Psychiatry and Fitness to Fly After Germanwings

Suicide-by-Plane

Available data suggest that pilots have up to a 13 percent one-week prevalence of clinically significant depressive symptoms, double the one-year prevalence of depression among all adults in the United States, and a 4 percent two-week prevalence of suicidal ideation.⁷ Based on findings and hypotheses from the cited study, potential explanations include the high stress of their occupation (e.g., long and continuous work hours) and sleep-related problems (e.g., circadian rhythm disruption, sleep medication use). Females, who account for 4 percent of U.S. pilots, were more likely than men to have depression, similar to the general population.⁷ Among fatal aviation incidents, 0.33 to 1.42 percent have been determined to be suicide-by-plane.^8,9 All pilots completing suicide-by-plane were male, and their average age was 38 years, significantly younger than the average pilot age of 45 years. Most were private pilots with personal aircraft, rather than commercial or military pilots. Most experienced recent life stressors, most often relationship problems (e.g., divorce, separation), followed by legal, financial, and occupational stressors. Among this group of suicides-by-plane, 38 percent involved pilots who had preexisting mental health conditions, 50 percent involved alcohol or drugs, and 60 percent of the pilots had previously reported suicidal ideations to someone.^8,–,11

Most instances of suicide-by-plane in these studies resulted in only the pilot's death. That said, plane-assisted homicide-suicides are a particular problem and have resulted in more than 700 deaths across at least 18 incidents. Homicide-suicides account for about 17 percent of pilot suicides, significantly higher than nonpilot suicides. Most commercial plane-assisted homicide-suicides occurred while the pilot was alone in the cockpit.^8,–,11 This latter finding, especially in the wake of the Germanwings incident, has led to policy changes throughout the world. For example, many airlines that did not already require it, such as those in Europe, began to require two aircrew members to be in the cockpit at all times.

Flying Impaired

Although suicides-by-plane and homicide-suicides are particularly frightening, not all unsafe acts are so deliberate or malevolent. Substance intoxication or withdrawal can lead to a variety of dangerous symptoms, including sedation, disinhibition, poor judgment, mood changes, psychosis, cognitive impairments, psychomotor impairments, and inattention. Alcohol use has repeatedly been linked with aviation accidents and poor flight-simulator performance, both during intoxication and hours after use when blood alcohol concentrations are low or even after they have returned to zero.^12,13 Prescription and over-the-counter medications, such as diphenhydramine, can have even more detrimental effects on driving performance than alcohol.¹⁴ These effects have led to stringent regulations on both substance use and allowable medications among pilots, and the FAA has implemented the Human Interventional Motivation Study (HIMS) program designed for pilots with substance use problems (https://himsprogam.com). Understanding of substance- and medication-induced impairments and related regulations are important for clinical treatment and independent psychiatric evaluations of pilots.

Fatigue, whether due to substances, stress, sleep deprivation, or long flights, can have detrimental effects on performance and can cause a pilot to ignore other risk factors. That is why the FAA has developed a policy for fatigue risk management.¹⁵ Studies have reported fatigue to be common among aircrew, with 21 percent of military aircrew and 31 percent of civilian aircrew reporting fatigue.¹⁶ Subclinical fatigue that may not cause impairment for the general population may cause unacceptable risks in pilots. Likewise, attempts to counteract fatigue, such as the use of stimulants (e.g., caffeine, prescribed, illicit), can cause risks. Unfortunately, the combination of stress, sleep deprivation, and stimulants is a recipe for the occasional presentation of brief psychotic episodes among pilots, such as among military pilots prescribed “go pills” to maintain alertness during flying.¹⁷ In cases where the symptoms resolve quickly and there is no recurrence after a prolonged period of time without antipsychotics, and the cause is definitively identified and determined to be preventable, waivers in the military for flying are often granted.

Organizational Factors

For forensic psychiatrists performing pilot evaluations and consulting with organizations, it is important to be aware of aviation industry concerns. In addition to operating within a safety culture, governmental organizations and airline companies have rules and regulations governing mental health that affect pilots' abilities to exercise the privileges of their license. When regulators are faced with mental health-related concerns reported by pilots, they may rely on experts to provide clinical observations and opinion data that subsequently allow them to determine the pilot's fitness for medical certification. The ultimate authority for this regulatory power derives from the public interest in ensuring safety in the skies. Therefore, it is important for psychiatrists seeing pilots, in both treatment and occupational or fitness for medical certification contexts, to have some familiarity with aviation regulations and common safety concerns.

Federal Aviation Regulations

FAA medical exams (i.e., flight physicals) are performed by physicians known as aviation medical examiners (AMEs), who are designated as representatives of the Federal Air Surgeon to conduct exams.²⁴ FAA medical certification is divided into three classes: airline transport pilot (first class), commercial pilot (second class), and private pilot (third class).²⁵ Table 1 presents federal aviation regulations regarding psychiatric disqualifiers.²⁶ According to the federal aviation regulations, the FAA does not use diagnostic codes from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, but the FAA specifically mentions psychosis, bipolar disorder, personality disorder, and substance use disorders as disqualifiers. Depression and suicidality are notably not mentioned. In fact, federal aviation regulations do not specifically address most psychiatric disorders (e.g., obsessive compulsive disorder, eating disorders, attention-deficit hyperactive disorder). These may fall under a “neurosis, or mental condition” that impacts safety or ability to perform duties, which the Federal Air Surgeon may deem disqualifying. A special issuance medical certificate may be granted on a case-by-case allowance for one of the following: major depressive disorder (mild to moderate), either a single episode or recurrent episodes (if treated); dysthymic disorder; adjustment disorder with depressed mood; and nondepressive disorder for which particular selective serotonin reuptake inhibitors (SSRIs) are used.²⁷ Special issuance certificates that allow a pilot to be on SSRI medications, for example, require stability and no aeromedically significant side effects for six months.²⁷ The FAA allows waivers for only four psychiatric medications, all of which are SSRIs: fluoxetine, sertraline, citalopram, and escitalopram.²⁷ FAA waivers are not permitted when the use of the SSRI is proposed in an individual with a history of psychosis, suicidal ideation, electroconvulsive therapy, multiple SSRI use, or history of use of other psychiatric medications with SSRIs.²⁷ Aviation industry concerns may not always be in sync with the regulatory responsibilities of the FAA and may not be readily obvious to those in forensic practice, but familiarity with regulations and consulting with aeromedical experts and forensic psychiatrists experienced in aeromedical regulations can help guide clinical assessments, treatment recommendations, and occupational recommendations.

Military Regulations

Unlike the FAA, the military classifies all mental disorders as potentially disqualifying.²⁸ Some conditions are potentially “unfitting” for military duty (e.g., psychosis, bipolar disorder, depression) and can result in disability benefits, but others are considered “unsuiting” (e.g., substance use, personality disorders) and can result in administrative separation without benefits.²⁸ Classification of unfitting and unsuiting diagnoses vary between military branches and jobs.²⁸ All disorders require assessment and can result in service members being discharged from service or returned to duty with or without restrictions. In the U.S. Air Force (USAF), flying waiver requirements include “no risk of sudden incapacitation,” “minimal potential for subtle performance decrement,” “low possibility” of progression or recurrence, expected stability even “under aviation stresses,” and condition-dependent time requirements for symptom remission (e.g., at least 1 year for psychotic or somatic disorders; at least 6 months for depression, anxiety, or suicidality; at least 3 months for alcohol use disorder; the flight surgeon's discretion for adjustment disorders).^17,29 Often psychotherapy “booster sessions” or antidepressants are permissible or even advisable after symptom resolution.¹⁷ In the experience of one author (J.G.), common restrictions for returning to duty included no deployments, no firearms, no alcohol use (e.g., on or off duty, with regular monitoring), no flying, no flying certain aircraft, no stimulants while flying, flying duration limits, preflight mandatory sleep durations, and only being stationed at bases with psychiatric services. Any of these will require at least annual reviews.¹⁷ Although these restrictions can reduce risk, clinicians and commanders should be mindful that they can also increase stigma and impact rank promotions, which in turn could increase risk. For example, pilot stress could be exacerbated by co-worker knowledge of the pilot's restrictions, and other pilots may be deterred from self-disclosure. Such matters should be carefully balanced and zero-tolerance, absolutist policies should be avoided in favor of case-by-case evaluations.

Medication policies vary depending on branch of service and job duties. For example, the USAF does not allow any psychiatric medications for personnel working around nuclear material.³⁰ For flyers, the USAF limits psychiatric medications to four antidepressant monotherapies (i.e., bupropion, citalopram, escitalopram, and sertraline), two “go pills” while in-flight (i.e., dextroamphetamine, modafinil), and three “no go pills” for premission sleep (i.e., temazepam, zaleplon, zolpidem).³¹ Although data related to these medications and accidents are scant, the USAF elected to allow three of the same antidepressants as the FAA but replaced fluoxetine with bupropion in an attempt to avoid longer-acting agents in the event of adverse effects.¹⁷ Clinicians must consider medication regulations to guide treatment decisions.

Pilot Medical Certification Evaluations

The FAA and military rely on clinicians to evaluate diagnosis, prognosis, treatment, and functioning of pilots. Their professional presentation of objective clinical findings in a systematic fashion allows regulatory bodies to ensure policy compliance, determine potential functioning and safety concerns, and mitigate risk when making individual certification decisions. Data related to medical reliability are essential to pilot certification and supervision.

Appropriately trained psychiatrists (and psychologists or neuropsychologists at times) are called upon by regulators when there is evidence to suggest that a pilot has a disqualifying mental health condition, or when there is a concern requiring additional information for certification. Regular medical certification is based on the premise of safety of the national air space system and defined by regulations unique to pilots. Familiarity with regulations is critical to conducting proper evaluations. Pilot medical certification varies in duration and requirements for type of work, time frame, and age factors for renewal. AMEs are usually primary care doctors, but a few are psychiatrists. Designations are made by Regional Flight Surgeons³² based on the needs of the Office of Aerospace Medicine. The FAA also may refer cases to forensic psychiatrists who are not AME- or HIMS-trained to opine on diagnosis, proper treatment, and prognosis. In the military, treating clinicians (both active-duty and civilian staff) are responsible for regularly assessing fitness for duty, although service members are often referred to nontreating evaluators for occupational assessments.

Aeromedical evaluations by forensic psychiatrists may be particularly helpful in specific cases, especially when there is a debate about diagnosis, dispute between the records and self-reporting, or competing clinical opinions. In other instances, addiction or other specialists might be preferable. Referrals for psychiatric evaluation for aeromedical certification can be based on discovery of a psychiatric history during certificate application or medical examination, pilot-monitoring plans, or pilot-conduct problems. Psychiatric evaluations can enter into legal arenas in that highly motivated pilots seeking medical certification can challenge findings that result in denial of their certification. The FAA has the authority to make final determinations, but cases related to medical certification denial can be appealed to the National Transportation Safety Board (NTSB) and adjudicated by an NTSB Administrative Law Judge, who determines whether regulations were appropriately followed. Even a pilot deemed fit for medical certification might be a poor company employee due to other conduct problems. Employment/administrative and medical/psychiatric concerns may be intertwined (e.g., certain personality factors) or separate and distinct. Employment factors are not relevant, however, for private pilots seeking certification.

Psychiatrists with specific training approved by the FAA are often utilized to conduct evaluations, provide context, sort through disparate clinical information, and render opinions. The FAA often needs psychiatrists to clarify ambiguities in a pilot's medical history and records, and to identify what is and is not relevant to occupational functioning and safety risk in accordance with federal aviation regulations. The AME is often confronted with balancing regulatory obligations with a competing desire for pilot advocacy. Countertransference factors may influence an AME's objectivity. It is important for those psychiatrists evaluating pilots to recognize that subclinical symptoms that would not impair the average person may be aeromedically significant. Symptoms such as mild inattention, fatigue, insomnia, or anxiety may not substantially interfere with the functioning of someone working in an office or stockroom, but these same symptoms could be detrimental to a pilot's ability to function as a crewmember. For example, someone experiencing a panic attack on the ground can take a break from work to employ relaxation techniques, but a pilot needs to remain attentive to maintaining aircraft safety. Evaluators assessing individuals for medical certification should assess how symptoms impact pilot functioning but focus examination on whether there are potential disqualifying factors that are elucidated in the overall assessment.

The Role of Treating Psychiatrists

Treating pilots requires consideration of both personal health and flight safety. There are disqualifying diagnoses and disqualifying treatments. Until relatively recently, all psychotropic medications were disqualifying. The concordance between what may be clinically appropriate and what is aeromedically acceptable is not seamless. Sometimes what the patient wants comes into conflict with flight safety. For example, a patient may have failed with all of the regulation-approved antidepressants and only responded to a medication that is not approved (e.g., a serotonin-norepinephrine reuptake inhibitor, antipsychotic augmentation). If the pilot decides to stop the effective medication to be eligible to fly again, both clinician and pilot must weigh the risk of relapse against the risk of worsened mental health if the pilot is no longer able to fly. Furthermore, both must be aware of the time period off the medication that the aviation regulatory body may require, as well as the risk that the pilot may not be approved to fly again. The best advice for a treating psychiatrist is to first provide the best treatment possible, and then work to support the patient when the treatment may have aeromedical implications. Prescribers should have knowledge of nondisqualifying treatments and try them first, if appropriate. For example, when treatment options are equally efficacious, favoring the ones permissible by regulations can save time and heartache.

Clinicians should ask pilots for details about their job and how they are functioning. Collateral information from an employer can also be helpful, but in civilian contexts this may not be part of routine treatment. Factors to investigate include career progression, awards, disciplinary problems, attendance problems, productivity and performance, the specific skills and tasks required of specific jobs, and sudden or progressive changes in any of the above. Pilots can have unique job demands, so understanding these demands and their performance can allow clinicians to better assess pilot patients and to better focus on specific strengths and vulnerabilities.

Documentation is important when evaluating pilots. Treating psychiatrists should be aware that their notes might be reviewed by an aviation regulatory body, but documentation should be maintained as needed for clinical purposes. Focusing on areas of functioning or dysfunction and supporting diagnoses with clear examples of symptoms can improve the occupational utility of records. Ambiguous or “soft” documentation may seem satisfying to clinicians worried about negatively affecting a patient's career, but when records are reviewed, inaccurate or unclear information can actually delay or prevent medical review processes, lead to incorrect or suboptimal treatment recommendations, or result in inappropriate occupational recommendations (e.g., unnecessary disqualification, unfit pilots putting themselves and others at risk). The FAA wants clinicians to do their job as they would with any other patients. The FAA does not want clinicians to opine on pilot fitness, but to provide factual information to allow the FAA to make determinations (e.g., the diagnosis and how that diagnosis affects the pilot).

When a patient is a pilot, the threshold for reporting concerns about public safety is arguably lower than for average patients. State laws and confidentiality rules may create barriers for reporting, however, and reporting concerns may be limited by fear of breaching confidentiality or concern that the patient will be dissuaded from providing information to help conduct a thorough risk assessment and remain in treatment. Psychiatrists evaluating pilots can face many risk-management challenges, particularly with pilots who are expressing suicidal or violent ideation or conveying risk of harm, but with no expressed plan or intent. Even in states with laws that mandate a duty to protect the public at large when a threat to safety is presented by a patient, beyond addressing the risk with hospitalization when feasible, there may not always be a clear means to take further action in the context of risk to airway safety. The FAA's and military's perspectives on overriding duties are clear in prioritizing aerospace safety, but to a private civilian psychiatrist with no attachment to the FAA or the military, this might not create a clear path of communication. For these regulatory oversight bodies, confidentiality concerns are not thought about in the same way as in treatment contexts; in clinical treatment of pilots, public safety concerns may supersede confidentiality in a way that would not occur in the treatment of people in other professions (e.g., the necessity to report substance use or subclinical symptoms). A full analysis of duty-to-protect statutes as they relate to pilots across jurisdictions is beyond the scope of this article, but consideration of these complexities is critical. Treating clinicians should consult liberally with risk-management entities, the FAA Aerospace Medical Certification Division (405-954-7653), or with colleagues who understand aerospace safety considerations and confidentiality guidelines.

Unlike civilian clinicians, military clinicians not only have a duty to the patient and the public, but also to the military mission. Beyond typical exceptions to confidentiality, such as risk to self or others and suspected child abuse,³³ military clinicians are also mandated to report risk to mission (e.g., inpatient care; problems with substance use, impulsivity, insight, reliability, judgment).³⁴ With stakes being as high as national security, such measures are necessary, but they also may deter self-disclosure and help-seeking among military aviation personnel.

Suicide Risk Assessment

It should be noted that suicide by pilots is rare, and most pilot mental health concerns are of a much lower severity. Nonetheless, whether assessing a pilot for treatment or as part of an occupational evaluation, suicide risk must be addressed because it is a potential danger to both the pilot and the public. The basic standards of care in assessing acute and chronic risk factors and protective factors apply here, but with additional considerations for pilots. As noted earlier, pilots may appear functional in many domains of life, hiding dysfunction in other domains. It is easy for clinicians to overlook or dismiss signs of potential problems that may in fact be the tip of the iceberg. Furthermore, pilots are motivated to appear reliable to keep their job, and therefore they have a propensity for intentionally or unintentionally under-reporting symptoms and engaging in positive-impression management. To best address this, clinicians might attempt to gather collateral sources (e.g., spouse, supervisor, commander in military contexts, parents, and friends). Basic clinical suicide and depression screens are often used in general care settings but could be misleading in suicide risk screening of pilots if the individual is motivated to appear nonsuicidal (e.g., it is easy to cite “none” or “never” on screening tests asking for presence or frequency of suicidal thoughts).

Additionally, clinicians should have an understanding of both the real and imagined consequences of self-disclosure. One can start by asking about the pilot's expectations of evaluation and treatment. Responses to and education about the pilot's concerns should be based on knowledge of the actual regulations and consultation with the FAA, aerospace medicine physicians, or military flight surgeons (e.g., the USAF Aerospace Consultation Service at Wright-Patterson Air Force Base). The consequences of having a mental health diagnosis or using certain substances or medications may vary based on diagnoses, the treatment needed, and the applicable regulatory body. Contrary to expectations of most pilots undergoing evaluation by the Aerospace Consultation Service, the USAF's goal is to get grounded pilots (i.e., those with duty-not-involving-flying restrictions) back into the air as quickly and safely as possible, and most of them will receive waivers once their condition is stable with appropriate treatment.¹⁷ Civilian standards with the FAA are focused on keeping the airways safe, and the federal aviation regulations will dictate what is disqualifying. Because the mission is to protect national airspace, however, regulatory bodies tend to be very conservative about these matters. Accurate policy knowledge is essential to avoid false promises and to establish trust. Trust and rapport encourage accurate reporting of suicide risk and preventive factors.

Aviation Rulemaking Committee (ARC)

In 2015, the FAA Administrator chartered the ARC in response to a recommendation by the Civil Aviation Safety Team following concerns over Germanwings Flight 9525 and Malaysia Flight 370.³⁵ The ARC included 23 members, comprising representatives from industry groups, unions, and the FAA. The ARC met monthly for the following year, both collectively and in working groups of subject matter experts, which reported information back to the ARC. Among these, the Medical Working Group included 12 individuals (i.e., psychiatrists, psychologists, and aerospace medicine specialist physicians).

The ARC report³⁵ recommended creating an environment encouraging pilot self-disclosure; improving access to health care and support; expanding pilot-support programs; educating air carriers and pilots on mental fitness for duty; ensuring that pilot care is confidential and nonstigmatized; building risk-mitigation processes on top of existing safety management system principles; and addressing pilot mental fitness using a holistic approach. On the basis of these recommendations, the FAA instituted enhanced mental health training for AMEs in 2016 and advocated for a uniform national policy on mandatory reporting of medical concerns that affect public safety, which was passed by the Aerospace Medical Association in 2016. On the basis of the ARC findings, the FAA determined there were no convincing data to suggest routine psychological testing would be helpful in periodic medical certification evaluations, and that no changes were needed regarding existing FAA standards for aircraft or flight deck door design, standard flight deck access, and the requirement for two persons to be on the flight deck at all times.^35,36 Progress is ongoing in the FAA's implementation of other ARC recommendations, such as the implementation of mental health education programs to improve awareness, reduce stigma, and promote available resources; the development of effective pilot assistance programs; and the creation and dissemination of information on pilot-support programs.

Pilot Support Programs

The Air Line Pilots Association (ALPA) is a union representing more than 58,000 pilots across 33 U.S. and Canadian airlines. ALPA's mission is air safety, security, advocacy, representation, and pilot assistance. Pilot-assistance programs include HIMS, the Critical Incident Response Program (CIRP), Professional Standards, and Aeromedical. HIMS began in the 1970s as a joint partnership with airlines, FAA, and ALPA to assist pilots diagnosed with substance use disorders to regain medical certification.³⁷ CIRP developed after the Origins 1988 Aloha Flight 243 incident and relies on trained peer volunteers who target pilots experiencing unexpected stressful events that overwhelm coping skills.³⁸ ALPA's Professional Standards uses peer volunteers who target pilot behavior and conflict resolution in the workplace. ALPA Aeromedical has a peer-assistance program that helps pilots with FAA medical concerns and with reporting medical conditions and treatments to the FAA for continued certification.³⁹

One author (H.M.P.) was instrumental in the development of an ALPA-sponsored, single-airline, peer-support program for pilots facing aeromedical, psychological, and physiological challenges.⁴⁰ It is called the Pilot Assistance Network (PAN) and began as a grassroots effort in 2000. “PAN,” like “may day,” is a pilot distress signal. A similar support program was adopted across ALPA.⁴¹ Unlike the more common phrase of “may day,” PAN refers to a slow or insidious onset that eventually overwhelms. Pilot peer volunteers are available at all times to provide strictly confidential support and encourage the utilization of all available resources. PAN encourages pilots to be mindful of their own mental health with the goal of helping pilots help themselves as they safely navigate treatment of an unfamiliar medical or mental condition that is perceived to be career-ending. Common pilot concerns seen in PAN include depression, anxiety, divorce, child-related stressors, elder care, training difficulties, and cognitive impairment. Common fears expressed among pilots seeking PAN support include concerns about loss of pay, job loss, negative action against the pilot, potential denial or loss of FAA medical certification, and embarrassment.

An equally important aspect of this program is that, by allowing pilots access to appropriate medical care, safety of the skies is increased. The reason this model appears to be so successful is the ability to leverage the value of peer support for a pilot in need. To be successful, the program requires mutual trust from union officials, the company, and regulators. With PAN, the airline has placed an incredible amount of trust in the peer volunteers and takes a hands-off approach, initially allowing pilots the space needed to obtain appropriate health care treatment without interference. This trust is enhanced through training supported by and attended by the leadership of administrative groups, aviation companies, and the FAA. In this way, the network provides additional layers of protection against holes in the defensive layers aligning in the overall system. Once a plan is in place to approach personal problems, pilots can approach their chief pilots (i.e., supervisors) in a confidential manner. The FAA has also provided assurance that the pilot will be treated fairly and in all likelihood can be requalified to fly after appropriate reporting. The PAN model was touted as an example of good practice in the final report on the Germanwings Flight 9525 investigation.¹ PAN′s future goals include improving mental health education for the pilot community, assistance in access to high-quality treatment, and enhancing safety nets to encourage accessing care before problems become more significant (e.g., removing risk to pay if a pilot engages in treatment, ensuring that psychiatric disability coverage is on par with medical disability).^40,42

Peer support allows for empathy with an understanding of how best to speak another pilot's language. As only other pilots can truly know, obtaining pilot medical certification and completing the FAA Form 8500-8 disclosing medical background can be daunting tasks. Confidential peer support and encouraging pilot access to appropriate care, with cooperation from companies and regulators, can increase the likelihood of treatment and improve aerospace safety, with the eventual goal of returning the pilot safely to the flight deck.