United States District Court, D. New Hampshire
MEMORANDUM AND ORDER
PAUL BARBADORO, District Judge.
Michelle Letellier seeks judicial review of a ruling by the Commissioner of the Social Security Administration ("SSA") denying her application for Supplemental Security Income ("SSI") and Disability Insurance Benefits ("DIB"). Letellier claims that the Administrative Law Judge ("ALJ") lacked substantial evidence to support his finding that she was not disabled. Letellier also claims that the ALJ failed to adequately consider and appropriately weigh the opinions of medical sources when making his residual functional capacity ("RFC") assessment.
For the reasons set forth below, I reverse the decision of the Commissioner and remand for further administrative proceedings.
A. Procedural History
Letellier applied for SSI and DIB on December 8, 2010, claiming that she became disabled due to a back injury on November 13, 2010. Tr. at 183, 190. The SSA denied Letellier's claims on April 27, 2011. Tr. at 88, 91. Letellier requested a hearing before an ALJ, which was held on May 7, 2012. She was represented by an attorney at the hearing, at which a vocational expert ("VE") testified. Letellier presented new evidence at the hearing regarding several impairments in addition to her back injury. On May 25, 2012, the ALJ issued a decision finding Letellier not disabled on or after her alleged disability onset date. The Appeals Council denied Letellier's request for review on April 29, 2013. Accordingly, the ALJ's decision is the final decision of the Commissioner.
B. Relevant Medical History
Several health care providers who treated Letellier for her physical ailments between 2007 and 2012 made note of her mental state during examinations. During numerous visits to Coos County Family Health Services during this period, Letellier complained of depression, anxiety, and panic attacks. Tr. at 436-521, 526-52, 996-1006. Nevertheless, examination notes indicate that she possessed intact judgment, insight, and memory, was oriented to time, place, and person, and showed no signs of depression or anxiety. In 2009 and 2010, Letellier's doctors at the Central Maine Pulmonary and Sleep Medicine facility reported that she was consistently alert and cooperative with normal mood, affect, attention span, and concentration. On November 29, 2010, Dr. Tiffany Pineda, M.D., noted that an examination of Letellier revealed intact memory and normal attention and concentration. Letellier's physical therapist noted that her affect was flat on May 19, 2011.
Dr. Cheryl Bildner, Ph.D., examined Letellier on March 2, 2011. Tr. at 373-77. Letellier reported a history of depression and anxiety, but Dr. Bildner noted that Letellier was not receiving treatment and had never been hospitalized for a psychiatric condition. Dr. Bildner nevertheless diagnosed Letellier with depressive disorder (not otherwise specified) and ruled out undifferentiated somatoform disorder. Upon examination, Dr. Bildner reported that Letellier was alert, oriented to person, place, time, and situation, and presented an appropriate affect, intact thought process, and a fund of knowledge and intelligence in the average range. In contrast, Letellier exhibited a depressed mood, low energy and motivation, and variable attention, concentration, distractibility, and insight. Letellier could follow simple directions but became tangential on several occasions and made errors on the Mini Mental State Examination ("MMSE"). Dr. Bildner noted that Letellier was working as a personal care assistant for seven hours a week and was able to perform most activities of daily living, although some of these activities were limited or modified. In particular, Letellier showered daily, took her own medications, drove, shopped, managed personal affairs, did laundry, and prepared meals. Dr. Bildner concluded that Letellier was able to interact appropriately with others, communicate effectively, understand and remember locations and work-like procedures, understand basic instructions, and make simple decisions. She determined that Letellier was unable to sustain attention and concentration for extended periods of time due to fatigue and distractibility, had poor motivation which interfered with task completion, had a delayed pace of completion, was unable to tolerate stress associated with a workplace, and was unable to maintain a full-time established schedule.
On March 8, 2011, Dr. Laura Landerman, Ph.D., conducted a review of Letellier's complete medical record. Tr. at 378-94. Dr. Landerman noted that Letellier's statements were credible and gave great weight to some of Dr. Bildner's findings, including her diagnosis of a depressive disorder. Dr. Landerman found that Letellier had not experienced any episodes of decompensation of extended duration. She determined that Letellier was mildly limited in her social functioning and activities of daily living, but moderately limited in her ability to maintain concentration, persistence, or pace, to understand, to remember, and to adapt. Dr. Landerman found that Letellier was able to remember locations and work-like procedures, make simple work-related decisions, function effectively without special supervision, maintain a schedule and appropriate attendance, sustain attention and concentration for two-hour periods, persist to task and pace within a normal eight-hour workday and forty-hour workweek without an undue number of interruptions from psychological symptoms, and accommodate to simple and routine changes in the workplace. She concluded that Letellier could interact with co-workers, but would fare better with a gentle, supportive, non-confrontational supervisor, and that she could understand, recall, and carry out short and simple instructions, but would be "unable to consistently do so with more complex and detailed ones." Tr. at 394.
After Drs. Bildner and Landerman had completed their assessments, Letellier began attending periodic therapy sessions with Janice MacKenzie, a licensed clinical social worker. Tr. at 425-35. On November 15, 2011, Ms. MacKenzie completed a medical source statement based on her observations of Letellier over the previous five months. Id . She diagnosed Letellier with recurrent, moderate major depressive disorder in addition to anxiety disorder (not otherwise specified) with posttraumatic traits. Ms. MacKenzie assessed Letellier's global level of functioning as indicative of "flat affect and circumstantial speech[ with] occasional panic attacks[, or] moderate difficulty in social[ or] occupational... functioning (e.g., few friends[ and] conflicts with peers or co-workers)." A mental status examination revealed that Letellier possessed intact memory, rational and organized thought process and content, sad or depressed mood, appropriate affect, and good insight, orientation, and judgment. Ms. MacKenzie concluded that Letellier was markedly limited in her ability to understand, remember, and carry out detailed instructions, to maintain attention and concentration sufficient to perform work tasks throughout an eight-hour workday, to complete a normal workday and workweek without interruptions from psychologically based symptoms, and to perform at a consistent pace without an unreasonable number and length of rest periods.
C. Administrative Hearing - May 7, 2012
1. Letellier's Testimony
In addition to her testimony regarding various physical impairments, Letellier testified that she experienced anxiety and stress. She noted that she had never been hospitalized for a psychological condition, but she participated in therapy once a week, took medication for anxiety, and had been prescribed Klonopin for panic attacks. She reported that she had difficulty shopping for groceries and cleaning the shower ...