United States District Court, E.D. Missouri, Northern Division
TALIA S. NELSON, Plaintiff,
ANDREW M. SAUL,  Commissioner of Social Security, Defendant.
MEMORANDUM AND ORDER
L. WHITE, UNITED STATES DISTRICT JUDGE
an action under 42 U.S.C. § 1383(c)(3) for judicial
review of the Commissioner of Social Security's final
decision denying plaintiff Talia S. Nelson's application
for Supplemental Security Income ("SSI") under
Title XVI of the Social Security Act ("the Act").
Because the Appeals Council denied Plaintiffs Request for
Review, the decision by the Administrative Law Judge
("ALJ") is the final decision of the Commissioner.
For the reasons set forth below, the Court reverses the
decision of the Commissioner.
protectively filed an application for SSI on July 29, 2015.
In the application, she alleged disability beginning August
24, 2007. Record ("R.") at 143. Plaintiffs claims
were denied on October 1, 2015. R. 15. Plaintiff timely filed
a request for a hearing before an ALJ on October 26, 2015.
Id. On March 20, 2017, plaintiff moved to amend her
alleged onset date to July 29, 2015. R. 159. On March 29,
2017, plaintiff testified at a hearing before the ALJ. R. 6.
In a decision dated October 19, 2017, the ALJ concluded
plaintiff was under a disability but also concluded that a
substance use disorder was a contributing factor material to
the determination of disability and determined that plaintiff
was not disabled under the Act at any time from the date the
application was filed through the date of decision. R. 15-26.
On May 25, 2018, the Appeals Council denied plaintiffs
request for review. R. 1-3. Accordingly, the Appeals Council
found that plaintiffs reasons did not provide a basis for
changing the ALJ's decision. R. 1. As a result, the
ALJ's decision stands as the final decision of the
claimant for social security disability benefits must
demonstrate that he or she suffers from a physical or mental
disability. The Social Security Act defines disability
"as the inability to do any substantial gainful activity
by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which
has lasted or can be expected to last for a continuous period
of not less than 12 months." 20 C.F.R. §
the Social Security Act, the Commissioner has established a
five-step process for determining whether a person is
disabled. 20 C.F.R. §§ 416.920, 404.1520. "If
a claimant fails to meet the criteria at any step in the
evaluation of disability, the process ends and the claimant
is determined to be not disabled." Goff v.
Barnhart, 421 F.3d 785, 790 (8th Cir. 2005) (quoting
Eichelberger v. Barnhart 390 F.3d 584, 590-91 (8th
Cir. 2004)). In this sequential analysis, the claimant first
cannot be engaged in "substantial gainful activity"
to qualify for disability benefits. 20 C.F.R. §§
416.920(b), 404.1520(b). Second, the claimant must have a
severe impairment. 20 C.F.R. §§ 416.920(c),
404.1520(c). The Social Security Act defines "severe
impairment" as "any impairment or combination of
impairments which significantly limits [claimant's]
physical or mental ability to do basic work activities.
..." Id. '"The sequential evaluation
process may be terminated at step two only when the
claimant's impairment or combination of impairments would
have no more than a minimal impact on [his or] her ability to
work.'" Page v. Astrue, 484 F.3d 1040, 1043
(8th Cir. 2007) (quoting Caviness v. Massanari. 250
F.3d 603, 605 (8th Cir. 2001)).
the ALJ must determine whether the claimant has an impairment
which meets or equals one of the impairments listed in the
Regulations. 20 C.F.R. §§ 416.920(d), 404.1520(d).
If the claimant has one of, or the medical equivalent of,
these impairments, then the claimant is per se disabled
without consideration of the claimant's age, education,
or work history. Id.
the impairment must prevent the claimant from doing past
relevant work. 20 C.F.R. §§ 416.920(f),
404.1520(f). The burden rests with the claimant at this
fourth step to establish his or her Residual Functional
Capacity ("RFC"). Steed v. Astrue, 524
F.3d 872, 874 n.3 (8th Cir. 2008) ("Through step four of
this analysis, the claimant has the burden of showing that
she is disabled."). The ALJ will review a claimant's
RFC and the physical and mental demands of the work the
claimant has done in the past. 20 C.F.R. § 404.1520(f).
the severe impairment must prevent the claimant from doing
any other work. 20 C.F.R. §§ 416.920(g),
404.1520(g). At this fifth step of the sequential analysis,
the Commissioner has the burden of production to show
evidence of other jobs in the national economy that can be
performed by a person with the claimant's RFC.
