Coffee v. Social Security Administration, Commissioner
Filing
15
MEMORANDUM OPINION - The Court remands this matter for further administrative proceedings consistent with this opinion. Signed by Judge Madeline Hughes Haikala on 3/4/2020. (KEK)
FILED
2020 Mar-04 AM 11:07
U.S. DISTRICT COURT
N.D. OF ALABAMA
UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
MIDDLE DIVISION
CONNIE JEAN COFFEE,
}
}
Plaintiff,
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}
v.
}
}
ANDREW SAUL, Commissioner of }
the Social Security Administration,1 }
}
Defendant.
}
Case No.: 4:18-cv-00028-MHH
MEMORANDUM OPINION
Pursuant to 42 U.S.C. § 1383(c), plaintiff Connie Jean Coffee seeks judicial
review of a final adverse decision of the Commissioner of Social Security. The
Commissioner denied Ms. Coffee’s claim for supplemental security income. For the
reasons stated below, the Court remands the Commissioner’s decision for additional
proceedings.
1
The Court asks the Clerk to please substitute Andrew Saul for Nancy A. Berryhill as the defendant
pursuant to Rule 25(d) of the Federal Rules of Civil Procedure. See Fed. R. Civ. P. 25(d) (When
a public officer ceases holding office, that “officer’s successor is automatically substituted as a
party.”); see also 42 U.S.C. § 405(g) (“Any action instituted in accordance with this subsection
shall survive notwithstanding any change in the person occupying the office of Commissioner of
Social Security or any vacancy in such office.”).
I.
PROCEDURAL HISTORY
Ms. Coffee applied for supplemental security income. (Doc. 8-4, p. 2). She
alleges that her disability began on May 17, 2014.
(Doc. 8-4, p. 2). The
Commissioner initially denied Ms. Coffee’s claim. (Doc. 8-4, p. 2). Ms. Coffee
requested a hearing before an Administrative Law Judge (ALJ). (Doc. 8-5, p. 10).
The ALJ issued an unfavorable decision. (Doc. 8-3, pp. 14-27). The Appeals
Council declined Ms. Coffee’s request for review, making the Commissioner’s
decision final for this Court’s judicial review. (Doc. 8-3, p. 2). See 42 U.S.C. §
1383(c).
II.
STANDARD OF REVIEW
The scope of review in this matter is limited. “When, as in this case, the ALJ
denies benefits and the Appeals Council denies review,” a district court “review[s]
the ALJ’s ‘factual findings with deference’ and [his] ‘legal conclusions with close
scrutiny.’” Riggs v. Comm’r of Soc. Sec., 522 Fed. Appx. 509, 510-11 (11th Cir.
2013) (quoting Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001)).
The Court must determine whether there is substantial evidence in the record
to support the ALJ’s factual findings. “Substantial evidence is more than a scintilla
and is such relevant evidence as a reasonable person would accept as adequate to
support a conclusion.” Crawford v. Comm’r of Soc. Sec., 363 F.3d 1155, 1158 (11th
Cir. 2004). In evaluating the administrative record, a district court may not “decide
2
the facts anew, reweigh the evidence,” or substitute its judgment for that of the ALJ.
Winschel v. Comm’r of Soc. Sec. Admin., 631 F.3d 1176, 1178 (11th Cir. 2011)
(internal quotations and citation omitted). If substantial evidence supports the ALJ’s
factual findings, then this Court “must affirm even if the evidence preponderates
against the Commissioner’s findings.” Costigan v. Comm’r, Soc. Sec. Admin., 603
Fed. Appx. 783, 786 (11th Cir. 2015) (citing Crawford, 363 F.3d at 1158).
With respect to the ALJ’s legal conclusions, the Court must determine
whether the ALJ applied the correct legal standards. If the Court finds an error in
the ALJ’s application of the law, or if the Court finds that the ALJ failed to provide
sufficient reasoning to demonstrate that the ALJ conducted a proper legal analysis,
then the Court must reverse the ALJ’s decision. Cornelius v. Sullivan, 936 F.2d
1143, 1145-46 (11th Cir. 1991).
III.
SUMMARY OF THE ALJ’S DECISION
To determine whether a claimant has proven that she is disabled, an ALJ
follows a five-step sequential evaluation process. The ALJ considers:
(1) whether the claimant is currently engaged in substantial gainful
activity; (2) whether the claimant has a severe impairment or
combination of impairments; (3) whether the impairment meets or
equals the severity of the specified impairments in the Listing of
Impairments; (4) based on a residual functional capacity (“RFC”)
assessment, whether the claimant can perform any of his or her past
relevant work despite the impairment; and (5) whether there are
significant numbers of jobs in the national economy that the claimant
can perform given the claimant’s RFC, age, education, and work
experience.
3
Winschel, 631 F.3d at 1178.
The ALJ determined that Ms. Coffee had not engaged in substantial gainful
activity since her application date of October 2, 2014. (Doc. 8-3, p. 16).2 The ALJ
determined that Ms. Coffee suffers from the following severe impairments: bipolar
I disorder, ADHD combined type, crystal meth induced disorder, polysubstance
abuse in remission, degenerative disc disease of the cervical and lumbar spine, and
panic disorder in partial remission. (Doc. 8-3, p. 16). The ALJ did not identify nonsevere impairments. (Doc. 8-3, p. 16). Based on a review of the medical evidence,
the ALJ concluded that Ms. Coffee does not have an impairment or a combination
of impairments that meets or medically equals the severity of the listed impairments
in 20 C.F.R. Part 404, Subpart P, Appendix 1. (Doc. 8-4, pp. 16-19).
Given Ms. Coffee’s severe impairments, the ALJ evaluated Ms. Coffee’s
residual functional capacity. The ALJ determined that Ms. Coffee has the RFC to
perform light work with restrictions. (Doc. 8-3, p. 19).
Light work involves lifting no more than 20 pounds at a time with
frequent lifting or carrying of objects weighing up to 10 pounds. Even
though the weight lifted may be very little, a job is in this category when
2
Social Security disability insurance benefits are available only to insured claimants. An insured
claimant is one who has “worked long enough and paid Social Security taxes. Unlike [disability
insurance] benefits, [supplemental security income] benefits are not based on . . . prior work or a
family member’s prior work.” https://www.ssa.gov/ssi/text-over-ussi.htm (last visited Jan. 23,
2020). Consequently, when a claimant seeks supplemental security income, but not disability
insurance benefits, a disability onset date is not part of the analysis. Instead, the ALJ must verify
that the claimant has not worked in a gainful capacity since filing the application.
4
it requires a good deal of walking or standing, or when it involves
sitting most of the time with some pushing and pulling of arm or leg
controls. To be considered capable of performing a full or wide range
of light work, [a claimant] must have the ability to do substantially all
of these activities. If someone can do light work, . . . [normally] he or
she can also do sedentary work, unless there are additional limiting
factors such as loss of fine dexterity or inability to sit for long periods
of time.
20 C.F.R. § 416.967(b). In an eight-hour day, the ALJ limited Ms. Coffee to four
hours of standing and walking and six hours of sitting. (Doc. 8-3, p. 19). The ALJ
found that Ms. Coffee can lift five pounds frequently and ten pounds occasionally
with her left extremity; one pound frequently with her right extremity. (Doc. 8-3, p.
19). The ALJ restricted Ms. Coffee to occasional overhead reaching and frequent
forward reaching, handling fingering, and feeling. (Doc. 8-3, p. 19). The ALJ found
that Ms. Coffee could occasionally climb, balance, kneel, crouch, or crawl. (Doc.
8-3, p. 19). The ALJ determined that Ms. Coffee could perform jobs with “no
specific production quota” and “infrequent contact with the general public.” (Doc.
8-3, p. 19).
The ALJ determined that Ms. Coffee lacks past relevant work. (Doc. 8-3, p.
25). Relying on testimony from a vocational expert, the ALJ found that Ms. Coffee
could perform the job of surveillance systems monitor, an unskilled sedentary job
that exists in the national economy. (Doc. 8-3, p. 26). Accordingly, the ALJ denied
Ms. Coffee’s disability claim. (Doc. 8-3, p. 27).
5
IV. ANALYSIS
Ms. Coffee argues that she is entitled to relief from the ALJ’s decision because
the ALJ did not properly evaluate the medical opinion evidence. Ms. Coffee relies
on the opinions of Dr. Feist and Dr. Nichols. (See Doc. 10, pp. 17-27). Dr. Feist
treated Ms. Coffee for more than two years. (Doc. 8-12, p. 3; Doc. 8-21, p. 35). Dr.
Feist prescribed the medicine Ms. Coffee used to treat her bipolar disorder after Ms.
Coffee’s release from the Gadsden Regional Medical Center’s adult psychiatric unit
in April 2014. (Doc. 8-13, p. 31; Doc. 8-12, p. 21). Dr. Nichols, a clinical
psychologist, evaluated Ms. Coffee at the request of the Commissioner. (Doc. 8-12,
pp. 44-48). The ALJ gave little weight to Dr. Feist’s opinion. (Doc. 8-3, p. 24). The
ALJ discussed but did not assign weight to Dr. Nichols’s opinion. (Doc. 8-3, pp.
21-22). In formulating Ms. Coffee’s residual functional capacity, the ALJ gave great
weight to the opinion of Dr. Williams, an agency medical consultant. (Doc. 8-3, p.
25). The ALJ relied on the opinion of Dr. Ernst, a consultative examiner, to support
the physical components of Ms. Coffee’s RFC. (Doc. 8-3, p. 22). To evaluate Ms.
Coffee’s argument concerning the ALJ’s treatment of the evidence, the Court begins
with Ms. Coffee’s medical history and then discusses the medical opinion evidence.
6
Ms. Coffee’s Medical History3
In February 2014, following her release from prison, Ms. Coffee sought
treatment at CED Mental Health Center. (Doc. 8-12, p. 4). 4 Ms. Coffee met with a
CED counselor. (Doc. 8-12, p. 4). Ms. Coffee reported that she had received
treatment for depression and bipolar disorder while in custody. (Doc. 8-12, p. 4).
According to the February 2014 intake record, Ms. Coffee had a one month supply
of medication. (Doc. 8-12, p. 4). Ms. Coffee stated during the intake process that
she was seeking help because “I’m bipolar and need to stay on medications.” (Doc.
8-12, p. 7).
Ms. Coffee answered questions about her mental state during the February
2014 visit. (Doc. 8-12, pp. 9-10). She described periods of “feeling ‘up’ or ‘high’
or ‘hyper’ or so full of energy . . . that [she] got into trouble, or that other people
thought [she] [was] not [her] usual self.” She also reported anxiousness, fear,
3
The Court has considered Ms. Coffee’s medical information that predates May 2014. (See, e.g.,
Doc. 8-9, pp. 3-8) (February 2006 records from Grand View Behavioral Health Center); (Doc. 811, pp 2-78; Doc. 8-10, pp. 2-121) (February 2007 to June 2010 records from Riverview Regional
Medical Center); (8-13, pp. 32-38) (September 2010 records from Quality of Life Health Services,
Inc. and Quest Diagnostics Incorporated); (Doc. 8-13, pp. 42-45) (January 2006 records from
Doctors Med Care of Gadsden, P.C.); (Doc. 8-13, pp. 47-62) (January 2012 to August 2012 records
from CED); (Doc. 8-14, pp. 2-30; Doc. 8-15, pp. 2-28; Doc. 8-16, pp. 2-12; Doc. 8-17, pp. 2-27;
Doc. 8-18, pp. 2-11; Doc. 8-19, pp. 2-18; Doc. 8-20, pp. 2-26) (January 2013 to February 2014
records from Alabama Department of Corrections); (Doc. 8-21, pp. 2-29) (February 2001 to
September 2003 records from CED); (Doc. 8-21, pp. 30-32) (February 2012 to May 2012 records
from CED). Many of these pre-onset documents support Ms. Coffee’s longitudinal history of
mental health symptoms and treatment. For purposes of this opinion, the Court focuses on records
dated shortly before or within the claimed disability period.
4
CED stands for Cherokee Etowah DeKalb. (Doc. 8-12, p. 2).
7
uncomfortableness, or uneasiness that “surge[d] to a peak, within 10 minutes of
starting.” (Doc. 8-12, p. 9). Ms. Coffee reported that in the previous six months,
she had experienced excessive anxiousness or worry “about several routine things.”
(Doc. 8-12, p. 10).
In mid-April 2014, a CED therapist completed a problem assessment form for
Ms. Coffee. (Doc. 8-12, pp. 11-15). According to this record, Ms. Coffee reported
that she was bipolar, and she had spent 17 months in prison after a cocaine-related
arrest. (Doc. 8-12, p. 11). The therapist noted that Ms. Coffee was “restless and
tearful.” (Doc. 8-12, pp. 11, 13). Ms. Coffee shared that she had run away from
family recently and “stay[ed] gone for several days.” (Doc. 8-12, p. 11). Ms. Coffee
stated that she had received inpatient mental health treatment from CED in 2013 and
outpatient treatment from Mountainview but did not recall the dates. (Doc. 8-12, p.
11). Ms. Coffee reported that her most recent job was with a restaurant in 2010.
(Doc. 8-12, p. 13). According to Ms. Coffee, she had last used cocaine in October
2011 and methamphetamine in 2006. (Doc. 8-12, p. 13). Ms. Coffee reported
attempting suicide in 2001 and 2009. (Doc. 8-12, p. 13).
The therapist characterized Ms. Coffee’s symptoms as chronic, (Doc. 8-12, p.
14), and recommended “individual therapy [and] medication management,” (Doc.
8-12, p. 15). The therapist diagnosed Ms. Coffee with bipolar I disorder (depression
as the most recent episode), combined attention deficit hyperactivity disorder,
8
hypoglycemia, and mitrovalve prolapse. (Doc. 8-12, p. 15). 5 The therapist assessed
50 as Ms. Coffee’s GAF score. (Doc. 8-12, p. 15).6 According to the therapist, Ms.
Coffee had occupational, economic, legal, and psychological problems. (Doc. 8-12,
p. 15). Later in April 2014, a CED medical doctor or licensed psychologist—the
signature is illegible—accepted the therapist’s diagnosis of Ms. Coffee. (Doc. 8-12,
p. 15).
5
According to Healthline.com, bipolar disorders
are characterized by episodes of extreme mood. The highs are known as manic
episodes. The lows are known as depressive episodes. The main difference between
bipolar 1 and bipolar 2 disorders lies in the severity of the manic episodes caused
by each type. A person with bipolar 1 will experience a full manic episode, while a
person with bipolar 2 will experience only a hypomanic episode (a period that’s
less severe than a full manic episode). A person with bipolar 1 may or may not
experience a major depressive episode, while a person with bipolar 2 will
experience a major depressive episode.
https://www.healthline.com/health/bipolar-disorder/bipolar-1-vs-bipolar-2 (last visited Feb. 19,
2020).
“Combined type ADHD is where both inattention and hyperactivity/impulsivity are present.”
https://www.verywellmind.com/what-is-adhd-combined-type-4135385 (last visited Jan. 28,
2020).
6
GAF stands for “Global Assessment of Functioning,” and the “GAF Scale” may be used to report
an individual’s “overall functioning.” Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR), p. 32, American Psychiatric Association (4th ed. text revision, 2000). “The GAF
Scale is to be rated with respect only to psychological, social, and occupational functioning. . . .
[and] is divided into 10 ranges of functioning.” DSM-IV-TR, p. 32. The later Diagnostic and
Statistical Manual of Mental Disorders (DSM-5), American Psychiatric Association (5th ed.
2013), no longer refers to the GAF Scale and includes a different global functioning measure–“the
WHO Disability Assessment Schedule (WHODAS) ....” DSM-5, p. 16.
A GAF score of 50 suggests “serious symptoms (e.g., suicidal ideation, severe obsessional rituals,
frequent shoplifting) OR any serious impairment in social, occupational, or school functioning
(e.g., no friends, unable to keep a job).” https://www.webmd.com/mental-health/gaf-scale-facts
(last visited Jan. 30, 2020).
9
In late April 2014, the Etowah County Probate Court granted a petition for
Ms. Coffee’s involuntary commitment, and Ms. Coffee was admitted to the Gadsden
Regional Medical Center’s adult psychiatric unit. (Doc. 8-12, p. 24; Doc. 8-13, pp.
38-40). Ms. Coffee was in the unit five nights. (Doc. 8-12, p. 21). Dr. Morton was
the attending physician during Ms. Coffee’s admission and discharge. (Doc. 8-12,
p. 24; Doc. 8-12, p. 21). Dr. Morton summarized the commitment petition: Ms.
Coffee had stopped taking her psychiatric medication at the beginning of April 2014;
had been repeating her words; had taken her sister’s truck without permission and
was gone for ten days; had experienced increased mood swings; had been yelling,
cursing, and screaming; and had hit her sister in the face. (Doc. 8-12, p. 24); (see
also 8-13, p. 39). Dr. Morton noted that Ms. Coffee felt that portions of the petition
were exaggerated. (Doc. 8-12, p. 24). Still, Ms. Coffee acknowledged having a
history of bipolar disorder. (Doc. 8-12, p. 24).
In her conversation with Dr. Morton, Ms. Coffee denied having a “significant
problem with alcohol” but acknowledged having a cocaine problem, including a
relapse from two years of abstinence one week before her commitment. (Doc. 8-12,
p. 25). Ms. Coffee reported that she had symptoms of “lots of energy and racing
thoughts,” “little need for sleep,” and disorganized thoughts. (Doc. 8-12, p. 24). Ms.
Coffee denied psychotic symptoms or past psychiatric hospitalizations. (Doc. 8-12,
pp. 24, 25). Ms. Coffee stated that she had been using Wellbutrin (75 mg twice
10
daily) and lithium (300 mg daily) to treat her symptoms for one year. (Doc. 8-12,
pp. 24, 25).7 According to Ms. Coffee, Wellbutrin was “very effective for her
depression,” but lithium caused “her hands and feet [to] swell.” (Doc. 8-12, p. 24).
Ms. Coffee stated that she did not want to take lithium. (Doc. 8-12, p. 24). Ms.
Coffee also tried Depakote but did not like it. (Doc. 8-12, p. 25). 8
Dr. Morton conducted a mental status examination and noted possible
pressured speech and thought processing issues but “no overt thought disorder” or
impaired judgment. (Doc. 8-12, p. 25). Ms. Coffee “described her mood as ‘okay.’”
(Doc. 8-12, p. 25). Dr. Morton’s diagnosed Ms. Coffee with bipolar I disorder (most
recent episode as manic and severe without psychosis) and cocaine abuse. (Doc. 812, p. 26). Dr. Morton assessed Ms. Coffee with a GAF score of 35. (Doc. 8-12, p.
26).9 Dr. Morton recommended admitting Ms. Coffee to the unit for safety and
7
“Wellbutrin is the brand name for bupropion, a prescription drug that’s used to treat depression.”
https://www.everydayhealth.com/drugs/wellbutrin (last visited Jan. 28, 2020).
“Lithium is used to treat the manic episodes of bipolar disorder (manic depression). Manic
symptoms include hyperactivity, rushed speech, poor judgment, reduced need for sleep,
aggression, and anger. Lithium also helps to prevent or lessen the intensity of manic episodes.”
https://www.drugs.com/lithium.html (last visited Jan. 28, 2020).
8
“Depakote is . . . used to treat manic episodes related to bipolar disorder (manic depression).”
https://www.drugs.com/depakote.html (last visited Jan. 28, 2020).
9
A GAF score of 35 suggests:
Some impairment in reality testing or communication (e.g., speech at times
illogical, obscure or irrelevant) OR major impairment in several areas, such as work
or school, family relations, judgment, thinking, or mood (e.g., depressed man
11
monitoring reasons.
(Doc. 8-12, p. 26).
Dr. Morton suggested “offer[ing]
psychotherapeutic interventions to Ms. Coffee, such as recreational and occupational
therapy.” (Doc. 8-12, p. 26).
During her hospitalization, Ms. Coffee took Wellbutrin and started using
Abilify (10 mg daily initially; 15 mg daily upon discharge). (Doc. 8-12, pp. 21, 22).
Dr. Morton reported that Ms. Coffee adapted well to the unit and was pleasant and
appropriate. (Doc. 8-12, p. 21). Staff began noticing “a rapid diminishing of [Ms.
Coffee’s] manic symptomatology” and reported that “[s]he was sleeping well.”
(Doc. 8-12, p. 21). Ms. Coffee stopped showing “flight of ideas or pressured
speech.” (Doc. 8-12, p. 21). Dr. Morton reported that Ms. Coffee “was clearly doing
much better” after several days of treatment. (Doc. 8-12, p. 21).
According to Dr. Morton, Ms. Coffee did not have suicidal ideation, and no
staff member observed signs that she was dangerous. (Doc. 8-12, p. 21). After a
family visit, the unit determined that Ms. Coffee could return home safely because
there no longer was an “indication that she was a danger to self or others . . . .” (Doc.
8-12, p. 21). Dr. Morton noted that Ms. Coffee’s condition was “[m]uch improved”
avoids friends, neglects family, and is unable to work, child frequently beats up
younger children, is defiant at home, and is failing at school).
https://www.webmd.com/mental-health/gaf-scale-facts (last visited Jan. 30, 2020).
12
and that her GAF score had increased to 55. (Doc. 8-12, p. 21). 10 According to
another discharge document, the unit released Ms. Coffee because she had met her
treatment goals, she denied suicidal or homicidal thoughts, and she showed an
improved and stable thought process and mood. (Doc. 8-12, p. 27). Ms. Coffee’s
discharge medications were Abilify (15 mg daily) and Wellbutrin (75 mg twice
daily). (Doc. 8-12, pp. 21, 29). Dr. Morton instructed Ms. Coffee to follow up with
Dr. Feist at CED. (Doc. 8-12, p. 22).
Dr. Feist supervised much of Ms. Coffee’s treatment at CED. Most of Ms.
Coffee’s medical records indicate that Dr. Feist is a physician at CED Mental Health
Center.
(See, e.g., 8-21, p. 35).
Dr. Feist is identified as a psychiatrist on
https://doctor.webmd.com/doctor/fredric-feist-sr-f02f32a9-3a12-4942-bf9072d0ba35d116-overview (last visited Jan. 30, 2020), but the title “physician”
appears beneath his signature on most of Ms. Coffee’s medical records.
He
prescribed Ms. Coffee’s mental health medications. (See, e.g., Doc. 8-12, p. 32). At
least one record—Ms. Coffee’s November 2014 treatment plan—shows that a
psychiatrist was responsible for Ms. Coffee’s monthly evaluations. (Doc. 8-12, p.
10
A GAF score of 55 suggests “[m]oderate symptoms (e.g., flat and circumstantial speech,
occasional panic attacks) OR moderate difficulty in social occupational, or social functioning (e.g.,
few friends, conflicts with co-workers).” https://www.webmd.com/mental-health/gaf-scale-facts
(last visited Jan. 30, 2020).
13
39). Dr. Feist signed the plan as Ms. Coffee’s psychiatrist/psychologist. (Doc. 812, p. 39). 11
Ms. Coffee saw Dr. Feist at the end of April 2014 and complained of agitation
and depression. (Doc. 8-12, p. 3). Dr. Feist noted that Ms. Coffee was taking
Wellbutrin (75 mg) and lithium (300 mg). (Doc. 8-12, p. 3). Dr. Feist reported that
Ms. Coffee had not made mental health progress and that she was suffering from
anxiety, insomnia, poor insight and judgment, tangential and loose thought process,
and hyperactivity. (Doc. 8-12, p. 3). Dr. Feist noted ADHD and bipolar disorder
and assessed Ms. Coffee as a high-risk patient. (Doc. 8-12, p. 3). 12
Dr. Bentley, who holds a Ph.D. and is a licensed professional counselor,
updated Ms. Coffee’s mental health assessment in early May 2014 at the
Commissioner’s request. (Doc. 8-12, pp. 33, 35). Dr. Bentley first evaluated Ms.
Coffee in April 2010. (Doc. 8-12, p. 33). Dr. Bentley provided the following
summary of Ms. Coffee’s mental health treatment:
[Ms. Coffee] admits to increasing anxiety, mood swings, irritability,
depression and episodes of euphoria since 2002. She was previously
evaluated at the CED Mental Health Center for a brief period of time in
2003. [Ms. Coffee] was also treated at Gadsden Psychological Services
11
The Court was able to verify the title under Dr. Feist’s signature by enlarging the image. (Doc.
8-12, p. 39). In another administrative appeal, Ms. Coffee’s attorney, representing another
claimant who Dr. Feist treated, stated that Dr. Feist is a psychiatrist who has practiced for years in
Northern Alabama. See Bryant v. Saul, 19-22 (Feb. 28, 2020 minute entry).
12
Many of Dr. Feist’s notes are handwritten and, at times, difficult to decipher. Consequently, the
Court discusses only those portions of Dr. Feist’s handwritten notes that the Court understands.
14
in 2006 and diagnosed as having [b]ipolar [d]isorder. The patient has
not received any formal psychiatric treatment in the last 7 to 8 years.
[Ms. Coffee] is being treated by her PMD for symptoms stemming from
her [b]ipolar [d]isorder. Ms. Coffee was discharged from GRMC one
week ago due to excessive swelling in her extremities x4. A list of her
medications accompanies this clinician’s report. She’s only recently
started her regimen of Neurontin and is uncertain as to the effectiveness
of this drug. There has been little improvement in her psychiatric
symptoms as a result of her other medications. [Ms. Coffee] has not
been hospitalized for psychiatric reasons.
(Doc. 8-12, p. 33).13 Although Dr. Bentley mentioned Ms. Coffee’s April 2014 stay
at the Gadsden Regional Medical Center, he did not discuss Ms. Coffee’s admission
to the psychiatric unit.
Ms. Coffee told Dr. Bentley that she was experiencing “moderate to severe”
insomnia and excessive anxiety. (Doc. 8-12, p. 34). Ms. Coffee also reported that
she was assisting with household chores and completing activities of daily living
unassisted. (Doc. 8-12, p. 35). Dr. Bentley described Ms. Coffee as alert, oriented,
and appropriately dressed with an unremarkable appearance. (Doc. 8-12, p. 34). Dr.
Bentley did not notice “obvious limitations” in Ms. Coffee’s psychomotor or
communication skills. (Doc. 8-12, p. 34). Dr. Bentley noted that Ms. Coffee’s
“tertiary and immediate memories were intact.” (Doc. 8-12, p. 34). Dr. Bentley
described Ms. Coffee as “reasonably cheerful” with a “mood congruent with her
13
“Neurontin (gabapentin) is an anti-epileptic drug, also called an anticonvulsant. It affects
chemicals and nerves in the body that are involved in the cause of seizures and some types of
pain.” https://www.drugs.com/neurontin.html (last visited Jan. 30, 2020).
15
affect during the interview.” (Doc. 8-12, p. 34). According to Dr. Bentley, Ms.
Coffee appeared “mildly restless and anxious when discussing her history of
substance abuse . . . .” (Doc. 8-12, p. 34). Dr. Bentley did not detect “evidence of
phobias, obsessions or bizarre mentation.” (Doc. 8-12, p. 34). Dr. Bentley tested
Ms. Coffee’s mental abilities in several ways. (Doc. 8-12, p. 34). Ms. Coffee was
unsure how many weeks are in a year but otherwise demonstrated no deficits. (Doc.
8-12, p. 34).
Dr. Bentley diagnosed Ms. Coffee with crystal methamphetamine induced
bipolar disorder, polysubstance abuse (in remission), probable cognitive disorder
(secondary to a motor vehicle accident), and chronic pain in her cervical spine. (Doc.
8-12, p. 35). Dr. Bentley provided the following functional assessment:
Ms. Coffee could be expected to have a moderate limitation in her
ability to perform complex or repetitive work-related tasks as a result
of her substance abuse and apparent onset of [] [b]ipolar [d]isorder. Ms.
Coffee would function at a diminished pace when performing these
activities. [Ms. Coffee] would appear capable of performing simple
work-related tasks of a non-stressful nature. She would also appear
capable of communicating effectively with coworkers and supervisors.
Additional limitations based on the injuries to her cervical spine would
need to be assigned by an appropriately trained physician.
(Doc. 8-12, p. 35). 14 Dr. Bentley detected no symptom exaggeration and found Ms.
Coffee’s prognosis for her level of functioning to be favorable. (Doc. 8-12, p. 35).
14
Part 12.00 of the regulations governs mental disorders and listing 12.04 covers bipolar disorder.
According to 12.00F, which listing 12.04 incorporates, a moderate limitation means that a person’s
ability to function “independently, appropriately, effectively, and on a sustained basis is fair” for
16
Ms. Coffee returned to Dr. Feist in November 2014, and her GAF score was
50. (Doc. 8-12, p. 37). During this visit, Ms. Coffee stated that she wanted “to be
independent and financial[ly] stable.” (Doc. 8-12, p. 37). According to Ms. Coffee’s
treatment plan, she wanted to reduce her days of depression from three to zero
weekly. (Doc. 8-12, p. 39). To reach this goal, Ms. Coffee planned to learn three
positive coping skills and comply with her medication regimen. (Doc. 8-12, p. 39).
Ms. Coffee was to attend an individual therapy session once every six weeks, and
she was to have a monthly psychiatric assessment. (Doc. 8-12, p. 39). Dr. Feist
approved the plan by signing the psychiatrist/psychologist section. (Doc. 8-12, p.
39).
Dr. Nichols provided a mental health assessment of Ms. Coffee in early
December 2014. (Doc. 8-12, p. 45). Ms. Coffee told Dr. Nichols that she (Ms.
Coffee) “began having problems with depression in 2001,” that she did not “‘get any
help and . . . got suicidal,’” that she started using drugs in 2002, and that her selfmedication “‘developed into a serious problem.’” (Doc. 8-12, p. 45). Ms. Coffee
acknowledged drinking alcohol and using marijuana, crystal methamphetamine,
cocaine, and crack. (Doc. 8-12, pp. 46-47). Ms. Coffee reported that she was
hospitalized in 2006 at Mt. View Hospital because she was unable to sleep for
that
work-setting
area.
https://www.ssa.gov/disability/professionals/bluebook/12.00MentalDisorders-Adult.htm (last visited Feb. 20, 2020).
17
several days and “then would crash” and was hospitalized again in 2014 at Gadsden
Regional Medical Center under the commitment order discussed above. (Doc. 8-12,
p. 45). According to Ms. Coffee, she had difficulty functioning after her 2014
hospitalization because the doctor changed her medications, so she stopped taking
them. (Doc. 8-12, p. 45). Because she did not comply with her medication regimen,
Ms. Coffee did not report weekly to her probation officer and spent 90 days in county
jail for violating the terms of her probation. (Doc. 8-12, p. 45).
Ms. Coffee stated that her then-prescribed medications were beneficial. (Doc.
8-12, p. 46). Ms. Coffee reported that she had stopped taking ADHD medication in
2011. (Doc. 8-12, p. 46). Ms. Coffee described memory deficits, low energy, and
suicidal feelings when she experienced “the lows.” Dr. Nichols listed Wellbutrin
(150 mg daily) and Neurontin (300 mg twice daily) as Ms. Coffee’s medications.
(Doc. 8-12, p. 46).
Ms. Coffee reported that she last worked for her aunt and took care of elderly
patients. (Doc. 8-12, p. 46). According to Ms. Coffee, she left because “she could
not manage her pain” and perform the job. (Doc. 8-12, p. 46).
After conducting a mental status examination, Dr. Nichols noted that Ms.
Coffee’s appearance was appropriate, that her “[e]ye contact was good,” and her
“[s]peech was clear and rapid in rate.” (Doc. 8-12, p. 47). Dr. Nichols described
Ms. Coffee’s mood as “anxious” and her affect as “agitated.” (Doc. 8-12, p. 47).
18
Ms. Coffee reported sleeping two or three hours nightly, having a good appetite and
“‘plenty’” of energy, and experiencing crying episodes. (Doc. 8-12, p. 47). Ms.
Coffee denied anhedonia and suicidal or homicidal thoughts. (Doc. 8-12, p. 47). 15
Dr.
Nichols
did
not
detect
cognitive
deficits
in
orientation,
concentration/attention, memory, fund of information, abstraction, thought
processes and content, or judgment and insight.
(See Doc. 8-12, pp. 47-48)
(describing findings as “adequate,” “fair,” “normal,” and “good”). Dr. Nichols
estimated that Ms. Coffee was functioning in the average range of intellectual ability.
(Doc. 8-12, p. 48). Dr. Nichols diagnosed Ms. Coffee with bipolar II disorder and
combined ADHD and assigned a GAF score of 55. (Doc. 8-12, p. 48).
Dr. Nichols noted that Ms. Coffee cooperated during the examination. (Doc.
8-12, p. 48). Dr. Nichols found that Ms. Coffee’s “[p]rognosis for significant
improvement over the next 12 months [was] poor as Ms. Coffee has pursued help
and yet had demonstrated little improvement with symptom resolution.” (Doc. 812, p. 48). Dr. Nichols ended the report with the following findings:
Ms. Coffee suffers symptoms of [b]ipolar [d]isorder, with rapid cycling
that affects everyday activities. She has been unable to find the right
medications to reduce symptoms. Her ability to relate interpersonally
and withstand the pressures of everyday work is compromised due to
the nature of her current symptoms. She reports three different closed
head traumas that could cause deficits, which would interfere with her
15
Anhedonia is “a psychological condition characterized by inability to experience pleasure in
normally pleasurable acts.” https://www.merriam-webster.com/dictionary/anhedonia (last visited
Jan. 29, 2020).
19
ability to remember, understand and carry out work related instructions.
She is able to handle her own funds and to live independently with the
assistant of family.
(Doc. 8-12, p. 48).
Dr. Ernst, an anesthesiologist with MDSI Physician Services, examined Ms.
Coffee in late December 2014 and provided a physical functional report. (Doc. 812, pp. 50, 54). Ms. Coffee primarily complained of daily neck pain that radiated to
her right shoulder, arm, and fingers. (Doc. 8-12, p. 50). Ms. Coffee attributed the
pain to a car accident decades earlier. (Doc. 8-12, p. 50). Ms. Coffee described the
pain as “sharp to . . . achy” and rated it six out of ten. (Doc. 8-12, p. 50). According
to Ms. Coffee, “[l]ooking up, standing more than 30 minutes, [and] reaching above
her shoulders” increased her pain but weather changes did not have an impact. (Doc.
8-12, p. 50). Ms. Coffee reported dropping things with and experiencing weekly
numbness in her right hand. (Doc. 8-12, p. 50). Ms. Coffee stated that she was
sleeping three to four hours nightly. (Doc. 8-12, p. 50).
Ms. Coffee told Dr. Ernst that she lived with her boyfriend. (Doc. 8-12, p.
50). She reported that she could cook and handle some household chores. (Doc. 812, p. 50). Dr. Ernst listed polysubstance abuse, bipolar and obsessive-compulsive
disorders, ADHD, and cervical degenerative disc disease as Ms. Coffee’s medical
history and listed Wellbutrin (150 mg daily) and Neurontin (300 mg twice daily) as
her medications. (Doc. 8-12, p. 50).
20
Based on the interview process, Dr. Ernst described Ms. Coffee as “very
hyper” with a short attention span. (Doc. 8-12, p. 53). Dr. Ernst’s physical findings
were mostly normal. (Doc. 8-12, pp. 51-53). Dr. Ernst detected a painful range of
motion in Ms. Coffee’s cervical region and decreased sensation in her right arm and
fingers. (Doc. 8-12, p. 53). Ms. Coffee’s straight leg raise test was positive on the
right, creating “achy [and] pinching low back pain.” (Doc. 8-12, p. 53). 16 Dr. Ernst
diagnosed Ms. Coffee with degenerative disc disease in her neck (moderately severe
but without a herniated disc) and back. (Doc. 8-12, p. 53).
Based on her degenerative disc disease, Dr. Ernst limited Ms. Coffee’s
standing and walking to four hours and limited her sitting to six hours. (Doc. 8-12,
p. 54). Dr. Ernst found that Ms. Coffee could lift ten pounds occasionally and five
pounds frequently with her left extremity. (Doc. 8-12, p. 54). Dr. Ernst restricted
Ms. Coffee’s use of her right extremity to one pound frequently. (Doc. 8-12, p. 54).
Dr. Ernst determined that Ms. Coffee could reach overhead occasionally and reach
forward, handle, finger, and feel frequently. (Doc. 8-12, p. 54). Dr. Ernst limited
most postural activities to occasionally, except for climbing stairs frequently. (Doc.
16
Examiners use the straight leg raise test to evaluate patients “with low back pain and nerve pain
that radiates down the leg.” https://www.ebmconsult.com/articles/straight-leg-raising-test (last
visited Feb. 12, 2020).
21
8-12, p. 54). Dr. Ernst found that Ms. Coffee should limit her exposure to hazardous
materials, temperature extremes, chemicals, and gases. (Doc. 8-12, p. 54).
During an early January 2015 visit with Dr. Feist, Ms. Coffee complained of
hyperactivity. (Doc. 8-13, p. 31). According to the treatment record, Ms. Coffee
exhibited an agitated and euphoric mood, fair insight, judgment, and motivation,
loose thought processes, normal and obsessive thoughts, inadequate attention, and
hyperactive behavior. (Doc. 8-13, p. 31). Dr. Feist classified Ms. Coffee’s risk as
moderate. (Doc. 8-13, p. 31). Dr. Feist noted that Ms. Coffee was taking Seroquel
(50 mg twice nightly) and Neurontin (300 mg twice daily) for bipolar disorder and
wanted to try a prescription for ADHD. (Doc. 8-13, p. 31). Dr. Feist recommended
that Ms. Coffee try Strattera. (Doc. 8-13, p. 31).17
Dr. Williams, a consulting physician, completed a physical and mental health
assessment of Ms. Coffee in early January 2015. (Doc. 8-4, pp. 3-17). With respect
to Ms. Coffee’s mental health assessment, Dr. Williams found that she had moderate
limitations in understanding and remembering instructions. (Doc. 8-4, p. 16). Dr.
Williams stated that Ms. Coffee could “understand, remember, and carry out short[,]
simple instructions and tasks, but would likely have difficulty with more detailed
tasks and instructions.” (Doc. 8-4, p. 16).
17
“Strattera (atomoxetine) . . . [is] used to treat attention deficit hyperactivity disorder (ADHD).”
https://www.rxlist.com/strattera_vs_adderall/drugs-condition.htm (last visited Jan. 29, 2020).
22
Dr. Williams determined that Ms. Coffee had moderate concentration and
persistence limitations in several areas, including “carry[ing] out detailed
instructions,” “maintain[ing] attention and concentration for extended periods,”
“perform[ing] activities within a schedule,” “maintain[ing] regular attendance,”
“be[ing] punctual within customary tolerances,” “sustain[ing] an ordinary routine
without special supervision,” “work[ing] in coordination with or in proximity to
others without being distracted,” and “complet[ing] a normal workday . . . without
interruptions from psychologically based symptoms and . . . perform[ing] at a
consistent pace without an unreasonable number and length of rest periods.” (Doc.
8-4, p. 16). Dr. Williams stated that Ms. Coffee could pay attention and concentrate
on uncomplicated tasks and instructions for two hours with rest breaks. (Doc. 8-4,
p. 16). According to Dr. Williams, “[a] well-spaced work environment” would
maximize Ms. Coffee’s concentration level. (Doc. 8-4, p. 16). Dr. Williams stated
that Ms. Coffee would miss one or two days of work monthly because of
psychological symptoms. (Doc. 8-4, p. 16).
Dr. Williams found that Ms. Coffee had moderate limitations in interacting
with the public and supervisors. (Doc. 8-4, pp. 16, 17). Dr. Williams explained that
Ms. Coffee should have “infrequent and non-intensive” public contact and “tactful,
constructive, and non-threatening” supervision. (Doc. 8-4, p. 17). Dr. Williams
found that Ms. Coffee had moderate limitations in adapting to work changes. (Doc.
23
8-4, p. 17). Dr. Williams stated that Ms. Coffee should experience workplace
changes infrequently and gradually. (Doc. 8-4, p. 17).
According to a CED progress note, Ms. Coffee missed a therapy appointment
in late January 2015. (Doc. 8-13, p. 30).
Ms. Coffee visited the emergency department of the Gadsden Regional
Medical Center in February 2015 and complained of coughing and congestion.
(Doc. 8-12, p. 69). Ms. Coffee saw Dr. Kadakia, the attending physician, and a nurse
practitioner. (Doc. 8-12, pp. 69, 70). Ms. Coffee did not describe psychiatric
symptoms. (See Doc. 8-12, p. 70). The providers noted that Ms. Coffee was “alert,”
in “mild distress,” and “[c]ooperative.” (Doc. 8-12, p. 70). According to the
treatment record, Ms. Coffee did not complain of back or neck pain. (Doc. 8-12, p.
69). The providers detected no tenderness in Ms. Coffee’s back and reported no
abnormalities in Ms. Coffee’s range of motion. (Doc. 8-12, p. 70). The providers
diagnosed Ms. Coffee with an upper respiratory infection and discharged her. (Doc.
8-12, p. 70).
In March 2015, Ms. Coffee returned to the emergency department of the
Gadsden Regional Medical Center and complained of shortness of breath, chest pain,
fever, coughing, and nausea. (Doc. 8-12, p. 62). Ms. Coffee saw Dr. Hunt, the
attending physician. (Doc. 8-12, p. 62). Ms. Coffee did not describe psychiatric
symptoms.
(Doc. 8-12, p. 62). Dr. Hunt observed that Ms. Coffee was
24
“[c]ooperative” and “appropriate” in her mood and affect. (Doc. 8-12, p. 63).
According to the treatment notes, Ms. Coffee complained of “chest wall” pain but
not back or neck pain. (Doc. 8-12, p. 62). Dr. Hunt detected no tenderness in Ms.
Coffee’s back or extremities. (Doc. 8-12, p. 62). Dr. Hunt reported no abnormalities
in Ms. Coffee’s neck, her range of motion, or her strength. (Doc. 8-12, p. 62). Dr.
Hunt diagnosed Ms. Coffee with pneumonia and discharged her with self-care
instructions. (Doc. 8-12, pp. 64, 75).
Ms. Coffee saw Dr. Feist in April 2015. (Doc. 8-13, p. 29). According to the
treatment record, Ms. Coffee exhibited an anxious and agitated mood, fair insight
and motivation, poor judgment, tangential and loose thought processes, and
hyperactive behavior. (Doc. 8-13, p. 29). Dr. Feist classified Ms. Coffee’s risk as
moderate. (Doc. 8-13, p. 29). Dr. Feist noted that Ms. Coffee’s progress was
minimal and that she had stopped taking Strattera because it caused nausea. (Doc.
8-13, p. 29). Dr. Feist issued prescriptions for Neurontin (300 mg twice daily) and
Wellbutrin (150 mg daily).
Ms. Coffee visited Riverview Regional Medical Center in July 2015 and
complained of chest pain. (Doc. 8-13, pp. 3, 7). Ms. Coffee was in the custody of
the Etowah County Jail and arrived by transport. (Doc. 8-13, pp. 3, 7). Ms. Coffee’s
secondary diagnoses included anxiety and episodic mood and bipolar disorders.
(Doc. 8-13, pp. 3, 7). Ms. Coffee stated she had “chronic neck stiffness due to a
25
previous neck injury,” “generalized muscle and joint stiffness,” and “anxiety and
depression related to [her] medical condition.” (Doc. 8-13, p. 8).
Dr. Sinha, the attending physician, described Ms. Coffee as “alert, awake,
oriented, and in no acute distress.” (Doc. 8-13, pp. 5, 9). Dr. Sinha detected no
range of motion, extremity, neck, or spinal issues. (Doc. 8-13, pp. 5, 13). Dr. Sinha
reported that Ms. Coffee was taking Wellbutrin and gabapentin (generic for
Neurontin) for pain and mood disorder symptoms. (Doc. 8-13, p. 3). Another record
from this visit shows that Ms. Coffee was taking trazodone (100 mg nightly). (Doc.
8-13, p. 7).18 The procedure report revealed no abnormal cardiovascular findings
for Ms. Coffee. (Doc. 8-13, pp. 19-22).
Ms. Coffee met with a CED therapist in October 2015 and updated her
treatment plan. (Doc. 8-13, p. 28). The therapist noted that Ms. Coffee had not been
able to take her medication while she was in a halfway house, and her symptoms
were deteriorating, causing PMA. (Doc. 8-13, p. 28). PMA stands for “psychomotor
agitation [and] is a state of motor restlessness and mental tension that requires
prompt recognition, appropriate assessment and management to minimize anxiety
for the patient and reduce the risk for escalation to aggression and violence.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5591519/ (last visited Feb. 19,
18
“Trazodone is an antidepressant drug that’s prescribed to treat the symptoms of depression.”
https://www.everydayhealth.com/drugs/trazodone (last visited Jan. 30, 2020).
26
2020). The therapist scheduled an appointment with Dr. Feist that day. (Doc. 8-13,
p. 28).
Ms. Coffee told Dr. Feist that she had not been taking medication since the
Etowah County Jail had released her to a halfway house. (Doc. 8-13, pp. 27, 28).
Ms. Coffee complained of depression and mood swings. (Doc. 8-13, pp. 27, 28).
Dr. Feist noted that Ms. Coffee had an anxious and labile mood. (Doc. 8-13, p. 27).19
Dr. Feist described Ms. Coffee’s progress as minimal, her insight, judgment, and
motivation as fair, her thought processes as loose, her thought content as normal and
obsessive, and her behavior as appropriate. (Doc. 8-13, p. 27). Dr. Feist diagnosed
bipolar disorder (severe depression as most recent episode) and combined ADHD.
(Doc. 8-21, p. 33). Dr. Feist discussed the benefits of medication with Ms. Coffee
and instructed her to return in three months. (Doc. 8-13, p. 27).
Ms. Coffee returned to the emergency department of Gadsden Regional
Medical Center in late December 2015 and complained of a sore throat. (Doc. 8-12,
p. 55). Ms. Coffee met with Dr. Daily, the attending physician, and a nurse
practitioner. (Doc. 8-12, pp. 55, 58). Ms. Coffee did not describe psychiatric
symptoms. (Doc. 8-12, p. 55). The providers noted that Ms. Coffee was “[a]lert,”
19
“Mood lability is an emotional response that is irregular or out of proportion to the situation at
hand. . . . [and] often evidenced by destructive or harmful behaviors. . . . Mood lability is present
in people with various mental illnesses, including bipolar disorder . . . . Because of how disruptive
mood
lability
can
be,
it
can
inhibit
daily
life
and
functioning.”
https://www.verywellmind.com/what-is-mood-lability-425304 (last visited Feb. 19, 2020).
27
in “no acute distress,” and “[c]ooperative.” (Doc. 8-12, pp. 56, 57). The providers
did not detect tenderness in Ms. Coffee’s back or extremities, and Ms. Coffee’s range
of motion and strength findings were normal. (Doc. 8-12, p. 56). The providers
diagnosed Ms. Coffee with strep throat and released her to self-care. (Doc. 8-12, p.
57).
Dr. Feist renewed Ms. Coffee’s Ritalin (20 mg) prescription in November
2015. (Doc. 8-13, p. 26).20 According to a CED progress note, Ms. Coffee missed
a therapy appointment in early December 2015. (Doc. 8-13, p. 25). Ms. Coffee
contacted CED in late December 2015 and requested a refill of her Ritalin (20 mg)
prescription. (Doc. 8-13, p. 24). Dr. Feist authorized Ms. Coffee’s refill request.
(Doc. 8-13, p. 24). Ms. Coffee missed another therapy appointment in early
February 2016. (Doc. 8-13, p. 23).
Later in February 2016, Ms. Coffee visited the emergency unit of the Gadsden
Regional Medical Center and complained of a sore throat. (Doc. 8-21, p. 37). Dr.
Killingsworth was the attending physician. (Doc. 8-21, p. 37). Ms. Coffee did not
complain of psychiatric, back, or neck symptoms.
(Doc. 8-21, p. 37).
Dr.
Killingsworth described Ms. Coffee as “[a]lert” and in “no acute distress.” (Doc. 821, pp. 38, 39). Dr. Killingsworth noted that Ms. Coffee was “[c]ooperative” and
20
“Ritalin (methylphenidate) is a central nervous system stimulant. . . . used to treat . . . attention
deficit hyperactivity disorder (ADHD).” https://www.drugs.com/ritalin.html (last visited Jan. 29,
2020).
28
“appropriate [in] mood [and] affect.”
(Doc. 8-21, p. 38). Dr. Killingsworth
diagnosed Ms. Coffee with an oral ulcer and strep. (Doc. 8-21, pp. 38, 42). Dr.
Killingsworth discharged Ms. Coffee. (Doc. 8-12, p. 39).
Ms. Coffee returned to CED in May 2016 to update her October 2015
treatment plan. (Doc. 8-21, p. 34). Ms. Coffee stated that she had not been taking
medication for three months and was experiencing depression, hyperactivity,
inattentiveness, and anxiousness. (Doc. 8-21, p. 34). The therapist described Ms.
Coffee as “hyper-fidgety.” (Doc. 8-21, p. 34). The therapist instructed Ms. Coffee
to monitor her symptoms, reiterated the importance of keeping appointments, and
scheduled appointments for May and July 2016 due to Ms. Coffee’s PMA status.
(Doc. 8-21, p. 34). Dr. Feist described Ms. Coffee’s progress as “fair” during a later
May 2016 visit. (Doc. 8-21, p. 35). According to Dr. Feist’s notes, Ms. Coffee
exhibited an anxious and labile mood, fair insight, judgment, and motivation,
circumstantial thought processes, normal thought content, hyperactive and agitated
behavior. Ms. Coffee was a moderate risk. (Doc. 8-31, p. 35).
Ms. Coffee met with a CED therapist in July 2016. (Doc. 8-21, p. 36). Ms.
Coffee reported experiencing “mild depression a couple days” weekly and “some
days of mood swings.” (Doc. 8-21, p. 36). The therapist noted that Ms. Coffee
appeared clean and appropriate and had a normal mood, affect, and orientation.
(Doc. 8-21, p. 36). Ms. Coffee stated that she had run out of one medication two
29
weeks earlier which caused increased agitation. (Doc. 8-21, p. 36). The therapist
instructed Ms. Coffee to monitor her symptoms and call in advance for refills to
avoid gaps in medication.
(Doc. 8-21, p. 36). The therapist scheduled an
appointment for September 2016. (Doc. 8-21, p. 36).
Dr. Feist completed a mental health assessment of Ms. Coffee in December
2016. (Doc. 8-21, p. 44). According to the assessment, Ms. Coffee could not
“understand, remember or carry out very short and simple instructions,” “maintain
attention, concentration and/or pace for periods of at least two hours,” “perform
activities within a schedule and be punctual within customary tolerances,” “sustain
an ordinary routine without special supervision,” “adjust to routine and infrequent
work changes, “interact with supervisors [or coworkers],” or “adhere to basic
standards of neatness and cleanliness.” (Doc. 8-21, p. 44). Dr. Feist stated that Ms.
Coffee would be off-task 93 percent of an eight-hour day in addition to customary
breaks. (Doc. 8-21, p. 44). Dr. Feist indicated that if Ms. Coffee stopped using
drugs and alcohol, her mental condition would not improve “to the point of nondisability.” (Doc. 8-21, p. 44). Dr. Feist noted that Ms. Coffee experienced side
effects from her medication including seizures, mood swings, behavioral changes,
anxiety, trouble sleeping, irritability, agitation, and aggressiveness. (Doc. 8-21, p.
44).
30
Medical Opinion Evidence
Ms. Coffee maintains that the ALJ did not properly evaluate the medical
opinion evidence. In the Eleventh Circuit, an “ALJ must state with particularity the
weight given to different medical opinions and the reasons therefor.” Winschel, 631
F.3d at 1179 (citing Sharfarz v. Bowen, 825 F.2d 278, 279 (11th Cir. 1987) (per
curiam)); see also McClurkin v. Social Sec. Admin., 625 Fed. Appx. 960, 962 (11th
Cir. 2015) (same). An ALJ must give considerable weight to a treating physician’s
medical opinion if the opinion is supported by the evidence and consistent with the
doctor’s own records. See Winschel, 631 F.3d at 1179. An ALJ may refuse to give
the opinion of a treating physician “substantial or considerable weight . . . [if] ‘good
cause’ is shown to the contrary.” Phillips v. Barnhart, 357 F.3d 1232, 1240-41 (11th
Cir. 2004). Good cause exists when “(1) [the] treating physician’s opinion was not
bolstered by the evidence; (2) [the] evidence supported a contrary finding; or (3)
[the] treating physician’s opinion was conclusory or inconsistent with the doctor’s
own medical records.” Phillips, 357 F.3d at 1240-41; see also Crawford, 363 F.3d
at 1159. “The ALJ must clearly articulate the reasons for giving less weight to a
treating physician’s opinion, and the failure to do so constitutes error.” Gaskin v.
Comm’r, Soc. Sec. Admin., 533 Fed. Appx. 929, 931 (11th Cir. 2013). Generally,
“the medical opinion of a specialist about medical issues related to his or her area of
31
specialty [is due more weight] than . . . the medical opinion of a source who is not a
specialist.” 20 C.F.R. § 404.1527(c)(5).
The opinion of a one-time examiner is not entitled to deference. McSwain v.
Bowen, 814 F.2d 617, 619 (11th Cir. 1987) (citing Gibson v. Heckler, 779 F.2d 619,
623 (11th Cir. 1986)); see also Eyre v. Comm’r, Soc. Sec. Admin., 586 Fed. Appx.
521, 523 (11th Cir. 2014) (“The ALJ owes no deference to the opinion of a physician
who conducted a single examination: as such a physician is not a treating
physician.”). “The opinions of nonexamining, reviewing physicians . . . when
contrary to those of the examining physicians, are entitled to little weight, and
standing alone do not constitute substantial evidence.” Sharfarz, 825 F.2d at 280
(citing Spencer ex rel. Spencer v. Heckler, 765 F.2d 1090, 1094 (11th Cir.1985) (per
curiam)). An ALJ “is free to reject the opinion of any physician when the evidence
supports a contrary conclusion.” Sryock v. Heckler, 764 F.2d 834, 835 (11th Cir.
1985) (internal quotation marks omitted).
In challenging the ALJ’s decision, Ms. Coffee argues that reversal is
appropriate because the ALJ rejected the opinion of Dr. Feist, Ms. Coffee’s “treating
psychiatrist,” and the opinion of Dr. Nichols, “the Commissioner’s examining
psychologist.” (Doc. 12, pp. 2, 4). Citing Wilder v. Chater, 64 F.3d 335 (7th Cir.
1995) and several district court cases, Ms. Coffee also contends that the ALJ
improperly substituted his opinion for the opinion of Dr. Nichols. (Doc. 12, pp. 532
6); see Wilder, 64 F.3d at 337 (“We are led to consider with a degree of suspicion
the administrative law judge’s decision to go against the only medical evidence in
the case, that of a psychiatrist not retained by the applicant but appointed by the
administrative law judge himself to advise on Wilder’s condition.”).
Dr. Feist opined that the limitations attributable to Ms. Coffee’s mental
impairments precluded Ms. Coffee from meeting the demands of gainful
employment. (Doc. 8-21, p. 44). The ALJ gave little weight to Dr. Feist’s opinion
because “the record as a whole does not substantiate the restrictive assessment by
Dr. Feist that [Ms. Coffee] was incapable of performing any work.” (Doc. 8-3, p.
24). The ALJ stated that “the most recent records from Dr. Feist’s own facility
document completely normal findings (i.e. clean and appropriate appearance,
euthymic mood, normal affect, [and] full orientation.” (Doc. 8-3, p. 24). 21 The ALJ
noted that Gadsden Regional Medical Center and Riverview Regional Medical
Center records “document unremarkable findings” and reflect Ms. Coffee’s denial
of psychiatric symptoms. (Doc. 8-3, p. 24). For those reasons the ALJ discounted
Dr. Feist’s opinion.
21
Euthymia means “a stable mental state or mood in those affected with bipolar disorder that is
neither manic nor depressive.” https://www.merriam-webster.com/medical/euthymia (last visited
Jan. 28, 2020).
33
The ALJ’s analysis of Dr. Feist’s opinion proceeds from the assumption that
Dr. Feist is a treating physician rather than a treating psychiatrist. (Doc. 8-3, p. 24).
Psychiatrists are medical doctors who specialize in the “assessment and treatment of
mental health disorders.”22 Consistent with the Commissioner’s duty to develop the
record, given the conflicting information in Ms. Coffee’s medical records
concerning Dr. Feist’s status, the ALJ should have clarified Dr. Feist’s credentials
and determined whether Dr. Feist’s opinion regarding Ms. Coffee’s mental health
was entitled to greater weight than the opinion of a treating physician. See Sims v.
Apfel, 530 U.S. 103, 110-11 (2000) (“Social Security proceedings are inquisitorial
rather than adversarial. It is the ALJ’s duty to investigate the facts and develop the
arguments both for and against granting benefits.”) (citing Richardson v. Perales,
402 U.S. 389, 400-401 (1971)). 23
The ALJ also should have considered Dr. Feist’s longitudinal treatment of Ms.
Coffee and determined whether Dr. Bentley was a psychologist, such that his
longitudinal psychological evaluation might provide a relevant comparison. If Dr.
Bentley is a psychologist, then he would be an acceptable medical source. See 20
22
https://www.webmd.com/mental-health/features/psychologist-or-psychiatrist-which-for-you#1.
(last visited March 2, 2020).
23
The ALJ’s reliance on the GRMC and RRMC records to discount Dr. Feist’s opinion may
require additional consideration because Ms. Coffee did not visit either facility seeking mental
health treatment. The ALJ’s selective treatment of Ms. Coffee’s CED records also may require
further consideration. For example, a May 2016 record indicates that Ms. Coffee was in PMA
status. (Doc. 8-21, p. 34).
34
C.F.R. § 404.1502(a) (acceptable medical sources for claims predating March 27,
2017, include licensed physicians and psychologists). According to Dr. Bentley’s
mental health assessment of Ms. Coffee, he is a Ph.D. and a licensed professional
counselor. (Doc. 8-12, pp. 33, 35). “Psychologists have a doctoral degree in an area
of psychology.”24 Consistent with Sims, the ALJ should have developed the record
concerning Dr. Bentley’s qualifications and determined whether to assign weight to
Dr. Bentley’s opinion. Dr. Bentley’s opinion contains mental limitations that the
ALJ did not include in Ms. Coffee’s RFC. (Compare Doc. 8-3, p. 19 and Doc. 812, p. 35).
According to the record, Dr. Nichols is a clinical psychologist. Dr. Nichols
concluded that Ms. Coffee’s “ability to relate interpersonally and withstand the
pressures of everyday work is compromised due to the nature of her current
symptoms.” (Doc. 8-12, p. 48). The ALJ noted that Dr. Nichols’s statements
“concerning [Ms. Coffee’s] perceived abilities are not medical opinions per the
regulations as they do not assess any actual limitations.” (Doc. 8-3, p. 22). Still, the
ALJ stated that he considered Dr. Nichols’s statements “with the totality of the
medical record.” (Doc. 8-3, p. 22). The ALJ did not assign weight to Dr. Nichols’s
opinion. (Doc. 10, p. 21).
24
https://www.webmd.com/mental-health/features/psychologist-or-psychiatrist-which-for-you#1.
(last visited March 2, 2020).
35
The Commissioner acknowledges that the ALJ erred when he failed to assign
weight to Dr. Nichols’s opinion. (Doc. 11, p. 13); Kemp v. Astrue, 308 Fed. Appx.
423, 426 (11th Cir. 2009) (An “ALJ must ‘state specifically the weight accorded to
each item of evidence and why he reached that decision.’”) (quoting Cowart v.
Schweiker, 662 F.2d 731, 735 (11th Cir. 1981)).
The Eleventh Circuit has
recognized that an ALJ may implicitly assign weight in discussing the evidence. See
Kemp, 308 Fed. Appx. at 426 (“[The ALJ] implicitly found that the VA disability
ratings were entitled to great weight.”). The Commissioner contends that the ALJ’s
treatment of Dr. Nichols’s opinion was harmless error because Dr. Nichol’s opinion
was vague. (Doc. 11, pp. 13, 14); see Mabrey v. Acting Comm’r of Soc. Sec. Admin.,
724 Fed. Appx. 726, 727 (11th Cir. 2018) (“Irrelevant errors are harmless and do not
require reversal or remand.”) (citing Diorio v. Heckler, 721 F.2d 726, 728 (11th Cir.
1983)). On remand, the ALJ should assign weight to Dr. Nichols’s opinion and
determine whether he should seek clarification from Dr. Nichols who examined Ms.
Coffee at the Commissioner’s request.
Ultimately, the ALJ gave great, determinative weight to the mental health
assessment of a non-treating physician who reviewed Ms. Coffee’s records. (Doc.
8-3, p. 25). Concerning Dr. Williams’s opinion, the ALJ explained:
The undersigned has taken into consideration the finding of nondisability made by State agency medical consultant, Samuel D.
Williams, M.D., pursuant to Social Security Ruling 96-6p. Dr.
Williams found that [Ms. Coffee] would likely have trouble with more
36
detailed tasks and instructions, but she could maintain attention and
concentration for 2 hours with normal customary rest breaks, and that
her social interaction should be infrequent and non-intensive with the
public as well as her supervision should be tactful, constructive, and
non-threatening (Exhibit B2A). Dr. Williams’[s] opinion was weighed
as a statement from a non-examining expert source with extensive
program knowledge. It was well supported and not inconsistent with
the other substantial evidence as documented by the claimant’s
excellent response to her minimal ongoing treatment (i.e. normal
findings found upon testing by Gadsden Regional Medical Center, the
normal finding found upon testing by the vast majority of her treating
therapist’s reports with the CED Mental Health, as well as her minimal
treatment over the prior year.). Accordingly, the undersigned gives Dr.
Williams’[s] opinion great weight.
(Doc. 8-3, p. 25). In his opinion, the ALJ discussed only some of the limitations that
Dr. Williams identified and incorporated few of those limitations into Ms. Coffee’s
the mental health restrictions in her RFC. (Doc. 8-3, pp. 19, 25).25 The RFC
mentions only two mental health restrictions—no specific production quota and
infrequent contact with the general public. (Doc. 8-3, p. 19). On remand, the ALJ
should consider whether other recommended mental health restrictions should be
incorporated into Ms. Coffee’s RFC.
25
The ALJ did not include Dr. Williams’s supervision limitation or the other moderate limitations
that Dr. Williams described in his functional assessment including being punctual within
customary tolerances, sticking to a schedule, staying on task without special supervision, being
distracted by coworkers, and completing a normal workday because of psychologically-based
symptoms. (Doc. 8-4, p. 16). The ALJ did not give a reason for excluding these limitations from
his RFC assessment. Based on the vocational expert’s testimony, the job of surveillance systems
monitor may be consistent with these additional restrictions.
37
In sum, the ALJ did not provide sufficient reasoning to demonstrate that he
conducted a proper legal analysis. Therefore, the Court reverses the ALJ’s decision.
Cornelius v. Sullivan, 936 F.2d 1143, 1145-46 (11th Cir. 1991).
V.
CONCLUSION
The Court remands this matter for further administrative proceedings
consistent with this opinion.
DONE this 4th day of March, 2020.
_________________________________
MADELINE HUGHES HAIKALA
UNITED STATES DISTRICT JUDGE
38
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