Jelinek v. Astrue

In the

United States Court of Appeals

For the Seventh Circuit

No. 10-3340

JESSICA J. JELINEK,

Plaintiff-Appellant,

v.

M ICHAEL J. A STRUE, Commissioner of Social Security,

Defendant-Appellee.

Appeal from the United States District Court

for the Northern District of Indiana, South Bend Division.

No. 3:09-cv-368—Christopher A. Nuechterlein, Magistrate Judge.

A RGUED A UGUST 2, 2011—D ECIDED N OVEMBER 7, 2011

Before W OOD , S YKES, and H AMILTON, Circuit Judges.

H AMILTON, Circuit Judge. Jessica Jelinek’s mother

applied for supplemental security income on her daugh-

ter’s behalf shortly before Jelinek’s eighteenth birth-

day. She contended that Jelinek was disabled by a combi-

nation of mental impairments (including bipolar disorder)

and by physical impairments resulting from a 2005 car

accident. An administrative law judge found Jelinek’s

2 No. 10-3340

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 pro-

ceedings.

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 deci-

sion 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, precipi-

tated in part by a history of abuse inflicted by her father.

Jelinek reported a history of cutting and burning herself.

No. 10-3340 3

Early treatment notes cite a “suicidal gesture” in Janu-

ary 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 peri-

odically assigned Jelinek a global assessment of func-

tioning (“GAF”) score, which is a psychiatric measure of

4 No. 10-3340

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 hospital-

ization 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

1

A GAF between 41 and 50 indicates “Serious symptoms (e.g.,

suicidal ideation, severe obsessional rituals, frequent shop-

lifting) OR any serious impairment in social, occupational, or

school functioning (e.g., no friends, unable to keep a job).” In

turn, a GAF between 51 and 60 reflects “Moderate symptoms

(e.g., flat affect and circumstantial speech, occasional panic

attacks) OR moderate difficulty in social, occupational, or

school functioning (e.g., few friends, conflicts with peers or

co-workers).” American Psychiatric Association, Diagnostic

and Statistical Manual of Mental Disorders, Text Revision

(DSM-IV-TR) 34 (4th ed. 2000).

No. 10-3340 5

examined by Dr. John Heroldt, a state-agency psycho-

logist. He noted that Jelinek reported being “bipolar

and manic,” but he opined that she did not exhibit psy-

chotic symptoms. He diagnosed her with major depres-

sion (with psychotic features) and borderline per-

sonality 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 depres-

sion, 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,

6 No. 10-3340

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 docu-

ment 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 med-

ications (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.

No. 10-3340 7

Among Jelinek’s symptoms, Dr. Radzeviciene listed poor

memory; sleep, mood, and emotional disturbance; dif-

ficulty 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 atten-

dance, to perform at a regular pace without an unreason-

able 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 concentra-

tion, 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 sopho-

more 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,

8 No. 10-3340

Jelinek testified that she was working eight hours per

week as a library assistant at her college and had previ-

ously 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 part-time

work. When the ALJ changed the hypothetical to seden-

tary, unskilled work, the expert opined that only 600 to

900 relevant jobs existed. The expert also opined,

however, that an unskilled worker with Jelinek’s profile

who missed more than one day a month (other than

vacation days, sick days, and holidays) would have

“difficulty in sustaining competitive employment.”

C. The ALJ’s Decision

In June 2008 the ALJ issued a written decision

concluding that Jelinek was not disabled. The ALJ found

that Jelinek had engaged in no substantial gainful

activity since her application was filed. Because Jelinek’s

initial application was a child application filed on her

behalf, the ALJ first examined her claims under the three-

step “child standard” for the period before her eighteenth

birthday. Under supplemental security income rules, a

child is disabled if she has a “medically determinable

physical or mental impairment, which results in marked

and severe functional limitations” that “has lasted or can

No. 10-3340 9

be expected to last for a continuous period of not less

than 12 months.” See 42 U.S.C. § 1382c(a)(3)(C)(i). This

assessment requires a three-step analysis set forth in

20 C.F.R. § 416.924(a). First, if the child is engaged

in substantial gainful activity, the ALJ will deny the

claim. Second, if the child does not have a severe

medical impairment or combination of impairments, then

she is not disabled. Third, the child’s impairments must

meet, medically equal, or functionally equal any of the

listings contained in 20 C.F.R. Pt. 404, Subpt. P, App. 1.

The ALJ found that Jelinek had the severe impairments

of ADHD, bipolar disorder, personality disorder, and

PTSD, and a history of pelvic, cervical, and thoracic

fractures. The ALJ also cited Jelinek’s poor school perfor-

mance and excessive absences. The ALJ found that none

of these impairments, alone or in combination, met,

medically equaled, or functionally equaled any listing

before Jelinek reached age 18.2 He found that Jelinek had

(1) “no limitation” in acquiring and using information,

attending and completing tasks, and caring for herself;

and (2) “less than marked limitation” in interacting or

2

To determine if an impairment is “functionally equivalent” to

a listing, an ALJ analyzes its severity in six “domains”:

(1) acquiring and using information; (2) attending and com-

pleting tasks; (3) interacting and relating with others; (4) moving

about and manipulating objects; (5) caring for oneself; and

(6) health and physical well-being. 20 C.F.R. § 416.926a(b)(1).

To functionally equal a listing, the ALJ must find an “ex-

treme” limitation in one category or a “marked” limitation

in two categories. 20 C.F.R. § 416.926a(a), (e)(2)(i).

10 No. 10-3340

relating to others, moving about and manipulating

objects, and health and physical well-being. He reasoned

that her symptoms were “reasonably controlled with

medication compliance” but noted that she sometimes

needed prompting to take her medication. On this basis,

the ALJ concluded that Jelinek had not been disabled

before her eighteenth birthday.

The ALJ then reviewed Jelinek’s application under

the five-step “adult standard” for the period after she

turned 18.3 He found that Jelinek had developed no

new impairments and found again, without additional

analysis, that Jelinek had no impairment or combination

of impairments that met or medically equaled a listing.

The ALJ acknowledged the restrictions in concentration,

persistence, and pace suggested by Dr. Radzeviciene’s

January 2008 opinion, as well as the doctor’s opinion

that she had no effective ability to maintain regular

attendance, perform at a consistent pace, or deal with

normal work stresses. But without explicit analysis, the

ALJ offset those concerns with a statement that Jelinek

“functioned well and passed the GED test, attended

college and obtained good grades, and worked selling

Avon and part-time at a hotel.” The ALJ opined that

Jelinek retained the residual functional capacity to

3

If a child claimant turns 18 after filing a disability application

but before a final decision, the ALJ uses the rules governing

child applications for the period before the claimant turned

18. For the period starting the day the claimant turns 18, the

ALJ uses the disability rules for adults who file new claims.

20 C.F.R. §§ 416.920, 416.924(f).

No. 10-3340 11

engage in light and sedentary unskilled work. In

making this determination, he concluded that Jelinek’s

statements about the intensity, persistence, and limiting

effects of her symptoms were not “entirely credible”

because progress notes often showed her to be doing

well. He reiterated that she had obtained her GED, and

he cited Dr. Radzeviciene’s April 2007 examination

as support for his conclusion that medication non-com-

pliance was often the culprit behind Jelinek’s decom-

pensation. Then, citing the vocational expert’s testimony,

the ALJ concluded that jobs existed for Jelinek in signifi-

cant numbers in the national economy. He concluded

that Jelinek was not disabled from her eighteenth

birthday to the date of the decision.

II. Discussion

On appeal Jelinek challenges several aspects of the

ALJ’s decision. Chiefly she contends that the ALJ improp-

erly discounted Dr. Radzeviciene’s assessment of her

mental impairments. This mistake led the ALJ in turn,

Jelinek argues, (1) to evaluate improperly whether her

mental impairments met the listing for “affective disor-

ders”; (2) to overstate her residual functional capacity

when questioning the vocational expert; and (3) to err in

finding her not credible. On judicial review, a court

will uphold the Commissioner’s decision if the ALJ

applied the correct legal standards and supported his

decision with substantial evidence. 42 U.S.C. § 405(g);

Castile v. Astrue, 617 F.3d 923, 926 (7th Cir. 2010); Terry

v. Astrue, 580 F.3d 471, 475 (7th Cir. 2009). A decision

12 No. 10-3340

denying benefits need not discuss every piece of evidence,

but when an ALJ fails to support her conclusions ade-

quately, remand is appropriate. Villano v. Astrue, 556 F.3d

558, 562 (7th Cir. 2009). We limit our review to the

reasons articulated by the ALJ in the written decision. See

SEC v. Chenery, 318 U.S. 80, 93-94 (1943); Spiva v. Astrue,

628 F.3d 346, 353 (7th Cir. 2010); Larson, 615 F.3d at 749.

We begin with Jelinek’s contention that the ALJ failed

to adhere to the “treating physician rule.” A treating

physician’s opinion that is consistent with the record is

generally entitled to “controlling weight.” 20 C.F.R.

§ 404.1527(d)(2); Schaaf v. Astrue, 602 F.3d 869, 875 (7th

Cir. 2010). An ALJ who chooses to reject a treating physi-

cian’s opinion must provide a sound explanation for the

rejection. 20 C.F.R. § 404.1527(d)(2); Campbell v. Astrue,

627 F.3d 299, 306 (7th Cir. 2010); Schmidt v. Astrue, 496

F.3d 833, 842 (7th Cir. 2007). Jelinek argues, and we

agree, that the ALJ did not explain satisfactorily in the

written decision his rejection of Dr. Radzeviciene’s

opinion. When an ALJ decides to favor another

medical professional’s opinion over that of a treating

physician, the ALJ must provide an account of what

value the treating physician’s opinion merits. See Scott v.

Astrue, 647 F.3d 734, 740 (7th Cir. 2011). The ALJ’s deci-

sion did not meet these requirements for rejecting

Dr. Radzeviciene’s opinion.

The ALJ’s decision does not allow us to conclude that

he weighed the merits of Dr. Radzeviciene’s opinion, let

alone engaged in the careful analysis required by the

regulations and case law. Dr. Radzeviciene’s assess-

No. 10-3340 13

ment, as reflected in the questionnaire he completed in

January 2008, addressed Jelinek’s symptoms and her

residual functional capacity and thus was highly

relevant to several parts of the ALJ’s analysis. But in a

section devoted to determining whether Jelinek’s mental

impairments met or medically equaled a listed impair-

ment under the adult five-step analysis, the ALJ limited

his comments to the following:

It is noted that . . . Dr. Radzeviciene opined in

January 2008 that the claimant has fair (seriously

limited) ability to maintain attention for two-hour

periods, sustain an ordinary routine without special

supervision; complete a normal workday and work-

week; work in coordination with others without being

unduly distracted; understand, remember, and carry

out detailed instructions; set realistic goals and

make plans independently of others; and use public

transportation; poor/no ability to maintain regular

attendance and be punctual; perform at a consistent

pace without an unreasonable number and length of

rest periods; and deal with normal work stresses.

However, the undersigned points out that the

claimant functioned well and passed the GED test,

attended college and obtained good grades, and

worked selling Avon and part-time at a hotel.

That’s it. Though the ALJ mentioned Dr. Radzeviciene’s

opinion once more in passing, the judge never linked the

activities he cited with an assessment of Dr. Radzeviciene’s

opinion or explained whether that opinion supported

a finding that Jelinek’s impairments met a listing.

14 No. 10-3340

The Commissioner does not defend the denial of

benefits by asserting that the ALJ’s discussion of

Dr. Radzeviciene’s opinion was adequate. Instead, in

his brief and at oral argument, the Commissioner has

asserted that the opinions of Dr. Kladder and Dr. Heroldt,

the two state-agency psychologists, explained the ALJ’s

rejection of Dr. Radzeviciene’s opinion. But the Commis-

sioner’s say-so is not enough.

We have made clear that what matters are the reasons

articulated by the ALJ. Spiva, 628 F.3d at 353; Larson,

615 F.3d at 749. Although the ALJ cited the opinions of

both psychologists, he did not use either opinion to

support his decision to reject Dr. Radzeviciene’s opinion.

See 20 C.F.R. § 404.1527(d)(2); Larson, 615 F.3d at 751;

Moss v. Astrue, 555 F.3d 556, 561 (7th Cir. 2009). In any

event, the ALJ would be hard-pressed to justify casting

aside Dr. Radzeviciene’s opinion in favor of these earlier

state-agency opinions. See Scott, 647 F.3d at 739-40.

By 2008, the state-agency opinions were two years old.

Dr. Radzeviciene’s opinion, on the other hand, was the

most recent professional word on Jelinek’s mental im-

pairments, by a treating psychiatrist who had seen

her repeatedly over a two-year period with full access

to her complete medical record to that point. No other

medical opinion available to the ALJ provided a

similarly comprehensive picture of Jelinek’s overall

mental health at the time of the hearing. Neither the

opinion of Dr. Heroldt nor the opinion of Dr. Kladder

fully supported the ALJ’s wholesale rejection of

Dr. Radzeviciene’s opinion. While these psychologists

No. 10-3340 15

did not think that Jelinek’s residual functional capacity

was as limited as Dr. Radzeviciene did, Dr. Heroldt

scored Jelinek’s GAF at 50, which corresponds to a

serious impairment of functioning, and Dr. Kladder

concluded, contrary to the ALJ’s decision, that Jelinek’s

claim of disability was credible.

Even if we could follow the ALJ’s reasoning from the

brief references to Jelinek’s college coursework and her

limited employment, the ALJ’s decision did not build a

logical bridge between those activities and his conclu-

sion that she had not met a listing after her eighteenth

birthday. See Clifford v. Apfel, 227 F.3d 863, 872 (7th

Cir. 2000). An ALJ may consider a claimant’s daily activi-

ties when assessing credibility, see Arnold v. Barnhart,

473 F.3d 816, 823 (7th Cir. 2007), but ALJs must explain

perceived inconsistencies between a claimant’s activities

and the medical evidence. Stewart v. Astrue, 561 F.3d

679, 684 (7th Cir. 2009); Carradine v. Barnhart, 360 F.3d 751,

755 (7th Cir. 2004); Zurawski v. Halter, 245 F.3d 881, 887

(7th Cir. 2001). The ALJ did not do so, and we are hard-

pressed to understand how Jelinek’s brief, part-time

employment supports a conclusion that she was able to

work a full-time job, week in and week out, given her

limitations. See Stewart v. Astrue, 561 F.3d 679, 684 (7th

Cir. 2009); Diaz v. Prudential Ins. Co. of Am., 499 F.3d 640,

648 (7th Cir. 2007); Zurawski, 245 F.3d at 887. The ALJ did

not ask the critical questions about Jelinek’s actual

work hours or absentee rates in the jobs she held, and

no medical provider or consultant opined that Jelinek

could hold down a full-time position. Rather, the record

suggests that Jelinek has experienced longstanding prob-

16 No. 10-3340

lem with absences. The activities the ALJ mentioned

reflected only her willingness and ability to stay

engaged in commendable but limited endeavors part-

time or at her own pace.

The remainder of the ALJ’s decision shows that the

failure to weigh Dr. Radzeviciene’s opinion appropri-

ately led to additional errors. If that opinion were fully

credited, it supports both a finding that Jelinek met

Listing 12.04 before the hearing date and that her residual

functional capacity was consistent with a finding of

disability. Dr. Radzeviciene noted that Jelinek exhibited

several symptoms of depression, including appetite and

sleep disturbance, psychomotor agitation or retarda-

tion, decreased energy, and difficulty concentrating or

thinking. Dr. Radzeviciene’s notes also reflect that Jelinek

was bipolar. A finding that she suffered from these ill-

nesses would satisfy Listing 12.04’s diagnostic “A criteria.”

See 20 C.F.R. Pt. 404, Subpt. P, App. 1 § 12.04(A); Larson,

615 F.3d at 747-48. Dr. Radzeviciene also opined that

Jelinek was experiencing “frequent” deficiencies of con-

centration, persistence, or pace and “repeated” episodes

of deterioration or decompensation in work or work-

like settings, together enough to meet Listing 12.04’s

diagnostic “B criteria.” See 20 C.F.R. Pt. 404, Subpt. P,

App. 1 § 12.04(B); Larson, 615 F.3d at 747-48; Craft v.

Astrue, 539 F.3d 668, 674-75 (7th Cir. 2008). These two

findings — that Jelinek satisfied both the A and B criteria

of Listing 12.04 — would together compel a finding that

Jelinek was disabled. See 20 C.F.R. Pt. 404, Subpt. P, App.

1 § 12.00. But the ALJ’s opinion did not mention any of

the symptoms cited in Dr. Radzeviciene’s 2008 opinion.

In fact, though the quoted text appears in the section of

No. 10-3340 17

the ALJ’s opinion devoted to whether Jelinek “met or

medically equaled” a listed impairment after the age of

eighteen, the section devoted to Dr. Radzeviciene’s

opinion cited only the portion devoted to Jelinek’s

residual functional capacity, not her symptoms or diag-

noses.

As noted, Jelinek also contends on appeal that the

ALJ’s failure to analyze Dr. Radzeviciene’s opinion led

the judge to omit key limitations when presenting his

hypothetical questions to vocational expert Fisher at

Jelinek’s hearing. As a result, Jelinek argues, the expert

could not give the ALJ an accurate picture of the jobs

available to her in the national economy. At the very

least, Jelinek contends, the ALJ should have included

hypothetical questions addressing issues of “concentra-

tion, persistence, or pace” consistent with the medical

opinions that he credited, including Dr. Kladder’s. Again,

we agree.

We have stated repeatedly that ALJs must provide

vocational experts with a complete picture of a claimant’s

residual functional capacity, and vocational experts must

consider “deficiencies of concentration, persistence, and

pace.” O’Conner-Spinner v. Astrue, 627 F.3d 614, 619 (7th

Cir. 2010); see Stewart, 561 F.3d at 684; Young v. Barnhart,

362 F.3d 995, 1004 (7th Cir. 2004); Kasarsky v. Barnhart,

335 F.3d 539, 544 (7th Cir. 2003); Steele, 290 F.3d at 942.

And though the hypothetical questions posed by an ALJ to

a vocational expert must include only the physical and

mental limitations the judge deems credible, Schmidt,

496 F.3d at 846, the ALJ did not do that in this case.

18 No. 10-3340

The ALJ limited his questioning of the expert to “seden-

tary” and “light” unskilled work. But “sedentary” and

“light” both describe a claimant’s ability to exert herself

physically over a workday or workweek. See 20 C.F.R.

§§ 404.1567, 416.967(b); Social Security Ruling (“SSR”) 83-

10, 1983 WL 31251, at *5-6 (1983); Haynes v. Barnhart, 416

F.3d 621, 627 n.2 (7th Cir. 2005). Similarly, “unskilled

work” is defined by regulation as “work which needs

little or no judgment to do simple duties that can be

learned on the job in a short period of time.” 20 C.F.R.

§ 404.1568(a). None of these terms addressed the impact

of the mental limitations reflected in Dr. Radzeviciene’s

opinion, which (as reflected in the above quotation

from the ALJ’s decision) limited Jelinek’s ability to main-

tain regular work attendance, to carry out instructions,

and to deal with the stresses of full-time employment.

What’s more, Dr. Kladder’s earlier opinion from 2006,

which the ALJ largely credited, concluded that Jelinek

was not a malingerer and that she suffered at least “mod-

erate limitations” in her abilities to concentrate, to com-

plete a normal workday or workweek, and to respond

appropriately to criticism from supervisors. At the

least, the ALJ was required to pose hypothetical questions

to the vocational expert consistent with Dr. Kladder’s

opinion (and with those of the other physicians on

whose opinions he relied) to give the expert a complete

picture of Jelinek’s residual functional capacity.

These are reasons enough to remand the matter to the

agency for further review. Nevertheless, we briefly

address as well Jelinek’s final argument — that the ALJ

No. 10-3340 19

failed to conduct a proper credibility analysis — to point

out a few additional flaws that should be avoided on

remand. Foremost among these is the ALJ’s repeated

reference to Jelinek’s “medication non-compliance” as

a reason for finding her not credible. The ALJ ap-

parently concluded that Jelinek’s symptoms would have

remained under control but for an unwillingness to

take her medications as directed. But we have often

observed that bipolar disorder, one of Jelinek’s chief

impairments, is by nature episodic and admits to

regular fluctuations even under proper treatment. ALJs

assessing claimants with bipolar disorder must consider

possible alternative explanations before concluding that

non-compliance with medication supports an adverse

credibility inference. See Punzio v. Astrue, 630 F.3d 704,

710 (7th Cir. 2010); Larson, 615 F.3d at 751; Bauer v. Astrue,

532 F.3d 606, 609 (7th Cir. 2008); Kangail v. Barnhart,

454 F.3d 627, 630-31 (7th Cir. 2006).

Here, the record shows a litany of changes to Jelinek’s

medications over the years, as well as concerns by her

doctors over side effects, ineffective drugs, costs, insur-

ance issues, and compliance issues due to both mental

illness and the potential lack of family and social sup-

port. Early notes from Jelinek’s visits to the Bowen Center

expressed concern that her mother might not have fully

supported her medication regimen. And at various times

Jelinek advised doctors that she did not have insurance

and was concerned about paying for therapy — a cost con-

cern that could have limited her access to her several

prescribed medications. Treatment notes did not al-

20 No. 10-3340

ways reflect why medication changes were made, but

several notes, including notes from as late as Decem-

ber 2007, show that doctors were concerned that Jelinek’s

medications were not optimally treating her symptoms

and that she would sometimes run out of her medica-

tions. These concerns must be addressed as part of any

consideration of Jelinek’s failure to comply with

prescribed medication.

We R EVERSE the district court’s judgment and R EMAND

to the Social Security Administration for further pro-

ceedings consistent with this opinion.

11-7-11