Citation Nr: 21015340 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 15-05 823 DATE: March 17, 2021 REMANDED Entitlement to service connection for a psychiatric disorder, including as secondary to the service-connected sinusitis and rhinitis, is remanded. REASONS FOR REMAND The Veteran had active duty in the United States Army from September 1990 to April 1991. This matter comes before the Board of Veterans’ Appeals (Board) from a July 2013 rating decision of the Department of Veterans Affairs (VA) San Juan Regional Office (RO). The Veteran provided testimony at a Board videoconference hearing before the undersigned in November 2018. A transcript of the hearing is within the record before the Board. The RO denied the Veteran’s claim based upon the lack of evidence within service treatment records showing an onset of depression or any other psychiatric disorder. This decision was made relying upon the opinion of a June 2013 VA examiner. This examiner indicated there is no evidence of psychiatric findings in the service treatment records, within one year of the Veteran’s separation from service, or for ten years after his April 1991 separation. The examiner indicated there is no evidence of a connection between any current psychiatric disorder and the Veteran’s service. This examiner did not discuss the June 2005 VA treatment record that shows the Veteran reported feeling the influence of his Persian Gulf War experiences were a possible precipitating factor for his depression. The examiner also did not discuss the May 2013 statement from the Veteran’s spouse. This handwritten statement was submitted in Spanish. The Board sought translation and this revealed the Veteran’s wife’s report that since the year the Veteran returned from the Gulf, he had suffered from a severe depression. As it does not appear the June 2013 VA examiner fully reviewed the claims file and did not consider relevant evidence, the Board finds the opinion to be inadequate. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 4489 (2000). Moreover, a review of the record reveals there may be a relationship between the Veteran’s psychiatric disorder and his service-connected disabilities, sinusitis and rhinitis in particular. An August 2012 VA treatment note shows the clinician’s indication that when the Veteran experiences a sinus infection, his sleep pattern is impacted and his mood worsens. Also, a July 2013 VA treatment record shows a clinician’s note that at the time of a sinusitis episode, the Veteran has increased depression symptoms. This raises the question of whether the Veteran’s psychiatric disorder is potentially caused or is being aggravated by his service connected sinusitis and/or rhinitis. An opinion is needed in this regard. 38 C.F.R. §§ 3.159(c)(4), 3.310. Finally, at the November 2018 Board hearing, the Veteran reported receiving treatment for depression as early as 1998 at the San Juan VA facility, before later moving to the United States and beginning his care at the VA facility in Orlando, Florida. On remand, the RO should make sure all relevant treatment records dated since the Veteran’s 1991 separation from service and related to the Veteran’s psychiatric care from both San Juan and any other VA healthcare facility from which the Veteran receives treatment are within the claims file. 38 C.F.R. § 3.159(c)(2). Also, given the indication in the August 2012 and July 2013 VA treatment records that there may be an association between the Veteran’s depression and his sinusitis/rhinitis, the Board finds any non-duplicative treatment records for those disorders should also be associated with the claims file. The matters are REMANDED for the following action: 1. Obtain the Veteran’s non-duplicative VA treatment records related to his psychiatric care and sinusitis/rhinitis care for the period from the Veteran’s 1991 separation from service through the present. The Veteran testified that he first started receiving treatment for depression in 1998 in San Juan, such that records from that date forward, in particular, are needed. 2. Once the record is complete to the extent possible, obtain an addendum opinion that addresses the Veteran’s claim both on a direct and secondary basis. The Board leaves it to the person writing the opinion to determine whether an additional examination is necessary. The examiner must review the claims file and discuss the relevant evidence from the Veteran’s medical history, some of which is noted in the narrative portion of this remand, above. The examiner is asked to provide a response to the following: (1) Is the Veteran’s psychiatric disability at least as likely as not related to service? The person writing this opinion should consider and discuss the June 2005 treatment record showing the Veteran’s report that he feels his Persian Gulf service was a precipitating factor for his depression, as well as his wife’s May 2013 statement indicating her recollection that the Veteran was experiencing severe depression since his return from service, including within the first year (and any other relevant evidence added to the claims file after this remand). (2) Is the Veteran’s psychiatric disability at least as likely as not proximately due to, or at least as likely as not aggravated, i.e., worsened beyond its natural progression, by his service-connected sinusitis and/or rhinitis? The person writing this opinion should consider and discuss the August 2012 and July 2013 VA treatment notes (and any other relevant evidence added to the claims file after this remand), which show reports of increasing depressive symptoms in correlation with sinus infections and other increases in sinus symptoms. A well-reasoned rationale should be provided for any opinion expressed. 3. After completing the above actions, to include any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If any claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. MICHAEL KILCOYNE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Adamson, 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.