United States District Court, D. Connecticut
LEE MOORE, ADMINISTRATOR OF THE ESTATE OF DANIEL E. WEAVER
v.
NANCY A. BERRYHILL, ACTING COMMISSIONER OF SOCIAL SECURITY[1]
RULING ON THE PLAINTIFF'S MOTION TO REVERSE THE
DECISION OF THE COMMISSIONER AND ON THE DEFENDANT'S
MOTION FOR AN ORDER AFFIRMING THE DECISION OF THE
COMMISSIONER
ROBERT
M. SPECTOR UNITED STATES MAGISTRATE JUDGE.
This
action, filed under § 205(g) of the Social Security Act,
42 U.S.C. § 405(g), seeks review of a final decision by
the Commissioner of Social Security [“SSA”]
denying the plaintiff Disability Insurance benefits
[“DIB”].
I.
ADMINISTRATIVE PROCEEDINGS
On or
about December 2, 2013, the plaintiff[2] filed an application for DIB
benefits claiming he has been disabled since December 1,
2012, due to bipolar disorder and attention deficit,
hyperactivity disorder [“ADHD”]. (Certified
Transcript of Administrative Proceedings, dated August 3,
2017 [“Tr.”] 198-201). The plaintiff subsequently
amended his onset date of disability to January 1, 2014. (Tr.
217). The plaintiff's application was denied initially
(Tr. 133-36) and upon reconsideration. (Tr. 141-49). On
August 15, 2014, the plaintiff requested a hearing before an
Administrative Law Judge [“ALJ”] (Tr. 150-51),
and on September 14, 2015, a hearing was held before ALJ
Eskunder Boyd, at which the plaintiff and a vocational expert
testified. (Tr. 63-95; see Tr. 164-88). On October
27, 2015, ALJ Boyd issued an unfavorable decision denying the
plaintiff's claim for benefits. (Tr. 42-62). On December
23, 2015, the plaintiff filed a request for review of the
hearing decision (Tr. 197), and on May 4, 2017, the Appeals
Council denied the request, thereby rendering the ALJ's
decision the final decision of the Commissioner. (Tr. 1-7).
On July
7, 2017, the plaintiff filed his complaint in this pending
action (Doc. No. 1), and on September 11, 2017, the defendant
filed her answer and administrative transcript, dated August
3, 2017. (Doc. No. 14). On September 29, 2017, the parties
consented to the jurisdiction of a United States Magistrate
Judge; the case was transferred to Magistrate Judge Joan G.
Margolis. (Doc. No. 18). On December 13, 2017, the parties
filed a Joint Stipulation of Facts (Doc. No. 21),
[3]and
the plaintiff filed his Motion to Reverse the Decision of the
Commissioner (Doc. No. 22), and brief in support. (Doc. No.
21-1 [“Pl.'s Mem.”]). On February 13, 2018,
the defendant filed her Motion to Affirm (Doc. No. 23), and
brief in support. (Doc. No. 23-1 [“Def.'s
Mem.”]). On May 1, 2018, this case was reassigned to
this Magistrate Judge. (Doc. No. 24).
For the
reasons stated below, the plaintiff's Motion to Reverse
the Decision of the Commissioner (Doc. No. 22) is
denied, and the defendant's Motion to Affirm
(Doc. No. 23) is granted.
II.
FACTUAL BACKGROUND
A.
HEARING TESTIMONY
As of
the date of his hearing in 2015, the plaintiff was
fifty-eight years old, living with his husband in a
“historical house museum.” (Tr. 69-70). He
testified that he could groom and bathe himself, do yard work
and laundry, and take out the trash, though he sometimes
lacked motivation. (Tr. 73). Additionally, he would run three
to four miles a day. (Tr. 73). He said he spent a lot of time
watching television (Tr. 77) and checked his emails once a
day. (Tr. 79).
According
to the plaintiff, he was disabled due to depression, ADHD,
borderline personality disorder, and post-traumatic stress
syndrome, which resulted in anxiety and panic attacks. (Tr.
74, 81). He testified that he got along with people, but had
trouble concentrating. (Tr. 77, 79). He had suicidal thoughts
“almost daily” and, indeed, felt suicidal during
the week of the hearing. (Tr. 80). He said he did not want to
go to the hospital because he was “starting a volunteer
program for hospice” the next day and had a per diem
job lined up later in the week that he wanted to keep. (Tr.
80).
