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UPDATE AGAIN***UPDATE on RFE for my husband

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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
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2 minutes ago, Bwaveteran said:

I believe, they only can reduce his percentage once the proposal is final.

Once it’s proposed, they give him a certain amount of time to appeal it or respond. I’m pretty certain, they can’t just drop his rating without due process.

I believe your correct. I just hate waiting for the mail haha. They should be able to give you an instant notice too!

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