Citation Nr: 21025733 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 18-10 900 DATE: April 28, 2021 REMANDED Entitlement to service connection for psychiatric disability, not to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had a period of active duty for training (ACDUTRA) from July 1977 to October 1977. This matter initially came before the Board of Veterans’ Appeals (Board) from an April 2017 rating decision. In June 2019, the Board denied service connection for PTSD and psychiatric disability other than PTSD (to include depression). The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In June 2020, the Court set aside the Board’s June 2019 decision, in part, and remanded to the Board the issue of entitlement to service connection for psychiatric disability other than PTSD for readjudication in compliance with directives specified in a May 2020 Joint Motion filed by counsel for the Veteran and VA. In November 2020, the Board remanded this matter for further development. Entitlement to service connection for psychiatric disability, not to include PTSD, is remanded. The Veteran contends that he has current psychiatric disability that is related to psychiatric stressors that he experienced during basic training. For instance, he has reported that he witnessed a fellow service member injure his hand when a land mine exploded, that he passed out when someone “put a mickey” in his drink, and that he had to take his mask off while training in a gas chamber. A VA psychiatric examination was conducted in March 2021 and the Veteran was diagnosed as having unspecified depressive disorder. The psychologist who conducted the examination opined that the Veteran’s depressive disorder was not likely related to service. However, this opinion is inadequate because the examiner did not acknowledge or discuss whether the Veteran’s psychiatric disability was related to any of his reported stressors in service. Also, the examiner did not discuss the potential significance of the Veteran’s report of “nervous trouble of any sort” on an October 1977 report of medical history form. In light of these deficiencies, a remand is necessary to obtain a new medical opinion as to whether the Veteran’s claimed psychiatric disability is related to service. Also, the evidence indicates that there may be outstanding relevant VA treatment records. During the March 2021 VA psychiatric examination, the Veteran reported that he began receiving psychiatric treatment at the VA Medical Center in Oklahoma City, Oklahoma in 2004. However, the VA treatment records from this facility that are in the claims file are only dated from June 2017 through October 2020. Any VA treatment records are within VA’s constructive possession, and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). See also Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (confirming the holding in Sullivan). A remand is required to allow VA to obtain them. Lastly, the evidence reflects that a copy of a March 2021 supplemental statement of the case (SSOC) was mailed to the Veteran’s representative, but that it was returned as undeliverable. Thus, the Board must assume that the Veteran’s representative did not receive the March 2021 SSOC. The Board notes that the SSOC appears to have been mailed to an incorrect address (see a November 2020 statement from the Veteran’s representative which includes an updated address). As such, in order to ensure due process, a copy of the March 2021 SSOC should be resent to the Veteran’s representative. The matter is REMANDED for the following action: 1. Re-send a copy of the March 2021 SSOC to the Veteran’s representative. 2. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for psychiatric disability, to include the dates of any such treatment. Ask the Veteran to complete a VA Form 21-4142 for all records of his treatment for psychiatric disability from any sufficiently identified private treatment provider from whom records have not already been obtained. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 3. Obtain the Veteran’s outstanding VA treatment records from the Oklahoma City VA Health Care System for the periods from October 1977 through June 2017 and from October 2020; and all such relevant records from any other sufficiently identified VA facility. 4. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding whether any psychiatric disability experienced by the Veteran since approximately November 2016 (including, but not limited to, depression and other specified trauma/stress related disorder) at least as likely as not (1) began during his period of ACDUTRA from July to October 1977; OR (2) is related to an injury or disease during that period of service, including his reported psychiatric stressors and his report of “nervous trouble of any sort” on an October 1977 report of medical history form. The clinician must provide reasons for each opinion given. In this regard, the clinician should acknowledge and comment upon the Veteran’s reported psychiatric stressors in service (including witnessing a fellow service member injure his hand when a land mine exploded, passing out when someone “put a mickey” in his drink, and taking his mask off while training in a gas chamber) and his report of “nervous trouble of any sort” on the October 1977 report of medical history form. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Elwood, 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.