3.Rebecca Jollotta — Direct (Part 1)
1,445 linesMS. BUCKINGHAM: The Commonwealth would call Rebecca Jollotta as its next witness please.
BAILIFF: Good morning, ma'am. Step right there and raise your right hand for the clerk please.
COURT CLERK: Good morning. Do you solemnly swear that the testimony you're gonna give in this courtroom will be the truth, the whole truth, and nothing but the truth, so help you God?
REBECCA JOLLOTTA: I do.
COURT CLERK: Thank you. You may be seated.
BAILIFF: Watch your step please.
THE COURT: Hey, good morning.
REBECCA JOLLOTTA: Good morning.
THE COURT: I'm gonna ask you to keep your voice up and speak into that microphone, all right?
REBECCA JOLLOTTA: Okay. Yes, Your Honor.
THE COURT: All right. Yes. Attorney Buckingham please.
MS. BUCKINGHAM: Thank you. Good morning.
REBECCA JOLLOTTA: Good morning.
MS. BUCKINGHAM: Could you please tell the jurors your first and last name?
REBECCA JOLLOTTA: Rebecca Jollotta.
MS. BUCKINGHAM: And how do you spell your last name for the record?
REBECCA JOLLOTTA: J-O-L-L-O-T-T-A.
MS. BUCKINGHAM: And what do you do for work?
REBECCA JOLLOTTA: I'm a psychiatric nurse practitioner.
MS. BUCKINGHAM: And what kind of training and education did you do in order to become a psychiatric nurse practitioner?
REBECCA JOLLOTTA: Thank you. I have my bachelor's degree from the University of Connecticut in Allied Health Sciences. I then went on to get my master's actually in counseling psychology in 2013 from William James College in Newton. I worked in the mental health field as a clinician in various positions for a time. Then I went back to school. I've been an RN in Massachusetts since 2017. I got my MSN in 2019 at which time I became a licensed and credentialed psychiatric nurse practitioner.
MS. BUCKINGHAM: And where is that? Here in Massachusetts?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Are you licensed anywhere else?
MS. BUCKINGHAM: Okay. And so can you tell us a little bit about your work history?
REBECCA JOLLOTTA: Sure. I have worked in—as a detox nurse at McLean. I have worked as a therapist in outpatient clinicians prior to becoming a nurse. I have worked in DMH respite facilities, and now I'm a nurse practitioner.
MS. BUCKINGHAM: And when you were a therapist doing outpatient therapist, was that something you were doing on your own, as a social worker or were you associated with a practice?
REBECCA JOLLOTTA: It was part of my training after I got my master's in counseling in 2013. So I had a panel of patients, but I was under the supervision of a licensed provider. It was up towards getting my licensure.
MS. BUCKINGHAM: And where do you currently work?
REBECCA JOLLOTTA: South Shore Health.
MS. BUCKINGHAM: And how long have you worked for South Shore Health?
REBECCA JOLLOTTA: Since 2021.
MS. BUCKINGHAM: And how did you come to work at South Shore Health? What was the role that you started?
REBECCA JOLLOTTA: I had been working sort of in general practice as a psychiatric nurse practitioner, but I was interested in working in women's mental health specifically. And at that point I was getting training to become, you know, more specialized in it. And when a job opportunity became available, I applied for it.
MS. BUCKINGHAM: And what kind of training is that that you were doing to be more specialized in women's health?
REBECCA JOLLOTTA: So Postpartum Support International is the certifying body, so that somebody can become certified in perinatal mental health. I did the two-day... Well, actually it was a two-day training plus a third day specifically for the psychopharmacology track of it, and then I took a examination and passed the examination.
MS. BUCKINGHAM: And so are you certified by the Postpartum Support International?
REBECCA JOLLOTTA: I am.
MS. BUCKINGHAM: Now as far as the South Shore Perinatal Behavioral Health Clinic, how did you become affiliated with that?
REBECCA JOLLOTTA: That was the job I applied to in 2021.
MS. BUCKINGHAM: Okay. And so when you came to the clinic, who was running the clinic or who was the director?
REBECCA JOLLOTTA: Julie Paul.
MS. BUCKINGHAM: And as far as the clinic itself, what is the clinic's... What's the patient base or who does the clinic service?
REBECCA JOLLOTTA: So we specialize in working with women who are pregnant and postpartum up to two years after the birth of their most recent baby. We offer medication management. We have a clinician on staff to do counseling. We have a few nurses that work in our program. We work with moms for any range of psychiatric disorders, including addiction.
MS. BUCKINGHAM: And when we talk about the range of psychiatric disorders in women who are postpartum—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: ... What are we talking about?
REBECCA JOLLOTTA: Postpartum depression, anxiety, postpartum psychosis, bipolar disorder, panic disorder, obsessive compulsive disorder.
MS. BUCKINGHAM: And so you mentioned postpartum psychosis.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Have you yourself had the experience of treating people, women with postpartum psychosis?
REBECCA JOLLOTTA: I have, yes.
MS. BUCKINGHAM: And how many patients approximately over the course of the last five years?
REBECCA JOLLOTTA: Approximately five.
MS. BUCKINGHAM: And how about postpartum depression and postpartum anxiety?
REBECCA JOLLOTTA: Hundreds.
MS. BUCKINGHAM: And in the range of services that the clinic offers and the work that you do, do you oftentimes collaborate with other community providers to offer additional referrals or services to patients if they need it?
REBECCA JOLLOTTA: We do.
MS. BUCKINGHAM: And how about when somebody appears before you and you believe they need a higher level of care than what you can offer? Do you have relationships with hospitalization programs? Are you able to make referrals for people for those services?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Is that pretty common practice?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And you mentioned that one of the services or one of the things offered to patients at the clinic is medication management.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Is that a big part of what you do as a psychiatric nurse practitioner?
REBECCA JOLLOTTA: It is.
MS. BUCKINGHAM: And what kind of training do you receive in order to be a prescriber?
REBECCA JOLLOTTA: So in order to be a prescriber, it's part of my master's in nursing. So you take courses like in advanced pharmacology, advanced health assessment, pathophysiology. It's part of the coursework of my degree, and then you actually have to take a certification exam, and you have to pass the exam. You have to go on and get a DEA license, a Massachusetts controlled substance license. You have to go on and get your advanced practice registered nursing license. So it's education and certification and licensure.
MS. BUCKINGHAM: And so you've done the education.
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: You did the certification. And do you have all the licensures that you just described—
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: ... here in Massachusetts?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: And you also mentioned part of the services of working with social workers in the clinic.
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: And what do the social workers do?
REBECCA JOLLOTTA: They provide short-term counseling to patients. Again, because we specialize in up to two years postpartum, they could be available to provide counseling during that phase.
MS. BUCKINGHAM: And traditionally postpartum period is a year after birth, right?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: So why does the clinic offer support for women up to two years?
REBECCA JOLLOTTA: We do acknowledge that while the highest risk period is the first three months postpartum, some women can struggle later on in the first year. You know, they may have symptoms that emerge nine, ten months in, so we wanna really be able to cover them and treat them if that happens and get them stable.
MS. BUCKINGHAM: And does it sometimes take some time to get a person stable?
REBECCA JOLLOTTA: Absolutely.
MS. BUCKINGHAM: And would that be why the program or your program goes up to two years?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: I wanna draw your attention to a particular patient, Lindsay Clancy. You're familiar with that patient?
REBECCA JOLLOTTA: I am.
MS. BUCKINGHAM: And how did you become involved with the care of Lindsay Clancy?
REBECCA JOLLOTTA: I became involved... She had initially seen Julie, and Julie was going to be leaving the clinic in December, and she wanted somebody to take care of Lindsay, you know, again, longer term since she would be leaving.
MS. BUCKINGHAM: And at that time in twenty twenty-two when Julie was leaving, how many psychiatric nurse practitioners were at the clinic?
REBECCA JOLLOTTA: Three.
MS. BUCKINGHAM: And that includes Julie?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And so who was the other nurse practitioner?
REBECCA JOLLOTTA: Andrea Warden.
MS. BUCKINGHAM: And fair to say you had a conversation with Julie about transferring care of this particular patient?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And did you have more experience than the other nurse practitioner in the field that you know?
REBECCA JOLLOTTA: Not necessarily.
MS. BUCKINGHAM: Okay. But as far as taking Lindsay on as a patient, you were agreeable to taking over for Julie?
REBECCA JOLLOTTA: Yeah. In all likelihood, Andrea Warden only works two days at our clinic, so it could have been that I was working five days at that time, so I would have been more available.
MS. BUCKINGHAM: Okay. So do you recall when the first contact you had with Lindsay Clancy, what date it was?
REBECCA JOLLOTTA: It was November twenty-ninth, twenty twenty-two.
MS. BUCKINGHAM: And so that was prior to Julie actually leaving, right?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And fair to say on that November twenty-ninth date, you had an actual follow-up with Lindsay?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: Do you recall if it was virtual, or was it in person?
REBECCA JOLLOTTA: I recall that it was virtual.
MS. BUCKINGHAM: Okay. And in the practice of the clinic, is there an option for patients to do in-person or face-to-face, um—
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: ... in-person visits?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And how does it come about that a person is either inpatient, excuse me, in person or virtual?
REBECCA JOLLOTTA: Our model is that we do initial assessments in person. Because new motherhood is very busy, there's a lot going on, we would rather see you than not, and so sometimes it is just easier to log on to a screen. Sometimes if we feel like someone would benefit from that face-to-face assessment, we'll say, "Please book your next appointment in person." And I know, I did see Lindsay in person on at least one occasion, but my first was virtual.
MS. BUCKINGHAM: And as far as kind of that choice—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: ... about whether a patient appears virtual or in person, is part of the calculus the patient's choice?
REBECCA JOLLOTTA: Yeah.
MS. BUCKINGHAM: What they want to have happen?
REBECCA JOLLOTTA: Yeah. Mm-hmm.
MS. BUCKINGHAM: And if there were circumstances where you believed or insisted that an in-person visit was required, would you articulate that to the patient?
REBECCA JOLLOTTA: Mm-hmm. Yes.
MS. BUCKINGHAM: And then have them scheduled for an in-person?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And as far as your contact, your first contact with Lindsay Clancy, were you aware that Julie Paul had done that initial intake with her in person?
REBECCA JOLLOTTA: I was.
MS. BUCKINGHAM: And you had the chance to speak with Julie and to also review the records prior to meeting with her?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And so were you aware that the day before, on November 28th, that Julie had had some contact with Lindsay Clancy?
REBECCA JOLLOTTA: I was.
MS. BUCKINGHAM: And that there was some phone interaction, and there had been some messages sent to the clinic prior to you scheduling the meeting with her?
REBECCA JOLLOTTA: That's correct, yes.
MS. BUCKINGHAM: So would you agree that there was an issue that needed to be discussed, and that led to you to have this appointment with her prior to Julie actually leaving the program?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: When you met with Ms. Clancy, did you go through kind of a history of her present presentation or present illness and kind of things that had occurred in the past?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And did you do kind of a nuts and bolts start to finish, or did you rely on some of the previous information she had disclosed?
REBECCA JOLLOTTA: I relied on some of the previous information she had disclosed, things like where she grew up, where she went to school, past clinical history, medication trials. But otherwise, I would add my own clinical assessment.
MS. BUCKINGHAM: Okay. And you were aware that, in her, the history she presented to the clinic, that she had previously been on some medications from another provider?
REBECCA JOLLOTTA: Correct, yes.
MS. BUCKINGHAM: And that she started with Zoloft and Ativan and Benadryl?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And that at some point she had visited the South Shore Hospital emergency room?
REBECCA JOLLOTTA: I believe it was November 16th.
MS. BUCKINGHAM: And as a clinic that's associated with the South Shore Health system, do you have access to those records to review—
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: ... when you're dealing with a patient?
REBECCA JOLLOTTA: I do. Yeah.
MS. BUCKINGHAM: And so you're aware that when she went to the ER on November 16th, that they prescribed her Trazodone?
REBECCA JOLLOTTA: I am.
MS. BUCKINGHAM: And that she was reporting significant sleep issues at that time?
REBECCA JOLLOTTA: I was aware.
MS. BUCKINGHAM: And then as far as the course of treatment at the clinic, were you able to review her course of treatment with Julie?
REBECCA JOLLOTTA: I was.
MS. BUCKINGHAM: And fair to say that had been very recent, correct?
REBECCA JOLLOTTA: Very recent, yes.
MS. BUCKINGHAM: Her first contact with the clinic was actually November 20th, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: So you were aware that Julie had originally prescribed Prozac and had already changed the medication plan?
REBECCA JOLLOTTA: Yes, I was aware.
MS. BUCKINGHAM: So in this meeting on November 29th, what was Lindsay reporting to you as the issues?
REBECCA JOLLOTTA: Would I be able to refer to my note, Your Honor?
THE COURT: Sure, you can.
REBECCA JOLLOTTA: I know most of it by memory, but just in case. So she had been taking Mirtazapine, Remeron, at that point for four nights. So I believe she started it on November 25th. I was then seeing her on November 29th. She wasn't yet appreciating much difference for mood, anxiety, or insomnia. She would say, you know, "I'm able to fall asleep for two hours, then I'm up for three hours in the middle of the night." And finding herself, like, in those three hours needing to take an Ativan to help her fall back asleep.
MS. BUCKINGHAM: Now, when she said not appreciating much difference after taking it for four nights, in your training experience, is that something that you would normally see with that type of medication?
REBECCA JOLLOTTA: Yes, I wasn't surprised by that.
MS. BUCKINGHAM: And for something like Mirtazapine or what's referred to as Remeron, right?
REBECCA JOLLOTTA: Remeron, yeah.
MS. BUCKINGHAM: What class of drug is that?
REBECCA JOLLOTTA: It is a noradrenergic specific serotonin antidepressant. So it's slightly different than an SSRI. It does work on serotonin. It also works on... The noradrenergic part is alpha receptors, which is what our body... Those are the receptors that our body responds to adrenaline, so it should help kind of calm you down. And it also works on histamine receptors, which is why it can make people sleepy.
MS. BUCKINGHAM: So for Remeron, the fact that it has a calming effect on somebody with anxiety, it's sometimes a good fit, right?
REBECCA JOLLOTTA: Correct. Yeah.
MS. BUCKINGHAM: And for somebody who might be complaining of sleep issues, it also has that secondary component that could help?
REBECCA JOLLOTTA: Yeah. It is a good choice for somebody who's having depression with prominent anxiety, insomnia, decreased appetite, 'cause it can also increase appetite, which sometimes we want to happen.
MS. BUCKINGHAM: And based on your review of her course of treatment with the clinic, those were issues that had arisen, right?
REBECCA JOLLOTTA: Mm-hmm. Yeah, I had noticed she had lost weight. When she had gone to her PCP on October 20th, I believe she weighed like 130 pounds. On the 16th, when she went to the ED, she weighed 124 pounds, and they had done a pretty good medical workup on her with labs and everything. And she had reported, like, decreased appetite, so that was part of the clinical picture and, of course, not sleeping and very anxious.
MS. BUCKINGHAM: Okay. And so with a medication like Remeron or Mirtazapine, does it take time to work or to see results?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And typically, what's the timeframe for that drug?
REBECCA JOLLOTTA: I usually tell patients four to six weeks at a given dose is really gonna give us a good idea of what that dose is gonna do. You may start to see improvements in the first two weeks, but full clinical benefit can take a month, sometimes eight weeks even.
MS. BUCKINGHAM: And you were aware prior to her coming to this follow-up appointment with you that she had been reporting after taking the Remeron feeling disoriented, forgetful, not feeling connected to the body, and anxious about whether she would actually sleep?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And so were you aware that on November 28th, that one of the nurses actually advised her to increase the Remeron?
REBECCA JOLLOTTA: I was.
MS. BUCKINGHAM: And in addition to the medication, there was also the recommendation that she add some cognitive behavioral therapy to her treatment plan?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And at that point on November 29th, by November 29th, were you aware of whether she had met with the social worker at the clinic?
REBECCA JOLLOTTA: She had not.
MS. BUCKINGHAM: So did you have any indication that she had been engaging in some sort of cognitive behavioral or psychotherapy?
MS. BUCKINGHAM: Now, in relation to the medication piece of this follow-up, did you have any conversations with her about the concerns with the Remeron and what to do about that?
REBECCA JOLLOTTA: Yes, I did. I explained to her that it takes time to work, that it has only been four days. So I did encourage her to give it some more time. I also made additional recommendations as well.
MS. BUCKINGHAM: Okay. And so what were the recommendations for?
REBECCA JOLLOTTA: I had known that Julie had tried, like, five milligrams of Ambien, so I had suggested maybe we could try 10, maybe we could try Ambien controlled release formulation. Because what—because she was having these wake-ups in the middle of the night, the controlled release, kind of like the outer layer gives you 60% of the dose, helps you sleep. Then throughout the night, the inner layer gives you 40% of the dose, keeps you asleep. I said that might be a good option while we're waiting for the Remeron to work. 'Cause I was sort of thinking that maybe the underlying depression, anxiety was causing the poor sleep, so while we're treating that, you know, let's try these alternatives.
MS. BUCKINGHAM: Okay. And so, was she receptive to the Ambien?
MS. BUCKINGHAM: And did she say why?
REBECCA JOLLOTTA: No, I don't recall.
MS. BUCKINGHAM: Okay. Did she express to you that she had some other concerns about taking certain types of medications for sleep, like benzodiazepines?
REBECCA JOLLOTTA: She did. She-
MS. BUCKINGHAM: What did she say about that?
REBECCA JOLLOTTA: ...was concerned about taking benzos. She had mentioned something called rebound anxiety. And what that is, is once the dose sort of wears off, your anxiety goes, like, above your baseline, once the dose of a benzodiazepine wears off. It usually typically has to do with half-life of a medication. So for Ativan, that's usually between eight and 24 hours. So if she's taking it in the middle of the night, the next morning she would feel more anxious. She was concerned about that. She also feels... She was concerned about getting physically dependent on it 'cause she had needed to take it for a number of nights.
MS. BUCKINGHAM: And when she used the term rebound anxiety, was that her terminology?
REBECCA JOLLOTTA: Yes, it was.
MS. BUCKINGHAM: And is that a terminology that you generally use in psychiatric care to describe that, what you just told us about?
REBECCA JOLLOTTA: Yeah, it's the clinical term.
MS. BUCKINGHAM: And was that something that she mentioned first, or did you mention?
REBECCA JOLLOTTA: I put it in quotes in my notes, so she had- That's usually when a patient mentions it, I put it in quotes.
MS. BUCKINGHAM: Okay. And so, as far as the plan to address the sleep and to help her with this complaint, with Ambien not a choice, what was your next recommendation?
REBECCA JOLLOTTA: I discussed hydroxyzine, because it's an as-needed medication for anxiety, but it's not a benzodiazepine. Doesn't really carry that risk of rebound anxiety or tolerance or dependence. And it could help her sleep, so I offered that as an alternative as well.
MS. BUCKINGHAM: Were you aware that she was offered hydroxyzine before?
REBECCA JOLLOTTA: I was not aware of that.
MS. BUCKINGHAM: Okay. Was she willing to try the hydroxyzine?
MS. BUCKINGHAM: And so what was her preference?
REBECCA JOLLOTTA: Her preference was to continue with the mirtazapine, the Remeron 15 milligrams, and with the as-needed lorazepam.
MS. BUCKINGHAM: And just so we kinda stay with the same terminology, when you're talking lorazepam, what—
REBECCA JOLLOTTA: Sorry. Ativan.
MS. BUCKINGHAM: Ativan?
REBECCA JOLLOTTA: Yeah.
MS. BUCKINGHAM: Okay. And that was something that she expressed to you?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Now, when you're dealing with a patient, and obviously this is your first interaction with her, right?
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: Do you take into account your contact and communication with them in assessing whether they have the ability to make these choices or make informed decisions?
REBECCA JOLLOTTA: Absolutely.
MS. BUCKINGHAM: And so your conversation with her about her medication, treatment that she had received and what you were proposing as a plan, was she able to engage with you in that conversation?
REBECCA JOLLOTTA: Yep.
MS. BUCKINGHAM: And so when sh—
REBECCA JOLLOTTA: It was collaborative.
MS. BUCKINGHAM: Sorry.
REBECCA JOLLOTTA: It was collaborative.
MS. BUCKINGHAM: And so when she declined the options that you first offered—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: ... did you then present her with alternatives?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And ultimately, at the end of the day, whose choice is it as to what medication regimen person would be on?
REBECCA JOLLOTTA: The patient.
MS. BUCKINGHAM: And why is that?
REBECCA JOLLOTTA: Because they have autonomy in their decisions. I'm only making recommendations based on my education, experience, training, what I'm seeing in terms of symptoms. The patient has the autonomy.
MS. BUCKINGHAM: Are there instances where you're dealing with a patient where you have concerns that they shouldn't have autonomy? Or that... Maybe if I rephrase that question.
REBECCA JOLLOTTA: Yeah.
MS. BUCKINGHAM: Are there instances where you're dealing with a patient where you're concerned that they don't have the ability to make the right choice for themselves?
REBECCA JOLLOTTA: There would be, yeah.
MS. BUCKINGHAM: And what options do you have in those instances?
REBECCA JOLLOTTA: In those instances, I mean, that sort of comes down to, like, competency, capacity to make decisions. Sometimes we might get our legal or ethics team, like, involved to make a determination about whether this patient needs, like, a healthcare proxy to make their decisions. Things like that.
MS. BUCKINGHAM: And what about if a person presents with a very serious risk to their own physical health or the health of others? What are your options then?
REBECCA JOLLOTTA: I guess it would depend, you know, if they had capacity to make their decisions.
MS. BUCKINGHAM: In your interaction with her on November 29th, did you also go through with her and perform a mental screening test or a mental status screening?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And why do you do that?
REBECCA JOLLOTTA: It gives me some, like, objective data of how the patient presents. Like, how is their speech? How's their appearance? What is their thought process? What's their thought content? Things of that nature.
MS. BUCKINGHAM: And in this meeting on November 29th of 2022, did you observe anything in which she displayed manic symptoms?
MS. BUCKINGHAM: And what traditionally are manic symptoms that you look for?
REBECCA JOLLOTTA: So there's a new mnemonic called DIG FAST. Try to do this quick. D is distractibility. Patient is highly distracted to lots of extraneous stimuli. There is pressured speech, grandiosity. So, like, suddenly someone's like, "I'm gonna run for office. I'm gonna be the president," and you're like, "Okay, you've never had an interest in that before." Sleep is really poor. So somebody might get like two hours of sleep but be like, "Go, go, go, go, go." Increased goal-directed activity, so somebody might be, like, painting the exterior of their house, painting the interior of their house. They might be, you know, doing a bunch of different projects with no, like, decompression time or feeling tired. Those are the general symptoms of mania. Sometimes there can be psychosis associated with it as well.
MS. BUCKINGHAM: Okay. And so when you say mania and psychosis, are those two different things?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And so are you also looking in these screenings to identify signs of psychosis?
REBECCA JOLLOTTA: Absolutely.
MS. BUCKINGHAM: And what would be signs of psychosis usually?
REBECCA JOLLOTTA: Signs of psychosis, they can be sort of subtle. It might look like somebody's, like, responding to, you know, stimuli in their head, like, based on the way that their eyes are kind of tracking and they're not really paying attention. They may be quite guarded. They may have a delusional thought process. Like for example, they might think that, like, somebody's out to get them, when there's really no, like, basis...
MS. BUCKINGHAM: When you say responding to internal stimuli, is that generally when a person hears things, auditory hallucinations—
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: ...or sees things that aren't there—
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: ...a visual hallucina-
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: And in addition to kind of watching for these things in your interaction, do you flat out ask somebody if they're experiencing those symptoms?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: And in this first interaction that you had with Lindsay Clancy on 11/29, did she display any psychotic symptoms?
MS. BUCKINGHAM: What about assessing for suicidality? Do you do that as well?
REBECCA JOLLOTTA: I do. Mm-hmm.
MS. BUCKINGHAM: And what do you do for that?
REBECCA JOLLOTTA: I generally ask, you know, "Are you having any thoughts of wanting to hurt yourself or anybody else?" And if the answer is yes, it sort of becomes a more in-depth assessment...
MS. BUCKINGHAM: Do you go back and ask them about past thoughts—
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: ...whether they've articulated that?
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: And in this case with Ms. Clancy, did she ever indicate whether she had a history of having suicidal thoughts or suicidal ideation?
REBECCA JOLLOTTA: She did not.
MS. BUCKINGHAM: And how about homicidal ideation? Do you ask about that?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: And in this instance, did she indicate whether she had any homicidal ideation or thoughts of harming other people?
MS. BUCKINGHAM: And as far as your observations of her presentation, like her mood and physically how she presented, did you... anything stand out to you as far as any of that?
REBECCA JOLLOTTA: She appeared... She seemed anxious.
MS. BUCKINGHAM: Okay.
REBECCA JOLLOTTA: As I remember.
MS. BUCKINGHAM: Okay, so as far as mood—
THE COURT: I'm sorry. Sorry, I couldn't hear that.
MR. REDDINGTON: Sorry, Judge. If she can finish her answer.
THE COURT: Sure. You done with that?
REBECCA JOLLOTTA: Yeah, I'm done.
THE COURT: Okay. All right.
MS. BUCKINGHAM: So as far as mood, you noted her to be anxious, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And you also look at a person's affect.
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: And did you—
THE COURT: You're gonna have to answer yes or no.
REBECCA JOLLOTTA: Oh. Yes. Sorry.
MS. BUCKINGHAM: You observed her affect to be consistent with her mood, which you identified as anxious, right?
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: And you examined somebody for their—
REBECCA JOLLOTTA: Yes. Sorry.
MS. BUCKINGHAM: That's okay. Thought process, right?
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: And did you... what did you observe her thought process to be?
REBECCA JOLLOTTA: I observed her thought process to be linear, meaning you could follow it when... her train of thought easily, and goal-directed. She understood that she was there to be assessed for treatment. Seemed to be her goal.
MS. BUCKINGHAM: And do you also perform other screenings like the generalized anxiety depression scale and the Edinburgh scale?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: And did you do that for Lindsay Clancy on November 29th?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And what were the results of those screens?
REBECCA JOLLOTTA: Her Edinburgh... So the Edinburgh scale is out of 30. She was 17.
MS. BUCKINGHAM: And what does that mean?
REBECCA JOLLOTTA: Moderate to severe symptoms, postpartum depression.
MS. BUCKINGHAM: Now, with that particular screening tool that you can use, is it fair to say that with postpartum women it often fluctuates?
REBECCA JOLLOTTA: It can. That... It's asked, the patient is asked about the previous seven days.
MS. BUCKINGHAM: And as far as the generalized anxiety depression scale, what were the results of that screen?
REBECCA JOLLOTTA: Let me look.
REBECCA JOLLOTTA: 14 out of a total of 21.
MS. BUCKINGHAM: And so what does that mean?
REBECCA JOLLOTTA: That would mean moderate anx— moderately severe anxiety.
MS. BUCKINGHAM: And do you recall about how much, or how long your interaction with her was on this telehealth visit?
REBECCA JOLLOTTA: It would have been 30 minutes.
MS. BUCKINGHAM: And as a result of your interaction with her, did you come up with a plan moving forward as to what to do to address her issues or her concerns?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: What was the plan?
REBECCA JOLLOTTA: Continue Remeron, 15 milligrams nightly, Ativan as needed. Those medications had been prescribed to her already. I did not write her any prescriptions at that visit.
MS. BUCKINGHAM: And again, you indicated that you kind of encouraged her to stick with the Remeron and give it a chance to work?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And was she receptive to doing that?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And as far as, again, the sleep issue, based on your conversation with her and her request to continue with the Ativan, that's what you recommended?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Did you also recommend other types of treatment that were not pharmacological?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And what were those?
REBECCA JOLLOTTA: I recommended therapy, mindfulness, physical activity, meditation.
MS. BUCKINGHAM: And you're aware that in the past she had reported physical activity was something that had been helpful to her?
REBECCA JOLLOTTA: Yes. I believe with her postpartum period with Dawson, her middle child, she had some anxiety. But it seemed to resolve with exercise, in particular.
MS. BUCKINGHAM: And fair to say as it pertains to that experience, her postpartum with Dawson—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: ... she had reported at some point to the clinic that she had sought medication after having Dawson, and that she didn't end up taking that medication, right?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: Now, after this particular follow-up, what's your practice when you're dealing with a patient to have them have a intervention if they need to get in touch with you or they have concerns before your next scheduled meeting?
REBECCA JOLLOTTA: I generally advise for non-emergencies you can message me on the Epic portal.
MS. BUCKINGHAM: Is that generally referred to as MyChart?
REBECCA JOLLOTTA: MyChart, yeah.
MS. BUCKINGHAM: And so MyChart, you could kind of go back and forth with messages, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Did you encourage Lindsay to utilize MyChart if she felt the need to reach out to you before your next scheduled appointment?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And at the end of that meeting, what was the plan for the next scheduled appointment? What was the track that you would ask her to be on as far as regular visits?
REBECCA JOLLOTTA: One week.
MS. BUCKINGHAM: And is that typical, one week?
REBECCA JOLLOTTA: One to two weeks would be typical for a new patient.
MS. BUCKINGHAM: And based on her report of symptoms or potential symptoms, was it important to you to identify if there were any changes?
REBECCA JOLLOTTA: Absolutely.
MS. BUCKINGHAM: Now, were you aware, by the time that meeting was completed, that she did have an appointment scheduled with a social worker at your clinic, Latiesha Dukes, for December 2nd?
REBECCA JOLLOTTA: I was aware of that, yes.
MS. BUCKINGHAM: Now after this meeting, so this was approximately 10:30 in the morning on 11/29, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Did you have communication or contact with Lindsay Clancy on November 30th?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: How did you have contact with her on that day?
REBECCA JOLLOTTA: She messaged me on the MyChart portal.
MS. BUCKINGHAM: And you're aware that on that particular morning, Julie had informed her that she was leaving?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Or were you aware, I should say?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Now when Lindsay messaged you, that was at 11:00 AM. That was the first message, correct?
REBECCA JOLLOTTA: So I'd have to look at the note for the time.
MS. BUCKINGHAM: Okay. Do you have those?
REBECCA JOLLOTTA: I do have the messages. I think, I believe... That'll be accurate. It was 11:00 AM. Yep.
MS. BUCKINGHAM: And did she ask you something specific in that message?
REBECCA JOLLOTTA: She did.
MS. BUCKINGHAM: What did she ask you?
REBECCA JOLLOTTA: She asked me if it would be safe to stop taking Remeron after five nights.
MS. BUCKINGHAM: So you had just met with her on November 29th?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And talked about stopping Remeron or talked about the concerns with Remeron.
REBECCA JOLLOTTA: We talked about continuing it on the 29th. Yes.
MS. BUCKINGHAM: But as far as— the starting of that meeting where you were talking with her about the medication, she had already reported concerns with that medication, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And so you encouraged her to stick with it.
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: And then the next day she's asking to stop again.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Okay. Do you recall that in that message she indicated that, in the course of that night, that the depression, she felt like the depression was much, much worse and not helping her sleep and that she only got two hours?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And she asked for a phone call from you, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And did you call her back or did you message her back?
REBECCA JOLLOTTA: I messaged her back, but I also believe I had my nurse call her back because I was in between patients.
MS. BUCKINGHAM: Okay. And so when you messaged her back, what did you ask her about to address that concern about stopping the Remeron after five nights?
REBECCA JOLLOTTA: I asked her what symptoms of depression did she notice was worsening.
MS. BUCKINGHAM: And why did you do that?
REBECCA JOLLOTTA: Because she had mentioned that she felt that she was more depressed. She was attributing it to the medication.
MS. BUCKINGHAM: But in her original message, did she give you any detail about what was worse?
REBECCA JOLLOTTA: Oh, yeah, no, she did not. Sorry.
MS. BUCKINGHAM: Is it important to you to know what symptoms are worse so that you know how to advise the patient?
REBECCA JOLLOTTA: Absolutely.
MS. BUCKINGHAM: And did you again express to her a concern with stopping that particular medication after the short period of time she had been on it?
REBECCA JOLLOTTA: Yes. I shared with her that from what I understood, there had been really short medication trials since October. You know, a short course of the Zoloft, a short course of Trazodone, and now what would be a short course of the Remeron. And I reiterated that sometimes it can take four to six weeks before these treatments start to work.
MS. BUCKINGHAM: Okay. And you also knew from Julie Paul that she had only taken Prozac for approximately four days?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: Even though you gave her that information and encouraged her to stay with it—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: ... did you suggest an alternative?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And why did you suggest an alternative?
REBECCA JOLLOTTA: At this point, I'm trying to establish a therapeutic relationship with her as a patient. So I had met with her on the 29th. She's concerned about the Mirtazapine. I'm kind of asking her to hang with me on it and give it a chance. But then the next day she's asking me again that she really doesn't like it. So at this point I'm trying to kind of give her an alternative, to establish a collaborative therapeutic relationship.
MS. BUCKINGHAM: And at the end of the day, if you prescribe a medication and the patient doesn't wanna take it—
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: ... you don't know if they're gonna take it, right?
REBECCA JOLLOTTA: Exactly.
MS. BUCKINGHAM: So what was the alternative you suggested?
REBECCA JOLLOTTA: I had suggested Prozac again, just because I had known that she had taken it in like 2012 whenever she was in nursing school, and she was able to take it for a year and she tolerated it okay. So I was kind of thinking maybe we can try to get you to retrial it, and it would be helpful.
MS. BUCKINGHAM: And in making that recommendation to potentially restart it, had you reviewed the notes from Julie Paul in which the defendant or Lindsay Clancy indicated that when she took the Prozac, she felt disconnected, and that she was concerned about that and that Lin- Julie had told her to stop it?
REBECCA JOLLOTTA: Mm-hmm. Yes.
MS. BUCKINGHAM: But you still felt that it was worth giving it another try?
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: And did you suggest anything else to pair with the Prozac to help sleep?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: What did you suggest?
REBECCA JOLLOTTA: I recommended Seroquel 25 milligrams.
MS. BUCKINGHAM: And now Seroquel, is that a drug that you're familiar with?
REBECCA JOLLOTTA: I am.
MS. BUCKINGHAM: And in your practice, especially dealing with women's health, perinatal issues, what would a low dose of Seroquel accomplish for a woman postpartum?
REBECCA JOLLOTTA: To get them to sleep.
MS. BUCKINGHAM: And you are aware that Seroquel at higher doses could be used to treat other types of mental illnesses?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: But in this circumstance and with this recommendation, what was the purpose of the Seroquel?
REBECCA JOLLOTTA: So at this stage, my awareness was that she had tried a first-line option, which would be the benzodiazepine. The second-line options are usually the, what we call the sedating antidepressants, like Trazodone, Remeron. So this would be more like a third-line option to try.
MS. BUCKINGHAM: And is that because Trazodone, she reported didn't help her?
REBECCA JOLLOTTA: Didn't help.
MS. BUCKINGHAM: And she didn't like the feeling on Remeron?
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: And so ultimately in that message, you kind of reiterated what your overall recommendations were, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And it was to continue with the Remeron for another 10 days.
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: And that the alternative would be to restart Prozac and add the 25 milligrams of Seroquel nightly for anxiety and insomnia. Is that fair?
REBECCA JOLLOTTA: Yes. Yes.
MS. BUCKINGHAM: And so were you recommending that she be on all of those at the same time?
MS. BUCKINGHAM: That she do the Remeron, the Seroquel, the Prozac?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And in your experience in psychiatric care and prescribing medication, is it a common practice to pair low doses or doses of particular types of medications together to effectively manage a person's symptoms?
REBECCA JOLLOTTA: Mm-hmm. At this clinical juncture, my thought was the combination of Remeron with the Prozac to treat the depression with prominent anxiety, the Seroquel to help alleviate the sleep.
MS. BUCKINGHAM: And you're also addressing the concern of benzodiazepine dependency, right?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: Did you encourage her to do something to help you to kind of manage her treatment track going forward?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: What did you encourage her to do?
REBECCA JOLLOTTA: I had noticed that Lindsay was attributing a lot of her symptoms to her medication, and so I attached to the MyChart message two different mood charts. And what those mood ch—one is daily, one is weekly. What it is, is it asks the patient each day to rate their mood from, like, zero to three. You know, good mood, bad mood, normal mood. It asks about, like, did you take your medications, what doses, what were they? Check the box. How many hours a night did you sleep? What's your anxiety level? What's irritability? And what I wanted from that was because it had all those parameters about mood and then also the medication, did you take it, we'd be able to track over time what the progression was. Was it getting worse since we started the medication? Was it actually getting better? I just wanted more data.
MS. BUCKINGHAM: And were you aware that she was actually tracking those things herself?
MS. BUCKINGHAM: Now, you continued to have some back-and-forth messages with her throughout the course of the day on November 30th, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: So we have, she reached out to you at 11:00.
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: You responded to her at 11:52.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: There's another message from her at 12:15, right?
REBECCA JOLLOTTA: Mm. Yes.
MS. BUCKINGHAM: And just going back for a second. When you were asking her about worsening symptoms, did you ask specifically about suicidal symptoms?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And why those if she was expressing some depression and sleep issues?
REBECCA JOLLOTTA: Suicidal thoughts can—are a symptom of, can be a symptom of depression. And I just wanted to make sure I assessed that one because it's—because of its severity. And—
MS. BUCKINGHAM: And is that something that's important to do before you make a recommendation to change a medication?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Now, when she responded at 12:15, did she tell you anything about the suicidal thoughts or if she was having any?
REBECCA JOLLOTTA: She said she's not at the point of being suicidal.
MS. BUCKINGHAM: Okay. She also indicated, "But I'm really feeling as if I can't go on like this," right?
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: And she asked you to call in the Seroquel.
REBECCA JOLLOTTA: She did ask me to call in the Seroquel, yes.
MS. BUCKINGHAM: So based on her response, did you feel that she was taking the alternative that you were offering?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And then at 12:29 PM, you get another message from her where she asks for a phone call, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And again, at that point, did you have a phone call with her or did you continue to interact with her on the MyChart portal?
REBECCA JOLLOTTA: I interacted with her on the MyChart between patients, and I had my nurse give her a call.
MS. BUCKINGHAM: And again, you said in between patients. So did you have the opportunity to pick up the phone and call?
REBECCA JOLLOTTA: I did not.
MS. BUCKINGHAM: Okay. And is that one of the benefits of the messaging portal, that you can get to somebody, get back to somebody quicker?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: So when...
MS. BUCKINGHAM: Before you were able to respond, did she send you some additional messages on MyChart, if you remember? Or if you could look at your notes.
REBECCA JOLLOTTA: Okay.
REBECCA JOLLOTTA: Let's see. I see that the symptoms of depression that she reported.
MS. BUCKINGHAM: Yep. So just drawing your attention to 12:58 PM.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: You get another message from her where she says, "The symptoms of depression that are much worse are just feeling completely hopeless and unmotivated to do anything at all." And that she says, "I printed the daily mood chart and will start it." Okay. Now you said that you did ask your nurse to give her a phone call at some point, and so you're aware that a nurse did call her on November 30th at approximately 3:10 PM.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And that during that phone call, that Lindsay agreed to the plan and that she was gonna pick up the Seroquel.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Okay. Now at that point, you had another meeting scheduled with her for a week out, right?
REBECCA JOLLOTTA: Mm-hmm. Yes.
MS. BUCKINGHAM: But prior to that, did you also continue to in- communicate with her via MyChart?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: So moving into December 1st, again, were you able to send her a message?
REBECCA JOLLOTTA: She sent me a message on December 1st, and I did reply to it.
MS. BUCKINGHAM: Okay. So December 1st at 12:20 PM, we have a message from Lindsay Clancy: "Hi Rebecca. I really don't like the way I feel on the Remeron, and I know that I can't stick with it," or, "I can't stick with taking it. I started having very intrusive thoughts that I never had before. I didn't take it last night. I would really like to go back to Julie's original plan of Prozac in the morning and using Ativan and Benadryl at night as a Band-Aid until I get to a therapeutic level of Prozac. Please let me know if you agree with this plan. I know that I need to give it a good couple of weeks to work." Is that the message that you first received on December 1st?
REBECCA JOLLOTTA: It was.
MS. BUCKINGHAM: And were you aware that, that same day that Lindsay had reached out to her primary care physician asking for an immediate appointment with her nurse practitioner?
REBECCA JOLLOTTA: I was.
MS. BUCKINGHAM: And that she was looking to discuss medications?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Do you know if she actually got an appointment or went to the appointment there?
REBECCA JOLLOTTA: They had reached out to her, and she did not respond to their voicemails or MyChart messages, so she did not see them that day to my knowledge.
MS. BUCKINGHAM: So you're able to review the notes from the network of South Shore Health, right?
REBECCA JOLLOTTA: Correct, yes.
MS. BUCKINGHAM: So you were able to review that she asked for an emergency appointment. They were able to find her an emergency appointment, but she wasn't... She didn't get back in enough time to actually get there.
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And so in the meantime, you're having a back and forth with her during the course of that day, December 1st.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: When she indicated to you in this message on December 1st about having intrusive thoughts, and not liking the Remeron and not taking it, what was your response?
REBECCA JOLLOTTA: I sent her a detailed message of signs and symptoms of postpartum depression and anxiety, including factors like onset, risk factors, predictors, common symptoms. And it highlighted how intrusive thoughts are quite common in postpartum depression and anxiety. And I asked her, you know, "I'm wondering if that's what's going on here." I then asked her if she took... was able to take the Seroquel that night and if she noticed any improvement in terms of sleep or anxiety with the Seroquel.
MS. BUCKINGHAM: Now, by giving her this information about postpartum depression and postpartum anxiety, was that consistent with a diagnosis that either you or Julie had given her in coming into the clinic?
REBECCA JOLLOTTA: Yes. We were thinking this could be some postpartum anxiety. And I wanted to familiarize her with the symptoms, so that she had them written down and she could report them to me. And understand that they are part of these disorders.
MS. BUCKINGHAM: Okay. And you also gave her some information about obsessions and compulsions, right?
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: And you said you asked her about the Seroquel and asked about sleep, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And did you also reiterate that you were still encouraging to keep up with the Remeron for a period of time?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And you further indicated to her that you wanted to kind of see if there was a correlation between the symptoms and the medication and that you just didn't have enough data.
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: In response to that message, she actually responded at two thirty-six on December 1st, correct?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And she indicated, "Thank you for the information. It was helpful." Then she says, "I panicked last night and just took Ativan and Benadryl, but tonight I'll stick with the plan and try the fifteen of Remeron and the twenty-five of Seroquel." Do you recall if you had ever had a conversation with her about kind of using Ativan and Benadryl as a backup, or if she just felt like she wasn't getting any relief?
REBECCA JOLLOTTA: I recall having a conversation about using the Ativan as a backup. I believe it was... Yeah, well, yes, in my initial, I said, "Continue the Remeron and the Ativan as needed."
MS. BUCKINGHAM: Okay.
REBECCA JOLLOTTA: Yeah.
MS. BUCKINGHAM: And what about the Benadryl?
REBECCA JOLLOTTA: The Benadryl I don't recall discussing.
MS. BUCKINGHAM: But you were aware that she had reported the combination of Ativan and Benadryl had worked for her before?
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: And in that message, she also says, "I'm sorry for all the messages. It's just a scary, very scary, stressful time for me, and starting new meds with side effects is very scary to me. I'll check in in the morning and let you know how it went." Right?
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: Okay. And again, you continued to have some contact with her on that same day after that.
REBECCA JOLLOTTA: I believe I responded to that, reassuring her that it's understandable to have fears, concerns about starting medications. And I sent her a detailed description of common question and answers I get from patients about medications. Things like what to expect, how long does it take to work, what are common side effects? Risks first. You know, is there any risk for suicide, homicide with medications? You know.
MS. BUCKINGHAM: So in providing all this information with her, what were you trying to do?
REBECCA JOLLOTTA: Provide information, because she had said it was so scary starting medications. So I wanted her to be equipped with understanding and, you know, what to expect possibly.
MS. BUCKINGHAM: And based on your interactions with her and your review of Julie Paul's interactions with her, this was a person that was very receptive to taking information, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And as her role as a nurse, she was not afraid to ask questions. Is that fair to say?
REBECCA JOLLOTTA: No. Yes.
MS. BUCKINGHAM: Okay.
REBECCA JOLLOTTA: She was not afraid.
MS. BUCKINGHAM: And one of the things that you provided her or the information you provided her in this detailed response back to her on December 1st at three oh four was that there are other sources or resources that she could utilize that are available at the clinic, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And—
REBECCA JOLLOTTA: Oh, go ahead.
MS. BUCKINGHAM: Just gonna show you these two books. Exhibit 148.
REBECCA JOLLOTTA: Yep.
MS. BUCKINGHAM: Good Moms Have Scary Thoughts, and this one, The Pregnancy Postpartum Anxiety Workbook.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Is this familiar to you?
REBECCA JOLLOTTA: Yes. I instructed her that we had copies of these books that we were giving out to patients, and that she should come grab them when she was in clinic. And she informed me she would be seeing Latiesha the next day for counseling, so she would grab them when she was there.
MS. BUCKINGHAM: Okay. And so that day, December 1st, fair to say you went back and forth with her from about 12:30 to her last message, she was at 4:37 that day?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And you said that she indicated that she did have an appointment the next day with Latiesha Dukes?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And were you aware of whether that was an in-person meeting?
REBECCA JOLLOTTA: Yes, it was in person because she said, "I'll be in clinic. I'll be able to get those resources."
MS. BUCKINGHAM: Okay.
MS. BUCKINGHAM: So moving to December 2nd, you didn't have a scheduled appointment with her, correct?
REBECCA JOLLOTTA: I did not.
MS. BUCKINGHAM: And you knew she was going to see Latiesha that morning in clinic, right?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And you received several messages from her that morning.
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: Again, through the MyChart portal?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Beginning at 7:51 AM, where she sends you a message saying, "Hi, Rebecca. I took the 15 Remeron and 25 Seroquel. I woke up at 12:00 with horribly intrusive thoughts of wanting it to be all over. I took one milligram Ativan and went back to sleep, and the thoughts went away now that I have the Ativan on board. I really need to explore the option that I'm addicted to Ativan. I have a therapy appointment with Latiesha in your office. I would really like to speak to with someone in the substance use clinic to explore the option." Do you recall getting that message?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: Okay. And did you respond to that message?
REBECCA JOLLOTTA: I did. I am credentialed at South Shore Health in addiction medicine, so I felt that I could be that person to discuss those concerns with her.
MS. BUCKINGHAM: Discuss the substance use—
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: ... concerns?
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: And so... And you're aware that the social workers can also screen for those as well?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: So at 8:51 on December 2nd, you respond to her, right?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And what do you tell her about the concerns she just expressed in her 7:51 message?
REBECCA JOLLOTTA: I fully appreciate and understand the concern for benzo tolerance. It's not something I want to happen to my patients ever. That being said, there's a place for benzodiazepines, especially at the beginning and acute phase of treatment in getting someone stable, and then we would always pull back slowly. I think another thing to try tonight would be to take 50 milligrams of Seroquel, the two tablets, and see if that works better. The intrusive thoughts are part of postpartum depression anxiety, very painful to think and experience, but I wanna reassure you that it's not uncommon and mean nothing about who you are as a mother. Let me know what you think.
MS. BUCKINGHAM: And so the recommendation from 25 to 50 milligrams of Seroquel, is that still within the range for treatment for insomnia?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: So would you characterize that as a low dose, a high dose?
REBECCA JOLLOTTA: A low dose.
MS. BUCKINGHAM: And as far as her statement about intrusive thoughts, fair to say your response doesn't ask her more specifics about those thoughts, right?
MS. BUCKINGHAM: But you reiterate to her, just as you had in the lengthy messages where you provided—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: ... information, that intrusive thoughts are pretty common.
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: Now, did she respond to that message? If she—
REBECCA JOLLOTTA: She did.
MS. BUCKINGHAM: And so at 9:04 on December 2nd, there's a response from Lindsay Clancy. "I'm willing to try anything. I just keep coming back to the feeling that I'm dependent on Ativan after my two and a half weeks of taking it daily with Benadryl following the bad reaction to Zoloft. I feel addicted to it, and I feel like I'm not being heard that that is a possibility. I feel like we are throwing all these different meds at my insomnia when the root cause is Ativan dependence. I don't feel any of the anxious thoughts I had before. I feel completely numb." So you got that message from her at 9:04, correct?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And what was your concern when you got that message, or did you have any concern?
REBECCA JOLLOTTA: I wouldn't say I had concern. I just wanted to, again, provide her some information about what I thought might be happening.
MS. BUCKINGHAM: Based on your training and experience as a psychiatric nurse—
MR. REDDINGTON: I'm sorry. She didn't finish her answer. Please.
THE COURT: Okay. Yeah. Go ahead.
REBECCA JOLLOTTA: I was finished.
THE COURT: Okay. Well, she's finished. All right. Next question.
MS. BUCKINGHAM: Based on your training and experience as a psychiatric nurse, and you said you had some experience with substance use, did you feel that there was a dependency issue or an addiction issue with Ativan?
REBECCA JOLLOTTA: I did not.
MS. BUCKINGHAM: Is it fairly common that Ativan is gonna make somebody feel better if they're feeling anxious?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: That's why you take it, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And that's why you take it as needed. Is that fair to say?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: So, in your response to her at 9:37, do you make clear to her the difference between dependence and addiction?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: Okay. And as far as benzodiazepines go, there is a real concern for dependence and addiction in the fields. Is that fair to say?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: But based on taking it for two and a half weeks, taking it to address actual symptoms of anxiety, did you have a concern of dependence?
MS. BUCKINGHAM: And so did you articulate to her that anything about that concept of dependence versus addiction? What did you say?
REBECCA JOLLOTTA: I said, "I wonder if you fear you're becoming dependent on the benzodiazepines, and there's a subtle difference between dependence and addiction. With addiction, there's a change in behavior caused by biochemical changes in the brain after continued substance abuse. The substance use becomes the main priority of the person with the substance use disorder, regardless of the harm it causes to themselves or others. With dependence, we're referring to physical dependence on a substance. Oh, sorry. Characterized by symptoms of tolerance and withdrawal. Benzodiazepine withdrawal is similar to alcohol withdrawal symptoms. We would be seeing things like elevated vital signs, high blood pressure, tachycardia, diaphoresis, mild alteration of mental status, initially with the possibility of perceptual disturbances, delirium, dysphoria, and tremors. Did the insomnia predate the Ativan use? I hear your concerns about the benzos. So my recommendation is do not take them every night. I recommend taking only every other night, and then we will not refill it."
MS. BUCKINGHAM: And so what's diaphoresis?
REBECCA JOLLOTTA: Sweating.
MS. BUCKINGHAM: Okay. And in the field of prescribing psychiatric medications, do you often have to deal with physical dependency and then addressing it later?
REBECCA JOLLOTTA: I wouldn't say often.
MS. BUCKINGHAM: Is there a way to address that as far—
REBECCA JOLLOTTA: Absolutely, yeah.
MS. BUCKINGHAM: And so that wasn't a concern of yours regarding Ativan, was it?
REBECCA JOLLOTTA: Not at that time.
MS. BUCKINGHAM: And…
MS. BUCKINGHAM: What about her statement about not being heard? Did you see that in her message? Where she says, "I feel like I'm not being heard," about addiction.
REBECCA JOLLOTTA: With that being a possibility.
MS. BUCKINGHAM: What, as a psychiatric nurse practitioner dealing in psychiatric medicine, is it important to you when a patient tells you that "I don't feel I'm heard"?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And do you take that into consideration when addressing them and continuing to build that relationship?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And so, in this case with the defendant, with Lindsay Clancy, did that change your approach with her at all?
REBECCA JOLLOTTA: I... It's why I sent the message that I did, trying to explain what addiction versus dependence intolerance is, and I wanted to reassure her that we will try to have you take these less frequently, and we don't need to continue them moving forward.
MS. BUCKINGHAM: So she advocated for herself, and you took that into consideration and created an alternative plan?
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: Or suggested an alternative plan?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Did your care of her change at all when she told you she wasn't being heard?
REBECCA JOLLOTTA: I wouldn't say it changed.
MS. BUCKINGHAM: You treated her as you would any other patient, right?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: Now, you continued to have messages with her throughout that day. Is that fair to say?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And so, at 10:02, you receive a message from her. She says, "The insomnia started from the Zoloft, but then after the two weeks of daily Ativan and Benadryl use, that's when the insomnia was at its worst. I've tried so many different sleeping aids at this point, Trazodone, Ambien, Remeron, Seroquel, and they all seem to barely touch the sleep until I take Ativan with them. So tonight I will try fifteen of Remeron with fifty of Seroquel. I fear that if I wake up in the middle of the night with intrusive thoughts again, I will feel like I need Ativan." Do you recall her sending that message at 10:02?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: And that she sent another message. It's kinda cut off. But it's still within the ten o'clock hour, where she adds, "I also just feel concerningly numb right now, like I have no emotion whatsoever. I feel like I'm going to die, and I don't care. What do I do about this?"
REBECCA JOLLOTTA: I do recall that message, yes.
MS. BUCKINGHAM: And this is a message that she sent when she would have been or have seen Latiesha Dukes already, right? If she had had a nine o'clock appointment.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: When she sent that message to you, did you respond back to her at 11:35?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And with the fact that she talked about being numb and having no emotions, "Feel like I'm going to die and don't care," what did you do?
REBECCA JOLLOTTA: I said, "This sounds like depression and anhedonia symptoms. I would say if you're feeling unsafe, particularly as we head into the weekend, it is important for you to have information for psych emergency services available to you." And I provided a list of the twenty-four-hour emergency service programs like mobile crisis intervention.
MS. BUCKINGHAM: Okay.
MS. BUCKINGHAM: And when you say anhedonia—excuse me if I mispronounced that.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: What does that mean?
REBECCA JOLLOTTA: Anhedonia is a symptom of depression where people are unable to feel pleasure. They might describe it as feeling numb. They're unable to look forward to things.
MS. BUCKINGHAM: And in her message where she says, "I feel like I'm going to die, and I don't care," did you take that as a suicidal thought or suicidal ideation?
MS. BUCKINGHAM: And so did you tell her to go to the ER right away?
MS. BUCKINGHAM: Okay. Did you have concerns that she needed to get a higher level of care at that moment when she sent that message?
REBECCA JOLLOTTA: My concern about that statement was that I wanted her to have access to resources if it escalated or if she—if it worsened. So I made sure she had it.
MS. BUCKINGHAM: Okay. And—
MS. BUCKINGHAM: Fair to say you also, at the end of that message, indicate, "Are you able to get rest or reach out to your support system so that you can be helpful, so they can be helpful to you right now, and that this is hugely important"?
REBECCA JOLLOTTA: I did say that, yes.
MS. BUCKINGHAM: And 11:41 AM she responds, "Yes, I have support. My parents are here to help." And again, this is 12:02, "Does this sound like side effects to Remeron or Seroquel? I've never felt like anything like... I have never felt anything like this before." And then 11:57 she sends another message, "Do you think over time these symptoms will go away over time?" 12:04, another message from her, "Is there any chance you could give me a call to discuss when you have a minute?" At 12:10 PM, "And just to confirm, your recommendation for tonight is 15 Remeron, 50 Seroquel, and avoid Ativan, even if I'm not sleeping." So you got those messages in succession, right?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And were you able to eventually respond to her with a phone call?
REBECCA JOLLOTTA: I responded to the message at 12:12 PM. I wrote—I wrote it down for her.
MS. BUCKINGHAM: And again, in your response to her, did you reiterate that these are pretty common signs of depression, and that what she was expressing to you wasn't uncommon in women with postpartum depression?
REBECCA JOLLOTTA: Correct. I said, "It sounds more like depression than side effects. It's not uncommon for me to hear, 'I've never felt anything like this before,' or, 'I just don't feel like myself.' All of this sounds like postpartum depression."
MS. BUCKINGHAM: And did you further try to give her some encouraging words?
REBECCA JOLLOTTA: Mm-hmm. I shared a passage from a book called This Isn't What I Expected.
MS. BUCKINGHAM: And is that book kind of centered around postpartum depression?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And did you also tell her this is gonna get better?
REBECCA JOLLOTTA: I said, "Even though they feel terrible, remember that they are symptoms of an illness that is very real and very treatable. This is going to get better."
MS. BUCKINGHAM: And after that message on 12:12, did you in fact send her another message?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And fair to say that next message was to kind of address the concern about her question what to take?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And you confirmed to take 15 milligrams Remeron, 10 milligrams Prozac, and 50 milligrams Seroquel?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And that taking Ativan every other day might help?
REBECCA JOLLOTTA: I said, "I would say taking Ativan every other day might help you to see you are not addicted, as one cannot be addicted to something they don't take every day. But we can also decide to let me be concerned about whether you have a problem with the Ativan and simply take it nightly for now. And if I have concerns about your use of it, I will make them apparent to you. My primary concern at this time is that you sleep, and if that means taking the Ativan for middle of the night wake-ups, that is what it means. I'm confident we can safely and successfully get you off Ativan in the near future." And then I also go on to make recommendations about if she does have trouble in the middle of the night, certain sleep hygiene techniques that she could do, like getting out of bed, and doing something non-stimulating. And then go back down to try to sleep again when you feel drowsy.
MS. BUCKINGHAM: So an alternative to medication intervention?
REBECCA JOLLOTTA: Yeah.
MS. BUCKINGHAM: And then at 1:40 PM—
REBECCA JOLLOTTA: Yeah.
MS. BUCKINGHAM: ... she responds, "Thank you. I'll stick with that plan. I really hope it works, and to feel like myself soon." Right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And then at 12, 2:35 you respond, "We will follow you closely. We have lots of alternatives. If this for some reason isn't the combination, we'll find one that gets you back to feeling like yourself."
REBECCA JOLLOTTA: I did say that, yes.
MS. BUCKINGHAM: In all your treatment of women, the women that you've treated with postpartum depression, is this common that you have to kind of trial different plans in order to find the right one?
REBECCA JOLLOTTA: Yes.
THE COURT: All right, Ms. Buckingham, it's 11 o'clock. Why don't we take the morning recess at this time? All right?
MS. BUCKINGHAM: Thank you.
THE COURT: So we'll take the break.
REBECCA JOLLOTTA: Thank you.
BAILIFF: Court all rise. Jurors, try and close your notebooks and place them on the chairs, please.
BAILIFF: This way.
THE COURT: All right. Counsel, anything we need to discuss before the break?
MR. REDDINGTON: No, thank you, Judge.
THE COURT: All right, so we'll be in recess for the morning recess at this time.
BAILIFF: This court is back in session. You may be seated.
THE COURT: All right. All set for the jury?
MS. BUCKINGHAM: Yes, Your Honor.
THE COURT: All right.
BAILIFF: Court, all rise. Jurors entering.
BAILIFF: This court's now in session. Please be seated.
COURT CLERK: Your Honor, for the purpose of the record, we return back to the matter, Commonwealth versus Lindsay Clancy. All parties are present, including the 18 jurors.
THE COURT: All right. Attorney Buckingham, please.
MS. BUCKINGHAM: Thank you. Nurse Jollotta, when we broke, we were talking about your interactions via MyChart with Lindsay Clancy on December 2nd of 2022, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And so the last one on December 2nd at 2:35 PM was from you to her. And then on December 3rd, do you recall that a MyChart message was sent on that day at 7:24 PM?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: And you were able to review that message when—after—some point after it was sent?
REBECCA JOLLOTTA: I was.
MS. BUCKINGHAM: And she reports to you basically that she didn't wanna wait till—to let you know some things that were fresh in her mind, and it says, "Last night I didn't take Ativan. My dose had been the night before at 1:00 AM. Only slept about four hours at the beginning of the night, about 9:30 to 1:45. Then I dozed off for maybe another 45 minutes from 4:30 to 5:00. Today, all day, I had horrible intrusive thoughts and felt very..." Or excuse me, "Felt deeply depressed. I finally took a .5 of Ativan at 6:00 PM and now the thoughts are gone, and I feel good." You recall receiving that message?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: Okay. And fair to say there was no more communication between you and her until December 6th?
REBECCA JOLLOTTA: Correct. I believe December 3rd was a Saturday.
MS. BUCKINGHAM: And you actually were out of the office on the 5th with a sickness.
REBECCA JOLLOTTA: I was.
MS. BUCKINGHAM: But you are aware that Lindsay Clancy did reach out to the office on December 5th?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And that the nurse was able to respond to her to let her know that you were out sick, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And Lindsay Clancy responds at 8:30 AM that day that she would just reschedule. Or excuse me, Lindsay reaches out to the nurse and says, "That's fine, she'll reschedule," and that she, in fact, changed her appointment with Latiesha Dukes to a virtual appointment for that day, for December 5th.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: So on the 6th, when you return, did you have a scheduled meeting with Lindsay Clancy?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And on this particular meeting on December 6th of 2022, do you recall if that was an in-person or a virtual visit?
REBECCA JOLLOTTA: It was an office visit.
MS. BUCKINGHAM: Okay.
REBECCA JOLLOTTA: In person.
MS. BUCKINGHAM: And so just kind of looking at the note from that day, from December 6th—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: ... It says encounter date December 6th. It says filed on December 7th. In the—under chief complaint history, do you have it in front of you?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: The second paragraph says, "Patient has verbally consented to this video visit." Is that just something that sometimes pre-fills into the narrative?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: But your memory was that this was an in-person visit.
REBECCA JOLLOTTA: It was.
