United States District Court, N.D. Indiana, Fort Wayne Division
OPINION AND ORDER
JON E. DEGUILIO, District Judge.
In 2010, claimant Evonne Thomas applied for but was denied social security disability benefits by the Social Security Administration. She then filed a complaint in this Court, seeking review of that decision, and the matter has been fully briefed [DE's 18, 24, 29]. For the following reasons, the Court REMANDS this matter to the Commissioner for further proceedings.
On November 5, 2010, claimant Evonne Thomas applied for Social Security Disability Insurance Benefits ("DIB"), and on January 29, 2010, she applied for Supplemental Security Income ("SSI),  alleging a disability onset date of October 9, 2009. (R. 204; 211). Her claims were denied upon initial consideration on April 26, 2011, and upon reconsideration on July 7, 2011. (R. 108-111). On August 9, 2011, she filed a written request for a hearing before an Administrative Law Judge ("ALJ"). (R. 146).
The hearing was held on May 11, 2012 (R. 36). Thomas appeared with counsel and testified on her own behalf before ALJ Steven Neary. (R. 36-56). Vocational Expert ("VE") Amy Kutschbach also appeared and testified at the hearing. (R. 36; 56-59). ALJ Neary issued his decision on June 22, 2012, denying Thomas benefits and finding that she is not disabled within the meaning of the Social Security Act. (R. 21-31). Thomas requested review of the denial on August 16, 2012. (R. 12-17). The Appeals Council denied Thomas' request for review on August 10, 2013, thereby rendering ALJ Neary's decision the final action of the Commissioner. (R. 1-5). Thomas then filed her complaint, and this Court has jurisdiction to review the decision of the Commissioner pursuant to 42 U.S.C. § 405(g).
Thomas alleges that she suffers from mental and physical impairments (mainly asthma and bronchitis); however, she only seeks review on the basis of her mental impairments which limit her ability to maintain concentration, persistence, and pace. In short, Thomas contends that the ALJ failed to account for this aspect of her mental limitations in the Residual Functional Capacity ("RFC") assessment and in the hypothetical questions posed to the VE, thereby requiring a remand.
Thomas was born on April 5, 1961. (R. 196). She was 48 years old at the time of her alleged onset date and 51 years old at the time of the ALJ's decision. (R. 39). She has a high school education (R. 322); and, she has performed past work as a telephone directory deliverer, order clerk, telephone solicitor, and nurse's aide. (R. 291).
A. Mental Health History
For the purpose of this appeal, Thomas' relevant medical history indicates that on May 14, 2009, she saw Tara Pelz for an Insight Diagnostic Evaluation at Park Center. (R. 311-319). Pelz found that Thomas "presented with racing thoughts, mood fluctuations, troubling sleep, overeating, and a lack of concentration, " and also had a history of cocaine dependence. In her interview with Pelz, Thomas chronicled her past. Pelz's assessment then noted Thomas' "problems with recent... [and] immediate memory, " as well as Thomas' inability to stay on task. (R. 314). In addition, Pelz noted that Thomas had trouble shifting focus from one activity to another and had "difficulties with sitting still, paying attention, or doing things without thinking." (R. 314). Pelz also found that Thomas had poor judgment, minimal insight, depression, anxiety, and anger. (R. 314). Ultimately, Pelz diagnosed Thomas with bipolar disorder NOS and cocaine dependence in partial remission. (R. 317). Pelz assigned Thomas a Global Assessment of Functioning ("GAF") score of 51,  indicating moderate symptoms or moderate difficulty in social, occupational, or school functioning. (R. 317). Thomas was referred to therapist Michele Jones and psychiatric nurse practitioner Karen Lothamer.
In July 2009, Michele Jones noted that Thomas was attending group therapy to help with mood regulation and she was scheduled for an evaluation with Karen Lothamer. (R. 359). Lothamer's evaluation was performed on August 4, 2009, at which time Thomas presented with depression, difficulty sleeping, lack of concentration, fatigue, loss of appetite, and anxiety. (R. 340-345). Lothamer noted that Thomas had a history of paranoia, hallucinations, and flashbacks. Specifically, Thomas indicated to Lothamer that she had been hearing "spiritual voices telling her to do right and wrong things." (R. 340). Lothamer also noted that Thomas presented with memory impairment and symptoms of inattention. (R. 340). On the mental status exam, Lothamer found that Thomas demonstrated poor judgment, minimal insight, depression, anxiety, anger, and problems with recent and immediate memory. (R. 342). Lothamer's diagnostic impression was bipolar disorder and cocaine dependence. (R. 344). Thomas' GAF score was 51 and the treatment plan indicated that Thomas was to start taking Geodon and return in one month. (R. 344).
On October 8, 2009, Michele Jones indicated that Thomas was having some problems with mood stabilization and was very manic. (R. 362). However, Thomas was not taking the Geodon as prescribed, but she was attending group therapy. (R. 362). The record reflects that Thomas then terminated her treatment with Park Center on December 21, 2009. (R. 350). Jones noted that Thomas had appeared to show some benefit with group therapy, but Thomas indicated that she would be receiving treatment at the Bowen Center. (R. 350).
On March 2010, Thomas underwent a psychiatric evaluation at the Bowen Center which was conducted by Dr. Mahender Surakanti, M.D. (R. 438-442). Psychiatrist Surakanti diagnosed Thomas with bipolar disorder and a history of cocaine dependence, alcohol dependence, and marijuana use. (R. 441). He recorded a GAF score of 60-65 and acknowledged Thomas' "[o]ngoing mood symptoms, history of substance abuse problems, and poor support system." (R. 441). Dr. Surakanti also noted that Thomas was no longer taking Geodon and had no insurance to get medication. (R. 438). In response to Thomas' financial situation and her report of mood swings, Dr. Surakanti started her on lithium carbonate as a treatment plan. (R. 442). Thomas met with Dr. Surakanti several times after this. (R. 305-306, 454-460).
Thomas underwent another Insight Diagnostic Evaluation at Park Center on December 6, 2010, this time performed by Brent Stachler. (R. 320-27). Now Thomas was suffering from pathological gambling, as well as bipolar disorder, cocaine dependence, and anxiety disorder NOS. Thomas' GAF score was 45, indicating serious symptoms or serious impairment. (R. 326). Thereafter, Stachler's February 2011 progress note indicated that Thomas was minimally engaged with her gambling addiction therapy program and was showing poor progress. (R. 366). Thomas reported that her schooling was interfering with her scheduled group time and that she no longer wanted to attend group therapy. (R. 366).
On April 18, 2011, Michael Scherbinski, a licensed clinical psychologist, performed a Mental Status Examination on Thomas. (R. 374-380). Scherbinski noted that Thomas expressed increased severity of her bipolar disorder since her son's death in January 2011. (R. 374). She reported no longer participating in counseling or mental health therapy, and she was experiencing suicidal ideation and engaging in self-injurious behavior by taking an overdose of pills. (R. 375). Thomas also reported experiencing both auditory (i.e. voices) and visual (i.e. shadows) hallucinations twice per week. (R. 375). She reported spending the morning in bed and semi-regular bathing, cooking, and shopping. (R. 375). Scherbinski observed that Thomas had appropriate social interactions, although her affect was "somewhat depressed as evidenced by occasional tearfulness and despondency." (R. 376). Scherbinski documented her short-term memory as being somewhat below average and her intellectual functioning as being variable, although he indicated that she was able to maintain focus and concentration during the examination. (R. 377-378). Scherbinski reported that she would potentially be able to gain and/or maintain employment but would benefit from ongoing medication management and mental health therapy. (R. 377). His diagnosis was bipolar disorder NOS and polysubstance dependence, in sustained full remission. Scherbinski rated her GAF score as 57. (R. 378).
On April 25, 2011, Benetta Johnson, PhD., completed a Psychiatric Review Technique, finding that although Thomas suffered from bipolar disorder and substance addiction disorder, Thomas' impairments were not severe. (R. 381-393). Johnson indicated that Thomas suffered from only mild limitations with respect to activities of daily living, maintaining social functioning, and maintaining concentration, persistence, or pace, and that she suffered from no episodes of decompensation of an extended duration. In June 2011, Johnson's report was reviewed and approved by Randall Norton, Psy.D. (R. 395).
In August 2011, Thomas was voluntarily admitted for three days at Parkview Behavioral Health with a diagnosis of major depression. (R. 403). Thomas reported feeling depressed and having thoughts about hurting others. (R. 403). Dr. Surakanti indicated that she had poor grooming, borderline hygiene, and severe depression. He detailed her affect as "sad and constricted, " noting that there was ongoing homicidal ideation during her stay. (R. 404). Thomas was started on lithium carbonate, celexa, and trazadone, and she showed good improvement. She was given a prescription and scheduled for a follow-up appointment at the Bowen Center. (R. 404). Upon her discharge, she had a reported GAF score of 45 to 50. (R. 403).
The following month, Thomas underwent evaluation at the Bowen Center by Klinton Krouse. (R. 409-416). Krouse's diagnostic impression was that Thomas, in addition to having been previously diagnosed with bipolar disorder, alcohol dependence, and cannabis abuse, showed features of suffering from post-traumatic stress disorder and psychosis. (R. 410). Krouse indicated that Thomas could benefit from "medication education" so that she can understand the need to be compliant with her medications; and, if she could "find some internal motivation to take her medication as prescribed, follow up with physicians and learn better skills to cope with her mental problems, then her prognosis would improve." (R. 410). Krouse scheduled Thomas for individual therapy with Connie Anderson, a social worker at the Bowen Center. (R. 410).
By October, Anderson noted Thomas' overall improvement as stable. (R. 464). The primary objective of Thomas' sessions was to address coping mechanisms and to work on processing her emotions related to the death of her son. (R. 464). On January 10, 2012, Thomas called the Bowen Center and asked to be placed on a lower dose of lithium because her increased dosage was too expensive. (R. 448). On February 17, 2012, Anderson recorded that Thomas was slightly improved overall, but Thomas had reported increased stress and agitation. (R. 463). It was noted that Thomas needed continued emotional support to maintain her current level of functioning and to develop coping skills. Later that month it was reported that, even though ...