Szymanski v. Commissioner, Social Security Administration

          MEMORANDUM OPINION AND ORDER

          Nina Y. Wang United States Magistrate Judge

         This civil action arises under Title II of the Social Security Act (“Act”), 42 U.S.C. §§ 401- 33 for review of the Commissioner of Social Security Administration's (“Commissioner” or “Defendant”) final decision denying Plaintiff Cynthia Szymanksi's (“Plaintiff” or “Ms. Szymanski”) application for Disability Insurance Benefits (“DIB”). Pursuant to the Parties' consent [#11], this civil action was referred to this Magistrate Judge for a decision on the merits. See [#17]; 28 U.S.C. § 636(c); Fed.R.Civ.P. 73; D.C.COLO.LCivR 72.2. Upon review of the Parties' briefing, the entire case file, the Administrative Record, and the applicable case law, this court respectfully REVERSES the Commissioner's decision and REMANDS for further proceedings.

         BACKGROUND

         I. Medical History

         Ms. Szymanksi, born January 15, 1957, alleges she became disabled on January 2, 2015, due to bipolar disorder; she was 57 years-old on the date of alleged onset of her claimed disability. See [#9-3 at 90, ^[1] 92; #9-6 at 181, 185]. In 1988, Plaintiff suffered her first major depressive episode, lasting approximately three months, which left Ms. Szymanski feeling depressed most days with a lack of feeling pleasure, energy, or desire to leave her house. See [#9-7 at 278, 302-03, 305]. Plaintiff suffered a second major depressive episode in 1993. See [id. at 278]. Doctors treated both episodes with Prozac, but Plaintiff experienced hypomania and mood destabilization not soon after starting Prozac. See [id.]. Dr. Ken Weiner then diagnosed Plaintiff with bipolar disorder in 1994; Dr. Weiner again prescribed Prozac, which had similar negative effects, but later prescribed Lithium that helped stabilize Plaintiff's mood with some negative side effects. See [id. at 278, 304, 306]. Plaintiff constantly dealt with “serious ups and downs” while hypomanic, including severe fluctuations in impulse control, anxiety, psychotic thoughts, suicidal ideations, depression, insomnia, and energy. See [id. at 278-79, 303-04].

         On May 30, 1996, Plaintiff presented to Dr. Steven L. Dubovsky for a psychiatric evaluation. See [#9-7 at 278]. Dr. Dubovsky noted that Ms. Szymanski's depression “has been accompanied by hypersomnia, slowed thinking, problems with memory and concentration, dissociative symptoms, loss of interest in food[, ] and suicidal thoughts.” [Id. at 278-79]. Dr. Dubovsky continued that Plaintiff “probably had chronically elevated levels of mood, energy and activity, ” but no significant decrease in need for sleep while taking antidepressants; that Plaintiff was “irritable and impatient when her mood [was] elevated but not when her mood is depressed”; that Plaintiff had “chronically racing thoughts during periods of elevated mood but her thinking [was] always slowed when she fe[lt] depressed”; and that Plaintiff sometimes heard her named called and saw movement out of the corner of her eye. See [id. at 279]. Upon examination, Dr. Dubovsky reported that Plaintiff's appearance was “somewhat subdued but [she was] clearly capable of looking much better than she feels”, that Plaintiff's speech was “very well organized and perhaps very slight pressured”, that Plaintiff's affect seemed “slight depressed”, and that Plaintiff's sensorium “appear[ed] intact.” [Id.]. Dr. Dubovsky opined that Ms. Szymanski was mildly depressed, and explained that Ms. Szymanski had “been so accustomed over the years to an abnormal mood that she [did] not notice minor mood swings” and could appear “well when this is not the case.” [Id. at 280].

         Sometime in 1999, Plaintiff checked herself into the hospital for a mental health hold, where she saw Dr. Ben Green. See [#9-2 at 78; #9-7 at 304]. Plaintiff saw Dr. Green quarterly between 1999 and 2006, and Dr. Green prescribed Tegretol, Zoloft, and Klonopin, which “worked ok” and were “tolerable.” [Id.]. Plaintiff eventually weaned herself from these medications and, in 2000, became pregnant with her daughter-a time she “felt the best mentally.” [Id. at 304-05]. Plaintiff managed her bipolar well between 2006 and 2015. See [id. at 282, 306].

         Plaintiff began treating with Dr. Morel Laronn on July 14, 2014. See [#9-7 at 272]. Plaintiff saw Dr. Laronn twice, once on July 14, 2014 and again on May 15, 2015. See [id. at 270-73]. Dr. Laronn noted Plaintiff's treatment history for bipolar disorder, among other ailments, assessed mild depression and generalized anxiety disorder upon psychiatric evaluation, and prescribed Lexapro for Ms. Szymanski's anxiety. See [id.].

         On October 26, 2015, Plaintiff presented to Dr. Moles and reported that “several challenging things happen[ed] to her in the last year”, including losing her house and her husband's treatment for amyloidosis, and that she had “lost interest in things she used to do for fun” and was struggling with anxiety and depression. [#9-7 at 274]. A physical exam revealed that Plaintiff was alert and oriented, could move all extremities, and had a normal affect. [Id. at 275]. Dr. Moles completed a Physical Residual Functional Capacity Questionnaire for Plaintiff, in which Dr. Moles indicated that while Plaintiff had no physical impairments, her psychological impairments rendered her incapable of performing low stress jobs. [Id. at 283-86].

         Plaintiff completed a Function Report on November 8, 2015. She stated that her mental impairment limited her ability to work because she “won't leave [the] house, ” she has a “lack of concentration, focus, confidence or worth, ” and struggles with “extreme fatigue, tearfulness & fear, no motivation, [and] memory problems.” [#9-6 at 199]. She continued that she can work for only short periods before her symptoms “reappear, ” and that she has severe issues with focus and concentration. See [id. at 199, 203-06]. As for her daily activities, Plaintiff reported that she stays indoors for most of the day but picks up and drops off her daughter, drives daily, that she cares for her husband and her daughter, that she does some cooking, that her husband does most of the housework, that she shops and handles finances, and that she has no issues with personal hygiene. See [id. at 200-03]. Plaintiff's husband provided a third-party Function Report that largely mirrors Ms. Szymanski's allegations. See [id. at 210-17].

         On November 9, 2015, state agency psychological consultant Mark Suyeishi, Psy.D. reviewed Plaintiff's medical records. Dr. Suyeishi found a severe mental impairment of anxiety disorders, but noted that there was insufficient evidence to evaluate this impairment because Plaintiff had not responded with requested additional documentation. See [#9-3 at 92-93].

         In 2016, Plaintiff began treating with psychiatrist Dr. Randall Buzan because she wanted “to have a more steady mood.” [#9-7 at 301 (stating Plaintiff complained of not knowing “if it [is] going to be a good day or a bad day.”)]. On April 7, 2016, Dr. Buzan noted that Plaintiff was “delightful, funning [sic], fidgety and bounced leg most of the time, ” sarcastic with a great sense of humor, and that Plaintiff reported that she felt good with her depression a 3/10. See [id. at 309]. Dr. Buzan reported that Plaintiff was “very bright and delightful” with bipolar I disorder, depression, and ADHD-type temperament, but was euthymic. See [id.].^[2] But treatment notes from April 18, 2016 indicate that Plaintiff presented crying and looking exhausted and sad, and that Plaintiff reported feeling “really depressed at this point”, but that she was “not suicidal” just “quite bored with life-no plan, ” and that she denied hypomania and mania. See [id. at 300, 309]. Treatment notes from May 4, 2016 indicate that Ms. Szymanski presented on time and looked more alert and focused with no tics or agitation, and that she reported that she felt good but scattered, that she had no suicidal ideation, that her mood was up and down lately but better for the most part, that she felt overcaffeinated, and that she “fe[lt] clearly improved on the meds so far.” [Id. at 300, 309-10].

         Dr. Buzan's June 14, 2016 Psychiatric Evaluation noted Plaintiff's symptoms as sadness, anxiety, lethargy, hopelessness, lack of motivation, not leaving the house, paranoia, isolation, inability to concentrate or work, and agitation. [#9-7 at 305]. A review of Plaintiff's psychiatric symptoms indicated that Plaintiff was positive for major depression, bipolar I disorder, panic disorder with recent panic attacks and anxiety, agoraphobia, general anxiety disorder, and social phobia. See [id. at 307]. Upon examination, Dr. Buzan noted that Plaintiff was euthymic, thoughtful, well-kempt, logical, and coherent. [Id. at 309].

         Dr. Buzan's treatment notes from September 19, 2016 indicate that Ms. Szymanski presented on time, was pleasant, articulate, oriented, logical, coherent, euthymic, maintained good eye contact, and had no suicidal ideation. See [#9-7 at 316]. Dr. Buzan reported that Plaintiff was “doing very well” psychiatrically and “doing very great” psychiatrically despite some neurological symptoms. See [id. at 317].

         On September 30, 2016, Ms. Szymanski presented to Dr. Ralph Round, per a referral from Dr. Buzan, to follow-up on Plaintiff's neurological symptoms. See [id. at 288-99]. Dr. Round's physical exam revealed that Plaintiff was alert and oriented with intact memory, a good amount of spontaneous speech, a broad fund of knowledge, and normal sensation and reflexes; Dr. Round suspected benign fasciculation syndrome. See [id. at 289-90].

         Plaintiff returned to Dr. Buzan on January 18, 2017, and reported that she thought she “was ok”, that her neurological testing came back normal, that she believed Ritalin was the cause of her neurological issues, and that she felt irritable and sad and like she was cycling a bit when not on Ritalin. See [#9-7 at 322-24]. Dr. Buzan indicated that Plaintiff was contracting for safety and denied current suicidal ideation (with some in the past), and Dr. Buzan requested that Plaintiff email him twice per week. See [id. at 324].

         Dr. Buzan's February 22, 2017 treatment notes reveal that Plaintiff presented sobbing, sad, depressed; tossed a pill bottle at Dr. Buzan while exclaiming “this is not working anymore!”; had passive suicidal ideation; and was too depressed to contact Dr. Buzan for medication suggestions. See [id. at 331-32]. Dr. Buzan implored Plaintiff to “stay in closer touch” for safety reasons. [Id. at 332].

         Ms. Szymanski had a follow-up appointment with Dr. Buzan on March 14, 2017. [#9-7 at 341]. Dr. Buzan noted that Plaintiff emailed often and called because she was “feeling so depressed”, and that Ms. Szymanksi stated that her mood was “ok, better than it was”, that her irritability was better, that she felt it was “too much effort to go out [or] engage”, that she was not exercising, and that she really had to work to “have any kind of affect[.]” [Id. at 347]. In addition to adjusting Ms. Szymanski's medications, Dr. Buzan indicated that Plaintiff struggled with “persisting severe depression” that improved on lithium and Zoloft, and directed Plaintiff to text, email, or call often to discuss how she was feeling. See [id. at 348-49].

         On May 4, 2017, Dr. Buzan provided two Medical Source Statements. Dr. Buzan assessed Ms. Szymanski's mental impairments as having a significant impact on her functionality. See [#9-7 at 355-67].

         II. Procedural History

         On August 14, 2015, Plaintiff protectively filed an application for DIB. [#9-3 at 149]. The Social Security Administration denied Plaintiff's application administratively on November 9, 2015. See [id. at 89]. Ms. Szymanski requested a hearing before an Administrative Law Judge (“ALJ”), see [#9-4 at 104-118], which ALJ Thomas Inman (“the ALJ”) held on May 11, 2017, see [#9-2 at 58]. The ALJ received ...