The opinion of the court was delivered by: Joe Billy Mcdade Senior United States District Judge
Before the Court are Plaintiff's Motion for Summary Judgment (Doc. 12) and Defendant's Motion for Summary Affirmance (Doc. 15). For the reasons set forth below, Plaintiff's Motion is DENIED and Defendant's Motion is GRANTED.
Plaintiff applied for Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI) on September 8, 2004 alleging a disability onset date of September 6, 2004 (Tr. 127-9). His application was denied initially and that denial was affirmed upon reconsideration and after a hearing before an administrative law judge (ALJ) (Tr. 46-59). The Appeals Council subsequently denied review (Tr. 9) rendering the January 25, 2008 decision of the ALJ final. This lawsuit follows.
II. Relevant Medical History
Plaintiff's medical problems stem from an incident where Plaintiff jumped from a moving vehicle on April 25, 2003 causing a right frontal temporal parietal subdural hematoma for which he underwent an immediate anterior temporal lobectomy with bone flap removal (Tr. 231). Immediately after the accident, Plaintiff was severely comatose, lethargic, and unable to verbalize responses (Tr. 236). Two weeks after the surgery, however, Plaintiff started rehabilitation where he was found to be alert and able to follow simple instructions (Tr. 225, 231). Two months after the accident, medical records indicate that Plaintiff showed "remarkable, rapid progress after the surgery and throughout the rehab process" (Tr. 222). On September 19, 2003, Plaintiff underwent a second surgery, right frontoparietal craniotomy, and was discharged to his home (Tr. 199). By October 6, 2003, Plaintiff was cleared to start driving again and reported that he was ready to return to work (Tr. 283). Dr. Todd R. Ridenour, Plaintiff's surgeon, noted that there were no restrictions at that time unless he is required to do heavy lifting or strenuous work (Tr. 283). This conclusion was mirrored in a December 1, 2003 progress note which indicated that Plaintiff should restrict contact sports and roller-coaster rides but, other than that, is able to "be involved in most of the routine activities that a gentleman in his mid-twenties would care to be involved in" (Tr. 282).
On April 19, 2004, however, Plaintiff went to the emergency room after a "complex partial seizure with secondary generalization" and was prescribed Dilantin (Tr. 321). Plaintiff was referred to a neurologist, Dr. Brian Anseeuw (Tr. 321). In a May 3, 2004 letter, Dr. Anseeuw noted that Plaintiff was seeing Dr. S. Govindaiah for depression and that he was taking Risperal, Adderall XR, Zoloft, and Phenytoin (Tr. 317). Dr. Anseeuw concluded that Plaintiff "most likely" had a seizure given his history of a craniotomy and recent sleep deprivation (Dr. Anseeuw otherwise noted that Plaintiff was sleeping normally), continued the Dilantin prescription, and set a follow up appointment 3 months later (Tr. 319). At the July 26, 2004 follow-up, Plaintiff had no intervening seizures, was compliant with his medication, no difficulty with his medication, but did see a slight increase in his depression (Tr. 315). Dr. Anseeuw set a follow-up appointment for 6 months later (Tr. 316). On July 11, 2005, Plaintiff reported no seizures over the past year (Tr. 426). On August 1, 2006, Plaintiff again reported no seizures (Tr. 419). On August 20, 2007, however, an electroencephalogram (EEG) indicated that Plaintiff may have suffered a seizure onset but that "clinical correlation is recommended before the diagnosis of seizure is made" (Tr. 444). On November 30, 2007, Plaintiff reported no further seizures, but indicated that he was extremely fatigued (Tr. 454). At this point, Plaintiff was taking Kepra and Phentek (Dilantin) for his seizure disorder (Tr. 454-455).
As noted above, Plaintiff also began suffering from depression after his accident. On November 19, 2004, Plaintiff began treatment at the Robert Young Mental Health Center under the care of Dr. Ralph Saintfort. In setting out a history, Dr. Saintfort stated that at the time of the accident, Plaintiff suffered from a "possible psychotic break, likely drug induced" wherein he jumped from the vehicle believing that someone wanted to harm him (Tr. 333). Dr. Saintfort also noted that Plaintiff became depressed and increasingly paranoid three weeks after he returned home from rehab and that he began treatment with Dr. Govindaiah in February, 2004*fn1 who prescribed Risperdal and Zoloft (Tr. 333). Plaintiff stopped treatment with Dr. Govindaiah in September, 2004 because he lost his health insurance (Tr. 333). Upon a mental status examination, Dr. Saintfort stated that Plaintiff had a depressed mood, a "congruent, anxious, withdrawn, and restricted" affect, but no formal thought disorder, no suicidal or paranoid ideation or delusions (Tr. 334). Dr. Saintfort diagnosed "mood or psychotic disorder secondary to general medical condition" and recommended continuation of the Risperdal (due to Plaintiff's "robust response" to this medication). Dr. Saintfort also substituted Lexapro for the Zoloft and prescribed Klonopin for the anxiety and insomnia (Tr. 335). Plaintiff also started therapy sessions.
Plaintiff followed upon January 7, 2005 (Tr. 332). He indicated that the medication was helping with his sleep and anxiety and denies any side effects (Tr. 332). However, Dr. Saintfort noted poor "sleep hygiene" wherein Plaintiff sleeps during the day until 4 p.m. and is up late at night (Tr. 332). Plaintiff's treatment plan was continued through January (Tr. 331, 401). On February 28, 2005, the Lexapro was discontinued and he was started on Lamictal (Tr. 400). On March 22, 2005, Plaintiff's treatment was continued and it was noted that he had missed three therapy sessions (Tr. 399). Plaintiff's mother, who attended the session, indicated that the Lamictal was helping and Plaintiff indicated that he was sleeping at night (Tr. 399). Dr. Saintfort noted that he was "engaging with full range of affect, more optimistic and upbeat about his short-term plans" (Tr. 399). He followed up with Dr. Saintfort from May 2, 2005 to March 21, 2007 (Tr. 383-384, 388-391, 394-398).
On July 12, 2007, however, Plaintiff presented at the emergency room "in a decompensated suicidal state" because he was not given a day off work to see the doctor (Tr. 381). Dr. Eric J. Ritterhoff*fn2 gave an impression of "bipolar disorder mixed type posttraumatic seizure disorder and major depression" (Tr. 382). He was discharged on July 19, 2007 with reported improvement in his mood and in a non-suicidal state; however, he was diagnosed with bipolar disorder, complex partial seizures, major motor seizures in remission, and panic disorder (Tr. 380). At a follow up appointment on July 27, 2007, Plaintiff reported "daytime sedation problems" from the medication Keppra, difficulty coping with stress, no suicidal ideation, no agitation, dysphoria, or sadness (Tr. 376). Dr. Ritterhoff noted that "his mood disorder is under fair control at this time." (Tr. 376).
On September 10, 2007, Dr. Ritterhoff drafted a letter indicating that he advised Plaintiff to discontinue his employment (Tr. 436). Dr. Ritterhoff stated that:
It is our opinion that he is not suitable for the employment that he was undertaking, that it was aggravating his overall health status to be employed in that job, that it was causing him to feel depressed and hopeless, and aggravating his pre-existing bipolar disorder and depression. And, that were he to continue in that employment it would raise the risk of potential ...