Statement of Principles
concerning
 
DEPRESSIVE DISORDER
No. 27 of 2008
 
for the purposes of the
 
Veterans’ Entitlements Act 1986
and
Military Rehabilitation and Compensation Act 2004
           
Title
1.                  This Instrument may be cited as Statement of Principles concerning depressive disorder No. 27 of 2008.
 
Determination
2.                  The Repatriation Medical Authority under subsection 196B(2) and (8) of the Veterans’ Entitlements Act 1986 (the VEA):
(a)       revokes Instrument No. 17 of 2007 concerning depressive disorder; and
(b)       determines in its place this Statement of Principles.
 
Kind of injury, disease or death
3.         (a)        This Statement of Principles is about depressive disorder and death from depressive disorder.
(b)              For the purposes of this Statement of Principles, "depressive disorder" means a group of psychiatric conditions which are manifested by a dysphoric mood.  The mood disturbance is prominent and persistent.  This definition is limited to major depressive episode, recurrent major depressive disorder, dysthymic disorder, depressive disorder not otherwise specified, substance-induced mood disorder with depressive features, or mood disorder due to a general medical condition with depressive features, or with major depressive-like episodes, where:
"depressive disorder not otherwise specified" means a disorder with depressive features that does not meet the criteria for major depressive disorder, dysthymic disorder, adjustment disorder with depressed mood, or adjustment disorder with mixed anxiety and depressed mood.  The disorders covered by this diagnosis (derived from DSM-IV-TR) include:
A.                     Premenstrual dysphoric disorder;
B.                     Minor depressive disorder;
C.                     Recurrent brief depressive disorder;
D.                     Postpsychotic depressive disorder of schizophrenia;
E.                      A major depressive episode superimposed on delusional disorder, psychotic disorder not otherwise specified, or the active phase of schizophrenia, or
F.                      Situations in which the clinician has concluded that a depressive disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced.
 
"dysthymic disorder" means a psychiatric condition meeting the following diagnostic criteria (derived from DSM-IV-TR):
A.                 Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least two years.  In children and adolescents, mood can be irritable and the duration must be at least one year.
B.                 Presence, while depressed, of two (or more) of the following:
(1)              poor appetite or overeating;
(2)              insomnia or hypersomnia;
(3)              low energy or fatigue;
(4)              low self-esteem;
(5)              poor concentration or difficulty making decisions; or
(6)              feelings of hopelessness.
C.                 During the two-year period (one year for children or adolescents) of the disturbance, the person has never been without the symptoms in criteria (A) and (B) for more than two months at a time.
D.                No major depressive episode has been present during the first two years of the disturbance (one year for children and adolescents); i.e., the disturbance is not better accounted for by chronic major depressive disorder, or major depressive disorder, in partial remission.  There may have been a previous major depressive episode provided there was a full remission (no significant signs or symptoms for two months) before development of the dysthymic disorder.  In addition, after the initial two years (one year in children or adolescents) of dysthymic disorder, there may be superimposed episodes of major depressive disorder, in which case both diagnoses may be given when the criteria are met for a major depressive episode.
E.                 There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder.
F.                  The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia or delusional disorder.
G.                The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
H.                The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
 
"major depressive episode" means a psychiatric condition meeting the following diagnostic criteria (derived from DSM-IV-TR):
A.                 Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.  Symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations, should not be included.
(1)              depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).  In children and adolescents, it can present as irritable mood;
(2)              markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others);
(3)              significant weight loss when not dieting or weight gain (e.g., a change of more than five percent of body weight in a month), or decrease or increase in appetite nearly every day.  In children, consider failure to make expected weight gains;
(4)              insomnia or hypersomnia nearly every day;
(5)              psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down);
(6)              fatigue or loss of energy nearly every day;
(7)              feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick);
(8)              diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others); or
(9)              recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
B.                 The symptoms do not meet criteria for a mixed episode.
C.                 The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D.                The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
E.                 The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than two months or are characterised by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
 
"mood disorder due to a general medical condition with depressive features, or with major depressive-like episodes" means a psychiatric condition meeting the following diagnostic criteria (derived from DSM-IV-TR):
A.        A prominent and persistent disturbance in mood predominates in the clinical picture and is characterised by depressed mood or markedly diminished interest or pleasure in all, or almost all, activities.
B.        There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition.
C.        The disturbance is not better accounted for by another mental disorder (e.g., adjustment disorder with depressed mood in response to the stress of having a general medical condition).
D.        The disturbance does not occur exclusively during the course of a delirium.
E.         The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
 
"recurrent major depressive disorder" means a psychiatric condition meeting the following diagnostic criteria (derived from DSM-IV-TR):
Presence of two or more major depressive episodes, with an interval of at least two consecutive months in which criteria are not met for a major depressive episode.
A.                 The major depressive episodes are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.
B.                 There has never been a manic episode, a mixed episode, or a hypomanic episode.  This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance-induced or treatment-induced or are due to the direct physiological effects of a general medical condition.
 
"substance-induced mood disorder with depressive features" means a psychiatric condition meeting the following diagnostic criteria (derived from DSM-IV-TR):
A.        A prominent and persistent disturbance in mood predominates in the clinical picture and is characterised by     depressed mood or markedly diminished interest or pleasure in all, or almost all, activities.
B.        There is evidence from the history, physical examination, or laboratory findings of either (1) or (2):
(1)       the symptoms in Criterion A developed during, or within 1 month of, substance intoxication or withdrawal;
(2)       medication use is etiologically related to the disturbance.
C.        The disturbance is not better accounted for by a mood disorder that is not substance induced. Evidence that the symptoms are better accounted for by a mood disorder that is not substance induced might include the following: the symptoms precede the onset of the substance use (or medication use); the symptoms persist for a substantial period of time (e.g., about a month) after the cessation of acute withdrawal or severe intoxication or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use; or there is other evidence that suggests the existence of an independent non-substance-induced mood disorder (e.g., a history of recurrent major depressive episodes).
D.        The disturbance does not occur exclusively during the course of a delirium.
E.         The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the mood symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention.
(c)              Depressive disorder attracts ICD-10-AM code F06.32, F10.8, F11.8, F13.8, F14.8, F15.8, F16.8, F18.8, F19.8, F32, F33, or F34.1.
(d)              In the application of this Statement of Principles, the definition of "depressive disorder" is that given at paragraph 3(b) above.
 
Basis for determining the factors
4.         The Repatriation Medical Authority is of the view that there is sound medical-scientific evidence that indicates that depressive disorder and death from depressive disorder can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the Military Rehabilitation and Compensation Act 2004 (the MRCA).
 
Factors that must be related to service
5.         Subject to clause 7, at least one of the factors set out in clause 6 must be related to the relevant service rendered by the person.
 
Factors
6.         The factor that must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting depressive disorder or death from depressive disorder with the circumstances of a person’s relevant service is:
 
(a)               for major depressive episode, recurrent major depressive disorder, dysthymic disorder and depressive disorder not otherwise specified only,
 
(i)           being a prisoner of war before the clinical onset of depressive disorder; or
 
(ii)        experiencing a category 1A stressor within the five years before the clinical onset of depressive disorder; or
 
(iii)      experiencing a category 1B stressor within the five years before the clinical onset of depressive disorder; or
 
(iv)       having a significant other who experiences a category 1A stressor within the two years before the clinical onset of depressive disorder; or
 
(v)          experiencing the death of a significant other within the two years before the clinical onset of depressive disorder; or
 
(vi)       experiencing a category 2 stressor within the one year before the clinical onset of depressive disorder; or
 
(vii)     having a clinically significant psychiatric condition within the two years before the clinical onset of depressive disorder; or
 
(viii)  having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability, within the five years before the clinical onset of depressive disorder; or
 
