Citation Nr: 1620863 Decision Date: 05/24/16 Archive Date: 06/02/16 DOCKET NO. 09-40 305 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an initial rating greater than 50 percent prior to June 20, 2011, and greater than 70 percent as of that date, for major depressive disorder (MDD). 2. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected MDD. REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD P. Wirth, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1974 to March 1979. This case comes before the Board of Veterans' Appeals (Board) on appeal from October 2012 and March 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The October 2012 rating decision granted service connection for MDD with initial disability ratings of 50 percent effective November 19, 2007, and 70 percent effective June 20, 2011. The March 2014 rating decision denied entitlement to a TDIU. In February 2010, the Veteran testified at a hearing before a Decision Review Officer (DRO) held at the RO. In October 2010, the Veteran testified at another hearing held at the RO before a Veterans Law Judge (VLJ). Transcripts of these hearings are associated with the claims file. In March 2016, the Veteran was notified by letter that the VLJ who conducted the October 2010 hearing is no longer employed by the Board. The Veteran was told that the Board could make a decision on the appellate record as it stood, but he had the right to testify at another hearing. The Veteran's representative responded in March 2016 that the Veteran did not desire a new hearing. Therefore, the Board has proceeded to consider the Veteran's case on the evidence of record. In August 2012, the Board remanded the Veteran's claim for entitlement to service connection for an acquired psychiatric disorder, to include an anxiety disorder, for the RO to initially consider new evidence. That issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. 38 C.F.R. § 19.9(b) (2015). FINDINGS OF FACT 1. The Veteran's service-connected MDD resulted in hospital treatment in a VA or an approved hospital for a period exceeding 21 days or hospital observation at VA expense for a service-connected disability for a period exceeding 21 days. 2. The Veteran's MDD resulted in occupational and social impairment with deficiencies in most areas due to symptoms of severity, frequency, and duration most nearly approximating the 70 percent disability rating from August 1, 2008, but not total social impairment. 3. The most probative evidence shows the Veteran's service-connected disability renders him unable to secure and follow a substantially-gainful occupation from August 1, 2008. CONCLUSIONS OF LAW 1. The criteria for a temporary total evaluation for hospital treatment exceeding 21 days have been met from November 19, 2007 through July 31, 2008. 38 U.S.C.A. §§ 1155 , 5107 (West 2014); 38 C.F.R. §§ 3.102, 4.29 (2015). 2. The criteria for an initial disability rating of 70 percent, but no more, for MDD have been met from August 1, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130 Diagnostic Code 9434 (2015). 3. The criteria for a TDIU have been met from August 1, 2008. 38 U.S.C.A. §§ 1155, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16, 4.19 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the Veteran's claims and what the evidence in the claims file shows, or fails to show, with respect to those claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). I. VA's Duty to Notify and Assist Before addressing the merits of the Veteran's claims, the Board is required to ensure that VA has satisfied its duties to notify and assist the Veteran in substantiating his claims for VA benefits, as provided for by the Veterans Claims Assistance Act of 2000 (VCAA). 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). In a December 2007 letter issued prior to the original July 2008 rating decision denying service connection for MDD, the Veteran was provided with fully compliant VCAA notice. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2015); Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The notice informed the Veteran of what evidence is needed to substantiate his claim for service connection, including what evidence must be submitted by the Veteran and what evidence will be obtained by VA. It also advised the Veteran of how disability ratings and effective dates are assigned, and the types of evidence that impact those determinations. This appeal arises from a disagreement with an initial rating decision in October 2012, which granted service-connection for MDD and disability ratings of 50 percent effective November 19, 2007, and 70 percent effective June 20, 2011. Courts have held that once service connection is granted the claim is substantiated, additional VCAA notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007) With respect to the Veteran's claim for a TDIU, a December 2013 letter, issued prior to the decision on appeal, informed the Veteran of what evidence is needed to substantiate a claim for a TDIU on a schedular and extraschedular basis. It also advised the Veteran of how effective dates are assigned, and the type of evidence that impacts those determinations. The record also reflects that VA has made efforts to assist the Veteran in the development of his claims. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159 (2015). VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, service personnel records, VA medical records, VA examination reports, private treatment records, a private examination report, employment information, and the statements of the Veteran, his sister, two friends, and his representative. The Veteran was provided with VA examinations in May 2008, June 2011, February 2014, and October 2014 to evaluate his mental status. The Board finds the examination reports to be adequate for rating purposes, as the examiners reviewed the Veteran's medical records and/or claims file, interviewed the Veteran, were informed of and documented the relevant facts regarding the Veteran's medical history and current status, conducted clinical evaluations, and described the current severity of the Veteran's depression in sufficient detail so that the Board's evaluation is an informed determination. The opinions show that the examiners considered all relevant evidence of record, including the Veteran's statements. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As previously noted, the Veteran was provided an opportunity to set forth his contentions during hearings before a DRO in October 2010 and a VLJ in October 2010. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the court held that 38 C.F.R. § 3.103(c)(2) requires that the hearing officer explain the issues and suggest the submission of evidence that may have been overlooked. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), or identified any prejudice in the conduct of the hearings. The hearings focused on the evidence necessary to substantiate the claim for depression and the Veteran, through his testimony, demonstrated that he had either actual knowledge of the evidence necessary to substantiate his claim, or that a reasonable person could be expected to understand from the notice what was needed. The Board notes that the Veteran testified to the past and current severity of his depression. As such, the Board finds that, consistent with Bryant, the DRO and VLJ complied with the duties set forth in 38 C.F.R. § 3.103(c)(2) and that any error in notice provided during the Veteran's hearings constitutes harmless error. As discussed above, the Board has carefully considered VA's duties to notify and assist, and finds that they have been met. The Veteran has been provided with a meaningful opportunity to participate in the claims process and has been an active participant in it by providing evidence and testifying at the hearings. Moreover, neither the Veteran nor his representative has identified any outstanding evidence that could be obtained to substantiate the claims; the Board also is unaware of any such evidence. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Dingess, 19 Vet. App. 473 (2006); see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). The Board thus finds that all necessary development has been accomplished and appellate review may proceed. II. Increased Rating for MDD Rating Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). See 38 C.F.R. Part 4 (2015). Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Rating Schedule, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. § 4.1 (2015). Individual disabilities are assigned separate diagnostic codes. 38 C.F.R. § 4.27 (2015). When a question arises as to which of two disability evaluations applies under a particular diagnostic code, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7 (2015). Consideration must be given to increased evaluations under other potentially applicable diagnostic codes. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). After careful consideration of the evidence, any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2015). In Fenderson v. West, 12 Vet. App. 119 (1999), it was held that evidence to be considered in the appeal of an initial assignment of a disability rating was not limited to that reflecting the then current severity of the disorder. Cf. Francisco v. Brown, 7 Vet. App. 55, 58 (1994) ("Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance."). In Fenderson, the court also discussed the concept of the "staging" of ratings, finding that, in cases where an initially assigned disability evaluation has been disagreed with, it was possible for a veteran to be awarded separate percentage evaluations for separate periods based on the facts found during the appeal period. 12 Vet. App. at 126-27. Thus, the analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods based on the facts found. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14 (2015). The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). In the present case, the Veteran contends that he is entitled to a higher initial disability rating for his MDD. Such disability has been rated under Diagnostic Code 9434, as 50 percent disabling prior to June 20, 2011, and as 70 percent disabling as of that date. Under Diagnostic Code 9434, which is governed by a General Rating Formula for Mental Disorders, a 50 percent rating 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; and/or difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9434 (2015). 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 work-like setting); and/or inability to establish and maintain effective relationships. Id. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and/or memory loss for names of close relatives, own occupation, or own name. Id. The psychiatric symptoms listed in the above rating criteria are not exclusive, but are examples of typical symptoms for the listed percentage ratings. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002) (symptoms recited in the rating schedule for mental disorders are to serve as examples of the type and degree of the symptoms and not an exhaustive list). Consideration is given to the frequency, severity, and duration of psychiatric symptoms; the length of remission; and the veteran's capacity for adjustment during periods of remission. The rating agency shall assign an evaluation based on all the evidence of record that bears on occupational and social impairment, rather than solely on the examiner's assessment of the level of disability at the moment of the examination. See 38 C.F.R. § 4.126(a) (2015). Furthermore, when evaluating the level of disability arising from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation solely on the basis of social impairment. 38 C.F.R. § 4.126(b) (2015). One factor for consideration is the Global Assessment of Functioning (GAF) score, which is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." Carpenter v. Brown, 8 Vet. App. 240, 242 (1995) (citing Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)). The DSM-IV provides examples of behavior corresponding to various GAF scores. A GAF score of 71 to 80 indicates that if symptoms are present, they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational, or school functioning. A GAF score of 61 to 70 indicates some mild symptomatology or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, with some meaningful interpersonal relationships. Scores ranging from 51 to 60 reflect moderate symptoms or moderate difficulty in social, occupational, or school functioning. Scores ranging from 41 to 50 reflect serious symptoms or any serious impairment in social, occupational, or school functioning. Scores of 31 to 40 indicate some impairment in reality testing or communication or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood. Scores of 21 to 30 reflect behavior that is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas. 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 (2015). Although GAF scores are important in evaluating mental disorders, the Board must consider all the pertinent evidence of record and set forth a decision based on the totality of the evidence in accordance with all applicable legal criteria. Carpenter, 8 Vet. App. 240. An assigned GAF score, like an examiner's assessment of the severity of a condition, is not dispositive of the percentage rating issue; rather, it must be considered in light of the actual symptoms of a psychiatric disorder (which provide the primary basis for the rating assigned). See 38 C.F.R. § 4.126(a) (2015). Accordingly, an examiner's classification of the level of psychiatric impairment, by word or by a GAF score, is to be considered, but is not determinative of the percentage VA disability rating to be assigned; the percentage evaluation is to be based on all the evidence that bears on occupational and social impairment. Id.; see also 38 C.F.R. § 4.126 (2015). The Board notes that the DSM-IV has been updated with the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5). Effective August 4, 2014, VA issued an interim rule amending the portion of its Rating Schedule addressing mental disorders and its adjudication regulations to refer to certain mental disorders in accordance with the DSM-5. 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). The provisions of the interim final rule, adopted without change in the final rule, only apply, however, to applications for benefits that are received by VA or that are pending before the agency of original jurisdiction on or after August 4, 2014, and do not apply to claims that have been certified for appeal to the Board, even if those claims are subsequently remanded to the agency of original jurisdiction. 80 Fed. Reg. 14,308 (March 19, 2015). The RO originally certified the Veteran's appeal to the Board in June 2010; therefore, the claim is governed by DSM-IV. The Board notes that the use of the GAF scale has been abandoned in the DSM-5 because of, among other reasons, "its conceptual lack of clarity" and "questionable psychometrics in routine practice." See DSM-5, p. 16 (2013). In this case, however, the Veteran's claim is governed by DSM-IV, and DSM-IV was in use most of the time the medical entries of record were made. Thus, the GAF scores assigned remain relevant for consideration in this appeal to the extent they are available. Background August 2005 records from a private hospital, S.G.H.C., show the Veteran was admitted due to severe depression, active suicidal ideation with a specific plan, and severe alcohol use. He reported a hospitalization four years earlier for similar complaints. He had increasing depression, poor appetite, feelings of hopelessness, and lack of motivation, and was isolating himself. He had a recent citation for driving while intoxicated (DUI) and was on probation due to a domestic violence conviction. He was divorced and had three adult children, with whom he had lost contact. He was living with a girlfriend, but moved to a motel after she broke up with him. He drank up to a half gallon of scotch a day, but had a recent episode where he drank a gallon of