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Brown v. Berryhill

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

March 14, 2017

CARLTON A. BROWN, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of the U.S. Social Security Administration, [1] Defendant.


          Sidney I. Schenkier, Magistrate Judge

         Plaintiff Carlton A. Brown ("plaintiff or "Mr. Brown") 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 Supplemental Security Income ("SSI") (doc. # 15: PL's Mot. for Sum. J.). The Commissioner has filed her own motion seeking affirmance of the decision denying benefits (doc. # 26: Def's Mot. for Sum. J.). For the following reasons, Mr. Brown's motion for remand is granted and the Commissioner's motion is denied.


         On October 15, 2012, Mr. Brown applied for SSI, claiming an onset date of October 1, 2010 (R. 130, 149). His application was denied initially on November 28, 2012 (R. 85), and upon reconsideration on May 24, 2013 (R. 109). On May 31, 2013, Mr. Brown filed a request for a hearing before an Administrative Law Judge ("ALJ") (R. 112).

         The hearing before an ALJ was held on June 10, 2014 (R. 33). At the hearing, Mr. Brown's attorney amended the alleged onset date to July 24, 2013 (R. 36).[3] Plaintiff, represented by counsel, a medical expert, and a vocational expert all testified at the hearing (R. 33). On June 30, 2014, the ALJ ruled that plaintiff was not disabled, and plaintiff appealed (R. 17, 28). The Appeals Counsel denied plaintiffs request for review on September 10, 2015, making the ALJ's determination the final opinion of the Commissioner (R. 1-4). See 20 C.F.R. § 404.981; Varga v. Colvin, 794 F.3d 809, 813 (7th Cir. 2015).

         Mr. Brown contends that the ALJ's determination that he is not disabled should be reversed because the ALJ erroneously: (1) dismissed the opinion of plaintiffs treating psychiatrist; (2) analyzed whether plaintiffs mental impairments meet or equal a listing level; (3) made a negative credibility finding; and (4) accepted the VE's testimony regarding other available work (doc. # 16: PL's Mem. In Supp. of Sum. J. at 4-5). The Court finds that the ALJ erred by inadequately supporting his decision to give little weight to the medical opinion of plaintiffs treating psychiatrist, Dr. Berman, as set forth in his Mental Residual Functional Capacity Statement ("Mental RFC") (R. 27). On that basis, we grant plaintiffs motion, without reaching the merits of plaintiffs other arguments. See Scott v. Astrue, 647 F.3d 734, 741 (7th Cir. 2011) (ALJ's improper consideration of treating physicians' opinions is "enough to require us to remand ... [and] [w]e therefore needn't decide whether the reasons the ALJ gave in support of her adverse credibility finding ... were so 'patently wrong' as to separately require remand").


         We now summarize the administrative record. As the Court bases its decision to remand on the ALJ's analysis of plaintiffs mental health issues, we will generally address only those parts of the record relevant to that issue. We set forth general background in Part A, followed by an abbreviated review of the medical record in Part B. In Part C, we discuss the hearing testimony and, in Part D, we address the ALJ's written opinion.


         Mr. Brown was born on October 16, 1966 (R. 145). At the time of the hearing, he was forty-seven years old, weighed 200 pounds, and was 5' 9" tall (R. 40).[4] He is a high school graduate, and is single (R. 41, 203). Plaintiff previously worked as a janitor and as an assembly line factory worker (R. 173). At the time of the hearing in June 2014, plaintiff was homeless and had been living at a shelter for nine months (R. 41). He previously lived with his mother, but he moved into the shelter when she died (R. 48).


         Mr. Brown originally filed for benefits alleging solely physical ailments, including bad knees (R. 149). Plaintiff received one consultative examination, an internal medicine consultation performed by Dante Pimentel, M.D., on March 28, 2013 (R. 202-208). After taking a history and performing an examination, Dr. Pimentel diagnosed Mr. Brown with internal derangement of his knees and right shoulder, gout, and a lipoma on the right scapula (R. 205). Dr. Pimentel opined that plaintiffs ability to lift, carry, and carry out work-related activities is mildly impaired due to his internal shoulder derangement (Id.).

         On July 17, 2013, Mr. Brown checked into the emergency department at Advocate Trinity Hospital ("Trinity ER"). Plaintiff presented with suicidal ideation and depression, and stated that he was hearing voices telling him to hurt himself (R. 341). Plaintiff reported that the symptoms had been occurring for the past twelve weeks but were getting worse (Id.), The Trinity ER transferred plaintiff to Chicago Lakeshore Hospital's psychiatric facility ("CLH Psychiatric") for a psychological evaluation (R. 341, 343). Mr. Brown received inpatient treatment at CLH Psychiatric under Dr. Paisner, and was discharged from the facility on July 22, 2013 (R. 509). At the time of discharge, plaintiff was prescribed aftercare treatment for depression; a discharge letter from CLH Psychiatric, dated June 22, 2013, stated that Mr. Brown "will be continuing treatment in an outpatient capacity" (R. 506, 509). A follow-up appointment was made to see Dr. Paisner on August 7, 2013 (R. 507); there is no evidence in the record indicating whether Mr. Brown attended that appointment.

         On October 18, 2013, Mr. Brown was again hospitalized for six days at CLH Psychiatric due to severe depression, acute psychoses and suicidal ideations, and was discharged on October 23, 2013 (R. 222, 235). At discharge, plaintiff was prescribed medication and aftercare treatment for depression and psychosis (R. 222). As part of his discharge, an appointment was made for the next morning for follow-up treatment at Community Counseling Centers of Chicago ("Community Counseling") (Id.). At his intake appointment with Community Counseling on October 24, Mr. Brown exhibited the following symptoms: anger, anxiety, confusion/difficulty understanding, crying, current auditory and visual hallucinations, high energy, panic attacks and paranoia (R. 231). Plaintiff was listed as taking Xanax (a sedative used to treat anxiety and panic attacks) and Prozac (Id.).[5] Mr. Brown was diagnosed with mood disorder, psychotic disorder, cocaine and opioid abuse in partial remission, antisocial personality disorder, seizure disorder and hypertension; he was assigned a Global Assessment of Functioning ("GAF") score of 50 (Id.). The intake assessment further noted that Mr. Brown has a "serious impairment" in social and occupational functioning, and "significant impairment in an important area of life functioning as a result of his mental disorders (R. 233). Plaintiff was scheduled for a psychiatric evaluation with a psychiatrist, Valentin Berman, M.D. (R. 241).

         Mr. Brown was first seen by Dr. Berman on November 26, 2013 (R. 245). At this appointment, plaintiffs affect was blunted, and Dr. Berman noted that plaintiff was experiencing auditory hallucinations and paranoid delusions (R. 250-251). Dr. Berman prescribed Mr. Brown Risperdal, an antipsychotic drug, 2 mg qhs[6] (R. 252). The record also contains physician's notes from Mr. Brown's subsequent appointments with Dr. Berman on December 17, 2013, and January 10, February 4, February 25, and March 18, 2014 (R. 253-298). At his December 17, 2013 appointment, Mr. Brown reported increased anxiety and an increase in hallucinations (R. 253). Dr. Berman opined that plaintiffs psychotic disorder problem was worsening and changed his prescription to Seroquel, a different type of antipsychotic drug, at a dosage of 200 mg qhs (R. 258-259). At Mr. Brown's later visits, Dr. Berman noted that plaintiff was doing better but still experienced hallucinations (R 261, 269, 278, 285). At the January 10, 2014 appointment, Dr. Berman increased the Seroquel dosage to 400 mg qhs and, at the February 4 appointment, Dr. Berman increased the Seroquel dosage to 600 mg qhs (R. 267, 275).

         Dr. Berman submitted a Mental RFC to the SSA, dated May 21, 2014, regarding plaintiffs functioning in the areas of social interaction, sustained understanding and memory, sustained concentration and memory, and adaption in a work setting (R. 518-521). In the Mental RFC, Dr. Berman diagnosed plaintiff with mood disorder, psychosis, and opioid and cocaine abuse in remission and assigned him assigned a GAF score of "65/75" (R. 518). In 20 different areas, Dr. Berman rated Mr. Brown's mental ability to "function independently, appropriately, effectively and on a sustained, consistent, useful and routine basis, without direct supervision or undue interruptions or distractions - 8 hours per day, 5 days per week - in a regular, competitive work setting for more than six consecutive months" (R. 518-520). For each area, Dr. Berman assessed the extent to which plaintiffs mental disorders affected his performance in an eight-hour workday (Id.). Dr. Berman found four areas in which plaintiffs mental disorders did not preclude his performance at all, including his ability to carry out "very short and simple instructions;" three areas in which plaintiffs mental disorders precluded his performance for only five percent of the workday, ...

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