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Edge v. Berryhill

United States District Court, N.D. Illinois, Western Division

February 21, 2017

Susan Edge, Plaintiff,
Nancy A. Berryhill,[1] Acting Commissioner of Social Security, Defendant.



         Plaintiff 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.

         I. BACKGROUND[2]

         In 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. 72.

         On 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.

         While 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.

         On 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[3] 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.

R. 378.

         In 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.

         On June 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.

         Plaintiff 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.

         Dr. 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 Crusader ...

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