Citation Nr: 20007705 Decision Date: 01/30/20 Archive Date: 01/29/20 DOCKET NO. 18-49 868A DATE: January 30, 2020 REMANDED Entitlement to service connection for an acquired psychiatric disorder, claimed as anxiety and depression is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1983 to August 1983, and then from July 2009 to July 2010. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. As to the claim for service connection for an acquired psychiatric disorder, in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) clarified how the Board should analyze claims, specifically to include those for an acquired psychiatric disorder. As emphasized in Clemons, though an appellant may only seek service connection for PTSD, the appellant's claim "cannot be a claim limited only to that diagnosis, but must rather be considered a claim for any mental disability that may be reasonably encompassed...." Id. Here, the Veteran applied for service connection for anxiety and depression and has been diagnosed by various VA personnel with various forms of depression, alcohol use disorder and alcohol induced mood disorder, there is a question as to which diagnosis is accurate. As such, the Board has recharacterized this claim to one for an acquired psychiatric disorder, as noted on the first page of this decision. Entitlement to service connection for an acquired psychiatric disorder, claimed as anxiety and depression is remanded. The Veteran was afforded a VA mental disorders examination in January 2019. Diagnoses of alcohol use disorder and alcohol induced mood disorder were noted. The examiner stated that there is evidence of alcohol abuse since youth and that the Veteran is still drinking which induced the mood disorder. The examiner then opined that these were less likely than not incurred in or caused by the Veteran’s service, noting again that the Veteran has been drinking since he was 16 and that his alcohol use induced his mood disorder. When VA undertakes to provide an examination or opinion, it must ensure that it is adequate. See, Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, the VA examiner’s statements and opinion are conclusions with no rationale. Further, the examiner failed to address relevant medical evidence that the Veteran’s symptoms, at least in part, may be related to his active duty service. As such, this opinion is of no probative value. A February 2019 Physical Evaluation Board report notes that the Veteran’s “unspecified depressive disorder (diagnosed by VA as alcohol induced mood disorder and alcohol use disorder)” does not meet retention standard and did not exist prior to service. It was further noted that it was incurred while entitled to base pay. The report then noted that on November 23, 2009, while in Africa, the Veteran reported insomnia related to work and was prescribed zolpidem for sleep induction and that a June 18, 2010 Post Deployment Health Assessment contained reports of insomnia, difficulty with concentration, irritability and forgetfulness. Finally, it was noted that a November 23, 2011 VA social worker record notes his marital problems worsened after his deployment to Africa. While relevant facts are cited, there is no rationale as to how the conclusion that the diagnosed unspecified depressive disorder is related to the Veteran’s service in Djibouti. As such, this report is of no probative value. Based on the above, a remand for a new VA examination is required. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any acquired psychiatric disorder. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s deployment to Djibouti. Whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. The examiner’s attention is invited to a July 9, 2009 Pre-Deployment Health Assessment which notes the Veteran was to have been deployed to Africa for Operation Enduring Freedom. It was further noted that he denied seeking any mental health care for the prior year and was found able to mobilize without behavioral health or medical issues. The examiner’s attention is invited to a June 28, 2010 De-Mobilization Behavioral Health Survey which notes the veteran reported having difficulty falling asleep, difficulty staying asleep and sleep terror. The examiner’s attention is invited to a June 28, 2010 Post-Deployment Health Re-Assessment which notes the Veteran was deployed to Djibouti from August 11, 2009 to June 21, 2010 for Operation Enduring Freedom and that he asserted that during the prior 4 weeks his emotional problems have made it very difficult for him to take care of things at home or get along with other people. It was further noted that he endorsed going to sick call for problems sleeping, trouble concentrating, forgetfulness and increased irritability. The examiner’s attention is invited to a July 22, 2010 Statement of Medical Examination and Duty Status which notes the Veteran was admitted on an inpatient basis to a military treatment facility, was noted as not being under the influence and was not mentally sound. It was further noted that the injury was likely to result in a claim for future medical care and was incurred in the line of duty. It was noted that during Operation Enduring Freedom the Veteran had problems with lack of concentration, sleeping and irritability. The examiner’s attention is invited to a May 16, 2018 Statement of Medical Examination and Duty Status notes that during Operation Enduring Freedom the veteran was referred by providers for a lack of concentration, problem going to sleep and irritability. The examiner’s attention is invited to the February 2019 Physical Evaluation Board report which notes that the Veteran’s “unspecified depressive disorder (diagnosed by VA as alcohol induced mood disorder and alcohol use disorder)” does not meet retention standard and did not exist prior to service. It was further noted that it was incurred while entitled to base pay. The report then noted that on November 23, 2009, while in Africa, the Veteran reported insomnia related to work and was prescribed zolpidem for sleep induction and that a June 18, 2010 Post Deployment Health Assessment contained reports of insomnia, difficulty with concentration, irritability and forgetfulness. Finally, it was noted that a November 23, 2011 VA social worker record notes his marital problems worsened after his deployment to Africa. All opinions provided must be thoroughly explained, and a complete and detailed rationale for any conclusions reached should be provided (a bare conclusory statement will be deemed inadequate). The examiner is reminded that the term “as likely as not” does not mean within the realm of possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. It is not sufficient to base an opinion on a mere lack of documentation of complaints in the service or post-service treatment records. 2. After completing the requested actions, and any additional development deemed warranted, readjudicate the claims in light of all pertinent evidence and legal authority. If the benefits sought remain denied, furnish to the Veteran a Supplemental Statement of the Case and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. C. TRUEBA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Brian P. Keeley 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.