Pass on Pills

Stress and depression can become debilitating enough to cost you your medical, but non-drug treatment can keep you safe and legal.


There are a wide variety of mental health problems that plague virtually everyone from time to time. They involve distressing symptoms that typically arise from adverse life events that go beyond whatever coping ability you may have at the moment.

These mood and stress symptoms are important to pilots because they not only impair general health, they also impair cognitive skills that are essential to safe flying – attention, concentration, problem solving, judgment, planning ability and self-confidence.

Going down to minimums on an ILS during heavy rain is challenging enough when the important aspects of your life are going well. Doing it while experiencing the negative emotional effects secondary to worry is even tougher. Everything being equal, the troubled and emotionally impaired pilot might be able to adapt to some flight demands safely, but then again, the pilot may be faced with demands that exceed his or her coping skills at the moment.

Stress and mood symptoms adversely affect the skills of all pilots, not just some, because everyone is affected from time to time. When problems of stress or mood – or both – become severe and prolonged, they are diagnosable by a psychologist or psychiatrist as mental disorders.

When stress builds up to the point where it becomes a diagnosable problem, its usually characterized as one of a variety of the anxiety disorders, such as panic disorder or generalized anxiety disorder. When mood problems reach diagnostic significance, one of the depressive disorders is diagnosed.

Psychiatry and Psychology
The important consideration, of course, is that the problem builds up to the point where a mental health professional considers it to be significant. In general, psychiatrists tend to see the diagnosable forms of stress and mood disorders as mental diseases that differ in kind – and not just degree – from the stress and mood problems of those whose problems are not diagnosable.

The psychiatrists model of depression, for example, stresses the importance of underlying biological factors, especially with regard to brain neurotransmitters such as serotonin that are believed to be very important in clinical depression and perhaps milder mood problems as well. Psychiatrists tend to stress biological factors as primary in depression and look to antidepressant medication as the primary treatment, while psychologists look for the cause in psychosocial factors.

The FAA does not allow pilots to be on either antidepressant or antianxiety drugs while exercising their flying privileges – and rightly so, in my view. Despite any questions of the efficacy of these drugs, these two classes of drugs are cognitive impairing and are inconsistent with even routine pilot demands. Unfortunately, there are far too many cases of pilots involved in fatal aircraft accidents while taking these and other behavioral drugs that are prohibited by the FAA.

One fundamental question is whether the stress and mood problems these pilots were having in their lives were the major cause of the accident or if the negative cognitive side effects of the drugs themselves played the critical role. Most likely, both contribute significantly.

In contrast to the disease model of anxiety and depression that psychiatrists hold, psychologists tend to consider anxiety and clinical depression as differing in degree but not kind from the more milder stress and mood problems that all of us are subject to from time to time in our daily lives.

Psychologists consider the diagnosable forms of these disorders significant and disabling departures from milder problems, essentially a difference of degree rather than kind. Instead of looking for medication to change behavior, psychologists look for adverse environmental influences, combined with the persons cognitive style, that give rise to the disabling symptoms.

Teaching the individual to resolve or better cope with distressing life situations such as marital unhappiness or job stress alleviates symptoms by addressing the cause or causes of the depression.

People who are prone to depression, for example, tend to be overly conscientious, self-blaming perfectionistics whose personal attitudes and style of thinking must be modified if there is to be any long-term resolution of the depression.

Scientific research suggests that a procedure known as Cognitive Behavioral Therapy is the most effective type of psychotherapy with both the anxiety and depressive disorders. This approach directly challenges and helps to modify the thought patterns that underlie the patients stress and mood problems.

Better Living Through Chemistry
The medical model of depression – which holds that depression is a disease whose primary treatment is medication – has become so popular and so ingrained that it seems to exist independently of whether there are any facts to support it. There is a very powerful emotional appeal to the belief that a complex and disabling mental disorder such as a clinical depression can be treated effectively by drugs alone administered by a family doctor.

Each year, perhaps 4-6 percent of pilots experience what could be diagnosed as clinical depression – and if they are responsible pilots, what are they to do? Turn in their medical for nine months, and take Prozac or other antidepressants for a six-month clinical trial by their family physician?

If the problem is such that drugs are indispensable in the effective treatment of that depression, assuming the pilot has been correctly diagnosed, then thats the only responsible path for the pilot to take – stop flying while you are taking these drugs and hope the FAA will give it back to you later.

But perhaps pilots should think again. Before accepting the conventional wisdom about depression and its treatment – a conventional wisdom shared by most physicians, the National Institute for Mental Health and society at large – consider the results of scientific studies, especially those that were controlled double-blind, placebo-controlled studies on treating well-diagnosed depressed patients with antidepressants alone.

Over the past 30 years, research has shown that most patients treated with antidepressants show no more improvement than patients treated with placebos or nothing at all. Suicide attempts and successful suicide rates dont vary either. In contrast, psychotherapy has been shown to be much more effective.

For pilots, the message is unmistakable: There is no apparent advantage in adding prescription drugs to psychotherapy with regard to depression outcome, even with major depression.

Popular Pills
Despite overwhelming scientific evidence to the contrary, the myth continues that depression is first and foremost a chemical imbalance in the brain and that antidepressant medication must be the primary treatment, with psychotherapy a useful addition in some cases. The National Institute of Mental Health, for example, tells primary care physicians who are treating depression to have two antidepressant drug failures before referring the patient to a therapist.

Though NIMH and psychiatry pay lip service to the need for psychotherapy, it is obvious from the above NIMH guidelines that drugs are considered the core treatment of these clinical problems.

Newer antidepressant drugs, such as the selective serotonin reuptake inhibitor drugs Prozac, Paxil and Zoloft, have become particularly popular because of their claimed increased effectiveness.

The Agency for Health Care Policy and Research commissioned a study to determine the effectiveness of the newer SSRI antidepressants in treating clinical depression with drugs alone. In a review of 80 studies that met the researchers criteria for scientific merit, the newer antidepressants were found to be far from wonder drugs.

Treatment recovery rates were found to be 50 percent for the newer antidepressants compared to 32 percent for inert placebos. The drug-placebo difference (18 points) means that one would have to give six clinically depressed patients the drug on average to be sure that one of the six had something more than a placebo response. If antidepressants do indeed treat clinical depression, they are very limited in their effectiveness.

Strategies for Pilots
Someone concerned about mental health has two avenues to explore – psychiatry and psychology. Those two fields are the only ones populated by mental health professionals trained and licensed to diagnose as well as treat a mental disorder.

To spare reporting to the FAA, pilots with stress/mood problems have sometimes been advised to go through their employee assistance program to see a counselor for any adjustment problems that may give rise to the stress or mood symptoms. Keep in mind, however, that counselors and social workers are not trained diagnosticians and are ill-equipped to advise the appropriate intervention.

A psychiatrist will typically treat these problems with drugs, leading to the pilot losing flight privileges. While that may be a small price to pay to get started down the road to happiness – especially for nonprofessional pilots – it doesnt have to be that way.

A psychologist will consider such non-drug treatment as cognitive behavioral therapy, but thats no cure-all either. For example, I once had a 42-year-old depressed patient referred to me after two failures on antidepressant medication by her family physician. In evaluating her, I determined that her diagnosable depression arose from a job change six months earlier that she was not suited for emotionally. The treatment was neither Prozac nor CBT; the treatment was a job change.

If you consult a psychologist as an impaired pilot, tell the psychologist that you must report to the FAA any diagnosis of a mental disorder such as anxiety or clinical depression, but if you do not meet the strict medical criteria for such diagnoses you are under no obligation to report either the consultation or any treatment that ensues.

Getting Back on Track
The correct diagnosis (whether its clinical depression, panic disorder or just the blues) is the beginning and not the end of the diagnostic enterprise. Your doctor or psychologist shouldnt just check off the presence or absence of Diagnostic and Statistical Manual criteria, but try to develop a dynamic understanding of how the symptoms relate to the patients environmental pressures, adaptive or maladaptive problem solving, and cognitive makeup.

If the signs point to marital or financial stress, for example, the therapeutic focus should be on teaching problem-solving skills to better master these situational stresses. More of a cognitive therapy focus would be required if the patients thinking/belief system needed to be challenged/modified by the therapist in order to resolve the symptom disorder and keep it from returning.

Remember, drugs or emotionally supportive counseling alone are not effective treatment for either anxiety or depression. The problem with depression is not to get rid of it (an exercise program, a sugar pill, or an antidepressant will often do it temporarily) but the goal is to keep it from returning, which requires the learning of cognitive, coping or problem solving skills for the patient to gain and maintain normal mood. It would be wonderful if a pill could do this, but it cannot.

Stress and mood problems, including diagnosable anxiety and depressive disorders, are the most effectively treated of all mental health problems and even severe cases requiring CBT can be treated in 20 sessions or five sessions or less for impairing but less serious forms of the disorders.

Women with stress and mood problems are much more likely to get professional help for these problems than are men (both pilots and non-pilots) and with many male pilots it is often the maleness rather than their fear of the FAA that keeps them from turning to an expert for help.

Unfortunately, some turn to increased alcohol use as a maladaptive response or use their wifes prescription for a Prozac-type drug under the mistaken belief that the pill is an effective treatment for their mental health problems.

As a pilot, you cannot safely execute your duties if worry, stress and mood problems are operating in the cockpit, compromising your focus and undermining your piloting skills. Even if the problem is diagnosable anxiety or depression, with expert treatment most pilots can expect to continue their flying while undergoing evaluation and treatment.

The good news for pilots with depression and anxiety is that these problems are effectively treated by psychologists with a variety of behavioral interventions and that these conditions rarely require that drugs supplement the behavioral treatment.

Also With This Article
Click here to view “The Literature Says…”
Click here to view “What Does The FAA Want, Anyway?”
Click here to view “The Federal Stance.”

-by Les Ruthven

Les Ruthven, a Lancair IV-P owner, is a licensed psychologist and instrument-rated pilot with over 1,600 hours.


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