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AF | PDBR | CY2013 | PD-2013-01950
Original file (PD-2013-01950.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-01950    
BRANCH OF SERVICE: AIR FORCE     BOARD DATE: 20150714
SEPARATION DATE: 20050801                


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Tactical Aircraft Maintainer) medically separated for a depressive disorder condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty. He was issued a S4 profile and referred for a Medical Evaluation Board (MEB). The depressive disorder condition, characterized as “depression” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated the depressive disorder condition as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The IPEB also adjudicated “Gilbert’s Syndrome” as Category II (condition that can be unfitting but is not currently compensable or ratable) and “alcohol abuse” as Category III (condition that is not separately unfitting and not compensable or ratable. There was no evidence that the CI made any appeals and thus was medically separated.


CI CONTENTION: “The applicant makes no specific contention in his application. His complete submission is at Exhibit A.”


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’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/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board 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, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


RATING COMPARISON :

Service IPEB – Dated 20050609
 VA - (~2 Mo. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Depressive Disorder 9434 10% Chronic Depressive Disorder 9434 10% 20050907
Other x 0 (Not In Scope)
 Other x 5
Combined: 10%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 200 50201 ( most proximate to date of separation [ DOS ] ).

ANALYSIS SUMMARY:

Depressive Disorder. The service treatment record documented a history of depressive symptoms in the context of protracted heavy alcohol abuse. The 7 January 2005 licensed clinical social worker encounter documented “Admits to suicidal thoughts. No current intent or plan. Mainly reactive to legal mess he has gotten himself into. No other suicidal indicators. Is making plans for the future. Getting good support from SQ [squadron]. … was referred to ADAPT [Alcohol and Drug Abuse Prevention and Treatment].” On 1 February 2005 the CI was referred to an Intensive Outpatient Program (IOP) for treatment of alcohol dependence. The discharge criteria were for the CI to attend 32 IOP sessions (4 days per week) and develop a relapse prevention plan. On 27 March 2005 the CI had an emergency admission to the behavioral medicine unit of a mental health/detoxification hospital. The admission assessment documented a recent discharge from the regional IOP and no support from his family. The CI complained of increased depression and suicidal ideation (SI). The mental status exam (MSE) recorded “Depressed, poor judgment, impulsive.” The assessment cited alcohol abuse as a contributing factor, a prior suicide attempt, and a poor support system as his family had recently left him. The diagnosis listed: Axis I: major depressive episode; alcohol abuse; Axis IV (psychosocial stressors): family issues, work; and Axis V Global Assessment of Functioning (GAF) score: current 20 (some danger to self or others or occasionally fails to maintain minimal personal hygiene or gross impairment in communication). The CI was discharged on 5 April 2005 on psychotropic (affect mind, emotions, and behavior) medications which included an antidepressant (Prozac) and an antipsychotic (Seroquel). The 5 April 2005 psychiatry encounter reported continued, but improved, depressive symptoms since hospitalization. The 11 April 2005 psychiatry encounter recorded ongoing severe depressive and anxiety symptoms. The CI’s mood was dysthymic (mildly depressed) and anxious and his affect was congruent. He had no current suicidal or homicidal ideation, intent, or plan. Alcohol abstinence (Acamprosate) medication was started and the antidepressant and antipsychotic medications were continued.

The narrative summary (NARSUM) by military psychiatry, 3 months prior to separation, documented that the CI was first seen in ADAPT after a domestic violence incident. The CI had been drinking heavily and was arrested for assaulting his wife while “blacked out.” He was diagnosed with alcohol abuse and completed IOP alcohol treatment program on 24 March 2005. He was admitted to a hospital behavioral medicine unit from 27 March through 5 April 2005 for suicidal thoughts with a suicide plan. At the time of his admission, the CI endorsed depressed mood, insomnia, anergia (abnormal lack of energy), anhedonia (inability to feel pleasure), poor concentration, and hopelessness. He was diagnosed with alcohol dependence, adjustment disorder with depressed mood, and cluster B and C personality features. At discharge, he continued to endorse severe symptoms of anxiety and depression, but noted improved suicidal thoughts. At the follow up with ADAPT on 6 April 2005, he appeared to be working well “to a full recovery plan.” At the mental health follow up on 11 April 2005, the CI noted a return of suicidal thoughts, but denied a plan or intent. He reported he would be able to follow his safety plan and was released with follow up scheduled in 2 days. Three hours after his appointment, the CI overdosed on approximately 20 tablets of Seroquel and 20 tablets of Prozac. Fortuitously, his supervisor contacted him, and he disclosed the overdose. He was transported to the emergency room, spent a day in the ICU, and fully recovered from the overdose. A suicide note was found, and he was transferred to a hospital behavioral medicine unit. The CI “… made a noose which was found by staff … placed on close suicide watch … continued to endorse ongoing suicidal thoughts and drew pictures of his gravestone … cut on himself with … his toothpaste tube … told staff that his suicide was ‘a matter of time’.” The history documented the CI denied prior medication for depression or anxiety, a history of manic or psychotic symptoms, or a history of illicit substance use. He denied alcohol use in the past 60+ days but reported drinking 24-48 beers and one-fifth of hard alcohol nearly every weekend for the past 4 years. Medications were an antidepressant (Prozac) and an antipsychotic (Seroquel). The psychosocial history documented that the CI was married for over a year and had a year-old son. He and his wife were separated and he anticipated a divorce. His supervisor indicated that the CI was an “awesome troop” and “a good kid.” There was no indication of alcohol use or intoxication on the job. The NARSUM recounted the MSE, performed by psychiatry, on the second hospital admission. The MSE documented the CI was alert and oriented times four, had no abnormal speech, and judgment and insight was fair. There was no psychosis including hallucinations, delusions, paranoid ideations, thought disorder, etc. “There was some question of whether there was secondary gain for the patient to get out of the military." The NARSUM recounted psychological testing performed by psychology that was deemed valid. The working diagnosis was major depressive disorder with some psychotic features and alcohol dependence in partial remission. The CI’s overall condition was made worse by low self-esteem, antisocial practices, anger, personality disorder, and poor impulse control. The examiner opined that he would appear to qualify for an impulse control disorder not otherwise specified (NOS) and his personality disorder seemed to have borderline and schizotypal features. He reported a long history of self-harm, ideation, and gestures. The CI first began harming himself "since age nine or ten ... I was infatuated with suffocating myself with a pillow." He related his most recent attempt to hurt himself as "I cut myself with the toothpaste tube and I was going to hang myself. I tested it out." The examiner opined that without significant interventions, the CI was judged to be at high risk of self-harm, ideation, and gestures. The psychiatrist opined the depressive disorder NOS diagnosis was supported by a history of depressive and anxiety symptoms over the past several months. It was unclear whether these symptoms represented a primary mood disorder or a chronic adjustment disorder related to a chronic stressor. This depressive disorder diagnosis was further evidenced by psychological testing. His symptoms existed prior to service and were exacerbated by military service. The premorbid disposition was listed as severe secondary to alcohol use and history of chronic suicidal thoughts. The social/industrial impairment was listed as mild and military impairment as marked. The disposition and recommendations recorded “… chronic depressive symptoms were exacerbated by recent stressors resulting in marked impulsivity, impaired judgment, and a suicide attempt. Despite ongoing, regular outpatient treatment, inpatient hospitalization, and antidepressant and antipsychotic medication … attempted suicide resulting in a second hospitalization. His ongoing instability of mood and judgment was evidenced by his continued suicidal threats and gestures while hospitalized. The severity and chronicity of his depressive symptoms in conjunction with his borderline personality features indicate a poor prognosis. His suicidal risk is chronically elevated.” The diagnosis listed: Axis I: depressive disorder NOS; alcohol dependence; Axis IV: partner-relational problem; and Axis V: GAF: 5 (persistent danger to self or others or persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death) upon hospitalization; 5-60 (moderate symptoms or moderate impairment in functioning) over the past six months.

Between 11 April and 5 May 2005, an antimanic (Depakote), antianxiety (Vistaril), and antipsychotic (Thorazine) medication were started and the previous antipsychotic (Seroquel) medication was discontinued. Five serial psychiatry encounters between 5 and 23 May 2005 documented waxing and waning depressive and anxiety symptoms. The 23 May 2005 psychiatry encounter documented worsened depressive symptoms. The suicide/homicide risk assessment listed moderate to severe risk. The CI was returned to the hospital behavioral medicine unit to be admitted. In the 27 June 2005 separation physical the CI reported a history of depression, suicidal ideations/gestures, fatigue, and tremors. He indicated he had been hospitalized for suicidal ideations and gestures to include a deliberate overdose. The active medications were Wellbutrin (antidepressant), Thorazine (antipsychotic), Inderall (off-label use for essential tremor), and Topamax (off-label use for alcohol dependence). The CI listed tremor and depression with suicidal ideations/gestures as conditions which limited his ability to work in his primary MOS. He intended to seek VA disability for depression and tremor.

The general physical exam documented the CI was well developed, well nourished, alert, and in no acute distress. The psychiatric exam recorded he was alert and oriented X 3, had good eye contact, was conversant, and cooperative. It documented normal affect and normal memory. The 27 June 2005 behavioral health clinical social worker encounter documented the CI was seen upon his release from the hospital and was going to be out-processed from the Air Force that day. The CI reported he had no serious suicidal ideation for the past several weeks. The objective findings documented he was casually dressed and groomed. The CI had good eye contact with speech of normal rate and rhythm. The examiner opined there was no evidence of imminent risk and he did not appear to require in-patient hospitalization that day. The CI’s history raised significant concerns about future safety, but he was future-oriented, and had a reasonable plan for self-care in the likely event his suicidal ideation returned. The diagnoses listed Axis I: depression NOS, alcohol dependence; and Axis II: personality disorder NOS. The plan was for the CI to follow his self-care plan, be released to his First Sergeant, be separated that afternoon, and to follow up with the VA the next day for on-going care.

The general medical compensation and pension (C&P) exam, 2 months after separation, recorded no specific history for a mental health diagnosis or associated medications. Under history of activities and functions it recorded “The usual occupation is mechanic, which he has performed for 3.5 years. He is currently employed in the same job.” The physical exam general appearance documented that the CI was well developed, well nourished, and in no acute distress. The mental exam recorded the CI was alert and oriented times three. Affect was appropriate and there were no signs of tension. Behavior and comprehension were normal and memory was intact.

The Board directed attention to its rating recommendation based on the above evidence. The PEB, 2 months before separation, rated the depressive disorder at 10% (VA code 9434; major depressive disorder). The PEB cited mild social and industrial impairment, existed prior to service , and service aggravation. The VA RD, 6 months after separation, rated the depressive disorder at 10% (9434). The VARD cited evidence from service medical records confirming chronic depressive disorder, recurrent symptomatology, and failure to report for a VA exam (30 September 2005). The NARSUM was a synthesis of early histories and exams and did not include a contemporaneous physical or mental status exam by the signing psychiatrist. While the NARSUM documented significant symptoms consistent with higher ratings (danger of hurting self [100%], suicidal ideation [70%], impaired impulse control [70%], impaired stress adaptation [70%], impaired judgment [50%], depressed mood [30%], and anxiety [30%]), these were in the context of alcohol abuse/withdrawal and significant social stressors. There was significant interval improvement in symptoms with hospitalization, alcohol cessation, IOP for alcohol dependence, pharmacotherapy, and psychiatric therapy.

Board members agreed that the preponderance of evidence did not approach the 50% rating, therefore, the Board deliberations centered on a 30% versus a 10% rating. The commander’s statement documented a strong work ethic and performance “… volunteers to come back to work after appointments so that he misses as little time at work as possible … currently works full duty shifts … return to duty will be positive for the mission and USAF. His condition has shown no ill effect on his duty performance … due to hospitalization, he has slipped in his upgrade training but is aggressively working toward completing … is a key component of his duty section and if he were separated the section would feel the negative effects.” The separation general physical exam documented a history of depression and suicidal ideations/gestures requiring psychotropic medications. The same day behavioral health encounter documented “… no serious suicidal ideation for the past several weeks … No evidence of imminent risk. … concerns about his future safety, but he did not appear to require … hospitalization today. He was future-oriented and had a reasonable plan for self-care in the likely event that he experienced a [return] of his suicidal ideation. … will [follow up] with VA tomorrow ….” The separation day evaluations documented symptoms consistent with a 30% rating (depressed mood). The general medical C&P exam recorded no specific history for a mental health diagnosis or associated medications. It recorded “The usual occupation is mechanic, which he has performed for 3.5 years. He is currently employed in the same job.” While the separation day evaluations documented symptoms consistent with a 30% rating (occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks), the general medical C&P exam documented symptoms consistent with a 10% rating (occupational and social impairment due to mild or transient symptoms which decrease work efficiency only during periods of significant stress, or; symptoms controlled by continuous medication). These facts, in the absence of C&P mental health diagnosis or associated medications, suggest a 10% rating. The separation day depression, and lingering concerns for suicidal ideation, suggests a 30% rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the depressive disorder (9434).


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 depressive disorder, the Board unanimously recommends a disability rating of 30%, coded 9434 IAW VASRD §4.71a. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board recommends that 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 as of the date of his prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Depressive Disorder 9434 30%
COMBINED 30%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131025, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record








XXXXXXXXXXXXXXXXXXXX
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 (Section 1554, 10 USC), PDBR Case Number PD-2013-01950 .

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.
Sincerely,







XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN

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