22?

Many. It's hard to give an exact number, but I did have specific training in that population.

In that population. And where did you have the training in that population?

At Boston Medical Center.

And can you tell us in that two-year period, approximately how many women that were in the postpartum period that you treated, as a resident?

Okay. So it's really hard to give an exact number, but if I had to say, at least 50.

So in the two-year period, you treated 50 people in the residency that had postpartum. And can you tell me, what is postpartum? What does that mean?

Well, I just want to address that it was a four-year period, not a two-year period.

Oh, I'm sorry. Okay.

I'm sorry, what was your question?

Hold on. You saw 50 people in a four-year period that had postpartum. In other words, that had been after having the baby, right?

Possibly. Yeah, more or less. I saw a number of other patients.

Of course.

I saw much more than 50, but yes.

So after you had your residency, and after you were hired by Aster, is that when you began in August of '22, your practice as a practicing psychiatrist?

Yes.

And when was it that you actually got your DEA license that authorizes you to prescribe medication to citizens?

So during residency, I had a DEA license, but it was affiliated with Boston Medical Center. And then when I started at Aster, I had my own DEA number. I don't know exactly when, maybe sometime around August.

So August of '22, you start working at Aster. August of '22, you got your DEA license individually that authorized you to prescribe medication, correct?

Yes.

And it was when that you saw Lindsay Clancy?

I believe our first visit was September 15th.

Of?

2022

So you were practicing as a psychiatrist for a little more than a month?

I was practicing independently with my full credentials for about a month, but the training is just immense that goes on before that.

Absolutely. It must be. But that's a residency that you're talking about, right?

Yes.

And you know with a residency... I mean, all I know is Grey's Anatomy, but I mean, you're working under a doctor, the doctors are supervising you, and they tell you what to do, and then you report to them, correct?

They don't really tell you what to do. They're there as a resource if you need additional support, but I followed many of my own patients. I was the only person in the room with them. And my notes were signed off by an attending physician and that attending was available for any support I needed.

So in August of '22, when you started working at Aster, you actually filled out a form for your advertising. Is that correct?

I believe that was handled by other people at the practice.

And who would that be?

Well, we have non-clinical staff that handle the administrative matters.

Okay. But you're a doctor, and you're out there to the public. You're advertising yourself and your services to the public. Is that fair?

I believe, yes. I'm not directing the marketing of our office, but yes.

Okay. Never mind your office. I'm talking about you. You had an ad that was on the computer that if somebody wanted to reach out to a doctor, they could see your ad amongst many others, right?

Well, I don't think there was an ad. I think we have a website that had some information about myself.

Okay. Now, in August of '22, up until when you saw Lindsay, how many patients in that month or so had you treated for postpartum psychosis?

How many patients in a month? Up until that month?

I'm asking you about when you started working in August of '22 for Aster. And you are now on your own as an employee. How many patients had you treated before you saw Lindsay Clancy for postpartum psychosis?

Well, in the span of one month, I would say none because it's a very rare disorder.

Okay. But it exists, doesn't it?

Absolutely.

And one of the things would be the voices that people hear, right?

That is a symptom of psychosis. Absolutely.

And that's legitimate, isn't it?

It is a legitimate diagnosis. Absolutely.

Ignore the diagnosis. People that have postpartum psychosis hear voices, do they not?

Many do. The disorder can manifest differently in different people, but yes, many people do hear voices.

How about postpartum depression? How many people in that month or so before you met Lindsay did you treat for postpartum depression?

In the span of one month? It's really hard to pinpoint that. Maybe a couple.

Maybe a couple? And do you recall how long you treated them for?

Again, it's hard to really pin down the individuals-

Okay.

... in a short span of time.

Can you tell the jury what you put in your ad or in the Aster website that you indicated that described you?

I don't recall.

Well, one of the things you did is that you said that you basically were a specialist in the postpartum... People that have postpartum psychiatry. You indicated that on your website, didn't you?

Are you able to read the actual document? I don't remember exactly the wording.

You've been working with them for how many years now? Three since you saw Lindsay or more?

Almost four, yes.

You haven't changed your ad on the website, have you?

I know, I have not personally, no.

And you've read it probably a bunch of times, right?

I've read it a couple of times, but I don't spend a lot of time on my website.

Okay. Do you recall that you indicated that you were specializing in any particular aspect of psychiatry?

Yes. It probably includes a special interest in women's health, in perinatal psychiatry, in trauma-related disorders, anxiety. And there may be some other things that were mentioned.

Yeah, like women that have babies, and they're suffering from postpartum depression, right?

Absolutely.

You advertised that after a month working for Aster, right?

That's listed as one of my interests, definitely.

And again, forgive me. How many women did you treat for postpartum depression in that month and a half before you met Lindsay?

