Jump to content
  • 0

UPDATE AGAIN***UPDATE on RFE for my husband


AirForceVetsWife

Question

The claim is complete. They've mailed our packet.

 

on SC disabilities list on ebenefits it used to say Major Depressive Disorder and now it says "Major Depression (Previously diagnosed as Major Depressive Disorder)" Is that a bad sign? or are they calling MDD Major depression now? Everything I've read it says Major depression IS major depressive disorder.

Now I'm worried that this is a reduction thing.

 

This is what the American Psychiatric Association says:

Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home.

Depression symptoms can vary from mild to severe and can include:

  • Feeling sad or having a depressed mood
  • Loss of interest or pleasure in activities once enjoyed
  • Changes in appetite — weight loss or gain unrelated to dieting
  • Trouble sleeping or sleeping too much
  • Loss of energy or increased fatigue
  • Increase in purposeless physical activity (e.g., hand-wringing or pacing) or slowed movements and speech (actions observable by others)
  • Feeling worthless or guilty
  • Difficulty thinking, concentrating or making decisions
  • Thoughts of death or suicide

Symptoms must last at least two weeks for a diagnosis of depression.

 

I think I'm just getting myself super hyped up

 

Ok, I really think I'm just worrying myself for nothing because it says MDD is also known as Major Depression

 

 

 

Ok, sorry you all...I just wanted to be sure to update you all. I got his C&P this morning.

I was feeling good about it because the social/work impairment that was checked was the same as his first C&P back in 2013 when he was initially rated at 70%. Well, looking at the ratings...the one that was checked then and now is under 50%....so now I'm confused.

 

The biggest thing I see, is at the end of the new exam, the doctor put "His current mental health status is the progression of his major depressive disorder" So that doesn't show that he's better

 

But, here's the C&P with personal info redacted

 

Mental Disorders

(other than PTSD and Eating Disorders)

Disability Benefits Questionnaire

 

Is this DBQ being completed in conjunction with a VA 21-2507, C&P

Examination

Request?

[X] Yes [ ] No

SECTION I:

----------

1. Diagnosis

------------

a. Does the Veteran now have or has he/she ever been diagnosed with a mental

disorder(s)?

[X] Yes [ ] No

If the Veteran currently has one or more mental disorders that conform to

 

DSM-5 criteria, provide all diagnoses:

Mental Disorder Diagnosis #1: MAJOR DEPRESSION

b. Medical diagnoses relevant to the understanding or management of the

Mental Health Disorder (to include TBI): HTN, HX OF TACHYCARDIA, HX OF

RIGHT SHOULDER SURGERY.

2. Differentiation of symptoms

------------------------------

a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes [X] No

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes [ ] No [X] Not shown in records reviewed

3. Occupational and social impairment

-------------------------------------

a. Which of the following best summarizes the Veteran's level of

occupational

and social impairment with regards to all mental diagnoses? (Check only

one)

[X] Occupational and social impairment with reduced reliability and

productivity

b. For the indicated occupational and social impairment, is it possible to

differentiate which impairment is caused by each mental disorder?

[ ] Yes [ ] No [X] Not Applicable (N/A)

c. If a diagnosis of TBI exists, is it possible to differentiate which

occupational and social impairment indicated above is caused by the TBI?

[ ] Yes [ ] No [X] Not Applicable (N/A)

SECTION II:

-----------

Clinical Findings:

------------------

1. Evidence Review

------------------

Evidence reviewed (check all that apply):

[X] VA e-folder

[X] CPRS

[X] Other (please identify other evidence reviewed):

PRIOR CXP EXAMS.

2. History

----------

a. Relevant Social/Marital/Family history (pre-military, military, and

 

post-military):

, WAS DRIVEN HERE BY HIS WIFE AS HE

DOES NOT DRIVE MUCH ON HIGH WAY.HE IS MARRIED SINCE 2008, ONLY

MARRIAGE,HAS 2 DAUGHTERS.THIS VET WAS AIR FROCE VET,SERVED FROM 2007 TO

2012.DURING HIS CARRIER, HE WAS STATE SIDE,NOT IN ANY WAR ZONE. HIS

MOTHER AND SISTER LIVE LOCALLY.

b. Relevant Occupational and Educational history (pre-military, military,

and

post-military):

SINCE DC FROM AIR FORCE, HE HAD 5 JOBS,HIS LONGEST JOB WAS FOR TRACTOR

SUPPLY FOR 3 YRS. SINCE LAST ONE YR, HE IS WORKING FOR LOWES FULL

TIME.

HE WAS NEVER FIRED FROM ANY JOB, WENT FOT BETTER PAYING JOB.MANY OF HIS

JOBS WERE SEASONAL JOBS.

c. Relevant Mental Health history, to include prescribed medications and

family mental health (pre-military, military, and post-military):

HE IS CURRENTLY NOT IN ANY MH CARE.HE DID RECEIVE MH CARE WHILE IN AIR

FORCE.HE HAS PROBLEMS WITH SLEEP, DIFFICULTY FALLING A SLEEP, WAKING UP

AND SOME TIME DIFFICULTY FALLING A SLEEP. DAY TIME HE FFELS TIRED. HE

ISOLATES HIM SELF FROM OTHERS.IN THE PAST HE USED TO ENJOY OUT DOOR BUT

NOT ANY MORE, LOST INTEREST.WHEN HE IS DEPRESSED, HE STAYS BY HIM SELF

AND AVOIDS OTHERS.HE DOES NOT LIKE TO BE OUT AWAY FROM HOME, HE FEELS

INSECURED AND BECAUSE OF THIS HE FEELS ANGRY AT HIM SELF.AT WORK HE

TRIES TO PUT SHOW THAT HE IS FEELING GOOD BUT IN REALITY, HE DOES NOT

FEEL GGOD. IF HE HEARS CRYING BABY, HE WANTS TO GO HOME AND BE WITH HIS

KIDS.AT HOME HE DOES NOT LIKE TO INTERACT WITH HIS WIFE AND KIDS BUT

BEING AT HOME HE FEELS VERY SECURED.OFF AND ON HE FEELS WORTHLESS, AND

AT WORK HE FEELS THAT HE IS GOING TO GET FIRED AND THAT MAKE HIS JOB

HARDER TO DO.

d. Relevant Legal and Behavioral history (pre-military, military, and

post-military):

NONE

e. Relevant Substance abuse history (pre-military, military, and

post-military):

NONE

f. Other, if any:

NA

3. Symptoms

-----------

For VA rating purposes, check all symptoms that actively apply to the

 

Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Chronic sleep impairment

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social

relationships

[X] Difficulty in adapting to stressful circumstances, including work or

a

worklike setting

4. Behavioral observations

--------------------------

ALERT,ORIENTEDX3,COOPERATIVE,POOR EYE CONTACT. AFFECT IS CONSTRICTED,

DYSPHORIC MOOD. RATE OF SPEECH NORMAL, GOAL DIRECTED. NO AH/VH OR ANY OTHER

PERCEPTUAL DISTURBANCES. NOT SUICIDAL OR HOMICIDAL. NO COGNITIVE DEFICIT.

5. Other symptoms

-----------------

Does the Veteran have any other symptoms attributable to mental disorders

that are not listed above?

[ ] Yes [X] No

6. Competency

-------------

Is the Veteran capable of managing his or her financial affairs?

[X] Yes [ ] No

7. Remarks (including any testing results), if any:

---------------------------------------------------

THIS VET CONTINUES TO EXPERIENCED SXS OF DEPRESSION SUCH AS INSOMNIA, LACK

OF

ENERGY, LACK OF INTEREST, ANHEDONIA, WORTHLESS, SOCIAL ISOLATION. THESE HAS

AFFECTED HIS JOB BUT SOME HOW HE COULD KEEP THE JOB, WITH UNDERSTANDING THAT

HE HAS TO SUPPORT HIS FAMILY.

HIS CURRENT MENTAL HEALTH STATUS IS THE PROGRESSION OF HIS MAJOR DEPRESSIVE

STATE.

/es/ PRAMOD A SHAH, MD

Signed: 05/10/2019 10:45

 

 

 

This was his first one in 2013

 

 

------------

a. Does the Veteran now have or has he/she ever been diagnosed with a mental

disorder(s)?

[X] Yes[ ] No

If the Veteran currently has one or more mental disorders that conform to

DSM-IV criteria, provide all diagnoses:

Diagnosis #1: Major Depressive Disorder

ICD code: 000

Indicate the Axis category:

[X] Axis I [ ] Axis II

b. Axis III - medical diagnoses (to include TBI): Hypertension,,Tachycardia

ICD code: 000

c. Axis IV - Psychosocial and Environmental Problems (describe, if any):

Moderate - financial

d. Axis V - Current global assessment of functioning (GAF) score: 55 - 60

2. Differentiation of symptoms

------------------------------

a. Does the Veteran have more than one mental disorder diagnosed?

[ ] Yes[X] No

b. Is it possible to differentiate what symptom(s) is/are attributable to

 

each diagnosis?

No response provided.

c. Does the Veteran have a diagnosed traumatic brain injury (TBI)?

[ ] Yes[X] No[ ] Not shown in records reviewed

d. Is it possible to differentiate what symptom(s) is/are attributable to

each diagnosis?

No response provided.

3. Occupational and social impairment

-------------------------------------

a. Which of the following best summarizes the Veteran's level of

occupational

and social impairment with regards to all mental diagnoses? (Check only

one)

[X] Occupational and social impairment with reduced reliability and

productivity

b. For the indicated level of occupational and social impairment, is it

possible to differentiate what portion of the occupational and social

impairment indicated above is caused by each mental disorder?

[ ] Yes[ ] No[X] No other mental disorder has been diagnosed

c. If a diagnosis of TBI exists, is it possible to differentiate what

portion

of the occupational and social impairment indicated above is caused by

the

TBI?

[ ] Yes[ ] No[X] No diagnosis of TBI

SECTION II:

-----------

Clinical Findings:

------------------

1. Evidence review

------------------

If any records (evidence) were reviewed, please list here:

VBMS, CPRS

2. History

----------

a. Relevant Social/Marital/Family history (pre-military, military, and

post-military):

Veteran denies family history of mental illness.He is married with 2

children (2,1 year old) in Paris,Tn. Due to his depressive symptoms

they are having domestic issues.He tends to isolate a great deal.He

has

very few activities he does that he enjoys to do.

b. Relevant Occupational and Educational history (pre-military, military,

and

 

post-military):

The Veteran graduated from High School. he served in the Air Force

from

7/24/2007 - 3/27/2012. He was not in combat.He was honorably

discharged

at E4 rank.Since discharge he has been working in the receiving

department of a tractor supply company in Paris,Tn. The Veteran's

productivity and reliability have been decreasing both at work and at

home.

c. Relevant Mental Health history, to include prescribed medications and

family mental health (pre-military, military, and post-military):

He denies pre - military mental problems. His depressive symptoms

gradually came in while in the service. By Christmas 2011 he notice

fatigue, sadness, poor concentration.His depression increased over the

next many months.His depressive symptoms are manifested by feelings

sad

most of the day, ahedonia,difficulty sleeping, fatigue, poor self

esteem, decreased libido and difficulty concentrating.He sought help

for these symptoms by Nov.2011 while in the service. The first

documentation I could find was in his problem list from his VBMS note

on 11/16/2011.Because of cardiac problems he says he was not started

on

antidepressant medication.He felt it was very stressful in the

military

not to be able to do mechanic work in service because of his right

should problems. He felt this stress was a possible trigger for his

depression.He says he did see a counselor while in the service. Since

discharge he has continued to have symptoms of depression. He is not

getting mental health treatment nor dis he on any psychotropic

medication.There is a mention of ADHD in his record but at the present

time he feels this is not an issue for him. He is not hyperactive.

His

concentration difficulty appears more related to his general

depression

at the present time. He denies manic - like episodes.

Mental Status Evaluation today.

General appearance is WNL.

Veteran showed no unusual gestures or grimaces.

Affect was flat.

The veteran is oriented in all 3 spheres.

General information WNL.

Recent and remote memory intact.

Number sense WNL including subtracting serial sevens.

Veteran denied auditory and visual hallucinations and/or delusions.

Veteran denied wanting to harm or kill himself or others.The Veteran

denied suicidal or homicidal ideation or intent.

 

d. Relevant Legal and Behavioral history (pre-military, military, and

post-military):

None.

e. Relevant Substance abuse history (pre-military, military, and

post-military):

He denies illegal drug use and rarely has an alcoholic

beverage.Veteran

denies any previous alcohol or drug treatment.

f. Sentinel Event(s) (other than stressors):

No response provided.

g. Other, if any:

No response provided.

3. Symptoms

-----------

For VA rating purposes, check all symptoms that apply to the Veteran's

diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Panic attacks more than once a week

[X] Chronic sleep impairment

[X] Flattened affect

[X] Difficulty in understanding complex commands

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social

relationships

[X] Difficulty in adapting to stressful circumstances, including work or

a

worklike setting

[X] Inability to establish and maintain effective relationships

4. Other symptoms

-----------------

Does the Veteran have any other symptoms attributable to mental disorders

that are not listed above?

[ ] Y

es[X] No

5. Competency

-------------

Is the Veteran capable of managing his or her financial affairs?

[X] Yes[ ] No

6. Remarks, if any:

-------------------

 

The criteria contained in DSM-1V are being used until the time of

transition to DSM-V.I suggested the Veteran seek Mental Health treatment

for his Depression symptoms.

****************************************************************************

Medical Opinion

Disability Benefits Questionnaire

Name of patient/Veteran: Reed, Jeremy Scott

Indicate method used to obtain medical information to complete this

document:

[ ] Review of available records (without in-person or video telehealth

examination) using the Acceptable Clinical Evidence (ACE) process

because

the existing medical evidence provided sufficient information on which

to

prepare the DBQ and such an examination will likely provide no

additional

relevant evidence.

[ ] Review of available records in conjunction with a telephone interview

with the Veteran (without in-person or telehealth examination) using the

ACE process because the existing medical evidence supplemented with a

telephone interview provided sufficient information on which to prepare

the DBQ and such an examination would likely provide no additional

relevant evidence.

[ ] Examination via approved video telehealth

[X] In-person examination

Evidence review

---------------

a. Was the Veteran's VA claims file reviewed? Yes

If yes, list any records that were reviewed but were not included in the

Veteran's VA claims file:

VBMS, CPRS.

MEDICAL OPINION SUMMARY

-----------------------

So great...they checked less boxes this time...this really doesn't look good...

Edited by AirForceVetsWife (see edit history)
Link to comment
Share on other sites

  • Answers 47
  • Created
  • Last Reply

Top Posters For This Question

Recommended Posts

  • 0
  • Moderator

yes  sorry I never seen it  I deleted my post.

Thanks

Link to comment
Share on other sites

  • 0
  • Moderator

The first exam is better than the last one  the first exam   should be at least  70% rating the last exam seems the examiner never did any favors  as it looks like  a depression rating of about 30%  unless he has a 70% rating now and this was for increase ? it may get him to 100%?   but I am not familiar with this case.  and I could be wrong here.

Link to comment
Share on other sites

  • 0

Oh this worries me so much now. Here I was thinking it'd all be ok.

This was just for a 5 year re-exam. It has been almost 6 years that he has 70%. So we weren't looking for an increase, just to stay at 70%.

 

This one just seemed like they didn't do anything very in depth.

Link to comment
Share on other sites

  • 0
  • Moderator

Well he certainlycould  be rated an additional 30%/50%    he will need the 50% to be increased to the 100%   but just my opinion from the last Exam only looks to be about 30%  but I certainly could be wrong  other members will chime in and look at this last Exam....try not to worry  this is only my opinion  from reading these two exams.

Link to comment
Share on other sites

  • 0

The only thing to me though is...it says this is progression of his depression....so why reduce if this is progressing? you know? but I know, we ARE dealing with the VA

 

and since this was an RFE exam, and it has been over 5 years, my understanding is that they wouldn't be able to reduce based just on that exam

 

Link to comment
Share on other sites

  • 0
1 minute ago, Buck52 said:

Well he certainlycould  be rated an additional 30%/50%    he will need the 50% to be increased to the 100%   but just my opinion from the last Exam only looks to be about 30%  but I certainly could be wrong  other members will chime in and look at this last Exam....try not to worry  this is only my opinion  from reading these two exams.

I appreciate your input, having more eyes than mine look at it helps.

 

yea, we really would be just fine with staying put at 70%. We aren't worried about getting to 100% or anything at this point. I just hope we don't need to fight to keep his 70%. I hate this process. It just doesn't seem like this doctor did much.

I hated not being in that exam. I knew that was a bad sign

Link to comment
Share on other sites

  • 0
  • Moderator

I doubt he will be reduced from 70% , if he has 70% rating for PTSD and not depression? then for PTSD rating the next higher rating after being rated 70% is the 100%  And to get a 100% rating  he will need an additional 50% increase.

I don't think he will be reduce  but never under estimate the Darn VA.

Edited by Buck52 (see edit history)
Link to comment
Share on other sites

  • 0
3 minutes ago, Buck52 said:

I doubt he will be reduced from 70% , if he has 70% rating for PTSD and not depression? then for PTSD rating the next higher rating after being rated 70% is the 100%  And to get a 100% rating  he will need an additional 50% increase.

I don't think he will be reduce  but never under estimate the Darn VA.

He has 70% rating for Major Depressive Disorder.

I know, the VA is so unpredictable, I just hope they don't reduce.

Link to comment
Share on other sites

  • 0
  • Moderator

If he is rated for MDD the last exam don't help matters much  it seems the examiner is saying he has improved  from the last exam   if so then yes  be ready for a possible reduction   but jusy my opinion I think he will stay at 70%

go back and compare these two exams  an see which exam  got him the 70% which was probably the 1st exam   this last exam maybe an inadequate exam?  it seems incomplete,  last exam is not as bad as the first exam.

Link to comment
Share on other sites

  • 0
  • Moderator

The next time he has an C&P EXAM  you need to insist you go in with him  he needs you there with him...ask the examiner to please let you come in with him.

Link to comment
Share on other sites

  • 0
13 minutes ago, Buck52 said:

The next time he has an C&P EXAM  you need to insist you go in with him  he needs you there with him...ask the examiner to please let you come in with him.

I know, I was so prepared to go in and I walked in with him and the doctor turned around and said "I'd like to speak with him alone, please" and my husband said after they shut the door he said he really wanted me in here...and when he came out he said he thought it actually worked out well...I guess the doctor wasn't as thorough as he thought. I was not a happy camper that they didn't let me go in there.

And I had some good lay statements too...maybe that'll help tip the scales to stay where he's at.

Edited by AirForceVetsWife (see edit history)
Link to comment
Share on other sites

  • 0
  • Moderator

Well sometime an examiner can be uncaring  but you need to say he has panic attacks  bad  and you help him with those...and just insist you come in with him, but at the same time you don't want the examiner to get pissed off before the exam, I understand what you mean though   when the examiner puts it to you like that  its hard to know what to do at that time.

Link to comment
Share on other sites

  • 0
3 minutes ago, Buck52 said:

Well sometime an examiner can be uncaring  but you need to say he has panic attacks  bad  and you help him with those...and just insist you come in with him, but at the same time you don't want the examiner to get pissed off before the exam, I understand what you mean though   when the examiner puts it to you like that  its hard to know what to do at that time.

Definitely so. I didn't want to mess up the process...but at the same time...I didn't want the doctor to overlook anything. Fingers crossed this will be ok

Link to comment
Share on other sites

  • 0
  • Moderator

Let other  elder members that are helping you give their opinion on this last exam?

I been known to be wrong  on these exams   so just wait and see what others opinions will be....you maybe surprised in a good way.

Link to comment
Share on other sites

  • 0
2 minutes ago, Buck52 said:

Let other  elder members that are helping you give their opinion on this last exam?

I been known to be wrong  on these exams   so just wait and see what others opinions will be....you maybe surprised in a good way.

Well, you all have been an awesome, welcomed help so I appreciate it all!

 

I would welcome a good surprise haha

Link to comment
Share on other sites

Join the conversation

You can post now and register later. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.

Guest
Answer this question...

×   Pasted as rich text.   Paste as plain text instead

  Only 75 emoji are allowed.

×   Your link has been automatically embedded.   Display as a link instead

×   Your previous content has been restored.   Clear editor

×   You cannot paste images directly. Upload or insert images from URL.



×
×
  • Create New...

Important Information

{terms] and Guidelines