Steed, 524 F.3d at 874 n.3. If the claimant meets
these standards, the ALJ will find the claimant to be
disabled. "The ultimate burden of persuasion to prove
disability, however, remains with the claimant."
Young v. Apfel, 221 F.3d 1065, 1069 n.5 (8th Cir.
2000). See also Harris v. Barnhart 356 F.3d 926, 931
n.2 (8th Cir. 2004) (citing 68 Fed. Reg. 51153, 51155 (Aug.
26, 2003)); Stormo v. Barnhart, 377 F.3d 801, 806
(8th Cir. 2004) ("The burden of persuasion to prove
disability and to demonstrate RFC remains on the claimant,
even when the burden of production shifts to the Commissioner
at step five."). Even if a court finds there is a
preponderance of the evidence against the ALJ's decision,
the decision must be affirmed if it is supported by
substantial evidence. Clark v. Heckler, 733 F.2d 65,
68 (8th Cir. 1984). "Substantial evidence is less than a
preponderance but is enough that a reasonable mind would find
it adequate to support the Commissioner's
conclusion." Krogmeier v. Barnhart, 294 F.3d
1019, 1022 (8th Cir. 2002). See also Cox v. Astrue,
495 F.3d 614, 617 (8th Cir. 2007).
not the district court's role to re-weigh the evidence or
review the factual record de novo. Cox, 495 F.3d at
617. Instead, the district court must determine whether the
quantity and quality of evidence is such that a reasonable
mind might find it adequate to support the ALJ's
conclusion. Davis v. Apfel, 239 F.3d 962, 966 (8th
Cir. 2001) (citing McKinney v. Apfel, 228 F.3d 860,
863 (8th Cir. 2000)). Weighing the evidence is a function for
the ALJ, who is the factfinder. Masterson v.
Barnhart, 363 F.3d 731, 736 (8th Cir. 2004). Thus, an
administrative decision that is supported by substantial
evidence is not subject to reversal because substantial
evidence may also support an opposite conclusion or because
the reviewing court would have decided differently.
Krogmeier, 294 F.3d at 1022.
determine whether the Commissioner's final decision is
supported by substantial evidence, the court must review the
administrative record as a whole and consider:
(1) Findings of credibility made by the ALJ;
(2) The education, background, work history, and age of the
(3) The medical evidence given by the claimant's treating
(4) The subjective complaints of pain and description of the
claimant's physical activity and impairment;
(5) The corroboration by third parties of the claimant's
(6) The testimony of vocational experts based upon proper
hypothetical questions which fairly set forth the
claimant's physical impairment; and
(7) The testimony of consulting physicians.
Brand v. Sec'y of Dep't of Health, Educ. &
Welfare, 623 F.2d 523, 527 (8th Cir. 1980).
analysis is necessary when an ALJ finds that a claimant is
disabled but there is medical evidence of substance abuse or
alcoholism in the record. 20 C.F.R. § 416.935(a). Where
there is such evidence, the ALJ is required to determine if
the substance abuse is a material contributing factor to the
claimant's disability, with the "key factor" in
the analysis being whether the ALJ "would still find
[the claimant] disabled if [she] stopped using drugs or
alcohol." 20 C.F.R. § 416.935(b)(1). The ALJ must
determine which of the claimant's disabling limitations,
physical or mental, would remain if the claimant stopped
using substances or alcohol, and then determine whether any
or all of the remaining limitations would be disabling. 20
C.F.R. § 416.935(b)(2). If the ALJ finds a
claimant's remaining limitations would not be disabling,
the substance abuse is a material contributing factor to the
claimant's disability and the ALJ must conclude the
claimant is not disabled. 42 U.S.C. § 1382c(a)(3)(J); 20
C.F.R. § 416.935(b)(2)(i). In contrast, if the ALJ finds
the remaining limitations would be disabling by themselves,
the substance abuse is not material and the ALJ must conclude
the claimant is disabled. 20 C.F.R. § 416.935(b)(2)(ii).
decision in this case, the ALJ found at step one that
plaintiff had not engaged in substantial gainful activity
since July 29, 2015, the application date. R. 18; see 20
C.F.R. § 416.971. At step two, the ALJ found that
plaintiff had severe impairments of mental disorders
variously diagnosed as a major depressive disorder, a panic
disorder, a borderline personality disorder, a post-traumatic
stress disorder, and a poly substance abuse disorder. The ALJ
found plaintiffs psoriasis was non-severe, and her migraine
headaches were not a medically determinable impairment due to
a lack of objective evidence. R. 18; see 20 C.F.R. §
416.920(c). At step three, the ALJ determined that plaintiffs
impairments including the substance use disorder met the
medical criteria of section 12.04, presumptively disabling
impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix
1 (the "Listings"). R. 18; see 20 C.F.R. §
416.920(d). The ALJ found that plaintiff had moderate
limitation in understanding, remembering, or applying
information; moderate limitation in interacting with others;
marked limitation in concentrating, persisting, or
maintaining pace; and marked limitation in adapting or
managing herself R. 18-19.
the ALJ found plaintiffs impairments met one Listing - and
thus that plaintiff was disabled - when the effects of
substance abuse were considered, he then considered whether
plaintiffs substance abuse was a material contributing factor
to her disability. See 20 C.F.R. § 416.935(a).
To do so, the ALJ re-evaluated plaintiff as if she had
stopped using substances. See R. 19-20. At
reconsidered step two, the ALJ found that if plaintiff
"stopped the substance use, the remaining limitations
would cause more than a minimal impact on [plaintiffs]
ability to perform basic work activities; therefore
[plaintiff] would continue to have a severe impairment or
combination of impairments." R. 19. At reconsidered step
three, the ALJ found that plaintiffs remaining severe
impairments or combination of impairments would not meet or
medically equal the impairments in Listings 12.04, 12.06,
12.08, or 12.15. R. 19-20. The ALJ found that if plaintiff
stopped substance use, she would have moderate limitation in
understanding, remembering, or applying information; moderate
limitation in interacting with others; moderate limitation in
concentrating, persisting, or maintaining pace; and moderate
limitation in adapting or managing herself The ALJ also noted
that no State agency psychological consultant concluded that
a mental listing was medically equaled if plaintiff stopped
then assessed plaintiffs residual functional capacity
("RFC") based on all her remaining impairments. R.
20; see 20 C.F.R. §§ 416.920(a)(4)(iv),
416.935(b)(2). The ALJ found that if plaintiff "stopped
the substance use" she would have the RFC to perform
"a full range of work at all exertional levels"
subject to these non-exertional limitations: Plaintiff can
never work at unprotected heights or around moving mechanical
parts, or operate a motor vehicle; she could only
"understand, remember, and carry out simple and routine
tasks;" "use judgment to make simple work-related
decisions;" and "respond appropriately to
supervisors, coworkers, and the public occasionally." R.
20. At reconsidered step four, the ALJ found that plaintiff
has no past relevant work, see 20 C.F.R. § 416.965, but
found that if plaintiff "stopped the substance use"
there would be a significant number of jobs in the national
economy she could perform, including dishwasher, housekeeper,
and addresser. R. 24-25; see 20 C.F.R. §§ 416.960,
416.966. On that basis, the ALJ found plaintiffs substance
abuse was material to the determination of disability and, as
a result, plaintiff had not been under a disability as
defined in the Social Security Act at any time from July 25,
2015, to October 19, 2017, the date of the decision. R. 25;
see 20 C.F.R. § 416.935(b)(2)(i).
Testimony at the Hearing
hearing was held before ALJ on March 29, 2017. Plaintiff
appeared in person and with counsel. R. 34. Plaintiff was 27
years old at the time of the hearing. Plaintiffs onset of
disability date was July 29, 2015. Plaintiff is single and
has two children, ages 8 and 5, who live with their father.
Plaintiff lives with her grandparents in their house. R. 36.
Plaintiff is four feet eleven inches tall, weighs 169 pounds,
and had gained weight due to her then-current pregnancy. R.
37. Plaintiff attended school through the 11th grade and was
in special education for all her classes. R. 37-38. Plaintiff
took classes at a community college after she dropped out of
high school, obtained a GED, and became a certified nursing
assistant ("CNA"). R. 38, 45. Plaintiffs employment
as a CNA lasted only a few days because she became upset,
contemplated suicide, and had a breakdown. R. 38. Before
trying CNA work, plaintiff worked as a hostess at a sports
bar three days a week for one year while she was a teenager.
R. 38-39. As a hostess, plaintiff took people to their
tables, seated them, and gave them menus. R. 49.
has been receiving mental health care since the summer of
2015 with Carol Greening. Plaintiff was diagnosed with major
depressive disorder and anxiety and has had multiple
hospitalizations because of suicide attempts. Plaintiffs
first suicide attempt was in August 2014. R. 39. Plaintiff
attempted suicide again in October 2014 and April 2015, the
latter with a hanging attempt, and was hospitalized after
both attempts. R. 40. Plaintiff has also cut herself and used
Claritin, ibuprofen, and Tylenol in overdose attempts.
Id. Plaintiff cuts herself approximately five times
per month, usually on her left hand but sometimes in her
chest area or stomach. R. 41. Plaintiff was hospitalized
again in December 2016 after she had suicidal thoughts when
she found out she was pregnant after a one-night stand. R.
testified she has suicidal thoughts five times per hour, when
she thinks of things such as hanging herself or trying to
find a gun to shoot herself. R. 42. Plaintiffs brother died
of a heroin overdose in January 2017 at age 22. Id.
Plaintiffs grandparents, who are retired, have guns in the
house but these are hidden from plaintiff. Id.
Plaintiff does not see her children unsupervised.
(Id.) Plaintiff hears voices telling her to kill
herself. R. 42-43. Plaintiff used street drugs once in
October 2016. Plaintiff is prescribed Prozac and Vistaril,
and previously was prescribed Trazodone and Gabapentin but
was not taking those during her pregnancy. R. 43-44.
testified she has migraine headaches five times each week,
that last "about a couple of hours" or until she
goes to bed. She takes Tylenol for these. During the
migraines Plaintiff is sensitive to light, especially
sunlight, and noise. She will often put her sweatshirt over
her head and lay down when she has a migraine. R. 44. The
migraines cause nausea twice a week. R. 45.
has never had a driver's license. She took the test six
times but was never able to pass. R. 45. When plaintiff was
taking community college classes for her GED, she had help as
someone took her in another room and helped her study and
read the questions to her. R. 46.
does not socialize but sees her two children every weekend.
R. 46. Two or three times a year, plaintiff does not feel up
to seeing her children. Plaintiff tries to see her children
because she likes to think they help with her mental state.
Id. Plaintiff feels anxious or depressed all day,
every day. Id. Plaintiff does not do anything all
day except watch TV. R. 46, 47. Plaintiff is not expected to
help her grandparents around the house. R. 46-47. Two or
three times per week Plaintiff has difficulty sleeping,
either being unable to fall asleep or waking at 2:00 or 3:00
a.m. and being unable to return to sleep. R. 47.
often has difficulty concentrating or following a TV show,
and some days can't concentrate. R. 47-48. Plaintiff is
compliant with her medications but is still anxious and
depressed. R. 48.
vocational expert ("VE"), Deborah A. Determan,
M.S., C.R.C., C.D.M.S., C.C.M, also testified at the hearing.
