2.Bhushan Agharkar — Direct/Cross
555 linesBHUSHAN AGHARKAR, being first duly sworn, testified as follows:
COURT CLERK: Have a seat right up there, sir. Once you're seated, state your full name, spelling your last.
BHUSHAN AGHARKAR: My full name is Bhushan, B-H-U-S-H-A-N, Agharkar, A-G-H-A-R-K-A-R. That's why I go by Shan.
DIRECT EXAMINATION BY MR. SECOR:
CASEY SECOR: Dr. Agharkar, will you tell the jury what you do?
BHUSHAN AGHARKAR: Sure. I'm a psychiatrist. I'm a medical doctor.
CASEY SECOR: And tell the jury about your education, if you will.
BHUSHAN AGHARKAR: You want to go back to high school or college?
CASEY SECOR: I think college is probably good enough.
BHUSHAN AGHARKAR: I did my undergraduate degree at Case Western Reserve University in Cleveland, Ohio. I finished there in three years and then I started medical school in Syracuse, which is where I'm from. I got my medical degree in 2000 and I moved to Atlanta and I trained at Emory. I did a four-year residency in adult psychiatry. I was Chief Resident my last year of residency. Then I did an additional one-year Fellowship in Forensic Psychiatry. So I'm an Adult and Forensic Psychiatrist. And I've been in private practice since then, which has been 2005, so almost 15 years.
CASEY SECOR: And I think what you just said included, obviously, your medical license, but any other certificates or licenses that you have?
BHUSHAN AGHARKAR: I am Board certified -- in addition to being licensed to practice medicine, I am Board certified in both Adult and Forensic Psychiatry. And then every ten years, you have to take the test again, which kind of sucks, and so I recertified in both of those a couple years ago whenever I took them.
CASEY SECOR: And what are your current professions in terms of your everyday work? What different things do you do?
BHUSHAN AGHARKAR: I treat patients in my office. I treat a wide variety of mental illnesses, from schizophrenia and bipolar disorder to depression, anxiety, substance abuse problems, ADHD. I treat them with both medications as well as talk therapy. So it's called psychotherapy. And so I do both of those things. I'm on faculty at Emory University School of Medicine as well as Morehouse School of Medicine. I've been teaching at Morehouse since 2005 and I teach a variety of courses there over the years. And then the rest of my time is spent in forensic consulting work like this. I have a national practice in that regard. I've testified and consulted in many states across the country.
CASEY SECOR: And I'm just going to ask you a few more categories about your experience for purposes of qualification. Can you tell the jury about any professional Societies or Boards or Honors that you have?
BHUSHAN AGHARKAR: I'm a member of the American Psychiatric Association, which is our National body. I'm actually a Distinguished Fellow of the American Psychiatric Association, which means that your local branch has to nominate you. First you're a Fellow, then they nominate you for a Distinguished Fellow status. You have to fill out an application. You have letters of recommendations, kind of show them what you've been doing. And then the national body votes on you and gives you that designation. So I received that designation three or four years ago or so, I think. And actually -- and as soon as I got that designation, the local branch asked me to be on the committee to nominate people for Distinguished Fellows, so now I review the applications for people who want to be Distinguished Fellows of APA. I'm a member of the American Academy of Psychiatry and the Law, the International Academy of Mental Health and the Law, the American Neuropsychiatric Association. So there may be more, I'm forgetting, but those come to my mind immediately.
CASEY SECOR: And how about publications, have you published professional writings and research?
BHUSHAN AGHARKAR: I have, yes. Generally, in a number of topic areas involving intellectual disability, mental illness, of course, like schizophrenia, I've published on that, as well as competency issues.
CASEY SECOR: And you mentioned that you work at Emory University, but you've also done some work for the Federal Government, is that correct?
BHUSHAN AGHARKAR: Yes.
CASEY SECOR: Can you tell the jury about that, please?
BHUSHAN AGHARKAR: Well, I've consulted to a number of agencies, the FBI. I currently have cases with the Army, the United States Army, as well as the DOD. I continue to consult for the DOD. So in a variety of areas, I've consulted in.
CASEY SECOR: And what about your work with schools, not Emory, but other schools? Do you work with other schools?
BHUSHAN AGHARKAR: I've consulted to school systems, hospitals. I do fitness for duty evaluations for our local police department. They send me firemen, police to see if they're fit to carry a gun and come back to work and that sort of thing. So I'll do those evaluations as well.
CASEY SECOR: Now, the area -- or the conditions that you most routinely are dealing with in your practice, can you tell the jury just the types of mental illnesses that you are dealing with on a regular basis with your patients.
BHUSHAN AGHARKAR: Well, I mentioned I pretty much see everything for the most part. I treat people 16 and up, so I don't treat children, but, you know, again, a variety of conditions. When I was starting my private practice -- I've never taken insurance in my practice, so that takes a while to build. So in my early years, probably the first five to eight years of my practice, I was also working at the Georgia Tech Health Center, the Georgia State Student Health Center. I continue to consult to the Georgia Tech Athletic Department when they have athletes that need to be seen. I've worked in community mental health centers and that's where we take care of the severely and persistently mentally ill. So I see the very sick patients. And, certainly, that was my training as well. So it runs the gamut.
CASEY SECOR: And in terms of the number of people that you've treated with those severe mental conditions, can you approximate the number of people that you've worked with or treated?
BHUSHAN AGHARKAR: Well, I've lost count. It's got to be over several thousand at this point in my career.
CASEY SECOR: And have you been qualified in the past as an expert in Adult and Forensic Psychiatry in courts before?
BHUSHAN AGHARKAR: Yes, I have.
CASEY SECOR: Do you have any idea how many times?
BHUSHAN AGHARKAR: I would say approximately 90 times. I testify about seven percent. Of all the cases I've consulted in, about seven percent of the time, I testify. So that's about 90 times.
CASEY SECOR: Your Honor, the Defense would offer Dr. Agharkar as an expert in the field of Adult and Forensic Psychiatry.
SUZANNE MAYES: The State has no objection, Your Honor.
THE COURT: All right. Ladies and gentlemen of the jury -- Dr. Agharkar?
BHUSHAN AGHARKAR: Agharkar, yeah.
THE COURT: Has been offered as an expert in the field of Adult and Forensic Psychiatry. He can offer opinions in that field.
CASEY SECOR: Thank you, sir.
THE COURT: Yes, sir.
CASEY SECOR: When did you first start working on Tim's case?
BHUSHAN AGHARKAR: I don't recall exactly, but I saw him in 2017, so my recollection would be that probably late 2016.
CASEY SECOR: And you've been working on it since then in some capacity, right?
BHUSHAN AGHARKAR: Correct.
CASEY SECOR: And this is going to come up at some point, can you approximate how much money you've been paid to work on Tim's case thus far?
BHUSHAN AGHARKAR: Well -- and I discount my rate for state and federal cases. So for this case, it's $400.00 dollars an hour, which is my old discounted rate. I would approximate -- you know, I didn't look at my billing right before I left town, but I think it's got to be around $25,000.00, it could be more.
CASEY SECOR: And who pays you to work on Tim's case?
BHUSHAN AGHARKAR: The State does.
CASEY SECOR: The State of South Carolina?
BHUSHAN AGHARKAR: Right.
CASEY SECOR: And -- because I'm sure this is going to come up in some way. Is the fact that you're paid influence the conclusions that you come to in cases that you work?
BHUSHAN AGHARKAR: No, not at all. I expect to be paid for my time, that makes sense. But I routinely tell lawyers who hire me things they don't want to hear. I mean, I tell them things that look, I just can't help you. This guy doesn't have it or whatever you're looking for isn't there. So I routinely do that.
CASEY SECOR: Which is why you end up testifying in so few of your cases that you're consulted on?
BHUSHAN AGHARKAR: Exactly right.
CASEY SECOR: So you were initially hired to do what in this case? What was the initial request?
BHUSHAN AGHARKAR: I was asked to perform an assessment of Mr. Jones to see whether or not he suffered from any major mental illnesses or any other problems that they should be -- that you guys should be aware of.
CASEY SECOR: And if you would, just sort of as concisely as you can, tell the jury what a psychiatric evaluation is. How do you do that?
BHUSHAN AGHARKAR: Well, you talk to the person, first and foremost, right. My training and experience in seeing many patients allows me to be able to see patterns and understand how mental illnesses present. So I'll talk with them, spend time with, kind of understand, ask questions and see how the responses are. I'm not only interested in what he says, but the way in which he says it. Are his thoughts organized? Do they make sense? Do they seem to follow in a linear and logical fashion? That's how our brains work. As far of that, as well, then I would review a number of records. As part of the evaluation, I'll review a great deal of records, medical records, all kinds of things to come to, as best I can, an understanding of this person and what could be going on with him.
CASEY SECOR: Now, can you tell the jury the role that a person's social history plays in your evaluation? First, let's make sure we all understand what a social history is and then tell the jury what role that plays in your evaluation.
BHUSHAN AGHARKAR: So social history really means as much information as we can get about a person's upbringing, the people around them, what they were experiencing, you know, what was going on in the environment, right? We don't exist in a vacuum. We don't just walk around without having any concept of where we are and where we come from, right? So social history tries to get that information, tries so that we can have a rounder, more 360 kind of view of a person and understand how they've come to be where they are now. And that's why it's very important in psychiatric evaluations to have a social history.
CASEY SECOR: And could the social history that you take into consideration conducting an evaluation like this, could it include records on a person that the person you're evaluating never even knew, but was biologically related to?
BHUSHAN AGHARKAR: Absolutely, yes. And we call that a family history. Because just diabetes and high blood pressure, mental illness runs in families, okay? So we know that depression, bipolar disorder, schizophrenia are highly hereditary. They pass through the genes. I can go into that in more detail if you want me to now or you can ask me that later.
CASEY SECOR: We'll do it in just a second.
BHUSHAN AGHARKAR: Sure.
CASEY SECOR: Your Honor, may I approach?
THE COURT: You may.
CASEY SECOR: I'm just going to ask -- show you, Dr. Agharkar what's been marked as Defense Exhibit 132 and just ask you if you recognize this?
BHUSHAN AGHARKAR: Yes. This is a list of all the materials I was provided and reviewed at some point.
CASEY SECOR: Okay. And it's a list that totals 262 items. Do you agree with that?
BHUSHAN AGHARKAR: Yes.
CASEY SECOR: And this is the actual list of things that you reviewed?
BHUSHAN AGHARKAR: Correct.
CASEY SECOR: Your Honor, we'd offer 132 -- I mean, I'd offer what's been marked for ID Defendant's 132 as Defendant's 132 in evidence.
SUZANNE MAYES: Your Honor, I would object to it coming into evidence. I have no objection to it being a Court's Exhibit or being used for identification purposes to refresh the memory of the witness.
THE COURT: What is that again?
CASEY SECOR: It's the list of the items that Dr. Agharkar considered in his evaluation, records and various things related to Tim and other family members.
THE COURT: I don't think it needs to come into evidence. So he can use it to refresh his memory and make certain of that. If you need to mark it as a Court's Exhibit, that's fine, also.
CASEY SECOR: So can we just make Defendant's ID 132 a Court's Exhibit?
THE COURT: We may, sure.
CASEY SECOR: Your Honor, that would be Defense 132 for ID is now Court's 202.
THE COURT: Court's 202, correct?
CASEY SECOR: Yes, sir.
COURT REPORTER: I'm sorry, I'm going to have to change that number. That will be Court's No. 88. (WHEREUPON, Court's Exhibit number 88 was marked for identification.)
CASEY SECOR: Your Honor, I'm sorry, I was wrong about that. What was previously marked as Defendant's Exhibit 132 for ID is actually going to be Court's 88.
THE COURT: Court's 88 then. Y'all understand the difference. This is what he looked at. All the evidence is in that y'all get to see. What he looked at, he can testify to.
CASEY SECOR: And you already mentioned that you look at records pertaining to Tim as part of the evaluation. Just tell the jury the types of records that you looked at that pertain specifically to Tim.
BHUSHAN AGHARKAR: So records like medical records, occupational records, school records, things that pertain to a substance abuse history, so those types of records for him.
CASEY SECOR: And anything that pertained to mental health concerns as well?
BHUSHAN AGHARKAR: Of course, yes, that's right, as well as any jail records as well.
CASEY SECOR: Right. And then those same type of records that apply to members of his family?
BHUSHAN AGHARKAR: Correct.
CASEY SECOR: Did you review any of the evaluations or examinations that other people involved in this case did on Tim?
BHUSHAN AGHARKAR: Yes, I have reviewed competency as well as criminal responsibility evaluations that have been done in this case.
CASEY SECOR: And what about the imaging regarding Tim's brain injury?
BHUSHAN AGHARKAR: Yes, I reviewed Dr. Bigler's reading of that as well as Dr. Snyder and I've seen the images myself.
CASEY SECOR: And in your in-person work with Tim, do you have any idea of the total amount of time that you've spent with Tim approximately?
BHUSHAN AGHARKAR: I've visited with him twice. Once in early 2017 and then once kind of in the middle of 2018. Total is about three and a half hours.
CASEY SECOR: And was he cooperative with you during that process?
BHUSHAN AGHARKAR: Yes, he was.
CASEY SECOR: Now, we're, obviously, going to get into this in more detail, but I think it's important the jury knows at this point. Can you tell the jury what your ultimate finding was based on the evaluation you conducted on Tim?
BHUSHAN AGHARKAR: So based on my assessment, he suffers from schizophrenia as well as what's called a minor neuro-cognitive disorder, that's just a fancy term for brain damage.
CASEY SECOR: Now, you and I talked a lot about you trying to explain things to me and we're going to try to do this as quick as we can because it's a lot of information. But if you can, talk to the jury about just what is schizophrenia.
BHUSHAN AGHARKAR: Sure. Schizophrenia is a major mental illness. It's what we call a thought disorder. You can have mood disorders, like depression, anxiety disorders, like panic attacks and things like that. Here, we're talking about a thought disorder. So it means somebody whose thinking isn't right. Well, why not. So it means that it's a psychotic illness. That means there's a break with reality, that this person's reality is not sane as the rest of our realities. So they may have hallucinations, they may hear things that other people don't hear. They may see things other people don't see. There's other kinds of hallucinations, like they can smell things other people don't. They can taste things other people don't. So those are called hallucinations. And the absence of -- in other words, they're not things that the rest of us would experience. People can have delusional thinking. A delusion is a fixed, false belief. So people can have paranoid delusions.
People who think that people are after them, they're being monitored, things like that when they're not. They can have grandiose delusions where they believe they have super powers that other people don't have or that they are a very important figure in some way. Some people have delusions in that way as well. Then you can have disorganization in thought, disorganization in behaviors and then what we call negative symptoms. Negative symptoms are a restricted range of affect. People will often talk about it being kind of a flat face, doesn't show much emotion. That's part of the illness. People can have problems with motivation. They can have problems with initiating behaviors and thoughts. Social withdrawal and social isolation is a common negative symptom. So those are the different types of symptoms that we see in the syndrome called schizophrenia.
CASEY SECOR: And do you see in your work with schizophrenics, or rather, people with schizophrenia, does it -- do they sometimes engage in violent behavior?
BHUSHAN AGHARKAR: Yes, that does happen.
CASEY SECOR: And is -- in your experience, is violent behavior that's committed by people with schizophrenia, does it usually involve substance abuse?
BHUSHAN AGHARKAR: It often does. Substance abuse and mental illness go hand in hand. You often see people use substances in addition to having a major mental illness. And, unfortunately, it can make those symptoms worse. They may think it's helping them in some way, but, oftentimes, it just makes those situations worse.
CASEY SECOR: If you would, please tell the jury about the spectrum of schizophrenia and the varying degrees of severity.
BHUSHAN AGHARKAR: So just like people exist on a spectrum, right? I mean, somebody with depression can go to work and function reasonably well, but still have depression versus somebody else with depression might not be able to get out of bed for two weeks because they have no energy and no motivation and they're crying all the time and such, okay. So there's a spectrum of any illness. There's a spectrum in schizophrenia. Some of you may be familiar with, you know, the homeless guy pushing the shopping cart down the street with five coats on in the middle of summer, okay, if you've seen that kind of thing. That person is schizophrenic oftentimes, very low functioning. You can have higher functioning schizophrenics, such as the Noble Prize winner in economics, John Nash. So there can be a wide variety. It's not a one size fits all type of category.
CASEY SECOR: And can you describe to the jury in considering mental illness, the idea of strengths versus deficits? What is that?
BHUSHAN AGHARKAR: Just listing mental illness, but we all have strengths and deficits, right. We can do some things well, we can do some things not so good, okay. And so everybody has that to some degree. So the same is true with mental illness and schizophrenics. But it's very important to understand that the way we make our diagnoses and the way we consider somebody having impairment, we look at what they can't do. We look at their deficits. So the deficits are what define the disease. It's not the strengths, okay. So somebody can have great strengths. So, for example, if you've seen the movie Rain Man. That -- I actually met him in person. Not the actor, the real person it was based on. He could tell you the weather in Kansas City, Missouri on June 18th, 1975 off the top of his head, but he can't tie his shoes. So that's somebody that has great strengths, but very significant deficits. And he relied on his father for everything. He was not able to live in an independent way. So that's an example of how you can have strengths coexisting with deficits. We look at the deficits, we look at what the person can't do. And that's how we determine whether somebody has an illness or not.
CASEY SECOR: Does that differentiate the difference between intelligence and cognitive issues or intellectual issues and cognitive issues?
BHUSHAN AGHARKAR: Yes. I mean, so intelligence is measured by IQ testing. That doesn't capture, though, fully who you are and what you're able to do. You can have people with very high IQs make very, very bad decisions and have many kinds of behavioral problems, okay. Because there's other parts of the brain that code for memory, for judgment, for weighing and deliberating and planning. So just because somebody's IQ is high doesn't mean everything else in their brain is good. You kind of have to look at everything together.
CASEY SECOR: If you would, just tell the jury the three categories of symptoms of schizophrenia and then we'll go through each briefly.
BHUSHAN AGHARKAR: So the way we think about the symptoms of schizophrenia are positive symptoms, negative symptoms and cognitive symptoms.
CASEY SECOR: And let's just start with the positive symptoms. It seems like a bit of a misnomer to me. Is that right?
BHUSHAN AGHARKAR: Yeah, they're really not positive at all. Unfortunately, that's what it's called, though, positive symptoms. What it means is what I talked to you earlier about, hallucinations, delusions. Those are what we call positive symptoms of schizophrenia.
CASEY SECOR: And hallucinations are auditory, visual, olfactory, what?
BHUSHAN AGHARKAR: Correct, it can be any of those.
CASEY SECOR: And negative symptoms?
BHUSHAN AGHARKAR: So the negative symptoms are again what I discussed about social isolation, having restricted range of affect, difficulties initiating behavior, those sorts of things.
CASEY SECOR: And those positive and negative symptoms, are they the same in every schizophrenia patient?
BHUSHAN AGHARKAR: They're not. There's variability among schizophrenics. Some can have a few of these symptoms and some can have many.
CASEY SECOR: And what about the category of cognitive symptoms, what is that?
BHUSHAN AGHARKAR: Well, what we knew about -- so, having untreated schizophrenia is bad for your brain, okay. Actually, even Freud talked about this. We didn't have antipsychotics back in that time, but he called schizophrenia dementia of praecox, which means, basically, he saw that people with untreated schizophrenia ultimately become demented. They, basically, look like dementia patients. So we know that it's bad for the brain, it causes deterioration in cognitive functioning. You'll often see cognitive problems in people with schizophrenia, mostly like executive functioning types of things, frontal lobe problems a lot of times.
CASEY SECOR: What do psychiatrists like yourself refer to the first phase of schizophrenia as?
BHUSHAN AGHARKAR: I think what you mean is there's something called a prodromal phase of schizophrenia. What that really means is they have -- they don't meet criteria for the full syndrome yet, but there's something going on. There's something unusual or strange. And it often is hard to detect. And the way we often figure it out is in retrospect. You know, once we know how the person is, we realize well, looking back, oh, there were even some strange things and it just kind of got, you know, looked at as kind of normal behavior in a sense. And what I mean by that is most people who have schizophrenia will have what we call a first break episode around 18 to 22 as an age range. It's a rough guide. But oftentimes looking back when they were younger, you will see things like kind of eccentric beliefs, kind of weird, you know. They may be social isolated, spend more time by themselves. The problem is what 16 or 17-year-old doesn't do that, right. So that's the difficulty. So it looks like normal teenage behavior, but, in fact, what it is is the starting of the disease. So it can be difficult to detect in that way. That period of time can go on for months or even years until eventually they have all the symptoms and they have what we call a psychotic break and then it's very clear that they have schizophrenia.
CASEY SECOR: If you would, just discuss with the jury the general -- from the field of psychiatry, the general beliefs about the age of onset of schizophrenia, whether it's fixed or whether it's a range?
BHUSHAN AGHARKAR: Again, it's epidemiology. So you're going to have some that are young and some that are older, but most people will tend to break between 18 and 22, which is right around college age.
CASEY SECOR: And when you say break, you mean having a psychotic episode?
BHUSHAN AGHARKAR: Correct.
CASEY SECOR: And if you would now, just discuss the inheritable or genetic nature of schizophrenia.
BHUSHAN AGHARKAR: It's a highly inherited condition. And we know from genetic research that if you have a twin, an identical twin, okay, and that twin has -- let me back up. The prevalence of schizophrenia in the population is one percent. That's one percent of the population will have schizophrenia. Now, if you have an identical twin, so the same genes, right, identical twin who has schizophrenia, your risk goes up to 50 percent, so 50 times risk, okay. It's pretty significant. If you have a first degree relative, like a father, a mother with schizophrenia, your risk goes up to. I've seen usually, at least, ten percent, can be as high as fifteen percent or so I've seen. That's pretty significant. You know, it's a ten to fifteen times increase in getting the disease if you have a family member who has it. And then the more family members who have it, it raises the risk, we're not exactly sure how much, you know, above that ten percent.
CASEY SECOR: Based on your review of records in this case, do you know whether or not Tim has a parent with schizophrenia?
BHUSHAN AGHARKAR: Yes, he does.
CASEY SECOR: And have you seen recently a video of his -- it's his mother, Cynthia, right?
BHUSHAN AGHARKAR: Yes, I've seen it.
CASEY SECOR: You've seen the video. In seeing her, obviously, you weren't there, but watching her, based on your expertise, how does she present to you?
BHUSHAN AGHARKAR: She appears very impaired. She strikes me as chronic schizophrenic. You can see in the video she has memory problems. Even answering sort of the most basic questions, she can only go maybe one step and can't really further tell you more. So she looks like someone who has been treated for a long time is what I've seen.
CASEY SECOR: In your review of the records, are you aware of other mental health conditions that have affected members of Tim's family on both sides?
BHUSHAN AGHARKAR: Yes. In addition to -- the mother has multiple diagnoses, but one of them is schizophrenia. He has a grandmother who is diagnosed with schizo-affective disorder, which, basically, just means schizophrenia, plus bipolar, that's all it means. A schizophrenic who has some mood problems, that is schizo-affective. So it's not important, but it's really just a term that means still has schizophrenia with mood issues. He also has multiple other family members with mental illness and pretty significant mental illness as well. So yeah, there's a number of family members.
CASEY SECOR: And to you, was that an important factor? In coming to your determination in this case, did that play a big role in it, knowing his family history of mental illness?
BHUSHAN AGHARKAR: Certainly. I mean, it doesn't make the diagnosis, obviously, but it sets the stage for it. It tells me that there's significant genetic loading for this illness.
CASEY SECOR: Now, in addition to the genetic component of schizophrenia, explain to the jury the environmental factors that can contribute to its growth, I guess.
BHUSHAN AGHARKAR: You know, we think that there's usually what we call a two-hit hypothesis of schizophrenia, which means you've got the genetics for it and then there's something in the environment as well that goes wrong and that tips you into schizophrenia, so to speak. He's had a host of issues, starting with childhood with abuse and neglect by his mother. His mother wouldn't feed him as an infant because she didn't want a fat baby, so she withheld milk from him. She left him in cold water. He would be screaming and crying. Again, he's a baby. She also had her own issues. She did some very significant and very serious things. Especially in those early years, you know, our brain is very much forming. It's forming all those neuro connections. So that's a state of high stress and that sort of thing, it's incredibly bad for brain development. He's then raised by his grandmother, it's my understanding is the primary caretaker. She has pretty significant mental illness problems as well. And then -- so that sets the stage for that later on development. He starts having symptoms, he reports around the age of ten or so of hearing voices. And then he starts using substances as well at an early age, around 12 years old or so. And he thinks -- he tries to calm the voices, but his moods, also. So those are the kinds of things I was able to glean from the history.
CASEY SECOR: Thank you. The list of symptoms for -- I guess these are both positive and negative. You discussed psychosis, delusions, hallucinations, thought disorganization, isolation, flat affect or restricted range of emotion, self-medication. Does that cover most of the things that you see in schizophrenic patients?
BHUSHAN AGHARKAR: Yes.
CASEY SECOR: And are those things that you identified in Tim as part of your evaluation?
BHUSHAN AGHARKAR: Yes, that's right. I did not see disorganized behaviors, but everything else, yes, I interviewed him for, was able to see in his history or in him.
CASEY SECOR: And just so that we're sure that everybody is on the same page, what do you mean by self-medication?
BHUSHAN AGHARKAR: Self-medication, basically, means that you're having some kind of problem. And for whatever reason, there can be lots of different reasons why you may not go see a doctor. You know, it's expensive, there's stigma associated with seeing a psychiatrist and getting put on medications. Some people don't like to take medications, some patients can have side effects. So there's a lot of reasons why people don't take medicine. So what do they do. They reach for things that are easily kind of in the environment, alcohol, drugs. So people will often drink alcohol to make themselves feel better. They'll smoke weed to relax, calm themselves, reduce their anxiety. And so schizophrenics, but people with mental illness in general will oftentimes do what we call self-medication. You know, they will use these substances to treat themselves. But, of course, it's not really treating it, it may be pushing the symptoms down somewhat so you can hopefully function and get through your day, but, eventually, they become their own problems.
CASEY SECOR: From an outsider's perspective, it might just look like some is just using drugs, right, or drinking?
BHUSHAN AGHARKAR: Exactly. Yes.
CASEY SECOR: Now, does a person who has schizophrenia and is experiencing these symptoms, are the symptoms constant and regular or do they wax and wane?
BHUSHAN AGHARKAR: Rarely is it ever constant. Symptoms wax and wane. People have good days, they have bad days just like everybody else. So you wouldn't expect to see all these symptoms present all the time, no.
CASEY SECOR: Do you see in your practice friends and family members of schizophrenics who miss some of these symptoms or attribute them to something else? Is that something that you see?
BHUSHAN AGHARKAR: All the time, yeah. Unless it's really, really bizarre or gets to the point where it's really dangerous like they try to kill themselves or something like that, tear the house up looking for monitoring devices, I've seen that. Unless it gets to that level, oftentimes, again, it just gets mistaken as regular teenage behavior or substance abuse or he's just weird. Something is just -- he's off. Something's not right with the guy, but, you know, we just don't want to talk to him that much.
CASEY SECOR: In your experience, can a person with schizophrenia control the disease themselves?
BHUSHAN AGHARKAR: No, they can't control it. I mean, you can't control your diabetes or your high blood pressure. You have it, you know. You can manage it as best you can, but you can't control it.
CASEY SECOR: How do you treat schizophrenics?
BHUSHAN AGHARKAR: First and foremost, medications. We have a number of antipsychotic medicines that are used and effectively can treat symptoms and get them under control. And then talk therapy as well. You can have, obviously, one-on-one psychotherapy has helped people. Sometimes they'll go to day programs. I was the medical director of a residential treatment facility at one point in my career. And we often took -- these are folks who are too sick to go home, but they're not so sick that they should be in the hospital, so they come and stay with us. So we often have group therapy with them, vocational training, skills development and things like that to help them focus on something other than voices. So there's lots of different treatment modalities we have.
CASEY SECOR: You also, from your evaluation, reviewed the fact that Tim has a traumatic brain injury?
BHUSHAN AGHARKAR: Yes.
CASEY SECOR: Can you just discuss briefly what is traumatic brain injury?
BHUSHAN AGHARKAR: So -- I mean, it's what it sounds like. It's, basically, a severe blow to the head. And you can have -- you know, it can actually crack the skull. It doesn't have to crack the skull. We call those concussions, right, mild traumatic brain injuries. So you don't necessarily have to have a skull fracture to have a traumatic brain injury.
CASEY SECOR: And what goes wrong -- what are some of the things that can go wrong as a consequence of that type of brain injury?
BHUSHAN AGHARKAR: Well, it somewhat depends on where the damage happens in the brain, okay. The brain also -- the brain is sitting in fluid in the skull and that's its cushioning, okay. When you have severe jolts, okay, then the brain hits against the skull, for example, that's -- so you'll actually get brain bruising. You'll have what they call axonal shearing, which means, basically, shearing forces, twisting forces are applied to the brain and that will destroy neuro-connections. That's not necessarily obvious on a scan. You have to get a special type of scan to be able to see those types of things. Just real quick, I can tell you about the brain. It kind of looks like a fist, okay. Your knuckles, in the front, this would be the frontal lobe. My thumb here on the side is the temporal lobe. Back here on top is what we call the parietal lobe. And then the back is the occipital lobe. And so those are the four main lobes of the brain. So depending on what gets hit, you'll have different types of deficits.
CASEY SECOR: And in terms of the consequences of a traumatic brain injury or how they manifest, I assume that, basically, you just said they're not necessarily always consistent, but could you give the jury some idea of what those are?
BHUSHAN AGHARKAR: Sure. Yeah, I mean, again, like I said, it depends on what gets injured. But the front part of the brain called the frontal lobe, which I think you've already heard about from Dr. Snyder who showed you on the scans. You're going to hear more about it. It sits right behind our eyes, okay. And right behind our nose, really, and right behind our eyes are two very sharp bones. It's very unfortunate because, basically, if you have a bad force, your brain gets impaled right there on these very sharp bones. So frontal lobe injuries are very common in traumatic brain injury for that reason. And we have problems in those areas -- you'll often see problems with what we call executive functioning, which means weighing and deliberating things, planning appropriately, making good rational plans. The primary role of the frontal lobe is impulse inhibition. So it means that, you know, if somebody insults me on the street my brain might be saying, you know, attack him.
He's insulted you, you've got to hit him. My rational part, the frontal lobe says no, don't do that. You do that and you're going to get arrested, you're going to go to jail, there's going to be big trouble, don't do it. And that's when you have intact frontal lobe functioning, it stops you from doing things. People with damage in that area will often have problems stopping themselves, will often have problems with impulse inhibition. So working memory is also part of what frontal lobes are responsible for. Modulating emotions. You have different parts of the brain -- like the temporal lobe, you have some memory issues, emotional regulation problems. Again, the frontal lobe mediates that and makes it like -- helps kind of translate and understand what's going on. So if you have damage in those areas, you can have a hard time controlling that. So those, in general, are the types of things you can see with traumatic brain injury.
CASEY SECOR: And does that -- can the signs of traumatic brain injury include changes to a person's personality or character or behavior?
BHUSHAN AGHARKAR: Yes, that's right. Oftentimes, people will act differently, people will notice changes and say that a person is not really the same after having a head injury of some type. We see that in veterans after an IED blast, for example, right, so bomb blast and things like that. Those are concussive forces. They can have a lot of difficulties, just not doing the things that they used to do. And that certainly happens when you get in car accidents and other types of head injuries as well.
CASEY SECOR: Is there a correlation between traumatic brain injury and things like substance abuse, mental illness, homelessness, imprisonment, those types of things?
BHUSHAN AGHARKAR: Yes. Studies have shown that people with traumatic brain injuries tend to have a higher incident of those things that you just mentioned. And again, it goes to people can develop mental illnesses more readily, or it's sort of a higher association with traumatic brain injuries. And the self-medication plays into that as well.
CASEY SECOR: Are there symptoms of traumatic brain and symptoms of schizophrenia that overlap one another?
BHUSHAN AGHARKAR: There are, yes. Again, as it relates to frontal lobe functions. So we talk about weighing and deliberating, being able to see the future consequences of your behaviors, certainly, some impulse inhibitions, things like that, sure, there's overlap. Because it's the same brain we're talking about. It's a matter of how it's being affected.
CASEY SECOR: Now, these symptoms -- if I know somebody that has a traumatic brain injury, but I don't know it, how are their symptoms or the manifestations of the traumatic brain injury, how are they frequently interpreted by somebody that's unaware of the fact that they have a brain injury? What would it look like to somebody that doesn't know?
BHUSHAN AGHARKAR: Again, it depends on the severity of the injury. But oftentimes, what people will experience are the guy's a jerk. He's irritable, he's aggressive, he's short with people, maybe his memory isn't so good. But that's typically what people will notice. Maybe his concentration is off. You know, there are things like that can be noticed. Sometimes, you don't notice anything at all. But that doesn't mean there isn't problems, it just means it's not necessarily obvious.
CASEY SECOR: Of course. And this seems like sort of a ridiculous question, but I just feel like I need to ask it. If you receive two brain injuries, my assumption is that's worse than one?
BHUSHAN AGHARKAR: Yeah, yeah. Two is worse than one, three is worse than two. What we think is that, basically, the brain doesn't recover as well after that first injury. So when you hit it again, it's got less reserve, kind of less -- you know, just doesn't bounce back as well. So the more times it gets hit, typically, the worse the outcomes will be.
CASEY SECOR: Okay. Now, I want to go through some of the things that you discovered in your evaluation and review of social history and family history that helped you come to the conclusion that you came to in this case. We've already talked about some of the environmental factors that played in it, like childhood neglect and abuse, right?
BHUSHAN AGHARKAR: Right.
CASEY SECOR: And I think you also touched on family history in terms of Tim's mother and grandmother. And you didn't name other people, but other family members, right?
BHUSHAN AGHARKAR: Yes.
CASEY SECOR: And I think you mentioned hallucinations. Can you just tell the jury based on your evaluation when Tim first experienced that?
BHUSHAN AGHARKAR: So what he reported was first hearing a voice at the age of ten, which told him to kill himself. And that this was different than his own thoughts. And it scared him, it really terrified him. That was his first recollection of voices.
CASEY SECOR: And what do you know about his drug and alcohol use? When did that start?
BHUSHAN AGHARKAR: As I say, it started somewhere around the age of 12 years old. He started smoking marijuana. He started drinking alcohol, think around the age of 13 to 15. And he was experimenting some with cocaine around the age of 19.
CASEY SECOR: What about things like mood swings and depression, did you find any evidence of that?
BHUSHAN AGHARKAR: Yes. That's what people noticed about him, that he would have mood swings and depression. And he actually had seen -- I had seen some psychiatric evaluations of him in which he was complaining of depression as well. And remember, he had a major head injury at the age of 15, a very serious car accident. All this was after that.
CASEY SECOR: And the car accident is what caused the traumatic brain injury, is that right?
BHUSHAN AGHARKAR: Yeah. I think there had been other head injuries as well. I think there were other car accidents, but that one was significant because he has a portion of his skull that's caved in.
CASEY SECOR: And what about past diagnoses, did you review any of those?
BHUSHAN AGHARKAR: I did, yes. And again, they were mostly the depressive types of disorders.
CASEY SECOR: And did you review his -- the evaluation records from when he was discharged from the Navy?
BHUSHAN AGHARKAR: Yes.
CASEY SECOR: And do you recall what influence that had on your opinion?
BHUSHAN AGHARKAR: Well, there again, he was complaining -- there was a substance abuse issue, but, also, the issues of depression with the Navy as well.
CASEY SECOR: Now, there were periods of sobriety in Tim's life, isn't that right?
BHUSHAN AGHARKAR: Yes.
CASEY SECOR: And do you remember the events that led to him returning to drugs and alcohol?
BHUSHAN AGHARKAR: Well, as I recall, primarily, it was after his divorce. That seemed to really hurt him pretty badly and sent him -- he started drinking and smoking marijuana quite a bit after that.
CASEY SECOR: And what about neuropsychological testing that was performed, how did that inform your opinion?
BHUSHAN AGHARKAR: So neuropsychological testing, if you haven't heard about it yet, is brain behavior testing. And it's pencil/paper testing. And so he's given tests to do and then they're timed and they sort of see how he does compared to the general population. And so I reviewed testing in that regard and there were findings of -- well, he had an IQ, I think a score of 89, which is much lower than you'd expect given how intelligent he seemed to be in the past. Additionally, there were, at least, some signs of frontal lobe dysfunction on those tests and some problems with memory, as I remember.
CASEY SECOR: From stuff I've read and our conversations, you told me that an important thing for people who may have mental illness is resilient factors in terms of whether or not -- or how they handle them. Can you just discuss with the jury what you mean by resilient factors and what resilient factors you saw in Tim's life?
BHUSHAN AGHARKAR: Well, what I mean by that is that, so why are some people higher functioning and some people lower functioning, right. So what is it about individuals that cause this variation. So for some, it's because of -- if you're highly intelligent, that can help. You know, you can mask a lot of symptoms. If you have a high education, those things help as well. And that's what I saw here with Mr. Jones. And I think partially why maybe people didn't know about his symptoms because he's able to hide them. He didn't talk to people about it because he was terrified he would end up like his mother, who was institutionalized for most of her life and was obviously very, very ill. But I think what happens is if you have problems with concentration or if you have problems with making decisions or things like this, but you're having a good day and you're very smart, sometimes you can get away with that sort of thing, you know. And people don't always know what you're talking about, but that's also because they think well, you're smarter than me, so maybe I just don't understand you. That's oftentimes what happens as well. So those can be reasons as to why somebody with schizophrenia with those factors can do better than somebody else.
CASEY SECOR: Can a person be smart enough to the point that they're invincible to schizophrenia?
BHUSHAN AGHARKAR: No. There's no barrier to schizophrenia. You can be very smart and schizophrenic.
CASEY SECOR: If you would, discuss with the jury the idea of impairment versus distress when you, as a psychiatrist, is coming to your conclusion about a patient.
BHUSHAN AGHARKAR: Whenever we are assessing somebody and we're assessing somebody's symptoms, how do we decide what's normal versus abnormal, right. Because that's my job, to figure out okay, this is normal, this is okay, this is not, this needs treatment. That's what I've got to figure out. And the way you do that is through deciding if a symptom causes clinically significant impairment or distress. It's an or, it doesn't have to be both. So earlier, as I was saying, you guys have all heard about a functional alcoholic, somebody who has a serious alcohol problem, but still can go to work, still can provide for their family, right, but just comes home and gets hammered every night, right. I would argue there's maybe some impairment there, but oftentimes, you won't see impairment in a lot of other areas. But, clearly, that's somebody who has a significant problem. They are something that most people wouldn't be doing, right. So same thing with feeling sad. All of us have felt sad in this room, right, but not all of us are depressed. So the way we decide is this depression normal or abnormal is, is it causing you significant impairment or distress. So the same way you look at hallucinations or delusions and things like this is, it doesn't necessarily have to cause impairment in somebody's functioning because again if -- you know, sometimes -- in his case, he took drugs, he said that that helped calm the voices and quiet them and allowed him to function. So sometimes people can do that. Sometimes if they're smart, they can find ways to try to adapt and cope so that they're not impaired, but they can still be very distressed by the symptoms that they're having. And that would be a mental illness.
CASEY SECOR: Based on everything that you've reviewed about Tim and what you did on the case, did you consider the possibility that what he has is substance-induced psychosis?
BHUSHAN AGHARKAR: Yes, I considered that.
CASEY SECOR: Okay. And can you tell the jury what your opinion on that is?
BHUSHAN AGHARKAR: So we know that he started using spice a great deal really in the last three months before these events occurred. And so, honestly, when asked to think about well, was it the drugs that caused this issue, well, the first thing is that he told me that the drugs calmed him, that the drugs actually let him function. They quieted the voices, they reduced his irritability, they helped his moods so he was able to actually function and go on. He was using drugs through that time and people didn't think he was psychotic. He wasn't doing anything flagrantly psychotic, openly hallucinating in front of them, that sort of thing. So it wouldn't be as a cause of substances as I would see it from there. But to me, I think the biggest piece of evidence in that is that he has been treated for schizo-affective disorder, but, basically, schizophrenia in the jail for four and a half years with high doses of antipsychotic medicines and there's no way substances would be causing him to have problems now four years later. Additionally, my examination of him is absolutely consistently with someone with schizophrenia. But again, I think the fact that he's been treated in the jail for as long as he's been treated with antipsychotics says this is a real psychotic illness that he has. This is not caused by drugs.
CASEY SECOR: You're aware of the medication that he's been given by the State of South Carolina, right?
BHUSHAN AGHARKAR: Yes.
CASEY SECOR: Okay. Is it legal to give those medications to somebody that does not have a psychotic mental illness?
BHUSHAN AGHARKAR: Well, I guess I don't know if it would be legal or not, but it's certainly unethical, it would be malpractice to give somebody medication for a disorder they don't have and don't need it for.
CASEY SECOR: Is it enjoyable to be on the medications that Tim is on?
BHUSHAN AGHARKAR: No, it is definitely not.
CASEY SECOR: What would I look like if I took the medications that Tim is on?
BHUSHAN AGHARKAR: You would be on the floor. I don't think you would be awake for much of the day, if any part of the day. They're highly sedating. The doses he's on are serious doses. A quote, unquote, a normal person who isn't psychotic takes those medicines, you'll sleep for days.
CASEY SECOR: How do you know that Tim wasn't faking?
BHUSHAN AGHARKAR: So faking or malingering is something I'm always considering in a forensic context, that somebody is trying to say they've got something they don't have. So it's certainly something I considered. But in my opinion, no, he's not faking this. Number one, people can -- people can tell you I'm hallucinating, right. You don't know whether that can be true or not true. So you look for behavioral signs of that and there's certainly are things that go along with that. Number one, he often has a restrictive range of affect. He's often very flat in discussing things. He describes hallucinations that are typically consistent with what we'd expect in people with schizophrenia. Remember that when somebody has schizophrenia and brain damage, oftentimes, they may be a little unusual in the way they present. That's part for the course when you have a brain injury as well.
He -- his thoughts -- when you allow -- oftentimes, the way I interview, I ask questions and then I'm quiet, just let them talk because I just want to see where his thoughts go. Does he stay on task or do things get disorganized and he got disorganized. I would often have to bring him back to the topic. I would often have to reframe the question or redirect him to get an answer. And you see that in people with brain disorders. Many of these things, especially thought disorganization, that's very hard to fake. Our brains typically want to be linear and logical in discussing things. People don't know to fake it, number one. And two, it's very difficult to do. He's been treated with medication for many years now. He says the voices are almost completely eliminated since taking the medication. He feels better with the medicine. Those things would be consistent with what you would expect in mental illness. He certainly cannot fake the neuro-imaging results, right, we see what his brain looks like. You can't fake that. That's certainly -- the damage is there. And then he performed well on effort testing by the psychologists who gave him different tests and things. And so for all those sorts of reasons, I have no reason to think that he is faking.
CASEY SECOR: Your Honor, may I have just a moment?
THE COURT: You may.
CASEY SECOR: May I approach, Your Honor?
THE COURT: You may.
CASEY SECOR: Dr. Agharkar, I just want to ask if you recognize what has been marked for identification purposes Defendant's Exhibit 131?
BHUSHAN AGHARKAR: Yes. This is a copy of the report that I prepared in this case.
CASEY SECOR: Is it an exact copy of the actual report?
BHUSHAN AGHARKAR: Yes.
CASEY SECOR: Your Honor, the Defense would offer Defense Exhibit 131, Dr. Agharkar's report, at this time. The State, I believe, objects.
SUZANNE MAYES: Yes, sir, Your Honor, we object, improper bolstering. Certainly, we've heard his report during his testimony.
THE COURT: 131?
CASEY SECOR: Yes, sir.
THE COURT: That's just a summary of his report to which he has testified, more or less in summary form?
CASEY SECOR: It's his actual report, but, yes sir.
THE COURT: I thought the general rule was reports stay out because he's here live to testify and you can question him till your heart's content.
CASEY SECOR: Okay. I appreciate it. Can I make it a Court's Exhibit?
THE COURT: So that's my -- you may.
COURT REPORTER: Judge, that will be number 89. (WHEREUPON, Court's Exhibit number 89 was marked for identification.)
CASEY SECOR: Your Honor, Defense 131 has now been marked Court's 89.
THE COURT: All right.
CASEY SECOR: Thank you.
THE COURT: You're welcome.
CASEY SECOR: Dr. Agharkar, one thing I forgot to ask you about earlier in terms of how schizophrenia manifest, which I think you said sometimes they're consistent with how traumatic brain injuries manifest. Can you discuss with the jury the idea of pressured speech or what that means?
BHUSHAN AGHARKAR: Yeah, kind of what I've been doing. I talk fast, but I can slow it down when I need to slow it down. When given feedback, I can adjust. When somebody has pressured speech, it's a psychiatric symptom. You often see it in people who are -- who may have mania, so they talk a mile a minute. They're rushing to get everything out in a very quick way. I would totally do it right now, but I think she'll kill me so I'm not going to do it. But it's talking a mile a minute and really just, you know, pressured to get -- like you've got to get it all in in a certain amount of time. That's what pressured speech is. And it is a sign of both brain injury as well as mental illness.
CASEY SECOR: Can I have one just --
THE COURT: Sure.
CASEY SECOR: Just one last question, Doctor -- in your practice, have you ever prescribed somebody Chantix?
BHUSHAN AGHARKAR: I have prescribed it once.
CASEY SECOR: And why only once?
BHUSHAN AGHARKAR: And why only once?
CASEY SECOR: Why only one time?
BHUSHAN AGHARKAR: So Chantix, as you may know from TV commercials, is an anti-smoking drug, smoking cessation medicine, but it can cause neuro-psychiatric effects. You know, it works in the brain, so it can worsen the risk for suicide. It can worsen depression or anxiety. My patients are often complicated and have those problems already, so I tried it once with somebody who I thought would be a good candidate and it made his depression symptoms worse. He got more irritable, more sort of restless and worsened his depression. He didn't like it. We stopped it pretty quick. So that's the only time I tried it.
CASEY SECOR: Thank you, Dr. Agharkar. I appreciate it.
THE COURT: All right. The jury has asked for a break, so we'll take a break. When y'all get done, let us know. (Whereupon, the jury was excused from open court for a break.)
(WHEREUPON, a short break was taken.)
THE COURT: Bring the jury in. (Whereupon, the jury came into open court at approximately 11:15 a.m.)
THE COURT: Ms. Mayes.
SUZANNE MAYES: Yes, sir, Your Honor.
CROSS-EXAMINATION BY MS. MAYES:
SUZANNE MAYES: Doctor, I just want to clear up a few things before we get started. First, I want to ask you to clarify what you said before on direct examination about your payment. I believe you said you've been paid upwards of $25,000.00 dollars for this case?
BHUSHAN AGHARKAR: Right.
SUZANNE MAYES: But you were hired by the Defense, correct?
BHUSHAN AGHARKAR: That's correct.
SUZANNE MAYES: So when you said you were paid by the State, you're referring to the fact that if it's an indigent Defendant, then you would be paid out of an indigent defense fund, correct?
BHUSHAN AGHARKAR: That's my understanding, correct.
SUZANNE MAYES: But, no doubt, in this case, you were not appointed by the Court?
BHUSHAN AGHARKAR: Right.
SUZANNE MAYES: You were not hired by the State?
BHUSHAN AGHARKAR: Correct.
SUZANNE MAYES: Defense counsel sought you out and hired you?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: And I believe you've given testimony as recently as 2018 that in death penalty trials, you have testified exclusively for the Defense, correct?
BHUSHAN AGHARKAR: That is correct. In death penalty cases, correct. I've worked for prosecutors, but not in Capital cases.
SUZANNE MAYES: And there have been numerous death penalty cases that you've testified in, but always for the Defendant, correct?
BHUSHAN AGHARKAR: Yes, that's right.
SUZANNE MAYES: And always hired by the Defendant?
BHUSHAN AGHARKAR: Right.
SUZANNE MAYES: So tell us a little bit about how you became involved in this case. When did they first reach out to you about meeting with Timothy Jones after his arrest?
BHUSHAN AGHARKAR: Well, like I say, I had to have received a phone call, I imagine, or possibly an email, but probably a phone call just asking if I had time to take a case. And that's about it. Like I say, I don't have my billing in front of me, but if I saw him in early 2017, knowing what my schedule is like, I typically am booking three to six months out. So I can estimate that probably late 2016 I was contacted.
SUZANNE MAYES: All right. I'm going to ask you a few more questions about that, but, first, I just want to make clear, you are here to testify that after his arrest, it's your opinion that he meets the criteria for a diagnosis of schizophrenia, correct?
BHUSHAN AGHARKAR: Yes, that's right.
SUZANNE MAYES: You are not giving us an opinion as to his mental state on the date of the killings of his children, correct?
BHUSHAN AGHARKAR: Correct. I did not perform a criminal responsibility evaluation. I'm leaving that to others.
SUZANNE MAYES: So you're leaving that to others and you're offering no opinion in this court today as to his mental state regarding the killings?
BHUSHAN AGHARKAR: Right. As it relates to criminal responsibility, correct.
SUZANNE MAYES: On the date and time of these killings, which was August 28th, 2014, correct?
BHUSHAN AGHARKAR: Correct.
SUZANNE MAYES: And when you said you're giving no opinion on criminal responsibility, I want to go a little bit further and just have you explain that in terms that we all understand. You're not giving an opinion as to whether he knew the difference between right and wrong, correct?
BHUSHAN AGHARKAR: Correct.
SUZANNE MAYES: You're here to testify that based on your examination of him, the first being February 21st, 2017, it's your opinion he met the criteria for schizophrenia, correct?
BHUSHAN AGHARKAR: That's correct. Of course, you're doing it by historical information as well, but, certainly, as of my evaluation, yes, that's right.
SUZANNE MAYES: So I want to follow-up on that. I believe your first interview with him was February 21, 2017, correct?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: So approximately two and a half years after the murders?
BHUSHAN AGHARKAR: Approximately so, yes.
SUZANNE MAYES: And that meeting or interview with him was 2.25 hours, correct?
BHUSHAN AGHARKAR: If that's what I wrote down in the report, yes.
SUZANNE MAYES: So two hours and 15 minutes?
BHUSHAN AGHARKAR: Correct.
SUZANNE MAYES: And then you had one more meeting with him September 27th, 2018, correct?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: And that meeting was one hour and five minutes, correct?
BHUSHAN AGHARKAR: I'll take your word for it if it's in the report, yes.
SUZANNE MAYES: So the entire time that you spent with Timothy Jones leading up to this diagnosis after his arrest was a total of three -- roughly, three and a half hours?
BHUSHAN AGHARKAR: That's right.
SUZANNE MAYES: Two interviews?
BHUSHAN AGHARKAR: Yep.
SUZANNE MAYES: And you testified that you did rely on some historical data, meaning all those records that you told us about earlier?
BHUSHAN AGHARKAR: Yeah.
SUZANNE MAYES: Family history, all of those things. But, ultimately, when it came to giving a history of delusions, hallucinations, that came straight from Timothy Jones, correct?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: So it was self-reported by him?
BHUSHAN AGHARKAR: Right, that's how we make the diagnosis.
SUZANNE MAYES: Is it fair to say, Doctor, when you are relying on the patient for that history and for that diagnosis, is it fair to say that you should consider whether or not he's been a reliable historian in the past?
BHUSHAN AGHARKAR: Sure, to some extent. But the mentally ill are often unreliable, so you have to take it with a grain of salt.
SUZANNE MAYES: So mentally ill people can be unreliable in even giving histories about themselves, is that your testimony?
BHUSHAN AGHARKAR: Yes, that can happen, sure.
SUZANNE MAYES: But they can also intentionally lie or withhold information when it benefits them, correct?
BHUSHAN AGHARKAR: Sure. Anyone can do that.
SUZANNE MAYES: So were you aware in this case that the Defendant has told many different stories about what happened on the night of the murders?
BHUSHAN AGHARKAR: I'm not aware of many, but I didn't interview him about the incident itself.
SUZANNE MAYES: Did you consider all the different versions, stories that were told to various law enforcement officials around -- along the way?
BHUSHAN AGHARKAR: I couldn't recite it for you, but I'm certainly aware of what he said to police, sure.
SUZANNE MAYES: Okay. So the night that he was initially stopped by law enforcement on September 6th, 2014, you're aware that he initially told the officer who stopped him at the checkpoint that his vehicle smelled because he had garbage in it?
BHUSHAN AGHARKAR: I think -- yes, I recall reading that. And, ma'am, I know you're moving farther away from me, but there's an AC thing right above my head, so it's very difficult.
SUZANNE MAYES: I'll speak up. I'll speak up.
BHUSHAN AGHARKAR: Okay.
SUZANNE MAYES: And then in addition to that, you're aware that one of the officers who arrived there at the scene of that stop questioned him about where his children were?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: And you're aware he told that officer, I don't have any children?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: And then when he was re-questioned by the same officer, he goes on to say, Well, I have three children, but they're in South Carolina with their mother, correct?
BHUSHAN AGHARKAR: I'm not sure I recall that, but if you represent it that way, I'll agree.
SUZANNE MAYES: And then he told numerous law enforcement officials along the way that the children had been put out of the car at Wal-Mart, that they were safe, but he put them out of the car, correct?
BHUSHAN AGHARKAR: I recall seeing something like that once, yes.
SUZANNE MAYES: Led law enforcement to believe that they're still alive somewhere in South Carolina, correct?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: And then, eventually, when he's pinned down by an FBI agent and this detective here and questioned about the contents of his vehicle where he had bought numerous items to dismember the bodies of his children, you are aware he came up with numerous lies to explain away those items, correct?
BHUSHAN AGHARKAR: Yes. He gave several statements about why he had those things, yes.
SUZANNE MAYES: He gave an explanation for why he bought the muriatic acid?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: He gave an explanation for why he had those jab saws, said he was going to cut tree limbs with them?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: He even gave explanations as to why he had blood in his Cadillac Escalade?
BHUSHAN AGHARKAR: I don't recall.
SUZANNE MAYES: And having reviewed that long list of materials that you told us about and the $400.00 dollars an hour to review those materials, do you recall him saying that the reason there was blood in the car is because of an animal, an animal had bled in his car?
BHUSHAN AGHARKAR: I don't remember. I didn't memorize all the records I read.
SUZANNE MAYES: And then, ultimately, he said, well, it's me. I bled in the car.
BHUSHAN AGHARKAR: I don't recall that.
SUZANNE MAYES: So is it fair to say he's given a lot of different versions about what happened up until he, ultimately, admitted to killing the children?
BHUSHAN AGHARKAR: That doesn't sound like a lot of different things about what happened. That's a lot of explanations about why things are where they are, but that's not an explanation of what happened that night.
SUZANNE MAYES: So in your opinion, he would still be a reliable historian having told all those different stories?
BHUSHAN AGHARKAR: I guess it depends on what.
SUZANNE MAYES: Okay.
BHUSHAN AGHARKAR: What history we're gathering.
SUZANNE MAYES: And that's part of what I'm asking you about, is whether or not you, as the diagnostic doctor in this case, whether or not you consider him to be a reliable historian. It sounds like even considering all of those things I just mentioned, you do consider him to be a reliable historian?
BHUSHAN AGHARKAR: For the most part, yes, about psychiatric symptoms, yes, and describing his past history. There were things he could not recall. There were things he was not able to fill in for me. And that does happen, but I never thought he was lying to me about those things.
SUZANNE MAYES: So you pretty much take him at face value, correct?
BHUSHAN AGHARKAR: No, I don't know if I take anyone at face value. I'm looking for a consistency or inconsistency. And I saw consistency in both his appearance, in terms of what I was able to observe. And also what he was telling me for psychiatric symptoms, understanding that I did not interview him about any of those things you were just talking about. But don't have anything to do with schizophrenia, frankly.
SUZANNE MAYES: So when you questioned him about drug usage, what did he say in that regard?
BHUSHAN AGHARKAR: As I mentioned earlier, that experimentation, you know, age 12, 13, 15 years old or so, then again -- and he had a longer period of time where he was sober, that it worsened after his divorce. He started using spice as well in about three months, like May to August before this happened.
SUZANNE MAYES: May to August. Okay. So he did report to you that he was using the drug known as spice, illegal here in South Carolina, in that period of time between May of 2014 up through August of 2014?
BHUSHAN AGHARKAR: Yes, that's right.
SUZANNE MAYES: Roughly, that three-month period. How many times or how frequently did he report to you that he was using spice?
BHUSHAN AGHARKAR: I believe that it was like daily, but I'd have to check my report again.
SUZANNE MAYES: So he told you that he was using spice daily. Did you question him as to whether he was using spice on August 28th, the date that the children were killed?
BHUSHAN AGHARKAR: As I recall, he said he had used it earlier that day.
SUZANNE MAYES: So he told you he used spice the day of the killings?
BHUSHAN AGHARKAR: That's my recollection.
SUZANNE MAYES: But yet, you're also aware he told that FBI agent and this detective he didn't use spice at all that day, correct?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: So now we're talking about something specific as to the date of the killings and that's not reliable information, is it, because he's giving two completely different stories?
BHUSHAN AGHARKAR: Well, you know, some of these drugs impair memory as well. So, you know, for that particular issue, yeah, there may be an issue of reliability in terms of what happened or what didn't happen. That's not pertinent, however, to my diagnosis.
SUZANNE MAYES: And that's reliability as to a material event on the day of the killings, correct, whether or not he used spice on that day?
BHUSHAN AGHARKAR: Right.
SUZANNE MAYES: And when we talk about spice, you're familiar with the effects of spice, which contains the ingredient AB Pinaca?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: And those effects include paranoia, agitation, anxiety, confusion, altered mental status and hallucinations, correct?
BHUSHAN AGHARKAR: Sure, that can happen.
SUZANNE MAYES: And he tells you he's using that drug with those side effects on the date of these crimes?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: That's what he told you?
BHUSHAN AGHARKAR: That's right. But, of course, that's why I further inquired about the typical effects that drug has on him and he reported the opposite of those types of symptoms.
SUZANNE MAYES: So he tells you I'm using spice on the date of the killings, which can cause all of those symptoms, but I didn't experience any of them?
BHUSHAN AGHARKAR: No, I'm not talking about that day particular, I'm talking about three months prior, a month prior, any of the times he's using it. He said that it quieted the voices for him.
SUZANNE MAYES: So for him, it didn't seem to exacerbate any type of condition because he's not experiencing anything when he's on spice according to what he told you?
BHUSHAN AGHARKAR: Right.
SUZANNE MAYES: No adverse reaction at all?
BHUSHAN AGHARKAR: At least, that he's aware of. I imagine there probably was some because drug users often do not have good insight into their behaviors when they're using, but that's what he's reporting.
SUZANNE MAYES: And then you mentioned some of what went into your determination as to whether or not he may be malingering. And that's just a fancy term for faking it, right?
BHUSHAN AGHARKAR: Yes, it's faking with a purpose. It's faking it to get out of something, that's typically what malingering means.
SUZANNE MAYES: Faking it to get out of a charge, for example?
BHUSHAN AGHARKAR: Could be.
SUZANNE MAYES: And you said part of what you considered is that when you met with him on those two occasions for that total of roughly three and a half hours that you noted that he had a restricted range?
BHUSHAN AGHARKAR: Of affect, yes.
SUZANNE MAYES: Flat affect?
BHUSHAN AGHARKAR: Correct.
SUZANNE MAYES: Doctor, you're also aware he was taking extremely high dosages of the antipsychotic drug, Geodon, at the time, correct?
BHUSHAN AGHARKAR: Correct, yes.
SUZANNE MAYES: Having been prescribed to him following his arrest, part of the treatment plan that other physicians came up with?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: And that drug, Geodon, is known to result in exactly what you're describing, correct, flat affect?
BHUSHAN AGHARKAR: You know, it can, but in my opinion, no, that's not what this was. The reason being is because when I did see him, he was on a high dose. The second time I saw him he was not, his affect is the same.
SUZANNE MAYES: And let me ask you about that a little bit more. What do you consider -- as a psychiatrist, what do you consider to be a high dosage of Geodon?
BHUSHAN AGHARKAR: Eighty twice a day, I've seen a hundred twice a day. I don't think I've ever seen -- he was treated with 160 twice a day. I don't think I've ever seen a dose that high before. That tells me about his severity of symptoms.
SUZANNE MAYES: So he was taking up to 320 milligrams of Geodon a day, correct?
BHUSHAN AGHARKAR: Correct. How he was standing, I don't know, but he was standing -- he was having a conversation with me, no problem, taking it.
SUZANNE MAYES: And one of the other things that you mentioned in considering that he's not faking it, as you put it, is that he could not stay on task. That's one of the things I wrote down as you testified earlier on direct examination?
BHUSHAN AGHARKAR: Yeah, what I was talking about was thought disorganization. That's a very difficult symptom to fake. That's correct, he did exhibit thought disorganization.
SUZANNE MAYES: All right. So when we talk about thought disorganization, inability to stay on talk is specifically what you mentioned was your observation of him during that interview. I'm going to ask you to take a look at what is State's 186 in evidence. And this includes the known side effects of that drug, Geodon and, specifically, as to the cognitive and motor impairment known to be caused by that drug. And that would be State's 186.
BHUSHAN AGHARKAR: You want me to read the whole thing or just the first page?
SUZANNE MAYES: No, I just want you to review it.
BHUSHAN AGHARKAR: Okay.
SUZANNE MAYES: So considering the known side effect of Geodon and the fact that he's taking twice what you would consider to even be a maximum dosage beyond, you said, anything you would ever prescribe to a patient, Doctor. It's certainly within the realm of possibility that what you observed to be cannot stay on task is a result of the Geodon side effects, correct?
BHUSHAN AGHARKAR: No. I didn't see anything in him that I just read on that paper. I know what side effects look like for medicine, he didn't have it, not in either of my examinations. And again, remember, I saw him a second time when he was on less, much less of the Geodon then and they added actually another antipsychotic, so he was taking two on the second time. He was not somnolent, he didn't have impaired -- all these things that are written here, no.
SUZANNE MAYES: So it's your opinion then that he was functioning absolutely fine cognitively having taken 320 milligrams of Geodon?
BHUSHAN AGHARKAR: Yes, at least, when I saw him, yes, I felt that way.
SUZANNE MAYES: You felt he was functioning at perfectly normal levels?
BHUSHAN AGHARKAR: I wouldn't say he was perfectly normal, he's schizophrenic. So within reason for what I expect somebody with schizophrenia who's taking the medicines he's taking, I was able to interview him -- let me put it to you another way. If I had had concerns the medicine was affecting things, I would have written that down in the report. I would have maybe seen him more often, something else, if I had concerns about the information that I was getting or how I was seeing him that day. Because I have seen people who are heavily sedated on medication and I'll make those types of statements either in the reports or to the attorneys.
SUZANNE MAYES: So on that same topic, which would be the ultimate effects of that 320 milligrams of Geodon, one of the things that you noted that you relied on was testing conducted by a Tora Brawley at the request of the Defense back in 2016, correct?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: And that testing was also conducted after he had been prescribed Geodon, correct?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: And you specifically note that the results of that testing done in 2016 after his arrest showed a full scale IQ of 89?
BHUSHAN AGHARKAR: Right.
SUZANNE MAYES: Eight-nine IQ. Doctor, you had that big list of things that you relied on. You're aware this individual is a computer engineer, correct?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: Graduated Summa Cum Laude from Mississippi State University, correct?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: Numerous academic awards and achievements leading up to his graduation, correct?
BHUSHAN AGHARKAR: Sure.
SUZANNE MAYES: And then performing not just satisfactorily, but exceeding expectations at a high level advanced job at the Intel Corporation in 2014, correct?
BHUSHAN AGHARKAR: Yes, I saw some job evaluations that said that, some were satisfactory, yes, but that's right.
SUZANNE MAYES: The most recent one in 2014, just months before these crimes, he was noted to be working exceedingly above expectations and was promoted in March of 2014 by Intel. You're aware of that?
BHUSHAN AGHARKAR: Right.
SUZANNE MAYES: So that's his status leading up to his arrest. And then after he's incarceration, he's prescribed these, what you consider to be high level of -- dosage level of Geodon, above what you would ever prescribe for a patient. And his full scale IQ in 2016 while on Geodon is 89, correct?
BHUSHAN AGHARKAR: Right.
SUZANNE MAYES: And you relied on that information?
BHUSHAN AGHARKAR: I did. I'm not a psychologist. They're the ones who have to give the tests. She believed that to be accurate. She did not find him to be faking in her evaluation. I think it represents a deterioration in cognitive functioning.
SUZANNE MAYES: Are you taking into consideration today during your testimony of what role Geodon played in that?
BHUSHAN AGHARKAR: Yes, Geodon does not reduce IQ scores.
SUZANNE MAYES: So you don't believe that his cognitive functioning was impaired at all by those high dosage levels of Geodon?
BHUSHAN AGHARKAR: Typically, when you see a side effect of medicine causing some sort of problem on testing, typically, it has to do with motor functioning or processing speed. Those are typically the two areas that you see it in. So I can certainly submit that -- and she actually says that in her testing, too, that she thinks that some of the scoring would be affected because of those two things, but she would not attribute it all to that. And there were other things that were affected that would not be caused by medicine.
SUZANNE MAYES: So another thing that you addressed and seemed to rely on is the information about the car accident that he was in back in 1998 when he was 15?
BHUSHAN AGHARKAR: Right.
SUZANNE MAYES: And you've also reviewed as part of that Appendix A that was marked for identification his testing scores from the State of Illinois 11 months after that incident, correct?
BHUSHAN AGHARKAR: I'd have to see it again. I don't remember. Are these academic testing?
SUZANNE MAYES: Correct.
BHUSHAN AGHARKAR: Okay. I would just point out academic testing is not neuropsychological testing. Academic testing is not meant to measure brain functioning.
SUZANNE MAYES: So when we talk about the Illinois testing, would it surprise you to learn that 11 months after the injuries, he tested above his school, his District and the State in numerous levels of academic excellence?
BHUSHAN AGHARKAR: Again, I think he's a -- was, at least, a very smart person, so that doesn't necessarily surprise me. And again, as I mentioned, the smarter you are, the more you can mask the symptoms you're having.
SUZANNE MAYES: When you talk about masking the symptoms, Doctor, you would have to mask it in multiple levels of academic testing on multiple subjects, correct?
BHUSHAN AGHARKAR: Sure. The question is strained. This is not how schizophrenia would present. We don't give schizophrenics academic tests and see how you do.
SUZANNE MAYES: And my question is specifically about the traumatic brain injury because that's something that you noted, so we're not talking yet about what your diagnosis would be regarding schizophrenia. I believe your testimony is that would present later in life most commonly?
BHUSHAN AGHARKAR: Most commonly, correct.
