Citation Nr: 21065808 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 15-06 668A DATE: October 27, 2021 ORDER Prior to January 29, 2014, entitlement to an initial rating in excess of 30 percent for an acquired psychiatric disorder is denied. From January 29, 2014, entitlement to a rating in excess of 50 percent for an acquired psychiatric disorder is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to special monthly compensation (SMC) based on the statutory housebound rate is granted, subject to the laws and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. Prior to January 29, 2014, the severity, frequency, and duration of the Veteran's acquired psychiatric disorder symptoms did not more closely approximate occupational and social impairment with reduced reliability and productivity. 2. From January 29, 2014, the severity, frequency, and duration of the Veteran's acquired psychiatric disorder symptoms did not more closely approximate occupational and social impairment with deficiencies in most areas. 3. The evidence is at least in equipoise that the Veteran's service-connected diabetic peripheral neuropathy alone precludes him from securing or following substantially gainful employment. 4. The evidence is at least in equipoise that Veteran has been unemployable due solely to his service-connected diabetic peripheral neuropathy and he has additional service-connected disabilities rated as at least 60 percent disabling, which are separate and distinct from his peripheral neuropathy and involve different anatomical segments or bodily systems. CONCLUSIONS OF LAW 1. Prior to January 29, 2014, the criteria for an initial rating in excess of 30 percent for an acquired psychiatric disorder 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 9434. 2. From January 29, 2014, the criteria for a rating in excess of 50 percent for an acquired psychiatric disorder 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 9434. 3. The criteria for the assignment of a TDIU due to a service-connected disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.16. 4. The criteria for entitlement to SMC based on the statutory housebound rate have been met. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i)(1). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1970 to May 1973. In October 2017, the Veteran testified before a Veterans Law Judge who is no longer employed at the Board. In February 2021 correspondence, the Veteran was given the opportunity to request another hearing and was notified that if he did not respond in thirty days, it would be assumed that he did not want another hearing. In March 2021, the Veteran responded that he did not want another hearing. The Board will therefore proceed with adjudication of the claim. This case is before the Board of Veterans' Appeals (Board) on appeal from September 2013 and April 2014 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). This case was first before the Board in March 2018. In this March 2018 Board decision, the Board denied the Veteran's claim of entitlement to an initial rating in excess of 30 percent for an acquired psychiatric disorder prior to January 29, 2014; and a rating in excess of 50 percent for an acquired psychiatric disorder since that time. The Veteran appealed the March 2018 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a November 2018 Court order, the Court vacated and remanded the March 2018 decision pursuant to the terms of a Joint Motion for Partial Remand (JMPR). The Parties found that the Board did not fulfill its duty to assist because the VA medical examinations of record from August 2013 and January 2014 were not adequate for rating purposes. Subsequently, this claim was remanded for additional development in June 2019, October 2020, and May 2021 Board decisions. The Board finds that there has been substantial compliance with those remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall). VA has a duty to maximize benefits and must adjudicate as part of any claim entitlement to ancillary benefits that arise as a result, such as entitlement to SMC. 38 C.F.R. § 3.155(d)(2); Bradley v. Peake, 22 Vet. App. 280, 294 (2008). Accordingly, the Board has appropriately assumed jurisdiction over the issue of entitlement to SMC and has added it to the cover page. Increased Rating Disability ratings are assigned in accordance with VA's Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from a disability. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. When a question arises as to which of two ratings shall be applied under a diagnostic code, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. The Veteran's acquired psychiatric disorder is rated under the General Rating Formula for Mental Disorders. Under 38 C.F.R. § 4.130, DC 9434, a 10 percent rating is warranted for 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 continuous medication. 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, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as, for example: 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. 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, for example: 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); inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as, for example: 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; memory loss for names of close relatives, own occupation, or own name. The symptoms listed in VA's general rating formula for mental disorders are not an exhaustive list, but rather serve as examples of the type and degree of symptoms, or their effects, that would justify a rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). 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). "[T]he presence or lack of evidence of a specific sign or symptom listed in the evaluation criteria is not necessarily dispositive of any particular disability level." Id. at 22. When evaluating a mental disorder, the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the veteran's capacity for adjustment during periods of remission must be considered. 38 C.F.R. § 4.126(a). 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). This appeal arises from the original assignment of a disability evaluation following an award of service connection, thus the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Turning to the evidence of record, a Social Security Administration decision found that the Veteran was disabled based on his diabetes mellitus and accompanying intractable and debilitating pain and numbness in his forearms and hands. The Administrative Law Judge noted that the Veteran's impairment prevented him from sitting, standing, or walking for prolonged periods. See September 2002 SSA Office of Hearings and Appeals Decision. In August 2013, the Veteran was afforded a VA mental disorders examination. The Veteran was found to have Axis I diagnoses of depression, not otherwise specified (NOS), complicated by chronic pancreatic pain; polysubstance dependence in remission, and generalized anxiety disorder (GAD). The examiner noted that the overall severity of his GAD since service was mild. He reported moderate ongoing health issues, noting that the Veteran had a history of pancreatic cancer and was status post pancreatic surgery in 2010, neuropathy, a history of prostate cancer, status post obesity, and diabetes mellitus. The VA examiner determined that the Veteran's acquired psychiatric disorder resulted in occupational and social impairment due to mild or transient symptoms which decrease his work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. At this examination, the Veteran reported that he got over the depression he had experienced while on active duty when he got married in 1978 and was busy raising children. He reported that he has been treated for anxiety since service and noted that his anxiety has been persistent over the years and still bothered him a great deal. The Veteran reported that sentinel stressful events in his life included two different cancersprostate and pancreatic cancer in 1997 and 2010 respectively. On examination, the VA examiner noted that the Veteran's symptoms caused by his mental health disorder included a depressed mood and anxiety. The examiner reported that the Veteran had other symptoms attributable to his mental disorder but failed to mention any other specific symptoms. The examiner note that psychological testing was not indicated at this time and reported that the Veteran had no history of suicide attempts and denied being suicidal or homicidal. In terms of his level of social functioning, the Veteran stated that he had been married for thirty-five years and described his marriage as a stable one, even adding that his marriage was "as good as you can get." He stated that he had two children and three grandchildren whom he visits on a regular basis. As for his level of occupational functioning, the examiner noted that the reason the Veteran was unemployable was due to his ongoing physical health issues and not his acquired psychiatric disorder. An August 2013 progress note reflects that the Veteran denied suicidal ideation. In an October 2013 letter from R.H., D.O., Dr. H. stated that the Veteran's is unable to hold onto a job due to his mental health in addition to his physical health issues. In January 2014, the Veteran was afforded another VA mental disorders examination. The Veteran was diagnosed with major depression with anxiety and polysubstance dependence in remission. The examiner, Dr. V., determined that these diagnoses resulted in occupational and social impairment with reduced reliability and productivity. He characterized the Veteran's acquired psychiatric disorder as moderate in severity. On examination, Dr. V. noted that his major depression with anxiety resulted in symptoms of a depressed mood, anxiety, chronic sleep impairment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a work like setting. The examiner noted that the Veteran had other symptoms attributable to his mental health disorder but failed to mention what other symptoms he was referring to. Dr. V. stated that the Veteran denied experiencing any suicidal/homicidal ideation or intent due to his psychiatric disorder, and further noted that the Veteran's medical history was negative for any history of suicide attempts. Dr. V. noted that the Veteran was not currently receiving psychiatric treatment. In terms of his occupational functioning, Dr. V. reported that the Veteran started receiving social security disability benefits in 2006 based on his medical issues of diabetes, arthritis, and chronic pain. Dr. V. reported that the Veteran's serious ongoing physical health issues prevented him from gainful employment and not his psychiatric disorder. The Veteran reported that he used to work as a professional guitar player all over the country but no longer plays the guitar due to numbness in his upper extremity. In a March 2016 preventative medicine note, the Veteran reported that he was depressed due to pain. In a November 2017 preventative health screen, the Veteran responded "no" to the question of in the past six months has there been a period of time when you felt sad, empty, or depressed but noted that in the past six months there had been things in his life that worried him and caused him stress. At an October 2017 Board videoconference hearing, the Veteran's attorney reported that his anxiety was primarily secondary to his diabetes and prostate cancer. The Veteran submitted a Mental Disorder (other than PTSD and Eating Disorders) Disability Benefits Questionnaire (DBQ) report dated in December 2017 that was completed by a licensed psychologist, E.T., Ph.D. In the DBQ form, Dr. T. diagnosed the Veteran with GAD and noted that his psychosocial problems included health/financial concerns and feeling alienated from others. Dr. T. noted that the Veteran had not worked since approximately 2001 and stated that his post military vocational adjustment had been poor. With regard to symptoms associated with the Veteran's diagnosis, Dr. T. noted that the Veteran's GAD was manifested by a depressed mood, anxiety, near continuous panic or depression affecting the ability to function independently, chronic sleep impairment, mild memory loss, impairment of short and long-term memory, flattened affect, impaired judgment, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work-like setting, the inability to establish and maintain effective relationships, and impaired impulse control. Dr. T. reported that the Veteran's acquired psychiatric disorder resulted in total occupational and social impairment. In the December 2017 Psychosocial Assessment and Employability Evaluation report, Dr. T. reported that the Veteran's poor sleep habits resulted in irritability and depression. She also noted that the Veteran had lost interest in things and activities he previously enjoyed and