I don't know, maybe a couple. But I've treated many of them in the residency, which was just immediately before.

So when a person needs to see a psychiatrist, generally they're not well. Is that fair?

Some are not well. It really can vary.

So when someone comes to see a psychiatrist like you, it's because they need help, right?

Yes.

And when they come to you because they need help, for example, with Lindsay Clancy, she came to you because of your ad, right? Or your website for Aster, what you said about yourself?

I don't know exactly how she found us.

Well, do you know why she came to see you?

I'm not sure exactly.

Friday, we spent a long period of time going through your initial or the initial intake that she had to fill out. Is that correct? Do you recall that?

Yes, we did.

And the district attorney kept asking you, and this is in September. Is it September 12th? Is that when that form was filled out?

I believe she completed the form on the 12th. The appointment was on the 15th.

So what does a person do? Do they call you or do they talk to somebody in administration? How do you get the form to fill out?

Yes. Our administration handles that.

And what do they do? How does that happen?

They send them the documents, probably by email, and the patient fills them out. Actually, it might be all within the portal that we use.

Within the portal?

The patient portal, yes.

Okay. And that means that you go online, and you can access Aster Mental Health and then all these little dropdown boxes would come up?

Something like that.

Are you aware? Something like that or are you aware of what it does?

So, because I don't handle the scheduling and send you the forms, I don't know exactly what it looks like.

Well, this is the form that you're giving a person that needs help because they're possibly mentally ill. Is that right?

Yes. And what's important is that I review the forms, and we go through them-

You do?

... in the appointment. Absolutely. Yes. Yes.

Now understand that your records, Exhibit 219, I believe that the jury will have access to the Tufts records. Okay? You're aware of that, right? You know it's an exhibit?

Yes.

Because you have talked to the prosecution about what an exhibit is, and you know that your records are now in evidence before this jury, right?

If that's what you say, yes.

I wouldn't take what I said. If you don't know, that's fine.

I don't know the details of how this works.

All right. Have you talked to them prior to your testimony?

No.

You haven't talked to the DA's office?

No, not at all.

You're a defendant in a very large lawsuit, are you not?

Objection.

Overruled.

Yes.

You wouldn't happen to be represented by an attorney, would you?

I am.

And the fact that you have an attorney is your right under the constitution. It doesn't mean that you're guilty of anything, right?

Right.

Okay. And you know that the outcome of this case is very, very major to the outcome of your lawsuit.

Objection.

Overruled.

I don't actually know that.

So you understand that if, in fact, it's determined that you advertised as an expert in postpartum psychiatry, and you've had a month experience plus a residency, would you consider that to be negligent or a misrepresentation?

I do not believe that I have been negligent.

Do you understand what misrepresentation is?

Yes.

With a month under your belt plus your residency, do you really want this jury to believe that you were an expert? Can you empathize that?

I don't think that's exactly the wording that I used.

Then what's the wording?

I think I said that it was an interest of mine. I think-

You were [inaudible 00:20:30]?

... was the answer.

No. Go ahead answer.

I just think the wording was that it's an interest of mine. I don't believe I called myself an expert.

Are you an expert in postpartum?

I may be. I don't know. I think it depends on what you define an expert as.

Well, when a patient comes to you, and they fill out the form, you agree with me that your records reflect that form that she filled out on September 12th of 2022, right?

Yes.

And the form that the district attorney went through painstakingly with you is basically put something like this, right? That's one of the forms that you have to fill out, right?

Yes.

Right?

Yes.

You see the little check mark?

Yes.

Who puts the check mark in there?

The patient.

So how many pages, because I don't want to go through all the pages again. How many pages does a patient or how many pages did Lindsay go through to check the boxes for Aster?

There were a lot of pages.

What's a lot? 10, 20?

Yeah, maybe between 10 and 20.

Okay. And basically they're all little checks and boxes, correct?

Not just checks.

No? So does the person then answer questions by typing in answers such as, "Do you have any legal problems?" "No." "Have you ever been arrested?" "No." Things of that nature, right?

Those are some of the questions.

And the questions also, do they ask the patient what medications they were on?

Yes.

Before seeing you?

Yes.

And Lindsay told you that she was on SSRIs in the past, right?

Yes.

And SSRI means what?

Selective serotonin reuptake inhibitors.

And that's pretty powerful stuff.

It's an effective treatment for depression and anxiety.

Well, it affects the serotonin levels in the brain, doesn't it?

Yes.

It rewires the brain, doesn't it?

It doesn't rewire the brain. It increases the serotonin, and many individuals with depression have low levels of serotonin.

So Lindsay told you that she had been prescribed an SSRI when she was in nursing school. Is that right?

Yes.

What was the SSRI?

Prozac.

And how long was she on the Prozac?

I'm not sure.

Did you ever ask her?

I probably asked.

Probably asked. Isn't it true? Don't you guys have a saying that if it's not written, it didn't happen? You take copious notes, do you not?

It's impossible to write down every single thing that's said. So I write down what is clinically relevant, clinically necessary. But there's a lot that is discussed over an hour that is not able to be written down.

Such as the fact that a person was on an SSRI when they were in nursing school was not a good important fact to find out-

Oh, no, that's important.

Excuse me.

Sorry.

No problem. I'm not doing the Sophie Cunningham. I'm just asking a question. That's all. And you can answer it. Okay? How about if she had a reaction to Prozac?

I asked her about the Prozac.

Is that written in your notes?

Yes.

And what did she say?

I mean, she said that she took it for a period of time. She didn't mention any side effects.

Oh, she didn't tell you that she had side effects. I see. So when a patient comes to see you with a month under your belt, and they're sick, and they're looking for help, you wait for them to volunteer facts to you?

She volunteered a lot of information. She knew very well what her medical history was and was able to provide that for me.

Such as what? That she was in nursing school and took Prozac?

That's part of it.

And she told you that, right?

Yes.

And she was pretty upfront and honest with you, wasn't she, in answering these questions, right?

I believe that she was.

We all spent some time talking about the fact that she declared that she had consumed alcohol and that she felt guilty about it. You recall that on Friday? We dwelled on that for a while, didn't we?

Yes. That was a component. Yes.

I mean, that's something that's important, right?

Yes.

What was her drink of choice?

I'm not sure.

Did you ever ask her?

I'm not sure. We were not concerned that her level of alcohol use-

Well, the VA certainly was Friday, right?

Objection. Give the witness time to answer.

[inaudible 00:25:44]. Doctor, wait for the question, all right? And then same thing. I'll have counsel wait till you finish your answer. All right? Go ahead, Mr. Reddington.

So is it important, doctor, for you as a physician to know your patient? In other words, know who they are?

Yes.

And you know that Lindsay was a nurse, correct?

Yes.

You know that she graduated obviously from college, right?

Yes.

Was she a good student?

I don't recall.

Do you know when she got married?

I don't recall-

Did you ask her?

... that specific detail. I don't know. I knew she was married.

She had three kids, right?

Yes.

And the reason that you knew that she was married is because you spoke to her husband, Patrick, correct? Or did you?

Sorry?

Or did you?

He attended one of the appointments and I spoke with him on that date.

And did you say, "Hi, how are you?" And give him a handshake when you came into your office?

It was telemedicine.

It was what?

Telemedicine.

Telemedicine. Is it fair to say that after, what is it, 14, that you said to the jury, 14 appointments that you had with Lindsay during that period from September till January? 14 appointments?

Yes.

Every single one of them were via telemedicine, weren't they?

Yes.

Until you came into this courtroom Friday, you never saw this woman in person. Did you?

Correct.

Were you ever concerned about her mental health as a person?

Absolutely.

She was crying. She told you symptoms that she couldn't get out of bed. Isn't that right?

At one time she said it was difficult to get out of bed.

Oh, difficult to get out. Why was it difficult for Lindsay Clancy to get out of bed?

Because she was very depressed.

And did you give her a hug? Oh no, you're on telemedicine, so you couldn't give her a hug, could you? You didn't have any chance to even look at her in person, did you?

I could look at her. It was always a video appointment. I couldn't give her a hug, but that's not actually something that psychiatrists typically do with patients.

I imagine. Now I'm looking at you, and you've got the witness stand cutting you off in half, right? So I can't see from your waist down, your legs, your feet, your hands, anything. That's the same view that you have on telemedicine, right?

Yes.

Isn't it fair to say that you've studied and that you've learned that there are objective manifestations that patients may have that would be a tell, like if you're playing poke, you have a tell that would be an indicia of the fact that they're stressed or emotionally disturbed, right?

Yes.

Like hand wringing, right?

Yes.

Were you able to see the hands wringing when you were on telemedicine?

I don't recall seeing her hands.

Do you recall how people sit there and they do this with their leg and the leg bounces because they're going through some type of emotional stress? You couldn't even see her legs, could you?

I couldn't see her legs, but I knew that she was under stress.

So when she came to you, September 15th, I believe is the first time that you all actually discussed her condition, correct?

Yes.

And looking at the medical records which the jury will be able to look at, it says visit date, September 15th, 2022. And you can look along with me if you wish. Indicates why she came to see you, right?

Yes.

Right? Yes?

Yes.

Okay. Why did she come to see you? Not guessing and speculating, never mind the TV. You just look at your notes. Tell me what brought Lindsay Clancy to your office.

