Depression Case Study #1
Mental Health + Back Pain Issues
Claimant: 44 year old female
Past work: jewelry store sales manager, jewelry store sales clerk, waitress, emergency medical technician, door to door salesperson, medical record custodian
Education: high school graduate + 1 year college
Hearing Info: my client applied for benefits in October of 2006 alleging a disability that began on January 31, 2006, her last day of work as the manager of a jewelry store. This date coincided with her receiving sacroiliac joint injections from her pain physician – instead of relieving pain, the injections left her in a great deal more pain. This hearing was held in Macon, Georgia in September, 2008. The judge in this case is an experienced jurist, very pleasant and very prepared.
Hearing Strategy: In reviewing the file, I noted that my client had impairments relating to both physical and mental health problems. I felt that the mental health issues were more compelling so I made that the focus of my case, so I decided to focus primarily on that. I also took a long look at Listing 12.04 and Listing 12.06 but I ultimately decided that rather than arguing the listing, I would use a functional capacity argument – e.g. that the combination of my client’s impairments prevented her from sustaining competitive, full time work.
The physical impairment component of this case included a long standing lower back issue that had been treated primarily with medications and anesthetic injections. My client’s low back issues did not lend themselves to surgery because there was no significant disc involvement in the lumbar spine. My client also had a significant history relating to her cervical spine, and she had undergone an anterior cervical discectomy and fusion at 2 levels. The post surgical notes suggested that the surgery was successful, but she advised me that after about 8 months, she began experiencing pain in the cervical spine.
Thus, while I felt that there was a history of on-going treatment and objective evidence of a problem, I was a little concerned that her testimony of on-going pain might be a little inconsistent with medical reports that talked about a successful surgery, and lumbar problems that were not surgical in nature.
The mental health component of this case also contained on-going treatment by both a psychiatrist and a therapist. My client alleged severe and chronic depression and post traumatic stress disorder arising from a very dysfunctional and abusive childhood. I also had a very strong mental functional capacity form from both the pain doctor (who had primarily been treating her for cervical and lumbar pain) and from her therapist (who was, unfortunately, a licensed clinical social worker and not a psychologist – Social Security gives less weight to a LCSW than a Ph.D. or a M.D.).
Nevertheless I felt that we had a good argument that my client’s mental health situation deteriorated after she left work in January, 2006 to recover from the SI joint injections and the cervical surgery. Often times patients’ work stamina “decompensates” after an extended time off from work – when there is an underlying mental health issue, that decompensation can become more or less permanent.
Hearing: the judge called the hearing and introduced himself and the vocational witness. As noted above, this judge was a very soft spoken, kind hearted man and he made an effort to put my client at ease.
He did not ask for an opening statement, and he immediately began questioning my client. The judge asked my client about her past work and he had her describe what she did in each of these occupations. Next, the judge asked my client “what is the main problem that keeps you from working?” My client responded that her low back pain was the main issue, which I think surprised the judge a little, but he went ahead and asked my client about her low back and neck issues.
After going over these orthopedic and neurological issues, the judge raised the question about depression and mental health problems. My client immediately became somewhat tearful but she testified effectively about how withdrawn she has become and about how much trouble she has staying focused and attentive.
My sense was that the judge was a little surprised that my client did not identify her mental health issues as the primary reason for her inability to perform work. However, I thought that he very deftly elicited testimony about this issue as the hearing went forward. I believe that the judge recognized that my client, not unreasonably, does not like to talk about her difficult childhood and the resulting mental health limitations and I don’t believe that he will hold her failure to raise this issue against her.
The judge then turned the questioning over to me and I asked a few more questions about the mental health issues. It was clear to me that the judge had reviewed this record and I did not want to go over the same information that he had just covered. I started by asking her if she found it difficult to stay at home and not work. This resulted in some tears and testimony about her frustration and unhappiness about not being able to contribute to her household. I then elicited testimony about her thoughts of suicide and the frequency of her crying spells (daily). I finished by asking about medication side effects and about her typical day.
The judge then turned to the vocational witness and posted a hypothetical question that contained the following limitations:
- limited to light work
- must alternate sitting and standing every 30 minutes
- can lift 20 lbs. occasionally and 10 lbs. frequently
- occasional climbing, balancing, kneeling, stooping and crawling
- no overhead lifting with the right (dominant) arm
- can perform frequent reaching with right arm
- no work on ladders, ropes or scaffolds
- limited to simple work
- no work involving interaction with the public
- no work involving close coordination with others
- can be in presence of others
The vocational witness responded that a person so limited could not return to the claimant’s past work but could do other, work – simple and unskilled.
The judge then continued by adding the following to his hypothetical:
- needs to lie down during the workday for 30 minutes to 1 hour
The vocational witness testified that this limitation would preclude all work
The judge then allowed me to question the vocational witness. I asked him to refer to the functional capacity form prepared by the claimant’s pain management physician:
Q: if the judge accepts Dr. ___’s conclusion that the claimant can work a total of 2 hours sitting and 2 hours standing during the course of a work day, could the claimant perform competitive work:
Q: if the judge accepts Dr. ___’s conclusion that the claimant would likely miss three or more days of work per month, could the claimant perform competitive work:
My sense is that the judge will find that the claimant was credible when talking about her need to lie down and that he will not discredit the treating doctor’s opinions about capacity and reliability.
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