Opinion ID: 170126
Heading Depth: 3
Heading Rank: 2

Heading: Treatment Medical Records

Text: It is clear from the record that Mr. Petree has a long history of mental impairment, stretching back over ten years prior to the ALJ’s hearing. It is also clear that Mr. Petree has been able to work for much of this time. The earliest mental impairment diagnosis in the record is for major depression in 1993 while Mr. Petree was a freshman in college. In 1995 he was again diagnosed with depression, but that diagnosis was subsequently changed to bipolar disorder. Since 1995 his various mental health treatment providers have consistently diagnosed him with bipolar disorder, with the later addition of an accompanying diagnosis of an anxiety disorder. This comports with Mr. Petree’s testimony that generally he experiences a manic phase in the spring of each year, which is -3- followed by a “plateau” during the summer and early fall, and then descends into depression from fall into winter, but that he also experiences panic attacks. 2 The last job held by Mr. Petree required him to perform general labor and packaging duties. He held this job from August 1998 until May 2002, when he was terminated for excessive absences and tardiness. We note that all of the medical evidence specifically referenced by the ALJ in support of his decision, and by Mr. Petree in attacking that decision, dates from before Mr. Petree claims he became disabled. Of this evidence, the most relevant is obviously from after the date that Mr. Petree last worked and it is this evidence that we will examine in detail. The first set of medical records from this period is from Grand Lake Mental Health Center (GLMHC), where Mr. Petree received treatment from July 2, 2002, until November 22, 2002. A clinician’s note prepared by a Dr. Linda Evans on that date references the fact that he was recently fired from his job and states that he was off his medication because he could not afford it, that he could not sleep, that his anxiety and agitation had both increased, and that he had been destructive of property but not assaultive. The note went on to reference his long history of mental impairment and that he claimed that he had been an alcoholic since age nineteen. 2 The record shows that Mr. Petree’s depressive phase is generally more severe than his manic phase. -4- The next relevant document is a comprehensive assessment prepared by a licensed professional counselor on August 2, 2002. The mental status examination section of the assessment related that Mr. Petree had a sad mood and flat affect, problems with eye contact, and that he talked softly. It went on to state that Mr. Petree related feelings of hopelessness, helplessness, and worthlessness all the time and that he had difficulty with reduced thinking and ability to concentrate or focus. The examination stated that while his thoughts were clear, logical, and linear, his concentration, attention, social judgment, and insight were all poor. On August 6, 2002, a physician’s note from Dr. Richard Luc discussed a new medication regime but stated that Mr. Petree “appears, overall, stable with perhaps some more social phobia symptoms.” Aplt. App., Vol. 2 at 146. On August 20, another note appears stating that Mr. Petree “says that he is feeling mild anxiety on occasion, but overall he does not feel bad,” that “[h]e has noted no panics,” and that he appeared “stable.” Id. at 145. On September 3, 2002, another note from Dr. Luc states that Mr. Petree “denie[d] any current symptomatology.” Id. at 142. Dr. Luc then prepared a mental status form on September 23, 2002, which stated that Mr. Petree had “feelings of hopelessness, helplessness and worthlessness on a daily basis” and was “tired and fatigued daily.” Id. at 141. He also found that Mr. Petree had “difficulty on a daily basis with reduced -5- thinking, and concentration/focus abilities.” Id. He stated that Mr. Petree could “carry out simple instructions.” Id. Dr. Luc finally found that Mr. Petree was being medicated and that the doctor expected to “level out [Mr. Petree’s] moods, decrease depression and improve ability to think,” and that while Mr. Petree’s “response to work pressure, supervision and co[-]workers [was] below average [at that time],” it could improve with the medications. Id. Dr. Luc’s notes continue after the mental status form was prepared. A note dated October 1, 2002, shows that Mr. Petree reported that he was “still feeling down,” mainly because he could not find a job and was having trouble sleeping, and further shows that a new medication was added to Mr. Petree’s regimen. Id. at 140. A note on October 21, 2002, stated that Mr. Petree was “feeling better with the addition of [a new medication]” and that “[Mr. Petree] denies any difficulties. He has not needed to take the daytime [dose of the new medication] very[] much.” Id. at 139. On November 18, 2002, Dr. Luc recorded: “[Mr. Petree] denies any difficulties on the current medications. He has used the [new medication] during the day when he is having ‘panic’ and it works fine.” Id. at 138. Mr. Petree was discharged from the GLMHC where Dr. Luc worked on November 22, 2002, and began receiving outpatient treatment through Family & Children’s Services (F&CS). See id. at 136, 165-80. As noted by Mr. Petree in his appellate brief, his records from F&CS show that his “new psychological team” noted that he was “withdrawn and depressed, -6- and had poor decision making skills, moderately impaired judgment, and few intrapersonal relationships outside his supportive family.” Aplt. Br. at 24. The records also contain the following notations: “[Client] unemployed & dependant on family for purchases of food, clothing & shelter,” Aplt. App., Vol. 2 at 169; “[Client] reports tending to his own ADL’s. Other needs are met by wife and [unintelligible],” id.; “[Client’s] needs are met basically through wife & family,” id. at 170; “[Client] mood & affect pleasant. Hygiene & grooming good. Dress casual. [Client] appears very passive & lacks motivation & a healthy sense of assertiveness. [Client] in need of counseling for self-esteem & improvement of motivation level,” id. at 174. The mental status exam prepared at F&CS indicates that Mr. Petree was alert and oriented, had normal speech and facial expressions, intact and circumstantial thought processes, good insight, moderate judgment impairment, no memory impairment, appropriate social judgment, appropriate affect, an appropriate but withdrawn manner, and a normal but depressed mood. Id. at 175-76. The records also show that Mr. Petree was “very receptive to counseling/therapy & medication regimen,” id. at 174, and that he was essentially prescribed the same medication regimen as he had been prescribed at the GLMHC. The last F&CS record is from January 16, 2003. It appears that Mr. Petree sought no further mental health treatment until 2004. There is a January 2004 record from Christian Medical Clinic of Grand Lake that discusses Mr. Petree’s history of bipolar disorder and notes that he had -7- lost his insurance and needed a refill of his bipolar medication. The record states that Mr. Petree “feels he is doing fairly well” but that he “gets manic in Spring [without his medication].” There is also a record from April 2004 from the same clinic that shows Mr. Petree returned for another prescription refill. That record shows that he reported “no new problems” and “no recent episodes of mania/depression.” Id. at 239. The remaining records from the clinic simply note five more prescription refills through the end of 2004. No later treatment records were presented.