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Roseann Lopez v. Michael J. Astrue

February 10, 2012


The opinion of the court was delivered by: Magistrate Judge Young B. Kim


Plaintiff Roseann Lopez seeks review of the final decision of the Commissioner of Social Security ("Commissioner") denying her application for Disability Insurance Benefits ("DIB") under Title II of the Social Security Act ("Act"), 42 U.S.C. § 423(d)(2), and Supplemental Security Income ("SSI") under Title XVI of the Act, 42 U.S.C. § 1382c(a)(3)(A). Before the court are the parties' cross-motions for summary judgment. Lopez asks the court to reverse the Commissioner's decision and award benefits, or in the alternative, to remand the case for further proceedings. The Commissioner seeks an order affirming the decision. For the following reasons, Lopez's motion for summary judgment is granted insofar as it requests a remand and the Commissioner's motion is denied:

I. Procedural History

Lopez applied for DIB and SSI on August 6, 2007, alleging that she became disabled on March 1, 2006, due to depression, mood swings, and insomnia. (Administrative Record ("A.R.") 50, 96-98, 101-03.) The Commissioner denied her applications on November 20, 2007, (id. at 46-50), and again on reconsideration on April 18, 2008, (id. at 53-60). Thereafter, Lopez requested and received a hearing before an administrative law judge ("ALJ"). (Id. at 62.) On August 24, 2009, the ALJ issued a decision finding Lopez not disabled. (Id. at 15-21.) The Appeals Council denied Lopez's request for review on August 10, 2010, (id. at 1-3), making the ALJ's decision the final decision of the Commissioner, see Getch v. Astrue, 539 F.3d 473, 480 (7th Cir. 2008). Pursuant to 42 U.S.C. § 405(g), Lopez initiated this civil action for judicial review of the Commissioner's final decision. The parties have consented to the jurisdiction of this court pursuant to 28 U.S.C. § 636(c).

II. Background

A. Summary of Medical Evidence

Lopez, who is 56 years old, has suffered from depression for more than 20 years. (A.R. 25, 243.) In February 2006, a month before she stopped working, Lopez sought treatment for her depression at Community Health Clinic. (Id. at 223-24, 255, 257.) She reported having days when she feels normal and days when she feels very sad and upset for no reason. (Id. at 223.) Lopez was prescribed Prozac, but by April 2006 she stopped taking it because she feared its side effects, which include an increased risk of suicide. (Id. at 226.) In lieu of taking Prozac, during the summer and fall of 2006 Lopez used art and music for relaxation and relied on a "positive mental attitude" to manage her depressive symptoms. (Id. at 227-28.) Lopez reported feeling better in the fall of 2006, (id. at 269), but by June 2007, Lopez's affect was flat and she displayed depressive symptoms, (id. at 273). Lopez had some thoughts of suicide, which were "set off" by home stressors. (Id.) She reported feeling better when taking Prozac and agreed to take the medication again. (Id.) Lopez also explained that she was having difficulty finding a job. (Id.)

Lopez continued to seek treatment for her depression in the summer of 2007. She reported to a Community Health treating source*fn1 in July 2007 that she continued to have "some low mood," but her mood had improved after she restarted taking Prozac. (Id. at 276.) Lopez denied having active or passive suicidal ideation, stating that she "tr[ied] not to think about it." (Id.) Treatment notes reflect that Lopez only slept three hours each night, she had a flat and tearful affect, and she spoke at a slow rate with "some latency to respond." (Id. at 276-77.) In August 2007, Lopez's mood was a little better and she denied suicidal ideation, but she continued to have difficulty sleeping for longer than three to four hours at night. (Id. at 279.)

Lopez's sleeping problems continued into October 2007 and, as a result, she always felt tired. (Id. at 243.) Although she had some improvement on Prozac, she displayed a blunt affect, halting speech, fair to limited insight, limited judgment, and mild psychomotor retardation.*fn2 (Id. at 243-44.) At the time, she did not have any suicidal ideation. (Id. at 244.) The individual treating Lopez hypothesized in his or her notes that her depression likely has "some biological component," but also documented that her 20-year history of depression stemmed from her childhood; she had an absent father and a verbally and physically abusive mother and stepfather. (Id. at 243-44.)

Lopez also underwent a psychiatric evaluation with Barbara Sherman, Psy.D., a state agency psychologist, in October 2007. (Id. at 192-95.) Lopez reported to Dr. Sherman that she suffered from a long history of depression and severe nightmares. (Id. at 192.) She explained that she was physically and emotionally abused as a child and sustained numerous head injuries, bruises, and lacerations during those years of abuse. (Id. at 192-93.) Lopez acknowledged feeling depressed, crying frequently, and experiencing some lethargy, withdrawal, and isolation from her peers. (Id. at 194.) During the evaluation, Lopez was dysphoric in appearance and tearful. (Id. at 193.) Although Lopez was distressed and worried about family problems, she denied any suicidal ideation or manic episodes. (Id. at 194.) But she reported having auditory and visual hallucinations, which take the form of feeling like she is being followed and thinking that someone is questioning her. (Id.) The hallucinations began 15 years earlier when her six-year old daughter was kidnapped and sexually abused by a teenage neighbor. (Id.) During the evaluation, Lopez displayed a diminished attentional focus, but her memory, conceptual ability, reasoning, and judgment appeared adequate. (Id.) Dr. Sherman diagnosed Lopez as having major depression with psychotic symptoms, and post-traumatic stress disorder ("PTSD"). (Id.)

In November 2007, David Gilliland, Psy.D., also a state agency psychologist, reviewed Lopez's medical file and completed forms assessing her mental ability to perform work-related activities. (Id. at 196-213.) Dr. Gilliland diagnosed Lopez with a depressive disorder and an anxiety disorder. (Id. at 199, 201, 212.) In assessing the degree of her functional limitations, Dr. Gilliland found that Lopez has mild restrictions in activities of daily living, moderate difficulties in maintaining social functioning, and moderate difficulties in maintaining concentration, persistence, and pace. (Id. at 206.) He noted that Lopez reported in an Activities of Daily Living Questionnaire that she was forgetful, afraid of people, overly sensitive to people's remarks, and easily upset when criticized. (Id. at 208.) Based on his review, Dr. Gilliland assessed Lopez as moderately limited in her ability to: (1) understand and remember detailed instructions; (2) carry out detailed instructions; and (3) interact appropriately with the general public. (Id. at 210-11.) He opined that Lopez is mentally able to perform simple repetitive tasks, but that she must have limited contact with the general public. (Id. at 212.)

Lopez continued to seek treatment for her depressive symptoms from November 2007 to December 2008. Toward the end of November 2007, Community Health treatment notes indicate that Lopez was doing well on Prozac. (Id. at 285.) A month later, Lopez was "visibly upset" recalling a stressful interaction with a man on a bus who recently threatened to attack her, but she also reported that Prozac "helps" and that her mood had been "good." (Id. at 285-86.) In April 2008, Lopez denied having any complaints; in May, she said her mood was stable and she denied having suicidal ideation; and in August, her depression had "improved on Prozac." (Id. at 289-90, 292.) In the fall of 2008, Lopez reported that her concentration, appetite, and energy were normal and she denied suicidal ideation. (Id. at 292.) But Lopez reported sleeping only about five hours each night and she cried when relating memories of her daughter being kidnapped. (Id.) Her thought process was generally linear with some tangential dimensions and her insight was poor to fair. (Id. at 293.) In November 2008, Lopez denied having depressive symptoms and said that her mood was "ok, not depressed." (Id. at 294-95.) But a few weeks later, Lopez reported being upset because the friend she lived with lost his job and she was concerned that she would become homeless. (Id. at 296.) Treatment notes reflect that Lopez was stressed, depressed, and crying. (Id.)

In December 2008, Lopez underwent a mental health assessment at Cicero Family Service and Mental Health Center. (Id. at 324-31.) Lopez reported that her symptoms were worsening and that she experienced random suicidal ideation, but she "has not thought about [suicide] for months and usually engages in leisure activities to take her mind off of those thoughts." (Id. at 324, 326.) She expressed feeling overwhelmed from the process of packing to move out of her friend's house. (Id. at 324.) Lopez relayed her history of being physically and verbally abused by her mother when she was a child. (Id.) She also described difficulty sleeping and feeling hopeless. (Id. at 330.)

Lopez's mental status examination indicated that she had an impaired memory, an inappropriate affect, an anxious and fearful mood, a history of hallucinations, and distractible attention. (Id. at 329.) During the evaluation, Lopez had poor eye contact, took several minutes to speak after a question was asked, and laughed during sad moments of her presentation. (Id.) She also reported "seeing something" in her home three months earlier that she knew was not really there. (Id.) The examiner assessed Lopez as having a Global Assessment of Functioning ("GAF") score of 49*fn3 and displaying a "serious impairment in social, occupational or social functioning." (Id. at 330, 332.) The examiner also diagnosed Lopez with a recurrent major depressive disorder (moderate) and referred her for a psychiatric evaluation and individual therapy. (Id. at 330-31.)

In February 2009, Lopez underwent a psychiatric evaluation with Dr. Raymond Gouttama, a psychiatrist. (Id. at 335-36.) He noted that Lopez's depressive symptoms included sadness, crying, and insomnia. (Id. at 335.) A mental status examination indicated that Lopez had fair memory, insight, and judgment, normal thought processes, no psychosis or suicidal ideation, and low average intelligence. (Id.) Dr. Gouttama ...

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