SUZANNE MAYES: But I'm asking about the -- what you termed the brain injury because it was something that you noted --
BHUSHAN AGHARKAR: Sure.
SUZANNE MAYES: -- specifically and said you relied on --
BHUSHAN AGHARKAR: Fair enough.
SUZANNE MAYES: -- that injury occurred in March of 1998. So I'm asking that 11 months later when tested by the State of Illinois, specifically in the area of application and decision making, he tested above the school, District and the State. Are you aware of that?
BHUSHAN AGHARKAR: That's fine. I may have read that. That's not a frontal lobe test. I would put no stock in that whatsoever as regard to frontal lobe functioning.
SUZANNE MAYES: So his test results post-injury would not be of any significance to you?
BHUSHAN AGHARKAR: No, I would certainly consider it and I did consider it. But I'm saying sometimes -- sometimes you see effects from the injury immediately, sometimes they may take five, ten years to present, so it really just depends. What I'm saying to you is you're using the wrong test to measuring functioning. By implying that somehow academic testing equals no brain damage is false, that's not an accurate statement. So that's what I'm trying to -- that's not right.
SUZANNE MAYES: So why is it, Doctor, that you mentioned the Chantix both in your opinion and in your testimony today? Why did you mention that?
BHUSHAN AGHARKAR: Because I was asked the question.
SUZANNE MAYES: Well, how exactly does Chantix relate to this case involving Timothy Jones?
BHUSHAN AGHARKAR: Well, I believe he was taking Chantix to try to quit smoking somewhere right before the incident occurred, but I don't really know the details on it. I seem to recall that he may have missed a dose or two here and there, so then he doubled the dose to make up for it. All I know is that it can cause neuropsychiatric effects, but I'm not saying more than that.
SUZANNE MAYES: Let me show you what is State's Exhibit 197 in evidence. Were you provided that document?
BHUSHAN AGHARKAR: I can't recall. If it's on the list, then, yes, but I can't remember a three-page medical record.
SUZANNE MAYES: Well, this medical record relates specifically to the Chantix that you mentioned and that you just testified to on direct examination.
BHUSHAN AGHARKAR: I think I literally said one sentence about Chantix.
SUZANNE MAYES: Okay.
BHUSHAN AGHARKAR: So it's not really a big part of my opinion, by any means.
SUZANNE MAYES: Well, one of the things you testified to on direct is that Chantix can aggravate a condition?
BHUSHAN AGHARKAR: Yes, that's right.
SUZANNE MAYES: Is that your testimony?
BHUSHAN AGHARKAR: That's true.
SUZANNE MAYES: But you don't have any information as to whether Timothy Jones was using Chantix anywhere around the timeframe of these crimes, do you?
BHUSHAN AGHARKAR: Not that I can recall, no, but I'm sure -- again, my examination was not a mental state at the time of the event, so I really wouldn't have dug that deeply into that.
SUZANNE MAYES: That's why I'm asking why it was testified to on direct? What connection does it have to the schizophrenia diagnosis?
BHUSHAN AGHARKAR: You're asking the wrong person. You should ask the attorney that. He asked me a question about the medicine, I answered the question about the medicine.
SUZANNE MAYES: All right. So, Doctor, regarding this Chantix, you're aware that according to Timothy Jones, he was prescribed Chantix in February of 2014, so roughly six months before the murders. According to him, he did well on Chantix in the past --
CASEY SECOR: Your Honor, I have an objection. May we approach?
THE COURT: You want to do it right here? All right. (WHEREUPON, a bench conference was held as listed below.)
CASEY SECOR: My objection would be to, Ms. Mayes, the use to the word, murder.
SUZANNE MAYES: I can rephrase that.
THE COURT: She was trying to use killing, I think.
CASEY SECOR: The second is that, the only question I asked Dr. Agharkar regarding Chantix, general question about his experience with a patient of his. I did not ask him whether or not it applied to this case. It is inappropriate impeachment for her to try to attack his credibility on an issue that he did not say, I ask him a complete and general question about whether he had ever prescribed it to somebody which all he said was yes.
THE COURT: One time.
CASEY SECOR: In one situation and it exacerbated the condition.
SUZANNE MAYES: I am not going to spend a lot of time on this.
THE COURT: But he did say I didn't consider in his time of the event because I didn't study the time, the criminal responsibility portion. He said that, stay away from that.
SUZANNE MAYES: I just need to clear up, since it was brought up in direct, that he doesn't have any information in this case linking to this.
THE COURT: You limit to that you are good.
CASEY SECOR: Thank you.
THE COURT: So sustained to your two grounds and she is going to clear that up.
CASEY SECOR: Thank you, sir.
BY MS. MAYES:
SUZANNE MAYES: So as to the Chantix, were you made aware that he took roughly nine pills since February of 2014?
SUZANNE MAYES: Noted, according to the exhibit, that there were no adverse effects. So that really doesn't play a role in your diagnosis at all, correct?
BHUSHAN AGHARKAR: I didn't see anything in here in what I just read, where they actually talked to him about adverse events as a result of it.
SUZANNE MAYES: Well, "did well in the past"?
BHUSHAN AGHARKAR: Sure, but that's assuming -- I don't know what that means. I assume what that means is he quit smoking, but that doesn't mean he didn't have an adverse psychiatric effect from it. You can still have a side effect, but it still helps you quit smoking.
SUZANNE MAYES: Well, if he did, he certainly didn't report it to that doctor at the time of that prescription, correct?
BHUSHAN AGHARKAR: Or the doctor didn't ask. I mean, this looks to me like a primary care doctor's note. They have a lot to do in one visit and I can guarantee you -- because I get referrals all the time from primary care doctors they are not taking in-depth psychiatric histories.
SUZANNE MAYES: The bottom line is, Doctor, you don't have any information as to when he last took Chantix, correct?
BHUSHAN AGHARKAR: I agree with you on that.
SUZANNE MAYES: With schizophrenia, there is most often a downward slide affecting one's life and career, correct?
BHUSHAN AGHARKAR: That is often seen, yes, correct. Doesn't always happen, though, but yes.
SUZANNE MAYES: I believe your testimony earlier on direct is that during those two meetings with the Defendant, during that three and a half hours, quote, I did not see disorganized behaviors, correct?
BHUSHAN AGHARKAR: Correct.
SUZANNE MAYES: And again, Doctor, you're giving us no opinion whatsoever as to whether he knew the difference between right and wrong on August 28th, 2014, correct?
BHUSHAN AGHARKAR: That's right. I'm not providing an opinion on that.
SUZANNE MAYES: Everything you're telling us is based on your diagnosis of him after his arrest, correct?
BHUSHAN AGHARKAR: Yes, that's right. Now, keep in mind, nobody wakes up one day and is schizophrenic, so I can see through the past history that he was developing symptoms. I mean, obviously, he's being in the jail, but everything is post crime.
SUZANNE MAYES: And when you say you can see, you're referring to you could see from his self-reported symptoms to you, correct?
BHUSHAN AGHARKAR: Yes, that's one part of it, but there's also in the social history other people who were interviewed who noted weird things about him, talking to himself, talking like people who were there weren't there.
SUZANNE MAYES: Who is that?
BHUSHAN AGHARKAR: Babysitter. And I just can't recall her name.
SUZANNE MAYES: Are you referring to Chrystal Ballentine?
BHUSHAN AGHARKAR: Yes.
SUZANNE MAYES: But you've never actually talked to Chrystal Ballentine, have you?
BHUSHAN AGHARKAR: I did not. I read an interview of her.
SUZANNE MAYES: All right. Chrystal Ballentine never said that he saw people that weren't there?
BHUSHAN AGHARKAR: I didn't say -- I didn't say --
SUZANNE MAYES: Okay.
BHUSHAN AGHARKAR: -- I didn't -- that is not what I said. I said talked to people who were not there. That's what she said.
SUZANNE MAYES: All right. I believe, Doctor, if you're going to rely on that information, what Chrystal Ballentine reported is that she was in another room and heard him in another room talking, correct?
BHUSHAN AGHARKAR: Correct, to no one.
SUZANNE MAYES: And do you know whether or not he was on the phone?
BHUSHAN AGHARKAR: I don't, but she didn't say he was on the -- she would have said something like he was on the phone.
SUZANNE MAYES: Right.
BHUSHAN AGHARKAR: And the context of the interview was that was weird. I thought there was somebody else in the room with him and there wasn't.
SUZANNE MAYES: And Chrystal Ballentine was also his girlfriend at the time in addition to being his babysitter, correct?
BHUSHAN AGHARKAR: That's my understanding.
SUZANNE MAYES: We're talking about roughly 2012 when he was going through his divorce?
BHUSHAN AGHARKAR: That sounds right. I got to trust you on that.
SUZANNE MAYES: And you are also aware he was using substances, such as alcohol and marijuana frequently during that timeframe, correct?
BHUSHAN AGHARKAR: I am aware.
SUZANNE MAYES: Nothing further.
THE COURT: Mr. Secor.
CASEY SECOR: Nothing further, Your Honor. Thank you.
THE COURT: You may step down.
BHUSHAN AGHARKAR: Thank you, guys.
THE COURT: Safe travels.
BHUSHAN AGHARKAR: Thank you.
THE COURT: All right. Y'all's planning -- the jury is going to eat about 12:30ish. It's about five minutes to 12:00, so with that in mind, we'll go forward. Is that right, Madam Clerk?
COURT CLERK: Yes, sir, supposed to go at 12:30.
SUZANNE MAYES: Judge, your microphone.
THE COURT: Is it on or off?
SUZANNE MAYES: We're having trouble.
THE COURT: Oh, okay, sorry. I was talking to my jury. We've got lunch coming at 12:30, so I want them to be mindful of that. They kind of know more about the witnesses.