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Needham v. Berryhill

United States District Court, N.D. California

October 31, 2019



          PHYLLIS J. HAMILTON, United States District Judge.

         Plaintiff Timothy Needham seeks judicial review of the Commissioner of Social Security's (the “Commissioner”) final decision denying Needham's claim for disability benefits pursuant to 42 U.S.C. § 405(g). This action is before the court on the parties' cross-motions for summary judgment. Having considered the parties' cross-motions, the pertinent legal authorities, and having reviewed the administrative record, the court hereby remands this case to the Commissioner for further proceedings in accordance with this court's order.


         A. Personal History

         In October 2013, Needham applied for Supplemental Security Income, alleging disability beginning in September 2006. Administrative Record (“A.R.”) 61. Needham attended school through the tenth grade, obtained his GED, and attended community college for a semester or two. A.R. 39, 539, 770, 913. Needham worked as a truck driver from at least 1996 (perhaps earlier) to about 2001, when he was attacked on the job and experienced trauma-related anxiety. A.R. 243-44, 258, 270, 289, 389, 519. Around 2006, he divorced his wife, and in 2012 he became homeless. A.R. 240, 389, 520, 769-70, 913. He has used methamphetamine off and on throughout his life. A.R. 519.

         On September 7, 2013, Needham attempted to commit suicide. A.R. 518. After being injured in an altercation and admitted into Eden Medical Center's emergency room, he entered a bathroom, slit his wrists, took a mixture of pills, wrote a suicide note on the mirror, and hit the call button. A.R. 408, 417, 420, 518, 543, 788, 808. Medical staff gave him medication and transferred him to John George Psychiatric Pavilion at the Highland Campus, where he was diagnosed with depressive disorder not otherwise specified (“NOS”) and alcohol abuse and assigned a Global Assessment Functioning (“GAF”)[1] score of 20. A.R. 443-45, 810. While at John George Psychiatric Pavilion, Dr. John Fenton, M.D. evaluated Needham and diagnosed him with major depressive disorder, alcohol abuse, and history of amphetamine abuse. A.R. 542. Dr. Fenton reported improvement in Needham's mood and that medication doses had been adjusted to “therapeutic effect.” A.R. 544.

         Needham was thereafter admitted to Woodroe Place Crisis Resolution, a residential mental health facility operated by Bay Area Community Services (“BACS”). A.R. 541, see also A.R. 904. At Woodroe Place, Dr. Edward Maxwell observed that Needham was restless with a dysphoric, expansive mood and mildly impaired judgment. A.R. 905-06. Needham continued to receive therapy from mental health counselors and was assessed GAF scores ranging from 45 to 55. A.R. 893, 907.

         On October 9, 2013, Needham was discharged from Woodroe Place and moved to the A Street shelter. A.R. 893. On October 10, 2013, Needham began participating in mental health treatment and case management with BACS Oakland Project Connect. A.R. 1074. He continued almost weekly contact with therapists and case managers until July 28, 2016. E.g., A.R. 922.

         Between October 2013 and December 2013, Needham was also treated at the Sausal Creek Outpatient Stabilization Clinic, a drop-in mental health clinic. A.R. 485- 505. On October 28, 2013, Dr. Emma Castro observed that he was alert and had anxious mood, irritable affect, logical thought process, and marginal judgment. A.R. 495. She also saw him on November 8, November 22, 2013, and December 6, 2013, diagnosing him with psychotic disorder NOS, bipolar disorder, and polysubstance dependence in partial remission, and assigning GAF scores of 50, 52, and 55. A.R. 486, 490, 495. By the last visit, “the meds seem[ed] to be working good” and Needham's insight and judgment were good. A.R. 486.

         In December 2013, Needham had several evaluations at the Winton Wellness Center.[2] On December 4, 2013, he saw Dr. Srilekha Puranam for his hypertension and bipolar disorder. A.R. 763, 768. He reported aggravation of the bipolar disorder by drug use as well as decreased sleep, depressed mood, and racing thoughts, but no suicidal ideation. A.R. 763. On December 13, 2013, Needham had an initial psychiatric evaluation with Dr. Catalina Villa. A.R. 769-72. He reported symptoms of severe depression at least one week per month, including crying, staying in bed, and decreased appetite. A.R. 769. Dr. Villa noted that despite a “constricted” affect, Needham showed “unremarkable” behavior, good impulse control, and no suicidal or homicidal ideation. A.R. 771. She diagnosed him with unspecified bipolar disorder, alcohol dependence in early remission, and amphetamine dependence in full remission. Id.

         On January 29, 2014, Needham returned to Sausal Creek with increased symptoms, reporting he was “up/down with depression” for three weeks and that his medications were not helping. A.R. 734. On February 24, 2014, he returned again to Sausal Creek requesting medication for depression. A.R. 729. The staff psychiatrist noted his euthymic affect and depressed mood and diagnosed him with psychotic disorder NOS, bipolar disorder, and polysubstance abuse with a GAF score of 55. A.R. 730. He prescribed him the same dosage of Remeron, Risperdone, Depakote, and Benadryl, and added Buproprin. A.R. 728.

         On February 14, 2014, psychologist Dr. Deepa Abraham examined Needham and conducted a records review. A.R. 516. She noted he had “somewhat pressured” speech, intact concentration, and average results on the Wechsler Adult Intelligence Scales. A.R. 521-23. She reported that Needham exhibited symptoms of depression such as lethargy, insomnia, and social withdrawal and a manic presentation including grandiosity, racing thoughts, and reckless behavior. A.R. 526. She diagnosed him with mood disorder NOS and polysubstance dependence while assigning him a GAF score of 35. A.R. 527. Because of his symptoms, she opined that he would “experience difficulty competing for jobs in an open labor market” and “difficulty coping with daily or the usual stresses encountered in a competitive work environment.” A.R. 528-29. She also noted his low auditory memory scores that “might reflect in difficulty with remembering work assignments, processing complex instructions or in completing tasks.” A.R. 528. She concluded that he had mild impairments in understanding, comprehending, and remembering information; no significant impairment in social interaction; and moderate impairment in adaptation. A.R. 528-29.

         On April 1, 2014, Dr. Puranam reported Needham's bipolar disorder and insomnia were “[w]ell controlled” and noted he had not used alcohol in two months and amphetamines in four months. A.R. 756. Around this time, Needham moved to transitional housing. A.R. 1056-58.

         Throughout 2014, Needham continued services at BACS Oakland Project Connect. He met with MacKenzie Stuart, a BACS unlicensed marriage and family therapist and Tiffany Smith, a BACS personal services coordinator, on a weekly basis for therapy and help with tasks and appointments. A.R. 1031-63. Ms. Stuart diagnosed Needham with a consistent GAF score of 45. A.R. 1031-63. His symptoms included “overwhelming sadness” (A.R. 1039), suicidal ideation (A.R. 1045-46), anhedonia (A.R. 1039-44, 1047), hypersomnia (A.R. 1039, 1050), and fear of leaving the house (A.R. 1054). He also presented with pressured speech, racing thoughts, and anxiety. A.R. 1033, 1037, 1049. Other times, he presented as euthymic (A.R. 1050-53) and reported having “significantly better” mood (A.R. 1037) and no recent manic or severe depressive episodes (A.R. 1053).

         On December 15, 2014, Needham had an intake appointment with psychiatrist Dr. Catherine Reed at Pathways to Wellness (“Pathways”), a mental health clinic. A.R. 531, 536. Needham reported mood swings, insomnia, and nighttime auditory hallucinations that affected his activities of daily living. A.R. 531, 535-36. Dr. Reed diagnosed him with bipolar disorder, depression, with psychotic features, and amphetamine dependence in remission with a GAF score of 65. A.R. 535. She noted he had normal behavior, normal speech, depressed mood but was “hopeful, ” and appropriate affect. A.R. 534. She added Latuda to his medications (A.R. 537) and opined that he had moderate restrictions in activities of daily living; moderate difficulties in social functioning; mild difficulties in maintaining, concentrating, and persistence of pace; and moderate episodes of decomposition and increase of symptoms (A.R. 535).

         Needham continued treatment at Pathways throughout 2015. On March 19, 2015, Needham reported improvement with medications and mild sadness. A.R. 889. Dr. Reed assessed a GAF score of 60-65. A.R. 888. On April 8, 2015, Needham told Dr. Puranam that he felt better as his medication changed from Risperdone to Latuda. A.R. 846. On July 9, 2015, Dr. Reed upgraded his GAF score to 65 after noting a good response to medications, his attendance in DUI classes, and lack of psychosis or mania. A.R. 884-85. On August 26, 2015, Needham reported feeling very sad after a friend's death and had not taken medication for two weeks. A.R. 882-83. On September 28, 2015, Needham reported fewer auditory hallucinations and better sleep after increased dosage of Latuda. A.R. 880-81. Starting in August 2015, Dr. Reed reduced Needham's Wellbutrin dosage because of his increased blood pressure, and on December 16, 2015 Nurse Practitioner Sarah Levine noted that Needham's depression was exacerbated by the holiday season. A.R. 876-77.

         Throughout 2015 and 2016, Needham continued to work with BACS for housing, employment, and symptom management. A.R. 990, 922. Shandra Guzman diagnosed him with major depressive disorder (severe without psychotic features), alcohol dependence, and amphetamine dependence (sustained remission) with a GAF score of 45. A.R. 990. On March 25, 2015, Ms. Stuart “supported” Needham to an internal medicine consultation and observed that he was anxious about attending the appointment. A.R. 1019. Needham reported needing help to complete tasks and periods of increased depression. A.R. 953-55, 986, 1008-11, 1025.

         In January 2016, Needham moved to permanent supportive housing, and he continued treatment at Pathways until November 2016. A.R. 939, 1078. On February 24, 2016, Needham reported anxiety over the recent move and increased auditory hallucinations. A.R. 875. On March 23, 2016, he reported improvement in mood since increasing his Latuda dosage. A.R. 872. On April 27, 2016, Needham reported he was doing fairly well but still spent most of the day in bed about once a week; Nurse Levine assigned a GAF score of 60. A.R. 870. As of June 23, 2016, a Pathways psychiatrist reported that Needham was stable on medications “after so many trials.” A.R. 869. On September 29, 2016, Needham said he was “doing well with his med[ication]s” and presented with normal speech and euthymic mood. A.R. 1077.

         In April 2017, Needham began therapy, social groups, and case management at Lifelong Medical Care. A.R. 1082. On April 27, 2017, Needham felt stable on his medications and denied suicidal ideation. On April 28, 2017, therapist Ann Sussman observed Needham had rapid speech, tangential thought processes with grandiose content, and that he “mostly blame[d] others for [his] problems.” A.R. 1093. On May 5, 2017, Needham said he was “doing pretty well” and admitted to “drinking and smoking pot on occasion[.]” A.R. 1096-97.

         B. Procedural History

         On October 25, 2013, Needham filed a Title II application for a period of disability and disability insurance benefits as well as a Title XVI application for supplemental security income. A.R. 15, 61, 85-86. Both applications stated an alleged onset date of September 29, 2006 for disability. A.R. 61. The Commissioner denied Needham's claims both initially and again upon reconsideration on September 17, 2014 and June 3, 2015, respectively. A.R. 84, 116. On July 13, 2015, Needham requested a hearing before an ALJ which took place on May 19, 2017. A.R. 145, 196. At the hearing, plaintiff amended his disability onset date to September 7, 2013. A.R. 15, 59, 390. Vocational expert Christopher Salvo testified at the proceeding. A.R. 54-59. Needham also testified and answered questions from the ALJ and his counsel. A.R. 38-54.

         In May 2017, the ALJ found that plaintiff was not disabled. The ALJ's May 2017 decision became the Commissioner's final decision when the Appeals Council denied plaintiff's request for review. A.R. 1-7.


         The Social Security Act provides for the payment of disability insurance benefits to people who have contributed to the social security system and who suffer from a physical or mental disability. See 42 U.S.C. § 423(a)(1). To evaluate whether a claimant is disabled within the meaning of the Act, the ALJ is required to use a five-step sequential analysis. See 20 C.F.R. § 416.920(a). The ALJ may terminate the analysis at any step if he determines that the claimant is or is not disabled. Pitzer v. Sullivan, 908 F.2d 502, 504 (9th Cir. 1990).

         At step one, the ALJ determines whether the claimant is engaging in any “substantial gainful activity, ” which would automatically preclude the claimant receiving disability benefits. 20 C.F.R. §§ 416.920(a)(4)(i) & (b). If not, at step two, the ALJ considers whether the claimant suffers from a severe impairment which “significantly limits [her] physical or mental ability to do basic work activities.” 20 C.F.R. §§ 416.920(a)(4)(ii) & (c).

         At the third step, the ALJ is required to compare the claimant's impairment(s) to a listing of impairments provided in an appendix to the regulations. 20 C.F.R. § 416.920(a)(4)(iii). If the claimant's impairment or combination of impairments meets or equals the severity of any medical condition contained in the listing, the claimant is presumed disabled and should be awarded benefits. Id.; 20 C.F.R. § 416.920(d).

         If the claimant's condition does not meet or equal a listing, at step four the ALJ considers whether the claimant has sufficient residual functional capacity (“RFC”) to perform his past work despite the limitations caused by the impairments. 20 C.F.R. §§ 416.920(a)(4)(iv) & (e)-(f). An individual's RFC is what he can still do in a workplace setting despite his physical and mental limitations. 20 C.F.R. § 416.945. In determining the RFC, the ALJ must consider all of the claimant's impairments, including those that are not severe, taking into account all relevant medical and other evidence. 20 C.F.R. §§ 416.920(e), 416.945. If the claimant cannot perform his past work, the Commissioner is required to determine, at step five, whether the claimant can perform other work that exists in significant numbers in the national economy, taking into consideration the claimant's RFC, age, education, and work experience. See 20 C.F.R. §§ 416.920(a)(4)(v) & (g).

         In steps one through four, the claimant has the burden to demonstrate a severe impairment and an inability to engage in his previous occupation. Andrews v. Shalala, 53 F.3d 1035, 1040 (9th Cir. 1995). If the analysis proceeds at step five, the burden shifts to the Commissioner to demonstrate that the claimant can perform other work. Id.


         On May 31, 2017, the ALJ applied the sequential analysis and found that Needham was not disabled, concluding that he could perform jobs within the national economy. A.R. 12-27.

         A. The ALJ's Sequential Analysis

         At step one, the ALJ determined Needham had not engaged in “substantial gainful activity” since his amended onset date of September 7, 2013. A.R. 17.[3]

         At step two, the ALJ found Needham suffered from severe impairments of bipolar disorder, amphetamine dependence, alcohol dependence, and obesity. A.R. 18. The ALJ also found that Needham's hypertension and sarcoidosis were non-severe impairments and that Needham did not provide evidence that these impairments would result in a significant limitation in basic work-related activities. A.R. 18-19.

         At step three, the ALJ concluded that the impairments failed to meet the criteria or severity of any section of the listing of impairments in 20 CFR Part 404, subpart P, Appendix 1. A.R. 19-23. In making that finding, the ALJ considered whether the “paragraph B” criteria were satisfied. The ALJ found that disability could not be established under paragraph B in light of the medical facts. A.R. 19-23. The mental health records “reveal one major crisis but are inconsistent with disability.” A.R. 19. The ALJ reviewed medical records, evaluated the persuasiveness of various sources in the record, and concluded that plaintiff's mental impairments do not cause at least two “marked” limitations or one “extreme” limitation, so paragraph B criteria were not satisfied. A.R. 23. The ALJ also briefly addressed paragraph C and determined plaintiff did not satisfy its requirements. A.R. 23.

         Having found that Needham did not suffer from a listed impairment, the ALJ determined Needham's RFC. The ALJ applied a two-step process that considered all symptoms regardless of severity. A.R. 23. First, the ALJ determined whether there was an underlying medically-determinable physical or mental impairment that could reasonably be expected to produce Needham's pain or other symptoms. A.R. 23. The ALJ concluded that Needham's medically-determinable impairments could reasonably be expected to cause the alleged symptoms. A.R. 24. Second, the ALJ evaluated the intensity, persistence, and limiting effects of Needham's symptoms to determine the extent to which they limited his functioning. A.R. 23. The ALJ concluded that Needham's testimony about the intensity, persistence and limiting effects of the symptoms was not entirely consistent with medical evidence and other evidence in the record. A.R. 24. Where Needham reported symptoms that did not match the objective medical evidence, the ALJ made a credibility determination based on the entire medical record:

Claimant alleges he quit working as a truck driver in 2004 because of his conditions. . . However, he has submitted no evidence from that time, and the current medical evidence of record shows claimant . . . lost his license/job after crashing into a pole and received a DUI. Claimant testified he is unable to work due to his depression . . . [and] hears voices, which prevents him from concentrating. On April 27, 2016, claimant reported he is not bothered by his auditory hallucinations . . . He reported “doing well with his meds, ” and was assigned a GAF score of 60 . . . . Recent records from Lifelong Medical indicate claimant remains stable on medications.

AT 24 (internal quotation marks and citations omitted). The ALJ determined that plaintiff has the RFC to perform light work, with certain exceptions. A.R. 23.

         At step four of the sequential analysis, the ALJ determined that Needham had no past relevant work. A.R. 25.

         At step five, based on the vocational expert's testimony, the ALJ determined that jobs existed in significant numbers in the national economy that Needham could perform. A.R. 25-26. Specifically, Needham's RFC did not prevent him from working as a “small products assembler”, “production assembler”, or “maid” as described in the Dictionary of Occupational Titles. A.R. 26. The ALJ therefore determined that Needham was not disabled and not eligible for disability benefits under the Social Security Act. A.R. 26.

         B. The ALJ's Weighing of the Medical Opinions and Testimony

         The ALJ considered and weighed the testimony and opinions of several medical professionals. The primary medical opinions were authored by:

         1. Dr. Deepa Abraham

         Dr. Abraham administered a psychological evaluation of Needham on February 14, 2014. A.R. 516. She opined that he would have “difficulty coping with [the] daily or [] usual stresses encountered in a competitive work environment” and that he has “mood changes that interfere with his ability to sustain effort or adapt to changes in tasks or responsibilities.” A.R. 529. She concluded he had mild impairments in understanding information, no significant impairment in social interaction, and moderate impairment in adaptation. A.R. 528-29.

         Dr. Abraham was an examining psychologist, and the ALJ gave her opinion “great weight” because her opinions were “consistent with the medical evidence…and based upon a thorough examination and records review.” A.R. 22.

         2. Dr. Catherine Reed

         Dr. Reed conducted an initial psychological intake of Needham on December 15, 2014 (A.R. 536) and treated him from February 11, 2015 to October 26, 2015 (A.R. 879, 891). At intake, she assessed that he had moderate restrictions in activities of daily living; moderate difficulties in social functioning; mild difficulties in maintaining, concentrating, and persistence of pace; and moderate episodes of decomposition and increase of symptoms. A.R. 535.

         Dr. Reed was a treating psychiatrist, and the ALJ gave her opinion “great weight” because it was “consistent with the medical evidence of record.” A.R. 22.

         3. Dr. Margaret Pollack

         On July 30, 2014, Dr. Pollack, Psy.D. conducted a psychological consultative review of the medical records that guided the Social Security Administration's determination of “Not Disabled.” A.R. 69, 72. Dr. Pollack noted that in Dr. Abraham's evaluation, Needham alleged auditory hallucinations, but “there was no evidence that he was responding to internal stimuli and no other evidence of psychosis.” A.R. 69. Dr. Pollack opined that his depression and bipolar disorder were negatively impacted by lack of reasonable compliance and “significant” substance abuse problems. A.R. 69. She believed that with sustained sobriety, Needham “should be capable of simple & detailed work-like activity for full workday/work week.” A.R. 69. She found his allegations about the severity of his condition to be “partially credible, ” enough to establish mild cognitive impairment but not enough to preclude all work-like activity. A.R. 70.

         As for Needham's social interaction, Dr. Pollack found he was not significantly limited in interacting with the general public and getting along with peers, however, his ability to respond to criticism from supervisors was moderately limited. A.R. 71. As for Needham's adaptation, she found he was not significantly limited in traveling to unfamiliar places or using public transportation, not significantly limited in setting realistic goals and being aware of hazards, but moderately limited in responding to changes in the work setting. A.R. 71. Accordingly, Dr. Pollack concluded plaintiff had mild restriction in activities of daily living; moderate difficulties in social functioning; mild difficulties in concentration, persistence, or pace; and no repeated episodes of decompensation of extended duration. A.R. 69.

         Dr. Pollack was a non-examining, state consultant physician, and the ALJ gave her opinion “most weight” because it was “consistent with the medical evidence of record. A.R. 21.

         4. Dr. ...

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