United States District Court, W.D. New York
DECISION AND ORDER
MICHAEL A. TELESCA, District Judge.
Robert Mills ("Plaintiff"), represented by counsel, brings this action pursuant to Titles II and 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 Supplemental Security Income ("SSI") and disability insurance benefits ("DIB"). The Court has jurisdiction over this matter pursuant to 42 U.S.C. § 405(g). Presently before the Court are the parties' competing motions for judgment on the pleadings pursuant to Federal Rule of Civil Procedure 12(c).
II. Procedural History
Plaintiff protectively filed applications for DIB and SSI on March 10, 2011, both of which were denied. T.50-60, 128-42. On July 30, 2012, Plaintiff, his attorney, and a vocational expert appeared at a hearing held before Administrative Law Judge Richard E. Guida ("the ALJ"), who issued an decision dated August 30, 2012, T.8-49, finding that Plaintiff has not been under a disability within the meaning of the Act from January 1, 2010, when he alleged he became disabled, through the date of the unfavorable decision. The Appeals Council denied Plaintiff's request for review on December 20, 2013, making the ALJ's decision the final decision of the Commissioner. T.1-6. This timely action followed.
III. Summary of the Administrative Record
A. Relevant Medical Evidence Between January 1, 2010 and August 30, 2012
1. Treating Psychiatrist
Plaintiff began treating with psychiatrist Ronald Spurling, M.D., on July 28, 2011. T.479. On August 10, 2011, Plaintiff presented for follow-up regarding his bipolar disorder and PTSD. T.426-29. Plaintiff reported that he was tolerating his medications well, aside from some sedation upon waking in the morning. He stated that his mood was more even, and he was less depressed. However, he complained of continued general anxiety and social anxiety. Plaintiff also reported continued daily use of marijuana, which he felt helped to "even out his mood." T.426. Plaintiff presented as being appropriately groomed and dressed; his facial expression appeared pleasant; his motor activity was within normal limits; and his affect was calm. Plaintiff described his own mood as normal. His language processing and associative thinking were intact; he was alert and oriented; and his memory, attention and concentration, and impulse control were all grossly intact. Judgment and insight were fair; and he evidenced no delusions, hallucinations, obsessions, preoccupations, or somatic thoughts. R427-28. During the examination, Plaintiff displayed anxiety periodically; his speech was pressured and rapid; his thought processes demonstrated circumstantial thinking; he showed increased tangentiality and some loosening of associations as the session progressed. Although Plaintiff had no "frank delusions, " some of Plaintiff's statements "seem[ed] to border on the delusional." T.427-28.
Dr. Spurling diagnosed PTSD (309.81), Bipolar I Disorder Current Depressed Mild (296.51), and Cannabis Abuse Continuous (305.21). T.428. He noted that Plaintiff seemed to have some improvement with the addition of lithium and low-dose risperidone (Risperdal). T.428. Dr. Spurling prescribed a trial of guanfacine at bedtime to address Plaintiff's complaints of anxiety and difficulty with concentration. T.428. Dr. Spurling also counseled Plaintiff to cease using marijuana and cigarettes. Dr. Spurling opined that individual psychotherapy would not be particularly beneficial at that time due to Plaintiff's "significant Axis I symptoms, " but he expected that would change in the future. T.428.
Plaintiff returned to Dr. Spurling for follow-up on September 21, 2011, T.430-32, reporting that the medications were working very well for him, his mood was much more even, and he was sleeping well. However, his psoriasis (including ocular) had been worsening, so he stopped taking the lithium and other prescribed medications the previous day. R430. He also reported that he had been more social recently, and he continued to look employment but had not been offered many opportunities. Plaintiff reported continued daily use of marijuana. T.430. Dr. Spurling noted that Plaintiff had seemed very much improved on lithium, so it was unfortunate that he was unable to tolerate that medication due to a psoriasis flare. Dr. Spurling prescribed Depakote, and he instructed Plaintiff to restart Risperdal and guanfacine. T.431. Plaintiff was counseled to stop smoking cigarettes and marijuana (which Plaintiff continued to insist was helpful for him). Id.
On October 20, 2011, Plaintiff reported to Dr. Spurling that he was doing very well on the Depakote, and he liked it better than the lithium. T.467-69. He continued to occasionally use hydroxyzine as needed. T.467. Overall, he felt that his mood was "fine." T.467. He slept about 7 hours per day, but he might stay up late reading and then sleep in. He denied any further difficulty with "rages" or anger episodes. T.467. He complained of stressors related to his finances and being isolated in his current housing situation, and he admitted to continued marijuana use. Id. Dr. Spurling concluded that Plaintiff was tolerating the Depakote well, and, symptomatically, seemed improved. T.468. Dr. Spurling continued Plaintiff's medications and added bupropion (Wellbutrin) in the morning to address Plaintiff's residual poor motivation and help him stop smoking. Dr. Spurling noted that Plaintiff believed very strongly that marijuana was helpful for him and he had no intention to cease using it. T.468.
On November 17, 2011, Plaintiff returned to Dr. Spurling reporting that he was doing very well on the Depakote, and stating that his mood was "very good." R470-72. His psoriasis had also dramatically improved. Plaintiff reported that he had been taking his medications more regularly. He also stated that he had stopped smoking marijuana altogether, at which point he started having nightmares. T.470. However, his sleep was now normal, and he was sleeping approximately eight hours per night. Id. Plaintiff also reported that the Wellbutrin was initially helpful and he had stopped chain-smoking cigarettes, but after he stopped smoking marijuana, he increased his cigarette smoking again. Id. He was using hydroxyzine occasionally as needed. He denied any further difficulty with "rages" or anger episodes. Dr. Spurling concluded that Plaintiff was tolerating the Depakote well, and symptomatically seemed greatly improved. T.471. He increased the dosage of Wellbutrin to further address Plaintiff's residual symptoms of poor motivation and to help him reduce his smoking. Id. He encouraged Plaintiff to continue abstinence from marijuana. T.471-72.
On January 19, 2012, Plaintiff returned to Dr. Spurling for follow-up. T.473-75. Plaintiff stated that he was "not too good" that day, and he complained of having frequent "little tantrums, " frustration, and inability to focus or accomplish tasks. T.473. Plaintiff thought he was drinking too much coffee and admitted that he had "not been taking his medication like he should be." T.473. Though he was "very evasive about exactly how frequently" he was taking the medication, it seemed to Dr. Spurling that he was primarily treating himself "as needed" with hydroxyzine and marijuana. Id. Plaintiff complained of frequently not wanting to get off of the couch, and difficulty with keeping his schedule. However, he admitted to shampooing his carpets, as he was thinking of selling his mobile home and moving to Florida. He thought moving there might improve his mood, be easier on his finances, and provide increased job prospects. Plaintiff admitted to smoking a lot of cigarettes since stopping the Wellbutrin, as well as two marijuana joints per day. He complained of nightmares related to his previous incarceration and continued bothersome psoriasis symptoms. He also complained of multiple stressors, including his history of a felony conviction, undergoing a thoracotomy, not having seen his daughter in 25 years, and being relatively isolated where he lived in the country. Clinical examination findings were essentially ...