Citation Nr: 21068424
Decision Date: 11/10/21	Archive Date: 11/10/21

DOCKET NO. 19-26 287A
DATE: November 10, 2021

REMANDED

Entitlement to service connection for a psychiatric disorder, to include a depressive disorder is remanded.

REASONS FOR REMAND

The Veteran had active service from September 1991 to March 1995.  

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).

Entitlement to service connection for a psychiatric disorder, to include a depressive disorder 

The Board cannot make a fully-informed decision on this issue because no VA examiner has opined whether the Veteran's psychiatric disorder, diagnosis of major depressive disorder, reflected in his December 2018 VA treatment notes, is related to service, to include his service-connected right knee disability.

The Veteran was first awarded service connection for a right knee disability in August 1996.  In a September 2018 claim, he contended he had a depressive disorder due to his right knee disability.  In support of his claim, he provided a September 2018 Disability Benefits Questionnaire (DBQ) completed by a private psychologist.  The psychologist opined that the Veteran had depressive disorder due to chronic pain syndrome with major depressive-like features, that was more likely than not a continuation of, related to, secondary to, or aggravated by the military service-connected skeletal system condition.  The RO declined to consider this DBQ on the basis that telemental health examination reports are not acceptable or actionable for rating purposes, the Board notes VA policy has changed in this regard.  However, an adequate rationale was not provided for the opinion.

In January 2019, the Veteran had a VA examination where the examiner declined to make a mental health diagnosis.  Nevertheless, the Veteran's VA treatment records reflect a December 2018 mental health integrated assessment, where a diagnosis was made of major depressive disorder, other specified anxiety.  As the January 2019 VA examiner did not comment on this diagnosis, nor the September 2018 private DBQ, an addendum opinon is needed.

The matter is REMANDED for the following action:

1. Obtain the Veteran's VA treatment records for the period from December 2018 to the present.

2. Obtain an addendum opinion from an appropriate clinician (or schedule the Veteran for a new VA examination, if necessary) to clarify whether the Veteran has a diagnosis of major depressive disorder, or any other acquired psychiatric disorder.  The examiner should specifically comment on the Veteran's diagnoses of depressive disorder due to chronic pain syndrome in the September 2018 private DBQ and major depressive disorder, other specified anxiety, in his December 2018 VA treatment records.

The examiner must review the claims file.

If a diagnosis of an acquired psychiatric disorder is found, the examiner is asked to provide responses to the following:

(a)	Is the acquired psychiatric disorder at least as likely as not related to service?

(b)	Is the acquired psychiatric disorder at least as likely as not proximately due to the service-connected right knee disability?

(c)	Is the acquired psychiatric disorder at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the service-connected right knee disability?

Provide rationales to support the opinions.

3. Then readjudicate the issue on appeal.  If the claim is not granted to the Veteran's satisfaction, send the Veteran and his representative a supplemental statement of the case and allow the appropriate time for response. 

 

C. CRAWFORD

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	A. Dean, 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.