RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX 	CASE:  PD-2017-05816
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty O3, Mobility Pilot, separated for “major depressive disorder, in remission, associated with anxiety panic disorder” with a disability rating of 0%.  

CI CONTENTION:  The CI submitted an appeal by his attorney for consideration by the panel.  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 -20041124	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder, In Remission, Associated with Anxiety Panic Disorder              	9434	0%*	No VA Examination in Evidence 	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS: NA	

*The PEB rated the MDD 10% and applied a 10% deduction for aggravating/contributory factors.

ANALYSIS SUMMARY:  

Major Depressive Disorder (MDD), In Remission, Associated with Anxiety Panic Disorder.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s MDD condition began in June 2004.  The CI was a graduate of the Air Force Academy as a C-130 pilot.  Following several deployments the CI attended command school, but had increased difficulty sleeping, developed anxiety and panic attacks and experienced difficulty concentrating and loss of confidence.  He asked his commander for permission to drop out of school and the request was granted.  At a flight medicine visit on 16 June 2004, the CI reported he had returned from deployment in April 2004 and everything went well on deployment and continued to go well on return.  Two Officer Performance Reports (OPRs) dated June 2003 and June 2004 indicated he was an excellent aviator and superior and meticulous leader.  

At a primary care visit on 16 June 2004, the CI reported the onset of mental health (MH) symptoms including decreased motivation, difficulty sleeping, decreased concentration, anhedonia (loss of pleasure), increased anxiety about work, and two panic attacks approximately 2 weeks earlier.  He denied suicidal/homicidal ideations (SI/HI) or hallucinations, but felt like everything was difficult and he just wanted to stay in bed.  The mental status examination (MSE) showed a depressed mood and flat affect and was otherwise unremarkable.  The Axis I diagnosis was depression with features of anxiety and the CI was referred to psychiatry.  At the initial psychiatry examination, also in June 2004, the CI appeared anxious, sleep deprived, and obsessive about minor decisions.  He was treated for depression and severe anxiety with an antidepressant medication (Zoloft), sleep medication (Ambien) and an as needed medication for anxiety (Ativan).  The psychiatric follow-up appointment on 13 July 2004 noted the CI’s depression symptoms had developed gradually over a couple of years.  A family history of bipolar disorder, recent suicide of an uncle and alcohol abuse on his father’s side was noted.  There had been little improvement in his symptoms on the medications and he reported SI.  The CI was admitted for inpatient psychiatric treatment and his medications were changed to Remeron (anti-depressant), Luvox (antidepressant for OCD) and Zyprexa (antipsychotic used for Bipolar disorder), as well as Ambien.  His sleep improved and he was discharged to outpatient care.  At a psychiatric follow-up visit in mid-August 2004, he was feeling much better, but was apprehensive about return to work.  The CI returned to work on 16 August 2004 as a part-time executive officer.  His commander observed that during this time the CI was quickly overwhelmed by the work and had difficulty handling even simple staff work.  

A flight medicine clinic note dated 22 August 2004 indicated that the examiner had received a call from the CI’s commander on 19 August 2004 indicating the CI was having work difficulties.  The CI did not report to work on 20 August 2004 and he called flight medicine the next day and reported he had become increasingly “fearful of the work environment” and was unable to get out of bed.  He took 20 Ambien tablets that day saying he planned to fall asleep and not wake up.  However, he awoke and began vomiting and decided to drive to see his wife, but was involved in a single car crash.  He did not sustain any serious physical injuries, but had no memory of the accident and he was admitted a second time for inpatient psychiatric treatment.  A brief admission note indicated complaints of insomnia and bombardment at night with racing thoughts and listed an Axis I diagnosis of bipolar II disorder.  In a daily hospital progress note written on 25 August 2004 the CI discussed that while his command was looking at possible separation from active duty, he was not sure if that was what he wanted.  A hospital note the next day summarized a discussion of deployment stressors.  The CI reported he had concerns for crew safety on combat supply missions without providing any specific details and he questioned his role in the overall mission, but indicated he could handle staying in the Air Force to finish his commitment of three and a half years if he had to, but wished he could be stationed closer to his wife (who was also in the military).  A psychiatric summary written while the CI was hospitalized listed Axis 1 diagnoses of MDD, single, severe with suicide attempt, anxiety/panic disorder and obsessive-compulsive personality disorder was noted on Axis II.  The Global Assessment of Functioning (GAF) was 45, which is in the serious range of impairment on this scale.  

The 15 September 2004 commander’s statement is excerpted below.

[The CI] is unable to perform duties as a pilot or crew member in the C-130 and I have seen first-hand his inability to handle simple staff work.  I wholeheartedly encourage his separation from the USAF.  His condition is too delicate for any unit to be able to absorb and care for him.  He is a bright, energetic young man, but there is no place for him in the USAF.  

A progress note for the MEB written by the psychiatrist on 7 October 2004 indicated the CI had improved significantly on his medications and had returned to work 4 hours per day in an office position and was volunteering at a local grade school to help poor readers.  

The 9 November 2004 MEB NARSUM examination, 3 months prior to separation, indicated the CI was in remission on his current psychotropic medications (Luvox, Remeron and Zyprexa).  He had returned to work (not on flight status) and was doing well.  The MSE showed the CI to be pleasant, gregarious, sleeping well, and not anxious, depressed, or suicidal.  The final Axis I diagnoses were MDD, single episode in remission, suicide attempt, overdose of Ambien, anxiety/panic disorder, in remission and an Axis II diagnosis of obsessive-compulsive personality disorder, with a GAF of 75, which is in the range of slight, if any, impairment on this scale.  Predisposing factors listed a positive family history of mental illness and stressors included the military lifestyle and deployments.  The psychiatrist indicated the CI would need psychotropic medication indefinitely and recurrence of symptomology was possible.  The psychiatrist also noted that at the time it was not possible to rule out bipolar disorder as a “likely possibility” and expressed concern that the CI’s illness might be chronic due to his requirement of an atypical antipsychotic medication to control the anxiety and sleep disturbance.  There was no VA examination proximate to separation in evidence.  In his application for review by the Physical Disability Board of Review, the CI did not consent to the release of his VA records.  

An outpatient behavioral health (BH) visit at a local military treatment facility on 15 December 2006, 22 months after separation, noted that it was the CI’s first visit to the clinic (his spouse was still in the military).  He reported a current 3 week history of depression symptoms with a history of treatment for depression from June 2004 to January 2005.  His marriage was stable and he endorsed a supportive relationship and very close family relationships with his parents and sister.  He reported anxiety and stress largely related to a teaching internship he was involved in at the time.  He also reported fleeting SI with worry “that it could happen.”  He had been to the emergency room a week earlier due to stress and insomnia.  The MSE noted a mood that was more anxious than depressed, and the examination was otherwise unremarkable.  Outpatient treatment with individual therapy sessions was recommended, as well as psychiatric evaluation for medication.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MDD condition 10%, coded 9434 (major depressive disorder), citing MDD in remission and deducted 10% due to aggravating factors, for a final 0% rating.  The PEB also adjudicated an obsessive-compulsive personality disorder as a Category III condition, a condition that is not separately unfitting and not compensable or ratable.  In its remarks, the PEB opined that were it not for the obsessive-compulsive personality disorder condition, the CI’s “social and industrial adaptability impairment rating would best be described as none” IAW DoD and VASRD guidelines and therefore deducted 10%.  

The panel first considered whether the provisions of VASRD §4.129 (mental disorders due to traumatic stress) were applicable.  The panel carefully reviewed the letter submitted by the CI with his application for review.  Although the CI’s multiple deployments were noted by the psychiatrist to be generally stressful (exhaustion, sleep deprivation, separation from family), the panel did not find evidence of the CI reporting any highly stressful events during active duty, during deployment or otherwise, in the available STR.  In June 2004 the CI had reported his most recent deployment went well and the OPRs indicated the CI was an excellent performer during multiple deployments.  The psychiatric note in July 2004 indicated that the CI’s depression symptoms had developed gradually over the past few years.  During his second hospitalization, the CI reported he did have concerns for the safety of himself and his crew while on supply missions in combat zones, but he did not recount any particular fearful or dangerous events.  He also indicated he thought he could remain in the military but desired to be stationed closer to his wife if so.  After deliberation, members agreed that, although some contribution of Service stressors to the psychiatric condition was clearly present; the requisite §4.129 link that the conditions occurred as a result of a “highly stressful event” was not adequately satisfied.  The panel therefore considered only the VASRD §4.130 impairment present at separation for a single rating recommendation.

The CI was hospitalized for MH symptoms twice in the 7 months prior to separation.  He was doing well at the time of the final MH MEB NARSUM, just a little more than 2 months after his most recent inpatient hospitalization for depression following a suicidal gesture.  His MSE was fully normal.  However, he was on multiple psychotropic medications and was working part-time in an office position.  After the CI’s return from his second hospitalization, his commander indicated that she did not think the CI’s retention in any unit would be successful.  The psychiatrist indicated the CI’s prognosis likely included indefinite treatment with psychotropic medications, recurrences of symptoms and possible chronic illness.  Outpatient BH notes from 22 months after separation indicated that the CI was apparently not involved in MH treatment or on any psychotropic medication between the time of his military separation and December 2006.  He had been doing well up to that point, with another recurrence of depression at that time.  

Panel members agreed the CI’s condition at the time of separation supported the 30% disability rating, and his level of impairment was appropriately described as 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), 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 was diagnosed with an Axis I MH condition of MDD with anxiety/panic disorder and the PEB adjudicated the MDD condition as unfitting.  Although a contribution to occupational impairment from the Category III personality disorder may have been a factor in this case, the panel consensus was that it was overly speculative to attribute the total MH disability to the non-ratable personality disorder alone and it is likewise not feasible to apportion impairment between the conditions without resorting to speculation.  A single §4.130 rating is applied based on the overall occupational and social impairment due to both conditions IAW VASRD §4.130 guidelines.  Therefore the panel does not recommend any rating deduction.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the MDD condition, coded 9434.  

BOARD FINDINGS:  In the matter of the major depressive disorder, the panel recommends a disability rating of 30% coded 9434 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	PERMANENT RATING	
Major Depressive Disorder	9434	30%	

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

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-05816.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.