The
plaintiff held a bachelor's degree in communications, and
at the time of the hearing, was working per diem as a
recreation therapy aide. (Tr. 70-71). He served as a paid
intern at the Residence House in 2013, and at the same time,
he went back to school to earn a certificate in recreation
therapy. (Tr. 82). However, the internship and the schooling
proved “too much for [him][]” in terms of his
ability to concentrate and deal with the behaviors of the
people around him. (Tr. 83). At his hearing, the
plaintiff's counsel explained that he amended the onset
date of disability to January 1, 2014 in light of the
plaintiff's “significant employment” in 2013.
(Tr. 68-69). Prior to performing his work in 2013, he was
self-employed as a video producer. (Tr. 72, 84). The
plaintiff worked at Foxwoods Casino from 2002-2010, first as
a video producer, and then as the director of communications.
(Tr. 84-85). He was “over [his] head[]” in the
director's position so he decided that “maybe it
was time for [him] to get out o[f] corporate work and . . .
start to try to do something with [his] business.” (Tr.
85). At that time, he started having “social issues
where [he] was uncomfortable around a lot of people.”
(Tr. 85). From 2001-2002, he was a supervising producer at
True Entertainment Television; he won an Emmy when working in
that capacity. (Tr. 85-86).
A
vocational expert testified at the plaintiff's hearing
that the job the plaintiff was then-currently performing as a
recreation aid was light, unskilled work. (Tr. 89). She
testified that an individual who could perform simple and
detailed tasks, with sustained concentration, pace and
persistence for three-to-four hour segments, with occasional
interaction with coworkers and brief superficial interaction
with the public, could perform the work of an office cleaner,
laundry worker, and hand packer. (Tr. 90). Additionally, if
the individual was (1) unable to perform work requiring a
specific production rate; (2) limited to performing simple,
routine, repetitive tasks, with sustained concentration, pace
and persistence for two hour segments, with occasional
interaction with coworkers, but no interaction with the
public; and (3) restricted to not making anything more than
simple, work-related judgments, such individual could perform
the work of a laundry worker and a housekeeper, but not a
hand packer. (Tr. 91). The vocational expert also
acknowledged that, if the individual could not sustain
concentration, pace and persistence for two-hour segments,
the individual could not work. (Tr. 91-92). Similarly, if
someone was absent three times a month, it would be
“unlikely” that he or she could maintain
employment. (Tr. 92).
B.
MEDICAL HISTORY
As
discussed above, the plaintiff's amended onset date of
disability is January 1, 2014. (Tr. 217). There are scores of
medical records pre-dating this onset date which this Court
has reviewed. (See Tr. 333-56 (treatment at Select
Behavioral Health from May 3, 2008 to June 23,
2012);[4] Tr. 357-59, 495-96, 579-80 (July 9, 2012
MRI of the brain showing abnormal findings and “[s]mall
foci of white matter disease[]”); Tr. 486-87, 593-94
(May 2011 new patient record with Dr. Anandhi Pathman at the
Community Health Center [“CHC”] noting,
“Moderate Depression”); Tr. 482-83, 587-88 (April
2012 referral from Dr. Pathman to Behavioral Health for
“Mild Depression[]”); Tr. 474-75, 583-84 (2012
records from Ngozi Mewe-Pirn, APRN regarding
fainting/dizziness); Tr. 360-75, 464-65, 471-72, 490-91,
570-78, 581-82, 585-86 (2012 records from Dr. Pathman
regarding fainting/dizziness); Tr. 480-81, 484-85, 589-90
(February and May 2012 treatment record from Dr. Pathman for
medication management for hypertension, hyperlipidemia, and
bipolar disorder); Tr. 376-414, 417-25, 428-30, 433-42,
444-53, 456-63, 466-70, 473, 476-79, 506-10, 514-16, 519-20,
523-27, 529-40, 617-20, 720-21, 724, 727, 769-70, 77, 778-79,
782-83, 786-89, 793-94, 797, 820 (May 2012-October 2013
bi-weekly treatment records from Janet Noyes, LMFT, Community
Health Center for bipolar disorder, PTSD and ADHD); Tr.
415-16, 431-32, 443, 511-12, 517-18, 521-22, 528, 541-42,
621-22, 722-23, 725-26, 771-72, 775-76, 780-81, 784-85,
791-92, 795-96 (December 2012 and February, April, May, June,
July, September and October 2013 treatment records from Dr.
