Citation Nr: 21074453 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 17-43 497 DATE: December 15, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include major depression and dysthymic disorder, is granted. REMANDED Entitlement to a disability rating in excess of 10 percent for hypertension is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disorders (TDIU) is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his acquired psychiatric disorder had its onset during active-duty service and has continued ever since. CONCLUSION OF LAW The criteria for entitlement to service connection for an acquired psychiatric disorder are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1983 to April 1991, from February 2003 to February 2004, from September 2006 to September 2007, from April 2008 to December 2008, from February 2009 to June 2009, with additional periods of service in the Air Force Reserves. The Board thanks the Veteran for his honorable service to our country. This matter comes before the Board of Veteran's Appeals (Board) from a June 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2021, the Veteran testified via videoconference before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. As will be addressed in detail below, while the agency of original jurisdiction (AOJ) characterized the claim of service connection for dysthymic disorder, as a reopened claim in the most recent Statement of the Case (SOC) of June 2017; the prior December 2012 and June 2016 rating decisions had not become final as to the matter. Accordingly, the Board has characterized the claim as entitlement to service connection, without the issue of whether new and material evidence had been submitted. Additionally, because the evidence of record suggests the Veteran has more than one diagnosed psychiatric disability, the Board has characterized the matter as "entitlement to service connection for an acquired psychiatric disorder, to include major depression and dysthymic disorder" pursuant to Clemons. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Finally, a TDIU claim has been raised by the Veteran. Accordingly, the matter has been added as a separate issue on appeal and will be addressed in the remand portion of this decision. Rice v. Shinseki, 22 Vet. App. 447 (2009). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.902 (c). 1. Entitlement to service connection for an acquired psychiatric disorder, to include major depression and dysthymic disorder. By way of history, the Veteran presented a claim of service connection for major depression in April 2012. See VA Form 21-526EZ, Fully Developed Claim, of April 2012. A December 2012 rating decision denied the claim, characterized as "service connection for dysthymic disorder, claimed as major depression." This rating decision indicated that the claim was denied because the Veteran's active-duty service treatment records (STRs) did not show complaint, treatment, or diagnosis for major depression. The RO did acknowledge that the Veteran's records showed voluntary treatment for alcohol dependence in 2002, but that the records did not show a diagnosis of a mental disorder until the diagnosis of dysthymic disorder during the Veteran's period of service with the Reserves. Additionally, the rating decision cited a treatment note by medical officer G.W. of January 2010 which indicated that the Veteran did not meet the DSM IV diagnostic criteria for major depression due to active alcoholism, which also clouded the diagnosis of dysthymic disorder. The note speculated that all of the Veteran's symptoms could be explained by alcoholism and recommended a finding of "EPTS" (existed prior to service) and "not service aggravated." See December 2012 rating decision. This rating was notified to the Veteran that same month. See notification letter of December 2012. The notification letter of December was corrected by a subsequent notification letter sent to the Veteran in January 2013. See notification letter of January 29, 2013. Thus, the Veteran had until January 2014 to submit a timely notice of disagreement (NOD) as to that decision. In January 2013, a Congressional Inquiry was associated with the claims file. The inquiry contained a statement by the Veteran indicating that he had submitted evidence in favor of his claim but that the decision was confusing and contradictory. See Congressional Inquiry of January 2013. In February 2013, the Veteran presented a VA Form 21-526b requesting reopening of the claim of service connection for major depression. See VA Form 21-526b, Veteran Supplemental Claim, of February 2013. This form was presented along evidence to include a medical opinion by Dr. C. L. indicating that the Veteran was under treatment for major depression and that while he did have a history of alcohol problems, that the Veteran continued to struggle with depression despite compliance with treatment. She also explained that the Veteran's history was consistent with the use of alcohol to self-medicate the depression. Thus, Dr. C.L. opined that it was more likely than not that the Veteran was depressed while on active duty and used alcohol to self-medicate. She also noted that a medical opinion referenced in the December 2012 rating decision had been subscribed by a physician who had never treated the Veteran. See medical opinion by Dr. C.L., dated February 2013. In September 2013, a rating decision denied reopening the Veteran's claim of service connection for dysthymic disorder, claimed as major depression, because the evidence submitted was not new and material. See September 2013 rating decision. In December 2013, the Veteran presented a NOD indicating disagreement with the notification letters of October 2013 and February 2013 that denied service connection for dysthymic disorder. The Board observes that there is no February 2013 notification letter in the claims file pertaining to a rating decision; however, there is a notification letter dated January 29, 2013. It is conceivable that the Veteran received that letter in February 2013. Additionally, as noted previously, the January 29, 2013 notification letter is a correction of the letter sent to the Veteran in December 2012 notifying him of the December 2012 rating decision. In February 2015, a Statement of the Case (SOC) addressing service connection for dysthymic disorder was issued. The SOC indicated that the Veteran had 60 days to complete a formal appeal which needed to address: the benefit sought, the facts in the SOC with which the Veteran disagreed and any errors the Veteran believed had been made in applying the law. Additionally, the SOC indicated that if VA did not hear from the Veteran within 60 days, his case would be closed. See SOC of February 2015. In April 2015, the Veteran presented a medical evidence that had not previously been associated with the claims file and a statement in support of his claim. The statement noted his periods of active duty, his period of service with the reserve until his retirement in April 2013, and his issues with depression during service to include an alcohol related incident while on active-duty orders that eventually led to the diagnosis of major depression and dysthymia. See Correspondence and medical records associated with the claims file in April 2015. In April 2016, the Veteran presented a VA Form 21-526EZ, claiming "major depression" "Gulf War." See Form 21-526EZ of April 2016. In June 2016, a rating decision confirmed and continued the previous denial of service connection for dysthymic disorder. The rating decision indicated that the Veteran's claim had been reopened but that the evidence continued to show that the condition was not incurred in or aggravated by military service. It also indicated that while the Veteran was treated for an alcohol use disorder in-service, the disorder was not subject to service connection. In July 2016, the Veteran presented a NOD and a Form 9, both disagreeing with the denial of service connection for major depression. The NOD was accepted by the RO and in June 2017 an SOC was issued addressing the matter. However, in July 2017, VA notified the Veteran that the Form 9 he had submitted on July 2016 was untimely as to the rating decision notified on January 2013 and the SOC of February 2015. The letter informed the Veteran that the January 2013 had become final. See VA Correspondence of July 2017. In August 2017, a Form 9 disagreeing with the SOC of June 2017, was associated with the claims file. The Veteran requested a hearing. See Form 9 of August 2017. In October 2021, the Veteran provided testimony before the undersigned and a transcript of the hearing has been associated with the claims file. Analysis as to finality of previous rating decisions Prior to addressing the merits of the claim, the Board needs to address whether the instant appeal regarding service connection for major depression presents a reopened claim or is an appeal from adjudication of the claim the Veteran initially filed on April 2012. Based on the above noted procedural history and for the reasons explains below, the Board finds that the Veteran's claim of service connection has remained pending since its initial denial in December 2012 and no reopening is warranted. Generally, rating decisions become final unless they are appealed or unless new and material evidence is received within one year of the promulgation of the rating decision. 38 U.S.C. § 5108 (2018); 38 C.F.R. § 3.156 (a) (2018). Once a decision becomes final it can only be reopened, if new and material evidence is received. 38 U.S.C. § 5108 (2018). Both "new" and "material" have regulatory definitions. Id. "New evidence is evidence not previously part of the actual record before agency adjudicators." Id. "Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim." Id. Where new and material evidence is received prior to the expiration of one year from the date of a legacy claim, a claim decided prior to February 19, 2019, such evidence will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 U.S.C. § 501 (2018); 38 C.F.R. § 3.156 (b) (2018). An appeal is initiated by the filing of a NOD. Once VA receives the NOD, an SOC must be issued to the veteran. Once the RO sends an SOC to the veteran, the veteran must file a Substantive Appeal within 60 days after the date of the SOC. Prior to March 2015, a substantive appeal consisted of a properly completed Form 9, "Appeal to Board of Veterans' Appeals," or correspondence containing the necessary information. 38 C.F.R. § 20.202 (2018). The Board notes that VA amended its adjudication regulations on March 24, 2015, to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. See 79 Fed. Reg. 57660 (Sept. 25, 2014). The amendments, however, are only effective for claims and appeals filed on or after March 24, 2015. Thus, that disposition does not apply to the appeal initiated by the NOD of December 2013 and addressed in the SOC of February 2015. Here, as noted in the procedural history above, the Veteran presented a statement in favor of his claim and new medical evidence in April 2015, within 60 days of the SOC of February 2015. He also submitted statements noting that he was submitting evidence in favor of his claim. The statements and new evidence were not addressed by the RO. Nonetheless, the Board finds that this statement and accompanying evidence should have been construed by the RO as a substantive appeal of the SOC of February 2015. 38 C.F.R. § 20.202 (2018). The statements were submitted along medical evidence and clearly demonstrated the Veteran's intent to continue to pursue his claim of service connection for a psychiatric disorder; notably the statements expressly indicated that the evidence was submitted in support for his claim of service connection. However, although the Veteran submitted a statement and medical evidence within 60 days of the SOC, no further action was taken on the claim. Accordingly, the Board finds the appeal remained pending and the September 2013 rating decision did not become final. Additionally, the Board finds that the December 2012 rating decision did not become final as evidence that was new and material to the claim of service connection for a psychiatric disorder was associated with the claims file within the year following the issuance of the rating decision. Notably, in February 2013, the Veteran submitted a medical opinion by Dr. C.L. that addressed the Veteran's alcohol dependence diagnosis and associated it with the Veteran's acquired psychiatric disorder. This evidence was new, as it had not been submitted previously to the RO and was material as it related to an unestablished fact necessary to substantiate the claim, mainly the onset of the Veteran's psychiatric symptomatology during active service and their relationship to the Veteran's diagnosis of alcohol dependence. Such evidence should have been considered as having been filed in connection with the claim which was pending at the beginning of the appeal period (i.e., the December 2012 rating decision adjudicating the claim of service connection for a psychiatric disorder). 38 U.S.C. § 501 (2018); 38 C.F.R. § 3.156 (b) (2018). Moreover, the Veteran submitted a claim to reopen the issue of major depression in February 2013. This claim to reopen could have been construed as an NOD regarding the December 2012 rating decision, as it was received within the year of the issuance of the rating decision. Furthermore, he presented a timely NOD in December 2013 that indicated disagreement with the December 2012 rating decision and the September 2013 rating decision. As noted in the procedural history above, the December 2012 rating decision was notified twice to the Veteran. The first notification was in December 2012 and the second notification was in January 2013. The January 2013 notification letter expressly indicated that it was a correction of the previous notification of December 2012 and that the Veteran had one year from the date of the letter to appeal the December 2012 rating decision. Within the year of the January 2013 notification, the Veteran presented a NOD that indicated disagreement with the December 2012 rating decision and the September 2013 rating decision. Thus, the December 2012 rating decision had remained pending in view of the timely NOD and the new evidence associated with the claims file within the year of its issuance. As such, it did not become final. Accordingly, because the previous December 2012 and September 2013 rating decisions did not become final in view of the above noted; the appeal has remained pending since then. Accordingly, the appeal period before the Board as to the matter of service connection for an acquired psychiatric disorder is from April 10, 2012, the date the Veteran presented his initial claim of service connection for major depression, forward. Service connection Generally, service connection may be established for a disability resulting from disease or injury