RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00830
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090928

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Public Health Journeyman, medically separated for “major depressive disorder (MDD), recurrent, associated with dysthymic disorder,” with a disability rating of 10%.

CI CONTENTION:  The CI contended her mental health condition and a skin disorder.  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 on 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 - 20090629	VARD - 20100624	
Condition	Code	Rating	Condition	Code	Rating	Exam	
MDD, Recurrent, Associated with Dysthymic Disorder	9434	10%	Depression with Anxiety	9434	NSC	20100526	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Major Depressive Disorder, Recurrent, Associated with Dysthymic Disorder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s depression condition began in 2007 without a history of psychiatric trauma, although symptoms worsened after receiving a letter of counseling and in the context of her husband’s deployment.  Despite treatment, the depression condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and she was referred for an MEB.  The MEB forwarded “major depressive disorder, recurrent, moderate” and “dysthymic disorder” for PEB adjudication.
Review of the STR found that between September 2007 and February 2009, the CI was followed in the mental health clinic for depression, and treated with 17 psychotherapy sessions during that time; psychotropic medication was not used.  The enlisted performance report covering the time from 10 September 2007 through 9 September 2008 reflected “above average” overall duty performance and stated “clearly ready for promotion.”  On 17 February 2009, 7 months prior to separation, the CI was “cleared for Real World Deployment.”

On 10 March 2009, she presented to the mental health clinic with complaints of fleeting suicidal thoughts, without intent or plan, during the prior week.  She endorsed feelings of depression, sleeping difficulty, lack of energy, appetite disturbance and difficulty concentrating.  She was subsequently placed on an anti-depressant medication and a medication for sleep, and followed closely as an outpatient.  At a 2 April 2009 mental health clinic visit the same suicidal thoughts were noted to persist, and the decision was made to initiate an MEB.  One week later the CI informed her primary care doctor that the antidepressant medication was helpful stating “haven’t been feeling as depressed.”  The Mental Status Examination (MSE) stated: “Normal not suicidal.”  The antidepressant dose was increased.

The MEB NARSUM examination on 29 April 2009, 5 months prior to separation, noted that symptoms of depressed mood, lack of energy, decreased concentration and sleep disturbance improved or remitted with psychotropic medication and psychotherapy over a period of 2 years, but that a dysthymic state was always present.  The examiner stated that the CI’s symptoms “have adversely affected her job performance and have been noticed by her coworkers.”  A history of “occasional fleeting suicidal ideation” was also noted, and “recently while preparing for deployment she also entertained the idea of shooting herself while deployed.  She shared this fact with her mental health provider and the deployment was canceled.”  MSE was normal; mood was described as “ok.”  Current suicidal thinking was not mentioned.  The examiner rendered an Axis I diagnosis of major depressive disorder, recurrent, not in remission; and dysthymic disorder as manifested by insomnia, lack of energy and depressed mood.  The assigned Global Assessment of Functioning (GAF) was 60, connoting moderate symptoms or impairment.  The examiner opined that, although she had never acted on thoughts of suicide, in the long-term she was at increased risk of suicide.

The commander’s statement reported that her medical condition allowed her to perform all primary in-garrison duties without restrictions or limitations, and did not require alteration in her work schedule.  She reportedly missed no duty time due to her condition (except for appointments).  Her only limitation was the restriction from deployment.  The commander observed that the CI performed “outstanding work.” 

At a separation physical examination on 3 August 2009, 2 months prior to separation, the CI reported she was taking antidepressant medication.  She denied feeling “down, depressed or hopeless” and denied loss of interest in activities or hobbies.  Examination showed a normal mood and affect.  On the Report of Medical Assessment (DD Form 2697) dated 3 August 2009, the CI wrote that her ability to work in her military specialty was limited due to an inability “to perform contingency operations due to stress/depression.”  The Enlisted Performance Report covering the time from 10 September 2008 through 9 September 2009 reflected “above average” overall duty performance and recommended promotion.

At an initial 17 May 2010 VA Compensation and Pension (C&P) intake evaluation, performed 8 months after separation, the CI reported that she was not receiving any mental health treatment.  She stopped the sleep medication prior to separation and stopped the antidepressant medication in January 2010 (3-4 months after separation).  She ascribed the cause of her mental symptoms while on active duty to being unappreciated by her leaders and an inability to get pregnant.  She thought she nevertheless performed well while in the Service because of her strong work ethic.  She reportedly interacted well with customers, but had difficulty with some co-workers.  The marital strain she had experienced improved after 2008.  She rated her current work functioning at a 7/10 and social functioning at 8/10.  She was employed since February 2010 at a daycare facility working 30-hour weeks, and had not left work early due to emotional reasons.  Active interests included reading, watching television and crafts.  She endorsed “occasional” sleep difficulty and denied crying spells.  She denied current suicidal thoughts, but reported she did have them in early 2009, which she characterized as fleeting thoughts of “how easy it would be or would anyone miss me?”  At a continuation of the C&P evaluation a week later the CI reported that she was “doing a lot better than I was,” but still experienced motivational difficulty getting out of bed on some mornings.  She endorsed some occasional marital strain and problems making close friends “sometimes.”  She was close to her father and maintained contact with a couple of friends 2-3 times per week.  She worked out at a gym regularly.  She stopped psychotropic medications after leaving the military because she felt no need for treatment, and subsequently pursued no treatment because she “has been doing well.”  She endorsed “occasional stressful moments” at her daycare center job.  MSE was normal.  Psychological testing reportedly “does not indicate any serious psychological issues at this time.”  The examiner indicated that there was no evidence of an Axis I diagnosis or of significant psychological impairment in social or occupational functioning.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the depressive disorder associated with dysthymic disorder condition 10%, coded 9434 (major depressive disorder).  The VA declined to service-connect a psychiatric condition because there was no evidence the condition still existed.  Board members agreed that the 50% rating (“occupational and social impairment with reduced reliability and productivity”) was not described by the evidence, and deliberation settled on arguments between a 10% and 30% rating.  The §4.130 criteria for a 10% rating is “Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.”  A 30% rating requires “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.”  The Board considered that some threshold symptoms of a 30% rating were described by the NARSUM (depressed mood, sleep disturbance), and that a possible 70% threshold symptom (occasional fleeting suicidal ideation) was present.  However, it was also noted that the history of possible suicidal thinking reflected in the record (and later confirmed by the CI at the C&P exam) was limited to early 2009, was never associated with intent or plan, and did not require hospitalization.  Soon after institution of psychotropic medication in March 2009, all symptoms improved.  Meanwhile, although the NARSUM reported occupational difficulty due to her symptoms, the commander’s statement and performance reports depicted occupational functioning that was quite good.  The CI’s statement on the Report of Medical Assessment (that the only impediment to adequate work performance was an inability to deploy), and her later characterization to the C&P examiner of her functioning while on active duty, were also consistent with that assessment.  The fact that the CI could discontinue all treatment near the time of separation, yet subsequently report to the C&P examiner intact social and occupational functioning in the context of a symptom description that warranted no Axis I diagnosis led Board members to conclude that the “intermittent inability to perform occupational tasks” stipulation of the 30% rating was not present, and that the condition was best described by the 10% rating criteria.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the major depressive disorder associated with dysthymic disorder condition.

BOARD FINDINGS:  In the matter of the major depressive disorder associated with dysthymic disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150604, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXXXXXX

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00830.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,