United States District Court, W.D. Oklahoma
OPINION AND ORDER
CHARLES B. GOODWIN, UNITED STATES MAGISTRATE JUDGE.
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
HISTORY AND ADMINISTRATIVE DECISION
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.
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.” 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.
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
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.
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.
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.
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).
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. The Court agrees and finds that remand is
required on this basis.
The Relevant Record
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
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.
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.
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,
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.
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