MAJOR DEPRESSIVE DISORDER

Summary

The Veteran, who served during the Persian Gulf War era from July 1989 to November 1989 and again in July 1991, appeals the denial of service connection for depression, anxiety, and PTSD. The Veteran submitted lay statements describing in-service traumatic events, including a grenade incident during training and exposure to gunfire during night training, which she believes caused her current symptoms of anxiety, nightmares, and flashbacks. The Board found the Veteran competent to report her symptoms and her lay statements credible, but noted that a diagnosis of a psychiatric disorder requires medical expertise. The Veteran's service treatment records were silent regarding complaints, treatment, or diagnosis of depression, anxiety, or PTSD. Post-service private treatment records from 2013 to 2020 consistently noted no depression, no feelings of hopelessness, no anhedonia, and appropriate mental status evaluations, with one record in February 2019 noting the Veteran was negative for psychiatric/behavioral problems. VA treatment records from July 2023 noted occasional anxiety, stress, and depression, but negative screenings for PTSD and MST. Multiple VA examinations were conducted, with examiners noting the Veteran's presentation was inconsistent with severe impairment, her credibility was poor during one examination due to inconsistent responses, and ultimately determining she did not meet the criteria for a DSM-5 diagnosis of depression, anxiety, or PTSD. The Board concluded that the probative evidence did not establish a current diagnosis of a psychiatric disorder, which is a prerequisite for service connection. Therefore, service connection for depression, anxiety, and PTSD was denied.

Rationale

No current diagnosis of depression per DSM-5 criteria.; Lay statements insufficient to establish diagnosis without medical expertise.; Service treatment records silent regarding depression.

Full Decision Text

Citation Nr: A26040937
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 260112-622756
DATE: April 30, 2026

ORDER

Entitlement to service connection for depression and anxiety is denied.

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

FINDINGS OF FACT

1. The evidence weighs persuasively against finding the Veteran has a current disability of depression and anxiety.

2. The Veteran does not currently have a diagnosis of depression and anxiety.

3. The evidence weighs persuasively against finding the Veteran has a current disability of PTSD.

4. The Veteran does not currently have a diagnosis of PTSD.

5. The Veteran does not currently have a diagnosed psychiatric disorder.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for depression and anxiety have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304.

2. The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from July 1989 to November 1989 and from July 13, 1991 to July 27, 1991.

This appeal is being processed under the modernized review system, commonly referred to as the "AMA," as established by the Veterans Appeals Improvement and Modernization Act of 2017. 115 Pub. L. No. 55, 131 Stat. 1105.

These matters come before the Board of Veterans' Appeals (Board) on appeal of an April 2025 rating decision issued by a Department of Veterans Affairs (VA) regional office, an agency of original jurisdiction (AOJ).  

The Veteran timely initiated an appeal by submitting a January 2026 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), and elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the AOJ's issuance of the April 2025 rating decision on appeal. 38?C.F.R. § 20.301.

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.

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).

The provisions of 38 C.F.R. § 4.125(a) require that a diagnosis of a psychiatric disorder conform to the Diagnostic and Statistical Manual (DSM). In this case, because the Veteran's claim was certified to the Board after August 4, 2014, the DSM-5 is applicable.

Pursuant to the requirements of 38 C.F.R. § 3.304 (f), service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that a claimed in-service stressor occurred; and (3) a link, established by medical evidence, between current symptoms and an in-service stressor. The sufficiency of a stressor is a medical determination and is presumed by a medical diagnosis of PTSD. Cohen v. Brown, 10 Vet. App. 128 (1997). If a PTSD claim is based on an in-service personal assault, medical opinion evidence may be submitted for use in determining whether the occurrence of a stressor is corroborated. Menegassi v. Shinseki
f), service connection for PTSD requires: (1) medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); (2) credible supporting evidence that a claimed in-service stressor occurred; and (3) a link, established by medical evidence, between current symptoms and an in-service stressor. The sufficiency of a stressor is a medical determination and is presumed by a medical diagnosis of PTSD. Cohen v. Brown, 10 Vet. App. 128 (1997). If a PTSD claim is based on an in-service personal assault, medical opinion evidence may be submitted for use in determining whether the occurrence of a stressor is corroborated. Menegassi v. Shinseki, 638 F.3d 1379, 1382 (Fed. Cir. 2011).

When there is an approximate balance between positive and negative evidence, equipoise, the benefit of the doubt doctrine must apply in favor of the Veteran. But when the evidence persuasively favors one side, the claim will be decided on its merits and the benefit of the doubt doctrine is inapplicable. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

Entitlement to service connection for depression and anxiety 

Entitlement to service connection for PTSD

The Veteran seeks service connection for depression, anxiety, and PTSD, which she contends are related to service. 

In October 2024, VA notified the Veteran that it sought private medical records from Road Home Project that the Veteran had suggested would assist her claim and asked that she fill out VA Form 21-4142a to authorize the disclosure of information. See VA Correspondence, October 7, 2024. On March 5, 2025, VA notified the Veteran that these private treatment records had been requested with her authorization and that she had the ultimate responsibility to see that VA received the requested private treatment records. The Veteran was notified if VA did not hear from the Veteran regarding information or evidence, it may make a decision on her claim after 30 days.VA notified the Veteran later in March 2025 that the private medical records requests did not receive a response and that VA would make a second request for the records. The Veteran was again reminded that she was ultimately responsible for submitting relevant evidence to support her claims. The Veteran was notified if VA did not hear from her regarding information or evidence, it may make a decision on her claim after 15 days.

A March 2025 Medical Records Request documented VA's attempts to contact the Road Home Program twice on March 5, 2025 and on March 21, 2025, without reply. An April 2025 Report of General Information noted that VA left a message with the provider, faxed a request to the fax number obtained online, and has attempted to contact the provider several times. It also noted that no response had been received and the request was being closed. 

Thus, the AOJ fulfilled its duty to assist in attempting to obtain the Veteran's private treatment records.

The Veteran's service treatment records (STRs) are silent for complaints, treatment, or a diagnosis of depression, anxiety, or PTSD.

In August 2023, the Veteran submitted a Statement in Support of Claim for PTSD. She stated that during training, she was in a foxhole with another soldier and her drill Sergeant. They were instructed to pull the pin, then throw the grenade as far as they could, then quickly duck into the foxhole and take cover. She stated that she followed the instructions, and the grenade blast scared her and gave her an instant headache. She stated that the other soldier pulled the pin on the grenade but did not throw it. The Sergeant had to grab the grenade from the other soldier to throw it and slammed their heads against the wall trying to cover them from the blast. She stated that her head was slammed so hard, she blacked out for a few seconds. The Veteran also stated that she has nightmares about that day and cannot go to sporting events or be around loud noises or fireworks because the noise causes her to feel anxious and nervous and she starts to sweat heavily. She also stated that during night training she was instructed to crawl under barbed wire. They were instructed to keep their heads down because live ammunition would be fired. She stated that she could hear bullets near her head and the sounds of the live fire scared her and she froze and could not move. She stated she thought she was going to die and she has flashbacks of this incident when she is around gun fire or fireworks. The Veteran stated she feels nervous and anxious and wants to run but her feet and legs will not move. She stated this has haunted her for 30 years.

The Veteran is competent to report on that of which she has personal knowledge,
 fireworks because the noise causes her to feel anxious and nervous and she starts to sweat heavily. She also stated that during night training she was instructed to crawl under barbed wire. They were instructed to keep their heads down because live ammunition would be fired. She stated that she could hear bullets near her head and the sounds of the live fire scared her and she froze and could not move. She stated she thought she was going to die and she has flashbacks of this incident when she is around gun fire or fireworks. The Veteran stated she feels nervous and anxious and wants to run but her feet and legs will not move. She stated this has haunted her for 30 years.

The Veteran is competent to report on that of which she has personal knowledge, including the onset and continuity of her symptomatology. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). The evidence does not impeach the Veteran's credibility. Therefore, the Board finds her competent lay statements to be credible and probative evidence.

Private treatment records from December 2013 note that the Veteran reported no feelings of hopelessness, no anhedonia, and was not taking medication for depression. In August 2015 and September 2016, private treatment records note that the Veteran was oriented to person, place, and time, was alert and interactive and her mood/affect were appropriate. It was noted that her judgment was not impaired, her attention span was normal, and her short-term memory was intact. In February 2015, it was noted that she had no anhedonia, had not been referred to a mental health center, and was not taking medication for depression. Her private treatment records from February 2015 also note that she had no feelings of hopelessness and no anhedonia. In December 2017, her private treatment records note "no depression." In December 2018, it was noted again that she had no feelings of hopelessness, no anhedonia, and was not taking medication for depression. In February 2019, private treatment records note that the Veteran was negative for psychiatric/behavioral problems. In March 2019 and January 2020, it was noted that the Veteran was negative for behavioral problems, confusion and decreased concentration. These records also note that she was not nervous/anxious and was not hyperactive.

VA treatment records from July 2023 note that the Veteran reported issues with anxiety, stress, and depression at times and is agreeable to receiving counseling. She denied suicidal and homicidal ideation. The Veteran's depression and PTSD screenings were negative and she denied experiencing military sexual trauma (MST). VA treatment records from February 2024 show anxiety was listed as an active problem.

The Veteran underwent a VA residuals of Traumatic Brian Injury (TBI) examination in July 2022. The examiner noted that no memory impairment was reported by the Veteran and that the Veteran has irritability, moodiness and occasional apathy that interfere with interactions at home and at work. The Veteran underwent a VA residuals of TBI examination in December 2022 and the examiner noted that the Veteran reported headaches, vertigo, and cognitive issues with attention, concentration, and memory deficits. The examiner noted the Veteran had no neurobehavioral effects. The Veteran underwent a VA residuals of TBI examination again in May 2023. The examiner noted the Veteran reported difficulty with memory in that she forgets things frequently. The examiner noted the Veteran's MOCA testing was invalid, however, as her effort during the testing was poor and her responses were inconsistent. The examiner noted that the Veteran maintains family relationships, cares for her mother, and maintains gainful employment in a managerial position. The Veteran reported she had been taking care of her parents and stepfather, including managing their medications, providing meals, changing their wounds, and household tasks. The examiner stated the objective testing using MOCA was invalid given the Veteran's poor effort and inconsistent responses, which raises concerns for credibility during the evaluation.

The July 2022, December 2022, and May 2023 VA examination findings are adequate and constitute highly probative evidence.

The Veteran underwent a VA mental disorders examination in February 2025. The examiner determined that the Veteran did not have a diagnosed mental disorder. The Veteran reported she has been married for 23 years, has 2 adult children, and has friends she frequently goes out to have meals with. The Veteran reported she had no disciplinary issues or reported problems while in the military. She reported she was employed as a stylist in a major department store and reported that she has no difficulty at her job and has had no disciplinary issues. The Veteran reported that she was at Road Home, but she could not report how long she had been in the program or when she left the program. She stated that she had entered
 findings are adequate and constitute highly probative evidence.

The Veteran underwent a VA mental disorders examination in February 2025. The examiner determined that the Veteran did not have a diagnosed mental disorder. The Veteran reported she has been married for 23 years, has 2 adult children, and has friends she frequently goes out to have meals with. The Veteran reported she had no disciplinary issues or reported problems while in the military. She reported she was employed as a stylist in a major department store and reported that she has no difficulty at her job and has had no disciplinary issues. The Veteran reported that she was at Road Home, but she could not report how long she had been in the program or when she left the program. She stated that she had entered the program in 2022 and attended for several months. 

The February 2025 VA examiner determined that the Veteran's symptoms include anxiety. The examiner noted that the Veteran was on time for her appointment and she appeared to be neat and well-groomed. Her eye contact was appropriate, and her attitude was somewhat evasive. Her level of consciousness was alert with normal arousal and normal motor behavior Her speech was clear, logical, concise, normal rate and volume and her observed affect was a bit detached but was appropriate. Her range and intensity of affect was broad and there was no volatility. The examiner stated, although the Veteran complained of severe anxiety, there were no signs or symptoms of any anxious affect. The Veteran's thought processes showed no pattern of interruption or disorganization of thought, her thought content showed no delusions, no phobic ideas, no ambivalence, no ideas of reference, and no preoccupations. Hallucinations were neither elicited nor observed and no delusions were present. The examiner noted that observations of relatedness showed a sense of entitlement and ego centricity. The examiner noted that the Veteran's credibility was poor and her judgment was intact. Her somatic functioning notes that she has no difficulty with sleep and that she has no nightmares. The examiner also stated, although the Veteran attempted to present herself as severely impaired, she is functioning well enough to maintain a job, to maintain her relationship with her husband, and to maintain relationships with her children. 

The February 2025 VA examination findings are adequate and constitute highly probative evidence.

A VA medical opinion was completed in February 2025 to address whether the Veteran's depressive disorder is at least as likely as not proximately due to or the result of TBI with vertigo. The examiner determined that the Veteran does not have a major depressive disorder. The examiner noted, despite the report of a TBI with vertigo, the Veteran had no complaints nor did she show any aspect of complaints of the TBI with vertigo. The examiner noted that the Veteran did not report that she had a major depressive disorder. The examiner stated that the Veteran "attempted to portray herself as a potential victim of ... abuse but she failed in either describing an event or events of a sexual nature, and she had no complaints related to potential sexual abuse in the military." The examiner stated that the Veteran did not report any symptoms that would be consistent with a generalized anxiety disorder. The examiner noted that the Veteran has a history of multiple vague mental health diagnoses. However, the Veteran did not report symptoms that are sufficient to make a diagnosis of major depressive disorder, bipolar disorder, or anxiety disorder.

The February 2025 VA medical opinion is adequate and constitutes highly probative evidence.

The probative evidence does not establish a diagnosis of depression, anxiety disorder, PTSD or other acquired psychiatric disorder. The examiner noted that the Veteran is not found to present with clinically significant mental health symptoms that meet criteria for a DSM5 diagnosis at the time of the examination.

The Veteran's representative contends that a medical diagnosis during service is not required to establish the in-service element for service connection. See March 2025 Brief. The representative further contends that the Veteran has demonstrated continuity of symptomatology following discharge, supported by post-service medical evidence and consistent reports describing persistent anxiety symptoms, which supports an inference that the condition began during service, even absent contemporaneous documentation

The Veteran has not provided competent evidence of a currently diagnosed psychiatric disorder per DSM-5, or that there is an acquired psychiatric disorder that is competently linked to service. While the Veteran is competent to report symptoms she observed at any time, the Veteran does not have the requisite medical training or credentials to be able to render a competent diagnosis of a psychiatric disability. A psychiatric disability is a psychological process that requires clinical interview, behavioral observation, and mental status evaluation to diagnose; therefore, the diagnosis of such is outside the realm of common knowledge of a lay person and, because the Veteran has not shown the appropriate medical training and expertise to render a diagnosis of a psychiatric disorder, the statements in this regard are insufficient to establish the presence of a current disability. See Young v. McDonald, 766 F.3d 1348,
5, or that there is an acquired psychiatric disorder that is competently linked to service. While the Veteran is competent to report symptoms she observed at any time, the Veteran does not have the requisite medical training or credentials to be able to render a competent diagnosis of a psychiatric disability. A psychiatric disability is a psychological process that requires clinical interview, behavioral observation, and mental status evaluation to diagnose; therefore, the diagnosis of such is outside the realm of common knowledge of a lay person and, because the Veteran has not shown the appropriate medical training and expertise to render a diagnosis of a psychiatric disorder, the statements in this regard are insufficient to establish the presence of a current disability. See Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014) (holding that "PTSD is not the type of medical condition that lay evidence... is competent and sufficient to identify"); see also Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (holding that a claimant without medical expertise cannot be expected to precisely delineate the diagnosis of his/her mental illness).

Although there is evidence that the Veteran experiences anxiety, the probative evidence does not show this symptom meets the criteria for a DSM5 diagnosis for a psychiatric disorder. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328 (1997).

Without evidence indicating a current disability, service connection cannot be granted. See 38 C.F.R. § 3.102, 3.303; Brammer v. Derwinski, 3 Vet. App. 223 (1995) (Congress specifically limited entitlement to service connection for a disease or injury to cases where such incidents had resulted in a disability). Because the Veteran does not have a current diagnosis of a psychiatric disability, the first element of service connection is not met. Accordingly, entitlement to service connection for depression, anxiety, and PTSD is not warranted.

 

SHAUN S. SPERANZA

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Magiros, Kristen N.

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.