RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02480
BRANCH OF SERVICE:  Coast Guard 	SEPARATION DATE:  20080228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Marine Science Technician Second Class, medically separated for “bipolar disorder,” with a disability rating of 10%.

CI CONTENTION:  The CI contends his condition continues to impact his daily living and request consideration of all conditions.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

SERVICE PEB - 20070731	VARD 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder	9432	10%	No VA Examinations in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Bipolar Disorder.  According to service treatment records and the mental health Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 25 October 2006, and updated on 8 January 2007, the CI’s Bipolar disorder began with depressed mood for at least 2 years.  He reported depression symptoms of depressed mood, decreased appetite, energy, concentration and sleep, social withdrawal, loss of interest and pleasure, without suicidal ideation (SI), alternating with periods of more energetic moods, requiring less sleep.  The CI reported a history of illicit drug use and alcohol abuse before enlisting in the military.  The MH examiner referenced notes in the record which showed concern for heavy drinking, but the CI reported a period of several weeks of abstinence and an interest in continued abstinence due to his medications.  In October 2006 he was taking an antidepressant medications for mood and sleep (Zoloft and trazadone).  At a psychiatric visit in November 2006 Lamictal was added to help with mood fluctuations.  The diagnoses were major depressive disorder, recurrent, moderate and polysubstance dependence, in early remission.  The psychiatrist indicated that in October 2006 neither condition was necessarily disabling for full duty and his medications did not disqualify the CI from shore duty.  After the holidays in December 2006, the CI became depressed and called crisis management after drinking alcohol.  He reported he was not suicidal, but “wanted to talk to someone.”  He was evaluated by a civilian psychiatrist and diagnosed with “Mood disorder, not otherwise specified and Chemical dependency.  He was entered into a partial hospitalization program (PHP) on 29 December 2006.  His medications were adjusted and he was taking Zoloft, trazadone, Lamictal, and Abilify.  Following the PHP which the CI continued in an Intensive Outpatient Program (IOP).  In the MH MEB NARSUM update interview the CI reported that he thought “depression was causing the drinking” and noted that his most recent drinking occurred while he was depressed.  The MSE noted a “moderately depressed” mood and congruent affect.  There was no suicidal ideation, evidence of delusions or hallucinations (or other symptoms suggestive of psychosis), speech disturbance, cognitive impairment or other abnormalities.  The diagnosis was changed to bipolar disorder, Type II, depressed phase, and polysubstance dependence with episodic drinking behavior.  The MEB psychiatrist indicated the CI’s depression had worsened and he was in a PHP.  The CI was determined to be psychiatrically not fit for duty.  The psychiatrist offered the medical opinion that the Bipolar II disorder existed independently of the alcohol and drug issues and noted that each condition likely aggravated the other.  The CI was advised to continue abstinence from alcohol and drugs “to maintain some remission of his depressive symptoms.”  The MEB forwarded “bipolar disorder, Type II, depressed phase” and “polysubstance dependence with episodic drinking behavior” for PEB adjudication.  

The MEB NARSUM examination, written on 10 April 2007, noted the CI continued in the IOP program 3 days per week.  The CI evidenced no psychotic symptoms and denied SI/HI.  The MEB NARSUM agreed with the MH diagnoses and indicated the CI was not fit for duty.  A commander’s statement (endorsement of the medical board) enclosed in the MEB package indicated the CI’s duty performance was impaired due to medical appointments and “continuing questionable medical status” due to both bipolar disorder and polysubstance dependence.  Multiple MH notes after the MEB NARSUM and before separation indicated the CI continued with variable mood despite psychotropic medications, often with reported symptoms of depression.  On serial MSEs, all but one noted sad, depressed, at times anxious moods and were otherwise normal.  Intermittently, the CI was noted to have rapid speech and/or be hypervigilant and hyperactive, though controlled.  At one examination, the CI was noted to be happy with at times “mania” that he was controlling by using coping skills to relax himself.  In a letter to the military dated 1 June 2007 the CI’s treating MH provider indicated the CI was attending a PHP 5 days per week, participating in four group sessions per day to maintain structure for stability of his condition.  The MH provider expanded, saying the CI had “a dual diagnosis of a psychiatric disorder with alcohol abuse/dependence” and he would “self-medicate with alcohol when his mood disorder, NOS symptoms…became more than he could handle.”  MH notes in record during June 2007 indicated the CI alternated between sad, depressed moods and happy, stable mood (mainly depressed- 6/7 visits), despite medication compliance, which he was managing with behavioral methods.  There was no documentation of alcohol relapse.  The PEB requested additional information from the CI’s MH provider.  In the response dated 11 July 2007, the CI was noted to have multiple persistent depression symptoms and experienced panic attacks under stress.  The MH provider indicated his job stability was “extremely unstable” and social functioning was described as borderline impaired.  The CI needed frequent psychotherapy and had occupational and social impairment with occasional decrease in efficiency and intermittent periods of inability to perform occupational tasks.  Elsewhere in the same response, the MH examiner indicated that the CI’s symptoms were controlled by continuous medication, but he still lacked the ability to perform consistently. 

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the bipolar disorder 10%, coded 9432 (bipolar disorder).  The CI appealed the PEB findings and the PEB response indicated that the rating was based on the fact that the CI was stable on his medications.  In an “Amplifying statement” the PEB stated “If member can maintain sobriety his symptoms are continuously controlled with medication and psychotherapy.”  In response to the CI’s request for reconsideration, the PEB response dated 11 June 2007 stated that “member has had three evaluations by military Psychiatrist in the past year without a change in his diagnosis or ongoing treatment plan.”  The CI appealed the PEB findings to the Formal PEB and requested a 30% rating for bipolar disorder IAW VASRD 4.130.  The FPEB upheld the PEB findings.  The CI did not apply for VA disability benefits and there are no VA records after separation.  

While the USCG diagnosis and diagnosis of civilian MH providers noted above differed slightly at separation (Bipolar disorder, Type II , Mood disorder, NOS), rating under §4.130 is based on overall occupational and social impairment due to mental health symptoms and not based on any specific MH diagnosis and both these diagnoses are classified as mood disorders.  The Board noted that there was no traumatic event causing the unfitting MH condition and therefore concluded that application of VASRD §4.129 was not appropriate in this case.  

The Board noted that MEB psychiatrist indicated that the CI had two independent diagnoses, which likely aggravated each other and recommended abstinence “to maintain some remission of his depression symptoms,” which the Board interpreted as meaning alcohol and drug abstinence was necessary, but not necessarily sufficient, for the CI to experience periods of absent or decreased psychiatric symptoms.  There was evidence in record that the CI continued with difficult to manage mood swings despite medication, and some evidence documented that he did at times experience alcohol related relapses secondary to increased depression symptoms.  The evidence above shows that the CI did have a diagnosis change by the military psychiatrist between October 2006 and January 2007, medications were continuously changed and/or dosages adjusted within 12 months of the PEB response dated 11 June 2007.  The record also indicates that in this same time frame the CI was entered into the PHP and transitioned to the IOP.  The CI was noted to be attending three times per week in April 2007, but in June 2007 he was noted to be attending the PHP five times per week, which appeared to the Board to an intensification of his treatment requirements.  The CI’s MH condition was being maintained in a highly structured environment, with psychotropic medications, and frequent, nearly daily, MH contact with group and individual counseling.  In the Board’s opinion, it is clinically impossible to separate out the psychiatric impairment due to alcohol/substance abuse from the impairment due to the bipolar d/o.  Furthermore, the evidence does not support that the CI was well controlled on medications even in periods of abstinence from alcohol.  

All Board members agreed that IAW VASRD 4.130, the disability due to the CI’s MH condition exceeded the 10% rating, specified as “occupational and social impairment due to mild or transient symptoms which decrease work efficiency … only during periods of significant stress, or; symptoms controlled by continuous medication.”  There was evidence of continued MH symptoms of mood swings with anxiety at times.  The CI was not suicidal or homicidal and there were no delusions, hallucinations or other symptoms suggestive of psychosis, speech disturbance, objective cognitive impairment, or other abnormality.  The Board consensus was that with treatment, at the time of separation, even when not using alcohol, the disability picture due to the psychiatric symptoms was most nearly approximated by the 30% rating, specified as “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily …)”; referencing typical symptoms of depression, anxiety, suspiciousness, panic attacks (≤ weekly), sleep disturbance, and mild memory loss.  The Board did not find evidence for a higher rating of 50% specified as “occupational and social impairment with reduced reliability and productivity,” without such typical symptoms such as stereotyped speech, frequent (> weekly) panic attacks, deficits in comprehension and memory, impaired judgment which help to discriminate between the 30% and 50% ratings which have overlapping symptoms.  Therefore, the Board concluded a 30% rating was appropriate.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the bipolar disorder.  

Contended PEB Conditions:  Polysubstance Abuse With Episodic Drinking Behavior.  Alcohol and substance dependence are conditions not constituting a physical disability IAW DoDI 1332.38, 
Enclosure 5 and they are not eligible for rating.  The Board therefore has no reasonable basis for recommending an additional rating for this condition.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bipolar disorder condition, the Board unanimously recommends a disability rating of 30%, coded 9432 IAW VASRD §4.130.  In the matter of the contended polysubstance dependence, with episodic drinking behavior condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Bipolar Disorder	9432	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140623, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Commandant
United States Coast Guard	Mail Stop 7907

	

Dear XXXXXXXXXX,
I am the Designated Decision Authority for the Coast Guard on applications submitted to the Department of Defense Physical Disability Board of Review (PDBR).  Under the authority of Title 10, United States Code, section 1554a, I accept the PDBR’s recommendation in your case (Case Number PD-2014-02480) and hereby modify the disability rating previously assigned to reflect a rating of 30% and re-characterization of your separation to permanent disability retirement. This decision will be effective as of the date of your prior medical separation.  Please allow up to ninety (90) days for the corrections to be made. 

Please note, if you received a lump-sum or other payment of back pay and allowances at separation, your disability retired pay may be reduced to take into account receipt of such lump-sum or other payment.  Please contact the Coast Guard Pay and Personnel Center at  for questions relating to retired pay matters. 

Enclosed for your information are a copy of the PDBR’s recommendation and a copy of the record of proceedings. 

A copy of this decision has also been provided to Coast Guard Enlisted Personnel Management Branch, the PDBR, and the Department of Veterans Affairs. 

If you have any further questions, please contact the Coast Guard Personnel Service Center at. 
	Sincerely,
2 Enclosures		
	
Copy:	CG Personnel Service Center (EPM-1)
DoD Physical Disability Board of Review
Department of Veterans Affairs