United States District Court, Western District of Missouri, Western Division
BLAKE L. LEISTER, Plaintiff,
CAROLYN W. COLVIN ACTING COMMISSIONER OF SOCIAL SECURITY, Defendant.
NANETTE K. LAUGHREY, United States District Judge
Plaintiff Blake Leister seeks review of the Administrative Law Judge’s decision denying his application for Social Security benefits. For the following reasons, the decision of the Administrative Law Judge (ALJ) is reversed, and the case is remanded for further consideration by the ALJ.
A. Leister’s Background
Leister was born on July 7, 1984, and has struggled with mental illness since he was in middle school. Leister’s school records from sixth grade indicate that he was poor at following instructions, paying attention to lectures, staying on task, and interacting appropriately with peers and adults. [Tr. 443]. At one point his teacher noted that he had to be redirected ten times in eighteen minutes. [Tr. 442]. In 1998 Leister spent time in juvenile detention. [Tr. 450]. He was then forced to repeat seventh grade due to truancy and his academic record. [Tr. 451]. Leister was expelled from three schools in elementary and middle school. [Tr. 416].
His ninth grade year, Leister was enrolled in public school for a number of very short periods of time, followed by significant periods of time in facilities for mental health and behavioral treatment. Leister was enrolled at Drexel High School for ten days in 1997, during which time he had four conduct incidents. [Tr. 414]. He subsequently withdrew and re-enrolled in an alternative program at Drexel in January 1998. Id. While enrolled in the alternative program, he was unpredictable and often violent and hostile. [Tr. 416-22]. Leister left the alternative program after a few months to enroll at Ozanam School for behavioral correction. During Leister’s time at Ozanam he earned improved grades but his problems with focus and truancy persisted. [Tr. 395-96]. Once removed from the structured environment of Ozanam and reenrolled at Drexel, Leister’s grades relapsed to F’s. [Tr. 382]. In 2000 he was briefly admitted to Royal Oaks Hospital Education Department, during which time his grades significantly improved. [Tr. 383].
In 1998, Leister was admitted to Crittendon behavioral health hospital for “‘taking a bunch of pills’ to get high.” [Tr. 819]. He was diagnosed with major depression, conduct disorder, mixed substance abuse, and rule out learning disabilities. [Tr. 820]. He was prescribed Prozac and Depakote. [Tr. 821]. In 1999, Leister was admitted to Lakeland Regional Hospital for fifteen days due to significant depression. [Tr. 947]. Prior to his admission, he self-mutilated his arm with staples and stated that the “angels of death” were coming to get him. Id. He stated that he had problems with depression, mood swings, aggression, low energy, isolative behaviors, anhedonia, hopelessness, and insomnia. Id. He was diagnosed at discharge with severe depression, polysubstance abuse, conduct disorder, and GAF score of 30. [Tr. 949]. Leister was discharged to the Lakeland Regional Hospital Residential Program.
Since he was thirteen, Leister has spent short periods of time employed in various capacities, including as a fast food worker, trash collector, and mowing lawns. Most of his periods of employment have lasted no more than a few weeks. Leister has not maintained a job long enough or made enough money to achieve substantial gainful activity. He has consistently been homeless, living with his mother or close friends. Leister has a few friends. He spends most of his time alone or with few other people. He generally spends his days watching TV, playing video games, or sleeping. Leister does not cook, but is able to feed himself with pre-prepared food.
Leister was incarcerated for periods of time from 2005 until 2010. While incarcerated, he saw doctors consistently for mental health treatment. In February 2005, Dr. Sutikant diagnosed Leister with bipolar II disorder, alcohol and polysubstance dependence, antisocial personality disorder, and GAF 40. [Tr. 497]. He was prescribed Loxapine and Trazodone. Id. In April 2005 his dosage of Loxapine was increased, Trazodone was discontinued, and Prozac was prescribed. [Tr. 500-02]. In October 2008 Leister saw Dr. Hogan because he was suffering from mood swings though medication compliant. [Tr. 515]. Dr. Hogan diagnosed bipolar I, polysubstance dependence, and GAF 55. Id. Leister experienced similar symptoms throughout the remainder of 2008 and much of 2009. In November 2009, Leister reported hearing whispers in his head. [Tr. 537]. One month later he had not received his medications and reported worsening depression, paranoia, mania, mood swings, and irritability. [Tr. 538]. In February 2010, Leister saw Dr. Imam and reported suffering from mood swings, paranoia, feeling suspicious, hearing and seeing things, and communicating through telekinesis. [Tr. 543]. Leister was diagnosed with bipolar disorder NOS with psychotic features, polysubstance dependence, antisocial personality disorder, and GAF 50. [Tr. 545]. Three weeks later, he reported that the voices were better. [Tr. 547].
In July 2010, following his release from prison, Leister saw Dr. Miciano and was diagnosed with schizophrenia and generalized anxiety diagnosis. [Tr. 559]. He was prescribed Valium. [Tr. 560]. His dosage was increased a month later. [Tr. 557]. In November 2010 he saw Dr. Miciano to report that he had been without medication for two days and was feeling shaky and jittery. [Tr. 588]. In January 2011 Dr. Miciano advised Leister to see a psychiatrist, but Leister was unable to afford to do so. [Tr. 586]. In July 2011 Leister returned because he had been out of his medication for five days and had been unable to find a psychiatrist. [Tr. 607]. Dr. Miciano noted that Leister had track marks on his right arm and Leister stated that he had been selling plasma for a few weeks. Id.
Around January 2012 Leister was again incarcerated and tested positive for Hepatitis C. [Tr. 743]. He was placed on suicide watch in April 2012 and requested a cell by himself. [Tr. 775]. In June, Leister reported that he had mild auditory hallucinations “all the time, ” which he described as whispers that he could not understand. [Tr. 987]. He was diagnosed with bipolar disorder and polysubstance abuse. Id. In July 2012 he was free of depressive symptoms and his irritability and paranoia had improved significantly with medication. [Tr. 991]. His auditory hallucinations persisted. Id.
The record contains two medical opinions regarding Leister’s psychological functioning. Dr. Rick Thomas, licensed psychologist, evaluated Leister in April 2007 and concluded that Leister’s paranoid tendencies, ADD, and depression prevented him from maintaining gainful employment. [Tr. 798]. In November 2010, Dr. Keith Allen, licensed psychologist, completed a Psychiatric Review Technique without examining or treating Leister. [Tr. 561]. Dr. Allen concluded that Leister suffered mild restriction of activities of daily living, mild difficulties in maintaining social functioning, moderate difficulties in maintaining concentration, persistence, or pace, and no repeated episodes of decompensation. [Tr. 569]. Leister was also examined by Dr. Holly Chatain, licensed psychologist, at the request of the Cass County Family Support Division in order to “aid his medical review team with the determination of his eligibility for medical assistance.” [Tr. 582]. Dr. Chatain recommended that Leister be referred to outpatient psychological treatment and continue medication monitoring by his prescribing physician. Id.
B. ALJ Decision
Upon review of the record, the ALJ concluded that Leister suffered from severe impairments including bipolar affective disorder, major depression, anxiety, and polysubstance abuse. [Tr. 11]. He then concluded that ...