Citation Nr: 0811402 Decision Date: 04/07/08 Archive Date: 04/23/08 DOCKET NO. 05-30 855 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUE Entitlement to an initial rating in excess of 10 percent for depression. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The veteran had active military service from April 2000 to May 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland that in pertinent part granted service connection and assigned a 10 percent disability rating for depression. Thereafter, the veteran perfected an appeal as to the initial evaluation assigned for this service-connected disability. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. 2. Competent medical evidence demonstrates that the veteran's service-connected depression is manifested by symptoms of depression with some transient symptoms indicative of no more than mild social and occupational impairment. CONCLUSION OF LAW The criteria for an initial rating in excess of 10 percent for depression have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9434 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (the Court) have been fulfilled. In this case, the veteran's claim for entitlement to service connection for depression was received in May 2004. She was notified of the provisions of the VCAA by the RO in correspondence dated in July 2004. This letter notified the veteran of VA's responsibilities in obtaining information to assist her in completing her claim, identified the veteran's duties in obtaining information and evidence to substantiate her claim, and requested that the veteran send in any evidence in her possession that would support her claim. In a February 2005 rating decision, the RO granted entitlement to service connection and assigned an initial 10 percent rating for depression. The veteran appealed the assignment of the initial evaluation for this benefit. She was again notified of the provisions of the VCAA by the RO in correspondence dated in March 2007. Thereafter, the claim was reviewed and a supplemental statement of the case was issued in June 2007. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Mayfield v. Nicholson (Mayfield III), 07-7130 (Fed. Cir. September 17, 2007). The claim for an initial evaluation in excess of 10 percent for depression is a downstream issue from the grant of service connection. See Grantham v. Brown, 114 F.3d 1156 (1997). VA's General Counsel recently held that no VCAA notice was required for such downstream issues, and that a Court decision suggesting otherwise was not binding precedent. See VAOPGCPREC 8-2003, 69 Fed.Reg. 25180 (May 5, 2004); cf. Huston v. Principi, 17 Vet. App. 370 (2002). The Board is bound by the General Counsel's opinion. See 38 U.S.C.A. § 7104(c) (West 2002). While this logic is called into some question in a recent Court case, neither this case nor the GC opinion has been struck down. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). During the pendency of this appeal, the United States Court of Appeals for Veterans Claims (hereinafter "the Court") in Dingess v. Nicholson, 19 Vet. App. 473 (2006), found that the VCAA notice requirements applied to all elements of a claim. An additional notice as to this matter was provided by the RO in a March 2007 letter. The veteran has been made aware of the information and evidence necessary to substantiate her claim and has been provided opportunities to submit such evidence. A review of the claims file also shows that VA has conducted reasonable efforts to assist her in obtaining evidence necessary to substantiate her claim during the course of this appeal. Private treatment records and all relevant VA treatment records pertaining to her service-connected depression have been obtained and associated with her claims file. She has also been provided with multiple VA medical examinations to assess the current state of her service-connected depression. Furthermore, the veteran has not identified any additional, relevant evidence that has not otherwise been requested or obtained. She has been notified of the evidence and information necessary to substantiate her claim, and she has been notified of VA's efforts to assist her. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating her claim. Laws and Regulations The severity of a service-connected disability is ascertained, for VA rating purposes, by the application of rating criteria set forth in VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4 (2007) (Schedule). To evaluate the severity of a particular disability, it is essential to consider its history. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1 and 4.2 (2007). Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. See 38 C.F.R. §§ 3.102, 4.3 (2007). In addition, where there is a question as to which of two disability evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2007). The Court has also held that, in a claim of disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). In a February 2005 rating action, the RO awarded the veteran service connection and assigned a 10 percent rating for depression pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9434 (2007). The symptoms listed in Diagnostic Code 9434 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). When all the evidence is assembled, the determination must be made as to whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990) General Rating Formula for Mental Disorders: Ratin g 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) 30 Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication 10 A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication 0 38 C.F.R. § 4.130 (2006) In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). Global Assessment of Functioning (GAF) Scale Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations. 80 ? ? 71 If symptoms are present, they are transient and expectable reactions to psycho-social stressors ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUE Entitlement to an initial rating in excess of 10 percent for depression. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. D. Deane, Counsel INTRODUCTION The veteran had active military service from April 2000 to May 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland that in pertinent part granted service connection and assigned a 10 percent disability rating for depression. Thereafter, the veteran perfected an appeal as to the initial evaluation assigned for this service-connected disability. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim on appeal has been accomplished. 2. Competent medical evidence demonstrates that the veteran's service-connected depression is manifested by symptoms of depression with some transient symptoms indicative of no more than mild social and occupational impairment. CONCLUSION OF LAW The criteria for an initial rating in excess of 10 percent for depression have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. § 4.130, Diagnostic Code 9434 (2007). REASONS AND BASES FOR FINDINGS AND CONCLUSION The provisions of the Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the United States Court of Appeals for Veterans Claims (the Court) have been fulfilled. In this case, the veteran's claim for entitlement to service connection for depression was received in May 2004. She was notified of the provisions of the VCAA by the RO in correspondence dated in July 2004. This letter notified the veteran of VA's responsibilities in obtaining information to assist her in completing her claim, identified the veteran's duties in obtaining information and evidence to substantiate her claim, and requested that the veteran send in any evidence in her possession that would support her claim. In a February 2005 rating decision, the RO granted entitlement to service connection and assigned an initial 10 percent rating for depression. The veteran appealed the assignment of the initial evaluation for this benefit. She was again notified of the provisions of the VCAA by the RO in correspondence dated in March 2007. Thereafter, the claim was reviewed and a supplemental statement of the case was issued in June 2007. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Pelegrini v. Principi, 18 Vet. App. 112 (2004). See also Mayfield v. Nicholson, 19 Vet. App. 103, 110 (2005), reversed on other grounds, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson (Mayfield II), 20 Vet. App. 537 (2006); Mayfield v. Nicholson (Mayfield III), 07-7130 (Fed. Cir. September 17, 2007). The claim for an initial evaluation in excess of 10 percent for depression is a downstream issue from the grant of service connection. See Grantham v. Brown, 114 F.3d 1156 (1997). VA's General Counsel recently held that no VCAA notice was required for such downstream issues, and that a Court decision suggesting otherwise was not binding precedent. See VAOPGCPREC 8-2003, 69 Fed.Reg. 25180 (May 5, 2004); cf. Huston v. Principi, 17 Vet. App. 370 (2002). The Board is bound by the General Counsel's opinion. See 38 U.S.C.A. § 7104(c) (West 2002). While this logic is called into some question in a recent Court case, neither this case nor the GC opinion has been struck down. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). During the pendency of this appeal, the United States Court of Appeals for Veterans Claims (hereinafter "the Court") in Dingess v. Nicholson, 19 Vet. App. 473 (2006), found that the VCAA notice requirements applied to all elements of a claim. An additional notice as to this matter was provided by the RO in a March 2007 letter. The veteran has been made aware of the information and evidence necessary to substantiate her claim and has been provided opportunities to submit such evidence. A review of the claims file also shows that VA has conducted reasonable efforts to assist her in obtaining evidence necessary to substantiate her claim during the course of this appeal. Private treatment records and all relevant VA treatment records pertaining to her service-connected depression have been obtained and associated with her claims file. She has also been provided with multiple VA medical examinations to assess the current state of her service-connected depression. Furthermore, the veteran has not identified any additional, relevant evidence that has not otherwise been requested or obtained. She has been notified of the evidence and information necessary to substantiate her claim, and she has been notified of VA's efforts to assist her. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). As a result of the development that has been undertaken, there is no reasonable possibility that further assistance will aid in substantiating her claim. Laws and Regulations The severity of a service-connected disability is ascertained, for VA rating purposes, by the application of rating criteria set forth in VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4 (2007) (Schedule). To evaluate the severity of a particular disability, it is essential to consider its history. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. §§ 4.1 and 4.2 (2007). Where there is a reasonable doubt as to the degree of disability, such doubt will be resolved in favor of the claimant. See 38 C.F.R. §§ 3.102, 4.3 (2007). In addition, where there is a question as to which of two disability evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7 (2007). The Court has also held that, in a claim of disagreement with the initial rating assigned following a grant of service connection, separate ratings can be assigned for separate periods of time, based on the facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). In a February 2005 rating action, the RO awarded the veteran service connection and assigned a 10 percent rating for depression pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9434 (2007). The symptoms listed in Diagnostic Code 9434 are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). When all the evidence is assembled, the determination must be made as to whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990) General Rating Formula for Mental Disorders: Ratin g 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) 30 Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication 10 A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication 0 38 C.F.R. § 4.130 (2006) In assessing the evidence of record, it is important to note that the Global Assessment of Functioning (GAF) score is a scale reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." See Richard v. Brown, 9 Vet. App. 266, 267 (citing DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4th ed. (DSM-IV) at 32). Global Assessment of Functioning (GAF) Scale Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations. 80 ? ? 71 If symptoms are present, they are transient and expectable reactions to psycho-social stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). 70 ? ? 61 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, has some meaningful relationships. 60 ? ?51 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). 50 ?? 41 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). Factual Background and Analysis After a review of the evidence, the Board finds that the evidence does not support the assignment of an initial rating in excess of 10 percent for depression. Service treatment records detail that the veteran was treated for borderline personality disorder, suicide attempt by overdose after a failed romantic relationship, and depression NOS (not otherwise specified) during active service in October 2003 and March 2004. During a July 2004 VA fee-basis psychiatric examination, the veteran complained of insomnia, oversleeping, shopping when she had no money, mood swings, and occasional suicidal thoughts. It was noted that the veteran was an extremely poor historian and that the examiner had difficulty getting symptomatology from her. The veteran was noted to be irritable and paranoid with very little insight or abstraction. She denied memory problems, feeling hopeless or helpless, appetite changes or concentration problems. She further reported a history drinking heavily, being unemployed, and having interpersonal difficulties. The examiner indicated that the veteran had a lot of protective blame. It was noted that she complained of not being able to find a job because the military put a diagnosis of personality disorder on her record. When it was suggested that she look for another type of job in retail or restaurant work, the veteran looked incredulous and indicated she did not want that type of work. On mental status examination, she was described as well groomed, with no psychomotor abnormalities, and no eye contact. She was paranoid, defensive, sullen uncooperative in the interview, had an irritable mood and affect, with no gross impairment in her memory or cognition. The veteran was fully alert and oriented, denied suicidal ideation or hallucinations. She had poor insight and judgment. The diagnoses were depression NOS and alcohol abuse, and a GAF score of 45 was assigned. The examiner indicated that he could not divide GAF score between the listed diagnoses due to the overlapping nature of those disorders. In an August 2004 VA Mental Health Clinic intake assessment, the veteran indicated that she was unemployed and depressed that she was unable to apply for the job she wanted due to the military's diagnosis of personality disorder. The veteran complained of depression, mood swings, and impulsive behavior. Mental status examination findings were noted as cooperative, good eye contact, euthymic mood, appropriate affect, intact memory, organized thoughts, unimpaired judgment and insight, no suicidal or homicidal ideation, and no psychotic, major affective, or organic symptomatology. The examiner assessed adjustment disorder with depressed mood, and a GAF score of 70 was assigned. A November 2004 treatment record from Dewitt Army Community Hospital listed an assessment/diagnosis of depression. An additional November 2004 treatment note from Kaiser Permanente noted complaints of suicidal thoughts and depression. The veteran indicated that she had broken up with her boyfriend a week earlier and denied any active suicidal or homicidal ideation. Mental status examination findings were noted as appropriate dress, good eye contact, depressed mood, normal speech, no formal thought process, no suicidal or homicidal ideation, fair judgment and insight, alert, and oriented. The examiner assessed rule out depression NOS, and a GAF score of 55 was assigned. It was further noted that the highest GAF score during the last 12 months was 65. An additional VA treatment note dated in December 2004 reflects complaints of depression, living alone, and financial stress. Mental status examination findings were noted as fair eye contact, linear thought processes, limited insight, intact judgment, minimally labile affect, no psychomotor abnormalities, and no paranoia, homicidal ideation, suicidal ideation, or hallucinations. The examiner diagnosed mood disorder NOS and rule out dysthymia, and a GAF score of 55 was assigned. A February 2005 VA treatment record reflected a finding of depression with no suicidal or homicidal ideation. An April 2005 VA treatment record with June 2005 addendum reflected that the veteran did not want to take antidepressants and noted a discussion concerning exploration of psychotherapy. Mental status findings were listed as oriented, alert, cooperative, smiles, and coherent and logical speech. In the addendum, the examiner diagnosed mood disorder NOS and resolving depression. Additional treatment records indicate that the veteran was oriented, cooperative, and logical as well as prescribed Celexa in August 2005. During a May 2007 VA psychiatric examination, the veteran complained of symptoms of depression. The veteran indicated that she was able to obtain a security clearance and was currently employed as a civilian government employee in supplies. The examiner reported that the veteran's depression was of mild severity and that she had adequate employment functioning, noting that she did not have any unemployment or time lost from work because of emotional reasons. The veteran's social functioning was considered adequate although she had a tendency for social isolation. The examiner acknowledged the findings of alcohol abuse in the July 2004 examination report discussed above but indicated that the only psychopathology noted in the current examination was dysthymic disorder. Mental status examination findings were listed as well kept personal hygiene, appropriately dressed, adequately groomed, normal psychomotor movements, spontaneous speech, no hallucinations or delusions, no obsessions, compulsions, or phobias, mildly depressed mood, appropriate affect, no suicidal or homicidal ideation, oriented, no cognition or memory impairment, mildly impaired concentration, and adequate judgment and insight. The diagnosis was dysthymic disorder and a GAF score of 72 was assigned. The examiner indicated that the veteran had mild depressive disorder impairment and that her depression symptoms had not improved sufficiently. The Board notes, at the outset, that in addition to depression, the record reflects that the veteran has been diagnosed with, and has suffered impairment from, alcohol abuse as well as mood and adjustment disorders, for which service connection has not been granted or sought. However, even if the Board were to give the veteran the benefit of the doubt and attribute all her psychiatric symptoms to service- connected depression-except in situations in which an examiner has distinguished the symptomatology attributable to and level of impairment resulting from alcohol abuse from those attributable to and resulting from depression (see Mittleider v. West, 11 Vet. App. 181, 182 (1998)), the Board finds, after a careful review of all pertinent evidence in light of the above-noted criteria, that the psychiatric symptoms have been consistent with the criteria for no more than the currently assigned 10 percent rating. Based upon the evidence of record, the Board finds that the veteran's service-connected depression is manifested by no more than occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by continuous medication. Objective medical evidence of record reflects that the veteran's service-connected psychiatric disability has been manifested by complaints of depression and difficulties in interpersonal relationships. These symptoms are reflective of occupational and social impairment no greater than what is contemplated in the currently assigned 10 percent disability rating. In fact, the evidence of record indicates that the veteran suffers from transient symptoms including depressed mood and suicidal thoughts during periods of significant stress, like breaking up with a boyfriend or being unable to apply for a specific job after separation from service. The Board notes that the veteran's depression symptomatology has not resulted in a disability picture that more nearly approximates the level of occupational and social impairment contemplated for a 30 percent rating under the applicable rating criteria. The assignment of a 30 percent rating is warranted 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 certain symptoms. In this case, treatment providers have determined that the veteran's service-connected depression was of mild severity. There is also no evidence that the veteran experienced the level of occupational and social impairment contemplated for a 30 percent rating specifically as a result of her service- connected depression. While some VA examiners have described the veteran as uncooperative or having a tendency toward social isolation, competent medical evidence of record clearly indicates that the veteran exhibits adequate social functioning, as she has maintained relationships with family members and has discussed multiple intimate and personal relationships. The Board notes that the veteran discussed her frustration with being unable to find a job because of a military diagnosis of personality disorder in the July 2004 VA fee-based examination report and in an August 2004 VA treatment note. However, the Board also notes that evidence of record does not indicate that the veteran was unemployed during this time period due to her service-connected residuals of depression. It was later indicated in the evidence of record that the veteran has adequate occupational functioning, as she was able to obtain a security clearance and is currently employed as a government employee. It was specifically noted in the May 2007 VA examination report that the veteran is not unemployed or has time loss from work because of emotional reasons. The Board also notes that the veteran has not been found to suffer from anxiety, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss. While the veteran has some documented symptoms of paranoia, impulsive behavior, limited insight, suicidal thoughts, and mildly depressed mood, these symptoms have not been shown to affect the veteran on a continuous basis and/or to limit her ability to function independently on a daily basis. Further, the assigned GAF scores of 65, 70, and 72 are indicative mild symptomatology and mild difficulty in social and occupational functioning. The Board notes that the GAF scores of 45 and 55, reflected in the record, suggest more significant impairment than is contemplated by the assigned 10 percent rating. However, the competent medical evidence of record clearly reflects that the veteran has not exhibited the symptoms identified in the DSM-IV as indicative of such a score on a continuous basis. The Board acknowledges the veteran's contentions that her depression residuals are more severely disabling. However, as noted above, the veteran is not a licensed medical practitioner and is not competent to offer opinions on questions of medical causation or diagnosis. See Grottveit v. Brown, 5 Vet. App. 91 (1993); see also Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Finally, the Board notes that objective medical findings also do not support the assignment of a 50 percent evaluation, as evidence of record clearly does not indicate that the veteran's depression symptomatology is productive of social and occupational impairment with reduced reliability and productivity due to symptoms like flattened affect, circumstantial speech, panic attacks, difficulty in understanding complex commands, memory impairment, impaired judgment, disturbances of motivation and mood, or difficulty in establishing and maintaining effective work and social relationships For all the foregoing reasons, the veteran's claim for entitlement to an initial rating in excess of 10 percent for depression must be denied. The Board has considered staged ratings, under Fenderson v. West, 12 Vet. App. 119 (1999) and Hart v. Mansfield, No. 05-2424 (U.S. Vet. App. Nov. 19, 2007), but concludes that they are not warranted. Since the preponderance of the evidence is against this claim, the benefit of the doubt doctrine is not for application. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board also finds there is no evidence of any unusual or exceptional circumstances, such as marked interference with employment or frequent periods of hospitalization related to her service-connected depression that would take the veteran's case outside the norm so as to warrant the assignment of an extraschedular rating. Consequently, referral by the RO to the Chief Benefits Director of VA's Compensation and Pension Service, under 38 C.F.R. § 3.321, is not warranted. See Bagwell v. Brown, 9 Vet. App. 337 (1996). ORDER Entitlement to an initial rating in excess of 10 percent for depression is denied. ____________________________________________ RENÉE M. PELLETIER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs