Flight #18 - FAA Approved Antidepressants for Pilots: SSRIs.
Welcome to The Flight Shrink newsletter! This is Dr. Kevin Heacock.
Just a quick update about me before we get to it. I’ll be attending the Aviation Mental Health Symposium at Middle Tennessee State University this week on the first and second of November. If you’re going, be sure to say hi. I’d love to meet some readers and listeners. If you’re not going, but still want to say hi drop me a line at kevinheacockmd@flightshrink.com and tell me a little bit about yourself and your interests in aviation mental health.
As The Flight Shrink newsletter and podcast grows, I think it would be great to interview some people with aviation related mental health stories. The more people out there sharing their mental health stories, the more we can reduce the stigma that keeps people from getting help. I’ve listened to some other podcasts, like The Pilots Pandemic, where pilots tell their mental health stories. And while some pilots have been frustrated with how long it takes for them to get back to flying, or in some cases, that they can’t fly anymore, none of them regret getting help and improving their mental health. All of them recommend other pilots with mental health concerns seek care. Hopefully, this podcast and newsletter is helping some pilots out there manage any mental health symptoms on their own or encouraging them to see a mental health professional if needed.
With that said…let’s prepare for take-off on today’s flight.
In the last two editions I started, thinking I was going to talk about the 5 antidepressants that are approved by the FAA, but I ended up talking about the decision-making process of starting them, the careful diagnostic evaluation by a mental health professional that should take place before starting them so as to avoid an inaccurate diagnosis that could lead to special issuance requirements, and what some of the concerns might be with starting an antidepressant. If you haven’t read or listened to those yet, I encourage you to go back to Flights #16 and #17.
On this flight though, I’m going to actually talk about the 5 antidepressants approved by the FAA for use in pilots. They are Prozac, Zoloft, Lexapro, Celexa, and the most recent one added in May 2023, Wellbutrin.
Prozac, Zoloft, Lexapro, and Celexa are classified as Selective Serotonin Reuptake Inhibitors (SSRIs). Since they were the only approved antidepressants when the FAA first started allowing their use in pilots in 2010, much of the FAA guidance refers to an SSRI Decision Path or SSRI Certification. But even though Wellbutrin is classified as a Norepinephrine and Dopamine Reuptake Inhibitor (NDRI) you can follow all the same FAA guidance for SSRIs. Before we get to Wellbutrin though, let’s talk about the antidepressants that the FAA has been allowing the longest, the SSRIs.
Before I move on, I’m going to be talking about the FAA and the FDA. So let me be clear of the difference between the FAA and the FDA. The FAA (Federal Aviation Administration) oversees aviation safety and regulation within the United States, focusing on pilot licensing, aircraft safety, and air traffic control. While the FDA (Food and Drug Administration) is responsible for regulating the safety and effectiveness of drugs, medical devices, and food products, primarily concerning public health.
Technically, each of the FAA approved SSRIs have different diagnoses for which they have an approved FDA indication for use. For instance, while all 4 are approved for treatment of Major Depressive Disorder, only Lexapro is approved by the FDA for treatment of Generalized Anxiety Disorder. But only Prozac and Zoloft have indications for Panic Disorder. But in real-world practice, even though not every antidepressant has an FDA approved indication for every mental health diagnosis, prescribers use SSRIs relatively interchangeably for diagnoses like Depression, Anxiety, Panic, PTSD, Obsessive-Compulsive Disorder, and even Eating Disorders.
While not my first choice for most people, if you go to your Primary Care Provider for a medication to treat depression and/or anxiety, you’re likely to get started on Lexapro. I think there are several reasons for this. First, Family Practice prescribers have so many patients, they are limited in the time they can spend with one patient to really dig down and figure out what the primary issue might be. Is it Depression, Anxiety, both, or something else? And since it has an FDA approved indication for treating both anxiety and depression, rather than prescribing one of the other antidepressants for an off-label use, Lexapro probably seems like a safe bet to non-mental health prescribers. Also, of the four FAA approved SSRIs, Lexapro is probably the one least likely to cause any side effects.
But really, all four have very similar side effects profiles. Side effects are rated on a scale of zero to four, with 0 meaning the medication does not cause that side effect, and 4 meaning it is quite likely to cause that side effect. In the newsletter you can see a spreadsheet of the five FAA approved antidepressants in a chart with the potential side effects and numbers showing how likely they are to cause that side effect.
Anyone looking at this might ask, why would I ever take a medication that is a 3 on a scale from 0 to 4 of potentially causing sexual side effects? And this is where it’s really important to talk with a mental health professional experienced in prescribing these medications. Because, while all four FAA approved SSRIs have the potential of causing sexual side effects, in my experience it really is quite rare. I’d say maybe 5% (1 out of every 20) of my patients have some sexual side effects such as decreased libido (decreased sex drive) or taking a longer time to orgasm. And while this can be concerning when you first start the medication, in my experience, this side effect, if it occurs at all, often subsides and resolves over time. At the same time, I’ve had patients who’s depression or anxiety was so bad they were not engaging in sexual activity and getting on the antidepressant relieved their symptoms and led to them resuming sexual activity they had long missed. So, again, it’s a risk versus benefit discussion to have with your prescribing provider. But generally, I’d say, go ahead and try an antidepressant if it’s indicated, and if you have a side effect like this, stick with it, but if it doesn’t resolve, know that there are other approved antidepressants you can switch to. And again, in my experience, you can usually find at least one SSRI that has good benefit for you with limited side effects.
One of the other side effects people are concerned about when starting an antidepressant is weight gain. For the most part, these medications do not really cause weight gain. On the chart you’ll see that only Zoloft, Lexapro, and Celexa have the potential for weight gain, and they’re just a 1 on that 0 to 4 scale. So very unlikely. What can happen though is that sometimes, someone’s depression or anxiety is so bad they aren’t eating much and so when they start feeling better on the antidepressant they start eating more and end up gaining some weight. This is why it is good to include healthy lifestyle interventions as part of your treatment rather than relying on a medication alone. Maintaining healthy eating, exercise, and sleeping habits will improve your overall health and limit weight gain while starting an antidepressant.
Probably the most common side effect I hear from my patients is some stomach upset or loose stool when starting an SSRI. As you can see, Zoloft is a 2 out of 4 in the GI toxicity column while the others are just a 1. And this lines up pretty well with my experience prescribing these medications. Zoloft is the most likely to cause some GI upset, sometimes even with some nausea or diarrhea. This usually just happens in the first week or so after starting the medication. So I warn my patients about it and tell them to stick with it, because after a week or so it usually goes away. I think this is just because there are some receptors in the GI tract that are similar to the ones we’re targeting in the brain, and it just takes them a little time to get used to the medication going through the system. But once these receptors are used to the medication, any GI upset usually resolves. So most of the time I just encourage patients to, literally, gut it out.
With that said, there are ways to choose an antidepressant to try first to give yourself the best chance of having a beneficial effect with limited side effects so you’ll stay on it long enough for it to improve your symptoms.
One way is to talk to your friends and family about antidepressants they’ve tried and used. If a family member has found benefit with limited side effects on one antidepressant, there may be some genetic similarities that would suggest this medication would work well for you too. Also, if you know a friend or family member who has done well on one antidepressant, just knowing it worked well for them may give you some more buy-in to it, or some confidence that it does work, and this may improve the likelihood that you’ll do well with it and stay on it. Often my patients know that a family member takes something, but they don’t know which medication, so I encourage them to talk to their family members and find out what they’re taking because it could be good information to know in the event we need to change medications at some point in the future.
You do have to be a little careful asking other people about their experience with antidepressants though. Especially if you’re going on the internet and looking up testimonials about peoples’ experiences with antidepressants. From what I’ve seen, when someone has a good experience with an antidepressant they just go on about their lives and don’t broadcast it to everyone on the internet. But when they have a negative experience, it seems they’re more likely to post about it online. But the vast majority of patients I’ve seen treated with antidepressants do quite well with short lived side effects, if any. So take those negative online reports of peoples’ experiences with antidepressants with a grain of salt.
Another way to choose the best antidepressant for you is to target the symptoms you’re most concerned about. If you’re main concern is typical depressive symptoms like feeling down, low, or depressed with some decreased interest in doing fun things, experiencing less enjoyment with things you used to find exciting, along with guilt or worthlessness, really any antidepressant could be helpful for what is potentially a Major Depressive Disorder.
However, if, in addition to these depressive symptoms, you also have some anxiety symptoms like nervousness, excessive worry that feels uncontrollable, or feeling restless with difficulty relaxing, it may be worth targeting your anxiety symptoms with an antidepressant that is more likely to help them as well, in addition to your depressive symptoms. I know I said before, the SSRIs can be used fairly interchangeably for many mental health diagnoses, but some may be a better choice for anxiety than others. While Lexapro is the only one with an indication for Generalized Anxiety Disorder, it’s maximum dose is relatively low in comparison to the max doses for Prozac and Zoloft. 20mg of Lexapro is equivalent to 40mg of Prozac and 100mg of Zoloft. But while 20mg is the max recommended dose for Lexapro, Prozac can be dosed as high as 80mg and Zoloft up to 200mg. And, in my experience, higher doses of SSRIs tend to be needed to fully treat anxiety that may linger even after most of the depressive symptoms have resolved at a lower dose. So, often, when I’m treating someone’s anxiety in addition to depression, I’ll start off with Prozac or Zoloft rather than Lexapro, so there is an option to increase the dose further if they’re still having some anxiety that might be better treated at a higher dose. This saves me from getting someone’s Lexapro dose up to the max dose of 20mg, finding out they’re still having some anxiety, and then having to switch to another medication like Prozac or Zoloft, and then waiting even longer to get them to full treatment.
I was planning on talking about Wellbutrin today too since it is the newest of the antidepressants allowed by the FAA, but I’ve spent a lot of time covering the SSRIs and Wellbutrin is quite different and has it’s own benefits and potential side effects to talk about, so I’ll leave that for our next flight together. 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’m 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 at least 50% off that. 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 any mental health related questions 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, or 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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Let's soar to new heights while prioritizing our mental health.
I love hearing from readers and listeners, so feel free to Email me at kevinheacockmd@flightshrink.com. Also, you can connect with me on Instagram, X (formally Twitter), Facebook, and Threads with the handle @flightshrink. And feel free to visit The Flight Shrink substack for archived posts covering a wide range of mental health topics. Until next time...
I'm Dr. Kevin Heacock, The Flight Shrink... Keep on flyin'!