The FAA’s plan to allow pilots to continue flying while taking antidepressant medication has finally generated a decent amount of public comment. As of early last month, there was only one comment from an individual in the rules docket, along with 10 other pieces of information such as the rule change itself and supporting materials. The FAA extended the comment period from May 5 to June 25 at the request of the Air Line Pilots Association International, and as this issue went to press, the total number of comments had reached 56. Comments range from support of the new policy to condemnation, and both viewpoints were expressed by medical professionals.

According to comments by Randy Helling, ALPA vice president of finance/treasurer, at a May 4 board meeting, ALPA aeromedical office doctor Quay Snyder submitted questions to the FAA about how the agency plans to implement the new policy. Because the FAA did not answer ALPA’s questions, the association asked the FAA for the 45-day extension so it could answer Quay’s questions before ALPA submits its comments.

The first public comment, from Meredith Birk of Los Angeles, expressed concern about the new policy. Birk’s comment noted, “These drugs all have a ‘Boxed Warning’ by the FDA that includes the possibilities of ‘suicide, aggressive behavior and acting without thinking.’ This may not occur in every case. However, this occurs frequently enough to have the FDA put this high-level warning on the drugs. This should not be downplayed. It is real. The FDA is reluctant to issue such warnings and does so only when it is absolutely necessary.”

Birk included in her comment a quote from the National Institutes of Health Web site: “You should know that your mental health may change in unexpected ways when you take fluoxetine or other antidepressants even if you are an adult over 24 years of age. You may become suicidal, especially at the beginning of your treatment and any time that your dose is increased or decreased. You, your family or your caregiver should call your doctor right away if you experience any of the following symptoms: new or worsening depression; thinking about harming or killing yourself, or planning or trying to do so; extreme worry; agitation; panic attacks; difficulty falling asleep or staying asleep; aggressive behavior; irritability; acting without thinking; severe restlessness; and frenzied abnormal excitement. Be sure that your family or caregiver knows which symptoms may be serious so they can call the doctor if you are unable to seek treatment on your own.”

In reviewing the NTSB accident reports that include the word antidepressant, two key pieces of information emerge. One is that of the 137 records found from 1991 through the present, only four were nonfatal. The second is that in many of the accidents, toxicology on deceased pilots found evidence of antidepressant usage, yet the pilots rarely reported such usage to their FAA medical examiners. Clearly, pilots are aware of the prohibition against the use of antidepressants and are not sharing that information. The new FAA policy is designed to bring that behavior out into the open so that at least pilots who need antidepressants or are using them already will have a process by which they can be monitored and treated. This is a similar approach to that taken by the FAA regarding treatment of alcohol-dependent pilots.

Antidepressant Accident History

What is interesting about the accidents where antidepressants were found in pilots’ bodies is the preponderance of elementary errors involved. Perhaps this suggests that pilots who use antidepressants without telling their medical examiners are willing to take greater risks when flying. Such a conclusion would require further rigorous analysis, but looking at some of the accidents is telling.

On Feb. 1, 2008, a Beech King Air crashed after the pilot descended below the minimum descent altitude and tried to circle below published minimums, killing all six occupants. The NTSB report noted, “Review of the cockpit voice recorder (CVR) audio revealed that the pilot had displayed some non-professional behavior before initiating the approach.” The “non-professional” behavior, apart from busting minimums, included the pilot singing to the passengers, “Save my life I’m going down for the last time.” This continued for a minute, when the pilot began a commentary to the passengers, stating, “If anybody back there believes in the good Lord, I believe now would be a good time to hit your knees.”

Most of the accidents occurred in light airplanes, two in Piper PA-46 Malibus modified with a turboprop upgrade, some in Beech Bonanza A36s, Cessnas, Pipers, Grummans and lots of homebuilts.

In a King Air 200 accident in Leominster, Mass., on April 4, 2003, six people were killed, including the pilot, and two survived. One of the passengers who survived told the NTSB that “she had flown with him before and knew he ‘liked to make sharp turns.’” According to the NTSB, “While on approach to the airport, the airplane entered a left turn, which the surviving passenger described as ‘almost completely upside down.’ The airplane briefly leveled, then entered another left turn with a bank angle of the same severity. The airplane seemed to roll level, then entered a steep dive, until it [hit] a building.” The pilot’s blood and urine contained imipramine and carbamazepine.

“According to the pilot’s medical and pharmacy records, he suffered from a severe neurological disorder, possibly a seizure disorder, that resulted in frequent, unpredictable episodes of debilitating pain. The pilot had been prescribed imipramine, an antidepressant that has detrimental effects on driving skills and other cognitive functions. He had also been prescribed carbamazepine, typically used to control seizures or treat certain chronically painful conditions.”

The pilot and passenger of a Rockwell 690B turboprop were killed after the airplane broke up in flight near Homerville, Ga., on March 27, 2003. Toxicology tests found the antidepressant paroxetine in the pilot’s blood, urine and liver. The NTSB doesn’t single out the drug as causal in the accident, which was blamed on “An in-flight encounter with unforecast severe turbulence in cruise flight, resulting in the design limits of the airplane being exceeded due to an overload failure of the airframe, and collision with a swampy area.”

In yet another case of a pilot not reporting antidepressant use, the pilot of a Grumman G164B cropduster was killed when the airplane ran into a 500-foot t-tower near Lydia, La. Besides evidence that the pilot had been taking the antidepressant Prozac, his blood also contained cocaine.

Both pilots of a DC-3 were killed after a night takeoff in Unalaska, Alaska, on Oct. 24, 2002. The DC-3 crashed into the slopes of a volcano 4.5 miles from the airport. The captain, previously convicted of distributing cocaine, was found to have cocaine in his blood. The first officer had previously suffered an episode of loss of consciousness but was able to obtain a second-class medical certificate after an appeal to the NTSB. Her toxicological tests revealed the presence of two prescription antidepressant drugs.

Jan. 8, 1997: six people were killed when a Cessna 421C crashed after flying into instrument conditions near Cleveland, Okla. The pilot received an unsatisfactory assessment after simulator training for the 421, with the instructor noting that “the pilot’s instrument scan was ‘extremely slow and insufficient to the extent that under IMC conditions he could not maintain altitude within 1,300 feet or heading within 40 degrees when given even the simplest of tasks.’” A number of drugs were found during toxicological testing, including the antidepressants Valium and Tofranil.

Nov. 17, 1996: a non-instrument-rated pilot flying an Aerostar 601P died along with four passengers after crashing shortly after takeoff from Eagle, Colo. The probable cause of the crash included the pilot’s use of contraindicated drugs. According to the NTSB, “A psychiatrist had recently treated the pilot for depression, attention deficit and bipolar disorders. The pilot also had a history of alcohol and drug abuse. Postmortem toxicology protocol disclosed the presence of fluoxetine (an antidepressant), norfluoxetine (its metabolite) and hydrocodone (the most commonly prescribed opiate).”

One of the comments submitted to the FAA was an Australian study of 10 years of data published in the journal Aviation, Space and Environmental Medicine in 2007.
“This study found no evidence of adverse safety outcomes arising from permitting individuals to operate as commercial or private aircrew or air traffic controllers while using antidepressants provided specific criteria are met and maintained. The study pointed out that policies prohibiting the use of antidepressants by pilots may cause pilots to:
• fail to disclose their use of antidepressants to regulatory authorities and continue to engage in aviation activity with symptoms that are incompatible with aviation safety.
• refuse to use antidepressants while continuing to operate in the aviation environment, with adverse effects on their health and on aviation safety.

In addition, according to the study, such policies might force pilots to leave the industry, with adverse consequences to the industry and the pilot’s financial security.

Australia has permitted aircrew to use certain antidepressants–selective serotonin reuptake inhibitors (SSRIs)–since 1989.

The Aircraft Owners and Pilots Association sent a letter to the FAA in 2006 and submitted to the recent policy change docket a suggested protocol for the FAA to use for special issuance (third-class) medical certification of pilots using antidepressants. “By granting our request to approve the use of SSRIs for special issuance, the FAA would encourage pilots on SSRIs to fully disclose their condition and would give a level of assurance that pilots who fly while taking SSRIs have had their condition evaluated and are determined not to pose a threat to aviation safety,” the letter concluded.