United States District Court, N.D. Ohio, Eastern Division
MEMORANDUM OPINION AND ORDER
R. Knepp, II Magistrate Judge
Plaintiff Mary Lou Garcia (“Plaintiff”) filed a
Complaint against the Commissioner of Social Security
(“Commissioner”) seeking judicial review of the
Commissioner's decision to deny supplemental security
income (“SSI”). (Doc. 1). The district court has
jurisdiction under 42 U.S.C. §§ 1383(c) and 405(g).
The parties consented to the undersigned's exercise of
jurisdiction in accordance with 28 U.S.C. § 636(c) and
Civil Rule 73. (Doc. 11). For the reasons stated below, the
undersigned affirms the decision of the Commissioner.
filed for SSI in August 2013, alleging a disability onset
date of August 15, 2013. (Tr. 151). Her claims were denied
initially and upon reconsideration. (Tr. 92, 104). Plaintiff
then requested a hearing before an administrative law judge
(“ALJ”). (Tr. 115). Plaintiff (represented by
counsel), and a vocational expert (“VE”)
testified at a hearing before the ALJ on September 2, 2015.
(Tr. 26-56). On November 2, 2015, the ALJ found Plaintiff not
disabled in a written decision. (Tr. 12-22). The Appeals
Council denied Plaintiff's request for review, making the
hearing decision the final decision of the Commissioner. (Tr.
1-4); see 20 C.F.R. §§ 416.1455, 416.1481.
Plaintiff timely filed the instant action on November 3,
2016. (Doc. 1).
Background and Testimony
was born in September 1963, making her 49 years old as of her
alleged onset date, and 52 years old at the time of the
ALJ's decision. See Tr. 156. She lived with her
husband and fifteen-year-old son. (Tr. 34). Plaintiff had
past work as a hotel housekeeper. (Tr. 38-39).
September 2013, Plaintiff completed a function report,
stating she had “no abilities . . . to work anywhere or
with anyone.” (Tr. 182). She claimed her “feet,
legs[, and] hands [were not] functional”. Id.
In describing her daily activities, Plaintiff reported making
coffee, getting her son up for school, “get[ting] mad
and yell[ing] [be]cause the trash is not taken out”,
“[r]oll[ing] cig[arettes]”, “try[ing] to do
dishes” (“I'll start then my back goes
out.”), and watching the news. (Tr. 183). Plaintiff
said she did not go anywhere, and could not be around people
(“People are out to get me”). Id. She
checked a box indicating she had “no problem”
with personal care, but noted forgetting shower, and needing
reminders to take medication. (Tr. 183-84). Plaintiff
reported she could prepare her own meals. (Tr. 184)
(“Cereal, sandwiches, pizza rolls, peanut butter
sandwiches, corn dogs”). She reported that she cooked
spaghetti “once in awhile” and that she did not
cook “hardly at all”. Id. Plaintiff
reported she straightened the living room, and “tr[ied]
to clean every day but . . . [could not] finish what [she]
started.” Id. Plaintiff stated she could not
bend or lift, and reaching up caused her back to “go
out.” (Tr. 185). She reported her “mind starts
going” and she gets so “frustrated that [she]
can't do anything.” Id. She indicated she
went outside twice per week, and could drive or use public
transportation. Id. She checked a box indicating she
could go out alone. Id. She grocery shopped twice
per month for around two hours. Id. Plaintiff
reported watching television and reading as hobbies. (Tr.
186). Plaintiff stated she did not get along with her
neighbors and had no friends. (Tr. 187). Plaintiff indicated
she had difficulty with squatting, bending, reaching,
walking, seeing, memory, completing tasks, concentration,
understanding, following directions, using her hands, and
getting along with others. Id. Plaintiff reported
difficulties with stress and changes in routine, as well as
with authority figures. (Tr. 188). She reported using two arm
braces, a TENS unit, and a back brace. Id.
September 2015 hearing, Plaintiff testified she stopped
working in 2009 because she “got real sick”, had
back problems, and her psychologist told her she should not
work. (Tr. 39). Plaintiff testified she was able to do
housework “[s]ometimes.” (Tr. 34). She testified
that “every day is different”, and that her son
and husband helped. Id. (“If I can't do
it, they'll have to get up and do it.”). Plaintiff
stated she did not cook. (Tr. 35). When asked why, she
responded: “I just don't cook. I don't feel it.
I don't know why. I haven't cooked in over a year
probably, maybe even longer.” Id. Plaintiff
grocery shopped “[m]aybe once a month”, getting
everything the family needed after receiving the monthly food
stamps; and she drove, “[s]ometimes” alone. (Tr.
36-37). When asked if she loaded the bags into the car, she
said: “Not me, he does. I don't carry
nothing.” (Tr. 37). Her son put the groceries away.
Id. She did not use a computer, but did watch
television. (Tr. 38). Plaintiff only left the house to
grocery shop and attend doctors' appointments. (Tr. 44).
testified she had been seeing Dr. Roheny for about six years.
(Tr. 32). Prior to that, Plaintiff had seen a pain management
physician, but stopped because she moved. (Tr. 32-33).
Plaintiff testified to lower back pain that traveled down her
right thigh. (Tr. 40). Plaintiff attributed her back pain to
“making all those stupid beds at the hotel”. (Tr.
43). She also testified to a feeling like “a million
needles” underneath her feet and in her nose. (Tr.
40-41). She estimated she could sit for “[a]bout two
hours” before she would need to get up and move; and
stand for about an hour. (Tr. 42). She estimated she could
walk for less than an hour, and stated she breaks to sit down
while grocery shopping. (Tr. 42-43) (“Yeah, I have to.
I'll be out of breath.”). Plaintiff testified the
only recent treatment for her back problem was pain
medication. (Tr. 47). She had back pain every day, but it
her mental health, Plaintiff testified she had been seeing
Dr. Bukuts for almost nine years. (Tr. 44).
had difficulty staying asleep, and typically got five to six
hours of sleep per night. (Tr. 45). She got up at 6:30 a.m.
to wake her son up. Id. On a good day, Plaintiff
could “get up, get [her] son off to school, get [her]
cats fed . . . and if [she] can try to get [her] house done,
[her] housework done”. (Tr. 46). Her house was small,
only two bedrooms, and she had to take breaks to get the
housework done. Id. On a bad day, Plaintiff got
angry more easily. Id.
time of the hearing, Plaintiff was taking Topamax, methadone,
and Percocet; she had recently stopped taking Xanax. (Tr.
to Alleged Onset Date
March 2010, Plaintiff underwent an initial psychiatric
evaluation with Katherine Proehl, N.D., C.N.S., at the Center
for Families and Children. (Tr. 214-16). Plaintiff reported
diagnoses of bipolar disorder, manic and depressive episodes,
and stated she had been “on some medication in
prison.” (Tr. 214). Ms. Proehl assessed bipolar I
disorder, noted Plaintiff's stressors were
“moderate to severe” and assessed a Global
Assessment of Functioning score of 49. (Tr. 216).
2012, Plaintiff saw James Bukuts, M.D., twice. (Tr. 239-40).
He noted Plaintiff was “[s]till dealing with ongoing
stress” regarding her daughter, who also had mental
health problems. (Tr. 240). He noted no psychosis, a
diagnosis of bipolar disorder, and continued Plaintiff's
medications. (Tr. 239-40). The next month, Plaintiff again
reported “ongoing family issues” and a viral
infection. (Tr. 238). Dr. Bukuts again continued
Plaintiff's medications, and noted Plaintiff should be
“follow[ed] closely.” Id. In July, Dr.
Bukuts noted Plaintiff had suffered a death in the family,
and would be away, and need additional medications. (Tr.
237). He continued Plaintiff's medication. Id.
did not show for her September 2012 appointment. (Tr. 236).
In October, Plaintiff reported she was getting married, and
back from California. (Tr. 234). She was compliant with
medications, and Dr. Bukuts noted her “[s]tress was up
but predictable” and that she had “increased
stress but [was] coping”. (Tr. 234-35). He noted
Plaintiff made some progress toward goals, and should
continue her current treatment plan and medications. (Tr.
235). Plaintiff did not show for her December 2012
appointment. (Tr. 233).
November 2012, Plaintiff saw neurologist Deepak Raheja, M.D.,
reporting difficulty focusing, anxiety, depression, and
insomnia. (Tr. 211). On mental status examination, Dr. Raheja
noted: “[n]ormal orientation, memory, concentration,
language, fund of knowledge.” Id.
Plaintiff's motor examination was also normal.
Id. Dr. Raheja assessed attention deficit disorder
of childhood, without mention of hyperactivity, anxiety,
pseudobulbar affect, and insomnia. Id. She
prescribed Ambien, Nuedexta, and “neuro stimulants for
the symptoms of ADD.” Id. In December 2012,
Plaintiff reported “feeling tired and fatigued all the
time” and reported “good days and bad
days”. (Tr. 210). Dr. Raheja's examination was
normal, and she continued Plaintiff's medications.
Id. Plaintiff returned in January 2013, reporting
“difficulty focusing and staying on task” and
anxiety. (Tr. 209). Her mental status was “[a]lert and
oriented to time, place and person” and her attention
span, concentration, mood, affect, memory, and speech were
normal. Id. Her physical examination was also
normal. Id. Plaintiff's medications were
January 2013, Dr. Bukuts noted Plaintiff was
“stable”, “possibly perimenopausal and
moody”. (Tr. 231). Plaintiff missed her February 2013
appointment. (Tr. 230). In March, Plaintiff was “stable
in spite of a lot of stress in her family”. (Tr. 228).
In both January and March, Dr. Bukuts again assessed some
progress, and noted under treatment recommendations:
“same/follow closely” (Tr. 229, 232), and that
Plaintiff was compliant with her medications (Tr. 228, 231).
Later in March, Plaintiff had an add-on appointment
“because her meds were stolen last week.” (Tr.
225). Dr. Bukuts noted anxiety and depression, and that
Plaintiff was “[s]lightly better since being on the
ADHD meds” (which had been prescribed by a neurologist
at Grace Hospital). Id. Plaintiff had been off Xanax
and Ambien for a week, with limited withdrawal symptoms.
Id. Her medication compliance was noted to be
“[p]artial”, and she had made some progress. (Tr.
225-26). Dr. Bukuts advised Plaintiff to “resume prior
meds but Xanax at lower dose since anxiety is better”.
April 2013, Dr. Bukuts “left a message to call the
Centers to review her meds.” (Tr. 224). At an
appointment two days later, Plaintiff had a “[h]igh
level of stress and used the session to vent.” (Tr.
222). Plaintiff reported she was no longer going to Grace
Hospital because of a “bad customer service
interaction” and was “off the vyvanase and
nudextra”. Id. Plaintiff was adherent to her
medications, which Dr. Bukuts instructed her to maintain, and
noted he would “follow closely in light of the current
stressors”. (Tr. 223).
2013, Plaintiff again “[d]iscussed various issues . . .
primarily related to her [daughter] and her legal
issues”. (Tr. 220). Dr. Bukuts noted Plaintiff reported
anxiety, depression, and panic attacks, explaining:
“steadily increasing over the last 2 months with
building process that she has/feels that she has no active
support or help outside of teenage son”. Id.
Dr. Bukuts noted: “With added stress she has been
cutting[, ] which is a behavior she hasn't done in
years.” Id. Dr. Bukuts assessed
“[g]lobally worsened [symptoms] with depression,
anxiety, and self injurious behavior”. (Tr. 221). He
also noted Plaintiff had “self discontinued
Topamax” due to a “lack of clear benefits”.
Id. She “[r]emain[ed] on nudextra from another
physician she is no longer seeing” and Dr. Bukuts
recommended she “stop since she wasn't taking it
for an approved indication.” Id. He noted
“[p]artial” compliance with medications. (Tr.
in May 2013, at a nursing visit, Plaintiff reported that she
and “her husband ha[d] been working on their
problems”. (Tr. 276). She was compliant with
medications, and reported Trazadone “has helped her
sleep” and “Xanax is also working well.”
Id. At the next visit one week later, Plaintiff
reported she “still ha[d] anxiety” and was
“bothered by her husband's friends calling her cell
phone”. (Tr. 277). She requested a counselor, and noted
she did not mind “coming in for weekly pill
minders.” Id. She noted she “fe[lt]
better coming [to the Centers for Families and Children] and
feels like she is not crazy”. Id. She was
compliant with her medications. Id. In mid-June,
Plaintiff was “changed to two week pill minders”
and was “looking forward to meeting with her counselor
very soon”. (Tr. 279). At the end of June,
Plaintiff's mood was “ok but not great” and
she was “[a]nxious to meet with her case worker
ASAP.” (Tr. 281). Plaintiff returned two weeks later
for her routine pill minder appointment. (Tr. 282). In July
2013, Plaintiff arrived early for her appointment with Dr.
Bukuts, and then left before the appointment time. (Tr. 219).
Alleged Onset Date
August 2013, Dr. Bukuts noted Plaintiff had last been seen
two months prior, but “has had close follow up with
nursing and CPST”, and had remained compliant with
medications. (Tr. 217). Plaintiff reported “ongoing
stressors and increased anxiety” and wanting “a
higher dose of xanax.” Id. Dr. Bukuts
recommended counseling to increase coping skills.
Id. Plaintiff was compliant with her medications
(Tr. 217), and Dr. Bukuts noted “[m]inimal
[p]rogress” and assessed “[s]low improvement with
understanding her [mental illness]”. (Tr. 218). He also
“educated [Plaintiff] further about the long term plan
with getting her of[f] her controlled substances”.
Id. In September, Plaintiff reported improved sleep,
and “mild benefits with depression and anxiety”
with Trazodone. (Tr. 287). She was compliant with her
medications, making “some” progress, and Dr.
Bukuts noted Plaintiff had “added stress with getting
her meds over the past 2 months” and she
“remain[ed] on board with reducing her controlleds long
term” (Tr. 288). He stated he would “hold off
reducing the Xanax or ambien for now[, ] but will at the next
visit as we increase the trazodone further”.
October, Plaintiff reported her stress was “low”.
(Tr. 289). She was compliant with her medications, making
“some” progress, and Dr. Bukuts continued
Plaintiff's medications. (Tr. 290). In November,
Plaintiff's “overall stress level ha[d] been better
over the past month and [she] notice[d] less issues with
depression, anxiety, panic attacks.” (Tr. 291). Dr.
Bukuts educated Plaintiff about her medication “with
the focus of using the trazodone as her main med so the xanax
and the ambien can be phased out.” Id.
Plaintiff was medication compliant, and Dr. Bukuts revised
her diagnosis from bipolar disorder to chronic adjustment
disorder with mixed features of depression and anxiety. (Tr.
292). He noted “slight global improvement of [symptoms]
with trazodone”. Id.
December, Dr. Bukuts noted Plaintiff was “still
handling the stress better with the addition of trazodone to
manage her anxiety and mood”, and her “sleep
remain[ed] improved”. (Tr. 294). She had
“[i]ncreased stress with other family living with her
temporarily” but was “handling [it] better than
she thought”. Id. Dr. Bukuts assessed no
change in Plaintiff's progress, noted medication
compliance, instructed Plaintiff to “[m]aintain same
meds” and noted he would “look at other helpful
ADs on the other side of the holidays so eventually we can
get her off the Xanax.” (Tr. 295). He again noted
“slight global improvement of symptoms with
January 2014, Dr. Bukuts again noted medication compliance,
“[m]inimal” progress, and that the “plan
[was] eventually to completely eliminate or infrequent use of
controlled substances”. (Tr. 297). Plaintiff
“misunderstood the directions at her last visit and
went off the trazodone”. (Tr. 296). He instructed
Plaintiff to “[m]aintain same meds and resume
trazodone”. Id. In February, Plaintiff
reported “limited issues handling the decrease in the
ambien”. (Tr. 300). She again reported increased stress
“and issues with the cold weat[h]er” but was
“handling it better than she thought.”
Id. Dr. Bukuts made similar comments as before:
there was no change in Plaintiff's progress, she should
continue her medications, and she had a “slight global
improvement of symptoms with trazodone”. (Tr. 301).
March 2014, Plaintiff reported “no further improvement
with sleep or irritability through the day but appears to
[be] more related to being perimenopausal.” (Tr. 302).
Plaintiff also reported sleep difficulty, but Dr. Bukuts
noted this “appear[ed] to be a function of poor sleep
hygiene with the culprit being the TV.” Id.
Plaintiff's stress was “up” but she was
“managing better than the past”. Id. Dr.
Bukuts noted medication compliance, minimal progress, and
continued Plaintiff's medications. (Tr. 303). In April,
Plaintiff reported she was doing well. (Tr. 304). Dr. Bukuts
noted medication compliance, and “limited dry mouth
that occurred with the higher dose of the trazodone”.
(Tr. 305). He instructed Plaintiff to continue the same
medications, and noted her primary care physician was slowly
weaning her off Percocet. Id. In May, Plaintiff
reported: “Things are so-so” and reported
stressors regarding “her children and their issues that
are focused around their legal issues”. (Tr. 306). Dr.
Bukuts assessed some progress, noted medication compliance,
and maintained Plaintiff on her medications. Id.
2014, Dr. Bukuts noted no change, medication compliance, and
continued Plaintiff's medications. (Tr. 308-09). In
August, Dr. Bukuts noted Plaintiff had “the positive
focus of her youngest who is doing well and looking forward
to school.” (Tr. 310). He noted medication compliance,
some progress, and maintained Plaintiff's medications.
(Tr. 311). In September, Plaintiff reported a problem with
bedbugs but believed it had been resolved. (Tr. 312). Dr.
Bukuts again noted medication compliance, some progress, and
maintained Plaintiff's medications. (Tr. 313). Notes from
November and December are similar. (Tr. 314-17).
next note in the record from Dr. Bukuts is from April 2015.
(Tr. 325-26). Dr. Bukuts noted he had last seen Plaintiff
“3 months ago because of scheduling issues”. (Tr.
325). Plaintiff reported “some improvement with sleep
and irritability through the day” and increased stress
“but managing better than in the past.”
Id. Dr. Bukuts noted medication compliance, assessed
some progress, and maintained medications. Id. He
noted he would “again increase the trazodone to make it
easier to slowly come off of the xanax and ambien.”
(Tr. 326). The following month, Plaintiff had “moderate
[symptom] impairment” but she was “tolerating the
recent decrease in the xanax 2 weeks ago.” (Tr. 327).
Dr. Bukuts assessed minimal progress, and noted medication
compliance. (Tr. 327-28). He noted he would “again
increase the trazodone” and would “continue the
theme in reduction in Xanax by ½ pill per at least
every 2 weeks and then with nursing support with in between
appointments.” (Tr. 328). He noted that then he would
“move forward with elimination of ambien”.
Id. Dr. Bukuts also “commended [Plaintiff] on
setting better priorities with taking more active
responsibility of her daily affairs”. Id.
August 2015, Dr. Bukuts found Plaintiff had “moderate
to severe” symptoms “with very limited coping
skills and impulse control.” (Tr. 339). However,
Plaintiff stated she was “remaining positive by keeping
herself busy” despite drama in her apartment building.
Id. He assessed minimal progress, noted Plaintiff
was “now off of xanax and trazodone as she did not see
the trazodone as being helpful” and was still taking
Ambien. (Tr. 341). Dr. Bukuts noted he would “educate
around other possible more appropriate med options” and
resumed Topamax, which Plaintiff reported had “some
benefits for anxiety and sleep”. Id.
records from December 2013 through June 2015 show Plaintiff
was prescribed, inter alia, methadone and oxycodone
by Dr. Nader Roheny. (Tr. 331-36).