Citation Nr: 21003996 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 11-24 250 DATE: January 25, 2021 ORDER For the appeal period prior to April 5, 2011, a disability rating of 50 percent, but no higher, for depression is granted. Beginning April 5, 2011, a disability rating of 70 percent, and no higher, for depression is granted. FINDINGS OF FACT 1. Resolving all reasonable doubt in favor of the Veteran, for the rating period prior to April 5, 2011, the Veteran’s depression resulted in symptoms causing occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, disturbances of motivation and mood, social isolation and withdrawal, anxiety, and suspiciousness. 2. Beginning April 5, 2011, the Veteran’s depression resulted in occupational and social impairment with deficiencies in areas such as work, thinking and mood due to such symptoms as suicidal ideation. The Veteran’s depression has not resulted in symptoms causing total occupational and social impairment. CONCLUSIONS OF LAW 1. Prior to April 5, 2011, the criteria for a disability rating of 50 percent, but no higher, for depression were met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9434. 2. Beginning April 5, 2011, the criteria for a disability rating of 70 percent, and no higher, for depression are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.130, DC 9434. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1974 to June 1977. This case originally came before the Board of Veterans’ Appeals (Board) on appeal from a November 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which continued a 30 percent disability rating for service-connected depression. This case was previously before the Board in August 2017, at which time it was remanded for additional development. Subsequently, by rating decision dated in November 2018, the RO increased the disability rating for depression from 30 to 70 percent disabling, effective November 28, 2017, the date of the most recent VA examination. The Board remanded the claim again in April 2019. The Board notes that the Veteran initially requested a Travel Board hearing in his August 2011 VA Form 9. However, he withdrew this hearing request in June 2017. Additionally, in a July 2012 statement, the Veteran indicated that the side effects from taking psychiatric medication affected his diabetes. Although any such associated disorders should be considered in evaluating the severity of a disability, any disorder secondary to a service-connected disability must first itself be service-connected pursuant to 38 C.F.R. § 3.310. A separate rating would then be awarded for that secondary disability. Therefore, to the extent that the Veteran desires to file a claim for service connection for diabetes mellitus as secondary to his service-connected depression, he is advised that a complete claim on an application form prescribed by VA regulations is required. 38 C.F.R. § 3.155. Legal Criteria Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The Veteran’s service-connected depression is rated pursuant to DC 9434 which is governed by a General Rating Formula for Mental Disorders and provides for the following rating criteria: A 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and/or mild memory loss (such as forgetting names, directions, or recent events). 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. 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. 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. In the process of evaluating a mental disorder, VA is required to consider a number of pertinent factors, such as the frequency, severity, and duration of a veteran’s psychiatric symptoms. See 38 C.F.R. § 4.126. After consideration of these factors and based on all the evidence of record that bears on occupational and social impairment, VA must assign a disability rating that most closely reflects the level of social and occupational impairment a veteran is suffering. 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 solely on the basis of social impairment. 38 C.F.R. § 4.126(b). Ratings are assigned according to the manifestation of particular symptoms, but the use of a term “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 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, 442 (2002). Effective August 4, 2014, VA amended the portion of the Rating Schedule dealing with mental disorders and its adjudication regulations that define the term “psychosis” to remove outdated references to the DSM-IV and replace them with references to the updated Fifth Edition (DSM-5). See 79 Fed. Reg. 149, 45094. The provisions of the interim final rule apply to all applications for benefits that are received by VA or that were pending before the AOJ on or after August 4, 2014. Id. VA adopted as final, without change, the interim final rule and clarified that the provisions of this interim final rule do not apply to claims that have been certified for appeal to the Board or are pending before the Board as of August 4, 2014. See 80 Fed. Reg. 53, 14308 (March 19, 2015). In this case, the RO certified the Veteran’s appeal to the Board in May 2016; therefore, this provision applies to this claim. Factual Background By way of history, the Veteran submitted an initial claim for service connection for depression secondary to his service-connected right knee disability in February 1995 and, by rating decision dated in August 2006, the RO granted service connection for depression, not otherwise specified, also diagnosed as adjustment disorder, assigning a 30 percent disability rating effective February 3, 1995. The Veteran submitted the current claim for an increased rating for his depression in July 2008 and, by rating decision dated in November 2008, the RO continued the 30 percent disability rating previously assigned. The Veteran disagreed with this decision and perfected this appeal. Subsequently, by rating decision dated in November 2018, the RO increased the disability rating for depression from 30 to 70 percent disabling, effective November 28, 2017, the date of the most recent VA psychiatric examination. Evidence relevant to the level of severity of the Veteran’s depression includes VA examination reports dated in August 2008 and November 2017 as well as VA/private treatment records and statements from the Veteran. VA treatment records reflect that in January 2008 the Veteran had a dysphoric and angry mood ranging from moderate to severe, congruent affect that was heightened and reactive, normal speech, depressive and angry thought content, no suicidal or violent ideations, normal thought process, no perceptual abnormalities, normal cognition, and limited judgment. In March 2008, he continued to suffer from depression, including poor appetite, irritability at times, and low mood. He also described his mood as “so-so” and stated that he was unable to sleep at night. He had dysphoric mood, congruent affect, normal speech, depressive and angry thought content, no suicidal or violent ideation, normal thought process, no perceptual abnormalities, normal cognition, normal insight, and normal judgment. An April 2008 VA treatment record reflects that the Veteran slept well after taking Amitriptyline but that his sleep was poor when he did not take it. He was cooperative and pleasant; oriented to person, place, and time; and adequately groomed. He had appropriate affect/mood, goal-directed speech, intact memory, no hallucinations or delusions, normal thought process, no suicidal or homicidal ideation, and good impulse control. In July 2008, the Veteran reported depressed mood, feeling like an “empty shell,” not eating right, not sleeping well, spending his time at home, not trusting anyone, and having normal concentration. In August 2008, he had dysphoric mood, congruent affect that was heightened and reactive, and depressive thought content. In an August 2008 statement, the Veteran’s niece noted that the Veteran “could use a little help” as he was struggling the last few months with “deep depression,” had trouble eating and sleeping, had mood swings and lack of energy, and had a very hard time trusting people. In August 2008, the Veteran’s daughter stated that the Veteran was stressed out a lot and sleeping less. He sometimes had mood swings, and stayed up all night. He never had energy when he did sleep so he slept during the afternoon. The August 2008 VA psychiatric examination report reflects review of the Veteran’s claims file and the Veteran’s report of daily symptoms of depression that were continual and moderately high in severity. He did not have any impairment in thought process or communication, and had difficulty trusting others. The examiner stated that the symptoms of depression had a moderate effect on both employment and social functioning. On examination, the Veteran was appropriately dressed and groomed; pleasant and cooperative; and oriented to person, place, time, and purpose. He had spontaneous speech with normal rate, volume, and tone; no hallucinations or delusions; moderately depressed mood; affect that was appropriate to thought content and mood; no suicidal or homicidal ideation; logical, coherent, and goal-oriented thought processes; normal cognitive functions; no deficiencies in cognition or memory; mildly impaired concentration and attention; and adequate insight and judgment. He had a diagnosis of recurrent major depression without psychosis. The examiner found that the Veteran’s major depression had remained unchanged since the last examination, noting that the Veteran had been treated irregularly. VA treatment records reflect that in September 2008 the Veteran started swimming at a local pool, and his sleep cycle was becoming more normalized. He was cooperative and pleasant; oriented to person, place, and time; clean and adequately groomed; and attentive. He had appropriate and euthymic affect/mood, goal-directed speech, no memory deficits, no hallucinations or delusions, normal thought process, no suicidal or homicidal ideation, and good impulse control. In November 2008, the Veteran had dysphoric mood, congruent affect, and normal thought content that was depressive. A February 2009 VA treatment record reflects that the Veteran was not able to sleep through the night and was “very depressed” as his increased rating claim for depression was not approved. On examination, his appearance and consciousness/attentiveness were within normal limits. He had dysphoric and depressed mood, congruent affect, normal speech that was goal-directed, depressive thought content, no suicidal or violent ideation, normal thought process, no memory deficits, good impulse control, and no hallucinations or delusions. He was cooperative and pleasant; oriented to person, place, and time; and adequately groomed. In November 2009, the Veteran reported trouble sleeping at night and only got maybe two hours of sleep the night before. He was planning on going to visit relatives in New Jersey