Citation Nr: 22014433 Decision Date: 03/12/22 Archive Date: 03/12/22 DOCKET NO. 18-09 377 DATE: March 12, 2022 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder (MDD) is remanded. REASONS FOR REMAND The Veteran served on active duty from January 2002 to November 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript is of record. Entitlement to service connection for an acquired psychiatric disorder, to include MDD is remanded. The record reflects current diagnoses of major depressive disorder with and without psychotic features, unspecified anxiety disorder, and unspecified depressive disorder. Accordingly, the appeal has been recharacterized as shown on the title page. Clemons v. Shinseki, 23 Vet. App. 1 (2009). On the Veteran's VA Form 9 received in January 2018, she related that her anxiety and fear began in service upon learning that 'there was a certainty of being deployed to a combat zone.' She stated that she suffered mental distress for approximately one year before being deployed to Kuwait in January 2003 and that she continued to suffer mental distress upon return from her two deployments in 2003, and upon release from service. On a January 2018 VA Form 21-4138, Statement in Support of Claim, the Veteran asserted that she denied having "issues" during her June 2003 post-deployment physical evaluation because it occurred only two weeks after she had returned, and her symptoms eased when she was back home in familiar territory. She noted, however, that symptoms of anxiety, flashback, nightmares, and difficulty sleeping returned when she learned of the possibility of another deployment. On this VA Form 21-4138, she also asserted that she did not suffer from these symptoms before entering military service and all of her conditions are related to deployment into combat zones during military service. On VA Form 21-0781's, Statement in Support of Claim for Service connection for PTSD, received in January 2018 and in January 2022, the Veteran identified various stressful events that reportedly occurred in service while deployed to Kuwait and Iraq. These events included learning of the death of a servicemember she met in Kuwait; traveling in Humvee convoys through crowds of angry people and being afraid for her life; fear due to alerts of incoming tear and mustard gas attacks; and threats of bombing and gas attacks. During the October 2021 Board hearing, the Veteran testified that the origins of her anxiety and depression stem from her military service and that she did not suffer from mental health problems as a teenager. The Board makes no credibility determinations with respect to any of these specific contentions at this time. The Board does observe that the service treatment and personnel records reflect mental health treatment, including hospitalization in May 2002. The Veteran's personnel records show she served in Kuwait from January 2003 to May 2003 and in Iraq from May 2003 to June 2003. Personnel records also confirm that she was absent without leave (AWOL) from June 1, 2004, until June 3, 2004. The Board cannot make a fully informed decision on the issue of service connection just yet. Based on a review of the file, there appear to be missing records. The Veteran's service treatment records appear incomplete. A June 2004 note indicates that the Veteran was evaluated at the Department of Behavioral Health, Ireland Army Community Hospital in Fort Knox, Kentucky; however, those records are also not contained in the file. The Veteran reports receiving medical treatment from a private facility, the Happy Mind Company in 2015. A letter from the D.R. indicates that the Veteran's treatment continued through at least February 2016. Although the undersigned VLJ afforded the Veteran 90 days from the date of her hearing to submit those medical records, they are not yet in the claims file. Thus, VA will assist the Veteran in obtaining these records on remand. Lastly, the Veteran's VA treatment records also appear incomplete. The claims file contains an initial primary care visit from February 2014 with sparse records in between. The Veteran has testified that she also has received treatment from Lake Baldwin VAMC since 2018. The Veteran recently provided VA treatment records from April 2021 through October 2021. Updated records should be obtained. The matter is REMANDED for the following action: 1. Obtain complete service treatment records. This should any mental health and inpatient treatment records, including from the Department of Behavioral Health, Ireland Army Community Hospital in Fort Knox, Kentucky. Document all requests for information as well as all responses in the claims file. 2. Obtain VA treatment records from Lake Baldwin and any other VAMC from February 2014 to April 2021, and from October 2021 to the present. 3. Ask the Veteran to complete a VA Form 21-4142 for The Happy Mind Company and any other private medical providers who have or are treating her for psychiatric disorders. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 4. Upon completion of the above directives, obtain an addendum opinion regarding the etiology of the Veteran's current psychiatric disorders. The need for an in-person psychiatric examination is at the examiner's discretion. The examiner is to review the claims file. The examiner must provide an opinion on whether any of the Veteran's current acquired psychiatric disorders at least as likely as not onset during service or, are related to her military service. [The examiner is advised that the Veteran places the onset of her mental health symptoms in service, upon learning that 'there was a certainty of being deployed to a combat zone.' She stated that she suffered mental distress for approximately one year before being deployed to Kuwait in January 2003 and that she continued to suffer mental distress upon return from her two deployments in 2003, and upon release from service. See the Veteran's VA Form 9 received in January 2018. The Veteran also relates her current psychiatric disorders to her experiences while deployed to Iraq and Kuwait. See the Board's full summary above as well as the January 2018 VA Form 21-4138, Statement in Support of Claim, and the VA Form 21-0781's, Statement in Support of Claim for Service connection for PTSD, received in January 2018 and January 2022. The Board makes no credibility determinations with respect to these specific contentions at this time.] A fully-explained rationale must be provided. In providing the requested opinion and rationale, consider the Veteran's description of her in-service symptoms as well as her post-service symptoms, which have been summarized herein. If there is any medical reason to accept or reject the proposition that the Veteran's diagnoses and reported symptoms in service and thereafter represented the onset of her current disability, this should be noted. Stated another way, do the Veteran's reports about her symptoms align with how the currently diagnosed disability(ies) is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Telamour, 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.