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Judy D. v. Saul

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

August 13, 2019

JUDY D. Plaintiff,
ANDREW SAUL, Commissioner of Social Security, [1] Defendant.



         Plaintiff, Judy D., moves for summary judgment seeking reversal and remand of the final decision of defendant, the Commissioner of Social Security ("Commissioner"), denying her application for disability insurance benefits ("DIB") (doc. # 15; doc. # 16: Pl.'s Summ. J. Mem.). The Commissioner has filed a response asking us to affirm his decision (doc. # 23: Def.'s Summ. J. Resp.), and Ms. D. has filed a reply (doc. # 24: Pl's Reply). For the following reasons, we grant Ms. D.'s motion and remand the case for further proceedings.


         On February 20, 2014, Ms. D. applied for DIB, alleging disability due to neuropathy and multiple sclerosis ("MS") and a disability onset date of October 31, 2006 (R. 84, 90, 104).[3] Her date last insured ("DLI") was December 31, 2011 (R. 18, 90), so the relevant time period for evaluating her DIB claim is October 31, 2006 through December 31, 2011 (the "Relevant Period"). See McHenry v. Berryhill, 911 F.3d 866, 869 (7th Cir. 2018) (explaining that a claimant must establish that she became disabled before the DLI to qualify for DIB).

         The Social Security Administration ("SSA") denied Ms. D.'s application at the initial and reconsideration stages of review, after which Ms. D. requested a hearing before an Administrative Law Judge ("ALJ") (R. 90-91, 104-07, 112-17). On August 24, 2016, the ALJ held a hearing at which Ms. D. and a vocational expert ("VE") testified (R. 35-83). On October 26, 2016, the ALJ issued a decision denying Ms. D.'s DIB claim (R. 15-34). The Appeals Council denied Ms. D.'s request for review, making the ALJ's decision the final word of the Commissioner (R. 1-5). See Varga v. Colvin, 794 F.3d 809, 813 (7th Cir. 2015); 20 C.F.R. § 404.981.


         Ms. D. was born on January 19, 1961 (R. 172). She worked as a patient care technician in a hospital from 1995 until 2006 (R. 209). She reported that she stopped working because of her conditions on October 31, 2006 (R. 208).[4] Although the ALJ ultimately found that Ms. D. had both mental and physical impairments that were medically determinable, we focus on evidence that touches upon Ms. D.'s mental impairments because the ALJ's treatment of those impairments forms the basis of our decision in this case.

         In January 2009, Ms. D. visited Steven Chandler, D.O., complaining of bilateral hip and leg pain that had begun four years earlier (R. 300). At the time, Ms. D. exhibited no psychological symptoms; specifically, "[n]o anxiety, no depression, and no sleep disturbances" (R. 301).

         On December 14, 2009, Ms. D. presented to Advocate Christ Medical Center after she attempted suicide by sitting in a bathtub filled with water while holding a plugged-in hair dryer (R. 282-83). Intake notes from Mohammad Razzaque, M.D., note that Ms. D. had a history of bipolar depression and that she had been drinking heavily on the weekends because she suspected that her husband was cheating on her (R. 282).[5] Ms. D. was admitted to the psychiatric floor and was "to continue psychotropic medication"; the notes, however, do not identify the specific psychotropic medication at issue (R. 282-83).[6] Although the ALJ indicated that this hospitalization lasted less than one week (R. 22), we have not seen anything in the record reflecting when Ms. D. was discharged.

         Less than two months later, on February 5, 2010, paramedics took Ms. D. to the emergency room at Little Company of Mary Hospital for alcohol intoxication (R. 655-63). She reported that she was drinking so heavily because her husband was having an affair (R. 657). Ms. D. was discharged the same night (R. 662).

         On March 15, 2010, Ms. D. voluntarily admitted herself to the hospital after another suicide attempt; while intoxicated, she took 40 aspirin and 10 Pepcid and then sat in her car in a closed garage with the car running (R. 667). Ms. D. stated that she had been depressed for several weeks regarding her husband's affair (Id.). The medical notes state that Ms. D. had "no formal psychiatric treatment" and "[n]o previous psychiatric hospitalization" and that, although she was previously admitted to the hospital for alcohol intoxication, "she minimize[d] any suicide attempts around that time of admission" (R. 667, 669). Ms. D. was diagnosed with major depressive disorder, status post-suicide attempt, and was treated with individual psychotherapy and medication (Id.). She was discharged from the hospital on March 21, 2010 (R. 667).

         Ms. D. saw Vijay Bajaj, M.D., from 2006 to November 2010 (R. 212, 288-90, 735). Sometime during this time period (the depression screening form at issue is undated), Dr. Bajaj screened Ms. D. for depression (R. 297). A diagnosis of major depression requires the presence of at least five out of the nine criteria listed on the form (Id.). Dr. Bajaj assessed Ms. D. as having three out of nine criteria: significant weight loss or weight gain, insomnia/hypersomnia, and psychomotor agitation/retardation (Id.).


         In denying Ms. D.'s DIB claim, the ALJ followed the familiar five-step process for assessing disability. See 20 C.F.R. § 404.1520(a). At Step One, the ALJ determined that Ms. D. had not engaged in substantial gainful activity during the Relevant Period (R. 20). At Step Two, the ALJ determined that Ms. D. suffered from the following severe impairments during the Relevant Period: chronic pain, degenerative disc disease, and a history of alcohol abuse (Id.). At this step, the ALJ also concluded that although Ms. D. reported an MS diagnosis, she had not established that it was a medically determinable impairment (R. 21). The ALJ further found that Ms. D. suffered from a medically determinable affective disorder, [7] but that this impairment was not severe (Id.). In making this finding, the ALJ evaluated Ms. D.'s degree of limitation in four broad functional areas (R. 21-22). The ALJ determined that Ms. D. experienced (1) no limitation in activities of daily living; (2) no limitation in social functioning; (3) ...

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