Citation Nr: 1403713 Decision Date: 01/28/14 Archive Date: 02/10/14 DOCKET NO. 07-20 741 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to special monthly compensation based on the need for regular aid and attendance or at the housebound rate. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. T. Hutcheson, Counsel INTRODUCTION The Veteran is the appellant in the instant appeal. He had active service from June 1978 to November 1979. This matter came before the Board of Veterans' Appeals (Board) on appeal from an August 2005 rating decision of the Houston, Texas, Regional Office (RO) which, in pertinent part, denied service connection for hypertension and special monthly compensation based on the need for regular aid and attendance or at the housebound rate. In March 2011, the Board, in pertinent part, remanded the issues of service connection for hypertension and special monthly compensation based on the need for regular aid and attendance or at the housebound rate to the RO for additional action. In April 2012, the Board, in pertinent part, again remanded the Veteran's appeal to the RO for additional action. In January 2013, the Board requested an opinion from a Veterans Health Administration (VHA) medical expert in internal medicine. In March 2013, the requested VHA opinion was incorporated into the record. In April 2013, the Veteran and his accredited representative were provided with a copy of the VHA opinion. In May 2013, the Veteran submitted additional argument. In June 2013, the Board determined that the March 2013 VHA opinion was inadequate and requested an addendum to the opinion. In October 2013, the requested amended VHA opinion was incorporated into the record. In November 2013, the Veteran and his representative were provided with a copy of the amended VHA opinion. In December 2013, the representative submitted additional argument. The Board has reviewed the physical claims files and both the Veterans Benefits Management System (VBMS) and the "Virtual VA" files so as to insure a total review of the evidence. The issue of entitlement to special monthly compensation based on the need for regular aid and attendance or at the housebound rate is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. Service connection is currently in effect for schizophrenia evaluated as 100 percent disabling. 2. Hypertension is related to antipsychotic medication prescribed for the Veteran's schizophrenia and associated weight gain and obesity. CONCLUSION OF LAW Hypertension was incurred proximately due to or as the result of the Veteran's schizophrenia. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.310(a), 3.326(a) (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Duty to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473(2006), which held that the notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In this decision, the Board grants service connection for hypertension. Therefore, no further discussion of VA's duties to notify and to assist is necessary as to that issue. II. Service Connection for Hypertension The Veteran asserts that service connection for hypertension is warranted secondary to the medications prescribed for his service-connected schizophrenia. Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Service connection is currently in effect for schizophrenia evaluated as 100 percent disabling. A December 1981 VA treatment record states that the Veteran complained of medication side effects. He exhibited a blood pressure reading of 140/90. A diagnosis of hypertension was not advanced. A January 1982 VA treatment record conveys that the Veteran complained of side effects of his prescribed antipsychotic medication. The Veteran's mother reported that the Veteran ate excessively. His prescribed Prolixin was discontinued and he was prescribed Mellaril. Mellaril is a brand name for the drug thioridazine, an antipsychotic medication used to treat schizophrenia. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1704 (28th ed. 1994). A February 1982 VA treatment record notes that the Veteran complained of "lots of [weight] gain." A March 1982 VA treatment record states that the Veteran claimed "some weight gain." A May 1982 VA treatment record states that the Veteran complained of eating too much; continued to take Mellaril; and was sent for a dietary consultation. A July 1982 VA treatment record states that the Veteran was "worried a lot about weight gain. He weighed 260 pounds. Impressions of paranoid schizophrenia and "obesity serious" were advanced. An August 1982 VA dietary consultation relates that the Veteran complained of weight gain while taking Mellaril. The Veteran was reported to weigh 272 pounds and to have an ideal body weight of 160-180 pounds. A May 1983 VA treatment record reflects that the Veteran's prescribed Mellaril was discontinued. In January 1984, the Veteran was reported to be taking "diet pills" to lose weight. He exhibited a blood pressure reading of 148/90. Clinical documentation from Charter Real Hospital dated in January 1991 indicates that the Veteran weighed 300 pounds. He was diagnosed with essential hypertension and obesity. The March 2013 VHA internal medicine opinion states that the record had been reviewed. The physician commented that: Regarding the specific questions put forth in the request: 1. The pre-service diagnoses from the April 1977 hospitalization, iterated above, could certainly reflect initial manifestations of chronic hypertension, as just discussed. 