Citation Nr: 21062222 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 17-31 653 DATE: October 6, 2021 ORDER Entitlement to an increased rating for major depressive disorder (MDD), currently rated at 50 percent prior to October 18, 2019, and 70 percent from October 18, 2019, is granted to 70 percent, but no higher, effective October 11, 2016, but no earlier; the appeal is otherwise denied. FINDINGS OF FACT 1. From February 19, 2016, to October 10, 2016, the Veteran's MDD has consistently manifested in symptoms suggesting occupational and social impairment with reduced reliability and productivity, but has not resulted in 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; spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances; or an inability to establish and maintain effective relationships suggesting occupational and social impairment with deficiencies in most areas and there was not a factually ascertainable increase in severity in the year prior to receipt of the Veteran's increased rating claim. 2. From October 11, 2016, the Veteran's MDD has consistently manifested in symptoms suggesting occupational and social impairment deficiencies in most areas, but has not resulted in gross impairment of thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss for names, close relatives, own occupation, or own name suggesting total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 50 percent from February 19, 2016, to October 10, 2016, for MDD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9434. 2. From October 11, 2016, but no earlier, the criteria for entitlement to an increased rating of 70 percent, but no higher, for MDD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, DC 9434. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1972 to March 1975. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2016 rating decision issued by the Department of Veterans' Affairs (VA) Regional Office (RO). The Board previously remanded this claim in a February 2019 decision for additional development. The Board finds substantial compliance with the February 2019 remand directives has been met. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board also remanded an inferred claim for a total disability rating based on individual unemployability (TDIU) due to service-connected MDD for additional development as part of the February 2019 decision. Following the additionally directed development, the RO issued a September 2020 rating decision granting TDIU effective July 9, 2015, the date of the Veteran's intent to file a claim. To date, the record lacks any contentions related to the effective date assigned for TDIU. The RO's award of TDIU from July 9, 2015, constitutes a full grant of the benefit sought; thus, this issue is no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). Accordingly, TDIU will not be addressed herein. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). 1. Entitlement to an increased rating for major depressive disorder (MDD), currently rated at 50 percent prior to October 18, 2019, and 70 percent from October 18, 2019, is granted to 70 percent, but no higher, effective October 11, 2016, but no earlier; the appeal is otherwise denied. The Veteran contends his MDD symptoms warrant a higher rating during the period on appeal. The Veteran is currently service connected for major depressive disorder (previously rated as depression) associated with ingrown toenail left big toe (also claimed as foot injury) with a 30 percent rating from March 25, 2008; 50 percent from July 21, 2014; and 70 percent from October 18, 2019, under DC 9434. As will be outlined below, the Board finds a 70 percent disability rating is warranted from October 11, 2016, but no earlier, and no higher. The Board finds this claim stems from a February 19, 2016, increased rating claim. The claim was initially denied in a March 2016 rating decision and, the Veteran again sought an increased rating in June 2016. The RO, once again, continued the denial of the claim in a September 2016 rating decision, pursuant to 38 C.F.R. § 3.156(b), and the Veteran perfected his appeal to the Board thereafter. As such, the Board will consider the severity of the Veteran's MDD from the date of receipt of the claim, February 19, 2016, or up to one year prior to VA's receipt of the claim, to the extent an increase in severity is factually ascertainable. See 38 C.F.R. § 3.400(o)(2). 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. 38 C.F.R. § 4.1. 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. Mental health disorders are evaluated under the General Rating Formula for Mental Disorders, a specific rating formula presented under 38 C.F.R. § 4.130. In addition, the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM-5) provides guidance for the nomenclature employed within 38 C.F.R. § 4.130. Under the General Formula for Mental Disorders, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). 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. 38 C.F.R. § 4.7. The basis of disability evaluations 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. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause 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 normal conversation). A 50 percent rating is assigned when symptoms such 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; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. 38 C.F.R. § 4.130, DC 9411. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 38 C.F.R. § 4.130, DC 9411. A 100 percent rating is assigned 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; or memory loss for names of close relatives, own occupation or own name. 38 C.F.R. § 4.130, DC 9411. Turning to the relevant evidence of record, in 2015 the Veteran reported his symptoms of depression included low mood, low interest, and low energy over "the last several years." See September 2015 VA treatment records. He reported some marital conflict related to his depression. He was noted to live with his wife. The Veteran denied any suicidal ideation or homicidal ideation. The provider found the Veteran to be fully oriented with speech within normal limits. Judgment and insight were noted as adequate. Thought process was coherent and goal oriented. The provider found no evidence of a thought disorder or hallucinations / delusions. In 2016, the Veteran denied thoughts of harming himself or others and denied currently hearing or seeing things that others do not. See February 2016 VA treatment records. He reported having a longstanding history of depression that is "worsening." The Veteran noted that his wife also thought his symptoms were "worsening." He endorsed low and sad mood, getting tearful, anhedonia, and low motivation and energy. He denied suicidal or homicidal ideation, psychotic symptoms, or manic symptoms. The Veteran was noted to be married with a supportive spouse. He was fairly groomed and nourished. The provider indicated the Veteran was alert and oriented without auditory or visual hallucinations or delusions. Later in 2016, the Veteran endorsed depressed mood, low motivation, lack of concentration, poor sleep, poor appetite, and loss of interest in activities he used to enjoy. See May 2016 VA treatment records. He denied anxiety or panic attacks. He continued to deny suicidal ideation, homicidal ideation, hallucinations, or delusions. He continued to be assessed as alert and oriented. In June 2016, he stated that he experiences regular anxiety, but it is constant for him so he "is used to it." See June 2016 VA treatment records. In June and July 2016, the Veteran again reported experiencing an increase in depression. See June 2016 and July 2016 VA treatment records. He endorsed low mood daily, loss of interest in things / activities, low motivation, eating more, sleep problems, decreased concentration, and short-term memory changes. He reported attending his grandchildren's sport events and activities. He remained married. He reported having support from children and his spouse. He denied experiencing suicidal ideation, homicidal ideation, hallucinations, or delusions. The provider found the Veteran was appropriately dressed and groomed. In August 2016, the Veteran continued to report a lack of energy, anhedonia, lack of motivation, difficulty concentrating, and poor sleep. See August 2016 VA treatment records. He reported problems in his marriage. He endorsed waking from dreams sweating and feeling "scatter brained." He denied suicidal ideation, homicidal ideation, hallucinations, and delusions. The provider noted appropriate dress and hygiene. In September, the Veteran denied having suicidal ideation, homicidal ideations, symptoms of depression, symptoms of psychosis, and anxiety. See September 2016 VA treatment records. In October 2016, the Veteran was admitted for suicidal and homicidal ideations for three days. See October 2016 VA treatment records. Upon admission, the Veteran was noted to have a history of cocaine abuse and depression. See October 2016 VA treatment records. The Veteran asked his daughter to take him to the VA because he was having suicidal and homicidal thoughts. He denied having a plan. The Veteran's daughter stated that he had been using drugs that week and was paranoid evidenced by false accusations against the family and thoughts that everyone is against him. The Veteran noted that he had recently experienced a breakup with his wife three weeks ago and medication non-compliance. See October 2016 VA treatment records. During the past three weeks, the Veteran endorsed difficulty sleeping, problems concentrating, low energy, and anhedonia. He reported that a few days ago, thoughts of not wanting to be alive anymore "popped" into his head. He declined experiencing a plan stating that it was passive suicidal ideation. He reported that his homicidal ideation was simply not wanting anyone to bother or interfere with his life but denied any specific plans to any specific people. He endorsed a "few day" history of cocaine abuse during which he explained he was "self-medicating." He had a negative mania screen denying any current or previous auditory or visual hallucinations. On the second day of admission, he denied any suicidal or homicidal ideation. The provider found the Veteran was alert and oriented with linear and goal-oriented thought process. Discharge notes reflect the Veteran was admitted for depressive symptoms and passive suicidal ideation in the context of recent separation from wife and cocaine use. Throughout admission, a provider noted that he reported problems with depression but "tended to not talk about cocaine use." At discharge, the Veteran declined experiencing suicidal ideation or homicidal ideation. In the days following discharge, the Veteran continued to deny experiencing suicidal or homicidal ideation. In December 2016, the Veteran was noted to be well dressed and groomed. See December 2016 VA treatment records. He complained of depression as a "major concern" at the time. He reported symptoms of not being interested in life, no motivation, appetite fluctuations, sadness, and isolating more than normal. The Veteran declined having any addiction or dependency issues with substances endorsing using cocaine three times a month sporadically. He denied suicidal or homicidal