Statement of Principles concerning depressive disorder (Reasonable Hypothesis) (No. 11 of 2024)

This instrument is a Statement of Principles (SoP) made by the Repatriation Medical Authority under subsection 196B(2) of the Veterans' Entitlements Act 1986 (VEA), dated 22 December 2023 and commencing 22 January 2024 (ss 2-3). Its immediate mechanical effect is to replace the earlier Statement of Principles concerning depressive disorder No. 83 of 2015 (s 4). The instrument applies to claims that fall within section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 (MRCA) (s 5). In practical terms, it sets out the medical criteria and enumerated factors that, if established and related to relevant service, are to be treated as sufficient to raise a reasonable hypothesis that depressive disorder or death from depressive disorder is connected with a person’s relevant service (s 9; s 10(1)).

The SoP performs two distinct decision‑making functions. First, it defines the clinical constructs that the decision‑maker must recognise as "depressive disorder", by importing DSM-5-TR diagnostic criteria for major depressive disorder, major depressive episode, persistent depressive disorder (dysthymia), depressive disorder due to another medical condition, substance/medication-induced depressive disorder, premenstrual dysphoric disorder, and other or unspecified depressive disorders (s 7(2)-(9)). Second, it lists the discrete factors which must, as a minimum, exist to say that a reasonable hypothesis has been raised connecting the disorder (or death from it) to relevant service; at least one such factor must be present (s 9).

The instrument distinguishes onset and worsening. Sections 9(1)-(30) list factors that can satisfy the reasonable hypothesis for clinical onset; sections 9(31)-(60) largely mirror those factors for clinical worsening but are expressly limited by s 10(2) to cases where the depressive disorder was suffered or contracted before or during (but did not arise out of) relevant service and the question is material contribution to or aggravation of that pre‑existing disorder. Section 11 provides that where a listed factor refers to an injury or disease already covered by another SoP, the terms of that other SoP apply.

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RMA Australian Government Coat of Arms

Statement of Principles

concerning

DEPRESSIVE DISORDER (Reasonable Hypothesis)

(No. 11 of 2024)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated 22 December 2023.

The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:<br>
<br> <br>Professor Terence Campbell AM<br>Chairperson<br>

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1 Name

This is the Statement of Principles concerning depressive disorder (Reasonable Hypothesis) (No. 11 of 2024).

2 Commencement

This instrument commences on 22 January 2024.

3 Authority

This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.

4 Repeal

The Statement of Principles concerning depressive disorder No. 83 of 2015 (Federal Register of Legislation No. F2015L00915) made under subsections 196B(2) and (8) of the VEA is repealed.

5 Application

This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.

6 Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

7 Kind of injury, disease or death to which this Statement of Principles relates

(1) This Statement of Principles is about depressive disorder and death from depressive disorder.

Meaning of depressive disorder

(2) For the purposes of this Statement of Principles, depressive disorder means:

(a) major depressive disorder; or

(b) major depressive episode; or

(d) depressive disorder due to another medical condition; or

(e) substance/medication-induced depressive disorder; or

(f) premenstrual dysphoric disorder; or

(g) other specified depressive disorder or unspecified depressive disorder; where:

(3) major depressive disorder meets the following criteria (derived from DSM-5-TR):

(a) Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either depressed mood or loss of interest or pleasure.

(i) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).

Note: In children and adolescents, can be irritable mood.

(ii) 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).

(iii) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.

(iv) Insomnia or hypersomnia nearly every day.

(v) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

(vi) Fatigue or loss of energy nearly every day.

(vii) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

(viii) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

(ix) Recurrent thoughts of death (not just fear of dying); recurrent suicidal ideation without a specific plan; a specific suicide plan; or a suicide attempt.

(b) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

(d) At least one major depressive episode is not better explained by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.

(e) There has never been a manic episode or a hypomanic episode.

Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological effects of another medical condition.

(4) major depressive episode meets the following criteria (derived from DSM-5-TR):

(i) Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).

Note: In children and adolescents, can be irritable mood.

(ii) 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).

(iii) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.

(iv) Insomnia or hypersomnia nearly every day.

(v) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).

(vi) Fatigue or loss of energy nearly every day.

(vii) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).

(viii) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).

(ix) Recurrent thoughts of death (not just fear of dying); recurrent suicidal ideation without a specific plan; a specific suicide plan; or a suicide attempt.

(b) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

(5) persistent depressive disorder (dysthymia) meets the following criteria (derived from DSM-5-TR):

(a) Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.

Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.

(b) Presence, while depressed, of two (or more) of the following:

(i) Poor appetite or overeating.

(ii) Insomnia or hypersomnia.

(iii) Low energy or fatigue.

(iv) Low self-esteem.

(v) Poor concentration or difficulty making decisions.

(vi) Feelings of hopelessness.

(c) During the 2-year period (1 year for children or adolescents) of the disturbance, the individual has never been without the symptoms in Criteria (a) and (b) for more than 2 months at a time.

(d) Criteria for a major depressive disorder may be continuously present for 2 years.

(e) There has never been a manic episode or a hypomanic episode.

(f) The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.

(g) The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hypothyroidism).

(h) The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

(6) depressive disorder due to another medical condition meets the following criteria (derived from DSM-5-TR):

(a) A prominent and persistent disturbance in mood that predominates in the clinical picture and is characterized 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 pathophysiological consequence of another medical condition.

(c) The disturbance is not better explained by another mental disorder (e.g., adjustment disorder, with depressed mood, in which the stressor is a serious medical condition).

(d) The disturbance does not occur exclusively during the course of a delirium.

(e) The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

(7) substance/medication-induced depressive disorder meets the following criteria (derived from DSM-5-TR):

(a) A prominent and persistent disturbance in mood that 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 both (i) and (ii):

(i) The symptoms in Criterion (a) developed during or soon after substance intoxication or withdrawal or after exposure to or withdrawal from a medication.

(ii) The involved substance/medication is capable of producing the symptoms in Criterion (a).

(c) The disturbance is not better explained by a depressive disorder that is not substance/medication-induced. Such evidence of an independent depressive disorder could include the following:

(i) the symptoms preceded the onset of the substance/medication use;

(ii) the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or

(iii) there is other evidence suggesting the existence of an independent non-substance/medication-induced depressive disorder (e.g., a history of recurrent non-substance/medication-related episodes).

(d) The disturbance does not occur exclusively during the course of a delirium.

(e) The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

(8) premenstrual dysphoric disorder meets the following criteria (derived from DSM-5-TR):

(a) In the majority of menstrual cycles, at least 5 symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.

(b) One (or more) of the following symptoms must be present:

(i) Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).

(ii) Marked irritability or anger or increased interpersonal conflicts.

(iii) Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.

(iv) Marked anxiety, tension, and/or feelings of being keyed up or on edge.

(c) One (or more) of the following symptoms must additionally be present, to reach a total of 5 symptoms when combined with symptoms from Criterion (b) above.

(i) Decreased interest in usual activities (e.g., work, school, friends, hobbies).

(ii) Subjective difficulty in concentration.

(iii) Lethargy, easy fatigability, or marked lack of energy.

(iv) Marked change in appetite; overeating; or specific food cravings.

(v) Hypersomnia or insomnia.

(vi) A sense of being overwhelmed or out of control.

(vii) Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain.

Note: The symptoms in Criteria a–c must have been met for most menstrual cycles that occurred in the preceding year.

(d) The symptoms cause clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home).

(e) The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder, or a personality disorder (although it may co-occur with any of these disorders).

(f) Criterion (a) should be confirmed by prospective daily ratings during at least two symptomatic cycles.

(g) The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism).

(9) other specified depressive disorder and unspecified depressive disorder have prominent symptoms of depression that cause clinically significant distress or impairment in social, occupational or other important areas of functioning, however, these depressive symptoms do not meet the full criteria for any of the other depressive disorders (derived from DSM-5-TR).

(10) Depressive disorder excludes disruptive mood dysregulation disorder and unspecified mood disorder.

Note: DSM-5-TR is defined in the Schedule 1 – Dictionary.

Death from depressive disorder

(11) For the purposes of this Statement of Principles, 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.

Note: terminal event is defined in the Schedule 1 – Dictionary.

8 Basis for determining the factors

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 MRCA.

Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary.

9 Factors that must exist

At least one of the following factors 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:

(1) being a prisoner of war before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

(2) experiencing a category 1A stressor within the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

Note: category 1A stressor is defined in the Schedule 1 – Dictionary.

(3) experiencing a category 1B stressor within the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

Note: category 1B stressor is defined in the Schedule 1 – Dictionary.

(4) experiencing severe childhood abuse before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

Note: severe childhood abuse is defined in the Schedule 1 – Dictionary.

(5) experiencing a potentially morally injurious event within the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

Note: potentially morally injurious event is defined in the Schedule 1 – Dictionary.

(6) having a family member or close friend who experiences a category 1A stressor within the 2 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

Note: category 1A stressor is defined in the Schedule 1 - Dictionary.

(7) experiencing the death of a family member or close friend within the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

(8) experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 6 months before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

(9) experiencing a category 2 stressor within the one year before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

Note 1: A category 2 stressor can arise in a variety of circumstances connected with service. Such circumstances can arise during the course of service, as a result of separation from service and the conditions associated with that separation, and in the transition to civilian life in the years following separation.

Note 2: category 2 stressor is defined in the Schedule 1 - Dictionary.

(10) having a clinically significant disorder of mental health within the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

Note: clinically significant disorder of mental health is defined in the Schedule 1 - Dictionary.

(11) having a sleep-wake disorder for at least the 6 months before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

Note: Examples of sleep-wake disorders include chronic insomnia disorder, hypersomnolence disorder, narcolepsy, restless legs syndrome and untreated obstructive sleep apnoea.

(12) having an injury which is life-threatening or which results in serious physical or cognitive disability, within the 5 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

(13) having a severe, chronic medical condition for at least the 2 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

Note: severe, chronic medical condition is defined in the Schedule 1 - Dictionary.

(14) having epilepsy at the time of the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

(15) having severe and permanent tinnitus at the time of the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

Note: severe and permanent tinnitus is defined in the Schedule 1 - Dictionary.

(16) having persistent pain of at least 3 months duration at the time of the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

Note: persistent pain is defined in the Schedule 1 - Dictionary.

(17) having untreated or unsuccessfully treated vitamin D deficiency, with a serum 25-hydroxyvitamin D level of less than 25 nanomoles per litre, at the time of the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

(18) being obese at the time of the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder or premenstrual dysphoric disorder;

Note: being obese is defined in the Schedule 1 - Dictionary.

(19) experiencing pregnancy or the first 12 months after childbirth as a parent, at the time of the clinical onset of major depressive disorder, major depressive episode or persistent depressive disorder;

(20) being in the menopausal transition or within the 2 years after the final menstrual period at the time of the clinical onset of major depressive disorder, major depressive episode or persistent depressive disorder;

Note: menopausal transition is defined in the Schedule 1 - Dictionary.

(21) having another medical condition, including an endocrine, cardiovascular, respiratory, metabolic, infectious or neurological disorder, where the signs or symptoms of depression are directly related to the pathological process of the medical condition and not solely due to its psychosocial stress effects, at the time of the clinical onset of “depressive disorder due to another medical condition”;

(22) taking mefloquine or corticosteroids, excluding topical or inhaled corticosteroids, within the 30 days before the clinical onset of substance/medication-induced depressive disorder, where substance/medication-induced depressive disorder persists after the discontinuation or tapering of mefloquine or corticosteroid therapy;

(23) using a psychoactive substance from the specified list of psychoactive substances at an intoxicant dose within the 30 days before the clinical onset of substance/medication-induced depressive disorder;

Note: intoxicant dose and specified list of psychoactive substances are defined in the Schedule 1 – Dictionary.

(24) taking a drug that cannot be ceased or substituted in the long term and which is associated in the individual with the development of depressive symptoms during drug therapy and either:

(a) the improvement of depressive symptoms within days or weeks of discontinuing or tapering drug therapy; or

(b) the redevelopment of depressive symptoms on rechallenge with the same drug;

where the drug was being taken within the 30 days before the clinical onset of substance/medication-induced depressive disorder;

(25) using a psychoactive chemical or substance at an intoxicant dose, which is associated in the individual with the development of depressive symptoms, and where the psychoactive chemical or substance was being taken within the 30 days before the clinical onset of substance/medication-induced depressive disorder;

Note: intoxicant dose is defined in the Schedule 1 – Dictionary.

(26) having ceased or reduced therapeutic or illicit drug use or other substance use within the 30 days before the clinical onset of substance/medication-induced depressive disorder;

(27) having an alcohol use disorder or a substance use disorder at the time of the clinical onset of substance/medication-induced depressive disorder;

(28) having smoked tobacco products:

(a) on an average of at least 20 cigarettes per day or the equivalent thereof in other tobacco products; and

(b) for at least the 2 years before the clinical onset of major depressive disorder, major depressive episode, persistent depressive disorder, premenstrual dysphoric disorder or substance/medication-induced depressive disorder; and

if smoking has ceased before the clinical onset then that onset occurred within 6 months of cessation;

Note: cigarettes per day or the equivalent thereof in other tobacco products is defined in the Schedule 1 - Dictionary.

(29) 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 5 years before the clinical onset of substance/medication-induced depressive disorder, and where the clinical onset occurs within 2 years of that period;

(30) having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester or paraquat poisoning within the 30 days before the clinical onset of substance/medication-induced depressive disorder;

Note: acute cholinergic poisoning, organophosphorus ester and paraquat are defined in the Schedule 1 – Dictionary.

(31) being a prisoner of war before the clinical worsening of depressive disorder;

(32) experiencing a category 1A stressor within the 5 years before the clinical worsening of depressive disorder;

Note: category 1A stressor is defined in the Schedule 1 – Dictionary.

(33) experiencing a category 1B stressor within the 5 years before the clinical worsening of depressive disorder;

Note: category 1B stressor is defined in the Schedule 1 – Dictionary.

(34) experiencing severe childhood abuse before the clinical worsening of depressive disorder;

Note: severe childhood abuse is defined in the Schedule 1 – Dictionary.

(35) experiencing a potentially morally injurious event within the 5 years before the clinical worsening of depressive disorder;

Note: potentially morally injurious event is defined in the Schedule 1 – Dictionary.

(36) having a family member or close friend who experiences a category 1A stressor within the 2 years before the clinical worsening of depressive disorder;

Note: category 1A stressor is defined in the Schedule 1 - Dictionary.

(37) experiencing the death of a family member or close friend within the 5 years before the clinical worsening of depressive disorder;

(38) experiencing miscarriage, fetal death in utero or stillbirth as a parent, within the 6 months before the clinical worsening of depressive disorder;

(39) experiencing a category 2 stressor within the 1 year before the clinical worsening of depressive disorder;

Note 2: category 2 stressor is defined in the Schedule 1 - Dictionary.

(40) having a clinically significant disorder of mental health within the 5 years before the clinical worsening of depressive disorder;

Note: clinically significant disorder of mental health is defined in the Schedule 1 - Dictionary.

(41) having a sleep-wake disorder for the 6 months before the clinical worsening of depressive disorder;

Note: Examples of sleep-wake disorders include chronic insomnia disorder, hypersomnolence disorder, narcolepsy, restless legs syndrome and untreated obstructive sleep apnoea.

(42) having an injury which is life-threatening or which results in serious physical or cognitive disability, within the 5 years before the clinical worsening of depressive disorder;

(43) having a severe, chronic medical condition for at least the 2 years before the clinical worsening of depressive disorder;

Note: severe, chronic medical condition is defined in the Schedule 1 - Dictionary.

(44) having epilepsy at the time of the clinical worsening of depressive disorder;

(45) having severe and permanent tinnitus at the time of the clinical worsening of depressive disorder;

Note: severe and permanent tinnitus is defined in the Schedule 1 - Dictionary.

(46) having persistent pain of at least 3 months duration at the time of the clinical worsening of depressive disorder;

Note: persistent pain is defined in the Schedule 1 - Dictionary.

(47) having untreated or unsuccessfully treated vitamin D deficiency, with a serum 25-hydroxyvitamin D level of less than 25 nanomoles per litre, at the time of the clinical worsening of depressive disorder;

(48) being obese at the time of the clinical worsening of depressive disorder;

Note: being obese is defined in the Schedule 1 - Dictionary.

(49) experiencing pregnancy or the first 12 months after childbirth as a parent, at the time of the clinical worsening of depressive disorder;

(50) being in the menopausal transition or within the 2 years after the final menstrual period at the time of the clinical worsening of depressive disorder;

Note: menopausal transition is defined in the Schedule 1 - Dictionary.

(51) having another medical condition, including an endocrine, cardiovascular, respiratory, metabolic, infectious or neurological disorder, where the signs or symptoms of depression are directly related to the pathological process of the medical condition and not solely due to its psychosocial stress effects, at the time of the clinical worsening of depressive disorder;

(52) taking mefloquine or corticosteroids, excluding topical or inhaled corticosteroids, within the 30 days before the clinical worsening of depressive disorder, where depressive disorder persists after the discontinuation or tapering of mefloquine or corticosteroid therapy;

(53) using a psychoactive substance from the specified list of psychoactive substances at an intoxicant dose within the 30 days before the clinical worsening of depressive disorder;

Note: intoxicant dose and specified list of psychoactive substances are defined in the Schedule 1 – Dictionary.

(54) taking a drug that cannot be ceased or substituted in the long term and which is associated in the individual with the worsening of depressive symptoms during drug therapy and either:

(a) the improvement of depressive symptoms within days or weeks of discontinuing or tapering drug therapy; or

(b) the worsening of depressive symptoms on rechallenge with the same drug;

where the drug was being taken within the 30 days before the clinical worsening of depressive disorder;

(55) using a psychoactive chemical or substance at an intoxicant dose, which is associated in the individual with the worsening of depressive symptoms, and where the psychoactive chemical or substance was being taken within the 30 days before the clinical worsening of depressive disorder;

Note: intoxicant dose is defined in the Schedule 1 – Dictionary.

(56) having ceased or reduced therapeutic or illicit drug use or other substance use within the 30 days before the clinical worsening of depressive disorder;

(57) having an alcohol use disorder or a substance use disorder at the time of the clinical worsening of depressive disorder;

(58) 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 5 years before the clinical worsening of depressive disorder, and where the clinical worsening occurs within 2 years of that period;

(59) having an episode of acute cholinergic poisoning from exposure to an organophosphorus ester or paraquat poisoning within the 30 days before the clinical worsening of depressive disorder;

Note: acute cholinergic poisoning, organophosphorus ester and paraquat are defined in the Schedule 1 – Dictionary.

(60) inability to obtain appropriate clinical management for depressive disorder before the clinical worsening of depressive disorder.

10 Relationship to service

(1) The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.

(2) The factors set out in subsections 9(31) to 9(60) 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 did not arise out of) the person's relevant service.

11 Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1) if a factor referred to in section 9 applies in relation to a person; and

(2) that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Schedule 1 - Dictionary

Note: See Section 6

1 Definitions

In this instrument:

acute cholinergic poisoning means symptoms and signs due to the inhibition of acetylcholinesterase enzyme activity which occur within 24 hours following exposure. These symptoms and signs are acute paralysis, overwhelming bronchial secretions, bradycardia, gastrointestinal distress, miosis, lacrimation and diarrhoea.

being obese means having a Body Mass Index (BMI) of 30 or greater.

Note: BMI is defined in the Schedule 1 - Dictionary.

BMI means W/H2 where:

(a) W is the person's weight in kilograms; and

(b) H is the person's height in metres.

category 1A stressor means one 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

category 1B stressor means one of the following severe traumatic events:

(a) killing or maiming a person;

(b) being a witness to a person being killed or critically injured;

(d) participating in the clearance of a corpse or a critically injured casualty; or

(e) viewing a corpse or a critically injured casualty as a witness.

Note: corpse and witness are defined in the Schedule 1 – Dictionary.

category 2 stressor means one 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, ethnicity, sexuality, 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 workloads, 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; or

(f) having a family member or close friend experience a major deterioration in their health.

cigarettes per day or the equivalent thereof in other tobacco products means:

(a) cigarettes, pipe tobacco or cigars, alone or in any combination; and

(b) one gram of cigar, pipe or other smoking tobacco (including roll your own smoking tobacco) is equivalent to one tailor made cigarette.

clinically significant disorder of mental health means one of the following conditions, which is of sufficient severity to warrant ongoing management:

(a) alcohol use disorder;

(b) another depressive disorder;

(d) disruptive, impulse-control or conduct disorder;

(e) dissociative disorder;

(f) elimination disorder;

(g) feeding or eating disorder;

(h) gambling disorder;

(i) gender dysphoria;

(j) neurocognitive disorder (including vascular neurocognitive disorder and Alzheimer disease);

(k) neurodevelopmental disorder;

(l) obsessive compulsive or related disorder;

(m) paraphilic disorder;

(n) personality disorder;

(o) schizophrenia spectrum or other psychotic disorder (including schizophrenia);

(p) sexual dysfunction;

(q) somatic symptom disorder or related disorder;

(r) substance use disorder; or

(s) trauma- and stressor-related disorder (including acute stress disorder, adjustment disorder and posttraumatic stress disorder).

Note 1: Management of the condition may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner.

Note 2: To warrant ongoing management does not require that any actual management was received or given for the condition.

corpse means the human remains or body parts of one or more persons who have met a violent or horrific death.

Note: Examples of a violent or horrific death may include death due to suicide, gunshot, improvised explosive devices, natural and technological disasters, terrorist attacks or motor vehicle accidents. Seeing a closed body bag or viewing a body in an open-casket coffin are excluded from this definition.

depressive disorder—see Section 7.

DSM-5-TR means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2022.

inhalants means breathable chemicals that produce psychoactive vapours or fumes and include organic solvents, aerosols and anaesthetics.

intoxicant dose means a dose sufficient to cause disturbances in level of consciousness, cognition, perception, affect or behaviour, or other psychophysiological functions and responses.

menopausal transition means the time from when the first menopausal symptoms appear until there has been no menstrual period for 12 consecutive months.

MRCA means the Military Rehabilitation and Compensation Act 2004.

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.

paraquat means a dipyridilium compound whose dichloride and

dimethylsulphate salts are used as contact herbicides.

persistent pain means:

(a) continuous; or

(b) severe, frequent and intermittent pain;

which may or may not be ameliorated by analgesic medication and is of a level to cause interference with usual work or activities of daily living.

potentially morally injurious event means an event that transgresses a person’s deeply held moral beliefs and expectations.

relevant service means:

(a) operational service under the VEA;

(b) peacekeeping service under the VEA;

(d) British nuclear test defence service under the VEA;

(e) warlike service under the MRCA; or

(f) non-warlike service under the MRCA.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

severe and permanent tinnitus means tinnitus that is present every day and requires use of a tinnitus masking device or causes loss of concentration, extreme discomfort and interferes with sleep.

severe childhood abuse means:

(a) serious physical, emotional, psychological or sexual harm whilst a child aged under 18 years; or

(b) neglect involving a serious failure to provide the necessities for health, physical and emotional development, or wellbeing whilst a child aged under 18 years,

where such serious harm or neglect has been perpetrated by a parent, a care provider, an adult who works with or around that child, or any other adult in contact with that child.

severe, chronic medical condition means an illness that:

(a) substantially impacts on social, occupational or other important areas of functioning; and

(b) requires on-going daily or almost daily management of symptoms under the supervision of a registered health practitioner, including assistance with activities of daily living, bed rest, dietary modification, drug therapy, nursing care, oxygen therapy and physiotherapy; and

(c) is of a type that does not usually resolve spontaneously, is rarely cured completely and may progress to a life-threatening illness.

Note: Examples of severe, chronic medical conditions include chronic kidney disease requiring dialysis, severe psoriasis, poorly controlled asthma and poorly controlled diabetes mellitus.

specified list of psychoactive substances means:

(a) amphetamine or amphetamine-type substances, including methamphetamine and 3,4-methylenedioxymethamphetamine (ecstasy);

(b) cannabis;

(d) hallucinogens (including phencyclidine);

(e) inhalants; or

(f) opioids.

Note: inhalants is defined in the Schedule 1 – Dictionary.

terminal event means the proximate or ultimate cause of death and includes the following:

(a) pneumonia;

(b) respiratory failure;

(d) circulatory failure; or

(e) cessation of brain function.

VEA means the Veterans' Entitlements Act 1986.

witness means a person who experiences an incident at the time it occurs and can give direct evidence of it. This excludes persons exposed only to public broadcasting or mass media coverage of the incident.

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Statement of Principles

concerning

DEPRESSIVE DISORDER (Reasonable Hypothesis)

(No. 11 of 2024)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.

Dated 22 December 2023.

The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:<br>
<br> <br>Professor Terence Campbell AM<br>Chairperson<br>

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1 Name

This is the Statement of Principles concerning depressive disorder (Reasonable Hypothesis) (No. 11 of 2024).

2 Commencement

This instrument commences on 22 January 2024.

3 Authority

This instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.

4 Repeal

The Statement of Principles concerning depressive disorder No. 83 of 2015 (Federal Register of Legislation No. F2015L00915) made under subsections 196B(2) and (8) of the VEA is repealed.

5 Application

This instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.

The core legal and medical concepts the SoP establishes are: depressive disorder (defined by DSM-5-TR criteria), reasonable hypothesis, relevant service, and a closed list of factors that, if present and related to service, raise a reasonable hypothesis linking the disorder or death from it to service (s 7-9; s 10). Each concept has operational consequences for evidence and decision‑making.

Depressive disorder: The instrument adopts DSM-5-TR diagnostic criteria for multiple depressive diagnoses (major depressive disorder, major depressive episode, persistent depressive disorder, depressive disorder due to another medical condition, substance/medication‑induced depressive disorder, premenstrual dysphoric disorder, and other/unspecified depressive disorder) (s 7(2)-(9); Schedule 1 defines DSM-5-TR). The SoP also expressly excludes disruptive mood dysregulation disorder and unspecified mood disorder (s 7(10)). Death from depressive disorder is included where the depressive disorder contributed to the person’s terminal event or condition (s 7(11); Schedule 1 terminal event).

Reasonable hypothesis: Section 9 frames the SoP’s role as setting out the factors 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". That is, the instrument identifies which factual medical or situational circumstances form the minimal basis for raising the statutory reasonable hypothesis in administrative determinations.

Relevant service and relationship to service: The SoP applies only where the listed factor(s) are "related to the relevant service rendered by the person" (s 10(1)). The Schedule defines relevant service broadly to include operational, peacekeeping, hazardous, British nuclear test defence service under the VEA, and warlike or non‑warlike service under the MRCA. For factors aimed at worsening of pre‑existing depressive disorder (ss 9(31)-(60)), s 10(2) limits their application to material contribution to or aggravation of a depressive disorder that was suffered or contracted before or during (but did not arise out of) relevant service.

Enumerated factors and timing thresholds: Section 9 lists 60 discrete factors. Many have explicit timing windows tied to the date of clinical onset or clinical worsening: for example, category 1A/1B stressors and several other events are assessed within five years before clinical onset (ss 9(2)-(3)); category 2 stressors have a one‑year window (s 9(9)); miscarriage/stillbirth has a six‑month window (s 9(8)); substance or medication exposures are often limited to 30 days before onset/worsening for substance/medication‑induced depressive disorder (ss 9(22), (23), (24), (52), (53), (54)).

