BVA9505183 DOCKET NO. 92-23 293 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Des Moines, Iowa THE ISSUES 1. Entitlement to service connection for major depression, on the basis that it is proximately due to and a manifestation of a service-connected post traumatic stress disorder. 2. Entitlement to an increased evaluation for post-traumatic stress disorder (PTSD), currently rated as 10 percent disabling. REPRESENTATION Appellant represented by: AMVETS WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD Carolyn Wiggins, Associate Counsel INTRODUCTION The veteran served on active duty from April 1968 until April 1972. This appeal arises from a February 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Des Moines, Iowa which denied an increased evaluation for post- traumatic stress disorder and service connection for major depression. This case was previously remanded by the Board in May 1994 for a VA psychiatric evaluation and to obtain medical records. The increased rating issue will be addressed in the Remand portion of this decision. CONTENTIONS OF APPELLANT ON APPEAL The appellant contends that service connection for major depression should be established and asserts that the loss of his children in a fire while he was in service is the origin of his depression. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the evidence supports the grant of service connection for major depression, on the basis that it is proximately due to and a manifestation of the veteran's service connected post- traumatic stress disorder. FINDINGS OF FACT 1. The veteran has carried a diagnosis of both major depression and post-traumatic stress disorder since 1990. 2. On VA examination in July 1994 it was stated that there can be much overlap within post-traumatic stress disorder and major depression and that often an exacerbation of one illness will worsen the other. 3. The veteran's post-traumatic stress disorder is one cause of his major depression and the major depression is a manifestation of post-traumatic stress disorder. CONCLUSIONS OF LAW 1. Major depression is proximately due to and a manifestation of post-traumatic stress disorder. 38 C.F.R. § 3.310(a)(1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The veteran's claim is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). He has presented a claim which is plausible. The Board is satisfied that all relevant facts have been properly developed. No further assistance to the veteran is required in order to comply with the duty to assist him mandated by 38 U.S.C.A. § 5107(a) (West 1991). To establish service connection for a claimed disability, the facts as shown by evidence must demonstrate that a particular disease or injury resulting in current disability was incurred during active service or, if preexisting active service, was aggravated therein. 38 U.S.C.A. § 1110 (West 1991). Service connection may also 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)(1993). On service entrance examination in August 1968 the veteran's psychiatric evaluation was normal. Service medical records reflect that he requested an appointment at the Mental Health Clinic in October 1971. Nervousness and mild anxiety were noted. It was noted that the problem involved the death of children. He was given Valium. He returned a few days later, again saying he was nervous and that the Valium had given him no relief. He requested to see the medical officer and was referred to Neuropsychiatry (NP). A consultation sheet to the NP Clinic noted severe nervousness since the loss of his children in a fire in June, which was becoming more severe. The provisional diagnosis was moderate anxiety, probable situational reaction. There were no notes of an NP consultation. On service separation examination in March 1972 the psychiatric evaluation was normal. The records of the veteran's private physician in March 1988 contain a notation that he gave the veteran a depression handout. In April 1988 he returned for treatment for depression. Mild depression was noted. Imipramine was prescribed. Private medical records reveal that the veteran sought counseling in October 1988 for assistance in dealing with anger, depression and intrusive thoughts. A VA psychiatric evaluation in November 1990 notes that he had been seeing a social worker for counseling for combat trauma and depression since 1988. It also notes that he was seeing his family physician who prescribed Imipramine. The examiner recorded that his wife reported that he had been in a low mood for the last four or five years which was accompanied by fatigue, weight gain, strong and pervasive feelings of worthlessness and uselessness, insomnia and a diminished ability to make decisions and take responsibility. She said when he came back from Vietnam he was angry and drank heavily, but after the death of the two children in the house fire in 1971 he became more depressed. Moderate chronic major depression was diagnosed. The private medical records reflect treatment for depression through 1990. On VA examination in November 1990 major depression and post- traumatic stress disorder were diagnosed. The physician and psychologist who signed the report stated that the combined stressors of experiences in Vietnam and losing his children in a fire are etiologically related to PTSD and to his major depression. A VA psychiatric evaluation in August 1991, was requested by the RO to determine what symptoms the veteran exhibited that were attributable to his service-connected post-traumatic stress disorder and which were attributable to his depression. The examiner described his symptoms of depression as depressed mood, a significant change in weight some time in the past, insomnia, fatigue, feelings of worthlessness and recurrent thoughts of death. He again was diagnosed with post-traumatic stress disorder and major depression. This case was remanded by the Board in May 1994 to determine if there was a causal connection between his service-connected post- traumatic stress disorder and his major depression. The VA in July 1994 conducted another psychiatric evaluation of the veteran. The examiner noted that he had had difficulty with depression most likely since his military experience. However, he did not seek help for these symptoms until 1988, after a friend encouraged him. Post-traumatic stress disorder and major depression were diagnosed. The examiner attempted to separately describe the symptoms of post-traumatic stress disorder and major depression . However, he noted that there could be much overlap with post-traumatic stress disorder and a major depressive disorder and that often an exacerbation of one illness will worsen the other. Several observations are in order here. First, neurotic symptoms associated with the death of the veterans children were recorded in service medical records. Second, when post service psychopathology surfaced in the late 1980's, depression was a prevalent symptom. And lastly, The VA physician who saw the veteran in 1994 indicated an overlapping of symptoms of post- traumatic stress disorder and major depression. These disorders cannot be satisfactorily differentiated for rating purposes. 38 C.F.R. § 4.14 (1994). Major depression is considered to be one of the manifestations of post-traumatic stress disorder. ORDER Service connection for major depression as proximately due to and a manifestation of post-traumatic stress disorder, is granted. REMAND In view of the grant of service connection for major depression, it is now appropriate that one rating be assigned for the currently service connected psychiatric disorder, classified as PTSD with major depression. As such, the case is REMANDED for the following action: The rating board should reevaluate the service connected psychiatric disorder as post-traumatic stress disorder with major depression. When the above development is completed the veteran should be informed of the determination made by the issuance of a supplemental statement of the case. If the appeal is not thereafter withdrawn by the veteran, the case should be returned to the Board for further appellate consideration. No action is required of the veteran unless notified. The purpose of this remand is to ensure due process of law. BRUCE E. HYMAN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. 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) (1994).