Disability benefits ordered to severely depressed woman

Where an administrative law judge, or ALJ, improperly accorded “little weight” to the testimony of the applicant’s long-time treating psychiatrist, failed to specify which specific objective evidence supported his conclusion that she was not disabled, inappropriately afforded more weight to her non-examining physicians’ opinion than to her treating physician’s opinion, and inadequately grappled with the unique nature of her mental health impairments, particularly chronic depression, his decision was reversed and the case was remanded with instructions to grant disability benefits.

Background

Shelley C. appeals the district court’s order affirming the Social Security Administration’s denial of her application for Social Security Disability Insurance, or SSDI. In her application, she alleged, among other things, major depressive disorder, anxiety disorder and attention deficit disorder, or ADHD. Following a formal hearing, the administrative law judge, or ALJ, determined that Shelley C. suffered from severe depression with suicidal ideations, anxiety features and ADHD, but he nonetheless denied her claim based on his finding that she could perform other simple, routine jobs and was, therefore, not disabled.

Shelley C. contends that the ALJ erred by (1) according only little weight to the opinion of her long-time treating psychiatrist, Dr. Mark Beale and (2) disregarding her subjective complaints based on their alleged inconsistency with the objective medical evidence in the record. The district court affirmed the ALJ’s denial of SSDI benefits.

Dr. Beale

The ALJ extended “little weight” to Dr. Beale’s opinion after concluding that it “is on an issue reserved for the Commissioner and … is inconsistent with the medical evidence of record. [His] treatment notes do not indicate any significant symptoms that would render [Shelley C.] unable to perform basic work activities.” The ALJ’s reasoning suffers two problems.

First, it failed to identify which medical evidence in Shelley C.’s extensive record presented inconsistencies with Dr. Beale’s opinion. Second, in deciding not to give great or controlling weight to Dr. Beale’s opinion, the ALJ is required to address each of the six regulatory factors to determine the appropriate weight it should be afforded. Here, the length, frequency and nature of Shelley C.’s relationship with Dr. Beale were important factors that the ALJ did not properly consider nor acknowledge. Due to this, the ALJ’s decision to allot “little weight” to Dr. Beale’s opinion was erroneous.

This court has held that where an ALJ fails to specify which specific objective evidence supports his conclusion, that “analysis is incomplete and precludes meaningful review.” Because the ALJ failed to point to specific objective evidence showing that Dr. Beale’s opinion was “inconsistent” with the record’s other medical evidence, his analysis, or lack thereof, has “frustrate[d]” this reviewing court’s “meaningful review.”

In addition, the ALJ inappropriately afforded more weight to Shelley C.’s non-examining physicians’ opinion than to her treating physician’s. There is a significant difference between a direct and physical examination, which in this case has spanned over years, of a claimant’s mental health impairments, and an examination of a written record. Thus, the ALJ erred by failing to consider the important distinctions between these treating and non-treating relationships and extending more weight to the non-examining physicians’ opinions than to Dr. Beale’s.

Subjective complaints

The ALJ stated that Shelley C.’s “statements concerning the intensity, persistence and limiting effects of these symptoms are not entirely consistent with the medical evidence and other evidence in the record … they are inconsistent with the medical evidence of record, which reflects a routine and conservative treatment history, and generally benign mental status examinations.”

Shelley C. contends that the ALJ’s decision was erroneous because it was unsupported by the record’s substantial evidence. Specifically, she asserts that her level of treatment could not fairly be characterized as “routine and conservative” and her mental status examinations illustrate repeated depressive, harmful and suicidal thoughts, which are not “benign” in nature. The court agrees with Shelley C.

The ALJ inadequately grappled with the unique nature of Shelley C.’s mental health impairments, particularly chronic depression. If analyzed correctly, Shelley C.’s depression demonstrated both marked and extreme limitations that would instantly qualify her as disabled. As such, substantial evidence does not support the ALJ’s decision that Shelley C. was not disabled. The commissioner’s decision is reversed and this case is remanded with instructions to grant disability benefits.

Reversed and remanded with instructions.

Shelley C. v. Commissioner of Social Security Administration, Case No. 21-2042, Feb. 22, 2023. 4th Cir. (Gregory), from DSC at Florence (Wooten). Robertson H. Wendt Jr. for Appellant. Maija DiDomenico for Appellee. VLW 023-2-057. 48 pp.