Citation Nr: 1313404 Decision Date: 04/22/13 Archive Date: 05/03/13 DOCKET NO. 08-12 025 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUE Entitlement to service connection for a psychiatric disorder claimed as depression. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD C. Bruce, Counsel INTRODUCTION The Veteran served on active duty from October 10, 1984 to April 10, 1985 and from October 2004 to December 2005, including service in Iraq. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts, which denied the benefit sought on appeal. The Veteran testified at a hearing before the undersigned Veterans Law Judge in September 2010. A transcript of that hearing is of record. In January 2011 and June 2012, the Board remanded the Veteran's appeal to the RO via the Appeals Management Center (AMC), in Washington, D.C., for further development. That development having been achieved, the issue is now ready for appellate review. FINDINGS OF FACT 1. The Veteran's depression clearly and unmistakable preexisted her military service. 2. There is no clear and unmistakable evidence that the Veteran's pre-existing depression underwent a chronic worsening or permanent increase in severity during or as a result of active service. 3. The competent and credible evidence fails to demonstrate that the Veteran has depression that is etiologically related to or aggravated by any qualifying period of service. CONCLUSION OF LAW The criteria for service connection for depression have not been met. 38 U.S.C.A. §§ 1110, 1111, 1131, 1153 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.306 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA's Duties to Notify and Assist Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of (1) the information and evidence not of record that is necessary to substantiate a claim, (2) which information and evidence VA will obtain, and (3) which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159 (2012); see also 73 Fed. Reg. 23,353-6 (April 30, 2008) (codified at 38 C.F.R. § 3.159 (May 30, 2008)). See Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). After careful review of the claims file, the Board finds that the letter dated in June 2006 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1) (2012); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). In this regard, this letter advised the Veteran what information and evidence was needed to substantiate the claim decided herein. This letter also requested that the Veteran provide enough information for the RO to request records from any sources of information and evidence identified by the Veteran, as well as what information and evidence would be obtained by VA, namely, records like medical records, employment records, and records from other Federal agencies. The United States Court of Appeals for Veterans Claims (Court) issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006) which held that the VCAA notice must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The June 2006 letter provided this notice to the Veteran. The Board observes that the June 2006 letter was sent to the Veteran prior to the May 2007 rating decision. The VCAA notice with respect to the elements addressed in this letter was therefore timely. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). In this regard, the notice provided in the June 2006 letter fully complied with the requirements of 38 U.S.C.A. § 5103(a), 38 C.F.R. § 3.159(b) (2008), and Dingess, supra. Therefore the Board concludes that the requirements of the notice provisions of the VCAA have been met, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. The Board finds that VA has also fulfilled its duty to assist the Veteran in making reasonable efforts to identify and obtain relevant records in support of the Veteran's claims and providing a VA examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4)(i) (2012). In this regard the Board notes that the Veteran's service treatment, Vet Center records, and VA treatment records were included in the claims file and were reviewed in relation to the claim. In January 2011 and June 2012 the Board remanded the issue to the agency of original jurisdiction (AOJ) for additional development. A remand by the Board confers on the appellant, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that the above stated issue was previously remanded to obtain complete treatment records, including outstanding private and VA treatment records, as well afford the Veteran a VA examination to include an etiological opinion. The records having been obtained, to the extent they were available, and requested examination having been afforded, the issue now returns to the Board for appellate review. The Board recognizes a duty to provide a VA examination when the record lacks evidence to decide the Veteran's claim and there is evidence of (1) a current disability or persistent or recurrent symptoms of disability, (2) an in-service event, injury, or disease, and (3) some indication that the claimed disability may be associated with the established event, injury, or disease. 38 C.F.R. § 3.159(c)(4)(i) (2012); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran was afforded VA examinations in March 2007 and March 2011. 38 C.F.R. § 3.159(c) (4). To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In this regard, the Board finds that the March 2011 examination obtained in this case is more than adequate, as it collectively considered all of the pertinent evidence of record including the statements of the Veteran, and provided a complete rationale for all opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issue on appeal has been met. 38 C.F.R. § 3.159(c) (4) (2012). With regard to the September 2010 Travel Board hearing, in Bryant v. Shinseki, 23 Vet App 488, 496-97 (2010), the Court held that the Veterans Law Judge who chairs a Board hearing fulfill two duties to comply with 38 C.F.R. § 3.103(c)(2). These duties consist of (1) fully explaining the issues pertinent to the claim(s) on appeal and (2) suggesting the submission of evidence that may have been overlooked. See also 38 C.F.R. § 3.103(c)(2). At the September 2010 hearing, the Veterans Law Judge and representative for the Veteran outlined