Citation Nr: 21005025 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 14-41 856 DATE: January 28, 2021 REMANDED The claim of entitlement to service connection for sleep apnea is remanded REASONS FOR REMAND The Veteran had active duty service with the United States Navy from September 1986 to December 1996. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision by the RO. The issue on appeal was remanded by the Board in November 2018 for further development. Regrettably, additional development is still necessary. Entitlement to service connection for sleep apnea is remanded. The Veteran asserts that he is entitled to service connection for sleep apnea. He contends that the medication used to treat his service-connected psychiatric disorder caused his currently diagnosed sleep apnea. He also asserts that his major depression, or treatment thereof, caused him to gain weight, which eventually led to his sleep apnea. The evidence of record includes a November 2007 treatment note from Dr. J.M. which notes that newly prescribed Seroquel’s side effects could include weight gain or metabolic syndrome. A September 2010 sleep study report included a diagnosis of moderate to severe obstructive sleep apnea hypopnea syndrome. He had a history of snoring, excessive daytime sleepiness, and a body mass index of 33.5. In accordance with the Board’s November 2018 remand, the Veteran was afforded a new VA examination in April 2020 in order, in part, to address the Veteran’s statements that his service-connected psychiatric disorder, or treatment of that disorder, caused his weight gain, which eventually led to his obstructive sleep apnea. Following a review of the Veteran’s claims file and examination of the Veteran, the examiner found that May 2019 documents included diagnoses of sleep apnea and posttraumatic stress disorder (PTSD) treated with oral Bupropion and Buspirone which did not cause weight gain and obesity. The examiner found that sleep apnea was not caused by psychiatric medication used to treat his PTSD and that obstructive sleep apnea was less likely than not aggravated by his service-connected psychiatric disorder, to include the medications used to treat the psychiatric disorder. Initially, the Veteran is service connected for major depression and not PTSD, thus an opinion finding that treatment for PTSD was not related to sleep apnea is not informative in this case. Moreover, in as much as it appears the use of Bupropion and Buspirone were used for major depressive disorder, the examiner failed to indicate whether the Veteran’s use of Seroquel (Quetiapine), which was used during the course of this appeal, caused or aggravated his sleep apnea. Further, and significantly, treatment records include multiple mental health diagnoses, the Veteran is service connected for major depressive disorder, and a February 2013 VA examiner found that the Veteran also had a mood disorder, not otherwise specified with anxious, depressive and possible hypomanic symptoms, and intermittent explosive disorder which the examiner found was as likely as not secondary to his mood disorder. The Veteran has additionally been diagnosed with adjustment disorder and rule out bipolar 2 disorder is noted in many treatment records, among other diagnoses. A medication log associated with the Veteran’s treatment dated in October 2008 includes a report that the Veteran was prescribed Quetiapine, Citalopram, Clonazepam and Lorazepam in August and September 2007. Under a section labeled “purpose” only Citalopram is noted as used for depression, whereas the other medications are cited as having “mental health” as their purpose. Additional information is necessary in order to determine whether the Veteran’s obstructive sleep apnea is related to his service-connected major depression or related symptoms, to include treatment thereof, as opposed to treatment for non-service connected psychiatric disorders, if the symptoms of such can be distinguished. A new medical opinion should be sought in order to determine whether there is a relationship between the Veteran’s major depression and obstructive sleep apnea. Of note, the medical expert is asked to identify any and all mental disorders, the medications taken for each disorder, and whether the symptoms identified are related to the Veteran’s service-connected major depression. The examiner is further asked to review and discuss articles submitted by the Veteran which discuss a relationship between depression and sleep apnea, and Seroquel and sleep apnea, if Seroquel is found to treat symptoms related to the Veteran’s service-connected major depressive disorder. The Board by this remand makes no determination, expressed or implied, concerning the credibility of any statements on file. The matters are REMANDED for the following action: 1. Send the claims file to the appropriate clinician for review. Following review of the relevant records, medical articles submitted by the Veteran, and lay statements, the examiner should: a) Identify the Veteran’s psychiatric diagnoses and symptoms associated with each diagnosis as well as the medications prescribed to treat each identified diagnosis. b) Address whether the Veteran’s obstructive sleep apnea is at least as likely as not (50 percent probability or greater) caused or aggravated by his service-connected psychiatric disorder, to include the medications used to treat the psychiatric disorder, and weight gain due to those medications. In so doing, the examiner must consider and discuss the following: (1) the February 2013 VA examination report noting that the Veteran slept a lot and had gained weight in the last few years; (2) the Veteran’s statements that his depression caused weight gain; and (3) the May 2014 VA medical opinion indicating that there was evidence of chronic obesity as the most significant risk factor for the Veteran’s obstructive sleep apnea. (4) Medical articles submitted by the Veteran discussing a relationship between depression and sleep apnea, and the side effects of Seroquel. The rationale for all opinions expressed must also be provided. If the examiner is unable to provide any required opinion, he or she should explain why. If an opinion cannot be provided without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, examiner should identify the additional information that is needed. 2. Then readjudicate the issue on appeal. If the benefit sought on appeal is not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. The case should then be returned to the Board. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Slovick, 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.