Major Depressive Disorder

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Major Depressive Disorder

Example 1 of 1 · fictitious patient (Veteran V)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

BOP Code: 12 of 2024 RH Code: 11 of 2024

ADF History

The veteran, Avionics Mechanic, 12 July 1990, 27 July 1996

Occupational History

As an Avionics Mechanic in the Royal Australian Air Force, the veteran role involved maintenance and repair of complex aircraft electronic systems under significant operational pressures. The occupation required working in physically demanding conditions including confined aircraft spaces, heights, and exposure to high noise environments. Chemical exposures included aviation fuels, hydraulic fluids, lubricants, industrial solvents, and cleaning agents through both inhalation and dermal contact. Physical demands involved manual handling of equipment exceeding 20 kilograms, sustained awkward postures, and repetitive movements placing biomechanical stress on the musculoskeletal system. The military environment created psychological stressors through strict discipline requirements, hierarchical pressures, operational readiness demands, and responsibility for aircraft safety directly impacting aircrew welfare.

History

The veteran an Avionics Mechanic in the Royal Australian Air Force, developed Major Depressive Disorder following evolution from an initial adjustment disorder during military service. The condition crystallized by discharge in 2000 following cumulative physical injuries, family stressors, and perceived institutional betrayal when compassionate leave was denied.

Timeline

1995-1996 - Initial development of adjustment disorder with mixed anxiety and depressed mood during military service. Symptoms arose following confluence of multiple stressors including physical injuries and parental separation. Documentation shows "adjustment disorder" requiring chaplaincy support during this period. Emotional and behavioral symptoms developed within three months of identified stressors causing marked distress. Sleep disturbance and early mood symptoms emerged during this timeframe. Initial psychiatric vulnerability established through inadequately treated adjustment disorder.
1996-2000 - Progressive evolution from adjustment disorder to discrete depressive symptoms during continued military service. Chronic pain from multiple musculoskeletal injuries created ongoing psychological burden affecting mood. Experience of "administrative violence" when compassionate leave denied contributed to feelings of worthlessness. Alcohol use increased as maladaptive coping strategy for managing depressive symptoms. Occupational functioning declined with consideration of medical discharge options. Depressive symptoms crystallized with persistent low mood, anhedonia, and fatigue documented.
27 Jul 1996 - Discharged from RAAF with established psychiatric condition documented in discharge paperwork. Medical records note ongoing "sporting injury" affecting physical and psychological wellbeing. Major depressive disorder established by time of separation though not formally diagnosed. Symptoms included depressed mood, loss of interest in activities, sleep disturbance, and fatigue. Functional impairment in occupational and social domains necessitated compassionate discharge. Post-discharge period marked by continuation and progression of depressive symptoms.
2000-2019 - Extended period without structured mental health treatment despite persistent depressive symptoms. Chronic course established with symptoms including low mood, anhedonia, and social withdrawal. Alcohol use disorder developed as "self-medication" for untreated depression consuming 10 drinks nightly. Social isolation progressed with complete avoidance of non-essential social interactions. Occupational functioning maintained despite symptoms through employment as electrician. Marriage provided protective factor though interpersonal difficulties emerged from untreated symptoms.
2019 - Severe decompensation with suicidal ideation during legal stressors approximately 4 years prior to assessment. Had formulated plan and taken "preparatory steps" indicating severe depressive episode. Prescribed antidepressant medication for first time but without structured follow-up. Incomplete treatment engagement with medication discontinued after initial prescription. Crisis resolved but underlying depression remained inadequately treated. This episode represents peak severity of depressive disorder requiring intervention.
04 Jul 2019 - Comprehensive psychiatric assessment confirming Major Depressive Disorder diagnosis meeting full DSM-5-TR criteria. DASS21 Depression score 9 indicating "Moderate" severity of depressive symptoms. Current symptoms include persistent low mood, anhedonia, psychomotor retardation, hopelessness, worthlessness, and emotional numbing. Significant functional impairment across social, occupational, and personal domains documented. Comorbid conditions including Generalized Anxiety Disorder and Alcohol Use Disorder identified. Treatment recommendations include antidepressant therapy, psychological intervention, and structured care plan.