MS. BUCKINGHAM: Was Lindsay Clancy there by herself or with somebody else?
REBECCA JOLLOTTA: She brought in her husband, Patrick.
MS. BUCKINGHAM: Had you met him before?
REBECCA JOLLOTTA: I had not.
MS. BUCKINGHAM: Had you talked to him before?
REBECCA JOLLOTTA: I had not.
MS. BUCKINGHAM: As part of your treatment plan or your course of treatment with Lindsay Clancy, was it your practice to speak with collateral individuals?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And in this instance, did you feel a need to speak to collateral individuals up to this point?
REBECCA JOLLOTTA: Not up to this point.
MS. BUCKINGHAM: If you did, would you have requested that of her?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And do you need her express permission to do that?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: So on this particular day, she presented with her husband, Patrick, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And was there anything different about your approach to the meeting than your previous meetings with her?
MS. BUCKINGHAM: You still go through history. You go through how she's doing now. You do your mental status exam. You do your screenings, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And so first just let's talk quickly about the screenings. The Edinburgh screen, what was her score on this day when she came in? Do you remember?
MS. BUCKINGHAM: Okay. And the GAD-7, fair to say that screen was a 19?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: So would you say that it was pretty consistent with the last time that you saw her?
MR. REDDINGTON: Objection. Objection.
THE COURT: What's your objection?
MR. REDDINGTON: My objection is that that's not right. She's now got a 21 Edinburgh scale. Prior testimony was not anywhere near 21. It's in- clearly it's deteriorated.
THE COURT: Well, I'm gonna allow that question. On cross-examination you can certainly explore the basis of what her opinion was. So I'm gonna allow that question. Go ahead, Commonwealth.
MS. BUCKINGHAM: Well, let me ask you about that score of 21. It's 21 out of how much?
MS. BUCKINGHAM: So what, in what range is that?
REBECCA JOLLOTTA: Moderate severe.
MS. BUCKINGHAM: Okay. And on your previous encounter with her on—or your actual telehealth on November 29th, you reported that the score was 17, and that's moderate.
REBECCA JOLLOTTA: Moderate. Yep.
MS. BUCKINGHAM: And then on the GAD-7 on this particular day on December 6th, it was 19, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And on the previous visit it was 14.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Okay. So as far as your observations of her on December 6th,
MS. BUCKINGHAM: Did you notice anything different about her speech and language?
MS. BUCKINGHAM: How about her mood? What did you note her mood to be?
REBECCA JOLLOTTA: Anxious.
MS. BUCKINGHAM: And the affect, fair to say consistent with mood, meaning anxious, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And thought process?
REBECCA JOLLOTTA: Thought process was linear and goal-directed.
MS. BUCKINGHAM: And thought content, did she indicate to you whether she was experiencing any auditory or visual hallucinations?
MS. BUCKINGHAM: Any delusions?
MS. BUCKINGHAM: Any suicidal ideation, a plan, or intent?
MS. BUCKINGHAM: And as far as your observations of her during this interaction, this in-person visit, did you observe any signs of psychosis?
MS. BUCKINGHAM: Did you observe any signs of mania?
MS. BUCKINGHAM: Did you observe any signs of obsessive thoughts or compulsive behaviors?
MS. BUCKINGHAM: Now when you met with Lindsay and Patrick on December 6th, did she or did they report why Patrick was there?
REBECCA JOLLOTTA: I don't recall if they indicated why he was there. I understood it to mean he was there to provide collateral and support for her.
MS. BUCKINGHAM: Were you aware that he was coming to the appointment?
REBECCA JOLLOTTA: I don't recall if I was aware beforehand or not.
MS. BUCKINGHAM: And you had engaged in pretty significant MyChart back and forth with her in the days preceding this meeting on December 6th, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Did she ever indicate to you...
THE COURT: Go ahead.
MS. BUCKINGHAM: Did she ever indicate to you in those messages that she wished to bring him along to one of the visits?
MS. BUCKINGHAM: And fair to say when a person brings a collateral and is willing to have somebody speak, you're more than happy to get that information?
REBECCA JOLLOTTA: Absolutely.
MS. BUCKINGHAM: This person, this collateral person, can they offer you a different perspective about the patient and what they're going through or what they're—how they're presenting?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: In this December 6th meeting or the visit, did she report to you some changes in her sleep or significant concern for her sleep?
REBECCA JOLLOTTA: I'd have to review the note. What I remember is that the sleep really hadn't improved much beyond getting a few hours, waking up in the middle of the night, maybe piecing together—
MS. BUCKINGHAM: Okay.
REBECCA JOLLOTTA: ...more time.
MS. BUCKINGHAM: And fair to say there was some conversation to go back and talk about when symptoms started—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: ...and try to get to kind of the root cause or what they believe the root cause of her symptoms were?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And did Lindsay and Patrick report to you the connection with the Zoloft medication in September as a concern?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And that at that they reported that, or she reported, "That exact night I took, went from 25 to 50 milligrams. I didn't sleep for 48 hours, and I wasn't tired."
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: So that's in your note as a quote, meaning that's directly what she told you?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Okay. Did you express to the Clancy on this particular meeting...
THE COURT: Okay. Go ahead.
MS. BUCKINGHAM: Did you express to Miss Clancy thoughts that you had about her diagnosis based on your interactions—
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: ...over the last few weeks?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And what was that?
REBECCA JOLLOTTA: I discussed with her and her husband the possibility of potentially an underlying bipolar disorder. I based this on several factors, one of them being that she had such what we call an activating response to the Zoloft. It's unusual for somebody to describe taking Zoloft and then going 48 hours without sleep and not being tired. So that raised my clinical suspicion a bit, and she had been, I would say, having difficulty tolerating other antidepressant medications that we had been trying to have her take since then. And so again, I'm wondering if it's because potentially there might be an underlying what we call mood disorder, bipolar disorder.
MS. BUCKINGHAM: And as far as the information that you had about her past psychiatric history, were there any indicators to you...
MS. BUCKINGHAM: ...about manic episodes?
REBECCA JOLLOTTA: No. So I do recall in reviewing Julie's note prior to meeting with Lindsay, she filled out what we call a mood disorder questionnaire. It's like a screener somebody can do to assess a history of mania and bipolar disorder. Lindsay had... It was a negative screen. So there's three questions. One question has 13 different symptoms. You have to score seven of, out of 13 on question one, but also on question two it asks about, are the symptoms happening at the same period of time, and then it asks about any functional impairment from the symptoms. So she, I recall the three symptoms she did endorse were not sleeping for that period of time with the Zoloft and not feeling tired, having racing thoughts, and trouble concentrating. None of the other symptoms did she endorse. They did occur at the same period of time, and I don't wanna be inaccurate. I can't remember what she said for functional impairment. But I believe it was minor impairment.
MS. BUCKINGHAM: Okay. And so the fact that those were reported—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: ...but ultimately the full screen revealed negative for potential mania.
REBECCA JOLLOTTA: I did also consider, though, that the MDQ is less specific when it comes to bipolar II or bipolar not otherwise specified. There's bipolar I and bipolar II. Both have mania symptoms as part of the diagnosis. Bipolar I is usually more severe in that it's typically, you know, a patient might be hospitalized or it causes greater functional impairment. Bipolar II, it's a shorter duration, and typically less functional impairment.
MS. BUCKINGHAM: And as far as determining diagnostically whether somebody might be presenting with bipolar disorder, is there a particular tool you use in your trade to try to assess that?
REBECCA JOLLOTTA: Typically something like the MDQ, and then you'll do more of an interview asking the patient about symptoms specifically and if they can ever recall a time where this may have happened in the past, 'cause sometimes patients can't always remember when they're manic. So I was glad to actually have Patrick in the visit because he could sort of help us look at Lindsay's history more longitudinally or at least since the time he knew her.
MS. BUCKINGHAM: Okay. And as far as—so those tools that you're talking about, the MDQ—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: …kind of screening tools that you use in practice, is there another tool that you use to assess whether a person meets particular criteria to be diagnosed with bipolar I or bipolar II?
REBECCA JOLLOTTA: There are others, not ones that I've used.
MS. BUCKINGHAM: So are you familiar with the DSM-V?
REBECCA JOLLOTTA: Oh, yes, yes.
MS. BUCKINGHAM: Okay. So, while that's not the end-all be-all—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: …it is a guide that tells you specific criteria, how to determine if episodes are manic or depressive, right, when it comes to bipolar?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: The difference between mania and hypomania.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And so while you noted that there were some concerns reported—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: …did what was reported to you rise to the level of diagnostic criteria for bipolar disorder?
REBECCA JOLLOTTA: Not at that time.
MS. BUCKINGHAM: Okay. And when you explained this to them, your thoughts about her reactions to the medication and these reported prior symptoms, did Patrick and Lindsay seem receptive to your diagnosis?
REBECCA JOLLOTTA: I recall Patrick saying, "My wife is not bipolar." Lindsay looked at me. She did not, she did not say anything.
MS. BUCKINGHAM: Okay. And was this the first time, in this meeting on December sixth, where you broached that issue or mentioned that?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Okay. Did the conversation continue about symptoms and managing symptoms after that?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Were you able to get any more specific information from Patrick during that meeting? Not what the information, what he said particularly, but did you get additional specific information that kind of helped you assess whether you would change your diagnosis at that point?
MS. BUCKINGHAM: And were there still concerns in that particular meeting that the focus was trouble sleeping and the potential for addiction?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: As far as recommendations, did you talk about what's called tapering medication?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And what were your recommendations regarding tapering?
REBECCA JOLLOTTA: So we talked about her concerns about the benzos. And we decided to come up with a plan to taper off of them.
MS. BUCKINGHAM: And the last that had been reported to you via the MyChart messages was that she tried not taking it at all, ended up having horrible thoughts and felt deeply depressed, then took it and felt better, right?
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: So was it realistic to recommend completely stopping?
MS. BUCKINGHAM: So what is a taper? Like, why do we, why do you recommend tapers?
REBECCA JOLLOTTA: I recommend tapers to slowly get somebody off of something. And tapers can be useful 'cause we might have somebody at a dose and they might say, "Oh, I'm too anxious to stop this," or, "I'm not ready to step down to another level," and we can kind of keep them on it longer. But at this point, since I had met her on November 29th and throughout the MyChart messages, there was multiple concerns voiced about benzodiazepines. And again, in this visit, so I even did what's called a CIWA assessment, which is something we use to determine if somebody's having actual withdrawal from benzodiazepines or alcohol. Again, I really wanted to show her I was assessing this and taking this seriously.
MS. BUCKINGHAM: When you say CIWA assessment, is that an acronym for something?
REBECCA JOLLOTTA: Yes. So it's—
MS. BUCKINGHAM: What are the letters? Just for the record.
REBECCA JOLLOTTA: C-I-W, CIWA. CIWA.
MS. BUCKINGHAM: Okay. And did you, it... When you do that assessment, does it give you some sort of score—
REBECCA JOLLOTTA: It does.
MS. BUCKINGHAM: ... ask the questions? And what was her score when you did that CIWA assessment?
REBECCA JOLLOTTA: One.
MS. BUCKINGHAM: And what does that mean?
REBECCA JOLLOTTA: Minimal to no withdrawal. Her, the only symptom she reported was anxiety. Her blood pressure was normal. Her pulse was normal. She had no nausea, no vomiting, no tremor, no tactile disturbances. People in withdrawal from benzos or alcohol will sometimes feel like there's bugs crawling or pins and needles. Auditory disturbances, so hearing things, seeing things. No sweats, no headache. She was oriented.
MS. BUCKINGHAM: Okay.
MS. BUCKINGHAM: So with that, and knowing that she wasn't in withdrawals for Ativan, did you still recommend the taper and an alternative?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: What was that?
REBECCA JOLLOTTA: I recommended Valium. The reason I recommended this is she had discussed rebound anxiety with me at our very first visit, feeling that rebound anxiety above her baseline once the benzo wears off. Valium has an extremely long half-life. It can... As in, like, 100 hours. It has a longer clinical duration of action. So I wanted to offset the chance that she would experience rebound anxiety. And it's often used when we're tapering somebody on shorter acting benzos. It's common practice to switch to longer acting benzos to do this.
MS. BUCKINGHAM: And did you also have conversations about the other medications that had been at issue, the mirtazapine and the Seroquel?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Did... What did the defendant, what did Lindsay Clancy express to you as far as Seroquel? Did she wanna continue with that?
MS. BUCKINGHAM: Did she explain why?
REBECCA JOLLOTTA: So she felt like when she took Remeron and Seroquel together, she felt weighed down and exhausted, but her mind was still awake and alert. And she just didn't seem to think there was a benefit to being on it.
MS. BUCKINGHAM: And so did she express to you a desire to wanna go back to trialing Prozac?
REBECCA JOLLOTTA: Both Lindsay and her husband expressed that that was their preference.
MS. BUCKINGHAM: And was that something that you agreed with?
REBECCA JOLLOTTA: I did. I had shared with them that I had concerns, could be bipolar. It's in my differential diagnosis, which is just all the typical diagnoses we might be considering. And that typically SSRIs are contraindicated, but she did have that history of being able to tolerate Prozac at 20 milligrams and do okay with no mania. So I thought that's what they were wanting to do, so we could do it. We could try it.
MS. BUCKINGHAM: When you say contraindication—
REBECCA JOLLOTTA: Okay, sorry.
MS. BUCKINGHAM: … What does that mean?
REBECCA JOLLOTTA: It means typically not something you would want to do if you were sure somebody had bipolar disorder. Because if you put somebody on just an SSRI or, like Prozac, like Zoloft, it can create a scenario where people are flipping back and forth between manic symptoms and depressed symptoms, or they're called rapid cycling. It's not that antidepressants or SSRIs are never prescribed in bipolar disorder, but you often would wanna have a mood stabilizer on board at the same time.
MS. BUCKINGHAM: And so, despite your suspicions, you listened to the patient and went along with her request.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: So at the conclusion of that meeting, did you indicate that she could discontinue the Seroquel at that point?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: With the plan that she was gonna restart Prozac?
REBECCA JOLLOTTA: Yes.
REBECCA JOLLOTTA: Which I had been recommending the Prozac earlier. I believe even on November 30th I had recommended it.
MS. BUCKINGHAM: And would that previous recommendation, it was in addition to—
REBECCA JOLLOTTA: The Remeron.
MS. BUCKINGHAM: … The Seroquel?
REBECCA JOLLOTTA: And the Remeron, yes.
MS. BUCKINGHAM: So after this meeting on December 6th,
MS. BUCKINGHAM: Did you have additional communications with Lindsay Clancy via the MyChart messaging on December 7th?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And fair to say that those communications started as early as nine forty-eight AM when she sent the first message, right?
REBECCA JOLLOTTA: Let me just make sure.
REBECCA JOLLOTTA: Oh, yes, yes.
MS. BUCKINGHAM: So on December 7th at nine forty-eight AM, she sends a message saying, "Hi, Rebecca. Last night did not go well at all. I took the Valium and melatonin and slept only, only slept from nine to one. Then around two I got desperate and took twenty-five milligrams of Benadryl and only slept about one more hour. What can I do? I really need help." So that was the message that you came into on December 7th, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: And did you respond to her in the messaging app?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: And what was the response?
REBECCA JOLLOTTA: I'm trying to find the sequence.
MS. BUCKINGHAM: Yeah. At ten nineteen AM.
REBECCA JOLLOTTA: Then it gets cut off.
REBECCA JOLLOTTA: Okay. So I mentioned, "So your husband made a good point yesterday. Despite taking the Ativan in the evening, you were still only able to get a five-hour stretch of sleep, which, yes, is improvement, but does sort of dispel the notion that benzodiazepines are the only thing that are helping you sleep right now, as you are still getting less than the target of six to eight hours with Ativan, and the Valium did not help for sleep much at all. My next step in this case is to try a higher dose of Seroquel on its own. Are you feeling any subsequent loss of energy, exhaustion, fatigue with lack of sleep?"
MS. BUCKINGHAM: Why would it be the next step to increase from seventy-five of Seroquel to one hundred?
REBECCA JOLLOTTA: So she had been taking fifty, so I was suggesting seventy-five to a hundred would be my next step. Because again, bipolar's still on my differentials, and now I have the data that she only slept two hours, so I asked her the follow-up question, "Are you feeling tired?" Or, you know, "Are you feeling exhausted? Any subsequent loss of energy?" It's still in the back of my mind that this could be bipolar.
MS. BUCKINGHAM: So as far as the Seroquel goes at that point, creeping up the dosage, do you get now from the using it to treat insomnia to using it to treat something else like bipolar?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And so, that piece of it about feeling subsequent loss of energy and exhaustion, fatigue. Why ask that?
REBECCA JOLLOTTA: Patients can have insomnia because they're anxious or because they're depressed. But typically they're exhausted or they're tired the next day, and it really does affect them. If a patient has an underlying bipolar, they could go on two hours of sleep and not feel tired at all, and that's unusual.
MS. BUCKINGHAM: And so that is one of the signs potentially of a manic episode?
REBECCA JOLLOTTA: Potentially, yes.
MS. BUCKINGHAM: So on December 7th at ten thirty-three, she responds, "No, the weird thing is I don't feel tired at all." And she says, "So just Seroquel tonight?" Question mark. "I feel like I'm going to panic without a benzo with it." And then again at eleven forty-four, another message. "Would it, I be able to do the Valium with Seroquel? Is that a safe option?" So again, in this exchange with her in MyChart, she's asking you questions to clarify what you've said and also alternatives to address the issue, right?
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: And as far as her questions go and then her response about not feeling tired, how did you respond in the message?
REBECCA JOLLOTTA: So she kind of sent those in succession, so the "I don't feel tired, would I be able to do the Valium with the Seroquel?" So I respond by, "If you're not sleeping well with the Valium alone, there's no need to continue it, and I will prescribe a short taper to get you off benzos altogether. Because you are not tired at all and had a significant reaction to Zoloft at fifty milligrams, I'm concerned this is an underlying mood and bipolar disorder. I know you and your husband did not necessarily agree with that, but I feel that I'm going to send along this information to review." So I sent her a list of symptoms of bipolar risk factors, so that she could have it to refer to.
MS. BUCKINGHAM: And again, at this point, the only symptom she was reporting of mania was this not being able to sleep and not feeling tired, right?
REBECCA JOLLOTTA: And yes, and the racing thoughts and the trouble concentrating.
MS. BUCKINGHAM: Okay. Is that things that she had reported to you in your visit on the sixth?
MS. BUCKINGHAM: Okay. In these messages that she was sending to you in her—
MS. BUCKINGHAM: On December seventh, she didn't talk about racing thoughts, did she?
MS. BUCKINGHAM: Okay. She just talked about the sleep.
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: Okay. But based on a review of her history, she had at one point indicated that she was feeling those in relation to a symptom she was describing. Is that—
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: So at this point, what do you recommend her to do?
REBECCA JOLLOTTA: I explain the importance of knowing if this is bipolar is significant, because SSRIs like Zoloft and even Prozac would be contraindicated. My recommendation is to do 100 milligrams of Seroquel tonight, 200 milligrams of Seroquel tomorrow night, 300 milligrams on 12/9, 400 on 12/10, and we will hold there. I actually say hold the Prozac, as I'm concerned this is a hypomanic mixed manic state.
MS. BUCKINGHAM: And what about the Remeron at that point? Where did this fall into the mix, if it fell in at all?
REBECCA JOLLOTTA: I had recommended a very short taper on December 6th. I think I advised her to take half of a 7.5 milligram tablet for three nights, but in her message to me on December 7th, she had not taken it that night. So I had assumed she had just stopped that entirely.
MS. BUCKINGHAM: Okay. Now, after you sent that message at 12:32—
MS. BUCKINGHAM: Did she respond at 2:53 indicating that she would stick with that plan, and that she said she needed a refill on the Seroquel because she only had 30 25 milligram tablets?
REBECCA JOLLOTTA: There were actually... She did say that. There were actually a few earlier messages as well that day. I provided an alternative. One as an option, it quickly came into my mind, "Oh, we're thinking about Prozac. We could add Zyprexa on board," because there's actually a combination pill of Prozac/Zyprexa. The brand name is Symbyax, and it's for bipolar. And I said, "For our purposes, we can prescribe them separately and take them both for the same effect." And I asked her to let me know which one she would prefer, and she responded, "I think I would like to do the Seroquel with the Valium taper."
MS. BUCKINGHAM: Okay. So that suggested alternative actually was on at 12:37.
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And then at 1:00, she elects that she'd like to do the Seroquel with the Valium, and asks for you to call in the Valium and the Seroquel.
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: Okay. So that's on December 7th, right?
REBECCA JOLLOTTA: Yes.
MS. BUCKINGHAM: On December 8th,
MS. BUCKINGHAM: At 6:35 AM, she sends you a message saying, "Did well last night. Need Valium. Feeling panicky. Don't know if ready to taper as quickly as planned."
MS. BUCKINGHAM: Kind of paraphrasing, but...
REBECCA JOLLOTTA: Yeah. She explained, "I actually did really well last night with the Valium and Seroquel. I mostly slept from 9:00 to 5:00 with a few wake-ups, but was able to go back to sleep." She was concerned that she felt like she needed to take the Valium around 5:00 'cause, PM, 'cause she was feeling panicky. "I feel really dependent on it. Can I taper any slower?"
MS. BUCKINGHAM: And what was your response to her request for a slower taper?
REBECCA JOLLOTTA: I said, "I'm hesitant to taper any slower. Remember, Valium has a really long half-life, 100 hours, so you will have some on board in your system throughout the weekend."
MS. BUCKINGHAM: And why were you hesitant to taper any slower?
REBECCA JOLLOTTA: I felt like she was anxious about being dependent on it. And so I was trying to facilitate the process of tapering her off, and I was clinically thinking we could cover her symptoms of anxiety as we titrated the Seroquel, 'cause Seroquel actually has several clinical trials that show it has really good efficacy for anxiety.
MS. BUCKINGHAM: And this conversation about the request to taper, that actually goes into February... Excuse me, December 9th of 2022, correct?
MS. BUCKINGHAM: And in her response to your indicating you were hesitant to taper, she indicates that she took the five milligrams of Valium, and that she didn't have any left, and that she was afraid that she was gonna take Ativan.
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And had you recommended to take Ativan as a alternative or in lieu of Valium?
MS. BUCKINGHAM: Were there any more communications on that day, February... Excuse me, December 9th of 2022?
MS. BUCKINGHAM: What were they?
REBECCA JOLLOTTA: Later that afternoon, Lindsay and her husband called.
MS. BUCKINGHAM: Okay. And so did you—fair to say they called the clinic, leave a message, and then you called them back?
MS. BUCKINGHAM: And when you called them back, what was the nature of that conversation? What'd you guys talk about?
REBECCA JOLLOTTA: Her symptoms, we discussed that the plan was to taper the Valium over the weekend, but they both agreed that Lindsay's symptoms were too acute. She's sleeping better, but still waking up with panic symptoms and intrusive thoughts, feels numb, has thoughts of SI, but no plan and no intent. I encouraged her to engage with Women and Infants in Rhode Island to complete an intake for a higher, partial hospitalization program. But she was able to contract for safety over the phone with her, with the three of us on the phone, that she didn't have a plan, no intent, that she would reach out if needed. I did agree to continue the Valium until our next appointment, which was scheduled for 12/13. I prescribed it as five milligrams, but I advised her she could take a half tablet twice a day, so two and a half milligrams twice a day.
MS. BUCKINGHAM: So—walk me through that.
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: She had indicated to you that she wanted to slow the taper.
MS. BUCKINGHAM: And then you said that wasn't a good idea.
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: And then on the 9th, they call you and say that she doesn't wanna taper. She wants to stay at where she is, right?
REBECCA JOLLOTTA: I think it was that same day. The messages were earlier in the day, and then later in the afternoon around—it's noted at 16:10, so 4:10 PM, that she and her husband then called, advocating to—
MS. BUCKINGHAM: Okay.
REBECCA JOLLOTTA: ... stay on.
MS. BUCKINGHAM: And in advocating to stay on the Valium, she reported she's still waking up with panic symptoms and having intrusive thoughts, feeling numb, right?
MS. BUCKINGHAM: So in addition to agreeing to continue the Valium, did you make a recommendation about the Seroquel?
REBECCA JOLLOTTA: Continue the titration.
MS. BUCKINGHAM: So when you say titration, what does that mean?
REBECCA JOLLOTTA: So, I had recommended 100 on day one, 200 day two, 300 day three, 400 day four. This is the manufacturer-recommended titration schedule to treat manic symptoms. Because again, I had shared with her, I think this is a mixed manic/hypomanic state. So that's what I was targeting.
MS. BUCKINGHAM: Okay. And so, as far as Seroquel goes, there's some guidance you get about Seroquel that's put out by the FDA, right?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And it talks about dosage and administration for particular... for every drug essentially, right?
MS. BUCKINGHAM: And as far as Seroquel goes, there is different recommended dosages or ranges for different mental illnesses that you're treating.
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: So in this instance where bipolar is in your differential diagnosis and you're recommending titrate up to 400, is that consistent with the thought that you believe she had bipolar diagnosis?
REBECCA JOLLOTTA: Right. So I was thinking it was a mixed manic state or possible hypomanic state. A mixed manic state is when patient has symptoms of mania like poor sleep, no loss of energy, but they also can feel depressed, numb, suicidal. It's sort of like, it's a mixed state. It's a mixture of symptoms. That, a mixed state presentation, is clinically acute. It's unstable. So I really wanted to get the manic symptoms under control. I really wanted to get her to sleep.
MS. BUCKINGHAM: And so going up slowly to 400 milligrams, what's the recommended dosage range for somebody with bipolar disorder of Seroquel?
REBECCA JOLLOTTA: For somebody, a manic presentation, you can titrate over days rather than weeks. You can actually go up to 800 milligrams.
MS. BUCKINGHAM: And so, even though you had previously indicated to them in your December 6th meeting that you were agreeable to discontinuing the Seroquel—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: ... based on her presentation in the days following, did you change your recommendation?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And with the increased Seroquel that you had requested as of December 9th, she was reporting sleeping better, right?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And that had been something that had been a recurring concern in your interactions with her, sleep?
REBECCA JOLLOTTA: Yes. My understanding was that she had been sleeping poorly since October.
MS. BUCKINGHAM: And was there... When you say you were recommending partial hospitalization during that phone call, did you give a particular place in which you would recommend her to try to seek treatment?
REBECCA JOLLOTTA: Women and Infants.
MS. BUCKINGHAM: And that's in Rhode Island?
REBECCA JOLLOTTA: Rhode Island.
MS. BUCKINGHAM: And are you familiar with whether they have particular perinatal or postpartum programs there?
REBECCA JOLLOTTA: They specialize.
MS. BUCKINGHAM: After that call with the Clancys on December 9th, when was the next time you had contact with Lindsay?
REBECCA JOLLOTTA: December 9th was a Friday, so I believe it was Monday, December 12th.
MS. BUCKINGHAM: Now people are able to send MyChart messages all hours a day every day of the week, right?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: But in this instance, you did not receive any messages over the weekend?
MS. BUCKINGHAM: So the next MyChart exchange was actually on December 12th of 2022, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: Now, on December 12th, do you recall who initiated the contact via MyChart?
REBECCA JOLLOTTA: Lindsay.
MS. BUCKINGHAM: And at 1:59 PM, she sent a message to you saying, "I've been noticing on my Apple Watch that my heart rate has been fluctuating more than usual. It has been going from 56 to 136 within a matter of minutes. I'm wondering if this is a side effect of the Seroquel, and if there's anything I should do about it. Thanks, Lindsay." Do you remember getting that message?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: And again, at that point, as of December 12th, you had recommended the titration plan going up to 400, right?
MS. BUCKINGHAM: So, by that Monday, where should she have been if she was following your instructions?
REBECCA JOLLOTTA: 400 milligrams.
MS. BUCKINGHAM: And did she report to you whether she took 400 milligrams of Seroquel?
REBECCA JOLLOTTA: She reported she was taking 200 milligrams.
MS. BUCKINGHAM: Okay. Did she say why?
MS. BUCKINGHAM: But your recommendation was that she should've been up to 400 at that point?
REBECCA JOLLOTTA: At that point, yes.
MS. BUCKINGHAM: As far as the concerns about the fluctuating heart rate, were you able to address that with her in a response?
REBECCA JOLLOTTA: Yes. I explained that medications like Seroquel can cause something called orthostatic hypotension, which is basically when you get up from sitting or standing, your blood pressure doesn't compensate in time, so it goes low, and people can feel dizzy. I explained that the mechanism for that is alpha adrenergic blockade. So the alpha receptors that help us with, like, adrenaline. They're also part of the picture here with Seroquel. It's often accompanied by orthostatic tachycardia, meaning getting up from sitting to standing, your heart weight—heart rate can fluctuate. I said both can be common in the first days of medication exposure or when the dose is being increased. It's generally benign, meaning non-harmful, and self-limiting, meaning it goes away on its own over time. I also advised that sometimes necessitates slowing a dose titration or dividing a dose into, like, two or three smaller doses.
MS. BUCKINGHAM: Okay. And so, with this response, and trying to address these concerns, you're aware that she had spoken to the nurse that morning?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And that she had expressed to the nurse a desire to get off the medications altogether.
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And what was your response to that concern that she had in the call to the nurse? What did you tell her?
REBECCA JOLLOTTA: I said, "As long as you are aware of the risks, I don't think you've been on Seroquel long enough for it to have a positive benefit on your mood or anxiety. But if you've noticed benefit, if you have noticed benefit, the risk would be worsening of mood and anxiety upon stopping the medication. We also discussed tapering off the Valium, which I'm fine with, if you would like to send—like me to send along the taper schedule. Being off medication might help you see where you are at baseline, but I do think you are experiencing significant and severe symptoms of postpartum depression that needs to be treated. I acknowledge that medication alone is not always the best option for someone, but often it's part of the puzzle. Other treatments include counseling, support from others, exercise, healthy diet, yoga, and relaxation techniques.
REBECCA JOLLOTTA: I know this has been brought to your attention several times, but I strongly, strongly recommend a partial hospitalization program so that you can get started on utilizing these treatment methods for relief."
MS. BUCKINGHAM: And you were aware at this point, as of December 12th, that she had met with Latiesha Dukes at least once, right?
REBECCA JOLLOTTA: At least once, yes.
MS. BUCKINGHAM: She had been given referrals for CBT or cognitive behavioral therapy programs out in the community, in her community, right?
MS. BUCKINGHAM: There have been other recommendations for her to obtain a partial hospitalization program at that point.
MS. BUCKINGHAM: Now, anything about these exchanges that made you concerned that you had to kind of raise the level, meaning, call her in for another meeting or make any sort of recommendations for in-patient hospitalization?
REBECCA JOLLOTTA: Not at this junction.
MS. BUCKINGHAM: And why is that?
REBECCA JOLLOTTA: I wasn't—she wasn't reporting any acute safety concerns in these messages at this point.
MS. BUCKINGHAM: It was just physical—
REBECCA JOLLOTTA: Just physical.
MS. BUCKINGHAM: …side effects, is what it is.
REBECCA JOLLOTTA: Physical side effects, yes.
MS. BUCKINGHAM: So the messages continued on December 12th, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: So, at 2:44, Lindsay messages you saying, "Thank you, Rebecca. It does seem to be orthostatic, and I'm glad to hear that it's benign and known side effect." And then she tells you a little bit more about the prior nights, right? So she says, "So the last three nights I've taken 2.5 milligrams of Valium and 200 of Seroquel. I have to say that I do like the way it makes me sleep very deeply and soundly for around seven to eight hours, but I don't like the way I feel in the morning and most of the day. Incredibly depressed and unmotivated to do anything at all. What would you recommend for tonight?"
MS. BUCKINGHAM: Is that the next message after you explained to her the side effects?
MS. BUCKINGHAM: Okay. So on, for 10:00 PM you respond to her, don't you?
MS. BUCKINGHAM: And what did you recommend to address those concerns about incredibly depressed and unmotivated?
REBECCA JOLLOTTA: So at this juncture, I recommended at least continuing the 200 of Seroquel because at least now she's sleeping. So I felt like although I had recommended getting up to 400, we had gotten sufficient, like, activation symptoms down. She was sleeping. And the 2.5 of Valium. I think I advised that, "We need to give time for Seroquel to work for your mood. Let's continue to accumulate good nights of sleeps, as this can only be a good thing in terms of recovering and feeling better moving forward. I would say take them tonight and we will discuss further at our visit tomorrow."
MS. BUCKINGHAM: And you had a visit scheduled for December 13th, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: The message continues on that day where, at 7:17 PM, where she says, "Okay, thank you. I need to make our visit virtual tomorrow. I will not be able to make it to the office. Can you please change it to that?" Is that right?
REBECCA JOLLOTTA: Yes. Yes.
MS. BUCKINGHAM: So after having met in person with her on December 6th, having had subsequent communications with her through the date of December 7th, and kind of again changing a little bit about the medication plan and having further communication with her on December 9th and now December 12th, the plan was for her to again come in person on the 13th, correct?
REBECCA JOLLOTTA: That was my recommendation, yes.
MS. BUCKINGHAM: Why did you recommend in-person at that point?
REBECCA JOLLOTTA: This was somebody who was communicating with me every day, and I did feel that she had significant symptoms of depression, some mixed symptoms with mania, anxiety. I felt that her symptoms were severe and significant enough that I wanted to touch base with her weekly and I wanted to see her in person. But again, I was okay with her doing virtual because I'd rather see her and lay eyes on her and try to treat her than not see her at all if that would've made her just cancel the visit outright.
MS. BUCKINGHAM: Because generally you do the same thing whether you're in person or virtual, right?
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: As far as getting the history, going through symptoms, asking how they're feeling, doing the mental status exam, right?
REBECCA JOLLOTTA: Right. Mm-hmm.
MS. BUCKINGHAM: So you meet with her on December 13th at 10:30, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And now this is a virtual at her request.
MS. BUCKINGHAM: And do you revisit with her kind of the recent events and the timeline of the changes that you've gone through through the MyChart messaging?
REBECCA JOLLOTTA: Yes. I structured my note as like a recent treatment timeline. So I put, you know, 12/6, what had happened, 12, nine, what had happened, and then I write, "Update today 12/13." That's sort of for me to like remember the treatment history that I've had with her so far.
MS. BUCKINGHAM: Okay. Because while the MyChart messages are available to you, they might be in a different place, right? So they're not all contained within their same note.
REBECCA JOLLOTTA: Right. So I made note of, again, our visit on 12/6. I made note that her—she and her husband had called me on 12/9, and then I made note on the 13th. So I wasn't documenting all the MyChart messages, but just sort of my visit history with her and phone calls.
MS. BUCKINGHAM: Okay. And so when you saw her in this virtual visit on December 13th, was she reporting a improvement in her sleep?
MS. BUCKINGHAM: And how was she sleeping during that time period?
REBECCA JOLLOTTA: Seven to nine hours.
MS. BUCKINGHAM: Okay. And that was holding at 200 on the Seroquel?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And was she taking anything else daily?
REBECCA JOLLOTTA: Valium, 2.5, just once daily at night.
MS. BUCKINGHAM: Okay. And while she reported sleeping better, she still had significant symptoms of depression, right?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And what were the symptoms she articulated?
REBECCA JOLLOTTA: Hopelessness, and again, anhedonia, that feeling no pleasure, feeling numb.
MS. BUCKINGHAM: Okay. And she also kind of complained of that racing heart beat and that's tachycardia, right?
REBECCA JOLLOTTA: Yep, the orthostatic tachycardia. So I recommended holding a bit longer at 200 milligrams. At this juncture, she had been on 200 milligrams for four nights. I wanted to continue it for a full seven nights. And then we were still discussing whether to taper benzos, and our plan was to kind of slowly phase them out at that point. So we were gonna decrease from 2.5 milligrams daily to 2 milligrams for seven days, and then we were gonna reassess at our next visit in a week. I also provided psychoeducation about behavioral activation, CBT techniques to utilize for depression. I also recommended postpartum.net for support groups, and I reiterated that she consider a partial hospitalization.
MS. BUCKINGHAM: And again, during this telehealth visit, you have these conversations with her, but you also do your mental status exam. You make observations of her, right?
MS. BUCKINGHAM: Did you observe any signs of mania?
MS. BUCKINGHAM: Did you observe any signs of psychosis?
MS. BUCKINGHAM: Did she articulate to you any suicidal ideation?
REBECCA JOLLOTTA: She had endorsed that she had had thoughts of it on the Edinburgh, over the previous weeks that she sometimes had thoughts of harming herself, but not at that visit.
MS. BUCKINGHAM: Okay.
MS. BUCKINGHAM: And would that have been something you'd follow up on? Would that statement from the Edinburgh or—
MR. REDDINGTON: Objection.
MR. REDDINGTON: Would that be something you'd follow up on?
THE COURT: No, I'll allow that.
REBECCA JOLLOTTA: So just to clarify, so again, the Edinburgh—
MR. REDDINGTON: After coming from the witness, Judge, I'm sorry.
THE COURT: Objection overruled. Next question.
REBECCA JOLLOTTA: The Edinburgh is over the previous seven days. So she had that thought sometimes. When I asked her, "Are you currently having SI?" It was no during the visit.
MS. BUCKINGHAM: Okay. And it just was the response sometimes?
MS. BUCKINGHAM: And so, did you ask further in your interaction with her on that day on the 13th about whether she was experiencing suicidal ideation?
MS. BUCKINGHAM: Did she say she was?
MS. BUCKINGHAM: Did she indicate whether she had any plan or intent?
MS. BUCKINGHAM: And as far as intrusive thoughts, did she speak about intrusive thoughts during that meeting?
MS. BUCKINGHAM: Did she tell you she was having horrible thoughts?
MS. BUCKINGHAM: And she had previously used that terminology in your MyChart exchanges, correct, at some point?
REBECCA JOLLOTTA: She's... I do remember the intrusive thoughts that she would mention. Intrusive thoughts. I don't recall horrible thoughts—
MS. BUCKINGHAM: Okay.
REBECCA JOLLOTTA: ... in the MyChart messages.
MS. BUCKINGHAM: As far as the intrusive thoughts—
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: … were they things that you followed up on in your telehealth or in-person visits?
REBECCA JOLLOTTA: Mm-hmm.
MS. BUCKINGHAM: And was she able to articulate to you—
REBECCA JOLLOTTA: Yes. Yes, I know. Sorry.
MS. BUCKINGHAM: Was she able to articulate to you what types of thoughts she was having?
MS. BUCKINGHAM: What were they?
REBECCA JOLLOTTA: Intrusive suicidal thoughts.
MS. BUCKINGHAM: So thoughts of harming herself or just wanting to die?
REBECCA JOLLOTTA: Thoughts of wanting to die.
MS. BUCKINGHAM: At any point did she ever indicate to you thoughts of wanting to harm her children?
MS. BUCKINGHAM: So at the conclusion of this visit on December 13th, what was the plan?
REBECCA JOLLOTTA: The plan was to continue Seroquel 200 milligrams and Valium 2 milligrams.
MS. BUCKINGHAM: Okay. And again, in this December 13th meeting, did you also indicate to her that she should engage with other services like support groups or partial hospitalization programs or CBT?
REBECCA JOLLOTTA: I did.
MS. BUCKINGHAM: Do you recall whether you received any MyChart messages from her after that visit on the 13th?
REBECCA JOLLOTTA: I did.
REBECCA JOLLOTTA: I actually sent her a message on the 13th.
MS. BUCKINGHAM: Okay. So on the 13th you meet with her at 10:30. At 2:27 you sent her a message. Why?
REBECCA JOLLOTTA: I wanted to send along some more ideas and information on what she could do to help herself feel better.
MS. BUCKINGHAM: Because even though she was reporting sleeping better, she was still presenting with these depressed symptoms, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And so, in the message you sent her on December 13th—so actually a fairly lengthy message that talks a lot about cognitive behavioral therapy, right?
MS. BUCKINGHAM: And the benefits of it, and sends encouraging words.
MS. BUCKINGHAM: Does she respond to you on the 13th?
MS. BUCKINGHAM: The next contact you have with her, is that in a MyChart message on December 16th?
MS. BUCKINGHAM: And December 16th, 12:50 PM.
REBECCA JOLLOTTA: Oh, no, I apologize. The next contact with her, there was a telephone call on December
REBECCA JOLLOTTA: 15th.
MS. BUCKINGHAM: Okay. Was it with you or was it with a nurse?
REBECCA JOLLOTTA: It was with me and her husband and Lindsay.
MS. BUCKINGHAM: Okay. Sorry about that. So December 15th at 3:53 PM, you have a phone call with them, and what do they report to you in this phone call? What does Lindsay report?
REBECCA JOLLOTTA: They inform this has been the worst day for Lindsay, is having persistent intrusive thoughts of suicide. No active plan. But both Lindsay and Patrick agree that higher level of care may be necessary at this time. Discussed options. They state they are likely to go to MGH ED as they have perinatal psychiatry as well as an inpatient psychiatric unit. Lindsay also deciding about McLean. This writer advised that they keep us posted and sign a ROI, release of information, so that we can communicate with treatment providers at higher level of care. Lindsay verbalized understanding and agreement.
MS. BUCKINGHAM: So on this phone call that you had with them on 12/15, what prompted the recommendation that they go to the emergency department?
REBECCA JOLLOTTA: Again, they had described it as the worst day and was having persistent intrusive thoughts of suicide, and they were at the point where they were ready to get assessed for a higher level of care.
MS. BUCKINGHAM: And, was this different than some of the other communications that you've had with, or that you had had with Lindsay Clancy over the course of the weeks?
REBECCA JOLLOTTA: I would say so.
MS. BUCKINGHAM: Okay. And so, you talked to them about the process of going to the emergency department and the potential for going to McLean for inpatient?
REBECCA JOLLOTTA: I recall advising them that if they were to go to their nearest ER, which would either be BI Plymouth or South Shore Health, the process would be that they would get evaluated. But if they were determined to need to go to a higher level of care or an inpatient psych, those facilities did not have inpatient psych units. So they may be sitting there waiting for a bed at any, first opening in the state, which could be, you know, up in, you know, Amesbury or Newburyport. But that if they were to go somewhere like MGH, MGH has a unit called Blake 11, which is a psychiatry unit, and oftentimes they prioritize admissions from their own emergency department. MGH and McLean are also combined under the umbrella of what's now MGB. So sometimes if somebody presents to MGH ED and there's no beds at Blake 11, they might reach out to McLean and try to get them in to McLean.
MS. BUCKINGHAM: So you communicated all of this information to them to kind of give them options on, on-
REBECCA JOLLOTTA: Yeah.
MS. BUCKINGHAM: ... the best course might be to get inpatient?
REBECCA JOLLOTTA: Yes. I summarized it in my note, but that's my recollection of the phone call.
MS. BUCKINGHAM: Okay. And you're aware that Ms. Clancy had been employed at Mass General as a labor and delivery nurse?
REBECCA JOLLOTTA: I was.
MS. BUCKINGHAM: So they were familiar with that facility.
REBECCA JOLLOTTA: So I did ask, "Would you be comfortable with that?"
MS. BUCKINGHAM: And so then you were able to communicate with Lindsay via MyChart that next day on December 16th, correct?
REBECCA JOLLOTTA: She reached out to me on December 16th via MyChart, yes.
MS. BUCKINGHAM: And she indicated to you, on December 16th at 12:50, that she, "After visiting the ER yesterday, I opted to remain outpatient and pursue the partial program at Women and Infants." And Women and Infants, that had been the program that you had previously recommended in Rhode Island, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: She indicates, "I'm waiting on a call back for them to schedule. In the meantime, I want to know how to proceed with my meds. Do you still recommend the two milligrams of Valium and 200 of Seroquel nightly? Again, it's making me sleep well, but I'm not, but still not improving my mood. So I will need a refill on those meds. Please let me know." So in this particular message, she indicates to you that she was waiting to schedule with Women and Infants, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: Were you aware that prior to, that Latiesha Dukes had already initiated the referral process for Women and Infants?
MS. BUCKINGHAM: And so on this particular message, she's kind of updating you, but also asking you if she should stay on the same track for her medication.
MS. BUCKINGHAM: And what was your response?
MS. BUCKINGHAM: So December 16th at 1:14.
REBECCA JOLLOTTA: I said, "Hi, Lindsay. I know Latiesha may have called you yesterday about information about Women and Infants, so I hope you were able to connect with her. Target dose for Seroquel treating depression is 300 milligrams, so we can increase it to 300 milligrams if you are willing. Yes, continue the Valium. Let me know what you think."
MS. BUCKINGHAM: And why, at this point, did you recommend increasing now to the 300 after having recommended staying at 200 for the Seroquel?
REBECCA JOLLOTTA: The FDA-recommended dose for treating depression, bipolar depression, with Seroquel is 300 milligrams.
MS. BUCKINGHAM: So on December 16th, you continue to have messages with, MyChart messages with Lindsay Clancy, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: In any of... Or do you know that she went to see her previous psychiatrist on that day, December 16th?
MS. BUCKINGHAM: And so in her messages later in the day at approximately 2:11 PM, she indicates, "I spoke with my original psychiatrist after my ER visit, and she recommended adding 25 milligrams of Lamictal to stabilize my mood. Is that something you would agree with?" Had you ever talked with her about Lamictal before?
MS. BUCKINGHAM: No? Is it a drug that you kind of commonly recommend for people?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: And was it something that you thought could be a good fit for this patient?
MS. BUCKINGHAM: And so in your response to her at 2:26 PM, do you further talk about using it as a mood stabilizer?
REBECCA JOLLOTTA: Yes. I state, "Absolutely. Lamotrigine works well for mood stabilization and depression." I talked to her about the side effects of it.
MS. BUCKINGHAM: Fair to say those side effects are like rash and skin changes, fever.
MR. REDDINGTON: Can we have pointed out what the witness feels the side effects are rather than counsel?
THE COURT: Well, why don't we let the question be what was she told? All right. I think that's the proper question. So why don't you ask what was told or what was said or messaged to the defendant.
MS. BUCKINGHAM: Can you tell us what you messaged her the side effects were?
REBECCA JOLLOTTA: So I recommended it needs to be a slow titration, meaning titration, you know, increasing the dose due to risk of SJS, which means Stevens-Johnson syndrome, which can be a very serious rash that somebody can get. There's a higher risk of it if somebody takes Lamictal, which is why the FDA recommends such a slow titration, 25 milligrams for two weeks, 50 milligrams for two weeks, 100 milligrams. You can't really go quick with it. But I also specified it can cause a benign rash with—as a side effect. So any skin changes you notice, you wanna be sure are not accompanied by things like fever, malaise, pharyngitis, swollen lymph nodes. Also watch for a rash that is purpuric or tender. Benign rash would be spotty, non-confluent, non-tender, and no systemic features like fever. Otherwise, I find this medication to be quite well-tolerated. Take with food to minimize any risk of GI such as nausea. I will send this to your phar-—I can send this to your pharmacy along with the dose change in Seroquel. Any luck with hearing back from Women and Infants?
MS. BUCKINGHAM: So the Lamictal. Am I saying that correctly?
REBECCA JOLLOTTA: Lamictal.
MS. BUCKINGHAM: Is that something that you would add to the Seroquel?
MS. BUCKINGHAM: And why would you add it to Seroquel?
REBECCA JOLLOTTA: They can—they work differently. They have different mechanisms of action, and they can work well together.
MS. BUCKINGHAM: And so at that point, on December 16th, do you recall kind of what the last version of the medication recommendations were?
REBECCA JOLLOTTA: From me?
MS. BUCKINGHAM: Yeah. So at this point you added a medication. So what was on the prescribed or recommended list for you for her as of December 16th?
REBECCA JOLLOTTA: So I asked her if she needed me to send along the lamotrigine, and she said that she had had her psychiatrist send it along.
MS. BUCKINGHAM: Okay. So but as far as now what you know to be the medications that she's been advised to take—
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: ... what are they at this point on December 16th?
REBECCA JOLLOTTA: Lamotrigine, 25 milligrams, Seroquel, 300 milligrams, and Valium, two milligrams.
MS. BUCKINGHAM: And the Valium, is that still a daily recommendation?
MS. BUCKINGHAM: At the end of that message that you just read, you asked her if there was any luck with hearing back from Women & Infants, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: Did she respond to you in a message about what was happening with the Women & Infants? The next message at 2:33.
REBECCA JOLLOTTA: On 2:33 she said, "Unfortunately missed the call this morning from Women & Infants, but I did request them to call back. I'm hoping they do so today."
MS. BUCKINGHAM: Okay. And you said that you'd also learned in this exchange that her other psychiatrist had already called in the lamotrigine prescription.
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And then—
MS. BUCKINGHAM: Did you have any further communication with her on 12/16?
REBECCA JOLLOTTA: I said, "Okay, sounds good. I hope so as well." And that was it.
MS. BUCKINGHAM: Okay. When's the next time you spoke with her?
REBECCA JOLLOTTA: 12/16 was a Friday, so I spoke to her on Monday, December 19th.
MS. BUCKINGHAM: And again, did you speak with her via the MyChart messaging, or did you speak to her on the phone?
REBECCA JOLLOTTA: MyChart messaging.
MS. BUCKINGHAM: And were you aware that on December 19th she had another appointment scheduled with Latiesha Dukes for that morning?
MS. BUCKINGHAM: And in your communications with her via MyChart, they started at 11:04 AM on December 19th?
MS. BUCKINGHAM: And does she indicate to you in that message that she is starting with Women & Infants partial hospitalization tomorrow, meaning the 20th?
MS. BUCKINGHAM: And that she's concerned 'cause she has an appointment scheduled with you already, and she's asking what she should do about that, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And what was your response to her?
REBECCA JOLLOTTA: "So she has an appointment but should be in the program. Should I call and cancel or reschedule?" Because she thought the program would be starting her medication. I said, "I'm so glad you were able to get into the program this week. That's great. So feel free to call and reschedule. The only issue is that I am on vacation next week, so it might be two weeks out that we touch base again. If that's okay with you, let me know what you think."
MS. BUCKINGHAM: Okay. And her response at 1:24, that says, "I think since I'll be followed by Women & Infants, that two weeks out will be okay. My only concern is potentially needing more Valium before that. I'm trying my best not to take it at night, but have still been taking two milligrams every other night. Can we refill that just in case I continue to need it?" Right?
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: So at that point when she sends that message saying she needs the new prescription for Valium, was that in line with the recommendations you made for a taper of Valium?
REBECCA JOLLOTTA: I had recommended that she take it daily.
MS. BUCKINGHAM: Okay. And so in this she indicates to you that she's trying not to take it at night, but taking it every other night.
REBECCA JOLLOTTA: Mm-hmm. Correct.
MS. BUCKINGHAM: And on December 19th you respond, "Sure, no problem. When will you be out of Valium?" And she responds, "I'll run out tonight." And then you agree to send in the refill.
REBECCA JOLLOTTA: Yes. I wanted to make sure she had an appointment rescheduled with me, and then I would refill enough of the Valium to get to that next appointment.
MS. BUCKINGHAM: And so did you refill the prescription based on what she reported she was taking or what your recommendation was that she take of the Valium?
REBECCA JOLLOTTA: What my recommendation was that she take.
MS. BUCKINGHAM: And so…
MS. BUCKINGHAM: Do you recall receiving a message on December 20th via MyChart from Lindsay?
REBECCA JOLLOTTA: I do.
MS. BUCKINGHAM: And she reported to you that she had been discharged from Women & Infants that day, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And that they recommended she find help getting off the Seroquel, and that she was indicating that she'd like to taper the Seroquel.
MS. BUCKINGHAM: Did you respond that day or the next day?
REBECCA JOLLOTTA: The next day.
MS. BUCKINGHAM: Okay.
REBECCA JOLLOTTA: Her message came in at 8:05 PM, so I responded the next morning.
MS. BUCKINGHAM: Okay. At 10:57?
MS. BUCKINGHAM: And what were your thoughts about her report that she was discharged and the recommendation for tapering the Seroquel? Or getting off the Seroquel, I should say.
REBECCA JOLLOTTA: I said, "I'm not opposed to that. However, I'm concerned she discharged you as I do feel you could benefit from the groups and added support separate even from medication changes. In fact, if we're not going the medication route, I think groups and therapy are the treatment needed as I feel the intrusive thoughts you've been having are nonetheless concerning, and I know they've caused you considerable distress. I'm also on vacation next week, so I'm hesitant to start a taper when I am not available to you for questions and concerns. Again, I'm open to starting a taper, but I want to be available to you as it happens. You mentioned you are connected to your previous psychiatrist. Would that be someone to consult as well?"
MS. BUCKINGHAM: And so when you sent this message at 10:57, were you opposed to the idea of tapering the Seroquel?
REBECCA JOLLOTTA: I understood that it was helping her to sleep, and I also understood that she felt as though she was still depressed, and she wanted to come off of it.
MS. BUCKINGHAM: And in this correspondence back and forth on the 21st, was there any conversation about the lamotrigine, and whether she took it as a mood stabilizer?
MS. BUCKINGHAM: As far as coming off medication, was that something that you thought might be a good option for her?
REBECCA JOLLOTTA: As I had expressed to her, I was hesitant. It could be done, but she would need a lot of what I would recommend to be group support, therapy, other types of treatment.
MS. BUCKINGHAM: At that point, based on your interactions with her through the clinic, through all the messages, through the meetings that you've had, were you aware of whether she was getting any other support, like groups, other than Latiesha Dukes and yourself?
MS. BUCKINGHAM: And this partial-
MR. REDDINGTON: I apologize. Is she aware or no, she wasn't? She just said no.
THE COURT: Okay. If you could just…
MS. BUCKINGHAM: Are you aware of whether she was?
REBECCA JOLLOTTA: I was aware it was recommended. I was not aware that she was interacting with any groups.
MS. BUCKINGHAM: In the South Shore Perinatal Behavioral program, you have groups that are offered through the clinic, correct?
REBECCA JOLLOTTA: At that time, we did, yes.
MS. BUCKINGHAM: And if she was attending groups through the clinic, would that be something that you would have access to or it would be noted in her records?
MS. BUCKINGHAM: And as far as your communications with her, did she report to you that she was attending any sort of groups or therapy at other places in the community?
MS. BUCKINGHAM: The only person you were aware of that she was communicating with was her previous psychiatrist, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And that's why you made that recommendation to consult with her?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And what's your concern or what was your concern for not being available to her while you were on vacation with a taper?
REBECCA JOLLOTTA: I wanted to be there to evaluate if the taper was going okay, if she was suddenly having a hard time sleeping again. So maybe I could recommend that we go back up or, you know, just to reassure her to be there for her while this was happening.
MS. BUCKINGHAM: In your prior communications with her, she was very communicative with you about symptoms, about issues, about concerns, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And if you're on vacation, are you responding to My Chart messages?
REBECCA JOLLOTTA: There would be someone that would respond. It would've been my nurse, and they would've consulted with the two other N- ... Well, Julie, I had believe her last day was the 22nd, but they would've consulted with the other NP there. But I would not be available, no.
MS. BUCKINGHAM: And you were invested in this patient's care, weren't you?
MS. BUCKINGHAM: So on December 21st, after you made that recommendation that she not start the taper while you weren't available or consult with her psychiatrist, other psychiatrists, did you get a response from her at 3:57?
REBECCA JOLLOTTA: 3:50.
REBECCA JOLLOTTA: On December 21st?
MS. BUCKINGHAM: Yes.
REBECCA JOLLOTTA: I see 3:47.
MS. BUCKINGHAM: Oh, I'm sorry. That's what I meant to say.
REBECCA JOLLOTTA: Okay.
MS. BUCKINGHAM: So at 3:47, she responds back to you, correct? And gives you some more information about the Women and Infants recommendation.
MS. BUCKINGHAM: And it reads, "The psychiatrist at Women and Infants recommended a more general mental health PHP," partial hospitalization program, right?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: "Such as the one at McLean, which I'm open to. I'm also looking to schedule with a CBT therapist in Duxbury. My other therapists is, have appointments this and next week, so I can follow up with her too. How would you recommend starting the taper? I will need smaller pills, as the ones I have now are all 300 milligrams." Right? That's her response?
REBECCA JOLLOTTA: Yes. She says her other psychiatrist does have appointments.
MS. BUCKINGHAM: Okay. And in the meantime, she had also sent an email to the clinic. Are you aware?
REBECCA JOLLOTTA: I'm not aware.
MS. BUCKINGHAM: Okay. Do you know if she spoke with the nurse at some point on the 21st?
REBECCA JOLLOTTA: Yes. I asked my nurse to call to again go over the risks of tapering, which could include worsening of mood, worsening of sleep. Verify that this was really something she wanted to move forward with, remind her that I wouldn't be there.
MS. BUCKINGHAM: Okay. And on December 21st, 2022, at 4:26 PM, you respond to her in the My Chart message, right?
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: And you had expressed reluctance for the taper, but ultimately did you provide her a plan for taper?
REBECCA JOLLOTTA: Right. I said, "I know Nicole reached out to you, and she relayed that you would like to proceed with the taper. I'm sending as 100 milligram tablets, 200 milligrams, two tablets for four nights, 100 milligrams, one tablet for four nights, 50 milligram tabs, half tablets, times four nights, then off. Let me know of any issues."
MS. BUCKINGHAM: And is that a standard or slow taper off of Seroquel being at 300 milligram dose?
REBECCA JOLLOTTA: Considering the fact that she had only been taking it for a few weeks, yes. If she had been on it for months, I would've done a slower taper.
MS. BUCKINGHAM: And in addition to giving her that plan, you also had the nurse provide her with some information about DBT groups, correct?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And what's DBT?
REBECCA JOLLOTTA: Dialectical behavioral therapy.
MS. BUCKINGHAM: And how is that different from cognitive behavioral therapy?
REBECCA JOLLOTTA: Dialectical behavioral therapy, there's certain tenets to it, like emotion regulation, distress tolerance, interpersonal communication. There's a lot of skills to it. There's a—it's a very skills-based treatment. So we had recommended that as an additional support.
MS. BUCKINGHAM: And the next time you had contact with the Clancys, when was that after December 21st?
REBECCA JOLLOTTA: I believe that was my last contact with Lindsay.
MS. BUCKINGHAM: Okay. As far as the Perinatal Behavioral Health Clinic at South Shore, you're aware that on December 30th, Patrick Clancy called in about his wife?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And that he spoke to a nurse, Katrina Malanson?
MS. BUCKINGHAM: And the record reflects that he reported that she was safe, right? But she'd like to go to McLean.
REBECCA JOLLOTTA: I do recall that.
MS. BUCKINGHAM: Okay. And he was advised to take her directly to the emergency department. You can't just go there, to McLean, right?
REBECCA JOLLOTTA: Right.
MS. BUCKINGHAM: In your experience.
REBECCA JOLLOTTA: In my experience.
MS. BUCKINGHAM: And that he said he didn't wanna waste a day in the ED. Is that your recollection of the record?
REBECCA JOLLOTTA: That is my recollection of the record.
MS. BUCKINGHAM: And that he was looking just to get the bed that was offered the last time, on December 15th?
MS. BUCKINGHAM: And fair to say that that's not how the process works?
REBECCA JOLLOTTA: They do not hold beds for that length of time.
MS. BUCKINGHAM: Okay. And so then he was advised to take her to the emergency department or call 911.
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: And was that the last contact that the South Shore Perinatal Behavioral Health Clinic had with Lindsay Clancy?
MS. BUCKINGHAM: You were never advised or got any messages from her after she went to McLean, did you?
REBECCA JOLLOTTA: No. We did ch-
THE COURT: Okay. It's a... The answer's no. Go ahead.
MS. BUCKINGHAM: Did you learn anything about her course of treatment at McLean after the fact?
REBECCA JOLLOTTA: We had been wondering if she would come back to us. We did review the Mass PMP, which is sort of log of controlled scripts, and we saw that she had medications filled from her previous psychiatrist, Dr. Tufts.
MS. BUCKINGHAM: And that would've been—
MR. REDDINGTON: I'm gonna object and move to strike. It's not responsive to the question about McLean. She's now talking about—
THE COURT: Overruled.
MS. BUCKINGHAM: So the Mass PMP, what is that?
REBECCA JOLLOTTA: It is a database that shows when patients fill controlled scripts such as benzodiazepines.
MS. BUCKINGHAM: And as a prescriber that has a DA license, you're able to review that information for any patient?
MS. BUCKINGHAM: And so after the 30th when the call came in about going to McLean, you were able to identify that she was prescribed additional medicines by a different prescriber?
MS. BUCKINGHAM: And she never came back to the clinic?
REBECCA JOLLOTTA: Correct.
MS. BUCKINGHAM: During all of your interactions with Lindsay Clancy, did she always present with clear, linear thinking?
MS. BUCKINGHAM: Was she able to express to you her concerns and ask appropriate questions when necessary?
MS. BUCKINGHAM: And was she able to advocate for herself and express that she had some knowledge base about some of these medications?
MS. BUCKINGHAM: And at no point during the time that you—she was your patient or that she was at the clinic, did she ever indicate that she was—had a plan to kill herself or harm her children? Did she?
MS. BUCKINGHAM: Thank you. I have nothing further.
THE COURT: All right. Counsel, could I see you at sidebar?
THE COURT: So I'm gonna excuse you till around 2:00. Same instructions. No research. No talking about this case. I hope everybody has a nice little break here. We'll see you back here right around 2:00. Okay?
BAILIFF: Court. All rise. Jurors close your notebooks, place them on your chairs please. This way.
THE COURT: All right. So we'll be in recess on this matter till around 2:00, okay?