Citation Nr: 20008360 Decision Date: 01/31/20 Archive Date: 01/31/20 DOCKET NO. 19-22 744 DATE: January 31, 2020 REMANDED Entitlement to service connection for a psychiatric disorder, to include depression and anxiety is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1990 to November 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), which, inter alia, denied service connection for depression and anxiety. In light of the Veteran’s contentions and the evidence of record, the Board has recharacterized the Veteran’s claims of service connection for depression and anxiety more broadly as a claim of service connection for a psychiatric disorder, to include depression and anxiety. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that VA must construe a claim for service connection to include any disability that may reasonably be encompassed by the claimant’s description of the claim, the symptoms the claimant describes, and the information the claimant submits or that the Secretary obtains in support of the claim). In light of the remand below, no prejudice to the Veteran has resulted from the Board’s recharacterization of the issue. Bernard v. Brown, 4 Vet. App. 384 (1993) (holding that before the Board may address a matter that has not been addressed by the RO, it must consider whether the claimant has been given adequate notice of the need to submit evidence or argument, an opportunity to submit such evidence or argument, and an opportunity to address the question at a hearing, and whether the claimant has been prejudiced by any denials of those opportunities). Entitlement to service connection for a psychiatric disorder, to include depression and anxiety is remanded. The Veteran contends that he suffers from anxiety and depression as a result of his military service. See July 2014 Statement in Support of Claim. A September 2003 VA treatment record noted that the Veteran had been experiencing the following depression symptoms for the past 6 months: difficulty initiating and maintaining sleep, decreased appetite, decreased libido, difficulty concentrating, decreased motivation, crying episodes, and passive thoughts of suicide. The assessment was major depression. See September 2003 Mental Health Triage Note. A March 2010 VA treatment record noted the Veteran’s reports that he was sleeping “slightly better” over the past 2 weeks but that he struggled to maintain a consistent sleep schedule. The Veteran also reported anhedonia and irritability. The assessment was major depressive disorder (MDD), recurrent, moderate and generalized anxiety disorder (GAD). See March 2010 Mental Health Note. A May 2010 VA treatment record noted the Veteran’s reports of depression, anxiety, trouble understanding, concentrating, and remembering, trouble with violent behavior, and thoughts of suicide. See May 2010 Mental Health Triage Note. Another May 2010 VA treatment record noted that the Veteran had been prescribed Venlafaxine HCL for depression. See May 2010 Active Outpatient Medication list. The Veteran was afforded a VA posttraumatic stress disorder (PTSD) examination in August 2016. The examiner noted that the Veteran denied any mental health history at any time or ever having received treatment for any mental disorder, including PTSD. After examination of the Veteran and review of the claims file, the examiner determined that the Veteran did not have a diagnosis of PTSD under DSM-5 criteria, or any other psychiatric disorder. The Board finds that the examination is inadequate in multiple respects. First, it appears that the examiner failed to consider multiple notations in the Veteran’s post-service clinical records regarding complaints of psychiatric symptomatology, to include depression and anxiety, and treatment therefor. Second, the examiner failed to consider March 2010 diagnoses of major depressive disorder and generalized anxiety disorder, noted above, and explain the basis for determining that the Veteran did not have a current psychiatric disorder, despite these previous diagnoses. Additionally, the Board notes that since the VA examination, the Veteran has been prescribed Sertraline for depression. See March 2019 Active Outpatient Medication List. In light of the above deficiencies, the Board finds that a remand is necessary in order to obtain another VA examination to determine the nature and etiology of any current psychiatric disability. Accordingly, the matter is REMANDED for the following action: 1. Provide the Veteran with an examination to determine the nature and etiology of any current psychiatric disability. Access to the Veteran’s electronic VA claims file should be made available to the examiner for review in connection with the examination. After reviewing the record and examining the Veteran, the examiner should delineate all current mental disorders exhibited by the Veteran, if any. If PTSD is diagnosed, the examiner should note all stressful events contributing to the diagnosis. If any other mental disorder is diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not that any psychiatric disorder identified is causally related to the Veteran’s active service or any incident therein. If depressive disorder or generalized anxiety disorder is not diagnosed, the examiner should explain why this is so, as such diagnoses have been made previously, including in a March 2010 VA treatment record. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Ruddy, 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.