ANDREW J. WISTRICH, Magistrate Judge.
Plaintiff filed this action seeking reversal of the decision of defendant, the Commissioner of the Social Security Administration (the "Commissioner"), denying plaintiff's application for disability insurance benefits and supplemental security income ("SSI") benefits. The parties have filed a Joint Stipulation ("JS") setting forth their contentions with respect to each disputed issue.
Plaintiff, then aged 38, filed her applications for benefits on February 17, 2009, alleging that she had been disabled since January 15, 2008. [JS 3; Administrative Record ("AR") 61-62, 125]. In a written hearing decision that constitutes the Commissioner's final decision in this matter, an administrative law judge (the "ALJ") found that plaintiff had severe impairments consisting of seizure disorder, right shoulder osteoarthritis, and osteopenia, but that she retained the residual functional capacity ("RFC") to perform a reduced range of light work. [AR 20, 24]. Based on the testimony of a vocational expert, the ALJ concluded that plaintiff's RFC did not preclude her from performing her past relevant work as a cashier and a greeter. Therefore, the ALJ found plaintiff not disabled at any time through the date of her decision. [AR 27].
The Commissioner's denial of benefits should be disturbed only if it is not supported by substantial evidence or is based on legal error.
Plaintiff contends that the ALJ erred in determining that her mental impairments of Bipolar II disorder, depressive disorder NOS, and chronic post traumatic stress disorder were nonsevere at step two of the sequential evaluation. [JS 11]. In determining the severity of plaintiff's mental impairment, the ALJ considered: (1) plaintiff's mental health treatment records; (2) plaintiff's testimony at the administrative hearing; (3) a February 10, 2010 mental health assessment completed by J. Eduardo Guzman, M.D., plaintiff's treating physician; (4) an April 12, 2011 mental health assessment completed by Dr. R. Morgan, M.D.; and (5) the consultative psychiatric examination report of Dr. G. Bartell, M.D. [AR 20-22].
"An impairment or combination of impairments may be found not severe only if the evidence establishes a slight abnormality that has no more than a minimal effect on an individual's ability to work."
The lack of a severe impairment must be "clearly established by medical evidence."
The ALJ concluded that the treatment evidence failed to establish the presence of a severe mental impairment. In finding plaintiff's mental impairments nonsevere, the ALJ noted that plaintiff had been hospitalized in November 2008 after a suicide attempt and was diagnosed with major depressive disorder, recurrent. [AR 21]. The ALJ also noted that plaintiff was in therapy from approximately June 2009 to May 2010. During that period, she was diagnosed with post traumatic stress disorder, generalized anxiety disorder, and major depressive disorder, and she was prescribed Zoloft.
The step two inquiry is "`a de minimis screening device [used] to dispose of groundless claims,' and an ALJ may find that a claimant lacks a medically severe impairment or combination of impairments only when [that] conclusion is `clearly established by medical evidence.'"
The medical evidence in this case does not "clearly establish" the absence of a severe mental impairment. The ALJ selectively highlighted those portions of plaintiff's mental health records that supported the ALJ's conclusion that plaintiff's mental impairments were nonsevere, while downplaying or omitting evidence to the contrary. For example, the ALJ stated that plaintiff's mental status evaluation on January 30, 2009 was largely within normal limits. [AR 21]. However, the ALJ failed to note that the same records also reveal that: (1) plaintiff had recently been discharged from the hospital after a suicide attempt; (2) although her medication was helping, plaintiff was still suffering from severe anxiety and social stressors; and (3) it was recommended that she attend psychiatric therapy and that Klonopin
Similarly, the ALJ stated that during plaintiff's mental health treatment with Dr. Guzman between June 17, 2009 and December 2, 2009, plaintiff "report[ed] her depression lifting, being in improved spirits, and becoming significantly stable." [AR 21]. However, a review of Dr. Guzman's treatment records demonstrates a more complicated picture of plaintiff's mental health, including continuing feelings of depression, tearfulness, hopelessness, anhedonia, panic attacks, and suicidal ideation. Although Dr. Guzman prescribed Zoloft, Trazodone,
Viewed in the context of the record as a whole, the ALJ overstated the evidence of plaintiff's positive response to treatment and understated the evidence that plaintiff continued to exhibit residual depressive symptoms despite compliance with her medications.
Moreover, evidence of improvement in plaintiff's condition does not negate the possibility that her mental impairment was severe.
While plaintiff may not "succeed in proving that [she] is disabled," the ALJ "lacked substantial evidence to find that the medical evidence clearly established [plaintiff's] lack of" a medically severe mental impairment,
In general, the choice whether to reverse and remand for further administrative proceedings, or to reverse and simply award benefits, is within the discretion of the court.
The proper remedy in this case is reversal and remand for further administrative proceedings to permit the ALJ to conduct a supplemental hearing and to issue a new decision with appropriate findings at each step of the sequential evaluation procedure.
For the reasons stated above, the Commissioner's decision is