Court Opinion

ID: 9374762
Source: CourtListenerOpinion
Date Created: 2023-02-23 21:00:53.224816+00
Date Added: 2024-06-11T17:16:52.755720
License: Public Domain

USCA4 Appeal: 21-2042      Doc: 42          Filed: 02/22/2023     Pg: 1 of 48

                                               PUBLISHED

                                UNITED STATES COURT OF APPEALS
                                    FOR THE FOURTH CIRCUIT

                                                No. 21-2042

        SHELLEY C.,

                             Plaintiff – Appellant,

                      v.

        COMMISSIONER OF SOCIAL SECURITY ADMINISTRATION,

                             Defendant – Appellee,

               and

        SOCIAL SECURITY ADMINISTRATION RECORD; US ATTORNEY SOCIAL
        SECURITY NOTICING,

                             Parties-in-Interest.

        Appeal from the United States District Court for the District of South Carolina, at Florence.
        Terry L. Wooten, Senior District Judge. (4:20-cv-01695-TLW)

        Argued: October 27, 2022                                       Decided: February 22, 2023

        Before GREGORY, Chief Judge, WYNN, Circuit Judge, and FLOYD, Senior Circuit Judge.

        Reversed and remanded with instructions by published opinion. Chief Judge Gregory
        wrote the opinion, in which Judge Wynn and Judge Floyd joined.

        ARGUED: Robertson H. Wendt, Jr., FINKEL LAW FIRM, LLC, North Charleston, South
        Carolina, for Appellant. Maija DiDomenico, SOCIAL SECURITY ADMINISTRATION,
USCA4 Appeal: 21-2042      Doc: 42        Filed: 02/22/2023     Pg: 2 of 48

        Baltimore, Maryland, for Appellee. ON BRIEF: Sarah H. Bohr, BOHR & HARRINGTON,
        LLC, Atlantic Beach, Florida, for Appellant. Brian C. O’Donnell, Regional Chief Counsel,
        Thomas Moshang, Supervisory Attorney, Office of the General Counsel, SOCIAL
        SECURITY ADMINISTRATION, Philadelphia, Pennsylvania; Corey F. Ellis, United States
        Attorney, Marshall Prince, Assistant United States Attorney, Columbia, South Carolina, for
        Appellee.

                                                    2
USCA4 Appeal: 21-2042      Doc: 42          Filed: 02/22/2023     Pg: 3 of 48

        GREGORY, Chief Judge:

               Plaintiff-Appellant Shelley C. appeals the district court’s order affirming the Social

        Security Administration’s (“SSA”) denial of her application for Social Security Disability

        Insurance (“SSDI”). In her application, she alleged, inter alia, major depressive disorder

        (“MDD”), anxiety disorder, and attention deficit disorder (“ADHD”). Following a formal

        hearing, the Administrative Law Judge (“ALJ”) determined that Shelley C. suffered from

        severe depression with suicidal ideations, anxiety features and ADHD, but he nonetheless

        denied her claim based on his finding that she could perform other simple, routine jobs and

        was, therefore, not disabled. Shelley C. contends that the ALJ erred by (1) according only

        little weight to the opinion of her long-time treating psychiatrist, Dr. Mark Beale (“Dr.

        Beale”) and (2) disregarding her subjective complaints based on their alleged inconsistency

        with the objective medical evidence in the record.

               We agree with Shelley C. that the ALJ failed to sufficiently consider the requisite

        factors and record evidence by extending little weight to Dr. Beale’s opinion. The ALJ

        also erred by improperly disregarding Shelley C.’s subjective statements. Finally, we find

        that the ALJ’s analysis did not account for the unique nature of the relevant mental health

        impairments, specifically chronic depression.        Thus, we reverse and remand with

        instructions consistent with this opinion.

                                                     3
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023      Pg: 4 of 48

                                                     I.

                                                     A.

               Before proceeding to the record in this case, we provide a brief overview of the step-

        by-step evaluation process used to decide whether a claimant is disabled.

               When a claimant files for SSDI benefits, she must show the existence of a

        “medically determinable physical or mental impairment” which has persisted for at least

        twelve months and prevented participation in “substantial gainful activity.” 42 U.S.C.

        § 423(d)(1)(A). The Code of Federal Regulations instructs ALJs to apply a sequential five-

        step test before benefits may be extended. The process is provided in a set order and a

        claimant’s failure at any step will disqualify her from benefits.           See 20 C.F.R.

        § 404.1520(a)(4)(i)–(v).

               At step one, the ALJ considers a claimant’s substantial gainful activity (“SGA”)—

        i.e., whether the claimant has been working. If the claimant has, that ends the inquiry and

        the ALJ will find that the claimant is not disabled regardless of medical condition, age,

        education, or work experience. If not, the ALJ will evaluate the medical severity of the

        claimant’s impairments under step two. A claimant must have an impairment or combination

        of impairments that significantly limits her physical or mental ability to perform basic work

        activities. Otherwise, the claimant will not be deemed disabled. To answer that question,

        the ALJ looks to the claimant’s age, education, and work experience. At step three, the

        ALJ—once again observing the medical severity of the claimant’s impairments—must

        determine whether the claimant has an impairment listed in 20 C.F.R. Part 404, Subpart P,

        Appendix 1. If a claimant’s impairment (or combination of impairments) meets or equals a

                                                     4
USCA4 Appeal: 21-2042       Doc: 42        Filed: 02/22/2023      Pg: 5 of 48

        listed impairment in Appendix 1, the ALJ will find the claimant disabled without

        consideration of the claimant’s age, education, and work experience. However, if the

        claimant’s impairment(s) do not meet or equal a listed impairment, the ALJ will reach a

        decision regarding the claimant’s residual function capacity (“RFC”) based on all the

        relevant medical and other evidence found in the record. Next, under step four, the ALJ

        considers the claimant’s RFC and whether the record evidence shows that her alleged

        disability inhibits her ability to perform her past relevant work. And finally, step five

        requires the ALJ to decide whether the claimant has the ability to adjust to other work

        depending on her RFC, age, education, and work experience.              See id. 20 C.F.R.

        § 404.1520(a)(4)(i)–(v). The claimant has the burden of proving the first four steps, but the

        burden shifts to the Commissioner at the final, fifth step. Lewis v. Berryhill, 858 F.3d 858,

        861 (4th Cir. 2017).

                                                     B.

               Shelley C., a 55-year-old woman and mother of two, resides with her husband of

        thirty years in South Carolina. After completing her first year of college, Shelley C. began

        her career primarily serving as a Preschool Director in different Baptist churches. Most

        recently, Shelley C. worked as a preschool’s Director of Religious Activities from 2013 to

        2016. However, after intentionally overdosing on painkillers and her antianxiety and

        antidepressant medications on July 30, 2016, Shelley C. left her job and filed for SSDI

        benefits shortly thereafter.

                                                     5
USCA4 Appeal: 21-2042         Doc: 42         Filed: 02/22/2023      Pg: 6 of 48

               Shelley C.’s struggle with depression began at 18 years old. When she was in her

        early 30s, she actively started seeing her long-time treating psychiatrist, Dr. Beale, who

        diagnosed her with major depression, dysthymia, and ADHD.

               During the SSDI benefits process, Shelley C. was diagnosed with endogenous

        depression. Though an outdated term which is now rarely diagnosed, endogenous depression

        is “any depressive disorder occurring in the absence of external precipitants and believed to

        have a biologic origin.” Stedman’s Medical Dictionary 238280 (28th ed. 2014). Although

        once distinct, endogenous depression is now classified and diagnosed as major depressive

        disorder (“MDD”). 1       Shelley C.’s SSDI benefits application alleged MDD which is

        characterized by “sustained depression of mood, anhedonia, sleep and appetite disturbances,

        and feelings of worthlessness, guilt, and hopelessness.” Stedman’s Medical Dictionary

        238320 (28th ed. 2014). The diagnostic criteria for a major depressive episode, found in the

        Diagnostic and Statistical Manual of Mental Disorders (“DSM-V”), reports “a depressed

        mood, a marked reduction of interest or pleasure in virtually all activities, or both, lasting for

        at least 2 weeks.” Id. Three or more of the following symptoms must exist: “gain or loss

        of weight, increased or decreased sleep, increased or decreased level of psychomotor

        activity, fatigue, feelings of guilt or worthlessness, diminished ability to concentrate, and

        recurring thoughts of death or suicide.” Id. Shelley C.’s treatment notes reflect both

        endogenous depression and major depressive disorder diagnoses. A.R. 51, 56, 424, 478. 2

               See Am. Psychiatric Ass’n, Diagnostic and Statistical Manual of Mental Disorders
               1

        205 [DSM-III] (3d ed. 1980).
               2
                   Citations to “A.R.” refer to the case’s administrative record.
                                                        6
USCA4 Appeal: 21-2042      Doc: 42          Filed: 02/22/2023     Pg: 7 of 48

               Although the earliest treatment notes in the record date back to 2015, Shelley C.’s

        relationship with her psychiatrist, Dr. Beale, was established years prior in 1999. As her

        long-term treating psychiatrist, Dr. Beale regularly transcribed notes concerning Shelley

        C.’s mental state, as well as her moods and affects. His treatment notes reveal that—at

        least since 2015—Shelley C. has struggled with severe mental health impairments, which

        have constantly ebbed and flowed. Dr. Beale prescribed, and often balanced, varying

        medications simultaneously, in an attempt to abate Shelley C.’s mental health symptoms.

               In addition to Dr. Beale, Shelley C. sought treatment from her psychotherapist, Hillary

        Bernstein (“Bernstein”). Dr. Beale’s and Bernstein’s notes, both pre- and post-overdose,

        reflect a constant waxing and waning of depressive and anxiety-based symptoms.

        Throughout their sessions with Shelley C., both Dr. Beale and Bernstein consistently

        described her mood and affect as “dysthymic,” “low,” “tearful,” or “so-so.” A.R. 363, 366,

        392–93, 451, 457, 598, 600, 603, 606. Her ability to perform household duties often

        wavered due to low motivation, and she suffered from constant crying spells. Regardless

        of events that brought temporary periods of joy—such as leaving town with her husband,

        visiting colleges with her daughter, and enjoying time with her nieces and nephews—

        Shelley C. still had the strong recurrent desire to self-isolate, sleep, and cry. Although

        Shelley C. later admitted that her intentional overdose was indeed a suicide attempt, one

        theme remained constant in her earlier treatment notes: she was adamant that she would

        not take her own life because she could not do that to her children.

               In a handful of sessions, Shelley C.’s mood appeared improved and brighter. She

        claimed her medications were helpful, and she attempted to involve herself in various

                                                      7
USCA4 Appeal: 21-2042      Doc: 42          Filed: 02/22/2023      Pg: 8 of 48

        activities. Though not simultaneously, she began attending an art class with her mother-

        in-law, joined swimming aerobics with a friend, and participated in daily walks with her

        husband and service dog. Shelley C. also often spoke about her body-image issues and her

        struggle to lose weight. She made several attempts to sustain a Weight Watchers dieting

        program, and her happiness often paralleled her weight loss progress.

               However, most, if not all, of these periods of improvement were short-lived; Shelley

        C. usually spiraled into deepened periods of heightened anxiety and depression mere days

        after she vocalized her improvement. As much was clear on July 30, 2016, when Shelley

        C. was admitted to Roper’s Hospital after an intentional medication overdose. Her hospital

        intake form reflected: “a long-standing history of depression . . . she was attempting to

        ‘have a deep sleep’ . . . [and] denies any suicidal ideation stating that she simply wanted to

        get a good night sleep.” A.R. 301. Notes from a psychiatric evaluation state: “[p]ositive

        for depression, suicide gesture.” Id. The following morning, social services indicated that:

               [S]he has depression . . . sees a psychiatrist, Dr. Mark Beal [sic], weekly, and
               she has been going to him for 20 years . . . took the medication to knock
               herself out. Pt did admit that a part of her was hoping that she would not
               wake up. Pt stated that she wishes she were dead on a daily basis. Pt has
               given to thought of how she would kill herself. Pt stated that when she drives
               she thinks about hitting a tree or driving off the bridge. Pt also stated that
               she has thought about a gun, but she does not know much about them and
               does not want it to be messy for her family . . . Pt stated that if she were to
               actually kill herself, she would take a Zofran so she would not get sick and
               then she would overdose on pills. Pt stated that she does not intend to act on
               these plans because of the responsibility she has to her children and family
               . . . Although pt has described plans of how she would hurt herself, she is
               presently contracting for safety and does not intend to follow through with
               any of her plans . . . An appropriate discharge plan would be to continue
               outpatient treatment with Dr. Beal [sic].

                                                      8
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023     Pg: 9 of 48

        A.R. 309. However, regardless of Shelley C.’s alarming statements, she was discharged

        the following day, diagnosed with “overdose without SI [suicidal ideations].” A.R. 308.

              Because her symptoms continued to waver despite her therapy and constant

        medication adjustment, Dr. Beale urged Shelley C. to pursue either Electro

        Convulsive/Shock Therapy (“ECT”) or Transcranial Magnetic Stimulation (“TMS”)

        therapy. 3 After a consultation in April 2017, doctors associated with TMS therapy

        determined that Shelley C. suffered from both major and recurrent depression and that she

        was a “good” candidate for the treatment “given severity of depression [and] failure of

        medication trials.” A.R. 470. Shelley C. officially began her 36 TMS treatments on May

              3
                 TMS is a noninvasive procedure that “uses magnetic fields to stimulate nerve cells
        in the brain to improve symptoms of depression . . . [It] is typically used when other
        depression treatments haven’t been effective.” Mayo Clinic, Transcranial magnetic
        stimulation (Nov. 27, 2018), https://www.mayoclinic.org/tests-procedures/transcranial-
        magnetic-stimulation/about/pac-20384625 (last viewed January 18, 2023) (saved as ECF
        attachment). ECT is given to patients with severe, treatment-resistant depression and is
        performed under general anesthesia, with “small electric currents . . . passed through the
        brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain
        chemistry that can quickly reverse symptoms of certain mental health conditions.” Mayo
        Clinic, Electroconvulsive therapy (ECT) (Oct. 12, 2018), https://www.mayoclinic.org/tests-
        procedures/electroconvulsive-therapy/about/pac-20393894 (last viewed January 18, 2023)
        (saved as ECF attachment).
                                                    9
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023      Pg: 10 of 48

        16, 2017, at which she had a PHQ-9 score of 27. 4 By the time her treatments concluded in

        mid-July, her score dropped to 9, demonstrating a significant improvement. 5

               Yet, as was common with her previous periods of progress, these positive results

        were fleeting, and Shelley C. quickly slipped back into a depressive state, plagued with

        melancholy, lethargy, and self-deprecating thoughts just weeks after finishing her final

        TMS session. Even though Dr. Beale recommended a second round of TMS treatment,

        Shelley C. decided not to pursue it. Desiring a break from psychotherapy, she later

        discontinued sessions with Bernstein yet still struggled with crying spells, poor

        concentration, anxiety, and depression-related affects.

               On August 23, 2016, Shelley C. filed for SSDI benefits claiming that her disabilities

        began on August 1, 2016, the day following her release from Roper’s Hospital.

               4
                A PHQ-9 or Patient Health Questionnaire is the “depression module” of a self-
        administered diagnostic instrument common for mental disorders. It is a “reliable and valid
        measure of depression severity.” Kurt Kroenke, Robert Spitzer, Janet Williams,
        The PHQ-9, Journal of General Internal Medicine (2001), https://www.ncbi.nlm.nih.gov/
        pmc/articles/PMC1495268/ (last viewed January 18, 2023) (saved as ECF attachment).
               5
                 Hospital personnel indicated that Shelley C. expressed the following during her
        TMS sessions: “I actually feel like I am starting to feel better, I’m scared to say that. But
        I woke up without the impending doom feeling, still having concentration issues, sleeping
        well trying to not sleep 14 hours a night.” A.R. 510. However, her condition seemed to
        plateau after this revelation, and her treatment was subsequently increased “due to lack of
        improvement.” Id. This increase appeared to benefit Shelley C. and she reported at her
        June 29 appointment: “thank God my anxiety and depression are starting to get better.”
        Id. Her mood seemed to dip for a period after this particular treatment but by her second-
        to-last appointment she stated: “I can really tell that TMS has helped me out a lot and my
        depression is so much better.” Id.
                                                     10
USCA4 Appeal: 21-2042       Doc: 42          Filed: 02/22/2023      Pg: 11 of 48

                                                       C.

               Shelley C. submitted answers to a Form SSA-3373-BK (“Function Report”)—which

        assists the SSA in understanding the claimant’s conditions—provided by a branch of the SSA.

        In her answers, Shelley C. emphasized that: “Most days I cannot get out of bed . . . My 20

        y[ea]r old son takes up the slack. I go nowhere because I don’t have the strength . . . I cry all

        day . . . I constantly think about suicide.” A.R. 204. She also reported that she “cannot talk

        to people without crying,” A.R. 209, “can put in a load of laundry every once in awhile but

        [she] cannot dry, fold and put up,” A.R. 210, and “[she has] no strength.” A.R. 211. Shelley

        C. also reported that she went outside “[o]nce a day to pick up [her] daughter from school,”

        A.R. 211, and she had “no desire to do any” of her former hobbies or interests A.R. 212.

        Despite her condition, she stated that on a regular basis she used to go to “[w]ork 6 days a

        week, [c]hurch, [e]xercise [c]lass, grocery store, [kids’] school events, out to dinner.” A.R.

        212.

               In December 2016, Shelley C. reported to the SSA that her medical conditions had

        changed. She stated that she now spent her “days in the bed and cannot accomplish

        anything,” could “make it to the couch if . . . forced,” no longer “interact[ed] with family

        or friends,” and could not “do any activities because it [was] too taxing on [her] body and

        heart.” A.R. 231. She also expressed that she had “no quality to [her] life” and did not

        “participate in activities with [her] family and/or friends. Most days [she did] not shower

        or get dressed.” A.R. 235.

               On January 11, 2017, the SSA instructed Shelley C. to complete a comprehensive

        disability evaluation with a consultative physician, Dr. Thaddeus J. Bell (“Dr. Bell”). He found:

                                                       11
USCA4 Appeal: 21-2042       Doc: 42          Filed: 02/22/2023       Pg: 12 of 48

               [t]here is a good chance that the patient is experiencing some element of
               empty nest syndrome. However, I feel that this is only part of a problem of
               endogenous depression which she continues to deal with. In spite of being
               happily married, she feels that life is not worth living. She feels suicidal
               almost every day. She states that the only reason that she has not tried to
               take her life is because of her children at this point.

        A.R. 423. Dr. Bell acknowledged that Shelley C.’s physical examination was completely

        normal but stated that she needed to be seen by a disability services psychiatrist for evaluation.

               On January 19, 2017, Dr. Jennifer Steadham—a government medical consultant

        who did not personally examine or treat Shelley C.—opined that Shelley C. was not

        disabled and, though she would have difficulty carrying out detailed instructions, she

               [i]s capable of performing simple tasks for at least two hour periods of time.
               She would be expected to occasionally miss a day of work secondary to her
               symptoms. She is expected to have difficulty working in close proximity or
               coordination with co-workers. She would be best suited for a job which does
               not require continuous interaction with the general public. She is capable of
               single, repetitive tasks without special supervision. She can attend work
               regularly and accept supervisory feedback.

        A.R. 63–65. After Shelley C. filed a request for reconsideration, Dr. Blythe Farish-

        Ferrer—a second, non-examining doctor hired by the government—affirmed Dr.

        Steadham’s decision on June 21, 2017.

               On May 19, 2017, Shelley C. completed a second Function Report. She updated

        the SSA about her ongoing, daily TMS therapy and her worsening symptoms. She

        lamented that: she was “dibilitated [sic] by depression . . . cannot get out of the bed and

        work or even focus.” A.R. 238. She also reported that she had “gained about 40 pounds”

        (A.R. 239); “w[oke] up and [took] a handful of prescription medicine then . . . [laid] on the

        couch to rest then go to bed and sleep off and on all day” (Id.); had “no drive or interest”

                                                       12
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023     Pg: 13 of 48

        to do house or yard work (A.R. 241); could not “focus on serious issues” (Id.); was “very

        moody to everyone” and “no longer socialize[d]” (A.R. 243); and could not “remember

        things or follow simple instructions.” Id.

                                                      D.

               Shelley C.’s official hearing with an ALJ was held on August 7, 2018. Providing

        further color to her mental health impairments, she described her debilitating symptoms

        and vegetative state. She confessed that her July 2016 “accident” was a suicide attempt.

        A.R. 38. She testified that she no longer cooked or did household chores, and she claimed

        she could not do anything or go anywhere. Shelley C. also revealed that the TMS treatment

        did not aid her beyond a short-lived period and that she constantly had an impending feeling

        of doom. Her time outside of the house was extremely limited, only leaving once every

        three weeks for doctor’s appointments. She reported that she has had more “bad” than

        “good” days, though, on occasion, she experienced some decent days. A.R. 44. Her

        depression has led to deep feelings of guilt, which often led to crying spells as often as

        every other day. She stated that she experienced thoughts about death and suicide daily

        and believed that her future was behind her. Because of this, Shelley C. claimed she would

        not be a dependable worker as she could not get up every day to attend work, where she

        would be required to focus and concentrate.

               Following Shelley C.’s testimony, the ALJ posed hypotheticals to the testifying

        vocational expert. The vocational expert opined that though Shelley C.’s limitations

        prohibited her from performing her past work as a Director of Religious Activities, other

        jobs were available, such as: hand packager, store laborer, and laundry worker. Yet, when

                                                     13
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023      Pg: 14 of 48

        the ALJ asked the vocational expert whether a person with Shelley C.’s psychological

        impairments—someone who could be distracted off task from their job for more than an

        hour a day, needed to take regular breaks, and would potentially miss more than two days

        of work a month on a regular basis—could perform such work, the vocational expert

        responded that no jobs were available with these criteria. At the hearing’s conclusion, the

        ALJ requested that Shelley C. undergo a consultative examination.

               On August 21, 2018, before the consultative examination took place, Dr. Beale

        submitted a medical opinion letter in support of Shelley C.’s claim. He summarized what was

        already reflected in his treatment notes: that Shelley C.’s depressive symptoms were severe

        and persistent, ranging from uncontrollable crying spells to low concentration, which “have

        made her unemployable.” A.R. 610. Even with “robust” treatment, Dr. Beale stated that “[h]er

        progress is guarded due to the number and severity of episodes.” Id. Due to her condition Dr.

        Beale opined that “the added stress of any job would very likely worsen her condition.” Id.

               Shelley C. was also examined by Dr. John Custer for a Mental Status Examination

        on September 24, 2018. He diagnosed her with persistent depressive disorder, potential

        maladaptive personality function, and, potentially, an unspecified personality disorder.

        Notwithstanding his diagnosis, Dr. Custer stated that Shelley C. was alert and oriented

        during the cognitive exam, followed commands, and scored well on the Folstein Mini-

        mental Status Exam—a commonly used instrument for testing cognitive ability. Dr. Custer

        reported to the SSA that Shelley C. did not have any issue with understanding,

        remembering, and carrying out simple instructions, or making judgments on simple work-

        related decisions. But Shelley C. did have mild issues with complex instructions, and she

                                                     14
USCA4 Appeal: 21-2042       Doc: 42         Filed: 02/22/2023      Pg: 15 of 48

        displayed moderate issues making judgements on complex work-related decisions. He also

        determined that Shelley C. did not have any problem with interacting appropriately with

        the public; she displayed mild issues interacting appropriately with supervisors and co-

        workers; and she had moderate issues responding appropriately to usual work situations

        and changes in a routine work setting.

                                                      E.

               On February 12, 2019, the ALJ denied Shelley C.’s request for SSDI benefits. He

        held that Shelley C. carried her burden at steps one and two of the test set forth in 20 C.F.R.

        § 404.1520(a)(4), finding (1) she had not been involved in substantial gainful activity at

        the time of her request and (2) her depression with suicidal ideation, anxiety features, and

        ADHD were severe impairments. But the ALJ found her evidence lacking at step three.

        Specifically, he found that her severe mental impairments did not meet the relevant listing

        disability criteria for mental disorders. Even if Shelley C. had prevailed at this point, the

        ALJ noted that she could not pass step four either. The ALJ found that Shelley C. still

        possessed the capacity to perform simple, routine, and repetitive tasks in a work

        environment free of fast paced production requirements, involving only simple, work-

        related decisions, and few if any workplace changes, with occasional interaction with the

        public. Based on this finding, the ALJ held that Shelley C. did not have a disability as

        defined in the Social Security Act, and though she was unable to perform her past relevant

        work, there were jobs in the national economy she could execute.

               Remarkably, the ALJ afforded only little weight to Dr. Beale’s opinion after

        acknowledging that Dr. Beale had been treating Shelley C. “since at least July 2015 for her

                                                      15
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023     Pg: 16 of 48

        mental impairments.” A.R. 24. The ALJ rejected Dr. Beale’s opinion because it is “on an

        issue reserved for the Commissioner,” “is inconsistent with the medical evidence [in the]

        record,” and his treatment notes “do not indicate any significant symptoms that would

        render the claimant unable to perform basic work activities.” Id.

               On February 26, 2020, the Office of Appellate Operations denied Shelley C.’s

        request for review. Shelley C. subsequently filed a complaint in the United States District

        Court for the District of South Carolina seeking review of the Commissioner’s final

        decision.   On May 18, 2021, a magistrate judge issued a 42-page Report &

        Recommendation (“R&R”) affirming the ALJ’s denial of SSDI benefits. After Shelley C.

        objected to the R&R, a district court judge adopted it and ordered the Commissioner’s

        denial of Shelley C.’s SSDI benefits. Shelley C.’s appeal timely followed.

                                                    II.

               “This Court is authorized to review the Commissioner’s denial of benefits under 42

        U.S.C.A. § 405(g).” Hancock v. Astrue, 667 F.3d 470, 472 (4th Cir. 2012). A reviewing

        court “must uphold the factual findings of the [ALJ] if they are supported by substantial

        evidence and were reached through application of the correct legal standard.” Id. (quoting

        Johnson v. Barnhart, 434 F.3d 650, 653 (4th Cir. 2005) (per curiam)). Substantial evidence

        is “such relevant evidence as a reasonable mind might accept as adequate to support a

        conclusion.” Richardson v. Perales, 402 U.S. 389, 401 (1971). We will not “reweigh

        conflicting evidence, make credibility determinations, or substitute our judgment for that

        of the [ALJ]” in reviewing for substantial error. Johnson, 434 F.3d at 653. In undertaking

                                                    16
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023      Pg: 17 of 48

        this review, this Court considers whether the ALJ examined all relevant evidence and

        offered a sufficient rationale in crediting certain evidence and discrediting other evidence.

        Milburn Colliery Co. v. Hicks, 138 F.3d 524, 528 (4th Cir. 1998).

                                                    III.

               We start by considering whether the ALJ’s decision to afford Dr. Beale’s opinion

        little weight complies with applicable law and is supported by substantial record evidence.

        In deciding not to give great or controlling weight to Dr. Beale’s opinion, the ALJ is

        required to address each of the six 20 C.F.R. § 404.1527(c) regulatory factors to determine

        the appropriate weight it should be afforded. Shelley C. contends that not only did the ALJ

        fail to address each of the six factors, but also that substantial evidence does not support

        the ALJ’s finding because Dr. Beale’s opinion: (1) was not on an issue reserved for the

        Commissioner; (2) was consistent with his treatment notes which confirm Shelley C.’s

        significant limitations; and (3) was not inconsistent with other medical evidence in the

        record. We find the weight afforded to Dr. Beale’s opinion erroneous and the ALJ’s

        decision unsupported by substantial evidence.

                                                     A.

               As a preliminary matter, the ALJ did not afford Dr. Beale’s opinion proper weight.

        When reviewing whether a claimant is disabled, the ALJ must evaluate every medical

        opinion received against the record evidence. See 20 C.F.R. § 404.1527(b)–(c). This often

        entails reviewing medical opinions from a claimant’s treating physician or other, non-

                                                     17
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023     Pg: 18 of 48

        treating physicians. Generally, ALJs possess the discretion to determine the level of weight

        given to each medical opinion provided and received. See 20 C.F.R. § 404.1527(d)(2).

               The regulation states that “[r]egardless of its source, [the ALJ] will evaluate every

        medical opinion[.]” 20 C.F.R. § 404.1527(c). In addition, ALJs must adhere to the

        “treating physician rule” which requires that they assign greater or “controlling” weight to

        the opinion of a claimant’s treating physician unless there is persuasive contradictory

        evidence. Mitchell v. Schweiker, 699 F.2d 185, 187 (4th Cir. 1983). If the ALJ decides

        not to give the treating physician’s medical opinion great or controlling weight under the

        treating physician rule, the ALJ turns to the following factors to determine its applicable

        weight: (1) the length of the physician’s treatment relationship with the claimant, (2) the

        physician’s frequency of examination, (3) the nature and extent of the treatment

        relationship, (4) whether the medical evidence in the record supports the physician’s

        opinion, (5) the consistency of the physician’s opinion with the entirety of the record, and

        (6) the treating physician’s specialization. 20 C.F.R. § 404.1527(c)(1)–(6); see also Burch

        v. Apfel, 9 F. App’x 255, 259 (4th Cir. 2001) (unpublished). 6

               Here, the ALJ extended “little weight” to Dr. Beale’s opinion after concluding that

        it “is on an issue reserved for the Commissioner and . . . is inconsistent with the medical

        evidence of record. [His] treatment notes do not indicate any significant symptoms that

        would render [Shelley C.] unable to perform basic work activities.” A.R. 24.

               6
                Because Shelley C. filed her claim prior to March 27, 2017, the ALJ must rely
        upon 20 C.F.R. § 404.1527 to evaluate the opinion evidence. All claims filed after March
        27, 2017, are subject to 20 C.F.R. § 404.1520.
                                                    18
USCA4 Appeal: 21-2042         Doc: 42         Filed: 02/22/2023     Pg: 19 of 48

                  The ALJ’s reasoning suffers two problems. First, it failed to identify which medical

        evidence in Shelley C.’s extensive record presented inconsistencies with Dr. Beale’s

        opinion. As we held in Arakas v. Commissioner, Social Security Administration, this

        “cursory explanation [falls] far short of [the ALJ’s] obligation to provide a narrative

        discussion of how the evidence supported his conclusion and as such, the analysis is

        incomplete and precludes meaningful review.” 983 F.3d 83, 106 (4th Cir. 2020) (citing

        Monroe v. Colvin, 826 F.3d 176, 190–91) (4th Cir. 2016) (cleaned up).

                  However, the second blemish in the ALJ’s reasoning is more problematic. After

        declining to apply the “treating physician rule” it failed to address each of 20 C.F.R.

        § 404.1527(c)’s six factors. The ALJ appropriately “acknowledged the existence of the

        Section 404.1527(c) factors,” Dowling v. Commissioner of Social Security Administration,

        986 F.3d 377, 385 (4th Cir. 2021), but he nonetheless failed to address them. Mere

        acknowledgement of the regulation’s existence is insufficient and falls short of the ALJ’s

        duties.

                  That is not to say that the ALJ considered none of the factors. 7 Shelley C. concedes

        that the ALJ addressed “supportability” by noting that Dr. Beale’s opinion was inconsistent

        with the medical evidence in the record which did not indicate significant symptoms that

                 Invoking the fifth factor, Shelley C. argues that the ALJ failed to consider or
                  7

        explicitly mention Dr. Beale’s specialization. Not so. The first page of the ALJ’s opinion
        reveals that he was cognizant of and did describe Dr. Beale as Shelley C.’s psychiatrist.
        See A.R. 14 (“Subsequent to the hearing, the claimant . . . submitted a statement from the
        claimant’s psychiatrist, Mark Beale, M.D.”). Although more weight is generally given to
        a specialist’s medical opinion on issues related to their specialty than to an opinion from a
        non-specialist, 20 C.F.R. § 404.1527(c)(5), the ALJ did acknowledge Dr. Beale’s
        specialization but believed his opinion warranted little weight.
                                                       19
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023      Pg: 20 of 48

        would render Shelley C. unable to perform basic work activities. From this discussion, we

        can infer that the ALJ was aware of the examining relationship that existed between Shelley

        C. and Dr. Beale, which satisfies 20 C.F.R. § 404.1527(c)’s first factor. The ALJ also

        appears to address the fourth factor, “consistency,” as the ALJ recognized what he believed

        was the discrepancy between Dr. Beale’s opinion and the entirety of the record. Further,

        the ALJ also acknowledged that Shelley C. was “seeing” Dr. Beale. A.R. 16. From this,

        we gather that the ALJ was aware of the examining relationship that existed between

        Shelley C. and Dr. Beale, thereby satisfying 20 C.F.R. § 404.1527(c)’s first factor.

               That said, we have made clear in Dowling and Triplett that an ALJ should give

        adequate attention to each 20 C.F.R. § 404.1527(c) factor. See Dowling, 986 F.3d at 385

        (reversing ALJ’s extension of “only negligible weight” to the claimant’s treating opinion

        because it touched on only a couple of factors); Triplett v. Saul, 860 F. App’x 855 (4th Cir.

        2021) (unpublished) (same). Upon review of all the factors, however, the record supports

        extending Dr. Beale’s opinion more than little weight.

               Turning to the regulation’s second factor, the ALJ improperly considered the length

        of Shelley C.’s treatment relationship with Dr. Beale and the frequency of her visits. If a

        treating source has seen a claimant a number of times and long enough to garner a

        longitudinal picture of the claimant’s impairment(s), that source’s opinion is generally

        entitled to more weight than an opinion from a non-treating source.               20 C.F.R.

        § 404.1527(c)(2)(i). Here, the ALJ noted that Shelley C. had been seeing Dr. Beale “since

        at least July 2015.” A.R. 22. The record indicates that Dr. Beale has been Shelley C.’s

        psychiatrist for much longer, since 1999. It is difficult to understand how the ALJ could

                                                     20
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023      Pg: 21 of 48

        ignore a treating relationship that has lasted the better part of two decades. Further,

        regardless of the ALJ’s reliance on the record’s extensive exhibits, he did not acknowledge

        that most of these notes were transcribed by Dr. Beale, demonstrating the breadth of Dr.

        Beale’s personal involvement in this case.

               Moreover, continuing the second factor’s analysis, the ALJ improperly considered

        the nature, frequency, and extent of the treatment relationship between Shelley C. and

        Dr. Beale.   The more knowledge a treating source retains concerning a claimant’s

        impairment, the more weight their opinion should receive. 20 C.F.R. § 404.1527(c)(2)(ii).

        The ALJ must consider the treatment that source has provided the claimant, including the

        extent of examinations and testing the source has performed or ordered other specialists and

        laboratories to perform. Id. Though the statement was not explicitly directed toward

        Dr. Beale, the ALJ maintained that Shelley C.’s treatment history was “routine and

        conservative.” A.R. 22. That is simply untrue. After Shelley C. was released from Roper’s

        Hospital following her intentional overdose in July 2016, she and Dr. Beale planned a

        rigorous treatment program with more frequent visits and medication management. When

        that was insufficient, Dr. Beale suggested that Shelley C. seek out TMS therapy or ECT

        treatment, two separate depression treatments that are offered only to patients with the most

        severe, resistant cases. Following through with the former treatment, Shelley C. completed

        36 rounds of TMS therapy. However, the beneficial results were short-lived, and Dr. Beale

        suggested either a second round of TMS or the more aggressive ECT treatment. Thus, the

        treatments Shelley C. received, and was prescribed, were anything but routine and

        conservative.

                                                     21
USCA4 Appeal: 21-2042       Doc: 42         Filed: 02/22/2023      Pg: 22 of 48

               The length, frequency, and nature of Shelley C.’s relationship with Dr. Beale were

        important factors that the ALJ did not properly consider nor acknowledge. Due to this, the

        ALJ’s decision to allot “little weight” to Dr. Beale’s opinion was erroneous.

                                                      B.

                                                      1.

               Turning to the first of Shelley C.’s substantive concerns, we agree that Dr. Beale’s

        opinion briefly touched on an opinion reserved for the Commissioner. Even so, that does

        not allow the ALJ to discount the entirety of the treating physician’s statement, which

        should have been allotted greater weight.

               Opinions on some issues are not medical opinions but are, rather, opinions reserved

        for the Commissioner “because they are administrative findings that are dispositive of a

        case.” 20 C.F.R. § 404.1527(d). This includes opinions, made by a medical source,

        concerning whether a claimant is disabled. A statement made by a medical source asserting

        that a claimant is “disabled” or “unable to work” does not mean that the Commissioner will

        determine that the claimant is actually disabled. Id. Indeed, the ALJ will not give any special

        significance to the source of an opinion on issues reserved to the Commissioner.

               In his opinion, Dr. Beale states: “[Shelley C.’s] low mood, crying spells, anxiety,

        low energy, and poor concentration have made her unemployable.” A.R. 610 (emphasis

        added). It would be a semantical dispute to argue that “unemployable” and “unable to

        work” are not synonymous. Yet, this statement was relegated to a minor portion of Dr.

        Beale’s overall opinion, and at bottom, we cannot accept the decision to extend “little

        weight” to the entire opinion on this ground.

                                                      22
USCA4 Appeal: 21-2042        Doc: 42         Filed: 02/22/2023      Pg: 23 of 48

              The Commissioner disagrees with Shelley C.’s argument that the ALJ discounted

        the entirety of Dr. Beale’s opinion, claiming that the ALJ addressed other statements made

        by Dr. Beale when assigning the opinion miniscule weight. But the ALJ’s decision does

        not isolate this sentence from the rest of the opinion. Rather, the ALJ merely refers to

        Dr. Beale’s opinion—in its whole state—as addressing an issue reserved for the

        Commissioner. And given the ALJ’s duty to balance the record’s evidence, to disregard a

        20-year treatment relationship due to a singular sentence is a disproportionate response.

        Thus, this aspect of the Commissioner’s reasoning cannot be accepted.

                                                       2.

              Next, we shift to the ALJ’s belief that disparities exist between Dr. Beale’s opinion

        and his own treatment notes. The ALJ specifically found that “Dr. Beale’s treatment notes

        do not indicate any significant symptoms that would render [Shelley C.] unable to perform

        basic work activities.” J.A. 18 (emphasis added). 8 The Commissioner agrees, asserting

        that Dr. Beale’s treatment notes show Shelley C.’s unremarkable mental status findings,

        improvement in her symptoms and functioning due to treatment, and no signs of a

        significant deterioration in her condition during the relevant period. We disagree and

        conclude that the record’s substantial evidence does not support the ALJ’s reasoning.

              Although the medical sources in the record disagree on Shelley C.’s disability status,

        substantial evidence indicates that Dr. Beale’s opinion was consistent with his own

        treatment notes.      Dr. Beale’s opinion touches on Shelley C.’s diagnoses, their

              8
                  Citations to “J.A.” refer to the Joint Appendix filed in this appeal.
                                                       23
USCA4 Appeal: 21-2042      Doc: 42          Filed: 02/22/2023     Pg: 24 of 48

        accompanying symptoms, and the respective forms of treatment he prescribed. His

        treatment notes, in comparison, consistently focus on her diagnoses—depression with

        anxious features and ADHD—and their symptoms: dysthymic moods, anxiety, low energy,

        crying spells, self-doubt. See A.R. 363, 366, 369, 372, 380–81, 414, 416, 419, 436–38,

        442, 598–600. These notes all validate what Dr. Beale stated in his opinion. See Coffman

        v. Bowen, 829 F.2d 514, 517 (4th Cir. 1987) (holding that a claimant’s treating physician’s

        opinion may be given lesser weight only if persuasive contradictory evidence is found in

        the record).

               The Commissioner challenges the validity of Dr. Beale’s opinion by claiming that

        his treatment notes confirm that Shelley C. portrayed effective responsiveness to varying

        medication management and the TMS therapy. However, both Dr. Beale’s treatment notes

        and his opinion demonstrate that these periods of improvement were consistently short-

        lived. For instance, at a treatment session, Shelley C. expressed to Dr. Beale that increasing

        her dosage of Zyprexa was “very helpful.” A.R. 437. However, at the following session,

        her mood was recorded as low, she had a tearful affect, she reported crying spells, requested

        another Zyprexa increase, and sought to pursue ECT treatment. A.R. 436. The same pattern

        occurred after Shelley C. completed TMS therapy. At the treatment’s conclusion, Shelley

        C. reported to the TMS-associated staff that she felt “so much better” and she was “so glad”

        to have tried TMS. A.R. 510. But just weeks later, she told Dr. Beale that her mood had

        plateaued and she was, again, relying on Zyprexa. A.R. 608. This common theme was

        prevalent throughout Dr. Beale’s treatment notes: Shelley C. experienced brief periods of

        improvement, which were quickly followed by incredible lows. As Dr. Beale’s opinion

                                                     24
USCA4 Appeal: 21-2042        Doc: 42          Filed: 02/22/2023     Pg: 25 of 48

        aptly noted: Shelley C.’s depression is chronic. This Court must acknowledge that a

        treating relationship spanning two decades would allow Dr. Beale to witness and

        comprehend the depths of Shelley C.’s mental health impairments. And due to this decades-

        long awareness, Dr. Beale’s opinion consistently aligns with his corresponding treatment

        notes.

                 Moreover, the ALJ’s determination that Dr. Beale’s notes did not reveal any

        significant symptoms that would hinder Shelley C. from performing basic work activities

        reflects a deep misunderstanding of mental health impairments, particularly severe

        depression. The fact is “people with chronic diseases can experience good and bad days”

        even “under continuous treatment for it with heavy drugs.” Schink v. Comm’r of Soc. Sec.,

        935 F.3d 1245, 1267 (11th Cir. 2019). “Suppose that half the time she is well enough that

        she could work, and half the time she is not. Then she could not hold down a full-time

        job.” Id. (citing Bauer v. Astrue, 532 F.3d 606, 609 (7th Cir. 2008); Singletary v. Bowen,

        798 F.2d 818, 821 (5th Cir. 1986)).

                 As an internal impairment, depression is incredibly subjective to each individual, with

        signs and symptoms experienced through intrusive feelings and thoughts, low and isolated

        moods, and even body aches and pains. National Institute of Mental Health, Depression (Signs

        & Symptoms), https://www.nimh.nih.gov/health/topics/depression (last viewed January 18,

        2023) (saved as ECF attachment). Shelley C.’s “endogenous” depression, which occurs

        without external precipitants and is recognized as a biological disorder, plagues her thoughts,

        moods, feelings, and physical ability. Her depression has no identifiable external or situational

        trigger that would be treatable by coping mechanisms. Instead, Shelley C. experiences an

                                                       25
USCA4 Appeal: 21-2042        Doc: 42        Filed: 02/22/2023      Pg: 26 of 48

        innate, chronic depression that will require life-long management, and that could easily impact

        her capacity to perform even basic work activities. As vividly portrayed in Dr. Beale’s

        treatment notes, her chronic depression comes with both good and bad days, with the latter

        varying in their severity.

               With these critical details in mind, we conclude that, consistent with his opinion,

        Dr. Beale’s treatment notes reveal that Shelley C. suffers from significant and severe

        symptoms that would undoubtedly hinder her from performing even basic work activities.

                                                      3.

               Finally, we address whether Dr. Beale’s opinion was inconsistent with the record’s

        other medical evidence. The Commissioner attempts to bolster the ALJ’s conclusion that

        Dr. Beale’s opinion was inconsistent with the other medical evidence in the record,

        particularly Bernstein’s treatment notes, the TMS records, and the expert opinions from

        the examining psychiatrist and two non-treating physicians who reviewed the record. We

        recognize that a reasonable mind may find that Dr. Beale’s opinion was inconsistent with

        the record’s other medical evidence, particularly the non-examining physicians’ findings,

        and therefore the ALJ was justified in not giving Dr. Beale’s opinion controlling weight.

        Yet, we find error in the “little weight” afforded for two particular reasons. First, the ALJ

        failed to articulate what evidence led him to his decision. And second, the ALJ erred in

        extending more weight to the non-examining physicians’ opinions than to Dr. Beale’s.

                                                      i.

               The ALJ failed to provide support for his vague and thin decision. This Court has

        held that where an ALJ fails to specify which specific objective evidence supports his

                                                      26
USCA4 Appeal: 21-2042       Doc: 42          Filed: 02/22/2023      Pg: 27 of 48

        conclusion, that “analysis is incomplete and precludes meaningful review.” See Arakas,

        983 F.3d at 106 (quoting Mascio v. Colvin, 780 F.3d 632, 636 (4th Cir. 2015)). Because

        the ALJ failed to point to specific objective evidence showing that Dr. Beale’s opinion was

        “inconsistent” with the record’s other medical evidence, his analysis, or lack thereof, has

        “frustrate[d]” this reviewing court’s “meaningful review.” Mascio, 780 F.3d at 636.

                                                      ii.

               In addition, the ALJ inappropriately afforded more weight to Shelley C.’s non-

        examining physicians’ opinion than to her treating physician’s.             Even though we

        acknowledge the ALJ’s decision not to extend controlling weight, it does not follow that

        we have accepted his conclusion to afford Dr. Beale’s opinion only “little weight.”

               To be sure, the record demonstrates disparities between Dr. Beale’s opinion and the

        non-examining physicians’ conclusions, specifically Drs. Steadham and Farish-Ferrer. Due

        to these inconsistencies, the ALJ was not required to extend controlling weight to Dr. Beale’s

        opinion. Yet, regardless of this finding, we believe the ALJ should have still afforded greater

        than “little weight” to Dr. Beale’s opinion and extended more weight to his opinion than

        those of the non-examining physicians. Under the 20 C.F.R. § 404.1527(c) factors, greater

        weight is usually given to the medical opinion of an examining source who has directly

        examined the claimant; a source that has treated the claimant; and a specialist in that relevant

        area of medicine. See Arakas, 983 F.3d at 110–11 (citing 20 C.F.R § 404.1527(c)(1), (2),

        (5)). In Arakas, we emphasized the treating physician rule as a “robust one,” and particularly

        found that, “the ALJ’s decision to assign greater weight to the non-examining, non-treating

        consultants’ opinion” than to the treating physician’s “makes little sense” and was not

                                                      27
USCA4 Appeal: 21-2042      Doc: 42          Filed: 02/22/2023    Pg: 28 of 48

        justified. Id. at 110. There, giving the non-treating consultant’s opinion more weight was

        “particularly improper” because the unique nature of the claimant’s fibromyalgia and its

        specific symptoms could “not be properly assessed and verified by a non-treating or non-

        examining source.” Id. at 110–11.

               Our holding in Arakas is directly relevant here. Drs. Steadham and Farish-Ferrer,

        both non-examining, non-treating sources who independently reviewed Shelley C.’s record

        but did not directly examine her, concluded that despite her severe mental impairments,

        Shelley C. was not disabled. Finding their conclusions somewhat persuasive, the ALJ

        afforded their opinions “partial weight.” A.R. 24. Particularly, he determined that their

        conclusions concerning Shelley C.’s moderate limitations in “Understanding,

        Remembering, or Applying Information, Interacting with Others, and Concentrating,

        Persisting, or Maintaining Pace” was consistent with the overall record.          A.R. 18.

        However, finding that their decisions marked Shelley C. as experiencing no limitation in

        “Adapting or Managing Oneself,” the ALJ determined that this conclusion was not

        consistent with the overall record, given Shelley C.’s testimony and other, unspecified,

        record evidence. Id.

               We are puzzled by the ALJ’s decision to extend greater weight to Drs. Steadham

        and Farish-Ferrer’s opinion than to Dr. Beale’s. Dr. Beale has treated Shelley C. for twenty

        years—much like the treating physician’s relationship with the claimant in Arakas—

        whereas the former doctors never directly examined Shelley C.. Naturally, we expect that

        Dr. Beale would be astutely aware and privy to the uniqueness of Shelley C.’s specific,

        severe depressive and anxious symptoms, which non-treating agents are unlikely to

                                                    28
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023      Pg: 29 of 48

        understand or decipher from a paper record. There is a significant difference between a

        direct and physical examination, which in this case has spanned over years, of a claimant’s

        mental health impairments, and an examination of a written record. Thus, the ALJ erred

        by failing to consider the important distinctions between these treating and non-treating

        relationships and extending more weight to the non-examining physicians’ opinions than

        to Dr. Beale’s.

                                                    ***

               Because we remain in the dark about the reasons why the ALJ arrived at his

        conclusions, which erroneously afforded more weight to the non-examining physicians,

        we cannot uphold the ALJ’s decision. Thus, we conclude, the ALJ improperly afforded

        Dr. Beale’s opinion “little weight” and we must reverse and remand.

                                                    IV.

               Shelley C. also argues that the ALJ did not properly evaluate her subjective

        complaints. The ALJ stated that Shelley C.’s:

               statements concerning the intensity, persistence and limiting effects of these
               symptoms are not entirely consistent with the medical evidence and other
               evidence in the record . . . they are inconsistent with the medical evidence of
               record, which reflects a routine and conservative treatment history, and
               generally benign mental status examinations.

        A.R. 22. Shelley C. contends that the ALJ’s decision was erroneous because it was

        unsupported by the record’s substantial evidence. Specifically, she asserts that her level of

        treatment could not fairly be characterized as “routine and conservative” and her mental

                                                     29
USCA4 Appeal: 21-2042      Doc: 42          Filed: 02/22/2023     Pg: 30 of 48

        status examinations illustrate repeated depressive, harmful, and suicidal thoughts, which

        are not “benign” in nature. We agree with Shelley C..

                                                     A.

               The ALJ evaluates a claimant’s symptoms through a two-prong framework found

        in SSR 16-3p, 2016 WL 1119029 (Mar. 16, 2016), which is further elaborated in 20 C.F.R.

        § 404.1529.    First, the ALJ must decide whether there is an underlying medically

        determinable physical or mental impairment that could reasonably be expected to produce

        the claimant’s symptoms. SSR 16-3p, 2016 WL 1119029.

               If the claimant clears this threshold, the ALJ then moves to the second prong, which

        involves evaluating the intensity and persistence of those symptoms to determine the extent

        to which they limit the claimant’s ability to perform work-related activities. Id. At this

        second prong, the ALJ considers the “entire case record, including the objective medical

        evidence; an individual’s statements about the intensity, persistence, and limiting effects

        of symptoms; statements and other information provided by medical sources and other

        persons; and any other relevant evidence in the individual’s case record.” Id. at *4.

        However, “objective evidence is not required to find the claimant disabled.” Arakas, 983

        F.3d at 95 (citing SSR 16-3p, 2016 WL 1119029, at *4–5). In other words, the ALJ “will

        not disregard [a claimant’s] statements about the intensity, persistence, and limiting effects

        of symptoms solely because the objective medical evidence does not substantiate the

        degree of impairment-related symptoms alleged by the individual.” SSR 16-3p, 2016 WL

        1119029, at *5. Indeed, “because pain is subjective [it] cannot always be confirmed by

        objective indicia[.]” Craig v. Chater, 76 F.3d 585, 595 (4th Cir. 1996). Instead, the ALJ

                                                     30
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023      Pg: 31 of 48

        is required to balance the record evidence as “[a] report of . . . inconsistencies in the

        objective medical evidence is one of the many factors . . . consider[ed] in evaluating” this

        prong. SSR 16-3p, 2016 WL 1119029, at *5.

               Finally, the ALJ must ascertain the extent of the claimant’s alleged functional

        limitations and restrictions due to their pain or symptoms that could be reasonably accepted

        as consistent with the medical signs, laboratory findings, and other evidence, in discovering

        how these symptoms impact the claimant’s ability to work. See Craig, 76 F.3d at 594.

                                                     1.

               After acknowledging that Shelley C.’s “medically determinable impairment could

        reasonably be expected to cause some of the alleged symptoms,” A.R. 22, the ALJ

        determined that Shelley C.’s statements relating to the intensity, persistence, and limiting

        effect of her symptoms were inconsistent with the medical and other evidence in the record.

        We hold that the ALJ erred in discounting Shelley C.’s subjective complaints as

        inconsistent with the record’s medical evidence.

               The ALJ’s legal error is clear: he could not dismiss Shelley C.’s subjective

        complaints based entirely upon the belief that they were not corroborated by the record’s

        medical evidence. The Fourth Circuit has long held that “while there must be objective

        medical evidence of some condition that could reasonably produce the pain, there need not

        be objective evidence of the pain itself or its intensity.” Walker v. Bowen, 889 F.2d 47, 49

        (4th Cir. 1989). Indeed, “[b]ecause pain is not readily susceptible of objective proof . . .,

        the absence of objective medical evidence of the intensity, severity, degree or functional

        effect of pain is not determinative.” Hines v. Barnhart, 453 F.3d 559, 564–65 (4th Cir.

                                                     31
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023     Pg: 32 of 48

        2006). Accordingly, Shelley C. was entitled to rely entirely on subjective evidence to

        demonstrate that her pain was sufficiently persistent and severe to support a disability

        finding. See id. at 564. As described in length above, the record contains no shortage of

        such evidence. 9

               Shelley C.’s statements were also directly corroborated by her testimony at the ALJ

        hearing. Because she reported being constantly clouded by an impending sense of doom,

        she mentioned that her daily routine consisted of swallowing a cocktail of pills followed

        by returning to her bed or the couch where she either slept or watched re-runs on TV all

        day. She found it difficult to have conversations with others because she “tear[ed] up a

        lot.” A.R. 41. She testified that her husband and children do all of the housework and her

        children no longer feel as if they have a mother. Shelley C. stated that her symptoms have

        worsened, and she thinks about suicide and death everyday because there is no “light at the

        end of the tunnel.” A.R. 45. For those reasons, she claimed she would not be a dependable

        employee because her “fatigue, memory loss, anxiety, and severe sadness” make it

        impossible for her to work. A.R. 46. Shelley C., at times, could not even find the words

        to express the level of her depression. For instance, she testified, “I don’t know how to

               9
                In her applications for SSDI benefits, Shelley C. wrote that most days she could
        not get out of bed, as she no longer possessed the strength to go anywhere. She was
        overwhelmed with crying spells—which also interrupted her ability to talk to others—and,
        on days with doctor’s appointments, she could not do anything else due to this deep
        sadness. Suicide haunted her thoughts constantly. Regardless of her harmful thoughts, she
        managed to push aside her feelings to pursue things—as needed—for her children. This is
        consistent with the copious treatment notes which reflected that, although her moods and
        affects were constantly dysthymic and depressed, she would not act on her suicidal
        thoughts due to her children.
                                                    32
USCA4 Appeal: 21-2042       Doc: 42          Filed: 02/22/2023      Pg: 33 of 48

        explain. It’s just a real deep, dark place where you don’t feel like you’ll ever come out of

        it. It just—I don’t know.” A.R. 47. Thus, Shelley C. has frequently and consistently

        disclosed how the pain and severity of her mental health impairments have impacted her

        life, her family, and her inability to be a reliable or dependable employee.

               In Arakas, we held that ALJs could not rely upon the absence of objective medical

        evidence to discredit “a claimant’s subjective complaints regarding symptoms of

        fibromyalgia or some other disease that does not produce such evidence.” 983 F.3d at 97

        (emphasis added). Today, we hold that depression—particularly chronic depression—is

        one of those other diseases. Characterized as a “mood disorder,” MDD “causes a persistent

        feeling of sadness and loss of interest . . . it affects how you feel, think and behave[.]”

        Mayo Clinic, Depression (major depressive disorder) Symptoms & Causes (Oct. 14 2022),

        https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

        (last viewed January 18, 2023) (saved as ECF attachment). Notably, the DSM-V declares

        that “no laboratory test has yielded results of sufficient sensitivity and specificity to be used

        as a diagnostic tool for [MDD.]” 10 But most importantly, “[s]ymptoms caused by major

        depression can vary from person to person.” Mayo Clinic, Depression (major depressive

        disorder) Diagnosis & treatment, https://www.mayoclinic.org/diseases-conditions/depression

        /diagnosis-treatment/drc-20356013 (emphasis added) (last viewed January 18, 2023) (saved

        as ECF attachment). Stated differently, symptoms of MDD, like those of fibromyalgia, are

        “entirely subjective,” determined on a case-by-case basis.           Arakas, 983 F.3d at 96

               Am. Psychiatric Ass’n, Diagnostic and Statistical Manual of Mental Disorders
               10

        187 [DSM-V] (5th ed. 2013).
                                                       33
USCA4 Appeal: 21-2042       Doc: 42         Filed: 02/22/2023      Pg: 34 of 48

        (emphasis added). Ultimately, because of the unique and subjective nature of MDD,

        subjective statements from claimants “should be treated as evidence substantiating the

        claimant’s impairment.” Id. at 97–98.

               Because the ALJ “improperly increased [Shelley C.’s] burden of proof,” id. at 96,

        in requiring that her subjective statements be validated by objective medical support, we

        must find error.

                                                      2.

               We must also assess the ALJ’s decision to disregard Shelley C.’s subjective

        statements concerning the intensity, persistence, and limiting effects of her symptoms

        finding they, allegedly, were inconsistent with the medical evidence in the record, which,

        in his view, “reflect[ed] a routine and conservative treatment history, and generally benign

        mental status examinations.” A.R. 22. We believe that substantial record evidence does

        not support this conclusion.

               Following this statement, the ALJ chronologically walked through the treatment notes

        from Bernstein and Dr. Beale. In so doing, however, the ALJ cherry-picked from the record,

        highlighting Shelley C.’s good moments and bypassing the bad. This violated an ALJ’s

        “obligation to consider all relevant medical evidence,” which prohibits him from “simply

        cherrypick[ing] facts that support a finding of nondisability while ignoring evidence that

        points to a disability finding.” Lewis, 858 F.3d at 869. At the outset of his analysis, the ALJ

        inappropriately brushed off Shelley C.’s intentional overdose, which she admitted was a

        suicide attempt. Specifically, he noted that Shelley C. denied any suicidal ideations and said

        that she “simply wanted to get a good night sleep.” A.R. 22. Although he acknowledged

                                                      34
USCA4 Appeal: 21-2042       Doc: 42         Filed: 02/22/2023      Pg: 35 of 48

        that Shelley C. had described the plans on how she would end her life, he noted that she was

        safely discharged from the hospital one day after the overdose. While true, the ALJ failed

        to mention Shelley C.’s statement that an argument with her husband led her to take the

        handful of pills which landed her in the ER. Nor did the ALJ acknowledge that Shelley C.

        directly reported to Social Services that “a part of her was hoping that she would not wake

        up . . . she wishes she were dead on a daily basis.” A.R. 309. This does not reveal a “benign

        mental status,” yet the ALJ failed to mention or consider this critical information.

               The ALJ’s cherry-picking also pervaded his consideration of Dr. Beale’s treatment

        notes. For example, the ALJ mentioned only that Shelley C. denied suicidal ideations, was

        able to enjoy things at times, performed all household duties, and had been regularly

        attending and enjoying water aerobics. However, other evidence indicated that Shelley C.

        performed her household duties because her family depended on her, and her motivation

        to complete them often wavered and eventually plateaued. And while Shelley C. did

        participate in water aerobics with a girlfriend, and an art class with her mother-in-law, those

        experiences and activities were few and far between, as they were discussed in only a

        handful of Shelley C.’s many treatment notes. A.R. 330, 449–50.

               The ALJ also recounted a weekend visit Shelley C. had with her niece and nephew,

        which, according to Dr. Beale’s treatment notes, she claimed to enjoy. Yet, the ALJ

        overlooked Shelley C.’s surrounding statements. Although Shelley C. told Bernstein at a

        psychotherapy session that she was able to enjoy being active with her niece and nephew

        over a period of their visit, Shelley C. continued to have a depressed mood and affect, and

        she reported a melancholic mood, low energy, poor motivation, and self-deprecating

                                                      35
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023     Pg: 36 of 48

        thoughts at the same psychotherapy session. A.R. 506. At another point, the ALJ

        discussed Shelley C.’s capacity to enjoy a family wedding but failed to address that Shelley

        C. was reluctant to attend the wedding based on concerns about her appearance and weight.

        Indeed, Shelley C. often spoke about her struggle with weight and body image. Her success

        or failure to lose weight often corresponded with her depressive states. Again, the ALJ did

        not acknowledge or discuss this correlation or notable theme in Shelley C.’s record.

               Further, the ALJ mischaracterized Shelley C.’s experience with the TMS treatment.

        Although he accurately discussed the decrease in her PHQ-9 score and the TMS’s gradual

        positive effect on her moods, he failed to note how brief the improvements were. Of

        course, the TMS treatment notes revealed Shelley C.’s gratitude for her participation. But,

        within a month of completing the treatments, Shelley C. reported to both Dr. Beale and

        Bernstein that her mood was depressed, she experienced self-deprecating thoughts, lack of

        motivation, and lethargy, with intermittent periods of anxiety and worry. These statements

        were vital to providing a comprehensive image of the waxing and waning of Shelley C.’s

        chronic depression, which was treatment resistant.

               At each step of Shelley C.’s poor mood and affect, Dr. Beale attempted to curb her

        symptoms with medication management. At multiple points, the record depicts Shelley

        C.’s medication adjustment, prescriptions for new medications, and the balancing and

        tapering of her existing medications. The medications Dr. Beale prescribed—Wellbutrin,

        Cymbalta, Ativan, Adderall, Zyprexa, and Progesterone—include, inter alia, atypical

        antidepressants, serotonin-norepinephrine reuptake inhibitors, benzodiazepines, and

        atypical antipsychotics. A growing number of district courts have held that in cases where

                                                    36
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023      Pg: 37 of 48

        claimants consume antidepressant, anticonvulsant, and/or antipsychotic drugs, consistently

        attend visits with mental health professions, and endure constant medication adjustment

        and management, their treatment is classified as anything but “routine and conservative.” 11

        Thus, at a minimum, Shelley C.’s constant medication management and sessions with

        Dr. Beale and Bernstein cannot be so classified.

               When medication management did not appear to abate her symptoms with any

        longevity, Dr. Beale recommended that Shelley C. enroll in either TMS or ECT treatment.

        As mentioned above, these forms of treatment are only offered and administered to those

        with the most severe cases of depression. Dr. Beale did not prescribe these courses of

        treatment lightly. He had first-hand knowledge that the medication management was not

        sufficient to abate Shelley C.’s symptoms, which appeared to be worsening. Overlooking

               11
                  See Edwin M. v. Saul, No. 4:19-cv-00046, 2021 WL 1565415, *9 (W.D. Va. Apr.
        21, 2021) (unpublished) (citing to similar cases and holding that, inter alia, where claimant
        was prescribed various antidepressants, anticonvulsants, and antipsychotics which were
        repeatedly changed due to the claimant’s ongoing symptoms, the claimant’s treatment
        could not be characterized as “routine” or “conservative”); see also Za Xiong Mua v. Saul,
        No. 1:19cv516, 2020 WL 5257592, at *8 (E.D. Cal. Sept. 3, 2020) (finding antidepressants,
        antipsychotics, and “frequent” visits with mental health professionals was “anything but
        conservative”); James N. v. Saul, No. ED CV 18-1199-KS, 2019 WL 3500332, at *6 (C.D.
        Cal. July 31, 2019) (concurring with “other district courts that have found antipsychotic
        medications such as Risperidone do not qualify as routine or conservative treatment”);
        Wilson v. Colvin, No. 8:15cv4185, 2016 WL 6471904, at *15 (D.S.C. Oct. 19, 2016)
        (rejecting ALJ’s characterization of claimant’s treatment as “conservative” where claimant
        treated with a psychiatrist, took psychotropic medications, and required repeated
        medication changes because of “ineffectiveness”); Mason v. Colvin, No. 1:12cv584, 2013
        WL 5278932, at *6 (E.D. Cal. Sept. 18, 2013) (finding treatment not “conservative” where
        claimant took antidepressants and antipsychotics “to treat her depression, anxiety, and
        auditory and visual hallucinations,” treated with a psychiatrist and psychiatric social
        worker, and continued to experience symptoms, including suicidal ideation, while taking
        her medication).
                                                     37
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023      Pg: 38 of 48

        the extensive and nuanced treatment Shelley C. received, the ALJ inappropriately “play[ed]

        doctor in contravention of the requirements of applicable regulations,” Lewis, 858 F.3d at

        869 (cleaned up), by concluding that her treatment was “routine and conservative.”

                                                     V.

               The ALJ determined that Shelley C. was not disabled because she only presented

        “moderate limitations” under step three of the 20 C.F.R. § 404.1520(a)(4) analysis.

        However, the ALJ inadequately grappled with the unique nature of Shelley C.’s mental

        health impairments, particularly chronic depression. We believe that if analyzed correctly,

        Shelley C.’s depression demonstrated both marked and extreme limitations that would

        instantly qualify her as disabled. As such, we conclude that substantial evidence does not

        support the ALJ’s decision that Shelley C. was not disabled.

                                                     A.

               In Arakas, we held that the ALJ erred in denying the claimant’s request for disability

        benefits by failing to properly understand the unique nature of fibromyalgia. We looked

        to SSR 12-2p’s Evaluation of Fibromyalgia to conclude that “the ALJ failed to appreciate

        the waxing and waning nature of fibromyalgia and to consider the longitudinal record of

        Arakas’s symptoms as a whole.” Arakas, 983 F.3d at 101. Unlike for fibromyalgia, the

        social security rulings do not neatly elaborate upon evaluations concerning depression with

        suicidal ideation, anxiety features, and ADHD. However, in step three of the ALJ’s

        required analysis, the SSA does detail, inter alia, mental health disorders nested within an

        extensive “Listing of Impairments.” At that stage, the claimant is required to prove that

                                                     38
USCA4 Appeal: 21-2042          Doc: 42      Filed: 02/22/2023    Pg: 39 of 48

        her impairment or combination of impairments meets or medically equals the severity of

        one of the listed impairments in 20 C.F.R. Part 404, Subpart P, Appendix 1.

               The ALJ determined that although Shelley C. suffered from severe mental

        impairments, she did not “meet or medically equal the criteria of listing 12.04, 12.06, and

        12.11.”     A.R. 16.     The SSA’s listings for mental disorders are arranged in eleven

        categories. 12 The listings relevant here are: depressive, bipolar and related disorders

        (12.04), anxiety and obsessive-compulsive disorders (12.06), and neurodevelopmental

        disorders (12.11). Listings 12.04 and 12.06 have three paragraphs—labeled A, B, and C.

        A claimant must satisfy either the requirements in both paragraphs A and B or the

        requirements in both paragraphs A and C. 20 C.F.R. Pt. 404, Subpt. P, App.1. Listing

        12.11, on the contrary, has only two paragraphs—characterized as A and B—and a

        claimant must satisfy the requirements of both. Id. For purposes of this Section, we will

        solely focus on Listing 12.04, pertinent to Shelley C.’s severe and chronic depression.

               Paragraph A of these listings hosts the medical criteria that must be present in a

        claimant’s medical evidence, whereas Paragraph B offers the functional criteria the ALJ

        assesses to evaluate how the claimant’s mental disorders limit their functioning, in

        accordance with a rating scale (12.00E and 12.00F). More specifically,

               12
                   The categories include: Neurocognitive disorders (12.02); schizophrenia
        spectrum and other psychotic disorders (12.03); depressive, bipolar and related disorders
        (12.04); intellectual disorder (12.05); anxiety and obsessive-compulsive disorders (12.06);
        somatic symptom and related disorders (12.07); personality and impulse-control disorders
        (12.08); autism spectrum disorder (12.10); neurodevelopmental disorders (12.11); eating
        disorders (12.13); and trauma- and stressor-related disorders (12.15). 20 C.F.R. Pt. 404,
        Subpt. P, App. 1.
                                                     39
USCA4 Appeal: 21-2042       Doc: 42          Filed: 02/22/2023      Pg: 40 of 48

               [t]hese criteria represent the areas of mental functioning a person uses in a
               work setting. They are: Understand, remember, or apply information;
               interact with others; concentrate, persist, or maintain pace; and adapt or
               manage oneself. We will determine the degree to which your medically
               determinable mental impairment affects the four areas of mental functioning
               and your ability to function independently, appropriately, effectively, and on
               a sustained basis (see §§ 404.1520a(c)(2) and 416.920a(c)(2) of this chapter).
               To satisfy the paragraph B criteria, your mental disorder must result in
               “extreme” limitation of one, or “marked” limitation of two, of the four areas
               of mental functioning.

        20 C.F.R. Pt. 404, Subpt. P, App. 1 (emphasis added). 13

               Paragraph C of listings 12.04 and 12.06 specifies the criteria the ALJ uses to

        determine “serious and persistent mental disorders.” Id. In order to qualify as “serious and

        persistent,” the claimant must demonstrate “a medically documented history of the

        existence of the disorder over a period of at least 2 years, and evidence that satisfies the

        criteria in both” prongs of Paragraph C. Id.

               Under the depressive, bipolar and related disorder listing (12.04), the claimant must

        satisfy either A and B, or A and C. Paragraph A requires medical documentation of

        depressive disorder characterized by five or more of the following: (a) depressed mood;

        (b) diminished interest in almost all activities; (c) appetite disturbance with change in weight;

        (d) sleep disturbance; (e) observable psychomotor agitation or retardation; (f) decreased

        energy; (g) feelings of guilt or worthlessness; (h) difficulty concentrating or thinking; or

        (i) thoughts of death or suicide. This must be satisfied in conjunction with:

               13
                  Here, the ALJ defined “marked limitation” as “serious limitation” of independent,
        appropriate, effective, and sustained basis functioning and “extreme limitation” as the
        “inability to function independently, appropriately or effectively, and on a sustained basis.”
        A.R. 19.
                                                       40
USCA4 Appeal: 21-2042       Doc: 42          Filed: 02/22/2023      Pg: 41 of 48

               B. Extreme limitation of one, or marked limitation of two, of the following
                   areas of mental functioning (see 12.00F):
               1. Understand, remember, or apply information (see 12.00E1).
               2. Interact with others (see 12.00E2).
               3. Concentrate, persist, or maintain pace (see 12.00E3).
               4. Adapt or manage oneself (see 12.00E4).
               OR
               C. Your mental disorder in this listing category is “serious and persistent;”
                  that is, you have a medically documented history of the existence of the
                  disorder over a period of at least 2 years, and there is evidence of both:
               1. Medical treatment, mental health therapy, psychosocial support(s), or a
                  highly structured setting(s) that is ongoing and that diminishes the
                  symptoms and signs of your mental disorder (see 12.00G2b); and
               2. Marginal adjustment, that is, you have minimal capacity to adapt to
                  changes in your environment or to demands that are not already part of
                  your daily life (see 12.00G2c).

        20 C.F.R. Pt. 404, Subpt. P, App. 1 (emphasis added). 14

               14
                   For the anxiety and obsessive-compulsive disorders listing (12.06), again, the
        claimant must meet either A and B, or A and C. Paragraph A requires medical
        documentation of anxiety disorder characterized by three or more of the following:
        (a) restlessness; (b) easily fatigued; (c) difficulty concentrating; (d) irritability; (e) muscle
        tension; or (f) sleep disturbance. Id. This paragraph must be met in combination with
        Paragraph B or C, the same language found under the 12.04 listing.

              Lastly, concerning the neurodevelopmental disorders listing (12.11), the claimant
        must meet both Paragraphs A and B. Paragraph A specifies that the claimant must
        demonstrate, in accordance with the criteria listed in Paragraph B above:
              A. Medical documentation of the requirements of paragraph 1, 2, or 3:
              1. One or both of the following:
              a. Frequent distractibility, difficulty sustaining attention, and difficulty
                 organizing tasks; or
              b. Hyperactive and impulsive behavior (for example, difficulty remaining
                 seated, talking excessively, difficulty waiting, appearing restless, or
                 behaving as if being “driven by a motor”).
              2. Significant difficulties learning and using academic skills; or
        (Continued)
                                                       41
USCA4 Appeal: 21-2042      Doc: 42         Filed: 02/22/2023     Pg: 42 of 48

                                                    B.

               Substantial evidence does not support the ALJ’s conclusion that Shelley C. did not

        meet or equal the relevant listing criteria. Instead, substantial evidence demonstrates that

        Shelley C. meets the disability criteria and therefore should be found disabled.

               The ALJ failed to discuss whether Shelley C. satisfied any of the requirements found

        in Paragraph A of listings 12.04, 12.06, and 12.11. However, the ALJ did note that Shelley

        C.’s mental impairments were severe and “significantly limit the ability to perform basic

        work activities.” A.R. 17. Although thin, we agree and infer that the ALJ’s language

        demonstrates Shelley C.’s satisfaction of Paragraph A’s criteria of the depressive disorder

        listing (12.04).

               Moving along to Paragraph B, the ALJ insisted that Shelley C.’s severe mental

        impairments did not meet or medically equal the severity of one of the 12.04, 12.06, or

        12.11 listings, noting that she suffered only from a “moderate limitation” in the four

        areas of mental functioning: (1) understanding, remembering, or applying information;

        (2) interacting with others; (3) concentrating, persisting, or maintaining pace; or

        (4) adapting or managing oneself. However, substantial evidence does not support this

        conclusion as the record’s medical evidence demonstrates two “marked” limitations and

        one “extreme” limitation in these categories.

               3. Recurrent motor movement or vocalization.

        20 C.F.R. Pt. 404, Subpt. P, App. 1.
                                                    42
USCA4 Appeal: 21-2042       Doc: 42         Filed: 02/22/2023      Pg: 43 of 48

               First, we agree with the ALJ that Shelley C. demonstrates a moderate limitation in

        understanding, remembering, or applying information. This much is clear from the test

        Dr. Custer administered where Shelley C. followed a three-stage command, copied a

        geometric design, and recalled 3/3 objects after a minute and 1/3 after five minutes. But with

        respect to Shelley C.’s ability to interact with others, the record does not reveal a “moderate

        limitation,” but rather a “marked limitation.” Shelley C. was often unable to speak to others

        without a tearful affect. She did not leave the house for weeks at a time, apart from doctor’s

        appointments once every three weeks, secluding herself to the couch each day. Moreover, her

        treatment notes describe Shelley C.’s constant desire to self-isolate. Outside of her immediate

        family, Shelley C. rarely interacted with others, particularly strangers. Any activities she

        joined—which either involved limited human interaction or were done with well-known

        individuals—do not demonstrate that Shelley C. was able to moderately interact with others,

        particularly individuals with whom she was not familiar. Instead, the record reveals that

        Shelley C. was a dysthymic, self-isolated, often tearful, worried person who struggled with

        social interaction. Shelley C.’s marked limitation in this area, supported by overwhelming

        evidence in the record, would inhibit her from performing “in an ordinary work setting on a

        regular and continuing basis” of “8 hours a day, for 5 days a week, or an equivalent work

        schedule.” SSR 96-p, 1996 WL 374184, at *2.

               Next, the ALJ found that Shelley C. had a moderate limitation in her capacity to

        concentrate, persist, or maintain pace. To reach that conclusion, the ALJ relied solely upon

        the record’s medical evidence regarding Shelley C.’s “good attention and concentration at

        treatment visits,” A.R. 20, and disregarded her subjective complaints. We find this reasoning

                                                      43
USCA4 Appeal: 21-2042       Doc: 42          Filed: 02/22/2023      Pg: 44 of 48

        not only defective, but also insupportably weak. The record’s substantial evidence parades

        a slew of instances concerning Shelley C.’s limited capacity to concentrate, persist, or

        maintain pace. Her inability to continue or complete new activities is also indicative of her

        shortcomings in persistence and maintaining pace. Shelley C. expressed her excitement to

        participate in new activities, as previously discussed, but the record clearly shows that each

        of those endeavors were brief, often only being spoken about for, at most, a handful of

        sessions. Thus, the ALJ improperly relied upon Shelley C.’s capacity to discuss her life

        outside of the doctor’s office as medical evidence to challenge the gravity of this limitation.

                Although we have found that Shelley C. reveals marked limitations in the preceding

        two functional areas (which is all that is required to find for a claimant’s disability status),

        for a fulsome review, we analyze the final functional area: Shelley C.’s ability to adapt

        and manage herself. Alas, we conclude that Shelley C. displays extreme limitations in this

        area.

                In reaching his decision, the ALJ pointed to Shelley C.’s capacity to count change,

        feed her pets and, on one occasion, Shelley C.’s report to her therapist that she had a good

        activity level and was able to follow through with her chores and responsibilities. The ALJ

        also relied on treatment notes indicating that Shelley C. appeared well-groomed during

        appointments. Yet, the ALJ’s explanation provides a prime example of the misconceptions

        surrounding depression.

                                                      44
USCA4 Appeal: 21-2042        Doc: 42        Filed: 02/22/2023    Pg: 45 of 48

               Per the DSM-V, depressive disorders, including MDD, are “accompanied by related

        changes that significantly affect the individual’s capacity to function.” 15 When those with

        MDD face a depressive episode, it involves “clear-cut changes in affect, cognition, and

        neurovegetative functions and interepisode remissions,” which are characterized by

        “pervasive unhappiness and misery.” 16 In other words, amidst a patient’s depressive

        episodes, she is capable of experiencing brief periods of diminished depression, which can

        appear—from the outside looking in—as overall improvement.

               The ALJ focused on Shelley C.’s “improved” periods to reject the lower, more

        frequent states of her depression which impacted her ability to adapt or manage herself.

        As the record reflects, Shelley C.’s daily routine often consisted of remaining in bed or on

        the couch, unbathed and in the same clothes. Treatment notes state that her ability to do

        chores was either “problematic,” “fair,” or “improving.” A.R. 328–29. Only once, which

        the ALJ fixated on, did Shelley C. report that she was able to complete all of her household

        tasks. The only activity she did on her own was attend necessary doctor’s appointments.

        Yet, Shelley C. detailed that on her appointment days, she would come home and cry,

        unable to participate or do anything else for the remainder of the day. Adapting herself to

        change was also trying. In therapy, she often lamented, through tears, her children leaving

        home. Similarly, Shelley C.’s participation in new activities was fleeting, often impacted

        by her symptoms, demonstrating that this extreme limitation persisted.

               15
                    Am. Psychiatric Ass’n [DSM-V], supra note 10, at 177.
               16
                    Id. at 177, 184 (emphasis added).
                                                    45
USCA4 Appeal: 21-2042       Doc: 42         Filed: 02/22/2023      Pg: 46 of 48

               Notably, the ALJ abandoned a critical piece of information. During Shelley C.’s

        hearing, the vocational expert stated that, not including her past work, there were other jobs

        that Shelley C. could perform. The ALJ utilized this portion of the vocational expert’s

        testimony to support his finding that Shelley C. had the capability to perform simple, routine,

        repetitive-styled jobs. Strikingly, however, the ALJ disregarded a powerful segment of the

        vocational expert’s testimony. When asked about a person with psychological impairments

        who would be off task from their job for more than an hour a day, in addition to regular

        breaks, and miss more than two days of work a month on a regular basis, the vocational

        expert vocalized that there were no such jobs in the national economy suitable for a person

        with such limitations. We are perplexed by the ALJ’s dismissal of this significant testimony.

        Given Shelley C.’s daily routine, she cannot possibly be expected to attend, let alone

        perform, the jobs suggested. The waxing and waning of her symptoms would hinder her

        from being a dependable employee. These environments would place her in constant

        communication and interaction with strangers. They also would force her to be active, when

        Shelley C. reported being unable to move from her bed or the couch. The ALJ erred by

        disregarding the vital vocational expert testimony and finding that Shelley C. had the

        capacity to work.

               Given our analysis, we will not “reflexively rubber-stamp [the] ALJ’s findings,”

        Lewis, 858 F.3d at 870, that Shelley C.’s severe mental health impairments do not rise to

        the disability criteria described in the relevant listing. As the reviewing court, we cannot

        “uphold the factual findings of the ALJ” because they were unsupported “by substantial

        evidence and were [not] reached through application of the correct legal standard.”

                                                      46
USCA4 Appeal: 21-2042       Doc: 42         Filed: 02/22/2023      Pg: 47 of 48

        Hancock, 667 F.3d at 472. Instead, Shelley C.’s two marked limitations and/or one extreme

        limitation meet the appropriate standard under the 12.04 listing to qualify her as disabled. 17

                                                     VI.

               Today, we join our sister circuits’ growing conversation surrounding chronic

        diseases, highlighting, in particular, the unique and subjective nature of chronic depression.

               In light of the reasons set forth above, we conclude that the ALJ erred in assigning

        “little weight” to Dr. Beale’s opinion and in disregarding Shelley C.’s subjective

        complaints. His decision not only presented several procedural errors but also failed to

        consider the record’s substantial evidence and the unique nature of Shelley C.’s severe

        mental impairments, particularly her chronic depression.

               Per 42 U.S.C. § 405(g), this Court has the power to reverse the Commissioner’s

        decision with or without the cause for a rehearing. We, along with our sister courts, have

        awarded disability benefits without remand for rehearing “where the record clearly

        establishes the claimant’s entitlement to benefits and another ALJ hearing on remand

        would serve no useful purpose.” Arakas, 983 F.3d at 111; see also Green-Younger v.

        Barnhart, 335 F.3d 99, 109 (2d Cir. 2003); Kalmbach v. Comm’r of Soc. Sec., 409 F. App’x

        852, 865 (6th Cir. 2011). Because substantial evidence in the record clearly establishes

        Shelley C.’s disability, remanding for a rehearing would only “delay justice.” Arakas, 983

               17
                 Because we have determined that Shelley C.’s disability status should have been
        granted at step three, we do not address or analyze Paragraph C under step three or steps
        four and five of 20 C.F.R. § 404.1520(a)(4).
                                                      47
USCA4 Appeal: 21-2042       Doc: 42          Filed: 02/22/2023   Pg: 48 of 48

        F.3d at 105.     We therefore reverse the Commissioner’s decision and remand with

        instructions to grant disability benefits.

                                            REVERSED AND REMANDED WITH INSTRUCTIONS

                                                     48