Citation Nr: A19001237 Decision Date: 09/10/19 Archive Date: 09/09/19 DOCKET NO. 190729-14126 DATE: September 10, 2019 ORDER Service connection for an acquired psychiatric disorder, to include major depressive disorder, anxiety disorder, adjustment disorder, and posttraumatic stress disorder (PTSD), is granted. FINDING OF FACT The evidence is at least evenly balanced as to whether the Veteran’s acquired psychiatric disorder, variously diagnosed, is related to his military service. CONCLUSION OF LAW With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for an acquired psychiatric disorder, to include major depressive disorder, anxiety disorder, adjustment disorder, and PTSD are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Board notes that the rating decision on appeal was issued in June 2018. Subsequent to the Veteran’s timely notice of disagreement, a statement of the case was issued in July 2019. In the same month, the Veteran elected the modernized review system. 84 Fed. Reg. 138, 177 (Jan. 18, 2019) (to be codified at 38 C.F.R. § 19.2(d)). The Veteran served on active duty from October 2002 to September 2005 and from July 2012 to February 2013. The Veteran submitted an intent to file a claim in December 2017. In February 2018, the Veteran filed a formal claim for entitlement to service connection for a mental disorder. His claim was denied in the June 2018 rating decision. In June 2019, the Veteran filed a timely notice of disagreement. The denial of his claim was continued in the July 2019 statement of the case. Subsequent to this statement of the case, the Veteran selected the Direct Review lane, without submission of additional evidence and without a Board hearing, when he opted in to the Appeals Modernization Act (AMA) review system by submitting a Decision Review Request: Board Appeal (Notice of Disagreement) form. In this decision, therefore, the evidence of record as of July 26, 2019 is reviewed. 84 Fed. Reg. 138, 155 (Jan. 18, 2019) (to be codified at 38 C.F.R. § 20.301). The Board notes that the Veteran’s initial claim for entitlement to service connection for PTSD was denied in an August 2008 rating decision, which became final subsequent to no submission of a timely notice of disagreement. Since the Agency of Original Jurisdiction (AOJ) has already readjudicated the merits of the claim, the Board concludes that there was an implicit finding of new and relevant evidence by the AOJ, and thus, proceeds to consider the merits of the claim herein. Although the Veteran initially filed a claim for PTSD, the Veteran has also been diagnosed with and filed a claim for, inter alia, anxiety disorder, major depressive disorder, and adjustment disorder. To afford the Veteran the broadest possible scope for his claim of entitlement to a psychiatric disorder, the issue has been recharacterized accordingly to that of entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder, anxiety disorder, adjustment disorder, and PTSD. Clemons v. Shinseki, 23 Vet. App. 1,6 (2009). Service connection for an acquired psychiatric disorder, to include major depressive disorder, anxiety disorder, adjustment disorder, and PTSD, is granted. The Veteran maintains that he has PTSD which began in service after deployment in Africa. Alternatively, he claims that he has chronic psychiatric symptoms caused by mefloquine, anti-malarial drug, he took just before the deployment began. See, e.g., June 2019 letter from his representative. In support of his claim, he submitted various documents, including in-service treatment records, a medical article by Dr. N., a medical opinion by Dr. N., lay statements from his former platoon leader/company executive officer and former spouse, as well as his own statement. Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service, or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. § 1110, 1131; 38 C.F.R. § 3.303. Generally, the evidence must show: (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, 1166 -67 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran meets the requirement of a current diagnosis of an acquired psychiatric disorder. The medical evidence shows that over the years since his initial visit to VA in June 2006 following separation from the first period of his service, the Veteran has been diagnosed with various acquired psychiatric disorders such as anxiety disorder, adjustment disorder, major depressive disorder, and PTSD. Most recently, he received a treatment for depression, diagnosed as major depressive disorder, recurrent, moderate. See July 2019 VA Treatment Record. The evidence of record also establishes that the Veteran was diagnosed with an acquired psychiatric disorder such as PTSD and depression while in service. Here, the Veteran’s entrance examination notes no psychiatric disability. A February 2003 pre-deployment examination indicates that he was to be deployed to Africa and that he had not sought counseling or treatment for mental health during the past year. A July 2004 post-deployment examination reveals that the Veteran served as a gunner while on deployment from December 2003 to July 2004. He reported that he had seen civilian wounded, killed, or dead during the deployment, though he was not engaged in direct combat where he discharged weapon. He reported yes to whether he felt great danger of being killed. entered or closely inspected destroyed military vehicle. It was noted “G6PD gesting [sic] prior to taking primaquine.” In a June 2005 report of medical history, the Veteran stated that he had concerns about stress, sleep problems, trust issues, and aggression. An August 2005 service treatment record indicates that the Veteran was prescribed with Prozac and he expressed he was feeling better after he started to take the medication. The history from a June 2005 clinic visit indicates that he had complaint of problems with sleep, appetite, focus, anhedonia, sadness, loss/grief, energy, irritability and he was diagnosed with PTSD. The assessment in the August 2005 service treatment record indicates that the Veteran described stressful deployment in Africa as the watershed event of his life, where he was sent on dangerous missions with little or no back-up support. He reported that he feared for his physical safety most of the time and since then has lost weight, become an insomniac and has also become “a loner” with irritability. The August 2005 service treatment record provides a diagnosis of PTSD and depression with insomnia and nightmares, confirming the previous diagnosis in June 2005. The clinician noted that the “basic problem is depression, endogenous type.” Thus, the issue before the Board is whether the current acquired psychiatric disorder began in service, or otherwise is causally related to his service. The Board concludes that the evidence is at least evenly balanced as to whether the Veteran’s acquired psychiatric disorder, variously diagnosed, began in service or otherwise is causally related to his service for the following reasons. Three medical opinions on nexus have been obtained and associated with the Veteran’s claims file. An April 2018 VA medical opinion was provided by Dr. A., PsyD. She opines that the Veteran’s current diagnosis of PTSD is “clearly linked to military service.” The rationale is that he was diagnosed with PTSD in service, he has a history of exposure to psychological trauma, both prior to and during the military service, and that “his trauma residuals/psychiatric treatment have continued since that time.” April 2018 VA behavioral health medical opinion, at 3. A May 2018 VA medical opinion was provided by Dr. W., Ph.D. He opines that the Veteran meets the diagnosis of anxiety disorder under DSM. but no evidence that it is related to service. The rationale is that the Veteran’s symptoms of mental health in service are not consistent with the Veteran’s current mental health symptoms, or no evidence that symptoms were continuous or the same entity since military service. May 2018 VA behavioral health medical opinion, at 1-2. Lastly, a February 2018 letter by Dr. N., MD, MPH, DrPH provides an opinion that it is more likely than not that the Veteran’s chronic psychiatric symptoms are primarily a direct causal result of his exposure to mefloquine during the deployment. Dr. N. states that “[t]hese conclusions are supported by information in the current U.S. drug label and by information in the peer-reviewed medical literature.” February 2018 letter by Dr. N., at 25. Specifically, the rationale is that mefloquine use is associated with reports of well-defined psychiatric symptoms of cognitive dysfunction, anxiety, sleep disorder, depression, and neurologic symptoms including paresthesias and dizziness and that the drug label for mefloquine warns that these psychiatric symptoms suggest a risk for more serious psychological disturbances and neurologic adverse reactions. Id., at 22. The Board notes that the Veteran also submitted an article concerning service connection claim for chronic neuropsychiatric adverse effects from mefloquine authored by Dr. N. and others. The Board’s responsibility is to assess the credibility and weight given to the evidence. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471(1993) (the probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). In reaching the determination in this case, the Board finds that the opinions from the two psychologists are more probative than the opinion provided by Dr. N., who is an expert in public health with board-certification in occupational medicine and public health, but not a specialist in psychology or psychiatry. See February 2018 letter by Dr. N., at 1-2. The psychologists’ opinions are accorded more weight as psychologists are specialists in the field. Considering the psychologists’ opinions, the Board finds that the evidence is at least evenly balanced as to whether the Veteran’s acquired psychiatric disorder, variously diagnosed, began in service or otherwise is related to his service. Therefore, resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for an acquired psychiatric disorder, to include major depressive disorder, anxiety disorder, adjustment disorder, and PTSD has been met, and the claim is granted. Emily Tamlyn Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Y. Taylor, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.