Citation Nr: 21007475 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 17-04 646 DATE: February 9, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia and depression, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1999 to July 1999. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In a December 2018 decision, the Board denied the Veteran’s claim for entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia, schizoaffective disorder, depression, and lack of sleep. The Veteran appealed the December 2018 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a November 2019 Memorandum Decision, the Court set aside the Board’s decision to deny the claim and remanded it for further development. In June 2020 and October 2020, the Board remanded the claim for further development.   Entitlement to service connection for an acquired psychiatric disorder, to include schizophrenia and depression, is remanded. Although the additional delay is regrettable, the Board finds an additional remand is required before a decision can be made regarding the Veteran’s claim. In the October 2020 remand order, the Board requested an addendum opinion concerning the Veteran’s acquired psychiatric disorder. Specifically, the Board asked the July 2020 VA examiner to confirm or rule out the presence of depression or major depressive disorder during the period of the claim and, if a diagnosis is not warranted, to provide a medical explanation supporting the finding. In the subsequent November 2020 opinion, the VA examiner opined that there was no current diagnosis of depression. In support of the opinion, the examiner noted that some past treatment records show a diagnosis of depression but most do not; that some notes reference the Veteran’s report of depressed mood, but document that he failed to meet criteria for depression based on that symptom alone; and that most treatment notes focus on the psychotic symptoms and their management. The examiner explained that this evidence shows the Veteran met criteria for depression in the past but not currently. The examiner further explained that it is not possible to create a clear timeline of the separate periods of depression but opined that the Veteran likely met criteria for depression from 2004 to 2009 since some records show the diagnosis was present during that period. The examiner added that most recent records do not show a diagnosis of depression. However, the Board finds the opinion inadequate. While the examiner indicated that the Veteran likely met criteria for a diagnosis of depression between 2004 to 2009 and reported that most recent records do not show a diagnosis of depression, an October 2012 private treatment record lists major depressive disorder as an active problem that onset in 2004. In addition, an April 2013 VA treatment record indicates the Veteran was receiving treatment for major depression since 2003 and private treatment records note treatment for depression in 2014. As it is unclear whether these more recent records documenting treatment for depression were considered by the November 2020 VA examiner, the Board finds remand for a new medical opinion necessary. This matter is REMANDED for the following action: 1. Obtain any updated VA treatment records for the period from December 2016 to the present. 2. Ask the Veteran to complete a VA Form 21-4142 to authorize VA to obtain any updated private treatment records concerning the Veteran’s psychiatric disorders. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 3. After obtaining any additional records, obtain an addendum opinion from a VA examiner other than the November 2020 VA examiner. An examination should only be scheduled if the examiner deems one is necessary to provide the requested opinions. Following a review of the relevant records and lay statements, and an additional examination if deemed necessary, the examiner is to confirm or rule out the presence of depression or major depressive disorder during the period of the claim (from approximately November 2012 to the present). If the examiner finds that such a diagnosis is not warranted, he or she is to provide a medical explanation in support of this finding, to include referencing the record, as needed. Please note the following for consideration regarding the Veteran’s treatment for depression. See 4/19/2016 CAPRI, at 3 (indicating that the Veteran was receiving treatment for major depression since 2003). In addition, an April 2013 VA treatment record and (5/9/2014 Medical Treatment Record – Non-Gov’t Facility, at 46, 50 (reflecting private treatment for depression in 2014). If the examiner finds a depression diagnosis is warranted, he or she is to state whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s depression originated during or is otherwise etiologically related to his military service. In providing this opinion, the examiner is to address the Veteran’s statements to the effect that he started having nightmares and loss of sleep, crying spells, and episodes of “schizing out” during service due to sergeants yelling at him. The examiner must provide a comprehensive rationale for any opinion. Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Jiggetts 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.