RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01723
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080505

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

CI CONTENTION:  His conditions continue to worsen and negatively impact daily activities.  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 - 20080307	VARD - 20080630	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	10%	Major Depressive Disorder	9434	30%	20070302	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:

Major Depressive Disorder (MDD).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was seen by the behavioral health clinic in February 2006 for homicidal thoughts.  He noted an ongoing depressed mood for about 6 months.  He also reported anxiety, feelings of helplessness, fear of abandonment, anger, rage, emptiness, loneliness, frustration, and feeling overwhelmed with issues at work.  The CI had an ongoing conflict with his chain of command.  In addition to problems at work, he began to experience problems with his wife who had an extramarital affair which exacerbated his suspiciousness, paranoid ideation, and depressive symptoms.  He was subsequently hospitalized for depression, and homicidal and suicidal ideation.  He was diagnosed with major depressive disorder, recurrent, severe, and post-traumatic stress disorder (PTSD).  The genesis of the PTSD diagnosis was not clarified nor found in the STR.  

The 24 July 2006 MEB mental health NARSUM, 3 months before TDRL placement, recorded the above stated history.  The mental status examination (MSE) documented the presence of psychomotor retardation, tired and depressed mood, and affect congruent with the mood.  He expressed paranoid ideations directed towards his chain of command.  There was no evidence of a thought disorder or psychosis.  Thought process was linear and goal-directed.  He was not suicidal or homicidal, and judgment was poor at times.  He was taking psychotropic medication and was receiving talk therapy.  The examiner assessed MDD, recurrent and severe with psychotic features, and PTSD, chronic.  A Global Assessment of Functioning (GAF) score of 45 (serious symptoms and impairment) was recorded.  

The 5 September 2006 commander’s performance statement, 2 months prior to TDRL placement, implicated the CI’s mental health condition, stating the CI showed violent tendencies toward his supervisor which arose from feelings of anger, frustration, or hurt, a bad combination for a soldier.  The commander went on to say the CI’s limitations were so restrictive that they precluded satisfactory performance in any military specialty.  

After having a history of three psychiatric hospitalizations, three convalescence leaves, and recurrent suicidal ideation, paranoid ideation, and depressive symptoms, the STR showed the CI’s mental health symptoms improved with medication, and suicidal ideation resolved.  However, his mental health condition did not stabilize and he was placed on the TDRL on 31 October 2006.  

At the 02 March 2007 VA Compensation and Pension (C&P) mental disorder examination, 4 months after TDRL placement, the CI reported sleeping well with medication, and had not had a physical outburst with his temper in over a year.  He reported crying spells and feeling worthless due to his work and finances, and also reported having one or two suicidal ideations that passed quickly.  The CI continued taking psychotropic medication.  Symptoms suggestive of PTSD were not documented.  Since TDRL placement the CI held one job for 2 months and then quit.  He was not able to focus on the job, but was seeking new employment.  The CI was also taking college classes but complained of problems with concentration; he reported a grade point average of 3.0.  The CI was accompanied by his spouse of 7 years.  He reported their marriage was “okay” while his wife reported the marriage was “good”.  The MSE was unremarkable with the exception of depressed mood and constricted affect, and leg bouncing.  Judgment was intact, and there was no evidence of disturbance in thinking, thought process, or cognition.  The examiner assessed MDD.  PTSD was not assessed.  

During a 12 April 2007 mental health telephone encounter, 5 months post TDRL placement, the CI reported he did “fine as long as he takes his medication” and felt “stabilized” on medications.  He denied depression or anxiety, and was able to laugh.  The CI missed his scheduled mental health appointment on that same day but called in from work.  

The 15 February 2008 TDRL evaluation, 3 months prior to TDRL removal, noted complaints of depressed mood, sleep disturbance, low energy, poor concentration, and continued flashbacks about his time in Iraq.  He continued taking psychotropic medication with no evidence of psychiatric hospitalization or emergency room visits since TDRL placement.  The CI was not working but noted he worked for 8 months in 2007 as a swimming pool repair diver.  He quit because of his irritability and issues with his supervisor.  He was enrolled in night-time college courses.  The MSE was unremarkable with the exception of depressed mood and affect, and at times he was tearful during the interview.  The single diagnosis recorded was MDD, chronic.  The GAF was not addressed.  

During the 23 September 2008 VA psychiatrist visit, 4 months after TDRL removal, the CI reported running out of psychotropic medication.  He denied depression and suicidal or homicidal ideations, noted no concentration problems, but had difficulty sleeping without sleep medication.  He felt “stable, on medications” since 2006.  The CI was working full-time as a veterinarian nurse.  There was no record of mental health hospitalization or emergency room visit after TDRL placement.  The CI was assessed with PTSD, rule out bipolar II, current hypomanic, and cluster B personality traits.  A GAF of 60 (moderate impairment symptoms) was recorded.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel first judged if application of VASRD §4.129 (discharge from military service due to a mental health disorder as a result of a highly stressful event) was appropriate.  The panel majority found that the CI’s deployments to Afghanistan and Iraq, and subsequent PTSD diagnosis recorded by the MEB and PEB, was reasonable evidence to apply §4.129.  

The panel next determined the rating recommendation at TDRL placement.  The PEB rated the mental health condition 50%, coded 9434 (major depressive disorder), citing considerable industrial impairment and additionally stating a separate diagnosis of PTSD cannot be separately rated due to symptoms that are inextricably intertwined, but is included in the overall rating.  The VA rated the mental health condition 30%, also coded 9434, based on the C&P examination, citing occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.  

IAW with DoDI 6040.44, DOD guidance, and VASRD guidance, the minimum §4.129 rating at TDRL placement is 50%.  A 70% rating encompasses “Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood.”  A 50% rating includes “Occupational and social impairment with reduced reliability and productivity due to symptoms such as:  flat affect, panic attacks more than once a week, difficulty in understanding complex commands, impaired short and long-term memory and impairment in judgment and thinking….”  The panel considered the CI’s three psychiatric hospitalizations, MEB mental health NARSUM, and commander’s statement most proximate to TDRL placement.  Although the CI continued to express homicidal thoughts towards his chain of command, he had improved with psychotropic medication and his suicidal ideation had resolved.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the mental health condition at TDRL placement.  

The panel next deliberated the rating recommendation at TDRL removal.  The PEB rated the mental health condition 10%, coded 9434 (major depressive disorder), citing the mental health symptoms controlled by continuous medication.  The VA continued to rate the mental health condition 30%, coded 9434, based on the C&P examination.  

The panel considered the TDRL evaluation, 3 months prior to TDRL removal, and the VA psychiatrist visit, 4 months after TDRL removal.  The TDRL examiner noted the CI continued to utilize psychotropic medication with no evidence of psychiatric hospitalization or emergency room visits since TDRL placement.  The CI was not working but worked 8 months in 2007 as a repair diver.  The CI was enrolled in on-site college courses.  The MSE was unremarkable with the exception of depressed mood and affect, and at times he was tearful during the interview.  The VA psychiatrist documented the CI denied depression, suicidal or homicidal ideation, and concentration problems.  The CI felt stable on medications since 2006 and was working full-time as a veterinarian nurse.  There was no record of mental health hospitalization or emergency room visit after TDRL placement.  A GAF of 60 (moderate impairment symptoms) was recorded.  Additionally, the panel noted the absence of panic attacks, chronic insomnia, or memory loss; and concluded the CI’s disability was most reflective of the 10% at TDRL removal.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the mental health condition at TDRL removal.  

BOARD FINDINGS:  In the matter of the major depressive disorder condition and IAW VASRD §4.130, the panel majority recommends no change in the PEB adjudication at TDRL placement or removal.  The single voter for dissent recommends TDRL placement at 70% and did not elect to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170329, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008640, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
Enclosure