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Jeffery Ray Golden v. Carolyn W. Colvin

April 29, 2013

JEFFERY RAY GOLDEN,
PLAINTIFF,
v.
CAROLYN W. COLVIN, ACTING COMMISSIONER OF SOCIAL SECURITY,
DEFENDANT.



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

ORDER REGARDING PLAINTIFF'S COMPLAINT

INTRODUCTION

Plaintiff seeks judicial review of a final decision of the Commissioner of Social Security (the "Commissioner" or "Defendant") denying his application for Disability Insurance Benefits ("DIB") pursuant to Title II of the Social Security Act (the "Act"). 42 U.S.C. §§ 405(g). 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

FACTUAL BACKGROUND

Plaintiff was born on January 4, 1969; he is a high school graduate with some college and vocational training. (Administrative Record ("AR") 13, 22, 42-43.) Plaintiff has past relevant work experience as a truck driver, lawn care specialist, security guard, deli worker, customer service agent, and has worked in construction as general laborer. (AR 13, 59, 199.) Plaintiff last worked in January 2008 and since then claims to have become unable to work because of his bipolar disorder and high blood pressure. (AR 177.)

A. Relevant Medical Evidence

Medical records from the Merced County Department of Mental Health ("Merced Mental Health") between February 2006 and January 2007, show that Plaintiff obtained some treatment for bipolar I disorder. (AR 246-53.) A January 2007 Merced Mental Health "discharge summary" shows that from February 2006 to January 2007, Plaintiff attended two medical and two counseling appointments. In January 2007, it was noted that Plaintiff's last prescription for medication was dated August 22, 2006, for Remeron and Depakote with two refills, and that Plaintiff reported poor compliance with his medication. (AR 246.) The discharge summary also indicated that Plaintiff reported the following problems and symptoms: excessive spending, agitation, hypersexuality, poor concentration, poor memory, poor self-image, poor impulse control, poor judgment, expansive mood, and poor hygiene. (AR 246.) The discharging physician also noted that Plaintiff had an unknown current Global Assessment of Functioning ("GAF"), but his GAF score over the past year was 55.*fn2 (AR 246.) Plaintiff was prescribed Atenenon and hydrochlorizide prior to discharge. (AR 248.)

In June 2008, Plaintiff returned to Merced Mental Health for treatment. (AR 251.) Plaintiff reported being off his medication for the prior three months, was presently unemployed, had no major problems at home or in the community, and was "fairly stable." (AR 251, 257.) He had stopped coming to Merced Mental Health in the previous year because he felt better, but reported he was depressed because he felt as though he could not function. (AR 251.) He also reported that his medication had caused him to gain weight. (AR 251.) Manolito V. Castillo, M.D., noted that Plaintiff's appearance was "normal," he had no hallucinations or delusions, and his judgment was intact. (AR 252.) Plaintiff's mental status examination showed "good grooming and hygiene," no thought disturbances, his mood was depressed and irritable, but he had no suicidal or homicidal ideation and reported no psychotic symptoms. His insight and judgment were intact, and Dr. Castillo noted Plaintiff had average intellect. (AR 257.) He was assigned a GAF score of 65 (AR 257), which corresponds to some difficulty in social, occupational, or school functioning but "generally functioning pretty well." See DSM-IV, 34.

On July 14, 2008, Plaintiff was again seen at Merced Mental Health. (AR 259.) His response to medication was deemed "fair," and his mood was mildly improved. (AR 259.) Plaintiff reported that he was tolerating his medication, but he was still experiencing severe mood swings and irritability. (AR 259.) His prescription for Depakote was increased, and his prescription for Remeron was continued. (AR 259.) He was to follow-up with additional treatment in three weeks. (AR 259.)

In August 2008, state agency medical consultant, H. Bilala, M.D., reviewed Plaintiff's medical records and completed a mental residual functional capacity assessment form (AR 266-68), and a psychiatric review technique form (AR 269-79). Dr. Bilala determined that Plaintiff was "not significantly limited" in his ability to (1) remember locations and work-like procedures; (2) understand, remember, and carry out very short and simple instructions; (3) maintain attention and concentration for extended periods; (4) perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances; (5) sustain an ordinary routine without special supervision; (6) work in coordination with or proximity to others without being distracted by them; (7) complete a normal workday and workweek without interruptions from psychologically based symptoms and perform at a consistent pace without an unreasonable number and length of rest periods; (8) interact appropriately with the general public; (9) ask simple questions or request assistance; (10) accept instructions and respond appropriately to criticism from supervisors; (11) get along with co-workers or peers without distracting them or exhibiting behavior extremes; (12) maintain socially appropriate behavior and adhere to basic standards of neatness and cleanliness; (13) respond appropriately to changes in the work setting; (14) be aware of normal hazards and take appropriate precautions; and (15) set realistic goals or make plans independently of others. (AR 266-67.) He found Plaintiff "moderately limited" in the ability to understand, remember, and carry out detailed instructions. (AR 266.) Dr. Biala also noted that Plaintiff had the cognition for simple tasks; Plaintiff's concentration, persistence, and pace were sufficient for two-hour intervals in an eight-hour day and forty-hour workweek; Plaintiff was socially available for "superficial contacts"; and he could adapt to workplace stressors. (AR 268.)

In completing the psychiatric review technique form, Dr. Biala noted that Plaintiff had an affective disorder that mildly limits his activities of daily living and social functioning. (AR 277.) It was noted that Plaintiff would have moderate difficulties in maintaining concentration, persistence, or pace. (AR 277.) Dr. Biala indicated that Plaintiff had responded to medication in the past, and was presently back on medication with "mild improvement," but his Depakote was to be increased. (AR 279.) Dr. Biala projected that, through June 2009, Plaintiff would be able to complete simple, repetitive tasks. (AR 279.)

On September 3, 2008, Plaintiff was seen by Dr. Castillo at Merced Mental Health. (AR 305.) Plaintiff reported that he had not taken the prescribed increased dosage of Depakote and was reminded to do so. (AR 305.) Plaintiff's response to medication was noted to be "good."

On September 26, 2008, Plaintiff was voluntarily admitted to the Marie Green Psychiatric Center ("Marie Green") as he was experiencing severe hallucinations. (AR 294.) Plaintiff's discharge summary was completed by Dr. Castillo who indicated that he knew Plaintiff because he had been treating Plaintiff for bipolar disorder at the Merced Adult Outpatient Clinic. (AR 296.) Plaintiff had been experiencing auditory hallucinations, and his Abilify prescription was increased to treat the hallucinations; however, the medication was not effective. Instead, the hallucinations had intensified and caused him severe headaches, anxiety, and agitation prompting his wife to bring him to emergency services, leading to his hospitalization. (AR 294.) During the course of his hospitalization at Marie Green, his prescription for Abilify was discontinued and Geodon was prescribed in its place. Plaintiff was also prescribed Thorazine for intense hallucinations. Plaintiff complained of weight gain on Depakote, and thus was prescribed Topamax to decrease his appetite. Plaintiff tolerated the medications, and felt greatly improved and ready to go home at the time of discharge. (AR 295.) His laboratory work was negative for any illicit substances. (AR 295.) At the time of discharge, Plaintiff was no longer experiencing auditory hallucinations and mood changes, he was tolerating his medications without any untoward side effects, and he denied having any suicidal or homicidal ideations, delusions, or hallucinations. Accordingly, Plaintiff was discharged on September 28, 2008, and was referred to Merced Adult Outpatient Clinic for a mental health follow-up with Dr. Castillo on October 1, 2008. (AR 296.)

Plaintiff followed-up with Dr. Castillo on October 1, 2008, who noted that Plaintiff was responding better with his current medication, he had no suicidal or homicidal ideation, and he was directed to continue his medication. (AR 306.) On October 22, 2008, Plaintiff was seen by Dr. Castillo for follow-up care; Plaintiff reported tolerating his medication, and his response to the medication was noted to be good. (AR 307.) On November 19, 2008, Plaintiff was again seen by Dr. Castillo for follow-up care, and reported that his medications were helping him "optimally," he did not feel "as down as before," and he was doing well. (AR 308.)

Plaintiff was seen at Merced Mental Health on January 12, 2009. (AR 352.) He stated his medication regime was working well, he was medication compliant, and he was "doing better than a few weeks ago." (AR 352.) The treatment plan required Plaintiff to keep all scheduled appointments, remain medication complaint, and follow-up in four weeks. (AR 352.) On February 5, 2009, Plaintiff was seen by Dr. Castillo at Merced Mental Health and reported hypomanic symptoms and that he was sleeping less yet remained energized in the morning. (AR 351.) Plaintiff was also making "silly" remarks and gestures at home. (AR 351.) Plaintiff's response to medication was marked as "good," and his Depakote dosage was increased. (AR 351.) On March 30, 2009, Plaintiff again saw Dr. Castillo and reported that he was medication compliant, but his wife indicated that his mood was worsening, and he had been under-reporting his symptoms to Dr. Castillo. (AR 350.) His auditory hallucinations were intensifying, and his wife had asked him to move out if the symptoms were not controlled. (AR 350.) Dr. Castillo discontinued the prescription for Geodon, and prescribed Zyprexa. (AR 350.)

Plaintiff was seen by Dr. Castillo at Merced Mental Health on April 15, 2009. (AR 349.) It was noted that Plaintiff's manic symptoms were diminishing, but he remained hypomanic. Plaintiff reported medication compliance and that his sleep had improved. (AR 349.) Plaintiff's medication was adjusted, and he was to follow-up for treatment in two weeks. (AR 349.)

On April 21, 2009, Plaintiff was provided emergency care at Mercy Medical Center. (AR 385-86.) Plaintiff reported acute chest pain, but chest x-rays were negative for heart failure, pneumonia, or pneumothorax. (AR 386.)

Plaintiff received follow-up treatment on April 29, 2009, and reported feeling "tormented" because his wife wanted him to stop his medications. (AR 348.) Plaintiff was unsure if the medication was fully working, but despite his medication concerns, he reported being medication compliant. (AR 348.) He noted he was over-sleeping, which Dr. Castillo attributed to the Zyprexa. Plaintiff reported showing no anger or irritability at home, unlike before. He was noted to be "immaculately dressed." (AR 348.) His medication was adjusted, and Dr. Castillo indicated he should return for follow-up treatment in two weeks. (AR 348.)

On May 6, 2009, Plaintiff was admitted again to Marie Green reporting suicidal thoughts, and intense hallucinations, and was treated by Dr. Castillo. (AR 323.) Dr. Castillo noted that during the previous weeks, changes in Plaintiff's medications had been made as his hallucinations and mood swings were intensifying. (AR 323.) Dr. Castillo indicated that Plaintiff had been compliant with his medications, but his hallucinations continued to persist, especially in the three to five days prior to hospitalization. (AR 323.) Plaintiff reported experiencing severe headaches due to constant messages he was hearing, rendering him unable to sleep. (AR 323.) The voices were also telling him to kill himself. (AR 323.) His family decided to take him back to Marie Green. (AR 323.)

Dr. Castillo noted that Plaintiff's wife stated that he had not been able to tolerate higher dosages of Depakote and that he seemed to do better on a lower dose. (AR 324.) Dr. Castillo lowered Plaintiff's prescription for Depakote, and noted that Plaintiff tolerated the medication adjustments. Dr. Castillo also noted that Plaintiff's hallucinations diminished, his mood was "far more stable," and he was discharged on May 11, 2009. The discharge recommendations included a referral to Merced Mental Health for follow-up care, to see a medical doctor for health problems, and to obtain a computed tomography ("CT") scan. His prognosis was considered "good" so long as Plaintiff remained compliant with medication and pursued follow-up care. (AR 325.)

On May 13, 2009, Plaintiff was seen by Dr. Castillo for follow-up care, and it was noted that Loxitane was helping to manage Plaintiff's auditory hallucinations. (AR 347.) Plaintiff was to follow-up with treatment in one month. (AR 347.) On May 29, 2009, Plaintiff was seen at Merced Mental Health for a therapy session, and he stated that he felt the best he had in many months and things were going well. (AR 346.)

On June 2, 2009, Plaintiff failed to keep a scheduled appointment for therapy. (AR 345.) On June 3, 2009, Plaintiff was seen at Mercy Medical Center with complaints of feeling overtired and over-medicated. (AR 381.) Plaintiff's wife reported that Plaintiff was not able to complete his thoughts, his speech was slurred, and he was mimicking her. (AR 381.) A CT scan was ordered, but it was negative for intracranial abnormality. (AR 382.) The examining physician noted an impression of acute hypersomnolence secondary to acute electrolyte abnormality/hypokalemia. (AR 382.) Although Plaintiff reportedly had taken his prescription medication that morning, a drug screen was negative even for benzodiazepines. (AR 378, 382.) Plaintiff was discharged and was instructed to follow-up in the Family Care Clinic in one day. (AR 382.)

On June 10, 2009, Plaintiff was seen at Merced Mental Health, he reported that his Bell's Palsy had flared up, and he was taken to the hospital where a CT scan was taken. His response to medication was reported to be good, and he was instructed to follow-up in three weeks. (AR 343.) On June 22, 2009, and on July 1, 2009, Plaintiff failed to appear for appointments. (AR 342.) On July 8, 2009, Merced Mental Health telephoned Plaintiff, due to his failure to appear at his last scheduled appointments. Plaintiff was unavailable, but his wife reported that his medication compliance was good, and he needed all his medications refilled. (AR 339.) On July 31, 2009, Plaintiff appeared for another mental health status examination. His medication compliance was noted to be good, but he had stopped taking his prescription for Topamax because he was experiencing tremors in his hand, which he attributed to the Topamax. (AR 338.) Plaintiff's medications were adjusted, and he was to report for follow-up care in one month. (AR. 338.) Plaintiff was seen for follow-up treatment on August 28, 2009. (AR 337.) Plaintiff reported feeling moody and that he had stopped taking Topamax; as a result, his tremors had stopped. (AR 337.) It was noted that Plaintiff had missed a therapy appointment. (AR 337.) Plaintiff had gained weight, possibly because of his discontinuation of the Topamax. (AR 337.) Dr. Castillo reported that he did not believe Topamax contributed to Plaintiff's tremors but that Loxitane was the cause instead. (AR 337.) Plaintiff described his mood as mildly unstable, but denied experiencing suicidal or homicidal thoughts, and he experienced no active hallucinations or delusions. (AR 337.) Plaintiff's medications were adjusted, and he was instructed to follow-up for care in two weeks. (AR 337.)

On September 11, 2009, Plaintiff presented for a follow-up appointment where Dr. Castillo noted that Plaintiff was still experiencing mood changes, alternating episodes of feeling "moody and mop[e]y," but did not report any hallucinations. (AR 336.) Plaintiff had also decided not to take his prescribed Abilify, fearing that it might induce hallucinations. (AR 336.) Dr. Castillo educated him that the likely cause of his hallucinations was that his mania worsened, and not because of the Abilify. Dr. Castillo advised Plaintiff to ...


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