Citation Nr: 21070106 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 18-37 598 DATE: November 23, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1968 to March 1970. In November 2020, the Veteran testified before the undersigned Veterans Law Judge (VLJ). A hearing transcript has been associated with the claims folder. The Veteran's claim for service connection for depression disorder has been recharacterized as acquired psychiatric disorders, to include major depressive disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. Indeed, the Board expressly defers a credibility determination in this appeal until the development has been completed to the extent feasible. Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder is remanded. The Veteran contends that he has a current psychiatric disorder that began in service when he was stationed in Germany in 1969 to an isolated area. He testified that, as a result of his feelings of isolation from others, he began abusing drugs and alcohol due to lack of supervision. The Veteran denies seeking treatment for mental health symptoms until years after service but reports that he used alcohol and drugs to self-medicate during service. The Veteran testified that he first sought mental health treatment in 1974 for sleep disturbances and mood swings, and he was prescribed Valium. He denied seeking mental health treatment again until 2005. The Veteran further asserts that his mental health symptomatology led to three failed marriages, and disputed that his failed marriages caused his current acquired psychiatric disorder. See Hearing Transcript (November 2020). The Veteran's service treatment records, including his enlistment and separation examinations, do not show history, complaints, or treatment for any mental health symptomatology. His service records include a certification for drug abuse training while assigned to 9th Maintenance Battalion, USAEUR, in Germany. See STR (June 2017). The available medical records also include a September 1984 private medical statement, which indicates that the Veteran participated in psychological therapy. See Medical Treatment Record - Non-Government Facility (September 1984). VA treatment records show that the Veteran first present for mental health treatment in March 2015 for complaints of depression associated with familial and financial stressors. He reported a prior history of receiving mental health treatment through an employment assistance program (EAP) in 1988 due to relationship issues. See CAPI (June 2017). The Veteran has a current diagnosis of major depressive disorder. See CAPRI (May 2019) and C&P Exam (July 2017). To ensure that VA has met its duty to assist, a remand is necessary for the following reasons. Initially, the Board notes that the record indicates there may be outstanding and relevant Social Security Administration (SSA) records. The record reflects that the Veteran is in receipt of SSA disability benefits. See SHARE Print Screen (January 2017). The record does not reflect that VA has made any attempt to obtain these federal records from SSA. To ensure that the record contains a complete and updated set of the Veteran's SSA records, a remand is required to allow VA to request those records. See Goltz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010); see also Baker v. West, 11 Vet. App. 163, 169 (1998). Next, a remand is required to obtain outstanding relevant treatment records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim, including making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159 (c)(1). During his November 2020 Board hearing, the Veteran testified that he received mental health treatment as part of an Employee Assistance Program (EAP). See Hearing Transcript (November 2020). The available medical records also reflect a reported medical treatment history of EAP in 1980s, however, the records from that program have not yet been associated with the claims folder. See CAPRI (June 2017). Finally, a remand is required to obtain an adequate VA medical opinion. A July 2017 VA examination reflects a diagnosis of major depressive disorder. However, no medical opinion was provided that addressed the etiology of the Veteran's diagnosed disorder. As such, the July 2017 VA examination is inadequate for adjudication of this claim. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that it is adequate). A remand is needed to obtain a VA medical opinion that addresses whether the Veteran's current diagnosed acquired psychiatric disorder had an onset during service or is otherwise related to his military service. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from May 2019 to the Present. 2. Obtain the Veteran's federal records from SSA. Document all requests for information as well as all responses in the claims file. 3. Ask the Veteran to complete a VA Form 21-4142 for all non-VA medical providers, to include from Employee Assistance Program, pertaining to symptoms and treatment of his mental health symptoms. Make two requests for the authorized records from all identified sources unless it is clear after the first request that a second request would be futile. 4. Obtain an addendum opinion from an appropriate clinician to address the etiology of the Veteran's claimed acquired psychiatric disorder. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptom consistent with the presence of mental disorder. RE-EXAMINATION IS NOT REQUIRED UNLESS DEEMED NECESSARY BY THE CLINICIAN PROVIDING THE MEDICAL OPINION. The opinion should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). The clinician should address the following: Whether any mental disorder shown during this appeal (that is since 2017) least as likely as not (1) began in service; or (2) is otherwise related to an in-service injury, event, or disease. Consider and expressly address the Veteran's lay statements regarding onset of depression symptoms in service and his contention that, rather than seeking treatment, he self-medicated with drugs and alcohol to handle his psychiatric symptoms. NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints/findings for the claimed condition. If another etiology is the more likely cause, the clinician must provide a complete explanation of his or her reasoning. NOTE (2): An adequate medical opinion will fully address the Veteran's theory of causation and must provide a complete explanation for any history rejected. 5. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. (Continued on next page) 6. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. M., 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.