Antidepressants in aviation

aviationmedicine
Antidepressants in Aviation
Australian researchers found that pilots who took
prescribed antidepressants were no more likely
than others to be involved in accidents and incidents.
use of antidepressant medications by crew or air traffic controllers while using antide- pilots and air traffic controllers does not pressants, provided specific criteria are met and maintained,” the report on the study said.
The criteria include having the pilot or 10 years of aviation safety data from Australia, controller interrupt flight or control duties while where aeromedical authorities have allowed the being introduced to the antidepressant medica- supervised use of antidepressants since 1987.
tion and ensuring that the pilot or controller The study, published in Aviation, Space, experiences only minimal side effects that do and Environmental Medicine, the journal of not interfere with flight or control duties, the the Aerospace Medical Association (AsMA), reviewed the cases of 962 pilots and controllers, The Civil Aviation Safety Authority of Aus- half of whom were treated with prescribed an- tralia (CASA) includes these criteria in assessing tidepressants and half of whom were not. There pilots and controllers — including those who was no statistical difference between the number participated in the study — along with other of accidents and incidents involving members of criteria requiring them to be under the care of the two groups.1 a medical practitioner with experience treat- “This study found no evidence of adverse ing depression; to be “stable on an established safety outcomes arising from permitting indi- and appropriate dose of medication for at least viduals to operate as commercial or private air four weeks” before resuming flight or control flight safety foundation | AeroSAfetyWorld | february 2008
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duties; and to have minimal side effects, no drug The Australian study included pilots and interactions and no allergies to the antidepres- controllers taking all types of antidepressants and found no difference in accident or incident history based on the type of antidepressant.
taking antidepressants to undergo a clinical Data indicated that a slightly higher num- review at least once a month and to submit a ber of accidents and incidents occurred among progress report to CASA every six months for pilots and controllers immediately before the at least the first year of treatment. In addition, start of antidepressant medication. Although CASA requires an absence of other significant the increase was considered statistical y insig- psychiatric problems and no use of other psy- nificant, the report said that “the data raise the choactive medications, along with control of all possibility that the earlier use of antidepressants symptoms of depression; an absence of suicidal might actual y improve safety in a group who Antidepressants in Aviation
thoughts and “features of arousal,” such as ir- subsequently go on to use them. If so, early ritability or rage; and the presence of a normal identification and treatment of this group may improve aviation safety while allowing contin- CASA’s decision to allow pilots and control- lers taking antidepressants to participate in The report added, “If there is an excess of aviation operations came soon after the intro- accidents in aircrew who would benefit from duction of a class of antidepressants called selec- antidepressants but were not [using] them at tive serotonin reuptake inhibitors (SSRIs), which the time of the accident, this might provide an had fewer and milder side effects than older argument for wider use of antidepressants than antidepressant medications such as monoamine is currently the case in Australia, and has pro- oxidase inhibitors (MAOIs) and tricyclics.2 found implications in those jurisdictions where The side effects associated with SSRIs and antidepressant use is prohibited [by] certificate a related class of antidepressants known as serotonin-norepinephrine reuptake inhibitors (SNRIs) — most common during the first days Common Condition
or weeks of use — are individualized, but they Depression within the general population is include decreased appetite, nausea, diarrhea, relatively common. The United Nations World nervousness, insomnia, headache and sexual Health Organization (WHO) estimates that dysfunction. Tricyclics may have side effects it affects 121 million people worldwide; other that include sedation, decreased blood pres- estimates have been considerably higher.5 Symp- sure, increased heart rate, dry mouth, blurred toms include a depressed mood, loss of interest vision, constipation, difficulty urinating or pleasure, feelings of guilt or low self-worth, and confusion. MAOIs — which usual y are disturbed sleep, poor appetite, lack of energy prescribed in cases in which other classes of and poor concentration — problems that WHO antidepressants have not helped — can cause says can lead to “substantial impairments in a dramatic increase in blood pressure if they an individual’s ability to take care of his or her are taken in combination with cold and cough everyday responsibilities.” Depression also can remedies that contain phenylpropanolamine lead to suicide, which claims about 850,000 lives CASA guidelines today specify that the au- thority may “on a case-by-case basis” certificate people with depression can be effectively treated applicants who are prescribed (and are taking) with antidepressant medications and “brief, SSRIs sertraline (brand name Zoloft) and cit- alopram (brand name Celexa), and venlafaxine The Australian study estimated that about (brand name Effexor) — a type of SNRI.4 4.5 percent of the adult population uses WWW.flightsafety.org | AeroSAfetyWorld | february 2008
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antidepressant medications, but only about 1 medication has been “well established and the percent of “aviation certificate holders” could depression has been ful y treated,” Evans said.
be identified as having taken antidepressants If the proposal is adopted, considerable time while certificated. The study said that the lower may be required to establish procedures for “There is a groundswell
rate among pilots and air traffic control ers “may reflect under-reporting of antidepressant “It is considered that it is safer to know that use rather than different levels of medication pilots are being treated for depression and being of opinion that supports
among pilots and air traffic controllers.” monitored rather than have pilots fly whilst de- CASA’s requirements differ from those of pressed (not on medication) or fly whilst taking the carefully controlled
most other civil aviation authorities, including undisclosed treatment,” Evans said.
those in the United States and Europe, which do use of antidepressants.”
not currently allow aeromedical certification of Canadian Study
Civil aviation authorities in a few countries In the United States, the Federal Aviation in addition to Australia already have taken Administration (FAA) policy is that “the medi- steps to allow some pilots to fly while taking cal condition of depression is disqualifying, as well as every medication that is used for the In Canada, for example, a long-term study condition,” Dr. Warren S. Silberman, manager is being conducted involving several pilots tak- of the FAA Civil Aerospace Medical Institute ing specific types of antidepressants to evaluate Aerospace Medical Certification Division, wrote their performance while using the medications, in a 2005 Federal Air Surgeon’s Medical Bul etin.6 and authorities are continuing to review related He added, however, that an FAA panel has been medical literature, a Transport Canada (TC) studying “the feasibility of granting medical cer- spokeswoman said. Each of the pilots is permit- tification to individuals that have been stable on ted to fly only as part of a two-member crew. SSRIs for the treatment of depression,” provided The study began in the mid-1990s, and in the depression has not been accompanied by 2001, Dr. Hugh O’Neil , then the TC director of civil aviation medicine, said that TC was “pro- The FAA allows pilots who have been treated ceeding very, very cautiously” with the study with antidepressants to receive medical certifi- while “looking for some consensus of opinion cation if they have had no significant symptoms of depression for at least 90 days after stopping TC’s Handbook for Civil Aviation Medical the medication. They also must be evaluated by Examiners describes requirements similar to a psychiatrist and a psychologist before issuance those outlined by CASA: Applicants for aero- of a medical certificate, and reports must be medical certification “who have been treated for a depressive illness and who are on main- In Europe, the Joint Aviation Authorities tenance or prophylactic therapy with … SSRIs medical committee has agreed to a proposal may be considered for medical certification on that — if it receives final approval — eventu- an individual basis after review by the CAM [the al y would allow commercial pilots taking “a TC Civil Aviation Medicine Division] Aviation few specific antidepressants” to continue flying, said Dr. Sal y Evans, chief medical officer of the U.K. Civil Aviation Authority and head of the Changing Opinions
European Aviation Safety Agency Flight Crew Worldwide, the opinions of some aeromedical Licensing Medical Core Group. The proposal would limit acceptable medications to a few “There is a groundswell of opinion that sup- SSRIs, require close monitoring of the pilots ports the careful y controlled use of antidepres- and allow medical certification only after the sants, this being better than having a policy that flight safety foundation | AeroSAfetyWorld | february 2008
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grounds pilots when they take any antidepres- groups to manage depressed aviators who require sant medication,” said Dr. Anthony Evans, chief SSRI antidepressants. Protocols designed to ag- of the Aviation Medicine Section at the Interna- gressively manage the ful spectrum of adverse tional Civil Aviation Organization (ICAO) and possibilities related to SSRI use may enable the no relation to the U.K. CAA’s Dr. Sal y Evans. safe use of SSRIs in formerly depressed aviators “The latter policy results in pilots flying when who suffer no aeromedical y significant side ef- depressed and untreated, or failing to declare fects. In these closely managed cases of depressive their depression/treatment to an AME [aviation disorders, special issuances or waivers for SSRI medical examiner] and potential y taking anti- depressants that have unacceptable side effects from the flying viewpoint.” Despite the increasing tendency of special- 1. Ross, James; Griffiths, Kathleen; Dear, Keith; ists to believe that some use of antidepressant Emonson, David; Lambeth, Len. “Antidepressant Use medications by pilots would be acceptable, and Safety in Civil Aviation: A Case-Control Study debate continues about precisely what medica- of 10 Years of Australian Data.” Aviation, Space, and tions are acceptable and what problems should Environmental Medicine Volume 78 (August 2007): be treated by these medications, which some- times are administered for conditions other 2. MAOIs include phenelzine (brand name Nardil) than depression; how long pilots might be and tranylcypromine (brand name Parnate). required to stop flying before and after they be- Tricyclics include amitriptyline (brand name Elavil), desipramine (brand name Norpramin), gin using the medications; and how these cases imipramine (brand name Tofranil) and nortrip- should be monitored. “In other words,” Evans said, “the logistics of introducing such medica-tion into the aviation system without compro- mising safety is not yet ful y harmonized.” ICAO has begun changing its standards and recommended practices to enable the use of an- ICAO has begun changing
tidepressants by pilots and air traffic controllers if the national licensing authority determines 5. United Nations World Health Organization. that the medications present no significant risk Depression. <www.who.int/mental_health/manage- its standards and
In a 2006 preliminary, unedited version of 6. Silberman, Warren S. “Certification Update: SSRI recommended practices
its Manual of Civil Aviation Medicine, ICAO Policy Reminder.” Federal Air Surgeon’s Medical said, “In recent years, the use of SSRI … has Bulletin Volume 43 (2005–2).
to enable the use of
become widespread, and there is indication that such treatment, aimed at preventing a new 8. Transport Canada. Handbook for Civil Aviation depressive episode, may be compatible with antidepressants.
flying duties in careful y selected and moni-tored cases.”9 9. The 1985 version of the manual had said that pilots AsMA has called for an end to “current typical y should not fly while taking antidepressant medication and “ordinarily … should not be allowed absolute prohibitions against pilots flying while to return to flying unless they have been off medica- taking SSRIs and adoption of aeromedical pro- tocols that include careful y controlled follow-up and review.”10 10. Jones, D.R.; Ireland, R.R. “Aeromedical Regulation of Aviators Using Selective Serotonin Reuptake In 2004, AsMA recommended that “all certifi- Inhibitors for Depressive Disorders.” Aviation, Space, catory and regulatory authorities … consider and Environmental Medicine Volume 75 (May 2004): immediately instituting a policy of using study WWW.flightsafety.org | AeroSAfetyWorld | february 2008

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