United States District Court, E.D. Louisiana
J. BARBIER, JUDGE
REPORT AND RECOMMENDATION
VAN MEERVELD, UNITED STATES MAGISTRATE JUDGE
plaintiff, Lisa Leehans, seeks judicial review, pursuant to
Section 405(g) of the Social Security Act (the
“Act”), of the final decision of the Commissioner
of the Social Security Administration (the
“Commissioner”) denying her claim for disability
insurance benefits (“DIB”) and supplemental
security income (“SSI”) under Titles II and
XVI of the
Act, 42 U.S.C. §§ 423, 1381. The matter has been
fully briefed on cross-motions for summary judgment. For the
following reasons, IT IS RECOMMENDED that the Motion for
Summary Judgment filed by the plaintiff (Rec. Doc.14) be
GRANTED in part and DENIED in part; and the Motion for
Summary Judgment filed by the Commissioner (Rec. Doc. 19) be
DENIED. The matter should be remanded to the ALJ for further
proceedings as recommended herein.
Leehans applied for DIB on July 7, 2015, and for SSI on
August 1, 2015,  asserting in both applications a
disability onset date of January 15, 2011. She alleged the
following illnesses, injuries, or conditions: bipolar. On
December 10, 2015, her claims were denied by the state
agency. The Disability Determination Explanations on her DIB
application concluded that “The medical evidence shows
you had a history of mental problems. The evidence was not
sufficient to show your condition was totally disabling prior
to 03 / 31 / 15, when you were last insured for these
benefits.” R. at 115. The Disability Determination
Explanations on her SSI application concluded that
“[t]he medical evidence shows your overall condition
restricts the types of jobs you can perform, but is not
totally disabling. You can perform most normal activities.
You can get along with others and follow simple
directions.” R. at 106.
Leehans obtained counsel and requested a hearing before an
Administrative Law Judge (“ALJ”), which was held
on March 15, 2017. At the hearing, Ms. Leehans noted that
there was a prior final ALJ decision dated January 13, 2014
and requested that the alleged disability onset date be
amended to March 12, 2014, the date on which Ms. Leehans was
hospitalized at the Greenbriar hospital. The motion to amend
the alleged onset date was granted. On June 9, 2017, the ALJ
issued an adverse decision. Ms. Leehans timely appealed to
the Appeals Council, which denied review on April 12, 2018.
16, 2018, Ms. Leehans filed a Complaint in federal court to
review the Commissioner's decision. (Rec. Doc. 1). The
Commissioner answered and filed the administrative record.
(Rec. Docs. 10, 11). The parties filed cross-motions for
summary judgment. (Rec. Docs. 14, ) 19. Ms. Leehans is
represented by counsel.
in the Record
hearing before the ALJ in March 2017, Ms. Leehans testified
that her most recent psychiatric hospitalization was in March
2014. R. at 43. She testified that since that time she had
been on medication and had been receiving treatment through
the St. Tammany Community Health Center. R. at 43-44. She
testified that she had no side effects from her medication.
R. at 45, 47. However, she later testified that the medicine
makes her “real zombified.” R. at 47. She
testified that even with the medication she still hears
voices about every other day. R. at 45. She testified that
she felt her condition was getting worse. R. at 48. She
testified that she did not think she could work because the
medication does not always work and she was afraid she would
not be able to multitask. R. at 50. When asked if she thought
she could work if she did not have to multitask, she said
“no” because her medication makes her feel like
she is in another world. R. at 60. Upon further questioning,
she explained that it made her feel sleepy and she thinks
about being somewhere else. R. at 61. She said that about
once a week, for 15-20 minutes, she wishes to be in Mexico.
Leehans testified that about 3 or 4 days a week she just
wants to stay in bed. R. at 51. She later testified she feels
that way every day. R. at 52. Ms. Leehans testified that she
had not had homicidal thoughts since her March 2014
hospitalization. R. at 56. She testified that she lives with
her husband and daughter and that she gets along well with
her daughter and “pretty good” with her husband.
R. at 56. She testified that she takes a shower and gets
dressed on her own every day. R. at 58.
hearing, Ms. Leehans amended her disability onset date to
March 12, 2014, and the court begins its summary of the
medical records on that date. Ms. Leehans was hospitalized at Greenbriar
Behavioral Hospital from March 12, 2014, through March 20,
2014 on referral from Slidell Memorial Hospital “on a
[physician's emergency commitment] secondary to suicidal
ideations with a plan.” R. at 503. Ms. Leehans reported
that she had recently started having auditory hallucinations,
that she was feeling paranoid, was experiencing low energy,
and was having intermittent crying and suicidal ideations.
Id. She reported spending money impulsively,
worrying excessively with tension and irritability, and that
she had been charged with theft of more than $500.
Id. Ms. Leehans was placed on Prozac, Haldol, and
Vistril. Id. At discharge she was tolerating her
medication well, denied suicidal or homicidal ideations,
reported an improvement in her depression and anxiety, and
reported no auditory of visual hallucinations. Id.
She was diagnosed with schizoaffective disorder, depressed
with a Global Assessment of Functioning (“GAF”)
score of 50. Id. She had been assessed with a GAF of
27 upon admission. R. at 508.
18, 2014, Ms. Leehans presented at the NMCH Emergency
Department reporting hearing voices telling her to rob a
store and hurt herself. R. at 336. She noted a recent
medication change to Risperdal on July 10, 2014. R. at
336-37. She was noted to be negative for suicidal ideas,
confusion, sleep disturbance, and self-injury. R. at 337. Dr.
John B. Seymour noted that Ms. Leehans did not appear to be
responding to internal stimuli and did not appear to be
delusional. R. at. 383. She was discharged later that day. R.
Leehans again presented at the NMCH Emergency Department on
August 27, 2014 reporting suicidal thoughts. R. at 348. She
reported multiple recent stressors. R. at 349. She reported
that she had not seen her psychiatrist since discharge
(presumably from her July 18, 2014, emergency department
encounter) and that she was compliant with her medication.
Id. Upon examination, Dr. Michael Knisley noted Ms.
Leehans had a restricted affect, depressed mood, but fair
insight. R. at 351. She was diagnosed with bipolar disorder.
R. at 352. When she spoke with registered nurse Kenitra
Payne, Ms. Leehans reported being under a lot of stress and
that she was going to a psychiatric facility that would help
her. Id. Nurse Payne noted that Ms. Leehans had a
pleasant mood and was calm and cooperative. Id. A
psychiatric placement was sought, and on August 28, 2014, the
NMCH records indicate that Ms. Leehans was transferred to
Northlake Behavioral Hospital for psychiatric evaluation and
treatment. R. at 353-55. Although neither party has addressed
their absence, it appears there are no records of treatment
at the Northlake Behavioral Hospital. There may not have been
an inpatient hospitalization at that time. Ms. Leehans
testified at the hearing before the ALJ in March 2017 that
the last time she had been hospitalized was in March 2014. R.
do not appear to be any medical records from September 2014
through December 2014.
Leehans presented at the Slidell Memorial Hospital on January
1, 2015 complaining of left ear pain. R. at 436. A physical
examination was performed, but no notes regarding her
psychiatric condition were made.
January 15, 2015, she visited the St. Tammany Community
Health Center and reported hearing voices and having thoughts
that people are out to get her for no reason. R. at 530. She
reported chest pain, anxiety and worry, impulsivity, and
irritability. Id. Her attitude was noted to be
guarded, her mood was noted to be dysthymic. Id. She
was nervous and fidgety. Id. But Ms. Leehans was
also noted to be non-psychotic. R. at 531. Her thought flow
was coherent and rational and her attention demonstrated no
abnormalities. Id. She had no suicidal or homicidal
ideation. Id. Invega and lithium were continued and
she was prescribed Risperdal. Id.
Leehans again presented at the Slidell Memorial Hospital on
February 11, 2015 with ear pain. R. at 454. Her behavior,
mood, and affect were noted to be within normal limits. R. at
456. She was awake and alert with orientation to person,
place and time. Id.
April 21, 2015, she visited the St. Tammany Community Health
Center and reported that she was hearing voices again. R. at
523. She denied a suicidal plan. Id. Her thinking
was vague at times and tangential, her mood was worrisome and
her thought content was of helplessness. Id.
Leehans presented at the Slidell Memorial Hospital on May 2,
2015 with a sore throat. R. at 493. Her behavior, mood, and
affect were noted to be within normal limits. Id.
She was awake and alert with orientation to person, place and
August 2015, Ms. Leehans filled out a Function Report and
reported feeling “the shakes” because of her
medication and feeling like “everybody is watching
everything I do.” R. at 211. She reported that her
daily activities included watching TV, doing housework,
washing clothes, and taking walks to calm her nerves. R. at
212. She reported going shopping for groceries or clothing
every week for about two hours. R. at 214. She reported that
she cannot talk intimately with others, cannot remember
everything she is supposed to, cannot concentrate enough to
complete, understand, and follow instructions. R. at 215.
November 2015, the consultative examiner Dr. Shah conducted a
medical status examination and found Ms. Leehans' affect
restricted and mostly euthymic, her speech normal, and her
thought process concrete. R. at 498. For memory and
understanding, she was able to recall three objects out of
three at the end of five minutes and was able to repeat seven
digits forward and five digits backward correctly.
Id. For concentration and attention, she was able to
do serial 3s subtractions from 20. Id. She was able
to interpret the proverb “spilled milk, ” her
insight was fair, and her judgment was normal (if she found a
stamped envelope in the street she would put it in a
mailbox). Id. Dr. Shah concluded that Ms. Leehans
“did well with cognitive tests on mental status
examination today.” R. at 499. Dr. Shah noted that Ms.
Leehans could manage personal hygiene daily on her own and
manage some cooking, cleaning, and doing laundry and that she
gets help from her spouse with shopping. Id. Dr.
Shah noted that Ms. Leehans reported avoiding socialization
and crowds in general. Id. Dr. Shah diagnosed Ms.
Leehans with Bipolar 1 Disorder MRE [Most Recent Episode]
Mixed with Psychosis in Partial Remission. Id.
of the Administrative Law Judge
ALJ found that Ms. Leehans meets the insured status
requirements of the Act through March 31, 2015. The ALJ found
that Ms. Leehans has not engaged in substantial gainful
activity since March 12, 2014, the amended alleged onset
date. The ALJ determined that Ms. Leehans has the following
severe impairments: bipolar disorder, schizoaffective
disorder with psychosis and depression, and anxiety disorder.
However, the ALJ determined that Ms. Leehans does not have an
impairment or combination of impairments that meet or
medically equals the severity of one of the listed
impairments in 20 C.F.R. § 404, Subpart P, Appendix 1.
The ALJ considered the criteria in listings 12.03, 12.04, and
12.06. The ALJ then found that Ms. Leehans has the residual
functional capacity to perform a full range of work at all
exertional levels but with the following non-exertional
limitations: performance of tasks commensurate with an SVP
level of two or less, only occasional interactions with
co-workers and supervisors, no interaction with the public,
and only work not requiring fast-paced production quotas such
as those quotas present in moving assembly work or lunchtime
work in a fast food establishment. The ALJ determined that
Ms. Leehans was unable to perform any of her past relevant
work. The ALJ found that Ms. Leehans was 38 years old, which
is defined as a “younger individual, ” on the
alleged disability onset date. The ALJ determined that Ms.
Leehans has at least a high school education and is able to
communicate in English. The ALJ found that transferability of
job skills was not material to the determination of
disability because using the Medical-Vocational Rules as a
framework supports a finding that Ms. Leehans is “not
disabled” whether or ...