United States District Court, D. Nebraska
MEMORANDUM AND ORDER
LAURIE SMITH CAMP, Chief District Judge.
Carol Mae Roland filed a complaint on April 19, 2013, against the Commissioner of the Social Security Administration. (ECF No. 1.) Roland seeks a review of the Commissioner's decision to deny her application for disability insurance benefits under Title II and Title XVI of the Social Security Act (the Act), 42 U.S.C. §§ 401 et seq., 1381 et seq. The defendant has responded to Roland's complaint by filing an answer and a transcript of the administrative record. ( See ECF Nos. 9, 10). In addition, pursuant to the order of Senior Judge Warren K. Urbom, dated June 25, 2013, (ECF No. 12), each of the parties has submitted briefs in support of her position. ( See generally Pl.'s Br., ECF No. 13; Def.'s Br., ECF No. 20, Pl.'s Reply Br., ECF No. 21). After carefully reviewing these materials, the Court finds that the Commissioner's decision must be affirmed.
Roland applied for disability insurance benefits and supplemental security income on May 20, 2010. ( See ECF No. 10, Transcript of Social Security Proceedings (hereinafter "Tr.") 62-63, 129-32, 136-39). Roland alleged she had affective and mood disorders and an onset date of April 3, 2010. (Tr. 62, 65, 129). After her application was denied initially and on reconsideration, (tr. 68-71, 76-79) Roland requested a hearing before an administrative law judge (hereinafter "ALJ"). (Tr. 80-81). This hearing was conducted on February 22, 2012. (Tr. 38-61). In a decision dated March 19, 2012, the ALJ concluded that Roland was not entitled to disability insurance benefits. (Tr. 17-36). The Appeals Council of the Social Security Administration denied Roland's request for review on March 28, 2013. (Tr. 1-5.) Thus, the ALJ's decision stands as the final decision of the Commissioner, and it is from this decision that Roland seeks judicial review.
II. SUMMARY OF THE RECORD
Roland was born on May 21, 1957. (Tr. 62). She has an associate's degree in liberal arts and paralegal training from Lincoln School of Commerce. (Tr. 164). Roland has work experience as a retail store clerk, a drug store price verifier, and a grocery store sacker. She was an instructor of English as a second language at Southeast Community College from 2000 to May 2010, when she had what she termed a nervous breakdown. (Tr. 44, 164).
A. Medical Evidence
Roland asserts that the medical issues related to her request for disability benefits began on April 4, 2010, when she was stopped by police for erratic driving and suspected of driving while intoxicated. (Tr. 247). She was taken to the emergency room of BryanLGH Medical Center West, where Kenton R. Sullivan, M.D., examined her. Sullivan stated that he could understand the reason the police officers thought Roland was confused, but he believed she was displaying her normal demeanor and personality. Roland stated that she sometimes felt she could not think clearly. The physical exam showed that she was awake and alert, "just generally a little eccentric." (Tr. 247). She was discharged in improved condition and asked to follow up with a physician as soon as possible. (Tr. 250).
Accompanied by her daughter, Roland returned to BryanLGH on May 3, 2010, complaining of a headache. (Tr. 239). Her daughter reported that Roland had been crying, upset, tremulous, anxious, and jumpy, apparently because of the headache pain. She also had difficulty sleeping. Roland did not report any depression. (Tr. 239). She was referred to mental health nurses for evaluation. (Tr. 240).
One week later, on May 10, 2010, Roland was seen at the People's Health Center for confusion, poor appetite, and panic. (Tr. 257). Kim Joy, APRN, noted that Roland had not been seen at the clinic for two years, but she appeared noticeably different and was less talkative. She was assessed as having anxiety and panic disorder. (Tr. 258).
Roland was admitted to BryanLGH on May 11, 2010. (Tr. 327). She presented with worsening anxiety, poor memory, and thought disorganization and was diagnosed with major depressive disorder, single episode with psychotic features. On admission her GAF was 35, and when she was discharged on May 16, 2010, her GAF was 55. With medication, she improved, her mood became brighter, and she was more talkative. She agreed to go to the partial hospitalization program at the Community Mental Health Center of Lancaster County (CMHC). Upon discharge from BryanLGH, Roland was calm, cooperative, and happy. (Tr. 327).
Upon admission to the partial hospitalization program at CMHC on May 17, 2010, Roland was diagnosed with mood disorder and cognitive disorder. Her GAF was 34. (Tr. 423). She appeared to be disorganized and impaired in day-to-day functioning. (Tr. 424). It was recommended that she be admitted to the program full time for an estimated two weeks. (Tr. 424). A history and physical evaluation on May 18, 2010, resulted in a diagnosis of brief reactive psychosis; adjustment disorder with mixed emotional features; major depression, severe, recurrent without psychotic feature; and R/O cognitive disorder, not otherwise specified. Her GAF was 40. (Tr. 429).
Notes from the People's Health Center on June 1, 2010, indicate that Roland was doing much better on her current medications. (Tr. 255). She was dismissed from the partial hospitalization program on June 4, 2010, with the diagnosis of major depressive disorder, moderate. (Tr. 426). Her GAF was 48. Roland reported improvement in most of her symptoms, although she still had some mild depression and mild anxiety symptoms. She demonstrated improved ability to cope. At dismissal, she appeared to track better and had a brighter affect. (Tr. 426).
Roland had an initial psychiatric diagnostic interview with Gary Nadala, M.D., at the CMHC on June 18, 2010. (Tr. 262). Roland said medication had helped since her visit to the emergency room and she wanted to continue taking it, but she said they were expensive. Nadala said she showed some delay in her responses, mild psychomotor retardation, anxious mood, fair memory, fair insight and judgment, and impulse control. She was diagnosed as having anxiety disorder, post traumatic stress disorder (PTSD), and dysthymic disorder. Her GAF was 49. (Tr. 262). Nadala recommended that Roland continue her medications and continue with outpatient partial hospitalization. (Tr. 263).
On October 29, 2010, Patricia Bohart, M.D., conducted an initial psychiatric diagnostic interview at the CMHC after Roland was transferred for psychiatric care from Nadala. (Tr. 300). Roland reported that she was greatly improved and that the medications she had been taking for five months were very helpful and had stabilized her moods considerably. Her anxiety level was under control. (Tr. 300). Dr. Bohart reported that Roland's mood was euthymic and her affect was mood-congruent. Her thoughts were logical and goal directed. (Tr. 301). She was diagnosed as having major depressive disorder, single episode, with psychotic features partially resolved. Her GAF was 50. (Tr. 301).
Roland attended group therapy sessions at the CMHC between June 9, 2010, and January 25, 2012. (Tr. 357-413). At the initial session in June 2010, Roland had a neutral affect and flat intensity. She was cooperative and attentive and participated well in open discussion. By the second session her affect was normal and her mood was euthymic. (Tr. 391). Through the first two months, she readily participated and engaged in the group discussions. (Tr. 382-90). Her mood continued to be euthymic and her affect was normal. (Tr. 379, 371). For two weeks in October 2010, her affect appeared blunted and her mood mildly dysphoric. (Tr. 365). By November 2010, she was pleasant and shared her plans for Thanksgiving with the group. (Tr. 363). At the end of December 2010, Roland was pleasant during group discussions, offered constructive feedback, and was attentive to peers. (Tr. 358).
In January 2011, Roland reported that she had decreased her medication and was having some low-level anxiety. However, her affect was within the appropriate range and she appeared to benefit from the group. (Tr. 412). By the end of February 2011, she reported that she was doing well. (Tr. 411). In April 2011, Roland reported that she was frustrated she was not where she wanted to be in her recovery from her "breakdown" a year earlier. (Tr. 407). In June 2011, Roland reported being more depressed and her mood appeared mildly dysphoric. (Tr. 402). By September 2011, her mood was cheerful. (Tr. 397), and in November 2011, her affect showed appropriate range. (Tr. 395). In January 2012, Roland expressed frustration waiting for her disability hearing. (Tr. 393). Throughout group therapy, Roland was an active participant and provided support to peers. (Tr. 393).
Roland also took part in individual therapy with Dr. Bohart between December 2010 and January 2012. Initially, Dr. Bohart reported that Roland was doing all right with an adjustment in her medication, although she reported that she had a little more anxiety and her depression had increased slightly. (Tr. 444). In February 2011, Dr. Bohart reported that Roland was coming out of a depression over the anniversary of her mother's death, but she was doing better, sleeping better, and getting along okay. (Tr. 443). Roland's moods were fairly even in April 2011. (Tr. 442). In May 2011, Dr. Bohart reported that Roland's moods were satisfactory, but she had noticed some increased anxiety since cutting back on cigarettes. (Tr. 441). Dr. Bohart adjusted Roland's medications in July 2011, reporting that Roland had a slight relapse of her depressive symptoms and things were not going as she had expected. (Tr. 440). By August 2011, Dr. Bohart reported that Roland's moods had improved and her affect was brighter. (Tr. 439). Overall she seemed to really enjoy life, and she volunteered one day each week at the Matt Talbot Kitchen. (Tr. 439). Roland's prognosis was fair to good in November 2011, and she had made fair progress by increased recognition of distorted/negative self-talk and its effect on her emotional responses. (Tr. 422).
On February 7, 2011, Joy at the Peoples Health Center stated that Roland was not capable of any substantial gainful employment due to the severity of her symptoms related to depression and anxiety. (Tr. 326). Joy opined that Roland was permanently disabled. (Tr. 325).
Progress notes from counseling sessions at CMHC in 2012 showed that in January, Roland's mood was dysphoric mixed with apprehension. (Tr. 420). She expressed uncertainty about failing to agree to help with her grandchildren but also resented it when she passively agreed to help with them. (Tr. 420). She continued to exhibit gradual improvements in the use of cognitive/behavioral strategies for coping with daily stressors and anxiety. (Tr. 421).
In March 28, 2012, Roland reported feeling angry about the denial of her disability. (Tr. 452). She did not think the reasons for the denial were an accurate reflection of her level of functioning, medical diagnoses, or current situation. She had good support through friends and treatment groups and planned to call on them to help her through the difficult time. (Tr. 452).
In a recovery plan and yearly review dated April 3, 2012, Roland was diagnosed with major depressive disorder, single episode with psychotic features partially resolved. Her GAF was 44. (Tr. 430). It noted that Roland's symptoms of anxiety and depression impaired her ability to follow through with activities of daily living, community participation, and socialization. She could benefit from community support services in order to re-establish adult daily living skills to improve her ability to function in the community and to maximum her stability and independence. (Tr. 430). The report indicated that Roland had a severe and persistent mental illness which required continued treatment for stability. A review was scheduled for one year. (Tr. 432).
Dr. Bohart noted on April 16, 2012, that Roland was frustrated because she was denied disability. (Tr. 435). She reported having a horrible time functioning and her social skills were quite impaired. Dr. Bohart reported concerns that Roland was starting to regress. (Tr. 435).
Roland continued counseling at the CMHC in May 2012, when she presented with dysphoria and apprehension. (Tr. 414). The clinician noted that Roland's emotional responses were appropriate considering the circumstances, which included the two-year anniversary of Roland's breakdown and the death of her best friend. (Tr. 415). Roland expressed anger and frustration with the process of applying for disability. (Tr. 416). Roland continued to report gradual increased participation in leisure and social activities, and proper management of her accompanying anxiety. (Tr. 417).
B. Medical Opinion Evidence
Robert G. Arias, M.D., completed a psychological report on September 21, 2010. (Tr.267). Roland reported that she had a psychotic depression in May 2010 and was hospitalized for one week. (Tr. 268). She was prescribed Zyprexa and Celexa and her mood had improved since then. She was occasionally having thoughts that someone might harm her, but she denied that the thoughts interfered with her daily activities. She had monthly flashbacks to childhood sexual abuse. Roland said she had not returned to work since her breakdown because she was afraid to enter the classroom. She also stated that she had no desire to return to work. She reported problems with concentration that resulted in difficulty putting together plans or completing tasks. However, she stated that she was eventually able to complete the tasks. (Tr. 268). Her typical day involved going to group therapy twice per week and volunteering once a week at Matt Talbot Kitchen. She denied any difficulty with accomplishing activities of daily living. She helped her daughter care for her grandchild. Roland said she had two close friends and several other friends. (Tr. 269).
Dr. Arias reported that Roland demonstrated intact ability to receive, organize, analyze, remember, and express information appropriately. Her mood was euthymic and her affect was stable and appropriate. There was no lack of contact with reality and there were no observable signs of tension, anxiety, psychomotor disturbance, or substance abuse. Her judgment and insight were reasonable. (Tr. 269). Dr. Arias found no restriction in the activities of daily living or maintenance of social functioning. There had not been recurrent episodes of deterioration when stressed resulting in withdrawal from situations and exacerbation of symptoms. (Tr. 269). Roland had a single episode of major depression in May 2010, but she appeared to maintain adequate ability to sustain concentration and attention needed for simple task completion, and she was able to understand and remember short and simple instructions and carry them out under ordinary supervision. She appeared capable of relating appropriately to coworkers and supervisors as well as adapting to basic changes in her environment. Dr. Arias diagnosed Roland as having major depressive episode, single episode, unspecified; and features of PTSD. Her GAF was ...