United States District Court, W.D. Pennsylvania
TERRENCE F. McVERRY, District Judge.
Plaintiff, Tracey Lee Hawley, brought this action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3), for judicial review of the final determination of the Commissioner of Social Security, who denied her application for disability insurance benefits ("DIB") and supplemental security income ("SSI") under Titles II and XVI of the Social Security Act ("Act"), 42 U.S.C. §§ 401-433, 1381-1383f (West 2012). The parties have filed cross-motions for summary judgment with briefs in support. (ECF Nos. 11-14). The record was thoroughly developed at the administrative level. (ECF No. 9). Accordingly, the motions are ripe for disposition.
Plaintiff was born on May 3, 1969. She has a ninth-grade education with past relevant work experience as a cashier, cook, and restaurant manager. (R. 30). The record reflects that she has not engaged in substantial gainful activity since her alleged onset date. (R. 25).
Plaintiff alleges disability as of August 2, 2008, due to several mental health impairments. She received some treatment for her impairments prior to her alleged onset date. In October 2003, Dr. Robert Rodak, Plaintiff's then-primary care physician, referred her to Safe Harbor Behavioral Health for counseling to deal with her panic attacks, anxiety, and depression. (R. 228). During her intake interview at Safe Harbor, Plaintiff reported that she experienced significant stressors, which included being a single parent, having a disabled child, financial strain, and the break-off of an engagement. (R. 237). She also reported that she had attempted suicide three times in the past and had a history of drug and alcohol abuse. (R. 237). Plaintiff was diagnosed with depression and panic disorder with agoraphobia. (R. 237). In the months following her initial appointment, she attended therapy at Safe Harbor on several occasions. (R. 238). However, records from Safe Harbor indicate that Plaintiff's treatment was terminated in June 2004, after she failed to respond to attempts to reach her. (R. 227).
The record contains treatment notes from Dr. Rodak spanning from January 31, 2005 until January 14, 2009. (R. 243-286). From 2005 until 2007, Dr. Rodak noted that Plaintiff experienced symptoms of anxiety, but that her medications were controlling those symptoms reasonably well. (R. 245, 250, 251). In December 2008, Plaintiff reported that her anxiety was worsening, but a mental status examination did not reveal significant abnormalities. (R. 258-59). A month later, Plaintiff reported that her depression had gotten worse due to "external problems." (R. 254). Upon examination, Plaintiff was anxious, tearful, and displayed a flattened affect. (R. 254). However, no cognitive or perceptual impairments were noted, and Plaintiff denied suicidal ideation. (R. 254).
Plaintiff started seeing a new primary care physician, Dr. Randy Edwards, in January 2009. (R. 410). Over the course of the next year, Plaintiff presented to Dr. Edwards' office on several occasions for treatment of a variety of complaints, none of which related to her mental conditions. (R. 410-40). Be that as it may, Dr. Edwards did keep Plaintiff on her depression and anxiety medications throughout this period. (R. 410-40).
On October 29, 2009, Dr. Edwards' provided an opinion regarding Plaintiff's mental and physical impairments. (R. 403). He indicated that Plaintiff suffered from "reflux, depression, [and] anxiety disorder", (R. 403), but that these conditions were "controlled on medication, " (R. 405). He also noted that Plaintiff had no history of psychiatric treatment or psychiatric hospitalizations. (R. 405). When asked to describe any abnormal emotional symptoms he witnessed during his encounters with Plaintiff, Dr. Edwards wrote, "none." (R. 405). Similarly, he opined that Plaintiff has no restrictions with respect to activities of daily living and social functioning and that her concentration, persistence, and pace were unaffected by her mental condition. (R. 406). He closed by noting that Plaintiff's prognosis was "excellent." (R. 407).
John Rohar, Ph.D., reviewed Plaintiff's file and completed a Psychiatric Review Technique form on November 9, 2009. (R. 473). According to Dr. Rohar, Plaintiff did not satisfy the listings for affective disorders or anxiety-related disorders because she displayed only mild limitations in each of the areas of functioning (activities of daily living, social functioning, and concentration, persistence, and pace) and did not experience repeated episodes of decompensation. (R. 483).
On September 23, 2010, Rachel Hill, Ph.D., a state agency consultant, performed a psychological evaluation. (R. 580). Plaintiff reported to Dr. Hill that she was hospitalized in 1992 following a suicide attempt, and years later, saw a counselor and psychiatrist at Safe Harbor. (R. 581). However, she was not currently receiving treatment. (R. 581). A mental status examination revealed that Plaintiff's thought processes were coherent and goal-directed with no evidence of hallucinations, delusions, paranoia, confusion, irrelevancy, circumstantiality, tangentiality, loosening of associations, flight of ideas, or blocking. (R. 582). Her affect was dysphoric, depressed, anxious, and tense, and her mood was dysthymic. (R. 582). She was well-oriented, and displayed good attention and concentration. (R. 583). Moreover, her intellectual functioning was average and her general fund of information was good. (R. 583). Finally, she displayed fair insight and fair-to-poor judgment. (R. 583). Based on this examination, Dr. Hill opined that Plaintiff can "follow and understand simple directions and instructions;" "perform simple tasks independently;" "maintain attention and concentration at least for a while;" "maintain a regular schedule occasionaly and not all the time;" "learn new tasks;" and "perform complex tasks independently." (R. 583). Dr. Hill also found that Plaintiff "does not make very good decisions;" "relates marginally with other people;" and "does not deal very well with stress." (R. 584). In conclusion, Dr. Hill remarked that "[t]he results of this evaluation are consistent with a psychiatric problem that I do believe significantly interferes with her ability to function on a daily basis, " and her prognosis was "[f]air given her level of functioning." (R. 584). Dr. Hill also recommended that Plaintiff seek treatment for her condition. (R. 584).
Five days later, Plaintiff returned to Safe Harbor for the first time since 2004. (R. 605). Shortly thereafter, she was diagnosed with depressive disorder and anxiety and assessed a GAF score of 55. (R. 622-23). From October 2010 until August 2011, Plaintiff had medication management appointments with the staff at Safe Harbor. Her condition was, for the most part, stable, with her global assessment of functioning ("GAF") scores consistently in the mid-to-upper 50s. (R. 614, 616, 619, 622).
On August 1, 2011, however, during a routine medication management appointment, Plaintiff reported to the nurse at Safe Harbor that she was "in a funk." (R. 610). She was feeling depressed and irritable, with continued sleep disturbances. (R. 610). Moreover, although she reported that her Zoloft prescription usually worked well, she recently "ran out" of pills and missed several days. (R. ...