United States District Court, D. Delaware
For Plaintiff: Gary L. Smith, Esquire of Gary L. Smith Attorney at Law.
For Defendant: Charles M. Oberly Ill, United States Attorney, Wilmington, Delaware and Dina White Griffin, Special Assistant United States Attorney, Office of the General Counsel Social Security Administration. Of Nora Koch, Esquire, Acting Regional Chief Counsel, Region III and Erica Perkins, Esquire, Assistant Regional Counsel of the Office of the General Counsel Social Security Administration, Philadelphia, Pennsylvania.
Sue L. Robinson, District Judge.
Claudia Winward (" plaintiff" ) appeals from a decision of Carolyn W. Colvin, Acting Commissioner of Social Security (" defendant" ), denying her application for Disability Insurance Benefits (" DIB" ) under Title II of the Social Security Act (the " Act" ), 42 U.S.C. § § 401-434, 1381-1383f. The court has jurisdiction pursuant to 42 U.S.C. § 405(g).
Currently before the court are the parties' cross-motions for summary judgment. (D.I. 15, 16) For the reasons set forth below, plaintiff's motion will be denied and defendant's motion will be granted.
A. Procedural History
Plaintiff filed an application for DIB on April 19, 2006 alleging disability beginning on July 1, 2000 for depression. (D.I. 8 at 24, 27-29) Plaintiff's claim was initially denied on June 15, 2006 and after reconsideration on July 18, 2006. ( Id. at 49-50) On
January 16, 2010, after a hearing on December 3, 2009, the ALJ issued an unfavorable decision, finding that plaintiff was not disabled under the Act for the relevant time period from July 1, 2000 to March 31, 2003. ( Id. at 7-21) After an unsuccessful appeal to the Appeals Council, plaintiff appealed to this court for review of the January 16, 2010 decision. ( Id. at 1-3)
B. Medical History
1. Mental health history before the relevant time period
Plaintiff sought help for depression from Richard Cruz, M.D. (" Dr. Cruz" ) beginning in June 1999. (D.I. 8 at 225, 227) Dr. Cruz prescribed various psychotropic medications in increasing dosages throughout plaintiff's treatment. ( Id. at 214-27) Dr. Cruz generally described plaintiff as depressed with decreased energy and insomnia. ( Id. at 221-227) On December 1, 1998, on a " Value Behavioral Health Outpatient Treatment Report," Dr. Cruz noted that plaintiff " presents with recurrent major depression over past 8 years . . . continues to have severe decreased energy and anhedonia with difficulty concentrating and hopelessness about work and marriage." ( Id. at 225) Dr. Cruz indicated plaintiff's current global assessment of functioning (" GAF" ) as 42 with a high of 50 in the last year. ( Id. at 224)
In March 2000, plaintiff reported " slightly more energy," but with continued insomnia. ( Id. at 221) In May 2000, plaintiff reported feeling " less depressed." ( Id. at 219) In June 2000, plaintiff described waking up at one a.m. with vivid dreams and " remain[ing] depressed." ( Id. at 219)
2. Mental health history during the relevant time period
In August 2000, plaintiff reported feeling " more depressed with decreased energy." She feared having a fatal illness. Plaintiff reported sleeping, but having vivid dreams. Dr. Cruz increased her medications. ( Id. at 218) In September 2000, plaintiff reported relief that her medical work-up was negative, but described continued dreams. Dr. Cruz noted that plaintiff had no hypomanic symptoms. ( Id.) In November 2000, plaintiff described depression " over [the] illness of [her] aunt's roommate." ( Id. at 219) In December 2000, plaintiff reported feeling anxious about a " heavy workload" as her daughter was returning home. Plaintiff reported having low energy. ( Id. at 219) In February
plaintiff reported anxiety about her husband's potential layoff from work. ( Id. at 216) In May 2001, Dr. Cruz noted that plaintiff remained depressed with decreased energy and insomnia. Plaintiff had decreased her psychotropic medication. Dr. Cruz noted adding medication to plaintiff's regime. ( Id. at 215)
There are no medical records for plaintiff's mental health treatment from May 2001 to August 2002. Dr. Ralph Burdick D.O. (" Dr. Burdick" ) treated plaintiff during this time and his notes indicate that plaintiff's medication included Prozac, Ativan, and Ambien. ( Id. at 238, 240)
On August 1, 2002, plaintiff sought treatment from Peter Zorach, M.D. (" Dr. Zorach" ), reporting feeling depressed daily for two weeks. ( Id. at 270-71) Dr. Zorach assessed a GAF of 52 and prescribed psychotropic medications. ( Id. at 271) On October 30, 2002, Dr. Zorach's impression was that plaintiff was " doing fairly well" with " some stress and anxiety, enough to be unpleasant." Plaintiff described keeping busy. ( Id. at 269) On December 12, 2002, plaintiff reported feeling " somewhat better." Plaintiff denied suicidal ideation. ( Id. at 268) Dr. Zorach noted plaintiff's condition was " improved." ( Id. at 268) On January 17, 2003, plaintiff reported being " more depressed than not depressed." Plaintiff described spending time with her family over the holidays and working with floral arrangements. Plaintiff was deciding whether to work " 2 days a week" or give up her work. ( Id. at 267-68) On February 24, 2003, plaintiff reported " doing pretty well" and being in a " pretty good" mood. Plaintiff was working one day a week to " do some of [her] own business." Plaintiff described " cleaning up." ( Id. at 267) On March 28, 2003, plaintiff cancelled her appointment. ( Id. at 267)
2. Mental health after the relevant time period
On April 16, 2003, plaintiff described some days as " not as good" and " [e]very day a fight." Dr. Zorach's impression was that plaintiff was " struggling" and " depressed," with low energy. On April 24, 2003, plaintiff reported that she was " still depressed," " never got up, showered, dressed." ( Id. at 266-67) On June 9, 2003, plaintiff described being " no better and no worse." On June 24, 2003, plaintiff described " doing a little better." ( Id. at 265) From July 21, 2003 to December 19, 2003, Dr. Zorach's impression of plaintiff was that she was " doing well" or " pretty well." ( Id. at 263-64) On March 5, 2004, plaintiff reported " not doing so well," three to four days per week. ( Id. at 262-63) On July 14, 2004, plaintiff reported " doing pretty well" with increased energy. ( Id. at 260) Such pattern continued throughout Dr. Zorach's treatment ending on March 7, 2006, with plaintiff reporting " doing pretty much the same - still depressed." ( Id. at 248-260)
On May 18, 2006, Carlene Tucker-Okine, Ph.D., reviewed plaintiff's file and
concluded that there was " [i]nsufficient evidence to assess severity between [July 2000] and [March 2003]." ( Id. at 277-89) Such opinion was affirmed by Pedro M. Ferreira, Ph.D., M.B.A. on July 18, 2006. ( Id. at 291-301) On June 15, 2006, V. K. Kataria completed a " Physical Residual Functional Capacity Asessment," concluding that there was " [n]ot enough medical evidence to make [a] decision between [July 2000] and [March 2003]." ( Id. at 272-276)
On September 21, 2007, Dr. Zorach completed a questionnaire concerning plaintiff's mental health impairments, expressing his opinion regarding " the entire treatment period."  Dr. Zorach treated plaintiff from August 2002 to March 2006 and described plaintiff's condition as " major depression, recurrent, severe," and " moderate, job stress." Dr. Zorach assigned plaintiff a GAF of 50 as of March 31, 2003 with a GAF " during treatment/at end of treatment" of 43. Dr. Zorach described plaintiff's treatment and response: " Initially appeared to respond to medicines but then became more depressed and dysfunctional, unable to work, sometimes hard to get up/get dressed/leave home." Dr. Zorach described his clinical findings: " [A]ppeared and sounded depressed; had feelings of being hopeless, helpless, lonely, worthless, shame; passive suicidal ideation." Plaintiff's prognosis was " guarded." ( Id. at 325) In describing plaintiff's " mental abilities and aptitude needed to do particular types of jobs," Dr. Zorach noted: " [S]everely depressed - problem getting up and dressed in morning - problems with concentration - racing thoughts." For plaintiff's functional limitations, Dr. Zorach provided that plaintiff had marked restrictions in her activities of daily living, extreme difficulties in her ability to socially function, and extreme difficulties in her ability to maintain concentration, persistence, and pace. As to her episodes of decompensation, Dr. Zorach noted " persistently depressed." ( Id. at 328) More specifically, Dr. Zorach indicated that plaintiff was unable to meet competitive work standards in her ability to understand, remember, and carry out very short and simple instructions and ask simple questions. Further, Dr. Zorach provided that plaintiff had no useful functional ability to maintain regular attendance and punctuality, maintain attention for two hours, make simple work-related decisions, respond appropriately to routine work changes, accept instruction and criticism from supervisors, interact appropriately with the general public, and maintain socially appropriate behavior. ( Id. at 327-28)
In August 2009, Brian Simon, Psy.D. (" Dr. Simon" ), performed a psychological examination at the request of the state agency. ( Id. at 336) Plaintiffs reported history was consistent with her hearing testimony described below. ( Id. at 336-338) Dr. Simon documented that plaintiff was cooperative and well-groomed; she maintained good eye contact and her attention and concentration were fair throughout the examination; her mood was " a bit" dysphoric; her thought processes,
insight, and judgment were intact. ( Id. at 339) Dr. Simon assessed plaintiff as [b]ipolar II [d]isorder, [d]epressed, [i]n [p]artial [r]emission," with a GAF score of 55. Plaintiff's prognosis is " guarded" and " dependent on how well she is able to continue to cope with her psychiatric and medical problems." ( Id. at 340)
From June to October 2009, plaintiff received treatment at Phoenix Behavioral Health. ( Id. at 346-60) On June 8, 2009, a licensed social worker completed an evaluation form and assigned plaintiff a GAF of 53 ( Id. at 350) On July 3, 2009, Archie Abashidze, M.D. (" Dr. Abashidze" ) described plaintiff as cooperative and friendly; maintaining eye contact; her behavior and motor activity were normal; her mood was normal; she denied suicidal ideation; her attention, concentration, and memory were intact; and her insight and judgment were good. Dr. Abashidze assessed her a GAF score of 70. ( Id. at 353-55)
On November 18, 2009, Dr. Abashidze completed a mental health questionnaire. ( Id. at 363) Dr. Abashidze's clinical findings were: " Episodes of major depression; sadness; hopelessness; and hypomania; . . .; [no] motivation; energy, . . . worthlessness." Plaintiff's prognosis was " poor to guarded." Dr. Abashidze provided that plaintiff had moderate difficulties in her activities of daily living, marked limitations in her social functioning, and marked limitations in her ability to maintain concentration, persistence, and pace. ( Id. at 365-66)
Plaintiff's current medications include Ambien, Ability, Effexor, Wellbutrin, Xanax, and Simvastatin. ( Id. at 206-07)
C. Administrative Hearing
1. Plaintiff's testimony
An administrative hearing was held on December 3, 2009. Plaintiff appeared, represented by counsel. (D.I. 8 at 24) Plaintiff was born on November 9, 1951 and was 58 years old at the time of the hearing. ( Id. at 36) She graduated from high school in 1969. She worked as an ID fingerprint person, then as a secretary. After having children, she worked as a bookkeeper at a scrap yard. She then worked as a secretary for four years with " Catalytic" and thirteen years with " Getty" (the oil refinery in Delaware City), performing typical clerical work. Plaintiff lives with her husband and has two children, 38 and 34 years old. ( Id. at 25-26) In 2003, she weighed 160 lbs and now weighs 168. ( Id. at 36) Both of her parents were alcoholics and her mother had depression. Her mother died at 57. She does not attend church. ( Id. at 38)
Her husband is in good health. He is currently a maintenance manager for an assisted living home. He retired from Chrysler in 2001, ...