United States District Court, N.D. Illinois, Eastern Division
MEMORANDUM OPINION AND ORDER 
I. Schenkier Magistrate Judge
Manuel Arriaga, seeks reversal and remand of the
Commissioner's decision denying his application for
Social Security benefits (doc. # 23: PL's Mot. for Summ,
J.). An administrative law judge ("ALJ") denied Mr,
Arriaga's application for benefits after a hearing, and
the Appeals Council denied his request for review of that
decision, making the ALJ's decision the final decision of
the Commissioner (R. 1). The Commissioner has filed a
cross-motion asking the Court to affirm its decision (doc. #
26: Def, 's Mot. for Summ. J.). For the reasons that
follow, we grant Mr. Arriaga's motion.
time of his alleged onset date of November 6, 2012, Mr.
Arriaga was 43 years old and a known diabetic with high
cholesterol (R. 326). On October 1, 2013, Mr. Arriaga was
evaluated by a psychiatrist, Laron Phillips, M.D., for the
Bureau of Disability Determination Services ("DDS")
(R. 359). Dr. Phillips noted Mr. Arriaga reported that he had
developed depression and anxiety due to health and family
problems, and his primary care physician had prescribed
Lexapro for depression and anxiety and Ambien for insomnia
(R. 359-60). During the examination, Mr. Arriaga was
cooperative and behaved appropriately, but he was tearful and
had a depressed mood and saddened affect (R. 360). Dr.
Phillips concluded that Mr. Arriaga had major depressive
disorder (moderate) and anxiety which resulted in
"moderate impairments in social, occupational and
interpersonal functioning" (Id.).
May through September 2014, Mr. Arriaga's primary care
physician, Dilip Patel, M.D., treated Mr, Arriaga for
diabetes, hypertension, and peripheral neuropathy (nerve
pain) related to his diabetes (R. 401-05). In addition, Dr,
Patel prescribed Trazadone (a sedative and antidepressant)
(R. 402-03). In September 2014, Mr. Arriaga began seeing a
podiatrist, Ronald Hugar, M.D., who treated him for bilateral
leg and foot pain and numbness with various medications,
including gabapentin, Lyrica (nerve pain medication), and
large doses of ibuprofen, as well as with physical therapy
(R. 387-97). On October 9, 2014, Deepti Shivakumar, M.D., Mr.
Arriaga's new primary care physician, restarted Mr.
Arriaga's prescription for Lexapro in response to his
complaints of increased depression and frequent crying
spells, and increased his dosage of gabapentin to address his
peripheral neuropathy (R. 407-09). On January 29, 2015, Dr.
Shivakumar referred Mr. Arriaga to a psychiatrist (R.
March 17, 2015, Mr. Arriaga began treatment with
psychiatrist, Evan Deranja, M, D., (R. 443). Dr. Deranja
wrote that Mr. Arriaga's reported symptoms of
"depressed mood, insomnia, anhedonia, feelings of guilt
and worthlessness, poor energy, poor concentration, decreased
[a]ppetite, and psychomotor retardation" met the
criteria for a "major depressive episode"
(Id.). Dr, Deranja noted that Mr, Arriaga was taking
Lexapro and Ambien daily, but with no benefit (R. 445). Dr.
Deranja found Mr. Arriaga had psychomotor retardation
(slowing down of thought and physical movements), depressed
mood with a constricted affect, and cognitive difficulties;
the remainder of the examination was normal (R. 445-46). Dr.
Deranja opined Mr. Arriaga had a single major depressive
episode which had been slowly worsening over the previous one
to two years, as well as a cognitive disorder (R. 446). Dr,
Deranja increased Mr. Arriaga's prescription for Lexapro
for depression and Trazodone for insomnia, and referred him
for cognitive testing (Id.). The following month, on
April 28, 2015, Mr. Arriaga told Dr. Deranja that, overall,
he felt "a little better, " but that he still
became anxious easily and continued to have trouble sleeping
(R. 448). Mr. Arriaga's mental status examination was
unchanged from the previous appointment (R. 448-49). Dr.
Deranja increased Mr. Arriaga's dosage of Trazadone and
maintained the same dosage of Lexapro (R. 449).
August 18, 2015, Mr. Arriaga reported to Dr. Deranja that the
use of Lexapro had not diminished his depressive symptoms,
and that he continued to have insomnia despite taking
Trazadone (R. 451). Mr, Arriaga's mental status exam was
unchanged (R. 452). Dr, Deranja increased Mr. Arriaga's
prescription for Trazadone, discontinued Lexapro, and
prescribed Effexor (nerve pain medication and antidepressant)
(R. 452-53). On September 28, 2015, Dr. Deranja's
progress notes stated that Mr, Arriaga "[c]ontinues to
meet criteria for major depressive episode" (R, 454). On
Effexor, Mr. Arriaga's motivation increased "a
little bit, " his drive to do things "somewhat
increased, " and his irritability decreased
"some;" however, he continued to have
"depressed mood, anhedonia, low concentration, low
energy, feelings of worthlessness, [and] insomnia, " and
he "continue[d] to struggle with cognitive
symptoms" (Id.). Dr. Deranja also performed a
cognitive assessment of Mr, Arriaga, which showed cognitive
impairment (R. 455). Dr. Deranja doubled Mr, Arriaga's
Effexor prescription and referred Mr. Arriaga for a
neuropsychological examination (R. 456), which was not
performed because it was not covered by Mr. Arriaga's
October 2015, Dr. Deranja filled out a Mental Impairment
Report for Mr. Arriaga (R. 427). Dr. Deranja diagnosed him
with major depressive disorder and cognitive disorder and
listed his symptoms as depressed mood, anhedonia, insomnia,
impaired concentration, daily headaches, easily overwhelmed,
decreased appetite, decreased energy, feelings of guilt and
worthlessness, and psychomotor retardation (Id.).
Dr. Deranga opined that these symptoms restricted Mr,
Arriaga's daily activities and capacity to function in
"multiple realms, " and they had lasted or could be
expected to last for more than 12 months (Id.). Dr.
Deranja also stated that based on Mr. Arriaga's reports,
his illness would affect his ability to sustain concentration
and attention and result in the failure to complete tasks (R.
428). He opined that Mr. Arriaga had moderate limitations in
activities of daily living ("ADLs") and maintaining
social functioning and marked limitations on maintaining
concentration, persistence or pace (R. 429). Dr. Deranja also
wrote that Mr. Arriaga had specific cognitive impairments,
including memory impairment, disturbance in mood, and
potential loss of intellectual ability (R. 432). Dr. Deranja
opined that depending on the circumstances, Mr. Arriaga's
cognitive impairments could cause moderate to marked
limitations in ADLs, maintaining social functioning and
maintaining concentration, persistence or pace
(Id.). He suspected that Mr. Arriaga's cognitive
deficits extended beyond that which he had seen thus far
November 2, 2015, at his hearing before the ALJ, Mr. Arriaga
testified that he had pain, numbness, and stiffness in his
legs and feet, swelling in both ankles, sharp pains in his
back, and numbness and stiffness in his hands which limited
his functional abilities (R. 48-52). In addition, Mr. Arriaga
testified that he had suffered from psychiatric impairments
for the past two years, including depression, insomnia,
headaches and anxiety attacks (R. 52, 57-58). His impairments
made him sad, and he cried daily (Id.). Mr. Arriaga
also had problems with concentration and memory; his wife had
to remind him to take his medication (R. 52-55).
presented the vocational expert ("VE") with several
hypothetical, including an individual who was limited to
sedentary work with frequent or constant bilateral handling,
and whose mental impairments limited him to "mild
activities of daily living, moderate social functioning,
moderate concentration, persistence, or pace, " simple
routine work, occasional interaction with coworkers and
supervisors, no interaction with the public, and work at a
variable rate with no fast-paced production line work (R.
70-71). The VE opined that there were unskilled, sedentary
employment options for this individual, but no work would be
available if the individual was limited to occasional
handling or had marked limitations in concentration,
persistence or pace (R. 71-73).
December 9, 2015, the ALJ issued a written decision
concluding that Mr. Arriaga was not disabled from November 6,
2012 through the date of the decision (R. 32). The ALJ
determined that Mr. Arriaga had the severe impairments of
diabetes mellitus, peripheral neuropathy, depression, cocaine
abuse, insomnia, and degenerative disc disease of the lumbar
spine, none of which - alone or in combination - met a listed
impairment (R, 18-19). The ALJ specified that Mr.
Arriaga's mental impairments did not satisfy the
"paragraph B" criteria because he experienced only
mild restrictions in ADLs, moderate difficulties in social
functioning, moderate difficulties in concentration,
persistence or pace, and no episodes of decompensation of
extended duration (R. 19-20). The ALJ found that Mr. Arriaga
had primarily physical limitations in ADLs, but he was able
to perform personal care, manage funds and shop, although he
had trouble remembering where items were in the store and his
wife had to write down his chores for him (R. 20). Further,
the ALJ noted that Mr. Arriaga was fully oriented and
demonstrated adequate memory at the consultative
psychological evaluation, although examinations with Dr,
Deranja showed limitations in delayed recall (Id.).
next determined Mr, Arriaga had a residual functional
capacity ("RFC") to perform sedentary work with
frequent bilateral handling, and he was limited to simple,
routine tasks, no interaction with the public, occasional
interaction with coworkers and supervisors, and no fast-paced
production line work (R. 21). In making this determination,
the ALJ reviewed Mr. Arriaga's testimony and the medical
reports in the record, including Dr. Patel's and Dr.
Shivakumar's decisions in 2014 to prescribe him Trazadone
and Lexapro (R. 25-27), Nevertheless, the ALJ wrote that
"[a]s to the claimant's mental ...