Citation Nr: 21076754 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 18-14 010 DATE: December 27, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected depression, is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran has OSA due to an event, injury, or disease in service, or secondary to a service-connected disability. CONCLUSION OF LAW The criteria for service connection for OSA are not met. 38 U.S.C. § 1131; 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from July 2004 to February 2007. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In September 2020, a Video Conference Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. Entitlement to service connection for obstructive sleep apnea The Veteran has asserted he has been diagnosed with OSA, as a direct result of his service. In the alternative, he asserts OSA is secondary to his service-connected depression. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). After having considered all the evidence of record, the Board concludes that the preponderance of the evidence is against finding that the Veteran suffers from OSA related to his military service, to include as secondary to his depression. The Veteran's service treatment records (STRs) are void for any indication of OSA. In September 2017, a statement from I. B. was submitted supporting the Veteran's contention that he has suffered from sleep difficulties since the time in service. The Veteran has submitted various articles in support of the contention that OSA is related to depression. The Veteran was afforded an examination in September 2017. The Veteran reported being asked to move out of the barracks during service due to his snoring. He recalled taking the train daily and sleeping as soon as he sat down. He reported memory and concentrating problems due to sleep apnea. He was utilizing a CPAP device. The examiner rendered an opinion that OSA is less likely than not caused by depression. The rationale was OSA is a sleep-related breathing disorder characterized by episodes of upper airway obstruction during sleep and is commonly associated with metabolic syndrome. The examiner indicated there is no medical evidence that OSA is caused or aggravated by psychologic factors. The examiner further noted there are many psychological and behavioral factors that can influence sleep quality and quantity these issues would not affect the pathophysiologic mechanisms of OSA. In June 2021, the Veteran underwent another examination. He reported being diagnosed in 2016 with OSA. He stated his wife noticed he would snore during the night and stop that he stopped breathing. During service, he also reported being confronted that he snored too loudly. Since onset, he reported his condition had improved. He reported his OSA has been somewhat controlled, but he still has days when he does not sleep well. He uses a CPAP device regularly. After consideration of the Veteran's lay statements and review of the evidence of record the examiner opined the Veteran's OSA is less likely than not related to his service. Per the July 2016 sleep study, he had a BMI of 51.7. Per the literature there is a linear correlation between obesity and OSA. In obese people, fat deposits in the upper respiratory tract and there is a decrease in muscle activity in this region leading to hypoxic and apneic episodes, ultimately resulting in sleep apnea. The examiner concluded the Veteran's obesity, and less likely his military service, led to the development of OSA. The examiner opined the claimed OSA is less likely than not proximately due to or the result of his depression and is less likely aggravated by depression. Per the literature, the examiner noted that sleep disordered breathing can be a sign of untreated OSA, which is associated with worse symptoms of psychiatric conditions, but this would not necessarily result in the development of OSA. Therefore, it is not clear that depression aggravated or caused OSA. The examiner went on to note that the Veteran served from 2004 to 2007 and was diagnosed with OSA in 2016. The examiner noted it is not clear that the Veteran's reported sleepiness during service was a manifestation of OSA. As to the July 2017 article in Sleep Review magazine, this is not accepted peer review literature, and does not support that depression clearly causes or exacerbates sleep apnea. In a July 2021 addendum opinion, the examiner noted that although the Veteran provided a buddy statement indicating the Veteran had a history of sleep difficulties, there is a lack of visit notes or medical documentation to support that OSA is related to service. As far as the articles the Veteran provided regarding OSA being related to depression, the examiner found that this is not supported by peer reviewed literature. Per literature, sleep disordered breathing can be a sign of untreated OSA, which is associated with worse symptoms of psychiatric conditions, but this would not necessarily result in the development of OSA. A 2015 study in the Clinical Psychology Review considered the presence of OSA to be a risk factor for PTSD. There is also literature suggesting untreated OSA appears to be associated with worse outcomes with PTSD. However, there is a lack of support in the literature that PTSD causes OSA. Research suggests that civilians with PTSD have higher rates of OSA than the general population. However, even though there are higher rates of OSA in civilians with PTSD than the general population, the literature does not support that PTSD causes OSA. OSA is a complete or partial airway obstruction that can cause significant physiologic disturbance with various clinical impacts. It is not clear by the literature that the OSA is related to psychiatric disabilities, as this is not recognized in peer reviewed literature. There is no competent opinion to the contrary. Although the Veteran sincerely believes he suffers from OSA due to service, or secondary to depression, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board affords more probative weight to the VA examiners' opinions. The 2021 examiner noted the Veteran's obesity and not military service, led to the development of OSA. Further, the examiner determined that OSA was not caused or aggravated by his depression. The examiner considered the buddy statement and lay testimony and found there remains no evidence otherwise of a diagnosis of OSA or manifestations of OSA during service or shortly thereafter. On separation there was no indication of a sleep condition or OSA, and the first report of OSA was not until 2016. Again, the examiner found that there is no peer reviewed literature that shows psychiatric disorders cause or aggravate OSA, and the examiner specifically found that is not the case for this Veteran. In so concluding, the examiners provided a detailed rationaleincluding consideration of the medical evidence and lay reports. The examiners' opinions, taken together, are probative, because they are based on an accurate medical history and provide explanations that contain clear conclusions and supporting data. There are no competent opinions to the contrary and in support of the Veteran's claim. The most probative evidence of record does not show that the Veteran suffers OSA directly due to service or secondary to depression. Absent probative evidence linking his claimed disability to service, service connection must be denied. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Skiouris, 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.