in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303 (a). To establish service connection for a disability, there must be (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Here, resolving reasonable doubt in the Veteran's favor, the Board finds service connection for an acquired psychiatric disorder is warranted. The Veteran's military personnel records, STRs and post-service medical records have been associated with the claims file. The STRs show that in February 1990, during the Veteran's first period of active-duty service, he was seen by a social worker for an "initial rehab meeting." The examiner did not render a diagnosis but noted that the "patient seem[ed] angry." See STRs for February 1990. It is observed that no further explanation regarding the Veteran's evaluation was noted to include any incident that may have prompted referral for evaluation. The Veteran's military personnel records do not include further information regarding the matter contemporaneous to 1990. Nonetheless, this visit suggests, in view of the other medical evidence of record which will be discussed below, that the Veteran was demonstrating behavior suggestive of a psychiatric condition as he was evaluated by a social worker although not diagnosed. Other medical evidence of record shows that the Veteran sought treatment for alcohol related issues in October 2002 and completed a rehabilitation program in November 2002. See letter of November 2002 in the STRs. It is noted this treatment does not correspond to a period of active-duty service. In a periodic evaluation dated June 2008, during a period of active-duty service, the Veteran noted that he had medical problems or symptoms that bothered him. The report includes a note stating that the Veteran "discussed issues of stress (coping ok)." See Health History Questions of June 2008, in the STRs, parenthesis in original. In January 2010, the Veteran was seen in a substance abuse clinic due to an alcohol related incident that occurred on duty. The records contemporaneous to this incident note that the Veteran reported anxiety from anticipation of separation from service, anxiety regarding his career, and occupational stressors. In March 2010, the Veteran discussed with his medical care provider his depressive symptoms. In April 2010, diagnoses of dysthymic disorder (depressive neurosis) and major depression were rendered by the social workers who were actively treating the Veteran. The records note that the diagnoses had not been confirmed by a psychiatrist. See records from DGMC available in the STRs from January through April 2010. Nonetheless, the Veteran was started on antidepressants. See records from DGMC available in the STRs for April 2010 (showing the Veteran reported no side-effects from his psychiatric medication) and VA medical records for June 2010. The Board observes these records appear incomplete as they reference an "ADAPT" file with further details regarding an appointment the Veteran had for medication management with Dr. S., a psychiatrist. See records from DGMC available in the STRs, dated March 26, 2010. Although these records appear incomplete, the Board finds there is sufficient evidence to adjudicate the claim on the merits. An Informal Line of Duty (LOD) Determination regarding the Veteran's alcohol related incident in January 2010 and subsequent psychiatric disorder diagnoses was prepared in May 2010 by medical officer G.W. This report noted that the Veteran had been diagnosed with dysthymic disorder and major depression but that due to the active alcoholism the DSM IV criteria for the diagnoses rendered was clouded. The officer speculated that "all of his symptoms could be explained by the alcoholism" and recommended a finding of EPTS (existed prior to service) and was not aggravated by service. The report noted the following regarding the alcohol related incident: "Member was to deploy [to a state] in support of [humanitarian operations] in January 2010. He reported for duty [on the specified report date] intoxicated and was taken to [medical facility] for validation of substance abuse. Member was not deployed and was eventually taken off orders. [...] He is now claiming major depression." A recommended finding of "EPTS-LOD not applicable" was noted. However, the Air Force Reserve Command (AFRC) LOD Board review did not concur with the finding by medical officer G.W. and recommended a "Line of Duty" finding instead. The AFRC LOD Board action determined that the condition was "in line of duty" and that finding was the approving authority's final decision on the matter. See Informal LOD Determination of May 2010 and approved in July 2010, available in the STRs associated with the claims file in December 2011. The Veteran was reprimanded for the alcohol related incident of January 2010. See record of nonjudicial punishment proceedings (officer) of June 2010, available in the military personnel records associated with the claims file in June 2016. The record specifically