Citation Nr: 21029156 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 18-12 273 DATE: May 12, 2021 ORDER Entitlement to service connection for acquired psychiatric disability, including a mood disorder, is granted. FINDING OF FACT The Veteran's acquired psychiatric disability, including a mood disorder, is at least as likely as not related to in-service symptoms such as sleep impairment and periods of depression and anxiety. CONCLUSION OF LAW The criteria for service connection for acquired psychiatric disability, including a mood disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from October 1971 to June 1995. In April 2017 he sought service connection for dysthymic disorder and generalized anxiety disorder (GAD). In a July 2017 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) denied service connection for dysthymic disorder and GAD. The Veteran appealed that denial to the Board of Veterans' Appeals. In November 2018, March 2020, and February 2021, the Board remanded the case to the RO for additional actions. 1. Service connection for acquired psychiatric disability The Veteran reports that during his service he had stressful experiences and had psychiatric symptoms including sleep impairment, anxiety, and depression. He contends that he had onset during service of a psychiatric disorder that continued after service and through the present. Service connection may be established on a direct basis for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, including psychoses, may be established based upon a legal presumption by showing that the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of discharge from service. 38 U.S.C. §§ 1112, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2020). The United States Court of Appeals for Veterans Claims (Court) has indicated that the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. In August 1971 the Veteran had a medical examination for entrance to service. He marked no for history of mental or emotional problems. The examiner marked normal for his psychiatric condition. His service personnel records show that he was stationed in Korea in 1979 and 1980 and in Panama in 1988 to 1992. His service treatment records do not reflect any complaints or findings of psychiatric problems. In a periodic examination in December 1993, the examiner marked normal for the Veteran's psychiatric condition. In a December 1994 treatment note, a clinician wrote, "No mental illnesses noted." The Veteran's assembled service treatment records do not contain the report of any examination at separation from service in June 1995. The Veteran's claims file does not contain any medical or mental health treatment records from the year following his 1995 separation from service. In July 2002 the Veteran established primary care at a VA facility. He reported shoulder pain. A depression screen did not show any signs of depression. In VA treatment in 2013 through 2020, screens of the Veteran for mental health issues, including depression, PTSD, alcohol use disorder, and anxiety, were negative. In March 2017 the Veteran had a private psychiatric consultation. He reported that during military service, during the (December 1989 and January 1990) invasion of Panama, he was in a mobile service hospital and he saw wounded soldiers. He stated that he began then to experience anxiety. He related that presently he had anxiety attacks two to three times per week. He reported hypervigilance. He indicated that he had only three hours of sleep per night. He reported that from 2014 forward he had nightmares up to once a week. Consulting psychiatrist E. W. H., M.D., made diagnoses of dysthymic disorders and generalized anxiety disorder. On VA examination in May 2020, the Veteran reported that in service basic training trainers used loud bangs to awaken trainees in the middle of the night. He related that from then forward he had trouble falling asleep and trouble staying asleep. He stated that he got two to three hours of sleep per night. He reported that the insufficient sleep caused difficulty focusing. He stated that in the late 1980s he felt depressed after the deaths of each of his parents. He related that he eventually recovered from the depression. He reported that the invasion period in Panama was stressful because bombs exploded in the middle of the night, because he was stationed there with his wife and their small children, and because he helped out at a service hospital for a few days. He stated that soon after separation from service he experienced anxiety. He reported that presently he had irritability and mood swings. He related occasional suicidal thoughts, particularly after the 2019 death of his son. The examining psychiatrist noted that the Veteran described his mood as slightly depressed. The examiner observed a restricted affect and normal speech and thoughts. The examiner provided a diagnosis of insomnia disorder. The examiner indicated that an earlier psychiatric clinic report was not available for review. The examiner expressed the opinion that the Veteran's current insomnia disorder was less likely than not related to the Veteran's service. The examiner noted the Veteran's current report of insomnia during service, and also noted that his service treatment records did not contain any reports of insomnia. In a July 2020 addendum, the May 2020 VA examiner reported having reviewed the Dr. H.'s March 2017 psychiatric report. The examiner stated that the report did not include specific history to explain the diagnoses of dysthymia and GAD. In August 2020, private psychologist J. H. P., Psy.D., reviewed the Veteran's claims file and interview him. The Veteran reported that he did not have any psychological issues before service. He related having several stressful situations during service. He stated that he saw a fellow soldier get shot. He reported that his best friend was killed in a motor vehicle accident. He stated that his chronic sleep impairment began in service, with the need for constant alertness during his service in Korea. He reported that during service he began to use alcohol to self-medicate for his difficulties. He stated that after service shame and stigma kept him from seeking mental health treatment for many years. He related present symptoms of depression, crying spells, social withdrawal, isolation, sleep impairment, and anhedonia. Dr. P. found that the Veteran's symptoms were consistent with a diagnosis of unspecified depressive disorder. Dr. P. expressed the opinion that the Veteran's depressive disorder at least as likely as not was incurred in service. In arguments the Veteran submitted in August 2020, he indicated that in service in Panama he saw wounded soldiers. On VA examination in March 2021, the Veteran reported that during service frequent transfers away from friends and community were depressing. He stated that he started drinking while stationed in Panama from 1988 to 1992. He indicated that his drinking had increased over the years. He stated that he never sought mental health treatment during service. He reported present symptoms of insomnia, depressed mood, low energy, loss of interest in most activities, and lack of motivation. The examining psychologist reviewed the Veteran's claims file. The examiner observed a depressive mood, flat affect, and slow motor activity. Memory, speech, and thought process were intact. The examiner listed diagnoses of persistent depressive disorder (dysthymia) and alcohol use disorder, moderate. The examiner found that the alcohol use disorder was secondary to the persistent depressive disorder. The examiner expressed the opinion that the Veteran's current disorders were less likely than not incurred in service or caused by events in service. The examiner noted that his service records did not reflect metal health issues, and that multiple screenings during post-service VA treatment were negative for depression. In April 2021 private psychologist J. L. G., Ph.D., reviewed the Veteran's claims file and examined the Veteran. The Veteran reported that during service he experienced stressful events, including the death of his best friend, and witnessing the shooting of a fellow soldier. He related onset during service of mental disorder symptoms including sleep impairment, episodes of depression, crying spells, isolation, irritability, defensiveness, rumination, hopelessness, anxiety, and episodes of suicidal ideation. He stated that he did not have mental health treatment in service. In the examination, the Veteran reported a dysphoric but stable mood. Dr. G. found no gross impairment of thought, speech, or cognition. Dr. G. provided a diagnosis of unspecified mood disorder. Dr. G. expressed the opinion that the Veteran's experiences during service at least as likely as not caused his mood disorder. Clinicians have applied a variety of diagnoses to the Veteran's post-service psychiatric issues. Their determinations overlap to the extent that each includes some form of mood disorder. The Veteran did not seek mental health treatment or otherwise report mental health problems during service. Records from that period do not corroborate his later accounts of his symptoms during service. He is in a position, however, to recall and describe his symptoms during service. His accounts are fairly consistent. His recent accounts are credible and significant evidence regarding his experiences and reactions during service. The Veteran's numerous denials of mental health symptoms in VA screenings undermine his claims that he had mental and emotional issues during service and through the present. Drs. P. and G. each opined in favor of a nexus between the Veteran's service and his current psychiatric disorders. Dr. P.'s failure to mention the negative screenings detracts somewhat from the weight of her opinion. In discussing the negative screenings, Dr. G. noted that Veteran's report that before 2017 stigma and embarrassment kept him from seeking mental health treatment. He found that the negative screenings were a factor in, but not dispositive of, an assessment of the Veteran's psychiatric history. The VA clinicians who examined the Veteran in 2020 and 2021 each opined against a nexus between the Veteran's service and his current psychiatric disorders. Those examiners reasonably noted the scarcity of objective professional evidence to support the Veteran's account. Those examiners did not explain whether or why the Veteran's accounts merited any consideration. The strengths and weaknesses of the assembled information and opinions make a determination difficult. On careful consideration, the Board finds that the evidence for depression and anxiety symptoms in service that continued after service approximately balances the evidence against such a history. Resolving reasonable doubt in the Veteran's favor, the Board grants service connection for his acquired psychiatric disability, including a mood disorder. K. PARAKKAL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. J. Kunz, 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.