Kohler v. Astrue

• Decision Date: 16 October 2008
• Docket Number: No. 06-5332-cv.,06-5332-cv.
• Citation: 546 F.3d 260
• Parties: Kathy KOHLER, Plaintiff, v. Michael J. ASTRUE, Commissioner of Social Security,<SMALL><SUP>*</SUP></SMALL> Defendant.
• Court: U.S. Court of Appeals — Second Circuit

546 F.3d 260

Kathy KOHLER, Plaintiff, v. Michael J. ASTRUE, Commissioner of Social Security,^* Defendant.

No. 06-5332-cv.

United States Court of Appeals, Second Circuit.

Argued: April 29, 2008.

Decided: October 16, 2008.

Mark Schneider, Plattsburgh, NY, for plaintiff.

Arthur Swerdloff, Special Assistant United States Attorney (Barbara L. Spivak, Chief Counsel — Region II, Office of the General Counsel Social Security Administration, on the brief), for Glenn T. Suddaby, United States Attorney for the Northern District of New York, Syracuse, NY, for defendant.

Before: STRAUB, POOLER, and SOTOMAYOR, Circuit Judges.

SOTOMAYOR, Circuit Judge:

Plaintiff Kathy Kohler appeals from a decision of the United States District Court for the Northern District of New York (Sharpe, J.), dated November 3, 2006, granting the motion for judgment on the pleadings by defendant Commissioner of the Social Security Administration ("Commissioner") and affirming the Commissioner's denial of her application for Social Security Disability Insurance ("SSDI") and Supplemental Security Income ("SSI") benefits. We hold that the Administrative Law Judge ("ALJ") erred by not following the mandatory "special technique" set forth in 20 C.F.R. § 404.1520a for evaluating the severity of a mental impairment, and we cannot conclude from the current record that this error was harmless. Accordingly, we VACATE the judgment of the district court insofar as it upheld the Commissioner's decision to deny Kohler benefits and we REMAND to the district court with instructions to remand the matter to the Commissioner for further proceedings consistent with this opinion.

BACKGROUND

Kathy Kohler, who is now 51 years old, was diagnosed with bipolar disorder in 1992. She applied for SSDI and SSI benefits on March 25, 2002, asserting that her mental impairment constituted a disability preventing her from engaging in substantial gainful employment. Her application was initially denied, but that decision was vacated and remanded by the United States District Court for the Northern District of New York on October 5, 2004 because of an inaudible tape of the hearing. A second hearing on Kohler's application was held by ALJ Carl Stephan on February 15, 2005. Kohler appeals from the ALJ's decision denying benefits following this hearing.

Medical History

In 1992, Kohler was hospitalized twice within about a month. On the first occasion she was brought to the hospital by police after she broke down the door of an acquaintance's house. Initially observed to be agitated and confused, her demeanor improved with medication and she was released after two weeks. She was returned to the hospital ten days later by her husband, who reported that she was "out of control." She again was treated with medication and was discharged after approximately two weeks.

In 1996, Kohler moved from Buffalo, N.Y. to the North Country near Plattsburgh, NY, and began receiving medical services from North Star Behavioral Health Services ("North Star"). Her treating physician at North Star at all relevant times has been Naveen Achar. In addition, she was treated at North Star (and later in private practice) by Lorna Jewell, a nurse practitioner. At Kohler's initial screening exam in 1996, Achar noted that Kohler was not in distress, appeared to have a calm mood and bright affect, and was alert and oriented, with good memory, concentration, and judgment. He observed that Kohler's lithium prescription for the prior 4 years "seems to have controlled her mania and depressive symptoms." His notes indicate that Kohler's "global assessment of functioning (GAF)" was 60, and that its highest value during the preceding year was 75.¹

In April 1998, Kohler was again hospitalized, for just over a week, after the staff of a hospital at which her boyfriend was being treated for injuries from a serious head-on collision found her wandering the hallways, talking to herself and acting bizarrely. She was diagnosed with mild lithium toxicity and showed improvement within 24 hours after her dosage was reduced. She was discharged with a GAF score of 65, which reflects "[s]ome mild symptoms (e.g. depressed mood or mild insomnia) OR some difficulty in social, occupational, or school functioning ... but generally functioning pretty well, has some meaningful interpersonal relationships." Am. Psychiatric Ass'n, Diagnostic and Statistical Manual of Mental Disorders 34 (4th ed.2000).

Jewell's notes from appointments with Kohler in 2000 indicate that Kohler continued to take her medications with good effect, was stable, and generally able to manage the stresses of her daily life, including stresses associated with ending a relationship of six years. After an appointment on January 3, 2001, Jewell similarly noted that Kohler was taking her medication with good effect, "appear[ed] to be stable," and was enjoying her independence.

Two weeks later, however, Kohler's condition deteriorated. On January 16, 2001, she was brought to the emergency room at the direction of Jewell, after Kohler's family reported that her behavior had become increasingly bizarre over the prior two days, and that she was agitated, talking rapidly, and unable to stop running around the house. Kohler reported that she had not been sleeping well, had missed two days of her lithium, and was experiencing symptoms such as extreme irritability and obsessive cleaning. She was given the medication Haldol to help her sleep and was sent home with her brother.

Kohler's family remained concerned about her "changed and still unstable behavior" throughout the following two weeks, leading to a telephone conference with Jewell on January 23, 2001 and an in-person appointment on January 30, 2001. At the appointment, Kohler acknowledged that she was "not doing her best and that an adjustment in medication might be called for." Jewell's notes indicate that Kohler was "not manic, but [was] perhaps approaching hypomania as indicated by her unpatterned sleeping and eating." Jewell hypothesized that the episode had been triggered by emotional stress, and suggested that Kohler might need the assistance of an "intensive case manager" ("ICM") to help organize her affairs. Kohler evidently agreed, and met with an ICM regularly for at least the next year.

Medical Evaluations

Achar, Kohler's treating physician, filled out an evaluation regarding Kohler's ability to do work-related activities on October 21, 2003. He indicated that she had only slight restriction in her ability to understand, remember, and carry out detailed instructions, and to maintain socially appropriate behavior. He further indicated that Kohler had no restriction in her ability to (a) understand, remember, and carry out short, simple instructions; (b) make judgments on simple work-related decisions; and (c) adhere to basic standards of cleanliness. Achar also reported that Kohler had no more than slight restrictions in various work-related social functions, such as interacting appropriately with the public or supervisors.

Kohler was independently evaluated by Brett T. Hartman, a psychologist, on October 9, 2003. He concluded that her prognosis was "fair, given her current stabilization of symptoms." He noted that Kohler reported a history of insomnia, but not in the previous year, and that she experienced a "variety of depressive symptoms at this time." He also noted that Kohler had reported that she "has a history of manic episodes, as recently as 1½ years ago, ... but she has not had such episodes since that time." With respect to Kohler's vocational and functional capacities, Hartman concluded:

[I]t appears that Ms. Kohler is able to follow and understand simple directions and instructions. She is also able to perform a variety of simple and rote tasks. She has fair attention and concentration skills and a fair ability to learn new information. She also has a fair ability to make appropriate decisions at this time. Claimant may have mild difficulty performing tasks on a consistent basis. She also would appear to have mild to moderate problems performing a variety of complex tasks independently, given her mild intellectual deficits. It would also appear that she would have mild problems relating adequately to others and dealing appropriately with the normal stressors of life.

In addition, Terri Linden Bruni, a state agency psychological consultant, evaluated the record evidence and completed a psychiatric review of Kohler's condition on June 3, 2002. She concluded that Kohler had "bipolar syndrome with a history of episodic periods manifested by full symptomatic picture of both manic and depressive symptoms." She rated Kohler's degree of functional limitation as "slight" for restriction of daily activities and deficiencies maintaining concentration, persistence or pace; as "moderate" for difficulties in maintaining social functioning; and "never" for repeated episodes of deterioration each of extended duration. Bruni evaluated Kohler to be "not significantly limited" for all indicators except three, in which she found Kohler "moderately limited": (1) ability to maintain attention and concentration for extended periods, (2) ability to complete a normal workday and work week without interruptions from psychologically-based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods, and (3) ability to interact appropriately with the general public. Bruni concluded that Kohler had good results controlling her manic symptoms with medication and that her recent mental status exams "ha[d] essentially been within normal limits on all parameters."

Employment

From approximately 1982 to 1991, Kohler worked as a housecleaner for about 30 hours per week. She has not since held steady, long-term employment.²

At the time of the hearing in 2005, Kohler's only employment was babysitting a child with Down syndrome once a week for approximately five hours, which s...