What should be included in a veteran's documentation of depression to obtain VA disability compensation?

Veterans Disability Depression Documentation

To obtain VA disability compensation for depression, documentation must include standardized symptom severity scores (PHQ-9 or BDI-II), functional impairment across specific life domains (occupational, social, family), suicide risk assessment with safety planning, DSM-5 diagnostic criteria confirmation, treatment history with response patterns, and service-connection evidence linking symptoms to military service. 1

Essential Documentation Components

Symptom Severity Assessment

• Document PHQ-9 scores with specific severity classifications: none/mild (1-7), moderate (8-14), moderate to severe (15-19), or severe (20-27). 1
• Record all nine core symptoms rated over the past 2 weeks using the 0-3 scale: 0 (not at all), 1 (several days), 2 (more than half the days), or 3 (nearly every day). 1
• The nine specific symptoms requiring documentation are: depressed mood, loss of interest/pleasure (anhedonia), sleep problems, low energy, appetite changes, low self-view/worthlessness, concentration difficulties, motor retardation or agitation, and thoughts of self-harm. 1
• For veterans specifically, consider using BDI-II with a cut score of 27 or higher to differentiate between veterans with and without mood disorders, as standard cut scores underestimate severity in veteran populations. 2

Functional Impairment Documentation

• Document specific functional impairment in three key domains: home, peer relationships, and work/school settings. 1
• The VA's proposed shift toward function-based ratings emphasizes real-world functioning over symptom counts, making detailed functional documentation increasingly critical. 3
• Include concrete examples of how depression interferes with daily activities, employment capacity, social relationships, and self-care. 3

Diagnostic Criteria Confirmation

• Reference DSM-5 or ICD-10 diagnostic criteria explicitly in documentation. 1
• Confirm that at least 5 symptoms have been present during a 2-week period, with at least one being depressed mood or anhedonia. 1
• Document that symptoms cause clinically significant functional impairment. 1

Critical Safety Assessment

Suicide Risk Documentation

• Every depression assessment must include suicide risk documentation—this is non-negotiable for VA disability claims. 1
• Document presence or absence of: suicidal ideation, suicidal behaviors, prior suicide attempts, availability of lethal means, adequacy of adult supervision and support. 1
• Include emergency contact information and safety plan details in the medical record. 1
• Note that approximately 7% of VA primary care patients report thoughts of death or suicide, 2% report thoughts of harming themselves, and 1% have specific plans. 4

Service-Connection and Risk Factors

Military Service Linkage

• Document deployment-related trauma, including history of military mild traumatic brain injury (mTBI), as the combination of depression, PTSD, and military mTBI creates especially high disability risk (OR = 3.52). 5
• Record any combat exposure, military sexual trauma, or other service-related stressors. 5
• Note comorbid conditions common in veterans: PTSD (present in over 90% of veterans with psychiatric conditions), anxiety disorders, substance use disorders, chronic pain, and sleep disturbances. 5, 6

Pertinent Historical Factors

• Document prior mood disorder episodes with or without prior treatment. 1
• Record comorbid mood and/or anxiety disorders, presence of other chronic illnesses, recurrent or progressive disease. 1
• Include social factors such as unemployment and education level, as these are recognized risk factors. 1

Treatment Documentation

Treatment History and Response

• Record specific treatment goals in each functional domain: home, peer, and school/work settings. 1
• Document patient and family education provided about depression causes, symptoms, impairments, and expected treatment outcomes. 1
• Record treatment choice and rationale: psychotherapy, pharmacotherapy, or combined treatment. 1
• Include discussion of confidentiality limits, particularly regarding risk of harm. 1

Ongoing Monitoring Requirements

• Conduct regular assessments using standardized instruments at: pretreatment, 4 weeks, 8 weeks, and end of treatment. 1
• Document symptom relief, side effects, adverse events, and patient satisfaction at each assessment point. 1
• Include both patient-reported outcomes (QIDS-SR) and clinician-administered scales. 1

Critical Timing for Documentation

Document depression screening and assessment at these specific timepoints: 1

• Initial diagnosis/start of treatment
• Regular intervals during active treatment
• 3,6, and 12 months after treatment initiation
• At diagnosis of recurrence or progression
• During times of personal transition or reappraisal

Common Pitfalls to Avoid

• Do not rely solely on single-item depression screens—the PHQ-2 (2 items) demonstrates superior sensitivity (97%) compared to single-item screens (78% sensitivity) while maintaining high specificity (91%). 4
• Avoid using general population BDI-II cut scores for veterans, as veterans score significantly higher than civilian samples even when non-depressed (Cohen's d = 1.34). 2
• Do not overlook comorbid serious mental illness (schizophrenia, schizoaffective disorder, bipolar disorder), which affects over 10% of male and 20% of female veterans with PTSD and dramatically worsens outcomes. 6
• Never omit suicide risk assessment—approximately one-third of patients endorsing thoughts of death or suicide report recent active suicidal ideation. 4
• Recognize that neurovegetative symptoms (insomnia, fatigue, appetite changes) may overlap with other medical conditions common in veterans, requiring careful differentiation. 7