The Question at the Heart of Every Mental Health Claim
When a veteran files a claim for a mental health condition, the VA needs to answer one
fundamental question: is this condition connected to military service? Establishing that
connection, what VA law calls service connection, is the threshold that determines whether
a veteran receives compensation.
For many veterans, the VA’s own C&P exam does not adequately answer that question.
The exam may be too brief, the examiner may lack forensic expertise, or the opinion may
simply be inadequate. An independent forensic psychologist can provide a more thorough,
well-documented opinion, but what does that process actually involve?
Three Things That Must Be Present
Before a meaningful nexus opinion can be offered, three elements need to exist in the record:
1. A Current Diagnosis
The veteran must have a recognized mental health condition, such as PTSD, major depressive
disorder, generalized anxiety disorder, or another condition defined by the DSM-5. A diagnosis
is a clinical conclusion based on specific criteria, not simply a report of symptoms or distress.
2. An In-Service Event, Stressor, or Injury
Something must have occurred during military service that is relevant to the diagnosed condition.
For PTSD, this is typically a traumatic event meeting the DSM-5 Criterion A standard. For
depression or anxiety, it might be chronic operational stress, a traumatic loss, a physical injury,
or prolonged exposure to difficult circumstances.
3. A Medical Nexus
A qualified clinician must connect the in-service event to the current diagnosis with a reasoned
professional opinion, stated to the VA’s evidentiary standard of
at least as likely as not.
How the Records Review Informs the Opinion
The foundation of any credible nexus opinion is a thorough review of the available record.
Dr. Howard reviews service records, VA treatment records, private mental health and medical
records, prior C&P examination reports, rating decisions, buddy statements, and any other
relevant documentation before forming an opinion.
This review serves several purposes. It establishes the timeline of when symptoms first appeared
and how they have progressed. It identifies documented references to in-service events or stressors.
It reveals what prior examiners found and where their conclusions may have been incomplete or
inaccurate. And it surfaces any alternative explanations for the veteran’s current condition that
need to be considered and addressed.
How the Clinical Interview Contributes
The records review tells Dr. Howard what is documented. The clinical interview tells him what
actually happened from the veteran’s perspective. A structured forensic interview covers the
veteran’s full history, including developmental background, family history, educational and
occupational history, military experiences, and current symptoms, in sufficient depth to build
a complete clinical picture.
This is important because the connection between a service experience and a current mental health
condition is not always visible in the official record. Veterans frequently do not seek mental
health care during service. Stressors may not be formally documented. Symptoms may have emerged
gradually over years following discharge. A thorough clinical interview allows Dr. Howard to assess
the relationship between what a veteran experienced and what they are living with now, even when
the paper trail is incomplete.
What Dr. Howard Considers When Forming a Nexus Opinion
Forming a nexus opinion requires weighing multiple clinical and evidentiary factors. These include
the nature and severity of the in-service stressor, the type of condition being diagnosed and what
the research says about its causes and risk factors, the timing of symptom onset relative to service,
the consistency of the veteran’s reported history across different records and sources, the presence
or absence of pre-service risk factors or alternative explanations, and the overall coherence of the
clinical picture when all available evidence is considered together.
Where relevant, Dr. Howard also references the peer-reviewed psychological and medical literature
supporting the relationship between the type of stressor the veteran experienced and the condition
being diagnosed. A well-reasoned nexus opinion is not simply a clinical judgment. It is a documented
argument that connects the evidence to the conclusion in terms a VA rater, a Veterans Law Judge, or
a court can follow and evaluate.
What the Opinion Actually Says
A nexus opinion is not a guarantee of service connection or a prediction about how the VA will rule.
It is a professional statement of clinical probability, expressed to the VA’s required evidentiary
standard: that the condition is at least as likely as not
related to military service.
That phrase has legal significance. It means the clinician believes the probability of a service
connection is 50 percent or greater. It is the threshold the VA requires, and an opinion that falls
short of it, using language like could be related
or may be connected
, is generally
given little weight.
Dr. Howard’s opinions are written to meet that standard explicitly, with the reasoning documented
in sufficient detail that the basis for the conclusion is clear and the opinion can withstand
scrutiny at every level of the VA appeals process.
When the Evidence Does Not Support a Nexus
An independent evaluation is not a guaranteed favorable opinion. Dr. Howard’s role is to document
what the evidence actually supports. In cases where the clinical record does not support a nexus
between a veteran’s service and their current condition, Dr. Howard may provide an oral report of
his findings to the veteran and allow the veteran and anyone supporting them in their claim process,
such as a VSO or attorney, to determine whether a written report is desired.
This approach protects the veteran from having an unfavorable written opinion in their file while
ensuring they receive an honest and complete account of the clinical findings. That honesty is also
what makes a positive opinion credible when the evidence does support it.