Citation Nr: 21024886 Decision Date: 04/26/21 Archive Date: 04/26/21 DOCKET NO. 16-25 881 DATE: April 26, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 1980 to September 1981. This matter comes before the Board of Veterans’ Appeals (Board) from an April 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In a March 2019 decision, the Board remanded this matter to the RO for further development. More specifically, the Board directed the RO to provide an addendum opinion to address the December 1981 VA treatment records documenting the Veteran’s report that he had been depressed and nervous since he incurred his service-connected right ankle injury. In July 2020, the RO issued a Supplemental Statement of the Case again denying service connection for the Veteran’s claimed acquired psychiatric disorder. The matter now returns to the Board. Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder, is remanded. The Veteran generally contends that his major depressive disorder, alcohol and drug use stems from his inability to cope with his right ankle injury and traumatic experiences incurred during service. See October 2014 Statement in Support of Claim and May 2016 Form 9. Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. 38 U.S.C.§ 5103A; 38 C.F.R. § 3.159. As will be discussed below, the Board finds that there has not been substantial compliance with the Board's previous remand directives regarding the issues of entitlement to service connection for acquired psychiatric disorder. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). In the March 2019 Board remand, the AOJ was directed to provide an opinion that address the December 1981 VA treatment records documenting the Veteran’s report that he had been depressed and nervous since he incurred his service-connected right ankle injury. However, the October 2019 VA examination addressed a January 1982 treatment that diagnosed the Veteran with depression secondary to alcohol and drug abuse, but did not address a December 1981 treatment record that the Veteran had been depressed and nervous since he broke his ankle in service and started drinking and doing drugs while in service. This statement was documented three months after the Veteran’s discharge and is pertinent to his service connection claim. The examiner stated that the Veteran did not report depression related to his right ankle disability in the February 2015 VA examination, but he had reported it in 1981 and it was documented multiple times prior to that examination. Furthermore, the 2015 VA examination noted the Veteran’s first depressive episode was in 1981. Moreover, in the Veteran’s October 2014 Statement in Support of Claim for PTSD, he stated that his traumatic experiences while in service led to suicidal ideations, nightmares and anxiety. Although this was addressed in the February 2015 VA examination for PTSD, his lay statements were not addressed in relation to his other diagnosis in the October 2019 VA examination. In addition, the October 2019 VA examiner provided an opinion as to whether the Veteran’s claimed condition clearly and unmistakably existed prior to service and was not aggravated beyond its natural progression by an in-service event, injury or illness. However, there is no indication in the record that the Veteran’s acquired psychiatric disorder preexisted service. Thus, the AOJ is directed to provide an addendum that addresses the Veteran’s statements about his traumatic experiences as it relates to major depressive disorder, alcohol and drug abuse and any other psychiatric diagnosis, as well as, address the December 1981 treatment record that notes the Veteran had been depressed and nervous since he broke his right ankle in service and started drinking and doing drugs while in service. The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. After obtaining any outstanding records, return the claims file, to include a copy of this remand, to the examiner for an addendum opinion. If the examiner who drafted the October 2019 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner must opine as to the following: (a) Is it at least as likely as not (50 percent or more probability) that the Veteran's diagnosed acquired psychiatric disorders are related to an in-service injury, event, or disease? (b) Is it at least as likely as not (50 percent or more probability) that the Veteran's diagnosed acquired psychiatric disorders are proximately due to or the result of the Veteran's service-connected residuals of a right medial malleolus fracture? (c) Is it at least as likely as not (50 percent or more probability) that the Veteran’s diagnosed acquired psychiatric disorders were aggravated by the Veteran’s service-connected residuals of a right medial malleolus fracture? The examiner should address the Veteran’s statements about his traumatic experiences while in service and the December 1981 treatment report about how his right ankle injury caused depression and anxiety. Ensure that any medical opinion obtained includes a complete rationale for the conclusions reached. Any medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; any medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Adeyemi, Associate 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.