2.Jennifer Tufts — Redirect/Recross (Part 3)

MS. SPRAGUE: Thank you. Good afternoon, doctor. I apologize for my voice. If you can't hear me, just let me know.

MS. SPRAGUE: You were asked on cross-examination about your residency. At that point, you were already a doctor, correct?

MS. SPRAGUE: And during your residency, that was a four-year period, correct?

MS. SPRAGUE: And you were saying that you treated patients during that time. Is that correct?

MS. SPRAGUE: Was there someone with you while you treated these patients telling you what to do and how to handle them?

MS. SPRAGUE: Were you alone responsible for the evaluation, diagnosis, and treatment of your patients?

MS. SPRAGUE: And approximately how many patients did you treat during those four years?

MS. SPRAGUE: And those were all psychiatric patients, correct?

MS. SPRAGUE: You said approximately 50 of those patients were patients dealing with postpartum depression or some postpartum issues. Is that correct?

MS. SPRAGUE: You also said you had some specialized or specific training in that area. Can you describe that for us?

MS. SPRAGUE: And how long was that clinic for?

MS. SPRAGUE: And so for a year you were evaluating and diagnosing and treating women with postpartum issues?

MS. SPRAGUE: And that's separate and apart from your residency?

MS. SPRAGUE: Okay.

MS. SPRAGUE: So for one year out of the four, that was specifically designated to postpartum issues?

MS. SPRAGUE: So you would follow those same patients throughout the year. Is that what you're saying?

MS. SPRAGUE: And you were asked about postpartum psychosis, and you said it was rare. How rare is it?

MS. SPRAGUE: Low. Have you dealt with patients in your four years of residency that had other types of psychosis?

MS. SPRAGUE: And psychosis, whether it's from postpartum or some other mental illness, does it present the same, or does it matter what the underlying illness is?

MS. SPRAGUE: And so what are the symptoms or signs that you look for to determine whether someone has psychosis?

MS. SPRAGUE: So although you'd never treated someone with postpartum psychosis, you had evaluated, diagnosed, and treated people with other types of psychosis. Is that correct?

MS. SPRAGUE: Did you see any signs of psychosis in any of your interactions with Lindsay Clancy?

MS. SPRAGUE: Defense counsel mentioned that part of your residency was during COVID. Did mental health issues just stop during COVID?

MS. SPRAGUE: And so it's fair to say you still kept busy seeing patients on a daily basis?

MS. SPRAGUE: You also mentioned that some of the patients you saw in your residency, it was outpatient care. Is that correct?

MS. SPRAGUE: Is that similar to the care you were providing to Lindsay Clancy?

MS. SPRAGUE: And was that all four years you were providing outpatient care to psychiatric patients?

MS. SPRAGUE: Three of the four. You were also asked about telehealth. Is telehealth, appointments in psychiatric care, standard in the industry?

MS. SPRAGUE: And how long has that been standard?

MS. SPRAGUE: And is it a fairly common and accepted practice at this point?

MS. SPRAGUE: Most of the session, for a psychiatric session, you're talking to someone, right?

MS. SPRAGUE: Does looking at someone through a computer screen somehow inhibit how you hear the answers?

MS. SPRAGUE: Or inhibit the way you ask your questions?

MS. SPRAGUE: And defense counsel asked you about, you know, not being able to see below the waist someone shaking or moving. But if someone's sitting and they're bouncing, can you see it elsewhere? Can you see other movement?

MS. SPRAGUE: You were also asked about the Edinburgh scale. You said you don't use it, right?

MS. SPRAGUE: You said you use the PHQ-9. Why do you use that instead of the Edinburgh scale?

MS. SPRAGUE: And the PHQ-9, what does that look for?

MS. SPRAGUE: And postpartum depression, are there questions on the PHQ-9 that look for the signs and symptoms of postpartum depression?

MS. SPRAGUE: So the PHQ-9 is asking the patient questions that would reveal whether or not they might be depressed, but not whether or not they just had a baby?

MS. SPRAGUE: And then with your interaction with the patient, you're able to know whether or not they are in the postpartum phase?

MS. SPRAGUE: And so would it be fair to say that you take the PHQ-9 plus the information you learn from the patient, put it together and come up with a diagnosis?

MS. SPRAGUE: When you take a history from a patient, you were asked about taking history from Ms. Clancy. How important is it that the patient give you accurate information?

MS. SPRAGUE: And why is that?

MS. SPRAGUE: And would you agree that people in the medical field, such as nurses, are acutely aware of the necessity of an accurate medical history and symptom presentation?

MS. SPRAGUE: You mentioned that the defendant was able to advocate for herself. In what ways did she show you that?

MS. SPRAGUE: Script or conversation?

MS. SPRAGUE: Providing therapy to someone like Ms. Clancy, is that dependent on what she's telling you and then how she's responding to what you're saying, basically a conversation?

MS. SPRAGUE: Listening. Would you say it's more important in therapy for the psychiatrist or therapist to talk or listen?

MS. SPRAGUE: And why is that?

MS. SPRAGUE: Now, is it accurate to state that in every one of your sessions with Ms. Clancy, you told her about individual therapy and encouraged her to attend individual therapy?

MS. SPRAGUE: And you in fact wrote it on the work form that we talked about previously. On page 104 of the records, it lists, "Was the patient referred to other healthcare providers for evaluation or treatment?" Says yes. "If yes, state the nature of such treatments and expected duration of treatment." And it says, "Individual weekly therapy," correct?

MS. SPRAGUE: And this is the form that the defendant asked you to fill out, correct?

MS. SPRAGUE: And you sent it back to her. And the first version she wanted you to make some corrections on, correct?

MS. SPRAGUE: But she didn't ask you to change that portion, correct?

MS. SPRAGUE: And in fact, on the second version, on page 107 of the record, it still says, "Individual weekly therapy recommended," correct, for follow-up?

MS. SPRAGUE: Would it be accurate to state that the defendant only saw Jennifer McAllister twice the entire time that she was with your practice for therapy?

MS. SPRAGUE: You were asked about Zoloft being used for general anxiety disorder. Is that a common drug used for general anxiety disorder?

MS. SPRAGUE: And why is that?

MS. SPRAGUE: You were also asked about the suicide warning on it, that there is a suicide warning. Is that for all ages?

MS. SPRAGUE: What ages or groups is that suicide warning for?

MS. SPRAGUE: Would it be accurate to state that the defendant was 32 years old when she saw you?

MS. SPRAGUE: Well, if you wanna check the records—

MS. SPRAGUE: ...just to be sure.

MS. SPRAGUE: Is that correct?

MS. SPRAGUE: Okay. So 32 years old is not three to four years older than 24, correct?

MS. SPRAGUE: Why didn't you have to titrate the 50 milligrams of Zoloft?

MS. SPRAGUE: Yes.

MS. SPRAGUE: So it wasn't necessary?

MS. SPRAGUE: The defendant waited about a month after receiving the prescription before taking the medication, correct?

MS. SPRAGUE: And she only took the medication when she decided she was ready to take it, correct?

MS. SPRAGUE: So she was taking in the information you gave her, correct?

MS. SPRAGUE: She was making her own decisions, correct?

MS. SPRAGUE: She was not forced to, correct?

MS. SPRAGUE: She actually had an appointment in between when you first prescribed it and when she started taking it where she was still discussing with you whether or not she wanted to take it. Is that correct?

MS. SPRAGUE: Is that part of the advocating for herself that you were talking about?

MS. SPRAGUE: Is that part of the medical sophistication that she possessed that you were talking about?

MS. SPRAGUE: Sure. I wanna direct your attention to the September 12th, 2022 form that the defendant filled out.

MS. SPRAGUE: On page 16 of the record... Oh, we have different page numbers, right?

MS. SPRAGUE: The past psychiatric history.

MS. SPRAGUE: What did she tell you, Miss Clancy, tell you about the—where it says, "If yes, list the reason and dates"? What did she tell you?

MS. SPRAGUE: And on the following page, under the past or current psychiatric medications, which ones did she list?

MS. SPRAGUE: Is there a column there that says effective, yes or no?

MS. SPRAGUE: What was the defendant's answer with whether or not Prozac was effective?

MS. SPRAGUE: What was her answer as to whether or not Wellbutrin was effective?

MS. SPRAGUE: Is there another column there that said experienced side effects?

MS. SPRAGUE: Did she check off any side effects experienced for Prozac?

MS. SPRAGUE: Did she check off any side effects experienced for Wellbutrin?

MS. SPRAGUE: Going to the October 20th, 2022 appointment.

MS. SPRAGUE: You were asked about this on cross-examination, about documenting side effects in your notes. Did you document the side effects that the defendant reported from the Zoloft on October 20th, 2022?

MS. SPRAGUE: And what did you document?

MS. SPRAGUE: And so what does GI mean?

MS. SPRAGUE: So would that mean stomach issues?

MS. SPRAGUE: And what did you put in your notes?

MS. SPRAGUE: And so you did document the side effects that she reported to you, correct?

MS. SPRAGUE: You also documented in the interval history, "Paranoid of getting suicidal thoughts." Was that the defendant's phrasing?

MS. SPRAGUE: And is there a difference between someone being worried about having suicidal thoughts and someone actually having suicidal thoughts?

MS. SPRAGUE: And what's the difference in terms of how a psychiatrist sees it?

MS. SPRAGUE: What's the difference in your training and experience between someone having fears of suicidal thoughts and actually having suicidal thoughts?

MS. SPRAGUE: And does that affect the way you proceed with treatment?

MS. SPRAGUE: How?

MS. SPRAGUE: And so according to the defendant, she was not yet having suicidal thoughts at that time.

MS. SPRAGUE: So when defense counsel asked you repeatedly why you didn't document how many times she had those thoughts, she hadn't had those actual thoughts yet, correct?

MS. SPRAGUE: That was later in December, is that right?

MS. SPRAGUE: Now, she also told you that she was worried about something, that something bad might happen, so she arranged for her mother to stay. Is that correct?

MS. SPRAGUE: Okay. So you don't recall the two being together as a thought?

MS. SPRAGUE: And the fact that she was struggling and arranged to have her mother stay, got support, advocated for herself, would those be protective factors?

MS. SPRAGUE: How so?

MS. SPRAGUE: So based on your training and experience with Ms. Clancy, where she says she's having... she's worried about getting suicidal thoughts, and she has her mom come stay with her. Do you see that as a positive decision?

MS. SPRAGUE: You were asked about not asking the defendant if she had called the suicide hotline. If a patient denies suicidal ideation, would you typically ask them if they had called a suicide hotline?

MS. SPRAGUE: And why not?

MS. SPRAGUE: You were asked about prescribing hydroxyzine, hydroxyzine, Ativan, and Buspar. Did you tell the defendant how to take those medications?

MS. SPRAGUE: What were your instructions?

MS. SPRAGUE: So there was never... Was there ever an instruction for her to take all three at the same time?

MS. SPRAGUE: And you were asked about the contraindications of Ativan and Benadryl. Do you recall that?

MS. SPRAGUE: Are there contraindications for taking the two together?

MS. SPRAGUE: And is that one of the reasons that you prescribed the hydroxyzine?

MS. SPRAGUE: Is the fact that the two of them together, Ativan and Benadryl... But let me strike that question. Why did you prescribe the hydroxyzine?

MS. SPRAGUE: Okay. And I'm just gonna direct you to your November 2nd, 2022 interval history.

MS. SPRAGUE: Now, would it be fair to say that on the November 2nd date, the defendant reported she was fine all day. Evenings, bedtime, get anxious. Ativan helps. Sleeping great on it. Afraid to try something else, but knows it's not a long-term solution. Is that correct?

MS. SPRAGUE: And what part of that did the defendant tell you was not a long-term solution?

MS. SPRAGUE: And why is that?

MS. SPRAGUE: And was there a plan developed based on that concern?

MS. SPRAGUE: What was the plan?

MS. SPRAGUE: So the defendant was able to express to you a concern she had about the medication, you had a conversation about it, and you addressed that with her and came up with a plan. Is that right?

MS. SPRAGUE: She also told you that day that she was in therapy and exercising daily, correct?

MS. SPRAGUE: Did the defendant ever tell you that she went to the South Shore Hospital Emergency Department on November 16th, 2022?

MS. SPRAGUE: Did she tell you that they had prescribed Trazodone to her at that time?

MS. SPRAGUE: Did she ever tell you that she was trying some alternative methods like weed gummies?

MS. SPRAGUE: Do you have any way of knowing these things if the patient doesn't tell you?

MS. SPRAGUE: Now, on December 1st, 2022, defense asked you about that date. That's the date that she again said she had the fear of thoughts of suicide. Is that correct?

MS. SPRAGUE: Up until that point, had she consistently denied suicidal ideation or intent or a plan?

MS. SPRAGUE: Had she consistently denied homicidal ideation, intent or a plan?

MS. SPRAGUE: What's the difference... Well, let me ask you this. When you talk to a patient, do you ask them, "Do you have suicidal ideation?"

MS. SPRAGUE: What do you-

MS. SPRAGUE: How do you get that information from them? What types of questions do you ask?

MS. SPRAGUE: And is there a difference between having thoughts of suicide versus having the intent and a plan to do it?

MS. SPRAGUE: And are there different types of treatment or things that you would do if someone has intent or plan to do it?

MS. SPRAGUE: And so if Ms. Clancy had told you she had thoughts of hurting herself, or actually, strike that. If she told you that she had a plan to hurt herself or a plan to hurt her children, would you have moved to commit her?

MS. SPRAGUE: Then that would be a Section 12?

MS. SPRAGUE: You were asked about the October 31st therapy session with Jennifer McAllister. And I know you weren't present from that. You're just going from the records. But you did say that in that session, the defendant denied suicidal ideation and homicidal ideation, correct?

MS. SPRAGUE: Would there be any reason, based on your training and experience, to do that further suicidal intent assessment?

MS. SPRAGUE: Why not?

MS. SPRAGUE: But that further evaluation, is that very specific questions about planning for suicide, how you do it, all of those things?

MS. SPRAGUE: You were also asked about evaluating the defendant for bipolar, and you said that she, based on your conversations with her, there were no signs of mania, correct?

MS. SPRAGUE: What are the types of questions you ask a patient to determine if they've experienced an episode of mania?

MS. SPRAGUE: And what would you see physically?

MS. SPRAGUE: Did you observe any of those behaviors with Lindsay Clancy?

MS. SPRAGUE: What do you mean it was the opposite?

MS. SPRAGUE: And in terms of the questions you asked about her past behavior, were any of the answers that she gave indicative of mania?

MS. SPRAGUE: You were asked about discussing Seroquel with the defendant, even though you weren't the prescriber. Why did you discuss that medication with her?

MS. SPRAGUE: And what did you tell them about it?

MS. SPRAGUE: What did you tell them in terms of how to tell?

MS. SPRAGUE: And prior to Ms. Clancy taking the Seroquel, had you—noticed signs of depression in her?

MS. SPRAGUE: And after she was off of the Seroquel, in January, did you see signs of depression in her?

MS. SPRAGUE: So that was completely off the Seroquel both before and after, still showing signs of depression?

MS. SPRAGUE: During January, the defendant told you she had trouble getting out of bed.

MS. SPRAGUE: I think it was right after the—she got out of the hospital. Maybe your first or second visit with her.

MS. SPRAGUE: Were you aware that she had gone to the Museum of Science with her family on January 8th and spent a few hours there interacting with the exhibits and the children?

MS. SPRAGUE: Were you aware on January 15th, the day before that session, she had been to the Cape Cod or down in Hyannis, with the family interacting with the kids and going down little water slides and all of that?

MS. SPRAGUE: Were you aware that on January 14th she watched all three kids while Pat went to a brunch and was fine?

MS. SPRAGUE: Were you aware that on January 16th, her husband took Cora skiing, and she was alone with the boys all day and had no issues?

MS. SPRAGUE: You were asked about the thyroid, and how that can affect mental health in postpartum. Were you aware that at both South Shore Hospital and Brigham and Women's Hospital her thyroid limits were in normal range?

MS. SPRAGUE: You received a discharge from—summary from McLean Hospital?

MS. SPRAGUE: What's contained in the discharge summary?

MS. SPRAGUE: Does it also include what medications they were prescribed and what the diagnosis might have been?

MS. SPRAGUE: And was that sufficient in terms of your review of the information that you needed to know about your patient at that time?

MS. SPRAGUE: Now, you were asked about your January 23rd, 2023, session with the defendant. Defense counsel asked if you had, you know, recommended a hospital evaluation for her on that day, and you said no. Why not?

MS. SPRAGUE: And during that session, did she ever tell you that she planned to harm herself or the children?

MS. SPRAGUE: If she had done that, what would you have done?

MS. SPRAGUE: You were asked by defense counsel about the amitriptyline that you prescribed on January 16th, 2023. That initial prescription was for 10 milligrams, correct?

MS. SPRAGUE: Showing the bottle from Exhibit 155 of amitriptyline. Would you agree with me that this shows that the prescription was filled on that same day, January 16th, 2023?

MS. SPRAGUE: And out of this pill bottle here, there were 30 pills in this prescription, correct?

MS. SPRAGUE: And there are only eight... There are eight pills missing from this bottle. So filled on January 16th, 16th, 17th, 18th, 19th, 20th, 21st, 22nd. 23rd would be eight days, correct?

MS. SPRAGUE: And on the 23rd is when you said she could raise it to 20 milligrams?

MS. SPRAGUE: So if there are only eight pills missing, she never took that additional dose, correct?

MS. SPRAGUE: So the amitriptyline, increasing it to, from 10 milligrams to 20 milligrams wouldn't have pushed her over the edge, correct?

MS. SPRAGUE: I have nothing further. Thank you.

MS. SPRAGUE: Objection.

MS. SPRAGUE: Objection. Didn't ask about those records.

MS. SPRAGUE: It's beyond the scope.

MS. SPRAGUE: No objection.

MS. SPRAGUE: I just wanna look at them at some point to make sure it's a clean copy.

MS. SPRAGUE: Objection. His writing on this.

MS. SPRAGUE: Yes.

MS. SPRAGUE: Just two brief questions. Approaching you with your records from October 21st, 2022, on the section labeled speech, where there are all the boxes where you can put pressured, worried, salad, all of the different things. What do you check off for speech on October 21st, 2022?

MS. SPRAGUE: And defense asked you about the thyroid levels. Would it be accurate to state that I asked you if you were aware that her levels were normal at South Shore Hospital and Brigham and Women's Hospital?

MS. SPRAGUE: And your answer was no, correct?

MS. SPRAGUE: 'Cause you don't have those records, correct?

MS. SPRAGUE: Thank you.

MS. SPRAGUE: Your Honor, the Commonwealth would move to submit the certified copy of the Spaulding rehabilitation records from the-