Opinion ID: 2978724
Heading Depth: 3
Heading Rank: 3

Heading: Medical Records – Mental

Text: The state agency referred Ealy to a psychologist, Jeanne M. Bennett, Psy.D., who performed a consultative examination on March 11, 2006. Dr. Bennett observed that Ealy’s attention and concentration were intact, his thoughts were organized in a logical and goal-oriented manner, and his thought content was appropriate to mood and circumstances. Dr. Bennett characterized Ealy’s recall for recent events as “spotty” and found his global intellectual functioning to be in the borderline range. Dr. Bennett noted that Ealy avoided eye contact and had a depressed affect. Ealy stated that he had “[a] little depression,” and Dr. Bennett wrote that “[h]e appeared very depressed to the examiner as tears roll silently down his cheeks during the assessment.” A.R. at 317. Relating to stress, Dr. Bennett wrote, “[w]hen asked about stressors, he replied that he No. 09-5451 Ealy v. Comm’r of Soc. Sec. Page 6 was stressed by his illness. He has also been experiencing grief and loss, even though his son has been deceased for five years. He has coped with stress by taking walks and watching birds.” A.R. at 318 Dr. Bennett’s diagnoses were “rule out vascular dementia” and “major depressive disorder, single episode, moderate to severe.” Id. Dr. Bennett gave Ealy a global assessment function (GAF) score of 45, indicating severe symptoms. Under “functional capacities,” Dr. Bennett concluded that 1) Ealy’s ability to understand, remember, and carry out instructions towards performance of simple repetitive tasks was not affected by his impairments, 2) Ealy’s ability to tolerate stress and pressure of day-to-day employment was markedly limited, 3) Ealy’s ability to sustain attention and concentration for simple repetitive tasks was moderately limited, and 4) Ealy’s ability to respond appropriately to supervisors, coworkers, and work pressures in a work setting was moderately limited. A.R. 318-19. Dr. Bennett characterized Ealy’s prognosis for improvement as “good with mental health intervention. In the absence of treatment, the prognosis is guarded.” A.R. 319. On March 29, 2006, a state agency psychological consultant, Stephen Scher, Ph.D., reviewed the available medical record, including Dr. Bennett’s examination, and completed a psychiatric review technique form and a mental residual functional capacity (mental RFC) form. Dr. Scher criticized Bennett’s assessment as involving “inconsistent interpretation of evidence.” A.R. at 322. Dr. Scher noted that “[Claimant] allegations are credible but not to marked degree of severity for mental.” Id. Dr. Scher concluded that Ealy retained the mental ability to 1) understand and remember simple instructions, 2) sustain attention to complete simple repetitive tasks for two-hour segments over an eight-hour day where speed was not critical, 3) tolerate coworkers and supervisors in a non-public setting, and 4) adapt to routine changes in a simple work setting. On July 18, 2006, a second state agency psychological consultant, Edward Stodola, Ph.D., reviewed the available medical evidence and affirmed Dr. Scher’s psychiatric review technique form and mental RFC assessment. A.R. at 478. No. 09-5451 Ealy v. Comm’r of Soc. Sec. Page 7 The state agency denied Ealy’s claim in October 2006 and denied his request to reconsider the same month.