Citation Nr: 0905952 Decision Date: 02/18/09 Archive Date: 02/24/09 DOCKET NO. 02-17 947 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia THE ISSUE Entitlement to an initial rating in excess of 30 percent for major depressive disorder. REPRESENTATION Appellant represented by: Virginia Department of Veterans Services ATTORNEY FOR THE BOARD J. W. Kim, Counsel INTRODUCTION The Veteran had active military service with the Army National Guard from May 1964 to November 1964. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2001 rating decision in which the RO granted service connection and assigned an initial 10 percent rating for major depressive disorder, effective January 2, 1997. The Veteran filed a Notice of Disagreement (NOD) in March 2002, and the RO issued a Statement of the Case (SOC) in April 2002. The Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in October 2002. In November 2003, the Board remanded the matter on appeal to the RO, via the Appeals Management Center (AMC) in Washington, DC, for further development and readjudication. In March 2005, the RO assigned a higher initial rating of 30 percent for major depressive disorder, as well as assigned an earlier effective date for the grant of service connection and award of initial compensation of September 19, 1995. See March 2005 rating decision and Supplemental SOC (SSOC)). In September 2006, the Board again remanded the claim to the RO, via the AMC, for additional development. After completing the requested actions, the AMC continued the denial of the claim (as reflected in the June 2007 SSOC), and returned this matter to the Board for further appellate consideration. As the claim on appeal involves a request for higher initial rating following the grant of service connection, the Board has characterized the issue on appeal in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for disabilities already service- connected). Also, although the RO granted a higher initial rating for major depressive order, as higher ratings are available and a claimant is presumed to seek the maximum available benefit for a given disability, the claim for higher initial rating for major depressive disorder remains viable on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. 2. For the period from September 19, 1995 to November 6, 1996, the Veteran's major depressive disorder was manifested , primarily, by anxiety, distress, and increased depression over the loss of his job (with some relief and benefit from treatment and medication) along with agitation, sleep disturbance, memory difficulties, and difficulty performing tasks to the same capacity as earlier; overall, these symptoms are indicative of no more than definite impairment in the ability to establish or maintain effective and wholesome relationships with people. 2. For the period since November 7, 1996, the Veteran's major depressive disorder has been manifested, primarily, by depressed mood, anxiety, and chronic sleep impairment; overall, these symptoms are indicative of no more than occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal). CONCLUSION OF LAW The criteria for an initial rating in excess of 30 percent for major depressive disorder have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & West Supp 2008); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9434 (as in effect since November 7, 1996); 38 C.F.R. § 4.132, Diagnostic Code 9405 (as in effect prior to November 7, 1996). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2008)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA have been codified, as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2008). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353- 23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. In rating cases, a claimant must be provided with information pertaining to assignment of disability ratings (to include the rating criteria for all higher ratings for a disability), as well as information regarding the effective date that may be assigned. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id.; Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. In this appeal, an October 2006 post-rating letter provided notice to the Veteran regarding what information and evidence was needed to substantiate the claim for a higher rating, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. The letter specifically informed the Veteran to submit any evidence in his possession pertinent to the claim on appeal and provided the Veteran with information pertaining to the assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. After issuance of this letter, and opportunity for the Veteran to respond, the April and June 2007 SSOCs reflect readjudication of the claim. Hence, the Veteran is not shown to be prejudiced by the timing of the notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SOC or SSOC, is sufficient to cure a timing defect). The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter on appeal. Pertinent medical evidence associated with the claims file consists of post- service private medical records, as well VA outpatient treatment records, and reports of VA examinations. Also of record and considered in connection with the appeal are various written statements provided by the Veteran and by his representative, on his behalf. The Board also finds that no further RO action is needed prior to appellate consideration of the claim. Regarding the above, the Board notes that the September 2006 remand was primarily for the AMC to provide further notice and to consider the claim under the former and revised applicable criteria, as appropriate. After providing further notice, as discussed above, and associating additional evidence with the claims file, in an April 2007 SSOC, the AMC considered the claim under both former and revised criteria. Although the April 2007 SSOC was initially sent to an incorrect address and was returned as undeliverable, The record appears to indicate that the RO resent the SSOC to the Veteran's correct address in June 2007. Thus, it appears that the RO substantially complied with the September 2006 remand directives, and that no further action in this regard is warranted. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). The Board further notes that, even if the April 2007 SSOC was not, in fact, resent by the AMC,, given the general nature of the former criteria (as discussed below)and the limited time period affected by the former rating criteria (from the September 19, 1995 effective date of the grant of service connection through November 6, 1996), the Board finds that the Veteran is not shown to be prejudiced by such error. Moreover, as regards the additional evidence discussed in the April 2007 SSOC, upon review, the Board observes that this evidence is essentially cumulative of evidence already of record and discussed in the prior March 2005 SSOC. Under these circumstances, a remand to reissue the April 2007 SSOC -if it were, in fact, not resent-would impose unnecessary additional burdens on adjudication resources, with no benefit flowing to the veteran, and is, thus, unnecessary. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). In summary, the duties imposed by the VCAA have been considered and satisfied. Through various notices of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate this claim, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claim. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matter on appeal, at this juncture. See Mayfield, 20 Vet. App. at 543 (rejecting the argument that the Board lacks authority to consider harmless error and affirming that the provision of adequate notice followed by a readjudication "cures" any timing problem associated with inadequate notice or the lack of notice prior to an initial adjudication). See also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). II. Higher Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which provides for ratings based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is or primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, in Fenderson, the United States Court of Appeals for Veterans Claims noted an important distinction between an appeal involving a veteran's disagreement with the initial rating assigned at the time a disability is service connected. Where the question for consideration is the propriety of the initial rating assigned, evaluation of the medical evidence since the effective date of the grant of service connection and consideration of the appropriateness of "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson, 12 Vet. App. at 126. As addressed in more detail below, the criteria for rating psychiatric disorders were revised effective November 7, 1996. As there is no indication that the revised criteria are intended to have a retroactive effect, the Board has the duty to adjudicate the claim only under the former criteria for any period prior to the effective date of the new diagnostic codes, and to consider the revised criteria for the period beginning on the effective date of the new provisions. See Wanner v. Principi, 17 Vet. App. 4, 9 (2003); DeSouza v. Gober, 10 Vet. App. 461, 467 (1997). See also VAOPGCPREC 3-2000 (2000) and 7-2003 (2003). In addition to the applicable rating criteria, in evaluating the Veteran's major depressive disorder, the Board has also considered the Global Assessment of Functioning (GAF) scores assigned, and the definition of those scores. According to the Fourth Edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM- IV), the GAF is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." There is no question that the GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown, 8 Vet. App. 240 (1995). However, the GAF score assigned in a case, like an examiner's assessment of the severity of a condition, is not dispositive of the evaluation issue; rather, they must be considered in light of the actual symptoms of the Veteran's disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a). A. Rating Criteria in Effect Prior to November 7, 1996 Prior to November 7, 1996, the rating criteria for rating psychoneurotic disorders, to include major depressive disorder (Diagnostic Code 9405), provided as follows: A 30 percent rating is assignable upon a showing of definite impairment in the ability to establish or maintain effective and wholesome relationships with people; the psychoneurotic symptoms resulted in such reduction in initiative, flexibility, efficiency, and reliability levels as to produce definite social impairment. 38 C.F.R. § 4.132 (as in effect prior to November 7, 1996). The term "definite" is defined as "distinct, unambiguous, and moderately large in degree," and as representing a degree of social and industrial inadaptability that is "more than moderate but less than rather large." O.G.C. Prec. 9-93, 59 Fed. Reg. 4752 (1994). See also Hood v. Brown, 4 Vet. App. 301 (1993). A 50 percent rating is assignable when the ability to establish and maintain effective or favorable relationships with people is considerably impaired, or when by reason of psychoneurotic symptoms the reliability, flexibility and efficiency levels are so reduced as to result in considerable industrial impairment. 38 C.F.R. § 4.132, Diagnostic Code 9405. A 70 percent rating is assignable when the ability to establish and maintain effective or favorable relationships with people is severely impaired, or when the psychoneurotic symptoms are of such severity and persistence that there is severe impairment of the ability in the ability to obtain or retain employment. Id. A 100 percent rating is assignable when the attitudes of all contacts except the most intimate are so adversely affected as to result in virtual isolation in the community, or for totally incapacitating psychoneurotic symptoms bordering on gross repudiation of reality with disturbed thought or behavioral processes associated with almost all daily activities, such as fantasy, confusion, panic, and explosions of aggressive energy resulting in profound retreat from mature behavior; demonstrably unable to obtain or retain employment. Id. These criteria represent 3 independent bases for granting a 100 percent rating. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). The evidence pertinent to the timeframe in question reflects that, in August and September 1995 letters, Dr. C., a private psychologist, noted that the Veteran had excellent cognitive functioning and that psychological testing indicated severe depression along with anxiety and agitation, confusion, forgetfulness, difficulty concentrating, sleep disturbance, and fatigue. Dr. C. noted that the Veteran was passive and hypersensitive in his interactions with others. An October 1995 VA mental hygiene clinic note reflects a blunted, stable, and congruent affect; anxious and moderately depressed mood; slow, spontaneous, and monotonous speech with normal volume and intensity; organized and goal-oriented thought process; suicidal ideation that he would never act upon; decreased energy, concentration, and self esteem; and chronic anxiety. A report of an October 1995 VA examination reflects the Veteran's complaints of anxiety, distress, and increased depression due to the loss of his job but that he had some relief and benefit from treatment and medication. He stated that he was doing an exemplary job but was asked to resign because of interpersonal difficulties with at least one co- worker. Examination revealed no evidence of thought disorder, auditory or visual hallucinations, delusions, or any organic dysfunction. The examiner noted that the Veteran clearly is quite distressed, with elements of depression and anxiety that are currently somewhat responding to medication. The examiner also noted that it appears that there are some underlying characterological struggles that may well lead to some of the difficulties in interacting with others. [Parenthetically, a December 1996 VA letter reflects that, upon the Veteran's objection to this examination, the December 1995 VA examination report, discussed below, was to supersede this examination report.] A report of a December 1995 VA examination reflects a history of marked anxiety and depressive symptoms earlier in the year with loss of interest in all activities that led to his resignation from his job in January. He eventually sought mental health care and was prescribed medication, which helped greatly. He reported being able to sleep but continued to have misgivings about his job. He stated that he regrets his rash decision and would like to return to his job. He also stated that he has been married for 30 years. Psychological testing suggested personality problems and major affective disorder. A February 1996 VA mental hygiene clinic note reflects the Veteran's report of significant improvement with current medication but with memory difficulties from time to time, such as forgetting where he parked his car, and difficulty performing tasks to the same capacity as earlier. In a March 1996 letter, Dr. C. essentially reiterated the contents of her earlier letters and added that the Veteran could work in the future at a non-stressful work activity and no detailed task job. Comparing the manifestations of the veteran's major depressive disorder to the applicable criteria as in effect prior to November 7, 1996, the Board finds that, prior to that date, the veteran's major depressive disorder symptoms more nearly approximated the criteria for the initial 30 percent rating assigned. During this time frame, the evidence reflects that the veteran's disability was manifested, primarily, by anxiety, distress, and increased depression (seemingly over the loss of his job, but with some relief and benefit from treatment and medication) along with agitation, sleep disturbance, memory difficulties, and difficulty performing tasks to the same capacity as earlier. These symptoms caused the Veteran's ability to establish or maintain effective and wholesome relationships with people to be definitely impaired, but his ability to establish and maintain effective or favorable relationships with people was not, at least, considerably impaired. In this regard, the record indicates that he was able to maintain his marriage of 30 years and he only had interpersonal difficulties with a few co-workers prior to resigning. In addition, his symptoms were shown to result in definite industrial impairment, but were not shown to result in considerable industrial impairment, as reflected by a notation that he performed his job well prior to resigning and that his treating psychologist thought that he could work in the future. As, for the period prior to November 7, 1996, the criteria for the next higher, 50 percent, rating are not met, it logically follows that the criteria for an even higher rating are likewise not met. B. Rating Criteria in Effect Since November 7, 1996 Under the General Rating Formula that became effective on November 7, 1996, psychiatric disorders other than eating disorders, to include major depressive disorder (Diagnostic Code 9434), are rated as follows: A 30 percent rating is assignable for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.132, Diagnostic Code 9434 (1997-2008). A 50 percent rating is assignable for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once per week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly-learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assignable for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. Id. A 100 percent rating is assignable for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Initially, the Board notes that, since the change in rating criteria, in continuing the 30 percent rating, the RO has referenced Diagnostic Code 9435 for mood disorder, not otherwise specified, although Diagnostic Code 9434 is specifically for major depressive disorder. In any event, comparing the Veteran's major depressive disorder symptoms to the criteria of the General Rating Formula, the Board finds that the criteria for a rating in excess of 30 percent for the disability have not been met at any point since November 7, 1996. The report of a June 2001 VA examination reflects a history of depression and anxiety due to tinnitus. The Veteran was taking medication for his mood. The examiner noted that recent case notes from just two weeks ago indicate that the Veteran has experienced almost total abatement of symptoms and that the Veteran is happy with full affect. The examiner added that, as of May 31, 2001, the Veteran did not appear significantly depressed. Examination revealed adequate memory for recent and remote events; average intelligence; affect of normal intensity and consistent with discussion content; clear, goal-directed, spontaneous speech of normal pace and volume; rational thought content; and normal energy level. Although the Veteran stated that he was depressed, the examiner observed that the Veteran did not appear significantly depressed or anxious. The Veteran denied delusions, auditory hallucinations, and suicidal ideation or intent. He reported that sleep and appetite were adequate, but noted difficulty motivating to do things. The examiner assigned a GAF score of 72. The examiner noted that the Veteran appears to be functioning better than he acknowledges and that psychological test results show evidence of malingering. The examiner further stated that the Veteran did not appear to be experiencing any significant mental disorder and that his depression appeared to be well in check through current medications. A November 2004 VA mental health note reflects compliance with current medication and improvement with this regimen with no depressive symptoms. Examination revealed good grooming; euthymic mood, affect congruent with mood, no suicidal or homicidal ideation, goal-directed thought process, good judgment and insight, and no evidence of delusions. The psychiatrist diagnosed the Veteran with major depressive disorder in remission, and estimated his GAF as ranging from 65 to 70. The report of a January 2005 VA examination reflects complaints of depressed mood most of the day with loss of all interest and pleasure, insomnia, loss of appetite, and recurring thoughts of death. The Veteran reported being close to his wife but seldom seeing their two adult children and that he is socially isolated. Examination revealed intermittently pressured speech; cooperative and friendly attitude to the examiner; constricted affect; agitated and depressed mood; intact attention; unremarkable, goal-directed thought process; preoccupation with one or two topics; intact judgment; normal remote, recent, and immediate memory; fair insight; moderate sleep impairment; no panic attacks; occasional suicidal thoughts but no homicidal thoughts. The Veteran reported difficulty adapting to stressful circumstances, noting anxiety in response to situation stress; and difficulty establishing or maintaining effective relationships, noting that his only relationship is with his wife. The examiner diagnosed the Veteran with recurring major depressive disorder in partial remission, and anxiety disorder not otherwise specified. The examiner assigned a GAF score of 55, but noted that this was based on the Veteran's self-report, and that, in November 2004, the Veteran's treating psychiatrist estimated the GAF as ranging from 65 to 70. The examiner noted that the record indicates depression in remission, albeit on medication, for at least the past six years but that today the Veteran claims to have been chronically and severely depressed since discharge from military service. The examiner further noted that the Veteran's statements in the claims file as well as those made on examination contradict one another and do not clearly establish the circumstances under which he left his job. Lastly, the examiner stated that the pattern of hostility reported by health care providers most likely contributed to the Veteran's resignation and subsequent unemployment. A May 2005 VA mental health note reflects sleep impairment but stable mood, with medication working well. Examination revealed good grooming; fluent, tremulous speech with deep tone; "pretty good" mood; anxious affect; no delusional thought content; goal-directed thought process; no auditory or visual hallucinations; no suicidal or homicidal ideation; and fair judgment and insight. Diagnoses included major depressive disorder in remission and anxiety disorder not otherwise specified. The GAF score was estimated as ranging from 65 to 70. An October 2005 VA mental health note reflects sleep impairment but stable mood, with medication being very helpful. Examination revealed good grooming; fluent, relevant, coherent, slow, and soft speech; euthymic mood; appropriate to anxious affect; normal thought content; no suicidal or homicidal ideation; fair judgment and insight; fair concentration; and average intelligence. Diagnoses were major depressive disorder in remission and anxiety disorder not otherwise specified, the examiner assigned a GAF score of 65.. An April 2006 VA mental health note reflects complaints of a chronically depressed mood that the Veteran described as level and with which he is satisfied. The Veteran reported no motivation to do anything during the day and that his day is mostly empty. Examination revealed depressed mood; appropriate to depressed affect; no hallucinations or delusions; no suicidal or homicidal ideation; and fair insight. The assigned GAF score was 50. New medication was prescribed. A May 2006 VA mental health note reflects that the Veteran has really benefited from the new medication and has noticed increased energy, elevated mood, and increased libido. He reported feeling more jittery which he was willing to tolerate. He denied any sleep or appetite disturbance. He noted that he was doing his usual activities of going shopping with his wife. He stated that he was not feeling well on his last visit and acknowledged being more depressed then. Examination revealed a euthymic mood; appropriate affect; no hallucinations or delusions; no suicidal or homicidal ideation; and fair insight. The assigned GAF score was 60. An August 2006 VA mental health note reflects that the Veteran was doing well and liked his current combination of medications. He reported feeling anxious and jittery at times but stated that this side effect is tolerable given the benefits. He reported occasionally feeling depressed for an hour or two but that would get better with medications. Examination revealed good grooming; fluent, relevant, and coherent speech; euthymic mood; appropriate affect; no hallucinations or delusions; spontaneous thought flow; no suicidal or homicidal ideation; and good judgment and insight. The diagnosis was recurrent, moderate major depressive disorder. The assigned GAF score was 60. A January 2007 VA mental health note reflects that the Veteran's mood was good on the current combination of medications. He denied vegetative symptoms or anxiety. Examination revealed good grooming; good mood; appropriate affect with full range; fluent, non-pressured, relevant, and coherent speech of regular rate and rhythm; linear, logical, and goal-oriented thought process; no suicidal or homicidal ideation; no delusions or obsessions; no hallucinations; good judgment; and fair insight. An April 2007 VA mental health note reflects complaints of more trouble with depression and side effects of medications. The Veteran reported that he stopped taking his medications for about four or five days while being treated for his prostate and that he recently received new generic forms of two of his medications. The examiner thought that the Veteran's symptoms were related to withdrawal from his medications and restarting them at a higher dose. The examiner also thought that the Veteran may need a different dose of the generic forms of his medications. Examination revealed adequate grooming; fair mood; appropriate affect with full range; fluent, non-pressured, relevant, and coherent speech of regular rate and rhythm; linear, logical, and goal-oriented thought process; no suicidal or homicidal ideation; no delusions or obsessions; no hallucinations; good judgment; and fair insight. Collectively, the aforementioned medical evidence reflects that, since November 7, 1996, the Veteran's major depressive disorder has been primarily manifested by depressed mood, anxiety, and chronic sleep impairment. These symptoms are reflective of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) contemplated in the currently assigned 30 percent rating. The Board also notes that the GAF scores assigned since November 7, 1996 are largely consistent with the 30 percent rating assigned. These scores have ranged from 50 to 72, although the have primarily been in the 60 to 70 range. According to the DSM-IV, GAF scores from 41 to 50 indicate serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). GAF scores ranging from 51 to 60 is indicative of moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). GAF scores ranging from 61 to 70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational or school functioning (e.g., occasional truancy or theft within the household) but generally functioning pretty well with some meaningful interpersonal relationships. Initially, the Board notes that the GAF score of 50 assigned in April 2006 was at a time that the Veteran acknowledged being more depressed. However, upon changing medications, from May 2006, his condition improved and assigned GAF scores have since primarily been 60 indicating overall moderate symptoms or moderate difficulty in social or occupational functioning. Further, before April 2006, his GAF score was primarily estimated as ranging from 65 to 70, indicating some mild symptoms or some difficulty in social or occupational functioning-even less impairment than contemplated I the 30 percent rating. While an April 2005 examiner assigned a GAF of 52, symptoms indicative of a GAF score from 51 to 60- flat affect, circumstantial speech, and occasional panic attacks-simply are not reflected in the record. The Board points out that, at no point during the period in question has the Veteran's psychiatric symptomatology more nearly approximated the level of disability contemplated in the next higher, 50 percent rating. In this regard, the medical evidence does not show that he had flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once per week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly-learned material, forgetting to complete tasks); impaired judgment; or impaired abstract thinking that are characteristic of a 50 percent rating. Although the Veteran may have had disturbances of motivation and mood, they have been alleviated by a combination of medication. In addition, although he may have difficulty in establishing and maintaining social relationships, he has been able to maintain his marriage and was close to his wife. Thus, his overall disability is not reflective of occupational and social impairment with reduced reliability and productivity. As, for the period since November 7, 1996, the criteria for the next higher, 50 percent, rating are not met, it logically follows that the criteria for an even higher rating are likewise not met. C. Both Periods The Board also finds that there is no showing that, at any point since the effective date of the grant of service connection, the disability under consideration has reflected so exceptional or so unusual a disability picture as to warrant the assignment of any higher rating on an extra- schedular basis. See 38 C.F.R. § 3.321(b). In this regard, the Board notes that the disability has not objectively been shown to markedly interfere with employment (i.e., beyond that contemplated in the assigned rating for each period). The Board observes that, although the record is unclear as to the exact circumstances surrounding his termination of employment, the record does reflect that he voluntarily resigned and that he could return to work to a non-stressful job. There also is no evidence that the disability has necessitated frequent periods of hospitalization, or has otherwise rendered inadequate the regular schedular standards. In the absence of evidence of any of the factors outlined above, the criteria for invoking the procedures set forth in 38 C.F.R. § 3.321(b)(1) have not been met. See Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996); Floyd v. Brown, 9 Vet. App. 88, 96 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). For all the foregoing reasons, the Board finds that there is no basis for staged rating of the disability under consideration, pursuant to Fenderson, and the claim for higher initial rating for major depressive disorder must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against assignment of any higher rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). ORDER An initial rating in excess of 30 percent for major depressive disorder is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs