IN THE UNITED STATES DISTRICT COURT 

FOR THE SOUTHERN DISTRICT OF OHIO 

EASTERN DIVISION 

MONTROSE P. FORD, 

 Plaintiff, 

 vs. Civil Action 2:11-CV-1139 

 Judge Sargus 

 Magistrate Judge King 

MICHAEL J. ASTRUE, Commissioner 

of Social Security, 

 Defendant. 

REPORT AND RECOMMENDATION 

I. 

Introduction and Background

 This is an action instituted under the provisions of 42 U.S.C. 

§§405(g), 1383 for review of a final decision of the Commissioner of 

Social Security denying plaintiff’s applications for disability 

insurance benefits and supplemental security income. This matter is 

now before the Court on plaintiff’s Statement of Errors, Doc. No. 11 

and the Commissioner’s Memorandum in Support, Doc. No. 12. 

 Plaintiff Montrose P. Ford filed his applications for benefits 

on September 16, 2005, alleging that he has been disabled since 

September 16, 2003, as a result of Guillain-Barré syndrome and 

“mental” and heart problems. PAGEID 196. The applications were denied 

initially and upon reconsideration, and plaintiff requested a de novo 

hearing before an administrative law judge. 

 A hearing was held on November 18, 2010, at which plaintiff, 

represented by counsel, appeared and testified, as did Richard P. 

Oestreich, who testified as a vocational expert. In a decision dated 

January 11, 2011, the administrative law judge concluded that 

plaintiff is not disabled within the meaning of the Social Security 

Act. PAGEID 47-59. That decision became the final decision of the 

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Commissioner of Social Security when the Appeals Council declined 

review on June 24, 2011. PAGEID 36-39. 

 Plaintiff was 41 years old on the alleged disability onset date. 

He has a high school education and past relevant work experience as 

a grocery store stock person and a security guard. 

II. 

Plaintiff’s Testimony 

 Plaintiff testified at the administrative hearing that he is 

five foot seven inches in height and weighs 240 pounds. PAGEID 71. 

He last worked on September 16, 2003, as a security guard. PAGEID 72. 

The job ended because he couldn’t get along with his supervisor. 

PAGEID 74. Plaintiff testified that the main cause of his disability 

is his depression. PAGEID 78. He cannot concentrate, experiences mood 

swings and suicidal ideation, suffers from sleep problems and has 

difficulty remembering and focusing. PAGEID 78-79. 

 Plaintiff also experiences fatigue and joint pains in his knees, 

ankles, hands and shoulders. The pain interferes with his sleep. 

PAGEID 81. 

 At the time of the hearing, plaintiff was not undergoing any 

medical treatment nor was he taking any medication, explaining that 

he lacked insurance. PAGEID 81-82. 

 Plaintiff has no hobbies but he reads and studies the Bible. 

PAGEID 86-87. He is able to care for his personal needs and he 

sometimes cooks. PAGEID 85. He sometimes “venture[s] out” to 

church. PAGEID 88. He has one or two friends who visit. PAGEID 89. 

III. 

The Medical Evidence of Record.

 Plaintiff presented to an emergency room on September 16, 2003 

with the chief complaint of chest pain after getting “very upset and 

angry at work.” PAGEID 255-58. Plaintiff described a pain in the left 

lateral aspect of his chest, a sharp, razor blade type sensation under 

his left breast and into his left side. He also complained of severe 

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shortness of breath and dizziness. Cardiovascular examination showed 

a regular rate and rhythm and no murmur, rub or gallop. There was no 

cyanosis, clubbing or edema; there was full range of motion and 

normal strength and tone. Neurologically, plaintiff was found to be 

alert and oriented x3; there were no motor or sensory deficits. 

Plaintiff was discharged with diagnoses of chest pain, rule out 

myocardial infarction; dyspnea; and anxiety. Id. 