with his daughter for Thanksgiving. His appearance, consciousness/attentiveness, attitude, and activity/behavior were within normal limits. He had dysphoric mood, congruent affect that was constricted, normal thought content, normal insight, and normal judgment. An April 2010 VA treatment record reflects that the Veteran presented with pleasant manner and broad range of affect. He reported still not sleeping and being “very depressed” because he learned he could not go back to school and he was “just not happy.” He enjoyed spending time with his 18-year-old daughter who lived with him. He was cooperative; pleasant; attentive; oriented to person, place, and time; and clean and adequately groomed. His affect was appropriate to mood that was depressed; goal-directed speech; no memory deficits; no hallucinations or delusions; normal thought process; no suicidal or homicidal ideation; and good impulse control. He was diagnosed with depression not otherwise specified (NOS). In November 2010, the Veteran reported feeling “exhausted all the time,” not being able to sleep at night, and having bad dreams every once in a while. He could not get to sleep at night, but fell asleep around 5:00 or 6:00 a.m. and did not sleep during the daytime. On examination, his appearance, consciousness, attentiveness, attitude, and activity/behavior were within normal limits. He had an apathetic mood that was dysphoric; congruent mood that was blunted, constrictive, partial, and under-reactive; normal speech; fatigue; no perceptual abnormalities; normal insight; and normal judgment. An April 5, 2011 private emergency record reflects an intentional drug overdose and suicidal thoughts. The Veteran noted prior thoughts of suicide “for a few years,” and increased arguments with his daughter. He was depressed and frustrated, and had a past history of depression. He was oriented to person, place, and time and had flat affect and a depressed mood. A separate treatment record reflects that the Veteran was very frustrated and had been having suicidal thoughts for a few weeks. He took about eight Percocet pills in an attempt to kill himself and was planning on taking more when his friend’s daughter saw him and took the pills away. This was his first attempt, and he stated that he was not currently suicidal although he felt very depressed. He carried a diagnosis of posttraumatic stress disorder (PTSD), depression, and a sleep disorder. He was alert and cooperative; future-oriented; and oriented to person, place, and date. He had normal speech, logical thought processes, no thought disorder, slightly sad mood, no suicidal or homicidal thoughts, no delusions or hallucinations, intact attention and concentration, intact recent and remote memories, good insight, and intact judgment. He expressed regrets about the overdose. He was diagnosed with adjustment disorder with depressed mood with a prior diagnosis of PTSD. VA treatment records reflect that in May 2011, the Veteran reported being “so exhausted” because he could not sleep. He also experienced recurrent vivid nightmares of an in-service assault with hyperstartle and intrusive memories of the event, and was reminded of the assault whenever he was around groups of people. He reported social withdrawal and isolation, flashbacks during the evenings, restlessness, sleeplessness, hyper-alert, hyperarousal, and trouble sustaining mental focus and reading. On examination, his appearance, consciousness/attentiveness, and activity/behavior were all within normal limits although he was frustrated with the VA system. He had apprehensive mood, difficulty sleeping at night, congruent affect that was blunted, normal speech, anxious and depressive thought content, no suicidal or violent ideations, normal thought process, no perceptual abnormalities, normal cognition, normal insight, and normal judgment. A subsequent treatment record reflects that the Veteran wanted to start walking around his apartment complex, watch a cooking show, and pick a day each month to go to the movies or out to dinner; he was also reading more. He was fatigued and frustrated with medication that did not seem to help reduce his symptoms of depression. He had dysphoric mood, congruent affect that was heightened, and depressive thought content. In June 2011, the Veteran reported that he continued to sleep poorly with middle insomnia of one to two hours. He had been more active, walking every day, and recently enjoyed attending a family reunion in North Carolina. He was cooperative; pleasant; oriented to person, place, and time; clean; and adequately groomed. He had affect appropriate to mood which was mildly to moderately depressed, goal-directed speech, no deficits in memory, no hallucinations or delusions, and good impulse control. He was diagnosed with depression NOS. In July 2011, the Veteran stated that, ever since his suicide attempt, he thought about it every day although he would never attempt it again. He had apprehensive mood as he was concerned about being rejected for increased benefits, congruent affect that was heightened, and anxious and depressive thought content with insomnia and nightmares. An August 2011 treatment record reflects apprehensive mood and anxious thought content with nightmares related to service. In August 2011, the Veteran’s daughter and niece submitted letters in which they noted the Veteran’s suicide attempt in April 2011 and an increase in his major depression and bad sleeping habits. They stated that he could not take the prescribed medication due to his diabetes. A September 2011 VA treatment record reflects that the Veteran reported that he continued to not sleep well, although the music he was given helped him to sufficiently relax and fall asleep. He did not have any suicidal ideation and had not had any for the past several months. He stated that, after his suicide attempt earlier that year, he would never try to kill himself again. On examination, his appearance, consciousness/attentiveness, attitude, and activity/behavior were all within normal limits. He had dysphoric mood, congruent affect, normal speech, normal thought content, insomnia, no suicidal or violent ideations, normal thought process, no perceptual abnormalities, normal cognition, normal insight, and normal judgment. A March 2012 VA treatment record reflects that his appearance, consciousness/attentiveness, attitude, and activity/behavior all within normal limits. He had apprehensive mood, congruent affect that was heighted and full, normal speech, anxious thought content, inability to sleep at night, no suicidal or violent ideations, normal thought process, no perceptual abnormalities, normal cognition, normal insight, and normal judgment. In April 2012, the Veteran reported low mood, poor self-esteem, feeling like a failure, anhedonia, and low energy. The Veteran noted how his self-harm attempt last year was “stupid.” He stated he lived an isolated life with no regular activities. He avoided socializing and had difficulty sleeping. He had a good relationship with his daughter, and had been reading some novels and a self-help book. On examination, he had full affect and spontaneous speech with normal rate and rhythm without a thought disorder. The Veteran was neatly dressed and well-groomed. His DSM-IV diagnoses were moderate recurrent MDD and insomnia. In June 2012, the Veteran noted that he had been going on online dating sites and expressed that it would “be nice to have someone in his life.” He expressed an interest in getting into some kind of physical activity, such as fencing. A July 2012 VA treatment record reflects that the Veteran took the BDI-2 and got a score of 30, which fell within the severe range of depression. His severe symptoms included crying and fatigue; moderate symptoms included past failure, loss of pleasure, self-dislike, indecisiveness, loss of energy, and difficulty concentrating; and mild symptoms included sadness, pessimism, guilty feelings, punishment feelings, self-criticalness, agitation, loss of interest, worthlessness, changes in sleeping pattern (less), irritability, changes in appetite (more), and loss of interest in sex. The Veteran stated that he was not suicidal. VA treatment records reflect that in January 2013, the Veteran had a normal appearance with poor eye contact and normal attitude and activity/behavior. He had apprehensive and dysphoric mood, congruent and blunted affect that was constricted, normal speech, depressive thought content, no suicidal or violent ideations, normal thought process, no perceptual abnormalities, normal cognition, normal insight, and normal judgment. An April 2013 VA treatment record reflects that the Veteran socialized with young veterans who lived in his building complex frequently, especially two of them. He was invited by one for a cookout a few days ago. He stated that he enjoyed their company, and that they expressed their appreciation for his service. His daughter continued to live with him. In October 2013, the Veteran reported not sleeping well and continuing to feel depressed. He had a couple of friends take him fishing, boat-riding, and camping, which he enjoyed. He was diagnosed with moderate recurrent major depressive disorder (MDD), dysthymic disorder, and primary insomnia. VA treatment records reflect that in December 2014, the Veteran was diagnosed with moderate recurrent MDD, persistent depressive disorder, and primary insomnia. On examination, his appearance, consciousness/attentiveness, attitude, and activity/behavior were all within normal limits. He had euthymic and apprehensive mood, congruent affect, normal speech, normal thought content, no suicidal ideations, normal thought process, no perceptual abnormalities, normal cognition, normal insight, and normal judgment. An April 2015 VA treatment record notes that the Veteran’s mother had recently passed away, resulting in discord among his family members. He was attending a literacy program to improve his reading skills and was due to take a literacy examination. He had dysphoric mood and depressive and angry thought content. In August 2015, the Veteran reported being more socially active than when he first began treatment. He socialized with his neighbors, some of whom were active duty military, on a regular basis. He also had trouble sleeping, but had been able to sleep a little better. VA treatment records reflect that in April 2016, he had just returned from Tennessee where he helped relocate a friend who was just separated from service and whom he was mentoring. In December 2016, he stated that he lived with his daughter, who worked for the airlines. He also recently found out that he had a younger sister who lived in California, whom he had visited and was planning on visiting again for Christmas. He reported being close to a neighbor and his family. On examination, he had mood that was “on and off” and mild depression. He was diagnosed with moderate recurrent MDD and persistent depressive disorder. A February 2017 VA treatment record reflects the Veteran’s report of chronic fatigue, low energy, and increased hunger/thirst particularly when he was in a depressive mood. He had some improvement in mood since his last appointment. In March 2017, he reported that he was going through a bout of depression and that he did not feel like taking his medications when he was depressed. August 2017 treatment records reflect the Veteran’s report of difficulty his whole life trusting people and being around people, and frustration with his physical limitations resulting from being assaulted years ago during service. He did some resistance exercise once a week and minimal walking. He had appropriate appearance and behavior, appropriate but sad affect, depressed mood, normal thought process, appropriate thought content, and no suicidal ideation or intent. He also reported living with a lady whom he was helping find a job and access medical treatment. He socialized with his neighbors, who had all cooked dinner together the night before. He was reading a lot more and was trying to open up and be around people despite his distrust of others. His mood was moderately dysphoric. The November 2017 VA psychiatric examination report reflects a diagnosis of moderate MDD with anxious distress causing moderate to serious difficulty in social and emotional functioning although he had some meaningful interpersonal relationships. His psychiatric disability resulted in occupational and social impairment with reduced reliability and productivity. The Veteran reported that he was not in a relationship and had difficulties in past relationships related to “trust.” He had a good relationship with his 27-year-old daughter, whom he raised alone. He had no relationship with any of his sisters and last spoke to them in 2013. He had three friends and liked to read and exercise for fun/leisure. He reported a depressed mood most of the day with episodes which occurred every two months and lasted two to three weeks. He was withdrawn and isolated himself from others. He reported a lack of motivation and interest; fatigue; irritability; crying spells; feelings of hopelessness, helplessness, and worthlessness; decreased sexual interest and performance; decreased appetite; lethargy; difficulties concentrating and focusing; restlessness; difficulty relaxing; and suspiciousness. He did not like crowds or people. He was short-tempered and got easily frustrated with little provocation. He reported getting six hours of sleep with no nightmares. He denied suicidal and homicidal ideations, panic attacks, and hallucinations. His symptoms included depressed mood; anxiety; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; mild memory loss such as forgetting names, directions, or recent events; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty adapting to stressful circumstances, including work or a work-like setting. His overall attire and grooming were appropriate and clean with no signs of self-neglect. He was alert and oriented to person, place, and time. He was cooperative, his speech was normal, and his affect was appropriate to content. The examiner noted that the diagnosis had progressed and changed to MDD with anxious distress, which met the criteria under DSM-5. VA treatment records reflect that in December 2018 the Veteran reported that he was only able to sleep for about 45 minutes at night because of stress. His appearance, attentiveness, attitude, and behavior were within normal limits. His mood was moderately dysphoric. He had congruent affect with intensity, mobility, range, and reactivity all within normal limits. His speech was within normal limits with depressive thought content. His insight, judgment, and motivation were within normal limits. A February 2019 VA treatment record reflects the Veteran’s report of anhedonia with no suicidal or homicidal ideations. He was cooperative, pleasant, and interactive. He had appropriate and relaxed mood and affect, a thought process within normal limits, goal-directed and organized speech, and a clean and well-groomed appearance. In July 2019, the Veteran reported not trusting others and not wanting to “deal with people” again. He had a lot of negative intrusive thoughts about “kids” dying in wars and feeling like the world was destroying itself, and being “triggered” by people harming or killing others such that he had to stop watching the news. He had an interest in electronics despite not having an avenue to engage in this interest. He had trouble falling and staying asleep, sometimes nightmares about the in-service assault, some irritability concerns when “triggered” by others, low energy, survivor’s guilt about almost going to Vietnam and about others who had to die, and concentration issues which he attributed to a lack of sleep. He was appropriately dressed with excellent grooming. He appeared to be alert and oriented to person, time, place, and situation. He had intact memory; fluent and spontaneous speech; linear, coherent, relevant thought process that was able to be followed; slightly depressed mood; restricted affect congruent to mood and circumstance; and intact judgment. He lived alone for the most part, although his daughter stayed with him when she was not working as a flight attendant. He had one close friend who relocated to Louisiana, and siblings with whom he was not close. A September 2019 VA treatment record reflects the Veteran’s plans to move to California after learning that he had a “baby sister who lived out there,” but then he “started picking up on red flags” so he decided not to move. He reported that this experience exacerbated symptoms of depression, anxiety, and distrust of others. Taking care of responsibilities became a challenge, and he recognized that watching the news was a trigger. He reported that his distrust of others led to further isolation and avoidance. He always felt like an outcast. He wanted to go back to school, learn how to use a computer, and get physically fit; and was interested in dating. He was oriented to person, place, and time. He had appropriate appearance and behavior, appropriate affect, normal mood, normal thought process, appropriate thought content, and no suicidal or homicidal ideation or intent. An October 2019 VA treatment record reflects his strengths to include having supportive family and/or friends and good hygiene. The Veteran complained of low mood, sleep disturbance, racing thoughts, difficulty focusing, and loss of appetite. He valued his relationship with his daughter, who was supportive of him. He was interested in obtaining his GED, learning how to use a computer, utilizing coping skills for depression, finding resources in his community that would improve his physical health, and in swimming and martial arts. In November 2019, he noted that he was working on building relationships in his life. He was extremely angry, hyperverbal, rambling, and perseverative about VA and how he had been treated. He reported that he had always been a worrier, but denied panic attacks. He also denied any auditory and visual hallucinations and paranoia. He enjoyed watching Bruce Lee movies, shadow-boxing, learning about martial arts, and playing dominoes and spades with his family. He had “depressed” mood; full and appropriate affect; normal rate, rhythm, and volume of speech; appropriate thought process; no delusions; no suicidal or homicidal ideation; fair insight; and fair judgment. He was found to have symptoms of chronic depression with no psychotic symptoms or suicidal ideation. He was assessed with depression with difficulty sorting out how much was moderate recurrent major depression vs. chronic dysthymia/chronic personality issues vs. adjustments to very real life problems/setbacks vs. PTSD spectrum symptoms from a lot of the difficult life events he had been through. A subsequent treatment record reflects the Veteran’s plans to go to his daughter’s friend’s house for Thanksgiving and his frustration with his sister who he believed should be “more understanding” and know his triggers. These thoughts often led him to feel angry and frustrated, leading him to keep his distance. December 2019 treatment records reflect that the Veteran participated in a holiday party and engaged in conversations with peers and staff, and a diagnosis of moderate recurrent MDD. A January 2020 VA treatment record reflects the Veteran’s report of low interest, appetite distress, sleep disturbance, concentration issues, low energy, some irritability, feelings of guilt or worthlessness, and some indecisiveness. He often felt overwhelmed by the news of violence in the world, and felt depressed or anxious about “the state of humans.” He denied any auditory or visual hallucinations, and any current suicidal or homicidal ideation. The Veteran attributed improvement in mood with engaging in activities in his community. He had been attending a computer literacy class, which he found to be helpful and enjoyable. He noticed that he was better able to trust others, although he still tended to quickly disengage from relationships when things got difficult. March 2020 group session notes reflect appropriate attitude and linear and goal-oriented thoughts. In March 2020, the Veteran reported that he had been out of town for a while at his niece’s house in Pennsylvania and that he was staying connected with family members by phone. His mood was good, and he had no other concerns. He was oriented to person, place, and time. He had appropriate but sad affect, normal mood, normal thought process, appropriate thought content, and no suicidal or homicidal ideation or intent. In April 2020, he stated that he was staying busy while in his home and that he continued to speak with some of his family members, although he noted that others should also reach out to him. He hoped to visit his niece in Pennsylvania again soon. He was happy with walking around his complex. He was oriented to person, place, and time. In May 2020, the Veteran was staying at a family member’s house in Virginia after being picked up by them. He felt supported by his family and reported that his mood was good. A June 2020 VA treatment record reflects that he was doing well and was planning on going to his niece’s house in Pennsylvania for the Fourth of July and then to his cousin’s house in Virginia. In July 2020, he reported sleeping more than usual and that his mood had been positive, which he attributed to limiting his exposure to the news, caring for his plants, and staying connected with family members. Analysis Upon review of the above evidence, the Board finds that the criteria for a 70 percent disability rating are met beginning April 5, 2011, the date of the Veteran’s suicide attempt. Notably, in Bankhead v. Shulkin, 29 Vet. App. 10, 19 (2017), the Court of Appeals of Veterans’ Claims (Court) noted that suicidal ideation is a serious symptom and that the presence of suicidal ideation alone might cause occupational and social impairment with deficiencies in most areas. With regard to the period of time prior to April 5, 2011, the Board finds that a disability rating of 50 percent, but no higher, is warranted for the Veteran’s depression. In other words, his symptoms prior to April 5, 2011, resulted in occupational and social impairment with reduced reliability and productivity. Prior to April 5, 2011, the evidence reflects that the Veteran was consistently found to have a diagnosis of recurrent moderate MDD. Additionally, his affect was described as congruent, heightened, and reactive, but also as constricted in November 2009 and blunted, constrictive, partial, and under-reactive in November 2010. He was also found to have limited judgment in January 2008, although he was found to have normal judgment otherwise. Furthermore, the evidence reflects disturbances of motivation and mood as he was found to have dysphoric and angry mood in January 2008, low mood in March 2008, continual and moderately high symptoms of depression in August 2008, and apathetic mood that was dysphoric and congruent in November 2010. His niece and daughter also noted mood swings and lack of energy in their August 2008 statements. Moreover, although the evidence reflects that he socialized with neighbors and friends who took him fishing and camping and helped friends find a job and relocate, he also consistently reported having difficulty trusting and being around people, which resulted in social isolation and withdrawal. Therefore, the evidence demonstrates that he had difficulty establishing and maintaining social relationships, although he was making attempts and progress in doing so. As such, the Board concludes that a disability rating of 50 percent, but no higher, is warranted from July 2008 (the date of the Veteran’s claim for an increased rating) to April 4, 2011. As for the potential for an even higher rating than 70 percent beginning April 5, 2011, a preponderance of the evidence shows that the Veteran does not meet the criteria for a 100 percent disability rating as he does not exhibit total occupational and social impairment. In fact, the November 2017 VA examiner found that the Veteran’s acquired psychiatric disability caused moderate to serious difficulty in social and emotional functioning although he had some meaningful interpersonal relationships, and resulted in occupational and social impairment with reduced reliability and productivity. Additionally, although the Veteran had difficulty trusting people, was withdrawn from others, and had no relationship with his sisters, he had three friends, had a good relationship with his adult daughter, reported an interest in dating, and expressed working on building relationships in his life. The evidence reflects that he had plans to go to his daughter’s friend’s house for Thanksgiving in November 2019, attended a holiday party and engaged in conversations with peers and staff in December 2019, visited his niece in Pennsylvania and stayed connected with family members by phone in March 2020, visited a family member in Virginia in May 2020, and planned on visiting family for the Fourth of July in June 2020. He also was interested in swimming, martial arts, obtaining his GED, learning how to use a computer, and electronics; and enjoyed reading, exercising, watching Bruce Lee movies, shadow-boxing, fishing, cooking, taking care of his plants, working on model airplanes, and playing dominoes and spades with family. Additionally, he was consistently found to have normal thought process with appropriate thought content, no homicidal or violent ideation, good hygiene, and intact memory. He also denied having any delusions or hallucinations, and was consistently oriented to time and place. The evidence also does not demonstrate grossly inappropriate behavior or any intermittent inability to perform activities of daily living. The Board acknowledges the Veteran’s contention in his September 2020 brief that a remand was required for a VA examination as the most recent VA examination was in November 2017. However, the Board does not find that a remand for a new VA examination is required as the Veteran has continued to receive treatment, which is reflected in VA treatment records associated in the claims file. This evidence does not support or indicate any worsening in the Veteran’s acquired psychiatric disability to the point that it results in total social and occupational impairment. Accordingly, the Board finds that the evidence does not support a disability rating in excess of 70 percent for an acquired psychiatric disability as of April 5, 2011. As the preponderance of the evidence is against this claim, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7. The Board notes that the Veteran’s psychiatric symptoms may not have manifested or reached such severity as to meet the rating criteria for a 70 percent rating exactly on April 5, 2011. However, the April 5, 2011 private treatment record is the earlier record that demonstrates symptoms resulting in occupational and social impairment with deficiencies in most areas, including suicidal ideation. Therefore, the Board finds that the Veteran’s depression more closely approximates the criteria for a 70 percent rating as of April 5, 2011. April Maddox Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Lee, 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.