Depression Secondary To Shoulder

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Citation NR: 9615910 Decision Date: 06/06/96 Archive Date: 06/18/96DOCKET NO. 95-36 296 ) DATE ) )On appeal from theDepartment of Veterans Affairs Regional Office in New York, New YorkTHE ISSUEEntitlement to service connection for a psychiatric disability, secondary to a service connected right shoulder disability.REPRESENTATIONAppellant represented by: Veterans of Foreign Wars of the United StatesWITNESS AT HEARING ON APPEALAppellantATTORNEY FOR THE BOARDK. Johnson, Associate CounselINTRODUCTIONThe veteran served on active duty from August 1976 to February 1978.This matter initially came to the Board of Veterans’ Appeals (Board) from an August 1993 decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which denied service connection for depression secondary to the veteran’s service-connected right shoulder disability. Although the RO in St. Petersburg, Florida made the initial determination, in February 1994, the veteran’s claims folder and claims were transferred to the RO in New York, New York, based on the veteran’s change of residence. The Board also notes that the veteran has raised the issue that his depression, claimed to be secondary to his service-connected right shoulder disability, has rendered him unemployable, and has filed an unemployability claim. The issue of veteran’s entitlement to unemployability benefits based on service connection for depression secondary to his service-connected right shoulder disability is not inextricably intertwined with the current appeal, and the RO has made no determination regarding the unemployability claim. Therefore, it is referred to the RO for the appropriate action. REMANDIn 1977, during service, the veteran sustained an injury to his right shoulder, and underwent surgery. In 1988, the veteran underwent another surgical procedure to improve his shoulder mobility. Since that time, however, the veteran has experienced residual pain and loss of range of motion. In February 1988, the veteran was granted service connection for his right shoulder disability. An April 1988 VA medical report noted that the veteran was hospitalized after an attempted suicide, and was given a diagnosis of adjustment disorder, with depressed mood. In July 1988, the veteran was afforded a personal hearing regarding his service-connected right shoulder disability, and raised the issue that his depression was related to his shoulder surgery. He testified that he had been under the care of psychiatrist.An August 1988 VA examination for rating purposes noted that the veteran had been suffering from depression. The physician who conducted the physical examination, reported that the veteran had a status post reactive depressive personality disorder, maybe related to his continuous pain and limited mobility of the right shoulder. The psychiatric examiner noted the veteran’s reporting of several months of intermittent dysphoric periods associated with stressors, including bills coming due, the inability to work due to his right shoulder disability and pain, car troubles, and not adequately providing for his family. The examiner noted that all of those social circumstances combined to produce intermittent periods of dysphoria. The examiner gave a diagnosis of continuous alcohol abuse, adjustment disorder with work inhibition and the presence of depressive features. This is the last VA examination of record that included a psychiatric evaluation.A January 1989 VA examination report noted that the veteran had chronic pain syndrome. It was also noted that there was a 15 year history of chronic ethanol abuse, and a history of adjustment reaction with depressive state. A February 1989 VA medical report noted a diagnosis of chronic pain syndrome of the right shoulder, and reported that there was the possibility of the associated depression bearing on the pain syndrome. Private physician reports, dated from June 1992 to August 1992, noted the veteran’s medical history regarding his right shoulder and chronic pain. The reports noted diagnoses of depression and anxiety, and the August 1992 report noted a diagnosis of recurrent depression with delusions. VA outpatient treatment reports also note that the veteran continued to seek treatment for his depression and anxiety. In view of the need for an evaluation which clearly defines the nature and onset of the veteran’s depression and anxiety, and since the last VA psychiatric evaluation was conducted in 1988, the Board has determined that, the veteran should be afforded a VA psychiatric examination. The claims folder should be made available to the examiner prior to such examination. In view of the foregoing, and in order to fully and fairly evaluate the veteran’s claim, the case is REMANDED to the RO for the following development:1. The RO should obtain the treatment records from all VA and non-VA medical care providers, which are not currently associated with the veteran’s claims file. After securing the necessary release for any private records, the RO should obtain these records, and associate them with the veteran’s claims file.2. The RO should schedule the veteran for a VA psychiatric examination. The claims folder should be made available to the examiner for review prior to the examination. The examiner should give a diagnosis of each psychiatric disorder that is present. For each disorder that is present, the examiner should state a medical opinion, based on the entire medical record, as to whether it is more likely than not that the disorder is the result of the service-connected right shoulder disability.3. The RO should readjudicate the veteran’s claim for service connection for a psychiatric disability, secondary to the service-connected right shoulder disability. If the determination remains adverse to the veteran, he should be provided a supplemental statement of the case which includes a summary of additional evidence submitted, any additional applicable laws and regulations, and the reasons for the decision. The veteran and his representative should be afforded the applicable time to respond.Thereafter, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. The veteran need take no action until he is further informed. The purpose of this REMAND is to obtain additional information and to afford the veteran due process of law. The Board intimates no opinion, either factual or legal, as to the ultimate conclusion warranted in this case. G. H. SHUFELT Member, Board of Veterans' AppealsThe Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741 (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board.Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1995).- 2 -

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