United States District Court, S.D. New York
OPINION AND ORDER
PITMAN, UNITED STATES MAGISTRATE JUDGE.
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.
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).
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.
"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)
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
Psychologist Dr. Melissa Halligan
Treatment by Dr. Halligan Before Plaintiff's Aliened
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).
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).
Treatment by Dr. Halligan Following Alleged Onset Date
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 (Tr. 360-62). Dr. Halligan diagnosed
plaintiff with depression (Tr. 360-61).
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).
October 23, 2013, plaintiff saw Dr. Roland Larkin at the VA
for depression (Tr. 343). 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).
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 of 58, indicating
moderate symptoms, prescribed fluoxetine, i.e., Prozac, and
recommended that plaintiff continue individual therapy (Tr.
Jennifer Reich and Dr. Uri Napchan
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.
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).
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).
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).
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
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).
Consultative Internal Medicine Evaluation: Dr. Gilberti
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.
Consultative Psychiatric Evaluation: Dr. Leslie Heiprin
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
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).
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.
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).
Opinion by Non-Examining, Consulting Dr. L. Hoffman
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, ...