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Fly Well

No laughing matter

"Sometimes, all I need is the air that I breathe and to love you," sang The Hollies in 1972. Nice sentiments, but wrong. You need air - not sometimes, all of the time. Many pilots scuba dive, always descending with a carefully checked tank, but many ascend without oxygen. Federal Aviation Regulation 91.211 states that a pilot of an unpressurized aircraft shall not operate from 12,500 to 14,000 feet for longer than 30 minutes without supplemental oxygen. Above 14,000 feet, oxygen has to be used by the crew, and above 15,000 feet it must be provided for everyone aboard.

Dr. Jonathan Sackier“Listen to what I say: in your life expect some trouble. /When you worry you make it double. /Don’t worry, be happy. Be happy now.” (Bobby McFerrin, Don’t Worry, Be Happy ,1998)

Depression is no laughing matter, but the news on April 5, 2010, from FAA Administrator Randy Babbitt allowing some pilots taking SSRI (selective serotonin reuptake inhibitor) drugs for this condition to obtain medical certification gives us plenty to smile about. Depression impedes activities of daily living, affects 20 million Americans, and can lead to suicide. However, major advances in medical therapy have dramatically changed the landscape.

There have been several years of intense effort and collaboration between AOPA, AOPA’s Board of Aviation Medical Advisors, and the FAA, and this development has been a long time coming. Indeed, in 2002 the Air Line Pilots Association Aeromedical Office proposed special medical issuance and in 2004 the Aerospace Medical Association recommended that the FAA allow pilots to fly when taking certain antidepressants; two years later AOPA’s recommendations were proposed. In 1987, the year the first SSRI was released, Australia’s Civil Aviation Safety Authority allowed pilots to fly while taking SSRIs, and no increase in accidents was seen in 481 pilots studied from 1993 through 2004.

The new rules state that pilots with mild to moderate depressive illness—including single or recurrent episodes, dysthymic disorder, or adjustment disorder with depressed mood—may be considered for a special issuance when all symptoms are controlled and the pilot has been on a stable dosage regimen for one year. The drugs referenced, the SSRIs, are the only class of drug allowed and only some of them—Fluoxetine (Prozac or generic), Sertraline (Zoloft or generic), Citalopram (Celexa or generic), and Escitalopram (Lexapro)—have been approved by FAA.

Another astonishing facet of this new development is the amnesty (immunity from prosecution, in FAA-speak) that runs to September 30, 2010. If a pilot has not declared that he or she takes an SSRI when applying for medical certification, coming clean absolves them from prosecution. This only applies to depression and the four medications noted above.

What is an SSRI? The brain consists of a bunch (medical-speak for “lots and lots”) of cells that communicate by releasing chemicals stimulating the cell next door to get off its lazy behind and send a message to the next chap down the line, and so on. Because doctors like big words, we call them neurotransmitters, and one of the chemicals is called serotonin (one of the “Ss” in SSRI). There are “reuptake mechanisms,” systems to devour these chemicals, preventing brain commotion (there is always a commotion in my brain, or maybe that is my children’s fault). The SSRIs prevent reuptake; where there is too little serotonin, SSRIs make what is there count. Depressive illness is not simply a matter of “pull yourself together, man!” This is a real disease with a solid scientific basis.

There is a big difference between the depressive conditions and “feeling depressed.” Everyone has a time in their life when things get you down—a bad relationship, foul weather preventing a flight, your team lost the big game, or too many taxes. Heck, that last one applies to all of us. Such worries delay sleep or make us reach for the double chocolate chip cookie dough extra mocha ice cream. This is a very different presentation than true depression, which tends to cause early morning waking and hunger suppression.

If you talk to your doctor about feeling low, his or hertemptation to reach for the prescription pad could lead to suspension of flight privileges—ascertain whether you have true clinical depression or are just sad. A pal of mine, a lifelong hypochondriac, used to eat M&Ms one by one with his glass of milk when he was a little boy—in other words, if you need to be taking SSRIs, fine; but if you just have some personal stuff to deal with, stick to the chocolate and Bobby McFerrin’s music. But please see a doctor. If there are issues in life affecting your mood, self-certify yourself out of the cockpit until you can put on your happy face again.

The process to obtain certification is laid out on AOPA Online, but basically the parameters laid out above are applied under the auspices of the treating psychiatrist and aviation medical examiner, and a program called the Human Intervention and Motivation Study (HIMS), which was established 40 years ago to evaluate pilots with such conditions. The AOPA medical certification department stands ready to assist pilots with this and all other issues that affect our ability to fly.

The stigma of depression has caused social isolation for too long, just as in biblical times leprosy, an infectious disease, was a sign that one had incurred the Lord’s displeasure. How silly it would be if we disparaged someone for getting the flu—that is how daft it is to be critical of a patient with depression. Our pilot brothers and sisters with this disease can now soar with the rest of us and attain real heights, as well as the emotional heights medical therapy makes possible.

E-mail the author at [email protected].

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