Citation Nr: 1313167 Decision Date: 04/19/13 Archive Date: 05/02/13 DOCKET NO. 08-24 483 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for depression. 2. Entitlement to service connection for headaches, to include as secondary to depression. REPRESENTATION Appellant represented by: Vietnam Veterans of America ATTORNEY FOR THE BOARD D.S. Lee, Counsel INTRODUCTION The Veteran served on active duty from February 1980 through June 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota, which declined to reopen the Veteran's claim for service connection for depression and denied service connection for headaches, to include as secondary to hearing loss and tinnitus. This matter was subsequently remanded by the Board in July 2010 for further development, to include: verifying the Veteran's representative as being Vietnam Veterans of America; obtaining in-service clinical treatment records from Ft. Leonard Wood Hospital; obtaining personnel records from the Veteran's reported National Guard service from April 1978 through June 1982; obtaining VA treatment records for treatment from January 1983 through December 1998, from October 2002 through April 2007, and from July 2007 through the present; obtaining treatment records from January 1998 through 2000; and arranging the Veteran for a VA examination of his claimed depressive disorder. After some efforts were made to comply with the directed remand action, the matter was returned to the Board. In August 2011, the Board remanded this matter again, after determining that the previously directed remand actions were not performed adequately. The development actions directed in the prior July 2010 and August 2011 remands have been performed. The Board is prepared to proceed with its de novo consideration of this matter. In this regard, the Board notes that the Veteran's original claim for service connection for depression was denied in an unappealed January 2003 rating decision. In August 2007, the Veteran submitted copies of service personnel records in support of his claim that had not been previously associated with the claims file at the time of the unappealed January 2003 decision. The RO denied the Veteran's application to reopen the claim in a January 2008 rating decision. As explained in the Board's 2010 remand, VA regulations provide that if relevant service department records are associated with the claims file after VA issues a decision on a claim, VA will reconsider the claim without regard to the provisions of 38 C.F.R. § 3.156(a) (2012), which provide for the standard for reopening previously denied claims based on new and material evidence. 38 C.F.R. § 3.156(c) (2009). Consequently, the issue was then recharacterized on the title page as entitlement to service connection for depression. See 38 C.F.R. § 3.156(c). The issue of the Veteran's entitlement to service connection for headaches, to include as secondary to depression is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT The Veteran has a current diagnosis of depressive disorder, not otherwise specified (NOS); however, the evidence does not show that the depressive disorder, NOS was sustained during service or is otherwise related to the Veteran's active duty service. CONCLUSION OF LAW The criteria for service connection for depression have not been met. 38 U.S.C.A. §§ 1131, 1153, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010) and 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical evidence or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). In accordance with 38 C.F.R. § 3.159(b)(1) , proper notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. VA's notice requirements apply to all five elements of a service-connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice should be provided to a claimant before the initial unfavorable decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). Regarding the issue of the Veteran's entitlement to service connection for depression, a pre-rating letter mailed to the Veteran in December 2007 notified him of the information and evidence needed to substantiate his claim. Consistent with Dingess, this letter also notified the Veteran that a disability rating and an effective date are assigned where a disability is determined to be service-connected. After affording the Veteran reasonable opportunity to respond, his claim was adjudicated in the RO's January 2008 rating decision. Thus, because the VCAA notice that was provided before service connection was granted was legally sufficient, VA's duty to notify has been satisfied. VA has also fulfilled its duty to assist in obtaining identified and available evidence needed to substantiate the Veteran's claims. The Veteran's service treatment records (to include clinical treatment records from Ft. Leonard Wood Army Hospital), service personnel records, and identified and pertinent VA and private treatment records have been associated with the claims file. The Veteran was also afforded VA examinations of his depression in August 2002, July 2010, and September 2011 to determine the nature and etiology of his depression. Further, an expert psychiatric opinion was obtained in January 2013 to examine any possible relationship between the Veteran's depressive disorder and concurrent personality disorder. The Veteran's claims file was reviewed by the examiners in conjunction with the VA examinations and expert opinion. Ultimately, the Board finds that these examinations and opinions, along with the other evidence of record, are fully adequate for the purposes of determining the etiology of the Veteran's depression. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Overall, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. II. Service Connection for Depression Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Notwithstanding the lack of evidence of disease or injury during service, service connection may still be granted if all of the evidence, including that pertinent to service, establishes that the disability was incurred in service. See 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503, 505 (1992). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107(b). In addition, the Board notes that personality disorders are not diseases or injuries within the meaning of applicable legislation. 38 C.F.R. §§ 3.303(c), 4.9 (2012). Service connection may be granted for diseases of congenital, developmental or familial origin if the evidence as a whole establishes that the conditions in question were incurred or aggravated during service. VAOPGCPREC 82-90 (July 18, 1990). However, disability resulting from a mental disorder that is superimposed upon a personality disorder may be service-connected. See VAOPGCPREC 82-90; 38 C.F.R. § 4.127 (2012). In a July 2002 statement submitted in support of his original claim for service connection for depression, the Veteran alleged that he experienced depression during his active duty service while stationed at Ft. Bliss, Texas, due to distress related to his mother's illness and his inability to care for her. He alleged further that he was treated during service for depression at Ft. Leonard Wood Army Hospital. In his August 2007 request to reopen his claim, he realleged the facts raised in his July 2002 statement, and added that he drank alcohol and took medications during service to manage his depression symptoms. In further support of his assertion that he was treated during service for depression, he also alleged in an October 2007 statement that he was discharged from service after he fell asleep while on duty due to side effects from psychiatric medications that were purportedly prescribed during service. Despite the Veteran's assertions, a careful review of the service treatment records and service personnel records in the claims file do not corroborate the Veteran's claims of in-service depression or psychiatric treatment. In that vein, the service treatment records do not reflect any complaints of psychiatric symptoms or any psychiatric treatment during service, nor do they reflect that any psychiatric medications were prescribed. A Report of Medical History completed by the Veteran in May 1982, just prior to his separation from service, reflects that the Veteran expressly denied any history of psychiatric problems, to include depression or excessive worry. Indeed, a psychiatric examination performed during his separation examination was normal, although he did report a history of nervous trouble at that time. Similarly, clinical treatment records obtained from Ft. Leonard Wood Army Hospital do not reflect any psychiatric treatment at that facility; in that regard, the records from that facility do not mention any psychiatric complaints or treatment. Also contrary to the Veteran's assertions, the service personnel records do not corroborate that he was separated from service due to sleeping on duty due to his purported psychiatric medications. In that regard, the Board acknowledges that the Veteran was disciplined in August 1981 on one occasion for sleeping while on duty. However, records related to disciplinary proceedings which ultimately resulted in the Veteran's separation indicate that the Veteran's performance of his duties was marked by multiple instances of insubordination toward civilian supervisors and inappropriate conduct toward other service members. These records, which include multiple statements from the Veteran's supervisors, show that the Veteran was ultimately separated from service in June 1982 for demonstrating a poor attitude and performance. Despite the Veteran's assertions that he received psychiatric treatment after service at Cook County Hospital, once again, there is simply no evidence in the record that supports the Veteran's assertions. In that regard, records obtained via the Veteran's signed VA Form 21-4142 release reflect only that he was treated at that facility in November 1996 for complaints related to a persistent cough and left shoulder symptoms. Post-service VA treatment records from the VA Medical Center in Chicago, Illinois reflect that the Veteran began treating for complaints of depression in 2001. During a psychiatric evaluation and treatment in July 2001, he reported symptoms of major depression which included inability to sleep, depressed mood, markedly diminished interest in all activities, insomnia or hypersomnia, psychomotor agitation, indecisiveness, difficulty concentrating, and recurring thoughts of death and suicide. During mental status examination, the Veteran acknowledged use of illicit substances and demonstrated poor grooming, pressured speech, anxious mood, blunted affect, and poor insight and judgment. At that time, the Veteran was diagnosed with substance-induced mood disorder (SIMD). The Veteran was subsequently enrolled in a group therapy program which he attended through August of 2001. After the Veteran failed to appear for multiple scheduled group therapy sessions, he was discharged from care. Records from The Vet Center, dated from June 2001 through January 2002, reflect that the Veteran was also treated for his psychiatric complaints at that facility during that time. Although these records indicate ongoing complaints of depression and anger, they do not indicate any specific diagnosis, nor do they reflect any opinion relating to the cause or origin of those symptoms. In January 2002, the Veteran sought VA treatment at the VAMC in Minneapolis, Minnesota, reporting various social stressors which included being on the verge of being evicted, being unemployed, and having financial difficulties which were resulting in inability to pay his bills. He stated that he had recently moved from Chicago to Minneapolis/St. Paul to seek out employment and that he initially stayed with a friend before she "went crazy" and asked the Veteran to leave. The Veteran related that he had been wandering the streets for the past several days and that during that time, he had "lost time", been involved in a confrontation with the driver of a moving truck, and had thoughts of suicide. During the examination, the Veteran appeared to feel better upon presentation; however, after being told that he would be discharged because the hospital was unable to keep him strictly for his housing and job needs, stated again that he had no reason to live and that he might as well kill himself. A mental status examination of the Veteran was grossly normal. Although the Veteran was apparently hospitalized, attending physicians opined that the Veteran did not have any psychiatric needs and had no need for in-patient care. The Veteran was diagnosed with depressive disorder, NOS, and psychotic disorder, not otherwise specified, versus substance-induced mood disorder and substance-induced psychotic disorder. During an August 2002 VA examination, the Veteran reported ongoing psychiatric symptoms. During mental status examination, he demonstrated some tension and underlying depression, hopelessness, isolation, and uncertainty, and reported that he was having difficulty falling asleep. He endorsed ideas of reference and auditory hallucinations during periods of depression. Socially, he stated that he was isolated; having no friends and stating that his whole family was "addicted." A multi-axis diagnosis included an Axis I diagnosis of depressive disorder, NOS with various severe psychosocial stressors which included the Veteran's unstable living and work situations and financial problems. Despite these noted stressors, the examiner opined that the Veteran's mental health problems were present during service and were ongoing since that time. It is unclear from the report as to the examiner's reasons and bases for this opinion. Subsequent treatment records from the Minneapolis VAMC through June 2010 reflect that the Veteran continued to be treated at that facility for depression, NOS. Overall, these records show that the Veteran's symptoms were well-managed by medication and individual therapy treatments. Once again, however, the VA treatment records do not provide any opinion as to the cause or origin of the Veteran's depression. In July 2010, the Veteran was afforded a new VA examination to explore the nature and etiology of his depressive disorder. During the examination, the Veteran indicated that he was relatively active socially, reporting that he maintained weekly contact with his mother and siblings and had frequent contact with his eight friends. In terms of his activities, he stated that he generally preferred to be alone and stayed home to read or watch television. He also reported, however, that he rode his bike and occasionally invited friends over. Regarding his symptoms, the Veteran reported daily depression, hatred and distrust toward others, frustration, and the feeling that he was being accused by others for doing things that he did not do. He also endorsed feelings of hopelessness and worthlessness. Although the Veteran reported that he was still able to have fun, he did acknowledge the overall loss of pleasure in activities. During mental status examination, the Veteran was observed wringing his hands and demonstrating tense psychomotor activity. His speech was loud and indicative of hostile, suspicious, and sarcastic attitude toward the examiner. His demonstrated mood was agitated and labile. The Veteran stated that without his medications, he had difficulty falling asleep. He also reported instances of panic, including an instance in which he had a verbal altercation with a group of teenagers. The Veteran also endorsed homicidal ideation, stating that he sometimes thought of killing people who were driving. He also reported having suicidal thoughts during times of anger. Impulse control was noted as being poor, marked by quick temper and poor self-control. Based upon the Veteran's reported psychiatric history, a review of the claims file, and the findings from the examination, the examiner diagnosed depression, NOS and concurrent personality disorder. During the interview, the Veteran was unable to recall specific dates and places for his purported in-service psychiatric treatment. He continued to report that he received psychiatric treatment at Cook County Hospital. Nonetheless, consistent with the Board's own review of the record, the examiner noted that there was no indication in the record of any in-service psychiatric treatment. Moreover, the examiner noted that records in the claims file obtained from Cook County Hospital did not indicate any psychiatric treatment. Overall, the examiner noted that the Veteran did not begin receiving psychiatric treatment until more than 20 years after his separation form service, and moreover, indicated a history of chemical dependency issues and personality disorder characteristics. In view of the same, the examiner concluded that it is less likely than not that the Veteran's current depression is related to his active duty service. During a September 2011 VA examination, the Veteran reported ongoing symptoms of sleep difficulties, problems with attention, increased irritability, daily depression, isolative behavior, needing to drink in order to help himself sleep, verbal and physical confrontations with other people, low energy level, poor motivation, poor concentration, loss of pleasure in activities, and feelings of hopelessness and worthlessness. During the interview, the Veteran demonstrated some paranoid thought, stating that "people will hurt you, lie to you, put one over on you, and in general take advantage of you whenever they can because that's how people are." He reported current marijuana use and that he drank a 12 pack of beer or a quart of whiskey on weekends. During mental status examination, the Veteran demonstrated a flat affect and agitated mood. As noted above, thought content included some paranoid ideation. Although the Veteran stated that he wished he were dead, he denied having any specific plan. Impulse control was deemed as being only fair and marked by episodes of anger and violence as noted above. Consistent with the previous treatment and evaluations, the examiner again provided an Axis I diagnosis of depression, NOS and a concurrent Axis II diagnosis of personality disorder with paranoid features. The Veteran continued to report that he was depressed during service due to guilt related to his mother's illness and his inability to take care of her. He also continued to allege that this depression led to him having a bad attitude during service and subsequently being discharged from service. Nonetheless, and also consistent with the Board's own review of the record, the examiner also noted that there was no evidence in the record of any psychiatric treatment until 20 years after the Veteran's separation from service. Further, the examiner noted that there was no evidence of depression in the record either during service or in the 1980s. Accordingly, the examiner concluded that the Veteran's depression is less likely as not related to his active duty service. In view of the concurring diagnoses of depression, NOS and personality disorder expressed in the January and August 2002 VA opinions, the Board sought an outside expert psychiatric opinion from Dr. V.P. Specifically, the expert was asked to address whether the Veteran's personality disorder was subject to a superimposed disease or injury sustained during active duty service, and if so, whether it is at least as likely as not that the Veteran's current depressive disorder had its onset in, or was otherwise related to, his active duty service. Based upon her review of the claims file, Dr. V.P. opined that the Veteran's personality disorder was not subject to a superimposed disease or injury during active duty service. In support of her opinion, she noted again that the Veteran was apparently separated from service due to "lack of motivation, promotion potential, poor attitude, failure to follow instructions from your superiors, and your failure to rehabilitate" (quoting the Veteran's June 1982 expeditious discharge). Dr. V.P. also noted that the Veteran's service was marked by multiple disciplinary actions following incidents of abusive and threatening language toward other servicemen and servicewomen as well as multiple instances of his refusal to follow orders and instructions from civilian superiors. She notes that by the Veteran's own June 1982 statement, he alleged that his problems were due to his feeling let down by the Army by not being allowed to "soldier with other soldiers" and moreover, blamed his behavior on the fact that he was not permitted to transfer out of his work area on his own request. Pertinently, he did not cite family problems, emotional distress, or depression as being a contributing or mitigating factor for the behavior that ultimately led to his discharge. Further, Dr. V.P. also noted that there was no evidence in the record that the Veteran ever received treatment during service for depression or other psychiatric complaints. Although the expert acknowledged the statements from the Veteran's sisters that he appeared to be depressed, gloomy, and quick-tempered after his separation from service, the expert noted that even though having a sad or depressed mood may occur in a variety of circumstances, this does not necessarily constitute a psychiatric mood disorder. In her reasoned analysis, Dr. V.P. acknowledged that the Veteran's service records appear to indicate that he initially performed well during basic and advanced training; however, began to manifest behavioral problems around March 1981 and in the context of work situations in which he was unhappy. She noted that this finding is consistent with a personality pathology, rather than the development of major depression or other mental health condition. Dr. V.P. reasoned that if the record had indicated several years of exemplary conduct, and then in the same work environment the Veteran began to exhibit conduct problems out of the blue, such a behavioral pattern might lend more credence to the possibility of an Axis I psychiatric disorder. However, such a pattern was not the case here. Dr. V.P. also pointed out that the evidence indicated that the Veteran had a longstanding alcohol and substance abuse problem which would appear to suggest the possibility of a substance-induced mood disorder. Overall, she determined, the record appears to indicate that there was no superimposed disease or injury during active duty service, but rather, a reaction with pre-existing personality disorder by a young man who was unhappy with his work environment. The expert determined further that it is not likely that the Veteran's current depressive disorder had its onset during service, or was otherwise related to his active duty service. In that regard, the expert noted again that there is simply no evidence in the record of any treatment for depression prior to 1998, which is consistent with the conclusion that depression was not present or manifest during the 16 years between the Veteran's separation from service and his initial psychiatric treatment. Having reviewed the record, the Board concludes that the weight of the evidence in this case is against the Veteran's claim for service connection for depression. In essence, the Board concludes that the preponderance of the evidence is against finding that his personality disorder was subject to any superimposed injury or disease in service, or that his current depression was otherwise incurred in or aggravated by service. As such, the Veteran's claim in that regard must be denied. As noted above, the evidence shows that the Veteran did not receive any psychiatric treatment during his active duty service. Although he has alleged that he experienced depression and was medicated for depression during service, the service records in the claims file are wholly inconsistent with such allegations. Similarly, the post-service evidence shows that the Veteran did not treat, much less report, his psychiatric symptoms until 2001, nearly 20 years after his separation from service. Although the post-service treatment records indicate a current diagnosis of depressive disorder, NOS, the evidence does not show that this disorder is related in any way to the Veteran's active duty service. As noted above, an August 2002 VA opinion expresses the conclusion that the Veteran's depressive disorder, NOS was present during service and was continuing. Nonetheless, there is no explanation of the reasons or bases for that examiner's opinion expressed anywhere in the August 2002 report. In the absence of such a reasoned rationale, the Board does not assign the August 2002 opinion significant probative weight. Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (holding that in assessing medical opinions, the physician's failure to provide a basis for the stated opinion goes to the weight or credibility of the evidence in the adjudication of the merits). By contrast, the negative July 2010, September 2011, and January 2013 opinions are supported by a complete discussion which reflects the relevant facts and evidence and a full and accurate understanding of the Veteran's psychiatric history that is consistent with the facts shown in the record. In view of the same, the Board is inclined to assign far greater probative weight to these opinions than it does to the August 2002 opinion. Owens v. Brown, 7 Vet. App. 429, 433 (1995) (holding that the Board's duty is to assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, may favor one medical opinion over another). The only other evidence in the record concerning the etiology of the Veteran's depression is contained in the lay statements received from the Veteran and his sisters. In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In that regard, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder). In view of the foregoing law, the Veteran and his sisters are certainly competent to provide probative statements as to the history and severity of any observed symptoms they believe to be related to the Veteran's current depressive disorder. Nonetheless, given the numerous psychosocial stressors reflected in the Veteran's post-service records (which include financial strain, periods of unemployment, periodic uncertainty as to employment and living arrangements), concurrent substance abuse, and the apparent existence of a concurrent personality disorder, the questions of what caused the Veteran's depressive disorder or when such order had its onset are complex ones. Indeed, as noted in Dr. V.P.'s January 2013 opinion, the Veteran's sister's observations that the Veteran was depressed, gloomy, and quick-tempered after service do not, in and of themselves establish the presence of a psychiatric disorder. Dr. V.P. explained that the Veteran's service records appear to indicate that he initially performed well during basic and advanced training; however, began to manifest behavioral problems around March 1981 and in the context of work situations in which he was unhappy. She indicated that this finding is consistent with a personality pathology, rather than the development of major depression or other mental health condition. Dr. V.P. also noted that having a sad or depressed mood may occur in a variety of circumstances, and that this does not necessarily constitute the onset or presence of a psychiatric mood disorder. In view of these complicating factors, and as neither the Veteran nor his sisters are competent to render an opinion as to the complex question of the cause of his depressive disorder, NOS, the Board finds the history of symptoms and observations provided by the Veteran and his sisters to be of very little probative value. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen v. Brown, supra. As such, the Board also places far less probative weight on these lay assertions than it does on the aforementioned VA and outside expert opinions. Even if the Board were able to find that the Veteran was competent to opine as to the cause and origin of his depressive disorder, NOS, his assertions in this case carry grave credibility concerns which also undermine their probative value. As noted above, the Veteran's assertions that he received treatment for depression during service are not supported by the evidence. Further, his assertions as to the circumstances of his discharge from service (namely, that he was discharged from service due to falling asleep due to his purported in-service medications) are contrary to the personnel records contained in the claims file. Even the Veteran's assertions that he was treated for depression prior to 2001 at Cook County Hospital are wholly contradicted by the records obtained from that facility. In view of these credibility concerns, the Board would be unable to assign significant probative weight to the Veteran's assertions concerning the onset and duration of his depression. The Board has also considered the representative's argument that the opinion of Dr. V.P. is inadequate because she did not consider the Veteran's report of having experienced "depression or excessive worry" and "nervous trouble of any sort" at separation. First, the Board notes that the Veteran qualified his report of nervous trouble to the examiner at that time by explaining that he often experienced nervousness when he was being examined. Also, it does not appear that the Veteran did report "depression or excessive worry" at separation. Although it appears that the box was initially checked, the Veteran clearly scratched it out and then checked that he had not experienced such service. Even assuming he did, however, as discussed in detail above, Dr. V.P. explained in detail while feelings of unhappiness regarding the circumstances of his service would be entirely consistent with a personality pathology, rather than signifying the onset of the development of major depression or other mental health condition. Dr. V.P. also explained that having a sad or depressed mood may occur in a variety of circumstances, and this does not necessarily constitute the onset or presence of a psychiatric mood disorder. In light of this rationale, and given that Dr. V.P. clearly reviewed the evidence of record in detail, including service records, the Board finds the failure of Dr. V.P. to specifically note the details of the medical history form completed at separation does not in any way render her opinion inadequate. The representative has also argued that Dr. V.P.'s opinion was inadequate because she did not note the specific type of personality disorder that was responsible for the Veteran's disciplinary problems. The Board notes, however, that her opinion was drafted in response to the Board's request, which did not ask her to identify the nature of the personality disorder. Rather, the Board's request referenced the Axis II diagnosis of personality disorder, not otherwise specified, that was rendered during both of the last two VA examinations conducted in this case. In essence, the Board had determined that the nature of the personality disorder had been established, and that it was the issue of whether such disorder had been subject to a superiposed injury to which she should focus her opinion. For this reason, the Board finds that the fact that Dr. V.P. did not identify the specific nature of the personality disorder also does not in any way render her opinion inadequate. Overall, the preponderance of the evidence is against the Veteran's claim of service connection for depression, and this claim must be denied. In reaching this determination, the Board again acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is inapplicable in this case because the preponderance of the evidence is against the Veteran's claim. See Gilbert, 1 Vet. App. at 55; 38 U.S.C.A. § 5107(b). ORDER Service connection for depression is denied. REMAND In relation to his claim for service connection for headaches, to include as secondary to depression, the Board notes that although service connection for depression has been denied, the Veteran is not precluded from establishing service connection for headaches on a direct basis. Subject to the above, service treatment records show that the Veteran was treated on multiple occasions for tension headaches beginning in January 1980 and over the remainder of his active duty service. Following his separation from service, the Veteran was afforded a VA examination for his claimed headaches in August 2002. In the corresponding report, the examiner opined that the Veteran's headaches were related to his in-service headaches. The examiner did not, however, provide any rationale or point to any supporting facts in support of his opinion. As such, the August 2002 opinion is incomplete and does not permit the Board to make a determination as to whether the Veteran's headaches are related to his active duty service. Subsequent post-service VA treatment records through June 2010 do not reflect any treatment for headaches. Indeed, a September 2002 record reflects that the Veteran reported that although he had a history of cluster headaches, his headaches had, for the most part, stopped. Nonetheless, during his September 2011 VA examination for depression, the Veteran appeared to indicate that his headaches had returned and had worsened over the preceding few months. No opinion was provided as to the nature or etiology of the reported headaches. Given the incompleteness of the August 2002 opinion and the apparent absence of headaches during the period from August 2002 through September 2011, the Veteran should be arranged to undergo a new VA examination to explore the nature of any current headaches, and, whether they are related to the Veteran's in-service tension headaches or to any other injury or illness sustained by the Veteran during his active duty service. 38 C.F.R. § 3.159(c)(4). Prior to arranging the examination described above, in order to insure that the most complete and up-to-date evidence has been associated with the claims file, the Veteran should be asked to identify any private or VA treatment providers who have rendered treatment for his headaches since June 2010. VA must then make efforts to obtain any treatment records that are identified by the Veteran. 38 C.F.R. § 3.159. Accordingly, the case is REMANDED for the following action: 1. A letter should be sent to the Veteran explaining, in terms of 38 U.S.C.A. §§ 5103 and 5103A, the need for additional evidence regarding his claim of entitlement to service connection for headaches. This letter must also inform the Veteran about the information and evidence that is necessary to substantiate his claim and provide notification of both the type of evidence that VA will seek to obtain and the type of evidence that is expected to be furnished by the Veteran. The letter must also notify the Veteran that VA is undertaking efforts to arrange a VA examination for his claimed headaches. The Veteran should be advised that it remains his responsibility to report for the scheduled VA examination and to cooperate with the development of his claim; failure to report without good cause may result in denial of his claim. The Veteran should also be provided a VA 21-4142 release and be asked to identify the name(s) and current address(es) for any private and/or VA treatment providers who have provided treatment for his headaches since June 2010. 2. Make efforts to obtain any private or VA treatment records identified by the Veteran. Any records obtained as a result of such efforts should be associated with the claims file. If such efforts yield negative results, a notation to that effect should be inserted in the file. The Veteran and his representative are to be notified of unsuccessful efforts in this regard, in order to allow the Veteran the opportunity to obtain and submit those records for VA review. 3. After the development actions described above have been performed to the extent possible, the Veteran should be afforded a VA examination, with an appropriate examiner, to determine the nature, severity, and etiology of the Veteran's headaches. The Veteran's claims file should be made available to the examiner prior to the examination, and the examiner is requested to review the entire claims file in conjunction with the examination. All tests and studies deemed necessary by the examiner should be performed. Based upon the review of the claims file, the relevant information obtained from the examiner's interview of the Veteran, and the clinical findings from the examination, the VA examiner is requested to offer an opinion as to whether it is at least as likely as not (i.e., at least a 50 percent probability) that the Veteran's current headaches are related to the headaches sustained by the Veteran during his active duty service, or to any other illness or injury sustained by the Veteran during his active duty service. A complete rationale should be given for all opinions and conclusions. Such rationale must include a discussion of all relevant evidence in the claims file (to include the Veteran's service treatment records; lay statements from the Veteran and his sisters; post-service treatment records; and previous VA examination reports), relevant findings on examination and from the Veteran's stated history, and applicable medical principles. All findings, conclusions, and supporting rationale should be expressed in a typewritten report. 4. If the Veteran fails to report to the scheduled examination, the RO must obtain and associate with the claims file a copy of any notice(s) of the date and time of the examination sent to the Veteran by the pertinent VA medical facility. 5. After completion of the above development, the issue of the Veteran's entitlement to service connection for headaches should be readjudicated. If the determination remains adverse to the Veteran, he and his representative should be furnished with a supplemental SOC and be given an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or 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 of Veterans' Appeals 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 Supp. 2012). ______________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs