Jelinek v. Astrue

Decision Date07 November 2011
Docket NumberNo. 10–3340.,10–3340.
PartiesJessica J. JELINEK, Plaintiff–Appellant, v. Michael J. ASTRUE, Commissioner of Social Security, Defendant–Appellee.
CourtU.S. Court of Appeals — Seventh Circuit

OPINION TEXT STARTS HERE

Marcie E. Goldbloom (argued), Attorney, Daley, Debofsky & Bryant, Chicago, IL, for PlaintiffAppellant.

Marc Boxerman (argued), Attorney, Social Security Administration Office of the General Counsel, Region V, Chicago, IL, for DefendantAppellee.

Before WOOD, SYKES, and HAMILTON, Circuit Judges.

HAMILTON, Circuit Judge.

Jessica Jelinek's mother applied for supplemental security income on her daughter's behalf shortly before Jelinek's eighteenth birthday. She contended that Jelinek was disabled by a combination of mental impairments (including bipolar disorder) and by physical impairments resulting from a 2005 car accident. An administrative law judge found Jelinek's collective impairments severe but not disabling. On appeal, Jelinek argues that the ALJ improperly rejected the opinion of her treating psychiatrist and that this mistake led to additional errors in the ALJ's reasoning. We reverse the judgment and remand for further proceedings.

I. Facts and Procedural Background

Jelinek, now 23 years old, was 17 in August 2005 when her mother filed an application for supplemental security income benefits on her behalf. Her application was denied initially and on reconsideration. In February 2008 Jelinek appeared at a hearing before an ALJ, who later issued a decision confirming the denial of benefits. The Appeals Council denied review, leaving the ALJ's decision as the Commissioner's final word. See 20 C.F.R. § 416.1481; Steele v. Barnhart, 290 F.3d 936, 940 (7th Cir.2002). Jelinek sought review in the district court, see 42 U.S.C. § 405(g), and a magistrate judge presiding by consent under 28 U.S.C. § 636(c) upheld the decision. This appeal followed.

A. The Medical Evidence

Jelinek received counseling at the Bowen Center (from several medical sources) on a near-monthly basis from October 2002 through February 2008. She was assessed initially with depression and thoughts of suicide, precipitated in part by a history of abuse inflicted by her father. Jelinek reported a history of cutting and burning herself. Early treatment notes cite a “suicidal gesture” in January 2002 (apparently including a plan to overdose by taking Aleve), but staff at the Bowen Center initially concluded that Jelinek posed a “low risk” of harm to herself or others and showed no sign of psychosis. Jelinek's school records from this period show 71 absences during the 2002–03 school year and 79 absences during the 2003–04 school year.

The diagnoses of Jelinek's mental impairments shifted over the course of her treatment at the Bowen Center. By the time of her hearing before the ALJ, she was either diagnosed with or had a history of major depression, bipolar disorder (with manic and psychotic features), ADHD, post-traumatic stress disorder, anxiety disorder, and borderline personality disorder. Adding to that, she also was obese and suffered from chronic pain. The treatment for her mental impairments included an ever-changing combination of medications and dosages, among them the anti-depressants Zoloft, Prozac, Trazodone, and Celexa; the anti-anxiety drugs Ativan, Trazodone, and Vistaril; the stimulant Adderall; and the anti-psychotic drugs Abilify, Geodon, Risperdal, and Zyprexa. Treatment notes show some concern among Jelinek's doctors that, at least initially, her mother was resistant to Jelinek's medication regimen. Doctors periodically assigned Jelinek a global assessment of functioning (“GAF”) score, which is a psychiatric measure of a patient's overall level of functioning. 1 The record shows that Jelinek's GAF scores tended to fluctuate between 50 and 55, numbers on the border between “moderate” and “serious” impairment in function, with a high of 65 in April 2007 and a low of 20 during her brief hospitalization in December 2007.

In July 2005, Jelinek was in a car accident that left her with fractures to her pelvis and two vertebrae. She did not require surgery, and by October 2005 her doctors deemed those fractures to be healed and recommended physical therapy. Jelinek, though, continued to report back pain. From February 2006 through December 2007, she visited Dr. Aashish Deshpande for pain management. Dr. Deshpande prescribed fentanyl for her pain and, by turns, Vicodin and later Percocet for “breakthrough” periods of additional pain.

It was the car accident that apparently precipitated Jelinek's application for supplemental security income benefits, and in October 2005, soon after filing, she was examined by Dr. John Heroldt, a state-agency psychologist. He noted that Jelinek reported being “bipolar and manic,” but he opined that she did not exhibit psychotic symptoms. He diagnosed her with major depression (with psychotic features) and borderline personality disorder, and assigned her a GAF score of 50. After meeting with Jelinek, Dr. Heroldt concluded that she was unable to handle her own finances.

In February 2006 a second state-agency psychologist, Dr. F. Kladder, reviewed Jelinek's treatment records to assess her residual functional capacity. Dr. Kladder opined that Jelinek presented several symptoms of depression, including anhedonia (the inability to experience pleasure), appetite and sleep disturbance, and difficulty concentrating. But he concluded that Jelinek suffered only mild restrictions in the activities of daily living and moderate difficulties in maintaining social functioning, and in concentration, persistence, and pace. He opined that Jelinek was “moderately limited” in her ability to complete a normal workday or workweek, that she had trouble in close relationships and would likely have trouble taking criticism or supervision, and that her allegations of disability were credible. He also noted that Jelinek's medical record showed one or two episodes of decompensation of prolonged duration. See 20 C.F.R. Pt. 404, Subpt. P, App. 1, § 12.00 (defining “episodes of decompensation” as “exacerbations or temporary increases in symptoms or signs accompanied by a loss of adaptive functioning, as manifested by difficulties in performing activities of daily living, maintaining social relationships, or maintaining concentration, persistence, or pace”); see also Larson v. Astrue, 615 F.3d 744, 750 (7th Cir.2010) (explaining term).

From August 2006 through January 2008, Dr. Snieguole Radzeviciene, a psychiatrist at the Bowen Center, over-saw Jelinek's psychiatric treatment. His notes from an April 2007 evaluation identify Jelinek's impairments as major depressive disorder, ADHD, anxiety disorder, PTSD, obesity, and chronic pain. Those notes also document Jelinek's concern that she did not have insurance and could not afford therapy. In August 2007 Dr. Radzeviciene observed that Jelinek appeared “more volatile” and documented her report that a recent breakup with her boyfriend had led to an increase in worry, depression, crying, and irritability.

In December 2007 Jelinek admitted herself to the Bowen Center's inpatient unit. She reported hearing voices and said she feared that someone was trying to kill her. The on-call psychiatrist, Dr. Barbara Eichman, was unsure how long Jelinek had been “decompensating” and characterized her as “very delusional.” Dr. Eichman cited Jelinek's breakup with her longtime boyfriend as a possible factor and opined that Jelinek was probably not taking all her medications. The doctor also expressed doubt about the efficacy of the series of medications (six in total, including two pain medications, two anti-depressants, and two anti-psychotics) that Jelinek was then prescribed.

One month later Dr. Radzeviciene completed a mental-impairment questionnaire. He diagnosed Jelinek with bipolar disorder with manic features, ADHD, and obesity . Among Jelinek's symptoms, Dr. Radzeviciene listed poor memory; sleep, mood, and emotional disturbance; difficulty concentrating; oddities of thought, speech, and behavior; manic syndrome; and general anxiety. He noted that Jelinek's mania had been resolved but that she remained depressed and that her mood episodes were likely to recur. He also noted that Jelinek's depression and anxiety tended to make her chronic pain worse. He assessed Jelinek's ability to maintain attention for two-hour segments as “fair,” and opined that she had poor or no ability to maintain regular attendance, to perform at a regular pace without an unreasonable number of rest periods, to deal with normal work stress, or to deal with the stress of skilled or semi-skilled work. He described Jelinek's deficiencies of concentration, persistence, or pace as “frequent” and episodes of deterioration or decompensation as “repeated.”

B. The Hearing Testimony

At her February 2008 hearing before the ALJ, Jelinek testified that she lived across the hall from her mother, who helped with shopping and cleaning her apartment. Jelinek recounted problems with insomnia and bipolar mania, and explained that she had missed a lot of school and ultimately dropped out of high school in her sophomore year because of depression and anxiety. She had gotten her GED and was then enrolled in four college classes, but added that she had dropped three of four classes the previous semester because of stress and the breakup with her boyfriend. Regarding her work history, Jelinek testified that she was working eight hours per week as a library assistant at her college and had previously worked part-time as a motel clerk for about three months.

Vocational expert Leonard Fisher also testified at the hearing. The ALJ prompted the expert to opine whether jobs existed in the local economy for light, unskilled work. The expert testified that about 10,000 jobs existed in the local four-county region for a claimant with Jelinek's age, education, and background of...

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