The VE classified plaintiffs past work as a hostess in the
Dictionary of Occupational Titles ("DOT"). The ALJ
asked the VE to assume a hypothetical individual of
plaintiffs age, education, and past work experience with the
following range of work at any exertional level: no exposure
to unprotected heights or moving mechanical parts; no
operation of motor vehicles as a job duty; limited to simple
routine tasks and simple work-related decisions; and
occasional interaction with supervisors, coworkers, and the
public. The ALJ testified such a hypothetical individual
would be precluded from plaintiffs past work. R. 51.
asked if there were other jobs in the national economy such a
hypothetical individual could perform. The VE testified there
were jobs at different exertional categories and gave these
examples: Such a hypothetical individual could work as a
sedentary, unskilled addresser, DOT code 209.587-010, of
which there are approximately 11, 000 jobs in the national
economy; as a light, unskilled housekeeper, DOT code
323.687-014, of which there are approximately 100, 000 jobs
in the national economy; or as a medium, unskilled
dishwasher, DOT code 318.687-010, of which there are
approximately 160, 000 jobs in the national economy. R.
inquired whether the hypothetical individual could perform
the same work at any exertional level if, in addition to
normal breaks, they were off task at least 20% of the work
day. The VE testified the hypothetical individual could not
perform the same work with the additional off-task condition,
based on her experience, knowledge, and training in the field
of vocational rehabilitation. R. 52.
counsel asked the VE how often the hypothetical individual
would have contact with supervisors or coworkers in the jobs
she identified. The VE testified the jobs were all level
eight, which would have the lowest level of interaction with
supervisors and coworkers. R. 53. Plaintiffs counsel asked
whether there would be any occasion to interact on a daily
basis at level eight. The VE testified the definition for
level eight is taking instructions and attending to work
assignment instructions or orders of supervisors. The VE
testified the jobs are routine and repetitive but each would
have some level of interaction with others, such as a
housekeeper getting room numbers for what is to be cleaned.
counsel asked the VE about employers' tolerance for
workers who talked back, had outbursts or other improper
reactions, or didn't take criticism well. The VE
testified there was a continuum in this context; a worker who
made a coworker or supervisor feel threatened would not be
able to maintain their job, but a worker who was verbally
inappropriate but did not show any aggression would probably
be a marginal employee, but this behavior would not preclude
competitive employment. R. 53-54.
counsel asked the VE about employers' tolerance for
workers who had anxiety that caused them to leave the
workplace. The VE testified an employer might allow this
twice but then the job would be in jeopardy. Plaintiffs
counsel also asked how many days a month the employers would
tolerate absenteeism. The VE testified that if a person
missed more than one day of work per month it would preclude
competitive employment. R. 54.
Relevant Medical Evidence
review of plaintiffs medical evidence of record regarding her
mental impairments reveals the following relevant evidence.
Plaintiffs medical history reveals numerous psychiatric
admissions, the first admission during her early teens
because of cutting self-injury and behavior problems. R. 345.
On October 10, 2014, plaintiff was admitted psychiatrically
to Blessing Hospital after she made statements in the office
of Dr. Salvador Sanchez, M.D. at Blessing Physician Services
of suicidal thoughts and plans to overdose, reporting
stressors increased just prior to the admission of starting a
new job as a CNA and a planned move. R. 250, 252, 272. Dr.
Sanchez reported plaintiff was depressed, hopeless, and her
psychiatric condition was unstable. R. 273, 395.
had previously been admitted psychiatrically to Blessing
Hospital several times and had a history of cutting and
suicidal ideation. R. 250. Plaintiff had past diagnoses of
depression, anxiety, and borderline personality disorder.
Id. Plaintiff admitted to not taking her
psychotropic medications since February 2014. Id.
These included Ativan, Citalopram Hydrobromide, and
Trazodone. R. 272. Plaintiff admitted a history of alcohol
and methamphetamine use but denied recent drug or alcohol
abuse. R. 250. Plaintiffs drug urine screen was negative. R.
257. On mental status exam on admission, plaintiff was alert,
"superficially cooperative, " had depressed mood
with dysphoric affect, linear thought processes, endorsed
suicidal thoughts with plans to overdose, with poor insight
and judgment. R. 253. On intake, Plaintiff was assessed as
having major depressive disorder, recurrent, severe, without
psychotic features, and borderline personality disorder. Her
GAF was 35. R. 253. The treatment plan was for
plaintiff to receive individual and group therapies and be
restarted on her medication. R. 253. Throughout her
hospitalization plaintiff insisted she was suicidal and would
harm herself if discharged; she responded affirmatively when
asked if she felt the need of an extended care program. R.
