What psychological evaluations has your airline put in place ?

[buzzc152]

Following the German Wings incident and EASAs recommendation that we undergo regular psychological evaluations, I'm curious to know what process airlines have put in place (if any) ? Does you airline do anything ? Is it left to your AME to assess you ?

Regards

[Zaphod Beblebrox]

I just read a little spiel that stated that the FAA had reviewed the data and has determined that airline pilot psychological testing would not be required.

FAA: No psychological testing needed of airline pilots | Fox News (http://www.foxnews.com/health/2016/06/10/faa-no-psychological-testing-needed-airline-pilots.html)

It's from FOX news so you know it must be good stuff.

[buzzc152]

As an AME, has anything changed in the aftermath of the German Wings incident. What obligations do you have to assess mental health of your patients and how do you go about it ?
And generally, what legal obligations do you have in reporting concerns with a patient ?
Many thanks

[Fantome]

The Australian Civil Aviation Safety Authority's aviation medicine section has not published any relevant guidelines for DAME's since the issue by BEA of the report into the GermanWings suicide.

Their website has this general information -

Depression and aviation safety fact sheet
While we all feel sad, moody or low from time to time, some people experience these feelings intensely, for long periods of time (weeks, months or even years) and sometimes without any apparent reason. Depression is more than just a low mood - it's a serious illness that has an impact on both physical and mental health.

Research suggests that continuing difficulties - long-term unemployment, living in an abusive or uncaring relationship, long-term isolation or loneliness, prolonged exposure to stress at work - are more likely to cause depression than recent life stresses. However, recent events (such as losing a job) or a combination of events can ‘trigger' depression in people who are already at risk because of past bad experiences or personal factors

Depression affects how people feel about themselves. They may lose interest in work, hobbies and doing things they normally enjoy. They may lack energy, have difficulty sleeping or sleep more than usual. Some people feel irritable and some find it hard to concentrate. Depression makes life more difficult to manage from day to day.

On average, one in six people - one in five women and one in eight men - will experience depression at some stage of their lives. There are different types of depression. Symptoms can range from minor (but still disabling) through to very severe.

The full extract is here-

http://services.casa.gov.au/avmed/pilots/faq_facts_case/facts/depression.asp


There ware 3468 posts here , some of which go into some of the questions for which you are seeking answers.
(If you are a medico and concerned there is quite a lot of information on the subject if you have the time to search the internet.)

http://www.pprune.org/rumours-news/558654-airbus-a320-crashed-southern-france.html

[pug]

I think it would be prudent for people to distinguish the difference between mild depression/anxiety, Bi-polar and psychosis (personality disorder etc)..

It is quite clear that in the case of Germanwings, the pilot concerned was on an anti psychotic medication that was either undisclosed to the relevant authority, or had managed to pass through the net.

I've found that Anxiety and depression is completely different - both in terms of severity and manageability - to that of someone with 'manic depression' or a borderline personality disorder or psychosis. The latter three, I understand, tend to be incurable (and therefore, understandably disqualifying).

I'm hoping the authorities aren't going to go into this with a wide brush stroke. Particularly when the more minor cases of depression and anxiety are highly treatable, often with CBT, removal of causal factors, and (allowed, according to the CAA flowchart) SSRI treatment. To focus too much on that aspect would detract from the more concerning mental illnesses, and create a high risk of current pilots not reporting such. I would suspect that most people who have been through a period of depression had no intention to self harm.. Most likely just wanted to get better. And those that have, and/or have been hospitalised, should be under further evaluation than those who have had a brush with it and recovered (provided this is backed up by doctors reports).

Edit; want to make it clear Im not a doctor or have any involvement in medicine, nor do I have any background of clinical psychology. Merely experiences the process myself.

[Cazalet33]

What psychological testing does Faux News give its employees and applicants?

How gently does the HR Dept break the bad news to those who are found not to be barking mad?

[vapilot2004]

Several US pilots' unions have expanded existing peer networks that were originally designed to foster fellow members helping one another through tough emotional times like divorce or recent disease diagnosis.

The common belief among US regulators is mental health checkups are not effective in preventing what happened to GermanWings.

[abgd]

In the unfortunate event of last year the issue was known but wrongly dealt with.

Perhaps it was poorly dealt with, but it was also 'correctly' dealt with. How should the issue have been handled differently, in your view?

[ShyTorque]

What psychological evaluations has your airline put in place ?

Dunno, but we all know the boss is nuts!

[Jwscud]

On joining my new airline, they required a form signed by my GP detailing significant medical history and a statement from them that I didn't have any conditions likely to affect my safe operation as an airline pilot.

[Jodelophile]

I think Lubitz probably had a narcissistic / psychopathic personality disorder and any depression was secondary but we may never know because of the extreme German medical confidentiality laws. People with 'straight forward' depression may commit suicide but would not kill 149 other people. There could be similarities with the mass shooters in the USA.

[Superpilot]

What qualifies the average GP to determine such such a thing?

[MrSnuggles]

Jodelophile,

you should not try to distance-diagnose someone over the Internet. It is also not true that people who commit suicide would "never" kill other people in the process. There are so many ways depression (which we know he had) and psychosis (which we also know he suffered from) can combine to form all kinds of evil, this combination Lubitz had just was the worst.

Just as a thought experiment, humour me on this one:

Imagine you suffer from depression. Depression is nothing like "yeah, I feel a bit low today" or "I am sad that my grandmother died". Depression is a state where you feel (note: ONLY feelings!) that whatever you do, however you do it, you are still worthless, you are unusable, a burden to society. It is a prolonged feeling of helplessness, uselessness and sometimes fatigue. You might not even manage to boil some water for your tea because if you would have to, then you would need to go to the cupboard, you would need to open it, you would need to pick out a pot, you would have to reach for the tap, you would have to start water flowing, you would have to put the pot under the flowing water.... do you understand how many different moves you need to do in order to get your tea? And in the end, what is the use anyway, because you are still worthless with or without tea.

The above is roughly what many depressed people experience. Some people manage to work for a while, when clinically depressed but it will only last for so long until they need sick leave.

If you combine this with a psychotic episode you get all kinds of weird things. Psychotic episodes are not necessarily evil, but the perception of what we usually call "the normal world" is distorted. Psychotic episodes can include paranoia (they are after me! they want to take me!) or hallucinations (as someone described, it was similar to an LSD trip) or a feeling that something is crawling under the skin (this condition has a name: I don't remember it but it is common in meth addicts too).

SPECULATION derived from other textbook cases:

In Lubitz case it seems like his depression made him too distraught to keep up with his job, which then led him in a downward spiral where he started worrying about his financial situation which increased stress, which reduced his ability to perform, which he took as a proof of his worthlessness and down the spiral he must have gone.
Being stressed out about his feelings of uselessness, he developed stress-psychotic eye problems which again he felt even more unusable about.

The reason why he ever took the planeload of people to join him, can never be understood unless someone in a similar situation was apprehended and prohibited from doing something like that. Maybe that person might shed some light on the thought process. It may be something along the lines that he thought he could spare all those people the pain of living. This is actually more common than you think. Murder-suicides within families are mostly committed by people who reason like this. Parents who kill their (small) kids also tell this story in the courtroom. Lubitz might have projected this reasoning on the entire passenger cabin.

I hope you do not interpret my post as a defence for Lubitz. I am just saying that noone needs to be a narcissist or psychopath (sp?) for this to happen. It can be explained by the two facts about his state of mind that we already know.

Sorry for the rant. Mental health and misconceptions of that is a pet peeve of mine.

[pug]

Mrsnuggles raises some good points, however I must contest the definition of 'Depression'.

Depression is low mood, in essence. May I suggest that how depression manifests is different in each affected person? Some may just find it difficult to get out of bed in a morning, others may lose interest in things they usually enjoy. Some may become socially reclusive. All of these can be combatted by effective CBT and SSRI treatment, I would go so far as to argue that once someone has suffered from this, the coping strategies they learn may put them in a far better position to deal with stressful situations in the future. Of course, chronic conditions are different, and their management will be different too.

I would be interested to find any statistics that may have been collated into how many patients being treated for depression have symptoms manifesting into psychotic episodes. I would suggest that they are (fortunately) reasonably remote in the bigger picture, and therefore the chances of such a person being at the controls of an aircraft are slim..?

Personality disorders are different. I tend to believe that those with a personality disorder will typically not believe they have a personality disorder (and be able to convince medical professionals of this too). This could therefore affect a far wider group of people than those with a history of depression/anxiety. I believe that most people receiving a form of treatment for depression or anxiety have never had thoughts of harming themselves or others.

I suppose, in relation to the Germanwings incident, was a personality disorder directly related to the depression? I fully believe, that in cases such as this, everybody is different. Assessment should be focused on the individual in my opinion. That said, I don't believe anybody who is taking a course of anti psychotics should be at the controls of an aircraft. SSRI's are completely different.

[MrSnuggles]

pug

Of course you are welcome to question my writings! I just made a little thought experiment. The thought experiment was compiled by some reading of books on the subject as well as conversations with affected people. As you correctly point out, the details vary but the feelings of hopelessness, uselessness and being very unimportant and... hmmm... (Swede here, trying to find English words)... a total waste of oxygen are surprisingly similar.

However! I am not an AME and therefore I will Shut! The! Eff! Up! now. :-)

Please PM for further communication! :-)

[pug]

I am not involved in the medical sector in any way, but I'm basing my judgements in personal experience (which I would argue varies greatly in each individual).

I suppose my argument is that mental health covers such a broad spectrum that it is simply not possible to lump everyone into the same bracket. There is a lot of (understandable) ignorance surrounding the subject. I feel many even in the medical sector may get flustered hen faced with the subject.

My caution is for people to not lump everyone who has suffered a form of mental illness into the same bracket, or judge them as a lesser individual. I think most are capable of rational thought, and seek help at the earliest opportunity. The important point is that everybody is at risk of going through a depressive episode at some point in their life, even pilots! I do believe that in many cases it is a result of modern life. Any decisions being made on the back of this sad incident should not neglect the importance of pilots feeling that they can report such illness without fear of being typecast/losing their medical privilidges in the long run.

[Zaphod Beblebrox]

Psychological pre-hire screening is done at most all major US carriers. These are generally pencil and paper tests. Some are quite involved like the MMPI, Minnesota Multi-Phasic Inventory. I think this test has over 1000 questions or statements with which the candidate is supposed to answer as agree or disagree. Delta used to have an interview with a psychologist.

I don't think any US carrier has testing after hiring. ALPA does have several programs for intervention in stressful situations. HIMS, is a well known peer operated intervention program for substance abuse. American has project Wingman where volunteers offer assistance in getting support for problems with kids, divorce, substance abuse, and other situations.

Overall the FAA and the Companies have been supportive of these programs as they offer good professional counseling and support but are administered and run by Pilot Unions. Pilots are more prone to trust their peers and a peer run support network rather than the company or the FAA.

[vapilot2004]

I understand psychological screening tests are primarily used by major US carriers as a way to weed out non-team players.

[Zaphod Beblebrox]

That is probably correct. The test screens out whack-job's and also allows the company to supposedly find the team players.

[Jwscud]

I imagine the GP letter was based on a rather rough and ready response to the fact that had anyone asked Lubitz for such a letter he might have been caught.

[Denti]

Why would he? His mental problems were well documented and part of his medical special approval. The real problems only started after he was already on the job and didn't disclose the resurfacing problems, as he should have done. Any pre-employment letter from his GP wouldn't have prevented anything.

And of course he passed (twice) a rather comprehensive psychological screening during his cadet selection and after he came back from his time out to deal with his depression. Didn't help at all, and it isn't designed to do it anyway, it is just there to see if he conforms to a certain psychological profile and fits into the pilo team of Lufty.

[abgd]

What qualifies the average GP to determine such such a thing?


Equally to the point, what do your employers do when your sensible GP states that this is not NHS work that they're obliged to do it, they're not qualified to do it, and consider it to be highly medicolegally risky and don't want to take it on as private work?

I'm not an AME but I was under the impression that for a class 1 medical your AME would request for your GP to send a summary anyway.

[Jodelophile]

Dear Mr Snuggles, The extreme German medical confidentiality laws mean that even after death we cannot see what the many medics he saw, recorded about their consultations and diagnosis. Before the disaster they were afraid to contact the authorities to stop him flying in case they were sued. We have therefore no significant detail about his mental state in the period leading up to Lubitz's actions.
The vast majority of people with depression would not harm others, except by causing psychological distress to friends and family by their suicide.
There is no clear evidence that Lubitz was psychotic as we cannot see his medical records. He did have anxieties about his eye sight which was probably more of a psychosomatic or hypochondriacal nature rather than being psychotic.
Due to German extreme secrecy we are losing an opportunity to understand what went on in Lubitz's mind in the weeks leading up to the crash. The Germans need to reform their confidentiality laws both so that we can understand this disaster and hopefully identify any future Lubitz.

[Radgirl]

Why do you think we can learn from Lubitz's medical notes?

Either he was bipolar (depressed) and the severity of the disorder increased to the extent that he was prepared to kill others as he committed suicide, or his bipolar disease resulted in a psychotic state.

I doubt if anyone would allow a pilot a medical with evidence of psychosis so the question is simply how do we allow for the fact that some patients with bipolar disease deteriorate, and deteriorate rapidly, without taking medicals off every pilot who is a tad depressed.

I have read lots of third hand reports about his previous problems but the fact remains that he was given a medical so at that moment in time he was considered 'safe'

A number of my colleagues have committed suicide. As doctors we dont really have the capability to take others with us but it does demonstrate that aviation is not the only profession with this problem although on the very rare occasions when pilots do become unsafe they do have the capability to cause much more harm to others.

[Jodelophile]

If we had full access to his notes we may begin to understand how he got into the state where he killed 149 others, this may help us to identify and prevent a future similar incident. You suggest he was bipolar in a depressed phase, but we do not know because the Germans will not release his notes. I think there was a degree of personality disorder but unless we can see the notes we won't know, neither do we know if he became psychotic. He had a sick note for the day of the crash, and maybe whoever gave him that note should have made sure he didn't fly. He was also prescribed four different medications before the crash, none approved by EASA.

[abgd]

whoever gave him that note should have made sure he didn't fly

How? Even in the UK, you would need a clear indication that he was going to fly despite being unfit, before you would be justified in breaching confidentiality.

If I breached confidentiality every time I told people not to drive, but half suspected they would anyway, I'd have lost my license to practice many times over.

[Jodelophile]

I did say 'maybe' whoever gave him the sick note, but we do not know why he was given the note because access to the files are denied to us.
I think in the UK it would have been more likely that he would have been made unfit by his AME. In Germany medics are terrified of breaching confidentiality. Yes, a pilot could get a sick note from his GP and not let his AME know then continue to fly but I think there is more openness and better communication in the UK because there is not the great fear of being sued or struck off for any breach of confidentiality. The DVLA doesn't have such strict rules as the CAA so it is more difficult to justify informing them, nevertheless it can be done and should be done at times.

[abgd]

I suspect it depends on whether the AME is made aware of it. If you see a psychiatrist privately then your GP need not necessarily be informed - though arguably if you did not want your GP to be informed and the psychiatrist knew you were a pilot that might be fishy enough for them to breach confidentiality. Any doctor can write a sick-note. It doesn't have to be a GP.

The AME will only know what he/she can glean from the patient, and the GP notes. And yes, you could be struck off for a breach of confidentiality even in the UK.

[Radgirl]

Agreed abgd, the differences between Germany and other countries are limited. Doctors are there to advise, and in the main not police.

Jodelophile people do this type of thing either due to bipolar disease (the medical term for depression) ie they are so fed up they want to kill themselves and dont care if they kill others, or because they have lost contact with reality, which is a psychotic state. Psychosis can be triggered by bipolar disease or schitzophrenia. Personality disorder doesnt really come into it - either he was a murderer or suffering from a mental illness, and in England at least it has to be on or the other. His medical notes wont IMHO help one iota as they wont teach us how to predict these states in other pilots.

Sadly psychiatry simply cant predict with accuracy who is going to become bipolar or psychotic, it can only identify those who are or have been. Unless we ground every pilot who has a history of bipolar disease, all we can do is monitor them and agree a certain level where we pull their medicals. Even then a small number of previously well pilots may become schitzophrenic or bipolar and not be picked up. It is far better to manage this hazard by a two person in the cockpit policy as the risk remains low and the harm to the pilot population otherwise is disproportionate

[Jodelophile]

Sorry but don't agree with you Radgirl! Bipolar is a type of depression with fluctuations of mood but is not the medical term for depression and the vast majority of people with depression may wish to harm themselves but not others. I think those who want to kill many people like the mass shooters in the US have a personality disorder and not depression. Psychosis is a mental disorder where there are abnormal experiences such as hallucinations or abnormal beliefs such as delusions,schizophrenia is a psychosis and does not trigger psychosis. Lubitz's medical notes may or may not help but they should be made available to the medics and air accident investigators involved in the aftermath of German Wings.
The vast number of pilots who develop some sort of mental disorder get a reactive depression which is secondary to stress at work and some domestic problem, it can nearly always be treated with some form of therapy and the pilot can safely return to work. Bipolar disorder and schizophrenia develop very rarely in pilots and would generally be disqualifying. Both disorders tend to manifest themselves quite early in life, teens or early 20s so would be unlikely to appear in an established pilot. It is the pilot with a latent personality disorder who decompensates who is the risky one.

[abgd]

I would agree that bipolar disorder is only one psychiatric disorder, but it isn't the only psychiatric disorder where you lose contact with reality, or even the only form of depression. Psychotic depression would be another. Agitated depression also often leads to suicide (non-agitated depressives often don't have the get-up-and-go to bother).

Whilst it's true that personality disorders can wax and wane in terms of severity, I think it's rare that they're truly 'latent'. That's why they're personality disorders - they're fundamental to someone's personality. Like having the flu, someone with depression can get better and has a 'normal self' to get back to.

[Jodelophile]

By 'latent' I mean they are there but not causing significant problems to others, like the shooters in the USA, after the event people would say, "He was a loner, interested in guns, polite but never really got to know him, he had no close relationships..." then something happens to cause the person to decompensate and there is another mass shooting.

[MrSnuggles]

From the BEA report. Page 8.

In December 2014, approximately five months after the last revalidation of his class 1 medical certificate, the co-pilot started to show symptoms that could be consistent with a psychotic depressive episode. He consulted several doctors, including a psychiatrist on at least two occasions, who prescribed anti-depressant medication.

And:
On 10 March 2015, the same physician [my comment: seems it is not one of those previously mentioned] diagnosed a possible psychosis and recommended psychiatric hospital treatment. A psychiatrist prescribed anti-depressant and sleeping aid medication in February and March 2015.

So we know that he suffered from depression. We know he suffered from a psychotic episode. He was medicated to treat both. He was put on sick leave. He never disclosed any of this to his employer, and the docs were too many to see the whole picture.

Radgirl: Bipolar is not another word for depression. Depression is a part of bipolar. Lubitz was not diagnosed with bipolar. Bipolar is another kettle of worms. You can not mix those terms like you do. It makes no sense.

According to the report, none of the doctors seems to have suggested any personality disorder so us speculating about that may be a fun pastime, but please do not consider it more than that. I have already explained how the two diagnoses Lubitz had, can work together in many many ways, and in his case they found the extreme.

I just want to stress that the possibility of this being a "mercy killing" is very real. "Mercy killings" has been seen before. As I wrote, some family murder-suicides and several parents killing their small children has been due to the belief that "this world is too cruel and I will spare my children the struggle of coping with the disappointments life hits you with". I know, that is a totally deranged logic but in their head it makes sense at the time. While in a psychosis you have no real connection with anything except your own feelings - whatever they might be at the moment.

I am however reluctant to draw similarities between the average US mass shooter and those "mercy killers" out there. Most mass shootings seems to the untrained eye to be brought on by some kind of jealousy/wish to be noticed and infamous/hatred towards a particular group in society/social status.

[Radgirl]

MrSnuggles your quotes seem to have provided the information requested. It appears any mental health issues were inadequate to withold his medical but he then deteriorated. Dont blame the doctors who were not AMEs - their role is to provide medical case not operate a police state.

The question is simple; how often does this situation occur such that a pilot passes a medical but then develops an unsafe medical health issue? I suspect rarely - if we look at the number of alleged deliberate CFITs (Air Egypt, Air Malaysia, German wings) compared to the millions of flights the risk is low. The two persons in the cockpit seems sensible. Is there evidence to indicate we should do more ie refuse medicals to more pilots? I think not, and I also fail to be convinced there is an objective assessment that can do so. I am not a psychiatrist, but IMHO psychiatry is more an art than a science, whose underlying process are in the main unknown and whose terminology varies with time and country - as the finger wagging confirms

[Jodelophile]

Because of the German refusal to release the full medical notes the BEA report on his mental condition is limited. Possible psychosis was referred to but we do not know how the interview with him led to this diagnosis, we don't have access to the recording of the mental state examination. Again, in the absence of details from the notes, we have to speculate and personality disorder is a possibility. Maybe there was a wish to be infamous, he allegedly said to his girlfriend "Some day everyone will know my name" and he seems to have put some planning into the crash, on the way to Barcelona he fiddled with the altitude setting, he had researched the cockpit door locking mechanisms, he had apparently ordered new cars for him and his girlfriend and then cancelled the order for his.

[Radgirl]

Sorry Jodelophile but we seem to be in parallel medical systems. Why do you think the interview was 'recorded'? Does it really matter? Are you criticising the other doctor, whose speciality is unknown? I find your phrase 'German refusal to release' rather telling. A number of countries have strict confidentiality rules for good reasons.

This pilot had mental health issues. He was a victim the health system could not help. Time and again we see people with mental health issues who commit crimes being treated as common criminals rather than additional victims, often let down by their carers. I for one do not want to rake over his illness, merely to ensure that we have an aviation system that is as safe as is practical.

With that I will bow out of this thread

[rantanplane]

Personality disorders are not looked at that often in the German medical system. Especially GP's and psychiatrist fail, they often think everything can be treated with some pills. With personality disorders, the side effects of psychiatric medication could be a recipy for disaster, when the dark side in s.b. Brain is released and really turns out like a sledge hammer. Some comments L. made clearly show significant signs of a narcissist personality disorder.

[gingernut]

What qualifies the average GP to determine such such a thing?

They ask the question, "do you feel like hurting yourself or anyone else."

Surprisingly, when they ask the question is asked, patients tend to give a very honest answer.

[Jodelophile]

Responding to Radgirl, by 'recorded' I meant that notes should be made to 'record' the meeting and to justify a diagnosis and treatment. And from these notes we should be able to try to analyse what made him do what he did.
Confidentiality is excellent but not when it puts others at risk, there has to be a point where confidentiality is justifiably breached.
I think we do need to 'rake' over or analyse his illness/disorder so we can try to understand what went wrong.
I think narcissistic personality disorder is quite a likely explanation and he decompensated when something happened to puncture an overinflated self-esteem, maybe it was a fear that his eyesight was deteriorating.