Case: 18-14455 Date Filed: 08/29/2019 Page: 1 of 24
[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT
________________________
No. 18-14455
Non-Argument Calendar
________________________
D.C. Docket No. 1:17-cv-22604-DPG
MILKA ELENA CASTRO,
Plaintiff-Appellant,
versus
ACTING COMMISSIONER OF SOCIAL SECURITY,
Nancy A. Berryhill,
Defendant-Appellee.
________________________
Appeal from the United States District Court
for the Southern District of Florida
________________________
(August 29, 2019)
Before TJOFLAT, JORDAN and JILL PRYOR, Circuit Judges.
PER CURIAM:
Case: 18-14455 Date Filed: 08/29/2019 Page: 2 of 24
Milka Elena Castro appeals the district court’s order affirming the decision
of the Commissioner of the Social Security Administration to deny her application
for benefits. On appeal, she argues that the administrative law judge (“ALJ”) erred
in assessing her residual functional capacity because the ALJ gave only partial
weight to the opinions of Dr. Hamlet Hassan, her treating psychiatrist. Because the
ALJ’s decision to give less than great weight to Hassan’s opinions is not supported
by substantial evidence, we reverse the district court’s judgment and remand to the
district court with instructions to remand to the Commissioner.
I. FACTUAL BACKGROUND
Castro applied for disability insurance benefits, a period of disability, and
supplemental security income, claiming that she was disabled due to various
physical and psychological impairments.1 After her application was denied, Castro
received a hearing before an ALJ.
A. The ALJ Hearing
At the hearing, the ALJ heard testimony from Castro about her limitations
and from a vocational expert. The ALJ also reviewed other evidence, including a
questionnaire that Castro had completed about her limitations, records from
1
Because Castro’s arguments on appeal relate to the ALJ’s assessment of her limitations
due to her psychological impairments, we discuss the evidence related to these impairments only.
2
Case: 18-14455 Date Filed: 08/29/2019 Page: 3 of 24
Castro’s medical providers, and the opinions of state agency consultants who had
reviewed Castro’s medical records.
1. Castro’s Testimony
Castro testified that she lived with her husband and two children. She
previously worked in a clothing store where her duties included changing
lightbulbs, stocking merchandise, and cleaning the bathroom. But she quit the job
due to her physical and psychological limitations.
In her testimony, Castro described how her anxiety and depression limited
her daily activities, leaving her unable to do much beyond sleeping and eating. On
a typical day, she would wake up around noon, eat a little, and then go back to bed.
She would spend most days at home alone crying. She had little appetite and had
lost approximately 20 pounds. Her hobby used to be cleaning, but she was no
longer able to clean. She cooked “just a little bit” and depended on her mother,
sister, and husband to cook for her family and clean her home. Doc. 13 at 56.2
She did not like to watch television because she was unable to concentrate or
follow the plot.
Castro also testified that she engaged in limited social activities because she
experienced panic attacks and felt suffocated and irritated when she was around
2
“Doc. #” refers to the numbered entries on the district court’s docket.
3
Case: 18-14455 Date Filed: 08/29/2019 Page: 4 of 24
other people. As a result, she would not go to the grocery store and avoided
talking to friends on the phone. She nonetheless went to church once a week.
2. Castro’s Questionnaire
Besides hearing Castro’s testimony, the ALJ also reviewed a questionnaire
that Castro completed around the time she applied for benefits in which she
described how her anxiety and depression limited her activities. In the
questionnaire, Castro indicated that she experienced panic attacks when she was
around other people. In addition, due to her obsessive-compulsive disorder, she
felt compelled to check her work multiple times, leaving her unable to work
efficiently.
Castro also described her daily activities. She usually would engage in
personal grooming but needed to be reminded to do so. Although she previously
cooked daily, she was able to cook only twice a week for about two hours at a
time. She could complete light household chores—like making the bed, washing
dishes, and tidying up—only about twice a week for two to three hours at a time.
And she would need help or encouragement to cook or clean.
Castro also provided information about her social activities. She reported
having problems socializing and getting along with friends, families, and
neighbors. In particular, if a person was talkative, she would experience panic
attacks or mood changes. About once a week, she received visitors and twice a
4
Case: 18-14455 Date Filed: 08/29/2019 Page: 5 of 24
week attended church. She did not need anyone to remind her to go to church or to
accompany her.
Castro also reported other information about how her limitations affected her
abilities. She indicated that she could pay attention for only about 15 minutes. She
could follow simple directions, but if the directions were too complex, she would
experience a panic attack. She could not handle stress well and became confused
when her routine changed.
3. Castro’s Medical Records
The ALJ also reviewed Castro’s medical records, which included records
from Hassan, Castro’s psychiatrist who treated her for several years. At her initial
appointment with Hassan, Castro stated that she repeatedly checked the same
things and performed repetitive routines and rituals without control of her thoughts
or behavior. She reported feeling depressed, lonely, hopeless, helpless, sad,
anxious, and irritable. Hassan noted that Castro had poor concentration but found
that her thought process was intact. He diagnosed her with obsessive-compulsive
disorder and prescribed her anti-depressant and anti-anxiety medications. He
determined that her Global Assessment of Function (“GAF”) score was 49. 3
3
The GAF is a standard measurement of an individual’s overall functioning “with respect
only to psychological, social, and occupational functioning” using a 1 to 100-point scale.
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders 32-33
(4th ed. 2000) (“DSM-IV”). According to the DSM-IV, a GAF rating in the range of 41-50
indicates that the person has either serious symptoms—such as suicidal ideation or severe
5
Case: 18-14455 Date Filed: 08/29/2019 Page: 6 of 24
At her second appointment, Castro reported feeling better about her
obsessive-compulsive disorder but stated that the medication had not helped and
made her angry. Based on this report, Hassan changed Castro’s medications. He
also observed that she was acting depressed and anxious during the appointment
and diagnosed her with major depressive disorder. At her next appointment,
Castro reported experiencing depression and anxiety and feeling apprehensive and
irritable. In his notes, Hassan indicated that Castro had no behavior issues and
good judgment, and he assigned her a GAF score of 55.
Several weeks later, Castro was admitted to the hospital for depression and
suicidal ideation. The ALJ reviewed the records from her hospital admission.
obsessional rituals—or a serious impairment in social, occupational, or school functioning—such
as no friends or an inability to keep a job. Id.
The more recent edition of the DSM, however, abandoned the use of GAF scoring, noting
“its conceptual lack of clarity” and “questionable psychometrics in routine practice.” American
Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders 16 (5th ed.
2013) (DSM-V). After the DSM-V was published, the Social Security Administration issued a
directive to its ALJs instructing them to consider GAF scores as medical opinion evidence but
emphasizing that a claimant’s GAF scores should not be considered in isolation. The directive
stated:
The GAF is unlike most other opinion evidence we evaluate because it is a rating.
However, as with other opinion evidence, a GAF needs supporting evidence to be
given much weight. By itself, the GAF cannot be used to “raise” or “lower”
someone’s level of function. The GAF is only a snapshot opinion about the level
of functioning. It is one opinion that we consider with all the evidence about a
person’s functioning. Unless the clinician clearly explains the reasons behind his
or her GAF rating, and the period to which the rating applies, it does not provide a
reliable longitudinal picture of the claimant’s mental functioning for a disability
analysis.
Soc. Sec. Admin., Administrative Message 13066 (July 22, 2013).
6
Case: 18-14455 Date Filed: 08/29/2019 Page: 7 of 24
When she was admitted, she reported having difficulty sleeping and concentrating
as well as suicidal ideation. She also indicated that she had less energy. The
treating physician noted that she exhibited signs of moderate depression, had a
glum demeanor, and appeared listless and downcast. The physician observed that
Castro’s thinking appeared slowed and that she had disorganized behavior, an
inappropriate affect, and illogical reasoning. The physician also wrote that she
expressed paranoid ideas and her social judgment appeared to be poor.
The physician performed a psychological assessment. During the
assessment, Castro was able to recall the date and her birthdate, define words,
perform simple math, explain the meaning of a proverb, describe the similarities
between arm and leg and tall and short, identify basic items by name, and recall
three words that she was asked to remember. To test her judgment and
comprehension, the physician asked her why people said hello to a cashier at a
store. Because she gave a correct response, the physician concluded that Castro
had good judgment and comprehension. The physician determined that her GAF
score was 30. Because Castro was able to function at a “baseline level,” she was
discharged. Doc. 13 at 393.
Approximately ten days after being released from the hospital, Castro
appeared for a follow-up appointment with Hassan. She complained of panic
attacks and was nervous and tearful during the appointment but denied suicidal
7
Case: 18-14455 Date Filed: 08/29/2019 Page: 8 of 24
ideation. At the appointment, her thought process was logical, and her insight and
judgment were fair. Hassan assigned her a GAF score of 55.
Over the next few appointments, Castro’s condition fluctuated. At her next
appointment, she reported a “little improvement in her mood” and that she had
experienced no panic attacks for two weeks. Id. at 550. Hassan also noted that she
appeared less anxious and assigned her a GAF score of 59. But at her following
appointment, Castro stated that she was frequently crying and reported feeling
depressed, anxious, and worthless. She had a disheveled appearance, was
experiencing insomnia, and reported passive death wishes. Hassan noted that she
lacked concentration and attention, her insight was poor, and her judgment was
fair. This time he assigned her a GAF score of 53 and changed her medications.
At her next appointment, Castro reported experiencing less frequent and intense
episodes of depression.
After treating Castro for nearly a year, Hassan completed an assessment
form evaluating her ability “to do work-related activities on a day-to-day basis in a
regular work setting.” Id. at 554. Among other things, he opined that she had no
useful ability to function independently. He reported that her ability to do the
following was poor: deal with the public, deal with work stress, maintain attention
and concentration, carry out detailed or complex job instructions, behave in an
emotionally stable manner, relate predictably in social situations, and demonstrate
8
Case: 18-14455 Date Filed: 08/29/2019 Page: 9 of 24
reliability. Hassan concluded that Castro had “severe problems” and would be
unable to function appropriately “in a regular environment,” and thus she could not
maintain a job. Id. at 554-55.
After completing the assessment form, Hassan continued to treat Castro,
seeing her regularly. At some appointments, he indicated that her condition was
improving or that her levels of anxiety and depression were decreasing. But at
other appointments, Hassan observed that Castro’s levels of anxiety and depression
were increasing and that her activities of daily living were worsening.
Approximately two years after completing the first assessment form, Hassan
completed a second assessment form rating Castro’s ability to do activities on a
day-to-day basis in a work setting. Most of Hassan’s assessments remained the
same. But this time he opined that Castro had no useful ability to deal with the
public, deal with work stress, or demonstrate reliability.4 To support his
assessment, he explained that she had “chronic severe depression” with a “poor to
fair response” to medications and treatment. Id. at 646.
4
Nonetheless, Hassan noted that Castro’s abilities in two areas had improved. In the first
assessment, he had determined that she had no useful ability to function independently and a
poor ability to carry out detailed job instructions, but in the second assessment he opined that she
had a fair ability in each of these areas.
