United States District Court, N.D. Ohio, Eastern Division
A. BARKER, JUDGE
REPORT AND RECOMMENDATION
KATHLEEN B. BURKE, UNITED STATES MAGISTRATE JUDGE
Clydes Winfield (“Plaintiff” or
“Winfield”) seeks judicial review of the final
decision of Defendant Commissioner of Social Security
(“Commissioner”) denying her applications for
Supplemental Security Income (“SSI”) and
Disability Insurance Benefits (“DIB”). Doc. 1.
This Court has jurisdiction pursuant to 42 U.S.C. §
405(g). This matter has been referred to the undersigned
Magistrate Judge for a Report and Recommendation pursuant to
Local Rule 72.2.
reasons set forth below, the undersigned recommends that the
Court AFFIRM the Commissioner's
28, 2015, Winfield protectively filed an application for DIB
and SSI. Tr. 16, 107, 137-138, 139, 236-248.
Winfield alleged a disability onset date of May 1, 2015, (Tr.
16, 236, 243), based on depression (Tr. 107, 139, 171, 180,
297). After initial denial by the state agency (Tr. 171-177)
and denial upon reconsideration (Tr. 180-191), Winfield
requested a hearing (Tr. 192-194). On July 19, 2017, a
hearing was held before an Administrative Law Judge
(“ALJ”). Tr. 41-66.
November 24, 2017, the ALJ issued an unfavorable decision
(Tr. 13-34), finding that Winfield had not been under a
disability within the meaning of the Social Security Act from
May 1, 2015, through the date of the decision (Tr. 17, 28).
Winfield requested review of the ALJ's decision by the
Appeals Council. Tr. 233-235. On May 18, 2018, the Appeals
Council denied Winfield's request for review, making the
ALJ's decision the final decision of the Commissioner.
Personal, educational, and vocational evidence
was born in 1958 and was 59 years old at the time of the
hearing. Tr. 44, 236. From July 2015 through the time of the
hearing, Winfield indicated that she had experienced periods
of homelessness. Tr. 57, 59. At the hearing, Winfield
indicated she had a mailing address that she used but she was
“still kind of homeless.” Tr. 59. Winfield
graduated from high school and has two years of college. Tr.
44. She earned a medical administrative assistant degree. Tr.
44. She has past work as a kitchen helper,
cleaner/housekeeping, and food service worker, hospital. Tr.
Medical evidence 
3, 2015, Winfield was seen by therapist Jen Lemmer-Graber at
Signature Health, Inc. for a mental health diagnostic
assessment. Tr. 371-377. Winfield relayed that she felt like
she was bipolar and had been feeling that way for about three
months. Tr. 371. She had been unable to find a job and was
under a lot of stress because she was facing homelessness.
Tr. 371, 377. Winfield was living with a friend and trying to
find a job. Tr. 377. Winfield reported no previous mental
health concerns and she was not taking any medications. Tr.
377. Ms. Lemmer-Graber diagnosed Winfield with adjustment
disorder with anxiety and noted Winfield had both housing and
economic problems. Tr. 372. Ms. Lemmer-Graber referred
Winfield for counseling and case management services. Tr.
saw therapist Kathleen Allen for an initial counseling
session on June 29, 2015. Tr. 378-380. Winfield relayed that
she had been very depressed and had been having mood swings
since losing her job six months ago. Tr. 380. Winfield
discussed her frustration and stress associated with her
housing situation, her inability to find employment, having
been mistreated by her boss while working at Hillcrest
Hospital, and being fired. Tr. 380. On mental status
examination, Ms. Allen observed that Winfield was well
groomed; she was cooperative; her eye contact was good; her
mood was agitated, constricted, and depressed; and her speech
was normal. Tr. 378. Ms. Allen felt that Winfield might need
an antidepressant so she scheduled Winfield for a psychiatric
evaluation. Tr. 380.
August 19, 2015, Winfield saw Ms. Allen again. Tr. 380-383.
At the beginning of her therapy session, Winfield met with
the case manager assigned to her case. Tr. 383. Winfield was
a on a waitlist for a homeless shelter and the case manager
noted his willingness to help Winfield with transportation to
the shelter once she made it off the waitlist. Tr. 383.
Winfield had started a job through a temp agency - Winfield
liked her supervisor but did not like the gossip and attitude
of her coworkers. Tr. 383. Winfield was going to get paid
later that week. Tr. 383. Winfield relayed that she had
filled out a social security disability application because
she was not certain that she would be able to obtain
permanent work again. Tr. 383. Ms. Allen instructed Winfield
that, once she was in the shelter, she should contact her to
schedule an appointment that would allow for transportation
and that would not conflict with Winfield's work hours.
on August 19, 2015, Winfield saw nurse practitioner Rachael
Martin for a psychiatric evaluation. Tr. 366-370. Winfield
discussed her employment history. Tr. 369. She explained she
was single and never married. Tr. 369. She had an adult
daughter and six-year old granddaughter. Tr. 369. Winfield
did not see them often because her daughter was living with
her boyfriend's mother, whom Winfield did not like. Tr.
369. Winfield was currently living in an abandoned home. Tr.
369. She had a good friend but could not live with him
because of the maximum occupancy allowed on the lease. Tr.
369. Winfield was working at a tea making company, 8 hours
per day, 5 days per week. Tr. 369. Nurse Martin observed that
Winfield had adequate attention and concentration; her affect
was appropriate; she was depressed but friendly, pleasant and
there was no anxiety; her speech was normal, clear and
coherent; her thought process was logical and relevant and,
there were no suicidal/homicidal ideations, ruminations, or
obsessions; she had no abnormal/psychotic thoughts; her fund
of knowledge was adequate; her memory was intact; and her
judgment and insight were intact. Tr. 367. Nurse Martin
diagnosed Winfield with depressive disorder, not otherwise
specified. Tr. 368, 369. She prescribed Celexa. Tr. 368, 369.
saw Nurse Martin on September 16, 2015. Tr.
389-392. Nurse Martin described Winfield's mood
and affect as “affect appropriate, euthymic, friendly,
pleasant, no anxiety.” Tr. 390. Winfield's
attention and concentration were adequate. Tr. 390. Nurse
Martin indicated that Winfield's fund of knowledge was
below average, her memory was intact, and her judgment and
insight were “fair, poor coping, lack of insight to
illness.” Tr. 390. Winfield relayed that things had
been okay. Tr. 391. However, she explained that the Celexa
was causing her to hallucinate. Tr. 391. She described
problems at work due to the hallucinations. Tr. 391. She was
seeing things coming off of the boxes and letters floating
and she was mispackaging tea bags because she did not think
they would fit. Tr. 391. Winfield had last taken her Celexa
the day before and was not currently having the
hallucinations. Tr. 391. She was waiting to hear from a temp
agency about a possible job. Tr. 391.
was interested in transferring her treatment from Signature
Health to Care Alliance. Tr. 429. On October 23, 2015,
Winfield saw Misty Funk, LISW, at Care Alliance for an
initial session. Tr. 436-437. Winfield reported the following
symptoms - anhedonia, anxiety, depressed mood, difficulty
concentrating, fatigue, impaired memory, psychomotor
retardation, weight gain, decreased concentration, fatigue,
sleep disturbance, and uncontrolled worry. Tr. 437. On mental
status examination, Ms. Funk observed Winfield's affect
to be constricted; her mood was depressed; her thought
process was within normal limits; her thought content
involved depressive cognitions; her speech was within normal
limits; and she was cooperative. Tr. 437. Ms. Funk discussed
with Winfield her current psycho-social stressors, including,
loss of employment, no income, and homelessness. Tr. 437. A
follow-up session was scheduled to continue with
Winfield's mental health assessment. Tr. 437.
returned to see Ms. Funk for completion of her mental health
assessment on October 26, 2015. Tr. 426-434. Winfield noted
that her daughter and God were her social supports. Tr. 427.
She also noted having a few close friends. Tr. 428. Winfield
was single and never married. Tr. 428. Her parents had both
passed away. Tr. 427. In her free time, Winfield indicated
she cleans, does laundry, looks for jobs, prays, watches
television and spends time with her granddaughter. Tr. 428.
Ms. Funk's mental status examination reflected a normal
mood and affect. Tr. 433. Ms. Funk diagnosed major depressive
disorder, recurrent episode, moderate with anxious distress
and she noted homelessness and extreme poverty as
psychosocial and contextual factors. Tr. 433. Recommendations
included continued counseling. Tr. 434.
saw Ms. Funk for an individual counseling session on November
2, 2015. Tr. 423-424. Winfield reported continued anxiety
about her homeless status and lack of income. Tr. 423.
Winfield's affect was constricted; her mood, thought
process, and speech were within normal limits; her thought
content was unremarkable; and her behavior was cooperative.
Tr. 423-424. Ms. Funk assisted Winfield with prioritizing her
goals and addressing her need for housing. Tr. 424.
saw Ms. Funk on December 2, 2015, for a behavioral health
follow-up visit. Tr. 418-419. Winfield reported the following
symptoms - anxiety, depressed mood, difficulty concentrating,
fatigue, somatic symptoms, restlessness, sleep disturbance
and uncontrolled worry. Tr. 418. Winfield was in the
processing of completing housing applications. Tr. 418.
Winfield's affect was constricted; her mood, thought
process, and speech were within normal limits; her thought
content was unremarkable; and her behavior was cooperative,
focused. Tr. 418. Ms. Funk continued to assess major
depressive disorder, homelessness, and extreme poverty. Tr.
419. Because Ms. Funk was going to be leaving the agency, Ms.
Funk discussed with Winfield the idea of meeting with another
counselor. Tr. 418-419. Winfield was not interested. Tr. 419.
saw Ms. Funk again on December 9, 2015, and December 16,
2015. Tr. 442-443, 444-445. During the December 16, 2015,
visit, Winfield relayed that she had completed two housing
applications and she was trying to get medication for her
mental health symptoms. Tr. 443. Winfield was still homeless
but she was staying with her daughter and several friends.
Tr. 443. Winfield's application for SSI had been denied
but she had engaged an attorney to advocate for her. Tr. 443.
On mental status examination, Ms. Funk observed that
Winfield's affect was constricted; her mood and thought
process were within normal limits; her speech was slowed; her
thought content was unremarkable; and her behavior was
cooperative. Tr. 443. Ms. Funk continued to assess major
depressive disorder, homelessness, and extreme poverty. Tr.
443. Ms. Funk provided Winfield with a referral for Murtis
Taylor and recommended that Winfield return in two weeks for
a follow-up visit and meet with her primary care physician to
discuss medication options for her depression. Tr. 443.
February 5, 2016, Winfield saw Crystal Mann, a professional
counselor, with Murtis Taylor Human Services for assessment
of her depression and anxiety. Tr. 544-554. Ms. Mann noted
that Winfield had been receiving treatment at Care Alliance
but she was interested in treatment closer to home. Tr. 544.
Winfield relayed that she felt depressed and anxious on a
daily basis, noting she had been on medication for a few
years to help decrease her symptoms but it caused
hallucinations. Tr. 544. Winfield reported that she had been
unable to keep a job and had no income at the time. Tr. 544.
While Winfield wanted to work, she did not feel that she was
able to work. Tr. 544. Winfield was living with her daughter
and her daughter was taking care of her until she could get
back on her feet. Tr. 545. Winfield had some friends that she
talked to from time to time. Tr. 545. As far as activities,
Winfield relayed that she watches television, visits the
library, plays on her phone and does research, cooks, cleans,
washes dishes, and reads her Bible. Tr. 545. On mental status
examination, Ms. Mann observed that Winfield's appearance
was unkempt; she reported no delusions or hallucinations; her
thought process was tangential and she needed to be
redirected at times; her mood was euthymic; her affect was
constricted, showing little range of emotion and presenting
her history in a very matter of fact manner with little
embellishment; Winfield was cooperative but she fidgeted
during the session; Winfield had mild impairment in memory,
attention and concentration, reporting some difficulty with
memory and giving very few details in regard to her history
and having difficulty focusing during the session; and she
showed little insight into her mental health and was quick to
blame others for the problems in her life. Tr. 549-550. Ms.
Mann noted that Winfield downplayed the severity of her
symptoms. Tr. 552. Ms. Mann diagnosed bipolar II disorder.
Tr. 544. Ms. Mann recommended medication management to
decrease Winfield's mental health symptoms and regulate
her mood and services to assist Winfield with benefits,
housing, community resources and support. Tr. 551.
on March 30, 2016, Winfield saw Dr. Manuel Gordillo, M.D., at
Murtis Taylor for a psychiatric evaluation. Tr. 555-557.
Winfield complained of mood swings. Tr. 555. Dr. Gordillo
noted that Winfield had been treated with Celexa in the past
for a diagnosis of bipolar depression but the medication
caused hallucinations. Tr. 555. Dr. Gordillo noted
Winfield's strengths and assets were “partial
insight, future oriented, has place to live, does volunteer
work for her church [and] cares for granddaughter while
[daughter] works.” Tr. 556. On mental status
examination, Dr. Gordillo observed Winfield's appearance
and grooming to be neat and clean; her affect was labile; her
mood was depressed; her thought content was coherent; her
speech was soft; she had average intelligence; her
concentration was intact; and she had limited
judgment/insight. Tr. 556. Dr. Gordillo diagnosed bipolar II
disorder and he prescribed Latuda. Tr. 555.
saw Dr. Gordillo for a follow-up medication management visit
on April 6, 2016. Tr. 558-565. During that visit, Dr.
Gordillo observed that Winfield's affect was appropriate;
her speech was clear and distinct; her mood was euthymic; her
thought processes/content were coherent; her judgment and
insight were fair; and there were no hallucinations,
delusions, or homicidal ideation. Tr. 559. Dr. Gordillo made
no changes to Winfield's medication, noting that her
medication was effective. Tr. 560.
November 16, 2015, consultative examiner, Richard N. Davis,
clinical psychologist, examined Winfield. Tr. 398-405.
Winfield relayed that she was applying for disability
benefits because of physical and emotional problems and she
indicated that her depression was caused by her homelessness
and inability to find a job to correct the problem. Tr. 398.
Winfield discussed her activities of daily living,
indicating that she spent most of her time at her
daughter's place. Tr. 402. If she is staying at her
daughter's, she tries to bathe daily and she helps her
daughter, who is employed, with chores and grocery shopping.
Tr. 402. Winfield reads the newspaper and watches about four
hours of television each day. Tr. 402. She indicated that she
liked to volunteer at concerts because she can then see the
concert for free. Tr. 402. She tries to keep in touch with
her friends and tries to attend religious services every
week. Tr. 402. Winfield indicated that she spends a lot of
time at her church. Tr. 403. Winfield indicated that, if she
had not had her appointment with Dr. Davis, she likely would
have attended a political event that day. Tr. 403.
Davis noted that Winfield presented with intellectual
limitations and seemed restricted in her daily activities.
Tr. 404. Dr. Davis diagnosed Winfield as having adjustment
disorder with mixed anxiety and depressed mood. Tr. 404. He
provided the following functional assessment regarding
1. DESCRIBE THE CLAIMANT'S ABILITIES AND LIMITATIONS IN
UNDERSTANDING, REMEMBERING AND CARRYING OUT INSTRUCTIONS.
This is an individual who had difficulty in keeping
information in mind long enough to deal with the math
problems that I was giving her. I gave her some very easy
math problems and she couldn't even deal with those
2. DESCRIBE THE CLAIMANT'S ABILITIES AND LIMITATIONS IN
MAINTAINING ATTENTION AND CONCENTRATION AND MAINTAINING
PERSIST[E]NCE AND PACE TO PERFORM SIMPLE TASKS AND TO PERFORM
She seemed to be paying attention and concentrating but then
when I would ask her if she was going to try and solve the
problems, she would ask me to repeat them. I suspect that
this behavior is what got her let go from as many jobs as she
says she has had and loses. She seemingly is able to perform
at simple repetitive tasks. In the job that she had at
Hillcrest she worked in food service. This was where she was
accused of stealing a burrito.
3. DESCRIBE THE CLAIMANT'S ABILITIES AND LIMITATIONS IN
RESPONDING APPROPRIATELY TO SUPERVISION AND TO CO-WORKERS IN
A WORK SETTING.
She apparently has difficulty getting along with supervisors,
saying that they constantly pick on her.
4. DESCRIBE THE CLAIMANT'S ABILITIES AND LIMITATIONS IN
RESPONDING APPROPRIATELY TO WORK PRESSURES IN A WORK SETTING.
She didn't seem to be having difficulties dealing with
the stresses and pressures in my office but says that certain
work settings were uncomfortable places for her to be because
of not being able to get along with the supervisors.
December 3, 2015, state agency reviewing psychologist Bruce
Goldsmith, Ph.D., completed a Psychiatric Review Technique
(“PRT”) (Tr. 114) and Mental RFC Assessment (Tr.
117-119). In the PRT, Dr. Goldsmith opined that
Winfield had moderate restrictions in activities of daily
living, moderate difficulties in maintaining social
functioning, and moderate difficulties in maintain
concentration, persistence, or pace. Tr. 114. He found no
repeated episodes of decompensation, each of extended
duration. Tr. 114. In the Mental RFC, Dr. Goldsmith opined
that Winfield retained the ability to complete simple 1-3
step tasks; sustain attention, concentration, persistence,
and pace to perform routine tasks that do not require
fast-paced performance or have strict production quota
requirements; interact in situations that do ...