MAJOR DEPRESSIVE DISORDER

M. SORISIO · 2026 · Case ID: 26001071

MIXED

Summary

The veteran, who served from June 1985 to September 1985 and again from February 1987 to July 1994, including service in Southwest Asia, appeals the denial of service connection for a psychiatric disorder (depressive and insomnia disorders), a heart disorder (coronary artery disease), a neurological disorder (syncope), and muscle and joint pain (osteoarthritis). The Board granted service connection for the psychiatric disorder as secondary to service-connected degenerative arthritis of the lumbar spine, chronic fatigue, and IBS, finding the evidence persuasively favored this link. The Board found the February 2025 VA examiner's opinions inadequate for the heart and neurological disorder claims, as they relied heavily on the lack of in-service treatment records and failed to adequately address the potential link to presumed toxic exposure risk activity (TERA) or earlier medical evidence. The examiner's opinions regarding muscle and joint pain were also found inadequate for failing to provide rationale and address the Veteran's reported history and earlier medical findings. The TDIU claim was deferred as it is intertwined with the other remanded issues. The case was remanded for new VA opinions addressing the Veteran's history and providing adequate rationale for the heart, neurological, and muscle/joint pain claims, including obtaining additional private treatment records and clarifying existing VA treatment records. The Board also noted that the Veteran's claims for heart and neurological disorders were potentially linked to his service in Kuwait and TERA exposure.

Rationale

Service connection granted on a secondary basis; Psychiatric disorder linked to service-connected degenerative arthritis, chronic fatigue, and IBS; Evidence persuasively favors finding of proximate causation

Special Benefit

TDIU

Docket No.

19-21 357

Full Decision Text

Citation Nr: 26001071
Decision Date: 01/28/26 Archive Date: 01/28/26

DOCKET NO. 19-21 357
DATE: January 28, 2026

ORDER

Service connection for a psychiatric disorder, to include diagnosed depressive and insomnia disorders, is granted.

REMANDED

Entitlement to service connection for a heart disorder, to include diagnosed coronary artery disease, is remanded.

Entitlement to service connection for a neurological disorder, to include diagnosed syncope, is remanded.

Entitlement to service connection for a disability manifested by muscle and joint pain, to include diagnosed osteoarthritis of the bilateral knees, right shoulder, and right ankle, is remanded.

Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded.

FINDING OF FACT

The evidence persuasively favors finding that the Veteran's diagnosed depressive and insomnia disorders are proximately caused by his service-connected disabilities.

CONCLUSION OF LAW

The criteria for service connection for a psychiatric disorder, to include diagnosed depressive and insomnia disorders, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty training from June 1985 to September 1985 and on active duty from February 1987 to July 1994, including service in Southwest Asia. These matters are on appeal of January 2014 and March 2016 rating decisions.

The Board remanded the appeal for further development in July 2023 and July 2024.

Following the March 2025 supplemental statement of the case (SSOC) where the agency of original jurisdiction (AOJ) most recently adjudicated the matters on appeal, VA added additional medical evidence regarding the psychiatric disorder claim to the claims file. Pertinent evidence is initially reviewed by the AOJ. Additional pertinent evidence that becomes available after the AOJ's SOC or SSOC after certification to the Board must be referred back to the AOJ for initial review. 38 C.F.R. §§ 19.31, 19.37, 20.1305(c). Exceptions are when the Veteran or his representative waives this review right, or when the Board grants the benefit being sought in full. 38 C.F.R. § 20.1305(c).

Here, the Board is granting the Veteran's claim for service connection for his diagnosed psychiatric disorder, and appellate review of this issue may proceed without prejudice to the Veteran.

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. § 1110. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).

Secondary service connection may be granted for a disability that is proximately due to the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence of (1) a current chronic disability for which service connection is sought; (2) an already service-connected disability; and (3) that there is "but for" causation or aggravation of the disability for which service connection is sought by a service-connected disability. See Spicer v. McDonough, 61 F.4th 1360, 1363 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and holding "but for" causation or aggravation is enough to show entitlement to secondary service connection).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

The Veteran and his attorney contend that his insomnia disorder either had its onset during his active-duty service or is a chronic undiagnosed disability or a diagnosed medically unexplained chronic multisymptom illness as a result of his service in Kuwait. The Veteran has also reported that his sleep disorder was a result of his pain, including pain associated with his service-connected lumbar spine degenerative arthritis. Additionally, the February 2025 VA clinician's examination report and opinion have also raised the issue of the Veteran's insomnia disorder being secondary to his service-connected disabilities, particularly his service-connected degenerative arthritis of the lumbar spine. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (Fed. Cir. 2009) (holding that all theories of entitlement reasonably raised by the evidence of record must be considered). As service connection is being granted on a secondary basis, the Board will not discuss other theories of entitlement.

A June 2018 VA psychiatric examiner found the Veteran had a diagnosed depressive disorder. A September 2024 VA psychiatric examination report indicates the Veteran was diagnosed with a mood disorder due to known physiological condition due to insomnia. A February 2025 VA examination indicates the Veteran was diagnosed with an insomnia disorder. Additionally, a September 2018 rating decision awarded service connection for diagnosed degenerative arthritis and degenerative disc disease of the lumbar spine. A June 2019 rating decision awarded service connection for chronic fatigue and irritable bowel syndrome (IBS). Therefore, the first two elements of the claim for service connection for a psychiatric disorder on a secondary basis are met.

The remaining issue is whether the Veteran's service-connected disabilities caused or aggravated his psychiatric disorder, including diagnosed depressive and insomnia disorders.

VA treatment records as early as December 2017, indicate that the Veteran was experiencing pain in multiple joints, including his back that was interfering with his ability to sleep.

In June 2018, a VA clinician, while finding the Veteran's diagnosed depressive disorder was not directly related to his service, opined that it was secondary to his seizure disorder, prostate condition and his pain condition. The rationale was that the functional impairments of these disabilities led to a poorer quality of life and increased feelings of depressed mood. Although the clinician did not indicate the Veteran had any diagnosed sleep disorder at that time, he did opine that the Veteran's sleep issues were secondary to his pain and anxiety.

In February 2025, a VA examiner diagnosed the Veteran with insomnia disorder and opined that it was due to a medical disorder. The examiner noted that the Veteran had chronic pain that appeared to be due to degenerative arthritis, as well as anxiety in part due to his medical problems that included chronic fatigue, degenerative arthritis, and IBS. The examiner noted that the Veteran reported that the pain from various joints, including his back due to degenerative arthritis and his anxiety were "drivers" of his poor sleep. The examiner indicated that the presence of physical pain due to degenerative arthritis, combined with subclinical anxiety was sufficient to explain his insomnia.

Thus, the Board finds that the evidence persuasively favors finding that the Veteran has a psychiatric disorder, including diagnosed depressive and insomnia disorders, that is proximately caused by his service-connected degenerative arthritis of the lumbar spine, chronic fatigue and IBS. Accordingly, service connection is granted for his psychiatric disorder as secondary to his service-connected disabilities. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

REASONS FOR REMAND

Unfortunately, the remaining claims for service connection on appeal must again be remanded for additional development as the Board finds that there has not been substantial compliance with the July 2024 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that where the remand orders of the Board are not substantially complied with, the Board errs as a matter of law when it fails to ensure substantial compliance).

Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasonable medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). A medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history, even if recorded in the course of the examination. Dalton v. Nicholson, 21 Vet. App. 23 (2007).

1. Heart Disorder and Neurological Disorder

The Veteran and his attorney contend that his current heart disorder and syncopal episodes, identified as a neurological disorder, either had their onset in service or are the result of his service, including his conceded exposure to environmental hazards while serving in Kuwait. The evidence of record also raised the issue of whether the Veteran's neurological disorder was proximately caused or aggravated by his heart disorder.

The July 2024 remand determined that, like earlier June 2018 and July 2018 VA etiological opinions, a November 2023 VA opinion that the Veteran's diagnosed heart murmur, syncope, coronary artery disease, and angina pectoris were all less likely than not a result of his service or any injury or event therein were inadequate to decide the claims. The remand noted that the rationale in support of the opinion was inadequate as it relied significantly on the lack of documentation of relevant treatment or diagnoses of the disabilities during service and did not adequately address the possible etiological link to his presumed exposure to particulate matter and toxic exposure risk activity (TERA). Dalton v. Nicholson, 21 Vet. App. 23 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (stating that the absence of documented treatment cannot, alone, serve as a basis for finding that lay evidence lacks credibility). The remand further found that the November 2023 VA examiner did not adequately address medical evidence of syncope and cardiac disability as early as April 1999.

The November 2023 VA examiner concluded that there was no current neurological disorder diagnosis, but failed to address the prior July 2023 remand's request, in the absence of a diagnosis, whether the Veteran had objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical exam, and laboratory tests, that have either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period.

In February 2025, a VA examiner opined that it was less likely than not that the Veteran's diagnosed unstable angina, coronary artery disease, valvular heart disease, and percutaneous angioplasty were caused by his TERA as there are no established links between these diagnoses and TERA. The examiner opined these diagnoses were caused by a sedentary lifestyle, lack of aerobic exercise, smoking, genetic factors, and poor diet. Likewise, the examiner opined that the Veteran's diagnosed syncope was less likely than not due to his in-service TERA as there were no established links between the diagnosis and TERA. The examiner opined that a syncopal episode while standing could be due to heightened vagal tone but indicated no testing had been done to rule this in. The examiner did not address why such testing had not been done. The examiner further opined that it is less likely than not that the Veteran's diagnosed heart conditions and syncope were otherwise incurred in or the result of in-service injuries, disease or events. The rationale for these opinions is again based almost entirely on there being no complaints, findings, treatment or diagnoses in the Veteran's service treatment records (STR). Finally, the examiner indicated that it was not possible to provide an opinion as to whether the Veteran's neurological disability was caused or aggravated by his heart disorder based on the evidence of record. The examiner did not indicate whether such an opinion could not be provided due to limitations of knowledge in
been done to rule this in. The examiner did not address why such testing had not been done. The examiner further opined that it is less likely than not that the Veteran's diagnosed heart conditions and syncope were otherwise incurred in or the result of in-service injuries, disease or events. The rationale for these opinions is again based almost entirely on there being no complaints, findings, treatment or diagnoses in the Veteran's service treatment records (STR). Finally, the examiner indicated that it was not possible to provide an opinion as to whether the Veteran's neurological disability was caused or aggravated by his heart disorder based on the evidence of record. The examiner did not indicate whether such an opinion could not be provided due to limitations of knowledge in the medical community at large or those of the particular examiner. Consequently, the Board finds the February 2025 opinions inadequate to decide the claims.

On remand, new VA opinions should be obtained that address the Veteran's history and provide adequate rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

In December 2025, the Veteran submitted private treatment records from North Oaks Medical Center from April to June 2025. The record previously contained other treatment records from North Oaks Medical Center dating through May 2018. As it appears there may be outstanding relevant medical records from North Oaks Medical Center, remand is necessary to attempt to obtain such medical records.

2. Disability Manifested by Muscle and Joint Pain

The Veteran and his attorney contend that he has disabilities manifested by muscle and joint pain, due to his service, specifically his conceded exposure to environmental hazards while serving in Kuwait. The Veteran has been diagnosed with osteoarthritis of several joints.

The July 2024 remand determined that a November 2023 VA clinician's determination that the Veteran had no current muscle and joint disorder present did not provide any rationale for the determination. The remand noted that VA and private treatment records throughout the appellate period showed the Veteran intermittently complained of pain in his shoulders, elbows, legs, and ankles and that the July 2018 VA examination reports found the Veteran had diagnosed osteoarthritis of the bilateral knee, right ankle, right shoulder, and left elbow that were not addressed in the November 2023 VA opinion. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (finding that the requirement of a current disability is satisfied when the claimant has the disability at any point proximate to the claim, during the claim, or to the appeal period). Likewise, the opinion did not address whether the Veteran's reported joint pain constituted a disability. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (finding that if pain alone results in functional impairment, even if there is no identified underlying diagnosis, such pain can constitute a disability). Nor did the November 2023 VA opinion address the May 1994 STR report of medical history at the time of the Veteran's separation examination, in which he reported joint swelling and/or pain.

During the February 2025 VA examinations of the Veteran's right shoulder, left elbow, bilateral knees and right ankle, the examiner diagnosed right shoulder rotator cuff tendonitis and acromioclaviculare joint osteoarthritis, left elbow osteoarthritis, right knee strain, left knee osteoarthritis, and right ankle Achilles spurs and post-traumatic arthritis. The examiner opined that all the diagnosed joint disabilities were less likely than not caused by his in-service TERA. The rationale for the opinions was that these conditions were mechanical dysfunctions that resulted from either trauma or an overuse syndrome at the level of the bones and soft tissues of the joints in question and were in no way due to a toxic exposure of any kind. Other than the TERA opinions, the VA examiner provided no other etiology opinions regarding whether the Veteran's muscle and joint diagnoses were incurred in service or were related to any in-service injury, disease or event (other than TERA) that addressed his May 1994 STR showing he reported joint swelling and/or pain at the time of his separation examination. Consequently, the Board finds the February 2025 opinions inadequate to decide the claims.

On remand, new VA opinions addressing direct service connection other than due to TERA should be obtained that address the Veteran's reported history and provide adequate rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008).

3. TDIU

The Board finds the issue of entitlement to TDIU is intertwined with the other issues on appeal. See Henderson v. West, 12 Vet. App. 11, 20 (1998), citing
ERA) that addressed his May 1994 STR showing he reported joint swelling and/or pain at the time of his separation examination. Consequently, the Board finds the February 2025 opinions inadequate to decide the claims.

3. TDIU

The Board finds the issue of entitlement to TDIU is intertwined with the other issues on appeal. See Henderson v. West, 12 Vet. App. 11, 20 (1998), citing Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). Therefore, a decision on this claim is being deferred pending completion of the development ordered on remand to avoid piecemeal adjudication.

The matters are REMANDED for the following action:

1. Ask the Veteran to complete VA Forms 21-4142 to allow VA to obtain private treatment records from North Oaks Medical Center for his cardiac disability and/or syncopal disorder. Based on his response, attempt to procure copies of the relevant records.

Make two requests for any authorized records unless a negative response is received after the first request. If any of the records requested are unavailable, clearly document the claims file to that effect and notify the Veteran of any inability to obtain these records, in accordance with 38 C.F.R. § 3.159(e).

2. Obtain and associate with the claims file updated VA treatment records from January 2025 to the present.

3. After associating the above records, return the claims file to the VA clinician who provided the February 2025 medical opinions regarding the Veteran's heart disorder and syncopal disability, or another qualified clinician if that clinician is not available, for addendum opinions based on a full review of the record. The Veteran's electronic claims file must be made available to the clinician for review. Another examination or telehealth interview should only be scheduled, including testing for heightened vagal tone, if the clinician deems such is necessary for providing the requested opinions.

Following a review of the claims file, and the Veteran's elicited history, the clinician is asked to provide an opinion on the following:

(a) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's current heart disorder was incurred in service or is related to an in-service injury, disease, or event (other than TERA), including his reported history of a heart murmur?

(b) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) the Veteran's diagnosed syncope was incurred in service or is related to an in-service injury, disease, or event (other than TERA)?

(c) If the clinician determines the Veteran's current heart disorder is at least as likely as not related to service, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) the Veteran's neurological disorder, diagnosed as syncope, was proximately caused or aggravated (any increase in the severity or worsening of functionality) by his heart disorder?

The clinician is advised that secondary service connection is warranted where a nonservice-connected disability would have been less severe but for a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the nonservice-connected disability.

A complete rationale for all opinions must be provided that addresses the Veteran's reported history and relevant medical records. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner.

4. Return the claims file to the VA clinician who provided the February 2025 medical opinions for the Veteran's claimed disability manifested by muscle and joint pain, or another qualified examiner if that clinician's not available, for addendum opinions based on a full review of the record. The Veteran's electronic claims file must be made available to the clinician for review. Another examination or telehealth interview should only be scheduled if the clinician deems one is necessary for providing the requested
whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner.

Following a review of the claims file, and the Veteran's elicited history, the clinician is asked to provide an opinion on the following:

For each of the Veteran's diagnosed disabilities manifested by muscle and joint pain, including those involving the right shoulder, left elbow, bilateral knees, and right ankle, is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's disability was incurred in service or is related to an in-service injury, disease, or event (other than TERA)?

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A complete rationale for all opinions must be provided that addresses the Veteran's May 1994 report of medical history at the time of his separation examination. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner.

M. SORISIO

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Wells-Green, L. J.

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.

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