United States District Court, N.D. Illinois, Western Division
MEMORANDUM OPINION AND ORDER
D. JOHNSTON, UNITED STATES MAGISTRATE JUDGE
Susan Edge brings this action under 42 U.S.C. § 405(g),
seeking a remand of the decision denying her social security
disability benefits. For the reasons set forth below, the
decision is remanded.
January and March 2014, Plaintiff filed applications for
disability insurance benefits and supplemental security
income. Plaintiff alleged a disability beginning on January
1, 2012, because of bipolar disorder, brain aneurysms,
dissection of the aorta, chronic back pain and depression. R.
October 8, 2013, Plaintiff went to Crusader Clinic
complaining of depression and anxiety and was referred to
Kimberly Mattei, APN. R. 327-28. Plaintiff reported taking
multiple antidepressants, but felt “little
relief.” R. 324. As a result, Nurse Mattei referred
Plaintiff to psychiatrist Dr. Zaffar Rizvi on October 10,
2013, for an evaluation of her depression and anxiety. R.
305. Dr. Rizvi diagnosed Plaintiff with bipolar disorder. R.
305. From October 2013 until January 2014, Dr. Rizvi
prescribed increasing doses of Trileptal, Latuda and
Trazadone to relieve Plaintiff's depression, agitation
and anger. R. 301-05. At the January 2014 visit, Dr. Rizvi
did not schedule another appointment, but instead instructed
Plaintiff to follow-up with Nurse Mattei. R. 302.
treating with Dr. Rizvi, Plaintiff continued mental health
counseling with Nurse Mattei. On October 16, 2013, Plaintiff
reported symptoms of depression since she was young, but has
felt much more depressed since she was terminated from her
job in 2011. R. 322. On December 17, 2013, Nurse Mattei
reported that Plaintiff had a better mood. R. 318. On January
29, 2014, Plaintiff reported feeling very depressed, was not
eating, sleeping or doing self-care and admitted that she ran
out of Trileptal the week before. R. 316. Nurse Mattei
believed the lapse in medication could explain
Plaintiff's abrupt change in mood. R. 316. On February 7,
2014, Plaintiff reported “good days and bad days,
” noting continued strained relationships with her
family, but she was still able to socialize with friends
sometimes. R. 314. On February 18, 2014, Plaintiff reported
that she was moving to Texas to work on her marriage. Nurse
Mattei stated her concern about Plaintiff's
“continued symptoms of depression. [Plaintiff] has been
on all the antidepressants.” R. 312. Nurse Mattei
provided a 90-day prescription to give Plaintiff time to
reestablish care in Texas. R. 312.
April 24, 2014, Plaintiff was evaluated by consultative
psychologist Dr. Michael Morris. R. 372. Plaintiff reported
that her primary concern was her depressive symptoms. R. 373.
Plaintiff reported that her psychiatric symptoms first began
to interfere with her work following her aneurism in 2001,
but that her depression worsened after she lost her job in
2011. R. 373. Plaintiff moved to Texas in early March 2014
and was unable to find a low-cost provider so some of her
prescriptions ran out. R. 374. Plaintiff reported worsening
depression since running out of her medications. R. 374.
Plaintiff reported improvement in her hygiene since moving to
Texas because her sister and brother-in-law supported and
encouraged her. R. 374. While in Texas, Plaintiff was not
required to do laundry, chores or yardwork, but helped her
sister cook and clean up after meals and accompanied others
on shopping trips. R. 374. Plaintiff reported being able to
use a phone directory and a computer. R. 375. Plaintiff
sometimes spoke with a friend or two on the telephone, but
did not otherwise participate in any activities or social
gatherings. R. 375. Dr. Morris opined that Plaintiff had mild
limitations in attention and concentration, difficulty with
short-term memory capacity, and mild problems focusing on
tasks during the evaluation. R. 377. Plaintiff exhibited a
depressed mood during the interview. R. 377. Dr. Morris made
the following conclusion:
[Dr. Morris] estimates a guarded prognosis for Ms.
Edge's bipolar disorder (specifically depressive)
symptoms to improve and remit. [Dr. Morris] expects the
course of treatment will be long-term and complicated. The
claimant reported, and medical records appear to confirm, a
history of poor response to treatment.
Based on the current evidence obtained during this
examination, Ms. Edge is demonstrating significant
limitations in her ability to reason and to make
occupational, personal, and social adjustments.
September 2014, Plaintiff returned to Illinois after her
relationship with husband failed. R. 399. On September 19,
2014, Plaintiff saw Nurse Mattei for mental health treatment.
R. 399. Plaintiff reported continued symptoms of depression,
thoughts of harming herself and her dog, panic attacks,
headaches, and anxiety. R. 399. However, Plaintiff was able
to maintain some social relationships and was going to church
and bible study. R. 399. Plaintiff reported that the
medications she took in Texas did not help. R. 399. Nurse
Mattei stated that Plaintiff's “overall response to
treatment has been poor.” R. 399. Nurse Mattei ruled
out bipolar disorder, but assessed Plaintiff as having
personality disorder, generalized anxiety disorder and major
depressive disorder. R. 400. On November 17, 2014, Nurse
Mattei reported that Plaintiff missed her last appointment
because she spent a week in Florida with her sister. R. 426.
Plaintiff reported feeling better in Florida, but became
overwhelmed and depressed when she returned to her house. R.
426. Nurse Mattei noted “ongoing deep
depression.” R. 426.
30, 2015, a hearing was held before an administrative law
judge (“ALJ”). R. 38-71. Plaintiff was then 53
years old. Plaintiff testified that she lived by herself in
public housing. R. 44-45. Plaintiff felt overwhelmed by her
daily activities, including cooking, bathing and
housekeeping. R. 55. She testified that she had a hard time
cooking meals for herself and would usually eat prepared,
frozen meals and sometimes would not eat at all. R. 45-46,
54. She would also go days without taking a shower. R. 54.
She explained that leaving her apartment was very
overwhelming and taking her dog for a short walk was the only
thing that motivated her to leave the apartment. R. 45, 49.
Plaintiff tried to keep her apartment “picked up,
” but did not do much cleaning. R. 46. Plaintiff drove,
but not often. R. 46. Plaintiff was married, but was
separated from her husband. R. 47-48. She had two daughters
in their late twenties, but had a “strained
relationship” with both. R. 48. Plaintiff was a school
bus driver for 11 years, but lost her job in 2011 because she
did not follow the proper drop-off procedure and also due to
poor attendance. R. 41-42, 66, 254.
sought mental health treatment at Crusader Clinic. R. 51. She
was taking 3 psychiatric medications, including Abilify,
Wellbutrin and Zoloft. R. 51. Plaintiff had been on some
combination of psychiatric medications for the past 20 years.
R. 52. Plaintiff did not feel like she responded well to the
medications because there were so many ups and downs. R. 52.
Plaintiff testified that she suffered from anxiety,
self-esteem issues and anti-social behavior resulting from
her depression. R. 53-54. Plaintiff confirmed having thoughts
about hurting herself and her dog. R. 55.
Mark Oberlander also testified as an expert in psychology. He
questioned Plaintiff about her lack of treatment at the
Crusader Clinic during the year before her September 2014
doctor visit. R. 58. Plaintiff explained that she and her
husband moved to Texas for 6 months to live with
Plaintiff's sister and work on their marriage. R. 59, 62.
Dr. Oberlander also noted that Plaintiff's records from