Author: JOHN J. D'ORAZIO
Last saved by: ADA, ROBERT P CIV USAF SAF/MRBD
Company: Pre-installed Company

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX                                                                    CASE: PD1200998
BRANCH OF SERVICE:  AIR FORCE                                                                    BOARD DATE:  20140115
Separation Date:  20031215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (3P0, Security Forces) medically separated for a mental health condition.  She was first seen in 2001 for depression related to relationship and financial challenges, but did not follow up with treatment.  Available evidence of record indicates the CI did not deploy to a combat theater.  There were suicide attempts in 2002 and 2003, and the condition could not be adequately rehabilitated to meet the requirements of her Air Force Specialty Code (AFSC), so she was issued an S4 profile and referred for a Medical Evaluation Board (MEB).  The mental health condition, characterized as “Major Depressive Disorder (MDD), recurrent, mild severity”, was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The PEB adjudicated the same diagnosis as unfitting, rated 10%, referencing the Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “major depressive disorder changed to bipolar due to continue suicidal thoughts and severe depression”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The Service ratings for the unfitting depression condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application or otherwise outside the Board’s defined scope of review remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service PEB – Dated 20030917 | VA - (2 Mos. Pre-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
MDD, Recurrent, Mild Severity | 9434 | 10% | MDD | 9434 | 50% | 20031021
No Additional MEB/PEB Entries | Other x 2 | 20031103
Combined:  10% | Combined:  50%
Derived from VA Rating Decision (VARD) dated 20040114

ANALYSIS SUMMARY:  The Military Disability Evaluation System (MDES) is responsible for maintaining a fit and vital fighting force.  While the MDES considers all of the service member's medical conditions, compensation can only be offered for those medical conditions that cut short a service member’s career, and then only to the degree of severity present at the time of final disposition.  However the Department of Veteran Affairs (DVA), operating under a different set of laws (Title 38, United States Code), is empowered to compensate service connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the veteran’s disability rating should his degree of impairment vary over time.

Mild, Recurrent Major Depressive Disorder Condition.  The CI had a long, well documented history of MDD as evidenced by the numerous notes in the Service Treatment Record (STR).  She developed symptoms of MDD in November 2001 related to relationship and financial problems.  A psychodynamic interview revealed a moderately dysphoric mild mood.  The examiner diagnosed Axis I adjustment disorder –anxiety, depressed mood with a Global Assessment of Functioning (GAF) of 65 - some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships and recommended individual psychotherapy.  The CI was enrolled in the Family Advocacy Program and from January 2002 throughout to November 2003, there were notes that indicated one case of substantiated intra familial neglect and several unsubstantiated reports of neglect. In May 2002 the CI’s mental status exam showed a moderately depressed mood; sad affect; mild transient suicidal ideation without plan or intent; irritability; low appetite; early awakening and fair attention and concentration.  The examiner changed the diagnosis to MDD, single episode, moderate with a GAF of 61- some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships.  The examiner recommended to continue the individual psychotherapy, possibly Healthy Coping Support Group and was referred to Family Practice for antidepressant medication.  In August 2002, the CI attempted suicide by ingestion of ten 20 mg Celexa tablets while in an acute dysphoric mood.  In follow-up the examiner noted a moderately depressed mood without suicidal intent.  The Axis I diagnosis of MDD, single episode, moderate was continued with a GAF of 58 - moderate difficulty in social, occupational, or school functioning.  In September 2002, the CI’s symptoms of depression showed improvement although she still had a mildly depressed mood.  The GAF was 65 - some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships.  In December 2002, the examiner noted that the depression was resolved on medication (Celexa) and the CI was doing well overall with a GAF of 75 - If symptoms are present they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational, or school functioning.  In June 2003, the CI had a second suicide attempt by ingesting twenty five tablets of non-aspirin medication.  Two weeks later, the CI was seen by her psychiatrist who noted that the CI reported mild depressive symptoms and a normal mental status exam.  The examiner diagnosed MDD, single episode, moderate severity, and exacerbation with a GAF – 65.  The MEB Narrative Summary (NARSUM) exam completed approximately five and one half prior to separation documented that the CI had a pattern of missing medical appointments in between episodes of crisis; and had relationship issues with her boyfriend and child care issues.  The mental status exam noted that her mood was mildly depressed but she exhibited no evidence of thought disorder and no psychotic ideation nor were there any concentration or speech problems.  The examiner opined that the CI had mild precipitating stress; definite social-industrial impairment; and marked military impairment.  The examiner further opined that that the CI exhibited emotional reactivity to life crises, particular relationship problems; the emotional volatility suggested borderline personality traits; however she did not suffer from borderline personality disorder; she was likely to suffer from affective instability during relationship stress with likely suicidal ideation and possible additional suicide attempts.  The diagnosis was Axis I MDD, recurrent, mild severity with a GAF of 65.  The CI was given a temporary S4 Profile.  A Commander’s Statement noted that the CI’s level of anxiety and depression affected her job performance along with her history of stopping her antidepressant “cold turkey” which contributed to her depths of depression and precipitated her suicide attempts.  The examiner further noted “She continues to attempt a positive attitude while among members of the unit, but the level of her anxiety and depression at times affects job performance”.  A Psychology MEB addendum completed approximately four months prior to separation noted that there was no change in the CI’s symptoms and she continued to experience a low mood due to recent psychosocial stressors involving her children’s daycare issues.  An updated MEB NARSUM addendum approximately three months prior to separation noted that the CI continued with increased psychosocial difficulties with her children and finances and these issues triggered anxiety which impaired her sleep and concentration.  The Psychologist assigned a GAF of 68.  The VA Compensation and Pension (C&P) exam approximately one and one half months prior to separation documented that the CI endorsed symptoms of stress; significant anxiety; poor sleep with frequent awakenings despite use of Tylenol pm; fatigue; intrusive thoughts about life problems; crying episodes; depressed mood; very emotional at times; impulsivity and hopelessness at times.  The mental status exam showed normal speech with an anxious and depressed mood with a full affect.  Her judgment was fair and she had poor concentration and insight, and her memory and abstract thinking were normal.  She endorsed chronic sleep impairment, anhedonia, significant guilt, impulsivity and suicidal thoughts- as recent as one week prior to this exam.  The examiner diagnosed Axis I MDD, recurrent, severe with a GAF of 50 - serious impairment in social, occupational, or school functioning.  The Board also notes that a C&P exam performed 24 months after separation documents that the CI’s mental health diagnosis was changed to Bipolar disorder sometime after her separation from military service while receiving treatment from the VA.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the MDD, recurrent, mild severity as 9434 and rated 10%.  The VA coded the MDD 9434 and rated at 50%.  The CI had a well-documented history of depression and two suicidal attempts.  At the time of the MEB NARSUM and MEB Addendums, the examiners continued to document definite social-industrial impairment; and marked military impairment, continued depression and anxiety which triggered impaired sleep and concentration.  She was given a temporary S4 Profile.  The VA C&P exam was closer to separation and more precisely demonstrated the CI’s symptoms at separation and therefore was deemed to be of higher probative value for rating purposes.  Based on the findings documented in the C&P exam, Board deliberations focused on 10% vs 30% deliberations as the CI did not have the occupational and social impairment with reduced reliability and productivity due to flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; or impairment of short- and long-term memory or abstract thinking as required for a 50% rating under the VASRD’s General Rating Formula for Mental Disorders.  The Board considered a 10% rating due to 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 majority of symptoms were related to stressful relationship or child related issues.  Her CC’s statement contained the following statement, “She continues to attempt a positive attitude while among members of the unit, but the level of her anxiety and depression at times affects job performance.”  The Board notes that the CI’s mental health condition was likely evolving at the time of her separation and was identified as Bipolar II sometime after separation by her VA providers.  The Board considers VA evidence within 12 months of separation only to the extent that it reasonably reflects the disability at the time of separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the MDD condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the Major Depressive Disorder condition, the Board by a vote of 2:1 recommends a disability rating of 10%, coded 9434 IAW VASRD §4.130.  The single voter for dissent who recommended a 30% rating did not elect to submit a minority opinion.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION | VASRD CODE | RATING
Major Depressive Disorder | 9434 | 10%
COMBINED | 10%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 201200998, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review

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

Dear XXXXXXXXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2012-00998.

	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,

XXXXXXXXXXXXXXXXXXXX 
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

PD1200998