Flight #16 - Antidepressants and How to Use Them in Aviation
Welcome to The Flight Shrink newsletter! This is Dr. Kevin Heacock.
In this edition, we'll take flight into the world of antidepressants and their aeromedical approval by the FAA. Managing mental health is paramount in the aviation industry, and for some, antidepressants are a crucial part of that journey. We'll look into the details of how antidepressants can be used by pilots and what that means for their medical certificates.
Housekeeping:
Before we take off though, I wanted to do a little bit of housekeeping. Last week I tried something a bit different for the newsletter and podcast. I called it an Upgrade edition and the audio was a 20 minute Visualization Meditation. I hope you listened to it and got some benefit out of it. I didn’t get any feedback though so I’m not sure if it’s something I’ll keep doing or not. I was thinking of maybe doing one a month and maybe other upgrades like a Yoga flow with my wife, who is a Yoga Teacher. If you’re interested in upgrades like this let me know in the comments or email me at kevinheacockmd@flightshrink.com
And now we can proceed with our departure…
Understanding Antidepressants
Antidepressants are medications that have been studied and shown to alleviate symptoms of depression and other mental health disorders. They work by modifying how neurotransmitters are utilized in the brain, which can help improve mood, anxiety, sleep, and overall well-being. Many pilots and aviation professionals have found benefit from these medications.
For pilots, the decision to start an antidepressant is a big deal because the FAA has a specified process of how to return to flying once stable on an antidepressant. This unfortunately has led some pilots to not seek help for their mental health concerns. In the worst case scenarios, this has sadly resulted in suicide.
I have heard several friends and family of these pilots asked what other pilots should do if they are dealing with mental health issues: should they get help that could led to not flying, or should they keep flying and not risk losing their medical certificate? And every friend or family member of a pilot who died by suicide has said, get help. Your friends and family love you because you’re alive, not because you’re a pilot. You don’t need to be a pilot, but we need you to be alive.
So the first step for pilots dealing with mental health concerns is to see a mental health professional. Social Workers and Licensed Clinical Therapists are great and can be great at providing care to just about everyone. For pilots though, they really need to be sure of their diagnosis and treatment. So I would suggest finding a doctoral level mental health provider such as a psychologist or psychiatrist. These are doctors who have had the best training in diagnosis and treatment and tend to have the most experience with cases that need very careful diagnostic considerations.
With a careful diagnostic evaluation it’s possible that a pilot could present with depression and anxiety symptoms that don’t quite rise to the level of a disqualifying condition such as Major Depressive Disorder or Generalized Anxiety Disorder. The 8500-8, the application pilots fill out for their medical certificate, asks if you’ve ever been diagnosed with, and I quote, “mental disorders of any sort; depression, anxiety, etc.” So you can see a psychiatrist or psychologist for depression and anxiety symptoms, and if those symptoms do not meet criteria for a diagnosable disorder, you can honestly check NO to this question.
So, this is an important conversation to have with your psychologist or psychiatrist. Let them know that you are a pilot and you want help managing your symptoms, but to not document a diagnosis if you really don’t meet criteria for one. Unfortunately, the way insurance works, insurance may not cover your mental health care if you don’t have a mental health disorder. So psychologists and psychiatrists often make a diagnosis of Major Depressive Disorder or Generalized Anxiety Disorder thinking they are helping the patient get their insurance to pay for the evaluation and treatment. But in the case of pilots, you really want to make sure they are making an accurate diagnosis. You may end up having to pay for care out of pocket, but at least you’ll be getting help for your mental health concerns without a full on mental health diagnosis, so you can keep checking NO to item 18m on the 8500-8.
That being said, pilots, like many people, often push through even severe symptoms of depression and anxiety and may not realize how significant their symptoms really are until evaluated by a mental health professional. It’s kind of like the frog in the pot story. The temperature turns up slowly over time to the point the frog never gets out of the pot before it’s boiled. Similarly, pilots might slowly adapt to dealing with depression and anxiety over time that they may not realize how bad their symptoms really are before they’re severe. In which case, even if you have that discussion with your mental health provider to not make a diagnosis if you don’t really have it…if you meet the criteria they have to diagnose it and make recommendations for treatment.
If you really don’t meet criteria for Major Depressive Disorder or another mental health diagnosis that can be treated with antidepressants, you probably shouldn’t start antidepressants. Some prescribers, particularly primary care providers, will start antidepressants even for conditions such as an Adjustment Disorder with depressed mood. When I teach primary care providers about treating mental health conditions I usually tell them that if they’re reaching for their prescription pad then the diagnosis is probably something other than Adjustment Disorder.
But here’s why this distinction is so important for pilots. If it truly is an Adjustment Disorder with depressed mood that is not treated with medications and resolves (as most Adjustment Disorders do once the stressor causing it has resolved), then the AME can issue your medical certificate without deferring to the FAA for a special issuance. But once antidepressants have been started, no matter what the diagnosis is, you’re going to need a special issuance if you want to continue taking the medication.
One alternative would be if you start an antidepressant and then once stable, you and your prescribing provider agree you can trial off the medication. If you remain clinically stable after 60 days off the antidepressant then your AME can also issue your medical certificate without deferring to the FAA for a special issuance.
This is a question I get from patients all the time: If I start this antidepressant do I have to take it for the rest of my life? It really is a case by case basis. Yes, there are people whose brains just function better on the medication and they probably should take it the rest of their lives. Some people may feel stigmatized by having to take a medication for their depression, but they really shouldn’t. Because we shouldn’t think of them any differently than we do, say, a person with diabetes who needs to take insulin because their pancreas doesn’t make it. Just like some people have pancreases that don’t have the right amount of insulin, some people have brains that don’t utilize their neurotransmitters effectively. And those people do best when they stay on their antidepressants for the rest of their lives.
Many people however, don’t find themselves depressed or anxious all the time, but may find themselves struggling to manage their depression and anxiety due to some significant stressor. Perhaps they managed things quite well when it was just school and relationships, but then they get married, have kids, start a demanding job, try to keep up with hobbies and it all gets to be a little too much even for some that have fairly good self-care routines like exercise, healthy eating, and good sleep. And they just need some help getting back on track. And an antidepressant can help with that.
In this situation I like to use the analogy of high blood pressure. Say you go to your doctor and they say you have high blood pressure. They recommend doing some diet and exercise, but we know that’s going to take a while, so in the meantime they prescribe you a medication to bring your blood pressure down. And you’re thinking, am I going to have to take this the rest of my life? No. But for now, take it while you work on your diet and exercise and in 6 months or a year, if you’re taking care of yourself we can stop the medication and see how you do. If your blood pressure remains stable, you don’t need the medication. But if your blood pressure goes back up, then we know there’s a medication that helps, so we just restart it.
It’s the same thing with an antidepressant. You’re struggling to manage your symptoms right now, so of course, focus on your self-care practices like exercise, healthy eating, and prioritizing sleep. But in the meantime, here’s an antidepressant that will help manage your symptoms. And in 6 months to a year, if you’re feeling like you’re back on your feet and you want to try coming off the medication we can give it a shot. And see how you do. If you do well, great! If not, hey, at least we know there’s medication that helps and we just restart it.
When I started writing this week’s newsletter, I thought I was going to talk about each of the antidepressants that are approved by the FAA for use in pilots. But as I wrote it I thought an understanding of when antidepressants were appropriate and how they might be used would be better to do first. I do still plan on talking in a future edition about the approved antidepressants, including the new one added this summer, Wellbutrin. But for now I’ll leave you with this…
Seeking Aeromedical Guidance
If you're considering antidepressants as part of your mental health strategy, it's crucial to consult with an AME (Aviation Medical Examiner) who understands the FAA's guidelines. They can provide guidance on how to navigate the process safely, ensuring that your well-being and aviation career can coexist harmoniously.
I am certified by the FAA as an AME and as a HIMS Psychiatrist. So I would be happy to consult with you confidentially on any mental health related aeromedical questions. I have looked up other services like this on the internet and they can charge as much as $90 per question. So for my newsletter subscribers and podcast listeners I figure you deserve 50% off. And so, if you have a mental health related aeromedical question you’d like me to address confidentially, just email me at kevinheacockmd@flightshrink.com and for just $45 I’ll address your question.
It can be about anything you need help with. Whether that be questions about a mental health condition and how it might affect your medical certificate, how antidepressants might impact your career, what evaluations the FAA will want if you’re trying to get a special issuance for your mental health condition. Whatever it is, email me at kevinheacockmd@flightshrink.com and for just $45 you’ll get your answer from an FAA certified AME and HIMS Psychiatrist with over 17 years of aeromedical experience.
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I'm Dr. Kevin Heacock, The Flight Shrink... Keep on flyin'!