Opinion ID: 158709
Heading Depth: 2
Heading Rank: 2

Heading: Evidence of Depression

Text: Plaintiff first contends that the ALJ failed to consider properly the evidence in the record that she suffered from depression when he failed to mention this evidence in his decision and failed to prepare a Psychiatric Review Technique (PRT) form. We agree. A claimant is responsible for furnishing medical evidence of claimed impairments, see 20 C.F.R. §§ 404.1512(a), (c), 416.912(a), (c) but the Commissioner also has the duty to ensure that an adequate record is developed relevant to the issues raised, see Hawkins v. Chater , 113 F.3d 1162, 1164 (10th Cir. 1997). The ALJ is required to “evaluate every medical opinion” he receives, 20 C.F.R. §§ 404.1527(d), 416.927(d), and to “consider all relevant medical -4- evidence of record in reaching a conclusion as to disability,” Baker v. Bowen , 886 F.2d 289, 291 (10th Cir. 1989). Although he is not required to discuss every piece of evidence, the ALJ “must discuss the uncontroverted evidence he chooses not to rely upon, as well as significantly probative evidence he rejects.” Clifton v. Chater , 79 F.3d 1007, 1009-10 (10th Cir. 1996) (citations omitted). Furthermore, when a claimant for disability benefits or supplemental security income presents evidence of a mental impairment that allegedly prevents her from working, the ALJ must follow the procedures for evaluating mental impairments set forth in 20 C.F.R. §§ 404.1520a and 416.920a, including the preparation of a PRT form, which the ALJ must attach to his written decision. See Cruse v. United States Dep’t of Health & Human Servs. , 49 F.3d 614, 617 (10th Cir. 1995); Andrade v. Secretary of Health & Human Servs. , 985 F.2d 1045, 1048-49 (10th Cir. 1993). The failure to do so is reversible error. See Hill v. Sullivan, 924 F.2d 972, 974-5 (10th Cir. 1991). In this case, plaintiff indicated that she suffered from depression during her application process; indeed, the Commissioner characterized her primary diagnosis as her mood disorder. See Appellant’s App., Vol. II at 77-78, 62. Plaintiff stated that her “depression [was] worse” in her request for an administrative hearing. See id . at 115. Plaintiff also stated that she does not get dressed when she is depressed in response to a question about how her illness -5- affects her ability to care for her personal needs. See id. at 113. At the administrative hearing, plaintiff testified that she does not have any hobbies because she is too depressed. See id . at 46. Dr. Dalessandro, a physician who examined plaintiff at the request of the Commissioner, diagnosed plaintiff with depression, noting that she had chronic fatigue and difficulty sleeping, that her affect was flat and her mood was depressed, and that she was observed crying. See id. at 193-95. Plaintiff’s application was reviewed by a psychologist for the Commissioner, Dr. Carolyn Goodrich, who also concluded that plaintiff had depression, though finding that her mental impairment resulted only in slight functional limitations. See id . at 66-67. The evidence in the record was sufficient to trigger the ALJ’s duty to develop the record concerning plaintiff’s depression and to follow the procedures set forth in 20 C.F.R. §§ 404.1520a and 416.920a. See Carter v. Chater , 73 F.3d 1019, 1021-22 (10th Cir. 1996) (ALJ had duty to develop record where mental health professional had diagnosed claimant as suffering from mental impairment); Hill , 924 F.2d at 974 (same). Nevertheless, the ALJ made no mention of any of the uncontroverted evidence that plaintiff suffered from depression, and did not mention, discuss, or weigh Drs. Dalessandro’s and Goodrich’s findings or -6- opinions with respect to plaintiff’s depression. 2 The ALJ also failed to follow the special procedures for evaluating mental impairments, including a failure to complete a PRT form. In light of the evidence in the record indicating that a mental impairment exists, the ALJ’s failure to develop the record and to follow the special procedures for mental impairments required by the regulations constitute errors warranting reversal. As a reviewing court, we cannot make factual determinations on the ALJ’s behalf. See Rapp v. United States Dep’t of Treasury , 52 F.3d 1510, 1515 (10th Cir. 1995) (reviewing court may not compensate for deficiencies in an agency’s decision “by supplying a reasoned basis for the agency’s action that the agency itself has not given.”); see also Casias v. Secretary of Health & Human Servs. , 933 F.2d 799, 800 (10th Cir. 1991) (appellate court may “neither reweigh the evidence nor substitute our judgment for that of the agency”). 2 The ALJ recited a general disclaimer that he had reviewed all of the medical evidence except those exhibits omitted because they “relate to a time not covered by the claim, illegibility, duplicity, different physicians reporting the same diagnoses, physician duplication of hospitalization records, failure to state a diagnosis, statement of the claimant’s complaints without a diagnosis, prescription of medication only, etc.” Appellant’s App. Vol. II at 16-17. We bring to the ALJ’s attention that a general disclaimer is not a substitute for the ALJ’s obligation to give careful consideration to all the relevant evidence and to expressly link his findings to specific evidence. See Huston v. Bowen , 838 F.2d 1125, 1133 (10th Cir. 1988). -7- Plaintiff also contends that the ALJ disregarded his duty to fully and fairly develop the record by not ordering a consultative mental examination to assess the severity of her depression. Because we are remanding for the ALJ consider plaintiff’s alleged mental impairment in the first instance, we do not address whether a consultative examination is required. On remand, the ALJ must determine whether to obtain a consultative examination. See Hawkins , 113 F.3d at 1167 (10th Cir. 1997) (holding that ALJ should order consultative examination if the claimant has shown “a reasonable possibility that a severe impairment exists” and the examination would be “necessary or helpful to resolve the issue of impairment.”)