 Manmohan Katapadi, M.D., a cardiologist, treated plaintiff from 

October 15, 2003 to April 19, 2005. PAGEID 275-89. On January 15, 2004, 

Dr. Katapadi reported that plaintiff had a positive stress EKG, but 

a negative scan. PAGEID 282. A repeat stress echocardiogram was 

negative for ischemia and Dr. Katapadi commented that plaintiff may 

not need further work up for coronary artery disease. PAGEID 281. In 

July 2004, Dr. Katapadi noted a normal S2 and S2 and no S3 or S4 and 

diagnosed borderline hypertension. PAGEID 281. See also PAGEID 302. 

 Plaintiff was treated at the Family Health Center by Pureza 

Jacaban, M.D., from May 28, 2004 through October 3, 2008. PAGEID

422-37. It was noted that plaintiff is non-compliant at times; he 

tends to “show up in crisis so he is always referred to Netcare.” 

PAGEID 424. 

 In December 2003, psychiatrist Edmond Goold, M.D., diagnosed 

post-traumatic stress disorder and assigned a current Global 

Assessment of Functioning (“GAF”) score of 60, with the highest GAF 

in the past year at 75. PAGEID 334. In January 2004, Dr. Goold 

indicated that plaintiff was “doing well” on Lexapro. PAGEID 332. 

 Plaintiff presented to an emergency room in April 2005, 

complaining that he was “[a]fraid for his life.” PAGEID 259-66. The 

emergency room physician noted that plaintiff was suffering from 

“paranoid delusional thinking.” PAGEID 259. Plaintiff was 

emotionally labile and tearful. PAGEID 260. Toxicology screening 

documented the presence of cocaine and cannabinoids. Plaintiff was 

diagnosed with an acute psychotic episode with a history of depression 

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and anxiety. The emergency room physician worried that plaintiff “may 

represent a significant risk of harm to himself and perhaps others 

. . . [and] that the patient warrants psychiatric hospitalization for 

further evaluation and stabilization.” PAGEID 260. 

 Plaintiff again presented to the emergency department later that 

month complaining of “hallucinations commanding him to harm himself;” 

he denied suicidal or homicidal intent, however. PAGEID 261-62. The 

emergency room physician was unclear whether plaintiff was taking 

prescribed medication. PAGEID 261. Plaintiff again tested positive 

for cannabinoids. Discharge diagnoses were suicidal ideation and 

schizoaffective disorder. PAGEID 262. 

 On December 8, 2005, R.A. Lewis, Ph.D., performed a consultative 

examination at the request of the state agency. PAGEID 337-39. 

Plaintiff reported depression and anxiety. He had received no 

treatment since April 2005; he discontinued his psychiatric 

medication against medical advice. PAGEID 337. Plaintiff admitted 

using street drugs, including marijuana and cocaine. PAGEID 338. 

There was no evidence of delusions, hallucinations, obsessions, 

compulsions or feelings of derealization or depersonalization. Id.

Plaintiff reported a low mood and low self esteem with feelings of 

hopelessness and helplessness. Dr. Lewis found no evidence of a 

thought disorder and noted that plaintiff’s associations were intact. 

Id. According to Dr. Lewis, plaintiff’s insight was fair, his 

intellectual functioning was average, his responses to general 

informational questions were normal, and plaintiff reported no 

suicidal or homicidal intent. Id. Judgment and attention were not 

within normal limits. Id. Dr. Lewis diagnosed dysthymic disorder and 

marijuana and cocaine abuse in early remission. PAGEID 339. He 

assigned a GAF score of 45. Id. According to Dr. Lewis, plaintiff was 

moderately impaired in his ability to relate to others, to understand 

and follow instructions, to withstand the stress and pressures 

associated with day-to-day work activity, to sustain concentration 

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and persistence, to interact and relate to other workers and in his 

ability to adapt. Id. Plaintiff was only mildly limited in his ability 

to perform simple repetitive tasks. Id. 

 State agency psychologist Todd Finnerty, Psy.D., reviewed the 

record in January 2006 and concluded that plaintiff had only mild 

restrictions in his activities of daily living, moderate difficulty 

in maintaining social functioning concentration, persistence, or 

pace and no extended episodes of decompensation. PAGEID 363. 

According to Dr. Finnerty, plaintiff retained the ability to perform 

simple and routine activities, to carry out tasks in situations where 

his duties are relatively static and changes are explained and to 

perform tasks that do not require independent prioritization or more 

than daily planning and in an environment that allows for limited 

interaction with others. PAGEID 351. Dr. Finnerty concluded that 

plaintiff was only partially credible because his subjective 

allegations of mental limitations are not supported by the objective 

medical evidence. Id. 

 In March 2008, plaintiff was psychiatrically hospitalized for 

ten days under the care of Hossam H. Guirgis, M.D., for suicidal 

ideation and increased depression. PAGEID 367-74. Plaintiff reported 

that he had run out of his medication several days prior to the 

hospitalization. PAGEID 367. He also complained that he was nervous, 

had been unable to sleep and could not concentrate or focus. Id. A 

toxicology screening was positive for alcohol, cannabinoids and 

cocaine. Id. Medications were managed to accommodate a mixed/manic 

state, and plaintiff's mood was stabilized. PAGEID 369. Discharge 

diagnoses were bipolar affective disorder, not otherwise specified, 

as well as alcohol and marijuana abuse. Dr. Guirgis assigned GAF 

scores of 5 on admission and 45 on discharge. Id.

 In August 2008, plaintiff was hospitalized for three days with 

complaints of homicidal ideation. PAGEID 376-419. Discharge 

diagnosis was major depressive disorder, severe with psychosis; he 

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was assigned a GAF score of 40. PAGEID 376. It was noted that 

plaintiff had poor medication compliance. PAGEID 389. 

 In October 2008, state agency psychologist Alice Chambly, 

Psy.D., reviewed the file but concluded that there was insufficient 

information to evaluate the severity of plaintiff’s conditions 

because plaintiff had not provided function and daily activities 

reports. Efforts to obtain the information from plaintiff or his 

counsel received no response. PAGEID 438-50. 

 In November 2008, Pureza Jacaban, M.D., who has treated 

plaintiff for both physical and mental impairments, reported to the 

state agency that plaintiff suffers from depression, for which 

plaintiff was referred to a mental health agency. PAGEID 424. In 

April 2009, Dr. Jacaban’s office again reported to the state agency 

that plaintiff is “severely depressed and non-com[pliant].” PAGEID

453. The report referred the state agency to plaintiff’s treating 

mental health professionals for treatment notes, but included the 

comment, “[T]his patient should not work anywhere!” PAGEID 456 

(emphasis in original). 

 A February 2009 MRI of the lumbar spine, for complaints of back 

pain and numbness, showed degenerative changes with lateral 

disc-osteophyte complexes toward the right causing narrowing of the 

neural foramina, predominantly at L3-4 and L4-5. PAGEID 566. 

 Plaintiff began mental health treatment at North Central Mental 

Health Services in April 2009. PAGEID 537-41, 542-63. The initial 

evaluation by a social worker noted a dysphoric mood and flat affect. 

PAGEID 539. Plaintiff was cooperative but almost sedated. According 

to the social worker, plaintiff’s insight was limited and he exhibited 

a high-moderate impairment in functioning due to psychiatric 

symptoms. PAGEID 540. Initial diagnoses were major depression, 

recurrent, with psychotic features; rule out schizoaffective 

disorder, depressive type. Plaintiff was assigned a GAF score of 51. 

Id. 

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 Plaintiff was seen in an emergency room in June 2009 complaining 

of chest pain. PAGEID 515-24. A chest x-ray was normal. PAGEID 520. 

He was discharged with a diagnoses of atypical chest pain. Id. 

 On July 13, 2009, plaintiff was seen in the emergency room for 

complaints of depression and suicidal ideation that included a 

“plan.” PAGEID 508-14. He reported that he had run out of his 

medication, Lexapro. PAGEID 510. The emergency room physician noted 

that plaintiff’s mood, affect, mentation and manner were appropriate. 

There was no apparent risk to either himself or others. Plaintiff 

showed no evidence of hallucinations or other psychotic thoughts. The 

attending physician noted that plaintiff “is not suicidal but is 

depressed. It sounds as if this depression has been a long-standing 

diagnosis for the patient.” PAGEID 511. 

 Plaintiff presented to the emergency room again on July 26, 2009, 

complaining of shortness of breath and chest pain. PAGEID 526. His 

EKG and x-ray were both normal. PAGEID 527. He was discharged with 

a diagnosis of atypical chest pain. Id. 

Plaintiff’s mental health treatment by North Central was 

terminated in May 2010 because he failed to participate in his 

treatment. PAGEID 562. 

IV. 

Administrative Decision 

 In his decision, the administrative law judge found that 

plaintiff’s severe impairments consist of degenerative disk disease, 

covertebral arthritis, degenerative joint disease of the spine, 

post-traumatic stress disorder, depression, schizoaffective 

disorder, bipolar disorder, narcissistic personality disorder and 

a history of poly-substance abuse. PAGEID 49. The administrative law 

judge expressly excluded Guillain-Barré syndrome, hypertension and 

cardiac condition as severe impairments, finding that those 

conditions do not cause more than minimal limitations in plaintiff’s 

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ability to perform basic work activities or, in the case of 

plaintiff’s claimed cardiac condition, was not supported by the 

objective medical evidence. PAGEID 49-50. 

 The administrative law judge went on to find that plaintiff’s 

impairments neither met nor equaled a listed impairment. PAGEID

51-52. 

 The administrative law judge found that plaintiff has the 

residual functional capacity to perform medium work, except that 

plaintiff would be limited to work that involves only simple, routine, 

repetitive activities; to carrying out tasks in situations where his 

duties are relatively static and changes are explained to him; to 

those tasks which will not require independent prioritization or more 

than daily planning; and to work that would permit plaintiff to 

function in an environment that allows for limited interaction with 

others. PAGEID 53. 

 Although this residual functional capacity would preclude the 

performance of plaintiff’s past employment, the administrative law 

relied on the testimony of the vocational expert to find that 

plaintiff is able perform other work that exists in significant 

numbers in the national economy. PAGEID 58-59. Accordingly, the 

administrative law judge concluded that plaintiff was not disabled 

within the meaning of the Social Security Act. PAGEID 59. 

V.

DISCUSSION

 Pursuant to 42 U.S.C. §405(g), judicial review of the 

Commissioner’s decision is limited to determining whether the 

findings of the administrative law judge are supported by substantial 

evidence and employed the proper legal standards. Richardson v. 

Perales, 402 U.S. 389 (1971). Longworth v. Comm’r of Soc. Sec., 402 

F.3d 591, 595 (6th Cir. 2005). Substantial evidence is more than a 

scintilla of evidence but less than a preponderance; it is such 

relevant evidence as a reasonable mind might accept as adequate to 

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support a conclusion. Jones v. Comm’r of Soc. Sec., 336 F.3d 469, 475 

(6th Cir. 2003); Kirk v. Secretary of Health & Human Servs., 667 F.2d 

524, 535 (6th Cir. 1981). This Court does not try the case de novo, 

nor does it resolve conflicts in the evidence or questions of 

credibility. Bass v. McMahon, 499 F.3d 506, 509 (6th Cir. 2007). 

 In determining the existence of substantial evidence, this 

Court must examine the administrative record as a whole. Kirk, 667 

F.2d at 536. If the Commissioner’s decision is supported by 

substantial evidence, it must be affirmed even if this Court would 

decide the matter differently, Tyra v. Sec’y of Health & Human Servs., 

896 F.2d 1024, 1028 (6th Cir. 1990)(citing Kinsella v. Schweiker, 708 

F.2d 1058, 1059 (6th Cir. 1983)), and even if substantial evidence 

also supports the opposite conclusion. Longworth, 402 F.3d at 595. 

 In his Statement of Errors, plaintiff argues the 

administrative law judge should have included plaintiff’s heart 

disorder in his severe impairments. Id. at PAGEID 580. Plaintiff 

also argues that the administrative law judge should not have relied 

on the 2006 opinion of the state agency psychologist, Dr. Finnerty, 

in formulating plaintiff’s residual functional capacity but instead 

should have given more weight to the assessments of other mental 

health professionals, as reflected in their GAF scores. In this 

regard, plaintiff specifically contends that the GAF scores 

“function[ed] as opinions as to the severity of Mr. Ford’s impairments 

and the limitations that derive from those impairments.” Statement 

of Errors, PAGEID 577. Alternatively, plaintiff contends, the 

administrative law judge should have secured the testimony of a 

medical expert. Id. 

 This court concludes that the administrative law judge did not 

err in failing to include plaintiff’s claimed cardiac condition among 

plaintiff’s severe impairments. Dr. Katapadi, plaintiff’s 

cardiologist, reported that, following essentially negative 

findings, there was no need for further testing for coronary artery 

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disease. PAGEID 281. He diagnosed only borderline hypertension. 

Id. 

This Court does conclude, however, that the matter must be 

remanded to the Commissioner for further consideration of plaintiff’s 

mental impairments. In reaching his decision regarding plaintiff’s 

mental residual functional capacity assessment, the administrative 

law judge relied on the January 2006 assessment of the state agency 

psychologist: 

The undersigned gives great weight to the State 

agency psychological consultant mental residual 

functional capacity assessment. The record greatly 

supports this assessment in that there is nothing in 

the record that contradicts the assessment. Further, 

the assessment takes into account the claimant’s 

allegations as to his aversion to those other than 

his family, his alleged mood swings, and his 

difficulties in remembering, concentrating and focusing. 

PAGEID 57. The administrative law judge rejected the opinion of 

disability articulated by Dr. Jacaban because that treating provider 

offered no descriptions of plaintiff’s actual mental impairments and 

because the ultimate conclusion as to disability is a determination 

for the Commissioner. Id. The administrative law judge provided no 

express evaluation of the reports or findings of other treating mental 

health providers, such as Dr. Guirgis, who in 2008 and 2009 assigned 

extremely low GAF scores to plaintiff.1

 The administrative law judge 

also noted references in the record to plaintiff’s non-compliance 

with treatment directives, although only in connection with the 

assessment of plaintiff’s credibility. 

 The state agency psychologist upon whose assessment the 

administrative law judge relied who did not have the benefit of the 

substantial evidence generated after the date of that assessment. 

Although the Commissioner, in his Memorandum in Opposition, relies 

heavily on plaintiff’s apparent failure to provide additional 

 

1 The administrative law judge did mention, in passing, that he considered 

plaintiff’s GAF scores when assessing his residual functional capacity, but that 

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information regarding his functioning and daily activities, 

Memorandum in Opposition, PAGEID 591, it does not appear that the 

administrative law judge relied on this failure in resolving 

plaintiff’s claim. 

 It is therefore RECOMMENDED that the decision of the 

Commissioner be reversed and that this action be remanded to the 

Commissioner of Social Security for further consideration of 

plaintiff’s mental impairments. 

 If any party seeks review by the District Judge of this Report 

and Recommendation, that party may, within fourteen (14) days, file 

and serve on all parties objections to the Report and Recommendation, 

specifically designating this Report and Recommendation, and the part 

thereof in question, as well as the basis for objection thereto. 28 

U.S.C. §636(b)(1); F.R. Civ. P. 72(b). Response to objections must 

be filed within fourteen (14) days after being served with a copy 

thereof. F.R. Civ. P. 72(b). 

 The parties are specifically advised that failure to object to 

the Report and Recommendation will result in a waiver of the right 

to de novo review by the District Judge and of the right to appeal 

the decision of the District Court adopting the Report and 

Recommendation. See Thomas v. Arn, 474 U.S. 140 (1985); Smith v. 

Detroit Federation of Teachers, Local 231 etc., 829 F.2d 1370 (6th 

Cir. 1987); United States v. Walters, 638 F.2d 947 (6th Cir. 1981). 

Date: January 30, 2013 s/Norah McCann King 

Norah McCann King 

 United States Magistrate Judge

 

GAF scores are “of very little value in determining disability.” PAGEID 54-55. 

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