Opinion ID: 2982946
Heading Depth: 3
Heading Rank: 1

Heading: Severity of Winn’s Mental Impairments

Text: As was mentioned above, an impairment is considered “severe” unless “the [claimant’s] impairment(s) has no more than a minimal effect on his or her physical or mental ability(ies) to perform basic work activities.” Soc. Sec. Ruling 85-28, 1985 WL 56856, at  (1985). We have previously observed that the claimant’s burden of establishing a “severe” impairment during the second step of the disability determination process is a “de minimis hurdle.” Higgs v. Bowen, 880 F.2d 860, 862 (6th Cir. 1988). “Under [this] prevailing de minimis view, an impairment can be considered not severe only if it is a slight abnormality that minimally affects work ability regardless of age, education, and experience.” Id. In this case, the ALJ concluded that Winn failed to establish that she suffered from a disability caused by her mental health impairments because she did not demonstrate that she had a “mental impairment that has existed at a ‘severe’ level for a continuous period of at least 12 months.” (R. 6-2, ALJ Decision, Page ID # 77.) In so determining, the ALJ rejected the opinions of three state psychologists as being “non-representative of the claimant’s longitudinal mental functioning capabilities” because Winn’s medical records indicate that she “responded 16 No. 14-3499 favorably to psychological counseling and the use of psychotropic medication,” which were prescribed only after the state assessments. (Id.) First and foremost, as was discussed above, the ALJ’s conclusion is explicitly contradicted by the assessment of Dr. Wee, Winn’s treating psychiatrist. Dr. Wee determined that Winn suffered from significant functional limitations over a year after she began taking psychotropic medications. By concluding that the improvement experienced by Winn rendered her no longer “severely” impaired, the ALJ impermissibly substituted her judgment for that of Winn’s treating psychiatrist. See McCain, 58 F. App’x at 193 (“[A]n ALJ is not free to set his own expertise against that of a physician who presents competent evidence.”) (internal quotation marks omitted). Moreover, the ALJ’s determination that the opinions of the state psychologists should be discounted as “non-representative of [Winn’s] longitudinal mental functioning capabilities” is inconsistent with Winn’s medical records as a whole. Winn’s treatment records strongly suggest a continuous severe mental impairment. On May 11, 2010, over a year after her first assessments by the state psychologists, a treatment note describes that Winn “continue[d] to present with [symptoms] of depression as evidenced by not bathing in almost 2 weeks, appeared unkempt, a lot of fatigue, lack of motivation.” (R. 6, Certified Administrative Record, Page ID # 641.) A treatment note from March 30, 2010 reports: “Client said her interests were waning for her books and other things she used to love . . . . She feels down, presented as depressed, but stable.” (Id. at 648.) Despite stating that Winn was “making definite progress,” an April 13, 2010 medical note describes the persistence of Winn’s mood swings: “The client presents differently from week to week, either very depressed or very happy, rarely in the middle.” (Id. at 643). On January 26, 2011, nearly two years after the state psychologists’ assessments, Winn’s 17 No. 14-3499 therapist observed that “[Winn] still has major bouts of depression and can’t always determine the reason for these.” (Id. at 755.) Although Winn’s medical records suggest that her treatment was helping her, the ALJ had no basis for the determination that Winn’s mental impairments had subsided to the point that they were no longer severe. Most of the comments in Winn’s notes regarding her improvement are relative rather than absolute. The ALJ repeated multiple times that Winn’s notes indicated she was “getting out more” and had “made a lot of progress.” (R. 6-2, ALJ Decision, Page ID # 72, 75 and 76.) However, what matters for the purposes of Winn’s functional limitation determination is Winn’s overall state, not the mere fact that treatment was helping. Nothing in the notes cited by the ALJ supports the conclusion that Winn’s degree of improvement from her previous baseline rendered her only mildly impaired. See Boulis-Gasche, 451 F. App’x at 494. (“The ALJ made no inquiry into the degree of improvement, or from what baseline Plaintiff had improved. Under the ALJ’s logic, any improvement in one’s mood, regardless of how small and from what level the individual improved, would defeat a claim of mental impairment. This cannot be so.”) The opinions of the three state psychologists in March and September of 2009 and that of Dr. Wee in August 2010, as well as a large volume of medical notes in the interim period indicating the persistence of Winn’s mental impairments, are uncontradicted by any other evidence in the record. The ALJ’s determination that Winn did not suffer from a ‘severe’ mental impairment is therefore not based on substantial evidence.