Psychiatrist Denies Side Effect from Marsh Medication

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Yolo-Count-Court-Room-600by Antoinnette Borbon

In the close of yesterday’s testimony by Daniel’s Kaiser psychiatrist, confusion loomed large as the defense had trouble eliciting useful responses to questions. At times, it appeared that Dr. Cheyenne He had no idea what Deputy Public Defender Ron Johnson was talking about in regard to questions about Daniel’s care.

Daniel Marsh is the teen accused of taking the lives of Oliver Northup and Claudia Maupin in their Davis home in April of 2013.

After being on the stand most of the day, the questions the defense asked were not being answered.

In fact, the defense often had to repeat the same question at least five or six times.

When talking about her notes from the visits she spent with young Marsh, Dr. He could not recall ever reading some of the reports from other doctors, nor could she remember any conversations she had with Marsh. It was perplexing, and she often seemed confused, staring at her attorney during testimony.

Mr. Johnson asked more than five times, “Did you ever talk to Daniel about homicidal thoughts?” Each time it was asked, she would respond, “Suicidal thoughts and depression,” as if she did not fully understand the question. Possibly there was a language barrier issue, but it was never made clear. She could never answer whether or not Daniel told her about any homicidal thoughts.

When asked by the defense, “Why did you keep giving him the meds if they were not working? He told you they were not working, why would you keep refilling them? And why wouldn’t you talk to him first before giving another prescription, why would you increase the dose?” The doctor’s reply was, “Um…I don’t know if it was the medicine, he tolerated it…sometimes it is not the medicine and [it is] hard to tell.”

Mr. Johnson asked, “Then why wouldn’t you bring him in to talk about it?” She had no real answer, and just repeated, “I don’t think it was the medicine, I don’t know…I don’t understand the question, can you repeat?”

In one conversation between Dr. He and Marsh’s mom, the doctor said his mother told her Daniel had been doing fine. But the defense asked her about a phone call from a school therapist regarding Daniel being a dangerous person and that they needed to consider moving him to an alternative schooling facility.

Mr. Johnson asked why she didn’t think it was important how contradictory the information seemed. She did not know.

Finally, the defense asked her, “Did you know Daniel was having side effects from the Zoloft?”  She replied, “I don’t think they were side effects…”

“Do you know about the black box warnings about medicine?”  Mr. Johnson asked.

“Yes, but those are just warnings, risks,” she answered. “So, what is the difference between a side effect and a risk?”  Johnson asked.

The doctor stated, “Uh…he tolerated them….didn’t think he had side effects” Johnson replied, “I don’t think you are understanding my questions.”

Mr. Johnson asked, “If Daniel told you he was feeling more agitated, more aggressive, angry, having nightmares of hurting others, homicidal thoughts, you wouldn’t think those are side effects? And doesn’t it say on the label of the medicine those are the things you notify your doctor about immediately?”

She appeared confused about the questions. Again, it was unclear whether she could understand the language. She kept repeating, “Well, that is a part of suicidal thoughts, depression. I don’t understand your question…can you repeat?”

“Didn’t you think the black box warnings were something you should have talked to him about? And what do you think more serious, suicidal thoughts or homicidal?”

Her reply was, “I didn’t think he was having side effects. But suicidal, more serious.”

In a brief re-direct, Assistant Chief DDA Mike Cabral brought up notes from 2008, where a doctor of Daniel’s reported that the patient felt aggression, was angry and agitated, and was having bad dreams. Mr. Cabral asked the doctor if she had any recollection of hearing this information before, and she replied, “Um…no, I did not…”

Taking the stand again to finish up his testimony for the prosecution’s case was Daniel’s high school counselor, Jordan Mulder.

He talked about the visits with Daniel while Daniel attended Davis High School.

Near the end of his testimony, he was asked about a couple of notes he had just found a couple of weeks ago.

DDA Amanda Zambor also asked about certain statements he had told her investigator when he was interviewed.

Ms. Zambor asked Mr. Mulder, “Did you tell our investigator that Daniel told you he had weapons?” He replied, “I cannot remember, I have seen a lot of kids in a year and a half, heard a lot of stories from the media and it is hard to recall exactly what he did say…only that he may have had a weapon. Something about a pocket knife? But I can’t say for sure.”

“Did he ever tell you he wanted to hurt anyone?” DDA Zambor inquired. “I know he said he was feeling like he may have wanted to…but again…not sure what it was exactly he said,” the counselor asserted.

“Were you telling the truth to our investigator when he interviewed you? Did you recall things more back then?” DDA Zambor asked.

The counselor responded, “Um…well, I think I was truthful and it has been awhile, I can’t recall specifics.”

In one incident the counselor talked about, he stated that Daniel had told him about killing a raccoon.

Daniel told Mr. Mulder that he had killed a raccoon in his backyard with a baseball bat but felt no remorse.

The counselor talked about Daniel’s depression being the main concern, but never felt an elevated level of concern until Daniel told him about the raccoon incident.

When the counselor questioned Daniel’s mother about it, she said Daniel hit the raccoon with a rock and thought he killed it and wept. She said he showed remorse and was sad.

He said he asked Daniel if he ever felt like harming others, but Daniel’s response was, “I would only hurt someone if they hurt me…or maybe the popular kids, the ones who think they are superior to others.”

The high school counselor said he did consult with Daniel’s therapist, Timothy Hesgard, about the raccoon incident. They discussed whether or not Daniel over-exaggerated things.

Mulder was asked if Daniel had ever talked about using a weapon to hurt others. But the counselor said he could not recall what Daniel told him specifically. He said he knew he talked about using martial arts but could not recall the details.

Overall, he stated, “Daniel is a smart kid, insightful and politically sharp, I felt Daniel to be engaging more and his moods [to be] improving.”

Although he was aware of Daniel’s troubled relationship with his mom and how difficult things were, the counselor stated, “I know he did show lack of respect but I did not feel he would harm her.”

DDA Zambor asked, “And did you ever think Daniel was in a dream state, out of body, delusional?”  “Um…no, he never seemed to be,” answered the counselor.

Mulder was asked why he stopped meeting with Daniel. He told Zambor, “I guess he must have improved…I am not sure, but it’s usually why we would stop meeting.”

In a brief cross-examination by Johnson, he asked Mulder, “Why did you write on the bottom of a note,  ‘Horizon Facility would be a good idea for Daniel?'” The counselor answered, “Um…I know I wrote it, but I do not recall if I said it or if Timothy Hesgard said it.”

“And what is it that makes you think Daniel’s moods improved? Do you have any notes on that? Ron Johnson asked.

“I don’t have any specific notes on that….but he was smiling, talking better,” replied the counselor.

Johnson asked, “You said you wanted to make Daniel feel safe at school. Do you recall when he told you he wanted to harm others?”

“Yes, I believe it was in January,” the counselor stated.

Continuing testimony today was by Dr. David Besa, a retired clinical social worker from Kaiser. Dr. Besa has also worked in forensics.

He has worked with several patients who have been committed to Napa State Hospital, found to be “guilty by reason of insanity.” He has been a doctor for Kaiser and Napa, totaling over 35 years.

He said the first time he met with Daniel was at the crisis center in May of 2010.

Ms. Zambor asked Dr. Besa to explain the written notes as well as forms filled out by Daniel and family during his stay at the crisis center.

He said Daniel was severely depressed, having suicidal thoughts.

On the form about family dynamics, Daniel’s father put down that his son was depressed, was not sleeping, had loss of interest in things, was not eating, was very sad and had low self-esteem.

Daniel’s dad wrote that he and his wife had had a contentious divorce. Daniel also had a contentious relationship with his sister, the father wrote.

Daniel’s father put down on the form that the heart attack he suffered, when Daniel saved his father’s life, may have been a factor in Daniel’s depression and sadness.

The doctor said he had conversed with Daniel’s father on the phone and the father told Dr. Besa he wanted Daniel seen because of his depression.

The father told Dr. Besa that he and Daniel’s and mom had split custody of him, and that made Daniel sad and stressed, and Daniel often talking about wanting to die.

Dr. Besa stated, “Daniel talked about a lot of stressors from the divorce to financial reasons and school bullying.”

He said in one session with Daniel that Daniel said his mother had told him to stop taking the medicine because of the way it made him feel. By the time Daniel was at the crisis center, he had not taken one of the medications for months.

The doctor noted that when he saw Daniel, he had only been back on his medications for about a week. The doctor felt that to be a contributing factor to Daniel’s severe depression.

But overall, the doctor said, on a scale, Daniel’s level of depression was noted to be moderate to severe.

