United States District Court, W.D. New York
DECISION and ORDER
MICHAEL A. TELESCA, District Judge.
Plaintiff Patti Beck ("Plaintiff"), represented by counsel, brings this action pursuant to Title XVI of the Social Security Act ("the Act"), seeking review of the final decision of the Commissioner of Social Security ("the Commissioner") denying her application for Social Security Insurance ("SSI"). This Court has jurisdiction over the matter pursuant to 42 U.S.C. §§ 405(g), 1383(c). Presently before the Court are the parties' motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure.
II. Procedural History
Plaintiff protectively filed an application for SSI benefits on October 6, 2010, alleging an onset date of disability of May 15, 2010, as the result of Major Depressive Disorder, Social Phobia, and Panic Disorder with Agoraphobia. T.125-30. The claim was denied on December 24, 2010, T.48-51, and Plaintiff sought an administrative hearing. Plaintiff appeared with counsel before administrative law judge Lawrence Levey ("the ALJ"). See T.7-31. The ALJ denied Plaintiff's claim on November 9, 2010. T.33-43. The Appeals Council denied Plaintiff's request for review on November 14, 2012, making the ALJ's decision the final decision of the Commissioner. T.1-4. This action followed.
III. Summary of the Administrative Record
A. Personal and Vocational History
Plaintiff was 49-years-old on the date of the hearing. She has a high school education and has not worked since September 30, 2010. Her last job was on a part-time basis at the Finger Lakes Times mail room T.12. Prior to moving from Michigan to New York, she worked as an animal caretaker at a veterinarian's office on a full-time basis for about two years. T.13. Plaintiff testified that she is currently unable to work because she cannot handle the stress of it mentally, and often becomes suicidal and depressed. She experiences severe depression eight to nine times per month T.15. She has difficulty concentrating; sleep disturbances (either sleeping too much or too little), decreased energy, and crying spells. T.17. At the time of the hearing, Plaintiff was currently public assistance benefits and was exempt from having to work. T.18. Prior to filing her SSI claim, Plaintiff worked part-time (about 20 hours per week) cleaning houses, but even this was difficult for her to do. T.21.
B. Medical Records Prior to the Onset Date
Plaintiff began treating with psychiatrist Kang Yu, M.D. at the Seneca County Community Counseling Center in October of 2002. T.286. However, the first treatment note from Dr. Yu in the administrative record is dated December 1, 2008. At that time, Dr. Yu noted that Plaintiff was taking paroxetine (Paxil), 60mg per day and clonazepam (Klonopin) l mg, 3 times per day. With this medication regime, her depression and "have been under good control." T.225. Plaintiff's affect was "very broad with pleasant mood." Id . She had been doing some work house-cleaning. Dr. Yu noted that her depression, social anxiety and panic attacks had been minimally severe. T.225.
On March 2, 2009, Plaintiff returned to see Dr. Yu, who again noted that her current medication regime of Paxil and Klonopin, her depression and "have been under good control." T.225. Plaintiff's affect was "very broad with pleasant mood." Id . She was still house-sitting for a disabled man in Stanley and had additional house-cleaning customers in Seneca Falls. Id.
On June 1, 2009, Plaintiff returned to see Dr. Yu and reported that she was still working as a house-cleaner. T.226. Dr. Yu noted that she was a "rapid metabolizer" of Paxil in that she excreted it much faster than other patients, so he increased her dosage slightly. Id . He noted that her affect was "very broad with pleasant mood." Id.
On September 1, 2009, Plaintiff reported to Dr. Yu that she felt as though she was doing "very well in her psychiatric condition and just want[ed] more work so that she can pay all the bills which are due." T.226. Currently, she was make the minimum amount needed to pay for rent, food, and clothing. Dr. Yu kept her medication regime the same as her anxiety and depression had been under good control. Id.
On December 1, 2009, Dr. Yu noted that Plaintiff "continues to have some depression" and recently had lost interest in working. T.226. She informed that Dr. Yu that as wintertime approaches, she experiences decreased energy, enthusiasm, and motivation. Her landlord had received a foreclosure notice, so Plaintiff faced becoming homeless. Plaintiff was seeking help through Lakeview to obtain housing. Dr. Yu noted that her affect was slightly constricted (i.e., she had a reduced range and intensity of emotional expression), with a mildly depressed and apprehensive mood. T.226.
On March 2, 2010, Plaintiff returned to see Dr. Yu. She was still on the same regime of Paxil and Klonopin, which, according to Dr. Yu, had been keeping her depression and anxiety "under good control." T.227. Plaintiff's affect was "very broad with pleasant mood." Id . Plaintiff was planning to move back to the Geneva area, as the disabled man for whom she had been working as a housekeeper had told her to move out because he no longer needed help. Id.
C. Medical Records After the Onset Date
1. Treatment Notes and Evaluation of Treating Psychiatrist Dr. Yu
On June 3, 2010, Plaintiff reported an increase in anxiety and depression because she had run out of clonazepam several days before the appointment. T.227. She said that without the clonazepam, she was having much worse anxiety and panic attacks. Id . Her medication regime was kept the same, and she was instructed to return in three months. T.227.
On September 2, 2010, Dr. Yu noted that with her current medication regime, her depression has been under good control and she was not having much anxiety. T.228. She had moved to Seneca County and was living at a hotel. She had begun receiving Medicaid and food stamps. The Seneca County Workforce Development Center had told her that she should not work. Dr. Yu commented, "[E]ven though she presented herself to be quite capable, .... [s]he apparently is more impaired than she presented herself in the past." T.228. Her affect was "fairly broad with pleasant mood." Id . Dr. Yu counseled her to take as little clonazepam as possible as she was on a high dose of paroxetine which should provide good anti-panic effect. Id.
Also on September 2, 2010, Dr. Yu completed an "Updated Psychiatric Evaluation - Seneca County Community Counseling Center, " T.287-89. Dr. Yu commented that "her depression seems to be under good control, but her Social Anxiety, Panic Disorder are not under good control." T.287. He stated that she had not been able to work in a competitive employment setting because of her "severe Social Anxiety Disorder and Panic Disorder." Id . With regard to her mental status, Dr. Yu noted that her affect was "fairly broad with pleasant mood" although she "continue[d] to have difficulty with panic attacks when she goes to a place where there are many different people, particularly strangers." Id . He noted that intellectual functioning and fund of knowledge were average and that she had "developed good insight into her illness" and her judgment was "considered to be fair at this time." Id . Dr. Yu issued the following diagnoses: Major Depressive Disorder, recurrent, in partial remission; Social Phobia, generalized, in partial remission; Panic Disorder, with agoraphobia, in partial remission; Cannabis Dependence; and Nicotine Dependence. T.287. He assigned a current GAF of 65, and noted that her highest GAF in the past year was 65. T.288. Dr. Yu stated that Plaintiff's prognosis was "fair" for her depression but "poor for her to be fully functioning, particularly working with other people." T.288.
On December 2, 2010, Plaintiff returned to see Dr. Yu, who noted that "her panic attacks have been under good control" with her medication regime. T.289. She reported being "still quite anxious" around crowds and strangers, but by avoiding these situations, "she has not felt much anxiety." Id . She had not smoked marijuana for about a month and was cautioned that if she continued to use marijuana, Lakeview might not be able to help her with housing.
On March 3, 2011, Plaintiff reported to Dr. Yu that her depression has "not been under complete remission" and she has been having difficulty falling asleep. T.289. Her affect was fairly broad with pleasant mood. Id . Dr. Yu increased her paroxetine CR. She had been taking only two clonazepam per day, and "her anxiety has been under good remission" with this dosage. Id.
On June 2, 2011, Dr. Yu noted that her depression and anxiety "have been under good control" with her current medication regimen. T.290. Her affect was "very broad with pleasant mood." Id . Although she "still has anxiety from time to time, " she has been able to take the bus. Id . Even though she was able to do some house-cleaning work, she "does not want to get into trouble with DSS, because if she is found to be working, DSS may sanction her benefit." Id.
Plaintiff saw Dr. Yu on September 1, 2011. She continued to take her medications and had her depression under fair control. She noted that she was "not having much anxiety symptoms." T.293. However, she still was having "difficulty being engaged in full-time employment due to her panic attacks and social phobia." Id . She was able to take the bus to attend her appointments and had not ...