depression and psychological support
Many Americans are affected by
psychological stressors in their every day lives. Sources of stress vary
widely ranging from arguments with family members, pressure from bosses
and management, urgent deadlines to meet, unrealistic workloads, financial
difficulties or the prolonged illness or death of a loved one. Positive
events in life also can cause stress and anxiety, such as a move to a new
location, marriage, a new child or the purchase of a house.
Stress may disturb sleep patterns, appetite, sex drive and energy levels.
The cumulative effect of these stressors may result in feeling of barely
maintaining control or helplessness in certain situations. Sometimes,
people experience these physical and emotional disturbances for no readily
identifiable reason. Most people in this situation are reluctant to ask
for help from medical experts, their clergy, friends or even family.
Over 17 million Americans meet the criteria for mental disorders of all
degrees of severity and more than one in ten will be afflicted sometime in
their life. The majority of these people will go undiagnosed, however. The
U.S. Preventive Services Task Force: Recommendations and Rationale for
Screening for Depression encourages physicians to perform simple
questionnaires on most adult patients to increase the detection rates in
this frequently undiagnosed condition. An excellent article in the
September 15, 2002 issue of American Family Physician clearly describes
the need for screening and treatment of depression. See Screening for
Depression Across the Lifespan: A Review of Measures for Use in Primary
American society previously has stigmatized mental health conditions and
equated the admission of these conditions as weakness. Fortunately, these
misperceptions are rapidly melting away. People are encouraged to seek
help for all types of stress and poor emotional well-being. A tremendous
number of resources are available to help anyone who asks for assistance
and support. Even the military is instituting a system of buddy care for
suicide prevention backed up by medical and chaplain resources. In most
cases, the help provided is beneficial. The major problem is persuading
someone to ask for assistance in the mental heath arena.
Pilots and controllers remain some of the most difficult groups to
persuade to seek mental health assistance, even when they can barely
function. Some of this reluctance is related to the personality types that
tend to seek aviation careers or hobbies: confident, independent, always
in control, able to compartmentalize problems and generally healthy.
Another major obstacle is fear of having to report any counselling or
treatment to the FAA and permanently losing their medical certificate and
perhaps their career. This fear is unjustified in the vast majority of
Types of Mental Health Conditions
There are many different types of mental health conditions. Each has
specific diagnostic criteria. Broad categories include anxiety disorders,
mood disorders, somatoform disorders, personality disorders,
schizophrenia, substance abuse and dependence and several others. This
article will address only anxiety disorders and mood disorders in broad
Types of Mental Health
Conditions - Anxiety Disorders
Anxiety is described as a feeling of discomfort, uneasiness, dread or
nervousness. Anxiety is a normal emotion in all people. Anxiety disorders
are amplifications of these emotions at inappropriate situations or to a
greater degree than would be expected. There are more than a dozen
specific anxiety disorders defined. They are the most common mental health
condition present in some estimates.
Anxiety disorders include Panic disorder, Posttraumatic Stress disorder,
Obsessive-Compulsive disorder and agoraphobia. They may be associated with
medical disorders or be the consequence of severely stressful events. Many
times, there is no definable provoking cause. The level of specific
chemicals in the brain may change in people with anxiety disorders.
Anxiety disorders are usually treated with a combination of counselling
techniques and anti-anxiety medications. Some of the newer anti-depressant
medications are effective in certain anxiety disorders. The conditions
tend to be more responsive to treatment if addressed early in the course
of the disorder. Of course, this is the time the condition is most
difficult to recognize, may not be apparent to others and denial of the
condition is common.
Types of Mental Health Conditions - Mood Disorders
Several types of mood disorders exist. The major subtypes include
Depressive disorder and Bipolar disorder (Manic - Depressive). Mood
disorders may be manifest by a depressed mood most of the time, diminished
interest or pleasure in activities of the day, unintentional weight
change, change in sleeping patterns, loss of sexual drive, crying
restlessness, fatigue, feelings of guilt or worthlessness, decreased
concentration ability or recurrent thoughts of death. These symptoms can
interfere with social or occupational functioning.
Some medications and the normal grieving process after the loss of a loved
one may precipitate these symptoms. This would not constitute the
diagnosis of depression. Bipolar disorders may have the above symptoms
during some periods of time with the complete opposite emotions at other
times without an explainable cause.
Treatment for these conditions involves short term intervention with
counselling and/or use of medication as well as long term supportive care
to prevent relapses. The supportive care may also involve the use
medication or counselling. Pilots obviously are currently prohibited from
flying if they have an ongoing need for medication to maintain remission
of the condition.
Types of Mental Health Conditions - Post Traumatic Stress Disorder
Post traumatic stress disorder, or PTSD, is a condition resulting in
anxiety, depression, panic attacks, sleep disturbances or a host of other
symptoms following a perceived life-threatening trauma to an individual or
persons close to the individual. Symptoms may occur immediately following
the event or may manifest months and years later. Pilots are at risk for
this condition particularly following an aircraft mishap or near mishap,
death of a fellow aviator or participation in a mishap investigation.
Controllers similarly are at increased risk following mishaps or near
The criteria required for the diagnosis fall into four main categories.
First, the person must be involved in a traumatic event with real of
perceived threat to death or serious injury to self or others with a
response of fear, helplessness or horror. Secondly, the event must be
persistently re-experienced in one of several ways. Thirdly, there must be
an avoidance of stimuli associated with the trauma and an accompanying
numbness of feelings. Finally, there must be symptoms of increased arousal
or agitation. These symptoms must be present for over one month and must
result in disturbance of social, occupational or other significant areas
of functioning. For a complete description of these criteria, techniques
for intervention and treatment, please see American Family Physician
Primary Care Treatment of Post-traumatic Stress Disorder.
The airline industry has a program in place to deal with this issue with
pilots, called the Critical Incident Response Program (CIRP). Peer
counsellors and stress debriefers are ready to respond to any potential
PTSD provoking situation. The airline pilot program was initiated under
the guidance of one of VFS's physicians, Dr. Don Hudson. In 1999, Federal
law mandated the institution of an industry wide program for all airline
employees and their families, families of passengers of aircraft involved
in significant instances and others associated with the reaction to an
The keys to successful treatment of PTSD provoking events are early
recognition of the potential with events and stress debriefings and
counselling. Once the symptoms have developed, a variety of treatments
exist including counselling and medications are available. Also see the
National Centre for Post Traumatic Stress Disorder website for an
excellent set of references and comprehensive information.
The FAA policy on counselling for PTSD through airline pilot unions or
corporate Employee Assistance Programs (EAP) is that the counselling is
not reportable on FAA medical applications. The use of medication is
temporarily disqualifying for flying duties. Once the need for medication
is resolved, clearance to resume flying is fairly quick following receipt
of reports from the treating mental health professional.
Acceptance of Treatment for Depression and Anxiety
The recent incorporation of mental health professionals into mainstream
medical practice and growing public acceptance today is due to several
factors. First, society has begun to realize that depression or dysphoria
(sad mood) is a common condition. Some reports postulate that up to 20% of
Americans will suffer from depression in their lifetime. The idea that
depression and other mental health conditions is related to chemical
imbalances in the brain, not weakness of character, has gained acceptance
in the lay public. Next, is a move of psychiatric care and psychiatrists/
psychologists from the hospital setting to the community office.
The rise of well trained and qualified para-medical mental health
professionals such as licensed counsellors and social workers has made
mental health services available for the entire range of psychological
problems, not just the most severe "crazy" ones. Insurance companies and
HMOs are beginning to pay for outpatient mental health services.
Perhaps the largest factor in the rapid rise and acceptance in treating
mental health conditions is the development of new classes of medications
that are very effective with relatively few side effects. Now effective
treatment exists for conditions from grief and anxiety to psychoses and
A review of the effectiveness of various treatment approaches is found in
an American Family Physician article outlining the British Medical Journal
on Clinical Evidence for Depressive Disorders.
Pilots/Controllers and Antidepressant Medications
For the pilot and controller, the widespread use of medications for mental
health issues is a double edged sword. On the positive side, effective
treatments exist for temporary conditions that will allow return to
aviation duties in minimal time. Also, counselling services are readily
On the negative side, insurance companies are reluctant to pay for
extended counselling. Primary care physicians, with schedules so hectic
that they canít take time to sit down and talk for 30 minutes, have a
lowered threshold for prescribing these effective medications. Many cases
of depressed mood could be handled effectively with exploration of the
causes and addressing solutions without medication, if time was taken to
do so. Medications may work faster and take less time for the physician.
Medications designed and approved to treat depression may be used for
other conditions. See American Family Physician.
For the pilot and controller, crossing the threshold of using medications
for psychiatric purposes disqualifies them for flying activities as long
as they are on the medication, and until they are cleared by the FAA to
return to flying or controlling after stopping the medication. This
includes usage of the medication for conditions other than depression.
Clearance depends on documented resolution of the condition and freedom
from symptoms that may affect flying safety.
What Should a Depressed or Anxious Pilot or Controller Do?
What should pilots and controllers who feel they have a need for
counselling or mental health evaluation do? We encourage (as does the FAA)
any one concerned about stress and anxiety in their lives to seek
The first step may be to discuss the concerns with a clergy member,
counsellor or personal physician. All can initiate counselling that is not
reportable to the FAA within the constraints above. Pilots and controllers
may also seek counselling referrals through their EAP personnel, although
there is an understandable reluctance to involve the company in matters
that may affect flying careers.
Many pilots and controllers are concerned that the insurance forms may
reflect a more serious condition that truly exists. Some insurance
companies reimburse for counselling services for specific conditions.
Insurance company records are not releasable to either the FAA or to your
employer. FAA physicians who do review mental health records understand
there may be inconsistencies between the diagnosis for insurance purposes
and the condition actually treated.
If the initial provider a pilot or controller seeks out for assistance is
unable to provide adequate counselling, the pilot or controller may be
referred to a counselling specialist, psychologist or psychiatrist. Again,
reporting to the FAA may not be reportable depending on the condition
(e.g. family counselling for a childís drug use or marital counselling).
Even if the counselling is for a personal psychiatric diagnosis and is
reportable, it may not be disqualifying for flying. If both the counsellor
and the pilot or controller feel it is safe to continue aviation duties
AND no medications are required, the pilot or controller may generally
continue to fly/control and attach a summary from the counsellor at the
next medical examination.
Many pilots feel that the only time they are happy is when they are
flying. They can compartmentalize their problems and leave them on the
ground. The counselling makes them a safer pilot. Those who can not avoid
bringing their problems into the aircraft probably should not be flying
until the issues are controlled.
Extreme cases of depression in pilots mandates that the pilot is grounded
immediately, either by self decision or by the decision of a co-worker or
supervisor. There are several cases of pilot's possibly trying to commit
suicide while flying a commercial aircraft. See the dramatic story of a
life-and-death struggle in the cockpit of a Federal Express aircraft
during a hijacking attempt by another pilot, Hijacked : The True Story of
the Heroes of Flight 705 by Dave Hirschman. The Silk Air crash in Thailand
in 1997 is one instance. See the testimony of Jim Hall, Chairman National
Transportation Safety Board before the Subcommittee on Aviation Committee
on Transportation and Infrastructure, House of Representatives, regarding
"Aviation Issues as a Result of the Crash Involving Egypt Air Flight 990."
If the condition can not be managed with counselling alone, medications
may be used. The pilot is disqualified for all classes of medical
certificate once treatment with psychiatric medication is initiated. This
is a serious step that pilots understandably resist.
What many do not recognize is that the use of medications in the early
stages of a significant psychiatric condition may actually DECREASE the
time they are grounded. Postponing treatment until the condition has
seriously deteriorated may require a more prolonged course of treatment
with reduced chances of cure. As a general rule of thumb, a pilot
requiring medications for treating mental health conditions must be off
the medications and observed for relapse one to three months, longer in
severe cases, before sending reports to the FAA requesting reinstatement.
Many mild depressive and anxiety conditions are routinely recertified with
standard medical certificates after they are controlled and off
medication. Conditions listed in FAR 67. 107, 67.207 and 67.307 result in
a mandatory denial and require the Special Issuance (SI) provisions of FAR
67.401 for reinstatement of medical privileges. This process requires
extensive review and possible forwarding to an FAA psychiatric consultant
prior to authorizing a medical certificate.
Though not specifically listed in FAR Part 67, depressive disorders
requiring the use of medication are disqualified under current FAA policy
under section (c) of the above regulations. Special Issuance consideration
may require a complete evaluation and documentation as noted in the FAA
Specifications for Psychiatric and Psychological Evaluation.
The FAA is currently reviewing the policy restricting the use of
antidepressants in pilots based on published several studies, experiences
with Canadian and Australian pilots and position papers from the several
international organizations. Virtual Flight Surgeons will publish an
update at the time of any policy changes.
Medications commonly used to treat psychiatric conditions fall in to
several categories and subtypes. More complete information is available on
the Internet Mental Health Psychiatric Medication List. Major depression
is generally treated with one of four types of medication: SSRI's, TCA's,
second generation antidepressants and rarely with MAOI's. Anxiety is
treated with antidepressant or anti-anxiety medications. Most
antidepressant medications take several weeks to reach their full effect.
Anti-anxiety medications may exert their effect in minutes to hours.
Medications - SSRI's
Antidepressants in widespread use today include the SSRIs (selective
serotonin reuptake inhibitors) which exert their effect by changing the
levels of certain chemicals in the brain called neurotransmitters. This
class of medications take several weeks to achieve their full effect, as
do most antidepressants. The usual course of treatment is 3-12 months in
typical cases. The medication is frequently tapered over several weeks
when a person has been free of significant symptoms for a period of time.
Examples of this category include Celexa (citalopram), Prozac (fluoxetine),
Paxil (paroxetine), Zoloft (sertraline) and Effexor (venlafaxine). These
are among the most widely prescribed medications in the United States.
They are also used for obsessive-compulsive disorders and panic disorders.
Medications - TCA's
The tri-cyclic antidepressants (TCA's) are an older generation of
medications that work by similar mechanisms to SSRI's. They are very
inexpensive and have measurable levels in the blood defined for treatment
responses. They may be used in other neurologic pain syndromes also. The
disadvantages include the potential for serious side effects in some
people and the significant overdose consequences. Because of these
disadvantages, they are less commonly used now. This category includes
imipramine (Tofranil), amitriptylene (Elavil), desipramine (Norpramin),
nortriptylene (Pamelor, Aventyl), doxepin (Sinequan), protriptylene (Vivactil)
and trimipramene (Surmontil). Use in bipolar disorder (manic-depressive
syndromes) may cause rapid cycling of symptoms.
Medications - Anti-anxiety, Insomnia Medications
Another group of medications used to treat mild, chronic anxiety and
resultant sleep disturbances are intermediate in side effects between the
above two categories. Several in this class carry an increased risk of
seizures in high dosage ranges according the Physician's Desk Reference.
The medications include amoxapine (Ascendin), trazodone (Desyrel) and
bupropion (Wellbutrin). Bupropion is also currently marketed in smaller
doses for relieving the anxiety of nicotine withdrawal under the name
Zyban. It is one of the medications with a reported increased risk of
seizures and prohibited by the FAA. Opinions among FAA reviewers have
varied on Zyban use for smoking cessation. At a minimum, 72 hours must
elapse before going back to flying. Some reviews and Regional Flight
Surgeons will require a much longer period and clinical narratives from
treating physicians before returning to flying or controlling.
Those pilots taking Ambien (zolpidem), another prescription medication,
must wait 48 hours after the last dose before flying. The The USAF has
waived the use of Ambien in its pilots after ground testing and in very
specific controlled situations.
For information on herbal sleep agents, see the VFS article on Herbal
Medications and Nutritional Supplements. There are no restrictions by the
FAA on the use of melatonin, but caution is warranted. Melatonin is most
effective in combating jet-lag, rather than other causes of insomnia. Some
users will have a hang-over like effect the following day and a small
percentage may have vivid nightmares and disturbed sleep. A ground testing
period before using it is appropriate for pilots considering taking this
Medications - Benzodiazepines
The benzodiazepines are primarily used for anxiety conditions and some
sleep disorders. The short acting medications work very quickly but may
have rebound anxiety, insomnia, agitation and even amnesia. They include
alprazolam (Xanax), oxazepam (Serax), temazepam (Restoril) and lorazepam (Ativan).
Longer acting forms may result in sedation, impaired thinking and delayed
reaction times. They include diazepam (Valium), chlordiazepoxide
(Librium), Flurazepam (Dalmane), clorazepate (Tranxene), halazepam and
prazepam. These medications are not compatible with aviation duties.
Non-traditional treatment - St. John's Wort
St. Johnís wort (hypercium) is an herbal preparation used for many years
for depression. It is widely used in Europe. Following a 1996 article in
the British Medical Journal touting its effectiveness, sales in the US
skyrocketed. Because it is an herbal compound, it is not regulated by the
FDA. Different manufactures have different strengths and preparations
available. The FAA does not restrict the use of non-regulated nutritional
supplements or herbal preparations, nor are they tested for in DOT drug
testing. Note, however, that all visits to healthcare practitioner's are
The effects of St. John's wort may take several weeks, as does most
antidepressant medications. A word of caution that depression should be
treated with a combination of therapies including counselling is
appropriate. Pilots using this compound for a self-diagnosed depression
may be depriving themselves of very effective counselling or may
misdiagnose an underlying mental or physical condition. Any nutritional
supplement should be ground tested for at least several days before flying
to determine that there are no adverse side effects. Please see an article
in American Family Physician, September 1, 2000 on Alternative Therapies:
Part I. Depression, Diabetes, Obesity for more information on the state of
research on St. John's wort and SAM-e for the treatment of depression.
Also see an abstract in AFP on St. John's Wort in the Treatment of
Depression from an article in the British Medical Journal.
Non-traditional treatment - Tryptophan - 5-HTP
Tryptophan is an amino acid which serves as a key building block for
chemicals in the brain. Tryptophan is converted to 5-hydroxytryptophan
(5-HTP) and then is converted to serotonin, N-acetyl serotonin and finally
melatonin. 5-HTP is much more active in the brain than tryptophan and
increases the level of endorphins and serotonin in the brain. This makes
it very useful in cases of depression and insomnia. It may also relieve
some cravings of tobacco withdrawal and food cravings in people on a diet.
A large number of studies has shown similar effectiveness of 5-HTP to both
tricyclic and SSRI anti-depressant medications in relieving the symptoms
of depression. Its onset of action is similar, 3-4 weeks, to the
anti-depressant medications, but seems to be tolerated with significantly
fewer and milder side effects. Gastrointestinal symptoms, dry mouth and
drowsiness are the most common side effects occurring in less than 10% of
5-HTP users, much less than conventional medication users though this is
not confirmed in large controlled clinical trials. 5-HTP is also much less
expensive. The usual dose in depression is 100 mg daily.
In 1989, a world-wide epidemic of eosinophilia-myalgia syndrome (EMS) was
observed in users of artificially produced L-tryptophan. The cause of the
epidemic was traced to a contaminant in the production process of one
Japanese manufacturer, Showa Denko. This company made over 50% of the L-tryptophan
used in the world. Ultimately, over 1,500 cases of EMS and 36 deaths were
attributed to the contaminated product. This is about 0.2% of the
tryptophan users at the time. As a result, the FDA banned the production
and recalled all L-tryptophan. Since then, U.S. manufacturers have
produced the more active 5-HTP without reports of EMS or contamination.
Persons using anti-depressant medications should not start taking 5-HTP
without consulting with their physician as side effects may increase.
People using 5-HTP should inform their physician prior to adding any
anti-depressant medication as it may effect dosage selection. Pilots using
5-HTP should not fly on the medication until they determine there are no
significant side effects, particularly drowsiness, and the mood changes
they are using it for do not interfere with the safe operation of
aircraft. The use of 5-HTP is not reportable to the FAA. Note, however,
that visits to healthcare practitioners are reportable.
Non-traditional treatment - S-Adenosylmethionine (SAM)
SAM is a component of many metabolic functions in the body, including the
production of brain chemicals, glutathione (antioxidant), and in the
manufacturing of sulphur containing compounds including glucosamine and
cartilage. There are double blind studies that have shown SAM to be more
effective than placebo and tricyclic antidepressant drugs in improving
generalized depression. It also has positive effects in postpartum (after
birth) depression and drug rehabilitation. Doses used ranged from 1,200 to
1,600 mg daily. Some studies have shown beneficial effects using SAM in
chronic liver diseases, chronic fatigue syndrome (CFS) and fibromyalgia, a
condition of chronic muscle pains often associated with depression and CFS.
SAM has no known toxicity but should be used with caution in bipolar
(manic-depressive) syndromes as it may provoke a manic episode.
Non-traditional treatment -
Electroconvulsive Shock Therapy
The FAA will consider certification for all classes for individuals
diagnosed with depression and successfully treated with electroconvulsive
shock therapy. Pilots and controllers should be off all medications and
should complete full neuropsychiatric testing before submitting cases for
Special Issuance consideration.
FAA Reporting Requirements
A 1991 change in the reporting requirements on FAA Form 8500-8 mandated
all visits to health care providers, including counsellors and
psychologists, were required to be reported on each physical. The Federal
Air Surgeon (FAS) wrote a letter to all Aviation Medical Examinerís (AMEs)
in September 1992 acknowledging that the effect of this interpretation of
the 8500-8ís instructions discouraged pilots from seeking mental health
assistance. The FAS indicated that the FAA encourages pilots to seek
assistance for all conditions, but does not want to restrict flying for
those conditions that did not affect flying safety. His clarification,
later incorporated into the explanation section of question 19 on the
8500-8, stated that visits to mental health professionals were reportable
ONLY if it was due to alcohol/substance abuse OR resulted in a personal
Clearly, pilots and controllers seeking counselling for marital or family
problems who were functioning well, but seeking to improve their
situation, have no obligation to report that counselling. Counselling by
clergy, or even your personal physician, is not reportable if there is no
personal psychiatric diagnosis, no alcohol or substance abuse and no
treatment with medications. Visits to Employee Assistance Programs (EAP)
for conditions described above are also not reportable.
The FAA will allow pilots and controllers who have been diagnosed with
depression and treated with medication to hold an Airman's Medical
Certificate after certain conditions are met. First, they must be off
medications and remain without significant depressive symptoms for at
least 90 days. Ongoing counselling is allowed and encouraged. They will
have to complete an psychiatric and psychological evaluation, usually
performed by their treating psychiatrist and psychologist. Upon
completion of this testing, a clinical summary and periodic progress notes
are forwarded to the FAA for review. The review process may take several
months. If the condition is waverable, the pilot will have to submit
periodic reports from treating physicians or counsellors at future medical
examinations. These summaries and other test results may be mailed to the
FAA at :
Federal Aviation Administration
Aeromedical Certification Division
CAMI Bldg./ AAM-300
P.O. Box 26080
Oklahoma City, OK 73126-9922
This is a very broad overview of a complex subject with many nuances.
Incomplete packages or unclarified comments of aeromedical significance
often result in significant delays or possibly even denials.