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Carter v. Colvin

United States District Court, W.D. New York

January 17, 2017



          HON. MICHAEL A. TELESCA United States District Judge.

         I. Introduction

         Represented by counsel, Michael Carter (“plaintiff”) 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 his application for supplemental security income (“SSI”). The Court has jurisdiction over this matter pursuant to 42 U.S.C. § 405(g). Presently before the Court are the parties' cross-motions for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. For the reasons discussed below, plaintiff's motion is granted to the extent that this matter is remanded to the Commissioner for further administrative proceedings consistent with this Decision and Order.

         II. Procedural History

         The record reveals that in January 2012, plaintiff (d/o/b July 28, 1989) applied for SSI, alleging disability beginning September 1, 1997. After his application was denied, plaintiff requested a hearing, which was held before administrative law judge Brian Kane (“the ALJ”) on May 16, 2014. On June 11, 2014, the ALJ issued an unfavorable decision. The Appeals Council denied review of that decision and this timely action followed.

         III. Summary of the Evidence

         The record, which is relatively sparse, includes treatment notes from plaintiff's treating psychiatrist, Dr. Prakash Reddy, treating therapist Denise Lampo, MSW, and treating therapist Kathleen Simpson. The record also contains records of a consulting examination performed by state agency psychologist Dr. Yu Ying Lin and opinions from state agency reviewing psychologist Dr. E. Kamin.

         Plaintiff was referred to Catholic Family Center (“CFS”) by New York's Consumer Directed Personal Assistance Program (“CD Program”) for a determination of the appropriateness of outpatient treatment. He underwent an initial evaluation on February 3, 2012 with Ms. Lampo, at which he reported frequent mood swings, a history of attention deficit hyperactivity disorder (“ADHD”), cannabis dependency, and a fear of reporting his symptoms due to the stigma associated with mental health conditions. Plaintiff reported frequent hallucinations, including hearing voices and “jail bells” in his head. Ms. Lampo opined that he met the diagnostic criteria for bipolar disorder, not otherwise specified (“NOS”) and possibly shizoaffective disorder. Ms. Lampo referred plaintiff to Dr. Reddy for psychiatric treatment and medication monitoring.

         On initial mental status examination (“MSE”) on February 23, 2012 with Dr. Reddy, plaintiff presented as “hypertalkative, ” reported visual and auditory hallucinations and paranoia, and demonstrated a depressed, irritable, and angry affect. T. 197. Dr. Reddy diagnosed him with bipolar disorder, NOS and prescribed plaintiff Seroquel (an antipsychotic often used to treat schizophrenia, bipolar disorder, and depression).

         In March 2012, plaintiff reported to Dr. Reddy that Seroquel had “not been helping his mood swings and anger problems” and made him excessively sleepy. T. 205. Dr. Reddy discontinued Seroquel and prescribed Risperdal, another antipsychotic medication. In March 2012, plaintiff reported to his therapist Kathleen Simpson that his mother and sister both carried diagnoses of bipolar disorder. Ms. Simpson recorded that plaintiff had a depressive affect to a “notable” degree. T. 207. In April 2012, plaintiff reported no adverse side effects from his medications; Dr. Reddy increased his Risperdal dosage. A July 2012 treatment note signed by Ms. Simpson indicated that plaintiff's treatment plan was reviewed and goals included “focus[ing] thoughts on reality” and sustaining recovery from substance abuse. T. 200.

         Plaintiff was referred by the CD Program to personalized recovery-oriented services (“PROS”), and on August 27, 2012, social worker Kelly Murrell evaluated him for this program. Plaintiff reported that he had not seen Dr. Reddy in several months and therefore did not have medication. He also reported continued auditory hallucinations and depression. He was scheduled to attend orientation for a GED program, and Ms. Murrell noted that this would be his third attempt at a GED since dropping out of school in the ninth grade.

         On April 26, 2012, Dr. Yu-Ying Lin completed a consulting psychiatric evaluation at the request of the state agency. Plaintiff reported completing the eighth grade in a special education program for learning disability and ADHD. Plaintiff reported both manic and depressive symptoms as well as continued visual and auditory hallucinations and paranoia. On MSE, plaintiff's “[m]anner of relating was poor”; motor behavior was lethargic; affect was dysphoric and mood dysthymic; he was “oriented to person, but not place and not date”; attention and concentration were “moderately impaired due to limited intellectual functioning and emotional distress [due] to current psychiatric disorder”; recent and remote memory skills were impaired; intellectual functioning appeared to be below average; and insight and judgment were poor. T. 158-60. Plaintiff reported that he did not perform any cooking, cleaning, or laundry because he made mistakes or did not know how; he did not shop because he made mistakes or “[got] into altercations with others”; he did not drive because he had no license; and he did not take public transportation due to paranoia. He stated that his mother and girlfriend helped him as needed with daily activities. T. 160.

         Dr. Lin diagnosed plaintiff with bipolar disorder with psychotic features and generalized anxiety disorder. In Dr. Lin's opinion, plaintiff could follow and understand simple directions and instructions, perform simple tasks with supervision, maintain a regular schedule, and learn new tasks. However, in Dr. Lin's opinion, plaintiff could not maintain concentration, perform complex tasks independently, make appropriate decisions, relate adequately with others, or appropriately deal with stress. According to Dr. Lin, these difficulties were “caused by psychotic symptoms and lack of motivation.” Id.

         Dr. Kamin reviewed plaintiff's medical record at the request of the state agency and completed a psychiatric review technique (“PRT”) form and mental residual functional capacity (“RFC”) assessment. According to Dr. Kamin, plaintiff was moderately limited in several areas involving understanding and memory, sustained concentration and persistence, social interaction, and adaptation. Dr. Kamin opined that plaintiff had overall mild restrictions in activities of daily living (“ADLs”); moderate restrictions in ...

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