Citation Nr: 21031019 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 15-42 562 DATE: May 20, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, other than posttraumatic stress disorder and to include depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1986 to January 1989. This matter is before the Board of Veterans' Appeals (Board) on appeal of a July 2015 rating decision of the Muskogee, Oklahoma, Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran appeared at a hearing before the undersigned Veterans Law Judge in November 2018. In March 2019 and October 2020, the Board remanded the case for further development. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran was afforded a VA examination in December 2019. A diagnosis of unspecified depressive disorder was provided. The VA examiner noted that the Veteran's entrance medical examination and discharge medical examinations were not remarkable for mental illness and provided a negative opinion concerning direct service connection. However, the VA examiner stated that the Veteran had preexisting depression with a suicide attempt at the age of 17, and that his continued depression had not progressed beyond that level of severity. The Veteran's service treatment records do not indicate that the Veteran had a mental disorder upon entrance. The Board notes that when no preexisting injury or disease is noted upon entry into service, the Veteran is presumed to have been sound upon entry. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). The burden then falls on the government to rebut the presumption of soundness by finding clear and unmistakable evidence that the Veteran's injury or disease was both preexisting and not aggravated by service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). If the presumption of soundness is not rebutted, the Veteran is entitled to service-connected benefits. Id. As it was unclear whether the VA examiner believed that the Veteran had an acquired psychiatric disorder which preexisted his service, was aggravated therein, or had its onset at that time, the Board remanded the issue in October 2020 for an addendum opinion. The Veteran was afforded a VA examination in March 2020. The VA examiner provided a diagnosis of moderate stimulant use disorder- amphetamines upon examination of the Veteran. The VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness and stated that the Veteran's current use of both marijuana on a daily basis and regular use of methamphetamines made it impossible for the examiner to distinguish symptoms of depression from the substance abuse. For an accurate assessment of depression symptoms, there would need to be an extended period of sobriety. The VA examiner also opined that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness and stated that the Veteran's mental health history prior to the military did not suggest a history of depression that required treatment. The Veteran reported one episode of suicidal thoughts that was situational and not ongoing. The Board finds that a contemporaneous VA compensation examination is necessary to decide the claim. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). While the March 2020 VA examiner conducted an evaluation of the Veteran's claimed condition at the time, it was noted that an accurate assessment of the Veteran's depression symptoms could not be obtained. Further, the VA examiner indicated that the Veteran's claimed condition clearly and unmistakably existed prior to service; however, it was noted that the Veteran reported one episode of suicidal thoughts that was situational and not ongoing. It remains unclear as to whether the Veteran had a diagnosis of an acquired psychiatric disorder which preexisted his service. The matters are REMANDED for the following action: The Veteran must be afforded a VA mental disorders examination, with a psychiatrist or psychologist, conducted by a VA examiner (preferably other than the VA examiners who provided the December 2019 and March 2020 VA examinations), to determine whether any psychiatric disorders (other than PTSD) present during the period of the claim, to include mood disorder and depressive disorder, are related to his service. All indicated diagnostic tests and studies must be accomplished. The evidence of record must be made available to and reviewed by the examiner. Based upon the examination results, a review of the record, and consideration of the Veteran's statements and contentions, the examiner must: a. Identify all current and previous psychiatric diagnoses and provide an opinion as to whether any currently or previously diagnosed psychiatric disorders clearly and unmistakably preexisted the Veteran's period of active duty service. b. If a currently or previously diagnosed psychiatric disorder is found to have clearly and unmistakably preexisted service, the examiner must state the specific evidence upon which the finding was made, as well as which specific diagnosis was present at the time of entry into service. c. The examiner must then provide an opinion as to whether the Veteran's service clearly and unmistakably did NOT aggravate a preexisting psychiatric disorder beyond the normal progression of the disease. d. If the examiner finds that the Veteran's service clearly and unmistakably did not aggravate a preexisting psychiatric disorder beyond the normal progression of the disease, the examiner must state the specific evidence upon which the finding is based. e. If the examiner finds that the Veteran did not have a psychiatric disorder that preexisted military service, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that any currently or previously diagnosed psychiatric disorder is related to the Veteran's service, or to any incident therein. A complete rationale for all opinions must be provided. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A-L Evans, 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.