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Risk a $250K fine or months without pay? Pilots have few reasons to get mental health help

Seattle Times - 11/3/2023

Nov. 2—Among the first things off-duty pilot Joseph Emerson is said to have told police after he was accused of trying to bring down a Horizon Air flight last month was that he'd been struggling with depression for six months and hadn't slept in 40 hours.

The Oct. 22 flight had left Everett's Paine Field for San Francisco, Emerson's home base with Alaska Airlines. Sitting in the cockpit jump seat, Emerson told the pilots, "I'm not OK." Prosecutors contend Emerson then tried to activate a fire suppression system that would have cut the fuel supply to the engines.

Emerson had renewed his pilot's license three months before, which means he passed the regular psychiatric evaluation required of all commercial airline pilots. The 44-year-old California man was not medicated, according to statements to police.

Emerson appears to have been among scores of U.S. pilots who keep quiet about their mental health struggles because of stigma, risks to their career and the understanding that commonplace mental health issues can ground them for months, if not longer.

U.S. pilots' struggles with mental health have drawn congressional interest since at least 2015. In June, the Senate introduced a bill that would boost the Federal Aviation Administration's 2024-2028 budget to allow the agency to form a working group that can address pilot mental health protocols. The bill would also improve the FAA's ability to issue special medical approvals to clear backlogs and get healthy pilots back to work.

In a country that relies heavily on air travel, passengers end up potentially affected by pilots who don't report mental health struggles due to systemic barriers. At the same time, pilots risk months without work if they report mental health issues or seek care.

Forty percent of American adults have anxiety or depression symptoms, but pilots may also struggle with additional stress, anxiety or depression because of the nature of the work, said Dr. Ryan Shugarman, an Alexandria, Va.-based psychiatrist who has worked for 10 years with pilots undergoing mental health evaluations.

"Pilots are not immune to mental health issues, and they have their own unique stressors," Shugarman said. "Being away from family for extended periods of time, the inconsistency of [their] schedule can lead to marital disruption, sleep issues."

The disclosure dilemma

One of the challenges of evaluating a person's mental health is the reliance on self-reporting. Examiners count on patients to be honest when talking about their symptoms. There's no universal test or scan for many of these seemingly invisible illnesses.

"There definitely are people that don't report it and may slip through the cracks," Shugarman said.

Mental health professionals routinely rely on self assessments, like Patient Health Questionnaire-9, to gauge a person's mental health. The PHQ-9 evaluation asks patients questions like how often they've experienced "thoughts that you would be better off dead or of hurting yourself in some other way." The FAA uses PHQ-9 as a tool as well.

Self-reporting can lead some pilots to minimize their symptoms. A 2022 study co-authored by William Hoffman, a neurologist and affiliated assistant professor of aviation at the University of North Dakota, showed 56.1% of pilots reported a history of health care avoidance due to the fear that they would lose their medical certificate, which attests to a pilot's fitness. According to the study, 45.7% sought informal medical care and 26.8% misrepresented or withheld information on a health care questionnaire.

The FAA can fine pilots who lie on their medical examination up to $250,000, imprison them for up to five years or both.

Pilots should be honest in their disclosures, but penalizing those who aren't does not fix the problem, Hoffman said. Risk of prosecution is part of a system that forces pilots to choose between flying or taking care of their mental health.

The FAA said in an email pilots should seek early help for mental health conditions since most, if treated, don't disqualify a pilot from flying. For example, mild depression and anxiety, if properly treated, are not necessarily disqualifying, the agency said.

If a pilot seeks help early and receives care, they can get their medical certification more easily, Hoffman said. But mental health stigma remains a big issue for pilots.

"To be faced with that situation where they're out of control, the loss of autonomy, in a lot of ways, the loss of identity of pilots who are flying is a very worrisome thing," Hoffman said.

Reporting a mental health issue can also lead to months without flying. Taking a prescribed antidepressant means at least six months without flying, according to FAA policies. After the six months are up, the pilot will be required to disclose whether they are still taking an antidepressant. Once they are no longer taking an antidepressant, the pilot will still be grounded for another two months before being cleared. During that time, pilots can apply for disability pay through their airline.

Psilocybin-assisted treatment is part of a growing trend of using psychedelics to treat mental health issues. Psilocybin is still unregulated in Washington, but research has shown it can help treat patients with severe PTSD or depression. Emerson told investigators he took mushrooms about two days before the Oct. 22 flight and a day after his last flight for Alaska, but it's unclear whether he was using them medicinally.

Time off the job can lead to loss of pay and the need for more training. Beyond that, pilots are often responsible for the expenses of FAA-required medical evaluations.

Shugarman, the psychiatrist, takes referrals from what are known as aviation medical examiners. These doctors evaluate pilots and send their findings to the FAA.

If a pilot is flagged by the FAA for further evaluation, Shugarman will conduct a more thorough review, which often requires several hours of evaluation, including reviewing medical records and interviewing family members. He then submits the results to the FAA. The agency has the final authority to accept or reject a pilot.

The last time Emerson was issued a flying certificate was July 10, according to FAA records. Pilots are required to go through a medical examination every six months to a year, depending on the type of flying and their age.

Emerson has never had his license revoked or denied, an Alaska Air spokesperson said. The crew on the Oct. 22 flight said he did not seem intoxicated when he boarded the Horizon Air flight.

"[Mental illness] can go undetected, unless symptoms are obvious to the aviation medical examiner," Shugarman said. "That is a challenge."

Shifting practices

Though the Horizon Air flight crew successfully stopped what prosecutors describe as Emerson's attempts to cut off fuel to the plane's engines, other pilots have brought down planes.

In 2015, a co-pilot crashed Germanwings Flight 9525 in the French Alps while he was alone in the cockpit. The crash killed 150 people, and the co-pilot's actions were determined to be suicide. After the crash, late U.S. Sen. Dianne Feinstein commissioned the Department of Transportation'sOffice of the Inspector General to carry out an investigation, the results of which were published in July.

Emerson's attorneys Noah Horst, Ethan Levi and Norah Van Dusen said in a statement that he was not under the influence of intoxicants when he boarded the Horizon flight and that he would not intentionally hurt people.

According to the July OIG report, the FAA could improve its procedures by collaborating with airlines, pilot unions and the aerospace medical community to address barriers that discourage pilots from disclosing mental health conditions and seeking treatment. The OIG recommended the FAA implement policy and protocol changes following that assessment.

Shugarman said he agrees with the OIG's recommendations.

In June, U.S. Sen. Maria Cantwell, D-Wash., and other senators introduced a bill that would establish an Aviation Medical Innovation and Modernization Working Group composed of licensed physicians with experience in aerospace medicine, psychological medicine and other relevant disciplines, to recommend improvements to the FAA's medical review process.

"When we fly we expect to get where we're going, safely," Cantwell said in a June statement. The bill has not passed yet.

The Senate-appointed group would recommend "improvements to FAA mental health protocols, including but not limited to, mental health conditions such as depression and anxiety, the use of medications for treating mental health conditions and neurocognitive testing rules and applicability."

Aviation is also seeing a generational change that is bringing younger pilots into an industry long dominated by baby boomers.

Younger pilots are more likely to make mental health a priority, former University of North Dakota aviation student John Dulski said in an article by Hoffman published in Scientific American. "Many are more willing to choose to get care at the risk of stepping away from flying," Dulski said.

Hoffman argues the FAA should change its policy to permit pilots with mild symptoms to seek therapy without losing their certification. Importantly, he said, changes should involve all stakeholders, from regulators to airlines, unions and the pilots themselves.

"You can absolutely be a pilot talking to a therapist. You can be a pilot and have a diagnosis of anxiety or depression," Hoffman said. "If a pilot feels that they need help, they should absolutely get help soon, like right away."


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