RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXX	CASE:  PD-2016-01154
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20040217

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aircraft Fuel Systems Journeyman, medically separated for “major depressive disorder” with a 30% rating with a 20% “contributory/aggravating factors” deduction for 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 - 20031009	VARD - 20040618	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	
10%
	Adjustment Disorder with Depressed Mood	9440	10%	20040504	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 40%	
*Formal PEB applied a 20% deduction for “less contributory/aggravating factors

ANALYSIS SUMMARY:

Major Depressive Disorder.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s major depressive disorder (MDD) was initially diagnosed in July 2002.  While in treatment he described migraine headaches and depressive thoughts and prescribed Zoloft x 2 doses.  He was then prescribed a different anti-depression medication (Paxil) and noted significant improvement in mood and thought process. An 11 December 2002 Life Skills interview for a security clearance revealed past and current alcohol use as well as poor insight into its potential effects.  The enlistment medical examination did not show evidence of prior alcohol or drug use.  The CI was referred for substance abuse evaluation.  

At the 03 February 2003 MEB NARSUM examination for alcohol dependence, 13 months prior to separation, the CI reported he had been using alcohol daily after work and often alone to manage his feelings of depression, loneliness and boredom.  He usually drank 2-3 nights per week, consuming up to 2-5 large pitchers of beer.  He binged drank every weekend and consumed up to a case of beer.  He completed 4 weeks of a residential treatment program (RTC).  The examiner noted he used alcohol to manage his depression and to fit into his peer group but continued to deny he had a problem with alcohol.  Upon completion of the RTC, he appeared minimally motivated to work a formal aftercare program.  Several follow-up treatment notes from 13 March 2003 noted “sobriety, and early remission” and no references to continued or excessive alcohol use.  

In May 2003, the CI was hospitalized after running away from the mental health clinic.  He was found by Security Police, restrained and transported for inpatient psychiatric hospitalization for 3 days due to suicidal ideation.  The 19 June 2003 commander’s statement noted he was not working in his primary assignment but was working in the gym.  He cited the CI’s Air Force Form 422 Physical Profile Serial Report, which noted significant depression, on medication and disrupted sleep cycle.  He had missed work due to inpatient alcohol treatment, mental health treatment, and outpatient treatment.  He visited his mental health physician from 3-5 times per week resulting in up to 8 hours of lost duty time.  

The 20 June 2003 MEB NARSUM Psychiatric examination, 8 months prior to separation, noted the CI had been in psychiatric care since 17 December 2002.  He reported onset of heavy drinking at 19 years of age while stationed in England.  After the 4-week residential treatment, the CI was transferred to aftercare.  He began to report depression and anxiety, suspicion of others, passive suicidal ideation but ongoing sobriety.  He reported he had not taken his Paxil for several days.  He was distrustful of everyone and believed others had ill intentions toward him and no reason to care for him.  He was guarded, perseverative and viewed the world in black/white frames of reference.  Post-discharge treatment had been “up and down,” complicated by disciplinary measures he was facing due to coming to work late.  When confronted by his First Sergeant after being seen drinking alcohol the night of 5 June 2003, the CI expressed homicidal ideation which he later interpreted as others wanting to “beat him up.”  He reported this was the only time and that he had drank alcohol to deal with the stress he faced at work.  He felt persecuted for this indiscretion and relayed he had not shared his recent struggles with his family for fear of letting them down.  He expressed fear of being kicked out of the Army and expressed a desire to kill himself if separated.  However, he accepted the addition of a mood-stabilizing, anti-psychosis medication (Zyprexa) to target agitation and suspiciousness.  He reported improvement and increased clarity of thoughts with the medication.  He was seeing a military psychologist weekly and a civilian psychiatrist every 2 weeks.  

Mental status examination (MSE) showed fidgeting of hands, dysphoric affect, mood frustrated/dysthymic, suspicious but no overt paranoia, themes of persecution and nihilism.  He had a good therapeutic alliance with his psychiatrist and substance abuse counselor.  He was taking an anti-depression and a mood-stabilizing/anti-psychosis medication.  Diagnoses of Axis I: MDD, severe and alcohol dependence, and Axis II. Paranoid personality disorder were rendered with a Global Assessment of Functioning (GAF) score of 55 (moderate.)  The psychiatrist noted his impairment was definite and military impairment was marked.  The examiner noted neither alcohol abuse nor paranoid personality disorder existed prior to service but each condition was exacerbated by service.  The CI required frequent psychiatric follow-up and demonstrated benefit from anti-psychotic medication.  The CI submitted a letter, dated 26 June 2003, stating he felt his alcohol dependence was due mainly to depression and he was fine with medication.  

The 08 August 2003 MEB NARSUM Psychological Addendum, noted , 6 months prior to separation, noted the CI reported counseling for one year when he was 8-9 years old due to being “shy and withdrawn.”  He understood that his current chief complaint was a combination of depression and alcohol use.  On 8 September 2003 due to being deemed to be a danger to self and to others and was involuntarily hospitalized.  His condition slowly deteriorated when he was informed the MEB recommended a medical discharge.  He filed a formal appeal that requested a return to duty.  A 7 October 2003 physician letter noted the CI was stable with medications and recommended his return to work without restrictions.  However, the full PEB found the CI unfit and recommended discharge.  

At the 04 May 2004 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported he had been falsely accused of being an alcoholic but complied with treatment because he wanted to keep his security clearance and a career in the Air Force.  It was noted that an examiner in January 2003 noted he had no history of driving under the influence, incarceration, or of any job-related issues due to alcohol.  He reported that prior to designation as an alcoholic, he had no problems in his career.  He reported he was depressed because of the situation he found himself in; being accused of being an alcoholic when he was not.  He denied any significant amount of alcohol and was having no problems with this.  He reported being in treatment with a psychologist and a psychiatrist nearly every week until he was discharged. The CI reported he was single, was living with his family and had not yet found a job due to the lack of opportunities where he was living.  He had no friends in the area where he was living and had not had much social life in the Air Force.  Physical examination showed an essentially normal examination.  A diagnosis of adjustment disorder with depressed mood was rendered with a GAF score of 61 (mild bordering on moderate symptoms)

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the major depressive disorder 30%, coded 9434 (major depressive disorder), with a 20% deduction for “aggravating/contributing factors,” thus, a final 10% rating.  The VA rated the mental health condition 10%, coded 9440, (chronic adjustment disorder), based on the C&P examination 3 months after separation, citing mild to transient symptoms.  Application of VASRD §4.129 is considered by the panel for all cases of service-connected psychiatric 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 next considered the deduction for “contributory/aggravating factors.”  The FPEB noted “the member’s Axis I and Axis II conditions are incompatible with the long-term rigors of military service.”  The FPEB identified MDD and alcohol dependence as Axis I conditions and paranoid personality disorder as an Axis 2 disorder.  Since MDD is a clearly ratable condition, one must reasonably consider the “contributory/aggravating factors” as references to alcohol abuse and personality disorder.  Per IAW DoDI 1338. 38 neither alcohol abuse nor personality disorder are physical disabilities and are not ratable or compensable conditions.  A deduction for the personality disorder and the substance abuse was made, but the amount was not specified nor was the relative contribution of each condition.  

The panel then considered the deduction made by the PEB for the drug and alcohol abuse.  He had no legal issues from public intoxication and was entered into the alcohol treatment program (ADAPT) after 3 years of service.  The CI had an EPR of 3 in 2002 and a 2 in 2003 but there was no record of performance deficit due to alcohol abuse.  At the time of the June Psychiatric NARSUM evaluation (upon which the PEB based a 30% rating), the CI had been observed drinking in a club but no further alcohol use was documented.  Subsequent treatment notes recorded “sobriety.”  There were no further reports/documentation of drinking for the 7 months prior to separation, a time during which the effect of alcohol on mental health symptoms was negligible or absent.  The C&P examiner declined to diagnosis alcohol dependence, stating “his current description of this particular problem does not match such a diagnostic criterion.”  Moreover, post-residential treatment for alcoholism outpatient notes, prior to separation, confirmed the persistence of problematic depressive symptoms, and resulted in two inpatient psychiatric hospitalizations due to suicidal ideation.  Furthermore, the CI had been in counseling for one year at age 8 or 9 due to symptoms of withdrawal and shyness, two symptoms often associated with depression or anxiety in a child.  The CI reported the onset of drinking as a result of depression, loneliness and boredom. The panel therefore concluded that imposing a deduction for alcohol dependence was not supported because alcohol use had ceased in time to assess symptoms and functioning solely attributed to MDD.  The panel considered this and determined that the PEB deduction for the alcohol was not appropriate.  

The panel then considered the deduction for paranoid personality disorder.  This Axis II diagnosis was assigned during the May 2003 hospital discharge, possibly related to his symptoms of distrust of others, suspiciousness and fears others were out to hurt him.  There was no documentation of other episodes either pre-hospitalization or post-hospitalization.  The June 2003 commander's statement implicated, “significant depression, on medication and disrupted sleep cycle” as a contributing mental health condition with no mention of a personality disorder.  The VA examination, within 3 months of separation, did not render any Axis II diagnosis.  The panel concluded that the evidence is not sufficient to support the diagnosis of paranoid personality disorder at separation and, therefore, no deduction is warranted for this condition.  Furthermore, members concluded it is impossible to clinically dissect psychiatric impairments into ratable and un-ratable origins, and any such attempt would require undue speculation.  There was no information on which to base such a mathematical calculation.  Members thus agreed that its recommendation should concede the total §4.130 impairment in evidence as subject to service rating.

The panel then considered the appropriate rating at the time of separation.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks,” while criteria for a 50% rating requires “occupational and social impairment with reduced reliability and productivity.”  The examination most proximal to separation was the C&P examination.  The CI was living with his family and unemployed.  His treating psychiatrist had noted he was stable on his medications and recommended return to work without restrictions in October, 2003, 4 months prior to separation.  The C&P examination noted he had no friends and virtually no social life.  He denied the use of alcohol.  The panel concluded there was no evidence of criteria to meet a 50% disability rating.  All panel members agreed the CI’s symptoms were not mild or transient, and were not controlled by medication, therefore, the 30% disability level better reflected the condition at separation.  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 major depressive disorder condition, coded 9434.

BOARD FINDINGS:  In the matter of the major depressive disorder condition, the panel unanimously recommends a disability rating of 30%, coded 9434 IAW VASRD §4.130, without deduction.  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%	

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

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXXX

Dear XXXXXXXXXXX,

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01154.

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 (210) 565-2273 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.