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Henneghan v. Berryhill

United States District Court, D. Connecticut

March 14, 2018



          VANESSA L. BRYANT, U.S.D.J.

         This is an administrative appeal following the denial of Shelby Henneghan's application for disability insurance benefits and supplemental security income benefits under 42 U.S.C. §§ 405(g) and 1383(c)(3).[2] Shelby Henneghan (“Henneghan”) has moved for an order reversing or remanding the decision of the Commissioner of the Social Security Administration (“Commissioner”). [Dkt. 17.] The Commissioner has moved for an order affirming the decision. [Dkt. 18.] For the following reasons, Henneghan's motion is granted in part and denied in part.

         I. Factual Background

         The following facts are derived from the record provided by the Social Security Administration.

         Shelby Henneghan is a 51 year old woman currently residing in a homeless shelter. She is separated from her husband and has three adult children. Ms. Henneghan has a history of mental disorders, substance abuse, diabetes, and hypertension and has been treated for edema, anemia, peripheral neuropathy, and migraines.

         a. Medical History Prior to Onset

         On March 5, 2009, Ms. Henneghan reported to Dr. Raymond Stewart at Optimus Health Care experiencing instability and popping in her right knee. [R. at 500.] Dr. Stewart conducted an MRI, and noted “a small amount of joint fluid at the upper limits of normal.” Id. Two months later, she underwent arthroscopic surgery of the right knee. [R. at 381.]

         On July 1, 2009, Ms. Henneghan was admitted to Greenwich Hospital for detoxification from heroin. [R. at 379.] She reported a history of smoking cigarettes and marijuana since the age of 10, and a history of using cocaine and heroin since the age of 13. Id. Henneghan reported having periods of abstinence as long as 7.5 years, but stated a 5-year period of abstinence ended two months prior when she was prescribed Percocet after her knee surgery. Id. After her prescription ran out, Henneghan reported that she began using up to five bags of heroin per day. Id. Her medical history at that time included hypertension and depression. Id.

         On July 23, 2009, Henneghan contacted Optimus Health Care (Stratford) stating she was depressed. [R. at 508.] She was referred for a clinical evaluation on July 28, 2009, and after that assessment was referred to a therapist for major depressive disorder. Id.

         On September 2, 2009, Henneghan returned to Greenwich Hospital to detox. [R. at 389]. She reported that, while she refrained from substance abuse for two weeks after her prior detox, she relapsed following an argument and she began using 8-12 bags of heroin per day and sporadically using crack cocaine. Id. On October 3, 2009, Henneghan was admitted to Bridgeport Hospital reporting abdominal pain. [R. at 481.] Dr. Pawan Dhawan found that her abdominal pain was caused by gastroparesis and gastric outlet syndrome related to a gastric-bypass surgery Henneghan underwent in 2003. Id. She also tested positive for cocaine and opiates. [R. at 481-82]. She was discharged with instructions to take antibiotics and hydromorphone, a pain killer. Id. at 482.

         b. Medical History After Onset

         From 2010-2012, Ms. Henneghan had sporatic appointments with Optimus Health Care (Bridgeport). [R. at 506-507.] At an unidentified time, Henneghan relocated to North Carolina. On April 2, 2012, she reported to Triumph, a North Carolina healthcare provider specializing in psychiatric and behavioral treatment. [R. at 522; see also] The intake assessment from Triumph reported that Henneghan was previously admitted to Holly Hill Hospital (HHH) from March 10, 2012 through March 21, 2012 exhibiting suicidal ideation without a plan. [R. at 510]. After her hospitalization, she began attending a substance abuse program at the Healing Place. Id. She claimed her substance abuse was an attempt to kill herself and went to Triumph seeking mental health treatment for depression and anxiety. Id. The Provisional Licensed Clinical Social Worker (P-LCSW) at Triumph, Kathryn Holt, gave a diagnosis of “Major Depressive Disorder, Recurrent, Severe with Psychotic features, ” Anxiety Disorder Not Otherwise Specified (NOS), and alcohol, cocaine, and opioid dependence. [R. at 518-20]. Although Ms. Henneghan reported abuse as a child, domestic violence, and seeing someone shot in the head 14-15 years prior, the clinician stated she “did not report enough criteria to meet a diagnosis of PTSD.” Id. The Clinician recommended individual therapy, medical management, a psychiatric evaluation and wellness management and recovery. [R. at 520].

         On April 17, 2012, Plaintiff reported to Rock Quarry Family Medicine (RQFM) in Raleigh, North Carolina as a new patient. [R. at 431-32.] The examiner, Dr. James Hartye, identified tenderness in Plaintiff's paraspinous muscle, a possible skin rash and minimal joint line tenderness of the knee. [R. at 432.] Dr. Hartye noted that Henneghan's medical history included high blood pressure, GERD, anemia, tobacco and opioid use, foot pain, a family history of breast cancer, and a malar rash. [R. at 431.]

         In May 2012, Henneghan continued attending the substance abuse program the Healing Place and going for medication management visits at Triumph. [R. at 398, 522-523.] In August 2012, Dr. Hartye at RQFM examined Henneghan and noted her hypertension, foot pain, anemia, GERD, depression, malar rash, and tobacco abuse were unchanged. [R. at 419.] Dr. Hartye noted that Henneghan was prescribed Risperdal, an antipsychotic, by a psychiatrist at Triumph and found Henneghan was “ok” on that medication. Id.

         On January 7, 2013 and February 28, 2013, Ms. Henneghan had follow-up visits with Dr. Hartye at RQFM, and he noted that Plaintiff's depression had improved. [R. at 531, 526.]

