DEPRESSIVE DISORDER DUE TO ANOTHER MEDICAL CONDITION

DELYVONNE M. WHITEHEAD · 2026 · Case ID: A26040709

MIXED

Summary

The Veteran, who served from May 2011 to September 2011, appeals the denial of service connection for an acquired psychiatric disorder, including major depressive disorder, generalized anxiety disorder, PTSD, and depressive disorder due to another medical condition. The Veteran also appeals the denial of service connection for a left shoulder condition and a lower back condition, and seeks entitlement to TDIU. The Board granted service connection for the acquired psychiatric disorder, finding the Veteran's diagnoses, difficulty adjusting to military life, and a private psychiatrist's opinion linking current diagnoses to service persuasively weighed in favor of the claim. The Board applied the benefit of the doubt, granting service connection for the psychiatric disorder. The claims for the left shoulder and lower back conditions were remanded due to a duty to assist error, as the VA failed to provide necessary examinations. Additionally, a private opinion regarding the left shoulder condition was deemed too vague. The TDIU claim was also remanded, as the Board is awarding service connection for the psychiatric disorder and the AOJ must now assign a rating and determine TDIU eligibility. The Veteran's service records indicate a premature discharge due to an "inability to adapt to the military environment."

Rationale

Medical records reflect diagnoses of major depressive disorder, generalized anxiety disorder, PTSD, and depressive disorder due to another medical condition.; Veteran's service records reflect premature discharge due to "inability to adapt to the military environment."; Private psychiatrist found current psychiatric diagnoses causally linked to military service, citing traumatic events derailing individual's plan.

Special Benefit

TDIU

Docket No.

210521-164977

Full Decision Text

Citation Nr: A26040709
Decision Date: 04/30/26 Archive Date: 04/30/26

DOCKET NO. 210521-164977
DATE: April 30, 2026

ORDER

Entitlement to service connection for an acquired psychiatric disorder, including major depressive disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), and depressive disorder due to another medical condition (acquired psychiatric disorder), is granted.

REMANDED

Entitlement to service connection for a left shoulder condition is remanded.

Entitlement to service connection for a lower back condition is remanded.

Entitlement to a total disability evaluation based on individual unemployability (TDIU) as due to the Veteran's service-connected acquired psychiatric disorder is remanded.

FINDING OF FACT

The probative evidence of record attributes the Veteran's acquired psychiatric disorder to his active duty service.

CONCLUSION OF LAW

The criteria for service connection for an acquired psychiatric disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from May 2011 to September 2011.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2021 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO).

In the May 21, 2021, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on November 7, 2024, during which the Veteran testified before the undersigned Veterans Law Judge (VLJ); a transcript is of record.

Therefore, the Board may only consider the evidence of record at the time of the April 2021 Agency of Original Jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or his 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(s), 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 claims of entitlement to service connection for a left shoulder condition and a low back condition, and entitlement to a TDIU, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection - Acquired Psychiatric Disorder

As a preliminary matter, the Veteran's medical records, including VA treatment records dated in December 2023 and November 2024 and a December 2024 opinion submitted in conjunction with this claim, reflect diagnoses of major depressive disorder, generalized anxiety disorder, PTSD, and depressive disorder due to another medical condition. Because the scope of a psychiatric disability includes any mental disorder that may reasonably be included with the Veteran's account of the claim, reported symptoms, and all other information of record, the Board finds that it is more appropriate to characterize the Veteran's claim broadly, as a single claim for entitlement to service connection for an acquired psychiatric disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009).

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires competent medical and lay evidence of three things: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (i.e., a nexus) between the current disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir.
, 23 Vet. App. 1 (2009).

A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

To be entitled to service connection for PTSD, as opposed to another psychiatric disorder, the record must include: (1) medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a) (i.e., DSM-V for appeals certified after August 4, 2014); (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) a link, established by medical evidence between current symptomatology and the claimed in-service stressor. 38 C.F.R. § 3.304(f); Cohen v. Brown, 10 Vet. App. 128, 138 (1997).

As noted above, the Veteran has been diagnosed with: major depressive disorder; generalized anxiety disorder; PTSD; and depressive disorder due to another medical condition. See December 2023 VA Mental Health Note (received in December 2024); November 2024 VA Psychiatry Outpatient E&M Note (received in December 2024); December 2024 Opinion by L.M.E.-C., MD, MPH. Further, the Veteran's service records reflect that he was prematurely discharged from the military, in part, due to an "inability to adapt to the military environment." See September 2011 Department of Defense Memoranda (received in February 2020).

The sole medical opinion of record was received in December 2024 by a non-VA psychiatrist, who found that the Veteran's current psychiatric diagnoses were causally linked to his military service. This psychiatrist reasoned that "traumatic events that completely and unexpectedly derail an individual's plan" (in this instance, adjustment to military life and an in-service shoulder injury, discussed below) will "often lead to the development of depression and anxiety." See December 2024 Opinion by L.M.E.-C., MD, MPH.

Given the medical evidence diagnosing different psychiatric conditions as noted above, the Veteran's evidence in service of difficulty adjusting to military life, and the medical opinion formulating a nexus between the Veteran's current diagnoses and his military service, the Board finds that the evidence persuasively weighs in favor of the Veteran's claim. 38 C.F.R. §§ 3.303, 3.304(f); Shedden, 381 F.3d at 1167. Resolving all reasonable doubt in the Veteran's favor, the Board finds that service connection for an acquired psychiatric condition is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

REASONS FOR REMAND

1. Service Connection - Left Shoulder Condition

The Board acknowledges that, as part of the March 2021 Supplemental Claim, the Veteran submitted private medical records indicating that he had been diagnosed with pain in the left shoulder, contour deformity of the posterior humeral head suggesting possible chronic Hill-Sachs deformity, and mild acromioclavicular joint osteoarthritis. The Board recognizes that pain is a disability when that pain reaches a level of functional impairment that affects a claimant's earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). The Veteran asserts that, while undergoing basic combat training, he injured his left shoulder, for which he did not report to sick call. See February 2020 VA Form 21-4138; December 2020 VA Form 21-4138; March 2021 VA Form 21-4138; November 2024 Hearing Transcript. Additionally, the Veteran reported to the military that he previously broke his collarbone. See May 2009 Report of Medical History.

An examination must be obtained in conjunction with a claim if there is competent evidence of a current disability, evidence of an in-service injury, event, or disease, an indication that the current disability may
1367-68 (Fed. Cir. 2018). The Veteran asserts that, while undergoing basic combat training, he injured his left shoulder, for which he did not report to sick call. See February 2020 VA Form 21-4138; December 2020 VA Form 21-4138; March 2021 VA Form 21-4138; November 2024 Hearing Transcript. Additionally, the Veteran reported to the military that he previously broke his collarbone. See May 2009 Report of Medical History.

An examination must be obtained in conjunction with a claim if there is competent evidence of a current disability, evidence of an in-service injury, event, or disease, an indication that the current disability may be associated with the Veteran's service or another service-connected disability, and there is otherwise insufficient competent medical evidence to decide the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Since the AOJ did not provide the Veteran an examination to determine the nature and etiology of his left shoulder disability, the AOJ committed a pre-decisional duty to assist error, which must be corrected on remand.

The Board also acknowledges that there is an opinion of record from the Veteran's non-VA provider regarding the nature and etiology of his left shoulder condition. Specifically, the Veteran's provider found that the Veteran's current condition was a "direct result [of] combative training" but also that "exercises aggravated the injury throughout continued training during his military service." See December 2024 Opinion by M.A.R., MD. However, the Board finds that this opinion is unclear as to whether the Veteran's current condition was either a new condition caused by the Veteran's claimed in-service left shoulder injury or a permanent worsening of a pre-existing shoulder condition. Further, if the author of this opinion was indicating that the Veteran had a pre-existing shoulder condition that was aggravated by his active military service, the author did not use the correct standard of clear and unmistakable evidence that the condition pre-existed the Veteran's entrance into service and that it was worsened by the Veteran's service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306.

Accordingly, because the AOJ committed a pre-decisional duty to assist error by not obtaining an examination, and because the non-VA medical opinion is too vague to determine whether the Veteran's current left shoulder condition was either caused or aggravated by his military service, the Board finds that remand is warranted to schedule the Veteran for an examination and obtain a new opinion regarding whether there is a causal link between the Veteran's left shoulder condition and his active duty service.

2. Service Connection - Lower Back Condition

As with the Veteran's claim for service connection for a left shoulder condition, the Board notes that the Veteran does not have a back diagnosis, other than lower back pain. Pain is a disability when that pain reaches a level of functional impairment that affects a claimant's earning capacity. Saunders, 886 F.3d. at 1367-68.

Whether the Veteran's pain reaches a level of functional impairment that affects his earning capacity is a medical determination which the Board cannot make on its own. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Additionally, the AOJ has not provided the Veteran an examination, despite his claims that his lower back condition is causally related to his left shoulder condition. McLendon, 20 Vet. App. at 81. Therefore, the AOJ committed a pre-decisional duty to assist error. On remand, this error must be corrected by affording the Veteran an examination to determine the nature and etiology of his lower back condition, to include pain.

3. TDIU

In the above-mentioned psychiatric opinion, the Veteran had indicated that he "cannot maintain employment due to his emotional instability and cognitive symptoms secondary to depression and anxiety." See December 2024 Opinion by L.M.E.-C., MD, MPH. The United States Court of Appeals for Veterans Claims (Court) ruled that a TDIU is a "rating option available whenever a claimant attempts to get service connection for a higher rating from VA and the record includes evidence of unemployability." Phillips v. McDonough, 37 Vet. App. 394, 396 (2024) (citing Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009)).

Here, not only did the Veteran tell the author of the December 2024 psychiatric opinion that his acquired psychiatric disorder impacted his ability to work, but he also told his VA psychiatric provider that "he has difficulty holding a job due to emotional trauma and also physical injury from military service." See November 2024 VA
) ruled that a TDIU is a "rating option available whenever a claimant attempts to get service connection for a higher rating from VA and the record includes evidence of unemployability." Phillips v. McDonough, 37 Vet. App. 394, 396 (2024) (citing Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009)).

Because the Board is awarding service connection for an acquired psychiatric disorder, the AOJ is now tasked with assigning a rating and effective date for this condition. Thus, at this time, the Board cannot determine whether TDIU is warranted based on the Veteran's acquired psychiatric disorder.

The AMA provides that remands may be issued by the Board to satisfy a regulatory or statutory duty, if such would have a reasonable possibility of aiding in substantiating the appellant's claim. 38 C.F.R. § 20.802(a). Therefore, because the AOJ is now tasked with assigning a disability evaluation for the Veteran's acquired psychiatric disorder, the Board finds that remand is warranted to assist the Veteran in his claim for entitlement to a TDIU.

The matters are REMANDED for the following action:

1. Schedule the Veteran for an appropriate examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible), to determine the nature and etiology of any and all left shoulder condition(s) attributable to the Veteran throughout the period on appeal. The entire claims file, including a copy of this remand, must be made available to the examiner, who must note its review.

(a) The examiner should identify any and all left shoulder condition(s) attributable to the Veteran throughout the period on appeal.

(b) For each condition so identified, the examiner should opine as to whether it is at least as likely as not that the Veteran's condition manifested during, or is the result of, his active duty service.

(c) For each condition so identified, the examiner should opine as to whether there is clear and unmistakable (i.e., medically undebatable) evidence that the Veteran had a left shoulder condition prior to service. If the examiner answers in the affirmative, the clinician should opine as to whether there is clear and unmistakable (i.e., medically undebatable) evidence that (i) there was no increase in disability during service or (ii) any increase in disability was due to the natural progress of the pre-existing condition.

