Diagnostic Assessment — Depressive Disorder
Example 1 of 1 · fictitious patient (Veteran DV)
Diagnostic Assessment
Depressive Disorder
BOP Code: 12 of 2024 (Depressive Disorder)
RH Code: 11 of 2024 (Depressive Disorder)
ADF History
Veteran DV, date of birth 08 March 1965, Australian Army, Medical Laboratory Technician with field medic duties, later Sergeant, enlisted 16 January 1984, medically discharged 30 June 2012. Operational service: Middle East Area of Operations (Iraq), 10 February 2003 to 30 June 2003 (warlike); Afghanistan, 01 March 2006 to 30 October 2006 (warlike).
Occupational History
As a medical laboratory technician the veteran processed pathology and histology specimens in garrison health facilities, working daily with xylene, toluene and other organic solvents, often in small rooms with poor ventilation. On deployment she served as a field medic and laboratory technician at forward and role 2 facilities, treating and evacuating casualties, triaging local nationals and travelling with medical evacuation convoys and aircraft.
Deployed health personnel are exposed to life-threatening incidents, mass casualties, the dead and the critically injured, and decisions about who can and cannot be treated, all recognised causes of posttraumatic stress disorder, moral injury and depression. Laboratory work carries chronic solvent exposure, and shift work and repeated deployments disrupt sleep and family life.
History
Veteran DV, a medical laboratory technician and field medic in the Australian Army, developed a depressive disorder on 15 June 2009, three months after the birth of her son, after captivity in Iraq in 2003, combat, casualty and moral trauma in Afghanistan in 2006, a fatal helicopter accident in 2007 that left her with brain and spinal injuries, posttraumatic stress disorder, epilepsy and chronic pain, and a series of losses in 2008 and 2009. The disorder worsened to a severe episode with suicidal ideation requiring admission on 08 July 2009.
Timeline
- 25 Mar 2003 — On warlike service in Iraq the veteran's medical vehicle was captured at a checkpoint by an opposing armed force. She was held as a prisoner of war for eleven days, threatened with a rifle at her head during interrogation, struck repeatedly and kept in isolation before her release. A psychologist recorded acute stress symptoms on her repatriation, and her history of severe physical and emotional abuse by her stepfather between the ages of 6 and 15. "held captive eleven days, assaulted"
- 14 Aug 2006 — On warlike service in Afghanistan her medical evacuation convoy was ambushed. Under fire she shot and killed an attacker who reached her vehicle, then cleared a soldier who died beside her and two critically injured casualties. On 02 Sep 2006, under the rules then in force, she was ordered not to treat a seriously burned local child at the gate of the facility, and she learned later that the child had died. She also witnessed the bodies of villagers who had been executed by insurgents. "ambush, killed attacker, cleared casualties"
- 22 Oct 2007 — During an aeromedical evacuation exercise in Australia her helicopter made a heavy landing. The pilot, a friend, was killed in front of her, and she helped extract a critically injured crewman. She sustained an L1 burst fracture and a moderate traumatic brain injury with a frontal contusion, and was in intensive care for four days. Controlled-release oxycodone was started for back pain. "helicopter crash, L1 burst fracture, TBI"
- 12 Mar 2008 — A psychiatrist diagnosed posttraumatic stress disorder related to the captivity, the ambush and the crash, with alcohol use disorder (about 60 grams a day) and chronic insomnia disorder present since February 2008. A neurologist had diagnosed post-traumatic epilepsy after two seizures and commenced levetiracetam. She had daily tinnitus from the ambush and the crash, used a masking device, and had had severe plaque psoriasis needing daily treatment since 2001. She smoked about 25 cigarettes a day. "PTSD, AUD, insomnia, epilepsy"
- 18 Nov 2008 — Her husband, an infantry soldier, survived an improvised explosive device strike on warlike service in Afghanistan with a traumatic brain injury and fractures, and his health deteriorated over the following months with posttraumatic stress disorder and cognitive impairment. She was then 24 weeks pregnant with twins after IVF, having had irregular cycles, hot flushes and a raised FSH since late 2007. "husband IED, life-threatening injuries"
- 12 Jan 2009 — Ultrasound at 32 weeks showed the death in utero of one of her twins. On 02 Feb 2009 her closest friend, a fellow medic, was killed in Afghanistan. Her surviving son was born by caesarean section on 10 Mar 2009. A neurologist recorded that levetiracetam could not be stopped, as lamotrigine had caused a severe rash and valproate was contraindicated. "fetal death of twin, friend killed"
- 10 Jun 2009 — Having returned to part-time laboratory duties on 01 Jun 2009, she was exposed to dichlorvos during pest fumigation of the laboratory building. She developed miosis, bronchial secretions, bradycardia and diarrhoea within hours, with depressed cholinesterase, and was treated with atropine in intensive care. Prednisolone 50 mg daily was given from 11 to 20 Jun 2009 for bronchospasm. She had abruptly reduced her oxycodone on 01 Jun 2009. "dichlorvos poisoning, atropine, ICU"
- 18 Jun 2009 — She presented with three days of pervasive low mood, anhedonia, tearfulness, guilt about her twin, early waking, poor appetite and hopelessness. She had been taking extra oxycodone before reducing it, and was drinking heavily and using cannabis. Edinburgh Postnatal Depression Scale 19, PHQ-9 score 16. TSH 24 mU/L with low free T4 (postpartum thyroiditis), 25-hydroxyvitamin D 21 nmol/L, BMI 32.4. Psychiatric review was waitlisted for six weeks. "low mood, anhedonia, PHQ-9 16"
- 08 Jul 2009 — She was admitted to a psychiatric unit with a severe major depressive episode, PHQ-9 score 26, active suicidal ideation and psychomotor retardation, after drinking heavily until 19 Jun 2009, stopping alcohol and cannabis abruptly on 20 Jun 2009, relapsing on oxycodone on 25 Jun 2009 and stopping it again on 30 Jun 2009. The psychiatrist diagnosed major depressive disorder, with substance/medication-induced and medical (hypothyroid) components, and commenced sertraline and psychotherapy. "severe MDE, suicidal, PHQ-9 26"
Symptoms
At onset the veteran had pervasive low mood, loss of interest and pleasure, tearfulness, guilt, early morning waking, poor appetite, fatigue and hopelessness. Within weeks these worsened to a severe episode with psychomotor retardation, inability to care for herself and her son without help, and active suicidal ideation.
She now reports persistent low mood, low motivation, poor concentration, social withdrawal and disturbed sleep despite treatment, with recurrent episodes of more severe depression.
Imaging
- 22 Oct 2007 — CT brain and spine: "Small left frontal contusion. Burst fracture of L1 with 30 per cent loss of height and minor retropulsion."
- 20 Feb 2008 — MRI brain: "Gliosis and haemosiderin at the site of the left frontal contusion, consistent with previous traumatic brain injury."
Onset Date
The most likely date of onset of this condition is 15 Jun 2009.
At that date the veteran was serving full time with a health support unit in Australia, three months after the birth of her son and on part-time duties. Five days earlier she had been poisoned by dichlorvos at work, and she was taking prednisolone, levetiracetam and oxycodone.
This date is appropriate because her postnatal check of 02 Jun 2009 recorded normal mood with an Edinburgh Postnatal Depression Scale score of 6, and she first presented on 18 Jun 2009 with symptoms of three days' duration. It falls within continuous full-time service.
For the stressor factors, the 5 years before onset run from 15 Jun 2004 to 15 Jun 2009, containing the ambush, the moral injury and the casualty clearance in Afghanistan in 2006 and the helicopter crash of 22 Oct 2007; the 2 years before onset run from 15 Jun 2007 to 15 Jun 2009, containing the crash, her husband's injury of 18 Nov 2008 and her friend's death of 02 Feb 2009; and the 1 year before onset runs from 15 Jun 2008 to 15 Jun 2009. The 6 months before onset run from 15 Dec 2008 to 15 Jun 2009 and contain the fetal death of 12 Jan 2009. The captivity of March 2003 and the childhood abuse preceded onset. The 3 years before onset run from 15 Jun 2006 to 15 Jun 2009 and contain the crash injuries. For the 30-day factors, the window runs from 16 May 2009 to 15 Jun 2009 and contains the oxycodone reduction of 01 Jun 2009, the dichlorvos poisoning of 10 Jun 2009, prednisolone from 11 Jun 2009, opioid and alcohol intoxication and levetiracetam. The insomnia was present from February 2008, more than 1 year before onset; the psoriasis from 2001, more than 5 years before onset; the back pain from October 2007; and she had smoked at least 20 cigarettes a day for more than 2 years. The solvent exposure ran from February 2002 to May 2008, ending within 2 years of onset.
For the worsening factors, the documented clinical worsening is on 08 Jul 2009. The 30 days before it run from 08 Jun 2009 to 08 Jul 2009, containing the dichlorvos poisoning, the prednisolone, heavy drinking to 19 Jun 2009, cessation of alcohol and cannabis on 20 Jun 2009, and the oxycodone relapse of 25 Jun 2009 and its cessation on 30 Jun 2009. The 6 months before it run from 08 Jan 2009 to 08 Jul 2009 and contain the fetal death of 12 Jan 2009; the 1 year before it runs from 08 Jul 2008 to 08 Jul 2009; and the 2 years before it from 08 Jul 2007 to 08 Jul 2009.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Depressive Disorder: major depressive disorder, single episode, severe without psychotic features (ICD-10-AM F32.2), with peripartum onset, with substance/medication-induced and medical (hypothyroid) contributions, under the Statements of Principles concerning depressive disorder, Balance of Probabilities No. 12 of 2024 and Reasonable Hypothesis No. 11 of 2024.
A depressive disorder is a mood disorder marked by persistent low mood or loss of interest and pleasure, with changes in sleep, appetite, energy, concentration and psychomotor activity, feelings of worthlessness or guilt and thoughts of death or suicide, causing significant distress and impairment. It arises from an interaction of traumatic and adverse life events, existing mental and physical illness, hormonal change, medicines and substances. A depressive disorder may be substance/medication-induced, or due to another medical condition such as hypothyroidism or brain injury.
The disorder followed captivity, combat and moral trauma on warlike service, a fatal service accident with brain and spinal injuries, posttraumatic stress disorder, epilepsy, chronic pain and substance use, and a series of losses around the birth of her son. It began on 15 June 2009 and worsened to a severe episode on 08 July 2009.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
15 June 2009.
When did the veteran first present to a health / medical provider for this condition?
18 June 2009.
When was the condition confirmed / formally diagnosed?
08 July 2009.
When did the veteran first present to you (or your practice) for this condition?
22 July 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was confirmed by a consultant psychiatrist on 08 July 2009 using DSM criteria: at least two weeks of pervasive low mood and anhedonia with sleep and appetite disturbance, fatigue, guilt, poor concentration, psychomotor retardation and suicidal ideation, causing marked impairment, meeting the criteria for a major depressive episode with peripartum onset. The psychiatrist documented that the onset followed prednisolone, dichlorvos poisoning, opioid and alcohol intoxication and withdrawal, and postpartum hypothyroidism, each of which contributed.
Validated measures were consistent: an Edinburgh Postnatal Depression Scale score of 19 and PHQ-9 score of 16 on 18 June 2009, rising to a PHQ-9 score of 26 on 08 July 2009, documenting the worsening. This meets the Statement of Principles definition of depressive disorder.
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Legislation: the clinical onset of this condition was on 15 June 2009, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service, including the helicopter accident of 2007 and the dichlorvos poisoning of 2009. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Iraq in 2003, where she was held as a prisoner of war, and in Afghanistan in 2006, where the ambush, the killing, the casualty clearance and the moral injury occurred and from which her posttraumatic stress disorder, tinnitus and alcohol use disorder arose.
Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Balance of Probabilities — Statement of Principles concerning Depressive Disorder, No. 12 of 2024
Causative factors
Factor 9(1): experiencing a category 1A stressor within the 2 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- On 22 October 2007, within the 2 years before onset, the veteran's helicopter made a heavy landing during an aeromedical evacuation exercise in Australia, a life-threatening event in which she sustained a burst fracture of L1 and a traumatic brain injury and spent four days in intensive care.
Factor 9(2): experiencing a category 1B stressor within the 2 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- In the same accident on 22 October 2007 she witnessed the pilot being killed and helped extract a critically injured crewman, within the 2 years before onset, from 15 June 2007 to 15 June 2009.
Factor 9(3): experiencing severe childhood abuse before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- A psychologist recorded on 25 March 2003 that she had suffered severe physical and emotional abuse by her stepfather between the ages of 6 and 15, including beatings requiring medical attention. This preceded onset.
Factor 9(4): having a family member or close friend who experiences a category 1A stressor within the one year before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- On 18 November 2008 her husband survived an improvised explosive device strike in Afghanistan with a traumatic brain injury and fractures, a life-threatening event, within the one year before onset, from 15 June 2008 to 15 June 2009.
Factor 9(5): experiencing the death of a family member or close friend within the 2 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Her closest friend, a fellow medic, was killed in Afghanistan on 02 February 2009, and the pilot killed on 22 October 2007 was also a friend, both within the 2 years before onset.
Factor 9(6): experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 6 months before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Ultrasound on 12 January 2009 showed the death in utero of one of her twins, within the 6 months before onset, from 15 December 2008 to 15 June 2009.
Factor 9(7): experiencing a category 2 stressor within the 6 months year before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- From November 2008 her husband's health deteriorated markedly with posttraumatic stress disorder and cognitive impairment after his injury, causing her ongoing distress and worry, and from mid 2008 she experienced persistent conflict with a supervisor over her duties and her pregnancy-related restrictions. These category 2 stressors were present throughout the 6 months before onset.
Factor 9(8): having a clinically significant disorder of mental health within the 2 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- A psychiatrist diagnosed posttraumatic stress disorder and alcohol use disorder on 12 March 2008, both warranting ongoing management, within the 2 years before onset.
Factor 9(9): having a sleep-wake disorder for at least the one year before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Chronic insomnia disorder was diagnosed from February 2008 and persisted throughout the one year before onset, from 15 June 2008 to 15 June 2009.
Factor 9(10): having an injury which is life-threatening or which results in serious physical or cognitive disability, within the 3 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- The burst fracture of L1 and moderate traumatic brain injury of 22 October 2007 were life-threatening and resulted in serious physical disability and post-traumatic epilepsy, within the 3 years before onset.
Factor 9(11): having a severe, chronic medical condition for at least the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Severe plaque psoriasis, present since 2001, substantially affected her work and social functioning and required daily topical and phototherapy treatment under a dermatologist, throughout the 5 years before onset, from 15 June 2004 to 15 June 2009.
Factor 9(12): having epilepsy at the time of the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Post-traumatic epilepsy was diagnosed after two seizures in early 2008 and was present at onset, treated with levetiracetam.
Factor 9(13): having persistent pain of at least 6 months duration at the time of the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Continuous lumbar pain from the L1 burst fracture of October 2007, interfering with her work and daily activities, had been present for more than 19 months at onset.
Factor 9(14): experiencing pregnancy or the first 12 months after childbirth as a parent, at the time of the clinical onset of major depressive disorder, major depressive episode or persistent depressive disorder; — MET
- Her son was born on 10 March 2009, and onset on 15 June 2009 fell within the first 12 months after childbirth. The psychiatrist specified peripartum onset.
Factor 9(15): having another medical condition, including an endocrine, cardiovascular, respiratory, metabolic, infectious or neurological disorder, where the signs or symptoms of depression are directly related to the pathological process of the medical condition and not solely due to its psychosocial stress effects, at the time of the clinical onset of “depressive disorder due to another medical condition”; — MET
- Postpartum thyroiditis caused hypothyroidism, with a TSH of 24 mU/L and low free T4 on 18 June 2009, present at onset. The psychiatrist recorded that the psychomotor slowing and fatigue were directly related to the hypothyroidism, and the frontal brain injury also contributed directly.
Factor 9(16): taking mefloquine or corticosteroids, excluding topical or inhaled corticosteroids, within the 30 days before the clinical onset of substance/medication-induced depressive disorder, where substance/medication-induced depressive disorder persists after the discontinuation or tapering of mefloquine or corticosteroid therapy; — MET
- Prednisolone 50 mg daily was given from 11 to 20 June 2009 for bronchospasm after the dichlorvos poisoning, within the 30 days before onset, and the depressive symptoms persisted after it was stopped.
Factor 9(17): using a psychoactive substance from the specified list of psychoactive substances at an intoxicant dose within the 30 days before the clinical onset of substance/medication-induced depressive disorder; — MET
- In the 30 days before onset, from 16 May 2009 to 15 June 2009, the veteran took extra doses of oxycodone, an opioid, to the point of sedation and euphoria, as recorded on 18 June 2009.
Factor 9(18): taking a drug that cannot be ceased or substituted in the long term and which is associated in the individual with the development of depressive symptoms during drug therapy and either: (a) the improvement of depressive symptoms within days or weeks of discontinuing or tapering drug therapy; or (b) the redevelopment of depressive symptoms on rechallenge with the same drug; where the drug was being taken within the 30 days before the clinical onset of substance/medication-induced depressive disorder; — MET
- Levetiracetam, which could not be ceased or substituted because lamotrigine had caused a severe rash and valproate was contraindicated, was associated with low mood and irritability. Her mood improved within two weeks when it was tapered in September 2008 and deteriorated again on rechallenge in October 2008. She was taking it within the 30 days before onset.
Factor 9(19): using a psychoactive chemical or substance at an intoxicant dose, which is associated in the individual with the development of depressive symptoms, and where the psychoactive chemical or substance was being taken within the 30 days before the clinical onset of substance/medication-induced depressive disorder; — MET
- She drank to intoxication, about 10 standard drinks on several nights, within the 30 days before onset, and her depressive symptoms were recorded as worse on the days after drinking.
Factor 9(20): having ceased or reduced therapeutic or illicit drug use or other substance use within the 30 days before the clinical onset of substance/medication-induced depressive disorder; — MET
- On 01 June 2009 she abruptly reduced her oxycodone from 80 mg to 20 mg a day, within the 30 days before onset.
Factor 9(21): having an alcohol use disorder or a substance use disorder at the time of the clinical onset of substance/medication-induced depressive disorder; — MET
- She had alcohol use disorder, diagnosed on 12 March 2008, and an opioid use disorder recorded in May 2009, both present at onset.
Worsening factors
Factor 9(22): experiencing a category 1A stressor within the 2 years before the clinical worsening of depressive disorder; — MET
- The life-threatening helicopter accident of 22 October 2007 fell within the 2 years before the worsening, from 08 July 2007 to 08 July 2009.
Factor 9(23): experiencing a category 1B stressor within the 2 years before the clinical worsening of depressive disorder; — MET
- Witnessing the pilot's death and extracting a critically injured crewman on 22 October 2007 fell within the 2 years before the worsening.
Factor 9(24): experiencing severe childhood abuse before the clinical worsening of depressive disorder; — MET
- The severe childhood abuse preceded the worsening.
Factor 9(25): having a family member or close friend who experiences a category 1A stressor within the 1 year before the clinical worsening of depressive disorder; — MET
- Her husband's life-threatening injury on 18 November 2008 fell within the 1 year before the worsening.
Factor 9(26): experiencing the death of a family member or close friend within the 2 years before the clinical worsening of depressive disorder; — MET
- The deaths of her friend on 02 February 2009 and of the pilot on 22 October 2007 fell within the 2 years before the worsening.
Factor 9(27): experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 6 months before the clinical worsening of depressive disorder; — MET
- The fetal death of 12 January 2009 fell within the 6 months before the worsening, from 08 January 2009 to 08 July 2009.
Factor 9(28): experiencing a category 2 stressor within the 6 months before the clinical worsening of depressive disorder; — MET
- Her husband's deteriorating health and the workplace conflict continued throughout the 6 months before the worsening.
Factor 9(29): having a clinically significant disorder of mental health within the 2 years before the clinical worsening of depressive disorder; — MET
- Posttraumatic stress disorder and alcohol use disorder were present within the 2 years before the worsening.
Factor 9(30): having a sleep-wake disorder for the 1 year before the clinical worsening of depressive disorder; — MET
- Chronic insomnia disorder was present throughout the 1 year before the worsening.
Factor 9(31): having an injury which is life-threatening or which results in serious physical or cognitive disability, within the 3 years before the clinical worsening of depressive disorder; — MET
- The crash injuries of October 2007 fell within the 3 years before the worsening.
Factor 9(32): having a severe, chronic medical condition for at least the 5 years before the clinical worsening of depressive disorder; — MET
- Severe psoriasis had been present for more than 5 years before the worsening.
Factor 9(33): having epilepsy at the time of the clinical worsening of depressive disorder; — MET
- Post-traumatic epilepsy was present at the worsening on 08 July 2009.
Factor 9(34): having persistent pain of at least 6 months duration at the time of the clinical worsening of depressive disorder; — MET
- Continuous lumbar pain of more than 20 months' duration was present at the worsening on 08 July 2009.
Factor 9(35): experiencing pregnancy or the first 12 months after childbirth as a parent, at the time of the clinical worsening of depressive disorder; — MET
- The worsening on 08 July 2009 fell within the first 12 months after the birth of her son.
Factor 9(36): having another medical condition, including an endocrine, cardiovascular, respiratory, metabolic, infectious or neurological disorder, where the signs or symptoms of depression are directly related to the pathological process of the medical condition and not solely due to its psychosocial stress effects, at the time of the clinical worsening of depressive disorder; — MET
- Untreated postpartum hypothyroidism was present at the worsening on 08 July 2009, directly contributing to the psychomotor retardation.
Factor 9(37): taking mefloquine or corticosteroids, excluding topical or inhaled corticosteroids, within the 30 days before the clinical worsening of depressive disorder, where depressive disorder persists after the discontinuation or tapering of mefloquine or corticosteroid therapy; — MET
- Prednisolone from 11 to 20 June 2009 fell within the 30 days before the worsening, and the depression persisted after it stopped.
Factor 9(38): using a psychoactive substance from the specified list of psychoactive substances at an intoxicant dose within the 30 days before the clinical worsening of depressive disorder; — MET
- On 25 June 2009 she relapsed on oxycodone, taking it to the point of sedation, within the 30 days before the worsening.
Factor 9(39): taking a drug that cannot be ceased or substituted in the long term and which is associated in the individual with the worsening of depressive symptoms during drug therapy and either: (a) the improvement of depressive symptoms within days or weeks of discontinuing or tapering drug therapy; or (b) the worsening of depressive symptoms on rechallenge with the same drug; where the drug was being taken within the 30 days before the clinical worsening of depressive disorder; — MET
- Levetiracetam, which could not be ceased or substituted and had been associated with worsening mood on rechallenge, was taken throughout the 30 days before the worsening.
Factor 9(40): using a psychoactive chemical or substance at an intoxicant dose, which is associated in the individual with the worsening of depressive symptoms, and where the psychoactive chemical or substance was being taken within the 30 days before the clinical worsening of depressive disorder; — MET
- She drank to intoxication on several nights between 12 and 19 June 2009, with worse mood after each episode, within the 30 days before the worsening.
Factor 9(41): having ceased or reduced therapeutic or illicit drug use or other substance use within the 30 days before the clinical worsening of depressive disorder; — MET
- She stopped alcohol and cannabis abruptly on 20 June 2009, and stopped oxycodone again on 30 June 2009, within the 30 days before the worsening.
Factor 9(42): having an alcohol use disorder or a substance use disorder at the time of the clinical worsening of depressive disorder; — MET
- Alcohol use disorder and opioid use disorder were present at the worsening on 08 July 2009.
Factor 9(43): inability to obtain appropriate clinical management for depressive disorder before the clinical worsening of depressive disorder. — MET
- After presenting on 18 June 2009 the veteran was waitlisted for six weeks for psychiatric review, no perinatal mental health service was available through her unit, and antidepressant treatment was deferred pending specialist advice because she was breastfeeding. Her depression was untreated for three weeks and worsened to a severe episode with suicidal ideation requiring admission on 08 July 2009. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management before the clinical worsening.
Reasonable Hypothesis — Statement of Principles concerning Depressive Disorder, No. 11 of 2024
Causative factors
Factor 9(1): being a prisoner of war before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- On 25 March 2003, on warlike service in Iraq, the veteran was captured by an opposing armed force and held as a prisoner of war for eleven days, before onset.
Factor 9(2): experiencing a category 1A stressor within the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- On 14 August 2006, on warlike service in Afghanistan, her convoy was ambushed and she came under direct fire, a life-threatening event, within the 5 years before onset. The helicopter accident of 22 October 2007 was a further life-threatening event within that period.
Factor 9(3): experiencing a category 1B stressor within the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- During the ambush in Afghanistan on 14 August 2006 she shot and killed an attacker, witnessed a soldier killed beside her, cleared critically injured casualties and later witnessed the bodies of executed villagers, within the 5 years before onset.
Factor 9(4): experiencing severe childhood abuse before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Severe physical and emotional abuse by her stepfather from age 6 to 15 was recorded by a psychologist after her captivity in Iraq in 2003. It preceded onset.
Factor 9(5): experiencing a potentially morally injurious event within the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- On 02 September 2006, on warlike service in Afghanistan, she was ordered not to treat a seriously burned local child, who later died. This transgressed her deeply held beliefs as a health worker, and the psychiatrist recorded persisting guilt and shame about it. It was within the 5 years before onset.
Factor 9(6): having a family member or close friend who experiences a category 1A stressor within the 2 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Her husband survived an improvised explosive device strike on warlike service in Afghanistan on 18 November 2008, within the 2 years before onset.
Factor 9(7): experiencing the death of a family member or close friend within the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Her closest friend, a fellow medic, was killed on warlike service in Afghanistan on 02 February 2009, within the 5 years before onset.
Factor 9(8): experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 6 months before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- The death in utero of one of her twins on 12 January 2009 fell within the 6 months before onset.
Factor 9(9): experiencing a category 2 stressor within the one year before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- The major deterioration in her husband's health after his injury on warlike service in Afghanistan, and her ongoing workplace conflict, were present throughout the one year before onset.
Factor 9(10): having a clinically significant disorder of mental health within the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Posttraumatic stress disorder arising from her captivity in Iraq and the ambush in Afghanistan, and alcohol use disorder, were diagnosed on 12 March 2008, within the 5 years before onset.
Factor 9(11): having a sleep-wake disorder for at least the 6 months before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Chronic insomnia disorder, driven by nightmares of the ambush and captivity, was present from February 2008, for more than the 6 months before onset.
Factor 9(12): having an injury which is life-threatening or which results in serious physical or cognitive disability, within the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- The L1 burst fracture and traumatic brain injury of 22 October 2007 were life-threatening and caused serious physical and cognitive disability, within the 5 years before onset.
Factor 9(13): having a severe, chronic medical condition for at least the 2 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Severe plaque psoriasis requiring daily management had been present since 2001, more than 2 years before onset.
Factor 9(14): having epilepsy at the time of the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Post-traumatic epilepsy after the brain injury of October 2007 was present at onset.
Factor 9(15): having severe and permanent tinnitus at the time of the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Daily tinnitus from blast and gunfire in the ambush in Afghanistan in 2006, made worse by the 2007 crash, required a masking device and disturbed her sleep and concentration. It was present at onset.
Factor 9(16): having persistent pain of at least 3 months duration at the time of the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Continuous lumbar pain from the L1 fracture had been present for more than 19 months at onset.
Factor 9(17): having untreated or unsuccessfully treated vitamin D deficiency, with a serum 25-hydroxyvitamin D level of less than 25 nanomoles per litre, at the time of the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Serum 25-hydroxyvitamin D was 21 nmol/L on 18 June 2009 and had not been treated, present at onset.
Factor 9(18): being obese at the time of the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder; — MET
- Her BMI was 32.4 on 18 June 2009, at onset.
Factor 9(19): experiencing pregnancy or the first 12 months after childbirth as a parent, at the time of the clinical onset of major depressive disorder, major depressive episode or persistent depressive disorder; — MET
- Onset on 15 June 2009 fell within the first 12 months after the birth of her son on 10 March 2009.
Factor 9(20): being in the menopausal transition or within the 2 years after the final menstrual period at the time of the clinical onset of major depressive disorder, major depressive episode or persistent depressive disorder; — MET
- Irregular cycles, hot flushes and a raised FSH had been recorded since late 2007, marking the menopausal transition, which continued after the birth and was present at onset at age 44.
Factor 9(21): having another medical condition, including an endocrine, cardiovascular, respiratory, metabolic, infectious or neurological disorder, where the signs or symptoms of depression are directly related to the pathological process of the medical condition and not solely due to its psychosocial stress effects, at the time of the clinical onset of “depressive disorder due to another medical condition”; — MET
- Postpartum hypothyroidism, with a TSH of 24 mU/L, and the frontal brain injury were present at onset and were recorded by the psychiatrist as directly causing part of the depressive picture.
Factor 9(22): taking mefloquine or corticosteroids, excluding topical or inhaled corticosteroids, within the 30 days before the clinical onset of substance/medication-induced depressive disorder, where substance/medication-induced depressive disorder persists after the discontinuation or tapering of mefloquine or corticosteroid therapy; — MET
- Prednisolone 50 mg daily from 11 to 20 June 2009 was taken within the 30 days before onset, and the depression persisted after it was stopped.
Factor 9(23): using a psychoactive substance from the specified list of psychoactive substances at an intoxicant dose within the 30 days before the clinical onset of substance/medication-induced depressive disorder; — MET
- She took oxycodone, an opioid, in excess of the prescribed dose to the point of sedation within the 30 days before onset.
Factor 9(24): taking a drug that cannot be ceased or substituted in the long term and which is associated in the individual with the development of depressive symptoms during drug therapy and either: (a) the improvement of depressive symptoms within days or weeks of discontinuing or tapering drug therapy; or (b) the redevelopment of depressive symptoms on rechallenge with the same drug; where the drug was being taken within the 30 days before the clinical onset of substance/medication-induced depressive disorder; — MET
- Levetiracetam could not be ceased or substituted, and her mood improved when it was tapered in September 2008 and worsened again on rechallenge. She was taking it within the 30 days before onset.
Factor 9(25): using a psychoactive chemical or substance at an intoxicant dose, which is associated in the individual with the development of depressive symptoms, and where the psychoactive chemical or substance was being taken within the 30 days before the clinical onset of substance/medication-induced depressive disorder; — MET
- Alcohol taken to intoxication within the 30 days before onset was associated in her with worsening low mood the following days.
Factor 9(26): having ceased or reduced therapeutic or illicit drug use or other substance use within the 30 days before the clinical onset of substance/medication-induced depressive disorder; — MET
- She abruptly reduced oxycodone on 01 June 2009, within the 30 days before onset.
Factor 9(27): having an alcohol use disorder or a substance use disorder at the time of the clinical onset of substance/medication-induced depressive disorder; — MET
- Alcohol use disorder, which developed after her captivity in Iraq and her service in Afghanistan, and opioid use disorder were present at onset.
Factor 9(28): having smoked tobacco products: (a) on an average of at least 20 cigarettes per day or the equivalent thereof in other tobacco products; and (b) for at least the 2 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder, premenstrual dysphoric disorder or substance/medication-induced depressive disorder; and if smoking has ceased before the clinical onset then that onset occurred within 6 months of cessation; — MET
- She smoked about 25 cigarettes a day from 1984, increasing after her warlike service, and continued through pregnancy, for more than the 2 years before onset.
Factor 9(29): inhaling, ingesting or having cutaneous contact with organic solvents, in an unventilated and confined space, on more days than not for a continuous period of at least 5 years before the clinical onset of substance/medication-induced depressive disorder, and where the clinical onset occurs within 2 years of that period; — MET
- From February 2002 to May 2008 she processed histology specimens with xylene and toluene on more days than not in a small laboratory room whose fume extraction had failed, a continuous period of more than 5 years. The exposure ended in May 2008, within 2 years of onset.
Factor 9(30): having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester or paraquat poisoning within the 30 days before the clinical onset of substance/medication-induced depressive disorder; — MET
- On 10 June 2009 she had acute cholinergic poisoning from dichlorvos, an organophosphorus ester, during fumigation of her laboratory, with miosis, bronchial secretions, bradycardia and diarrhoea within hours, within the 30 days before onset.
Worsening factors
Factor 9(31): being a prisoner of war before the clinical worsening of depressive disorder; — MET
- Her captivity as a prisoner of war in Iraq in 2003 preceded the worsening.
Factor 9(32): experiencing a category 1A stressor within the 5 years before the clinical worsening of depressive disorder; — MET
- The ambush in Afghanistan in 2006 and the helicopter accident of 2007 fell within the 5 years before the worsening.
Factor 9(33): experiencing a category 1B stressor within the 5 years before the clinical worsening of depressive disorder; — MET
- The killing, the death of a soldier beside her and the casualty clearance in Afghanistan in 2006 fell within the 5 years before the worsening.
Factor 9(34): experiencing severe childhood abuse before the clinical worsening of depressive disorder; — MET
- The severe childhood abuse preceded the worsening.
Factor 9(35): experiencing a potentially morally injurious event within the 5 years before the clinical worsening of depressive disorder; — MET
- The moral injury of 02 September 2006 in Afghanistan fell within the 5 years before the worsening.
Factor 9(36): having a family member or close friend who experiences a category 1A stressor within the 2 years before the clinical worsening of depressive disorder; — MET
- Her husband's life-threatening injury in Afghanistan on 18 November 2008 fell within the 2 years before the worsening.
Factor 9(37): experiencing the death of a family member or close friend within the 5 years before the clinical worsening of depressive disorder; — MET
- Her friend's death in Afghanistan on 02 February 2009 fell within the 5 years before the worsening.
Factor 9(38): experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 6 months before the clinical worsening of depressive disorder; — MET
- The fetal death of 12 January 2009 fell within the 6 months before the worsening.
Factor 9(39): experiencing a category 2 stressor within the 1 year before the clinical worsening of depressive disorder; — MET
- Her husband's deteriorating health and the workplace conflict continued throughout the 1 year before the worsening.
Factor 9(40): having a clinically significant disorder of mental health within the 5 years before the clinical worsening of depressive disorder; — MET
- Posttraumatic stress disorder and alcohol use disorder were present within the 5 years before the worsening.
Factor 9(41): having a sleep-wake disorder for the 6 months before the clinical worsening of depressive disorder; — MET
- Chronic insomnia disorder was present throughout the 6 months before the worsening.
Factor 9(42): having an injury which is life-threatening or which results in serious physical or cognitive disability, within the 5 years before the clinical worsening of depressive disorder; — MET
- The crash injuries of 2007 fell within the 5 years before the worsening.
Factor 9(43): having a severe, chronic medical condition for at least the 2 years before the clinical worsening of depressive disorder; — MET
- Severe psoriasis had been present for more than 2 years before the worsening.
Factor 9(44): having epilepsy at the time of the clinical worsening of depressive disorder; — MET
- Post-traumatic epilepsy was present at the worsening on 08 July 2009.
Factor 9(45): having severe and permanent tinnitus at the time of the clinical worsening of depressive disorder; — MET
- Severe daily tinnitus from her service in Afghanistan was present at the worsening on 08 July 2009.
Factor 9(46): having persistent pain of at least 3 months duration at the time of the clinical worsening of depressive disorder; — MET
- Continuous lumbar pain was present at the worsening on 08 July 2009.
Factor 9(47): having untreated or unsuccessfully treated vitamin D deficiency, with a serum 25-hydroxyvitamin D level of less than 25 nanomoles per litre, at the time of the clinical worsening of depressive disorder; — MET
- Vitamin D deficiency remained untreated at the worsening on 08 July 2009.
Factor 9(48): being obese at the time of the clinical worsening of depressive disorder; — MET
- Her BMI was 32.1 at the worsening on 08 July 2009.
Factor 9(49): experiencing pregnancy or the first 12 months after childbirth as a parent, at the time of the clinical worsening of depressive disorder; — MET
- The worsening fell within the first 12 months after the birth of her son.
Factor 9(50): being in the menopausal transition or within the 2 years after the final menstrual period at the time of the clinical worsening of depressive disorder; — MET
- She remained in the menopausal transition at the worsening on 08 July 2009.
Factor 9(51): having another medical condition, including an endocrine, cardiovascular, respiratory, metabolic, infectious or neurological disorder, where the signs or symptoms of depression are directly related to the pathological process of the medical condition and not solely due to its psychosocial stress effects, at the time of the clinical worsening of depressive disorder; — MET
- Untreated postpartum hypothyroidism was present at the worsening on 08 July 2009.
Factor 9(52): taking mefloquine or corticosteroids, excluding topical or inhaled corticosteroids, within the 30 days before the clinical worsening of depressive disorder, where depressive disorder persists after the discontinuation or tapering of mefloquine or corticosteroid therapy; — MET
- Prednisolone from 11 to 20 June 2009 fell within the 30 days before the worsening, and the depression persisted after it stopped.
Factor 9(53): using a psychoactive substance from the specified list of psychoactive substances at an intoxicant dose within the 30 days before the clinical worsening of depressive disorder; — MET
- Her oxycodone relapse to the point of sedation on 25 June 2009 fell within the 30 days before the worsening.
Factor 9(54): taking a drug that cannot be ceased or substituted in the long term and which is associated in the individual with the worsening of depressive symptoms during drug therapy and either: (a) the improvement of depressive symptoms within days or weeks of discontinuing or tapering drug therapy; or (b) the worsening of depressive symptoms on rechallenge with the same drug; where the drug was being taken within the 30 days before the clinical worsening of depressive disorder; — MET
- Levetiracetam was taken throughout the 30 days before the worsening.
Factor 9(55): using a psychoactive chemical or substance at an intoxicant dose, which is associated in the individual with the worsening of depressive symptoms, and where the psychoactive chemical or substance was being taken within the 30 days before the clinical worsening of depressive disorder; — MET
- Alcohol intoxication between 12 and 19 June 2009, with worse mood after each episode, fell within the 30 days before the worsening.
Factor 9(56): having ceased or reduced therapeutic or illicit drug use or other substance use within the 30 days before the clinical worsening of depressive disorder; — MET
- She stopped alcohol and cannabis on 20 June 2009 and oxycodone on 30 June 2009, within the 30 days before the worsening.
Factor 9(57): having an alcohol use disorder or a substance use disorder at the time of the clinical worsening of depressive disorder; — MET
- Alcohol use disorder and opioid use disorder were present at the worsening on 08 July 2009.
Factor 9(58): inhaling, ingesting or having cutaneous contact with organic solvents, in an unventilated and confined space, on more days than not for a continuous period of at least 5 years before the clinical worsening of depressive disorder, and where the clinical worsening occurs within 2 years of that period; — MET
- The solvent exposure from February 2002 to May 2008 lasted more than 5 years and the worsening occurred within 2 years of its end.
Factor 9(59): having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester or paraquat poisoning within the 30 days before the clinical worsening of depressive disorder; — MET
- The dichlorvos poisoning of 10 June 2009 fell within the 30 days before the worsening.
Factor 9(60): inability to obtain appropriate clinical management for depressive disorder before the clinical worsening of depressive disorder. — MET
- The veteran was waitlisted for six weeks for psychiatric review and no perinatal mental health care was available, so her depression went untreated and worsened to a severe episode requiring admission on 08 July 2009. Her posttraumatic stress disorder from warlike service had also been managed only intermittently because of waiting lists in 2008.
The % contribution of the causes is 100% and significant.
Sequelae
The depressive disorder is a sequela of the veteran's accepted posttraumatic stress disorder, alcohol use disorder, post-traumatic epilepsy, tinnitus, traumatic brain injury and lumbar fracture, all arising from her warlike service and the 2007 service helicopter accident.
Unintended Consequence
Met. The depressive disorder is in part an unintended consequence of treatment provided by the Commonwealth: prednisolone given after the dichlorvos poisoning, levetiracetam for post-traumatic epilepsy and oxycodone for the service-related lumbar fracture are each recognised causes of depressive symptoms (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. After presenting on 18 June 2009 with a PHQ-9 score of 16, the veteran was waitlisted for six weeks for psychiatric review, no perinatal mental health service was available through her unit, and antidepressant treatment was deferred while she was breastfeeding. Within three weeks her depression worsened to a PHQ-9 score of 26 with active suicidal ideation, requiring admission on 08 July 2009. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), a delay in specialist care of this length in a high-risk postpartum patient amounts to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 25 Mar 2003, Post-repatriation psychological assessment, Psychologist
- 14 Aug 2006, Incident report and outpatient health record, Afghanistan
- 22 Oct 2007, Trauma admission, CT and intensive care record, Regional hospital
- 20 Feb 2008, MRI brain and neurology consultation, Neurologist
- 12 Mar 2008, Psychiatric assessment, Consultant psychiatrist
- 18 Nov 2008, Obstetric review, Obstetrician
- 12 Jan 2009, Obstetric ultrasound report, Radiologist
- 10 Mar 2009, Operation report, Obstetrician
- 02 Jun 2009, Postnatal check, General practitioner
- 10 Jun 2009, Emergency and intensive care admission, Regional hospital
- 18 Jun 2009, Outpatient health record and pathology, Medical Officer, Garrison health centre
- 08 Jul 2009, Psychiatric admission, Consultant psychiatrist
- Statement of Principles concerning Depressive Disorder (Balance of Probabilities) No. 12 of 2024, Repatriation Medical Authority
- Statement of Principles concerning Depressive Disorder (Reasonable Hypothesis) No. 11 of 2024, Repatriation Medical Authority
