The opinion of the court was delivered by: McLAUGHLIN, Sean J., District Judge.
Sharon E. Longo ("Plaintiff"), commenced the instant action pursuant to 42 U.S.C. § 405(g), seeking judicial review of the final decision of the Commissioner of Social Security ("Commissioner"), denying her claims for disability insurance benefits ("DIB") under Title II of the Social Security Act, 42 U.S.C. § 401, et seq. Plaintiff filed her application on December 6, 2006, alleging disability since June 1, 2006 due to "acute depression", "[g]all [b]ladder surgery" and "aches in joints" (AR 101-103).*fn1 Her application was denied and she requested and was granted an administrative hearing before an administrative law judge ("ALJ") (AR 59-64; 81). Following a hearing held on October 27, 2008 (AR 33-54), the ALJ concluded, in a written decision dated November 21, 2008, that Plaintiff was not entitled to a period of disability or DIB under the Act (AR 9-17). Plaintiff‟s request for review by the Appeals Council was denied (AR 1-5), rendering the Commissioner‟s decision final under 42 U.S.C. § 405(g). Plaintiff filed her complaint in this Court on May 12, 2010 challenging the ALJ‟s decision. Presently pending before the Court are the parties‟ cross-motions for summary judgment. For the following reasons, the Commissioner‟s motion will be denied and the Plaintiff‟s motion will be granted only to the extent she seeks a remand for further consideration.
Plaintiff was 58 years old on the date of the ALJ‟s decision and has a high school education earned through a G.E.D. (AR 16). She has special training in bookkeeping, and past relevant work experience as a bar/restaurant owner (AR 144-145; 168). Plaintiff reported that she stopped working after her business was destroyed by a fire in May 2006 (AR 140).
The relevant medical records reveal that Plaintiff had a laparoscopic cholecystectomy (gallbladder surgery) for symptomatic cholelithiasis (gallstones) on September 18, 2006 (AR 202). Ten days after surgery her incision was healing well and she had no complaints (AR 199). In October and November 2006, Plaintiff complained of depression to her primary care physician, Frank J. McLaughlin, D.O., and he prescribed Lexapro (AR 223-226).*fn2 On November 1, 2006, Dr. McLaughlin increased her Lexapro dosage amount (AR 225). When seen on November 9, 2006, Plaintiff was still withdrawn but her mood was better with the increased dosage amount (AR 223). She was diagnosed with depression and fatigue, "most likely" secondary to her depression (AR 223).
Psychologists Martin Meyer, Ph.D. and Julie Uran, Ph.D. performed a psychological evaluation of Plaintiff on January 25, 2007 (AR 237-242). Plaintiff reported a health history of shoulder and muscular pain, joint pain, daily headaches, and constant back pain (AR 238). Plaintiff stated that she had difficulty with extended sitting and standing, and was unable to engage in extended fine motor work, such as writing, computer work or sewing (AR 238). Plaintiff further reported that she received no mental health counseling, but took Seroquel and Lexapro (AR 238). Plaintiff claimed she would have difficulty sustaining employment due to poor concentration, lack of motivation and an inability to "keep [her] figures straight", noting that her husband handled their checkbook (AR 238). Plaintiff also reported feelings of helplessness, withdrawal, worthlessness and hopelessness, as well as suicidal ideation without intent or plan of action, and fatigue (AR 238). She reportedly engaged in verbal aggression, struck objects, and stated that she previously struck her husband (AR 238). She admitted to having homicidal thoughts, but denied any intent or plan of action (AR 238).
Drs. Meyer and Uran noted that Plaintiff was cooperative, properly attired and exhibited good hygiene (AR 238). Her speech was coherent and spontaneous, her mood and affect were situationally appropriate and she laughed intermittently (AR 239). There were no reported perceptual disturbances and her thought process was normal and relevant, although homicidal thought was admitted (AR 239). Drs. Meyer and Uran found evidence of excessive rumination regarding an expressed desire for relocation (AR 239). Plaintiff appeared guarded and/or suspicious of others, and her statements reflected low self-esteem and worthlessness (AR 239). Plaintiff was found to be of average intelligence with an adequate vocabulary, she was alert and oriented and had no difficulty recalling recent events, although she could not recall childhood experiences and reported limited childhood memories (AR 239). Plaintiff demonstrated appropriate social judgment and was a good narrator of personal history (AR 239-240). It was noted however, that she had difficulties with impulse control as marked by displays of anger (AR 239).
Plaintiff tested at a high school level on the WRAT-3 (AR 240). Personality testing indicated depression and mild anxiety, with ruminative tendencies, as well as social alienation, avoidance and paranoia (AR 240). Drs. Meyer and Uran diagnosed Plaintiff with major depression, recurrent, and generalized anxiety disorder, and assigned her a global assessment of functioning*fn3 ("GAF") score of 50 (AR 241). They opined that Plaintiff‟s functional limitations included difficulties interacting with others and social withdrawal (AR 240-241). They found that she was a poor candidate for vocational rehabilitation, but recommended that she undergo therapy and psychiatric medication monitoring (AR 241).
On February 8, 2007, Juan B. Mari-Mayans, M.D., a non-examining state agency reviewing physician, reviewed the medical evidence of record and opined that Plaintiff could perform medium work with no limitations (AR 243-248). Dr. Mari-Mayans noted that Plaintiff alleged disability due to acute depression, gall bladder surgery and aches in her joints, and that she claimed limitations in standing, walking, lifting carrying and bending (AR 248). He found her statements regarding her symptoms and functional restrictions only partially credible, since the medical evidence established that Plaintiff underwent successful gall bladder removal surgery in September 2006 and had only treated infrequently for complaints of joint pain (AR 248).
On March 8, 2007, Sharon Becker Tarter, Ph.D., a state agency reviewing psychologist, reviewed the psychiatric evidence of record and determined that Plaintiff had mild limitations in completing activities of daily living and in maintaining social functioning, and moderate limitations in maintaining concentration, persistence or pace (AR 268).*fn4 Dr. Tarter completed a mental residual functional capacity assessment form, and opined that Plaintiff was only moderately limited in her ability to interact appropriately with the general public, and accept instructions and respond appropriately to criticism from supervisors (AR 256). Dr. Tarter found that Plaintiff was not significantly limited in all other work-related activities, including the abilities to remember locations and work-like procedures; understand, remember, and carry out very short and simple instructions; understand, remember and carry out detailed instructions; maintain attention and concentration for extended periods; perform activities within a schedule, maintain regular attendance, and maintain punctuality; sustain an ordinary routine; work in coordination with or proximity to others; make simple work-related decisions; complete a normal workday and workweek; ask simple questions or request assistance; get along with co-workers; maintain socially appropriate behavior; respond appropriately to changes in the work setting; be aware of normal hazards and take appropriate precautions; travel in unfamiliar places or use public transportation; and set realistic goals or make plans independently of others (AR 255-256).
Dr. Tarter noted that Plaintiff suffered from depression, but had not been hospitalized and was prescribed psychotropic medications by her primary care physician (AR 257). She found Plaintiff was functional with respect to her activities of daily living and social skills, and her memory processes were intact (AR 257). Dr. Tarter concluded that Plaintiff was able to meet the basic mental demands of competitive work on a sustained basis despite the limitations resulting from her impairments (AR 257).
On March 20, 2007, Plaintiff complained of left shoulder pain and joint pain when seen by Dr. McLaughlin (AR 285).
Plaintiff was evaluated by Tariq Qureshi, M.D. a psychiatrist at Stairways Behavioral Health Outpatient Clinic on April 24, 2007 (AR 300-302). Plaintiff complained of depression, tiredness, lack of motivation, diminished concentration and feelings of helplessness, hopelessness and worthlessness, but denied any suicidal or homicidal ideations (AR 300). Plaintiff reported that she took Lexapro and Seroquel for her symptoms as prescribed by Dr. McLaughlin, but they were not helpful (AR 300). On mental status examination, Dr. Qureshi reported that Plaintiff exhibited adequate hygiene, was cooperative, and maintained good eye contact (AR 301). Her speech was normal, her thought processes were organized and goal directed, and her insight and judgment were fair (AR 301). Dr. Qureshi noted her mood was depressed, but she denied any suicidal or homicidal thoughts, obsessions, compulsions or phobias (AR 301). Dr. Qureshi diagnosed Plaintiff with major depressive disorder and assigned her a GAF of 55 (AR 302). He switched her medications to Prozac and Trazedone (AR 302).
On May 24, 2007, Stairways treatment notes reflect that Plaintiff‟s depression had "eased somewhat" but her sleep problems persisted (AR 299). Dr. Qureshi reported that her mood was less depressed and she denied experiencing any suicidal or homicidal ideations (AR 299). She was continued on Prozac and her Trazodone dosage was increased (AR 299).
On June 8, 2007, Plaintiff called Dr. McLaughlin‟s office and requested medication for arthritic pain and Dr. McLaughlin prescribed Motrin (AR 282). Plaintiff was seen by Dr. McLaughlin on June 19, 2007 for follow up of hypercalcemia (AR 281). No other concerns were noted, and her physical examination was unremarkable (AR 281). She was diagnosed with hypercalcemia and back pain, and continued on her medication regimen (AR 281).
On May 29, 2007, Plaintiff returned to Dr. McLaughlin and complained of lesions on her face and legs, increased fatigue and weight gain, but had no other complaints (AR 283). Her physical examination was unremarkable, and she was continued on her medication regimen (AR 283).
Plaintiff returned to Dr. Qureshi on June 21, 2007 who noted she was "doing well" on her medications and that her sleep issues had improved (AR 298). Dr. Qureshi reported that Plaintiff was pleasant, cooperative and well groomed, and her thoughts were well organized (AR 298). She was continued on her medication regimen (AR 298).
On August 15, 2007, Plaintiff reported increased depression and insomnia (AR 298). She denied suffering from any suicidal or homicidal ideations (AR 298). Dr. Qureshi increased her Prozac dosage (AR 298).
On September 5, 2007 Plaintiff reported that her depression had lifted with the increased Prozac dosage and she had minimal insomnia (AR 298). Dr. Qureshi reported that her mood and affect ...