Pilot mental health was thrust into the headlines by tragedies such as the Germanwings and MH370 losses, but many factors surrounding the issue can still cause flightcrew to stay silent.
When pilot Alan Smith took an anti-depressant medication after a stressful relocation to a new city, he had no idea what lay in store: a months-long odyssey that almost derailed his future career prospects and cost thousands of dollars in unexpected expenses.
Smith was feeling a little on edge and he hoped a selective serotonin reuptake inhibitor, one of the most commonly prescribed anti-depressants, would help him settle. “I took one pill. I didn’t like how it made me feel, so I stopped,” Smith says.
He had already started flight training and, like all pilots, needed a medical certification before he would be permitted to fly solo or sit for exams. So he went to an aviation medical examiner (AME) who came highly recommended by the local pilot community.
But that is when Smith’s nightmare began.
“Things got really weird. He asked me all sorts of questions that have nothing to do with my fitness to fly, like about my tattoos, and a drunk driving event I had 20 years ago,” Smith says. “I wanted to be truthful, so I told him that I had taken a pill six weeks before. At the end of the appointment, he gave me a deferral and told me to expect a letter from the FAA. That wasn’t the outcome I expected.”
A deferral, in the language of the Federal Aviation Administration, means the medical certificate application is denied. It thrusts the candidate into a burdensome, costly and time-consuming battery of psychological and neurological tests that many medical professionals consider outdated, archaic and irrelevant. It is the terrifying situation every pilot desperately tries to avoid.
“There was very little information online, but what I did find was, this was the worst case scenario, it’s going to cost an obscene amount of money, and I might as well not expect [a certificate] at all,” Smith says.
Pilots have strong opinions about mental health assessments. Ask a question about the topic in any pilot forum and reactions will range from anger to frustration and helplessness.
Pilot mental health – both in general aviation and commercial contexts – is a massive white elephant in the cockpit, say aviation medical professionals worldwide. That is because regulators hold all the power, and some say the system forces pilots to make unwise choices to avoid losing their permission to fly.
No pilot would shun medical treatment for a physical ailment – say, a fractured bone or stomach flu. However, a fractured psyche, even a few weeks of high stress, no matter the reason – is a much more delicate matter.
“Mental health assessments differ from physical evaluations due to limitations in objectively assessing mental health status at a specific point in time,” says Ansa Jordaan, chief of the aviation medicine section at ICAO.
Jordaan founded and chairs the organisation’s mental health working group, which is focussed on removing the social stigma associated with mental health and enhancing trust between aviation licence holders and medical examiners.
“Mental health assessments are often subjective, with few tools that could provide an immediate objective indication of health status,” she adds.
In other words, there are no blood tests or X-rays, and doctors typically diagnose based on discussions with patients. For that reason, people with mental health conditions might go years without a proper diagnosis, while others can be misdiagnosed.
“The interpretation of clinical observations, collateral information and reports is a complex process in reaching a decision to determine the risk to flight safety.”
An admission of any kind of problem, or treatment, comes with many strings attached.
“One problem is that licence holders may not disclose psychological conditions or medications for fear of stigmatisation, loss of licence or loss of employment,” says Jordaan. “Even worse would be to stop using a medication in an effort to maintain a licence or flight status, as this could pose an even greater risk to flight safety.”
Brent Blue is a senior AME, based in Idaho. He calls the current assessment system “onerous and arcane”.
“The FAA relies on a significant amount of testing that is not relevant for mental health,” Blue says.
In the USA, pilots who take (or have taken) antidepressants – as did Smith – or those with a history of mental health issues are likely to be sent through the so-called Human Interventional Motivational Study (HIMS). The Airline Pilots Association, airlines and the FAA established HIMS decades ago to help identify and treat pilots with substance abuse problems.
“They threw the mental health section into that, and that’s caused a lot of major issues,” Blue says.
In a recent unscientific online survey, Blue asked pilots if they had ever used an anti-depressant medication and not reported it to the FAA. Almost half of the respondents answered in the affirmative. He then asked if they ever had mental health issues for which they did not receive professional help due to fear of losing their medical certification. Yes, said 63%.
The final question, “Do you think the FAA handles pilot mental health issues appropriately?” was met with resounding rejection, with 96% of respondents saying no.
“Most pilots who have been in that situation have lied,” Blue says. “They just don’t tell their AME or admit on the application forms that they have ever had depression or been on medicine because they don’t want the FAA to know that.”
The upshot, he adds, is that many more pilots than the FAA knows take anti-depressants, and many who should be taking medication are not.
“This may be a hard pill to swallow, but the FAA’s psychiatric and psychological evaluation process is antiquated,” Blue says. “You can have a board-certified psychiatrist say, ‘This pilot is absolutely okay to fly’, and the FAA will say, ‘Well, he’s got to have this test, and this test, and this test, and spend literally thousands of dollars to try to get his medical back,’” Blue says. “It’s just crazy.”
The FAA meanwhile, maintains it has “made significant strides” in the mental health arena, and is asking the aviation community to “help change the narrative”.
“We can’t afford to lose even one more life that could be saved with early treatment that helps that individual successfully recover from their mental health condition,” Federal Air Surgeon Sarah Northrup wrote in a June 2022 medical bulletin. “Early treatment is a win-win: the person gets help more quickly; typically the symptoms are less severe; and obtaining a special issuance is more likely to be successful.”
Before issuing a medical certificate, the FAA requires that pilots report “any health professional visits during the previous three years, all medications being taken and other medical history… [including] questions about mental health”.
Blue thinks that requirement is ridiculous.
“Do you remember every medical or mental health visit you had in the last three years? Do you remember every supplement you’ve taken? I mean, come on! And more importantly – how significant is that? They’ve created this impossible system,” he adds. “Either by intent or inadvertent omission, the [pilot-submitted documents] are rarely correct.”
Blue says the subject resurfaced after two aviation students committed suicide last year. “[They] had mental health issues, and they thought their careers were over,” he says. “That finally got the FAA’s attention.”
The FAA declined to make Northrup or any other medical expert available for an interview.
There are no easy answers on how to get pilots to open up about mental health. The stigma, shame and fear of permanent repercussions to their livelihoods and their passion – into which many have invested large sums of money for training – remains.
In Europe, pilot mental health was on aviation regulators’ priority list even before a mentally ill pilot flew an Airbus A320 into a French mountainside in March 2015, killing all 144 passengers and six crew.
Germanwings flight 9525 from Barcelona to Dusseldorf crashed after first officer Andreas Lubitz, who had previously been treated for suicidal tendencies and declared “unfit to work” by his doctor, withheld that information from his employer. When the flight’s captain briefly left the cockpit, Lubitz locked the door from the inside and initiated a controlled descent that continued until the aircraft crashed into the ground.
Former FAA administrator Steve Dickson recently called the Germanwings disaster “a wake-up call about pilot mental health”. Still, substantial problems – especially relating to trust – persist.
“When it comes to mental health, we see that pilots are reluctant to self-report,” says Cristian Panait, a medical expert in the aircrew and medical department of the European Union Aviation Safety Agency (EASA). “After Germanwings we put a lot of effort into enhancing the system of trust between the AMEs and the pilots, to encourage them to speak up.”
EASA has implemented several changes in response to the accident. The regulator introduced a comprehensive mental health assessment at the beginning of pilots’ careers – before they invest in training – to detect certain pathologies that could develop into more-complex conditions.
In addition, most airlines now have peer support groups, which Panait says can encourage employees to talk about issues they face.
“The peer support groups are fully confidential. If the pilot cannot open up to the AME, at least a well-trained peer can recognise some signs and, if need be, refer the case to medical specialists, or just suggest to the airline that the pilot needs time off,” he says.
A third tactic is allowing pilots with certain diagnoses to fly as long as they receive treatment.
“It is better to know and to monitor, including any potential side effects, than not knowing, and the pilots hiding these things from us,” he says.
However, Panait admits, “It’s a very, very difficult balance” – and one of the hardest processes to improve. Mental health assessments remain an inexact science.
“It’s one of the areas of medicine about which is least known, and we don’t have enough tools to do a proper screening,” he adds. “We have several layers [now]. None of them is perfect, and we hope that approach will allow a minimal number of people to slip through. The holes in the Swiss cheese are smaller.”
In May, EASA announced it is investing in research to modernise its approach to diagnosing and treating mental health conditions for aircrew.
“We’re trying to find better screening methods that would be safer, and would have less false negative and false positive results,” he says. “Either way is not good. If you have false positives, the pilot’s career is affected, and if you have false negatives then it’s the lives and the safety of the passengers which are affected.” That research is expected to be complete in mid-2024.
“Mental health covers a wide spectrum of psychological well-being,” Jordaan says. “All of us experience changes in our psychological well-being, even within short time periods. A person with no history of mental health problems might experience severe anxiety or stress due to external factors, and… should make the decision not to fly or work until they are better.”
A minor, short-term issue can thereby be prevented from escalating into a serious or chronic problem.
“Conversely, a person diagnosed with a mental condition could still be able to function safely while using aviation-approved treatment and being followed up regularly by a health professional,” she adds.
“Obviously, there are people who shouldn’t be flying,” aviation doctor Blue says. Those include individuals diagnosed with serious mental illnesses such as schizophrenia, personality disorders or at risk of uncontrolled seizures.
“But the most important thing to remember is, if I certify you today, every day that you get [in] that airplane, as long as the medical certification is valid, you are self-certifying that you’re safe to fly.”
Yet tragedies still happen. In October 2021, University of North Dakota student pilot John Hauser deliberately crashed his plane because he was afraid that his depression was likely to disqualify him from ever flying again.
A flight instructor based in Las Vegas took his own life in June 2022 for a similar reason. And in late July, a pilot jumped out of a twin-engined Airbus Defence & Space C212-200 in North Carolina after a hard landing attempt and subsequent go-around seemingly triggered a mental breakdown.
It also has been surmised that the crash of a China Eastern Airlines Boeing 737 in March 2022 that killed 132 was also intentional – an act by one of the pilots. Likewise, investigators think the 2013 crash in Namibia of a LAM Mozambique Airlines Embraer 190, which killed 33 people, was due to deliberate pilot action.
The US National Transportation Safety Board determined that a pilot deliberately crashed an Egyptair 767-300ER into the Atlantic Ocean in 1999, killing 217 people, although Egyptian authorities have disputed that finding.
And one of the biggest aviation mysteries in history, the disappearance of Malaysia Airlines flight MH370 in March 2014 with 239 people aboard, has been ascribed – but never actually confirmed – to a murder-suicide plot by one of the pilots of the 777-200 (9M-MRO).
Making the topic even more complicated is the fact that mental illness remains a taboo subject in many cultures, and within certain career groups.
Depression and anxiety among flightcrew are almost certainly just as common as in the population as a whole. Data shows that one in five people report “symptoms consistent with depressive disorder”, and nearly one in three have symptoms of anxiety. But in aviation, these are often interpreted as signs of weakness, causing embarrassment or shame. That means such conditions can go unrecognised, unacknowledged and misinterpreted.
Jordaan says, though, that awareness around mental health disorders is growing. With that awareness, differentiation is essential.
“This increased mental health literacy has become an ingrained part of society and people are more forthcoming about their mental health than before,” she says. “The specific roles and responsibilities of aviation organisations for mental health are relatively new, however, and still evolving.”
For Smith, who is pursuing a career as a cargo pilot, the decision to divulge having once taken a single anti-depressant pill cost him $5,000 and too many sleepless nights to count. His quest to get a medical certificate sent him to three FAA-approved specialists and took almost six months.
For some candidates, the process can cost upwards of $10,000 and take years, in part because of a shortage of FAA-approved professionals. It is not unheard-of for candidates to have to wait several months for an appointment and then to have to drive eight hours or more, perhaps to another state, to see that doctor.
Smith considers himself lucky, but his odyssey through the FAA’s mental health maze is yet incomplete. He has now been flagged and it is still unclear what effect the episode will have on his long-term career prospects.
Knowing what he knows now, Smith says, if he had to do it all over, he would lie. “I’d just be quiet about it all to avoid undue hassle,” he says.
He is frustrated that being truthful landed him in the FAA’s HIMS programme, and angry that his experience is not unique.
“Aviation is my passion and my goal – why would I do anything to jeopardise that? Why would I purposely do something to risk a major goal in my life?
“If my story can help one other person not have to go through what I did, I’d be glad,” he adds. “There has got to be a better way”.