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Rousey v. Commissioner of Social Security

United States District Court, S.D. New York

January 11, 2018

CATHY ROUSEY, Plaintiff
v.
COMMISSIONER OF SOCIAL SECURITY, Defendant.

          OPINION AND ORDER

          HENRY PITMAN, UNITED STATES MAGISTRATE JUDGE.

         I. Introduction

         Plaintiff brings this action pursuant to section 205(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), seeking judicial review of a final decision of the Commissioner of Social Security ("Commissioner") denying her application for disability insurance benefits ("DIB"). The parties have consented to my exercising plenary jurisdiction in this matter pursuant to 28 U.S.C. § 636(c) (Docket Item ("D.I.") 17). Both parties have moved for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure (D.I. 19, 23). For the reasons set forth below, plaintiff's motion for judgment on the pleadings is granted to the extent of remanding this matter for further proceedings pursuant to sentence four of 42 U.S.C. § 405(g) and the Commissioner's motion for judgment on the pleadings is denied.

         II. Facts [1]

         A. Procedural Background

         Plaintiff filed an application for DIB in July 2013, alleging that she became disabled on March 22, 2012 due to "two slipped discs 1-4 and 1-5, " severe arthritis, sciatica, arthritis of all joints and hearing loss (Tr. 13, 75-76, 86). The claims were initially denied on October 10, 2013 (Tr. 86-94), and plaintiff requested a hearing before an administrative law judge ("ALJ") (Tr. 95-99). ALJ Michael Rodriguez held a hearing by videoconference on January 20, 2015 during which plaintiff and a vocational expert testified (Tr. 36-74). On May 1, 2015, the ALJ issued a decision finding that plaintiff was not disabled (Tr. 13-31). This decision became the final decision of the Commissioner on October 17, 2016 when the Appeals Council denied plaintiff's request for review (Tr. 1-5).

         B. Social Background

         Plaintiff was born in December 1963 and was forty-nine years old as of the date of her DIB application (Tr. 75). Plaintiff has a college degree in social work, served in the military as a cable installer, a training officer, a child protective specialist and most recently had worked as a budget and administrative specialist at the Department of Veterans Affairs (the "VA") (Tr. 45-46, 48-51, 193-204). Plaintiff retired from the VA in February 2012 (Tr. 171, 291). Plaintiff lives in a single-family house with her father and her two adult sons, who were twenty-one and twenty-four years old as of the date of the hearing (Tr. 41-44).

         In a "function report" submitted to the Social Security Administration by plaintiff in September 2013, plaintiff stated that she was disabled due to chronic illnesses that included arthritis, carpal tunnel syndrome, sciatica with two slipped discs, numbness in her left arm, pain in her shoulders, feet and hands, hearing loss, depression and due to stress (Tr. 176-88) . Plaintiff reported that she suffered from depression and felt stressed but also stated that she had not experienced anxiety attacks (Tr. 186-87) . She reported that "stress affects [her] whole body vision, nerves, bones, movements & physical appearance [and] gives [her] migraine headaches" (Tr. 184}. She stated that she did not participate in social activities on a regular basis because she was embarrassed about not being able to walk without complaining, but that she spoke with her mother and grandmother over the telephone once or twice a week and shopped in stores once or twice a week for fifteen to twenty minutes (Tr. 180-81) . Plaintiff stated that she had no problems with her attention or memory, could finish what she started, could follow spoken and written instructions and had no problems getting along with bosses or people in authority (Tr. 183-84)

         C. Medical Background

         Although plaintiff applied for DIB on the basis of both her physical and mental impairments, on this appeal, plaintiff only challenges the ALJ's findings with respect to her mental health impairments. Therefore, only the facts concerning plaintiff's mental health history are discussed in detail below.

         1. Psychologist Dr. Melissa Halligan

         a. Treatment by Dr. Halligan Before Plaintiff's Aliened Onset Date

         On January 11, 2012, plaintiff saw psychologist Dr. Melissa Halligan at the VA for continued individual therapy (Tr. 277-79}. Dr. Halligan reported that plaintiff was "quite tearful [when] discussing the financial and work stressors that [were] impacting her recently, " including foreclosure proceedings directed at her home and pressure to meet the deadlines of heavy workloads (Tr. 278). A mental status exam was normal except for a dysphoric mood and constricted affect (Tr. 277-78). Plaintiff had good insight, judgment and impulse control and Dr. Halligan diagnosed plaintiff with adjustment disorder (Tr. 277-78).

         On January 30, 2012, plaintiff saw Dr. Halligan again and reported that she was continuing to deal with the ongoing stress of foreclosure proceedings (Tr. 268-69). A mental status exam showed that plaintiff had a dysphoric mood, had a normal affect and had good insight, judgment and impulse control (Tr. 269) . Plaintiff missed an appointment with Dr. Halligan on February 13, 2012 because she forgot about it (Tr. 260). Plaintiff missed an appointment on February 22, 2012 because it was her last day at work and she was clearing out her desk (Tr. 260).

         b. Treatment by Dr. Halligan Following Alleged Onset Date

         Plaintiff saw Dr. Halligan again in September 2013 with complaints of severe depression and stress related to chronic pain and financial distress (Tr. 359-62). Dr. Halligan noted that plaintiff "reports passive wishes that she would die naturally but . . . denies any plan or intention to harm or kill herself" (Tr. 360). Plaintiff scored in the severely depressed range on a PHQ-9 questionnaire[2] (Tr. 360-62). Dr. Halligan diagnosed plaintiff with depression (Tr. 360-61).

         On October 23, 2013, plaintiff met with Dr. Halligan for therapy and reported stress resulting from a recent car accident and from financial problems (Tr. 348-49). A mental status exam showed that plaintiff had a dysphoric mood, good insight, judgment and impulse control and that there was no evidence of suicidal ideation (Tr. 348-49). Dr. Halligan diagnosed plaintiff with depression (Tr. 349).

         c. Dr. Roland Larkin

         On October 23, 2013, plaintiff saw Dr. Roland Larkin at the VA for depression (Tr. 343).[3] Plaintiff told Dr. Larkin that she had seen Dr. Halligan on and off for approximately six years, that she had a history of sexual abuse and that she had never taken any psychotropic medications (Tr. 344-45). Plaintiff stated that she felt depressed, hopeless and overwhelmed and had poor energy, motivation and sleep (Tr. 344). Plaintiff denied suicidal ideation, severe emotional distress, severe anxiety and panic symptoms (Tr. 340-41). Plaintiff complained of physical pain, insomnia and hopelessness and/or demoralization and had minimal indications of impulsive behavior (Tr. 340-41).

         A mental status exam showed that plaintiff had a cooperative attitude, calm motor activity, regular speech, intact thought processes, unremarkable thought content, fair insight, appropriate but tearful affect, grossly intact memory and cognitive function, intact abstraction, judgment and appetite (Tr. 346), Dr. Larkin diagnosed plaintiff with major depressive disorder, assessed a GAF score[4] of 58, indicating moderate symptoms, prescribed fluoxetine, i.e., Prozac, and recommended that plaintiff continue individual therapy (Tr. 346-47) .

         d. Dr. Jennifer Reich and Dr. Uri Napchan

         Plaintiff's primary care physician, Dr. Jennifer Reich, and her pain management physician, Dr. Uri Napchan, also monitored plaintiff's depression during visits in 2013 and 2014.

         In August and September 2013, Dr. Napchan and/or Dr. Reich noted that plaintiff's judgment, insight, memory, mood and affect were normal (Tr. 415-16, 426-27, 434).

         In October 2013, Dr. Reich noted that plaintiff's judgment, insight, mood and affect were normal with no anxious-ness or suicidal ideation (Tr. 411-13).

         In November 2013, Dr. Reich noted that plaintiff had started taking Prozac on October 23, 2013 and was "starting to feel better at [that] time" (Tr. 401-03).

         In December 2013, Dr. Reich noted that plaintiff was "under excessive amounts of stress, " was following up with a psychiatrist at the VA and had recently started taking Prozac (Tr. 398-99).

         In February 2014, Dr. Reich noted that plaintiff had normal insight, mood, affect and judgment (Tr. 388). She also noted that plaintiff was receiving therapy at the VA and was "on Prozac and seemed to be doing well" (Tr. 388-89). In March 2014, Dr. Reich again noted plaintiff was "on Prozac and [was] doing well" (Tr. 377).

         2. Consultative Internal Medicine Evaluation: Dr. Gilberti Jenouri

         On October 2, 2013, internal medicine physician Dr. Gilberti Jenouri examined plaintiff at the request of the New York State Division of Disability Determination (Tr. 285}. Plaintiff reported that she had a history of depression, back problems, hearing loss and neck problems (Tr. 285). Plaintiff said that she cooked two to three times a week, cleaned one to two times a week, shopped once a week but did not do laundry (Tr. 285). She did not shower but bathed three to four times a week, watched television and socialized with friends (Tr. 286). Dr. Jenouri diagnosed plaintiff with several physical impairments and a history of depression (Tr. 288}.

         3. Consultative Psychiatric Evaluation: Dr. Leslie Heiprin

         On October 2, 2013, Dr. Leslie Heiprin, a psychologist, examined plaintiff and prepared a consultative psychiatric evaluation (Tr. 291). Plaintiff told Dr. Heiprin that she saw a psychologist at the VA once a week and had been seeing a psychologist since 2007 or 2008 (Tr. 291). Plaintiff complained of symptoms including waking up twice at night, loss of appetite, crying spells and social withdrawal (Tr. 291). She denied suicidal thoughts and suicide attempts but said that she sometimes felt that she did not want to live (Tr. 291). She said that she occasionally felt nervous but denied significant symptoms of anxiety, mania, thought disorder or cognitive symptomatology (Tr. 291). She reported she could drive, dress, bathe, cook and clean, but did not do laundry and needed help with grocery shopping due to back pain (Tr. 293}. She also said she needed help with money management because she sometimes forgot when to pay bills (Tr. 293). Plaintiff did not socialize with friends in person but talked to her best friend in Georgia over the telephone and reported that her only leisure interest was watching TV (Tr. 293).

         Dr. Heiprin examined plaintiff and found that plaintiff was dressed appropriately, her posture and motor behavior was normal, her speech was fluent and clear with adequate expressive and receptive language skills and her thought processes were coherent and goal directed with no evidence of hallucinations, delusions or paranoia (Tr. 292). Dr. Helprin found that plaintiff had a dysphoric affect and her mood was dysthymic with "some crying" (Tr. 292). Plaintiff's attention and concentration were intact and her insight and judgment were good (Tr. 293). However, plaintiff's recent and remote memory skills were "[i]mpaired due to cognitive deficits. She recalled 3 of 3 objects immediately, and none after a five-minute time delay" (Tr. 293). Plaintiff's intellectual skills were in the below average range (Tr. 293).

         Dr. Helprin diagnosed plaintiff with adjustment disorder with depressed mood, moderate episodic, and an amnestic disorder, not otherwise specified ("NOS") (Tr. 294). Dr. Helprin concluded that plaintiff

evidences no limitations in her ability to follow and understand simple directions and instructions, cognitively perform simple tasks and complex tasks independently, and maintain attention and concentration, though with moderate short-term memory limitations. She evidences no limitations in her ability to maintain a regular schedule as it pertains to psychiatric and cognitive outlooks, make appropriate decisions, and relate adequately with [those] whom she encounters. She evidences mild limitations in her ability to deal with stress.
The results of the examination appear to be consistent with some secondary psychiatric problems, but in itself this does not appear to be significant enough to interfere with the claimant's ability to function on a daily basis.

         (Tr. 293-94). Dr. Helprin recommended that plaintiff take an antidepressant, continue psychological treatment and undergo a medical evaluation "to determine if her medical conditions preclude her from all work;" Dr. Helprin found that plaintiff's prognosis was "good given the above treatments" (Tr. 294).

         4. Opinion by Non-Examining, Consulting Dr. L. Hoffman

         In October 2013, at the request of the Social Security Administration, Dr. L. Hoffman reviewed plaintiff's records, including Dr. Helprin's report, and completed a psychiatric review technique form (Tr. 79-86, 298). Dr. Hoffman opined that plaintiff had an affective disorder that imposed mild restrictions on her activities of daily living, mild difficulties in maintaining social functioning, mild difficulties in maintaining concentration, ...


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