2.Avram Mack — Direct (Part 1)
643 linesMS. SPRAGUE: The Commonwealth will call Dr. Avram Mack.
COURT CLERK: Good morning. Do you solemnly swear the testimony you're going to give this court today will be the truth, the whole truth, and nothing but the truth, so help you God?
AVRAM MACK: I do.
COURT CLERK: Thank you. You may be seated, sir.
THE COURT: All right. Good morning, Doctor.
AVRAM MACK: Morning.
THE COURT: All right. I just ask you to keep your voice up so the jury can hear you. And with that, Attorney Buckingham, please.
MS. BUCKINGHAM: Thank you. Good morning, sir.
AVRAM MACK: Good morning.
MS. BUCKINGHAM: Could you please tell the jurors your first and last name?
AVRAM MACK: Avram Mack.
MS. BUCKINGHAM: And would you spell your name for the record, please?
AVRAM MACK: Avram is spelled A-V, like Victor, R, like Robert, A, like apple, M, like Mary.
MS. BUCKINGHAM: And I'm just gonna ask you to speak in a loud, clear voice, and if you need to kind of push closer to the microphone, that might help.
AVRAM MACK: I will.
MS. BUCKINGHAM: Thank you. What do you do for work, sir?
AVRAM MACK: I'm a psychiatrist.
MS. BUCKINGHAM: And how long have you been a psychiatrist?
AVRAM MACK: After training, I've been a psychiatrist for twenty-two years now.
MS. BUCKINGHAM: Can you tell us a little bit about your educational background?
AVRAM MACK: Sure. I went to the University of Michigan for college, Cornell University for medical school. I was here at the Brigham for residency in psychiatry, and then that was followed by a fellowship in child psychiatry at Columbia University and a one-year fellowship in forensic psychiatry at New York University.
MS. BUCKINGHAM: And what do you do now? What's your area of practice now?
AVRAM MACK: I'm a psychiatrist. For all these twenty-two years, I've been serving in a lot of different roles. Currently, I'm a professor of psychiatry at Thomas Jefferson University in Philadelphia, and I see patients at a child hospital called Nemours.
MS. BUCKINGHAM: And so you, in your current practice, have a clinical practice, and you also do forensic psychiatry. Is that correct?
AVRAM MACK: That's correct.
MS. BUCKINGHAM: And do you have any board certifications?
AVRAM MACK: I do.
MS. BUCKINGHAM: And what are you board-certified in?
AVRAM MACK: I'm board-certified in psychiatry, child and adolescent psychiatry, and also forensic psychiatry. I had been board-certified in addiction medicine by the American Board of Addiction Medicine, but they closed, so I don't know if I can still say that I'm board-certified by them.
MS. BUCKINGHAM: Okay. And to what extent are you engaged in the forensic psychiatry? What areas of forensic psychiatry have you testified in?
AVRAM MACK: I've provided testimony in perhaps almost every area of forensic psychiatry, ranging from testamentary capacity of adults who engage in contracts, or appropriateness for adoption or whether or not a person is competent or if a person is criminally responsible.
MS. BUCKINGHAM: Now, in what areas of the country have you testified on those topics?
AVRAM MACK: Around the country. I'm not sure how many states I've testified in, but I've been engaged in reviews or investigations of cases in, I think, more than half the states.
MS. BUCKINGHAM: And what does it mean to conduct a forensic evaluation in psychiatry?
AVRAM MACK: Well, it can mean a lot of different things depending on the question that's being asked by a court or other authority. Sometimes there are statutes that you as the forensic psychiatrist need to try to answer, a particular question that a statute requires. Or sometimes it is a matter of giving an opinion, say in a civil case, where it's your understanding of, say, the degree of harm that the person has experienced, sometimes great, sometimes not so great.
MS. BUCKINGHAM: And you, in your experience, have testified as a forensic psychiatrist in both civil and criminal matters, correct?
AVRAM MACK: Correct.
MS. BUCKINGHAM: And are you aware of a difference between forensic psychiatry versus forensic psychology?
AVRAM MACK: There are differences. Aside from the fact that they are both... They're different professions, but they both cover mental health. There are different rules that apply to forensic psychologists in their carrying out their roles as psychologists.
MS. BUCKINGHAM: Now, when you are... You mentioned that you have done some work and testified in matters regarding criminal responsibility, right?
AVRAM MACK: Correct.
MS. BUCKINGHAM: And you're aware that different states have slightly different statutes when it comes to criminal responsibility?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And so in this case, you were asked to review the matter of the Commonwealth versus Lindsay Clancy, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And so in order to do that, did you review the statutes here in Massachusetts regarding criminal responsibility?
AVRAM MACK: Yes, I did.
MS. BUCKINGHAM: And can you tell us how it came that you were involved in this case?
AVRAM MACK: I was asked by the prosecutor's office to be involved as a psychiatrist reviewing the matter.
MS. BUCKINGHAM: And when you're asked or you're retained by either side in a case, a defense or a prosecution, what is the goal of the evaluation? Are you just trying to advocate for the side who hired you, or are you conducting an independent evaluation of the evidence?
THE COURT: Overruled.
MS. BUCKINGHAM: You can answer.
AVRAM MACK: Well, to answer your question, certainly the goal is to provide an independent evaluation, or one would also add, to provide clarity and to say what can be said. In criminal matters, sometimes it's a very certain question that it's either a yes or a no. In other matters, it's not always necessarily a strict yes or a no.
MS. BUCKINGHAM: Now, in criminal matters where you were asked to conduct these independent evaluations, how do you approach it? What do you... kind of information do you seek or would you prefer to have in order to conduct the evaluation?
AVRAM MACK: Well, generally one starts with the statute, and then tries to gather or review what information exists to understand the mental state of the person, if that's pertaining to the particular statutory question. And to understand the mental history and the mental state of the individual and to see if that can be applied to the questions at hand.
MS. BUCKINGHAM: And so what types of records are you generally looking at when conducting a forensic evaluation for something like criminal responsibility?
AVRAM MACK: Well, one would certainly want to review psychiatric records if they exist. Ideally also to have examined the individual, and to gather information, not only historical information from the individual, but to do, in that sense, an examination in real time. And that provides you the information, what we call a mental status examination.
MS. BUCKINGHAM: Okay. And—
AVRAM MACK: Other records are also important, medical records, educational records, and other records that describe the individual.
MS. BUCKINGHAM: And when we're talking about a criminal case, fair to say you review the entire criminal file too, right?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And when you're doing these evaluations and creating a database of this particular information, are there any limitations to your opinion or evaluation?
AVRAM MACK: Not sure how you mean that.
MS. BUCKINGHAM: Well, when you have these evaluations that you're conducting, namely for criminal responsibility, do those evaluations, are they limited based on the information that you have? Meaning, if you don't have everything at the time you do your evaluation, is there kind of a caveat to your opinion?
AVRAM MACK: Well, when I write an opinion or state an opinion, it is based on the totality of the information that I have. If additional information comes along, I am open to receiving that and integrating that into my understanding of the totality.
MS. BUCKINGHAM: Now, when you interview the individual in these evaluations, the purpose of the interview or purpose of your contact with them is not to provide treatment, correct?
AVRAM MACK: Correct.
MS. BUCKINGHAM: And the opinion that you reach ultimately is based on the defendant's mental state, correct?
AVRAM MACK: To the extent that impacts the question, yes.
MS. BUCKINGHAM: Okay. Well, when we're talking about criminal responsibility, you'd agree that's the kind of the central issue, is the person's mental state at the time of the alleged offense, correct?
AVRAM MACK: That's correct.
MS. BUCKINGHAM: Okay. So in Massachusetts here, with the question of criminal responsibility, are you aware of what the standard is?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And what is it?
AVRAM MACK: Well, it uses particular language based on the common concept throughout the country called the McNaughton standard. And I could read to you the specifics of the language, but effectively it refers to two pieces. Well, actually starts with three. One is, did the person have a mental disorder—
MS. BUCKINGHAM: Mm-hmm.
AVRAM MACK: …at the time of the event? And then secondly, the two prongs, speak to specifics about the mental state at the time. One being, did the… And I would have to, I would wanna refer to the actual statute.
MS. BUCKINGHAM: Well, if we can, maybe we break that down for the jury.
AVRAM MACK: Yeah.
MS. BUCKINGHAM: So the first part of this for criminal responsibility, is the question of, does the person suffer from a mental disease or defect, correct?
AVRAM MACK: Correct.
MR. REDDINGTON: Objection to the leading. Let's see if he knows.
