Citation Nr: 21014768 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 16-05 709A DATE: March 15, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder is granted. FINDING OF FACT The Veteran’s acquired psychiatric disorder, most recently diagnosed as major depressive disorder, is etiologically related to her active service. CONCLUSION OF LAW The criteria for service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.301, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1978 to January 1983. This claim comes to the Board of Veterans’ Appeals (Board) from a February 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in September 2018, when it was remanded for further development. Case law provides that a claim for a mental health disability includes any mental disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. Brokowski v. Shinseki, 23 Vet. App. 79 (2009); see also Clemons v. Shinseki, 23 Vet. App. 1 (2009). The record reflects mental disorders other than depressive disorder, including major depression, recurrent, bipolar disorder, and an anxiety disorder. Thus, pursuant to the holding in Clemons, the Board has more broadly characterized the psychiatric claim on appeal. To the extent the record contains information not yet considered by the Agency of Original Jurisdiction (AOJ), the Veteran waived consideration of such evidence and requested that the Board proceed to the merits in multiple waivers, with the most recent waiver having been submitted to VA in July 2020. 38 C.F.R. § 20.1304(c). Therefore, the Board will proceed in adjudicating the Veteran’s claim. 1. Acquired Psychiatric Disorder The Veteran asserts that she has an acquired psychiatric disorder related to her active service. Specifically, she contends that she had a long history of depressive episodes, and that her in-service depressive episodes were related to relationship difficulties and military experiences such as being yelled at by training officers and adjustment to routine military life. See Mental Disorders Disability Benefits Questionnaire (DBQ), November 8, 2019. The law provides that every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. §§ 1110, 1111. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). In order to rebut the presumption of soundness, there must be clear and unmistakable evidence demonstrating that the injury or disease existed before acceptance and enrollment and clear and unmistakable evidence that it was not aggravated by such service. VAOPGCPREC 3-2003 (July 16, 2003). Essentially, to rebut the presumption of sound condition VA must show by clear and unmistakable evidence both that the disease or injury existed prior to service and that the disease or injury was not aggravated by service. Because the Veteran’s acquired psychiatric disorder was not noted at entry on her April 1978 physical, but after her separation from active service, she is presumed to have been in sound condition at entry. See 38 C.F.R. § 3.304(b). To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. § 1131; 38 C.F.R. § § 3.303 (a). A disability may be service connected on a secondary basis if it is proximately due to or the result of a service-connected disease or injury; or, if it is aggravated beyond its natural progress by a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.310 (a), (b) (2019). The question for the Board is whether the Veteran has a current diagnosis of an acquired psychiatric disorder and, if so, if the disorder either began during active service, or was caused or aggravated by any service-connected disabilities. The Board finds that competent, credible, and probative evidence establishes that an acquired psychiatric disorder is related to her active service. The Veteran has a current diagnosis of an acquired psychiatric disorder, major depressive disorder. See Mental Disorders DBQ, November 8, 2019. Thus, the first element of service connection has been met. As to the issue of in-service incurrence, the Veteran’s service treatment records do not show any complaints, treatment, or diagnosis of any acquired psychiatric disorder. However, she has stated that she experienced significant distress from being yelled at by training officers and generally adjusting to routine military life. Therefore, the second element of service connection has also been met. Turning to whether there is a medical nexus, a medical professional has stated that the Veteran’s diagnosed acquired psychiatric disorder is related to her active service. Private treatment records include an examination in which a private physician opined that the Veteran’s depressive disorder was more likely than not related to her active service. The psychologist stated that the Veteran’s acquired psychiatric disorder began in active service, continued uninterrupted until present time, and has remained severe and at times debilitating. See private examination, H.H.G., received by VA August 4, 2020. The Board finds this opinion highly probative. Thus, the third element of service connection has been met. As such, the Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder is granted. MARTHA R. LUBOCH Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Lech, 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.