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Short v. Astrue

August 14, 2009

DALENE SHORT, FOR SHANDALE R. NAVARRO, A MINOR, PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF THE SOCIAL SECURITY ADMINISTRATION, DEFENDANT.



The opinion of the court was delivered by: Patrick J. Walsh United States Magistrate Judge

MEMORANDUM OPINION AND ORDER

Before the Court is Plaintiff's appeal of a decision by Defendant Social Security Administration ("the Agency"), denying her application for Supplemental Security Income ("SSI"). Because the Agency's decision that Plaintiff was not disabled within the meaning of the Social Security Act is not supported by substantial evidence, it is reversed and the case is remanded.*fn1

On July 22, 2005, Plaintiff applied for SSI. (Administrative Record ("AR") 27.) The Agency denied the application initially and on reconsideration. (AR 28-37.) Plaintiff then requested and was granted a hearing before an Administrative Law Judge ("ALJ"). (AR 38- 41.) On August 31, 2007, Plaintiff and her mother appeared with counsel at the hearing and testified. (AR 213-21.) On October 18, 2007, the ALJ issued a decision denying benefits. (AR 7-21.) Plaintiff appealed the ALJ's decision to the Appeals Council, which denied her request for review. (AR 3-5.) She then commenced this action.

Plaintiff claims that the ALJ erred by failing to properly consider: 1) the opinion of her treating psychiatrist; 2) the type, dosage, and side effects of her medication; and 3) Plaintiff's and her mother's testimony at the hearing. (Joint Stip. at 3-4, 9-10, 11-13, 15-16.) For the following reasons, the Court concludes that the ALJ erred when he rejected Plaintiff's and her mother's testimony without providing adequate reasons for doing so and that the matter must be remanded for further consideration of their testimony.

In her first claim of error, Plaintiff contends that the ALJ failed to provide legally sufficient reasons for rejecting the opinion of her treating psychiatrist, Dr. Louis Glatch. (Joint Stip. at 3-4.) As explained below, the Court disagrees.

In October 2005, state agency reviewing physicians Schrift and Holmes found that Plaintiff had "no psychiatric impairment." (AR 105.) Plaintiff claims that, in January 2006, she attempted to kill herself by overdosing on medication. (AR 88, 92, 118, 196-98.*fn2 ) She was hospitalized for a week. (AR 196-98.) Thereafter, she reported to a mental health clinic for outpatient treatment and therapy. (AR 92-97.) Plaintiff was initially screened at the clinic by therapist Cristina Dawes, who took Plaintiff's history and ultimately diagnosed her with "major depressive episode recurrent severe without psychotic feature." (AR 97.) She assessed Plaintiff with a Global Assessment of Functioning ("GAF") score of 40. (AR 97.) Dawes' form was endorsed by psychiatrist Louis F. Glatch because, as a therapist, Dawes was apparently not authorized to diagnose patients on her own. (AR 97.)

In a treatment note dated March 28, 2006, Dr. Glatch noted that Plaintiff reported that her mood was "O.K.," that her affect was appropriate, and that her thoughts were linear. (AR 90.) He diagnosed her with "depression [not otherwise specified]," and assigned a GAF of 45. (AR 90.) He prescribed Zoloft and scheduled Plaintiff's next appointment for six weeks later. (AR 91.) His treatment notes between April and August 2006 show that Plaintiff reported improvements in her appetite, sleep, and energy, and no further suicidal ideations. (AR 85-87.)

In an evaluation completed in October 2006, neurologist Joel Ross and another reviewing physician ("M. Skape" it appears) found, among other things, that Plaintiff had low "self esteem as 'different from peers' but still less than marked." (AR 114.) They determined that Plaintiff's impairments did not meet or equal any Listing. (AR 111-16.)

In November 2006, Plaintiff "went off her meds" and her suicidal ideations returned, leading Dr. Glatch to increase her dosage of Zoloft. (AR 83, 98.) In February 2007, Dr. Glatch determined that Zoloft was not effective and prescribed Prozac, instead. (AR 82, 98.) Plaintiff visited Dr. Glatch in March 2007, again, and reported that her behavior, mood, appetite, and energy were all good. (AR 81.) Dr. Glatch instructed her to return 12 weeks later. (AR 81.) Plaintiff returned in July 2007, and again reported doing better. (AR 80.) Dr. Glatch scheduled her next appointment for 12 weeks later. (AR 80.)

In his October 2007 decision, the ALJ concluded that Plaintiff's mood disorder with depression constituted a severe impairment, but that it did not restrict her activities of daily living or her ability to maintain concentration, persistence, or pace. (AR 13-14.) He noted that the reports from her mental health examinations indicated that she was within normal limits, oriented in all spheres, and had normal intellectual functioning. (AR 13.) He also noted that she was in school at the appropriate grade level for her age (though she studied at home because of back pain), that she was being seen by a psychiatrist only once a month, and that her depression was being controlled with medication. (AR 13.)

The ALJ discounted the February 28, 2006 assessment prepared by Dawes and endorsed by Glatch--diagnosing Plaintiff with major depression and a GAF score of 40--on the grounds that the findings were not supported by the medical record and "not credible or consistent with the mental status examination" conducted that same day, which revealed nothing more than "occasional insomnia due to back pain." (AR 14.) The ALJ did not directly address Dr. Glatch's March 28, 2006 report, noting only that Plaintiff's mental health treatment had been "minimal," that she underwent psychotherapy once a month, and that she took Prozac, which he contended she admitted improved her symptoms. (AR 13.) He also noted that her mental health condition was apparently good enough by March 2007 that Dr. Glatch did not schedule her next appointment until July 2007, and that, in July 2007, her condition was reported as stable. (AR 13.)

Plaintiff argues that the ALJ rejected Dr. Glatch's "opinions" (at pages 88-91 and 97 of the administrative record) without providing legally sufficient reasons. (Joint Stip. at 3.) For the following reasons, the Court disagrees.

As a general rule, a treating doctor's opinion is given priority over the opinions of non-treating doctors. Orn v. Astrue, 495 F.3d 625, 632 (9th Cir. 2007). To reject a treating doctor's opinion that is contradicted by another doctor's opinion, an ALJ must provide specific and legitimate reasons, supported by substantial evidence in the record, for doing so. Id. Where, however, the ALJ's findings are consistent with the treating doctor's opinion, the ALJ is not required to explain why the treating doctor's opinion was not followed. See Meanel v. Apfel, 172 F.3d 1111, 1113 (9th Cir. 1999).

The ALJ read and considered the February 28, 2006 screening form prepared by Dawes and endorsed by Dr. Glatch found at pages 92-97 of the administrative record. (AR 14.) He summarized the findings from the form in his decision. (AR 14.) In rejecting Dr. Glatch's conclusions, including the GAF score of 40, he noted that Plaintiff had not reported any behavioral or school problems, that she interacted well with others, and that, therefore, the GAF score was not "credible or consistent with the mental status examination" performed at the time. (AR ...


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