Dori H. Leland, Esq., for Plaintiff.
Ana H. Voss, Asst. United States Attorney, 55415, for the Commissioner.
REPORT AND RECOMMENDATION
ARTHUR J. BOYLAN, Chief Magistrate Judge.
Pursuant to 42 U.S.C. § 405(g) Plaintiff Mark Steven Gaul seeks judicial review of the final decision of the Commissioner of Social Security. This matter is before the undersigned Chief United States Magistrate Judge Arthur J. Boylan for a report and recommendation to the District Court on the parties' cross-motions for summary judgment. [Doc. Nos. 12, 18.] See 28 U.S.C. § 636(b)(1) and Local Rule 72.1 Based on the reasoning set forth below, this Court recommends that Plaintiff's motion for summary judgment be granted [Docket No. 12], and Defendant's motion for summary judgment be denied [Docket No. 18].
I. FACTUAL AND PROCEDURAL BACKGROUND
A. Procedural History
Plaintiff protectively filed an application for supplemental security income ("SSI") on June 24, 2009, based on major depressive disorder. (Tr. 32, 160-65, 177.) His application was denied initially and upon reconsideration. (Tr. 73-77, 82-85.) Plaintiff requested a hearing before an administrative law judge, and hearings were held on January 24, 2011, and August 29, 2011, before Administrative Law ("ALJ") Diane Townsend-Anderson. (Tr. 89-91, 29-69.) The ALJ issued an unfavorable decision on November 8, 2011. (Tr. 8-28.) Plaintiff requested review of the ALJ's decision by the Appeals Council, and the Appeals Council denied Plaintiff's request on November 27, 2012, making the ALJ's decision the final decision of the Commissioner. (Tr. 1-4.) See 20 C.F.R. § 416.1481. On January 18, 2013, Plaintiff sought review from this Court. The parties then filed cross-motions for summary judgment.
B. Background and Medical Evidence
Plaintiff has a high school education. (Tr. 181.) In the last fifteen years, he could not hold a job for more than two or three months at a time. (Tr. 178.) Plaintiff was homeless and living in a shelter when he applied for SSI. (Tr. 194.) He alleges disability due to anxiety, difficulty concentrating and following instructions, and depression preventing him from getting out of bed. (Tr. 178.)
Plaintiff presented to HCMC Mental Health Center on June 18, 2009, just days after losing his housing in a board and lodging facility where he had lived for seven years, because he was caught drinking in his room. (Tr. 312, 317.) Plaintiff wanted treatment for depression. ( Id. ) His symptoms were isolation, disrupted sleep, loss of appetite, lethargy and low motivation. ( Id. ) Plaintiff began attending group therapy days later. (Tr. 309.) He said he was "in a void" for seven years, not accomplishing anything, just existing. ( Id. ) Plaintiff was cooperative, but he was depressed. ( Id. )
Plaintiff underwent a diagnostic assessment with John W. Robertson-Smith, a licensed psychologist at Hennepin County Mental Health Center, on June 22, 2009. (Tr. 320-322.) Plaintiff was living in a shelter and had no income. (Tr. 320.) His depression had increased when he was evicted. ( Id. ) Plaintiff's mood was dysthymic, but otherwise his mental status examination was normal. ( Id. ) Dr. Robertson-Smith referred Plaintiff to Dr. Langsten for medication evaluation. (Tr. 322.)
Dr. Langsten saw Plaintiff the same day to assess his need for psychiatric medication. (Tr. 316.) The death of Plaintiff's sister triggered his first relapse with alcohol in November 2008, and he relapsed again recently, causing him to be evicted. (Tr. 317.) Plaintiff had some friends, but for the last two or three years, he isolated himself because he felt anxious around other people. ( Id. ) Plaintiff's feeling of isolation was longstanding, going back to his childhood; his father died when Plaintiff was eleven, and his mother "was not available emotionally." (Tr. 318.) Plaintiff was the youngest of nine siblings, and most of Plaintiff's siblings were out of the home when Plaintiff was growing up. ( Id. ) Plaintiff was ostracized and isolated in high school. ( Id. )
Plaintiff was living in a shelter, not sleeping well, and he felt hopeless. ( Id. ) He had a very distant history of a suicide attempt. ( Id. ) He did not want to take medication unless his troubled sleep continued. (Tr. 319.) Plaintiff admitted that he had difficulty maintaining employment primarily due to his alcohol use. (Tr. 318.) He had been through chemical dependency treatment several times and he was abstinent for several years. ( Id. ) His last job was in 2000 as a mail clerk at a bank. ( Id. )
On examination, Plaintiff was cooperative but anxious and dysthymic. ( Id. ) His affect was appropriate, and he was fully oriented. ( Id. ) His memory and cognitive functions were intact. ( Id. ) His intelligence was in the normal range, and his judgment, insight and motivation appeared to be good. ( Id. ) Dr. Langsten diagnosed depressive disorder, not otherwise specified ("NOS") with situational features versus major depressive disorder by history; alcohol abuse/dependence in early remission; and to further consider (or rule out) post traumatic stress disorder, anxiety disorder and personality disorder. (Tr. 319.) He assessed Plaintiff with a GAF score of 50 to 60. ( Id. ) Under Axis IV of the diagnosis, Dr. Langsten noted Plaintiff had a long history of emotional and chemical problems. ( Id. ) Plaintiff had a history of being emotionally neglected and possibly emotionally abused during childhood. ( Id. ) Dr. Langsten recommended individual and group therapy. ( Id. )
Plaintiff returned to see Dr. Langsten in July 2009, asking for medication to help him sleep. (Tr. 315.) He complained of ongoing anxiety and fluctuating moods. ( Id. ) Plaintiff's mood was anxious and a bit dysthymic. ( Id. ) Dr. Langsten prescribed Ambien on an as needed basis. (Tr. 315-16.) On August 19, 2009, Plaintiff asked Dr. Langsten to refer him for individual therapy to work on managing his feelings. (Tr. 352-53.) Plaintiff was anxious and dysthymic. (Tr. 353.) His mental status was unchanged on October 23, 2009. (Tr. 351.) Plaintiff had been attending group therapy on a regular basis. ( Id. ) Dr. Langsten prescribed Remeron. (Tr. 352.)
Plaintiff had his first individual therapy session with Social Worker Kathleen Sapp on November 9, 2009. (Tr. 350.) Sapp noted Plaintiff was managing his depression, and he recognized his need to get out into the community and engage in activities and relationships. ( Id. ) In group therapy the next month, Plaintiff said he had a few good leads on getting into school. (Tr. 404.) In occupational therapy, Plaintiff talked about obtaining housing, finding work, and looking into volunteer opportunities. (Tr. 403.) Plaintiff was able to get medical assistance and YMCA membership. (Tr. 402.) At the end of December, Plaintiff expressed his frustration with seeking SSI, stating that he would rather go to school and learn a trade. (Tr. 400.) The next week, Plaintiff was feeling overwhelmed and had not followed through with housing and employment opportunities. (Tr. 399.) In mid-January 2010, Plaintiff urgently needed to find housing. (Tr. 397.)
Plaintiff saw Dr. Langsten on January 15, 2010, and he was still having problems, but he was finding therapy helpful. (Tr. 394.) On mental status examination, Plaintiff was anxious and dysthymic. (Tr. 394-95.) Dr. Langsten diagnosed major depressive disorder, PTSD, alcohol abuse/dependence in full remission, and to rule out personality disorder. (Tr. 395.) Plaintiff was in better spirits a few days later. (Tr. 393.)
In February 2010, Plaintiff obtained transitional housing, although he had not moved in. (Tr. 386.) Dr. Grant Berg praised Plaintiff for his progress. ( Id. ) Kathleen Sapp noted that Plaintiff would graduate from the Connections Group for homeless men. (Tr. 382.) Shortly after Plaintiff moved into his new residence, he seemed more relaxed and well rested. (Tr. 374.) In March 2010, Plaintiff was still waiting to hear if he was eligible for rehabilitative services. (Tr. 391.)
On February 16, 2010, Dr. Langsten completed a Medical Source Statement of Ability to Do Work-Related Activities (Mental) ("MSS") regarding Plaintiff for the Social Security Administration. (Tr. 366-68.) Dr. Langsten opined Plaintiff had severe anxiety with depressed mood and impaired concentration. (Tr. 366.) He believed Plaintiff's emotional instability prevented him from keeping a job since 2000. ( Id. ) Dr. Langsten opined Plaintiff had moderate limitations in understanding, remembering and carrying out short, simple instructions; and he had marked limitations in understanding, remembering and carrying out detailed instructions, and in making judgments on simple work-related decisions. ( Id. ) Furthermore, he opined Plaintiff would be moderately impaired in interacting appropriately with the public, and markedly impaired in interacting appropriately with supervisors, coworkers, and in responding to work pressure and changes in a routine work setting. (Tr. 367.) Dr. Langsten stated that Plaintiff was abstinent from chemical substances since June 2009. (Tr. 368.)
Plaintiff underwent a vocational evaluation in March 2010, at Courage Center Vocational Services. (Tr. 439-49.) He demonstrated the ability to multitask, adjust to interruptions, and change work locations without difficulty. ( Id. ) Plaintiff was advised to volunteer to address his lack of work history. (Tr. 448.) Plaintiff had defaulted on a student loan, and he had a 1997 felony conviction that would impact his education and employment opportunities. (Tr. 449.) The evaluator also noted that pursuing education or a new career often causes stress and anxiety, and it was important for Plaintiff's mental health to be monitored. (Tr. 448.)
Nurse Marva Thurston wrote a letter on Plaintiff's behalf in April 2010, to help him obtain housing based on his disability status. (Tr. 411.) She noted that Plaintiff was treated at her clinic for the past year, and he was working on improving his mental health in every way possible. ( Id. ) He was currently sober. ( Id. )
Dr. Langsten completed another MSS regarding Plaintiff for the Social Security Administration on April 12, 2010. (Tr. 405-07.) Dr. Langsten opined Plaintiff had slight impairments in understanding and remembering short, simple instructions and in the ability to make judgments on simple work-related decisions. (Tr. 405.) Plaintiff had moderate impairments in carrying out short, simple instructions, and in interacting appropriately with the public. ( Id. ) Plaintiff's was markedly impaired in understanding, remembering and carrying out detailed instructions, and in interacting appropriately with supervisors, coworkers, responding to work pressure, and responding appropriately to changes in a routine work setting. ( Id. )
Kathleen Sapp wrote a letter in support of Plaintiff's SSI claim on June 28, 2010. (Tr. 410.) She opined that Plaintiff's depressive and anxiety symptoms posed a significant obstacle to his maintaining employment, housing and other basic needs. ( Id. ) He suffered low energy and motivation, difficulty making decisions, anxiety in many situations, and low self-esteem and confidence. ( Id. ) Plaintiff was fully compliant with treatment, but there was little change in his symptoms. ( Id. )
Licensed Psychologist Harry David Linder also wrote a letter in support of Plaintiff's SSI claim in June 2010. (Tr. 409.) Linder facilitated the group for formerly homeless men that Plaintiff attended for the last seven months. ( Id. ) Linder stated:
The prevailing factors which would limit the client's employability and capacity to achieve normal functioning appear to be: a general lack of energy and ability to maintain motivational focus; low selfesteem, poor concentration and difficulty making decisions, and a general feeling of either hopelessness or discouragement in the ability for his situation to change.
( Id. )
Dr. Langsten wrote a letter on July 28, 2010, opining that Plaintiff was totally disabled by his psychiatric disorders and offering to provide further information upon request. (Tr. 408.) Plaintiff saw Dr. Langsten that day and reported struggling emotionally with low self-esteem. (Tr. 425.) He continued his abstinence from alcohol. ( Id. ) He experienced anxiety but hoped to go back to school. ( Id. ) On mental status examination, his mood was anxious and dysthymic. ( Id. ) In group ...