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Fred Ison, Jr v. Michael J. Astrue

March 12, 2012


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


Michael T. Mason, United States Magistrate Judge:

Plaintiff, Fred Ison, Jr. ("Ison" or "claimant"), has brought a motion for summary judgment [21] seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner") denying his claim for Supplemental Security Income ("SSI") under the Social Security Act (the "Act"), 42 U.S.C. § 1382c(a)(3)(A). The Commissioner filed a response [26] asking the Court to uphold the decision of the Administrative Law Judge. This Court has jurisdiction to hear this matter pursuant to 42 U.S.C. § 1383(c). For the reasons set forth below, claimant's motion for summary judgment is granted.


A. Procedural History

Ison filed an application for SSI onDecember 19, 2007, alleging an onset date of October 2, 2003 due to Bipolar disorder, Hepatitis C, and a left leg injury. (R. 49.) His claim was denied initially on March 21, 2008, and again on June 3, 2008 after a timely request for reconsideration. (R. 49-53, 67-71.) Thereafter, Ison requested a hearing, which took place on October 21, 2008 before Administrative Law Judge Linda Halperin ("ALJ Halperin" or "ALJ"). (R. 7-34.) On March 17, 2009, ALJ Halperin issued a written decision denying Ison's request for benefits. (R. 37-48.) Ison filed a timely request for review (R. 6), which the Appeals Council denied on December 4, 2009. (R. 1-3.) The ALJ's decision then became the final decision of the Commissioner. Zurawski v. Halter, 245 F.3d 881, 883 (7th Cir. 2001). This action followed.

B. Medical Evidence

1. Community Counseling Centers of Chicago

Records reveal that in late 2007 Ison sought treatment at Community Counseling Centers of Chicago ("C4"), an outpatient recovery program, for his "drug abuse" and "bipolar condition." (R. 244.) It appears that Ison was first evaluated at C4 by a Dr. Wilson on December 18, 2007, eight months after he was released from prison. (R. 244-247.) At that time, Ison complained of difficulty sleeping, foot pain from fallen arches, as well as muscle pain in his lower legs. (R. 245.) He stated that he was diagnosed with Hepatitis C in 2003, but had not had any treatment. (Id.) The evaluation also indicated that he had seen a psychiatrist while in prison and that he was admitted to Read Mental Health Center's psychiatric unit in 1984. (R. 244.)

Ison reported mood swings, racing thoughts, and irritability. (R. 243.) He described periods of high energy with rapid speech, followed by low periods that last a few days. (Id.) Ison explained that he could not read for very long and that he had to write things down because he cannot remember anything. (R. 246.) Ison told Dr. Wilson that he uses marijuana and crack, and drinks heavy amounts of alcohol. (R. 243.) He denied suicidal thoughts, but reported recent homicidal thoughts. (Id.)

Dr. Wilson's exam revealed poor attention and memory, depressed mood, irritability and restricted affect. (R. 246.) At the time, Ison's Global Assessment of Functioning ("GAF") was 58.*fn1 (R. 247.) Dr. Wilson assessed Bipolar disorder and polysubstance dependence. (Id.) He prescribed Seroquel and Lithium. (Id.) Ison was also advised to participate in group therapy sessions twelve hours a week and in individual therapy one hour a week. (R. 194.)

During a follow-up appointment on January 4, 2008, Ison reported that he was doing better. (R. 248.) Ison stated that he had not used drugs for the last 12 days. (Id.) His mood and affect were documented as "vague." (Id.) On January 28, 2008, Ison claimed that he had been sober for 35 days. (R. 249.) He was not taking the Seroquel and was inadvertently taking only half of the prescribed dose of Lithium. (Id.) His mood was "ok," but Dr. Wilson noted that he was irritable. (Id.)

By April 7, 2008, claimant told Dr. Wilson that he was unhappy with his medication, explaining that the Lithium made it hard to get up in the morning and gives him carbohydrate cravings. (R. 250.) Ison admitted that the Lithium helped his mood somewhat, but not enough to put up with the side effects. (Id.) Ison also complained of mood swings, racing thoughts, and poor concentration. (Id.) Ison reported that he was still sober. (Id.) Dr. Wilson granted Ison's request to go off the prescribed medication, noting that he may no longer need medication if he could maintain his sobriety. (Id.)

On May 28, 2008, after being off medication since his last visit, Ison denied sustained depression, suicidal or homicidal thoughts, or psychotic symptoms. (R. 251.) However, he reported mild racing thoughts, and his affect was noted as mildly irritable. (Id.) Ison was cooperative, but somewhat antagonistic. (Id.) Although hesitant, Ison agreed to try Abilify as long as there were no side effects. (Id.)

By July 9, 2008, Ison had returned to using alcohol, cocaine, and marijuana, and had ceased taking Abilify a few days after the May 28 appointment because it "wasn't doing anything." (R. 252.) While he initially agreed to undergo inpatient treatment, he became hostile and belligerent when Dr. Wilson raised the subject of medication. (Id.) Ison was described as uncooperative, antagonistic, nervous, hyper, and anxious. (Id.)

On September 17, 2008, Ison told Dr. Wilson that he had checked himself into Chicago Read Mental Health Center about a month prior.*fn2 (R. 253.) Ison also told Dr. Wilson that he had restarted taking Lithium (although less than prescribed due to side effects) and had sustained sobriety. (Id.) He reported that the Lithium was helping keep his mood stable, and his mood was described as "pretty good." (Id.) This was the best Dr. Wilson had ever seen him. (Id.) But, on September 29, 2008, Ison confessed to Dr. Wilson that he had actually been high on marijuana during his last appointment.

(R. 254.) Ison reported he was having a hard time maintaining hope that sobriety would lead to any positive changes in his life. (Id.) His frustration, combined with lack of structure, "leads to using." (Id.) As a result, he described his mood as "pissed off." (Id.) Dr. Wilson acknowledged that Ison was not doing well, but noted that this appeared to be a result of drug use rather than psychological symptoms. (Id.)

2. Other Treatment

On February 8, 2008, Ison underwent an evaluation with Dr. Charles Yingling, who completed a "Medical Evaluation" for the State of Illinois Department of Human Services. (R. 205-208.) Dr. Yingling's report indicated that Ison had the full capacity to walk, bend, stand, stoop, sit, turn, climb, push, pull, speak, perform activities of daily living, and engage in fine or gross manipulation with either hand. (R. 208.) He had no limitations on lifting other than his own ability. (Id.) Dr. Yingling also noted that Ison was enrolled in Thresholds' "pysch rehab." (Id.) He assessed Hepatitis C and Bipolar disorder, but noted that any observations or results regarding Ison's mental impairments "need[ed] to come from [a] psychiatrist." (R. 205, 208.)

In May of 2009, claimant sought voluntary mental health and substance abuse treatment from Trilogy Behavioral Healthcare. (R. 266-279.) On admission, his GAF was documented as 37. (R. 266.) Among other things, claimant complained of racing thoughts and mood swings, and addressed the difficulties he faces trying to stay sober as a result of emotional distress and a low tolerance for conflict. (R. 268, 270.) At one point during the interview, Ison left abruptly due to increased irritability and frustration about the interviewer's questions. (R. 278.) The Trilogy evaluators diagnosed Bipolar II disorder, Narcissistic Personality disorder, alcohol abuse, and cannabis abuse. (R. 266.)*fn3

3. State Agency Consultants

On March 13, 2008, Dr. Erika Altman completed a "Psychiatric Review Technique" and a "Mental Residual Functional Capacity Assessment." (R. 213-230.) She determined that Ison suffered from Bipolar disorder with episodes of both manic and depressive symptoms, as well as substance addiction with behavioral changes associated with the regular use of substances. (R. 216, 221.) Dr. Altman determined that Ison had mild limitations in activities of daily living and maintaining social functioning, and moderate limitations in maintaining concentration, persistence, or pace.

(R. 223.) More specifically, Dr. Altman found that Ison was moderately limited in his ability to maintain attention and concentration, and in his ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances. (R. 227.) Dr. Altman did conclude that Ison could "understand, carryout, and remember simple instructions, make simple work ...

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