5.Jennifer Tufts — Direct (Part 1)
1,348 linesMS. SPRAGUE: Commonwealth calls Dr. Jennifer Tufts.
COURT CLERK: [oath administered]
JENNIFER TUFTS: I do.
COURT CLERK: Thank you, ma'am. You may have a seat.
THE COURT: A bunch of stuff there.
JENNIFER TUFTS: Mm-hmm.
THE COURT: All right. Good afternoon, doctor.
JENNIFER TUFTS: Good afternoon.
THE COURT: I'm gonna ask you to keep your voice up and speak into that microphone. All right?
JENNIFER TUFTS: Okay.
THE COURT: Counsel.
MS. SPRAGUE: Thank you, Your Honor. Good afternoon. Can you please state and spell your name for the record?
JENNIFER TUFTS: Jennifer Tufts. J-E-N-N-I-F-E-R T-U-F-T-S.
MS. SPRAGUE: Your date of birth?
JENNIFER TUFTS: December 31st, 1989.
MS. SPRAGUE: Where do you work?
JENNIFER TUFTS: Aster Mental Health.
MS. SPRAGUE: And how long have you worked there?
JENNIFER TUFTS: For three and a half years.
MS. SPRAGUE: What is your role there?
JENNIFER TUFTS: I'm a psychiatrist.
MS. SPRAGUE: And how long have you been a psychiatrist?
JENNIFER TUFTS: I've been officially a fully licensed psychiatrist for close to four years.
MS. SPRAGUE: I wanna ask you if you could just explain to us your educational background and your training background that qualifies you to be a psychiatrist.
JENNIFER TUFTS: Absolutely. So I went to medical school at University of Vermont, graduated in 2018 with an MD. I did a post-graduate training in psychiatry at Boston Medical Center. That was four years, going into 2022. And then I began working at Aster Mental Health in 2022.
MS. SPRAGUE: And are you a licensed psychiatrist in Massachusetts?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: While you were working at Aster Mental Health, did you have a patient named Lindsay Clancy?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And at this time, Your Honor, I'd move to submit the records of Lindsay Clancy from Aster Mental Health as the next exhibit.
THE COURT: Okay. They may be admitted.
MS. SPRAGUE: Do you recall when you first saw Lindsay Clancy as a patient?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: When was that?
JENNIFER TUFTS: It was in September of 2022.
MS. SPRAGUE: And was that first appointment on September 15th, 2022?
JENNIFER TUFTS: I believe that it was.
MS. SPRAGUE: And prior to a patient coming in for their first appointment, is there paperwork that they fill out, either online or that's provided to them to fill out?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what type of paperwork is that?
JENNIFER TUFTS: It's fairly extensive. It includes past health history, past psychiatric history, medications they have taken in the past. It includes names of any therapists or other doctors they work with, usually primary care. It includes any report of substances that they may use or may have used in the past. It includes a number of scales, so scales assessing things like anxiety, depression, ADHD. So it's a fairly lengthy document.
MS. SPRAGUE: Are you aware that Lindsay Clancy filled out those documents on September 12th, 2022, three days prior to her first appointment?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did you have an opportunity to review what Lindsay filled out prior to meeting with her for that first appointment?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Okay. And do you recall what you learned from those documents about her prior mental health treatment?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What was that?
JENNIFER TUFTS: That she had previously taken some medication. I believe it was in nursing school. It may have been fairly brief. But she had tried the medication Prozac.
MS. SPRAGUE: Do you recall that she also listed that she had tried Wellbutrin as well while she was on the Prozac?
JENNIFER TUFTS: That was listed as well.
MS. SPRAGUE: Okay. And do you recall that when she listed that she took the Prozac and the Wellbutrin while in nursing school, she listed that she had no side effects from those medications?
JENNIFER TUFTS: That is correct.
MS. SPRAGUE: Prozac, is that an SSRI?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Okay. So she reported—Lindsay reported that she had previously taken an SSRI while in nursing school with no side effects, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: Did she also report that she had no history of any kind of abuse that had occurred to her at any point in her life?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: What did she report in regards to alcohol consumption?
JENNIFER TUFTS: I believe she reported one to two drinks at a time.
MS. SPRAGUE: Okay.
JENNIFER TUFTS: And possibly up to five times a week.
MS. SPRAGUE: And is there a portion, when the patient fills that in, how much they drink, is there a question there about whether they feel guilty about that?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was her response?
JENNIFER TUFTS: Am I allowed to go check that just to make sure?
MS. SPRAGUE: Is there an objection to her reviewing the records?
JENNIFER TUFTS: Yes. She indicated yes.
MS. SPRAGUE: And so in that section, is it correct that she listed that she was drinking five times per week and feeling guilty at that time about it?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did she list her height as five foot six in those documents?
MS. SPRAGUE: I believe on the same page, page 20.
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Now, did those—that initial survey or questionnaire that she filled out get into what symptoms she was experiencing at the time?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what symptoms did she report experiencing at that time?
JENNIFER TUFTS: Anxiety attacks, decreased appetite, depressed mood, easily distracted, excessive worry, guilt, unable to feel pleasure, unable to fall asleep, and racing thoughts.
MS. SPRAGUE: And would it be fair to say that there's a checklist of symptoms, and the patient checks off which ones they're experiencing, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And so on that list, engage in risky behaviors, that was not checked off, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: And excessive energy wasn't checked off, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: Feelings of hopelessness, feelings of abandonment, feelings of emptiness, none of those were checked off, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: Impulsive behavior, that was not checked off, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: Now, was there also a suicide risk assessment form that Ms. Clancy filled out?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what is a suicide risk assessment?
JENNIFER TUFTS: Well, it assesses various factors that may increase a person's risk of committing suicide.
MS. SPRAGUE: And the form that Ms. Clancy filled out, one of... The first question is, "Have you been so distressed you seriously wish to end your life?" And her response was no, correct?
JENNIFER TUFTS: I'm just looking for—
MS. SPRAGUE: Page 23.
JENNIFER TUFTS: Correct.
MS. SPRAGUE: And the second question is, "Has anything happened recently to make you feel you don't want to live?" And her answer was no, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: There's question three: "A specific plan. Do you have a specific plan of how you would kill yourself?" And her answer was no, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: Fourth question is, "Access to weapons or means of hurting her— yourself." And the answer is no, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: The fifth question is, "Made a serious suicide attempt." And the answer was no, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: The sixth question, "Purposely done something to hurt yourself." Again, no, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: Seventh question, "Heard voices telling you to hurt yourself." Her answer was no, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: Number nine, "Having thoughts of killing or seriously hurting someone else." The answer was no, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: Number 10, "Heard voices telling you to hurt others." The answer was no, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: "Hurt someone or destroyed property on purpose." The answer was no, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: In fact, the answers to every question on this suicide checklist was no, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: Did you— Was there also a substance use assessment form that was filled out on page 24?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And there were no issues with substance use, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: Did you— Is there also an ADHD self-report scale that's filled out?
JENNIFER TUFTS: There usually is.
MS. SPRAGUE: Direct you to page 25.
JENNIFER TUFTS: Okay.
MS. SPRAGUE: And ADHD, is that attention deficit hyperactive disorder?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And given the answers that Ms. Clancy gave on that self-reporting form, were there any concerns about attention deficit hyperactive disorder?
JENNIFER TUFTS: Not significantly.
MS. SPRAGUE: Were there any concerns at all?
JENNIFER TUFTS: Well, she reported often to some of the questions, yes.
MS. SPRAGUE: And would that— Is that significant to you based on your training and experience?
JENNIFER TUFTS: You have to look at this form within the entire picture of the patient. So no. I didn't suspect that Lindsay had ADHD.
MS. SPRAGUE: So these forms are a tool, and you use them together along with your observations of the patient to come to conclusions. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: There was also a, I believe it's entitled a GAD screening. Is that generalized anxiety disorder?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Okay. And did Ms. Clancy fill that out as well?
MS. SPRAGUE: Page 27.
JENNIFER TUFTS: Sorry, my pages are a little bit different than yours.
MS. SPRAGUE: Oh, I apologize.
JENNIFER TUFTS: I'll find it.
JENNIFER TUFTS: Okay.
MS. SPRAGUE: Ms. Clancy's answers to these questions, did they give you cause for concern based on your training and experience?
JENNIFER TUFTS: They were highly suggestive of anxiety and an anxiety disorder.
MS. SPRAGUE: And for example, number one, "Feeling nervous, anxious, or on edge," she responded nearly every day. Correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: "Not being able to stop or control worrying," she answered nearly every day. Correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And so several of these questions were either nearly every day or several days, correct?
JENNIFER TUFTS: Yes.
MR. REDDINGTON: I apologize. Can I just ask what page that is?
MS. SPRAGUE: 25. 27, I'm sorry.
MR. REDDINGTON: Thank you.
MS. SPRAGUE: And then is there also a patient questionnaire that the patient fills out?
JENNIFER TUFTS: Yes, I believe so. Yes.
MS. SPRAGUE: And what is the purpose of this patient questionnaire?
JENNIFER TUFTS: I'm not sure exactly which one you're referring to. It might be the one that asks about things like whether the symptoms affect their daily living, what their history is. Is that what you're looking at?
MS. SPRAGUE: It's entitled Tools-PHQ-9 Patient Questionnaire.
MS. SPRAGUE: And the date is 9/12.
THE COURT: Do you think you wanna go over and show her?
JENNIFER TUFTS: Are you able to? Thank you. Yes.
JENNIFER TUFTS: Okay. Yes.
MS. SPRAGUE: So this form that's entitled PHQ-9 Patient Questionnaire, what is the purpose of that form?
JENNIFER TUFTS: It's a screening tool for depression.
MS. SPRAGUE: Okay. And can you talk about the defendant's answers to those questions and what they told you, based on your training and experience?
JENNIFER TUFTS: Well, some of the answers were positive. So that really indicates that she should be assessed for depression. She might have it.
MS. SPRAGUE: Okay. And when you say positive, what do you mean by positive?
JENNIFER TUFTS: So for example, she said for number two, feeling down, depressed, and hopeless more than half of the days, a positive response means indicating yes.
MS. SPRAGUE: So it's not a positive happy response. It's a positive "this might be an issue" response.
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And,
MS. SPRAGUE: On the next form, A1, Initial Diagnostic Assessment—
JENNIFER TUFTS: Yes.
MS. SPRAGUE: … There is a place there again— Well, this is for September 15th, the day you actually met her, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So the patient fills out the forms in advance of meeting with you. Do they then again fill out the forms when they meet with you?
JENNIFER TUFTS: No. These are the same forms.
MS. SPRAGUE: Same forms, just a different date on them.
JENNIFER TUFTS: Yes, because they're… Yeah, they're included in the intake note, which is what I write, but some of the information is from the patient self-report.
MS. SPRAGUE: So would it be a combination of the forms they fill out and then what you observe and ask about during your initial meeting?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And that initial meeting with Ms. Clancy, was that in person or was that a telehealth?
JENNIFER TUFTS: Telehealth.
MS. SPRAGUE: Okay. Does the— Who controls whether it's an in-person meeting or a telehealth, you or the patient?
JENNIFER TUFTS: Both.
MS. SPRAGUE: Both?
JENNIFER TUFTS: Both.
MS. SPRAGUE: And if a patient told you, "I don't wanna do telehealth, I only wanna do in person," is that an option?
MR. REDDINGTON: Objection.
JENNIFER TUFTS: Yes.
THE COURT: Go ahead.
THE COURT: I'll let that stand.
MS. SPRAGUE: And can you just tell us, when you met with Ms. Clancy on that first day, did you ask her questions such as, "Do you have suicidal intent?"
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was her response?
JENNIFER TUFTS: That she did not.
MS. SPRAGUE: Did you ask her if she had homicidal intent?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What was her response?
JENNIFER TUFTS: That she did not.
MS. SPRAGUE: Did you ask her if she was experiencing any auditory hallucinations or visual hallucinations?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What was her response?
JENNIFER TUFTS: That she did not.
MS. SPRAGUE: Did you ask her questions to determine if she was experiencing any symptoms of mania?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What types of questions do you ask to determine that?
