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Burton v. Colvin

United States District Court, W.D. Oklahoma

September 11, 2017

CAROLYN W. COLVIN, Acting Commissioner of Social Security Administration, Defendant.



         Plaintiff Robin Brian Burton brings this action pursuant to 42 U.S.C. § 405(g) for judicial review of the final decision of the Commissioner of the Social Security Administration (“SSA”) denying Plaintiff's applications for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under the Social Security Act, 42 U.S.C. §§ 401-434, 1381-1383f. The parties have consented to the jurisdiction of a United States Magistrate Judge. Upon review of the administrative record (Doc. No. 13, hereinafter “R._”), and the arguments and authorities submitted by the parties, the Court reverses the Commissioner's decision and remands the case for further proceedings.


         Plaintiff protectively filed his applications for DIB and SSI in January 2013, alleging disability beginning on November 1, 2011. R. 32, 188-200, 221. Following denial of his applications initially and on reconsideration, a hearing was held before an administrative law judge (“ALJ”) on January 15, 2014. R. 25-121, 126-34, 137-42. In addition to Plaintiff, Plaintiff's father and a vocational expert both testified at the hearing. R. 25-73. The ALJ issued an unfavorable decision on February 26, 2014. R. 6-24.

         As relevant here, the Commissioner uses a five-step sequential evaluation process to determine entitlement to disability benefits. See Wall v. Astrue, 561 F.3d 1048, 1052 (10th Cir. 2009); 20 C.F.R. §§ 404.1520, 416.920. At step one, the ALJ found that Plaintiff had not engaged in substantial gainful activity since the alleged onset date of November 1, 2011. R. 11. At step two, the ALJ determined that Plaintiff had the severe impairments of bipolar disorder with psychotic features and “paranoid delusophenia.”[1] R. 11. At step three, the ALJ determined that Plaintiff's condition did not meet or equal any of the presumptively disabling impairments listed in 20 C.F.R. Part 404, Subpart P, Appendix 1. R. 11-13.

         The ALJ next assessed Plaintiff's residual functional capacity (“RFC”) based on all of his impairments. R. 13-17. The ALJ determined that:

[Plaintiff] has the [RFC] to perform a full range of work at all exertional levels but with the following nonexertional limitations:
He can perform simple tasks (defined by the undersigned as unskilled work with a specific vocational preparation (SVP) of one or two). He must avoid contact with the public, but can engage in superficial contact with supervisors and coworkers (defined as brief and cursory contact).

R. 13. At step four, the ALJ determined that Plaintiff was unable to perform any past relevant work. R. 18.

         At step five, the ALJ considered whether there are jobs existing in significant numbers in the national economy that Plaintiff-in view of his age, education, work experience, and RFC-could perform. R. 18-19. Relying upon the vocational expert's testimony regarding the degree of erosion to the unskilled occupational base caused by Plaintiff's nonexertional limitations, the ALJ concluded that Plaintiff could perform unskilled, medium occupations such as machine packager, dishwasher, or hand packager, and that such occupations offer jobs that exist in significant numbers in the national economy. R. 19. Therefore, the ALJ concluded that Plaintiff had not been disabled within the meaning of the Social Security Act during the relevant time period. R. 19-20.

         Plaintiff's request for review by the SSA Appeals Council was denied. R. 1-3. The unfavorable determination of the ALJ stands as the Commissioner's final decision. See 20 C.F.R. §§ 404.981, 416.1481.


         Judicial review of the Commissioner's final decision is limited to determining whether factual findings are supported by substantial evidence in the record as a whole and whether correct legal standards were applied. Poppa v. Astrue, 569 F.3d 1167, 1169 (10th Cir. 2009). “Substantial evidence is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Doyal v. Barnhart, 331 F.3d 758, 760 (10th Cir. 2003) (internal quotation marks omitted). “A decision is not based on substantial evidence if it is overwhelmed by other evidence in the record or if there is a mere scintilla of evidence supporting it.” Branum v. Barnhart, 385 F.3d 1268, 1270 (10th Cir. 2004) (internal quotation marks omitted). The court “meticulously examine[s] the record as a whole, ” including any evidence “that may undercut or detract from the ALJ's findings, ” “to determine if the substantiality test has been met.” Wall, 561 F.3d at 1052 (internal quotation marks omitted). While a reviewing court considers whether the Commissioner followed applicable rules of law in weighing particular types of evidence in disability cases, it may not itself reweigh the evidence or substitute its judgment for that of the Commissioner. Bowman v. Astrue, 511 F.3d 1270, 1272 (10th Cir. 2008).


         Plaintiff challenges the ALJ's consideration of certain evidence in the record from Plaintiff's treating psychiatrist, Shantharam Darbe, MD. Plaintiff contends that the ALJ's assessment of Dr. Darbe's opinions was legally erroneous and failed to properly comply with the treating physician rule. See Pl.'s Br. (Doc. No. 19) at 12-21.[2] The Court agrees and finds that remand is required on this basis.

         A. The Relevant Record

         The record evidence pertaining to Plaintiff's psychiatric condition reflects that he received mental health treatment throughout the November 2011 to February 2014 disability period. See R. 283-301 (Ex. 1F), 302-04 (Ex. 2F), 305-20 (Ex. 3F), 321-25 (Ex. 4F), 327-32 (Ex. 6F), 333-45 (Ex. 7F).[3]

         In late October 2011, Plaintiff presented to a Midwest City emergency room with paranoia and suicidal ideations. Dr. Darbe, who had referred Plaintiff to the emergency department and was noted to be Plaintiff's primary care physician, admitted Plaintiff to the hospital for mental health evaluation. See R. 284-96. Plaintiff's chief complaint was suicidal ideation, and his admitting diagnosis was bipolar I disorder; Dr. Darbe also noted his clinical impressions of “Acute mania with delusions” and “Suicidal ideation, possible.” R. 283, 289-91. Dr. Darbe ordered that Plaintiff continue taking his antipsychotic medication and also prescribed medications for bipolar disorder and anxiety. R. 284-85. The records indicate that Plaintiff was hospitalized overnight and then discharged to his parents' house. R. 284. Dr. Darbe, Plaintiff, and Plaintiff's family also agreed that Plaintiff and his parents would begin to visit Dennis Ferguson, PhD (a psychologist in practice with Dr. Darbe) at least once per month. R. 284.

         Plaintiff attended counseling sessions with Dr. Ferguson twice, in December 2011 and in January 2012. See R. 302, 303. Dr. Ferguson noted abnormalities in Plaintiff's speech, mood, affect, judgment, and insight. R. 302, 303. At both visits, Dr. Ferguson diagnosed Plaintiff as having bipolar disorder with psychotic features. R. 302, 303.

         Plaintiff otherwise was treated exclusively by Dr. Darbe during the relevant disability period. See R. 305-25, 333-45. Following his hospital admission in October 2011, Plaintiff was examined in person by Dr. Darbe at least fourteen times. R. 305, 307, 311, 313, 315, 317, 319, 327, 329, 330, 335, 340, 343, 345. Plaintiff also was prescribed multiple antipsychotic, anxiolytic, and antidepressant medications by Dr. Darbe. Dr. Darbe consistently diagnosed Plaintiff as having paranoid schizophrenia. R. 305-07, 309-19, 327-30, 334-35, 337-45.

         In July 2012, Plaintiff reported to Dr. Darbe that he had attempted suicide while his parents were away on vacation. R. 315 (noting that Plaintiff exhibited “no remorse about suicide attempt”). The next month Plaintiff reported that he was still isolating himself and was wearing women's underwear. R. 313, 314. In July and August 2012, Dr. Darbe noted that Plaintiff reported feeling better but also noted a decline in Plaintiffs affect, judgment, and insight as compared to his previous visits. See R. 313, 315, 317, 319. In November 2012, Plaintiffs mother visited Dr. Darbe's clinic to report that Plaintiff had thrown a large pot of boiling water at her and that she was staying at a friend's house out of fear. R. 308.

         In March 2013, Plaintiff reported that he had hit his mother in the head with a can of soda and that he was experiencing hallucinations as well as an increasingly frequent and more violent temper. R. 330. Dr. Darbe referred Plaintiff to a group home, where Plaintiff stayed for a short while. R 328, 330, 345; see also R 33-34, 39, 60-61. Plaintiff continued to be seen by Dr. Darbe, who at times noted Plaintiffs poor hygiene and weight gain, as well as abnormalities in Plaintiffs appearance, speech, mood, affect, insight and judgment, thought, memory, and attitude. R. 327, 335, 340, 343, 345. In June 2013, Plaintiff reported to Dr. Darbe that he “[c]an't . . . keep a job” and ...

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