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Lewis Hughes v. Michael J. Astrue

February 2, 2012


The opinion of the court was delivered by: David Stewart Cercone United States District Judge

Electronic Filing



Lewis Hughes ("Plaintiff") brings this action pursuant to 42 U.S.C. § 405(g), seeking review of the final determination of the Commissioner of Social Security ("Defendant" or "Commissioner") denying his application 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 -- 433, 1381 -- 1383f ("the Act"). This matter comes before the court on cross motions for summary judgment. (ECF Nos. 8, 12). The record has been developed at the administrative level. For the following reasons, Plaintiff's Motion for Summary Judgment will be granted in part and denied in part, and Defendant's Motion for Summary Judgment will be denied.


Plaintiff filed for DIB and SSI with the Social Security Administration on June 13, 2008, claiming an inability to work due to disability beginning March 1, 2007. (R. at 122 -- 30).*fn1 Plaintiff initially was denied benefits on October 3, 2008. (R. at 76 -- 85). A hearing was scheduled for December 2, 2009, and Plaintiff appeared to testify represented by counsel. (R. at 25). A vocational expert also testified. (R. at 25). The Administrative Law Judge ("ALJ") issued a decision denying benefits on January 28, 2010. (R. at 6 -- 24). Plaintiff filed a request for review with the Appeals Council, which request was denied on August 26, 2010, thereby making the decision of the ALJ the final decision of the Commissioner. (R. at 1 -- 5).

Plaintiff filed his Complaint in this court on October 7, 2010. (ECF No. 3). Defendant filed his Answer on December 22, 2010. (ECF No. 5). Cross motions for summary judgment followed.


A. General Background

Plaintiff was born on December 11, 1987, and was twenty-one years of age*fn2 at the time of his administrative hearing. (R. at 32). He is six feet, three inches tall, and weighed approximately two hundred and seventy pounds. (R. at 32). Plaintiff graduated high school, and wanted to become an electrical engineer; however, he did not complete his first year of college and had not returned. (R. at 33, 54). Plaintiff rented a room in the home of a family friend, and had subsisted on welfare and food stamps for approximately two years. (R. at 33). Plaintiff also received medical benefits through the state. (R. at 33). His past employment included positions with McDonald's, Quizno's, Sunoco, Country Market, and Maid with Care. (R. at 34 -- 36, 55). Plaintiff last worked briefly in April through July of 2009 on weekends as a cashier at Sunoco.

(R. at 57 -- 58, 402).

B. Medical History

Plaintiff was admitted to Butler Memorial Hospital, in Butler, Pennsylvania on March 30, 2007, for an alleged benzodiazepine/Klonopin overdose. (R. at 230 -- 32). He was diagnosed with depression. (R. at 230). Hospital staff noted that Plaintiff stated he wanted to "end it all."

(R. at 239). At the hospital, he was noted to be awake, oriented, and appropriate, and reportedly had become unconscious shortly after being discovered by friends. (R. at 233, 239 -- 40, 249). A toxicology report did not detect the actual presence of benzodiazepine in his system. (R. at 236, 258). No one had witnessed him overdose. (R. at 249). He was transferred to UPMC Western Psychiatric Institute and Clinic ("Western Psych") for inpatient treatment. (R. at 230, 243).

Initially, staff at Western Psych noted Plaintiff's overdose to be questionable. (R. at 258). He supposedly swallowed a handful of Klonopin following an argument with his mother and a friend. (R. at 258 -- 67). While at Western Psych, Plaintiff claimed he had suffered symptoms of depression for several years, worsening over time. (R. at 258 -- 67). His global assessment of functioning*fn3 ("GAF") score at admission was 25, and he was diagnosed with depression and impulsive control disorder. (R. at 258 -- 67). Eventually, Plaintiff admitted that he had been depressed over recently being "dumped" by his boyfriend, and did not take the quantity of Klonopin he originally had claimed. (R. at 259). Plaintiff was started on Lexapro and subsequently reported an improved, stable mood. (R. at 260). At the time of discharge from Western Psych on May 7, he was noted to have normal speech, congruent affect, intact memory, concentration, and attention, logical thought, good insight, and good judgment. (R. at 260). Plaintiff's mood was good, he was fully oriented, and he denied suicidal or homicidal ideation.

(R. at 260). Plaintiff was referred for follow-up care. (R. at 261). The hospital reported its treatment objective had been achieved. (R. at 261).

Plaintiff appeared at UPMC St. Margaret Hospital in Pittsburgh, on June 26, 2007, for follow-up care. (R. at 270). He reported that his mood was good, but that he had recently been feeling a little down and irritable. (R. at 270). He was seeing a therapist. (R. at 270). He complained of knee pain while walking stairs. (R. at 270). No significant injury was noted. (R. at 270). Plaintiff had quit college and was working at the time. (R. at 270). He was found to exhibit no compliance issues, but worsening depression negatively affected his social interaction and increased conflicts at work. (R. at 270).

Plaintiff also presented with joint pain, stiffness and anxiety; however, no bone pain, decreased range of motion, joint instability, joint swelling, joint warmth, phobia, or suicidal ideation was observed. (R. at 270). Plaintiff was obese, but walked normally and without assistance, and showed no signs of distress. (R. at 271). His mood was anxious but appropriate, his behavior was appropriate, his mental status and thought process were normal, and his speech was clear and coherent. (R. at 271 -- 72). Muscle tone and strength were normal. (R. at 271). Plaintiff was prescribed Darvocet, as needed, for pain, and was instructed to do exercises for leg pain. (R. at 272). Plaintiff's Lexapro for his depression was increased. (R. at 272).

Plaintiff was seen in the emergency room of Frick Hospital in Mt. Pleasant, Pennsylvania, on April 21, 2008 for complaints of chest pain and anxiety. (R. at 324 -- 33). He appeared to be alert and oriented, but in mild distress. (R. at 324 -- 33). Testing revealed no physical abnormalities. (R. at 324 -- 33). Plaintiff reported that his anxiety and chest pain began the previous day, he had no history of suicidal ideation or thoughts of harming himself, no history of threatening or violent behavior, no hallucinations or delusions, and no significant somatic complaints. (R. at 324 -- 33). Hospital staff noted a history of anxiety and bipolar disorder, and that Plaintiff had recently stopped taking his medications due to a lack of insurance. (R. at 324 -- 33).

Plaintiff was seen once at the Wesley Health Center in Connellsville, Pennsylvania, for complaints of depression, bipolar disorder, and panic disorder on May 1, 2008. (R. at 282). Plaintiff complained of fatigue, anxiety and insomnia. (R. at 282). He was diagnosed with depression, anxiety, and a history of panic attacks. (R. at 282). Symptoms related to these diagnosed conditions were thought to be worsening. (R. at 282).

On May 5, 2008, Plaintiff was assessed for intake at Chestnut Ridge Counseling Services ("Chestnut Ridge") in Connellsville, Pennsylvania. (R. at 423 -- 25). He was noted to have been previously diagnosed with depression, bipolar disorder and anxiety disorder. (R. at 423 -- 25). Plaintiff described having difficulty focusing, lacking motivation, and attempting suicide in the past. (R. at 423 -- 25). He denied past violence or engaging in self-harm/mutilation. (R. at 423 -- 25). No anxiety was observed during the intake assessment, and Plaintiff's thought processes were noted to be relevant/intact, he was alert and oriented, and he denied hallucinations or delusions. (R. at 423 -- 25). He was given a GAF score of 45. (R. at 423 -- 25).

On May 9, 2008, Plaintiff underwent a psychiatric evaluation by Marjorie Tavoularis, M.D., at Chestnut Ridge. (R. at 335 -- 37). Plaintiff described a history of bipolar disorder to Dr. Tavoularis with an onset date approximately one year earlier. (R. at 335 -- 37). He described spending five months in a constant manic state followed by a severe depressive episode during which he was admitted to Western Psych for an attempted overdose. (R. at 335 -- 37). Since that time he had been prescribed Lexapro and Klonopin for treatment, but had recently switched to Prozac because Lexapro had adverse side-effects. (R. at 335 -- 37). He believed that the medications were working. (R. at 335 -- 37). He stopped taking his medications until approximately a few weeks prior to his evaluation due to the lack of funds, but after resuming his medications he had not experienced bad mood swings. (R. at 335 -- 37). He did report some depression and confusion. (R. at 335 -- 37). Plaintiff also claimed to have been diagnosed with chondromalacia*fn4 in his knee, and a functional heart murmur -- although diagnostic testing did not support it. (R. at 335 -- 37). He also described using poor judgment when spending money, and his compulsive spending often made him suicidal because of his indebtedness. (R. at 335 -- 37).

Upon examination, Dr. Tavoularis described Plaintiff as well-developed, tall, and muscular appearing. (R. at 335 -- 37). He was alert and cooperative, although slightly sad. (R. at 335 -- 37). His intelligence seemed well above average. (R. at 335 -- 37). He had significant insight and no signs of psychosis. (R. at 335 -- 37). Plaintiff was diagnosed with bipolar disorder. (R. at 335 -- 37). He was assessed a GAF score of 48, with an estimated high score of 60 and an estimated low score of 40 for the year. (R. at 335 -- 37). Plaintiff was continued on Klonopin and Prozac, and directed to engage in counseling. (R. at 335 -- 37). He had motivation to improve. (R. at 335 -- 37).

Records indicate Plaintiff continued to see Dr. Tavoularis, and other physicians and counselors at Chestnut Ridge, through August of 2009. (R. at 338 -- 43, 397 -- 447). During this period his medications were regularly updated. (R. at 338 -- 43, 397 -- 447). His GAF scores ranged from 50 to 55, gradually improving over the course of treatment. (R. at 338 -- 43, 397 -- 447). His typical diagnoses included depression, bipolar disorder, and anxiety disorder. (R. at 338 -- 43, 397 -- 447). Plaintiff's speech was usually clear, he fully participated and was able to maintain attention, he was alert and oriented, he was cooperative, he exhibited organized thoughts, and he did not endorse suicidal ideation. (R. at 338 -- 43, 397 -- 447). However, his mood, affect, concentration, and motivation fluctuated. (R. at 338 -- 43, 397 -- 447).

Plaintiff again visited Frick Hospital on June 9, 2008 for right knee pain. (R. at 284 -- 89). Plaintiff claimed that his knees caused him to fall. (R. at 284 - 89). At the time, Plaintiff was alert and oriented, with clear speech, but was somewhat anxious. (R. at 284 -- 89). Plaintiff was given a knee immobilizer and crutches, and instructed to avoid weight bearing. (R. at 284 -- 89). Plaintiff was diagnosed with sprain/strain of the right anterior knee, bipolar disorder, anxiety disorder, and nervousness. (R. at 284 -- 89). An x-ray of Plaintiff's knee was unremarkable. (R. at 294).

While at Chestnut Ridge on June 16, 2008, Plaintiff reported that he was tolerating his medications without side effects and his Klonopin was treating his anxiety effectively. (R. at 338 -- 43, 397 -- 447). His mood swings had decreased significantly, his sleep was better, and his appetite was good. (R. at 338 -- 43, 397 -- 447). He did mention occasional breakthrough anxiety, however. (R. at 338 -- 43, 397 -- 447).

On October 1, 2008, Plaintiff was again admitted to Western Psych. He was transferred from UPMC Presbyterian Hospital in Pittsburgh after a near fatal intentional overdose of his prescription medications. (R. at 370, 468 -- 530). Plaintiff claimed that he was feeling depressed after a fight with his boyfriend and wanted to "make it all go away." (R. at 370, 468 -- 530). Plaintiff was discovered by his boyfriend ingesting the medication. (R. at 370, 468 -- 530). Plaintiff was treated for coma and respiratory failure. (R. at 370, 468 -- 530). He was involuntarily admitted for inpatient treatment. (R. at 370, 468 -- 530). Plaintiff's psychological history was noted. (R. at 370, 468 -- 530). He was brought back to mental baseline, and was treated with prescription medications, individual therapy, group therapy, psychoeducation and behavioral techniques. (R. at 370, 468 -- 530).

Plaintiff was discharged from Western Psych on October 7, 2008. (R. at 371 -- 73, 468 -- 530). Plaintiff had been stabilized and his suicidal ideation was resolved. (R. at 371 -- 73, 468 -- 530). He denied suicidal ideation or behavioral impulsivity prior to discharge. (R. at 371 -- 73, 468 -- 530). Staff notes indicate he exhibited marked improvement. (R. at 371 -- 73, 468 -- 530). No psychomotor agitation or retardation was present, Plaintiff's speech was normal, his mood was good, his affect was congruent, his memory was intact, his attention and concentration were intact, his thought processes were normal, his cognitive functions were at baseline, his insight was fair, and his judgment was fair. (R. at 371 -- 73, 468 -- 530). Plaintiff denied hallucination.

(R. at 371 -- 73, 468 -- 530). He was diagnosed with depression. (R. at 371 -- 73, 468 -- 530). Plaintiff's GAF score at admission was assessed at 20. (R. at 371 -- 73, 468 -- 530). His score at discharge was 50. (R. at 371 -- 73, 468 -- 530). The hospital noted that the treatment objective had been achieved. (R. at 374, 468 -- 530).

At a December of 2008 visit to Chestnut Ridge, Plaintiff described his medications as helpful and denied side effects. (R. at 338 -- 43, 397 -- 447). He denied depression, anger issues, and hallucinations. (R. at 338 -- 43, 397 -- 447). His concentration and sleep were improved, and his appetite was good. (R. at 338 -- 43, 397 -- 447). Panic attacks did occasionally occur when he was overwhelmed. (R. at 338 -- 43, 397 -- 447).

Over the next few months Plaintiff continued to report progress with his psychological symptoms during his appointments at Chestnut Ridge. (R. at 338 -- 43, 397 -- 447). His mood was increasingly reported as stable, and his affect was appropriate. (R. at 338 -- 43, 397 -- 447). Around March of 2009, some increased depression and moodiness was noted. (R. at 338 -- 43, 397 -- 447). By April 4, 2009, his physician indicated that he was doing well overall. (R. at 338 -- 43, 397 -- 447). Plaintiff indicated that he was feeling significantly better, that his mood swings had improved substantially, and his medications were working very well. (R. at 338 -- 43, 397 -- 447). He denied suicidal or homicidal ideation. (R. at 338 -- 43, 397 -- 447). His sleep and appetite were also good. (R. at 338 -- 43, 397 -- 447). By May of 2009, Plaintiff indicated he had been feeling well enough to return to work at a gas station on weekends. (R. at 338 -- 43, 397 -- 447). His attention span was good, his mood was even, he denied depression, and he denied side effects from his medication. (R. at 338 -- 43, 397 -- 447). He did endorse continued panic attacks. (R. at 338 -- 43, 397 -- 447). Notwithstanding the improvement observed in April and May, in June of 2009 Plaintiff reported an increase in mood fluctuation and panic. (R. at 338 -- 43, 397 -- 447).

Plaintiff appeared at the Highlands Hospital emergency room in Connellsville, Pennsylvania, on August 12, 2009. (R. at 376 -- 85). He was admitted for depression with suicidal ideation. (R. at 376 -- 85). He complained of nausea and admitted to discontinuing his prescribed medications. (R. at 376 -- 85). Plaintiff was alert and oriented, and was in no apparent distress. (R. at 376 -- 85). He had full strength in all extremities. (R. at 376 -- 85). He was noted to have stable spinal ...

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