Introduction

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 Care Settings.

Seeking Help

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 cases.

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 terms.

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 mishaps.

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 aircraft accident.

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 schizophrenia.

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 available.

On the negative side, insurance companies are reluctant to pay for extended counselling. Primary care physicians, with schedules so hectic that they can’t 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 assistance.

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.

Counselling

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 child’s 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."

Antidepressant Medications

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

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 supplement.

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. John’s 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 reportable.

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 Examiner’s (AMEs) in September 1992 acknowledging that the effect of this interpretation of the 8500-8’s 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 psychiatric diagnosis.

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.