3.Avram Mack — Cross (Part 2)
775 linesTHE COURT: All right, Mr. Reddington.
MR. REDDINGTON: Dr. Mack, part of your evaluation would be an intent to investigate the person that you're being asked to evaluate for purposes of an opinion regarding criminal responsibility or lack thereof for the District Attorney's office, correct?
AVRAM MACK: What do you mean by investigate?
MR. REDDINGTON: You don't know what investigate means? You want me to explain that to you?
AVRAM MACK: You want—
MR. REDDINGTON: You're a psychiatrist that's employed by the District Attorney's, right?
AVRAM MACK: Retained by, yes.
MR. REDDINGTON: Oh, okay. So we're gonna talk semantics. Isn't employed by, retained by, mean that you get money from it, right?
AVRAM MACK: I'm paid for my time, yes.
MR. REDDINGTON: Exactly. And normally I don't even go there. Every one of us are getting paid for our time. Jurors not so much, but nevertheless, you get paid for your time, right?
AVRAM MACK: Correct.
MR. REDDINGTON: I get paid for my time. The judge, Chrissy, Don, everybody gets paid for their time, right?
AVRAM MACK: I imagine, yes.
MR. REDDINGTON: So when you are retained by the District Attorney's office, you are to evaluate an individual, right?
AVRAM MACK: Yes.
MR. REDDINGTON: And the individual in this case is Lindsay Clancy, correct?
AVRAM MACK: Yes.
MR. REDDINGTON: And you recognize her, do you not?
AVRAM MACK: I do.
MR. REDDINGTON: And you actually had a chance to meet with her and do your evaluation, right?
AVRAM MACK: Yes.
MR. REDDINGTON: And part of your evaluation, you had to investigate into who she was. For example, her education, what she did for work, friends, family, right?
AVRAM MACK: I asked her about her life, and I reviewed records to learn about her life, yes.
MR. REDDINGTON: Okay. So you're in a mental institution investigating or questioning a woman who's on medication, who is there because she's suicidal and under one-on-one 24/7 observation. Would you agree with that?
AVRAM MACK: Yes.
MR. REDDINGTON: And you get the history from her?
AVRAM MACK: Yes.
MR. REDDINGTON: So did you talk to any collateral contacts?
AVRAM MACK: No.
MR. REDDINGTON: So how is it that you can tell this jury what her life story is? Did you get it from her?
AVRAM MACK: I got it from her.
MR. REDDINGTON: What did she tell you about her—
AVRAM MACK: To the extent that... I'm sorry, I'm—
MR. REDDINGTON: What did she tell you about her—
AVRAM MACK: What, can you say your...
MR. REDDINGTON: Never mind looking at the judge.
MS. BUCKINGHAM: Objection.
MR. REDDINGTON: What did she tell you about the education?
THE COURT: Wait, listen. You look over there, you listen to the question, and answer the question.
MS. BUCKINGHAM: Well, if Attorney Reddington would let him answer the question.
AVRAM MACK: Can you state the question, please?
MR. REDDINGTON: What did she tell you about... I'm sorry.
THE COURT: Ask the question.
MR. REDDINGTON: What did she tell you—
THE COURT: Ask the question and we'll go from there.
MR. REDDINGTON: What did she tell you about her education?
AVRAM MACK: She described her education in terms of being a hard worker through high school and college, and then going to nursing school.
MR. REDDINGTON: Okay. Where'd she go to nursing school?
AVRAM MACK: I think the nursing school was through Partners HealthCare, I think at the MGH.
MR. REDDINGTON: And do you recall what the nature of the nursing was?
AVRAM MACK: Well, she had always wanted to be a labor and delivery nurse, and she was able to achieve that.
MR. REDDINGTON: So she worked as a labor and delivery nurse?
AVRAM MACK: That's my understanding, yes.
MR. REDDINGTON: For a period of time?
AVRAM MACK: For several years, yes.
MR. REDDINGTON: Nine years, seven years?
AVRAM MACK: I'm not sure exactly.
MR. REDDINGTON: Did you talk to any of the nurses that she worked with? I mean, was she respected? Was she a hard worker? Was she somebody that was ducking out early, didn't wanna work?
AVRAM MACK: I didn't talk to any of her colleagues. I'm aware that she had been there for some time, and I did not hear about any aspects in which her work was deleterious.
MR. REDDINGTON: Who would you hear from, them?
AVRAM MACK: Well, one might have heard it from the notes from her spouse, and might have heard it from—
MR. REDDINGTON: Let's talk about—
AVRAM MACK: ... the defendant herself.
MR. REDDINGTON: ... let's talk about 'one might have heard it.' Is the one you? You're testifying.
AVRAM MACK: Yes.
MR. REDDINGTON: Did you hear about it through the notes of the spouse?
AVRAM MACK: No, I didn't hear about any way in which her work—
MR. REDDINGTON: Okay, so why are you telling me that?
AVRAM MACK: ... wasn't—
MR. REDDINGTON: Why are you saying one might have heard about it through the notes of the spouse?
AVRAM MACK: Well, I think your question was, how would one learn about any deleterious acts or components of the person's work? So I didn't hear about any way in which she wasn't working hard and retained as a nurse at an excellent institution.
MR. REDDINGTON: So basically you don't know, is what you're telling me. You don't know what her reputation for work ethic was. You don't know what her hours were. You don't know what her reputation in her work community was. You just don't know. Isn't that right?
AVRAM MACK: Combined with the records and also the report from Dr. Resnick, who described her own view of herself as being a hard worker, I don't know further than that.
MR. REDDINGTON: So in addition to being a labor and delivery nurse at Mass General Hospital for a number of years, you know that she obviously was married, right?
AVRAM MACK: Yes.
MR. REDDINGTON: And her husband was Patrick, right?
AVRAM MACK: Yes.
MR. REDDINGTON: You know how many years she was married, right?
AVRAM MACK: I do.
MR. REDDINGTON: How many?
AVRAM MACK: I don't know it offhand, but I believe I understand or knew the date when they were married, which may have been 2013.
MR. REDDINGTON: So the fact that she was married, you know that... Did she want to have kids, or did she find them to be a burden?
AVRAM MACK: She very much wanted to have children.
MR. REDDINGTON: And—
AVRAM MACK: She described that that was her lifelong interest.
MR. REDDINGTON: Okay. Had one child, Cora, right?
AVRAM MACK: She... Say that again. I can't hear you.
MR. REDDINGTON: Child, the first child was Cora, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Did she have any delivery issues with Cora?
AVRAM MACK: Not that I recall.
MR. REDDINGTON: How about the second child? What was the second child's name?
AVRAM MACK: Dawson.
MR. REDDINGTON: And how old was Dawson at the time of the incident, as we say?
AVRAM MACK: I think he was around four.
MR. REDDINGTON: And did she have any issues with his delivery?
AVRAM MACK: Do you mean the delivery or in the postpartum period?
MR. REDDINGTON: I mean the delivery.
AVRAM MACK: If I recall, I think she had a tear, which is called an episiotomy, and that was something she was unhappy about.
MR. REDDINGTON: Sure. Did she have medication prescribed to her after Dawson?
AVRAM MACK: Do you mean psychiatric medication?
MR. REDDINGTON: Sure.
AVRAM MACK: At some point I think she was prescribed an antidepressant medication in that period.
MR. REDDINGTON: What was it?
AVRAM MACK: I think it was sertraline.
MR. REDDINGTON: And do you know whether she took it?
AVRAM MACK: She has told us that she did not.
MR. REDDINGTON: And when she went home after having the baby— ... Dawson, she then came home to a little daughter, obviously Cora. Had Dawson as an infant, correct?
AVRAM MACK: Yes.
MR. REDDINGTON: And was she living in a town or was she living... Where was she living when she had these two kids?
AVRAM MACK: I think she was living in the same house in Duxbury.
MR. REDDINGTON: She wasn't living in Weymouth or...?
AVRAM MACK: She may have been. I'm sorry, I don't know.
MR. REDDINGTON: That's all right. So at some point she moves to Duxbury. She's with her husband, and she goes back to work, does she?
