This is Part 4 of my series looking at FAA policies with regards to the mental health of Pilots and Air Traffic Controllers. If you have been following my comments, you’ll know I consider the system deeply flawed. Current policies encourage vast underreporting of medical issues, resulting in large amounts of untreated depression among pilots and ATCs.
We can do better.
Today, I am going to discuss some of the most recent FAA attempts to address the problems we have been discussing. Specifically, the FAA has modified the processing of Deferred cases and, in a second policy change, may allow an Aviation Medical Examiner (AME) to approve licensure where, in the past, a Deferral was mandated.
As we know from my prior posts, a pilot may sometimes decide to lay it all on the line and tell their AME about a history of depression. Usually they don't. But, if the pilot admits to it, it gets documented on the FAA form 8500-8.
Officially, the FAA wants to encourage pilots to be honest. However, there has always been a wink-wink culture around pilot’s health; minimization and outright lying was understood to occur, sometimes encouraged, and usually tolerated -- as long as the medical issue was not too overt. But after the Germanwings event (see prior posts), the FAA started cracking down. As we shall discuss later in this series, they are cross-checking governmental databases-- trying to cull out these folks that admit to medical problems in one database but deny them to the FAA.
As I have argued, it is wrong and unethical to treat highly-trained professionals like automatons whom we throw out of their jobs when we realize they are not machines but humans – humans with human problems. It is also counterproductive. The FAA uses big sticks and legal threats to bully pilots and force disclosures. But, for the most severely affected pilots with their careers at risk, that just serves to push them deeper into silence. It discourages seeking medical care and makes untreated mental illness a larger threat in the skies..
The FAA knows this. As recent testimony in the Capitol has demonstrated, the FAA understands they have a credibility problem. In an effort to placate Congress, get some positive PR, and perhaps even incrementally improve matters, the FAA recently tossed a bone to induce pilots to buy into the disclosure program. The FAA released a new procedure wherein you can admit to past depression while still keeping your pilot's license. This is different from the past, where depression pretty much led to an automatic deferral.
To remind the reader, a "Deferral" is nasty. It generally means a 12-month to 4-year loss of one's flying license while the pilot spends a lot of time and money jumping through various FAA hoops. During that time, the pilot has a multitude of new expenses and a lot less income. Chief among the costs are difficult to arrange medical exams that the pilot needs to schedule and pay for. Often there are also legal bills.
Depending on their insurance, the pilot might get some relief. It is hard to say as the policies vary from airline to airline. The pilots' unions also lack consistency. Actual estimates as to what sort of financial hit you can anticipate when considering going on a Deferral are largely non-existent. Contemplating the process is best thought of as a blind jump from a window; you may be on the ground floor or the 30th. You’ll find out after you jump.
Sometimes the pilot can be reemployed by the airline in a non-flight capacity while awaiting FAA clearance. I could not find any hard data on how often this happens but it seems unusual and mainly a good outcome for very senior pilots who are well connected to the airline. But for the most part, pilots on Deferral live on short-term disability.
Unfortunately, disability ends – sometimes as soon as within a year– and a Deferral can often go twice that long. The length of the various airline disability program differs and seems to depend on several factors: the specific airline, their pilot’s union, the insurer, and perhaps what options the pilot selected during their annual enrollment.
Anecdotally, pilots have described to me that when Deferred, their incomes dropped by half, or more.
All of this makes a Deferral dangerous, clouded with uncertainty, and difficult to willingly agree to. If one were depressed, a condition marked by indecision, ambivalence, and clouded thought, choosing to be honest with your AME would be that much harder – and unlikely.
But, let's say a pilot goes to their medical exam and tells their AME that they have anxiety issues and, perhaps, that they are seeing a therapist. Or, maybe, that they had a past depression and took medications for it. Well, in a revision of policy, now the FAA allows the AME to issue the flight license and not Defer.
Yes, getting a flight license is now possible, in the regulations. Possible, but unlikely.
The system is complicated. Very complicated. If you really want to understand it -- and I suggest you should if you are about to see an AME,-- I would recommend a deep dive with a professional. I'll touch on the surface here but there are a lot of caveats that you’ll want to understand.
Rather than tell you how the AME awards the license, it is easier to describe why they issue the unwanted Deferral. There are other disqualifiers but they are fairly obvious and I don't repeat them here (e.g., psychosis).
The pilot will get deferred if:
The pilot has taken an antidepressant in the past two years.
The pilot describes any significant unresolved symptoms of depression or anxiety in the past 2 years.
The pilot ever -- over their entire lifetime -- had depression or anxiety symptoms reemerge after they previously went away.
The pilot was ever put on two different medications at the same time for depression or anxiety (i.e., supplementation).
The pilot ever had any suicidal thought or self-harm behaviors.
The pilot ever took Ketamine, Transcranial Magnetic Stimulation (TMS), or Psychedelics for treatment.
So, if you clear these hurdles, the AME might issue you a pilot's license without Deferring …assuming they know of the new policy and don’t have any doubts about you.
These criteria may sound kinda-sorta reasonable, but it is really a lot of hooey. If we are being honest, the odds of having past depression and being able to pass such a screening test are low. By promoting such policy, the FAA is just encouraging more tried-and-true lying.
Why are these criteria so difficult to overcome?
- After an initial case of depression resolves, a relapse with the illness often occurs. If we really are looking for truthful answers from pilots, we should expect about half of them will get Deferred due to having more than one episode of depression.
- Suicidal ideation is also common, even in healthy individuals. Take a recent study by Oquendo,et al., titled “Occurrence and characteristics of suicidal ideation in psychiatrically healthy individuals based on ecological momentary assessment.” The study has far-ranging implications.
122 people were followed over seven days. During the study, about nine-tenths of the depressed participants recorded suicidal thoughts. Remarkably, about 11% of the totally normal and vibrant un-depressed individuals also recorded suicidal ideation.
So, here we have the FAA asking the same question. But the pilot is not being queried about their past week, past month, or even past year. Instead, they are answering about their entire lifetime. If 90% of depressed people have such a thought over a week, what are the odds of some past, vague, suicidal thought over a lifetime?
As psychiatrists, we always ask about suicidal thought. Very early in my career, it became evident just how normal such thoughts were. Life sometimes sucks and deals us terrible blows. And, as the injuries pile up, nearly all of us sometimes have suicidal fantasies. But such thoughts come in different flavors. Does the thought merely provide some sort of comfort, as in “well, if things got bad I could always do xyz” or is it dangerous, like “I have bought everything I need and, tonight, I am going to...”?
I remember early during the AIDS epidemic when HIV was, literally, a death sentence. We had no treatments and the disease just…progressed.. Almost all of my psychiatry patients with AIDS had stockpiles of pills in their refrigerators, to take an early exit if “things ever got real bad.” None, to my knowledge, ever used them. But, they got comfort from the sense of control and the choice that they represented.
I’ll get off my soap box in a moment and return to the pilots. However, first this: asking for any suicidal thought is only the first question. But, too often in today’s society it is the only thing asked. When answered in the affirmative, in a lot of settings a friggin’ fire alarm goes off and everybody panics.
Often the real threat is our own anxiety – not the patient’s. Our own anxiety pulls us from what is curative – hearing and acknowledging the individual’s despair. Rather we worry about our own liability or institutional mandates (god help me, “safety planning” – one of the most useless time-sucks and cover-your-ass mandates in my field).
Anyhow, back to pilots. The criteria of having past suicidal thought is met by almost anyone that has been depressed...and many people who have never been depressed. You want a valid index? Screen for pilots that have made actual suicide attempts.
- Antidepressants are hit-and-miss. As a result, doctors often try their patients on several different antidepressants, usually with a "cross-taper" overlap. So, two mood or anxiety meds are frequently prescribed at the same time. I'd guess psychiatrists do cross-tapers around 90% of the time. However, this standard medical practice would lead to a Deferral. Moreover, nearly all doctors know diddly about FAA policies, like this silly one. The policy leaves no room for reasoned and practical judgement.
- Doctors (and patients) like treatments that work quickly. If you haven't already gathered, I am a huge advocate for Accelerated TMS. I mean, seriously, this treatment is for my profession something like a caveman discovering fire. Just name a better option wherein I can safely treat a depression in a week – that bears repeating – a week, with no ongoing meds, no concerns of medication-induced cognitive confusion/fatigue, and no significant side effects.
Ok, sure, there is Ketamine. It is also damn good. A tad more complicated and difficult to use but, arguably, with an even faster onset of action. So why punish pilots for getting Ketamine or TMS? With regards to TMS, it is a good, rapid, and safe treatment that does not involve ongoing or systemic medications.
So the new policy is flawed in a framework that is flawed in an agency that is flawed. What else is new?
Next time, we will continue to review the new policies. In particular, we will take a close look at the FAA regulations governing pilots that are actively taking psychiatric medications.
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