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Yolanda Trice v. Michael J. Astrue

November 9, 2012


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

Magistrate Judge Young B. Kim


Plaintiff Yolanda Trice challenges the Commissioner's denial of her application for Social Security disability benefits ("DIB") and supplemental security income ("SSI), claiming that the combination of her diabetes, high blood pressure, back and leg pain, asthma, and depression precludes her from working. For the following reasons, Trice's motion is granted insofar as it requests a remand, and the Commissioner's motion for summary judgment is denied.

Procedural History

Trice previously applied for disability benefits in November 2003 and October 2004. (Administrative Record ("A.R.") 178.) Following a hearing on the 2004 application, an ALJ ("ALJ") denied Trice benefits. (Id.) Trice's request for review was then denied by the Appeals Council on May 12, 2006, but she did not seek judicial review. (Id.) On May 30, 2006, Trice filed her current application for SSI and DIB, alleging that her disability began on January 6, 2006. (Id. at 178, 280-82, 283-85.) The Commissioner denied her applications in September 2006 (id. at 202-05), and again on reconsideration in December 2006 (id. at 213-15, 216-18). Trice then requested and was granted a hearing before an ALJ. (Id. at 222, 227-30.) On September 17, 2009, the ALJ concluded that she is not disabled as defined under the Social Security Act. (Id. at 178-201.) When the Appeals Council denied Trice's request for review on January 14, 2011 (id. at 1-3), the ALJ's decision became the final decision of the Commissioner, see Shauger v. Astrue, 675 F.3d 690, 695 (7th Cir. 2012). Pursuant to 42 U.S.C. § 405(g), Trice initiated the current suit seeking judicial review of the ALJ's decision. The parties have consented to the jurisdiction of this court. See 28 U.S.C. § 636(c).


Trice, who is presently 43 years old, suffers from several physical ailments including diabetes mellitus, hypertension, asthma, back and leg pain, and obesity. She also suffers from major depression, recurrent, and anxiety, which she believes stem from the sexual abuse she suffered as a child and the physical and mental trauma that followed a 2003 police raid that was mistakenly conducted on her residence when she was six months pregnant with her daughter.

A. Summary of Medical Evidence

At the hearing before the ALJ, Trice submitted both documentary and testimonial evidence in support of her claim. Beginning in May 2005, Trice began reporting muscle spasms and persistent and severe lower back pain. (A.R. 532.) An examination revealed back tenderness, but a musculoskeletal examination reported normal findings. (Id.) Trice was given a Toradol injection for the pain and oral medication for her diabetes and hypertension. (Id.) Trice returned for a follow-up visit, still complaining of severe low back pain. (Id. at 531.) She was given another Toradol injection and prescribed Vicodin and Ibuprofen for the pain. (Id.) A CT scan of her lumbar spine revealed mild diffuse disk bulges at multiple levels but no evidence of spinal canal stenosis. (Id. at 558.) For the remainder of 2005, Trice followed up with her doctors, continuing to report back pain and receiving injections to alleviate it. (Id. at 522, 526, 529.) She also sought and received treatment for her diabetes, asthma, hypertension, obesity, and anemia. (Id. at 523-24, 540-41.)

In February 2006, Trice was evaluated at a mental health clinic, reporting depression, insomnia, fatigue, low energy, lack of interest, and poor concentration but denying any suicidal or homicidal ideation. (Id. at 512-21.) Trice told the intake evaluator that she attempted suicide once when she was 20 years old and cut her wrists in 2003. (Id. at 512-13.) Although Trice had "passive thoughts of death," she indicated to the evaluator that she had no intention to act on them. (Id. at 516.) Trice also described her history of sexual abuse as a child, her mother's failure to act on it when she was told about it, and the police raid on her home, all of which continued to cause her emotional trauma. (Id. at 513, 518.) The clinic referred Trice for a formal psychiatric evaluation. (Id. at 521.)

In April 2006, Trice met with a psychiatrist, Dr. Ji Shin, reporting depression, insomnia, loss of appetite, low energy, and lack of interest. (Id. at 505.) She told Dr. Shin about her long history of depression-which had been effectively treated with Prozac-and that she was on medication for her back pain. (Id. at 505-06.) Dr. Shin diagnosed Trice with major depression,*fn1 recurrent, and identified stressors aggravating her depression as including her history of sexual abuse and current medical problems. (Id. at 509.) Dr. Shin noted Trice's Global Assessment of Function*fn2 ("GAF") score was then 55 but had been as high as 60 in the past year. (Id.) Dr. Shin prescribed Prozac for Trice's depression and recommended she participate in mental health treatment. (Id. at 504, 510.)

The next day, Trice met with Dr. William Giricz for a follow-up visit, presenting with poorly controlled diabetes, occasional swelling in the extremities, hypertension, and intermittent low back pain. (Id. at 538.) Trice requested a refill on Vicodin for her back pain, but Dr. Giricz declined to prescribe it. He instead refilled Trice's routine medications and prescribed 800 milligrams of Ibuprofen. (Id. at 538-39.) In June 2006, Dr. Shin completed a psychiatric report for Trice's application for disability benefits, diagnosing her with major depression, recurrent, for which Prozac had been prescribed but had resulted in no significant improvement. (Id. at 563-66.) Dr. Shin noted that Trice walked slowly with a cane; that she had "appropriate" clothing, hygiene, and manners; and that she presented with depression, paranoia, insomnia, and severe back pain. (Id. at 563.) Trice maintained that she was unable to work because she was afraid to be around people. (Id. at 563-64.) In the ensuing months, Trice followed up with her doctors regarding her physical ailments, complaining of constant, severe low back pain that radiated to her legs and weakness in her upper extremities. (Id. at 795, 803-06.)

On October 1, 2006, Trice sought emergency care, reporting a loss of appetite, feelings of worthlessness and helplessness, insomnia, and recent suicidal ideation. (Id. at 601-44.) She was admitted to the hospital for three days. Notes from her in-patient stay reveal the exacerbation of her depressive disorder, partly brought on by new psychosocial and financial stressors-including the loss of her apartment, the possibility of moving in with her estranged mother, and her continuing difficulty dealing with the sexual abuse she suffered as a child. (Id. at 671-84, 696-700.) Her treatment notes also reveal that she suffered from severe fatigue and weakness because of anemia, which was treated through an outpatient iron infusion. (Id. at 641-44.) After her discharge, her treating psychiatrist, Dr. Joseph Beck, recommended an intensive outpatient mental health program, which Trice successfully completed. (Id. at 717, 747.) Progress notes from that program show that Trice seemed "upbeat" and had demonstrated an investment in her therapy. (Id. at 736, 738, 747.) Dr. Shin, Dr. Giricz, and Dr. Beck continued to prescribe Prozac for Trice's depression. (Id. at 795, 800-01, 1003, 1014.) Although she denied any suicidal ideation, Trice reported that she remained depressed even with medication and that she had become homeless and was staying with a friend. (Id.)

In November and December 2006, Dr. Shin and Dr. Beck each completed a Mental Impairment Questionnaire ("MIQ"). (Id. at 850-57, 858-65.) Dr. Shin diagnosed Trice with major depressive disorder, recurrent, diabetes, hypertension, and back pain, noting a current GAF score of 50. (Id. at 850.) Dr. Shin identified the following symptoms as demonstrative of this diagnosis: poor memory and appetite; mood and sleep disturbance; emotional lability; pervasive loss of interests; feelings of guilt and worthlessness; difficulty concentrating; suicidal ideation; decreased energy; and intrusive recollections of a traumatic experience. (Id. at 851.) Dr. Shin noted that despite the daily prescribed dose of 40 milligrams of Prozac and individual therapy, Trice remained depressed, and her prognosis was "guarded." (Id. at 852.) Based on her impairments, Dr. Shin opined that Trice had poor to no useful ability to: maintain attention for two-hour segments; perform at a consistent pace without an unreasonable number and length of rest periods; accept instructions and respond appropriately to criticism from supervisors; understand and remember instructions; carry out detailed instructions; deal with the stress of semiskilled and skilled work; and to interact appropriately with the general public. (Id. at 853-55.) Dr. Shin noted extreme restrictions of daily living activities; marked difficulties in maintaining social function; frequent deficiencies of concentration, persistence, and pace; and repeated episodes of deterioration or decompensation. (Id. at 856.)

Dr. Beck diagnosed Trice with major depressive disorder, recurrent, noting a current GAF score of 50, and 55 as the highest score in the past year. (Id. at 858.) Dr. Beck noted many of the same symptoms as Dr. Shin and additional clinical findings of a restricted affect, dysphoria, and fearfulness. (Id. at 859.) He gave Trice a "fair" prognosis and opined that based on her impairments, she had poor to no ability to complete a workday and workweek without interruptions from psychologically-based symptoms, or to respond appropriately to changes in a routine work setting. (Id. at 860, 862.) In contrast to Dr. Shin's evaluation, Dr. Beck noted slight restriction of daily living activities and difficulties in maintaining social function, and one or two episodes of deterioration or decompensation. (Id. at 864.) Like Dr. Shin, Dr. Beck noted that Trice has frequent concentration difficulties. (Id.)

The next year, Trice continued to follow-up with her doctors. (Id. at 1002, 1012-13, 1043, 1061-63.) She complained of broken sleep. (Id. at 1002.) She also reported that she was taking an additional 20 milligrams of Prozac daily and that she intended to have a hysterectomy to resolve her anemia. (Id.) She had also recently received Section 8 housing. (Id.) Following her hysterectomy (id. at 896-99), Trice continued with her mental health treatment (id. at 901-05, 906-12, 1011). When she saw Dr. Shin in August 2007, the doctor reported that Trice's GAF score was 60 and that the severity of her depression and anxiety were mild, but also noted that she had reported suffering an "episode" when she encountered her stepfather, one of her sexual abusers. (Id. at 1010.) Trice also saw Dr. Beck that month who noted that she was "doing well," had a better affect, and was exhibiting less dysphoria. (Id. at 1001.) During the visit, Trice reported experiencing panic episodes after encountering a family member who had sexually abused her. (Id.) Dr. Beck recommended counseling and prescribed medications to help her sleep. (Id.) Trice had a follow-up with Dr. Shin in November, complaining of "feeling sluggish" and pain in her left leg. (Id. at 1009.) Dr. Shin noted a GAF score of 60 and described the severity of Trice's symptoms as mild. (Id.)

Trice continued her treatment throughout 2008. (Id. at 982-84, 1008, 1065-66.) In May, Trice complained of severe pain in her left calf. (Id. at 980-81.) A Doppler scan revealed no evidence of deep venous thrombosis, but an EMG-a test that measures the electrical activity of muscles-suggested evidence of left S1 (L5) chronic radiculopathy. (Id. at 985, 987.) In July, Trice underwent an assessment of her treatment plan. (Id. at 1032-42.) She reported depression, fatigue, anger, paranoia, and low back pain, and at that time, was taking a number of medications including Trazodone-which she reported was effective-Prozac, Seroquel, Lexapro, and Ambien. (Id. at 1032-33.) The case manager assessed Trice's GAF score as 65 and described her demeanor as "cooperative" and appearance as well-groomed. (Id. at 1033, 1035.) Continued treatment, including individual or group counseling, was recommended. (Id. at 1041-42.) Trice also saw Dr. Shin that month, reporting increased symptoms such as mood swings, insomnia, and depression. (Id. at 1007.) Dr. Shin assessed her GAF as 60 and prescribed Seroquel, Lexapro, and Ambien. (Id.)

In October 2008, Dr. Shin completed a second MIQ, diagnosing Trice with major depression, recurrent, diabetes, hypertension, and chronic back pain, and noting a "guarded" prognosis. (Id. at 997-1000.) Dr. Shin noted many of the same findings as in his November 2006 MIQ, but added poor to no ability in Trice's ability to: understand, remember, and carry out very short and simple instructions; maintain regular attendance; make simple work-related decisions; get along with co-workers; respond appropriately to changes in a routine work setting; and deal with normal work stress. (Id. at 999.) Dr. Shin further opined that Trice would experience extreme difficulties in maintaining social functioning; constant deficiencies of concentration, persistence, or pace; and continual episodes of deterioration or decompensation. (Id. at 1000.)

A few months later, in January 2009, Dr. Shin wrote a letter explaining that he had treated Trice since April 2006 and diagnosed her with major depression that required daily medication. (Id. at 1023.) Dr. Shin opined that Trice was unable to work because of her physical problems-diabetes, hypertension, and chronic back pain-and the symptoms of her depression-poor concentration, forgetfulness, sad and irritable moods, difficulty with understanding simple instructions, and getting along with supervisors and co-workers. (Id.)

B. Trice's Testimony

At the hearing before the ALJ, Trice began by testifying about her physical ailments. According to Trice, she is unable to work because of nerve damage in her left leg, caused by an injury she sustained in 2003 after the police attacked her in her home while executing a warrant on the wrong residence. (A.R. 107-11.) She stated that she suffers severe pain in her back and left leg, affecting her knee and her ankle. (Id. at 117-18.) Her left leg and knee "buckle[ ]" after standing for 15 to 20 minutes, and the pain is exacerbated by changes in the weather and when prolonged pressure is placed on her knee. (Id. at 107, 119, 148.) To alleviate the pain, Trice takes a variety of pain medications, including several 600 or 800 milligrams of Motrin daily, along with 500 or 750 milligrams of Vicodin every other night. (Id. at 120-21.) Trice testified that the Vicodin works best for her leg pain, but it makes her sleepy so she cannot take it during the day, and in any event, the doctors discontinued this medication. (Id.) Trice also suffers from back pain, sometimes so severe she cannot get out of bed. (Id. at 121-22). She takes Naproxen that "helps" to ease the pain, but which she must take continually because the pain relief wears off. (Id. at 123.) Despite these medications, Trice stated that her pain remains severe. (Id. at 119-23.) She underwent a course of prescribed physical therapy, but found it not to be beneficial. (Id. at 113-14.) Trice testified that she currently weighs between 200 and 215 pounds. (Id. at 124.) She also testified that she smokes a pack per week to stay calm. (Id. at 124-25.)

Trice testified that because of these ailments, she suffers certain restrictions. She cannot lift 50 pounds or a case of soda but can lift a gallon of milk. (Id. at 147-48.) She can only stand for 15 to 20 minutes before she experiences left knee pain and must sit down. (Id. at 148.) She uses a cane to walk even short distances, get out of bed, and steady herself while standing, and estimated that it would take her an hour to walk even a short block. (Id. at 148-49.) She is comfortable sitting if she can get up and stretch her legs from time to time. (Id. at 149-50.) And she experiences ...

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