Citation Nr: 1317162 Decision Date: 05/24/13 Archive Date: 05/31/13 DOCKET NO. 08-29 495 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for major depression prior to March 1, 2012. 2. Entitlement to a disability rating in excess of 50 percent for major depression on and after March 1, 2012. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. M. Celli, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1970 to February 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, the Commonwealth of Puerto Rico. These issues originally came to the Board from a March 2008 rating decision that denied an evaluation in excess of 30 percent for major depression. In February 2012, the Board remanded the Veteran's claim, and while the appeal was in remand status, the RO, in an October 2012 rating decision, granted a 50 percent rating for major depression effective March 1, 2012. Because the increased rating assigned to the Veteran's service-connected major depression is not the maximum rating available for this disability, the claim remains in appellate status, and the Board has re-characterized the issues to include staged ratings as shown on the title page. See AB v. Brown, 6 Vet. App. 35 (1993); see also Hart v. Mansfield, 21 Vet. App. 505 (2007). FINDING OF FACT Throughout the appeal period, the Veteran's major depression was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as anxiety, isolation, depressed mood, poor appetite, avoidance, insomnia, poor impulse control, difficulty concentrating, some suicidal thoughts, and difficulty in establishing and maintaining effective work and social relationships. CONCLUSIONS OF LAW 1. Prior to March 1, 2012, the criteria for a disability rating of 50 percent for major depression have been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9434 (2012). 2. On and after March 1, 2012, the criteria for a disability rating in excess of 50 percent for major depression have not been met. 38 U.S.C.A. §§ 1155, 5107(b) (West 2002); 38 C.F.R. §§ 4.7, 4.130, Diagnostic Code 9434 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS After review of the claims file, the Board finds that VA has met all statutory and regulatory notice and duty to assist provisions with respect to the issues on appeal. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). The information contained in letters dated in December 2007 and June 2008 satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The June 2008 letter notified the Veteran that he must submit, or request that VA obtain, evidence of the worsening of his disability, the different types of evidence available to substantiate his claim for a higher rating, the need to submit evidence of how such worsening affected his employment, and the requirements to obtain a higher rating. See Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1275-82 (Fed. Cir. 2009). Following the issuance of the June 2008 letter, the Veteran's claim was re-adjudicated in a September 2008 Supplemental Statement of the Case. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (finding that a notice defect may be cured by issuance of a fully compliant notification followed by a re-adjudication of the claim). For these reasons, the Board finds that the content requirements of the notice VA is to provide have been met, and, thus, no further development is required regarding the duty to notify. See Pelegrini v. Principi, 18 Vet. App. 112, 120 (2004). The Veteran's service treatment records, VA treatment records, VA examination reports, Social Security Administration (SSA) records, and identified private treatment records have been obtained. In February 2012, the Board remanded the Veteran's claim for additional development. Specifically, the Board requested that the RO obtain and associate with the claims file the Veteran's treatment records from the San Juan VA Medical Center and all associated outpatient clinics dated from April 2006 to the present, the report of the Veteran's VA general examination on October 7, 2010, and a copy of a letter from a private physician, Dr. Nanette Ortiz, dated in June 2010. The Board also instructed that the RO associate the Veteran's SSA records, which were previously obtained in August 2010, with the claims file. The Board stated the RO should contact the Veteran and request that he provide complete releases for any treatment received from a private physician, Dr. Fernando J. Cabrera de la Rosa, from March 2008 to the present and identify any other medical care providers not yet of record. The RO should also obtain and associate with the claims file any medical records subsequently identified by the Veteran. Finally, the Board instructed the RO to provide the Veteran a VA examination to determine the current nature and severity of his service-connected major depression. The record demonstrates that the Veteran was sent the requisite notice letter and that the identified VA treatment records, VA examination report, private treatment records, and SSA records were obtained and associated with the claims file. In addition, the Veteran underwent VA examination in February 2012. A review of all the VA examinations of record demonstrates that the examiners reviewed the pertinent evidence of record and the Veteran's lay statements. Additionally, the examinations provided sufficient information to decide the issues on appeal. 38 C.F.R. § 3.159(c)(4); Barr v Nicholson, 21 Vet. App. 303 (2007). As such, the Board finds the examinations to be sufficient and adequate for rating purposes. Furthermore, the record shows the RO substantially complied with the remand directives. See 38 U.S.C.A. § 5103A(b); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). In May 2008, the Veteran, his representative, and Dr. Cabrera de la Rosa testified at a hearing held before a decision review officer (DRO) at the RO. 38 C.F.R. § 3.103(c)(2) (2012) requires that the DRO who conducts a hearing fulfill two duties to comply with the above regulation. Those duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Here, during the hearing, the DRO noted the issue on appeal and questioned Dr. Cabrera de la Rosa regarding his treatment of the Veteran. The DRO also asked the Veteran about the nature and severity of his symptoms and the existence of other treatment records. The Veteran was assisted at the hearing by an accredited representative from the Disabled American Veterans. No pertinent evidence that might have been overlooked and that might substantiate the claim was identified by the Veteran or his representative. The hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. Therefore, the Board finds that the DRO complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). There is no indication in the record that any additional evidence relevant to the issues decided herein is available and not part of the claims file. See Pelegrini, 18 Vet. App. 112. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of the case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 20 Vet. App. 537 (2006); see also Dingess, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). The Board has thoroughly reviewed all of the evidence in the Veteran's claims file. Although an obligation to provide sufficient reasons and bases in support of an appellate decision exists, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the entire record must be reviewed, but each piece of evidence does not have to be discussed). The analysis in this decision focuses on the most salient and relevant evidence and on what the evidence shows or fails to show with respect to the matters on appeal. The Veteran should not assume that pieces of evidence, not explicitly discussed herein, have been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Disability ratings are determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2012). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule but findings sufficient to identify the disease and the resulting disability, and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2012); see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). The primary concern for an increased rating for a service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Considerations in evaluating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. 38 C.F.R. § 4.126(a) (2012). Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV), a global assessment of functioning (GAF) score reflects the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." DSM-IV, American Psychiatric Association (1994), pp. 46-47; 38 C.F.R. §§ 4.125(a), 4.130 (2012). A GAF score of 31-40 indicates some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). A GAF score of 41-50 indicates 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). A GAF score of 51-60 represents moderate symptoms (e.g., flattened 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). A GAF score of 61-70 indicates some mild symptoms (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, and has some meaningful interpersonal relationships. The Veteran's service-connected major depression has been rated under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9434, which provides: A 30 percent disability rating is warranted when 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; and mild memory loss (such as forgetting names, directions, recent events). A 50 percent disability rating is warranted when the Veteran experiences 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- 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; and difficulty in establishing and maintaining effective work and social relationships. A 70 percent disability rating is warranted when the Veteran experiences occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work-like setting); and inability to establish and maintain effective relationships. A 100 percent disability rating is warranted for total occupational and social impairment due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent ability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of closest relatives, own occupation, or own name. 38 C.F.R. § 4.130. Prior to March 1, 2012, the Veteran's major depression is rated as 30 percent disabling. Therefore, to warrant a higher disability rating, the evidence must show 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- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130. On and after March 1, 2012, the Veteran's major depression is rated as 50 percent disabling. As a result, to warrant a higher disability rating for this period, the evidence must show 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; and inability to establish and maintain effective relationships. In January 2008, the Veteran underwent VA examination in connection with his claim. The VA examiner noted that the Veteran's medical records were reviewed; however, the Veteran's claims file was not available for review. The Veteran denied any hospitalization for his major depression but reported taking anti-psychotic, anti-depressant, and anti-anxiety medication. The VA examiner noted that the Veteran wore disheveled clothes and had impoverished speech, a guarded attitude, and constricted affect. His mood was dysphoric, and he was unable to do serial 7's. The Veteran was able to spell a word forward and backward and was oriented to person, time, and place. His thought process and thought content were unremarkable, and he had no delusions. He understood the outcome of his behavior, his intelligence was average, and he understood that he had a problem. He reported no sleep impairment, no hallucinations, and no inappropriate behavior. He denied obsessive/ritualistic behavior, panic attacks, homicidal thoughts, and suicidal thoughts. The Veteran had good impulse control and interpreted proverbs appropriately. The Veteran denied any episodes of violence, was able to maintain minimum personal hygiene, and had no problems with activities of daily living. His remote, recent, and immediate memory were normal. The VA examiner diagnosed major depressive disorder and assigned a GAF score of 70. The VA examiner found there was no total occupational and social impairment due to the Veteran's signs and symptoms and that the Veteran's symptoms did not result in deficiencies in the areas of judgment, thinking, family relations, work, mood, and school. The VA examiner further opined that there was not reduced reliability and productivity due to the Veteran's major depression, and there was not an occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks. The VA examiner stated the Veteran did not have symptoms that were transient or mild and decreased work efficiency and the ability to perform occupational tasks during periods of significant stress. The VA examiner reported that the Veteran's symptoms were controlled by continuous medication. In support of his claim, the Veteran submitted a letter dated in March 2008 from Dr. Cabrera de la Rosa. Dr. Cabrera de la Rosa reported that the Veteran had an extensive treatment record dating back to January 1993 and that the Veteran's relationships with his immediate family had deteriorated to the point where he now lived by himself. Dr. Cabrera de la Rosa stated the Veteran's medication had to be increased due to his emotional hostility and belligerent attitude toward others, including his family members. Dr. Cabrera de la Rosa opined that the Veteran was totally unable to engage in any gainful or productive activity. At the May 2008 hearing, Dr. Cabrera de la Rosa testified that from 1991 until 2008, the Veteran had symptomatology of major depression, recurrent, with psychosis. Dr. Cabrera de la Rosa stated that the Veteran did not like to eat, had problems sleeping and concentrating, and had suicidal thoughts. He stated that the Veteran had not worked during the time he had been treating him and had difficulty with relationships, especially with his immediate family. He also had problems with his neighbors, did not cook, and did not have food in his home. Dr. Cabrera de la Rosa reported that the Veteran had a lot of problems in terms of personal cleanliness and had an emotional impediment that prevented him from interacting with other people. Dr. Cabrera de la Rosa also stated the Veteran had an impediment that prevented him from relating and working with other people. Dr. Cabrera de la Rosa testified that the Veteran had a period of hallucinations and had a paranoid personality, as demonstrated by a wall in front of his house that prevented his neighbors from seeing him. The Veteran also took medication to prevent his aggression with other people. Dr. Cabrera de la Rosa stated the Veteran's GAF score was between 30 and 40. The Veteran testified at the May 2008 hearing that he had a lot of anger and spent a lot of time shut up in his house. He reported that he had problems remembering things and concentrating. He stated that he ate out of obligation and that the only thing that kept him alive was his granddaughter. The Veteran reported that he had no interest in socializing with anyone and preferred to be left alone. He stated that on various occasions he had seen things that were not really there and thought it felt dangerous to have anyone beside him. The Veteran indicated that he had gone through three or four tough episodes in the past year. The Veteran underwent additional VA examination in August 2008 in connection with his claim. The VA examiner reviewed the Veteran's claims file and performed a psychological examination. The VA examiner noted that the Veteran had not had a decompensating crisis since 2005 and was now considered stable. The Veteran reported symptoms of isolation, insomnia, poor appetite, poor concentration, feeling bad about his life, irritability, poor impulse control, a bad temper, avoidance, poor stress tolerance, and being tired of living. He asserted that his symptoms were severe and had occurred almost daily since 1992. On examination, the Veteran was clean and casually dressed, his speech was spontaneous, rapid, loud, coherent, and pressured, and his attitude was cooperative and manipulative. His affect was appropriate, and his mood was anxious and agitated. The Veteran was easily distracted, unable to do serial 7's, and unable to spell a word forward and backward. He was oriented to person, time, and place, his thought process and content were unremarkable, and he had no delusions. The Veteran did not understand the outcome of his behavior, did not understand he had a problem, and his intelligence was average. The Veteran reported sleep impairment but denied hallucinations, inappropriate behavior, obsessive/ritualistic behavior, panic attacks, homicidal thoughts, and suicidal thoughts. He reported poor impulse control with no episodes of violence and was able to maintain minimum personal hygiene. He stated he had no problems with activities of daily living. The Veteran's remote, recent, and immediate memory were normal. The August 2008 VA examiner diagnosed major depression recurrent and assigned a GAF score of 70 based upon moderate symptoms of anxiety, a depressed mood, insomnia, irritability, an ill-humored temper, and social and occupational dysfunction. The VA examiner found there was occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to symptoms but with generally satisfactory functioning. The VA examiner opined that the Veteran's symptoms did not interfere with the ability to obtain a job, although the Veteran believed his mental condition was severe and debilitating. The Veteran also submitted a June 2010 letter from Dr. Ortiz, who reported that the Veteran had a history of severe major depression. Dr. Ortiz stated the Veteran had decreased interest and pleasure in most activities as the result of his physical disabilities. The Veteran also presented with frustration, anxiety, and irritability. He had depressed mood and vegetative changes, consisting in alteration in sleep and eating patterns. The Veteran presented with fatigue and low energy nearly every day and had episodes where he felt sad and isolated himself. The Veteran reported frequent crying spells, a sensation of worthlessness, and self-esteem problems. Dr. Ortiz also reported that the Veteran had suicidal thoughts and episodes of suicidal attempt, and he had memory and concentration problems. Dr. Ortiz opined that the Veteran presented with a serious nervous problem that, along with his other conditions, incapacitated him and prevented him from realizing any kind of job or duty. Dr. Ortiz found the Veteran was totally unable to engage in any occupational activity on a permanent or temporary basis. In October 2010, the Veteran underwent a general VA medical examination. He reported a history of depression and anxiety but denied a history of interpersonal relationship difficulties, panic attacks, substance abuse, memory problems, loss of control, homicidal symptoms, confusion, sleep impairment, and suicidal symptoms. The Veteran had normal affect, mood, and judgment. He had no obsessive behavior, hallucinations, or delusions. The Veteran's behavior was appropriate, and his intelligence was average. In a February 2012 letter, Dr. Cabrera de la Rosa repeated his findings regarding the Veteran's diagnosis of major depression, recurrent type with psychosis, chronic, and stated that the Veteran was totally and permanently disabled with respect to maintaining gainful employment. Dr. Cabrera de la Rosa opined that the Veteran's mental symptoms had persisted and stated the Veteran was depressed, psychotic, delusional, isolated, withdrawn, unable to sleep or eat well, and had poor relations with his family members and neighbors. Dr. Cabrera de la Rosa asserted the Veteran's GAF score was between 35 and 40. The Veteran underwent additional VA examination in February 2012 in conjunction with his claim. The VA examiner diagnosed major depression and assigned a GAF score of 70 to 75. The VA examiner opined that based on a review of the evidence, the Veteran's service-connected major depression was in stable condition, and his current GAF score demonstrated minimal improvement since 2008. The VA examiner found the Veteran had occupational and social impairment with reduced reliability and productivity. The VA examiner found the Veteran had symptoms of anxiety, suspiciousness, difficulty in establishing and maintaining effective work and social relationships, and an inability to establish and maintain effective relationships. Given the above record, the Board concludes that the evidence demonstrates the Veteran's major depression throughout the appeal period was manifested by occupational and social impairment with reduced reliability and productivity. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 4.130, Diagnostic Code 9434. Initially, the Board notes the Veteran experienced symptoms that are not listed in the rating criteria, and as a result, the Board has considered many of the Veteran's symptoms as "like or similar to" the schedular rating criteria of occupational and social impairment with reduced reliability and productivity. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The evidence demonstrates that during this period, the Veteran's major depression was manifested specifically by anxiety, isolation, depressed mood, poor appetite, avoidance, insomnia, poor impulse control, difficulty concentrating, some suicidal thoughts, and difficulty in establishing and maintaining effective work and social relationships. Here, the Board acknowledges the Veteran's statements concerning his persistent disturbances of mood and is particularly cognizant of the private physicians' findings with respect to the Veteran's serious difficulty with familial, neighborly, and co-worker relations. The Board also finds it especially significant that although the earlier VA examinations present a markedly different picture of the severity of the Veteran's symptoms from that reported by the private physicians, both Dr. Cabrera de la Rosa and the February 2012 VA examiner found the Veteran's symptoms had persisted throughout the appeal period with minimal improvement. Furthermore, throughout the appeal period, VA physicians assigned GAF scores ranging from 30 to 75, indicating a range of mild symptoms, such as depressed mood and insomnia, to major impairment in several areas, such as work and family relations. In addition, the evidence indicates the Veteran's specific symptoms presented a broad spectrum in nature and severity during the appeal period. In this case, the Board affords considerable probative value to the evidence demonstrating a significant history of impairment in familial relations and occupational functioning and therefore finds that a 50 percent rating is warranted throughout the appeal period. See Hart, 21 Vet. App. 505. However, the Board finds that a rating in excess of 50 percent is not warranted for major depression at any time during the pendency of the appeal. The evidence of record does not show 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; spatial disorientation; or neglect of personal appearance and hygiene. Although the Board notes the assertions of the Veteran, Dr. Cabrera de la Rosa, and Dr. Ortiz that the Veteran was totally and permanently disabled as the result of his symptoms, VA examiners did not find the Veteran's major depression produced this level of impairment. In this respect, the Board affords the VA examiners' opinions greater probative value as the VA examinations were performed specifically for the purpose of determining the severity of the Veteran's symptoms and with explicit consideration of VA rating criteria. Additionally, although the VA examinations were performed by different VA examiners approximately four years apart, the clinical findings were consistent, which lends greater credibility to the opinions rendered. Furthermore, the Veteran's symptoms as reported by Dr. Cabrera de la Rosa at times contradicted the Veteran's own reported symptomatology on VA examination, specifically with respect to suicidal thoughts, delusions, and the performance of activities of daily living. In addition, the Board finds it significant that the records show disability benefits were awarded by SSA on the basis of the Veteran's physical disabilities, and the VA examination reports reflect similar findings regarding the functional impact of the Veteran's major depression in comparison to his physical disabilities. For these reasons, the Board finds the criteria for a disability rating of 50 percent, but no more, for major depression have been met throughout the appeal period. 38 C.F.R. § 4.130. An exceptional or unusual disability picture occurs where the diagnostic criteria do not reasonably describe or contemplate the severity and symptomatology of a veteran's service-connected disability. Thun v. Peake, 22 Vet. App. 111, 115 (2008). If there is an exceptional or unusual disability picture, the Board must consider whether the disability picture exhibits other factors such as marked interference with employment and frequent periods of hospitalization. Id. at 115-116. When those two elements are met, the appeal must be referred for consideration of the assignment of an extraschedular rating to the Chief Benefits Director or the Director, Compensation and Pension Service. 38 C.F.R. § 3.321(b)(1) (2012). Otherwise, the schedular evaluation is adequate, and referral is not required. Thun, 22 Vet. App. at 116. Here, the Board finds the Veteran's disability picture is not so unusual or exceptional in nature as to render the rating assigned herein inadequate. The Veteran's service-connected major depression is evaluated as a psychiatric disability, the criteria of which is found by the Board to specifically contemplate the level of occupational and social impairment caused by this disability. Thun, 22 Vet. App. at 115; see also 38 C.F.R. § 4.130, Diagnostic Code 9434. Throughout the appeal period, the Veteran's major depression was manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as anxiety, isolation, depressed mood, poor appetite, avoidance, insomnia, poor impulse control, difficulty concentrating, some suicidal thoughts, and difficulty in establishing and maintaining effective work and social relationships. When comparing this disability picture with the symptoms contemplated by the Rating Schedule, the Board finds the Veteran's experiences are contemplated by a 50 percent disability rating. A rating in excess of 50 percent is provided for certain manifestations of major depression, but the medical evidence in this case demonstrates that those manifestations are not present. The criteria for the 50 percent disability rating assigned herein more than reasonably describe the Veteran's disability level and symptomatology, and therefore, the schedular evaluation is adequate and no referral is required. See 38 C.F.R. § 4.130, Diagnostic Code 9434; see also VAOGCPREC 6-96; 61 Fed. Reg. 66749 (1996). By this decision, the Board has found that a 50 percent rating for major depression is warranted throughout the appeal period based on the evidence of record. However, as occupational and social impairment with deficiencies in most areas was not established at any time during the pendency of the appeal, the preponderance of the evidence is against the assignment of a 70 percent disability rating for major depression. Therefore, there is no doubt to be resolved, and a rating in excess of 50 percent for major depression is not warranted at any time during the appeal period. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to a disability rating of 50 percent, but no more, for major depression is granted prior to March 1, 2012. Entitlement to a disability rating in excess of 50 percent for major depression is denied on and after March 1, 2012. ____________________________________________ ROBERT C. SCHARNBERGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs