Citation Nr: 21001393 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 16-24 545A DATE: January 7, 2021 ORDER Entitlement to a rating in excess of 50 percent for major depressive disorder, for accrued benefits purposes, is denied. Entitlement to a total rating based on individual unemployability due to service connected disability (TDIU), for accrued benefits purposes, is denied. Entitlement to service connection for the cause of the Veteran’s death is granted. Entitlement to dependency and indemnity compensation (DIC) benefits is granted. FINDINGS OF FACT 1. The Veteran’s major depressive disorder was manifested with occupational and social impairment with reduced reliability and productivity and without occupational and social impairment with deficiencies in most areas or total social and occupational impairment. 2. Throughout the period on appeal, the Veteran’s combined rating was 60 percent, and as such, the Veteran did not meet the schedular criteria for entitlement to a TDIU. 3. The Veteran’s service-connected disabilities did not render him unable to secure or follow a substantially gainful occupation. 4. The Veteran died in July 2012 and his death certificate reflects that the immediate cause of death was cardiovascular disease. 5. At the time of his death, the Veteran was service connected for major depressive disorder, left knee patellofemoral syndrome, and right knee patellofemoral syndrome. 6. Resolving reasonable doubt in his favor, the Veteran’s major depressive disorder was either a contributory cause of death or had a material influence in accelerating his death. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 50 percent for major depressive disorder for accrued benefits purposes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.125, 4.126, 4.130, Diagnostic Code 9434. 2. The criteria for a TDIU for accrued benefits purposes have been not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. 3. The criteria for service connection for the cause of the Veteran’s death have been met. 38 U.S.C. §§ 1310, 5107; 38 C.F.R. §§ 3.102, 3.312. 4. The criteria for DIC benefits pursuant to 38 U.S.C. § 1318 have been met. 38 U.S.C. §§ 1318, 5107; 38 C.F.R. §§ 3.102, 3.22, 20.1106. REFERRED ISSUE In a November 2020 Informal Hearing Presentation, the appellant’s attorney appears to raise the issue of entitlement to service connection for coronary artery disease for accrued benefits purposes. This issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ) and it is referred for appropriate action. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1986 to August 1987. Regrettably, the Veteran died in July 2012. The appellant is his surviving spouse. These matters come to the Board of Veterans’ Appeals (Board) on appeal from July 2012 and December 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction of this appeal is currently with the Milwaukee Pension Center RO. In January 2019, the Board issued a decision denying entitlement to service connection for the cause of the Veteran’s death, entitlement to DIC benefits, entitlement to an increased rating for major depressive disorder and entitlement to a TDIU. The appellant subsequently appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In April 2020, the Court issued a Memorandum Decision and remanded the case to the Board for action consistent with the Memorandum Decision. Increased Rating – Major Depressive Disorder The appellant contends that the Veteran’s major depressive disorder symptoms were more severe than contemplated by the rating assigned. Specifically, the appellant’s representative argues that the Veteran’s major depressive disorder symptoms included “thoughts of death, depressed mood ‘most of day nearly every day,’ loss of pleasure in almost all activities, feeling worthless, hypersomnia, fatigue, and being unemployed for the last decade.” See Appellate Brief, October 30, 2020. In this regard, the appellant’s representative points to the April 2012 VA examination report that indicated the Veteran had severe symptoms of major depressive disorder, and VA treatment records of record. Id. Additionally, the April 2020 Memorandum Decision found that the January 2019 Board did not adequately address potentially favorable evidence regarding suicidal ideations and explosive anger when addressing the appellant’s claims for an increased rating. See Court Memorandum Decision, April 29, 2020. Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant’s current symptoms. See Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011). 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 concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). However, the Board must also consider staged ratings. Hart v. Mansfield, 21 Vet. App. 505, 509–10 (2007). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, 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 conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran’s claim. The Veteran was rated at 50 percent for his major depressive disorder. Psychiatric disabilities are rated based on the General Rating Formula codified in 38 C.F.R. § 4.130, which provides disability ratings are based on a spectrum of symptoms. “A veteran may qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of a similar severity, frequency, and duration.” Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013). VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 1994) (DSM-IV) and (5th ed. 2013) (DSM-5). See Mauerhan v. Principi, 16 Vet. App. 436, 442–43 (2002). VA is to engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran’s service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). Under the General Rating Formula for Mental Disorders per 38 C.F.R. § 4.130, a 50 percent rating is warranted if the disability is productive of 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. 38 C.F.R. § 4.130, Diagnostic Code 9423. 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); 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 hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. In addition, when evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the lengths of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating agency shall assign an evaluation based on all 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. Id. However, when evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment, but shall not assign an evaluation on the basis of social impairment. The Board notes that with regard to the use of the phrase “such as” in 38 C.F.R. § 4.130 (General Rating Formula for Mental Disorders), ratings are assigned according to the manifestations of particular symptoms. However, the use of the phrase “such as” in 38 C.F.R. § 4.130 demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve only as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). Accordingly, the evidence considered in determining the level of impairment under 38 C.F.R. § 4.130 is not restricted to the symptoms provided in the Diagnostic Code. Instead, VA must consider all symptoms of a claimant’s condition that affect the level of occupational and social impairment. The Board acknowledges that psychiatric examinations frequently include assignment of a global assessment of functioning (GAF) score. The American Psychiatric Association has released the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.) (DSM-5), and 38 C.F.R. § 4.130 has been revised to refer to the DSM-5. The DSM-5 does not contain information regarding GAF scores. Effective August 4, 2014, VA amended the portion of its Schedule for Rating Disabilities dealing with mental disorders to remove outdated references to the DSM-IV and replace them with references to the DSM-5. See 79 Fed. Reg. 45,093, 45,094 (Aug. 4, 2014). VA adopted as final, without change, the interim final rule and clarified that the provisions of the final rule did not apply to claims that were pending before the Board, this Court, or the U.S. Court of Appeals for the Federal Circuit on August 4, 2014, even if such claims were subsequently remanded to the agency of original jurisdiction. See 80 Fed. Reg. 14,308 (Mar. 19, 2015). In Golden v. Shulkin, 29 Vet. App. 221 (2018), the Court held that given that the DSM-5 abandoned the GAF scale and that VA has formally adopted the DSM-5, the Board errs when it uses GAF scores to assign a psychiatric rating in cases where the DSM-5 applies. This appeal was certified to the Board in July 2017. As such, the DSM-5 applies, and the GAF scores will not be considered. A review of the record reveals that the Veteran sought mental health treatment from VA and private facilities, as well as treatment for his other health needs. To the extent that the Veteran’s treatment records contain information relevant to the severity of his mental health, to include mental health screenings, the Board will summarize this evidence. Turning to the evidence, the Veteran was afforded a VA examination in April 2012. At that time, the examiner opined the Veteran’s major depressive disorder was manifested by occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by medication. The Veteran reported that he was married, had two children, was close with his mother and step-father until their deaths, and that he worked with his step-father as a mechanic for many years. The Veteran last worked in 2002. He reported a significant history of alcohol abuse, and that he quit drinking in 1997 because his wife “would have probably left him” if he continued drinking alcohol. Symptoms attributable to his major depressive disorder included depressed mood; anxiety; panic attacks that occur weekly or less often; flattened affect; impaired judgment; impaired abstract thinking; disturbance of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and neglect of personal appearance and hygiene. The examiner noted that although the Veteran denied suicidal ideation, he endorsed thinking about being dead more frequently than weekly; and he endorsed anhedonia and avolition. The Veteran reported that when he heard news of killed soldiers, he felt that it should have been him. He also reported he continued to fish and hunt once or twice a year, and attended his daughter’s recitals. The Veteran was capable of managing his financial affairs. The examiner noted that there was no evidence that the Veteran would be incapable of performing sedentary and self-paced work given his mental condition; and noted that whether the Veteran’s physical limitations would impact his work was not within the scope of the mental evaluation and would require the opinion of a separate medical provider. The examiner further noted that when discussed with the Veteran, he appeared surprised when asked if there were any employment whatsoever he felt he could manage; and the Veteran said “yes, he thought he could handle some kinds of jobs, but could not do what he used to.” Of record is an April 2012 VA treatment record that indicates the Veteran had anxiety problems and slept approximately 14 hours a day. A separate April 2012 VA treatment record indicates the Veteran reported extreme depression that was increasing; isolated himself; and turned his phone off and would not leave his house. He denied suicidal and homicidal ideation. Of record is a May 2012 VA treatment record that indicates the Veteran had recently filed for unemployability, and stated he had been depressed since 2005. He reported that he would not drive because he had anger and anxiety issues, and that he could not deal with traffic. He reported he had been married for 17 years, and that his wife encouraged him to come for help; she was present at the session. The Veteran indicated he was not good around a lot of people, was very detached from others, and had physical chronic pain. He went to church and stated that his religion deterred suicide. Of record is a June 2012 VA treatment record that indicates the Veteran reported chronic depression; anxiety; problems with varying mood for any years, but that his mood had been especially bad in the last several years due to the loss of his mother and unemployment. He reported that he spent much of his time at home, stayed on the couch, and remained socially isolated. He was treated with medication, but his wife reported that the medication did not seem to help much. Of record is a July 2012 VA treatment record that indicates the Veteran reported chronic depression; anxiety; problems with varying mood; staying home most of the time on the couch; remained socially isolated; and was unhappy in his marriage. An additional July 2012 VA treatment record indicates that the Veteran and his wife were seen for couples and/or family psychotherapy. The couple was referred to the clinic by a nurse practitioner who noted difficulties with anxiety, depression, and anger by the Veteran. At this time, the Veteran and his wife believed that the Veteran’s mental health and physical stressor contributed to his being irritable and withdrawn, and the family felt as though they must “walk on eggshells around him,” at times. They expressed concern regarding the Veteran’s anxiety, isolation, health, and anger that approached explosiveness at times. Marital discord had been present for approximately 12 years, and intensified within the last two years. The Veteran and his wife lived together with their two children, and never separated in the past. They had previously tried couple’s therapy, but the Veteran discontinued the appointments because he did not agree with the therapist. The Veteran was noted to have difficulty sustaining focus on issues surrounding his marital relationship. The Veteran was described as having anger that was “frightening” at times, and noted concern that he would “snap” on someone due to rapidly escalating rage. He stated that his concerns about reactivity were central in his no longer working or driving, as well as social isolation. The Veteran and his wife described depression, irritability, limited affective range, feelings of inadequacy and rumination, and anxiety (regarding the future and his health, as well as feeling out of control of his anger). The Veteran indicated that he had ongoing stressors and coping with anxiety and depression; and sought individual therapy. In that regard, the Veteran and his wife indicated that they believed their discord was mostly related to concern to the Veteran’s mood and/or reactive state. Domestic violence in the marriage was denied, and the Veteran denied any suicidal and/or homicidal ideation. The Veteran noted that he recognized his depression and reactivity was problematic, and wished to pursue individual therapy before he could commit to work on his marital relationship. The treatment provider recommended that the Veteran initiate individual therapy to address issues of “vegetative depression, social isolation, anger, anxiety, and coping with chronic medical conditions.” Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities. However, there is no indication from the treatment notes of record that the Veteran has reported mental health symptoms that are worse than those noted above. Based on the foregoing, the Board finds that a rating of 50 percent for major depressive disorder is not warranted. In this regard, the Board finds that such disability was manifested by occupational and social impairment with reduced reliability and productivity without deficiencies in most areas without social and occupational impairment with deficiencies in most areas or total social and occupational impairment. Impairment to mood was demonstrated as the Veteran reported depressed mood, “vegetative” depression, anxiety and anger. Additionally, the Veteran reported thinking about death frequently, endorsed anhedonia and avolition and reported “extreme depression” that was increasing, isolation, and angry outbursts. Some impairment to family relations was shown as the Veteran reported social isolation, reactive anger, to include “explosiveness,” feeling detached from others, being unhappy in his marriage, chronic marital discord, irritability and being withdrawn from his family resulting in his family feeling as though they must “walk on eggshells around him,” frightening his family with his anger and rapidly escalating rage (“snapping”). Further, social impairment was shown by the Veteran’s reports of some limited socialization because he did not like being around groups of people. Impairment to family relations was not shown as the Veteran did not report, and the evidence does not show that the Veteran’s family relations were impaired due to his major depressive disorder. Rather, the Board notes that the Veteran reported he had never separated from his wife, and had lived with his wife and two children until his death. He reported participation in religious events, and cited his religion as a deterrent for suicide. Although he reported that he stayed home most of the time and reported social isolation, the Veteran also reported he continued to fish and hunt regularly and attended his daughter’s recitals. He also reported that he had remained close with his mother and step-father until their deaths, and demonstrated he was motivated to work on his individual and marital issues through therapy. In that regard, the Veteran sought individual therapy to help his psychiatric symptoms, and voiced desire to improve his marriage. Further, social impairment was shown by the Veteran’s reports of some limited socialization because he did not like being around groups of people. No impairment to thinking was demonstrated. Judgment was not impaired as it was consistently found to be intact or good during the appeal period. School was not attempted during the appeal period. Therefore, the Board finds that the Veteran’s major depressive disorder showed occupational and social impairment with reduced reliability and productivity, without deficiencies in most areas. Further, while the Veteran reported thinking of being dead more frequently than weekly in an April 2012 VA examination, in Bankhead v. Shulkin, 29 Vet. App. 10 (2017), the Court held that the language of the general rating formula "indicates that the presence of suicidal ideation alone...may cause occupational and social impairment with deficiencies in most areas." However, as recognized by the Court, VA must engage in a holistic analysis in assessing the severity, frequency, and duration of the signs and symptoms of a veteran's service-connected psychiatric disability, and their resulting social and occupational impairment. In this regard, the Veteran has denied suicidal ideations in the April 2012 VA examination. He also denied thoughts of self-harm in a June 2012 VA treatment note and suicidal ideations in an April 2012 VA treatment note. In an April 2012 VA behavior health treatment note, the Veteran denied thoughts about taking his life or suicidal ideations. Ultimately, while the Veteran did exhibit some of the hallmarks of a 70 percent rating during this period, including reported thought of being dead more frequently than once a week they did not result in social and occupational impairments with deficiencies in most areas. Moreover, the record reflects that the Veteran’s symptoms have not been consistent with occupational and social impairment with deficiencies in most areas. In this regard, the Veteran has consistently presented without impairment to thought processes or communications; has consistently denied suicidal or homicidal ideation, plan or intent, although indicating he had frequent thoughts of death; has never shown to have impaired judgment, hallucinations, delusions, or obsessive rituals; and has consistently oriented to person, place, time or place. The appellant’s attorney argued that a total rating was warranted because of the Veteran’s suicidal ideations; however, the Board notes that such ideations occurred during service, which is prior to the instant appeal period. Although the Veteran reported thinking of being dead more frequently than weekly in an April 2012 VA examination, the Veteran denied suicidal ideations. Moreover, such reports of thinking of death do not constitute a persistent danger of hurting himself or others. The Board notes that the Veteran had reported a suicide attempt as a teenager but there is no evidence of suicide attempts during the appeal period. There is no evidence or allegation that the Veteran’s psychiatric symptoms manifested in interference or difficulties resulted in the inability to perform activities of daily life, to include maintenance of minimal hygiene, although one instance of neglect of personal appearance hygiene was noted. Additionally, the Veteran maintained a long-term marriage and relationships with his family members, albeit with some tension and discord and total social impairment was not shown. Moreover, this is not a disability picture indicating occupational and social impairment with deficiencies in most areas at any time during the appeal period. In assessing the severity of his major depressive disorder, the Board has considered the competent lay assertions regarding symptoms experienced and observed. See, e.g., Layno v. Brown, 6 Vet. App. 465, 470 (1994) and Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). However, the criteria needed to support higher ratings as the required medical findings that are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-138 (1994). As such, the lay assertions are not considered more persuasive than the objective medical findings which, as indicated above, do not support assignment of any higher rating pursuant to any applicable criteria at any point pertinent to this appeal. The Board notes the contentions of the appellant and her representative that the Veteran’s major depressive disorder is more severe than currently shown on examination; and the Board observes that the appellant, while competent to report her observable symptoms, she is not competent to report that the Veteran’s mental health symptoms are of sufficient severity to warrant a higher rating under VA’s tables for rating such disabilities because such an opinion requires medical expertise which he has not been shown to have. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002). Despite the foregoing, the Board acknowledges the appellant’s representative assertions that the Veteran’s symptoms of thoughts of death, depressed mood ‘most of day nearly every day,’ loss of pleasure in almost all activities, feeling worthless, hypersomnia, fatigue, anger, and being unemployed for the last decade warrant a higher rating. However, even after considering such contentions as to the effects of the disability on his daily life, the Board finds that the criteria for a higher rating are not met. See Lendenmann, supra. The Rating Schedule contemplates such impairment under the ordinary conditions of daily life. 38 C.F.R. § 4.10; see also Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). This argument is therefore without merit. The Board has considered whether a staged rating under Hart, supra is appropriate; however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning staged ratings is not warranted. The appellant and/or her representative has not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claim adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 50 percent for major depressive disorder. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to a TDIU The appellant contends that the Veteran’s psychiatric symptoms, in combination with his physical disabilities, prevent him from obtaining and maintaining substantially gainful employment prior to his death. Specifically, the appellant’s representative asserts that the Veteran could no longer work due to the “great deal of stress,” that may have contributed to his unemployment, that his major depressive disorder caused clinically significant stress and impaired his social and occupation function and that obvious difficulties with his ability to concentrate. See Appellate Brief, October 30, 2020. Additionally, her representative argues that the Veteran’s had become very forgetful and developed short-term memory problems that negatively affected his ability to maintain attention and concentration for extended periods of time or understand and carry out detailed instruction. Id. Further, her representative notes that the Veteran was unemployed from 2001 to the time of his death and that all occupational and social impairment was attributable to his major depressive disorder. Id. Additionally, the appellant and her representative assert that the Veteran’s service-connected bilateral knee disorders rendered the Veteran unemployable. Id. In this regard, her representative notes that the Veteran had to use a cane for his knees, had limited range of motion in his knees, and that an April 2012 VA examiner noted the Veteran’s knees impacted his ability to work due to less movement that normal, pain, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. Id. Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Rating boards should submit to the Director of Compensation Service for extraschedular consideration all cases of veterans who are unemployable by reason of service-connected disabilities but who fail to meet the percentage standards set forth in 38 C.F.R. § 4.16(a). See 38 C.F.R. § 4.16(b). Unlike the regular disability rating schedule, which is based on the average work-related impairment caused by a disability, “entitlement to a TDIU is based on an individual’s particular circumstances.” Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). Therefore, when adjudicating a TDIU claim, VA must take into account the individual veteran’s education, training, and work history. Hatlestad v. Derwinski, 1 Vet. App. 164 (1991) (level of education is a factor in deciding employability); see Friscia v. Brown, 7 Vet. App. 294 (1994) (considering Veteran’s experience as a pilot, his training in business administration and computer programming, and his history of obtaining and losing 19 jobs in the previous 18 years); Beaty v. Brown, 6 Vet. App. 532 (1994) (considering Veteran’s 8th grade education and sole occupation as a farmer); Moore v. Derwinski, 1 Vet. App. 356 (1991) (considering Veteran’s master’s degree in education and his part-time work as a tutor). Age may not be considered as a factor when evaluating unemployability or intercurrent disability, and it may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. There must be a determination that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age or a non-service-connected disability. 38 C.F.R. §§ 3.340, 3.341, 4.16. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A high rating in itself is recognition that the impairment makes it difficult to obtain or keep employment. The ultimate question, however, is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether he or she can find employment. Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). An assessment of TDIU entitlement based on the combined effects of all service-connected disabilities should address all such disabilities. Therefore, the cumulative effects (functional impairment) of all service-connected disabilities should be addressed in determining if the service-connected disabilities prevent substantially gainful employment. Floore, 26 Vet. App. 376; accord Geib v. Shinseki, 733 F.3d 1350, 1353-54 (Fed. Cir. 2013). In making such a determination, the Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of evidence contained in a record and every item does not have the same probative value. The Board must analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad, 1 Vet. App. at 169. The Veteran’s credibility affects the weight to be given to his or her testimony and lay statements, and it is the Board’s responsibility to determine the appropriate weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, the demeanor of the witness, the facial plausibility of the testimony, the internal consistency of the testimony, impairment in memory, or, to a certain extent, bad character, among other factors. Caluza, 7 Vet. App. at 510-11, aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). In particular, personal interest may affect the credibility of the evidence. Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991). The ultimate question is whether he is capable of performing the physical and mental acts required by employment, not whether he can find employment. 38 C.F.R. § 4.16(a); Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). At the time of his death, service connection was in effect for major depressive disorder (evaluated as 50 percent disabling from August 4, 1987); left knee patellofemoral syndrome (evaluated as 10 percent disabling from March 6, 2012); and right knee patellofemoral syndrome (evaluated as 10 percent disabling from March 6, 2012). The combined rating is 60 percent from March 6, 2012. Therefore, the criteria for consideration of a TDIU pursuant to 38 C.F.R. § 4.16(a) have not been met at any time. However, when a Veteran is unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities, but fails to meet the percentage requirements for a TDIU set forth in 38 C.F.R. § 4.16(a), the case may be referred to appropriate VA officials for consideration of assignment of a TDIU rating. 38 C.F.R. § 4.16(b). Turning to the evidence, Social Security Administration (SSA) records submitted by the appellant indicate the Veteran filed for Social Security Disability benefits in August 1996. At that time, the Veteran indicated he could no longer work due to his heart, psychosis, and hypertension. Specifically, the Veteran reported that he had heart surgery in 1995 that resulted in limited physical capabilities and psychiatric symptoms, so that he could no longer work like he should. Additionally, he reported that the medication he took for his heart and his psychiatric symptoms kept him from working on occasion. The Veteran was afforded a VA examination in April 2012. At that time, the examiner noted that he was last employed in 2000 as a manager or maintenance of a horse farm; and quit working due to his back condition, history of Crohn’s disease, being easily fatigued, and noted he had recently had a myocardial infarction and congestive heart failure. The examiner also noted the Veteran’s back condition impacted his ability to work due to limited bending, lifting, and carrying; persistent pain; and limitations with squatting. The examiner also noted the Veteran’s bilateral knee condition impacted his ability to work due to some limitations with walking and climbing, and limited ability for prolonged ambulation and climbing. As noted above, the Veteran’s major depressive disorder symptoms manifested in, at worst, occupational and social impairment with reduced reliability. His psychiatric symptoms and occupational impairment are described above. Based on the foregoing, and in consideration of the pertinent clinical findings, including the Veteran’s reports that his barriers to employment included his depression, knees, back, Crohn’s disease, and heart. The Board notes that the Veteran’s employment history as reported is conflicting. Specifically, the Veteran reported to SSA that he was no longer working as of August 1996 and at other times, reported he worked until 2000, 2001, 2002, or 2005. However, the Board notes that throughout the period on appeal, the Veteran remained unemployed prior to his death. The Board notes that the Veteran’s subjective reports about his ability to obtain and maintain gainful employment is also conflicting. Specifically, the Board notes that at his April 2012 VA psychiatric examination, the examiner noted the Veteran appeared surprised when asked if there were any employment whatsoever he felt he could manage; and the Veteran said “yes, he thought he could handle some kinds of jobs, but could not do what he used to.” In contrast, the Veteran later reported that his concerns about reactivity were central in his no longer working or driving, as well as social isolation. The Board has carefully considered the appellant’s statements regarding the effects of the Veteran’s service connected major depressive disorder, left knee, and right knee on his employability. Although the Veteran experienced some limitations as a result of his service-connected disabilities, and these have been found to cause some impact on his daily functioning and earning capacity, that impact was considered in the scheduler ratings currently assigned. Simply stated, if he did not have impairment with his service connected major depressive disorder and knees, there would be no basis for the 60 percent combined disability impairment for such. The fact that he was having problems does not provide a basis to grant TDIU. Significantly, the April 2012 VA examiner noted that there was no evidence that the Veteran would be incapable of performing sedentary and self-paced work given his mental condition and noted that whether the Veteran’s physical limitations would impact his work was not within the scope of the mental evaluation and would require the opinion of a separate medical provider. However, as indicated previously, the examiner noted that the Veteran himself indicated he would be able to work in spite of any psychiatric and/or physical limitations when asked. The Board has assigned the examiner’s opinion report great probative value as it was based on an examination of the Veteran and a review of the pertinent evidence of record. The examiner addressed the question of employability directly and the opinion is consistent with the treatment records and prior examination findings. This opinion is uncontroverted. Moreover, the Board notes that the Veteran himself asserted that he was unemployable as a result of a combination of his service-connected and nonservice-connected disabilities. In that regard, the Veteran included heart, psychosis, and hypertension; and his knees and back as reasons for his unemployment. The Board also notes the arguments of the appellant and her representative that his psychiatric symptoms, in combination with his knee disorders, produce unemployability. However, as discussed above, the impact of such disorders, and their impact, are considered in the schedular ratings assigned. This argument is therefore without merit. Accordingly, referral of this claim to the Director, Compensation Service for consideration of such rating is not warranted and a TDIU rating is not warranted. While the Veteran clearly had functional impairments associated with his service-connected major depressive disorder and bilateral knees, these problems form the basis of the functional impairment assigned. Accordingly, the Board concludes that referral of this issue for extraschedular consideration of TDIU pursuant to 38 C.F.R. § 4.16(b), is not appropriate, and that a TDIU is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Service Connection for the Cause of the Veteran’s Death The appellant contends that she is entitled to service connection for the cause of the Veteran’s death. Specifically, her representative asserts that the Veteran’s service-connected major depressive disorder and/or knee disorders contributed to, or aided and lent assistance, to his immediate cause of death from cardiovascular disease. See Appellate Brief, October 30, 2020. In this regard, she contends that the Veteran’s lengthy history of significant major depressive disorder symptoms and use of pain killers to treat his knee disorders resulted in an increased risk for cardiovascular disease. Id. Moreover, the appellant’s representative asserts that the Veteran’s cardiovascular disease symptoms began during active service and continued since. Id. Specifically, the Veteran sought treatment for sharp pain in his left chest with associated symptoms. See June 1986 service treatment record. In order to establish service connection for the cause of the Veteran’s death, applicable law requires that the evidence show that a disability incurred in or aggravated by service either caused or contributed substantially or materially to death. For a service-connected disability to be the cause of death it must singly, or with some other condition, be the immediate or underlying cause, or else be etiologically related. For a service-connected disability to constitute a contributory cause, it is not sufficient to show that it casually shared in producing death, but rather it must be shown that there was a causal connection. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. In the alternative, service connection for the cause of death may be warranted where the evidence indicates that the cause of the Veteran’s death should have been service-connected. That is to say that, to establish service connection for a particular disability found to have caused his death, the evidence must show that the disability resulted from disease or injury which was incurred in or aggravated by service or, in the alternative, is secondary to another service-connected disability. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303, 3.304. The Veteran passed away in July 2012, and the death certificate reflects that the immediate cause of death was cardiovascular disease. At the time of his death, the Veteran was service connected for major depressive disorder, left knee patellofemoral syndrome, and right knee patellofemoral syndrome. Turning to the question of whether there is an etiological relationship between the Veteran’s service and the cause of his death, the Board notes that the record contains multipole etiology opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998). The Board will consider each of these opinions below. The Board notes that the April 2016 and May 2016 VA opinions are inadequate to decide the claim. In this regard, the VA examiners failed to adequately provide supporting rationale for the conclusions reached, and did not address whether the Veteran’s complaints of chest pain were symptoms manifested during active service of later diagnosed cardiovascular disease. Therefore, the Board finds the April 2016 and May 2016 VA opinions inadequate to decide the claim and are afforded little, if any, probative weight. Of record is an August 2017 private opinion by Dr. H.S. In this opinion, Dr. H.S. opined that it was at least as likely as not that the Veteran’s service connected major depressive disorder aided in the development of and permanently aggravated his hypertension and cardiovascular disease and that the Veteran’s hypertension aggravated his chronic kidney disease and coronary artery disease. In this regard, Dr. H.S. noted that psychiatric symptoms cause a dysfunctional immune response and affect the hormone system that controls blood pressure and that the Veteran had daily stress on his heart continuously since service. Dr. H.S. noted research that indicated anxiety and depression were predictive of later incidence of hypertension and that depression and hypertension are risk factors for coronary artery disease. Moreover, Dr. H.S. noted the Veteran was a smoker, had used cocaine and alcohol, had a family history of coronary artery disease, and used medication to control his hypertension; all of which are factors that contributed to the Veteran’s coronary artery disease. Dr. H.S. noted that it would be “impossible to determine the bigger aggravator.” Therefore, Dr. H.S. opined that it was at least as likely as not that the Veteran’s service connected major depressive disorder contributed both substantially and materially to the Veteran’s cause of death. Subsequently, the appellant submitted a May 2020 private opinion by Dr. S.B. In this opinion, Dr. S.B. opined that the Veteran’s psychiatric symptoms impacted his overall health and led to his demise. Specifically, Dr. S.B. noted that depression and anxiety are a “strong cause and risk factor” for coronary artery disease, and that it had been shown in numerous research articles that major depressive disorder and heart disease are related. Moreover, Dr. S.B. noted that the Veteran’s major depressive disorder symptoms resulted in a sedentary lifestyle which is a precursor to obesity, that obesity is a “bridge to numerous medical complications and that the Veteran’s obesity negatively impacted his diabetes which resulted in hypertension and hyperlipidemia and then eventually resulted in cardiovascular disease. In this regard, Dr. S.B. notes that risk factors included metabolic syndrome related to obesity and sedentary lifestyle. Further, Dr. S.B. noted other risk factors of smoking and polysubstance abuse that are directly connected to major depressive disorder, which also serve as risk factors in the development of coronary artery disease. Thus, Dr. S.B. opined that the Veteran’s diagnosis of coronary artery disease is “multifactorial and was directly and indirectly influenced by his diagnosis of [major depressive disorder]… [and the] Veteran’s medical charges is quite convincing that this Veteran’s service connected [major depressive disorder] is at least as likely as not responsible for his development of coronary artery disease.” The Board finds that the August 2017 and May 2020 private opinions are the only competent, persuasive opinions to address the cause of the Veteran’s death, as the opinions have clear conclusions and supporting data, as well as reasoned medical explanations when determining that the Veteran’s major depressive disorder aided in the development of and permanently aggravated the Veteran’s hypertension and cardiovascular disease. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Thus, the Board finds no adequate basis to reject these supportive opinions, and has accorded they significant probative weight with respect to establishing the nexus element of the claim. These opinions are therefore afforded great probative weight. Moreover, the Board also finds that no further evidentiary development in this regard is necessary. Cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003). In sum, the Board notes that service connection was in effect for major depressive disorder at the time of the Veteran’s death and that his immediate cause of death was cardiovascular disease. There is no probative etiology opinion of record against the claim, rather there are probative etiology opinions of record for the claim. In this regard, the August 2017 and May 2020 private opinions of record indicate that the Veteran’s service connected major depressive disorder aided in the development or and permanently aggravated his hypertension and cardiovascular disease, resulting in his death. The Board also notes that it is prohibited from developing additional evidence for the purpose of obtaining evidence against a claimant’s case. See Mariano v. Principi, supra. Accordingly, the Board finds that the evidence for and against the claims of entitlement to service connection for the cause of the Veteran’s death is at least in equipoise. Therefore, reasonable doubt must be resolved in favor of the Veteran and entitlement to service connection for the cause of the Veteran’s death is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to Dependency and Indemnity Compensation Benefits The appellant seeks DIC benefits. Such benefits are payable to the surviving spouse, child, or parents of a veteran if the veteran’s death was from a service-connected disability. 38 U.S.C. § 1310; 38 C.F.R. § 3.5. Specifically, the appellant’s representative asserts that DIC benefits should be awarded because the Veteran’s cause of death should be service connected. See Appellate Brief, October 30, 2020. VA death benefits may be paid to a deceased Veteran’s surviving spouse or children in the same manner as if the Veteran’s death was service-connected. 38 U.S.C. § 1318(a); 38 C.F.R. § 3.22(a). A deceased Veteran is one who died not as the result of his or her own willful misconduct and was in receipt of or entitled to receive compensation at the time of death for a service-connected disability continuously rated totally disabling for a period of 10 or more years immediately preceding death; or continuously rated totally disabling for a period of not less than five years from the date of the veteran’s discharge or other release from active duty; or the veteran was a former POW and died after September 30, 1999, and the disability was continuously rated totally disabling for a period of not less than one year immediately preceding death. 38 U.S.C. § 1318(b); 38 C.F.R. § 3.22(a). The total rating may be either schedular or based on unemployability. 38 C.F.R. § 3.22(c). For purposes of the statute and regulation, “entitled to receive” includes a situation in which the Veteran would have received total disability compensation at the time of death but for clear and unmistakable error in a decision on a claim filed during the Veteran’s lifetime. 38 C.F.R. § 3.22(b)(1). (Continued on the next page)   As of the date of this decision, service connection for the cause of death has been granted. As such, the Board concludes that the Veteran died from a service-connected disability and, to this extent, the appellant’s claim (and DIC) is granted. 38 U.S.C. § 1310; 38 C.F.R. § 3.312. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mariah N. Sim, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.