RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00828
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20070523

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Chemical Operations Specialist, medically separated for “major depressive disorder” with a disability rating of 10%.  

CI CONTENTION:  He has other conditions in addition to his PTSD and all have worsened.  His ratings are too low.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20070405	VARD - 20080116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	10%	Post-Traumatic Stress Disorder; Major Depressive Disorder	9434-9411	30%	20070719	
Posttraumatic Stress Disorder	Not Unfitting					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Major Depressive Disorder (MDD)/ Post Traumatic Stress Disorder (PTSD).  The CI was given co-morbid mental health (MH) diagnoses of MDD and PTSD.  Although the PEB adjudicated the MDD as unfitting and the PTSD as not unfitting, no distribution of psychiatric impairment can be allocated between the two diagnoses without undue speculation.  In this case, the CI’s MH disability is due to symptoms from both conditions and a single §4.130 rating is applied based on the overall occupational and social impairment.  Therefore, both conditions are discussed together, rather than discussing the PTSD condition separately under the contended not unfitting conditions section as would be standard.  

According to the service treatment record and the MH MEB narrative summary (NARSUM), the CI’s depressive condition began in July 2001 after self-referral to the MH clinic.  He reported 2 months of depression with difficulty sleeping, loss of interest and pleasure (anhedonia), and intermittent suicidal ideation (SI), without a plan or intent.  He was diagnosed with adjustment disorder with depressed mood and tried briefly on an antidepressant, which he stopped after a few days because he did not like the side effects.  His file was closed in February 2002 due to lack of follow-up.  The CI again sought MH services in December 2004.  He reported recurrent depression with sleep difficulty, anhedonia, decreased energy and concentration, increased appetite with weight gain, feelings of guilt and worthlessness, and SI and homicidal ideation (HI) without plan or intent.  He was diagnosed with major depression.  Medication to decrease anxiety and improve sleep and an antidepressant medication were started and he was also referred for marriage counseling.  A 5 January 2005 marriage counseling session indicated the marital stress was related to the military lifestyle and the CI indicated he wanted to get out of the military.  At a March 2005 psychiatric follow-up, the CI reported that his psychotropic medications were not working.  His wife had given him an ultimatum to get out of the Army or she would leave.  He was given diagnoses of adjustment disorder with mixed features and occupational problem, and psychotropic medications were discontinued and continued counseling was recommended.  The CI subsequently deployed with his unit in August 2005 to November 2006.  

On the 28 November 2006 Post-Deployment Health Assessment (PDHA), the CI responded that he had seen wounded, killed, or dead during the deployment; he was not in direct combat where he discharged a weapon; and he denied feeling he was in great danger of being killed during the deployment.  He did endorse MH symptoms and indicated he was currently interested in receiving MH help.  At a MH evaluation the same day, the CI reported some symptoms of depression and combat stress symptoms of irritability, difficulty sleeping, bad dreams, hypervigilance, avoidance of recollections of combat experiences, and exaggerated startle response.  He was in the process of a divorce and he reported that his depression was related to his marital situation.  The Axis I diagnoses were depression and anxiety disorder, not otherwise specified, rule out PTSD.  The CI sought treatment for depression related to his marital stress three times in ten days (29 November and 7-8 December 2006).  At the 8 December 2006 MH visit, pervasive depression symptoms were noted as well as PTSD symptoms and the CI indicated he wanted out of the military.  He was referred to PTSD group therapy for PTSD/depression symptoms.  At a 15 December 2006 psychiatric visit for psychotropic medication, the CI reported multiple combat engagements and seeing dead service members.  He reported insomnia, nightmares, flashbacks, hypervigilance, and depression and he was diagnosed with chronic PTSD.  

At a 25 January 2007 psychiatric visit, the CI reported significant concern about return to work after block leave due to ongoing conflict with his direct supervisor.  The MSE noted depressed mood and affect but the examination was otherwise unremarkable.  Psychiatric examinations in record from January 2005 to January 2006 noted mental status examinations (MSEs) showing depressed mood or depressed and anxious mood with depressed affect, and were otherwise normal.  At the 8 February 2007 psychiatric follow-up, the CI reported mild improvement in PTSD and depression symptoms on psychotropic medications for sleep (Seroquel, Ambien), an anti-anxiety medication (Klonopin), and an antidepressant (Zoloft).  A MEB was initiated in February 2007.  All MSEs from February 2007 (3 months before separation) until separation were normal.  At a 26 April 2007 psychiatric follow up, the CI reported good reduction of PTSD symptoms on current medications 

The 22 February 2007 commander’s statement, 3 months before separation, is excerpted below.  

[The CI] has been under my command for the last 27 months.  He has always met all requirements as per his duty position.  I have no issues with [the CI’s] performance in his MOS related requirements…In addition to his normal duties as my Nuclear Chemical and Biological (NBC) Noncommissioned Officer, he also served as one of my Battle Captains in the Troop Command Post during this deployment.  However, there was several times that the stress of managing the information flow from the platoons in the battlefield, while continuing to maintain his daily MOS requirements affected his performance.  [He] could not always separate the stresses from his family life from the stresses of his profession.  There were several occasions that [he] allowed his emotions to affect his duty performance and military bearing.  I also had to take his weapon away from him on one occasion for fear that he would hurt himself.  [The CI’s] strength is his administrative ability.  His hand receipts are always in order and his NBC room is immaculate.  However, his leadership performance has been average.  I do believe that he has the potential to be an outstanding leader in the Army, but that his current family situation and the resulting stress prevents him from continuing to perform to the level expected of an NCO.

The 16 March 2007 MEB NARSUM examination, 2 months prior to separation, noted complaints of anxiety, depression, and nightmares about Iraq.  The MSE described his mood as “anxious, depressed” and affect was depressed.  The remainder of the examination was normal.  The MH examiner indicated that the CI manifested multiple difficulties functioning at work due to his MH symptoms, including issues with memory, attention, and concentration, communication, making work-related decisions, and requiring frequent rest periods.  He was in the process of a divorce.  He had good relationships with his mother, father, and siblings.  He reported social alcohol use and no illicit drug abuse.  The Axis I diagnoses were PTSD, chronic, and MDD, recurrent, with a global assessment of functioning (GAF) assignment of 55, which is in the moderate range of impairment on this scale.  The MEB psychiatrist determined the CI did not meet retention standards due to his MH conditions.  

After separation, a letter dated 10 July 2007 written by the CI’s MH therapist indicated the CI reported traumatic stressors including the death of multiple friends during his tour, one a relative who had been kidnapped; a suicide of a friend for personal reasons; exposure to improvised explosive devices, rockets, and mortar attacks.  He related that a friend had been killed by a Stryker rollover and that he was involved in the recovery.  

At the 19 July 2007 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported that while in Iraq he lost a relative and six of his friends, and he witnessed people being killed and dead bodies.  He reported he sought MH help in Iraq due to difficulty sleeping, nightmares, and anxiety.  He reported that his psychotropic medications were not very helpful and he had been off medications since military separation.  He was not employed.  He was divorced and caring for his 2-year-old daughter about half the time, and was living with a military friend and reported they got along well.  He also reported many friends in the community, both military and civilian friends, and social support from his family.  He enjoyed fishing, hiking, and riding motorcycles and snowmobiles, and he had started going to church again.  He reported drinking daily since discharge to the point of intoxication.  He denied blackouts.  He did not think he needed help and believed he could stop at any time.  The CI reported symptoms of anger, depression, anxiety, and occasional panic episodes.  He had trouble sleeping and cried for no reason at times.  He reported nightmares, anhedonia, low energy, and feeling numb.  He reported flashbacks when he heard loud noises and was easily startled, though with some decrease in his hypervigilance.  He denied any suicidal or homicidal intent.  He was attending weekly individual counseling sessions at the VA Center.  On the MSE, the CI reported a “blah” mood and his affect was subdued.  He had “mild paranoid ideation,” without thought insertion or broadcasting.  The remainder of the MSE was normal.  The Axis I diagnoses were PTSD, combat related; MDD, recurrent, moderate; and alcohol abuse, with a GAF assignment of 55, which is in the moderate range of impairment.  

At the 24 July 2007 psychiatric examination, 3 months after separation, the CI reported that in Iraq he drove trucks for the detainee center.  He witnessed the death of several friends in combat and one by suicide.  He related his brother’s brother-in–law was killed in Iraq and he found that topic difficult with his family.  In addition, his wife left him while he was deployed.  He expressed survivor’s guilt.  He reported depressed mood most of the time, sleep problems, overeating, anger and irritability, low energy anhedonia, difficulty with concentration and attention, anxiety, hypervigilance, difficulty making decisions, and low self-esteem.  He reported intrusive thoughts most days, but reduced frequency of nightmares.  On the MSE, the CI reported his mood was often depressed, anxious, and irritable.  His affect was dysphoric.  The remainder of the MSE was normal.  The CI was caring for his daughter most evenings and two nights per week overnight.  He was waiting on vocational rehab benefits from the VA and hoped to go to college.  The Axis I diagnoses were PTSD, combat related, and alcohol abuse, episodic.  The GAF assignment was 51, which is in the moderate range of impairment.  He was started on an antidepressant (Celexa) nightly and encouraged to restart medication to help with nightmares (prazosin- prescribed by his primary care provider). 

At the 24 August 2007 VA MH follow-up, 4 months after separation, the CI reported he had stopped the Celexa and prazosin because they made him too tired.  He reported a depressed, but level mood.  He was in training to be a truck driver while he waited for vocational rehab benefits to enable him to go to college.  He reported depressed mood, low energy, and PTSD symptoms of intrusive thoughts, avoidance, and hypervigilance.  He reported decreased alcohol intake, now only occasional.  The MSE noted a dysphoric mood and flat affect and was otherwise normal.  The Axis 1 diagnoses remained PTSD and MDD, and alcohol abuse, episodic, was noted to be in early remission.  The GAF assignment was 53, which is in the moderate range of impairment.

The PEB adjudicated the MDD as existing prior to service (EPTS), permanently service aggravated with an undetermined EPTS factor, and rated 10%, coded 9434 (major depressive disorder).  The VA rated PTSD/MDD 30%, coded 9434-9411 (major depressive disorder-post traumatic stress disorder).  

The PEB adjudicated the MDD condition as EPTS.  However, the panel noted that the EPTS evidence was limited to a period of mild depressive symptoms at the time of the CI’s first divorce (6 years before enlistment) that did not cause impairment or require treatment, and a family history of recent depression in the CI’s father.  There was no other history of MH symptoms or treatment prior to enlistment.  During active duty prior to deployment, the CI experienced two episodes of depression symptoms that required minimal treatment, with the episode just prior to deployment related to current marital problems.  The application of VASRD §4.129 is appropriate when “a mental disorder that develops in service as a result of a highly stressful event is severe enough to bring about the veteran’s release from active military service.”  Therefore, the panel agreed it would not be appropriate to recommend application of §4.129 to the unfitting diagnosis of MDD alone, since it was determined to be EPTS with exacerbations after enlistment prior to deployment.  However, following return from deployment, the CI immediately sought MH help and was diagnosed with PTSD by every MH professional in the record.  The PTSD condition was adjudicated by the PEB as not unfitting and was contended by the CI in his application to the Physical Disability Board of Review.  As noted above, the two MH conditions cannot be separated and impairment cannot be apportioned between them without undue speculation.  The PEB allocated all unfitting impairment to the MDD, one of two Service MH diagnoses, which is not a supportable conclusion.  Therefore, the panel contends that the CI was found unfit for a MH condition which was an amalgam of MDD that existed prior to deployment and PTSD that developed during deployment, and the two cannot be separated for fitness or rating purposes.  The panel’s contention that PTSD is an equal contributor to the CI’s MH impairment is strengthened by the fitness evidence in record.  The PTSD condition was listed on the permanent profile along with MDD.  The MEB psychiatrist determined that PTSD caused severe impairment for further military duty and mild impairment for social and industrial adaptability.  The MEB forwarded both the PTSD and MDD conditions as individually falling below standards.  

The panel judged that the evidence cited above constitutes a preponderance of the evidence in favor of recommending that PTSD was unfitting at separation, if considered on its own.  Therefore, the panel considered whether the provisions of VASRD §4.129 were applicable for the CI’s post-deployment MH condition.  The traumatic stressors documented in record included seeing wounded, killed, or dead.  The CI reported engagement in combat although on the PDHA he indicated he had not been in combat where he discharged a weapon or ever felt that he was in great danger of being killed.  However, the commander’s statement indicated the CI was a battle captain in the troop command post and the panel speculated the CI may have been referring to his involvement in combat in this regard.  The CI related to a therapist that a friend had been killed by a Stryker rollover and the CI was involved in the recovery.  At MH visits, the CI consistently reported the death of multiple friends and a relative during the deployment and that he continued to have intrusive thoughts and nightmares about them.  The panel agreed that the stipulations of §4.129 were met in this case and therefore recommended a minimum 50% rating for a retroactive 6‐month period on the Temporary Disability Retired List (TDRL).  All members agreed there was no evidence to support a rating higher than 50% at the time of placement on the TDRL.

The panel then turned to its permanent rating recommendation at the time of removal from the TDRL.  The most proximate sources of comprehensive evidence on which to base the permanent rating recommendation in this case are the C&P examination, 2 months after separation, the initial VA MH evaluation, 3 months after separation, and VA MH follow-up 4 months after separation.  Taken together the three post-separation VA encounters provide evidence that the CI’s social and occupational functioning was gradually improving.  He reported persistent symptoms of both MDD and PTSD, but he was socially interactive with friends, both civilian and military friends, and enjoyed recreational activities.  He was in good relationships with his family, and cared for his young daughter, emotionally and physically.  By 4 months after separation, he was able to seek employment despite the obstacles his MH symptoms presented and he had a longer-term goal of going to college.  

All members agreed that the §4.130 threshold for a 50% rating was not approached.  The deliberation therefore settled on consideration of a 10% versus a 30% permanent rating recommendation.  Although the CI continued to have MH symptoms despite psychotropic medications at 4 months after separation, he was returning to work, anticipating going to school, and caring for his child on a regular weekly basis.  There was no 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).  All members agreed that his level of impairment was better described as occupational and social impairment due to mild or transient decrease in work efficiency and inability to perform occupational tasks only during periods of significant stress, consistent with a 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the MH condition at the time of permanent separation.  

BOARD FINDINGS:  In the matter of the major depressive disorder/PTSD condition, the panel recommends an initial TDRL rating of 50%, coded 9434-9411, in retroactive compliance with VASRD §4.129 as directed by DoD, and a 10% permanent rating at six months 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
MDD/PTSD	9434-9411	50%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170217, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180006627, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to constructively place you on the Temporary Disability Retired List (TDRL) at 50% disability for six months effective the date of your original medical separation for disability with severance pay and then following this six month period no re-characterization of your separation or modification of the permanent disability rating of 10%.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The constructive TDRL period will result in an adjustment to your pay providing you 50% retired pay for six months from the date of your original medical separation and then no re-characterization of your separation or modification of the permanent disability rating of 10% following the constructive six month TDRL period. 

	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure