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CM5570 Dealing With Co-Morbid Psychiatric Conditions
REPATRIATION COMMISSION GUIDELINES
These Guidelines are not directives and should not be used as a substitute for the proper application of the law to the particular circumstances of each case.
The Guidelines set out the Repatriation Commission's position on investigating and determining claims involving more than one psychiatric diagnosis. They are based on the words of the legislation. The Guidelines indicate the way in which the Commission believes the legislation should be applied.
DEALING WITH CO-MORBID PSYCHIATRIC CONDITIONS
A recent examination of the files of veterans with psychiatric disabilities showed that the treatment of co-morbid psychiatric conditions is not consistent across State Offices.
The Repatriation Commission has directed that policy advice clarifying the method of dealing with co-morbid psychiatric conditions be circulated to its delegates.
The examination of cases with co-morbid psychiatric conditions highlighted two main areas of concern relating to possible subsequent eligibility for Special Rate consideration:
- Entitlement issues relating to the application of S24(1)(c) of the VEA which deals with the 'alone' test; and
- Assessment issues relating to S24(1)(a)(i), which specifies the minimum degree of service-related incapacity which must exist before Special Rate pension can be granted.
A veteran may submit a claim for a specific psychiatric condition (eg PTSD) or for the more general 'emotional and behavioural disorder'.
In most cases, the claimed condition has not yet been diagnosed by a clinical psychiatrist in accordance with the “Diagnostic Guidelines for Psychiatric Assessment and Reports for the Department of Veterans' Affairs”.
The veteran is then sent to a clinical psychiatrist for diagnosis and assessment of his psychiatric condition.
The psychiatrist frequently diagnoses more than one psychiatric condition, which may or may not include the original claimed condition. For example, a veteran who claims for PTSD may be diagnosed with PTSD plus depressive disorder plus alcohol abuse.
In all cases where more than one psychiatric disorder is diagnosed, the VEA requires that each diagnosed condition BE INVESTIGATED AND DETERMINED SEPARATELY.
This investigation and determination should be carried out in accordance with Departmental Guidelines as set out in “The Second Opinion Protocol – Administrative Processes – Psychiatric Cases”.
If this approach is not taken, in any subsequent consideration of eligibility for an Above General Rate pension it may be difficult to make due allowance for the 'alone' test in S24(1)(c) of the VEA and a decision to grant an Above General Rate pension may be made unlawfully.
It can happen that in cases where a veteran is diagnosed with multiple psychiatric conditions, not all of the diagnosed psychiatric conditions are accepted as being causally related to VEA service.
In these (admittedly rare) cases, the impairment assessment from the diagnosing psychiatrist may only reflect the veteran's overall psychiatric impairment and an estimation of the relative contribution of each condition may not be provided.
For example, in one case a veteran with no physical disabilities ceased work due to his psychiatric condition. This was subsequently diagnosed as 3 separate conditions. After all 3 were rejected at the primary level, the VRB accepted one psychiatric condition but rejected the other two. The psychiatrist had assessed the overall psychiatric impairment without specifying the relative contribution of each of the 3 co-morbid conditions, and this overall impairment rating was used to assess his eligibility for Special Rate consideration. It is not clear that had the total impairment been attributed to each of the 3 conditions, the veteran would have been granted pension at the Special Rate.
In cases where a veteran has both accepted and non-accepted psychiatric conditions, the total psychiatric impairment assessment should be apportioned appropriately in consultation with the diagnosing and/or assessing psychiatrist.
31 March 2004