United States District Court, D. Connecticut
RULING ON PLAINTIFF'S MOTION FOR AN ORDER
REVERSING THE DECISION OF THE COMMISSIONER AND ON
DEFENDANT'S MOTION FOR AN ORDER AFFIRMING THE DECISION OF
GLAZER MARGOLIS, UNITED STATES MAGISTRATE JUDGE
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
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).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).
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). 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),  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).
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.
HEARING TESTIMONY AND ACTIVITIES OF DAILY LIVING
time of his hearing,  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.
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
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).
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.).
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).
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]
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.”
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.”
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.).
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.).
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).
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).
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).
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
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.
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.).
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.).
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).
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.).
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).
2013 plaintiff began participating in the InterCommunity
Depression and Anxiety Therapy Group, led by Vivian
Carr-Allen, LCSW. 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.
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,
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.
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).
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).
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).
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.).
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.).
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). 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
(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).
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.).
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).
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).
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