ideation and auditory or visual hallucinations. He endorsed exercising. In 2017, the Veteran reported that his depression has been "up and down." See January 2017 VA treatment records. He endorsed spending time with his children over the holidays. He said he was sleeping more. In January and April 2017, he declined experiencing suicidal or homicidal ideation and auditory or visual hallucinations. See January and April 2017 VA treatment records. In August 2017, he reported that his mood "has not been good lately" and people have been "making him angry." See August 2017 VA treatment records. He endorsed sleeping more than he is awake. He endorsed chronic passive suicidal thoughts but denied an intent or plan. He reported that he does not have or want any friends. Upon examination, the provider noted that the Veteran does not think about suicide seriously and has many reasons for living. He declined ever making and plan. He was alert and oriented with appropriate dress and grooming. In November 2017, the Veteran reported staying home, eating, and sleeping. See November 2017 VA treatment records. He declined going out or doing anything. He stated that his mood has been "very down." The Veteran endorsed passive suicidal thoughts without intent or plan. He reported experiencing "a lot of trouble" with anger and irritability. The provider noted he was alert and oriented with appropriate dress and grooming. He had normal speech with logical and coherent thought process. In January 2018, the Veteran stated that he feels like "anger outburst, punch everything." See January 2018 VA treatment records. He was noted to "look" irritable and angry. He reported poor sleep. During the interview, the provider noted the Veteran was angry and irritable throughout. He reported hearing screams, or his name being mentioned, while asleep, waking startled. He declined having hobbies or enjoying people. He experienced low energy and stays in his apartment. He declined experiencing suicidal or homicidal ideation and denied auditory or visual hallucinations. The provider found the Veteran was alert and oriented with appropriate dress. He was uncooperative during the interview and had slow speech. His thought process was linear with appropriate content. In March 2018, the Veteran continued to report being isolated in his apartment alone. See March 2018 VA treatment records. He endorsed anhedonia, low mood, and difficulty with concentration. He reported having thoughts of not wanting to live or sometimes feeling like "what is the point of being here" and hopelessness. He denied current suicidal or homicidal ideation and auditory or visual hallucinations. The provider found the Veteran was alert and oriented with appropriate dress and grooming. He had coherent thought process with appropriate content. In April, the Veteran attended an anger management class. See April 2018 VA treatment records. In August 2018, the Veteran reported being tired "all of the time" and being not motivated. See August 2018 VA treatment records. He closed his eyes throughout the interview and put his head on the provider's desk. He endorsed low mood with low energy, low motivation, isolation, tiredness, and anhedonia. He denied experiencing any anxiety, nightmares, suicidal or homicidal ideation, or auditory or visual hallucinations. He was casually dressed and exhibited coherent thought process. He was alert and oriented and able to recall current events. In 2019, the Veteran continued to endorse low mood, low energy, low motivation, isolation, problems concentrating, increased appetite, sleep disturbance, and feeling overwhelmed by tasks / chores. See April 2019 VA treatment records. He reported trying to leave the house more and exercise more. He denied anxiety, suicidal or homicidal ideation, and auditory or visual hallucinations. He was alert and oriented with an ability to recall current events. In November 2019, the Veteran declined suicidal or homicidal ideation. See November 2019 VA treatment records. In December, he reported difficulty sleeping due to nightmares. See December 2019 VA treatment records. In 2020, the Veteran reported that he sleeps, eats, and watches television but does not feel like doing anything else. See January 2020 VA treatment records. He endorsed going on the porch "once in a while." He does walk to the mailbox. The Veteran denied suicidal ideation stating that he has had some thoughts but does not have a plan stating that he wants to be there for his wife and grandchildren. He endorsed depressed mood, anhedonia, low energy, poor focus, poor concentration, and lack of motivation. He denied suicidal or homicidal ideation and auditory or visual hallucinations throughout 2020. In April, he reported feeling down with everything that has been happening and increased anxiety in light of coronavirus. In September, the Veteran endorsed poor sleep, poor energy, low motivation, anhedonia, irritability, and variable concentration. See September 2020 VA treatment records. He endorsed daily anxiety with racing thoughts and panic attacks but did not know the frequency. He was alert and oriented. The Veteran has been afforded multiple VA examinations during the period on appeal to determine the severity of his service-connected MDD, the first of which occurred in March 2016. The examiner opined that the Veteran's MDD symptoms were productive of occupational and social impairment with reduced reliability and productivity. See March 2016 VA examination. Symptoms were noted to include depressed mood, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, and disturbances of motivation and mood. Other symptoms were noted to include irritability, chronic fatigue, anhedonia, and loss of libido. The examiner found the Veteran capable of managing financial affairs. During the examination, the Veteran reported sleeping most of the day and at night so that he does not "feel anything." He reported being married for almost forty years describing the relationships as "good to excellent." He conveyed keeping in contact with his three adult children. During a September 2016 VA examination, the examiner opined the Veteran's MDD was productive of occupational and social impairment with reduced reliability and productivity. Symptoms were noted to include depressed mood, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, and disturbances of motivation and mood. The Veteran endorsed also experiencing poor energy and difficulty concentrating. He conveyed continued contact with his adult children, seeing them regularly. The Veteran reported completing chores around the house including mowing the lawn, dishes, and laundry. He endorsed mild-to-moderate problems completing tasks around the house citing struggles with motivation. He said free time is spent watching television, playing games, and browsing the internet. He did report attending religious services and going to his grandchildren's activities. The Veteran reported that he used to volunteer and coach his children's sports, but he does not have the desire for that anymore. The Veteran said that there is no consistency in his mood and that it is "up and down." When his mood is low, he becomes more easily irritable and withdraws from people. Most recently in October 2019, a VA examiner opined the Veteran's MDD symptoms are productive of occupational and social impairment with reduced reliability and productivity. See October 2019 VA examination. Symptoms were noted to include depressed mood, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The examiner also noted symptoms of anhedonia, decreased concentration, and recurrent thoughts of death. The examiner found that the Veteran's MDD "significantly impairs" his concentration, ability to establish and maintain relationships at work and in social situations, and his motivation to participate in either social or work activities. His depressed mood and anhedonia underlie all of these impairments. Together, the symptoms cause reduced reliability and productivity in both social and employment environments. The Veteran reported vacuuming his apartment, washing his own clothes, and washing the dishes when they are dirty. He denied participating in fun or enjoyable activities. He reported staying at home, sleeping, eating, and watching television. He declined having friends and expressed not wanting to because his idea of friendship is different. He reported talking to his brothers and sisters. From February 19, 2016, to October 10, 2016 Upon review of the totality of the record, from February 19, 2016, to October 10, 2016, the Board finds a rating in excess of 50 percent for MDD is not warranted. The evidence shows that the Veteran's MDD symptoms caused occupational and social impairment with reduced reliability and productivity due to such symptoms as: impairment of short-term memory, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Board finds highly probative the March and September 2016 VA examinations during this period reflecting that the Veteran's symptoms were productive of occupational and social impairment with reduced reliability and productivity. The examiners noted symptoms including depressed mood, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, and disturbances of motivation and mood while the Veteran also endorsed symptoms that are not listed with a specific rating, such as anhedonia, low energy and difficulty concentrating, and feeling like his brain was scattered. While the Veteran reported having a good relationship with his wife, children, and grandchild, he did not report having friends. The Board finds the Veteran's symptoms more nearly approximate a 50 percent rating as currently assigned from February 19, 2016, to October 10, 2016. The Board finds that the Veteran's disability is fully capable of evaluation under the rating schedule during this period. In so finding, the Board also concludes that the Veteran's symptoms during this period did not cause the level of impairment required for a disability rating of 70 percent or higher. There has been no suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships of the severity contemplated by a 70 percent rating. Indeed, during this period the Veteran has consistently and credibly declined experiencing suicidal ideation or homicidal ideation. He also declined experiencing panic attacks. Impaired impulse control was not indicated through the VA examinations or referenced in the corresponding treatment records. Further, during the relevant VA examinations and various assessments in the medical records, the Veteran was noted to be appropriately dressed and groomed during this period and oriented. The Veteran himself endorsed completing household chores including mowing the lawn, laundry, and dishes albeit expressing difficulty at times to be motivated. While the Veteran expressed not wanting to have friends, he did maintain relationships with his children, grandchildren, and wife during this time. Thus, the Board finds the Veteran's symptoms during this period are appropriately rated as 50 percent disabling. The Board notes the Veteran consistently reported experiencing worsening MDD symptoms in February 2016, June 2016, and July 2016. Even considering the Veteran's subjective reports of symptom worsening, the Board finds the evidence of record during this period more nearly approximates the 50 percent disability rating criteria. The Board has considered whether there was a factually ascertainable increase in symptom severity prior to February 19, 2016, but notes the Veteran was already in receipt of a 50 percent disability rating in the year prior to his increased rating claim. Based on the aforementioned, the Board finds the preponderance of the evidence weighs against finding that the severity, frequency, and duration of the Veteran's MDD symptoms resulted in the level of impairment required for a 70 percent rating. Consequently, a rating in excess of 50 percent for the Veteran's service-connected MDD is not warranted from February 19, 2016, to October 10, 2016. From October 11, 2016 Upon review of the totality of the record from October 11, 2016, the evidence is at least in equipoise as to whether the Veteran's MDD manifested in symptoms largely supported by the 70 percent criteria. While all of the VA examinations of record have found that the Veteran's MDD symptoms are productive of occupational and social impairment with reduced reliability and productivity, the Veteran's treatment records during this time reflect symptom severity more nearly approximating that contemplated by the 70 percent rating criteria. In this case, the Board took special attention regarding suicidal ideation pursuant to Bankhead, 29 Vet. App. at 22. Prior to October 11, 2016, the Veteran declined experiencing suicidal or homicidal ideation. On October 11, 2016, however, the Veteran was admitted for three days due to suicidal ideation and homicidal ideation. During the entire period on appeal, this was the first time the Veteran endorsed suicidal ideation and homicidal ideation within treatment records. The Board finds the documented suicidal ideation warrants a 70 percent disability rating from October 11, 2016, the day the Veteran was admitted, in-part, for suicidal ideation. While the October 2019 VA examiner did not indicate suicidal ideation as a symptom, the examiner did note the Veteran experiences recurrent thoughts of death. While the Veteran has always denied having a plan even during the hospital admission and in the months and years following, treatment records reflect the Veteran has consistently continued to endorse experiencing suicidal thoughts. During this period, the Veteran also endorsed not having any friends, experiencing "a lot of trouble" with anger and irritability, feeling like he wants to "punch everything", experiencing angry outbursts, and increased isolation noting that he rarely leaves his apartment. The Board also notes the October 2019 VA examiner found the Veteran's MDD "significantly impairs" his concentration, motivation, and ability to establish and maintain relationships. Thus, while the October 2019 VA examiner endorsed only occupational and social impairment with reduced reliability and productivity, the Board finds the Veteran's symptoms during this period more nearly approximate the 70 percent disability rating criteria, especially in light of the Veteran's newly reported suicidal ideation. The Board finds that the Veteran's disability is fully capable of evaluation under the rating schedule during this period. In so finding, the Board also concludes a higher 100 percent rating is not warranted at any point during the period on appeal because the Veteran has never demonstrated total occupational and social impairment or symptoms of similar severity, frequency, or duration as to those contemplated by the 100 percent criteria. There has been no gross impairment of 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; or disorientation to time or place of the severity contemplated by a 100 percent rating. While the October 2016 hospital admission was related to both suicidal and homicidal ideation, the Veteran declined having a specific plan for a specific person. Since October 11, 2016, the Veteran has declined experiencing homicidal ideation. While the Veteran continued to endorse thoughts of suicide, it does not rise to the level contemplated by the 100 percent rating criteria. Indeed, treatment records from October 2016 to 2020 contain multiple incidents where the Veteran declined experiencing suicidal or homicidal ideation. Thus, the Board finds while the Veteran experiences suicidal ideation as contemplated by the 70 percent rating criteria, it does not amount to "persistent" as contemplated by the 100 percent rating criteria. Additionally, the Veteran has never endorsed experiencing hallucinations or delusions. While treatment records note the Veteran reported hearing names during a dream, he has never been found to experience hallucinations or delusions. Indeed, from October 11, 2016, the Veteran has always been evaluated as alert and oriented without psychotic or manic features. Further, while the Veteran endorsed struggling to stay motivated to complete household chores, there has never been an intermittent inability to perform activities of daily living referenced. Indeed, during the 2019 VA examination the Veteran reported vacuuming his apartment, washing his own clothes, and washing the dishes. Based on the aforementioned and resolving any doubt in favor of the Veteran, from October 11, 2016, the Board finds that the severity, frequency, and duration of the Veteran's MDD symptoms resulted in the level of impairment required for a 70 percent rating, but no higher. Thus, entitlement to a disability rating of 70 percent, but no higher, is warranted from October 11, 2016. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.C. Allen, 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.