Hi all,

First time posting here. I wanted to give all a head's up that I am 6-parts into an extensive dive into existing FAA policy with regards to pilots and ATCs. I happened into this topic when considering using "accelerated TMS" for pilots to treat depression in a week but found barriers. As it turned out, there is a lot to consider and write about. Let's just say I am not a big fan of existing FAA policy around the mental health care of pilots. I still see a few more posts coming up but it is also a moving target, as the policy evolves. If there are comments or questions, I will do my best to address them. Questions / comments are welcome here or on the blog site.

Anyhow, my blog can be found at: www.jeraldblock.blogspot.com

 

Jerald,

Do you treat pilots, or are you a pilot? I ask, because your comments do not sound as though you are familiar with aviation, the FAA, the certification process, the airman medical process, or airman medical standards. You make a series of references, or statements, which are not correct, in your blogged articles, beginning with basic terminology, and continuing through the certification process.

I am not unsympathetic to the special issuance process, having recently completed a round with it myself. Presently, special issuance times have been dropping considerably, but it's difficult to stipulate an "average" given the variety of cases for which a special issuance is needed. One can't really compare two unique conditions or cases and average them; an apples-apples comparison is needed between similar or same-type diagnoses, such that a common denominator is found between them. Diabetes is not the same as a cardiac issue, and one even among diabetics, for example, the extent of the condition, medical intervention, and other factors may have a significant impact on both the probability of a special issuance, and the timeline.

Those who use a dedicated service when applying for their special issuance tend to have faster returns on their paperwork, vs. attempting to go it alone. One ought not attempt to navigate the legal system without retaiining an attorney, and one ought not navigate the special issuance process without seeking assistance from those who specialize in handling special issuances and FAA medical issues. One of the single biggest delays in getting FAA approval isn't the FAA's backlog, but failure to submit all the necessary documentation. The matter gets kicked down the road repeatedly as the FAA asks for more documentation. In many cases, the applicant would have been done, had (s)he sought guidance through the process and submitted all the documentation at the outset. This guidance costs, but so does a lengthy delay which can cost a job, keep one from applying or interviewing, or from earning a living while deferred. Pay now, or pay later, as they say. In my own case, I was told to expect four months, but had a fresh medical in hand after seven weeks. It would have been much longer had I attempted it without specialized assistance.

I don't disagree with your base premise that the FAA, or the threat of the FAA's action, intimidates many pilots from stepping forward. I do believe, however, that many who are afraid of being medically grounded don't have the moral ground to crow foul: if the pilot does not meed the medical standard, then the pilot is not airworthy. If one is afraid to tell the FAA about a grounding condition, one is already in posession of an invalid medical certificate. The rear of the certificate itself reiterates the regulation. A pilot who does not meet the medical standard may not exercise the privileges of his or her medical certificate, whether (s)he reports it or not. (A pilot is not required to report every medical deficiency between examinations, incidentally. Your articles suggest otherwise).

Your overall point is well-taken: a pilot may not get the medical care (s)he needs, for fear of the treatment, or revelation of the condition, impacting medical certification. Many pilots confer within the community as to which doctor or AME to see, who is "pilot-friendly," and most of us understand the implications of putting anything "on the record," whether with a general practitioner, specialist, or aviation medical examiner (AME). That said, that concern also doesn't change the fact that a pilot who is afraid to seek treatment for a grounding condition, and elects to continue operating unsafely and illegally, knowingly violates the regulation just as much as taking an unairworthy airplane into the air. One might say he was afraid to seek maintenance for the airplane, lest the FAA find out the airplane is broken...a very bad idea. We all experience medical issues. We can hide them and operate unsafely and illegally, or seek help, and accept the outcome. If we're not medically fit, then we're not medically fit, and until we are, the medical certificate we may have in our pocket isn't legally valid. It's only valid when we meet the standard for which the certificate was issued, under 14 CFR Part 67. Outside of that, it's invalid, regardless of whether the pilot reports it, seeks medical assitance, or is investigated by the FAA. This is as true of a sinus infection as an extensive medical condition; one may be temporarily grounded, pending returning to an airworthy state, or one may be grounded for an extended period of time. While there are many conditions which must be reported and which require medical intervention (and medical certificate intervention), there are also many temporarily-grounding conditions for which a pilot is required to exercise the responsible act of refraining from flying on his or her own. In this case, the pilot also determines when (s)he is able to return to flying.

Please don't take my comments as an attack on your efforts; I'm not in disagreement that some standards, and the means by which they're applied, need some reform, not the least of which include mental and emotional health issues. The ARC's work is but a part of that long-term reform, and it may well be that professionals such as yourself will be the activists that create and promote better change. I can only hope so. It is, however, a cautious hope. I am not anxious, in the zeal that surrounds this topic, to see those put into the air who ought not yet be there, and it is my sincere hope that those who can be there, and should be there, find an expediated path to fly.

I will be interested to read your continued posts.

 

John,

There is a lot to unpack in your response.

1. I am not a pilot. I do treat pilots. I am not an AME. I am a Board-Certified Psychiatrist. If it means anything,I served in the military and believe I understand the pilot culture.

2. I would say I came into this topic naive. I am not now. It has been a slog to learn the process, with a numbing level of byzantine details that continue to evolve. The terminology I use will, no doubt, convey I am a psychiatrist and not a pilot. Moreover, I am an "outsider" looking into what has been "standard" within the aeronautical medical world and, frankly, is very wrong.

3. Please be specific.

4. The FAA has data that they do not share that tracks "average" times to issuance. They could and should disclose it, if only to manage pilot expectations. Moreover, a large part of the time required to process Deferral applications is due to the FAA's own processes. By not releasing data, their is no accountability. As I have stated in the Blog, mental health deferrals often take over a year and are know to go as long as three years. Using the IG data from 2019-20, I calculate 328 days on average. I also calculated from the same data that 43% of the mental health deferrals are closed out as "Fails." If this is the case, it is a pretty devastaing data point and something the FAA has not disclosed. To the contrary, they publish a "0.1%" Fail rate or, in another source, a "96%" success rate on Deferrals.

Yes, I agree the delays in getting the required reports and exams is a major time sink. In addition, the notion of 6-months on a unchanging dose of an antidepressant before any approval process can be started is a huge burden. I am focussed on mental health issues and am not sure if there is a similar rule for other medical conditions, such as antihypertensives. Do you know?

5. Yes, I also agree that you need to line your ducks up before entering the process. Before going to the AME and disclosing depression or anxiety disorder, I would recommend paying for a lawyer that specializes in assisting pilots/ATC with FAA goverance.

6. I really don't spend much time considering the "moral ground." I would just like to make the skies a bit safer. The current system that relies on a heavy stick and false promises is failing. When you observe that pilots are 40-times less likely to get antidepressant than the rest of the US public, you know there are epidemic levels of undertreated illness. The FAA has a problem -- hell, even the Agency acknowledges it has a problem -- but doubling down on enforcement is not solving anything. And arguing that pilots are acting immorally by not signing "yes" on the 8500-8 may be true. But they are also acting rationally. There are better solutions.

7. You are correct. See: https://www.faa.gov/air_traffic/publ...tion_1.15.html. If you KNOW the medical issue is a problem, then "The Federal Aviation Regulations prohibit a pilot who possesses a current medical certificate from performing crewmember duties while the pilot has a known medical condition or increase of a known medical condition that would make the pilot unable to meet the standards for the medical certificate." The question is what you knew, or should have known. The FAA advises consulting an AME if you are unsure. I'll look in the blog to correct this item. Do you recall in which part I wrote it?

Thanks for your extensive comments.

 

I don't know that the 40x statisic is valid at face value.

This has come up in regard to retirement age as well, people toss out demographic stats based on the population as a whole.

But we (pilots) are not representative of the population as a whole... we are older, educated, and affluent. We're traditionally athletic and have a lot of initiative, ie tend to control our own destinies. We also have more lifestyle flexibility than white collar professionals in general. Those factors might imply fewer externally-induced pressures that might push someone into the yellow or red zone. For me personally it's far easier to stay well in the green with this career relative to previous mil and white collar jobs.

Flip side of that is time away from home and lifestyle constraints while traveling might tend to push us in the wrong direction.

With all that said, it is clear that pilots are less likely to seek therapy for relatively minor anxiety/depression. But in the US it doesn't seem to be a looming catastrophe. One recent incident doesn't make a trend and mental health wasn't directly causal in that one, it was illicit substance abuse (although it did get some publicity for the issue).

The notable incident in Europe was probably not applicable to us... that pilot was documented certifiable but their privacy laws prevented the info from getting to airline regulators and employers.


Lot of wiggle room on "knew, or should have known". If your femur is in a cast, or you had triple bypass last Monday then yeah you should have known.

But if it's just between you, yourself, and the fence post there's some legal grey area. Likely not ethical grey area, but legally you're getting into thought crimes without documented objective medical signs.

Also there's some plausible deniability... if you're "down in the dumps" but didn't see a healthcare provider, pilots are not held to the standard of being expected to properly diagnose every symptom and sign.

 

The focus is therapy and special issuance under N06ABs?

 

N06ABs -- i.e., medication. However, what got me into this was the potential use of TMS. The FAA has not yet really addressed TMS for depression/anxiety except as part of the AME "Fast Track" process. There, TMS (and ketamine/mushrooms) will result in a Deferral. In my opinion, TMS has huge potential with the possibility of treating a depression in as little as one week (accelerated TMS), no use of meds, excellent remission rates, good long-term stability, and mild side effects. The military strongly supports TMS for those reasons -- they don't want Soldiers on sedating meds or the logistics of SSRI delivery into combat zones, etc.

Jerald

 

Interesting, never heard of it. My spouse struggles with both anxiety & OCD. Takes very little to set her off. Sometimes, no reason at all.
I’m year 3 sertraline, 50mg. Don’t know how it works or anything about clinical efficacy, pharmacology. Best I can relate, it’s like having gotten used to always waking up in welding goggles. Normal but miserable. On ssri, tint lightens so what you see, over time, appears brighter, more in focus. The upside, doesn’t change your personality profile or create substance like rollercoasters. Drawback, as you mentioned, they do affect alertness, sleep rhythm. When your main AC busses are powered, peachy. Default to batt, energy is limited.

Anxiety and depression aren’t synonymous imho. Each experience unique as much common. You're the subject matter expert. On another note, Hims is predominantly perceived more punishment than cure. Need not be compulsory for Class1 approvals. Just my 2 pennies. Thanks for your input & time Doc.

 

Thanks for the kind words. Be very careful not to change the Zoloft dose unless necessary as it will trigger Deferral hell. That's a low dose but quite enough for many people.

TMS is new but old. It's been around since something like 2008 when it was FDA-certified but was mainly used in specialized clinics. Now there have been enough studies that it has hit mainstream. So, since around 2019, the use of TMS has expanded greatly. I am abivulent about the expansion of its use -- It's a valuable addition but there are some big corporate TMS clinics that are providing doc-in-the-box type care. Nevertheless, I own a machine so, yes, I am quite partial to it for the right kind of patient.

As for HIMS, if we believe the stats...they do a great job with substance abuse. I mean, hit-the-ball-out-of-the-park good w/r to outcomes. Better than most the care outside the FAA.

But HIMS should have no role for other Mental Health issues, like depression or anxiety. Nonetheless, the HIMS folks are involved and I agree, it is more punishment than not. They are familar with and operate from a methodology for substance use that is not really applicable to other mental health issues. That is why, in my profession, we have a subspeciality for substance use disorders. People in that field spend alot of their time "trusting but checking" for sobriety and building structure and accountability into their patient's lives. These are not at all the same needs/demands of someone who is depressed or anxious.

Regards,

Jerald

 

Thank you, kindly. Been reading up on TMS treatment, latest developments & so on. May pursue it, don’t know. Won’t hog your thread time further. Obviously I’d like to think non rx therapy advances. Happy hunting.

As for the rest of youzz…
Except for sims, haven’t turned a wheel since 2015. By choice. Closing in on 65 pretty soon. Substance dependent since around my late 20’s probably. No excuses. Just like a belt or 3 when happy hour rolls round. Smoke cigars on the golf course, the front porch. Burn a little herb to help keep the drinking in check. Well controlled I’d argue but given the choice hims or no medical, outta here as a younger, working pilot. No dui, arrests or drama to speak of. Just can’t imagine a life without freedom to honky tonk occasionally. No, no, no

 

One hopes you are not advocating magic mushrooms for pilots.

In light of recent events, you may find that an uphill battle.