the issue on appeal and engaged in a colloquy with the Veteran as to substantiation of the service connection claim. This hearing was fully adequate. Further, with respect to any evidence that may have been overlooked, the Board remanded the case on two occasions after the hearing to ensure that the Veteran's complete treatment records were obtained and that a medical opinion was obtained. Therefore, any deficiency in this regard is nonprejudicial. Under the circumstances of this case, "the record has been fully developed," and "it is difficult to discern what additional guidance VA could have provided to the Veteran regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). Furthermore, as discussed above, the Board finds that there has been substantial compliance with its January 2011 and June 2012 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (a remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand instructions, and imposes upon the 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); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Therefore, the Board is satisfied that VA has complied with the duty to assist requirements of the VCAA and the implementing regulations and the record is ready for appellate review. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). As a general matter, service connection for a disability on the basis of the merits of such a claim requires (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the current disability and the in-service disease or injury (or in-service aggravation). Holton v. Shinseki, 557 F.3d 1362, 1355 (Fed. Cir. 2009). The absence of any one element will result in the denial of service connection. Coburn v. Nicholson, 19 Vet. App. 427, 431 (2006). If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b) (2012). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2012). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Lay persons can also provide an eye-witness account of an individual's visible symptoms. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). Under the benefit-of-the-doubt rule embodied in 38 U.S.C.A. § 5107(b), in order for a claimant to prevail, there need not be a preponderance of the evidence in the veteran's favor, but only an approximate balance of the positive and negative evidence. In other words, the preponderance of the evidence must be against the claim for the benefit to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1994). Every Veteran shall be taken to have been in sound condition when examined, accepted and enrolled in service, except for defects, diseases, or infirmities noted at the time of entrance, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto and was not aggravated therein. See 38 U.S.C.A. § 1111 (West 2002). According to 38 C.F.R. § 3.304(b) (2012), the term "noted" denotes only such conditions that are recorded in examination reports. The existence of conditions prior to service reported by the Veteran as medical history does not constitute a notation of such conditions, but will be considered together with all other material evidence in determining the question of when a disease or disability began. See 38 C.F.R. § 3.304(b)(1) (2012). Determinations of whether a condition existed prior to service should be "based on thorough analysis of the evidentiary showing and careful correlation of all material facts, with due regard to ... manifestations, clinical course, and character of the particular injury or disease or residuals thereof." Id.; see also Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir 2004) (concluding that "if a preexisting disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder."). Thus, there is a rebuttable presumption of soundness unless a condition is noted at entry. VA's General Counsel has held that to rebut the presumption of sound condition under 38 U.S.C.A. § 1111, VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). See also Wagner, supra; 38 U.S.C.A. § 1153 (West 2002). Concerning clear and unmistakable evidence that the disease or injury was not aggravated by service, the second step necessary to rebut the presumption of soundness, a lack of aggravation may be shown by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the pre-existing condition. Wagner v. Principi, 370 F.3d at 1096; 38 U.S.C.A. § 1153. A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a) (2012); see Wagner, supra. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(b). Temporary or intermittent flare-ups of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted with symptoms, has worsened. See Davis v. Principi, 276 F.3d. 1341, 1346-46 (Fed. Cir. 2002) ("[E]vidence of temporary flare-ups symptomatic of an underlying preexisting condition, alone, is not sufficient for a non-combat veteran to show increased disability under 38 U.S.C.[A.] § 1153 unless the underlying condition is worsened."); Maxson v. West, 12 Vet. App. 453, 458 (1999) (citing Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991)), aff'd 230 F.3d 1330 (Fed. Cir. 2000). It is the veteran who bears the burden of establishing aggravation under 38 U.S.C.A. § 1153. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed.Cir.1994). In other words, the Veteran must submit, or the record must contain, some evidence demonstrating that the preexisting disability increased in severity during service for the presumption of aggravation to attach. See Wagner, supra; Verdon v. Brown, 8 Vet. App. 529, 538 (1996) (stating that the question of whether a preexisting defect or injury underwent an increase in severity "must be answered in the affirmative before the presumption of aggravation attaches."). Once the presumption of aggravation under section 1153 attaches, it may be rebutted only by clear and unmistakable evidence. See Cotant v. Principi, 17 Vet. App. 116, 123-30 (2003); 38 C.F.R. § 3.306(b). It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. Reasonable doubt is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 (2012). The Veteran contends that her currently diagnosed depression is related to her period of service from October 2004 to December 2005. Specifically, she contends that she currently suffers from depression with symptoms of anxiety due to her wartime service in Iraq. The RO denied her claim on the basis that medical examination reports from 2000 showed a reported history of depression which established that her depression pre-existed active military service. The Veteran contends that while she has experienced some depression in the past, she has always been able to "come out of it" before the current episode, which began shortly after discharge from active service, in approximately February or March 2006. See April 2008 Appeal; VA treatment records. A review of the Veteran's medical history shows that the Veteran has had various episodes of depression. Some of these episodes preceded the Veteran's period of active duty service. The Veteran's December 1994 report of medical history noted counseling in 1991 for depression associated with loss of relationship with the father of her child during pregnancy. The January 2000 reports of medical history and medical examination noted depression and excessive worry with outpatient treatment for episodes of clinical depression. The September 2000 and July 2001 reports of medical examination and medical history, however, are absent complaint or diagnosis of a psychiatric condition even by history. The Veteran's September and October 2004 pre-deployment examinations did not note any complaints of psychiatric or mental health problems and the associated health assessment noted that she had not been treated in the prior year for mental health. The November 2005 post-deployment examination noted little interest or pleasure in doing things, but denied feeling down, depressed, or hopeless. The Veteran specifically noted that she did not seek, nor did she intend to seek, counseling for her mental health. Following the Veteran's period of active duty service, the Board observes that the April 2006 report of medical examination noted that the Veteran had lifelong problems with anxiety and depression causing problems with organization and getting tasks done. It was further noted that her problems with depression were ongoing and that she had been counseled in the past for depression associated with alcohol abuse and relationship problems. Her functional capacity certificate, also dated in April 2006, however, noted that she had not been treated for any mental health condition in the last 5 years. A June 2006 VA psychological treatment report noted that the Veteran had started feeling depressed 2-3 months prior and provided an Axis I diagnosis of moderate major depressive disorder. An October 2006 National Guard treatment note indicated that the Veteran was being treated with medication for depression. A VA mental health note dated in October 2006 reported that most of the Veteran's readjustment difficulties were related to family issues, financial stressors of unemployment, concentration, difficulty prioritizing, and a feeling of being overwhelmed. A subsequent psychiatry note again stated the Veteran was suffering from depression due to multiple psychosocial and financial stressors as well as anxiety resulting from physical health issues. Subsequently, a November 2006 letter from the Veteran's treating physician at the Veteran's Outpatient Clinic noted that she had been treated for depression, but was doing well on her medication and was doing much better with her mood swings more balanced. An April 2007 physical profile report provided a temporary profile for depression noting no access to weapons or ammo, no driving, no deployment, and no field duty. In a June 2007 VAMC outpatient psychiatric progress note the Veteran was diagnosed with major depressive disorder, recurrent, in partial remission and alcohol dependence in sustained full remission on Axis I. The Veteran was afforded a VA psychiatric examination in March 2007. She reported that while serving in Iraq from October 2004 to December 2005 she experienced moments of fear associated with the potential for being bombed, lack of food facilities, support issues, and adjustment to unknown events. Primarily, the Veteran reported, she was in constant fear of being put down and ridiculed. All of these events caused her to feel depressed. She also noted she had difficulty sleeping and as a result difficulty concentrating on tasks during the day. She stated she did not seek treatment while in Iraq. The Veteran also reported prior treatment for depression in 1986. She noted her depression, lack of motivation, and decreased interest were currently negatively affecting her ability to obtain and maintain employment. The Veteran was diagnosed on Axis I with chronic depression with psychosocial stressors listed as "no job, supporting two daughters, and as relating to her emotional symptoms." An August 2007 post deployment examination noted problems sleeping and difficulty remembering. The Veteran reported that she had a few or several days of feeling down, depressed, or hopeless and had very little interest or pleasure in doing things. She also reported having an experience in the prior month the she tried not to think about or went out of her way to avoid situations that reminded her of it. There was no indication as to the nature of the experience. Finally she noted she was currently under care for depression symptoms that were of minor concern. An August 2009 VA mental health treatment report noted the Veteran was depressed and anxious based primarily on family and financial stressors. An October 2009 psychiatry report noted that the Veteran was diagnosed with recurrent depression, but that she had not been as depressed since her disability benefits came through eliminating some financial difficulties. The Veteran was again afforded a VA examination in March 2011. The examiner noted the Veteran's past periodic outpatient treatment for depression and anxiety beginning as early as 1986, as well as her inpatient treatment for alcohol abuse in 1980. The Veteran described chronic problems with self esteem, anxiety without cause, and a lack of self confidence. It was noted that she experienced depressive episodes on average once per year with duration of "not much longer than two weeks." The examiner then noted that the Veteran's poverty of interests, lack of social support, chronic fatigue, and low self-esteem all indicate a sub-clinical level of depression or dysthymic syndrome. The Veteran was diagnosed on Axis I with major depressive disorder, recurrent, in partial remission; alcohol dependence, in full sustained remission; cannabis dependence, in full sustained remission; and ADD, predominantly inattentive type. After a thorough examination and review of the Veteran's claims folder and medical history the examiner determined that it was more likely than not that the clinical onset of depression was prior to the Veteran's active duty service. While the Board notes that an incorrect standard was used by the examiner, determination of pre-existence was established independent of this examiner's opinion. Next, the examiner addressed the issue of aggravation stating that there is no factual evidence which supported a conclusion that during the identifiable permanent increase in severity beyond the natural progression. As part of his rationale, he noted that the Veteran had no complaints of depression during her active duty period and episodes of depression had decreased in number as was generally the case, according to naturalistic studies, with regard to major depression after a year of treatment. With the above criteria in mind, the Board recognizes that the Veteran did not provide a history of and no mention was made of any psychiatric disorder at the time of entry in October 2004. The Veteran was clinically evaluated as "normal." Accordingly, with no psychiatric disability, to include depression, noted at the time of the induction examination, the Veteran is entitled to a presumption of soundness at service entrance. The questions, therefore, are whether the evidence clearly and unmistakably demonstrates that the Veteran had a psychiatric disability prior to her entrance into active duty service, and, if so, whether it clearly and unmistakably shows that any psychiatric disability was not aggravated during service. VAOPGCPREC 3- 2003; see also Wagner, supra. The evidence undebatably shows that prior to service, the Veteran sought treatment for and was diagnosed with depression. As noted above, the December 1994 report of medical history noted counseling in 1991 for depression and January 2000 reports of medical history and medical examination note depression and excessive worry with outpatient treatment for episodes of clinical depression. While records pertaining to the treatment sought were unable to be obtained, the evidence supports that she has had an ongoing problem with depression since she was a teenager. See March 2011 VA examination report. The Veteran did state at the March 2011 VA examination that previous examiners must have misunderstood her when she said she had depression issues since her teenage years, but the March 2011 examiner noted that the Veteran exhibited a pattern of making statements then denying them, and that most likely she had suffered from depression as early as her teenage years given multiple examples of having stated that in a clinical setting. To the extent that the Veteran states that she did not have depression prior to service, the Board finds that she is not credible. The record indicates that she sought treatment for depression multiple times before her period of active duty service dating from October 2004 to December 2005. Therefore, the Board finds that there is clear and unmistakable evidence that the Veteran had depression, which existed prior to her entry into active duty service. The next question for the Board is whether the evidence clearly and unmistakably demonstrates that the Veteran's depression was not aggravated by service. In this regard, the Board notes the absence and indeed denial of complaints of depression during the Veteran's period of active duty dating from October 2004 to December 2005. The Veteran specifically denied feeling down, depressed, or hopeless in her November 2005 post-deployment examination, further stating that she did not seek, nor did she intend to seek counseling for any mental health issue. Furthermore, when the Veteran did seek treatment for her depression, after her period of active duty service, the records indicated that the Veteran was depressed because she was having readjustment issues that revolved around family problems, financial stressors of unemployment, and generally feeling overwhelmed. The treatment records consistently associate the Veteran's depression with family and financial concerns, and in June 2006 she stated that she had only been depressed for the past two to three months (i.e., since March 2006, which is post service). The Veteran repeatedly complains of lack of motivation, sleep problems and decreased interest in activities. While she does report, at her March 2007 VA examination, being afraid of being picked on and put down while serving in Iraq, the examiner associates her depression with stress due to her lack of employment and need to support two daughters. The evidence of record prior to the March 2007 VA examination fails to indicate any association between the Veteran's period of active service and her depression. The Veteran does not even directly associate her depression with her service in Iraq until the September 2010 Travel Board hearing. At the hearing, the Veteran stated that she had trouble with a commanding officer while serving in Iraq which led to a bad review and problems after her period of active duty including eventually being retired from the National Guard. The Veteran's testimony is not very clear and the record does not appear to support her contentions. The Veteran did not mention any problems during her period of active duty service at the March 2011 VA examination. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert, denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. In weighing lay evidence, the Board must render a finding with regard to both competency and credibility. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) held that lay evidence is one type of evidence that must be considered, and competent lay evidence can be sufficient in and of itself. The Board, however, retains the discretion to make credibility determinations and otherwise weigh the evidence submitted, including lay evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). This would include weighing the absence of contemporary medical evidence against lay statements. In addition, the U.S. Court of Appeals for Veterans Claims (Court) held that the credibility of lay evidence can be affected and even impeached by factors such as inconsistent statements, internal inconsistency of statements, and inconsistency with other evidence of record. See Macarubbo v. Gober, 10 Vet. App. 388 (1997). Here, the Board notes that the appellant has made several inconsistent statements regarding the nature of her service in Iraq as well as the nature of her previous psychiatric problems, and therefore the probative value of these statements is greatly diminished. In this regard, service records do not support the Veteran's contentions made at her September 2010 Travel Board hearing. The Veteran's statements at her various VA examinations have also been inconsistent except for her continual complaints of lack of motivation, disinterest, concern over financial difficulties, and family problems. Due to the inconsistency of the Veteran's statements as well as the lack of corroborating documentation to support her statements, indeed some that are contradictory to her contentions, the Board finds that the Veteran lacks credibility. The Board acknowledges that it cannot determine that credibility is lacking merely because there is no corroborating contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, in this instance it is not the absence of contemporaneous medical evidence that is at issue, rather, it is the abundance of medical evidence that fails to note the Veteran's contentions that her depression is associated with incidents during her active duty service that serves as evidence of a lack of credibility. See Caluza v. Brown, 1 Vet. App. 498, 510-511 (1995) (Credibility can be generally evaluated by showing of interest, bias, or inconsistent statements, and the demeanor of the witness, facial plausibility of the testimony, and the consistency of the witness testimony). Thus, when appropriate, the Board may consider the absence of evidence when engaging in a fact finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). The only evidence of record supporting the Veteran's claim is her own opinion that her pre-existing depression was aggravated during service. In this regard, the Veteran is competent to give evidence about observable symptoms such as lack of motivation and disinterest. Layno v. Brown, 6 Vet. App. 465, 469 (1994); Jandreau, supra ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer.") However, the Veteran is not competent in this instance to opine that her pre-existing depression was aggravated during service as that is a complex medical question that requires medical expertise and training including : knowledge of the etiology and progression of disease; and correlation with past medical records and reported history. As a lay person, the Veteran is not qualified through education, training, or experience to provide an opinion on whether her depression was aggravated during service. The question of aggravation of the underlying condition would not be subject to lay observation, as contrasted with the situations contemplated by Jandreau and Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of varicose veins). For the reasons discussed above, the Board finds the contemporary medical evidence, and the opinion of the March 2011 VA examiner, to be the more probative evidence. With regard to the pertinent question of whether the Veteran's depression was clearly and unmistakably aggravated during service, the examiner definitively stated that there is no factual evidence which supports a conclusion that the pre-existing psychiatric disorder underwent an identifiable permanent increase in severity beyond its natural progression. As is true with any piece of evidence, the credibility and weight to be attached to medical opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993); see also Winsett v. West, 11 Vet. App. 420 (1998) (Court affirmed the Board's decision which weighed two medical opinions, from an expert and a treating physician); Owens v. Brown, 7 Vet. App. 429,433 (1995) (Board favoring one medical opinion over another is not error). The Board gives greater probative value to the medical opinion of a skilled clinical professional such as the examiner from the March 2011 VA examination than to the contentions of the Veteran. In light of the above, the Board finds that the evidence of record clearly and unmistakably shows that the Veteran's depression, which existed prior to service, was not chronically worsened during service. The Board acknowledges that an assessment from the Vet Center dated in 2007 notes that the Veteran has depression "that is associated with a military stressor (harassment)." However, the Board finds that this statement carries little probative weight, as it does not appear to be based upon a full and accurate history and no rationale was provided. On review of the report, the Veteran made no mention of her pre-service problems with depression and it does not appears that the examiner had access to her complete medical records showing pre-service treatment for depression. Finally, the Board observes that it is not necessary to address the issue of aggravation under the provisions of 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306(b). This statue and regulation do not apply to this case because the Board has determined under 38 U.S.C.A. § 1111 that the evidence clearly and unmistakably demonstrates that the Veteran's pre-existing depression was not aggravated by active service. See VAOPGCPREC 3-2003. For the reasons discussed above, the Board finds that the Veteran's depression clearly and unmistakably pre-existed active service and was not aggravated during active service. Thus, the preponderance of the evidence is against the claim and the doctrine of reasonable doubt is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Accordingly, service connection for a psychiatric disorder, including depression, is not warranted. ORDER Service connection for a psychiatric disorder claimed as depression is denied. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs