Citation Nr: 1319988 Decision Date: 06/20/13 Archive Date: 07/02/13 DOCKET NO. 05-02 268 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for diabetes mellitus, secondary to service-connected major depression. REPRESENTATION Appellant represented by: Susan Carpenter, Attorney WITNESSES AT HEARING ON APPEAL The Veteran and spouse ATTORNEY FOR THE BOARD S. Lipstein INTRODUCTION The Veteran had active service from April 1976 to April 1979. This matter came before the Board of Veterans' Appeals (Board) on appeal from a January 2009 RO decision. The Board remanded the appeal for additional development in May 2010. A hearing before the undersigned was held at the RO in December 2009. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran claims that the diabetes mellitus, type II, is secondary to service-connected depression. The Veteran underwent a VA examination in January 2012. Noting generally that medical literature shows depression was only a risk factor for diabetes, rather than causative, and that the Veteran's blood work and medication has been stable since his diabetes diagnosis, the examiner concluded that that diabetes mellitus, type II, is less likely than not proximately due to or aggravated by the Veteran's service-connected depression. Thereafter the Veteran's attorney provided a statement where she cited three studies that she interpreted as showing depression as a "significant cause" of diabetes. The file was then returned to the January 2012 examiner who again noted the distinction between risk factor and causation, explaining for example that obesity and depression are risk factors for diabetes, but not all who are diabetic are obese or depressed, and not all who are obese or depressed are diabetic. However, she only cited to one of the three studies identified by the Veteran's attorney, noting that it supported her comments as it simply recognized depression as risk factor for diabetes. Follow-up should be undertaken to clarify whether the other 2 studies cited by the Veteran's attorney would lead the examiner to change her opinion. Lastly, relevant ongoing medical records should also be obtained, which could reflect whether diabetes has increased in severity since he was last examined, and whether his psychiatric disability had a role in that increase. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992). Accordingly, the case is REMANDED for the following actions: 1. Obtain relevant VA treatment records from the Central Texas Health Care System dated from October 2012 to the present. 2. Following the completion of the development above to the extent possible, return the claims file to the September 2012 VA examiner, if available for a clarifying opinion. If this examiner is not available, arrange for the opinion to be provided by another qualified person. If a new examination is deemed necessary, one should be scheduled. Following review of the claims folder and relevant electronic VA treatment records, the examiner should provide a clarification to the September 2012 report. Noting the relevant facts and specifically all 3 studies cited by the Veteran's attorney, (the 2004 Norway study, the 2007 Oxford study, and the article from The American Journal of Psychiatry) the reviewer should express an opinion whether this evidence changes the opinions previously provided regarding whether this Veteran's diabetes was caused or aggravated by his service connected psychiatric disability. The reviewer is requested to provide a clear rationale for the opinion expressed on both the causation question and the question of aggravation, to include a brief discussion on the distinction between risk factors, associations and causation. If the examiner must resort to speculation to answer any question, he or she should so indicate and explain why it would be speculative to respond. The examiner is informed that aggravation is defined for this purpose as a chronic worsening of the underlying condition beyond its natural progression, versus a temporary flare-up of symptoms. 3. After the development requested above as well as any additional development deemed necessary has been completed, the record should again be reviewed. If the benefit sought on appeal remains denied, then the Veteran and his representative should be furnished with a supplemental statement of the case and be given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, 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 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 E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), 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) (2012).