1.Avram Mack — Cross (Part 3)
831 linesBAILIFF: This court is now in session. You may be seated.
COURT CLERK: May I proceed, Your Honor?
THE COURT: Yes, please.
COURT CLERK: Your Honor, before the court today we have the matter of Commonwealth versus Lindsay Clancy, Ms. Clancy represented by Attorney Kevin Reddington. The Commonwealth is represented by Assistant District Attorney Jennifer Sprague and Assistant District Attorney Shanan Buckingham.
THE COURT: All right. Well, good morning, everyone. Good morning, counsel.
MR. REDDINGTON: Morning.
THE COURT: Good morning, Ms. Clancy.
MS. CLANCY: Morning, Your Honor.
THE COURT: All right. So are we ready for the jury?
MR. REDDINGTON: We are.
THE COURT: All right. So what we'll do is we'll— can I see counsel just very briefly, just in regards to today's schedule?
BAILIFF: All rise. Jurors entering.
BAILIFF: Hear ye, hear ye, hear ye. All persons having anything to do before the Honorable William Sullivan, Justice of the Superior Court now sitting in Plymouth within and for the Commonwealth, draw near, give your attendance and you shall be heard. By the state of the Commonwealth of Massachusetts, this court is now in session. Please be seated.
COURT CLERK: Good morning, Your Honor. May I proceed?
THE COURT: Yes, please.
COURT CLERK: Your Honor, before the court today we have the continuation of the jury trial in the matter of Commonwealth versus Lindsay Clancy. Ms. Clancy is present. She is represented by Attorney Kevin Reddington. The Commonwealth is represented by Assistant District Attorney Jennifer Sprague and Assistant District Attorney Shanan Buckingham.
THE COURT: All right. Well, thank you, Madam Clerk. Good morning, members of the jury.
JURORS: Good morning.
THE COURT: I hope everybody had a nice weekend. And so what we're gonna do, as we have done so many times before, I'm gonna ask you those questions, and then we're kinda gonna go over what today's schedule is, and then we'll get right back to the trial. So the first question, has any member of the jury read, seen, heard, or overheard anything from any source about any aspect of this case that would affect your ability to be a fair and impartial juror?
JURORS: No.
THE COURT: All right. Last question, is there any other serious matter of concern bearing on your service as a juror in this case that anybody needs to bring to my attention at this time? Again, thank you so much for following those instructions. What we are going to do from the schedule today, if you remember on Friday, there was— we were in, during cross-examination of Dr. Mack, who testified Friday afternoon. We're gonna return to the cross-examination, and the only difference is, Dr. Mack is gonna be available by Zoom here. We've had a couple other witnesses, so you all kinda know how that's gonna work. So we're gonna finish the cross-examination of Dr. Mack by Zoom. Commonwealth, if they have redirect question, and then we're gonna continue with the Commonwealth's rebuttal. All right?
THE COURT: And so, just to kinda go back as far as the procedures that we followed. So the Commonwealth presented their case, then after they were done, the defendant presented their case, and we're now on to the Commonwealth's rebuttal. All right? And when the Commonwealth's rebuttal is done, we're gonna move to the next portion of the procedure, process, which will be the closing arguments and the legal instructions. All right? So that comes after the Commonwealth's rebuttal witnesses. So that's kind of where we are at this point. And so, as we go through today I'll kinda keep you up to date in regards to the schedule for go forward. All right? So that's where we are. So at this point, we'll get Dr. Mack on the screen and then it'll be Mr. Reddington continuing cross-examination.
COURT CLERK: I need to swear him in.
THE COURT: Yeah, please.
COURT CLERK: Dr. Mack, could you please raise your right hand? Do you solemnly swear that the testimony and the evidence you shall give to the court and the jury in the matter now pending between the Commonwealth and the defendant at the bar shall be the truth, the whole truth, and nothing but the truth, so help you God?
AVRAM MACK: I do.
COURT CLERK: Thank you, sir.
THE COURT: All right. Attorney Reddington.
MR. REDDINGTON: Thank you. Sir, how many times have you testified in courts on the issue of criminal responsibility?
AVRAM MACK: I would estimate one or two.
MR. REDDINGTON: So if you estimate one or two times, would this be your third time?
AVRAM MACK: By that estimation, yes.
MR. REDDINGTON: Okay. So it's not by my estimation though, it's by your estimation, and you would know better than me, right?
AVRAM MACK: Yeah.
MR. REDDINGTON: Okay. So this is the third time in your career that you've testified on a criminal trial on the issue of lack of criminal responsibility. Is that correct?
AVRAM MACK: It's... I know there are other times that I've created opinions.
MR. REDDINGTON: Oh, I'm sure.
AVRAM MACK: I'm not sure how mu-
MR. REDDINGTON: I'm just asking about criminal responsibility. That's it.
AVRAM MACK: I'm talking about criminal responsibility, and I know there are other times I've created opinion, but I'm not sure that I've testified about them-
MR. REDDINGTON: Okay.
AVRAM MACK: ... in the courtroom.
MR. REDDINGTON: So my question was simply, how many times have you testified in court on criminal cases regarding the issue of lack of criminal responsibility, and this would be a third time, right?
AVRAM MACK: That is my recollection.
MR. REDDINGTON: Okay. And you have testified in court on behalf of various governmental agencies on other matters in addition to criminal responsibility, correct?
AVRAM MACK: Yes.
MR. REDDINGTON: And you are operating under the umbrella, if you will, of the Park Dietz conglomerate of a lot of expert witnesses that, as I understand, would parcel out cases to different people. Is that right?
AVRAM MACK: There are times that I do cases through Park Dietz & Associates. I can't speak to how many experts they have and exactly how they, as you put it, parcel things out. But over the span of my career, there have been times that I've done it when cases have been presented through Park Dietz & Associates, and times that I've done it through other entities. As I discussed the other day— I had a role for the State of Maryland, and at times, and in this case, there was a criminal responsibility trial that I was a part of, when I had a role for the State of Maryland. So going throughout my career, it's been multiple different entities.
MR. REDDINGTON: You've also testified, since we're talking about it, in the State of Pennsylvania, right?
AVRAM MACK: What's your question?
MR. REDDINGTON: You've also testified, since we're talking about it, in the State of Pennsylvania, right?
AVRAM MACK: I believe I have.
MR. REDDINGTON: Was that at Park Dietz, or was that you individually or one of your other entities?
AVRAM MACK: You'd have to specify which case.
MR. REDDINGTON: Commonwealth versus Torres, 342 MAL 2021, Pennsylvania.
AVRAM MACK: Can you cite that case again, please?
MR. REDDINGTON: Sure. Commonwealth versus Torres, 342 MAL 2021, Pennsylvania, where the court held that you, that would be Avram Mack, was apparently certified only in child and adolescent psychiatry. You lacked forensic certification to testify in the field that you were ostensibly gonna testify in. Does that refresh your memory?
AVRAM MACK: No.
MR. REDDINGTON: Did you testify in—
AVRAM MACK: But I'm happy to look.
MR. REDDINGTON: Did you testify in Commonwealth versus Torres in Pennsylvania?
AVRAM MACK: I don't remember.
MR. REDDINGTON: How about Commonwealth versus Cotter in New Jersey? You remember that one?
AVRAM MACK: No.
MR. REDDINGTON: Do you recall the court held on an appeal that you used an approach that fell below the standard of forensic practice?
AVRAM MACK: No.
MR. REDDINGTON: How about Feder Lebrun versus the Secretary of DCF, 710 Fed 3d 1202 in Florida? You remember that case, I'm sure, right?
AVRAM MACK: I do.
MR. REDDINGTON: And in Feder, there was a gentleman, Mr. Feder Lebrun, who was a Navy veteran, who was a single father and had a child. And he was a member of, or a person that was able to get benefits from what's called TANF, T-A-N-F, Temporary Aid to Needy Families. You remember that?
AVRAM MACK: I do.
MR. REDDINGTON: And the State of Florida decided that because needy families consisted of either minorities or drug users or people that would not be reliable to work, in the confines of working underneath the TANF, so they wanted to have blood testing and drug testing of all the people that were Temporary Aid to Needy Families, right?
AVRAM MACK: That's your conception of what was happening with that—
MR. REDDINGTON: Well, that's my conception from reading the case, sir. Do you agree, sir, that TANF is an acronym for Temporary Aid to Needy Families?
AVRAM MACK: Yes, it is.
MR. REDDINGTON: Do you agree, sir, that Mr.—does this gentleman, Mr. Feder LeBron, was a plaintiff in a lawsuit against the State of Florida?
AVRAM MACK: Yes.
MR. REDDINGTON: Do you agree, sir, that it was in federal court?
AVRAM MACK: Yes.
MR. REDDINGTON: Do you agree, sir, that in federal court, the court held that in fact you were unqualified to give an opinion that you attempted to give, saying that it was perfectly appropriate to test by way of urine or blood people that are benefiting from the TANF program because your testimony was that they belong to a class of people that I guess had to be tested, right?
AVRAM MACK: I don't agree with your conceptualization.
MR. REDDINGTON: Okay. So the court ultimately ruled that your argument, your testimony on behalf of the State of Florida, the government, and you indicated that TANF benefits, applicants for TANF were people that were involved with drug use, violence, and higher rates of suicide. Remember those words, those three words?
AVRAM MACK: The testimony that I provided in that case—
MR. REDDINGTON: Do you remember testifying, sir, about the people that are the beneficiaries of the TANF program, people that need aid because of needy families, are people that should be tested by way of blood or urine, and your argument, sir, was because they are of a class that would be more likely to commit a crime or have suicide or drug use. Did you testify to that?
