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Rice v. Berryhill

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

May 2, 2018

NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.


          Sidney I. Sehenkier, United States Magistrate Judge

         Plaintiff, Sheila Denise Rice, seeks reversal and remand of the final decision of the Acting Commissioner of Social Security ("Commissioner") denying her application for Social Security benefits (doc. # 12: Pl.'s Mot. for Summ. J.). After a hearing, an administrative law judge ("ALJ") denied Ms. Rice's application for benefits, and the Appeals Council denied her 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 the ALJ's decision (doc, # 14: Def.'s Mot. for Summ. J.). For the reasons that follow, we grant Ms. Rice's motion.


         Ms. Rice has been depressed most of her life (see, e.g., R. 579, 601, 663). She was treated for depression as early as 1994, and has taken anti-depressant medications since 2011 (R. 476-77). From 1990 through July 2013, Ms, Rice worked full-time as an administrative assistant for Luster Products ("Luster") (R. 54), but testified that she stopped working in July 2013 because her depression worsened to the point she became overwhelmed and was unable to control her frequent bouts of crying (R. 57-58, 62-63; see also R. 601, 607).

         Ms. Rice's application for Social Security disability benefits alleged that she became disabled on July 31, 2013, due to breast cancer, anxiety, depression, thyroid disorder, high blood pressure, tendonitis and osteoporosis (R. 110-11). The day before, July 30, 2013, psychiatrist, Filogonio Moises Gaviria, M.D., conducted an IOP (intensive outpatient program) intake evaluation of Ms. Rice (R. 425). Dr. Gaviria noted Ms. Rice had been in the hospital for a week before her insurance approved her for IOP treatment (Id.), He observed that Ms. Rice "appear[ed] glum, listless, irritable, distracted" and "severely depressed, " and he diagnosed her with major depression and mixed personality disorder (R. 425-26). Dr. Gaviria prescribed Ms. Rice two antidepressants, Effexor and citalopram (R. 426). On February 28, 2014, Dr. Gaviria filled out a mental capacity assessment that diagnosed Ms. Rice with major depressive disorder, [2] and - via checked boxes - opined that she had moderate to marked limitations in understanding and memory, marked to extreme limitations in sustained adaptation, concentration and persistence, and moderate to extreme limitations in social interaction (R. 503-05).

         On December 11, 2013, Ms. Rice was evaluated by Ericka Swanson, Psy.D., for the Department of Disability Services ("DDS") (R. 475). Dr. Swanson observed Ms. Rice had poor eye contact and was tearful throughout the meeting (R. 475, 478). She diagnosed Ms. Rice with major depressive disorder, moderate without psychotic features and assigned her a Global Assessment Functioning ("GAF") score of 43 (R. 479).[3]

         On May 9, 2014, Ms. Rice visited her primary care physician, Mohammad Shamshuddin, M.D., for follow-up after she was seen at urgent care for agitation and an anxiety attack (R. 540). He observed Ms. Rice had a depressed affect, was anxious, and complained of palpitations and dizziness (R. 542-44). Dr. Shamshuddin prescribed an additional antidepressant, sertraline (Id.).

         On September 22, 2014, Ms. Rice was admitted to Ingalls Memorial Hospital because she had thoughts of killing herself and was assessed as a high risk of harm to herself or others (R. 665, 668-70). She was tearful and depressed, with poor judgment, insight and impulse control, and she was assessed a GAF score of 30 (R. 663, 668-70).[4] Ms. Rice reported that her mood had been worsening for four to five weeks, since she "weaned" herself off mental health medications after she lost her insurance and could no longer afford to see Dr. Gaviria or purchase her medications (R. 678, 663, 681). Intake notes described some of Ms. Rice's behavior as "manic[], " including buying two guitars and a keyboard, tearing wood off her front porch, moving a 400 pound couch outside her house, cutting off all her hair, and getting a facelift in January 2014 (R. 665-66). Her primary diagnosis was major depression, secondary to drug abuse (she tested positive for opioids and cannabis) (R, 677-79). While in the hospital, Ms. Rice was given citalopram and lamotrigine (an anticonvulsant used to treat bipolar disorder) (R. 679). At discharge on September 27, 2014, her GAF score was 50, she was feeling less hopeless and helpless and sleeping and eating better, but she still had a depressed mood and affect (R. 682).

         On October 1, 2014 Ms. Rice began outpatient mental health treatment at Sertoma Centte ("Seitoma") for severe major depressive disorder (R. 583-85). Her GAF during that month was (7th Cir. 2018). The DSM-V, issued in 2013, is the latest version of the Diagnostic and Statistical Manual of Mental Disorders; in it the American Psychiatric Association eliminated use of the GAF system. Id. at 263 n.l. consistently assessed at 40 (see, e.g., R. 607, 624). At her appointment on October 8, 2014, Ms. Rice reported that she felt out of control of her emotions; she described having crying spells, feelings of hopelessness and worthlessness, fatigue, difficulty sleeping, low motivation, difficulty concentrating, and depression so bad that she often had difficulty getting out of bed (R. 610-11). On October 13, 2014, Ms. Rice said her "stress has been especially overwhelming and difficult to manage in the last few years;" she "kept it pretty much under control at work until last year" when she could no longer "deal with confrontations" and "would get upset easily at work during meetings, would leave and cry" (R. 601).

         On October 24, 2014, J.B. Goebel, Ph.D., conducted a mental status evaluation of Ms. Rice for DDS, at which Ms. Rice was tearful and had poor eye contact (R, 579-80). Dr. Goebel diagnosed her with major depressive disorder and opined Ms. Rice was mildly impaired in understanding and memory, moderately impaired in her ability to sustain persistence and concentration, and not limited in her ability to interact and adapt socially (R, 581). On November 4, 2014, DDS consultant, Russell Taylor, Ph.D., opined based on the medical record that Ms. Rice had severe affective and anxiety disorders, resulting in moderate impairment in concentration, persistence, and pace; mild restriction in activities of daily living ("ADLs") and social functioning, and no repeated episodes of decompensation (R. 127-29, 132-33).

         Ms. Rice continued receiving therapy at Sertoma over the next few months. In November 2014, she was depressed and tearful, and her GAF score was 40 (R, 590, 713). In December, Ms. Rice reported struggling with feelings of sadness after attending church for the first time in months, but later that month, she began to feel less depressed and expressed the desire to work again so she could provide for herself (R. 717, 721, 725). On January 6, 2015, however, Ms. Rice reported feeling mistreated and left out by her family over the holidays (R. 731), and the next week, she was "almost immediately depressed and in tears during [the] meeting" (R. 739).

         On January 21, 2015, Ms. Rice walked into Ingalls hospital, presenting as stressed, tearful and anxious, and complaining of headaches; she was discharged with a prescription for Alprazolam (a sedative) (R.648, 650, 654). The next day, Ms. Rice returned to Sertoma. She was tearful and stressed, but she wanted to start working as a caregiver for her mother to earn money (R. 747, 751). On January 29, 2015, Ms. Rice reported feeling less depressed, and in February, despite remaining a bit depressed and stressed, Ms. Rice was working at her mother's house and applying for other jobs (R. 753-57). On February 26, 2015, however, she was stressed because she had taken on three caregiver jobs and had been fighting with her mother (R, 761).

         On March 5, 2015, Ms. Rice cried throughout her session at Sertoma because she was frustrated with her job search and felt she was getting "old and tired;" she became guarded and defensive and left her session abruptly (R. 763). On March 12, 2015, Ms. Rice was again tearful, and she became angry at her therapist and walked out of the session (R, 769). Ms. Rice did not return to Sertoma; between March 26 and June 8, 2015, she informed staff by phone that she was unable to meet because she had job interviews and appointments and was too busy working (R. 772-74, 795). Ms, Rice also said she felt better emotionally and no longer needed services (Id.).

         Ms. Rice did not receive mental health therapy over the next year-, but notes from her rheumatologist during that time listed citalopram and Effexor among her medications (R. 819-34). A report from her gynecologist on June 17, 2015, also stated that Ms. Rice was on multiple antidepressants and made a referral for her to re-establish psychiatric care (R. 873). In addition, on September 15, 2015, Ms. Rice was kept overnight at Ingalls hospital for observation after she complained of chest pain. Cardiac testing was unremarkable, but she appeared anxious, depressed and tearful, and a recommendation was made for her to change her dosages of citaiopram and Effexor (R. 897, 927, 940-41, 1063, 1068).

         On February 24, 2016, Ms. Rice had an appointment with a gynecologist and primary care doctor. She was anxious and tearful during her appointments, and both physicians recommended Ms, Rice seek psychotherapy (R. 703-04, 862-67). The primary care physician prescribed clonazepam, a sedative used ...

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