This is the second installment recounting Day 7 of the trial of Daniel Marsh. We begin with the initial examination of Dr. Cheyenne He by Assistant Chief Deputy District Attorney Mike Cabral.
Part of Dr. He’s routine with patients is to review side effects and risks of medications. Drugs have a “Black Box Warning” to address the potential risks.
Wellbutrin was added to Daniel’s existing medications with the first visit to Dr. He on January 30, 2013, and was started at 50 mg. On the second visit, February 12, 2013, it was increased to 100 mg. This was after Daniel’s mother told the doctor that Daniel was attending school daily, eating properly and had no problems with the additional medication. It was noted in the file that the medication may be increased later to 150 mg. On February 27, the mother called and asked that the medication be increased to 150 mg.
Daniel was seen by Dr. He again on March 14, 2013. Daniel’s mood and anxiety were noted as improved, but he was still depressed, and somehow anxious about his friends. As on the initial visit, he answered, “No,” to Dr. He’s questions about having homicidal/suicidal feelings or tendencies. The doctor’s summary was that he “tolerates” the medication.
On April 16, 2013, the next office visit, Daniel appeared more depressed and anxious. Daniel told the doctor that he had become angry and kicked the family dog. His mother said he had stopped taking the Seroquel that had been prescribed since December of 2012 because he didn’t like how it made him feel. It was noted that he was in the severe clinical range. The Zoloft, also being prescribed since December, was increased to 150 mg at that time.
By telephone on May 1, 2013, Daniel’s mother reported that Daniel was in crisis. He refused to restart the Seroquel and she requested different medications to calm him down. Abilify was prescribed. Lab tests were ordered because Dr. He wanted to know what triggered the crisis. The tests came back positive for marijuana.
The next office visit was on May 30. Daniel showed signs of severe depression, anxiety, muscle tension and anger. The Wellbutrin was increased to 300 mg. Daniel had been recently suspended for bringing a pocket knife to school. Daniel’s mother reported that he would only take the Abilify as needed, when he had extreme anxiety, not as prescribed on a daily basis. This was the last time Dr. He saw Daniel.
During cross-examination by Deputy Public Defender Ron Johnson, Dr. He could not recall if she had reviewed Daniel’s history prior to the first visit. Nor was she sure if she reviewed the notes from the Kaiser therapist, Timothy Hesgard, about Daniel’s hospitalization in December, 2012. Dr. He confirmed that the Zoloft was a new prescription as of December. Daniel was taking Celexa before he entered the hospital. Johnson questioned why Daniel wasn’t seen in person until January 30, about a month after release from the hospital. Dr. He said the notes showed no side effects reported by the mother when she called for a refill on January 9, so there was no need.
Johnson asked Dr. He whether she was aware at the initial visit on January 30 that Daniel had been previously hospitalized twice. Dr. He asked Daniel’s mother and was told of only one hospitalization. Johnson then asked if it was her responsibility to review the file and if the file would have those records, to which she responded yes. She believes she reviewed the record about anorexia and asked Daniel about his eating habits.
Dr. He was not sure if she had read, before the January 30 visit, the psychological testing report from Berkeley that suggested Daniel may have PTSD (post-traumatic stress disorder). Continued questions received the same response, that she was not sure if she had reviewed the record before the visit.
Johnson asked if she ever spoke with Daniel alone. Dr. He said only briefly, on the first visit. Johnson said there is nothing in the notes about that separation. The attorney asked what was discussed. Dr. He responded that they talked about depression and Daniel’s problems with his mother.
When Johnson asked how she determined that Daniel did not have PTSD, Dr. He said it was based on his behavior in the office and what was reported by Daniel and his parents. Dr. He said it would not be helpful to her diagnosis to know that previous records showed signs of PTSD.
Johnson asked if she reviewed the side effects of medications with the patient and mother. Dr. He said they didn’t report any side effects. Johnson read a note that Daniel did not volunteer information but responded when asked direct questions. Daniel was noted as irritable. Then Dr. He was asked to describe the common side effects of the medications. Dr. He responded that they include headaches, irritated stomach, tiredness, diarrhea and interference with sleep.
Johnson asked about the Black Box Warning that lists feelings of being more excited. Dr. He said that is not a side effect. She was then asked if hypomania, in which a person becomes more excited, more anxious and restless, is a side effect and she responded that yes, it could be. When Johnson asked about the Black Box Warning regarding suicidal feelings, Dr. He became a little tongue-tied. At this point, Johnson asked her to look at the NIH (National Institute of Health) site to refresh her memories about what the side effects may be. Lunch break was called at that point.
After the break there was a discussion about whether something posted on a website is hearsay – inadmissible evidence. Johnson was allowed to submit a printed copy of the information from the NIH. Judge Reed will decide later if it is permissible. It was allowed to be used to refresh the memory of the witness.
Johnson went on to ask Dr. He if being more anxious could be a possible side effect of the medications and what the doctor’s response would be to such a symptom. Dr. He said if a patient can’t carry out everyday functions, the dosage would be reduced. This symptom was not reported to her. Johnson asked if something is only considered a side effect if it is reported. The doctor said the parents’ observations in this are important because they know what has changed with medication compared to without medication. It was in the notes that Daniel’s mother said he was always anxious.
