Opinion | There is more to the story of pilots avoiding mental health care

A photo of the copilot and view through the windshield over a commercial airliner.

Hoffman is a neuroscientist and aviation researcher focused on the health behaviors of pilots.

AND The Washington Post last month’s article titled “5,000 pilots suspected of hiding serious health problems. Most still flying,” sparked a debate in our department. While we, like the millions of Americans who trust and depend on our exceptionally safe aviation system, have a slightly different take on the story. While the article was compelling, we, as researchers of pilot healthcare seeking behavior, know there is more to the story.

Airline pilots are required to meet certain mandatory medical standards to maintain active flying status. If a pilot develops a new symptom or mental health condition — and reveals it during a regular medical evaluation by a physician designated by the Federal Aviation Administration (FAA) — he can risk his certification, usually temporarily, to fly. Because of this, many say pilots face a barrier to seeking mental health care because of the fear of what it could mean for their ability to work. Interestingly, airline pilots are only one of the few professionals who must disclose all of their health information (often including an interview with a mental health therapist) in order to work.

This has real-world implications. If you’re a high-earning commercial airline pilot with a mortgage, a car payment, and two kids in school, how high does your mild anxiety have to be for you to take months or even years off flying and seek care? Quite significant for many pilots.

Research conducted by myself and several colleagues reveals the wide scope of this issue. In our sample of 3,765 US pilots, 56.1% reported that they had avoided medical care in the past (eg, not seeking medical care for a new symptom or seeking informal medical care outside the traditional system) due to fear of losing their pilot certificate. This problem is not unique to the US. We found a similar level of avoidance of pilot health care due to fear of loss of flying status among Canadian pilots. Interestingly, pilots who do not fit typical workforce demographics—male, white, and heterosexual—may be more likely to report avoiding health care than their counterparts. This is a pervasive problem in the US and beyond.

While The Washington Post the article identified one important manifestation of this gap, the broader issue was overlooked. The Post article compared Veterans Administration (VA) disability benefit rates with medical information released by the FAA and found that more than 5,000 former military pilots claimed VA disability for conditions not disclosed by the FAA. First, it is problematic that some pilots have deliberately broken the rules. The safety and efficiency of our aviation system depends on the personnel who work within it, and this type of behavior cannot be tolerated. However, it is not really a safety story. Aviation is exceptionally safe, thanks to redundancy and system-wide security program measures. We, as doctors caring for pilots, see this story as much bigger than the 5,000 pilots identified The Washington Post. For us, this is a story about the many thousands of pilots who potentially suffer in silence and avoid mental health care because it could compromise their ability to fly. This is the story of the unintended barrier this unique population—a population that 853 million American travelers relied on last year—faces in getting the care they need.

We currently approach aviation mental health in a clinical way. We identify pilots with a diagnosed mental illness or using mental health care services and believe they may pose a disproportionate risk to safety. At first glance, taking these pilots out of service seems to make sense. Proponents of such an approach will point to major disasters attributed to suicidal pilots (such as the 2022 China Eastern crash or the 2015 Germanwings crash) as evidence of aggressive airline screening programs. While this is logical and with some truth in the extremes, reality may not be so straightforward and our clinical approach may inadvertently leave many pilots in trouble. It is important to recognize the remarkable diversity of mental health symptoms and their multiple manifestations. We’re not talking about pilots with severe mental health symptoms – that population certainly shouldn’t be flying. Instead, we’re interested in finding a way to help pilots with mild symptoms—perhaps those on the spectrum of common life problems—get the support they need easily and quickly.

Of course, every step must be taken to prevent another mental health-related aviation tragedy, but we must question whether our current clinical approach is correct. Importantly, it is unclear whether regular clinical assessments are the best way to identify pilots at disproportionate safety risk. Unfortunately, they are not foolproof: after all, significant disasters have occurred using such an approach. Further, there is insufficient research to determine whether meeting diagnostic criteria for a mental health condition correlates with reduced pilot performance in most cases and outside of the extremes. In fact, a large population of flying pilots who quietly manage their life stress, mild anxiety or occasional depression on their own can agree that it does not affect their professional performance. Now is the time to rethink how we can build a system that minimizes barriers to mental well-being while maintaining exceptional aviation safety.

So what do we do now? Duplicating an imperfect system is not the right answer. While the minority of pilots who clearly break the law for their own personal gain should be held accountable, broad and tough enforcement is unlikely to bring about the change we want to see. Such an approach will only further perpetuate the stigma around mental health and drive this population further underground. Instead, The Washington Post The story is an opportunity for us to rethink how we approach mental health in aviation and how we might achieve mental wellbeing in the aviation system of the future.

How can we achieve this goal? We should explore ways to move from our current clinical approach—one focused on mental health diagnoses and health care utilization—to one focused on performance. Can a pilot perform his duties regardless of the mental health designation on his medical record? Such an approach would focus on pilot peer review and repeated performance-focused cognitive testing. The science behind this approach is developing and is already being used in other parts of the transportation industry and in healthcare. One study of emergency medicine physicians showed that a similar performance-based assessment was able to identify alertness in physicians at risk for fatigue, a finding that could potentially reflect some types of mental health symptoms in the workplace. These types of technologies have the potential to identify risk within a system and enable targeted security measures. Such a paradigm shift can promote timely presentation of mental health care services when needed, reduce airline and pilot costs associated with flying, and further support existing safety programs within the U.S. aviation system.

Despite its problems, the FAA certainly deserves credit. Positive steps forward include efforts including an extensive mental health outreach program, new expedited protocols for reviewing pilot medical applications, and the approval of several new drugs for the treatment of mental health conditions. US Federal Aviation Surgeon Susan Northrup, MD, MPH, and her team should be applauded. That means there’s still work to do.

William R. Hoffman, MD, is a movement disorders specialist at Columbia University Medical Center and an associate professor of aeronautics at the University of North Dakota John D. Odegard School of Aerospace Science. His research interests focus on pilot brain health and health care-seeking behavior. Follow @billy_hoffmanmd on Instagram.

The views expressed in this document are those of the author and do not necessarily reflect the official policy or position of the Defense Health Agency, Brooke Army Medical Center, US Air Force Institute of Technology, Uniformed Services University of Health Sciences, Department of Defense, Federal Aviation Administration, or any agency under by the US government.

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