THE COURT: Yeah, if you just ask him.
MS. BUCKINGHAM: I can rephrase that.
THE COURT: He's aware, and if you wanna refresh his memory, you can.
MS. BUCKINGHAM: Well, you've already testified the first part of the analysis, and I think you used the terminology mental disorder, right?
AVRAM MACK: Yes, I did.
MS. BUCKINGHAM: And you're aware that a mental disorder is a clinical term?
AVRAM MACK: Yes.
MR. REDDINGTON: I'm sorry, I didn't hear that. I apologize. What was that?
MS. BUCKINGHAM: A mental disorder is a clinical term.
MR. REDDINGTON: Okay.
MS. BUCKINGHAM: The terminology mental disease or defect, are you aware that's a legal term?
AVRAM MACK: Okay.
MS. BUCKINGHAM: Okay. Well, so when you are conducting evaluations for criminal responsibility—
MR. REDDINGTON: Is that, is that an answer?
THE COURT: Yes.
MR. REDDINGTON: He said okay.
AVRAM MACK: I'm sorry, yes.
MR. REDDINGTON: Yeah, all right.
MS. BUCKINGHAM: When you're conducting an evaluation for criminal responsibility and you're trying to determine whether a person suffers from a mental disease or defect, do you look to mental disorders to see if that meets criteria?
AVRAM MACK: I would evaluate if the person has ever had a psychiatric or a mental disorder.
MS. BUCKINGHAM: And how—what kinds of tools do you have available to you to do that?
AVRAM MACK: Well, there are two tools. One is gathering of historical information, and the other is the information you gather from actually seeing the person face-to-face.
MS. BUCKINGHAM: And as a psychiatrist, that's something you do in your clinical practice all the time, right?
AVRAM MACK: Correct.
MS. BUCKINGHAM: 'Cause one of the main things you're going to do is look to try to diagnose an individual.
AVRAM MACK: Correct.
MS. BUCKINGHAM: And so, how do you go about determining that if a person has a mental disorder?
AVRAM MACK: In psychiatry, we make diagnoses in a descriptive manner. We look to see ways in which the individual has symptoms or signs of mental disorders or mental defects, or psychiatric disorders. So in particular, one will start with trying to gather as much information as possible about what are the things that bother the individual. That may be their mood, that might be things that they get anxious about, that may be abnormal movements that they make. And that will also be aligned with understanding their medical condition, any medications that they take, any substances that they use. There is a array of sets of information that one gathers in that portion where you ask questions, but effectively, you're asking questions about symptoms. And one is trying to understand not just symptoms, but the degree of impairment that symptoms might be causing an individual.
MS. BUCKINGHAM: Okay. And do you work with any sort of tools that help you identify particular characteristics of symptoms associated with disorders in your field?
AVRAM MACK: Well, at times, individuals use scales or tests, which can be psychological tests or scales that ask particular questions. Or other times, you might use tests that are biological tests, like the person brain waves called an EEG or laboratory tests.
MS. BUCKINGHAM: When you're talking about diagnosing an individual for any particular mental disorder, are there specific criteria for different types of disorders?
AVRAM MACK: Yes, there are.
MS. BUCKINGHAM: And is there a source that you use as a psychiatrist in order to identify the criteria for different disorders?
AVRAM MACK: We use a text called the DSM, otherwise known as the Diagnostic and Statistical Manual.
MS. BUCKINGHAM: Mm-hmm.
AVRAM MACK: It's currently in its fifth edition, or actually a revision was made of its fifth edition. And so that text, which is created and vetted by a large number of professionals, provides criteria for the different disorders, and these are known as operational criteria. In psychiatry, there aren't necessarily gold standards that you can use for diagnosis, like finding a bacterium or finding an anatomical tissue. So for the last sixty years, seventy years, psychiatry has turned to agreed upon definitions that are listed in the DSM.
MS. BUCKINGHAM: Okay. And you said it's not, it's not the end-all be-all, right, of diagnosing. You use your training and experience as well. But it's a tool that you use.
AVRAM MACK: Well, it is— they are the criteria that one uses to make the diagnosis. It is not a guidebook for how to gather that information. It's not a how-to, but it is the standard.
MS. BUCKINGHAM: Okay. So now going back to the legal standard here in Massachusetts, so one part is the disorder, right? And you said there's a second part.
AVRAM MACK: Right. So the second part are particular criteria about the person's state at the time of the event. So one of them is—they both utilize the verb 'to have retained,' retained substantial capacity to know that the act was wrong, or against the law, and the other being retained substantial capacity to control or conform one's behaviors to the law.
MS. BUCKINGHAM: Okay. And so, when you're talking about criminal responsibility here in Massachusetts, is it fair to say you're looking at the person's conduct and their condition at the time of the offense?
AVRAM MACK: That's right.
MS. BUCKINGHAM: And the information that you're gathering in this overall evaluation, getting history and kind of looking at the person as a whole, is that helpful to understand the person's diagnosis when you're being asked this particular question?
AVRAM MACK: Yes.
MS. BUCKINGHAM: But ultimately, you're rendering an opinion of the person at the time of the offense.
AVRAM MACK: That's correct.
MS. BUCKINGHAM: So in this particular case, you were provided a series of records and information regarding the defendant, Lindsay Clancy, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And can you just give us a general overview of the sources of information you had available to you?
AVRAM MACK: Generally speaking, there was the criminal file, as you mentioned before, and then in terms of medical or psychiatric records, there was the records from the hospital that she's at right now, the hospital that she was at right before called Spaulding, the hospital that she was at before that, which was Brigham and Women's. In addition, there was the medical records from outpatient treaters, and there was also the records from her admission to McLean Hospital. So, overall, there were outpatient records, there were inpatient records. For the most part, those all correlated with her own care. Additionally, we received the pediatric records for some of the victims in this matter. And as I mentioned before, the criminal file.
MS. BUCKINGHAM: Okay. And in addition to the records related to the defendant herself, we also provided some other reports to review—
AVRAM MACK: I was—
MS. BUCKINGHAM: ... by other psychiatrists and psychologists.
AVRAM MACK: Yes.
MS. BUCKINGHAM: Now you mentioned that one of the things that's useful in these evaluations is a interview with the person themselves, right?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And did you engage in an interview with the defendant?
AVRAM MACK: I did.
MS. BUCKINGHAM: And when did that occur?
AVRAM MACK: I interviewed her on April 10th and April 12th of this year.
MS. BUCKINGHAM: And that's of this year in twenty twenty-six?
AVRAM MACK: Correct.
MS. BUCKINGHAM: And what were your observations of her when you first met with her on April 10th? Can you describe her demeanor?
AVRAM MACK: Generally, she was friendly and cooperative. I—
MS. BUCKINGHAM: When you begin an interview with an individual that you're evaluating, do you conduct the—what's referred to as a mental status exam?
AVRAM MACK: Well, the mental status exam happens all the while that you're interacting with somebody. You're always observing for aspects of their emotions, how they speak, their mood, and so forth. Sometimes there are directed aspects of the mental status examination where you are asking about particular cognitive capacities like executive functioning and attention and concentration. But the gathering of information about the person's mood, for example, or their thought process, that happens throughout the entire portion.
MS. BUCKINGHAM: Okay. And so over the course of the time that you met with the defendant, were you able to make observations of, for instance, whether she maintained eye contact with you when speaking?
AVRAM MACK: Right. So she did maintain eye contact.
MS. BUCKINGHAM: Okay. What about her emotional state?
AVRAM MACK: So overall, if we go through the various components like what's called her affect, which was, or her emotional expression or her mood, generally speaking, there were not many abnormalities in her presentation, and I can go through them. They include the way in which she speaks, that is to say, the rapidity of speech, if the speech is made in sort of regular intervals between words. In terms of thought, does the person, and in this case, did Ms. Clancy make goal-directed ideas?
MS. BUCKINGHAM: Mm-hmm.
AVRAM MACK: Was there a particular content of the ideas? So generally speaking, for all the components of mental status examination, excuse me, there were not really abnormalities. I would say at some points she seemed distressed by some topics. I believe tearful at one point, but otherwise nothing remarkable on mental status examination.
MS. BUCKINGHAM: Okay. And in these evaluations when you're interviewing the individuals, are you also kind of taking account of their physical presentation?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And obviously when you met with her in April of twenty twenty-six, you were able to observe her physical condition, right?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And what were your observations of her physical condition?
AVRAM MACK: Well, she's utilizing a wheelchair. Generally speaking, there were not necessarily abnormal movements that I observed. She seemed comfortable physically.
