Citation Nr: 1302292 Decision Date: 01/22/13 Archive Date: 01/31/13 DOCKET NO. 10-01 465 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to an increased initial evaluation for major depressive disorder, initially evaluated as 30 percent disabling. 2. Entitlement to an increased evaluation for diabetes mellitus, currently evaluated as 20 percent disabling. 3. Entitlement to a disability evaluation in excess of 10 percent for hypertension. 4. Entitlement to an award of total disability compensation based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Allen T. Fenley, Attorney at Law ATTORNEY FOR THE BOARD Tresa M. Schlecht, Counsel INTRODUCTION The Veteran had active service from August 1965 to January 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2008 and November 2008 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New York City, New York. By a January 2008 rating decision, the Veteran was awarded service connection for major depressive disorder. An initial 30 percent rating was assigned, effective October 4, 2007. A November 2008 rating decision continued the initial 30 percent evaluation for major depressive disorder, in addition to addressing other claims. The Veteran disagreed with the November 2008 decision in December 2008, before the January 2008 initial rating for major depressive disorder became final. The Board interprets the December 2008 notice of disagreement (NOD) as a disagreement with the initial evaluation for major depressive disorder assigned in the January 2008 rating decision as well as a disagreement with the denials of service connection addressed in the November 2008 rating decision. Additional evidence was added to the record after the last November 2008 statement of the case. The Board sent the Veteran a letter in October 2012 asking the Veteran whether he wanted to waive RO consideration of the new evidence or have the case remanded back to the RO. The Veteran submitted a response form received by the Board on October 31, 2012 noting that he wanted his case remanded for RO consideration. However, his attorney submitted the same form that was received on October 31, 2012 and noted that they wanted to waive RO consideration of the evidence. As the issues below are being remanded, a clarification is not necessary. The following claims are addressed in the REMAND portion of the decision below: claim for an initial evaluation for major depressive disorder in excess of 50 percent prior to June 11, 2008 on an extraschedular basis; the claim for an initial evaluation in excess of 30 percent for major depressive disorder, from June 11, 2008, on a schedular or extraschedular basis; the claim for an evaluation in excess of 20 percent for diabetes mellitus; the claim for an evaluation in excess of 10 percent for hypertension; and, the claim for an award of TDIU. These claims are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT Effective October 4, 2007 through June 11, 2008, the Veteran's difficulty in establishing and maintaining effective work and social relationships, sleep disturbance, depression, occasional suicidal ideation and hallucinations, productive of occupational and social impairment comparable to no more than reduced reliability and productivity. CONCLUSION OF LAW Effective October 4, 2007 through June 11, 2008, the criteria are met for a 50 percent initial evaluation, but no higher initial evaluation, for the Veteran's major depressive disorder. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.130, Diagnostic Code 9434 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Before addressing the merits of the appeal, the Board will address VA's duties to the Appellant. Duty to Notify As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist a claimant who is seeking to substantiate a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). In cases such as this appeal for an increased initial rating, where service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering 38 U.S.C.A. § 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, supra; Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Regardless, the Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Prinicipi, 353 F.3d 1369 (Fed. Cir. 2004). Letters satisfying the notice requirements were sent to the Veteran in October 2007, May 2008, and August 2009, followed by readjudication of the claim in a November 2009 statement of the case. The appellant bears the burden of demonstrating any prejudice from defective notice with respect to the downstream elements. Goodwin v. Peake, 22 Vet. App. 128 (2008). That burden has not been met in this case. Duty to Assist In addition, the duty to assist the Veteran to develop the claim is fulfilled. VA has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, as to the evaluation addressed in the decision below, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained and the Veteran has submitted VA and private treatment records. Records were requested from the Social Security Administration (SSA). In May 2008, SSA provided a written response that searches had failed to disclose any records for the Veteran. The Veteran has been notified of this negative response for SSA records by way of the November 2009 statement of the case. Moreover, the record indicates that the Veteran retired in 2000 after a head injury on-the-job, rather than due to any psychiatric disability. Therefore, it does not appear that any SSA records, if they exist, would be relevant to the Veteran's claim on appeal. The Veteran was afforded two VA medical examinations for his major depressive disorder during the period addressed in the decision below, the first in November 2007 and the second in June 2008. Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the portion of the claim for an increased initial rating for major depressive disorder that is addressed below. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). The record establishes the Veteran was afforded a meaningful opportunity to participate in the adjudication of the claim. See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). All requirements of the duty to notify the Veteran and the duty to assist the Veteran are met. Facts and analysis The RO granted service connection for a major depressive disorder in January 2008 and assigned a 30 percent rating, effective October 4, 2007. The Veteran attended a VA examination in November 2007. The Veteran had retired from work based on disability several years prior to the examination. He reported conflict with his wife. He reported difficulties with short-term memory in everyday activities, such as taking medications. Long-term memory was intact. There was no obsessive or ritualistic behavior, however, he described frequent anxiety and panic attacks. He had no interaction with the community, except for superficially with neighbors. He rarely interacted with his wife, except during arguments. He reported missing work a few days a year when he was employed. He also indicated constant depression with short periods of difficulty with personal hygiene, with such severe depression lasting less than two days at a time. Chronic sleep impairment was noted. The examiner stated that the Veteran's demeanor and behaviors were consistent with his reports of depression. The examiner found the Veteran's symptoms moderate. The Veteran had ceased attending group therapy because several of the aging Veterans in the group with whom he had formed bonds had died. The examiner assigned a Global Assessment of Functioning (GAF) score of 50. VA outpatient treatment records from November 2007 through June 2008 reflect that the Veteran requested assignment to another PTSD group in March 2008, as he felt his symptoms had increased after he stopped attending group sessions. The Veteran continued with medications and individual care. On June 11, 2008, the Veteran was again afforded VA examination. He continued on medication for depression and other psychiatric diagnoses. He reported that he was "doing about the same." There was no apparent thought disorder. The Veteran made good eye contact. He denied suicidal or homicidal ideation. The examiner stated that the Veteran was "modestly" symptomatic. A GAF score of 50 for service-connected depression was assigned; the same GAF score, 50, was assigned for PTSD (for which service connection is not in effect). No examiner has distinguished between occupational and social impairment due to PTSD and between occupational and social impairment due to the service-connected disability. Specifically, the June 2008 VA examiner noted that there was only an apparent discrepancy between his clinical treatment for PTSD and major depression, as these psychiatric diagnoses often occurred as co-morbid conditions, with severities that go "hand-in-hand." The Board is precluded from differentiating between symptomatology attributed to a non service-connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam), citing Mitchem v. Brown, 9 Vet. App. 136, 140 (1996). Therefore, all symptoms of impairment described in the VA examinations are addressed in this decision. Disability ratings are based on the average impairment of earning capacity resulting from a disability. 38 U.S.C.A. § 1155 (West 2002); 38 C.F.R. § 4.1 (2012). An evaluation of the level of disability present includes consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.10. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluations will be assigned if the disability more closely approximates the criteria required for that rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. See 38 C.F.R. §§ 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). In Fenderson v. West, 12 Vet. App 119 (1999), the United States Court of Appeals for Veterans Claims (Court) emphasized the distinction between a new claim for an increased evaluation of a service-connected disability and a case, such as this one, in which a veteran expresses dissatisfaction with the assignment of an initial disability evaluation where the disability in question has just been recognized as service-connected. VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the life of the claim-a practice known as "staged rating." See also Hart v. Mansfield, 21 Vet. App 505 (2007). In this case, there has not been a material change in the level of impairment in the left knee and uniform ratings are warranted. The Veteran bears the burden of presenting and supporting his claim for benefits. 38 U.S.C.A. § 5107(a). In its evaluation, the Board considers all information and lay and medical evidence of record. 38 U.S.C.A. § 5107(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Board gives the benefit of the doubt to the claimant. Id. The Veteran's major depressive disorder is rated under Diagnostic Code 9434. A 30 percent evaluation is warranted where there is 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). A 50 percent evaluation requires occupational and social impairment with reduced reliability and productivity due to symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks occurring more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material or forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation requires occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; 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 work-like setting); and an inability to establish and maintain effective relationships. A 100 percent evaluation requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting herself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. Diagnostic Code (DC) 9434. Symptoms listed in the VA's general rating formula for mental disorders serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating, and are not intended to constitute an exhaustive list. See Mauerhan v. Principi, 16 Vet. App. 436, 442-44 (2002). The nomenclature employed in the rating formula is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, of the American Psychiatric Association (DSM-IV). See 38 C.F.R. § 4.130. According to the applicable rating criteria, when evaluating a mental disorder, the frequency, severity, duration of psychiatric symptoms, length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. See 38 C.F.R. § 4.126(a). In addition, the evaluation must be based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. Id. Further, when evaluating the level of disability from a mental disorder, the extent of social impairment is considered, but the rating cannot be assigned solely on the basis of social impairment. See 38 C.F.R. § 4.126(b). In evaluating the evidence, the Board has also considered various Global Assessment of Functioning (GAF) scores which the clinicians have assigned. A GAF score is a scaled rating reflecting the "psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness." Richard v. Brown, 9 Vet. App. 266, 267 (1996) (citing DSM-IV at 32). An examiner's classification of the level of psychiatric impairment at the moment of examination, by words or by a GAF score, is to be considered, but it is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. See generally 38 C.F.R. § 4.126; VAOPGCPREC 10-95 (March 31, 1995). The Board notes that an examiner's classification of the level of psychiatric impairment, by words or by a GAF score, is to be considered but is not determinative of the percentage rating to be assigned. See VAOPGCPREC 10-95. GAF scores ranging between 41 and 50 are assigned when there are 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). The VA examiners described the Veteran's symptoms as modest or moderate. The evidence reflects that, at least at times, the Veteran's symptoms increased, and he had occasional brief periods of inability to maintain hygiene. The potential impact of the Veteran's symptoms of depression on industrial functioning was not demonstrated during this period, since the Veteran was not working reportedly since September 2000, and reported that he was retired as the result of head injury and seizure disorder incurred on the job. The Veteran's symptoms caused moderate difficulty in establishing and maintaining effective social relationships. He indicated that he had limited involvement in the community and only superficial interaction with neighbors, and had few friends and few leisure activities. He reported conflict with his wife, who was the person he interacted with most consistently. His mood was often depressed, sometimes to the point of not caring for personal hygiene, and he often had trouble concentrating and remembering things. In addition he described frequent panic and anxiety attacks. The Veteran displayed some significant symptoms consistent with a 50 percent schedular evaluation, specifically impairment in short-term memory, disturbances of motivation and mood, and difficulty establishing and maintaining effective social relationships. He also described frequent panic and anxiety attacks, which could arguably be considered as occurring more than once a week. Thus, the evidence warrants assignment of a 50 percent rating for the portion of the appeals period addressed in this decision. However, at no time during the appeals period is the Veteran entitled to a schedular rating greater than 50 percent. The evidence does not support a finding that the there have been deficiencies in most areas. In particular, the evidence reflects that the Veteran maintained relationships adequate to obtain and maintain regular health care. He reported conflict with his wife, but remained married. He maintained relationships with his children and he was able to visit with his grandchildren during the Christmas holidays. He reported that he was happy to see his grandchildren. As such, the Board finds that the Veteran's social functioning was, at worst, consistent with no more than moderate impairment. There is no evidence of such serious symptoms as suicidal ideation, obsessional rituals, illogical, obscure, or irrelevant speech, spatial disorientation. Reported occasional neglect of personal appearance and hygiene was for brief periods of time. Two GAF scores were assigned during the portion of the appeal addressed in this decision, both of which were 50. As previously mentioned, GAF scores ranging between 41 and 50 are assigned when there are 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). See Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Washington, D.C., American Psychiatric Association (1994) (DSM-IV). The Board notes that a GAF score generally reflects an examiner's finding as to the Veteran's functioning score on that day and, like an examiner's assessment of the severity of a condition, is not dispositive. Rather, the GAF score 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). The Board finds that the range of 41-50 is not consistent with most of the evidence of record. While the Veteran's depression symptoms are significant, they are not shown to be serious, as denoted for a GAF score of 50. The Veteran has never been shown to have serious symptoms, such as suicidal ideation, obsessional rituals, or frequent shoplifting; nor is he shown to have serious impairment in social or occupational functioning. He indicated that he missed some work due to his depression when he was working, but was not shown to be unable to keep a job. His retirement was reportedly due to an injury unrelated to his depression. He also had some friends and was married, and also maintained a relationship with his children. The Board also notes that his GAF score of 50 is close to the next higher GAF score range of 51-60, which reflects 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). See DSM-IV. These findings are best reflected in the assignment of a 50 percent rating. Thus, the Board has determined that the 50 percent rating is more appropriate. The claim for TDIU is addressed in the Remand, below, and the question of entitlement to a higher evaluation for major depressive disorder on an extraschedular basis should be considered after the development directed on Remand is conducted. Therefore, the claim for a higher rating on an extraschedular basis, including during the period addressed on a schedular basis in this decision, is also addressed in the Remand below. The Board finds no symptom or group of symptoms of such severity as to warrant a schedular evaluation in excess of 50 percent