3.Julie Paul — Direct (Part 1)
493 linesMS. BUCKINGHAM: Should I call the next witness?
THE COURT: Yes, please, counsel.
MS. BUCKINGHAM: Commonwealth would call Julie Paul.
JULIE PAUL: Good afternoon.
BAILIFF: Stop right there. Raise your right hand for the court.
COURT CLERK: Good afternoon. Do you solemnly swear that the testimony and the evidence you shall give to the court and the jury in the matter now pending between the Commonwealth and the defendant at the bar shall be the truth, the whole truth, and nothing but the truth, so help you God? Thank you. You may have a seat.
BAILIFF: Watch your step, please.
JULIE PAUL: Thank you.
THE COURT: All right. Good afternoon.
JULIE PAUL: Good afternoon.
THE COURT: All right. Yes, Attorney Buckingham, please.
MS. BUCKINGHAM: Thank you. Good afternoon.
JULIE PAUL: Good afternoon.
MS. BUCKINGHAM: Could you please tell the jury your first and last name?
JULIE PAUL: Julie Paul.
MS. BUCKINGHAM: And what do you do for work?
JULIE PAUL: I am a psychiatric mental health nurse practitioner, board certified.
MS. BUCKINGHAM: And can you tell us a little bit about your educational background?
JULIE PAUL: Sure. I graduated in 1991 from St. Anselm College with my nursing degree, worked as a labor and delivery nurse for 17 years, and then graduated in 2006 from Frontier Nursing University with my midwifery degree. And then in 2018, I graduated from Frontier Nursing University with my psychiatric nurse practitioner degree. I also have a perinatal mental health certification from Postpartum Support International from 2018.
MS. BUCKINGHAM: Okay. Are you also a certified midwife?
JULIE PAUL: Yes, I am.
MS. BUCKINGHAM: And are you licensed in the state of Massachusetts to be a psychiatric nurse practitioner?
JULIE PAUL: Yes, I am.
MS. BUCKINGHAM: And what is required in order to, for you to become certified to be a psychiatric nurse practitioner in Massachusetts?
JULIE PAUL: I attended a certified program, did two years additional training, and then took the certification exam through the ANCC.
MS. BUCKINGHAM: And can you tell us a little bit about your work history, your work background?
JULIE PAUL: Sure. Like I said, in New Hampshire, I worked as a labor and delivery nurse before transferring to Massachusetts in 2006 to work as a certified nurse midwife. And then in 2018, I started the Perinatal Behavioral Health Program at South Shore Hospital as a psychiatric nurse practitioner.
MS. BUCKINGHAM: And so, the Perinatal Behavioral Health Clinic, explain to us a little bit about how that came about.
JULIE PAUL: Sure. There's a lack of resources on the South Shore for perinatal, for pregnant and postpartum people with mood disorders. So I really felt compelled because I had a couple clients that really struggled with mental health issues as a nurse midwife—
MS. BUCKINGHAM: Mm-hmm.
JULIE PAUL: …and really wanted additional education and be able to prescribe for them, so, and take care of them in a proper way. So I went back, got my psych NP, and then worked with South Shore Hospital to establish the program.
MS. BUCKINGHAM: And where was the program actually located?
JULIE PAUL: It was located right in Weymouth, Massachusetts.
MS. BUCKINGHAM: And you said you worked with the South Shore Hospital?
JULIE PAUL: Correct.
MS. BUCKINGHAM: So the clinic is tied to South Shore Hospital in the South Shore Health system?
JULIE PAUL: Yes, it is.
MS. BUCKINGHAM: Now, when did you start that program specifically? When was it up and running?
JULIE PAUL: 2018 is when I started, in October of 2018.
MS. BUCKINGHAM: Okay. And what—did you do that by yourself, or did you have other practitioners that were doing that with you?
JULIE PAUL: Initially it was just me. I started doing it two days a week and then grew the program gradually over the next year or two.
MS. BUCKINGHAM: And what makes up this program other than you?
JULIE PAUL: So at the time when it was just me, I just saw patients two days a week and then gradually built up to five days a week, and we included a therapist in the team, two additional prescribers. We also worked with women with substance use disorders as well, so we had additional support that way. And then when the building grew, we also had substance, the Bridge Clinic on the other side, and then we were on the other side of that program.
MS. BUCKINGHAM: And what's a Bridge, the Bridge Clinic?
JULIE PAUL: The Bridge Clinic works with people with substance use disorders.
MS. BUCKINGHAM: And all of this is kind of under that umbrella of what's classified as South Shore Behavioral Health, correct?
JULIE PAUL: That's correct.
MS. BUCKINGHAM: Now, as the clinic grew, did your role there change?
JULIE PAUL: I'm sorry. Can you repeat that?
MS. BUCKINGHAM: As the clinic grew to what you described as having additional therapists and other prescribers on staff, did your role there change at all?
JULIE PAUL: I became the director of the program.
MS. BUCKINGHAM: And as director of the program, did you still see patients?
JULIE PAUL: Yes, I did.
MS. BUCKINGHAM: And was that at the same level as it had before, or did it decrease because of your administrative roles?
JULIE PAUL: It actually increased 'cause I increased my hours to five days a week. I did have a little bit of administrative time.
MS. BUCKINGHAM: Okay.
MS. BUCKINGHAM: And can you tell us a little bit about how the clinic would work for a woman who is coming in either during the birth period or prior to birth and after birth? What kinds of things would they be offered at the clinic?
JULIE PAUL: So I'd receive a referral, and then the client would come in. We would do a 90-minute intake. When they left—when it was just me, it was—I was using outside therapists, that sort of thing. But as the program grew, we had moms groups run by doulas. We had therapists that we brought in that was brought in from Aspire, but part of our program, embedded within our program. And I brought in two additional prescribers as well as nursing staff.
MS. BUCKINGHAM: And when you talk about people as prescribers and your role as a psychiatric nurse practitioner who could prescribe, what were you offering to patients as part of this clinic as a prescriber?
JULIE PAUL: We were offering the proper medication for anxiety, depression, mood disorders, really any psychiatric disorder that came in, mostly for pregnant and postpartum people up to two years postpartum. We also offered, like, therapy, focused on sleep hygiene, really looked at the whole person, not just medication management.
MS. BUCKINGHAM: And fair to say that the medication is one piece and the therapy is another piece, and this is part of a team approach that you had at the clinic—
JULIE PAUL: That's correct.
MS. BUCKINGHAM: ... to address all these resources for patients?
JULIE PAUL: That's correct.
MS. BUCKINGHAM: So while you as the psychiatric nurse practitioner might have been a prescriber... were you also engaged in the therapy or psychotherapy?
JULIE PAUL: I would do supportive therapy, but I'm not a therapist. I mainly am responsible for assessing, diagnosing, prescribing, but I also really understand the importance of sleep, nutrition, and exercise.
MS. BUCKINGHAM: And so, being that you had a history of working as a midwife and working as a nurse in labor and delivery, do you have a lot of experience with moms or women who are in that postpartum period?
JULIE PAUL: Yes.
MS. BUCKINGHAM: And how about your experiences with diagnosing and prescribing for women in that period? Do you have experience in that?
JULIE PAUL: In the labor and delivery room as a nurse midwife, yes, I diagnosed, like, labor and that sort of thing, and even depression, anxiety, not to the extent of higher acuity psychiatric conditions.
MS. BUCKINGHAM: Mm-hmm.
JULIE PAUL: But as a psychiatric nurse practitioner, I did.
MS. BUCKINGHAM: Okay. And as far as your role at the Perinatal Behavioral Health Clinic, fair to say that your primary patient base was all gonna be women who are either pregnant or after birth?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And a part of this team approach at the clinic, is it also to work on developing a treatment plan for patients when they come in?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And so what encompasses a treatment plan generally?
JULIE PAUL: Generally, if it were a situation where we were referring them for therapy, then we would work with the therapist to kinda work... bring in the client to figure out what their needs are, and then really stress whatever. The therapist works on certain aspects of the therapy that the... We kind of work together, but in—not in tandem. Kinda, we talk, but not to the extent. We journey in our own disciplines.
MS. BUCKINGHAM: Okay. And as far as the resources that the clinic had available to you, is it fair to say that there are certain types of therapy, for instance, cognitive behavioral therapy or dialectic behavioral therapy, that are not necessarily encompassed in with the social workers that you work with at the clinic?
JULIE PAUL: Our social workers primarily did cognitive behavioral therapy. We did group therapy for more social support. What I did mainly was just supportive therapy.
MS. BUCKINGHAM: Okay. And would you oftentimes through the clinic refer clients out to other local community providers?
JULIE PAUL: Yes, we would.
MS. BUCKINGHAM: Now, as the psychiatric nurse practitioner, does medication play an important role when you are dealing with a particular patient that came into the clinic?
JULIE PAUL: Yes, it does play a role.
MS. BUCKINGHAM: And how is it that you determine what's the appropriate medication track for any given patient?
JULIE PAUL: We do proper screening, and then we do a complete interview with the client, and then based on what their responses are, together we work as a team to develop the best medication options or treatment options for that client.
MS. BUCKINGHAM: When you say work as a team, does that include the patient themselves?
JULIE PAUL: Absolutely. The patient is the most important part of the team.
MS. BUCKINGHAM: And in your training and experience working with postpartum women, what is the acceptable period for, to determine postpartum?
JULIE PAUL: Anywhere within the first year.
MS. BUCKINGHAM: Did you know a nurse, or do you know a nurse named Susan Clancy?
JULIE PAUL: I do.
MS. BUCKINGHAM: How do you know her?
JULIE PAUL: I worked with her off and on throughout my years as a nurse midwife.
MS. BUCKINGHAM: And what was—what's the nature of your relationship with her other than the working with her?
JULIE PAUL: Essentially, we just worked together. We worked—when we did births together, we worked well as a team.
MS. BUCKINGHAM: Okay. And do you know where she worked?
JULIE PAUL: She worked at Telshire Hospital.
MS. BUCKINGHAM: On November 20th of 2022, did you have a conversation or did you get a call from Sue Clancy?
JULIE PAUL: I did. She was received. She was referred to me through Nanette Landry, another midwife that I work with.
MS. BUCKINGHAM: Okay. And so as a result of the phone call that you had with her, did you get in contact with a woman by the name of Lindsay Clancy?
JULIE PAUL: Yes, I did.
MS. BUCKINGHAM: Was that the same day or a different day?
JULIE PAUL: It was the same day.
MS. BUCKINGHAM: And your contact with Lindsay Clancy, was it by phone or virtual or in person?
JULIE PAUL: It was by phone.
MS. BUCKINGHAM: And so what was the purpose of calling Lindsay Clancy?
JULIE PAUL: I just wanted to get her side of what had been going on with her history. Sue had alluded that she was struggling in the postpartum period, so I wanted to know exactly what she was struggling with to see if she'd be a good candidate for our program.
MS. BUCKINGHAM: So did you initiate the call to Lindsay Clancy?
JULIE PAUL: With the permission. I asked Sue Clancy if Lindsay had given permission. She said she had.
MS. BUCKINGHAM: Okay. And in the conversation that you had with her, do you know approximately how long that phone conversation lasted?
JULIE PAUL: I don't recall.
MS. BUCKINGHAM: Okay. But were you able to get all the pertinent information from her during the—that phone call?
JULIE PAUL: I got enough data to determine that she would be a good candidate for the program.
MS. BUCKINGHAM: So she would've met criteria for a referral from any other resource?
JULIE PAUL: Correct.
MS. BUCKINGHAM: Now, is it fair to say that in this conversation, in order to determine whether she qualified, you had to ask her some background questions?
JULIE PAUL: I did.
MS. BUCKINGHAM: And so were you able to identify whether she was in that postpartum period?
JULIE PAUL: Yes. I asked when the birth of Callan was, and she said it was May 26th, 2022.
MS. BUCKINGHAM: And so after determining that she was in fact postpartum, with a baby at home, did you ask her any questions or did you learn any information about how the experience was earlier in the postpartum right after birth?
JULIE PAUL: I did. She said she did really well for the first 12 weeks. She was excited, really happy. And then when Patrick went back to work, she said she started to struggle with some anxiety.
MS. BUCKINGHAM: And you knew Patrick to be her husband, Patrick Clancy?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And do you recall her indicating that she was having difficulty leaving the baby, that she was feeling overwhelmed and having racing thoughts?
JULIE PAUL: Yes.
MS. BUCKINGHAM: And so in your training and experience, are those things that you would hear from new moms?
JULIE PAUL: It was very typical of what I'd hear.
MS. BUCKINGHAM: Did you learn from her whether she had engaged with any other treatment prior to contacting or prior to you having this conversation with her?
JULIE PAUL: She did say that she had met with a psychiatrist. She didn't give the name, and then she'd also said that she had been in the emergency room a few days prior, too.
MS. BUCKINGHAM: Okay. And were you able to determine that was actually the South Shore Emergency Room?
JULIE PAUL: Yes, it was.
MS. BUCKINGHAM: And that would have been on November 16th of 2022?
JULIE PAUL: Correct.
MS. BUCKINGHAM: Now, in addition to seeing a psychiatrist, did she identify to you some medications that she had been taking up to that point?
JULIE PAUL: She did. She said she had trialed Zoloft for one week. She also said that she'd been trialing Ativan and Benadryl, which worked the best to help her sleep. She identified she had questions about Buspar. Didn't say specifically whether she had been prescribed that or not, but that she had questions about Buspar.
MS. BUCKINGHAM: Okay. And did she mention anything about that combination of Ativan and Benadryl in her treatment history that was of concern to her?
JULIE PAUL: Just that she had been taking it for two weeks. It worked really well, but then she was getting concerned about dependence, so she self-weaned herself off of that.
MS. BUCKINGHAM: And were you aware, did she tell you that she had been prescribed Trazodone after that?
JULIE PAUL: Yes. After she went to the emergency room, she was prescribed Trazodone.
MS. BUCKINGHAM: Did she indicate whether the Trazodone gave her any relief to her sleep issues?
JULIE PAUL: She said she was able to fall asleep but was having difficulty staying asleep.
MS. BUCKINGHAM: Did she also indicate to you that one of her goals was not to be on long-term medications?
JULIE PAUL: Yes, she did.
MS. BUCKINGHAM: And based on this initial phone conversation, did you recommend that she come in for an intake appointment?
JULIE PAUL: I did.
MS. BUCKINGHAM: Okay. How about the immediate need for sleep? Did you address that with her in the phone call?
JULIE PAUL: I just encouraged her to take the medication that she already had on hand, that if the Benadryl and the Ativan were working, she should take that to help her sleep that night, and we'd talk the next morning about different options.
MS. BUCKINGHAM: And also in this initial phone call, did you have a conversation with her about options and risks of various types of SSRIs or continued use of benzodiazepines?
JULIE PAUL: Yes, we reviewed that. Being on SSRI most of the time is preferable than being on benzodiazepines for long periods of time, especially to address her concern about addiction or dependency on the medication.
MS. BUCKINGHAM: Okay. And is this kind of a normal conversation you would have with somebody to screen them and determine whether the clinic, the South Shore Perinatal Clinic, was an appropriate fit?
JULIE PAUL: Yes. It's more to establish rapport and get a basic understanding and make sure that she was safe.
MS. BUCKINGHAM: Okay.
JULIE PAUL: And she did indicate that she was safe.
MS. BUCKINGHAM: And so that's kind of my follow-up to that. So in the course of that phone call, you were able to communicate with her, correct?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And what she was telling you about her reported history, did that seem to make sense to you?
JULIE PAUL: Yes, it did.
MS. BUCKINGHAM: And did you identify or were you addressing or assessing during the whole course of this conversation whether there was any immediate safety risk or need for her?
JULIE PAUL: Yes, I was.
MS. BUCKINGHAM: And did you find that there was any?
JULIE PAUL: There was no immediate need.
MS. BUCKINGHAM: Now, as a result of this conversation, did you determine whether she was having any suicidal ideations?
JULIE PAUL: Yes. I asked her specifically if she felt like she wanted to harm herself or her children, and she said no.
MS. BUCKINGHAM: And how about asking her about homicidal ideations?
JULIE PAUL: Yes.
MS. BUCKINGHAM: And did she indicate whether she had any?
JULIE PAUL: She did not.
MS. BUCKINGHAM: Did you also ask her whether she had experienced any auditory hallucinations?
JULIE PAUL: I did.
MS. BUCKINGHAM: And did she experience any?
JULIE PAUL: Not at the time, no.
MS. BUCKINGHAM: And did she indicate to you whether she'd ever experienced any?
JULIE PAUL: No.
MS. BUCKINGHAM: How about visual hallucinations? Did you ask her about those?
JULIE PAUL: I did.
MS. BUCKINGHAM: And did she indicate that she had experienced any?
JULIE PAUL: No.
MS. BUCKINGHAM: And delusions. Did you ask her whether she had any delusions?
JULIE PAUL: I didn't ask specifically about delusions, I believe.
MS. BUCKINGHAM: Okay. And in the course of talking with an individual, do you kind of constantly keep that in mind with what they're telling you, whether they're having any ideas or, of delusion?
JULIE PAUL: Yes, I do.
MS. BUCKINGHAM: In the conversation you had with her on November 20th, did you identify, based on your conversation with her, whether she was experiencing delusions?
JULIE PAUL: No, I did not.
MS. BUCKINGHAM: And fair to say, a standard set of questions that you also ask have to do with drug use or tobacco or alcohol. Did you ask those questions as well?
JULIE PAUL: I don't recall.
MS. BUCKINGHAM: Okay. If I were to show you your note, would that refresh your memory?
JULIE PAUL: I have my notes right here. I could look at it.
MS. BUCKINGHAM: Okay. I'm gonna draw your attention to the note from November 20th of 2022.
JULIE PAUL: Yes, I did ask her apparently. And she said no to illicit drug use, tobacco or marijuana or alcohol at that time.
MS. BUCKINGHAM: Okay. And she also indicated to you that at this time on November 20th, that she had stopped breastfeeding?
JULIE PAUL: That's correct.
MS. BUCKINGHAM: Now did she schedule or did you schedule with her an intake for the next day, November 21st?
JULIE PAUL: We did.
MS. BUCKINGHAM: And at the clinic, what generally is the practice for whether a person appears in person or on a telehealth visit or virtually?
JULIE PAUL: Generally speaking, we like to do the intake in person if, as long as it's feasible. And for her it was.
MS. BUCKINGHAM: Okay. And just kind of while we're on that topic, going forward with a patient who's being seen at the clinic, what are the criteria to determine an in-person visit or a telehealth visit?
JULIE PAUL: They're given the option about what works best for them.
MS. BUCKINGHAM: And are there instances where you as a provider might insist a person comes in in-person?
JULIE PAUL: If somebody needs to do like a urine drug screen or laboratory work, we'll have them come in, or if they seem to be not making sense or having more difficulties, we'll have them come in in-person.
MS. BUCKINGHAM: And if a person is scheduled for an in-person visit and there are no observed issues on your end, can they opt to change it to a virtual appointment at any point?
JULIE PAUL: Yes.
MS. BUCKINGHAM: Okay. And that's just the normal course of business at the clinic?
JULIE PAUL: Correct.
MS. BUCKINGHAM: Now, in this particular instance, you said the intake was in person, right?
JULIE PAUL: Yes.
MS. BUCKINGHAM: And during the course of the intake, are there particular types of questions that are asked of the person to get to know them and get to know their situation?
JULIE PAUL: Yes. Generally, we do a full intake. She... The first thing they do is meet with the nurse, who does all the screenings.
MS. BUCKINGHAM: And one of the things that is asked of an individual when they come in is to tell you why they are there, right?
JULIE PAUL: Correct.
MS. BUCKINGHAM: What their complaint is.
JULIE PAUL: Yes.
MS. BUCKINGHAM: And so for this patient, for Lindsay Clancy, what did she identify as the reason for the visit?
JULIE PAUL: Would it be okay if I refer to my note?
MS. BUCKINGHAM: Sure.
JULIE PAUL: So she said, “Pretty much I cannot sleep,” was her major concern.
MS. BUCKINGHAM: Okay. And is that something that you've seen in your experience with new moms, that come through the clinic and are postpartum?
JULIE PAUL: It's very typical.
MS. BUCKINGHAM: Now even with that report or that reason, do you do a full history to try to identify kind of what's going on in the present and what has happened in the past?
JULIE PAUL: Yes, I do.
MS. BUCKINGHAM: And generally, is it fair to say that's kind of the goal of an intake, right? Is-
JULIE PAUL: I do that with every client. I have a standard set of questions.
MS. BUCKINGHAM: Is that just for the intake or any follow-up?
JULIE PAUL: Any follow-up I have a basic kind of script, but I always adjust it based on what they're saying.
MS. BUCKINGHAM: Okay. But fair to say once a person gives kind of that history of their background, especially if they've had prior births before, prior experiences with mental health professionals or psychiatric history, that that kind of follows the patient as they go through with their subsequent visits?
JULIE PAUL: Yes.
MS. BUCKINGHAM: So in this instance, you had some background information from the phone call you had with her, but did you go back through those standard questions that you'd ask in an intake?
JULIE PAUL: I did.
MS. BUCKINGHAM: And did you learn a little bit more about—
MS. BUCKINGHAM: About her current mental status? Did you ask her some questions about currently how she was at, in this November 21st meeting?
JULIE PAUL: I did.
MS. BUCKINGHAM: And so, again, do you kind of go through in each and every instance whether the person has any thoughts of suicide or harming themselves or others?
JULIE PAUL: At every visit, those are standard questions that I ask if they have any type of suicidal, homicidal ideation or auditory or visual hallucinations.
MS. BUCKINGHAM: Do you ask the same questions each time, or is it kind of fluid based on your rapport and conversation with the patient?
JULIE PAUL: Generally, I try and touch upon the topic. Sometimes we get to that answer indirectly just by the line of questioning that we're using.
MS. BUCKINGHAM: Okay. And where... It had been reported to you that she had been on the Zoloft and stopped due to insomnia, that she was overwhelmed and her mind was racing. Did you talk with her about intrusive thoughts?
JULIE PAUL: I did.
MS. BUCKINGHAM: And did she indicate whether at that point she was having any intrusive thoughts of harming herself or her babies?
JULIE PAUL: She was not.
MS. BUCKINGHAM: Did she report to you how she was feeling at home with having now three children to take care of?
JULIE PAUL: She was feeling overwhelmed.
MS. BUCKINGHAM: And that, again, reiterating that around 12 weeks when Patrick went back to work, that she was having increased anxiety?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And did she indicate to you that that was something that she had experienced to some extent with her other two children?
JULIE PAUL: At least with her second pregnancy.
MS. BUCKINGHAM: And was she able to manage that with her second pregnancy without medication?
JULIE PAUL: As far as what I was told, yes.
MS. BUCKINGHAM: And fair to say she indicated that she would use breathing, meditation, and yoga to work through it?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And so on this November 21st intake date, you again ask about drug use, right?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And at this point, she had told you that she had—did trial one CBD gummy at some point, but that did not help?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And you also learn about any prior psychiatric medications she had been on?
JULIE PAUL: Yes. She had been on the Zoloft, the Ativan. She had been prescribed Buspar, but she hadn't as ... She didn't indicate whether she had taken that or not.
MS. BUCKINGHAM: Okay. And so that was her report of her most recent course of treatment. But did she talk about having anxiety issues—
JULIE PAUL: Yes.
MS. BUCKINGHAM: ... further back in her history?
JULIE PAUL: Yes. In college she had trialed Prozac, Propranolol, and Wellbutrin.
MS. BUCKINGHAM: And fair to say she indicated that, to you, that she did well on those medications in nursing school?
JULIE PAUL: That's correct. With the only side effect being sexual side effects.
MS. BUCKINGHAM: Did you talk to her at this point in November 20, on November 21, excuse me, 2022, about whether she had a plan to go back to work?
JULIE PAUL: I don't know if that was the specific day. I know that we talked about work at a different date.
MS. BUCKINGHAM: Okay. If you have your note in front of you, I just draw your attention to maybe the last paragraph of the history of present illness.
JULIE PAUL: Oh, I'm sorry. And you're talking about the day of the intake?
MS. BUCKINGHAM: Yes. Sorry.
JULIE PAUL: Sorry, I thought you said the 22nd. So yeah, she had planned to go back to work in October, but it got delayed. She pushed it forward to November because she was having anxiety.
MS. BUCKINGHAM: Okay. And during the course of this intake, again, you did those same mental status screens for any concerns, right?
JULIE PAUL: Correct.
MS. BUCKINGHAM: Did you note any in this face-to-face, in-person meeting with her?
JULIE PAUL: No, she was goal-directed, linear. She was a great historian. Actively participated in the care plan.
MS. BUCKINGHAM: And as far as some of the screenings that you do during these visits, for a person who is in that postpartum period, are there any specific screenings that you do?
JULIE PAUL: Yes. We do the postnatal—the Edinburgh Postnatal Depression Scale. We did the GAD, which is the Generalized Anxiety Depression Scale. We did the Mood Disorders Questionnaire Scale, the Colombian Suicidal Scale, as well as the five Ps, which assesses for substance use disorders in pregnancy and postpartum.
MS. BUCKINGHAM: And so as far as in each one of those screens, what did you find as it pertained to this particular patient?
JULIE PAUL: She was significantly high in the GAD-7, which is for generalized anxiety. She scored twenty-one out of twenty-one, which is indi— They're just screening, so it's not diagnostic, but it did indicate that she was experiencing extreme anxiety or— And then with the Edinburgh Postnatal Depression Scale, she scored a twenty-three out of thirty. But the one that I look for the most in that scale is number ten, and she was negative, and that's for suicidality.
MS. BUCKINGHAM: Okay. And so why is it that you look at that one in particular? Or why do you consider that most?
JULIE PAUL: Because that shows significant depression, especially if they have thoughts of harming themselves.
MS. BUCKINGHAM: Is it fair to say that that Edinburgh scale, it also could fluctuate with a postpartum mom, depending on their situation?
JULIE PAUL: Yes.
MS. BUCKINGHAM: And in the other screens that you performed, did you identify whether there was any substance use issues?
JULIE PAUL: No, there wasn't.
MS. BUCKINGHAM: Now, once you were able to kind of gather all this information from her and do these screenings, were you able to come up with an assessment and a plan for how to help
MS. BUCKINGHAM: Her?
JULIE PAUL: Yes. She-
MS. BUCKINGHAM: And what was going to be the plan with Ms. Clancy?
JULIE PAUL: So we had discussed starting Prozac.
MS. BUCKINGHAM: Okay. And is that... Or why Prozac? Why start there?
JULIE PAUL: Because she'd had a history of being successful on it in the past, and that's a good indicator that instead of trying multiple medications, to start with the ones that actually work. So I gave her ten milligrams for the first four days to make sure there were no adverse reactions, and then I gave her... I was gonna increase her to twenty milligrams if she tolerated that well.
MS. BUCKINGHAM: Okay. And what about some of the medications that she had already, that she was already on, the Ativan and Benadryl and the Trazodone? Did you have a plan for those?
JULIE PAUL: I did. So I encouraged her to take the Ativan. So when Prozac can sometimes be very activating, it can make the anxiety worse before it gets better when you first start it. So I wanted to pair it with the Ativan just in the beginning, just to help her be more comfortable with the anxiety and to make sure that it didn't interfere with her sleep.
MS. BUCKINGHAM: And as far as Prozac goes, what kind, what class of medication is it?
JULIE PAUL: It's an SSRI, a selective serotonin reuptake inhibitor.
MS. BUCKINGHAM: Is it commonly prescribed to treat people with depression?
JULIE PAUL: Yes, it is a first-line treatment.
MS. BUCKINGHAM: You said first-line treatment?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And the idea of pairing a particular medication like an SSRI with another medication, is that a fairly common practice with psychiatric medications?
JULIE PAUL: Yes.
MS. BUCKINGHAM: As far as the... You mentioned that sometimes symptoms could get worse before they get better. Is that also common with SSRIs?
JULIE PAUL: Yes, it is.
MS. BUCKINGHAM: Does it take a while for a medication to get into a person's system and stabilize them?
JULIE PAUL: Generally, side effects are the first week or two, but to get to a therapeutic level, it's about four to six weeks.
MS. BUCKINGHAM: And was this something that you discussed with her about the timetable it would take to reach a therapeutic level?
JULIE PAUL: Yes.
MS. BUCKINGHAM: And when we say therapeutic level, what's the goal of reaching therapeutic level?
JULIE PAUL: Is remission in symptoms.
MS. BUCKINGHAM: People start to feel better then, right?
JULIE PAUL: Correct.
MS. BUCKINGHAM: Now, even though you were advising that she continue with the Ativan, and she had told you that there—she had concerns about continuing with the benzodiazepine, did you indicate that there would be a plan to taper that or reduce that?
JULIE PAUL: Yes. Once the activating symptoms went away, then we would look at reducing that and moving away from the Ativan and moving more towards, like, a Buspar.
MS. BUCKINGHAM: Okay. And as far as talking about that plan and what the risks and benefits of that plan were, did she appear to understand and engage in conversation with you about that?
JULIE PAUL: Yes, she verbally understood and said that she understood the instructions.
MS. BUCKINGHAM: Did she ask the appropriate questions or follow up?
JULIE PAUL: Yes, she did.
MS. BUCKINGHAM: And as far as kind of overall what the plan was moving forward, was medication the only recommendation that you were making, or did you have other recommendations for her?
JULIE PAUL: No, I set her up with talk therapy with Latiesha Dukes as well.
MS. BUCKINGHAM: Sorry. When you say talk therapy, what do you mean by that?
JULIE PAUL: So coming in and actually doing cognitive behavioral therapy with a clinician, someone who is trained in this.
MS. BUCKINGHAM: And so you mentioned Latiesha Dukes?
