United States District Court, D. South Carolina
V. Hodges, United States Magistrate Judge
appeal from a denial of social security benefits is before
the court for a final order pursuant to 28 U.S.C. §
636(c), Local Civ. Rule 73.01(B) (D.S.C.), and the order of
the Honorable Patrick Michael Duffy, United States District
Judge, dated April 10, 2018, referring this matter for
disposition. [ECF No. 16]. The parties consented to the
undersigned United States Magistrate Judge's disposition
of this case, with any appeal directly to the Fourth Circuit
Court of Appeals. [ECF No. 15].
files this appeal pursuant to 42 U.S.C. § 405(g) of the
Social Security Act (“the Act”) to obtain
judicial review of the final decision of the Commissioner of
Social Security (“Commissioner”) denying the
claim for disability insurance benefits (“DIB”).
The two issues before the court are whether the
Commissioner's findings of fact are supported by
substantial evidence and whether she applied the proper legal
standards. For the reasons that follow, the court reverses
and remands the Commissioner's decision for further
proceedings as set forth herein.
12, 2015, Plaintiff filed application for DIB in which he
alleged his disability began on August 19, 2014. Tr. at
172-79. His application was denied initially and upon
reconsideration. Tr. at 95-98 and 101-04. On March 20, 2017,
Plaintiff had a video hearing before Administrative Law Judge
(“ALJ”) John T. Molleur. Tr. at 39-58 (Hr'g
Tr.). The ALJ issued an unfavorable decision on April 20,
2017, finding that Plaintiff was not disabled within the
meaning of the Act. Tr. at 10-26. Subsequently, the Appeals
Council denied Plaintiff's request for review, making the
ALJ's decision the final decision of the Commissioner for
purposes of judicial review. Tr. at 1-5. Thereafter,
Plaintiff brought this action seeking judicial review of the
Commissioner's decision in a complaint filed on November
2, 2017. [ECF No. 1].
Plaintiff's Background and Medical History
was 58 years old at the time of the hearing. Tr. at 44. He
obtained his high school GED. Id. His past relevant
work (“PRW”) was as an insurance agent. Tr. at
44-45. He alleges he has been unable to work since August
2014. Tr. at 45.
25, 2015, Plaintiff's treating psychiatrist, Dr. Marshall
A Staton (“Dr. Staton”), completed a medical
assessment form. Tr. at 263. Dr. Staton stated Plaintiff
suffered from depressive disorder and had been prescribed
Wellbutrin, Effexor, and Trazodone. Id. He noted
Plaintiff was oriented to time, person, place, and situation
and had intact thought processes, appropriate thought
content, depressed mood, adequate attention and
concentration, and adequate memory. Id. Dr. Staton
also indicated Plaintiff had good ability to complete basic
activities of daily living (“ADLs”); adequate
ability to relate to others; good ability to complete simple,
routine tasks; and adequate ability to complete complex
August 14, 2015, Dr. Dalal Akoury (“Dr.
Akory”)performed a comprehensive medical examination
upon Plaintiff's complaints of vision loss in his left
eye, depression, and anxiety. Tr. at 265. Dr. Akoury noted
Plaintiff's vision loss in the lower left eye was
permanent and caused inability to focus on anything outside
Plaintiff's direct line of sight. Id. Plaintiff
reported losing all vision in his left eye in 2012 after
experiencing a severe hypertensive episode. Id. He
also reported experiencing some moderately blurry vision in
both eyes with infrequent artifacts appearing. Id.
Dr. Akoury noted Plaintiff's medical history included
hypertension, hyperlipidemia, depression and anxiety, and
vision loss in the left eye. Id. Dr. Akoury
indicated Plaintiff was taking Lisinopril, Trazodone,
Wellbutrin, and Atorvastatin. Id. Plaintiff denied
any past use of alcohol or illicit substance use or abuse,
but admitted to smoking an occasional cigar. Id.
Plaintiff stated he last worked in August 2014 as an
insurance agent and sales representative, but was unable to
continue this type of work. Id. Plaintiff also
reported he was divorced, lived alone, and did not receive
assistance with his ADLs. Id. Dr. Akoury indicated
Plaintiff was oriented to person, place, and time and found
his neurological and mental status within normal limits. Tr.
at 266-67. Dr. Akoury assessed left eye vision loss and
depression and anxiety based on Plaintiff's reported
history. Tr. at 267.
January 12, 2016, Plaintiff presented to Oceano Counseling,
LLC, for an initial psychological assessment by Monica Sojka
(“Sojka”), a licensed social worker. Tr. at 281.
Plaintiff reported a 20-year history of treatment for anxiety
and depression, including ten years of consultation with a
psychiatrist, and indicated he had been depressed for about a
year. Id. Plaintiff stated he graduated high school
and attended some college and previously worked as an
insurance agent, but had been out of work for a year. Tr. at
283. Plaintiff reported experiencing a transient ischemic
attack (“TIA”) a few years prior and having sleep
apnea, high cholesterol, and hypertension. Id. Sojka
noted Plaintiff was alert and well-oriented; his mood was
severely depressed, with blunted affect; and he had
significant irritability. Tr. at 287. Sojka found Plaintiff
met the criteria for recurrent major depression without
psychosis. Id. She also indicated he might meet the
criteria for generalized anxiety disorder, but she suspected
his depression was the source of his anxiety. Id.
had weekly counseling sessions with Sojka through February
2017. See Tr. at 289, 294-96, 297-378. In notes from
each of those sessions, Sojka indicated Plaintiff was
oriented to time, place, person, and situation; his
perception, thought content, and judgment were normal; he had
excessive appetite and sleep; his insight was fair; his
thought process was coherent; he was cooperative; his
appearance was appropriate to his age; he was severely
depressed; he had trouble concentrating, very low energy, and
low motivation; he was socially withdrawn; and he exhibited
psychomotor slowing and blunted/tearful affect. Tr. at
297-378. Her diagnostic impression remained Major Depressive
Disorder, Recurrent episode, Severe, throughout
Plaintiff's course of treatment. Id.
February 25, 2016, Dr. Douglas R. Ritz (“Dr.
Ritz”) performed a consultative mental status
examination regarding allegations of anxiety, depression,
permanent partial vision loss in the left eye, hypertension,
and headaches. Tr. at 290-93. Plaintiff indicated he had
received treatment for depression for 20 years, but suspected
he was depressed dating back to high school. Tr. at 290. He
said he thought the depression had worsened over the prior
eight years since his mother died suddenly and he and his
wife separated. Id. He reported low energy, trouble
sleeping through the night, sleeping too much during the day,
and crying easily. Id. Plaintiff reported past
medical conditions of high cholesterol, sleep apnea, vision
loss from a TIA, and hypertension. Id. Dr. Ritz
noted Plaintiff's medications included Lisinopril,
atorvastatin, bupropion, venlafaxine, and trazodone. Tr. at
290- 91. Plaintiff stated he used to drink fairly heavily,
but started going to alcoholics anonymous (“AA”)
and has been sober for many years. Tr. at 291.
reported he began working as an insurance agent in 1989, was
last employed at Allstate for a year and a half, but resigned
in 2014. Id. Plaintiff stated he was prevented from
working because he did not get along with people and tended
to be irritable around others. Id.
had a driver's license and drove himself to the
evaluation. Id. Plaintiff reported he lived alone;
went to bed between 1:00 and 2:00 a.m. and set an alarm for
8:00 a.m., but rarely got up on time; took medication and
made coffee; did household chores when he felt like it; spent
time watching television and on the computer; consistently
took care of his personal grooming; regularly attended AA
meetings and church; occasionally went to the golf driving
range; and shopped for groceries. Id.
Ritz noted Plaintiff maintained eye contact throughout the
evaluation; his speech was low in volume and monotone; his
mood was sad, but not tearful; and his affect was flat.
Id. Plaintiff was alert, responsive, and in no
distress. Id. He was coherent, logical, but had no
goals for himself. Id. His insight and judgment were
good. Id. During a Mini-Mental Status, second
edition, Plaintiff did not know the correct date or the full
address of the examiner's office; was able to recall one
of three words after a few minutes; could do serial 7s
without error, but could not accurately repeat a nine-word
sentence; could point to figures in a directed order; and
could draw intersecting pentagons. Tr. at 291-92.
Plaintiff's score was 25 out of 30, which was in the
unimpaired range. Tr. at 292. Dr. Ritz estimated
Plaintiff's cognitive skills to be within the average
Ritz noted Plaintiff consistently took care of his personal
grooming, did household chores when he felt like it,
maintained some social contacts, and was able to avoid
physical danger and handle funds. Id. Dr. Ritz
concluded Plaintiff had a depressive disorder that would not
necessarily prevent him from performing in the work setting.
Id. He opined that, while Plaintiff may have some
difficulty in his prior job, he might be able to function in
a more unskilled type work setting. Id. Dr. Ritz
listed Plaintiff's diagnoses as recurrent mild major
depressive disorder and alcohol use disorder, in sustained
March 9, 2016, Sojka wrote a letter disagreeing with Dr.
Ritz's diagnosis of mild recurrent major depression. Tr.
at 294-96. Sojka opined Dr. Ritz's mental status exam, in
which he noted Plaintiff's speech was low and monotone
and his affect was flat, was consistent with severe
depression, not mild. Tr. at 294. Sojka noted Plaintiff's
20-year history of severe depression that had been only
minimally responsive to medication. Id. She listed
Plaintiff's symptoms of severe depression as trouble
concentrating, very low energy, low motivation, social
withdrawal, psychomotor slowing, and blunted affect. Tr. at
294-95. Sojka indicated in her initial assessment Plaintiff
had scored a five on the SADPERSON screening, a score that
suggests a significant risk and a need for immediate suicide
screening. Tr. at 295. She stated in her 30 years of
experience as a mental health clinician, she had only seen
five or six patients as depressed as Plaintiff and the Social
Security Administration found those patients disabled.
Id. Sojka emphasized her diagnosis was made solely
based on clinical presentation and prior to knowing Plaintiff
had applied for disability. Id. She concluded by
offering her professional opinion that Plaintiff was fully
and completely disabled by his severe recurrent major
April 5, 2016, in a counseling session with Sojka, Plaintiff
reported worsening anxiety and muscle tension. Tr. at 304.
April 21, 2016, Plaintiff returned to Dr. Staton for
psychotherapy and medication management. Tr. at 379.
Plaintiff reported seeing a psychotherapist for four months
and wanting to reestablish treatment with Dr. Staton to
assist with his disability application. Id.
Plaintiff expressed distress over the state of his life and
indicated a lack of support system. Id. Dr. Staton
noted Plaintiff was taking Wellbutrin, Effexor, and Trazodone
and prescribed Abilify to augment Plaintiff's other
medications. Id. Plaintiff continued to see Dr.
Staton every several months until March 2017. Tr. at 379-84.
In records from each of these sessions, Dr. Staton notes
Plaintiff as oriented, his affect is depressed, associations
are intact, speech is within normal limits, he does not have
psychotic symptoms, and he denies suicidal or homicidal
ideations. Id. Dr. Staton continued his diagnosis of
recurrent major depressive disorder throughout
Plaintiff's treatment. Id.
10, 2016, Plaintiff told Sojka that Dr. Staton had prescribed
Abilify. Tr. at 310. He said the medication made him edgy, so
he cut the dosage in half, and indicated he did not think it
was helping his depression at all. Tr. at 310-11.
19, 2016, Plaintiff told Dr. Staton the Abilify had not been
helpful and Dr. Staton discontinued it and renewed
Plaintiff's other medications. Tr. at 380.
16, 2016, Plaintiff reported he did not feel any better or
worse after stopping Abilify and Dr. Staton supplied
Plaintiff with Deplin samples to augment his antidepressants.
Tr. at 381.
17, 2016, Plaintiff told Sojka that Dr. Staton had prescribed
another medication to boost the effect of his current
medications. Tr. at 319.
19, 2016, Dr. Staton counseled Plaintiff on structuring his
free time. Tr. at 382. Plaintiff stated he attended AA
meetings three or four times per week, despite being sober
for 30 years, because it helped his mood and feelings of
isolation. Id. Plaintiff indicated the Deplin had
not helped and Dr. Staton discontinued it and stated he would
consider other antidepressant options. Id.
August 30, 2016, Plaintiff reported worsening depression due
to financial struggles and told Sojka he was finding it
difficult to get out of bed. Tr. at 328. He also stated he
had not responded to his new medication. Tr. at 331. Sojka
noted Plaintiff had severe treatment resistant depression.
December 8, 2016, Dr. Staton noted Plaintiff was also taking
Lisinopril and a cholesterol medication and stated
Plaintiff's current psychiatric medications were helpful
and well-tolerated. Tr. at 383. Plaintiff reported he was no
better than his prior visit. Id.
January 24, 2017, Plaintiff told Sojka he continued to
struggle with multiple stressors and a lack of resources. Tr.
at 366. He felt discouraged about his future and ...