Postpartum anxiety.

Is that it? Is that what you noted in the records?

Well, those were her words when asked, "What are the problems for which you are seeking help?"

I see. Postpartum anxiety. Now, as a psychiatrist, meeting with this young woman, after a month or so of working as a psychiatrist for Aster, there are tests that you administer to a woman who's in postpartum to find out what type of anxiety they have, right?

There are some screening tests, but the most important thing is what the patient tells you and what my assessment is in the session.

I see. And that would carry through the Tufts evaluations for all 14 of those meetings is what the patient tells you, right?

Yes, and what I observed from the session.

Through the telephone?

Through the computer.

What, if you can tell me, is the Edinburgh test?

It is a scale that looks at symptoms of postpartum depression.

And when you administer... That's a major test, isn't it, for a doctor to evaluate a patient for PPD?

I wouldn't say it's a major test.

It's a pretty big one though, isn't it? It's the only one that measures postpartum depression, right?

It's a common one.

It's a what?

Common.

Common.

Commonly used.

Commonly, right. So when you used it on Lindsay, when was that administered to her?

I did not use it on Lindsay.

Why?

We...

Why?

We used the PHQ-9, which is a-

What is PHQ-9?

It's a depression screening form.

That's like generalized anxiety disorder, general depression. It's got nothing to do with a woman suffering from postpartum depression, does it?

I disagree.

Well, do you agree that people perhaps that may know a little more than you determined that the Edinburgh scale is the appropriate scale to administer to a pregnant or postpartum woman?

Objection.

Sustained as to form.

You're familiar with the Edinburgh scale, right?

I've heard of it.

And can you explain to me how it's graded?

No, I cannot.

There are 30 questions in it, are there not?

‍

‍ I don't use this scale, so I don't know how many questions there are.

So the Edinburgh scale, do you even know that [inaudible 00:32:57] for someone that is depressed in their condition of postpartum would be 15? Anything over that, they're in severe depression?

Okay.

Do you know that her first Edinburgh test that was administered to her put her at a 23?

Objection.

Overruled.

Severe depression?

I was not aware of this test. I was not aware that this had been administered to her.

Well, you know that except for the Prozac that she had when she was a nurse, what, 23, 24, 23 years old, she hadn't, other than seeing her own doctor for having a baby, she hadn't seen any doctors. You knew that, right?

I didn't know exactly which doctor she sees. I think we ask about your primary care doctor, but she did not report any other medical issues that she was under treatment for.

So is it important for Dr. Jennifer Tufts to know whether or not a patient who is coming to you for help has a prior medical history other than what they might tell you?

Well, when patients are able to advocate for themselves and share their medical history, we rely on what they tell us.

Was she able to advocate for herself in your opinion when she came to see you when you evaluated her in September?

Absolutely.

What about October?

Yes.

How about November?

Yes.

What about December?

Yes.

And your medical records, you would agree, show that during that period of time that she was deteriorating, was a word that was used on Friday. Isn't that right?

So-

No, no. No so. You used the word "deteriorating" on Friday, did you not?

She was a little bit worse at certain appointments. And the "deteriorating" word, which is not my word choice, is what is in the note because I had to select that.

Because why? You have some kind of a program that you have to check the box and you have to bring down the drop box. You can't take a pen and write something down about a patient.

There are certain parts of the note where I can write whatever I feel is necessary, but that specific aspect of the note is a button where you have to click one of three choices.

So when the jury's going through your medical records, one of the things that they're going to see is that when you meet with a patient, you have a form that you fill out where it says, "If you feel like you're going to harm yourself or somebody else, make sure you go to the emergency room," right?

Yes.

"If you have any urges to harm yourself or others, go to the nearest emergency room." That's in every single time that you meet with a patient, right?

Yes.

And it indicates that if there's any... "Call the suicide prevention and crisis hotline if you feel that you're in crisis, you may text "home" to a particular number at any time." What's a suicide hotline?

It's a phone number that patients in crisis can call and speak to a trained counselor.

Now a psychiatrist, you'd agree with me, is not a counselor, that's for sure, right?

Well, a psychiatrist has training in therapy as well as in medicine.

Did you give Lindsay Clancy any therapy?

There was some therapy incorporated in our sessions, but we did-

Like what? Like what?

Providing emotional support, listening to her-

Excuse me. Hold on.

Objection.

No, please.

She can finish her answer.

No, she can't.

Hold on everybody.

I'm sorry, Judge.

You asked the question. Sustained. I'm going to let her finish and then you can follow up with any questions you want.

[inaudible 00:37:19].

Go ahead, Doc.

Is there anything else you want to say?

So her sessions were largely focused on the medication management, but there was an aspect of therapy including those items.