JULIE PAUL: Correct. She was the clinician in our program at the time.
MS. BUCKINGHAM: And when you make this recommendation and this intake visit, do you work with the patient to schedule something before they leave, or is it up to them to schedule the time with the social worker?
JULIE PAUL: It was set up with her before she left, I believe.
MS. BUCKINGHAM: Okay. And you're aware that the first appointment, scheduled appointment with Latiesha was for December 2nd?
JULIE PAUL: Correct. I believe because it was a holiday week that week.
MS. BUCKINGHAM: Okay. Now, this time that you were with Ms. Clancy during this initial intake, fair to say it was approximately 60 minutes?
JULIE PAUL: Yeah. She spent 30 minutes with my nurse and 60 minutes with myself.
MS. BUCKINGHAM: So she was there for an hour and a half?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And is that normal time period that you allot for people coming in for intakes?
JULIE PAUL: Yes.
MS. BUCKINGHAM: And as far as follow-up with you as the clinician and prescriber, was there a plan set for when she was going to return?
JULIE PAUL: Yes, we had established a return in two weeks.
MS. BUCKINGHAM: Now, at this point, because you had made that initial contact with her and you had done this intake, was she going to be assigned to you as a patient?
JULIE PAUL: This was gonna be a short-term arrangement. I was already in the process of leaving the program at the time.
MS. BUCKINGHAM: Had that been communicated to her?
JULIE PAUL: I don't recall.
MS. BUCKINGHAM: Okay. And as far as what your plan was, how long were you remaining at the practice?
JULIE PAUL: I was at the practice until mid-December.
MS. BUCKINGHAM: So this was, like, a pre-planned, um-
JULIE PAUL: I was moving back to New Hampshire, yes.
MS. BUCKINGHAM: But as far as the preliminary care, did you continue on with Lindsay as a patient?
JULIE PAUL: No. I transferred her care on November 30th, and I communicated with that to Lindsay.
MS. BUCKINGHAM: Okay. So, as far as after the intake, she was provided with that December 2nd vide- excuse me, intake or meeting with Latiesha Dukes, the social worker, and then the next scheduled event would have been December 7th, right? Tech- for a follow-up.
JULIE PAUL: She had a... I believe, I don't recall the actual, what her next follow-up with me was. I don't recall that date. But she did have a follow-up with Rebecca Jollotta.
MS. BUCKINGHAM: Okay. Prior to you communicating November 30th that you were transferring her care, did you have further contact with Lindsay Clancy?
JULIE PAUL: Yeah, we had a few phone calls and MyChart messages going back and forth.
MS. BUCKINGHAM: Can you just explain to the jury what the MyChart messaging system is in your practice?
JULIE PAUL: It's kind of a chat feature between the client. They can reach out directly to the provider. It goes right to our inbox, and we can talk back and forth between visits.
MS. BUCKINGHAM: And do you encourage patients when they come in, in that first meeting, to utilize the MyChart messaging system?
JULIE PAUL: I do. Often, it's the quickest way to get ahold of me if they're experiencing any major issues.
MS. BUCKINGHAM: And fair to say it's just an easy way in between visits to communicate particular points of information or concerns or symptoms?
JULIE PAUL: Yes.
MS. BUCKINGHAM: Do you in your practice often use MyChart messages, if you're not available to meet with a patient, to make changes to their treatment plan?
JULIE PAUL: Occasionally, yes.
MS. BUCKINGHAM: Now, prior to your first MyChart message with Lindsay Clancy, did you get a text message from her on your personal phone?
JULIE PAUL: I don't recall.
MS. BUCKINGHAM: Okay. Do you recall whether Sue Clancy provided your number to Lindsay?
JULIE PAUL: I know I did. So she must have... She had my number because I called her from my direct, my personal phone call, 'cause it was on a Sunday when I reached out to her initially.
MS. BUCKINGHAM: So that November 20th phone conversation was a communication between you and her on your personal phone?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And so do you recall on November 22nd getting a message from her saying, “Hi, Julie. This is Lindsay Clancy. I'm sorry to contact you like this, but when you have a minute, can you please call?”
JULIE PAUL: I can't recall whether that was a MyChart message or if that was on my personal phone. I apologize.
MS. BUCKINGHAM: That's okay. As a result of some way her contacting you, did you then have a, or send her a message or have a conversation with her on November 23rd?
JULIE PAUL: I know we communicated on the 22nd. I sent a message saying... That was the day she was getting nervous about starting the Prozac, so we encouraged her to go ahead and start the Prozac. I know we communicated on the 23rd either by phone or by MyChart message that indicated that she had taken the medication. She had started it on the 22nd.
MS. BUCKINGHAM: Okay. And were you aware at this time period that she was currently already a patient in the South Shore Health System network with a primary care physician named Margaret Anastasi?
JULIE PAUL: Yes.
MS. BUCKINGHAM: And she's a nurse practitioner, right?
JULIE PAUL: Correct.
MS. BUCKINGHAM: Now, as far as these concerns that she relayed to you about starting the Prozac, do you know whether she did start the Prozac?
JULIE PAUL: Yes, that she started the Prozac on the 22nd of November.
MS. BUCKINGHAM: Okay. And by November 25th of 2022, did you start having some MyChart communications with Lindsay Clancy?
JULIE PAUL: I did.
MS. BUCKINGHAM: And so just referring first to November 25th of 2022, fair to say that you gave her or sent her a MyChart message encouraging to kind of stick with the plan, right?
JULIE PAUL: Correct. Prior to that, yes.
MS. BUCKINGHAM: At that point, had you prescribed her something to help her sleep outside what you had previously provided or outside what she had?
JULIE PAUL: Before November 25th, I did not.
MS. BUCKINGHAM: Okay. So on November 25th, did you prescribe her some additional medications?
JULIE PAUL: I did. So she wasn't tolerating the Prozac, so we had a conversation about stopping the Prozac. I gave her... She was really having a hard time sleeping, so I gave her a one-time dose of Ambien, and then I also prescribed mirtazapine, which is another antidepressant, but it works really good for sedation and anxiety. So started that at 7.5 milligrams, told her to stop the Prozac, and I also paired it with Klonopin. But I told her explicitly not to take the Ativan, just to take the Klonopin to help... It's longer acting benzodiazepine to help her with sleep and longer acting anxiety support while we got this new medication up and running.
MS. BUCKINGHAM: And so in your conversations with her about her concerns about the Prozac, fair to say she reported to you that she was feeling disconnected, out of it, a little bit spacey. Does that sound right?
JULIE PAUL: Yes, that's correct.
MS. BUCKINGHAM: And so you said your recommendation at that point was to discontinue the Prozac.
JULIE PAUL: Correct.
MS. BUCKINGHAM: And as far as the Prozac went, she hadn't taken it for very long, had she?
JULIE PAUL: She took it for three days.
MS. BUCKINGHAM: Three days?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And again, you had that conversation with her about kind of waiting it out for the four to six weeks, but based on what she was reporting to you, did you have any concerns about her stopping the Prozac after only three days?
JULIE PAUL: She... When a client doesn't have buy-in to the medication, it's awful. It doesn't work as well. So I was working with Lindsay to try and find a medication that would make her feel more comfortable. She was feeling very uncomfortable, very anxious, and the Prozac, she just wasn't tolerating the activation from the Prozac. So mirtazapine is a little bit more calming, which I thought she would resonate with better.
MS. BUCKINGHAM: Okay. And so again, this is not one of those follow-up visits on a telehealth or a face-to-face. So were you relying heavily on what she was reporting to you?
JULIE PAUL: Yes.
MS. BUCKINGHAM: And again, in that MyChart message, you did indicate to stop the Prozac, Benadryl, and Ativan, and don't take while taking Klonopin, right?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And in your practice as a psychiatric nurse practitioner who prescribes medication, is it common that you have to kind of trial different medications to find the right one to work for any given patient?
JULIE PAUL: Yes, it's pretty common practice in psychiatry.
MS. BUCKINGHAM: And fair to say there's no way to anticipate how a particular patient is gonna respond to any particular treatment, medication treatment?
JULIE PAUL: Correct.
MS. BUCKINGHAM: So after prescribing the Klonopin, Klonopin, the mirtazapine, and giving her that single dose of Ambien, did you do anything or set anything up to follow up with her after changing those prescriptions?
JULIE PAUL: I just told her to keep... She can MyChart message me over the weekend. It was the holiday weekend.
MS. BUCKINGHAM: Okay.
JULIE PAUL: So I made sure she knew I was available to answer her questions.
MS. BUCKINGHAM: And fair to say she did, in fact, MyChart, send you MyChart messages over the course of that weekend, correct?
JULIE PAUL: She did, yes.
MS. BUCKINGHAM: And so, starting at 7:51 on November 26th, she reported to you kind of how that night went, didn't she?
JULIE PAUL: Yes.
MS. BUCKINGHAM: Where she said, "I did better last night. I took 7.5 mirtazapine and .5 Klonopin at bedtime. Slept fairly well on and off until 3:45." And then she asked, "Do you think increasing the mirtazapine will help me stay asleep longer? I can survive like this, but would be helpful to get to sleep until at least 5:00. Thoughts? Thank you. Lindsay."
JULIE PAUL: Yes.
MS. BUCKINGHAM: Did you respond to that message?
JULIE PAUL: I did.
MS. BUCKINGHAM: And what did you advise her to do when she asked about increasing the mirtazapine and wanting to stay asleep longer?
JULIE PAUL: I said she could trial the 15 milligrams.
MS. BUCKINGHAM: And again, is that something that is common for you to do in prescribing, that maybe you have to adjust the dosage?
JULIE PAUL: Yes.
MS. BUCKINGHAM: Did you have any concerns that increasing the mirtazapine up to 15 would've had any issues or problems?
JULIE PAUL: No.
MS. BUCKINGHAM: And then again, on November 27th, you had a correspondence with her starting at 9:59 AM, where she again reports to you how she did that night. Is that something you encourage her to do, to just give you a nightly or, like, a follow-up the next day, check in to let you know how she was or what she was experiencing by way of symptoms?
JULIE PAUL: I do that with a lot of clients that are really anxious. I like to make myself available to them so that they have that reassurance.
MS. BUCKINGHAM: Okay. So this wasn't, this wasn't kind of unexpected?
JULIE PAUL: It wasn't out of the ordinary for me.
MS. BUCKINGHAM: And so on the 27th, she indicated she slept well taking the 15 of mirtazapine and the .5 Klonopin. "Feel rested but super disconnected with myself and reality," and describes it was a scary feeling. "Thinking of stopping Klonopin tonight and just taking the mirtazapine." Do you recall that—
JULIE PAUL: I do.
MS. BUCKINGHAM: …communication? And she acknowledges that, "I've only taken it two nights, so that it should, so that should be right, okay?" Or, sorry, "I've only taken it two nights, so that should be okay, right?" Do you recall her asking that?
JULIE PAUL: She's referring to the Klonopin, and yes, she did. She was really anxious about being dependent on benzodiazepines, so I think her goal was to not be on them. And if she was gonna… She, the disorientation might have been because of all the sedation from the mirtazapine, which is a common side effect, which is why we chose that, and she knew that. And adding the Klonopin, maybe removing that might have helped with some of the sedative factors for it.
MS. BUCKINGHAM: So did you find there to be any issues with stopping the Klonopin or her deciding not to take it after two days?
JULIE PAUL: No, I did not.
MS. BUCKINGHAM: And in fact, you indicated and told her that would, that should help with the disorientation, right?
JULIE PAUL: Yes, it might.
MS. BUCKINGHAM: Okay. And so that was on November 27th. And…
MS. BUCKINGHAM: Fair to say that there was another communication via MyChart on November 28th with Lindsay Clancy?
JULIE PAUL: Yes, there was.
MS. BUCKINGHAM: And at this point she was asking for, or there was some back and forth about needing a note for work, correct?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And is that something that you had talked about with her about getting another note for work?
JULIE PAUL: Yes.
MS. BUCKINGHAM: Okay.
JULIE PAUL: That's what I do that often.
MS. BUCKINGHAM: And in fact, you kind of went back and forth with her and ultimately she said never mind, that she didn't qualify for short-term disability anymore, and she's just gonna be on personal leave.
JULIE PAUL: Correct.
MS. BUCKINGHAM: So on the 28th, there was no back and forth about her taking the medicine and the effects or how she was feeling?
JULIE PAUL: She actually had a panic attack earlier in the day before those communications about work, and I recommended she take .5 of Ativan and go for a run. And I also recommended that she consider doing the partial hospitalization program at Women and Infants.
MS. BUCKINGHAM: And what was her response to the recommendation for the partial hospitalization program?
JULIE PAUL: At that time, she felt it wasn't gonna work logistically for her or her family.
MS. BUCKINGHAM: Okay. And why did you recommend maybe going for a run?
JULIE PAUL: To get rid of some of the adrenaline from the anxiety, and running has been a really good thing for her in the past, and I thought it would help calm her down.
MS. BUCKINGHAM: Okay. Now on November 29th of 2022, that was the first day that she actually met with Rebecca Jollotta, but you had some conversation with her, or she sent you a message, I should say, earlier in the day, correct?
JULIE PAUL: She sent me a message earlier in the day, and at that time I wasn't working that day, and Rebecca had an opening, so I offered the appointment with Rebecca for her. So I then didn't actually communicate with her that day.
MS. BUCKINGHAM: Okay. But you did receive her message at 6:05 AM, where she reported that at that point she took 15 Remeron and CBD and it only worked slightly?
JULIE PAUL: Correct.
MS. BUCKINGHAM: So how did you get from what you have told us now was the mirtazapine, or is that... That's Remeron, right?
JULIE PAUL: Correct.
MS. BUCKINGHAM: How do we get from just the mirtazapine with not the other, the Klonop- without the Klonopin or without some other—
JULIE PAUL: The Klonopin was an as-needed medication.
MS. BUCKINGHAM: Okay.
JULIE PAUL: So I honored her choice to be able to decide whether she wanted to take that or not.
MS. BUCKINGHAM: Okay. So after this panic attack, after the communication about the work form, she reports the next morning that she took the 15 of the mirtazapine or Remeron, and then she was having some sleep issues, right?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And that she tried breathing meditation and muscle relaxation, but that she ended up having to take the Ativan?
JULIE PAUL: Correct.
MS. BUCKINGHAM: Now, had you had any conversation with her in this back and forth in these MyChart messages about whether Ativan was something that she should continue to take?
JULIE PAUL: It was understood that she wouldn't take it unless, until I had that conversation with her. I was under these understanding that she wouldn't be taking it while taking the Klonopin.
MS. BUCKINGHAM: But she had told you she wanted to discontinue the Klonopin?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And so you said as of November 30th that you had then fully transferred care?
JULIE PAUL: I let her know that I would be leaving the clinic, and I thought it would be best if she saw a clinician that was working five days a week.
MS. BUCKINGHAM: And Rebecca Jollotta, is she a clinician that works at the clinic?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And had you worked with her for quite some time?
JULIE PAUL: She had been at the clinic, I think, for two years, I believe, at the time.
MS. BUCKINGHAM: And you said that you had recommended on the day before, on the 29th, that she set up that meeting with Rebecca because she was available?
JULIE PAUL: Correct.
MS. BUCKINGHAM: So it just was kind of happenstance that she ended up with Rebecca, or...
JULIE PAUL: I was in the process of transferring all of my patients between Rebecca and our new hire. And Rebecca was an experienced clinician, so I felt she would be a better match for Lindsay.
MS. BUCKINGHAM: Okay. And as far as when you sent or communicated to Ms. Clancy that you were transferring her care, that was via MyChart message, right?
JULIE PAUL: Correct.
MS. BUCKINGHAM: And Lindsay then responded to you. Or do you recall if she responded to you? I'm sorry.
JULIE PAUL: She did respond to me saying, "Thank you for the care that I provided." She appreciated it and wished me luck.
MS. BUCKINGHAM: Okay. Did you have any other contact with Lindsay Clancy after that point?
JULIE PAUL: No, I did not.
MS. BUCKINGHAM: And just to be clear, so when we were talking about moving from November 28th to the 29th in time, did you have a phone call with her outside the MyChart messages about that panic attack? Or do you recall having, entering a progress note about that?
JULIE PAUL: I do remember entering a progress note about that.
MS. BUCKINGHAM: Okay.
JULIE PAUL: And that's when I told her to go for the run and made the recommendation for the PHP.
MS. BUCKINGHAM: Did you ever have any further contact with Sue Clancy about Lindsay Clancy's care after that first contact on November 20th, 2022?
JULIE PAUL: I don't recall that.
MS. BUCKINGHAM: I have no further questions at this time.
THE COURT: Counsel, can I see you at sidebar?
THE COURT: All right. You may step down. Thank you.
THE COURT: All right. Well, members of the jury, just a couple minutes here. So we're gonna break. The Commonwealth is finished on their direct. We're gonna start with the cross-examination of this witness, but we're gonna start that tomorrow. All right? So we're gonna break till tomorrow. Remember my instructions. Don't talk about this case. Don't read about this case or even similar cases in regards to this. Don't read anything. Don't take any field trips. Don't do any research. You kinda know what the instructions are. I'm gonna ask you those questions. I will come in. We might start... I'd ask you to be here ready to go at 9:00. There may be an issue I have to talk to counsel. It might cause a little bit of a delay, but we'll try and keep that minimized. We'll get you in here tomorrow. Okay? Great. Thank you for all your work, and I hope you're nice... Have a nice evening. We'll see you tomorrow.
BAILIFF: All rise.
BAILIFF: Jurors, would you please follow me?
BAILIFF: Jurors have exited the courtroom. This court's in session. Please be seated.
THE COURT: All right. Anything else we need to address the court?
THE COURT: All right. Thank you. So the plan will be to start tomorrow. Before we bring the jury back in, my plan would be to address the defendant's motion for that additional witness. We could maybe do that first thing, and then after we... I do that, go right back into the presentation evidence. All right? All right. All right. Thank you, everyone. Thank you.
BAILIFF: Court, all rise.