United States District Court, S.D. New York
MEMORANDUM AND ORDER
JAMES C. FRANCIS, IV, Magistrate Judge.
The plaintiff, Miosotys Lopez-Delgado, brings this action pursuant to section 405(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), seeking review of a determination of the Commissioner of Social Security (the "Commissioner") finding that she is not entitled to disability insurance benefits. The parties have submitted cross-motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons set forth below, the Commissioner's decision is vacated and the case is remanded to the Social Security Administration (the "SSA") for further proceedings consistent with this opinion.
A. Personal History
Ms. Lopez-Delgado was born on June 30, 1974. (R. at 37). She lives at home with her mother and her four children, ages 2 to 18. (R. at 37). The plaintiff last worked in 2009 as a babysitter, watching one child in her own home. (R. at 41, 133-34). She also testified that she worked for a few years as a receptionist, sometime around 2000, answering phones and making copies (R. at 42-43), although this job is not listed on her disability report (R. at 132). There is conflicting evidence as to what level of schooling the plaintiff has attained, but it is clear that she has a limited education.
According to her testimony, the plaintiff leaves her home only for the purposes of therapy, grocery shopping, and sometimes attending church. (R. at 47, 143-44). At home, she is sometimes able to cook, clean, and help her mother take care of her children, but usually just stays in her room on account of depression and the effects of her medications. (R. at 46-49, 55, 140-42). At the hearing, she denied doing anything at all other than sleeping. (R. at 46, 54-55). The plaintiff reports having no hobbies (R. at 144, 212) and no friends (R. at 47, 214) other than one good friend that she sees at times (R. at 250).
B. Medical History Prior to Disability Application
The plaintiff alleges a disability onset date of December 31,
2009, due to depression, insomnia, and panic attacks. (R. at 128-32). She first sought a psychiatric evaluation from Montefiore Medical Center ("Montefiore") on October 2, 2009, complaining of anxiety and depression. (R. at 265, 269). She did not follow up on her initial assessment, but returned to Montefiore almost a year later, on August 2, 2010, with similar complaints of depression. (R. 208-11). In her initial intake with social worker Maria Casillas, the plaintiff listed symptoms including depressed mood, decreased energy, appetite disturbance, hopelessness, impaired concentration, decreased motivation, memory impairment, irritability, and mild anxiety. (R. at 208). She denied any previous psychiatric treatment or use of psychiatric medications (R. at 209-10) and any suicidal or homicidal ideation (R. at 211). Ms. Casillas noted that the plaintiff exhibited a depressed mood and symptoms of depression attributed to her boyfriend's drug abuse and the conflict it had caused in the home. (R. at 210-11).
Ms. Lopez-Delgado saw Ms. Casillas again on August 18 and 31, 2010, regarding similar complaints of depression. (R. at 206-07). The plaintiff admitted a desire to work or receive training but expressed frustration with herself due to her continued depression and feelings that she could not rouse herself to do anything. (R. at 206). Ms. Casillas referred her to Dr. Anthony Stern, a psychiatrist at Montefiore. (R. at 207).
Ms. Lopez-Delgado first met with Dr. Stern on September 7, 2010, and explained that she had been "very depressed for the last two years." (R. at 204). The plaintiff recounted that one year prior, she was admitted for a day to Lincoln Hospital for a "nervous breakdown" resulting from relationship problems and the birth of her child. (R. at 204). She reported that she had experienced depression intermittently for "many years, " but that it had recently gotten worse. (R. at 204). She also reported trouble sleeping and "some degree" of agoraphobia ("being afraid to get out") over the past two years. (R. at 204). The plaintiff presented an intermittently tearful affect and depressed mood, though she remained coherent and continued to report no delusions or hallucinations and no suicidal or homicidal ideation. (R. at 205). Dr. Stern diagnosed her with "major depressive [disorder], recurrent, moderate" and prescribed trials of Wellbutrin for depression and Trazodone for insomnia. (R. at 205). In addition, he advised that the plaintiff continue talk therapy with Ms. Casillas. (R. at 205).
On September 15 and October 8, 2010, Ms. Lopez-Delgado again saw Ms. Casillas, who noted that the plaintiff was depressed. (R. at 202-03). The plaintiff reported continued feelings of depression, loneliness, and longing for the father of her child and admitted that it was "difficult for her to cope on her own." (R. at 202). At an appointment on October 19, 2010, Dr. Stern noted that Ms. Lopez-Delgado "tolerated Wellbutrin poorly" and that she "had obtained no relief from depression or anxiety" and in fact felt "more anxious." (R. at 201). She continued to present a "depressed affect and mood." (R. at 201). In response, Dr. Stern discontinued the Wellbutrin and assigned a trial of Remeron. (R. at 201).
The following month, Ms. Lopez-Delgado met twice with Ms. Casillas, who noted the plaintiff's depression and anxiety. (R. at 199-200). The plaintiff expressed that she "[knew] she [was] not ready to work, " but was anxious that "her benefits [would] be taken away from her if she [did] not go through this process." (R. at 199). Ms. Casillas advised that she continue to set goals and attempt to read every day to improve her reading skills. (R. at 200).
At an appointment on December 21, 2010, Dr. Stern noted that the plaintiff presented a "less depressed affect and mood." (R. at 198). In an additional note from the same appointment, however, he described her affect and mood as "somewhat depressed." (R. at 197). The plaintiff reported that "the Remeron has helped a little, " but she was "still depressed" and "[did not] want to be around people." (R. at 198, 197). She was "still [having] trouble sleeping." (R. at 198). In response, Dr. Stern increased the Remeron dose, prescribed a trial of Doxepin to help with the insomnia, and "strongly encouraged [her] to counter [her] wish to withdraw most of the time." (R. at 197). Dr. Stern diagnosed Ms. Lopez-Delgado with "persisting chronic depression with insomnia." (R. at 197).
C. Medical History After Disability Application
On February 4, 2011, Ms. Lopez-Delgado was evaluated by a consulting psychologist, Dr. Edward Hoffman. Dr. Hoffman noted her history of depression and treatment through therapy and medication. (R. at 212). In considering her current functioning, he noted that "her sleeping is poor... [and] [s]he feels depressed. She has no hobbies or interests." (R. at 212). Her mood was "anxious, but stable." (R. at 213). Dr. Hoffman found that "[o]verall, she shows impaired adaptive functioning and socialization skills." (R. at 214). He concluded that Ms. Lopez-Delgado's "allegations of psychiatric problems are supported by the examination today, and her history of psychiatric hospitalization and current outpatient mental health treatment." (R. at 214). He also noted her "history of academic failure and special education." (R. at 214).
based on her history Dr. Hoffman diagnosed Ms. Lopez-Delgado as having learning problems with depressive features on Axis I, mild mental retardation on Axis II, and asthma and frequent dizziness on Axis III. (R. at 214). He recommended that she continue treatment "for depression" and that she be referred to a sheltered workshop program. (R. at 214).
The plaintiff saw Dr. Stern on February 17, 2011. Again, he noted that her mood and affect were "somewhat depressed." (R. at 253). Ms. Lopez-Delgado reported that she was "sleeping better with the medicine" and "still depressed but managing better." (R. at 253). Dr. Stern determined that the Doxepin was helping with the insomnia and the depressive symptoms had lessened but still persisted. He advised that the plaintiff continue her current medications and see him again in two months. (R. at 253). Ms. Lopez-Delgado then saw Ms. Casillas on March 14, 2011 and complained of increased symptoms of depression ...