whiskey and blacked out. He was working in a glass factory. On mental status examination, he was casually dressed and engaged hesitantly, but appropriately with staff. Speech was normal. He was fully oriented and his thought process was logical. There were no homicidal ideations or hallucinations. He exhibited poor insight and judgment. The diagnoses were major depression, recurrent, severe; alcohol dependence, and alcohol withdrawal. A GAF score of 50 was assigned at discharge. July 2006 records from inpatient treatment at a private hospital, L.H. show the Veteran reported overdosing on Xanax and extreme stress from a situation with his girlfriend, causing depressive symptoms. He admitted occasional panic attacks, feelings of hopelessness and helplessness, and difficulty coping with being homeless. He was working until December 2005, at which time he received a DUI citation and served thirty days in jail. The Veteran's depression and anxiety improved with medication and therapy. On examination, his speech was normal. Thought processes were logical and goal directed. His attention and concentration were fair. Memory was intact. His insight and judgment were fair and limited. He denied panic, and suicidal or homicidal ideation. He had no psychosis. The diagnoses were major depression, recurrent; history of alcohol dependency; and status post benzodiazepine overdose. Assigned GAF scores were 40 on admission and 55 at discharge. The highest functioning in the past year was 60. An August 2006 VA treatment record shows complaints of depression with flat affect, and anxiety with racing thoughts. The Veteran had been depressed since he stopped drinking alcohol in August 2005. He reported the Xanax overdose in July 2006 was a suicidal gesture. He was living in a public shelter, but was to start a new job doing fabrication. He had been involved for four and a half years with a woman who had an alcohol and pill problem, but did not know whether he would resume the relationship. Conversation was relevant and goal directed. There was no evidence of hallucinations, and no suicidal or homicidal ideation. The diagnosis was depressive disorder. The highest GAF score in the last year was 55. In September 2006, the Veteran reported fleeting thoughts of suicide, but no plan or intent. In December 2006, he was less depressed, with no suicidal thoughts. He was getting along better at work and was forcing himself not to be reclusive. He did exhibit some pacing at work and worrying. His girlfriend died the end of September 2006, but he was coping with her death. In February 2007, the Veteran reported his drinking had increased in the past month to help him feel better. He denied suicidal thoughts. He had not been able to concentrate well and had a low energy level. He felt a little less anxious, and was not pacing at work as often. On examination, he was casually groomed and dressed, had good eye contact, and was open and cooperative. Mood was mildly depressed, but his affect was appropriate. Speech was normal and conversation was relevant and spontaneous. There were no delusions or hallucinations, or suicidal or homicidal thoughts elicited. No hopeless, helpless, or worthless verbalizations were present. Insight and judgment were good. In March 2007, the Veteran had been alcohol free for five weeks. His mood was better, but still mildly depressed with low energy. He was isolating at home. He had been given rent money, but was not sure if he was pleased or disappointed because he had an optional plan of suicide. He started seeing his grandchildren weekly and was feeling hopeful. He was relieved he was not thinking of dying. In September 2007, the Veteran reported that he stopping taking his medications several months ago, but did not recall why. He had been having suicidal thoughts the past five weeks with the same plan. He had been drinking every other day. The suicidal thoughts subsided when he was drinking. The Veteran reported severe depression and irritability. He was isolating at work and in the community, but was working every day. He had no appetite or interest in ordinary things. He was going to move in with his daughter until he went for a triage to determine treatment. On examination, he was casually groomed and dressed, had good eye contact, and was open and cooperative. Mood was depressed with flat affect. His speech was slow, but normal rate. Conversation was relevant and spontaneous. There were no delusions or hallucinations. Insight and judgment were good. In October 2007, the Veteran was suicidal with a plan. He had been contemplating suicide for the past six months. He sought help because he did not want to hurt his grandchildren. He was homeless and very lonely. He went to work, but did not socialize there. When he got home, he drank until he passed out. His children were his only support system, but his relationship with his three sons was "not so close." On examination, he had adequate hygiene and was cooperative. His mood was very depressed and affect was tearful. Speech was normal. He was fully oriented with logical, coherent, and goal-directed thought process. There were no psychotic symptoms. His insight and judgment were limited. The Veteran was admitted on October 16, 2007 for treatment of depression and addiction. The admission GAF score was 40. Relevant discharge diagnoses were alcohol dependence; major depressive disorder, recurrent; and rule out pathological gambling. The discharge GAF score on November 20, 2007 was 45. The Veteran was admitted to a VA domiciliary program in November 2007 for continuing care of alcohol dependence, depression, and cannabis dependence. He was working fulltime in information technology at the facility. He was described as a "good worker," but had foot surgery in March 2008 and did not work thereafter. The Veteran was discharged on July 24, 2008 to The Ohio Veterans' Home with a GAF score of 45. His VA treatment plan was closed. See July 2008 VA Mental Health Discharge Note. It appears the Veteran lived at The Ohio Veterans' Home, a state-run home that provides shelter to homeless veterans, through August 2009. See April 2009 Report of Contact (VA Form 119); August 2009 transmittal of Notice of Disagreement by The Ohio Veterans' Home. The Veteran was afforded a VA examination in May 2008. He reported that he had been married for eight years until 1985 and had three children. He was not on solid terms with his children, but was trying to improve the relationships. He had lived with another woman for several years and considered her three children as his own. His days were organized around treatment groups and rehabilitation activities at the a VA domiciliary. He was able to manage all his own self care and daily needs. He last worked in a truck parts factory for about one year until August 2007, when he quit to enter an alcohol addiction treatment program. On mental status examination, he was casually and cleanly dressed, alert, cooperative, and appropriate to the situation. He showed good eye contact and was fully oriented. Speech was normal. His affect was varied and mood congruent. His judgment and insight appeared congruent with his intellectual capacity. Thought process was goal oriented with no looseness. He had no signs of delusional or paranoid belief systems, and no symptoms of psychosis. The Veteran had transient chronic problems with depression, diminished pleasure, insomnia, fatigue, loss of self-esteem, and poor concentration. He thought rage and anger problems were a key component to his depression. He was socially avoidant, felt estranged, and had some mild anxiety around people. He had periods of suicidal ideation in the remote past. Testing revealed scores in the severe range for depressive symptoms and in the moderate range for anxiety symptoms. The diagnoses were major depressive disorder and alcohol dependence in early remission. The examiner found that the Veteran's symptoms would likely cause mild discomfort when interacting with other people, without loss of communication effectiveness. His level of fatigue, concentration problems, and inner turmoil would likely cause moderate work inefficiency and lack of productivity. The alcohol addiction appeared to have had caused catastrophically reduced reliability, such as quitting or losing jobs to enter treatment. The amount of avoidance of social contact and confrontation would likely interfere moderately with his ability to interact effectively. The examiner found that the Veteran had some mild to moderate reduction in his ability to adapt to stressful circumstances, such as in the workplace and social environments. A GAF score of 55 was assigned because of the overall moderate symptoms associated with low moderate reduction of social, vocational, and mental functioning. VA treatment records from November 2007 to November 2009 show the Veteran complained of depression, a lack of motivation, and lethargy. He had intermittent periods of anxiety. He felt less irritable as time progressed, but had increased irritability in November 2009 due to a fight with his girlfriend. He reduced his self-isolation somewhat, but felt he had no one with whom. Beginning in July 2008, he was living at the Ohio Veterans Home and reported that he was making friends. He was taking computer graphic and web design classes, but quit due to poor concentration. He struggled with why the actions of others bothered him so much and had long held resentments he was beginning to identify. The Veteran denied alcohol use since September 2007. On mental status examinations, he was casually dressed with fair grooming and cooperative. Speech was clear. He had linear thought process. Mood was fairly good, but his affect was restricted. He had recurrent feelings of hopelessness, worthlessness, and helplessness. He also had a history of long-standing passive suicidal ideation ("I wish I was dead!"), but denied any intent or active plan to hurt himself. The Veteran denied homicidal ideation, hallucinations, delusions, or paranoia. His insight was limited and judgment fair. Memory and concentration were good. GAF scores were 45 in November 2007, 46 in January 2008, 45 in April 2008, 46 in June and July 2008, 48 in August 2008, and 55 in November 2009. In December 2009, the Veteran reported that he had not been taking his medications for about a month. He had problems with depression and was overly holding back tears, problems with sleep latency, nightmares occurring 1-2 times a week, anxiety and saw white dots when extremely anxious, nervousness worry, restlessness with pacing, intermittent problems with constant movement of feet and sometimes legs (but also said he did that as a self-soothing strategy), neck tension, some irritability, decreased motivation and interest anhedonia, self-isolation, varying levels of energy, feelings of guilt and worthlessness, apathy, avoidance behaviors with a passive approach to problem solving, difficulty concentrating, recurrent intrusive thoughts, and feelings of detachment. He rated his depression at 8/10 and anxiety at 9/10. The Veteran moved out of The Ohio Veterans' Home in August 2009 to care for his aging mother, who suffered from dementia. He was pleased that he was reconnecting with his children. He walked a little for exercise. On assessment, he was casually and appropriately dressed with good hygiene and grooming. He was cooperative and made good eye contact. He was alert and fully oriented, but presented as anxious and dysthymic with affect congruent. There was some psychomotor restlessness with jiggling of the leg. Speech was spontaneous, relevant, and coherent. Thought processing speed was unremarkable. Thought content was with some distortion, but focused and goal directed. His insight was fair, but judgment was good. At his February 2010 DRO hearing, the Veteran testified that when his depression increased he would drink, which was the only thing that would stop the feelings. However, he had been sober for two and a half years. He was tired at the hearing because he did not sleep well due to nervousness about the hearing and worrying about getting to it. He was suffering from mood swings, depression, anxiety, short- and long-term memory problems, and difficulties with concentration. He had difficulties reading for extended periods and particularly reading instructions. However, he was a quick learner. He could look at wiring diagrams, for example, and figure out what he needed to do to install a door. He was taking an online course, but could not focus long enough to do it. He also paced and sometimes could not sit still. In February 2010, the Veteran reported feeling very down lately and that he did not have the energy to do things anymore. He reported some suicidal thoughts at times, but denied wanting to act on them or having a plan. His medication was improved. His GAF score was 50. A March 2010 record shows the Veteran enjoyed a nice visit to California to see his daughters and grandchildren. He was utilizing his hobby of digital photography as a means of coping. In April 2010, the Veteran reported a recent incident that was triggered by discussing his military experience during a card came. After that, he began having symptoms that lasted for several days. He contemplated harming himself, but stated that he would not do it. However, he also reported that, since his medication had been increased in February, he had been feeling better overall. His suicidal ideations had resolved, and his depression had been under better control. His motivation and interest. He was riding a bicycle daily, writing to a daughter in California, playing cards with friends, and looking forward to a family visit to California in June. His anxiety, nervousness, worry, restlessness, and pacing were under better control. On examination, he was casually and appropriately dressed with good hygiene and grooming. He was alert and fully oriented, and was less anxious and dysthymic with affect congruent. He was cooperative and made good eye contact. Speech was spontaneous, regular, and coherent. Thought was logical, focused, relevant, and goal directed. His insight was improving, and judgment was good. He denied psychotic symptoms and suicidal and homicidal ideations. Impulse control was intact. At his June 2011 VA examination, the Veteran reported limited social activity and a tendency to isolate. He had contact with the daughter of a women in California with whom he had had a long-term relationship in the 1990s. He was caring for his mother and had one good friend with whom he talked on a regular basis. He enjoyed rock engraving as a hobby. The Veteran reported that he left work to enter substance abuse treatment in 2007. Currently, he cited to the poor economy, inability to drive (fines), and caring for his mom as reasons for unemployment. However, he also contended his unemployment was due to his mental disorder, in that depression impacted his energy, motivation, and self-confidence. On mental status examination, the Veteran was clean, neatly groomed, appropriately dressed, cooperative, friendly, relaxed, attentive, and fully oriented. Speech was unremarkable. His affect was normal and mood good. Attention was intact. Thought process and thought content were unremarkable. There were no delusions, hallucinations, inappropriate behaviors, obsessive behaviors, panic attacks, or present homicidal or suicidal thoughts. The Veteran reported a long history of persistent suicidal ideation, but denied intent and plan. With respect to judgment and insight, he understood the outcome of behavior and that he had a problem. Impulse control was fair. He had a past history of impulsive behavior, but the Veteran felt that had improved considerably. There were no episodes of violence. His domestic violence charge was related to heavy drinking by both parties. He did not care and did not contest the charge. Mildly impaired remote, recent, and immediate memory were noted. Psychological testing was indicative of a moderate level of depressive symptomatology, a severe level of pessimism symptomatology, and a moderate level of symptomatology in the areas of past failure, loss of pleasure, self-dislike, worthlessness, and decreased concentration. The Veteran was endorsing a mild level of symptomatology in the areas of fatigue, appetite change, loss of energy, loss of interests, agitation, suicidal ideation, self-criticalness, guilt, and sadness. He endorsed a mild/nonsignificant level of anxiety symptomatology, but a moderate level of symptomatology in the area of an inability to relax. He was endorsing a mild level of symptomatology in the areas of numbness, fear the worst will happen, unsteadiness, nervousness, and indigestion. The diagnoses were major depressive disorder, recurrent, moderate, and alcohol dependence, sustained full remission. The examiner opined that the Veteran did not meet the diagnostic criteria for a separate anxiety-related diagnosis. A chart review revealed a history of anxiety that was situational/stress related. He did have some anxiety symptoms that appeared secondary to his depression. The examiner found that overall the Veteran appeared to be functioning at a fair level. While he had made gains in stability, he continued to experience depressive symptomatology that impacted psychosocial functioning. The examiner opined that the Veteran did not have total occupational and social impairment due to his depression. However, he had a long history of poor judgment and "just not caring." Much of this was secondary to his alcohol abuse, but also his depression. He did appear to be exercising better judgment with increased mental health stability. Impairment was found in thinking in that his depression was marked by low self-esteem, self-criticalness, pessimism, decreased concentration, and transient suicidal ideation. He also had a history of failed relationships and a marriage due to alcohol abuse and depression. Occupational impairment was noted in that the Veteran stopped work to enter long-term substance abuse treatment and had not worked since. Depressive symptomatology appeared to be impacting on his motivation and desire to work. Significant depressive symptomatology impaired his mood and was manifested by transient/associated anxiety, frustration, and agitation. A private psychological report prepared by E.M, Ed.D., in April 2012 shows the Veteran reported that he had no friends beyond his current girlfriend and isolated himself from all contact with people. The diagnoses were major depressive disorder, anxiety disorder not otherwise specified (NOS), and personality disorder NOS. A GAF score of 42 was assigned. It was noted that the Veteran exhibited depression and anxiety, as well as an "increasing touchiness" and loss of control. Low self-esteem, fatigue, and sense of hopelessness and worthlessness were pervasive. The psychologist opined that the Veteran "remains disabled from remunerative occupational activity as a direct result of his Major Depression and accompanying emotional instability." VA treatment records from November 2012 to February 2014 show ongoing complaints of varying levels of depression, anxiety, and worry, but overall only little irritability. However, in June 2013, he reported increased frustration and angry outbursts. Also in about June 2013, VA denied the Veteran's request to pay for college, which increased his symptoms. In October 2014, he described panic attacks with driving and when he had to be in a crowd. He enjoyed doing art work and crafts, using the computer and playing games on it, bowling weekly, reading, fishing, and spending time with his girlfriend, who was reported to be supportive. He went to a family reunion and a high school reunion, as well as Alcoholics Anonymous (AA) meetings and activities. On examination, he consistently was clean and well groomed, cooperative with good eye contact, and fully oriented. Speech was normal. His motivation and interest were generally improving. His ability to think and concentrated varied due to anxiety and worry. At times, his thought content was with some anticipatory anxiety, but otherwise was relevant and goal directed. He consistently denied suicidal and homicidal ideations, hallucinations, delusions, and paranoia. There were no psychotic symptoms. His memory and impulse control were intact. He had good judgment and improving insight. GAF scores were assigned in January 2013 of 56, April 2013 of 56, July 2013 of 52, and October 2013 of 56. The Veteran was afforded a VA examination in February 2014. He described difficulty with feeling sad, irritability, sense of guilt, worthlessness, disappointment, and difficulty with concentration. He did not note any disturbance of sleep, appetite, energy level, or memory. He kept in contact with his three sons and two step-daughters, and lived with his girlfriend of two years. He had increased his social interaction. He attended meetings once a week, visited family once a week, and went bowling once a week. However, he continued to have difficulty feeling comfortable around other people and felt "anxious to leave, preferring to be on the side lines." He reported being sober since 2007. The Veteran last worked in 2007 as a fabrication shop worker. He reported that he lost his job due to difficulties with anxiety and depression, self-medication with alcohol, homelessness, and legal and financial issues. He described that he would be capable of work that accommodated for his perceived difficulties with reading instructions ("I can't read anymore") and being around other people. He had done well when shown visually what to do and in isolation. He described the aggravation and embarrassment he felt after completing job fair assistance, when he was unable to participate in an interview. He became too overwhelmed and was unable to manage his anxiety and anger. He used distraction, art work, and avoidance to cope and to help manage his anger and mood. On examination, the Veteran was casually, cleanly, and reasonably neatly dressed. He was alert, fully oriented, and cooperative, and showed good eye contact. His affect was varied and mood congruent to content of discussion. He described a history of perceived wrongs that he found difficult to move forward from and said he lacked closure. Speech and thought processes were normal. Judgment and insight appeared congruent with his intellectual capacity. There were no signs of delusional or paranoid belief systems. He denied panic attacks and current suicidal or homicidal ideation. He did, however, describe significant difficulty with concentration, losing focus, and anxiety around other people. The diagnosis was major depression. The examiner noted that, when compared to 2008 testing, the Veteran continued to demonstrate a low level of anxiety and an improvement in the level of depression, from severe to moderate. While he had been able to make some progress in treatment with symptom reduction for periods of time, the examiner found that the Veteran's symptoms became worse with ongoing life stressors. The more recent stressors included his girlfriend's daughter's problem with alcohol abuse, financial issues, and the recent death of a friend. The examiner found symptoms of depressed mood and anxiety, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner opined that the Veteran's symptoms would likely cause discomfort when interacting with other people and reduced communication effectiveness. His difficulty with poor concentration, avoidance, distraction, felt sense of injustice, and inner turmoil would likely cause moderate work inefficiency and lack of productivity. He was highly distractible. The amount of difficulty he had for what he described as paranoia and anxiety around others would likely cause reduced reliability. The Veteran's difficulty with irritability and perceived sense of lack of safety would likely interfere with his ability to interact effectively. His ability to maintain a logical thinking process appeared adequate and would not likely impact his social or vocational functioning, unless under times of increased stress and a sense of being wronged. He had moderate reduction due to distractibility and avoidance in his ability to adapt to stressful circumstances. The examiner concluded that the Veteran's mental health issues would likely have a moderate impact on his ability to obtain and maintain fulltime, competitive, gainful employment. At an October 2014 VA examination, the Veteran reported that he continued to live with his girlfriend of four years in an apartment. He worked out daily at the YMCA. He spent the majority of his time playing computer games or watching television. He bowled once a week in a league. He enjoyed spending time with his grandchildren and traveled to North Carolina to visit them once a month. Since the last evaluation, the Veteran looked in to attending school at a community college, "but was told by a VA employee that until his legal case is closed he should not be taking classes." He had seen little change in his mental health. He continued to experience mild-to-moderate anxiety in social situations, and rated his anxiety from 5-8/10. His depression went "like a roller coaster" with a rating of 4-7/10. He thought about suicide "about once or twice a month," but denied any plan or intent. The examiner noted symptoms of depressed mood, anxiety, panic attacks that occurred weekly or less often, mild memory loss, impairment of short- and long-term memory, disturbances of motivation and mood, and suicidal ideation. The Veteran was diagnosed with generalized anxiety disorder, persistent depressive disorder, and alcohol use disorder in sustained remission. The examiner noted that the long-standing duration and significant symptom overlap between the Veteran's anxiety and depression diagnoses made it impossible to determine symptom attribution. Moreover, the diagnoses were reciprocal in that each condition appeared to prolong and/or reinforce the other. The examiner opined that the Veteran's diagnoses resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. VA treatment records from February 2014 to May 2015 show an overall increase in the Veteran's symptoms. In early 2014, the Veteran was biking, walking, and going to the YMCA regularly. However, in August 2014, it became a struggle for him to go anywhere or to do anything. In November 2014, he reported a decrease in motivation and interest. He got important things done, but was not reading, watching television, or doing art work. He avoided issues by playing computer games. He did go to Florida in December 2014 and planned to move there in June 2015. In January 2015, the Veteran reported having problems for the last six weeks or so with depressed mood, difficulty concentrating and focusing, anxiety, anticipatory anxiety, excessive worry, and intermittent sleep problems. His motivation was decreased and he was spending more time playing on the computer. The Veteran's anxiety generally increased as the move to Florida grew nearer. Analysis A temporary total disability rating will be assigned when it is established that a service-connected disability has required hospital treatment in a VA or an approved hospital for a period exceeding 21 days, or has required hospital observation at VA expense for a service-connected disability for a period exceeding 21 days. 38 C.F.R. § 4.29 (2015). If living in a domiciliary is a treatment requirement, the veteran is eligible for benefits under 38 C.F.R. § 4.29. In this case, the evidence of record shows the Veteran was discharged from inpatient hospital care for treatment of his service-connected MDD and related alcohol addiction on November 20, 2007. He was then admitted directly to a VA domiciliary program for continuing care of alcohol dependence, depression, and cannabis dependence, and was discharged on July 24, 2008. Thus, the evidence establishes that the Veteran's service-connected MDD resulted in treatment beginning in the hospital and continuing in the VA domiciliary for a period exceeding 21 days during the period on appeal. See 38 C.F.R. § 4.29 (2015). Therefore, assignment of a temporary total disability rating is warranted for treatment of the Veteran's MDD from November 19, 2007, the date of the Veteran's claim, through July 31, 2008 (the last day of the month of termination of treatment). The Board notes that a temporary total disability rating is not warranted for the period that the Veteran was housed at The Ohio Veterans' Home. The evidence shows that the Veteran's VA treatment plan was closed when he was discharged from the VA domiciliary in July 2008, and was transferred to The Ohio Veterans' Home because of his homelessness. Veterans living in a domiciliary as part of their social safety net (e.g., due to homelessness) are not eligible for benefits under 38 C.F.R. § 4.29. With respect to the remainder of the period on appeal, having carefully considered the Veteran's contentions in light of the evidence of record and applicable law, the Board finds that a 70 percent rating is warranted for the Veteran's MDD from August 1, 2008. The evidence establishes the Veteran experienced occupational and social impairment with deficiencies in most areas, including mood, thinking, judgment, family relations, and work due to his MDD. With respect to disturbances of mood, thinking, and judgment, the Veteran experienced ongoing depression that varied between moderate to severe. His depression was marked by a lack of motivation, lethargy, apathy, low self-esteem, a sense of hopelessness and worthlessness, self-criticalness, guilt, pessimism, irritability and anger, and decreased concentration. His anxiety ranged from mild to severe, with occasional panic attacks that precluded him from participating in some activities, such as a job interview. The June 2011 VA examiner found that the Veteran had a long history of poor judgment and "just not caring." He had one suicide attempt in July 2006, had an optional plan of suicide if he did not get rent money in March 2007, reported he had been having suicidal thoughts for the past five weeks with the same plan in September 2007, was suicidal with a plan in October 2007, and had recurring passive thoughts of suicide. Although the Veteran had some periods with improved symptoms and fair functioning, those periods were relatively short. Moreover, the depressive symptoms returned with stressors, such as the incident of discussing his Navy experiences while playing cards. There also is evidence of social impairment. The Veteran had a history of failed relationships and a marriage due to alcohol abuse and depression. He tended to avoid social contact. While the Veteran had the support of his family and was able to participate in some social activities, he continued to have difficulty feeling comfortable around other people and felt "anxious to leave, preferring to be on the side lines." Occupational impairment was found in that the Veteran stopped work to enter long-term treatment for substance abuse and depression, and had not worked since August 2007. Although he did work and take classes while living in the VA domiciliary and The Ohio Veterans' Home, he was not successful with the classes because of his lack of concentration. Moreover, the Board assumes the work amounted to a sheltered-work environment. Even before the appeal period when the Veteran was working, he had difficulties maintaining employment and lost a job because of his drinking in December 2006. The evidence does not show, however, that the Veteran's MDD was productive of total occupational and social impairment that would warrant a 100 percent disability rating at any time from August 1, 2008. The evidence consistently shows that the Veteran's symptoms were not manifested by 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 (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. The Veteran has always been neat, clean, adequately groomed, and appropriately dressed. He has consistently been found to be capable of managing his own care and daily needs. While there was one assessment in December 2009 that the Veteran's thought content was with some distortion and at times from November 2012 to February his 2014 his thought content was with some