By Genevieve Ghamian
The 8th day of the Daniel Marsh trial began with the re-direct examination of Dr. Cheyenne He. Dr. He is a Child & Adolescent Psychiatrist and was responsible for administering and monitoring the medications prescribed for Daniel since January 2013.
When Assistant Chief Deputy District Attorney Mike Cabral asked about how Dr. He decides which medication to prescribe, Dr. He stated she looks to three of the medications the FDA has approved for use in children: “Prozac, Zoloft and Lexapro.” She stated that if the patient does not tolerate one, she tries a different one. Alternatively she will try a different medication if it is determined that the medication is not working after maintaining the course of therapy.
Dr. He talked of starting a low dosage of antidepressants, increasing in two weeks after an office visit or phone call and increasing every two weeks until the patient does not tolerate the medication or they get to the highest recommended dose. At the highest tolerated dosage, she has them maintain the medication for 30 days. If there is no improvement, she tries another medication.
Mr. Cabral then questioned about the risks of stopping Seroquel “cold turkey.” Dr. He said there could be increased anxiety and insomnia, anger, and decreased eating, but she stated it could be an effect of stopping the medication or a pre-existing condition.
Dr. He went on to explain that marijuana taken with Seroquel could cause mania or hypomania. She stated that mania is a mood, and is the opposite of depression: extremely elevated, energetic, and irrational behavior, which is out of character. Additionally, she explained that alcohol is extremely discouraged when taking any SSRI (selective serotonin reuptake inhibitor), as it changes the brain chemistry and the normal metabolism of the medication.
Questioning then moved on to Daniel’s office visit on April 16, 2013, three days after the killings. Dr. He’s notes stated, “Daniel feels he is still quite depressed…he would like to increase dosage.” She planned to increase his dosage to 300 mg in two weeks. On May 30, 2013, the medication had not been increased (possibly due to an error in communication). Daniel was seen because he wanted an increase in his medication – he had been suspended from school due to carrying a knife.
Deputy Public Defender Ron Johnson cross-examined again. When asked why Daniel wanted an increase in his medication, Dr. He stated that it was because he was not improving. She insisted that his not improving did not mean the medication was not working, but she did not explain any further.
Questioning changed to why she didn’t answer with specifics, but used the general terms, “I usually…” or “I would…” She stated that she relies on her routine and records, not memory.
Dr. He would then explain that she would ask more questions to determine if an increase in a previous condition was an adverse reaction to a new medication. She would “rely on what the patient reports to me” as the baseline. In Daniel’s case she agreed that she had not met him prior to January 30, 2013, he was already on medication, and she did not look at the notes from his prior treatments, even though she had them. She changed her answer when asked about refilling Daniel’s medication before seeing him in the office. At that point she stated she “probably read the intake notes.”
When asked if she knew Daniel was using pot daily, as stated in his prior doctor’s notes, the doctor responded, “I think I did.” She said she knew he was using pot daily, but chose to prescribe SSRIs. When asked if she talked to him about marijuana and its effect on SSRIs, she said he was cutting down from daily to several times a week. She did not consider taking him off the medication, but advised him to store the marijuana. “I told him marijuana is not good with the medication.” She was then excused from the stand.
Mr. Cabral then called Dr. Jason Bynum, a Kaiser pediatric psychiatrist who saw Daniel prior to his admission to the Adolescent Eating Disorder clinic in the Bay Area. He stated he had reviewed some records before coming today, because this was a long time ago. He stated he only saw Daniel once, on November 30, 2011, to evaluate his medication because he was on Prozac and seemed to need a change. He was informed that Daniel had been depressed for a week and had had an anxiety attack while talking to the nutritionist.
Dr. Bynum’s notes stated that Daniel was irritable, withdrawn and moderately disrespectful (because he did not respond to questions, only nodded his head). He laughed mockingly at questions of mania and suicide. Dr. Bynum then noted that he had Daniel leave the room, and Daniel’s dad stated that Daniel acts like that just because he is a teenager. Dr. Bynum’s notes led him to believe that he was not sure if Daniel was depressed or operationally defiant, but the way Daniel communicated led the doctor to believe he was depressed.
Dr. Bynum decided to increase Daniel’s dosage of Celexa to 20 mg and, if he did not have any side effects, he would increase to 30 mg when he returned for another visit in two weeks. A side effect of concern was “activation,” which included restlessness and anxiety. Dr. Bynum did not see Daniel again because he was then hospitalized at Heritage Oaks for his eating disorder.
After Daniel’s stay at Heritage Oaks, on February 23, 2012, Dr. Bynum received a call from Daniel’s father about the current medications, Lexapro and Abilify. Daniel was having a feeling of inner restlessness, so the doctor lowered the dosage of Abilify. After another conversation with Daniel’s father on March 1, 2012, the doctor stopped Abilify and added Seroquel. The doctor insisted he proscribed Celexa and Seroquel at that time, but the Kaiser pharmacy records showed that Daniel was also taking Prozac and that Dr. Bynum had approved its refill. Dr. Bynum said, “I have no idea what is going on with that. He failed at trial of that and his mother did not want him to be on it.” Apparently, Dr. Bynum thought Daniel had stopped Prozac on November 30, 2011, the day he prescribed Celexa.
On cross-examination, Dr. Bynum was asked about his role in Daniel’s care, which he described to have been very much limited to eating disorder issues. He did not look at Daniel’s previous psychiatric testing, but stated, “If there is a note to be read, I read it.”
Dr. Bynum is subject to recall.
The next witness, Jordan Mulder, was the psychologist at Davis High School. He works with students who have disabilities to help with their Individualized Education Plans (IEPs). He stated that Daniel was diagnosed with “emotional disturbance.” School started the last week of August, 2012. By Sept 5, 2013, the IEP was amended to adjust his class schedule. It was amended again on October 30, 2013, to include Kings View behavioral mental health services. On January 31, 2013, the IEP was scheduled to be amended due to a “Kings View employee expressing safety issues.”
Mr. Mulder was contacted on January 16, 2013, when the Kings View employee said that Daniel was having thoughts of harming other people. Mr. Mulder met with Daniel, but felt it was a low-risk situation because Daniel had no plan and did not have a specific person identified as a target. The employee felt otherwise and called the police. Mr. Mulder observed Daniel talking to the officer for about 10 minutes. “Daniel was toning down some of what he told me.” He did not remember saying anything to the officer about it, and released Daniel back to class.
On February 1, 2013, Mr. Mulder came to the school to talk to Daniel because someone had raised concern over his potential for self-harm. He found Daniel did not talk of self-harm, but of harming others. Daniel had stated that students who acted like they thought they were better than other students are okay to hurt – that they need to be punished.