Melvin v. Social Security Administration, Commissioner

Filing 14

MEMORANDUM OF OPINION. Signed by Judge L Scott Coogler on 9/19/2018. (PSM)

FILED
2018 Sep-19 PM 03:08
U.S. DISTRICT COURT
N.D. OF ALABAMA

IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
MIDDLE DIVISION
TAMMY G. MELVIN,
Plaintiff,
vs.
NANCY BERRYHILL,
Acting Commissioner of
Social Security,
Defendant.

)
)
)
)
)
)
)
)
)
)
)

4:17-cv-00852-LSC

MEMORANDUM OF OPINION
I.

Introduction
The plaintiff, Tammy G. Melvin, appeals from the decision of the

Commissioner of the Social Security Administration (“Commissioner”) denying
her applications for a period of disability, Disability Insurance Benefits (“DIB”)
and Supplemental Security Income (“SSI”). Ms. Melvin timely pursued and
exhausted her administrative remedies and the decision of the Commissioner is
ripe for review pursuant to 42 U.S.C. §§ 405(g), 1383(c)(3).
Ms. Melvin was fifty-four years old at the time of the Administrative Law
Judge’s (“ALJ’s”) decision, and she has a high school education. (Tr. at 685.) Her
past work experiences include employment as a loan department supervisor, loan
1

department processor, loan clerk, receptionist, data entry clerk, reservation clerk,
and payroll clerk. (Tr. at 248-58.) Ms. Melvin claims that she became disabled on
October 18, 2013, due to attention deficit disorder, major depressive disorder,
anxiety/panic disorder, headaches, obesity and degenerative disc disease of the
lumbar spine. (Id.)
The Social Security Administration has established a five-step sequential
evaluation process for determining whether an individual is disabled and thus
eligible for DIB or SSI. See 20 C.F.R. §§ 404.1520, 416.920; see also Doughty v.
Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001). The evaluator will follow the steps in
order until making a finding of either disabled or not disabled; if no finding is made,
the analysis will proceed to the next step. See 20 C.F.R. §§ 404.1520(a)(4),
416.920(a)(4). The first step requires the evaluator to determine whether the
plaintiff is engaged in substantial gainful activity (“SGA”).

See id. §§

404.1520(a)(4)(i), 416.920(a)(4)(i). If the plaintiff is not engaged in SGA, the
evaluator moves on to the next step.
The second step requires the evaluator to consider the combined severity of
the plaintiff’s medically determinable physical and mental impairments. See id. §§
404.1520(a)(4)(ii), 416.920(a)(4)(ii). An individual impairment or combination of
impairments that is not classified as “severe” and does not satisfy the durational

2

requirements set forth in 20 C.F.R. §§ 404.1509 and 416.909 will result in a finding
of not disabled. See 20 C.F.R. §§ 404.1520(a)(4)(ii), 416.920(a)(4)(ii).

The

decision depends on the medical evidence contained in the record. See Hart v.
Finch, 440 F.2d 1340, 1341 (5th Cir. 1971) (concluding that “substantial medical
evidence in the record” adequately supported the finding that plaintiff was not
disabled).
Similarly, the third step requires the evaluator to consider whether the
plaintiff’s impairment or combination of impairments meets or is medically equal
to the criteria of an impairment listed in 20 C.F.R. Part 404, Subpart P, Appendix
1. See 20 C.F.R. §§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii). If the criteria of a listed
impairment and the durational requirements set forth in 20 C.F.R. §§ 404.1509
and 416.909 are satisfied, the evaluator will make a finding of disabled. 20 C.F.R.
§§ 404.1520(a)(4)(iii), 416.920(a)(4)(iii).
If the plaintiff’s impairment or combination of impairments does not meet or
medically equal a listed impairment, the evaluator must determine the plaintiff’s
residual functional capacity (“RFC”) before proceeding to the fourth step. See id.
§§ 404.1520(e), 416.920(e). The fourth step requires the evaluator to determine
whether the plaintiff has the RFC to perform the requirements of his past relevant
work.

See id. §§ 404.1520(a)(4)(iv), 416.920(a)(4)(iv).

3

If the plaintiff’s

impairment or combination of impairments does not prevent him from performing
his past relevant work, the evaluator will make a finding of not disabled. See id.
The fifth and final step requires the evaluator to consider the plaintiff’s
RFC, age, education, and work experience in order to determine whether the
plaintiff can make an adjustment to other work. See id. §§ 404.1520(a)(4)(v),
416.920(a)(4)(v). If the plaintiff can perform other work, the evaluator will find
him not disabled. Id.; see also 20 C.F.R. §§ 404.1520(g), 416.920(g). If the plaintiff
cannot perform other work, the evaluator will find him disabled. 20 C.F.R. §§
404.1520(a)(4)(v), 404.1520(g), 416.920(a)(4)(v), 416.920(g).
Applying the sequential evaluation process, the ALJ found that Ms. Melvin
was insured through the date of his decision. (Tr. at 22.) He further determined
that Ms. Melvin has not engaged in SGA since the alleged onset of her disability.
(Id.) According to the ALJ, Plaintiff’s attention deficit disorder, major depressive
disorder, anxiety/panic disorder, headaches, obesity, and degenerative disc disease
of the lumbar spine are considered severe based on the requirements set forth in
the regulations. (Id.) However, he found that these impairments neither meet nor
medically equal any of the listed impairments in 20 C.F.R. Part 404, Subpart P,
Appendix 1. (Tr. at 23.) With regard to Plaintiff’s RFC, the ALJ determined that
she can perform light work as is defined in the regulations with the following

4

additional restrictions: she can frequently use bilateral foot controls, frequently
reach overhead with her right dominant hand, and frequently climb ramps and
stairs but never climb ladders or scaffolds; Plaintiff can frequently stoop and
crouch, should never be exposed to unprotected heights, dangerous machinery,
dangerous tools, hazardous processes, or operate commercial motor vehicles;
Plaintiff is limited to remembering short simple instructions and precluded from
dealing with detailed or complex instructions; Plaintiff can do simple routine
repetitive tasks but is unable to do detailed or complex tasks and would be limited
to making simple work-related decisions; Plaintiff should have no more than
occasional interaction with the general public, but could have frequent interaction
with co-workers and supervisors; Plaintiff could accept constructive nonconfrontational criticism, work in small group settings, and accept changes in the
work place setting if introduced gradually and infrequently; Plaintiff would be
unable to perform assembly line work with production rate pace but could perform
other goal-oriented work; and in addition to normal workday breaks, Plaintiff would
be off-task approximately five percent of an eight-hour workday in non-consecutive
minutes. (Tr. at 24).
According to the ALJ, Ms. Melvin is unable to perform any of her past
relevant work, she is an “individual closely approaching advanced age,” and she

5

has a high school education, as those terms are defined by the regulations. (Tr. at
33.) Because Plaintiff cannot perform the full range of light work, the ALJ enlisted a
vocational expert (“VE”) and used the Medical-Vocational Rules as a guideline for
determining that there are a significant number of jobs in the national economy that
she is capability of performing, such as marker, cleaner or housekeeper, and
garment sorter. (Tr. at 34.)
The ALJ concluded his findings by stating that Plaintiff “was not under a
‘disability,’ as defined in the Social Security Act, at any time through the date of
this decision.” (Id.)
II.

Standard of Review
This Court’s role in reviewing claims brought under the Social Security Act

is a narrow one. The scope of its review is limited to determining (1) whether there
is substantial evidence in the record as a whole to support the findings of the
Commissioner, and (2) whether the correct legal standards were applied. See Stone
v. Comm’r of Soc. Sec., 544 F. App’x 839, 841 (11th Cir. 2013) (citing Crawford v.
Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th Cir. 2004)). This Court gives
deference to the factual findings of the Commissioner, provided those findings are
supported by substantial evidence, but applies close scrutiny to the legal
conclusions. See Miles v. Chater, 84 F.3d 1397, 1400 (11th Cir. 1996).

6

Nonetheless, this Court may not decide facts, weigh evidence, or substitute
its judgment for that of the Commissioner. Dyer v. Barnhart, 395 F.3d 1206, 1210
(11th Cir. 2005) (quoting Phillips v. Barnhart, 357 F.3d 1232, 1240 n.8 (11th Cir.
2004)). “The substantial evidence standard permits administrative decision
makers to act with considerable latitude, and ‘the possibility of drawing two
inconsistent conclusions from the evidence does not prevent an administrative
agency’s finding from being supported by substantial evidence.’” Parker v. Bowen,
793 F.2d 1177, 1181 (11th Cir. 1986) (Gibson, J., dissenting) (quoting Consolo v. Fed.
Mar. Comm’n, 383 U.S. 607, 620 (1966)). Indeed, even if this Court finds that the
proof preponderates against the Commissioner’s decision, it must affirm if the
decision is supported by substantial evidence. Miles, 84 F.3d at 1400 (citing Martin
v. Sullivan, 894 F.2d 1520, 1529 (11th Cir. 1990)).
However, no decision is automatic, for “despite th[e] deferential standard
[for review of claims], it is imperative that th[is] Court scrutinize the record in its
entirety to determine the reasonableness of the decision reached.” Bridges v.
Bowen, 815 F.2d 622, 624 (11th Cir. 1987) (citing Arnold v. Heckler, 732 F.2d 881,
883 (11th Cir. 1984)). Moreover, failure to apply the correct legal standards is
grounds for reversal. See Bowen v. Heckler, 748 F.2d 629, 635 (11th Cir. 1984).
III.

Discussion

7

Ms. Melvin alleges that the ALJ’s decision should be reversed and remanded
because the ALJ’s credibility determination was allegedly flawed and because he
erred in giving little weight to the opinion of her treating psychiatrist.
A.

Credibility Determination

Plaintiff generally alleged crippling fatigue, malaise, drastic mood shifts, and
memory problems. (Tr. at 71-73.) More specifically, she testified that she goes out
about once a week. (Tr. at 52). She reported she goes out as late as midnight to get
groceries so she will not run into anybody. (Tr. at 53). Plaintiff explained that she
went on several interviews in 2013 and the first part of 2014 but she cried in every
one of them. (Tr. at 54). She reported that since her electroconvulsive therapy, she
has a really hard time grasping words and terms. (Tr. at 54). Plaintiff testified she
spends a lot of her time sleeping. (Tr. at 71). According to Plaintiff, she has
problems communicating and coming up with words. (Tr. at 72). She explained
that she has a horrible time with maintaining focus and concentration. (Tr. at 73).
Plaintiff testified that she has approximately four bad days out of a week where she
is unable to carry out her daily activities. (Tr. at 78.)
When a claimant attempts to prove disability based on her subjective
complaints, she must provide evidence of an underlying medical condition and
either objective medical evidence confirming the severity of her alleged symptoms

8

or evidence establishing that her medical condition could be reasonably expected to
give rise to her alleged symptoms. See 20 C.F.R. § 416.929(a), (b); SSR 96-7p;1
Wilson v. Barnhart, 284 F.3d 1219, at 1225–26 (11th Cir. 2002). If the objective
medical evidence does not confirm the severity of the claimant’s alleged symptoms
but the claimant establishes that she has an impairment that could reasonably be
expected to produce her alleged symptoms, the ALJ must evaluate the intensity
and persistence of the claimant’s alleged symptoms and their effect on her ability to
work. See 20 C.F.R. § 416.929(c), (d); SSR 96-7p; Wilson, 284 F.3d at 1225-26.
This entails the ALJ determining a claimant’s credibility with regard to the
allegations of pain and other symptoms. See id.
The ALJ must “[explicitly articulate] the reasons justifying a decision to
discredit a claimant’s subjective pain testimony.” Moore v. Barnhart, 405 F.3d
1208, 1212 n.4 (11th Cir. 2005). When the reasoning for discrediting is explicit and
supported by substantial evidence, “the record will not be disturbed by a reviewing
court.” Foote v. Chater, 67 F.3d 1553, 1562 (11th Cir. 1995).

Effective March 28, 2016, the Commissioner replaced SSR 96-7p with SSR 16-3p. The
Commissioner explained that the new ruling “eliminat[ed] the use of the term ‘credibility’ from
[the Social Security Administration’s] sub-regulatory policy, as our regulations do not use this
term. In doing so, we clarify that subjective symptom evaluation is not an examination of an
individual’s character. Instead, we will more closely follow our regulatory language regarding
symptom evaluation.” SSR 16-3p at *1-2. Neither party has asserted that SSR 16-3p applies
retroactively to Plaintiff’s claim in this case, which was decided before March 28, 2016.
1

9

In making the credibility evaluation, the Commissioner considers objective
medical evidence and information from the Plaintiff and treating or examining
physicians, as well as other factors such as evidence of daily activities, the
frequency and intensity of pain, any precipitating or aggravating factors, medication
taken and any resulting side effects, and any other measures taken to alleviate the
pain. See 20 C.F.R. §§ 404.1529, 416.929. A credibility determination is a question
of fact: like all factual findings by the Commissioner, it is subject only to limited
review in the courts to ensure the finding is supported by substantial evidence. See
Hand v. Heckler, 761 F.2d 1545, 1548-49 (11th Cir. 1985), vacated for rehearing en
banc, 774 F.2d 428 (11th Cir. 1985), reinstated sub nom. Hand v. Bowen, 793 F.2d 275
(11th Cir. 1986).
In this case, the ALJ properly followed the two-step process in assessing
Plaintiff’s alleged symptoms and ultimately found that her complaints of disabling
pain were not entirely credible. (Tr. at 31.) The ALJ articulated several reasons for
discounting Plaintiff’s credibility despite her mental limitations. First, while the
ALJ acknowledged that she has been treated for attention deficit disorder, major
depressive disorder, and anxiety disorder, he correctly noted that her treatment
notes do not show such severe symptoms or limitations as she alleged. (Tr. at 36).
Overall, her treating psychiatrist Dr. Simon McClure’s treatment notes reflect

10

Plaintiff had only mild to moderate mental limitations. Dr. McClure reported on
many occasions that Plaintiff was neat, cooperative, had a euthymic mood, normal
affect, her sensorium was intact, her judgment/insight were good, her thinking was
goal directed, and she denied suicidal ideation, homicidal ideation, hallucinations,
and delusions. (Tr. at 513-15, 552, 556-57, 598, 600, 671, 672, 706). When Plaintiff
reported increased symptoms, Dr. McClure adjusted her medications and noted
subsequent improvement. (Tr. at 552-55, 597-98, 599).
Additionally, despite Plaintiff’s allegations of sleeping for multiple days and
memory loss, the ALJ noted that she only rarely complained of such issues to her
treating physicians. Neither Dr. McClure, her treating psychiatrist, nor Dr. Toner,
another treating physician, ever categorized her reported fatigue or memory
problems as very serious or disabling. (Tr. at 522, 599, 670, 705). Additionally, Dr.
Waltz, a consulting psychological examiner, reported in October 2015 that Plaintiff
had no limitations in her ability to understand, remember, and carry out simple
instructions. (Tr. at 688). On testing, Dr. Waltz reported Plaintiff’s concentration,
attention, and memory were adequate. (Tr. at 685).
The ALJ also reviewed the medical documentation related to Plaintiff’s
hospitalization in March 2015 for “depression with plan to commit suicide.” (Tr.
at 603). During her admission, her medications were adjusted, and she received

11

electroconvulsive therapy. (Id.) Although Plaintiff alleged that the therapy did not
work, the hospital discharge report contradicts her assertion. Specifically, Plaintiff
had no side effects from the therapy, received significant improvements, and was
stable at discharge. (Id.) Plaintiff reported that subsequent outpatient
electroconvulsive therapy treatments were also helpful. (Tr. at 670).
The ALJ also took note of Dr. Waltz’s findings on examination in October
2015. She reported Plaintiff had only mild restrictions on her ability to make
judgments on simple work-related decisions and only mild to moderate limitations
in her ability to understand, to carry out and to remember instructions and to
respond appropriately to supervision, co-workers, and work pressures in a work
setting, and would benefit from vocational, employability, and/or social skills
training (Tr. 686-87, 688-89).
The medical record reveals that Plaintiff’s symptoms worsened when she
was less than fully compliant with her medications and treatments. (Tr. at 670,
702). The regulations provide that a claimant may be denied benefits for failing to
follow prescribed treatment without good reason. 20 C.F.R. §§ 404.1530, 416.930;
see Crawford, 363 F.3d at 1159. In contrast, when Plaintiff did take her medications
as prescribed, she consistently reported to Dr. McClure that her symptoms were
stable. (Tr. at 600, 671, 672, 684, 706). See 20 C.F.R. §§ 404. 1529, 416.929

12

(Commissioner considers the effectiveness of any medications claimant has taken
to alleviate pain).
Finally, the ALJ also took note of Plaintiff’s self-reported daily activities in
assessing her overall credibility. Plaintiff reported that she lives alone, balances her
limited resources, does chores, crafts, and drives. (Tr. at 51, 66-67, 71, 238, 686).
Although not dispositive, a claimant’s daily activities may show that the claimant’s
symptoms are not as limiting as alleged. See 20 C.F.R. §§ 404.1529(c)(3)(i),
416.929(c)(3)(i); Dyer, 395 F.3d at 1212. In evaluating a claimant’s testimony, the
Eleventh Circuit has held the ALJ should also consider the claimant’s daily
activities, among other things. See e.g., Brown v. Comm’r of Soc. Sec., 442 F. App’x
507, 513 (11th Cir. 2011).
In sum, there was substantial evidence in the record to support the ALJ’s
credibility determination, and reversal on this ground is not warranted.
B.

Weight Given to Treating Psychiatrist’s Opinion

The record contains two opinions from Dr. McClure, Plaintiff’s treating
psychiatrist. (Tr. at 547-50, 693). Dr. McClure completed a Mental Residual
Functional Capacity Assessment (“RFC”) on July 15, 2014, wherein he addressed
how Plaintiff’s mental impairments affected her ability to perform certain job
functions. (Tr. at 547-50). Dr. McClure noted he has been treating Plaintiff since

13

June 22, 2011, for major depressive disorder and attention deficit disorder. (Tr. at
547). He opined that Plaintiff had extreme limitations in her ability to maintain
attention and concentration for extended periods; in her ability to complete a
normal workday and workweek without interruptions from psychologically based
symptoms and to perform at a consistent pace without an unreasonable number and
length of rest periods; and in her ability to tolerate normal levels of stress. (Tr. at
548-50). He opined that Plaintiff had marked limitations in the following areas: in
her ability to perform activities within a schedule, maintain regular attendance, and
be punctual within customary tolerances; in her ability to sustain an ordinary
routine without special supervision and in her ability to respond appropriately to
changes in the work setting. (Tr. at 548-49). He opined that Plaintiff’s impairments
would substantially interfere with her ability to work a regular and sustained basis
at least 20% of the time and she would miss approximately seven days of work per
month due to her mental impairments. (Tr. at 550). He further opined that Plaintiff
could not work on a regular and sustained basis due to being anxious and having
poor concentration. (Id.)
Dr. McClure also submitted a one-page “To Whom It May Concern” letter
on December 2, 2015, stating that Plaintiff

14

is currently stable on medications which have also included
electroconvulsive therapy treatments. Ms. Melvin has displayed
symptoms of suicidal ideations, paranoia, decreased sleep, anxiety,
worsening depression, decreased appetite, memory loss, poor
concentration and even anhedonia at times. Due to the severity of
symptoms and her persisting condition it is likely that she would miss
three or more shifts of work in a calendar month. Ms. Melvin is unable
to search out or maintain competitive employment. She has reached
maximum benefits of treatment and due to her symptoms will not be
able to maintain employment.
(Tr. at 693.)
The ALJ must articulate the weight given to different medical opinions in the
record and the reasons therefore. See Winschel v. Comm’r of Soc. Sec., 631 F.3d 1176,
1179 (11th Cir. 2011). The weight afforded to a medical opinion regarding the
nature and severity of a claimant’s impairments depends, among other things, upon
the examining and treating relationship the medical source had with the claimant,
the evidence the medical source presents to support the opinion, how consistent
the opinion is with the record as a whole, and the specialty of the medical source.
See 20 C.F.R. §§ 404.1527(d), 416.927(d).
Within the classification of acceptable medical sources are the following
different types of sources that are entitled to different weights of opinion: 1) a
treating source, or a primary physician, which is defined in the regulations as “your
physician, psychologist, or other acceptable medical source who provides you, or

15

has provided you, with medical treatment or evaluation and who has, or has had, an
ongoing treatment relationship with you;” 2) a non-treating source, or a consulting
physician, which is defined as “a physician, psychologist, or other acceptable
medical source who has examined you but does not have, or did not have, an
ongoing treatment relationship with you;” and 3) a non-examining source, which is
a “a physician, psychologist, or other acceptable medical source who has not
examined you but provides a medical or other opinion in your case . . . includ[ing]
State agency medical and psychological consultants . . . .” 20 C.F.R. § 404.1502.
The regulations and case law set forth a general preference for treating
medical sources’ opinions over those of non-treating medical sources, and nontreating medical sources over non-examining medical sources. See 20 C.F.R. §
404.1527(d)(2); Ryan v. Heckler, 762 F.2d 939, 942 (11th Cir. 1985). Thus, a
treating physician’s opinion is entitled to “substantial or considerable weight
unless ‘good cause’ is shown to the contrary.” Crawford, 363 F.3d at 1159 (quoting
Lewis v. Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997)) (internal quotations
omitted). “Good cause” exists for an ALJ to not give a treating physician’s opinion
substantial weight when the: “(1) treating physician’s opinion was not bolstered by
the evidence; (2) evidence supported a contrary finding; or (3) treating physician’s
opinion was conclusory or inconsistent with the doctor’s own medical records.”

16

Phillips, 357 F.3d at 1241 (11th Cir. 2004) (citing Lewis, 125 F.3d at 1440); see also
Edwards v. Sullivan, 937 F.2d 580, 583-84 (11th Cir. 1991) (holding that “good
cause” existed where the opinion was contradicted by other notations in the
physician’s own record). On the other hand, the opinions of a one-time examiner or
of a non-examining medical source are not entitled to the initial deference afforded
to a physician who has an ongoing treating relationship with a plaintiff. McSwain v.
Bowen, 814 F.2d 617, 619 (11th Cir. 1987). However, an ALJ “may reject the
opinion of any physician when the evidence supports a contrary conclusion.”
McCloud v. Barnhart, 166 F. App’x 410, 418–19 (11th Cir. 2006) (citing Bloodsworth
v. Heckler, 703 F.2d 1233, 1240 (11th Cir. 1983)).
The Court must also be aware of the fact that opinions such as whether a
claimant is disabled, the claimant’s residual functional capacity, and the application
of vocational factors “are not medical opinions, . . . but are, instead, opinions on
issues reserved to the Commissioner because they are administrative findings that
are dispositive of a case; i.e., that would direct the determination or decision of
disability.” 20 C.F.R. §§ 404.1527(e), 416.927(d). The Court is interested in the
doctors’ evaluations of the claimant’s “condition and the medical consequences
thereof, not their opinions of the legal consequences of his [or her] condition.”
Lewis, 125 F.3d at 1440. Such statements by a physician are relevant to the ALJ’s

17

findings, but they are not determinative, as it is the ALJ who bears the
responsibility for assessing a claimant’s RFC. See, e.g., 20 C.F.R. § 404.1546(c).
The ALJ gave little weight to Dr. McClure’s July 2014 mental RFC
assessment, noting that it was not consistent with his own treatment notes, which
indicated that Plaintiff’s abilities were “substantially greater,” and some weight to
his December 2015 letter because his statements were “somewhat consistent with
the medical evidence of record, though again, appear to overestimate her
limitations.” (Tr. at 33.)
Substantial evidence supports the ALJ’s decision here. As an initial matter,
the check box form completed by Dr. McClure and his December 2015 letter
provide little to no narrative or insight into the bases for the conclusions recorded.
This form and letter, therefore, have little probative value. See Spencer o/b/o Spencer
v. Heckler, 765 F.2d 1090, 1094 (11th Cir. 1985) (rejecting an opinion from a
physician who merely checked boxes on a form without providing any explanation
of his conclusions).
More importantly, however, as the ALJ noted, Dr. McClure’s treatment
notes reflect Plaintiff has only mild to moderate limitations, which contradicts his
RFC assessment of extreme and marked limitations. (Tr. at 33, 513-15, 552, 556-57,
598, 600, 671, 672, 706). For example, Dr. McClure’s treatment notes show that on

18

the same day he completed the RFC assessment form, in July 2014, Plaintiff
reported to him that her sleep was good, her appetite was good, she had no
hallucinations, she had no side effects from her medications, she was compliant
with treatment, and she was feeling better with her new medications. (Tr. at 554.)
On August 15, 2014, she reported that she was sleeping well with a good appetite,
she was feeling better, she was not having hallucinations, and she was noted as
neat, cooperative, and euthymic with normal affect. (Tr. at 553). By September
2014, Plaintiff denied psychosis, had lost some weight, looked and sounded better,
and was neat and cooperative. (Tr. at 552.) Although in December 2014 Plaintiff
was teary and alleged poor concentration and focus with decreased energy, she
denied suicidal ideations. (Tr. at 599.) By February 2015 she reported sleeping and
eating well, but had a flat affect and was teary. (Tr. at 597.) However, she was also
goal directed, cooperative, and casual in dress, and had no suicidal ideations or
hallucinations. (Id.) By April 2015 she had an “okay” mood and reported that she
was applying for disability but was trying to get a part time job. (Tr. at 598.) In June
2015, Dr. McClure reported that she was “doing very well,” was calm, neat,
cooperative, and had a normal mood and affect, and he continued to diagnose her
with attention deficit disorder and major depression. (Tr. at 671.) In September of
that year she reported that she was trying to get a disability hearing and that she

19

was “not doing very well,” but had been doing better for awhile due to the
electroconvulsive therapy treatments. (Tr. at 670.) By December 2015 she reported
to Dr. McClure that she was worried about her disability hearing and that she was
positive for suicidal but that her parents and her children were a deterrent. (Tr. at
700-06.)
Other evidence of record undercuts Dr. McClure’s dire conclusions as well.
For example, as noted, on October 27, 2014, Plaintiff underwent a psychological
evaluation conducted by Dr. Waltz. (Tr. at 684-90.) Plaintiff reported being
depressed, but her attention and concentration were adequate. (Id.) She reported
memory problems but had no problem describing that day’s and the previous day’s
events and recalling major life events. (Id.) She obtained a Global Assessment of
Functioning “GAF” score of 62, which indicates mild symptoms, such as
depressed mood and mild insomnia. (Id.) See Am. Psychiatric Ass’n, Diagnostic &
Statistical Manual of Mental Disorders, 32-34 (4th ed. Text Revision 2000)
(“DSM”). Dr. Waltz reported Plaintiff had only mild restrictions on her ability to
make judgments on simple work-related decisions and only mild to moderate
limitations in her ability to understand, to carry out and to remember instructions
and to respond appropriately to supervision, co-workers and work pressures in a
work setting and would benefit from vocational, employability and/or social skills

20

training. (Tr. at 686-87, 688-89). The ALJ gave Dr. Waltz’s opinion substantial
weight because it was consistent with the other medical evidence of record.
In sum, the ALJ had good cause to give little weight to Dr. McClure’s mental
RFC assessment and letter because they were inconsistent with his own treatment
notes and conflicted with the other medical evidence of record.
IV.

Conclusion
Upon review of the administrative record, and considering all of Ms.

Melvin’s arguments, the Court finds the Commissioner’s decision is supported by
substantial evidence and in accord with the applicable law. A separate order will be
entered.
DONE and ORDERED on September 19, 2018.

_____________________________
L. Scott Coogler
United States District Judge
160704

21