MAJOR DEPRESSIVE DISORDER

E. I. VELEZ · 2026 · Case ID: A26038463

MIXED

Summary

The Veteran served on active duty from April 2008 to December 2008. This case involves an appeal of a July 2021 rating decision concerning acquired psychiatric disabilities. The Veteran claimed service connection for PTSD, adjustment disorder, anxiety disorder, and major depressive disorder, asserting that these conditions began in service. The Board reviewed evidence including service treatment records, VA treatment records, a VA examination, and a private medical opinion. The Veteran testified at a Board hearing, reporting psychiatric symptoms since service, including a diagnosis of adjustment disorder with depressed mood during service, and ongoing symptoms of depression and suicidal ideation. The Board found the evidence persuasive for major depressive disorder with anxious distress, noting it was incurred in service, and granted service connection. However, service connection for PTSD was denied because the record lacked a clear clinical diagnosis meeting DSM-5 criteria, despite the Veteran's belief he had PTSD. The Board assigned significant probative weight to the VA examiner's finding that the diagnosed disability was incurred in service and to the private examiner's clear rationale for a mood disorder diagnosis over a trauma disorder. The issues of service connection for numbness in the left and right lower extremities were remanded due to a duty to assist error, as the prior VA opinion failed to address whether the service-connected cervical spine disability aggravated these conditions.

Rationale

Service treatment records document extensive rehabilitation and mental health symptoms.; VA and private examiners opined the current psychiatric disability was incurred in service.; Board assigned more weight to private examiner's rationale for mood disorder diagnosis over trauma disorder.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210830-181547

Full Decision Text

Citation Nr: A26038463
Decision Date: 04/24/26 Archive Date: 04/24/26

DOCKET NO. 210830-181547
DATE: April 24, 2026

ORDER

Entitlement to service connection for major depressive disorder with anxiety is granted.

Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied.

REMANDED

Entitlement to service connection for numbness left lower extremity is remanded.

Entitlement to service connection for numbness right lower extremity is remanded.

FINDING OF FACT

1. The Veteran has a current diagnosis of major depressive disorder with anxiety that was incurred in service.

2. The evidence of record persuasively weighs against finding that the Veteran has been diagnosed with PTSD.

CONCLUSION OF LAW

1. The criteria for service connection for major depressive disorder with anxiety have been met. 38 U.S.C. §§ 1131, 5107 (2024); 38 C.F.R. §§ 3.102, 3.303 (2025).

2. The criteria for service connection for PTSD have not been met. 38 U.S.C. §§ 1131, 5107 (2024); 38 C.F.R. §§ 3.102, 3.303, 3.304(f), 4.125(a) (2025).

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from April 2008 to December 2008. This matter came before the Board of Veterans' Appeals (Board) on appeal from a July 2021 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO).

In the August 30, 2021, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on August 6, 2024. Therefore, the Board may only consider the evidence of record at the time of the July 2021 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the issues of service connection for left and right lower extremity numbness, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those issues. 38 C.F.R. § 3.103(c)(2)(ii).

Evidence in the record suggests that the Veteran has been diagnosed with multiple acquired psychiatric conditions; therefore, the Board will broadly construe the issue of service connection for PTSD as a claim for service connection for an acquired psychiatric disability, to include PTSD, adjustment disorder, anxiety disorder, and major depressive disorder. Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) (holding that the Board must consider any disability that "may reasonably be encompassed by" the description of the claim and symptoms and other submitted information).

Entitlement to service connection for an acquired psychiatric disability, to include PTSD, adjustment disorder, anxiety disorder, and major depressive disorder

The Veteran contends that he is entitled to service connection for an acquired psychiatric disability, and he has specifically contended that he has PTSD related to events in service. The Board concludes that the Veteran has a current diagnosis of major depressive disorder with anxiety that was incurred in service and service connection is therefore warranted. However, service connection for PTSD is denied as the record does not show that the Veteran has a current diagnosis of PTSD.

Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). Service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d).

Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); credible supporting evidence that the claimed in-service stressor occurred; and a link, established by medical evidence, between current symptoms and the in-service stressor. 38 C.F.R. § 3.304(f).

VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay testimony is competent to prove that a claimant exhibited certain lay-observable symptoms and the time that those symptoms appeared. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006).

When the evidence is in approximate balance in a veteran's favor or nearly equal regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

At the August 2024 Board hearing, the Veteran reported that his psychiatric symptoms started in service. He reported that he spent over 100 days in medical rehabilitation after a fall during service, and that he underwent a psychiatric evaluation while still in service where he reported problems sleeping and suicidal ideation. He also reported being harassed by other recruits. The Veteran reported that he had ongoing symptoms ever since service and has never felt that he was whole since that time. The Veteran is competent to report the onset of lay-observable symptoms and their persistence.

July 2008 service treatment records show that the Veteran underwent a psychiatric evaluation and was diagnosed with adjustment disorder with depressed mood. The provider noted that he had been in rehabilitation for 100 days, and that he reported current symptoms of depression and suicidal ideation. He also reported limited motivation and sleep disruption. The provider specifically noted that the Veteran had no past mental health history.

November 2020 VA treatment records contain a mental health consult. The provider noted a history of anxiety disorder and that the Veteran reported some symptoms of PTSD, including hypervigilance. The provider noted subthreshold symptoms of PTSD but diagnosed the Veteran with anxiety disorder. December 2020 VA treatment records noted that the Veteran was upset that he had been diagnosed with anxiety disorder and not PTSD, and that he felt his symptoms were in line with that diagnosis.

April 2021 VA mental health records show a diagnosis of adjustment disorder, rule out PTSD. The provider noted that the Veteran reported restless nights but no other PTSD symptoms. Additional April 2021 VA treatment records noted that the Veteran believed he had PTSD related to an in-service injury. The provider diagnosed unspecified anxiety disorder and other specified trauma disorder. May 2021 VA treatment records again noted a diagnosis of anxiety disorder.

A VA initial PTSD examination was provided in June 2021. The examiner did not diagnose PTSD, and the report indicates that the Veteran did not meet all of the Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) diagnostic criteria for PTSD. The examiner instead diagnosed the Veteran with other specified trauma and stressor-related disorder, with panic attacks. The examiner also provided a June 2021 opinion stating that the Veteran did not meet the full criteria for PTSD.

The examiner also provided a June 2021 opinion regarding the etiology of the Veteran's other specified trauma and stressor-related disorder. While checking the box that the condition was not due to service, the rationale provided by the examiner stated that it was at least as likely as not that the diagnosed other specified trauma and stressor-related disorder was incurred during service and that it was due to the self-described mistreatment by fellow marines. The examiner then stated that there were no "direct evidence" or markers in the STRs to connect the diagnosis to events in service. The Board notes that this statement appears to relate to the requested opinion, which asked the examiner whether the diagnosed mental disorder was the result of "the direct evidence noted in service." First, the requested opinion's notation of "direct evidence" appears to incorrectly apply the criteria for service connection for PTSD (which requires a corroborated stressor) to the criteria for other acquired psychiatric disabilities (to which the general service connection criteria apply). The Board therefore assigns the portions of the opinion that respond to the inaccurate phrasing in the examination request no probative weight. In contrast, the examiner provided a clear finding that the diagnosed disability was incurred in service, and specifically cited the Veteran's reports of harassment in service as supporting evidence as well as symptoms shown in the VA treatment records. The Board assigns that portion of the opinion significant probative weight.

The Veteran submitted a September 2024 private opinion which found that the Veteran met the full DSM-5 criteria for major depressive disorder with anxious distress. The examiner also found that the disability was incurred during service, specifically noting that the Veteran's records and self-reports showed the onset of diagnosable psychopathology during service after his placement in a 100-day rehabilitation program. With regards to the current diagnosis, the provider noted that there was a question of which DSM-5 diagnosis best accounted for the Veteran's symptoms, and that the considerations were between a mood disorder versus a trauma disorder. The provider cited various clinical tools that were utilized to make the differential diagnosis, and opined that the Veteran's documented depressive episode in service along with ongoing depressive episodes, indicated that the appropriate diagnosis was recurrent major depression. The provider stated that full consideration was given to a trauma-based diagnosis, but that neither the DSM-5 criteria nor the symptoms for PTSD were met. The provider noted that a diagnosis of major depressive disorder did not require the identification of an external event at the time of onset, but that the evidence of distress in service was additional evidence supporting a finding of onset in service.

At the outset, except for inadequacies specifically noted above, the Board finds the VA and private opinion adequate for appellate review. There is no evidence that the providers were not competent or credible, and as the opinions are based on the Veteran's statements, in-person examination and the examiners' observations, the Board finds them entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-05 (2008).

The Board therefore finds that the probative evidence of record indicates that the Veteran has a current disability of major depressive disorder with anxious distress that began in service and has continued since service. Service treatment records document the extensive rehabilitation, mental health symptoms, and mental health treatment reported by the Veteran at his Board hearing. Both the VA and private examiners opined that the current psychiatric disability was incurred in service.

The only question for which there is any conflicting evidence in the record is the nature of the Veteran's current acquired psychiatric disability. The Veteran's VA providers variously diagnosed anxiety disorder and other specified trauma disorder, the VA examiner diagnosed other specified trauma disorder, and the private examiner diagnosed major depressive disorder with anxious distress. However, the September 2024 private opinion is the only opinion of record that clearly explained the process
current disability of major depressive disorder with anxious distress that began in service and has continued since service. Service treatment records document the extensive rehabilitation, mental health symptoms, and mental health treatment reported by the Veteran at his Board hearing. Both the VA and private examiners opined that the current psychiatric disability was incurred in service.

The only question for which there is any conflicting evidence in the record is the nature of the Veteran's current acquired psychiatric disability. The Veteran's VA providers variously diagnosed anxiety disorder and other specified trauma disorder, the VA examiner diagnosed other specified trauma disorder, and the private examiner diagnosed major depressive disorder with anxious distress. However, the September 2024 private opinion is the only opinion of record that clearly explained the process of differentiating between a mood-based and trauma-based diagnosis, and provided a clear rationale for the mood disorder diagnosis. The Board therefore assigns more weight to the findings of the private examiner and finds that the Veteran has a current acquired psychiatric disability of major depressive disorder with anxious distress. As discussed above, the evidence of record consistently indicates that this current disability was incurred in service. Service connection for major depressive disorder with anxious distress is therefore warranted.

The Board has also considered whether service connection is warranted for PTSD. However, the evidence does not show that the Veteran has a clinical diagnosis of PTSD in accordance with the relevant diagnostic criteria. Service connection for PSTD requires medical evidence establishing a clear diagnosis of PTSD in accordance with the DSM-5 criteria. See 38 C.F.R. §§ 3.304(f), 4.125(a). Here, while the Veteran has contended that he has PTSD and that his symptoms fit that diagnosis, the record does not indicate that he has the training to attribute his symptoms to a specific acquired psychiatric disability under the DSM-5 criteria. The issue is medically complex and requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran's VA providers, the VA examination of record, and the private opinion submitted by the Veteran have all found that he did not meet the criteria for PTSD. Thus, the record does not contain medical evidence with a clear diagnosis of PTSD, and service connection for PTSD must be denied.

In sum, with regards to service connection for PTSD, the evidence is not in approximate balance in the Veteran's favor or nearly equal and indicates that the Veteran does not have a current diagnosis of PTSD. However, the evidence does show that he has a current disability of major depressive disorder with anxious distress was incurred in service. Thus, while service connection for PTSD is not warranted, service connection for major depressive disorder with anxious distress is granted. 38 C.F.R. § 3.303.

REASONS FOR REMAND

1. Entitlement to service connection for numbness left lower extremity

2. Entitlement to service connection for numbness right lower extremity

The issues of entitlement to service connection for numbness in the left and right lower extremities are remanded to correct a duty to assist error that occurred prior to the July 2021 rating decision on appeal. The AOJ obtained a July 2021 medical opinions prior to the rating decision on appeal. However, the medical opinion does not provide an adequate rationale regarding whether the Veteran's left and right lower extremity numbness is caused or aggravated by the service-connected cervical spine disability as it did not address the question of aggravation.

A July 2021 VA peripheral nerves examination diagnosed bilateral lower extremity peripheral neuropathy. The examiner then provided July 2021 opinions that the left and right lower extremity numbness were not secondary to the service-connected cervical spine disability. As a rationale, the examiner stated in both opinions that cervical spine roots did not innervate the lower extremities or play a role in their sensation, and that the lower extremity numbness was therefore less likely than not proximately due to or the result of the cervical spinal stenosis.

The Board notes that the July 2021 opinions were focused on the question of causation and did not address whether the cervical spine disability aggravated the diagnosed bilateral lower extremity numbness. The opinions are therefore inadequate, and remand for new opinions that address the question of aggravation is required. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013); Allen v. Brown, 7 Vet. App. 439 (1995).

The matters are REMANDED for the following action:

Obtain a VA opinion from an appropriate provider regarding the etiology of the Veteran's left and right lower extremity numbness/peripheral neuropathy. The examiner should review the file and provide a complete rationale for
were focused on the question of causation and did not address whether the cervical spine disability aggravated the diagnosed bilateral lower extremity numbness. The opinions are therefore inadequate, and remand for new opinions that address the question of aggravation is required. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013); Allen v. Brown, 7 Vet. App. 439 (1995).

The matters are REMANDED for the following action:

The opinion should address whether it is at least as likely as not (ie, the evidence is at least in approximate balance in favor of the Veteran) that any such disability is caused or aggravated by the Veteran's service-connected cervical spine disability. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran's statements regarding the onset and persistence of his symptoms.

E. I. VELEZ

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board A. Arnold, 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.

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