RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00888
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20041101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E5, Supply Management Craftsman, medically separated for “depression” 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(s) 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 - 20040722	VARD - 20050419	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Depression with Psychotic Features	9434	10%	Psychotic Disorder, Not Otherwise Specified	9210	10%	20050228	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Depression with Psychotic Features.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mental health condition began in July 2003 after 7 years of service following the death of his brother when the CI reported visual hallucinations of ghosts.  CI reported some paranoia and feared the ghosts and had episodes of catatonia.  He was subsequently admitted to inpatient psychiatry for 7 days for initial evaluation and treatment.  While admitted, the CI was successfully treated with an anti-depression medication, an anti-psychotic medication, and a sleep aid.  Shortly after his discharge, the CI was transferred to Hawaii.  The CI related some confusion regarding medication use which resulted in him discontinuing his medications.  
The CI experienced a recurrence of the visual hallucinations and delusions (his deceased brother attacking him), was referred to the emergency room (ER) and re-admitted involuntarily on 8 August with bizarre posturing, a disorganized thought process, and inability to recognize family members in the emergency room.  He was restarted on medications with good results.  Medical work-up for psychosis at that time were normal.  On 14 August 2003, the CI was discharged and doing well.  Two months after discharge, the CI requested his medications be discontinued.  On 27 May 2004, the CI had a significant episode of psychosis (delusions, hallucinations) associated with depression.  The CI presented to the Emergency Department (ED) describing psychotic like symptoms.  CI reported he had not slept for over 24 hours secondary to a change in his work schedule and had no food intake since his visual hallucination the day prior.  The CI detailed paranoia and felt ghosts (one of whom he thought was his brother) were out to get him.  This resulted in a third admission to the inpatient psychiatry ward.  Medications were restarted.  Although improved, he continued to have some bizarre behavior and posturing, related to cultural and religious themes.  The CI was discharged to outpatient management.  From 8 June to 10 June 2004 the CI was admitted to Psychiatry ward for a suicidal remark make in the presence of command.  He stated he wanted to kill himself.  No psychosis was noted and no medications changes were made.  There was no evidence of psychiatric illness prior to July 2003.  The Commander noted the CI had missed 47 duty days since August 2003 due to hospitalization and convalescent leave.  He was also attending2-hour daily group counseling appointments 5 days per week and working a modified work schedule of 2-3 hours per day.  

The 30 June 2004 MEB psychiatry NARSUM examination, 5 months prior to separation, noted CI had been seen twice since his last hospitalization.  He reported no hallucinations.  He continued to take high dose anti-psychosis medication and a sleep aide and attended inpatient group therapy 3 days per week on the Psychiatry unit.  Physical examination May 2004 was normal.  Mental status exam (MSE) noted no hallucinations but there was inappropriate laughing at times with fair insight and judgment.  Articulation was poor.  Mini-mental status exam was 30/30.  A diagnosis of major depressive disorder (MDD), Severe, with Psychotic Features was rendered with a Global Assessment of Functioning (GAF) score of 75 (transient symptoms, slight impairment.)

At the 28 February 2005 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported additional information that he was on his way to visit his 14 year old brother and the family when he brother was shot to death.  On the 1 year anniversary of the death, he was hospitalized the third time for the same condition, “psychotic disorder.” Sometimes he had a great deal of difficulty with sleep and denied any current symptoms.  He had stopped his medication about 2-3 months after the last hospitalization because he felt he didn’t need it.  He was unemployed and denied change in daily activities or social function.  MSE showed limited communication due to cultural and language problems but he did describe some anxiety around economic issues and “boredom.”  He was not revealing of his thought processes and judgment seemed fair.  Diagnoses of psychotic disorder NOS and bereavement disorder were rendered with a GAF score of 60-65 (moderate bordering on mild symptoms, impairment.)  The examiner opined that he and his wife were in denial of any serious problem and that he required some monitoring of his condition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the depression with psychotic features condition 10%, coded 9434 (MDD), citing mild social and industrial impairment.  The VA rated the psychotic disorder condition 10%, coded 9210, (psychotic disorder NOS), based on the C&P examination 4 months after separation, citing mild or transient symptoms.  Application of VASRD §4.129 is considered by the panel for all cases of service connected mental health conditions resulting in separation; but, all members agreed that the ‘highly stressful event’ requisite for §4.129 was not satisfied in this case.  The panel then considered if there was evidence for a §4.130 rating higher than the 10% adjudicated by the PEB.  

The June MEB NARSUM documented the CI was taking two psychotropic medications, including a high dose anti-psychosis medication and attending 3 psychiatry inpatient groups per week.  Despite this, his commander noted the CI had missed 47 days of work due to psychiatric hospitalizations and convalescent leave since August 2003.  He was working a modified schedule of 2-3 hours daily, not including group-counseling sessions.  There were episodes of incoherent and strange acting behaviors, saying foolish things, and acting weird in between the May and June 2004 hospitalizations.  The panel agreed there is evidence of ongoing mental impairment requiring repeated hospitalizations and intense outpatient treatment due to chronic, recurring symptoms within months of his discharge.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the MDD with psychosis condition, coded 9434.  

BOARD FINDINGS:  In the matter of the depression with psychotic features condition, the panel unanimously or by majority recommends a disability rating of 30%, coded 9434 IAW VASRD §4.130.  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	
Depression With Psychotic Features	9434	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160915, 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

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00888.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  The Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at XXXXXXXXXXXXXXXXXX to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

XXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings