Melton v. Comm'r of Soc. Sec. Admin.

LATANYA MELTON, Plaintiff, v. COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION, Defendant.

No. 5:21-CV-02193-BYP

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

October 13, 2022

BENITA Y. PEARSON JUDGE

REPORT AND RECOMMENDATION

DARRELL A. CLAY UNITED STATES MAGISTRATE JUDGE

Introduction

Plaintiff LaTanya Melton filed a Complaint against the Commissioner of Social Security (Commissioner) seeking judicial review of the Commissioner's decision denying disability insurance benefits (DIB) and supplemental security income (SSI). (ECF #1). The District Court has jurisdiction under 42 U.S.C §§ 1383(c) and 405(g). On November 18, 2021 pursuant to Local Rule 72.2, this matter was referred to me for preparation of a Report and Recommendation. (Non-document entry dated November 18, 2021). Following review, and for the reasons stated below, I recommend the District Court REVERSE and REMAND the Commissioner's decision for further proceedings consistent with this Report and Recommendation.

Procedural Background

Ms Melton filed for DIB and SSI on June 20, 2019, alleging a disability onset date of January 3, 2019. (Tr. 430-38). The claims were denied initially and on reconsideration. (Tr. 287322; 325-62). She then requested a hearing before an Administrative Law Judge. (Tr. 382-83). Ms. Melton (represented by counsel) and a vocational expert (VE) testified at a hearing before the ALJ on September 3, 2020. (Tr. 243-86). On October 15, 2020, the ALJ issued a written decision finding Ms. Melton not disabled. (Tr. 222-42). The Appeals Council denied Ms. Melton's request for review, making the hearing decision the final decision of the Commissioner. (Tr. 1-6; see 20 C.F.R. §§ 404.955, 404.981, 416.1455, and 416.1481). Ms. Melton timely filed this action on November 17, 2021. (ECF #1).

Factual Background

I. Personal and Vocational Evidence

Ms. Melton was 43 years old at the time of her alleged onset date and 44 at the time of the administrative hearing. (Tr. 250). Ms. Melton has an Associate's degree in business administration. (Tr. 252). In the past, Ms. Melton has been employed as a daycare worker, loan processor, nursing assistant, health aide, state tested nurse aide (STNA), scheduler, medical biller, and office manager. (Tr. 252-64).

II. Relevant Medical Evidence^[1]

In July 2019, in connection with her social security claims Ms. Melton underwent a psychological consultative exam with Herschel Pickholtz, Ed.D. (Tr. 1464). At the time of her evaluation, Ms. Melton was not married or otherwise attached and lived with her mother and two children, ages five and three. (Tr. 1465). Although her relationship with her mother was strained, her relationships with her children and siblings were good. (Id.). She noted that psychiatric problems run in her family. (Id.).

Ms. Melton reported doing well in school. (Tr. 1467). While Ms. Melton's relationships with her teachers were “okay,” she identified as a loner and did not have much of a relationship with classmates. (Id.). Ms. Melton noted that she liked to watch TV and read, socialized with two friends about once a month, and could care for her personal hygiene needs and do light household chores. (Tr. 1470-71).

Dr. Pickholtz noted Ms. Melton appeared to be experiencing moderate impairments due to her depression and moderate to severe levels of anxiety. (Tr. 1468). According to Dr. Pickholtz's report, Ms. Melton had “lost many good jobs due to bipolar issues. She usually didn't receive psychiatric treatment.” (Id.). Ms. Melton said she last worked in early 2019 but left “due to a lot of physical problems and was having anxiety and depression.” However, Dr. Pickholtz noted that with respect to her most recent job, “[u]ntil she left, she did fair at work without psychiatric treatment.” (Id.).

Dr. Pickholtz found Ms. Melton was compliant during the evaluation but appeared to be experiencing some anxiety. (Tr. 1468). She had appropriate and consistent eye contact, logical

Melton's brief asserts that the ALJ's decision is not supported by substantial evidence as it pertains to the opinion of Ms. Melton's treating psychiatric nurse practitioner (PNP), Rachael McLaughlin. The Commissioner noted that “Plaintiff only challenges the ALJ's assessment of her depression, anxiety, and posttraumatic stress disorder (PTSD)” and limited her brief accordingly. (Comm'r's Br., ECF # 13, PageID 2264). Because Ms. Melton's Complaint relates only to an opinion regarding her psychiatric conditions, I have limited my discussion of the medical evidence to that relating to Ms. Melton's mental health. speech, and normal long-term memory, but a somewhat constricted affect and depressed mood. (Tr. 1468-70). The report notes that Ms. Melton cried on several occasions and smiled twice during the evaluation. (Tr. 1469). Dr. Pickholtz found Ms. Melton was capable of monitoring benefits in an independent fashion should they be granted, but that her overall level of intellectual functioning was in the borderline to low average range. (Tr. 1470).

For his functional assessment, Dr. Pickholtz observed that Ms. Melton had somewhat of an impairment in her ability to understand, remember, and perform simple one- to two-step tasks. (Tr. 1472-73). He said that even with her current medications, she had a significant impairment in responding to supervisors or coworkers in a work setting, and a “very serious impairment at the present time” in her ability to respond to work pressures. (Tr. 1473).

On August 2, 2019, Ms. Melton presented to a social worker at Signature Health Inc. (Tr. 1556). Ms. Melton reported having “mental health symptoms since she was a child” but “never received any kind of formal diagnosis or treatment.” (Tr. 1557). The intake notes state Ms. Melton came to Signature Health to “get help because she is having interpersonal problems and difficulty maintaining employment due to mental health symptoms.” (Id.).

Ms. Melton reported experiencing symptoms for over a decade, resulting from a history of trauma. (Id.). She reported being repeatedly molested by family members as a child, teased for being biracial, and was largely raised by her grandparents because her mother was an addict. (Id.). Her symptoms - including being easily angered, frustrated, argumentative, and overwhelmed; having mood swings and racing thoughts; low mood and energy; and a poor memory for about six months - worsened when her child died unexpectedly in 2012. (Id.). Ms. Melton scheduled psychiatric and counseling appointments at Signature Health. (Id.).

Two days later, on August 5, 2019, Ms. Melton saw a Signature Health counselor. A mental status exam found she was well-groomed, cooperative, had good eye contact, full range mood, broad affect, and normal speech. (Tr. 1542). Ms. Melton described a tumultuous relationship with the father of her children and said her mother was “extremely negative and invalidating.” (Tr. 1545). Ms. Melton “filed for disability for physical health issues” and was sent to a “state doctor” for an evaluation, who had encouraged her to get treatment for her mental health. (Id.).

The next day, on August 6, 2019, after reviewing Ms. Melton's records, state agency psychologist Richard Hamersma, Ph.D., issued his administrative findings on Ms. Melton's workplace abilities and limitations. Dr. Hamersma determined that Ms. Melton had no more than moderate limits in each of the Paragraph B criteria. (Tr. 301-02). In particular, he determined she retained the capacity to understand, remember, concentrate, persist, and maintain pace to complete one- to two-step simple routine tasks; interact with coworkers on a brief and superficial basis in a non-public environment; and adapt to a static environment. (Tr. 301-02).

On August 19, 2019, Ms. Melton had another counseling session at Signature Health where she reported having been “an emotional wreck” due to living with her mother who was “very invalidating” and impatient with Ms. Melton's two children. (Tr. 1550). She reported she was “afraid to try to go back to work,” felt like she needed medication to “help her calm down,” and was glad her psychiatric appointment was “soon.” (Id.).

On August 26, 2019, Ms. Melton had her first psychiatric appointment at Signature Health, with PNP Rachael McLaughlin, a Board Certified Psychiatric Mental Health Nurse Practitioner. A mental status exam found Ms. Melton to be friendly and pleasant with adequate attention and concentration, consistent eye contact, good hygiene, normal speech and thoughts, intact memory, mild anxiety, a depressed mood, fair judgment, and poor coping skills. (Tr. 153435). Ms. Melton reported feeling depressed some days, but also said that she was occasionally able to enjoy things. (Tr. 1538). Ms. Melton said she was easily irritated and agitated and PNP McLaughlin noted she was “very defensive.” (Id.). Ms. Melton reported symptoms of panic about every other day that lasted for up to 20 minutes. (Id.). She reported episodes of staying up all night, up to two days in a row, in which she “hears people calling her name or sees shadows sometimes, like ghosts.” (Id.). Ms. Melton reported thoughts of suicide a few months prior, but thoughts of her children prevent her from coming up with plans. (Id.). PNP McLaughlin diagnosed her with bipolar II disorder, PTSD, and panic disorder, and prescribed a mood stabilizer. (Tr. 1539).

At a follow-up with PNP McLaughlin on September 9, 2019, Ms. Melton's mental status exam was unchanged. (Tr. 1561-61). Ms. Melton reported concerns that her new medication was “not strong enough,” and PNP McLaughlin prescribed a medication to use as needed for anxiety. (Tr. 1564).

On September 26, 2019, Ms. Melton saw PNP McLaughlin. Ms. Melton reported she had a panic...