There exists a prevailing culture within the aviation industry that contributes to the problem of not reporting medical disorders, particularly those linked to mental health. This cultural barrier feeds off fear and distrust. The fear of losing one’s job, career, income, certification, or professional reputation, along with potential prosecution, and bearing the associated stigma of these outcomes can push aviation professionals to hide mental health symptoms or conditions.

Pilots/controllers are specifically trained to deal with complex emergencies as a team; however, when faced with a mental health issue, they often try to handle it alone.

The culture of the professional aviator and controller has evolved over multiple generations to be one of strength, resilience, and decisiveness; but multiple generations of pilots/controllers have also encouraged firewalling of information, perpetuating a culture of healthcare avoidance for new aviators. Moreover, many pilots/controllers’ sense of self-worth is attached to their job, position, and professional reputation. Anything that suggests or even hints at a potential weakness may be met with a lack of acceptance within the aviation community and further discourages one from seeking help.

Fact Check: Medical Requirements

Many people believe the FAA requires extreme evaluations and assessments for any disclosed mental health issue. This statement is false.

Some of that distrust is understandable given the current concerns with the medical certification program; and those concerns are heightened by anecdotal tales of pilots/controllers that have experienced long and complicated journeys to return from a mental health condition.

The Culture barrier to mental health reporting is the most wide-ranging barrier that will require the greatest effort to overcome. To overcome the Culture barrier, all other barriers must be removed. As challenging as this may seem, the aviation industry has repeatedly demonstrated the ability to affect culture change through programs designed to benefit the overall safety of the NAS.

Justified or not, pilots/controllers do not trust that the FAA will manage the medical certification application process fairly and in a timely manner. Further, the failure to report by pilots/controllers erodes the trust on the part of the FAA as the entire system is built on full disclosure by the applicant. The challenges, complexities, and lack of transparency regarding the FAA processes for a given mental health condition contribute to a lack of trust in the relationship between pilots/controllers and the AME, further straining the interface between the pilot/controller and the FAA.

Fact Check: Medical Process Perceptions

The lack of trust in the medical certification process is caused by the broad criteria for what is considered a safety risk related to mental health (i.e. imprecision), the inconsistent application of those criteria, and administrative inefficiencies. This belief is somewhat true, but the FAA is working to address this. 

The current FAA aeromedical process is a barrier impeding healthcare-seeking behaviors and the reporting of mental health conditions. The Trust barrier, however, is a much larger systemic issue involving the FAA, AMEs, and aviation medical certificate/clearance holders.

In reality, a pilot may be considered an aeromedical risk for any of the following reasons: 

• Sudden incapacitation, which rapidly and without warning makes the pilot or controller unable to perform their duties (e.g. seizure, sudden cardiac death, hypoglycemia, MI, stroke)
• Impairment, or subtle incapacitation, which may gradually impair the pilot or controller in such a way they are unaware of the impairment (e.g. fatigue, cognitive deficits, depression, pain, medication effects, disturbances of sensory input)

Trust is built over time through consistent behavior, and if not carefully guarded, can easily be destroyed. Stories of pilots/controllers who have come forward to report a mental health concern or diagnosis when the FAA, the AME, the pilot/controller’s doctor, or employer did not handle the situation in an effective manner spread quickly throughout the aviation community. These stories contribute to the lack of trust in the medical certification system, and further serve as a barrier to pilots/controllers getting the help they need and reporting mental health issues during FAA medical evaluations.

Fear is a driving emotion behind both pilots/controllers’ decisions to not disclose a mental health issue. Current data suggest that fear, anxiety, and avoidance in seeking health care is due to the fear of loss of medical certification/clearance. This is common in pilots/controllers, which can negatively impact individual health, aeromedical screening, and ultimately the safety of the NAS. Further, if a pilot/controller choses to conceal a mental health condition, they add fear of potential future certificate action, enforcement, or disciplinary action may further deter the individual from future disclosure.

Fact Check: Medical Decisions

Aeromedical decisions are subjective. This statement is false. 

The FAA has a host of resources for AMEs to determine whether a certification or clearance should be approved. The FAA provides input to assist an Aviation Medical Examiner (AME), otherwise known as an Examiner, in performing his or her duties in an efficient and effective manner. It also describes Examiner responsibilities as the Federal Aviation Administration (FAA) representative in medical certification matters and as the link between airmen and the FAA. The recertification/clearance process relies on AMEs to use their training and resources available to do their job to the best of their abilities. 

One tool to combat Fear is education. The goal of the ARC and the FAA is to combat misinformation, improve transparency surrounding the aeromedical certification process, and build a culture of Trust so that pilots/controllers will report their mental health concerns and seek the help they need without Fear of negative impact to their livelihood and careers. This will place a priority on wellness and enhance the overall safety of the NAS.

Stigma refers to the notion of having a defect or imperfection due to a personal or physical trait that is considered socially unacceptable, leading to feelings of embarrassment, shame, and fear of judgement.

Fact Check: Impacts to Career Growth

Disclosing mental health issues will jeopardize pilots'/controllers' careers or stunt their career growth. This statement is somewhat true in the short term, but long term the opposite is generally true. 

Although pilots/controllers find the recertification/clearance process to be time consuming and potentially damaging to a person's career, it still is important in maintaining safety. The FAA is constantly improving the medical certification/clearance process by adding Fast Track programs for certain conditions, decreasing follow-up requirements, decreasing decision times, and increasing the number of AME-issues certificates. The FAA is also championing Pilot Peer Support Programs to aid with the stigma surrounding seeking mental health diagnoses and treatment. Finally, it cannot be emphasized enough that early treatment is the best option to ensure both long term health and a successful career. The longer a problem persists, the more challenging the recovery. 

Within the aviation community, mental health stigma, both internalized and public, is a pervasive barrier that often has profound implications for pilots, controllers, and other aviation professionals. Research suggests that stigma is associated with lower intentions to seeking help, decreased rates of accessing information about resources and services, and lesser use of counseling services.

The FAA has made some progress by defining several mental health-related situations where an AME can issue a certificate during the exam using a Decision Tool in the AME Guide.

Financial concerns are another barrier to reporting. The pilot/controller frequently faces an uncertain financial future once a mental health condition/diagnosis is reported with the immediate loss of medical certification/clearance. The use of sick leave, insurance coverage, or transitioning to disability benefits can provide some financial relief, but it may not cover the entire time between loss of medial certification/clearance and the return of work. There is also significant variability in the cost of treatment borne by the individual. 

The cost of evaluation and treatment can be expensive. A provider may need to follow a patient with multiple visits or testing, even when the condition is considered stable. For some mental health conditions, the FAA requires increased monitoring, thus increasing the number of visits required and the cost. In addition, providers who evaluate patients must provide a diagnosis for their service. In some cases, the diagnosis used for insurance reimbursement (particularly for mental health conditions) may not exactly represent the actual diagnosis. For example, many physicians may assign Major Depressive Disorder where the individual actually has a different type of depression or anxiety. This complicates FAA medical certification by leaving pilots/controllers to obtain additional evaluations to determine the exact diagnosis. 

Fact Check: Transferring Skills

To a greater extent than many professions, pilots/controllers develop highly specialized skills and are generally compensated well for their years of technical experience. Pilots/controllers are not as readily successful in transferring their skills to another industry at a similar level of compensation. This statement is somewhat true. 

Although industry employment interruptions have proven this to be somewhat true, there are still career opportunities to former pilots/controllers. Ultimately, universal reporting is still important to maintaining the safety of the national aerospace system. 

The possibility of financial loss during the treatment and FAA medical recertification/clearance process may occur. Nonetheless, it is imperative that the pilot/controller get healthy. Universal and honest reporting is key to maintaining the safety of our national aerospace system. 

The ARC determined the FAA Aeromedical Certification Division’s (AMCD) processes to be unclear, complex, and sometimes overly conservative and recommended implementing a process flow description and an incorporated feedback loop to provide information to end users during the process. The ARC identified two additional areas of improvement for the recertification/clearance process:

• Access to AMEs: lack of access to medical professionals trained in aviation or aerospace medicine is a major challenge. Mental health professionals, especially those familiar with FAA processes, are limited in quantity and location. Variability of financial resources, mobility, and time impedes access to the required healthcare resources.
• Documentation & Standards: The documentation required can be extensive and difficult to navigate. 

Fact Check: Therapy and the Effect on Aviation

Many types of therapies have little to no impact on aviation safety. This statement is false. 

The FAA currently requires pilots/controllers to report any visit to a mental health professional. Although, from a laymen's perspective, this may feel like an invasion of privacy. Ultimately, the FAA relies on mental health professionals qualified in aviation medicine with knowledge of FAA's processes in order to determine a treatment's effect on aviation safety. 

What is the FAA Doing to Improve its Process for Mental Health?

• Added three additional allowable medications (SNRIs): Pristiq, Cymbalta, Effexor
• Updated Guide for Aviation Medical Examiners to allow AMEs to issue for eleven anxiety or depression diagnoses if certain criteria are met 
• Increased the ability for AME-issued certificates 
• Added Decision Tools for Adjustment Disorder and Anxiety, Depression and Related Conditions (including PTSD)
• ADHD Fast Track pathway
• Decreasing follow-up requirements
• Decreasing decision times
• Champion Pilot Peer Support Programs
• Hired additional FAA psychiatrists and neuro-psychologists 
• Implemented Grand Rounds to update AMEs on many topics including Mental Health 

The ARC has identified the Knowledge and Information Gap pertaining to pilots/controllers’ mental health literacy as a barrier to reporting a mental health condition. Mental health literacy has been defined as “knowledge about mental disorders which aid in their recognition, management, and prevention," including knowledge related to:

• the ability to recognize disorders,
• sources of information,
• risk factors and causes,
• self-treatment,
• availability of professional help, and
• attitudes that promote recognition or appropriate help seeking behaviors\

Pilots/controllers and the FAA share responsibility for closing the Knowledge and Information Gap. Pilots/controllers are responsible for accessing and assimilating guidance material, while the FAA is responsible for providing accurate, clear, and timely information.

Current methods of sharing FAA information on mental health (e.g., Pilot Minute, presentations at industry events, aviation magazine articles, mental health forums, or changes to the AME Guide), while frequent and thoughtful, are, for the most part, not viewed or well understood by most of the pilot/controller population. The role of electronic communications/social media in reaching and appealing to all generations of aviation professionals should not be underestimated. Narrative-driven accurate information, peer-to-peer programs, and transparency are all key to closing the knowledge and information gap. When pilots/controllers understand and have reliable information about the requirements and timeline of the process, their worry and distrust will be lessened, as will their reliance on inaccurate narratives.