8.Sejal Shah — Direct/Cross/Redirect/Recross
405 linesMS. SPRAGUE: Commonwealth calls Dr. Shah.
THE COURT: Raise your right hand please.
COURT CLERK: Good afternoon. 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?
SEJAL SHAH: I do.
COURT CLERK: Thank you.
BAILIFF: You can have a seat.
COURT CLERK: You may be seated.
THE COURT: All right. Good afternoon, doctor.
SEJAL SHAH: Hi.
THE COURT: I'm gonna ask you to keep your voice up and speak into that microphone, all right?
SEJAL SHAH: Thanks, Your Honor.
THE COURT: Thank you.
MS. SPRAGUE: Thank you, Your Honor. Good afternoon. Can you please state and spell your name for the record?
SEJAL SHAH: Sure. My first name is Sejal, S-E-J-A-L. Last name is Shah, S-H-A-H.
MS. SPRAGUE: What's your date of birth?
SEJAL SHAH: 5/8/81.
MS. SPRAGUE: What do you do for a living?
SEJAL SHAH: I'm a psychiatrist.
MS. SPRAGUE: And can you briefly describe your education and training background that qualifies you to be a psychiatrist?
SEJAL SHAH: Yeah. Absolutely. So I did my undergraduate in Philadelphia at the University of Pennsylvania, followed by medical school at Jefferson Medical College, also in Philadelphia. I moved... Oh, sure. I moved up to Boston to do my residency in psychiatry at Brigham and Women's Hospital and Beth Israel Deaconess, followed by a fellowship in consultation liaison psychiatry at Brigham and Women's Hospital, and then stayed on as a faculty member.
MS. SPRAGUE: And where do you work currently?
SEJAL SHAH: I work at Brigham and Women's Hospital.
MS. SPRAGUE: And what is your role there?
SEJAL SHAH: I'm associate chief of the Division of Psychiatry and Medicine, leading the Consultation Liaison Psychiatry Service at Brigham.
MS. SPRAGUE: And what is the consultation and liaison service?
SEJAL SHAH: Yeah. So consultation liaison psychiatry is a subspecialty of psychiatry that works at the interface of psychiatry and medicine. So we work both in the inpatient and outpatient settings. In this particular instance, we get called by other healthcare providers that may need help with their patients or have a question related in the psychiatric realm. And so I would see a patient that's admitted to the hospital and help provide recommendations to the physicians and the rest of the care team that's caring for that patient.
MS. SPRAGUE: So basically, say at the Brigham, if a patient's being treated there and a medical doctor is treating them and thinks that they need a consultation with a psychiatrist, your department would be called?
SEJAL SHAH: That's correct.
MS. SPRAGUE: Okay. And how long have you been with the Brigham?
SEJAL SHAH: 19 years.
MS. SPRAGUE: Now I wanna direct your attention to January of 2023. Did you interact with a patient named Lindsay Clancy?
SEJAL SHAH: I did.
MS. SPRAGUE: And was that on January 29th, 2023?
SEJAL SHAH: Yes. That was the first of a handful of times that I saw her.
MS. SPRAGUE: And why did you meet with Lindsay Clancy on January 29th, 2023?
SEJAL SHAH: Yeah. So my team was seeing Ms. Clancy for a number of reasons, including for psychiatric safety risk assessment. She had come in reporting a suicide attempt, which is a common reason why my team would be called, is to continue to ensure that patients are safe when they're in the hospital. So we make recommendations about kind of safety status. You know, what can we do to help keep a patient safe? But then we also make recommendations related to medications. So that's why my team was following her. So that was one of the reasons why I saw her on the 29th, is to continue that assessment. I was also called to ask a new... Well, I was asked a new question that day, a consult question on whether she was able to make the decision to change her healthcare proxy from her, at the time, husband to her parents.
MS. SPRAGUE: And when you consult to help determine whether someone's capable of making a decision like that, changing their healthcare proxy, are you evaluating their medical decision-making capacity?
SEJAL SHAH: That's correct.
MS. SPRAGUE: Okay. How do you go about doing that?
SEJAL SHAH: So there's generally four parts to medical decision-making capacity. The first is whether somebody's able to voice a choice, and whether that choice is consistent over time. The second is whether they understand the situation under which they're making that choice. The third part is appreciation of the risks and benefits. And the fourth part is kind of being able to reason or rationalize that information, to be able to come to a choice and how they came to that choice.
MS. SPRAGUE: Now, if you're doing this evaluation to determine someone's capacity to make decisions, would a traumatic brain injury factor into that evaluation?
SEJAL SHAH: It could.
MS. SPRAGUE: When you evaluated Lindsay Clancy, was she able to voice a choice to you about who she wanted to be her healthcare proxy?
SEJAL SHAH: Yes.
MS. SPRAGUE: And is she speaking to you or writing this down?
SEJAL SHAH: She's speaking.
MS. SPRAGUE: Speaking. So she's already been extubated at that point?
SEJAL SHAH: That's correct.
MS. SPRAGUE: And she's speaking to you. And were you aware that Patrick Clancy was her healthcare proxy?
SEJAL SHAH: I was told that by her primary medical team.
MS. SPRAGUE: Okay. And when you talked to Ms. Clancy, did she tell you who she wanted to take over that role?
SEJAL SHAH: She did.
MS. SPRAGUE: And who was that?
SEJAL SHAH: Both her parents.
MS. SPRAGUE: And you talked about that needing to be a consistent choice. How did you ensure that was a consistent choice with her?
SEJAL SHAH: Yeah. So we waited to make the change from Patrick Clancy to her parents until the next day, for a variety of reasons. We wanted to ensure that that choice was consistent over time, and especially because the day that I saw her she had just gone through some pretty major medical events, including she had a major spine surgery, a decompression and a fusion. She had gone through some oxygen desaturations overnight, so was not breathing as well. Her heart rate was up, all of which then led to her being what we call delirious. She was quite—she was confused overnight, to the point where she asked her nurse, "Am I delirious?" And she was also experiencing some visual hallucinations. So that was one of the reasons why I was called in, to make sure that she was able to make that decision to change her healthcare proxy. And then in addition, the team had also voiced, you know, concerns that she had come in after a reported suicide attempt, and so making sure that she was able to make that decision of sound mind. And so we actually waited until the next day when she could be reassessed. At that point, her delirium had cleared, and she was continuing to make that consistent choice to change her healthcare proxy to her parents.
MS. SPRAGUE: And in fact, it's—you noted in the medical records that the hallucinations were part of an issue with oxygen?
SEJAL SHAH: It could be. That could be one of the reasons. Delirium is usually due to a variety of different medical reasons, and oxygen desaturation could be one of them. She had also just recently had anesthesia related to a surgery that she had on her spine, so that could be another reason. And then her heart rate was also actually quite elevated. So that could be another reason.
MS. SPRAGUE: Mm-hmm. Is it common for patients who are just coming off of anesthesia from surgery who have an issue with oxygen and other medical issues that you described to have visual hallucinations?
SEJAL SHAH: They can. It's not a—it's not that everybody does, but they can. And delirium can be quite common after surgery and particularly anesthesia.
MS. SPRAGUE: And those hallucinations that she was having, those were resolved by the next day. They were over by the next day, correct?
SEJAL SHAH: That's correct.
MS. SPRAGUE: And her choice to change her healthcare proxy to her parents was consistent the following day, correct?
SEJAL SHAH: That's right.
MS. SPRAGUE: You also talked about the patient has to understand the risks and benefits of the decision, correct?
SEJAL SHAH: That's correct.
MS. SPRAGUE: How do you make sure the patient understands that?
SEJAL SHAH: Yeah, so one of the things we do is really ask patients to take us through their thought process of why they're making that decision and what led to them making that decision at that moment in time, so we're able to kind of see their thought process and ensure that they're understanding, you know, what it means to remove one person and add another.
MS. SPRAGUE: And what was Ms. Clancy's thought process in explaining that to you?
SEJAL SHAH: Yeah. She was saying that her parents are quite supportive to her, and that she was thinking that she would have to change her healthcare proxy from her husband to somebody else. And we didn't necessarily go into the reasons as to, you know, why she would have to change it, but she explained that she was very close with her parents. They would see each other frequently given that they lived in close geographic proximity, and that she felt that they were very supportive to her and would have her best interests in mind should we need to invoke the healthcare proxy or that she couldn't be... if she couldn't make her own medical decisions.
MS. SPRAGUE: So was there a concern on her part that her husband wouldn't have her best interests in mind at that point in time?
THE COURT: Sustain.
MS. SPRAGUE: You also talked about the patient. You have to make sure the patient's thinking about the information rationally. How do you go about doing that?
SEJAL SHAH: Yeah. So one of the things we do is really ensure that the patient understands the situation and, you know, all of the kind of parts around it. So this comes into play much more when it's about a specific medical intervention like an invasive medical procedure or something like an amputation or a surgery. With a healthcare proxy, one of the things you wanna make sure is that the person that they wanna change their healthcare proxy to or appoint as their healthcare proxy makes sense in the context of their life. And, you know, Ms. Clancy was able to talk about how her parents were quite involved in her life, and so that's one of the things that we would assess.
