United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER 
I. SCHEMKIER United States Magistrate Judge.
Shedward Johnson ("plaintiff or "Mr. Johnson")
has filed a motion for summary judgment seeking reversal or
remand of the final decision of the Commissioner of Social
Security ("Commissioner") denying his claim for
Disability Insurance Benefits ("DIB") and
Supplemental Security Income ("SSI") (doc. # 9:
Pl.'s Mot. for Sum. J.). The Commissioner has filed her
own motion seeking affirmance of the decision denying
benefits (doc. # 22: Def.'s Mot. for Sum. J.). For the
following reasons, Mr. Johnson's motion is denied and the
Commissioner's motion is granted.
Johnson applied for benefits on June 28, 2011, alleging he
became disabled on November 30, 2010 due to asthma,
arthritis, depression and alcohol abuse (R. 107, 189). His
date last insured ("DLI") was March 31, 2011 (R.
95). Mr. Johnson's application was denied initially on
September 13, 2011 (R. 98, 103), and upon reconsideration on
December 23, 2011 (R. 108. 112). Mr. Johnson, represented by
counsel, appeared and testified before Administrative Law
Judge C'ALJ") Daniel Dadabo on December 6, 2012 (R.
48). A vocational expert ("VE") also testified. The
ALJ issued a written decision on March 15, 2013, finding that
Mr. Johnson was not disabled from his onset date through the
date of the decision (R. 28-43). The Appeals Council then
denied Mr. Johnson's request for review, making the
ALJ's ruling the final decision of the Commissioner (R.
11-13). Varga v. Colvin, 794 F.3d 809, 813 (7th Cir.
begin with a summary of the administrative record. Part A
sets forth Mr, Johnson's medical history, Part B
discusses the testimony provided at the hearing before the
ALJ, and Part C sets forth the ALJ's written opinion.
Johnson was born on October 9, 1955. His medical record
begins in January 2010 with two visits to Weiss Memorial
Hospital because of intoxication (R. 247-49). Mr. Johnson also
spent nearly two weeks inpatient at the hospital between July
22 and August 4, 2010 because of atypical chest pain; he
additionally complained of abdominal pain during his hospital
stay (R. 255-64). During this admission, a doctor wrote in
Mr. Johnson's progress notes that he exhibited signs of
"questionable depression" and suggested Mr. Johnson
undergo a psychiatric evaluation (R. 266-67, 273, 276). There
is no evidence in the record that Mr. Johnson ever underwent
psychiatric testing pursuant to the recommendation. Mr.
Johnson was discharged with no prescription ongoing treatment
needs regarding his chest or abdominal pain.
in September 2009, Mr. Johnson also began attending
appointments with his primary care doctor, Madhuri Thota,
M.D., at the Heartland Health Center (R. 550). Between
September 21, 2009 and October 23, 2012, Mr, Johnson visited
Heartland Health Center a total of seventeen
times. Initially, Mr. Johnson visited Heartland
primarily for asthma medication refills and various
complaints of joint and abdominal pain. Dr. Thota
prescribed Singulair and Abuterol for Mr. Johnson's
asthma; she prescribed Ibuprofen, and later Flexeril, for the
pain (R. 558, 587). On March 1, 2011, during an appointment
regarding treatment for a rash, Dr. Thota noted that Mr.
Johnson was experiencing finger clubbing and tremors (R.
Johnson first complained to Dr, Thota about feeling depressed
at a follow up appointment for his asthma treatment on July
5, 2011(R. 598) - three months after his DLI, and one week
after his application for benefits, in which he listed
depression as one of the bases for his claim. Specifically, Mr.
Johnson stated he felt hopeless, with little interest or
pleasure in doing things on "[m]ore than half the clays,
" because of the deaths of his two siblings over the
previous two years; he also reported he was socially
isolating himself and had little appetite and poor sleep (R.
445). Dr. Thota consequently diagnosed Mr. Johnson with Major
Depressive Disorder and prescribed Remeron and Zoloft (R.
thereafter, Mr. Johnson was the subject of a number of
consultative examinations and other written evaluations. Mr.
Johnson's physical impairments were the subject of two
non-examining evaluations by DDS physicians.
August 30, 2011, after reviewing the four records from
Heartland dated between Mr. Johnson's alleged onset date
("AOD") and DLI, DDS physician Bharati Jhaveri,
M.D., determined that Mr. Johnson's application for
benefits would be denied for insufficient evidence prior to
the DLI (R. 502). Dr. Jhaveri noted that the medical record
revealed no respiratory problems, that at one appointment,
Mr. Johnson had clubbing and slight tremors of his fingers,
and at another appointment, complained of pain in his right
September 8, 2011, after reviewing Mr. Johnson's records
from Heartland, Vidia Madala, M.D. also denied Mr.
Johnson's claim for benefits (R. 508). With respect to
Mr. Johnson's asthma, Dr. Madala found it was not severe
because the medical records showed that Mr. Johnson did not
have current severe respiratory problems and that inhalers
helped his asthma. (Id.). With respect to Mr.
Johnson's other physical impairments, Dr. Madala found
that his gait and neurological exams were normal, and that he
had full range of motion and strength in his extremities and
no joint enlargement or tenderness, all of which demonstrated
an essentially normal physical exam (Id.). Together,
the two consultative opinions accounted for Mr. Johnson's
complaints of difficulty lifting, bending and stair climbing,
and noted that he continued to smoke and abuse alcohol, both
of which could affect his impairments and which made Mr.
Johnson's statements about his abilities only partially
respect to his mental health impairments, on August 10, 2011,
Mr. Johnson underwent a mental status examination with Norton
Knopf, Ph.D, a Commission-hired psychologist (R. 475-79).
During the examination, Mr. Johnson complained his depression
was "controlling [his] life, " and he reported poor
appetite, difficulty sleeping, fatigue, loss of interest, and
weight loss, along with arthritis in his hands, muscle aches
and twitching (R. 475-76). Dr. Knopf opined that Mr.
Johnson's thought processes were logical and coherent,
and estimated his intellectual ability to be in the
borderline range (R. 476). He also noted that Mr. Johnson
reported being able to bathe and dress himself, cook, do
laundry, shop and take public transportation, but that he
spent the majority of his days doing nothing except sitting
in his room (R. 477-78). Dr. Knopf diagnosed Mr. Johnson with
severe major depressive disorder, anxiety disorder, and
alcohol abuse (R. 479). Dr. Knopf did not express any
conclusions regarding Mr. Johnson's ability to work.
September 2, 2011, DDS psychologist David Gilliland, Psy.D,
completed two psychiatric review forms for Mr, Johnson (R.
488-500, 510-527). The first document states that it covers
the period from November 30, 2010 to March 31, 2011,
i.e., the AOD to the DLI (R. 510). In it, Dr.
Gilliland checked the box saying that there was insufficient
evidence to make a determination about whether Mr. Johnson
was disabled prior to his DLI; he did not indicate that an
RFC evaluation was needed for this time period
(Id.). At the end of the document, Dr. Gilliland
wrote a short note repeating his assessment that there was
insufficient evidence to make a determination and cited his
review of records of Mr. Johnson's treatment at Weiss
Memorial Hospital for intoxication (R. 510, 522); there is no
other information in this document.
second form completed by Dr. Gilliland states that it is an
assessment as of September 2, 2011; on the form, Dr.
Gilliland checked the box indicating a full assessment
required the completion of both a separate RFC determination
as well as referral to another medical specialty to assess
coexisting non-mental impairments (R. 488). In the
"notes" section of the document, Dr. Gilliland
indicates that he had reviewed treatment notes from Heartland
Health and Weiss Memorial Hospital, in addition to Dr. Knopfs
report (R. 500). Dr. Gilliland diagnosed Mr. Johnson with an
affective disorder (depression), an anxiety-related disorder,
and a substance-abuse disorder (R. 488, 491, 493. 496). Next,
Dr. Gilliland assessed Mr. Johnson's "Paragraph
B" functional limitations as resulting in mild
limitations in daily living, and moderate limitations in both
social functioning and maintaining concentration,
persistence, or pace, with no episodes of decompensation, and
no evidence establishing the presence of "Paragraph
C" criteria (R. 498-99).
Gilliland also completed an RFC form, also dated September 2,
2011, which assessed Mr. Johnson as being "not
significantly limited" in his ability to perform various
functions in the categories of "understanding and
memory, " "sustained concentration and persistence,
" "social interaction;' and
"adaptation." Dr. Gilliland opined that Mr. Johnson
had a mental RFC that left him "mentally capable of
performing simple tasks in a rouitine [sic] work
schedule with reasonable rest periods and limited interaction
with the general public" (R. 524-526).
on October 5, 2011, approximately six months after his DLI,
Mr. Johnson began receiving mental health services from The
Carl Rogers Institute of Client-Centered Therapy (R. 9-10,
544). The medical record contains no treatment notes, but a
letter from psychology extern Katie Poole indicates that Mr.
Johnson met with her for 25 sessions between October 2011 and
May 2012 (R. 544). Ms. Poole was overseen by Kevin Kukoleck,
Psy.D, who co-signed a May 1, 2012 letter Ms. Poole wrote in
support of Mr. Johnson's claim for benefits; there is no
evidence that Dr. Kukoleck ever saw Mr. Johnson himself
(Id.). In the letter, Ms. Poole wrote that Mr.
Johnson often "withdraws into his room for several days
at a time and is unable to eat or sleep" and that Mr.
Johnson suffers from leg pain, asthma, chronic dizziness, and
hearing voices (Id.). She also opined that Mr.
Johnson would not be able to find gainful employment because
of his chronic mental and physical health issues.
Dr. Thota's notes from appointments between September
2011 and April 2012 also document Mr. Johnson's
depression. Specifically, on September 6, 2011, at a
follow-up appointment for a medication refill, Mr. Johnson
reported feeling depressed (R. 603-04). At a November 1, 2011
follow-up appointment related to Mr. Johnson's hepatitis
C, Mr. Johnson complained of feeling depressed "[n]carly
every day, " even while taking his medication, but felt
like Zoloft was helping him; Dr. Thota responded by doubling
Mr. Johnson's Zoloft dosage (R. 617). Notes from
appointments for unrelated medical conditions on January 12,
2012, April 24, 2012, and June 4, 2012 relate that Mr.
Johnson reported feeling depressed when asked about his
mental state by staff at Heartland (R. 621, 628,
April 24, 2012, Dr. Thota provided the record's only
evaluation of Mr. Johnson's physical impairments other
than those provided by the agency consultants, a
physician's report and RFC assessment diagnosing Mr.
Johnson with major depression, persistent asthma, alcohol
abuse, Hepatitis C, and hyperlipidemia (R. 545). Dr. Thota
wrote that Mr. Johnson had a full ability to walk, bend,
stand, sit, push, pull, and speak (R. 546). There was no
joint pain, swelling, or tenderness, and no loss of joint
motion (Id.). In her RFC assessment, Dr. Thota
opined that Mr. Johnson had a 20 percent reduction in his
ability to travel, perform activities of daily living, stoop,
or turn, a 20-50 percent reduced capacity for finger
dexterity and fine manipulation in both hands, and was able
to lift no more than twenty pounds at a time, with frequent
lifting up to ten pounds during an eight-hour workday (R.
548). Other than listing depression as one of Mr.
Johnson's diagnoses, Dr. Thota's RFC did not contain
an assessment of Mr. Johnson's mental health.
August 7, 2012, Dr. Thota wrote in a progress note that Mr.
Johnson had not been taking anti-depressant medication for
the previous seven months, as he had mistakenly believed
Singulair was his anti-depressant medication instead of
Zoloft (R. 639). Dr. Thota restarted Mr. Johnson's Zoloft
prescription (Id.). On October 23, 2012, Dr. Thota
noted that Mr. Johnson reported feeling depressed
"[m]ore than half the days" (R. 654-56).
Johnson began receiving mental health treatment from
therapist Thomas Miller, M.A. in September 2012, eighteen
months after his DLI; he saw Mr. Miller for a total of eleven
sessions between September and December 2012 (R. 661-63). Mr.
Johnson missed several additional appointments with Mr.
Miller, claiming he was too depressed to leave his room; at
other appointments, Mr. Johnson reported feeling less
depressed and in a more positive mood (Id.). Mr.
Miller wrote a December 1, 2012 letter in support of Mr.
Johnson's application for benefits, stating that Mr.
Johnson had "periodic episodes of severe depression
which may last up to several days at a time, " during
which Mr, Johnson "isolates himself in his room and
cannot find the energy or motivation to get out of bed"
(R. 641). Mr. Miller noted this could be symptomatic of Major
Depressive Disorder, and wrote that Mr. Johnson "would
benefit from a formal psychological evaluation in order to
confirm these diagnoses" as well as a "referral to
a physician" regarding Mr. Johnson's chronic asthma
and arthritis (Id.).
Johnson met with therapist Keven Sprenkle, M.A., between
August 2013 and July 2014; Dr. Kukoleck oversaw this
treatment (R. 9-10). On July 10, 2014, Mr. Sprenkle wrote a
letter in support of Mr. Johnson's claim for benefits,
reiterating that Mr. Johnson's depression left him too
depressed to leave his apartment for days at a time. Mr.
Sprenkle noted that Mr. Johnson had little sleep or appetite,
which was indicative of Major Depressive Disorder (R. 9). Mr.
Sprenkle also wrote that Mr. Johnson's asthma and
arthritis limited his ability to sleep through the night, to
function around his depression, and to find and maintain
hearing before the ALJ, Mr. Johnson testified that he did not
graduate high school. From 2000-2004, Mr. Johnson worked at
Milestone Mental Health Care as a cleaner, where he performed
housekeeping duties for two years and then did maintenance
and shampooed carpets for two years (R. 37, 195). From 2006
to 2011, Mr, Johnson worked sporadically as a security guard
(Id). In 2010 and 2011, Mr. Johnson worked as a
security guard for Armageddon Services, taking public
transportation to work security at six or seven Chicago Bears
games; during the games he stood at an entrance watching
people enter and leave through the security gates (R. 36,
195). Mr. Johnson testified that he had a break to sit down
every hour during the three-to-four hour long games (R. 37).
In 2009, Mr. Johnson worked for four months at Cleanslate as
a security guard (R. 195). Mr. Johnson also worked for Andy
Frain as a temporary security guard in 2006 (R. 36).
Johnson currently lives in a supportive public housing
environment called Mercy Housing (R. 70-71). He testified
that his arthritis causes pain in his ankles and that it
radiates from his knees to his feet (R. 59). Mr. Johnson said
he also sometimes has pain in his hands, and that he takes
Ibuprofen for his various pains (R. 59-60). With respect to
his asthma, plaintiff testified that he would be unable to
shampoo carpets and could not lift ten-to-fifteen pounds (R.
66-67). He also testified that he gets winded walking up a
flight of stairs (R. 67). Regarding his mental state, Mr.
Johnson explained that he would not be able to work regularly
because his depression caused him to not care about anything
and made him unable to leave his room (R, 68-69).
Johnson's case manager at Mercy Housing is Darcell
Chapel, who testified that she had known Mr. Johnson for two
years, i.e., since approximately March or April 2011
(R. 76). She also testified that she meets with Mr. Johnson
once or twice per week at his apartment complex, helps make
sure he sees his therapists regularly, and encourages him to
leave his room to socialize with neighbors or visit his
family (R. 76-78). She gave her personal opinion that Mr.
Johnson was depressed because of the recent deaths of his
brother and sister (R. 77).
Jeffrey Lucas testified as well. He explained that Mr.
Johnson's past work as a cleaner, as performed, was at
the light and unskilled level (R. 83). The ALJ then
gave the VE a hypothetical that tracked Dr. Thota's
RFC. In giving the VE the hypothetical, the
ALJ noted that Dr. Thota did not really explain his reasons
for reducing Mr. Johnson's fine manipulation ability by
20 to 50 percent, but he would leave the limitation in the
hypothetical anyway (R. 85). The ALJ noted that Dr.
Thota's RFC did not contain any mental health or
environmental limitations, but he added them based on the
record (R. 85-86). Specifically, the ALJ's hypothetical
to the VE added the limitation of avoiding exposure to dust,
fumes, odor or temperature extremes, presumably due to Mr.
Johnson's asthma (Id.). Based on Dr.
Gilliland's RFC finding that Mr. Johnson had moderate
restrictions due to depression, the ALJ also included in the
hypothetical a need to avoid public contact and have no
frequent communication, as well as a limitation to
"unskilled work of a routine nature [that] stays the
same day to day" (Id.). The ALJ also asked the
VE to opine ...