250. Plaintiff "verbalized intense suicidality" and
she was ordered transported to McFarland Zone Center for
continuing care and treatment. Id, Plaintiff was discharged
on October 24, 2014 with a GAF of 40. R. 250. On discharge,
plaintiff was taking the antidepressant Trazodone and the
selective serotonin reuptake inhibitor Citalopram.
from a comprehensive psychiatric evaluation during inpatient
treatment at McFarland Mental Health Center reflect that
plaintiff had eight previous psychiatric hospitalizations and
had been prescribed numerous psychiatric medications
including Sertraline, Viibryd, Bupropion, Lexapro,
Clonazepam, and Ability. R. 263. Plaintiff reported previous
heavy drinking, recent problems with Adderal, past use of
marijuana, pills including Percocet and Oxycodone,
methamphetamine, and snortable heroin, but no past substance
abuse treatment. Id. Plaintiff scored a 24 on the
substance abuse audit screen but had a negative drug screen.
Id. There were two suicides in her family history.
Id, Plaintiffs appearance was somewhat disheveled, she was
generally cooperative and made good eye contact but was
depressed, her judgment was chronically poor, and she needed
a structured setting for safety. R. 264. Plaintiff had joint
custody of her children, ages six and three. Id, Plaintiff
had longstanding diagnoses of depression, anxiety, and
borderline personality disorder, in the context of
significant substance abuse. R. 265. Plaintiff was diagnosed
with depressive disorder, anxiety disorder, alcohol and
amphetamine abuse, and borderline personality disorder. R.
265-66. Her GAF was 25. R. 266. Among the report's
recommendations were that plaintiff "will be admitted to
Jefferson Hall as per court order." Id. Her
prognosis was "guarded, given her personality traits,
lack of adherence to treatment and substance use." Id,
The discharge plan was for plaintiff to live with her
grandparents. R. 268.
saw Dr. Sanchez for a medication evaluation on February 6,
2015. She was on Trazodone and Venlafaxine, reported anxiety,
and had a stable psychiatric condition. R. 270-71.
March 28, 2015, plaintiff was admitted to Blessing Hospital
following a suicide attempt after a verbal and then physical
argument with her children's father. R. 275. Plaintiff
tried to hang herself after cutting herself with the children
present in the household. Id. Plaintiff had been
prescribed Effexor, 225 mg per day, but had been taking 75 mg
per day due to cost and insurance issues. R. 277. Plaintiff
drank six beers prior to the admission and used
methamphetamine recently. Her urine tested positive for
amphetamines. Id.; R. 284. On mental status exam,
plaintiff was calm, cooperative, had good eye contact,
depressed mood, and normal speech. Her judgment and insight
were poor. R. 277. Plaintiff s GAF was 35 to 40. R. 278.
During hospitalization, plaintiff attended group therapy and
was started on Paxil 20 mg daily, trazodone 200 mg at
bedtime, BuSpar 10 mg three times per day for anxiety, and
Vistaril 25 mg three times per day as needed for anxiety. R.
275. A report was made to the Division of Children and Family
Services and plaintiff was served with an order of protection
under which she was not allowed to be close to her children
or the children's father. Id. Plaintiff was
discharged from Blessing Hospital on April 3, 2015. R. 275.
Discharge diagnoses included major depressive disorder,
severe, recurrent, without psychotic features, and borderline
personality disorder. Id. Plaintiff s GAF on
discharge was greater than 50. Id.
began outpatient treatment at Transitions of Western
Illinois, a mental health and crisis intervention center in
Quincy, Illinois, on April 1, 2015, and received services
until June 23, 2015 when she moved from the area. R. 288.
Plaintiffs GAF at the time of both admission and discharge
was 40. Id. Plaintiff had impairments in the daily
living skill of money management, and impairments in social
adjustment of employment, social/interpersonal relationships,
family relationship, and communication skills. R. 292, 299.
