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Greiner v. Colvin

United States District Court, E.D. Missouri, Eastern Division

January 19, 2017

CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.



         This action is before the court for judicial review of the final decision of the defendant Commissioner of Social Security denying the application of plaintiff Ronald Edward Greiner Jr. for disability insurance benefits under Title II of the Social Security Act, 42 U.S.C. § 401- 434. The parties have consented to the exercise of plenary authority by the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, the final decision of the Commissioner is reversed and the action is remanded for further proceedings.

         I. BACKGROUND

         Plaintiff was born in 1964 and was 49 years old at the time of his hearing. (Tr. 34, 73.) He filed his application on December 2916, 2011, alleging an August 30, 2011 onset date, and alleging disability due to depression, bipolar disorder, anxiety, sleep disorder, and an eating disorder. (Tr. 154-60, 185.) His application was denied initially, and he requested a hearing before an administrative law judge (ALJ). (Tr. 73, 81-82.)

         On June 17, 2014, following a hearing, the ALJ issued a decision, concluding that plaintiff was not disabled under the Act. (Tr. 13-27.) The Appeals Council denied his request for review. (Tr. 1-6.) Thus, the decision of the ALJ stands as the final decision of the Commissioner.


         On April 3, 2012, plaintiff saw Timothy Leonberger, Ph.D., a clinical neuropsychologist, for a psychological evaluation at the state agency's request. (Tr. 271-74.) Plaintiff reported he lived with his wife, three children, and 78-year old father. He helped his father with medication, made his appointments at the VA, and drove him to appointments. At home, plaintiff did laundry, drove, cleaned house, went grocery shopping, and prepared simple meals. He and his wife occasionally went to movies or out to dinner, and he sometimes got together with friends to play music. (Tr. 273.)

         Plaintiff's speech was normal, but droning, and his thinking was logical and sequential. His attention and concentration were fair. He rarely made eye contact. Plaintiff reported past suicidal ideation, but denied current suicidal ideation or intent. Dr. Leonberger concluded that plaintiff was “apathetic, unmotivated, and chronically depressed” and believed he had a chronic low level depression with subdued affect. (Tr. 273.) He noted that although plaintiff claimed to have panic attacks, he described them as lasting all day long. He also noted that plaintiff complained about chronic pain, but seemed to be able to do quite a bit, including helping his father and performing chores around the house. Dr. Leonberger diagnosed plaintiff with recurrent major depressive disorder, anxiety disorder, and personality disorder. (Tr. 273-74.)

         Dr. Leonberger believed that plaintiff had mild to moderate limitations in activities of daily living; moderate to marked limitations in social functioning; moderate to marked limitations in concentration, persistence, and pace; and moderate to marked deterioration or decompensation in work or work-like settings. He assigned a GAF score of 50, indicating “serious” symptoms. He opined that plaintiff was able to handle funds in his own best interest. (Tr. 274.)

         On April 12, 2016, Robert Cottone, Ph.D., a psychologist, completed a Mental RFC Assessment. He opined that plaintiff had marked limitations in the ability to understand and remember detailed instructions and to carry out detailed instructions. He had moderate limitations in his ability to maintain attention and concentration for extended periods; to work in coordination with or proximity to others without being distracted by them; to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods; to interact appropriately with the general public; to accept instructions and respond appropriately to criticism from supervisors; to get along with coworkers or peers without distracting them or exhibiting behavioral extremes; and to set realistic goals or to make plans independently of others. Dr. Cottone opined that plaintiff was not significantly limited in all other areas. (Tr. 275-87.)

         Plaintiff was treated by Eduardo Garcia, M.D., a psychiatrist, every three months from February 3, 2011 to December 5, 2013. (Tr. 527-51.) On March 9, 2011, Dr. Garcia noted plaintiff was having trouble at work and was depressed. (Tr. 549.) On October 19, 2011, Dr. Garcia noted he was not improving on a psychotherapeutic level. Plaintiff had given up his job and applied for disability. (Tr. 547.) On January 17, 2012, his condition was unchanged; his mood was depressed and he reported that he had a lot on his plate. He stated he was very busy applying for disability and being a house dad. (Tr. 545-46.) Plaintiff thought that Cymbalta, an antidepressant, caused increased shaking. Dr. Garcia noted his depressed mood and worked with him on coping skills. (Tr. 545.) On April 19, 2012, he was “not real good.” (Tr. 541.) His mood was depressed and he had moderate restlessness. He reported that he had taken Abilify, an anti-psychotic, for seven days before stopping it. Dr. Garcia reported that he was focused on disability. He had decreased concentration and activity and expressed a desire to try Abilify again. (Tr. 543-44.)

         On July 3, 2012, plaintiff told Dr. Garcia that he had been going through a lot. (Tr. 541.) He did not like leaving the house. He was trying to get disability and spending much of his savings. He had slight decrease in concentration. He had not taken his Abilify. Dr. Garcia noted he was depressed and nervous. (Tr. 541-42.) On November 1, 2012, plaintiff was slightly depressed and felt stressed out by most things. (Tr. 539-40.)

         On February 14, 2013, Dr. Garcia assigned him a GAF score of 55, indicating “moderate” symptoms. (Tr. 538.) He had an anxious affect, with fair judgment, fair insight, decreased concentration, and constricted affect. (Tr. 537.) In March 2013 Dr. Garcia noted his condition was worsening. (Tr. 536.)

         Plaintiff was hospitalized at St. Anthony's Medical Center June 14-21, 2013, after he ingested medication in a possible suicide attempt. A toxicology report revealed THC (marijuana) and benzodiazepines. Plaintiff was anxious, agitated, and depressed. The cause of his agitation was unclear; plaintiff apparently reported that he became upset because his son attacked him and because his band of thirty years was breaking up. His discharge diagnoses were recurrent severe major depression and arthritis. Plaintiff stated that Cymbalta had been very effective. He was significantly improved at discharge. (Tr. 450, 462, 491-94).

         By July 2013, Dr. Garcia thought his condition was improving, but he still exhibited depressed mood. He had fair insight and fair judgment. Dr. Garcia noted chronic depression. (Tr. 533-34.) Later that month Dr. Garcia changed his medication to stabilize his mood. (Tr. 532.)

         On July 22, 2013, Dr. Garcia completed a Depression and Anxiety Questionnaire. Dr. Garcia diagnosed a depressive syndrome and checked boxes indicating plaintiff's depressive symptoms, including loss of interest in activities, sleep disturbance, decreased energy, feelings of guilt or worthlessness, and difficulty concentrating or thinking. He also indicated that plaintiff had no restrictions of activities of daily living; mild difficulties in maintaining social function; marked deficiencies of concentration, persistence or pace resulting in failure to complete tasks in a timely manner; and marked difficulties in episodes of deterioration in work or work-like settings. (Tr. 430-32.)

         In September 2013, he was stable and improving and he reported doing pretty well that month. Dr. Garcia changed his medication due to cost. (Tr. 530.) By his next appointment in December 2013 he was “not real well” with depressed mood and anxious affect. (Tr. 527-29.)

         Plaintiff was hospitalized at St. Anthony's Medical Center February 15-17, 2014, for a drug overdose. He had ingested 39 tablets of trazodone and several beers after his wife had left him, taking their two daughters. He had been recently depressed but denied any suicide attempt. He stated that that he was okay and wanted to go home; he did not want to leave his elderly father at home alone. He reported that his regular psychiatrist was Dr. Garcia. His insight and judgment were impaired. Ahmad Ardekani, M.D., diagnosed recurrent major depression, panic, anxiety, and chronic pain. He was discharged and transferred to Hyland Behavioral Health for continued inpatient treatment. (Tr. 552-84.)

         In February 3, 2014 correspondence, Kevin Shuler, Ph.D., a psychologist, wrote the following. He had seen plaintiff in over 25 sessions of psychotherapy during the period from 1999 through 2010. Plaintiff had severe symptoms of anxiety and depression. He appeared motivated to contain or control these symptoms and would attempt to comply with recommendations and cognitive behavioral strategies in dealing with them. Plaintiff's anxiety and depressive symptoms, which included panic and suicidal episodes, would recur and were extremely resistant to treatment. He believed that plaintiff was motivated to keep his job and maintain his employability and made serious efforts to treat his symptoms. He believed that plaintiff's psychiatric condition was severe and ...

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