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Rojas v. Astrue

March 22, 2010


The opinion of the court was delivered by: Denise Cote, District Judge


Plaintiff Carmen M. Rojas ("Rojas") brings this action pursuant to § 205(g) of the Social Security Act, 42 U.S.C. § 405(g), seeking review of the final decision of the Commissioner of Social Security ("Commissioner") denying her eligibility for Supplemental Security Income ("SSI") benefits as provided for under the Social Security Act ("the Act"). The Commissioner has moved for judgment on the pleadings affirming his final decision. The petitioner has cross-moved for judgment on the pleadings asserting the Commissioner's decision was based on legal error and is not supported by substantial evidence. For the following reasons, the Commissioner's motion is granted and the plaintiff's motion is denied.


The following facts are taken from the administrative record and are undisputed. The plaintiff was born in 1950 and has a high school education. She was fifty-six years old at the alleged onset of her disability in 2006, which she describes as severe depression and nervousness. Rojas previously worked from 1982 to 2006 as an unpaid caretaker for her elderly mother and for the children of friends and family. She also worked as a sales clerk in the shoe department at Wal-Mart and at another retail store, with some interruptions, for a total of about twenty years between 1969 and 1998. When the plaintiff's mother passed away in March 2006, she babysat others' children less, until she stopped working entirely in August 2006 due to depression.

I. Medical Record

In August 2006, a nephew came to Florida, where Rojas had been living and taking care of her mother, and took her back to New York with him because she was having trouble caring for herself. He took her to Arden Hill Hospital where she was admitted as an inpatient to the Behavioral Care Unit on an involuntary basis. She complained of lack of appetite, poor sleep, depression, anxiety, and hopelessness. She was diagnosed with major depression and a Global Assessment of Function ("GAF") of 20.*fn1 She was put on a prescription medication regimen including clonazepam, Abilify, lithium, and Zoloft, to which she responded "very well," and was discharged two weeks later. When discharged, her mood was euthymic (normal, neither depressed nor manic), her diagnosis was major depressive disorder, and her GAF was 55.*fn2

Rojas began outpatient treatment in September 2006, at Occupations, Inc. There she was seen approximately once a month by her treating psychiatrist, Dr. Kathpalia. She was diagnosed with a mood disorder, not otherwise specified ("mood disorder NOS") in November 2006, and a GAF of 60. Her treatment notes show that she experienced no side effects from her medications, which were gradually adjusted and reduced, with some of the prescriptions being eliminated. Rojas also saw a therapist named Elizabeth Raun ("Raun") at Occupations approximately every two weeks. Through the end of 2006, Raun's treatment notes indicate good progress and improvement in Rojas's mood stability and coping skills, physical appearance, and anxiety, including that she was more active and social.

In March 2007, Dr. Minola, a state agency psychiatrist, reviewed Rojas's records in order to determine Rojas's residual functional capacity ("RFC")*fn3 for the purpose of her SSI claim. He found that her activities of daily living were mildly restricted; that she had mild difficulties maintaining social functioning; that she had moderate difficulty in maintaining "concentration, persistence, or pace;" and had not had any episodes of deterioration. Dr. Minola determined that Rojas was moderately limited in her ability to remember locations and work-like procedures and to understand and remember detailed instructions, but was not limited in her ability to understand, remember, and carry out short and simple instructions. He found that she was moderately limited in her ability to carry out detailed instructions, maintain attention and concentration for extended periods, maintain a routine without special supervision, or work in coordination with others without being distracted by them. She was not significantly limited in her social interactions with the public, peers, co-workers, or supervisors. In sum, Dr. Minola determined that Rojas "appears to be able to understand[,] remember[,] and carry out simple tasks in a low stress environment and to relate to peers and supervisors in a work setting."

From March to July 2007, Raun's treatment notes show a downturn, with Rojas complaining of increased anxiety and depressed mood. Dr. Kathpalia's treatment notes also indicate an anxious and sometimes depressed mood with symptoms of anxiety. To Raun, Rojas expressed agitation and anxiety over being dependent on her nephew and fearing she would not regain independence. By late spring and early summer 2007, however, Rojas was once again demonstrating progress and improved mood and coping skills. In July, Rojas indicated that she was feeling "more empowered and good about [her]self." By August, Dr. Kathpalia's treatment notes indicate a normal mood. In the fall and early winter of 2007, Rojas traveled to Florida and Georgia to visit family. Raun's notes indicate some agitation and frustration by Rojas due to the uncertainty of receiving benefits and gaining independence, and some fear about returning to work, but in February 2008, reported feeling a little better and less depressed and hopeless.

In February 2008, Dr. Kathpalia responded to a functional capacity questionnaire for Rojas. He stated that she had a chronic mood disorder and a history of psychosis and hallucinations as well as depression and anxiety. He stated that Rojas was unable to travel alone by bus or subway because she had difficulty following multi-step directions due to poor memory, poor concentration, and being anxious. He indicated that Rojas had a marked limitation in her activities of daily living, marked limitation in maintaining social functioning, and extreme limitation with respect to deficiencies of concentration, persistence or pace resulting in failure to complete tasks in a timely manner. She had extreme limitation in her ability to understand, remember, and carry out instructions, as well as marked limitations in her ability to respond appropriately to supervision or co-workers. She also was extremely limited with respect to her ability to respond to customary work pressures, to satisfy an employer's normal quality expectations, and to perform even simple tasks on a sustained basis in a full-time work setting. Dr. Kathpalia also indicated that Rojas had experienced one or two episodes of deterioration. In sum, Dr. Kathpalia commented that Rojas had a chronic mood disorder and was "completely disabled and unable to work." She is often confused, frustrated, tearful and easily overwhelmed.

In March 2008, Raun's treatment notes indicated that Rojas had moved into her own apartment and "was happy" about it, although she continued to suffer from anxiety, and had "difficulty balancing worry with living her life." In June 2008, Raun indicated that Rojas "continues to get anxious to [the] point i[t] affects her health."

II. Procedural History

Rojas applied for SSI benefits on December 13, 2006, alleging a disability starting on August 31, 2006. She alleged that she was disabled due to nervousness and a severe, major depression that limited her ability to work because of difficulty concentrating, anxiety in social settings, and general fatigue. She indicated that she could not lift things or stand for long periods of time. She claimed that she was capable of taking public transportation, handling money, and caring for her personal needs without help, except that she sometimes forgot to take her medication. Her claim was initially denied on March 14, 2007. She timely requested a hearing before an administrative law judge on May 14, 2007.

The hearing before Administrative Law Judge James B. Reap (the "ALJ") took place on May 13, 2008. At the hearing, Rojas testified that she suffers from depression and is unable to work. She said that she lives alone in her own apartment. For activities, she reads the newspaper, books, and the Bible, makes crafts with beads, and works crossword puzzles. She testified that she watches movies and television and can generally follow the plot of these programs, but sometimes has to read things in books twice because she has trouble focusing. She said that whenever she could (because she was not able to drive) she goes out to church and to visit friends and family. She socializes over the telephone with family, follows an exercise program on television, and sometimes takes walks outside. She also does household chores like laundry, preparing meals, and sweeping. She said that if it were available, she'd be able to use public transportation, and that she attends her medical appointments alone. Rojas testified that her job at Wal-Mart in the shoe department required to her work standing up and that customers generally helped themselves there. ...

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