In formulating his or her opinions, the examiner must consider and address the competent medical and lay evidence of record, including but not limited to:

(i) The Veteran's service treatment records;

(ii) The Veteran's post-service medical records;

(iii) The statement by K.G., received in December 2020, regarding his observations of the Veteran's in-service injury to the left arm;

(iv) The statement by E.S., received in December 2020, regarding the timing of the Veteran telling her that he injured his left shoulder and arm in service; and

(v) The Veteran's competent lay statements, including but not limited to those made to his medical providers, the February 2020 VA Form 21-4138, the December 2020 VA Form 21-4138, the March 2021 VA Form 21-4138, and the Veteran's November 2024 hearing testimony, regarding his first-hand in-service experiences and the onset and continuity of his symptomatology.

If the examiner determines that the Veteran's left shoulder condition(s) is/are less likely than not caused and/or aggravated by his active duty service, the examiner should discuss what other factor(s) caused the disorder(s). In other words, the examiner should ascertain the most likely etiology of the Veteran's left shoulder condition(s).

A complete rationale must be provided for all opinions and conclusions reached.

2. Schedule the Veteran for an appropriate examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the nature and etiology of any and all lower back condition(s) and/or pain attributable to the Veteran throughout the period on appeal. The entire claims file, including a copy of this remand, must be made available to the examiner, who must note its review.

(a) The examiner should identify any and all lower back conditions attributable to the Veteran throughout the period on appeal.

(b) If no such condition is identified, the examiner should opine as to whether the Veteran's lower back pain
left shoulder condition(s).

A complete rationale must be provided for all opinions and conclusions reached.

(a) The examiner should identify any and all lower back conditions attributable to the Veteran throughout the period on appeal.

(b) If no such condition is identified, the examiner should opine as to whether the Veteran's lower back pain is such that would reach a level of functional impairment that would affect his earning capacity.

(c) For each condition so identified, and/or if the examiner determines that the Veteran's lower back pain is such that would reach a level of functional impairment that would affect his earning capacity, the examiner should opine as to whether it is at least as likely as not that the Veteran's condition and/or pain manifested during, or is the result of, his active duty service.

(d) For each condition so identified, and/or if the examiner determines that the Veteran's lower back pain is such that would reach a level of functional impairment that would affect his earning capacity, the examiner should opine as to whether it is at least as likely as not that the Veteran's condition and/or pain was either (i) caused or (ii) aggravated by his left shoulder condition(s).

NOTE: With respect to the question concerning aggravation, the examiner is advised that aggravation under 38 C.F.R. § 3.310(b) does not require "permanent worsening" of the nonservice-connected disability. If aggravation is found, the examiner should attempt to identify the baseline level of severity of disability prior to such aggravation.

In formulating his or her opinions, the examiner must consider and address the competent medical and lay evidence of record, including but not limited to:

(i) The Veteran's service treatment records;

(ii) The Veteran's post-service medical records; and

(iii) The Veteran's competent lay statements, including but not limited to those made to his medical providers, the February 2020 VA Form 21-4138, the December 2020 VA Form 21-4138, the March 2021 VA Form 21-4138, and the Veteran's November 2024 hearing testimony, regarding his first-hand in-service experiences and the onset and continuity of his symptomatology.

If the examiner determines that the Veteran's lower back condition(s) and/or pain is/are less likely than not due to his active duty service and/or is/are less likely than not caused and/or aggravated by his left shoulder condition(s), the examiner should discuss what other factor(s) caused the disorder(s). In other words, the examiner should ascertain the most likely etiology of the Veteran's lower back condition(s) and/or pain.

A complete rationale must be provided for all opinions and conclusions reached.

3. The AOJ should assign a rating for the Veteran's service-connected acquired psychiatric disorder.

4. After the AOJ completes this task, and conducts any additional appropriate development, the AOJ should determine whether entitlement to a TDIU is warranted.

DELYVONNE M. WHITEHEAD

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board S. Hoffman

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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