(ix)       having chronic pain of at least three months duration at the time of the clinical onset of depressive disorder; or
 
(x)         having a sleep disorder for the six months before the clinical onset of depressive disorder; or
 
(xi)       being in the second or third trimester of pregnancy, or the one year period following childbirth, at the time of the clinical onset of depressive disorder; or
 
(xii)    having a miscarriage, foetal death in-utero or stillbirth, within the six months before the clinical onset of depressive disorder; or
 
(b)              for substance-induced mood disorder with depressive features only,
 
(i)           being treated with a drug which is associated in the individual with the development of depressive symptoms during drug therapy, and the cessation or significant reduction of the depressive symptoms within days or weeks of discontinuing drug therapy, where treatment with the drug continued for at least the two days before the clinical onset of depressive disorder; or
 
(ii)        having ceased or reduced therapeutic or illicit drugs within the one month before the clinical onset of depressive disorder; or
 
(iii)      having alcohol dependence or alcohol abuse at the time of the clinical onset of depressive disorder; or
 
(iv)       taking a drug from a class of drug in Specified List 1, within the one month before the clinical onset of depressive disorder; or
 
(v)          taking a drug in Specified List 2, within the one month before the clinical onset of depressive disorder; or
 
(vi)       having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester within the one month before the clinical onset of depressive disorder; or
 
(vii)     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 five years before the clinical onset of depressive disorder, and where the clinical onset of depressive disorder occurs within two years of that period; or
 
(c)              for mood disorder due to a general medical condition with depressive features, or with major depressive-like episodes only, having an endocrine, cardiovascular, respiratory, metabolic, infectious, or neurological disorder, where the general medical condition is a direct physiological cause of the depression at the time of the clinical onset of depressive disorder; or
 
(d)              experiencing a category 1A stressor within the five years before the clinical worsening of depressive disorder; or
 
(e)              experiencing a category 1B stressor within the five years before the clinical worsening of depressive disorder; or
 
(f)               having a significant other who experiences a category 1A stressor within the two years before the clinical worsening of depressive disorder; or
 
(g)              experiencing the death of a significant other within the two years before the clinical worsening of depressive disorder; or
 
(h)              experiencing a category 2 stressor within the one year before the clinical worsening of depressive disorder; or
 
(i)                having a clinically significant psychiatric condition within the two years before the clinical worsening of depressive disorder; or
 
(j)                having a medical illness or injury which is life-threatening or which results in serious physical or cognitive disability, within the five years before the clinical worsening of depressive disorder; or
 
(k)              having chronic pain of at least three months duration at the time of the clinical worsening of depressive disorder; or
 
(l)                having a sleep disorder for the six months before the clinical worsening of depressive disorder; or
 
(m)            being in the second or third trimester of pregnancy, or the one year period following childbirth, at the time of the clinical worsening of depressive disorder; or
 
(n)              having a miscarriage, foetal death in-utero or stillbirth, within the six months before the clinical worsening of depressive disorder; or
 
(o)              being treated with a drug which is associated in the individual with the development of depressive symptoms during drug therapy, and the cessation or significant reduction of the depressive symptoms within days or weeks of discontinuing drug therapy, where treatment with the drug continued for at least the two days before the clinical worsening of depressive disorder; or
 
(p)              having ceased or reduced therapeutic or illicit drugs within the one month before the clinical worsening of depressive disorder; or
 
(q)              taking a drug from a class of drug in Specified List 1, within the one month before the clinical worsening of depressive disorder; or
 
(r)               taking a drug in Specified List 2, within the one month before the clinical worsening of depressive disorder; or
 
(s)               having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester within the one month before the clinical worsening of depressive disorder; or
 
(t)                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 five years before the clinical worsening of depressive disorder, and where the clinical worsening of depressive disorder occurs within two years of that period; or
 
(u)              having a medical condition as specified at the time of the clinical worsening of depressive disorder; or
 
(v)               inability to obtain appropriate clinical management for depressive disorder.
 
Factors that apply only to material contribution or aggravation
7.         Paragraphs 6(d) to 6(v) apply only to material contribution to, or aggravation of, depressive disorder where the person’s depressive disorder was suffered or contracted before or during (but not arising out of) the person’s relevant service.
 
Inclusion of Statements of Principles
8.         In this Statement of Principles if a relevant factor applies and that factor includes an injury or disease in respect of which there is a Statement of Principles then the factors in that last mentioned Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.
 
Other definitions
9.                  For the purposes of this Statement of Principles:
 
"a category 1A stressor" means one or more of the following severe traumatic events:
(a)               experiencing a life-threatening event;
(b)              being subject to a serious physical attack or assault including rape and sexual molestation; or
(c)              being threatened with a weapon, being held captive, being kidnapped, or being tortured;
 
"a category 1B stressor" means one of the following severe traumatic events:
(a)               being an eyewitness to a person being killed or critically injured;
(b)              viewing corpses or critically injured casualties as an eyewitness;
(c)              being an eyewitness to atrocities inflicted on another person or persons;
(d)              killing or maiming a person; or
(e)              being an eyewitness to or participating in, the clearance of critically injured casualties;
 
"a category 2 stressor" means one or more of the following negative life events, the effects of which are chronic in nature and cause the person to feel on-going distress, concern or worry:
(a)               being socially isolated and unable to maintain friendships or family relationships, due to physical location, language barriers, disability, or medical or psychiatric illness;
(b)              experiencing a problem with a long-term relationship including: the break-up of a close personal relationship, the need for marital or relationship counselling, marital separation, or divorce;
(c)              having concerns in the work or school environment including: on-going disharmony with fellow work or school colleagues, perceived lack of social support within the work or school environment, perceived lack of control over tasks performed and stressful work loads, or experiencing bullying in the workplace or school environment;
(d)              experiencing serious legal issues including: being detained or held in custody, on-going involvement with the police concerning violations of the law, or court appearances associated with personal legal problems;
(e)              having severe financial hardship including: loss of employment, long periods of unemployment, foreclosure on a property, or bankruptcy;
(f)               having a family member or significant other experience a major deterioration in their health; or
(g)              being a full-time caregiver to a family member or significant other with a severe physical, mental or developmental disability;
 
"a clinically significant psychiatric condition" means any Axis I disorder of mental health that attracts a diagnosis under DSM-IV-TR which is sufficient to warrant ongoing management, which may involve regular visits (for example, at least monthly), to a psychiatrist, clinical psychologist or general practitioner;
 
"acute cholinergic poisoning" means symptoms and signs due to the inhibition of acetylcholinesterase enzyme activity which occur within twenty-four hours following exposure. These symptoms and signs are acute paralysis, overwhelming bronchial secretions, bradycardia, gastrointestinal distress, miosis, lacrimation or diarrhoea;
 
"a drug from a class of drug in Specified List 1" means:
(a)              alpha-adrenoceptor agonists;
(b)              amphetamines, including methamphetamine and 3,4-methylenedioxymethamphetamine (ecstasy);
(c)              anabolic-androgenic steroids;
(d)              angiotensin converting enzyme (ACE) inhibitors;
(e)              antiepileptics;
(f)               atypical antipsychotics;
(g)              benzodiazepines;
(h)              beta adrenergic blocking agents;
(i)               calcium channel blockers;
(j)               centrally acting antihypertensives;
(k)              corticosteroids, other than topical steroids;
(l)               gonadotropin releasing agents;
(m)           hallucinogens;
(n)              inhalants;
(o)             interferons;
(p)              opiate analgesics; or
(q)              oral contraceptive agents;
 
"a drug in Specified List 2" means:
(a)              amantadine;
(b)              clozapine;
(c)              cocaine;
(d)              depot medroxyprogesterone acetate;
(e)              digoxin;
(f)               fluphenazine;
(g)              fluspirilene;
(h)              hydralazine;
(i)               interleukin-2;
(j)               isocarboxazid;
(k)              levodopa;
(l)               marijuana;
(m)           mefloquine;
(n)              phencyclidine;
(o)             reserpine;
(p)              rimonabant; or
(q)              thiazide;
 
"a medical condition as specified" means an endocrine, cardiovascular, respiratory, metabolic, infectious, or neurological condition, that causes symptoms consistent with depression, as a direct physiological consequence of the condition;
 
"a significant other" means a person who has a close family bond or a close personal relationship and is important or influential in one’s life;
 
"a sleep disorder" means a dyssomnia, a sleep disorder related to another mental disorder other than depressive disorder, a sleep disorder due to a general medical condition or substance-induced sleep disorder, as defined in DSM-IV-TR;
 
"an eyewitness" means a person who observes an incident first hand and can give direct evidence of it.  This excludes a person exposed only to media coverage of the incident;
 
"an organophosphorus ester" means an agent used to inhibit acetylcholinesterase, and includes the organophosphate pesticides chlorpyrifos, dichlorvos, EPN, leptophos, methamidophos, mipafox (diisopropyl phosphorofluoridate), omethoate, parathion, TOCP (tri-ortho-cresyl phosphate), trichlorfon and trichlornat;
 
"chronic pain" means continuous or almost continuous pain, which may or may not be ameliorated by analgesic medication and which is of a level to cause interference with usual work or leisure activities or activities of daily living;
 
"death from depressive disorder" in relation to a person includes death from a terminal event or condition that was contributed to by the person’s depressive disorder;
 
"DSM-IV-TR" means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.  Washington, DC, American Psychiatric Association, 2000.
 
"inhalants" means breathable chemicals that produce psychoactive vapours and include organic solvents, aerosols, some anaesthetics, and other chemicals;
 
"ICD-10-AM code" means a number assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, 10th revision, Australian Modification (ICD-10-AM), Fifth Edition, effective date of 1 July 2006, copyrighted by the National Centre for Classification in Health, Sydney, NSW, and having ISBN 1 86487 772 3;
 
"miscarriage" means the spontaneous or induced expulsion of the products of conception from the uterus before the foetus is viable;
 
"organic solvents" means:
(a)               chlorinated organic solvents,
(b)              aliphatic hydrocarbon solvents,
(c)              aromatic hydrocarbon solvents, or
(d)              oxygenated organic solvents;
 
"relevant service" means:
(a)     operational service under the VEA;
(b)     peacekeeping service under the VEA;
(a)          hazardous service under the VEA;
(b)          warlike service under the MRCA; or
(c)          non-warlike service under the MRCA;
 
"terminal event" means the proximate or ultimate cause of death and includes:
(a)     pneumonia;
(b)     respiratory failure;
(c)     cardiac arrest;
(d)     circulatory failure; or
(e)          cessation of brain function;
 
"the general medical condition is a direct physiological cause of the depression" means signs or symptoms of depressed mood are directly related to the pathological process of the general medical condition, and:
(a)               the depressive symptoms have a close temporal relationship with the onset or exacerbation of the general medical condition, and the depressive symptoms developed at the same time or after the onset of the general medical condition;
(b)              treatment which causes remission of the general medical condition also results in remission of the depressive symptoms; or
(c)              features of the depressive disorder, such as an unusual age of onset, a qualitative difference in symptoms, or disproportionately severe or unusual symptoms, are inconsistent with a primary diagnosis of any of the mood spectrum disorders.
 
Application
10.       This Instrument applies to all matters to which section 120A of the VEA or section 338 of the MRCA applies.
 
Date of effect
11.       This Instrument takes effect from 5 March 2008.
 
Dated this       twentieth           day of              February    2008
 
 
The Common Seal of the                  )
Repatriation Medical Authority       )
was affixed to this instrument          )
in the presence of:                            )
 
KEN DONALD
CHAIRPERSON