Citation Nr: 1329763	
Decision Date: 09/17/13    Archive Date: 09/25/13

DOCKET NO.  13-07 094	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Atlanta, Georgia


THE ISSUES

1.  Whether new and material evidence has been received to reopen a claim of entitlement to service connection for headaches.  

2.  Entitlement to service connection for hypertension. 

3.  Entitlement to service connection for gastroesophageal reflux (GERD).

4.  Entitlement to service connection for stress fractures of the tibias.

5.  Entitlement to service connection for a bilateral quadriceps disability. 

6.  Entitlement to an effective date earlier than March 30, 2005 for the grant of service connection for depression.

7.  Entitlement to an initial increased rating for depression, currently rated as 30 percent disabling from March 30, 2005 to April 4, 2005, as 70 percent disabling from April 5, 2005 to October 21, 2008, and as 100 percent disabling from October 22, 2008 to the present.

8.  Entitlement to an increased initial rating for subluxation of the lumbar spine with degenerative changes, currently rated as 20 percent disabling from April 1, 1999 to October 2, 2006, and as 60 percent disabling from October 3, 2006 to the present.

9.  Entitlement to an effective date earlier than October 22, 2008 for the grant of special monthly compensation (SMC) at the housebound rate as set forth in 38 U.S.C.A. § 1114(s).  

10.  Entitlement to a total disability rating based upon individual unemployability (TDIU) for service-connected disability other than depression beginning on October 4, 2006.

11.  Entitlement to an effective date earlier than June 16, 2004 for the grant of service connection for right lower extremity radiculopathy.


REPRESENTATION

Appellant represented by:	Disabled American Veterans


WITNESS AT HEARING ON APPEAL

The Veteran


ATTORNEY FOR THE BOARD

E. Joyner, Counsel




INTRODUCTION

The Veteran served on active duty from July 1982 to March 1999.  

This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia.  

An August 2000 rating decision denied service connection for hypertension.  The August 2000 rating decision also granted service connection for subluxation of the lumbar spine with degenerative changes.  A 10 percent rating was assigned, effective April 1, 1999.  The Veteran appealed the initial rating assigned for subluxation of the lumbar spine with degenerative changes and in an August 2003 rating decision the RO granted an increased initial rating of 20 percent for subluxation of the lumbar spine with degenerative changes, effective April 1, 1999.  As this is not the highest possible rating for this disability, the appeal continues.  See AB v. Brown, 6 Vet. App. 35 (1993).

In February 2005 the Board remanded the claims of entitlement to service connection for hypertension and entitlement to an initial rating in excess of 20 percent for subluxation of the lumbar spine with degenerative changes.  Thereafter, in a March 2006 supplemental Statement of the Case, the RO again denied service connection for hypertension and denied an initial rating in excess of 20 percent for subluxation of the lumbar spine with degenerative changes.  

In a March 2006 rating decision, the RO granted service connection for radiculopathy of the right lower extremity.  A 20 percent rating was assigned, effective January 13, 2005.  In June 2006 the Veteran filed a notice of disagreement with respect to the effective date assigned for the grant of service connection for radiculopathy of the right lower extremity.  In September 2006, the Board remanded the issue of entitlement to an effective date earlier than January 13, 2005 for the grant of service connection for radiculopathy of the right lower extremity for issuance of a Statement of the Case.  In September 2006 the Board also remanded the claims of entitlement to service connection for hypertension and entitlement to an initial rating in excess of 20 percent for subluxation of the lumbar spine with degenerative changes in order to schedule the Veteran for VA examinations concerning these disabilities.  

In an October 30, 2006 rating decision, the RO granted an earlier effective date of June 16, 2004 for the grant of service connection for radiculopathy of the right lower extremity.  Thereafter, in a February 2007 statement, the Veteran disagreed with the June 16, 2004 effective date assigned for the grant of service connection for radiculopathy of the right lower extremity.

In an October 20, 2006 rating decision, the RO granted service connection for depression.  A 30 percent rating was assigned, effective March 30, 2005.  In a November 2006 notice of disagreement, the Veteran disagreed with the assignment of a 30 percent rating, and the effective date assigned for service connection for depression.

The October 20, 2006 rating decision also denied service connection for a bilateral quadriceps disability, GERD, stress fractures of the tibias, a right knee disability, and a cervical spine disability, and denied reopening of the Veteran's claim for service connection for headaches.  The Veteran filed a notice of disagreement with respect to each of these issues.

In a May 2007 Statement of the Case, the RO continued to deny service connection for a bilateral quadriceps disability, GERD, stress fractures of the tibias, a right knee disability, and a cervical spine disability.  The May 2007 Statement of the Case also denied reopening the claim of entitlement to service connection for headaches, denied an initial rating in excess of 30 percent for depression, and denied an effective date earlier than March 30, 2005 for the grant of service connection for depression.

In his June 2007 substantive appeal the Veteran requested a Board hearing on all issues listed in the May 2007 Statement of the Case.  In a June 2007 VA Form 21-4138 the Veteran requested a Decision Review Officer (DRO) hearing as well.  As noted below, in a March 2013 statement, prior to certification of the issue on appeal to the Board, the Veteran withdrew his claim of entitlement to service connection for a cervical spine disability.  As such, this issue is not currently before the Board.

In a March 2008 rating decision, the RO, in pertinent part, granted an increased rating of 70 percent for depression, effective October 5, 2006.  As this is not the highest possible rating for this disability, the appeal continues.  See AB v. Brown, 6 Vet. App. 35 (1993).

The March 2008 rating decision also granted an increased rating of 60 percent for subluxation of the lumbar spine with degenerative changes, effective October 3, 2006, and granted service connection for a right knee disability.  As this represents a total grant of benefits sought on appeal, the issue of entitlement to service connection for a right knee disability is no longer before the Board.  See Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997).

In a November 2008 rating decision the RO granted an earlier effective date of April 5, 2005, for the grant of a 70 percent rating for the service-connected depression.

In a May 2010 rating decision, the RO denied a rating in excess of 70 percent for depression.  The May 2010 rating decision also addressed several other issues, all of which the Veteran filed a notice of disagreement with; however, despite a Statement of the Case being issued in September 2011, the Veteran did not perfect an appeal with respect to these issues.  Therefore, these issues are not currently before the Board.  (Moreover, he submitted a statement in March 2013 withdrawing his appeal of the issues of entitlement to an earlier effective date for the assignment of a 60 percent rating for his lumbar spine disability, entitlement to an earlier effective date regarding his erectile dysfunction, entitlement to service connection for hypertension, and entitlement to service connection for a cervical spine disability, most of which were addressed in the September 2011 Statement of the Case.)  

In a March 2011 rating decision, the RO granted an increased rating of 100 percent for service-connected depression, effective September 17, 2010.  The RO also granted SMC at the housebound rate as set forth in 38 U.S.C.A. § 1114(s), effective September 17, 2010.  The Veteran filed a notice agreement with the effective date assigned for the 100 percent rating for depression and with the effective date for the grant of SMC at the housebound rate as set forth in 38 U.S.C.A. § 1114(s). 

In a September 2011 rating decision the RO granted an earlier effective date of October 22, 2008 for the grant of a 100 percent rating for depression, and granted the same earlier effective date for the grant of SMC at the housebound rate as set forth in 38 U.S.C.A. § 1114(s).  In a January 2012 statement, the Veteran disagreed with the October 22, 2008 effective dates assigned for the 100 percent rating for depression and for SMC at the housebound rate.  In a March 2013 supplemental Statement of the Case the RO denied an effective date prior to October 22, 2008 for both the grant of a 100 percent rating for depression and for the grant of SMC at the housebound rate as set forth in 38 U.S.C.A. § 1114(s).  In his March 2013 VA form 9 the Veteran requested a hearing on these two issues. 

In May 2013 a videoconference hearing was held before the undersigned Veterans Law Judge (VLJ) on the issue of entitlement to an effective date earlier than October 22, 2008 for the grant of a 100 percent rating for depression and entitlement to an effective date earlier than October 22, 2008 for the grant of SMC at the housebound rate.  A transcript of that hearing is of record.

Additionally, during the course of the appeal, the Veteran testified at a Travel Board hearing at the RO before another VLJ in October 2004.  A transcript of that hearing is of record.  Among the issues he provided testimony on at this hearing were entitlement to service connection for hypertension and entitlement to an initial rating in excess of 20 percent for subluxation of the lumbar spine with degenerative changes.  The VLJ who conducted the October 2004 Travel Board hearing is now retired.  In a July 2013 letter, the Veteran was informed that the VLJ who conducted his October 2004 hearing is no longer employed by the Board.  The Veteran was offered the opportunity to testify at another hearing.  However, in July 2013 he submitted a statement in response, indicating that he did not wish to appear at another hearing. 

Although the Veteran had also requested DRO and/or Board hearings on several other issues, the Board sent the Veteran a letter in July 2013 explaining which issues were currently on appeal, and requested that the Veteran indicate whether he wished to have any additional DRO or Board hearings on any of these issues.  In his July 2013 statement in response, the Veteran indicated that he did not wish to have any further hearings on any issues.  As such, the Veteran's hearing requests are considered withdrawn and the Board may proceed with the appeal.

Despite the RO's characterization of the issues on appeal involving the disability ratings for Veteran's service-connected depression being earlier effective date issues, the Board finds that because the Veteran filed a notice of disagreement with the initial 30 percent rating assigned for depression in the October 20, 2006 rating decision, the issue is really an increased initial rating claim.  Moreover, based upon the RO's subsequent granting of an increased rating of 70 percent, effective April 4, 2005, and an increased rating of 100 percent, effective October 22, 2008, the Board had recharacterized this issue as an increased initial rating claim, involving staged ratings, as indicated on the title page of this decision.

As will be discussed below, because the Board grants in this decision a 100 percent rating for depression as of October 4, 2006, and also grants an earlier effective date of October 4, 2006 for SMC at the housebound rate, the question of whether TDIU is warranted for the time period beginning on October 4, 2006, is rendered moot.  Thus, the Board dismisses that portion of the Veteran's TDIU claim.  The Board notes that in the March 2008 rating decision, the RO informed the Veteran that his TDIU claim was rendered moot.  However, the issue of entitlement to TDIU prior to October 4, 2006 is referred to the RO for appropriate action.

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012).  38 U.S.C.A. § 7107(a)(2) (West 2002).

The issue of entitlement to an increased initial rating for lumbar spine disability, rated as 20 percent disabling prior to October 3, 2006, and as 60 percent disabling beginning October 3, 2006, entitlement to an effective date earlier than June 14, 2004, for the grant of service connection for right lower extremity radiculopathy, and entitlement to an effective date earlier than October 4, 2006 for the grant of SMC at the housebound rate as set forth in 38 U.S.C.A. § 1114(s), 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.  In a July 2013 statement, prior to the promulgation of a decision in the appeal, the Board received notification from the appellant of his desire to withdraw his appeal for the issues of whether new and material evidence has been received to reopen a claim of entitlement to service connection for headaches, entitlement to service connection for hypertension, entitlement to service connection for GERD, entitlement to service connection for fracture of the tibias, and entitlement to service connection for a bilateral quadriceps disability.  

2.  Resolving reasonable doubt in the Veteran's favor, the Veteran's claim of entitlement to service connection for depression was received on March 10, 2005.  

3.  A December 2004 VA treatment record indicates that the Veteran's depression may be related to his dismissal from his Army recruiting position and subsequent discharge from the military.

4.  For the time period from March 10, 2005 to October 3, 2006, the Veteran's PTSD was manifested by occupational and social impairment with deficiencies in most areas; there is no evidence of total social impairment due to his depression signs and symptoms. 

5.  For the time period beginning on October 4, 2006 the Veteran's depression is manifested by total social and occupational impairment.

6.  As of October 4, 2006, the Veteran's depression is rated at 100 percent, and his remaining service-connected disabilities have a combined disability rating of at least 60 percent.

7.  The Veteran is in receipt of special monthly compensation (SMC) under the criteria of 38 U.S.C.A. § 1114(s), from October 4, 2006.


CONCLUSIONS OF LAW

1.  The criteria for withdrawal of a Substantive Appeal by the appellant have been met with respect to the issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for headaches.  38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012).

2.  The criteria for withdrawal of a Substantive Appeal by the appellant have been met with respect to the issue of entitlement to service connection for hypertension.  38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012).

3.  The criteria for withdrawal of a Substantive Appeal by the appellant have been met with respect to the issue of entitlement to service connection for GERD.  38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012).

4.  The criteria for withdrawal of a Substantive Appeal by the appellant have been met with respect to the issue of entitlement to service connection for fracture of the tibias.  38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012).

5.  The criteria for withdrawal of a Substantive Appeal by the appellant have been met with respect to the issue of entitlement to service connection for a bilateral quadriceps disability.  38 U.S.C.A. § 7105(b)(2), (d)(5) (West 2002); 38 C.F.R. §§ 20.202, 20.204 (2012).

6.  The criteria for an effective date of March 10, 2005, but no earlier, for the grant of service connection for depression have been met.  38 U.S.C.A. §§ 5103, 5103A, 5107, 5110 (West 2002); 38 C.F.R. §§ 3.159, 3.400 (2012).

7.  The criteria for an initial rating of 70 percent, but not higher, for depression for the time period from March 10, 2005 to October 3, 2006, have been met.  38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9434 (2012).

8.  The criteria for an initial rating of 100 percent for depression for the time period beginning on October 4, 2006, have been met.  38 U.S.C.A. §§ 1155, 5103A, 5107 (West 2002); 38 C.F.R. §§ 4.1, 4.7, 4.130, Diagnostic Code 9434 (2012).  

9.  The criteria for an earlier effective date of October 4, 2006, for the grant of SMC at the housebound rate under 38 U.S.C.A. § 1114(s) have been met.  38 U.S.C.A. §§ 5103, 5103A, 5107, 5110 (West 2002); 38 C.F.R. §§ 3.159, 3.400 (2012).

10.  The 100 percent rating for depression, along with the ratings for the Veteran's other disabilities, renders moot the appeal for a TDIU from October 4, 2006.  38 U.S.C.A. §§ 1114(s), 1155 (West 2002); 38 C.F.R. §§ 3.340, 3.341, 3.350(i), 4.16 (2012).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

Withdrawal of Substantive Appeal

Under 38 U.S.C.A. § 7105, the Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed.  A Substantive Appeal may be withdrawn in writing at any time before the Board promulgates a decision.  38 C.F.R. § 20.202 (2012).  Withdrawal may be made by the appellant or by his or her authorized representative.  38 C.F.R. § 20.204.  The appellant, in correspondence received by VA in July 2013, has withdrawn his appeal of the issues of whether new and material evidence has been received to reopen a claim of entitlement to service connection for headaches, entitlement to service connection for hypertension, entitlement to service connection for GERD, entitlement to service connection for fracture of the tibias, and entitlement to service connection for a bilateral quadriceps disability.  Such withdrawal is effective the date the letter was received at the Board.  38 C.F.R. § 20.204(b)(3).  Accordingly, the Board does not have jurisdiction to review the appeal of these issues.

Duties to Notify and Assist

VA has met all statutory and regulatory notice and duty to assist provisions.  See 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 (2012).  August 2005, September 2005, April 2008, March 2009, and August 2009 letters satisfied the duty to notify provisions, and the April 2008, March 2009, and August 2009 notice letters notified the Veteran of regulations pertinent to the establishment of an effective date and of the disability rating.  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).  Once a claim for service connection has been substantiated, the filing of a notice of disagreement with the initial rating or effective date of the disability on appeal, as the Veteran did in November 2006 with respect to the initial rating and effective date assigned for his depression, and in January 2012 with respect to the effective date assigned for SMC at the housebound rate, does not trigger additional 38 U.S.C.A. § 5103(a) notice.  Therefore, any defect as to notice with respect to these issues is non-prejudicial.  See id; Dunlap v. Nicholson, 21 Vet. App. 112 (2007); see also Goodwin v. Peake, 22 Vet. App. 128, 134 (2008) (where a claim has been substantiated after August 29, 2000, the appellant bears the burden of demonstrating any prejudice from defective notice with respect to any downstream elements).

In this decision, the Board grants entitlement to SMC at the housebound rate for the time period from October 4, 2006 to the present, which constitutes a complete grant of the claim for this time periods (the earlier time period for the claim is being remanded).  Therefore, no discussion of VA's duty to notify or assist is necessary with respect to this claim.  

The Veteran underwent multiple VA examinations in conjunction with his appeal for an increased rating for his depression.  He has not argued, and the record does not reflect that these examinations were inadequate for rating purposes.  The examinations were adequate because they were based on an examination of the Veteran and as a whole, they provided sufficient information to address the rating criteria for the disability on appeal.  38 C.F.R. § 3.159(c) (4); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). 

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 v. Principi, 18 Vet. App. 112 (2004).  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/Hartman, 19 Vet. App. at 486; Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009). 

In Bryant v. Shinseki, the United States Court of Appeals for Veterans Claims (Court) recently held that 38 C.F.R. 3.103(c)(2) (2012) requires that the VLJ who conducts a hearing fulfill two duties to comply with the above the regulation.  Bryant v. Shinseki, 23 Vet. App. 488 (2010).  These duties consist of (1) the duty to fully explain the issue or issues on appeal and (2) the duty to suggest the submission of evidence that may have been overlooked.  In this case, the Veteran was assisted at his May 2013 Board hearing by an accredited representative from Disabled American Veterans.  During the Veteran's hearing, the VLJ and the Veteran's representative asked the Veteran questions about the symptoms and severity of his depression, as well as questions regarding the effective date claims involving his service-connected depression and SMC based upon housebound status.  Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2) nor identified any prejudice in the conduct of the Board hearing.  As such, the Board finds that the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2), consistent with Bryant, and that any error in notice provided during the Veteran's hearing constitute harmless error. 





Legal Analysis

	Increased Initial Rating for Depression

Disability ratings are determined by the application of the 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 that 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).  Where the Rating Schedule does not provide for a noncompensable evaluation for a diagnostic code, a noncompensable evaluation shall be assigned when the requirements for a compensable evaluation are not met.  38 C.F.R. § 4.31 (2012).

The primary concern in a claim for an increased evaluation for 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).  However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply.  Fenderson v. West, 12 Vet. App. 119 (1999).  Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports.  Id.  VA has a duty to consider the possibility of assigning staged ratings in all claims for increase.  See Hart v. Mansfield, 21 Vet. App. 505 (2007). 

Service connection for the Veteran's depression was granted in an October 20, 2006 rating decision.  An initial 30 percent rating was assigned, effective March 30, 2005, under the provisions of 38 C.F.R. § 4.130, Diagnostic Code 9434.  Thereafter, in a March 2008 rating decision, the RO increased the rating for the Veteran's service-connected PTSD to 70 percent, and later in a November 2008 rating decision made the 70 percent rating effective April 5, 2005.  Thereafter, in a March 2011 rating decision, the RO increased the rating to 100 percent, and later in a September 2011 rating decision, the 100 percent rating was made effective October 22, 2008.  In this decision, the Board grants an earlier effective date of March 10, 2005 for the grant of service connection for depression.  Therefore, the Veteran's depression is now currently rated as 30 percent disabling from March 10, 2005 to April 4, 2005, as 70 percent disabling from April 5, 2005 to October 21, 2008, and as 100 percent disabling from October 22, 2008 to the present, under Diagnostic Code 9434.

Diagnostic Code 9434 is subsumed into the General Rating Formula for Mental Disorders (General Rating Formula).  Under the General Rating Formula, a 30 percent evaluation is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to 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 is warranted for 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; difficulty in establishing and maintaining effective work and social relationships.  Id.

A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 

A 100 percent evaluation is warranted where there is evidence of 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 inability to perform activities of daily living; disorientation to time or place; memory loss for names of close relatives, own occupation or own name. 

One factor to be considered is the GAF score which is a scale reflecting the "psychological, social and occupational functioning on a hypothetical continuum of mental health-illness."  See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995); see also Richard v. Brown, 9 Vet. App. 266, 267 (1996) [citing the American Psychiatric Association  's Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM IV), page 32].  A GAF Score of 11 to 20 indicates that there is some danger of hurting oneself or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement), or an occasional failure to maintain minimal personal hygiene, or gross impairment in communication.  A GAF score of 21 to 30 indicates that behavior is considerably influenced by delusions or hallucinations, or serious impairment in communication or judgment (e.g., sometimes incoherent, acting grossly inappropriately, suicidal preoccupation), or an inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends).  A GAF Score of 31 to 40 indicates some impairment in reality testing or communication (e.g., speech at times illogical, obscure, or irrelevant), or where there is 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).  A GAF of 41 to 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., few friends, unable to keep a job).  A GAF of 51 to 60 indicates 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 of 61 to 70 indicates some mild symptomatology (e.g., depressed mood and mild insomnia) or some difficulty in social, occupational, or social functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, with some meaningful interpersonal relationships. 

While the Rating Schedule does indicate that the rating agency must be familiar with the DSM IV, it does not assign disability percentages based solely on GAF scores.  See 38 C.F.R. § 4.130.  Accordingly, GAF scores do not automatically equate to any particular percentage in the Rating Schedule.  Rather, they are but one factor to be considered in conjunction with all the other evidence of record. 

At the outset, in addition to depression, the medical evidence reflects diagnoses during the pendency of the claim of mood disorder not otherwise specified, alcohol abuse secondary to depression, adjustment disorder, dysthymic disorder, rule-out intermittent explosive disorder, and PTSD.  Where it is not possible to distinguish the effects of a nonservice-connected condition from those of a service-connected condition, the reasonable doubt doctrine dictates that all symptoms be attributed to the Veteran's service-connected disability.  See Mittleider v. West, 11 Vet. App. 181 (1998). Although the Veteran is only service-connected for his depression, his alcohol dependence has been linked to his depression, and the medical evidence otherwise suggests that it is not possible to distinguish the depression symptoms from the symptoms of his other psychiatric disabilities.  Consequently, all of his psychiatric symptoms have been considered in evaluating his service-connected depression.

The medical evidence of record includes a January 2004 VA treatment record which notes the Veteran's complaint of chronic back pain since being in a motor vehicle accident.  He also indicated that he has stress with his wife regarding his pain, which affects his ability to work and have intercourse.  He reported feeling depressed, tearful, and not enjoying things in life.  He asked about treatment for depression.  The impression was depression.  He was started on Zoloft and instructed to follow up with social worker in one month to assess the effect of medication.  

A March 2004 VA treatment record notes that the Veteran was seen in January 2004 for complaints of depression.  He was started on Zoloft and reportedly does not feel any better.  The assessment was depression.  Zoloft was increased from 50 mg to 100 mg.  

A May 2004 VA psychiatry note indicates that the Veteran displayed poor eye contact.  He was not suicidal or homicidal currently.  There were no hallucinations or fixed delusions noted and insight and judgment were fair.  

A December 2004 VA treatment record notes that the Veteran initially presented with complaints of depressive symptoms in May 2004.  He currently reported depressed mood, insomnia, loss of interest in activities, lack of energy, difficulty concentrating and decreased appetite.  He also reported increased alcohol use beginning in June 2004.  He stated that his symptoms of depression first began in late 1996.  Before this time, the Veteran described himself as energetic, sociable, hard-working, and possessing a great sense of humor.  Beginning in 1996 he reported being highly stressed and under a great deal of pressure at work.  By 2003 he stated that he had become very isolated and withdrawn, very negative, feeling depressed more days than not, and had appetite and sleep changes.  He denied any current suicidal or homicidal ideations.  Before presenting in May 2004 he had not ever sought psychological help.  It was noted that the Veteran was married in 1982.  However, he and his wife have been separated since March 2004.  He speaks regularly with his children and believes his relationship with his kids is good.  He described his relationship with his wife as contentious.  He reported having a very limited social support system, naming only his daughter and one significant friend as supports.  He described distant relationships with co-workers and reported few hobbies and no leisure activities.  On examination he was extremely well-groomed and neatly dressed.  He had no odd movements, tics, or mannerisms.  He did not maintain eye contact often or for very long.  His speech was clear with normal rate, rhythm and volume.  He was cooperative and engaged throughout all sessions.  He was alert and fully oriented.  His memory was intact.  His stream of thought was normal with clear continuity.  He exhibited no obsessions or phobias, ideas of reference, hallucinations, delusions, faulty perceptions, perceptual disturbances, or deficits with reality testing during evaluation.  He demonstrated good judgment and insight.  His self presentation was friendly and modest but with a definite view of himself as a failure.  His mood was subdued.  His affect was slightly dysphoric and with a constricted range.  He expressed no suicidal or homicidal ideations during the evaluation.  He reported recent increases in consumption of alcohol beginning about four months earlier.  He also reported ruminating thoughts that he is unable to control regarding being fired from his position as an Army recruiter.  He stated that these thoughts can sometimes affect his ability to sleep.  He also reported many examples of patterned behavior characterized by obsessions over orderliness, cleanliness, and repeated doubts that he has failed to secure the house (locking doors, closing windows, and turning off the iron).  He asserted that these obsessions have been disruptive in his work, in his family, and with his friends.  He also reported many years of experiencing an odd sensation of not being able to move.  This is very scary to him and makes him feel panicked until he is able to move.  He reported that during periods of suicidal or homicidal ideation he feels somewhat detached from himself.  Test results indicated that he falls into the severe category of depression.  His severe symptoms include pessimism, past failure, punishment feelings, loss of interest, loss of energy, sleep changes, and fatigue.  Other test results indicate high levels of anxiety, somatoform, major depression, alcohol dependence, and drug dependence.  The examiner opined that the Veteran appears to have been a well-functioning, conscientious and committed individual prior to his dismissal from his Army recruiting position and subsequent discharge from the military.  He had a great deal of loyalty to his work and to the military and a great deal of pride in his personal abilities and strengths.  Because of these self-perceptions, the Veteran had and continues to have a great deal of difficulty dealing with what he considers a failure on his part to live out his life plan of raising a family and retiring from the military.  He continues to struggle with difficulties adjusting to his current work situation and needs to find constructive ways to cope with these difficulties.  Given his history of depression and suicidal thoughts as well as his current substance abuse, this is a potentially dangerous choice of lifestyle and he should be followed closely.  He was diagnosed with major depression, recurrent, moderate, alcohol abuse, continuous, and opiod abuse, in remission.  His GAF score was noted to be 55.  

A March 2005 private initial evaluation report notes that the Veteran had been seen for depression through VA.  He complained of decreased interest and pleasure, as well as feeling anxious and nervous.  He also reported increased sleep, decreased sexual desire, and difficulty handling normal stress.  On examination the Veteran had a normal appearance.  He was noted to be sad and anxious.  His motor activity was noted to be both normal and decreased.  His speech was normal and his behavior was appropriate but irritable.  His flow of thought was indecisive and distractible.  His mood and affect were anxious and depressed.  His thought content was appropriate.  He denied hallucinations.  He was fully oriented but was noted to have an inability to concentrate.  It was further noted that his appetite and energy/activity were decreased.  His attitude was cooperative.  He denied suicidal or homicidal ideation.  He was noted to have excessive worry.  The examining physician indicated that the Veteran had moderate impairment in terms of activities of daily living, social functioning, concentration and adaptation, with some, but not all, useful functioning.  He was prescribed Effexor and referred for therapy.  The diagnosis was mood disorder not otherwise specified.  His GAF was noted to be 68.  The clinical impression was depression secondary to medical problems.  It was noted that the Veteran works as a mail handler and has worked in this position for five years.  

An April 1, 2005 private treatment record notes that the Veteran had stress at home and at work.  He was noted to have suicidal ideation but he denied homicidal ideation.  His appearance was noted to be casual and his face was relaxed.  His movement was average and he was noted to be cooperative.  He was alert and his attention was on target.  His mood was described as appropriate and his speech was normal.  His memory and thought processes were within normal limits.  He denied hallucinations.  His sleep was noted to be disturbed.  His energy level was decreased.  His motivation was normal and his attitude was cooperative.  Effexor was discontinued and Lexapro was started.  Ambien was also prescribed.  

An April 2005 private treatment record from Gwinnett Hospital System notes a complaint of major depression with suicidal ideation.  It was noted that on April 5, 2005 the Veteran was seen for altered mental status.  The Veteran reported that he had been feeling upset and depressed as a result of his boss/employer sending him a letter stating that he was at fault for an accident he was involved in four months earlier.  He stated that as a result, he has thoughts of harming his co-worker.  The Veteran admitted to having suicidal ideations at times, but he does not have any current definitive plans.  He denied auditory or visual hallucinations.  The admission diagnosis was major depression with homicidal and suicidal ideation.  The Veteran endorsed feelings of hostility and anger towards anyone, anhedonia, isolation/withdrawal, crying spells, irritability, decreased concentration, poor sleep, low energy, loss of appetite, increased stress, problems at work with co-workers and management, and feelings that people at work are out to get him.  He indicated that he has a positive support system in his spouse and children.  However, it was further noted that his wife is in and out of his life.  He was noted to have suicidal thoughts with a plan.  He denied previous suicide attempts.  On examination, the Veteran was neat in terms of his appearance.  His behavior was described as calm and cooperative.  His speech was normal, his mood was depressed, and his affect was constricted.  The Veteran was described as having impaired insight and judgment.  There were no memory problems.  The Veteran was admitted to the hospital on April 5, 2005.  It was noted that he was a postal worker with chronic back pain and that he was unable to do certain things at work.  He has been written up for his inability.  He stated that he angers quickly in general.  The Veteran stated that he had been depressed for two years and finally decided to get help for it.  He was discharged on April 6, 2005.  He denied suicidal or homicidal ideation.  His mood was noted to be happy.  The diagnosis was major depression.  

A May 10, 2005 private treatment record notes that the Veteran had been going to work periodically.  It was further noted that since being released from the hospital, the Veteran had not followed up.  On examination the Veteran's appearance was described as neat.  His face was described as sad.  His movement was noted to be average.  He was noted to be alert but distracted and with difficulty concentrating.  His mood was noted to be anxious and labile.  His speech was hyperverbal and his orientation was full.  His memory and thought processes were within normal limits.  He denied hallucinations.  His sleep was noted to be disturbed and his energy was noted to be decreased.  His Lexapro was increased and he was prescribed Lunesta.

A July 15, 2005 VA psychology note indicates that the Veteran presented to therapy with complaints of chronic pain and depression.  He described his past failure with his marriage and in the military.  He expressed frustration and anger that his past hobbies of basketball and running were no longer an option for him given his pain.  He appeared slightly resistant to discussing finding new alternate positive activities.  The Veteran was described as being divorced and living alone.  His thought contents were ruminative.  He denied suicidal and homicidal ideation but admitted that these thoughts come and go.  He denied any specific plans or targets.  No abnormal movements were noted.  His mood varied from tearful when describing his past failure, to anger, when discussing his work situation, and euthymic.  His affect varied and was consistent with his mood.  He appeared very eager to continue his medications, although at times he stated he was unmotivated in life from the chronic pain.  

Additional VA psychology notes dated from July 2005 to September 2005 generally indicate that the Veteran was appropriately dressed for the appointment.  He did not maintain appropriate eye contact during the session.  His attitude was cooperative but guarded.  His affect was normal or appropriate to content.  He denied suicidal/homicidal ideation, hallucinations, and delusions.  His insight and judgment were fair.  He presented with a depressed mood in July 2005.  From August 2005 to September 2005 he presented with a pleasant or euthymic mood.  The assessment was major depressive disorder.  

A January 2006 VA psychiatry note indicates that the Veteran was dressed casually but neatly, and was well-groomed.  His affect was flat, and his mood appeared depressed.  His eye contact was good and he was readily engaged in discussion.  He stated that he is employed at the post office and often misses because of pain and because he does not want to face his superiors, whom he feels are skeptical about his absences and think he is faking.  He denied currently having suicidal thoughts but said he has attempted suicide previously and was subsequently hospitalized.    

A February 2006 VA treatment record notes that the Veteran indicated that he related to a workplace shooting by a postal worker in California.  Notably, he stated that he worries that he could snap because of the insensitive treatment he has received, although he denied suicidal or homicidal ideation.  He had 380 hours of leave without pay last year.  He has not been able to get medical verification of his need for light duty so he continues to work on the docks, where his service-connected back injury is constantly exacerbated.  He stated that he is essentially homeless, either staying with a friend or his ex-wife.  He does not work enough to afford an apartment.  He was neatly groomed.  His mood appeared depressed and his affect was flat.  The assessment was depressed, obsessing about prior trauma.  There was no evidence of suicidal or homicidal ideation but it was noted that he has numerous stressors and he feels pretty hopeless.  

A June 2006 VA treatment record notes that on examination the Veteran had a depressed mood.  He was fully oriented.  He was coherent, irritable, and had a constricted affect.  He was not suicidal or homicidal.  His insight and judgment were fair.  He also did not have auditory hallucinations or fixed delusions.  The assessment was depressive disorder secondary to his physical problems.  

A June 2006 letter from the Veteran's VA psychiatrist notes that the Veteran stated that he is having increased depression and that he feels that he is under a lot of stress at work and in his life.  The VA psychiatrist stated that because of his increased depression, he is more isolative, irritable and unable to deal with the stress from the job.  The VA psychiatrist opined that the Veteran needs to be away (stay home) from his job stress for two days to deal with his depressive symptoms before he can get back to his job at the post office.

A July 2006 VA treatment record notes that the Veteran's emotional estrangement from his wife continues to increase.  She reportedly refuses to come with him for couples therapy.  Although they are living together, they remain effectively separated.  He stated that his wife berates him, and calls him crazy.  He spoke about prior suicidal thoughts but said he has ruled out suicide.  The assessment was chronic depression.  

An application for Family Medical Leave Act, signed by the Veteran in July 2006, states that the Veteran has depressive disorder related to physical problems.  It was noted that he had been treated for his depression through VA since 2004.  It was noted that the Veteran's ability to work depends on the type of work performed because of the degree of pain and depression.  

An October 3, 2006 incident report from the Veteran's employer states that the Veteran and a co-worker were involved in a verbal confrontation concerning unloading two trailers on a dock.  The Veteran was being instructed by his coworker about which trailer to unload first.  The Veteran expressed to his co-worker that the co-worker was not his supervisor and could not tell him what to do.  They began arguing, it got heated, and the co-worker proceeded to take the dock plate out of the trailer.  The Veteran was very displeased with his co-worker taking the dock plate out of the truck because it created a hazardous situation that could have caused injuries.  The Veteran was suspended due to a display of possible violence toward his co-worker.  During his suspension, his request for disability retirement was approved in March 2007.  The Veteran's supervisor stated that the Veteran began experiencing difficulties at work as early as January 2004.  His supervisor further opined that the Veteran only remained employed as long as he did by the good grace of his employer, and his prolonged employment should not be considered a reflection of his ability to function in a work environment.  

Various forms dated in October 2006 through April 2007 note that the Veteran was incapacitated and could not work due to his lumbar disc disability.  A March 2007 Family Medical Leave Act form notes that the Veteran continues to experience depression that impairs his ability to work.  His GAF score is 53.

An October 5, 2006 VA treatment record notes that the Veteran had an incident on the job two days earlier that caused him to have homicidal thoughts about a co-worker.  It was noted that he had not returned to work and that he still felt so angry that he thought he would stab this worker if he had to work alongside him.  The other worker intentionally lowered the lift connecting the shipping dock to the truck the Veteran was unloading.  Had another worker not noticed it and called out for the Veteran to stop, the Veteran would have plunged off the truck along with the loaded pallet, and would have had serious injuries.  The dock supervisor met with the Veteran and the co-worker, who acknowledged the act.  However, the Veteran said there was no plan to remove the other worker from the site.  The Veteran was noted to be paranoid about the other worker and stated that he contacted the EEO office to file a claim based upon hostile work environment, but expects no action for at least a week.  The Veteran stated that he was unable to sleep and that he keeps obsessing about getting revenge by stabbing the other worker.  He reported that his relationship with his wife is going pretty well.  On examination, the Veteran was noted to be coherent, cooperative, anxious, angry, and with homicidal ideation.  He denied suicidal ideation.  

A November 2006 VA psychiatry note indicates that the Veteran reportedly tried to return to work twice since the incident with his co-worker but both that worker and a former supervisor with whom he had a conflict are working on the dock and he fears what might happen if he had to work around them.  He stated that he has been having panic attacks several times a day when he thinks of going back to work.  However, he stated that the main reason he has not returned to work is his cervical and lumbar spine and hip pain.  His work entails a lot of lifting, pulling, and pushing heavy items.  Overall, his GAF was noted to be 50.  On examination he denied suicidal or homicidal ideation.  There was no evidence of hallucinations or delusions.  He was logical and coherent, his affect was flat, and his mood was depressed.  He continues to live with his wife but has little emotional connection with her or with her son.  The assessment was depression.  Stressors include medical problems, conflict at work, lack of support system, and finances.  

A February 2007 VA psychiatry note indicates that the Veteran reportedly only worked two days this year.  He was sent home without pay while the postal service investigates complaints that he hit and threatened another employee.  He had not previously mentioned that he assaulted the worker.  He also stated that he had not been working regularly anyway and earned only half his base pay last year because of absences that he attributed to pain, depression and conflict with co-workers.  The Veteran was still living with his wife although they have little communication.  He stated that he enjoys his relationship with his daughter who is in college.  He has no friends and spends his days watching television and doing exercises to increase range of motion in his hips.  He admitted to increased alcohol consumption (he stated that he drinks two or three glasses of whiskey daily to help him go to sleep).  He stated that he often has nightmares.  He is hoping to go on medical disability from the post office.  He is also planning to apply again to VA vocational rehabilitation about retraining.  He was rejected when he applied previously but his physical condition has worsened since then.  He was noted to be irritable and pessimistic.  He denied suicidal and homicidal ideation.  The assessment was depression with alcohol abuse.  It was noted that his job situation had worsened and he may lose his job due to the altercation previously mentioned.  

Another February 2007 VA treatment record notes that the Veteran reported that he was working but that he was having difficulty dealing with people.  He has specific difficulty with people who directly or indirectly say things to him that make him angry.  He tries not to get into fights and sometimes feels like he cannot control his anger.  He admitted to missing a lot of work.  He reported feeling like the post office is trying to get rid of him because of his poor attendance.  The authoring VA psychiatrist stated that the Veteran does not seem to have much insight or motivation in working on changing his behavior at this time.  On mental status examination he was appropriately dressed.  His attention/concentration was sufficient.  He was fully oriented.  His behavior was reserved/cautious and he exhibited poor eye contact.  His speech was clear and coherent.  His mood was anxious and irritable.  His affect was restricted.  His thought processes were organized and goal directed.  His thought content was paranoid.  His judgment was normal but his insight was poor/limited.  There was no evidence of auditory or visual hallucinations and the Veteran did not have suicidal or homicidal ideation.  The assessment was depressive disorder secondary to chronic pain.  

A February 2007 letter from the Veteran's wife states that she has been married to the Veteran since July 1983.  It was noted that the Veteran and his wife were currently living together.  It was further noted that in April 2005 the Veteran was admitted to the hospital and that in October 2006 he threatened a co-worker and was asked not to come to work until he cooled down.  He misses an average of six to eight days a month from work due to lack of motivation and he is always isolating himself from others.  Additionally, he refuses to take a shower every day (he takes a shower once a week) and he is always in bed.  

A March 2007 VA psychiatry note reflects the Veteran's statement that he was called back to work at the post office because the employee he hit in November 2006 said he was no longer frightened by the Veteran.  When he showed up on the job, he discovered that not only the co-worker he was involved in the altercation with, but a supervisor he had previous conflicts with, both worked in his area of the dock.  He remained on the job that day but has not returned.  He is also having conflict with his wife.  She says he is neglecting his hygiene in that he bathes only twice a week.  She also stated that when she returns from work every day he is sitting on the sofa watching television and drinking beer,.  He denied suicidal ideation.  He continues to be motivated primarily by love for his daughter.  The assessment was chronic depression with alcohol abuse.  

An April 2007 statement of disability reflects the Veteran's contention that he became disabled on April 1, 2007 due to his major depression, dysthymic disorder, chronic back pain, cervical spine problems, arthritis of the ankles, knees and shoulder, osteoarthritis of the hips, hypertension, and peripheral neuropathy.  

An April 2007 VA psychiatry note states that the Veteran reported having problems with coworkers and supervisors at his workplace and that he is trying to retire from the post office.  He indicated that he has had several panic attacks on the way to work.  He is trying to be declared unemployable.  He reported that he is still living in his ex-wife's house but the relationship is strained.  He requested to be included in an anger management group.  The authoring social worker determined that the Veteran's chronic depression is exacerbated by his being in unsupportive environments both at work and at home because of financial considerations.  

A June 2007 VA treatment record notes a diagnosis of dysthymic disorder.  It was noted that the Veteran has had difficulty working due to conflicts with coworkers and back pain, and is currently waiting for disability retirement to be approved.  On mental status examination the Veteran was appropriately dressed.  His attention/concentration was sufficient.  He reported intact memory.  He was found to be fully oriented.  His behavior was described as complaining, poor eye contact, and defensive.  His speech was clear and coherent.  His mood was described as dysphoric (noted to be depressed/anxious/irritable).  His affect was angry, irritable, and dissatisfied.  His thought processes and content were relevant.  His judgment was described as unrealistic and his insight was fair.  The assessment was dysthymic disorder and borderline personality traits.  

A July 2007 letter from one of the Veteran's treating VA psychiatrists notes that the Veteran has been treated for depression, adjustment problems, and anger management problems since May 2004.  It was noted that the Veteran has problems controlling his anger in adjusting to his job at the post office.  

A July 2007 VA treatment record notes that the Veteran was seen for help with his drinking.  He reported problems with his boss at work and separation from his wife.  He endorsed depression, anxiety, and suicidal/homicidal thoughts or action.  He endorsed occupational problems such as poor performance and tardiness/absence.  He also endorsed relationship problems with his spouse and excessive anger.  Objective examination revealed that the Veteran was alert and fully oriented.  His general appearance and behavior were normal.  There was no psychomotor agitation or retardation.  Speech was normal and mood and affect were both euthymic and full-range.  Thought content and thought process were normal.  Memory was within normal range.  Concentration, fund of knowledge, and abstraction were normal.  Perceptions, insight, and judgment were normal.  The assessment was depression, adjustment disorder, and alcohol dependence.  

An August 2007 letter from the Office of Personnel Management (OPM) indicates that the Veteran's application for disability retirement under the Federal Employees Retirement System has been approved.  OPM stated, in another August 2007 letter to the Veteran, that the Veteran has been found to be disabled due to his musculoskeletal limitations.  

A September 2007 VA Form 21-4192 reflects the Veteran's statement that he was employed at the United States Postal Service as a mail handler/dock worker from January 2000 through August 13, 2007.  It also reflects that he last worked on April 20, 2007 and retired on disability.  

A December 2007 VA examination report notes that the Veteran reported that his depression began in 1994.  His current symptoms include irritability, hopelessness, and helplessness.  The Veteran described the symptoms as constant.  He stated that the symptoms severely affect his daily functioning on bad days because he is constantly hurting.  He takes medications for his psychiatric condition.  The Veteran reported that he was not currently working and had not been working for six months because of disability retirement.  He was employed at the post office for seven years.  He reported using alcohol once a day since 1998 because of depression at separation from service.  He reported quitting this habit.  On mental status examination orientation was normal and appearance and hygiene were appropriate.  His behavior was appropriate and his mood was depressed.  His depressed mood was noted to be near-continuous in that it affects his ability to function independently.  He may stay lying in bed all day.  He is isolative, negative, and hopeless.  His communication, speech, and concentration are within normal limits.  Panic attacks occur once a week.  There are signs of suspiciousness but no delusions.  There is no history of hallucinations and no signs of hallucinations on examination.  Obsessional rituals were noted to be absent.  The Veteran's thought processes were described as appropriate and his judgment was not impaired.  His abstract thinking was normal but his memory was noted to be moderately impaired in that he has problems with retention of highly learned material and forgetting to complete tasks.  His short term memory is also poor.  There are passive thoughts of death.  Homicidal ideation is absent.  The diagnosis was noted to be depression due to his service-connected lumbar spine disability and alcohol abuse, which is due to the depression.  The examiner opined that the Veteran's depression makes him very irritable and he becomes confrontational at work.  He occasionally has some interference in performing activities of daily living because of his irritability.  He has difficulty establishing and maintaining effective work and social relationships because of his irritability.  The best description of the current psychiatric impairment was determined to be occupational and social impairment with reduced reliability and productivity due to flattened affect, panic attacks more than once a week, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships.  He has no difficulty understanding commands.  The examiner further opined that the Veteran appears to pose no threat of persistent danger to himself or others.  

A December 2007 Social Security Administration (SSA) mental impairment questionnaire, completed by a physician, notes that the Veteran has depression secondary to physical problems.  It further notes that he has poor impulse control and anger management problems.  His affect and mood were described as depressed and irritable.  His orientation, appearance, and general behavior were normal.  His thought processes and flow of mental activity were noted to be normal, but with paranoia.  The Veteran denied suicidal/homicidal ideation and the physician found that there were no psychotic signs or symptoms.  The Veteran's recent and remote memory was noted to be normal.  The Veteran was found to have poor impulse control and insight.  He was noted to have problems in relationships and paranoid thinking.  The diagnosis was dysthymic disorder, major depressive disorder, and rule-out posttraumatic stress disorder.  The physician found that the Veteran's paranoia and poor impulse control interfere with his function the job, especially when under stress.  The physician rated the Veteran's ability to get along with the public, with supervisors, and with co-workers as abnormal.  The physician also rated the Veteran's ability to deal with changes in the work setting as abnormal.  The physician found that it was highly likely that the Veteran would decompensate or become unable to function under stress.

A January 2008 private mental status examination from Dr. Rush (contained within the Veteran's SSA records) notes that the Veteran was referred for psychological evaluation in connection with his SSA disability application.  It was noted that the Veteran reported feeling depressed daily.  He also reported being irritable often, which has caused problems with his marriage and children.  He stated that he is mistrustful of others and isolative.  He further reported being compulsive and obsessive.  He denied a history of drug use, but reported that he drank excessively from age 30 until age 47 or 48.  He underwent alcohol treatment through a six week outpatient program through the VA.  He has been married 23 years but he and his wife have been separated nine months.  He graduated from high school and received no other formal education.  It was noted that he last worked in April 2007 as a mail handler with the United States Post Office.  After seven years of employment, it was noted that he retired on disability.  It was noted that previously, he worked six months as a customer service representative for Delta Airlines.  He left this position for a better position at the post office.  He also worked three months as a supervisor for Argon Bright Security but he quit this position.  It was noted that he currently lives with his sister and brother-in-law.  He reported that his appetite is poor and he often has difficulty sleeping.  On examination he was dressed appropriately and his grooming and hygiene were adequate.  He reported his mood as sad.  At times he appeared teary eyed and his affect appeared congruent to his mood.  Rapport was difficult to establish, as he appeared very agitated.  He responded very curtly to direct questions.  His insight was considered good and judgment fair.  He exhibited poor eye contact.  His attention and concentration were good, and he was fully oriented.  His long-term and working memory appeared intact.  He had some short-term memory deficits.  There were no speech deficits reported or noted.  Although his thought processes appeared logical and coherent, the Veteran reported that he sometimes hears voices telling him that he is worthless.  He denied suicidal and homicidal ideation.  The diagnoses were major depressive disorder and posttraumatic stress disorder.  It was determined that the Veteran is capable of understanding and following simple instructions and is capable of performing routine tasks independently.  However, it was also determined that he is likely to have difficulty handling supervision and getting along with others due to agitation.  It was further noted that he continues his medication to help his psychological symptoms and continues counseling to help him cope with his anger, depression, and frustration.  His prognosis was determined to be fair.  

A March 2008 VA treatment record notes that the Veteran was unemployed after having worked for the U.S. Postal Service for six years.  On mental status examination it was noted that the Veteran was alert and oriented.  It was also noted that he had good hygiene and grooming.  He had no eye contact during the interview, but he was calm and forthcoming with information.  His speech was normal.  His mood was depressed/irritated, with congruent affect, complaining, and some entitlement.  His thought process was circumstantial.  His thought content was without active suicidal or homicidal ideation, audio/visual hallucinations, or delusional content.  He ruminated about his VA treating psychiatrist and his service connection claim.  His insight and judgment were determined to be fair and his impulse control was noted to be good. 

An April 2008 VA social work progress note notes that the Veteran was seen for depression.  He denied active suicidal ideation, homicidal ideation, and visual hallucinations.  However, he endorsed continued audio hallucinations (voices with no harmful command component) and occasional suicidal ideation.  He also endorsed continued medication compliance.  He reported nightmares twice a month.  He continues to live with his sister.  He stated that he and his daughter communicate, but he indicated that his daughter describes him as crazy and irritable.  He does not agree with his daughter's comments.  Objective examination revealed that the Veteran was alert, fully oriented, and had good hygiene and grooming.  He displayed intermittent eye contact.  He was calm and forthcoming with information.  His speech was normal.  His mood was depressed/irritated and his affect was congruent.  His thought process was circumstantial.  His thought content showed no active suicidal or homicidal ideation, no audiovisual hallucinations, and no delusional content.  Impulse control was noted to be good.  

An October 2008 psychiatric/psychological impairment questionnaire contained in the SSA disability records notes that the Veteran is diagnosed with PTSD and major depression with psychotic features.  His current GAF core was noted to be 45.  His prognosis was noted to be poor.  Positive clinical findings included poor memory, perceptual disturbances, sleep disturbance, mood disturbance, social withdrawal or isolation, blunt, flat, or inappropriate affect, delusions or hallucinations, decreased energy, past substance dependence, anhedonia, intrusive recollections of a traumatic experience, psychomotor agitation or retardation, paranoia or inappropriate suspiciousness, generalized persistent anxiety, feelings of guilt/worthlessness, difficulty thinking or concentrating, hostility and irritability, and suicidal ideation or attempts.  However, the primary symptoms are irritability, hallucinations, suicidal/homicidal ideation at the height of depression, and social isolation.  On examination the Veteran had markedly limited memory and understanding, moderately to markedly limited sustained concentration and persistence, moderately to markedly limited social interactions, and moderately to markedly limited adaptation.  It was determined that work stress, mild or severe, will likely exacerbate irritability and other depression/PTSD symptoms.  The Veteran was found to be incapable of tolerating work stress.  

A November 2008 letter from the Veteran's treating VA psychiatrist notes that the Veteran has been under this psychiatrist's care since March 2008 and was previously treated by another psychiatrist through VA since May 2004.  It was noted that the Veteran was diagnosed with PTSD, major depression and alcohol dependence in full remission.  His most recent GAF score is 45, indicating major impairment of functioning in several areas of his life.  He endorses near continuous depression which impairs his ability to function independently.  He reported unprovoked irritability, auditory hallucinations, impaired concentration, sleep disturbance, anhedonia, social isolation, persistent anxiety, paranoia and suspiciousness of others.  At the height of his depression he has experienced suicidal ideation, culminating in attempts with wreckless driving and being stationary in the middle of train tracks.  He has been hospitalized and his chronic issues with irritability impaired concentration, and paranoia would affect his ability to sustain work routine, adjust to changes at work, and interact appropriately and effectively with others.  

A February 2009 VA Form 5655 notes that the Veteran stated that he retired from employment due to disability in March 2007.  

A June 2009 letter from the Veteran's daughter notes that the Veteran has had symptoms of depression since at least 1998.  She described the Veteran as always angry and isolative, and no longer able to work.  He does not like to form close relationships with others because he seems to believe that other people have alternative motives to hurt him.  This causes him to threaten people often.  

A June 2009 statement from the Veteran's spouse indicates that the October 2004 VA examiner told her that the Veteran was suffering from severe symptoms of depression and that she should monitor him very closely.  It was noted that in March 2005 the Veteran was hospitalized for suicidal ideation, homicidal ideation and history of violence towards others.  In October 2006 the Veteran was suspended from work for perceived threats toward a coworker because the Veteran felt that the coworker was trying to hurt or kill him.  He was suspended for six weeks.  In August 2007 the Veteran attempted suicide with a shot gun.  

An August 2009 VA treatment record notes that mental status examination revealed good self care.  He got emotionally aroused at times, especially if questioned for details and expressed his frustration in various ways.  He became threatening at one point with staring eye contact and perceived imminent violence.  His attitude was guarded and the examiner found it to be a difficult interview.  His speech was coherent, his psychomotor was variable, his mood was depressed, guarded and irritable, and his affect was restrained and restricted.  His thought process was linear and his thought content was devoid of suicidal or homicidal ideation.  There were no delusions.  Insight was noted to be good and judgment was fair.  Impulse control was fair.  The Veteran was alert and oriented.  The impression was history of dysthymic disorder, adjustment disorder with depressed features, rule-out intermittent explosive disorder and anger management problems, and rule out alcohol dependence.  

An August 2009 letter from the Veteran's VA psychiatrist notes that the Veteran has been a patient at the Atlanta VA Healthcare System since 2003 and his first mental health record on the system dates back to May 4, 2004.  It was noted that the Veteran has diagnoses of PTSD, major depressive disorder and alcohol dependence in remission since 2007.  He reported an exacerbation of his depression secondary to significant chronic psychosocial stressors.  He reported that he was dismissed at work and that his wife asked him to leave their marital home.  

An August 2009 letter from the Veteran's sister notes that the Veteran experiences hallucinations and is a persistent danger to himself and others.  It was noted that the Veteran has lived with his sister off and on over the past 10 years.  During his stays with his sister, he has been observed depressed, irritable and isolative.  He expresses suicidal and homicidal ideation.  Specifically, she stated that the Veteran says things like, "I would blow the brains out of anyone I please."  Then when her husband and she ask him if he wants to spend the rest of his life in jail, he would say, "I am not going to jail because I am going to kill myself before that happens."  She also indicated that the Veteran neglects his personal care and showers once a week or not at all.  Further, she stated that he always expresses paranoid ideation and is constantly depressed with outbursts of intense rage.  Moreover, he forgets things such as his sister's children's names and when to take his medication.  Finally, she stated that he occasionally hears voices in his head and is unable to maintain a social life.  

A December 2009 VA examination report (of a November 2009 examination) notes that the Veteran reported symptoms of sleep disturbance, mood disturbance, loss of interest and motivation, lack of energy, hopelessness, helplessness, guilt, and trouble concentrating.  He reported that the symptoms are constant and they affect his total daily functioning, resulting in relationship, social, and occupational problems.  He takes medication, undergoes psychotherapy, and has been hospitalized for his psychiatric problems.  He reported being involved in church activities, social activities and sports activities before military service.  Since leaving the military he has been separated from his wife, but he has a good relationship with his daughter, but not with his son.  He has also experienced a loss of interest and motivation in activities in that he has been socially withdrawn and isolated.  He is not currently working and has not worked for two years because he is not mentally capable of working.  He got into altercations at work when he was employed at the United States Postal Service.  He reported using alcohol once or twice a day.  It was noted that this began in 2000 because of his depression.  He is no longer abusing alcohol and has not used for two years.  On mental status examination the Veteran was fully oriented, with appropriate appearance and hygiene.  His behavior was appropriate.  He had poor eye contact during the exam.  He had a disturbance of motivation and mood, and a flattened affect, with anxiety, sadness, helplessness, irritability, anger, and loss of interest and motivation.  Communication and speech were within normal limits.  The examiner noted that the Veteran displayed impaired attention and/or focus.  He had poor concentration due to impaired focus and attention.  Panic attacks and obsessional rituals were noted to be absent.  There were signs of suspiciousness.  There was no reported history or observation of delusions.  There was noted to be a history of audio hallucinations.  At the time of examination hallucinations were not observed.  Thought processes were appropriate.  The Veteran was determined to be able to read and understand directions.  He did not have slowness of thought or appearance of confusion.  Judgment was not impaired, and memory and abstract thinking were normal.  Suicidal ideation and homicidal ideation were absent.  The diagnosis was major depression.  The current GAF score was noted to be  55.  The examiner stated that the Veteran is mentally unable to maintain gainful employment due to clinically significant symptoms of his depressive disorder.  It was also noted that the Veteran's alcohol abuse, in remission, is secondary to his major depressive disorder because he started drinking to cope with his depression.  

A February 2010 letter from the Veteran's treating VA psychiatrist indicates that the Veteran is diagnosed with major depression, recurrent, with psychotic features, and PTSD.  The letter states that he last worked in March 2007, when he was terminated subsequent to confrontations with his supervisor and co-workers.  He continues to have problems with severe unprovoked irritability, anger outbursts, and low frustration tolerance.  Consequently, he stays isolated from even family members in order to minimize confrontations.  Chronic pain aggravates his irritability and he notes near continues depression and anxiety.  Moreover, he endorses recurrent nightmares, hallucinations with derogatory content, and suicidal ideations.  He has attempted suicide on more than one occasion.  He has been compliant with his medications and is involved in his mental health treatment.  Due to the severity of his anger symptoms, he has been referred to an anger management group.  Despite active treatment, his symptoms remain severe and persistent, and they render him unemployable.  

An April 2010 letter from the Veteran's former administrative supervisor (not his direct supervisor) at the U.S. Postal service (from January 2000 through March 2007), C.W.H., notes that from January 2004 to March 2007 the Veteran began missing a lot of work or leaving early.  He was described as moody.  Specifically, it was noted that other employees seemed to have to "walk easy" around the Veran so he would not yell or get upset with them.  He began to get into verbal altercations with other employees.  It was further noted that he was covered by the Family Medical Leave Act for his psychiatric illness and in March 2007 he was recommended for disability retirement because of his inability to cope and the severity of his impairment, which had a serious impact on his overall job functioning as a mail handler.  C.W.H stated that from personal observation, the Veteran began experiencing difficulties as early as January 2004.  

A February 2010 VA psychiatry note indicates that the Veteran reported that due to poor memory, he missed his daughter's college graduation.  He has much guilt, remorse, and anger over this.  He was living with his sister and brother-in-law and got into a fight with his brother-in-law, which resulted in the police coming and ordering him to move out of his sister's house.  He is now staying with a friend.  He stays isolated throughout the day because he is highly irritable and wants to avoid confrontations.  He has not worked since March 2007 when he was terminated following threats to his supervisor and coworkers.  He thinks that no one would hire him and he avoids contact with others due to his extreme unprovoked irritability.  Mental status examination revealed that the Veteran was casually dressed and adequately groomed.  His mood was irritable with congruent affect.  He denied active suicidal or homicidal ideations.  He endorsed auditory hallucinations.  He was fully alert and oriented.  The impression was PTSD, major depressive disorder with psychotic features, and alcohol dependence in full remission.  His GAF score was noted to be 45.  

A September 2010 letter from the Veteran's treating VA psychiatrist notes that the Veteran has been under treatment from the VA Community Based Outpatient Clinic since 2008 and prior to that he was in treatment at the Atlanta VAMC since January 2004.  He is diagnosed with major depression and PTSD.  He last worked in March 2007.  He continues to have problems with severe unprovoked irritability, anger outbursts, and low frustration tolerance.  Consequently, he stays at home and is isolated from any social interaction.  Moreover, he is essentially estranged from all but two family members due to a recent confrontation.  He endorses recurrent nightmares, persistent hallucinations with derogatory content, memory loss of names (even close relatives), and suicidal/homicidal ideations.  He has been perceived as threatening in his demeanor and endorses persistent danger of hurting himself and/or others.  He has experienced increasing difficulty with interpersonal interaction since March 2007.  His functional impairments resulting from severe depression restricts his ability to establish and maintain effective relationships, adapt to stressful circumstances in a workplace, make sound judgments, and carry out simple tasks that once were easy for him to do.  There is marked limitation in his ability to work in coordination with others without being distracted and/or experience a normal work week without interruptions from psychological symptoms.  He would have difficulty getting along with others, including supervisors, especially when receiving criticism.  He easily decompensates under stress, and following a confrontation, would retreat into complete isolation.  In light of his inability to effectively interact with family members, his impairment in regulating his mood, and inability to function at a job, his GAF has been rated at 45 (his lowest score in the past year), which is indicative of severe impairment in multiple domains.  It was determined that his symptoms remain severe and persistent.  The authoring psychiatrist opined that due to the chronicity and the severity of his psychiatric symptoms, he is considered to be unemployable and his disabilities have made him totally and permanently disabled.  

A December 2010 VA examination report notes that the Veteran reported that he suffers from depression and is treated through VA.  He sees his psychiatrist monthly.  He has been separated for five years.  He has two adult children and he stated that he communicates a little with his daughter but has no relationship with his son.  He reported that his symptoms began in 2004 as a result of chronic pain and an inability to work.  He was also having problems getting along with others.  He described current symptoms of social isolation, poor relationships with the family, chronic pain, low mood, and irritability.  He stated that the symptoms are severe, constant, and affect total daily functioning, which results in separation from his wife and kids.  He reportedly has had trouble sleeping for three years.  He takes several medications and has been hospitalized for psychiatric treatment.  The Veteran reported that he is not currently working and has not been working since October 2006.  He stated that his unemployment is not due primarily to the effects of a mental condition.  He stated that as a result of his chronic back problems, his performance was poor.  He stated that he has not abused alcohol for four years.  On mental status examination he was fully oriented and his appearance and hygiene were described as appropriate.  His behavior was noted to be appropriate but he had poor eye contact during the examination.  His affect was flattened and he was flat throughout the examination.  Communication and speech were within normal limits.  Concentration was within normal limits.  There were no panic attacks, suspiciousness, delusions, hallucinations, or obsessive compulsive behavior.  The Veteran denied a history of delusions and hallucinations as well.  Thought processes were appropriate; he was able to understand directions.  He did not have slowness of thought nor did he appear confused.  Judgment, abstract thinking and memory were normal.  There was no suicidal or homicidal ideation.  The examiner did not review the claims file.  The diagnosis was mood disorder secondary to degenerative joint disease, alcohol dependence in remission.  The examiner found that the symptoms of his mood disorder are more consistent with a depressive episode, such as insomnia, social isolation, guilt and irritability.  His GAF score was noted to be 47.  The examiner further opined that the substance abuse is related to his mood disorder in that the Veteran used alcohol to deal with his chronic pain and mood lability.  The examiner opined that the Veteran is intermittently unable to perform activities of daily living (but he can provide self-care).  The examiner further opined that currently, the Veteran is unable to establish and maintain effective work and social relationships because he has poor communication skills and argues with his family members a lot.  The best description of his current psychiatric impairment is psychiatric symptoms cause occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks although generally the person is functioning satisfactorily with routine behavior, self-care, and normal conversation.  The examiner determined that this finding is supported by the following symptoms:  depressed mood, chronic sleep impairment, and irritability.  The examiner determined that the Veteran has no difficulty understanding commands.  

A December 2010 letter from the Veteran's former direct supervisor at the U.S. Postal Service, C.P.,  indicates that from January 2004 to October 2006 the Veteran had problems during work.  C.P. observed symptoms of depressed mood and loss of interest in previously enjoyed activities within the work place.  Additionally, the Veteran had difficulty adapting to work place changes.  He had a tendency to become irritable, particularly with figures of authority.  He also had difficulty maintaining and establishing work and social relationships with others because of anger.  In January 2006 the Veteran was reprimanded for his failure to follow orders of management.  Again, in October 2006 the Veteran got into an altercation with a coworker.  The coworker said he was verbally and physically threatened by the Veteran.  On October 3, 2006, the Veteran was suspended from work until an investigation was completed, and he was informed by management to seek assistance with his physical and mental issues through the Employee Assistance Program that had been provided.  After returning to work in January 2007 (after the investigation) the Veteran was isolated in an area where he worked alone, monitoring the parking lot via security cameras.  In March 2007 he was approved for retirement disability through the Office of Personnel Management, effective April 2007.  C.P. stated that the Veteran started having severe work related issues prior to his retirement, and his last day of meaningful work was October 3, 2006.  After returning to work in January 2007 from his suspension, he was only working two to four hours daily, until his retirement was approved in March 2007.

A January 2011 letter from the same VA psychiatrist states that the Veteran continues to carry the diagnoses of major depression, severe with psychotic features, and PTSD.  His symptoms include unprovoked irritability, anger outbursts, low frustration tolerance, recurrent nightmares, persistent hallucinations, and suicidal ideations.  He has not worked since 2007, and it is unlikely that he would ever maintain gainful employment.

A certification of attending physician signed by the Veteran's VA psychiatrist in April 2011 indicates that the Veteran because totally disabled from performing any and every kind of duty pertaining to his occupation from October 1, 2006 to the present due to his PTSD.  

A July 2011 letter from a VA psychiatrist notes that the Veteran has not worked since March 2007 and from that time, he has not been able to maintain gainful employment.  It was the opinion of the VA psychiatrist that the Veteran has total and permanent occupational and social impairment due to his disabilities since March 2007.

Based on the evidence, and resolving all doubt in the Veteran's favor, the Board finds that his depression symptoms more nearly approximate the criteria for a 70 percent disability rating for the time period from March 10, 2005 to October 3, 2006, and more nearly approximate a 100 percent rating beginning on October 4, 2006.

In reaching this decision, the Board notes that the criteria for a 70 percent disability rating for depression are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood.  See Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). 

The Veteran was employed during this time period, but he has had definite deficiencies at work.  Notably, there is evidence of serious irritability and anger problems, as well as concentration problems, and isolation.  There is also evidence of deficiencies in the area of family relations, as he has consistently reported being detached, having marital difficulties, and having a very limited social support system.  Although he was living with his wife for a portion of this time period, the Veteran's relationship with his wife was described as contentious and he often lived with his sister.  He named only his daughter and one friend as supports, he was not interested in leisure activities, and had increased his consumption of alcohol. 

Deficiencies in terms of thinking have also been demonstrated for this time period.  The medical evidence shows that the Veteran's depression signs and symptoms result in deficiencies in the areas of thinking as evidenced by his disturbed sleep, ruminating thoughts, obsessional behaviors, excessive worry, and resistance to finding alternate positive activities.  The VA treatment records show the Veteran's thought processes have generally been normal throughout this time period.  However, the record also reflects that he has some concentration problems and thoughts of harming his co-worker.  The records further reflect that the Veteran has endorsed suicidal ideation and paranoid thoughts.  Thus, the evidence reflects some level of deficiency in his thinking. 

There is also evidence of deficiencies in the area of judgment and mood.  The VA treatment records reflect that the Veteran's depression signs and symptoms result in deficiencies in mood as evidenced by his irritability, feelings of hopelessness, and an inability to deal with stress on the job.  The VA treatment records also show the Veteran reported feeling angry at anyone and feeling paranoid.  He has consistently reported marked social avoidance and a diminished interest and participation in activities.  This is evidence of a deficiency in his mood. 

In short, the evidence reflects that for the time period from March 10, 2005 to October 3, 2006, the Veteran has deficiencies in most of the areas of work, family relations, judgment, thinking, and mood due to his service-connected depression.  Accordingly, the criteria for a 70 percent disability rating have been met for the period from March 10, 2005 to October 3, 2006. 

A higher, 100 percent rating for the time period from March 10, 2005 to October 3, 2006 is not warranted, however.  In this regard, the evidence does not show that the social and occupational impairment from the Veteran's depression is total.  Although the Veteran had definite occupational impairment due to his depression, he was employed at a postal worker during this time period.  The record reflects that he took a substantial amount of leave for physical illness and his VA psychiatrist indicated in June 2006 that the Veteran needed to stay home and not go to work for about two days to deal with his depression before he could return to work; however, the evidence does not reflect that the Veteran could not work after two days or that there was otherwise total occupational impairment due to his depression signs and symptoms.  Importantly, his speech was consistently normal, his thought processes were consistently normal, and his thought content was not found to contain hallucinations, perceptual disturbances, or delusional material at the time of examination.  

Additionally, the Veteran was not totally socially impaired during this time period.  For example, the March 2005 private evaluation report notes that the Veteran had only moderate impairment in terms of social functioning.  Moreover, the December 2004 VA treatment record indicates that the Veteran reported speaking regularly with his children and that he believes his relationship with his kids is good.  Although he reported having a contentious relationship with his wife, he also indicated that he receives social support from one friend and his daughter.  Similarly, although he was noted to be anhedonic and isolative, he was noted to have a few hobbies in December 2004, he was found to be cooperative and engaged during the December 2004 VA treatment session, he was noted to be cooperative according to the April 2005 private treatment record, and his mood was described as pleasant and euthymic in August and September 2005.  In sum, the Veteran's depression caused serious occupational and social impairment during the time period from March 10, 2005 to October 3, 2006, but it did not cause total social or occupational impairment because the evidence does not show that his depression precluded him from working or relating to his daughter and a friend. 

For the time period beginning on October 4, 2006, the Board finds that a higher, 100 percent rating is warranted for the Veteran's depression.  In this regard, the evidence for this time period shows total social and occupational impairment due to signs and symptoms of depression.  For example, on October 3, 2006, the Veteran was involved in an altercation with a co-worker in which the Veteran reportedly threatened his co-worker with violence.  As a result, the Veteran was suspended pending an investigation.  The Veteran reported homicidal ideation and obsessional thoughts about stabbing his co-worker.  The Veteran's former direct supervisor at the U.S. Postal Service stated in a December 2010 letter that the Veteran's last day of meaningful work at the post office was October 3, 2006.  After returning to work in January 2007 from his suspension, he was only working two to four hours daily, and that was in an isolated area where he worked alone, monitoring the parking lot via security cameras.  This assignment lasted until his retirement was approved in March 2007.  Additionally, a certification of attending physician, which was signed by the Veteran's VA psychiatrist in April 2011, indicates that the Veteran became totally disabled from performing any and every kind of duty pertaining to his occupation in October 2006.  Further, an October 2008 SSA record (psychiatric/psychological impairment questionnaire) indicates that the Veteran was found to be incapable of tolerating work stress.  Although the Veteran technically remained employed until March 2007, and a July 2011 letter from a VA psychiatrist notes that the Veteran has had total and permanent occupational and social impairment only since March 2007, the Board finds that the evidence is at least in equipoise with regard to whether the Veteran was totally occupationally impaired as of October 4, 2006.  Therefore, in giving the Veteran the benefit of the doubt, the Board finds that the Veteran was totally occupationally impaired beginning on October 4, 2006.  

Beginning October 4, 2006, the Veteran was also totally socially impaired.  In addition to his being detached from others, and generally estranged from his wife, he was described by the December 2010 VA examiner as exhibiting poor communication skills.  His wife indicated, in a February 2007 letter, that when the Veteran was living with her, he spent his time sleeping or watching television and drinking beer.  Moreover, a February 2010 VA psychiatry note indicates that he had to move out of his sister's house because he got into a fight with his brother-in-law, which resulted in the police coming and ordering him to move out.  Significantly, the Veteran's sister stated in an August 2009 letter that the Veteran was extremely angry, and expressed homicidal ideation and suicidal ideation, and was unable to maintain a social life.  In general, during this time period, he was found to have increased difficulty with interpersonal interaction, estrangement from all but two family members, persistent hallucinations with derogatory content, memory loss of names of even close relatives, and an inability to maintain personal hygiene.  Finally, his GAF score was noted to be 45 during this time period, representing a higher level of impairment.  The Board finds this to be an increase in the social impairment as compared to the previous time period.  

In sum, the treatment records and lay statements show that his anger and impaired impulse control appear to have worsened during this time period, and in the September 2010 letter from his treating VA psychiatrist, it was noted that his ability to adapt to stressful circumstances in a workplace and make sound judgments had deteriorated.  Although some of the evidence shows that this increase occurred in March 2007 (when the Veteran went on disability retirement) the Board finds, as described above, that the Veteran's total occupational and social impairment began when the Veteran was suspended for the altercation at work in October 2006.  The medical and lay evidence for the time period beginning on October 4, 2006 further reflect that the Veteran has more frequent hallucinations, impaired attention, concentration and memory problems, and impaired social judgment.  Moreover, in April 2008, it was noted that the Veteran's relationship with his daughter, once his primary motivator, had deteriorated.  In August 2009, he became threatening toward the VA treatment provider.  VA treatment records further reveal that his mood was no longer described as euthymic or happy and he was not described as cooperative during this time period.  A February 2010 letter from the Veteran's treating VA psychiatrist notes that the Veteran stayed isolated even from family members in order to minimize confrontations.  As the evidence now shows greater social isolation, increased anger, even at a treatment provider, poor communication skills, and lack of personal hygiene, the Board finds that the evidence also shows total social impairment.  As such, the Board finds that a 100 percent rating is warranted for this time period. 

Extraschedular Consideration Prior to October 4, 2006

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, then 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, for consideration of an extraschedular evaluation.  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.

The Board finds that the schedular rating for the Veteran's depression is adequate for the time period prior to October 4, 2006.  A rating in excess of the assigned rating is provided for a higher level of severity of depression, but such a rating is for certain manifestations which the medical evidence reflects are not present in the Veteran's clinical picture.  The diagnostic criteria also adequately describe the severity and symptomatology of the Veteran's depression.  Therefore, the Veteran's disability picture is contemplated by the Rating Schedule; no extraschedular referral is required for the time period prior to October 4, 2006.  In sum, the record does not reflect that the Rating Schedule is inadequate to contemplate the manifestations of his depression.  Thus, no extraschedular referral is required for the time period prior to October 4, 2006.

	Earlier Effective Date

The effective date of an award of benefits based on an original claim, a claim after final allowance or a claim for an increase is either (1) the date of receipt of the claim or (2) the date entitlement arose, whichever is later.  38 U.S.C.A. § 5110 (West 2002); 38 C.F.R. § 3.400 (2012).  A claim is defined in the VA regulations as a formal or informal communication in writing requesting a determination of entitlement, or evidencing a belief in entitlement, to a benefit.  38 C.F.R. § 3.1(p) (2012).  An informal claim is defined as any communication or action indicating intent to apply for one or more benefits.  38 C.F.R. § 3.155(a) (2012).

Earlier Effective Date for Service Connection for Depression

Service connection for depression was granted in an October 20, 2006 rating decision.  The effective date assigned was March 30, 2005, the date the RO determined that the Veteran's claim was received.  The Veteran contends that an earlier effective date is warranted.  In an August 2005 statement the Veteran indicated that he has been dealing with depression since 1997.  In a March 2010 statement the Veteran stated that he wished for the effective date for the grant of service connection for depression to be January 15, 2004, because that is when he was diagnosed with depressive disorder, and was prescribed the medication Zoloft for his depression.  

The RO concluded that March 30, 2005 was the appropriate effective date for the grant of service connection for depression, because the RO determined that the Veteran's claim for service connection was received by VA on that date.  In this regard, the Board notes that the Veteran submitted a statement, dated on March 21, 2005, which notes that the Veteran's service-connected disabilities have caused him to become very depressed.  There is no date stamp indicating when this statement was received by VA.  

The record also contains a March 10, 2005 letter from the Veteran's wife which was noted to be in response to a March 2005 post-remand letter from the AMC to the Veteran regarding certain claims on appeal.  The letter from the Veteran's wife indicates that the Veteran had become very depressed about his situation, including his medical and physical problems, and resulting work/attendance problems and financial limitations.

The Board will broadly construe the March 10, 2005 letter from the Veteran's wife to be an informal claim for service connection for depression.  As there is no date stamp on the letter, it is unclear when the letter was received by VA.  Therefore, the Board will accept the date of the letter, March 10, 2005, as the date the claim was received.  See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).  There is no correspondence in the claims file, or any other document which could be considered correspondence or a claim, received by VA prior to the Veteran's March 10, 2005 claim. 

Thus, the remaining question is when entitlement arose.  Treatment records dated in January 2004 from the Atlanta VA Medical Center reflect that the Veteran reported being depressed; he asked about treatment for depression.  He further reported being tired of experiencing a cycle of chronic back pain flare-ups, which he stated was causing stress in several areas of his life.  The impression was depression and he was started on Zoloft.  Moreover, a December 2004 VA treatment record reflects an opinion that the Veteran's depression may be related to his dismissal from his Army recruiting position and subsequent discharge from the military.  Thus, 2004 is arguably when entitlement arose.  However, because, as determined above, the Veteran's claim was received by VA on March 10, 2005, and the date entitlement arose was in 2004, the proper effective date for the award of service connection for depression is March 10, 2005, the later of those two dates.  38 C.F.R. § 3.400.  Even if the Board considers that entitlement arose in 1997 based upon the Veteran's lay statements reporting symptoms of depression in 1997, the later of the two dates would still be March 10, 2005.  38 C.F.R. § 3.400.

Therefore, in considering the evidence of record under the laws and regulations as set forth above, the Board finds that an earlier effective date of March 10, 2005 for the grant of service connection for depression is warranted.


Earlier Effective Date for SMC

The Veteran seeks entitlement to an effective date earlier than October 22, 2008, for the grant of SMC at the housebound rate as set forth in 38 U.S.C.A. § 1114(s). 

Special monthly compensation is payable where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities.  This requirement is met when the Veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime.  38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350(i).

In this decision, the Board increased the disability evaluation for the Veteran's service-connected depression from 70 percent to 100 percent, effective October 4, 2006. 

As of October 4, 2006, the Veteran also had additional service-connected disabilities that were independently ratable at 60 percent and which were separate and distinct from the depression rated totally disabling.  See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (2008) (finding that SMC  "benefits are to be accorded when a Veteran becomes eligible without need for a separate claim" and remanding, pursuant to VA's duty to maximize benefits, for VA to determine whether the Veteran's posttraumatic stress disorder, rated 70 percent disabling, would entitle him to a TDIU and, therefore, to SMC).  Notably, the Veteran's additional service-connected disabilities as of October 4, 2006 included subluxation of the lumbar spine, rated at 60 percent; right shoulder strain, rated at 10 percent; left knee strain with degenerative changes, rated at 10 percent; left knee instability, rated at 10 percent; right ankle injury, rated at 10 percent; tinnitus, rated at 10 percent; right knee instability, rated at 10 percent; right knee degenerative joint disease, rated at 10 percent; and left ankle injury, rated at 10 percent.  The combined evaluation of these additional disabilities exceeds 60 percent.

Therefore, based on the facts of this case, an earlier effective date of October 4, 2006 for the grant of SMC benefits at the housebound rate is warranted.  This is because the record shows that as of October 4, 2006, the Veteran's depression is rated 100 percent, and his additional service-connected disabilities are independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability.

As October 4, 2006 is the date entitlement to SMC at the housebound rate arose, this is the proper effective date.  38 U.S.C.A. § 5110(a); 38 C.F.R. §§ 3.400.  

Entitlement to TDIU from October 4, 2006

VA will grant a TDIU when the evidence shows that the Veteran is precluded, by reason of his service-connected disabilities, from securing or following "substantially gainful employment" consistent with his education and occupational experience.  38 C.F.R. §§ 3.340, 3.341, 4.16; VAOPGCPREC 75-91; 57 Fed. Reg. 2317 (1992).  A TDIU is provided where the combined schedular evaluation for service-connected diseases and disabilities is less than total, or 100 percent.  38 C.F.R. § 4.16(a). 

The Court has recently noted that VA has a "well-established" duty to maximize a claimant's benefits.  See Buie v. Shinseki, 24 Vet. App. 242, 250 (2011); AB v. Brown, 6 Vet. App. 35, 38 (1993); see also Bradley v. Peake, 22 Vet. App. 280 (2008).  This duty to maximize benefits requires VA to assess all of a claimant's disabilities to determine whether any combination of disabilities establishes entitlement to SMC under 38 U.S.C.A § 1114.  See Bradley, 22 Vet. App. 280, 294 (2008) (finding that SMC "benefits are to be accorded when a Veteran becomes eligible without need for a separate claim").  As noted in Bradley, VA must consider a TDIU claim despite the existence of a schedular total rating and award SMC under 38 U.S.C.A. § 1114(s) if VA finds the separate disability supports a TDIU rating independent of the other 100 percent disability rating.  See Bradley, 22 Vet. App. 280, 294 (2008); see also DVA Sum. Op. Gen. Counsel Prec., 75 Fed. Reg. 11229-04 (March 10, 2010) (withdrawing VAOPGCPREC 6-99, 64 Fed. Reg. 52375 (1999) (the logic of Bradley suggests that if a veteran has a schedular total rating for a particular service-connected disability and subsequently claims TDIU for a separate disability, VA must consider the TDIU claim despite the existence of the schedular total rating and award SMC  under section 1114(s) if VA finds the separate disability/disabilities support a TDIU rating independent of the other 100 percent disability rating. 

The Veteran has been awarded SMC under the provisions of 38 U.S.C.A. § 1114(s), effective October 4, 2006, on the basis that he is in receipt of a 100 percent rating for depression, along with a combined rating for all other service-connected disabilities that is at least 60 percent.

Here, the Veteran's depression is rated as 100 percent disabling from October 4, 2006.  Thus, for SMC purposes, this disability satisfied the requirement of a "service-connected disability rated as total."  See Buie v. Shinseki, 24 Vet. App. 242, 251 (2011); see also Bradley v. Peake, 22 Vet. App. 280, 293 (2008).  Because the Veteran has a single service-connected disability rated as total (i.e. his depression), and has additional service-connected disabilities that are independently rated at more than 60 percent combined, the criteria for SMC at the housebound rate were met as of October 4, 2006.  Entitlement to this benefit, effective October 4, 2006, has already been granted.

In sum, the only possible increased benefit that could be assigned based upon a finding of entitlement to a TDIU when there is another disability rated at 100 percent disabled is already assigned to the Veteran from October 4, 2006. 

Therefore, because the TDIU rating is a lesser benefit than the 100 percent disability rating for depression, and the Veteran has already been awarded SMC under 38 U.S.C.A. § 1114(s) (the only benefit for which the assignment of a TDIU from October 4, 2006 could be beneficial), the claim for TDIU is moot for this time period.  The appeal as to the TDIU issue for the time period beginning on October 4, 2006 is therefore dismissed.


ORDER

The appeal for the issue of whether new and material evidence has been received to reopen a claim of entitlement to service connection for headaches is dismissed.

The appeal for the issue of entitlement to service connection for hypertension is dismissed.

The appeal for the issue of entitlement to service connection for GERD is dismissed.

The appeal for the issue of entitlement to service connection for stress fractures of the tibias is dismissed.

The appeal for the issue of entitlement to service connection for a bilateral quadriceps disability is dismissed.

Entitlement to an effective date of March 10, 2005 for the award of service connection for depression is granted, subject to the criteria governing the payment of monetary benefits.

Entitlement to an initial rating of 70 percent for depression for the time period from March 10, 2005 to October 3, 2006 is granted, subject to the criteria governing the payment of monetary benefits.

Entitlement to an initial rating of 100 percent for depression beginning on October 4, 2006 is granted, subject to the criteria governing the payment of monetary benefits.

Entitlement to an earlier effective date of October 4, 2006 for the grant of SMC at the housebound rate as set forth in 38 U.S.C.A. § 1114(s) is granted, subject to the criteria governing the payment of monetary benefits.

The appeal as to the issue of entitlement to a TDIU for the time period beginning October 4, 2006 is dismissed.


REMAND

Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's remaining claims so that he is afforded every possible consideration.  38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159.

As previously noted, in September 2006 the Board remanded the Veteran's claim of entitlement to an initial rating in excess of 20 percent for subluxation of the lumbar spine with degenerative changes.  The September 2006 remand instructed the RO to schedule the Veteran for a VA examination in order to determine the nature and severity of his service-connected low back disability.  Then, the remand instructed that if the benefit sought on appeal remained denied, the Veteran should be furnished a supplemental Statement of the Case and given the opportunity to respond.  

The Veteran underwent VA examinations in both August 2007 and December 2007.  Subsequently, in a March 2008 rating decision, the RO granted an increased rating of 60 percent for subluxation of the lumbar spine with degenerative changes, effective October 3, 2006.  As that is less than the maximum schedular rating available for such disability, and the Veteran has not expressed satisfaction with the rating, the appeal continues.  See AB v. Brown, 6 Vet. App. 35 (1993).  However, the RO never issued a supplemental Statement of the Case on this issue.  

Where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance.  Stegall v. West, 11 Vet. App 268 (1998).  Accordingly, the Board is required to remand the issue of entitlement to an initial increased rating for subluxation of the lumbar spine with degenerative changes, currently rated as 20 percent disabling prior to October 3, 2006, and as 60 percent disabling beginning on October 3, 2006, to the RO for the issuance of a supplemental Statement of the Case.  See 38 C.F.R. § 19.31.  

It has been almost six years since the Veteran last underwent a VA examination to determine the nature and severity of his subluxation of the lumbar spine with degenerative changes.  Therefore, a new VA examination should be scheduled on remand.  See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (noting that an examination too remote for rating purposes cannot be considered "contemporaneous").

Because the Veteran receives treatment for his subluxation of the lumbar spine with degenerative joint disease through VA, and the most recent VA treatment records contained in the claims file are dated in July 2008, up-to-date VA treatment records should also be obtained.  38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim).

The Board finds that the issue of entitlement to an increased initial rating for subluxation of the lumbar spine with degenerative changes, rated at 20 percent prior to October 3, 2006, and at 60 percent beginning October 3, 2006 may affect the issue of entitlement to SMC at the housebound rate under 38 U.S.C.A. § 1114(s) for the time period prior to October 4, 2006.  Therefore, it would be inappropriate at this time to enter a final determination on the issue of entitlement to SMC at the housebound rate under 38 U.S.C.A. § 1114(s) prior to October 4, 2006, and this issue is remanded along with the increased rating claim for the lumbar spine disability.  Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined).  

In a March 2006 rating decision, the RO granted service connection for right lower extremity radiculopathy.  A 20 percent rating was assigned, effective January 13, 2005.  In June 2006 the Veteran filed a notice of disagreement with the effective date assigned for the right lower extremity radiculopathy.  Thereafter, in September 2006, the Board remanded the issue of entitlement to an effective date earlier than January 13, 2005 for the grant of service connection for right lower extremity radiculopathy for issuance of a Statement of the Case pursuant to Manlincon v. West, 12 Vet. App. 238 (1999).

Subsequently, in an October 30, 2006 rating decision the RO granted an earlier effective date of June 16, 2004 for the grant of service connection for right lower extremity radiculopathy.  Thereafter, in a February 2007 statement, the Veteran indicated that he disagreed with the June 16, 2004 effective date.  

To date, the RO has not issued a Statement of the Case regarding the effective date issue.  Accordingly, the Board is required to remand this issue to the RO for the issuance of a Statement of the Case on the issue of entitlement to an effective date earlier than June 16, 2004 for the grant of service connection for right lower extremity radiculopathy.  See Manlincon v. West, 12 Vet. App. 238 (1999).  After the RO has issued the statement of the case on this issue, the claim should be returned to the Board only if the Veteran perfects the appeal in a timely manner.  See Smallwood v. Brown, 10 Vet. App. 93, 97 (1997).

Accordingly, the case is REMANDED for the following action:

(This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012).  Expedited handling is requested.)

1.  Obtain copies of the Veteran's VA treatment records from the Atlanta VA Medical Center dating from July 2008 to the present, and associate them with the claims file.

2.  Schedule the Veteran for a VA spine examination in order to determine the current severity of his service-connected subluxation of the lumbar spine with degenerative changes.  

The claims folder must be provided to the examiner in conjunction with the examination.  All pertinent symptomatology and findings must be reported in detail.  Any indicated diagnostic tests and studies, to include those required to objectively document neurologic manifestations of the Veteran's service-connected disorder must be accomplished.  

The examiner must state whether there is any evidence of favorable or unfavorable ankylosis of the spine, and determine range of motion, in degrees, noting by comparison the normal ranges of motion of the spine.  It must also be determined whether there is weakened movement, excess fatigability, or incoordination attributable to the Veteran's lumbar spine disorder, expressed in terms of the degree of additional range of motion loss or favorable or unfavorable ankylosis due to any weakened movement, excess fatigability, or incoordination.  Furthermore, an opinion must be given as to whether any pain associated with the Veteran's lumbar spine disorder could significantly limit functional ability during flare-ups or during periods of repeated use, noting the degree of additional range of motion loss or favorable or unfavorable ankylosis due to pain on use or during flare-ups.

Any neurological manifestations of the Veteran's service-connected degenerative disc disease of the lumbar spine must be identified, including any numbness of the legs.  It must also be noted whether the Veteran experiences incapacitating episodes, as defined by 38 C.F.R. § 4.71a, and the frequency and total duration of such episodes over the course of the past 12 months.

A complete rationale for all opinions expressed must be provided, to include reference to specific clinical findings or documents in the claims file.

3.  The RO must notify the Veteran that it is his responsibility to report for any VA examination scheduled, and to cooperate in the development of the claim.  The consequences for failure to report for a VA examination without good cause may include denial of the claim.  38 C.F.R. §§ 3.158, 3.655 (2012).

4.  Issue a Statement of the Case on the issue of entitlement to an effective date earlier than June 16, 2004 for the grant of service connection for right lower extremity radiculopathy.  The Veteran should be apprised of his right to submit a substantive appeal and to have his claim reviewed by the Board.  The Veteran should be allowed the requisite period of time for a response.  If, and only if, the Veteran files a substantive appeal on this issue, then it should be returned to the Board for appellate action.

5.  The issues of entitlement to an initial increased rating for subluxation of the lumbar spine with degenerative changes, currently rated as 20 percent disabling prior to October 3, 2006 and as 60 percent rating beginning October 3, 2006 and entitlement to SMC at the housebound rate under 38 U.S.C.A. § 1114(s) for the time period prior to October 4, 2006 should be adjudicated by the RO on the basis of additional evidence.  If the benefits sought are not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. 

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).



______________________________________________
ROBERT C. SCHARNBERGER
Veterans Law Judge, Board of Veterans' Appeals

Department of Veterans Affairs