United States District Court, N.D. Indiana, Fort Wayne Division
DONALD E. HAMPTON, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of the Social Security Administration, Defendant.
OPINION AND ORDER
JOHN E. MARTIN, Magistrate Judge.
This matter is before the Court on a Complaint [DE 1], filed by Plaintiff Donald E. Hampton on August 14, 2012, and an Opening Brief of Plaintiff in Social Security Appeal Pursuant to L.R. 7.3 [DE 21], filed by Plaintiff on March 26, 2013. Plaintiff requests that the November 22, 2010, decision denying Disability Insurance Benefits and Supplemental Security Income benefits be remanded. For the reasons set forth below, the Court GRANTS Plaintiff's request for remand.
On March 19, 2009, Plaintiff filed an application for Disability Insurance Benefits ("DIB") and Supplemental Security Insurance ("SSI"), alleging disability as of October 1, 2004, due to various mental and physical impairments. Plaintiff was denied initially and on reconsideration, and he timely filed a request for hearing. On August 4, 2010, a hearing was held before Administrative Law Judge ("ALJ") Terry L. Miller at which Plaintiff, Plaintiff's brother, and a Vocational Expert ("VE") testified. On November 22, 2010, the ALJ issued a decision in which he found Plaintiff not disabled. The Appeals Council denied Plaintiff's request for review, making the ALJ's decision the final decision of the Commissioner. See 20 C.F.R. §§ 404.981, 416.1481. Plaintiff filed this civil action pursuant to 42 U.S.C. §§ 405(g) and 1383(c)(3) for review of the Commissioner's decision.
The parties filed forms of consent to have this case assigned to a United States Magistrate Judge to conduct all further proceedings and to order the entry of a final judgment in this case. Therefore, this Court has jurisdiction to decide this case pursuant to 28 U.S.C. § 636(c) and 42 U.S.C. § 405(g).
Plaintiff was 43 years old at the time of his alleged onset date. He had a high school equivalency diploma. He had past relevant work as an industrial cleaner and a foundry worker.
B. Medical Evidence
Because Plaintiff bases his appeal solely on the ALJ's evaluation of Plaintiff's mental impairments, the Court will discuss only evidence related to those impairments. The first record relating to Plaintiff's mental health is a psychological evaluation from September 2006, done by Neil S. Shamberg, PhD, at the request of Plaintiff's Vocational Rehabilitation counselor. Dr. Shamberg noted that Plaintiff had been prescribed medication to treat depression by a doctor at a local clinic. Dr. Shamberg agreed that Plaintiff was suffering from "major depression with some psychotic features" and wrote that he saw evidence of "at least three learning disabilities." AR 319, 322. He assigned a global assessment of functioning ("GAF") score of 34. Dr. Shamberg recommended Plaintiff seek psychotherapy and further medical treatment at Park Center.
Plaintiff's Park Center records begin with a treatment plan from April 2007. In it, the clinician notes that Plaintiff believed his medications to be effective in managing his symptoms and that his affect and thought content were normal, but it was also noted that Plaintiff had suffered from excessive worry, recent memory deficits, and difficulty with concentration. AR 479. A GAF of 55 was assigned.
The next record from Park Center is a mental status exam report prepared by psychiatric nurse Viann Ellsworth in June 2008. The record contains two more reports from visits with Ms. Ellsworth in 2008, five reports from 2009, and two reports from 2010, the last of which is dated less than two months before Plaintiff's administrative hearing. The 2008 reports are generally unremarkable, noting that Plaintiff's medications seemed to be treating his symptoms but recording his affect as "blunted" on one occasion and his thought content as "helpless" on another. At Plaintiff's first visit with Ms. Ellsworth in 2009, however, Ms. Ellsworth reported that Plaintiff's medications were not adequately addressing his symptoms, so she adjusted them. She also noted sleep problems due to pain, stress, or medication side effects at all five visits in 2009 and checked the box for "impaired recent memory" for two of those visits. She also noted at various times throughout 2009 Plaintiff's blunted affect; helpless, hopeless, and paranoid thought content; fair judgment; and withdrawn behavior. In 2010, Ms. Ellsworth recorded sleep problems due to stress on one report and impaired recent memory on the other. She also noted Plaintiff's mood was depressed or fluctuating and that his judgment was fair or poor.
On August 4, 2010, Ms. Ellsworth filled out a form titled "Opinion on Ability to do Work-Related Mental Activities." She responded "Yes" when asked if Plaintiff's mental illness was serious enough to cause Plaintiff to be absent from work. She explained that Plaintiff had missed his scheduled appointments with her that year because he forgot them and that he would likely miss work because it would be difficult for him to remember a schedule. She also wrote that he would call off or miss work because he was "too tired to function" because of his sleep problems. Ms. Ellsworth also wrote that Plaintiff easily becomes stressed and overwhelmed, which would require him to take 30 to 60 minutes of extra breaks a day to calm down.
In September 2009, Dr. Sherwin Kepes performed a mental status examination at the request of the Social Security Administration. He wrote that Plaintiff "appeared rather depressed, forlorn, and tearful" and diagnosed him with schizoaffective disorder. AR 380. He also noted some problems performing memory tests and wrote that Plaintiff reported not sleeping well and that he was "nervous and afraid of sleeping." AR 378. Dr. Kepes assigned a GAF of 49.
C. Plaintiff's Testimony
At the administrative hearing, Plaintiff testified that he has problems getting to sleep every night even with medications intended to help him sleep and has problems staying asleep because he does not like the night and because he hears things. Plaintiff testified that his siblings make sure he keeps his appointments because he "forget[s] everything." AR 83. He also stated that on a bad day, which happens two or ...