JENNIFER TUFTS: Well, a lot of it can be assessed without asking. But questions may look like, "Have you ever had a period of time in your life where you were excessively energetic and euphoric?" I might leave it there and then follow up with some of the other symptoms.
MS. SPRAGUE: Did any of the questions you asked Ms. Clancy related to mania or manic episodes, did any of her answers to those questions indicate that she had experienced mania or manic episodes?
MS. SPRAGUE: Now, in that first meeting, do you... What's your exam process? Like, how do you start the meeting and how does it flow?
JENNIFER TUFTS: Sure. So I start the meeting by introducing myself, explaining what we're going to be doing for the day. Then I ask the patient why they're there. We talk about why they're there. I assess for different mood symptoms, anxiety symptoms, psychosis symptoms, mania symptoms, safety concerns. Then we start talking about the history. We start talking about the past psychiatric history, the past medical history, substance use. We start talking about other medicines that they have tried in the past or may still be taking. And it's not always in that order, but that's the general order. Sometimes things come up sooner. And we talk a bit about what the patient's goals are, what they're looking for in this time period. And then I may give some of my recommendations.
MS. SPRAGUE: And did you follow that process for that initial meeting with Lindsay Clancy?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Now, you mentioned that you... Part of the initial evaluation is looking for signs of psychosis. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What types of things are you looking for to see if someone's experiencing psychosis?
JENNIFER TUFTS: So there are a number of things. They start with how the patient appears. So some signs of psychosis might be that they appear disheveled. I assess what their attitude is. If they might be agitated or very uncooperative, that's, you know, a red flag. I will assess what their speech is like. Is it very loud? Is it very fast? Or sometimes it could be the opposite, where they're not really even speaking at all. I assess what their mood is like, what they're saying that they're feeling and how they appear visually. I assess what their thoughts are like. So are their thoughts disorganized where it's really hard to understand? They're jumping around and you can't follow their line of thought. I assess what the thought content is. If it's particularly about anything very bizarre or very paranoid, that would be potentially indicative of psychosis.
MS. SPRAGUE: And you conducted that type of evaluation on Lindsay Clancy in that first meeting. Is that correct?
JENNIFER TUFTS: Yes. That assessment is done with every patient.
MS. SPRAGUE: And did you note any signs or symptoms of psychosis with Ms. Clancy that day?
MS. SPRAGUE: Do you also, in addition to the observations you're making of the patient that day, are you also asking questions about their past behavior and things that have happened to them in the past that might indicate whether psychosis is an issue?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what types of things are you asking them about their past?
JENNIFER TUFTS: Well, I may ask, "Have you ever heard voices? Have you ever seen something that other people didn't see?"
MS. SPRAGUE: And did you ask those questions of Ms. Clancy?
JENNIFER TUFTS: I believe I did.
MS. SPRAGUE: And what was her response?
MS. SPRAGUE: Do you—and as part of this evaluation, are you making an assessment about the patient's judgment and insight?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And when we talk about psychiatry, what are we talking about when we say judgment?
JENNIFER TUFTS: So judgment indicates their decision-making process, and whether it is a logical decision-making process or perhaps not.
MS. SPRAGUE: And same question in terms of insight. What does that mean in psychiatry when you're assessing their insight?
JENNIFER TUFTS: So that's more about a patient's awareness, both of their inner feelings as well as mental health a bit more broadly.
MS. SPRAGUE: And in terms of orientation when you're assessing a patient, what does that mean?
JENNIFER TUFTS: Orientation is awareness of where someone is, who someone is, what day it is, what's going on.
MS. SPRAGUE: And based on your evaluation of Lindsay Clancy that first day, September 15th, 2022, did she appear to have any issues with judgment, insight, or orientation?
MS. SPRAGUE: Do you also assess the patient's memory?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And how do you do that?
JENNIFER TUFTS: Well, it depends. Often, unless there is a specific concern about memory or dementia, it's based off of my conversation with them. Are they able to recall medications that they have taken? Are they were able to recall, you know, things that they have done with a lot of detail and specificity?
MS. SPRAGUE: And did there appear to be any issues with Lindsay Clancy's memory in your evaluation of her?
MS. SPRAGUE: And what about attention and concentration? What are you looking for as a psychiatrist when evaluating attention and concentration?
JENNIFER TUFTS: I'm looking for whether they're paying attention to the conversation, if they can follow it, or maybe if they get distracted, it seems like they're not listening. Something like that.
MS. SPRAGUE: Did Lindsay Clancy appear to have any issues with attention or concentration?
MS. SPRAGUE: There was something in the records called fund of knowledge. What does that mean?
JENNIFER TUFTS: So basis of knowledge, what someone understands about the world. So maybe if somebody has a very low education, they might have a low fund of knowledge.
MS. SPRAGUE: And was there any issue with Lindsay Clancy's fund of knowledge?
MS. SPRAGUE: Are you also assessing mood?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And how do you assess the mood of a patient, and why do you assess it?
JENNIFER TUFTS: Well, it's very important. The mood is based on what the patient says.
JENNIFER TUFTS: What they say about how they're feeling.
MS. SPRAGUE: Okay. And so are there circumstances where a patient might say they're feeling happy, but you make observations that they appear depressed?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Okay. And so, when we see mood in the records, that refers to how the patient is reporting their mood is?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So if it says appropriate mood and affect, or actually, if it says patient description of their emotional state, it says, "Okay," does that mean the patient said, "Okay"?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Is there a place in the record where you describe what your observations of the mood are?
JENNIFER TUFTS: That's the affect.
MS. SPRAGUE: Affect. Okay. And so affect is how the patient presents?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: This first meeting with Lindsay, what was her mood?
JENNIFER TUFTS: It was okay.
MS. SPRAGUE: And what was her affect?
JENNIFER TUFTS: Anxious.
MS. SPRAGUE: So she was reporting to you she felt okay. You were seeing she looked a little anxious.
JENNIFER TUFTS: Yes.
MS. SPRAGUE: How do you, or what is it about a person that tells you they look anxious? Like, what were you seeing with Lindsay Clancy that told you she looked anxious?
JENNIFER TUFTS: It's hard to recall exactly what she seemed like. Sometimes, you know, a person might look anxious by—
MR. REDDINGTON: Sometimes, Your Honor.
THE COURT: All right. Sustained.
MS. SPRAGUE: In your general observations of patients, what things would you look for in a patient to determine whether their affect is anxious?
JENNIFER TUFTS: Is their voice quivering? Are they shaking a little bit? Do they appear very nervous?
MS. SPRAGUE: And what is psychomotor behavior?
JENNIFER TUFTS: So psychomotor behavior refers to someone's body and their movements. So sometimes that can be abnormal.
MS. SPRAGUE: Okay. And did you notice anything abnormal about Lindsay Clancy's psychomotor behavior?
MS. SPRAGUE: This first meeting, was that approximately forty minutes?
JENNIFER TUFTS: It was a little bit longer than that. Maybe fifty to sixty minutes.
MS. SPRAGUE: Is that typical for that first meeting where you're doing this initial assessment?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did she appear alone in that virtual meeting, or was she with anyone?
JENNIFER TUFTS: Alone.
MS. SPRAGUE: And what are treatment modality and interventions
MS. SPRAGUE: in general?
JENNIFER TUFTS: So that section is referring to therapy treatment modalities. It's not asking about medications. So different forms of therapy that might be done in a session.
MS. SPRAGUE: And what would be treatment goals?
JENNIFER TUFTS: Goals that we are working on or will plan to work on since this is only the first visit.
MS. SPRAGUE: So how do you determine for an individual patient the treatment modality or interventions that are needed?
JENNIFER TUFTS: It depends on the patient.
MS. SPRAGUE: So basically on what you're seeing, what you're hearing, and the history they provide?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And how do you determine treatment goals?
JENNIFER TUFTS: So a lot of that is driven by what the patient's goals are.
MS. SPRAGUE: And you mentioned earlier that, as part of your evaluation, you ask the patient why they've come to you, what they're concerned about. Do you recall Lindsay's response to that question, why she was there, what she was concerned about?
JENNIFER TUFTS: I believe her biggest concern was about anxiety.
MS. SPRAGUE: And what was the treatment modality or interventions that you determined would be needed for Lindsay Clancy based on this initial evaluation?
JENNIFER TUFTS: So I recommended a medication, sertraline, as well as individual therapy.
MS. SPRAGUE: And the medication sertraline, is that Zoloft?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Okay. And when you say you recommended the Zoloft to her, was that you telling her, "You have to take this medication," or did you have a discussion about it?
JENNIFER TUFTS: A discussion.
MS. SPRAGUE: And during that discussion, did you get the patient, Ms. Clancy's input on whether she wanted to take the medication or what her thoughts were about the medication?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And do you recall the details of that conversation with her?
JENNIFER TUFTS: I recall that she was generally reluctant to take medications. But at this point she was considering it and was interested in learning about what medications might be helpful for her.
MS. SPRAGUE: And as part of that discussion, did you explain what the medication was and the side effects and all of that?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did she have any questions for you based on your explanation of what the medication was for and what the side effects could be?
JENNIFER TUFTS: I'm not sure.
MS. SPRAGUE: And why did you recommend that particular medication?
JENNIFER TUFTS: So it's a first-line medication used for treating anxiety disorders. It also is a first-line treatment when women are breastfeeding. It's the safest SSRI for babies.
MS. SPRAGUE: And when you say a first-line medication, what does that mean?
JENNIFER TUFTS: It just means it's one of the medications that is recommended first. Sometimes you have to try a number of different medications, but that is often a first choice.
MS. SPRAGUE: And is that based on studies and the experience of the psychiatric profession?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What was the dosage that you recommended or prescribed for her for the Zoloft?
JENNIFER TUFTS: 25 milligrams.
MS. SPRAGUE: And were there instructions on the prescription in terms of how many milligrams to take the first week, and then how many to take the second week?
JENNIFER TUFTS: Yes. It was 25 milligrams for one week, and then increasing to 50 milligrams.
MS. SPRAGUE: And that was your initial prescription and what should've been on the pill bottle, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Was there ever a call from the defendant where she called you and said that she was having trouble with the 25 milligrams and you recommended her go to the 50 milligrams?
MS. SPRAGUE: You said you also recommended therapy, is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And Aster Mental Health, did they have therapists on staff that you referred Ms. Clancy to?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And do you know if she took advantage of that resource?
JENNIFER TUFTS: She did.
MS. SPRAGUE: Do you know which therapist she saw?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Who was that?
JENNIFER TUFTS: Jennifer McAllister.
MS. SPRAGUE: And with... How does it work when a patient is at Aster Mental Health, they're being seen by a psychiatrist, they're being seen by a therapist. Is there someone that's kind of in charge of the treatment of the patient that oversees everything, or is it all just individual?
JENNIFER TUFTS: The psychiatrist is in charge.
MS. SPRAGUE: Okay. So you would've been in charge of Ms. Clancy's treatment?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And as part of being in charge of her treatment, would you review the records from her therapy sessions to inform and guide your treatment of her?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What were the treatment goals for the defendant?
JENNIFER TUFTS: I don't recall exactly what her words were.
MS. SPRAGUE: Would the goals be what your patient tells you?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Just ask that you look at page 41 of the records for Exhibit 219, to the treatment goals section. Does that refresh your memory?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what were the treatment goals according to Ms. Clancy?
JENNIFER TUFTS: So these are not her words. They are... There's a list in the electronic medical record where I can indicate which ones might apply, or I can type out my own. So the treatment goals based on what we had decided on together were symptom reduction and improved functioning.
MS. SPRAGUE: And you said that Ms. Clancy had been a little reluctant about starting medication. Did she tell you why she was reluctant?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And why was that?
JENNIFER TUFTS: She was worried about having side effects.
MS. SPRAGUE: And did she mention which specific side effects or just side effects in general?
JENNIFER TUFTS: I thought it was in general.
MS. SPRAGUE: And as a result of that concern, is that when you went over the potential side effects of Zoloft?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And after having that discussion and you explaining the side effects of Zoloft, how did the two of you leave it in terms of whether she was going to take the medication or not?
JENNIFER TUFTS: I told her what my recommendation was, that she should start the sertraline. I'm not sure if she told me definitively if she was going to take it or not. She might have needed some time to think about it.
MS. SPRAGUE: And based on your evaluation with Ms. Clancy, everything you learned about her history and how she presented that day, did you have an initial diagnosis?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was that?
JENNIFER TUFTS: It was a generalized anxiety disorder, and it was an adjustment disorder with depressed mood.
MS. SPRAGUE: What is generalized anxiety disorder?
JENNIFER TUFTS: It's an anxiety disorder where an individual may have a lot of different worries. They may also have physical feelings of anxiety, but they're worried about a lot of things, not really just one thing specifically.
MS. SPRAGUE: And what is adjustment disorder with depressed mood?
JENNIFER TUFTS: So adjustment disorder refers to the fact that there may be symptoms, but they are kind of secondary to the situation. So they don't meet the full criteria, say, of a major depressive disorder, but there were some symptoms of depression.
MS. SPRAGUE: Okay.
THE COURT: Is this a good—
MS. SPRAGUE: Yes.
THE COURT: ... place to stop? All right. Members in the jury, this is— it's 1:00. We're gonna take the afternoon recess. I'm gonna ask you to be ready to come back at 2:00. And again, same instructions and orders. Don't— during the break, don't read anything about this case or similar cases. Don't do any research. Don't talk about this. Just kinda relax as best you can for the next hour. We'll have to bring you back in. We'll continue with the evidence this afternoon. Okay.
BAILIFF: Court, all rise. Jurors, close your notebooks and place them on the chairs. This way, please.
THE COURT: All right. Doctor, you may step down.
BAILIFF: Jurors have exited the courtroom.
THE COURT: All right. Before we recess, I just wanna make, I guess, a comment. I just wanna make it real clear—
BAILIFF: You may be seated.
THE COURT: ...that there is to be no inappropriate comments or disruptive comments to be made inside of this courtroom. If anybody's found to make those, they will be immediately escorted out and barred for the balance of this. All right? Just wanna make that real clear. And just in case you're wondering, there are microphones all around. And so if we hear, if I get a report of that, there's gonna be some serious issues and serious problems. So I just kinda wanted to put that out for everybody so it's crystal clear. There's gonna be no warnings, no yellow cards. You're out. All right? So I just kinda wanna make that real clear. And so with that, we'll be in recess on this matter till 2:00.
BAILIFF: Court, all rise.
BAILIFF: Court stands in recess. Please exit the courtroom. Thank you.
BAILIFF: Court is in session. You may be seated.
COURT CLERK: So for the purpose of the record, we return back to the matter of Commonwealth versus Lindsay Clancy.
COURT CLERK: Are all parties are present, including the defendant, excluding the jury.
THE COURT: All right. Counsel, are you ready for the jury?
MS. SPRAGUE: Can we be seen briefly at sidebar?
THE COURT: Sure.
THE COURT: Could we have the witness on the stand?
THE COURT: All right. We all set?
BAILIFF: Court, all rise. Jurors entering.
BAILIFF: This court's now in session. Please be seated.
COURT CLERK: Your Honor, for the purpose of the record, we return back to the trial, Commonwealth versus Lindsay Clancy. All parties are present, including the defendant and including the 18 jurors.
THE COURT: All right. Attorney Sprague.
MS. SPRAGUE: Thank you, Your Honor.
MS. SPRAGUE: So, Dr. Tufts, back on that first appointment with Ms. Clancy on September 15th, 2022, as part of the record, did you detail a section, history of present illness?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And in that section, you put in here, initial presentation, nursing school, Prozac helped, got treatment after second baby, two for anxiety, Zoloft one week, was nervous about breastfeeding, initial side effects. Can you just tell us where that information came from?
JENNIFER TUFTS: My conversation with the patient.
MS. SPRAGUE: Okay. And where it says Zoloft one week, was nervous about breastfeeding, what does that mean?
JENNIFER TUFTS: So she had tried Zoloft before during the postpartum period after her second baby.
MS. SPRAGUE: And did she tell you whether she had any side effects when she took Zoloft after her second baby?
JENNIFER TUFTS: She mentioned something about initial side effects, which are pretty common for many people. I didn't detail what those side effects were, but they sounded like the very normal ones that people might experience, that are transient in the beginning of the treatment.
MS. SPRAGUE: And what would those side effects be?
JENNIFER TUFTS: Possibly, upset stomach, appetite issues—
MR. REDDINGTON: Excuse me. I apologize. Can we know what related to this patient rather than somebody?
THE COURT: Right. So why don't, why don't you ask if she remembers what the defendant said the side effects were.
MS. SPRAGUE: Do you remember what the defendant said the side effects were?
JENNIFER TUFTS: I don't remember them exactly, but they were ones that did not seem concerning.
MS. SPRAGUE: And in your experience, in your training and experience as a psychiatrist who prescribes Zoloft, what are the common side effects that you deal with, that patients deal with from this medication?
JENNIFER TUFTS: So in the first couple weeks of treatment, we describe that there's a lot of serotonin in the gut, as well as the brain, so the medicine often affects the gut first. So you might have diarrhea, constipation, difficulties with appetite, nausea, things like that.
MS. SPRAGUE: And you also wrote in the note about history of present illness, three months postpartum, also four and two-year-old feeling overwhelmed. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And that came from the patient, Ms. Clancy?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And furthermore, you wrote that the baby needing more attention, other kids more challenging, too. Is that coming from the patient?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And does she also describe she's having trouble leaving the baby, too anxious to do anything when she leaves, physical tension, heart racing, worries he won't eat or sleep because he's refusing the bottle?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did she say that makes her irritable?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And in that same note is where you detail that she denied audio hallucinations, visual hallucinations. You also... Correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And you also detail suicidal ideation, homicidal ideation, denies, no concern about hurting baby. Is the no concern about hurting baby, is that a note, an observation you're making or something that comes from, came from Ms. Clancy?
JENNIFER TUFTS: It came from our conversation.
MS. SPRAGUE: So at some point in time she told you she had no concerns about harming the baby?
JENNIFER TUFTS: Yes. It was—
MR. REDDINGTON: I object.
THE COURT: All right. You can rephrase that question.
MS. SPRAGUE: What did she tell you about her thoughts about the baby?
JENNIFER TUFTS: I asked if there were those thoughts and she denied them.
MS. SPRAGUE: And did you also provide information to her about what to do if, in between appointments, there were emergencies or issues?
JENNIFER TUFTS: Yes. I believe that I did. I usually do when I meet a patient.
MS. SPRAGUE: Okay. And in the page describing treatment follow-up plan, which would be in the initial diagnostic assessment from September 15th, in that treatment follow-up plan section, is there a part... There's a part there that says, "If having urges to harm self or others, go to the nearest emergency room, call 911, or call the National Suicide Prevention and Crisis hotline," correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Is this page given to the patient?
JENNIFER TUFTS: They can access it online on the portal.
MS. SPRAGUE: Okay. So Ms. Clancy would have the ability to go on here, look at the portal, and see what to do if she was having a crisis?
JENNIFER TUFTS: Yeah. Just this plan section, yes.
MS. SPRAGUE: Just the treatment plan section?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So is it that she would have to search through the records, or is that something you can click on to see the treatment plan?
JENNIFER TUFTS: I'm not sure exactly what it looks like for a patient.
MS. SPRAGUE: Okay. But that's one of the sections that's available to the patient, Lindsay Clancy, if she goes onto the portal?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: There's also in here, "If you feel you're in crisis, you may text Home to a certain text number from anywhere in the United States." Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what does that do when you text that text number to the... You text Home to that text number?
JENNIFER TUFTS: It connects you to a counselor.
MS. SPRAGUE: Now, what was the treatment or follow-up plan for Ms. Clancy?
JENNIFER TUFTS: To start the sertraline, to start individual therapy, and to follow up with myself.
MS. SPRAGUE: So your recommendation wasn't just that she take pills. You recommended that she attend therapy, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And...
MS. SPRAGUE: When you recommended the therapy, did you... And the medication, did you also go over with Ms. Clancy alternatives to the medication that you were recommending?
JENNIFER TUFTS: I believe she was aware that the alternative was that she could not take a medication, which is what she had been doing before.
MS. SPRAGUE: And after you went over all of this information with Ms. Clancy, did she convey to you that she understood the plan and was agreeable to the plan?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What is informed consent?
JENNIFER TUFTS: Informed consent means you communicate with a patient what the risks and benefits are of treatment, and they understand that, and they agree to the treatment.
MS. SPRAGUE: And did Ms. Clancy show that she had informed consent to everything you discussed?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Now, was your next appointment with Ms. Clancy on September 28th, 2022?
JENNIFER TUFTS: Yes, it was.
MS. SPRAGUE: And so, during that appointment, did you discuss the medication, the Zoloft, that you had prescribed to her?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what did you learn from Ms. Clancy about whether or not she had taken that medication?
JENNIFER TUFTS: She shared that she decided not to take it.
MS. SPRAGUE: Did she tell you that she had picked it up but had decided not to take it?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did she tell you how she was feeling?
JENNIFER TUFTS: She said a little bit better.
MS. SPRAGUE: And did she elaborate on that?
JENNIFER TUFTS: The baby was getting some more sleep, so she was also able to get some more sleep, and that helped her feel better.
MS. SPRAGUE: And at this appointment, did you go through a mental status exam of Ms. Clancy?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what is a mental status exam?
JENNIFER TUFTS: So a mental status exam is an assessment of the patient at the point of meeting. It can change at different times. But it's comprehensive, referring to how the patient appears, how they cooperate, how they speak, how they describe their thoughts, how they're able to communicate with you, and what their mood is like.
MS. SPRAGUE: And do you do that at every appointment with every patient?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And so on the September 28th, 2022, when you met with Lindsay Clancy for that second meeting, did you do a mental status examination?
JENNIFER TUFTS: Yes, I did.
MS. SPRAGUE: And what was the result of that?
JENNIFER TUFTS: So I can... Is it okay if I read it from the note, or do you just want me to—
MS. SPRAGUE: There's no objection.
THE COURT: Go ahead. You may.
JENNIFER TUFTS: She was alert. She was oriented. She was appropri—her rapport, meaning how she worked with me, was appropriate. Dressed appropriately. Euthymic, meaning not, not depressed, not angry. Kind of a normal mood. Her affect was full. Her speech was appropriate. Her thought content and process were appropriate. She did not mention any hallucinations. At this point, I mentioned her insight was poor. Her judgment was excellent. Her cognition was... did not show any deficits. And there was normal psychomotor activity.
MS. SPRAGUE: And why did you list that her insight was poor?
JENNIFER TUFTS: So I think that that must have been related to the fact that at this point, she did have some very clinically significant anxiety. Usually, when people come to a psychiatrist, they believe that their symptoms are significant and that a medication is something that might be prescribed. But despite these symptoms, she still didn't wanna try the medicine.
MS. SPRAGUE: And what is the difference between a psychiatrist and a psychologist?
JENNIFER TUFTS: So a psychiatrist is a medical doctor. We go to medical school, and then we specialize in psychiatry. A psychologist does not go to medical school. They may do a lot of research in their training. They may learn a lot about psychotherapy. But they don't learn about the human body, about how we metabolize medications, and things like that.
MS. SPRAGUE: And so, a psychiatrist—can a psychiatrist prescribe medication?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Can a psychologist prescribe medication?
MS. SPRAGUE: Now, in the medical records, exhibit 219, page 47, it lists here recent lab work, no lab results were found. Is it that you had ordered lab work and you couldn't find the results, or that none were ordered?
JENNIFER TUFTS: None were ordered.
MS. SPRAGUE: And why is that?
JENNIFER TUFTS: It was not necessary.
MS. SPRAGUE: And why isn't it necessary at that point for Ms. Clancy to order blood work?
JENNIFER TUFTS: There's no blood work that is commonly done when a patient presents with generalized anxiety disorder and no other medical complications.
MS. SPRAGUE: What types of situations would you order blood work for?
JENNIFER TUFTS: I mean, there could be a lot. You know, certain medications require laboratory monitoring. Maybe something that, you know, could affect the kidneys or could affect the thyroid, could affect the cholesterol. These are things that we monitor to make sure that the medicine is prescribed safely.
MS. SPRAGUE: And so Zoloft, that's- is that not one of the ones that would need to be monitored because of its potential effects on the body?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: And at that time she reported to you she wasn't even taking it yet, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: And your appointment that day, I think according to the records, it was approximately 17 minutes long. Is that correct?
JENNIFER TUFTS: So can I explain that?
MS. SPRAGUE: Absolutely.
JENNIFER TUFTS: Because I think there's a bit of a misunderstanding. So the 17 minutes, I think people are looking at the note where it says a therapy start time of 10:00 AM, a therapy end time of 10:17, so they're calculating 17 minutes. But those timestamps are specifically related to the therapy portion of the exam. They're not reflective of the complete duration of time when I met with her.
MS. SPRAGUE: So what would be the complete time that you met with her on that day?
JENNIFER TUFTS: So I don't know the exact amount of minutes. But the appointments are 25-minute appointments, so it would be more or less a few minutes, about 25.
MS. SPRAGUE: And so the 17 minutes that are for the therapy portion of the appointment, what comprises therapy? What does that involve?
JENNIFER TUFTS: It really varies based on the person, based on the situation. It can involve, you know, providing some emotional support.
MR. REDDINGTON: I apologize. Can we talk about Lindsay Clancy rather than in general? That's all.
MS. SPRAGUE: It's admissible that-
THE COURT: I'm gonna allow a little bit of the background so that we ... then we'll move into the defendant.
MS. SPRAGUE: Thank you. So you were saying that therapy portion is kind of talking to the patient, seeing how they are, and getting an assessment of their current mental state?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And the other eight minutes, typically, what happens in those eight minutes?
JENNIFER TUFTS: That's more focused on specifically medications and medication management.
MS. SPRAGUE: So these appointments that you had with Lindsay Clancy, when it says 17 minutes, that's the therapy, the talk portion of the appointment, and then there was a separate portion where medication was discussed?
JENNIFER TUFTS: Yes. In the real world, those two segments are intertwined. So it's not necessarily that we say, "This is the end of your therapy component." It's a bit more seamless than that.
MS. SPRAGUE: Now in your training, experience and the way you conduct your practice, if you're having a therapy portion, or you're conducting therapy with a client and that 25 minutes has run out, is it a hard stop, or is there an option to continue?
JENNIFER TUFTS: It's not a hard stop. I do have limitations because I have other patients that are waiting. But if there's something urgent, I can go a little bit over. If there's an emergency, I can cancel the next patient if I have to.
MS. SPRAGUE: Okay. And these 25-minute appointments that you have, if a patient were to request a longer appointment with you, is that available?
JENNIFER TUFTS: It's an option.
MS. SPRAGUE: Did Lindsay Clancy ever request a longer appointment time with you?
MS. SPRAGUE: Now, that appointment on September 28th, 2022, was that also a virtual appointment?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did Ms. Clancy appear to be alone in that virtual appointment?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And based on your conversations and assessment of her on that day, what was the plan going forward?
JENNIFER TUFTS: So at this point, she was improving, and we decided to pause on the medication question and have her meet with one of our therapists.
MS. SPRAGUE: So that first appointment was on September 15th. You recommended therapy. The next appointment was September 28th. So had Lindsay not scheduled a therapy appointment yet with Jennifer McAllister at that point?
JENNIFER TUFTS: I'm not sure when she called to schedule that.
MS. SPRAGUE: Okay. And, but that was the plan going forward, that your recommendation was that she attend therapy with Jennifer McAllister?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did Ms. Clancy seem receptive to that plan?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did she tell you she was going to make an appointment with Ms. McAllister?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Now, according to the records, the next appointment was October 3rd, 2022, just five days later. Was there a reason that you had such a short time span between that September 28th appointment and the October 3rd appointment with Ms. Clancy?
JENNIFER TUFTS: I believe that the patient must have scheduled the appointment on her own, and that's why the span of time was rather short.
MS. SPRAGUE: Do you recall Ms. Clancy reaching out to you about getting paperwork for a maternity leave extension?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did she reach out to you through the portal for Aster Health?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did you respond to her on that portal?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did you fill out paperwork for her to extend her maternity leave?
JENNIFER TUFTS: I think that I did.
MS. SPRAGUE: So there is a message from Ms. Clancy to you on September 30th, 2022, in the portal that states, "Hi, Dr. Tufts. Thanks again for all your help at our last two appointments. While I'm feeling just better enough to function without medication, I did reach out to my employer about extending my leave for reasons of postpartum anxiety/depression. I don't feel mentally well enough to return to taking care of patients with a baby at home that still won't take the bottle. I know this will trigger my anxiety too much, and also having to stay up all night as a nurse, I don't feel it's possible right now. They asked that my provider could fill out a form so they could process this request. Can I please send you the form to fill out?" And you responded on September 30th, 2022, at 2:41 PM, "This type of paperwork often requires a lot of information, so it's best if we go through it together in an appointment." Do you recall that?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So would that have been why the October 3rd appointment was set up?
JENNIFER TUFTS: That may have been, yes.
MS. SPRAGUE: Okay. And then, do you recall receiving a message from Ms. Clancy on October 10th, 2022, stating, "Hi, Dr. Tufts. There is a part on the serious health condition form that you filled out for me that needs to be changed. On the second page you put I could work a reduced schedule of eight hours per day, two days per week. However, we discussed not working at all until January 1st. I think we talked about when I return to work, that is what I could do, but that, the way it appears on the form makes it seem like I can do that now. Do you still have the form to make the adjustment, or do I need to send it back to you?" And then, you responded that you would send back an updated version. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So do you recall having a conversation with Ms. Clancy at the October 3rd appointment about not returning to work and how long she should be out of work for?
JENNIFER TUFTS: I recall having a conversation about that.
MS. SPRAGUE: And that January 1st date, was that something you decided or something Ms. Clancy requested?
JENNIFER TUFTS: I think it was something that we decided together.
MS. SPRAGUE: And in that appointment on October 3rd, did Ms. Clancy tell you that she was on the verge of taking the medication?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did you discuss that with her?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was that discussion?
JENNIFER TUFTS: Well, she was having more anxiety again. It seemed like maybe it had started getting better, and then it was kind of where it had been when she initially reached out. And so she was feeling like a medication might be helpful.
MS. SPRAGUE: And did Ms. Clancy tell you at that appointment that she wanted to try therapy before taking the medication?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: But she had not, had an appointment with Jennifer McAllister yet, correct?
JENNIFER TUFTS: I'm not sure what date her first appointment was with Jennifer McAllister.
MS. SPRAGUE: Showing you page fifty-seven of exhibit two nineteen. An initial therapy assessment by Jennifer McAllister on October 3rd, 2022. Would that have been the first time she saw Ms. McAllister?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Okay. So that's on that same day that you saw her. It looks like from the records you saw her at 11:30. Is that correct?
JENNIFER TUFTS: I don't have the time on my paper, but I'm sure that's correct.
MS. SPRAGUE: Okay. So apparently she saw you about the work form, and then she had an appointment with Ms. McAllister. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And it says here in the records that Jennifer McAllister is an LMHC. What is that?
JENNIFER TUFTS: A licensed mental health counselor.
MS. SPRAGUE: And so is a counselor, a licensed mental health counselor, someone who can conduct therapy sessions?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And why is it in your practice that you have a psychiatrist who does therapy and prescribes medication, but in addition you would have a therapist doing counseling?
JENNIFER TUFTS: So today, a lot of psychiatry is practiced as a team. At least that's how we practice at my office. So oftentimes the therapist is able to see the patient every single week. They're able to focus in more depth on certain aspects of, you know, the patient's well-being. And so it's helpful to have one person paying extra attention to the therapy component, especially when the psychiatrist does have to spend a lot of time discussing the medications and thinking about the medications.
MS. SPRAGUE: And so is that the teamwork approach that Lindsay Clancy received in her treatment at Aster Mental Health?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And in that October 3rd assessment with Ms. McAllister, you reviewed those notes and records so that you could properly treat Ms. Clancy, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And in that first meeting with Ms. McAllister, the defendant described her relationship with her parents as very supportive and stable, correct?
JENNIFER TUFTS: I don't have doc- Jennifer's notes in front of me.
MS. SPRAGUE: It's only on page 60. You wanna just review the notes?
JENNIFER TUFTS: Sure.
MS. SPRAGUE: You look up when you're finished. Does that refresh your memory as to the notes that you reviewed from her—from Lindsay's session with McAllister?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And so in that session, Ms. Clancy stated that her parents were very supportive and stable?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Okay. And she also mentioned having the support of an older sister who only lived two and a half hours away. Is that correct?
JENNIFER TUFTS: That's what she stated in the note to Jen.
MS. SPRAGUE: Yeah. Did she also say that she was not close with her in-laws who lived in Scituate? She would see them often as they were her husband's parents, but they don't—she didn't generally allow them to watch the children. Is that correct?
JENNIFER TUFTS: That's what I read.
MS. SPRAGUE: Yeah. And there's a quote in here, "Don't have a particular reason why. They don't bug me about it either." Is that correct?
JENNIFER TUFTS: That's what I read.
MS. SPRAGUE: And October 3rd, 2022, when you met with her that day, did you again do a mental status exam?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Had anything changed in that mental status exam from the September 28th meeting that you had with her?
JENNIFER TUFTS: Can I review it?
MS. SPRAGUE: Yes.
JENNIFER TUFTS: I mean, there isn't anything that stands out to me right now.
MS. SPRAGUE: And I think that what you put on the October 3rd date was that her insight was still poor.
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And was that for the same reasons you described earlier?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: The next time that you saw Ms. Clancy, was that on October 20th, 2022?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what information did you learn on that date about whether or not she was taking the Zoloft you had prescribed?
JENNIFER TUFTS: So she told me that she decided to start the Zoloft.
MS. SPRAGUE: And did she tell you how long she had been taking it?
JENNIFER TUFTS: For one week.
MS. SPRAGUE: And did she tell you that the previous night she had increased the dose?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And that's what was in the original prescription, correct? To take the pills at 25 milligrams for one week, and then increase to 50?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So if that had been done, taking the seven pills, taking the pills for one week would be the seven pills, and then increasing the dosage the next night would be two pills?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And so that would be nine pills?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: When she told you she increased the dose, she told you she now feels awful. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was it that was bothering her?
JENNIFER TUFTS: She was having increased difficulty sleeping. She had loss of appetite, diarrhea. She was feeling her mood was down. She was tearful and feeling very foggy and feeling very anxious.
MS. SPRAGUE: Now, what is the lowest dose of Zoloft that you would prescribe a patient or could prescribe?
JENNIFER TUFTS: The smallest pill is 25.
MS. SPRAGUE: And what's the highest dose of Zoloft?
JENNIFER TUFTS: 200.
MS. SPRAGUE: Okay. So she was on the lowest dose of 25, is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And then, according to what she told you, she had increased for one night to 50 milligrams. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did she also tell you she was scared to start something new?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Is that in terms of another medication?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So what was your discussion with Ms. Clancy when she's telling you that she's having these issues with Zoloft, but she's afraid to try something new?
JENNIFER TUFTS: So we discussed what to do moving forward. So we discussed whether it would make sense to switch to a different medication at that point. And at that moment, because of her negative experience with the Zoloft, she did not want to start a new medication at that point.
MS. SPRAGUE: At this meeting with her, did you ask her if she had any suicidal thoughts?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What was her response?
MS. SPRAGUE: Did you ask her if she had any homicidal ideation or thoughts?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What was her response?
MS. SPRAGUE: Did you ask her if she was hearing any voices or seeing any visual hallucinations?
JENNIFER TUFTS: I'm not sure if I asked that in that appointment, but she was very clearly not psychotic.
MS. SPRAGUE: And why do you say that?
JENNIFER TUFTS: Because of how I described some of the signs of psychosis that are on the mental status exam. None of those were present.
MS. SPRAGUE: Okay. What was her affect during this meeting?
JENNIFER TUFTS: It was depressed.
MS. SPRAGUE: And did you write that she w-? Strike that. What was it about her affect that made you write that she was depressed?
JENNIFER TUFTS: She visually appeared like she was feeling sad.
MS. SPRAGUE: And her mood, how did she report that to you?
JENNIFER TUFTS: That was depressed as well, and anxious.
MS. SPRAGUE: What about her thought content and process that day?
JENNIFER TUFTS: That was appropriate.
MS. SPRAGUE: And her speech?
JENNIFER TUFTS: It was appropriate.
MS. SPRAGUE: And her judgment and cognitive skills?
JENNIFER TUFTS: Her judgment was excellent, and her cognition didn't have any deficits.
MS. SPRAGUE: And her psychomotor activity?
JENNIFER TUFTS: Normal.
MS. SPRAGUE: So the main change here from previous visits was that she appeared depressed and anxious.
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Although she had appeared anxious that first visit, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So to make sure we have the timeline correct, the first visit she appeared anxious. The second visit she appeared to be doing better. The third visit, she still had that poor insight, when you met about the paperwork, and then this fourth visit she appears depressed. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did she also tell you that she was worried about getting suicidal thoughts?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So that would have come directly from her, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what were the details of that conversation?
JENNIFER TUFTS: So it was one of the things that she was anxious about. It was a fear of one day having suicidal thoughts if she were to continue to feel poorly.
MS. SPRAGUE: Okay. And showing you page 77 of exhibit 219. I know you said earlier you weren't sure if you asked her about audio or visual hallucinations, but just directing your attention to the interval history, if that refreshes your memory.
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So did you ask her about audio hallucinations and visual hallucinations?
JENNIFER TUFTS: On the 21st I did.
MS. SPRAGUE: Okay. All right. So then there was an appointment the following day on October 21st?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So why did she have an appointment that following day?
JENNIFER TUFTS: Because she was feeling pretty poorly after starting the Zoloft, so we were following her closely.
MS. SPRAGUE: And at that point you knew that she had had an appointment on the 3rd with Ms. McAllister, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And do you know whether or not she had followed up making another appointment or was struggling with that?
JENNIFER TUFTS: I... She was planning on making another appointment. I don't know when that second appointment was scheduled.
MS. SPRAGUE: That first appointment, where she was seeming depressed and having issues with Zoloft on October 20th, did you tell her to stop taking the medication at that point?
JENNIFER TUFTS: Yes, I did.
MS. SPRAGUE: Okay. And did you discuss other options with her other than medication, like natural remedies?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what type of natural remedies did you discuss with Ms. Clancy?
JENNIFER TUFTS: So I mentioned things like fish oils, something called L-methylfolate or SEAM. These are supplements.
MS. SPRAGUE: And is that- Why would you offer alternative remedies to a patient?
JENNIFER TUFTS: So it was because she seemed reluctant to start a prescribed medication. I thought she might be more open to something that was natural.
MS. SPRAGUE: So you weren't pushing her to take a prescription medication, correct?
MS. SPRAGUE: Now, on October 21st when you saw her, did she tell you that she had—hadn't been able to get any sleep the night before?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: You've already said she told you she wasn't having audio or visual hallucinations, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did you ask her if she was having suicidal ideation or homicidal ideation?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was her response?
MS. SPRAGUE: What was her affect that day?
JENNIFER TUFTS: It was depressed.
MS. SPRAGUE: And did she tell you during your conversation that day that she had been anxious all day, not depressed or irritable, getting better?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Okay. So she's telling you she's not depressed, but her affect to you appeared depressed. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And is that for the same reasons you stated earlier, those visual cues that you saw?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did she appear hyper or manic in any way?
MS. SPRAGUE: Was there any changes in her rate of speech or pattern of speech?
MS. SPRAGUE: Was there any difference in her mental status exam?
MS. SPRAGUE: And this appointment, was this appointment virtual as well?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Had all your appointments up to this point been virtual?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Was she alone in that virtual meeting?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What was the plan that was formulated on October 21st?
JENNIFER TUFTS: So the plan was that she start a medication called Ativan, to be taken as needed, which means not necessarily every day, but in the instance of severe anxiety.
MS. SPRAGUE: And how did you explain to Ms. Clancy when to take the medication?
JENNIFER TUFTS: I don't, I don't remember exactly how I explained that.
MS. SPRAGUE: Okay. So in general, as a psychiatrist, when you're prescribing a medication like Ativan and you're telling a patient to take as needed, what does that mean?
JENNIFER TUFTS: So it means when the symptoms are present and, in this case in particular, when the symptoms are severe.
MS. SPRAGUE: So with Ms. Clancy, what were the symptoms that she was experiencing that made you decide that Ativan would be an appropriate medication?
JENNIFER TUFTS: Anxiety.
MS. SPRAGUE: So would it be when she was feeling anxious, feeling those symptoms of anxiety, that she should take the medication?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was the dose again?
MS. SPRAGUE: What's the lowest dose of Ativan you can give?
MS. SPRAGUE: What's the highest dose?
JENNIFER TUFTS: Maybe two.
MS. SPRAGUE: Okay. So you started her at the lowest dose, the .5?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And was there a specific timeframe that you wanted her to try this in?
JENNIFER TUFTS: Yes, this was for one week.
MS. SPRAGUE: And was the prescription for a one-week amount, or is it hard to tell that because it's as needed?
JENNIFER TUFTS: It's hard to tell that without seeing exactly how many pills were prescribed.
MS. SPRAGUE: And was there also, again, a recommendation to go to Ms. McAllister for therapy?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And when were you recommending follow-up with Ms. Clancy?
JENNIFER TUFTS: One week.
MS. SPRAGUE: And why a short turnaround at this point?
JENNIFER TUFTS: Because she was still having very significant symptoms.
MS. SPRAGUE: And did you in fact see her on October 26th, 2022?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And at that appointment, what was Ms. Clancy's affect?
JENNIFER TUFTS: Depressed.
MS. SPRAGUE: What was her mood according to her?
JENNIFER TUFTS: It was anxious and depressed.
MS. SPRAGUE: And did you discuss with her whether the Ativan, whether she was taking the Ativan and whether it was working?
JENNIFER TUFTS: She said that it was not helpful for her sleep, but it made her feel less anxious.
MS. SPRAGUE: And in this appointment there was a discussion of Benadryl, is that correct?
JENNIFER TUFTS: So she reported that Benadryl was something she had tried, and it was helpful. It was taken over the counter.
MS. SPRAGUE: Had you recommended or told her to take the Benadryl at that point?
JENNIFER TUFTS: I don't think so.
MS. SPRAGUE: And so when you met with her and she told you that she had taken the Benadryl and it had helped, what was your reaction to that?
JENNIFER TUFTS: I was glad that something was helping.
MS. SPRAGUE: And did she tell you how often she was taking it or how much of it she was taking?
JENNIFER TUFTS: I don't recall.
MS. SPRAGUE: Yeah. Did you ask her that day if she had any suicidal or homicidal ideation?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was the response?
MS. SPRAGUE: Did you see any signs of psychosis that day?
MS. SPRAGUE: Up to that point on August—sorry, October 26th, 2022, had you ever had any difficulties in communicating with Ms. Clancy?
MS. SPRAGUE: Any, ever any difficulties understanding her or thinking she wasn't understanding what you were saying?
MS. SPRAGUE: At this appointment on October 26th, 2022, did she tell you that she had scheduled an appointment for therapy with Ms. McAllister?
JENNIFER TUFTS: I don't remember. Oh, yes, she did. She said she has an upcoming appointment.
MS. SPRAGUE: And what was the plan after meeting with Ms. Clancy on the 26th?
JENNIFER TUFTS: So at that point we discussed trying a new medication, because she felt that whatever side effects were caused by the Zoloft had resolved, but she still had the same anxiety that she had had beforehand. So we discussed starting the medication Buspar at five milligrams twice a day.
MS. SPRAGUE: And what is the lowest dose of Buspar?
JENNIFER TUFTS: Five milligrams.
MS. SPRAGUE: And what is the highest dose you can prescribe?
JENNIFER TUFTS: The pills probably come up to 30, and multiple 30 pills taken per day.
MS. SPRAGUE: So you could prescribe someone more than 30 milligrams per day?
JENNIFER TUFTS: Like a total dose of 60.
MS. SPRAGUE: Okay. So you started her again at the lowest dose?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And why did you choose Buspar?
JENNIFER TUFTS: So Buspar is very well-tolerated. It's a very mild medicine, especially for someone who is experiencing side effects from another medication.
MS. SPRAGUE: And what does Buspar do?
JENNIFER TUFTS: It lowers anxiety.
MS. SPRAGUE: And was she to continue taking the Ativan with the Buspar?
JENNIFER TUFTS: She could continue taking it as needed if she were to have those extreme moments of anxiety.
MS. SPRAGUE: So would it be that the Buspar was twice a day, and then if things—if she felt really anxious, she could take an Ativan?
JENNIFER TUFTS: Yes, because given that low dose of the buspirone, it might not have been enough of a dose to be effective right away.
MS. SPRAGUE: And Buspar and buspirone are the same thing?
JENNIFER TUFTS: Yes. Sorry.
MS. SPRAGUE: There's also a note in here prescribing hydroxyzine 25 milligrams daily as needed for anxiety. What is that?
JENNIFER TUFTS: Hydroxyzine is an antihistamine. It's similar to the Benadryl that she had been taking for sleep. So I recommended that she try the hydroxyzine. It is a safer medicine to take compared to the Ativan. So if someone is feeling very anxious, and they can take a hydroxyzine and that prevents them from needing to take the Ativan, that's good. So I wanted her to at least try that option instead.
MS. SPRAGUE: So you gave her several options on how to deal with the anxiety as it appeared each day. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And why take hydroxyzine, which is an antihistamine, instead of just taking the Benadryl?
JENNIFER TUFTS: So they're very similar, but hydroxyzine is indicated for anxiety, whereas Benadryl is really indicated for allergies.
MS. SPRAGUE: And you discussed this plan with Ms. Clancy, and did she agree to that plan?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And in discussing it with her, did you go over all the possible side effects and the interactions of the medications that you had prescribed?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did she voice any concerns about any of that?
JENNIFER TUFTS: No. I mean, I think she was still apprehensive about starting a new medicine and about potential side effects.
MS. SPRAGUE: But just—
JENNIFER TUFTS: But nothing specific.
MS. SPRAGUE: So it was a general concern about medication in general?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: But after you had the conversation and explained what you were recommending and prescribing, did she agree to that plan?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And was there any change in her mental status that day?
MS. SPRAGUE: Now, going to the next time that you saw Ms. Clancy, was that October 30... I'm sorry. Was her next appointment on October 31st with Jennifer McAllister?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So you were able to review in the records, in preparation for your next appointment, that she had in fact went to a therapy appointment. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And the therapy appointment, was that approximately an hour-long appointment with Ms. McAllister?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: When was your next appointment with Ms. Clancy?
JENNIFER TUFTS: November 2nd.
MS. SPRAGUE: And on that date, was that also a virtual appointment?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Do you know whether the therapy appointment with Ms. McAllister was in person or virtual?
JENNIFER TUFTS: I'm not 100% sure, but I think it was virtual.
MS. SPRAGUE: Okay. And up to this point, had Ms. Clancy ever told you that she didn't want to do virtual, that she wanted to come in in person?
MS. SPRAGUE: Now, on this November 2nd appointment, did you have a discussion about the Buspar?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was that discussion?
JENNIFER TUFTS: So she did not start it. She was too afraid to start a new medication.
MS. SPRAGUE: Did she tell you that she had continued with the Ativan and the Benadryl?
JENNIFER TUFTS: She said she continued with the Ativan.
MS. SPRAGUE: Ativan. Was there any further discussion about the Benadryl or the other antihistamine that you had prescribed, the hydroxyzine? I hope I'm saying that correctly.
JENNIFER TUFTS: You are. And I'm not sure. I don't think there was much conversation about the Benadryl or the hydroxyzine.
MS. SPRAGUE: And what was her affect that day?
JENNIFER TUFTS: It appeared appropriate.
MS. SPRAGUE: And what was her mood? How did she report feeling?
JENNIFER TUFTS: Euthymic.
MS. SPRAGUE: What does that mean?
JENNIFER TUFTS: Euthymic means a normal mood, not necessarily sad or angry or euphoric. It's just kind of neutral, in the middle.
MS. SPRAGUE: And would that have been a word coming from Ms. Clancy or just how you descri- the word you use to describe?
JENNIFER TUFTS: It's a clinical word.
MS. SPRAGUE: Clinical. And did you ask her if she had any suicidal or homicidal ideation?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What was her response?
MS. SPRAGUE: Did you see any signs of psychosis present in her that day?
MS. SPRAGUE: That day, did you discuss alternatives to Ativan?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And why were you discussing alternatives to the Ativan?
JENNIFER TUFTS: Because Ativan was not a medication I intended her, for her to be taking for a long period of time. It was a short-term medication.
MS. SPRAGUE: And why is that?
JENNIFER TUFTS: Because it does have a risk of dependency when people take it for a long period of time and especially at high doses.
MS. SPRAGUE: So did you bring up this discussion about alternatives to Ativan, or did Ms. Clancy ask about it?
JENNIFER TUFTS: I think that was something I brought up.
MS. SPRAGUE: And what were the alternatives that you discussed with her?
JENNIFER TUFTS: Remeron, trazodone, pregabalin, and hydroxyzine.
MS. SPRAGUE: And what was it about those medications that you thought they would be appropriate for Ms. Clancy?
JENNIFER TUFTS: That they might be safer medications that could also help her with sleep, also help her with some of the anxiety.
MS. SPRAGUE: And how are they safer?
JENNIFER TUFTS: So they don't have that risk of the dependency.
MS. SPRAGUE: And while you're interacting with her and discussing the alternative to Ativan, what was her mental status that day? Was there any change in it?
MS. SPRAGUE: And so after this discussion with her about the alternatives, was there a decision made on how to proceed?
JENNIFER TUFTS: Yes. So we discussed tapering the Ativan by .25 milligrams every two weeks.
MS. SPRAGUE: And what does tapering mean?
JENNIFER TUFTS: It means slowly reducing.
MS. SPRAGUE: And why do you slowly reduce a medication?
JENNIFER TUFTS: So when you are taking Ativan, like I mentioned, the risks of dependency, there's also risks of withdrawal symptoms if a medication like that is abruptly stopped. So that's why we gradually decrease it.
MS. SPRAGUE: And so if the plan was to decrease it by .25 milligrams a week, what amount was she taking per week?
JENNIFER TUFTS: So it was by .25 milligrams every two weeks.
MS. SPRAGUE: Oh, two weeks. Okay.
JENNIFER TUFTS: So at first we were decreasing it from one to .75.
MS. SPRAGUE: Okay. So it was a one milligram pill that she was taking, and then she would just take less and less and less until she wasn't taking it any longer?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Okay. And then had you, with Ms. Clancy, decided on a replacement for the Ativan?
JENNIFER TUFTS: At this point I don't think there was a medicine that we had decided on.
MS. SPRAGUE: Okay. So the plan at that point was just to taper off the Ativan, but nothing was added at that point?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did you next see Ms. Clancy on November 22nd, 2022?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And do you recall why there was a 20-day gap in between seeing her on the 2nd and then seeing her on the 22nd?
JENNIFER TUFTS: Well, I'm not sure. I would really be guessing if I said.
MS. SPRAGUE: Okay. Did you learn at that appointment on November 22nd of 2022 that Ms. Clancy had started another program?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what program was that?
JENNIFER TUFTS: It was a South Shore Perinatal Mental Health Clinic.
MS. SPRAGUE: And was that the first that you learned of Ms. Clancy being involved in that program?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did she tell you she was thinking about doing it or that she was already enrolled in that program?
JENNIFER TUFTS: That she was enrolled in it, and that, what it sounded like she was going to be transferring her care there.
MS. SPRAGUE: Okay. And did she tell you that she was starting a new medication?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What did she tell you she was starting?
JENNIFER TUFTS: She said she was going to start Prozac.
MS. SPRAGUE: And did she also tell you that she, what she was currently using for medication?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was that?
JENNIFER TUFTS: The Ativan and the Benadryl.
MS. SPRAGUE: And did she tell you that was for sleep as needed?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And so, you had put in place a plan on November 2nd to taper off the Ativan, but on November 22nd, she was still on the Ativan. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And had she tapered off or reduced the dose to your knowledge?
JENNIFER TUFTS: I don't, I don't have it documented exactly what dose she was taking on that date other than she was just taking, still taking the medicine.
MS. SPRAGUE: Still taking it. Okay. On that date, did Ms. Clancy deny suicidal and homicidal ideation?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did she show any signs of psychosis?
MS. SPRAGUE: Did she also tell you that she was going to be transferring her therapy care to that South Shore Perinatal Health Clinic?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So basically at that point, the plan was for her to receive her mental health care at the South Shore Perinatal Clinic and no longer see you?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Was that the plan? Okay. Was there also discussion of a return to work letter that day?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did she request that from you?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did you give her a return to work letter?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And was that authorizing her to return to work immediately or on January 1st as the previous form had said?
JENNIFER TUFTS: I don't remember what date it was for her to return to work. I don't think it was immediate.
MS. SPRAGUE: Did you then have a further appointment with Ms. Clancy on December 1st, 2022?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And how is it that, you know, she was planning on transferring care to the South Shore Perinatal Clinic on November 22nd, but then on December 1st, she has an appointment with you?
JENNIFER TUFTS: So patients can schedule their own appointments. I'm not involved in the scheduling. I can schedule a patient an appointment if someone asks me to, but they can schedule it without my awareness. So she had scheduled it.
MS. SPRAGUE: Okay. So she hadn't reached out to you in advance to ask about it. She just scheduled an appointment with you for December 1st, 2022. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Okay. And in that appointment, did she tell you that she ended up not returning to work?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was discussed at that appointment?
JENNIFER TUFTS: That she wasn't getting better.
MS. SPRAGUE: And in what ways wasn't she getting better?
JENNIFER TUFTS: She had tried the Ativan taper. But without the Ativan, she was having a lot of difficulty sleeping. So she tried a few different medications, a few different medication combinations. But she was having trouble with them.
MS. SPRAGUE: And did she tell you what types of medication she had tried?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what were those?
JENNIFER TUFTS: Trazodone, 50 to 150 milligrams, was minimal effect. Ativan and Benadryl combination was helpful. Then she added the Prozac 10 milligrams with the Ativan and Benadryl to help with the sleep. But she still had worse sleep, so that was stopped. Then she tried a combination of Remeron with Klonopin. But she felt disoriented, had rebound anxiety, and it was of minimal help. Then she tried Remeron and Seroquel. And I... Actually, that was prescribed, but she didn't take it.
MS. SPRAGUE: And these medications that she was talking to you about, those weren't prescribed by you, correct?
JENNIFER TUFTS: Correct.
MS. SPRAGUE: Did she tell you that those had been prescribed by her provider at South Shore Perinatal Clinic?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what is Trazodone?
JENNIFER TUFTS: It is... The category is an antidepressant, but the doses that we use are low, so it's really a sleep medicine.
MS. SPRAGUE: And what is the lowest dose of Trazodone?
MS. SPRAGUE: And what is the highest?
JENNIFER TUFTS: It can go very high, up to maybe 600.
MS. SPRAGUE: Okay. So the 50 to 150 milligrams that Ms. Clancy told you she had taken, is that on the lower end of the dosage?
JENNIFER TUFTS: Yes. It's the commonly prescribed dose, again, because it's mostly used as a sleep medicine. So those are the normal ranges.
MS. SPRAGUE: Okay. And Prozac, I think you had said earlier, was an SSRI?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And that was a medication Ms. Clancy had told you she had taken in nursing school, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: With no side effects then?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And she told you on December 1st, 2022, that the Prozac had worsened her sleep?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And then what is Remeron?
JENNIFER TUFTS: Remeron is Mirtazapine.
MS. SPRAGUE: And what's that?
JENNIFER TUFTS: It's another antidepressant.
MS. SPRAGUE: And what is Klonopin?
JENNIFER TUFTS: It is a benzodiazepine like the Ativan.
MS. SPRAGUE: So prescribing Remeron for, as an antidepressant and Klonopin as an anxiety medication, is that an unusual combination?
MS. SPRAGUE: And then she told you she had been prescribed Remeron and Seroquel but hadn't started that, correct?
JENNIFER TUFTS: So I think she had started the Remeron, but maybe hadn't started the Seroquel yet.
MS. SPRAGUE: Okay. And did she also tell you that she was having some intrusive thoughts on the Remeron so she was planning on stopping?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did she tell you what those intrusive thoughts were?
JENNIFER TUFTS: She said it was, "It was a feeling like I'm going to die."
MS. SPRAGUE: Not a feeling that she wanted to kill herself, but a feeling like she was going to die?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did she... Did you ask her if she had suicidal ideation?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What was her response?
JENNIFER TUFTS: So she denied having suicidal ideation. But she was feeling pretty badly. She said she was close to it, meaning close to having some suicidal thoughts, and that she was feeling very hopeless. But she didn't have any active thoughts of hurting herself, didn't have any intention of doing anything, didn't have any plans.
MS. SPRAGUE: Did she also tell you, and this is a quote in the records on page 144, "I think it's my problem. I keep reaching out to different people and not sticking with the plan"?
JENNIFER TUFTS: That's what I documented.
MS. SPRAGUE: Okay. And did you discuss that with her, that concern that she kept reaching out to different people and wouldn't stick with the plan?
JENNIFER TUFTS: Yes. I advised that she have one person who is managing the medications.
MS. SPRAGUE: And why is that important?
JENNIFER TUFTS: So that it's very clear what's happening.
MS. SPRAGUE: And what is the importance, if any, of sticking with a plan, a mental health plan?
JENNIFER TUFTS: Well, the importance of sticking with a plan, you know, obviously the psychiatrist comes up with a plan for very particular reasons. And so, you know, sticking with the plan is advisable.
MS. SPRAGUE: When you prescribe psychiatric medications, do those medications take effect immediately?
MS. SPRAGUE: How do they... How does that effect start to happen in a person?
JENNIFER TUFTS: Well, it depends which medicine. Some medicines do work very quickly, like the benzodiazepines, Ativan and Klonopin. But the medicines that prevent anxiety, the medicines that prevent depression, those do take a long time to actually kick in.
MS. SPRAGUE: And why is that?
JENNIFER TUFTS: So the way that the medications interact with the brain, the serotonin receptors, the way that they change the neurotransmitters, it takes time for those changes to happen.
MS. SPRAGUE: Okay. Now, was there... Did you also talk to Ms. Clancy about bipolar disorder that day?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And why did you do that?
JENNIFER TUFTS: So it was mentioned because of the poor reaction she had had to some of her medications, the insomnia. So we discussed whether these side effects she was experiencing indicated she had bipolar disorder. But when that was assessed, it was not deemed that she had bipolar disorder.
MS. SPRAGUE: And why was that?
JENNIFER TUFTS: Because she really didn't meet the criteria.
MS. SPRAGUE: And which—what criteria didn't she meet?
JENNIFER TUFTS: So there's a number of different criteria for bipolar disorder or, you know, specifically looking at mania because she did have some symptoms of depression, but the other side is mania. So the most important one is euphoria. So actually seven days of continued euphoria with very high energy levels. That's the most important one. But then in addition to that, you need some other things like potentially pressured speech, grandiosity, which is like a person feeling superhuman or godlike. You might see increased risk-taking behaviors. Usually those are significant risks, like somebody having affairs or using drugs, things that really negatively impact their life. The person might have a decreased need for sleep, which is not just insomnia, but it's truly not needing the sleep and having enormous amounts of energy otherwise.
MS. SPRAGUE: What is pressured speech?
JENNIFER TUFTS: It means talking very fast, so fast that it's really hard to interrupt them.
MS. SPRAGUE: And did you ask Ms. Clancy on December first questions that would potentially elicit whether or not she met that criteria?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did any of her responses to your questions indicate any instances of mania in her past or present?
MS. SPRAGUE: What was the plan going forward from that day?
JENNIFER TUFTS: So at this point, she was still seeing the doctors or the providers at South Shore, and so they were still managing her medications. So the plan was that she had an appointment with them tomorrow. She was considering taking the Remeron with... Or sorry, considering taking the Seroquel without the Remeron because she had had side effects with that, but that wasn't decided on. That was something to consider. And we also talked about starting a medicine called Lamotrigine. I just gave her some information about the medicine. And we also talked about her going to a partial hospitalization program, which provides extra support for people who are really struggling.
MS. SPRAGUE: Lamotrigine, is that Lamictal?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did you prescribe it to her that day or just discuss that option with her?
JENNIFER TUFTS: Just discussed on that day.
MS. SPRAGUE: And why did you discuss that option with her?
JENNIFER TUFTS: Because it was clear that she had depressive symptoms, and she was not tolerating some of the other antidepressants. So I thought that that might be another option to explore.
MS. SPRAGUE: And you also discussed with her a partial hospitalization program?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And why did you do that?
JENNIFER TUFTS: Because she was really having a hard time. She had, you know, mentioned those thoughts of feeling hopeless and the intrusive thoughts. So I referred her to a program that would provide extra support. It would be a program that she went to every single day. Not hospitalized. She could still stay at home and be with her family, but that she would have all-day care every day for, you know, as long as that was needed.
MS. SPRAGUE: And what program was that that you referred her to?
JENNIFER TUFTS: The HRI program.
MS. SPRAGUE: What does HRI stand for?
JENNIFER TUFTS: It's a hospital. I'm not sure what it stands for.
MS. SPRAGUE: And where is that program located?
JENNIFER TUFTS: It's in Massachusetts. I think Brookline.
MS. SPRAGUE: And when you referred her, when you talked about that program with Ms. Clancy and referred her to that program, what was her response?
JENNIFER TUFTS: Well, I gave her the information for it. It's a program where the patient can call and schedule their intake appointment, so I gave her that information.
MS. SPRAGUE: And was there any concern at that point— You had mentioned earlier that it's important to have, you know, one provider prescribing medication, knowing what you're taking. You knew she was going to the South Shore prenatal program. Was there any concern about discussing medications with her, like Lamictal, on the first when you knew she was seeing these other providers?
JENNIFER TUFTS: Well, she continued to see me in more of a supportive role. And I was just trying to help her, give her as much information that could potentially be helpful. So it was something for her to discuss with the other providers.
MS. SPRAGUE: Did you ever reach out to South Shore or, to get those records or ask Lindsay for some type of waiver to get the South Shore records?
JENNIFER TUFTS: No, I didn't. And, you know, the reason why is because she was very aware of what the medications were. She was very, very able to communicate what the different treatment decisions were. She was very medically sophisticated. So I didn't think it was necessary.
MS. SPRAGUE: And you were aware she was a labor and delivery nurse, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So you were aware she was familiar with medications, and she was able to communicate with you on a level that's not a typical patient, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did you next see her on December 16th, 2022?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did you make that appointment for her, with her, or did she reach out, as she did on the December 1st and make her own appointment?
JENNIFER TUFTS: I'm not sure.
MS. SPRAGUE: Okay. And that appointment on December 16th, 2022, what did you discuss with her that day?
JENNIFER TUFTS: So she was still not feeling well. She said, "I'm having a really rough time." Though it… she said she found something that was helpful for her sleep, Valium and quetiapine, which is Seroquel. She said it finally works, but feeling very depressed during the day. No motivation. Had some SI, so a suicidal ideation. So she went to Mass General Emergency Room, declined inpatient. She was feeling hopeless but didn't have any intent or suicidal plans.
MS. SPRAGUE: So when she told you that she had had some suicidal ideation, did you ask her specifics about that?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was her response?
JENNIFER TUFTS: So she described it as this hopelessness, like a fear of not getting better.
MS. SPRAGUE: Did she have a plan to kill herself or a plan of how to kill herself?
MS. SPRAGUE: And you mentioned she told you she went to Mass General Hospital Emergency Department because of these feelings. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did she tell you that they had offered her an inpatient program at McLean and she had turned them down?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did she tell you why she turned them down?
JENNIFER TUFTS: I don't remember.
MS. SPRAGUE: Did she tell you about plans… Well, did she tell you what she was taking for medication at that point and the plans for medication?
JENNIFER TUFTS: She said she was taking a mixture of the Valium and the quetiapine. And there was a plan to increase the quetiapine, but currently she was taking 200 milligrams.
MS. SPRAGUE: And did she also talk to you about the women and infants program in Rhode Island?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what did she tell you about that?
JENNIFER TUFTS: She said that she was referred and appointments were being scheduled.
MS. SPRAGUE: And were you familiar with that program?
JENNIFER TUFTS: I've heard about it.
MS. SPRAGUE: Okay. What type of program is it?
JENNIFER TUFTS: It's one of those partial hospitalization programs that I had mentioned. But it is focused on postpartum. So I thought that that was a good fit.
MS. SPRAGUE: Did she tell you during this appointment that she thought that her depression was related to the Seroquel?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did she tell you why she thought that?
JENNIFER TUFTS: She thought there was some coinciding of the timing in which she started the Seroquel and started feeling more depressed.
MS. SPRAGUE: And did you note in the records that it was unclear if Seroquel was causing the depression as reported, she was more depressed the last visit before taking it?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Can you just explain that, what your observations were?
JENNIFER TUFTS: Yeah. I wasn't sure if the Seroquel was making her worse, because she did already seem depressed before she had started the Seroquel. So I just ... I wasn't sure. I thought it was possible, but ...
MS. SPRAGUE: What was the plan going forward from that appointment?
JENNIFER TUFTS: So the plan was for her to go to this women and infants program. And if she was having more suicidal thoughts, to go back to the emergency room.
MS. SPRAGUE: And was she also planning to start Lamictal 25 milligrams daily?
JENNIFER TUFTS: Yes. At that moment, given how the depression was continuing and worsening, I did feel like after we had discussed the Lamictal numerous times, that I did need to step in and prescribe that for her.
MS. SPRAGUE: And you prescribed the 25 milligram daily dose for her?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What's the lowest level of Lamictal that you would prescribe?
MS. SPRAGUE: And what's the highest?
JENNIFER TUFTS: So in psychiatry, typically 200. But, I mean, it really can go up to 400 or 500.
MS. SPRAGUE: And so again, you prescribed the lowest dose to start with, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And was she to continue with the Seroquel that she had been prescribed by the South Shore Perinatal Program?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what about Valium?
JENNIFER TUFTS: So, I didn't make a recommendation on the Valium. I think there was a plan already in place on tapering it that I supported.
MS. SPRAGUE: And did you do anything in terms of reaching out to her providers at South Shore Perinatal to let them know you were adding a prescription? Or did you communicate with Ms. Clancy about letting her providers know?
JENNIFER TUFTS: I communicated with Lindsay about that. And she was so good at giving me all of these updates about what she did with them. I figured she would tell them when she next saw them.
MS. SPRAGUE: And did she tell you that she would update them?
JENNIFER TUFTS: I believe so.
MS. SPRAGUE: Was the next time you saw Ms. Clancy on January 6th, 2023?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And how did that appointment come about?
JENNIFER TUFTS: So again, I don't often do the scheduling. I'm not sure exactly whether I had scheduled that or she had.
MS. SPRAGUE: Did you learn during that appointment that Ms. Clancy had just been discharged from McLean Hospital?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what, if anything, did Ms. Clancy tell you about her current mental state and what had happened between your last appointment on December 16th and now this appointment on January 6th?
JENNIFER TUFTS: So, she was continuing to feel depressed and attributing it to the Seroquel that she had been taking. So, the idea was going to McLean so that she could be safely taken off of the Seroquel.
MS. SPRAGUE: And was it at McLean, according to Ms. Clancy, that she had tapered off the Seroquel?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And so on January 6th, did she tell you what she was prescribed at that time?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was that?
JENNIFER TUFTS: Trazodone 100 milligrams, Ativan one milligram, and melatonin five milligrams.
MS. SPRAGUE: Okay. And are these all low doses of these medications?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did you ask her if she had current suicidal ideation?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what did she say?
MS. SPRAGUE: Did you ask her if she had homicidal ideation?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was her response?
MS. SPRAGUE: Did you observe any signs or symptoms of psychosis in her presentation, answers, or behavior?
JENNIFER TUFTS: No, I did not.
MS. SPRAGUE: Did you ask her about whether she was having side effects from these medications, the Trazodone, and the Ativan and the melatonin?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What was her response?
JENNIFER TUFTS: So the only side effect she felt was that, potentially when the Ativan would wear off, she would take it at night, and then in the morning it would wear off, and she would feel more anxious after it wore off.
MS. SPRAGUE: And in terms of the Trazodone, did she say she had any side effects from the Trazodone?
MS. SPRAGUE: And melatonin, what is melatonin?
JENNIFER TUFTS: Melatonin is a chemical that the brain makes that tells us it's time to go to sleep. It's associated with the circadian rhythm. It's not a prescription, actually. It's a medicine that you can pick up in, over the counter at the pharmacy.
MS. SPRAGUE: And is it just to help regulate sleep?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: What was her mood, according to Ms. Clancy on that date?
JENNIFER TUFTS: She was feeling numb.
MS. SPRAGUE: Numb?
JENNIFER TUFTS: Numb.
MS. SPRAGUE: Did that cause you any concern?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And why is that?
JENNIFER TUFTS: Well, she still appeared quite depressed.
MS. SPRAGUE: And in what way? Was that her affect?
JENNIFER TUFTS: It was... Yes. Her affect was congruent. Meaning it was the same as her mood.
MS. SPRAGUE: So, just so we can understand. So, if I tell you I'm happy and I appear happy, is that congruent?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And if I tell you I'm happy but I appear sad, is that incongruent?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And is that important when evaluating a patient?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And why is that?
JENNIFER TUFTS: Sometimes it's not congruent. And, you know, there could be all sorts of reasons why, but it's just something to pay attention to.
MS. SPRAGUE: And so on this day, though, her mood and her affect were congruent?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Okay. And was there a plan formulated for that day, on that day?
JENNIFER TUFTS: Yes. So the plan on that day was to increase the Trazodone to 150 milligrams. She had previously taken that dose and tolerated it well. And she had just come off of the Seroquel at Mass General, or sorry, at McLean. So we were still in the phase where we were monitoring to see if the depression might get better off of that medicine.
MS. SPRAGUE: And is that why you didn't immediately prescribe a new antidepressant?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And was she to continue the Ativan at one milligram per night and the melatonin at five milligrams per night?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And I believe in this note, for—under condition, you wrote deteriorating.
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And why is that?
JENNIFER TUFTS: So it sounds like a very strong word. I will give some context that it's not my choice of a word. I have three options when I'm filling that out. I can say a patient is improving, unchanged, or deteriorating. So she wasn't improving, and she wasn't really unchanged. She appeared a little bit worse than the last time I had seen her. So the best word is to say deteriorating.
MS. SPRAGUE: Okay. Was there anything about her presentation or affect, things that she told you, that led you to believe that she was in imminent danger of harming herself or someone else?
JENNIFER TUFTS: No, there wasn't. And we had, you know, she was feeling depressed and we had a plan to address that.
MS. SPRAGUE: Is there something you can do if you have a patient who you think is at risk of harming themselves or others?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what is that?
JENNIFER TUFTS: I could issue a Section 12, which would mandate that they be brought to a hospital for treatment, or at least for evaluation and then possible treatment.
MS. SPRAGUE: And did you feel that was necessary at that time with Ms. Clancy?
MS. SPRAGUE: And when you're evaluating a patient, taking the history, looking at their current state, looking at the answers they give you to the questions, are you reliant on the information that they give you?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: So if a patient withholds important information, is it hard to make a diagnosis or a plan?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Was your next appointment with Ms. Clancy on January 9th, 2023?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was discussed at that appointment?
JENNIFER TUFTS: So she said that the Trazodone increase was helpful. She was still getting that rebound anxiety the day after she took the Ativan. The mood was okay. But she was feeling like she was still flat. She wasn't able to cry, but she said she was able to laugh a little bit. And hadn't been having recent thoughts of suicidal ideation.
MS. SPRAGUE: Had not been?
JENNIFER TUFTS: Had not been.
MS. SPRAGUE: And did you also ask her if she had any homicidal ideation?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what was her response?
MS. SPRAGUE: Did you notice any signs or symptoms of psychosis?
JENNIFER TUFTS: No, I did not.
MS. SPRAGUE: Did you have a discussion with her about trying an antidepressant?
JENNIFER TUFTS: Yes, I did.
MS. SPRAGUE: And what was that discussion?
JENNIFER TUFTS: So at this point, she had been off of the Seroquel for a couple weeks, and she wasn't getting better. So I thought that suggested the Seroquel might not have been what was causing depression and it was depression. So that was what we needed to treat.
MS. SPRAGUE: And what were your suggestions for treatment of the depression?
JENNIFER TUFTS: We considered some different options. We didn't pick a medicine on that date. But we considered amitriptyline and Wellbutrin.
MS. SPRAGUE: And Wellbutrin was one of the medications she had taken when she was in nursing school, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And you discussed those medications on the 9th. Why wasn't a decision made that day?
JENNIFER TUFTS: Because we had made a different medication change. Because of that rebound anxiety with the Ativan, we decided to switch that to diazepam, which is Valium. And it has a longer half-life, meaning it's broken down by the body much more slowly, so you're less likely to get that rebound anxiety. And also, the nice thing about the diazepam is it's easier to stop gradually. You can, every week or every couple weeks, you can increase the dose by just one or two milligrams. So it's a lot easier to stop. So I felt that that was a better alternative. And she also wanted to be off of the Ativan, so, and be able to sleep without that kind of medicine.
MS. SPRAGUE: And I don't think I asked you this before, but what is rebound anxiety?
JENNIFER TUFTS: It just means that when the medication that treats the anxiety gets out of the system, the anxiety comes back, and it comes back even worse.
MS. SPRAGUE: And I... You explained it a little bit, but what is a half-life of a medication, and what does that mean in terms of the body processing it and how it affects you?
JENNIFER TUFTS: Yeah. So it's a little bit complicated, but it's basically the time it takes for half of the medicine to be broken down by the body.
MS. SPRAGUE: And that tells you or indicates to you how long it lasts in the system?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And so you were saying that Valium, the diazepam, the Valium, might avoid the rebound anxiety because it's slower to leave the body. Is that right?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did Ms. Clancy send you... After this appointment on the 9th, January 9th, did she send you emails on January 11th, 2023, asking you about your knowledge and thoughts on ketamine therapy and whether that would be a good option for her?
JENNIFER TUFTS: Yes, she did.
MS. SPRAGUE: And what was your response to that?
JENNIFER TUFTS: Hmm.
MS. SPRAGUE: If you can't find it, I can bring it up to you.
JENNIFER TUFTS: I think I have it. So I mentioned that it's a great option. But it can be hard to get the insurance coverage for it. Usually you need to have demonstrated that you've tried four different antidepressants first. And so that it might be necessary to try another medicine first.
MS. SPRAGUE: Okay. In that email where she was asking you about ketamine therapy, did she tell you that she was, s- Did she say, "I'm still feeling a very low mood, no motivation, and just very depressed. This has been going on for months now, and I'm getting desperate for something that would work quickly to get me out of this depressed state"? Do you remember that being part of the email?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Had she indicated thoughts like that to you before, wanting something that would work quickly to help her feel better quickly?
JENNIFER TUFTS: I mean, she may have said that once or twice.
MS. SPRAGUE: Do you know where... Strike that. Did you ever recommend ketamine therapy to you, or is this something she broached to you in this email for the first time?
JENNIFER TUFTS: It was something I had considered. Because at this point, she was starting to be a bit treatment resistant, and ketamine is a treatment for treatment-resistant depression. So it's a reasonable thought. But I didn't think we were at that point yet.
MS. SPRAGUE: And you mentioned that insurance companies usually require you to try four, is, antidepressants. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And when you say treatment resistant, is that someone who is in depression, but the typical medications aren't working for them?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did you have an appointment with Ms. Clancy on January 16th, 2023?
JENNIFER TUFTS: Yes, I did.
MS. SPRAGUE: And what was your interaction with Ms. Clancy on January 16th?
JENNIFER TUFTS: Her mood was still very low. She was still depressed. It was—she was able to get out of bed and take care of her basics, like hygiene and eating. Her concentration was fine, and she was doing what she needed to do to take care of her baby. Though she subjectively felt like the bonding was forced with the baby.
MS. SPRAGUE: She told you that the bonding felt forced with the baby?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Did you ask her if she had suicidal or homicidal ideation?
JENNIFER TUFTS: I did.
MS. SPRAGUE: And what was her response?
MS. SPRAGUE: Did she show any of the signs or symptoms of psychosis on that day?
JENNIFER TUFTS: No, she did not.
MS. SPRAGUE: What—well, did you have a discussion about a Valium taper?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And why did you have that discussion? Who brought that up?
JENNIFER TUFTS: That was because she really did not want to have to take a benzodiazepine medication every day for sleep. So we discussed how to come off of that medication safely.
MS. SPRAGUE: And that again, is that, like, taper off to take a little bit less each time?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And did she agree with that plan?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Was a decision made at that point on which, if any, antidepressant to take?
JENNIFER TUFTS: No. We had not made a decision.
JENNIFER TUFTS: Oh, sorry. Sorry. At this point, we did. We did go ahead and decide to try the amitriptyline.
MS. SPRAGUE: And what is amitriptyline?
JENNIFER TUFTS: So it is a tricyclic antidepressant.
MS. SPRAGUE: What does that mean?
JENNIFER TUFTS: It's an older antidepressant that's been around for very many years. It helps treat insomnia and some pain, headache conditions as well.
MS. SPRAGUE: And the dose that you prescribed, did you say it was ten milligrams?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: Is that the lowest dose?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And what's the highest dose?
JENNIFER TUFTS: Can get quite high. Maybe a hundred and fifty.
MS. SPRAGUE: And so, again, you started her at the lowest dose. Why was it that throughout this time you're treating her and trying these different medications, that you always start at the lowest dose with her?
JENNIFER TUFTS: That's standard practice. Because the medications, they have side effects, and the lower the dose, the more mild the side effects are, and it gives the patient time to acclimate to the medicine. And then you gradually increase it depending on how they're tolerating it.
MS. SPRAGUE: And what was the plan going—well, strike that. What was her mood and affect that day?
JENNIFER TUFTS: It was depressed. Mood was depressed. Affect was depressed and flat.
MS. SPRAGUE: And at that point in time, where she's denying suicidal ideation, denying homicidal ideation, showing no signs of psychosis, were there any grounds for you or any reason for you to seek a Section twelve?
MS. SPRAGUE: Your next appointment with her was January 23rd, 2023. Is that correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And again, all of these appointments were virtual appointments, correct?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: During this appointment, what was her mood and affect?
JENNIFER TUFTS: Mood was depressed. Affect was depressed and flat.
MS. SPRAGUE: Did she tell you she had started the amitriptyline?
JENNIFER TUFTS: She did.
MS. SPRAGUE: And did she tell you if there were any effects, side effects to that?
JENNIFER TUFTS: It didn't appear that there were side effects.
MS. SPRAGUE: What was the conversation or interaction with her that day, on the 23rd?
JENNIFER TUFTS: So she said she was doing all right. A little more anxious. And the anxiety was described as the feeling of her heart racing. She had a decreased appetite as well. She was on only two milligrams of Valium at this point, and feeling more anxious in the morning. Mood was the same. Flat, anxious, no motivation. She has to force herself to get out of bed and out of the house, but is able to do that. And she is sleeping okay.
MS. SPRAGUE: And did you ask her if she had suicidal ideation or homicidal ideation on the 23rd?
JENNIFER TUFTS: Yes, I did.
MS. SPRAGUE: What was her response?
MS. SPRAGUE: And did you notice any symptoms or signs of psychosis that day?
MS. SPRAGUE: Was there any difference in her rate of speech or speech pattern?
MS. SPRAGUE: Was there any difference in her ability to think or communicate in any way?
MS. SPRAGUE: Was there any change in her—your evaluation of her judgment or insight?
MS. SPRAGUE: Did you still consider her insight poor at that point?
JENNIFER TUFTS: I did.
MS. SPRAGUE: And why were you still considering her insight poor?
JENNIFER TUFTS: So I think there were just a couple of things that came up throughout our, you know, 14 visits that suggested that to me, like I explained earlier. But later on, it had to do with her over attribution, it seemed, to the medications, about certain symptoms that she was feeling. Meaning, like, how she felt about the Seroquel, how she felt that that was making her depressed, when in reality, I think she was just depressed. So it was related to her thoughts about medications and how she was feeling.
MS. SPRAGUE: So would it be accurate to state that instead of accepting that she was depressed, she was placing the blame on the medication?
MR. REDDINGTON: Objection.
THE COURT: Sustained.
MS. SPRAGUE: In your mental status exam of her on the 23rd—how was her appearance?
JENNIFER TUFTS: She was appropriately dressed.
MS. SPRAGUE: How was your rapport with her?
JENNIFER TUFTS: It was appropriate.
MS. SPRAGUE: How was her speech?
JENNIFER TUFTS: It was appropriate.
MS. SPRAGUE: How was her thought content and process?
JENNIFER TUFTS: Appropriate.
MS. SPRAGUE: How was her cognitive abilities?
JENNIFER TUFTS: There were no deficits.
MS. SPRAGUE: And her psychomotor, motor activity?
JENNIFER TUFTS: Normal.
MS. SPRAGUE: What was the plan going forward on that day?
JENNIFER TUFTS: So we were going to continue the same dose of the diazepam because she was feeling a bit more of the anxiety. So we said to slow down the taper, and we increased the amitriptyline to 20 milligrams, thinking that that would also help with the sleep.
MS. SPRAGUE: And...
MS. SPRAGUE: At any point in time, did she tell you she was planning to kill herself?
MS. SPRAGUE: At any point in time on the 23rd, did she say she was planning to kill her children?
JENNIFER TUFTS: No, absolutely not.
MS. SPRAGUE: At any point in time during your interaction with her in that session, was there anything about her affect or demeanor, her behavior, that indicated to you that she was a danger to herself or others?
MS. SPRAGUE: Was there any reason, based on your evaluation of her in that session, that would give you grounds to file a Section 12 on her that day?
MS. SPRAGUE: Throughout your time treating Ms. Clancy, did you continue to recommend that she attend individual therapy?
JENNIFER TUFTS: Yes.
MS. SPRAGUE: And why is that?
JENNIFER TUFTS: It's very important.
MS. SPRAGUE: And is there a reason it's important or, like, what are the benefits?
JENNIFER TUFTS: Yeah. It has—many studies have been done to show the efficacy of therapy as a component of treatment for depression and anxiety. So, you know, some people may only do medicine, some people may only do therapy, but the best response is a combination.
MS. SPRAGUE: Thank you, doctor. I have nothing further.
THE COURT: All right. Counsel, could I see a brief sidebar?
THE COURT: Doctor, you may step down. Thank you.
JENNIFER TUFTS: Thank you.
BAILIFF: Watch your step, please.
THE COURT: All right, so members of the jury, I'm gonna— we're gonna break at this point. I'm gonna excuse you till Monday morning at nine o'clock. The schedule I'm gonna suggest would be similar to today. You should be pretty much a full day. We are still, if not on schedule, ahead of schedule. All right? So I just kinda wanna let you know that. So now you're gonna have the weekend, and so I just kinda wanna reiterate those instructions I've been giving you every day. 'Cause you know the questions I'm gonna ask you on Monday, right? And so I'm gonna instruct you and remind you: don't talk about this case with anyone. Don't do any research on this case. Don't take any field trips and happen to drive by any place that you have questions about. It's also very important that you don't read anything about this case or similar cases that might come up. All right? And don't listen to anything, don't watch anything. You've gotten a fair amount of evidence so far. We've been here for a couple of weeks. You don't have all the evidence, all right? And so it's important for you to keep an open mind, and the best way to do that is basically shut your mind off until Monday. All right? I know it's been a long couple of weeks for you, so I hope you have a nice weekend. Get rested. We'll see everybody on Monday. And again, thank you so much for all your time and your work on this. And I really do hope you have a nice weekend, and we'll see you Monday. Okay?
BAILIFF: Court, all rise.
BAILIFF: This court's in session. Be seated.
THE COURT: All right. And counsel, if I could ask you to come one more time, basically just talk about kinda the schedule for Monday.
THE COURT: All right, so we'll be in recess on this matter until nine o'clock on Monday. All right? Thank you.
BAILIFF: Court, all rise.