AVRAM MACK: That is not the way that that testimony or that report was presented. No, I disagree.
MR. REDDINGTON: Okay. So your answer's no.
MR. REDDINGTON: Let's keep it that way. Your answer's no. So you recall, sir, that there was an appeal, and in fact, on the appeal, it was determined that again, yet again, you were not qualified to offer a relevant opinion because number one, you never studied the TANF population. You recall that?
AVRAM MACK: No, that is not the correct conceptualization.
MR. REDDINGTON: Says you. Number two, that you did not survey any data. You recall that, sir?
AVRAM MACK: Specifically in Florida is the nuance on that issue.
MR. REDDINGTON: And number three, that you had no research whatsoever on the data that you based your opinion on. Would you agree with that, sir?
AVRAM MACK: No.
MR. REDDINGTON: Do you agree, sir, that the court held that you relied on other researchers' studies and didn't make any effort whatsoever to form an opinion based on your own research? Do you agree with that?
AVRAM MACK: I don't remember the specific language of the court.
MR. REDDINGTON: All right. Do you recall that ultimately your testimony was stricken?
AVRAM MACK: No, I don't believe that it was stricken.
MR. REDDINGTON: Okay. In any event, sir, you would agree with me that you have a memory of Avram Mack being subject to this attack, if you will, by the attorneys on behalf of the people that were involved with TANF, right? You remember that much, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay.
AVRAM MACK: I do.
MR. REDDINGTON: Thank you. Now, in summary, sir, you're here to testify in front of this jury regarding your testimony and opinion that you've given regarding Lindsay Clancy's state of mind at the time of the killing of her children. Is that correct?
AVRAM MACK: Yes.
MR. REDDINGTON: And you evaluated her in 2026, is that right?
AVRAM MACK: Yes.
MR. REDDINGTON: So you really evaluated her about three years after the incident that occurred in January '22, right?
AVRAM MACK: January 2023.
MR. REDDINGTON: So you do recall the date that the incident occurred, '23, right?
AVRAM MACK: Right. So to answer your question, I'm not—
MR. REDDINGTON: Okay. The answer is right.
AVRAM MACK: Yeah.
MR. REDDINGTON: Okay. And in reference to your answer, sir, you would agree with me that there was a significant passage of time between the incident in 2023 and when you saw her about two or three months ago, right? Correct. Okay. And you drove out there with the guy that's gonna be in here testifying in about an hour or so, Helbron. Is it Helbron or Hei- Heilbron?
AVRAM MACK: When you say that I drove out there—
MR. REDDINGTON: I'm just asking the guy's name. Is it Helbron or Heilbron?
AVRAM MACK: You'll have to ask him how he likes to pronounce it.
MR. REDDINGTON: Well, did you know how to call him or what to call him when you were out there with him for two days at Tewksbury?
AVRAM MACK: Kirk.
MR. REDDINGTON: Kirk, okay. And you met Kirk, I imagine, that morning that you were gonna evaluate Lindsay?
AVRAM MACK: Yes.
MR. REDDINGTON: And what was the date that you evaluated her? Was it February date?
AVRAM MACK: I think the first, the first date was April 10th.
MR. REDDINGTON: Okay.
AVRAM MACK: The second date was April 12th. And those are the two days that I was there.
MR. REDDINGTON: Right, because Kirk had to give her psychological testing on the middle day, right?
AVRAM MACK: Correct.
MR. REDDINGTON: Okay. So did you stay in a hotel or a van or where'd you stay?
AVRAM MACK: You're asking me where I stayed?
MR. REDDINGTON: Yeah. I don't wanna meet up, I just wanna know where you stayed.
AVRAM MACK: I stayed in Massachusetts.
MR. REDDINGTON: Where?
AVRAM MACK: I believe in Wellesley.
MR. REDDINGTON: Where? Was it like Holiday Inn? Was it a Ritz-Carlton? Where?
AVRAM MACK: A private home.
MR. REDDINGTON: A private home, okay. Kirk didn't stay there, did he?
AVRAM MACK: I don't know.
MR. REDDINGTON: You don't know?
AVRAM MACK: No, he didn't stay there. He didn't stay there, that's for sure.
MR. REDDINGTON: Okay. So in any event, you must have had plans to meet up with Kirk at Tewksbury Hospital, right?
AVRAM MACK: I did meet Dr. Heilbrun at Tewksbury Hospital, yes.
MR. REDDINGTON: Okay. I'm calling him Kirk because that's what you told me is, that you refer to him as. But is Dr. Hoffman, how do you pronounce it?
AVRAM MACK: I believe it's Heilbrun, but you'll have to ask him how he prefers it.
MR. REDDINGTON: Okay, I will. And then did you meet him in the parking lot of Tewksbury?
AVRAM MACK: Yes, I think that's right.
MR. REDDINGTON: And you had—
AVRAM MACK: Or in the lobby.
MR. REDDINGTON: Sorry, what'd you say?
AVRAM MACK: Or in the lobby.
MR. REDDINGTON: Okay. So when you went there on that date in April, the first day, you already had your information that you were able to form your opinion based upon, is that right?
AVRAM MACK: At the time that I initiated the examination, I had reviewed records related to Ms. Clancy. But creation of the ultimate opinion—
MR. REDDINGTON: No, no, no.
MR. REDDINGTON: I'm asking, I'm asking about the records, sir. Real simple, the records that you reviewed. You had already reviewed them before you went to Tewksbury Hospital. Is that fair?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay. And the records would be, obviously cell phone extraction records, yes?
AVRAM MACK: I don't know exactly when I reviewed the cell phone records.
MR. REDDINGTON: How about defense expert forensic psychiatric evaluations, Dr. Phillip Resnick, Dr. Margaret Spinelli? You reviewed the reports that were already prepared by my experts, is that correct?
AVRAM MACK: And also Dr., is it Zeizel?
MR. REDDINGTON: Zeizel, yeah. Thank you. Okay. You were... 'Cause I had sent them to you, isn't that right?
AVRAM MACK: You had sent them, I believe, to Dr. Heilbrun.
MR. REDDINGTON: To doctor who? I'm sorry.
AVRAM MACK: I think Dr. Kirk Heilbrun. And I think he was able to give them to me.
MR. REDDINGTON: Okay, fine. So you also were able to review division or Department of Children and Family records dated February 3rd of 2023, correct?
AVRAM MACK: Correct.
MR. REDDINGTON: And those would be records that pertained obviously after the death of the children, but it was just an interview of Patrick, the father, and Lindsay's husband, right? That's what those were.
AVRAM MACK: That was a substantial component of that, but that was the DCF evaluation that occurred, and they, I believe, interviewed him when he was at Boston Children's Hospital.
MR. REDDINGTON: Okay. All I'm asking is all I'm asking is that the DCF... In other words, there's no DCF records that shows that Lindsay was abusive to her children, right?
AVRAM MACK: I don't think that that was necessarily the conclusion of that report.
MR. REDDINGTON: Well, it wasn't a conclusion of any report. There were no other reports other than February 3rd, correct?
AVRAM MACK: Yeah, that's right.
MR. REDDINGTON: Okay. And that would be interviewing Pat, the father and the husband, right?
AVRAM MACK: As I said, I think effectively that is the core component of that report.
MR. REDDINGTON: Okay. That's a component of the report. The answer is yes. You also had medical records from Aster Mental Health records, right?
AVRAM MACK: Yes.
MR. REDDINGTON: That would be Jennifer Tufts?
AVRAM MACK: Yes.
MR. REDDINGTON: Jennifer McAllister, right?
AVRAM MACK: I'm not sure if that's the name of another doctor in that practice, but substantially Aster Mental Health included the work of Dr. Tufts.
MR. REDDINGTON: Dr. Tufts. And how about Nurse Practitioner Jollotta? Did you review her records as well?
AVRAM MACK: The records of her that came from the organization that she had worked in, yes.
MR. REDDINGTON: What organization was that, do you know?
AVRAM MACK: I'm not exactly recalling the title of it, but I believe it's South Shore Mental Health, but I'm not exactly sure of the exact title.
MR. REDDINGTON: Boston Children's Hospital, Brigham and Women's Hospital, and McLean Hospital records, you reviewed them, correct?
AVRAM MACK: Yes.
MR. REDDINGTON: Spaulding Rehab, right?
AVRAM MACK: Yep.
MR. REDDINGTON: Tewksbury Hospital from March 7th, March 27th of '23 up through April 1st of '26, which is a little bit before you saw Lindsay, right?
AVRAM MACK: Correct.
MR. REDDINGTON: There were about 7,000 pages. A lot of, lot of paper, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Toxicology records, police reports, grand jury testimony, you read all that, too, right?
AVRAM MACK: Correct.
MR. REDDINGTON: Police interviews, interviews of witnesses, right?
AVRAM MACK: Correct.
MR. REDDINGTON: And you had met with, I imagine, or spoken to, by telephone perhaps, with the district attorneys, the prosecutors here?
AVRAM MACK: Yes.
MR. REDDINGTON: And where did you meet them?
AVRAM MACK: The prosecutors?
MR. REDDINGTON: Yeah.
AVRAM MACK: Only by phone.
MR. REDDINGTON: Okay, so you met them by phone. When was that?
AVRAM MACK: I don't know offhand when that was.
MR. REDDINGTON: How long was the conversation?
AVRAM MACK: I don't recall. It could have been somewhere between 15 minutes to 45 minutes.
MR. REDDINGTON: And basically they told you that they wanted you to evaluate a defendant who had been indicted for triple homicide of her own children, by the name of Lindsay Clancy. You knew that from speaking with them, right?
AVRAM MACK: Effectively I knew that, yes.
MR. REDDINGTON: And, you know, I normally don't go there with expert witnesses, but it was fair game on Dr. Zeizel. How much money do you make a year on your forensic evaluations?
AVRAM MACK: It ranges over the years, you know, several hundred thousand of dollars.
MR. REDDINGTON: Yeah.
AVRAM MACK: Can be a few-
MR. REDDINGTON: And a lot of that-
AVRAM MACK: ... could be more.
MR. REDDINGTON: I'm sorry. Go ahead.
AVRAM MACK: No, go ahead.
MR. REDDINGTON: So a lot of that, it would be appointed cases or cases either from Park Dietz or some other warehouse that asks you to evaluate people and testify in the court, right?
AVRAM MACK: Or, over the years, people contact me directly.
MR. REDDINGTON: Really?
AVRAM MACK: We're talking about over the last 15 to 20 years.
MR. REDDINGTON: Right. So when you were contacted by... Strike that. Did the DAs here call you, or did you call them?
AVRAM MACK: I don't recall.
MR. REDDINGTON: Do you recall that they told you what a horrible case this was, that this woman killed her three children by strangling them? Did they tell you that?
THE COURT: Sustained. Next question.
MR. REDDINGTON: Well, did you know what the factual allegations were of the case? Yes or no?
AVRAM MACK: Well, all the factual allegations, yes, I believe they were conveyed to me during a phone call.
MR. REDDINGTON: Yeah. Okay. And when you were engaged or retained through Park Dietz & Associates to work for the Plymouth County District Attorney's Office, I mean, that's fair to say, you were working for them, right?
AVRAM MACK: Effectively, I was retained by the District Attorney's Office, yes.
MR. REDDINGTON: All right. And let's talk about confirm-
MR. REDDINGTON: Let's talk about confirmatory bias. You know what that is?
AVRAM MACK: Well, you were asking me the other day about the cognitive bias think tank, and we talked about how as a part of my work in patient safety-
MR. REDDINGTON: No, no, no, no, no, no. This is con- This is-
MR. REDDINGTON: Doctor-
AVRAM MACK: ... I would like to be able to finish.
THE COURT: Hold on. Doctor, please. Listen to the question, and answer the question. Go ahead, Mr.
MR. REDDINGTON: This is confirmatory bias, sir, not, not a think tank talking about safety of anybody, okay? Confirmatory bias. Have you heard of that term?
AVRAM MACK: I have.
MR. REDDINGTON: And what does it mean?
AVRAM MACK: Well, if you're talking about the work in diagnosis in medicine, as I was getting at before, it refers to the idea that an individual has a idea as to what they're aiming for, and they gather information that accedes to that and that brings that point together.
MR. REDDINGTON: Okay. So would you agree with me, sir, that when you are retained in your practice working, whether it's for Dietz or somebody else, and you are engaged by a prosecutor such as the Plymouth County DA's office, is it fair to say that you go into your work and your evaluation in—I hesitate to use the word investigation—but you have a confirmatory bias? You're hoping that you're gonna be able to help them out, right?
AVRAM MACK: No.
MR. REDDINGTON: No. Okay. So you had read all this material, you had spoken with the prosecutors, and I imagine you had done a team back with Kirk Heilbrun, right?
AVRAM MACK: A what?
MR. REDDINGTON: You talked to Kirk Heilbrun about the fact that you guys were gonna go in and evaluate Lindsay, right?
AVRAM MACK: We had worked with the prosecutors, and I believe them with you, to schedule-
MR. REDDINGTON: No, you didn't work... You... Excuse me. You didn't work with me. What do you mean? You didn't work with me.
AVRAM MACK: I imagine there was interactions in terms of setting up the dates on which this would occur.
MR. REDDINGTON: I had nothing to do with it. My office manager Laura Mather would have done that. I had nothing to do with it, sir.
MS. BUCKINGHAM: Objection.
THE COURT: Yeah. Okay, next question.
MR. REDDINGTON: So when you went out there on the two days that you went out, forget the middle day, 'cause that's when Kirk was by himself. When you went out there, the two of you met in the parking lot or the lobby, one or the other, correct?
AVRAM MACK: Yep.
MR. REDDINGTON: Yes?
AVRAM MACK: I said yes.
MR. REDDINGTON: And the purpose was to go interview her, right?
AVRAM MACK: Ms. Clancy, yes.
MR. REDDINGTON: So you guys go down the hallway, you go in the elevator, you go upstairs to the locked wards. They have to open the door. They have orderlies and people that escort you. Is that right?
AVRAM MACK: Yeah. Effectively.
MR. REDDINGTON: You have to sign in. You have to have ID because it's a locked ward, right?
AVRAM MACK: Effectively, yes.
MR. REDDINGTON: Effectively. And the two of you, you and Kirk, go into a room—
AVRAM MACK: Dr. Heilbrun.
MR. REDDINGTON: ...where she's sitting in her wheelchair by herself so that you- two of you can interview her. Is that correct?
AVRAM MACK: Yes.
MR. REDDINGTON: For how many hours did you interview her the first time?
AVRAM MACK: The first day, it was roughly, ended up being about, I think, four or five hours.
MR. REDDINGTON: And have in mind, sir, as counsel has already elicited, she's incontinent. She has issues because of being paralyzed and had to have a break, didn't she?
AVRAM MACK: Mm, she did not ask for a break.
MR. REDDINGTON: Oh, she was able to power through—
AVRAM MACK: Yeah.
MR. REDDINGTON: ...the four hours?
AVRAM MACK: I don't know if that's the appropriate way to frame it. We took a break. During the interview, we discussed the schedule that she has for catheterization, if that's your question.
MR. REDDINGTON: So you and Kirk Heilbrun sat down, and you questioned Lindsay, the both of you together, or one at a time, or how'd that work out?
AVRAM MACK: One would ask questions, and if another one had additional questions to ask about that particular topic, then the other would ask.
MR. REDDINGTON: And she was—fair to say she was pretty cooperative with you guys, right?
AVRAM MACK: Yes.
MR. REDDINGTON: She was polite. She was affable, right?
AVRAM MACK: Yes.
MR. REDDINGTON: She answered your questions, right?
AVRAM MACK: Yes.
MR. REDDINGTON: And then when you concluded that first day, then the next day, Kirk Heilbrun went on his own to Tewksbury and had another multi-hour interrogation, questioning or whatever of Lindsay, right?
AVRAM MACK: He was there for a second day for psychological testing.
MR. REDDINGTON: So you're aware of the fact that he was there for psychological testing, right?
AVRAM MACK: Yeah.
MR. REDDINGTON: Now, a psychiatrist doesn't do psychological testing. The psychologist does, right?
AVRAM MACK: Typically, that's true.
MR. REDDINGTON: And there are a number of tests that are administered to people when they are being evaluated for purposes of a criminal case such as this, right?
AVRAM MACK: There are a number of different tests that test different aspects of an individual's psychiatric or psychologic or cognitive functioning.
MR. REDDINGTON: Right. Like, for example, you wanna determine, I would imagine, whether or not they're lying or exaggerating or minimizing their symptoms, right?
AVRAM MACK: That's always an interest, yes.
MR. REDDINGTON: And it's of interest because if a person is, in fact, masking or lying about their mind, trying to fake out an evaluating forensic psychiatrist or psychologist, when you say that's of interest, that's something that can be a test result that a jury could look at, right?
AVRAM MACK: Well, I'm not sure if there's a test that specifically states a person is lying.
MR. REDDINGTON: No. Have you ever heard of the MMPI?
AVRAM MACK: I have.
MR. REDDINGTON: Okay. You ever heard of the K-scale?
AVRAM MACK: Yes.
MR. REDDINGTON: What is that?
AVRAM MACK: Well, the K-scale is among the internal validity scales of the MMPI.
MR. REDDINGTON: Okay.
AVRAM MACK: The MMPI is an assessment of the individual's personality.
MR. REDDINGTON: Okay. So let's focus on the K-scale, sir. When you say that it's a… Let me ask you again. What is your understanding of what the K-scale is seeking to find out?
AVRAM MACK: I answer this in the context of the purpose of the MMPI and what the MMPI is designed to do—
MR. REDDINGTON: What are you smiling for? This is not funny, sir.
MS. BUCKINGHAM: Objection.
THE COURT: Sustained. Next question.
MR. REDDINGTON: Well, you know—
THE COURT: Next question.
MR. REDDINGTON: MMPI, K-scale, focus. What does it mean, sir?
AVRAM MACK: So the MMPI is an assessment of personality, and it is a set of questions that the individual responds to, to provide the test and to provide the user of the test to understand what is their personality like. The K-scale is a set of questions embedded in the MMPI that are designed to see whether or not the individual is exaggerating in their responses, generally speaking.
MR. REDDINGTON: Okay. Or lying, right? They call the K-scale the lie scale, right?
AVRAM MACK: Well, if you're simply referring to your own personality style, the issue is whether or not the answers are reliable or valid. It's not a matter of assessing if the person is lying on the MMPI.
MR. REDDINGTON: Does the MMPI assess to any degree whether or not a person is lying, in your opinion?
AVRAM MACK: No.
MR. REDDINGTON: No? So let's stay with Dr. Mack opinion on the K-scale. What would that do? It would determine if somebody is not being truthful about their symptoms or they're exaggerating their symptoms?
AVRAM MACK: Well, the MMPI assesses the individual's personality and their thoughts about themselves. So the question is how to get an accurate reading of the person's personality. If it is the case that they are having a deviation on the K-scale, then you might not utilize the MMPI as a whole. But the MMPI is not designed as a lie detector.
MR. REDDINGTON: So what does that mean, sir, when you say, if there's a manipulation of the K-scale? What does that mean?
AVRAM MACK: I don't think I used the word manipulation.
MR. REDDINGTON: What word did you use?
AVRAM MACK: I may have said deviation.
MR. REDDINGTON: Okay. So if there's a deviation on the K-scale, according to you, what does that mean?
AVRAM MACK: It may come to a threshold that the MMPI is not usable, and that we, the users, cannot gather information about the individual's personality as a result.
MR. REDDINGTON: Because they're lying, and it's not a reliable test, right? That's the ultimate consideration, right?
AVRAM MACK: Right. So it's not saying that the person is lying. It's saying that the test is not reliable.
MR. REDDINGTON: Because the person who's the subject of the test is not being, let's say, forthright. Is that fair?
AVRAM MACK: I don't know that it's always necessarily a conscious act. An individual, it simply reflects the tendency the individual has when answering the questions that are on that subpart of the test.
MR. REDDINGTON: Okay, so if somebody has been indicted by the Plymouth County, by the Plymouth County District Attorney's Office for triple murder, and you are working for the DA evaluating whether or not they are suffering from a mental disease or defect, would you agree with me, sir, that there may be a tendency for somebody to exaggerate their symptoms to try to paint a positive picture of themself?
THE COURT: Overrule.
AVRAM MACK: Not necessarily.
MR. REDDINGTON: Well, how about a little bit necessarily?
AVRAM MACK: I don't know that there's a relationship.
MR. REDDINGTON: Okay. So you are aware, regardless, that when Lindsay took the test for Dr. Kirk Heilbrun, that there was no indication whatsoever of any malingering, exaggeration, or anything along those lines in that test. Would you agree with that?
AVRAM MACK: If you're talking about the MMPI, correct.
MR. REDDINGTON: That's what we've been talking about.
THE COURT: Is there a question?
MR. REDDINGTON: I don't know. We're looking at each other. I-
THE COURT: I wasn't sure if he was gonna answer, but yes, next question.
MR. REDDINGTON: ... yeah, okay. So you... Tell me again what your answer was, sir.
AVRAM MACK: That effectively, that's what the testing elicited, that she was, that her K-scale effectively, there was a valid test.
MR. REDDINGTON: Okay. Now, you, in your review of all of the records, Tufts, Jollotta, McLean, you knew that one of the healthcare providers, which would be Jollotta, was focusing on the possibility that Lindsay could have been suffering from bipolar II. Is that right?
AVRAM MACK: I'm aware that that was on her mind, that that was something she was concerned about, yes.
MR. REDDINGTON: And bipolar II is quite common, is it not, sir, as a precursor of a person who is suffering from postpartum depression or postpartum psychosis, right?
AVRAM MACK: I don't understand your question.
MR. REDDINGTON: Okay. Well, how about, is it appropriate, in Dr. Mack's opinion, to give a person suffering from bipolar II or bipolar I an SSRI?
AVRAM MACK: An individu- there is a need in one's practice, traditionally at least, that if an individual might be suffering from bipolar I or bipolar II to avoid using SSRI medications. However, that has been reduced, in terms of our worry about that over time, but that was maybe 20 years ago, 15 years ago, something that psychiatrists were more concerned about. But the concern has lessened over time.
MR. REDDINGTON: It has. So in your opinion, sir, it's okay to give a woman who is coming to you for help, who's been diagnosed with a bipolar II, it's okay to give her the SSRI, in your opinion. Is that what you're telling this jury?
AVRAM MACK: That's not what I said.
MR. REDDINGTON: Oh, okay. Tell me what you said.
AVRAM MACK: I said the concern about the relationship—... between SSRIs and mania or bipolar disorder has lessened, but that doesn't necessarily mean that people's practices have changed.
MR. REDDINGTON: And when you say mania, what does that mean to you, sir?
AVRAM MACK: Mania is a state defined in the DSM. I believe we discussed this the other day.
MR. REDDINGTON: Well, go ahead. What is it? What are the symptoms of mania?
AVRAM MACK: So mania is a condition, and it's defined not only by the symptoms that I'm going to mention, but also by a timeframe. And as we discussed the other day, it is a mood state that is used as a building block for bipolar type 1. So one would need to see seven days consecutive and where the following symptoms, four at least of the following symptoms are present most of the day for all of these days. And that would include a thought process called flight of ideas. Secondly, distractibility. Thirdly, an engagement in activities that are pleasurable but have painful consequences. Rapid speech or what we would call pressured speech.
MR. REDDINGTON: Pressured speech.
AVRAM MACK: Or rapid speech. Additionally, grandiosity and an exaggerated amount or excess degree of goal-directed behavior. So-
MR. REDDINGTON: And what is your... Go ahead.
AVRAM MACK: Oh, go ahead.
MR. REDDINGTON: What is your understanding, sir, of the symptoms of bipolar II?
AVRAM MACK: So bipolar II, well, we didn't finish the definition of bipolar I, but in terms of bipolar-
MR. REDDINGTON: Go ahead.
AVRAM MACK: ... Type II, in terms of bipolar type II, one would need to have had a major depressive episode, I believe we discussed that the other day as well, and also one needs to have had what's called a hypomanic episode, which is similar to a manic episode, but lesser in terms of time course that's required, and only three out of the seven symptoms are required.
MR. REDDINGTON: So bipolar II, you would agree with me, sir, is in fact a major or a serious mental illness, right?
AVRAM MACK: Yes.
MR. REDDINGTON: And your opinion after you had your opportunity to go back again with Kirk on the third day and interview Lindsay in Tewksbury Hospital—and how long did you interview her for the third day asking her questions?
AVRAM MACK: I'm not sure I remember. It was perhaps, perhaps three hours.
MR. REDDINGTON: So after you completed your evaluation, you came to a conclusion that, in fact, Lindsay was suffering from a major mental disease or defect, to wit, bipolar II. Is that correct?
AVRAM MACK: No.
MR. REDDINGTON: No. So why don't we look at your report, and you tell me what your ultimate opinion was of your diagnosis of Lindsay after evaluating her, sir?
AVRAM MACK: I think I said this the other day that my opinion was—
MR. REDDINGTON: Why don't you say it again, sir?
AVRAM MACK: Yes, I'm happy to. My opinion was that, and is, that she suffered from a major depressive episode, and that that was a part of major depressive disorder.
MR. REDDINGTON: Well, looking at your report, sir, on your conclusions, would you agree with—
MS. BUCKINGHAM: Objection. Your Honor, he's reading from the wrong report.
MR. REDDINGTON: Do you have your report?
MS. BUCKINGHAM: He's reading from the wrong report.
MR. REDDINGTON: Do you have your report, sir?
THE COURT: Can I see you sidebar just for a second?
MR. REDDINGTON: It's not the wrong report.
MR. REDDINGTON: So sir, you would agree that your opinion on page 35 is that at the time of the incident, that Lindsay Clancy was suffering from a mental disease, and then you have the opinion, however, she retains substantial capacity to appreciate the wrongfulness or criminality of her conduct. Is that correct? Did I read that right?
AVRAM MACK: Yeah.
MR. REDDINGTON: And the mental disease from which she suffered, in your opinion, was a mood disorder, major depressive episode. Is that right?
AVRAM MACK: Yes.
MR. REDDINGTON: And you further opined that she may have also had an anxiety disorder that preceded or continued to be present while the major depressive episode proceeded through January 24th. Is that right?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay. Now, you're aware that she has been at Tewksbury under a particular diagnosis of a mental disease or defect, right?
AVRAM MACK: Yes.
MR. REDDINGTON: What is that?
AVRAM MACK: I believe it's adjustment disorder.
MR. REDDINGTON: Adjustment disorder. Is it not your understanding, sir, that she's suffering according to diagnosis of bipolar disorder?
AVRAM MACK: I think she... Well, you'd have to show me where you're referring to.
MR. REDDINGTON: So did you have a chance to review Dr. Heilbrun's report?
AVRAM MACK: I did.
MR. REDDINGTON: And do you know what Dr. Heilbrun's opinion was of the diagnosis—
AVRAM MACK: In terms of—
MR. REDDINGTON: Diagnosis?
AVRAM MACK: Yeah.
MR. REDDINGTON: What was it?
AVRAM MACK: I think he made a diagnosis of bipolar type II.
MR. REDDINGTON: So you have nurse practitioner Jollotta, who as a treating practitioner indicates that the diagnosis possibly is bipolar disorder. Correct?
AVRAM MACK: I don't know that she used those terms, but I know that she was concerned about—
MR. REDDINGTON: Okay. And you know, 'cause you've obviously read and incorporated into your report Dr. Resnick's opinion, correct?
AVRAM MACK: Correct.
MR. REDDINGTON: And what is Dr. Resnick's opinion, sir, to your understanding?
AVRAM MACK: In terms of diagnosis?
MR. REDDINGTON: Yeah.
AVRAM MACK: Bipolar type II.
MR. REDDINGTON: Okay. How about Dr. Zeizel? You also had access to and incorporated into his report, your report, his diagnosis. What was that?
AVRAM MACK: No, offhand I don't remember what his diagnosis was.
MR. REDDINGTON: Okay. How about Meg Spinelli? Did you have a chance to review her report and incorporate that into your report?
AVRAM MACK: I reviewed her report.
MR. REDDINGTON: Do you know what her diagnosis was, sir?
AVRAM MACK: I believe it was bipolar type I.
MR. REDDINGTON: Right. So with all of the various healthcare providers that have an opinion of bipolar type I, would you agree that that is a very strong indicator that a person could very well be suffering from postpartum depression?
AVRAM MACK: It... I'm confused by your question because that last piece is not necessarily inconsistent with the diagnosis of major depressive episode.
MR. REDDINGTON: I'm asking you, sir, about—
AVRAM MACK: The matter I discussed the other day was when that specifier is able to be used, that would be a diagnostic question.
MR. REDDINGTON: So with the understanding that nurse practitioner Jollotta is bipolar, or looking at bipolar, that Zeizel report, you don't know or recall what it is, but you incorporated it into your report. Dr. Resnick is bipolar too. You feel that this is or is not indicative of a precursor to a person suffering from postpartum depression? It's in the books, in the articles, right?
AVRAM MACK: Your use of terms, to me, seems apples and oranges. The question of postpartum depression would be, does the person have a mood disorder, and is it in the timeframe following birth?
MR. REDDINGTON: I can't hear you. I'm sorry, sir.
AVRAM MACK: So—
MR. REDDINGTON: I can't... Can you say that again, please?
AVRAM MACK: We're talking about categories that are not aligned with each other.
MR. REDDINGTON: No, I'm asking you what your answer was, okay?
AVRAM MACK: Diagnosis—
MR. REDDINGTON: What's your answer?
AVRAM MACK: You'd have to restate the question.
MR. REDDINGTON: Okay. You recall Friday, sir, that you were talking about onset of postpartum depression symptoms occurring within a particular timeframe. Do you recall that, sir?
AVRAM MACK: The diagnosis would be a depressive episode—
MR. REDDINGTON: No, no, my question is simple. Do you recall saying what the timeframe was Friday?
AVRAM MACK: I'm trying to answer your question.
MR. REDDINGTON: What is the timeframe?
AVRAM MACK: The timeframe designated for the diagnostic specifier called with postpartum onset is four weeks.
MR. REDDINGTON: Okay. And that's your opinion, right?
AVRAM MACK: Well, I believe that's what the DSM says.
MR. REDDINGTON: Okay.
AVRAM MACK: The four-week period in which—
MR. REDDINGTON: So let's talk about—
AVRAM MACK: The four-week period, the four-week period in which that specifier may be added.
MR. REDDINGTON: Okay. You recall saying that—
AVRAM MACK: The diagnostic book.
MR. REDDINGTON: You recall saying that a person can be postpartum, and it has to be within four weeks. Do you recall saying that Friday?
AVRAM MACK: What I would have intended to say—
MR. REDDINGTON: No, no, no.
AVRAM MACK: ...which I believe I did say—
MR. REDDINGTON: What did you say to the... Come on. What did you say to the jury last Friday?
THE COURT: I don't... Hold on. Doctor, please listen to the question and just answer the question as asked, okay? And then if the Commonwealth has any redirect, they can follow up with their questions. Go ahead.
MR. REDDINGTON: Thank you. Do you recall saying that a person has to be postpartum within four weeks according to the DSM? You recall saying that?
AVRAM MACK: To meet that specifier, yes.
MR. REDDINGTON: Right. Well, do you understand, sir, that every woman that has a baby for the rest of their life is postpartum 'cause postpartum, quite frankly, means having a baby, right?
AVRAM MACK: Sure. But that wouldn't be the specifier of, with postpartum onset in the DSM.
MR. REDDINGTON: Yeah, but you can't, it's... Postpartum is not a disease, Doctor. Postpartum—
AVRAM MACK: Right, it's an application that is defined in terms of four weeks.
MR. REDDINGTON: Okay. According to you, right? You understand that World Health Organization is different, right?
AVRAM MACK: If you're talking about the ICD?
MR. REDDINGTON: What is that timeframe, sir?
AVRAM MACK: I'm not sure what it is. I think you said it was 12 weeks.
MR. REDDINGTON: How about the proposal to amend the DSM-V text revision or TR? What's the proposal for that?
AVRAM MACK: Well, there's a proposal specifically around the proposed diagnosis called postpartum psychosis, and for that it's a six-week period.
MR. REDDINGTON: So you've got four weeks, you got six weeks, you got 12 weeks. Would you agree, sir, that postpartum depression, postpartum psychosis can occur up to a year or even a year or longer?
AVRAM MACK: I don't know, but I am telling you what the DSM says in terms of how to diagnose it and how to code it.
MR. REDDINGTON: Okay. You would agree, sir, that she is at Tewksbury with a diagnosis of bipolar, right?
AVRAM MACK: That may be among her diagnoses.
MR. REDDINGTON: Okay. And she's on medication, right?
AVRAM MACK: Yes.
MR. REDDINGTON: And she hasn't had, over the past three and a half years, any problems with sleep, anxiety, depression, symptomology of the same while she's been medicated at Tewksbury, right?
AVRAM MACK: She has not demonstrated any signs of mania.
MR. REDDINGTON: And she hasn't demonstrated any signs of anxiety either, has she, while she's been on the medication, the right medication, right?
AVRAM MACK: I note that she's complaining of anxiety. I'm not sure she's demonstrating signs of anxiety.
MR. REDDINGTON: Other than the fact that she's paralyzed and has to be in a wheelchair, she's not exhibiting the inability to bathe, the inability to emote, to have feelings, to talk to people. She's able to communicate with people, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay.
MR. REDDINGTON: Do you know what medications that she's on while she's at Tewksbury?
AVRAM MACK: She's taking, I think we discussed this the other day, a low dose of Zyprexa, I believe clonidine and trazodone, and propranolol occasionally.
MR. REDDINGTON: Okay. Now, after you had a chance to review the medical records from Dr. Tufts, which would be from end of September of '22 up through October of '22, for example, initial prescription, right?
AVRAM MACK: I've reviewed all the records from Dr. Tufts, yes.
MR. REDDINGTON: And you recall what the first prescription was that she got, right?
AVRAM MACK: Sertraline.
MR. REDDINGTON: And that would be, what, 25?
AVRAM MACK: Yes.
MR. REDDINGTON: Was that increased?
AVRAM MACK: It was.
MR. REDDINGTON: And was there an issue or a problem according to Lindsay when that was increased from 25 to 50?
AVRAM MACK: Yes.
MR. REDDINGTON: And what was the problem that she indicated to the doctor?
AVRAM MACK: She wanted to sleep, but she was finding it hard to sleep.
MR. REDDINGTON: She was unable to sleep for a period in excess of 48 hours, is what she said, right?
AVRAM MACK: I think it was at that point, yes.
MR. REDDINGTON: And also, she indicated that there was, in her opinion, a symptom that she didn't really have a need to sleep even though she had gone 48 hours without sleeping, right?
AVRAM MACK: No, she wanted to sleep.
MR. REDDINGTON: Well, would you agree with me, sir—
AVRAM MACK: Wanted to sleep. Was tolerating... She described that she was tolerating during the daytime, and functional, sufficiently without the sleep. But she found that she was trying very hard to sleep and she couldn't sleep.
MR. REDDINGTON: And do you recall her indicating that she did not feel, regardless of 48 hours straight without sleep, that she had a need? She said she didn't feel like she had a need to sleep. Did you see that in the records?
AVRAM MACK: Well, I'm not sure that it would be characterized that way.
MR. REDDINGTON: Did you see—
AVRAM MACK: As she discussed with us—
MR. REDDINGTON: Okay. Did you see anything in the records—
AVRAM MACK: She definitely wanted to sleep.
THE COURT: One at a time. Go ahead, Mr. Reddington.
MR. REDDINGTON: Did you see anything in the records that indicated that she complained of the fact that she had gone 48 hours without sleeping after she was on the sertraline, and then felt that she did not need to sleep even though she'd been without for 48 hours?
AVRAM MACK: I don't exactly recall what was written by Dr. Tufts, but she described to me that in that period—
MR. REDDINGTON: Doctor, I'm asking you about the medical records, not what you think she told you three years later. The medical records.
AVRAM MACK: The medical records review the fact that she was not able to sleep.
MR. REDDINGTON: And would you agree with me that one of the symptoms, sir, that you would be concerned about as a psychiatrist is when a woman who is postpartum after having a baby is complaining of a number of symptoms, one of which is that she went a long period of time unable to sleep but didn't feel that she had the need to sleep. That's textbook, isn't it?
AVRAM MACK: Well, the DSM textbook refers to a decreased need for sleep as the seventh element of mania.
MR. REDDINGTON: Okay. So that is an indicia of mania. Is that... Can I get that out of you?
AVRAM MACK: The way it's written is a decreased need for sleep.
MR. REDDINGTON: Okay. And she—
AVRAM MACK: I don't know that she has a decreased need for sleep.
MR. REDDINGTON: And in the medical records—
AVRAM MACK: She was trying very hard—
MR. REDDINGTON: Go ahead.
AVRAM MACK: I think she desperately wanted to sleep.
MR. REDDINGTON: Is that what you think, sir? Or is that what your opinion is based on the medical records?
AVRAM MACK: That is my understanding based on the totality of the information.
MR. REDDINGTON: Okay. So is it your understanding that she also exhibited signs or symptoms of postpartum depression?
AVRAM MACK: So to the extent that she had depression in a period after having had a baby, that is not how DSM would refer to it, but as you said, everybody would be postpartum in that regard. So my opinion is that she had major depressive episode in this year, or within four or five months following birth.
MR. REDDINGTON: Sir, you're familiar with the postpartum psychosis. You're familiar with that, right?
AVRAM MACK: So there's the concept of having psychosis in this—
MR. REDDINGTON: Are you familiar with postpartum psychosis, sir? Yes or no.
AVRAM MACK: I'm familiar with a proposed diagnostic entity called postpartum psychosis, and the idea that people can have psychosis as a mental disorder at other times.
MR. REDDINGTON: You're familiar with the Department of Mental Health in Massachusetts, right?
AVRAM MACK: Yes.
MR. REDDINGTON: You're familiar with the funding of the Department of Mental Health for the Massachusetts Child Psychiatry Access product. You're familiar with that, right?
AVRAM MACK: No.
MR. REDDINGTON: Called the MCPAP. It focuses on postpartum psychosis and postpartum depression. Are you familiar with that, sir?
AVRAM MACK: No.
MR. REDDINGTON: Would you agree with me that when a person has a child and is within the postpartum period, that they may present to a doctor with symptoms that might lead the doctor to believe that they are suffering from postpartum depression? Would you agree with that?
AVRAM MACK: I'm not familiar with that particular program. I'm happy to review it with you.
MR. REDDINGTON: Right. I'm—no, and I know you're happy, but I'm just asking, sir, about postpartum depression. Forget the program. You're not familiar with the program. We get it. I'm asking you now, sir, about your familiarity with postpartum depression.
AVRAM MACK: Yeah.
MR. REDDINGTON: Okay. And there are symptoms of postpartum depression. Fair to say?
AVRAM MACK: Postpartum depression—
MR. REDDINGTON: Are there symptoms, sir? Yes.
AVRAM MACK: I am familiar.
MR. REDDINGTON: Okay.
AVRAM MACK: Sure.
MR. REDDINGTON: And forget the DSM. Let's just focus on the symptoms as you understand it for postpartum depression, which according to you, has to occur within the first four weeks of birth. But quite frankly, it could be six weeks, it could be 12 weeks, it could be a year, right?
AVRAM MACK: You said forget the DSM, except that making diagnoses in psychiatry requires an authority, and we utilize, in this country, the DSM.
MR. REDDINGTON: Maybe we shouldn't?
AVRAM MACK: No.
MS. BUCKINGHAM: Objection.
THE COURT: All right. Sustained. Next question.
MR. REDDINGTON: So are you familiar, sir… You're not familiar with MCPAP for Mothers in Massachusetts. You're not familiar with that subsidiary of the Department of Mental Health, right?
AVRAM MACK: No.
MR. REDDINGTON: Are you familiar with the Department of Mental Health Postpartum Psychosis Provider Training? In other words, what the LISCWs are learning and what the psychologists or psychiatrists working for the DMH are learning about postpartum depression, postpartum psychosis. Are you familiar with those standards?
AVRAM MACK: No.
MR. REDDINGTON: How about the Edinburgh Postnatal Depression Scale? We talked about that Friday. You're familiar with that, sir?
AVRAM MACK: I am.
MR. REDDINGTON: But you don't feel it's important. You think the regular GAD scale, General Anxiety Scale, is sufficient, I guess, right?
AVRAM MACK: I don't think I said that.
MR. REDDINGTON: Oh, okay. So do you think that the Edinburgh Postnatal Depression Scale is important as a tool for a diagnosing physician dealing with a woman that's within the timeframe and exhibiting symptoms of postpartum depression?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay. So what was Lindsay's scale, if you know now? You had the weekend, I imagine, to look it up.
AVRAM MACK: I don't offhand know what it was.
MR. REDDINGTON: Okay. So if I offhand told you that it was pretty much off the chart, would that have any impact on your opinion as to the utility of the Postnatal Depression Scale that was administered to her?
MS. BUCKINGHAM: Objection to the form of the question.
THE COURT: No, sustained. I mean, overruled. Re-ask. Sorry.
AVRAM MACK: It's a scale that elicits distress, which she had, and it elicits depression, which she had.
MR. REDDINGTON: And it's not just limited to distress and depression. It's focused on, and again, I'll read it, the Edinburgh Postnatal Depression Scale, right?
AVRAM MACK: Right. The—
MR. REDDINGTON: So no, no, the answer's right.
AVRAM MACK: She had diagnosis of depression. She was being treated for depression.
MR. REDDINGTON: All right. So you, in any event, you don't utilize, apparently, the EPDS, right? You don't utilize in your practice, whatever that may be.
AVRAM MACK: Correct.
MR. REDDINGTON: Okay.
AVRAM MACK: Not that I'm against it. I just haven't had the opportunity to use it in some time.
MR. REDDINGTON: Right. Just like you think that, you know, an episiotomy is a tear, I guess, when a person has a baby, right?
AVRAM MACK: I'm sorry?
MR. REDDINGTON: You remember Friday you said that when a baby is born and the woman suffers a tear, that you called it a particular name?
AVRAM MACK: An episiotomy.
MR. REDDINGTON: Right.
AVRAM MACK: When there's a need for repair for a tear, there are several different degrees—
MR. REDDINGTON: No, no, no, no. Wait a minute. Hold on now. Hold on.
AVRAM MACK: … that one can have.
MR. REDDINGTON: Excuse me, sir. Friday, you said that the episiotomy is in fact a tear. Do you remember saying that?
AVRAM MACK: I'm not sure exactly the wording.
MR. REDDINGTON: Did somebody tell you that you were way off base on that testimony Friday, sir?
AVRAM MACK: I'm not sure what you're referring to.
MR. REDDINGTON: I'm referring to you saying that an episiotomy is a tear, and it's not.
MS. BUCKINGHAM: Again, Your Honor, is there a question before the witness?
MR. REDDINGTON: I already asked the question. I'm looking at him. He's staring back at me.
THE COURT: All right. Why don't you—
MS. BUCKINGHAM: The last—
THE COURT: Just hold on. Well, you can rephrase that.
MR. REDDINGTON: Do you remember saying Friday that— … episiotomy is a tear? Do you remember saying that to this jury, sir?
AVRAM MACK: I don't remember the exact words that I stated.
MR. REDDINGTON: Okay.
AVRAM MACK: She used the term episiotomy—
MR. REDDINGTON: Did anybody—
AVRAM MACK: … after a tear
MR. REDDINGTON: ... Did anybody over the weekend tell you that in fact you were wrong and that it is a surgical procedure, and that a natural tear has nothing to do with that procedure other than repairing? Did anybody talk to you about that at all over the weekend?
AVRAM MACK: No.
MR. REDDINGTON: Okay.
AVRAM MACK: No.
MR. REDDINGTON: So you would agree with me at least that postpartum depression, even though you don't use the EPDS, does have symptoms that a doctor would consider if a patient came to him or her for help, right? Yes or no.
AVRAM MACK: So-
MR. REDDINGTON: Yes or no?
AVRAM MACK: You're asking me about a condition-
MR. REDDINGTON: Right.
AVRAM MACK: ... which is not the way that it's defined.
MR. REDDINGTON: I'm asking you, sir, whether or not you understand as a doctor that if a woman has a baby and comes to you because she is in trouble, that you would look for symptoms, would you not? Yes or no?
AVRAM MACK: Yeah.
MR. REDDINGTON: Okay.
AVRAM MACK: Yeah.
MR. REDDINGTON: And if the woman told you that she was less able to laugh, no emotion, unable to see the funny side, is that a symptom, sir, in your opinion, of postpartum depression, yes or no?
AVRAM MACK: It's a symptom of depression.
MR. REDDINGTON: Was Lindsay Clancy complaining that she was unable to laugh or emote or see the funny side, if you will, of life when she went to see Dr. Tufts and Dr. Jollotta? Do you recall that, sir?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay.
AVRAM MACK: Yeah.
MR. REDDINGTON: Okay, so let's just say the next issue would be stopped looking forward to things. You're familiar with that? People don't look forward to things, and they... What is that called? Anhedonia or something like that?
AVRAM MACK: Right. So the other... That was one of the several elements of major depressive episode that I referred to the other day.
MR. REDDINGTON: Right. But it's also one of the symptoms of postpartum depression, correct?
AVRAM MACK: They are the same.
AVRAM MACK: When you have depression and you meet the qualifier, then you can call it post... You can call it depression with postpartum onset.
MR. REDDINGTON: How about a person that comes to you and says that they're anxious and worried constantly for no good reason? Would you agree, sir, yes or no, that that's a symptom of postpartum depression according to the authorities?
AVRAM MACK: So if the symptoms of depression-
MR. REDDINGTON: Can you answer that yes or no, sir? It's real easy.
AVRAM MACK: ... of depression-
MR. REDDINGTON: Sir.
THE COURT: All right. Hold on. If you can't answer the question as asked, Doctor, just say you can't answer it as asked, and I'll ask counsel to rephrase it. Go ahead.
AVRAM MACK: Yeah.
MR. REDDINGTON: So would you agree with me, sir, that the next symptom of postpartum depression would be anxious or worried for no good reason?
AVRAM MACK: So I can't-
MR. REDDINGTON: Is that-
AVRAM MACK: ... answer that question.
MR. REDDINGTON: You can't. You can't?
AVRAM MACK: I said I can't.
MR. REDDINGTON: Okay. Was Lindsay Clancy expressing to the doctors and the nurse practitioners and the LICSWs or whatever on the medical records that she was anxious and worried on a daily basis for no apparent reason?
AVRAM MACK: Yes.
MR. REDDINGTON: Did Lindsay Clancy also indicate that she was, would have episodes of fear or panic for no good reason?
AVRAM MACK: Yes.
MR. REDDINGTON: Did she also indicate, sir, that she was overwhelmed by life, basically, overwhelmed?
AVRAM MACK: Yes.
MR. REDDINGTON: Did she also indicate that she was so unhappy and worried and anxious that she had trouble sleeping?
AVRAM MACK: Yes.
MR. REDDINGTON: Did she indicate that she was sad or miserable and unable to enjoy things like family, friends, society?
AVRAM MACK: That is a symptom that progressed as those months moved on, yes.
MR. REDDINGTON: Sure did. Did she also say that she's unhappy, she was so unhappy that she was crying on a daily basis?
AVRAM MACK: Yes.
MR. REDDINGTON: Did she also indicate that she had thoughts of harming herself?
AVRAM MACK: Well, or suiciding, yes.
MR. REDDINGTON: So if she's successful in harming herself and she dies, then it's suicide. Either way, it's a thought of harming herself, right?
AVRAM MACK: I don't think she had the interest of harming herself simply for the interest of harming herself. She had the interest of suiciding.
MR. REDDINGTON: And she wasn't successful, obviously, right?
AVRAM MACK: Are you referring to January 24th?
MR. REDDINGTON: So the postpartum depression, sir, which invariably involves the EPDS, which you don't use, consists of 1 to 10 symptoms, and she hits every one in the medical records that you reviewed. Is that correct?
AVRAM MACK: First of all, I'm not sure what you're... Well, I can't answer the question as you asked it.
MR. REDDINGTON: Okay. Let's talk about postpartum psychosis because that is something that can follow postpartum depression. Is that right?
AVRAM MACK: You're using terms that make it that I can't answer your question.
MR. REDDINGTON: Postpartum psychosis, you can't answer? You know what that is, don't you?
AVRAM MACK: Are you referring to the proposed diagnosis that we referred to earlier, the one published in the Journal of-
MR. REDDINGTON: I'm referring to the fact that this young lady was suffering from postpartum psychosis when she killed her kids. Do you know what postpartum psychosis means?
AVRAM MACK: So there is a observation that a person may have psychosis, or there is the proposed diagnosis that we referred to the other day.
MR. REDDINGTON: Let's do this. Symptoms of postpartum psychosis. Number one, hearing voices. Would you agree, sir, that hearing voices is indicative of having a symptom of postpartum psychosis?
AVRAM MACK: You're referring to a condition or a illness called postpartum psychosis, and I don't know that I can answer questions as a psychiatrist based on that.
MR. REDDINGTON: Would you agree, sir, that when a person is suffering from postpartum psychosis... You understand that term, do you not?
AVRAM MACK: When we elicit... Are you asking about the-
MR. REDDINGTON: Sir, do you understand the term postpartum psychosis? It's real easy. Do you understand that term?
AVRAM MACK: It's actually not easy. It's serious.
MR. REDDINGTON: So would you—
AVRAM MACK: But when we do elicit psychosis after a birth, we take it very seriously. Typically—
MR. REDDINGTON: Who's we? Who's we?
AVRAM MACK: I've seen a—
MR. REDDINGTON: “We take it seriously.”
AVRAM MACK: No, I—
MR. REDDINGTON: Who's we?
AVRAM MACK: We psychiatrists. I as a psychiatrist.
MR. REDDINGTON: Yeah. So would you agree with me, sir, that when you are diagnosing, if you do, a patient that's coming to you for help after having a baby, so it's postpartum, and has been through, let's say, postpartum depression, and is now complaining of hearing voices or a voice commanding her to act, that is a symptom of postpartum psychosis? Yes or no? Is it?
AVRAM MACK: That would be psychosis. I don't know exactly based on your hypothetical as to whether it would count as the proposed postpartum psychosis illness, disease, but it certainly would be a concerning symptom or sign.
MR. REDDINGTON: Okay. So if you had administered the Edinburgh test, that is something that may have assisted you in evaluating the claim that the person is hearing voices, 'cause that's one of the things that you would be concerned about with a patient, right?
AVRAM MACK: You're always concerned if you're encountering somebody who's hearing voices—
MR. REDDINGTON: Right.
AVRAM MACK: ... especially if they're new.
MR. REDDINGTON: Especially if they're a mother, right?
AVRAM MACK: Anybody.
MR. REDDINGTON: How about thought broadcasting? You ever heard of that?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay. How about a patient that says that they're worried about hearing voices, and they're worried that people such as teachers could hear the voices in their head? Is that something that would concern you?
AVRAM MACK: Yes.
MR. REDDINGTON: How about if the person was afraid that somebody is able to hear the voices in their head and would call the police or DCF and they'd lose their kids? Is that something that would concern you?
AVRAM MACK: Hypothetically, yes, it would be of concern.
MR. REDDINGTON: How about actually in this case with Lindsay Clancy? Did you come across that in all of your investigation?
AVRAM MACK: I came across in my evaluation a period where she worried that people could hear what she was thinking. That's different, first of all, from thought broadcasting. But in either event, as I've said, she was in a serious psychiatric state, and she was suffering.
MR. REDDINGTON: How about number two: postpartum psychosis symptomology, delusional beliefs with distorted reality? Did she complain to Tufts or Jollotta about having distorted reality, being disassociated, things weren't real? Do you recall coming across that?
AVRAM MACK: So there were times that in the context of some of the medications she was taking, that she felt that things weren't real, yes.
MR. REDDINGTON: Okay. So my question—
AVRAM MACK: Or that she felt—
MR. REDDINGTON: My question, sir—
AVRAM MACK: ... she felt uncomfortable.
MR. REDDINGTON: My question, sir, is whether or not she complained of that to her healthcare providers. You'd agree with me—
AVRAM MACK: Yes.
MR. REDDINGTON: ... that she did, right?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay. How about appears normal in between episodes, calm, even laughing? Would you agree with me, sir, that postpartum psychosis waxes and wanes, it comes and it goes, right?
AVRAM MACK: So are you referring to a particular time when—
MR. REDDINGTON: I'm asking you a simple question. Do you agree that postpartum psychosis waxes and wanes, that it can come out of nowhere and then leave, and a person can appear normal? They can even laugh. Would you agree with that, sir?
AVRAM MACK: Are you referring to postpartum psychosis, an illness, or the findings of psychosis in somebody who's postpartum?
MR. REDDINGTON: I am asking you about Lindsay Clancy, the young lady that's sitting right here, that you're testifying against in front of this jury, telling this jury that she was responsible for the death of her children. You with me?
AVRAM MACK: I'm not sure I understand exactly the context that you just stated.
MR. REDDINGTON: Okay. The context I'm giving you is—
AVRAM MACK: But to your question about the National Core of an illness called postpartum psychosis, that illness has not been refined. It's not something that we in psychiatry, at least as far as I'm aware, can talk about as an illness where we understand its typical course and we understand what the—
MR. REDDINGTON: Okay, okay. Time out. Time out.
THE COURT: All right, hold on.
MR. REDDINGTON: Are you telling—
THE COURT: Let him finish. Doc, you done with that answer?
AVRAM MACK: I'm done.
THE COURT: Okay, go ahead.
MR. REDDINGTON: You're telling me, sir, that you don't, basically you don't believe or buy postpartum psychosis. Is that what you're telling me?
AVRAM MACK: I didn't say that at all.
MR. REDDINGTON: Okay. So you do believe that postpartum psychosis is a serious mental illness?
AVRAM MACK: I don't think it's a matter of belief or not belief. I'm aware of how to elicit the symptom or sign of psychosis. I am also aware that there's a proposal for an illness that would be recognized where we understand its typical course and how it progresses, that has been proposed, and that has not been approved for use in psychiatry in the United—
MR. REDDINGTON: Approved by who?
AVRAM MACK: By the American Psychiatric Association.
MR. REDDINGTON: The APA, so you're s—
THE COURT: Hold on, hold on.
AVRAM MACK: By the team that... Let me... If I can finish.
MR. REDDINGTON: That's the judge you're talking to, not me.
AVRAM MACK: By the particular body within the American Psychiatric—
MR. REDDINGTON: All right.
MR. REDDINGTON: Do you agree that postpartum psychosis is a legitimate disease or defect? Yes or no?
AVRAM MACK: When you have a symptom or sign of postpartum, of psychosis at any time, but particularly in the postpartum period, it is a legitimate finding and something to be concerned about and to treat.
MR. REDDINGTON: Okay. And when you say within the timeframe, you're referring to the Dr. Mack timeframe of four weeks, right?
AVRAM MACK: No. I think, as I said, any time that a person has psychosis—
MR. REDDINGTON: Okay. So any—
AVRAM MACK: The issue about four weeks has to do with how we would diagnose it or what wording we would use to diagnose it, but that doesn't have to do with the reality of the individual.
MR. REDDINGTON: Okay. So any time that there's a psychosis, and if it's postpartum, you would agree that you can put the two words together and it's postpartum psychosis, right?
AVRAM MACK: You would not utilize that in your diagnostic terminology.
MR. REDDINGTON: Okay. Well, you would agree, sir, that—
AVRAM MACK: You would see that, and you would be concerned about it.
MR. REDDINGTON: You would—
AVRAM MACK: According to the DSM, you would not—
THE COURT: All right.
AVRAM MACK: ... utilize that—
THE COURT: Well, hold on. I'm sorry. Doc, if you could, repeat that answer. We had some problems following it. Go ahead.
AVRAM MACK: So the presence of psychosis is always of concern, especially if it's new onset. To the extent that we are talking about the proper terminology of labeling something, whether it is postpartum onset or not, the DSM provides guidance as to the timeframe. That is different than my saying that is a not serious condition.
MR. REDDINGTON: So symptom number one complaint according to the Mass General Hospital major research project, along with the Department of Mental Health dealing with postpartum psychosis, would indicate that hearing voices, a voice commanding her to act, is a symptom of postpartum psychosis. Do you agree with that? Yes or no? Just give me a yes or no.
AVRAM MACK: I can't answer that. I don't know what authority you—
MR. REDDINGTON: Okay, the answer's no. The answer's no.
MS. BUCKINGHAM: Objection.
THE COURT: All right. He just doesn't agree with it. Next question.
MS. BUCKINGHAM: We asked... We answered these questions several times.
MR. REDDINGTON: Really?
THE COURT: Overruled. You can let him ask that question if you wanna ask that again.
MR. REDDINGTON: So let's move on, sir, so we don't fight over number one. How about number two? Delusional beliefs, distorted reality. Would you agree that that's a symptom of postpartum psychosis, sir? Yes or no?
AVRAM MACK: You said number one, number two. I don't know what authority you're referring to.
MR. REDDINGTON: Do you agree, sir, that a symptom of postpartum psychosis, in addition to the hearing of the voices, would be delusional beliefs and a distorted reality?
AVRAM MACK: I can't answer because I still don't know if you're referring to the phenomenon of psychosis or you're referring to some illness.
MR. REDDINGTON: I'm referring to the illness that Lindsay Clancy was suffering that's in her medical records, sir, that you told this jury you read. That's all I'm asking.
AVRAM MACK: Well, I didn't find any evidence of psychosis in her record—
MR. REDDINGTON: Okay.
AVRAM MACK: ... other than—
MR. REDDINGTON: Excuse me. Was there any indication that she was hearing voices? Did she complain about that, sir? Yes or no?
AVRAM MACK: She complained about intrusive thoughts—
MR. REDDINGTON: Okay.
AVRAM MACK: ... if that's what you're ref—
MR. REDDINGTON: How about the delusional beliefs and distorted reality? Do you recall her complaining about distorted reality, sir? Yes or no?
AVRAM MACK: I'm not sure she used those terms. If you're referring to the wording—
MR. REDDINGTON: No, no, never mind what I'm referring to. Your answer is no, right?
AVRAM MACK: No, she did not display psychotic features.
MR. REDDINGTON: I didn't ask about psychotic features. I'm asking you about delusional beliefs and distorted reality, Doctor.
AVRAM MACK: That is a type of psychosis.
MR. REDDINGTON: Okay.
AVRAM MACK: So I didn't see any evidence of any psychotic features throughout the medical record.
MR. REDDINGTON: So it's your understanding from reviewing her medical records that Lindsay never indicated that she was not participating in reality, that she was in a disassociated state, that she was out of touch with reality. You're telling this jury you never saw that?
AVRAM MACK: I did see that component that she discussed with her physician.
MR. REDDINGTON: Right. Good. Great.
AVRAM MACK: I don't see that as a sign, strictly speaking, of psychosis. It may have been in some cases, but—
MR. REDDINGTON: Right. Let the—
AVRAM MACK: I don't see any signs of psychosis or delusions.
MR. REDDINGTON: Like in this postpartum psychosis, sir, you'd agree that delusional beliefs, distorted reality is a symptom, yes or no? Not waxing and waning with your answer. Yes or no?
AVRAM MACK: Are you referring to an authority there?
MR. REDDINGTON: Do you agree—
THE COURT: Doctor, doctor, hold on. Here's the way this works, all right? You don't really ask a lot of questions. You answer the questions, all right? If—I told you before—if you can't answer a question the way it's framed, just let me know, and I'll tell counsel to frame it in a different way, all right?
AVRAM MACK: Yes.
THE COURT: So that's the rules. That's how it works here. So go ahead, Mr. Reddington.
MR. REDDINGTON: Thank you. Would you agree, sir, that a symptom of postpartum psychosis with a woman who is coming to a physician for treatment, indicates that they appear to have normal periods between episodes of disassociation where they're calm, they're even laughing, and they can drive cars, they can talk to people, they can use telephones, all of that, right?
AVRAM MACK: It would be... That description may be of other things, but it's not necessarily of psychosis.
MR. REDDINGTON: How about severe sleep deprivation, sir? Do you agree that severe sleep deprivation is a symptom when you're considering the whole of the patient complaining of various symptoms? Severe sleep deprivation is a symptom of postpartum psychosis.
AVRAM MACK: I can't answer the question the way you phrased it.
MR. REDDINGTON: Okay. So let's say postpartum psychosis, you're somewhat familiar with it, and would you agree that severe sleep deprivation is a symptom of it?
AVRAM MACK: I can't answer the question the way you phrased it.
MR. REDDINGTON: Okay. You can't answer it. Okay. How about rapid mood swings? Would you agree that rapid mood swings are a symptom of postpartum psychosis, sir?
AVRAM MACK: I'm not sure I understand your question.
MR. REDDINGTON: Okay. How about a person saying that they're not herself, "I wanna be myself. I wanna go back to being myself. I can't be myself"? Is that a complaint that is a symptom of postpartum psychosis, sir?
AVRAM MACK: It might be, if the person has psychosis.
MR. REDDINGTON: Okay, the answer is it might be. Did Lindsay Clancy indicate that she wanted to go back to being herself?
AVRAM MACK: Yes.
MR. REDDINGTON: Now, did she also, was there any evidence, sir, of thoughts of harming her children?
AVRAM MACK: There were periods when she had impulses or intrusive thoughts about harming her children.
MR. REDDINGTON: And when you say intrusive, if I come to you and s- If a person comes to you and postpartum psychosis is on your radar, and says that they're having intrusive thoughts about harming their children, would you not ask them what that means? In other words, is it a voice in their head? Is it their thought process? What is it? Do you ask that question?
AVRAM MACK: Of course.
MR. REDDINGTON: Did anybody ask that question when she was complaining about having intrusive thoughts about suicide, for example? Did anybody ask her what that meant, voices in the head or thoughts?
AVRAM MACK: I believe that the clinicians at McLean, at Mass General, Dr. Jollotta, Dr. Tufts, all asked about or all made inquiries to understand the nature of her suicidal ideation.
MR. REDDINGTON: Do you believe that based on your review of the medical records and based on your review of the numerous cocktail of drugs that were prescribed to her, that she received good medical care from Jollotta and Tufts?
MS. BUCKINGHAM: Objection.
THE COURT: Overruled.
AVRAM MACK: I don't have an opinion on that.
MR. REDDINGTON: Did she complain that she was not herself and her family could see the change?
AVRAM MACK: Yes.
MR. REDDINGTON: Okay. Did she also complain of thoughts of suicide?
AVRAM MACK: Yes.
MR. REDDINGTON: Did she also have poor insight?
AVRAM MACK: I'm not sure that she had poor insight.
MR. REDDINGTON: Well, if you are looking at postpartum psychosis and the symptoms are one through 10, if a person is complaining to you as a doctor, and when I say complain, I don't mean complaining, I mean that's medical language, that they're complaining or giving you a symptom, of one through nine, that is a very, very strong indicia that the person is suffering from postpartum psychosis, is it not?
AVRAM MACK: One through nine? I'm not sure I can answer that question.
MR. REDDINGTON: Okay. How about blood tests? You think they're important when you're dealing with prescribing medications like Tufts was after a month?
AVRAM MACK: They can be.
MR. REDDINGTON: And do you think, sir, to a reasonable degree of medical certainty, that a person should be given a basic blood test when you're prescribing these medications to them?
THE COURT: Overruled.
AVRAM MACK: There are some situations where blood tests are required or needed, and other times when psychiatrists may feel comfortable making prescriptions without such tests.
MR. REDDINGTON: So there is a further test that can be given that would actually determine whether or not a person's enzymes are reacting to the drugs, the narcotics that are being prescribed to them. Isn't that right?
AVRAM MACK: You say narcotics?
MR. REDDINGTON: Well, drugs.
AVRAM MACK: Sure.
MR. REDDINGTON: You know, like certainly or-
AVRAM MACK: Yeah, but narcotics. Can you say the question again?
MR. REDDINGTON: Sure. Prescriptions. When a person is prescribed prescriptions— It is well within reason that a competent physician would, number one, take a simple blood test, right?
AVRAM MACK: It's possible.
MR. REDDINGTON: Okay. And I guess that's up to the doctor that you're seeing, right?
AVRAM MACK: Well, sure. Or depends on what i- concerns the person may have, what's their medical history, what's your awareness of other factors that are affecting their biological health.
MR. REDDINGTON: So let's take Lindsay Clancy for ex-
AVRAM MACK: Depends on which medication we're talking about also.
MR. REDDINGTON: Let's take Lindsay Clancy, for example, sir. The medical records that you reviewed when she's dealing with Tufts and Jollotta, did they administer any blood tests to her at all?
AVRAM MACK: Not that I recall.
MR. REDDINGTON: Is there a further analysis that can be performed on the blood that is drawn from the woman when she sees the doctor to determine whether or not there are enzyme reactions to the prescription drugs that they're prescribed?
AVRAM MACK: There are tests that can be done to determine the relative degree of one enzyme or another, and how much they would do in terms of breaking down the medications, if that's what you're talking about.
MR. REDDINGTON: Well, that test wasn't administered to Lindsay, was it?
AVRAM MACK: I don't think so.
MR. REDDINGTON: In spite of numerous, innumerable, which we won't have to go through, complaints that she had, and her husband, about what was happening to her as a result of her postpartum, as well as postpartum depression, symptomology of postpartum psychosis, in conjunction with the narcotics, the drugs, the prescriptions that she was given. They never did any further testing, right?
AVRAM MACK: Correct.
MR. REDDINGTON: How about thyroid? Is that something that's important to you as a doctor dealing with a postpartum depression or postpartum psychosis?
AVRAM MACK: Thyroid would be important to assess in a person complaining of mood problems, yes.
MR. REDDINGTON: Well, how about a woman who is complaining that during the postpartum, which goes on ad infinitum, is complaining of postpartum depression symptoms and/or postpartum psychosis, it's important to check their thyroid level, isn't it?
AVRAM MACK: It would be important to check thyroid in multiple different psychiatric conditions, including—
MR. REDDINGTON: So the answer is yes, right? The answer's yes.
AVRAM MACK: Well, I'm not sure that that specifically answers your question.
MR. REDDINGTON: I don't care. Thank you. That's all I have, Judge.