Citation Nr: 22011122 Decision Date: 02/25/22 Archive Date: 02/25/22 DOCKET NO. 15-38 845 DATE: February 25, 2022 REMANDED Entitlement to service connection for an acquired psychiatric disability, to include unspecified depressive disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1999 to September 1999, from February 2003 to December 2003 and from October 2006 to April 2008, with additional periods of Army National Guard service. This matter comes before the Board of Veterans' Appeals (Board) from an April 2014 rating decision by the Agency of Original Jurisdiction (AOJ) that denied service connection for unspecified depressive disorder. The Veteran contends that his acquired psychiatric disability, to include unspecified depressive disorder, is related to service. In the Mental Health section of a February 2010 Periodic Health Assessment Form, the Veteran indicated that over the past two weeks, he sometimes felt little pleasure in doing things. In an April 2011 Post-Deployment Health Care Provider Review, Interview, and Assessment, the Veteran indicated that he sought or intended to seek counseling or care for mental health. However, when afforded a VA examination in April 2014, which confirmed a diagnosis of unspecified depressive disorder, the examiner opined that it was less likely than not incurred in or caused by in-service injury, event or illness. The examiner stated that there is no evidence of psychiatric complaints, psychiatric findings, nor psychiatric treatment prior to the military service, during military service, or within one year after discharge from the military service. The examiner stated that the Veteran sought psychological care in 2012 after being referred by his primary physician in September 2012 and that psychological evaluation established a diagnosis of "Anxiety Disorder" and no identified stressors was documented. Based on the above, the examiner concluded that the link between the Veteran's neuropsychiatric condition and his military combat activity cannot be made. The Board regrets the further delay but finds that a remand is needed in this appeal to afford the Veteran full consideration of his claim. The April 2014 medical opinion is inadequate because it is based on an inaccurate account of the Veteran's medical history. Although the Veteran's service treatment records show psychiatric complaints, the examiner based the opinion on a lack of such complaints shown during service. As the examiner's opinion is based on an inaccurate factual history, an additional medical opinion must be obtained. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that medical opinions based on an incomplete or inaccurate factual history are of little probative value); see also Colvin, 1 Vet. App. at 175; Hatlestad, 3 Vet. App. at 216; Barr, 21 Vet. App. at 311. Accordingly, the matter is REMANDED for the following action: 1. Schedule the Veteran for an examination by a qualified clinician to determine the nature and etiology of the Veteran's acquired psychiatric disability, to include unspecified depressive disorder. The evidentiary record, including a copy of this remand, must be made available to and be reviewed by the clinician. After the record review and examination of the Veteran, the examiner is asked to respond to the following inquiry: Is it at least as likely as not that any acquired psychiatric disability, to include the Veteran's unspecified depressive disorder, was incurred in, or is otherwise related, to his time on active service? If PTSD is diagnosed, the examiner should identify the stressors that led to the condition. In rendering the opinion above, the reviewing clinician is directed to the February 2010 Periodic Health Assessment Form, indicating that over the previous two weeks, the Veteran had little pleasure in doing things; and an April 2011 Post-Deployment Health Care Provider Review, Interview, and Assessment, indicating that the Veteran sought or intended to seek counseling or care for mental health. In rendering the opinion above, the examiner is also advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. A complete rationale for the opinion should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 2. Thereafter, readjudicate the claim. If the benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC), and return the case to the Board, if otherwise in order. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Wilson, 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.