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Angela L. Vasquez v. Michael J. Astrue

September 23, 2012

ANGELA L. VASQUEZ,
PLAINTIFF,
v.
MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY,
DEFENDANT.



The opinion of the court was delivered by: Sheila K. Oberto United States Magistrate Judge

ORDER REGARDING PLAINTIFF'S SOCIAL SECURITY COMPLAINT (Docket No. 1)

I. BACKGROUND

Plaintiff Angela L. Vasquez ("Plaintiff") seeks judicial review of a final decision of the Commissioner of Social Security (the "Commissioner" or "Defendant") denying her application for Disability Insurance Benefits ("DIB") and Supplemental Security Income ("SSI") pursuant to Titles II and XVI of the Social Security Act (the "Act"). 42 U.S.C. §§ 405(g), 1383(c)(3). The matter is currently before the Court on the parties' briefs, which were submitted, without oral argument, to the Honorable Sheila K. Oberto, United States Magistrate Judge.*fn1

II. FACTUAL BACKGROUND

Plaintiff was born in 1965, completed two years of college, has an associate science degree, and previously worked as a respiratory therapist. (Administrative Record ("AR") 34, 76, 189, 194, 197, 233.) On November 27, 2007, and December 18, 2007, respectively, Plaintiff filed applications for SSI and DIB, alleging disability beginning on September 2, 2004, due to bipolar disorder, depression, and adult attention deficit disorder. (AR 67-84.)

A. Relevant Medical Evidence

The earliest medical evidence in the record indicates that Plaintiff was seen by Wen Liang Chu, M.D., at Community Behavioral Health Center/Fresno Mental Health ("Fresno Mental Health") on December 14, 2004. (AR 284.) Dr. Chu noted that Plaintiff was being seen for a follow-up visit after having a panic attack, where she had palpitations, was anxious, could not sleep, and had crying spells. (AR 284.) Plaintiff had been clean from methamphetamine use for two months, since October 2004, and would be living with her mother after leaving drug rehabilitation. Dr. Chu found Plaintiff to be fidgety, but her speech was coherent and goal-oriented and she stated that she had better concentration. (AR 284.) Plaintiff was seen again at Community Behavioral Health Center on January 7, 2005, by Ramon Q. Raypon, M.D., and on January 13, 2005, by Dr. Chu. (AR 282-83.)

On April 5, 2005, the staff at Fresno Mental Health requested that Dr. Chu see Plaintiff because she was "agitated and angry" at her ex-boyfriend. (AR 281.) Plaintiff had been "off" her medication for three days. (AR 281.) Dr. Chu directed Plaintiff to restart the medication and participate more often in her group therapy sessions. (AR 281.) On April 28, 2005, Dr. Chu indicated that Plaintiff was taking her medication "but not everyday" and was "feeling no improvement." (AR 280.) However, Dr. Chu noted that Plaintiff was "calmer" and able to "focus on [the] conversation." (AR 280.) Plaintiff denied recent drug use. (AR 280.)

On May 3, 2005, Plaintiff was admitted to Community Medical Center "on a 5150 due to strong suicidal ideations." (AR 249.) Plaintiff was diagnosed with depressive disorder not otherwise specified ("NOS"), anxiety disorder NOS, adjustment disorder with mixed depression, anxiety and major depressive disorder, alcohol dependence, and methamphetamine abuse. (AR 249.) Plaintiff's mental status examination on admission indicated that she "reported suicidal thoughts," "felt worthless and hopeless," and "reported auditory hallucinations, mostly derogatory voices telling [her] that she was no good and needed to kill herself." (AR 250.) Plaintiff's medication was adjusted. The hospital summary indicates that Plaintiff had "a long history of alcohol dependency and methamphetamine abuse," although Plaintiff "stated that she had been clean and sober for the past few months after she [had] graduated from a drug treatment program." (AR 250.) However, while in the hospital, Plaintiff informed Surinder P.S. Dhillon, M.D., that she had been "drinking very heavily and ha[d] even been taking some cough medication very heavily." (AR 255.) Plaintiff indicated that she missed her six-year-old son who was living with his father and feared that she would never see her son again because the father did not allow visitation. (AR 250.) Plaintiff was discharged from the hospital after two days on May 5, 2005; she was discharged against medical advice because she did "not meet the criteria for 5150 at the time" and could not "be held against her will." (AR 251.)

On May 13, 2005, Plaintiff was readmitted to Community Medical Center on another 5150 hold. (AR 244-45.) Plaintiff reported suicidal ideations and auditory hallucinations. (AR 244.) She was diagnosed with bipolar disorder NOS, polysubstance abuse, and relationship problems. (AR 245.) Plaintiff had been staying at the Westcare Rehabilitation program but stated that "she was upset because she wanted a dual diagnosis program instead of a program purely focused on chemical dependency." (AR 244.) Additionally, Plaintiff was"upset at [her] family for not believing she had been clean and sober, [and] also upset at her ex-husband." (AR 246.) Plaintiff's medication dosages were adjusted and "she continued to make gradual improvement." (AR 244.) Upon discharge on May 18, 2005, Plaintiff "[s]tated [that] her mood was 'okay.'" (AR 244.) At discharge, Plaintiff was instructed to continue her medication and to follow up with her mental health care provider; she was also provided referrals to rehabilitation programs. (AR 245.)

Plaintiff returned to Dr. Chu on May 23, 2005, for samples of Seroquel and Cymbalta, medications that she had run out of two days previously.*fn2 (AR 278-79.) Plaintiff indicated that the medications had been "helping her"; she did not report any side effects. (AR 278.)

On May 24, 2005, Plaintiff was admitted to the Apollo therapy program. (AR 276.) On May 31, 2005, Plaintiff was treated by Sarah Morgan, M.D., who reviewed Plaintiff's medical history and indicated that Plaintiff's hospital admissions had been secondary to "DTs" (delirium tremens),*fn3 noncompliance with medication, not eating, and taking cough syrup with codeine. (AR 276.) Plaintiff informed Dr. Morgan that Plaintiff's last drink had been on May 8, 2005, but prior to that it had been one year since she had been drinking. Plaintiff reported that her last use of methamphetamine was on October 8, 2004, and her last use of cocaine had been more than two years prior. (AR 276.) Plaintiff indicated that she "feels [her] depression is better" on the medication but that the dosage was "too much." (AR 276.) However, she was "still talking fast." (AR 276.) Dr. Morgan diagnosed Plaintiff with bipolar disorder NOS and polysubstance dependence in early full remission. (AR 277.)

Plaintiff was seen by Dr. Morgan between June 9 and July 8, 2005. (AR 269-71, 273.) Plaintiff indicated that she had been compliant with her medication, denied any side effects, but was having problems sleeping. (AR 269-71, 273.) Plaintiff had tried numerous medications and felt that they were working. (AR 271.) Her mood was consistently "good." (AR 269-71, 273.) On June 14, 2005, Plaintiff reported that she had used methamphetamine "last week." (AR271.) On June 24, 2005, although Plaintiff "denie[d] craving currently," she also reported that "meth[amphetamine] was helping her calm down [and] stop the racing thoughts." (AR 270.) Dr. Morgan "talked [to Plaintiff] at length about the importance of staying [and] living sober." (AR 270.) Plaintiff was seeking to have her own apartment and to gain 50 percent custody of her son. (AR 269.)

On August 2, 2005, Dr. Morgan indicated that Plaintiff had been compliant with her medication, denied any side effects, and was "ready for discharge" from the Apollo treatment plan. (AR 267.) Plaintiff was "stable on current medication" and felt that the medication was "helpful." (AR 267.) Plaintiff's mood was "good," although she was a "little depressed" about her son. (AR 267.)

Plaintiff returned to Dr. Chu on September 8, 2005. (AR 265-66.) Plaintiff indicated that the medication "calmed her down" and she had stopped hearing voices. (AR 265.) Plaintiff did not report any side effects to the medication. (AR 265.) She was participating in group therapy, and stated that she had been "clean" since October 2004. (AR 266.)

Plaintiff was seen regularly at Fresno Mental Health from September 2005 through February 2006. (AR 258-64.) On October 5, 2005, Plaintiff informed Dr. Chu that she had been clean for four months. (AR 263.) Plaintiff's medication helped with her depression, helped her sleep, slowed her down, and allowed her to focus better. (AR 262-63.) On February 2, 2006, Plaintiff reported to Dr. Chu that she was attending City College and had no problem with concentration. (AR 258.) Dr. Chu noted that Plaintiff was "fidgety" but that her mood was "okay." (AR 258.)

On June 29, 2006, Plaintiff was seen by Dr. Chu. (AR 304.) Plaintiff reported that she had been clean for one year and that she was "[p]lanning to attend City College." (AR 304.) Plaintiff stated that she was still taking her medication as prescribed and agreed to attend group therapy. (AR 304.) On August 3, 2006, Plaintiff informed Dr. Chu that she had no recent drug use and that the medication helped her sleep. (AR 302.) However, on September 11, 2006, Plaintiff was seen for an unscheduled session by Laura Ballard, LPT; Plaintiff indicated that she was anxious and having trouble sleeping due to an upcoming court date over her son's custody. (AR 298.) Plaintiff also admitted that she drank "a lot of caffeinated sodas with lots of sugar" and a "huge thermos of coffee every morning," and agreed that "her daily habits are keeping her awake." (AR 298.) Three days later, on September 14, 2006, Dr. Chu noted that Plaintiff still had "anxiety" over the upcoming child custody case and "need[ed] something to calm down." (AR 300.) Dr. Chu also noted that Plaintiff had improved on medication, had no side effects, and had been clean for one year. (AR 300.) In October and November 2006, Dr. Chu indicated that Plaintiff's response to medication had improved, that she had no side effects, and that she was "coping well." (AR 296-97.)

Plaintiff's care was transferred from Dr. Chu to Ramon Q. Raypon, M.D., at Fresno Mental Health, and on February 16, 2007, Plaintiff indicated that she was "doing al[l] right but still feeling nervous and anxious going [through a] custody battle with ex-BF [boyfriend] for their child." (AR 291, 293.) Plaintiff reported "benefits with medications to control depression and abil[ity] to sleep." (AR 291.) Dr. Raypon noted that Plaintiff's mood was anxious, but that she had normal thought processes and organization. (AR 291.) Plaintiff reported no side effects of the medication. (AR 291.) Dr. Raypon diagnosed Plaintiff with bipolar disorder NOS and polysubstance dependence in remission. (AR 289.)

On April 3, 2007, Dr. Raypon noted that Plaintiff requested a refill of her medications and that she was "feeling depressed and nervous following [a] mediation hearing for child custody and [was] informed [that] custody [was] to be granted to the father." (AR 289.) Dr. Raypon assessed Plaintiff with restless motor activity and noted that she was "jittery." (AR 289.) Plaintiff indicated that she had "read about [the] side effects to Seroquel like movements," but stated she had those "problems . . . before taking" the medication. (AR 289.) Plaintiff "appear[ed] very nervous and restless" and stated that she "did not sleep well without Seroquel." (AR 289.) On June 8, 2007, Plaintiff informed Dr. Raypon that she was "feeling depressed" because it was a "struggle looking for work" and she was "trying to get custody" of her son. (AR 288.) Dr. Raypon noted that Plaintiff had restless motor activity and was anxious, but the rest of her mental status exam was normal. (AR 288.)

On April 11, 2008, Plaintiff was seen by Shireen R. Damania, M.D., for a psychiatric evaluation. (AR 307-10.) Prior to the examination, Dr. Damania noted that Plaintiff had completed a Disability Report that indicated that Plaintiff stated that she was "not able to perform [her] job due to mood swings," which would range from being "happy" to "then . . . crying." (AR 307.) Dr. Damania reported that Plaintiff was "somewhat jumpy" throughout the exam. (AR 307.) Plaintiff had changed her medication two weeks prior to the visit due to changes in her coverage with Medi-Cal. (AR 307.) Plaintiff "[i]nitially . . . state[d] that she [had been] in counseling on a regular basis, then towards the end of the interview [with Dr. Damania] she state[d] she had not seen a counselor in six months." (AR 308.) Plaintiff informed Dr. Damania that she was bipolar "because she had 'mood swings'" and stated that when she stops taking her medication she feels as if she is "'dreaming and talking to people who are not there.'" (AR 308.) Plaintiff stated that she had gone on job interviews but was told that she was not hireable. (AR 308.) Upon mental status examination, Dr. Damania found that Plaintiff's "[s]peech was normoproductive and there was no evidence of a speech defect. Mood was anxious. Affect was appropriate to the thought content and situation." (AR 309.) Plaintiff "denied any suicidal or homicidal ideations and impulse control and frustration tolerance were within normal limits." Dr. Damania also found that "[t]here was no evidence of hallucinations or delusions" and "no evidence of a thought disorder." (AR 309.) The diagnostic impression was mood disorder NOS, anxiety disorder NOS, and polysubstance dependence in remission two years by history. (AR 309.) Dr. Damania opined that:

[Plaintiff] is able to understand, carry out, and remember three- and four step instructions in a work like setting. She would have difficulty with complex and detailed job instructions. She is able to respond appropriately to co-workers, supervisors, and the public. She is able to respond appropriately to dual work situations and deal with changes in a routine work setting with normal supervision. (AR 309-10.)

Plaintiff was seen by Dr. Raypon on April 3, 2008. Plaintiff reported "feeling depressed and anxious" because she had run out of Cymbalta for over a week as it was "no longer covered by [her] insurance." (AR 330.) Dr. Raypon prescribed a trial of Celexa.*fn4 (AR 330.)

On May 14, 2008, Robert B. Paxton, M.D., reviewed Plaintiff's medical records and completed a mental residual functional capacity ("RFC")*fn5 assessment. (AR 311-26.) Dr. Paxton found that Plaintiff was moderately limited in her ability to understand, remember, and carry out detailed instructions, but had no other significant limitations. (AR 311-12.) Dr. Paxton opined that, "[w]hen sober[,] claimant has the cognitive and concentrative capacity to perform[,] understand and remember simple level tasks and instructions. No adaptive limitations. Able to work in a non public setting. When [not sober,] claimant cannot [perform tasks]." (AR 313.) Plaintiff had mild restrictions of activities of daily living, mild difficulties in maintaining concentration, persistence, and pace, moderate difficulties in maintaining social functioning, and had one or two repeated episodes of decompensation. (AR 322.)

On May 29, 2008, Plaintiff was seen by Dr. Raypon for a medication visit and reported that she was "doing al[l] right but [was] depressed at times because of [her] life situation." (AR 329.) Plaintiff stated that she was "denied social security [benefits] and want[ed] to get some job training." Plaintiff did not report delusions, hallucinations, or suicidal ideations. (AR 329.) Plaintiff's motor activity was restless, her thought processes organized and coherent, and her mood was anxious. (AR 329.) Plaintiff indicated no side effects to the medication, which she reported as "somewhat" effective. (AR 329.)

On July 29, 2008, Randall J. Garland, Ph.D., performed a complete review of Plaintiff's case file, and affirmed the prior analysis by Dr. Paxton. (AR 340.)

Plaintiff was seen by Dr. Raypon throughout 2008. (AR 389-401.) On July 24, 2008, Plaintiff reported that Celexa was "not working" and she was "feeling depressed when taking it." (AR 401.) The Celexa was discontinued and Plaintiff was prescribed Prozac.*fn6 (AR 401.) On September 18, 2008, Plaintiff reported that she had no medication for a week because her insurance was discontinued and she was applying for a continuation of coverage. (AR 396.) Plaintiff reported that she was "feeling more nervous, not sleeping, nauseous at times, depressed, [and] hearing voices." (AR 396.) Dr. Raypon found Plaintiff's thought processes to be organized and coherent. (AR 396.) On December 11, 2008, Plaintiff reported that she had "been without medications for over a month [because it] was not covered by insurance and [she] cannot pay for it." (AR 392.)

Plaintiff stated that she was "getting more nervous, depressed, [and] restless." (AR 392.) She also reported problems concerning ...


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