         On September 9, 2013, Plaintiff returned to Optimus Health Care in Connecticut for a “well person physical” and complained of dizziness and right leg pain with numbness. [R. at 697.] Plaintiff indicated that she was “constantly depressed and feeling suicidal” and that she would like to see a therapist. Id. Howard Smith, a Physician's Assistant (PA), conducted an examination which did not reveal any abnormal physical findings. [R. at 698-700.] PA Smith indicated the Plaintiff possibly had “neuropathy in her upper and lower extremities but has not been seen by a neurologist.” [R. at 701.] Plaintiff was referred for psychiatric evaluation of her anxiety and depression. [R. at 702.]

         Plaintiff returned to Optimus Health Care on October 7, 2013 for a follow-up visit with an additional complaint of right foot swelling with tingling sensations. [R. at 693.] PA Smith indicated he would refer the Plaintiff to a psychiatric provider again so she could reestablish care. Id.

         On November 25, 2013, Plaintiff relapsed on opiates and cocaine. Plaintiff was admitted to Kinsella Treatment Center on November 26, 2013. [R. at 542-543.] She began using methadone as a part of her substance abuse treatment. [R. at 551.] On December 30, 2013, Plaintiff requested an increase in her methadone, stating that she was “still using” and having cravings. [R. at 558.]

         On January 16, 2014, Plaintiff presented at the Bridgeport Hospital emergency room. [R. at 612.] She reported “having thoughts of hurting [her]self and others.” [R. at 613.] When asked if she was suicidal or homicidal, Plaintiff state “not really” and “I really just need a long break from my husband.” [R. at 614.] She also admitted to using $40-100 worth of crack cocaine daily and heroin several times a week. [R. at 613-614.] Her psychiatric evaluation indicated that she presented with hallucinatory voices which said “destructive things, ” but her risk levels for suicide, self-harm, homicide and violence were low. [R. at 617.] Plaintiff was discharged on January 20, 2013. [R. at 613.] Staff at Kinsella Treatment Center were notified of Plaintiff's admittance to Bridgeport Hospital. [R. at 556.]

         At a March 13, 2014 follow up at Optimus Health Care, Plaintiff was seen by Dr. Stewart Raymond, and she complained that she had feelings of dizziness. [R. at 685.] Physician notes state Plaintiff lost 35 pounds since her visit in September. Id. Plaintiff stated she lost her appetite and denied using drugs. Id. At a follow-up on March 19, 2013, Plaintiff alleged bilateral foot pain. [R. at 680.] Plaintiff was referred to podiatry and told to take over-the-counter pain medication for foot pain and to avoid wearing shoes with heels. [R. at 683.]

         On March 25, 2014, Plaintiff reported to treatment staff at Kinsella that she was “us[ing] about every other day.” [R. at 552.] She requested another methadone dosage increase. Id. Plaintiff indicated an interest in going to inpatient treatment. Id.

         Plaintiff was admitted to New Prospects (an inpatient treatment facility) on March 31, 2014. [R. at 655.] In her intake forms, Plaintiff indicated her abilities were “[p]aperwork[, ] school[, ] [l]ove working and helping people.” [R. at 657.] Plaintiff's mental examination showed she was cooperative, had decreased motor activity, normal speech, a depressed mood, full range of affect, coherent thought processes and unremarkable thought content. [R. at 667.] Plaintiff showed no risk of suicide, homicide and did not indicate having a history of violence. [R. at 668.] Her concentration and abstract reasoning were deemed intact and her intellectual function was estimated as above average. Id.

         On April 1, 2014, Plaintiff was taken to the emergency room for complaints of right leg pain. [R. at 573.] Plaintiff told the emergency department physician Dr. Zellner that she “ran out of her Lyrica [pain medication] several months ago.” [R. at 574.] An examination showed no abnormal findings. Id. Plaintiff was discharged on April 2, 2014. [R. at 576.]

         On June 6, 2014, Plaintiff returned to the shelter late and agitated. [R. at 741-746.] She was taken to the emergency room and released to the shelter after a negative urine toxicology screen. [R. at 743-744]. On June 10, 2014, Plaintiff returned to Dr. Raymond for a follow-up examination. [R. at 675-79]. Plaintiff had gained weight and reported seeing a social worker for stress. [R. at 675]. She stated that she was depressed but not suicidal or homicidal. Id. Dr. Raymond indicated Plaintiff needed prescription refills. [R. at 679].

         Later that day, Plaintiff was taken to the emergency room after she had an “altered mental status related to hypoglycemia.” [R. at 747.] After her mental status was resolved, she was examined, denied suicidal and homicidal ideations, exhibited linear thought processes, and reported no hallucinations. Id. Plaintiff reported that she had repeated hypoglycemic episodes and the examining doctor ordered her to discontinue her prescription of Metformin. [R. at 749.] Plaintiff was advised to follow up with her psychiatrist, as a safe house director reported Plaintiff was delusional and paranoid after discharge. [R. at 750.]

         On June 19, 2014, plaintiff was taken to the emergency room after stating that she did not want to live anymore, fell, and was unresponsive for about 10 seconds. [R. at 722.] Plaintiff denied she was suicidal. Id. A physical examination showed no acute distress and that she had “no focal neurological deficit” that was observed. [R. at 723.] According to her discharge documentation on June 20, 2014, Plaintiff had intact memory, was able to focus, had coherent thoughts, denied hallucinations, and was capable of reality-based thinking. [R. at 725].

         On July 21, 2014, Plaintiff had a follow-up visit at Optimus Health Care, and was seen by PA Smith. Plaintiff complained of pain under her left breast. [R. at 670.] The report indicated Plaintiff was not using drugs. [R. at 671.] PA Smith ...

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