notes the reprimand was associated with the incident in January 2010 when the Veteran was found under the influence of alcohol while on duty. This incident corresponds to a period of active duty with the Air Force reserves, as the Veteran had received orders for deployment as indicated in the Informal LOD Determination of May 2010. The military orders for that period of service were presented by the Veteran in April 2015 and were also associated with the claims file as part of the Veteran's military personnel records in April and October 2012. VA medical records show that the Veteran transferred treatment to a VA center in 2011. The Veteran reported being followed at DGCM for dysthymia and major depression. He reported having gotten in trouble for drinking on duty and having been sent to treatment for substance abuse, where it was discovered he was depressed. The Veteran's depression was noted to had been increased by losing his active-duty position and by some financial difficulties. The psychiatrist noted in the assessment that the Veteran had self-medicated with alcohol for depression, which caused issues at work and that despite compliance and sobriety, the Veteran remained depressed. A diagnosis of major depression was noted, and the psychiatrist determined to taper and decrease the Veteran's medication to eventually start another. See VA medical records of September 2011. In October 2011, the Veteran was administered a Psychosocial Assessment by a psychiatrist where a diagnosis of major depression was noted. See VA medical records for October 2011. In April 2012, a medical opinion by Dr. C.L., the Veteran's psychiatrist, was associated with the claims file. In this opinion, the psychiatrist noted that she was treating the Veteran for major depression, that he was initially treated for depression during active duty and that in her professional opinion, the Veteran's depressive symptoms were related to his military stressors. See medical opinion by Dr. C.L. of January 2012, associated with the claims file in April 2012. In February 2013, a second medical opinion by Dr. C.L. was associated with the claims file. The psychiatrist noted in pertinent part that while the Veteran indeed had a history of alcohol problems, he had been sober for 3 years and continued to struggle with depression despite compliance with treatment. She explained that the Veteran's history is consistent with use of alcohol to self-medicate the depression. Thus, she opined that it was more likely than not that the Veteran was depressed while on active duty and used alcohol to self-medicate. Additionally, she questioned the adequacy of the opinion provided by medical officer G.W. in the Informal LOD Determination of May 2010, which was cited in the December 2012 rating decision, as the medical officer never treated the Veteran, and his determination was not ultimately approved by the AFRC LOD Board. See medical opinion by Dr. C.L. of February 2013. In December 2013, a mental health assessment was associated with the claims file. This assessment included the Veteran's reports of increased difficulty with depression. It also noted that the Veteran reported experiencing depression while in service but that he was reluctant to disclose his symptoms because it would have affected his flight status. He also reported he used alcohol to medicate his depressive symptoms but that he had been sober for years prior to the assessment. The Veteran reported his symptoms were particularly intense between 2007 and 2010. The physician that subscribed the assessment noted the Veteran's symptomatology at the time and rendered a diagnosis of recurrent major depression in accordance with the DSM-IV. See assessment subscribed by Dr. J.J., dated November 2013 and associated with the claims file in December 2013. In February 2014, a third medical opinion by Dr. C.L. was associated with the claims file. The psychiatrist noted having treated the Veteran since September 2011 and that despite treatment the Veteran remained depressed and somewhat hopeless, with passive suicidal ideation. See medical opinion by Dr. C.L. associated with the claims file in February 2014. In April 2015, a fourth medical opinion by Dr. C.L. was associated with the claims file. She noted that she treated the Veteran for major depression and dysthymia and explained that dysthymia is a chronic condition that is present for many years. She explained that the mood component of dysthymia is often low grade enough that the patient may not seek active treatment, especially with the stigma associated with mental health issues in the military. She opined that it is more likely than not that the Veteran has suffered from dysthymia for many years including while in the military. See medical opinion by Dr. C.L of March 2015 associated with the claims file in April 2015. It is noted that this medical opinion was submitted in April 2015, along the previous opinions subscribed by Dr. C.L., medical records and an additional medical opinion, dated February 2013, by the social worker that treated the Veteran in 2010. The medical opinion subscribed by the social worker that treated the Veteran in 2010, following his alcohol related incident on duty, noted in pertinent part that "it is often difficult to determine with chronic alcohol use whether depressive symptoms are caused or exacerbated by substance abuse or post-acute withdrawal." However, she noted that the Veteran continued to receive treatment for depression after being sober for years. She further noted that the Veteran was being treated by Dr. C.L. for depressive symptoms that were diagnosed while the Veteran was in the military. See medical opinion by social worker C.G., dated February 2013 and associated with the claims file in April 2014. Additionally, in April 2015, a statement by the Veteran was associated with the claims file. This statement was interpreted by the Board as a substantive appeal, as explained above. The statement noted the Veteran's periods of active-duty service, with additional service in the Air Force Reserves until his retirement in April 2013. He explained that he had issues with depression during active-duty orders and described some specific incidents. Particularly, the Veteran noted that in 1989, there was a training accident involving some of his friends and an airplane crash. He also noted that his symptoms increased while in Germany, in 1990, because he was away from home and the base announced closure soon after his arrival. He further noted that from 2003 to 2004 and from 2007 to 2008 he delt with international flying in support of wartime activities and leadership stresses. Additionally, he noted the following as having an effect on his mental health: 7,000 flying hours, the pressures inherent to the responsibility of his rank, his flying in combat arenas such as the Panama Invasion, Desert Storm, Somalia, Bosnia, Operation Iraqi Freedom, and hurricane relief missions. He explained that he had issues with depression in early 2009 due to his military work and personal issues and that in January 2010 he had an alcohol related incident that was ruled "ILOD" (in line of duty) for depression while on orders. See lay statement by the Veteran, associated with the claims file in April 2015. In April 2015, a mental health re-assessment was associated with the claims file. This re-assessment noted the Veteran's increased depression which began in service. The assessment also noted that in 1989, the Veteran lost friends in an aircraft crash at an Air Force base. He also reported challenges of "support" and "leadership stresses" which influenced his depression during service from 2003 to 2004 and from 2007 to 2008; as well as the impact his participation in numerous missions had on his mental health. The assessment concluded that the Veteran's depressive symptoms appeared to have occurred while in the military, as supported by the available documentation. The subscriber also noted that the Veteran's distress makes him unemployable. See re-assessment subscribed by Dr. J.J. of March 2015, associated with the claims file in April 2015. At the hearing, the Veteran provided testimony regarding some stressors that occurred during his military service, to include the aircraft crash at the Air Force Base in 1989 during a training exercise and a crash of a crew the Veteran had put (or ordered) to rest in 1990, among other things. He also explained that he avoided complaining while in service because he did not want to not be mission ready. See hearing transcript. Based on all of the above, the evidence of record, and resolving reasonable doubt in the Veteran's favor, the Board finds that service connection for an acquired psychiatric disorder is warranted. Here, the evidence of record shows that the Veteran has a current acquired psychiatric disorder diagnosis, as evidenced by the medical opinions of record noting diagnoses of major depression and dysthymic disorder. Accordingly, the Veteran's claim surpasses the first prong of the Shedden service connection test, a current disability. Additionally, the Veteran's STRs show that while on active duty the Veteran was seen by a social worker for an initial evaluation in 1990 and that the Veteran reported issues of stress in 2008. While these two notations, if read in isolation from the other evidence available in the claims file, do not show a diagnosis or complaint of a psychiatric disorder; they do suggest the presence of symptomatology in view of the other evidence of record, to include the Veteran's lay statements regarding active-duty onset and medical opinions. Moreover, although the Veteran's in-service stressor regarding an airplane crash in 1989 or the crew incident in 1990 have not been verified by the RO, the Board finds that the lack of such corroboration is not determinative, as the other stressors reported by the Veteran such as his flying hours, the stresses and responsibilities inherent to his rank, and his participation in numerous missions, are verifiable through his military personnel records. Notably, the Veteran's military personnel records show that he was awarded medals for his service. In pertinent part, the Veteran was awarded the Air Medal for Meritorious Achievement while participating in aerial flight as an instructor pilot, from July 2003 to March 2006. The award document indicates that during this period, the Veteran flew 20 combat missions into hostile locations, to include Iraq, in direct support of Operation Iraqi Freedom. See military personnel records associated with the claims file in July 2010. Similarly, the Veteran was awarded the Aerial Achievement Medal for Sustained Meritorious Achievement while participating in sustained aerial flight from September 2001 to September 2003. During this time, the Veteran performed numerous time critical missions into surrounding boundaries of hostile airspace in support of Operations Enduring Freedom, Iraqi Freedom and Southern Watch. He was awarded a second Aerial Achievement Medal for sustained meritorious achievement while participating in sustained aerial flight from March 2005 to February 2007. During this time, the Veteran flew 11 combat and combat support missions into and the surrounding boundaries of hostile airspace, including Iraq, Kuwait, and Qatar, in support of Operation Iraqi Freedom. See correspondence associated with the claims file in October 2012. Additionally, the Board observes that the alcohol-related incited of January 2010 happened on the day the Veteran was supposed to report for duty with the Reserves, as noted in the Informal LOD Determination of May 2010. Accordingly, in view of the above, the Board finds that the second prong of the Shedden service connection test, the in-service incurrence, has been surpassed as the evidence of record shows that the Veteran's described stressors consistent with the circumstances of his service and are supported by the evidence of record. Thus, the remaining question before the Board is whether the probative evidence of record supports the finding that the Veteran' current psychiatric disorder is at least as likely as not related to his active-duty service, the nexus requirement of the Shedden service connection test. Resolving reasonable doubt in the Veteran's favor, the Board finds that the probative evidence of record suggests such is the case. Here, there are medical opinions from at least 3 different medical care providers that support the finding that the Veteran's psychiatric disorder originated in active-duty service and has persisted ever since. Notably, Dr. C.L. the Veteran's psychiatrist, subscribed four different opinions providing a positive nexus between the Veteran's acquired psychiatric disorder and his service. Moreover, Dr. C.L. explained that the Veteran's history of alcohol use is consistent with using alcohol to self-medicate a mental health condition and explained how such conclusion was further supported by the Veteran's continued need for psychiatric treatment despite his sustained sobriety. Furthermore, the other opinions noted the Veteran's avoidance of reporting symptoms while on active duty due to his worry that such would render him unable to perform his job (no fly status). See assessment of 2015. The Board recognizes that there is a single document of record that suggests the Veteran's psychiatric disorders did not originate during service. That is the opinion provided by medical officer G.W. in the Informal Line of Duty Determination of May 2010. This officer determined that the Veteran's alcohol-related disorder could explain his psychiatric symptomatology and recommended a finding of "EPTS-LOD not applicable." This opinion, however, is inadequate for adjudication purposes due to the use of speculative language regarding how the Veteran's alcoholism could explain his symptomatology and in view of its lack of rationale. Further, its probative value is low as the subscriber's recommendation was not approved by the AFRC LOD Board which ultimately made an in line of duty determination and because the medical officer's professional qualifications to confirm psychiatric diagnoses according to diagnostic criteria are not clear from the record. Moreover, Dr. C.L. noted in her medical opinion of February 2013, that this medical officer did not directly treat the Veteran. The Board observes that his name does not appear in the Veteran's STRs for 2010. Thus, the Board finds this medical opinion inadequate for adjudication purposes and affords it low probative value. The Board acknowledges that the Veteran had an extensive military career with periods of active duty and periods of service in the Reserves and that the matter of a specific onset date was not clearly addressed by the medical opinions of record. Nonetheless, here, the Board finds that the evidence supports the finding that his psychiatric disorder had its onset during active service and continued since then. Notably, the record does contain at least 1 evaluation of the Veteran by a social worker in 1990 and at least 1 complaint of stress in 2008, which are both periods of active-duty service. These two instances support the Veteran's lay statements regarding the onset of his psychiatric symptomatology during active-duty service, in view of the medical opinions of record which conclude the condition had its onset while on active duty. Further, the evidence of record shows that the Veteran flew into hostile territory multiple times and participated of critical missions during his active-duty period of service as well as during his service in the Reserve, as evidenced by the medals he was awarded for his meritorious service. Moreover, the January 2010 alcohol related incident, which eventually led to the Veteran's diagnosis, seems to suggest that his psychiatric condition, existed prior to 2010 but had not yet been diagnosed. Furthermore, the Veteran's alcohol-related disorder has been found to be associated with his psychiatric disorder, as Dr. C.L. noted in her medical opinions that the Veteran continued to experience psychiatric symptomatology although he ceased his alcohol use and noted that the Veteran used alcohol while in service to self-medicate for his depression. Thus, the Board finds that, resolving reasonable doubt in the Veteran's favor, service connection for an acquired psychiatric disorder, to include major depression and dysthymic disorder, is warranted, on a direct basis. REASONS FOR REMAND 1. Entitlement to a disability rating in excess of 10 percent for hypertension is remanded. The Veteran seeks a disability rating in excess of 10 percent for hypertension. His last VA examination for the condition is dated May 2016. At the hearing, the Veteran asserted that his condition has worsened since the last VA examination. See hearing transcript, page 6. In view of the Veteran's assertion regarding a worsening of the condition and that the most recent examination is from 2016, the Board finds the matter must be remanded for a new examination. Allday v. Brown, 7 Vet. App. 517 (1995); Caffrey v. Brown, 6 Vet. App. 377 (1994); Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993). Additionally, the Board observes that there are no recent medical records for the Veteran in the claims file. The most recent VA medical record dates back to April 2017. Accordingly, upon remand, VA medical records must be updated. Finally, at the hearing the Veteran noted that he was treated by a private provider for his hypertension. See hearing transcript pages 7 and 8. Thus, upon remand, the RO must attempt to obtain these records if the Veteran provides the necessary releases. 2. Entitlement to a TDIU is remanded. At the hearing, the Veteran asserted that he is unable to work due to his service-connected disabilities, including his psychiatric disorder. See hearing transcript, page 12. Thus, the Board has added the issue of TDIU to the present appeal, as part and parcel of the increased rating claim for hypertension. See Rice v. Shinseki, 22 Vet. App. 447 (2009). However, because the matter is inextricably intertwined with the increased rating claim of hypertension and the evaluation of the Veteran's psychiatric disorder which has been granted service connection in this decision, the Board finds the matter must be remanded for development. See Harris v. Derwinski, 1 Vet. App. at 183 (1990). Upon remand, the RO must provide the Veteran with written notice regarding the evidence necessary to establish entitlement to a TDIU, in addition to a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. The matters are REMANDED for the following actions: 1. Update existing VA medical records. 2. Send the Veteran written notice regarding the evidence necessary to establish entitlement to a TDIU, in addition to a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. Request the Veteran to return the completed VA Form 21-8940. 3. Request the Veteran identify any outstanding private treatment records and provide the necessary releases for VA to obtain these records. At the hearing the Veteran noted he received treatment from a private provider, Dr. A.M., for hypertension. After securing the necessary releases, attempt to obtain and associate any identified treatment records with the claims file. 4. Schedule the Veteran for an examination regarding his hypertension. The examiner is asked to determine the current severity of the Veteran's condition and whether the Veteran has developed any complications associated with the condition. 5. Following any additional indicated development, the AOJ should review the claims file and readjudicate the claim on appeal and adjudicate entitlement to a TDIU in the first instance. If the benefit sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto before the case is returned to the Board for further consideration. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Gonzalez-Maldonado 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.