MS. BUCKINGHAM: Did you find that she was able to kind of navigate her situation herself? Meaning you were in a room with her with other individuals, right?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And she was able to kind of take care of her own—
MR. REDDINGTON: I'm gonna object, leading at this point, just as they object.
THE COURT: Sustained. He just asked the observations.
MS. BUCKINGHAM: What did you observe her do as far as moving herself around the room? Was she able to do that?
AVRAM MACK: Yes. At the moments when there were transitions, when we took a break and she went out to the hall, she was able to navigate her wheelchair one place or another.
MS. BUCKINGHAM: And when you spoke with her on April 10th and April 12th, were you able to kinda have a conversation with her about her level of functioning at the Tewksbury?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And did she tell you anything about what her general day looked like? Like—
AVRAM MACK: She described her general day. She described basically her existence there at Tewksbury.
MS. BUCKINGHAM: Okay. And did she indicate to you whether she engaged with other patients, or did she spend her day mostly in bed, or what did she say about that?
AVRAM MACK: Mostly she described she stays in bed or on her own. I didn't necessarily... I don't think she described interacting with patients very much. There were a couple of ways in which she did interact with staff at least. There was a therapist that she described working with. She did describe having had a physical therapist at a certain point. I'm not sure if I remember if she still was getting physical therapy. She stated she wasn't very interested in the physical therapy that she was getting there. She wasn't interested in the food there. She described having visitors, on a not infrequent basis, and that sometimes she was able to eat food or drinks that were brought in by them.
MS. BUCKINGHAM: And who were her visitors, if you remember at all?
AVRAM MACK: Family members mostly, as well as, I believe, both... And I'm not sure if they were specifically from the Brigham or Mass General, but, or any place in particular, but I believe religious figures, chaplain or priest from some organizations.
MS. BUCKINGHAM: And her having told you that she kind of has visitors, were you able to corroborate that in reviewing records that she had visitors?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And were you able to corroborate or were you able to identify in the records that she did interact with staff and patients at the hospital according to the records?
AVRAM MACK: To some degree, yes.
MS. BUCKINGHAM: And you said that she had indicated to you that the food wasn't appealing at the hospital. And did you have the chance to observe her consuming her own snacks or beverages?
AVRAM MACK: Beverages, yes.
MS. BUCKINGHAM: Now, did she indicate to you her level of attention to hygiene and grooming while at Tewksbury?
AVRAM MACK: She did. She described that she wasn't very interested in her own hygiene or grooming.
MS. BUCKINGHAM: And were you able to later in the conversation speak with her about her ability to take care of her own daily activities like grooming? For instance, showering. Was she able to do that on her own?
AVRAM MACK: Showering is embarrassing. It requires staff to help her, and that's one way in which she would rather not. It may also be that she described a lack of interest, so it's both components.
MS. BUCKINGHAM: When you observed her, did she appear to be disheveled or not properly groomed in your meetings on April 10th and 12th?
AVRAM MACK: No, she appeared groomed sufficiently, and I believe her hair was combed, and she was wearing neat clothing.
MS. BUCKINGHAM: Now, did she describe to you her thoughts or feelings about her current situation?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And what did she say about that?
AVRAM MACK: Well, she described feeling depressed, which she termed situational depression. She described feeling- I'm not sure of the exact terms she used, but feeling miserable. Not wanting to be alive.
MS. BUCKINGHAM: And—
MR. REDDINGTON: Let him finish, please. If he's finished, that's fine, but don't cut him off.
THE COURT: No, yeah. It's all right.
MS. BUCKINGHAM: I'm sorry, doctor. Were you done?
AVRAM MACK: Yes.
MS. BUCKINGHAM: Thank you. So when you were meeting with her, do you recall her indicating that she reported being devastated?
AVRAM MACK: Yes.
MS. BUCKINGHAM: That she was devastated and grieving by her current situation?
AVRAM MACK: Yes.
MS. BUCKINGHAM: When you met with her at the Tewksbury Hospital, did you go over with her what her current treatment regimen is, what current medication she was on?
AVRAM MACK: I did.
MS. BUCKINGHAM: Was she able to tell you what medication she was taking?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And were you able to confirm that with the records, that that was an accurate report?
AVRAM MACK: Yes.
MS. BUCKINGHAM: So what medications, when you met with her in April 2026, was she currently on?
AVRAM MACK: Well, in terms of psychiatric medications, the main medication of note is olanzapine. I believe that there were several medications being used for her physical needs.
MS. BUCKINGHAM: Mm-hmm.
AVRAM MACK: One that helps with her bladder, one that helps with movement of the GI system.
MS. BUCKINGHAM: Well, let's just kinda focus on the psychiatric medications, right, 'cause that's of your interest here. You mentioned olanzapine. What's the common or the brand name for that?
AVRAM MACK: It's called Zyprexa.
MS. BUCKINGHAM: And what is it used to treat?
AVRAM MACK: Originally it was created to be an antipsychotic medication, so to treat psychosis.
MS. BUCKINGHAM: Okay. And are you aware that it's prescribed to Ms. Clancy for bipolar?
AVRAM MACK: Yes, it is also used for mania. It is also sometimes used—
MR. REDDINGTON: Unresponsive, the question was bipolar.
THE COURT: Yeah. Yeah. The question. If you could just listen to the question.
MR. REDDINGTON: Hmm?
THE COURT: Listen to the question, and then they'll—the Com—if the Commonwealth or the other side wants to add to the answer, they'll ask you, okay? Go ahead.
MS. BUCKINGHAM: So I think my question was, are you aware that the Zyprexa is prescribed for bipolar?
AVRAM MACK: So bipolar is a disor—yes, bipolar is a disorder of mania, which is, I'm sorry, why I was mentioning at that point.
MS. BUCKINGHAM: And what was the dosage of the Zyprexa that she was on, if you recall?
AVRAM MACK: I believe it was two and a half milligrams.
MS. BUCKINGHAM: And in your experience, is that a significant dosage?
AVRAM MACK: No, it's a small dose.
MS. BUCKINGHAM: Are you aware of any other psychiatric medications that she's prescribed at Tewksbury?
AVRAM MACK: I believe she's also taking Trazodone.
MS. BUCKINGHAM: Okay. How about Wellbutrin, does that ring a bell?
AVRAM MACK: Yes. Wellbutrin is an antidepressant medication.
MS. BUCKINGHAM: Okay. And Clonidine, does that sound familiar?
AVRAM MACK: Yes. Clonidine is a medication that's sometimes used for anxiety or to help people go to sleep.
MS. BUCKINGHAM: And are you familiar with the Propran—excuse me, Propranolol?
AVRAM MACK: Propranolol is also a medication. It also is sometimes used to help with anxiety.
MS. BUCKINGHAM: Okay. And as far as the dosage of medication that she's on, based on your review of the records, where... Are those high doses, low doses?
AVRAM MACK: Overall they are on the lower side of dosages.
MS. BUCKINGHAM: And you indicated briefly in your testimony that she had reported to you that she believes to have situational depression.
AVRAM MACK: Yes.
MS. BUCKINGHAM: Did you have a conversation with her about the diagnosis from Tewksbury?
AVRAM MACK: There were times that she... If you're asking about bipolar disorder, at one point she made the statement that she wasn't convinced that she has bipolar or has had bipolar disorder. She described situational depression in terms of feeling depressed about the several stressors that she experiences today.
MS. BUCKINGHAM: And what are those stressors?
AVRAM MACK: Well, the remorse and sadness about the events that this case is about. Her separation or estrangement from her then husband. Her being separated from the world. Her physical injury.
MS. BUCKINGHAM: Do you recall her actually using the term remorse, or is that just your description of her—the conversation you had?
AVRAM MACK: That's my summarization right there.
MS. BUCKINGHAM: Okay. Now when you were meeting with her, did you talk to her about past medication regimens that she had been on prior to the current regimen of the Zyprexa and Wellbutrin?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And so are you aware that she had previously been prescribed, at some point, lithium?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And is that something that would be important to you to know when you were conducting your own evaluation for diagnosis, about whether somebody was on lithium?
AVRAM MACK: It might help, but in psychiatry, we don't make diagnoses based on medication response.
MS. BUCKINGHAM: And when it came to the report of the lithium, fair to say it was not something that was trialed for a very long period of time?
AVRAM MACK: Yes, and let me correct that. It's not that we don't make diagnoses. We don't categorize or define disorders by medication response. So it— I heard the description of the trial of lithium, and that was a short trial.
MS. BUCKINGHAM: Okay. And about her physical injuries, did you have a conversation with her about her understanding of her physical injuries?
AVRAM MACK: Yes.
MS. BUCKINGHAM: Do you recall whether she reported that she had any head injuries after January 24th?
AVRAM MACK: She denied that she had had a head injury.
MS. BUCKINGHAM: And was she familiar with the extent of her spinal injury?
AVRAM MACK: Yes.
MS. BUCKINGHAM: Meaning she was able to explain to you where the injuries occurred and—
AVRAM MACK: That's correct.
MS. BUCKINGHAM: Were you able to review, in your interview with her, past psychiatric history?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And did she have a significant past psychiatric history?
AVRAM MACK: Prior to the year 2022, she had not. She had been, over time, very hard driving. Someone who tended to get anxious, and anxiety sometimes pushed her to achieve or to do things. There had been a— two short periods of depression or anxiety throughout her lifetime. In one, she had been prescribed antidepressant medication around two years before 2022, which she had not actually taken. She had tended to resolve her anxiety or depression through exercise and hard work.
MS. BUCKINGHAM: And when you say the two short periods, are you speaking of periods after childbirth?
AVRAM MACK: One was while she was in nursing school, and the other was after the birth of her second child.
MS. BUCKINGHAM: So you were able to have the conversation with her about nursing school and going on medications during that experience, right?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And as far as the second episode where she described anxiousness and seeking medication, did she indicate to you whether she actually took medication—
AVRAM MACK: No, she had—
MS. BUCKINGHAM: … after the birth?
AVRAM MACK: Sorry.
MS. BUCKINGHAM: After the birth of her second child.
AVRAM MACK: She had been prescribed it, but she hadn't taken it.
MS. BUCKINGHAM: Now, based on your review of records and your interview with her, were you able to identify and learn some general information about her family history?
AVRAM MACK: Yes.
MS. BUCKINGHAM: Did anyone— did she report anyone in her family suffering from any other mental illness in the past?
AVRAM MACK: No.
MS. BUCKINGHAM: So no, no history of bipolar disorder or prior depression?
AVRAM MACK: Correct. No such history.
MS. BUCKINGHAM: Did you also review with her work history?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And did you talk to her about whether there were any adverse events in her past that affected her?
AVRAM MACK: That is something we asked about, I asked about. And also I was able to look at her records to try to elicit if there were any particular adverse events in her life.
MS. BUCKINGHAM: Did... So did you find any—
AVRAM MACK: No.
MS. BUCKINGHAM: ... evidence of any? And you said that prior to twenty twenty-two there hadn't been, or there was minimal psychiatric history. Did you look at and talk to her about the period of twenty twenty-two from approximately September leading up to the events of January 24th, twenty twenty-three?
AVRAM MACK: Yes, I did.
MS. BUCKINGHAM: So as far as going through that time period, you were able to review her medication history during that time?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And fair to say there was a significant amount of medications that you looked at—
AVRAM MACK: Yes.
MS. BUCKINGHAM: ... as far as what she was taking and what it was prescribed for?
AVRAM MACK: Correct.
MS. BUCKINGHAM: Did anything stand out to you in the timeline of her medication history that was significant in this case?
AVRAM MACK: Well, she was initially prescribed medication in September of twenty twenty-two. She didn't actually start taking that medication, sertraline, until October. There were several different medications that were prescribed. It is not clear that she actually took every medication that was ever prescribed, or that she necessarily took it more than one or two times. There was a period of trial on a second antidepressant called Prozac. There were various medications used to help her to sleep. And then there was a several week period of taking a medication called Seroquel or quetiapine.
MS. BUCKINGHAM: Are you familiar with that medication in your practice?
AVRAM MACK: I am.
MS. BUCKINGHAM: And is it fair to say that that medication has multiple functions, like most psychiatric medications? When you reviewed her history, what was the initial dose that she was prescribed for it?
AVRAM MACK: Just twenty-five milligrams.
MS. BUCKINGHAM: And what is a twenty-five milligram dose of Seroquel? What is that generally prescribed for?
AVRAM MACK: Well, it's often prescribed these days to help individuals to sleep. But Seroquel is also, like Zyprexa, a antipsychotic medication. It can be used to help people to sleep. It can be used to help psychosis. It can be used to help the treatment of depression.
MS. BUCKINGHAM: Okay. And as far as your review of the medication timeline for this defendant with the Seroquel, would the amount of time that she took the Seroquel have had any lasting effects biologically on her brain or her body?
AVRAM MACK: It—there's no known effect that one would have from the amount of time that she took it. There could have been temporary effects, which could have been affecting her functioning or her psychological reaction to her functioning. But there's no known biological long-term effect.
MS. BUCKINGHAM: So when you say that there's some... They could have some effect, are we talking about symptoms or negative symptoms maybe?
AVRAM MACK: So Seroquel might affect a person's ability to think straight. We talked earlier about cognition, the ability to pay attention, to concentrate, to have memory, and Seroquel can negatively affect your cognitive functioning, although it is expected that that will eventually go away when you stop taking the medication.
MS. BUCKINGHAM: And is Seroquel a type of medication that lingers in a person's system?
AVRAM MACK: Not substantially. There are some medications that do linger like diazepam or Valium, which is another medication that she was later prescribed. All medications are, you know, on a relative basis, so diazepam will stay in your body much longer than, say, lorazepam, a different benzodiazepine.
MS. BUCKINGHAM: Okay. But as far as the Seroquel goes, once a person stops taking it, is it fair to say that the symptoms or any negative symptoms that they have would eventually resolve themselves?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And you're aware of the medications, the last reported medications that the defendant was on right before the events of January twenty-fourth?
AVRAM MACK: I am.
MS. BUCKINGHAM: And what were those?
AVRAM MACK: Melatonin, lorazepam, trazodone, and an antidepressant medication called amitriptyline.
MS. BUCKINGHAM: And as far as the amitriptyline, you're aware of what the dosage was?
AVRAM MACK: Well, on the day before, January twenty-fourth, it became twenty milligrams, but for several days before that, it was ten milligrams.
MS. BUCKINGHAM: Now, in your experience, a ten milligram to twenty milligram dose of amitriptyline, is that a significant dosage?
AVRAM MACK: It's small. The usual starting dose for an adult is a hundred and fifty milligrams.
MS. BUCKINGHAM: Are you aware of what the chief complaints or problems that the defendant had been reporting at the time when these medications were all being prescribed to her in twenty twenty-two?
AVRAM MACK: Well, it's a several month period, but it started in September, with September of twenty twenty-two, with complaints of anxiety and depression.
MS. BUCKINGHAM: And fair to say in reviewing all the records and with your conversation that sleep also was a main issue or a complaint?
AVRAM MACK: Yes, that's right.
MS. BUCKINGHAM: And some of the medications that you reviewed is, sleep... Could the medications themselves affect a person's sleep?
AVRAM MACK: Yes, certainly can.
MS. BUCKINGHAM: Now, as far as past diagnosis of this defendant, you were able to review overall and all the records that were available to you what different providers had given as far as past diagnoses, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And as far as your overall evaluation in determining criminal responsibility, where you have to answer first that question of mental disease or defect, do you rely on those prior diagnoses, or do you come to your own conclusions?
AVRAM MACK: I come to my own conclusions.
MS. BUCKINGHAM: Are the fact that there were past diagnoses something that you consider?
AVRAM MACK: Yes, especially to the extent that they highlighted the basis for those prior diagnoses. I don't necessarily have to agree with the diagnoses, but I'm interested in what was observed in terms of coming to those diagnoses.
MS. BUCKINGHAM: And when you're doing these types of evaluations for criminal responsibility, why do you not rely on a past diagnosis? Why do you come to your own conclusion?
AVRAM MACK: Well, that's part of being an independent evaluator, where in your mind you're able to collate the information and make your own diagnosis.
MS. BUCKINGHAM: As far as kind of before you move on to your actual diagnosis, in addition to the interview that you had with the defendant over those two days, reviewing all the records, did you attempt to speak with what are called collaterals?
AVRAM MACK: I did not.
MS. BUCKINGHAM: Is that something that you sometimes do in these evaluations?
AVRAM MACK: Sometimes.
MS. BUCKINGHAM: Fair to say in this particular case, you did have a significant amount of information from people that were close to the defendant, right?
AVRAM MACK: That was my view, yes.
MS. BUCKINGHAM: And after speaking with the defendant, did she identify to you some people that maybe you could talk to?
AVRAM MACK: I don't remember who she said, but I think she suggested perhaps her husband or then husband.
