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Sutton v. Berryhill

United States District Court, D. Massachusetts

February 20, 2019

NANCY A. BERRYHILL, Acting Commissioner of the Social Security Administration, Defendant.




         Plaintiff 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.

         For the 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).


         Plaintiff 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.

         I. Medical History[1]

         On 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.

         On 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.

         Plaintiff 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. R. 465-66.

         On 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. Id.

         Plaintiff 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.

         Dr. 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.

         Plaintiff 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

         Plaintiff 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.

         II. State Agency Medical ...

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