Okay. And the sessions were for what, 17 minutes?

No.

How long were they?

25 to 30 minutes.

So 25 to 30 minutes on the television. And were you faced the TV screen with her for the full 25 minutes?

Yes.

And that's not noted in your records. It says 17 minutes on all the records, doesn't it?

So if you look closely, it says the therapy component was for 17 minutes. It doesn't say the entire duration is 17 minutes.

So what do you do when you're trying to give therapy as a psychiatrist to a patient that came to see you? What do you do? What do you do with therapy?

It depends on the person.

Well, how about Lindsay Clancy? What did you do for therapy with her?

I listened to her. I listened to her concerns and provided support. I tried to provide her with hope that eventually things would improve.

So you listened to her, you listened to her concerns, and you'd agree with me that her concerns were, for example, that she actually was unable to sleep is one of her concerns, right?

She was having a lot of difficulty with sleep.

On the September 15th meeting, you indicate that her mood was okay, but her affect was anxious and you called it incongruent. What does that mean?

So she said she was feeling okay. She appeared anxious, and she also stated that she was anxious.

So one of the things that you talked about Friday is when a patient presents with an incongruent something or other, I don't remember, appearance perhaps. That would mean that they're saying I'm okay, but they don't look like they're okay, right?

Well, it could. I don't think her affect and her mood were really that incongruent at that time. I think that she didn't appear terribly depressed. I didn't say she was terribly depressed in that initial visit, but she said she was anxious and she appeared anxious. That's pretty congruent.

Okay. So did you put in the report that she was congruent or incongruent?

So that is not an option for me to indicate in that section-

So-

But it was congruent.

So you're like a robot. You can't take a pen and write something down. You have to do the drop box and the Xs on the computer?

Well, if it's on the computer, I'm limited by the options that are up there.

Why? You're a doctor? Why are you limited?

Because of the technology.

What technology? The fact that there's a form on a computer? You're trying to treat a human being who comes to you for help.

And that's what's most important. What's most important was the treatment, not what is checked off on a box.

Makes sense. So you were unable to make a note as to whether or not her affect and her mood appeared to be in conflict and that she wouldn't have been incongruent and that she had poor insight. You couldn't write that down, is that right, because the box doesn't let you.

Correct.

So basically she's telling you that I'm okay. Well, actually, when she came... Do you know that she never saw her, other than when she was in nursing school, would it surprise you, a psychiatrist? And that was only for like a week when she got the Prozac in nursing school because she was afraid of public speaking. Did you know that?

I was aware that she did not have a significant past psychiatric history. I was aware of that.

Okay. So you were the first psychiatrist that she had the pleasure of meeting. Is that correct?

Yeah. I think it was.

And isn't that important for you as a doctor to take a history?

I did take a history.

So can you tell us, you're testifying here for the government. Tell us whether or not she had any past psychiatric history other than in nursing school for weekly Prozac.

She did not report any other past psychiatric history other than the Prozac and Wellbutrin.

So when a patient comes to see you and you're treating to help that patient, if they don't report something to you, you don't know about it apparently, right?

Well, I think it depends. There are certainly things I can assess, but if it's related to their history, I do need them to tell me.

Well, you can't assess it unless you ask, right?

Unless I ask or they volunteer it or they [inaudible 00:43:04].

Of course. We already talked about the volunteering. How about you as a doctor when you're evaluating a patient coming to you for help, do you ask them questions?

Yes.

You didn't ask her a prior history.

I did.

What did she tell you?

She said that her prior history was what we discussed about the Prozac in the nursing school.

So basically, other than hoping to give her hope is what you said for the therapy. How do you give someone hope for therapy, you're the doctor?

Try to encourage them. And-

What did you encourage her on September 15th?

Sorry?

What did you encourage her to give her hope on September 15th?

What did I encourage her?

Yeah.

I don't remember exactly the words. It was almost [inaudible 00:44:05].

Did you write it down in your records?

No, we don't write those details of everything else.

Well, that's the therapy you're talking about, right? Yes?

Yes.

And you don't write down the therapy you give the patient in the records, right?

Well, I write something about it. I'd mention that-

You write it down... No, not... Excuse me.

Hold on. Hold on.

It's a yes or no.

Hold on. Let her finish the question. Listen to the question and answer just what they asked, okay? Go ahead. You could rephrase that question.

No, I'll let her answer it.

All right.

I mentioned that I provided supportive therapy.

What is supportive therapy?

It's listening to the patient's concerns and providing emotional support and validation.

So emotional support and validation all sounds good. Here's a young woman who was what? 29, 30 years old, came to see you?

Yes.

And came to see you for help, right?

Yes.

Told you she couldn't sleep and she was anxious, correct?

Yes.

You know that she was postpartum, correct?

Yes.

You know that as a patient who was postpartum, and by the way, what is your opinion of the period of postpartum wherein one could have postpartum depression and more importantly, postpartum psychosis? What's the timeframe?

It's typically one year.

So she was well within that timeframe, correct?

Yes.

And you tried to provide therapy by giving her hope. And how long do you figure did that take? Five minutes, 10 minutes, two minutes?

I'm not sure. I think it was different in each session.

Okay. So the only thing that you diagnosed Lindsay with on September 15th was GAD, generalized anxiety disorder, correct?

It was generalized anxiety disorder as well as an adjustment disorder with depressed mood.

And you prescribed medications to her, right?

Yes.

And the medication that you provided to her was the sertraline, right?

Yes.

And the sertraline would be Zoloft, right?

Yes.

Now this is a little chart that shows the prescriptions that Lindsay was on, and you are the yellow columns. You can see that. Would you agree with me that on September 15th, you prescribed Sertraline, Zoloft, 30 count on September 15th, 25 milligrams, right?

Yes.

Have you ever read the website for Sertraline?

The website for sertraline?

Yeah. I mean, sertraline, Zoloft is a chemical that is marketed as a pharmaceutical, right?

Yes.

Right?

Yes.

It's a pill, right?

Yes.

And as we said, it's an SSRI pill, correct?

Yes.

Do you know that Zoloft is not indicated for generalized anxiety? Why'd you give her Zoloft?

It is a very effective medication for generalized anxiety disorder.

So you're familiar with the drug labeling for Zoloft, is that correct?

Generally.

Generally. Are you aware of what the manufacturer of Zoloft indicates it can be used for to treat?

I'm aware that it's used to treat various forms of anxiety disorders as well as major depression.

So when Lindsay came to see you, you know that she had stopped breastfeeding her son, right?

Not at the time of the first appointment.

When did she stop breastfeeding in October?

Something around then.

You know that she had little or no psychiatric history other than seeing you, correct?

And the Prozac, yes.

You know that, in fact, that she had stopped drinking whatever it was that she was drinking because you never asked, right?

I was not concerned about her level of drinking.

Well, it's in your form, right?

That was at the intake, but I-

You know that she wasn't drinking when you were meeting with her, correct?

Yeah, that's what she told me.

Okay. And you believe what she told you, right?

Yes.

So when she sees you, she's not on any psychiatric anti-tropics or whatever they're called, medications, correct? She wasn't on any medication?

Correct.

And she had stopped drinking anything, whatever it may have been, right?

I'm not sure when she completely stopped drinking, but yes.

You don't know when she started, when she stopped, what she drank, do you?

Well, I was not concerned that she was an alcoholic.

That's a yes or no. Did you have any idea, because we spent a long time on Friday talking about her guilt and having that she drank alcohol. You don't know what she drank, when she drank, when she started, when she stopped, do you?

I know some details about her alcohol use, but it was overall minimal.

What were the details then? Tell me what the details were. There was that one little box that was checked off. What other details were there?

That she drank one to two times a week, one to two servings, five times a week.

And you don't know where, what it was? You have no idea, right?

I think she had mentioned at some point that it was calming. It was something that was-

It was what? I'm sorry.

Calming.

Calming. Okay. So it was numbing. It was like trying to numb something, I guess, right?

That's one way of saying it.

I imagine you've treated veterans that had post-traumatic stress disorder, right?

Yes.

And would you agree with me that many times when people have an anxiety disorder or PTSD, whatever the case may be, they try to numb their feelings. Is that fair?

Sometimes they do.

And sometimes they use alcohol, right?

Sometimes they do.

We don't know what alcohol she was drinking, we don't know if it was a beer, do we?

I didn't think that was relevant for her.

Okay. So with that information, you then prescribed Zoloft to her, correct?

Yes.

You went over the side effects of Zoloft, sertraline, I imagine with her, right?

Yes.

Did you tell her that one of the known side effects is suicidal thoughts and actions and ideation?

Well, that's specifically in children. So I don't think I mentioned that because it wasn't relevant.

Well, not really. Suicidal ideation and homicidal ideation, there's a black box warning on Zoloft, along with other SSRIs, right?

Under-

Yes or no?

For children and adults younger than Lindsay.

Excuse me, Doctor. I apologize. Can you just listen to my question and answer it yes or no? Is there a black box warning on the Zoloft?

Yes.

All right. And a black box warning is required or prescribed by what? The FDA?

Probably.

Probably. And it basically warns that, especially with young people or young adults, that it may cause suicidal or God forbid a homicidal ideation, yes?

Yes. In-

And you're aware that in fact, the FDA has determined that that goes up possibly to a 23, 24, 25 year old. You know that, right?

