United States District Court, D. New Jersey
KEVIN McNULTY, District Judge.
Plaintiff Frances Cruz appeals the final determination of the Commissioner of the Social Security Administration (the "Commissioner") denying her disability benefits under the Social Security Act. This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. § 405(g). This motion has been decided based on the written submissions of the parties pursuant to Rule 78 of the Federal Rules of Civil Procedure. For the reasons set forth below, the decision of Administrative Law Judge Richard L. De Steno (the "ALJ") is REMANDED. On remand, the ALJ is directed to do the following:
(1) Develop the record, particularly by including consideration of supplemental Raritan Bay mental health records from July 11 through October 26, 2011;
(2) Reconsider Plaintiffs Directions for Mental Health (DMH) records and the report of Dr. Greenberg, and adequately explain his reasons for rejecting or relying on competent medical evidence;
(3) Considering all of the evidence, old and new, perform a de novo analysis of whether the Plaintiff's mental and physical impairments, singly or in combination, render her unable to "engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months." 42 U.S.C. § 1382c(a)(3)(A).
Plaintiff first filed an application for Supplemental Security Income ("SSI") payments from the Social Security Administration ("SSA") on February 25, 2009, alleging disability beginning June 1, 2005. (Tr. 14.) Plaintiff's claim was denied initially, on August 28, 2009, and again upon reconsideration on December 14, 2009. (Id.) On January 18, 2010, Plaintiff filed a written request for a hearing, pursuant to 20 C.F.R. § 416.1429. (Id.) The hearing was originally set for November 17, 2010, in Florida. (Id.) However, on November 3, 2010, Plaintiff requested that the hearing be cancelled and her file transferred to Newark, New Jersey. (Pl.'s Br. 6-7.) Plaintiff appeared and testified at a hearing held before the ALJ on July 5, 2011, in Newark, New Jersey. (Tr. 14.) Plaintiff was informed of her right to representation but chose to appear and testify pro Se. (Id.) On August 31, 2011, the ALJ determined that Plaintiff was not disabled. (Tr. 30.) On March 25, 2013, the Appeals Council denied Plaintiff's request for review, rendering the ALJ's decision the Final Judgment of the Commissioner. (Id.) Plaintiff subsequently initiated this action, requesting that this Court reverse or remand the ALJ's decision. (Pl.'s Br. 1.)
Plaintiff placed before the ALJ an extensive medical history of physical infirmities. I touch on these in my discussion of the ALJ's Opinion, below. Because I am remanding for deficiencies in the ALJ s treatment of mental health claims, I concentrate here on the mental health history.
1. DMH evaluations
On February 11, 2009, Plaintiff went to Directions for Mental Health ("DMH") for a psychiatric evaluation. (Tr. 367.) Plaintiff was referred to DMH by her primary care physician. (Id.) The psychiatrist who evaluated Plaintiff reported that Plaintiff's strengths included that Plaintiff had peer support, age-appropriate intellectual development, the ability to relate to others, and adequate education. (Tr. 371.) The psychiatrist also reported that Plaintiff appeared appropriately dressed and groomed, had good hygiene, was interactive, pleasant, and cooperative, but was fidgety. (RI.) The psychiatrist further noted that Plaintiff's speech, thought process, thought content, and cognitive functioning were all normal, that Plaintiff did not have any violent or homicidal thoughts, but that Plaintiff's mood was depressed. (Id/) The psychiatrist's diagnosis was as follows: Axis 1: mood D/O NOS; cocaine dependence; A.N., B.N.; RIO Bipolar DIO; Axis II: borderline personality traits; Axis III: HCV, glaucoma, narcolepsy, sleep apnea, acid reflux, angina, stage II cervical cancer; Axis IV: mod: recent legal stressors, medical problems, limited social support, family discord; Axis V: mGAF: 54. (Id.) The psychiatrist ordered that Plaintiff take Lexapro for her depression and anxiety, and Ability for mood swings and impulsivity. (Tr. 372.) The psychiatrist ordered laboratory tests for Plaintiff, including cbc w. diff, cmp, sh, lipid panel, uds, and us. (Id.) Plaintiff's reported risk assessments included current mood instability and a history of parasuicidal behavior, with a moderate suicidal potential. (Id.) The psychiatrist noted that some interventions to reduce Plaintiff's risk would be to prescribe psychotropics, refer Plaintiff for substance treatment, and schedule more frequent appointments. (Id.)
On February 20, 2009, Plaintiff returned to DMH for a follow-up appointment, and ARNP Julie Stanphill noted that Plaintiff's appearance was the same as the last visit, except that Plaintiffs reported mood was moderately anxious. (Tr. 374.) Plaintiff told ARNP Stanphill that she was getting married that weekend. (Id.) Plaintiffs reported risk for suicidal potential was low. (Tr. 375.) Her GAF at this time was reported to be 59. (Id.)
Plaintiff returned to DMH for another follow-up with Julie Stanphill, ARNP, on March 9, 2009. (Tr. 376.) Plaintiff reported that she was depressed about two days per week, where she does not get out of bed and that she had been having mood swings. (Id.) Plaintiff also reported that she experienced fatigue due to having HCV. (Id.) Plaintiffs appearance, attitude, speech, thought process, thought content, and cognitive functioning were all normal. (Id.) Her reported mood was euthymic, appropriate, and stable, and her risk for suicide was reported as low. (Id.) Her GAF at this time was reported to be 56. (Id.)
On June 1, 2009, Plaintiff returned to DMH for another follow-up, and reported difficulty falling asleep, decreased appetite, and continued mood swings. (Tr. 783.) Plaintiff reported that she was waiting for a referral for endoscopy, and that she was receiving vitamin b-12 injections once a month for pernicious anemia. (id.) Plaintiffs appearance, attitude, speech, thought process, thought content, and cognitive functioning were all normal. (Id.) Her reported mood was moderately anxious, but she was not found to have suicidal or violent thoughts. (Id.) Her GAP at this time was reported to be 56. (Id.)
On July 29, 2009, Plaintiff went back to DMH for another follow-up appointment, and reported anxiety, mood swings, sleeplessness, and loss of appetite. (Tr. 781.) Plaintiffs appearance, attitude, speech, thought process, thought content, and cognitive functioning were all normal. (Id.) Her reported mood was moderately anxious, but she was not found to have suicidal or violent thoughts. (Id.) Her GAF at this time was reported to be 58. (Id.)
On October 14, 2009, Plaintiff had a follow-up at DMH. (Tr. 779.) She reported that her husband is supportive, but her fourteen-year-old daughter had been calling her and expressing suicidal ideations. (Id.) Plaintiff's reported mood was moderately anxious, but she was not found to have suicidal or violent thoughts. Her GAF at this time was reported to be 55.
Plaintiff went to the DMH again on November 6, 2009. (Tr. 842.) She reported that her daughter was depressed but did not have any history of suicide attempts. Plaintiff's reported mood was moderately anxious, but she was not found to have suicidal or violent thoughts. (iii.) Her GAF at this time was reported to be 50. (Id.) The doctor prescribed Plaintiff Welibutrin SR for her depression.
2. Dr. Greenberg
Plaintiff was referred to Florida Center for Cognitive Therapy, Inc. ("FCCT") by the Division of Disability Determinations. (Tr. 438.) On July 27, 2009, Plaintiff visited FCCT, where she was evaluated by Dr. Michael S. Greenberg. Dr. Greenberg conducted a clinical interview and mental status examination of Plaintiff, but did not receive medical or mental health documents supporting Plaintiff's allegation of disability for depression. (Id.) Dr. Greenberg noted that Plaintiff was neatly dressed and groomed, alert, and fully oriented. (Tr. 439.) Plaintiff's speech was logical and there were no reported indications of delusions or thought disorder, but Plaintiff claimed that she had heard voices and had seen shadows at home. (Id.) Plaintiff reportedly denied suicidal ideation, but her mood was depressed and anxious. (Id.) Plaintiff was able to recall one of three common objects after five minutes, and Dr. Greenberg noted that Plaintiff's working memory, abstract thinking, verbal reasoning, arithmetic ability, and fund of information were all impaired. (Id.) Dr. Greenberg diagnosed Plaintiff as follows: Axis I: Major Depression, recurrent, severe, cocaine dependence (reportedly in remission); Axis II: Borderline Personality Disorder, R/O borderline intellectual functioning; Axis III: cancer reported; Axis IV: unemployment, medical problems reported, chronic dysfunction; Axis V: GAF 48. (Tr. 439-40.)
3. Dr. Ragsdale
On August 28, 2009, Plaintiff was evaluated by Dr. Kevin Ragsdale. (Tr. 441-58.) In his report, Dr. Ragsdale noted in the medical dispositions section that an RFC assessment was necessary, and that Plaintiff had coexisting nonmental impairment(s) that required referral to another medical specialist. (Tr. 441.) Dr. Ragsdale based the medical dispositions on the following categories: 12.02 organic mental disorders (recorded as "r/o bif'); 12.04 affective disorders (recorded as "mood disorder, NOS vs. MDD"); 12.08 personality disorders (recorded as "BLPD"); and 12.09 substance addition disorders (recorded as "coc dep in sfr"). (Tr. 441-449.) Dr. Ragsdale reported the degree of Plaintiffs functional limitations as follows: mild restriction of activities of daily living; moderate difficulties in maintaining social functioning; moderate difficulties in maintaining concentration, persistence, or pace; and insufficient evidence as to long episodes of decompensation. (Tr. 451.) In his report, Dr. Ragsdale noted:
[B]ased on the objective, professional observations of the claimant and descriptions of the claimant's functioning in the file, it appears that the claimant is able to accomplish a daily routine of basic personal, household and community activities relatively independently and effectively from a strictly psychological point of view. The claimant's abilities to interact with others and sustain focused attention to complete tasks effectively and consistently appear to be interfered with, at least in part, by the psychiatric signs and symptoms. The consistency between the claimant's and third party's statements regarding psychiatric symptoms and corresponding functional limitations and the objective medical evidence is marginal resulting in less than optimal credibility.
(Tr. 453.) The doctor noted that Plaintiffs mental functioning would be adequate with treatment and abstinence from cocaine, and that despite the psychiatric symptoms that could potentially lead to a reduction in Plaintiff's "most favorable functioning in some activities, the requisite cognitive abilities for completing simple routine tasks in a work setting remain preserved." (Id.)
Dr. Ragsdale also assessed Plaintiff's mental RFC on the same day. (Tr. 455-58.) The doctor reported that most of Plaintiff's mental activities were not generally significantly limited in the context of Plaintiff's capacity to sustain those activities over a normal workday and workweek, on an ongoing basis. (Tr. 455-56). Some activities-such as Plaintiffs ability to complete a normal workday and workweek without interruptions from psychologically base symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods, as well as Plaintiffs ability to maintain attention and concentration for extended periods-were reported to be moderately limited. (Id.) Dr. Ragsdale noted that the limitations he had acknowledged appeared to "be at least moderately, positively correlated with the psychiatric MDI(s) noted on the PRTF." (Tr. 457.) Nevertheless, the doctor reported that Plaintiff had "ample capacity to enact the principal cognitive abilities and social skills essential to the execution of simple, routine tasks in a full time employment setting." (Id.)
Dr. Ragsdale also conducted a physical RFC assessment of Plaintiff on August 28, 2009, based on a primary diagnosis of hepatitis A, B, and C, a secondary diagnosis of tendinitis in Plaintiffs bilateral thumbs, and migraines as an additional impairment. (Tr. 459-466.) Dr. Ragsdale reported that Plaintiff had the following exertional limitations: Plaintiff was reported to be able to occasionally lift or carry a maximum of fifty pounds, frequently lift or carry twenty-five pounds, stand and/or walk for a total of about six hours in an eight-hour workday, sit for a total of about six hours in an eight-hour workday, and push or pull with no limitations. (Tr. 460.) Dr. Ragsdale reported that Plaintiff may have had minor limitations in handling/gross manipulation, and no visual, communicative, or environmental limitations. (Tr. 462-63.)
4. Dr. Putney
On December 11, 2009, Dr. Martha Putney conducted a psychiatric review technique on Plaintiff. (Tr. 536.) Dr. Putney's medical disposition was that Plaintiffs impairments were not severe. (Id.) Dr. Putney based this medical disposition on the following categories: 12.04 affective disorders (recorded as "depression/context psd. stable w/abstinence/meds from ARNP"); 12.08 personality disorders (recorded as "antisocial bx/arrests/context polysubstance dependence"); and 12.09 substance addiction disorders. (Tr. 536-544.) Under the section for substance addiction disorders, Dr. Putney noted that behavioral changes or physical changes associated with the regular use of substances that affect the central nervous system. (Tr. 544.) The doctor evaluated this under Listing 12.04-affective disorders, and Listing 12.08-personality disorders. (Id.) Dr. Putney reported the degree of Plaintiffs functional limitations as follows: no restriction of activities of daily living; mild difficulties in maintaining social functioning; mild difficulties in maintaining concentration, persistence, or pace; and no long episodes of decompensation. (Tr. 546.)
In her report, Dr. Putney went through Plaintiffs history and treatment, and noted that this was Plaintiffs fourth application for benefits. (Tr. 548.) Dr. Putney noted that the mental portion of Plaintiffs claim from February of 2009 "was adjudicated as moderately impaired, but this was based on a mental CE, during which [Plaintiff] clearly malingered." (Id.) Dr. Putney also stated that the current status of Plaintiffs polysubstance dependence was unknown, as Plaintiff dishonestly alleged to the September 2007 CE vendor that she had been clean and sober since September of either 2000 or 2002, when in fact Plaintiffs cocaine addiction was ongoing subsequently per the MER. (Id.)
Dr. Putney concluded that Plaintiff had no world-related mental impairment, but she did have a reduced motivation for responsible management of personal finances. (Id.) Dr. Putney also stated:
[Plaintiff's] cognitive ability (cognitively intact with average range IQ) is adequate. [Plaintiff] is able to prepare meals, shop, do self-care, [household] chores, handle routine financial transactions, cognitively manage her finances (per the 9/07 CE), drive when has [sic] a vehicle (has a [history] of suspended [driver's license], but her [driver's license] had been re-instated as of the 9/07 CE), use public transportation when clean and sober.
(Id.) The doctor additionally noted that Plaintiff had indicated to a previous mental CE vendor in July of 2009 that Plaintiff had a history of seeing shadows and hearing voices, which led that vendor to report that Plaintiff had severe depression. (Id.) However, Dr. Putney noted that during her examination of Plaintiff, Plaintiff was able to be cooperative and appropriate when clean, sober, and compliant with her psych medications. (Id.) Dr. Putney also stated that, per Dr. Appenfeldt, Plaintiff's depressive symptoms were reactive to her medical condition and did not exceed the level of an "ADJ D/O" when clean and sober. (Id.) Plaintiff was reported to get along with friends, family, coworkers, the public, and authorities in the workplace. (Id.)
Dr. Putney further stated in her report that Plaintiffs "CPP" was mildly decreased, and that there were inconsistencies between Plaintiffs allegations and the objective evidence, which raised ...