Trial Day 11

This court is now in session. You may be seated.

Good morning, Your Honor. May I proceed?

Yes, please.

Your Honor, before the court today, we have the matter of Commonwealth versus Lindsay Clancy. Ms. Clancy is present. She is represented by Attorney Kevin Reddington, and the Commonwealth is represented by Assistant District Attorney Jennifer Sprague and Assistant District Attorney Shanan Buckingham.

All right. Well, good morning everyone. Good morning, Counsel.

Morning.

Good morning, Ms. Clancy.

[inaudible 00:00:23].

All right. What I want to do first, let me just talk to counsel just for a second. Before we get going, I just wanted to remind everybody that there is a media order that has been issued on this case. And for some of the media and the individuals who've been here for the last couple of weeks, I'm sure are familiar with it, but I know there's a constant people coming in and out. So I just want to remind everyone that there is a specific media order that's been issued on this case, and everybody is presumed to have reviewed it and agreed to it. So if there are any violations or problems with that, we'll have to deal with it. But I just wanted to remind everybody, especially people who may have just come into the courtroom recently. And if you have any questions about what that order is, you can speak to any of the court officers. They have a copy of it. We can get a copy of it to everybody who needs to see it and review it. All right. And with that, what we'll do is we're going to go. The defendant, excuse me, had filed a motion for addition to the witness list, to add to the witness list regarding a Ms. Thorndike. So what I'm going to do first, I'll hear from the defendant. Then I'll hear from the Commonwealth. Thank you. Mr. Reddington.

Thank you. Your Honor, basically as the motion speaks for itself, there is a woman. Her name is Emily Thorndike, who's a LICSW here in Massachusetts. She owns and is an independent operator of her own clinical social work establishment called Wise Mind Therapy. Your Honor has her resume. She graduated from Dover-Sherborn High School, received a Bachelor of Arts in Sociology from Hartwick College, master's degree from BC 2019, is licensed in Massachusetts. And interestingly enough, she did work at the McLean Hospital in the very short term unit that the doctor was testifying that Lindsay was in for five days in January of '22 into '23. She worked for five years as a mental health specialist from May of 2014 to May of 2019. She was a clinical social worker manager of that unit from 2019, 2021. So she's basically got about seven years and seven months of experience working in that unit for majority of that period of time, full-time employee, and then for one year as a supervisor. She left, as the court is aware, from the motion. I vetted her out. I obviously would be concerned if there's any so-called ax to grind, if you will, any lawsuits pending. Were you fired? Did you have any difficulties? Any claims for harassment, hostile workplace? Absolutely nothing. She has friends that are still employees that still work at McLean. And I do not know this woman. I have literally never met her. Her involvement in this case came about after one of the prosecutors, I don't recall which, made it out on direct examination that McLean is some kind of a five-star institution where the doctors, the psychiatrists, the psychotherapists, the counselors were all banging into each other in the hallway trying to interview Ms. Clancy, who was just blithely refusing care and treatment which is not the case. Patrick testified as to his observations. The court is aware that Patrick's testimony clearly in all fours landed on the fact that it was clear to him that there was no staff that was available other than kids behind plexiglass on their cell phones. She colored. She took walks. There was no therapy. She didn't speak to any therapists or counselors. So now, the jury is left with that image that McLean is purportedly some kind of a five-star hospital because they're affiliated quote, unquote, "with Harvard," which you, from your practice, I'm sure as I know from my practice, is as far from the truth as can be possible in my opinion. But it doesn't matter what my opinion is. I could cross-examine somebody till the cows come home. It doesn't matter. This woman posted a video on TikTok, which much like yourself, I'm sure. I hardly know what TikTok is, but I received an email from one of the very, very active people in the community of TikTok saying, "Look, you got to check this video out." So I did. This is about a week ago, maybe longer now. When I saw her video saying that she could not stand for, and I quote, "The lies and the misrepresentations from that witness stand about McLean Hospital." I then said to my private investigator, Bob Jones, I said, "Bob, I can't find this woman because she had a pseudonym name or whatever." He went, we wrote, he called her, left messages. She never got back to us for three days. He went to her house. He sat out in front of her driveway. She came home from work. They interacted. He waved, didn't want to scare her. And she said, "I thought..." Oh, by the way, I believe that actually my wife had written her a letter as well because she's a nurse and was trying to reach out to her to have her get in touch with me to no response. She then tells Bob, "I thought you guys were all AI. I didn't know that you were real. I though it was spam." He then gave me her number. I spoke to her. She told me exactly what I put in the affidavit or in the motion. And she is available, ready, willing, and able to testify to an employee's observations over seven years, including as a supervisor, as to what woeful environment McLean Hospital offers, especially on holidays such as major holidays like New Year's, which is fine. We all enjoy New Year's. But nevertheless, New Year's, the day after, that weekend, Monday, nobody was there. And I think it's important to rebut the inference that was created through the examination by the DA.

All right. Ms. [inaudible 00:07:19], let me ask you this, and I'm going to ask the Commonwealth the same thing. What's the relevance? What's the argument for the relevance of what McLean's was at least the... Because she wasn't there for about a year if I looked at the motion. Is that correct?

[inaudible 00:07:40].

That's all right.

Yeah, that's true. She left. She has her own business now, and she left, but it was just a year.

Yeah.

There's no change in the circumstances from Lindsay going into that hospital on New Year's of 2022 to '23 and this woman's work experience where she left a year before. And I agree with you. This would've been a non-issue. Were it not for the flavor of the government's repeated argument that she was a person who was spurning healthcare, didn't want healthcare, had the opportunity and she walked away from the opportunity, which as I say, is as far from the truth as possible. So I think it is now because of their questioning squarely before the jury to leave that impression. And the woman that was the doctor from McLean was just a pleasure. She was just a lovely, lovely woman and testified as best she could in the case. But they're left with the impression that McLean is this wonderful place that she just did not have any interest in utilizing what was available to her that was not available to her. And she's testifying to custom practice and her observations over seven and a half years.

Is there another alternative to get there if someone who actually works there or worked there during this time period? It's the time period that-

A year?

... is one of the things that. Well, yeah, but things can change in a year.

I don't think so at McLean.

I don't know so. I guess that's the question. I don't know so. That's one of the things I may have to wrestle with, but that's what I was asking whether or not there is... I understand the argument.

Okay.

And I understand the argument regarding relevance. But if we're talking about staffing or the availability of programs and how that work, this witness, there's a gap there. I guess that's all. I'm wondering if there's another way to get there.

So the realities of trial practice, if you're the government, you send summonses. You have people come to your office. You're interviewing witnesses. If you're the defense, they run for the hills. For example, one motion I'm bringing with you is merely looking for pediatric records that I have had to have Bob Jones go and try to get the HIPAA forms, everything. And they're avoiding us horribly. And I'm going to have a contempt hearing request very shortly. But the point I'm getting at is if they want to reach out to McLean, I'm sure that McLean administration would bend over backwards to give them every record that they would need as to how many employees they had, what their work records were, their doctors, their counselors, all available. I know I can't get it. So I'm suggesting to Your Honor that this is an opportunity for a person who worked there for all those years who does not have any dog in the fight to testify to what her observations were clearly within her timeframe. She left a year before Lindsay went in there on New Year's. So I certainly agree with that cross-examination. They could get records if they wish, but I think it is relevant. I think it's material, and I think it has to be used to rebut the inference that was raised.

All right. Thank you.

Thank you, Judge.

Yeah. Commonwealth?

Your Honor, the Commonwealth would object to the witness, the late disclosed witness. In addition to the obvious Rule 14 issues, the fact that we didn't have notice of this individual, there's been no discovery other than what's contained in the affidavit and what we could identify from this woman's TikTok video. There's no report from the investigator who admittedly by counsel has spoken to this witness, this individual. Aside from that, we have a number of other issues with this witness. One is this isn't somebody that's proposed to be an expert. So they're not relieved. They wouldn't be relieved of a sequestration order. But this woman's TikTok, admittedly, she's been following the trial. She goes on for several minutes in a very long TikTok video where she identifies what she thinks are lies based on her observations of Patrick Clancy's testimony. We have no idea what her thoughts are or what her comments are on the rest of the trial that we assume she's watched based on her comments in this particular video, that she outlines in this video her experiences at McLean and her observations and how they are different from what was portrayed in that particular witness's testimony. But in the course of this trial, we not only have that particular witness's testimony, we have records from McLean and the records speak from themselves about what she was offered, what she did, what she declined, what the contact was with each and every person who wrote a note in that record. But this witness admittedly wasn't there, had no contact, has no knowledge of the case in of itself. And in this case, Your Honor, we deal with facts. We're presenting facts to the jury. We're not presenting somebody's opinion about what kind of care the defendant got during her stay at McLean. That's not what this trial is about. That's not what it should be about. And if it wants to play out in the court of public opinion, that's fine, but not inside the walls of this courtroom. So this person who said that she cares about Lindsay in this video, whether other people do or don't, this person who said that the prosecution of this case is an abomination, this person who said that the health profession needs to be held responsible for their care of the defendant, that's not a witness that presents facts to this jury. And I would also agree that there is a problem with what relevant testimony that she could give. There is no indication that what her experiences were in those seven years up until December of 2021 are exactly the same as they would've been when the defendant was at that short-term unit at McLean. And the defense had the opportunity to ask that of Dr. Goodheart and he didn't. So there is-

Wait a minute. I think she said, "I don't know what the staffing was." Didn't she say, "I don't know how many people were on. I don't know if it was a skeleton crew"?

She said on that particular weekend. She didn't know what the staffing was. But she wasn't asked any-

That's the only weekend we're talking about.

Right. But now, he wants to make this an issue about the practices and the common practice of the hospital. But that was not a question that was asked of her, nor would Your Honor necessarily have permitted it where he was trying to tailor the testimony to the exchanges with the defendant. So to then have the witness available to answer those questions that was at the facility during that time period, and then not take that opportunity and then offer this subsequent witness and call it a rebuttal witness, it's not a fair line of examination. It's not a fair line of rebuttal where she wasn't there during the time period. So we would object for all of those reasons.

Just so everybody knows where we're going. I can't imagine that that witness would be allowed to give her, in a sense, review of McLean's. If it's five star and she may say it's two star, this is not TripAdvisor. I wouldn't allow that.

And no one-

But the question seems to be, for me, a closer call about what the standard staffing and programs may be available on a holiday weekend, because the Commonwealth's witness said, "I don't know that." And that seems to be something that maybe the parties could come to an agreement about establishing either... There's got to be somebody who's still working there that says, "The weekend after this wasn't a holiday, we have X amount of people there. We have X amount of programs that are available. On the holiday weekend, we do or we don't." To me, that's where the battle on this motion is. I do understand the Commonwealth's objections regarding allowing people who watched the trial to then say, "I disagree with it, and I want to testify about what I disagree with." That's troubling, but I'm talking about the facts on this thing. If it was anything other than those kind of facts and this witness had not worked there, I'm not sure we'd even be having this hearing.

Well, and I would suggest that counsel indicated that in trial practice that people are reluctant to give information to the defense, but there are avenues, procedural avenues that he could pursue to get that information involving the court or involving subpoenas in which there's been no indication that he's actually tried to do. And again, I would suggest to the court that we have the McLean records from that time period in evidence, and they are the best evidence of the contact that people there, staff that were there that day had, or those four days, had with the defendant on that day. So from the perspective of if there's missing information, there are avenues he could pursue if he wants to rebut it. I would suggest that this person's testimony is not relevant because they weren't there. And I would agree that the better option from if defense wants to present this as a rebuttal would be from somebody that is there, but he doesn't have that. And so for those reasons, this motion should be denied.

And you don't have to commit to this at all, but it seems to me that it would be a very simple solution to get the staffing records or somebody at McLean's who can testify to this. What was the program availability on mid-December weekend if you went in there as opposed to the weekend of New Year's? And it may be no different whatsoever, and that eliminates the argument. So I think probably the best way to deal with this is to maybe have a voir dire of this witness. So then the record's clear too. But it also allows the parties to consider while we're setting this up. Maybe, there's another way to do it, a lesser alternative, so to speak, that would reduce the prejudice to both parties.

I don't know how a voir dire of this particular witness who clearly wasn't there and didn't have contact with the facility during that time period would answer Your Honor's questions. But I do agree-

Maybe, we can find out. I can ask the questions, and we could see. I understand. The problem that I had as the case was going, the individual that was probably, you would anticipate, could talk about the staffing, the difference of a holiday weekend and a non-holiday weekend, said she wasn't aware of that.

Well, I don't know that she said she wasn't aware of the difference. She said she wasn't aware of who was there on that weekend because she wasn't working that weekend. So I think there's a slight distinction in that. But again, the witness was available. Counsel could have crossed her on that subject to any sort of objection, and we could have addressed it at that time when the witness was on the stand. But again, that witness is under summons. And if counsel wants to recall her, he can. There are avenues that he could pursue if he wants to pursue this line of rebuttal that's short of calling this particular witness that's been proposed is the point that the Commonwealth wants to express.

So I need to take this under advisement. I want to review it. Just so everybody can maybe make some idea where we may go with this, I'm inclined to have a voir dire with this witness or some other witness. So maybe the defendant can get somebody who hasn't watched the trial because I do understand there's an issue regarding sequestration, but that may be a function of a trial like this that's being broadcast. How do we guard against that? But that's not going to affect really the relevance, the prejudice, the determinations I have to make really under all the rules, 401, 403, all of those considerations that I have to make. So I'm inclined to do that unless the parties can think of a, I won't say better, alternative, that's not fair to this witness, a different alternative that might address everybody's-

[inaudible 00:21:04] we're going to be able to agree on anything, Judge. So it would really be up to the-

I know.

... referee to make a decision.

Right. What I'm trying to do is put that out there. If the parties can agree, I think the three of you know me. I don't have a problem making a decision. I really don't. But I just wanted to give everybody that opportunity to maybe craft the solution. And if I have to do it, that's what I'm saying by saying I'll take it under advisement. So I'll let the parties know.

Can I just ask, Your Honor?

Sure.

If you're reviewing this, taking it under advisement, that you do look in more detail at those records, the McLean Hospital records [inaudible 00:21:42] evidence so that Your Honor can see the extent of the contact, the extent of the notes of people who actually dealt with her because, again, that is the issue. That is the factual issue here, is the contact that she actually had, not what maybe she wasn't offered at other points, but what she had while she was there. So I'd ask that you just review that.

All right. I'll review that. I'll review my notes regarding the doctor who testified from McLean's, and then we can deal with this. This would be a witness that would be called later in the trial anyway. So give me a chance to do that, review that, get a decision to the three of you. And then we can, depending what happens, either schedule a voir dire or go from there. All right.

All right.

Thank you for everybody for agreeing to argue this a little bit earlier. So it gives me a chance to review the records and the arguments. All right. With that now, we ready for the jury?

Yes.

Come on. Yeah.

[inaudible 00:23:50]

All right. All rise. Jurors entering. Oyez, oyez, oyez. All persons having anything to do before the Honorable William Sullivan, Justice of the Superior Court, now sitting in Plymouth within and for the Commonwealth. Draw near, give attendance, and you shall be heard. God saved the Commonwealth of Massachusetts. This court is now in session. Please be seated.

Good morning, Your Honor. May I proceed?

Yes, please.

Your Honor, before the court today, we have the continuation of the jury trial in the matter of Commonwealth versus Lindsay Clancy. Ms. Clancy is present. She is represented by attorney Kevin Reddington. The Commonwealth is represented by Assistant District Attorney Jennifer Sprague and Assistant District Attorney Shanan Buckingham.

All right. Well, good morning, everyone.

Good morning, Your Honor.

Thanks for your patience. I told you we got a little late to start, but I appreciate you waiting for us. And so what I'm going to do is going to go through those questions. And then at that point, we'll talk a little bit about the schedule, and then we'll get right back into the trial. So first question, as you all know by this point, 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?

[inaudible 00:26:24].

All right. Second question 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?

[inaudible 00:26:33].

Again, thank you for following those instructions. And then in regards to today's schedule, I'll probably be wrong again, but the best aspect I think will probably be similar to yesterday, okay? So we'll return to the case. We'll take a break hopefully around 11:00. Take a break from 1:00 to 2:00, and then we'll go into the afternoon depending on how the case testimony goes. And then at the end of the day, I'll try to remember, bring counsel over here. We'll talk about where we are on the timeline of the case, where we are scheduled for the week and going forward. So I'll try and give you that hopefully this afternoon before I send you home. All right. So with that, we're going to return. There was a witness. Ms. Paul was on the stand. The Commonwealth had finished their direct examination, and we're about to begin cross-examination of that witness. So I would ask the witness if the witness could retake the stand, please.

Good morning, ma'am.

Good morning.

Can you stop right there and raise your right hand for the clerk, please?

Good morning. Do you solemnly swear that the testimony you'll [inaudible 00:28:09]

Yes.

Thank you. You may have a seat.

Watch your step, please.

All right. Good morning.

Good morning.

All right. Mr. Reddington?

Thank you, Judge. Morning, Nurse Paul.

Good morning.

And if I understand, you now live and perhaps work in New Hampshire. Is that right?

That's correct.

And are you still doing the same type of work that you were doing with the South Shore Health?

Yes, I am.

Excellent. Very good. You obviously are a very, very dedicated person to this field, if you will, in helping people that are pregnant women after they had birth and during that postpartum period, right?

Correct.

You worked with Lindsay. And the reason you were involved with Lindsay is because, if I understand it correctly, her mother-in- law, Patrick's mother, Sue, worked with a friend of yours.

Correct.

So basically, Sue asked her friend if she could reach out and have you step in and help out.

That's correct.

And then, that's what you did?

Yes.

And you stepped up, and you treated this woman obviously with care and professionalism, in my opinion.

Thank you.

Your Honor, I would like to offer the records from South Shore Health, if I could.

Objection?

No objection.

Those records may be admitted.

Is that [inaudible 00:29:48] 222?

In the course of your treatment of Lindsay, actually, you went so far as to give you a cell phone, if I'm correct. Is that right?

She did have my cell phone because I called her on my day off. Yes, sir.

Okay. I don't have any other questions, Judge. Thank you very much for your care.

All right. Counsel, anything further?

No, thank you.

All right. Thank you. You may step down.

Thank you.

The Commonwealth would call Rebecca Jollotta as its next witness, please.

Good morning, ma'am. Stop right there and raise your right hand for the clerk, please.

Good morning. Do you solemnly swear that the testimony you'll [inaudible 00:31:50]

[inaudible 00:31:50].

Thank you. You may have a seat.

Watch your step, please.

Hey, good morning. I'm going to ask you to keep your voice up and speak into that microphone, all right?

Okay. Thank you, Your Honor.

All right. Yes. Attorney Buckingham, please.

Thank you. Good morning.

Good morning.

Could you please tell the jurors your first and last name?

Rebecca Jolotta.

And how do you spell your last name for the record?

J-O-L-L-O-T-T-A.

And what do you do for work?

I'm a psychiatric nurse practitioner.

And what kind of training and education did you do in order to become a psychiatric nurse practitioner?

Thank you. I have my bachelor's degree from the University of Connecticut in Allied Health Sciences. I then went on to get my master's actually in counseling psychology in 2013 from William James College in Newton. I worked in the mental health field as a clinician in various positions for a time. Then I went back to school. I've been an RN in Massachusetts since 2017. I got my MSN in 2019, at which time I became a licensed and credentialed psychiatric nurse practitioner.

And where is that? Here in Massachusetts?

Yes.

Are you licensed anywhere else?

No.

Okay. And so can you tell us a little bit about your work history?

Sure. I have worked as a detox nurse at McLean. I have worked as a therapist in outpatient clinicians prior to becoming a nurse. I have worked in DMH respite facilities. And now, I'm a nurse practitioner.

And when you were a therapist doing outpatient therapists, was that something you were doing on your own as a social worker or were you associated with a practice?

It was part of my training after I got my master's in counseling in 2013. So I had a panel of patients, but I was under the supervision of a licensed provider. It was up towards getting my licensure.

And where do you currently work?

South Shore Health.

And how long have you worked for South Shore Health?

Since 2021.

And how did you come to work at South Shore Health? What was the role that you started?

I had been working in general practice as a psychiatric nurse practitioner, but I was interested in working in women's mental health specifically. And at that point, I was getting training to become more specialized in it. And when a job opportunity became available, I applied for it.

And what kind of training is that that you were doing to be more specialized in women's health?

So postpartum support international is the certifying body so that somebody can become certified in perinatal mental health. I did the two-day... well actually, it was a two-day training plus a third day specific...

Actually, it was a two-day training plus a third day specifically for the psychopharmacology track of it. Then I took a examination and passed the examination.

And so, are you certified by the Postpartum Support International?

I am.

Now, as far as the South Shore Perinatal Behavioral Health Clinic, how did you become affiliated with that?

That was the job I applied to in 2021.

Okay. When you came to the clinic, who was running the clinic or who was the director?

Julie Paul.

As far as the clinic itself, what's the patient base or who does the clinic service?

We specialize in working with women who are pregnant and postpartum up to two years after the birth of their most recent baby. We offer medication management. We have a clinician on staff to do counseling. We have a few nurses that work in our program. We work with moms for any range of psychiatric disorders, including addiction.

When we talk about the range of psychiatric disorders in women who are postpartum, what are we talking about?

Postpartum depression, anxiety, postpartum psychosis, bipolar disorder, panic disorder, obsessive compulsive disorder.

You mentioned postpartum psychosis. Have you yourself had the experience of treating people, women with postpartum psychosis?

I have, yes.

How many patients approximately over the course of the last five years?

Approximately five.

How about postpartum depression and postpartum anxiety?

Hundreds.

In the range of services that the clinic offers and the work that you do, do you oftentimes collaborate with other community providers to offer additional referrals or services to patients if they need it?

We do.

How about when somebody appears before you and you believe they need a higher level of care than what you can offer? Do you have relationships with hospitalization programs, or are you able to make referrals for people for those services?

Yes.

Is that pretty common practice?

Yes.

You mentioned that one of the services or one of the things offered to patients at the clinic is medication management.

Yes.

Is that a big part of what you do as a psychiatric nurse practitioner?

It is.

What kind of training do you receive in order to be a prescriber?

In order to be a prescriber, it's part of my master's in nursing. You take courses in advanced pharmacology, advanced health assessment, pathophysiology. It's part of the coursework of my degree. Then you actually have to take a certification exam and you have to pass the exam. You have to go on and get a DEA license, a Massachusetts controlled substance license. You have to go on and get your advanced practice registered nursing license. It's education and certification and licensure.

You've done the education, you did the certification, and do you have all the licensures that you just described here in Massachusetts?

I do.

You also mentioned part of the services of working with social workers in the clinic. What do the social workers do?

They provide short-term counseling to patients. Again, because we specialize in up to two years postpartum, they could be available to provide counseling during that phase.

Traditionally, postpartum period is a year after birth, right?

Correct.

So why does the clinic offer support for women up to two years?

We do acknowledge that while the highest risk period is the first three months postpartum. Some women can struggle later on in the first year. They may have symptoms that emerge 9, 10 months in. We want to really be able to cover them and treat them if that happens and get them stable.

Does it sometimes take some time to get a person stable?

Absolutely.

Would that be why the program or your program goes up to two years?

Yes.

I want to draw your attention to a particular patient, Lindsay Clancy. You're familiar with that patient?

I am.

How did you become involved with the care of Lindsay Clancy?

I became involved. She had initially seen Julie and Julie was going to be leaving the clinic in December. She wanted somebody to take care of Lindsay, again, longer term since she would be leaving.

At that time in 2022, when Julie was leaving, how many psychiatric nurse practitioners were at the clinic?

Three.

That includes Julie?

Yes.

Who was the other nurse practitioner?

Andrea Warden.

Fair to say you had a conversation with Julie about transferring care of this particular patient?

Yes.

Did you have more experience than the other nurse practitioner in the field, if you know?

Not necessarily.

But as far as taking Lindsay on as a patient, you were agreeable to taking over for Julie?

Yeah. In all likelihood, Andrea Warden only works two days at our clinic, so it could have been that I was working five days at that time, so I would have been more available.

Do you recall when the first contact you had with Lindsay Clancy, what date it was?

It was November 29th, 2022.

That was prior to Julie actually leaving, right?

Correct.

Fair to say on that November 29th date, you had an actual follow-up with Lindsay?

I did.

You recall if it was virtual, or was it in person?

I recall that it was virtual.

Okay. In the practice of the clinic, is there an option for patients to do in-person or face-to-face in-person visits?

Yes.

How does it come about that a person is either inpatient... Excuse me, in-person or virtual?

Our model is that we do initial assessments in person, because new motherhood is very busy, there's a lot going on, we would rather see you than not. Sometimes it is just easier to log on to a screen. Sometimes if we feel like someone would benefit from that face-to-face assessment, we'll say, "Please book your next appointment in person." And I know I did see Lindsay in person on at least one occasion, but my first was virtual.

As far as that choice about whether a patient appears virtual or in-person, is part of the calculus the patient's choice, what they want to have happen?

Yeah.

If there were circumstances where you believed or insisted that an in-person visit was required, would you articulate that to the patient?

Yes.

Then have them scheduled for an in-person?

Correct.

As far as your contact, your first contact with Lindsey Clancy, were you aware that Julie Paul had done that initial intake with her in person?

I was.

You had the chance to speak with Julie and to also review the records prior to meeting with her?

Correct.

Were you aware that the day before, on November 28th, that Julie had had some contact with Lindsay Clancy?

I was.

And that there was some phone interaction and there had been some messages sent to the clinic prior to you scheduling the meeting with her?

Correct. Yes.

Would you agree that there was an issue that needed to be discussed and that led to you to have this appointment with her prior to Julie actually leaving the program?

Yes.

When you met with Ms. Clancy, did you go through a history of her present presentation or present illness and things that had occurred in the past?

I did.

Did you do a nuts and bolts start to finish, or did you rely on some of the previous information she had disclosed?

I relied on some of the previous information she had disclosed. Things like where she grew up, where she went to school, past clinical history, medication trials, but otherwise I would add my own clinical assessment.

You were aware that in the history she presented to the clinic that she had previously been on some medications from another provider?

Correct. Yes.

And that she started with Zoloft and Ativan and Benadryl?

Yes.

And that at some point she had visited the South Shore Hospital emergency room?

I believe it was November 16th.

As a clinic that's associated with the South Shore Health System, do you have access to those records to review when you're dealing with a patient?

I do. Yeah.

And so you're aware that when she went to the ER on November 16th, that they prescribed her Trazodone?

I am.

And that she was reporting significant sleep issues at that time?

I was aware.

Then as far as the course of treatment at the clinic, were you able to review her course of treatment with Julie?

I was.

Fair to say that had been very recent, correct?

Very recent, yes.

Her first contact with the clinic was actually November 20th, correct?

Correct.

You were aware that Julie had originally prescribed Prozac and had already changed the medication plan?

Yes, I was aware.

In this meeting on November 29th, what was Lindsay reporting to you as the issues?

Would I be able to refer to my note, Your Honor?

Sure, you can.

I know most of it by memory, but just... She had been taking mirtazapine, Remeron, at that point for four nights. I believe she started it on November 25th. I was then seeing her on November 29th. She wasn't yet appreciating much difference from mood, anxiety or insomnia. She would say, "I'm able to fall asleep for two hours. Then I'm up for three hours in the middle of the night." And finding herself in those three hours needing to take an Ativan to help her fall back asleep.

Now, when she said not appreciating much difference after taking it for four nights, in your training and experience, is that something that you would normally see with that type of medication?

Yes. I wasn't surprised by that.

For something like mirtazepam or what's referred to as Remeron, right?

Remeron, yep.

What class of drug is that?

It is a noradrenergic specific serotonin antidepressant. It's slightly different than an SSRI. It does work on serotonin. It also works on... The noradrenergic part is alpha receptors, which is what our body... Those are the receptors that our body responds to adrenaline, so it should help calm you down. It also works on histamine receptors, which is why it can make people sleepy.

For Remeron, the fact that it has a calming effect on somebody with anxiety, it's sometimes a good fit, right?

Correct. Yep.

For somebody who might be complaining of sleep issues, it also has that secondary component that could help?

Yeah. It is a good choice for somebody who's having depression with prominent anxiety, insomnia, decreased appetite, because it can also increase appetite, which sometimes we want to happen.

Based on your view of her course of treatment with the clinic, those were issues that had arisen, right?

Yeah. I had noticed she had lost weight. When she had gone to her PCP on October 20th, I believe she weighed like 130 pounds. On the 16th when she went to the ED, she weighed 124 pounds and they had done a pretty good medical workup on her with labs and everything, and she had reported decreased appetite. That was part of the clinical picture, of course, not sleeping and very anxious.

With a medication like Remeron or mirtazapine, does it take time to work or to see results?

Yes.

Typically, what's the timeframe for that drug?

I usually tell patients four to six weeks at a given dose is really going to give us a good idea of what that dose is going to do. You may start to see improvements in the first two weeks, but full clinical benefit can take a month, sometimes eight weeks even.

You were aware prior to her coming to this follow-up appointment with you that she had been reporting after taking the Remeron, feeling disoriented, forgetful, not feeling connected to the body and anxious about whether she would actually sleep?

Correct.

Were you aware that on November 28th that one of the nurses actually advised her to increase the Remeron?

I was.

And in addition to the medication, there was also the recommendation that she add some cognitive behavioral therapy to her treatment plan?

Yes.

At that point on November 29th, by November 29th, were you aware of whether she had met with the social worker at the clinic?

She had not.

Did you have any indication that she had been engaging in some sort of cognitive behavioral or psychotherapy?

No.

Now, in relation to the medication piece of this follow-up, did you have any conversations with her about the concerns with the Remeron and what to do about that?

Yes, I did. I explained to her that it takes time to work, that it has only been four days. I did encourage her to give it some more time. I also made additional recommendations as well.

Okay. What were the recommendations for?

I had known that Julie had tried like 5 mg of Ambien. I had suggested maybe we could try 10. Maybe we could try Ambien controlled release formulation because she was having these wake-ups in the middle of the night. The controlled release, the outer layer gives you 60% of the dose, helps you sleep. Then throughout the night, the inner layer gives you 40% of the dose, keeps you asleep. I said that might be a good option while we're waiting for the Remeron to work, because I was thinking that maybe the underlying depression anxiety was causing the poor sleep, so while we're treating that, let's try these alternatives.

Was she receptive to the Ambien?

No.

Did she say why?

No, I don't recall.

Did she express to you that she had some other concerns about taking certain types of medications for sleep, like benzodiazepines?

She did.

What did she say about that?

She was concerned about taking benzo. She had mentioned something called rebound anxiety. What that is is once the dose wears off, your anxiety goes above your baseline once the dose of a benzodiazepine wears off. It usually typically has to do with half-life of a medication. For Ativan, that's usually between 8 and 24 hours. If she's taking it in the middle of the night, the next morning, she would feel more anxious. She was concerned about that. She was concerned about getting physically dependent on it, because she had needed to take it for a number of nights.

When she used the term rebound anxiety, was that her terminology?

Yes, it was.

Is that a terminology that you generally use in psychiatric care to describe that, what you just told us about?

Yes. It's a clinical term.

Was that something that she mentioned first or did you mention?

I put it in quotes in my notes. That's usually when a patient mentioned it, I put it in quotes.

As far as the plan to address the sleep and to help her with this complaint, with Ambien not a choice, what was your next recommendation?

I discussed hydroxyzine because it's an as-needed medication for anxiety, but it's not a benzodiazepine, doesn't really carry that risk of rebound anxiety or tolerance or dependence, and it could help her sleep, so I offered that as an alternative as well.

Were you aware that she was offered hydroxyzine before?

I was not aware of that.

Was she willing to try the hydroxyzine?

No.

What was her preference?

Her preference was to continue with the mirtazapine, the Remeron, 15 milligrams, and with the as-needed lorazepam.

Just so we stay with the same terminology when you're talking lorazepam with-

Sorry, Ativan. Yeah.

That was something that she expressed to you?

Yes.

Now, when you're dealing with a patient, and obviously this is your first interaction with her, right?

Mm-hmm.

Do you take into account your contact and communication with them in assessing whether they have the ability to make these choices or make informed decisions?

Absolutely.

Your conversation with her about her medication treatment that she had received and what you were proposing as a plan, was she able to engage with you in that conversation?

Yep. It was [inaudible 00:54:06] collaborative.

Sorry.

It was collaborative.

When she declined the options that you first offered, did you then present her with alternatives?

I did.

Ultimately at the end of the day, whose choice is it as to what medication regimens a person would be on?

The patient.

Why is that?

Because they have autonomy in their decisions. I'm only making recommendations based on my education, experience, training, what I'm seeing in terms of symptoms. The patient has the autonomy.

Are there instances where you're dealing with a patient where you have concerns that they shouldn't have autonomy? Or that maybe if I rephrase that question. Are there instances where you're dealing with a patient where you're concerned that they don't have the ability to make the right choice for themselves?

There would be, yeah.

What options do you have in those instances?

In those instances, I mean, that comes down to competency, capacity to make decisions. Sometimes we might get our legal or ethics team involved to make a determination about whether this patient needs a healthcare proxy to make their decisions, things like that.

What about if a person presents with a very serious risk to their own physical health or the health of others? What are your options then?

I guess it would depend if they had capacity to make their decisions.

In your interaction with her on November 29th, did you also go through with her and perform a mental screening test or a mental status screening?

I did.

Why do you do that?

It gives me some objective data of how the patient presents, like how is their speech? How's their appearance? What is their thought process? What's their thought content? Things of that nature.

In this meeting on November 29th of 2022, did you observe anything in which she displayed manic symptoms?

No.

What traditionally are manic symptoms that you look for?

There's a mnemonic called Dig Fast. Try to do this quick. D is distractability. Patient is highly distracted to lots of extraneous stimuli. There is pressured speech, grandiosity, like suddenly someone's like, "I'm going to run for office. I'm going to be the president." And you're like, "Okay, you've never had an interest in that before." Sleep is really poor. Somebody might get two hours of sleep, but be like, "Go, go, go, go, go." Increased goal-directed activity. Somebody might be painting the exterior of their house, painting the interior of their house. They might be doing a bunch of different projects with no decompression time or feeling tired. Those are the general symptoms of mania. Sometimes there can be psychosis associated with it as well.

When you say mania and psychosis, are those two different things?

Yes.

Are you also looking in these screenings to identify signs of psychosis?

Absolutely.

What would be signs of psychosis usually?

Signs of psychosis, they can be subtle. It might look like somebody's responding to stimuli in their head based on the way that their eyes are kind of tracking and they're not really paying attention. They may be quite guarded. They may have a delusional thought process. For example, they might think that somebody's out to get them when there's really no basis.

When you say responding to internal stimuli, is that generally when a person hears things, auditory hallucinations or sees things that aren't there?

Yes.

‍ Court, all rise. [inaudible 01:41:39] try and close your notebooks. Fix all your chairs, please. This way.

All right. Counsel, anything we need to discuss before the break?

No. Thank you, Judge.

All right. So we'll be in recess for the morning recess at this time.

This court is back in session. You may be seated.

I do appreciate you still under oath.

Yes.

Thank you.

All right. All set for the jury?

Yes, Your Honor.

All right.

Bring in the jurors when you're ready.

Court, all rise. Jurors entering. This court's now in session. Please be seated.

Your Honor, for the purpose of the record, we return back to the matter of Commonwealth versus Lindsay Clancy. All parties are present, including the 18 jurors.

All right. [inaudible 01:43:45] Buckingham, please.

Thank you. Nurse Jollota, when we broke, we were talking about your interactions via MyChart with Lindsay Clancy on December 2nd of 2022, right?

Yes.

And so the last one on December 2nd at 2:35 PM was from you to her. And then on December 3rd, do you recall that a MyChart message was sent on that day at 7:24 PM?

I do.

And you were able to review that message some point after it was sent?

I was.

And she reports to you basically that she didn't want to wait to let you know some things that were fresh in her mind. And it says, "Last night, I didn't take Ativan. My dose had been the night before at 1:00 AM. Only slept about four hours at the beginning of the night, about 9:30 to 1:45. Then I dosed off for maybe another 45 minutes from 4:30 to 5:00. Today, all day, I had horrible, intrusive thoughts and felt deeply depressed. I finally took a 0.5 of Ativan at 6:00 PM. And now the thoughts are gone-"

I took a .5 of Ativan at 6:00 PM and now the thoughts are gone and I feel good. Do you recall receiving that message?

I do.

Okay. And fair to say there was no more communication between you and her until December 6th?

Correct. I believe December 3rd was a Saturday.

And you actually were out of the office on the 5th with sickness?

I was.

But you were aware that Lindsay Clancy did reach out to the office on December 5th?

Yes.

And that the nurse was able to respond to her to let her know that you were out sick, right?

Yes.

And Lindsay Clancy responds at 8:30 AM that day that she would just reschedule... Or excuse me, Lindsay reaches out to the nurse and says that's fine, she'll reschedule. And that she in fact changed her appointment with Leticia Dukes to a virtual appointment for that day for December 5th?

Yes.

So on the 6th, when you return, did you have a scheduled meeting with Lindsey Clancy?

Yes.

And on this particular meeting on December 6th of 2022, do you recall if that was an in-person or a virtual visit?

It was an office visit.

Okay.

In person.

And so just kind of looking at the note from that day from December 6th, it says encounter date December 6th. It says filed on December 7th. Under chief complaint history, do you have it in front of you?

Yes.

The second paragraph says, "Patient has verbally consented to this video visit." Is that just something that sometimes prefills into the narrative?

Yes.

But your memory was that this was an in-person visit?

It was.

Was Lindsay Clancy there by herself or with somebody else?

She brought in her husband, Patrick.

Had you met him before?

I had not.

Had you talked to him before?

I had not.

As part of your treatment plan or your course of treatment with Lindsey Clancy, was it your practice to speak with collateral individuals?

Yes.

And in this instance, did you feel a need to speak to collateral individuals up to this point?

Not up to this point.

If you did, would you have requested that of her?

Yes.

And do you need her express permission to do that?

I do.

So on this particular day, she presented with her husband, Patrick, correct?

Correct.

And was there anything different about your approach to the meeting than your previous meetings with her?

No.

You still go through history, you go through how she's doing now, you do your mental status exam, you do your screenings, right?

Yes.

And so first, just let's talk quickly about the screenings. The Edinburgh screen, what was her score on this day when she came in? Do you remember?

21

Okay. And the GAD-7, fair to say that screen was a 19?

Yes.

So would you say that it was pretty consistent with the last time that you saw her?

Objection. Objection.

What's the objection?

My objection is that that's not right. She's now got a 21 Edinburgh scale. Prior testimony was not anywhere near 21. It's deteriorated.

Well, I'm going to allow that question. On cross-examination, you can certainly explore the basis of what her opinion was. So I'm going to allow that question. Go ahead, Camella.

Well, let me ask you about that score of 21. It's 21 out of how much?

30

So in what range is that?

Moderate severe.

Okay. And on your previous encounter with her on, or your actual telehealth on November 29th, you reported that the score was 17 and that's moderate?

Moderate. Yep.

And then on the GAD-7 on this particular day, on December 6th, it was 19, right?

Yes.

And on the previous visit, it was 14?

Yes.

Okay. So as far as your observations of her on December 6th, did you notice anything different about her speech and language?

No.

How about her mood? What did you note her mood to be?

Anxious.

And the affect, fair to say, consistent with mood, meaning anxious, right?

Yes.

And thought process?

Thought process was linear and goal directed.

And thought content, did she indicate to you whether she was experiencing any auditory or visual hallucinations?

No.

Any delusions?

No.

Any suicidal ideation, a plan or intent?

No.

And as far as your observations of her during this interaction, this in-person visit, did you observe any signs of psychosis?

No.

Did you observe any signs of mania?

No.

Did you observe any signs of obsessive thoughts or compulsive behaviors?

No.

Now, when you met with Lindsay and Patrick on December 6th, did she or did they report why Patrick was there?

I don't recall if they indicated why he was there. I understood it to mean he was there to provide collateral and support for her.

Were you aware that he was coming to the appointment?

I don't recall if I was aware beforehand or not.

And you had engaged in a pretty significant MyChart back and forth with her in the days preceding this meeting on December 6th, right?

Yes.

Did she ever indicate to you...

Go ahead.

Did she ever indicate to you in those messages that she wished to bring him along to one of the visits?

No.

And fair to say when a person brings a collateral and is willing to have somebody speak, you're more than happy to get that information?

Absolutely.

This person, this collateral person, can they offer you a different perspective about the patient and what they're going through or how they're presenting?

Yes.

In this December 6th meeting or the visit, did she report to you some changes in her sleep or a significant concern for sleep?

I would have to review the note. What I remember is that the sleep really hadn't improved much beyond getting a few hours, waking up in the middle of the night, maybe piecing together more time.

And fair to say there was some conversation to go back and talk about when symptoms started and try to get to kind of the root cause or what they believe the root cause of her symptoms were?

Yes.

And did Lindsay and Patrick report to you the connection with the Zoloft medication in September as a concern?

Yes.

And that they reported that, or she reported, "That exact night I went from 25 to 50 milligrams. I didn't sleep for 48 hours and I wasn't tired."

Correct.

So that's in your note as a quote, meaning that's directly what she told you?

Yes.

Okay. Did you express to the Clancy on this particular meeting...

Okay, go ahead.

Did you express to Ms. Clancy thoughts that you had about her diagnosis based on your interactions over the last few weeks?

I did.

And what was that?

I discussed with her and her husband the possibility of potentially an underlying bipolar disorder. I based this on several factors, one of them being that she had such what we call an activating response to the Zoloft. It's unusual for somebody to describe taking Zoloft and then going 48 hours without sleep and not being tired. So that raised my clinical suspicion a bit. And she had been, I would say, having difficulty tolerating other antidepressant medications that we had been trying to have her take since then. And so again, I'm wondering if it's because potentially there might be an underlying, what we call mood disorder, bipolar disorder.

And as far as the information that you had about her past psychiatric history, were there any indicators to you about manic episodes?

No. So I do recall in reviewing Julie's note prior to meeting with Lindsay, she filled out what we call a mood disorder questionnaire. It's like a screener somebody can do to assess history of mania and bipolar disorder. Lindsay had, it was a negative screen. So there's three questions. One question has 13 different symptoms. You have to score 7 out of 13 on question one. But also in question two, it asks about are the symptoms happening at the same period of time? And then it asks about any functional impairment from the symptoms. So I recall the three symptoms she did endorse were not sleeping for that period of time with the Zoloft and not feeling tired, having racing thoughts and trouble concentrating. None of the other symptoms did she endorse. They did occur at the same period of time. And I don't want to be inaccurate, so I can't remember what she said for functional impairment, but I believe it was minor impairment.

Okay. And so the fact that those were reported, but ultimately the full screen revealed negative for potential mania.

I did also consider though that the MDQ is less specific when it comes to bipolar II or bipolar not otherwise specified. There's bipolar I and bipolar II. Both have mania symptoms as part of the diagnosis. Bipolar I is usually more severe in that it's typically a patient might be hospitalized or it causes greater functional impairment. Bipolar II, it's a shorter duration and typically less functional impairment.

And as far as determining diagnostically whether somebody might be presenting with bipolar disorder, is there a particular tool you use in your trade to try to assess that?

Typically something like the MDQ and then you'll do more of an interview asking the patient about symptoms specifically and if they can ever recall a time where this may have happened in the past, because sometimes patients can't always remember when they're manic. So I was glad to actually have Patrick in the visit because he could sort of help us look at Lindsay's history more longitudinally or at least since the time he knew her.

Okay. And as far as... So those tools that you're talking about, the MDQ and kind of screening tools that you use in practice, is there another tool that you use to assess whether a person meets particular criteria to be diagnosed with bipolar I or bipolar II?

There are others, not ones that I've used.

So are you familiar with the DSM-5?

Oh yes. Yes.

Okay. So while that's not the end all be all, it is a guide that tells you specific criteria, how to determine if episodes are manic or depressive, when it comes to bipolar?

Yes.

The difference between mania and hypomania?

Yes.

And so while you noted that there were some concerns reported, did what was reported to you rise to the level of diagnostic criteria for bipolar disorder?

Not at that time.

Okay. And when you explained this to them, your thoughts about her reactions to the medication and these reported prior symptoms, did Patrick and Lindsay seem receptive to your diagnosis?

I recall Patrick saying, "My wife is not bipolar." Lindsay looked at me. She did not say anything.

Okay. And was this the first time in this meeting on December 6th where you broached that issue or mentioned that?

Yes.

Did the conversation continue about symptoms and managing symptoms after that?

Yes.

Were you able to get any more specific information from Patrick during that meeting? Not what the information, what he said particularly, but did you get additional specific information that kind of helped you assess whether you would change your diagnosis at that point?

No.

And were there still concerns in that particular meeting that the focus was trouble sleeping and the potential for addiction?

Yes.

As far as recommendations, did you talk about what's called tapering medication?

Yes.

And what were your recommendations regarding tapering?

So we talked about her concerns about the benzos and we decided to come up with a plan to taper off of them.

And the last that had been reported to you via the MyChart messages was that she tried not taking it at all, ended up having horrible thoughts and felt deeply depressed, then took it and felt better. So was it realistic to recommend completely stopping?

No.

So what is a taper? Why do you recommend tapers?

I recommend tapers to slowly get somebody off of something. And tapers can be useful because we might have somebody at a dose and they might say, "Oh, I'm too anxious to stop this," or, "I'm not ready to step down to another level," and we can kind of keep them on it longer. But at this point, since I had met her on November 29th and throughout the MyChart messages, there was multiple concerns voiced about benzodiazepines. And again, in this visit, so I even did what's called a CIWA assessment, which is something we use to determine if somebody's having actual withdrawal from benzodiazepines or alcohol. Again, I really wanted to show her I was assessing this and taking this seriously.

When you say CIWA assessment, is that an acronym for something?

Yes. So it's a-

What the letters, just for the record?

C-I-W-A.

Okay. And when you do that assessment, does it give you some sort of score?

It does.

Ask the questions. And what was her score when you did that CIWA assessment?

One.

And what does that mean?

Minimal to no withdrawal. The only symptoms she reported was anxiety. Her blood pressure was normal. Her pulse was normal. She had no nausea, no vomiting, no tremor, no tactile disturbances. People in withdrawal from benzos or alcohol will sometimes feel like there's bugs crawling or pins and needles, auditory disturbances. So hearing things, seeing things. No sweats, no headache. She was oriented.

So with that, and knowing that she wasn't in withdrawals for Ativan, did you still recommend the taper in an alternative?

I did.

What was that?

I recommended Valium. The reason I recommended this is she had discussed rebound anxiety with me at her very first visit, feeling that rebound anxiety above her baseline once the benzo wears off. Valium has an extremely long half-life, as in like a hundred hours. It has a longer clinical duration of action. So I wanted to offset the chance that she would experience rebound anxiety. And it's often used when we're tapering somebody on shorter acting benzos. It's common practice to switch to longer acting benzos to do this.

And did you also have conversations about the other medications that had been at issue, the mirtazapine and the Seroquel?

Yes.

What did the defendant, what did Lindsay Clancy express to you as far as Seroquel? Did she want to continue with that?

No.

Did she explain why?

So she felt like when she took Remeron and Seroquel together, she felt weighed down and exhausted, but her mind was still awake and alert. And she just didn't seem to think there was a benefit to being on it.

And so did she express to you a desire to want to go back to trialing Prozac?

Both Lindsay and her husband expressed that that was their preference.

And was that something that you agreed with?

I did. I had shared with them that I had concerns, could be bipolar. It's in my differential diagnosis, which is just all the typical diagnoses we might be considering. And that typically SSRIs are contraindicated, but she did have that history of being able to tolerate Prozac at 20 milligrams and do okay with no mania. So I thought that's what they were wanting to do, so we could do it. We could try it.

When you say contraindication-

Okay, sorry.

What does that mean?

It means typically not something you would want to do if you were sure somebody had bipolar disorder because if you put somebody on just an SSRI or like Prozac, like Zoloft, it can create a scenario where people are flipping back and forth between manic symptoms and depressed symptoms, or they're called rapid cycling. It's not that antidepressants or SSRIs are never prescribed in bipolar disorder, but you often would want to have a mood stabilizer on board at the same time.

And so despite your suspicions, you listened to the patient and went along with her request?

Yes.

So at the conclusion of that meeting, did you indicate that she could discontinue the Seroquel at that point?

Yes.

With the plan that she was going to restart Prozac?

Yes. Which I had been recommending the Prozac earlier. I believe even on November 30th, I had recommended it.

And with that previous recommendation, it was in addition to the Seroquel.

And the Remeron, yes.

So after this meeting on December 6th, did you have additional communications with Lindsay Clancy via the MyChart messaging on December 7th?

Yes.

And fair to say that those communications started as early as 9:48 AM when she sent the first message, right?

Let me just make sure. Oh, yes. Yes.

So on December 7th at 9:48 AM, she sends a message saying, "Hi, Rebecca. Last night did not go well at all. I took the Valium and melatonin and only slept from 9:00 to 1:00. Then around 2:00, I got desperate and took 25 milligrams of Benadryl and only slept about one more hour. What can I do? I really need help." So that was the message that you came into on December 7th, right?

Yes.

And did you respond to her in the messaging app?

I did.

And what was the response?

I'm trying to find the sequence.

Yeah. 10:19 AM.

I think it's cut off. Okay. So I discussed, I mentioned, "So your husband made a good point yesterday. Despite taking the Ativan in the evening, you were still only able to get a five hour stretch of sleep, which yes is improvement, but does sort of dispel the notion that benzodiazepines are the only thing that are helping you sleep right now as you are still getting less than the target of six to eight hours with Ativan and the Valium did not help for sleep much at all. My next step in this case is to try a higher dose of Seroquel on its own. Are you feeling any subsequent loss of energy, exhaustion, fatigue with lack of sleep?"

Why would it be the next step to increase from 75 of Seroquel to 100?

So she had been taking 50. So I was suggesting 75 to 100 would be my next step. Because again, bipolar is still on my deferentials and now I have the data that she only slept two hours. So I asked her the follow-up question, "Are you feeling tired? Are you feeling exhausted? Any subsequent loss of energy?" It's still in the back of my mind that this could be bipolar.

So as far as the Seroquel goes at that point, creeping up the dosage, do you get now from the using it to treat insomnia to using it to treat something else like bipolar?

Correct.

And so that piece of it about feeling subsequent loss of energy and exhaustion, fatigue, why ask that?

Patients can have insomnia because they're anxious or because they're depressed, but typically they're exhausted or they're tired the next day and it really does affect them. If a patient has an underlying bipolar, they could go on two hours of sleep and not feel tired at all. And that's unusual.

And so that is one of the signs potentially of a manic episode?

Potentially, yes.

So on December 7th at 10:33, she responds, "No, the weird thing is I don't feel tired at all." And she says, "So just Seroquel tonight? I feel like I'm going to panic without a benzo with it." And then again at 11:44, another message, "Would I be able to do the Valium with Seroquel? Is that a safe option?" So again, in this exchange with her in MyChart, she's asking you questions to clarify what you've said and also alternatives to address the issue, right?

Right.

And as far as her questions go, and then her response about not feeling tired, how did you respond in the message?

So she kind of sent those in succession. So the, "I don't feel tired. Would I be able to do the Valium with the Seroquel?" So I respond by, " If you're not sleeping well with the Valium alone, there's no need to continue it. And I will prescribe a short taper to get you off benzos altogether. Because you are not tired at all and had a significant reaction to Zoloft at 50 milligrams, I'm concerned this is an underlying mood and bipolar disorder. I know you and your husband did not necessarily agree with that, but I'm going to send along this information to review." So I sent her a list of symptoms of bipolar risk factors so that she could have it to refer to.

And again, at this point, the only symptoms she was reporting of mania was this not being able to sleep and not feeling tired, right?

Yes. And the racing thoughts and the trouble concentrating.

Okay. Is that things that she had reported to you in your visit on the 6th?

No.

Okay. In these messages that she was sending to you on December 7th, she didn't talk about racing thoughts, did she?

No.

Okay. She just talked about the sleep?

Mm-hmm.

Okay. But based on a review of her history, she had at one point indicated that she was filling those in relation to a symptom she was describing. Is that-

Correct.

So at this point, what do you recommend her to do?

I explain the importance of knowing if this is bipolar is significant because SSRIs like Zoloft and even Prozac would be contraindicated. My recommendation is to do 100 milligrams of Seroquel tonight, 200 milligrams of Seroquel tomorrow night, 300 milligrams on 12/9, 400 on 12/10, and we will hold there. I actually say hold the Prozac as I'm concerned, this is a hypomanic mixed manic state.

And what about the Remeron at that point? Where did this fall into the mix, if it fell in at all?

I had recommended a very short taper on December 6th. I think I advised her to take half of a 7.5 milligram tablet for three nights, but in her message to me on December 7th, she had not taken it that night. So I had assumed she had just stopped that entirely.

Okay. Now, after you sent that message at 12:32, did she respond at 2:53 indicating that she would stick with that plan and that she said she needed a refill on the Seroquel because she only had 30 25 milligram tablets?

She did say that. There were actually a few earlier messages as well that day. I provided an alternative as an option. It quickly came into my mind, "Oh, we're thinking about Prozac. We could add Zyprexa on board because there's actually a combination pill of Prozac, Zyprexa. The brand name is Symbyax and it's for bipolar." And I said, "For our purposes, we can prescribe them separately and take them both for the same effect." And I asked her to let me know which one she would prefer. And she responded, "I think I would like to do the Seroquel with the Valium taper."

Okay. So that suggested alternative actually was at 12:37.

Correct.

And then at 1:00, she elects that she'd like to do the Seroquel with the Valium and asks for you to call in the Valium and the Seroquel.

Yes.

Okay. So that's on December 7th, right?

Yes.

On December 8th at 6:35 AM, she sends you a message saying, "Did well last night. Need Valium. Feeling panicky. Don't know if ready to taper as quickly as planned."

Yes.

Kind of paraphrasing, but.

Yeah. She exclaimed, "I actually did really well last night with the Valium and Seroquel. I mostly slept from 9:00 to 5:00 with a few wake-ups, but was able to go back to sleep." She was concerned that she felt like she needed to take the Valium around 5:00 PM because she was feeling panicky, "I feel really dependent on it. Can I taper any slower?"

And what was your response to her request for a slower taper?

I said, "I'm hesitant to taper any slower. Remember, Valium has a really long half-life, 100 hours, so you will have some onboard in your system throughout the weekend."

And why were you hesitant to taper any slower?

I felt like she was anxious about being dependent on it, and so I was trying to facilitate the process of tapering her off. And I was clinically thinking we could cover her symptoms of anxiety as we titrated the Seroquel, because Seroquel actually has several clinical trials that show it has really good efficacy for anxiety.

And this conversation about the request to taper, that actually goes into December 9th of 2022, correct?

Yes.

And in her response to your indicating you were hesitant to taper, she indicates that she took the five milligrams of Valium and that she didn't have any left, and that she was afraid that she was going to take Ativan.

Correct.

And had you recommended to take Ativan as an alternative or in lieu of Valium?

No.

Were there any more communications on that day, December 9th of 2022?

Yes.

What were they?

Later that afternoon, Lindsay and her husband called.

Okay. And so fair to say they called the clinic, leave a message, and then you called them back?

Yes.

And when you called them back, what was the nature of that conversation? What'd you guys talk about?

Her symptoms. We discussed that the plan was to taper the Valium over the weekend, but they both agreed that Lindsay's symptoms were too acute. She's sleeping better, but still waking up with panic symptoms and intrusive thoughts, feels numb, has thoughts of SI, but no plan and no intent. I encouraged her to engage with women and infants in Rhode Island to complete an intake for a partial hospitalization program, but she was able to contract for safety over the phone with the three of us on the phone, that she didn't have a plan, no intent, that she would reach out if needed. I did agree to continue the Valium until our next appointment, which was scheduled for 12/13. I prescribed it as five milligrams, but I advised her she could take a half tablet twice a day, so two and a half milligrams twice a day.

So walk me through that. She had...

So walk me through that. She had indicated to you that she wanted to slow the taper.

Yes.

And then you said that wasn't a good idea.

Right.

And then on the 9th, they call you and say that she doesn't want to taper. She wants to stay where she is, right?

I think it was that same day. The messages were earlier in the day and then later in the afternoon around ... it's noted at 16:10, so 4:10 PM that she and her husband then called, advocating to stay on.

Okay. And in advocating to stay on the Valium, that she reported she's still waking up with panic symptoms and having intrusive thoughts, feeling numb, right?

Yes.

So in addition to agreeing to continue the Valium, did you make a recommendation about the Seroquel?

Continue the titration.

So when you say titration, what does that mean?

So I had recommended 100 on day one, 200, day two, 300, day three, 400, day four. This is the manufacturer recommended titration schedule to treat manic symptoms because again, I had shared with her, I think this is a mixed manic, hypomanic state. So that's what I was targeting.

Okay. And so, as far as Seroquel goes, there's some guidance you get about Seroquel that's put out by the FDA, right?

Correct.

And it talks about dosage and administration for particular ... for every drug essentially, right?

Yes.

And as far as Seroquel goes, there is different recommended dosages or ranges for different mental illnesses that you're treating.

Correct.

So in this instance where bipolar is in your differential diagnosis and you're recommending titrate up to 400, is that consistent with the thought that you believe she was ... had bipolar diagnosis?

Right. So I was thinking it was a mixed manic state or possible hypomanic state. A mixed manic state is when patient has symptoms of mania, like poor sleep, no loss of energy, but they also can feel depressed, numb, suicidal. It's sort of like ... it's a mixed state. It's a mixture of symptoms. A mixed state presentation is clinically acute. It's unstable. So I really wanted to get the manic symptoms under control. I really wanted to get her to sleep.

And so going up slowly to 400 milligrams, what's the recommended dosage range for somebody with bipolar disorder of Seroquel?

For somebody, a manic presentation, you can titrate over days rather than weeks. You can actually go up to 800 milligrams.

And so, even though you had previously indicated to them in your December 6th meeting that you were agreeable to discontinuing the Seroquel, based on her presentation in the days following, did you change your recommendation?

Correct.

And with the increased Seroquel that you had requested as of December 9th, she was reporting sleeping better, right?

Correct.

And that had been something that had been a recurring concern in your interactions with her sleep?

Yes. My understanding was that she had been sleeping poorly since October.

And when you say you were recommending partial hospitalization during that phone call, did you give a particular place in which you would recommend her to try to seek treatment?

Women & Infants.

And that's in Rhode Island?

Rhode Island.

And are you familiar with whether they have particular perinatal or postpartum programs there?

They specialize.

After that call with the Clancy's on December 9th, when was the next time you had contact with Lindsay?

December 9th was a Friday, so I believe it was Monday, December 12th.

Now, people are able to send MyChart messages all hours a day, every day of the week, right?

Correct.

But in this instance, you did not receive any messages over the weekend?

No.

So the next MyChart exchange was actually on December 12th of 2022, correct?

Correct.

Now on December 12th, do you recall who initiated the contact via MyChart?

Lindsay.

And at 1:59 PM, she sent a message to you saying, "I've been noticing on my Apple Watch that my heart rate has been fluctuating more than usual. It has been going from 56 to 136 within a matter of minutes. I'm wondering if this is a side effect of the Seroquel and if there's anything I should do about it. Thanks, Lindsay." Do you remember getting that message?

I do.

And again, at that point, as of December 12th, you had recommended the titration plan going up to 400, right?

Yes.

So by that Monday, where should she have been if she was following your instructions?

400 milligrams.

And did she report to you whether she took 400 milligrams of Seroquel?

She reported she was taking 200 milligrams.

Did she say why?

No.

But your recommendation was that she should have been up to 400 at that point?

At that point, yes.

As far as the concerns about the fluctuating heart rate, were you able to address that with her in a response?

Yes. I explained that medications like Seroquel can cause something called orthostatic hypotension, which is basically when you get up from sitting or standing, your blood pressure doesn't compensate in time, so it goes low and people can feel dizzy. I explained that the mechanism for that is alpha adrenergic blockades. So the alpha receptors that help us with adrenaline. They're also part of the picture here with Seroquel. It's often accompanied by orthostatic tachycardia, meaning getting up from sitting to standing, your heart rate can fluctuate. I said both can be common in the first days of medication exposure or when the dose is being increased. It's generally benign, meaning non-harmful, and self-limiting, meaning it goes away on its own over time. I also advise it sometimes necessitates slowing a dose titration or dividing a dose into like two or three smaller doses.

Okay. And so with this response and trying to address these concerns, you're aware that she had spoken to the nurse that morning?

Correct.

And that she had expressed to the nurse a desire to get off the medications altogether?

Correct.

And what was your response to that concern that she had in the call to the nurse? What did you tell her?

I said, "As long as you are aware of the risks, I don't think you've been on Seroquel long enough for it to have a positive benefit on your mood or anxiety, but if you have noticed benefit, the risk would be worsening of mood and anxiety upon stopping the medication. We also discussed tapering off the Valium, which I'm fine with. If you would like me to send along the taper schedule. Being off medication might help you see where you are at baseline, but I do think you are experiencing significant and severe symptoms of postpartum depression that needs to be treated." "I acknowledge that medication alone is not always the best option for someone, but often it's part of the puzzle. Other treatments include counseling, support from others, exercise, healthy diet, yoga and relaxation techniques. I know this has been brought to your attention several times, but I strongly, strongly recommend a partial hospitalization program so that you can get started on utilizing these treatment methods for relief."

And you were aware at this point, as of December 12th, that she had met with Leticia Dukes at least once, right?

At least once, yes.

She had been given referrals for CBT or cognitive behavioral therapy programs out in the community, in her community, right?

Yes.

There have been other recommendations for her to obtain a partial hospitalization program at that point.

Yes.

Now, anything about these exchanges that made you concerned that you had to kind of raise the level, meaning call her in for another meeting or make any sort of recommendations for inpatient hospitalization?

Not at this junction.

And why is that?

She wasn't reporting any acute safety concerns in these messages at this point.

This is just physical side effects?

Just physical, physical side effects, yes.

So the messages continued on December 12th, correct?

Correct.

So at 2:44, Lindsay messages you saying, "Thank you, Rebecca. It does seem to be orthostatic and I'm glad to hear that it's benign and known side effect." And then, she tells you a little bit more about the prior nights, right? So she says, "So the last three nights I've taken 2.5 milligrams of Valium and 200 of Seroquel. I have to say that I do like the way it makes me sleep very deeply and soundly for around seven to eight hours, but I don't like the way I feel in the morning and most of the day." "Incredibly depressed and unmotivated to do anything at all. What would you recommend for tonight?" Is that the next message after you explained to her the side effects?

Yes.

Okay. So at 4:10 PM, you respond to her, don't you?

Yes.

And what did you recommend to address those concerns about incredibly depressed and unmotivated?

So at this juncture, I recommended at least continuing the 200 of Seroquel because at least now, she's sleeping. So I felt like although I had recommended getting up to 400, we had gotten sufficient activation symptoms down. She was sleeping. And the 2.5 of Valium, I think I advised that we need to give time for Seroquel to work for your mood. Let's continue to accumulate good nights of sleeps as this can only be a good thing in terms of recovering and feeling better moving forward. I would say take them tonight and we will discuss further at our visit tomorrow.

And you had a visit scheduled for December 13th, correct?

Correct.

The message continues on that day at 7:17 PM where she says, "Okay, thank you. I need to make our visit, virtual tomorrow. I will not be able to make it to the office. Can you please change it to that?" Is that right?

Yes.

So after having met in person with her on December 6th, having had subsequent communications with her through the date of December 7th and kind of again, changing a little bit about the medication plan and having further communication with her on December 9th and now December 12th, the plan was for her to again come in person on the 13th, correct?

That was my recommendation, yes.

Why did you recommend in person at that point?

This was somebody who was communicating with me every day. And I did feel that she had significant symptoms of depression, some mixed symptoms with mania, anxiety. I felt that her symptoms were severe and significant enough that I wanted to touch base with her weekly and I wanted to see her in person. But again, I was okay with her doing virtual because I'd rather see her and lay eyes on her and try to treat her than not see her at all if that would've made her just cancel the visit outright.

Because generally, you do the same thing whether you're in person or virtual, right?

Right.

As far as getting the history, going through symptoms, asking how they're feeling, doing the mental status exam, right?

Right. Mm-hmm.

So you meet with her on December 13th at 10:30, correct?

Correct.

And now, this is a virtual at her request?

Yes.

And do you revisit with her kind of the recent events and the timeline of the changes that you've gone through, through the MyChart messaging?

Yes. I structured my note as like a recent treatment timeline. So I put 12-6, what had happened, 12- 9 what had happened. And then I write update today, 12-13. That's sort of for me to remember the treatment history that I've had with her so far.

Okay. Because while the MyChart messages are available to you, they might be in a different place, right? So they're not all contained within your same note.

Right. So I made note of, again, our visit on 12-6. I made note that she and her husband had called me on 12-9 and then I made note on the 13th. So I wasn't documenting all the MyChart messages, but just sort of my visit history with her and phone calls.

Okay. And so when you saw her in this virtual visit on December 13th, was she reporting improvement in her sleep?

Yes.

And how was she sleeping during that time period?

Seven to nine hours.