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Wendy S v. Saul

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

July 2, 2019

WENDY S., Plaintiff,
ANDREW M. SAUL, Commissioner of Social Security, [1] Defendant.



         Plaintiff, Wendy S., [3] moves for reversal and remand of the final decision of the Commissioner of Social Security ("Commissioner") denying her application for disability insurance benefits ("DIB"). (D.E. 14.) The Commissioner has filed a response brief, asking this Court to affirm the Commissioner's decision. (D.E. 22.) The matter is now fully briefed. For the following reasons, the Court grants Plaintiffs motion and remands the case.

         I. Procedural History

         Plaintiff applied for DIB on August 20, 2014, alleging she has been unable to work due to mental impairments since the alleged onset date of her disability on May 14, 2011, which was later amended to October 16, 2012. (R. 38.) Her date last insured ("DLI") was June 30, 2013.[4] (R. 17.) After her claim was denied initially and on reconsideration, Plaintiff received a hearing on January 17, 2017 before an Administrative Law Judge ("ALJ"). (R. 33.) On March 13, 2017, the ALJ issued a decision denying Plaintiffs claim. (R. 28.) The Appeals Council denied Plaintiffs request for review of the ALJ's decision, making the ALJ's ruling the final decision of the Commissioner. (R. 1.) See Lanigan v. Berryhill, 865 F.3d 558, 563 (7th Cir. 2017).

         II. Evidentiary Record

         Plaintiff was born on December 6, 1971. (R. 26.) She was first treated for major depressive disorder in 2005, three weeks after giving birth to her daughter, and she was prescribed an anti-depressant. (R. 464.) In 2007, after her grandfather died, Plaintiff was hospitalized after exhibiting psychotic symptoms, and her mood stabilized with medication. (R. 464.) Plaintiff lives in her parents' home with her daughter. She last worked in 2011, earning $3, 625.51 working part time at Target as a stock clerk. (R. 275.) In 2009 and 2010, Plaintiff earned between $7, 000.00 and $8, 000.00 doing the same work. (Id.)

         A. Medical Record

         In 2010, Plaintiff received treatment from psychiatrist Alicia Martin, M.D., for bipolar disorder type II.[5] (R. 458.) Dr. Martin prescribed her Zoloft and Seroquel, and throughout 2010, Plaintiffs mood was stable with medication.[6] (R. 455-60.) On February 7, 2011, Plaintiff presented to Dr. Martin feeling depressed and irritable over her daughter's oppositional and disobedient behavior; Dr. Martin increased Plaintiffs dose of Seroquel to 200 mg and recommended that she receive counseling (R. 461-62.) In March 2011, Plaintiff was still having problems with depression and mood swings, but she was feeling better with the increased dose of Seroquel. (R. 464.) Dr. Martin noted that Plaintiff was unable to work full-time due to her continued problems with episodic mood instability. (R. 465.) In April and May 2011, Plaintiff did not report mood swings or depression, but she was still worried about her daughter's behavior. (R. 467-68.)

         On July 29, 2011, Plaintiff reported to Dr. Martin that she had quit her job at Target because she felt anxious and nauseated every time she went to work, and her supervisor indicated to her that she was slow and unable to keep up with her job. (R. 469.) Plaintiff reported that she felt much better since leaving her job. (Id.) In July, August and October 2011, Dr. Martin's mental examinations of Plaintiff were normal. (R. 470-71.)

         On December 20, 2011, Plaintiff reported to Dr. Martin that she became nervous and nauseated when she tried to apply for jobs. (R. 472.) She was also having periods of sadness and depression, so Dr. Martin increased her daily dose of Zoloft to 150 mg. (Id.) Dr. Martin noted that she had encouraged Plaintiff "to combine treatment with counseling for quite some time, but she gave reasons or excuses for not being able to see the therapist." (Id.) In January 2012, Plaintiff "insist[ed] that she is unable to work due to problems with anxiety at times so severe that she feels nauseated and vomits when she has these symptoms." (R. 474.)

         In April 2012, Plaintiff reported to Dr. Martin that she was having mood swings, irritability and mild racing thoughts at night. (R. 476.) Dr. Martin increased her dose of Seroquel to 250 mg. (Id.). The next month, although Plaintiff still got "very upset" sometimes, Dr. Martin moved the dose back to 200 mg because Plaintiff did not like the effects of a higher dose. (R. 480.)

         In May 2012, Plaintiff began receiving therapy from Rob Luck, LCSW, LPHA, MSW. (R. 478.) During their May and June sessions, Plaintiff reported that she preferred to stay inside her house. (R. 478, 481.) She was having problems with anger toward her family members, and she was tearful and sad due to the recent passing of family members. (R. 483.) Dr. Martin's mental examinations of Plaintiff remained normal; Dr. Martin noted that Plaintiff sometimes felt sad, especially on the anniversary of a loved one's death, but she did not experience symptoms of major depression or psychosis. (R. 485-86, 551.)

