Beware the witch-hunt – people who have suffered depression can and should still fly planes
Raj Persaud FRCPsych Consultant Psychiatrist
One of the most recent studies of aircraft assisted suicides in the United States found in a 20-yr period (1993- 2012) the proportion of general aviation suicides in relation to the total number of fatal aviation accidents is 0.33%.
The study entitled ‘Aircraft-Assisted Pilot Suicides: Lessons to be Learned’, is important to the issue of whether forcing psychological or psychiatric assessments onto pilots will do anything to make the skies safer.
Lead author of the study, Alpo Vuorio , and colleagues, also reviewed the statistics for other countries and found in the United Kingdom, during a 30-yr period (1956 – 1995), aircraft-assisted pilot suicide frequency was 0.3% (3 of 1000 fatalities).
The largest single data source in their study is from Germany, where during 1974 – 2007 the figure was 0.29%.
The authors of the study published in the academic journal, ‘Aviation, Space, and Environmental Medicine’, point out that suicides may occur without previous warning and studies show that only 22% of individuals committing suicide communicate such an intention during their last appointment with health personnel.
If in five out of the eight (63%) completed suicides in this series from the United States during 2003-2012, someone knew of a victim ’ s suicidal ideation. Indications and warnings for suicides should be taken seriously, so that effective interventions can be implemented.
The reality is that reliably detecting psychological problems, particularly at the beginning stages, if the patient does not cooperate, can become extremely difficult.
If one’s livelihood depends ever more on passing a psychiatric testing, the number of people opening up with mental health problems will in fact decline.
It is already small as people fear stigma and discrimination. Also most pilots are male and hence perhaps struggle much more with seeking medical help in general and mental health treatment even more so.
The authors quote another study that found among U.S. Air Force military pilots who attempted suicide, a majority (79%) actually returned to flying duties following aeromedical assessment.
Similarly, The Civil Aviation Safety Authority (Australia) do not consider suicide attempts, after careful consideration, necessarily as disqualifying and holistically include that as an indication of the severity of psychiatric illness.
But pilots, as other professionals, may find themselves under pressure to not declare they have depression as the diagnosis, or the treatment, could end their careers.
Getting treatment often involves taking an anti-depressant. Many pilots recover from depression, indeed the vast majority of sufferers do, but they may need to continue taking the tablet for a while after recovery, in order to prevent relapse. Anti-depressants in the longer term then become an issue for pilots worrying about going for treatment for depression or other psychological problems.
Based on the pilots’ telephone inquiries database of the United States Aviation Medicine Advisory Service, it has been reported that, when instructed about the then United States regulations limiting the use of SSRI anti-depressants by US pilots, 59% of the airmen preferred to refuse the medication and continue to fly. However, about 15% said that they would prefer to take the medications without informing the United States FAA (Federal Aviation Administration).
If you ban some pilots from flying if they are accessing treatment for depression, then do you discourage them for seeking professional help? Is it worse to have a pilot flying with untreated depression than one whose psychological problems are being addressed professionally?
The more modern anti-depressants are often referred to as Selective Serotonin Reuptake Inhibitors (SSRIs) and are frequently prescribed for treating depression. Which of these drugs are approved by aeromedical regulatory authorities for use by pilots varies from country to country. Prescription medication and depression both have the potential for impairing performance and there is also the possibility of drug-drug interactions.
The prevalence of SSRIs in pilot fatalities of civil aviation accidents was recently evaluated in a study entitled ‘Selective Serotonin Reuptake Inhibitors in Pilot Fatalities of Civil Aviation Accidents, 1990-2001’.
Post-mortem samples from pilots involved in United States fatal civil aircraft accidents during 1990-2001 revealed that out of 4,184 fatal civil aviation accidents, there were 61 in which pilot fatalities had SSRIs, in this study published in the academic journal ‘Aviation, Space, and Environmental Medicine’.
As determined by the National Transportation Safety Board, the use of an SSRI has been a contributory factor in at least 9 of the 61 accidents.
The authors of this study, Ahmet Akin and Arvind Chaturvedi, conclude that the numbers of SSRI-involved accidents were low, and that the presence of SSRIs in pilot fatalities is apparently less than expected, considering their heavy use in the general population. However, the interactive effects of other drug(s), ethanol, and even altitude hypoxia in producing adverse effects in the pilots cannot be ruled out.
In contrast, a similar study of 5383 fatal aviation accidents in the USA found there were 338 accidents wherein pilot fatalities (cases) were found to contain anti-histamines. The use of antihistamines was determined by the National Transportation Safety Board to be the cause of 13 and a factor in 50 of the 338 accidents.
The authors point out that considering the prohibition for use of SSRIs by pilots, during the period of the study in the USA, an SSRI should not have been found in any pilot fatality.
The 61 SSRI-related cases were identified only because the pilots were victims of fatal accidents and their post-mortem samples were toxicologically evaluated. Also, contributing roles of weather conditions, mechanical deficiencies, and/or piloting errors cannot be completely ruled out in the 61 accidents.
In a further analysis entitled, ‘Medical Histories of 61 Aviation Accident Pilots with Post-mortem SSRI Antidepressant Residues’, 59 pilots from the study above who had medical records in the FAA’s (Federal Aviation Administration) Certiﬁcation Database were further investigated.
The authors of the study, found that disqualifying psychological conditions were self-reported in the past examinations of only 7 of the 59 pilots, and the use of an SSRI was reported by 3 of the 7 pilots.
Although 88% of the pilots had not reported their psychiatric condition and 95% had never reported the use of an antidepressant, the higher percentage of reporting of DUI (Driving Under the Influence) incidents — 39% — the authors found an interesting observation.
The reporting of DUIs in such relatively high numbers, compared to the reporting of SSRI use, could have been because the FAA has the authority to access the records of pilots from the National Driver Registry. Also, some pilots may have assumed that they could continue to fly even with a history of DUI.
This observation might support the suggestion that a policy allowing a supervised maintenance anti-depressant use could prevent airmen from using medication without informing the FAA.
For example, Canadian aviation authorities have an aeromedically supervised treatment protocol that allows a small number of pilots to fly “with or as co-pilots” during maintenance antidepressant therapy, and the Australian Civil Aviation Safety Authority (ACASA) had allowed during January 1993 – June 2004 nearly 500 pilots and air traffic controllers to return to duty while their depression was under control with SSRIs.
So, make it easier, not harder to come forward, so treatment can be given.
If we allow people who have had depression to fly, and it is treated properly, the skies will be safer.
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An interview with Professor Robert Bor is available as a free download from the free app below and also here: http://www.rcpsych.ac.uk/discoverpsychiatry/podcasts/pilotsuicide-drrobertbor.aspx
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