2. Based on these findings, one could not conclude that it is as likely as not that his chronic hypertension originated during his active service or that subsequent hypertension is "due to" his inservice elevated blood pressure reading. Clearly his hypertension is not caused by diabetes mellitus (which was diagnosed in 1994), and there is no established mechanism whereby schizophrenia per se (aside from certain drugs used to treat schizophrenia) can lead to increased severity of hypertension "beyond its natural progression." (emphasis added). The October 2013 addendum to the March 2013 VHA internal medicine opinion clarifies that: There is no medication record or summary in the seven volumes of records submitted, and the medications identified in my review were extracted from handwritten and typed office or clinic notes, correspondence, or hospital discharge summaries scattered throughout these records in an entirely haphazard fashion. I mention this because of the possibility that my review might be incomplete, i.e., that there may have been other medications used that have been overlooked. A few general points should be emphasized: 1. All antipsychotic medications have complex effects on several central nervous system mechanisms, so that some interaction with complex control of cardiovascular function (including blood pressure control) is always possible. 2. The main blood pressure effect of virtually all antipsychotics, and especially the older or so-called "first generation" antipsychotics, is actually to lower blood pressure or to cause orthostatic hypotension (a drop in blood pressure upon arising), due to "alpha-blocking" effect on the sympathetic nervous system. 3. Many antipsychotics also have the potential to cause minor elevations in blood pressure through mechanisms that are not fully understood. Careful monitoring of hypertension is always emphasized to practitioners when prescribing antipsychotics, and the effects on blood pressure are generally mild and are easily treated by adjustment of antihypertensive medications. 4. Several antipsychotic medications, and particularly the newer "second generation" or "atypical" antipsychotics, have the potential to cause metabolic disturbance including weight gain, glucose intolerance (diabetes), lipid elevation, and hypertension. For the most part, the blood pressure elevations are not due to specific effects on blood pressure regulations per se, but are rather a minor but inescapable consequence of weight gain which is widely recognized as a significant factor in hypertension control. There are a few second generation antipsychotic medications, most notably quetiapine (Seroquel) and olanzapine (Zyprexa) which appear to have a particularly strong affect on raising blood pressure, again through uncertain mechanisms including weight gain). This Veteran has not been treated with these medications as far as I can determine. The following medications have been identified that have been used in his care: the first-generation antipsychotics haloperidol (Haldol), benztropine (Cogentin), chlorpromazine (Thorazine), perphenazine (Trilafon), fluphenazine (Prolixin), and thiothixene (Navane); the second-generation (atypical) antipsychotic risperidone (Risperdal), and intermittent adjunctive use of amitriptyline (Elavil), antidepressant, and clonazepam (Klonopin), a minor tranquilizer. *** In my review of the chart notes, it appears that the Veteran's hypertension was generally easily controlled on relatively little antihypertensive medication. Although the issue could not be reviewed systematically, casual inspection of the notes indicates that there was no discernible loss of blood pressure control, need for blood pressure medications adjustments, or substantial weight gain, that could be attributed to the use of any of the specific antipsychotic medications mentioned above. (emphasis added). The Veteran was prescribed Mellaril (thioridazine) for his schizophrenia and exhibited closely associated significant weight gain and obesity. The VHA opinion and the addendum thereto concluded that weight gain is a potential side effect of antipsychotic medications used to treat schizophrenia and the resulting substantial weight gain and obesity could result in the onset of hypertension. For these reasons and upon resolving all reasonable doubt in the Veteran's favor, the Board concludes that service connection for hypertension secondary to the Veteran's service-connected schizophrenia is now warranted. 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102, 3.310. ORDER Service connection for hypertension is granted. REMAND Service connection was established above for hypertension. Entitlement to special monthly compensation based on the need for regular aid and attendance or at the housebound rate d requires an accurate assessment of the disability associated with all of the Veteran's service-connected disorders. Accordingly, the case is REMANDED for the following action: Readjudicate the Veteran's entitlement to special monthly compensation based on the need for regular aid and attendance or at the housebound rate. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs