Secondary Conditions to Depression

Depression is rated under the General Rating Formula for Mental Disorders at 0, 10, 30, 50, 70 or 100 percent. The physical conditions it causes or worsens are rated separately, under their own codes. Under 38 CFR § 3.310, a condition caused or worsened by your service-connected depression, or by the medication that treats it, is service connected too. This page covers what you can claim, why a second mental health diagnosis does not add a second rating, the research behind each physical link, which claims to file first, and how the ratings combine.

What can you claim secondary to depression?

Any condition a doctor can tie to your depression, with reasoning, can be claimed. In the Board's 2021 to 2026 decisions the most common were these.

• Sleep apnea. See sleep apnea secondary to depression.
• Migraines.
• High blood pressure.
• Erectile dysfunction, often through medication.
• GERD.

The Board section further down lists every condition claimed secondary to depression with enough rulings to show, with its count and grant rate. Anxiety and other mental health diagnoses are claimed too, but they are rated together with the depression, as the next sections explain.

How secondary service connection works for depression

VA grants a secondary claim in two ways under 38 CFR § 3.310.

• Caused by. Your service-connected depression caused the condition, at least as likely as not.
• Aggravated by. The condition is worse because of your depression, meaning it would be less severe but for the depression (M21-1 V.ii.2.D). VA rates only the part above the condition's baseline before the aggravation.

The text of § 3.310(b) still tells VA to subtract "natural progress," but VA's current claims manual (M21-1 V.ii.2.D, revised after Spicer v. McDonough) no longer applies that part, and the worsening does not have to be permanent. VA still needs a baseline shown by medical evidence, and it rates the difference between that baseline and the current level.

The file needs service-connected depression, a current diagnosis of the secondary condition, and a medical opinion linking the two. Opinions that work name a specific pathway, cite the research and apply it to your history; opinions that call the condition "multifactorial" without that analysis tend to lose. An opinion that answers only "caused by" and skips aggravation is inadequate (El-Amin v. Shinseki, 26 Vet. App. 136 (2013)).

Some chains run through weight. VA does not treat obesity as a disability on its own, but VA's General Counsel (VAOPGCPREC 1-2017) allows it to be a middle step when depression or its medication caused weight gain, the weight gain was a substantial factor in causing the claimed condition, and the condition would not have happened without it. The Court of Appeals for Veterans Claims built on that framework in Walsh v. Wilkie, 32 Vet. App. 300 (2020).

One mental health rating: why anxiety or PTSD is not a separate rating

38 CFR § 4.130 rates every mental disorder from schizophrenia through chronic adjustment disorder (Diagnostic Codes 9201 to 9440) under the same General Rating Formula, and 38 CFR § 4.14 says that "the evaluation of the same disability under various diagnoses is to be avoided." Together, those rules are why VA assigns one rating for the combined impairment from all of your service-connected mental health conditions.

So anxiety or PTSD claimed secondary to depression does not add a second percentage. A new diagnosis can still matter: if it adds impairment the depression rating did not capture, it can support a higher level on the one formula, for example 50 to 70 percent. The PTSD cause hub explains the same rule from the PTSD side. The physical conditions below are different, because they are rated on their own codes.

The most common secondary conditions to depression

Sleep apnea

Genetic studies point from depression toward sleep apnea. A two-way Mendelian randomization study (Wang and colleagues, Journal of Psychosomatic Research, 2024) found genetic liability to depression raised the odds of sleep apnea (odds ratio 1.29), found no effect in the reverse direction, and the result mostly held after adjusting for smoking, alcohol, obesity, diabetes and insomnia. A second study (Liu and colleagues, BMC Psychiatry, 2024) reached a similar result for major depressive disorder. These studies test genetic predisposition, so they do not show how the link works.

Medication is the more concrete path. In a UK cohort of 294,719 adults (Gafoor and colleagues, BMJ, 2018), people prescribed antidepressants had a 5 percent or greater weight gain at 11.2 per 100 person-years against 8.1 for others, an adjusted rate ratio of 1.21, and the higher risk lasted at least six years; the authors note the link may not be causal. A population cohort (Peppard and colleagues, JAMA, 2000) found a 10 percent weight gain predicted about a 32 percent rise in the apnea-hypopnea index. An opinion built on that chain should show the medication start, the weight gain and the sleep study in order. Sleep apnea that requires a CPAP rates 50 percent under Diagnostic Code 6847. See sleep apnea secondary to depression.

Migraines

In a community cohort followed for two years (Breslau and colleagues, Neurology, 2003), major depression at the start predicted a first migraine (odds ratio 3.4), and migraine predicted a first major depression (odds ratio 5.8); neither link held for other severe headaches. The same study found depression did not change how often migraine attacks occurred or how disability progressed, so a "caused by" argument is better supported than an aggravation argument. Migraines are rated under Diagnostic Code 8100 at 0, 10, 30 or 50 percent, by how often prostrating attacks occur.

High blood pressure

A meta-analysis of nine prospective cohorts with 22,367 people followed for an average of 9.6 years (Meng and colleagues, Journal of Hypertension, 2012) found depression raised the risk of developing hypertension (adjusted relative risk 1.42). The authors called depression probably an independent risk factor and said further studies are needed to rule out confounding. Hypertension rates at least 10 percent under Diagnostic Code 7101 when a history of diastolic pressure predominantly 100 or more requires continuous medication.

Erectile dysfunction

A meta-analysis of 49 publications (Liu and colleagues, Journal of Sexual Medicine, 2018) found depression tied to erectile dysfunction (pooled odds ratio 1.39) and erectile dysfunction tied to depression (2.92), but could not say which causes which. Medication is often the clearer argument. A meta-analysis of antidepressant side effects (Serretti and Chiesa, Journal of Clinical Psychopharmacology, 2009) found sexual dysfunction significantly more often than with placebo for sertraline, venlafaxine, citalopram, paroxetine, fluoxetine, imipramine, phenelzine, duloxetine, escitalopram and fluvoxamine, at rates from 25.8 to 80.3 percent, and no significant difference for bupropion, mirtazapine, agomelatine, amineptine, moclobemide and nefazodone. Your pharmacy record matters. Erectile dysfunction rates 0 percent under Diagnostic Code 7522, and the code's footnote sends VA to review special monthly compensation (SMC-K) under 38 CFR § 3.350. Erectile dysfunction secondary to PTSD covers the medication path in more depth.

GERD

A meta-analysis of 36 studies (Zamani and colleagues, American Journal of Gastroenterology, 2023) found anxiety and depression symptoms more common in people with reflux, cohort studies showing each raising the risk of the other, and genetic studies pointing both ways; the authors concluded the relationship is likely causal in both directions. A UK Biobank genetic study (Chen and colleagues, Turkish Journal of Gastroenterology, 2023) found depression slightly increased the risk of reflux disease. GERD is rated under Diagnostic Code 7206; the GERD page covers the current criteria.

Which secondary claims to file first

Three questions sort the claims worth filing.

1. Is there a current diagnosis? Sleep apnea needs a sleep study; high blood pressure needs readings on at least three different days; migraines need a record of how often they stop you.
2. Can it be rated on its own? Sleep apnea, migraines, high blood pressure and GERD have their own ratings. Anxiety and other mental health diagnoses do not, and erectile dysfunction rates 0 percent apart from SMC-K.
3. Will a doctor explain the link? Medication chains are often the most concrete, so bring your pharmacy history and weight records to the doctor writing the opinion.

Raven Nexus organizes your records and the relevant research into a draft your doctor can review, and a personal statement can describe when your sleep, headaches or weight changed.

How secondary ratings combine with depression

VA combines ratings under 38 CFR § 4.25, largest first, and each smaller rating takes its share of what remains. A veteran with depression at 70 percent who adds sleep apnea at 50 percent reaches 85, which VA rounds up to 90 percent. Adding high blood pressure at 10 percent and GERD at 10 percent brings the combined value to about 88, which still rounds to 90 percent. The first strong physical claim matters most.

Secondary conditions also count toward TDIU. Under 38 CFR § 4.16(a), one service-connected disability rated 60 percent or more meets the percentage test by itself, so a 70 percent depression rating meets that test on its own.

Questions veterans ask about secondary conditions to depression

What conditions are secondary to depression?

The most common in Board decisions are sleep apnea, migraines, high blood pressure, erectile dysfunction and GERD. Any condition a doctor can tie to your depression with reasoning can be claimed under 38 CFR § 3.310.

Can sleep apnea be secondary to depression?

Yes. Genetic studies point from depression toward sleep apnea, and antidepressants are tied to weight gain, which raises apnea severity. The opinion should lay out that chain with your own dates.

Can anxiety get a separate VA rating from depression?

No. VA rates all mental health diagnoses under one formula and avoids rating the same impairment twice, so anxiety is rated together with depression. It can still support a higher level if it adds impairment.

Can depression medication cause erectile dysfunction for a VA claim?

Yes. Many common antidepressants cause sexual side effects, including arousal problems, significantly more often than placebo, so erectile dysfunction can be claimed secondary to depression through its treatment.

Do I need a nexus letter for a condition secondary to depression?

Usually yes. The link between a mental health condition and a physical one is not obvious to every examiner, so a private opinion that answers both "caused by" and "aggravated by" with reasoning often decides these claims.

Sources

• 38 CFR § 3.310, secondary service connection; M21-1 V.ii.2.D, aggravation of a nonservice-connected disability by a service-connected one; Spicer v. McDonough (Federal Circuit).
• 38 CFR § 4.130, General Rating Formula for Mental Disorders; 38 CFR § 4.14, avoiding pyramiding; 38 CFR § 4.16, TDIU; 38 CFR § 4.25, combined ratings.
• 38 CFR § 4.97, Diagnostic Code 6847; 38 CFR § 4.124a, Diagnostic Code 8100; 38 CFR § 4.104, Diagnostic Code 7101; 38 CFR § 4.115b, Diagnostic Code 7522; 38 CFR § 3.350(a); 38 CFR § 4.114, Diagnostic Code 7206.
• VA General Counsel Precedent Opinion 1-2017 (VAOPGCPREC 1-2017), obesity as an intermediate step; Walsh v. Wilkie, 32 Vet. App. 300 (2020).
• El-Amin v. Shinseki, 26 Vet. App. 136 (2013), an opinion must address aggravation.
• Wang X, Song S, Dong N, et al. The causal relationship between depression and obstructive sleep apnea: A bidirectional Mendelian randomization study. Journal of Psychosomatic Research. 2024;179:111620. PMID 38430795.
• Liu H, Wang X, Feng H, et al. Obstructive sleep apnea and mental disorders: a bidirectional mendelian randomization study. BMC Psychiatry. 2024;24(1):304. PMID 38654235.
• Gafoor R, Booth HP, Gulliford MC. Antidepressant utilisation and incidence of weight gain during 10 years' follow-up: population based cohort study. BMJ. 2018;361:k1951. PMID 29793997.
• Peppard PE, Young T, Palta M, et al. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA. 2000;284(23):3015-3021. PMID 11122588.
• Breslau N, Lipton RB, Stewart WF, et al. Comorbidity of migraine and depression: investigating potential etiology and prognosis. Neurology. 2003;60(8):1308-1312. PMID 12707434.
• Meng L, Chen D, Yang Y, et al. Depression increases the risk of hypertension incidence: a meta-analysis of prospective cohort studies. Journal of Hypertension. 2012;30(5):842-851. PMID 22343537.
• Liu Q, Zhang Y, Wang J, et al. Erectile Dysfunction and Depression: A Systematic Review and Meta-Analysis. Journal of Sexual Medicine. 2018;15(8):1073-1082. PMID 29960891.
• Serretti A, Chiesa A. Treatment-emergent sexual dysfunction related to antidepressants: a meta-analysis. Journal of Clinical Psychopharmacology. 2009;29(3):259-266. PMID 19440080.
• Zamani M, Alizadeh-Tabari S, Chan WW, et al. Association Between Anxiety/Depression and Gastroesophageal Reflux: A Systematic Review and Meta-Analysis. American Journal of Gastroenterology. 2023;118(12):2133-2143. PMID 37463429.
• Chen G, Xie J, Ye J, et al. Depression Promotes Gastroesophageal Reflux Disease: New Evidence Based on Mendelian Randomization. Turkish Journal of Gastroenterology. 2023;34(5):457-462. PMID 36789979.
• Board figures on this page: Claim Raven's read of every Board decision from 2021 to 2026 that it holds.