He said, “Daniel had ideas of suicide but didn’t say how he would do it or talk about having any weapons.” But over the course of a few visits, he felt that “Daniel was improving, feeling less suicidal, sad.”

When asked by Ms. Zambor if Daniel ever seemed to be “delusional, in a dream state, out of body, or not understanding the consequences of his actions,” Dr. Besa replied, “No, he seemed to be coherent, just severely depressed. But seemed to be able to talk about his feelings.”

Dr. Besa stated, “Daniel checked the box on the form that asked him if he felt like hurting people.” Daniel wrote: “I would only hurt someone if they hurt me or others.”

The doctor said he never spoke with Daniel’s mother about her son as he could not ever reach her, but he did, of course, converse with Daniel’s father. He said the father was usually present at the visits, but he testified that he also consulted with Daniel separate from his father.

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The Vanguard Court Watch operates in Yolo, Sacramento and Sacramento Counties with a mission to monitor and report on court cases. Anyone interested in interning at the Courthouse or volunteering to monitor cases should contact the Vanguard at info(at)davisvanguard(dot)org - please email info(at)davisvanguard(dot)org if you find inaccuracies in this report.

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21 thoughts on “Psychiatrist Denies Side Effect from Marsh Medication”

  1. Elizabeth Bowler

    The psychiatrist is incorrect that Black Box Warnings are “just warnings, risks”. A Black Box Warning is the most serious step that the FDA can take against a medication. The only thing that the FDA can do that is more serious is to take a drug off the market altogether. The “simple” warnings and risks are listed as adverse reactions, contraindications and cautions, not Black Box Warnings. The specific Black Box Warning for Zoloft and the other SSRI medications states ” observe all patients for clinical worsening, suicidality, or unusual behavior changes; advise families and caregivers of need for close observation and communication with prescriber; not approved in pediatric patients except for obsessive compulsive disorder.”

  2. DrSteve

    Reading this testimony has me furious. This is one case in which there are three victims. This testimony illustrates the need for our community to take pediatric mental health, childhood trauma and child development extremely seriously.

    The Black Box Warning is most important in the first weeks of starting any SSRI as it can cause “activation” which may appear as irritability, increased energy and even the energy to attempt a suicide already contemplated as a result of major depression. It is clear that depression is the root of suicide and SSRI’s are quite effective in treating depression. The irritability can persist and that prompt a change in medication, a reevaluation of the diagnosis and intensification of therapy.

    The real issue is the lack of coordination and the obvious lack of patient ownership that should be the cornerstone of a good physician. It is unrealistic to think that we should rely on a school psychologist in this situation and there should have been more immediate response by his psychiatrist.

    As a physician specializing in developmental and behavioral pediatrics who works with many challenging children in our region, I often run mental simulations in my head of “what would I have done?”

    With his history of early childhood trauma (as reported in vanguard), he should have been involved in early counseling to address the impact of the trauma to facilitate healing. During this time, a full assessment of his behavioral symptoms and potentially educational or neuropsychological testing to help inform his social-emotional skills and his learning-coping styles.

    During the immediate crisis that was described by the school counselor and the brief information outlined by his psychiatrist, it would have been prudent to have been monitoring his symptoms and response to therapy every 1-2 weeks by the psychiatrist to build both provide psychotherapy and to adjust medications. With the activation observed with zoloft and the disorganized thinking with hallucinations, I would have changed his SSRI and added a mood stabilizer. The main target would have been the depression. His most likely diagnosis would have been Severe Major Depression with psychotic features. The first step is to reduce the psychotic symptoms (mood stabilizer) and aggressively treat the depression with an SSRI and in his case TB-CBT. The key is really to have very close follow up and be very responsive to his symptoms. He may have required a couple of coordinated hospitalizations for safety until stabilized.

    Daniel Marsh is the type of kid that needed the most help and did not receive it. Now it is clear that we lost 3 people in this tragedy that should have been avoided.

  3. DavisBurns

    The treatment Marsh got is pretty standard. While we sometimes find a doctor or counselor who is more available, has more time, is less burned out, what is described here is how our system works. Currently, Yolo County mental health sees patients once every three months to review medication. There is no talk therapy and CBT.

    UCDavis hospital is planning to release a patient who needs psychiatric in patient admission because she has Partnership Advantage insurance and they cannot find a bed for her after 3 weeks. They just want to make sure she will keep her next appointment with Yolo County Mental health. It’s all about money. If you rewound the clock and put Marsh through the system again, he would get pretty much the same treatment again. If there are others like him in school today, they will get the same hit and miss care (or lack of care) Marsh got.

    1. tj

      Certainly agree with the above!

      “Medication management” generally means the patient is asked how he is and an answer that’s he’s “fine, okay, tired, or hmmm” is all that is wanted. The patient’s temperature, blood pressure and pulse are checked. The patient is asked whether he has a headache, constipation, or tummy ache. Then the med management psych renews the meds, and the patient is sent on his way.

      Kaiser has just agree to pay the state a big fine for deficient mental health treatment. Marsh might be Exhibit #1.

      1. DavisBurns

        We shouldn’t be to hasty to criticize Kaiser. They provide their members with access to both psychiatrists to prescribe medication and therapist to provide talk therapy. Most insurance plans do not include psychologist. Many people have to rely on Yolo County mental health which has very few resources which are spread thin.

  4. TrueBlueDevil

    In a high school of 1,000 or 2,000 students not in a bad neighborhood, how many students have serious thoughts about causing physical harm? Thinking back to my high school days, and with wild guesswork, I can just think that a few were somber / slightly depressed, and 1 or 2 had major depression, but not to this degree. Is this a new development?

    So (a), I’m trying to get my arms around the quantifiable, serious numbers; and (b), even if there are 4 or 5 students with serious issues, aren’t on-site counselors, principals, and vice principals able to effectively deal with these students’ serious needs?

    1. Tia Will

      TBD

      The answer to your question “aren’t on sight counselors, principles, vice principals. Able to effectively deal with
      these serious problems?” is a resounding “NO”

      I am largely in agreement with Dr Steve’s comments. This case as presented on the Vanguard is a perfect example of the fragmentation of health care in our society on a number of levels
      1) fragmentation of primary care from psychiatric care.
      2) fragmentation of inpatient from outpatient care
      3) fragmentation of psychiatric from psychological care. What many may not know is that many if not most psychiatrist are trained in the use of medication, but are not trained in psychotherapy.
      4) fragmentation in the form of lack of communication between those who know the patient best including family members,
      Friends , school personnel and health care providers .

      Over the past 20 years, Kaiser has taken many steps towards true integration of such as
      1. Change to a fully integrated medical record ( ther was a time when medical and psych records were completely segregated)
      2. Same day consultative services when an imminent danger is perceived
      3. Routine separate interviews of parent and child so that each may freely express their concerns

      I see this case as a need for comprehensive change in our approach to mental health with wellness as the goal rather than our current system of reaction to crisis situations.

      1. DavisBurns

        Tia, I agree with all you said and I will add that Kaiser provides better assess than most but we still have a lack of coordination between schools and doctors. I suspect everyone is doing what there is funding to do. We suffer from the efficiency syndrome imposed by budget cuts; do more with less. The bottom line is when it comes to mental health you do less with less. WE ARE GETTING WHAT WE PAY FOR. Daniel Marsh is not the only distressed child in the system, he is just one of the distressed who made us pay attention. The outcome for him is unacceptable to us but if he’d just cut his wrist, become a drug user, a drop out, lived his life in misery depressed and hopeless, WE WOULD NOT CARE. If he had done all that and become homeless, we’d have another set of platitudes for his condition.

  5. Antoinnette

    Absolutely agree with all of you…but I do believe Dr. Timothy Heskar may have been one of the doctors who felt more concerned about Daniel’s behavior.

    Daniel should have been kept longer to keep closer eye on him and his condition. But, yes, it may have come down to our systems protocol?

    I feel as though Daniel and his parents had been screaming for help and did not get what was needed, even prior to his side effects of the medications.

    Family members of Northrups were even shocked at this doctor’s responses…often shaking their heads. Jurors too, appeared to be stunned at parts of her testimony, especially when she made the statement that, “Suicide, more serious than Homicide,” you could hear the courtroom gasp…unbelievable!

    Once again, I pray this case sets a precedence….and for both families who in part, were indeed failed…:(

  6. Antoinnette

    Too, I believe if there was ever a case covered by the Vanguard that the public should be aware of, this one is it.

    I know defense has fought media attention, and rightly so for certain reasons but he cannot ignore the fact that these things absolutely NEED to be brought to someone’s attention for the betterment of our system, and all of the families out there who suffer from mental health issues and need help!

    I would guestimate…even Prosecution may deem it worthy of putting it in the light…we can all learn something.

    Facts are facts and they were ignored, passed on from one doctor to another…and so on…and so on…and here we sit, watching a tragic story that should have Never happened.

  7. tribeUSA

    Its interesting that many of the subjective mental experiences Daniel reports–uncontrollable thoughts, nightmares, out-of-body experiences–are common to what was once called ‘spirit possession’. There is no way to talk about mental states like this in modern times except in the left brain/rational/scientific lexicon of psychological or organic brain disorders. In modern times, exhibition of such symptoms are regarded as indicative of a broken brain/mind, to be repaired thru powerful drugs that modulate brain chemistry and nuerotransmitter mechanisms. Perhaps the old time shamans may have been on to another (complementary?) facet of the healing process, by apprehending such experiences as profound spiritual events or crises, and treating the symptoms on that level, which included a respect for the patients subjective mental experiences and healing thru spiritual growth (or with the aid of the spirits, as the shamans would have regarded the process). Often those tribe members that went thru such profound trials and emerged of whole and healthy mind (of course not all of them were thus healed) would find themselves on a path of lifelong spiritual growth, and went on to become spiritual leaders of the tribe.

  8. Themis

    Unfortunately, too many Psychiatrists and other medical doctors just dispense medication without really understanding what those medications entail, they tend to get the information about medications from pharmaceutical sales people.

    1. Tia Will

      Themis

      This was a common practice in the past and is an area in which there has been significant improvement.
      When I first started with Kaiser over 25 years ago, it was common practice for drug reps to come by our offices on a regular basis with drug company funded studies , information sheets,
      samples and small gifts such as pens and note pads with drug names on them.
      This has not been allowed within Kaiser for at least the past 10 years.
      We can of course still communicate with pharmaceutical representatives but it is done only by individual doctor invitation with no drug rep outreach. While I used to receive a steady stream of solicitations, and invitations to “informational luncheons and dinners, that number is now zero.
      Another risk has arisen to take the place of the direct to doctor sales pitch. Now we have the direct to patient sales pitch with half truths and fine print disclaimers of side effects on TV, radio, internet magazine ads.
      So while my time is no longer wasted in fending off unwanted drug reps, it is now often spent convincing my patients why the drug that cured some superstar is not a good choice for her.

      1. Elizabeth Bowler

        While the influence of pharmaceutical sales representatives on individual physicians has declined in the last 10 years, the influence of the pharmaceutical industry has sharply increased. There is now widespread pharmaceutical company sponsorship of professional journals, meetings, professional associations, academic medical centers (with academic leaders even sitting of the Boards of pharmaceutical companies) and medical schools, and the most egregious of all, the revolving door between the pharmaceutical industry and their government regulatory agencies including the CDC and FDA.

  9. Tia Will

    Elizabeth

    Agreed. My comment was limited to the influence of the drug reps on the individual prescribing doctor.

    One other place that I have seen improvement is a gradually spreading viewpoint within the medical community that emphasizes a three tiered approach to health and medical management. This is comprised of integrating all three approaches to problem solving. Within Kaiser we have already seen a strong movement towards the first step being a behavioral approach emphasizing diet, exercise, non medical stress reduction techniques and establishing healthy behaviors within families. This is supported by a wealth of programs both in person, by phone and on line to promote health as well as to manage minor problems.
    The second step is a gradually escalating medical approach using medications with the least possibility for complications first and only gradually moving on to more complicated medical regimens if needed after failure of the first two approaches.
    Finally, if nothing else is working satisfactorily, surgical approaches may be considered moving from the least invasive first, to the most invasive if ultimately needed. This is in stark contrast to how things are done in a fee for service setting where the most financially advantageous approach for the practitioner may still be offered as a first line treatment. Not necessarily because of greed, but because that was the way medicine was thought of previously, reactively rather than proactively with an emphasis on cure rather than prevention and harm reduction which are strongly emphasized in training today.

    1. Elizabeth Bowler

      I am in complete agreement with the need for a preventive medicine approach to health, beginning with food and nutrition which forms the basis of optimal health. Our current industrial food system is in desperate need of overhaul.

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