MS. BUCKINGHAM: But you yourself didn't have an interview with Patrick Clancy, did you?
AVRAM MACK: No.
MS. BUCKINGHAM: But you were able to review his grand jury testimony and interviews he's given with the police in the past, right?
AVRAM MACK: Yes, I did.
MS. BUCKINGHAM: Okay.
AVRAM MACK: And CPS.
MS. BUCKINGHAM: And as far as speaking with the defendant's parents or her sister, are you aware that attempts were made or requests were made to speak with them, but they didn't respond?
AVRAM MACK: I wasn't aware of that.
AVRAM MACK: I was not.
MS. BUCKINGHAM: So based on everything that you reviewed in this case, were you able to come to a conclusion about diagnosis?
AVRAM MACK: Yes, I did.
MS. BUCKINGHAM: And at the time that you conducted this evaluation, what is your opinion about diagnosis?
AVRAM MACK: My opinion about her diagnosis in the span from twenty twenty-two to twenty twenty-three is that she suffered from what's called a major depressive episode. That probably is a part of what's called a major depressive disorder, but the important point about it is the major depressive episode.
MS. BUCKINGHAM: What made you come to that conclusion, based on her presentations?
AVRAM MACK: The information about her feelings and the progression of her illness highlighted that it was best represented by a major depressive episode. It's a condition defined in DSM V where an individual displays problems with mood, problems with feeling pleasure, feelings of guilt or worthlessness, problems with appetite, problems with sleep, preoccupation with death or suicide, poor concentration, poor energy, perhaps also what's called psychomotor agitation or retardation. So one doesn't necessarily need to show all of those, but as it is in the DSM criteria sets, one needs to have a certain threshold. And her history and her description of her experience, in my view, that—sorry—matched a major depressive episode.
MS. BUCKINGHAM: Okay. And you indicated that it was kind of a progressive thing from the fall into January of twenty twenty-four—twenty twenty-three, right?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And in addition to the low mood, were you able to identify that she presented with anxiety at various points?
AVRAM MACK: Yes, very much.
MS. BUCKINGHAM: And did you also make observations of obsessive thinking?
AVRAM MACK: Yes. Obsessive thinking is a kind of anxiety where you repeatedly think about a topic, maybe that you're asking, what if, what if, what if. And it's the kind of form of anxiety that you frequently see in a anxiety disorder called generalized anxiety disorder. I think it's possible she also had generalized anxiety disorder, but that is sort of secondary to the major depressive episode.
MS. BUCKINGHAM: Okay. Now in the time closest to January 24th of twenty twenty-three, did you take a look at what her presentation or what her mental state was then based on all the information that you had available to you?
AVRAM MACK: Yes, I did.
MS. BUCKINGHAM: Did you identify whether she was ever presenting in a manic state or a hypomanic state?
AVRAM MACK: Throughout the period from 2022 to 2023, no. There was never indication of any element of mania or hypomania.
MS. BUCKINGHAM: So just to kinda make it kind of clear to the jury here, when you talk about major depressive disorder, that's a identified disorder in the DSM, right?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And when we use terminology like mania, right, what is mania?
AVRAM MACK: So mania is a mood state, just like major depressive episode is a mood state, and these are the sort of building blocks of the mood disorders, bipolar disorders and major depressive disorder. So just like major depressive episode, mania is defined in the DSM where with a certain time threshold, in this case for mania seven days, where you consistently have at least four of the following symptoms, you would be called being in a manic state. So that includes distractibility, a term, a type of thinking called flight of ideas, grandiosity, excessive goal-directed behavior, pressured speech or some abnormality of speech, a reduced in, degree of, need for sleep. And also the seventh would be in, an engagement in activities that are, have a high potential for... that are pleasurable but have a high potential for painful consequences. So mania requires seven days of that, most of the day, every day, and you need four over seven days. Hypomania is a lesser type of mania, and you need only three over a four-day period. In both cases, as it is for major depressive episode, you also need to demonstrate that the person is impaired in a clinically significant way. That is to say, they have clinically significant impairment or distress. So these are the building blocks for the mood conditions that we're talking about.
MS. BUCKINGHAM: And so when you say you looked at the defendant's condition from September through January, September 2022 through January 2023, did you observe or did you find any evidence of mania or hypomania in what was reported was her conduct or her presentation?
AVRAM MACK: I could not find any example of behavior or thinking that corresponded with those elements of mania or hypomania.
MS. BUCKINGHAM: Now, what about in the days immediately after the incident, were there... you said you reviewed records from Brigham and Women's Hospital, correct?
AVRAM MACK: Correct.
MS. BUCKINGHAM: Did you identify or could you find any evidence of mania or hypomania during that time period?
AVRAM MACK: No.
MS. BUCKINGHAM: And in fact, there are actually some instances that would tell you that she was in those states, correct? Like her behavior.
MR. REDDINGTON: Objection.
THE COURT: Sustained.
MS. BUCKINGHAM: During the time period of immediately after the incident, what did you observe, or did you observe in the records some activity at Brigham and Women's Hospital that would show that she had linear thinking and goal direction?
AVRAM MACK: Well, after she was removed from the medication called dexmedetomidine, which was sedating her and having her sleep, intentionally. After that point, she awakened, the records indicate, and was able to think coherently with goal-directed thoughts. One example, and so the various mental status examinations done by the doctors at the Brigham generally showed normal mental status. One particular portion of the record reviews, their review of whether or not she had the ability to make a decision, in that case, a change to her healthcare proxy. And so the physicians there were able to examine her closely in order to understand that she did have decision-making capacity.
MS. BUCKINGHAM: And that's an example of something you reviewed in the record that was close in time to the incident itself, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And you also were able to review records from Jennifer Tufts from an appointment with the defendant the day before the incident occurred, correct?
AVRAM MACK: I did.
MS. BUCKINGHAM: And again, in those records, did you find anything that would have been suggestive of mania or hypomania?
AVRAM MACK: Not of mania or hypomania, no.
MS. BUCKINGHAM: What about psychosis? Did you observe any of that?
AVRAM MACK: I did not throughout the period in question.
MS. BUCKINGHAM: So tell us what psychosis means.
AVRAM MACK: Psychosis is a form of thinking where the person has disorganization, and also may have a lack of what is called reality testing. So the individual may not be able to engage in behaviors or activities or cognitive thoughts to check if a belief or an experience is real or not.
MS. BUCKINGHAM: So is there any particular way in which a person can display psychosis?
AVRAM MACK: Psychosis can be displayed in many different ways. It can be based on the things a person says. For example, delusions are fixed false beliefs that the individual has, and that they exist despite the person being told that that's not true or testing it with others. You also can, at least suspect psychosis in the form of hallucinations, which are unreal stimuli that an individual experiences. Sometimes you may see individuals actually moving their body to respond to stimuli that they think or they are experiencing in the environment. But hallucinations can also be taste—... smell, or things that you hear or things that you see or feel on your body. And there is a kind of psychosis that is, includes some of that, but also simply includes an individual's lack of ability to act in an organized manner.
MS. BUCKINGHAM: So a person in psychosis can sometimes do the normal things that they always do, right?
AVRAM MACK: It depends on what kind of psychosis and how bad the psychosis is or to what extent it is occurring. But individuals with, say, delusional disorder, which is a disorder where your problem is you have a delusion that is affecting your life, those individuals can mostly go about their lives in other areas, at least other areas that don't have to do with that particular false belief.
MS. BUCKINGHAM: What about with hallucinations? How does that manifest itself?
AVRAM MACK: There is a subgroup of the population that actually experiences hallucinations frequently and has no negative effect from it. But for those who have hallucinations as a part of a disorder of psychosis or bipolar or, or mood, there are ways in which the individual can live with the psychosis or live with the hallucination and be able to be resilient to it and go ahead with their lives.
MS. BUCKINGHAM: So even if a person does have some form of psychosis or has delusions or hallucinations, they could still manage in society by following the rules, right?
AVRAM MACK: Like I said, it depends on which delusion or which hallucination, but there are individuals, and it may be, who can, and there may also be people who are, who can on a stable basis. But there are also are individuals—
THE COURT: All right. Next question.
MS. BUCKINGHAM: As far as a person who might be suffering from psychosis, can they appreciate, or do they know right from wrong?
AVRAM MACK: There's no reason that psychosis in of itself inhibits a person's ability to know right from wrong.
MS. BUCKINGHAM: Now, as far as in this case with this particular defendant, you have identified that you believe it's a major depressive disorder, right?
AVRAM MACK: Yeah.
MS. BUCKINGHAM: Did you consider other diagnosis?
AVRAM MACK: Yes.
MS. BUCKINGHAM: What about bipolar? Did you consider bipolar?
AVRAM MACK: I weighed whether there might have been bipolar disorder.
MS. BUCKINGHAM: And so why not for this defendant?
AVRAM MACK: Well, to be diagnosed with bipolar disorder, you need to have had a manic episode. That's at least for bipolar type one. For bipolar type two, you need to have had a hypomanic episode, and there's no information in the available record that displays either of those. So you can't diagnose bipolar disorder.
MS. BUCKINGHAM: Did you consider the fact that this defendant, or that there's been some indication of postpartum for the defendant?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And did that affect your opinions about diagnosis?
AVRAM MACK: As I said before, in psychiatry, we diagnose based on the symptoms that the individual presents with. So in the DSM, in our manner of diagnosing, when you have discerned what is the prominent symptom that the individual is suffering from, that becomes the disorder that carries your diagnosis. There are times that you can designate that it has occurred in the postpartum period. DSM states that that would be within four weeks of birth. It also allows for the symptoms to have occurred before birth. So that is the standard that we utilize when we choose to add on that designation of something being postpartum.
MR. REDDINGTON: Could I object? It doesn't matter what we do. It's what he does.
THE COURT: All right. Next question.
MS. BUCKINGHAM: So as far as consideration of postpartum, do you rely on the DSM-V in your diagnostic criteria?
AVRAM MACK: I do.
MS. BUCKINGHAM: You're aware that there are other—that it's not universal across the world and that there are other opinions about the postpartum period, right?
AVRAM MACK: I'm aware that there are psychiatrists and others who have asked to make a specific diagnosis that relates to psychiatric problems in the postpartum state. That has been studied over the years. At this point, that has been suggested to the makers of the DSM and has been rejected.
MS. BUCKINGHAM: But it's... So I guess my question is more based on your overall view of, or review of this particular defendant. The onset of symptoms, when did they occur in this postpartum period, or did they?
AVRAM MACK: The distress that we're talking about began in September, which is about four months after the birth of the most recent child.
MS. BUCKINGHAM: And so if you're relying on the DSM as four weeks postpartum for a lot of these illnesses, mental illnesses, then the defendant was well outside that period, right?
AVRAM MACK: Correct.
MS. BUCKINGHAM: And as far as, for the last child, when the killings occurred, that would've been eight months after the postpartum period, correct?
AVRAM MACK: Roughly, yes.
MS. BUCKINGHAM: Okay. Now in this case, you are aware of certain behaviors and thoughts that the defendant had that have been suggested as psychotic, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And did you consider those as potential psychotic features for this defendant?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And so, can you explain to us some of those potential features and what your opinion is about them?
AVRAM MACK: Right. Well, some of them are—were beliefs or concerns that Ms. Clancy had, which weren't necessarily psychotic. So one was the idea that in the midst of her distress and her impairment, that Child Protective Services or the child welfare agency would act on—somehow take away her kids, to speak in a global way, but to somehow interact with her. I don't know that that's psychotic. Another is the idea that she was damaged permanently by the medications that she took. I can appreciate that she felt side effects and a degree of change from the medications that she took. So I don't know that that feeling or that belief is necessarily psychotic. So those are two that I would mention right off the bat.
MS. BUCKINGHAM: What about the idea that somebody could hear her thoughts? Did you look into that?
AVRAM MACK: There is one episode where she wasn't sure and asked her mother, I believe, the question, "Can you hear my thoughts?" And was told no. And so while there is a form of psychosis called thought broadcasting, that wasn't her belief. That wasn't her belief that she was engaging in thought broadcasting, where she was putting her thoughts out into the world. Her—as I read it, the question was not psychotic. The question was one that reflected the distress and the intrusive thoughts that she was having, without it necessarily being psychotic. She engaged in reality testing when she asked, "Did you hear that?"
MS. BUCKINGHAM: And you had the conversation with her about thought broadcasting in your interview, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And you were able to ask some follow-up questions of her directly to identify whether she was or wasn't doing that?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And based on your conversation with her and what you learned in that interview, did you believe that she was engaged in thought broadcasting?
AVRAM MACK: No, I do not.
MS. BUCKINGHAM: You're aware that there were also concerns that were voiced by her that there was other things wrong with her body, not just damage from medication, right?
AVRAM MACK: Yes.
MS. BUCKINGHAM: Do you recall that?
AVRAM MACK: Yes.
MS. BUCKINGHAM: Did you consider that to determine whether that was a psychotic feature for this defendant?
AVRAM MACK: Yes. So an example was her worry that she had ketoacidosis. I didn't necessarily think that that was psychotic. It may have been wrong, but it wasn't necessarily psychotic. She had been given a medication, Seroquel, where one of the side effects is that it negatively interferes with your glucose system, and ketoacidosis is the worst case scenario when you have glucose, poor control of your glucose. So I don't know that she had a fixed false belief that she had ketoacidosis, but she was worried about having ketoacidosis.
MS. BUCKINGHAM: So when you say that you considered these things and you didn't believe them to be psychotic, are you talking about them in the realm of, were they delusional? Were they fixed false beliefs or something else?
AVRAM MACK: Right. So I used that term specifically. As I said before, a delusion, which is a form of psychosis, is a fixed false belief, which is really immutable. You can't be convinced otherwise. But these were not fixed false beliefs. These were concerns.
MS. BUCKINGHAM: And did you find that the concerns were rational based on your overall view of everything?
AVRAM MACK: Right. Not only were they concerns, but they aligned with the realities that she had experienced.
MS. BUCKINGHAM: Now, what about the idea of these intrusive thoughts? You reviewed the records to know that was a common report of her, that she had intrusive thoughts, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And that at various points she did identify that she did want to die.
AVRAM MACK: Yes.
MS. BUCKINGHAM: Is being suicidal a form of psychosis?
AVRAM MACK: No.
MS. BUCKINGHAM: What, if anything, does the idea of suicide tell you about this defendant or about her situation?
AVRAM MACK: Well, it tells me that she was suffering, and that it was a part of—in my view, it was a part of a major depressive episode. You know, ten to fifteen percent of women in the postpartum period have depressive disorders, and can be very serious, and it can lead to suicidality, or the need for hospitalization, or other interventions. So the records show in my interviews that I gathered information that she was suffering, and suicidality is a form of suffering.
MS. BUCKINGHAM: Now, when you talk about suicidality, does it have to make sense why the person is suicidal?
AVRAM MACK: No. Suicidality occurs, but it doesn't always make sense. Sometimes, there might be places where one might say, "Well, why was that person suicidal? They had only good things in life." Speaking hypothetically. But especially when an individual has depression, it just occurs.
MS. BUCKINGHAM: Now, when you're talking about people that have suicidal ideation, are there certain things known as protective factors?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And did you identify in your review of this case in the records whether the defendant presented with any protective factors when it comes to suicidality?
AVRAM MACK: Well, are you asking, did Ms. Clancy identify protective factors?
MS. BUCKINGHAM: Yeah. At some point, is it fair to say she did identify protective factors?
AVRAM MACK: She did.
MS. BUCKINGHAM: And what were the protective factors?
AVRAM MACK: Mainly her mother and her children.
AVRAM MACK: That is to say... Sorry. That is to say she wanted to... Her urges or her interest in suiciding was something that she chose not to do because of the worry that she would hurt them by suiciding.
MS. BUCKINGHAM: And your review of the records from McLean Hospital, fair to say that one of the reasons for discharge was that she herself identified that she wouldn't have commit the act because of her kids?
AVRAM MACK: That was one of the factors. When we make decisions, when I make decisions, to allow somebody to be discharged, it's an overall weighing of risk factors and protective factors.
THE COURT: All right. Counsel, it's 1:00. Why don't we take the afternoon recess at this point, okay? All right. Thank you, Doctor. Members of the jury, we're gonna take the afternoon recess. As I always tell you, no research, writing, talking about this matter, and we'll have you back here approximately 2:00. Okay?
BAILIFF: All rise, please, jurors.
BAILIFF: Jurors may exit the courtroom.
THE COURT: All right. Counsel, any need to discuss anything before the break?
MR. REDDINGTON: Nothing.
THE COURT: All right. So we'll be in recess till approximately 2:00.
BAILIFF: This court is back in session. You may be seated.
COURT CLERK: Your Honor, for the purpose of the record, all parties are present excluding the 18 jurors.
THE COURT: All right. Counsel, are we ready for the jury?
MS. BUCKINGHAM: Yes.
THE COURT: All right. Yeah.
BAILIFF: Court, all rise, please.
BAILIFF: Court is back in session. You may be seated.
COURT CLERK: Your Honor, for the purpose of the record, all parties are present including attorneys and including the 18 jurors.
THE COURT: All right. Commonwealth.
MS. BUCKINGHAM: Thank you.
MS. BUCKINGHAM: Dr. Mack, before we broke, we were talking about protective factors in suicide. Do you recall that?
AVRAM MACK: Yes, I do.
MS. BUCKINGHAM: Can you just explain to the jury what a protective factor is?
AVRAM MACK: Well, when a person is suicidal, they have risk factors and they have protective factors. Risk factors are those aspects of the individual that make it more likely that the person is going to act on their suicidal thoughts, and protective factors do the opposite. They are things that hold the person back from acting on their suicidal interests.
MS. BUCKINGHAM: And in this case, you're aware that the defendant had previously indicated that her kids and her mother were reasons why she didn't continue with the thoughts of suicide in the past, right?
MR. REDDINGTON: Objection. It's not the thoughts, it's the action.
THE COURT: No, overruled. You can answer.
AVRAM MACK: I'm not sure if your question is that kept her from acting on suicidal interests or ideation.
MS. BUCKINGHAM: Right. I guess the important part I'm trying to piece together is, it was her statements to professionals that her mother and her kids were reasons why she wouldn't have committed the act.
AVRAM MACK: Correct.
MS. BUCKINGHAM: Okay. And you are aware that at the time of the event, or after the event, she indicated that, so a voice told her that she needed to kill the kids so that she could kill herself?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And this was the same day that she then attempted to kill herself?
AVRAM MACK: Correct.
MS. BUCKINGHAM: Now, on the day of January 24th, 2023, you're aware that the defendant had reported that that, for all intents and purposes, earlier in the day was a good day?
AVRAM MACK: There are reports that earlier in the day was a good day.
MS. BUCKINGHAM: And is the fact that she reported good feelings consistent with the suicidality or inconsistent?
MR. REDDINGTON: I apologize. Did he say that she said she had a good day or someone else did? I just didn't hear that.
THE COURT: Yeah, if you could maybe kinda bring that out, what that source is.
MS. BUCKINGHAM: Well, as far as the reports of it being a good day, when you spoke with her, did she describe the events earlier in the day as a good day, playing with the kids, that kinda thing?
AVRAM MACK: She described the day as being a fun and productive day.
MS. BUCKINGHAM: And you're aware that others reported, including her husband, Patrick, that earlier that day it appeared to have been a good day?
AVRAM MACK: Right. So one example is when Patrick was talking to the child welfare agency that evening, I believe, he said that was the best day she had had in a long time.
MS. BUCKINGHAM: Okay. So—
AVRAM MACK: Or something to that effect.
MS. BUCKINGHAM: … The fact that there were reports of it being a good day, is that inconsistent or consistent with the idea of the attempted suicide?
AVRAM MACK: It's not inconsistent with suicide. It's also not inconsistent with the depressive disorder that she had. Much of the time depression, major depressive episodes start to recover after around three or four months. It also is a, in my own view in psychiatry, and I believe others, an awareness that as a person is beginning to recover from the worst of their depression, sometimes suicides do happen when the person starts developing a little bit more energy and ability to act on their interests.
MS. BUCKINGHAM: So in your experience, do people sometimes display those positive feelings immediately prior to either an attempt or a suicide?
AVRAM MACK: Yes, that is something that does happen, in my experience. While they're still very depressed, but they begin to be on the trajectory towards relative improvement.
MS. BUCKINGHAM: Okay. Now, just going back for a quick second, you had talked a little bit about hallucinations, and you described different types of hallucinations, meaning things that you can taste or hear or see, right?
AVRAM MACK: Yes.
MS. BUCKINGHAM: Are you familiar with the, what's called command hallucinations?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And what are those?
AVRAM MACK: Command auditory hallucinations are a type of hallucination where you're hearing something and it is telling you or telling you of an expectation for you to do.
MS. BUCKINGHAM: And are those things usually persistent?
AVRAM MACK: It can be… It can vary sometimes. It can be persistent. Other times it can be sporadic.
MS. BUCKINGHAM: Going to your conversation with the defendant on about the events of January 24th, 2023, you, in your interview with her, were able to speak with her about her recollection of that day, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And one of the things that was done in that interview was that you—or she was explaining what happened in chronological order, right? From the beginning of the day to the last thing she could remember.
AVRAM MACK: That's correct.
MS. BUCKINGHAM: Did she also tell it to you in reverse?
AVRAM MACK: She was asked to recite it in reverse, yes.
MS. BUCKINGHAM: And did she tell the same story forwards and backwards?
AVRAM MACK: Yes.
MS. BUCKINGHAM: Was she able to recall details of some parts of the day but not others?
AVRAM MACK: Yes, I would say that's correct.
MS. BUCKINGHAM: And did she describe to you when she heard this voice?
AVRAM MACK: Her experience that is called a voice occurred in the late afternoon.
MS. BUCKINGHAM: Do you recall what she reported about the voice?
AVRAM MACK: Her experience was that the voice was of a male, and it was loud.
MS. BUCKINGHAM: And what did the voice say?
AVRAM MACK: The voice said to the effect of, "You should kill the kids. This is your last chance so that you can kill yourself."
MS. BUCKINGHAM: And what did she say happened after she heard this voice?
AVRAM MACK: She engaged in the activity of taking her children's lives.
MS. BUCKINGHAM: And she was able to describe to you how she did that, correct? And she first stated that she took Dawson down to the basement.
AVRAM MACK: Yes.
MS. BUCKINGHAM: And then wrapped the exercise band around his neck and strangled him.
AVRAM MACK: Yes.
MS. BUCKINGHAM: And what did she say that she said when she did that?
AVRAM MACK: She described that while that was happening, she was saying out loud, "Go to God."
MS. BUCKINGHAM: And did she describe the same for both Cora and then Callan?
AVRAM MACK: Essentially, yes.
MS. BUCKINGHAM: Okay. And the voice that she said she heard, was it one time or more than one time she heard the voice?
AVRAM MACK: Multiple times is what she described.
MS. BUCKINGHAM: And after the kids—after she had killed the kids, did the voice continue in her report?
AVRAM MACK: I don't remember that it did. It may have. I don't remember.
MS. BUCKINGHAM: And then after the kids were gone, she then made an effort to take her own life, correct?
AVRAM MACK: Correct.
MS. BUCKINGHAM: And how did she do that?
AVRAM MACK: Right, so she did. She described that she went ahead to take her life, or attempt to take her life, with multiple steps. She went to her room, upstairs in the house and took the various medications that were present. She cut at her wrists and at her neck, and then she caused herself to fall from the window.
MS. BUCKINGHAM: Okay. And as far as going out the window, did she tell you whether she had to do anything with the screen?
AVRAM MACK: She described to me that she cut the screen.
MS. BUCKINGHAM: Okay. And then she dove out the window.
MR. REDDINGTON: Well, objection. That's not what he said.
MS. BUCKINGHAM: Well, what did she do after she cut the screen?
AVRAM MACK: She fell from the window.
MS. BUCKINGHAM: Did you ask her, or was there conversation about the phone call that she received from Patrick?
AVRAM MACK: There was.
MS. BUCKINGHAM: And was she able to clearly identify when the call came from Patrick?
AVRAM MACK: I don't exactly recall exactly when, but it was sometime in the—around 18 to 20 minutes that this was happening that she received that call.
MS. BUCKINGHAM: Do you recall if part of the conversation about the timeline of events, whether the voice came as soon as Patrick left the house or before or after the phone call?
AVRAM MACK: My recollection is that it happened as soon as Patrick had left.
MS. BUCKINGHAM: Now, were there some things in what she was telling you about the events that was different from what you reviewed from other information in this case?
AVRAM MACK: Can you say that again?
MS. BUCKINGHAM: Yeah. I'm just asking if you recall that there were things in the version that she told you in your interview that were different or not consistent with the information you knew about the case.
AVRAM MACK: Well, two things come to mind. One is the locking or the closing of the bedroom door, and the other is the cutting of the screen of the window.
MS. BUCKINGHAM: Okay. And as far as the locking or closing of the bedroom door, do you recall what she told you about that?
AVRAM MACK: She denied that she had done that.
MS. BUCKINGHAM: And so from the information you reviewed, about reports from Patrick and everything else, did you know that the door had been locked?
AVRAM MACK: That was my understanding.
MS. BUCKINGHAM: And the second thing that you indicated about the screen, what information did you have about the screen that was different from what she reported to you?
AVRAM MACK: I believe there was a question as to whether the screen had been cut, perhaps with a sharp.
MS. BUCKINGHAM: And as far as the going out the window piece of it, you are aware that she didn't have any head injury, correct?
AVRAM MACK: Yes, I am.
MS. BUCKINGHAM: That she had the spinal injuries, the C1 injury, but no injuries to her head.
AVRAM MACK: Correct.
MS. BUCKINGHAM: And as far as her report of taking medication or taking pills, did you know whether she took all the pills that she had in the house or...?
AVRAM MACK: Well, I'm not sure about the house. She described all the pills in her bedroom.
MS. BUCKINGHAM: Okay. And were you aware that there were other pill bottles located in other parts of the house?
AVRAM MACK: I'm not sure I knew that.
MS. BUCKINGHAM: Okay. How about the phone call? She indicated that at the time of the phone call, she believed she had the baby in her hand, and she was doing something like taking food out of the fridge or getting food ready for the kids. Do you recall that?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And were you aware—do you recall seeing crime scene photos that show that the kids' bowls were in the living room?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And that Patrick later reported that he had seen Dawson eating green beans and chicken nuggets before he left the house.
AVRAM MACK: Yes.
MS. BUCKINGHAM: Were you aware of that?
MS. BUCKINGHAM: So Dr. Mack, based on your review of this case, were you able to come to an opinion to a degree of medical certainty about whether this defendant was suffering from a mental disease or defect on January 24th of 2023?
AVRAM MACK: Yes, I did.
MS. BUCKINGHAM: And what is that opinion?
AVRAM MACK: That yes, she was suffering from a mental disease or defect, namely a major depressive episode as a part of major depressive disorder.
MS. BUCKINGHAM: And as far as the substantial capacity to appreciate wrongfulness or criminality of conduct, were you able to come to an opinion to a reasonable degree of medical certainty about that?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And what's your opinion regarding that?
AVRAM MACK: That she had retained that capacity.
MS. BUCKINGHAM: And what information do you rely upon to come to that conclusion?
AVRAM MACK: The first point is that this was a continuation. Her mental state at that time was a continuation of the mental state she had had for months. And it was a mental state that included the capacity to control her behavior and also to be able to conform her conduct to standards of law. So in that sense, first of all, there is not an indication to me that there was something that changed the overall capacity in that regard. Secondly, to the extent we are talking about the ability to conform her conduct to the law, one can analyze her actions and her behaviors and her thoughts on that day or as close as possible to the moments of the deaths, and that includes taking one of her children to a pediatrician that day, engaging in fun activities around the house that day, having gone to a...
AVRAM MACK: Having engaged with one of her children's teachers the day before, having engaged in normal conversations with the restaurant that she ordered food from, 3V, and then also interactions with the pharmacy, CVS, where she was getting MiraLAX from. So in all these places, there was the ability to act normally. There doesn't seem to be any deviation from where she had been all along, which included this capacity. Furthermore, I would add that as a part of her interactions with the community or in driving, you know, she had abided by law and abided by standards of the community at all those times. So there isn't necessarily, to me, any way in which that deviated that afternoon.
MS. BUCKINGHAM: So you're speaking about her ability to conform conduct, which is one of the things we're talking about here. But I wanna go back to the appreciation for wrongfulness or criminality. As far as that goes, were you able to form an opinion about that?
AVRAM MACK: Yes. Sorry about that.
MS. BUCKINGHAM: That's okay. So what's your opinion about her ability to substantially conform, or excuse me, her substantial capacity to appreciate the wrongfulness or criminality of her conduct?
AVRAM MACK: So I, again, would go to thinking about what had been her state of mind for at least the month prior, the several months prior, and in all that time, there wasn't any feature that indicated that she didn't have that capacity. But furthermore, when there were moments when she thought about harming the children, when she had the thoughts about that, she was aware in those moments beforehand that that was wrong or against the law, and that she could be punished for such an act.
MS. BUCKINGHAM: You're referring to the December conversation with her husband and her mom?
AVRAM MACK: Yes, and her thoughts about the idea that "If anyone knew what I was thinking, I would... They... The children might be taken away from me."
MS. BUCKINGHAM: And also, did the fact that she hadn't had any significant medication changes during that time period, does that also inform your opinion about that?
AVRAM MACK: Well, as that aligns with what I was saying before about how while depressed, her mental state was relatively stable. It was perhaps improving, I'm not sure about that, but it was stable. There—
MR. REDDINGTON: Move to strike that he's not sure about it.
THE COURT: All right. That answer is stricken. All right.
MS. BUCKINGHAM: So the fact that she hadn't undergone any more significant medical or medication changes, I should say, did that signify to you that she had been in the same kind of state she had in the months before?
AVRAM MACK: Yes.
MS. BUCKINGHAM: Okay. Now, what about the interaction with Dr. Tufts on January 23rd? Did anything about that suggest that there were any concerns or distress that would have changed her ability to appreciate wrongfulness of her conduct?
AVRAM MACK: No. In that interaction, she displayed normal thinking and the ability to think ahead and to navigate the world.
MS. BUCKINGHAM: And what about the statements that she referred to when she was killing the kids, the "Go to God"? Did that—does that inform your opinion?
AVRAM MACK: It does.
MS. BUCKINGHAM: And why?
AVRAM MACK: My understanding is that the sentiment, "Go to God," is a way of bestowing or thinking about the children as innocents, as ones who hadn't done wrong, while what she was doing was the opposite, was wrong, or could be construed as wrong. And so "Go to God" not only was a hope for the children, but also a description of the situation.
MS. BUCKINGHAM: Okay. And what about the report from her that the voice was telling her, "This is your last chance"? Is that significant to identify whether she would have had some knowledge or known that it was something that was wrong?
AVRAM MACK: Well, to the extent that it was seen as her last chance, yes, because there was an awareness that it was something that would be disallowed by their father.
MS. BUCKINGHAM: And as far as after the incident, when she woke up at the Brigham Women Hospital, you're aware that she reported to the staff there that she was horrified, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And so the fact that she immediately afterwards identified that she was horrified, does that go to her capacity to appreciate the wrongfulness of her conduct?
AVRAM MACK: Yes. One can consider that her mental state, once she was removed from the dexmedetomidine, was similar to what it had been on January 24th. And in that regard, the feeling of horror, the feeling of shame that comes from being horrified, indicates that she was aware that it had been the wrong thing to do.
MS. BUCKINGHAM: And then finally, just to go back to the substantial capacity to conform conduct. You've told us a little bit about that, about the fact that her condition hadn't really changed all that much. You outlined what she did that day. But is there anything else to consider, based on everything that you reviewed, that would indicate to you that she did maintain the substantial capacity to conform her conduct to the requirements of the law?
AVRAM MACK: I think that in the household, she was engaging this activity methodically, which highlights to me that there was an ability to conform her behavior to expectations of living in a household.
MS. BUCKINGHAM: What do you mean methodically?
AVRAM MACK: The... As I understand the deaths, they were done methodically, and I think you asked me about that earlier. One by one, in a way that was organized, and that was intended to achieve a particular goal. Similarly, her attempt at suicide was organized and thoughtful in the sense that it included as many possible methods as possible.
MS. BUCKINGHAM: And as far as the killings of the children methodically, did she report to you in any way that she was given direction by this voice on how to complete the act and what to exactly to do?
AVRAM MACK: No, she did not.
MS. BUCKINGHAM: And what about the call with Patrick? Is there anything about that that indicates that she maintained some control or the ability to control herself, where she did engage in a short conversation with him?
AVRAM MACK: Well, that aligns with what we were talking about before in terms of not... or in terms of being aware that he would disapprove or disallow this, and yet she didn't say anything. She didn't say, "Help," or she didn't say, "I'm having these thoughts." So it wasn't stated.
MS. BUCKINGHAM: So again, as far as your overall evaluation of this defendant, Lindsay Clancy, regarding the events of January 24th, 2023, what ultimately is your opinion to a degree of medical certainty regarding criminal responsibility?
AVRAM MACK: My opinion is that she retained the capacity that are required for having criminal responsibility for these actions.
MS. BUCKINGHAM: Thank you. Oh, and I would just like to admit Dr. Mack's CV as the next exhibit.
THE COURT: Any objection? That may be admitted.
COURT REPORTER: 291.