MS. SPRAGUE: Okay. And then the last thing was making sure the patient understands the risk if the change doesn't happen.
SEJAL SHAH: Mm-hmm.
MS. SPRAGUE: Did you go over that with Ms. Clancy, and how did you do that?
SEJAL SHAH: Yeah. I did go over that with her. We talked a little bit about how it could mean that she would not have a healthcare proxy, were she not to appoint her parents. And so we went through that, you know, it's always— In healthcare, we always talk about how it's great to have a healthcare proxy just in case you become unable to make medical decisions, and who would you want that to be?
MS. SPRAGUE: And during this conversation with the defendant, going over all these points, did you ever have difficulty understanding her?
SEJAL SHAH: I did not.
MS. SPRAGUE: Did she ever appear to have difficulty understanding you?
SEJAL SHAH: So the first day when I saw her on January 29th, she described herself as feeling confused, and I definitely witnessed that as well. We went through a bedside cognitive evaluation, and she definitely made some mistakes on some of the cognitive evaluation. Therefore, I did diagnose her at that time with delirium.
MS. SPRAGUE: And then she was re-evaluated the following day, and there were no issues with her understanding, and the delirium was gone, correct?
SEJAL SHAH: That's correct.
MS. SPRAGUE: And were you aware during this evaluation that Ms. Clancy did not have a brain injury?
SEJAL SHAH: It— I'm sorry. Can you repeat the question?
MS. SPRAGUE: Were you aware that Ms. Clancy did not have a brain injury at that time?
SEJAL SHAH: So what, one of the things that we look at is any kind of relevant medical information that might be available to us, and I noticed that her Glasgow Coma Scale when she was transferred to Brigham and Women's Hospital was a 10, which would indicate that she could potentially have had a moderate brain injury. But I don't recall thinking about whether, you know, specifically whether she had a brain injury.
MS. SPRAGUE: Were you aware that a CAT scan was done, page 110 of the records? And—
MS. SPRAGUE: On the CAT scan, the impression was no acute intracranial findings, so no, no brain injury.
SEJAL SHAH: So you can-
MS. SPRAGUE: On the CAT scan, correct?
SEJAL SHAH: I did review the head imaging that was available at the time. You can have a normal CAT scan and still have a brain injury.
MS. SPRAGUE: Were you aware that she had multiple CAT scans that showed no bleeding in the brain, no skull fractures, no injuries, just... visible injuries whatsoever?
SEJAL SHAH: What... I'm sorry, but can you repeat the question?
MS. SPRAGUE: Were you aware that she had multiple CAT scans at South Shore Hospital and at Brigham and Women's that showed no skull fractures, no intracranial bleeding, no hemorrhaging, no visible damage whatsoever?
SEJAL SHAH: Yes.
MS. SPRAGUE: And were you aware that she was evaluated at South Shore Hospital and at the Brigham and she had no external injuries on her head either?
SEJAL SHAH: Yes.
MS. SPRAGUE: Now—
MS. SPRAGUE: She was allowed to change her healthcare proxy to her parents, correct?
SEJAL SHAH: That's correct.
MS. SPRAGUE: So if someone had an injury, a brain injury to the point where they didn't know what was going on or they were having trouble processing or thinking, they wouldn't be allowed to change their healthcare proxy, correct?
SEJAL SHAH: It depends to what extent. Most patients that have either a head injury or severe mental illness, let's say, just anything going on with the brain, retain the ability to make most medical decisions. And we think about changing healthcare proxies as a pretty low risk decision. As I mentioned before, something like an amputation or a major surgery, invasive procedure is something that we would hold somebody to a higher bar. But a healthcare proxy is a pretty low risk, especially if it makes sense in terms of who they want to change it to.
MS. SPRAGUE: And when was her Glasgow score a 10?
SEJAL SHAH: I believe it was as she was being transferred from the outside hospital to Brigham and Women's.
MS. SPRAGUE: And you're seeing her several days later, correct?
SEJAL SHAH: Correct.
MS. SPRAGUE: And so when she was transferred from the outside hospital to Brigham, she was unconscious, correct?
SEJAL SHAH: I believe so.
MS. SPRAGUE: Okay. So now she's conscious, correct?
SEJAL SHAH: That's correct.
MS. SPRAGUE: And when she was transferred from the outside hospital to Brigham, she wasn't communicating or speaking or opening her eyes on her own, correct?
SEJAL SHAH: That's what the reports said. I was not there at that time, but the notes that I read, that's correct.
MS. SPRAGUE: So when you're speaking to her a couple days later, she's opening her eyes, she's communicating, she's responsive, she's interacting, correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: So it's fair to say that her Glasgow score would be higher than the 10 when you were speaking to her, correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: Now...
MS. SPRAGUE: You did a mental status examination of her while you were doing this evaluation about her decision-making capacity, correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: And it's fair to say under mood, you listed "okay"?
SEJAL SHAH: Yes.
MS. SPRAGUE: That you listed her thought process as organized, goal-directed. Is that correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: You asked her if she was having hallucinations or delusions, and she, other than those initial ones the first day, she denied those?
SEJAL SHAH: During my evaluation, yes.
MS. SPRAGUE: And she also denied suicidal intent and homicidal intent, correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: And you listed her insight and judgment as fair, correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: Her behavior was calm and cooperative?
SEJAL SHAH: Yes.
MS. SPRAGUE: And...
MS. SPRAGUE: You didn't see anything about her behavior that would indicate to you that she was responding to some type of voices or hallucination that you couldn't see?
SEJAL SHAH: At that moment, no. But as I mentioned, I did speak with the nurse beforehand, and Ms. Clancy was able to report to me that she reported visual hallucinations overnight.
MS. SPRAGUE: Overnight after surgery?
SEJAL SHAH: That's right.
MS. SPRAGUE: Okay. And then never again?
SEJAL SHAH: Not during my evaluation.
MS. SPRAGUE: And did you speak to Ms. Clancy again on February 19th, 2023?
SEJAL SHAH: Yes.
MS. SPRAGUE: And was the purpose for that to prepare her for a transition from Brigham and Women's to Spaulding Rehabilitation?
SEJAL SHAH: That was one of the reasons.
MS. SPRAGUE: Okay. And what were the other reasons?
SEJAL SHAH: So it was an ongoing safety evaluation, ongoing evaluation of psychiatric safety risk, as well as medication evaluation, to determine if her medications were at the right level, the right dosage, and that she was on the right medications. And then just ongoing evaluation in terms of kind of her mental status.
MS. SPRAGUE: And during that meeting, she denied suicidal intent, correct?
SEJAL SHAH: That's correct.
MS. SPRAGUE: She denied homicidal intent, correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: She denied having auditory or visual hallucinations, correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: She reported her mood as okay, is that correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: And she told you she was looking forward to moving to Spaulding, correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: She also denied any confusion or disorientation, is that correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: And again, you described her mood as okay on that day?
SEJAL SHAH: Yes.
MS. SPRAGUE: And you described her as future-oriented on that day?
SEJAL SHAH: Yes.
MS. SPRAGUE: And then you spoke to her again on February 21st, 2023, is that correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: And on that day, is it the same purpose that you just described, getting her ready... assessing her mental status and getting her ready to transfer to Spaulding?
SEJAL SHAH: Yes.
MS. SPRAGUE: Okay. And during that time, you wrote that the patient reported feeling down about her current situation, her paralysis, and the events leading up to her hospitalization. Is that correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: And you also noted that she said her thoughts about what she had done were not constant throughout the day, correct?
SEJAL SHAH: Correct.
MS. SPRAGUE: So she wasn't thinking about killing her children throughout the day every day, correct?
SEJAL SHAH: Correct.
MS. SPRAGUE: And she said she had no suicidal intent, no homicidal intent, correct?
SEJAL SHAH: Correct.
MS. SPRAGUE: No auditory or visual hallucinations, correct?
SEJAL SHAH: Correct.
MS. SPRAGUE: You also write no PI. What does PI stand for?
SEJAL SHAH: Paranoid ideation.
MS. SPRAGUE: And there was none of that either?
SEJAL SHAH: Correct.
MS. SPRAGUE: You also made a note, “Notes low mood today in the context of her physical and legal situation, but does not currently meet criteria for major depressive episode.” Is that correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: So her focus seemed to be on her physical and legal situation, but being hopeful about moving on to Spaulding.
MR. REDDINGTON: Legal situation.
THE COURT: Okay. Can I see counsel?
MS. SPRAGUE: And so her focus at that time appeared to be her physical situation, her legal situation, and looking forward to going to Spaulding Rehab?
SEJAL SHAH: Yes.
MS. SPRAGUE: And then your last visit with her was February 22nd, 2023, correct?
SEJAL SHAH: Yes.
MS. SPRAGUE: And again, she indicated she was hopeful about treatment at Spaulding?
SEJAL SHAH: Yes.
MS. SPRAGUE: She was future-oriented?
SEJAL SHAH: Yes.
MS. SPRAGUE: And she denied suicidal ideation, homicidal ideation?
SEJAL SHAH: Yes.
MS. SPRAGUE: She denied audio hallucination, visual hallucination, and anything else of that nature?
SEJAL SHAH: Yes.
MS. SPRAGUE: Okay. Thank you.
