RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02506
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050718

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Unit Supply specialist, medically separated from the Temporary Disability Retired List (TDRL) for “major depressive disorder” with a disability rating of 10%.   

CI CONTENTION:  Review all conditions. 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 FPEB - 20050613	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	10%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Major Depressive Disorder (MDD).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s MDD began after starting a new assignment in June 2001.  She was recovering from abuse by her ex-husband from 1997-1999 and a divorce in 2000, but no medical or psychiatric problems were documented in 2000.  She felt she was doing well in her new job, but her chain of command disagreed, and she was frequently counseled.  She became frustrated and angry when counseled or criticized at work, and the commander noted that she showed little motivation to accomplish assigned tasks, required excessive supervision, and was unable and unwilling to meet minimum standards.   Her command planned to refer her to mental health (MH), but she self-referred for treatment in the fall of 2001 and was placed on Zoloft (anti-depressant) for post-traumatic stress disorder (PTSD).  

In May 2002, the CI felt unable to face her non-commissioned officer-in-charge (NCOIC), and did not go to work, stating she was so angry she might “slap somebody.”  She was hospitalized from 3-6 May 2002 and discharged with a diagnoses of PTSD and depressive disorder, not otherwise specified (NOS).  She took daily psychotropic medications and received weekly counseling, but her relationship with her chain of command worsened, and in October 2002 she was notified of a pending Article 15.  She became extremely depressed and angry, called a counselor, and stated she might use a broken bottle to hurt herself or someone else.  She was subsequently hospitalized from 15 October to 4 November 2002, and reported auditory command hallucinations which told her to kill herself and others, especially her NCOIC.  The voices were difficult for her to resist and she attempted to cut her wrist in the hospital with a plastic knife.  A diagnosis of psychosis was made and an antipsychotic medication was added.  After discharge, she continued intensive counseling and medication follow-up.  The commander’s statement dated 16 January 2003 noted she continued to be a “burden” to command and the MEB NARSUM examiner rendered diagnoses of MDD and PTSD with severe occupational stress.  The CI was separated and placed on the TDRL on 9 October 2003.  

Multiple STR entries documented frequent, regular psychiatric follow-up during the TDRL period, and on 2 February 2005, a brain MRI revealed prominent atrophy of both cerebellar hemispheres (slight more on the right than left), and mild atrophy of the cerebral hemispheres.  The pattern was non-specific and unusual for her age. 

The 6 April 2005 TDRL re-evaluation examination, 3 months prior to TDRL removal, noted CI complaints of only mild depressive and anxiety symptoms since TDRL placement.   She reported daily fatigue, poor concentration, insomnia and mildly depressed mood, despite some improvement.  She had been teaching in a special education program at a teen parenting center near her home since October 2004, and enjoyed the job.  She was told she was performing well, and only had one episode of conflict with a coworker.  She maintained social relationships, had not required psychiatric hospitalizations since TDRL placement, and denied any further auditory hallucinations or suicidal thoughts.  She attended therapy every 2-4 weeks, which was helpful, and psychiatric medication included high doses of Zoloft, Depakote (mood stabilizer) and trazodone (sleep aid) as needed.  The mental status examination (MSE) showed a brief period of tearfulness when discussing recent nightmares, and poor recall with 5-minute recall of only one object.  Concentration and insight were fair.  A diagnoses of MDD, in partial remission, and PTSD were rendered.  The examiner noted the CI was functioning reasonably well in her work and social relationships despite ongoing residual depressive symptoms.  Her treatment compliance was excellent, and she had stabilized significantly over the previous 18 months, although she was at high risk for recurrence into full major depression and psychosis.  

The 21 May 2005 neurology consultation noted a history of forgetfulness for 2 years, which coincided with starting Depakote, but no significant cerebral atrophy.  The examiner reviewed radiographic imaging and opined that there was no significant cerebral atrophy and “doubt early dementia.”  The neuropsychology follow-up, 5 days later, documented that the CI was very confused and upset about termination of her TDRL status with a 10% disability rating.  She reacted with extreme anger, partially related to feelings that the Army was ‘trying to screw her’ again.  She described episodes of depersonalization and evidence of self-injury during her sleep. 

On 29 June 2005, she was admitted for inpatient psychiatric treatment for suicidal ideation with Axis I diagnoses of PTSD and depression, Axis III assessment of “R/O [rule out] early dementia,” and a Global Assessment of Functioning score of 40 (symptoms, impairment in several areas).  The CI was discharged on 5 July 2005 with Axis I diagnoses of PTSD and history of MDD and bipolar disorder.  The Axis III conditions included “cerebral and cerebellar atrophy, significance undetermined,” and the GAF score was 60 (moderate bordering on mild symptoms, impairment).  There was no VA examination proximate to separation in evidence. 

The panel directed attention to its rating recommendation based on the above evidence.  The CI was removed from the TDRL with a permanent disability disposition of separation with severance pay at 10%.  The PEB cited “single episode, in partial remission, requiring psychotropic medication and psychotherapy” and noted no hospitalization, and “employed” with mild social and industrial impairment.  The panel considered the provisions of VASRD §4.129 (mental disorders due to traumatic stress), and determined that the MDD with PTSD was due to a “highly stressful event,” and that application of §4.129 was appropriate in this case.  Therefore, a minimum 50% rating for a retroactive 6‐month period on the Temporary Disability Retired List (TDRL) is recommended.  Members agreed there was no evidence to support a rating higher than 50% at the time of TDRL placement.  

The panel then turned to its permanent rating recommendation at TDRL removal, and noted the most proximate sources of comprehensive evidence were the 6 April TDRL re-evaluation and June 2005 inpatient admission entries recorded 3 weeks prior to TDRL removal.  Panel members noted the CI had been in the service for 8 years and did not have any known MH diagnosis until 2001.  The panel also considered the CI’s traumatic relationship with her husband and weak work performance.  Re-evaluation noted that while she was enjoying and performing well in her job and had social relationships, she still had symptoms of anxiety and depression, despite high doses of two psychotropic medications.  The MSE showed documented significant impairment of recent memory, and while the CI appeared to be markedly improved, there was still evidence of a fragile emotional state.  Prior to TDRL removal, the CI required inpatient hospitalization due a return of suicidal ideation, self-injury and depersonalization. The STR continued to record multiple, frequent MH visits after TDRL removal due to persisting psychiatric symptoms, including suicidal ideation, depression and anxiety, and the role of brain atrophy remained unclear.  Panel members concluded the CI met criteria for a 30% disability for “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal).”  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 50% at the time of TDRL placement IAW §4.129and a permanent 30% rating at the time of TDRL removal for the MDD, coded 9434.   

BOARD FINDINGS:  In the matter of the major depressive disorder, the panel recommends a disability rating of 50%, coded 9434 at the time of TDRL placement IAW §4.129, and a permanent 30% rating at the time of TDRL removal  IAW VASRD §4.130.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends 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 the date of medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Major Depressive Disorder 	9434	50%	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170301, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190007576, 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 re-characterize your separation as a disability retirement with the combined disability rating of 30%.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The constructive TDRL period and the re-characterization of your separation as a disability retirement 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 30% disability retired pay effective the date following the constructive six month TDRL period, minus the amount of severance pay you were previously paid at separation.
 
	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 and will provide information on your retirement benefits.  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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

Sincerely,					      
Enclosure