When asked if the doctor made note that the mother reported Daniel was more anxious after starting Zoloft, there was a contentious exchange between Johnson and Dr. He. This resulted in the doctor saying she discussed the side effect but didn’t make a note. In the end, Dr. He admitted that anxiety was a common side effect of SSRI (selective serotonin reuptake inhibitor) medications.
The therapist, Timothy Hesgard, noted that Daniel had recurring thoughts about death. Dr. He was asked if this concerned her. The response was that it can be part of the depressive syndrome. She wouldn’t speculate on whether it was a side effect of the drugs because there were no notations as to when the thoughts began. Dr. He did not discuss the therapist’s note with Daniel or his mother. She only asked her standard questions and Daniel denied having such symptoms. Johnson then asked if the mother was in the room and if the doctor was aware that their relationship was difficult. Johnson also asked if she noticed the documentation of Daniel saying in December that, if he had to get in the car with his mother, he was going to kill her. Dr. He said it is always her concern that the patient doesn’t tell her everything.
Dr. He confirmed that she didn’t speak to Daniel alone. She also responded affirmatively when Johnson asked if thoughts of death could be a side effect of the medications. Because her primary goal is to manage the medications, she does not pursue psychological questions with the patient. She asks her questions and, if the patient doesn’t respond differently from when the medication was prescribed, it’s left at that.
Hesgard had noted on February 1, 2013, that Daniel’s school was recommending alternative placement because they thought he could be dangerous. The mother believed Daniel was improving, even though the school reported suicidal and homicidal tendencies. When asked if the doctor reviewed these notes, Dr. He responded she believed she followed her normal routine. This was her response to several questions asked regarding the therapist’s notes. Included in these notes was an entry that Daniel was feeling worse and had more anxiety. After a fight with his friend, he did everything in his power not to kill the friend.
On February 11, 2013, Daniel had to leave a group therapy session because he had homicidal thoughts about the people in the group. He didn’t have identifiable specific intent, just low-level general thoughts. He was allowed to decompress and then rejoin the group. This was noted in his file.
The team that treats a patient meets weekly. Dr. He doesn’t recall if Daniel was discussed in the meetings, but that would be the usual routine.
Dr. He was asked if at any point she thought it would be appropriate to switch Daniel’s medications. Her response was it would depend on what Daniel tells her in their encounters. After a rewording of the question, she answered that she had considered adjusting the medications. Dr. He also confirmed that it would have been an alternative to speak with Daniel alone.
When asked about the side effects of Wellbutrin, Dr. He said suicidal thoughts are a “risk.” Once again, she continued to increase the medication based on Daniel’s verbal response to her questions. There were notes by Hesgard in the record on February 22, 2013, saying Daniel talked about killing a raccoon. Hesgard thought maybe Daniel wasn’t being truthful. Dr. He did not address anything specific in Daniel’s next appointment after that, once again asking the standard questions. Johnson asked why she didn’t pursue the issue further. Dr. He said it’s not a side effect of the medications, it’s a risk – a risk of how a person could react to the medications that could be triggered by something else.
Johnson asked what it would take for the doctor not to increase the dosage. Dr. He said that would happen as a result of the patient not tolerating the medication. The notations in the file were not an indication to her that Daniel wasn’t tolerating the medications. Dr. He admitted that aggression could be a side effect of Wellbutrin and Zoloft. Johnson asked the doctor if she is supposed to do something different when aggression is seen. Dr. He said the aggression could be from something else. At the time, Daniel was not benefiting from a lower dose; he had not been doing his full-time job or attending school.
Hesgard’s notes in the file, from a March 26 session, said Daniel still had feelings of impending doom and worry, and had difficulty controlling his anger. Daniel had kicked the family dog that morning and said nothing seems to work. He wanted to get better. When asked, Dr. He said she couldn’t speculate on why a patient would say nothing is working, because it doesn’t specifically say he’s referring to the medications. Anyway, a patient can’t just stop taking them suddenly.
Daniel’s mother reported that Daniel had stopped taking the Seroquel on his own in mid-March. When the doctor asked Daniel, he said he didn’t like the way he felt on the medication. Dr. He didn’t inquire further or substitute any other drug. On May 1, as stated above, Daniel’s mother called and requested another medication, and Abilify was prescribed. Daniel had been having symptoms of high anxiety, anger, rage and racing thoughts for the previous three days.
Johnson asked if Dr. He ever at any point considered taking Daniel off the medications. She responded, “No.”
Johnson raised the point that Dr. He brought an attorney with her to court. Dr. He said he was a Kaiser attorney. When asked if he were a malpractice attorney, she claimed not to know what his specialty is. Dr. He said she brought the attorney for support, because she was anxious.
During redirect and juror questions, Dr. He stated there is a correlation between SSRIs and an increase in suicide, but reiterated that she did not find that his anxiety was caused by the medications. Part of this was based on the first diagnosis, in 2008, of Daniel’s night terrors, severe nightmares, accompanied by uncontrolled rages.
Dr. He was asked why she only handles the medications and not the therapy. She responded that therapists don’t go to medical school and can’t prescribe medications.