anticipatory anxiety, there is no evidence of gross impairment of thought. With one exception of a finding that his speech was slow in September 2007, his speech and communication otherwise has been found to be normal, logical, and coherent. Although the Veteran was found at times to have mildly impaired memory, that impairment does not rise to the level of memory loss contemplated by a 100 percent rating for MDD. As noted above, the Veteran had one suicide attempt in July 2006, had an optional plan of suicide if he did not get rent money in March 2007, reported he had been having suicidal thoughts for the past five weeks with the same plan in September 2007, and was suicidal with a plan in October 2007. However, these episodes occurred over a brief period of about one year while the Veteran was drinking heavily and before he received treatment. Although he had fleeting passive thoughts of suicide after he stopped drinking and received intensive treatment, VA examiners and treating providers never found that the Veteran was a persistent threat to himself, expressed concern that he would act on his thoughts, or put a suicide plan in place after October 2007. The evidence does not show total social impairment. Although he had a failed marriage and several girlfriends, the Veteran has maintained several long-term relationships. He also moved in with and cared for his mother. He developed relationships with his children and grandchildren. He visited them weekly and even went to North Carolina, California, and Florida to visit them. He made friends when he moved into The Ohio Veterans' Home and participated in activities with them, such as playing cards. Moreover, the Veteran was able to live and engage in a group home setting for about two years without difficulty. He had at least one friend with whom he maintained regular contact. There is no evidence of record that the Veteran was unable to venture outside of his home to engage in society generally. He traveled, began bowling in a weekly league, rode his bicycle, and went to the YMCA to exercise. He also attended a family reunion, a class reunion, and AA meetings and activities. Regarding total occupational impairment, as will be discussed more fully below, the Board is granting entitlement to a TDIU from August 1, 2008. However, the laws and regulations pertaining to entitlement to a TDIU and a 100 percent disability rating for MDD are different. For a 100 percent disability rating, in addition to total occupational impairment, there must be shown total social impairment. For reasons discussed above, total social impairment is not persuasively shown in this case. In sum, the Board realizes that the symptoms noted in the rating criteria are not intended to be an exhaustive list, but are examples of the types and severity of symptoms that indicate a certain level of disability. Thus, the Board finds that based on the overall record evidence, including the lay statements of the Veteran, his symptoms were not described to be of a type, frequency, and severity that are in accord with the level of impairment contemplated by the criteria for a schedular rating higher than 70 percent from August 1, 2008. General Considerations All potentially applicable diagnostic codes have been considered, whether or not they were raised by the Veteran, and no other diagnostic code would allow for a higher rating. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Although there were some periods of increased and decreased functioning, those episodes were not so distinct as to warrant a different level of disability rating. Thus, additional staged ratings are not appropriate from August 1, 2008. See Fenderson v. West, 12 Vet. App. 119 (1999). The Board also has considered whether extraschedular consideration is warranted. See 38 C.F.R. § 3.321(b)(1) (2015). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Considering the matter on appeal in light of the above, the Board finds that the schedular criteria reasonably describe the Veteran's disability level and symptomatology for his MDD. The General Rating Formula for Mental Disorders allows for evaluation rated based on the level of occupational and social impairment. While the code lists examples to be considered, it is not exclusive and allows for consideration of a broad range of symptoms. The Board has taken into consideration all of the Veteran's symptoms, including those that are not explicitly listed as examples under Diagnostic Code 9434, and finds that there are no additional symptoms that are not addressed by the rating schedule or that have not been considered by the Board in assigning the appropriate rating. The Veteran also has not described any exceptional or unusual features of his MDD, and there is no objective evidence that any manifestations are unusual or exceptional. Therefore, the Board finds that the rating schedule is adequate to evaluate the Veteran's disability picture. Consequently, the Board concludes that referral of this case for consideration of an extraschedular rating is not warranted. Id. at 115-16. The Board notes that under Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014), a veteran may be awarded an extraschedular rating based upon the combined effect of multiple conditions in an exceptional circumstance where the evaluation of the individual conditions fails to capture all the service-connected disabilities experienced. However, in this case, the Veteran is only service-connected for MDD. As such, there can be no additional service-connected disabilities that have not been attributed to a specific service-connected condition. Accordingly, this is not an exceptional circumstance in which extraschedular consideration may be required to compensate the Veteran for a disability that can be attributed only to the combined effect of multiple service-connected conditions. III. Entitlement to a TDIU In order to establish entitlement for a TDIU, there must be impairment so severe that it is impossible for the average person to follow a substantially-gainful occupation. See 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.16 (2015). Consideration may be given to the veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his or her age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19 (2015). When the veteran's schedular rating is less than total, a total rating based upon unemployability may nonetheless be assigned. If there is only one service-connected disability, it must be rated at 60 percent or more. If there are two or more service-connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be at least 70 percent. See 38 C.F.R. § 4.16(a) (2015). A total disability rating also may be assigned on an extraschedular basis, pursuant to the procedures set forth in 38 C.F.R. § 4.16(b), for veterans who are unemployable by reason of service-connected disabilities, but who fail to meet the percentage standards set forth in section 4.16(a). For a veteran to prevail on a claim for a TDIU, the sole fact that a veteran is unemployed or has difficulty obtaining employment is not enough. The question is whether the veteran is capable of performing the physical and mental acts required by employment, not whether the veteran can find employment. See 38 C.F.R. 4.16(a) (2015); Van Hoose v. Brown, 4 Vet. App. 361 (1993). Marginal employment cannot be considered substantially-gainful employment. Generally, marginal employment exists when a veteran's earned annual income does not exceed the Federal poverty threshold for one person. 38 C.F.R. § 4.16(a) (2015). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). During the pendency of the Veteran's claim, service connection has been in effect for MDD, now evaluated as at least 70 percent disabling for the entire period on appeal. Therefore, the Board finds that the Veteran meets the schedular criteria for a TDIU. 38 C.F.R. § 4.16(a) (2015). The Board notes that the Veteran filed his application for a TDIU in February 2013. See February 2013 Veteran's Application for Increased Compensation Based on Unemployability (VA Form 21-8940). However, in the present case under Rice v. Shinseki, 22 Vet. App. 447 (2009), the Veteran's claim for a TDIU is deemed to relate back to his initial request for service connection of MDD. Because the Board granted a 100 percent rating for the Veteran's MDD for the period from November 19, 2007 through July 31, 2008, that constitutes a full grant of the benefits sought for that period. Thus, the remaining inquiry is whether the Veteran's MDD rendered him unable to secure or follow a substantially-gainful occupation from August 1, 2008. The Veteran has a high school education. See February 2013 VA Form 21-8940. He was trained in the Navy as a machinist mate and in nuclear technology. See May 2008 VA examination. He took some computer graphic and web design classes, but quit due to poor concentration. After service, the Veteran worked as a glazer for his father and another company until about 1991. He then worked from 1991 to 1995 as a project manager in construction. From 1995 to 2001, he worked as a glass cutter, estimator, glazier, and door repairman. He worked as a metal fabricator from January 2001 to January 2005 and from September 2006 to August 2007. See May 2008 VA examination; February 2008 VA Mental Health Initial Evaluation Note; February 2013 VA Form 21-8940. His job skills are being good with his hands and able to follow blue prints, and experience working on electrical equipment and in factories. He reported that he was a quick learner. See February 2008 VA Mental Health Initial Evaluation Note. The Veteran last worked in August 2007 when he entered residential treatment for his depression and alcohol addiction. A record from his employer provides that the Veteran was terminated due to absenteeism. See December 2013 Request for Employment Information in Connection with Claim for Disability Benefits (VA Form 21-4192). The findings of the VA examiners and the private psychologist concerning the Veteran's employability were set forth above. The Board begins by noting that the Veteran's representative contends that the Board is bound to award a TDIU in the present case based on VA's grant of nonservice-connected pension to the Veteran. See July 2015 correspondence from Chisholm Chisholm & Kilpatrick LTD. Given that the Board has exercised its authority to determine independently that a TDIU is warranted in the present case, it is unnecessary to address the relative merits of the representative's contentions. The Board finds that the weight of the evidence shows the Veteran is unable to secure or follow a substantially-gainful occupation due to his service-connected MDD. While the Veteran is physically able to perform many jobs, has skills that would allow him to secure employment, and is intellectually capable of employment, the evidence as a whole shows that the Veteran does not have the mental ability to maintain employment due to his MDD. The Board acknowledges that no VA examiner has determined that the Veteran is unemployable. Even the Veteran reported in February 2014 that he would be capable of work that accommodated for his difficulties with reading instructions and being around other people. He stated that he had done well when shown visually what to do and worked in isolation. The Veteran has also expressed interest in going to college to learn new skills. However, the VA examiners have identified moderate impairment in several areas that combine to make it unlikely that the Veteran could successfully maintain employment. For example, the May 2008 VA examiner found that the Veteran's level of fatigue, concentration problems, and inner turmoil would likely cause moderate work inefficiency and lack of productivity, and the amount of avoidance of social contact and confrontation would likely interfere moderately with his ability to interact effectively. The June 2011 VA examiner opined that the Veteran's depression resulted in a long history of poor judgment and impairment in thinking. The February 2014 VA examiner opined that the Veteran's symptoms would likely cause discomfort when interacting with other people and reduced communication effectiveness. His difficulty with poor concentration, avoidance, distraction, felt sense of injustice, and inner turmoil would likely cause moderate work inefficiency and lack of productivity. The amount of difficulty he had for what he described as paranoia and anxiety around others would likely cause reduced reliability. The Veteran's difficulty with irritability and perceived sense of lack of safety would likely interfere with his ability to interact effectively. He had moderate reduction due to high distractibility and avoidance in his ability to adapt to stressful circumstances. The examiner concluded that the Veteran's mental health issues would likely have a moderate impact on his ability to obtain and maintain fulltime, competitive, gainful employment. While the VA examiners did not find that the Veteran is totally unable to secure or follow a substantially-gainful occupation, applicable regulations place responsibility for the ultimate TDIU determination on the adjudicator, not a medical examiner. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). As found above, the Veteran's MDD caused serious occupational impairment. The clinical evidence shows that the Veteran's depression has improved for only short periods and returns with minimal stress. Associated with his depression are lack of motivation, lethargy, apathy, low self-esteem, a sense of hopelessness and worthlessness, self-criticalness, guilt, pessimism, irritability and anger, and decreased concentration. Indeed, the Veteran was unsuccessful at his computer classes due to a lack of concentration. In addition, the Veteran has some mild memory impairment and a perceived inability to read instructions that hamper his ability to learn and be successful in employment. It is highly doubtful that the Veteran could tolerate the stress of learning a new job. In light of the constraints noted above and resolving all doubt in favor of the Veteran, the Board finds that his service-connected disability renders him unable to secure or follow a substantially-gainful occupation consistent with his educational background and employment history. Therefore, entitlement to a TDIU is warranted from August 1, 2008. 38 U.S.C.A. § 5107 (West 2014); 38 C.F.R. § 3.102 (2015); see Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). IV. Special Monthly Compensation (SMC) The Board notes that SMC is a potential element of increased rating claims without the need for a separate claim. Buie v. Shinseki, 24 Vet App 242 (2010). SMC at the housebound rate is awarded where there is a single service connected disability rated total and additional disability that combines for a rating of 60 percent or more. 38 U.S.C.A. § 1114(s) (West 2014). The Veteran was found above to be 100 percent disabled due to MDD from November 19, 2007 through July 31, 2008. In addition, a TDIU may satisfy the requirement for a single disability rated total, if awarded on the basis of a single disability. Bradley v. Peake, 22 Vet. App. 280 (2008). In this case the record shows that MDD was the cause of the Veteran's unemployability; hence, the TDIU based on MDD satisfies the requirement for a single disability rated total. However, the Veteran does not have any additional service connected disabilities. As such, the Veteran is not entitled to SMC at the housebound rate. (CONTINUED ON NEXT PAGE) ORDER Entitlement to a temporary total evaluation based on hospital treatment for a service-connected disability is granted from November 19, 2007 to July 31, 2008. Subject to the laws and regulations governing payment of monetary awards, a disability rating of 70 percent for MDD is granted from August 1, 2008. Subject to the laws and regulations governing payment of monetary benefits, entitlement to a TDIU due to service-connected disability is granted from August 1, 2008. ____________________________________________ TANYA SMITH Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs