“Supportability & Consistency Reign Supreme”
The Fourth Circuit’s Definitive Guidepost for Evaluating Mental-Health Evidence after the 2017 SSA Rule

1. Introduction

Dawn M. Drumgold, a former Social Security Administration employee living with long-standing mental-health disorders, sought disability benefits for the second time in 2020. Her case generated an administrative record typical of modern Social Security litigation: multiple—and conflicting—opinions from a primary-care physician, a treating mental-health counselor, an agency-retained psychological examiner, and two non-examining state consultants. The Administrative Law Judge (“ALJ”) credited the latter two opinions, denied benefits, and was affirmed by the district court. On 18 July 2025, the United States Court of Appeals for the Fourth Circuit affirmed in a published opinion authored by Judge Richardson and joined by Judge Wilkinson; Judge Gregory dissented.

Although the case superficially turns on the weight assigned to one counselor’s checkbox forms, it unmistakably sets a new precedent: under the post-2017 Social Security regulations, “supportability” and “consistency” now dominate the ALJ’s persuasiveness analysis to such an extent that conclusory mental-health submissions—especially those lacking treatment notes—will rarely survive substantial-evidence review, even if the source is long-term and specialized.

2. Summary of the Judgment

The Fourth Circuit held that substantial evidence supported the ALJ’s decision to:

• Find treating counselor Shideh Sarmadi’s opinions “only partially persuasive” because they lacked objective support and conflicted with the record.
• Credit the two state-agency psychological consultants whose assessments were documented and consistent with other evidence.
• Conclude that Drumgold retained a residual functional capacity for certain low-stress, low-interaction work and therefore was not disabled.

Central to the holding is the court’s endorsement of the ALJ’s methodological sequence: identify each “medical source,” apply the supportability and consistency factors required by 20 C.F.R. §404.1520c(b)(2), provide a brief rationale, and move on. The majority rejected arguments that a “special report” from a mental-health professional automatically satisfies supportability, or that an ALJ must overlook conflicts simply because psychotherapy notes are withheld for privacy reasons.

3. Detailed Analysis

3.1 Precedents Cited and Their Influence

• Biestek v. Berryhill, 587 U.S. 97 (2019) – Established the “more-than-a-scintilla” substantial-evidence threshold. The panel invoked Biestek to illustrate how modest records can still justify an ALJ’s conclusion.
• Dowling v. Commissioner, 986 F.3d 377 (4th Cir. 2021) – Re-affirmed that appellate courts review both legal standards and substantial evidence. Dowling’s framework anchors the standard of review applied here.
• Arakas v. Commissioner, 983 F.3d 83 (4th Cir. 2020) – Warned against re-weighing evidence. The majority quotes Arakas to limit the court’s re-evaluation of conflicting opinions.
• Oakes v. Kijakazi, 70 F.4th 207 (4th Cir. 2023) & Shelley C. v. Commissioner, 61 F.4th 341 (4th Cir. 2023) – Both recent cases addressed ALJ duties under the new regulations, particularly misuse of daily activities and “conservative treatment” language. The court distinguishes Oakes and Shelley C. to show that the ALJ here appropriately used daily-activity evidence and accurately characterized treatment.
• Patterson v. Commissioner, 846 F.3d 656 (4th Cir. 2017); Radford v. Colvin, 734 F.3d 288 (4th Cir. 2013) – Supply the “logical bridge” requirement for agency reasoning. The majority asserts that the ALJ built such a bridge by citing specific contradictory records.

3.2 The Court’s Legal Reasoning Step-by-Step

1. Identify governing regulation. Because Drumgold filed post-March 2017, the case is governed by 20 C.F.R. §404.1520c (no “treating-physician rule,” five persuasiveness factors, but only supportability and consistency require articulation).
2. Apply supportability. The ALJ found Sarmadi offered no treatment notes, data, or narrative explanation—only checkbox forms. Under §404.1520c(c)(1) this lack of objective medical evidence rendered her opinions weak.
3. Apply consistency. The ALJ compared Sarmadi’s assessment to:
   • Dr. Luther’s routine primary-care notes (mostly “depression in remission”).
   • Dr. McCleary’s mixed findings (normal affect, orientation, average concentration).
   • Drs. Montgomery & McClain’s non-examining reviews (moderate limitations).
   Observing stark contrast, the ALJ deemed the counselor’s “marked” limitations inconsistent with the bulk of the record.
4. Address counterarguments. The court dismissed claims that HIPAA prevented disclosure: regulations allow redacted notes or detailed summaries, and the claimant bears the burden to produce evidence.
5. Substantial-evidence confirmation. Citing Biestek, the court reiterated that “reasonable mind might accept” evidence as adequate; the ALJ’s citations to examination reports, daily activities, and doctor notes meet that standard.

3.3 Impact on Future Litigation & Social-Security Practice

• Treating Counselors and Psychologists: The opinion signals that short, conclusory “to whom it may concern” letters—or checkbox MSS forms—without progress notes will routinely receive little weight. Mental-health providers should expect ALJs to discount them unless accompanied by objective testing, session summaries, or specific functional examples.
• Claimant Representatives: Counsel must proactively secure detailed narratives or redacted notes compliant with HIPAA to satisfy the supportability factor. Simply labeling a letter a “special report” is insufficient.
• Administrative Law Judges: Drumgold authorizes succinct persuasiveness discussions. An ALJ who methodically references items showing inconsistency or lack of support will be upheld—even if the discussion spans only a paragraph—so long as a “logical bridge” is discernible.
• Appellate Review Scope: The decision tightens the boundary between harmless error and reversible error. The majority emphasizes deference whenever the ALJ mentions conflicting evidence and cites logical reasons, limiting remands for more detailed analysis.
• Conservative Treatment Language: While Shelley C. critiqued the generic label “conservative,” Drumgold clarifies that the term remains permissible if the ALJ links it to record evidence (e.g., routine therapy + standard antidepressants) and does not exaggerate its significance.

4. Complex Concepts Simplified

a. Residual Functional Capacity (“RFC”)

Think of RFC as a personal “work-ability score card.” It measures what tasks you can still do—mentally and physically—eight hours a day, five days a week, despite your medical conditions.

b. Supportability vs. Consistency

• Supportability = “Show Your Work.” Did the doctor attach lab results, therapy notes, cognitive tests, or explain the reasoning? The more data, the stronger the support.
• Consistency = “Everyone Else Says So Too.” Are the doctor’s conclusions in line with other doctors, imaging, daily-life evidence, and objective findings? If alone in the corner, the opinion loses persuasive power.

c. Substantial Evidence

Less than “preponderance,” more than “a speck.” If a reasonable person could agree with the ALJ based on the cited material, the finding stands—even if another reasonable person might disagree.

d. “Special Report” (Psychotherapy Exception)

To protect patient privacy, mental-health professionals may submit a narrative summary instead of raw notes. However, the report must still describe observations, treatment course, and functional effects; a mere checklist or diagnosis is not enough.

5. Conclusion

Drumgold cements the primacy of supportability and consistency in the Fourth Circuit’s application of the 2017 Social Security regulations, especially in the arena of mental-health evidence. The decision:

• Demonstrates how ALJs can lawfully discount richly-tenured but thinly-documented treating-source opinions.
• Reassures agency adjudicators that concise explanations—if logically tethered to record citations—will survive appellate scrutiny.
• Warns practitioners that “checkbox” evaluations and privacy-shielded notes must be supplemented with concrete, objective information.

Going forward, litigants should treat supportability as the linchpin: no matter how experienced or specialized the source, their opinion must be backed by discernible testing, observation, and longitudinal detail, and must fit coherently with the overall evidentiary mosaic.