RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02079
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20011011

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Airmen, medically separated for “major depressive disorder” with a disability rating of 10%.   

CI CONTENTION:  The CI made no specific contention.  The 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 Board 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 determination 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 progression or complications of service-connected conditions after separation.  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 - 20010608	VARD - 20030214	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	10%	Schizo-Affective Disorder	9211	70%	20020405	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70% 	

ANALYSIS SUMMARY:    

Major Depressive Disorder.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mental health (MH) condition began in January 2000.  The CI reported the emergence of depressive symptoms that consisted of almost daily depressed mood, decreased appetite, insomnia, decrease interest in pleasurable activities, and suicidal ideation (SI).  The CI also had a history of childhood sexual trauma, and was being treated for alcohol dependence.  The CI underwent three MEB examinations and 2 months prior to the second NARSUM, he had full duty endorsement.  At the time of the first MEB, the NARSUM dated June 2000 stated the CI was in early full remission of alcohol, and was being treated with anti-depressant medication for his depression.  It was recommended that he be placed on 8 months of limited duty, stationed in CONUS near an MTF with MH treatment available.  

During the 19 December 2000 MEB NARSUM examination, 10 months prior to separation, the CI was a patient on the inpatient psychiatry acute unit after he expressed SI.  It was noted that he had initially been referred to psychiatry for SI in the context of the break-up with his fiancé about 2 weeks prior.  He also reported financial problems, and stress over not being able to obtain his “C” school (the CI was enrolled in the Navy school), and dissatisfaction with his career in the Navy.

While on the inpatient unit, the CI participated in all activities, complied with the rules, took his medications, and his mood and affect reportedly improved slightly and he reported improved sleep and appetite.  He had no history of psychosis.

At the final MEB NARSUM examination dated 1 February 2001, 8 months before separation, the CI was again evaluated as an inpatient on the acute psychiatry unit, where he was admitted from 10 to 28 January 2001.  He had expressed SI in the context of occupational problems.  The CI had just been discharged from the inpatient unit 3 weeks prior to the current admission as noted above (19 December NARSUM).  In between the admissions, the CI made several suicidal gestures that consisted of cutting on his arm and picking at a suture site on his hand.  The NARSUM examiner reported that during the course of the January hospitalization, the CI, after discussing discharge plans, became extremely angry and punched a hole in the wall of his room.  After that incident, he reported that he was acutely suicidal.  This became an intermittent pattern of behavior.  He did in fact used a razor to cut himself, which required suturing.  During hospitalization, his medications were adjusted and he reported some improvement in symptoms, specifically his anxiety, depressed mood, and mood lability.  At the time of discharge, he was not suicidal, homicidal or psychotic.  The mental status examination (MSE) documented in the NARSUM reflected his status at the time of admission.  There was no evidence of a discharge MSE.  The CI was discharged directly into alcohol rehabilitation treatment program.  His diagnoses included MDD, recurrent, alcohol dependence, and borderline personality disorder.  The CI was admitted to the addiction rehabilitation program on 29 January, and was discharged on 8 February for being “unamenable to treatment.”  Treatment records fell silent after separation until the VA examination.

At the April 2002 VA Compensation and Pension (C&P) mental evaluation, 6 months after separation, the CI reported he was diagnosed with MDD with psychotic features and borderline personality disorder.  The examiner documented current treatment at the VA for schizophrenia.  The examiner stated that the CI has had three admissions to the VA for schizophrenia and SI during the current year (between January and February 2002) and was receiving day treatment for the past couple of months.  The CI reported he had attempted to work as a salesperson at a department store in December 2001 but left after a couple of weeks due to paranoia.  The examiner wrote, “Patient reports frequent auditory hallucinations up to the current moment, describes paranoid ideation, the last occurred last night.”  He believed at times that people were trying to hurt him and he hears voices telling him to kill himself.  He had problems with sleep, and had limited social interaction.  MSE recorded depressed mood and flat affect.  He was fully oriented.  Evidence of psychosis during the examination was absent.  Insight and judgment were not noted to be impaired.  The examiner stated that the CI reported he has had auditory hallucination since age 19.  The examiner wrote, “His [CI] overriding diagnosis appears to be that of paranoid schizophrenia.”  The diagnosis of depression was not assessed, and his alcohol dependence was noted as “several month reported remission.”  A Global Assessment of Functioning (GAF) score of 50 (borderline of serious to moderate symptoms and or impairment) was noted.  The diagnosis of schizoaffective disorder was rendered.  Post-separation treatment record in November-December 2002 showed that the CI participated in group therapy at the local VAMC, where he was noted to have participated adequately in sessions, and had described his mood consistently as “good” over the period of 2 months.  However, he was again hospitalized in February 2003 secondary to psychotic symptoms that included hearing voices telling him to hurt himself.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MDD condition 10%, coded 9434 (MDD).  The VA rated the condition of schizoaffective disorder 70%, coded 9211 (schizoaffective), based on the C&P examination 6 months after separation. The panel, IAW DoDI 6040.44 and DoD guidance considered if the definition of §4.129 was met for any psychiatric condition resulting in medical separation; i.e., “a mental disorder that develops in service as a result of a highly stressful event.”  All panel members agreed, §4.129 was not applicable in this case.  The panel next proceeded with its rating recommendation under VARSD§ 4.130 based on the evidence.

The record demonstrated, that the CI had three hospitalizations for SI before separation.  The last admission occurred 10 months before separation.  He was admitted on 29 January 2001 to a residential addiction rehabilitation program for alcohol dependence upon discharge from the psychiatry inpatient.  The CI was then discharged from the program on 8 February for being “unamenable to treatment.” The STR fell silent over the following 6 months.  The C&P examination noted that he had three hospitalizations within 3 months after separation, and all three were the result of psychosis.  The panel noted the absence of documented psychotic symptoms in the STR prior to separation.  In fact, all three MEB examinations specifically indicated that psychotic symptoms were absent.  At the time of separation, the CI’s symptoms had taken on a pattern of intermittent SI, generally in response to specific stressors that resulted in hospitalization.  He demonstrated the ability to have stable periods of time, indicated by the absence of hospitalization or visits to the ER in the 8 months before separation.  In the review of the 2001 NARSUM, the panel noted the absence of a MSE upon discharge from acute hospitalization.  He was transferred directly to rehab, and therefore, would have been considered stable for transfer, and no longer suicidal.  However, his condition going forward until the C&P examination was largely unknown, except that he had no additional hospitalizations in the 8 months before separation.  The C&P examination suggested that his condition deteriorated in the 3 months after separation, with new-onset symptoms.  According to the C&P examination, there were three hospitalizations in the 3-4 months after separation due to psychotic symptoms and command hallucinations.  However, active psychotic symptoms were not present during the C&P examination, and again, he had no prior documented history of psychosis.  Findings on the examination were poor sleep, little social interest, and a history of hearing voices that began at age 19.  A formal MSE was not conducted; however, it was noted that the CI was not psychotic or delusional during the evaluation, but he had flat affect.  The examiner acknowledged that the CI may have exaggerated his symptoms.  Panel members considered the absence of hospitalization in the 8 months before separation, the absence of a legal history or a history of violence towards others, the impulsiveness that led to hospitalizations in response to interpersonal conflict, and the absence of psychotic symptoms while in service, and the CI’s partial response to medication.  Panel members agreed that his condition warranted a higher rating.

The 30% description (“occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks”) better reflected his condition, since the evidence clearly demonstrated his condition was not mild or transient, and was not controlled by medication.  All panel members agreed that the 30% disability level was supported by the evidence.  After due deliberation, and in consideration of all the evidence and VASRD §4.3 (reasonable doubt), the panel recommends a 30% disability rating for the condition of MDD.  

BOARD FINDINGS:  In the matter of the major depressive disorder condition, the panel majority recommends a disability rating of 30%, coded 9434 IAW VASRD §4.130.  The single voter for dissent recommends modification to 50% and elected not to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Major Depressive Disorder	9434	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161024, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 13 Oct 17 ICO XXXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXXX  
	(d) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 11 Apr 17 ICO XXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 16 Jun 17 ICO XXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 25 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXXX 

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXXX, former USN: Placement on Temporary Disability Retired List with a 60 percent disability rating for six months at time of separation followed by a permanent disability rating of 20 percent.

     f. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 0 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on Temporary Disability Retired List with a 50 percent disability rating for six months at time of separation followed by a permanent disability rating of 10 percent.

     h. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                                  XXXXXXXXXXXXXXXXXXX
                                  Principal Deputy, Assistant Secretary
                                  Of the Navy (Manpower and Reserve Affairs)	
                                  Performing the Duties of Assistant 
                                  Secretary of the Navy 
                                  (Manpower and Reserve Affairs)