had become withdrawn from others. Dr. T. reported that the Veteran had problems with concentration, noting that his mind wanders. According to Dr. T., the Veteran's depression was moderately severe to severe in nature. Dr. T. stated that the Veteran's mental health condition prevents him from maintaining substantially gainful employment. She explained that the Veteran reported that he would become anxious and depressed on his jobs that would often quit or be fired because of his emotional state. Dr. T. noted that the Veteran's chronic history of not working was established well before his physical problems of diabetes and cancers were discovered, noting that he has not worked since 2001. Dr. T. reported that the Veteran last worked as a delivery driver but left that job because he could not stop crying on the job. In an April 2018 opinion from R.T., D.O., he states that the Veteran's depression alone presents a significant barrier to his employability, explaining that he does not think the Veteran is capable of critical thinking due to his mental health. A November 2018 psychiatry consult notes that the Veteran was admitted for management of his chronic neck pain. On interview, the Veteran admits he made a suicide statement earlier when his pain was unbearable; however, since admission with current pain medication treatment regimen, he feels much better and is no longer suicidal. He shared that he was very pleased with his treatment thus far and wanted help. On examination, the Veteran denied significant depression. His mood was calm, behavior appropriate, thought process coherent, judgment was adequate, and insight was fair. The Veteran denied current suicidal or homicidal ideation and denied hallucination or delusions. In August 2020, the Veteran was afforded another VA psychiatric examination. The psychologist, M.M., diagnosed the Veteran with GAD and reported that the Veteran's diabetes and chronic pain were relevant to the understanding of his GAD diagnosis. The examiner explained that the Veteran has chronic pain related to having rods put in both legs and undergoing seventeen neck surgeries. She noted that the Veteran also has diabetes and neuropathy and stated that his medical conditions have decreased mobility, energy and self-esteem and increased symptoms of depression. The examiner noted that symptoms related to the Veteran's mental health disorder included a depressed mood, anxiety, suspiciousness, panic attacks that occur weekly or less often, chronic sleep impairment, flattened affect, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships and difficulty in adapting to stressful circumstances. Overall, the examiner found that the Veteran's acquired psychiatric disorder resulted in occupational and social impairment with reduced reliability and productivity. The examiner reported that the Veteran was somewhat anxious, and noted that his engagement, appearance, and speech were normal. She noted that the Veteran did not have any other symptoms attributable to his mental disorder that were not listed above. At this examination, the Veteran reported that he worked as a musician and reported no issues with work. He stated that his son had committed suicide a year ago which put a strain on his marriage. The Veteran reported being socially isolated during the coronavirus outbreak which exacerbated his depressive symptoms. Progress notes dated in 2020 reflect mild to moderate depression. A January 2020 mental health diagnostic study noted a PHQ-9 score of 6 indicating mild depression. An April 2020 psychiatry nurse practitioner note reflects a diagnostic impression of MDD, recurrent, moderate. A May 2020 mental health diagnostic study note reflects that the Veteran scored a 4 on the PHQ-9 test indicating minimal depression. In July 2020 entry, the Veteran responded that he was currently experiencing anxiety and depression and in a September 2020 progress note, the examiner noted that the Veteran answered in the negative when asked whether he was currently experiencing anxiety and depression. In a December 2020 mental health note, the Veteran expressed grief and loss related to his son's suicide and reported that he did not feel like the antidepressant was helping him anymore. He was instructed to increase his medication for depression and to consider seeing a therapist to discuss grief issues. In November 2020, the Veteran was afforded another VA psychiatric examination conducted using video telehealth. The Veteran was diagnosed with major depressive disorder, recurrent, GAD secondary to MDD and opioid use disorder in remission. The examiner opined that the Veteran's acquired psychiatric disorders resulted in a depressed mood, anxiety, near continuous depression affecting the ability to function, mild memory loss and disturbances of motivation and mood. The psychiatrist, F.M. found that the Veteran's mental health disorders caused occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress, or; symptoms controlled by medication. On examination, the Veteran was well-groomed, his behavior was calm and cooperative, and his speech was coherent. His mood was depressed, his affect was depressed and anxious, his thought process was goal directed and his thought content reflected no evidence of hallucinations or delusions. The Veteran denied any suicidal thoughts, intent, or plans. His insight and judgment were fair, and his memory was limited. Dr. F. reported that the Veteran did experience other symptoms attributable to his mental disorders that were not listed above. To discern these other symptoms, Dr. F. administered the PHQ-9. The Veteran reported that over the last two weeks, he experienced little interest or pleasure in doing things, feeling down, poor appetite or overeating, feeling bad about himself, feeling nervous, anxious or on edge, not being able to control worrying, feeling unproductive and having trouble focusing on achieving his goals. Dr. F. assessed the Veteran with moderate depression and GAD. She reported that the prognosis for substantial improvement of psychiatric symptoms and functional status is guarded as much of Veteran's current distress and diminished quality of life is related to his chronic pain for which he is receiving limited relief. The Veteran reported that his physical conditions have limited his occupational functioning and aggravated his mental health. An addendum opinion to the November 2020 VA examination explained that the Veteran's GAD and depression worsened when he was diagnosed with his cancers (prostate cancer in 1997) and (pancreatic cancer around 2009). His anxiety surrounded his survival and living and battling cancer. Dr. F. noted that the Veteran's prostate cancer resolved in 1997 and his pancreatic cancer appears to have resolved after his 2009 surgery. Dr. F. stated that the Veteran's anxiety and depression symptoms improved/resolved when his cancers were considered treated and in remission. At this point in time, Dr. F. noted that the Veteran was able to resume work as a guitar player. However, Dr. F. reported that the Veteran's depression and anxiety flared up again in 2014 after he was dealing with recurrent and multiple health stressors starting with his legs that needed rods placed followed by other surgeries. Dr. F. noted that the Veteran retired in 2001 as a delivery truck driver due to neuropathy related to his diabetes but continued to work playing his guitar. The Veteran continued playing guitar until his son's suicide in 2019 at which point, he developed near continuous depression and disturbance of mood and motivation. In sum, Dr. F. noted that prior to 2014, the Veteran's symptoms included depressed mood, anxiety, sleep disturbances and mild memory impairment. However, Dr. F. reported that these symptoms only arose during periods of stress related to his cancer diagnoses around 1997 and 2009 respectively and resolved with resolution of his cancers. During a June 2021 addendum opinion, which included a review of the records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination), the November 2020 VA examiner clarified that essentially, the Veteran's symptoms related to his MDD and GAD, were waxing with his life stressors and waning with engagement in treatment. Dr. F. stated that the Veteran's engagement in treatment since his last VA examination shows that his symptoms of depression and anxiety are improving and resolving. She clarified her earlier statement that the Veteran's depression and anxiety had resolved after his pancreatic cancer resolved in 2009. Specifically, Dr. F. stated that as of his VA examinations in 2013 and 2014, the Veteran continued to have depression and anxiety and noted that this persisted until his November 2020 VA examination. However, Dr. F. noted that the Veteran's medical records from April 23, 2021 indicate that his anxiety and depressive symptoms are resolving and are mild and near remission. After interviewing the Veteran, Dr. F. summarized that as of 2020, the Veteran volunteers playing music gigs with his band at retirement homes. He had no issues with difficulty adapting to stressful worklike settings while playing guitar in his band at nursing homes. Dr. F. reported that the Veteran's ability to play guitar in a band indicates that he has no difficulty in establishing and maintaining effective work relationships with his band members. She again noted that the Veteran had been married to his wife for forty plus years and his medical records indicate that he is in a good relationship with his wife, indicating that he is able to establish and maintain effective social relationships. Dr. F. further clarified her November 2020 opinion and June 2021 addendum opinion in a June 2021 Report of General information. She stated that the symptoms listed on the 2014 VA examination were the only symptoms the Veteran had in 2014 and that any additional symptoms noted in the November 2020 examination were not present in January 2014 and to consider the January 2014 VA examination for the severity of the Veteran's symptoms at that time. Further, Dr. F. clarified that prior to January 29, 2014, although she stated that the Veteran's depression and anxiety symptoms had resolved as of 2009 when both of his cancers had resolved, Dr. F. also stated that the nature and severity of the Veteran's acquired psychiatric disorder was accurately depicted by the exam taken at the timethe August 2013 VA examination. VA treatment records dated from January 2021 to May 2021 reflect mental health treatment each month with mild symptoms found. A January 2021 entry reflects that the Veteran is spending time playing cards and playing his guitar. He reported sleeping eight hours most nights and feeling rested on most days. The Veteran reported that although he is unable to change the outcome of his son's death, he now needs to start with one step at a time to find happiness in his life. He rated his mood as a 7/10. On examination, the Veteran was oriented and cooperative. His thoughts were congruent, intact, and focused on the noted problems. His judgment and insight were fair to good and the Veteran denied suicidal or homicidal ideation. The psychiatric advanced practice nurse gave a diagnostic impression of MDD, recurrent, severe without psychotic features and noted the Veteran's ongoing grief over his son's suicide. The examiner noted that the Veteran's scores on the mental health diagnostics used to evaluate the severity of depression (PHQ-9) and generalized anxiety disorder (GAD-7) represented mild symptoms. In February 2021, a psychiatric advanced practice nurse assessed the Veteran with recurrent, mild MDD and noted that the mental health testing given at the examination to assess the severity of his depression and anxiety reflected mild symptoms. In March and April 2021 VA mental health treatment notes, the Veteran reported that treatment was helping him and verbalized improvements with his mood. On both the March and April 2021 mental status examinations, the Veteran was oriented, cooperative and his mood was euthymic. His thoughts were congruent, intact, and focused, his insight and judgment were fair to good, and he did not report or demonstrate suicidal or homicidal ideation. The diagnosis provided was mild MDD. The examiners found mild depression and anxiety symptoms after administering testing to evaluate the severity of his symptomsspecifically the PHQ-9 and GAD-7. At his April 2021 treatment session, the Veteran noted that he had ample energy to engage with friends and play guitar. In an August 2021 statement, the Veteran reported that he has severe depression that impairs his personal and professional relationships. He reported that he is unable to communicate effectively, loses him temper easily and no longer speaks with family and friends. The Veteran reported that he struggles to regulate his emotions, resulting in inappropriate