Citation Nr: 22017683 Decision Date: 03/25/22 Archive Date: 03/25/22 DOCKET NO. 16-63 396 DATE: March 25, 2022 ORDER Entitlement to service connection for major depressive disorder is granted. FINDING OF FACT The evidence of record is in equipoise as to whether the Veteran's major depressive disorder developed as a result of in-service injury and events. CONCLUSION OF LAW The criteria for service connection for major depressive disorder are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from November 1967 to September 1971, to include service in the Republic of Vietnam. The Veteran testified at a Board hearing in November 2021 before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file. Entitlement to service connection for major depressive disorder is granted. The Veteran asserts that his acquired psychiatric disorder was incurred or the result of service injury and events. The Board concludes that the Veteran has a current diagnosis of major depressive disorder that is related to an in-service injury and events. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease that was incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. When all the evidence is assembled VA is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). Military personal records show the Veteran served in the Republic of Vietnam. The Veteran's specialty was as a cannoneer. In an October 1969 service treatment record (STR), the Veteran was treated for a wound fragment in left thigh. The Veteran sustained injury when he was fired upon by United States forces in Vietnam. In a January 2002 VA treatment record, the Veteran established care at VA. He stated that he stopped abusing alcohol in February 2001. The medical provider noted the Veteran was started on medication for anxiety the month prior. In a May 2005 VA treatment record, the Veteran reported that he stopped taking the medication for anxiety. He reported no problems with anxiety. He stated his children were supportive and helpful with his wife's death. The medical provider noted the Veteran has a history of anxiety and is a recovering alcoholic. In a January 2014 statement in support of claim for PTSD, the Veteran reported two in-service stressors during deployment in Vietnam. The Veteran stated his company was ambushed in one incident and the second incident was when his company was on a search and destroy assignment that resulted in a fire fight. On the April 2014 VA PTSD examination, the examiner indicated the Veteran has a diagnosis of major depressive disorder with anxious distress. The examiner noted that the Veteran was prescribed medication in December 2001 for treatment of anxiety after he quit abusing alcohol. The examiner stated Veteran discontinued with the medication prior to his wife's death in May 2005. The examiner found that there were no mental health concerns until 2011. The April 2014 VA examiner opined that the Veteran's acquired psychiatric disorder is less likely than not caused by service. The examiner stated that the Veteran was treated with an antidepressant for anxiety after he stopped abusing alcohol in 2001, but he discontinued the medication in 2005, at which time he denied continued symptoms of anxiety. The examiner stated that the Veteran's symptoms of depression developed after the death of his wife in 2004. The examiner reasoned that there is no evidence of mental health symptoms or treatment in service and the Veteran has limited mental health treatment in the 40 years after separation from service. The examiner stated the Veteran has a relatively stable psychosocial history. The examiner stated that despite the Veteran's combat experiences, his reported trauma does not appear to be the primary underlying cause of his current mental symptoms. The examiner stated that it is more likely that the Veteran's depression developed in response to personal losses, to include his wife's death, adjustment to semi-retirement, aging, and other situational stressors. In a March 2016 VA treatment record, the medical provider noted the Veteran reported having used alcohol and marijuana excessively for years after deployment in Vietnam. The provider stated that without realizing it, the Veteran may have been striving to manage thoughts, feelings, and memories associated with his wartime experience. On the December 2016 substantive appeal, the Veteran stated that he suffers from major depressive disorder that is directly linked to his PTSD as a consequence resulting from his combat experiences in Vietnam. He stated he was wounded in combat and experienced the loss of several friends that has caused him a great amount of difficulty in his adjustment to life and affects his ability to related to others. In September 2015 through September 2017 VA treatment records, the medical provider had the impression that the Veteran has a diagnosis of PTSD. In a September 2017 VA treatment record, the Veteran stated he continues to attend daily alcoholic anonymous meetings. In an October 2017 VA treatment record, the Veteran stated he experiences nightmares from Vietnam. At the November 2021 Board hearing, the Veteran testified that he was deployed to Vietnam. Board hearing transcript (T.) at 3-4. He stated his unit's mission was to search and destroy after receiving intelligence reports. T. at 4. The Veteran testified that he experienced several in-service stressors where he feared for his life or for the life of others. T. at 4-5. The Veteran stated he was involved in firefights during his deployment in Vietnam. T. at 5-7. After deployment in Vietnam, the Veteran testified that he self-isolated and began to abuse alcohol and use marijuana to "help me get through." T. at 9. The Veteran stated in 2001 he stopped abusing alcohol due to the alcohol abuse causing legal, professional, and family difficulties. T. at 12. The Board finds that the evidence of record is in equipoise. The April 2014 VA examiner did not address the Veteran's report of marijuana use and alcohol abuse that began after separation from service in assessing the continuity of symptoms. The Board finds that April 2014 VA examination therefore has limited probative value as evidence against the claim for service connection for an acquired psychiatric disorder. In support of the claim, the Veteran competently and credibly reported abusing alcohol and using marijuana to cope with his psychiatric symptoms, beginning shortly after service. Also, the March 2016 VA mental health treatment provider assessed that the Veteran was abusing alcohol and marijuana to manage thoughts and feelings about his service in Vietnam. Accordingly, the Board finds that the evidence for and against the claim of entitlement to service connection for an acquired psychiatric disorder is in equipoise. Therefore, reasonable doubt must be resolved in favor of the Veteran, and entitlement to service connection for major depressive disorder is warranted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Thompson, 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.