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Daggett v. Astrue

May 5, 2010

JULIAN DAGGETT, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Magistrate Judge Michael T. Mason

MEMORANDUM OPINION AND ORDER

Plaintiff, Julian Daggett ("Daggett" or "Claimant"), filed a motion for summary judgment [18] seeking judicial review of the final decision of the Commissioner of Social Security (the "Commissioner") denying his claim for disability insurance benefits under the Social Security Act, 42 U.S.C. §§ 416(I) and 423. Claimant asks this Court to reverse the decision of the Administrative Law Judge and remand for further proceedings. The Commissioner filed a cross-motion for summary judgment [20] requesting that this Court uphold the ALJ's decision. Jurisdiction to review this matter is proper pursuant to 42 U.S.C. § 405(g). For the reasons set forth below, Daggett's motion for summary judgment is granted in part and denied in part, the Commissioner's motion is denied, and this case is remanded for further proceedings consistent with this Opinion.

I. PROCEDURAL HISTORY

Daggett filed applications for Social Security disability insurance benefits ("DIB") on November 24, 1986 and April 15, 1992, but did not pursue those claims. On May 5, 2004, Claimant filed an application for DIB, alleging a disability onset date of January 15, 1984, due to posttraumatic stress disorder, depression, and leg pain. (R. 40). Claimant's date last insured is December 31, 1989. (R. 27). The Commissioner denied Daggett's claim on July 23, 2004. (R. 30). Daggett filed a timely request for reconsideration on September 23, 2004. (R. 36). The Commissioner denied that request on October 19, 2004. (R. 37-40). Thereafter, Daggett requested a hearing. (R. 41). On May 30, 2006, Claimant appeared with counsel at a hearing before ALJ Helen Cropper ("ALJ Cropper" or the "ALJ"). (R. 1325-59).

At the hearing, ALJ Cropper determined that the record before her was incomplete. (R. 1345-46). Claimant's attorney informed the ALJ that the West Side VA Medical Center ("West Side") could not recover Claimant's medical records from 1984 to 1989. (R. 1332-33). ALJ Cropper also noted gaps in the medical records from 1989 to 1991, December 1992 to April 1996, 1999 to December 2001, and limited records existed from 2001 to 2004. (R. 1333-37). As a result, the ALJ informed both Claimant and his attorney that she would need to review all additional medical records before making her decision. (R. 1342, 1345-46, 1357). The ALJ stated that she may schedule a subsequent hearing. (R. 1342, 1350-51).

ALJ Cropper held another hearing on November 21, 2006. (R. 1194-1324). On May 9, 2007, the ALJ issued a decision denying Daggett's claim for benefits. (R. 17-23). On May 17, 2007, Daggett filed a timely request for review. (R. 12-13). The Appeals Council denied that request, and the ALJ's decision became the final decision of the Commissioner. (R. 14-16); Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). Daggett subsequently filed this action in the District Court.

II. BACKGROUND

A. VA Rating Decisions

Dagget submitted records from the Veteran's Administration (the "VA") in support of his claim for benefits. On November 1, 1968, Claimant received a 50% service-connected disability rating ("VA rating").*fn1 (R. 1153). On July 29, 1970, Claimant requested an increase of his VA rating. (R. 1151). After VA doctors conducted an examination of Claimant, the VA upwardly adjusted his VA rating to 70%. (R. 1151-52). On January 30, 1992, Daggett requested another VA rating increase. (R. 1149). The VA granted a rating increase to 80%, based on an evaluation of posttraumatic stress disorder ("PTSD"). (R. 1148, 1150). In the most recent VA rating decision, dated May 23, 2000, an evaluator indicated that Claimant had "poor anger management and poor impulse control." (R. 1146). In addition, the 2000 VA rating decision reflected the VA's grant of "total disability based on individual unemployability."*fn2 (Id.). This VA rating decision further reflected that Claimant had been "unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities," and that he last worked in 1984. (Id.). Lastly, the VA rating decision reflected that Claimant "cannot seek or maintain any employment now or in the foreseeable future." (Id.).

B. Medical Records

Claimant's earliest medical records reflect treatment from July 1988 and are largely illegible. (R. 146, 148-149). The legible portions of these medical records reflect that Claimant visited Hines VA Medical Center ("Hines") for a substance abuse evaluation. (R. 146, 148-149). An unknown author of a July 14, 1988 consultation sheet wrote that Daggett "has a 20 year history of drug use [and] states he has been using cocaine regularly for [the] past 4 yrs." (R. 149). The author also wrote that Daggett spent "approx. $1500/month and uses at least 1-5x/wk, but would use daily when money is available. Last use was Tuesday 7.12.88." (Id.). Furthermore, the author noted that Claimant had been unemployed "since 11/86." (Id.). Lastly, the author found that Claimant was appropriate for admission to the inpatient drug treatment program, but there was no space to admit Claimant at the time. (Id.).

After the July 14, 1988 visit, there is an approximate three-year gap until Claimant's next recorded medical treatment. According to Dr. M. Bringas ("Dr. Bringas"), on November 2, 1991, Claimant was admitted into the "4S" ward at Hines on an inpatient basis for treatment of depression and "nightmares due to post-traumatic stress disease." (R. 279). The doctor diagnosed Claimant with the following: (1) "cocaine dependence;" (2) "major depression, treated;" (3) "chronic nicotine dependence;" (4) "post-traumatic stress disease;" and (5) "upper respiratory tract infection, treated." (Id.). The doctor indicated that Claimant had PTSD due to "Vietnam memories" and was unable to sleep at night. (Id.). Dr. Bringas noted that Claimant had attended few group and individual meetings during treatment. (Id.). In addition, the doctor described Claimant as a "jobless construction carpenter" since November 1989 who supported himself with "occasional odd jobs." (Id.). Dr. Bringas also noted that Claimant had used cocaine several times since December 1988 until October 31, 1989, "spending $125.00 daily." (Id.). On December 1, 1991, Claimant was irregularly discharged for being absent without official leave, prior to completing his treatment. (Id.). Dr. Bringas discharged Claimant "with good response and no complications" and provided him with prescriptions for Haldol [an antipsychotic], Cogentin [an anticholinergic], Tylenol, and Benadryl. (Id.).

Two days later, on December 3, 1991, Claimant was admitted into the "3S" inpatient psychiatry ward at Hines. (R. 226-27). During admission, VA staff informed Daggett that his urine would be tested daily for drugs. (R. 226-27). Dr. E. Garb ("Dr. Garb") diagnosed Claimant with "organic mood syndrome secondary to substance use [and] cocaine dependence." (R. 226). Dr. Garb prescribed Prozac [an antidepressant] to treat his depressive symptoms. (R. 227). On December 11, 1991, Claimant's urine tested positive for cocaine, resulting in his irregular discharge from Hines. (Id.).

Approximately one year later, on December 4, 1992, the medical personnel at Hines's 3S psychiatry ward readmitted Daggett for inpatient treatment of his depression and PTSD. (R. 203-25). On December 17, 1992, Claimant tested positive for cocaine.

(R. 162). As a result, Claimant was administratively discharged from 3S before completing his treatment. (Id.). Claimant's psychiatric treatment team transferred him to Hines's substance abuse unit. (R. 150-202, 420-21). While in drug treatment, a social worker noted that Claimant "[h]elped in his father's trucking business in 1986--1988 [and] [h]elped his mother rehab old 'HUD' homes from 1988 to 1991." (R. 179). On December 22, 1992, a Hines nurse, indicated that Daggett had "[i]neffective individual coping related to abuse of substances and PTSD [and] could benefit from extended treatment." (R. 184). After Claimant left the hospital grounds in violation of ward policy on January 4, 1993, Dr. L. Mini (Dr. Mini"), Daggett's supervising doctor, and Daggett mutually decided that Daggett had "maximized the benefit" of his substance abuse treatment and would be discharged. (R. 194, R. 420-21).

The medical records indicate that Claimant returned to Hines for substance abuse treatment approximately three years later, on April 12, 1996. (R. 389-431). In connection with that admission, Claimant's treatment team completed a substance abuse patient assessment and developed a treatment plan. (R. 398-407). As reflected in the assessment, Claimant reported that he worked "full time (40/hrs/wk)" for the past three years. (R. 400). Claimant also stated that, prior to his treatment for drug abuse, he was last sober six months earlier. (R. 401). In addition, Claimant reported that within the last 30 days, he had experienced serious depression; serious anxiety or tension; trouble understanding, concentrating or remembering; trouble controlling violent behavior; and serious thoughts of suicide. (R. 404). The treatment plan for Claimant's "PTSD, flashbacks, nightmares, [and] agitation" included providing emotional support and reassurance; encouraging Claimant to verbalize feelings and thoughts; referral to the PTSD clinic; and providing medication. (Id.). Dr. P. Desai ("Dr. Desai") noted that Claimant used $100--$200 of cocaine per day "to deal with symptoms" of PTSD. (R. 387). On April 29, 1996, his treatment team discharged Claimant to the outpatient "mental hygiene" clinic. (R. 388).

Claimant's next psychiatric hospitalization occurred approximately one year later, on April 23, 1997, when he was admitted to West Side. (R. 633-36). Dr. William Mahoney ("Dr. Mahoney") diagnosed Claimant with (1) "Polysubstance dependence (cocaine, opiates, alcohol);" (2) "Asthma by history;" (3) "Multiple bone/tendon injuries lower extremities;" and (4) "Rule out posttraumatic stress disorder." (R. 633). The doctor noted that Claimant had difficulty managing his anger while in treatment. (R. 635). Dr. Mahoney also noted that Claimant was scheduled for discharge from West Side on May 12, 1997, in order to enter the 35-day PTSD treatment program at North Chicago VA Medical Center ("North Chicago"). (Id.). On May 9, 1997, Claimant received a pass to go to the Veterans Commission to obtain funds for travel to North Chicago for that program. (Id.). Claimant did not return to West Side and was irregularly discharged for being absent without leave. (R. 635-36).

Claimant's next psychiatric admission occurred a year-and-a-half later. (R. 378-79, 548-62). On October 11, 1998, Dr. Barbara L. Benton ("Dr. Benton") noted that Claimant arrived at Hines stating that he has "two choices, I will kill somebody or somebody will kill me." (R. 378). Dr. Benton also indicated that Claimant had been the recent target of an attempted robbery. (Id.). Claimant reported "being clean" since 1993, but that he smoked "speed balls [cocaine and heroin]" worth approximately $4,000 for two weeks after the attempted robbery. (R. 378; 562). Dr. Pravin Bhatt ("Dr. Bhatt"), the attending psychiatrist, diagnosed Claimant with PTSD and "poly-substance abuse." (R. 1120). Dr. Bhatt prescribed individual and group therapy, and Trilafon [an antipsychotic medication]. (R. 1121). On October 19, 1998, Dr. Bhatt indicated that Daggett "is presenting with October anniversary of Vietnam." (R. 554). By October 21, 1998, Dr. Benton noted that Claimant was ready for discharge by responding "very well" and achieving "full benefit" of inpatient treatment. (R. 549). The next day, Claimant received a regular discharge from Hines. (R. 378-79).

On November 13, 1998, Claimant returned to Hines. (R. 377, 533-48). Dr. Bhatt indicated that Claimant was experiencing flashbacks of Vietnam and may have been using illicit drugs. (R. 377). On November 23, 1998, Daggett informed a medical student that he felt "hopeful for the first time ever" and "excited" about entering North Chicago's 35-day PTSD treatment program. (R. 539). A discharge planning note written by a social worker stated that "Vet is in need of PTSD [treatment] as he continues to have flashbacks." (R. 534). Claimant was discharged from Hines on December 4, 1998, in order to attend a screening interview at North Chicago. (Id.).

On December 4, 1998, Dr. John J. Schaut ("Dr. Schaut"), a psychologist, screened Claimant for admission into North Chicago's Stress Disorder Treatment Unit ("SDTU") for its 35-day PTSD treatment program. (R. 912-13). At that time, Daggett reported that he was "self-employed as a journeyman carpenter," but had not worked for the previous three weeks due to his PTSD. (R. 912). On December 10, 1998, Claimant began the program. (R. 830-33). As part of his treatment, Claimant attended individual and group therapy sessions. (R. 903). Dr. Remedios N. Galang ("Dr. Galang"), the attending psychiatrist, noted that Claimant had been diagnosed with PTSD as early as 1985 and participated in intermittent outpatient PTSD treatment since that time. (R. 831). Dr. Galang further noted that Claimant's admission to North Chicago's day program marked his first inpatient PTSD treatment. (Id.). Claimant did not complete the program. (R. 833). Instead, on January 5, 1999, the treatment team irregularly discharged Daggett for failing to return after receiving temporary leave to spend time with his family during the holiday season. (Id.).

On January 28, 1999, Claimant returned to the 3S psychiatry ward at Hines and complained of homicidal thoughts after reportedly spending twelve days in jail. (R. 521-33, 1072-90). Dr. Bhatt diagnosed Daggett with PTSD and substance abuse. (R. 1088). The doctor recommended restarting psychotropic medication, individual and group therapy, milieu therapy, and the PTSD program. (Id.). On February 4, 1999, Dr. Bhatt opined that Claimant continued to "progress well" and recommended that he continue with psychotropic medications and psychotherapy. (R. 1076, 1086). According to a February 5, 1999 note by Dr. Kiran F. Siddiqui ("Dr. Siddiqui"), a medical resident, Claimant demanded to leave treatment after being arrested in the VA cafeteria for fighting. (R. 1075). The note reflected that Dr. Siddiqui prescribed Haldol and Ativan [an anti-anxiety medication] to treat Daggett's agitation. (Id.). The next day, however, Claimant signed himself out of treatment. (R. 1074-75). On February 6, 1999, Claimant was irregularly discharged for leaving against medical advice. (R. 1073-74). A Hines social worker noted that Daggett "has a poor history of compliance" with treatment and follow up, but that he planned to follow up at North Chicago for outpatient PTSD treatment. (R. 1072).

On February 11, 1999, Claimant received treatment from the Acute Rehabilitation Unit ("ARU") at North Chicago. (R. 864-88). The attending psychiatrist, Dr. Elizabeth Wood (Dr. Wood"), indicated that Claimant had "low grade depressive symptoms" and "emotional management issues." (R. 886). In a February 12, 1999 progress note, Dr. Wood stated that Claimant's use of Zoloft over the past year yielded "good results" in stabilizing his mood and managing his anger. (Id.). Dr. Wood recommended continued use of Zoloft. (Id.). During treatment in the ARU, Virginia C. Edingburg ("Ms. Edingburg"), a psychology technician, noted that Claimant reported that he was "clean" from 1970 to 1990 and from 1991 to 1998. (R. 877). However, when asked about the years he reported not using illicit drugs in a group therapy session, Claimant stated: "Maybe I did use in some of those years that I reported as being clean time. I have used in treatments before." (Id.). Ms. Edingburg noted that Claimant's statement "directly conflicts" with his medical records from Hines, West Side, and private treatment centers for the years 1988, 1991--1993, and 1995--1998. (Id.).

On March 10, 1999, the director of the ARU noted that Claimant's treatment team granted him a one-day, "therapeutic" pass to leave treatment to attend a family funeral.

(R. 869). The next day, Claimant called Lynne Vaughn ("Ms. Vaughn"), a social worker at North Chicago, "in great distress." (R. 866). He informed the social worker that the funeral had triggered flashbacks to his experiences in Vietnam. (Id.). Ms. Vaughn assessed that Claimant was in a "very agitated, labile mood alternating between tears, anger, and fear." (Id.). Claimant did not return to the ARU on March 11, 1999, as expected. (Id.). According to Ms. Vaughn's discharge note dated March 12, 1999, Claimant's wife informed Ms. Vaughn that Claimant relapsed and would not be returning to treatment. (R. 865-66).

On April 7, 1999, Claimant was admitted to the North Chicago acute psychiatric unit for PTSD problems and homicidal ideation. (R. 845-64). That day, Dr. Medeia Gartel (Dr. Gartel"), a psychiatric resident, noted that someone tried to rob Claimant.

(R. 862). The doctor stated that Claimant spent two days "on the streets" looking for the robber and when he found him, broke the robber's jaw. (Id.). According to the doctor's admission note, Claimant reported that he could not control his urge to "finish the g[u]y" and that the only way for him to avoid murder was to be "locked up." (Id.). Dr. Gartel diagnosed Claimant with PTSD and "chronic impulse control disorder." (R. 863). The doctor prescribed Ativan to treat Claimant's agitation. (Id.). Additionally, Dr. Gartel noted that Daggett "presently works as a taxi driver." (R. 862).

Claimant met with his treatment team on April 8, 1999. (R. 855). A treatment nurse noted that, during the meeting, Claimant expressed "difficulties revealing himself to strangers" and "coping with the guilt of being [the] lone survivor of his patrol" in Vietnam. (Id.). Claimant indicated that he had trouble sleeping and that he needed "a plan on how to survive in life." (Id.). Daggett's treatment team prescribed Trazodone. (Id.). On April 12, 1999, Dr. Purna Chalansani ("Dr. Chalansani"), an attending psychiatrist, noted Claimant's request for an increased dosage of Motrin for his ankle pain. (R. 850). The doctor also noted that Claimant wished to return to North Chicago's SDTU. (Id.). On April 16, 1999, Dr. Schaut met with Claimant to discuss treatment options following discharge from the acute psychiatry unit. (R. 846). Dr. Schaut discussed various housing options with Claimant, and the doctor agreed to facilitate referral to an appropriate program. (Id.). On April 18, 1999, Claimant reported continued difficulties sleeping, but denied having hallucinations. (Id.). He agreed to a trial of Mellaril [an antipsychotic] to help him sleep. (Id.). On April 19, 1999, Claimant was irregularly discharged for not returning to treatment after leaving without authorization. (R. 845).

Claimant was admitted to West Side on July 6, 1999. (R. 631-32). At the time of admission, Daggett's urine tested positive for cocaine. (R. 632). Dr. W. Biber ("Dr. Biber"), a staff psychiatrist, noted Claimant's report of an "exacerbation of his PTSD symptoms." (R. 631). The doctor also noted that Daggett "expressed a fear that he could lose control and become violent," and reported a fight over the July 4th holiday. (Id.). Dr. Biber diagnosed Claimant with "probable PTSD" and "cocaine dependency." (Id.). Claimant's treatment team recommended individual and group therapy, and that he start Prozac every morning and Trazodone at bedtime for sleep. (R. 631-32). Claimant's treatment team increased the dosage of Trazodone from 50 mg to 100 mg on July 7, 1999, and to 150 mg on July 9, 1999. (R. 632). On July 12, 1999, Daggett was irregularly discharged due to his refusal to participate in group therapy. (Id.).

Nearly two weeks later, on July 24, 1999, Claimant returned to Hines and was readmitted to the 3S psychiatry ward for treatment due to his PTSD and homicidal thoughts. (R. 1043-72). Claimant informed a medical resident that his wife accused him of infidelity with her niece. (R. 1071). He further reported that he went to the niece's home "wanting to beat her" and felt that he could not control himself. (Id.). Dr. Bhatt recommended that Claimant start taking Serzone [an antidepressant] and Trazodone, and attend therapy. (R. 1072). On August 2, 1999, Mark Butterfly, a medical student, noted that "Mr. Daggett admits it is in his daily routines . . . where he needs the most help coping with his present condition." (R. 1050-51). That same day, Dr. Bhatt reassessed Claimant's treatment plan and noted that Claimant "has begun to show consistent improvement in his state of anger and agitation." (R. 1053). Consequently, the doctor elected to initiate discharge planning. (R. 1053). On August 5, 1999, a nurse noted Daggett's report, in group therapy, that "he ha[d] been coming to Hines since 1970 with the same problem." (R. 1048). The nurse indicated that Claimant characterized this admission as "different" from his previous treatments, as it marked the first time that he had been admitted drug free. (Id.). Furthermore, the nurse noted that Claimant believed that "this [was] a very important step for him and that now he can finally move on." (Id.). Two days later, on August 7, 1999, Claimant's wife informed him of his nephew's incarceration. (R. 1045). In response, Claimant demanded to leave treatment to "bail [his] nephew out of jail and [to] make a statement to police on [his nephew's] behalf." (Id.). Claimant was discharged against medical advice on that same day. (Id.).

Peyton R. Keller, Jr. ("Mr. Keller"), a social worker at Hines, documented Claimant's status through an outreach effort at a homeless shelter in Chicago on February 25, 2000. (R. 1042-43). Mr. Keller noted that Claimant had been homeless for at least thirty days. (R. 1043). He indicated that Daggett had dental problems, a history of substance abuse, and had spent time in jail. (Id.). Mr. Keller further noted that Daggett received outpatient treatment for his PTSD at the shelter and at the Oak Park veteran center with a Dr. Jean Douglas ("Dr. Douglas").*fn3 (R. 1043). In addition, Mr. Keller assessed that Daggett may be a candidate for "HCHV" [health care for homeless veterans], ...


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