Citation Nr: 0814841 Decision Date: 05/05/08 Archive Date: 05/12/08 DOCKET NO. 01-00 178A ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida THE ISSUE Entitlement to a rating in excess of 50 percent for a bipolar disorder. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Matthew W. Blackwelder, Associate Counsel INTRODUCTION The veteran served on active duty from March 1981 to February 1983, with seven years of prior active service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2000 RO decision which denied an increased disability rating in excess of 30 percent for the veteran's service-connected bipolar disorder. The veteran timely filed an appeal of this decision. In June 2003, the RO issued a rating decision granting an increased disability rating of 50 percent for the veteran's bipolar disorder, effective from October 1999. The veteran maintained his disagreement with the newly assigned disability rating. In January 2005, the Board issued a decision which denied the veteran's claim for an increased disability rating in excess of 50 percent for his bipolar disorder. Thereafter, the veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In February 2006, the Court granted a Joint Motion for Remand, vacating the Board's January 2005 decision and remanding the claim for additional review and consideration. The case has since been returned to the Board. During the course of this appeal, the veteran filed a claim seeking entitlement to a rating of total disability based on individual unemployability (TDIU). The RO has not previously considered this claim. Therefore, it is referred to the RO for appropriate development and adjudication. FINDING OF FACT The veteran's bipolar disorder is not shown to be productive of 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 a worklike setting); or an inability to establish and maintain effective relationships. CONCLUSION OF LAW Criteria for a rating in excess of 50 percent for a bipolar disorder have not been met. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.130, Diagnostic Code (DC) 9432 (2007). REASONS AND BASES FOR FINDING AND CONCLUSION I. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board notes that while the regulations require review of the recorded history of a disability by the adjudicator to ensure an accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). It is also noted that staged ratings are appropriate for an increased rating claim whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). The veteran is currently rated at 50 percent for his bipolar disorder under 38 C.F.R. § 4.130, DC 9432. A 50 percent rating is assigned when a bipolar disorder causes 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 a week; difficulty in understanding complex commands; impairment of short-term 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; or difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation is assigned when a veteran has 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 a worklike setting); or an inability to establish and maintain effective relationships. In the Joint Motion for Remand, the veteran disagreed with the previous Board decision in several ways. First, it was noted that the Board did not fully discuss a July 2000 letter from the veteran's employer. Secondly, the Joint Motion found that the Board provided inadequate analysis addressing the veteran's Global Assessment of Functioning (GAF) score decrease from 80/85 in June 2000 to 51 in January 2001 and then to 49 in May 2003, and presumably, why this was not accompanied by corresponding rating increase. It was also asserted that the Board did not discuss the veteran's reported symptoms of a 40 pound weight loss, inability to sleep, difficulty concentrating, and depression 90 percent of the time. However, while these concerns will be addressed below, the Board once again concludes that the medical evidence still fails to demonstrate that a rating in excess of 50 percent is warranted for the veteran's bipolar disorder. In November 1999, December 1999, January 2000, February 2000, and April 2000, a VA psychiatrist indicated that the veteran continued to feel well, he was working and doing well at work, including often working a double shift. The veteran's mood was stable, and he was sleeping well, although he was worried about his son who was having emotional problems. The veteran was alert and oriented to person, place, and time. His thoughts were logical and coherent with no looseness of association, no delusions, no hallucinations, and no suicidal or homicidal ideations. The veteran's affect was appropriate, his mood was neutral, his intellect and memory were intact, and his insight and judgment were fair. The psychiatrist assigned a Global Assessment of Functioning (GAF) score of 71 after each session. In June 2000, the veteran was noted to be having some mood swings with some irritability, but the veteran continued do well at work and was even working a double shift six days per week. A GAF score of 67 was assigned. The psychiatrist continued to note that the veteran's bipolar disorder was moderate, and in partial remission. The veteran underwent a VA examination in June 2000 at which he complained that he continued to have manic episodes roughly five to six times per year that lasted anywhere from weeks to months; although he noted that the depressive episodes were not as bad with medication. The veteran indicated that he has difficulty sleeping because his mind was in constant motion. The veteran denied any loss of interest, feelings of guilt, or lack of energy, concentration, or appetite; and he denied any psychomotor agitation, suicidal thought, crying, or anhedonia. During the veteran's manic symptoms, he experienced increased energy and racing thoughts; and would often become involved in risky behavior. The veteran reported having inflated self esteem at these times, and it was noted that the veteran had quit his job three times in the last year while on manic highs, although his boss had been very understanding and had allowed him to return each time. It was also recorded the veteran continued to see a psychiatrist once a month, but he did not require any hospitalization. It was noted he had been married for 18 years with two children, and he worked 10 hours a day, 6 days per week, to support his family. At the examination the veteran was well-groomed, and he was alert and oriented to person, place, and time. His mood was euthymic, his affect was bright, and his mood was congruent. His speech was within normal limits and his eye contact was good. His thought content was without suicidal or homicidal ideations; his insight and judgment were good; and his memory and concentration were intact. The examiner assessed the veteran with a GAF score of 80-85. In July 2000, the operations manager of the veteran's employer (a moving and storage company) wrote a letter indicating that the veteran had a hot temper when things did not go his way; and noting that the veteran had difficulty working with other employees. It was specifically noted that the veteran did not harm or injure anyone. In April 2002, the veteran's employer wrote a second letter indicating that the veteran had been removed from one job because of his temper, but he indicated that the veteran had been a good employee, and for that reason his was still employed at the company. The employer commented that it was hard to control the veteran when he flared-up, but the veteran had been good since the last incident. Thereafter, the veteran continued his employment with this company until 2004, when, as discussed more below, the veteran's physical disabilities rendered him no longer able to perform the requirements of his job. A treatment record from August 2000 noted that the veteran continued to do well at work and was still working a double shift six days per week. The veteran was noted to be sleeping better, and he reported having lots of energy. The veteran was alert and oriented to person, place, and time, and his thoughts were logical and coherent with no looseness of association, no delusions, and no suicidal or homicidal ideations. The veteran was assigned a GAF of 66. The veteran's GAF score decreased to 51 after a VA treatment session in January 2001 as it was noted that the veteran was having a lot of stress at work and he was having frequent arguments both at work and at home. Nevertheless, the veteran continued working a double shift six days per week. The veteran was also found to be alert and oriented to person, place, and time. His thoughts were logical and coherent with no looseness of association, no delusions, and no suicidal or homicidal ideations. The veteran had some racing of thoughts and slight pressure of speech, and his mood was irritable. However, the veteran's intellect and memory remained intact and his insight and judgment remained fair. Additional treatment records in March, April, and June 2001 show many of the same symptoms and continue to list the veteran's GAF as 51, but it was noted that the veteran had multiple stresses in his life at that time, such as arguments at work, his son's health, a motor vehicle accident for which he received a citation; and financial problems. In December 2001, the veteran was transferred to another job after an argument with a coworker. It was noted that the veteran now had less pressure at work and he was enjoying the new job. It was also noted that there was less friction at home with his wife and kids, although his wife had lost her job and could not get another unless they got a second car. Treatment records from 2002 (April, June, September, and December) continued to find the veteran to be alert and oriented to person, place, and time, and his thoughts were logical and coherent with no looseness of association, no delusions, and no suicidal or homicidal ideations. The veteran continued to have concerns such as the economic downturn and the war in Iraq, but there was no indication that his bipolar disorder was anything but moderate. The veteran underwent a second VA examination in May 2003 at which he reported that his symptoms had grown worse over the previous eight years. At that time, the veteran reported he was living with his wife of nearly 20 years and he had three children. The veteran also reported having no friends and he described himself as a loner, stating he had no hobbies or activities that he enjoyed and he was disgusted with his life. The veteran reported having a broken pattern of sleep, indicating that he slept between 4-6 hours per night. He also reported having a poor appetite, stating that he generally had no desire to eat during the daytime, and he reported losing approximately 40 pounds in the past year and a half. The veteran indicated that he was easily confused if too much was going on around him. The veteran explained that he was depressed roughly 90 percent of the time, and indicated that his day could go from perfect to a disaster in a split second. The veteran also indicated that he had racing thoughts and had an ongoing problem making decisions. Although he had worked with the same employer for seven-and- a-half years and worked 60-80 hours per week; the veteran reported several run-ins with supervisors and a dozen complaints by co-workers. The examiner found that the veteran had a history of bipolar disorder with significant impairment in interpersonal, occupational, and social functioning. The veteran was noted to be compliant with his medication, but he remained impulsive, easily over stimulated, and had a low frustration tolerance. The examiner assigned a GAF score of 49, indicating that the veteran's symptoms had resulted in "difficulties in interpersonal relationships both at work and at home." The veteran testified at a hearing before the RO in April 2003 that he was currently receiving treatment every three months both for ongoing treatment and to monitor his medication. When asked whether the medication controlled his mood swings, the veteran indicated that it helped but did not entirely control the swings, which could last for several months at a time. The veteran was concerned that his condition was getting worse to the point that he anticipated that he would eventually be terminated from his employment. Treatment records from 2003 (March, July, September) note that the veteran had his hours cut back due to the economy, although it also was noted that the veteran's company had begun to do better financially. The veteran and his wife continued to go to couples therapy, and it was noted that the veteran's situation at home was improved and less stressful, although the veteran's daughters had moved back in after separating from their husbands. The veteran's GAF continued to be at 51, but it was nevertheless recorded he was alert and oriented to person, place, and time; and his thought processes were logical and coherent with no looseness of association. The veteran reported being mildly depressed, but he denied any suicidal ideations and his insight and judgment continued to be fair. In September 2003, the veteran was noted to be sleeping 8-9 hours a night and he reported feeling well physically with good energy and motivation. In March 2004, a treatment record noted that the veteran continued to have problems with his right knee and might have to quit driving trucks. The veteran had concerns about health and legal problems with his children, but he was having less friction with his wife. The veteran's mental status evaluation was similar with those that had been seen earlier, and it was noted that the veteran's mood was stable and he was not having mood swings. The veteran once again was alert and oriented to person, place, and time; and while he reported being depressed, the depression was only 3/10 in intensity. The veteran was noted to be sleeping well and he had energy and motivation. In July 2004, the veteran indicated that he had given up on the moving business and was seeking social security disability. The veteran indicated that he had been having problems with his hands and knee, and was becoming irritable. He also stated that he could not tolerate the heat any more. The veteran felt anxiety about his financial situation, indicating that he and his wife had taken custody of two grandchildren. The veteran again reported depression, but it was noted to be only 5/10 in intensity. The veteran was well-groomed, and he was alert and oriented to person, place, and time. He had normal speech, no hallucinations or delusions, and his insight and judgment were fair. The veteran had mild racing thoughts, but there was no pressure of speech. In November 2004, the veteran indicated that he was not himself anymore, as he could not relax, he was too irritable, and his back and neck were bothering him. The veteran reported mood swings and mild racing thoughts. The veteran was nevertheless alert and oriented to person, place, and time with logical and coherent thoughts and his insight and judgment were fair. The veteran's GAF remained at 51. In April and June 2005, the veteran was noted to feel calm most of the time, and his mood swings were not as intense or frequent. The veteran indicated that he and his wife were busy looking after their two grandchildren over whom they had been given custody. The veteran continued to be alert and oriented to person, place, and time; and he was logical and coherent, without any looseness of associations. It was also noted that the veteran continued to have multiple medical problems including knee pain, high blood pressure, and a spur that was impinging on a nerve root in his neck. The veteran continued to be alert and oriented and his GAF remained at 51. Nevertheless, the veteran denied any anxiety and indicated that his mood swings were not as intense or frequent. The veteran continued to report depression that was 5/10 in intensity. In January 2006, it was noted that mood swings were not as intense or frequent. The veteran's motivation was fair, and no crying spells or suicidal ideation was reported. The veteran continued to have multiple medical problems. The veteran reported occasional racing thoughts, but he was otherwise alert and oriented, and was logical and coherent. The veteran was assigned a GAF of 50. In June 2006, the Social Security Administration (SSA) determined that the veteran had been disabled since April 2004. However, while the veteran was found to be unable to work, the SSA decision found numerous physical disabilities, in addition to the bipolar disorder, that contributed to rendering the veteran unemployable. These non-service- connected disabilities included pain and limitation of function due to degenerative joint disease in his hands; peripheral neuropathy; a left-sided C3-4 osteophyte-disc complex touching the cervical spine and moderately narrowing the left neural foramen; cervical spondylosis; benign prostate hypertrophy; gastroesophageal reflux disease; and hypertension. Indeed, the primary diagnosis for SSA purposes was "osteoarthritis and allied disorders," rather than the veteran's service connected psychiatric disorder. As part of his SSA application, the veteran underwent a mental residual functional capacity assessment which evaluated understanding and memory, sustained concentration and persistence, social interaction, and adaptation. The veteran was found not significantly limited in 12/20 categories and only moderately limited in the remaining categories. The medical consultant indicated that because of arthritic problems, the veteran could no longer do the heavy work he had done in the past. His mental condition was noted to have been relatively stable, and no mental deterioration was found since he was able to do his last job. In February 2007, the veteran reported that he was not having as many stressors in his life lately. It was noted that the veteran's son had moved home, and his daughter had gotten married and moved out. The veteran reported occasional mood swings of varying intensity, but he stated that he was having less anxiety and felt calmer. He continued to have some feelings of depression and had mild racing of thoughts, but no paranoid ideations were reported. The veteran's motivation was poor, but neither crying spells nor suicidal ideation were reported. The veteran was noted to be sleeping better (about 7 hours per night). The veteran also reported spending a lot of time in bed because of his multiple medical problems. The veteran was well-groomed, and was alert and oriented to person, place, and time. His thoughts were logical and coherent and there was no looseness of association, no delusions, and no hallucinations. The veteran's affect was appropriate and his insight and judgment were fair. The veteran was assigned a GAF of 50. The veteran underwent a third VA examination in July 2007 at which he reported having continued mood swings, despite his medication; and he reported depression and mania (episodes of energy and happiness and agitation, including sleep avoidance and eating) without medication. The examiner indicated that the veteran was controlled by medication, which made his mood swings milder. He had been married to his wife for 24 years, and described her as the boss, reporting that he relied on her for a lot. It was noted they have three children and were raising two grand children in their house. The veteran indicated that he goes out to dinner and visits his family with his wife, but he denied having any friends. He denied any substance problems or suicide attempts. The veteran wore a hat, a t-shirt, and shorts, and it was noted that his hair was unkempt under his hat and his mustache was untrimmed. The veteran arrived two hours early for his examination and he was cooperative and friendly and his affect was appropriate. He was oriented to person, place, and time; and his thought processes were intact. He did not have any delusions or hallucinations and he understood the outcome of his behavior. No inappropriate behavior was noted. The veteran reported some ritualistic behavior such as checking the stove and water before leaving the house, but he denied any panic attacks or suicidal or homicidal ideations. The veteran was found to have fair impulse control and no episodes of violence, although he had threatened his neighbor due to loud music three months earlier. Additionally it was noted that the veteran was getting road rage and confronting others, which had previously caused him to be taken off driving responsibility at work. The veteran reported that he then got Social Security and retired. The examiner assigned a GAF of 48 noting that it would be lower if not for the medication. As described above, the veteran's claims file contains VA treatment records from throughout the course of his appeal. While each individual record was not fully discussed, when taken as a whole, the treatment records mirrored the results found on the multiple VA examinations. Throughout the course of his appeal, the veteran's treatment records described bipolar disorder with no more than moderate symptoms. The veteran has had the normal stresses of life, such as children going through separations (noted in July 2003); his family having financial difficulty such as his wife losing her job; having children and grandchildren move home; having stress at work; worrying about the economy; and worrying about the Iraq war among others. Nevertheless, the veteran has denied ever having suicidal or homicidal ideations, his judgment and insight have consistently been found to be fair, and his speech has routinely been natural, logical and coherent. The veteran has also been well-groomed at most treatment sessions and he has always been alert and oriented. The medical evidence shows that the veteran has both occupational and social impairment as a result of his bipolar disorder. However, the veteran's bipolar disorder has been consistently found to be moderate throughout much of his appeal. Even when the bipolar disorder was not specifically described as moderate, the veteran's GAF scores did not change from those assigned when it was specifically found to be moderate. While the veteran no longer works, this is largely due to non-service connected physical disabilities, as even though he would have irritability due to his bipolar disorder at work, he did not cease working until the physical ailments rendered him no longer able to complete the requirements of the job. Additionally, while the veteran describes himself as a loner without friends, he nevertheless has a strong family relationship. He has been married to his wife for 25 years and they have had several children live with them throughout the course of this appeal and have taken custody of two grandchildren. While there is no doubt that these situations, and financial struggles, could create added stress and anxiety that alone does not justify a rating in excess of 50 percent for bipolar disorder. In the Joint Motion, the veteran's representative questioned how the veteran's GAF score could drop from 80/85 to 48 while the veteran maintained the same 50 percent disability rating. However, this is more a reflection that the veteran's initial rating at the beginning of his appeal period was too high, rather than showing that his bipolar disorder is presently underrated. The veteran's symptoms from throughout the course of his appeal show that while the veteran's bipolar disorder clearly affected his life, it was not totally disabling and it did not cause deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. The veteran has a good family life. He has been married to the same woman for roughly 25 years and they have several children and grandchildren who have lived at home at various times during the course of this appeal. The veteran did retire from work once he received SSA disability, but this was largely caused by his numerous physical ailments, as the veteran was able to work for many years with his bipolar disorder, even working double shifts, six days per week, prior to the onset of his physical problems. While a GAF score between 41-50 is assigned for either serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or for any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job); it is noted that the higher the score, the milder the symptomatology. Thus, the GAF of 48 is on the milder side of that rating. Additionally, the GAF score is merely a snap shot of the veteran's condition on a single day throughout the course of his appeal. As such, while the veteran received a single GAF score of 48, he received numerous GAF scores of 51, which is assigned for either moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or for moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with co-workers). As such, the veteran was consistently assigned GAF scores that were consistent with moderate symptoms they are taken as more representative of the veteran's condition than are a few lower scores. Regardless of the GAF scores, the treatment records and VA examinations reports also fails to show the severity of symptomatology that is associated with a rating in excess of 50 percent. The record is void of any reports of suicidal ideation; and the veteran's speech has not been intermittently illogical, obscure, or irrelevant. The veteran has not complained of near-continuous panic; and, while the Joint Motion pointed out that the veteran complained about having depression 90 percent of the time, the treatment records fail to show that the veteran's depression affects his ability to function independently, appropriately and effectively; as even when depression was noted in the treatment records it was only of an intensity of 5/10. The veteran has also been irritable at times, but he has not been shown to resort to violence at these times. The veteran has not shown spatial disorientation; and while he occasionally has not shaved for treatment sessions or has been noted to have unkempt hair (such as at his VA examination in July 2007), the veteran was frequently found to be well groomed (such as at his VA treatment session in February 2007), and his hygiene has not been questioned. Additionally, while the veteran at one point complained about obsessional rituals, they were never shown to be of such severity that they would interfere with his routine activities. The Joint Motion also pointed out that the veteran reported not liking to associate with people. Nevertheless, the veteran has remained married to his wife for 25 years, he has three children and several grandchildren, most of whom have lived with the veteran and his wife during the course of his appeal; and the veteran has reported at several treatment sessions that taking care of his grandchildren has kept him quite busy. Furthermore, while the veteran had a somewhat tumultuous experience at work, he reported that his boss understood him, and he appears to have had a good relationship with at least one of his bosses. The Joint Motion also notes that the veteran lost a lot of weight; but there is no indication in the medical evidence that the veteran was malnourished or that medical intervention was needed on account of the weight loss. That the veteran's bipolar disorder impairs his life is not in dispute. However, his symptoms are simply not of the severity to warrant a rating in excess of 50 percent. The examiner at the last examination indicated that the veteran's symptoms would be more severe if his medication was not working, but the veteran's rating is based in part on the ability of medication to stabilize the impact of his disorder. Therefore, while the veteran's condition may have deteriorated somewhat from the initiation of his claim, his symptoms are not of the severity necessary for a 70 percent rating. As such, the veteran's claim is denied. II. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2007); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2007). Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (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 in accordance with 38 C.F.R. § 3.159(b)(1). Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In addition, the notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. VCAA notice errors are presumed prejudicial unless VA shows that the error did not affect the essential fairness of the adjudication. To overcome the burden of prejudicial error, VA must show (1) that any defect was cured by actual knowledge on the part of the claimant; (2) that a reasonable person could be expected to understand from the notice what was needed; or, (3) that a benefit could not have been awarded as a matter of law. See Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). For an increased-compensation claim, § 5103(a) requires, at a minimum, that VA notify the claimant that, to substantiate a claim, the medical or lay evidence must show a worsening or increase in severity of the disability, and the effect that such worsening or increase has on the claimant's employment and daily life. Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008). Further, if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by demonstrating a noticeable worsening or increase in severity of the disability and the effect that worsening has on employment and daily life (such as a specific measurement or test result), VA must provide at least general notice of that requirement. VA must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask the Secretary to obtain) that are relevant to establishing entitlement to increased compensation. Id. In this case, a letter satisfying the notice requirements under 38 C.F.R. § 3.159(b)(1) was sent to the veteran in August 2006, informing him of what evidence was required to substantiate the claim and of his and VA's respective duties for obtaining evidence. He was also asked to submit evidence and/or information in his possession to the RO. The letter also informed the veteran how disability ratings and effective dates were calculated. The Board acknowledges that the VCAA letter sent to the veteran in August 2006 does not meet all the requirements of Vazquez-Flores and is not sufficient as to content and timing, thereby creating a presumption of prejudice. Nonetheless, such presumption has been overcome for the reasons discussed below. In this case, the veteran was provided with correspondence regarding what was needed to support his claim. Specifically, the statement of the case in August 2000 provided the veteran with notice of the rating criteria for rating a bipolar disorder; and the veteran's claim was readjudicated following provision of this information. See Overton v. Nicholson, 20 Vet. App. 427, 437 (2006). Additionally, the Joint Motion for remand based an argument around the rating criteria, demonstrating that at the very least, the veteran's representative had actual knowledge of what was needed to support the veteran's claim. As such, any notice deficiencies do not affect the essential fairness of the adjudication. Therefore, the presumption of prejudice is rebutted. For this reason, no further development is required regarding the duty to notify. VA treatment records have been obtained; as have SSA records and several letters from the veteran's former employer. The veteran was also provided with several VA examinations (the reports of which have been associated with the claims file). Additionally, the veteran testified at a hearing before the RO and he was offered the opportunity to testify at a hearing before the Board, but he declined. VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the veteran in adjudicating this appeal. ORDER A rating in excess of 50 percent for a bipolar disorder is denied. ____________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs