Citation Nr: 1314867 Decision Date: 05/06/13 Archive Date: 05/15/13 DOCKET NO. 12-11 440A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Whether new and material evidence has been submitted sufficient to reopen a claim for service connection for depression with psychosis, claimed as a mental condition. 2. Entitlement to service connection for a psychiatric disorder, to include bipolar disorder, schizophrenia, psychotic disorder not otherwise specified, major depressive disorder, and mood disorder. 3. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU). REPRESENTATION Appellant represented by: James Brakewood, Jr., Agent ATTORNEY FOR THE BOARD M. Zawadzki, Counsel INTRODUCTION The Veteran served on active duty from August 2003 to February 2007. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which, in pertinent part, confirmed and continued a previous denial of service connection for depression with psychosis (also claimed as a mental condition). In April 2011, the Veteran filed a claim for a TDIU. Although the RO advised the Veteran via letter in September 2011 that his claim for a TDIU could not be processed, this issue was included in the May 2012 statement of the case (SOC). The Veteran subsequently submitted a VA Form 9 indicating that he wanted to appeal all of the issues listed on the SOC. In light of the inclusion of this issue in the May 2012 SOC, and the Veteran's subsequent timely filing of a VA Form 9, this issue has also been included on the title page. While, in the September 2010 rating decision, the RO reopened the claim for service connection for depression with psychosis and addressed the claim for service connection on the merits, regardless of the RO's actions, the Board has a legal duty under 38 U.S.C.A. §§ 5108, 7104 (West 2002) to address the question of whether new and material evidence has been received to reopen the claim for service connection. That matter goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim on a de novo basis. See Barnett v. Brown, 83 F. 3d 1380, 1383 (Fed. Cir. 1996). As the Board must first decide whether new and material evidence to reopen the claim has been received, this matter on appeal has been characterized as reflected on the title page. Additionally, while the RO has characterized the issue on appeal as entitlement to service connection for depression with psychosis (also claimed as a mental condition), recent medical evidence reflects findings of and treatment for several psychiatric conditions, including, bipolar disorder, schizophrenia, psychotic disorder not otherwise specified, major depressive disorder, and mood disorder. Accordingly, the reopened claim has been characterized as reflected on the title page. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of a mental health disability claim includes any mental disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). The Board has reviewed the contents of the Veteran's Virtual VA file and found that it contains additional medical evidence that was considered by the RO in the most recent supplemental statement of the case (SSOC). Therefore, the Board's consideration of this evidence will not result in prejudice to the Veteran. The Board's decision reopening the claim for service connection for depression with psychosis is set forth below. The remaining issues listed on the title page are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. All notification and development action needed to fairly adjudicate the claim herein decided has been accomplished. 2. In a January 2008 rating decision, the RO denied service connection for depression with psychosis, also claimed as a mental condition. Although notified of the denial in a February 2008 letter, the Veteran did not initiate an appeal. 3. Evidence associated with the claims file since the January 2008 denial, when considered by itself or in connection with evidence previously assembled, relates to an unestablished fact necessary to substantiate the claim for service connection for a mental condition and raises a reasonable possibility of substantiating the claim. CONCLUSIONS OF LAW 1. The RO's January 2008 rating decision denying service connection for depression with psychosis, also claimed as a mental condition, is final. 38 U.S.C.A. § 7105(c) (West 2002); 38 C.F.R. §§ 3.104(a), 20.302(a), 20.1103 (2012). 2. As pertinent evidence received since the January 2008 denial is new and material, the criteria for reopening the claim for service connection for depression with psychosis, also claimed as a mental condition, are met. 38 U.S.C.A. §§ 5108, 7105 (West 2002); 38 C.F.R. § 3.156 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's 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. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Given the favorable disposition of the request to reopen the claim for service connection, the Board finds that all notification and development actions needed to fairly adjudicate this claim have been accomplished. Factual Background and Analysis VA may reopen and review a claim that has been previously denied if new and material evidence is submitted by or on behalf of a veteran. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). See also Hodge v. West, 155 F. 3d 1356 (Fed. Cir. 1998). Regarding petitions to reopen filed on or after August 29, 2001, 38 C.F.R. § 3.156(a) defines "new" evidence as evidence not previously submitted to agency decision makers and "material" evidence as evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Service connection may be established for disability resulting from personal injury or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability on the basis of the merits of such claim is focused upon (1) the existence of a current disability, (2) the existence of the disease or injury in service, and (3) a relationship or nexus between the current disability and any injury or disease during service. See Cuevas v. Principi, 3 Vet. App. 542 (1992); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Psychoses will be presumed to have been incurred in service if manifested to a compensable degree (meaning to at least 10-percent disabling) within one year of separation from service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). According to 38 C.F.R. § 3.384, a "psychosis" includes the following specific disorders: brief psychotic disorder, delusional disorder, psychotic disorder due to general medical condition, psychotic disorder not otherwise specified, schizoaffective disorder, schizophrenia, schizophreniform disorder, shared psychotic disorder, and substance-induced psychotic disorder. Every person employed in the active military, naval, or air service shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. See 38 U.S.C.A. §§ 1111, 1137. In July 2003, the VA General Counsel issued a precedent opinion holding that to rebut the presumption of soundness in 38 U.S.C.A. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. See VAOPGCPREC 3-2003 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. Id. See also Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). Generally, a pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability was due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). The underlying disorder, as opposed to the symptoms, must be shown to have worsened in order to find aggravation. See Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Generally speaking, personality disorders are "defects" that are not "diseases" or "injuries" within the meaning of applicable legislation for VA disability compensation purposes and, therefore, cannot be service connected as a matter of express VA regulation. 38 C.F.R. §§ 3.303(c), 4.9, 4.127. Defects are defined as "structural or inherent abnormalities or conditions which are more or less stationary in nature." VAOPGCPREC 82-90 (July 18, 1990). Congenital or developmental "defects," such as a personality disorders, automatically rebut the presumption of soundness and therefore are considered to have preexisted service. 38 C.F.R. §§ 3.303(c), 4.9; Quirin v. Shinseki, 22 Vet. App. 390, 397 (2009); Winn v. Brown, 8 Vet. App. 510, 516 (1996) (holding that the Secretary's exclusion of personality disorders from "diseases" or "injuries" as a congenital or developmental defect, such that the presumption of soundness does not apply, to be a valid exercise of the authority granted to the Secretary). Personality disorders are not diseases or injuries for compensation purposes and, except as provided in 38 C.F.R. § 3.310(a), disability resulting from them may not be service-connected. 38 C.F.R. § 4.127. However, disability resulting from a mental disorder that is superimposed upon a personality disorder may be service connected, and, in accordance with 38 C.F.R. § 3.310(a), personality disorders that result from service connected disabilities may be service connected on a secondary basis. Id. See also VAOPGCPREC 82-90 (July 18, 1990) (noting that congenital and developmental defects can be subject to superimposed disease or injury such that service connection may be granted where the superimposed disease or injury occurs during service); 61 Fed. Reg. 52,695 (explaining that "except as provided in § 3.310(a) in this chapter" § 4.127 was added for reinforce the principle that organic personality disorders that develop secondary to head trauma, epilepsy, etc., will be service connected secondary to these conditions). In October 2007, the Veteran filed a claim for service connection for a mental condition. In the January 2008 rating decision the RO denied service connection for depression with psychosis, also claimed as a mental condition, finding that while there was a record of treatment in service for depression with psychosis, no permanent residual or chronic disability subject to service connection was shown by the service treatment records or the evidence following service. Although notified of the January 2008 rating decision by letter in February 2008, the Veteran did not initiate an appeal; hence, that decision is final as to the evidence then of record, and is not subject to revision on the same factual basis. See 38 U.S.C.A. § 7105(b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. In addition, no new and material evidence was received