Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alsd-1_04-cv-00436/USCOURTS-alsd-1_04-cv-00436-0/pdf.json

Nature of Suit Code: 864
Nature of Suit: Social Security - SSID Title XVI
Cause of Action: 42:405 Review of HHS Decision (SSID)

---

IN THE UNITED STATES DISTRICT COURT

FOR THE SOUTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

DANIEL M. STANLEY, )

 ) 

Plaintiff, )

)

vs. )CIVIL ACTION NO. 04-00436-BH-B

)

JO ANNE B. BARNHART, )

Commissioner of )

Social Security, )

)

Defendant. )

REPORT AND RECOMMENDATION

Plaintiff Daniel M. Stanley (“Plaintiff”) brings this action

seeking judicial review of a final decision of the Commissioner

of Social Security denying his claim for disability insurance

benefits and supplemental security income under Titles II and

XVI of the Social Security Act, 42 U.S.C. §§ 401-433 and 1381-

1383c, respectively. This action was referred to the

undersigned for report and recommendation pursuant to 28 U.S.C.

§ 636(b)(1)(B). Oral argument was held on August 2, 2005. Upon

careful consideration of the administrative record, oral

argument and the memoranda of the parties, it is recommended

that the decision of the Commissioner be REVERSED and REMANDED.

I. Procedural History

On June 11, 1997, Plaintiff protectively filed an

application for disability insurance benefits and supplemental

security income, alleging that he has been disabled since

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1While the case was pending Appeals Council review, Plaintiff

protectively filed subsequent concurrent applications for disability

insurance benefits and supplemental security income on January 18,

2000; said applications were denied at the initial level and were

consolidated with his pending claims pursuant to the Appeals

Council’s Remand Order. (Tr. 21).

2

January 22, 1997 due to residuals of a total hip replacement,

chronic back syndrome with collapsed discs in his lower back,

leg weakness, seizures, migraine headaches, back pain and

depression. (Tr. 21, 24, 220-246, 522-525). Plaintiff’s

initial applications were denied and he filed a Request for

Hearing before an Administrative Law Judge (“ALJ”). (Id. at

161-168). ALJ Ricardo M. Ryan (“ALJ Ryan”) conducted a hearing

on August 19, 1998, which was attended by Plaintiff, his

counsel, and David R. Peavy, a vocational expert. (Id. at 49-

54). On December 28, 1999, ALJ Ryan entered a decision wherein

he found that Plaintiff has severe residuals from total right

hip replacement and is unable to perform his past relevant work,

but is capable of performing a full range of light work such as

assembler, hand packer and machine operator. (Id. at 144-156).

Plaintiff sought review before the Appeals Council, and in

a decision dated April 23, 2002, the Appeals Council remanded

the case with instructions for further proceedings.1 (Id. at

201-204). The Appeals Council directed the ALJ to further

evaluate Plaintiff’s “mental impairment” in accordance with the

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3

special technique described in 20 C.F.R. §§ 404.1520a and

416.920a, give further consideration to Plaintiff’s maximum

residual functional capacity and provide appropriate rationale

with specific references to record evidence in support of the

assessed limitations, and to obtain supplemental evidence from

a vocational expert to clarify the effect of the assessed

limitations on Plaintiff’s occupational base. (Id. at 203).

Pursuant to the Remand Order, ALJ Ryan conducted a

supplemental hearing on October 16, 2002, which was attended by

Plaintiff, his counsel and Barry W. Murphy, a vocational expert.

(Tr. 104-136, 210-216). ALJ Ryan issued a second unfavorable

decision on January 23, 2003. (Id. at 18-33). ALJ Ryan

determined that Plaintiff possesses the severe impairments of

status post right total hip replacement with chronic

instability, status post right greater trochanter fracture, and

mild lumbar degenerative disc disease without radiculopathy.

(Id. at 32). The ALJ found that Plaintiff’s depression does not

constitute a severe mental impairment because it is the direct

result of Plaintiff’s continuous, chronic drug abuse. (Id. at

24). The ALJ also concluded that Plaintiff’s severe impairments

do not meet or equal the listings, and that although Plaintiff

is unable to return to his past relevant work, he maintains the

residual functional capacity to perform a range of unskilled

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sedentary work and can perform jobs such as bench assembler,

hand mounter and order clerk, which exist in significant numbers

in the national economy. (Id. at 18-33). On May 12, 2004, the

Appeals Council denied Plaintiff’s request for review of the

ALJ’s decision, making it the final decision of the

Commissioner. (Id. at 9-11). See 20 C.F.R. § 404.981; 20

C.F.R. § 416.1481. The parties agree that this case is now ripe

for judicial review and is properly before this Court pursuant

to 42 U.S.C. §§ 405(g) and 1383(c)(3).

II. Background Facts

Plaintiff was born on June 29, 1969 and was 33 years old at

the time of the second administrative hearing. (Tr. 58, 112).

Plaintiff has an eighth grade education, and past relevant work

as a building maintenance worker, laborer, chipper/grinder,

stock clerk and painter. (Id. at 23, 60-69, 90). According to

Plaintiff, he is unable to work because of problems with his

hip, pain in his back and legs, seizures, migraine headaches and

depression. (Id. at 21, 24, 113-117, 220-246, 522-525).

Plaintiff testified that he had a right hip replacement in 1993,

and that due to the wear and tear on his hip, it needs to be

replaced again, but he cannot afford to have it done. (Id. at

123-124). Plaintiff further testified that his hip keeps

popping out of the socket when he is standing, walking and

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laying down, but when he is seated normally, it does not rotate,

move or pop out. (Id. at 116-117). Plaintiff testified that

his back and legs begin to hurt after ten or fifteen minutes of

walking or standing. (Id. at 113). Plaintiff testified that

does not take any medication for his pain; however, at one point

he was prescribed Lortab for his pain. (Tr. 82-85). Plaintiff

testified that now, he only takes aspirin and BC powder for his

pain. (Id. at 117).

Plaintiff also testified that he suffers from depression,

for which he has sought treatment at the Mobile Mental Health

Center (“MMHC”). (Id. at 117). According to Plaintiff, he was

physically and emotionally abused by his father, and was raped

at age five or six by a family friend. (Id. at 118-122).

Plaintiff indicated that he has a hard time thinking and

remembering, and has difficulty sleeping. (Id.) Plaintiff

further testified that he has used “dope” for approximately ten

years, that he smokes “dope” on average about three times a

month, and that he had used “dope” two weeks before the October

16, 2002 hearing. (Id. at 111-112). Plaintiff testified that

the last time he was seen at MMHC was three months prior to the

October hearing, and that at that time, they did “nothing” for

him, even though he told them he was depressed. (Tr. 117).

According to Plaintiff, one of the doctors at MMHC suggested

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that his memory and cognitive problems might be due to his drug

use, and suggested that he attend group meetings. (Id. at 118).

Plaintiff testified that he does not attend the group meetings

because he does not like to talk about the abuse that he has

suffered with others. (Id. at 118-122). 

Plaintiff testified that he lives with his girlfriend, and

that he spends most of his time sitting around the house. (Id.

at 122-123). According to Plaintiff, he cleans, helps with

cooking, and is able to drive and care for himself. (Id. at

123). In a daily activities questionnaire dated May 23, 2000,

Plaintiff indicated that he has no problems getting along with

others, and that he visits with and talks on the phone to family

and friends approximately three to four times weekly. (Id. at

319-323).

III. Issues On Appeal

A. Whether the ALJ committed reversible error, by adopting his

own medical opinion, without citation to any medical

evidence, in finding that Plaintiff does not suffer from

a severe mental impairment (i.e., depression) in violation

of the April 23, 2002 Social Security Administration

Appeals Council remand order;

B. Whether the ALJ committed reversible error, by holding that

Plaintiff’s drug use was a material contributing factor to

the determination that he is totally disabled (because the

ALJ’s conclusion that Plaintiff’s depression does not

constitute a severe medical impairment, as it is the direct

result of his continuous chronic drug abuse, is a

substitution of his own unqualified medical opinion for

those of a medical expert – without any supporting medical

evidence) in violation of Social Security Program

Case 1:04-cv-00436-BH-B Document 21 Filed 08/12/05 Page 6 of 29
2957 F.2d 837, 840-841 (11th Cir. 1992) (Johnson, J.,

concurring).

7

Operations Manual System (“POMS”) DI 90010.010(b)(3) and

Social Security Regulation 20 C.F.R. § 416.935, and because

the ALJ never found Plaintiff disabled, thus triggering a

DAA analysis?

C. Whether the ALJ committed reversible error, by failing in

his obligation to develop a full and fair record regarding

the vocational opportunities available to Plaintiff in this

case in violation of Social Security Ruling 00-4p, by

failing to ask the vocational expert on the record whether

the evidence he provided conflicts with the Dictionary of

Occupational Titles (“DOT”) and to obtain a reasonable

explanation for any apparent conflict?

D. Whether the ALJ committed reversible error in acting as

both judge and physician by arbitrarily substituting his

own medical opinion, without any supporting medical

opinions or substantial evidence, for the opinion of a

medical professional in violation of Marbury v. Sullivan2

and 20 C.F.R. §§ 404.1545 and 416.945, when he found a

medical improvement in Plaintiff’s impairments, from his

last decision, to allow him to perform a full range of

sedentary work without the necessity for a sit-stand

option?

IV. Analysis

A. Standard of Review

In reviewing claims brought under the Act, this court’s role

is a limited one. The court’s review is limited to determining:

1) whether the decision of the Secretary is supported by

substantial evidence; and 2) whether the correct legal standards

were applied. Martin v. Sullivan, 894 F.2d 1520, 1529 (11th Cir.

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3This court’s review of the Commissioner’s application of legal

principles is plenary. Walker v. Bowen, 826 F.2d 996, 999 (11th Cir.

1987).

8

1990).3 A court may not decide the facts anew, reweigh the

evidence, or substitute its judgment for that of the

Commissioner. Sewell v. Bowen, 792 F.2d 1065, 1067 (11th Cir.

1986). The Commissioner’s findings of fact must be affirmed if

they are based upon substantial evidence. Brown v. Sullivan,

921 F.2d 1233, 1235 (11th Cir. 1991); Bloodsworth v. Heckler, 703

F.2d 1233, 1239 (11th Cir. 1983) (stating that substantial

evidence is defined as “more than a scintilla, but less than a

preponderance[,]” and consists of “such relevant evidence as a

reasonable person would accept as adequate to support a

conclusion[]”). In determining whether substantial evidence

exists, courts must view the record as a whole, taking into

account evidence favorable as well as unfavorable to the

Commissioner’s decision. Chester v. Bowen, 792 F.2d 129, 131

(11th Cir. 1986); Short v. Apfel, 1999 U.S. Dist. Lexis 10163

(S.D. Ala. 1999).

B. Discussion

An individual who applies for Social Security disability

benefits or supplemental security income must prove their

disability. 20 C.F.R. § 404.1512; 20 C.F.R. § 416.912.

Disability is defined as the “inability to do any substantial

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gainful activity by reason of any medically determinable

physical or mental impairment which can be expected to result in

death or which has lasted or can be expected to last for a

continuous period of not less than twelve months.” 42 U.S.C. §

423(d)(1)(A); 20 C.F.R. § 404.1505(a); 20 C.F.R. § 416.905(a).

The Social Security regulations provide a five-step sequential

evaluation process for determining if a claimant has proven his

or her disability. 20 C.F.R. § 404.1520; 20 C.F.R. § 416.920.

First, Plaintiff must prove that he has not engaged in

substantial gainful activity. Id. Second, Plaintiff must prove

that he has a severe impairment or combination of impairments.

Id. Third, if Plaintiff proves that the impairment or

combination of impairments meets or equals a listed impairment,

then he is automatically found disabled regardless of age,

education, or work experience. Id. If the Plaintiff cannot

prevail at the third step, he must proceed to the fourth step

where he must prove an inability to perform his past relevant

work. Jones v. Bowen, 810 F.2d 1001, 1005 (11th Cir. 1986);

Barnes v. Sullivan, 932 F.2d 1356, 1358 (11th Cir. 1991) (per

curiam). In evaluating whether the claimant has met this

burden, the examiner must consider the following four factors:

1) objective medical facts and clinical findings; 2) diagnoses

of examining physicians; 3) evidence of pain; 4) the claimant’s

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age, education and work history. Jones, 810 F.2d at 1005. Once

Plaintiff meets this burden, the burden shifts to the

Commissioner to prove at this fifth step that Plaintiff is

capable of engaging in another kind of substantial gainful

employment which exists in significant numbers in the national

economy, given his residual functional capacity, age, education,

and work history. Wolfe v. Chater, 86 F.3d 1072, 1077 (11th Cir.

1996). See generally Sryock v. Heckler, 764 F.2d 834 (11th Cir.

1985). If the Commissioner can demonstrate that there are such

jobs that the Plaintiff can perform, the burden shifts back to

the Plaintiff who must prove an inability to perform those jobs,

in order to be found disabled. Jones v. Apfel, 190 F.3d 1224,

1228 (11th Cir. 1999); Allen v. Sullivan, 880 F.2d 1200, 1201

(11th Cir. 1989); Hale v. Bowen, 831 F.2d 1007, 1011 (11th Cir.

1987) (citing Francis v. Heckler, 749 F.2d 1562, 1564 (11th Cir.

1985)).

In the case sub judice, the ALJ concluded that Plaintiff has

not engaged in substantial gainful activity since his alleged

onset of disability, and that he has the impairments of status

post right total hip replacement with chronic instability,

status post right greater trochanter fracture, and mild lumbar

degenerative disc disease without radiculopathy, which are

“severe” within the meaning of the Act. (Tr. 24, 32). The ALJ

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found that Plaintiff’s alleged depression was not a severe

impairment because “it is the direct result of the claimant’s

continuous, chronic drug abuse.” (Id. at 24). The ALJ further

determined that the record contained no evidence establishing

that he had a seizure disorder during the relevant time period.

(Id. at 24-26). Plaintiff argues that the ALJ erred at this

early stage, because he misapplied the regulation dealing with

alcoholism and drug addiction and thus, did not conduct a proper

analysis in this case. 

As a preliminary matter, the undersigned notes that the

regulations define a non-severe impairment as “an impairment or

combination of impairments” that do “not significantly limit

your physical or mental ability to do basic work activities.”

20 C.F.R. § 416.921(a); 404.1521(a). Basic work activities are

defined as 

the abilities and aptitudes necessary to do most jobs.

Examples of these include-- (1) Physical functions

such as walking, standing, sitting, lifting, pushing,

pulling, reaching, carrying, or handling; (2)

Capacities for seeing, hearing, and speaking; (3)

Understanding, carrying out, and remembering simple

instructions; (4) Use of judgment; (5) Responding

appropriately to supervision, co-workers and usual

work situations; and (6) Dealing with changes in a

routine work setting.

See 20 C.F.R. § 416.921(b); 20 C.F.R. § 404.1521(b).

Plaintiff’s impairments may be considered “not severe” only if

they are slight abnormalities which have such a minimal effect

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on him that they are not expected to interfere with his ability

to work, regardless of age, education or work experience. Brady

v. Heckler, 724 F.2d 914, 922 (11th Cir. 1984). In McDaniel v.

Bowen, 800 F.2d 1026 (11th Cir. 1986), the Eleventh Circuit

clarified the severity determination and stated as follows:

[a]t step two of § 404.1520 and § 416.920 a claimant’s

impairment is determined to be either severe or not

severe. Step two is a threshold inquiry. It allows

only claims based on the most trivial impairments to

be rejected. The claimant’s burden at step two is

mild. An impairment is not severe only if the

abnormality is so slight and its effect so minimal

that it would clearly not be expected to interfere

with the individual’s ability to work, irrespective of

age, education or work experience. Claimant need show

only that her impairment is not so slight and its

effect is not so minimal.

Id. at 1031. Based upon a review of the record evidence, the

undersigned finds that the ALJ erred in concluding that

Plaintiff’s depression does not constitute a severe mental

impairment because it is the direct result of Plaintiff’s

continuous, chronic drug abuse. The medical evidence clearly

demonstrates that Plaintiff’s depression is not so slight as to

be trivial. 

Specifically, the record reflects that during late 1998,

Plaintiff began treatment at the Mobile Mental Health Center

(“MMHC”) for depression. (Tr. 475-479). On November 17, 1998,

Plaintiff complained of a depressed mood and thoughts of suicide

about two to three times per month. (Id. at 479). Plaintiff

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reported that “I couldn’t do it[,] [p]ull the trigger that is.”

(Id.) Plaintiff was noted as having symptoms of hopelessness as

well as loss of energy and motivation. (Id.) Plaintiff also

reported that he was physically abused as a child, and that his

parents were alcoholics. (Id.) Plaintiff acknowledged the use

of “pot” and “crack cocaine” but denied using alcohol. (Id.)

Plaintiff also reported that he was unable to get disability

benefits due to his hip replacement, so his attorney was going

to “try the psyc evaluation rout[e].” (Tr. 479). The MMHC

treating physician noted that Plaintiff’s affect was

appropriate, his mood was anxious and irritable, he had suicidal

thoughts but no plans or means, his sleep was poor, his appetite

was fair/poor, his orientation was normal and his motor activity

was calm. (Id.) The doctor noted “possible malingering.”

(Id.)

Plaintiff returned to the MMHC on November 30, 1998. (Id.

at 478). Plaintiff reported a depressed mood and nightmares.

(Id.) Plaintiff also reported that his sleep was bad; however,

he indicated that he was sleeping six hours a night. (Id.)

Plaintiff reported a fair/poor appetite and denied any

hallucinations or suicidal/homicidal thoughts. (Tr. 478). The

physician noted that Plaintiff’s affect was appropriate and that

his mood was irritable. (Id.) Plaintiff was not prescribed any

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medication, but was encouraged to keep a log, comply with

therapy and stay sober. (Id.)

Plaintiff was seen at MMHC again on December 15, 1998. (Id.

at 477). Plaintiff reported that he had not been sleeping for

three to four days, and that he was easily aggravated. (Id.)

Plaintiff also reported marijuana abuse and experimentation with

cocaine and crack. (Id.) The physician observed that Plaintiff

still has much anger related to his childhood, and that he was

sad and tearful when discussing the neglect by his parents.

(Tr. 477). Plaintiff was diagnosed with major depression,

probable posttraumatic stress disorder and polysubstance abuse,

and was prescribed Paxil. (Id.) 

Plaintiff visited the MMHC on March 23, 1999. (Id. at 476).

Plaintiff reported that the Paxil “helped a lot.” (Id.)

Plaintiff stated that he had not used marijuana since New

Year’s, but when asked to submit to a drug test, admitted to

continued daily marijuana use. (Id.) The physician’s diagnosis

was as follows: “[r]/o [rule out] major depression-doubt[,]

probable PTSD 2d [secondary to] abandonment-mild[,] chronic

marijuana use [and] 2d [secondary gain] - wants SSI.” (Id.)

Plaintiff was asked to choose his form of therapy – marijuana

abuse or abstinence with regular follow-up and mental health

treatment – and was referred for outpatient substance abuse

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treatment. (Tr. 476).

Plaintiff sought treatment from Southwest Alabama Health

Services for depression on November 1, 1999. (Id. at 460).

Plaintiff reported that he was depressed and was having problems

eating and sleeping. (Id.) Plaintiff stated that his father

died in June, and that his mother and grandmother had died in

September as a result of a motor vehicle accident. (Id.)

Plaintiff was diagnosed with depression, and given Paxil and

Doxycycline. (Id.) Plaintiff returned to Southwest on January

20, 2000, and reported that the Paxil helped quite a bit, but

that the Doxycycline did not. (Id. at 459). Plaintiff was

diagnosed with depression, and given Paxil. (Tr. 459).

At the request of the Social Security Administration

(“SSA”), Annie Formwalt, Psy. D. (“Dr. Formwalt”) conducted a

psychological evaluation of Plaintiff on June 27, 2000. (Id.

at 423-425). This evaluation reflects that:

• Plaintiff reported experiencing erratic sleep

patterns, decreased appetite, feelings of sadness

daily, vague auditory hallucinations, frequent

thoughts of death but no current suicidal or

homicidal ideation, decreased pleasure in

activities he formerly enjoyed and feelings of

loneliness and being socially withdrawn.

Plaintiff reported that in 1999, he lost his

mother, father and grandmother within 90 days of

each other; he also indicated that his childhood

was abusive and he was neglected.

• Plaintiff told Dr. Formwalt that his daily

activities consist of watching TV, listening to

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the radio, playing his guitar and trying to

sleep; however, he added that he is able to

drive, cook and clean (dust, mop and sweep).

• Dr. Formwalt’s mental status exam of Plaintiff

found him to be alert and oriented, appropriately

dressed and groomed, his thought processes were

intact, he did not appear confused, his

conversation was normal, no phobias, obsessions

or compulsions were observed, and it appeared

that he was able to understand, remember and

carry out instructions. Dr. Formwalt noted that

Plaintiff’s insight and understanding of himself

are limited, that his judgment is limited, and

that “[d]ue to substance abuse issues, he may

benefit from assistance with managing his funds.”

• Plaintiff admitted to smoking two to three

marijuana joints per week, that he has been using

for about ten to fifteen years, that he also

drinks three to four beers twice a week, that he

used crack cocaine in 1996 but has not used it

since 1997, and that he had completed thirty days

of a ninety day treatment program.

• Plaintiff reported applying for disability

“because of my hip and back problems[]” and that

he had not worked “because of my leg and my

back.”

(Id.) Dr. Formwalt diagnosed Plaintiff with major depressive

disorder and polysubstance abuse, and noted that “[i]t is likely

that within the next six to twelve months he will receive some

benefit from treatment.” (Id. at 425).

At the request of the SSA, Kim M. Zweifler, Ph.D. (“Dr.

Zweifler”), conducted a consultative psychological evaluation of

Plaintiff on July 18, 2002. (Id. at 465-468). Dr. Zweifler’s

report reflects that:

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• Plaintiff reported that he has been depressed for

10 years and is “anti-social,” stating that he

has difficulty forming close relationships, is

withdrawn and feels anxious. Plaintiff added

that he has trouble concentrating, problems with

early and mid-insomnia and poor self-esteem.

Plaintiff reported further, that he has lost

interest in most activities, has occasional

crying spells, has feelings of hopelessness and

helplessness, is aggravated at times, displays

angry verbal outbursts, and has passive suicidal

ideations at times but has not attempted to harm

himself.

• Plaintiff reported that his daily activities

include eating, watching TV, listening to the

radio, playing with his nephews, visiting with

family and friends and sometimes picking up toys

around the house, washing dishes and bathing.

• Plaintiff reported that he began smoking

marijuana as a teenager and continues to smoke

marijuana two to three times per week, that he

last smoked marijuana the previous weekend, that

he used cocaine for several months in 1997 and

that he drinks alcohol “socially.”

• Dr. Zweifler observed that Plaintiff was

appropriately dressed, adequately groomed,

displayed no obvious difficulties with fine or

gross motor skills and exhibited no unusual

behaviors. Dr. Zweifler further observed that

Plaintiff had a good ability to perform simple

calculations, his abstract reasoning skills were

good, his general fund of knowledge was adequate,

his immediate and remote memory appeared

adequate, he spoke at a normal pace, he did not

appear confused, he had appropriate mood and

affect and did not appear anxious. Dr. Zweifler

also opined that Plaintiff has little insight

into himself and his condition, and that he might

benefit from assistance managing funds.

• According to Dr. Zweifler, on the WAIS-III,

Plaintiff scored in the low average range of

intelligence and displayed weakness in work

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knowledge, expressive vocabulary and short term

auditory memory and attention.

• Dr. Zweifler diagnosed Plaintiff with depression

NOS and cannabis abuse. Dr. Zweifler concluded

that Plaintiff’s ability to understand and

complete simple verbal instructions seemed

adequate; however, his ability to respond to

others seemed restricted.

(Id.) 

Additionally, Dr. Zweifler completed a medical source

opinion form (mental) on Plaintiff, on this same day, in which

she indicated that Plaintiff experienced no limitations in the

following areas:

• using judgment in simple one and two-step workrelated decisions;

• understanding, remembering and carrying out

simple one and two-step verbal instructions;

• maintaining attention, concentration or pace for

periods of at least two hours; and

• maintaining activities of daily living.

(Tr. 469-470). Dr. Zweifler found that Plaintiff had “moderate”

limitations in: 1) responding appropriately to supervisors, coworkers, customers or the general public (due to depression); 2)

using judgment in detailed or complex work-related decisions and

dealing with changes in a routine work setting (due to cannabis

abuse); 3) understanding, remembering and carrying out detailed

or complex verbal instructions (due to low average IQ and

cannabis abuse); and 4) maintaining social functioning (due to

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depression NOS). (Id.) Dr. Zweifler concluded that if

Plaintiff stopped using drugs and/or alcohol, there would be an

improvement in these limitations, such that he would have better

social skills, judgment, concentration and productivity. (Id.

at 470).

At the request of Plaintiff’s counsel, psychologist Michael

S. Rosenbaum, Ph.D. (“Dr. Rosenbaum”) conducted a consultative

psychological examination (including a semi-structured interview

for making the Major Axis 1 diagnoses from the DSM-IV) of

Plaintiff on October 14, 2002, which reflects that: 

• Plaintiff exhibited a cooperative attitude, sad

facial expression, blunted affect, depressed

mood, appropriate eye contact, normal quality and

quantity of speech, coherent thought processes,

appropriate judgment and limited insight.

Plaintiff did not exhibit characteristics of

hallucinations, delusions, suicidal ideation or

homicidal ideation.

• Plaintiff testified that his daily activities

include having coffee, watching TV, visiting with

his cousin, eating, listening to the radio and

taking his girlfriend to work; he has no

household tasks to complete because he does not

have a permanent home and his girlfriend does his

laundry.

• Plaintiff admitted to drinking one or two beers

per week and to smoking marijuana on a regular

basis – from two to three times per week to two

to three times per day. Plaintiff was arrested

once for possession of marijuana.

• Plaintiff reported having had difficulties with

episodes of depression since he was eight or nine

years old. Plaintiff reported physical and

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emotional abuse by his father until age ten, and

sexual abuse by a family friend at age five or

six. Plaintiff’s depression manifested in sleep

disturbance, difficulty concentrating, loss of

interest in usual activities, fatigability,

negative thoughts about himself, thoughts of

suicide, frequent crying episodes and psychomotor

agitation or psychomotor retardation.

• Plaintiff was diagnosed with major depressive

disorder (recurrent), cannabis dependence and an

undifferentiated somatoform disorder. Dr.

Rosenbaum opined that Plaintiff likely

experienced a disturbing traumatic event in the

past which continues to distress him today, and

produces recurrent episodes of anxiety.

• Dr. Rosenbaum concluded that it was questionable

whether Plaintiff could sustain performance in a

work-related setting for a reasonable period of

time due to his physical impairments when

combined with his depression, fatigue, confusion,

distractibility, difficulty concentrating and his

excessive concern about physical functioning and

interpersonal difficulties. Dr. Rosenbaum also

opined that Plaintiff’s drug abuse was a

contributing material factor to his mental

functional restrictions and limitations, and that

it was “important” for Plaintiff to get involved

in an outpatient program for the treatment of

substance use disorders so he can achieve and

maintain abstinence from drug use. Dr. Rosenbaum

recommended that Plaintiff resume mental health

treatment for his depression and begin an

outpatient program for substance abuse treatment.

(Id. at 511-517). Additionally, Dr. Rosenbaum completed a

mental residual functional capacity questionnaire for Plaintiff

in which he noted that Plaintiff has “mild” restrictions in his

daily activities and in his ability to understand, carry out and

remember instructions, respond appropriately to supervision and

Case 1:04-cv-00436-BH-B Document 21 Filed 08/12/05 Page 20 of 29
4Dr. Simpson’s assessment, which was based on a review of the

medical records, does not contain information from Dr. Zweifler or

Dr. Rosenbaum’s evaluation of Plaintiff, because those evaulations

took place after Dr. Simpson’s assessment was generated.

21

perform simple and/or repetitive tasks. (Id. at 518-520). Dr.

Rosenbaum also found that Plaintiff has “moderate” restrictions

in his ability to maintain social functioning and respond

appropriately to co-workers as well as “moderate” deficiencies

of concentration, persistence or pace. (Id.) Dr. Rosenbaum

found further, that Plaintiff has “marked” limitations in

responding appropriately to customary work pressures. (Tr.

520). 

The record also contains a July 21, 2000

4 mental residual

functional capacity assessment form completed at the request of

the SSA, by William H. Simpson, Ph.D. (“Dr. Simpson”). (Id. at

429-432). Based on his review of the medical records, Dr.

Simpson concluded that Plaintiff is “moderately” limited in his

ability to understand and remember detailed instructions, carry

out detailed instructions, maintain attention, concentrate for

extended periods of time and set realistic goals or make plans

independently of others. (Id. at 429-430). On this same day,

Dr. Simpson also completed a psychiatric review technique form

in which he noted that Plaintiff has a history of treatment for

mood disorder NOS, cannabis dependence, cocaine abuse, major

Case 1:04-cv-00436-BH-B Document 21 Filed 08/12/05 Page 21 of 29
22

depressive disorder and polysubstance abuse, but that his

activities of daily living do not appear to be severely

restricted. (Id. at 433-441). Dr. Simpson concluded that

Plaintiff’s functional limitations include a “slight” degree of

limitation for restrictions of activities of daily living and

difficulties in maintaining social functioning; and an “often”

degree of limitation relating to deficiencies of concentration,

persistence or pace resulting in a failure to complete tasks in

a timely manner (in work settings or elsewhere). (Id. at 440).

In light of the foregoing, it is clear that the ALJ erred

in concluding that Plaintiff’s depression does not constitute a

severe impairment. The substantial medical evidence regarding

Plaintiff’s depression conclusively establishes that it results

in limitations in a number of areas, including Plaintiff’s

ability to concentrate and relate to coworkers and supervisors.

Interestingly, in concluding that Plaintiff’s depression is not

severe, the ALJ did not find that his depression is so slight

and its effect so minimal that it would not be expected to

interfere with his ability to work. Instead, the ALJ found that

Plaintiff’s depression does not constitute a severe medical

impairment because it is the direct result of Plaintiff’s

continuous, chronic drug abuse. The ALJ erred by focusing on

the purported cause of Plaintiff’s depression, namely his

Case 1:04-cv-00436-BH-B Document 21 Filed 08/12/05 Page 22 of 29
23

chronic drug abuse, to totally dismiss the effects of his

depression at step two of the five-step sequential evaluation

process.

The Contract with America Advancement Act of 1996 (“CAAA”),

42 U.S.C. § 432(d)(2)(C), amended the SSA to preclude an award

of benefits when alcoholism or drug addiction is determined to

be a contributing factor material to the determination that a

claimant is disabled. See, e.g., Doughty v. Apfel, 245 F.3d

1274, 1275 (11th Cir. 2001); Mand v. Apfel, 2001 WL 267457, *4

(M.D. Fla. 2001); Tucker v. Apfel, 2000 WL 548178, *1 (S.D. Ala.

Apr. 12, 2000); Englert v. Apfel, 1999 WL 1289472, *8-13 (M.D.

Fla. Jun. 16, 1999). Specifically, the CAAA provides that a

claimant “shall not be considered to be disabled for purposes of

this subchapter if alcoholism or drug addiction would (but for

this subparagraph) be a contributing factor material to the

Commissioner’s determination that the individual is disabled.”

Doughty, 245 F.3d at 1279. The regulations implementing the

CAAA, namely 20 C.F.R. § 404.1535 and 20 C.F.R. § 416.935,

provide that once the Commissioner determines that a claimant is

disabled and finds medical evidence of drug addiction or

alcoholism, there must then be a determination of whether the

drug addiction or alcoholism is a contributing factor material

to the determination of disability. Id. “The key factor” in

Case 1:04-cv-00436-BH-B Document 21 Filed 08/12/05 Page 23 of 29
24

this “materiality determination,” is “whether the claimant would

still be found disabled if he stopped using drugs or alcohol.”

Id. (citing to 20 C.F.R. § 404.1535(b)(1)). 

The problem in this case is that the ALJ did not properly

consider the effects of Plaintiff’s depression at step two, and

moreover, he proceeded to the materiality determination without

first determining whether Plaintiff was disabled. The

regulations require, however, that the sequential evaluation

process be followed in adjudicating disability before any

consideration is given to whether drug addiction is the cause of

disability. 20 C.F.R. §§ 404.1535(a); 20 C.F.R. § 416.935. To

find that drug addiction is a contributing factor material to

the determination of disability, without first finding that

Plaintiff is disabled, as the ALJ did here, is to put the cart

before the horse. Indeed, the implementing regulations make

clear that a finding of disability is a condition precedent to

an application of § 423(d)(2)(C). “The Commissioner must first

make a determination that the claimant is disabled [and] then[,]

make a determination whether the claimant would still be found

disabled if he . . . stopped abusing [drugs]. . . .” See

Drapeau v. Massanari, 255 F.3d 1211, 1214 (10th Cir. 2001). “The

ALJ cannot begin to apply § 423(d)(2)(C) properly when, as here,

he has not yet made a finding of disability.” Id. at 1215.

Case 1:04-cv-00436-BH-B Document 21 Filed 08/12/05 Page 24 of 29
25

In Brueggemann v. Barnhart, 348 F.3d 689, 693-695 (8th Cir.

2003), the Eighth Circuit explained that the regulations require

the ALJ to first determine whether the claimant is disabled.

The ALJ must reach this determination using the standard fivestep approach detailed in 20 C.F.R. § 404.1520, “without

segregating out any effects that might be due to substance use

disorders.” Id. at 694. In other words, the ALJ must base this

initial disability determination on substantial evidence of

medical limitations “without deductions for the assumed effects

of use disorders.” Id. “The inquiry here concerns strictly

symptoms, not causes[]” such that “if the gross total of a

claimant’s limitations, including the effects of substance use

disorders, suffices to show disability, then the ALJ must next

consider which limitations would remain when the effects of

substance use disorders are absent.” Id. at 694-695. 

As noted infra, the ALJ conducted a faulty five-step

sequential evaluation because he did not properly consider the

limitations caused by Plaintiff’s depression, or the cumulative

effect of such limitations in conjunction with Plaintiff’s other

severe impairments, such as his right hip impairment. This

error was further compounded because the ALJ did not follow the

prescribed method for evaluating substance abuse, but instead,

addressed the materiality of Plaintiff’s substance abuse at step

Case 1:04-cv-00436-BH-B Document 21 Filed 08/12/05 Page 25 of 29
26

two of the sequential evaluation process rather than after

making a disability finding.

The undersigned has endeavored to ascertain the extent to

which the above-described errors can be deemed harmless, as it

would seem that Plaintiff cannot rely on his depression while

his chronic drug use, is, according to some of the doctors,

contributing to his depression. However, while there is medical

evidence suggesting that Plaintiff’s depression would improve if

he discontinued his drug use, the ALJ’s decision does not

address whether any of the limitations, including those

associated with his depression, would likely continue and/or

whether such limitations coupled with his other severe

impairments would render Plaintiff disabled in the absence of

his drug use. Accordingly, the undersigned concludes that the

decision of the ALJ should be reversed and the cause remanded

for further administrative proceedings to properly assess the

limitations associated with Plaintiff’s depression. If, upon

completion of the five-step sequential evaluation process, the

ALJ determines that Plaintiff is disabled, he should then

proceed to engage in the substance abuse analysis set forth in

regulations. In so doing, the ALJ shall make specific findings,

based on the medical evidence, regarding the extent to which

Plaintiff’s limitations, including those associated with his

Case 1:04-cv-00436-BH-B Document 21 Filed 08/12/05 Page 26 of 29
5Given the nature of this ruling and for the reasons set forth

herein, this Court finds that there is no need to address and/or rule

upon the remaining three (3) issues on appeal.

27

depression, would remain in the absence of drug use. 

V. Conclusion

For the reasons set forth, and upon careful consideration

of the administrative record and memoranda of the parties, it is

recommended that the decision of the Commissioner of Social

Security denying Plaintiff’s claim for disability income

benefits and supplemental security income, be REVERSED and

REMANDED.5

The attached sheet contains important information regarding

objections to this report and recommendation.

DONE this 11th day of August 2005.

 /s/SONJA F. BIVINS 

UNITED STATES MAGISTRATE JUDGE

Case 1:04-cv-00436-BH-B Document 21 Filed 08/12/05 Page 27 of 29
28

MAGISTRATE JUDGE’S EXPLANATION OF PROCEDURAL RIGHTS 

AND RESPONSIBILITIES FOLLOWING RECOMMENDATION

AND FINDINGS CONCERNING NEED FOR TRANSCRIPT

1. Objection. Any party who objects to this recommendation or

anything in it must, within ten days of the date of service of

this document, file specific written objections with the clerk

of court. Failure to do so will bar a de novo determination by

the district judge of anything in the recommendation and will

bar an attack, on appeal, of the factual findings of the

magistrate judge. See 28 U.S.C. § 636(b)(1)(c); and Lewis v.

Smith, 855 F.2d 736, 738 (11th Cir. 1988). The procedure for

challenging the findings and recommendations of the magistrate

judge is set out in more detail in SD ALA LR 72.4 (June 1,

1997), which provides, in part, that:

A party may object to a recommendation entered by a

magistrate judge in a dispositive matter, that is, a

matter excepted by 28 U.S.C. § 636(b)(1)(A), by filing

a “Statement of Objection to Magistrate Judge’s

Recommendation” within ten days after being served

with a copy of the recommendation, unless a different

time is established by order. The statement of

objection shall specify those portions of the

recommendation to which objection is made and the

basis for the objection. The objecting party shall

submit to the district judge, at the time of filing

the objection, a brief setting forth the party’s

arguments that the magistrate judge’s recommendation

should be reviewed de novo and a different disposition

made. It is insufficient to submit only a copy of the

original brief submitted to the magistrate judge,

although a copy of the original brief may be submitted

or referred to and incorporated into the brief in

support of the objection. Failure to submit a brief

in support of the objection may be deemed an

abandonment of the objection.

A magistrate judge’s recommendation cannot be appealed to a

Court of Appeals; only the district judge’s order or judgment

can be appealed.

2. Opposing party’s response to the objection. Any opposing

party may submit a brief opposing the objection within ten (10)

Case 1:04-cv-00436-BH-B Document 21 Filed 08/12/05 Page 28 of 29
29

days of being served with a copy of the statement of objection.

See Fed. R. Civ. P. 72; SD ALA LR 72.4(b). 

3. Transcript (applicable where proceedings tape recorded).

Pursuant to 28 U.S.C. § 1915 and Fed.R.Civ.P. 72(b), the

magistrate judge finds that the tapes and original records in

this action are adequate for purposes of review. Any party

planning to object to this recommendation, but unable to pay the

fee for a transcript, is advised that a judicial determination

that transcription is necessary is required before the United

States will pay the cost of the transcript.

 /s/ SONJA F. BIVINS 

UNITED STATES MAGISTRATE JUDGE

Case 1:04-cv-00436-BH-B Document 21 Filed 08/12/05 Page 29 of 29