THE COURT: All right. Attorney Reddington.
MR. REDDINGTON: Yes, Your Honor. So doctor, from your testimony, and correct me if I'm wrong, was she, to your opinion and your experience, an honest patient telling you what her symptoms were, if any?
MS. SPRAGUE: Objection.
MR. REDDINGTON: That's an evaluation in the psychiatric.
THE COURT: Allowing it. I allow that question.
SEJAL SHAH: Yes.
MR. REDDINGTON: In other words, she didn't go off and try to exaggerate to you and say, “I'm seeing visions, and I'm hearing voices, and I'm suicidally ideated, and I'm homicidally ideated.” She didn't say any of those things to you, did she?
SEJAL SHAH: No.
MR. REDDINGTON: She actually denied them, right?
SEJAL SHAH: Correct.
MR. REDDINGTON: So this is not, in your opinion, someone who was trying to exaggerate her conditions for some legal reason, correct?
SEJAL SHAH: No.
MR. REDDINGTON: And you obviously were in close contact with her for about a month, right?
SEJAL SHAH: That's right.
MR. REDDINGTON: Just a couple of questions. Counsel asked you whether or not, and I think it may have been in the beginning in January, that you had difficulty understanding her. Obviously, after removing the tubes and everything else, you were able to talk with her, correct?
SEJAL SHAH: Correct.
MR. REDDINGTON: And you knew that one of the concerns, if you will, was postpartum issues. You knew that, right?
SEJAL SHAH: Yes.
MR. REDDINGTON: And in your experience as a psychiatrist, you're familiar with the concept of postpartum psychosis, correct?
SEJAL SHAH: Yes.
MR. REDDINGTON: And you know that people can communicate and plan and act on plans even if they're in the middle of a psychosis, right?
SEJAL SHAH: Yes.
MR. REDDINGTON: You don't have to be drooling and stumbling and unable to walk and talk to be in a psychosis, do you?
SEJAL SHAH: No.
MR. REDDINGTON: So in other words, a person can be in a psychosis and can communicate to friends, family, people, talk. Correct?
SEJAL SHAH: Yes.
MR. REDDINGTON: So you didn't, as counsel asked, you didn't have any difficulty understanding her. She wasn't slurring her words or anything like that when she was able to talk?
SEJAL SHAH: Right.
MR. REDDINGTON: Okay. One of the things that, when she was admitted, and then without going through, I'm not gonna go through all the stuff we've already talked about with her medical condition and everything else. You indicated she—that she was very, very ill, correct?
SEJAL SHAH: Correct.
MR. REDDINGTON: Did she appear to be cooperative to you when you would interact with her?
SEJAL SHAH: Yes.
MR. REDDINGTON: As a doctor, as a psychiatrist, you're familiar with bipolar, the concept of a bipolar diagnosis, correct?
SEJAL SHAH: Correct.
MR. REDDINGTON: Can you tell me what bipolar means?
SEJAL SHAH: Yeah. So bipolar disorder is a mood disorder, categorized as a mood disorder, where patients have distinct depressive episodes, as well as, depending on the type of bipolar disorder, either hypomanic episodes or manic episodes, to the point where they don't sleep for days. They still have lots of energy. There's this decreased need for sleep. There could be irritability. There could be impulsiveness, racing thoughts. A lot of patients describe that they're out of control of their behavior. And then severe episodes can also include psychosis.
MR. REDDINGTON: And in reference to bipolar, as you were referring to, when somebody is hypomanic, what does hypomanic mean?
SEJAL SHAH: Yeah. It's a lesser degree of mania. So when patients are hypomanic, they don't always experience things like psychosis. But they might experience some of the other symptoms that I described, including racing thoughts, kind of moving too quickly, talking too quickly, being irritable.
MR. REDDINGTON: And as it relates to the hypomania, would that include things such as somebody who is getting up early in the morning and exercising or cleaning out their house or selling their property out of a garage and having difficulty sleeping, and they're awake all night?
SEJAL SHAH: Yes.
MR. REDDINGTON: As a psychiatrist, one of the things you were concerned about when you were first started to deal with her, as well as when you were releasing her, if you will, is the medication that she had on board, so to speak, when she came into the hospital, right?
SEJAL SHAH: Yes.
MR. REDDINGTON: Do you remember, and I know it's difficult to recall offhand, but do you recall the medications that she was actually under, from purposes of taking her blood when it was tested?
SEJAL SHAH: When she first came to the hospital?
MR. REDDINGTON: Yeah, if you know.
SEJAL SHAH: I believe her medication list for, you know, previous to the incident, she was on amitriptyline, diazepam. I believe she was also on, prescribed lorazepam. And there may have been one other.
MR. REDDINGTON: Okay. So looking at that, if I tell you that—there was a toxicology report done on her as of January 24th by way of taking her blood. You're familiar with that, right? When they analyze for toxicology?
SEJAL SHAH: Mm-hmm.
MR. REDDINGTON: And toxicology obviously would tell us what the medications, if any, what type of drugs she had on board, booze, cocaine, anything, right?
SEJAL SHAH: Yes.
MR. REDDINGTON: And you're aware that the toxicology report as well as the report from the Department of State Police as well as the NMS laboratory, which would be in Pennsylvania. So that's an international or a national respected laboratory, isn't it? The NMS lab? If you know.
SEJAL SHAH: I don't know.
MR. REDDINGTON: Okay. But you know that they did take her blood, they did test her blood, and it was at the state police laboratory as well as any other labs that test it, right?
SEJAL SHAH: Yes. I believe I found that out later. I did not know that the first time—
MR. REDDINGTON: Okay.
SEJAL SHAH: ... I saw her because those labs take a little bit of time to come back.
MR. REDDINGTON: Sure. And you treated her for about a month, so you were pretty—
SEJAL SHAH: That's right.
MR. REDDINGTON: ... close to her and got to know her quite well.
SEJAL SHAH: Yes.
MR. REDDINGTON: Would you agree with me that one of the things that her blood reflected or that she was on was trazodone?
SEJAL SHAH: Yes.
MR. REDDINGTON: And can you tell me what trazodone is?
SEJAL SHAH: Yeah. Trazodone is an antidepressant medication. It's more often utilized as a sleep aid, because of one, one of the side effects is sedation. And so patients that are often having difficulty sleeping are placed on trazodone.
MR. REDDINGTON: And is trazodone... Does that share some of the qualities of what are referred to as SSRIs, even though... or SSRA, even though he's not, it's not an SSRI? It shares similar qualities.
SEJAL SHAH: Yes.
MR. REDDINGTON: Can you tell me what SSRI means?
SEJAL SHAH: Yeah. So that's a selective serotonin reuptake inhibitor, and it's a class of medications, in, that are antidepressants.
MR. REDDINGTON: And the SSRIs, that would also include Zoloft, for example?
SEJAL SHAH: Correct.
MR. REDDINGTON: Would also include Prozac, for example?
SEJAL SHAH: Yes.
MR. REDDINGTON: Are you as a psychiatrist aware that Zoloft and/or SSRI Prozac should not be prescribed to a patient who has bipolar?
SEJAL SHAH: Yeah. It can be prescribed. Oftentimes, it's prescribed together with another medication that can be protective, because patients with bipolar disorder may be experiencing depression. And so they may be prescribed an antidepressant, but along with another medication that, what we call protective.
MR. REDDINGTON: And in reference to the SSRIs, the selective serotonin reuptake inhibitor, what does that mean? Selective serotonin reuptake inhibitor, what does that mean?
SEJAL SHAH: Yeah. So oftentimes in depression, patients are kind of lacking serotonin in the spaces, in their brain, that helps with—
MR. REDDINGTON: Can I interrupt you? What is serotonin?
SEJAL SHAH: Yeah. Serotonin is a neurotransmitter. So it's a hormone in the brain that works on the brain. It works in other areas in the body as well, but for these purposes, it works in the brain at nerve endings throughout the body. And that neurotransmitter helps with things like mood regulation. For patients with depression, they're often lacking kind of that ability to have enough serotonin in those spaces. And so a selective serotonin reuptake inhibitor prevents serotonin being kind of sucked back into the cell. So it allows for serotonin to be more available.
MR. REDDINGTON: And what is an SSAI? What does that mean? Antagonist, selective serotonin antagonist?
SEJAL SHAH: So those are medications that kind of do the opposite.
MR. REDDINGTON: Okay. And you know, as a psychiatrist, at least looking at her history, you knew that she had been seeing psychiatrists immediately prior to her suicided time, correct?
SEJAL SHAH: Correct.
MR. REDDINGTON: And you knew that she had been prescribed a number of drugs by these various psychiatrists, correct?
SEJAL SHAH: Correct.
MR. REDDINGTON: And to your knowledge, was she prescribed diazepam?
SEJAL SHAH: Yes.
MR. REDDINGTON: Valium. Was she prescribed buspirone, otherwise known as Buspar?
SEJAL SHAH: Yes.
MR. REDDINGTON: How about Wellbutrin?
SEJAL SHAH: Yes.
MR. REDDINGTON: And what is Wellbutrin? Is that an antidepressant?
SEJAL SHAH: It is an antidepressant.
MR. REDDINGTON: Hydroxyzine. What is hydroxyzine?
SEJAL SHAH: It can be used for a number of reasons, but for psychiatric purposes, it's often used as an anti-anxiety medication.
MR. REDDINGTON: And Klonopin?
SEJAL SHAH: Yes.
MR. REDDINGTON: Is hydroxyzine, is that a… Strike that. Klonopin, that's a benzodiazepine, right?
SEJAL SHAH: That's correct.
MR. REDDINGTON: And then lamotrigine.
SEJAL SHAH: Yep. Lamotrigine.
MR. REDDINGTON: Lamotrigine. Sorry.
SEJAL SHAH: Yes.
MR. REDDINGTON: What type of medication is that? Is that a mood stabilizer?
SEJAL SHAH: It is. Yeah. It's also an anti-seizure medication. But in the psychiatric realm, it's used as a mood stabilizer.
MR. REDDINGTON: And then we talked about Prozac. That's an SSRI, correct?
SEJAL SHAH: Correct.
MR. REDDINGTON: And what's Remeron?
SEJAL SHAH: Also an antidepressant.
MR. REDDINGTON: So in addition to all of the drugs that I had mentioned, she was also prescribed Remeron, correct?
SEJAL SHAH: Correct.
MR. REDDINGTON: She was also prescribed Seroquel or queti- quetamine- quet-
SEJAL SHAH: Yeah.
MR. REDDINGTON: … Quetiapine.
SEJAL SHAH: Yeah. Quetiapine, yes.
MR. REDDINGTON: Quetiapine.
SEJAL SHAH: Mm-hmm.
MR. REDDINGTON: Okay. And what is Seroquel?
SEJAL SHAH: So Seroquel is an antipsychotic medication.
MR. REDDINGTON: And she was prescribed, as we already talked, trazodone. Was she also prescribed amitriptyline?
SEJAL SHAH: Yes.
MR. REDDINGTON: What is amitriptyline?
SEJAL SHAH: Amitriptyline is one of the older antidepressants. It's a tricyclic antidepressant that can often be used to help with sleep, but also mood.
MR. REDDINGTON: And Ambien, correct?
SEJAL SHAH: Correct.
MR. REDDINGTON: And zop- zopidem. Zolpidem.
SEJAL SHAH: Yeah. Zolpidem is the generic name of Ambien.
MR. REDDINGTON: Oh, okay. Some of these drugs, they also have what's called a suicide warning or a black box warning. Isn't that right?
SEJAL SHAH: Yes.
MR. REDDINGTON: Can you tell me what that means?
SEJAL SHAH: Yeah. So, in studies that have been done, some of them show that the—especially after starting an antidepressant, it can increase someone's risk of suicidality. Many of those studies showed that it was mostly in adolescents and young adults, but it can happen in adults as well.
MR. REDDINGTON: And Celexa was also a drug. Is that an SSRI too?
SEJAL SHAH: It is.
MR. REDDINGTON: And all of these drugs that we just went through were all prescribed from...
MR. REDDINGTON: September, end of September, till January.
SEJAL SHAH: Yes, September 2022.
MR. REDDINGTON: Four, four-month period.
SEJAL SHAH: Yes.
MR. REDDINGTON: It's an awful lot of drugs to be prescribed in four months, isn't it?
MS. SPRAGUE: Objection.
THE COURT: Sustained.
MR. REDDINGTON: Thank you.
SEJAL SHAH: Thank you.
THE COURT: Commonwealth redirect?
MS. SPRAGUE: Yes. Doctor, all those drugs that defense counsel just listed, you're aware she wasn't on all of those drugs at the same time, correct?
SEJAL SHAH: Correct.
MS. SPRAGUE: And did you know that many of those drugs she took a very small amount of, some she didn't take any pills at all?
SEJAL SHAH: I was not aware of that.
MS. SPRAGUE: For Abusebar, which is one of the ones he mentioned, were you aware the first prescription she only took two pills out of that bottle?
SEJAL SHAH: I was not aware.
MS. SPRAGUE: Were you aware the second prescription, a month or so later, for Abusebar she took zero pills out of that bottle?
SEJAL SHAH: I was not aware.
MS. SPRAGUE: So you're just... Where are you getting this information about what she was on and when?
SEJAL SHAH: Yeah, so one of the things that we do is try to collect as much information as we can during our assessments. And so we look through the record in terms of what was prescribed. We also talk with other providers as to what they prescribe. But in the context of the assessments that we were doing, it did not require us to determine, you know, what exactly she had been on before, because we were using a different set of medications to treat something, different symptoms that she was experiencing.
MS. SPRAGUE: So you really have no idea what she was taking or when. You just know what was prescribed.