Cross‑reference to other SoPs: If a factor in s 9 refers to an injury or disease already covered by another SoP, that other SoP governs how that factor is treated (s 11). The Schedule contains definitions that will govern interpretation of terms such as category 1A stressor, category 2 stressor, clinically significant disorder of mental health, persistent pain, severe childhood abuse, and specified list of psychoactive substances.

Quantitative and clinical thresholds: The instrument specifies objective thresholds and clinical diagnostics which will be material to decision‑making: e.g. BMI >=30 to be "being obese" (Schedule); serum 25‑hydroxyvitamin D level <25 nmol/L for vitamin D deficiency (ss 9(17), 9(47)); smoking defined as at least 20 cigarettes per day for at least two years (s 9(28); Schedule). It also includes clinical constructs such as untreated or unsuccessfully treated conditions, and the capacity for certain drugs to be associated with development or worsening of depressive symptoms (ss 9(22)-(26), (52)-(55)).

Evidence implications: By enumerating specific medical, exposure and temporal criteria, the SoP channels decision-makers and claimants toward particular forms of proof: diagnostic statements matching DSM-5-TR language, laboratory values, medication histories, service records, documented dates for clinical onset and worsening, and evidence of the specified stressor events. The SoP does not itself set evidentiary rules but prescribes which factual predicates must minimally be present to raise a reasonable hypothesis (s 9; s 10).

Primary affected persons: The instrument applies to claimants with depressive disorder or death from depressive disorder who are seeking a connection between that condition and their relevant service under the VEA or MRCA, specifically claims covered by s 120A of the VEA or s 338 of the MRCA (s 5). That cohort includes veterans, members of Peacekeeping Forces, and members of the Forces for whom relevant service is defined in the Schedule. The instrument therefore directly affects those veterans or their estates bringing claims where a nexus between depressive disorder and service is in issue.

Administrative decision-makers and medical assessors: Decision-makers in the Department administering the VEA and MRCA will use the SoP as the medical policy instrument to determine whether a reasonable hypothesis exists. Medical practitioners providing opinions for claims (forensic psychiatrists, general practitioners, specialists) will need to frame their opinions in terms compatible with the SoP: application of DSM-5-TR criteria, timing of clinical onset and worsening, and whether one or more of the enumerated factors is present and related to relevant service (s 7; s 9; Schedule).

Legal and other advisers: Practising lawyers, advocates, claims officers, and rehabilitation providers will be affected because their casework must align evidence-gathering and submissions to the SoP’s listed factors, timing windows, and the requirement that factors be related to relevant service (s 10). Where a listed factor refers to an injury or disease covered by another SoP, practitioners must obtain and apply the terms of that other SoP (s 11).

Medical record keepers and treating clinicians: Treating clinicians will be affected indirectly because the SoP requires clinical detail that may not routinely be recorded in general practice notes, such as precise DSM-5-TR symptom counts over specified periods, dates of clinical onset or worsening, vitamin D levels, BMI calculations, documentation about sleep‑wake disorders, and clear descriptions of drug exposures that meet the SoP’s time thresholds (s 7; s 9; Schedule).

Families and dependants: Because the SoP expressly includes death from depressive disorder where the disorder contributed to a terminal event (s 7(11)), dependants and estates making death claims may be affected and will need to marshal evidence to show the depressive disorder contributed to the terminal event.

System costs and administrative parties: Although the SoP is a medical listing rather than an appropriation, it directs administrative decision-making and thus has fiscal consequences for the veterans’ compensation system. The instrument’s use of objective thresholds and many time windows may increase the volume and type of medical and documentary evidence required of claimants, shifting costs to claimants and administrative agencies in evidence procurement and review.

Who does not gain rights or face penalties under the SoP: The instrument does not itself create criminal sanctions, new statutory entitlements, or directions on benefits calculation; it functions as part of the statutory decision framework under the VEA and MRCA to determine whether a reasonable hypothesis linking the disorder to relevant service is raised (s 5). The SoP does not alter other eligibility criteria in those Acts.

The SoP establishes no direct private legal duties, statutory rights or criminal penalties on its face. Its legal effect is procedural and evidential: it specifies the medical criteria and factors that constitute the minimum factual foundation for a decision-maker to conclude that a "reasonable hypothesis" connects depressive disorder or death from depressive disorder with relevant service (s 9). That has predictable consequences for the duties of administrative decision-makers and the expectations of claimants.

Duties of decision‑makers: Administrative decision‑makers are obliged to apply the SoP when considering claims to which it applies (s 5). The SoP identifies minimal factual criteria that must exist before it can be said a reasonable hypothesis has been raised (s 9). Practically, decision-makers must determine whether at least one listed factor is present and whether that factor is related to the claimant’s relevant service (s 10(1)). For issues of material contribution or aggravation of pre‑existing depressive disorder, decision‑makers must apply the limitations in s 10(2) so that ss 9(31)-(60) only operate where the disorder was suffered or contracted before or during relevant service and did not arise out of it.

Duty to consider other SoPs when relevant: Section 11 requires that, where a factor in s 9 refers to an injury or disease covered by another SoP, the factors and terms of that other SoP must apply "in accordance with the terms of that Statement of Principles as in force from time to time". That creates an inter‑SoP duty of incorporation where there is overlap.

Evidence and medical assessment duties: Decision-makers will necessarily require medical evidence that aligns with the SoP’s diagnostic requirements and timing thresholds. The DSM-5-TR language adopted in s 7 means clinicians preparing reports should map observed symptoms and clinical history to those criteria if the opinion is meant to address whether the SoP is met. Specified laboratory thresholds and exposure windows (for vitamin D, BMI, smoking history, drug exposures) suggest decision-makers will expect objective documentation for those particular factors (s 9; Schedule). The SoP does not set how evidence is weighed, but it establishes the factual predicates that must exist to raise a reasonable hypothesis.

Claimant rights and expectations: Claimants have the expectable right to have their claim assessed according to the SoP if their claim falls within s 5. This means claimants can present evidence that at least one of the listed factors existed and that it was related to their relevant service. For example, a claimant asserting substance/medication-induced depressive disorder must show the required temporal relationship to a drug exposure or intoxication (ss 7(7), 9(22)-(26)). A claimant asserting death from depressive disorder must show that depressive disorder contributed to the terminal event (s 7(11)).

No new monetary entitlements created: The SoP does not itself create compensatory entitlements or alter benefit levels. It is a guide used by the statutory decision-processes in the VEA and MRCA to determine whether a condition is connected to service for purposes of those Acts. Any consequent monetary or rehabilitation entitlements remain governed by the VEA or MRCA.

No criminal penalties or licence duties: The instrument contains no provisions imposing criminal penalties, licensing obligations, or professional disciplinary standards. It is a medical‑administrative standard to be used in adjudication of statutory claims.

Consequences for medical practitioners giving evidence: Practitioners providing medico-legal opinions should be aware that the SoP lists specific clinical and exposure criteria. To be useful in the claim context, clinical opinions should address whether DSM-5-TR criteria are met, specify dates of clinical onset/worsening, and address the presence or absence of any of the enumerated factors with reference to the applicable timing windows (s 7; s 9). The SoP does not require a particular format for opinions, but its structure creates an expectation that opinions will engage with its elements.

This Statement of Principles is not an instrument that creates offences or civil penalties. It is an interpretive medical instrument made under s 196B(2) of the VEA and functions as part of the administrative decision framework for claims under the VEA and MRCA (s 3; s 5). The instrument itself contains no enforcement provisions, regulatory sanctions, or criminal penalties. Consequently, the legal mechanisms for enforcement are administrative application and judicial review of administrative decisions that use the SoP, rather than enforcement against specific conduct under the SoP.

Administrative enforcement through decision-making: The SoP will be enforced indirectly by decision-makers applying it to claims. If a claimant fails to establish that one or more of the specified factors exist and are related to relevant service, the decision-maker may find that a reasonable hypothesis is not raised and decline to accept service connection under the VEA or MRCA. Such determinations can have financial and rehabilitation consequences for the claimant, but those are effects of decisions under the VEA or MRCA, not direct penalties in the SoP.

Judicial review and merits review: The instrument does not itself describe review rights. However, because the SoP is an instrument used in administrative determinations under federal legislation, decisions applying it may be subject to merits review (where available under the Acts or by administrative tribunals) or judicial review in the courts for jurisdictional error, failure to take into account relevant material, or misapplication of the SoP. The SoP does not purport to oust judicial oversight; it provides the medical framework for decision-making. The text of the SoP does not identify any particular tribunal, timeframe, or special review mechanism.

Professional and evidential consequences: There are no explicit penalties for medical practitioners who provide opinions that do not align with the SoP. However, practitioners should be aware that opinions which do not address the SoP’s criteria may be less persuasive for the purposes of claim adjudication. That is an evidential consequence rather than a statutory sanction.

Relevance to other statutes: The SoP makes no statement about penalties under other statutes. For example, evidence or false statements in a claim remain subject to the general statutory and common law rules applicable to the VEA and MRCA; this instrument does not augment or replace those provisions.

Transitional enforcement issues: The SoP repeals the previous 2015 SoP (s 4). The instrument itself does not set out transitional enforcement arrangements or saving provisions for claims started under the earlier SoP. That gap creates an implementation issue for claims spanning the repeal and commencement dates; the SoP does not, within its text, dictate how such claims are to be treated.

Statutory context: The SoP is made under subsection 196B(2) of the VEA (s 3). It expressly applies to claims to which section 120A of the VEA or section 338 of the MRCA applies (s 5). Therefore, its practical legal effect is to inform determinations made under those provisions of the VEA and MRCA about whether a reasonable hypothesis exists linking depressive disorder or death from depressive disorder to relevant service. The instrument does not amend the VEA or MRCA; it operates within their decision-making frameworks.

Cross‑SoP interaction: Section 11 creates a specific interaction rule where a listed factor refers to an injury or disease that is the subject of another SoP. In such cases, "the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time" (s 11). Practitioners must therefore assess whether any factor in s 9 invokes another SoP and then apply that other SoP’s terms. This produces a hierarchy where the technical terms of the other SoP govern the treatment of that factor.

Integration with DSM-5-TR: The SoP imports DSM-5-TR diagnostic criteria by reference (s 7; Schedule 1). This is an explicit interaction with a recognised clinical diagnostic standard. The use of DSM-5-TR means that changes in the text revision (the instrument cites DSM-5-TR 2022) or future revisions of the DSM could have practical implications if the SoP is not updated. The SoP does not itself commit to future versions; it incorporates the 2022 DSM-5-TR as the basis for the diagnostic descriptions included in the instrument.

Evidence rules under VEA and MRCA: The SoP does not specify evidence admissibility or burden rules; those are governed by the Acts and their administration. Nonetheless, the SoP defines the factual predicates decision-makers must look for, which channels what evidence will be relevant: military service records, medical records, lab tests, pharmaceutical histories, and incident reports.

Overlap with workers’ compensation, civil claims and coronial processes: The SoP is limited to the statutory regime under the VEA and MRCA and does not purport to govern workers’ compensation systems, civil tort claims, or coronial findings. That said, evidence that meets SoP criteria (for example, lab results, documented clinical onset dates, or service records) could be used in those other processes, but the SoP does not speak to how those processes should use that evidence.

Data privacy and record access laws: The SoP anticipates the production and review of clinical, service and exposure data. It does not address how such records are to be obtained or the privacy regimes that apply. That remains governed by relevant privacy and information‑access laws and the administrative processes of the departments handling claims.

Transitional and repeal interaction: The instrument repeals the 2015 SoP (s 4). The SoP itself contains no transitional clauses explaining how a claim that was commenced under the 2015 SoP and is pending at commencement should be handled. Consequently, administrative practice will need to address whether decisions are to be made under the new SoP from commencement or whether older applications are to be assessed under the prior instrument; the SoP is silent on this point.

Interaction with medical practice standards and professional regulation: The SoP stipulates DSM-5-TR criteria and specific laboratory thresholds which clinicians will need to address in medico-legal reports. The SoP does not alter medical professional standards, but professional regulation bodies may view medico-legal opinions through the lens of whether the SoP-relevant criteria were properly considered.

This instrument is the Statement of Principles concerning depressive disorder (Reasonable Hypothesis) (No. 11 of 2024), dated 22 December 2023 and commencing 22 January 2024 (ss 1-2). It expressly repeals the Statement of Principles concerning depressive disorder No. 83 of 2015 (Federal Register of Legislation No. F2015L00915), which had been made under subsections 196B(2) and (8) of the VEA (s 4). The SoP itself records no earlier amendments within its text; it is presented as a substitute instrument replacing the 2015 SoP entirely.

Implementation date and repeal: The instrument’s commencement date is specified as 22 January 2024 (s 2). The repeal of the 2015 SoP is absolute as stated in s 4; the instrument does not express any savings or transitional provision within its text concerning claims that were in process under the 2015 SoP. That omission is a factual matter falling in the gap between this instrument and the administrative treatment of pending claims.

No other amendments or schedules: The instrument comprises sections 1 to 11 and a Schedule 1 - Dictionary. The Schedule furnishes a comprehensive set of defined terms used throughout the main body, including definitions for BMI, category 1A/1B stressors, category 2 stressor, clinically significant disorder of mental health, and specified list of psychoactive substances, among others. The SoP makes no reference to any other amending instruments or delegations.

Effect on earlier decisions: The instrument does not itself state whether determinations made under the 2015 SoP remain final or can be revisited relying on the new SoP. That is an administrative and legal consequence that may be addressed by the administering department or in litigation; the SoP does not provide transitional text on retrospective application.

Potential for future amendment: The SoP is made under statutory power and, as such, can be amended or replaced by further instruments in accordance with the VEA. The text of the SoP includes a cross-application clause referring to other SoPs "as in force from time to time" (s 11), which contemplates future changes in other SoPs. There is no express mechanism in this instrument that limits or freezes future amendments to the DSM or other SoPs; administrative practice will determine how updates are handled.

Document provenance: The instrument is signed and sealed by the Repatriation Medical Authority, with the Chairperson named (front matter). The presence of the Authority’s seal and signature indicates the instrument is formal and intended to be applied by the decision-makers charged with implementing the VEA and MRCA.

The Statement of Principles as supplied does not record any litigation history, court decisions, tribunal findings, or administrative appeals relating to its content. The instrument contains no citations to judicial decisions and does not narrate prior case law about its interpretation or the interpretation of the prior 2015 SoP. Consequently, there is no litigation history contained in the text to quote or summarise.

Practical implications for advisers: Because the SoP itself contains no litigation history, practitioners and decision-makers will need to look beyond the instrument to identify how courts and tribunals have interpreted similar SoPs, the "reasonable hypothesis" standard, and the weight to be given to particular kinds of medical or service evidence. The absence of litigation references in the instrument means that precedential guidance will come from external sources, including tribunal determinations and judicial review decisions analysing the VEA, MRCA, and the use of SoPs in claims adjudication. That material is not included in the instrument and must be obtained separately.

Risk points for challenge: Listing the reasons why decisions applying the SoP might be subject to review or appeal is not the same as recounting litigation history. Nevertheless, administrative decisions that misapply the SoP , for example by failing to require that a listed factor be related to relevant service (s 10(1)), or by incorrectly applying s 10(2) in cases of pre-existing disorder , could be susceptible to merits review or judicial review on jurisdictional error grounds if a court finds the decision-maker failed to apply the SoP correctly. The instrument itself does not discuss these review pathways.

No reported authority in the instrument: Because the SoP repeals the 2015 SoP, there may be an existing body of decisions interpreting the earlier instrument. The current document does not summarise or endorse any such decisions; users should not assume continuity of administrative interpretation. Legal advisers will therefore need to research case law and tribunal decisions that interpret the reasonable hypothesis test, the relevant SoP factors, and the interplay of DSM‑5‑TR criteria with statutory decision-making, none of which are set out in this instrument.

Practical next steps for litigators and advisers: To understand how the SoP is being applied in practice and whether administrative decisions are being appealed successfully, practitioners will need to review decisions and appeals after the SoP’s commencement date. The instrument itself contains no litigation items, so practitioners must compile a litigation history from external repositories of tribunal and court decisions that apply or challenge SoPs under the VEA and MRCA.

The SoP contains many concrete drafting choices and technical thresholds that can catch claimants, clinicians, and advisers if not attended to carefully. Below are discrete "gotchas" drawn from the text that affect proof, timing, and interpretation.

DSM‑5‑TR language is mandatory: The SoP defines depressive disorder by reference to DSM‑5‑TR diagnostic descriptions (s 7; Schedule). A clinical note that uses non‑DSM labels or looser descriptions may be insufficient on its face to satisfy the instrument’s diagnostic framing. Practitioners should ensure that diagnostic statements map to the criteria as set out in s 7 (for example, five or more symptoms over the same two‑week period for major depressive disorder, and duration requirements for persistent depressive disorder).

Timing windows are specific and must be matched to clinical onset/worsening: Many factors carry fixed time limits relative to the clinical onset or clinical worsening. Examples include five years for category 1A/1B stressors (ss 9(2)-(3)); one year for category 2 stressors (s 9(9)); six months for miscarriage, fetal death in utero or stillbirth (ss 9(8), 9(38)); 30 days for many drug‑exposure related factors (ss 9(22), (23), (24), (52), (53), (54), (59)). Claims failing to establish these time relations with clear documentary or medical evidence risk being insufficient to raise the reasonable hypothesis.

Relation to relevant service must be established separately: The fact that a listed factor exists is not enough; s 10(1) requires that the factor be "related to the relevant service rendered by the person". The SoP does not define what proof of that relation is acceptable. Practitioners must therefore obtain service records, incident reports, unit logs or contemporaneous documentation linking the stressor or exposure to the claimant’s service.

Pre‑existing disorder rules limit some factors: Sections 9(31)-(60) are framed around clinical worsening and s 10(2) limits their application to the question of material contribution to, or aggravation of, a depressive disorder that was suffered or contracted before or during (but did not arise out of) service. This is a precise legal limitation. If a claimant’s depressive disorder arose out of service, those particular factors do not apply in the same way.

Objective laboratory thresholds and measurements are specified: For vitamin D deficiency the SoP specifies serum 25‑hydroxyvitamin D <25 nmol/L (ss 9(17), 9(47)); "being obese" is BMI >=30 (Schedule). If records do not contain these precise measurements, decision‑makers may not accept a claimed factor based on lower precision evidence.

Smoking threshold is relatively high: The SoP defines smoking as an average of at least 20 cigarettes per day for at least two years, and if smoking has ceased before clinical onset the onset must have occurred within six months of cessation (s 9(28); Schedule). Claims based on lighter smoking histories or cessation outside the six‑month window will not satisfy the factor as drafted.

Narrow definitions for exposure types: The specified list of psychoactive substances is explicit (Schedule). The SoP also defines "intoxicant dose" in clinical terms. For inhalation or solvent exposure, the required pattern is "in an unventilated and confined space, on more days than not for a continuous period of at least 5 years" with a 2‑year window for onset/worsening to occur after that period (ss 9(29), (58); Schedule). Casual or shorter‑term exposures will not meet the listed factor.

"Corpse" and "witness" exclusions: The Schedule defines "corpse" to exclude closed body bag viewing or viewing a body in an open‑casket coffin; "witness" requires direct experience of an incident, excluding exposure via public broadcasting or mass media coverage. Claims relying on media exposure to traumatic events will therefore not meet the category 1B definitions (Schedule).

Some drug exclusions are explicit: Corticosteroid exposures are only covered when not topical or inhaled (ss 9(22), 9(52)). Mefloquine and systemic corticosteroids are singled out; other medications are captured under different clauses only if the drug cannot be ceased or substituted in the long term and is associated with depressive symptoms in the individual (ss 9(22), (24), (52), (54)).

"Potentially morally injurious event" is a defined term: The instrument includes "potentially morally injurious event" (ss 9(5), 9(35); Schedule). The Schedule definition is broad but anchors the term to the transgression of a person's deeply held moral beliefs. Proving such an event will typically require narrative documentation and corroboration from service records.

"Severe childhood abuse" requires specific perpetrators: The Schedule requires that serious harm or neglect be perpetrated by a parent, care provider, an adult who works with or around the child, or another adult in contact with the child. Abuse by peers or non‑contact strangers may not fall within this definition (Schedule).

"Inability to obtain appropriate clinical management" included as a factor for worsening: Section 9(60) includes inability to obtain appropriate clinical management as a factor prior to clinical worsening. This shifts attention to access to care and the documentation of unsuccessful attempts to obtain treatment, which may be difficult to prove.

No savings or transitional detail for the repealed SoP: The instrument repeals the 2015 SoP (s 4) but does not set out transitional arrangements. Practitioners handling claims that straddle the repeal/commencement dates should be aware that the instrument contains no guidance on whether an older application remains governed by the former SoP.

For practitioners preparing a claim or medico-legal evidence that the SoP is met, compliance is primarily about aligning documentary, clinical and service evidence to the SoP’s diagnostic criteria, enumerated factors and specified time windows. Below are practical steps, organised around the SoP’s structure, to help ensure a claim is framed so a decision-maker can assess whether a reasonable hypothesis has been raised.

Establish the diagnosis using DSM‑5‑TR language

Ask treating clinicians to state the diagnosis in DSM‑5‑TR terms where possible (s 7; Schedule). For major depressive disorder and major depressive episode ensure opinions address the 2‑week symptom threshold, list the specific symptoms present (refer to s 7(3)-(4)), and comment on functional impairment and attribution to substances or other medical conditions.
For persistent depressive disorder, document depressive mood present for the requisite duration (at least 2 years in adults; 1 year in children/adolescents) and the presence of two or more listed symptoms (s 7(5)).
For substance/medication-induced depressive disorder and depressive disorder due to another medical condition, obtain opinion that explicitly addresses the causal relationship and the SoP’s criteria (s 7(6)-(7)).

Fix dates for clinical onset and clinical worsening

The SoP’s many timing windows require precise dates. Obtain medical notes specifying when symptoms first met diagnostic thresholds (clinical onset) and when any clinically significant worsening occurred. Where dates are estimated, obtain clinician statements explaining the basis for the timing.

Map one or more factors from s 9 to the case facts

Identify which of the 60 factors in s 9 is relied upon. Remember at least one listed factor must exist to raise a reasonable hypothesis (s 9 introductory text).
For each factor, assemble the evidence the SoP implies: for example, for a category 1A stressor (s 9(2); Schedule) provide operational or incident records proving life‑threatening event, serious assault, or being threatened with a weapon; for being a prisoner of war, obtain official POW records (s 9(1), 9(31)).
For drug exposure factors (ss 9(22)-(26), (52)-(55)), obtain pharmacy records, prescription histories, hospital discharge summaries and contemporaneous notes showing timing and response to cessation or rechallenge.

Demonstrate the factor is related to relevant service

The SoP requires that factors be related to relevant service (s 10(1)). Obtain service records, deployment orders, unit diaries, incident reports, witness statements from fellow members, operational reports, and any internal investigations that link the stressor or exposure to the claimant’s service.

For pre‑existing disorders, apply s 10(2)

If the depressive disorder pre‑existed or was contracted before or during service, and the focus is on worsening rather than new onset, ensure the evidence establishes that the service materially contributed to or aggravated the disorder. This will control the application of ss 9(31)-(60) (s 10(2)).

Provide objective measurements where the SoP specifies thresholds

For vitamin D deficiency: provide serum 25‑hydroxyvitamin D test showing <25 nmol/L if that factor is relied on (ss 9(17), 9(47)).
For obesity: include height and weight so BMI can be calculated as W/H2 and demonstrate BMI >=30 if relying on "being obese" (Schedule).
For smoking: document average cigarettes per day and duration to meet the 20 cigarettes/day for at least 2 years rule, and if smoking ceased link clinical onset timing to cessation within six months where relevant (s 9(28); Schedule).

Document sleep‑wake disorders, persistent pain and chronic medical conditions

For factors addressing sleep‑wake disorders (ss 9(11), 9(41)), obtain sleep study results, specialist sleep clinic notes, or regular treating clinician records covering at least six months prior to onset/worsening.
For persistent pain, provide pain clinic assessments, analgesic regimens, functional impact statements, and documentation of at least three months duration (s 9(16), Schedule).
For severe, chronic medical conditions, obtain specialty notes demonstrating ongoing daily or almost daily management and functional impact as defined in Schedule.

Address exposures to solvents, organophosphorus esters and paraquat

For solvent exposure, provide occupational or service records showing frequency, duration and environment (unventilated and confined space, "on more days than not" for a continuous period of at least 5 years) and timing relative to onset/worsening (s 9(29); Schedule).
For organophosphorus ester or paraquat poisoning, include emergency department notes, toxicology results, and the timing of the acute cholinergic poisoning episode within 30 days of onset/worsening (s 9(30), (59); Schedule).

Map overlapping SoPs

If any factor refers to an injury or disease that is the subject of another SoP, obtain and apply the terms of that other SoP (s 11). Incorporate any specific evidentiary or timing rules from that SoP into the claim.

Address inability to obtain appropriate clinical management

If relying on s 9(60) for clinical worsening, compile evidence of attempts to obtain care, reasons for inability to access appropriate care (for example, location, administrative denials, inability to access specialists), and consequent deterioration in the clinical record.

Use witness and corroborative evidence properly

Ensure "witness" evidence is direct and contemporaneous; the Schedule excludes persons who only saw incidents via mass media. For traumatic exposures involving corpses, the Schedule excludes certain modes of viewing (closed body bag, open‑casket funeral) from the "corpse" definition; tailor evidence accordingly.

Anticipate cross-checks and gaps

Be ready to explain missing evidence such as absence of a serum vitamin D test, or the lack of formal DSM‑5‑TR diagnostic phrasing by a treating clinician. Where objective measurements are missing, obtain reasoned clinical statements explaining likely values or the reasons the measurements are unavailable, while noting that objective thresholds in the SoP are clear.

Prepare medico‑legal reports to speak to the SoP

Medico-legal reports should explicitly state whether the DSM‑5‑TR criteria are met, identify which s 9 factor(s) are being relied upon, state dates of clinical onset and worsening, and address the relation of the factor(s) to the person’s relevant service. Opinions should also set out the basis for causal or contributory opinions in terms of the SoP’s language.

Monitor commencement and transitional practice

This SoP repeals the 2015 instrument (s 4) and commences on 22 January 2024 (s 2). Practitioners should check administrative guidance about how claims spanning the repeal/commencement are treated, as the SoP itself contains no transitional clauses.

Document control and checklists: Use the SoP’s Schedule definitions as a checklist for evidence. For every relied factor, create a one‑page evidence log that states the s 9 sub‑paragraph, the Schedule definition (where applicable), the required timing window, and the documents that satisfy each element.

Finally, note that the SoP is a minimum list for raising a reasonable hypothesis; absence of a listed factor does not necessarily foreclose other lines of inquiry under the VEA or MRCA. The SoP sets the baseline for the "reasonable hypothesis" decision point; practitioners should still consider the broader statutory framework and administrative law remedies where an adverse decision is made.

Statement of Principles concerning depressive disorder (Reasonable Hypothesis) (No. 11 of 2024)

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