                      United States Court of Appeals
                           FOR THE EIGHTH CIRCUIT
                                   ___________

                                   No. 06-3448
                                   ___________

Donna Sloan,                             *
                                         *
             Plaintiff - Appellant,      *
                                         * Appeal from the United States
      v.                                 * District Court for the Southern
                                         * District of Iowa.
Michael J. Astrue, Commissioner          *
of Social Security,                      *
                                         *
             Defendant - Appellee.       *
                                    ___________

                             Submitted: May 14, 2007
                                Filed: August 22, 2007
                                 ___________

Before BYE and SMITH, Circuit Judges, and NANGLE,1 District Judge.
                               ___________

BYE, Circuit Judge.

       Donna Sloan appeals the district court’s judgment affirming the decision of the
Commissioner of the Social Security Administration (SSA) denying her application
for disability insurance benefits under Title II of the Social Security Act. See 42
U.S.C. § 1383(c)(3). A new SSA ruling clarifies the extent to which the agency
should consider medical opinions from sources other than those deemed “acceptable



      1
        The Honorable John F. Nangle, United States District Judge for the Eastern
District of Missouri, sitting by designation.
medical sources.” The SSA must determine whether the new ruling affects its
decision in this case. We reverse and remand.

                                             I

       Sloan first applied for benefits in December 2001 claiming total disability as
a result of depression, anxiety disorders, back pain and migraine headaches. She is
a high-school graduate with four semesters of college. Her work history includes
having been a data-entry clerk, a secretary, a file clerk, a store clerk, and a paratransit
driver. She reports to have struggled with anxiety and depression since childhood,
with a nervous breakdown at age sixteen. She last worked on November 18, 2001,
when she was fired by her temporary service agency for absenteeism.

       Sloan suffered a panic attack on October 3, 2001, which sent her to a hospital
emergency room complaining of chest pain and numbness. She had taken
nitroglycerin, which had not helped. A doctor diagnosed “possible unstable angina”
with a secondary diagnosis that included “anxiety with depression” and prescribed
Effexor and Xanax. She returned to the emergency room the next day after suffering
an adverse reaction to her new medications.

      On October 5, Sloan visited her primary-care physician, Ben Gaumer, D.O., an
osteopath, complaining of numbness in her arms and chest, “problems thinking,” and
being “shaky.” Dr. Gaumer diagnosed anxiety and depression. Over the next few
months, Dr. Gaumer adjusted her medications, which included Vistaril (anti-anxiety),
Tranxene (same), and Premarin (menopausal symptoms). Though Sloan had ups and
downs, Dr. Gaumer noted several times she was “happy” and her judgment, insight
and memory were normal. Dr. Gaumer told her during this period her working days
were over. He recommended she apply for disability.




                                           -2-
      In August 2003, Dr. Gaumer filled out the physician’s certification section of
a form Sloan was filing to seek forgiveness of her student loans. He wrote, “Severe
Depression – In my opinion Ms. Sloan is totally disabled from this condition and I
have no hope of recovery – this will persist the rest of her life.”

       In May 2003, Dr. Gaumer wrote, “Cont current meds / Overall, I see definite
improvement but not well!!” His last examination of Sloan was September 26, 2003,
when he described her as sad and anxious and suffering from depression and anxiety,
along with nightmares and diarrhea.2 Dr. Gaumer declined to give a diagnosis of
Sloan’s mental condition for the Social Security proceedings as he is not a mental-
health specialist.

      At the request of the Disability Determination Service (DDS), Sloan visited
Greg Cohen, D.O., in February 2002 for a disability examination which focused
primarily on her physical symptoms. Dr. Cohen found Sloan did have “significant
migraines from time to time”; she did not have “any significant problems in terms of
a back injury or back related problems”; and “any disability that she has is probably
more related to psychiatric problems if at all and neurological problems and I believe
those probably would benefit from continued workup.”

      In March 2002, also at the request of DDS, Sloan underwent a psychological
evaluation by Jennifer Mac Connell, M.A., a psychologist, and Richard A. Martin,
Ph.D., a licensed psychologist.3 In their report, Mac Connell and Dr. Martin




      2
       The record elsewhere indicates these are side effects of her medications.
      3
       Sloan notes Mac Connell and Dr. Martin’s report described their work as a
“brief mental status examination” and a “brief interview,” though a review of the
document also shows they called it a “standard mental status examination.” They do
not indicate they thought the examination was inadequate to reach their conclusions.

                                         -3-
concluded Sloan had the cognitive capabilities required to perform unskilled work,
and her judgment was intact:

      Given her social and vocational history, she will not likely experience
      significant problems in her relationships with co-workers, supervisors,
      or the public. However, her memory, attention, and concentration
      abilities may vary somewhat as a function of her overall emotional
      condition. In summary, Ms. Sloan appears to have the intellectual
      abilities to handle a number of unskilled vocational options.

(emphases added). They rated her global assessment of functions (GAF) as having
been 65 (mild impairment) for the prior year, and dropping to 57 (moderate
impairment) at the time she was tested. Though Mac Connell and Dr. Martin made
reference to Sloan’s emotional condition, they did not comment on how they thought
it bore on her ability to perform any sort of work.

       A psychologist, Laura Mutchler, Ph.D., examined Sloan in October 2002. Dr.
Gaumer had suggested seeing a psychiatrist, but she could not pay the costs out of
pocket, and was instead referred to Dr. Mutchler, who assigned Sloan a GAF of 50
(serious impairment). She noted Sloan was struggling with her decision to apply for
disability benefits. She recommended individual therapy for Sloan and an assessment
of her medications. Dr. Muchtler’s report was also signed by a psychiatrist.

       In accordance with Dr. Mutchler’s advice, Sloan began seeing Charlotte Kraai,
a licensed mental health social worker, in November 2002. They met for a total of ten
sessions over the next seven months. In a February 2003 report, Kraai described
Sloan as “debilitated” and assessed her as having a GAF of 45-50. She wrote:

      Little has changed in the time she has been coming to therapy. If she
      continues to attend therapy and take prescribed medications prescribed
      appropriately by her physician, she can make some improvement through
      continuing to challenge irrational beliefs and continue teaching her

                                         -4-
      coping skills with probably very slow progress based on her initial
      response to therapy.

       Kraai’s analysis of Sloan’s current condition was: restriction of daily living
activities, “severely impaired” social functioning, and deficiency of concentration.
Kraai predicted “decompensation in work or worklike settings. High likelihood as
much of stress that contributed to current mental distress is workplace related.” She
rated Sloan’s work-related mental ability to remember and understand instructions,
procedures and locations as “difficult or impossible for her.” She opined that Sloan
“would probably have difficulty relating to authority figures and co-workers as [she]
easily feels threatened and/or pressured and could quickly [become] overwhelmed and
rapidly decompensate.” Kraai’s analysis was co-signed by a psychiatrist, Kent Kunze,
M.D., who wrote next to his signature, “reviewed but not evaluated by me.”

      Patti Campidilli, a licensed clinical social worker, had counseled Sloan earlier,
from November 1995 to February 1998, and from July 1999 until October 2001. In
May 2003, Sloan decided to return to her after being dissatisfied with the counseling
she received from Kraai (and finding Campidilli would charge her a lower fee as a
former patient). They met monthly from June to December 2003. Campidilli noted
at the outset in June 2003 that Sloan “had a difficult time making decisions,
concentrating, and remembering information regarding dates and times.” In a January
2004 report, Campidilli wrote:

      I believe Donna would have a very difficult time working at an
      acceptable pace for any employer. She tends to tire easily and has very
      little energy to perform tasks. Her inability to concentrate or focus
      would also make it difficult for her to work for someone. Donna tends
      to worry, almost obsessively[,] about what others are thinking of her and
      her performance. This kind of worry would be a hindrance to her job.
      I believe she would continue to be quite nervous and would, therefore,
      have a hard time completing her job duties with confidence and
      accuracy.” Campidilli also noted she did not think Sloan was seeing her

                                         -5-
      doctor as often as she should “because she is completely responsible for
      those expenses.

      She concluded, “I believe Donna will never be able to work full time again. At
the present time the limitations of her depression combined with her physical
condition would make it quite difficult for her to work at any job for any consistent
amount of time.”4

      On January 28, 2002, Sloan completed a Daily Activities Questionnaire, in
which she reported she regularly did laundry, cleaned dishes, changed sheets,
vacuumed, took out the trash, and washed her car; she occasionally cooked; that she
enjoyed reading, listening to the radio, “doing some family history work on [her]
computer,” and watching movies and television shows; and she lived with her
82-year-old mother, whom she took grocery shopping once weekly. She also reported
going to the drive-through bank, the beauty shop, her doctors’ offices, and the
pharmacy. Overall, she reported as to her ability to drive an automobile, “as
necessary, several times a week.”

       On the other hand, Sloan reported in the same document she no longer
performed any chores outside her house. Her only trips to the grocery store, always
with her mother, were early in the morning – and short, as “being around a lot of
people really bothers me.” She reported having “a lot” of difficulty going out in
public. She also reported as to not participating in any type of group activities and
had to give up being her church’s organist because her nervousness was so severe she
could not get her fingers to play right. “I was really having a time of it.” She reported
her medication was helping with panic attacks, but she did not say it was helping with
“her anxiety” overall, as the Commissioner asserted.


      4
       The government makes a point of stating that Campidilli diagnosed Sloan with
merely “moderate depression,” failing to add she ended the sentence, “moderate only
because she denied suicidal or homicidal thoughts or attempts.”

                                          -6-
      At a January 2005 hearing, an ALJ heard testimony from Sloan and a vocational
expert (VE), Patricia Reilly. The ALJ asked for evidence from her attending
psychiatrist. Sloan’s lawyer replied she had never seen a psychiatrist because of her
having to pay for her medical care out of pocket and could not afford one. Her lawyer
explained she usually saw counselors instead.

      The ALJ noted the evidence from the DDS psychologists and said:

      So I don’t have any other opinions, I guess, from, well, I have the
      counseling opinion, from the social worker, but as I said, we don’t get
      real excited about social workers just because it’s sort of a pecking order
      of authority, and usually in a mental case a person is seen by a
      psychiatrist, but you’re saying today she has never been evaluated by a
      psychiatrist?

Legal counsel agreed, and reiterated Sloan could not afford such care.

       The ALJ asked the VE to assume a hypothetical claimant who could perform
sedentary to medium work, but who had moderate limitations in carrying out detailed
work, maintaining attention and concentration for extended periods of time,
performing activities within a fixed schedule, completing a normal workday without
interruption from psychologically based symptoms, responding to changes in the work
place, and setting realistic goals. Reilly testified such a claimant could not perform
Sloan’s past work, but could perform a variety of sedentary-to-medium-effort
unskilled jobs, such as cashier, interviewer, administrative support worker,
bookkeeper, and messenger. But when asked, “If [Sloan’s] testimony is to be
considered credible, the variety of symptoms that she had endorses [sic] today, do you
feel that she could do the unskilled work that you’ve identified?” Reilly replied, “No.
She mentioned several things that would preclude her from full-time employment.
One of the largest barriers it looked like is the amount of sleep that she requires.”



                                         -7-
      The ALJ concluded the objective medical evidence did not support the severity
of Sloan’s alleged symptoms. Reasons cited were:

      •     While Sloan went to the hospital for a severe panic attack on
            October 3, 2001, nothing in the record showed she ever had
            another attack severe enough to send her to the emergency room.

      •     Dr. Gaumer’s notes provide no evidence to support his opinion
            that Sloan is disabled, because (a) he had only treated her for six
            months before filling out the form giving his opinion that she was
            sufficiently disabled that she should be released from her student-
            loan obligations,5 and (b) his notes reflect she was improving. Dr.
            Gaumer’s opinion of Sloan as disabled was given in a loan-
            forgiveness application context, with unknown criteria.

      •     “Likewise,” the ALJ wrote, “a few intermittent visits to two
            different social workers do not establish a foundation for behavior
            modification to address anxiety successfully.” He noted the social
            workers were not recognized as sources that could give evidence
            to prove a medically determinable impairment.

      •     “The undersigned gives little weight to the opinions expressed by
            these two social workers,” Kraai and Campidilli, the ALJ wrote.
            “The dates of visits to social workers were intermittent and do not
            reflect any commitment to long term therapy which would be
            beneficial in dealing with treatment of mental impairment. One
            of the social workers suggested claimant attend group therapy but
            claimant did not do so . . . . The undersigned does take note that
            a psychiatrist also signed the report provided by Ms. Kraai.
            However, it is also noted that the psychiatrist also wrote that he
            reviewed the report but did not evaluate the claimant.”




      5
      This is incorrect. Dr. Gaumer had been treating Sloan for nearly two years –
from October 2001 to August 2003 – when he filled out the form.

                                        -8-
      •     “When compared to the evaluation done by DDS psychologists
            [Mac Connell and Dr. Martin] . . . more weight should be given to
            the DDS mental health professionals as the entire record provides
            more support to their conclusions that the claimant has some
            moderate mental limitations in her ability to function.” The ALJ
            noted the psychologists found Sloan “possessed the cognitive
            capabilities required to work within a range of unskilled
            positions.”

      •     The ALJ made note of Sloan’s daily activities, and found, without
            further explanation, “These do not appear to be the activities of an
            individual with disabling anxiety.”

      •     Without finding any particular part of Sloan’s testimony to be
            false, the ALJ wrote, “In view of the preceding discussion, [I
            find] that the claimant’s testimony, insofar as it pertained to the
            inability to perform virtually any type of work activity on a
            sustained basis, was not credible.”

      •     The ALJ then noted the list of positions the vocational expert
            provided, and stated, “the vocational expert also testified that
            these jobs represent a larger field of jobs that the claimant could
            perform.”

       The ALJ denied Sloan’s disability claim, as did the SSA’s appeals council,
which made the ALJ’s decision the final decision of the Commissioner. The district
court affirmed the Commissioner’s decision.

                                         II

      On August 9, 2006, the SSA issued Social Security Ruling (SSR) 06-3p, 71
Fed. Reg. 45,593 (Aug. 9, 2006). The ruling clarified how it considers opinions from
sources who are not what the agency terms “acceptable medical sources.”




                                         -9-
     Social Security separates information sources into two main groups: acceptable
medical sources and other sources. It then divides other sources into two groups:
medical sources and non-medical sources. 20 C.F.R. §§ 404.1502, 416.902 (2007).

      Acceptable medical sources include licensed physicians (medical or osteopathic
doctors) and licensed or certified psychologists. 20 C.F.R. §§ 404.1513(a), 416.913(a)
(2007). According to Social Security regulations, there are three major distinctions
between acceptable medical sources and the others: (1) Only acceptable medical
sources can provide evidence to establish the existence of a medically determinable
impairment, id., (2) only acceptable medical sources can provide medical opinions,
20 C.F.R. §§ 404.1527(a)(2), 416.927(a)(2) (2007), and (3) only acceptable medical
sources can be considered treating sources, 20 C.F.R. §§ 404.1527(d) and 416.927(d)
(2007).

       Other sources: Medical sources include nurse practitioners, physician
assistants, licensed clinical social workers, naturopaths, chiropractors, audiologists,
and therapists. Non-medical sources include school teachers and counselors, public
and private social welfare agency personnel, rehabilitation counselors, spouses,
parents and other caregivers, siblings, other relatives, friends, neighbors, clergy, and
employers. 20 C.F.R. §§ 404.1513(d), 416.913(d) (2007).

       “Information from these ‘other sources’ cannot establish the existence of a
medically determinable impairment,” according to SSR 06-3p. “Instead, there must
be evidence from an ‘acceptable medical source’ for this purpose. However,
information from such ‘other sources’ may be based on special knowledge of the
individual and may provide insight into the severity of the impairment(s) and how it
affects the individual’s ability to function.”

      SSR 06-3p is a clarification of existing SSA policies. The SSA explained its
reasons for issuing the ruling:

                                         -10-
      With the growth of managed health care in recent years and the emphasis
      on containing medical costs, medical sources who are not “acceptable
      medical sources,” such as nurse practitioners, physician assistants, and
      licensed clinical social workers, have increasingly assumed a greater
      percentage of the treatment and evaluation functions previously handled
      primarily by physicians and psychologists. Opinions from these medical
      sources, who are not technically deemed “acceptable medical sources”
      under our rules, are important and should be evaluated on key issues
      such as impairment severity and functional effects, along with the other
      relevant evidence in the file.

     The ruling directs the SSA’s adjudicators to give weight to opinions from
medical sources who are not “acceptable medical sources”:

      Opinions from “other medical sources” may reflect the source’s
      judgment about some of the same issues addressed in medical opinions
      from “acceptable medical sources,” including symptoms, diagnosis and
      prognosis, what the individual can still do despite the impairment(s), and
      physical and mental restrictions . . . .

      [D]epending on the particular facts in a case, and after applying the
      factors for weighing opinion evidence, an opinion from a medical source
      who is not an “acceptable medical source” may outweigh the opinion of
      an “acceptable medical source,” including the medical opinion of a
      treating source. For example, it may be appropriate to give more weight
      to the opinion of a medical source who is not an “acceptable medical
      source” if he or she has seen the individual more often than the treating
      source and has provided better supporting evidence and a better
      explanation for his or her opinion.

      In general, according to the ruling, the factors for considering opinion evidence
include:

      •      How long the source has known and how frequently the source
             has seen the individual;


                                         -11-
      •      How consistent the opinion is with other evidence;

      •      The degree to which the source presents relevant evidence to
             support an opinion;

      •      How well the source explains the opinion;

      •      Whether the source has a specialty or area of expertise related to
             the individual’s impairment(s); and

      •      Any other factors that tend to support or refute the opinion.

                                         III

      We review de novo the district court’s decision upholding the Commissioner’s
denial of disability benefits. Bowman v. Barnhart, 310 F.3d 1080, 1083 (8th Cir.
2002).

       The SSA issued SSR 06-3p in August 2006, after the ALJ and the district court
had issued their decisions. “Generally, if an agency makes a policy change during the
pendency of a claimant’s appeal, the reviewing court should remand for the agency
to determine whether the new policy affects its prior decision.” Ingram v. Barnhart,
303 F.3d 890, 893 (8th Cir. 2002). Such a remand is appropriate in this case.6 Sloan
presented evidence from her health-care providers which could very well have led to
a different result had the ALJ assessed them in accordance with SSR 06-3p.




      6
       We note the SSA terms the ruling a clarification in how it should consider
opinions from sources who are not “acceptable medical sources.” We also note the
agency cited the ruling twice in its brief to this court in this case.

                                        -12-
                                          IV

        Sloan is a seriously ill person of very limited financial means who lacks the
ability to afford a psychiatrist, or even to see social workers more than once a month.
The ALJ summarily dismissed the records and recommendations from her health-care
professionals simply because they were too low on the pecking order as he understood
it to exist at the time of the hearing. The SSA must determine whether its new ruling
clarifying its assessment of opinions from sources other than those deemed
“acceptable medical sources” affects its prior decision in this matter. Accordingly, we
reverse and remand the judgment of the district court with instructions to remand to
the SSA for an administrative rehearing consistent with this opinion.
                           ______________________________




                                         -13-