Plaintiffs diagnosis was major depressive disorder,
recurring, severe. R. 299. Plaintiffs anxiety resulted in a
lack of friendships, difficulty maintaining relationships, a
lack of relaxing activities; her depression resulted in
social withdrawal, lack of assertiveness, and difficulty
getting out of bed in the morning, and post-traumatic stress
disorder resulted in difficulty initiating relationships. R.
August 6, 2015, plaintiff was admitted to the emergency room
at Blessing Hospital after the attempted to overdose by
taking approximately 120 Tylenol tablets, some Claritin and
ibuprofen, and drinking two 40-ounce beers. R. 314. Plaintiff
said she "was just not feeling right" and stated
this was her fifth suicide attempt. Id. Plaintiff
was living with her grandparents. Id. Plaintiff
denied illegal drug use and stated she drank alcohol twice
per week. Id. Her urine drug screen was negative. R.
322. A behavioral consultation on August 7, 2015, showed
plaintiff to be alert, oriented, calm, and cooperative. R.
317. Her speech was decreased in tone, volume, and
production, and her mood was depressed and her affect
dysphoric. Id. Plaintiff endorsed ongoing suicidal
ideas. Id. Her thought process was linear and goal
directed. Id. Her insight and judgment were poor and
her impulse control was impaired. R. 317. Plaintiffs GAF was
35 and the examining doctor recommended that she be admitted
to the inpatient psychiatric unit when she was medically
cleared. R. 318.
August 7, 2015, plaintiff was admitted to Blessing Hospital.
R. 239. The intake history noted that plaintiff had an
argument with her boyfriend, "She went home. She was
drinking. She impulsively overdosed on Tylenol and Motrin,
and she was at the same time talking to her boyfriend."
Id, It was noted she has a long history of psychiatric
disorders with multiple prior psychiatric admissions and
significant borderline personality traits. Id.
Plaintiff was "still feeling depressed, anxious,
hopeless, helpless, worthless, and suicidal, no specific
plans." Id. Plaintiff had a serious history of
methamphetamine use but "has been clean for about five
months. She is drinking." Id. Plaintiff was
cooperative, had fairly good eye contact, monotone speech,
appropriate language, depressed mood, normal thought
processes, with poor insight, judgment, and impulse control.
R. 240. Plaintiff s GAF was 35. Plaintiff s Risperdal, Paxil,
and BuSpar were discontinued, Vistaril was increased to 50 mg
three times per day as needed, and plaintiff was started on
Gabapentin 100 mg three times daily and a trial of Celexa 20
mg daily. Id., R. 242. Plaintiff was to receive
individual and group therapy with discharge when she became
stable. R. 240. Plaintiff was discharged seven days later on
August 14, 2015. R. 242. At discharge, plaintiff had
"better" mood, denied suicidal ideation, her
judgment and insight were fair, and she was alert and
oriented times three. Plaintiff was to follow up at the
Hannibal Free Clinic ("HFC") for further medication
adjustment and counseling. Id.
September 14, 2015, plaintiff went to the HFC for a mental
health screening. R. 341. Plaintiff was taking Celexa,
Gabapentin, Hydroxyzine P, and Trazodone, which she reported
was "helping" and her moods were stable, but she
scored "very high" on the Patient Health
Questionnaire (PHQ-9), which indicated severe depression.
Id., R. 385. Plaintiff reported frequent feelings of
hopelessness, worthlessness, and loneliness, difficulty with
memory, concentration, and the ability to make decisions. She
reported feelings that she would be better off dead or of
hurting herself nearly every day. R. 341. Plaintiff reported
past drug use-"all kinds of stuff-but stated she
hadn't used drugs for years. Id., R. 381, 342, 382.
Plaintiff stated she had not been in any
drug/alcohol/rehab/detox program in the past. R. 342, 382.
visited Clarity Healthcare for a medication refill on
September 17, 2015. She reported a long history of mental
health problems that began during childhood, and stated she
began cutting herself and having suicidal ideation in fifth
grade and began counseling and medication at age thirteen. R.
397. Plaintiff reported she had a distant illicit drug use
history and stated she quit drinking "a couple months
ago, " but the provider noted this was inconsistent with
Blessing Hospital discharge notes. Plaintiff stated she
suffered post-partum depression after the birth of both ...