Veterans Affairs' Problematic Evaluation of a Veteran's Claim for Service-Connected Psychiatric Disability

Carlos A. Salgado; Charles C. Dike

In Determining Service Connection for Mental Illness, the Etiology of the Psychiatric Disability Is Irrelevant

In Mann v. Gibson, 2014 U.S. App. Vet. Claims LEXIS 1048 (Vet. App. 2014), the United States Court of Appeals for Veterans Claims reviewed a 2011 decision by the Board of Veterans' Appeals (the Board), which relied on inconclusive medical opinion to deny Mr. Mann's claim for service connection of a psychiatric disorder. The court of appeals set aside the decision and remanded the case for clarification of the medical examiner's opinion or to obtain a new opinion regarding the relationship between his claimed psychiatric disorder and military service.

Facts of the Case

Leon C. Mann II served in the U.S. Air Force from June 1970 to February 1974. In May 1973, he was diagnosed with adult situational reaction (a Diagnostic and Statistical Manual of Mental Disorders, first edition (DSM I) diagnosis), which would be equivalent to an adjustment disorder in more recent versions of the DSM. In a subsequent document in October 1973, he was found “sufficiently free from mental illness, defects or derangement” (Mann, p 2) and was then deemed medically qualified for duty. Soon after his discharge from service, Mr. Mann reported a history of depression and sleep difficulties “due to service tension” (Mann, p 2). However, the evaluator documented normal findings in a psychiatric examination.

Mr. Mann's first course of legal action occurred in August 1999, 25 years after he left the service, at which time he filed a claim for service connection for a “nervous condition.” He stated that in 1971 he was hospitalized for “some type of psychosis” (Mann, p 2) after taking a hallucinogenic drug and has had psychiatric problems ever since. The Veterans Affairs (VA) regional office (RO) denied the claim as not well grounded.

In February 2001, a veterans' service organization requested that the claim be readjudicated under the recently passed Veterans Claims Assistance Act of 2000, which would require the VA to provide any information or evidence needed to support the claim, and help the claimant in obtaining any such evidence (114 Stat. 2096 (2000)). The RO took no action on the request.

In October 2005, Mr. Mann filed a claim for service connection posttraumatic stress disorder (PTSD), but the RO denied the claim because there was no confirmed diagnosis of PTSD on record. Mr. Mann filed a Notice of Disagreement, stating that he was hospitalized in June 1971 for a “mental breakdown … and has had PTSD ever since” (Mann, p 3). In April 2009, the Board “recharacterized Mr. Mann's claim as one for service connection for a psychiatric disability to include PTSD and remanded that claim for a … VA medical examination” (Mann, p 3).

After a review of the veteran's file and a psychiatric evaluation in August 2009, Mr. Mann was diagnosed with depression not otherwise specified, opioid dependence in sustained full remission, and cocaine dependence in sustained full remission. The examiner was not able to provide an opinion on the etiology of those conditions.

Once again, the Board recharacterized Mr. Mann's claim for service connection to include PTSD and depression in April 2010; another VA medical examination was conducted in October 2010. The examiner concluded that since it was “impossible to delineate whether Mr. Mann's depression … started prior to or subsequent to his substance abuse” (Mann, pp 5–6) while in service, opining on the etiology of his symptoms would be speculation. However, the examiner offered two possible hypotheses for consideration: that the substance abuse led to problems in the military and in finding a job thereafter, which contributed to his depression, or that the stress of the military caused some of his symptoms of depression, which, in turn, may have led to substance abuse. The examiner diagnosed Mr. Mann with depressive disorder, not otherwise specified, and opioid dependence in remission.

In December 2011, the Board denied Mr. Mann's claim, because the October 2010 medical examiner could not provide a conclusive opinion on the etiology of Mr. Mann's psychiatric disorder and because of the lack of “competent and credible evidence linking any psychiatric condition to service” (Mann, p 7). Mr. Mann subsequently appealed the decision.

Ruling and Reasoning

The appeals court held that the October 2010 VA medical opinion was inadequate because the examiner did not explain why he was unable to assess the likelihood that Mr. Mann's depression was related to service without resorting to speculation. The Board therefore erred in relying on it. The court noted that in order for a medical opinion to be considered adequate, it must be based on consideration of a veteran's prior medical history and examinations, and also [describe] the disability in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one…. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two [Mann, p 9].

The court noted that the October 2010 medical examiner's stated purpose of the examination was “to attempt to determine whether Mr. Mann's claimed psychiatric illnesses were at least as likely as not related to his active service in the Air Force” (Mann, p 9). The court then wondered why the examiner could not provide a nonspeculative opinion despite having “affirmatively identified two possible causes for the veteran's depression, both service related” (Mann, p 11) without alluding to any non–service-related cause.

Accordingly, the court concluded that the Board erred in relying on the October 2010 VA medical opinion, and subsequently directed the Board on remand, to “seek clarification of the October 2010 VA opinion or obtain a new opinion addressing the relationship between Mr. Mann's claimed psychiatric disabilities and service” (Mann, pp 13–4).

Discussion

This case highlights two considerations critical to all forensic psychiatric evaluations: what is the purpose of the evaluation, and what are the points to be addressed? In addition, the case raises concerns regarding the adequacy of collateral materials or information sought and reviewed. The Board asked the medical examiners to opine whether Mr. Mann's symptoms and subsequent disability were service connected. This question requires two inquiries: did Mr. Mann have a psychiatric disability during service, and what constitutes service connection?

In answering these questions, the medical examiners conducted a psychiatric evaluation of Mr. Mann and reviewed his veteran's file. It is not clear what Mr. Mann's file contained, but neither of the two medical examiners discussed Mr. Mann's adult situational reaction. What exactly were the symptoms he reported for which he received the diagnosis? Also, following another evaluation five months after his diagnosis of adult situational reaction, Mr. Mann was found to be sufficiently free of mental illness or defect to be deemed medically qualified for duty. The statement suggests he had been deemed medically unfit for duty following his diagnosis of adult situational reaction and that being cleared for duty did not require that he be completely free of mental illness. Therefore, careful reading of his record around this time would be crucial in answering the question of the presence of psychiatric disorder during service. It would be important to note his level of functioning during that period and at other times during his service.

Further, Mr. Mann reportedly gave a history of depression upon separation from the military. If so, did the history of depression occur during service? There was no description of records related to that psychiatric evaluation. Finally, there was no mention of collateral information from Mr. Mann's relatives or military colleagues to corroborate or refute his complaints of mental illness during service.

With regard to service connection, under 38 U.S.C. § 1110 (2009), service connection is established when there is a disability resulting from injuries sustained or diseases contracted in line of duty or for aggravation of a preexisting injury. Although the stress of military service or combat could lead to psychiatric disability, service-connected disability refers only to development of psychiatric disability while in military service; it is not necessary to establish a causal relationship between stress of service and psychiatric disability. Surprisingly, the VA medical examiners focused their opinions regarding service connection on being able to identify the etiology of the psychiatric disability rather than on the mere presence of mental illness during service.

Unfortunately, 40 years after Mr. Mann's discharge from service and 15 years after he first filed a claim for service connection, his case remains unresolved.