Disease Protocols - Depression Treated with SSRI Medications
SPECIFICATIONS FOR NEUROPSYCHOLOGICAL EVALUATIONS FOR TREATMENT WITH SSRI MEDICATIONS
Why is a neuropsychological evaluation required? Depression and other conditions treated with selective serotonin reuptake inhibitor (SSRI) medications, as well as the SSRIs themselves, may produce cognitive deficits that would make an airman unsafe to perform pilot duties. This guideline outlines the requirements for a neuropsychological evaluation.
Who may perform a neuropsychological evaluation? Neuropsychological evaluations must be conducted by a licensed clinical psychologist who is either board certified or board eligible in clinical neuropsychology. Board eligible means that the clinical neuropsychologist has the education, training, and clinical practice experience that would qualify him or her to sit for board certification with the American Board of Clinical Neuropsychology, the American Board of Professional Neuropsychology, and/or the American Board of Pediatric Neuropsychology.
Will I need to provide any of my medical records? You should make records available to the neuropsychologist prior to the evaluation, to include:
- Copies of all records regarding prior psychiatric/substance-related hospitalizations, observations or treatment not previously submitted to the FAA.
- A complete copy of your agency medical records. You should request a copy of your agency records be sent directly to the psychiatrist and psychologist by the Aerospace Medical Certification Division (AMCD) in Oklahoma City, OK. For further information regarding this process, please call (405) 954-4821 and select option 3.
What must the neuropsychological evaluation report include? At a minimum:
- A review of all available records, including academic records, records of prior psychiatric hospitalizations, and records of periods of observation or treatment (e.g., psychiatrist, psychologist, or pediatric neuropsychiatrist treatment notes). Records must be in sufficient detail to permit a clear evaluation of the nature and extent of any previous mental disorders.
- A thorough clinical interview to include a detailed history regarding: psychosocial or developmental problems; academic and employment performance; legal issues; substance use/abuse (including treatment and quality of recovery); aviation background and experience; medical conditions, and all medication use; and behavioral observations during the interview and testing.
- A mental status examination.
- Interpretation of testing including but not limited to the tests as specified below.
- An integrated summary of findings with an explicit diagnostic statement, and the neuropsychologist's opinion(s) and recommendation(s) regarding clinically or aeromedically significant findings and the potential impact on aviation safety consistent with the Federal Aviation Regulations.
What is required for testing?
- CogScreen-AE (a brief test battery developed specifically for use with pilots to assess the neurocognitive domains most critical to flight performance). If the neuropsychologist interprets the clinical interview and CogScreen-AE results to show no evidence of neuropsychological impairment or deficiencies, then no further neurocognitive testing needs to be conducted at that time as part of the evaluation.
- If the neuropsychologist interprets the clinical interview and CogScreen-AE results as raising concerns about or showing neuropsychological impairment or deficiencies, then the neuropsychologist should perform a full battery of testing. The required testing must include:
- The Wechsler Adult Intelligence Scales (Processing Speed and Working Memory Indexes must be scored)
- Trail Making Test, Parts A and B (Reitan Trails A & B should be used since aviation norms are available for the original Reitan Trails A & B, but not for similar tests [e.g., Color Trails; Trails from Kaplan-Delis Executive Function, etc.])
- Executive function tests to include:
- Category Test or Wisconsin Card Sorting Test; and
- Stroop Color-Word Test
- Paced Auditory Serial Addition Test (PASAT)
- A continuous performance test (i.e., Test of Variables of Attention [TOVA], or Conners' Continuous Performance Test [CPT-II], or Integrated Visual and Auditory Continuous Performance Test [IVA+]), or Gordon Diagnostic System [GDS].
- Test of verbal memory (WMS-IV subtests, Rey Auditory Verbal Learning Test, or California Verbal Learning Test-II)
- Test of visual memory (WMS-IV subtests, Brief Visuospatial Memory Test-Revised, or Rey Complex Figure Test)
- Tests of Language, to include the Boston Naming Test and testing for verbal fluency (i.e., the COWAT and a semantic fluency task)
- Psychomotor testing, to include Finger Tapping and either Grooved Pegboard or Purdue Pegboard
- Personality testing to include Minnesota Multiphasic Personality Inventory (MMPI-2). (The MMPI-2-RF is not an approved substitute. All scales, subscales, content, and supplementary scales must be scored and provided. Computer scoring is required. Abbreviated administrations are not acceptable.)
NOTES: (1) All tests administered must be the most current edition of the test unless specified otherwise; (2) At the discretion of the examiner, additional tests may be clinically necessary to assure a complete assessment.
What must be submitted? The neuropsychologist's report as noted above, plus the supporting documentation below:
- Copies of all computer score reports (e.g., Pearson MMPI-2 Extended Score Report, CogScreen-AE Report).
- An appended score summary sheet that includes all scores for all tests administered. When available, pilot norms must be used. If pilot norms are not available for a particular test, then the normative comparison group (e.g., general population, age/education-corrected) must be specified. Also, when available, percentile scores must be included.
Recommendations should be strictly limited to the psychologist's area of expertise. Psychologists with questions are encouraged to call Chris Front, Psy.D, FAA Psychologist, at (202) 267-3767.
What else does the neuropsychologist need to know?
- The FAA will not proceed with a review of the test findings without the above data.
- The data and clinical findings will be carefully safeguarded in accordance with the APA Ethical Principles of Psychologists and Code of Conduct (2002) as well as applicable federal law.
- Raw psychological testing data may be required at a future date for expert review by one of the FAA's consulting clinical psychologists. In that event, authorization for release of the data by the airman to the expert reviewer will need to be provided.
Additional Helpful Information
- Depressive disorders and medications used to treat depression are medically disqualifying for pilots. However, the Federal Air Surgeon has established a policy for Authorizations for Special Issuance of medical certificates for pilots treated with selective serotonin reuptake inhibitor (SSRI) medications who meet specific criteria.
- Where can I find the policy? The current policy is published in the Guide for Aviation Medical Examiners, located at Item 47. Psychiatric.
- What will be required if special issuance is authorized? Pilots found eligible for Special Issuance will be required to undergo periodic re-evaluations. Requirements for re-evaluation testing will be specified in the letter authorizing special issuance, and may be limited to the CogScreen-AE or expanded to include additional tests.
- Useful references for the neuropsychologist:
- MOST COMPREHENSIVE SINGLE REFERENCE: Aeromedical Psychology (2013). C.H. Kennedy & G.G. Kay (Editors). Ashgate.
- Pilot norms on neurocognitive tests: Kay, G.G. (2002). Guidelines for the Psychological Evaluation of Aircrew Personnel. Occupational Medicine, 17 (2), 227-245.
- Aviation-related psychological evaluations: Jones, D. R. (2008). Aerospace Psychiatry. In J. R. Davis, R. Johnson, J. Stepanek & J. A. Fogarty (Eds.), Fundamentals of Aerospace Medicine (4th Ed.), (pp. 406-424). Philadelphia: Lippencott Williams & Wilkins.