Citation Nr: 1501742 Decision Date: 01/14/15 Archive Date: 01/20/15 DOCKET NO. 10-44 428 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, claimed as depression. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty training in the Army National Guard from February 1979 to June 1979 and on active duty in the Army Reserve from March 2004 to July 2004. It appears that he had additional unverified service in the Reserve, to include being called to active duty on March 15, 2003. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Jurisdiction was subsequently transferred to the RO in San Juan, Puerto Rico. The September 2009 rating decision denied service connection for depression. The Board has recharacterized the issue on appeal to reflect that several psychiatric diagnoses have been made in this case. See Clemons v. Shinseki, 23 Vet. App. 1 (2009); see also Brokowski v. Shinseki, 23 Vet. App. 79 (2009). The Veteran presented testimony at a personal hearing before the undersigned Veterans Law Judge in April 2014. A transcript is of record. At the time of his hearing, the Veteran submitted additional evidence directly to the Board, which was accompanied by a waiver of RO consideration. The evidence will therefore be considered in this decision. 38 C.F.R. § 20.1304 (2014). The current record before the Board consists of a paper claims file and an electronic file known as Virtual VA. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND Additional development is needed before the Board can adjudicate the issue on appeal. As noted in the Introduction, the Veteran has unverified service in the Army Reserve. Although it appears some service treatment and service personnel records from his Reserve service have been obtained by VA, the bulk of the service treatment and service personnel records located in the claims file were submitted by the Veteran. Of the records reviewed by the Board, to include the Veteran's DD 214s, it is clear that the Veteran had active duty training in the Army National Guard from February 1979 to June 1979; a period of active duty in the Army Reserve that began on March 15, 2003, though there is no indication how long this period of active duty lasted; that he was attached to Ft. Stewart, Georgia, on November 7, 2003; that he had another period of active duty in the Army Reserve from March 2004 to July 2004; and that he was ordered to annual training between April 21, 2001, and May 4, 2001, and on April 21, 2005, though there is no indication how long the latter period of annual training lasted. The Veteran contends that he was treated for depression in 2003 while on active duty at Ft. Stewart. In that vein, he has submitted documents indicating that he attended group therapy classes for anger management, individual counseling, and outpatient therapy at Winn Army Community Hospital in Ft. Stewart, Georgia, in 2003. All treatment appears to be related to charges of domestic violence and the group therapy appears to have been conducted by the psychiatry clinic. See e.g., DA Form 3982. Given that the Veteran asserts he was treated for depression at Ft. Stewart while on active duty in 2003, and the record from this assumed period of active duty is incomplete, efforts should be made on remand to verify the Veteran's complete record of service in the Army Reserve and to request his complete service personnel and service treatment records associated with his Reserve period of service. In addition to the foregoing, while the Board acknowledges that VA was unsuccessful in obtaining records from Winn Army Community Hospital at Ft. Stewart, since the Veteran has submitted some records that were clearly generated by this facility, another attempt should be made to obtain the Veteran's complete clinical record from this facility. As noted above, although service personnel records indicate that the Veteran had a period of active duty beginning on March 15, 2003, there is no indication how long he was on active duty in 2003. The Veteran has submitted prescription records indicating that he was prescribed several medications to treat depression in 2003 and 2004. More specifically, he was prescribed Desyrel in August 2003, Prozac in September 2003, and Wellbutrin in May 2004 (during a verified period of active duty). VA records also document that an Axis I diagnosis of depression was made in March 2005, within one year of the Veteran's July 2004 discharge from a verified period of active duty (though the Board notes that depression is not listed as a psychotic disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and is, therefore, not subject to service connection on a presumptive basis pursuant to 38 C.F.R. § 3.309). Given the assertions raised by the Veteran, which include his assertion that he has received mental health treatment from 2003 to the present, and the evidence he has submitted in support of his claim, a VA examination should be scheduled on remand. Contemporaneous VA treatment records should also be obtained. Accordingly, the case is REMANDED for the following action: 1. Verify the dates and types of the Veteran's service in the Army Reserve. Complete copies of the Veteran's service treatment records, to include any clinical records, and service personnel records, should be obtained for any Reserve service. If no records can be found, indicate whether the records do not exist and whether further efforts to obtain the records would be futile. Document all efforts made in this regard. 2. Make a specific request to obtain the Veteran's complete clinical record from Winn Army Community Hospital at Ft. Stewart, Georgia, related to group therapy classes for anger management, individual counseling, and outpatient therapy, to include through the psychiatry clinic. 3. Obtain the Veteran's treatment records from the Orlando VA Medical Center, dated since May 2011. 4. Ascertain whether the Veteran has received VA treatment since relocating to Puerto Rico and if he has, obtain his complete record from the treating facility. 5. When the foregoing development has been completed, schedule the Veteran for a VA psychiatric examination. The examiner must review the claims file and any relevant electronic medical records. Any indicated studies should be conducted and the examiner should review the results of any testing prior to completion of the report. The examiner is requested to provide an opinion as to the diagnosis of all psychiatric disorders found to be present. The examiner must provide an opinion as to whether it is at least as likely as not (i.e., probability of 50 percent or greater) that any current psychiatric disorder had its onset during active duty training or active service or is related to any in-service disease, event, or injury. In providing this opinion, the VA examiner must consider the following: * documents indicating that the Veteran attended group therapy classes for anger management, individual counseling, and outpatient therapy at Winn Army Community Hospital in Ft. Stewart, Georgia, in 2003 (though it is unclear at the time of this remand whether this treatment was rendered during a period of active duty training or active duty); * that the Veteran was prescribed several medications for depression, to include Desyrel in August 2003 (though it is unclear at the time of this remand whether this treatment was rendered during a period of active duty training or active duty), Prozac in September 2003 (though it is unclear at the time of this remand whether this treatment was rendered during a period of active duty training or active duty), and Wellbutrin in May 2004 (during a verified period of active duty); and * that VA records document that an Axis I diagnosis of depression was made in March 2005, within one year of the Veteran's July 2004 discharge from a verified period of active duty. The examiner must provide a comprehensive report including complete rationales for all conclusions reached. 6. Review the claims folder and ensure that all of the foregoing development actions have been conducted and completed in full. If any development is incomplete, appropriate corrective action is to be implemented. 7. Finally, readjudicate the claim. If the benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case and provide an appropriate period of time to respond. The case should then be returned to the Board for further appellate review, if in order. The appellant has the right to submit additional evidence and argument on the matter 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 for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). _________________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2014).