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Hampton v. Berryhill

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

February 21, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security,[1] Defendant.



         Plaintiff Tyron Hampton has moved for reversal and/or remand of the Commissioner's decision denying his applications for a closed period of Social Security benefits (doc. # 17: Pl.'s Mot. for Summ. J.). The Commissioner has filed a cross-motion asking the Court to affirm its decision (doc. # 24: Def.'s Mot. for Summ. J.). We find that the Administrative Law Judge's ("ALJ") determination that Mr. Hampton's substance abuse disorder during the closed period was a contributing factor material to the determination of disability was supported by substantial evidence. However, due to an evidentiary gap regarding the percentage of time Mr. Hampton would have been off-task during a workday, we grant Mr. Hampton's motion to remand and deny the Commissioner's motion to affirm.


         Mr. Hampton applied for disability benefits on July 25, 2007, alleging disability beginning on April 1, 2003 (R. 164-69, 170-71). After a hearing on August 13, 2010, the ALJ denied benefits in a written decision, and the Appeals Council denied review (R. 1-5, 19-34). Mr. Hampton filed a complaint in federal district court on October 11, 2011, and on May 23, 2012, the Commissioner agreed to a reversal and remand of the case (R. 647-48). In May 2013, the ALJ held a second hearing (R. 517-638), and on June 7, 2013, Mr. Hampton amended his disability onset date to July 1, 2008, and sought a closed period of disability benefits from that date through December 31, 2011 (R. 524, 1198).[3] On July 12, 2013, the ALJ issued an opinion again denying plaintiffs claim for benefits (R. 658-81).

         Mr. Hampton sought review of this decision, and on October 24, 2014, the Appeals Council remanded the case to a new ALJ (R. 684-86). That ALJ held a hearing on March 25, 2015 (R. 618-38), and on August 10, 2015, issued a written decision denying Mr. Hampton's claim. The ALJ found Mr. Hampton was under a disability during the closed time period at issue, but that a "substance abuse use disorder [wa]s a contributing factor material to the determination of disability" such that Mr, Hampton was not considered disabled under the Social Security Act (the "Act") (R. 491). The Appeals Council denied plaintiffs request for review, making the ALJ's decision the final decision of the Commissioner (R. 1-6). See Cullinan v. Berryhill, 878 F.3d 598, 603 (7th Cir. 2017).


         Mr. Hampton was 40 years old when he applied for benefits in July 2007 (R. 51). He has been treated at the Hines VA Hospital ("Hines") for polysubstance abuse, depression, and physical health issues since 2000 (R. 263-64). Mr. Hampton was sober for "a long period" before resuming drug use in 2007; this coincided with increased depression, anxiety, hallucinations and paranoia (doc. # 18: Pl.'s Mem. at 4). He was admitted to a substance abuse treatment program at Hines in June 2007, and he stayed off drugs for several months thereafter (R. 265-93, 366-400, 416-28). Mr. Hampton took Seroquel (quetiapine, an anti-psychotic) and Zoloft (sertraline, an anti-depressant), which made him feel less anxious (R. 335-37). However, during a state agency mental health examination on October 30, 2007, Mr. Hampton reported that he continued to experience depression, paranoia, suicidal ideation and auditory hallucinations (Id.).

         Unfortunately, by June 2008, Mr. Hampton had resumed using heroin and cocaine, and he had stopped taking anti-depressant medication (R. 1188-89). Mr, Hampton re-entered the Hines substance abuse treatment program, and his anti-depressant medications were reinstated (Id.). On June 26, 2008, Luz Cuaresma, M.D., the attending psychiatrist, noted that the medication seemed to help alleviate Mr. Hampton's depression (R. 1191-92).

         Mr. Hampton did not seek substance abuse or psychiatric treatment again at Hines until May 23, 2010. On that date, he was admitted to Hines for detoxification from cocaine and heroin abuse and treatment for depression, hallucinations, paranoia and suicidal ideation (R. 1126-27, 1183-84). Mr. Hampton reported that after his father died in the summer of 2008, he stopped going to school and started using cocaine once a week and heroin daily to self-medicate, rather than seek prescriptions for anti-depressant or anti-psychotic medication (R. 1122, 1131). He stated that the frequency and magnitude of his psychotic symptoms were heightened while using drugs, but that he also experienced them when sober (R. 1123, 1140). On May 28, 2010, Mr. Hampton was discharged with prescriptions for Seroquel and sertraline, and with plans to attend a substance abuse treatment program (R. 1124, 1136). In June 2010, however, Mr. Hampton was a "consistent no-show" for that program (R. 1134).

         On July 15, 2010, Mr. Hampton met with Dr. Cuaresma (R. 1111). Mr. Hampton admitted to smoking heroin and cocaine multiple times a week since being discharged from Hines in May 2010, and reported dysthymic (depressed) mood, loss of interest and appetite, social withdrawal and intermittent auditory hallucinations (Id.). Mr. Hampton stated that he had those symptoms even when he abstained from drugs (Id.). Dr. Cuaresma diagnosed him with polysubstance dependence and major depression with psychotic features, increased his prescription for sertraline and continued his prescription for Seroquel (R. 1111-12), On July 28, 2010, Mr. Hampton reported difficulty sleeping, weight loss and continued heroin use (R. 1107-08). Dr. Cuaresma decreased his sertraline dose, continued Seroquel, and started him on trazadone (anti-depressant and sedative) (Id.).

         At a follow-up appointment with Dr, Cuaresma on August 9, 2010, Mr. Hampton stated that he had improved appetite, less depression, better sleep and some weight gain (R. 1106). Mr. Hampton had no more delusions or hallucinations, but he had some "thought broadcasting" (the idea that his thoughts were being broadcast from his head to the external world), for which Dr. Cuaresma increased his Seroquel dose (Id.). Dr. Cuaresma also started Mr. Hampton on mirtazapine (anti-depressant) (Id.). That day, Dr. Cuaresma filled out a medical source statement, which indicated that since July 2007, Mr. Hampton had been mildly to moderately limited in understanding and memory, sustained concentration and persistence, social interaction, and adaptation abilities, and markedly limited in his ability to maintain attention and concentration for extended periods (R. 474-76, 479). Dr. Cuaresma opined that Mr. Hampton had a "substantial loss" in the ability to respond appropriately to supervision and co-workers and in the ability to deal with routine changes in the work setting (R. 477-78).[4] The directions for the medical source statement instructed the physician not to include any limitations that he or she believed were the result of substance addiction (R. 473). Three weeks later, on August 30, 2010, Mr. Hampton admitted to still using heroin (R. 1104).

         On September 9, 2010, Mr. Hampton underwent open heart surgery (R. 933). The following month, Mr. Hampton returned to Hines multiple times with complaints of chest pain, and at those visits, he admitted he continued to use heroin and cocaine (R. 916-19, 923). On November 8, 2010, Mr, Hampton appeared non-depressed to Dr. Cuaresma and reported being sober from drugs and alcohol (R. 909), but on December 20, 2010, Mr. Hampton admitted to using heroin and cocaine regularly, and he appeared mildly depressed (R. 902).

         On January 7, 2011, Mr. Hampton was admitted to a residential inpatient substance abuse treatment program at Hines (R. 982, 988). His primary mental health care provider was Dheeraj Raina, M.D., who started him on a drug detoxification program with methadone (R. 980-81). Upon intake, Mr. Hampton reported snorting heroin daily and last using cocaine two weeks prior, but the intake sheet noted that "does not seem accurate given positive cocaine on urine drug screen today" (R. 988). On January 10, 2011, Mr. Hampton denied any depressive or psychotic symptoms since admission (Id.). On January 15, 2011, Mr, Hampton left the facility on a therapeutic day pass (R. 955). Upon his return, staff suspected that he had taken illicit drugs (Id.). He denied it, but his urine screening was positive for opiates (R. 939-41). On January 21, 2011, Mr. Hampton was discharged from the residential inpatient program (R. 941-42).

         Mr. Hampton continued to use heroin until January 28, 2011, when he entered a 28-day detoxification program at the Salvation Army (R. 1099, 1102). In February 2011, he reported to outpatient group counseling at Hines and to Dr. Cuaresma that he was feeling good (R. 1096). Dr. Cuaresma refilled his medications and noted that his mood and affect were normal and he had no hallucinations or delusions (R. 1097).

         Mr, Hampton asserts that "[o]ver the course of the year [2011], his functionality and his depressive symptoms slowly improved as he received treatment, individual and group counseling and therapy and medication" (Pl.'s Br. at 7). Mr. Hampton became a resident of the Salvation Army and returned to outpatient substance abuse recovery treatment (R. 1090, 1094). He stayed sober and complied with his medications (R. 1092-93). His sleep, appetite and mood improved, and he had no delusions, hallucinations or suicidal thoughts (R. 1084-85). Mr. Hampton still had occasional thought broadcasting, but he "learned to live with it" (Id.). During treatment, Mr. Hampton no longer appeared depressed (R. 1035-36).

         Mr. Hampton's success with sobriety dramatically -- and positively - affected his daily life activities. Later in 2011, Mr. Hampton moved into his own apartment, participated in vocational rehabilitation and began attending classes at Roosevelt University (see, e.g., R. 1025, 1030-33, 1036-39). In October 2011, Mr. Hampton sought discharge from the substance abuse treatment program because he remained abstinent from substances and was doing well (R. 1028-29). At a follow-up appointment on November 16, 2011, Dr. Cuaresma observed that he had no depressive symptoms (R. 1025).

         However, Mr. Hampton had persistent problems with concentration and memory (R. 1084-85, 1064). In July 2011, Mr. Hampton underwent a neuropsychology evaluation, which showed that he had a mild cognitive impairment within the domains of attention, working memory and higher order executive functioning, secondary to his history of polysubstance dependence and psychiatric issues (R. 1045).

         On December 20, 2011, Dr. Timothy Buckley became Mr. Hampton's mental health provider at Hines (R. 1021). Dr. Buckley began tapering Mr. Hampton off his psychotropic medications (first mirtazapine, then Seroquel) because he remained sober, his mood was stable with no current symptoms of depression, and he was functioning well (R. 1021). Dr. Buckley noted that Mr. Hampton's possible history of bipolar mood disorder and mania was "not clearly differentiated" from his history of drug use, and he opined that Mr. Hampton's polysubstance abuse and major depressive disorder were in remission (R. 1021-23). Mr. Hampton retained his prescription for trazadone to help with insomnia (R. 1013-14). By April 2012, Mr. Hampton continued to function well; he was still attending college classes, and he was working for the Illinois Department of Corrections ("IDOC") (R. 1009).


         On May 21, 2013, during the second hearing in this case, Mr. Hampton testified that he had recently graduated from Roosevelt University with a degree in hospitality and tourism management (R. 526-27). He attended Alcoholics Anonymous ("AA") meetings, took medication for depression and trazadone to help him sleep, and saw his psychologist periodically (R. 527, 545, 554). Mr. Hampton testified that he still heard "auditorial signals" from radio and television, but he managed them (R. 537-38). In 2012, he had a problem with an IDOC supervisor and was let go from his job (R. 540).

         The ALJ asked the vocational expert ("VE") to assume an individual who could perform medium work with the following non-exertional limitations: "unable to remember ... and carry out detailed and complex job tasks ... not [] suited for work that requires intense focus and concentration for extended periods and . . . only be able to have casual interaction with the general public, as well as superficial or casual contact with coworkers and occasionally be able to set goals and make plans independently of others" (R. 561). The VE testified that individual would not be able to perform Mr. Hampton's prior work, but a substantial number of other jobs would be available, provided the individual would be on task 90 percent of the time and miss no more than one day of work per month (R. 562-64).

         On March 25, 2015, at his third ALJ hearing, Mr, Hampton testified that he had not used illegal drugs since January 2011 (R. 625). He continued to take anti-depressant and antipsychotic medication and trazadone; his depression and auditory broadcasting had not stopped, but he could "manage it better" (R. 625, 628, 631). Mr. Hampton testified that if he had not been depressed between 2007 and 2011, he "would like to think" that he would have been able to hold a job, "but [he] really do[es]n't know" (R. 625-26). He "c[ould]n't say" whether his depression had gotten better since he stopped using cocaine and opiates, "[b]ut overall since 2011, .. . since being off the dependency of drugs, yes, [his] life [wa]s better" (R. 627-28). The ALJ asked the VE "if an individual was to be off task 20 percent of the work ...

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