I think 24 exactly is what they said.

24. All right, I'll give you 24. It's possible, is it not, that the SSRIs that get into a person's brain affect a person that's three or four years older than the FDA cutoff with suicidal ideation or homicidal ideation? It's possible.

There's a lot of development that happens in the brain between ages up to 24 and closer to 30. The brain is fully matured past age 24. And so it's less vulnerable than in a younger individual.

So with 24, you're suggesting as a cutoff. Are you suggesting to the jury that a drug that increases the risk of suicide in a 24-year-old patient cannot increase the risk of suicide in a 29 or a 30-year-old patient, just a little bit?

I don't believe there's evidence that it causes that at all in individuals over 24.

So as a psychiatrist who had the ability to issue these types of medications to patients and citizens, what research did you do on Zoloft and suicidal ideation, homicidal ideation?

I was taught extensively about SSRIs and suicidal ideation in my training.

That's back in Vermont, right?

In Vermont, in Boston, yes.

Okay. So in Vermont was when you got your medical degree, right?

Yes.

And Boston would be when you were a resident, right?

Yes.

And then you have board certification on general psychiatry, right?

Yes.

You can have the certification on the subspecialty, right?

There are certain subspecialties, yes.

Right. And some of the subspecialties deal with postpartum or women that are pregnant and have babies and have psychiatric symptomology.

There's no board certification for perinatal or reproductive psychiatry.

Well, there are plenty of classes that are recognized as, for example, at Harvard Medical School, there's an annual class or symposium, if you will, for postpartum. Have you ever been to that?

No, sir.

What have you done to research or to improve your education? I understand you went to med school and that you were a resident. What programs, continuing education, symposiums, have you attended since you got the ability to prescribe these medicines to people?

I have not attended a symposium.

Have you attended anything?

I have not, but I have done a lot of reading on my own of research and guidelines about this area in psychiatry.

Did you tell Lindsay when you were going... Because one of the things that you guys are always concerned about is what's called informed consent, right?

Yes.

And what is informed consent? What does that mean?

It means that-

In a medical sense, not just like out in the street or something.

Explaining to a patient the risks and benefits of treatment and possible alternatives and making sure that the patient understands what you're saying.

Now, when you were going over the symptomology or when you were going over the side effects of Zoloft, one of the side effects of Zoloft is, and I quote, "Severe trouble sleeping," right?

Yes.

Did you tell her that?

Well, insomnia is listed as a side effect.

No, no, no, no, no. You already said yes, you know it. Did you tell her that Zoloft has a side effect of giving the patient severe trouble sleeping? That's all.

So I didn't use the word "severe" because it typically doesn't cause severe trouble sleeping, but I though you were referring to when she told me that she did have severe trouble sleeping.

Well, that's what she told you, right? That she had severe trouble sleeping, right?

She told me, yes.

Yes? And you know that one of the side effects of Zoloft is, let's say, trouble sleeping. You know that, right?

Yes.

Your answer is yes. The jury has to be able to hear you.

Yes.

And why would you prescribe Zoloft to a young woman who's postpartum, who's coming to you with anxiety, who's telling you she can't sleep. She's got all of these symptoms and you prescribe a medication that would have a side effect of trouble sleeping?

So individuals have very varied responses to medications. Some have no side effects. Some have one or two. It's impossible to predict but Zoloft is a top choice, a first line medication for-

Says who? Says who?

It's the general consensus. [inaudible 00:57:52]-

Well, you know about the lawsuits against Zoloft, right?

Again, we can't have both of you talking at the same time. So let her finish her answer and then I'll give you plenty of time to follow-up any questions regarding her answer. So can you finish your answer on that?

There's extensive research supporting the use of sertraline in this instance. And the general consensus among psychiatrists is that it's a first line safe medication for individuals, including postpartum women.

How about the kids that shoot other kids in high school from the lawsuits that come out of that against Zoloft? Do you ever read about them?

Objection.

Overruled.

Sorry? I wasn't sure what the question was.

The question was, in response to your observation about how all the psychiatrists or the psychiatrists think it's a very, very safe, wonderful first line drug in research. How about the kids that kill other kids in schools with the lawsuits that arise out of the use of SSRIs? Have you ever researched that?

I don't know much about that.

Do you know about the SSRIs messing with someone's brain that they go out and they shoot people for no reason, right?

I'm not aware that that's linked to SSRIs.

So you didn't really talk to her about increased risk of suicide in 24-year-olds or down because she's four or five years older than that. You didn't talk to her about the trouble sleeping, that can be a side effect. But she describes there's other drugs that you could have given her that would be perfectly safe and common and allow someone with no psychiatric history to sleep better, right?

Not necessarily.

