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Shand v. Colvin

United States District Court, D. Connecticut

January 12, 2018




         This action, filed under § 205(g) of the Social Security Act, 42 U.S.C. §§ 405(g) and 1383(c), seeks review of a final decision by the Commissioner of Social Security [“SSA”] denying plaintiff Disability Insurance Benefits [“DIB”] and Supplemental Security Income Benefits [“SSI”].


         On July 23, 2013, plaintiff filed an application for DIB and SSI benefits claiming that he has been disabled since December 19, 2011 due to depression and right hip problems. (Certified Transcript of Administrative Proceedings, dated June 17, 2015 [“Tr.”] 218-29; see also Tr. 83). Plaintiff's application was denied initially (Tr. 83-106; see also Tr. 81-82, 138-47) and upon reconsideration (Tr. 107-35; see also Tr. 136-37, 148-57).[2]On July 10, 2014, plaintiff filed his request for a hearing before an Administrative Law Judge [“ALJ”](Tr. 158-59; see also Tr. 160-77, 180-204, 210-11, 216-17). A hearing was held briefly on September 2, 2014 and then again December 16, 2014 before ALJ Ryan A. Alger, at which plaintiff, plaintiff's case worker, and a vocational expert testified. (Tr. 27-80; see also Tr. 214-15). On January 13, 2015, ALJ Alger issued an unfavorable decision. (Tr. 7-21). On February 6, 2015, plaintiff filed his request for review of the hearing decision (Tr. 26), which the Appeals Council denied on March 23, 2015, thereby rendering the ALJ's decision the final decision of the Commissioner. (Tr. 1-6).

         On May 19, 2015, plaintiff filed his complaint in this pending action (Dkt. #1), and on March 4, 2016, defendant filed her answer. (Dkt. #16; see also Dkts. ## 14-15).[3] On July 22, 2016, plaintiff filed his Motion for Order Reversing the Decision of the Commissioner, with brief in support (Dkt. #22; see also Dkts. ##18-21), [4] which was followed by defendant's Motion for an Order Affirming the Decision of the Commissioner and brief in support on October 20, 2016 (Dkt. #25; see also Dkts. ##23-24).

         For the reasons stated below, plaintiff's Motion for Order Reversing the Decision of the Commissioner (Dkt. #22) is granted in limited part such that this case is remanded consistent with this Ruling, and defendant's Motion for an Order Affirming the Decision of the Commissioner (Dkt. #25) is denied.



         At the time of his hearing, [5] plaintiff was fifty-three years old, unmarried, and had recently obtained an apartment in East Hartford after being homeless for years. (Tr. 40, 43, 218). Plaintiff lives by himself, does not drive, and takes the bus. (Tr. 41, 43). He graduated from high school and can read and write. (Tr. 40, 47-48). Plaintiff testified that due to his homelessness, he spends most of his time in the library and likes to read “poetry stuff, comic books, things like that[, ]” but he could not remember the last book he read, although he thought it was a comic book. (Tr. 62-63).

         Plaintiff began working when he was sixteen and testified that he has worked his entire life. (Tr. 49-50). Plaintiff testified that before 1999, he held many jobs, including making boilers, unloading and loading trucks at Staples, and performing heavy and light housekeeping and laundry duty at a nursing home. (Tr. 50-51). At Staples, plaintiff loaded and unloaded ten trucks in a shift and lifted somewhere between fifty and one hundred pounds for the entire shift. (Tr. 50-51, 66). Although plaintiff testified that he liked this job, the “position and the hours were terminated.” (Tr. 51). Plaintiff worked fulltime at a nursing home for three years, where he stripped and waxed floors using machinery and sorted, washed, dried, and folded laundry. (Tr. 51-52). Plaintiff “decided to leave[]” the company when it was sold and “they had to cut everybody's hours. . . .” (Tr. 52). Plaintiff testified that in 2010[6] he worked as a deli clerk at Stop & Shop for about “six months or so[]” until he cut his hand on a slicer and “actually just left” because he “didn't like the job anymore.” (Tr. 40-41). At the hearing, plaintiff provided multiple explanations for why he did not go back to work. At times, plaintiff testified that he was unable to work because “with [his] body, it's all about wear and tear, and [he doesn't] have the strength anymore.” (Tr. 41). At other times, plaintiff testified that his father's death in June 2010 was a turning point after which he did not have “a real job[]” because he and his father were extremely close. (Tr. 53, 55). And at still other times, plaintiff testified that he could not work because he “do[esn't] have a vehicle to [get] around[, ]” but subsequently denied that he could work even if given transportation because his “body can't go through the wear and tear anymore.” (Tr. 54).

         Plaintiff testified that his most troubling medical issues are pain in his right hip and depression. (Tr. 41-42). Plaintiff testified that he has rheumatoid arthritis in his hip, for which he does not take any medication. (Tr. 42, 61). When asked how he was diagnosed with rheumatoid arthritis, plaintiff testified that his doctor tested for it by continually “hitting [him] with a little rubber hammer.” (Tr. 61). Plaintiff's counsel asked if the “little rubber hammer” gave his doctor the answer “like a divining rod?” (Id.). Plaintiff answered, “Right.” (Id.). Plaintiff testified that his hip prevents him from “bending, stooping down, and trying to do other things.” (Tr. 62). He added that while sitting at the hearing, he was “feeling numb[]” and if “you see [him] kind of rotate a little bit . . . that means [he is] trying to ease up the pressure a little bit.” (Id.). Plaintiff testified that he has to sit in “an upright chair[]” with a sturdy back. (Id.).

         Due to his depression, plaintiff goes to group counseling at InterCommunity Health every Friday, which he finds helpful and enjoyable. (Tr. 42-43). Plaintiff takes one medication for depression which he described as “[m]ostly” helpful, but he could not recall any details about his medication at the hearing. (Tr. 42-43). Plaintiff explained that after his father's death, he was “[v]ery much[]” distracted such that at “[c]ertain times, [he] cannot communicate with people and work at the same time[, ]” and has “[a] little bit[]” of trouble concentrating because he is thinking too much and his brain is “full of ideas[.]” (Tr. 53). Plaintiff testified this was “[s]ome sort[]” of a problem with keeping jobs and getting tasks done with his caseworker. (Tr. 54). Plaintiff explained that it was hard for him to participate in his group therapy at first, but that after a while he was referred to a new therapy group for participants who experience psychosis. (Tr. 55-56). Plaintiff testified that this group “opened up a bigger door for him[, ]” but denied that he experiences any psychosis. (Tr. 56). When counsel asked plaintiff why he was put in this therapy group if he did not have a similar condition, plaintiff responded “[b]ecause, they have the same type of problem, what I have, and they have a couple of more other things.” (Id.). Plaintiff testified that he has problems with isolation, and there are times he does not want to see or hear from anyone and will “lock [him]self in a room [so that he does not] have to see or hear anyone at all[, ]” going “maybe a day or two[]” without even going outside. (Tr. 56-57). Plaintiff added that he “still see[s] shadows . . . [e]very now and then.” (Tr. 57). Although plaintiff at first denied it, plaintiff testified that his father still “c[a]me [to] visit” plaintiff after his father died, and plaintiff even saw “[a] couple[]” of other dead people. (Tr. 55).

         Plaintiff admitted that he was very thin and that putting on weight “grosses [him] out[]”; he also testified that he washes himself every time he touches something, but denied that this was unusual. (Tr. 57). Plaintiff indicated that he “[does not] get to sleep too often[, ]” that sleeping “is a problem[, ]” and that he sleeps on average “[p]robably[] two hours, maybe less, maybe a half hour[]” each night because he is “not comfortable.” (Tr. 58). In this testimony, plaintiff referred to the fact that he did not have any furniture in his apartment, and slept on the floor. (Id.). When asked if he would sleep well if he had a bed, plaintiff testified that he believed he would still struggle to sleep because “so many different things . . . [are on his] mind, and [he] ha[s] to try to sort it, and [he's] trying.” (Id.).

         Plaintiff denied that mental health professionals have encouraged him to adjust his medication, but he testified that his dosage has been increased by one milligram, which he described as “pretty all right.” (Tr. 59). Plaintiff explained that he takes his medication as instructed, but admitted that there was a time when he took his medication every other day to make it last longer because he could not remember to get refills. (Id.). When asked why his InterCommunity records noted that he had been drinking alcohol and smoking marijuana, plaintiff answered that such behavior “was a thing of the past, ” and he is “[a]bsolutely, positively, 100 percent sure[]” he has not done either since he left Manchester Hospital. (Tr. 63-64). Plaintiff presented to Manchester Hospital in 2012, and plaintiff testified that he was drunk at that time due to depression because his father died and “reality set in.” (Id.).

         Before plaintiff moved into the apartment in East Hartford, he was homeless for two years. (Tr. 43). At times, plaintiff lived in a homeless shelter, but at other times plaintiff lived on the street or in a park. (Tr. 43-44). Plaintiff testified that he did not always go to a shelter because he “never really had the - the know-how towards everything with a shelter. . . .” (Tr. 44). When asked why he did not get an apartment, plaintiff testified that he “didn't have any money, any income, nothing.” (Tr. 44-45). Plaintiff did not live with family or friends because “[t]hat's a hard thing to do, because everybody wants something.” (Id.). Before becoming homeless, plaintiff testified that he had lived with “[p]robably [his] only friend[, ]” but then was thrown out. (Tr. 45-46). At times during his adult life, plaintiff lived with his mother. (Tr. 46). The only time plaintiff lived on his own was about ten years earlier when he lived in a rooming house, and plaintiff explained that he never had his own residence “[b]ecause, [he] was busy, going from one place to the next, working-wise.” (Id.).

         Plaintiff testified that he has not cooked anything in “a long time” and feeds himself by buying “a sandwich here, a sandwich there[]” and drinking Ensure “to build up [his] immune system. . . . If [he] miss[es] a meal, [he] can drink this, and [he'll] be okay for a day.” (Tr. 47). Because he does not eat regularly, plaintiff's weight fluctuates. (Id.).

         Plaintiff received state benefits in the form of health insurance, cash assistance, and food stamps, mostly coordinated by Shawn Decker, his case worker at InterCommunity. (Tr. 43, 47-48). According to plaintiff, Decker helped plaintiff with many responsibilities, including accessing housing, getting bus passes, and managing his social services applications for food stamps and SAGA cash. (Tr. 47). Plaintiff testified that he was unable to do any of this himself because “most of the stuff, [he] do[es]n't understand.” (Tr. 48). Plaintiff added that Decker had been trying to have plaintiff handle some of these responsibilities on his own, but that “[s]ome of it came out well, some didn't[.]” (Id.). Plaintiff had no furniture in his apartment and relied on Decker to “tak[e] care of that[.]” (Tr. 49). Plaintiff does not know how to use a computer. (Id.). Decker makes sure plaintiff goes to his scheduled appointments, checks in to ensure that plaintiff is not suicidal, and has been “managing [plaintiff's] affairs[]” for two years. (Id.).

         Decker testified at the hearing that he met plaintiff two years prior and generally communicates with plaintiff two or three times a week, either in person or by phone. (Tr. 67). Decker described that he does “pretty much everything[]” for plaintiff, including ensuring he takes his medication, going to his appointments, helping him get an apartment by bringing him to see it and signing the paperwork, and managing his entitlements. (Tr. 67-68). Decker indicated that he tried to encourage plaintiff to be more self-sufficient, but usually plaintiff would not complete assigned tasks and Decker would have to do them with plaintiff, or for him. (Tr. 70). Decker testified that plaintiff missed a deadline to submit information for his apartment application by three or four days, and that Decker had to call the East Hartford Housing Authority to get his application “put back in place[] so that he would be able to get this apartment[.]” (Tr. 71). Decker added that he had to obtain all the required documentation and bring it to the Housing Authority for plaintiff, because plaintiff “has a difficult time following through on everything[.]” (Id.). Decker testified that plaintiff avoids making phone calls because he is isolative, and plaintiff would often wait until meeting with Decker to bring up the need to make a phone call related to his benefits so that Decker would do it with him. (Tr. 71-72). Decker explained that he has to constantly prompt plaintiff to do things he should be able to do on his own, and that Decker believes plaintiff has trouble concentrating because in conversation, Decker “ha[s] to refocus [plaintiff] to what [they]'re talking about[.]” (Tr. 72-73). Decker testified that when he encouraged plaintiff to reach out to people in his life to help him acquire needed furniture and supplies for his new apartment, plaintiff refused because he “doesn't like to reach out to anybody. He wants to kind of, just, stay to himself.” (Tr. 73).

         The vocational expert testified that plaintiff's past work as a store laborer was medium work likely performed at the heavy exertional level, and his work as both a hospital cleaner and a floor waxer was medium work. (Tr. 75-76). In response to the ALJ's hypothetical of a person limited to medium level work who could carry out and remember simple instructions, handle normal changes in the work place with no interaction with the general public and only occasional interaction with co-workers, the vocational expert testified that such a person would be able to do plaintiff's past work as a laborer in stores, at the medium level. (Tr. 76). In response to the same hypothetical, except that the person is limited to light level work, the vocational expert testified that such a person could not perform any of plaintiff's past work but could perform the job of a marker, routing clerk, or mail clerk. (Tr. 76-78). The vocational expert testified that no job could accommodate such a person who also was unable to maintain concentration such that he was off-task at least fifteen percent of the work day. (Tr. 78).


         Plaintiff's medical records in the administrative transcript cover a twenty-eight month period within plaintiff's period of alleged disability, from September 2012 (Tr. 350-62) through December 2014 (Tr. 896-902).[7]

         On September 29, 2012, plaintiff was admitted to the Emergency Department of Manchester Memorial Hospital [“MMH”] with suicidal thoughts. (Tr. 350-57). Plaintiff was despondent and homeless, without much sleep; he admitted to consuming some alcohol that evening, and complained of bilateral leg pain from walking. (Id.). Plaintiff presented with a prescription for Abilify PO. (Tr. 351, 354). Dr. Jesse Fisk, an emergency room physician, described plaintiff as disheveled and despondent-appearing but alert, oriented, and in no apparent distress; plaintiff's physical exam was normal. (Tr. 351). Dr. Fisk noted that plaintiff could not be assessed at that time because he was intoxicated, “tearful[, ] and had his hands covering his eyes as he rambled about life being unfair and doors closing and no others opening.” (Tr. 353). Dr. Fisk diagnosed plaintiff with prolonged depression. (Tr. 352). Upon subsequent evaluation, Dr. Theodore Sherry, another emergency room physician, wrote that plaintiff was experiencing “psychiatric decompensation with worsening depression and thoughts of suicide, [and he] will remain overnight for crisis evaluation in the morning.” (Id.).

         Upon evaluation the following morning, Dr. Fisk found that plaintiff was “profoundly depressed, ” kept his eyes closed and head turned away, and was only able to answer questions with minimal information in barely audible speech. (Tr. 353). Plaintiff had been homeless for months, and reported going to a friend's home to borrow a gun to kill himself before he was sent to the Emergency Department. (Id.). Dr. Fisk noted that plaintiff reported he recently was connected by a homeless shelter to outpatient care at Community Health Resources [“CHR”]; Dr. Fisk contacted CHR to confirm plaintiff's medication and treatment history, noting that plaintiff had sought treatment on his own in August 2012, was evaluated for medication, and was prescribed Abilify 2mg by “S. Hinton” on September 11, 2012. (Tr. 353-54). Dr. Fisk reported that plaintiff was unable to sleep, lost his appetite, and lost more than twenty pounds in a few months; he had suicidal ideation with intent and a plan; he could not reliably contract for safety; and he “sees and hears strange things[, ]” and experiences auditory and visual hallucinations that come and go but are not distressing or disruptive. (Id.). Plaintiff exhibited underproductive speech; an indifferent attitude towards the examiner; cooperative behavior and organized thought processes; alert and oriented cognitive function; suicidal thought content; auditory and visual perceptual disturbances; depressed mood; flat and tearful affect; fair impulse control; poor insight; poor judgment; and suicidal risk factors including ideation, intent, plan, and inability to contract for safety. (Tr. 354-55). Dr. Fisk diagnosed plaintiff with depressive disorder, not otherwise specified, and rule out Schizoaffective disorder; he opined that plaintiff had a GAF score of 25. (Id.). Plaintiff was transferred to MMH Mental Health on September 30, 2012. (Tr. 358-62).

         After his transfer, Dr. David Hedberg, a psychiatrist, performed another mental status examination during which plaintiff struggled to answer questions, presumably due to his depression; plaintiff discussed suicidal feelings but contradicted his statements from his admission the prior evening by denying that he had a suicidal plan. (Tr. 359). Dr. Hedberg opined that plaintiff's “concentration is only fair[.]” (Id.). Plaintiff stated that he heard voices, although not at that time, and he was unable to describe what the voices said. (Id.).

         On October 3, 2012, Dr. Jamshid Marvasti, a psychiatrist, examined plaintiff and described him as a highly intelligent, charming young man who came to the emergency room asking for help because he is “falling apart, has no place to live, has no money and shelter would not accept him because he has been there too long.” (Tr. 361-62). Dr. Marvasti's mental status evaluation did not reveal any indication of psychotic sickness or organic mental disorder; plaintiff was cooperative, communicative, and informative; and plaintiff admitted to being anxious and depressed because he had no place to live. (Id.). Dr. Marvasti reported that within a short period of time, plaintiff improved substantially and requested to be discharged. (Id.). Dr. Marvasti discharged plaintiff but noted that he would be followed by Sharon Hinton, APRN, at CHR on October 16, 2012. (Id.).

         Six months later, on April 1, 2013, plaintiff presented to Dr. Sultan Quraishi, a family physician, with depression. (Tr. 365-67, 373-75). Dr. Quraishi diagnosed plaintiff with dysthymic disorder and prescribed 20mg Lexapro, daily. (Tr. 365-66, 373-74). Eleven days later, on April 12, 2013, plaintiff returned to Dr. Quraishi with depression, and Dr. Quraishi added a current working diagnosis of “anxiety state unspecified.” (Tr. 367-68, 375-76). On May 7, 2013, plaintiff presented to Dr. Quraishi complaining of pain in his right hip. (Tr. 369-70, 377-78). Physical examination revealed tenderness over the right hip joint with painful and limited movement. (Id.). Dr. Quraishi diagnosed plaintiff with “osteoarthrosis localized not specified whether primary or secondary involving pelvic region and thigh (working)”; “pure hypercholesterolemia (working)”; “myalgia and myositis unspecified (working)”; and “dysthymic disorder (working)”. (Tr. 370, 378). One week later, on May 14, 2013, plaintiff presented for a routine physical at which Dr. Quraishi described him as well-nourished with a comfortable appearance and demeanor, and plaintiff's exam was completely normal. (Tr. 371-72, 379-80).

         On May 3, 2013, plaintiff was suicidal and presented at InterCommunity with depression that was “getting heavier and heavier.” (Tr. 381-87, 847-53; see also Tr. 424-28). Gillian Workman-Stein, LCSW, reported that plaintiff had become increasingly depressed after he became homeless and lost his father, who was his primary emotional support. (Tr. 384, 425, 850). Workman-Stein's mental status examination of plaintiff that day (Tr. 708-13) found that he was well-groomed and mildly thin, with clear speech and average demeanor, eye contact, and activity. (Tr. 708). Plaintiff's thought content exhibited mild paranoid delusions, and his thought process exhibited mild auditory and visual hallucinations but was generally logical. (Tr. 709). Plaintiff was moderately depressed, moderately anxious, had a full affect, behaved cooperatively, and exhibited moderate despair/worthlessness. (Tr. 710). Plaintiff exhibited mild impairment of his concentration/attention, average estimated intelligence, and fair insight and judgment. (Tr. 711). Workman-Stein noted that plaintiff's depressed mood was evidenced by hospitalization, low motivation, low energy, feelings of worthlessness and “a lot” of suicidal thoughts; plaintiff's anxiety was evidenced by daily worry, racing thoughts about the future, and one panic attack. (Tr. 382, 711, 848). Plaintiff experienced sleep problems such that sometimes he does not sleep at all, and reported sometimes “you see something that you think is there but it is not.” (Tr. 383, 849). Workman-Stein noted that plaintiff has a disturbed reality as evidenced by visual hallucinations, paranoia with respect to others putting thoughts in his head, and possibly hearing things, but it is “[u]nclear if psychosis or if there is a malingering quality[.]” (Id.).

         Workman-Stein opined that plaintiff had major depressive disorder, single episode, moderate, but rule out severe with psychotic features; plaintiff had severe housing problems, severe occupational problems, and severe problems with primary support group; and plaintiff had a current GAF score of 43. (Tr. 385, 426, 851). Plaintiff expressed interest in any behavioral health clinical and rehabilitative services offered to him, and agreed to participate in a weekly therapy group for depression/anxiety, but was not interested in medication. (Tr. 384, 386, 425, 427, 850, 852).

         In May 2013 plaintiff began participating in the InterCommunity Depression and Anxiety Therapy Group, led by Vivian Carr-Allen, LCSW.[8] Plaintiff did not participate in the first two sessions, and after the second session Carr-Allen referred plaintiff for a crisis evaluation because he exhibited a flat affect and was non-responsive when called upon. (Tr. 533-36). Workman-Stein performed the crisis evaluation (Tr. 448-52) and described plaintiff as friendly and well-spoken, but overwhelmed by his physical needs and lack of housing support. (Tr. 450). Plaintiff was not interested in offers of shelter and was “contemplative about hospital stating he is not suicidal, doesn't sleep there anyway and feels more confined and increasingly frustrated.” (Id.). In later sessions of the Anxiety and Depression Psychotherapy Group, Carr-Allen reported that plaintiff asked not to participate but demonstrated a better affect (Tr. 541-42); was attentive but reported that things were not good and rated his depression as a ten (Tr. 543-44); and actively participated with brighter affect but rated his depression as a ten (Tr. 549-50).

         Plaintiff began individual psychotherapy with Carr-Allen on June 10, 2013 with a goal of returning to baseline functioning with his depression; he rated his depression as a ten, and reported daily suicidal thought as well as feeling as if he is “losing it.” (Tr. 593-95). In group therapy plaintiff continued to rate his depression at a ten and was attentive but generally did not participate, although he did participate in some role playing. (Tr. 553-54, 557-60, 563-64, 724-25).

         In July 2013, InterCommunity paired plaintiff with Decker, a case worker, to help plaintiff complete a Housing and Urban Development [“HUD”] packet. (Tr. 453-57). Decker assisted plaintiff on a regular basis by helping plaintiff obtain documents for his HUD application (Tr. 458-59), reapply for disability (Tr. 460-61), gather disability and housing paperwork (Tr. 462-63), obtain bus passes (Tr. 464-65), and check the status of various benefits. (Tr. 466-69).

         Carr-Allen evaluated plaintiff on August 5, 2013 (Tr. 388-91, 572-75, 854-57) because he continued to have no energy or motivation; she assigned plaintiff a GAF score of 36. (Tr. 388, 390-91, 572-75, 854, 856-57). Plaintiff continued to not participate in group therapy, showed poor comprehension of concepts covered in the session, and told Carr-Allen privately that “things were not good” and he had “too much going on to participate in the anxiety and depression group.” (Tr. 596-98, 728-29). Decker had reported to Carr-Allen that plaintiff was unable to follow through on what Decker recommended and seemed to want Decker to do everything for him. (Tr. 597).

         Two days later on August 16, 2013, Marina Sciucco, APRN, performed a medical evaluation at the suggestion of plaintiff's therapist because he was depressed, exhausted, hopeless, not sleeping, experiencing mild thought derailment, and had a poor appetite. (Tr. 392-97, 614-19, 903-08). APRN Sciucco recorded that plaintiff lost twenty-three pounds in eight months. (Tr. 392, 614, 903). APRN Sciucco performed a mental status exam, noting that plaintiff was dressed appropriately and had hygiene that was “surprisingly very good considering his living in the park[, ]”; he had a steady gait and clear speech with normal rate and rhythm; he was pleasant, engaging, and had good eye contact; he was alert and fully oriented; he had thoughts that were at times illogical with some derailment; he exhibited no aggression, psychosis, or suicidal or homicidal ideation, but had a sad affect with mild constriction; and he exhibited no abnormal involuntary movements or distractability. (Tr. 392-95, 614-17, 903-06).

         On September 5, 2013, plaintiff told Carr-Allen that his appetite was so diminished that he was eating three or four bites of food per day; he was tired with little interest or motivation; he was not sleeping; and he had suicidal thoughts off and on. (Tr. 603; see Tr. 602-04). In therapy on September 19, 2013 (Tr. 605-06), plaintiff agreed to consider the SECURE Intensive Outpatient Program [“IOP”]. (Tr. 606). APRN Sciucco met with plaintiff on September 24, 2013 to evaluate his prescription (Tr. 398-403, 620-25, 909-14); at that time plaintiff still had some Invega pills left even though he should have run out of his prescription nine days earlier. (Tr. 398, 620, 909). APRN Sciucco opined that plaintiff could benefit from an increase in medication dosage, but plaintiff refused. (Tr. 399, 621, 910).

         On October 2, 2013, Decker noted plaintiff has “a hard time fighting through [his depression] to get his work done.” (Tr. 520; see Tr. 520-23). Decker continued to help plaintiff check the status of his benefits and obtain bus passes. (Tr. 474-79). Decker also accompanied plaintiff to therapy, where he and Carr-Allen encouraged plaintiff to begin IOP treatment. (Tr. 480-81, 608-13). On October 28, 2013, Heidi Friedland, LCSW, assessed plaintiff because he was attending therapy but not making progress. (Tr. 567-71). Plaintiff reported auditory and visual hallucinations, had not eaten in days, and said he has “felt depressed every day of [his] life [and is] worried all the time.” (Tr. 567). Plaintiff experienced anxiety, disorganized and depressed mood, and poor eating and sleeping, which were constantly present. (Id.). Friedland described plaintiff as “highly tangential[, ]” and noted that when asked about the level of intensity of his symptoms, plaintiff was unable to rate them. (Tr. 567-68). Plaintiff reported experiencing both auditory and visual hallucinations all the time, “but they do not appear unmanageable today.” (Tr. 568). In light of plaintiff's difficulties expressing himself, Friedland recommended that plaintiff join another small group for individuals with persistent mental illness. (Id.).

         APRN Sciucco examined plaintiff for a medication refill on October 30, 2013 (Tr. 404-09, 622-31, 915-20), and again encouraged him to increase his medication dosage; plaintiff declined. (Tr. 404, 626, 915). Plaintiff had a stable mood and improved appetite with gradual weight gain, although he was still very thin. (Id.). APRN Sciucco evaluated plaintiff for another medication refill on December 5, 2013 (Tr. 410-15, 632-37, 921-26), and plaintiff again refused an increase in dosage but reported he was taking the medication more consistently. (Tr. 410, 632, 921). Plaintiff had a stable mood but poor appetite and had lost three pounds since his previous visit. (Id.).

         In November 2013, plaintiff began participating in the Moving Forward Therapy Group for participants experiencing “symptoms of schizophrenia, schizoaffective disorder, bipolar disorder, and depression with psychosis.” (Tr. 734-35, 760-61).[9] Mary Salustri, LCSW, reported that plaintiff appeared at ease with this group and actively participated, but he shared a lot of off-topic information. (Tr. 734-35). In group session on November 15, Salustri described plaintiff as “tangential” and plaintiff insisted that there was

nothing that he can change or wants to change in his life. [Plaintiff] appears to be pre contemplative regarding all potential changes in behavior. [Plaintiff] did express that he was happy to be in the group and that it feels good to be around other people and to have people listen to him when he talks.

(Tr. 740-41). After session on November 22, Salustri opined that plaintiff was making progress in understanding his illness because he told the group, “I see people running by men [sic] that aren't there. When things don't go my way I shut the world out.” (Tr. 744-45). On December 13, 2013, Salustri reported that plaintiff actively participated in group therapy with good comprehension, and plaintiff observed that he was better able to manage heated situations and that his medication was helping him have clear thoughts. (Tr. 746-47). On December 27, Salustri reported that plaintiff avoided discussing his mental illness in group therapy even when asked direct questions and wanted to focus on his physical illness instead. (Tr. 752-53). Salustri reported that on January 10, 2014, plaintiff actively participated in group therapy with good comprehension of the topic, which was understanding mental illness, and noted that he had thoughts that people in the television are watching him; he also reported that he was getting better at taking care of his needs at the shelter by asking for the space he needs. (Tr. 754-55). Salustri reported that in session the following week plaintiff continued to actively participate and reported he was getting better at being able to cope with his symptoms. (Tr. 758-59).

