Assessing and Managing Pilots in Distress
Chris Kenedi, MD, MPH, FRACP, FACPDepartments of General Medicine and Liaison Psychiatry, Auckland HospitalDepartments of Internal Medicine and Psychiatry, Duke University Hospital, USANeuropsychiatric Consultant to the NZ CAA
What we will talk about
Types of Mental IllnessRisk assessmentsGeneral Assessments of Pilots with mental distressRed FlagsFunctional assessmentsCheck-in/re-assessmentpointsduring recovery
What we won’t talk about
Specific diagnosis – focus is on patterns of concern
By definition
Anything that impacts your ability to function in work or life is a disorder.Life events (divorce, cancer, bereavement)VersusClinical/Major DepressionAdjustment Disorder
SadSuicidal?MadDrugs?BadDangerous?
Are they Sad?Difficulty Coping versus Mental Illness
Sad, down, irritable, anxious, panic attacksnot sleeping,feeling guilty or ashamed or out of controlnot finding joyeating too much or not enoughfeeling you wish you were just alone,having trouble getting up to things, trouble sitting stillSuicidal Ideations (Overwhelmed/hopeless)
SAD PERSONS – Suicide risk
SexAge (15-25) or (59+)Depression or Hopelessness
PreviousAttemptEtOH or Drug UseRationality (lack)SocialSupport (limited)Organized PlanNo spouseSickness
Are they mad?
Perceptions:Seeing or hearing (or tasting or feeling) things other people can’t seeThought ContentBizarre behaviour or bizarre explanations for behaviourParanoiaThought ProcessFOI/LOADisorganizationSleep fragmentation or not needing any sleepPTSDSx***Only hope for the pilot is that there are recreational drugs on board
Are they Bad?
Impulse/Anger issuesNarcissistic traits versus disorderFactitious behaviourMalingering
Are they dangerous?
Threats to themselves or othersSomatoform complaintsPrevious acts or threats?Evidence of planning?New Financial/Legal/Relationship or Occupational Conflict
A Systematic Review of Suicide and Murder-Suicide involving Aircraft 2016Aerosp Med Hum Perform 2016 Apr;87(4):388-96
Christopher Kenedi, MDSusan Hatters Friedman, MDDougal Watson MBBSClaude Preitner MD
Methods
PRISMA ChecklistMedlinePSychInfoEMBASEGoogle ScholarFAANTSBCDCNIMHAviation Safety NetworkAVWebAOPAFlight Safety FoundationMedia sources (CNN, BBC, etc)
Results
64 reports/articles contributed71 incidents involved suicide6 jumped from aircraft3/65 involved commercial airliners18 Involved homicide-suicide732 people died13 involved the pilot as perpetrator2 were attempted suicide-homicide
Assessing Risk to self and others in pilots
USAF Data re aviator suicide:
Substance abuse in 54% attempts/79% completionsImpulsivity - 77% attemptsPlanned- 93% completionsPattern of reckless/ self-destructive behavior outside of flying
Patterson JC. Suicide and suicide at- tempts: USAF Aviators. Aerospace Medical Association, New Orleans, Louisiana, May, 1988
Suicide involving large Aircraft
Homicide-Suicide (GA + Commercial)
17% of Suicides involving aircraft were actually homicide-suicidesCompared to the US general population where <0.001% of suicides are homicide-suicides13% of people killed in commercial airliner crashes in 2013 were homicide-suicide victims29% had evidence of mental illness (compared to 36% of pilot suicides)
Perpetrator Background
Average age 33Average age of pilots was 37Average age of commercial pilots was 39Of 14 with data: 3 had legal/criminal issues, 2 had financial crises and 4 had relationship conflict. 4 had occupational conflict.All of the perpetrators were men
Commercial Airliners
5/6 cases occurred when the perpetrator was alone on the flight deck3/6 had evidence of mental illness2/6 had evidence of occupational conflict2/6 had relationship conflict
Murder-Suicide Risk
Overlap of suicide, murder, domestic violence, filicide and mass-murder epidemiologyMales with intense sexual jealousy or threatened loss of identityGenerally have a comorbid mental health condition or personality disorderReckless behavior outside of work
Marzuk PM, Tardiff K, Hirsch CS. The epidemiology of murder-suicide. JAMA. 1992 Jun 17;267(23):3179-83.
Conclusions
Pilot suicide and pilot homicide-suicide are not identical eventsCommercial perpetrators waited to be alonePremeditation appeared to have occurred in most casesRisks around the rule of 2 and non-pilot crew on the flightdeck?Japan Air event took two male crew to wrestle the controlsUnscreenedFire axes and other unknown quantities
Pilot assessment
Who needs assessment?
Anyone who has taken sick leave needs medical evaluation/TriageAnytime a doctor such as a GP or AME has a concern about the pilot’s healthThey should be viewed by the AME/GP/Medical Office/ALPA as routine and non-discretionary to reduce stigmaPilot has a serious concern before it is impairing their functionNot the worried well with family, interpersonal, occupational conflicts or mildanxiety, although this may need re-evaluation.
Specialist Evaluation
Aviation Medical ExaminerSpecialist Psychiatrist – ideally should have awareness of aviation regulations, operations and culture
Unique Issues
Aviation regulations and laws pertaining to pilotsRegulatory Environment – post German WingsEvidence Base/ Best practicesPrivacyFiduciary responsibilityTrust of the pilot and the CommunitySpecial Interests – Corporation/HR, ALPA, PMBF, CAAPilot Identity
How to Triage
Nature of the incident/eventInsightCollateralDefence mechanismsDangerousness
Evaluation should involve
Subjective and Objective Clinical InterviewCollateral Information - employer, family, PMBF, GPPattern of Behaviour/ Past HxNeuropsychiatric/neuropsychological testing
Laboratory testing
TSH, free T4HIV, RPR,Chemistry including, LFTs, Ca++FBC/CBCLow threshold Urine Toxicology Screen
The Evaluation should result in
Cross – sectional assessmentRisk Assessment for SafetyInitial diagnostic impressionDifferential DiagnosisTreatment PlanIncludes an initial assessment on return to flightBarriersSupports/strengthsEvidence baseTimeline– including re-evaluation
Red Flags
Lack of engagementLack of insightThreats to othersPersonality Disorder/pattern of maladaptive coping skills/ pattern of emotional dysregulationEvidence of psychosis
Assessing versus Treating Clinicians(Dual Agency)
Should be separateTransferenceCounter-TransferenceObjectivity for the pilot, for the referrer, and the regulatorChecksum and second opinion
Treatments
Psychology (CBT/ACT)/ Psychotherapy (in specific cases)PsychiatricMedicationApprovable versus non-approvableInpatient versus outpatientECTPastoral/ SocialProcess GuidanceCounsellingComorbid issuesDrugs/AlcoholMedical IssuesStressors – work, family, life, aging
Thank you
Chris Kenedi MD, MPHcckenedi@yahoo.com
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