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Ojala v. Commissioner of Social Security Administration

United States District Court, D. Arizona

October 31, 2017

Sylvia Janine Ojala, Plaintiff,
Commissioner of Social Security Administration. Defendant.



         Plaintiff Sylvia Janine Ojala (“Claimant”) appeals the Commissioner of the Social Security Administration's decision to adopt Administrative Law Judge Thomas Cheffins' (ALJ's) ruling denying her application for Disability Insurance Benefits pursuant to Title II of the Social Security Act. (Doc. 1 at 1-10)[1] Claimant argues the ALJ erred by improperly rejecting the assessments of Claimant's treating psychiatrist, and by rejecting her own symptom testimony. (Doc. 16 at 1)

         This Court has jurisdiction pursuant to 42 U.S.C. § 405(g) and with the parties' consent to Magistrate Judge jurisdiction pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, the Court orders the decision of the Commissioner of Social Security vacated and remands this matter to the Commissioner for an award of benefits.

         I. BACKGROUND

         A. Claimant's Application and Social Security Administration Review

         Claimant was 47 when she filed her application for disability benefits on February 16, 2012, alleging a disability onset date of December 31, 2009. (Docs. 10-4 at 2, 10-6 at 4) Claimant asserted in her application a disabling diagnosis of major depressive disorder, generalized anxiety, and post-traumatic stress disorder. (Doc. 10-4 at 3) Her application was initially denied by the state agency on August 30, 2012 (Id. at 2-17) and again upon reconsideration on April 15, 2013 (Id. at 18-29). The ALJ conducted a hearing on Claimant's application on September 25, 2014. (Doc 10-3 at 47-78) The ALJ filed a notice of an unfavorable decision on November 19, 2014. (Id. at 17-41) Claimant requested review by the Appeals Council (Id. at 8-15), which was denied on April 11, 2016. (Id. at 2-4) At that point, the Commissioner's decision became final. Brewes v. Comm'r of Soc. Sec. Admin., 682 F.3d 1157, 1162 (9th Cir. 2012).

         B. Relevant Medical Treatment and Examining Physicians' Evidence

         1. Michael Rockwell, M.D. and Northlight Counseling Associates

         Claimant began treatment at Northlight Counseling Associates on January 22, 2010. (Doc. 10-9 at 145-149) She had been hospitalized for approximately five days earlier that month due to depression, and had been prescribed medication. (Id. at 145) Her first appointment with Dr. Rockwell, who became her treating psychiatrist, was on February 22, 2010. (Doc. 10-8 at 73-77) He initially diagnosed her with a “long time combination of depression and anxiety, ” and prescribed Risperdal (a medication for schizophrenia and bipolar disorder) in addition to her existing prescriptions for Ambien (a sedative) and Effexor (an antidepressant). (Id. at 77) He recommended that she commence counseling (Id.) In March 2010, Dr. Rockwell noted that the Risperdal did not seem to be working and that a different medication should be attempted. (Id.) He assessed her suicide risk level as moderately high. (Id.) Later in March 2010, Dr. Rockwell again recommended changing her medication, as Claimant was not responding well. (Id. at 70) He noted that Claimant's “depression remains severe [and] that she cannot return to work yet.” (Id.)

         On April 16, 2010, Dr. Rockwell signed a “to whom it may concern” note, presumably advising Claimant's employer that she was “too symptomatic for work, ” and that he hoped medication adjustment would alleviate her symptoms so that she could return to work by May 17, 2010. (Id. at 67) On May 14, 2010, Dr. Rockwell noted that Claimant seemed somewhat improved, and documented that her medication would continue to be adjusted for “better depression coverage” and “better sleep/night time anxiety.” In June 2010, the doctor documented that Claimant's affect was restricted, and that she appeared to be depressed, anxious, and near tears, with a thought process that was normal in flow and content. (Id. at 62) A handwritten notation on Claimant's examination summary states, “She is now on LTD, ” possibly in reference to a “long-term disability” policy. (Id.) Dr. Rockwell reported in July 2010 that Claimant's medication had not improved her symptoms. (Id. at 60)

         In September and November 2010, the doctor indicated no significant change in Claimant's mental state. (Id. at 51, 55) On November 30, 2010, the doctor documented that Claimant's suicide risk level was “high.” (Id. at 49) On February 24, 2011, Dr. Rockwell noted that Claimant's depression, crying, and anxiety were not improved, that her suicide risk remained high, and suggested that she begin a prescription for lithium (used to treat the manic episodes of bipolar disorder). (Id. at 46) At the same time, the doctor noted that at-home issues are “major contributors” to her mental state, and that he would like her to see a counselor. (Id.) Dr. Rockwell observed on March 24, 2011, that Claimant was still depressed or anxious, but not tearful on the prescription for lithium, and that her suicide risk had lowered to a moderately high level. (Id. at 95) On April 21, 2011, the doctor reported that Claimant's prescription for 900 mg of lithium was “helping” because she seemed only slightly depressed and not tearful, although she was speaking more slowly. (Id. at 92) He also noted that he planned to reduce her lithium dose. (Id.)

         On May 26, 2011, Dr. Rockwell recorded that after reducing Claimant's lithium dose, she showed no signs of sedation but she had “bad days” of crying and anxiety. (Id.) Consequently, he planned to increase her lithium dose. (Id. at 89) In June 2011, the doctor observed that Claimant displayed some word retrieval issues, and reported feeling down at times but not teary, and had done some yardwork. (Id. at 87) On August 25, 2011, Claimant was reported to have unintentionally lost 20 to 30 pounds due to elevated stress. (Id. at 86) She was still on 900 mg lithium, but was depressed and tearful, and the doctor increased her perceived suicide risk to moderately high. (Id.) Claimant's condition had only worsened by October 20, 2011, and the doctor documented that he would substitute one medication for another. (Id. at 84) On December 15, 2011, Dr. Rockwell noted that Claimant reported that she had not returned sooner for an appointment because, in her paranoia, she thought the doctor was “out to kill her, ” and that she had stopped taking all medications because she could not eat, drink, or even talk, was crying daily, and could only sleep a couple of hours at a time. (Id. at 83) The doctor assessed her suicide risk as “high.” He noted that Claimant opted to go back on her previous medications rather than try an antipsychotic prescription. (Id.)

         Claimant's condition had improved on medication by January 5, 2012. (Id. at 82) She reported that her ability to write had diminished, but that her paranoia had lessened, and that she was eating and having some good days. (Id.) The doctor documented that her depressed state was mixed with some laughter, and that he planned to switch one of her depression medications. (Id.) However, on February 2, 2012, Claimant displayed increased moodiness and anger, and Dr. Rockwell diagnosed her with bipolar traits. (Id. at 81) Claimant's next visit was on June 28, 2012, during which the doctor noted that she was again off her medications, crying a lot more, and reporting that her husband wanted to leave her. (Doc. 10-8 at 162) The doctor indicated he would place Claimant on Abilify, an anti-psychotic medication. (Id.) By September 26, 2012, Claimant's symptoms had improved to the point that she said she was feeling better, doing more than usual, and that her depression was not a “10” anymore, but rather a “6 to 7.” (Id. at 168) On October 31, 2012, Dr. Rockwell observed that Claimant's anxiety was out of control, and that she reported that the presence of more than one or two persons in a room with her caused her to develop diarrhea or other feelings of sickness. (Id. at 170)

         On November 30, 2012, Dr. Rockwell documented that Claimant's pulmonary doctor declined to fill out Social Security forms for her because she was not using her sleep apnea machine. (Id. at 180) He further noted that Claimant reported being frequently angry and that her medications did not help. (Id. at 180-181) He also reported that Claimant had threatened to ingest a full bottle of Restoril pills (a sedative), but eventually spontaneously surrendered the bottle. (Id. at 181) He noted that her mood was angry, intense, irritable, anxious, and sad/depressed. (Id. at 182) On January 16, 2013, Claimant reported having begun to use her CPAP machine nightly, and had experienced reduced sleepiness. (Id. at 158) He noted that Claimant not taken Valium (an anxiety medication) in several weeks, suggesting this was the reason her anxiety was “so high.” (Id.) Although Claimant reported that her anxiety was “really high, ” Dr. Rockwell observed that her depression/anger was not as bad. (Id. at 159).

         On March 13, 2013, Dr. Rockwell recorded that Claimant had been taking Saphris (a medication for schizophrenia and bipolar disorders) and Valium, and was using her CPAP machine, but still felt tired, was more depressed, that her anxiety very high, and that she had threatened suicide. (Doc. 10-9 at 99-100) He also recorded that she had not used her Viibryd (an antidepressant) prescription because she was too anxious about side effects. (Id. at 100) On March 29, 2013, however, the doctor noted that Claimant had taken Viibryd, which seemed to have helped. (Id. at 94) Claimant reported that she felt better, and that her depression had lifted somewhat. (Id.) She said that she had been to a bipolar support group twice. (Id.) The doctor reduced her suicide risk to moderate. (Id. at 95).

         On April 26, 2013, Dr. Rockwell recorded that although Claimant was still taking Saphris and Valium, she had been exhausted and “down, ” and he assessed her suicide risk as increased to moderately high. (Id. at 89-90) During examinations in May 2013, Dr. Rockwell documented Claimant's reports of her arguments with her husband, which had put her in a “murderous rage.” (Id. at 84) He noted that Claimant displayed a dysphoric mood, and was irritable, sad and depressed. (Id. at 86) He also noted discussing a plan for a hospital program or visits with an individual counselor. (Id. at 79-80) On May 31, 2013, Dr. Rockwell reported that Claimant had been hospitalized for a week. (Id. at 73) He reported that the hospital physicians had altered Claimant's medications and that she was still crying, but was not as depressed. (Id. at 74) He lowered her suicide risk assessment to low/moderate. (Id. at 75) On July 1, 2013, Dr. Rockwell documented that Claimant had again been in the hospital for eight days in June 2013. (Id. at 69) He observed that Claimant was not crying but was still depressed. (Id.) He also noted that Claimant's daughter-in-law reported that Claimant was doing a lot better after leaving her husband, and had not demonstrated any mood swings. (Id. at 70).

         On August 5, 2013, the doctor reported that Claimant had started to cry again, suffered panic and anxiety at a restaurant with her family, suffered from depression without anger or tension, and assessed her suicide risk as low. (Id. at 64-65) In September 2013, Claimant reported some agoraphobia and active depression, and said that she was seeing a counselor. (Id. at 59) The doctor assessed her suicide risk as low. (Id. at 60) In October 2013, Claimant told Dr. Rockwell that she experience both good and bad days with depression, that she had bad anxiety around the children, and that she had been able to leave her house, but only “as little as possible.” (Id. at 54) On November 15, 2013, although Claimant reported having panic attacks and was always nervous, she said she was doing fairly well. (Id. at 49) The doctor noted she was a bit tearful and displayed a depressed affect, but that she was not overtly anxious. (Id.).

         On January 17, 2014, Claimant reported that her down mood was not lifting. (Id. at 44) She said she was anxious and tired all the time, but had suffered no panic attacks. (Id.) Dr. Rockwell noted that Claimant was more tearful and depressed than at her previous appointment, and raised her suicide risk to low/moderate. (Id. at 45) In February 2014, the doctor recorded that Claimant was still down and angry at her husband, and that her depression and anxiety symptoms were about the same. (Id. at 39) He documented that she reported no panic attacks or psychosis, and that she could not afford counseling but had attended Al-Anon meetings. (Id.) On March 7, 2014, Claimant appeared to be “low energy, ” depressed and tearful, but not overtly anxious. (Id. at 34) When Dr. Rockwell saw Claimant on April 9, 2014, he reported she was suffering from an intense, diffuse anger. (Id. at 29) He concluded that Claimant was more restricted and depressed than angry. (Id.) In May 2014, the doctor reported that Claimant said she had tried to take care of her grandson, and was too tired to take her medications and “now I am a mess.” (Id. at 24) She said she had not taken Risperdal on days she was caretaking, which was three times per week. (Id. at 24) She reported active depression and that she was more tearful, and apathetic about minding the baby. (Id.) Dr. Rockwell raised her suicide risk assessment to moderate, and documented her having demonstrated “impaired judgment” because she had adjusted her medication without his input. (Id. at 25).

         On June 4, 2014, the doctor reported Claimant's statements that she was feeling better, was not as tired, and was less anxious. (Id. at 19) He lowered her assessed suicide risk to low. (Id. at 20) A few days later, on June 9, 2014, Claimant called because she had experienced a really bad panic attack. (Id. at 17) She told Dr. Rockwell that she did not want to take Ativan (an anti-anxiety medication) if she did not have to. (Id.) On July 3, 2014, Claimant reported memory lapses, and that she had experienced five panic attacks lasting up to 30 minutes. (Id. at 13) The doctor noted that she had suffered some depression, but was not angry or anxious. (Id. at 14) During an office visit on July 30, 2014, Claimant reported having daily panic attacks and scattered thoughts. (Id. at 9) Dr. Rockwell noted that her hypersensitivity to sounds was “almost auditory hallucinations” and that she was more depressed. (Id.) On August 27, 2014, Doctor Rockwell reported Claimant had left her husband, that her panic and anxiety were not too bad, that she was not sleeping and was tearful and depressed, and raised her suicide risk assessment to moderately high. (Id. at 3-4).

         2. Arcadia Family Clinic

         Claimant was first seen at this practice on February 5, 2010, to follow up on her hospitalization in January 2010. (Doc. 10-8 at 100) The exam notes indicate both that Claimant was “[i]mproved but not all better on 225[mg] of [E]ffexor XR a day. To psych later this month, ” that she “[d]enies sadness or nervousness, ” and that her “mood is appropriate[, ] [a]ffect normal.” (Id. at 100-101) She was prescribed both Effexor (an anti-depressant and anti-anxiety drug) and Ambien (for insomnia). (Id. at 101) Claimant was next seen at this practice on December 30, 2011. (Id. at 102) The examination notes indicate she was seen to review her medications, and that she had “not respond[ed] well to [P]axil or Cymbalta [both depression and anxiety medications].” (Id. at 103) She had been prescribed lithium and Xanax (a treatment for anxiety and panic disorder) by her psychiatrist, Dr. Rockwell. (Id. at 102) The notes also indicate that Claimant “[d]enies depression and anxiety, ” and that her judgment, insight, memory, mood and affect “(i.e., depression, anxiety)” were all normal. (Id. at 103).

         On January 19, 2012, Dr. Woellner documented that the “last [blood work] shows therapeutic lithium level” and that Claimant was “[t]ried on Seroquel [a treatment for schizophrenia, bipolar disorder and depression] but didn't do well on it.” (Id. at 106) On February 13, 2012, Claimant was seen because she reported having troubles with her medication, had not been “on meds and is having a reaction.” (Id. at 108) Although the doctor's review of symptoms continued to document that Claimant denied any depression or anxiety, and that her psychiatric status was normal, Dr. Woellner prescribed her to “go back on Seroquel until Dr. Rockwell sees.” (Id. at 109-110) Subsequent to a follow up visit on March 12, 2012, Dr. Woellner's notes state that Claimant had done “better since starting meds, [S]eroquel XR has switched to[A]bilify 5.” (Id. at 112).

         On May 30, 2013, Claimant had blood drawn for testing in association with diagnoses of shortness of breath, anxiety and chest pain. (Doc. 10-9 at 173) She was assessed as “[p]ositive for behavioral problems, confusion and dysphoric mood. The patient is nervous/anxious.” (Id. at 170) On June 27, 2013, she again was assessed as having “behavioral problems, confusion and dysphoric mood, ” as well as appearing nervous and anxious. (Id. at 167) On October 30, 2013, she was seen by Dr. Woellner, whose exam notes indicate that Claimant was then taking prescriptions of Haldol and Risperdal (both anti-psychotics), Ativan (an anti-anxiety treatment), and Desyrel (an anti-depressant). (Id. at 164) At examinations in June and September 2014, Claimant continued to display behavioral problems, nervousness, anxiety and dysphoric mood. (Id. at 162, 159).

         3. Family Service Agency

         Claimant received counseling between May and August 2010 at the Family Service Agency. (Doc. 10-9 at 150-158) She was assessed as suffering from major depressive disorder. (Id. at 153)

         C. Hospitalizations

         1. St. Luke's Behavioral Health Center

         On January 4, 2010, Claimant was taken to the hospital by her husband because she demonstrated a worsening depressed mood, with suicidal ideation. (Doc. 10-8 at 12) She later explained that she felt she needed medications, she had been very tired working two jobs, was unable to sleep or eat, and that an incident at work had made her feel she could not “handle it anymore.” (Id. at 29) She had impulsively quit her job the night before. (Id. at 12) The hospital's notes indicated that Claimant had stopped taking her medications about a year prior because the antidepressants made her tired. (Doc. Id. at 36) She was assessed as having an intact memory, but with psychomotor slowing, slowing of speech, a constricted affect and depressed mood, and was positive for suicidal ideation with intent and plan. (Id. at 13) On discharge, Claimant was assessed as anxious, with appropriate affect, reality-based perceptions, fair judgment, intact memory and lacking suicidal ideation. (Id. at 7) The discharge notes indicated that medication had improved Claimant's mood and sleep. (Id.)

         2. Valley Hospital

         Records indicate that Claimant was admitted to Valley Hospital on May 17, 2013, and discharged on May 24, 2013. (Doc. 10-9 at 135) She was referred by Dr. Rockwell for “treatment and evaluation secondary to suicidal ideation.” (Id.) Her admitting diagnosis was bipolar disorder and generalized anxiety disorder. (Id.) Claimant was documented as stating she was not compliant with her prescriptions because they “weren't working” and she “cannot afford these medicines anyway.” (Id.) After adjustment of her medication over her hospital stay, Claimant was discharged in stable condition. (Id. at 136) She was documented as suffering no “acute signs and symptoms, ” or suicidal ideation. (Id. at 137) Her affect was noted as both appropriate and blunted, but her mood was “much better.” (Id.) Claimant's thought process was logical, her judgment intact, and her insight partial. (Id.) Her GAF score upon admission was 25 to 30, and on discharge had improved to 45 to 50. (Id. at 135, 137)

         The following month, on June 17, 2013, Claimant presented again to Valley Hospital and reported she experienced suicidal ideation and that her medications were not working. (Id. at 116) She was noted as having attended an intensive outpatient program at the hospital for the previous three weeks. (Id.) She stated she had stopped all medications two weeks prior because she believed they were not effective. (Id.) It appears that Claimant was discharged from the hospital on June 24, 2013. (Id. at 121) Claimant completed the intensive outpatient program on September 12, 2013. (Id. at 119) An assessment of her progress while in the program indicated that Claimant improved in her “mood, thinking and behavior, communication skills” and reported improvement in regulating her mood by using coping skills. (Id. at 119) Her completion notes further indicated that her “self-esteem improved and social anxiety has decreased since the date of admission to [the intensive outpatient program].” (Id.)

         D. Treating Psychiatrist's and Examining ...

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