         Decker continued to assist plaintiff to obtain bus passes, understand the Social Security Disability process, acquire more intensive services, complete paperwork and medical forms for his Social Security application, and check the status of his benefits. (Tr. 482-97). On May 3, 2013, Decker performed a mental status examination during which he described plaintiff's current mental status as flat and depressed, and noted that plaintiff isolates and does not leave his home. (Tr. 416-19). Plaintiff appeared clean, his cognitive status was fine, and he exhibited normal speech, depressed mood, flat affect, limited judgment, and limited insight. (Tr. 416-17). Decker opined that plaintiff had a slight problem with personal hygiene, caring for physical needs, using good judgment regarding safety and dangerous circumstances, and using appropriate coping skills to meet ordinary demands of a work environment; Decker further opined that plaintiff had a serious problem with handling frustration appropriately, interacting appropriately with others in a work environment, asking questions or requesting assistance, respecting/responding appropriately to others in authority, and getting along with others without distracting them or exhibiting behavioral extremes. (Tr. 417-18). Decker found that plaintiff had a slight problem with carrying out single-step instructions; plaintiff had an obvious problem with carrying out multi-step instructions, focusing long enough to finish assigned simple activities or tasks, changing from one simple task to another, or performing basic work activities at a reasonable pace/finishing on time; and plaintiff had a serious problem performing work activity on a sustained basis (i.e., eight hours per day, five days a week). (Id.).

         Plaintiff continued to participate in the Moving Forward group through January and February 2014. (Tr. 764-67, 772-73, 776-78). Salustri opined that plaintiff's understanding of his illness had increased a little as a result of participation in group therapy; plaintiff reported seeing shadows of people who are not there a few times per day and reported auditory hallucinations once a week; and plaintiff experienced low motivation and low energy. (Tr. 581, 863; see Tr. 581-86, 863-68). Salustri performed an evaluation of plaintiff's capability for activities of daily living, and opined that plaintiff had moderately severe impairment or problems functioning with respect to health practices, housing stability, communication, safety, managing time, managing money, nutrition, problem solving, family relationships, leisure, community resources, social network, productivity, and coping skills. (Tr. 583-84, 865-66). Salustri opined that plaintiff had moderate impairment or problems with respect to alcohol/drug usage, behavioral norms, personal hygiene, grooming and dress. (Id.). Salustri opined that plaintiff had mild impairment, within normal limits, with respect to sexuality, maintaining appropriate behavior towards others, and respecting the privacy and rights of others. (Id.). Salustri changed plaintiff's Axis I diagnosis to major depressive disorder, recurrent, severe with psychotic features, with a GAF score of 33. (Tr. 584-85, 866-67).

         On February 6, 2014, plaintiff presented to APRN Sciucco for a refill of medication of which he ran out one month earlier. (Tr. 638-44, 927-33). Plaintiff had a stable mood and his appetite had improved such that he gained four pounds since his previous visit; he still was not sleeping well and had not been able to avail himself of social services or case management enough to help him achieve a more stable living situation. (Tr. 638, 927). APRN Sciucco described plaintiff as “depressed due to severe psychosocial stress of being homeless but also exhibits some odd thought patter[n]s suggestive of a possible thought disorder.” (Tr. 639, 928). On February 28, 2014, APRN Sciucco reported that plaintiff's mood was stable and he had odd thought patterns suggestive of a possible thought disorder but that plaintiff is “[p]resenting as more coherent as I get to know him.” (Tr. 645-46, 934-35; see Tr. 645-50, 934-39). In April 2014, APRN Sciucco observed symptoms of flat affect, severe weight changes, thought errors, and depression. (Tr. 652, 941; see Tr. 651-56, 940-45). Plaintiff continued to actively participate in the Moving Forward therapy group, where he mentioned seeing and hearing things that others do not (Tr. 772-73) and described himself as “lucky” that there are “[n]o voices at this time.” (Tr. 776-77). Plaintiff listened to other group members share their experiences with psychotic symptoms and indicated that he knows how they feel. (Tr. 778-79). In a session on March 7, 2014, plaintiff reported that he was in a lot of physical pain, which was making his depression worse. (Tr. 782-83).

         In therapy in April 2014, plaintiff told the group that at times he thought he could read minds, or “feel[s] like hands are around [his] neck or [] feel[s] breath on the back of [his] neck[.]” (Tr. 794-95, 800-01). During April 2014, Decker helped plaintiff arrange a meeting with a doctor after plaintiff missed a scheduled doctor's appointment. (Tr. 502-05). In May 2014 Decker helped plaintiff schedule a ...

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