         In November 2012, Mr. Luck noted that Plaintiff was more depressed, tearful and focused on death. (R. 488.) Plaintiff told Dr. Martin that there were significant stressors in her life, including ailing family members and concerns about child support, but Plaintiff continued to do well with her medications, and Dr. Martin did not observe any signs of depression or hypomania. (R. 490-92.) On April 25, 2013, Dr. Martin completed a psychiatric reassessment of Plaintiff. (R.493.) Dr. Martin opined that "[e]ven though the patient's symptoms are ameliorated with the current doses of Seroquel and Zoloft, her symptoms limit her social involvement and the symptoms of her mental illness affects her ability to function at her normal level, causing her some relationship problems at work and poor performance." (R. 494.)

         In June 2013, Plaintiffs insurance stopped covering the extended release Seroquel she had been taking, so Dr. Martin prescribed the same dose (200 mg) of Seroquel immediate release. (R. 495.) With the new medication, Plaintiff experienced a recurrence of "very disturbing" auditory hallucinations, where she heard someone calling her name. (R. 497.) Dr. Martin increased the dose of Seroquel to 300 mg and noted that although Plaintiff could complete her activities of daily living ("ADLs"), she was "unable to work, as the symptoms of her mental illness affect social involvement and also ability to function." (Id.)

         By September 2013, Plaintiff was no longer experiencing auditory hallucinations, and her mood was stable. (R. 501.) She began meeting with a new therapist, David Hughes, LCSW, LPHA, MSW. (R. 499.) In September and October 2013, Plaintiff told Mr. Hughes that she was stressed and frustrated with trying to raise her daughter in her parents' household, and she had frequent conflicts with her parents about raising her daughter. (R. 503-05.) In November 2013, Plaintiff reported to Dr. Martin that she was having problems with irritability during the day. (R. 507.) In addition to Seroquel 300 mg at bedtime, Dr. Martin added a small dose of Seroquel, 50 mg, to be taken during the day. (Id.)

         On February 5, 2014, Dr. Martin increased Plaintiffs dose of Zoloft to 200 mg to help alleviate her increased depressive symptoms, including sadness, low energy and lack of motivation. (R. 516.) The following month, Plaintiff told Mr. Hughes that she was experiencing periods of increased anxiety that led her to withdraw into her room. (R. 519.) On March 3, 2014, Mr. Hughes wrote a letter opining that medication reduces but does not eliminate Plaintiffs symptoms of isolation, angry outbursts, anxiety and agoraphobia, which sometimes caused her to become physically sick in crowds of people. (R. 441.)

         On April 9, 2014, Plaintiffs father attended her meeting with Dr. Martin. (R. 520.) Plaintiff and her father accused Dr. Martin of reporting that Plaintiff was able to work, and thus causing Plaintiff to be denied Social Security benefits. (Id.) Dr. Martin stated that to the contrary, she had opined Plaintiff was unable to work because her symptoms of mental illness affect her level of functioning. (Id.) Dr. Martin noted that Plaintiffs mood was unstable; although she was initially calm, she easily became very angry and stormed out of the office when Dr. Martin asked her not to yell. (Id.) Later that month, Plaintiff told Mr. Hughes that she was experiencing increased anxiety as well as manic episodes during which she experienced increased energy and cleaned her house non-stop. (R. 522.)

         In May 2014, Plaintiffs father submitted a "function report" stating that Plaintiff had a "very hard time interacting with people" and preferred not to interact outside the home. (R. 302, 307.) In addition, he wrote that Plaintiff got lost easily, had a very short temper and did not deal well with pressure. (Id.) He explained that he and his wife help care for Plaintiffs daughter; Plaintiff takes her daughter to school but then goes back to bed. (R. 303, 307.) Also that month, a non-examining state agency psychologist, Donald Henson, Ph.D., reviewed the record and opined that Plaintiff had severe affective disorders which caused moderate limitations in her ADLs, social functioning, and concentration, persistence or pace, including in her ability to carry out detailed instructions, perform activities within a schedule, maintain regular attendance, complete a normal workday and workweek without interruption from psychologically based symptoms, perform at a consistent pace without an unreasonable number and length of rest periods and interact appropriately with the general public. (R. 122-25.)

         In June 2014, Plaintiff began seeing psychiatrist Syed Anwar, M.D. He initially continued her on the same medications - 200 mg of Zoloft and 50 mg plus 300 mg of Seroquel - but in August 2014, Plaintiff reported increased daytime anxiety, and Dr. Anwar increased her morning dose of Seroquel to 100 mg. (R. 587-88.) In October 2014, Dr. Anwar noted that Plaintiff appeared anxious and had a lot of mood instability. (R. 589.) Plaintiff reported that the medication makes her very sleepy, and she recently got in trouble with the police. (Id.) Dr. Anwar had Plaintiff go back to Seroquel 50 mg in morning and added a prescription for Lamictal.[7] (R. 590.) In November ...

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