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Perry v. Colvin

United States District Court, D. Minnesota

July 31, 2014

Lucretia Perry, Plaintiff,
v.
Carolyn W. Colvin, Acting Commissioner of Social Security, Defendant.

Laura S. Melnick, Southern Minnesota Regional Legal Services, Inc., (for Plaintiff); and Ann M. Bildtsen and Gregory Brooker (on brief), United States Attorney's Office, (for Defendant).

REPORT & RECOMMENDATION

TONY N. LEUNG, Magistrate Judge.

I. INTRODUCTION

Plaintiff Lucretia Perry brings the present case, contesting Defendant Commissioner of Social Security's denial of her application for supplemental security income ("SSI") under Title XVI of the Social Security Act, 42 U.S.C. § 1382. This matter is before the undersigned United States Magistrate Judge on cross motions for summary judgment, Plaintiff's Motion for Summary Judgment (Docket No. 9) and Defendant's Motion for Summary Judgment (Docket No. 15). These motions have been referred to the undersigned for a report and recommendation to the district court, the Honorable Joan N. Ericksen, District Judge for the United States District Court for the District of Minnesota, under 28 U.S.C. § 636 and Local Rule 72.2(b).

Based upon the record, memoranda, and the proceedings herein, IT IS HEREBY RECOMMENDED that Plaintiff's Motion for Summary Judgment (Docket No. 9) be DENIED and Defendant's Motion for Summary Judgment (Docket No. 15) be GRANTED.

II. PROCEDURAL HISTORY

Plaintiff applied for SSI in July 2009, asserting that she has been disabled due to dysthymic disorder since October 1, 2008.[1] (Tr. 10, 74, 128, 140.) Plaintiff also reported that she was disabled due to depression, generalized anxiety disorder with social phobia, and post-traumatic stress disorder ("PTSD"). (Tr. 79.) Plaintiff's application was denied initially on February 18, 2010, and again upon reconsideration on September 30, 2010. (Tr. 74-77, 80-88.) Plaintiff appealed the reconsideration determination by requesting a hearing before an administrative law judge ("ALJ"). (Tr. 67-70; see also Tr. 92-93.)

The ALJ held a hearing on February 16, 2012. (Tr. 10; see also Tr. 104, 110.) After receiving an unfavorable decision from the ALJ, Plaintiff requested review from the Appeals Council, which denied her request for review. (Tr. 1-22.) Plaintiff then filed the instant action, challenging the ALJ's decision. (Compl., ECF No. 1.) Plaintiff moved for summary judgment on September 5, 2013 (ECF No. 9), and the Commissioner filed a cross motion for summary judgment on November 20, 2013 (ECF No. 15). This matter is now fully briefed and ready for a determination on the papers.

III. RELEVANT MEDICAL HISTORY

Plaintiff challenges only the ALJ's findings and decision relating to her mental impairments. Accordingly, the Court focuses on the records relevant to these impairments.

A. 2007

On November 7, 2007, Plaintiff was seen at the Bethesda Clinic by Samuel Inkumsah, M.D., for a complaint unrelated to her mental health. (Tr. 389, 390.) As related to the issues present in this case, Dr. Inkumsah noted that Plaintiff had chronic PTSD, mild recurrent major depression, and obsessive compulsive disorder. (Tr. 389.) Plaintiff was in "no distress, comfortable, [and] pleasant" and had an "appropriate mood." (Tr. 390.) Dr. Inkumsah made the same notations with regards to Plaintiff's condition when he saw her both in early and late December. (Tr. 385, 387.) At the late December appointment, Dr. Inkumsah additionally noted that Plaintiff's depression "is mild and currently stable." (Tr. 385.) Dr. Inkumsah noted that Plaintiff will "follow[] up with her counselor" and "[o]verall, [Plaintiff] is a very pleasant lady and seems to be doing pretty well at this point in time." (Tr. 386.)

B. 2008

Dr. Inkumsah saw Plaintiff twice in January 2008. Each time, she appeared to be in no distress and had an appropriate mood. (Tr. 380, 382, 383, 384.)

On February 12, Plaintiff saw Dr. Inkumsah "due to an encounter with police that has left her shaking." (Tr. 378.) Plaintiff reported that "her 18[-]year[-]old son had been involved with possible illegal activities that resulted in the police breaking into her house recently and searching the house for any kind of illegal material." (Tr. 378.) Dr. Inkumsah noted that Plaintiff "finds herself [waking up in the middle of the night, ] getting up[, ] and walking around the house to make sure everything is locked up." (Tr. 378.) This incident appeared to have aggravated Plaintiff's PTSD already present from an encounter with police several years ago. (Tr. 378.) Dr. Inkumsah noted that Plaintiff had been prescribed Paxil[2], but was not currently taking it. (Tr. 378.) Plaintiff was in "no acute distress" and her mood seemed "appropriate... considering the circumstances." (Tr. 379.) Dr. Inkumsah diagnosed Plaintiff with "[PTSD], acute and chronic" and advised Plaintiff to continue taking her Paxil prescription. (Tr. 379.) Dr. Inkumsah also prescribed "Ambien[3] for the next seven days since [Plaintiff] was also complaining of insomnia." (Tr. 379.)

Plaintiff saw Dr. Inkumsah once in March, twice in June, and once in July for conditions unrelated to her mental health. (Tr. 376, 374, 372, 370.) During these visits, Plaintiff appeared "comfortable, " "pleasant, " and in "no distress" and had an "appropriate mood." (Tr. 377, 374, 375, 372, 373, 370, 371.)

Plaintiff saw Dr. Inkumsah again on August 12 for conditions unrelated to her mental health. (Tr. 368.) Plaintiff also reported, however, that she was having trouble falling asleep and medication sometimes helps. (Tr. 368.) Plaintiff mentioned that she was "working with the Y to get a membership very soon." (Tr. 368.) Dr. Inkumsah "discussed good sleeping habits including not having the TV or radio on and also exercising." (Tr. 369.) Plaintiff was "in no distress, " "comfortable, " "pleasant, " and had an "appropriate mood." (Tr. 369.)

In October 2008, Plaintiff underwent a psychological evaluation by Ronald L. Hoschouer, Ph.D. (Tr. 282, 289.) When asked by Dr. Hoschouer "if she is currently disabled and unable to work[, Plaintiff] respond[ed], No, I can work.'" (Tr. 282.) Plaintiff described "her disability" as depression, anxiety, and obsessive compulsive disorder. (Tr. 282.) Plaintiff stated that these conditions make it so that she "[d]o[es not] like to be around people, [she] like[s] to be alone a lot, can[not] take orders from people, (can[not] stand) someone bossing [her] around...." (Tr. 282.)

When asked about her interests, Plaintiff answered that "she likes to swim and read." (Tr. 282.) Plaintiff described her typical day to Dr. Hoschouer as follows:

[S]he arises between 5:30 a.m. and 6:00 a.m. After arising, she will do hygiene, get dressed, get the kids up from bed, and clean most of the day, or go to doctor appointments and physical therapy for her arms and back. She states that she will eat a simple breakfast and lunch that she prepares. She starts making dinner around noon. She will read most of the day and wash clothes. The kids come home around 2:45 and after they arrive, she will talk with them about their day, make sure the [seven]-year-old reads, and the rest of the children do their homework. They will then get their school materials ready for school the next day. The family eats dinner between 6 and 7 p.m. She says that she makes sure all the kids get their bath and then they watch TV until 9-9:30 p.m., when it's bedtime for everyone. [Plaintiff] and the teen children shop for food and the teenage children shop for the clothing.

(Tr. 283.)

At the time of Dr. Hoschouer's evaluation, Plaintiff had been "recently evicted from her apartment" and was living with "the children's grand[parents]." (Tr. 283.) Of Plaintiff's seven children, five of them were "living with their older sister." (Tr. 283.) Plaintiff reported getting along well with her family. (Tr. 283.) Plaintiff denied having any friends or interacting with her neighbors. (Tr. 283.) When she was working, Plaintiff did not socialize with her coworkers and "stayed to [her]self." (Tr. 283.)

Dr. Hoschouer noted that Plaintiff was "adequately groomed[;]... appear[ed] relaxed, pleasant, and cooperative[;]... [was] able to maintain intermittent eye contact[; and was] able to communicate adequately." (Tr. 283.) Plaintiff "g[ave] relevant and coherent information." (Tr. 283.) As for Plaintiff's thought content, Plaintiff endorsed symptoms of cognitive dysfunction, including "difficulty with attention/concentration, distractibility, impaired memory, impaired cognitive functioning, poor judgment, and poor decision making." (Tr. 283.) Plaintiff reported "a history of disorientation" and described symptoms of "thinking disturbance, " such as hallucinations, "false beliefs of persecution, inappropriate jealousy, excessive possessiveness, defensiveness, suspiciousness, distrust, and paranoid thinking." (Tr. 283.)

As for Plaintiff's affect and mood, Plaintiff "report[ed] that she has been depressed since childhood" and "is depressed every day.'" (Tr. 283.) Within the past month, Plaintiff reported experiencing a

depressed or lowered mood, sadness, boredom, crying spells, easily teary-eyed, grief about the loss of loved ones (two children), despair or despondency, hopelessness, helplessness, passive suicidal thoughts, low self-esteem, negative selfconcept, negative personal identity, feelings of inadequacy, feelings of worthlessness, guilt, shame, decreased interest in daily activities, loss of pleasure in activities, loss of motivation and drive, apathy, decreased energy or tiredness, fatigue and exhaustion, sleep difficulty..., poor concentration, indecisiveness, psychomotor agitation, and psychomotor retardation.

(Tr. 284.) Plaintiff also "describe[d] symptoms of mood disturbance, " including "moodiness, irritability, ... emotional instability, ... energized behavior, decreased need for sleep, psychomotor agitation, restlessness, high-strung behavior, inflated self-esteem or grandiosity, excessive verbosity, pressured speech, racing thoughts, poor focus and distractibility, excessive but inefficient activities, and impulsive involvement in risky or self-defeating behaviors." (Tr. 284.)

In addition, Plaintiff described symptoms of anxiety, including "social anxiety (uncomfortable around people, crowds, and public places), obsessive thinking (A child who has recently passed'), compulsive behavior (cleaning, everything straightened up and in order, checking doors and windows) and generalized anxiety and apprehensiveness." (Tr. 284.) Plaintiff stated that she "excessively worries about 1) bills/money, 2) the kids, 3) her family, 4) her health, and 5) her future." (Tr. 284.) Plaintiff also stated that she experienced "restlessness, concentration difficulty, easy fatigue, muscle tension, and sleep disturbance." (Tr. 284.) Plaintiff also reported "a history of panic attacks." (Tr. 284.)

Plaintiff told Dr. Hoschouer that "she was physically, sexually, emotionally, and verbally abused as a child and as an adult." (Tr. 284.) The abuse was perpetrated by her stepfather as a child and by her boyfriend/partner as an adult. (Tr. 284.) Dr. Hoschouer noted that Plaintiff had the following symptoms associated with "post-traumatic anxiety: distressing recollections of traumas, emotional re-experience of traumas, memory loss associated with traumas, diminished interest/detachment/restricted affect, exaggerated startle reflex, hypervigilance, irritability or anger outbursts, and avoidance of situations causing memories of the traumatic situations." (Tr. 284.)

Plaintiff also described "anger and stress management symptoms, " which included "excessive anger, difficulty managing anger, easy emotional upset, low stress tolerance, limited stress coping skills, easily frustrated, difficulty dealing constructively with frustration, ... impulsivity, over-reactions to situational stresses, and difficulty dealing with changes in routines." (Tr. 284.) Dr. Hoschouer noted that Plaintiff expresses her anger and stress "in conflict and aggressive behaviors, " such as conflicts with others, "oppositional behaviors, defiant behaviors, difficulty dealing with authority figures, blaming others for problems, verbal aggression (swearing), name-calling, physical aggression..., and self-abuse (picking at sores or skin)." (Tr. 284.) Plaintiff also reported "a history of conflicts with coworkers." (Tr. 284.)

Dr. Hoschouer noted that Plaintiff "demonstrates adequate reality contact" and "is oriented to person, day, date, and place." (Tr. 285.) Plaintiff could name two of the last three presidents of the United States, but had no knowledge of current events as she "do[es not] like the news." (Tr. 285.) Plaintiff could not "interpret simple proverbs" and, "[w]hen asked what she would do if she were the first person to see smoke or fire in a crowded movie theater, she respond[ed], Yell smoke, fire.'" (Tr. 285.)

Dr. Hoschouer stated that Plaintiff "describes symptoms that may be related to a personality disorder. These symptoms include depression, moodiness, anxiety, posttraumatic anxiety, anger and stress, conflict and aggressive behaviors, cognitive dysfunctioning, and thinking disturbance." (Tr. 285.)

Dr. Hoschouer also performed a series of tests in connection with his assessment of Plaintiff. Dr. Hoschouer observed that Plaintiff "is able to understand the testing instructions"; "is able to attend adequately and concentrate during the testing"; and "does not become unduly upset when she does not know the answers to the question items." (Tr. 285.) Dr. Hoschouer performed the Wechsler Adult Intelligence Scale-III ("WAIS-III")[4] IQ test, where Plaintiff "achieve[d] a Verbal IQ of 65 and a Performance IQ of 70, which yields a Full Scale IQ of 64." (Tr. 285.) This score placed Plaintiff "in the extremely low section of the normal distribution of scores" and Plaintiff "would be considered extremely low intelligence' as compared with her peers." (Tr. 285.) Based on the Wide Range Achievement Test-3 ("WRAT-3")[5], Plaintiff's reading ability was at a sixth-grade level and her arithmetic ability was at a fourth-grade level. (Tr. 286.)

On the Adaptive Behavior Assessment System-II[6], Plaintiff received borderline scores in the areas of communication and self-direction; below average scores in the areas of community use, home living, and health and safety; extremely low scores in the areas of functional academics, leisure, and social; and an average score in the area of selfcare. (Tr. 286.) Collectively, these scores placed Plaintiff in the "extremely low range of ability" with respect to general adaptive skills, conceptual skills, and social skills, and "below average range of ability" with respect to practical skills. (Tr. 286-87.)

Based on Plaintiff's low test scores, Dr. Hoschouer concluded that "it appears very likely that [Plaintiff] will not be able to maintain competitive employment." (Tr. 287.) Dr. Hoschouer also observed that Plaintiff's "depression, moodiness, anxiety, posttraumatic anxiety, anger and stress management, conflict and aggressive behaviors, cognitive dysfunctioning [sic], and thinking disturbance" would likely interfere with Plaintiff's ability to pay attention and concentrate, which "in turn would interfere with her ability to maintain competitive employment." (Tr. 287.) Dr. Hoschouer found no evidence of decompensation. (Tr. 287.)

Dr. Hoschouer diagnosed Plaintiff with depression, generalized anxiety disorder with social phobia and obsessive-compulsive features, and PTSD. (Tr. 287.) Dr. Hoschouer concluded that Plaintiff had "[m]ild mental retardation with extremely low general adaptive skills, " (Tr. 287), and "serious symptoms, serious impairment in social and occupational functioning, " (Tr. 288). Dr. Hoschouer gave Plaintiff a Global Assessment of Functioning ("GAF") score of 40 to 45[7], indicating "[s]erious symptoms, serious impairment in social and occupational functioning." (Tr. 288.) Dr. Hoschouer also concluded that Plaintiff "is unable to handle her own funds." (Tr. 288.)

Dr. Hoschouer opined that Plaintiff "is likely to experience vocational limitations because of her extremely low intelligence and mental health problems. [Plaintiff] is not likely to be able to engage in competitive employment.... Her ability to work with male staff may be affected by her post-traumatic experiences." (Tr. 288.)

Dr. Hoschouer stated that Plaintiff "should be considered a vulnerable adult' because of her extremely low intelligence and mental health problems." (Tr. 288.) Dr. Hoschouer stated that Plaintiff "will continue to require at least a moderate degree of external structure, supervision, and support over the long-term" and recommended that Plaintiff "receive individualized skill training for independent living in the community" due to Plaintiff's "functional deficits" in the areas of "management of mental health symptoms, accessing mental health services, vocational functioning, educational functioning, social/interpersonal functioning, family relationships, medical health, obtain/maintain financial assistance, and obtain/maintain housing." (Tr. 288.)

Dr. Hoschouer recommended that Plaintiff "receive individual psychotherapy and psychiatric medication management" as well as "group therapy with a social/adaptive skills approach." (Tr. 288.) Dr. Hoschouer also recommended that "application be made for county developmental disability services and for [SSI]." (Tr. 288.)

Plaintiff was next seen at the Bethesda Clinic in late December by Stefan Pomrenke, M.D. (Tr. 364.) While Plaintiff's visit was prompted by a complaint unrelated to her mental health, Dr. Pomrenke made the following notes concerning Plaintiff's mental health:

[Plaintiff] also scored high on PHQ9 ~ 17.[8] [Plaintiff] states she is depressed currently, gained 20 pounds over the past three months. Over the summer she hosted a party at which a male was shot and killed outside of her house. Also the house she was renting was placed into foreclosure in [S]eptember and she has been living with her sister since then with her 5 children eldest is 16 [years old] youngest 7 [years old].... Not currently with a job or seeking a job is being assisted by the state for her children, she does not have any other disability. She states she does not talk to anyone about her problems. She had been in therapy about 1 year ago.... She is willing to start therapy again.

(Tr. 364.) Dr. Pomrenke "referred [Plaintiff] to [DIAMOND[9] to arrange continuing therapy along with [Paxil] and possible [Paxil] augmentation in the future." (Tr. 365.)

C. 2009

On January 2, 2009, Deanna Bass, M.D., of the Bethesda Clinic, reviewed Plaintiff's chart in connection with the DIAMOND program and met with DCC[10] Chris Castro. (Tr. 363.) Dr. Bass noted Plaintiff's past diagnoses of PTSD, depression, and obsessive compulsive disorder. (Tr. 363.) Dr. Bass recommended "a referral to Chrysalis" for "non-medication intervention, " which "DCC will facilitate." (Tr. 363.) Noting that Plaintiff was experiencing daytime fatigue and difficulty sleeping, Dr. Bass recommended that Plaintiff take Paxil in the evening. (Tr. 363.) Dr. Bass also recommended the DCC discuss with Plaintiff whether Paxil "had ever been helpful" to her so that Dr. Bass could make "[a] specific med rec.... at that time." (Tr. 363.)

On January 8, Plaintiff had a follow-up appointment through DIAMOND and was seen by Christina Miller. (Tr. 361, 362.) During her appointment, Plaintiff's PHQ-9 score was 16, indicating "[s]evere depression." (Tr. 361.) Miller also noted that Plaintiff is in the process of renewing her state identification as "[s]he would eventually like to apply for a job and then the YMCA...." (Tr. 362.) Miller noted that Plaintiff's obsessive-compulsive-disorder diagnosis is "unclear" and Plaintiff no longer feels as though cleaning interferes with her life. (Tr. 362.)

Additionally, Miller documented an "episode" Plaintiff had approximately one month before "when she thought the sidewalk was veering off towards a ramp. She followed it and went into the street where there was traffic. Her kids stopped her and asked her what was wrong. After the kids pointed it out, [Plaintiff] realized that the ramp did not exist." (Tr. 362.) Plaintiff was taking her medication at the time, but was also "under a lot of stress" due to the lack of permanent housing. (Tr. 362.)

In a follow-up appointment with DIAMOND approximately one week later, Plaintiff's PHQ-9 score was 12, indicating "[m]oderate depression." (Tr. 359.) Miller expressed concern over the effectiveness of Plaintiff's Paxil prescription as Plaintiff felt there had been "little improvement in the past year." (Tr. 359.) Plaintiff was, however, sleeping better since she began taking the prescription at night. (Tr. 359.) Plaintiff had not been able to renew her identification, but still wanted to do so in order to "obtain a job and go to the YMCA." (Tr. 360.)

Plaintiff also discussed her mother's health. (Tr. 360.) Plaintiff was "tearful" when talking about her mother. (Tr. 360.) Plaintiff talked about "possibly traveling to New Jersey to visit her mother, " but Miller noted that finances were a barrier and so they discussed how Plaintiff "can start[] saving and planning for the trip." (Tr. 360.) In addition, Miller noted that Plaintiff's housing status was "resolved." (Tr. 360.) Miller also made notes for Plaintiff's primary care giver, questioning whether a medication was necessary given that there is "[s]ome improvement in PHQ-9 especially in regards to ability to fall asleep at night-otherwise remains about the same. (Tr. 360.)

Plaintiff's chart was reviewed by Dr. Bass and Ann Brosnan at the Bethesda Clinic on January 30. (Tr. 358.) They observed a "[d]ownward trend...." in Plaintiff's PHQ-9 scores, with her most recent score of 6 on January 23. (Tr. 358.) They also noted that Plaintiff's "OCD symptoms seem less dominant over the last year and that may be partly due to Paxil, " which Plaintiff is tolerating better. (Tr. 358.) They recommended that no changes be made to Plaintiff's medication at this time; Plaintiff continue treatment for at least one year "and then reassess with Dr. Bass"; and Plaintiff continue participating in the DIAMOND program. (Tr. 358.)

Plaintiff was next seen at the Bethesda Clinic on March 3 by Kimberly Bigelow, M.D., for complaints unrelated to her mental health and difficulty sleeping. (Tr. 355.) Plaintiff was described as "comfortable, " "pleasant, " and in "no distress." (Tr. 355.)

Plaintiff had another DIAMOND appointment with Miller approximately one week later. (Tr. 354, 357.) Plaintiff's PHQ-9 score was now 20, indicating "[s]evere depression." (Tr. 354, 357.) Miller also noted a corresponding mood change for no apparent reason and difficulty falling and staying asleep. (Tr. 354.) Nevertheless, Plaintiff had renewed her identification; her "[h]ousing issues have resolved themselves"; and her stress over her mother "ha[d] improved with some extra services." (Tr. 357.)

During this appointment, Plaintiff also reported "hearing voices" calling her name, approximately twice per day. (Tr. 357.) Plaintiff reported that she previously heard voices "a few years ago, " but they stopped and only recently started again within the last two weeks. (Tr. 357.) Plaintiff also reported that she "has been more agitated and prefers to be alone." (Tr. 357.)

At Plaintiff's next DIAMOND appointment with Miller approximately one week later, Plaintiff's PHQ-9 score was 19, still indicating "[s]evere depression." (Tr. 352; see also Tr. 351.) Miller documented concerns of increased difficulty sleeping and psychosis related to the voices. (Tr. 352, 353, 351.) Miller stated that this was a "joint visit... to determine best plan of care and how to treat potential psychosis, " which included Dr. Bass, David Hunter, M.D., and the DCC. (Tr. 353; see also Tr. 351.) Dr. Bass recommended that Plaintiff take Abilify.[11] (Tr. 353; see also Tr. 351.)

Dr. Bass reviewed Plaintiff's chart on March 18 and noted that Plaintiff's "depression needs more aggressive treatment." (Tr. 349.) Dr. Bass stated that "[t]his would probably be a good [point] to get to a psychiatrist-both for diagnostic clarity and long[-]term management." (Tr. 349.) Dr. Bass stated that "constant updates" would be needed to make ongoing medication recommendations and observed that the Abilify might improve Plaintiff's depression as well as treat her psychosis. (Tr. 349.)

Dr. Hunter saw Plaintiff for a follow-up visit related to her depression two days later. (Tr. 347.) Dr. Hunter recommended that Plaintiff continue taking Abilify as she was tolerating it well. (Tr. 347.) Plaintiff still reported difficulties sleeping and hearing voices "but fel[t] as if the voices are less." (Tr. 347.) Plaintiff appeared more relaxed and spontaneous although "she does not feel that she is having a steady improvement." (Tr. 347.) In coordination with Dr. Bass, Dr. Hunter increased Plaintiff's Paxil prescription. (Tr. 347, 348.)

Plaintiff was seen at the Bethesda Clinic by Tajinder Singh, M.D., on March 25 for reasons unrelated to her mental health. (Tr. 344, 346.) Dr. Singh noted a new diagnosis of "Major Depression, Recurrent with Psychotic Features." (Tr. 344.) Dr. Singh observed that Plaintiff was in "no distress, comfortable, [and] pleasant" and had an "appropriate mood." (Tr. 345, 346.)

Plaintiff saw Dr. Bigelow at the Bethesda Clinic for follow-up appointment regarding her depression on March 27. (Tr. 342, 343.) Dr. Bigelow noted that the voices "ha[ve] improved greatly" and Plaintiff was feeling less agitated. (Tr. 342.) Plaintiff still reported "feel[ing] a bit restless at times and still has some difficulty with sleeping." (Tr. 342.) Dr. Bigelow noted "a slight improvement" in Plaintiff's PHQ-9 score, which was now 15. (Tr. 343.) Plaintiff was in "no distress, comfortable, [and] pleasant." (Tr. 342.) Plaintiff reported feeling "a bit better." (Tr. 343.) Dr. Bigelow discussed with Plaintiff "that Paxil takes some time, a couple of more weeks, to take full effect." (Tr. 343.)

At a follow-up appointment in mid-April, Dr. Bigelow noted that Plaintiff's depression is "improving"; Plaintiff's medications were "working quite well"; Plaintiff "is feeling much, much better." (Tr. 340.) Plaintiff had some continuing difficulties with sleep, but attributed them to her teenager slamming the door late at night. (Tr. 340.) Plaintiff was no longer hearing voices and her PHQ-9 score was down to 9. (Tr. 340.) Dr. Bigelow observed that Plaintiff was in "no distress, comfortable, [and] pleasant." (Tr. 340.) Dr. Bigelow continued Plaintiff's depression-related medications. (Tr. 340.)

Plaintiff returned to the Bethesda Clinic at the end of April "complaining of increased irritability, high energy, restlessness, [and] agitation for the past... week." (Tr. 338.) She was seen by Kene Ogbogu, M.D. (Tr. 339.) Plaintiff had stopped taking Abilify and lowered her dose of Paxil when she started experiencing these symptoms. (Tr. 338.) Since the self-reduction in Paxil, Plaintiff did not feel as "agitated, restless[, ] or irritable." (Tr. 338.) Abilify made sleeping difficult and Plaintiff did not want to resume taking it. (Tr. 338; see also Tr. 339.) Plaintiff was also unwilling to resume her prescribed dose of Paxil. (Tr. 339.) Dr. Ogbogu counseled Plaintiff on "the importance of medications in management of [Plaintiff's] symptoms, " and attempted to put Plaintiff in touch with the Fairview Mental Health Clinic for a psychiatric consultation. (Tr. 339.)

Plaintiff saw Dr. Ogbogu again the following week, reporting improvements in her irritability and sleep. (Tr. 336; see also Tr. 337.) Plaintiff stated that she had not been hearing voices and her PHQ-9 score was 9. (Tr. 336; see also Tr. 337.) During this visit, Plaintiff also told Dr. Ogbogu that "she lost a close family friend about a year ago. Every week[, ]... she reflects on her friend's death and is emotional about it.... [H]er son was shot 3 y[ea]rs ago but survived. She tends to worry a lot about her kids." (Tr. 336.) Dr. Ogbogu noted that a psychiatric appointment had been scheduled for Plaintiff for May 12 and Plaintiff would continue with the reduced dose of Paxil until this appointment. (Tr. 337.) Dr. Ogbogu also recommended that Plaintiff attend psychotherapy and coordinated "with the clinical psychologist [Christine] Danner, [Ph. D., ] who evaluated [Plaintiff] and helped set up a visit with one of the psychologists on May 4." (Tr. 337.)

Dr. Danner also made notes from the visit. (Tr. 334.) Plaintiff told Dr. Danner that "[a] 15[-]year[-]old boy, a friend of her daughter, was shot and killed by another teen while leaving a party at their home. Her daughter was also with him at the time." (Tr. 334.) Dr. Danner noted that Plaintiff "has intrusive thoughts of this incident and ongoing sadness and guilt about not having preventing it." (Tr. 334.) Plaintiff also relayed to Dr. Danner that, approximately three years ago, her teenage son was shot and survived. (Tr. 334.) Dr. Danner noted that this incident "has contributed to feelings of anxiety and depression in [Plaintiff's] life." (Tr. 334.) Dr. Danner observed that Plaintiff "appeared sad and tearful at times... when relaying some of the traumatic history" and "endorse[d] intrusive thoughts of death, a trend towards isolating herself secondary to not wanting to talk about what happened, she feels guilt and responsibility for not having prevented the incident and worries that others may judge her as well." (Tr. 334.) Dr. Danner set an appointment for Plaintiff "with Jane at the Associated Clinic[] of Psychology... [for] May 4." (Tr. 334-35.) Dr. Danner also "[p]rovided some psychoeducation regarding the nature of trauma and the potential for post-traumatic stress" and "[d]iscussed how social isolation may be hurtful to [Plaintiff]." (Tr. 335.)

On May 4, Plaintiff was seen at the Associated Clinic of Psychology by Jane M. Hollis, M.A., L.P. (Tr. 318-24, 601.) In her intake form, Plaintiff stated that she was seeking counseling "for the death of my children's friend." (Tr. 318.) When asked what she hoped to achieve from counseling, Plaintiff stated "not blame myself" and "to get off my mind every day [and] night." (Tr. 318.) Plaintiff reported that she lived in a home with five of her children, ages 7 through 16. (Tr. 320.) She had no housing, financial, or legal concerns. (Tr. 320, 321.) Plaintiff reported having good relationships with her children, mother, and siblings, and frequently talked with her mother and siblings on the phone. (Tr. 320.) Plaintiff's motivation was "[l]ow" and she reported experiencing major changes within the past year, including "[b]lended family issues" and the "[d]eath of a family member or friend." (Tr. 321.) Plaintiff enjoyed walking, running, swimming, attending the YWCA, and reading. (Tr. 322.) Plaintiff reported that she had no friends. (Tr. 322.) Plaintiff also reported that she was sexually abused by her stepfather. (Tr. 322; see also Tr. 303.) Plaintiff checked "Yes" when asked whether she had any safety concerns for members of her family, but did not describe those concerns. (Tr. 322.)

Plaintiff was then asked to check which functional concerns she had and to rate the "severity/frequency" of the concern. (Tr. 323-24.) Among other things, Plaintiff reported that she was extremely/constantly concerned about social withdrawal, diminished social interaction, isolation, and "[i]nhibitions in social situations." (Tr. 323.) Plaintiff was mildly/occasionally concerned about arguments, aggression, oppositional behavior, stormy relationships with others, and "[e]xcessive dependency." (Tr. 323.) Plaintiff also reported that she was extremely/constantly concerned about "[d]ifficulty having fun" and "[l]ack of relaxing and pleasurable activities." (Tr. 324.)

Hollis noted that Plaintiff presented with symptoms and a history of depression and anxiety; "described symptoms of bipolar disorder"; and "exhibit[ed] signs of PTSD" from the party shooting. (Tr. 302.) Hollis wrote that Plaintiff had since moved from the home where the shooting took place, but "still constantly checks doors/windows [and] reexperiences event." (Tr. 302.) Hollis also noted that Plaintiff "hears voices calling her name." (Tr. 302.) Hollis listed Plaintiff's concerns as depression, lack of motivation, anxiety, difficulty sleeping, isolation, and "intrusive memories." (Tr. 302.)

Hollis observed that Plaintiff was well-groomed, cooperative, and calm. (Tr. 306.) Plaintiff had an appropriate mood and affect and her thought process was intact. (Tr. 306.) Hollis described Plaintiff's "[r]ecent memory" as "mildly impaired" and both her judgment and insight as minimally impaired. (Tr. 306.)

Evaluating a series of functional impairments, Hollis observed that Plaintiff had a moderate to severe occupational impairment and a mild to moderate educational impairment. (Tr. 306.) Hollis described Plaintiff as mildly impaired in the areas of parenting, obsessive thinking, and "[p]sychosis (current & historical)." (Tr. 307, 308.) Hollis described Plaintiff as being moderately impaired in the areas of "[m]arital/[r]elationships, " "[l]ack of pleasure, " sleep, appetite, irritability, energy, concentration, anger, "[c]rying spells, " and "[h]eart racing." (Tr. 307.) Similarly, Plaintiff was moderately impaired with regards to "[r]ituals (washing, checking, counting), " "[l]abile mood, " "[r]acing thoughts, " "[m]ania (current & historical), " and paranoia. (Tr. 308.) Hollis determined that Plaintiff was moderately to severely impaired in the areas of "[d]epressed mood, " "[f]eelings of guilt/worthlessness, " and anxiety. (Tr. 307.) Plaintiff was severely impaired in the area of "[s]ocial [w]ithdrawal." (Tr. 307.) Hollis noted that Plaintiff had past suicidal thoughts, but no current suicidal ideation. (Tr. 308, 309.) Plaintiff also had problems with anger management. (Tr. 309.)

Hollis concluded that Plaintiff met the criteria for bipolar disorder and PTSD. (Tr. 316; see also Tr. 311-12, 601.) Hollis noted that Plaintiff had "[e]conomic problems- low income (SSI)" as well. (Tr. 316; see also Tr. 601.) Hollis's treatment goals were to stabilize Plaintiff's mood, refer Plaintiff to a psychiatrist for medication to treat her bipolar disorder and PTSD, and work with Plaintiff to reduce her current stressors. (Tr. 317.) Once Plaintiff was stabilized, Hollis would address Plaintiff's PTSD. (Tr. 317.) Hollis gave Plaintiff a GAF score of 41. (Tr. 316; see also Tr. 601 ("41-36").) Finally, Hollis also gave Plaintiff a psychiatric referral. (Tr. 316; see also Tr. 601.)

Plaintiff saw Hollis again approximately one week later. ( See Tr. 301.) Plaintiff felt about "the same, " but stated that she was supposed to have turned herself in to the workhouse for five days related to a shoplifting incident. (Tr. 301.) Hollis ascribed the shoplifting incident to a "manic" event associated with Plaintiff's bipolar disorder. (Tr. 301.) Hollis noted that Plaintiff was scheduled for a psychiatric appointment in June to address her medication. (Tr. 301.) Hollis also noted that she would see about resuming Plaintiff's GED coursework. (Tr. 301.)

Plaintiff was seen at the Bethesda Clinic on May 11 for a complaint unrelated to her mental health. (Tr. 332.) Dokka Williamson, M.D., observed Plaintiff to be in "no distress, comfortable, [and] pleasant." (Tr. 332.)

When Plaintiff saw Hollis the following week, Plaintiff reported that she was "doing fairly well, " but experienced a "PTSD flashback" at a barbeque over the weekend. (Tr. 300.) Hollis observed that Plaintiff had some PTSD-related anxiety and was "also anxious due to possible arrest/[Plaintiff] need[s] to turn self in for shoplifting." (Tr. 300.)

Plaintiff returned to the Bethesda Clinic on May 26 for a follow-up appointment with Dr. Ogbogu regarding her depression. (Tr. 329, 331.) Dr. Ogbogu noted that Plaintiff still thinks about the party shooting. (Tr. 329.) Plaintiff reported that "[t]he kid that pulled the trigger was also visiting at her house the same day" and "[t]hese thought[s] are in her mind daily and affect[] her functioning-[s]he avoids mingling with friends for fear of being asked about that event." (Tr. 329.) Dr. Ogbogu noted that Plaintiff's sessions with Hollis had "helped her somewhat." (Tr. 329.) Plaintiff's PHQ-9 score was 15, and Plaintiff endorsed symptoms of a "[d]epressed mood most of the day"; "[m]arkedly diminished interest or pleasure in almost all activities nearly every day"; "insomnia"; "[f]atigue or loss of energy"; and "[i]mpaired concentration, indecisiveness." (Tr. 329, 330.) Plaintiff reported that she was "[w]alking, [r]unning daily." (Tr. 330.) Plaintiff denied any episodes of mania. (Tr. 330.) Dr. Ogbogu increased Plaintiff's Paxil prescription and prescribed Ambien to help Plaintiff sleep. (Tr. 330.)

During Plaintiff's next appointment with Hollis in early June, Hollis noted that Plaintiff is "still having flashback of shooting [and] is afraid of police coming by to pick her up for shoplifting." (Tr. 299.) Hollis provided Plaintiff with a letter discussing her bipolar disorder in an effort to ease Plaintiff's worries. (Tr. 299.) Hollis also worked on some relaxation exercises with Plaintiff. (Tr. 299.)

