ptsd Mental Health Intake

[donews]

I grabbed the most recent medical records when I was at the VAMC today.

It contained the information from my mental health intake consult (even tho the roi person said I was not allowed to have my metal health records with prior doctors consent.)

It has a section for diagnosis and reads as follows:

Axis I: Major Depression, r/o Depression secondary to dementia

Axis II: deferred

Axis III: see list above

Axis IV: no psychosocial stressors at this time

Axis V: 49-51

Does any of this make sense to anyone?

If so please help me understand.

She also stated somewhere in there that further evaluation was waranted to decided if I had a PTSD.

I had another appointment with a Mental Health since then, but those records were not included in this packet.

[donews]

Ok, here goes....

I got the records finally today.

I am going to post a few sections of the records and hopefully someone can help me decifer it.

Phychiatric Review of Additional Symptoms

Somatic Sx: chronic pain, awakens him at night and during the day.

Depression: hpi

Panic: hpi

Anxiety: hpi

Eating Disorder

ETOH/CAGE: denied

Psychosis: hpi

Other Substance Use/Abuse: hpi

PTSD/Trauma: hpi

Suicidal Gestures/Thoughts: hpi

Violence: denied

Parasuicidal Behaviors: denied

Mania: denied

Seizures: denied

AXIS I: Major Depression, recurrent

Possible complicated bereavement

Possible PTSD by history

Fairly revent delirium, March 2006 (Taken off Methadone)

AXIS II: None

AXIS III: CHF, CAD, Diabetes w/Complications, Hypertension, Elevated Lipids, Hip Fracture

AXIS IV: Social Isolation, Complications of Chronic Medical Illness

AXIS V: 35

So if anyone has a clue please help me understand what these two sections are saying.

[cowgirl]

Done, now that I reread the posts here, I see your situation. Yes, your doc can provide you a statement of your current diagnosis and that will support the reopening of your claim nicely. I hope you are doing fine for now and its nice to see you here at Hadit. I'm going to back off a bit and see what a few of the more experienced members here offer for you. I'll keep you on my radar and in my prayers, cg

p.s. My bad! The abbreviation mh stands for mental health, Sure are abbreviations for so many things. Years ago I learned to type the word first then add the abbreviation for clarification. ie. mental health (MH).

Ok, here goes....

I got the records finally today.

I am going to post a few sections of the records and hopefully someone can help me decifer it.

Phychiatric Review of Additional Symptoms

Somatic Sx: chronic pain, awakens him at night and during the day.

Depression: hpi

Panic: hpi

Anxiety: hpi

Eating Disorder

ETOH/CAGE: denied

Psychosis: hpi

Other Substance Use/Abuse: hpi

PTSD/Trauma: hpi

Suicidal Gestures/Thoughts: hpi

Violence: denied

Parasuicidal Behaviors: denied

Mania: denied

Seizures: denied

AXIS I: Major Depression, recurrent

Possible complicated bereavement

Possible PTSD by history

Fairly revent delirium, March 2006 (Taken off Methadone)

AXIS II: None

AXIS III: CHF, CAD, Diabetes w/Complications, Hypertension, Elevated Lipids, Hip Fracture

AXIS IV: Social Isolation, Complications of Chronic Medical Illness

AXIS V: 35

So if anyone has a clue please help me understand what these two sections are saying.

[donews]

Done, now that I reread the posts here, I see your situation. Yes, your doc can provide you a statement of your current diagnosis and that will support the reopening of your claim nicely. I hope you are doing fine for now and its nice to see you here at Hadit. I'm going to back off a bit and see what a few of the more experienced members here offer for you. I'll keep you on my radar and in my prayers, cg

p.s. My bad! The abbreviation mh stands for mental health, Sure are abbreviations for so many things. Years ago I learned to type the word first then add the abbreviation for clarification. ie. mental health (MH).

As always Cowgirl, Thank You for your knowledge, help, and prayers.

[tssnave]

Don,

What was their basis for saying your depression was due to your heart disease and not your dmII?

I take it your CHF is not sc?

I am waiting for someone to clue us both in on what "hpi" means in your report:

Phychiatric Review of Additional Symptoms

Somatic Sx: chronic pain, awakens him at night and during the day.

Depression: hpi

Panic: hpi

Anxiety: hpi

Eating Disorder

ETOH/CAGE: denied

Psychosis: hpi

Other Substance Use/Abuse: hpi

PTSD/Trauma: hpi

Suicidal Gestures/Thoughts: hpi

Violence: denied

Parasuicidal Behaviors: denied

Mania: denied

Seizures: denied

God Bless,

TS

[donews]

Don,

What was their basis for saying your depression was due to your heart disease and not your dmII?

I take it your CHF is not sc?

I am waiting for someone to clue us both in on what "hpi" means in your report:

God Bless,

TS

TS,

They gave no exact basis for opining that my Depression was due to my Heart Disease vs my DMII.

Actually that is what has me confused. Originally my Heart Disease (CHF included) was not Service Connected, but after a Denovo Review, they gave me a full grant of Service Connection for my Heart Disease. One would think that they would go back and fix the denial of the Depression due to this, bu they have not. I am trying to figure out if I need to do a CUE or what to get them to go back and fix the denial, because now my Heart Disease is connected and was on appeal when the Depression denial was made.

HPI = History of PResent Illness

I think she forgot to write / delete the HPI on some of the headings in my report, as I don't and haven't had any substance abuse issues or suicidal thoughts.

As for everything else, I am now taking Sertraline 200mg a day, Buproprion 200mg a day, and Trazadone 100mg a day. I am also now getting pain management throught the home health, they are giving me 15mg Morphine 2 times a day and Tramadol 4 times a day. I have not noticed a big change in my mood / mental state, but I for the first time in a long time have had a lot less pain.

[donews]

As per some questions in the thread that I posted my claim timeline in, I am updating the status of my Depression claim.

I think I understand a little more about what my records and the VA mental health doc ( i dunno if she is phycologist or phyciatrist) indicated about my depression and ptsd.

If I add them all together, it basically amount to I have Major Depression due to two tours in nam and several of my service connected conditions. It does not really go into which is the most prevalent reason, nor do I think that is a major factor in my claim as it should be service connected either way.

They also go on to say that my depression is aggrivated by chronic pain, heart disease (service connected now), the loss of my wife to cancer when she was 48, and the loss of my job due to my service connected conditions.

They state that I either have a slight case of PTSD or at least a non compensable cause of PTSD. It basically states that they would have to investigate further but doubted it would meet the criteria of a PTSD at this time.

In general the last time I dicuss my condition with the Va mental health doc, she said my gaf was about 35.

They list that I spend about 20-22 hours a day in bed most days, that I don't give a sh&t (thats in the records) about anything or myself, that I can not be employed not only due to my physical health, but also due to my depression. They also go on to say that I am non functioning, do not leave the house, am not suicidal but couldn't care one way or the other if I die sooner or later.

The VA mental health doc said she was goign to put as much as possible in my records to indicate that the depression was tied to service, my time in nam, and my service connected conditions, to make sure things are clear in my record.

I originally filed for Depression as secondary to DMII in 2005 when I filed my original claim for compensation. In 2006 they denied my Depression stating that it was caused by my Heart Disease (my heart disease claim was on appeal at that time).

Now fast forward to January 2008 and they finally after getting their heads straight grant me service connection for all of my heart diseases. However, the VA being as they are did not nor would they pick up the Depression claim and go back and give it service connection to fix it.

My thought is that they shoudl grant me Service Connection (I do not care if its due to heart disease or DMII or directly to my service in nam) for the depression and back date the claim to the orginal date of April 2005.

The DAV rep said that was unlikely because the first thing the VA would do if they granted the Service Connection is they would date it the same as if it was a new claim. He said we might be able to fight and argue it to get the former date, but it was unlikely that it would be given at first.

I feel that I should be at least 70% based on what I heard of other vets and their claims for Major Depression, yes I know its gonne be different, and I am not that same as them, I basically I have seen a few other vets in the condition I am and they were rated 70-100%.

So now that I have requested the DRO hearing for my Heart claim to get that fixed, my next move is to fill out an NOD that asks for a DRO hearing to fix my Depression claim.

Ok enough rambling for now, I do have a question to add tho:

Any opinions as to if you think I should be due an effective date of the original claim in 2005?