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Farley v. Berryhill

United States District Court, W.D. Missouri, Western Division

September 19, 2017

TANYA FARLEY, Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          ORDER

          NANETTE K. LAUGHREY, UNITED STATES DISTRICT JUDGE

         Plaintiff Tanya Farley appeals the Commissioner of Social Security's final decision denying her application for disability and disability insurance benefits under the Social Security Act. The decision is affirmed.

         I. Background

         Farley was born in 1972 and claims a disability onset date of 1/21/2014. The Administrative Law Judge held a hearing on 3/4/2015 and denied Farley's application on 5/22/2015, and the Appeals Council denied her request for review on 8/1/2016. In this appeal, Farley focuses on mental health issues.

         A. Mental health history

         On the recommendation of her therapist, Farley established care with a psychiatrist, Rameshlal Rawlani, M.D. on 1/31/2014. Farley told Dr. Rawlani that her primary care doctor had prescribed medication, Prozac and Trazadone, and that her depression was better with therapy and medication. Exam showed that her behavior was appropriate and cooperative; she made good eye contact; her affect was euthymic; she had flow of logical, goal directed thought; she had no delusions; her insight, judgment, and memory were fair; and her attention and concentration were good. Tr. 370. The doctor diagnosed dysthymia; instructed her to continue the medications that her primary care doctor had prescribed, and continue therapy; and to return in six weeks.

         At a visit with her primary care physician, Paul Bernabe, M.D., in February 2014, the doctor advised her about relaxation and stress reduction for managing depression.

         Farley saw Dr. Rawlani on 4/2/2014. Her mental status exam results were the same as her 1/31/2014 exam results. Tr. 356-57. She said her medications were not helping. The doctor prescribed Wellbutrin, and instructed her to continue therapy and return in four weeks. Later the same month, Farley reported that the Wellbutrin made her itch, so Dr. Rawlani prescribed Paxil instead.

         At a medication management visit with Dr. Rawlani on 5/30/2014, Farley said she was doing okay, but might be depressed in the future because her father was going to pass away. She said her anxiety was good, looked happy, was satisfied with her current medication, and said she felt “10 out of 10.” Tr. 334. Mental status exam was normal and the doctor noted that Farley's condition was stable. He instructed her to return in six weeks.

         On 7/11/2014, Farley told Dr. Rawlani that she was doing okay, her anxiety was good, she looked happy, and said she felt “7 out of 10.” Tr. 326. She said her sleep was disrupted. Mental status exam was normal. Dr. Rawlani continued the Paxil and added Trazadone for sleep, and instructed Farley to return in six weeks.

         On 8/15/2014, Farley told Dr. Rawlani that her father had passed away two days earlier. Farley was not in acute distress and the mental status exam was normal. The doctor continued Farley's medications, and instructed her to continue therapy and return in six weeks.

         On 9/26/2014, Farley's mental status exam findings were normal. She told Dr. Rawlani that she could not afford her medications. The doctor arranged to give her samples of Vibryd or Brintellix, and instructed her to continue therapy and return in six weeks. She followed up on 11/5/2014 and asked for more samples. Mental status exam was normal and Dr. Rawlani instructed her to return in six weeks. On 12/17/2014, Farley told Dr. Rawlani that she was feeling better on the Brintellix and he noted that Farley was alert, cooperative, oriented, and smiling. He instructed her to continue therapy and return in six weeks.

         On 1/28/2015, Farley was still doing well on her medication, and reported good mood, sleep, and energy. Dr. Rawlani noted she was alert, cooperative, and smiling. He continued Farley's medications, and instructed her to continue therapy and return in eight weeks. Her next visit with Dr. Rawlani, on 3/25/2015, was essentially the same and she reported that she was “doing alright[.]” Tr. 289. On 5/27/2015, Farley was not in distress although she reported having physical problems. Dr. Rawlani continued her medications, and instructed her to continue therapy and return in six weeks.

         A short, “Multi-Service Progress Note” dated 7/1/2015, bearing Dr. Rawlani's electronic signature, states that Farley's “case was discuss for consultation by her case worker[.] [Sic.]” Tr. 273. The Progress Note gives some background about Farley's medical and psychiatric history, ending with the note, “Pt been reporting she is doing good on Brintellix. [Sic.]” Id. The Progress Note continues,

Problem. After she is on Medicaid therapist report not actively encourage with treatment protocol. May be due to her health condition. Has multiple medical problem not doing proper f/u, totally dependent on caseworker for her physical and mental health. Since caseworker was unable to take her eye appointment she is mad with caseworker.
Plan. Encurrage pt to participate more activities for her physical and mental health, encourage to keep medical and psychiatric appointments. Comply with treatment recommendation. Home ...

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