On June 25, Plaintiff was seen by Kathi Lietzau, M.E.D., M.S., R.N., C.S., a nurse clinical specialist in psychiatry, at Associated Clinic of Psychology. (Tr. 394.) Lietzau noted that Plaintiff was referred by Hollis in order "to establish with a psychiatric medication provider and look at medications for bipolar and PTSD." (Tr. 394.)

Lietzau noted that Plaintiff's Beck II[12] score "is 34, indicating major depression, " and a mood questionnaire Plaintiff completed supported symptoms of bipolar disorder. (Tr. 394.) Plaintiff reported that she began having difficulty sleeping and started feeling depressed following the party shooting. (Tr. 394.) "Since that time, [Plaintiff] has struggled with increased depression and PTSD." (Tr. 394.) Plaintiff told Lietzau that Ambien helped her fall asleep, but she frequently wakes after midnight and cannot fall back asleep. (Tr. 394.) Plaintiff also reported putting on weight "as a result of increased stress from the shooting." (Tr. 394.) Plaintiff reported that "she has always been a loner, " but has done things recently with her children. (Tr. 395.) Plaintiff "joined the YMCA and is hoping [to attend with her children]... over the summer." (Tr. 395.)

Lietzau made the following observations:

Appearance and grooming are casual. Behavior is restless at times. Eye contact is made.... Mood appears depressed; affect is appropriate. Speech is clear. [Plaintiff] reports that several weeks ago she did have some auditory hallucinations where she heard voices calling her name. The Abilify was helpful with that but she just found it too activating. She does feel that people are watching her. She has some paranoid thinking. She does endorse raging thoughts. Abstract thinking is intact. She also endorses obsessive thinking. Compulsive behaviors seem to be mostly germ[-]based cleanliness.... Insight and judgment appear to be intact at today's appointment. Cognition and memory are intact. However, [Plaintiff] declined to do serial sevens.

(Tr. 395.) Lietzau diagnosed Plaintiff with bipolar disorder and PTSD. (Tr. 395.) Lietzau assessed Plaintiff as having a GAF score of 45 to 50. (Tr. 395.) Lietzau recommended continuing Plaintiff's Paxil, Ambien, and Vistaril prescriptions. (Tr. 395, 396.) Lietzau also recommended that Plaintiff begin taking Seroquel.[13]

Plaintiff saw Dr. Ogbogu again on June 30, 2009. (Tr. 327, 328.) Plaintiff reported that "[s]he is still depressed every day" and felt the same, but was sleeping better. (Tr. 327.) Dr. Ogbogu noted that Plaintiff still thinks about the party shooting and these thoughts were recently "heightened" by an incident in which a child was killed. (Tr. 327.) Dr. Ogbogu observed that Plaintiff "isolates herself and avoid[s] mingling with people"; "does[ not] have much social support"; and "does[ not] have any particular activity that takes her mind off her thoughts." (Tr. 327.) Plaintiff was in "no distress, comfortable, [and] pleasant" and her PHQ-9 score was 15. (Tr. 328.) Plaintiff's depression was "stable." (Tr. 328.) Dr. Ogbogu noted that Plaintiff will follow up with her psychiatrist and continue taking her medications. (Tr. 328.) Dr. Ogbogu counseled Plaintiff on the importance of engaging in social and physical activities. (Tr. 328.)

Plaintiff was seen at Associated Clinic of Psychology on August 10 for medication management. (Tr. 393.) It is not clear from the record which provider Plaintiff saw. ( See Tr. 393.) Plaintiff was described as "hypomanic." (Tr. 393.) Plaintiff's energy level was up and her need for sleep down. (Tr. 393.) Plaintiff's appearance, grooming, speech, mood, and affect were all "appropriate." (Tr. 393.) Plaintiff did, however, appear fidgety and her insight/judgment, concentration, and memory were just "ok." (Tr. 393.) Plaintiff's thought process was "circumstantial." (Tr. 393.) Plaintiff was given a trial prescription of Depakote ER.[14] (Tr. 393.)

Plaintiff met with Dr. Ogbogu at the Bethesda Clinic again on August 28. (Tr. 417.) Dr. Ogbogu noted that Plaintiff "is still depressed daily" and "is not convinced that the medications are helping maximally. She also thinks she is forgetful on some occasions, but mainly limited to tasks and not orientation." (Tr. 417.) Plaintiff still had trouble sleeping, but the Ambien was helping. (Tr. 417.) Dr. Ogbogu advised Plaintiff to follow up with her psychiatrist and psychologist and take her medications as prescribed "as a continuous attempt is made to get her on the effective dose." (Tr. 418.) Dr. Ogbogu noted that Plaintiff's forgetfulness could be a side effect of the Ambien and told Plaintiff to use reminders and to come back if things started getting worse. (Tr. 418.)

Plaintiff was seen at Associated Clinic of Psychology on September 3 for medication management. (Tr. 392.) Again, it is not clear from the record which provider Plaintiff saw. ( See Tr. 392.) Plaintiff's Beck II score was 22. (Tr. 392.) Plaintiff reported sleeping better, but her appetite and energy level were just "ok." (Tr. 392.) Plaintiff's appearance, grooming, speech, mood, and affect were "appropriate"; her behavior "relaxed"; and her thought process "logical." (Tr. 392.) Plaintiff's insight/judgment, concentration, and memory were still just "ok." (Tr. 392.) Plaintiff was "still depressed" and her moods were "still labile, " but the Depakote was helping. (Tr. 392.) Plaintiff's prescriptions for Paxil and Depakote were increased. (Tr. 392.)

Plaintiff saw Dr. Ogbogu at the Bethesda Clinic for a physical on September 17. (Tr. 414.) Plaintiff experienced "[d]epression daily[] and [had] racing thoughts, " but "[n]o hallucinations or hyperactivity." (Tr. 414.) Plaintiff had difficulties sleeping and felt tired. (Tr. 414.) Plaintiff also reported "[l]ittle interest or pleasure in doing things" and "[f]eeling down, depressed, or hopeless" for "[s]everal days" in the last two weeks. (Tr. 415.) Dr. Ogbogu observed that Plaintiff was in "no distress, comfortable, [and] pleasant." (Tr. 416.) Dr. Ogbogu assessed Plaintiff as having "[d]epression with psychotic features.... [and] advised [Plaintiff] on medication compliance." (Tr. 416.)

Plaintiff saw Lietzau for medication management on November 3. (Tr. 391.) Lietzau noted Plaintiff's anxiety was "stable"; her depression and mania were "ok"; and her sleep, appetite, and energy levels were all "good." (Tr. 391.) Plaintiff's appearance, grooming, speech, mood, and affect were all "appropriate"; her behavior "relaxed"; and her thought process "logical." (Tr. 391.) Plaintiff's concentration was "focused" and her memory within normal limits whereas her insight/judgment was "fair." (Tr. 391.) Lietzau continued Plaintiff's medications at current levels. (Tr. 391.)

Plaintiff returned to the Bethesda Clinic on November 17 and was seen by Leah Witt and Dr. Ogbogu. (Tr. 412, 413.) Plaintiff was in "no distress, comfortable, [and] pleasant, " but had a "flat affect, mild anxiety." (Tr. 413.) Plaintiff reported that "she has been cancelling psychology/other appointments and staying in the house." (Tr. 413.) Witt assessed Plaintiff with major depression and noted that Plaintiff would continue with her medications as prescribed. (Tr. 413.) Plaintiff's Ambien prescription was also continued and, in response to dependency concerns, Plaintiff was advised "that she can cut tabs in half in order to wean self down/decrease tolerance." (Tr. 412-13.)

Dr. Ogbogu saw Plaintiff again on December 3 for reasons unrelated to her mental health. (Tr. 410.) Plaintiff was again in "no distress, comfortable, [and] pleasant." (Tr. 411.) Dr. Ogbogu noted that Plaintiff "has been doing well so far without psychotic features" and continued her medications as prescribed. (Tr. 411.)

D. 2010

On January 28, 2010, Plaintiff met with Dr. Ogbogu to have a form completed. (Tr. 408, 409.) Plaintiff reported that she "is still depressed every[]day[ and d]oes [not] feel like participating in activities." (Tr. 408.) Plaintiff also did not feel the Ambien was working anymore. (Tr. 408.) Dr. Ogbogu observed that Plaintiff was in "no distress, comfortable, [and] pleasant." (Tr. 409.) Dr. Ogbogu assessed Plaintiff as having major depression. (Tr. 409.) Dr. Ogbogu advised Plaintiff to keep an upcoming appointment with her psychiatrist and to continue taking her Paxil and Depakote prescriptions. (Tr. 409.) Dr. Ogbogu also completed the form, indicating Plaintiff has severe depression and is compliance with treatment, but does not appear to be improving. (Tr. 409.)

Plaintiff saw Hollis at the beginning and end of February. (Tr. 599, 600.) Prior to these visits, Plaintiff had not seen Hollis in seven months. (Tr. 600.) Plaintiff reported that she has been under increased stress on account of her financial situation and her mother, sister, and sister's children coming to live with her. (Tr. 599, 600.) Plaintiff also reported that she is "having some problems [with] mood swings" and "[i]s afraid to go out." (Tr. 599.) Hollis assessed Plaintiff as having bipolar disorder and PTSD. (Tr. 600.) Hollis noted that Plaintiff should work on maintaining boundaries with her mother and sister and practice relaxation techniques at night in order to help her sleep. (Tr. 600.)

Plaintiff saw Dr. Ogbogu again on February 25. (Tr. 496.) Plaintiff reported that feeling "depressed most days" and having trouble sleeping, and did not think her medications were helping. (Tr. 496.) Plaintiff was seeing her psychiatrist and psychologist. (Tr. 496.) Dr. Ogbogu noted that there were "[n]o hallucinations or suicidal ideation." (Tr. 496.) Plaintiff was in "no distress, comfortable, [and] pleasant" and had an "appropriate mood." (Tr. 497.) Dr. Ogbogu recommended that Plaintiff continue taking Paxil and Depakote and meeting with her psychiatrist and psychologist. (Tr. 497.) Dr. Ogbogu also "advised [Plaintiff] to start exercising/going to the gym." (Tr. 497.) Dr. Ogbogu indicated that tremors Plaintiff reported were likely a side effect of the Paxil and prescribed propranolol[15] to treat them. (Tr. 496, 497.)

Plaintiff next met with Hollis on March 23 and during the following week. (Tr. 597, 598.) During both appointments, Plaintiff expressed apprehension over her mother, sister, and sister's children moving in with her. (Tr. 597, 598.) Hollis encouraged Plaintiff to keep her medical appointments, try to keep stress to a minimum, and employ a coping strategy. (Tr. 597, 598.)

Plaintiff was seen by Dr. Ogbogu in early April for medication concerns. (Tr. 494.) Plaintiff reported that "she was busy in the past week and has[ no]t been taking her medications.... [Plaintiff] started feeling more irritable in the past two days and is wondering if she can go back on the medications." (Tr. 494-95.) Dr. Ogbogu observed that Plaintiff was in "no distress, comfortable, [and] pleasant." (Tr. 495.) Dr. Ogbogu listed Plaintiff's diagnosis as "[m]oderate depression with psychotic features" and advised Plaintiff to resume taking her medications. (Tr. 495.)

Plaintiff saw Hollis the following day. (Tr. 596.) Plaintiff reported that she has been "a bit anxious [and] has been biting [her] nails" and picking at her skin. (Tr. 596.) Hollis encouraged Plaintiff to continue walking each day, stating it was good for both anxiety and Plaintiff's mood level. (Tr. 596.)

Plaintiff was seen by Sushila Mohan, M.D., at Associated Clinic of Psychology on April 13 for medication management. (Tr. 448.) Dr. Mohan noted that Plaintiff "is fairly stable except for the situational issues." (Tr. 448.) Plaintiff reported that the recent arrival of her mother, sister, and sister's family "means a lot of work for her." (Tr. 448.) Plaintiff attributed her low mood to "the stress at home." (Tr. 448.) Plaintiff's "medications seem to be working fine" and Plaintiff denied having any side effects. (Tr. 448.) Dr. Mohan observed that Plaintiff was "[c]asually attired, affect a bit subdued." (Tr. 448.) Dr. Mohan noted that "[s]ituational issues [were] impacting [Plaintiff's] mood"; Plaintiff was cognitively aware with "[n]o neurovegetative symptoms of depression" and "[n]o overt psychosis"; and Plaintiff's "[i]nsight and judgment are reality based." (Tr. 448.) Dr. Mohan gave Plaintiff a GAF score of 60 to 65. (Tr. 448.) Dr. Mohan continued Plaintiff's medications at their current levels and told Plaintiff to return in three months. (Tr. 448.)

When Plaintiff saw Dr. Pomrenke on May 26 for a complaint unrelated to her mental health, Plaintiff reported that her depression had "increased." (Tr. 492.) Plaintiff's PHQ-9 score was 10. (Tr. 492.) Dr. Pomrenke described Plaintiff as "[s]lightly depressed, not tearful, goal directed[, ] eye contact, communicative" and noted that Plaintiff had an appointment with her psychiatrist in two days. (Tr. 493.)

Dr. Ogbogu saw Plaintiff on June 10 for a follow-up appointment concerning her depression. (Tr. 484.) Plaintiff reported that "her moods are worse"; she is not able to get enough sleep "and wakes up feeling very energetic"; and she has become "increasingly irritable." (Tr. 484.) Plaintiff stated that "[s]he tends to clean the house a lot and could go on cleaning even when she has an appointment in a few minutes." (Tr. 484.) Plaintiff reported that her symptoms have worsened over the last month, which "coincided with her mother coming to stay with her." (Tr. 485.) Dr. Ogbogu noted that Plaintiff's "mother has multiple medical problems and the pressure of taking care of her is getting to [Plaintiff] emotionally and physically." (Tr. 485.) Plaintiff denied having suicidal ideations as well as visual and auditory hallucinations. (Tr. 484.)

This time, Dr. Ogbogu assessed Plaintiff as having bipolar disorder and noted that "her symptoms appear consistent with bipolar disorder [rather] than a [m]ajor [d]epression with psychotic features." (Tr. 485.) Dr. Ogbogu increased Plaintiff's Depakote prescription, directing Plaintiff to increase it again after one week. (Tr. 485.) Dr. Ogbogu also ran tests to check, among other things, the level of Depakote in Plaintiff's blood. (Tr. 485.)

When Plaintiff followed up with Dr. Ogbogu one week later, she reported that she believes the increased Depakote prescription is helping because "[s]he is less irritable and sleeps better." (Tr. 481.) Plaintiff's "overall mood[, however, ] ha[d] not improved." (Tr. 481.) Dr. Ogbogu observed that Plaintiff was in "no distress, comfortable[, and] pleasant." (Tr. 481.) Dr. Ogbogu increased Plaintiff's Depakote prescription again and made the following notes:

Bipolar disorder II: Although in the past she had indicated that she takes her medication regularly, after questioning her, it appears she misses some doses. Partly because she forgets to take them. She does[ no]t appear to know how often she misses these doses.... She will benefit from a weekly nurse visit to ensure she is complying to medication. I talked to patient about getting a pill box to help set up her medications.

(Tr. 483.)

Plaintiff met with Dr. Ogbogu again on June 24 to evaluate the increased dose of Depakote. (Tr. 479.) Although Plaintiff did not report any side effects during the week before, her moods were still "low" and she still had difficulty sleep. (Tr. 479.) Plaintiff described feeling "anxious the night before an appointment or event and [being] unable to sleep because she is overwhelmed by the thoughts of that particular activity." (Tr. 479.) Plaintiff also reported "wak[ing] up with lots of energy." (Tr. 479.) Additionally, Plaintiff stated that "[s]he has little interest in activities." (Tr. 479.) Dr. Ogbogu noted that "[w]e have discussed in the past going to [the] gym or participating in leisure activities, walking, exercising etc. She would like to do them but at times is not motivated." (Tr. 479-80.)

In assessing Plaintiff, Dr. Ogbogu concluded that bipolar disorder was the more likely diagnosis but "further diagnostic clarification will be needed." (Tr. 480.) Additionally, Dr. Ogbogu noted:

She is quite forgetful and I doubt she really takes her medications as prescribed. It became apparent to me as the vitamin D level had[ no]t gone up significantly even after high doses of [vitamin] D. On her last visit, she endorsed forgetting to take her medications and this might have happened on more than one occasion. I had suggested getting a pill box which she currently does[ no]t have.... I discussed with the DIAMOND contact here in the clinic to try and set her up with a case manager and nurse visits to help set up medications and ensure she is complying to these medications.

(Tr. 480.) Dr. Ogbogu made no changes to Plaintiff's medications at this time. (Tr. 480.)

Plaintiff's next session with Hollis was on June 28, over two months after her last session. (Tr. 595.) Plaintiff reported feeling badly after she had an argument with her sister wherein she told her sister and her kids to get out of her house. (Tr. 595.) Hollis counseled Plaintiff to make appointments with Drs. Mohan and Lietzau. (Tr. 595.)

Plaintiff had an additional follow-up appointment with Dr. Ogbogu on June 30. (Tr. 477.) Plaintiff answered "yes" when asked whether she had often felt down, depressed, or hopeless in the past month and whether she had been bothered by feelings of little interest or pleasure in doing things. (Tr. 477.) Listing Plaintiff's historical diagnoses of PTSD, obsessive compulsive disorder, and depression, [16] Dr. Ogbogu noted that Plaintiff still

has low moods daily and has not improved. She endorses symptoms of agitation and difficulty sleeping. She has a history of [obsessive compulsive disorder] and reports cleaning repeatedly.... She has[ no]t been compliant with her medication including the recent increase in her [D]epakote. There is still need for diagnostic clarification as she does have a complicated history and has[ no]t had much improvement in symptoms. I discussed with her the need to get her set up with a nurse visit and case manager to help ensure medication compliance. She adheres to all her scheduled visits. She seems to be forgetful at times but otherwise appears interested in her care.

(Tr. 478.) Dr. Ogbogu assessed Plaintiff as having major depression and obsessive compulsive disorder. (Tr. 478.)

Plaintiff saw Dr. Mohan again on July 13. (Tr. 447.) Dr. Mohan's observations of Plaintiff were much the same. ( Compare Tr. 447 with Tr. 448.) This time, however, Dr. Mohan gave Plaintiff a GAF score of 55 to 60. (Tr. 447.) Dr. Mohan noted that Plaintiff was stressed on account of her mother and sister staying with her, including the "fall out" Plaintiff had with her sister. (Tr. 447.) Dr. Mohan continued Plaintiff's medications at their current levels and told Plaintiff to follow up in three months. (Tr. 447.)

On July 14, Plaintiff was seen at the Bethesda Clinic by Sarah Masrud, M.D., for a complaint unrelated to her mental health. (Tr. 469.) When asked if she had felt down, depressed, or hopeless in the last month or bothered by a lack of interest or pleasure in doing things, Plaintiff answered "yes" to both questions. (Tr. 469.)

Plaintiff met with Hollis on July 21. (Tr. 594.) Plaintiff reported that she is "feeling good about taking responsibility for [her] mother, " who recently moved into an apartment. (Tr. 594.) Plaintiff also reported having some reconciliation with her sister. (Tr. 594.) Plaintiff told Hollis that she "has been having more mood swings, " which she described as "clean[ing] too much." (Tr. 594.) Plaintiff wanted to begin treating her PTSD symptoms and Hollis gave her diaphragmatic breathing exercises. (Tr. 594.)

Plaintiff returned to the Bethesda Clinic approximately three weeks later for a concern unrelated to her mental health; she was seen by Cherilyn Wicks, M.D. (Tr. 465, 466.) Plaintiff again answered "yes" to feeling depressed and having little interest in doing things over the past month. (Tr. 465.) Dr. Wicks noted that Plaintiff "does have some depression symptoms today" and administered the PHQ-9, wherein Plaintiff scored 16. Dr. Wicks also noted Plaintiff's bipolar-disorder diagnosis. (Tr. 465.) Plaintiff reported that "[s]he feels like things are stable although she does have some depression symptoms still." (Tr. 466.) Dr. Wicks observed that Plaintiff's "[m]ood is depressed; her "[a]ffect appears normal"; "[s]he has good eye contact"; "[h]er speech is normal[, ]... not pressured"; and her "[t]houghts seem logical and she denies suicidal or homicidal ideation." (Tr. 466.) Dr. Wicks told Plaintiff to "continue to follow-up with her psychologist and psychiatrist" and gave Plaintiff "a crisis number handout" but noted that Plaintiff "appears stable though." (Tr. 466.)

Plaintiff's next session with Hollis was on August 17. (Tr. 592.) Plaintiff reported that her partner of 30 years is leaving her because "he[ ha]s had enough." (Tr. 592; see also Tr. 593.) Hollis noted that Plaintiff "feels a lack of support due to [his] leaving." (Tr. 592.) Hollis noted that Plaintiff's partner still helps take care of the children, but is "tired of [Plaintiff's] angry spells." (Tr. 592.) Plaintiff reported "[f]eel[ing like her] mood swings are wrecking her life.'" (Tr. 592.) Hollis encouraged Plaintiff to practice diaphragmatic breathing and visualization and referred Plaintiff to Jennifer Wolfe, CNS, with Associated Clinic of Psychology, to address Plaintiff's bipolar disorder. (Tr. 588, 592, 593.)

Plaintiff was seen at the Bethesda Clinic for a complaint unrelated to her mental health on September 20. This time, when asked if she felt depressed in the last month or was bothered by a lack of interest in doing things, Plaintiff answered "no" to both questions. (Tr. 461.) When Plaintiff had a follow-up appointment for the unrelated condition approximately ten days later, however, Plaintiff answered "yes" to both questions. (Tr. 458.) Casey Martin, M.D., noted that Plaintiff expressed "concern[] about her psychiatric diagnoses and her medications." (Tr. 459.) Plaintiff reported that she "has been taking divelproex [sic]"[17] for the "past few months, " but ...


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