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Nelson v. Saul

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

September 23, 2019

TALIA S. NELSON, Plaintiff,
v.
ANDREW M. SAUL, [1] Commissioner of Social Security, Defendant.

          MEMORANDUM AND ORDER

          RONNIE L. WHITE, UNITED STATES DISTRICT JUDGE

         This is 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.

         I. Procedural History

         Plaintiff 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 Commissioner.

         II. Legal Standard

         A 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. § 404.1505(a).

         Under 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)).

         Third, 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.

         Fourth, 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).

         Fifth, 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).

         It is 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.

         To 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 claimant;
(3) The medical evidence given by the claimant's treating physicians;
(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 physical impairment;
(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).

         Additional 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).

         III. Administrative Decision

         In the 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.

         Because 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 substance use.

         The ALJ 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).

         IV. Testimony at the Hearing

         A 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.

         Plaintiff 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. 41.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         Plaintiff 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.

         A 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.

         The ALJ 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. 51-52.

         The ALJ 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.

         Plaintiffs 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. R. 53.

         Plaintiffs 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.

         Plaintiffs 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.

         V. Relevant Medical Evidence

         A 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.

         Plaintiff 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.[2] 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. Id.

         Records 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.

         Plaintiff 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.

         On 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.[3] 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.

         Plaintiff 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. 306.

         On 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.

         On 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.

         On 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.

         Plaintiff 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 ...


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