Victor Tirado-Montanez at CHC for bipolar disorder, PTSD and
ADHD); Tr. 426-27, 560, 567-69, 774, 777, 790, 909 (February,
June September, and October 2013 treatment records from Dr.
Anandhi Baleswaren[5] for blood pressure checks)).[6] As required, the
Court will focus on the relevant period at issue and the
records related to that time period.
On
September 26, 2013, Dr. Baleswaren, the plaintiff's
primary care provider at CHC, completed a Medical Report for
DDS in which she opined as to the plaintiff's physical
limitations, but noted that a “mental health
provider” will complete the mental health portion of
the form; that portion, however, is not attached. (Tr.
552-59, 597-604, 634-42). Dr. Baleswaren indicated that the
plaintiff's mental health had recently declined, but that
he was not prevented from working at that time. (Tr. 552,
597, 634). On November 14, 2013, the plaintiff's
therapist at CHC since 2012, Janet (also referred to as Jana
in the record) Noyes, LMFT, and his psychologist, Dr. Victor
Tirado-Montanez, completed the same Medical Report. (Tr.
607-14). In their report, they noted that the plaintiff had
been working part-time but that, since he started his
internship through the Bureau of Rehabilitation Services
[“BRS”], his “symptoms of anxiety and
depression have exacerbated to the point of feeling unable to
function and wanting to sleep all the time.” (Tr. 607).
They reported that the plaintiff experienced “severe
depressive episodes with suicidal ideation, weight loss,
insomnia, depressed mood, fatigue, loss of energy, feelings
of despair, hopelessness, worthlessness, [and] diminished
ability to think/concentrate.” (Tr. 610). They opined
that he was moderately limited in his ability to remember
locations and work-like procedures; understand and remember
very short, simple instructions; understand, remember and
carry out detailed instructions; respond appropriately to
changes in a work setting; be aware of normal hazards; and,
set realistic goals or make plans independently. (Tr.
611-12). Additionally, they opined that the plaintiff was
markedly limited in his ability to maintain attention and
concentration; perform activities within a schedule; sustain
an ordinary routine; work in coordination with others without
being distracted; and, complete a normal workday or workweek.
(Tr. 611).
Consistent
with his treatment history at CHC, and to address his
depression and anxiety, from November 2013 to August 2015,
the plaintiff regularly met with Noyes. On November 7, 2013,
the plaintiff reported to Noyes that he was “not doing
well, fearful; feeling a sense of impending doom; fear of
everything; working, responsibility, everything.” (Tr.
719, 768). Similarly, he reported to Dr. Baleswaren that he
felt “hopeless.” (Tr. 766-67, 907-08). On
November 14, 2013, the plaintiff told Dr. Baleswaren that he
would be in need of health insurance and was thinking about
quitting his job on November 29, 2013 and applying for Social
Security Disability. (Tr. 715-16, 762-63).[7]
On
November 14, 2013, the plaintiff also saw Noyes, who noted a
“pale, dead expression in eyes, tearful, limp posture,
low energy[, and] [a]nhedonia.” (Tr. 717-18, 764-65).
On November 19, 2013, the plaintiff reported suicidal
ideation without plan or intent; Noyes noted that the
plaintiff “seems unable to continue working.”
(Tr. 713-14, 760-61). The next day, the plaintiff returned to
Noyes reporting “vague, pervasive anxiety, but cannot
specify, just reports he lacks confidence.” (Tr. 712,
759). On November 21, 2013, he reported to Noyes that he was
in a “dark place[, ]” but Noyes found his
judgment minimally impaired, his insight moderately impaired,
and that he had no suicidal ideation. (Tr. 711). Noyes saw
the plaintiff on December 2, 5, 9, 13 and 17, 2013; he had no
suicidal ideation, minimal impairment in judgment, and
moderate impairment in his insight. (Tr. 697-98, 705-06, 742,
749-50, 753-55). On December 5, 2013, Dr. Baleswaren noted
that the plaintiff quit his job as he could “not
complete the tasks at work.” (Tr. 751-52, 905-06).
Seven days later, on December 12, 2013, Dr. Tirado-Montanez
noted that the plaintiff had “chronic stressors but
[he] seem[ed] to be coping.” (Tr. 743).
