RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03509
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20091026

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Security Forces Craftsman, medically separated for “major depressive disorder (MDD), recurrent associated with anxiety disorder not otherwise specified (NOS)” with a disability rating of 10%.  

CI CONTENTION:  No specific contention was made.  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 - 20090528	VARD - 20100420	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent MDD in Partial Remission, associated with Anxiety Disorder NOS	9434	10%	Mild MDD and Anxiety Disorder NOS 	9413-9434	30%	20100228	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Recurrent MDD, in Partial Remission, associated with Anxiety Disorder NOS.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s MDD condition began in 2006 in the context of interpersonal problems at work.  The CI self-referred to the mental health (MH) clinic on 1 August due to symptoms related to stress.  She reported headaches, sleep difficulties, irritability, anxiety, sadness, loss of pleasure, low self-esteem, decreased appetite, fatigue, increase in obsessive-compulsive behaviors, and guilt.  Treatment was terminated due to a reduction of symptoms per CI report.  A second period of treatment began when she returned to MH on 23 April 2008 due to anxiety and depression. Symptoms returned in the context of occupation stressors and she reported increased symptoms during and after the pregnancy of her first child.  At that time she met criteria for a recurrent mild MDD. Under care of MH providers, she participated in 44 diagnostic treatment and crisis management appointments.  Treatment included both psychotherapy and medication management.  The psychiatrist treated her with Prozac (anti-depression) and she participated in psychotherapy to improve depressive and anxiety symptoms and to increase marital satisfaction. Symptoms significantly decreased in frequency and severity.  Prozac was effective but tapered to avoid any prenatal risks since CI was planning to become pregnant.  She received the last medication around 5 December 2008.  Anxiety symptoms, including crying, irritability, emotional lability, and obsessive-compulsive behaviors occurred.  She experienced increasing difficulty managing stress, anxiety, and emotional reactivity at work, and endorsed thoughts of cutting to manage anxiety.  

The 11 February 2009 MEB NARSUM examination, 8 months prior to separation, noted complaints of frequent symptoms of anxiety and emotional reactivity that was functionally impairing.  She reported she was engaged in therapeutic behaviors at home and at work to manage her emotions and anxiety but with minimal success.  She followed up with a MH provider weekly and participated in psychotherapy, which helped in decreasing her depression to a currently functional level.  However, anxiety had not decreased to a level that allowed function at full capacity in her job duties.  She was permanently decertified on 9 January 2009 due to her anxiety disorder.  Depressive symptoms largely resolved during treatment and improvements in anxiety symptoms were significantly diminished with cessation of the anti-depressant.  A mental status examination (MSE) showed mild anxiety and speech of a slightly increased rate.  Her stated mood was anxious.  Diagnoses of anxiety disorder NOS and MDD were rendered with a Global Assessment of Functioning (GAF) score of 65 (mild symptoms, impairment.)  The examiner opined the CI’s conditions were likely to worsen without consistent prolonged psychotherapy and medication. After the MEB NARSUM there were multiple STR entries where the examiner reported either the CI had either a calm or anxious mood.  The appointments where these entries took place did not provide a robust elaboration regarding information exchanged or gathered during the visits.  

At the 27 August 2009 life skills clinic visit appointment, 2 months prior to separation, the CI was seen for medication management.  The CI was given a prescription by an obstetrician for Prozac, but she was uncertain if she should use it at this time in her pregnancy.  The CI previously used Prozac daily for her anxiety symptoms, however, she discontinued use prior to pregnancy.  She was concerned regarding possible post-partum depression and the impact of anxiety.   The examiner noted they discussed potential risks and benefits and limitations of knowledge regarding its use in pregnancy and breastfeeding.

At the 23 September 2009 life skills clinic visit appointment, one month prior to separation, the CI was seen for follow-up on anxiety/depressive symptoms.   She reported no increase in depressive symptoms or significant anxiety symptoms since the birth of her baby.  She reported her husband had even commented that she was “nicer.”  The CI did report some mild anxiety over an upcoming trip to see family.  The examiner noted overall, the CI was doing well.

During the 13 October 2009 life skills clinic visit appointment, 2 weeks prior to separation, the CI reported an increase in depressive symptoms and feeling “blah,” and not happy although things were going well.   The CI reported feeling sick with a cold and was unsure if her blah feeling was related to the cold. The examiner noted they would reassess at the next appointment and consider medication options given she was breastfeeding and not able to follow up until processing through the VA system.  The CI and family were moving to Kansas in 2 weeks and shw was to follow up with the VA there.  The examiner noted a plan to meet with the CI one more time before closure and that the CI had her 4-week old daughter with her and showed appropriate connectedness to her.  MSE showed a depressed mood and diagnoses of anxiety disorder NOS and mild recurrent MDD in partial remission were rendered.  Axis II borderline traits were noted.   

At the 8 February 2010 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported she was receiving treatment (psychotherapy) for a MH disorder but she was not receiving medication due to breastfeeding.  Depressed symptoms began after the birth of her son in October 2007.  Episodes of depression occurred every 5-7 days and lasted about 2 hours.  During these times she isolated in her room and did not interact with others.   The CI reported feeling depressed most days with fatigue or loss of energy nearly every day.  She also reported feelings of worthlessness, guilt, poor concentration, and excessive worry.  She reported a pattern of overeating to cope with negative moods.  The CI reported obsessive and compulsive symptoms displayed through her cleaning the house about 2 hours each day.  She kept a daily chore list, and kept labels facing out.  Symptoms intensified with stress and seemed to start after the birth of her son.  She also reported a pattern of chronic worry and problems. Once a week she had anxious thoughts and would sleep 7 instead of 8 hours. She was unemployed but at home caring for her two young children.   MSE showed a depressed mood and affect.  She was tearful through the interview, stating she was more depressed than usual.  She reported when she felt depressed she had problems focusing on simple tasks and had problems thinking clearly.  She reported no panic attacks since 2008.  She reported mild memory problems.  Diagnoses of mild MDD and anxiety disorder were rendered with a GAF score of 62 (mild-moderate symptoms, impairment.)  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MH condition 10%, coded 9434 (MDD), citing depressive symptoms had largely resolved to a functional level with treatment, and improved anxiety symptoms, which had diminished due to cessation of anti-depression medication due to pregnancy.  The VA rated the MH condition 30%, dual coded 9413-9434 (anxiety disorder, NOS-MDD), based on the C&P examination, citing symptoms reported during the VA examination, and a GAF at VA examination which indicated moderate symptoms.  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. 

As noted in the NARSUM, the CI had frequent MH visits due to anxiety and depression symptoms which responded well to therapy and medication.  Anxiety symptoms returned with the discontinuance of medication, and depression, obsessions and compulsions occurred after the birth of her child.  The CI returned to MH and therapy sessions were beneficial but, she was unable to resume medication due to breastfeeding.  Although MH symptoms remained, the VA examination noted the CI was able to care for her two children at home.  Panel members concluded the CI most closely met criteria for 10% disability based on the NARSUM examination which annotated the depressive symptoms were largely resolved during treatment and improvements in anxiety symptoms were controlled by continuous medication.  Panel members also took into consideration the pre-separation life skills clinic examinations where the examiner noted the CI was doing well and the mild recurrent major depression was in partial remission.   These clinic visits were most proximate to separation.  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 MDD condition.  

BOARD FINDINGS:  In the matter of the major depressive disorder associated with anxiety disorder not otherwise specified 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.  

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

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Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-03509.

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.