Trial Day 21

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.

Good morning, everyone and good morning, Counsel.

Good morning.

Good morning.

Good morning, Ms. Clancy.

Good morning, Your Honor.

All right. Before we start, can I see everybody at sidebar?

Hear ye, hear ye, hear ye. 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. For all here, give your attendance and you shall be heard. God save 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, thank you, Madam Clerk. Good morning, members of the jury. All right. It's nice to see everybody once more, unto the breach, as they say. We're going to continue with this trial. So I appreciate everybody being here. I'm going to ask those questions and I'll go a little bit into today's schedule and kind of where we're going to go on this. So, first question, has any member of the jury read, seen, heard, or overheard anything from any source about any aspect about this case that would affect your ability to be fair and impartial? All right. Second, is there any other serious matter or concern bearing on your service as a juror in this case that anybody needs to address at this time? Again, thank you so much for following those instructions. And so, what we're going to do, as I said yesterday, we're going to continue with the testimony of the doctor who was on the stand yesterday, and it's anticipated that that is the last witness in the trial. And then we will then take a break because before we go to the next portion of the trial, which is the closing arguments and the legal instructions, the court has to make some arrangements. I've got to speak to Counsel, so it takes a little while. So, I'm going to excuse you at that point and have you come back tomorrow. All right? So we're going to finish the evidence today. We're going to excuse you. I'm going to then deal with Counsel and then we will do hopefully arguments and charge tomorrow. All right? So, again, I can't tell you how much I appreciate everybody's dedication and commitment in following those instructions and being here every day. So, that's kind of where we are at this point. All right? And so with that, I'm going to ask the Commonwealth, if you could have the doctor retake the stand please.

Yes, Your Honor.

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

Good morning. Do you solemnly swear that the testimony and the evidence you shall [inaudible 00:04:33] now pending between the Commonwealth and the Defendant now shall be the truth, the whole truth and nothing but the truth, so help you God?

I do.

Thank you, sir. You may be seated.

Watch your step, please.

All right. Good morning, Doctor.

Good morning.

All right. Attorney Sprague.

Thank you, Your Honor. Good morning.

Good morning.

Yesterday when we left off, you were testifying about the decision-making process of the Defendant and what she told you about that. Going to what she told you about the voice and what it said to her, did the Defendant tell you that the voice told her where to kill the children?

No.

Did the voice tell her how to kill the children?

No.

Did the voice tell her what to use to kill the children?

No.

Did the voice tell her in what order to kill the children?

No.

Did the voice tell her where to try to kill herself?

No.

Did the voice tell her in what way to kill herself?

No.

The fact that the voice... According to the Defendant, the voice didn't tell her any of those things, but instead just said, "Kill the kids so you can kill yourself." Is that significant in your evaluation in any way?

Yes.

How so?

Well, in the small amount of time that Ms. Clancy had in the home without her husband, it was important in order to carry this out as well as her suicide to do this quickly, methodically, and the like. And so, this is having no instructions as to how to do it, but being able to execute those decisions, including being able to get a phone call and then return it to her husband in the process of all of this; certainly the phone call was not expected. That is surprising that she was able to accomplish all of this without any other kind of direction or plan.

Does that indicate to you that she was making decisions about those things, about where and how and when?

Your Honor, this is again, for the record, direct examination. It's leading. I object, but I have a standing objection.

Yeah, if you could just rephrase that.

What does the fact that she was able to do all of that indicate to you, if anything?

Well, it indicated that she had control, control of the sequence of what she was doing throughout.

Doctor, you talk in your report about interpersonal psychological theory of suicide. What is that?

Well, that has to do with the decision-making process or the capability for someone who attempts suicide.

And are there three parts to that theory?

Yes.

And what are they?

Well, one would be called aloneness or the sense of isolation, people not understanding. So, that is a real difficult challenge for people to face. They feel that they can't fully share with others. Another is burdensome-ness. If someone feels that they are a burden to others, that is also something that we find is a component to those who make serious suicide attempts and completions. And third is what I would call capability. But you can have that sense of aloneness, you can have that sense of burdensome-ness. But if you don't have the capability of taking your life, you can be very suicidal, but not ultimately accomplish the suicide. It does not mean that you're not suicidal, but that issue of capability is one that's very difficult because we have a natural will to live, and that is the most difficult thing for people to overcome.

The thing that's the most difficult thing to overcome, that's the capability of actually committing suicide, is that what you're saying?

Correct.

And this theory in the three parts, did you compare what Ms. Clancy told you and what you saw in the records to this theory and have any conclusions about that?

Yes.

And what were they?

Well, certainly the documentation from the medical and mental health records demonstrates that sense of isolation she felt, even in the company of others. That sense that she was just having a problem that was difficult. Difficult for her to understand, difficult for others to understand, and, of course, the suicidal feelings that came about, and then ultimately those feelings about harming her children. This is not something that she could share. The sense of burdensome-ness, she had planned to go back to work as she had for her first two children, Cora and Dawson. And the time that she was expecting to go to work kept extending because she just did not feel mentally healthy enough to be able to return to work and to function. And so, in some of the documentation where she filled out concerns and was asked about the kind of stressors in her life, she indicated that financial was one of the stressors that she was encountering. So, to believe that her brain had been damaged, that she was not able to do what she loved, which was labor and delivery nursing, but also not in a position to help support the family, really would be a burden for anyone. And certainly that sense of burdensome-ness was something that I believe she was experiencing. And then the last component, capability, I truly believe that her suicide attempt was very, very serious, which is why she employed three different methods. The fact that the use of the knife and the lacerations were not deep doesn't mean that she wasn't intending to kill herself with a knife. But oftentimes that, as I mentioned, is the most difficult thing. I think the employment of the three different avenues, locking the door and also not being dressed for the cold, indicate to me that this attempt was very, very serious, despite the fact that the use of the knife was not successful in cutting her arms, cutting her neck.

And so, Doctor, in terms of the cutting on the arms and the neck not being sufficient to cause death, is that what you're referring to is that as someone faces difficulty or an inability to be capable of actually following through to commit suicide?

Correct.

So, in this case, it's your opinion that she was trying to commit suicide, but struggling with that third capability issue?

Correct.

Now, you testified yesterday about the intrusive thoughts that Ms. Clancy was having about harming herself in the fall leading up through December into January. And those thoughts at times, would it be accurate to state that Ms. Clancy reported at times that taking Ativan helped with those thoughts?

Yes.

And was there anything significant in your review of the case in terms of her reporting that Ativan helped her with those thoughts?

Yes.

How so?

So, Ativan is a Lorazepam, a benzodiazepine. This is a medication that is very helpful for treating anxiety. It also can help relax people, help them sleep, which was very helpful to Ms. Clancy. And she stated that when she had the intrusive thoughts, taking the Ativan resolved those thoughts. And I think that's significant because it's not a medication. Ativan, Lorazepam is not an antipsychotic medication. It's not meant to treat psychosis. It make people feel more calm, and sometimes it's used for people who are having significant symptoms. But in terms of actually treating psychosis, making a voice go away, it's just not designed to do that.

And Doctor, did the fact that the intrusive thoughts went away when taking the Ativan, according to Ms. Clancy, give you further evidence that it was, in fact, internal thoughts and not an external voice?

Yes.

Now, if someone is experiencing psychosis and is experiencing command hallucinations, can that person still know the difference between right and wrong?

Yes.

How so?

Well, hallucinations, even command hallucinations when they occur, do not propel an individual to automatically obey them. And, in fact, many people will engage in behaviors to stop the actions that the voice is claiming. That's something that makes sense, particularly when the command is just so serious and so against someone's values. So, it's possible and common for people to engage in behaviors to avoid doing what a command hallucination is saying.

And, Doctor, is it possible for someone who is experiencing psychosis and command hallucinations to conform their behavior to the law?

Yes.

And how so? Is it basically what you were just telling us?

Yes. If someone is having a command hallucination to do something out in public, but there is a police officer nearby, it certainly is possible for that person to choose not to engage in that behavior because of the consequences. Even though a voice might be saying this, there's other decision-making going on based upon the environment.

Now, Doctor, in your evaluation of Lindsay Clancy, did you come to an opinion to a reasonable degree of medical certainty as to whether or not she was suffering from a mental disease or defect on January 24th, 2023?

Yes.

And what was that opinion?

I believe that Ms. Clancy was suffering from a mental disease or defect. And I felt that based upon the presentation, a Bipolar II diagnosis seemed to make the most sense given the symptoms of insomnia that she had that were precipitated by the Zoloft. And this was just very, very significant. And while it didn't fulfill all the criteria or many of the criteria, if she were a patient of mine, I would diagnose her as Bipolar II, because I would want to make sure that any doctor who saw her afterwards would be very wary of using an SSRI antidepressant in treating her.

And, Doctor, you mentioned the drug effects, Zoloft had an effect and SSRIs might have an effect. Is there a difference when you're treating someone and they're taking medications between being overmedicated and having an adverse reaction to medication?

Yes.

And what is the difference?

Well, when we think about side effects, that is an example of a medication having a response. Now, sometimes we have side effects when we're not necessarily overmedicated, but we put up with those side effects. When there is too much medication, certainly. We can experience those side effects. For example, over sedation, or there are some medications that can cause stimulation, so people are not able to sleep. An adverse reaction is much more serious. An adverse reaction could be, for example, an allergic reaction that could cause death. Or some type of reaction that you don't see in most people, but has been reported. So, there is a difference between side effects, no matter how difficult they are, and what we would call, adverse effects, which can be extremely serious.

And in your review of the records of the medications that the Defendant was prescribed from September through December, did you see any evidence of her having adverse effects from the medication?

Well, the insomnia secondary to the Zoloft was very concerning to me, and it would mean not just cutting the Zoloft back, but stopping it. I would say that the Zoloft was precipitating insomnia. I mean, she reported 48 hours straight of not being able to sleep, but that was an adverse effect. And an adverse effect really requires one to stop the medication.

And that is what Dr. Jennifer Tufts did with Ms. Clancy, correct? She had her stop the medication?

Correct.

And in reviewing those records again from September through December of 2022, did you see any evidence that Ms. Clancy was overmedicated?

She experienced some significant side effects from some of her medications. She was given, I think Nurse Practitioner Paul gave her Clonazepam, which is also a benzodiazepine. And she really had a uncomfortable reaction to that, just woke up and felt quite confused. So, she stopped that medication, understandably. Seroquel is a medication, quetiapine, that at high doses can cause some significant side effects. At lower doses, it generally helps treat insomnia. At higher doses, it can have more significant effects and in terms of just ability to think and organize one's thoughts. However, Ms. Clancy in December of 2022 chose at that time to continue on Seroquel, a combination of Seroquel and Valium. Nurse Practitioner, Julotta, had suggested another medication, olanzapine, Zyprexa, which she's taking now, and Ms. Clancy asked that she continue on the Seroquel at that point and the Valium. So, it's a challenge. One has side effects, but one also sees benefit in the medication. And certainly that combination at that time, I think it was around December 7th, December 9th, that was really helping her sleep. And so, she asked to continue on those two medications.

So I guess when I ask about overmedication and you talk about the side effects of the medication, there seems to be a disconnect between maybe what a lay person calls overmedicated versus what the medical definition of that is. So, is what you're saying that being overmedicated medically means having side effects to the medication?

Well, no, not necessarily.

So, what does overmedicated mean to you in your profession?

Well, if someone were to prescribe a medication that was beyond the limit that safely can be prescribed. For example, it's possible to be toxic on say, lithium, which is a medication that she took for a while while she was at Tewksbury. And if I were prescribing, say, 1,200 milligrams of lithium twice a day and her lithium level was toxic as it would likely be, that would clearly be an example of overmedication.

And did you see any evidence of that scenario in the Defendant's records that she was prescribed too high a dose to make her be at a toxic level of any medication?

I think those who were prescribing for her were responding to the symptoms that she was bringing. There was a kind of a rapid increase in the dose of Seroquel. And that higher dose of Seroquel was... I believe she was ultimately prescribed at 400 milligrams and she never ended up taking that. But, as a clinician, we do our best to try and treat symptoms.

Objection.

So, Doctor, did you see-

Next question.

Doctor, did you see, other than the Seroquel, any medications that the amount that was prescribed, you would think would be over medication?

No.

And then the Seroquel itself, you said she was prescribed up to 400 milligrams, but she reported that she never took that amount, correct?

Correct.

And after her stay at McLean Hospital, she had been weaned off of the Seroquel, correct?

That's right.

And the only medications immediately after leaving McLean Hospital were Trazodone and Valium, correct?

Correct.

Dr. Tufts added a medication as a result of her appointments with the Defendant in January, is that correct?

That's right.

And what was that medication?

That was amitriptyline, also known as Elavil.

And you saw what the initial dose of that was, correct?

Correct.

What was that?

The initial dose from Dr. Tufts was 10 milligrams.

Is that a high dose for an adult?

No, it's the very smallest dose possible.

And then did Dr. Tufts increase that dose?

Yes.

And when was that?

After a week, she increased the dose from 10 milligrams to 20 milligrams.

And is that a significant increase in the dose?

No.

Is 20 milligrams a significant or large dose for an adult?

Not at all.

10 milligrams or 20 milligrams of amitriptyline, is that something you could even prescribe to a child?

Yes.

Now, Doctor, based on your review of all of the records and your meetings with Ms. Clancy and your collateral interviews, did you form an opinion to a reasonable degree of medical certainty as to whether or not Lindsay Clancy on January 24th, 2023, could appreciate the difference between right and wrong?

Yes.

And what was that opinion?

My opinion is that she did have the capacity to appreciate right from wrong.

And what do you base that on?

Well, on a number of things. Ms. Clancy had just met with her psychiatrist, Dr. Tufts, the day before. And in that discussion with Dr. Tufts, as documented, she denied suicidal ideation, and she also denied thoughts of harm to others. And also, there was an ongoing conversation regarding future possible treatments, esketamine or TMS, which I spoke about yesterday, that could be employed to help her. Also, with regard to the appreciation between right and wrong, the planning involved prior to the strangling of her children, I thought was significant. The searches for distance of ThreeV, the searches of CVS, all done prior to her sending fairly late in the afternoon a text asking her husband if he didn't mind takeout from ThreeV and then adding on. So, that planning, that preparatory planning, I thought was significant. The avoidance of witnesses. A witness during a time when one is committing a crime can intervene, not just report, but also intervene. And so, the fact that this was done without any witness present during a time where she had asked the potential witness to go on a longer errand, also I thought was significant. Concealment is another thing that I think indicated an understanding of right and wrong. I mean, the children were strangled all in the basement. And according to Mr. Clancy, the door to his office had been closed when he arrived to the basement. Timing. Timing was really, really significant in this. There was a window of time that Ms. Clancy was aware of in which she would need to kill her three children as well as to kill herself, which she expected would happen. She was conscious of time and told me that she had mapped out the distance, et cetera, because she didn't want her husband to be gone too long. But in this case, I think the issue of time and her husband returning rather than being a solution for her was a problem. And so, to accomplish all of this in the course of that amount of time that Mr. Clancy was gone, I thought was significant, really showed an awareness of time. In terms of the weapons used, now these were exercise bands, but they were all near where the children were strangled. They were placed there. That's where they kept those exercise bands. And the exercise bands were nearly identical. I mean, very similar in terms of what they could do as ligatures. And so, that use of weapons that were readily available and nearby also was significant to me in terms of her understanding of and planning. I did not see any evidence that she had delusions about her children, delusions as to something wrong with them or something that required them, because of a delusion, that they needed to die. I don't recall that she ever spoke about her children in a delusional way.

... spoke about her children in a delusional way. Now-

[inaudible 00:34:09].

Sure. Next question.

Were there other factors that influenced your opinion that she knew the difference between right and wrong?

Yes.

And what were they?

Well, the phone call at what, 5:34 in the afternoon, I thought was significant. So Mr. Clancy was at CVS and he called his wife and she did not pick up, she did not answer, but she called him back and had that ability to deviate from what she was doing to be able to respond. And so had the presence of mind to do that, but also to conceal from him what was going on. Locking the door is another example. I mean, certainly Ms. Clancy was aware of time and the limited amount of time to accomplish this. But by locking the door, it kept her husband from being able to enter the bedroom and therefore being able to see what had happened. So delayed that time. On arrival, her husband asked her what happened and she did not confess. She did not tell him what had happened other than I tried to kill myself. She also did not report auditory hallucinations, but rather said that the children were in the basement. It's my belief that she expected to die and that by the time Mr. Clancy arrived, she would have successfully been able to take her life.

And sir, did you form an opinion to an unreasonable degree of medical certainty as to whether or not Lindsay Clancy on January 24th, 2023 had the ability to conform her behavior to the requirements of the law?

Yes.

And what is that opinion?

Well, if we look at that day, we know that in the morning, she took Cora to a pediatrician's appointment. And all physicians receive training in psychiatry, no matter what specialty they go in. That's part of medical school. And so like other doctors who had seen her who were not psychiatrists at appointments and whatever, the pediatrician also did not notice any unusual things about her. She was able to conform to the type of behavior that a concerned mother would engage in. She was able to drive to the pediatrician's office and then back. And the day was really one of significant control. The activities that she engaged in that day, spending time with her children with Play-Doh, taking them outside to build a snowman, sending photographs of the children to her mother, to her husband on Instagram. Fixing lunch and also fixing dinner for the children. So the activities of that day were controlled, as were the activities in terms of the planning that we already mentioned. So throughout the day, she was methodical and quite controlled and organized even in that space of time that was short. There was a lot to do in terms of killing her children and also killing herself. And I would say that the last point with regard to conforming to the law is that when she received the phone call from her husband, she did not report to him that she was in distress, that she was having hallucinations, that she needed help. So with that phone... By calling her husband back and reassuring him by the fact that yes, she knew the medication, whatever, that helped guarantee that he would continue on the errands. Had she not called him back, it certainly was possible that he would be concerned enough that he would return home. And so I think the phone figures in just in terms of her awareness and conforming her behavior such that the strangling of her children could be concealed.

And, Doctor, did you form an opinion to a reasonable degree of medical certainty as to whether Lindsay Clancy on January 24th, 2023 when she strangled her children was criminally responsible?

Yes.

And what is that opinion?

Yes. It is my opinion within a reasonable degree of medical certainty that Ms. Clancy was criminally responsible.

Move to submit Dr. Saathoff's CV as the next exhibit.

Any objection, counsel?

No.

All right. That may be admitted.

I have no further questions. Thank you.

Okay. Hold on a sec, Mr. Reddington.

[inaudible 00:40:43].

Thank you. All right, Counsel.

Good morning.

Good morning.

So Dr. Saathoff, as I understand it, you conducted your investigation or examination of Lindsay by Zoom, correct?

Did you say by June?

Sorry, Zoom.

By Zoom. Okay.

Zoom. [inaudible 00:41:19].

I thought you said because it was the 4th of June. Yes, sir.

Okay. And can you tell us when you were first engaged by the district attorney's office to assist them in this case?

I first was informed about the case, I think in January or early February of 2026, of this year. The final contract with the university was not completed, as I recall, until April.

And is that a matter of significant import when you're engaged in evaluating a young woman that's charged with triple homicide and you're hired by the government, the fact that there's a contract that wasn't signed by your school?

Well, sometimes it's a long process that I don't have any control over.

Sure. I understand.

I've seen those kinds of things take a while, take longer than one would necessarily want.

So the contract with your school that you're talking about would be the contract for your compensation, for your opinion?

Well, I would never be contracted for an opinion.

Okay. But you're getting paid, right?

No, I'm getting paid a salary.

Yes.

The university's getting paid.

And the university is deriving a benefit monetarily from your testimony or working on this case for the DA, right?

That's right.

All right. And how much did the university get as a result of your involvement in this case?

I don't know what the hourly rate is that they charge.

So you don't know what the hourly rate for your time is, right?

Correct.

You don't know how much money was paid by the district attorney's office to the university, right?

Correct.

You don't know how much money will be paid for perhaps yesterday, today, whatever balance billing. You don't know that either, right?

That's right.

You were retained or engaged in January of '26, right?

Yes.

This is an incident that occurred on January of '23, right?

Yes.

In January of '23 to January of '26, three years-

That's right.

... to being engaged on the case, right?

Correct.

And when you were engaged on the case, at some point, the university must have been out of the picture and you must have started to communicate with the DA's office, the police or whoever.

That's right.

And you knew about this case, it had a significant amount of publicity, right?

Yes.

Did you know that other doctors, on behalf of the district attorney's office, were being hired to also evaluate Lindsay?

I didn't specifically know that, but that's usually the case.

Is it important to see someone, to evaluate them as close in time as the incident is alleged to have occurred to your evaluation, or does it matter? In other words, is it better to see someone within a month or two after an incident or three, three and a half years later?

Well, what's most important is the collateral information that was gathered at the time to understand what was going on at the time. Ms. Clancy's behavior during her hospitalization and the like, there are records, but certainly there are benefits to an examination closer to the event.

And you would agree with me, sir, that you actually saw and questioned or interrogated Lindsay, what, two months ago?

May 29th and June 4th.

Okay. And when you went to interview her in purposes of your evaluation, you had already accessed the collateral information, sir?

Yes.

Before I go there, let me just review a few things here on your CV, which the jurors will have to examine. You indicated to us your present employment, you have a private practice as a psychiatrist?

No.

Okay. So where do you see patients?

Well, I see patients in the prison system.

They're your patients?

Yes.

What do you do for those people that are in jail?

In prison within the Virginia Department of Corrections, we have inmates within the prison system who suffer from mental illness and require assessment and treatment.

I see. When you said to the jury a little while ago, "If I'm treating my patient, I would prescribe a particular prescription for my patient and I wouldn't tell my patient to do," whatever it is you said, it's not people that go to an office or see you or even on the television to be treated. These are people that are in jail, right?

Prison, yes.

So there's a difference between jail and prison, right?

Yes.

And this would be in Virginia, is it?

Correct.

So you're dealing with people that are serving hard time in the Iron Mansion, as they say. It's not a house of correction down the street, right?

I see patients who have different varying sentences. Some have life sentences. Some are scheduled for release in the coming months, so that really varies.

And you work on behalf of the state to evaluate prisoners to determine whether or not they are fit, if you will, to be released into society, right?

Once someone's sentence is over, the only way that they could be continued within a prison system would be to be committed to a psychiatric hospital. And I would say that in the 34 years that I've been treating inmates who are patients, I can only recall two times where when discharge came up, their condition was such that they required to be civilly committed because of mental illness.

And when you are talking as a forensic psychiatrist evaluator, would that be on behalf of the BOP, Bureau of Prisons?

I have consulted with the Bureau of Prisons on just a few occasions, but Bureau of Prisons is federal and-

Yeah, I know that.

... most of my work has been with the state.

Okay. But on your resume, sir, you indicate from 2019 through the present, that's a number of years, that you have been employed or engaged as a forensic psychiatrist evaluator on behalf of the United States Bureau of Prisons as it relates to probation or parole. Is that in your resume?

Yes.

And that means, sir, that you evaluate inmates that are trying to get out of jail, and you would evaluate them to determine if they're appropriate for parole, right?

No.

Okay. So when you indicate on your resume from 2019 through the present, you were employed as a forensic psychiatrist evaluator for the United States Bureau of Prisons, how many of these evaluations did you do in the years from 2019 through 2026, seven years?

I think I've done two or three.

Two or three?

Yes.

Okay. 2016 through 2022, you're engaged as a consultant psychiatrist for the Elson Student Health Center. What is that?

That's the Student Health Center at the University of Virginia, so that serves students who are at the university.

Like what? I mean, do you evaluate them? Do you treat them? Do you analyze them? What do you do for college students?

My work with the university and the health center really had to do with students who were having difficulty and had left the university and were interested in getting back. And so I was part of a three person panel to evaluate the students to see whether or not it would be appropriate to bring them back to the university.

Were they thrown out of the university or they were disciplined or something? Why would you bring them back? What does that mean?

Well, if there was an event that caused concern, potentially was a threat, for example, then just for the student safety and the safety of all, they would leave the university in order to get the type of care that they needed. And then if they want to come back, then I was part of a panel that would evaluate these students and make a determination about whether it was safe for them to come back.

I'm sorry, I cut you off. Go ahead.

Yeah. No, that's all right.

Okay. These are students, right?

Correct.

In college, right?

That's right.

That have been thrown out or disciplined or suspended or something, and they're trying to get back into school, right?

That's right.

And when the parents of the students come, they retain you to advocate on their behalf?

No.

No, you work for the school, right?

Correct.

You evaluate them and then back the school up so that these kids can't get back into the school, right?

Can you ask that question again?

No, that's all right. 1999 through the present, you work for the United States Department of Justice, the United States Department of State, right?

Yes.

Okay. And that would be the United States Attorney's Office, the prosecutors. They're the state prosecutors, you get federal prosecutors, right?

Well, federal prosecutors and defenders. I've worked with both.

Well, the defenders certainly don't work for the United States Department of Justice or the United States Department of State, do they?

I was under the impression that federal public defenders were under the umbrella of the Department of Justice.

No, that's called the CJAC. That would be a totally different group of people. Those are people that defend people to try to have them not be abused by the system, if you will.

Objection.

Yeah, that question will be stricken.

2015, you're a psychiatric consultant for the Virginia Office of the Attorney General, another prosecuting arm, right?

Yes.

2013, Virginia Department of Corrections, Least Restrictive Measures for Segregation. You evaluate people to determine if they should be in like max or disciplinary unit as opposed to general population, is that what you do?

Yes, I've been asked to do that.

Okay. And you certainly don't advocate on behalf of the prisoners that are being placed in seg or being placed in those closed units with higher security, right?

No, that's not true at all.

The National Security Expert 2007 to the present, Oak Ridge United Associated Universities, what is that?

Yes, that is a group that does research with the Behavioral Analysis Unit and the National Center for Analysis of Violent Crime, and I have done work with them.

Okay. Critical Incident Analysis Group, CIAG, University of Virginia?

Yes.

Okay. Behavioral Analysis Unit, as you told us yesterday for the FBI at Quantico, right?

That's right.

Psychiatric consultant to the Virginia Department of Corrections, medium, maximum, and super max facilities, right?

Yes.

Continuing on with your experience, sir, as a witness in this case, you agree with me that you were involved as a psychiatric consultant with the Macro Task Force onsite consultation for the Australian Police Service?

Yes. ‍

Former Soviet Union Project, Republic of Georgia, T-B-I- L-I-S-I, Georgia. You were involved with that, sir?

Tbilisi.

Tbilisi, yeah. Critical Incident Response Group for the US Air Force, you're in the Assessment Unit?

Yes.

Crisis Management Unit, Investigative Support for Operation Gray Sunset Jordan?

Correct.

Crisis Management Unit, Investigative Support Unit, Critical Incident Response in Montreal, Quebec?

Yes.

FBI, National Center for Analysis of Violent Crime Operation New Hope?

Yes.

Bureau of Criminal Investigation, that's BCI, for the Department of the State Police, would that be Virginia?

Yes.

You also have an interest in and have studied or written about various topics in your career, correct?

Yes.

Okay. Hostage Negotiations Course, Crisis Management Unit, you were involved with that, is that correct?

Correct.

That was a number of years ago though. I guess that was like 1996.

That's right.

But you've been involved with the FBI for a long time, right?

Yes.

Fair to say that you're a government man?

Objection.

Sustained.

Hostage negotiation course. How about Virginia Department of State Police? You involved with them as well, sir? Yes?

Yes.

Advisory positions. You deal with Islam in Prison is one of your interests, right? That was a TV program or something?

Correct.

Talk about National Institute for Justice, standing committee to advise the Department of State on unexplained health effects on US government employees and their families overseas, right?

Yes.

Analysis of pre-attack behaviors of the Las Vegas Shooter Behavioral Analysis Unit for the FBI?

Yes.

Skipping ahead, papers published. Now, when a doctor or a psychiatrist, or any doctor really, I guess, publishes a paper that's of interest to other doctors or people, that's called a learned treatise, right? Peer review?

Yes.

Okay. Can you tell me, what is peer review? What does that mean when you're dealing with a person's focus and interest in writing about what they're focused on?

So a peer review journal is one in which once an article is submitted, a paper for publication, that goes to qualify people within the same field who review it and make determinations about the quality and whether or not it should be published. Oftentimes, there will be some edits or suggested edits from those who have expertise. It's a blind process, so if I submit a paper and it's peer reviewed, I don't know necessarily at all who is reviewing it, but it's a way to ensure quality of articles that are published, and that's just an important standard.

So it's kind of a rigorous standard to make sure that what you're writing about is reliable and would be helpful to others that are interested in it, right?

Correct.

Okay. So for example... But also it depends on where you're publishing it. You can put something in the National Enquirer or you could put it in International Psychiatric something or other, which would be a better publication.

I don't think The Enquirer is peer reviewed, but.

So you certainly would agree with me that the International Journal of Law and Psychiatry is a respected source for learning treatises, right?

Yes.

And you would agree with me, sir, that you've been in here telling this jury all about Lindsay and how she didn't hear voices or did hear voices or exaggerated and lied. Have you written any articles at all on the concept of auditory hallucinations?

No.

Have you read any of them?

Read any articles? Yes.

Yeah. Okay. You certainly have heard of Dr. Phillip Resnick, yes?

Yes.

And fair to say, tell me if I'm wrong, is he literally a world known authority in your field for filicide or the killing of children by their parents?

Yes, he's well known.

And is he also well-written as far as auditory hallucinations, same stuff you've been testifying about?

Yes.

And he published an article in the International Journal of Law and Psychiatry, which is considered to be, if you know, a landmark article about, and I captioned, "Listening to voices: the use of phenomenology to differentiate malingered from genuine auditory verbal hallucinations." Now, did you read that article?

Yes.

So it is a peer-reviewed article published in a recognized journal, correct?

Correct.

Your Honor, I would offer this under Commonwealth versus need for the jury if they wish.

Objection.

Counsel, can I see at sidebar?

Your Honor, while the copy is being made for the district attorney, could I continue?

Sure.

Thank you. Leaving aside peer review article and the article written by Dr. Phillip Resnick, sir, for a minute, papers that you published and you have in your resume, it says peer reviewed, so that's just what we were talking about, right?

That's right.

All right. Using the Moral Situational Action Model of Extremist Violence to Assess Fluctuating Levels of Risk in Women: The Relevance of Risk, Promotive, and Protective Factors, what does that mean, levels of risk in women with extremist violence?

We're looking at risk assessment in terms of violence and what may be mitigating factors, in other words, decreasing the risk or the threat or increasing, that would be enhancing factors, but this is looking at a group in terms of research.

And it's research about women that are involved with extremist violence?

Yes.

Okay. Assessing... Strike that. Using the Moral Situational Action Violence Risk Model for Assessing Women Involved in Extremist Violence and Empirical Study, is that a similar article?

Yes.

Operationalizing Theory: A Moral Situational Action Model for Extremist Violence. That would include guys plus women, I guess, right?

I'm sorry?

That would include men plus women, I guess, right because-

Yes.

... it doesn't say women. Suicide Terrorism: Performance Violence as Public Plunge. You wrote that, right?

Correct.

It's another interest there. Crisis Leadership and Military Community Resilience. Wrote that, right?

Correct.

Painting by numbers: Capturing the Pathology of Sociopolitical Conflict Dealing with Depression Amongst Palestinians, you wrote that, right?

Correct.

Psychological Challenges of Bioterror, you wrote that, right?

Correct.

Trauma and Intergenerations Transmissions in Kuwait, you wrote that, right?

Yes.

Recognizing Borderline Personality Disorder in the Family Practice Setting, you wrote that, right?

That's right.

Mortality Among Elderly Patients Discharged from a State Hospital, it's one of your interests, right?

That's right.

Postpartum Psychosis Induced by Bromocriptine, that's the one that you told the jury about originally that you published 40 years ago, right?

Yes.

Okay. Morality and the Radicalization of Women, what is that? What was that all about?

Could I be refreshed with that?

Sure. I mean, you can look at your resume if you wish. I'm just going through it. It's under B, books and chapters. This one is the first one and it deals with radicalization of women, a handbook, I guess, for terrorism studies. You remember that? It was only four years ago.

Yes.

Okay. Application of Big Data for National Security: A Practitioner's Guide, you wrote that, right?

Correct. I was one of four editors.

Crisis Guide of Psychoactive Drugs and Poisons for the Crisis Negotiation Unit, you wrote that, right?

That's right.

International Handbook of Threat Assessment, right?

Yes.

Protection of Children During Armed Political Conflicts: A Multidisciplinary Perspective, right?

Yes.

The Negotiator's Guide, like when somebody's locked in a building and they're threatening to kill people or something, the Negotiator's Guide to Psychoactive Drugs Second Edition. You wrote a chapter on that, right?

That's right.

The Negotiator's Guide, and it goes on and on with the negotiators and things like that. Terrorism negotiators, right? Is it fair to say that's your focus?

Correct.

Well, I know you can talk about postpartum, but I mean, I'm asking you if your resume that you prepared, I imagine well before you were hired by this DA's office, sets forth your interest, right?

Yes.

Okay.

The characterization of negotiation as trying to stop killers is not accurate.

I'm probably wrong?

Not comprehensive.

I apologize. You see it on TV that negotiators and they're trying to help people that are being kidnapped

On a bridge, in crisis, something like that.

Just a few more, Doctor. Panels and symposia, you'd agree with, let's see, national security. I just want to run through a quick... Attachment theory, mental wellness as it relates to threat management, threat assessments, corrections, psychiatry presentations, substance abuse and misuse in prisons, perspective on providing medical support during conflict and chaos, targeted violence in the media, lessons from history, the profile of poisons, understanding the female extremist, crisis operations, leadership, how to fool doctors by injecting chemicals into muscle to obtain opioids, a prison inmate comes clean. Did I read all those topics correctly, sir?

Correct.

Invited lectures, talk about extremism, extremism, terrorism, the future of policing, children in long-term abductions, how to prevent terrorism, mass shooters, US prisoners, religious rights, religious radicalization, terrorism and the unknown enemy. Basically-

... terrorism and the unknown enemy, basically that's what your focus is, sir, correct?

No.

And that's coupled with your experience of the two people or so that you recall dealing with in your.... It's not a practice, but working for the Bureau of Prisons or the state for Virginia, the people that are in jail, that is the sum total, to be respected, of Dr. Sadoff, correct? I mean, you treated two people. You've written a lot about terrorism and other issues that we went through.

That's not at all a correct characterization.

Oh, I'm sorry. Because I read your resume right, right?

Yes.

Okay. And I related what you indicated to the jury, your experience when I asked you about patients or treating people. I said that right, right?

I've been treating patients and I continue to for the last 40 years.

Now, in all of your experience, sir, have you ever treated a woman suffering from postpartum psychosis?

Yes.

When?

In the late 1980s and also during the 1990s when I ran a unit in a state hospital.

So this would be women, 1980s, about 30 years ago or 20 years ago, depending on which one, in a prison that you were-

No.

Oh, was it?

In a state hospital.

State hospital.

Correct.

Were they committed? Were they there because they wanted to be there or were they committed by order of the court?

Yes.

Yes what?

Usually committed.

Okay. So other than that, sir, do you have any interest, writing, knowledge about postpartum depression, postpartum psychosis?

Well, it really is a requirement when you assess and treat women to be aware of their histories and making determinations. So that has continued really throughout my career. Men and women.

What did you just say? Can you repeat that again? You're treating women with what?

Treating women with psychiatric problems, serious illness, psychosis.

So when you define for the district attorney the concept of, let's say psychosis yesterday, were you referring, in any degree, to a woman who has had a baby and is in a period of postpartum depression, shall we say?

Yes.

Okay. And when and how were you treating those people?

That was during the period of 15 years when I ran a unit of men and women who came in with serious psychiatric symptoms.

So what would you do? Would you analyze them? Would you talk to them? Counsel them? What would you do while they're in the hospital?

Well, do a full assessment with a multidisciplinary team and make determinations about proper treatment, proper therapy, medications and the like to treat the symptoms.

And generally, what would the symptoms be, sir, in your experience?

Symptoms of postpartum depression?

Yeah.

Okay. Well, certainly within that period of time around birth or after birth, the DSM has a four-week period. Others expand that to as much as a year. But certainly depressive symptoms, postpartum are similar to the symptoms that you see in a regular depression. You can have suicidality, you can have guilt, changes in appetite, changes in weight, changes in concentration, changes in physical activity. You can also have significant problems with sleep, either sleeping too much or not enough. So these are depressive symptoms that come in the postpartum period and require assessment-

Are you aware, sir, in your practice or studies of the number of women that commit suicide during the postpartum period? Are you aware of that?

I can't quote you a figure.

Do you have any clue at all?

No.

Would you agree with me, sir, that one of the unfortunate components... who has had a baby and is suffering from postpartum depression and living with it, that can on a dime turn into postpartum psychosis very quick, right?

It can be rapid.

And you indicated, sir, that there, according to the DSM, is a four-week cutoff for symptomology. And then you mentioned that there are others. Is it the World Health Organization that you said that talks about a year?

Correct.

There are some other psychiatric organizations that talk about different periods of time, six weeks, eight weeks, right?

Correct.

So when a woman is dealing with these symptoms and goes to a doctor, or even you when you're treating, as you indicated, 15, 20 years ago you were treating, is it important to take a blood test?

I'm sorry, can you repeat that?

I'm sorry. My bad. Is it important to take a blood test?

Is it important to take a blood test?

Yeah. You just went through the whole thing about, we're going to have the team and they're going to evaluate and we're going to prescribe. I'm just asking, is it important to take a blood test of the patient?

It can be.

Based on what?

Based on the presenting symptoms, based on the history, based on medical history. For example, if someone has recently been in a hospital and been treated, there may not be a necessity for drawing blood again, depending on the types of symptoms that you encounter. It's not a standard that everyone who presents to a psychiatrist requires blood tests.

So if you're a psychiatrist who's been practicing private practice for about, I don't know, a month, maybe two, and is prescribing anti-psychotic medications, selective serotonin reuptake inhibitor medications, benzodiazepine medications to a young woman who is complaining of what the young woman perceives to be difficulties postpartum, is it important to take a blood test to find out what, if any, prescription drugs they have on board in their system?

To check and find out, did you say, what drugs are on board?

Yeah. I mean, you're treating this patient, right? And they're coming off this... Hypothetically with you, but they're coming off the street to see a psychiatrist for help, right?

Yes.

And if they're already been prescribed drug after drug after drug by a particular doctor with their two months of robust experience, is it a fair statement that you should take a blood test of that person?

Well, it really depends on the medication. There are some medications that really require blood tests because of levels and the like. Many psychotropic medications are not easily... There's not an easy test for the amount of medication in a system. So it depends on the circumstances and it depends on the medication. I mean, for example, lithium or carbamazepine or valproic acid, those are all mood stabilizers. Certainly taking a blood test would be very important. So it depends.

Depends. Can I just ask you to spell those two drugs that you just pronounced for the stenographer, please?

Carbamazepine?

Yeah.

C-A-R-B-A-M-E-Z-A-P-I-N-E.

Okay.

Valproic acid, V-A-L-P-R-O-I-C, acid, also known as valproate, V-A-L-P-R-O-A-T-E. And did I mention lithium?

That's not a hard one. The record has to be accurate, that's all.

Understood.

Okay. Now, Doctor, are there other tests in your experience that are or can be or should be administered to a young woman or a woman who's had a baby and is coming to a doctor like Dr. Tufts, for example? Are there other tests that can be administered to determine if in fact that person is suffering from postpartum depression?

I'm not aware of any specific test that specifically diagnoses depression years and years ago.

Postpartum depression, sir.

Pardon me?

Postpartum depression is my question.

Correct.

Correction. I know you want to say it's the same thing, but postpartum depression is my question.

And you're asking if there's a blood test for postpartum depression?

I'm asking if there's any tests at all that a psychiatrist can or should administer to the patient, coming to them for help.

Well, there's the Edinburgh scale, which is a self-report that patients fill out who are postpartum.

You look that up last night?

No.

No? You knew about the Edinburgh scale?

Yes.

Have you administer the Edinburgh scale?

Pardon me?

Have you administered the Edinburgh scale?

No. It's a self-report usually given by nurses.

Nurses? Okay. In any event, it's a scale that is a useful tool to determine the level or degree of depression that a person may be expressing that is suffering from postpartum depression, correct?

That's right.

And do you know what the numbers are on the scale? Is it 1 to 23 or is it 1 to 50 or do you know what it is?

It's a 30-point scale.

And when you say-

So 1 to 30 as I understand it.

And when you say a self report, the patient would then advise what symptomology they're suffering at that particular point in time, right?

Correct.

And then the doctor would then determine whether or not there is a risk or an extreme risk or a deadly risk of this person committing suicide, harming someone else, whether it's a baby or anybody else, and determine what the level of their postpartum depression is, right?

Yes, it can help.

And did Dr. Tufts administer Edinburgh test to this young woman?

I know that Ms. Clancy, there were a number of Edinburgh tests that were given to her so that there are some scores in her record. I can't recall which practitioner gave her the Edinburgh test, but I do recall that there are a number of scores within her medical record.

Right. And what was her highest score?

The highest score that I recall was 23.

23 out of 30, right?

Correct.

And over 15, the patient is in pretty serious trouble, right?

Over 15 is concerning, definitely.

Right. And she was 23, right?

Yes, I believe so. I think they ranged from 19 to 23, just from my memory.

They increased as time went by, right? She was getting worse, right?

Correct.

Yeah. All right. And in addition to the regular blood test, which costs like, I don't know, about 100 bucks to administer a blood test to see what somebody's got in their system, it's not a lot of money, right, for the insurance company?

I just didn't hear you.

Blood test. It's not a lot of money for an insurance company to pay, right? To cover?

Correct.

Okay. So do you feel that it is reasonable medical procedure for a psychiatrist dealing with a woman... on the Edinburgh scale off the charts or serious trouble who is on medication as we went through, the antipsychotic drugs, the SSRI drugs, the amitriptylines at the end of the period of treatment with these people, the benzodiazepines, it's helpful to take a blood test, right?

It can be.

And is that, in your opinion, sir, to a reasonable degree of medical certainty, a step that should be taken by a competent doctor?

That taking blood tests can be appropriate, yes.

And then there's an additional blood test that you can use when you're dealing with a woman who's suffering from postpartum depression or coming to the doctor for help and they have significant narcotics or prescription drugs in their system, and that would be an enzyme test, right?

I'm not aware of an enzyme test being typically available or used.

Well, it costs a lot of money, doesn't it? It costs a couple of grand?

I don't know.

All right. In any event, sir, are there any other concerns that one would have, if they're competent and they're treating somebody that's come to them for help in addition to a blood test and perhaps enzyme test to determine the metabolizing aspect of the person's system, metabolizing or processing these drugs that are in their system, the enzyme test, are there any other tests or concerns that you have with a woman whose postpartum depression complaints come to your doorstep?

Well, depending on the presentation, sometimes it's helpful to check thyroid function. That can certainly be a cause of psychiatric symptoms.

Did they do a thyroid test on Lindsay?

No.

That's not a lot of money that the insurance company would complain about, right?

Correct.

One of the things that I just don't want to forget, sir, is that the district attorney asked you while we're talking about the drugs, about the Lamictal, otherwise known as lamotrigine. Did I pronounce that right?

Lamotrigine, yes.

Lamotrigine. And she said that Lamictal, it has a side effect of a rash, right? Do you recall that, sir?

I think I said serious rash.

No, I think she said rash.

Oh.

It's up to the jury what their recollection is, but you may have said serious rash, but we both agree it's a serious rash, right?

Yes.

In fact, it can be fatal, right?

In very rare occasions, yes.

It can be fatal, right?

Yes, in very rare occasions.

Well, if one person out of a thousand gets Stevens-Johnson syndrome or Prurigo Nodularis as a result of taking that medication, that's something that we should not tolerate as doctors, right?

Risks and benefits are something that every physician, every prescriber needs to think about.

So you've heard of, as it relates to Lamictal as a prescription drug, what's called TEN, you've heard of that, right, as a side effect?

Yes.

And that means that what?

It is a pretty severe reaction of the skin, as I recall, causing blistering. I mean, it's very significant.

So if you have a young woman who is a nurse, an RN, who worked for seven years in a very prestigious hospital's labor and delivery unit, who was so nervous about drugs that were being prescribed to her that she would at night sit in her kitchen on her phone and Google all sorts of side effects of narcotics, the drugs, the Seroquel, Lamotrigine, all of these drugs, is it an unreasonable decision for her to say, "I don't want to take that drug," in your opinion?

It seems like you're asking, is it reasonable to decide not to take the drug?

Yeah, that's what she did. That's what you told us yesterday. That's what the DA asked her yesterday, right?

It was a decision that she made.

And in your opinion, sir, after we just went through all of this with the TENS, with the toxic epidural necrolysis and all the rest of that, and she's a nurse and she's looking up these drugs that she's being prescribed and says, "I don't wish to take that drug," in your opinion, to a reasonable degree of psychiatric certainty based on your experience, is that a reasonable decision for her to say, "I don't want to take it"?

The benefits of that drug are profound, and millions and millions of Americans take that medication and find it to be very important for them.

Doctor, you're an intelligent man, you're a doctor, you've got a lot of experience dealing with the prison system. We've already gone over all of that. You understand my question, don't you?

Yes.

I'm just asking, is that a reasonable decision for Lindsay to make to say, "I don't wish to take that drug?" Based on all the side effects, whether or not it's rare that people die, whether or not it's rare that they break out on their skin with these permanent lesions and bleeding pustules, is it reasonable for her to say, "I don't want to take it"?

In her mind, it was.

Yeah. And certainly, we don't want to leave it with the jury that she's so vain that she just didn't want to take something that she might get a little rash. In any event, now have in mind, there's no blood test, there's no enzyme test for metabolite test, there's no thyroid test, but we still have the pill factory through Dr. Tufts and then into Dr. Jolotta for that period of time. You're telling this jury that that is, in your opinion, reasonable little, little drug doses that she was prescribed. Is that what you're telling this jury, sir?

That it was reasonable to prescribe?

Yeah, the drugs one right after the other. And then stopping the SSRI, not weaning off, stopping it flat out. Is that reasonable?

Objection.

Sustained. Just as to form.

Is it reasonable, sir, in your opinion, to tell someone who's on an SSRI such as-

... expressed concerns that she was not following a plan and that it would've been better for her had she tried to stick with a plan.

Is that that one sentence in all of the medical records where it makes reference to the fact that she said something like, "I should have stuck with the plan." Is that what you're referring to?

Yes.

Okay. My question, sir, was Dr. Tufts, Dr. Paul, Dr. Jolotta.

Nurse Practitioner Paul and Jolotta.

I apologize. Again, it's-

It's all right.

... my bad. Nurse Practitioner Jolotta, up to that point, bringing us into November, these people... And other emergency room visits that she had, she was not going out looking to score drugs off of drug prescriptions. Is that fair?

Correct.

And she, in fact, looked up Tufts, but she didn't even know who Tufts was. She went online and Googled postpartum depression and found an expert, isn't that right?

That's my understanding.

But she was only practicing for like a month or two. Was she, in your opinion, to a reasonable degree of psychiatric certainty, an expert?

Objection.

Overruled.

It depends on the amount of training that she received, not just as a physician and a resident, but also in the area of women's health.

So the young lady goes online, Google's trying to get help, goes to see the expert, Dr. Tufts, ultimately deals with Nurse Practitioner Jolotta and counselor that worked in that medical field business, Leticia Dukes, I believe is her name.

Right.

And then she had the need to go to an emergency room and went to Mass General Hospital, right?

That's right.

And she was with her husband, Pat, right?

Correct.

And she had been complaining about lack of sleep, insomnia, right?

Yes, as I understand.

She had been complaining about inability to emote, feeling hollow, "not myself," right?

Correct.

And a number of other complaints that were brought to the fore, and the hospital made a recommendation that she go to McLean Hospital, which is a locked ward mental institution in Massachusetts, and she chose not to do that, correct?

That's right.

So then what she did is went back to her home and immediately hooked up again, if you will, with Tufts, right?

That's right.

In December, one of the people at the South Shore Perinatal Unit advised her to go to a hospital that specializes in postpartum women, that would be Women & Infants Hospital in Rhode Island, right?

That's right.

And she went there the next day, right after they called, right?

Yes. I think they fit her in pretty quickly. Was it maybe the 20th of December?

And her husband dropped her off for that day program, right?

That's right.

And she participated with the coloring with the conferences or with the discussions and evaluations with the doctor, right?

Yes.

For about eight hours. It was about an eight-hour day, right?

Something like that.

And on that date, in December 20th, she was turned away basically, right?

I don't know that I would term it turned away-

Did they help her.

But by Dr. Diaz's notes, but-

Did they help her?

Pardon me?

Did they help her?

They felt that another program might be more appropriate, either inpatient... ... impression that most of the women who were in that program were much closer to having had given birth to their children. And so in that respect, it was not. The group that they served were much closer to that postpartum period, as I understand.

You're not going to say to this jury that because Lindsay was outside of the, let's say, four month cutoff, that she was not a good candidate for postpartum depression treatment? Is that what you're [inaudible 01:36:25]?

No.

Oh, okay. I'm sorry. I thought you said because of the timeframe from giving birth to the time that she went to see them.

I was just speaking about my understanding from the note from Women & Infants in terms of their decision making.

Okay. And Women & Infants basically discharged her after about eight hours, right?

Yes.

And her husband was up skiing, and then she contacted him and he had to come down and pick her up and bring her home, right?

That's right.

And the reason that she was discharged from Infants Hospital in Rhode Island included a statement RO, rule out issues regarding prescription medications, correct?

Yes, that's my recollection.

She indicated that she was going to go right back to Tufts, right?

Yes.

And she did, didn't she?

Yes, as I understand.

And would you agree, sir, that every time a doctor said to Lindsay to do something, whether it was to make an appointment somewhere, whether it was to take another drug, any advice, that she was on it immediately, is that fair?

She attended her appointments, yes.

Well, not just that. She attended them right away. She was told, for example, at McLean, you read those records, that she should hook up with her provider and she did the very next day, right?

Yes.

Okay. So she wasn't avoiding seeing healthcare professionals, was she?

No.

And she was continuing to express concern about her state of mind. She felt that her mind, her brain was being damaged. Isn't that right?

That's right.

Those are in the records, right?

Correct.

And she felt that her brain being damaged was permanent and she was never going to get better, right?

Yes.

She was complaining not just to her physicians, but she was complaining to people in her community that she was having intrusive thoughts, dark thoughts, suicidal thoughts, and homicidal ideation. She said that, correct?

The homicidal ideation, as I understand, was just voiced to her husband and her mother.

Just voiced? Is that what you just said? Just voiced? Is that like talking about the Red Sox?

Objection.

She's talking about homicidal ideation of her children.

Sustained. Next question.

I asked you about her complaints of intrusive thoughts, complaining to doctors, complaining to friends, complaining to neighbors, family about dark, intrusive thoughts of suicide and homicidal ideation, didn't she?

I just don't recall that she complained of homicidal ideation to-

Okay. So-

... healthcare providers.

Let him finish answering.

Doc, did you finish? Did you finish the answer? Doctor, did you finish that last answer?

[inaudible 01:40:09]. Okay.

All right. Next question.

So we'll put homicidal ideation aside for a minute. Would you agree that for that period of time, short as it may have been in her life, November into December, that she was reaching out to people that would listen to her for help?

Yes.

Would you agree, sir, that she would tell, for example, neighbors or friends with the Learning Sprouts School, her family, her doctors, that she was having these dark, intrusive thoughts of suicide? Yes or no?

Did you ask whether or not she was telling her children's teachers at Learning Sprouts?

Anyone that she would come in contact with at Learning Sprouts, whether it's another mother, whether it's a friend, whether it's a teacher, whether it's an administrator, whether it's somebody that just watches the kids in the playground. Did she tell anyone that she had dark, intrusive thoughts, to your investigation?

Those people that you named, I wasn't aware that she informed them about that.

When someone says with her history up to this point in December that they're having dark, intrusive thoughts to a professional, in your opinion, sir, to a reasonable degree of medical certainty, does it make sense that the professional should ask the person whether or not these are voices that they're hearing in their head or whether or not they are just thoughts that they're having?

... whether or not they are just thoughts that they're having.

Certainly exploring that is important.

And would you agree with me, sir, that when you have a young woman that, again, by all accounts, done nothing wrong in her life, exemplary citizen, has these issues and sees the doctors that, to a reasonable degree of medical certainty, a physician should do a little bit more than asking, "Do you have a plan?" I mean, is that accepted practice just to say, "Do you have a plan?" And if they say no, you're okay.

I wasn't aware that that was the only question.

Okay. She was also told that counsel had asked you yesterday about other recommendations that were given to her by women and infants and that you said that she did not follow through on that, but she did see Dr. Tufts pretty much the next day, right?

That's my understanding, yes.

Okay. And she said that, that she was going to go see Dr. Tufts the next day, right?

Yes.

And just to mention, before I forget it, the Lamictal, I think you mentioned to the jury that she had a prescription for Lamictal that she was able to fill, right?

Correct.

But she didn't take it, right?

That's right.

And then Tufts told her that she was going to, she meaning Tufts, was going to give her a script for Lamictal. And she said, "No, I already have one." Right?

It was Nurse Jollotta.

Okay, sorry.

She had gotten the prescription and filled it from Dr. Tufts. And Nurse Jollotta, when asked about the Lamictal, was very favorable about it and said, "Yes, that's great. That would be great."

Sir, I know. I know. You want to tell me that it's wonderful drug. Did she tell Nurse Practitioner Jollotta, "I already have a script. I don't need it"?

Yes.

Among other things, when people are in trouble and they're having dark suicidal thoughts, whether or not it's voices in their head, whether or not it's thoughts that they can't go on anymore, they can't live life, they have to kill themselves, many times they're told to call suicide hotlines, right?

Yes. Aspire.

Aspire. What is Aspire?

I don't know what it stands for, but it is a hotline that Ms. Clancy called twice because of her suicidal ideation.

When did she call Aspire saying that she had thoughts of killing herself?

I can't recall specifically.

But she did call them not once, but twice and told them... So she complained and told them that she was going to kill herself, right? Twice. Right?

She spoke to them about suicidality.

So here's a young woman with all of what she's been through who now is to the verge of killing herself and reaches out to people that her healthcare providers told her to call for help, said that she was going to kill herself, and what did Aspire do?

As I understand, they redirected her to her provider. They did not make a decision to hospitalize or to recommend hospitalization.

They didn't make a decision to do anything.

Objection.

Yeah. So you could form that as a question, please.

Did you read the records dealing with Aspire? Did they do anything other than tell her, "No, you're not someone that we can help"?

I know that they were not responsive to her suicidality because she did not indicate that she had a plan.

And did you read a transcript or listen to a tape or how do you know that?

I recall it someplace in the documents it being referred to, but I can't tell you exactly where.

So this sir obviously is a murder trial and you are a witness for the government and you've indicated that you've read the records. You just told this jury that in the conversation that she had with the people from Aspire that she expressed suicidal ideation and was asked if she had a plan. Where were you getting that from?

I can't tell you exactly within the records.

How about the second time she called Aspire? Why would she call Aspire again if they wouldn't help her the first time, in your opinion as a psychiatrist? Looking for help?

Continuing to seek help.

And yet again, she didn't get any, did she?

That's my understanding.

To a reasonable degree of psychiatric certainty with treating the patients to the extent that you've told this jury that you have, what kind of a devastating effect would that have on a person who's ready to kill themselves, that's called Aspire hotline twice and has been turned away?

Objection.

Overruled.

It could have a very serious effect.

And after being discharged from Women & Infants Hospital and reaching out to Aspire, you'd agree with me that one of the concerns that the doctor at Women's Hospital in Rhode Island had is the medication that she had been prescribed by Tufts and Nurse Practitioner Jollotta, right?

Correct.

And that's one of the reasons that they could not treat her. It wasn't just that, "No, we don't think that you're postpartum depressed. We just think that there's a complicated overlay involving the medications that you've been prescribed," right?

Yes.

‍ And these medications obviously included selective serotonin reuptake inhibitors, right?

Yes. Prozac and Zoloft.

Right. And one of the things that a doctor would be concerned about, especially with a woman who's had a baby and has stopped breastfeeding the baby, is the effect that that may have on the woman physically, mentally, emotionally when they stop breastfeeding a baby, right?

Yes.

And you've heard of gamma aminobutyric acid, otherwise known as GABA, right?

Yes.

And can you tell us please what that is, sir?

I'm sorry?

Can you tell us please what that is, sir? What is GABA?

I believe that you're referring to Lyrica.

No, I'm asking about the actual acid in the person's system, their blood that is gamma amino, B-U-L-R-Y-C acid. It's got nothing to do with Lamictal. It's got nothing to do with Seroquel. It's got nothing to do with the drug industry. This is in the body. When a woman stops lactating, woman stops breastfeeding-

Yes.

... there is a physical effect on the person, the body, right?

Yes.

What is that effect?

It depends on the individual. There's variable responses, postpartum. And as I understand, she stopped breastfeeding around October, by October 21st or so, when the Ativan was started.

Would you agree with me, sir, that the GABA, make it easier to type, is basically affects, its primary effect is on the neurotransmitters in the brain, right?

Yes.

Okay. That sounds pretty complicated. Neurotransmitters, I mean, is that like where you have a spark plug on a motorcycle and you can actually gap it and get it to kick over? It's a neurotransmitter in the brain. That sounds like it.

Well, yeah, it's more complicated than that-

I figured.

... obviously.

But nevertheless, it's still basically, you're talking about the actual organic matter of the brain, right?

Yes.

And would you agree, sir, that when a woman is pregnant, that there are progesterone hormone surges during that pregnancy?