United States District Court, D. Massachusetts
MEMORANDUM AND ORDER
B. SARIS, CHIEF UNITED STATES DISTRICT JUDGE
Richard Elton Sutton brings this action under 42 U.S.C.
§ 405(g) for judicial review of a final decision denying
his application for Social Security Disability Insurance
(“SSDI”) and Supplemental Security Income
(“SSI”) benefits. Plaintiff suffers from various
mental impairments including anxiety, depression, and
post-traumatic stress disorder (“PTSD”). He
argues that the Administrative Law Judge (“ALJ”)
deciding his case erred in two respects: (1) by improperly
weighing the medical opinion evidence from his treating
psychiatrist, and (2) by failing to properly evaluate his
subjective statements regarding his symptoms.
reasons set forth below, the Court ALLOWS
Plaintiff's motion for judgment on the pleadings (Dkt.
No. 12) and remands the action, and DENIES
Defendant's motion to affirm the Commissioner's
decision (Dkt. No. 15).
was 46 years old when he filed his applications for SSDI and
SSI on May 5, 2014. R. 287. He had previously worked as a
construction laborer, a material handler, and an order
filler. R. 96-97. Plaintiff alleged disability due to PTSD,
depression, and diabetes. R. 144. He also experienced
homelessness and struggled with substance abuse. R. 623-24.
April 8, 2014, Plaintiff had his first visit with Dr.
Jonathan Rothberg, a psychiatrist. R. 471. Plaintiff scored
“very high” on a questionnaire that screens for
depression. R. 471. Dr. Rothberg noted that the depression
was “possibly situational, ” as Plaintiff was
unable to secure a case manager at the homeless shelter or
find steady work. R. 468, 471. Plaintiff expressed
hopelessness. R. 468.
April 11, 2014, Plaintiff underwent psychiatric evaluation by
Dr. Esther Valdez. R. 623-28. Plaintiff displayed symptoms of
anxiety and depression including agitation, depressed mood,
irritability, low self-esteem, and worry. R. 626. Dr. Valdez
noted that Plaintiff had a depressed and
“angry/hostile” mood and displayed “anxious
preoccupations.” R. 626-27. His appearance, alertness,
memory, attention, behavior, thought process, and perception
were otherwise normal. R. 626-27. Despite his complaints of
“severe depression, ” Plaintiff declined
psychiatric intervention because he was “looking to
find an employment advocate and legal aid only.” R.
627-28. Plaintiff reported regular marijuana use, as well as
a history of cocaine and alcohol abuse. R. 623, 625.
then saw Dr. Dyanne London, a psychotherapist, on April 16,
2014. R. 464-66. During the visit, Plaintiff expressed a
desire “to meet before he explodes” and reported
a history of depression. R. 465. His mental status exam
showed cooperative behavior, good impulse control, euthymic
mood, appropriate affect, coherent thought process, intact
memory, good insight to disorder, and no judgment impairment.
April 23, 2014, Plaintiff met with Karen Fink, a licensed
social worker, who diagnosed him with anxiety disorder and
depressive disorder, and considered a PTSD diagnosis. R. 330.
Ms. Fink did not record any mental status findings.
saw Edwige Berrouet, another licensed social worker, two days
later on April 25, 2014. R. 339. Mr. Berrouet noted that
Plaintiff displayed symptoms of anxiety and depression
including difficulty concentrating, irritability, worry,
anhedonia, fatigue, difficulty sleeping, and depressed mood.
R. 342. Plaintiff told Mr. Berrouet that he regularly used
marijuana to self-medicate, and that he used cocaine
“off and on.” R. 339, 341. Plaintiff also
reported that he had twice seen a psychiatrist for treatment
and had been prescribed Paxil, a drug used to treat anxiety
and depression. R. 340.
Anna Fitzgerald, a board-certified psychiatrist, also
evaluated Plaintiff on April 25, 2014. R. 312. Dr. Fitzgerald
noted the following symptoms: decreased appetite, decreased
energy level, loss of interest in pleasurable activities,
isolation, avoidance, and panic attacks. R. 315-16.
Plaintiff's appearance, behavior, attention, language,
thought process, perception, orientation, and memory were
again normal. R. 316-17. Plaintiff's Global Assessment of
Functioning (“GAF”) score was 55, which was
indicative of moderate symptoms. R. 317. Dr. Fitzgerald
prescribed Zoloft, an antidepressant, and recommended that
Plaintiff begin individual therapy. R. 317-18.
saw Dr. Fitzgerald again on May 2, 2014. R. 321. Dr.
Fitzgerald noted that Plaintiff “continue[d] to feel
depressed” and “also [had] some panic symptoms
and posttraumatic reexperiencing [sic], avoidance, and
hyperarousal.” R. 321. Dr. Fitzgerald added trauma to
Plaintiff's list of symptoms and noted that Plaintiff
experienced flashbacks and nightmares. R. 323. She urged
Plaintiff to stop using marijuana and cocaine both “for
his health and for his application for disability.” R.
321. Dr. Fitzgerald diagnosed Plaintiff with major depressive
disorder (recurrent, moderate) and anxiety disorder, but she
ruled out a PTSD diagnosis. R. 324
continued seeing Dr. Fitzgerald every three months through at
least March 2016. R. 696. Notes from these visits, however,
are not included in the administrative record.
State Agency Medical ...