comments and actions and is easily provoked. He reported feeling hopeless, unmotivated, confused two to three times per week and unable to focus. The Veteran stated that his symptoms are worsening and noted that treatment was not helping. He reported suffering from panic attacks where he cries uncontrollably and noted that he experiences suicidal thoughts on a regular basis. The Veteran stated that his symptoms have persisted for years at this level with no change and believed that his depression alone limits his ability to work. 1. Entitlement to an initial rating in excess of 30 percent for an acquired psychiatric disorder prior to January 29, 2014. In this case, the preponderance of the evidence is against finding that the Veteran's mental health disability picture more nearly approximates the criteria for a higher 50 percent evaluation prior to January 29, 2014. Essentially, as noted by Dr. F., prior to January 29, 2014, the Veteran's symptoms related to his MDD and GAD, were waxing with his life stressors and waning with engagement in treatment. She explained that the Veteran's anxiety and depression had surrounded living and battling his cancers, including prostate cancer in 1997 and pancreatic cancer in 2009. However, when his pancreatic cancer went into remission in 2009, his depression and anxiety symptoms improved tremendously to near resolution because the Veteran was no longer battling cancer. Dr. F. noted that the Veteran's anxiety and depression flared back up again in 2014 when multiple physical health stressors again emerged, including surgery to place rods in his legs. See November 2020 addendum opinion, June 2021 addendum opinion and June 2021 Report of General Information. This longitudinal analysis of the severity of the Veteran's acquired psychiatric disorders prior to January 29, 2014, is supported by Dr. V.'s assessment made during the August 2013 VA examination. He described the severity of the Veteran's GAD as "mild" and opined that his depression and GAD resulted in occupational and social impairment due to mild or transient symptoms which decrease his work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication, which approximates the 10 percent rating criteria. Further, regarding the Veteran's level of social functioning, the preponderance of the evidence is against finding that the Veteran has difficulty establishing and maintaining effective social relationships, which is indicative of a higher, 50 percent rating. The August 2013 examiner explained that the Veteran had been married for thirty-five years and described his marriage as a stable one. The Veteran reported that his marriage was "as good as you can get." He also stated that he had two children and three grandchildren whom he visits on a regular basis. In terms of the impact of the Veteran's mental health disorder on his occupational functioning, as just noted, the August 2013 VA examiner opined that the Veteran's mild psychiatric symptoms decreased his work efficiency and ability to perform occupational tasks only during periods of significant stress. The VA examiner did not find that the Veteran's psychiatric symptoms resulted in occupational and social impairment with reduced reliability and productivity which is indicative of a 50 percent rating. The examiner noted that the reason the Veteran was unemployable was due to his ongoing physical health issues and not his mental health. Dr. V.'s opinion is supported by SSA records which reflect that the Veteran was disabled based on his severe diabetes mellitus and accompanying neuropathy. See September 2002 SSA Office of Hearings and Appeals Decision. In fact, the Veteran stated that he retired in 2001 as a delivery truck driver due to neuropathy related to his diabetes. See November 2020 addendum opinion by Dr. F. He also reported that he continued to play the guitar professionally after retiring in 2001, but no longer plays his guitar professionally due to numbness in his upper extremity. See January 2014 VA examination. Additionally, evidence throughout the appeal period does not reflect psychiatric symptoms that more closely approximate a higher 50 percent rating. The August 2013 VA examiner, Dr. V., specifically reported that for VA rating purposes, the Veteran's acquired psychiatric disorder included symptoms of a depressed mood and anxiety. Dr. V. did not report symptomatology indicative of a 50 percent rating such as a flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once per week; difficulty in understanding complex commands; impairment of short and long-term memory or impaired judgment or abstract thinking. The Board acknowledges that the August 2013 VA examiner stated that there were other symptoms attributable to the Veteran's mental health disorder that were not mentioned in the VA rating criteria but failed to elaborate on what symptoms he was referring to. Although this diminishes the probative value of Dr. V.'s 2013 evaluation, the Board finds that his opinion is still entitled to some probative weight because Dr. V. reviewed the claims file, obtained thorough social, occupational, educational, and mental health histories from the Veteran, and conducted an in-person examination. In sum, although the Veteran experienced depression and anxiety prior to January 29, 2014, these symptoms primarily arose and intensified during periods of stress related to his cancer diagnoses in 1997 and 2009, and essentially "resolved" when his cancers were considered in remission. See November 2020 addendum opinion by Dr. F. The Board finds that prior to January 29, 2014, the level of occupational and social impairment noted by the August 2013 VA examiner, Dr. V., coupled with Dr. F.'s account of the severity of his anxiety and depression symptoms during this time frame, does not more closely approximate a higher, 50 percent disability rating. While the Veteran experienced a depressed mood and anxiety, the frequency, severity, and duration of these symptoms are contemplated by the currently assigned 30 percent evaluation. Essentially, the evidence reflects that the Veteran experienced periods of remission in his psychiatric symptoms prior to January 29, 2014 and demonstrated the capacity for adjustment during these periods. See 38 C.F.R. § 4.126(a). When he was experiencing symptoms of anxiety and depression, his symptoms were described as "mild" (see August 2013 VA examination) and are therefore considered less severe, less frequent, and shorter in duration than those contemplated by a 50 percent rating. 2. From January 29, 2014, entitlement to a rating in excess of 50 percent for an acquired psychiatric disorder. Considering the pertinent evidence in light of the applicable rating criteria, the Board finds that the preponderance of the evidence weighs against finding that the Veteran's MDD and GAD symptoms have caused occupational and social impairment with deficiencies in most of the areas of functioning needed for a 70 percent rating, including work, family relations, judgment, thinking and mood. After reviewing the record and conducting in-person examinations, the January 2014 VA examiner, Dr. V., and the August 2020 VA examiner, Dr. M., both opined that the Veteran's depressive disorder and GAD resulted in reduced reliability and productivity, indicative of a 50 percent evaluation. The November 2020 VA examiner, Dr. F., opined that the Veteran's mental health disorders caused occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during period of significant stress, or symptoms controlled by medication, which is indicative of a 10 percent rating. Significantly, three different psychologists reviewed the claims file, took social, occupational, and mental health histories, and examined the Veteran (two in-person examinations and one examination via telehealth). All three psychologists determined that ultimately, his depression and anxiety symptoms resulted in at worst, occupational and social impairment with reduced reliability and productivity which is indicative of a 50 percent evaluation. The Board acknowledges that similar to his August 2013 examination, Dr. V. in his January 2014 examination of the Veteran stated that other symptoms were attributable to the Veteran's mental health disorder beyond those listed but failed to note what other symptoms he was referring to. However, given that he is a psychologist and thus qualified to evaluate the Veteran, and reviewed the record and conducted an in-person examination, the Board finds that his opinion is still entitled to some probative weight. Further, the Veteran's psychiatric symptoms noted by the Veteran and the examiners during the January 2014, August 2020 and November 2020 VA examinations more closely correspond to symptoms described in the 30 and 50 percent rating criteria, including, flattened affect (50 percent); depressed mood (30 percent); anxiety (30 percent); suspiciousness (30 percent); panic attacks that occur weekly or less often (30 percent); chronic sleep impairment (30 percent); mild memory loss (30 percent); disturbances of motivation and mood (50 percent); and difficulty in establishing and maintaining effective work and social relationships (50 percent). Although two symptoms mentioned by the VA examiners are indicative of a higher, 70 percent evaluationthe Veteran's difficulty in adapting to stressful circumstances (see January 2014 and August 2020 VA examinations) and the Veteran's near continuous depression described by the November 2020 VA examiner, the Veteran does not experience other symptoms indicative of a higher, 70 percent evaluation. For example, his depression and anxiety symptoms do not cause obsessional rituals, speech intermittently illogical obscure or irrelevant, unprovoked irritability with periods of violence, spatial disorientation or neglect of personal appearance or hygiene. Further, by June 2021, Dr. F. reported that the Veteran had no issues adapting to stressful worklike settings as demonstrated by his ability to volunteer to play guitar in his band at nursing homes. See Dr. F.'s June 2021 opinion. In sum, despite the mention of two symptoms indicative of a 70 percent rating during the appeal period, examinations were conducted by three different VA psychologists who did not find that the Veteran's mental health disorder symptoms resulted in occupational and social impairment with deficiencies in most areas which is indicative of a 70 percent rating. The Board finds that there is continuity between the severity of the Veteran's mental health disorder noted in the VA examinations and the level of severity described in VA treatment records, which bolsters the persuasiveness of the VA examiners' opinions. VA medical records show mild to moderate symptoms of depression and anxiety that wax and wane based on the state of the Veteran's physical health, including chronic pain and other life stressors. Progress notes dated in January and May of 2020 contain diagnostic testing to assess the severity of the Veteran's depression, specifically the PHQ-9 test, which revealed minimal depression. Similarly, VA treatment records dated from January to May of 2021 also reflect mild to moderate depression and anxiety symptoms which are not reflective of a 70 percent rating. Testing was conducted every month during this time period to evaluate the severity of the Veteran's depression using the PHQ-9 test and his generalized anxiety disorder utilizing the GAD-7 test. Scores on this testing consistently represented mild symptoms. Although in January 2021, the Veteran was found to have "severe" MDD, with the clinician noting the Veteran's ongoing grief over his son's suicide, by February, March and April of 2021, VA treatment records show that after evaluating the Veteran, the psychiatric advanced practice nurse assessed him with recurrent "mild" MDD on all three occasions. Significantly, at his April 2021 treatment session, the Veteran reported that he had ample energy to engage with friends and play guitar, demonstrating that he is not isolating himself from friends or unable to establish effective relationships (a symptoms indicative of a 70 percent rating) but instead chooses to engage with friends and the community by volunteering to play his guitar at nursing homes. The Board finds that the VA examinations are entitled to more probative weight than the December 2017 opinion rendered by Dr. T., which is not supported by, and at times contradicted by, the facts contained in the record. In particular, Dr. T. reported that the Veteran's acquired psychiatric disorder resulted in total occupational and social impairment. She reasoned that the Veteran's chronic history of not working was established well before his physical problems of diabetes and cancers were discovered, noting that he has not worked since 2001. Dr. T. reported that the Veteran last worked as a delivery driver but left that job because he could not stop crying on the job. However, the preponderance of the evidence reflects that the Veteran's inability to work has been attributed to his physical health issues and not his mental health. See January 2014 and November 2020 VA examinations. SSA records support this conclusion, reflecting that the Veteran is receiving disability benefits for his diabetes mellitus and associated neuropathy. Further, the Veteran has previously reported that he retired in 2001 as a delivery truck driver due to neuropathy related to his diabetes, rather than leaving his job for a mental health reason. He reported that he continued to play the guitar professionally after retiring in 2001, but no longer plays his guitar professionally due to numbness in his upper extremity, which again supports the conclusion that the Veteran stopped working due to his physical health. See January 2014 VA examination and November 2020 addendum opinion. Additionally, Dr. T. did not sufficiently support her conclusion that the Veteran's mental health disorder results in total social impairment and an inability to maintain effective relationships with adequate facts from the record. Although Dr. T. reported that the Veteran had become withdrawn from others, she failed to provide specific examples from the Veteran's life with his family and friends to support her opinion, which diminishes the probative value of her opinion. In fact, the record contradicts her assessment of the level of social impairment experienced by the Veteran. As previously noted, the Veteran has been married for over 35 years and describes his marriage as stable and "as good as you can get." He also reported regular visits with his children and grandchildren and most recently, the Veteran stated that he has ample energy to engage with friends and volunteer to play his guitar at nursing homes. See April 2021 VA treatment record. In sum, Dr. T.'s December 2017 DBQ report and Psychosocial Assessment report documents more severe symptomatology than VA examinations and VA treatment records during the appeal period both before and after Dr. T.'s 2017 DBQ. Dr. T.'s opinion that the Veteran's psychiatric symptoms are severe enough to result in total occupational and social impairment is an outlier during the period on appeal from January 29, 2014 forward and not supported by the other evidence of record. Based on the above analysis, the Board finds the VA examinations and VA treatment records produced during this period on appeal to be more persuasive than Dr. T.'s December 2017 DBQ. Finally, the Board recognizes the Veteran's August 2021 statement noting that he experienced suicidal thoughts on a regular basis and notes that suicidal ideation is a symptom contemplated by a 70 percent evaluation. The Board also acknowledges that the record contains a November 2018 VA psychiatry consult where the Veteran made a suicidal statement when he was admitted for chronic neck pain because the pain was unbearable, but also showed that after admission and receiving a pain medication treatment regimen, he felt much better and was no longer suicidal. In this case, after conducting a longitudinal analysis and reviewing the contemporaneous medical records from January 29, 2014 forward, the November 2018 mention of suicidal thoughts in the context of severe pain is an outlier. VA examinations dated in January 2014, August 2020 and November 2020 reflect no evidence of suicidal ideation and VA treatment notes dated in 2020 and 2021 also do not show evidence of suicidal ideation. Thus, after considering all of the Veteran's symptoms caused by his depression and anxiety disorders, the Board finds that the severity, frequency, and duration of the Veteran's psychiatric symptoms, to include suicidal ideation, do not more closely approximate symptomatology indicative of a 70 percent rating. The Board acknowledges the Veteran's contention that a higher, 70 percent rating is warranted because he experiences severe depression that impairs his personal and professional relationships and limits his ability to work. See August 2021 statement. However, these statements are not competent evidence to identify a specific level of severity relating this disability to the appropriate diagnostic code, as this requires specialized medical education, training, or experience. See 38 C.F.R. § 3.159(a). Consequently, the Board affords greater probative weight to the opinions rendered by the VA examiners. In conclusion, the record shows that although the Veteran's symptoms associated with his depression and anxiety disorders waxed and waned with stressful life events, including a multitude of physical health issues, including cancers, diabetes with neuropathy, and chronic neck pain, the salient point to make is that since January 29, 2014, the preponderance of the evidence is against finding that the severity, frequency and duration of the Veteran's psychiatric symptoms more closely approximated occupational and social impairment with deficiencies in most areas. As such, a higher, 70 percent rating for an acquired psychiatric disorder is not warranted. 3. Entitlement to a TDIU due to service-connected disability The issue of entitlement to a TDIU has been raised as part and parcel of the increased rating claim for an acquired psychiatric disorder, to include MDD and GAD. Thus, the Board assumes jurisdiction over the matter pursuant to Rice v. Shinseki, 22 Vet. App. 447, 452 (2009). From October 22, 2012, the Veteran's residuals of prostate cancer are rated 60 percent disabling and his diabetes mellitus, type II is rated as 60 percent disabling. Since October 22, 2012, the Veteran is also service connected for peripheral neuropathy associated with his diabetes mellitus. Specifically, peripheral neuropathy of the right upper extremity is rated 40 percent disabling; peripheral neuropathy of the right lower extremity (sciatic) is rated as 40 percent disabling; peripheral neuropathy of the left lower extremity (sciatic) is rated 40 percent disabling; peripheral neuropathy of the left upper extremity is rated 40 percent disabling; and peripheral neuropathy of the left and right lower extremities (femoral) are both rated 20 percent disabling respectively. The Veteran is also service connected for an acquired psychiatric disorder, evaluated as 30 percent disabling prior to January 29, 2014, and 50 percent disabling since that time. Finally, the Veteran is in receipt of noncompensable evaluations for residuals of a wart excision and erectile dysfunction, from October 1976 and October 2012 respectively. The Veteran is currently in receipt of a 100 percent combined schedular rating from October 22, 2012 forward, which encompasses the entire period on appeal for the Veteran's claim for an increased rating for his acquired psychiatric disorder. Although the Veteran's claim for TDIU has been previously characterized as moot, the Board finds that such characterization is not proper. A TDIU claim does not automatically become moot when a combined 100 percent schedular rating is assigned based on multiple service-connected disabilities because a separate award of TDIU predicated on a single disability could form the basis for an award of special monthly compensation (SMC) under 38 U.S.C. § 1114(s) (SMC warranted where veteran has a totally rated service-connected disability, as well as "additional service-connected disabilities independently ratable at 60 percent or more"). See Bradley v. Peake, 22 Vet. App. 280, 293 (2008) (holding that a grant of TDIU based on a single disability constitutes a totally rated service-connected disability for purposes of section 1114(s)). See also Buie v. Shinseki, 24 Vet. App. 242, 250 (2010). As such, pursuant to Bradley and Buie, VA has a duty to maximize benefits and therefore must consider the TDIU issue for the entire period covered by the claim to include whether a TDIU based on a single disability is warranted. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340(a). A Veteran's service-connected disabilities, employment history, educational and vocational attainment, and all other factors having a bearing on the issue must be addressed. Age may not be considered as a factor in evaluating service-connected disability; and unemployability, in service-connected claims, associated with advancing age or intercurrent disability, may not be used as a basis for a total disability rating. 38 C.F.R. § 4.19. The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough. A higher rating alone is a recognition that the impairment makes it difficult to obtain and maintain employment. The question is whether a veteran can perform the physical and mental acts required by employment, not whether the veteran can find employment. Van Hoose v. Brown, 4 Vet. App. 361 (1993). The central inquiry is "whether [a] veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). In this case, the Board finds that the Veteran is unemployable due solely to his peripheral neuropathy associated with his diabetes mellitus, type II. In an April 2018 DBQ by Dr. R.T., he reported that the Veteran has struggled with bilateral upper and lower extremity neuropathy for decades. He described the neuropathy as severe and stated that it remained largely uncontrolled and debilitating. On examination, Dr. T. found that the Veteran's diabetic peripheral neuropathy resulted in severe constant pain which may be excruciating at times, in his right upper and lower extremities, and moderate constant pain in his left lower extremity. Dr. T. also described severe intermittent pain in the right and left lower extremities and severe paresthesias and numbness of the right lower extremity. He reported that the Veteran's diabetic peripheral neuropathy impacted his ability to work, noting that the Veteran's use of his fingers, hands and legs were severely diminished as a result of his peripheral neuropathy. Dr. T. stated that the Veteran's foot drop will make walking difficult and noted that pain and discomfort will make any type of sedentary, low impact activity difficult. Further, as noted above, SSA records reflect that the Veteran was awarded disability benefits based on his diabetes mellitus and severe accompanying peripheral neuropathy which included intractable and debilitating pain and numbness in his forearms and hands. See September 2002 SSA Office of Hearings and Appeals Decision. In fact, the Veteran stated that he was forced to quit his job in 2001 as a delivery truck driver due to neuropathy related to his diabetes and also reported that he was forced to stop playing his guitar professionally due to his upper extremity peripheral neuropathy. See August 2013 VA treatment record, November 2020 addendum opinion by Dr. F. and January 2014 VA examination. In sum, the evidence is at least in equipoise as to whether the Veteran's diabetic peripheral neuropathy renders him unable to secure or follow physical or sedentary employment. The Board affords Dr. T.'s assessment of the impact of the Veteran's diabetic peripheral neuropathy on his ability to obtain or maintain employment significant probative weight because his opinion is supported by other evidence of record, including the SSA records and statements made by the Veteran. After considering the severe nature of the Veteran's diabetic peripheral neuropathy coupled with findings that the Veteran was forced to leave his previous employment as a result of his peripheral neuropathy, the Board finds that the evidence is in relative equipoise as to whether the Veteran's service-connected diabetic peripheral neuropathy alone precludes him from securing or following substantially gainful employment. As such, entitlement to a TDIU based solely on diabetic peripheral neuropathy is granted. 4. Entitlement to SMC based on the statutory housebound criteria (Continued on the next page) In pertinent part, SMC at the housebound rate is payable where a veteran has a single service-connected disability rated at 100 percent and has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). As the Veteran has been granted a TDIU based on a single service-connected disabilitydiabetic peripheral neuropathy, this finding means that the Veteran has "a service-connected disability rated as total" for the purposes of establishing eligibility to benefits under 38 U.S.C. § 1114(s). The Veteran's other service-connected disabilities, to include an acquired psychiatric disorder and residuals of prostate cancer, are rated as at least 60 percent disabling, are separate and distinct from his diabetic peripheral neuropathy, and involve different anatomical segments or bodily systems. Thus, entitlement to SMC at the statutory housebound rate is warranted. See 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i)(1). Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Alison M. Mecone, 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.