United States District Court, N.D. Illinois, Eastern Division
STEPHANIE L. MAILHOT, Plaintiff,
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER
I. Schenkier, Magistrate Judge 
Stephanie Mailhot ("Claimant" or "Ms.
Mailhot") has filed a motion for summary judgment
seeking reversal or remand of the final decision of the
Commissioner of Social Security ("Commissioner")
denying her claims for Supplemental Security Income benefits
("SSI") benefits (doc. # 15: Pl.'s
Mot. for Summ. J.). The Commissioner has filed a motion
seeking affirmation of the decision denying benefits (doc. #
20: Def.'s Mot. for Summ. J.), and Claimant has filed a
reply (doc. # 22). For the following reasons, we
remand the case.
6, 2010, Ms. Mailhot filed an application for SSI, alleging a
disability beginning on September 1, 2009, with a date last
insured of December 31, 2014 (R. 337-38, 423). After her
claim was initially denied on January 13, 2011 and on
reconsideration on March 18, 2011 (R. 107, 108), Ms. Mailhot
participated in a hearing before an Administrative Law Judge
("ALJ") (R. 71-106), who ruled that Ms. Mailhot was
not disabled (R. 109-124). The Appeals Council then remanded
the case to the ALJ for consideration of additional evidence
related to Claimant's back pain and treatment (R.
125-29). The ALJ conducted a second hearing, at which Ms.
Mailhot and a vocational expert ("VE") testified
(R. 41-70). On April 23, 2015, the ALJ ruled that Ms. Mailhot
was not disabled, and Ms. Mailhot filed a request for review
(R. 7-9, 19-40). On September 4, 2016, the Appeals Council
upheld the ALJ's determination, making the ALJ's
determination the final opinion of the Commissioner (R. 1-3).
See 20 C.F.R. § 404.981; Varga v.
Colvin, 794 F.3d 809, 813 (7th Cir. 2015).
remand because the ALJ failed to adequately address the
evidence concerning Ms. Mailhot's mental impairment, or
to adequately support her determination that this impairment
was non-severe. Because we remand on this ground, we do not
reach the other challenges the Claimant raises to the
ALJ's decision, and we focus our discussion of the record
and the ALJ's decision on the mental health issue.
Ms. Mailhot did not list any mental health impairments in her
initial application for benefits, she reported a history of
depression at medical appointments related to her back pain
in September 2009 and 2010 (R. 524, 528, 531). Records from
those appointments show that Ms. Mailhot was taking an
anti-depressant, Amitriptyline, prescribed by a doctor at the
Yorkville clinic that Ms. Mailhot visited for treatment for
her back pain (R. 533).
2012, Ms. Mailhot underwent a private psychiatric evaluation
prior to having a spinal cord stimulator implanted (R.
822-24). The examiner diagnosed Ms. Mailhot with generalized
anxiety disorder and noted that her "Beck Depression
Inventory" score placed her in the mild mood disturbance
category (R. 822-23). At this examination, Ms. Mailhot
reported that she had noticed problems with her short term
memory and that her attention decreased when her pain
worsened (R. 911). It is not apparent from the record if Ms.
Mailhot was still taking an antidepressant at the time of
this examination; the examiner's recommendations
including a suggestion that Claimant would benefit from
psychopfarmacological treatment of her anxiety (R. 913). Ms.
Mailhot began taking Alproazolan (Xanax) for anxiety in April
2014 and was still taking it at the time of her 2015 hearing
(R, 58, 488). At that hearing, Ms. Mailhot testified that she
had experienced problems with anxiety for the previous two
years and had been taking Xanax for about one year (R. 58).
opinion, the ALJ analyzed Ms. Mailhot's claims using the
traditional five-step sequential evaluation process for
determining disability. 20 C.F.R. §§
404.1520(a)(4); 416.920(a). The process requires the ALJ to
consider: (1) whether the Claimant has engaged in any
"substantial gainful activity" since the alleged
disability onset date; (2) if her impairment or combination
of impairments is severe; (3) whether her impairments meet or
medically equal any impairment listed in Appendix 1 of the
regulations; (4) whether her residual functional capacity
("RFC") prevents her from performing past relevant
work; and (5) if her RFC prevents him from performing any
other work existing in significant numbers in the national
economy. 20 C.F.R. §§ 404.1520(a)(4), (b)-(f);
relevant for this decision, the ALJ found at Step Two that
Ms. Mailhof s anxiety was not a severe impairment. The
entirety of the ALJ"s evaluation of Ms. Mailhot's
mental health was the comment that, "other than taking
Xanax ... the record does not show either regular treatment
or counseling, or regular complaints of anxiety. . .
Therefore, this impairment is 'non-severe', with no
more than mild deficits in the Part B criteria of the
Listings" (R. 25). In establishing Ms. Mailhot's
RFC, the ALJ found that Ms. Mailhot could perform sedentary
work as long as she did not lift more than 15 pounds, and
that she could sit for six hours in an eight hour workday
with seated intervals of up to two hours. The ALJ also found
that Ms. Mailhot could walk and/or stand for a total of two
hours in an eight hour workday and was limited to occasional
stooping and crouching and frequent crawling, climbing,
stairs, kneeling, balancing, handling, and fingering (R. 26).
The ALJ did not include any limitations in Ms. Mailhot's
RFC related to her mental health condition.
uphold the ALJ's determination if it is supported by
substantial evidence, meaning "such relevant evidence as
a reasonable mind might accept as adequate to support a
conclusion." Pepper v. Colvin, 712 F.3d 351,
361-62 (7th Cir. 2013) (quoting McKinzey v. Astrue,
641 F.3d 884, 889 (7th Cir. 2011) (internal citations
omitted). We do not reweigh evidence or substitute our own
judgment for that of the ALJ. Shideler v. Astrue,
688 F.3d 306, 310 (7th Cir. 2012). In rendering a decision,
the ALJ "must build a logical bridge from the evidence
to his conclusion, but he need not provide a complete written
evaluation of every piece of testimony and evidence."
Schmidt v. Barnhart, 395 F.3d 737, 744 (7th Cir.
claimant alleges mental health issues, the ALJ must use the
so-called "special technique" to evaluate whether
the claimant has a medically determinable mental health
impairment, and whether that impairment causes functional
limitations. The first part of the special technique involves
having the ALJ look at the claimant's "symptoms,
signs, and laboratory findings" to determine whether a
mental health impairment exists. 20 C.F.R. § 404.1520a;
Craft v. Astrue, 539 F.3d 668, 674-75 (7th
Cir.2008). If the ALJ determines that the claimant has a
medically determinable mental health impairment, the ALJ must
next undertake a "Part B" analysis, which rates the
degree of the functional limitation resulting from the
claimant's impairment with respect to four broad
functional areas: activities of daily living; social
functioning; concentration, persistence, or pace; and
episodes of decompensation, 20 C.F.R. § 404.1520a(c)(3).
For the first three categories, the ALJ must rate the
claimant's limitations as none, mild, moderate, marked,
or extreme. Id. § 404.1520a(c)(4). If there are
no episodes of decompensation and the rating in each of the
first three categories is none or mild, the impairment
generally is not considered severe and the claimant thus is
not disabled. Id. § 404.1520a(d)(1).
initial matter, it is undisputed that the ALJ did not use the
special technique to evaluate Ms. Mailhot's mental health
condition or its effects on her ability to function. Instead,
the ALJ merely acknowledged Ms. Mailhot's mental health
complaints but then dismissed them as non-severe because the
record did not show regular treatment or counseling (other
than Ms. Mailhot's use of Xanax). While the ALJ used the
term "Part B ...