2.Avram Mack — Redirect/Recross (Part 4)
186 linesTHE COURT: Okay. Does Commonwealth redirect?
MS. BUCKINGHAM: Good morning, Dr. Mack.
MS. BUCKINGHAM: Now,
MS. BUCKINGHAM: Defense counsel kept referring to your investigation in this case. Do you see your role as an investigator when you're retained to do these evaluations?
AVRAM MACK: No.
MS. BUCKINGHAM: And in fact, you are evaluating for a specific question, correct?
AVRAM MACK: That's correct.
MS. BUCKINGHAM: And in your evaluation in this case, you were asked to focus on the mental condition of Lindsay Clancy at the time of January 24th, 2023, right?
MR. REDDINGTON: So, excuse me. He's able to answer yes or no, but this is direct, so I'm objecting to the leading.
THE COURT: I'm gonna allow just to kind of focus to the area, and then we'll go from there. Go ahead, counsel.
MS. BUCKINGHAM: Thank you. You can answer that question.
AVRAM MACK: Yes.
MS. BUCKINGHAM: Now, were you provided the information that you reviewed?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And were you aware where that came from, whether it was the court or the district attorney's office or from defense?
AVRAM MACK: I'm not necessarily aware of the origin of any of the documents that I reviewed, only that I, they, that I did review them, and I did possess them.
MS. BUCKINGHAM: And as far as the timing of when you were retained in this case, I believe your testimony on Friday was that your memory was early 2025 you were retained. Is that right?
AVRAM MACK: Yes. I would say that the initial discussion about it was at the end of 2024. I'm not exactly sure when Commonwealth or the district attorney's office exactly made the retention happen, but I understand it to be early 2025.
MS. BUCKINGHAM: And you were provided a significant amount of information, after you were retained, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And that information continued to come to you up until the point that you were going to meet with the defendant in April of 2026. Is that fair to say?
AVRAM MACK: That's correct.
MS. BUCKINGHAM: And were you able to set up that interview with her on your own?
AVRAM MACK: No.
MS. BUCKINGHAM: Is it your understanding that it had to be with the permission of the court and the parties?
AVRAM MACK: That's my understanding.
MS. BUCKINGHAM: And that date in April was a date that was provided to you as a date that you could go and speak with her, correct?
AVRAM MACK: Yes, the two dates, April 10th and April 12th.
MS. BUCKINGHAM: And in conducting these evaluations, is it standard or best practice to review as much information as you can prior to that interview?
AVRAM MACK: That's correct.
MS. BUCKINGHAM: And you were provided records from the Tewksbury State Hospital in the weeks prior to your interview. Is that fair to say?
AVRAM MACK: Yes.
MS. BUCKINGHAM: Now, when you're retained on cases, this case and any other, you're paid for your time and your work regardless of what your ultimate opinion is, correct?
AVRAM MACK: That's right.
MS. BUCKINGHAM: Can you explain to us the relationship that you have with Park Dietz and Associates?
AVRAM MACK: Yes. There are times that attorneys around the country go to Park Dietz and Associates, seeking or asking if they have an expert in a particular field. And Park Dietz and Associates may be able to propose one expert or another who might be able to help that attorney or law firm.
MS. BUCKINGHAM: And so in your relationship with that company, you are simply an independent contractor, or are you employed by the company?
AVRAM MACK: Independent contractor.
MS. BUCKINGHAM: And fair to say, there's not kind of a group email that somebody can send out asking for experts on all these types of areas in which you testify, right?
AVRAM MACK: No. The Park Dietz and Associates would go to individual experts that they think might be appropriate for one or another case given the topic.
MS. BUCKINGHAM: Now, you were asked some questions about Dr. Heilbrun, and I think last week on Friday you indicated that you didn't know him prior to working on this case. Is that correct?
AVRAM MACK: Correct. I had never met him.
MS. BUCKINGHAM: And so, is he a name that was familiar to you in your area of general psychiatry?
AVRAM MACK: I knew that he was another expert that works with the Park Dietz and Associates group, but I had never met him.
MS. BUCKINGHAM: And in fact, he's not in your ... He's not a general psychiatrist, is he?
AVRAM MACK: I believe he's a psychologist.
MS. BUCKINGHAM: Okay. And so your focus is different than his focus, correct?
