Citation Nr: 21012227 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 15-18 882 DATE: March 3, 2021 REMANDED Entitlement to service connection for a psychiatric disorder, including major depressive disorder (MDD), is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1963 to November 1965. This matter is on appeal of an October 2014 rating decision. The Board remanded the appeal for further development in January 2018 and June 2020. The Veteran was afforded a hearing before a Decision Review Officer (DRO)at the Regional Office (RO) in April 2016. A DRO conference report of the hearing has been associated with the claims file. Regrettably, the claim of entitlement to service connection for a psychiatric disorder, including MDD, must again be remanded, as the Agency of Original Jurisdiction (AOJ) has not substantially complied with the directives of the prior January 2018 and June 2020 remands as required. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that AOJ substantial compliance with remand directives is not optional or discretionary, and the Board errs as a matter of law when it fails to ensure substantial compliance). The Board initially remanded the issue in January 2018 because it was inextricably intertwined with other issues for which service connection was subsequently granted. Pursuant to the remand, the Veteran was afforded a VA examination in February 2020 to determine whether his service-connected disabilities either caused or aggravated his diagnosed MDD. Although VA treatment records indicate the Veteran was treated for diagnosed MDD from 2013 to 2014, the February 2020 VA examiner found that the Veteran had no current symptoms that met the diagnostic criteria for a mental disorder and that his previously diagnosed MDD had resolved. The Board again remanded the issue in June 2020 to obtain the opinion regarding whether the Veteran’s claimed psychiatric disorder was either caused or aggravated by his service-connected disabilities, as he was clearly diagnosed with MDD during the pendency of the appeal. See McClain v. Nicholson, 21 Vet. App. 319 (2007). A September 2020 VA clinician opined that the Veteran’s previously diagnosed MDD was less likely as not directly linked to his service because there was no evidence of treatment in service and that it was not proximately caused or aggravated by any of his service-connected disabilities. The examiner stated that there was no evidence in the available medical record that the Veteran’s initial depressive condition, diagnosed in 2013 to 2014, involved any of his physical health problems. The examiner further notes that an earlier 2016 VA examination showed no diagnosed psychiatric condition and that by his own self-report, the Veteran did not assert any physical health symptoms in conjunction with his current report of mental health symptoms. A medical opinion is inadequate if it does not take into account the Veteran’s reports of symptoms and history, even if recorded in the course of the examination. Dalton v. Nicholson, 21 Vet. App. 23 (2007); see also Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). The February 2020 and September 2020 opinions are based on inaccurate facts and do not address the Veteran’s credible history of symptoms of depression since his discharge from service. Nor have the examiners addressed contemporaneous VA treatment records that described his deteriorating medical health as a risk factor for his previously diagnosed MDD. Thus, an addendum opinion, addressing this evidence should be obtained on remand.   The matter is REMANDED for the following action: 1. Obtain any updated VA treatment records from November 2020 to the present. 2. After associating the above records, an addendum medical opinion must be obtained from the examiner who conducted the September 2020 VA mental health examination. If the examiner is unavailable, another clinician with sufficient experience and expertise should provide the requested opinion. Another examination or telehealth interview need only be performed if deemed necessary by the clinician providing the opinion. The electronic claims file must be made available to the examiner. Based on review of all the evidence of record, and the Veteran’s elicited history, the examiner must first provide diagnoses for any psychiatric disorder, including MDD, that has existed during the pendency of the claim (since May 16, 2014): (a) Is it at least as likely as not (50 percent or better probability) that any currently or previously diagnosed psychiatric disorder, to include MDD, is related to the Veteran’s service, or any incident therein? (b) If the answer to (a) is that it is less likely than not, then is it at least as likely as not (50 percent or better probability) that any currently or previously diagnosed psychiatric disorder, to include diagnosed MDD, is or was caused by his service-connected disabilities (including diabetes mellitus type II, peripheral neuropathy in all extremities, peripheral vestibular disorder, keratoderma of the plantar heels, hypertension and tinnitus)? (c) If the answer to (b) is that it is less likely than not, is it at least as likely as not (50 percent or better probability) that any currently or previously diagnosed psychiatric disorder, to include diagnosed MDD, is or was aggravated by (where aggravation is any increase in severity beyond the natural progress of the disability) his service-connected disabilities (including diabetes mellitus type II, peripheral neuropathy in all extremities, peripheral vestibular disorder, keratoderma of the plantar heels, hypertension and tinnitus)? In providing these opinions, the examiner must consider and address the Veteran’s report of experiencing depression continuously since his discharge from service, as well as the April 2013 VA psychiatric admission evaluation note identifying the Veteran’s worsening physical health as a risk factor for his diagnosed MDD, single episode, and Axis IV notation of health deterioration. The examiner must also address the April 2013 VA psychiatric consult treatment record noting the Veteran’s reported history of depression symptoms in the distant past, after his military discharge, and subsequent VA mental health treatment records noting his health or medical problems. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or   testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. J. Wells-Green 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.