RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01301
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090527

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Security Forces Journeyman, medically separated for “major depressive disorder [MDD], recurrent,” rated 10%.

CI CONTENTION:  The CI requests that all conditions be considered.  Her complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel's scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the panel for Correction of Military Records.  Furthermore, the panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’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 panel 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 panel 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 - 20090113	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
MDD, Recurrent…	9434	10%	VA Claim Filed 6 Years Post-Separation	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Major Depressive Disorder (MDD).  According to the service treatment records and the Medical Evaluation Board (MEB) mental health (MH) narrative summary (NARSUM), the CI sought treatment for her symptoms of depression and anxiety, consistent with MDD and panic disorder, in May 2007.  At the time of presentation, she reported difficulties with sleep, decreased energy and concentration, increased appetite, sad mood, distractibility, increased guilt associated with feelings of inadequacy, tearfulness and hopelessness.  She also reported passive suicidal ideation and panic attacks.  The CI’s condition was treated with medication and talk therapy, and her condition improved enough for her to deploy in November 2007.  In July 2008, the CI returned to MH, noting that her deployment had gone well, and that her condition had improved and stabilized during deployment.  She decided to discontinue her medication because she felt better.  In August 2008, she was admitted to the psychiatry inpatient unit after she made superficial cuts to her wrist with a pen-knife and expressed suicidal ideation.  Although her condition improved with treatment, she was referred to the MEB.

At the MEB examination on 10 October 2008, approximately 7 months before separation, the CI related that after she returned from deployment, she had two panic attacks, one occurred at work and the other while on a 30-day leave.  She was re-started on antidepressant medication for her symptoms of depression and panic attacks.  In the first week of August 2008, she presented to the emergency room (ER) after cutting her wrist with the intention to “kill myself so that I could end the pain.”  Her cuts were superficial.  For safety reasons, she was admitted to the hospital where she remained for 3 weeks.  She was discharged to outpatient care and continued to take her medication.  The CI also noted that her depression began in 2007, brought on by social isolation and the unpredictability and absence of a structured work environment.  She noted that she had done well in environments where there were regular social interactions, routine and predictable schedules, and structure such as she experienced during her deployment.  She was able to discontinue her medication during deployment because her depression had improved and resolved.  The CI attributed the resolution of her depression to having structure and social interactions.  However, after returning from deployment, the same stressors that originally contributed to her depression returned -- social isolation and absence of structure; and she once again found herself becoming depressed and hopeless, leading to her hospitalization.  The examiner noted that the CI had not had a panic attack since hospitalization and was not required to use abortive medication to treat panic attacks as needed.  All of her depressive symptoms had improved with the exception of chronic insomnia, which appeared to have been resistant to treatment.  It was noted that prior to her hospital discharge, her treatment team had met with her commander who expressed support and expectation for her to return to full duty.  The commander reportedly mentioned that the CI’s name was on the promotion list and she had been awarded “dorm room of the quarter.”  The mental status examination (MSE) was unremarkable.  

The diagnoses of MDD, recurrent, in partial remission, and panic disorder without agoraphobia were recorded, and a Global Assessment of Functioning (GAF) score in the very mild range was noted.  The examiner documented that the CI’s mood symptoms had significantly improved with medication and other behavioral interventions and that she should remain on antidepressant medication for at least 12 months to minimize risk of relapse.  There were no further treatment entries in the STR with the exception of a note dated 22 October 2008 that recorded the pharmacy was unable to fill the CI’s prescription for sleep medication. No other MH symptoms were recorded and the CI indicated that she was receiving adequate MH treatment.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the condition of MDD, recurrent, associated with panic disorder without agoraphobia, at 10%, coded 9434. The VA did not receive a claim until March 2014 (6 years after separation), granting an evaluation effective 31 March 2014.  The Board first considered whether the application of VARSD §4.129 was applicable in this case.  In accordance with VASRD §4.129, when a mental disorder that develops in service as a result of a highly stressful event is severe enough to bring about the CI’s release from active military service, the rating agency should assign an evaluation of not less than 50% and schedule an examination within the 6-month period following the veteran’s discharge to determine whether a change in evaluation is warranted.  All Board members agreed that the preponderance of evidence did not support the application of §4.129. 

The Board next proceeded with its rating recommendation under VARSD§ 4.130 based on the evidence. Regardless of the diagnosis, 4.130 rating is based on symptoms independent of diagnosis, therefore, all MH symptoms were considered in the rating.  The higher rating of 30% requires evidence of “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks” due to  such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events.  The Board noted that although the CI was hospitalized for 3 weeks in 2008, evidence of additional hospitalizations or visits to the ER in the 5 months before separation was absent.  There was no recorded report of suicidal ideation or panic attacks beyond the incident which led to hospitalization.  The NARSUM noted the CI was not taking medication for panic attacks, and that her only remaining symptom of chronic insomnia, was the focus of continued treatment.  Her MSE was normal.  The examiner noted that although the CI’s condition of depression was in partial remission she would need to continue her antidepressant to decrease the risk of relapse.  There was no additional evidence in the STR.  The Board members agreed, there was insufficient evidence to justify the higher rating of 30%.  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 MDD condition.  

BOARD FINDINGS:  In the matter of the major depressive disorder, recurrent, associated with panic disorder without agoraphobia and IAW VASRD §4.130, the Board 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 20150608, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01301.

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,

Attachment:
Record of Proceedings