There is an elephant in the cockpit. Pilots have described the elephant as “at best humiliating or embarrassing, at worst the end of our flying careers.”[i] The “elephant” is mental illness, which the general public has universally stigmatized. There is an increasing number of pilots flying while suffering from an untreated mental illness that would normally bar them from being able to fly at all.[ii] A physical or mental health diagnosis can potentially cause a pilot to lose their medical certificate required to operate an airplane.

The consequences of the Federal Aviation Regulations under Title 14 of the Code of Federal Regulations are significant. Over 50% of pilots admitted in an anonymous survey that they are avoiding the mental and physical healthcare they need due to the unnecessarily harsh federal laws regulated by the FAA.[iii] Although a pilot has the possibility of flying again after receiving proper treatment, receiving a diagnosis typically suspends one’s career by at least six months or may even be career-ending. Additionally, the process of being reinstated after a mental health treatment can be extremely expensive.  The loss of income, compounded with legal and medical fees that could potentially exceed six figures, can be devastating to a pilot.[iv]  Further, a pilot found lying to the FAA on a medical form could face a potential of five years in prison and a $250,000 fine.

However, after several international and domestic incidents, policymakers should no longer avoid the lack of access to mental health care in the cockpit. On March 24, 2015, a depressed, suicidal airline pilot for Germanwings locked his other co-pilot out of the cockpit and deliberately crashed the plane into the French alps, killing himself and 149 other people on board.[v] On October 22, 2023, an off-duty pilot attempted to shut off the engines of an Alaskan Airline flight while suffering a grieving depressive episode with 88 passengers on board. While the FAA medical evaluation system aims to ensure pilots are fit to fly, there is significant room for improvement in the current system, which has unintended and negative consequences of healthcare aversion and a culture of secrecy. In 2015, over 5% of fatal aircraft accidents in the U.S. were attributed to a pilot’s health condition that was not reported to the FAA.[vi] Pilots who are treated for minor mental illnesses are safer than untreated pilots.[vii]

The Federal Aviation Administration was created by Congress’ Federal Aviation Act of 1958.[viii]   The Act granted the FAA the power to regulate a pilot’s medical certificates in the interest of promoting safety in aviation. This regulation includes constructing certification policies and processes to reflect current medical developments. To become a pilot, whether commercially or recreationally, the FAA requires the individual to have a medical certificate. The minimum medical requirements for pilots to attain a medical certificate are stated under the Federal Aviation Regulations (FAR) under Title 14 of the Code of Federal Regulations.[ix] Medical certificates play a vital role in aviation safety. Unknown or dangerous medical conditions of a pilot could lead to a medical emergency mid-flight, which could have tragic consequences. The FAA mitigates this risk by requiring pilots to meet minimum health standards through an authorized examination before they are able to fly. All classes of medical certificates require a physical medical examination and a comprehensive medical history check conducted by an Aviation Medical Examiner (AME).

Data suggests pilots do not seek care for symptoms of a potentially medically disqualifying condition and continue to fly, putting passengers and people on the ground at risk.   A recent Harvard study found through an anonymous online survey that 12.6% of the 1,848 airline pilots were clinically depressed, and 4% reported having suicidal thoughts within the past two weeks.[x] The current FAA mental health policy discourages the employment of qualified individuals and disincentives proper treatment for currently licensed pilots.

There are different classes of medical certifications for different kinds of pilots. These levels are first-class, second-class, and third-class medical certificates. All passenger airline transportation pilots (ATP) are required to have a first-class medical certificate, which is the most restrictive certificate. There are three types of first-class medicals: (1) unrestricted certificates, (2) restricted certificates, and (3) an Authorization for Special Issuance of a Medical Certificate (SI). The typical first-class certificate is an unrestricted certificate that is issued to applicants who do not have significant medical conditions. Restricted certificates are Statements of Demonstrated Ability (SODA). They are issued to those who do not meet the standards for an unrestricted first-class certificate but have relatively minor health conditions. SI certificates may be approved for applicants with otherwise disqualifying medical conditions that are sufficiently managed to the extent that the pilots do not pose a danger to those in their care.

The medical standards for the various types of medical certificates can be found in the FAR’s Part 67.[xi] The FAA has created two categories of medical conditions: Conditions AMEs Can Issue (CACI) and automatically disqualifying conditions. Pilots must not have a current clinical diagnosis or any established medical history of disqualifying conditions. The following mental health conditions require the AME to deny or defer the certificate directly to the FAA: attention-deficit/hyperactivity disorder (ADD/ADHD), bipolar or personality disorder, depressive disorders, psychosis, substance abuse or dependence, or suicide attempt.

Additionally, several medications are classified under “Do Not Issue,” meaning if the pilot is using any of these drugs, the AME is forced to defer the application directly to the FAA. Do Not Issue drugs include the psychiatric and psychotropic drugs category, which includes widely prescribed types of drugs such as antidepressants, antianxiety drugs, antipsychotics, medications for ADD / ADHD, mood stabilizers, sedative-hypnotics, stimulants, and tranquilizers. Notably, the prescription rate of these drugs are growing, and it is now more difficult than ever to find candidates to fill the pilot shortage who do not use these medications.

Despite the FAA’s regulatory purpose to reflect modern medical developments, Part 67 has not been significantly changed since 1996.[xii] In 2010, the FAA did create some flexibility within the Do Not Issue drugs list regarding four specific antidepressant medications that are selective serotonin reuptake inhibitors (SSRI). However, upon closer examination of the exemption details, pilots soon realized that minimal progress, if any, had been made. Foremost, only four brands of SSRIs out of the dozens of different anti-depressant medications were included in the policy change. Additionally, the exemption is much more inflexible than it seems.  As of May 2020, only .09% of First-Class pilots are authorized for a Special Issuance based on the use of the four approved SSRIs.[xiii] Although the FAA publicly tells pilots to get treatment if needed, their policies perpetuate the stigma on mental health because most of the treatments ban the pilot from flying. The FAA boasts other measures that could help pilots beyond medication, such as developing peer support networks. However, these networks will have limited impact on pilots with mental health diagnoses, as a study has shown peer support networks are unlikely to improve clinical symptoms.[xiv] Given these circumstances, it’s understandable why pilots might withhold information or avoid seeking professional or pharmaceutical assistance for their mental health concerns, even when facing potential fines from the FAA.

In conclusion, the FAA’s policy on pilot mental health is not only counterproductive but also dangerous. It perpetuates stigma, deters treatment, and compromises aviation safety. The FAA should establish a non-punitive framework for pilots to disclose previously undisclosed mental health conditions, treatments, or medications. This would encourage lifesaving transparency while ensuring that pilots feel comfortable seeking help for mental health issues without fear of punitive consequences. Additionally, the FAA or the NTSB could appoint an expert panel to conduct further research on expanding the SSRI medication list, which would allow more pilots to be adequately treated and get back to work. Congress can also exert pressure on the FAA to better develop aviator’s mental health law through various means, including legislative actions, hearings, budget allocations, and oversight responsibilities. Congressional committees overseeing aviation and transportation have the authority to hold hearings, summon FAA officials to testify, and introduce legislation affecting the FAA’s mental health operations and policies. Congress could specifically allocate funding for initiatives such as a special expert panel to research more SSRI medications. Urgent reform is necessary to prioritize pilot well-being, foster inclusivity, and ensure the continued safety and sustainability of the aviation industry.

[i] Jim Moore, ‘THEY NEED TO GET THE CARE’, Aircraft Owners & Pilots Ass’n (Aug. 17, 2022) https://www.aopa.org/news-and-media/all-news/2022/august/17/they-need-to-get-the-care, (explaining the culture of stigma about mental health among pilots, and the unspoken rule to not discuss it or face the possible consequences of an investigation).

[ii] See id.; see also 14 C.F.R. § 67.107 (2022) (explaining mental health diagnoses are grounds for revocation of a medical certificate at the discretion of the Federal Air Surgeon).

[iii] See William Hoffman, Healthcare Avoidance in Aircraft Pilots Due to Concern for Aeromedical Certificate Loss, J. of Occupational & Env’l Med. (Apr. 2022), https://journals.lww.com/joem/Abstract/2022/04000/Healthcare_Avoidance_in_Aircraft_Pilots_Due_to.21.aspx (stating the study found “56.1% of pilots who reported a history of healthcare avoidance behavior due fear for losing their aeromedical certificate.  There were 45.7% who sought informal medical care and 26.8% who misrepresented/withheld information on a written healthcare questionnaire for fear of aeromedical certificate loss.”).

[iv] See Rob Mark, John King Vows Battle with the FAA to Reinstate His Medical Certificate, Flying (Feb. 25, 2017), https://www.flyingmag.com/john-king-vows-battle-with-faa-to-reinstate-his-medical-certificate/ (describing a well-known aviator’s battle to reinstate his medical certificate includes engaging with aeromedical professionals and attorneys, and spending thousands of dollars, and the FAA continually asking the aviator to get expensive and burdensome medical tests done); see also Pilar Wolfsteller, Why aerospace must do more to get pilot mental health reporting on the level, Flight Global (Oct. 24, 2022), https://www.flightglobal.com/flight-international/why-aerospace-must-do-more-to-get-pilot-mental-health-reporting-on-the-level/150639.article (describing how pilot Alan Smith was deferred his medical certificate for admitting to an AME he took a single anti-depressant pill once, which caused the FAA to require him to get “burdensome, costly and time-consuming battery of psychological and neurological tests that many medical professionals consider outdated, archaic and irrelevant.”).

[v] See Nicholas Kulish & Ni-cola Clark, Germanwings Crash Exposes History of Denial on Risk of Pilot Suicide, N.Y. Times (Apr. 18, 2015), https://www.nytimes.com/2015/04/19/world/europe/germanwings-plane-crash-andreas-lubitz-lufthansa-pilot-suicide.html/.

[vi] See Alpo Vuorio et al., Duty of Notification and Aviation Safety-A Study of Fatal Aviation Accidents in the United States in 2015, Int. J. Env’l Res Public Health (June 13, 2018), https://pubmed.ncbi.nlm.nih.gov/29899311/ (noting the authors of this study believed 5% is likely an under estimation since toxicology and autopsies are not always conducted on the pilots after a crash, and these statistics depends on those reports); see also Hoffman et al., supra note 21 (describing the implications of pilots foregoing medical treatment are not hypothetical, and actually make aviation less safe).

[vii] See Joshua Smith et al., Anxiety and Substance Use Disorders: A Review, Psychiatr Times (Oct. 25, 2008), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2904966/ (stating delaying treatment of anxiety has an increasing the risk of developing depression and substance use issues); see also Depression (major depressive disorder), Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007 (last visited Mar. 15, 2024) (describing patients with untreated long-term depression are more prone to sleep disruptions, heart disease, weight gain or loss, and weakened immune system).

[viii] See 85 P.L. 726, 72 Stat. 731.

[ix] See 14 C.F.R. § 61.23(a) (2022).

[x] See Alexander Wu, et al., Airplane pilot mental health and suicidal thoughts: a cross-sectional descriptive study via anonymous web-based survey, Environ Health (2016), https://ehjournal.biomedcentral.com/articles/10.1186/s12940-016-0200-6#citeas.

[xi] See 14 C.F.R. § 67 (2022).

[xii] See Historical FARs, Fed. Aviation Admin., http://rgl.faa.gov/Regulatory_and_Guidance_Library/rgFAR.nsf/HistoryFARPart!OpenView&Start=1&Count=200& Expand=33#33 (noting Section 67.107(b)(2) was updated in 2006 to modify the definition of “substance abuse” slightly, and a reference to another provision was deleted from Section 67.3. Additionally, the phrasing of Section 67.413 was updated for clarity in 2008).

[xiii] See Valerie Skaggs et al., 2020 Aerospace Medical Certification Statistical Handbook, Fed. Aviation Admin., https://www.faa.gov/sites/faa.gov/files/2022-04/2020_handbook.pdf (stating only 232 First Class medical certificate pilots out of the entire U.S. workforce were approved to use anti-depression medication, revealing a large number of aviators apply for these exemptions are typically denied).

[xiv] See Sarah White et al., The effectiveness of one-to-one peer support in mental health services: a systematic review and meta-analysis, BMC Psychiatry (Nov. 11, 2020), https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-020-02923-3 (explaining “[o]ne-to-one peer support in mental health services might impact positively on psychosocial outcomes, but is unlikely to improve clinical outcomes.”).