United States District Court, D. Connecticut
RULING ON THE PLAINTIFF'S MOTION TO REVERSE AND
THE DEFENDANT'S MOTION TO AFFIRM THE DECISION OF THE
VANESSA L. BRYANT, U.S.D.J.
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). 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.
following facts are derived from the record provided by the
Social Security Administration.
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,
Medical History Prior to Onset
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
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
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
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.
Medical History After Onset
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
http://www.triumphcares.com/aboutus.html.] 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].
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.]
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.
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.]
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.]
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.
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.]
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
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.]
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.
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.
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.]
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.
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.]
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].
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