James is a tall, well -built, sporty looking man in his early 40’s, showing up for his first appointment after a few calls and cancellations. We have a technical name for that pattern of behavior: we call it “resistance“. The prospective patient knows at some level he is in need for treatment but he is afraid of the “change” that undertaking such action might entail.
James, on first approach, though, does not seem hesitant, he tells me right away what he does for a living: he is a major commercial airline pilot and his flight schedule is irregular and subject at times to unpredictable changes. This appears to be a realistic problem, but there is more: for a pilot to see a psychiatrist might put his career at risk. James has been suffering from the cardinal symptoms of depression: sadness, no zest
For life, negative vision of the future, a persistent sense of gloom and doom that accompanies him everywhere he goes. He is not as talkative at home, his wife feels he has become distant, he knows he loves her and their young daughter but cannot express that feeling the way he once could. James has lost his mother after a long battle with cancer four months ago. He did not have time to mourn, after the funeral, he had to leave, go back on his flight schedule. Initially work seemed like a needed distraction, he was grateful he could afford not to think much about his personal life till this tiredness, heaviness started. It could be depression, he thought, he had read about it, but was he allowed to admit it without consequences for his dream career?
James was right: there are restrictions for pilots as far as the psychiatric diagnoses and treatments that are allowed for a pilot to continue to fly. “The Federal Aviation Administration (FAA) strictly regulates a pilot’s physical and mental status to protect the safety of the pilot and their passengers.”
These restrictions may reflect some deep societal prejudices about mental illness and may unfortunately convince some pilots that it’s better to hide their symptoms rather than risk their jobs to get treatment. Here an important distinction needs to be made: while” Major depression”, “Dysthymic disorder”, “Adjustment disorder with depressed mood “( all the varieties of what we commonly know as depression) do not prevent a pilot from flying, the existence of psychosis and suicidal ideation certainly do.
On April 24 th this year a change in the FAA regulation made the news: “FAA renames the “SSRI Protocol” called now “The Antidepressants protocol expansion“ & approves 3 New Antidepressants”.
Until that date only 4 antidepressants were allowed to be used for treatment of depression in a pilot: Prozac (fluoxetine), Zoloft (Sertraline), Celexa (Citalopram), Lexapro (escitalopram), all antidepressants active on the serotonin channel. With the current expansion now Wellbutrin (bupropion), that uses the dopamine / norepinephrine channel and Effexor (venlafaxine), Pristiq (desvenlafaxine) and Cymbalta (Duloxetine) that activate both serotonin and norepinephrine, can be added.
This new protocol highlights the importance of treating depression swiftly and openly for all categories of professionals that have direct responsibility towards others, including physicians, policemen, judges, where failure to do so could put the public at a higher risk.
