Flight #22 - Aeromedical Safety - Previous Suicide Attempt
Welcome to The Flight Shrink newsletter! This is Dr. Kevin Heacock.
I had the opportunity to attend the National Transportation Safety Board (NTSB) Aviation Safety Summit on Navigating Mental Health in Aviation last week in Washington DC. It was great to see so many people in the aviation industry advocating for pilots to receive the best mental health care possible to allow them to maintain their livelihood and dream of flying.
I had expressed some concern last week that up to this point the discussion of improving pilot mental health has not included psychiatrists or psychologists. I was hopeful when the agenda and panelists were released the day before the summit that there was at least one psychologist on the panel. But after some discussions at the end of the day it was clear he was only added last minute.
The lack of mental health provider representation was evident as a common catch phrase was repeated over and over to the point that it eventually became a joke, and brought laughter from the other panelists and audience when they would say, “I’m not a neuropsychologist but…”
I mean, think about it. If this summit was titled Navigating Heart Health in Aviation, how many cardiologists do you think would have been on the panel? And if there were no cardiologists on the panel for a heart health summit, how much validity could we really give to the proposals and recommendations of the group on how to reduce cardiovascular risk in pilots and the severity of medical events such as heart attacks to the safety of flight?
When the question was raised by one of the panelists, “What is it about depression that makes it difficult for a pilot to fly anyway?” The non-psychiatry trained physicians this question was directed at just kind of looked at each other wondering who was going to take this question.
It was eventually taken by FAA Director of Medical Divisions Dr. Penny Giovanetti, who gave a reasonable answer. But one wonders how helpful it might have been to have a clinical psychiatrist or psychologist on the panel who could have spoken to the impairment that the symptoms of a Major Depressive Disorder can cause in the cockpit. For reference, check out Flight #5 where I address The Impact of Depression on Pilots.
After my post last week about the 1% rule, it was interesting to hear the topic raised as an issue. One senior AME asked Dr. Giovanetti of the FAA why the FAA was still using the 1% rule. She noted that while European countries have used the 1% rule, the FAA has never used it. So I stand corrected from last week when I said I thought the FAA followed the international use of the 1% rule.
Instead, Dr. Giovanetti said they use a risk assessment method that considers the chance of a medical event occurring along with the severity of the event, should it occur. This is very similar to the Risk Matrix idea I mentioned at the end of my last post and so now seems like an apt time to better describe it and how it is probably a better way to assess Mental Health diagnoses than the 1% rule.
As a reminder, I have been a flight surgeon for 17 years and have spent most of my career treating and evaluating pilots and assessing their aeromedical risk. So thinking about and acting on the aviation safety of various medical conditions is something I have a lot of experience in. As I discuss it here, I’d like to note that these are my views and they do not reflect the official policy or position of the Department of Defense, The United States Air Force, or any other organization I am associated with.
With that said, let’s see if I can help you understand aeromedical safety beyond the 1% rule with something like a Risk Matrix.
As a reminder, a quick summary of the 1% rule suggests that, if there is a 1% chance that within the next year a pilot’s medical condition would lead to a catastrophic failure of a flight, the risk is too high to allow that pilot to fly.
I used seizures as an example last week because once you have one seizure the risk of having another seizure in the next year is about 36%. And obviously, if you have a seizure in the cockpit that would be a bad day. So hopefully it’s understandable that the someone who had a seizure within the last year wouldn’t be granted a medical.
A comparable mental health concern is a history of a suicide attempt. To understand the topic a little more, let’s look at some statistics. In the U.S. general population, there are about 45,000 suicides per year or about 15 per 100,000 people. A very low risk of dying by suicide at 0.02% per year.
But if you look at suicide attempts, about 1.4 million American adults attempt suicide each year, which means there are about 30 attempts for every death by suicide. Still a pretty low risk of attempting suicide at 0.6% per year.
But when you’re thinking about the aeromedical safety of someone who has already attempted suicide, you’re not concerned with just anyone’s risk of attempting suicide, but the risk of another suicide attempt in someone who has already had a failed attempt. How often do they die by suicide on a subsequent attempt? One study showed that one out of every 100 who previously attempted, will die by suicide within one year [Hawton K. Suicide and attempted suicide. In: Handbook of Affective Disorders, 2nd ed, Pankel ES (Ed), Guilford, 1992. p.635]*. The greatest risk was in those with Schizophrenia, Bipolar Disorder, or Major Depressive Disorder.
So, if one out of every 100 who attempted suicide die by suicide within the next year that means the risk of a catastrophic failure of flight due to the medical concern of suicide is about 1% and right at that limit of the 1% rule.
However, we’re not just concerned about a pilot dying from a future suicide attempt. We don’t want them to have any suicidal behavior in the future. Because even a failed attempt could be catastrophic if it occurred in the cockpit. And I would argue, even the thoughts of suicide prior to an attempt could be distracting enough to lead to a catastrophic event even if the pilot was not intending to die in the airplane.
And so we need to, not just ask about suicide deaths after a failed attempt, but suicidal behavior after a failed attempt. Remember, the risk of completing suicide within the next year after a failed attempt is about 1%. So, the risk of suicidal behavior in the next year after a failed attempt is likely greater than 1%. But how much greater?
Well remember, we know from above that there are about 30 attempts for every suicide death. And so this suggests the risk of future suicidal behavior following a previous failed attempt could be as high as 30%.
So, in a pilot who has had a failed suicide attempt, there is about a 30% risk of them attempting suicide again in the next year. This is a very similar number to the seizure example. And so, if you’re not willing to fly with someone who’s had a seizure in the last year, you probably wouldn’t want to issue a medical certificate to someone who’s attempted suicide in the last year.
So with seizures and suicide attempts having about a 30% chance of recurring in the next year, you can see how something like the 1% rule would essentially keep pilots with these medical histories from ever flying again.
But what if there was something we could do to reduce the chance from 30% and reduce the severity of the event should it recur? Reducing the chance of recurrence would be great. And while we may not be able to reduce the risk to less than 1% any reduction would be better than none.
Now the risks I discussed before are for the general population and so when you’re looking at an individual you also have to consider all of the other factors that are used to determine risk. Have they been in therapy? Are they taking an antidepressant? Have they reduced their alcohol intake? Do they have a healthy lifestyle with adequate sleep, good food choices, and regular exercise?
These are all things that should be considered following a suicide attempt. The more protective factors they have and the longer they have maintained these following a suicide attempt the more they can improve their aeromedical safety. While there may be a limited chance of regaining a medical certificate in the year following a suicide attempt, I would like to think that if a pilot really got good care and made the necessary lifestyle changes they could resume flying at some point in the future. But will they really reduce the risk to less than 1%? Probably not.
So how is it you can even consider getting your medical back after a suicide attempt?
I thought I was going to be able to use suicide as an example of how to use a risk matrix approach to aeromedical safety. But, the risk following a suicide attempt is an extreme example. And while the principles of understanding aeromedical safety in a probability and severity matrix are the same regardless of the medical issue you’re concerned about, it may be easier to explain using something like a Major Depressive Disorder. So, I’ll attempt to do that on our next flight.
If you made it this far through the newsletter or podcast, thanks for sticking with me as I try to explain some pretty technical stuff. But most of you are probably pilots, so you probably like technical stuff like this. And I hope you liked this one. If so, please like and share. And…
Keep on flyin’!
Seeking Aeromedical Guidance
The Flight Shrink newsletter and podcast is an extension of my civilian aerospace psychiatry consultation practice. 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. Other services like this on the internet 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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Until next time...
I'm Dr. Kevin Heacock, The Flight Shrink... Keep on flyin'!
* Edited 12 Dec 2023 for accurate citation.