Symptoms

At initial development during service, the veteran experienced depressed mood most days, diminished interest in previously enjoyed activities, sleep disturbance with insomnia, fatigue and loss of energy, feelings of worthlessness particularly after compassionate leave denial, difficulty concentrating affecting work performance, and early alcohol use for symptom management. These symptoms caused clinically significant distress and impairment in military functioning.

Current symptoms demonstrate moderate depression with persistent low mood occurring on most days, marked anhedonia with inability to experience positive emotions, psychomotor retardation with difficulty initiating activities, feelings of hopelessness regarding the future, periodic feelings of worthlessness, emotional numbing and affective restriction, fatigue without apparent cause occurring frequently, significant weight changes not documented but poor dietary habits noted, insomnia continuing as chronic problem, diminished concentration impacting work efficiency, and previous suicidal ideation during 2019 crisis though currently denied. Associated features include severe social withdrawal, loss of interest in golf and other recreational activities, and alcohol use disorder with nightly consumption of 10 standard drinks.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Major Depressive Disorder, Moderate, Single Episode (F32.1 per ICD-10). DVA SOP codes are BOP 12 of 2024 and RH 11 of 2024.

Major Depressive Disorder is characterized by five or more symptoms present during the same 2-week period representing change from previous functioning, with at least one symptom being either depressed mood or loss of interest/pleasure. Symptoms include depressed mood most of the day nearly every day, markedly diminished interest in activities, significant weight loss/gain or appetite changes, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or inappropriate guilt, diminished concentration, and recurrent thoughts of death or suicidal ideation. The symptoms cause clinically significant distress or impairment in functioning and are not attributable to substance effects or another medical condition.

Additional diagnoses identified include Generalized Anxiety Disorder (F41.1) and Alcohol Use Disorder (F10.20) which developed concurrently with or secondary to the depressive disorder.

The temporal relationship demonstrates initial adjustment disorder during service (1995-1996), evolution to major depressive disorder by discharge (2000), with chronic course and severe exacerbation in 2019.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition? First depressive symptoms experienced 1996-2000 as evolution from adjustment disorder during military service [CIA - MH - the veteran - WORD.docx, page 3; CHART REVIEW.docx, Mental Health Timeline]

When did the veteran first present to a health/medical provider for this condition? 1996 (chaplaincy support for adjustment disorder evolving to depression)

When was the condition confirmed/formally diagnosed? 04 July 2019 (formal diagnosis of Major Depressive Disorder)

When did the veteran first present to you (or your practice) for this condition? 03 February 2018

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.

Diagnosis confirmed through comprehensive psychiatric assessment documenting full DSM-5-TR criteria for Major Depressive Disorder. Key symptoms included persistent depressed mood, anhedonia, insomnia, psychomotor retardation, fatigue, feelings of worthlessness, diminished concentration, and previous suicidal ideation with plan in 2019 [CIA - MH - the veteran - WORD.docx, pages 4-5]. Psychological assessment tools showing DASS21 Depression score 9 (Moderate), K10 score 23 (High distress), supporting moderate severity diagnosis [CIA - MH - the veteran - WORD.docx, Scoring section]. Clinical interview revealed chronic course with onset during military service, severe exacerbation 2019, persistence post-discharge [CIA - MH - the veteran - WORD.docx, complete assessment]. Mental State Examination showed restricted affect, anxious quality, mood-congruent presentation [CIA - MH - the veteran - WORD.docx, MSE section].

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.

Causative Factors:

Factor 1 (BOP): experiencing a category 1A stressor within the 2 years before the clinical onset of major depressive disorder - NOT MET

No life-threatening events or serious physical attacks documented within 2 years before onset

Factor 2 (BOP): experiencing a category 1B stressor within the 2 years before the clinical onset - NOT MET

No witnessing of deaths or critical injuries documented during relevant timeframe

Factor 3 (BOP): experiencing severe childhood abuse before the clinical onset - NOT MET

No evidence of childhood abuse documented in records

Factor 5 (BOP): experiencing the death of a family member or close friend within the 2 years before the clinical onset - NOT MET

No deaths documented, though parental separation occurred

Factor 7 (BOP): experiencing a category 2 stressor within the 6 months before the clinical onset - MET

Multiple category 2 stressors present including problem with family relationships due to parental separation, perceived lack of support within military environment, experiencing serious physical injuries affecting career progression

Factor 8 (BOP): having a clinically significant disorder of mental health within the 2 years before the clinical onset - MET

Adjustment disorder documented 1995-1996, within 2 years of major depressive disorder development by 2000

Factor 10 (BOP): having an injury which is life-threatening or which results in serious physical or cognitive disability within the 3 years before the clinical onset - MET

Multiple musculoskeletal injuries from 1994-1996 resulting in serious physical disability, affecting occupational functioning

Factor 11 (BOP): having a severe, chronic medical condition for at least the 5 years before the clinical onset - NOT MET

Chronic pain conditions present but not meeting full 5-year duration before onset

Factor 13 (BOP): having persistent pain of at least 6 months duration at the time of the clinical onset - MET

Documented chronic lower back pain from August 1992, exceeding 6 months duration by time of depression onset

Worsening Factors:

Factor 43 (BOP): inability to obtain appropriate clinical management for depressive disorder - MET

No structured mental health treatment from onset 2000 until 2019, antidepressant prescribed 2019 without follow-up, no psychological therapy documented, prolonged period without treatment allowed progression to moderate severity

The % contribution of the causes is 100% and significant

Sequelae

Major Depressive Disorder developed as sequela of inadequately treated Adjustment Disorder that arose during military service. The progression from adjustment disorder to major depression represents natural evolution when initial psychiatric condition not appropriately managed.

Unintended Consequence

The Major Depressive Disorder does not represent an unintended consequence of medical management. The condition arose from inadequate treatment of initial adjustment disorder rather than as consequence of medical intervention.

Inability to Attain Appropriate Medical Management (for worsening)

Clear evidence of inability to obtain appropriate clinical management - MET. Despite chronic depressive symptoms spanning over 20 years, the veteran received only intermittent and inadequate mental health treatment. Prescribed antidepressants in 2019 but no structured follow-up or optimization. Currently sees GP opportunistically rather than scheduled mental health management. No engagement with specialist psychiatric services or structured psychological therapy. The prolonged period between initial presentation (1996) and current lack of comprehensive treatment (2023) demonstrates systemic barriers to appropriate mental health care. Military culture stigma likely contributed to help-seeking barriers.

5. Please provide a Health Summary and a medication/prescribing history. -see attached report

References

1995-1996, Chaplaincy Support Records, Military Chaplain, Pastoral Care
11 Apr 1992, CT Lumbar Spine, A. Pallewatte/Mackley, Radiology
07 May 1992, MRI Lumbar Spine, Hunter Valley Medical Imaging, Radiology
20 July 1992, Discharge Health Statement, V. Duffy, Military Medicine
27 July 1996, Discharge Documentation, RAAF Administration, Administrative
2019, Antidepressant Prescription Record, General Practitioner, General Practice
20 Jun 2019, MRI Multiple Regions, Gaurav Khera, Radiology
04 July 2019, Psychiatric Assessment, Treating Psychiatrist, Psychiatry
04 July 2019, DASS21 Assessment, Treating Psychiatrist, Psychiatry
04 July 2019, K10 Assessment, Treating Psychiatrist, Psychiatry

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