Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Copeland v. Commissioner of Social Security

April 7, 2010

WILLIAM W. COPELAND, PLAINTIFF,
v.
COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.



The opinion of the court was delivered by: Craig M. Kellison United States Magistrate Judge

MEMORANDUM OPINION AND ORDER

Plaintiff, who is proceeding with retained counsel, brings this action for judicial review of a final decision of the Commissioner of Social Security under 42 U.S.C. § 405(g). Pursuant to the written consent of all parties, this case is before the undersigned as the presiding judge for all purposes, including entry of final judgment. See 28 U.S.C. § 636(c). Pending before the court are plaintiff's motion for summary judgment (Doc. 24) and defendant's cross-motion for summary judgment (Doc. 28).

I. PROCEDURAL HISTORY

Plaintiff applied for social security benefits on November 22, 2005. In the application, plaintiff claims that disability began on October 1, 2005. Plaintiff claims that disability is caused by a combination of: "Bipolar I; Bipolar Mixed; Bipolar II, recurrent major, with depressive and hypomania episodes; personality disorder; and borderline personality traits." Plaintiff's claim was initially denied. Following denial of reconsideration, plaintiff requested an administrative hearing, which was held on December 14, 2007, before Administrative Law Judge ("ALJ") James A. Mitchell. In a April 23, 2008, decision, the ALJ concluded that plaintiff is not disabled based on the following relevant findings:

1. The claimant has the following severe impairments: bipolar disorder, alcohol abuse, and substance abuse disorder;

2. The claimant does not have an impairment or combination of impairments that meets or medically equals an impairment listed in the regulations;

3. The claimant has the residual functional capacity to perform the full range of work at all exertional levels but with the following non-exertional limitations: his attention, concentration, understanding, and memory are slightly limited; his ability to do simple routine repetitive tasks is slightly limited; he requires occasional close supervision for more than two hours on a work shift due to his non-compliance with his medication regime and drug and alcohol abuse; he is able to lift up to fifty pounds occasionally and twenty five pounds frequently;

4. Considering the claimant's age, education, work experience, and residual functional capacity, and based on vocational expert testimony, there are jobs that exist in significant numbers in the national economy that the claimant can perform.

After the Appeals Council declined review on August 19, 2008, this appeal followed.

II. SUMMARY OF THE EVIDENCE

The certified administrative record ("CAR") contains the following evidence, summarized chronologically below:

October 3, 2005 -- A contact sheet completed by staff at San Joaquin County Mental Health reflects that plaintiff's current GAF was 50. On mental status examination, plaintiff's mood was depressed, thought content was clear, and memory was intact. Plaintiff reported having used methamphetamine three weeks prior and marijuana four days prior.

October 11, 2005 -- Notes from San Joaquin County Mental Health indicate that plaintiff reported initially complaining of insomnia but then added he needs an antidepressant. He reported mood swings and intermittent suicidal ideation. Plaintiff said he had recently broken up with a physically abusive boyfriend.

October 25, 2005 -- Chart notes from San Joaquin County Mental Health indicate that plaintiff reported Depakote was making him dizzy and oversedated. However, he also stated that he does not sleep well at night despite being tired all day. The diagnosis indicated on the chart note is "Mood D/O NOS R/O Bipolar II." Plaintiff was prescribed Zyprexa.

November 23, 2005 -- Records from San Joaquin County Mental Health indicate that plaintiff failed to attend his appointment the day before with his treating physician, Dr. Graff, and that he walked in because he ran out of medication. Plaintiff reported that he was doing good and that medication was helping him sleep. Plaintiff said that he was experiencing increased depression, but firmly denied any suicidal ideation. Plaintiff was cooperative and denied any acute distress. Plaintiff was provided medication.

January 2, 2006 -- The CAR contains a "Function Report -- Adult -- Third Party" submitted by plaintiff's sister, Jamie Copeland. She stated that plaintiff spends most of his day sleeping and, when not sleeping, he eats and watches television. Ms. Copeland stated that plaintiff is "dependent on others to cook, due to tiredness and side effects [of medication]." She added that he needs help remembering to take his medication because he "forgets track of time."

Ms. Copeland also stated that plaintiff cannot cook for himself because of "drowsiness, muscle aches, lack of motivation." She stated that plaintiff does his own laundry once a month, but doesn't go out to do any kind of shopping. She also stated that he is moody with "highs & lows" and that plaintiff is emotional and depressed.

As to functional capabilities, Ms. Copeland stated that plaintiff's impairments make it difficult for him to lift, talk, complete tasks, concentrate, understand, and get along with others. She stated that plaintiff could maybe walk a mile before needing rest. She added that he is easily distracted and cannot pay attention for long, though she stated he had no problems following written or spoken instructions. Ms. Copeland stated that plaintiff does not handle stress well.

January 4, 2006 -- The CAR contains a "Contact Sheet" prepared by staff at San Joaquin County Mental Health. The document indicates that, at that time, plaintiff's GAF score was 50 and had remained unchanged over the past year. On mental status examination, it was noted that plaintiff was cooperative. His mood was reported as "tired." Plaintiff had a nervous affect. Thought content was appropriate. Memory and abstraction were both good. Plaintiff denied drug and/or alcohol use. Plaintiff reported suicidal ideation, but no plan, and that he wants to cut himself.

January 6, 2006 -- Plaintiff provided responses on a "Function Report -- Adult" submitted with his application for benefits. Plaintiff stated that he lives with his family. For daily activities, plaintiff stated: "I wake up and watch T.V. and eat if some one cooks." He added that lately he hadn't been "feeling good do to my meds." He stated that he needs reminders to take his medications. He also stated that he bathes once a week, does laundry once every other week with assistance, doesn't do anything with his hair, does not shave, and his mother cooks meals for him. Plaintiff stated that, before the onset of disability, he was more energetic and able to think more clearly. He states his impairments cause him to "get dizzy and drozie." When asked, however, to check boxes next to various activities his impairments prevent or limit (such as lifting, stooping, sitting, etc.), plaintiff did not check any boxes or otherwise indicate any limitations.*fn1 Plaintiff added that he does not handle stress well due to "anxieties and panic attacks." Plaintiff concluded his statement by adding: "I am trying to fix these problems."

January 11, 2006 -- San Joaquin County Mental Health records reflect that plaintiff failed to attend this scheduled appointment.

February 22, 2006 -- Chart notes from San Joaquin County Mental Health reflect that plaintiff had missed at least four of his last appointments. The notes refer to "chronic missed MD appts."

February 28, 2006 -- Chart notes from San Joaquin County Mental Health reflect that plaintiff had stopped taking his medications. The notes also state: "Pt. was drinking a couple weeks ago."

April 27, 2006 -- Agency examining doctor David C. Richwerger, Ed.D., reported on a comprehensive psychiatric evaluation. The doctor reported the following history:

The claimant denies ever being admitted to a psychiatric hospital. The claimant states he has gone to the Crisis Center at Mental Health when he was sixteen to see a counselor. The claimant states he began some outpatient psychiatric treatment in October 2005. He states his friends referred him because he was "climbing the walls, crying, and getting angry." He states his last visit was with Dr. Graff in earlier April 2006. The claimant states he has difficulty concentrating and difficulty with his memory. He states, "Not always. It just depends." The claimant states in the past he thought he heard voices. He states, "For a while I did, but I don't hear them now." The claimant then stated he was not actually hearing it. The claimant may have been referring to his own thoughts. The claimant states he has troubling thoughts. The claimant states he often feels anxious and depressed. The claimant states he is not always depressed but often has anxiety in public. The claimant denies suicidal ideation but says he had suicidal thoughts about a month ago. He states at the age of 17 or 18 he tried to get hit by a car. The claimant denied homicidal ideation in the past but none at this time -- just when he gets very angry. The claimant states he had seen Dr. Graff once a month and now his appointments with him are p.r.n. The claimant states he was prescribed Depakote and Prozac. The claimant states the Depakote makes him more stable than before.

Plaintiff told the doctor that "he used to drink a lot at the age of 16 but does not drink at all now." He last used drugs when he was 16. As to current functioning, Dr. Richwerger reported:

The claimant lives in a house with his family. The claimant states he does not sleep very well. He has often had problems sleeping and he does not know why. He states his appetite varies a lot. The claimant states he does household chores such as washing clothes and drying them on the line. He takes care of his own personal needs. The claimant states he has no outside activities or hobbies. The claimant states he handles his own financial affairs. The claimant states he usually gets around by getting a ride. The claimant is able to move about alone. The claimant's mother drove him to this evaluation. The claimant states he does not interact that well with family and relatives. Things vary a lot. He avoids friends and neighbors. The claimant states what he does just depends on the day. Nothing is consistent. The claimant states, "Lately, I have been cleaning a lot. Sometimes, I am depressed. Sometimes, I have a lot of energy." The claimant states his last schooling was last year.

Based on mental status examination results, Dr. Richwerger diagnosed bipolar II, mixed, and assigned a GAF of 55. The doctor outlined the following functional assessment:

The claimant appears to have a moderate impairment in his ability to perform detailed and complex tasks.

The claimant appears to have no impairment in his ability to perform simple and repetitive tasks.

The claimant appears to have a slight impairment in his ability to perform work activities on a consistent basis.

The claimant appears to have no impairment in his ability to perform work activities without special supervision.

The claimant appears to have a moderate impairment in his ability to complete a normal workday or workweek without interruption from a psychiatric condition.

The claimant appears to have a slight impairment in his ability to understand and accept instructions from supervisors.

The claimant appears to have a slight impairment in his ability to interact with co-workers and the public.

The claimant appears to have a slight impairment in his ability to maintain regular attendance in the workplace.

The claimant appears to have a slight impairment in his ability to deal with the usual stresses encountered in competitive work.

July 26, 2006 -- Agency consultative doctor V.M. Meenakshi, M.D., submitted a psychiatric review technique form. Plaintiff was assessed with mild difficulties in activities of daily living and social functioning. The doctor opined that plaintiff is moderately limited in ability to maintain concentration, persistence, and pace. There was insufficient evidence to establish episodes of decompensation. The doctor also completed a mental residual functional capacity assessment. Dr. Meenakshi opined that plaintiff was moderately limited in ability to understand, remember, and carry out detailed instructions. In all other categories of functioning, plaintiff was assessed as not significantly limited.

September 12, 2006 -- Records from San Joaquin County Mental Health indicate that plaintiff reported using marijuana at age 15 and later methamphetamines. Plaintiff stated that he last used methamphetamine in September 2005.

November 27, 2006 -- Chart notes from San Joaquin County Mental Health indicate that, on mental status examination, plaintiff appeared to be very intelligent. His attitude was angry, speech normal, mood depressed, and thought content clear. Plaintiff denied hallucinations. He said he had not been sleeping and admitted to suicidal ideation. The notes indicate that, at the time, plaintiff was taking Zoloft, Seroquel, and Hydraxine.

December 21, 2006 -- Plaintiff reported to a case worker from San Joaquin County Mental Health that his medications were working well and he denied any depression at the time.

January 12, 2007 -- Progress noted from San Joaquin County Mental Health reveal the following comment by plaintiff's case manager: "He admits to struggling with methamphetamine abuse, but has been clean for several months."

January 19, 2007 -- Records from San Joaquin County Mental Health indicate that plaintiff called in to cancel his therapy appointment because he had the flu. He denied any psychiatric problems.

January 30, 2007 -- Plaintiff reported to a case manager from San Joaquin County Mental Health that he had been feeling depressed and that he reported to a crisis center the week before because he started "cutting" himself. He denied feeling suicidal.

February 9, 2007 -- Plaintiff told a case manager from San Joaquin County Mental Health that he felt his medications had been effective since being changed the week prior. Plaintiff denied experiencing any anxiety attacks or episodes of self-abuse.

February 13, 2007 -- Plaintiff reported to a case manager from San Joaquin County Mental Health that he had not taken his medications for a few days and that he was "not good." Plaintiff stated that he did not feel his medications were working.

February 15, 2007 -- Notes from San Joaquin County Mental Health indicate the following:

Case manager met with client at HEART Office. He was appropriately groomed, alert, and oriented x 3. He said he was feeling much better today. He denied feeling depressed and denied any desire to harm himself. He said he went home Tuesday and slept after taking his meds. He is continuing his med regime now. He also attended group today. . . . February 22, 2007 -- Chart notes from San Joaquin County Mental Health indicate:

Case manager met with client at HEART Office. He was well groomed, alert, and oriented x 3. He reported he is doing much better. He started taking his meds as prescribed and denies adverse effects. He said he feels much calmer and has slept much better since taking his meds. Case manager engaged him in conversation about med education. He said he wants to change his meds to better stabilize his meds. . . .

Plaintiff was encouraged to "continue working on recovery for his mental illness and drugs."

February 27, 2007 -- Plaintiff reported to mental health staff at San Joaquin County Mental Health that he finds himself "crying for hours on end about my flashbacks." Plaintiff also reported feeling "insulted that his sister's boyfriend, Brendan, wants to have sex with him." Chart notes indicate that plaintiff and his case manager discussed employment and plaintiff said he wanted to try the "moving crew."

February 28, 2007 -- Progress notes from San Joaquin County Mental Health reveal as follows:

Case manager met with client when we were done moving. He said he is going well and his mood has been stable. Right now his meds are working and he has no complaints. . . .

March 20, 2007 -- Progress notes from San Joaquin County Mental Health reflect that plaintiff had stopped attending the community skills building group class and that plaintiff "gives many somatic complaints . . . as reasons not to work toward his goal at this time."

March 23, 2007 -- Progress notes from San Joaquin County Mental Health reveal that plaintiff was feeling good "because he just had a good session with his therapist." Plaintiff's case manager helped him move his belongings to Sutter Manor.

March 27, 2007 -- Progress notes from San Joaquin County Mental Health indicate that plaintiff attended a hockey game with staff from and other members of the HEART Program. Plaintiff appeared to enjoy the game and was ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.