On
December 11, 2013, Noyes and Dr. Tirado completed another
assessment of the plaintiff in connection with his
application for benefits in which they reported that the
plaintiff has suffered from major depression for 25 years and
bipolar disorder for 13 years. (Tr. 627). The plaintiff had a
disheveled appearance, short-term memory loss, difficult
concentrating, a depressive, anxious and constricted mood,
and mild-to-moderate judgment. (Tr. 627-28). They rated the
plaintiff as having an “[o]bvious [p]roblem”
taking care of his personal hygiene, caring for his physical
needs, interacting appropriately with others, carrying out
single-step instructions, and changing from one simple task
to another; he was having a “[s]erious [p]roblem”
handling frustration and carrying out multi-step
instructions; and, a “[v]ery [s]erious [p]roblem”
using appropriate coping skills to meet the ordinary demands
of work, focusing long enough to finish assigned simple
activities, performing basic work activities at a reasonable
pace, and performing work on a sustained basis. (Tr. 628-29).
They commented that the plaintiff was having frequent
suicidal ideation, a sense of feeling overwhelmed
“(anxiety) and despair (depression)[, ]” with
“[e]pisodes of depression alternating with hypomania
[and] memory loss.” (Tr. 628).[8]
On the
same day, Noyes and Dr. Baleswaren saw the plaintiff because
he claimed to be experiencing dementia. (Tr. 702-03, 746-48,
904). The next day, on December 12, 2013, Dr. Baleswaren
again saw the plaintiff, who reiterated that he was
“quitting his full job and would like to explore
applying for Social Security Disability.” (Tr. 700-01,
707-08, 744-45). He also noted that “he may be open to
part-time employment and is not fully committed to the idea
of applying for permanent disability.” (Tr. 700, 707).
He planned to explore unemployment benefits as well. (Tr.
701). The plaintiff also saw Dr. Tirado-Montanez for
medication management; he reported “increased anxiety
associated with poor sleep[]” and “[d]escribed
increased financial stress.” (Tr. 699).
On
December 17, 2013, he returned to Noyes; he had minimal
impairment in his judgment, moderate impairment in his
insight, and no suicidal ideation. (Tr. 741). On December 18,
2013, Dr. Tirado-Montanez and Noyes submitted an identical
medical report to the one submitted on December 11, 2013 in
connection with his application for benefits, but in the
December 18 version, they added that the plaintiff was
hospitalized on two occasions for severe major
depression.[9] (Tr. 649; see Tr. 643-50). The
next day, on December 19, 2013, the plaintiff reported to
Noyes that he was feeling “worse, overwhelmed,
tired.” (Tr. 696, 740). On December 27, 2013, he told
Dr. Baleswaren that “he wanted to sleep all the time,
” felt lethargic, and had nausea with panic attacks.
(Tr. 733-37, 900-01).
The
plaintiff was admitted to the Pond House at Lawrence &
Memorial Hospital from December 28, 2013 to January 6, 2014
for “safety and stabilization[]” after presenting
in the emergency room on December 27, 2013 (Tr. 660-71) with
“long-terms feelings of suicide as well as feeling
somewhat depressed[.]” (Tr. 653; see Tr.
651-91). The plaintiff reported that he was having financial
problems and “started to feel that his career is not
very fulfilling and not very worthwhile.” (Tr. 655,
665). He was discharged with a diagnosis of major depression,
single episode, in remission, and a GAF score of 60. (Tr.
654). The plaintiff returned to Noyes the day of his
discharge. (Tr. 737).
The day
after his discharge, Dr. Tirado-Montanez saw the plaintiff
for medication management and noted that the plaintiff had
been admitted “due to mood decompensation in the
context of limited financial limitations.” (Tr. 693-94,
735-36). On January 8, 2014, Dr. Baleswaren rated the
plaintiff's depression as “[s]evere.” (Tr.
897-98). On January 16, 2014, the plaintiff returned to Noyes
who found his judgment and insight to be moderately impaired.
(Tr. 692, 730-31). He saw her again on January 21, for a
family therapy visit (Tr. 944), and on January 23, 2014, at
which time he was referred to Backus “PHP [Partial
Hospitalization Program] for two to four weeks.” (Tr.
728-29, 942-43).
Upon
intake at the PHP, the plaintiff reported that he could not
remember a time when he had not felt depressed in his life;
the intake counselor noted that “the patient ha[d] been
very successful in the past in his work life. . . . He [did]
not feel that he [was] capable of meeting the expectations of
his new role [as the tour guide of his historic home when his
spouse starts his new job] . . . and he was very focused on
[that] for a good part of his treatment[]” which ran
from January 27 to March 11, 2014. (Tr. 801, 836, 856, 893;
see Tr. 801-20, 836-77, 893-96; see also
Tr. 802, 837, 857, 894 (reporting that “this new job
[as a tour guide] should give him a sense of purpose, but it
[did] not, and he [was] exploring options for other careers
that might give him more of a sense of purpose.”)).
Upon admission, the plaintiff rated his depression and
anxiety as a nine on a scale to ten; he had a ten pound
weight loss in the past two months; and his concentration and
attention were poor. (Tr. 818, 853, 872). The plaintiff
reported that he was employed at Reliance House for three
months and left the job in November 2013 which he felt was a
“mistake[.]” (Tr. 818, 853, 872). He was
attending school while working and “this was too much
for him to handle, ” and he “‘deeply
regret[ed]' leaving” that job. (Tr. 818, 853, 872).
Treatment notes reflect improvement over the course of the
program. (Tr. 803, 838, 858 (felt “significant
improvement from the time that he had started the
program[]”), 807, 842, 862 (noting the plaintiff was
neatly groomed, bright, articulate, and “showing
significant increase in spontaneity[]”)).[10]
On
March 13, 2014, the plaintiff returned to treatment with Dr.
Tirado-Montanez; he reported episodes of anxiety and
rumination; the mental status exam revealed an anxious mood,
appropriate affect, normal speech, and circumstantial thought
process. (Tr. 940-41). When he returned to Noyes on March 18,
2014, he was smiling and appeared more comfortable and
relaxed. (Tr. 938-39). On April 1, 2014, the plaintiff told
Noyes that he was looking into Massage Therapy school; he was
bowling and walking for recreation, and he was smiling and
had a neat appearance. (Tr. 936-37). Noyes's notes
reflect the same positive improvement on April 10, 2014 and
May 1, 2014, as well as the plaintiff's report that he
was “[l]ooking forward to working outside of [his]
home” and he was planning to volunteer at hospice. (Tr.
930-31, 934-35). On April 22, 2014, the plaintiff reported to
Dr. Tirado-Montanez that he experienced ruminations at
bedtime, but that his depression improved; he
“continue[d] to be fragile with a low tolerance to
stress.” (Tr. 932-33). A month later, the plaintiff
reported that the sedation he was experiencing with Seroquel
improved with a decreased dose. (Tr. 928). On May 23 and 28,
2014, Noyes noted that the plaintiff felt lonely, but that he
had “moderate[]” progress towards treatment. (Tr.
924-27; see also Tr. 922-23 (participation in group
therapy)). On June 4, 2014, the plaintiff told Noyes that he
was considering continuing school and internship placements.
(Tr. 920-21). Six days later, he expressed
“excessive[]” worry (Tr. 918-19), and on June 12,
2014, Noyes noted that he was in work-out clothes, and the
plaintiff reported that he was jogging, walking and doing
yoga. (Tr. 916-17). On June 18, 2014, Noyes noted that the
plaintiff was planning on an internship at Apple Rehab, two
days a week, plus taking a class, and two more classes in the
Spring. (Tr. 914-15). The plaintiff was thinking about it to
“make sure he want[ed] to do [that].” (Tr.
914).[11]
On June
30, 2014, Noyes completed another assessment of the plaintiff
in connection with his application for benefits; Dr.
Tirado-Montanez co-signed this assessment on July 1, 2014.
(Tr. 1048-51). Noyes found “[s]light
[i]mprovement” in the plaintiff's condition while
noting the exacerbation of symptoms in the “winter
2013-14[.]” (Tr. 1048). According to Noyes, the
plaintiff had difficulty focusing and concentrating even with
ADHD medications, and he had memory issues that “seem
related to anxiety and [ADHD].” (Tr. 1048). At that
point, his speech was normal, although she noted it was
“pressured at times over this past year[.]” (Tr.
1049). She opined that he had a “mild impairment at
present” and “[had] been mild-moderately impaired
at times over this past year.” (Tr. 1049). She noted
continuing suicidal ideation, “sense of overwhelm and
anxiety. Sense of despair has lessened since PHP treatment.
Depression continues. Client tends to ruminate over
stressors. Depression and anxiety lead to feelings of
hopelessness [and] worthlessness.” (Tr. 1049). She
rated him as having a “[s]erious [p]roblem” using
appropriate coping skills, handling frustration
appropriately, carrying out ...