Disability Determinations and Chronic Mental Illness

Facts of the Case

On August 23, 2016, Ms. Cannon applied for SSDI benefits, claiming disabilities due to her diagnoses of major depressive disorder (MDD), anxiety disorder, and attention-deficit/hyperactivity disorder (ADHD). Ms. Cannon's depression started when she was 18 years old. In 1999, she started seeing her psychiatrist, Dr. Beale. Over the course of her treatment, Dr. Beale prescribed multiple medication combinations to address Ms. Cannon's “severe mental health impairments,” which, when they helped, provided only brief respite. Ms. Cannon also participated in psychotherapy with Hillary Bernstein. Both Dr. Beale's and Ms. Bernstein's notes describe chronic, recurring episodes of severe depression with occasional, temporary periods of a few weeks during which her mood was improved. On July 30, 2016, Ms. Cannon attempted suicide by intentionally overdosing on medications. Following the overdose, Dr. Beale increased the frequency of his appointments with Ms. Cannon, and he recommended either electroconvulsive therapy or transcranial magnetic stimulation (TMS). Ms. Cannon opted for the latter and underwent 36 TMS treatments in May 2017. Her symptoms improved significantly, but after a few weeks her severe depression returned. Shortly after the suicide attempt, Ms. Cannon left her job as a preschool's Director of Religious Activities and applied for SSDI benefits.

Ms. Cannon provided multiple subjective statements to the SSA describing her symptoms, including difficulty getting out of bed, low energy, substantial difficulty with daily tasks, frequent crying spells, trouble interacting with family and friends, and loss of enjoyment in former hobbies and interests. Two psychiatrists consulted by the government reviewed Ms. Cannon's records but did not examine her; both opined that she was not disabled and that she can perform simple work tasks. During her official hearing with the ALJ on August 7, 2018, Ms. Cannon reiterated her subjective experience of symptoms, and the ALJ requested a consultative examination. The consultation was completed by Dr. Custer, who diagnosed Ms. Cannon with depression. He noted that she had some difficulties with complex instructions, interacting with supervisors, and adapting to changes in a work setting. Dr. Beale, Ms. Cannon's treating psychiatrist, submitted a medical opinion letter supporting her disability claim in which he summarized her treatment history, symptom severity, and his conclusion that her conditions would worsen with the stress of any employment.

On February 12, 2019, the ALJ denied Ms. Cannon's application for SSDI benefits on the grounds that her “severe mental impairments” did not meet the disability criteria for mental disorders, and that she retained sufficient ability to perform some tasks adequately enough for some form of employment. The decision was affirmed by the district court on appeal. Ms. Cannon subsequently appealed to the Fourth Circuit.

Ruling and Reasoning

The Fourth Circuit Court of Appeals considered whether the ALJ had erred by giving little weight to the opinion of Dr. Beale and disregarding Ms. Cannon's subjective complaints because of “their alleged inconsistency” with objective evidence in her medical records. The Fourth Circuit found that the ALJ had erred on both counts. Additionally, the court of appeals determined that the ALJ erred by not properly considering the unique nature of Ms. Cannon's major depression diagnosis. The ALJ's decision was reversed and remanded with instructions to grant SSDI benefits to Ms. Cannon.

In its reasoning, the court of appeals relied upon previous case law regarding review of ALJ findings. The court first considered Hancock v. Astrue, 667 F.3d 470 (4th Cir. 2012), which recognized its authority to review the SSA Commissioner's denial of benefits under 42 U.S.C.A. § 405(g) (2020). The court then relied upon Johnson v. Barnhart, 434 F.3d 650 (4th Cir. 2005), which held that the reviewing court must defer to the decision of the ALJ if it was supported by “substantial evidence” and reached after applying the “correct legal standard.” Additionally, the court will not “reweigh conflicting evidence, make credibility determinations, or substitute our judgment for that of the [ALJ]” in reviewing for substantial error (Johnson, p 653). Finally, the court considered whether the ALJ in Ms. Cannon's case looked at all the appropriate evidence and adequately explained the decision to credit or discredit certain evidence based on Milburn Colliery Co. v. Hicks, 138 F.3d 524 (4th Cir. 1998).

The court reasoned that the ALJ must follow the “treating physician rule” which requires that greater or “controlling” weight be assigned to the opinion of the treating physician unless there is “persuasive contradictory evidence” in the record (Shelley C., pp 353-4). If the ALJ assigns lower weight to the treating physician's opinion, under 20 C.F.R. § 404.1527(c)(1)-(6) (2017), the ALJ must address six factors when providing the rationale for the decision: the length of the physician's treatment relationship with the claimant; the frequency of examinations; the nature and extent of the treatment relationship; whether the medical evidence in the record supports the physician's opinion; the consistency of the physician's opinion with the entirety of the record; and the treating physician's specialization. The Fourth Circuit found that the ALJ failed to both adequately explain the rationale for discounting Dr. Beale's opinion and to address all six factors after doing so, and that the “decision to allot ‘little weight’ to Dr. Beale's opinion was erroneous” (Shelley C., p 355). Additionally, the court held that the ALJ inappropriately afforded more weight to Ms. Cannon's nonexamining physicians' opinion than to her treating physician's.

The Fourth Circuit also evaluated Ms. Cannon's assertion that the ALJ did not give adequate attention to her subjective complaints when it found a lack of objective evidence in her treatment record. The court agreed with Ms. Cannon. In doing so, it relied upon Arakas v. Comm'r Soc. Sec. Admin., 983 F.3d 83 (4th Cir. 2020), in which it held that an ALJ could not use the absence of objective medical evidence to discount subjective reports of symptoms of “fibromyalgia or some other disease that does not produce such evidence” (Arakas, p 97). In Ms. Cannon's case, the Fourth Circuit held “that depression – particularly chronic depression – is one of those other diseases … [S]ymptoms of MDD, like those of fibromyalgia, are ‘entirely subjective’” (Shelley C., p 361). The court concluded that the ALJ erred by improperly increasing Ms. Cannon's burden of proof when it failed to treat her subjective statements as substantiation of her impairments.