through June 11, 2008. As noted in the Remand below, the Veteran reports that his service-connected psychiatric disorder has increased in severity. The evidence of record establishes that the increased severity did not begin until after the VA examination conducted on June 11, 2008. Therefore, a 50 percent evaluation, but no higher evaluation, is assigned through the date of the examination, June 11, 2008. There is no period prior to June 11, 2008, when the symptoms approximated the criteria for a 70 percent rating, so further staging of the rating is not warranted. The preponderance of the evidence is against an initial rating greater than 50 percent. Because the evidence is not in equipoise, the provisions of 38 U.S.C.A. § 5107(b) regarding reasonable doubt are not applicable to warrant a more favorable result. Therefore, the Veteran is granted a 50 percent rating, but no higher, for the entire appeals period. ORDER Effective from October 4, 2007 through June 11, 2008, an increase to 50 percent, but not higher, in the initial schedular evaluation assigned for major depressive disorder is granted, subject to law and regulations governing the effective date of an award of monetary compensation; the appeal is granted to this extent only. REMAND The Veteran has disagreed with the ratings assigned for his major depressive disorder, hypertension, and diabetes mellitus. He was last evaluated for some of his disabilities in June 2008. On his notice of disagreement and VA Form 9 appealing the ratings assigned for his claims, he and his representative have asserted that he should be entitled to a more recent examination to address the present severity of his disabilities. The record shows that the Veteran underwent a general VA examination in June 2008. Regarding the physical findings for diabetes mellitus it notes that the reader shoulder reference the "GM Exam Worksheet" but there is no additional information concerning this disability in the record. And the examination report as it is does not address the relevant criteria for adjudicating the diabetes claim. Hypertension is not addressed at all. With respect to the depression claim, the VA outpatient clinical records associated with the claims file disclose no assignment of a GAF score since the most recent VA psychiatric examination of record, conducted June 11, 2008. Thus, the record does not provide a complete picture of occupational and social functioning from June 11, 2008. As the Veteran has essentially contended that his disabilities have increased in severity since they were last evaluated in June 2008, to the extent that they were, in fact, evaluated, additional examination is warranted to address the Veteran's claims. In addition, the claims file reflects that the Veteran is treated by a private neurologist. The claims file, including 204 pages of VA treatment records dated through June 2011, does not reflect that the Veteran receives current treatment for diabetes or hypertension. The VA records fail to establish that diabetes or hypertension have resolved, so the Board assumes that some treatment records should be available. The Veteran must be asked to identify the current source of treatment for those disabilities before the disabilities may be evaluated. After all necessary development has been conducted, the claim of entitlement to TDIU should be addressed. The issue of an increased evaluation for major depressive disorder on an extraschedular basis, either before or after June 11, 2008, should be readjudicated after all development necessary to adjudicate the claim for TDIU has been completed. Accordingly, the case is REMANDED for the following action: 1. Obtain and associate with the claims file or virtual file all relevant VA treatment records pertaining to depression, diabetes mellitus, and hypertension from June 2011 to the present. 2. Ask the Veteran to identify each private or non-VA provider who has treated him for a psychiatric disorder, or diabetes mellitus, or for hypertension. With the Veteran's consent, as appropriate, obtain any identified records, or advise the Veteran that it is his responsibility to submit them. 3. Ask the Veteran to identify any VA clinical records which would show treatment of a psychiatric disorder, or diabetes mellitus, or for hypertension, such as records of blood pressure checks, pharmacy or medication records, and the like. 4. Afford the Veteran cardiovascular evaluation to describe the severity of hypertension from April 2007 to the present, including a description of the current severity. The examiner should review private and/or VA clinical records from April 2007 to the present. The claims folder must be made available for review by the examiner and the examination report must state whether such review was accomplished. All indicated tests and studies should be conducted as deemed necessary by the examiner. Specifically the examiner should address the following: (a) The examiner should provide an opinion as to whether the Veteran's diastolic blood pressure is predominantly 110 or more and has definite symptoms, or is predominantly 120 or more. (b) If the Veteran manifested an increase in the severity of hypertension during any portion of the appeal period, the examiner should describe the beginning and ending dates of an increased severity of hypertension during the period from April 2007 to the present. (c) The examiner should also discuss the extent to which the service-connected hypertension affects the Veteran's daily life and industrial capability. If the examiner is unable to provide any requested opinion, the examiner should expressly discuss why it is not possible to provide the requested opinion. 5. Afford the Veteran evaluation of the severity of diabetes mellitus from April 2007 to the present. The claims folder must be made available for review by the examiner and the examination report must state whether such review was accomplished. The examiner should review private and/or VA clinical records from April 2007 to the present. Specifically the examiner should address the following: (a) Is the severity of the Veteran's diabetes mellitus such that regulation of activities is required? (b) Are the Veteran's activities limited by disorder other than diabetes mellitus? (c) Is the severity of the Veteran's diabetes mellitus such that a restricted diet is medically required for control of the diabetes mellitus? (d) Does the Veteran's diabetes mellitus require control through use of insulin? (e) The examiner should state whether the Veteran has experienced episodes of ketoacidosis or hypoglycemia requiring hospitalization or twice monthly outpatient treatment at any time during the period since April 2007. (f) The examiner should also discuss the extent to which the service-connected diabetes affects the Veteran's daily life and industrial capability. (g) The examiner should also describe the severity of any symptoms or complications of diabetes mellitus, so that it may be determined whether there are symptoms or complications of diabetes mellitus which may be separately evaluated. (h) If the Veteran manifested an increase in the severity of diabetes during any portion of the appeal period, the examiner should describe the beginning and ending dates of an increased severity during the period from April 2007 to the present. The examiner should discuss the rationale underlying the answer to each question. If the examiner is unable to provide any requested opinion, the examiner should expressly discuss why it is not possible to provide the requested opinion. 6. Afford the Veteran evaluation of the severity of major depressive disorder since June 11, 2008. The examiner should review private and/or VA clinical records from June 11, 2008 to the present. The claims folder must be made available for review by the examiner and the examination report must state whether such review was accomplished. All indicated tests and studies should be conducted as deemed necessary by the examiner. The examination report should include a complete discussion of the Veteran's subjective complaints, findings on mental status examination, and a multi-axial diagnosis with Global Assessment of Functioning (GAF) score. In particular, the examiner should discuss all disorders which affect the Veteran's psychiatric functioning, and should assign a diagnosis for each disorder present. The examiner should distinguish between symptoms of the Veteran's service-connected major depressive disorder and symptoms of any psychiatric disorder for which service connection is not in effect, to the extent medically possible. The examiner should explain the rationale for determining the frequency and severity of the symptoms of major depressive disorder and how symptoms of that service-connected disability may be medically distinguished from symptoms of other disorders. If the examiner cannot distinguish among various psychiatric symptomatology, this should be indicated. The examiner should also discuss the extent to which the service-connected major depressive disorder affects the Veteran's daily life and industrial capability, and should describe the effects from April 2007 to the present, identifying any increases or decreases in the impact of the major depressive disorder on employability during that period. A complete rationale for any opinion expressed shall be provided. 7. The agency of original jurisdiction (RO/AMC) should provide a list of the Veterans' service-connected disabilities to the examiner who is to conduct general medical review for purposes of addressing the claim for TDIU. 8. After the development listed in paragraphs #1 through #7 above has been completed, an appropriate examiner should be asked to address the questions set forth below. The reviewer should be advised of the following: A Veteran is entitled to TDIU when service-connected disabilities result in individual unemployability, regardless of advancing age, without reference to disorders for which service connection is not in effect. The reviewer should address the following: (a) Provide an opinion as to the types of activities required by employment that the Veteran would be unable to perform currently as a result of his service-connected disabilities. (b) Has impairment due to service-connected disabilities varied from April 2007 to the present? (c) If there is a period when the Veteran's employability improved, indicate the additional employment tasks the veteran was able to perform during the period of improvement, and indicate the beginning and ending dates of that period. (d) If there is a period or periods when the service-connected disabilities caused a decreased ability to perform the tasks required for employment, as compared to the Veteran's present ability to perform occupational tasks, indicate the indicate the additional employment tasks the Veteran was unable to perform during the period of decreased industrial capability, and indicate the beginning and ending dates of each such period. The rationale for each opinion expressed should be provided. If any requested opinion cannot be provided without resort to pure speculation, the reviewer should so indicate, and explain the reasoning underlying the conclusion that it is not possible to provide the opinion requested. 9. After completing the above actions, and any other development indicated, and with consideration of all evidence that has been added to the file since the last November 2009 statement of the case, readjudicate the claims for increased evaluations for hypertension and diabetes mellitus, including consideration of schedular and extraschedular criteria from April 2007. Readjudicate the claim for an increased evaluation on an extraschedular basis for major depressive disorder prior to June 11, 2008, and the claim for an increased schedular evaluation for major depressive disorder from June 11, 2008. Then, readjudicate the claim for TDIU. If any claim remains denied, a supplemental statement of the case (SSOC) must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal should be returned to the Board for appellate review, if appropriate. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ SARAH B. RICHMOND Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs