Appeal from the United States District Court for the Northern District of Illinois, Eastern Division. No. 1:09-cv-01744-John W. Darrah, Judge.
The opinion of the court was delivered by: Tinder, Circuit Judge.
Before WOOD, EVANS, and TINDER, Circuit Judges.
Curtis Campbell appeals from the district court's judgment upholding the Social Security Administration's denial of his application for disability insurance benefits and supplemental security income. Campbell contends that the Administrative Law Judge ("ALJ") who denied his application erred in discounting the opinion of his treating psychiatrist and in weighing the psychiatric medical evidence. We reverse the district court's denial of relief and remand with instructions to return this matter to the Commissioner.
On January 13, 2004, Campbell applied for social security disability benefits and supplemental security income. Although Campbell has physical impairments and limitations, this appeal concerns his mental impairments and limitations.
Campbell has a history of treatment for depression. On March 13, 2004, Myrtle Mason, M.D., M.P.H., conducted a psychiatric examination of Campbell at the agency's request. Campbell indicated that he had been depressed since 1986, but was not currently being seen by a mental health professional. He reported that his primary care physician had prescribed medications for depression: Zoloft, Lexapro, and Elavil. Dr. Mason concluded that Campbell's past treatment and hospitalizations had been mostly for substance abuse, not depression. Upon examination, Dr. Mason noted that Campbell was a little guarded intermittently during the interview, but found no evidence of any perceptual disorder or disturbance in form or content of thought. She diagnosed substance induced mood disorder and polysubstance abuse. Dr. Mason rated Campbell's current Global Assessment of Functioning (GAF) Scale as 60-75, indicating at worst some mild symptoms or some difficulty in functioning, but generally functioning pretty well. See Am.
Psychiatric Ass'n, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) 34 (4th ed. 2000).
On April 6, 2004, Kirk Boyenga, Ph.D., a state agency psychologist, reviewed the record and assessed Campbell's mental functional capacity. Boyenga opined that Campbell was mentally capable of performing simple and detailed tasks as well as routine and repetitive tasks in settings with reduced interpersonal contact. In August 2004, state agency psychologist Bronwyn E. Rains and state agency psychiatrist Glen D. Pittman reviewed the record and affirmed Dr. Boyenga's assessment.
On May 7, 2004, Campbell presented at the Community Mental Health Council, Inc. ("CMHC"), for a mental health assessment which was conducted by Anne Crowe, LCPC, a clinical therapist. Campbell reported depression, decreased sleep, decreased appetite, anhedonia, and a*fn1 hopeless feeling. He said that he was not active and not motivated, but denied suicidality. He reported anxiety and impulsivity as well as auditory and visual hallucinations. He stated that he was going through a divorce and that he was consuming alcohol daily. Crowe thought Campbell's affect was depressed. She recommended a psychiatric evaluation, medication as needed, case management services, individual therapy, and a mental health assessment. That day, a psychiatrist at CMHC also saw Campbell. His affect was depressed and sad, but otherwise within normal limits. The clinician diagnosed Major Depression with psychotic features, history of polysubstance abuse, current muscle relaxant abuse and assessed a GAF rating of 40-45, reflecting some impairment in reality testing or communication or major impairment in several areas, such as work, judgment, thinking, or mood. See DSMV-IV-TR 34.
On October 19, 2004, CMHC psychiatrist Traci Powell first evaluated Campbell. She treated him regularly through the date of the ALJ's hearing, January 25, 2006, and thereafter. On mental status exam, Dr. Powell noted that Campbell had a flat affect, soft voice, fair judgment and insight, paranoid/suspicious thought, and auditory hallucinations. Her note states: "Reports using ETOH [alcohol] on a daily basis and states it helps to calm him." Dr. Powell noted that Campbell reported symptoms of depression and psychosis dating back ten years. She diagnosed Major Depressive Disorder with psychotic features and prescribed Paxil to address his depressive symptoms and Seroquel for psychosis and sleep disturbance. Dr. Powell rated Campbell's GAF at 45-50, reflecting serious symptoms or serious impairment in social or occupational functioning, for example, the inability to keep a job. See DSMV-IV-TR 34.
Campbell did not see Dr. Powell again until January 4, 2005. He reported that the past two months were "terrible" and that he continued to have anxiety attacks. Dr. Powell noted that "[h]e states his ETOH use has increased" and that Campbell reported using drugs once since his last appointment. On his mental status exam, Dr. Powell noted that Campbell's affect was flat, his thought content was paranoid/suspicious, and he had auditory hallucinations. Her assessment included that Campbell "has not been compliant with meds and continues to use ETOH." She diagnosed Major Depressive Disorder with psychotic features and rated him 45-50 on the GAF Scale, again reflecting serious symptoms or impairments in functioning. See DSMV-IV-TR 34. Dr. Powell restarted Campbell's medications, increasing the dosage of Seroquel by 200 mg.
Dr. Powell saw Campbell on February 17, 2005. He stated that things were not going well, but was not forthcoming about what was happening. He reported using ETOH a few times per month and denied using illegal drugs. Based on her exam, Dr. Powell noted that Campbell's affect was flat, his thought content was paranoid/suspicious, and he had auditory hallucinations. She noted that he had not been fully compliant with his medications and was "using ETOH which is likely contributing to his presentation today." Dr. Powell diag-nosed Major Depressive Disorder with psychotic features and noted the need to rule out the existence of a learning disability. His GAF score was 45-50.
On February 22, 2005, Dr. Powell completed a mental impairment questionnaire, assessing Campbell's impairments and functional capacity. She diagnosed Major Depressive Disorder with psychotic features and noted the need to rule out a learning disability. She identified Campbell's associated symptoms as sleep disturbance, mood disturbance, anhedonia or pervasive loss of interests, paranoia or inappropriate suspiciousness, feelings of guilt/worthlessness, perceptual disturbance, and flat affect. In her clinical findings, Dr. Powell noted that Campbell's speech was hesitant, his affect was flat, he was positive for paranoia and auditory hallucinations, and his insight and judgment were fair. Dr. Powell noted that Campbell was not a malingerer. His prognosis was fair. His medications were Seroquel and Paxil. Dr. Powell indicated that Campbell had fair, poor, or no ability to perform mental activities required for even unskilled work. She found that he had the following functional limitations: moderate restriction in activities of daily living; marked difficulties in maintaining social functioning; constant deficiencies in ...