We Have No Way to Screen Every Pilot for Mental Illness

The regular physical exams pilots go through don't seriously address the risk of mental illness.

The revelation that Germanwings Flight 9525 may have been intentionally brought down by a suicidal pilot raises the troubling question of what a man mentally ill enough to kill himself and 149 other people was doing flying an airliner.

Investigators still have many questions about just what caused the Airbus A320 to crash into a mountainside in the French Alps on Tuesday, but the the focus is squarely on pilot Adreas Lubitz. And it shows that even the most strenuous screening and training procedures cannot guarantee a mentally or emotionally troubled person does not step into the cockpit.

And it also suggests that, as rigorous as those procedures are, more could be done.

In the US, airlines subject pilots to physical examinations and background checks when they are hired, and the FAA requires annual medical certifications. But those focus on physical issues, not mental. "There's no formal psychological testing that is done routinely." says Dr. James Vanderploeg, who performs FAA examinations as part of his practice.

This is worrisome, because depression and other mental illnesses can strike at any point in life, and there is no meaningful way of screening the 50,000 or so airline pilots in the US and Canada. You simply cannot line them all up in front of a clinical psychologist each year.

The State of Testing

Depending on age, American airline pilots undergo annual or semi-annual medical exams throughout their careers. These exams, by one of 3,000 FAA-approved physicians, include a standard physical along with vision, hearing, and cardiac tests. There's a medical history form with all the standard questions about physical health---any history of heart disease, that sort of thing---and mental health inquiries about things like a history of depression, substance abuse, or suicidal thoughts.

It is up to the patient to answer the questions honestly, and although the doctor can ask questions---having problems at home? trouble sleeping?---that checklist is extent of any specific inquiry into mental health.

FAA guidelines say the doctor is not expected to perform a "formal psychiatric evaluation," but "should form a general impression of the emotional stability and mental state of the applicant." That involves gathering information through casual conversation, and noticing if the patient is, say, "odiferous," hallucinating, or delusional.

In short, pilots must self-report mental health issues---issues that could mean losing their flight certification. "They trust us to be truthful," says Sean Wood, a pilot at a regional airline he did not want revealed so he might speak frankly. "I can see why someone, where this is their livelihood, would be inclined not to mention" anything that might hurt their career.

Still, any mental health issues might be revealed during the hiring process: Many airlines, particularly large carriers like American, Delta, and Lufthansa, which owns Germanwings, subject applicants to rigorous personality tests with psychological components. Airlines conduct thorough background checks and seek reference letters. But that happens only at the beginning of a pilot's employment, and means little if problems develop later.

If a French prosecutor is correct in his assertion that the crash of Flight 9525 was brought down by a suicidal pilot, it will be just one of a handful of such cases. Still, but a depressive mood disorder carries other risks. According to the International Civil Aviation Organization, symptoms include "reduced energy, impaired concentration and memory, loss of interest in surroundings, slowed cerebration, [and] difficulty in making decisions." Things that, in the organization's dry language, make one "unsuitable to work in the aviation environment." This is not insignificant, when you realize depression afflicts more than 350 million people worldwide.

Testing's Impractical

So why doesn't the FAA require serious psychological testing along with the annual physical? Why don't airlines, rightfully terrified of litigation in the event of an accident, enforce it themselves?

Because it's impractical. There are more than 50,000 airline pilots in the US and Canada. Testing each of them annually simply is not feasible, says Dr. Diane Damos, who holds a doctorate in aviation psychology and has been working on the pilot selection process since 1970. Having a tool that would reliably root out and prevent the exceedingly rare instance in which a pilot might commit suicide by crashing a plane is "probably beyond our capabilities."

There's also the fact that this level of testing would inevitably generate false positives, Damos says. "You're gonna flag a lot of people who are normal but for some reason or other, on that day, give you a strange response." You'd have to follow each one, check up on them, monitor them, "and that's a tremendous cost and effort." Cost is a major issue for the airline industry, most of which operates on thin profit margins and already bemoans "excessive taxation."

Even if you saved on cost by administering a computerized test, you'd have to deal with the fact that with tens of thousands of pilots taking it regularly, "pretty soon everybody knows what the test is. And then the test becomes invalid."

Self-Reporting Can Work

If rigorous testing for depression and other disorders isn't workable, how do we ensure pilots are as up to the job mentally as they are physically? The answer is making self-reporting, and reporting on one's colleagues, work.

For that to be practical, it has to be non-punitive, so a pilot who is at risk for depression or depressed doesn't fear losing his livelihood if his employer or the FAA learns he is seeking help. Many airlines offer paid medical leave, but a pilot who isn't certified to fly doesn't have much of a career ahead of him.

For depression, at least, things are changing. A history of the illness was for many years grounds for automatic failure of a medical test, which made hiding it a reasonable and common choice for pilots. One survey cited by the International Civil Aviation Organization found 15 percent of pilots advised by a doctor to take anti-depressant medication intended to keep flying without informing the FAA. A study of post-mortem toxicological evaluations of more than 4,000 pilots found that of the 223 who were taking psychotropic medication, just 14 had reported their condition to the FAA. Only one had reported actually taking the medication.

But in 2010, the FAA changed its policy to allow pilots taking certain types of antidepressant drugs to return to flying---following an example Australia set in 1987. Canada has a similar program, Europe does not.

Under the American program, Vanderploeg says, a pilot would have to be stable in terms of controlling their symptoms, and on the same dosage, for at least six months. Then they would undergo psychological tests and be evaluated by a psychiatrist. The results would go to an FAA-designated medical examiner for review. Those results would be passed to an FAA psychiatrist, who would decide if the pilot can fly. If that happens, there are many follow-ups: status reports every six months, annual psychological testing, reports from the airline's chief pilot every three months. If that all goes well, they can be reissued a medical certification for the next six months. "So it's a very intensely followed process."

Of course, no amount of surveillance can eliminate the risks that come with letting pilots with histories of depression and reliance on medication take the cockpit. But the idea of making depression something a pilot can be open about, rather than need to hide---or worse, ignore---is a step in the right direction, Damos says. "That's something that needs to be reinforced." Maybe not every airline could handle all the extra work, but "that's something we can encourage. It incurs very few costs, and I think would be very beneficial."