SEJAL SHAH: I know what was prescribed, and then we were also getting reports of what was being taken, what wasn't being taken. But—
MS. SPRAGUE: From the defendant?
SEJAL SHAH: Correct.
MS. SPRAGUE: Okay. So she's reporting to you that she took those medications, but you'd be surprised to know that at least one of them, zero pills were taken.
SEJAL SHAH: I don't think I'm surprised, no.
MS. SPRAGUE: Okay. And you talked about, well, talked about prescription and what she was taking. Were you aware that in the timeframe just prior to her being admitted to the hospital, she was only prescribed Trazodone, Valium, and Amitriptyline, just three medications?
SEJAL SHAH: Yes. I was aware.
MS. SPRAGUE: And you were asked about, you know, mania and, you know, exercising and cleaning out your garage and selling your belongings could be signs of mania, correct?
SEJAL SHAH: Correct.
MS. SPRAGUE: But there are people who just exercise every day, and they're not manic, correct?
SEJAL SHAH: Correct.
MS. SPRAGUE: And there are people who have a messy garage and have accumulated a lot of junk and decide to clean out the garage that aren't manic, correct?
SEJAL SHAH: Correct.
MS. SPRAGUE: And in fact, if someone is manic and attempts to do one of those tasks, like cleaning out a garage, it's usually in a disorganized way and oftentimes they don't finish the task, correct?
SEJAL SHAH: Sometimes.
MS. SPRAGUE: So if someone approaches a task like cleaning out the garage by organizing, with another party, organizing the belongings, separating them into keep, sell, throw out, that's pretty organized behavior, correct?
SEJAL SHAH: Correct.
MS. SPRAGUE: And if someone sells belongings that they no longer need, that's not necessarily a sign of mania, correct?
SEJAL SHAH: Correct.
MS. SPRAGUE: That's more if they're selling their stove and then they have nothing to cook with, correct?
SEJAL SHAH: Correct.
MS. SPRAGUE: So if they're selling junk in their garage that they no longer need, that's not necessarily manic, correct?
SEJAL SHAH: Not necessarily.
MS. SPRAGUE: Thank you.
THE COURT: All right. Mr. Reddington. Go ahead.
MR. REDDINGTON: So if the person, as counsel said, they're exercising every day, and they have a messy garage, that obviously would not be indicative of hypomania, would it?
SEJAL SHAH: Probably not.
MR. REDDINGTON: A normal person could have, as counsel said it. How about a person that at the same time can't sleep because the insomnia is so bad they go 48 hours without sleep? Is that something to be considered in the whole evaluation?
SEJAL SHAH: Yes.
MR. REDDINGTON: How about the fact of the person saying that “my brain is broken,” and that they can't concentrate, they can't think? Is that something that the person you would consider in conjunction with the messy garage and the exercise?
SEJAL SHAH: Yes.
MR. REDDINGTON: Thoughts of hurting themselves, suicidal ideation, that's something that's important to evaluate?
SEJAL SHAH: Yes.
MR. REDDINGTON: Homicidal ideation, telling your husband that you're having thoughts about hurting your children, that's something you'd consider, isn't it?
SEJAL SHAH: Yes.
MR. REDDINGTON: In reference to counsel's comment about just three medications that she was on prior to committing—trying to commit suicide, you're not aware of the doctors telling her to discontinue this medication, start a new medication, go onto a different medication depending on the doctor. You're not aware of that, right?
SEJAL SHAH: No.
MR. REDDINGTON: And finally, if you know, did she sign a DNR, do not resuscitate?
SEJAL SHAH: She asked to, the day after the first evaluation that I did of her, which was the capacity assessment to change her healthcare proxy. But in the context of her reporting a serious suicide attempt, we did not change her code status. We continued to chat with her about that, and she ultimately came to the conclusion that it made sense to make sure that her mental health was stable before she considered her code status.
MR. REDDINGTON: Okay. But her initial reaction or her conversations with you all was that she wanted to have a do not resuscitate status?
SEJAL SHAH: Correct.
MR. REDDINGTON: Thank you.
THE COURT: Commonwealth?
MS. SPRAGUE: Nothing further.
THE COURT: All right. Thank you, doctor.
SEJAL SHAH: Thank you, Your Honor.
THE COURT: All right. Members of the jury, we're gonna take the afternoon recess at this point. So I'm gonna ask you to go back to the jury room, and then we'll come back here approximately 2:00, okay?
BAILIFF: All rise.
BAILIFF: Jurors have exited the courtroom.
THE COURT: Counsel, anything we need to address before the break?
MS. SPRAGUE: No, Your Honor.
THE COURT: All right, so we'll be in recess till about 2:00. Thank you.