9
Case: 18-14455 Date Filed: 08/29/2019 Page: 10 of 24
4. State Agency Consultants’ Opinions
The ALJ also reviewed opinions about Castro’s psychological limitations
from two state agency consultants who reviewed her medical records but never
treated or examined her. 5 The first consultant, Arthur Hamlin, Psy.D., provided his
opinion before Castro was admitted to the hospital for suicidal ideation and before
Hassan completed either assessment form. After reviewing records from Castro’s
first several appointments with Hassan, Hamlin opined that she had mild
restrictions in activities of daily living and moderate difficulties in social
functioning. He concluded that she had no problems recalling detailed instructions
and was not significantly limited in carrying out detailed instructions, sustaining an
ordinary routine without special supervision, making simple work-related
decisions, or interacting appropriately with the public. But he indicated that she
would have moderate limitations in maintaining attention and concentration for
extended periods and in responding appropriately to changes in the workplace
setting. Hamlin also found that due to her history of panic and anxiety, Castro
would need a setting with reduced social interactions.
A second state agency consultant, Kathryn Bell, Ph.D., offered an opinion
based on her review of Castro’s medical records. Bell provided her opinion after
5
A third state agency consultant, Dr. P.S. Krishnamurthy, offered an opinion about
Castro’s physical residual functional capacity. Because the opinions related to her physical
limitations, we do not discuss them.
10
Case: 18-14455 Date Filed: 08/29/2019 Page: 11 of 24
Castro was admitted to the hospital for suicidal ideation and depression but before
Hassan had completed either assessment form. Bell opined that Castro had mild
restrictions in her activities of daily living and moderate restrictions in maintaining
social functioning and concentration, persistence, or pace. She found that Castro
had no significant limitations in remembering short and simple instructions but
moderate restrictions in remembering and carrying out detailed instructions. She
also determined that Castro was moderately limited in her abilities to maintain
attention and concentration for extended periods, interact appropriately with the
general public, get along with her coworkers and peers, and respond appropriately
to changes in the work setting.
5. The Vocational Expert’s Testimony
At the hearing, the ALJ also heard testimony from a vocational expert. The
ALJ asked the vocational expert what work a hypothetical person with Castro’s
age, education, and past work history could perform if she were limited to
sedentary work that involved simple, routine, and repetitive tasks; was not at
production-rate pace; and entailed no interaction with the public. The vocational
expert opined that such a hypothetical person could not perform Castro’s past work
but could perform the jobs of table worker, final assembler, or semi-conductor
bonder.
11
Case: 18-14455 Date Filed: 08/29/2019 Page: 12 of 24
Castro’s counsel then asked the vocational expert what work a hypothetical
person could perform if she had the limitations identified in Hassan’s first
assessment, including that the person had no useful ability to function
independently and a poor ability to deal with the public, deal with work stress, and
maintain attention or concentration. The vocational expert answered that there was
no work such a person could perform. Castro’s counsel then asked the vocational
expert what work a hypothetical person could perform if she had the limitations
identified in Hassan’s second assessment—meaning the person had no ability to
deal with work stress or the public and a poor ability to relate to coworkers, use
judgment, interact with supervisors, and maintain attention or concentration. The
vocational expert again responded that there was no work such a person could
perform.
B. The ALJ’s Decision
In a written decision, the ALJ applied the five-step sequential evaluation
process and determined that Castro was not disabled. At the first step, the ALJ
found that she had not engaged in substantial gainful activity since the alleged
onset-of-disability date. At the second step, the ALJ concluded that she had severe
impairments, including depression, obsessive-compulsive disorder, and anxiety.
At the third step, the ALJ found that Castro had no impairment or combination of
impairments that met or medically equaled the severity of a listed impairment.
12
Case: 18-14455 Date Filed: 08/29/2019 Page: 13 of 24
At step four, the ALJ assessed Castro’s residual functional capacity, finding
that she could perform sedentary work subject to certain limitations. In relevant
part, the ALJ found that she was limited to performing simple, routine, and
repetitive tasks that were not at a production-rate pace; was limited to having
occasional interaction with supervisors and coworkers; and was precluded from
any interaction with the general public.
In reaching this conclusion, the ALJ gave great weight to a portion of
Hassan’s opinions and less weight to the rest. From the first assessment, the ALJ
gave great weight to Hassan’s opinions that Castro had a poor ability to deal with
the public but a fair ability to relate to coworkers, interact with supervisors, follow
work rules, and use judgment. Great weight also was given to Hassan’s opinions
that she had a fair ability to understand, remember, and carry out simple
instructions and a poor ability to understand, remember, and carry out detailed or
complex instructions. The ALJ explained that these portions of Hassan’s opinions
were consistent with his treatment notes and the medical record as a whole.
The ALJ gave less weight to Hassan’s other opinions in the first assessment,
including the opinions that Castro had no ability to function independently or
maintain attention or concentration. In particular, the ALJ found that these
opinions were inconsistent with Castro’s statements that she was able to cook,
clean, go to church, and leave her home unaccompanied as well as Hassan’s
13
Case: 18-14455 Date Filed: 08/29/2019 Page: 14 of 24
treatment records where he noted that she had fair judgment, insight, thought
process, and thought content. 6
With respect to Hassan’s second assessment, the ALJ again gave great
weight to some of Hassan’s opinions and partial weight to the remaining opinions.
The opinions to which the ALJ gave great weight included that: Castro had no
ability to deal with the public; a poor ability to relate to coworkers and interact
with supervisors; a fair ability to function independently; a fair ability to
understand, remember, and carry out simple instructions; and a poor ability to
understand, remember, and carry out complex instructions.
But the ALJ gave the remainder of Hassan’s opinions only partial weight,
finding that they were inconsistent with the objective medical record and the
record as a whole. In particular, according to the ALJ, these opinions were
inconsistent with treatment notes from Hassan and the hospital admission records,
which indicated that Castro had good judgment, comprehension, insight, thought
process, and thought content and that her condition improved during treatment.
6
The ALJ stated that Hassan opined that Castro had no ability to maintain attention or
concentration. But the ALJ’s characterization of Hassan’s opinion was inaccurate. In the first
assessment, Hassan opined that she had a “poor” ability to maintain attention or concentration,
meaning her ability to function in this area was “seriously limited but not precluded.” Doc. 13 at
554. The ALJ offered no explanation as to how this opinion was inconsistent with Castro’s
statements that she occasionally could cook, clean, go to church, or leave her home
unaccompanied.
14
Case: 18-14455 Date Filed: 08/29/2019 Page: 15 of 24
The ALJ next addressed the opinions from Hamlin and Bell, the state agency
consultants, generally giving them great weight.7 The ALJ found that these
opinions were consistent with the objective medical evidence and Castro’s
statements about her abilities.
The ALJ also discussed Castro’s GAF scores. After acknowledging that a
GAF score can offer some evidence regarding the severity of a claimant’s mental
impairment, the ALJ gave little weight to Castro’s GAF scores, explaining that
each score was a mere snapshot of her ability to function at the particular time of
the assessment and did not include a function-by-function assessment of her ability
to perform specific work-related activities.
Based on Castro’s residual functional capacity, the ALJ found that she was
unable to perform her past relevant work. At step five, the ALJ determined that
given Castro’s age, education, work experience, and residual functional capacity,
there were jobs that existed in significant numbers in the national economy that she
could perform, including table worker, final assembler, and semi-conductor
bonder. The ALJ thus determined that she was not disabled.8
7
The ALJ did not give great weight, however, to Hamlin’s opinion that Castro was
capable of following multi-step instructions.
8
Castro requested that the Appeals Council review the ALJ’s decision, but the Appeals
Council denied her request for review.
15
Case: 18-14455 Date Filed: 08/29/2019 Page: 16 of 24
C. District Court Proceedings
Castro then filed an action in federal district court asking the court to reverse
the Commissioner’s decision. The magistrate judge issued a report and
recommendation that the district court affirm the Commissioner’s decision. Castro
objected. The district court overruled the objection, adopted the report and
recommendation, and affirmed the ALJ’s decision. This is Castro’s appeal.
II. STANDARD OF REVIEW
When, as here, an ALJ denies benefits and the Appeals Council denies
review, we review the ALJ’s decision as the Commissioner’s final decision. See
Doughty v. Apfel, 245 F.3d 1274, 1278 (11th Cir. 2001). We review the
Commissioner’s decision to determine whether it is supported by substantial
evidence, but we review de novo the legal principles upon which the decision is
based. Moore v. Barnhart, 405 F.3d 1208, 1211 (11th Cir. 2005). “Even if we
find that the evidence preponderates against the [Commissioner’s] decision, we
must affirm if the decision is supported by substantial evidence.” Barnes v.
Sullivan, 932 F.2d 1356, 1358 (11th Cir. 1991). Substantial evidence refers to
“such relevant evidence as a reasonable person would accept as adequate to
support a conclusion.” Moore, 405 F.3d at 1211. Our limited review precludes us
from “deciding the facts anew, making credibility determinations, or re-weighing
the evidence.” Id.
16
Case: 18-14455 Date Filed: 08/29/2019 Page: 17 of 24
III. LEGAL ANALYSIS
A disabled individual may be eligible for disability insurance benefits and
social security income benefits. 42 U.S.C. §§ 423(a)(1), 1382(a)(1)-(2). To
determine whether a claimant is “disabled,” an ALJ applies the five-step sequential
evaluation process to determine whether the claimant: (1) is engaging in
substantial gainful activity; (2) has a severe and medically determinable
impairment or combination of impairments; (3) has an impairment or combination
of impairments that satisfies the criteria of a “listing”; (4) can perform her past
relevant work in light of her residual functional capacity; and (5) can adjust to
other work in light of her residual functional capacity, age, education, and work
experience. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).
In this case we are concerned with step four of this analysis, particularly
whether substantial evidence supports the ALJ’s assessment of Castro’s residual
functional capacity. In assessing a claimant’s residual functional capacity, an ALJ
must consider all relevant medical and other evidence. See Phillips v. Barnhart,
357 F.3d 1232, 1238 (11th Cir. 2004). “[T]he ALJ must state with particularity the
weight given to different medical opinions and the reasons therefor.” Winschel v.
Comm’r of Soc. Sec., 631 F.3d 1176, 1179 (11th Cir. 2011).
An ALJ considers many factors when weighing medical opinion evidence,
including the examining and treatment relationships between the claimant and the
17
Case: 18-14455 Date Filed: 08/29/2019 Page: 18 of 24
treating source, whether the treating source’s opinion is well-supported, and
whether it is consistent with the record. 20 C.F.R. §§ 404.1527(c); 416.927(c). In
general, an ALJ must give the medical opinions of a treating source “substantial or
considerable weight unless good cause is shown to the contrary.” Lewis v.
Callahan, 125 F.3d 1436, 1440 (11th Cir. 1997) (internal quotation marks
omitted). We have found that good cause existed when the opinion was not
bolstered by the evidence, the evidence supported a contrary finding, or the
opinion was conclusory or inconsistent with the doctor’s own medical records. Id.
Here, Hassan, Castro’s treating psychiatrist, prepared two assessment reports
evaluating Castro’s limitations. Although the ALJ assigned great weight to some
of Hassan’s opinions, the ALJ found that there was good cause to give less weight
to the remainder of his opinions—including that Castro had no useful ability to
demonstrate reliability or deal with work stress and a poor ability to use judgment,
behave in an emotionally stable manner, and relate predictably in social
situations—because they were inconsistent with the record as a whole, including
her medical records. In particular, the ALJ found that Castro’s medical records
contradicted these opinions in three ways: (1) Hassan’s treatment notes said that
Castro had good judgment, insight, thought process, and thought content; (2)
Hassan’s treatment notes said that Castro’s condition had improved; and (3) the
assessment from Castro’s hospital admission showed that she had good judgment
18
Case: 18-14455 Date Filed: 08/29/2019 Page: 19 of 24
and comprehension. Substantial evidence does not support any of these findings
because, with respect to each purported inconsistency, a reasonable person would
conclude that the record evidence was inadequate to establish a contradiction.
First, substantial evidence does not support the ALJ’s conclusion that
Hassan’s opinions were inconsistent with his treatment notes stating that Castro
had good judgment, insight, thought process, and thought content. No reasonable
person would accept the conclusion that the observations in the treatment notes
contradicted Hassan’s opinions. Hassan’s treatment notes reflected his
observations of Castro during treatment appointments in a medical environment.
But in the assessments Hassan opined about Castro’s abilities “to do work-related
activities on a day-to-day basis in a regular work setting.” Doc. 13 at 554. As
other courts have recognized, “the work environment is completely different from
home or a mental health clinic.” Morales v. Apfel, 225 F.3d 310, 319 (3d Cir.
2000). Without more, we cannot say that Hassan’s observations of Castro’s
judgment, insight, thought process, and thought content in a treatment environment
absent work stressors were inconsistent with his assessments about the limitations
she would face in a day-to-day work environment.
In response, the Commissioner argues that our precedent clearly permits an
ALJ to look to whether a medical source’s treatment notes are consistent with his
opinions. We agree with the Commissioner that good cause to give less weight to
19
Case: 18-14455 Date Filed: 08/29/2019 Page: 20 of 24
a treating source’s opinions exists when the source’s opinions are “inconsistent
with [the source’s] own medical records.” Lewis, 125 F.3d at 1440. The problem
for the Commissioner here is that substantial evidence does not support the ALJ’s
conclusion that there was an inconsistency. Because the ALJ failed to identify any
inconsistency, we cannot say that substantial evidence supports the ALJ’s decision
to give less weight to Hassan’s opinions. See id. at 1440-41 (concluding that
substantial evidence did not support the ALJ’s decision to give less weight to
opinions of treating physicians when the ALJ had failed to identify medical
evidence that was inconsistent with the treating physicians’ opinions).
Second, substantial evidence also did not support the ALJ’s conclusion that
Hassan’s opinions that Castro continued to experience limitations were
inconsistent with his treatment notes stating that her condition had improved. The
ALJ’s position rests on the premise that a treatment note stating that a patient’s
condition improved amounts to an opinion that the patient is experiencing no
limitations. But we have held that a provider’s treatment note stating that a
patient’s condition has improved is not necessarily inconsistent with an opinion
that the patient continues to experience limitations. See Sharfarz v. Brown, 825
F.2d 278, 280 (11th Cir. 1987).
In Sharfarz, a treating physician opined that a patient was totally incapable
of employment because he suffered from osteoarthritis with pain and limited
20
Case: 18-14455 Date Filed: 08/29/2019 Page: 21 of 24
motion. Id. The ALJ gave this opinion little weight, finding that it was
inconsistent with a treatment note from the same physician stating that the patient
was “‘significantly better.’” Id. We held that this note did not provide a “sound
basis” for the ALJ to reject the physician’s opinion that the patient was unable to
work. Id. We explained that the statement about the patient’s improvement
needed to be viewed in context of the entire record, which included a treatment
note from the previous appointment stating that the patient had complained of
exacerbating pain and was unable to walk unless assisted by another person. Id.
Given this context, we concluded that there was no contradiction between a
treatment note stating that the patient was doing “significantly better” and the
physician’s ultimate opinion that the patient was unable to work. Id.
Although Sharfarz involved a provider’s assessment of a patient’s physical
condition, the analysis applies with equal force when a provider opines about a
patient’s limitations due to a mental health condition. After all, a provider’s
treatment note that a patient improved after receiving psychological treatment or
medication may not necessarily contradict an opinion that the patient continued to
face limitations because “[t]here can be a great distance between a patient who
responds to treatment and one who is able to enter the work force.” Scott v. Astrue,
647 F.3d 734, 739 (7th Cir. 2011). When the medical evidence shows that a
patient’s condition fluctuated, “any single notation that a patient is feeling better or
21
Case: 18-14455 Date Filed: 08/29/2019 Page: 22 of 24
has had a ‘good day’ does not imply that the condition has been treated.” Id. at
740; see also Holohan v. Massanari, 246 F.3d 1195, 1205 (9th Cir. 2001) (“That a
person who suffers from severe panic attacks, anxiety, and depression makes some
improvement does not mean that the person’s impairments no longer seriously
affect her ability to function in a workplace.”).
We cannot say that substantial evidence supports the ALJ’s conclusion that
the treatment notes stating that Castro had improved contradicted Hassan’s opinion
that she continued to experience limitations. Viewed as a whole, the objective
medical evidence showed that Castro’s condition fluctuated. For example, at one
appointment, she reported worsening depression, and Hassan noted that her levels
of anxiety and depression had increased. At her next appointment, Castro reported
that she was still nervous, anxious, and depressed. But Hassan also wrote in his
treatment notes that she had significantly improved as compared to her previous
appointment. No reasonable person would accept Hassan’s statement noting
significant improvement as adequate to support a determination that her depression
and anxiety had been treated or that she no longer faced limitations. Indeed, just a
few months later, Hassan noted that Castro’s depression had worsened again and
that her activities of daily living had declined. Given these fluctuations, substantial
evidence does not support the ALJ’s conclusion that Hassan’s notes stating that
22
Case: 18-14455 Date Filed: 08/29/2019 Page: 23 of 24
Castro had improved were inconsistent with his opinions that she continued to
experience limitations due to her depression and anxiety.
Third, substantial evidence does not support the ALJ’s conclusion that
Hassan’s opinions were inconsistent with records from the hospital where Castro
was admitted with complaints of suicidal ideation. The ALJ found that Hassan’s
opinion that Castro had a poor ability to use judgment was contradicted by hospital
records indicating that she had good judgment and comprehension.
A closer look at the hospital records shows no inconsistency. The hospital
physician determined that Castro had good judgment and comprehension because
she was able to explain why people say hello to a cashier at a store. Viewed in
context, the physician was offering an opinion about Castro’s ability to exercise
judgment or comprehension to determine whether, after reporting suicidal ideation,
she should be admitted to the hospital or released. No reasonable person would
accept this assessment as adequate to support a conclusion that Castro would
exercise good judgment or comprehension in a work environment. Given this
context, we find substantial evidence does not support the ALJ’s conclusion that
the hospital physician’s notes contradicted Hassan’s opinion that in a work
environment she would have a poor ability to use judgment. See Lewis, 125 F.3d
at 1441.
23
Case: 18-14455 Date Filed: 08/29/2019 Page: 24 of 24
Because Hassan was a treating provider, the ALJ was required to give his
opinions great weight unless good cause existed. Although the ALJ found good
cause based on contradictions between Hassan’s opinions and the medical
evidence, the ALJ’s findings are not supported by substantial evidence. Because
the ALJ erred in assigning these opinions less than great weight, the case must be
remanded for the Commissioner to assess the weight to be given to Hassan’s
opinions.9
IV. CONCLUSION
For the reasons stated above, we reverse the judgment of the district court
and remand with instructions to remand to the Commissioner.
REVERSED AND REMANDED.
9
The ALJ identified a second reason for giving less than great weight to one aspect of
Hassan’s opinion in his first assessment—that Castro had no ability to function independently—
finding that this opinion was contradicted by Castro’s statements about the activities that she
could perform. On appeal, Castro argues that substantial evidence also did not support this
determination. Because we conclude that the ALJ erred in its finding that good cause existed to
give less weight to Hassan’s opinions, including this one, on the basis that they were
contradicted by medical evidence, we do not reach this issue.
Castro also argues on appeal that the ALJ erred in assigning greater weight to the
opinions from the two state agency consultants. Because the case must be remanded to the ALJ,
we do not reach this issue.
24