AVRAM MACK: To some degree, yes.
MS. BUCKINGHAM: Now, why was it ... W- how did it come about that you and Dr. Heilbrun ended up going to Tewksbury at the same time?
AVRAM MACK: Well, my memory is that to the extent that he also had been retained, that there was a need to be ... that there was only going to be one opportunity for an examination by the prosecution. And so rather than create two different sets of interviews for Ms. Clancy, it was better to overlap them and have them happen concurrently.
MS. BUCKINGHAM: And in relation to the purpose of the interview with the person being evaluated, the defendant here, was there anything different about your approach and his approach as far as the information you were seeking to gather?
AVRAM MACK: Generally, no. As has been mentioned, he went ahead and did psychological testing on the second day. But other than that, it's still the same topic, the individual's mental health.
MS. BUCKINGHAM: And in regards to that particular, those days that you were there, it wasn't just you and Dr. Heilbrun in the room with the defendant, correct?
AVRAM MACK: That's right.
MS. BUCKINGHAM: Who else was in the room?
AVRAM MACK: One person who served as a videographer. Well, two individuals who served as videographers.
MS. BUCKINGHAM: Do you know who retained the videographer?
AVRAM MACK: I don't.
MS. BUCKINGHAM: And you're aware that Ms. Clancy was also on a one-to-one, so was there a staff member from Tewksbury close by, if not in the room?
AVRAM MACK: Close by, but not in the room.
MS. BUCKINGHAM: And the person who was conducting the video, they were in the room running the video the whole time?
AVRAM MACK: That's correct.
MS. BUCKINGHAM: And fair to say, as it pertained to taking breaks, you and Dr. Heilbrun offered the defendant multiple opportunities to take a break, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And—
AVRAM MACK: We made it clear that we could take a break any time.
MS. BUCKINGHAM: And she repeatedly declined a break. Right?
AVRAM MACK: I recall that, yes.
MS. BUCKINGHAM: Okay. And that would be contained within the video that was running throughout the course of your interaction with her, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: At this time, Your Honor, I'd like to present as the next exhibit the recorded interview—
MR. REDDINGTON: No objection.
MS. BUCKINGHAM: ... of the experts.
THE COURT: All right. Let's see counsel at sidebar.
THE COURT: That'll be exhibit, yes.
COURT REPORTER: Exhibit 292.
THE COURT: Okay. No objection. Go.
MS. BUCKINGHAM: Dr. Mack, on cross-examination you were asked about the LeBron case that you were involved in. You recall that line of questioning?
AVRAM MACK: I do.
MS. BUCKINGHAM: And in that case you were retained by the State of Florida. Is that right?
AVRAM MACK: Yes, the executive office of the governor.
MS. BUCKINGHAM: And you offered an opinion in that case, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And was that testimony or by way of a declaration, or a report?
AVRAM MACK: It was a report, and then there was a deposition.
MS. BUCKINGHAM: And so you were part of a hearing with the court in Florida to determine whether your ultimate opinions could be considered in the case, correct?
AVRAM MACK: I don't think that there was a specific separate hearing after that point.
MS. BUCKINGHAM: Okay. Was—
AVRAM MACK: My recollection is that in the phase of a summary judgment proceeding, that the use of my testimony was discussed in the summary judgment documents all from each side.
MS. BUCKINGHAM: And then ultimately, your opinion wasn't utilized by the court, right?
AVRAM MACK: If I recall, the statement of the court in the documents, it was that Dr. Mack is not an expert in this case, or it may have said Dr. Mack is not a qualified expert in this case.
MS. BUCKINGHAM: And why was that?
AVRAM MACK: My recollection of the case, which is now almost fifteen years ago, was that the information that I was aware of in terms of the rate of substance use in individuals who received TANF was nationwide and was not specific to Florida.
MS. BUCKINGHAM: And the issue was a Florida TANF case, right? Having to do with residents in the state of Florida.
AVRAM MACK: Correct.
MS. BUCKINGHAM: So as far as—
AVRAM MACK: Correct.
MS. BUCKINGHAM: … the limitations there, and your testimony in these types of cases is could be nationwide. In that particular case, it was just that you weren't, you didn't have enough information about the residents in that state, correct?
AVRAM MACK: Well, that was—
MR. REDDINGTON: Objection.
THE COURT: Well, go ahead. If he can answer that, and then go ahead.
AVRAM MACK: My understanding is that that was one of the elements by which the court determined or made the statement that it did.
MS. BUCKINGHAM: Okay. And you were offering some opinions about your expertise in the area of addiction during that time period, correct?
AVRAM MACK: Yes.
MS. BUCKINGHAM: Had nothing to do with criminal responsibility.
AVRAM MACK: Correct.
MS. BUCKINGHAM: Now, you talked a lot with defense counsel about the DSM, so I don't wanna go too far into it. But on Friday, you directed Attorney Reddington to a particular part of the bipolar and related disorder chapter having to do with specifiers. Do you remember that?
AVRAM MACK: Yes.
MS. BUCKINGHAM: And you directed him to page one seventy-three, which referred to the specifier with peripartum onset. Can you just explain to us first what is a specifier when we're talking about the DSM?
AVRAM MACK: Specifiers are a way in which the DSM allows a diagnostician to highlight certain details of the individual's presentation. But as I was mentioning the other day, psychiatric classification nowadays refers to the larger presenting symptoms that the individual has, and specifiers can be added on. So a person can have a severe mood disorder, and then one can add on the specifier of, with postpartum onset, or atypical features or other specifiers that have been defined.
MS. BUCKINGHAM: And so when you were referring to page one seventy-three, where it starts the long paragraph about with peripartum onset, is that the portion of the specifier categories for bipolar related disorders where we're talking about postpartum periods?
AVRAM MACK: Yes. There is a defined way in which a person can add as a diagnosis whether or not there was onset in that particular timeframe.
MS. BUCKINGHAM: And that's where we find the four, the four-week timeline, correct?
AVRAM MACK: Correct.
MS. BUCKINGHAM: And it also talks about different mood episodes, including manic and depressive episodes in that section, right?
AVRAM MACK: That's right.
MS. BUCKINGHAM: And that section also talks about the fact that it could present, mood episodes could present with psychotic symptoms and without psychotic symptoms or psychotic features, I should say. Is that right?
AVRAM MACK: Right. Yes. Bipolar disorder is a disorder of mood. Abnormal mood is what the diagnostician observes and is aware of. And if there is a way to determine that it's a major depressive episode or a manic episode or a hypomanic episode, that will help to determine if this severe mood condition is bipolar or major depressive disorder.
MS. BUCKINGHAM: And so in that regard, the same specifier is also part of the major depressive category, correct? As a specifier.
AVRAM MACK: Right. As I said, the specifiers provide detail, but they are not the, so to speak, the major element of the diagnosis. The major element of the diagnoses in DSM are the observable major symptoms and signs.
MS. BUCKINGHAM: Well, I'm asking about just what's contained within those specifiers because you and counsel went back and forth quite a bit on Friday about what's in there and what's not in the DSM when it comes to the peripartum onset. But as far as in both the specifier for bipolar and depressive disorder, there are a number of those features that you were discussing that is in the DSM as a specifier.
AVRAM MACK: Right.
MS. BUCKINGHAM: Okay.
AVRAM MACK: Yeah.
MS. BUCKINGHAM: And those are presentation with psychotic features, the frequency of occurrence or reoccurrence of the peripartum onset for these disorders, right?
AVRAM MACK: Yeah.
MS. BUCKINGHAM: That's in there.
AVRAM MACK: The description has that, yes.
MS. BUCKINGHAM: As well as the risk of postpartum episodes being greater when people have history of depressive disorders or bipolar disorder. That's within that specifier for each of those two chapters, is it not?
AVRAM MACK: Yes, that portion of the specifier is a description of what's been observed over time. It's not necessarily the criteria, but it's the observations that have been so commonly observed that they were able to write that in the manual.
MS. BUCKINGHAM: So this concept of a peripartum onset, or we've been using it as postpartum interchangeably, it's within the DSM-V, right?
AVRAM MACK: Yes. The DSM, the DSM-V provides a manner by which to make a diagnosis that provides this specification or highlights this detail of the individual's illness.
MS. BUCKINGHAM: And as far as your conclusions, again, when you're asked to do an evaluation, do you rely on other people's conclusions about diagnosis when making your own diagnosis?
AVRAM MACK: It's important to understand what others have observed and what they're concerned about. And then as a physician, one will make one's own diagnosis.
MS. BUCKINGHAM: And so in this case, you came to the conclusion that the defendant presented with a major depressive episode, right?
AVRAM MACK: Correct.
MS. BUCKINGHAM: And you relied on diagnostic criteria in the major depressive disorder category. Is that fair to say?
AVRAM MACK: Yes. That was the diagnostic criteria that I used to support that diagnosis.
MS. BUCKINGHAM: And Counsel went through with you today a number of different, I think he called them symptoms, of postpartum depression. But as far as major depressive disorder, what are the nine general symptoms that you see or you can find five or more of to find that somebody suffers from a major depressive disorder?
AVRAM MACK: So a major depressive episode is defined, and this is parallel to the description I was giving earlier of a manic episode. They're both problems of mood. They're both discrete periods of mood problems. So a major depressive episode would be a two-week discrete change in a person's mood and it include... You have to have at least five of nine different symptoms or signs, and it has to be persistent, and it has to be most of the day, most of the days. So the nine include, starting out with anhedonia, meaning lack of feeling pleasure. Secondly, actually feeling depressed mood. It can be feelings of guilt or worthlessness. And then it also may include problems with thinking about death or suicidality. Furthermore, problems with sleep, eating, what we call energy, psychomotor activity, either psychomotor slowing or agitation. And then all these, you have to have five out of these nine—
MS. BUCKINGHAM: Right.
AVRAM MACK: ... in order to meet the major depressive episode, stat.
MS. BUCKINGHAM: And I think maybe you might have missed one. Diminished ability to think or concentrate. Is that one?
AVRAM MACK: Sorry. Concentration.
MS. BUCKINGHAM: Concentration.
AVRAM MACK: So—
MS. BUCKINGHAM: So a lot of the symptoms that counsel read to you are symptoms that are in the category of a major depressive disorder. Is that correct?
AVRAM MACK: Yes. This is the method of making the diagnosis of a major depressive episode.
MS. BUCKINGHAM: So when you were asked on cross-examination about postpartum depression, and you kept in, answering that you found her to have a depressive disorder, is that... Are those the symptoms that you were speaking of when you were saying you found a major depressive disorder?
MR. REDDINGTON: I object.
THE COURT: Overruled.
MR. REDDINGTON: Is it leading?
AVRAM MACK: Correct.
THE COURT: Overruled. I'll allow it.
MS. BUCKINGHAM: I have nothing further.
THE COURT: Okay.
MS. BUCKINGHAM: Thank you.
THE COURT: Anything further?
MR. REDDINGTON: Just briefly. Sir, are you suggesting that my office had any control over when you were able to go visit Lindsay in the hospital?
MS. BUCKINGHAM: Objection.
THE COURT: Overruled.
AVRAM MACK: I don't know if your office was involved, but I imagine... So I don't know.
MR. REDDINGTON: You don't know. Okay.
AVRAM MACK: I imagine—
MR. REDDINGTON: Fair enough. That's fine.
AVRAM MACK: ... your office was aware.
THE COURT: All right. Thank you.
AVRAM MACK: But I don't know who made the call.
THE COURT: All right. Doctor, I—doctor, I think you've answered the question. All right. Next. Anything further?
MR. REDDINGTON: Nothing. Thank you, Judge.
THE COURT: Anything further, Commonwealth?
THE COURT: All right. Thank you, Doctor. Thank you very much.
AVRAM MACK: Thank you.
THE COURT: All right. All right. Take a break here. All right. So, members of the jury, we're gonna take the morning break at this point. And we're gonna come back and continue with the Commonwealth's rebuttal case. We'll have a witness who will go on the stand after we get back.
THE COURT: So we'll take the break at this time. Thank you.
BAILIFF: Court, all rise.
BAILIFF: Jurors have exited the courtroom.
THE COURT: All right. Anything we need to discuss before the break, Commonwealth?
MS. BUCKINGHAM: No, Your Honor.
MR. REDDINGTON: No, thank you.
THE COURT: All right. So we'll be in the morning recess at this time.
MR. REDDINGTON: All right.
THE COURT: Thank you.
MR. REDDINGTON: Thank you.
BAILIFF: All rise. Court is in session.