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

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-02115.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

								XXXXXXXXXX

Attachment:
Record of Proceedings 

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-02115
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090824

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Security Forces Apprentice, medically separated for “major depressive disorder, associated with generalized anxiety disorder” which was determined to have existed prior to service (EPTS) with service aggravation and given a disability rating of 10%.  

CI CONTENTION:  Review of all conditions requested.  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 - 20090505	VARD - 20100222	
Condition	Code	Rating	Condition	Code	Rating	Exam	
MDD, Associated with Generalized Anxiety Disorder	9434	10%	MDD, associated with Generalized Anxiety Disorder	9413-9434	10%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Major Depressive Disorder (MDD) Associated with Generalized Anxiety Disorder.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s mental health (MH) condition began in the fall of 2007 when he gradually noticed increased symptoms of depression and anxiety.  On 17 November 2008, he was admitted to an inpatient psychiatric ward on a voluntary basis for suicidal ideation with a plan, intent and means.  He reported chronic subclinical symptoms of depression since age 15, which he managed via distraction, staying busy, and socializing.  Treatment consisted of medication that was modified based on efficacy and side effects and individual cognitive behavioral therapy.  At the time of discharge, 3 weeks after admission, his depression and mood improved and he reported resolution of suicidal ideation while on Prozac (fluoxetine, an antidepressant).  His Global Assessment of Functioning (GAF) score on discharge was 45-50 (serious symptoms).  However, by 12 December 2008 he reported a decreased mood, function and overall sense of well-being and had thoughts of suicide “every day” when he was alone, but without intent to act.  He agreed to medication management and weekly individual CBT and thereafter reported episodic improvement in mood and hope interspersed with periods of increased anxiety, worry, depression and sense of hopelessness; suicidal ideation was chronic.  Nevertheless, he continued to report to work and demonstrated a willingness to do his best, but was not able to perform his duties, which involved carrying a weapon.  His mood remained predominantly dysphoric and he continued to struggle with anxiety and suicidal ideation.  He did not endorse any benefits from Prozac (an antidepressant) other than he had less thoughts of self-harm or suicide and he continued Seroquel at bedtime for insomnia concerns.  

The 20 February 2009 MEB NARSUM psychiatry examination, 6 months prior to separation, noted complaints of anxiety (worrying about “everything”) and symptoms of depression.  Mental status examination (MSE) showed the CI to be alert and oriented to time, person, place and circumstances, but he appeared tired, morose and weary.  Psychomotor activity was within normal limits.  He was respectful and courteous and maintained culturally appropriate eye contact.  His speech was readily understood, fluent, and of regular rhythm and rate; volume and tone were soft.  His linguistic prosody (intonation, pitch, stress and rhythm) was preserved.  Observed mood was dysphoric.  He stated his mood was depressed.  His affect was restricted but congruent to mood.  His thought processes were goal-directed and logical.  He demonstrated an ability to think abstractly.  His thought content was significant for an absence of current suicidal ideation.  He denied any intent to die or immediate desire to be dead.  He denied current plans to kill himself.  He did not manifest any delusional thoughts or disturbance of perception.  He displayed no expansibility, grandiosity or increased goal-directed behavior.  His judgment, impulse control and cognition were intact and his insight into the presence of mental illness was deemed good.  The examiner’s Axis I diagnoses were MDD, moderate, recurrent with definite impairment for civilian social and industrial adaptability and generalized anxiety disorder with mild impairment for civilian social and industrial adaptability.  His GAF score was 60 (moderate symptoms).

At a MH clinic visit on 13 May 2009, 3 months prior to separation, the CI’s MSE revealed he was alert and oriented, cooperative and open.  Eye contact was good.  Speech rate and tone were within normal.  Mood was euthymic and optimistic and affect was congruent and appropriate to mood.  Thought processes were logical, linear and goal-directed.  Thought content and cognitive perceptions were within normal limits and insight and judgment were fair.  He denied current suicidal ideation, intent, means or plan, and denied homicidal ideation, plan means or intent.  The acute suicide risk was mild.  The CI underwent individual psychiatric therapy and the examiner’s diagnoses were major depression, recurrent, moderate and anxiety disorder NOS.  

The VA Compensation and Pension (C&P) examination on 29 October 2009, 2 months after separation, did not address the CI’s MH condition.  The CI failed to show for a scheduled MH examination in February 2010.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MDD, associated with generalized anxiety disorder condition 10%, coded 9434 (MDD), citing a condition that existed prior to service with service aggravation.  The VA also rated the MDD, associated with generalized anxiety disorder condition 10%, analogously coded 9413-9434 (anxiety disorder, not otherwise specified-MDD), based on the STR, citing occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress; or symptoms controlled by continuous medication.  

The panel considered the provisions of VASRD §4.129 (mental disorders due to traumatic stress), and agreed there was no evidence of a traumatic event or stressor causing the unfitting MH condition, and that application of VASRD §4.129 was not appropriate in this case.  The panel then noted that both the PEB and VA rated the CI’s MH condition 10%; however, the higher rating of 30% requires 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).”  The CI’s symptoms of depressed mood, anxiety, and sleep impairment were controlled to some extent by medication; however, the CI was unable to perform his full duties as a security forces apprentice because his diagnosis precluded him from carrying a weapon, but he did perform other assigned tasks satisfactorily.  However, he did not show symptoms of suspiciousness, panic attacks or mild memory loss.  Therefore, a 30% rating is not warranted.  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 MH condition.  

BOARD FINDINGS:  In the matter of the mental health condition and IAW VASRD §4.130, the panel recommends no change in the PEB adjudication.  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 20170406, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record