AVRAM MACK: Yes.
MR. REDDINGTON: You didn't make any, in your investigation, you didn't come across any information that she didn't wanna go back to work because she was lazy or just didn't wanna work, right?
AVRAM MACK: No, I think she always wanted to work.
MR. REDDINGTON: Okay. Did she have anxiety about going back to work after Callan, the third child?
AVRAM MACK: After Callum?
MR. REDDINGTON: Yeah, Callan. It's Callan, C-A-double L-M.
AVRAM MACK: Yes. Yes. She wanted to go back. As August and September arrived, she was hopeful to go back to work, but she became anxious about working. There were other factors too. She became anxious—
MR. REDDINGTON: No, no, no other factors yet. We'll get to the other factors. Why was she anxious about going back to work?
AVRAM MACK: Well, I was about to say.
MR. REDDINGTON: Go ahead.
AVRAM MACK: She was anxious about the wellbeing and nurturance of her children as she went back to work. One being that the baby was not taking a bottle. Another that in that span between the point that her husband went back to work and she was expected to go back to work, it was overwhelming to have three young children that she was caring for all by herself. As time went on, she was ambivalent about hiring somebody to help, hiring a nanny, and that was another area of anxiety. So there were several areas of anxiety, and as we've discussed earlier today, anxiety was something that she had had throughout her life.
MR. REDDINGTON: Okay, you know what? I'm gonna pull you in, okay? This is a cross-examination, sir.
AVRAM MACK: All right.
MR. REDDINGTON: I gave you a little room.
THE COURT: All right. Next, just ask the next question.
MR. REDDINGTON: So when you say that she had anxiety, and the anxiety was about having her youngest child, Callan, correct?
AVRAM MACK: Yes.
MR. REDDINGTON: She was anxious about going back to work, correct?
AVRAM MACK: Yes.
MR. REDDINGTON: But you also, as you were waxing eloquently, indicated that she was having anxiety about having a nanny.
AVRAM MACK: Yes.
MR. REDDINGTON: What was she anxious about with the nanny?
AVRAM MACK: In my understanding—
MR. REDDINGTON: No, no. What is your under— Tell the jury what you investigated about her anxiety with the nanny.
AVRAM MACK: So through my evaluation, what I understood was that there was ambivalence about having a nanny. That is to say, having somebody who helped. There was some degree of wanting to be able to handle the children on her own. The other part of it is some ambivalence about other people, other than herself or perhaps her mother, caring for the children. Because I know that my evaluation discerned that she felt very positively about her ability to take care of her children, but also some ambivalence about other people taking care of the children.
MR. REDDINGTON: What time frame are we talking about? Summertime? Fall?
AVRAM MACK: The end of summer.
MR. REDDINGTON: Well—
AVRAM MACK: Late August, early September.
MR. REDDINGTON: Isn't it true that in the summer she and Patrick and the kids felt that they were on top of the world, having a great summer, right?
AVRAM MACK: Well, that's what she said. That's her quote.
MR. REDDINGTON: Okay. And then come the fall, towards the end of September, that's when she started to have symptoms of anxiety, right?
AVRAM MACK: Yes. Most—
MR. REDDINGTON: But to this point in your investigation, you have a young woman who was a nurse for a number of years. We assume, from your investigation, a good reputation as a hard worker, right?
AVRAM MACK: I can't hear you. I'm sorry.
MR. REDDINGTON: Yeah. One of the things that you had mentioned is that she was... How about exercise? Did she like to do exercise?
AVRAM MACK: Yes.
MR. REDDINGTON: Yeah.
AVRAM MACK: In the past, exercise was her—
MR. REDDINGTON: The answer's yes, right? Yes?
AVRAM MACK: Can you repeat the question?
MR. REDDINGTON: Sure, I can repeat the question. I asked you, sir—
MS. BUCKINGHAM: I'm objecting because he's interrupting the witness and not letting him answer the question.
THE COURT: The question called for a yes or no answer, all right? And so go ahead.
MR. REDDINGTON: Go ahead.
AVRAM MACK: Can you state the question, please?
MR. REDDINGTON: Sure. You mentioned in direct examination for the DA that she was, liked to do exercise, correct?
AVRAM MACK: Yes.
MR. REDDINGTON: And would you consider a person who is an exercise aficionado, especially a woman who, for example, runs, let's say a 5K or a five mile road race within about a couple of weeks after having a baby, is that hyper-exercise? Is that hypomanic, okay?
AVRAM MACK: In of itself, it's not hypomanic, no.
MR. REDDINGTON: How about if there's a string of exercise that is a little bit out of the norm, coupled with decluttering, removing personal property from the home, cleaning out the home, things of that nature. Would that be hypomanic in your opinion?
AVRAM MACK: Not in and of itself. But are you talking... When you were asking about exercise, were you talking about in the period 2022 or 2020?
MR. REDDINGTON: 2022.
AVRAM MACK: Okay.
MR. REDDINGTON: After Callan. Okay? And I asked you about running the road race after Callan, okay? You with me?
AVRAM MACK: Yes, I am.
MR. REDDINGTON: Good. So would you suggest, sir, that that is something that one would at least anticipate, consider, or investigate as being this manic or hypomanic that you're talking about?
AVRAM MACK: No.
MR. REDDINGTON: So by the way, one of the questions that you were asked, sir, is that when you got involved with investigating this case, do you recall that from the DA?
MR. REDDINGTON: Do you recall that from the DA?
AVRAM MACK: The term investigate, I'll... If it's okay, I'll use the term evaluate, but—
MR. REDDINGTON: Oh, when you got appointed or retained by the DA.
AVRAM MACK: Right. So and your question is?
MR. REDDINGTON: My question is when were you retained by the district attorney, the prosecutors?
AVRAM MACK: It was sometime in early 2025.
MR. REDDINGTON: Early 2025. So like, what? February? January?
AVRAM MACK: I think, I think the reach out had occurred in maybe December of 2024, and I think that the retention was early in 2025.
MR. REDDINGTON: And what's a reach out?
AVRAM MACK: Well, the communication. The reaching out.
MR. REDDINGTON: From? From?
AVRAM MACK: From the district attorney's office.
MR. REDDINGTON: Okay. And then when you were asked that question, you indicated that you had to wait for a motion to be filed or something with the court. Do you recall answering that question?
AVRAM MACK: No.
MR. REDDINGTON: Well, if I suggest to you, sir, it was in December of 2024 that a notice of lack of criminal responsibility was filed, does that seem to fit with the reach out?
MS. BUCKINGHAM: Objection. Can we approach?
THE COURT: Sure.
THE COURT: All right, counsel.
MR. REDDINGTON: Thank you, Judge. So, your understanding of the procedure is that a notice has to be given to the court, that a person like Lindsay is raising the issue of criminal responsibility, correct?
AVRAM MACK: I imagine that's the case, but I don't know the procedure here in Massachusetts—
MR. REDDINGTON: You don't know the—
AVRAM MACK: ... in that regard.
MR. REDDINGTON: Okay. You don't know the procedure?
AVRAM MACK: The procedure for making notice?
MR. REDDINGTON: Right.
AVRAM MACK: No, I am—
AVRAM MACK: I do not.
MR. REDDINGTON: ... if I tell you, sir, that the notice is filed in December of '24, when was it that you had the reach out?
AVRAM MACK: The first communication about the case was in, as I said a few minutes ago, in late 2024.
MR. REDDINGTON: And do you recall the circumstances of that communication?
MR. REDDINGTON: DA call you? A letter? What?
AVRAM MACK: No, I was contacted through a retention firm called Park Dietz and Associates.
MR. REDDINGTON: Dietz?
AVRAM MACK: Mm-hmm.
MR. REDDINGTON: Park, he's a psychiatrist, isn't he?
AVRAM MACK: Sounds like you know him.
MR. REDDINGTON: I do know him. And actually, Park Dietz is a rather famous psychiatrist, is he not?
AVRAM MACK: Yes.
MR. REDDINGTON: He's testified in many cases, correct?
AVRAM MACK: Yes, but—
MS. BUCKINGHAM: Objection.
THE COURT: Overruled.
AVRAM MACK: I said Park Dietz and Associates. I didn't say Park Dietz himself.
MR. REDDINGTON: Okay. Well, you know Park Dietz, I imagine, right?
AVRAM MACK: I do.
MR. REDDINGTON: Yeah. And you know that he's a guy that testified in a case and cited a Law & Order episode that didn't exist at the time—
MS. BUCKINGHAM: Objection.
MR. REDDINGTON: ... he gave his opinion.
THE COURT: Sustained.
MR. REDDINGTON: So is he still active?
MS. BUCKINGHAM: Objection.
THE COURT: Sustained.
MR. REDDINGTON: Is he a psychiatrist now?
AVRAM MACK: Yes, he's a psychiatrist.
MR. REDDINGTON: And on your letterhead, it says Park Dietz, D-I-E-T-Z, and Associates, forensic experts, right?
AVRAM MACK: I can't see what you're looking at, but that's what the letterhead basically says.
MR. REDDINGTON: Well, it's right on the map, right?
AVRAM MACK: I am.
MR. REDDINGTON: Okay. And this is your curriculum vitae, right?
AVRAM MACK: Yes.
MR. REDDINGTON: And in big letters up above it says Park Dietz and Associates, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Now, how does that work? You get a call from this retention group, Park Dietz, and then you get assigned a case?
AVRAM MACK: When an attorney or a district attorney's office contacts them, they might think that it might be a case that I might want to be retained on.
MR. REDDINGTON: Okay. Do they, to your knowledge, try to get someone that's familiar with that particular topic or just anybody that has a random psychiatry degree?
AVRAM MACK: Well, there are only certain people that they think of or consider, people that Dr. Dietz has thought of in terms of having a robust career and background.
MR. REDDINGTON: You have a robust career?
AVRAM MACK: I've been active as a teacher and as a clinician over about 20 years, and I've been a full professor at Penn and Jefferson and Georgetown.
MR. REDDINGTON: So that's in your curriculum vitae, correct?
AVRAM MACK: The three professor-level appointments?
MR. REDDINGTON: All of your stuff. The things you wrote, things that you're interested in, your fellowships, professorships. All that, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay. And that's introduced into evidence by the DA, right?
AVRAM MACK: Yes.
MR. REDDINGTON: So the jury's gonna have it to look at, right?
AVRAM MACK: Okay. I didn't know that.
MR. REDDINGTON: Let's just take a look at it now. Is it your understanding that when you are—and I mean you individually, not Park Dietz Associates—requested to look at and investigate into the lack of criminal responsibility of a individual charged with a crime, that you gotta try to be independent?
AVRAM MACK: Being independent is the expectation.
MR. REDDINGTON: The answer yes? You try to be independent?
AVRAM MACK: Yes, I do.
MR. REDDINGTON: Okay. Is it appropriate for you to evaluate an individual with another Park Dietz associate guy?
AVRAM MACK: You're referring to Dr. Heilbrun?
MR. REDDINGTON: I am referring to Dr. Heilbrun. He's another one of the DA's witnesses in this case, right?
AVRAM MACK: Correct.
MR. REDDINGTON: And you know Heilbrun, right?
AVRAM MACK: I had not met him until we jointly went to do the evaluation this April.
MR. REDDINGTON: Jointly went to do the evaluation.
AVRAM MACK: Yes.
MR. REDDINGTON: What'd you do, both ride in the same car over to Tewksbury to talk to her?
AVRAM MACK: No.
MR. REDDINGTON: How'd you... Did you have separate cars?
AVRAM MACK: We did.
MR. REDDINGTON: And then you met up beforehand and you went in to meet with Lindsay?
AVRAM MACK: Yes. I think that that was—
MR. REDDINGTON: Both of you together? Both of you together.
AVRAM MACK: Yes.
MR. REDDINGTON: So you work under the umbrella of Park Dietz and Associates. Heilbrun, who's gonna be testifying Monday for the government, works under the umbrella of Park Dietz and Associates, and the both of you interviewed her at the same time is what you're telling this jury?
AVRAM MACK: Yes.
MR. REDDINGTON: In your opinion, is that appropriate, sir?
AVRAM MACK: Yes.
MR. REDDINGTON: Did you talk to Kirk about your opinion?
AVRAM MACK: We have talked about each other's opinion. We have different opinions as far as I understand it.
MR. REDDINGTON: Did you talk to him about his report?
AVRAM MACK: No.
AVRAM MACK: I have not talked to him about his report.
MR. REDDINGTON: Have you talked to him about testifying here today?
AVRAM MACK: Not in terms of content, no.
MR. REDDINGTON: What does that mean?
AVRAM MACK: The other day he called me and said, "What day are you going up to Boston?"
MR. REDDINGTON: Okay.
AVRAM MACK: And then—
MR. REDDINGTON: Tripping up to Boston. Did you tell him?
AVRAM MACK: No, I wasn't sure what day I was going up to Boston.
MR. REDDINGTON: Okay. Did you review his report?
AVRAM MACK: I have reviewed his report.
MR. REDDINGTON: All right. And has he reviewed your report?
AVRAM MACK: I don't know. I assume so, but I don't know.
MR. REDDINGTON: Now, looking at your CV, you indicate that you're educated at Cornell. You got your medical degree. You had some fellowships. Do you have any particular interest in your practice, sir?
AVRAM MACK: Yes.
MR. REDDINGTON: And you have licensure in Delaware, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Pennsylvania?
AVRAM MACK: Yes.
MR. REDDINGTON: District of Columbia?
AVRAM MACK: Not at the moment.
MR. REDDINGTON: It says 2005 to the present, but not anymore?
AVRAM MACK: Well, I'm not sure what date that CV is, but I allowed my DC license to—
MR. REDDINGTON: Okay.
AVRAM MACK: ... not be renewed.
MR. REDDINGTON: Maryland?
AVRAM MACK: Same, I let it not be renewed.
MR. REDDINGTON: New York?
AVRAM MACK: I actually renewed that recently.
MR. REDDINGTON: Massachusetts?
AVRAM MACK: No, I haven't had that since I left here.
MR. REDDINGTON: South Carolina?
AVRAM MACK: I haven't renewed that in many years.
MR. REDDINGTON: Connecticut?
AVRAM MACK: Same.
MR. REDDINGTON: Virginia?
AVRAM MACK: Same.
MR. REDDINGTON: So what does that mean, that you have licensure? Does that mean you can be a psychiatrist in these states as long as it's active, or what does that mean?
AVRAM MACK: Licensure means that one can act as a physician when your licensure is in effect, yes.
MR. REDDINGTON: Okay. And as far as professional and scientific societies, you belong to the American Academy of Child & Adolescent Psychiatry, right?
AVRAM MACK: Yes.
MR. REDDINGTON: You belong to the American Academy of Juvenile and Family Court Judges. Is that correct?
AVRAM MACK: I don't belong to that group at the moment.
MR. REDDINGTON: Well, did you? Is that on your resume?
AVRAM MACK: Yes. There was a moment when I was the representative from the American Academy of Child & Adolescent Psychiatry and the American Psychiatric Association, and also the American Academy of Psychiatry and the Law, of all three, to the National Council of Juvenile and Family Court Judges.
MR. REDDINGTON: Right.
AVRAM MACK: So at that point, I was a member of the—
MR. REDDINGTON: Okay.
AVRAM MACK: ... National Council.
MR. REDDINGTON: So I asked you about your interests or focus as a doctor. Would you agree, sir, that one of the things you put down is that you were involved in ad hoc reviewerships in the Journal of American Academy of Child and Adolescent Psychiatry, right?
AVRAM MACK: It does say that, yes.
MR. REDDINGTON: And then, American Journal of Addictions?
AVRAM MACK: Yes.
MR. REDDINGTON: Pediatric Quality and Safety?
AVRAM MACK: Yes.
MR. REDDINGTON: That's dealing with little kids, right, pediatrics?
AVRAM MACK: Well, at the Children's Hospital of Philadelphia, we see patients up to 24.
MR. REDDINGTON: Okay.
AVRAM MACK: At Nemours, I believe up to 21.
MR. REDDINGTON: So you also express interest in child psychiatry. This comes under academic responsibilities. Child psychiatry, right?
AVRAM MACK: Yes.
MR. REDDINGTON: You have been involved in the doctoring course for first-year medical students, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Supervision of adult psychiatry residents, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Clinical evaluation, Department of Psychiatry, dealing with children and adolescents, right?
AVRAM MACK: I'm not sure of that last one that you read, but—
MR. REDDINGTON: Number eight on...
AVRAM MACK: No, but what does it say in its entirety?
MR. REDDINGTON: Ongoing clinical education of PGY-3 residents, Department of Psychiatry, Georgetown University Hospital, Institute for Children and Adolescents.
AVRAM MACK: Do you mean Regional Institute for Children and Adolescents?
MR. REDDINGTON: Resume. I don't know what it means.
AVRAM MACK: I'm just wanting to make sure I'm responding to your question.
MR. REDDINGTON: Do you have it with you? I mean, you can look at it.
AVRAM MACK: The Regional Institute for Children and Adolescents was a residential center in, outside the Beltway, where I served for three years.
MR. REDDINGTON: Okay. The focus, nevertheless, is on children and adolescents, right?
AVRAM MACK: Not at that time. I… Well, you mean when I was at Georgetown?
MR. REDDINGTON: I'm just looking at your resume.
AVRAM MACK: Okay.
MR. REDDINGTON: How about lecturer appearance, patient safety and quality improvement in child and adolescent mental health? That something that you were involved with as a lecturer, sir?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay.
AVRAM MACK: About patient safety and quality, yes.
MR. REDDINGTON: The answer is yes?
AVRAM MACK: Yes.
MR. REDDINGTON: Just make it quick. You were a lecturer on MARAS Returns: Adolescent Cannabis, doubles lettuce, and Other Hallucinogen Use, dealing with what? Pediatrics, kids?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay. You also did, under lectures by invitation, that you've been involved with lecturing on Wither Psychosis in Adolescents, right?
AVRAM MACK: That was the title of a paper I gave, yes.
MR. REDDINGTON: So the answer is yes, right?
AVRAM MACK: The answer is I gave that paper, yes.
MR. REDDINGTON: Okay. Adolescents Accused of Murder and Manslaughter, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay. Wither Psychosis Adolescent Killers a couple of years later, again, maybe an update, right?
AVRAM MACK: Right.
MR. REDDINGTON: Divorce for the Clinician, right?
AVRAM MACK: Right.
MR. REDDINGTON: Divorce: Legal Process in Medical, Social, and Psychiatric Sequel, right?
AVRAM MACK: Right.
MR. REDDINGTON: Killer Adolescents: Drugs, School, and the Courts, right?
AVRAM MACK: Right.
MR. REDDINGTON: Jumping ahead, 2014, for example, you had the MARAS Returns: Adolescent Cannabis and Other Hallucinogens, right? 2014.
AVRAM MACK: I imagine, yes. I don't know exactly which one you're looking at, but that's a title of a lecture that I was giving.
MR. REDDINGTON: Childhood Development and Psychopathology, right? Is an interest, right?
AVRAM MACK: It is an interest, yes.
MR. REDDINGTON: Childhood Development, again, and Psychopathology, lecture to the United States Department of Justice, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Lecturing to the United States Department of Justice, Department of Immigration, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Cognitive Bias Think Tank is another one of the lectures that you gave. Is that correct?
AVRAM MACK: Well, it was a committee or a task force that I co-led—
MR. REDDINGTON: Okay.
AVRAM MACK: …about the prospect of diagnostic error when people have cognitive biases.
MR. REDDINGTON: And what's a cognitive bias? Just curious.
AVRAM MACK: So when you think about diagnoses, there's always a possibility that an individual is sort of guided to one diagnosis or another based on various forms of preconceptions or biases. So a major part of this concept of patient safety is to prevent misdiagnosis, and there are a lot of techniques that are used in medicine and, in this case, in pediatric hospitals and also in psychiatry to try to make sure that the users or the diagnostician's biases don't creep in to making the wrong diagnosis.
MR. REDDINGTON: Research publications, sir, dealing with neuropsychiatric systemic lupus erythematosus, age and the neurodevelopment model. That's one of your research publications, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Dealing with psychiatric classification from the ancients to DSM-IV, Psychiatric Clinics of North America, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Alcohol abuse is another research that you did?
AVRAM MACK: I've written or edited several textbooks on substance use—
MR. REDDINGTON: Right.
AVRAM MACK: ... disorders, yes.
MR. REDDINGTON: Okay. So in addition to child and adolescent aspects of psychiatry, you're also interested in focusing in on alcohol abuse, substance related disorders, alcohol abuse disorders, addictive disorders, treatment of addictive disorders, right?
AVRAM MACK: Those are some of the areas of interest, yes.
MR. REDDINGTON: Novel risk factors for central line associated bloodstream infections in critically ill children, right?
AVRAM MACK: Yes.
MR. REDDINGTON: And it goes on and on, with a lot of your focuses on children, minors, probate court, correct?
AVRAM MACK: I don't know about probate court, but—
MR. REDDINGTON: Well, you've had occasion to do evaluations for probate court, haven't you?
AVRAM MACK: You'd have to remind me. There was a period—
MR. REDDINGTON: Okay, never mind probate court.
AVRAM MACK: ... when I was the physician leader of the State of Maryland's Office of Forensic Services.
MR. REDDINGTON: Right.
AVRAM MACK: So—
MR. REDDINGTON: That's what you said on direct, so that's why I'm asking you, but how about the new tools in the toolbox, proactive prevention of CLABSI, one, in patients with behavioral health and concerns. What does that mean?
AVRAM MACK: Well, CLABSI, central line associated bloodstream infections, are something that is a major concern of all hospitals around the country, and preventing them from happening is not only the work of cleaning the apparatus that touches patients, but also we learned that when patients have psychiatric problems, they actually are at a greater risk of developing a central line associated bloodstream infection, which is a significant complication of being in the hospital. So I started that work when I was at Georgetown, when I was an adult, mainly focused on adults, and carried it on when I was at Children's Hospital Philadelphia and at Nemours in terms of the pediatric risks for CLABSI.
MR. REDDINGTON: Okay. About Clinical Manual of Adolescent Substance Abuse Disorder. That's another one of your chapters, right? A book?
AVRAM MACK: I don't think I wrote a book about adolescent substances.
MR. REDDINGTON: Well, it says number twenty-nine, Mack, A., A Clinical Manual of Adolescent Substance Abuse Treatment, Journal of Psychiatric Practice. Nothing wrong with that.
AVRAM MACK: Yeah, that was a chapter, not a book. But yes.
MR. REDDINGTON: Oh, okay. But nevertheless, your focus and your interest is on adolescents that like to smoke weed and drink, right?
AVRAM MACK: No.
MR. REDDINGTON: Okay. Would you agree, sir, that you were interested in the American Psychiatric Press textbook you wrote for, Substance Abuse Treatment, right?
AVRAM MACK: Yes.
MR. REDDINGTON: All right. And, Think Like a Psychiatrist, But Always a Doctor, Be a Doctor, Web Drugstore Perils, Drugs, Alcohol, Bloodstream Infections in Children's Hospital, focusing on that, right? Where in here does it say that you ever came within breathing distance of a pregnant woman in your practice, in your interest, in your writings?
AVRAM MACK: So I remember being at the Brigham as a resident, and—
MR. REDDINGTON: How long ago was that?
AVRAM MACK: ... going to... How long ago was that?
MR. REDDINGTON: Yeah, give us a year.
AVRAM MACK: Well, you asked me when, so I'm starting—
MR. REDDINGTON: Yeah, I'm asking you when. When?
AVRAM MACK: That was two... The memory I have for that particular situation was two thousand and one.
MR. REDDINGTON: Two thousand and one. So twenty-five years ago.
AVRAM MACK: Right.
MR. REDDINGTON: What did you do?
AVRAM MACK: And so since then, I went to the Medical University of South Carolina, and then I went to Georgetown. And all that period up until twenty fifteen, I was doing general psychiatry work with fo- areas of focus in peds or in addictions, but also with forensics as an area. I see myself as somebody who's a generalist, who happens to have a couple of areas of focus. In twenty fifteen, I did move from that generalist model to, when I left Georgetown, I moved to the Children's Hospital of Philadelphia and the University of Pennsylvania. And in those years, since then, I've been working in pediatric hospitals, where at CHOP, Children's Hospital of Philadelphia, the age is up to twenty-four, and at Nemours, it's up to twenty-one. So that is the overall area of adult and child psychiatry that I've been working in. Throughout the years at Georgetown—
MR. REDDINGTON: Okay, go—
AVRAM MACK: I would like to answer because I have more to tell you.
MR. REDDINGTON: Sorry.
THE COURT: Hold on. Let him finish the answer. Go ahead.
AVRAM MACK: So at Georgetown, certainly that was all adult, and Georgetown has its own labor and delivery unit. And so that was plenty of engagement with women who were pregnant or who had just given birth. And then at both Children's Hospital of Philadelphia and at Nemours, there are these special units that have been under design for the last several years, of high-risk pregnancy units. So actually at CHOP—one of my first roles there was to develop the psychiatry services, coverage of the high-risk maternity unit there called the Special Delivery Unit. And I was the co-leader and then the leader of the consultation service at CHOP. And so I led the group of adult and child psychiatrists to tend to the psychiatric needs of that unit. Recently at Nemours, the same unit was built. And so yes, in these pediatric hospitals, there actually are units of women who are about to have birth, who have just had birth.
MR. REDDINGTON: Well, I'm sure in these pediatric hospitals there are women about to have birth and have had birth, and I'm sure that there are competent doctors that treat them. Correct?
AVRAM MACK: I would agree with you.
MR. REDDINGTON: How about you? How many women with postpartum psychosis have you treated?
AVRAM MACK: Roughly 10 would be my estimate.
MR. REDDINGTON: Over what period of time?
AVRAM MACK: Over the period since 2001.
MR. REDDINGTON: And when you would treat these individuals, you're involved in, for example, testing them for their mental health?
AVRAM MACK: Well, usually the teaching has been that what was called postpartum psychosis is actually a form of bipolar disorder. So what is important is to say, "Let's do a full evaluation of the individual's symptoms and signs, and then treat them and engage in treatment." And usually that's going to be a form of bipolar disorder treatment. That's the teaching, that is the general perspective.
MR. REDDINGTON: So with your wealth of knowledge on women that are pregnant and suffering from postpartum psychosis, do you know whether or not Lindsay was ever diagnosed with postpartum depression?
AVRAM MACK: I believe that the various notes from the clinicians over the year of 2022 to 2023 utilize the term unspecified mood disorder.
MR. REDDINGTON: Right. How about postpartum depression?
AVRAM MACK: I don't think that appellation was used.
MR. REDDINGTON: Okay. So was she ever administered the—what is it? EPDS?
AVRAM MACK: You mean the Edinburgh?
MR. REDDINGTON: Yeah. Was she ever administered that?
AVRAM MACK: I don't know if she was or wasn't. I'm not—I don't remember.
MR. REDDINGTON: Isn't that something you're in here testifying about this case? Wouldn't that be important to know that she was almost off the chart on the Edinburgh scale for postnatal depression?
AVRAM MACK: Well, I have said that she had depression.
MR. REDDINGTON: Well, postnatal depression for a woman who's pregnant or had a baby recently is a heck of a lot different than some guy who's just depressed about his job. Right?
AVRAM MACK: I don't understand your question.
MR. REDDINGTON: Well, do you know what her readings were on the Edinburgh test?
AVRAM MACK: Not to my memory at the moment, no.
MR. REDDINGTON: Why not? You read the medical records, didn't you?
AVRAM MACK: I mean, if you would like to show me, I'd be happy to review.
MR. REDDINGTON: I don't want to show you anything. I'm asking you as a testifying witness for this jury, did you look at her medical records?
AVRAM MACK: I did.
MR. REDDINGTON: And the medical records pertain to her being a person that just had a baby. Right?
AVRAM MACK: I'm not sure that—which records you're talking about.
MR. REDDINGTON: I'm talking about—
AVRAM MACK: But when I... Can I finish?
MR. REDDINGTON: I'm talking about—
AVRAM MACK: Can I finish?
MR. REDDINGTON: You're not gonna finish. 2022, obviously, 'cause we already talked about the summer. She was fine. When did she see Tufts?
AVRAM MACK: She started to see Dr. Tufts in 2022.
MR. REDDINGTON: When?
AVRAM MACK: I believe it was, well, she went to Dr. Tufts in September, and it was in October that she started taking the medication that Dr. Tufts had prescribed.
MR. REDDINGTON: Okay. And that was for what?
AVRAM MACK: You mean which medication or what was the purpose?
MR. REDDINGTON: Medication.
AVRAM MACK: Sertraline.
MR. REDDINGTON: And otherwise known as?
AVRAM MACK: Zoloft.
MR. REDDINGTON: And she took it after a while. Is that correct? Is that what you said?
AVRAM MACK: A few weeks, yes.
MR. REDDINGTON: A few we— And the reason she didn't take it was what?
AVRAM MACK: Time. As my evaluation—
THE COURT: Hold on a sec. Hold on a second, Doc.
THE COURT: Sorry. All right.
THE COURT: Go ahead.
MR. REDDINGTON: Do you want me to re-ask that question?
AVRAM MACK: I'm okay.
MR. REDDINGTON: Okay.
AVRAM MACK: So over time, Ms. Clancy has avoided taking medications.
MR. REDDINGTON: She's what?
AVRAM MACK: Avoided taking medications.
MR. REDDINGTON: Says who?
AVRAM MACK: The description she gave me.
MR. REDDINGTON: She told you that?
AVRAM MACK: My awareness from my evaluation is that she resists taking medications. And for example—
MR. REDDINGTON: No, no, no. Tell me what you mean by she resists taking medications.
AVRAM MACK: There are individuals in this world who do not want to take medications, and I think she described that she is one of them.
MR. REDDINGTON: You know that she saw Dr. Tufts because she apparently was anxious, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Prior to that, other than having anxiety about public speaking as a nurse from nursing school, and after she had one of her children, she didn't have any psychiatric history of medications, right?
AVRAM MACK: She had not taken medications, but she had had a lifelong degree of anxiety. It hadn't been at the level of disorder, but she'd had—
MR. REDDINGTON: Lifelong?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay. How about in grammar school, high school, college? Did she have difficulty that she was anxious?
AVRAM MACK: So what I was saying is that anxiety drives, can drive people. But she had a lot of anxiety, and she was hardworking. And the anxiety helped her to be hardworking.
MR. REDDINGTON: My question, my question was—
AVRAM MACK: But when it comes to medications—
THE COURT: Hold on. Mr. Reddington, you gotta... Go ahead, Doc, finish the question.
AVRAM MACK: But when it comes to medications, she described that she didn't want to take medications. And an example was the time that, after the birth of her second child, that sertraline had been prescribed. But she chose to get through her anxiety and depression by exercising. And that is something that people do. But it also highlights that in this case, she didn't want to be taking medications. And I think that we also understand that in the fall of 2022—
THE COURT: All right. All right. At this point, I'm gonna stop. Next question.
MR. REDDINGTON: My question was, you said that she had a lifelong resistance to taking medication. That's what you said, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Yes? Okay.
AVRAM MACK: Yes.
MR. REDDINGTON: Then I asked you, grammar school, high school, college, did she have any records, any witnesses, any documents that she had a resistance to taking medication?
AVRAM MACK: Only her description to me.
MR. REDDINGTON: She didn't tell you that she was resistant to medication in grammar school and high school and college? What, are you making this up?
MS. BUCKINGHAM: Objection.
THE COURT: Yeah, sustained. Next question.
MR. REDDINGTON: She didn't tell you that.
AVRAM MACK: I understand her to have told me that generally she did not want to be taking medications. She didn't necessarily specify in grammar school, but that is her basic—
MR. REDDINGTON: How about college?
AVRAM MACK: Yes, I think that her description was, as a adolescent and as a young adult, she was not interested in taking medications.
MR. REDDINGTON: Do you really have that written down somewhere?
AVRAM MACK: I'm happy to be proven wrong, but I believe that that's what I understand it to mean.
MR. REDDINGTON: So you believe that's what it is. You don't know whether you have it written down somewhere, right?
AVRAM MACK: Am I—can I refer to my report?
MR. REDDINGTON: You can read it all you want. I don't care, 'cause it's not there.
AVRAM MACK: Well, on page eight, what I had written was, "Ms. Clancy's reluctance to take medication generally was accompanied by her concern for medications entering her breast milk." So the general—
MR. REDDINGTON: Her breast milk? She's pregnant. Come on. That's the only time that she indicates that she did not wanna take, except for benzos, medication, because she was breastfeeding, right?
AVRAM MACK: I don't, I don't agree. I'm happy to be proven wrong, but my understanding is that she described that she generally did not want to take medication.
MR. REDDINGTON: All right.
AVRAM MACK: Benzodiazepines included.
MR. REDDINGTON: Let's not, let's not guess, all right? Let's look at Dr. Mack's report, okay? Medication history. During the period before January 24, '23, she was taking several medications, and that would be Tufts and Jollotta and all the rest of them, right?
AVRAM MACK: Okay.
MR. REDDINGTON: Is that right?
AVRAM MACK: I didn't exactly hear your question. I'm sorry. Can you repeat it?
MR. REDDINGTON: You said in your report, "Defendant was taking several medications that had been prescribed for her," right?
AVRAM MACK: In the fall, and December of 2022, yes.
MR. REDDINGTON: So it's real easy. It's Tufts and Jollotta that were prescribing these meds, right?
AVRAM MACK: They were among the prescribers, yes.
MR. REDDINGTON: All right. And her reluctance to take medication was accompanied by her concern for medications entering her what?
AVRAM MACK: I believe it says breast milk.
MR. REDDINGTON: Breast milk, okay. So other than her concerns as a mother about her breast milk and having these drugs get into an infant's body, when else did she tell you that she was resistant, as you just told this jury, to taking medication, like she's somebody who doesn't want to take the medication, doesn't care to take the medication? Where is it?
THE COURT: Overruled.
AVRAM MACK: Well, I didn't say that she didn't care.
MR. REDDINGTON: Okay. How about she was resistant?
AVRAM MACK: My recollection, and I'm happy to, if you would like me to spend time finding it, I'd be happy to.
MR. REDDINGTON: Prove you wrong. No.
AVRAM MACK: What?
MR. REDDINGTON: Prove you wrong. It's not in your report though, is it?
AVRAM MACK: Okay.
MR. REDDINGTON: Okay. We'll leave it at that. Now, you had mentioned, sir, I believe, that the DSM is something that you all use in your diagnoses of people, right?
AVRAM MACK: Yes.
MR. REDDINGTON: And one of the things that you are here to testify about would be postpartum issues, postpartum psychosis, postpartum depression, right?
AVRAM MACK: Are you referring to postpartum psychosis the disorder, the proposed disorder, or as a symptom?
MR. REDDINGTON: Well, when you come in here as an expert hired by the DA to tell this jury that this woman was not suffering from postpartum psychosis, and you in your testimony refer to the fact that you use the DSM to guide you, if that's the right word, in your diagnoses, would you agree with me that that's a fair statement?
AVRAM MACK: That the DSM is the standard for making diagnoses? Yes.
MR. REDDINGTON: Right. It is not a very good standard though, is it?
AVRAM MACK: Well, it is the standard.
MR. REDDINGTON: It is the standard. How about, are there other standards, sir, that, like, for example, World Health Organization, International Disease Control, IDC. Have you ever heard of them?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay. Does the IDC... What does that stand for?
AVRAM MACK: The ICD.
MR. REDDINGTON: What does that stand for?
AVRAM MACK: The International Classification of Disease.
MR. REDDINGTON: Does that classify postpartum psychosis?
AVRAM MACK: I think it actually does not.
MR. REDDINGTON: Does it classify... You think, or you're sure?
AVRAM MACK: My recollection is that it does not.
MR. REDDINGTON: Okay. How about postpartum depression? Does the international category indicate that?
AVRAM MACK: I'm not sure. We in the United States use the DSM.
MR. REDDINGTON: No, no, no. I'm asking about the other, the ICD or whatever it is.
AVRAM MACK: I don't know.
MR. REDDINGTON: Okay, that's good enough. This here is what you're talking about, the DSM, though, right? Five TR for text revision, right?
AVRAM MACK: Yes.
MR. REDDINGTON: And you're talking about the fact that at some point in DSM-6, there, it appears as though postpartum depression, postpartum psychosis will be added into the DSM-6. Is that correct?
AVRAM MACK: Who said that?
MR. REDDINGTON: I'm asking you if that's what you mean when you told the jury about it possibly being put into the next edition.
AVRAM MACK: There is a syndrome that's been proposed called postpartum psychosis. So I would differentiate that from the idea that the person... Of psychosis in a postpartum period. The syndrome, proposed syndrome of postpartum psychosis has not been included, and I am not aware that it is going to be included. Although, I understand there are calls for that. I would also say actually the movement for DSM-6 is not necessarily active at this point. But I would highlight again, 'cause I wrote my college history thesis on the history of the DSMs, that—
MR. REDDINGTON: What was it? DSM 1, 2, 3 back then?
AVRAM MACK: Well, there's been a classification made by the American Medical Association going back to the end of the 19th century. DSM-1 was in 1952, DSM-2 was in 1968, DSM-3 was in 1980. The major change in 1980 was to fall in, as I discussed earlier, the descriptive model for diagnoses. And that is to say that since DSM-3, diagnostic groups are grouped, or disorders are grouped by what you see, what symptoms we are seeing, not by what we assume is the cause of the illness, and not by any theories about how the illness works. So since DSM-4 in 1994, as a part of making DSM-4, a literature review was completed by a Dr. Ellen Frank, which indicated a roadmap for what to include in terms of postpartum designations. And since then, there's been what's called a specifier. So if you highlight depression, you can add a specifier to say when this depression occurred. The limit is that it's a four-week limit. So under the rules of DSM, after four weeks, you wouldn't necessarily...
Well, you wouldn't call it postpartum. Postpartum psychosis, and here I'm referring mainly to literature, including a review in Biological Psychiatry in the last 12 months, is a proposal that there is a type of bipolar disorder called postpartum psychosis where you can have mania or bipolar attributes, you can have depression, you can have delirium. And so when you think about the rules and the guidelines that have been in place since 1980 for revisions of the DSM, they look for, can this category be sufficiently separated from other categories, and does it help treatment? And over time, even though there have been calls... Well, there have been hundreds of diagnoses that have been proposed or requested to be in the DSMs. Very few new diagnoses get inserted. And right now, that is the situation for the syndrome called postpartum psychosis, that it is not something that has been approved. And I know there are people who are calling for it, but in the current time—
MR. REDDINGTON: Okay.
AVRAM MACK: Yeah.
MR. REDDINGTON: Okay.
THE COURT: Next, next question.
AVRAM MACK: Okay.
MR. REDDINGTON: Thank you. Are you aware, sir, that postpartum psychosis and postpartum depression are pretty much virtually not even mentioned in your DSM-5 TR?
AVRAM MACK: I wouldn't agree with that. I was about to say—
MR. REDDINGTON: Okay. So you would not agree with it, right?
AVRAM MACK: Well, I was... Actually, I was about to get to that.
MR. REDDINGTON: I'm sure you were, but you would not agree with it, right? Is that correct?
AVRAM MACK: I don't have a basis to say that.
MR. REDDINGTON: Okay. So looking at, and this is 1,050 pages of people putting together, like a cookbook, fair to say, right?
AVRAM MACK: No, I wouldn't call it a cookbook.
MR. REDDINGTON: No? Would you agree, sir, that postpartum is referred to page 147 in sex and gender related diagnostic issues? Would you agree with that, sir?
AVRAM MACK: Is that the introductory chapter?
MR. REDDINGTON: This is the chapter, sir, that is pertinent to bipolar disorder. You're familiar with it, I'm sure.
AVRAM MACK: Okay. So it's the bipolar chapter.
MR. REDDINGTON: And referencing 147, sex and gender related diagnostic issues. You're familiar with that, I imagine, right?
AVRAM MACK: That's a subset. I mean, that's a portion of the chapter, I imagine, that describes those issues.
MR. REDDINGTON: Right. It's a paragraph.
AVRAM MACK: Okay.
MR. REDDINGTON: It's a paragraph. Out of 1,000 pages, it's a paragraph.
AVRAM MACK: What's your question?
MR. REDDINGTON: Women may be more likely to experience rapid cycling and mixed states and to have patterns of comorbidity that differ from those of men, including higher rates of lifetime eating disorders. Come on. This is what they talk about with postpartum psychosis and postpartum depression, eating disorders and the difference between women and men?
AVRAM MACK: Is that your question?
MR. REDDINGTON: Yeah.
AVRAM MACK: I'm not sure I understand your question.
MR. REDDINGTON: Now you answer it. Yeah.
AVRAM MACK: What's your question?
MR. REDDINGTON: Postpartum disorders, sir, the difference between women and men, and they make reference to eating disorders.
AVRAM MACK: Well, I think the section header, if you don't mind reading it again, was aspects about gender. And so in that section, I imagine they're describing it. I didn't write the DSM—
MR. REDDINGTON: No, I know.
AVRAM MACK: ...so I'm not here to represent it.
MR. REDDINGTON: Okay.
AVRAM MACK: I can just tell you about it.
MR. REDDINGTON: All right. Okay. Right here. Sex and gender related diagnostic issues, right? Would you agree that's under the bipolar and related disorder section—
AVRAM MACK: Yeah.
MR. REDDINGTON: ...of the DSM? Okay. Page 147 talks about women more likely to experience rapid cycling and mixed states and have patterns of comorbidity that differ from those of men, including higher rates of lifetime eating disorders, right? Did I read that right?
MR. REDDINGTON: That's all right. Okay. And then it goes on for the rest of the paragraph that women with bipolar I, if you want, or II disorder are more likely to experience depressive symptoms than are men. Did I read that right?
AVRAM MACK: Yeah.
MR. REDDINGTON: That they, meaning women apparently, have a higher lifetime risk of alcohol use disorder than men. Really? That's a- Did I read that right?
AVRAM MACK: Yes.
MR. REDDINGTON: And that they also... a much greater likelihood of alcohol misuse disorder than women in the general population. Some women with bipolar disorder experience exacerbation of mood symptoms during their premenstrual phase period. Right?
AVRAM MACK: It says that, yeah.
MR. REDDINGTON: Yeah. And that this has been associated with a worse course of illness. Many women with bipolar disorder also report severe emotional disturbances during perimenopause when estrogen levels are decreasing. Did I read that right?
MR. REDDINGTON: Wait, 'cause it—
AVRAM MACK: It does say that, yeah.
MR. REDDINGTON: Okay. And that there does not appear to be an increased risk of mood episodes in pregnant women with bipolar disorder, except for those who discontinue medications for pregnancy, right? Is that what it says then in the DSM?
AVRAM MACK: It does, yeah.
MR. REDDINGTON: Okay. So what does that tell you, in 25 words or less, sir, when that sentence, where it talks about there does not appear to be an increased risk of mood episodes in pregnant women with bipolar disorder except for those who discontinue medications for pregnancy? What does that mean?
AVRAM MACK: What it means is, when thinking about women who have bipolar disorder who are pregnant, the risk of having either a manic episode or a hypomanic episode or a depressive episode generally stay stable compared to when the person is not pregnant, except in people who do not take medications for bipolar during the pregnancy.
MR. REDDINGTON: And then it goes on to read the specifier with peripartum onset should be used for mood episodes that begin during pregnancy or within four weeks of delivery. Is that the four-week cutoff that you're telling the jury about?
AVRAM MACK: That's the four-week cutoff that's on that specifier, the peripartum specifier, yes.
MR. REDDINGTON: When was this last amended, 1958?
AVRAM MACK: This, well, the—you're talking about the four-week number?
MR. REDDINGTON: Yeah.
AVRAM MACK: That was created in DSM IV in 1994.
MR. REDDINGTON: And how about the World Health Organization? What's their cutoff using that term?
AVRAM MACK: I don't know. I can tell you that the—
MR. REDDINGTON: How about the i—
AVRAM MACK: ... proponents of—
MR. REDDINGTON: Go ahead.
AVRAM MACK: ... postpartum psychosis, the illness, utilize, I believe, 12 weeks, maybe six weeks, but not more than 12.
MR. REDDINGTON: How about the, what is it, IDC, ICD?
AVRAM MACK: The World Health Organization's International Classification—
MR. REDDINGTON: If I tell you it's a year, would that mean anything to you? It's not six, maybe 12. It's a year.
AVRAM MACK: Does it mean anything to me?
MR. REDDINGTON: Yeah. Does it mean anything to you?
AVRAM MACK: With regard to what?
MR. REDDINGTON: It's a year. You're talking about four weeks, but they're referring to a year.
AVRAM MACK: Well, the distinction between the ICD and the DSM is substantial. The DSM—
THE COURT: All right. Mr. Reddington, why don't you ask the question?
MR. REDDINGTON: Thank you. So would you agree with me, sir, that the way that women are treated postpartum, after having babies, prior to having babies in Europe is a heck of a lot different than we treat women here, right?
MS. BUCKINGHAM: Objection.
THE COURT: Sustained.
MR. REDDINGTON: So that paragraph that we just went through, we're talking about sex and gender related diagnostic issues, right?
AVRAM MACK: Yes.
MR. REDDINGTON: They mentioned the words postpartum period. They mentioned—I don't mean period like the end of a sentence, I mean postpartum period. They mentioned that, right?
AVRAM MACK: Yes.
MR. REDDINGTON: And I read that correct. That's a paragraph, right?
AVRAM MACK: Yes.
MR. REDDINGTON: And then out of the 1,050 pages, we can then go to another, page 156, sex and gender related diagnostic issues. And it makes reference to the gender ratio for bipolar I disorder, right?
AVRAM MACK: Okay.
MR. REDDINGTON: Would you agree that the gender ratio for bipolar I disorder is equal between women and men?
AVRAM MACK: Yes.
MR. REDDINGTON: And does it then go on and say that bipolar II disorder are mixed differing by type or sample? There is little or no evidence of bipolar gender difference in the general population. In some, but not all, clinical examples suggested bipolar II disorder is more common in women than in men. Is that right?
AVRAM MACK: It may be. As I was—
MR. REDDINGTON: It may be because you wanna look at it, or it may be because they might be wrong.
AVRAM MACK: Well, women have depression more than men, unfortunately. And so that is something that it gets reflected when it comes to D, to bipolar type II.
MR. REDDINGTON: So patterns of illness and comorbidity, however, differ by sex, with females being more likely than males to report hypomania. Does that sound right?
AVRAM MACK: That sounds right.
MR. REDDINGTON: And that women would have mixed depressive features in a rapid cycling course, correct?
AVRAM MACK: That sounds right.
MR. REDDINGTON: And childbirth may be a trigger for the hypomanic episode, which can occur in 10 to 20% of females in non-clinical populations, most typically in the early postpartum period. Does that sound right to you?
AVRAM MACK: It sound... I mean, you're reading it, so I agree.
MR. REDDINGTON: Yeah, yeah.
AVRAM MACK: Okay.
MR. REDDINGTON: Okay. And there's a big difference between DSM and WHO, right?
AVRAM MACK: I don't know the WHO's 12 months, what it refers to. When it comes to the proposed postpartum psychosis, one of the elements of the proposal is that it is particularly related to the physiologic changes that happen at the time of birth. And actually, one of the objections that that group has to the way that the DSM is written right now is that they would like it to be solely post-birth rather than one that encompasses pregnancy and birth because it aligns with the theory that this type of disorder is related to those physiologic changes. So the timing of being closest to birth is instrumental in that proposal for postpartum psychosis, the disorder. When it's described, it's described as a disorder that occurs almost right away at the time of birth, and it is urgent.
MR. REDDINGTON: Who, who says that? Who?
AVRAM MACK: The literature on postpartum psychosis, whether it's postpartum psychosis—
MR. REDDINGTON: But what literature? What literature?
AVRAM MACK: The—
MR. REDDINGTON: It's not in the Bible, right?
AVRAM MACK: Well, it's not in the Bible, but the reports by the people who are advocates and expert consensus panel who are advocates for inclusion of the syndrome of postpartum psychosis describe it—
MR. REDDINGTON: And they've been trying real hard.
THE COURT: Let him finish.
MR. REDDINGTON: Well, he's just gonna go on for another half hour.
THE COURT: No, I'll... Finish, Doctor. Go ahead.
AVRAM MACK: I don't have anything more. Sorry.
THE COURT: Okay. All right. Go ahead.
MR. REDDINGTON: Would you agree with me, sir, as it relates to this panel of people that you're talking about, these are the people that are trying to get postpartum psychosis, postpartum depression into the DSM-6, right?
AVRAM MACK: I don't think they're trying to get postpartum depression included because it already is there.
MR. REDDINGTON: In the two paragraphs that I just read?
AVRAM MACK: No.
MR. REDDINGTON: Okay, is there somewhere else that talks about postpartum depression?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay. Where?
AVRAM MACK: Well, the report mentions, and I'll find for you the—
MR. REDDINGTON: Okay.
AVRAM MACK: ...what are called the specifiers—
MR. REDDINGTON: Okay.
AVRAM MACK: ...where for both bipolar disorder and also for depressive disorders—
MR. REDDINGTON: There you go.
AVRAM MACK: ...well, it's in there, but I'll find it in the book.
MR. REDDINGTON: Okay.
MR. REDDINGTON: Why don't you look for it?
THE COURT: Why don't, why don't we, why don't we do one thing at a time? All right.
AVRAM MACK: Yeah. I'd like to finish speaking.
THE COURT: And that would be, you said you're gonna find it. Just find it.
AVRAM MACK: Okay.
THE COURT: And then once you find it, then we'll go on to the second part, which would be asking questions and answering questions.
AVRAM MACK: Okay. So right here on page one hundred and seventy-three.
MR. REDDINGTON: Read it.
AVRAM MACK: I'll describe what I'm talking about before I read it, if that's okay. So this is the section, actually starts on page one hundred and sixty-nine, where it goes through what are called the specifiers for the bipolar disorders. And so those include with atypical features, with rapid cycling, with melancholic features. And here on page one hundred and seventy-three is the portion about with peripartum onset.
MR. REDDINGTON: Read it. Read it.
AVRAM MACK: Well, let me see how many paragraphs it is. It's many paragraphs. Do you want me to read all of them?
MR. REDDINGTON: No, that's all right.
AVRAM MACK: Okay.
MR. REDDINGTON: Just summarize it as best you can.
AVRAM MACK: What I would summarize, and a similar passage is in the chapter on depressive disorders, is that it provides a way to designate that somebody's depressive disorder, or in this case their bipolar disorder, had peripartum onset. Now, that's important, and they provide a lot of important information there about epidemiology and the course. And the course, by course, I mean how it's going to go in terms of the disease. That's what the DSM does. Besides giving criteria for disorders, it provides basic information about course, epidemiology, and the features that the individual has. So there's a similar section in the depressive disorders.
MR. REDDINGTON: Let's stick with the section that you just pointed out.
AVRAM MACK: Yes, sir.
MR. REDDINGTON: Okay. Do you agree with me in a nutshell that that talks about with psychotic features, delusions, hallucinations present at any time in the current manic or major depressive episode in bipolar I disorder, right?
AVRAM MACK: No, I'd have to see what you're reading from.
MR. REDDINGTON: Okay. Sure. It's right here.
THE COURT: Yeah, but that's a different portion.
MR. REDDINGTON: No, no, no. That's what you were reading from. Okay.
AVRAM MACK: No, sir.
MR. REDDINGTON: So how about down below here where it says with peripartum onset?
AVRAM MACK: Yes. That was what I was referring to.
MR. REDDINGTON: The specifier. What's a specifier?
AVRAM MACK: So the system has a way where we can emphasize features of a person's illness. Remember, as I said, the groupings in the DSM revolve around the major psychiatric symptoms. So this is the bipolar chapter. There's a depression chapter. There's an anxiety chapter. So here the specifier is our way of communicating that the person's problem, in this case, has peripartum onset.
MR. REDDINGTON: Okay.
AVRAM MACK: And as I-
MR. REDDINGTON: Did you-
AVRAM MACK: Can I, if I could connect it all.
MR. REDDINGTON: Oh, go ahead.
AVRAM MACK: The emphasis on the proposed postpartum psychosis disorder, they object to it being peripartum. They would like it to be postpartum.
MR. REDDINGTON: And who's they?
AVRAM MACK: The authors of the expert consensus group that I referred to published a paper in Biological Psychiatry in the last year.
MR. REDDINGTON: About what? I mean, psychiatry covers a large realm.
AVRAM MACK: Yes. It's a paper that summarizes information about this proposed disorder, highlights their assumption that it is actually a type of bipolar disorder.
MR. REDDINGTON: Can I just interrupt? What disorder are you referring to?
AVRAM MACK: The proposed postpartum psychosis disorder.
MR. REDDINGTON: All right. So there is a group of people that are trying, to your knowledge, to get postpartum disorder in the next version of the Bible, right?
AVRAM MACK: Effectively, yes—
MR. REDDINGTON: Okay.
AVRAM MACK: …but I wouldn't use all those words, but yes.
MR. REDDINGTON: Okay. And then when you're referring to the peripartum onset, in one paragraph, you're talking about the specifier applied to current manic, hypomanic, or major depressive episode in bipolar I disorder, right? Did I read that right?
AVRAM MACK: Well, it's more than just one paragraph.
MR. REDDINGTON: Okay, let's just—
AVRAM MACK: It goes on for all the next—
MR. REDDINGTON: Let's just—
THE COURT: All right, counsel, let me see counsel at sidebar here just regarding scheduling.
THE COURT: Members of the jury, we're gonna break at this point, all right? So you know what I'm gonna tell you, all right? You've now heard more evidence. You've heard testimony from a number of people. You've got more and more exhibits, but you still have to keep that open mind, all right? 'Cause you haven't heard all the evidence. You haven't heard the closing arguments, as I've said it before. You haven't even heard the law that you are to apply to this in arriving at your verdict. So I'm gonna stress, as I always do, don't talk about this case. Don't read anything about it. Don't listen to anything about it. Just really just guard against that, and really keep an open mind, all right? So I'm gonna excuse you till Monday morning, and then I ask you to be here hopefully at nine o'clock. We'll come back out, and we'll continue with the evidence. All right? And as I'm telling you, we are well on schedule. All right? So I don't wanna get ahead of myself, but in case you're wondering, we are definitely well on schedule, much because of your work on this. So I hope everybody has a nice weekend. Maybe it'll stop raining. Get outside a little bit. So again, thank you for all your time and dedication on this, and we'll see you on Monday. Okay.
BAILIFF: All rise, please. Jurors exiting.
BAILIFF: Jurors have exited the courtroom. This court's in session. Please be seated.
THE COURT: Doc, you may sit down.
AVRAM MACK: Oh, am I excused, sir?
THE COURT: We talked to the DA's office and you guys' schedule. We did discuss that.
AVRAM MACK: Okay.
THE COURT: Okay. All right. Counsel, anything else we need to address before Monday?
MS. BUCKINGHAM: No, Your Honor.
THE COURT: All right, and so the plan would be, we'll continue with the Commonwealth's rebuttal. At some point, we'll do the final charge conference, and we'll go from there. So I wanna thank everybody for their work. I hope everybody has a nice weekend. Thank you.
MR. REDDINGTON: Thank you.
BAILIFF: Court, all rise.