Mental Health Caused by Your Service-Connected Conditions

Step 6 of the method is one many veterans never think to file for. Depression and anxiety that grow out of any service-connected condition are real disabilities. In the Board decisions we have indexed, the conditions most often named as the cause are a bad back first, then a bad knee, then tinnitus and hearing loss. This article uses chronic pain as the example, but the same rule covers tinnitus, sleep apnea, a brain injury, hearing loss, a disfiguring scar, or sexual dysfunction. The VA rates them. A mental health rating can be a substantial part of a combined rating, and under the General Rating Formula it can reach 100 percent on its own. Many never file for it.

What secondary service connection means

The rule is 38 CFR 3.310. Paragraph (a) says a disability "which is proximately due to or the result of a service-connected disease or injury shall be service connected." Once that is established, the secondary condition is treated as part of the original condition.

Paragraph (b) covers aggravation. If a service-connected condition makes a nonservice-connected condition worse, the increase is service connected too, as long as the increase is not just the natural progress of the nonservice-connected condition. But the VA will not accept that a condition was made worse unless medical evidence shows how bad it was before the worsening began. If nothing from before exists, the earliest medical evidence after it began, and before the evidence showing how bad it is now, can serve. If you had depression before the back injury made it worse, the record has to show how bad it was before.

Nothing in 3.310 limits the secondary condition to physical problems. Depression that results from living with a service-connected knee is a disability proximately due to that knee. The depression itself does not need any connection to your time in service.

How the rating works

Mental disorders are rated under 38 CFR 4.130, using the General Rating Formula for Mental Disorders. The diagnosis does not change the math. Major depressive disorder (DC 9434), unspecified depressive disorder (DC 9435), generalized anxiety disorder (DC 9400), persistent depressive disorder (DC 9433), and chronic adjustment disorder (DC 9440) all use the same formula. It asks one question: how much do the symptoms get in the way of work and relationships? The schedule calls that occupational and social impairment.

The formula has six levels, from 0 to 100 percent. Here is the language at the 30, 50, and 70 percent levels, quoted from the schedule.

30 percent:

Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).

50 percent:

Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.

70 percent:

Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships.

Read those lists again. Chronic sleep impairment. Depressed mood. Anxiety. Disturbances of motivation and mood. If you live with daily pain, you probably recognized yourself in there. The words "such symptoms as" mean the lists are examples, not checklists. 38 CFR 4.126(a) tells the rater to weigh frequency, severity, and duration of symptoms and all the evidence of occupational and social impairment, not just what the examiner saw in one appointment.

Two more rules. 38 CFR 4.125 requires a diagnosis that conforms to the DSM-5 and is supported by the exam findings. And 38 CFR 4.14 prohibits rating the same symptom twice. Your pain is rated under the orthopedic code. The depression caused by the pain is a separate disability with its own symptoms, and once it is service connected it is rated on its own.

Why veterans miss this claim

• Veterans think mental health claims are for combat trauma. PTSD is one code among many under 4.130.
• Veterans do not connect the dots. You stopped sleeping because of the pain in your back. You stopped going out because standing is painful. You snap at your kids. You never called that depression, so you never told a doctor.
• Do not count on anyone at the VA to suggest it. The VA has a duty under 38 CFR 3.159 to tell you what evidence a claim needs and to help gather records. In citation 1302500 the secondary theory was already part of the appeal, and the Board sent the exam back because the examiner never addressed it, even though VA had never told the veteran what evidence a secondary claim needs. But the claim you file is what gets decided.

What the Board actually does with these claims

Board decisions are public on va.gov. Each one below is linked. Three from the 1993 archive show the whole picture.

In BVA 93-14591, a roofer with a service-connected gunshot wound to the right hand claimed a psychiatric disorder secondary to it. He could not grip a hammer. A psychiatric exam by an outside doctor, paid for by the VA, tied his depression to the pain and to what the hand did to his ability to work as a roofer. Lay statements backed up what the hand did to his work. A Board medical adviser wrote that a chronic condition had "slowly evolved in response to the problems of living with a chronic, painful, physical handicap and meeting family responsibilities." The Board granted under 3.310(a).

In BVA 93-10278, a veteran with service-connected diabetes had years of records showing job loss from medical visits, then depression tied to the job loss. A VA examiner diagnosed recurrent depressions associated with chronic physical illness. Granted.

In BVA 93-10940, a veteran with a 60 percent left knee claimed depression secondary to it. His wife testified he had gone from "happy-go-lucky" to unable to be around people. Denied. The examiners listed a nonservice-connected right knee, diabetes, heart surgery, back and elbow problems, money trouble, and the recent death of a son as contributors. The Board found the service-connected knee was not "an essential cause" of the depression. The lay evidence was good. The medical opinion never isolated the service-connected condition.

That is the lesson. Winning claims have a clinician stating in writing that the service-connected condition caused or aggravated the mental health condition. Losing claims have a clinician listing five causes and never sorting them. In a 2013 decision, citation 1302500, the Board sent a claim back in part because the examiner blamed "aging, medical issues, and increased dependency" without saying whether any of the veteran's service-connected disabilities were among those medical issues. The Board granted service connection for his knees and cold injuries in the same decision, then ordered the examiner to answer directly whether those or his other service-connected conditions caused or aggravated the psychiatric disorder, and to discuss the lay evidence.

What evidence supports the claim

1. A current diagnosis that meets 4.125. See a psychologist or psychiatrist. Tell them about the pain and what it has done to your life.
2. A nexus opinion. The clinician should state that it is at least as likely as not that the service-connected condition caused or aggravated the mental health condition, and explain why. If the claim is that a service-connected condition made an existing mental health condition worse, the file has to show how bad it was before. That is what 3.310(b) requires.
3. Treatment records showing the timeline. Pain first, then sleep loss, withdrawal, mood changes.
4. Lay statements. Under 38 CFR 3.159(a)(2), lay evidence is competent when it comes from someone who knows the facts and describes what a layperson can observe. Your spouse can say you stopped sleeping. Your battle buddy can say you stopped answering the phone. These are the people who watched you suffer and chose to support you. Their statements carry the part of the story the medical records leave out.
5. Your own statement. Describe a normal week. What the pain stops you from doing, and how that makes you feel.

What to do

If you already have a service-connected condition, file the mental health claim as secondary to it now, with the evidence attached. If your primary claim is pending, file them together and state in writing that the mental health condition is claimed as secondary.

At the exam, be honest. Do not put on a show. Do not play it down either. If you have thought about hurting yourself, say so. If the examiner or the Board decides you exaggerated, your credibility takes a hit, and credibility carries over to the other issues in your file.

Last thing. 38 CFR 4.16 covers a total rating based on being unable to work. The test in paragraph (a) is whether your service-connected conditions leave you unable to secure or follow a substantially gainful occupation. Earning no more than the Census poverty threshold for one person is one marker of work that does not count, and the regulation says work above that line can still be marginal on the facts, such as a job in a family business or a sheltered workshop. Paragraph (a) also sets rating levels: one condition at 60 percent, or one at 40 percent with a combined rating of 70 percent.

If your percentages fall short of those levels, that is not the end of it. 38 CFR 4.16(b) says the rating board should send the case to the Director, Compensation Service, for extraschedular consideration when a veteran is unable to secure and follow substantially gainful work because of service-connected disabilities but does not meet the percentages in paragraph (a). Ask for that in writing. A mental health rating is one of the things that carries a veteran there.

This is education drawn from the regulations and public Board decisions, not legal advice, and I am not your representative. Read the rules, read the decisions, and file what is true.