Citation Nr: 1338969 Decision Date: 11/26/13 Archive Date: 12/06/13 DOCKET NO. 13-01 597 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUE Entitlement to service connection for an acquired psychiatric disorder, to include depression, paranoia, attention deficit disorder, and posttraumatic stress disorder (PTSD). WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from May 1978 to June 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah, which denied the Veteran's claim for an acquired psychiatric disorder. In July 2013, the Veteran testified before the undersigned at a video conference hearing. A copy of the transcript has been associated with the claims file. The Board notes that, in addition to the paper claims file, there is a paperless, electronic record associated with the Veteran's claim (including Virtual VA and Veterans Benefits Management System (VBMS)). A review of the documents in such file reveals that certain documents, including the July 2013 hearing transcript and VA medical records dated from January 2011 to February 2013, are potentially relevant to the issue on appeal. Thus, any future consideration of this appellant's case should take into consideration the existence of this electronic record. 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 Although the Board regrets the additional delay, after a review of the record, further development is required prior to adjudicating the Veteran's claim of entitlement to service connection for an acquired psychiatric disorder, to include depression, paranoia, attention deficit disorder, and PTSD. Relevant ongoing medical records should be requested. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Specifically, the Board notes that the Veteran was hospitalized on January 19, 1981 after he threatened to shoot himself while locked in his mother's bathroom. He was discharged on January 30, 1981, and his psychiatric diagnoses included major depression, single episode without melancholia; alcohol abuse; and antisocial personality disorder. A February 1981 discharge evaluation indicates that the Veteran had been attending weekly counseling sessions with J.S. at Jordal Area Counseling Services for approximately 2 months for symptoms of depression and suicide attempts. The Veteran was also noted to have been receiving counseling services from Copper Mountain Mental Health Center during times of overt depression and feelings of suicide. However, it does not appear that any attempts have been made to obtain these records from Jordal Area Counseling Services and Copper Mountain Mental Health Center. Therefore, as the private treatment records from Jordal Area Counseling Services and Copper Mountain Mental Health Center may be helpful to the Veteran's claim for service connection for an acquired psychiatric disorder, they should be obtained. Additionally, the Board notes that on VA examination in November 2012, the examiner reviewed the Veteran's claims file, examined the Veteran, and diagnosed the Veteran, in pertinent part, with major depressive disorder. The examiner opined that it was less likely as not that the Veteran's major depressive disorder was caused by or a result of his military experiences. She noted that there was no evidence that the Veteran had been treated for depression during service and that records showed that the Veteran was first treated for depression after discharge after service. She acknowledged the Veteran's report of difficulty coping with his discharge from service, but found that it was likely that recent psychosocial stressors, including homelessness and adjustment following incarceration, had aggravated his depressive symptoms. The Board notes that at the time of the November 2012 VA examination, the only available medical records in the Veteran's claims file were VA treatment records dated from January 2011 to November 2012. However, subsequent to the November 2012 VA examiner's opinion, the RO obtained the Veteran's medical records pertaining to his Social Security Administration disability benefits claim and associated them with the claims file. These medical records included private medical reports dated from January 1981 to February 1981 documenting the Veteran's hospitalization for a suicide attempt and major depression. Moreover, as mentioned above, these medical reports suggest that the Veteran had received counseling for depression and suicide attempts prior to the 1981 hospitalization. The Veteran has asserted that after his rushed discharge from service, he had experienced depression and difficulty coping with his military discharge. These medical records show that the Veteran had received treatment and hospitalization for depression and suicide attempts within 3 years after his discharge from service. Thus, the Board finds that the VA examiner should reconsider her opinion in light of the additional medical evidence that has been associated with the Veteran's claims file subsequent to the November 2012 VA opinion. Given the above, the claims file should be returned to the November 2012 examiner, if available, in order to give her an opportunity to receive the additional medical evidence and provide an opinion regarding whether the Veteran's acquired psychiatric disorder is related to his period of service. The Board also finds that the Veteran's complete service personnel records should be obtained and records pertaining to any Medical Evaluation Board or Physical Evaluation Board proceedings the Veteran may have underwent prior to his discharge. Accordingly, the case is REMANDED for the following action: 1. The AMC/RO should contact the National Personnel Records Center (NPRC) and/or any other appropriate custodian, and request records pertaining to any Medical Evaluation Board and Physical Evaluation Board proceedings the Veteran may have underwent prior to his discharge. All efforts to obtain these records and any negative responses received must be documented and associated with the file, and the Veteran must be notified of VA's inability to obtain the records and the efforts it made in this regard. 2. Obtain the Veteran's complete service personnel file. 3. The Veteran should be requested to provide the names, addresses and approximate dates of treatment of all medical care providers, VA and non-VA, who have treated him for an acquired psychiatric disorder. After the Veteran has signed the appropriate releases, those records should be obtained and associated with the claims folder. Appropriate efforts must be made to obtain all available VA treatment records. The Veteran should specifically be asked to provide the appropriate release forms for Jordal Area Counseling Services and Copper Mountain Mental Health Center. All attempts to procure records should be documented in the file. If the AMC/RO cannot obtain records identified by the Veteran, a notation to that effect should be inserted in the file. The Veteran is to be notified of unsuccessful efforts in this regard, in order to allow him the opportunity to obtain and submit those records for VA review. In addition, obtain all relevant ongoing VA treatment records dating since February 2013 from the VA Medical Center in Salt Lake City, Utah. 4. After taking appropriate measures to obtain the above, return the claims file to the examiner who conducted the November 2012 VA psychiatric examination for an addendum opinion, if available. The examiner should once again review the claims file. Based on the review of the record, to specifically include any additional relevant service treatment and personnel records, the January 1981 and February 1981 hospitalization reports and any other post-service treatment reports dated in 1981 or prior to 1981, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any current acquired psychiatric disorder arose during service or is otherwise related to any incident of service, to include a rushed discharge from service due to an in-service fight. The examiner should explain the medical basis for the conclusions reached. In rendering her opinion, the examiner must consider the Veteran's lay statements with regard to onset and continuity of symptomatology of his disability. If the examiner determines that an examination of the Veteran is necessary to provide the requested opinion with rationale, then such examination should be scheduled. If the previous examiner is no longer available, then the requested opinion with rationale should be rendered by another qualified examiner. 5. After the development requested has been completed, the record should again be reviewed. If the benefit sought on appeal remains denied, then the Veteran 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 or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). (CONTINUED ON NEXT PAGE) 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. 2013). _________________________________________________ TANYA A. SMITH Acting 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) (2013).