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Manchook v. Commissioner of Social Security

United States District Court, N.D. Ohio, Eastern Division

May 9, 2019





         I. Introduction

         Plaintiff, Margaret A. Manchook, seeks judicial review of the final decision of the Commissioner of Social Security denying her application for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act. Because the ALJ failed to adequately explain his consideration of a treating physician's opinion, I recommend that the final decision of the Commissioner be VACATED, and the matter be REMANDED for further proceedings consistent with this report.

         II. Procedural History

         Margaret A. Manchook applied for DIB and SSI on April 7, 2015 and April 9, 2015. (Tr. 745-749)[1]. She alleged a disability onset date of February 15, 2015. (Tr. 745). Her application was denied initially on September 3, 2015 (Tr. 650-656) and on reconsideration on December 21, 2015. (Tr. 660-671). Manchook requested a hearing (Tr. 672) and Administrative Law Judge (“ALJ”) Joseph Vallowe heard the case on July 19, 2017. (Tr. 523-573). On December 28, 2017, the ALJ issued a decision finding that Manchook was not disabled. (Tr. 485-511). On May 16, 2018, the Appeals Council denied Manchook's request for further review, rendering the ALJ's conclusion the final decision of the Commissioner. (Tr. 1-4). On July 12, 2018, Manchook filed this action to challenge the Commissioner's denial of her claim. ECF Doc. 1.

         III. Evidence

         A. Relevant Medical Evidence [2]

         Manchook was born on January 7, 1981 and was 36 years old on the day of her hearing. (Tr. 745). She had past relevant work as a state tested nurse assistant (“STNA”), a parts assembler and a fast food worker. (Tr. 538, 565).

         Manchook began suffering from depression and mental health issues when she was fifteen years old. (Tr. 2163). Starting in October 2012, she was attending medication management sessions with nurse practitioner, Bernard Nosanchuk. Manchook complained of depression and anxiety. However, Mr. Nosanchuk often observed a full-range of affect; that Manchook was friendly, talkative and smiled appropriately; and that she did not appear to be in any emotional distress. (Tr. 2211, 2218, 2225, 2233). Mr. Nosanchuk consistently assigned a Global Assessment of Functioning “GAF” score of 60, indicating moderate symptoms of functioning. (Tr. 2165-2255). Manchook was able to work until February 2015.

         Manchook began attending an intensive outpatient partial hospitalization program (“PHP”) in March 2015. She attended group therapy five days per week from 9:00 a.m. to 12:00 p.m. (Tr. 2275). Progress notes show that she reported feeling anxious, hopeless, and overwhelmed at times, but she was generally alert, taking her medications, and participating in the group. (Tr. 2275, 2280, 2282, 2284, 2286, 2287, 2289, 2290, 2292, 2294, 2296, 2304, 2360, 2370). She continued through August 2015. She had two panic attacks during group therapy. (Tr. 2406, 2410).

         On March 10, 2015, Manchook told her case worker, Leslie Green, that she had increased anxiety since her surgery and quitting her job. She was frustrated with her lack of motivation and had been sleeping a lot more lately. (Tr. 1367-1368). On March 23, 2015, Ms. Green noted that Manchook was coping well with her anxiety and attributed her reduction of symptoms to accepting things the way they are presented. (Tr. 1366). On April 13, 2015, Ms. Green noted that Manchook had added art therapy to motivate her toward change and resolution. Manchook reported feeling low energy, having crying spells, and isolating from the outside world. She felt increased frustration and helplessness. (Tr. 1362).

         Manchook was discharged from services at Ohio Guidestone in June 2015 when she “abruptly declined services after two and a half years of treatment.” Ms. Green noted that Manchook had been consistent with her appointments but was very resistant and in denial about resolving issues. She avoided at times and blamed others in addition to feeling inappropriately guilty toward circumstantial stress. Ms. Green opined that Manchook continued to need intensive services in an outpatient setting including partial hospitalization, individual counseling and medication services. (Tr. 1443). Manchook received counseling several times a week from August 2014 to November 2015. (Tr. 2155-2457).

         From September 9 to September 24, 2015, Manchook was hospitalized for depression and suicidal ideations. She reported a loss of interest in doing things, low energy levels, poor concentration, and feeling hopeless, helpless, and worthless. (Tr. 1546). She reported suicidal thoughts with no specific plan. She complained of symptoms of anxiety, having difficulty with interactions with other people, being out in public in common areas, and in front of groups of people. (Tr. 1546). Her mental status examination showed that she was conscious, alert in all spheres, and cooperative. Her memory was intact, and her attention and concentration were fair. Her thought process was linear and concrete and her thought content had no specific paranoia. Her insight was fair. She was diagnosed with bipolar disorder, current episode depressed, severe, without psychotic features; and anxiety disorder, not otherwise specified. (Tr. 1547). During her hospitalization, she underwent five electroconvulsive therapy (“ECT”) sessions. (Tr. 1545-1603). At discharge, she was sleeping better, eating better, was more social, not suicidal and was taking her medications. (Tr. 1599).

         After her hospitalization, Manchook continued to attend intensive outpatient therapy in a PHP at Signature Health four days a week from 9:00 a.m. to 12:00 p.m. (Tr. 265). Her progress notes show that she continued to struggle with anxiety and frustration, but was alert, an active participant, responded well to feedback, denied any problems with her medication and denied suicidal ideation. (Tr. 2420, 2422, 2424, 2426, 2450, 2452, 2455).

         On September 25, 2015, Manchook went to the emergency room with tremors that began three days earlier. She reported that her tremors began after ECT. (Tr. 1606). Physical examination was normal and she did not have any tremors while at the hospital. (Tr. 1608). She was instructed to follow up with a neurologist and her psychiatrist. (Tr. 1608). Manchook returned to the emergency room on September 26, 2015 with similar complaints. The physician opined that the tremors were caused by increased serotonin and were secondary to the ECT. Manchook was advised to reduce her dosage of sertraline. (Tr. 1629).

         Manchook returned to the emergency room on October 1, 2015. She complained of somnolence and memory loss following an AA meeting; she may have passed out but was not sure. Her physical examination was negative for any acute medical cause for her symptoms. (Tr. 1643). On November 2, 2015, Manchook told her family physician that her episode of amnesia may have been caused by the electroconvulsive therapy. (Tr. 1702).

         In October 2015, after Mr. Nosanchuk left the practice, Manchook began treating with Dr. Adella Wasserstein. (Tr. 2163). Dr. Wasserstein assessed anxiety and episodic mood disorder (mostly depressed with good control of mania.) At her first visit, Manchook kept nodding off and Dr. Wasserstein sent her to the emergency room. (Tr. 2164).

         In November 2015, Manchook was less sleepy and no longer dozing off. (Tr. 2272). Her mental status examination showed that she was alert and oriented, withdrawn, but pleasant; her attention and concentration were within normal limits; her mood and affect were euthymic; her speech was regular; her thought process was goal oriented; and her associations and thought content were within normal limits; her recent and remote memory were grossly intact; her judgment and insight were fair. (Tr. 2268). Her mental examination returned similar results on December 1, 2015. (Tr. 2606). Manchook reported that group therapy was the only place she fell asleep. (Tr. 2612).

         Manchook received counseling on a weekly basis from January 2016 to May 2017. (Tr. 2791-3120, 3170-3311, 3487-3510, 3550-3693). Dr. Wassertein occasionally noted a depressed and anxious mood, but many of her mental status examinations were normal. Dr. Wasserstein repeatedly assigned a GAF score of 60. (Tr. 2603-2623, 2747-2789, 3133-3167, 3479-3510).

         In January 2016, Manchook was evaluated by neurology for potential seizure. A prolonged EEG was normal, both awake and asleep. (Tr. 2646).

         On February 2, 2016, Dr. Wasserstein's findings were similar except that Manchook's mood was “euthymic to upset.” (Tr. 2750). Dr. Wasserstein noted that PHP ended on February 8, 2016, that dialectical behavior therapy (“DBT”) was to start on February 10, and that art therapy was to start on February 9. However, Manchook missed therapy because she was ill. (Tr. 2755). Her mood and anxiety were okay with medications despite stressors related to her daughter. She did not feel ready to take possession of her yet because she was too newly on her own. (Tr. 2755).

         On February 23, 2016, she told Dr. Joshua Sunshine that she was doing well and had no complaints; she felt less depressed. (Tr. 2633). On March 14, 2016, Manchook's mood and affect returned to euthymic and her mental status examination was unremarkable. (Tr. 2760). She had custody of her daughter again and was unable to go to DBT and group therapy but had been attending appointments. (Tr. 2766).

         In April 2016, she had a depressed and anxious mood and affect but otherwise a normal mental examination. (Tr. 2771). Manchook reported anxiety and difficulty feeling motivated over the past two weeks. She was not interested in going anywhere and was sleeping about six hours. (Tr. 2777). On May 9, 2016, Manchook's mood was euthymic to overwhelmed and her affect was euthymic. Her mental status examination was normal. (Tr. 2782).

         In June 2016, Manchook reported an increase in depression to her therapist, Kaitlyn Baker. She was staying home and not feeling motivated to complete daily tasks. (Tr. 3081). Later in June, Manchook reported that she was feeling more optimistic; she was modelling positive healthy behavior for herself and her two daughters. (Tr. 3094).

         On August 12, 2016, Manchook reported that she was not feeling depressed or hopeless to her primary care physician. (Tr. 3122). When she met with Dr. Wasserstein on August 22, 2016, she had a depressed to anxious mood, but euthymic affect. Otherwise, her mental examination was normal. (Tr. 3133-3134). Manchook reported that she had stopped taking all her medications two weeks ago at the instruction of her counselor, Ms. Baker. She had actually been instructed to stop taking supplements that were causing diarrhea and had decided to stop all of her medications. Three days before her appointment, she had started taking all her medications again except Gabapentin. Dr. Wasserstein continued her medications and prescribed a lower dose of Gabapentin. (Tr. 3136).

         Manchook's status examination was the same in September 2016. She told Dr. Wasserstein that she continued to feel tired and depressed but was not hopeless or suicidal. (Tr. 3142). In October 2016, Manchook complained of feeling depressed, isolative, having low appetite, intermittent waking and suicidal ideation. She had gone to the emergency room with suicidal ideation but did not require hospitalization. She was attending PHP every day. Dr. Wasserstein did not note any changes to her status examination. (Tr. 3149).

         In November 2016, Manchook reported sleeping more during the day because she was only attending group therapy two times a week. She was still having suicidal ideation and had called the crisis hotline the night before. (Tr. 3156). In December 2016, she continued to complain of occasional passive suicidal ideation. She reported depressive symptoms of ...

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