The opinion of the court was delivered by: McLAUGHLIN, Sean J., District Judge.
Melissa Lynne Newman ("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") and supplemental security income ("SSI) under Titles II and XVI of the Social Security Act, 42 U.S.C. § 401, et seq. and § 1381 et seq. Plaintiff filed her applications in November 2006, alleging disability since October 9, 2006 due to "[m]anic depression, anxiety attacks, mood swings [and] stress" (AR 90-96; 126).*fn1 Her applications were denied and she requested and was granted an administrative hearing before an administrative law judge ("ALJ") (AR 61-70). Following a hearing held on December 12, 2008 (AR 19-58), the ALJ concluded, in a written decision dated February 19, 2009, that Plaintiff was not entitled to a period of disability, DIB or SSI under the Act (AR 10-18). 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 24, 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 31 years old on the date of the ALJ‟s decision and has a high school education and completed one year of college (AR 16; 130). She has past relevant work experience as a cashier/sales clerk (AR 127). Plaintiff reported that she stopped working full time on October 9, 2006 due to an inability to handle stress (AR 126).
Prior to her alleged onset date, Plaintiff was treated by William Mix, M.D., her primary care physician, for complaints of depression from January 7, 2005 through April 28, 2006 (AR 169-182). On January 7, 2005, Plaintiff presented for a physical examination and complained of insomnia (AR 176). She reported a past history of depression but denied any previous hospitalizations (AR 176). Plaintiff complained that she was "moody" and "snappy" with suicidal thoughts, but had no plan (AR 176). Dr. Mix restarted her on Elavil and prescribed a trial of Zoloft for her symptoms, and recommended she begin counseling (AR 176).
Plaintiff returned to Dr. Mix for follow up on June 7, 2005 and reported an improvement in her symptoms on medication (AR 175). She reportedly suffered from two anxious episodes but otherwise did fairly well (AR 175). Dr. Mix reported that her affect had improved and she was smiling and talkative (AR 175). She was diagnosed with PMS, insomnia, and depression/anxiety (AR 175). She was continued on her medication regimen and was encouraged to begin counseling (AR 175). One month later on July 5, 2007, Plaintiff reported no problems with her medications, but requested a higher dosage amount due to problems with her mood (AR 174). Dr. Mix diagnosed her with PMS based anxiety/depression and increased her Zoloft dosage (AR 174). On December 2, 2005 Plaintiff reported that the increased Zoloft dosage made her feel "zoned out" but the lower dosage was ineffective in controlling her mood (AR 173). Dr. Mix reported that she was mildly depressed and started her on Wellbutrin (AR 173).
On March 3, 2006, Plaintiff reported that the Wellbutrin had not helped her symptoms. She complained of irritability, mood swings, sleep disturbances, appetite fluctuations and memory and concentration problems (AR 171). On mental status examination, her affect was reported as appropriate, and her mood was, on occasion, "sad" at times (AR 171). She was prescribed Wellbutrin and Celexa, and encouraged to keep her appointment with a mobile therapist for evaluation and consideration of bipolar treatment if appropriate (AR 171).
On March 13, 2006, Plaintiff was seen at Stairways Behavioral Health and a treatment plan was formulated (AR 223). Areas to be addressed were her medications and depression (AR 223). Plaintiff was to continue her medications as prescribed and report any reduced depressive symptoms (AR 223).
Plaintiff returned to Dr. Mix on March 31, 2006, and reported no change in her symptoms on Celexa (AR 170). She further reported suffering one or two panic attacks associated with a fight with her boyfriend (AR 170). Plaintiff stated that work was very stressful, and she occasionally suffered panic attacks at work (AR 170). She was diagnosed with persistent depression and situational panic attacks, and her Celexa dosage was increased (AR 170). On April 28, 2006, Plaintiff was doing well on Celexa but still complained of occasional panic attacks (AR 169). She was diagnosed with improved depression and continued on Celexa (AR 169).
On May 22, 2006, a psychiatric evaluation was performed by Sean Su, M.D. from Stairways Behavioral Health (AR 183-185). Plaintiff reported that she lived with her boyfriend and five year old son, and was employed part time at a convenience store (AR 183). She presented with complaints of depression and mood instability, for which she recently sought help from her primary care physician (AR 183). Plaintiff stated that she suffered from various problems, including mood, appetite and sleep disturbances, difficulty concentrating, poor energy levels, increased anxiety and irritability, and feelings of hopelessness (AR 183). Plaintiff reported that her depressive symptoms had improved since her medication was increased, but that during the three weeks prior to the evaluation, she was more irritable, had mood swings and a high energy level (AR 183). She denied a history of manic episodes or psychotic symptoms (AR 183).
Plaintiff reported that she took Celexa as prescribed by her primary care physician and had been previously prescribed Zoloft without results (AR 183). She indicated that her Celexa dosage was recently increased and had helped with her depressive symptoms, but she suffered from increased irritability (AR 183). She denied having any suicidal or homicidal thoughts (AR 183). She reported problems with verbal agitation, but had not been physically assaultive towards others (AR 183).
On mental status examination, Dr. Su reported that Plaintiff was fully oriented, her speech was coherent and goal directed, and her long term and short term memory were intact (AR 184). He found her to be of average intelligence, with "fair" insight and judgment (AR 184). Dr. Su found that her affect at times was excessively bright and that she appeared "somewhat hypo-manic" (AR 184). He diagnosed her with major depressive disorder, and rule out bipolar disorder, and assigned her a global assessment of functioning*fn2 ("GAF") score of 55 (AR 184-185). Dr. Su continued her on Celexa for her depression and added Lamictal for her mood instability (AR 185; 230). She was to continue outpatient psychiatric treatment through Stairways (AR 185).
On July12, 2006, Stairways progress notes reflect that, following three psychiatric appointments and eight individual therapy sessions, Plaintiff‟s treatment goal of an improved mood had not been met (AR 222). On July 19, 2006 Dr. Su doubled Plaintiff‟s Lamictal dosage (AR 230). On November 11, 2006, progress notes reflect that Plaintiff‟s treatment goals remained unmet (AR 221). On November 11, 2006, Dr. Su discontinued Celexa and prescribed Effexor (AR 230).
Clinical Psychologist Byron E. Hillin, Ph.D., performed a psychological evaluation of Plaintiff on January 26, 2007 (AR 186-193). Dr. Hillin reported that Plaintiff was cooperative with the evaluation, provided information freely and consistent with previous psychiatric reports from Stairways, and appeared truthful (AR 186). Plaintiff stated that she worked 20 to 25 hours per week at a convenience store, and could only work part-time because she became "too stressed" if she worked more hours (AR 186). She claimed to carry a good deal of anger which resulted in occasional outbursts, which caused her to have difficulty with co-workers and authority figures (AR 186). She also complained of low energy at times, as well as feelings of tearfulness, helplessness and hopelessness (AR 186). Plaintiff relayed her mental health treatment history, including her previous medications (AR 187). She indicated that her current medications helped alleviate her symptoms and that counseling had been beneficial (AR 187). She stated that she continued however, to find herself moody and depressed (AR 187).
On mental status examination, Dr. Hillin reported that Plaintiff was fully oriented, appeared mildly anxious with nervous laughter, and her speech was relevant, coherent and goal directed (AR 189). Her affect was appropriate, and she appeared mildly anxious and mildly tearful in discussing past losses (AR 190). Dr. Hillin found her thoughts were relevant, coherent and goal directed, with no loosening of associations or flight of ideas (AR 190). Her general intelligence was in the average to low average range, her attention and concentration were fair, her long-term and short-term memory were intact and her social judgment remained intact (AR 190).
Dr. Hillin diagnosed Plaintiff with major depressive disorder, single episode, mild, and avoidant personality features, and assigned her a GAF score of 65 (AR 190). He found that she continued to perform most activities of daily living, including cooking, cleaning, shopping, caring for her child and working part-time (AR 191). He found that her cognitive abilities, attention and concentration, speech and language, motor skills, and problem solving abilities remained intact (AR 191). He indicated that Plaintiff would be able to do simple, repetitive tasks, as well as more moderately complex tasks (AR 191). He found her ability to relate to others mildly compromised by her irritability and somewhat labile mood, and that her "[c]oping appear[ed] fair to fragile" (AR 191). Dr. Hillin stated that she needed continued psychiatric care to help stabilize her moods and that her prognosis remained favorable (AR 191).
Dr. Hillin concluded that Plaintiff‟s ability to understand, remember, and carry out instructions were not affected by her mental impairments (AR 192). He also concluded that she was only slightly limited in her ability to interact appropriately with the public; and moderately limited in her ability to interact appropriately with supervisors and co-workers, and respond appropriately to work pressures in a usual work setting (AR 192). He also found her slightly to moderately limited in her ability to respond appropriately to changes in a routine work setting (AR 192).
On March 6, 2007, Ray M. Milke, 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 concentration, persistence or pace, and moderate limitations in maintaining social functioning (AR 208). Dr. Milke completed a mental residual functional capacity assessment form, and opined that Plaintiff was only moderately limited in her ability to accept instructions and respond appropriately to criticism from supervisors, get along with co-workers, maintain socially appropriate behavior, respond appropriately to changes in the work setting, and set realistic goals or make plans independently of others (AR 194-195). Dr. Milke found that Plaintiff was not significantly limited in all other work-related areas (AR 194-195).
Dr. Milke found that Plaintiff suffered from major depression with avoidant personality disorder features (AR 196). He concluded that she was socially isolated but could sustain an ordinary routine and adapt to routine changes without special supervision, and could function in production oriented jobs requiring independent decision making (AR 196). He found she could perform most of her daily activities, was able to manage her own benefits, and that her prognosis remained favorable (AR 196). He noted that Dr. Hillin had assigned her a GAF score of 65, which indicated only mild functional limitations (AR 196). Dr. Milke found Dr. Hillin‟s assessment of Plaintiff‟s functional abilities "fairly consistent" with "the other evidence in the file" and gave it ...