The opinion
UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF OHIO
WESTERN DIVISION AT DAYTON
BROOKE H.,1 : Case No. 3:21-cv-044
:
Plaintiff, : Magistrate Judge Peter B. Silvain, Jr.
: (by full consent of the parties)
vs. :
:
COMMISSIONER OF THE SOCIAL :
SECURITY ADMINISTRATION, :
:
Defendant. :
DECISION AND ENTRY
Plaintiff Brooke H. brings this case before the Court challenging the Social Security
Administration’s denial of her application for Supplemental Security Income (SSI). This case is
before the Court upon Plaintiff’s Statement of Errors (Doc. #12), the Commissioner’s
Memorandum in Opposition (Doc. #16), Plaintiff’s Reply (Doc. #17), and the administrative
record (Doc. #10).
I. Background
The Social Security Administration provides Supplemental Security Income to individuals
who are under a “disability,” among other eligibility requirements. Bowen v. City of New York,
476 U.S. 467, 470 (1986); see 42 U.S.C. § 1382(a). The term “disability” encompasses “any
medically determinable physical or mental impairment” that precludes an applicant from
1 The Committee on Court Administration and Case Management of the Judicial Conference of the United States has
recommended that, due to significant privacy concerns in social security cases, federal courts should refer to
plaintiffs only by their first names and last initials. See also S.D. Ohio General Rule 22-01.
performing “substantial gainful activity.” 42 U.S.C. § 1382c(a)(3)(A); see Bowen, 476 U.S. at 469-
70.
In the present case, Plaintiff applied for benefits on August 17, 2018, alleging disability
due to several impairments, including bipolar disorder, obsessive compulsive disorder, post-
traumatic stress disorder, and endometriosis. After Plaintiff’s application was denied initially and
upon reconsideration, she requested and received a hearing before Administrative Law Judge
(ALJ) Heidi Southern. Thereafter, the ALJ issued a written decision, addressing each of the five
sequential steps set forth in the Social Security Regulations. See 20 C.F.R. § 416.920. She reached
the following main conclusions:
Step 1: Plaintiff has not engaged in substantial gainful employment since August
17, 2018, the application date.
Step 2: She has the severe impairments of depression, bipolar disorder, anxiety,
insomnia disorder, cocaine use disorder, and opioid use disorder.
Plaintiff has the following nonsevere impairments: mild sedative, hypnotic
or anxiolytic use disorder and a history of endometriosis.
Step 3: She does not have an impairment or combination of impairments that meets
or equals the severity of one in the Commissioner’s Listing of Impairments,
20 C.F.R. Part 404, Subpart P, Appendix 1.
Step 4: Her residual functional capacity (RFC), or the most she could do despite her
impairments, see Howard v. Comm’r of Soc. Sec., 276 F.3d 235, 239 (6th
Cir. 2002), consists of “a full range of work at all exertional levels subject
to the following limitations: (1) simple, routine, repetitive tasks defined as
work that can be learned in 30 days or less; (2) no production-rate pace work
(e.g., assembly line work) but can perform goal-oriented work (e.g., office
cleaner); (3) occasional contact with coworkers and supervisors; (4) no
contact with the general public; and (5) occasional changes in an otherwise
routine work setting.”
She is unable to perform any past relevant work.
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Step 5: She can perform a significant number of jobs that exist in the national
economy.
(Doc. #10-2, PageID #s 57-68). Based on these findings, the ALJ concluded that Plaintiff was not
under a benefits-qualifying disability since August 17, 2018, the date the application was filed. Id.
at 68.
The evidence of record is adequately summarized in the ALJ’s decision (Doc. #10, PageID
#s 57-66), Plaintiff’s Statement of Errors (Doc. #12), the Commissioner’s Memorandum in
Opposition (Doc. #16), and Plaintiff’s Reply (Doc. #17). To the extent that additional facts are
relevant, they will be summarized in the discussion section below.
II. Standard of Review
Judicial review of an ALJ’s decision is limited to whether the ALJ’s findings are supported
by substantial evidence and whether the ALJ applied the correct legal standards. Blakley v. Comm’r
of Soc. Sec., 581 F.3d 399, 406 (6th Cir. 2009); see Bowen v. Comm’r of Soc. Sec., 478 F.3d 742,
745-46 (6th Cir. 2007). Substantial evidence is such “relevant evidence that a reasonable mind
might accept as adequate to support a conclusion.” Gentry v. Comm’r of Soc. Sec., 741 F.3d 708,
722 (6th Cir. 2014) (citing Rogers v. Comm’r of Soc. Sec., 486 F.3d 234, 241 (6th Cir.2007)). It is
“less than a preponderance but more than a scintilla.” Id.
The second judicial inquiry—reviewing the correctness of the ALJ’s legal analysis—may
result in reversal even if the ALJ’s decision is supported by substantial evidence in the record.
Rabbers v. Comm’r of Soc. Sec., 582 F.3d 647, 651 (6th Cir. 2009). Under this review, “a decision
of the Commissioner will not be upheld where the [Social Security Administration] fails to follow
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its own regulations and where that error prejudices a claimant on the merits or deprives the claimant
of a substantial right.” Bowen, 478 F.3d at 746 (citing Wilson v. Comm’r of Soc. Sec., 378 F.3d 541,
546-47 (6th Cir. 2004)).
III. Discussion
In her Statement of Errors, Plaintiff argues that the ALJ erred in evaluating the opinions of
Brendan Carroll, M.D., and Mr. Donald Amos, MS, PCC as well as Plaintiff’s mental health
symptoms. (Doc. #12, PageID #s 1774-79). The Commissioner maintains that the ALJ
appropriately reviewed these opinions and that her decision is supported by substantial evidence.
(Doc. #16, PageID #s 1494-1501).
Social Security Regulations require ALJs to adhere to certain standards when weighing
medical opinions. Those standards recently changed for claims filed on or after March 27, 2017.
20 C.F.R. § 416.920c. Because Plaintiff’s claim for disability was filed in August 2018, the Social
Security Administration’s new regulations for evaluating medical opinion evidence apply to this
case.
Under the new regulations, the ALJ “will not defer or give any specific evidentiary weight,
including controlling weight, to any medical opinion(s) ….” 20 C.F.R. § 416.920c(a). Instead, the
new regulations direct the ALJ to evaluate the persuasiveness of each medical opinion by
considering the five following factors: (1) supportability; (2) consistency; (3) relationship with the
plaintiff; (4) specialization; and (5) any other factor “that tend[s] to support or contradict a medical
opinion or prior administrative medical finding.” § 416.920c(c). Further, because the regulations
consider supportability and consistency the “most important factors,” ALJs are obligated to
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“explain how [they] considered the supportability and consistency factors for a medical source’s
medical opinions,” while they “may, but are not required to, explain how [they] considered” the
remaining factors. § 416.920c(b)(2).
With respect to the supportability factor, “[t]he more relevant the objective medical
evidence and supporting explanations presented by a medical source are to support his or her
medical opinion(s) ... the more persuasive the medical opinions ... will be.” § 416.920c(c)(1).
Similarly, with respect to the consistency factor, “[t]he more consistent a medical opinion(s) ... is
with the evidence from other medical sources and nonmedical sources in the claim, the more
persuasive the medical opinion(s) ....” § 416.920c(c)(2).
While these new regulations are more relaxed than the former rules governing the
evaluation of medical opinions, “they still require that the ALJ provide a coherent explanation of
[her] reasoning.” Lester v. Saul, No. 5:20-CV-01364, 2020 WL 8093313, at *14 (N.D. Ohio Dec.
11, 2020), report and recommendation adopted sub nom. Lester v. Comm’r of Soc. Sec., No.
5:20CV1364, 2021 WL 119287 (N.D. Ohio Jan. 13, 2021). At bottom, the new regulations “set
forth a ‘minimum level of articulation’ to be provided in determinations and decisions, in order to
‘provide sufficient rationale for a reviewing adjudicator or court.’” Warren I. v. Comm’r of Soc.
Sec., No. 5:20-CV-495 (ATB), 2021 WL 860506, at *8 (N.D.N.Y. Mar. 8, 2021) (quoting 82 Fed.
Reg. 5844-01, 5858 (January 18, 2017)). An “ALJ’s failure to meet these minimum levels of
articulation frustrates [the] court’s ability to determine whether [the plaintiff’s] disability
determination was supported by substantial evidence.” Id.
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In this case, Plaintiff alleges that the ALJ erred in her review of the opinions by Donald
Amos, MS, PCC and Brendan Carroll, M.D. On December 6, 2018, Plaintiff’s therapist, Donald
Amos, MS, PCC, authored a Daily Activities Questionnaire. (Doc. #10-7, PageID #s 464-65). In
his assessment, Mr. Amos indicated that Plaintiff was currently residing with her boyfriend, his
mother, and her children. Id. at 464. As for her deficits in her ability to live independently, Mr.
Amos noted that Plaintiff is unable to maintain financial subsistence, work behavior and has
childcare responsibility. Id. He stated that Plaintiff has a history of erratic relationship functioning
and rage behavior. Id. As for her social functioning, Mr. Amos pointed out that plaintiff rarely
visits friends and that she is limited in social activities with no regular social activity away from
home. Id. She also has a history of short-term job behavior, struggles with multitasking, and easily
conflicts with others, especially her boyfriend. Id. Mr. Amos noted that Plaintiff has irregular
attendance with keeping her appointments due to transportation problems and no driver’s license.
Id. at 465. Mr. Amos also indicated that Plaintiff has tried several medications from the
psychiatrist but has had poor response/tolerance for multiple medications. Id.
On April 29, 2019, Mr. Amos completed another Daily Activities Questionnaire, reporting
that Plaintiff is dependent on others, unable to establish sufficient income or childcare, has no
transportation, and unstable relations. Id. at 473-74. According to Mr. Amos, Plaintiff relates only
to immediate family and her boyfriend and is prone to conflicted relations. Id. at 473. He noted
that Plaintiff has only attempted brief jobs for which she is usually fired for conflicted relations
and poor attendance. Id. He also indicated that Plaintiff has poor attention, labile mood, and has
not responded well to most medications. Id. Mr. Amos described Plaintiff’s past legal difficulties,
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including a robbery charge and a dismissed charge of domestic violence. Id. He noted that she is
dependent upon others for transportation and bill paying and has missed counseling appointments
due to transportation issues. Id. at 474. Finally, Mr. Amos stated that Plaintiff has required
recurrent medication changes because of her poor responses. Id.
Plaintiff’s psychiatrist, Brendan Carroll, M.D., completed a Mental Status Questionnaire
on May 5, 2019. Id. at 476-78. In the assessment, Dr. Carroll noted that he had been treating
Plaintiff from August 2015 through April 2019 for bipolar disorder and that he has prescribed her
numerous medications. Id. He described Plaintiff as having euthymic mood and affect, normal
speech, no psychosis, fair judgment, fair insight, well oriented, and a good fund of knowledge. Id.
at 476. As for her mental functioning, Dr. Carroll opined that Plaintiff could only remember,
understand, and follow directions for two hours a day. Id. at 477. He found that she was likewise
limited to two hours a day in tasks such as maintaining attention, sustaining concentration,
persisting, and completing them in a timely fashion. Id. Dr. Carroll further opined that Plaintiff
has severe social anxiety and poor adaptation ability and may decompensate. Id. Dr. Carroll
concluded that Plaintiff “would worsen” in reaction to the pressures in work settings or elsewhere,
involved in simple, routine, or repetitive tasks. Id. at 477.
The final opinion at issue was rendered on May 22, 2020, and signed by both Dr. Carroll
and Mr. Amos. (Doc. #10-11, PageID #s 1423-1425). In the assessment, they listed Plaintiff’s
diagnoses as Bipolar I disorder, manic with psychosis, and cocaine dependence. Id. at 1423. They
further noted that Plaintiff suffers from poor memory; oddities of thought, perception, speech, and
behavior; sleep disturbance; mood disturbance; emotional lability; manic syndrome; recurrent
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panic attacks; obsessive or compulsions; psychomotor agitation or retardation; generalized
persistent anxiety; and difficulty thinking or concentrating. Id. Dr. Carroll and Mr. Amos opined
that Plaintiff is moderately to markedly limited in understanding, remembering, or applying
information; markedly to extremely limited in concentrating, persisting, or maintaining pace; and
primarily markedly impaired in adapting or managing herself. Id. at 1424. They found Plaintiff is
markedly limited in her overall ability to learn, recall, or use information to perform work
activities. Id. at 1425. They also determined that Plaintiff is extremely limited in her abilities to
relate to and work with supervisors, co-workers, and the public, to focus attention on work
activities and to stay on task at a sustained rate, and to regulate her emptions, control her behavior
and maintain well-being in a work setting. Id. They opined that Plaintiff would be unable to
perform regular, full-time, competitive work without missing work more than three times per
month or without being off task more than 20% or the workday. Id. at 1423. Finally, when asked
whether Plaintiff would still have severe underlying psychiatric conditions that markedly impair
her ability to complete a normal work schedule if she no longer abused drugs or alcohol, Dr. Carroll
and Mr. Amos indicated “yes.” Id. at 1425.
In reviewing the opinions of Mr. Amos, ALJ Southern concluded that they were only
“somewhat persuasive as they are not entirely consistent with the balance of the record which
indicates that medication actually stabilizes [Plaintiff’s] thought processes and mood when she is
fully compliant and refrains from drug use.” (Doc. #10-2, PageID #59). The ALJ also pointed out
that Mr. Amos’ description of Plaintiff’s social abilities “belies notes in treatment records[.]”
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Nonetheless, she concluded that the social limitations included in Plaintiff’s RFC would
accommodate any problems she might have in this area. Id.
ALJ Southern found Dr. Carroll’s May 2019 opinion to not be persuasive and the May
2020 opinion he authored with Mr. Amos to be “somewhat persuasive” as it was “not entirely
consistent with the balance of record.” Id. at 59-60. In support, the ALJ acknowledged that it was
“plausible to conclude that [Plaintiff] does exhibit some functional difficulties particularly related
to mood variance[]” but pointed out that she was only hospitalized once and that this was the result
of a short-term exacerbation of her symptoms associated with drug abuse and noncompliance with
medication. Id. at 59. Otherwise, ALJ Southern found that Plaintiff had conservative treatment and
that “[h]er ability to maintain attention and concentration, relate to others in an appropriate manner,
cope with work stress, and adapt to change inherent with multistep tasks are limited to no more
than a moderate extent when she is drug-free[.]” Id. According to ALJ Southern, these findings
were supported by Dr. Carroll’s own treatment notes, which most recently described Plaintiff as
having “normal associations, speech, and fund of knowledge; intact memory; focused attention
and concentration; euthymic mood; intact judgment/insight/and coherent thought processes.” Id.
at 59-60.
The ALJ’s reasons for finding the opinions of Mr. Amos and Dr. Carroll at most somewhat
persuasive are clearly articulated and supported by substantial evidence. The ALJ specifically
discussed the two most important factors listed in 20 C.F.R. § 416.920c—supportability and
consistency. She pointed out that discrepancies between Dr. Carroll’s opined limitations of
Plaintiff’s functioning and his clinical conclusions that Plaintiff’s mental status examinations are
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quite normal. Indeed, on the mental status examination he completed, Dr. Carroll reported that
Plaintiff presented with euthymic mood and affect, appropriate appearance and orientation, no
psychosis, fair judgment, and a good fund of knowledge. (Doc. #10-7, PageID #476). ALJ
Southern also noted that Dr. Carroll’s findings were not supported by Plaintiff’s largely
conservative treatment and ordinary level of psychological functioning.
Similarly, the ALJ pointed out inconsistencies between Mr. Amos’ assessments and the
balance of the treatment records, which indicate that medication stabilizes Plaintiff’s thought
processes and mood when she is fully compliant and refrains from drug use. She also found that
Mr. Amos’ descriptions of Plaintiff’s level of social functioning was at odds with other evidence
in the record indicating that Plaintiff retains “the ability to conform her behavior to socially
acceptable standards presenting as pleasant calm and cooperative with euthymic appropriate mood
and affect.” (Doc. #10-2, PageID #61) (citing Doc. #10-7, PageID #s 285, 469; Doc. #10-8,
PageID #s 727, 765, 860, 906; Doc. #10-9, PageID #s 942, 951, 967, 976, 990; Doc. #10-10,
PageID #s 1099, 1100, 1104, 1109, 1116, 1122). ALJ Southern also noted that Plaintiff has been
able to maintain her relationship with her boyfriend of eight years and has at least one friend, who
she describes as “supportive.” Id. (citing Doc. #10-9, PageID #1008; Doc. #10-10, PageID #1072).
Further, ALJ Southern evaluated the different categories of mental functioning and found
that Plaintiff had no more than moderate limitations while Dr. Carroll and Mr. Amos found
limitations ranging from marked to extreme in all of these categories. (Compare Doc. #10-2,
PageID #s 60-61 with Doc. #10-11, PageID #1425). In fact, in the context of discussing the
severity of Plaintiff’s mental impairments, the ALJ provided an in-depth explanation as to why
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she concluded that Plaintiff only had moderate limitations in the realms of mental functioning.
(Doc. #10-2, PageID #s 60-61). This also supports the ALJ’s conclusion that the opinions of Dr.
Carroll and Mr. Amos were inconsistent with the record. See Sprague v. Colvin, 2015 WL
2066227, at *3 (S.D. Ohio) (Graham, D.J.) (“Where, as here, the ALJ thoroughly addressed such
matters as the consultants’ reports, the other medical evidence of record, and plaintiff's credibility
earlier in his decision, the ALJ was not required to repeat his discussion of those matters again in
his discussion of the weight to be assigned to the medical opinions.”). In short, the ALJ clearly
satisfied the articulation requirements and was not required to discuss any other factor. See 20
C.F.R. § 416.920c(b)(2) (requiring only that the ALJ articulate how she considered the
supportability and consistency factors).
Additionally, while ALJ Southern discounted the weight given to the opinions of Dr.
Carroll and Mr. Amos, she did include several restrictions in Plaintiff’s RFC that accommodate
her psychological limitations. In fact, the ALJ restricted Plaintiff to (1) simple, routine, repetitive
tasks defined as work that can be learned in 30 days or less; (2) no production-rate pace work (e.g.,
assembly line work) but can perform goal-oriented work (e.g., office cleaner); (3) occasional
contact with coworkers and supervisors; (4) no contact with the general public; and (5) occasional
changes in an otherwise routine work setting. (Doc. #10-2, PageID #63). In formulating this RFC,
the ALJ thoroughly considered all of the evidence of record and rendered a mental RFC
assessment, which was supported by substantial evidence, including Plaintiff’s complaints,
medical records, and state medical opinions. See 20 C.F.R. § 416.945(a)(3) (stating that RFC
assessments should be “based on all of the relevant medical and other evidence”).
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Finally, the ALJ did not err in discounting Plaintiff’s credibility based on her failure to
comply with her psychiatric treatment. A lack of medication and treatment compliance, without
good reason, provides valid grounds for finding an individual’s reported symptoms less than fully
credible. See Lawson v. Comm’r of Soc. Sec., 192 Fed. Appx. 521, 527-28 (6th Cir. 2006)
(upholding a denial of benefits where “the ALJ held that ‘Lawson’s credibility with respect to her
symptoms and impairments is significantly diminished by her failure to follow-up with
recommendations of treating physicians to seek psychiatric or mental health treatment [and] failure
to take medications as prescribed[.]’”). In this case, Plaintiff has not offered any reason or
evidence as to why she did not comply with her medication and psychiatric treatment. As Plaintiff
herself acknowledged, when she avoided drug abuse and complied with her treatment regimen,
her symptoms positively responded to medication management. (Doc. #10-7, PageID #s 420, 425,
427; Doc. #10-9, PageID #954). Accordingly, the ALJ validly considered Plaintiff’s treatment
noncompliance when assessing her symptom severity.
For all these reasons, the undersigned finds that the arguments raised in Plaintiff’s
Statement of Errors are without merit.
IT IS THEREFORE ORDERED THAT:
1. Plaintiff’s Statement of Errors (Doc. #12) is DENIED;
2. The Commissioner’s non-disability determination is AFFIRMED; and
3. The case is terminated on the docket of this Court.
September 19, 2022 s/Peter B. Silvain, Jr.
Peter B. Silvain, Jr.
United States Magistrate Judge
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