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Cordeiro v. Saul

United States District Court, D. Massachusetts

August 2, 2019

ANDREW M. SAUL, Commissioner of the Social Security Administration, Defendant.




         Plaintiff Cheryl Ann Cordeiro brings this action under 42 U.S.C. § 405(g) for judicial review of a final decision denying her application for Social Security Disability Insurance (“SSDI”). She suffers from major depressive and anxiety disorders and seeks SSDI benefits for September 1, 2000 to December 31, 2005. She claims that the Administrative Law Judge (“ALJ”) ignored and misconstrued key evidence, failed to develop the record, and misapplied the vocational expert's testimony.

         For the following reasons, the Court ALLOWS Plaintiff's motion to vacate (Docket No. 45) and remands. The Court DENIES the Commissioner's motion to affirm (Docket No. 26).


         The following facts are taken from the administrative record. Plaintiff is a 59-year-old woman who lives with her husband of 38 years in Somerset, Massachusetts.

         I. Educational and Work History

         Plaintiff has an eleventh-grade education and has not earned a GED. She volunteered at a women's center from 1994 to 1996. Between 1995 and 2000, she worked as a babysitter at a counseling office. She resigned from that position due to severe depression and panic attacks. She worked as a caregiver part-time from 2008 to 2014. She was insured for the purposes of SSDI through December 31, 2005.

         II. Medical History

         At age 13, Plaintiff was admitted to a psychiatric facility after overdosing on her mother's medications in an attempted suicide. She has a family history of mental illness but not suicide attempts or substance abuse. She has consistently reported being a victim of sexual, physical, and domestic abuse.

         On August 8, 2000, at age 40, Plaintiff sought mental health treatment at Child and Family Services of Fall River (“CFS”) following a severe depressive incident that she called a “nervous breakdown.” Soon after, Dr. Marshall Wold, a psychiatrist who saw her four times, diagnosed her with “Major Depressive Disorder, Recurrent, Severe With Psychotic Features.” See Am. Psychiatric Ass'n, Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. 2000) code 296.34 (DSM-IV-TR). Dr. Wold prescribed her Zoloft, which improved but did not eliminate her symptoms. Plaintiff also saw John McMullen, a licensed independent clinical social worker at CFS. He noted slight improvements in her symptoms, some of which were followed by recurrences. Mr. McMullen also continuously noted that she felt unable to return to work. Plaintiff was forced to stop treatment at CFS at the end of 2000 due to a lack of insurance. On February 4, 2002, CFS formally terminated its relationship with Plaintiff. In that document, CFS noted that her GAF had improved as a result of treatment.

         Around the time of her nervous breakdown in 2000, Plaintiff applied for disability benefits (though it is unclear from the record which state or federal disability program she applied to). A hearing on her application was scheduled for November 7, 2000, but she was erroneously sent a denial letter and did not attend. She did not appeal the erroneous denial because she was debilitated following her breakdown.

         After her 2000 treatment at CFS, there is a gap in the medical records regarding Plaintiff's psychiatric condition. Except for one visit to a doctor for lower back pain after a motor vehicle accident in 2002, the next medical care reflected in the records is Plaintiff's August 2007 visit to Dr. Gloria Mercado, a physician at Healthfirst Family Care Center. Plaintiff saw Dr. Mercado more than thirty times over the next ten years for treatment of a variety of physical issues. Throughout those ten years, Dr. Mercado consistently referenced Plaintiff's severe depression and anxiety in her progress notes and prescribed Plaintiff Celexa and Xanax to treat these symptoms. In 2008, Dr. Mercado wrote a note excusing Plaintiff from jury duty based on the attention deficits caused by her anxiety and depression. In March 2017, Dr. Mercado wrote that Plaintiff “has [had] anxiety and depression since 2000.”

         In January 2016, Plaintiff suffered a severe depressive incident and went to the emergency department of Corrigan Mental Health Center in Fall River, Massachusetts. Alison Hathaway, a licensed independent clinical social worker, described Plaintiff as in “crisis” and referred her to urgent care. Plaintiff was regularly evaluated at Corrigan for several months, during which she made slow and inconsistent progress. In June 2016, Dr. Roger Boshes, a psychiatrist whom Plaintiff had seen multiple times at Corrigan, filed out two assessments for her. He diagnosed her with chronic PTSD related to late onset psychosis, depression, debilitating anxiety, and agoraphobia. He found Plaintiff to be disabled and unable to hold a job.

         In August 2016, Plaintiff first saw Mary Cruz, a licensed independent clinical social worker at East Side Counseling. Ms. Cruz made a primary diagnosis of chronic PTSD and a secondary diagnosis of generalized anxiety disorder. Ms. Cruz saw Plaintiff at least twenty times between August 2016 and May 2017. During that time, she did not note any consistent amelioration of Plaintiff's symptoms.

         III. Medical Opinions

         In the fall of 2000, Dr. Wold, Plaintiff's treating psychiatrist at CFS, assigned Plaintiff a Global Assessment of Functioning (“GAF”) score of 41. A GAF score rates a person's overall level of functioning. See DSM-IV-TR at 34. A GAF score of 41-50 indicates serious symptoms or any serious impairment in social or occupational functioning, such as an inability to have personal relationships or keep a job. Id.

         On October 13, 2000, Disability Evaluation Services (“DES”) at the University of Massachusetts Medical School conducted a review of Plaintiff's medical records in connection with her application for disability benefits. Dr. Paul Kaufman, a board-certified psychiatrist, and Pat Gaucher, a registered nurse, determined that Plaintiff suffered from sleep disturbance, decreased energy, feelings of guilt and worthlessness, difficulty concentrating, and paranoid thinking. They also found that she suffered from panic attacks and fatigue. They noted her marked difficulties in maintaining social functioning and deficiencies in concentration, persistence, and pace.

         Accordingly, they concluded that she was disabled for the purposes of Supplemental Security Income (“SSI”) benefits because she met the criteria for the ...

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