United States District Court, D. Rhode Island
REPORT AND RECOMMENDATION
PATRICIA A. SULLIVAN, Magistrate Judge.
In January 2012, Plaintiff Mark Coulombe was focused on ending almost twenty years of abusing heroin, cocaine and other illicit substances; he was stabilizing on methadone and initiating treatment for his underlying bipolar, post-traumatic stress and mood disorders. In the same month, he applied for social security. The denial of his application has brought the matter to this Court on Plaintiff's motion for reversal of the decision of the Commissioner of Social Security (the "Commissioner"), denying Supplemental Security Income ("SSI") under § 1631(c)(3) of the Social Security Act, 42 U.S.C. § 1383(c)(3) (the "Act"). Plaintiff contends that the Administrative Law Judge ("ALJ") erred in affording little weight to the expert medical opinions of the examining psychiatrist, Dr. Alvaro Olivares, the treating psychiatrist, Dr. Jack Belkin, and the treating therapist, Ms. Lisa Langlois. Because of these errors, he argues, the ALJ's residual functional capacity ("RFC") finding is not based on substantial evidence, requiring remand. Defendant Carolyn W. Colvin asks the Court to affirm the Commissioner's decision.
These motions have been referred to me for preliminary review, findings and recommended disposition pursuant to 28 U.S.C. § 636(b)(1)(B). Having reviewed the record, I find that the ALJ improperly based his RFC on a non-examining expert whose opinion was prepared before Plaintiff's sobriety was well established, as well as on the ALJ's lay interpretation of raw medical data. Accordingly, I recommend that Plaintiff's motion for remand (ECF No. 10) be GRANTED and Defendant's motion for order affirming the decision of the Commissioner (ECF No. 12) be DENIED.
Plaintiff is a younger individual, 39 years old on the date of his SSI application. Tr. 25, 171. After dropping out of high school in tenth grade, Tr. 70, he worked intermittently as a general laborer, landscaper, roofer, stocker, prep cook, and security guard, Tr. 198, although none of these jobs lasted long. Tr. 68, 215. He has lived in a sober house, with his mother and with a girlfriend. Tr. 70. His mother cares for his twin daughters. Tr. 285. Unable to drive, he uses public transportation, has no friends and goes out principally for his frequent medical appointments. Tr. 70, 80, 231-32. In his SSI application, Plaintiff alleged that he has been disabled due to bipolar disorder, anxiety, depression, and post-traumatic stress disorder ("PTSD") since January 1, 2010. Tr. 19, 214.
A. Pre-Sobriety Mental Health History
Beginning at the age of nineteen or twenty and regularly from the age of twenty-five, Plaintiff abused various substances, including intravenous heroin, cocaine, benzodiazeprines and marijuana, and illicitly used various prescription medications such as Suboxone and Oxycontin, until approximately the end of 2011, when he started mental health treatment at The Providence Center. Tr. 88-89, 274, 284, 799. During the period of active substance abuse covered by the medical record (2002 through January 1, 2012), Plaintiff was repeatedly hospitalized due to the consequences of drug addiction. Tr. 253-56 (2010 hospitalization at Landmark Hospital for suicidal ideation and withdrawal symptoms); Tr. 262-69 (2010 hospitalization at Kent Hospital for suicide attempt following heroin relapse); Tr. 785-89 (2010 hospitalization at Roger Williams Hospital for suicide overdose attempt); Tr. 272-73 (2011 hospitalization at St. Joseph's Hospital following family fight over money to buy drugs); Tr. 299-361 (Butler Hospital records reflect at least nineteen hospitalizations from 2002 to 2007 for detox and suicide attempts).
Based on mental status examinations ("MSE") by an array of mental health professionals on intake at various hospitals during the period of active substance abuse, Plaintiff was assigned Global Assessment of Functioning ("GAF") scores ranging from 30 to 35, Tr. 256, 303, 308, indicating major functional impairment, delusions, hallucinations or impaired reality testing. DSM-IV-TR, at 34. Whether Plaintiff also had an underlying mental health impairment was impossible to ascertain; as Dr. Elahi at Landmark Hospital noted in 2010, "[it is] not clear whether [Plaintiff] was having all these symptoms in the context of ongoing use of drugs... needs to have an extended period of sobriety before he can be clearly diagnosed with bipolar disorder." Tr. 255-56. While engaged in active substance abuse, Plaintiff was incarcerated three times, once for a year. Tr. 89, 344, 799.
B. Post-Sobriety Mental Health History
In December 2011, Plaintiff initiated mental health treatment at The Providence Center, with methadone maintenance at CODAC. Tr. 274. His last use of illicit drugs was in February 2012, which he tested positive for cocaine, and in May 2012, when he tested positive for marijuana; otherwise, all screens in the record in 2012 and 2013 were negative for illicit use. Tr. 796-97. After a rocky start as the methadone dose was calibrated in April 2012, Plaintiff entered a new life phase characterized by compliance with prescribed medications, including methadone, and complete avoidance of "maladaptive use of... illegal drugs, prescription medications, and toxic substances." SSR 13-2p, 2013 WL 621536, at *3 (Feb. 20, 2013). As a result, his mental health treatment shifted from crisis management at hospital emergency departments to a regular pattern of appointments at CODAC in connection with methadone, coupled with monthly or bimonthly appointments with his treating psychiatrist Dr. Belkin and weekly individual and group counseling sessions with therapists Lisa Langois and Marissa Tavares. Tr. 274-90, 362-479, 795-97, 816.
Based on his complaint that "I was doing a lot of drugs... I was out of control, " Plaintiff's initial assessment at The Providence Center was performed on December 13, 2011. Tr. 274-88. At the time of this encounter, he was three and a half weeks sober "from cocaine and cannabis" and had started methadone at CODAC while living in a sober house; the assessment writer noted that his mood-related symptoms "are clouded by his chronic poly substance abuse/dependence and the subsequent impact of his functioning due to the same." Tr. 274. MSE findings included pressured speech, tangential and circumstantial thought process, inadequate thought content, anxious mood, constricted and anxious affect, distractible attention, poor concentration, and impaired judgment and insight. Tr. 278-79. Plaintiff's GAF score was assessed at 43, consistent with serious symptoms or functional impairment. Tr. 280; see DSM-IV-TR, at 34. The Providence Center diagnosed mood disorder and polysubstance dependence, with "mood instability as evidenced by depression and mania like behaviors and feeling states, " but no acute issues. His symptoms were deemed sufficiently serious to justify the intensive case management services of The Providence Center's "CSP" team. Tr. 280 ("appropriate for CSP level of care based on frequency of i/p admissions (dual), poor functioning and dx criteria being met").
On January 13, 2012, Plaintiff had his first appointment with psychiatrist Dr. Belkin for "serious mental illness." Tr. 284-88. During the clinical interview, he reported that his psychiatric history began in childhood, when he was "in and out of institutional programs, " with his first hospitalization at age 15 and a suicide attempt at 17. Tr. 284. He began to use heroin and cocaine at twenty and had one four-year period of sobriety from 1994 to 1997, when he was medicated with Lithium, Xanax and other medications. Tr. 284. Dr. Belkin's MSE included observations of elevated mood and affect, but with good control, no tangential thinking or pressured speech, average intelligence, and apparently good insight and judgment. Plaintiff denied suicidal or homicidal thoughts and auditory or visual hallucinations; he seemed logical and coherent. Tr. 285. Dr. Belkin diagnosed bipolar disorder and polysubstance dependence and assigned a GAF score of 40. Tr. 285. Plaintiff was started on Lithium and continued on Zyprexa and Klonopin; he also was started on regular (bi-monthly) appointments with Dr. Belkin and weekly group and individual therapy. Tr. 286.
On February 3, 2012, Plaintiff returned to Dr. Belkin, whose notes state:
Still has period of paranoia and overwhelming anxiety... Sleep is interrupted by nightmare once or twice a week. Energy level fluctuates: high energy for a couple days, then stays in bed for a full day.
Tr. 287. The MSE findings include moderate anxiety, but otherwise Plaintiff was alert, polite, and cooperative with no suicidal or homicidal intent, no hallucinations, average intelligence, and capable of making informed decisions in his own medical care. Tr. 287. Nevertheless, Dr. Belkin increased the Lithium dose and substituted a different anti-psychotic, Risperdal, for Zypexa. Tr. 287. Three weeks later, without seeing Plaintiff again, Dr. Belkin signed his first of three RFC opinions.
Plaintiff's next appointment with Dr. Belkin, on April 5, 2012, was an urgent visit triggered by a financial issue that was causing CODAC to taper him off methadone. Tr. 370. The treating notes reflect that Plaintiff was sweating excessively, very uncomfortable, anxious, and sleeping poorly. Tr. 370. Dr. Belkin opined that, although Plaintiff was not "exhibiting mania or mixed bipolar but definitely at risk for it;" to "avoid a true decompensation, " Dr. Belkin increased the doses of Klonopin and Lithium and noted that Klonopin might need to be increased further. Tr. 370.
In early July 2012, The Providence Center team, including Dr. Belkin, prepared Plaintiff's Treatment Plan Review. It assessed Plaintiff as "making progress" on psychiatric stability, but "no progress" on decreasing methadone reliance or seeing his children. The team assessed Plaintiff with a GAF stuck at 40,  in both the current month and over the past year. Tr. 411-14. In light of these symptoms, the Plan recommended that treatment continue at the same level of intensity.
By the next Belkin appointment, on July 27, 2012, Plaintiff's methadone treatment had resumed (as a result of financial assistance from his mother) and stabilized, although he was not making progress towards the goal of reducing methadone to nothing. Tr. 412, 420. Dr. Belkin recorded that an increase in obsessive behaviors was causing family friction, but also noted that, with almost eight months of sobriety, he was "feel[ing] great." Tr. 420. Obsessive compulsive disorder was added to Plaintiff's list of diagnoses and a prescription for Anafranil was introduced to address it. Tr. 420. On MSE, Plaintiff had mildly elevated mood, but was not hypomanic or manic, with rapid speech, but no abnormal volume or content. He was alert, verbal, cooperative, and polite, with no suicidal or homicidal ideation and no hallucinations. Tr. 420.
Dr. Belkin next saw Plaintiff on September 21, 2012, and noted that Anafranil was working well; his MSE reflects no abnormal findings. Tr. 439. However, the next record is Dr. Belkin's report on Plaintiff's mental health status to CODAC dated October 31, 2012; in it, Dr. Belkin advises that Plaintiff suffers from "significant mental illness, " and is prescribed to take Anafranil, Lithium, Risperdal and Klonopin, although ...