United States District Court, E.D. California
ORDER ON PLAINTIFF'S COMPLAINT (Doc No. 1)
SHEILA K. OBERTO, Magistrate Judge.
Plaintiff Martin Lee Brooks ("Plaintiff") seeks judicial review of a final decision of the Commissioner of Social Security (the "Commissioner" or "Defendant") denying his application for Supplemental Security Income ("SSI") pursuant to Title XVI of the Social Security 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.
Plaintiff was born on July 30, 1956. (Administrative Record ("AR") 28, 154, 222.) Plaintiff worked as a printer from 1978 to 1987, as a laborer in oilfield construction from 1989 to 1990, and as a doorman at a nightclub from January to October 1991. (AR 189.) Plaintiff stopped working in 1991 because of depression, anxiety, and back and neck problems. (AR 182.) On November 25, 2008, Plaintiff applied for SSI benefits, alleging his disability began in July 1992. (AR 182.)
A. Summary of Relevant Medical Evidence
In April 1996, Plaintiff underwent a mental health evaluation at Kern County Substance Abuse, administered by Dirk O. Wales, M.D. (AR 254-56.) Plaintiff reported feeling down for several years prior to the examination, and that he had been self-medicating with drugs and had used "everything known to man." (AR 254-55.) His drug of choice was crank, but he had used cocaine, LSD, mushrooms, and marijuana. (AR 255.) He noted he had been chemical-free since 90 days prior to the examination, which was his longest period of sobriety in several years. (AR 255.) He stated he was living with his mother and living on food stamps "and the generosity of his family." (AR 254-55.) He also indicated he had experienced suicidal thoughts in the past but not recently. (AR 255.)
Dr. Wales diagnosed him with an adjustment disorder, dysthymia, and assigned a Global Assessment of Functioning ("GAF") score of 50. (AR 256.) Dr. Wales prescribed Desyrel and advised Plaintiff to follow-up in four weeks. (AR 256.) His prognosis was listed as fair. (AR 256.)
On February 7 and 10, 2006, Plaintiff was referred to Michael G. Musacco, Ph.D., for psychological evaluation. (AR 309-13.) Psychological testing was administered, including a Minnesota Multiphasic Personality Inventory and a Personality Assessment Inventory. (AR 311.) Plaintiff was diagnosed with amphetamine dependence, partial remission; cannabis abuse; dysthymia; anxiety disorder; panic disorder, without agoraphobia; and a personality disorder. (AR 312.)
Apparently in association with a prior claim, Plaintiff was sent to Kimball Hawkins, Ph.D., for a mental status examination on June 30, 2006. (AR 305-08.) At the time of evaluation, Plaintiff was 49 years old and lived with his mother. He had a driver's license, but his mother dropped him off for the assessment.
He attended Strathmore Union High School, taking regular classes, as opposed to special education classes, but he never graduated. (AR 305.) He reported a history of psychiatric treatment for behavioral issues as a child.
Dr. Hawkins reviewed the psychological evaluation administered by Dr. Musacco, and performed a mental status examination. Dr. Hawkins indicated Plaintiff has a history of an anxiety disorder, and appeared to have some problems with self-defeating personality traits. (AR 307.) He did not show substantial handicap in cognitive functioning. Despite complaints of avoiding people and anxiety, he was not receiving ongoing psychiatric treatment.
Dr. Hawkins opined Plaintiff's ability to understand, remember, and carry out complex instructions was good; and his ability to understand, remember, and carry out simple instructions was unlimited. He had adequate ability to maintain concentration, attention, and persistence; perform activities within a schedule and maintain regular attendance; complete a normal workday and workweek without interruptions from psychologically based symptoms, although he reported significant problems that were not observable; and would be able to respond appropriately to changes in the work setting. (AR 308.)
On August 22, 2006, Barry Rudnick, M.D., reviewed Plaintiff's records from October 15, 2003, through August 22, 2006, and completed a Psychiatric Review Technique form as well as a Mental Residual Functional Capacity Assessment form. (AR 320-37.) He found Plaintiff to be mildly limited in his activities of daily living and in maintaining concentration, persistence, or pace. He opined Plaintiff was moderately limited in maintaining social functioning; interacting appropriately with the general public, and accepting instructions and responding appropriately to criticism from supervisors. (AR 330-36.) In all other functional abilities, he found Plaintiff not significantly limited. (AR 335-37.)
On March 13, 2007, state-agency non-examining doctor R. Starace, Ph.D, rendered an opinion for purposes of a "reconsideration determination" that Plaintiff could understand, remember, and execute instructions; sustain concentration, pace, and persistence; and socially interact adequately and adapt to change. (AR 342.)
On March 10, 2008, a Kern County Mental Health progress note from Richard Feldman, M.D., indicated he believed Plaintiff's current disability was mild, and that Plaintiff would be able to perform part-time work. (AR 623.) Between May and July 2008, Plaintiff was incarcerated in Kern County Correctional Facility. (AR 389-406.) At the intake screening, Plaintiff reported he had been smoking methamphetamine and marijuana the prior night. (AR 392.) After Plaintiff's release in July 2008, he was placed on probation for five years and ordered to enter a sober living facility for one year. (AR 259, 813.)
In October 2008, Plaintiff continued mental health treatment at Kern County Mental Health pursuant to court order. (AR 809-14.) He reported his mother had secured a donation to pay for his living arrangement through December 2008, but she could not pay after that time and it was noted that Plaintiff would be homeless again. (AR 810.) Marriage and Family Therapist Sylvia Petitt indicated Plaintiff could not work due to his depression and physical pain. (AR 813.) On evaluation, the therapist noted Plaintiff's ability to concentrate was impaired, he was inattentive, he had poor immediate and long-term memory, and he demonstrated poor judgment and insight. (AR 816.) Plaintiff's treatment goal was listed as reaching mental stability on medication, obtaining stable housing, and achieving sobriety. (AR 817.)
On December 4, 2008, Dr. Feldman completed a "psychiatric medication evaluation." (AR 805-08.) He indicated Plaintiff was initially evaluated on October 24, 2008, a diagnostic impression of Depressive Disorder, not otherwise specified and polysubstance dependence was made, and Plaintiff had been assigned a GAF score of 50 at that time. (AR 805.) Upon examination, Dr. Feldman noted Plaintiff had clear speech, his mood was subdued, but his affect range was full. (AR 807.) Plaintiff presented his dilemma without delusional elaboration, but he suffered infrequent, brief auditory hallucinations, which did not appear problematic. (AR 807.) His judgment was noted to be fair but could deteriorate under stress; Plaintiff's insight was "present" and his impulse control was noted to be fair. (AR 807.) Dr. Feldman diagnosed depressive disorder, not otherwise specified, and noted a need to rule out dysthymic disorder. He assigned Plaintiff a GAF score of 48. (AR 808.)
Plaintiff continued treatment with Dr. Feldman at Kern County Mental Health from 2008 to 2010. His treatment included group and individual counseling, as well as oversight by Dr. Feldman for medication management. (AR 588-821.) During the course of his treatment, he occasionally stopped taking his medication and underwent medication adjustments to address his trouble sleeping. He participated in group therapy and it was noted that other group members appeared to "look up to [Plaintiff] as he is quite knowledgeable and appears to be like a father figure to others." (AR 769.)
On January 21, 2009, K. Loomis, M.D., a state-agency non-examining physician, reviewed Plaintiff's medical records and opined on his functional abilities. (AR 407-20.) Dr. Loomis found Plaintiff only mildly limited in his activities of daily living and in maintaining social functioning, but found Plaintiff moderately limited in his ability to maintain concentration, persistence, or pace; and in his ability to understand, remember, and carry out detailed instructions. (AR 415.) Dr. Loomis found Plaintiff not significantly limited in any other area of functioning. (AR 418-20.) Dr. Loomis concluded Plaintiff was capable of understanding, remembering, and carrying out simple one- to two-step tasks; maintaining concentration, persistence, and pace throughout a normal workday; interacting adequately with coworkers and supervisors without difficulty; dealing with the demands of the general public; and making adjustments and avoiding hazards in the workplace. (AR 420.)
A May 2009 Kern County Mental Health progress note indicates Plaintiff had passed the General Educational Development Test ("GED") to obtain a high-school diploma equivalent, had been "clean" for 13 months, was leading group-therapy sessions, and had participated in many mental health services, demonstrating "motivation to improve and change." (AR 777.)
On June 11, 2009, a progress note signed by Dr. Feldman assessed Plaintiff's current disability as mild, but indicated Plaintiff was not able to work. (AR 791.) His prognosis was marked as "fair." (AR 791.) On June 25, 2009, Dr. Feldman completed another progress note indicating that Plaintiff's current disability was moderate, he was unable to work, and his prognosis was considered fair. (AR 776.)
On July 4, 2009, Helen C. Patterson, Ph.D., a state-agency non-examining physician, reviewed Plaintiff's medical records and completed a Psychiatric Review Technique form and a Mental Residual Functional Capacity Assessment form. (AR 484-502.) Dr. Patterson determined Plaintiff was moderately limited in his ability to understand, remember, and carry out detailed instructions; work in coordination with or proximity to others without being distracted by them; complete a normal workday and workweek without interruptions from psychologically-based symptoms; perform at a consistent pace without an unreasonable number and length of rest periods; accept instructions and respond appropriately to criticism from supervisors; and get along with coworkers or peers without distracting them or exhibiting behavioral extremes. (AR 499.) Dr. Patterson also found Plaintiff markedly limited in his ability to interact appropriately with the general public.
In sum, Dr. Patterson concluded the preponderance of evidence indicated Plaintiff is capable of understanding and remembering at least simple instructions and can effectively perform routine tasks; sustaining a normal workday and workweek, despite occasional interruption from mood-disorder symptoms and maladaptive personality traits; maintaining appropriate social interaction with supervisors and co-workers, but may have difficulty handling a job requiring close interaction with the public; and adapting to normal changes within a work environment. (AR 501.)
On August 6, 2009, Dr. Feldman again completed a progress report assessing Plaintiff's current disability as mild, finding Plaintiff unable to work, and noting his prognosis remained "fair." (AR 747.) On September 16, 2009, a similar progress note was entered by Dr. Feldman. (AR 722.) On September 28, 2009, a progress note indicated a discussion regarding sending Plaintiff to a job developer, which Plaintiff "thought... to be a good idea." (AR 712.) Plaintiff was encouraged to see the job developer and "not depend [on] getting SSI because nothing is a guarantee." (AR 712.)
Progress notes and counseling records in November and December 2009 indicate Plaintiff was volunteering at Goodwill Industries two days a week, as well as volunteering two days a week at the Salvation Army. (AR 665-66.) In January 2010, Plaintiff reported he was continuing to volunteer at Good Will, and stated he was "trying to get hired on fulltime." (AR 652.) He was also able to pay his rent at Griffen's Gate, a transitional living facility, by performing "work for them" and the General Assistance Program was paying for his food. (AR 652.) In February 2010, Plaintiff reported continuing his volunteer work at Good Will and he reported a desire to be hired there for pay. (AR 643.) In May 2010, Plaintiff was reminded that his mental health case would be closed with Kern County at the end of June, and Plaintiff reported he was hoping to get a job in Tehachapi helping an elderly man who needed companionship, which was why he was trying to get his driver's license back. (AR 595.) He also indicated he wanted to move back to Washington. (AR 595.)
Plaintiff was seen by Dr. Feldman on June 2, 2010, who noted Plaintiff was leaving the program. Dr. Feldman indicated Plaintiff had been sober for two years, and was planning to move to Tehachapi if he could get a job there. (AR 594.) His current disability was listed as "mild, " and his prognosis was listed as "good." (AR 594.) Plaintiff still had auditory hallucinations, but his thought process was unremarkable, and his insight, memory, and judgment were noted to be "good." (AR 593.) His concentration and attention were also intact. (AR 593.) Plaintiff was seen for a final visit at Kern County Mental Health on June 8, 2010, and he was noted to be in a good mood and ready to move on in his life. (AR 588.)
On October 25, 2010, Robyn Field, Ph.D., completed a mental function capacity questionnaire. Dr. Field diagnosed Plaintiff with Bipolar I Disorder, most recent episode mixed, severe with psychotic features. (AR 823.) Dr. Field also noted chronic back pain and peripheral neuropathy. (AR 823.) Dr. Field found Plaintiff had no discernable improvement in response to treatment, and he was assigned a current GAF score of 50. (AR 823.) Plaintiff's prognosis was said to be very poor for sustained employment, but fair prognosis overall if he "stayed clean, " and that he was compliant with his medication regime. (AR 824.) Dr. Field noted Plaintiff's problems started in school, which was "probably ADHD, " but it was never diagnosed, ...