Citation Nr: 22016373 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 16-33 623 DATE: March 22, 2022 ORDER Entitlement to service connection for major depressive disorder, as secondary to posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for a psychiatric disorder other than posttraumatic stress disorder (PTSD) and major depressive disorder, to include bipolar disorder and alcohol use disorder, is remanded. FINDING OF FACT The evidence of record demonstrates that the Veteran's major depressive disorder is secondary to his service-connected PTSD. CONCLUSION OF LAW The criteria for entitlement to service connection for major depressive disorder, as secondary to PTSD, are met. 38 U.S.C. §§1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the United States Marines Corp (USMC) from December 1992 to March 1994. This issue is before the Board of Veterans' Appeals (Board) from an initial August 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In a July 2019 decision, the Board remanded the issue for further development and a VA examination. Caffrey v. Brown, 6 Vet. App. 377 (1994); 38 C.F.R. § 3.327(a). The matter returned to the Board in April 2021 and was remanded again for consideration of the issue being a congenital disease or defect and a comment on the connection between an acquired psychiatric disorder and service connected TBI. The Veteran returned to the Board once more in August 2021 and the issue was remanded again due to a finding that the May 2021 VA examination was insufficient. The Board is partially satisfied and is prepared to fully adjudicate one issue at hand, while regrettably remanding one issue for a new VA opinion. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). In the most recent October 2021 VA examination, the Veteran found diagnoses of PTSD, alcohol use disorder, and major depressive disorder. Upon the examination, the Veteran found the major depressive disorder was at least as likely as not secondary to the Veteran's PTSD. See Initial Posttraumatic Stress Disorder (PTSD) Disability Benefits Questionnaire, October 2021. PTSD with traumatic brain injury (TBI) is now service connected. See December 11, 2021 rating decision; December 13, 2021 Notification Letter. Therefore, service connection for major depressive disorder as secondary to the Veteran's service-connected under secondary service connection, the Board finds that the Veteran is also service connection for the major depressive disorder, as secondary to PTSD. See 38 C.F.R. § 3.310. REASONS FOR REMAND The Board reflects that the evidence demonstrates that the Veteran has been diagnosedin addition to PTSD and major depressive disorder, which are already service connectedwith bipolar disorder and alcohol use disorder during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim . . . even though the disability resolves prior to the Secretary's adjudication of the claim."); Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Veteran's service treatment records (STRs) were silent for any complaint, treatment, or diagnosis of an acquired psychiatric disorder upon entry into service, while on active duty, or upon separation and discharge from service. The entrance examination found no indication of any psychiatric issues or disorder. It was noted that the Veteran attended an alcohol treatment facility before entering service. In approximately January 1993, the Veteran suffered a personal assault that left him with lacerations in the head. Additionally, the Veteran was seen at the US Navy Hospital in July 1993 for alcohol rehabilitation. On the Veteran's February 1994 separation examination, the blunt trauma to the head was noted. However, no indication of psychiatric issues or disorders were noted, only the Veteran's participation in alcohol rehabilitation. In April 2018, the Veteran was seen at the Mountain Home VA Medical Center (VAMC) emergency department where he reported "bad thoughts" for the past 20 years and currently experiencing suicidal and homicidal ideation. The Veteran reported that he believed his in-service head injury was contributing to his mental problems and that he had been suffering for 20 years with no assistance. He also reported severe headaches, depression, irritability, anger, and chronic pain with no assistance. At the emergency department the Veteran endorsed depression for 20 years, suicidal ideation, feelings of guilt, and a dislike of being around people. He also reported a long history of violence with legal charges coming against him. The Veteran was found to have symptoms of a depressed mood, weight loss, insomnia, fatigue, feelings of hopelessness, helplessness, worthlessness, poor concentration, poor motivation, poor interest in previously enjoyed activities, indecisiveness, inappropriate guilt, thoughts of death, increased irritability, excessive worrying, recurrent and persistent intrusive memories, suicidal ideation, homicidal ideation, nightmares, flashbacks, hypervigilance, and avoidance. In November 2019, the Veteran stated that he had six staples in the back of his head after he was assaulted by fellow Marines. He also reported a decrease in appetite, out of control temper, difficulty keeping a job or relationships. He also stated that he has struggled with addiction and depression which has forced him to spend time in mental health and addiction counseling centers. He also noted that he has been arrested numerous times and he feels like a loner or hermit. The Veteran was afforded a VA examination in February 2020. The examiner found a diagnosis of bipolar disorder on the examination. The examiner reported that it was possible to differentiate between TBI and non-TBI mental health issues, finding that TBI symptoms were the Veteran's mild memory problems and headaches while the other symptoms were all attributed to the Veteran's bipolar disorder. The Veteran reported that he had been married to his wife for 14 years and had one adult child. He reported a good relationship with his wife but a loss of interest in most things, and only works and stays at home. He states that he is uncomfortable around people and isolated himself. He also has a noted history of physical altercations and has been arrested over 20 times. He served prison time between 2003 and 2006. The Veteran was also found to have attempted suicide several times but had not made such an attempt since 2018. He has frequent panic attacks, nightmares, excessive worry, and sometimes will go days without sleeping. He is also noted to have some paranoid ideation. The Veteran has abused alcohol since his time in service and continued to abuse alcohol until 2018. The examiner stated that alcohol abuse may have been masking his bipolar disorder. Finally, the examiner reported that the Veteran has frequent manic episodes related to his bipolar in which he is unable to sleep, has racing thoughts, pressured speech, and engagement in high-risk behavior. The examiner ultimately opined that the claimed condition of an acquired psychiatric disorder was less likely than not incurred in or caused by an in-service injury, event, or illness. The examiner offered a rationale stating that a review of the Veteran's medical records from active duty, including his hospitalization from August to October 1993 did not include any reports of depression, sleep problems, or any other mental health problem that could be considered prodromal for bipolar disorder. The examiner also noted that the claimant stated he never had sleep problems during his time in service. Some symptoms of bipolar disorder were recorded in the VA treatment notes in April 2018 when the Veteran was seen at the Mountain Home VAMC emergency department however, bipolar was denied. The examiner reported that symptoms fully consistent with bipolar were present upon the examination. Furthermore, the Veteran claimed that two of his uncles had committed suicide, suggesting that there may be a familial connection for the diagnosed bipolar disorder. Regarding the Veteran's 1993 head injury and its relation to bipolar, the examiner stated that bipolar is a biological condition that is not typically related to a specific event or trauma. Therefore, given the lack of records indicating or suggesting symptoms of bipolar during active duty, the examiner found that it was less likely than not that the claimant's bipolar disorder was related to service. The Board also notes that the Veteran had VA examinations in May 2021 regarding the Veteran's bipolar disorder, which specifically discussed whether the bipolar disorder was a congenital disease or defect. The Veteran also received a September 2021 VA examination to discuss whether the Veteran's acquired psychiatric disorder was proximately due to or aggravated by a service connection condition. In October 2021, a VA examiner noted that the Veteran's alcohol use disorder was at least as likely as not related to military service. The Board reflects that substance abuse disorders can only be service-connected on a secondary basis and therefore this opinion is not adequate to decide the claim. Likewise, as the last VA examination was in October 2021 and prior to the Veteran's award of service connection for PTSD and major depressive disorder, any opinions rendered did not take such service-connected disabilities into account. Accordingly, a remand is necessary in order to ascertain whether any psychiatric disorders other than PTSD and major depressive disorder, to include bipolar disorder and alcohol use disorder, are secondary to the Veteran's service-connected psychiatric disability. The matters are REMANDED for the following action: Schedule the Veteran for an examination with an appropriate examiner to ascertain whether any psychiatric disorder other than PTSD and major depressive disorder, to include bipolar disorder and alcohol use disorder, are related to service or a service-connected disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including a copy of this remand, the Veteran's STRs, post-service medical records, and lay statements. After examining the Veteran and reviewing the record, the examiner should opine as to: (1) State all psychiatric disorders found during the appeal period, to include PTSD, major depressive disorder, bipolar disorder and alcohol use disorder. (2) For all disorders found under the DSM-5 other than PTSD and major depressive disorder, to specifically include bipolar disorder (but not alcohol use disorder), the examiner should opine whether such disorders at least as likely as not (50 percent or greater probability) began in or otherwise were the result of military service, to include the Veteran's noted head injury and personal assault therein. (3) For any psychiatric disorder other than PTSD and major depressive disorder, to specifically include bipolar disorder and alcohol use disorder, that were not found to be related to military service directly, the examiner should opinion whether such disorders were (a) caused by; or (b) aggravated (i.e., worsened) by the Veteran's service-connected disabilities, to include PTSD with associated major depressive disorder and traumatic brain injury (TBI) and headaches. The examiner should assess whether any of those disabilities individually or in the aggregate caused or aggravated those psychiatric disorders. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E.L. Aumiller, 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.