Citation Nr: 20003566 Decision Date: 01/16/20 Archive Date: 01/15/20 DOCKET NO. 18-26 031 DATE: January 16, 2020 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with depressed mood, is remanded. REASONS FOR REMAND The Veteran served on active duty from November 2006 to June 2012. He served in the United States Navy, including sea service. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from the March 2018 rating decision of the Roanoke, Virginia, Department of Veterans Affairs (VA) Regional Office (RO), which denied the Veteran’s claim for entitlement to service connection for adjustment disorder with depressed mood. The Veteran appealed the decision to the Board. In June 2019, the Board remanded the issue to obtain a VA examination. As discussed below, the VA examination has not occurred as of this date and there is no evidence of proper notification to the Veteran. 1. Entitlement to service connection for an acquired psychiatric disorder, to include adjustment disorder with depressed mood, is remanded. Unfortunately, there has not been substantial compliance with the Board’s previous remand directives regarding the issue of entitlement to service connection for an acquired psychiatric diorder, to include adjustment disorder with depressed mood. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). In June 2019, the Board remanded this matter to obtain a VA examination. The June 2019 Board remand directed the RO to schedule the Veteran for an examination to determine the nature and etiology of his acquired psychiatric disorder. In a June 2019 letter, the Veteran was advised that a private facility would contact him with a time and location for his examination. However, there is no evidence in the record that the private facility properly notified the Veteran of the time and location of his examination. On remand, a VA examination should be scheduled to determine the nature and etiology of the Veteran’s claimed acquired psychiatric disorder. The RO should properly document all efforts to schedule the VA psychiatric examination for the Veteran. On remand, the Veteran should be asked to furnish, or to furnish an authorization to enable VA to obtain, any additional private treatment records from providers who treated him for his claimed acquired psychiatric disorder. The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records, to include VA treatment records dated June 2019 to the present, should be obtained. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Schedule the Veteran for an examination by an appropriate clinician to address the nature and etiology of the Veteran’s claimed acquired psychiatric disorder. The entire claims file must be made available to and be reviewed by the examiner in conjunction with the examination. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. The examiner is requested to provide an opinion as to whether it is at least as likely as not (a 50 percent probability or more) that the Veteran’s disability began in service, was caused by service, or is otherwise related to active military service. Any indicated tests should be conducted. Based on a review of the record, the examiner should identify, by diagnosis, all psychiatric disabilities, to include adjustment disorder with depressed mood, and, as to each diagnosed disorder, should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the psychiatric disability is related to service. In addressing these questions, the examiner is requested to consider the following: • In his February 2015, February 2007, December 2011, and May 2012 service treatment records, the Veteran affirmatively denied having or having had nervous trouble of any sort and depression or excessive worry. • In a January 2018 note, the Veteran reported that his depression started when he joined the military and left his mother and siblings. • In his May 2018 VA Form 9, the Veteran stated that pain and stress during service caused problems which he addressed with daily consumption of alcohol. He stated that mood swings that he experienced caused him to drink, not knowing that he was dealing with depression. • The Veteran’s service personnel records, associated with the record on March 2, 2018, included multiple reports of alcohol-related infractions. He was discharged for alcohol rehabilitation failure. • VA treatment records from September 2017 and November 2017 reflect no anxiety, no depression, no suicidal ideations, and no homicidal ideations. • In a December 2017 note, the treatment provider noted depression as an alcohol trigger. • In a May 2018 note, the Veteran reported that his depressive symptoms first started in the military, stating, “I saw a lot of things that I never told anybody about. I didn’t want to be discharged because of what I saw.” He did not describe these experiences. He stated that he still struggles with these memories. A complete rationale must be provided for any opinion offered. The examiner should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. When scheduling the aforementioned VA examination, notify the Veteran that it is his responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for any VA examination without good cause may include denial of the claim. See 38 C.F.R. §§ 3.158, 3.655. A copy of the notification letter advising him of the time, date, and location of the scheduled examination(s) must be included in the claims folder and must reflect that it was sent to his last known address of record. If he fails to report to the examination(s), the record must indicate whether the notification letter was returned as undeliverable. Kristy L. Zadora Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Deemer 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.