Okay. So you prescribed her with the Zoloft. It was 25 milligrams, right?

Yes.

And when you prescribed her with the Zoloft, 25 milligrams, was that increased up to 0.05 milligrams or did you increase it at some point?

The instructions were to increase it to 50 after one week.

After one week?

Yes.

And you expected that she would listen to your instructions, right?

Yes.

And she did, right?

She waited about a month, but then yes, she did.

Why did she wait a month?

I think it took her some time to decide whether that was truly what she wanted to do.

Right. She was afraid of the drugs, wasn't she?

She was afraid of side effects.

And she didn't want to take the pills, did she?

She eventually did want to take the pills because she wanted to feel better.

A month later, right?

Yes.

So you prescribe the Zoloft, SSRI, and then you tell her after a week to increase it, and she doesn't take that medication for a month, correct?

Correct.

And then she did take the medication, right?

Yes.

And did you meet with her or talk to her before she actually started to implement that particular regimen?

I had met with her beforehand, but I was not aware of when she made the decision to go ahead and take it.

So you met her on the 15th of September, right?

Yes.

When was the next time you met her?

Can I check?

Sure, of course. Absolutely. You can look at anything you want.

September 28th.

And on September 28th, did you discuss with her the fact that she was afraid to take the Zoloft?

Yes.

And did you recommend that she do that?

Well, she said that she was feeling better at that point.

It's a real easy question. When you talked with her, did you recommend that she increase or take this Zoloft?

At that visit, I don't think that I did.

Okay. So when did she actually take the Zoloft?

She told me in her October 20th visit that she had taken it one week prior.

And she told you that when she increased it in accordance with your instructions, she went off the rails, right?

I don't think she used those words, but she had said that-

What words did she use for you as her doctor?

She felt awful.

Awful. Why did she feel awful? Did she have a stomachache? Did she have a headache? Why did she feel awful?

She did have some stomachaches. She had some diarrhea and had a difficult time eating. She also had increased anxiety. She had some more depressed feelings. She had more difficulty sleeping.

And what was your advice to her as her doctor on the 28th of October, after she told you about the effect that Zoloft had on her?

I told her to stop it. Stop the medication.

Okay. Now, Zoloft being an SSRI and a patient that is taking the Zoloft in 0.05 we spent Friday afternoon going over the drugs and 0.05 milligrams is the lowest dose and all that, that's the dose that is prescribed to people invariably, correct?

It goes up to 200, but that is a starting dose.

For pretty much all of you psychiatrists would agree with that, right? 0.05, right?

50

50. Okay. And you then told her to stop?

Yes.

... stop?

Yes.

What does it mean to titrate something?

To slowly increase the amount.

What do you tell patients when they're on an SSRI as to weaning them off the SSRIs?

Depends what the dose is. If it's a high dose, you need to slowly decrease the dose, so kind of the opposite of titration. But if it's a low dose to begin with, you can stop it.

Are you supposed to tell a person that's on an SSRI to stop immediately or to slowly withdraw from it?

At 50 milligrams, it is perfectly fine to stop it immediately.

So you didn't have any concerns at all about telling her to immediately stop taking the Zoloft. And what'd you do, put her on another drug?

Not immediately.

Okay. So did she relate to you on that October 28th meeting that you had, was it the 28th or the 26th?

I met with her the 21st and then the 26th.

Okay. Now on the 26th of October, what did she tell you her condition was?

So she was feeling back to how she was before the Zoloft, which is not great still, and that she was considering a new medication.

So she was considering it. Did she do research on medication as to what medication she wanted to take? Is that what you were telling this jury?

She didn't specify exactly what medication she wanted to take, but that she wanted to try something else because she was still having significant anxiety.

So when you say she wanted to try something else, I'm just asking, did you tell her what you recommended she try or is that something that she decided to do on her own?

No, I gave her my recommendation.

Okay. The only reason why I asked that is that a lot of times people might think that she's a psychopharmacologist, that she's a heart surgeon, that she's a vascular surgeon, that she knows everything about medicine. That's not true, is it?

No.

Would you agree with me that prior to telling her to stop the Zoloft, that one of the concerns that you had is that Zoloft affects anxiety and affects sleep, and you hope that it treats the underlying anxiety by balancing brain chemistry and increasing serotonin, right?

Yes.

That fair? Okay. And you'd agree with me that it does, as a side effect, have an impact on a person's falling asleep or staying asleep as a common side effect, right?

It can happen. It doesn't happen to everyone, but it certainly happens to some, but it is temporary. That's the important distinction, is that there are many side effects that disappear entirely and then the medicine is quite helpful for those certain conditions.

What's that?

Yes.

She had problems sleeping, didn't she?

Yes.

Even after the Zoloft, right?