Fitness for Flight - Mental Health & Antidepressants

Andreas Lubitz, Co-Pilot of Germanwings 9525

The recent Germanwings tragedy has called commercial aviation's concept of 'Fitness for Flight' into question. In case the reader has just returned from a week long hike in the wilderness and missed the news headlines - on 24 March 2014 an Airbus 320 carrying 150 passengers destined for Dusseldorf, Germany from Barcelona crashed in the French Alps. Although the official mishap investigation has not yet concluded, available information at the time of this writing points to an intentional crashing of the plane by the 27 year old co-pilot, Andreas Lubitz.

Reports from the co-pilot's medical records allege he had previously experienced episodes of depression and carried diagnoses for other psychosomatic disorders. Antidepressants and torn medical memorandums stating that he was not fit for flight were apparently found at the home of Lubitz by investigators. Despite this, at one of the company's first press conferences, Lufthansa CEO stated on the record that Andreas Lubitz was "100% fit to fly" based on his most recent flight physical in 2014.

The FAA's guide for Aviation Medical Examiners (AME's) regarding depression and treatment with antidepressants can be reviewed here. In summary, the FAA allows pilots who demonstrate stability in symptoms while on one antidepressant for at least 6 months to be approved for continued flight duties on a case-by-case basis, which requires special issuance of medical certification.

One reactionary response to this incident currently being discussed is to implement a 'zero tolerance' policy towards depression and mental health disorders among pilots. Although many readers may sympathize with a 'zero tolerance' approach to keep pilots with mood disorders or antidepressant use out of the cockpit, this is not the most pragmatic approach. The current system as it stands is logical and preferred. Here are 3 reasons why pilots should have an opportunity to remain in the cockpit with a known diagnosis of depression or while taking antidepressants:

Depression is a very common mental health condition in the Western World. A WHO survey of 14 nations determined a 12% prevalence of depression. The CDC National Health and Nutrition Examination Survey from 2009-2012 found that 7.6% of all respondents had symptoms of depression during the previous 2 weeks from date of survey. There are and will continue to be airline pilots meeting criteria for this diagnosis.
Depression severity lies on a spectrum and appropriate treatment can often effectively treat the condition's symptoms. Depression is divided into 3 subcategories - mild, moderate, severe. One meta-analysis looked at 37 separate randomized trials and found that full remission from depression was achieved by 43% of treated patients within 6 weeks.
A 'zero tolerance' approach will incentivize depressed pilots to not admit their symptoms to primary care doctors or AME's. Mental health disorders are already stigmatizing and further rigid, reactive policies will only force depressed pilots to hide their symptoms and forego treatment. This unintended consequence would likely increase the risk of worsening the untreated patient's depression with possible catastrophic results.

DETERMINING FITNESS FOR FLIGHT

The challenge of the Aviation Medical Examiner (AME) or flight surgeon is to use his or her clinical judgment to determine if a pilot is 'Fit for Flight'. The first step is acquiring an exhaustive history and performing a thorough physical exam. Like any physician, this information is then translated into diagnoses. During the annual flight physical, rather than providing medical treatments for each diagnosis, the flight doc must instead apply the regulating body's published aeromedical standards.

In the case of major depression disorder affecting an FAA pilot, an AME can use the aforementioned FAA guidance to determine if a pilot is in fact medically certified for flight (fit to fly). Upon meeting these very specific criteria, the AME must request a special issuance from the appropriate regulating body (in this example, the FAA) to allow the pilot to continue flight duties.

DETERMINING FITNESS FOR FLIGHT

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