within one year of the January 2008 rating decision. See 38 C.F.R. § 3.156(b). The Veteran sought to reopen his previously denied claim for service connection for a mental condition in May 2010. The provisions of 38 U.S.C.A. § 5108 require a review of all evidence submitted by or on behalf of a claimant since the last final denial on any basis to determine whether a claim must be reopened. See Evans v. Brown, 9 Vet. App. 273, 282-3 (1996). Here, the last final denial of the claim is the January 2008 rating decision. Furthermore, for purposes of the "new and material" analysis, the credibility of the evidence is presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The Court has held that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA must not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead must examine and determine if it could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary's duty to assist. Id. at 118. The evidence of record at the time of the January 2008 rating decision included service treatment records reflecting that, in his January 2003 Report of Medical History at enlistment, the Veteran denied having or ever having had nervous trouble of any sort, depression, or excessive worry. He indicated that he had never received counseling of any type or been evaluated or treated for a mental condition. On enlistment examination, clinical evaluation of the psychiatric system was normal. The service treatment records further reflect that, on November 14, 2006, the Veteran presented with a long history of being fearful, ashamed, and paranoid about things he had done in the past. He complained of feeling insecure with decreased interest level and feelings of guilt. He denied suicidal or homicidal ideations. The assessment was avoidant personality disorder, and the Veteran was referred to the mental health clinic. An undated record reflects that the Veteran was evaluated after attempting to obtain the gun of the gate guard to commit suicide precipitated by voices in his head telling him to kill himself. He reported that his mother had a history of a suicide attempt and depression and his maternal uncle and maternal grandfather had died from self-inflicted gunshot wounds. He reported that he started hearing voices in his head that week, but denied hearing voices prior to that time. The impression was that the Veteran was actively suicidal with probable schizophrenia. On November 17, 2006, the Veteran was admitted to the locked inpatient psychiatric ward at the Naval Medical Center in San Diego for evaluation after his attempt to grab a gun from a security officer to kill himself. During this hospitalization, the Veteran reported hearing voices in his head telling him that he was "evil" since childhood. He added that, up until two months earlier, he had been able to talk himself out of believing that the voices were real. He reported a prior psychiatric hospitalization at age 12 for depression and at age 22 for drug and alcohol rehabilitation. The narrative summary of this hospitalization reflects that the Veteran appeared to primarily have a personality disorder, exhibiting longstanding borderline, antisocial, and avoidant traits. He also reported a long history (since childhood) of depressive symptoms, delusions, and auditory hallucinations which, in the opinion of the examiners, were most likely best explained by a personality disorder diagnosis; however, a provisional diagnosis of major depressive disorder, recurrent, with psychotic features, was being considered. The Axis I diagnoses were alcohol dependence in sustained full remission, sexual disorder not otherwise specified, and a provisional diagnosis of major depressive disorder, recurrent, with psychotic features. The Axis II diagnosis was personality disorder, not otherwise specified, with borderline, antisocial, and avoidant features. It was determined that the Veteran was unsuitable for duty, and it was recommended that the Veteran be administratively separated. The Veteran's Form DD 214 reflects that the reason for his separation from service was a personality disorder. Post-service VA treatment records associated with the claims file at the time of the January 2008 rating decision reflect that, in April 2007, the Veteran was admitted to the VA hospital with auditory hallucinations and suicidal ideation. He was noted to have a history of major depression with psychosis and alcohol dependence. He reported that he started hearing voices during childhood, but they had gotten worse. The Axis I discharge diagnoses were major depressive disorder with psychotic features and alcohol dependence in partial sustained remission. During a May 2007 social work assessment, he reported that his family had a long history of psychiatric problems, including suicides. The Veteran's active problem was described as psychotic disorder, not otherwise specified. The impression following treatment in September 2007 included alcohol abuse and depression. The Veteran was afforded a VA mental disorders examination in December 2007. He gave a history of being diagnosed with depression in 2000, for which he tried Prozac, but not for long. He reported that he was hospitalized for a suicide attempt during service, and was not under the influence of alcohol at that time. The diagnoses at the time of the in-service hospitalization were noted to be personality disorder and depression with psychosis. The examiner noted that the Veteran had also been hospitalized for major depressive disorder with psychotic features and alcohol dependence in April 2007. He indicated that the Veteran had had an episode of severe depression with auditory hallucinations at that time which was treated with Risperdal and Zoloft. The Veteran stated to the examiner that he stopped taking these medications about two to three months earlier and no longer had auditory hallucinations. The Veteran denied feeling severe depression, but reported that he continued to struggle with feeling down from time to time. On mental status examination psychomotor activity, speech, thought process, and thought content were unremarkable; attention and orientation were intact; affect and memory were normal; and there were no delusions, hallucinations, panic attacks, or suicidal or homicidal thoughts. The Axis I diagnosis was major depressive disorder with psychotic features, recurrent, mild. The examiner commented that the Veteran had periods of severe depression when he was unable to function and needed hospitalization, with residual lack of motivation. The examiner opined that the Veteran's depression and psychosis were not caused by or a result of his depression requiring hospitalization in service as he had depression prior to being in service and there was no indication in the service records of any event which predisposed the Veteran to having another depressive episode. The examiner further noted that the Veteran had a large family history of severe depression and mood problems, which made it more likely that his depression was genetic in nature. The examiner added that the Veteran was predisposed to having recurrent depressive episodes given his family history and periodic use of alcohol. He commented that the psychosis was secondary to the Veteran's depression and resolved when his depression resolved and, therefore, was not connected to his military service. Based on the foregoing evidence, the RO denied service connection for depression with psychosis in the January 2008 rating decision. At the time of that rating decision, the medical evidence, in particular, the December 2007 VA examination report, indicated that the Veteran's mental condition was not caused by or a result of military service. His psychosis was described by the examiner as secondary to depression and was found by that examiner to have resolved when his depression resolved. Evidence associated with the claims file since the January 2008 rating decision includes private treatment records dated from June to September 2009 reflecting diagnoses of bipolar disorder, mixed, with psychotic features, and schizophrenia, paranoid type. Also associated with the claims file and Virtual VA e-folder since the January 2008 rating decision are VA treatment records dated from April 2007 to December 2011 which reflect findings of and treatment for bipolar affective disorder; bipolar I disorder with psychotic features; psychotic disorder, not otherwise specified; mood disorder, not otherwise specified; and depression. These VA treatment records include an April 2007 psychiatry outpatient note from the Pasco Outpatient Clinic (OPC) indicating that the Veteran agreed to voluntary admission to psychiatry at the Tampa VA Medical Center (VAMC). The psychiatrist's impression was major depression with psychosis and alcohol dependence. While VA treatment records dated in April 2007 were previously of record and considered at the time of the January 2008 rating decision, this psychiatry outpatient note, which reflects a finding of psychosis within one year after separation from service, was not. While the May 2007 social work assessment which was of record at the time of the prior final denial did list psychotic disorder, not otherwise specified, as the Veteran's active problem, the December 2007 VA examiner found that the Veteran's psychosis had resolved. Nevertheless, more recent treatment records, dated after the VA examination report, reflect that the Veteran does have diagnoses of psychoses as he was diagnosed with schizophrenia in September 2009 and recent VA treatment records include an assessment which included psychotic disorder, not otherwise specified, in December 2008 and October 2010. Although the December 2007 VA examiner indicated that the Veteran's psychosis had resolved, the evidence associated with the claims file since the January 2008 rating decision indicates that the Veteran may have a current psychosis, to include schizophrenia and/or psychotic disorder, not otherwise specified. This evidence, coupled with the findings of psychotic disorder, not otherwise specified, within one year of separation from service, raises the question of whether the Veteran has a current psychosis which was manifested within one year after separation from service. This evidence raises a reasonable possibility of substantiating the claim. Thus, the claim must be reopened. As the Court explained in Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), new evidence is sufficient reopen a claim if it contributes to a more complete picture of the circumstances surrounding the origin of the disability at issue, even where this additional evidence is not enough to convince the Board to grant the claim. See also Shade, 24 Vet. App. at 117. Therefore, as new and material evidence has been received, the claim for service connection for depression with psychosis, claimed as a mental condition, is reopened. See 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156. ORDER New and material evidence having been presented, the claim for service connection for depression with psychosis, claimed as a mental condition, is reopened. REMAND The Board finds that further action on the claim for service connection, on the merits, is warranted. As indicated above, service treatment records reflect that no psychiatric disorders were noted on enlistment examination in January 2003. During service, however, the Veteran was found to have a personality disorder and was noted to have a long history (since childhood) of depressive symptoms, delusions, and auditory hallucinations which, in the opinion of the examiners who evaluated the Veteran in November 2006, were most likely best explained by a personality disorder diagnosis; however, a provisional diagnosis of major depressive disorder, recurrent, with psychotic features, was being considered. Post-service VA treatment records reflect, as discussed above, an assessment which included major depression with psychosis and alcohol dependence in April 2007, just two months after separation from service. The post-service records also reflect findings of numerous psychiatric disorders, including psychotic disorder and schizophrenia. As discussed above, the Veteran was afforded a VA examination to evaluate his claimed mental condition in December 2007. The examiner noted that the Veteran had been hospitalized for major depressive disorder with psychotic features and alcohol dependence in April 2007. He indicated that the Veteran had had an episode of severe depression with auditory hallucinations at that time which was treated with Risperdal and Zoloft but that the Veteran had stopped taking these medications about two to three months earlier and no longer had auditory hallucinations. The Veteran denied feeling severe depression, but reported that he continued to struggle with feeling down from time to time. The Axis I diagnosis was major depressive disorder with psychotic features, recurrent, mild. The examiner opined that the Veteran's depression and psychosis was not caused by or a result of his depression requiring hospitalization in service, and his psychosis was secondary to depression and had resolved when his depression resolved. This opinion, however, appears to be based on the Veteran's report that he no longer had auditory hallucinations since stopping his medication following his April 2007 hospitalization and did not currently experience severe depression, as well as the normal findings on mental status examination. More recent medical evidence, however, suggests that the Veteran's psychosis may not be resolved, as evidenced by the findings of schizophrenia in September 2009 and psychotic disorder, not otherwise specified, in December 2008 and October 2010. Additionally, since December 2007, the Veteran has been diagnosed with psychiatric disorders other than depression and psychosis. Further, while the December 2007 VA examiner opined that the Veteran had depression prior to being in service, he did not sufficiently address whether the Veteran's current psychiatric disorder clearly and unmistakably existed prior to service and clearly and unmistakably was not aggravated during service. Because VA undertook to provide a VA examination to evaluate the claimed psychiatric disorder, the Board must ensure that such an examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Stefl v. Nicholson, 21 Vet. App. 120 (2007). In light of the evidence discussed above, the claims file should be returned to the December 2007 VA examiner to obtain a supplemental opinion. The AMC/RO should arrange for the Veteran to undergo VA examination only if the examiner who conducted the December 2007 VA examination is not available, or the designated examiner is unable to provide the requested opinion without examining the Veteran. The record also reflects that there are outstanding treatment records which are potentially pertinent to the claim for service connection for a psychiatric disorder. In this regard, as indicated above, the Veteran has reported treatment for depression prior to entry into service. Specifically, service treatment records include his report that he was hospitalized for depression at age 12 and the December 2007 VA examination report includes his reported history of being diagnosed with depression in 2000. However, no records of psychiatric treatment prior to service are currently of record. Further, a December 2008 VA treatment record indicates that the Veteran had been transferred to the Tampa VAMC from Bayonet Point Medical Center. Private treatment records dated in June and September 2009 indicate that the Veteran presented to that facility in June 2009 on the Baker Act which was initiated by Bayonet Point Hospital. [The Florida Mental Health Act or Baker Act provides for involuntary inpatient placement of a person who is mentally ill and, because of his or her mental illness, has refused voluntary placement for treatment after sufficient and conscientious explanation and disclosure of the purpose of placement for treatment or is unable to determine for himself or herself whether placement is necessary; and, he or she is manifestly incapable of surviving alone or with the help of willing and responsible family or friends, including available alternative services, and, without treatment, is likely to suffer from neglect or refuse to care for himself or herself, and such neglect or refusal poses a real and present threat of substantial harm to his or her well-being; or there is substantial likelihood that in the near future he or she will inflict serious bodily harm on himself or herself or another person, as evidenced by recent behavior causing, attempting, or threatening such harm; and all available less restrictive treatment alternatives which would offer an opportunity for improvement of his or her condition have been judged to be inappropriate. Fla. Stat. §§ Vet. App. 394.451, 394.467.] VA treatment records also include a fee basis claim review regarding the Veteran's eligibility for reimbursement of medical expenses regarding treatment at Bayonet Point Hospital in April 2011. However, no treatment records from Bayonet Point Medical Center and/or Hospital are currently of record. During VA treatment in October 2010, the Veteran's mother reported that he had been Baker Acted to The Harbor Behavioral Health Center a few months earlier. While records regarding treatment at this facility in June and September 2009 are currently of record, the above evidence indicates that more recent records are available. Another October 2010 VA treatment record indicates that the Veteran was Baker Acted to a community hospital in March 2010. While records of hospitalization at the Bay Pines VAMC dated in March 2010 are currently of record, no private records from this time are currently available for the Board's review. The records from the Bay Pines VAMC do indicate that the police had taken the Veteran to a community hospital in New Port Richey, but he had been transferred to the Bay Pines VAMC for admission because the Tampa VAMC had no psychiatric beds. VA has a duty to obtain relevant records of treatment reported by private physicians. Massey v. Brown, 7 Vet. App. 204 (1994). In light of the foregoing evidence, on remand, the AMC/RO should attempt to obtain any outstanding pertinent treatment records from the Bayonet Point Medical Center and/or Hospital, the Harbor Behavioral Health Center, and any other private facilities, to include any records regarding psychiatric treatment dated prior to the Veteran's entry into service. Additionally, an April 2007 VA treatment record indicates that the Veteran was applying for vocational rehabilitation. However, no VA vocational rehabilitation folder has been forwarded to the Board. On remand, the AMC/RO should associate with the claims file the Veteran's vocational rehabilitation records or folder. See Dunn v. West, 11 Vet. App. 462, 466-67 (1998); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). The Veteran also reported during private treatment in September 2009 that he was on disability. The RO asked the Veteran to indicate whether he had any Social Security medical records that pertained to his claim for service connection in December 2010 and January 2011; however, the Veteran identified no such records. While Social Security Administration (SSA) records are not controlling for VA determinations, they may be "pertinent" to VA claims. See Collier v. Derwinski, 1 Vet. App. 412 (1991); Murincsak v. Derwinski, 2 Vet. App. 363 (1992). As the claim for service connection is being remanded, the AMC/RO should ask the Veteran to clarify whether he has filed a claim for SSA disability benefits. The reopened claim for service connection for a psychiatric disorder is inextricably intertwined with the claim for a TDIU, and the claims should be considered together. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 2 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a veteran's claim for the second issue). Accordingly, remand of the TDIU claim is warranted. See Gurley v. Peake, 528 F.3d 1322 (2008) (remand of inextricably intertwined claims warranted for reasons of judicial economy even in absence of administrative error). The Board further finds that additional notification action, pursuant to the VCAA, is warranted. The Veteran has not yet been provided VCAA notice regarding the claim for a TDIU. Further, while a June 2010 letter advised him of the information and evidence necessary to reopen the claim for service connection for depression with psychosis (also claimed as a mental condition) and provided notice regarding the information and evidence needed to substantiate the underlying claim for service connection, in light of the of the recharacterization of this claim, per Clemons, the Veteran should be furnished VCAA notice regarding the expanded claim. The Board further notes that the most recent VA treatment records currently available for the Board's review are dated in December 2011. On remand, the AMC/RO should obtain all outstanding pertinent VA treatment records. Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for a psychiatric disorder. After acquiring this information and obtaining any necessary authorization, obtain and associate any outstanding pertinent records with the claims file or Virtual VA e-folder. A specific request should be made for (1) treatment records from the Tampa and/or Bay Pines VAMC, dated since December 2011; (2) any records regarding psychiatric treatment prior to service, including records of hospitalization when the Veteran was 12 and records regarding treatment for depression dated in 2000; (3) any pertinent treatment records from Bayonet Point Medical Center and/or Hospital, to include records dated in May or June 2009 and records dated in April 2011; (4) any records from The Harbor Behavioral Health Center dated since September 2009; and (5) any records regarding psychiatric treatment at a community hospital in March 2010. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified and the record clearly documented. 2. Provide the Veteran VCAA notice under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), that advises him of the information and evidence necessary to substantiate his claim for service connection for a psychiatric disorder, to include bipolar disorder, schizophrenia, psychotic disorder not otherwise specified, major depressive disorder, and mood disorder, and his claim for a TDIU. 3. Associate with the claims file any VA vocational rehabilitation folder pertaining to the Veteran. 4. Ask the Veteran to clarify whether he has filed a claim for SSA disability benefits. If so, obtain from the SSA a copy of any decision regarding the Veteran's claim for disability benefits, as well as copies of all medical records underlying those determinations. 5. After all available records have been associated with the claims file, forward the claims file to the examiner that conducted the December 2007 VA examination, if available, for a supplemental medical opinion. The claims folder must be made available to the examiner for review of the case. A notation to the effect that this record review took place should be included in the report of the examiner. The examiner should identify any psychiatric disorders present at any time since May 2010. In regard to each OR any diagnosed condition, the examiner should specifically provide an opinion as to whether the condition clearly and unmistakably preexisted service. If so, the examiner should also provide an opinion as to whether there is clear and unmistakable evidence that the condition was not aggravated by service. If the examiner finds that the Veteran has any current psychiatric disorder which did not clearly and unmistakably pre-exist service, he should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the condition was incurred or aggravated as a result of active service. The examiner should also provide an opinion as to whether the Veteran has a personality disorder which was subject to a superimposed disease or injury during active service, resulting in disability. Finally, the examiner should provide an opinion as to whether any current psychiatric disorder which is a psychosis (to include schizophrenia and/or psychotic disorder, not otherwise specified) initially manifested within one year of separation from service (so by February 2008). If further examination of the Veteran is deemed necessary, arrange for the Veteran to undergo VA examination to obtain the above-noted opinion. In conjunction with the examination, the claims folder must be made available to the examiner for review of the case. A notation to the effect that this record review took place should be included in the report of the examiner. All indicated tests and studies should be accomplished. All examination findings, along with the complete rationale for all opinions expressed, should be set forth in the examination report. 6. Next, review the claims file and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action must be implemented. If the examination report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. 7. Finally, after completing the requested actions, and any additional notification and/or development deemed warranted, readjudicate the claim on appeal in light of all pertinent evidence and legal authority. If any benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate supplemental statement of the case that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matters that the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims 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). ______________________________________________ KELLI A. KORDICH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs