RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04026
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050807

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Indirect Fire Infantryman, medically separated for “major depressive disorder associated with symptoms similar to posttraumatic stress disorder, chronic,” with a disability rating of 0%.

CI CONTENTION:  The CI makes no specific contention in his application.  His 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 - 20050525	VARD - 20070717	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	0%	Post-Traumatic Stress Disorder	9411	30%	20070321	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY: 

Major Depressive Disorder.    The CI deployed to Iraq from March 2003-March 2004.  The CI reported combat exposures and development of insomnia, increased startle response, hypervigilance and nightmares of combat in September 2003.  Symptoms persisted upon redeployment, including 3-4 nightmares per week involving traumatic events.  He came to the attention of mental health in July 2004 after completing a post-traumatic stress disorder (PTSD) screening form that was positive for many symptoms of PTSD.  He reported his performance declined after redeployment.  He reported a past suicide attempt involving an overdose of Dramamine during high school at age 18.  He did not seek help but was feeling depressed and uncertain about his future.  The CI was evaluated by a psychiatrist in Italy and referred for inpatient admission due to suicidal thoughts.  He was transferred and admitted to Walter Reed on 8 August 2004.  

At the September, 2004 narrative summary (NARSUM) examination, the CI reported depressed mood with associated weight loss of 15 pounds, loss of appetite, low energy, poor sleep and poor concentration.  He had a recent history of self-mutilation, as reflected by new superficial lacerations and several self-inflicted healing cigarette burns, noted on admission to Walter Reed.  Mental status exam (MSE) showed depressed mood, restricted affect, slight psychomotor agitation and a denial of suicidal ideation.  He was treated with psychotherapy and anti-depression and anti-anxiety medication.  He was discharged to medical holding on 13 August 2004 with follow-up with continuity services on another ward.  He was taking two medications for sleep, and an anti-depression and anti-anxiety medication.   A diagnosis of PTSD and major depression were rendered with a Global Assessment of Functioning (GAF) score of 40 (deficiencies in most areas.)  The commander’s statement, dated January 2005, denied the CI had any significant combat exposures, that he tested positive for a controlled substance in July (year unstated), and that he be discharged without benefits.  A psychiatric addendum dated March 2005 noted his condition did not impair his social adaptability and industrial adaptability was listed as definite and mild, due to his underlying personality structure.  He could hold any job as a civilian.  At the psychiatric consultation dated 18 August the CI reported the anti-depressants made him aggressive, angry, and made his heart beat fast so he stopped the medication about 4 months previously.  He had multiple night awakening and depression symptoms.  MSE revealed the CI could not identify any activities that gave him satisfaction.  He reported being preoccupied with death but denied suicidal/homicidal ideation.  During a preventive health examination the previous day he reported nightly nightmares, no employment, and living with his parents.   He noted the transition home had been very stressful.  Diagnoses of PTSD and major depressive disorder (MDD) were rendered with a GAF score of 45 (severe symptoms, impairment.)  Service treatment records (STR) dated November 2005 noted the CI had lacerated his right anterior wrist the day after an episode of severe depression.  

At the VA Compensation and Pension (C&P) examination performed 20 months after separation the CI reported he had taken an overdose of sleep and pain pills in November 2005 and was treated in the emergency room.  He had problems with sleep, nightmares off and on, had vague suicidal and homicidal ideation and had flashbacks about Iraq.  He had seen a counselor a few times but was not taking his psychotropic medicines regularly.  He was living with his parents and mainly stayed at home since he did not feel like talking to anyone.  He did work out, go jogging and did some housework.  He was drinking off and on and had received a misdemeanor after leaving the scene of an accident.  A diagnosis of PTSD was rendered with a GAF score of 65 (mild symptoms, impairment.)  The examiner noted there was a 50/50 probability that his psychiatric symptoms were due to service conditions in Iraq.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a disability rating of 0%, coded 9434 (MDD) due to mild industrial adaptability and ability to hold a job as a civilian.  The PEB noted the MDD was associated with symptoms similar to PTSD, treated and improved, due to service in Iraq.  The VA assigned a 30% disability rating under code 9411 (PTSD) based on the C&P examination 20 months post-separation.  Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130 general rating formula for mental health conditions.  The Board agreed the CI met criteria for 4.129 and then considered if there was evidence for a §4.130 rating higher than the §4.129 minimum mandated 50% at time of TDRL placement.  The Board agreed that the §4.130 criteria for a rating higher than 50% were not met near the time of separation, and therefore the minimum 50% initial TDRL rating is applicable.  The most proximate source of comprehensive evidence on which to base the permanent rating recommendation in this case is the psychiatric consultation examination performed 11 days after separation.  This exam confirmed the presence of symptoms of PTSD and MDD at the time of separation.  The C&P examination 20 months later provided some important historical context, specifically that the CI was seen in the emergency room 3 months after separation for treatment of an overdose due to severe depression.  He had remained symptomatic since separation and had never been employed.  He had lived at home since separation, had few activities, and remained isolated.  Board members therefore concluded that the 50% rating most accurately depicted the condition at the time of removal from TDRL.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 50% for 6-months of constructive TDRL and a 50% permanent rating thereafter for the MDD condition. 

BOARD FINDINGS:  In the matter of the MDD condition, the Board unanimously recommends a disability rating of 50%, coded 9411 IAW VASRD §4.129 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent separation rating of 50% IAW VASRD §4.130.  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, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Major Depressive Disorder	     9434	 50%	        50%	

The following documentary evidence was considered:

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

AR20160011791, 

Dear:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to constructively place you on the Temporary Disability Retired List (TDRL) at 50% disability for six months effective the date of your original medical separation for disability with severance pay and then following this six month period re-characterize your separation as a disability retirement with the combined disability rating of 50%.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The constructive TDRL period and the re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing you 50% retired pay for six months from the date of your original medical separation and then 50% disability retired pay effective the date following the constructive six month TDRL period, minus the amount of severance pay you were previously paid at separation.

The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S.
Defense Finance and Accounting Service to make the necessary adjustment to your
pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

Enclosure