Citation Nr: 18145746 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-26 974 DATE: October 30, 2018 REMANDED Entitlement to a rating in excess of 50 percent for major depression with psychotic features is remanded. Entitlement to a total rating based upon individual unemployability (TDIU) due to service-connected disability is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1966 to October 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2014 rating decision, which denied the Veteran's claim of entitlement to a rating in excess of 50 percent for major depression with psychotic features. He perfected a timely appeal to that decision. On March 2, 2017, the Veteran testified at a videoconference hearing before the undersigned. A transcript of that hearing is of record. 1. Entitlement to a rating in excess of 50 percent for major depression with psychotic features is remanded. After examining the record, the Board concludes that further assistance to the Veteran is required in order to comply with the duty to assist as mandated by 38 U.S.C. § 5103A (2012). The specific bases for remand are set forth below. The Veteran essentially maintains that his PTSD is more disabling than reflected by the 50 percent rating currently assigned. At his personal hearing in March 2017, the Veteran maintained that his condition has worsened since his last examination in April 2014; he noted that he can’t be around people because he becomes very irritated. The Veteran related that he has no close friends or relative. It was argued, thus, that the Veteran is unable to establish and maintain effective relationships. The Veteran also reported that, when he moved to South Bend, he was in a homeless shelter for three years because he never had any friends. The Veteran indicated that he was currently unemployed. The Veteran indicated that he takes about two medications for his psychiatric disorder; he noted that, since 2014, his private doctor, “Dr. Coleville,” has changed his medication and increased the dosage. A review of the file reflects that the last examination provided in this case was conducted in April 2013. Since then, the Veteran has submitted VA progress notes dated from May 2011 to April 2016 which show ongoing follow up evaluation for PTSD symptoms; these records would suggest that the Veteran's symptoms may have been worse, at least at times, than currently rated. For example, A VA progress note, dated in February 2015, indicated that the Veteran was admitted to hospital following suicidal ideation due to chronic left flank pain. He denied current suicidal or homicidal ideations, but acknowledged passive thoughts of suicidal ideations related to severe pain. The discharge diagnosis was unspecified depression. As the record suggests that the Veteran's symptoms have worsened since the April 2014 DBQ examination, the Board finds that a remand is necessary to obtain a new examination to ascertain the current severity and manifestations of the Veteran's major depression with psychotic features. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). 2. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disability is remanded In light of his testimony at the March 2017 Board hearing that he was currently unemployed partly as a result of his psychiatric disorder, the Board finds that the issue of a TDIU has been raised by the record in connection with the claim for a higher rating for major depression with psychotic features. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Therefore, the AOJ should develop a claim for a TDIU in accordance with Rice. The matter is REMANDED for the following action: 1. Send a letter to the Veteran providing him with notice as how to substantiate the claim for a TDIU, to include VA Form 21-8940. In that letter, request that the Veteran identify the names, addresses, and approximate dates of treatment for all of the non-VA health care providers who have treated him for his major depression with psychotic features. Assist the Veteran in obtaining such evidence as appropriate. 2. Obtain any outstanding VA treatment records and associated them with the claims file. If, there are no additional VA treatment records, indicate such fact in the claims file. 3. Thereafter, ensure that the Veteran is scheduled for a VA examination to determine the current nature and severity of his major depression with psychotic features. The examiner must review the claims file. All appropriate tests and studies must be accomplished and all clinical findings reported in detail. A detailed history, to include work history, should be obtained from the Veteran. Following examination of the Veteran, the examiner must describe the frequency and severity of the manifestations of the Veteran's service-connected major depression with psychotic features, to include the functional impairment resulting from this disability. The report of examination must include a complete rationale for all opinions expressed. 4. After the requested development has been completed, readjudicate the claims that are the subject of this remand. If any determination remains unfavorable to the Veteran in any way, he and his representative should be furnished a supplemental statement of the case (SSOC), which includes a summary of additional evidence submitted, and any additional applicable laws and regulations. Thereafter, they should be given the opportunity to respond before returning the case to the Board. JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs