Consider two patients. Patient A develops abdominal pain and visits his doctor, who notes the patient has a low-grade fever and tenderness localized to the lower right side of the abdomen. Additionally, if the doctor presses slowly on the lower abdomen and then suddenly lets go of the pressure, the patient winces. A CT scan or other imaging study is ordered and it’s obvious that there is fluid surrounding the appendix, which is itself swollen.
The patient is taken to the operating room where the appendix is removed. When examined by the pathologist, the removed appendix shows the typical findings of acute inflammation. The next day the patient feels fine. This patient had a clearly defined anatomic condition that could be objectively demonstrated by physical examination, radiographic imaging and then confirmed by pathologic examination of the abnormal tissue that was removed.
He had acute appendicitis. Furthermore, this patient could have gone to any of hundreds of doctors and all of them would have reached the same diagnosis and recommended the same treatment.
Patient B, on the other hand, complains of feeling tired, sad, and sometimes out of control. He is having trouble sleeping. His work performance is suffering and he is drinking or smoking more in an effort to relax and “get a grip” on it. If he sees a doctor, the physical examination will be normal. Any lab or imaging studies will be normal as well. The patient has no objective evidence of any disease, yet he will be given a diagnosis.
What’s more, that diagnosis might vary from doctor to doctor depending on how they interpret his subjective symptoms or how the patient himself explains them. The severity of the condition can only be based on those same subjective symptoms. Patient B is suffering from some sort of depression.
Why should this matter to pilots? The FAA is quite concerned about depression and other diagnoses that fall under the general category of mental or psychiatric disturbances. FARs 67.107, 67.207, and 67.307 list “mental conditions” and substance abuse issues that must result in the denial of a medical certificate. Because the diagnosis of these conditions are in large part highly subjective, how a given practitioner describes and classifies the condition can make a great deal of difference in how the FAA will react. Furthermore, the medications usually prescribed for psychiatric disturbances all work on the chemistry of the brain, modify behavior, and therefore are viewed with great suspicion by the FAA.
To add insult to injury, the conditions classified as “mental illnesses” vary with societal norms, which change over time. Yesterday’s psychiatric condition is today’s non-pathological lifestyle choice. For example, homosexuality was classified as a mental disease until fairly recently; and conditions that were previously classified as laziness, malingering, etc. are now bona fide mental “conditions” with specific diagnoses. In the classification of mental conditions, the only constant is change.
In an attempt to rationalize the methodology used to diagnose mental disorders, the American Psychiatric Association publishes a thick book called Diagnosis and Statistical Manual of Mental Disorders in an attempt to accurately describe a variety of conditions and what must be present to diagnose them. The most recent iteration of this series is Volume V and this Bible of Psychiatric Diagnosis is called DSM-V. This book is used in conjunction with the World Health Organization’s “International Classification of Diseases” (ICD-11) as the standard for the diagnosis of mental conditions.
DSM-V is quite complex. Mental conditions are broken down into 20 major groups, including Schizophrenia Spectrum and Other Psychotic Disorders, Bipolar and Related Disorders, Depressive Disorders, Anxiety Disorders, Personality Disorders, Neurocognitive Disorders and so on. The diagnoses described are grouped according to age of onset, internal factors like anxiety, mood changes, and physical symptoms, as well as external factors like disturbances of conduct, impulsive behavior, substance abuse and so on.
As you might imagine, the various groups overlap in many ways and this can lead to confusion in the precise classification of a specific patient. It is this uncertainty that makes the FAA uncomfortable. It is also why it can be difficult to get a Special Issuance (SI) for psychiatric diagnoses. In evaluating a diabetic or cardiac patient for an SI, the FAA has objective data to use in making its decision. Such objective data is lacking in most psychiatric situations and therefore psychiatric conditions are problematic when it comes to deciding who should be allowed to fly and who should not.
Let’s consider some specific diagnosis and see how they can affect a pilot’s ability to obtain or maintain a medical certificate.
Many psychiatric conditions are clearly incompatible with flying. Schizophrenia and disorders where the patient is out of touch with reality are clear examples. Patients who have a history of suicidal ideation form another group that will not, and should not, be medically certified. The crash of Germanwings 9525 in 2015, where the first officer locked the captain out of the cockpit and flew his Airbus into a mountain, thereby simultaneously committing suicide and murdering 149 innocent bystanders brought this issue into clear focus. There is clearly a problem with these diagnoses, as medical ethics prevents a physician from divulging information about their patients, but if a pilot is diagnosed with a significant psychiatric disorder and fails to report it on his FAA medical application, there is a good chance it will not be discovered by the examiner. This issue of patient confidentiality versus aviation safety is a hot topic for certification and regulatory agencies worldwide.
Unfortunately, the majority of psychiatric diagnoses are not clear cut. When does sadness become depression? When does vigorous hyperactivity become mania? When does compulsive behavior, something that can be really useful for a pilot, cross into abnormally compulsive behavior? Generally speaking, the line between normal and pathological is drawn when the behavior in question begins to interfere with normal everyday activities. When feeling low makes it hard to go to work, or accomplish tasks or personal goals, or when compulsivity gets in the way of normal functioning, we call it pathologic. It’s very important for pilots to be diagnosed accurately when they have complaints that can point to actual psychiatric problems. Situational sadness, for example, is not depression. Yet it is often treated as if it is. The problem for a pilot arises when he or she goes to a health care professional and is given a psychiatric diagnosis. This diagnosis will almost certainly come with a prescription for a sedative, a tranquilizer, or an anti-depressant, and at that point the pilot will run into major problems with the FAA.
Briefly stated, most psychiatric diagnoses are disqualifying and an AME cannot issue a medical certificate. These diagnoses include: Adjustment Disorders requiring medication, Attention Deficit Disorders, Bipolar Disorders, Minor Depressions requiring medication, Major Depressive Disorders, Personality Disorders, Psychosis, History of Suicide Attempt and Substance Dependence. While an applicant might be able to obtain a certificate via the Special Issuance Process, the AME is not allowed to issue the certificate to an applicant with any of those conditions, and those categories make up the bulk of psychiatric diagnoses.
The real difficult part for pilots who have psychiatric issues is that while many psychiatric conditions can be fairly well managed with medications, essentially all psychoactive medications, with four specific exceptions, are not acceptable to the FAA. The FAA will not certify pilots who are taking sedatives, tranquilizers, antipsychotic drugs, antidepressant drugs (with four exceptions), analeptics (nervous system stimulants), anxiolytics (anti-anxiety agents), and hallucinogens. The four exceptions are all in the antidepressant drug category and are specific SSRI (Selective Serotonin Reuptake Inhibitors). Serotonin is a chemical that is involved in transferring information between neurons (nervous system cells), and SSRI drugs increase the amount of serotonin available in the brain. These drugs are quite useful in treating depression, but because they increase the available serotonin levels in the brain, and since serotonin affects nerve cell transmission generally, they have potential side effects, including drowsiness, nausea, insomnia, diarrhea, restlessness, dizziness and blurred vison.
The four specific SSRI medications that can be approved by the FAA are: Fluoxetine (Prozac), Sertraline (Zoloft), Citalopram (Celexa), and Escialopram (Lexapro). But even here, there are conditions.
Below is the decision tree that an AME must use when evaluating an applicant on one of the “approved” medications:
As you can see, getting approval when you are on an “approved” SSRI antidepressant is not for the faint of heart. It’s time consuming, expensive and generally very difficult. It requires visiting with an HIMS AME, an AME with special training in “Human Intervention and Motivation Study” programs. These programs were originally set up to deal with pilots who had substance abuse issues and have now been expanded to deal with pilots on SSRI medications. There are only about 200 HIMS AMEs in the country, so finding one may present issues for pilots who live away from large metropolitan areas.
The very few approved psychiatric medications and the difficulties in getting a medical certificate when taking one of those specific medications presents a real dilemma for a pilot. On the one hand, if a pilot has a true psychiatric condition and needs medication then he ought to be on medication, even if this will make it difficult for him to fly. On the other hand, if a pilot can do without such medication he can continue to fly, but if his symptoms are significant he may actually be more at risk than a pilot who is properly medicated. It’s a real Catch 22. It will be interesting to see how, or if, the FAA addresses this problem when it issues rules implementing the medical certification reform promised in the Pilot’s Bill of Rights (PBOR) II legislation.
The items discussed in this column are related to experiences by Dr. Seckler in his many years as an AME, and made hypothetical for the article. Any information given is general in nature and does not constitute medical advice.
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