United States District Court, D. Arizona
BRIDGET S. BADE, Magistrate Judge.
Tomas Martinez (Plaintiff) seeks judicial review of the final decision of the Commissioner of Social Security (the Commissioner) denying his application for disability insurance benefits under the Social Security Act (the Act). The parties have consented to proceed before a United States Magistrate Judge pursuant to 28 U.S.C. § 636(b) and have filed briefs in accordance with Local Rule of Civil Procedure 16.1. For the following reasons, the Court reverses the Commissioner's decision and remands for further administrative proceedings.
I. Procedural Background
In August 2009, Plaintiff applied for disability insurance benefits and supplemental security income under Titles II and XVI of the Act. 42 U.S.C. § 401-34. (Tr. 165-78.) After the Social Security Administration (SSA) denied Plaintiff's initial application and his request for reconsideration, he requested a hearing before an administrative law judge (ALJ). (Tr. 70-71, 96-97.) After conducting a hearing, the ALJ issued a decision finding Plaintiff not disabled under the Act. (Tr. 12-22.) This decision became the final decision of the Commissioner when the Social Security Administration Appeals Council denied Plaintiff's request for review. (Tr. 1-6); see 20 C.F.R. § 404.981 (explaining the effect of a disposition by the Appeals Council.) Plaintiff now seeks judicial review of this decision pursuant to 42 U.S.C. § 405(g).
II. Medical Record
The record before the Court establishes the following history of diagnosis and treatment related to Plaintiff's health. The record also includes opinions from State Agency Physicians who examined Plaintiff or reviewed the records related to his health, but who did not provide treatment.
A. Treatment Records
On January 5, 2008, Plaintiff was admitted to the hospital for psychiatric treatment after reporting suicidal thoughts and alcohol abuse. (Tr. 925.) On January 7, 2008, Melissa Finch, Ph.D., conduced a mental status examination and determined that Plaintiff was not seriously mentally ill (SMI) under the Arizona criteria. (Tr. 610.) However, after consulting with Plaintiff's treating psychiatrist, on January 8, 2008, Dr. Finch changed her determination and found that Plaintiff met the SMI criteria. (Tr. 889.) Plaintiff was discharged on January 17, 2008 with diagnoses of schizophrenia (paranoid type), and alcohol abuse. (Tr. 927.) The treatment notes indicate that, at the time of discharge, Plaintiff had a suspicious mood, flat affect, and somewhat impaired judgment, but that he was oriented and had normal speech, an intact memory, partial insight, and no hallucinations or suicidal ideation. (Tr. 926.)
A year later, on February 2, 2009, Plaintiff was admitted to the emergency room for a medication overdose and suicidal thoughts. (Tr. 297, 303.) After a psychiatric evaluation, he was diagnosed with schizoaffective disorder and polysubstance abuse and discharged from the hospital. (Tr. 297-303.)
The following month, on March 4, 2009, Plaintiff was involuntarily admitted to the hospital as a danger to himself and others. (Tr. 920.) Plaintiff's mother reported that he had "decreased hygiene, " refused to take his medication, and that he had paranoid and disorganized thoughts. (Tr. 920.) On March 12, 2009, Plaintiff was placed on "court-ordered" treatment for one year "as persistently or acutely disabled." (Tr. 467, 921.) He was discharged on March 16, 2009 and was diagnosed with psychosis and personality disorder (not otherwise specified), dysthymia, and polysubstance abuse. (Tr. 922.) He was referred to Magellan Health Services for medication management and to Terros for substance abuse services. (Tr. 921-922, 467.)
Plaintiff was admitted to the hospital again on July 17, 2009; he reported feeling suicidal and hearing voices. (Tr. 410.) He was diagnosed with schizoaffective disorder, "depressed, " and chronic psychosocial health problems and discharged on July 27, 2009. (Tr 412.) His tests were negative for drug and alcohol use. (Tr. 411-14.) The treatment notes indicate that, at the time of discharge, Plaintiff was alert and oriented, and that he had concrete thoughts and intact insight and judgment. ( Id. at 411) Plaintiff was diagnosed with schizoaffective disorder and he was "depressed." ( Id. ) Plaintiff was advised to follow-up with his psychiatrist within three days. (Tr. 411-12.)
The next month, on August 28, 2009, Plaintiff was involuntarily admitted to the hospital as a danger to others. (Tr. 420.) At the time of admission, it was noted that Plaintiff was "on court-ordered treatment." ( Id. ) Plaintiff was discharged the next day and was advised to follow-up with his outpatient clinic within seven days. (Tr. 421.) He was diagnosed with schizoaffective disorder (bi-polar type), and his noted stressors included chronic mental illness and limited coping skills. ( Id. )
On January 26, 2010, Plaintiff was involuntarily admitted to the hospital as a danger to others after he stopped taking his prescribed medication for two months. (Tr. 530.) Plaintiff was angry, yelling at his mother, and talking to himself. ( Id. ) His clinical findings included decreased motivation, feelings of worthlessness, and fair insight and judgment. (Tr. 531.) A screening test was negative for drug use. ( Id. ) The clinical findings also stated that Plaintiff's coping skills were not commensurate with his age and that he had poor interpersonal skills. (Tr. 534.) Plaintiff was diagnosed with schizoaffective disorder (bi-polar type). (Tr. 532.) He was discharged on January 27, 2010, and was advised to seek more frequent outpatient care. ( Id. )
A month later, on February 17, 2010, Plaintiff was admitted to the hospital with suicidal thoughts, anxiety, and auditory hallucinations. (Tr. 546.) Although a drug screening test was negative, the treatment notes on admission indicate the Plaintiff had been drinking three forty-ounce beers a day. ( Id. ) He was discharged the next day with diagnoses of bipolar depression, personality disorder, and interpersonal stressors. (Tr. 547.)
A year later, on January 8, 2011, Plaintiff went to the hospital for anxiety and suicidal ideation. (Tr. 649 (patient "feels like he doesn't want to wake up or be around anymore").) A screening test was positive for drug use. (Tr. 665.) He was discharged on January 9, 2011 with anxiety disorder, depression, and suicide risk, and referred for outpatient treatment. (Tr. 652.) On January 15, 2011, Plaintiff was admitted to the hospital for suicidal ideation and anxiety. (Tr. 640-41.) He tested positive for drug and alcohol use. (Tr. 644.) Plaintiff was diagnosed with depression and suicidal risk. (Tr. 643.) He was discharged on January 16, 2011 and referred for psychiatric evaluation, treatment, and "long term management." (Tr. 645.)
On January 30, 2011, Plaintiff went to the emergency room and was admitted for several days for psychiatric observation due to suicidal ideation (he had cut his wrist), and to treat an unrelated medical condition (rhabdomyolysis). (Tr. 627-629.) Plaintiff was discharged on February 2, 2011 with several diagnoses, including depression with suicidal ideation and suicide attempt, depression, and bipolar disorder. (Tr. 623.) He was referred to inpatient psychiatric care. ( Id. )
During this same time period, Plaintiff was treated by Dr. Amanda Troutman, a psychiatrist at Magellan DDC, for schizoaffective disorder and alcohol abuse. She prescribed anti-depressants and anti-psychotic medications for mood swings, hallucinations, paranoia, and social isolation. (Tr. 459, 862.) Her treatment notes reflect that Plaintiff was anxious (Tr. 590 (Jun. 2010)), had a constricted or blunted affect (Tr. 584 (Sept. 2010), (Tr. 588 (Jul. 2010), Tr. 590 (Jun. 2010), Tr. 761, Tr. 802, 823 (Dec. 2011), Tr. 814 (Jan. 2011)), "fair/limited" insight and judgment (Tr. 589 (Jul. 2010), Tr. 587 (Aug. 2010)), limited insight and judgment (Tr. 803 (Dec. 2011)), lacked insight into his mental illness (Tr. 818 (Dec. 2010)), had an irritable mood and an argumentative attitude (Tr. 802 (Dec. 2011)), and poor memory and motivation. (Tr. 764 (Dec. 2011).)
Her treatment notes also indicate that Plaintiff was alert and oriented and had logical thought processes, fair concentration, intact memory, and fair insight and judgment. (Tr. 592-93 (May 2010), Tr. 589-90 (Jun. 2010), Tr. 586-87 (Aug. 2010), Tr. 584-85 (Sept. 2010), Tr. 582-83 (Nov. 2010), Tr. 823-24 (Dec. 2010), Tr. 802-03 (Jan. 2011) 783-84 (Feb. 2011), Tr. 775-76 (Mar. 2011), Tr. 762 (May 2011), Tr. 729-30 (Jul. 2011), Tr. 719-20 (Sept. 2011), Tr 708-09 (Nov. 2011).) She also assessed the severity of Plaintiff's symptoms as "mild." (Tr. 593, 591, 589, 587, 585, 583, 824, 803, 784, 776, 730, 762, 720, 709.)
In April 2011, treating physician Christopher Hiler, M.D., found Plaintiff's mental status questionable, and that he was incapable of self-care. (Tr. 675.) He recommended that Plaintiff reside in a group home. ( Id. )
B. Medical Opinions
1. Amanda Troutman, M.D.
Treating psychiatrist Dr. Amanda Troutman completed two forms assessing Plaintiff's work-related limitations in November 2010 and May 2011. On both forms, Dr. Troutman opined that Plaintiff had severe limitations in eight areas, moderately severe limitations in three areas, and a moderate limitation in one area. (Tr. 579-80, 617-180.)
2. Charles House, Ph.D.
In November 2009, State Agency physician Dr. Charles House evaluated Plaintiff. (Tr. 475-81.) Dr. House noted that Plaintiff reports of his alcohol and marijuana use varied from the information in his medical records. Thus, Dr. House found that Plaintiff was an unreliable historian. (Tr. 478.) Dr. House noted that Plaintiff did not have difficulty with the mini-mental status examination, he was not obviously depressed, and there were no signs of a thought disorder. (Tr. 478.) He further noted that Plaintiff did not report any significant limitations in his daily life. (Tr. 480.) Dr. House diagnosed polysubstance dependence, mood disorder (likely substance related), and dependent and avoidant traits. (Tr. 480.) Dr. House opined that Plaintiff was not severely limited in the areas of understanding and memory, sustained concentration and persistence, social interaction, or adaptation, "except perhaps when abusing substances." (Tr. 475.)
3. Sheri Tomak, Psy.D.
In December 2009, State Agency physician Dr. Sheri Tomak reviewed Plaintiff's medical records. She opined that Plaintiff was not significantly limited in twelve areas, and was ...