Citation Nr: 21070816 Decision Date: 11/26/21 Archive Date: 11/26/21 DOCKET NO. 17-11 848 DATE: November 26, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder other than posttraumatic stress disorder (PTSD), to include anxiety and depression, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from March 1965 to March 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). The issue on appeal was previously before the Board in February 2019 as a claim of entitlement to service connection for PTSD. The claim was expanded to include a claim of entitlement to service connection for an acquired psychiatric disorder. The PTSD claim was denied by the Board at that time and is no longer on appeal. The acquired psychiatric disorder claim was remanded for additional evidentiary development. The Veteran contends that his acquired psychiatric disorder manifested during active service. The claim was remanded to obtain an opinion regarding whether it is at least as likely as not that any acquired psychiatric disorder other than PTSD, originated during or is otherwise etiologically related to the Veteran's military service. A review of the STRs does not reveal any mental health reports or complaints and clinical examination was normal on separation. The Veteran's military personnel records include a Kuwait liberation medal for Saudi and Kuwait along with a Southwest Asia Service metal with two bronze stars. A review of the post-service VA treatment records reveals a diagnosis of adjustment disorder with depression and anxiety in June 2013. The Veteran has received intermittent treatment and medication for his condition since then, including a diagnosis of major depressive disorder in remission in 2020. The Veteran attended a VA examination for mental disorders, to include anxiety disorder and depressive disorder in October 2019. See October 2019 VA Examination. The examiner reviewed the file, to include the Veteran's DD-214, VA medical records and statements from the Veteran. The examiner found that the medical record lacked evidence to establish the mental disorders claimed by the Veteran. At the time of the opinion, the examiner noted that no medication or counseling notes were found after 2016, and that those notes were brief, "SSRI continued. No current symptoms." The Veteran started medication in 2012. The Veteran's medical records at the time of the VA examination included a June 2013 diagnosis for adjustment disorder with depression and anxiety. See CAPRI Records. In April 2016, a medical note indicated the Veteran was experiencing anxiety and depression. The Veteran was taking medication for these conditions and he reported he was "responding well." No current mood disorder was found. The Veteran also shared that he was feeling sad about the end of his relationship and indicated that his financial missteps have been problematic in past relationships. Additionally, in October 2006 and April 2013, the Veteran had negative PTSD screenings. Following the Veteran's VA Examinations, additional medical records were added to the record. The Board finds the opinions inadequate for adjudicative purposes. The examiner based his opinion on an inaccurate factual background, namely that there were "no medication or any counseling notes ... found after 2016." The medical records reflect that the Veteran has received both medication and counseling since 2016 for his acquired psychiatric disorders. Based on a review of the Veteran's file, it appears that the medical treatment records after 2016 were not available for the examiner to review at the Veteran's 2019 examination. These medical treatment records are imperative for an adequate opinion to be rendered as it demonstrates the treatment for a possible acquired psychiatric disorder. Service connection may be granted for a disorder present at any time during the appeal period. An opinion is required which addresses this evidence. Based on an inadequate examination, the Board must remand this matter for an addendum VA medical opinion. The matter is REMANDED for the following action: 1. In remanding this matter, 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. 2. Obtain updated VA and/or private treatment records to the extent possible. If such records are unavailable, the Veteran's claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 3. Obtain an addendum medical opinion regarding the etiology of the Veteran's acquired psychiatric disorder from a medical professional with appropriate expertise. The examiner should review the Veteran's claims file and make a notation on the examination report that the claims file was reviewed. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one (or a telehealth interview, if an in-person examination is not feasible). Based on a review of the record, and a new examination if necessary, the examiner must address the following: Whether it is at least as likely as not (a 50 percent or greater probability) that any acquired psychiatric disorder, other than PTSD, to include anxiety and depression, is related to an in-service injury, event, or disease. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. The examiner is not to improperly discount the Veteran's lay statements or rely solely on an absence of medical evidence in the record to support his or her conclusions. The examiner must specifically address, and reconcile to the extent possible, his or her medical opinion with the December 2013 and September 2019 VA medical opinions. A complete rationale must be provided for all opinions presented. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). (Continued on the next page) (Continued on the next page) G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V. Schmidt 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.