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Winfield v. Commissioner of Social Security Administration

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

August 16, 2019

CLYDES WINFIELD, Plaintiff,
v.
COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

          PAMELA A. BARKER, JUDGE

          REPORT AND RECOMMENDATION

          KATHLEEN B. BURKE, UNITED STATES MAGISTRATE JUDGE

         Plaintiff 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.

         For the reasons set forth below, the undersigned recommends that the Court AFFIRM the Commissioner's decision.

         I. Procedural History

         On July 28, 2015, Winfield protectively filed an application for DIB and SSI.[1] 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.

         On 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. Tr. 1-6.

         II. Evidence

         A. Personal, educational, and vocational evidence

         Winfield 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. 44-47, 61.

         B. Medical evidence [2]

         1. Treatment history

         On June 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. 377.

         Winfield 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.

         On 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. Tr. 383.

         Also, 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.

         Winfield saw Nurse Martin on September 16, 2015. Tr. 389-392.[3] 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.

         Winfield 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.

         Winfield 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.

         Winfield 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.

         Winfield 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.

         Winfield 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.

         On 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.

         Thereafter, 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.

         Winfield 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.

         2. Opinion evidence

         Consultative examiner

         On 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, [4] 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.

         Dr. 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 Winfield's abilities:

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 successfully.
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 MULTI-STEP TASKS.
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.

Tr. 403-404.

         State agency reviewers

         On December 3, 2015, state agency reviewing psychologist Bruce Goldsmith, Ph.D., completed a Psychiatric Review Technique (“PRT”) (Tr. 114)[5] and Mental RFC Assessment (Tr. 117-119).[6] 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 ...


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