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Goodman v. Berryhill

United States District Court, N.D. California

April 14, 2017

NANCY BERRYHILL, [1] Defendant.


          JACQUELINE SCOTT CORLEY United States Magistrate Judge

         Plaintiff Coley Fernandez Goodman (“Plaintiff”) seeks social security benefits for depression and suicidal tendencies. Pursuant to 42 U.S.C. § 405(g), Plaintiff filed this lawsuit for judicial review of the final decision by the Commissioner of Social Security (“Commissioner”) denying his benefits claim. Now before the Court is Plaintiff's Motion for Summary Judgment or Remand and Defendant's cross-motion for summary judgment. (Dkt. Nos. 11 & 17.) Because the Administrative Law Judge (“ALJ”) improperly weighed the medical evidence and erred in discrediting and selectively relying on the evidence in the treatment notes, the Court GRANTS Plaintiff's motion, DENIES Defendant's cross-motion, and REMANDS for further proceedings consistent with this Order.[2]


         A claimant is considered “disabled” under the Social Security Act if he meets two requirements. See 42 U.S.C. § 423(d); Tackett v. Apfel, 180 F.3d 1094, 1098 (9th Cir. 1999). First, the claimant must demonstrate “an inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” 42 U.S.C. § 423(d)(1)(A). Second, the impairment or impairments must be severe enough that he is unable to do his previous work and cannot, based on his age, education, and work experience “engage in any other kind of substantial gainful work which exists in the national economy.” 42 U.S.C. § 423(d)(2)(A). To determine whether a claimant is disabled, an ALJ is required to employ a five-step sequential analysis, examining: (1) whether the claimant is “doing substantial gainful activity”; (2) whether the claimant has a “severe medically determinable physical or mental impairment” or combination of impairments that has lasted for more than 12 months; (3) whether the impairment “meets or equals” one of the listings in the regulations; (4) whether, given the claimant's “residual functional capacity, ” the claimant can still do her “past relevant work”; and (5) whether the claimant “can make an adjustment to other work.” Molina v. Astrue, 674 F.3d 1104, 1110 (9th Cir. 2012); see 20 C.F.R. §§ 404.1520(a), 416.920(a).


         Plaintiff was born on September 15, 1961 and grew up in the Miami/South Carolina area. (Administrative Record (“AR”) AR 94.) Plaintiff has suffered from depression for many years. He has attempted suicide twice: the first time in the 1990's and the second time in 2012. (AR 431, 488.) Plaintiff is gay, and has never married or had any children. (AR 492.) He currently lives alone. (AR 256.) Plaintiff alleges he became disabled on October 1, 2011. (AR 216.) Prior to his alleged onset, Plaintiff worked as an administrative assistant, security guard, and most recently as a certified nursing assistant at an adult day center. (AR 251.)

         On November 6, 2013, Plaintiff filed for Social Security Disability Insurance (“SSDI”) and Supplemental Security Income (“SSI”) under Title II and Title XVI of the Social Security Act, respectively. (AR 140-148.) The Social Security Administration denied Plaintiff's application initially and at reconsideration. (AR 1-3, 140-148.) On July 7, 2015, an ALJ held a hearing where Plaintiff, a medical expert, and vocational expert testified. (AR 15-33.) The ALJ subsequently issued a decision denying Plaintiff's application, finding that Plaintiff was not disabled. (Id.) Thereafter, the Appeals Commission denied review making the ALJ's decision final. (AR 1-4.) Plaintiff commenced this action for judicial review on May 5, 2016 pursuant to 42 U.S.C. § 405(g).

         I. Medical Evidence

         Plaintiff has seen a variety of medical professionals in connection with his psychiatric conditions. A discussion of the relevant medical evidence follows.

         A. Medical History

         1. Prior to October 1, 2011

         Plaintiff first sought treatment for mental health issues in May 2007 from the San Francisco Department of Personal Assisted Employment Services' Counseling Services (“PAES”), to help him deal with the loss of his mother earlier that year. (AR 523-528.) A provider there diagnosed Plaintiff with “bereavement.” (AR 527.) From 2007-2009, Plaintiff saw a number of PAES counselors, including counselors Kamtha Keow and Carrie Lagenbach. (AR 298-410, 510-527, 537-596.) Plaintiff consistently reported grief over the death of his mother. (Id.)

         2. October 1, 2011 to July 7, 2015

         Although Plaintiff's disability onset date is October 1, 2011, there is no medical evidence in the record for the period of October 2011 to August 2013. Other than a few documents predating Plaintiff's disability onset date, the medical evidence begins with a September 11, 2013 Disability Services evaluation, wherein Plaintiff stated he “just can't take it anymore.” (AR 431.) Disability Services contacted San Francisco General Hospital Psychiatric Emergency Services. The hospital placed Plaintiff on a “5150” psychiatric hold and admitted him to the hospital for “crisis stabilization.” (Id.; AR 488.) The admission report noted that Plaintiff was “irritable, anxious, distraught, clenching hands over his head, agitated and rocking in his seat . . . uncooperative with interview refuses to answer further, threatening ‘If you keep talking I'm going to hurt you...Stop asking me all this!'” (AR 440.) Plaintiff was prescribed Ativan because he was “agitated, threatening.”[3] (AR 432.) The hospital discharged Plaintiff the next day. (AR 442.)

         A few days later, Plaintiff began receiving counseling and psychiatric care at South of Market Outpatient Health Center (the “Health Center”). (AR 491-92.) Through the Health Center, Plaintiff began seeing therapist Natalie Henry-Berry, LCSW on a bi-monthly basis, and psychiatrist Dr. Steven Wozniak on a monthly basis. (AR 48.) Plaintiff also received treatment on a monthly basis for medication management and psychotherapy purposes. (Id.) During his first appointment with Ms. Henry-Berry, Plaintiff stated he was “seeking treatment for depression after being in SF for the last 7 years and being mainly isolated, unemployed, at risk of homelessness with poverty.” (AR 468.) Plaintiff further stated he “just can't put in for another job application and get another no.” (Id.) At around the same time, Plaintiff began seeing Dr. Wozniak who prescribed Plaintiff Fluoxetine.[4] (AR 496.)

         During their first few meetings, Ms. Henry-Barry described Plaintiff as “cooperative, adequately groomed but odorous[.]” (AR 468, 469, 471.) Then, in November 2013, Dr. Wozniak and Ms. Henry-Barry placed Plaintiff on a second “5150” psychiatric hold after he showed up to his appointment and “described having ‘41 personalities' and seemed to indicate that these were in conflict.” (AR 472-473.) He endorsed suicidal ideation and agreed with the plan of going to the hospital.” (Id.) Plaintiff stated he felt “better and less overwhelmed” after spending the night in the hospital. (AR 474-75.)

         Plaintiff continued to see both Dr. Wozniak and Ms. Henry-Berry on a consistent basis. (AR 476-496.) In December 2013, Ms. Henry-Berry noted Plaintiff was “in good spirits on this date but continues to struggle with trying to maintain housing. He reports ongoing depression, problematic relationships, and the inability to get many of his needs met[.]” (AR 479.) In a subsequent appointment, Plaintiff reported he was “better but still down.” (AR 480.) When Ms. Henry-Berry discussed possible vocational training, Plaintiff replied “I just can't get myself to look for jobs, I have no energy…I don't want to be around people…I am tired, I have been working since I was 7 yo in the fields of South Carolina.” (AR 486.) In April 2014, Ms. Henry- Berry reported that Plaintiff “continues to report he is in no condition to work and prefer to be in his current position than go out and seek employment. He feels mentally unable to be in an employment environment at this time.” (AR 625.) A month later, Dr. Wozniak reported that Plaintiff “remains down but not as bad as before” and his mood was “depressed though better[.]” Dr. Wozniak reported Plaintiff “continues to have significant functional impairment due to depression” and increased his Fluoxetine dose. (AR 629.)

         Throughout 2014, Ms. Henry-Berry described Plaintiff as “cooperative, [and] adequately groomed[.]” (AR 625, 628, 631, 633, 635, 637, 642, 644, 649, 652.) In June 2014, Dr. Wozniak prescribed Plaintiff Wellbutrin XL as “add-on therapy” to Fluoxetine.[5] (AR 632.) In July 2014, Dr. Wozniak stated “[Plaintiff] still unable to work due to severity of psychiatric symptoms . . . [] Client has partially responded to medication therapy. Likely symptoms remain so severe due to heave [sic] level of stressors.” (AR 634.) Dr. Wozniak increased Plaintiff's Wellbutrin XL dose. (Id.) After a few months on his adjusted medication, Dr. Wozniak reported that although Plaintiff's “mood is better” he “feels unsatisfied with his routine now that he has stable housing and acute depressive symptoms are largely resolved.” Dr. Wozniak “explored with [Plaintiff] ways to increase community contact and decrease isolation . . . [Plaintiff] seemed engaged with the idea and responded well.” (AR 640.) Plaintiff continued reporting progress with his medications, “[Plaintiff] feels somewhat better with fluoxetine dose. [] ‘I'm good more days than not' . . . mood ‘better than not[.]'” (AR 627.) Then, in May 2015, Dr. Wozniak noted, “[d]epressive symptoms persist despite fairly consistent med adherence. Significant functional impairments as a result. Will recommend Abilify[6] to augment [F]luoxetine and Wellbutrin XL.” (AR 653.)

         B. Medical Evaluations

         In addition to routine and emergency medical visits, Plaintiff underwent several examinations to determine his functional capacity in support of his application for disability benefits. Below is a summary of these evaluations.

         1. Rauderic De Silva, MFT

         In September 2013, Mr. De Silva completed an Assessment Report of Plaintiff in connection to his admission to the South of Market Outpatient Health Center. (AR 491.) Mr. De Silva diagnosed Plaintiff with “Depressive Disorder NOS” and a Global Assessment Functioning (“GAF”) scores of 45 to 48 -on a scale of 41-50 - indicating “Serious Symptoms or Impairment[.]” (AR 491.)

         2. Treating Psychiatrist Dr. Wozniak and Therapist Henry-Berry

         a. The July 2014 Mental Functional Assessment

         Dr. Wozniak and Ms. Henry-Berry completed two evaluations of Plaintiff. In July 2014, the practitioners completed a Mental Functional Assessment. (AR 597-598.) They noted Plaintiff had moderate impairments with activities of daily living, moderate impairments with social functioning, moderate impairments with concentration, persistence, and pace, and a marked limitation in his ability to adapt to work type settings. (Id.) Specifically, they noted Plaintiff had “low mood, lack of interest, lack of energy, sleep problems, poor concentration, lack of appetite, frequent SI w/ past attempts.” (Id. at 597.)

         b. The April 2015 Mental Disorder Assessment

         A little less than a year later, in April 2015, Dr. Wozniak and Ms. Henry-Berry completed a Mental Disorder Assessment (AR 600-602) which diagnosed Plaintiff with Major Depressive Disorder Recurrent Moderate and noted that “treatment has relieved sxs of depression but client does have intermittent low moods that can be disabling.” (AR 600.) Their joint functional assessment listed Plaintiff as being markedly limited in all categories. (Id.) In particular, they noted that “[Plaintiff's] depressive episodes leave him unable to function adequately. He becomes tearful distraught unable to verbalize. [Plaintiff] becomes easily overwhelmed, stressed and have (sic) difficulty stabilizing.” (Id. at 601.) Regarding his ability to work, they reported that “[Plaintiff's] depressive sxs have left him unable to socialize, concentrate maintain relationships. [Plaintiff] would not do well in a work environment due to his symptoms reports ongoing sadness SI when facts with stressful situations.” (Id. at 602.)

         3. Cindy Le, M.D.

         Dr. Le evaluated Plaintiff on September 11, 2013 at San Francisco General Hospital after Plaintiff's treating psychiatrist, Dr. Wozniak, placed him on a “5150” psychiatric hold. (AR 440-441.) Dr. Le assessed Plaintiff's GAF score as ...

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