As an AME, I read with interest Les Ruthvens article Pass on Pills [Medical Matters, September] relating to depression and stress. While I certainly agree with much of his article, I wish to remind readers that clinical trails have also demonstrated the benefit of pharmacologic therapy and that this treatment can be life saving in the case of major depression.
In addition, the medical and psychological models of depression are not mutually exclusive and often these approaches can be complimentary. On a number of occasions I have had a clinical psychologist refer a patient back to me for institution of medical treatment to supplement the psychological therapy.
I do wish to take issue with Dr. Ruthvens statement: … tell the psychologist that you must report to the FAA any diagnosis of a mental disorder … but if you do not meet the strict medical criteria for such diagnosis you are under no obligation to report either the consultation or any treatment that ensues.
The instructions for Item 19 of the Airmens medical application form states: The applicant should list all visits in the last 3 years to a physician, physician assistant, nurse practitioner, clinical social worker or substance abuse specialist for treatment, examination or medical/mental evaluation. The instructions go on to state that counseling sessions need only be reported if related to substance abuse or psychiatric condition.
If the strict diagnostic criteria of depression or anxiety disorder are not met, subsequent counseling sessions do not need to be reported as Ruthven correctly states, but the instructions clearly require that the initial evaluation/examination must be reported. The AME will likely wish to discuss the outcome of any evaluation and counseling with the applicant, as the AME needs to assess the applicants mental as well as physical fitness to meet the demands of piloting an aircraft.
-Mark Van Etten
Meds and Counseling Both Have Role
Les Ruthven penned what I would call an inflammatory article denigrating the use of antidepressant medications, and by association, those of us who prescribe them. He makes several claims, some legitimate and some that I would frankly question. I have the credentials to challenge this; I am one of those family practitioners he faults for prescribing these medications.
I agree with his observation that, in large controlled studies, the effects of these medications compared to placebo have been less than spectacular. I would, however, point out that they are still significant, and are not without effect.
I can certainly attest to that effect in selected patients. Several of my own were unable to be helped by his magical counseling, and were, in fact, sent to me by psychologists much like himself specifically for the initiation of medications. Ruthven paints a nihilistic picture in which one either pursues counseling or takes (worthless) medications. This is clearly not the case.
I disagree that these medications have negative cognitive effects, however. The package insert (which summarizes all the research presented to the FDA to obtain initial licensure) for Paxil, for example, specifically states that there has never been a study demonstrating negative cognitive effects. In addition, animal research and human research demonstrate no negative cognitive effects.
In fact, depressed patients who are adequately treated generally demonstrate marked improvement in their thinking process, whether they are treated with medications, counseling or both.
There is no doubt that people with mental illness are subject to discrimination. As an AME, I can easily return a pilot to flying who has had a major myocardial infarction and who is still at increased risk of dying because of this disease. But my physician assistant, who is one of the sharpest folks I know, cannot get into the left seat because she has done extremely well for many years on Prozac. I trust my patients lives with this very capable medical professional; I would trust her flying my airplane too.
Lets stop the ruthless discrimination and treat depression like any other chronic illness that is often easily treated and should be waiverable.
Youre right that medical certification standards dont seem to make much sense in this area. Personally, wed rather fly with someone who is on top of whatever health problems they might have rather than someone who ignores obvious danger signs – and that certainly applies to both mental and physical health.
Meds are Quicker
It was heartening to me to observe that an article on mental health problems would appear in Aviation Safety. It is an important subject, and I thought the author provided much useful information.
Having read and re-read the article several times, I have several comments.
I am a semi-retired family physician (40 years of practice) presently limiting my patient schedule to those having depression, general and acute anxiety disorders, marital difficulties, adolescent adjustment problems, obsessive-compulsive disorders, and other similar problems.
It has been my experience that these syptoms are relieved much faster with medication than with cognitive therapy. Furthermore if those symptoms are the main reason for a patient seeking medical care, use of the newer antidepressants alleviates them to a much greater degree than causing side effects.
I am not arguing that there arent side effects from the meds, but these kinds of symptoms usually disappear quite impressively beginning several weeks after initiation of treatment. This is certainly, however, not meant to support a patient acting as pilot in command when taking the meds.
There is a great deal of literature supporting cognitive therapy as equally effective treatment. Indeed, my personal bias is that spirituality is the greatest tool and that the true answer lies within each of us to alleviate or prevent these symptoms.
But as a speedy Band-Aid until one can get in to see a therapist, I find the selective serotonin uptake inhibitors very beneficial. Yes, this means at least temporary grounding. But arent we still talking about the importance of safety and prevention of accidents?
From all sides, whether psychologists or medical doctors or osteopathic physicians, we are hearing that there are many undiagnosed and untreated cases of these disorders. This is a tragedy. And it is a serious concern to flight safety.
My main concern with the article is that pilots might read it, become aware that they might have one of the disorders discussed, and feel that its OK to just wait and see rather than seek some sort of help, because their flight status might be in jeopardy if they seek attention. While I dont believe that is the message the author intends, it is the impression that I personally had when I read the article for the first two times.
-James R. Bell
While its clear that Ruthvens article struck a nerve, we think its an important piece of dialog to add to the medical certification debate. The American consumer is accustomed to immediate gratification. Combine that with rampant consumer advertising for prescription drugs, and you get a patient base that demands results now, even if thats not medically possible.As Ruthven points out, its up to the pilot/patient to consider all of the options (and the implications of each choice) and pick what makes sense rather than searching for a quick and easy magic bullet.
Planes Collided at Pattern Entry Gate
One afternoon I heard on the radio about a mid-air collision near McClellan-Palomar Airport (CRQ) in Carlsbad, Calif., between a Beechcraft Duchess and a Mooney. The pilot and passenger aboard one plane, and the solo pilot aboard the other plane were all killed.
Speaking from experience from flying in and out of CRQ many times, I noticed the location of the wreckage is roughly 1 to 2 nautical miles west-northwest of the departure end of runway 24 at CRQ. This is where the right-hand traffic pattern turns from crosswind to downwind, and is also where VFR arrivals from the north and west enter the downwind on the 45.
This hot-spot is why I always use extra vigilance when approaching CRQ from over the coastline from the northwest. I always establish contact roughly 5 miles or more from the edge of the Class-D airspace and immediately try to form a mental picture of where aircraft are in the pattern by listening closely to the tower and other aircraft on the frequency.
There have been a couple of times I have remained wide or have slowed down to allow an aircraft in the pattern to make that turn to downwind and get well ahead of me before I enter the pattern.
CRQ is one of the busiest single-runway airports in the country, if not the busiest.
Slow Down, Pal
I am glad to again receive Aviation Safety, after several years without it. Im very glad to see your new web site, with access to back issue articles.
Since the magazine promotes safety, I was surprised when I read the letter Outta the Way, Pal in the September issue and the editors response. I would have thought the editor would have mentioned the danger of taxiing at rotation speed. In fact even the letter writers conservative 12 to 15 knots, seems a little fast for me, since I was taught and now teach, to taxi at a brisk walking pace. I would think FAR 91.13(b) would certainly apply to taxiing at rotation speed.
Web Site Rocks
I would like to thank you for the web site. I have saved all of the magazines since I became a subscriber. Being able to download, view and access the information is outstanding. My hat is off to one of the best magazines in the aviation industry.
-Cecil T. Gurganus
More Web Wonders
Just wanted to pass a note of thanks for setting up this web site. Im impressed! This is yet another value add that will keep me reading.
San Antonio, Texas
I was delighted to see the new Aviation Safety web site and immediately went to it.
I entered my name as on the mailing label. I then entered the last nine digits of the account number on the label. My subscription runs through April 2003, yet my registering for the web site was rejected.
-Robert E. L. Talley
Punta Gorda, Fla.
Follow the instructions on the web site, under Get Web Access Now, paying particular attention to the location of the account number in the example. The cover wrap on the September issue highlighted the account number incorrectly. If that doesnt work, send an e-mail to email@example.com and our technical support people will set it up for you.
Rethinking Turnback Strategies
I have been studying the turnback on takeoff after engine failure problem in simulators, analytically and in actual aircraft for nearly three decades. I was quite pleased to see your article on Engine Out on Takeoff in July, and in particular the sidebar on page 14.
However, I was dismayed to read the letter Turnback Technique [Unicom, September] describing the method taught by the Bonanza Pilot Proficiency Program (BPPP) of climbing out at the velocity for maximum rate-of-climb, climbing to 1000 feet agl before considering a turnback, flying the turn at 35 degree bank angle at 1.35 times the stall speed and performing a 270-degree turn followed by a reverse 90-degree turn.
Each and every one of those recommendations has been shown to be non-optimal, as I demonstrate in my technical paper published in the scientific Journal of Aircraft, published by the American Institute of Aeronautics and Astronautics. (Rogers, David F., The Possible Impossible Turn, AIAA JAC, Vol. 32, No.1, pp. 392-397, March-April 1995). This paper is available in any good technical library and online at www.nar-associates.com (follow the link to technical flying articles) or at http://web.usna.navy.mil/~dfr/possible.html.
The sea level results found in that paper are:
(a) climb out at the velocity for maximum climb angle – it keeps you closer to the runway,
(b) for a 285 hp Bonanza and a typical 3000-foot general aviation runway, the failure altitude in the no-wind condition can be as low as 650 feet agl,
(c) use a 45-degree bank angle in the turn as recommended in your original article and in your answer to Jim Pipers letter,
(d) fly the turn at or nearly at the stall velocity in the turn, again, as recommend in your original article and in your answer to Jim Pipers letter,
(e) a teardrop flight path is optimal. Furthermore, the actual heading change using a failure altitude of 650 feet agl, a 45-degree bank angle and a velocity 5 percent above the stall velocity in the turn is approximately 200 degrees. It decreased with increasing failure altitude but increases with decreasing bank angle.
The reason for using a 45-degree bank angle and stall velocity in the turn is that, for a given aircraft weight and altitude, analysis shows that these conditions minimize the altitude loss for a given change in heading.
The final point is that the turn must be coordinated. Excess bottom rudder to hurry the turn will likely result in an over the top inverted spin.
-David F. Rogers
Thanks for the feedback. Aviation Safety ran a long article after flight-testing your technique in the November 1999 issue. It works great. Our biggest concern is that people wont practice it and then will be incompetent when nibbling around stall speed in the bank.
Learning the Turnback
I read your articles on turnbacks on departure in July and the response in Septembers Unicom from Jim Piper.
The turnback has been the topic of discussion in the Grumman Gang forum in the last few weeks, and there is some good practical advice for Grumman pilots there, including the results of some practical testing.
Id like to see more advocacy of safe ways to practice the teardrop maneuver. It does appear that 700 feet agl is the minimum that most pilots could expect to execute this maneuver, and that this could be significantly higher in aircraft with poor glide performance or with a non-proficient pilot at the controls.
Only practice will establish a reasonable basis for each pilot/aircraft combination, and Id like to understand more of the risks and safety factors involved with practicing and establishing personal minimums.
There is no doubt that Rogers technique is a high-performance maneuver that needs to be practiced periodically to be safe. We encourage trying this at a safe altitude in uncongested airspace with an instructor or safety pilot on board. Its not rocket science, but it does take some practice.