GUIDELINES FOR FLIGHT SURGEONS

[Guest guest]

LIMITED USE OF SSRI/SNRI MEDICATION IN CF AIRCREW

BACKGROUND

Depressive illnesses are not uncommon in the general population,

occuring with an incidence lifetime prevalence of 5- 20% depending

on the population studied, and it is likely that the prevalence in

the aircrew population is within this range and this incidence is

reflected in the aircrew population. Because of various factors

including the stigma associated with psychiatric diagnoses, the

prolonged grounding period required for pharmacologic treatment, and

the delay in returning to flight duties even after treatment is

completed, aircrew are generally reluctant to come forward to

discuss depressive symptoms with their Flight Surgeon, and

depression is infrequently diagnosed. Depressive symptoms are often

camoflaged beneath somatic complaints, or self-treated with

available drugs such as alcohol. This situation often results in

aircrew trying to " tough it through " a significant depressive

illness, with resulting significant degredation of performance.

Once medically diagnosed and pharmacologic treatment has been

initiated, current therapeutic guidelines recommend up to a year of

treatment with antidepressant medications, which for aircrew is

followed by a further period of up to three months of observation

before a return to flight duties is recommended. Fifteen months off

flying duties for most aircrew means a significant retraining period

before being operationally qualified again. This amounts to quite a

chunk out of an operational tour, complicated by the fact that since

the aircrew is not on MPHL, a replacement can not be posted in

against his/her position.

Further, if an aircrew recovers from one episode of depression and

is unlucky enough to be one of the 50% who suffer a second episode

sometime later, the current psychiatric recommendation is to treat

again with medications, but then to leave the individual on life-

long prophylactic medication. Given the current aeromedical

approach, this essentially means the end of a flying career.

Previous anti-depressive medications generally had side-effects

quite incompatible with flying duties including fatigue, drowsiness,

and marked anti-cholinergic effects including dry mouth. In the past

decade, increasing experience has been gained with a new generation

of anti-depressants including selective serotinin reuptake

inhibitors (SSRIs), selective noradrenalin reuptake inhibitors

(SNRIs), and related other other related medications whose effect is

to modulate the intracellular action of neurotransmitters in various

parts of the brain whose imbalance is thought to be a causative

factor in depression.

There is aan increasing consensus of growing groundswell of medical

opinion that it might be is possible to define conditions which

would to allow the use of anti-depressive medications in aircrew in

certain very specific and limited circumstances which would not

compromise flight safety or operational effectiveness, and would

allow the preservation trained aircrew resources.

A symposium debating discussing this issue was held at the 1999

Annual Scientific Meeting of the Aerospace Medical Association, and

although the position taken by formal licencing agency

representatives such as the FAA was that it was " against

regulations " , much of the input focussed on the depth of the problem

in aircrew, the operational considerations, and the requirement for

specific guidelines to consider the limited use of such medications

With this information and repeated requests for SSRI use in aircrew

from Flight Surgeons, the Central Medical Board including the 1CAD

Flight Surgeon and the Medical Advisor to the CAS recommended that

CMB convene a Symposium to discuss the possible use of SSRI

medication in CF aircrew. This Symposium was held at DCIEM 6

December 1999, with presentations by Dr. S. Kennedy, Professor of

Psychiatry at the University of Toronto, Dr. Flynn, previous

USAF Chief of Psychiatry at the USAFSAM Aeromedical Consult Service

and currently NASA Flight Surgeon and Chairman of the International

Space Station Human Behaviour and Performance Working Group, and Dr.

Marvin Lange, ex-CF aircrew and previous Chief of Psychiatry at NDMC

and currently the psychiatric consultant to the Civil Aviation

Medicine Aviation Medical Review Board.

Based on the information presented at the seminar and the following

discussions which addressed flight safety and operational concerns

in the various aircrew roles, the Central Medical Board has

recommended the following policy regarding the use of SSRI/SNRI

medications in CF aircrew, based on accredited medical opinion.

Indications For Use

Major depression (or recurrence) including post-partum

Uncomplicated illness

No psychosis

No suicidal behaviour

No significant anxiety component

[index of Flight Surgeon's Guidelines]

[Top]

AIRCREW ELIGIBILITY FOR RETURNING TO FLYING DUTIES

ELIGIBLE UNDER SPECIFIC PROTOCOL ELIGIBLE WITH CASE MANAGEMENT AT

WING INELIGIBLE FOR FLYING DUTIES ON SSRIs

Pilots – transport pilots, strategic airlift only; maritime patrol

pilots on non-ASW missions only Flight Nurses All other pilot roles

Navigators

Non-Tac roles only??? Flight Med As SAR Techs

Flight Engineers Non Tac Hel roles only??? Flight Surgeons

AECs/ACOPs

AMTOs/AMTs

AESOPs

Flight Attendants

Loadmasters

[index of Flight Surgeon's Guidelines]

[Top]

PROTOCOL

Eligible aircrew will be managed initially at Wing/Base level by the

Flight Surgeon with a psychiatric consultation to provide assessment

and treatment recommendations. At this stage, the aim is to provide

optimal clinical management and support. At this stage, During

initial treatment , aircrew will be grounded and geographically

restricted to allow appropriate treatment and follow-up (G4 (T6) –

requires specialist follow-up; unfit deployment, A7 (T6) – unfit

aircrew duties). During this period, the Flight Surgeon should

liaise with the Head/Central Medical Board regarding the

individual's status and potential consideration for return to flying

duties.

Recommended Medications

Sertraline

Bupropion

For consideration for return to flight status, the above two

medications are recommended based on side-effect profiles including

lack of drowsiness and CNS depression. If in the opinion of the

psychiatrist providing clinical management a different medication is

preferable on clinical grounds, priority should clearly be given to

providing optimal clinical management.

Six months following resolution of clinical symptoms of depression

as confirmed by the attending Flight Surgeon and psychiatric

consultant, consideration can be given to return to flight duties.

This will require the following:

Referral to DCIEM/Medical Assessment Section for

Clinical aeromedical review

Neurocognitive testing (Cogscreen Aeromed)

Referral to Dr. Marvin Lange at the Royal Ottawa Hospital. This

referral ideally should be co-ordinated with the visit to DCIEM.

Appointments with Dr. Lange can be arranged by contacting his

secretary at 613.722-6521 extension 6306, indicating the referral is

for a CF aircrew for SSRI flight status assessment.

It is imperative that these referrals be accompanied by a detailed

clinical referral letter from the attendingg Flight Surgeon as well

as copies of all consultation information from the consultant

clinical psychiatrist.

Ops assessment and Command endorsement. This should be arranged once

a " good-to-go " decision has been approved from the Central Medical

Board based on the above assessments.

Once these conditions have been satisfied, aircrew may be returned

to restricted duties. A CF2033/CF2088 should be raised and forwarded

to DCIEM/CMB, to include the Ops assessment and Command endorsement.

GEOGRAPHIC & OPERATIONAL FLYING RESTRICTIONS WHILE ON TREATMENT

While on treatment with SSRI/SNRI medications for treatment/control

of depression, aircrew should be assigned the following temporary

restrictions:

Air Factor

Pilots

A3(T6) – restricted to fly with or as copilot, restricted to

strategic transport operations or non-ASW Aurora operations only

with a pilot/copilot not on SSRI/SNRIs

Other Aircrew

No operational flying restriction required

Geographic

G4 (T6) – requires medical follow-up at minimum of three monthly

intervals, unfit deployments exceeding 8 weeks. Annual follow-up at

DCIEM/CMB and by Dr. Lange required while on medication.

OTHER AIRCREW – MANAGEMENT AT THE WING

Flight Nurses, Flight Med As and Flight Surgeons once stabilized on

treatment may be returned to A4 status with the same temporary G4

geographic restrictions as noted above ie requires regular follow-up

at minimum three monthly intervals, unfit deployment.

Neurocognitive Laboratory Assessment Of SSRIs:

In parallel with this limited introduction of of SSRIs in aircrew,

DCIEM will undertake a study of the neurocognitive effects of one or

more selected SSRI medications in a controlled laboratory

environment. This, along with information gained from the restricted

clinical use in aircrew, will hopefully allow more in-depth

conclusions to be made as to the potential for use in other aircrew

such as pilots in other operational roles, or for other clinical

indications.

[index of Flight Surgeon's Guidelines]

Last Updated: 2003-05-26 Important Notices

[Guest guest]

LIMITED USE OF SSRI/SNRI MEDICATION IN CF AIRCREW

BACKGROUND

Depressive illnesses are not uncommon in the general population,

occuring with an incidence lifetime prevalence of 5- 20% depending

on the population studied, and it is likely that the prevalence in

the aircrew population is within this range and this incidence is

reflected in the aircrew population. Because of various factors

including the stigma associated with psychiatric diagnoses, the

prolonged grounding period required for pharmacologic treatment, and

the delay in returning to flight duties even after treatment is

completed, aircrew are generally reluctant to come forward to

discuss depressive symptoms with their Flight Surgeon, and

depression is infrequently diagnosed. Depressive symptoms are often

camoflaged beneath somatic complaints, or self-treated with

available drugs such as alcohol. This situation often results in

aircrew trying to " tough it through " a significant depressive

illness, with resulting significant degredation of performance.

Once medically diagnosed and pharmacologic treatment has been

initiated, current therapeutic guidelines recommend up to a year of

treatment with antidepressant medications, which for aircrew is

followed by a further period of up to three months of observation

before a return to flight duties is recommended. Fifteen months off

flying duties for most aircrew means a significant retraining period

before being operationally qualified again. This amounts to quite a

chunk out of an operational tour, complicated by the fact that since

the aircrew is not on MPHL, a replacement can not be posted in

against his/her position.

Further, if an aircrew recovers from one episode of depression and

is unlucky enough to be one of the 50% who suffer a second episode

sometime later, the current psychiatric recommendation is to treat

again with medications, but then to leave the individual on life-

long prophylactic medication. Given the current aeromedical

approach, this essentially means the end of a flying career.

Previous anti-depressive medications generally had side-effects

quite incompatible with flying duties including fatigue, drowsiness,

and marked anti-cholinergic effects including dry mouth. In the past

decade, increasing experience has been gained with a new generation

of anti-depressants including selective serotinin reuptake

inhibitors (SSRIs), selective noradrenalin reuptake inhibitors

(SNRIs), and related other other related medications whose effect is

to modulate the intracellular action of neurotransmitters in various

parts of the brain whose imbalance is thought to be a causative

factor in depression.

There is aan increasing consensus of growing groundswell of medical

opinion that it might be is possible to define conditions which

would to allow the use of anti-depressive medications in aircrew in

certain very specific and limited circumstances which would not

compromise flight safety or operational effectiveness, and would

allow the preservation trained aircrew resources.

A symposium debating discussing this issue was held at the 1999

Annual Scientific Meeting of the Aerospace Medical Association, and

although the position taken by formal licencing agency

representatives such as the FAA was that it was " against

regulations " , much of the input focussed on the depth of the problem

in aircrew, the operational considerations, and the requirement for

specific guidelines to consider the limited use of such medications

With this information and repeated requests for SSRI use in aircrew

from Flight Surgeons, the Central Medical Board including the 1CAD

Flight Surgeon and the Medical Advisor to the CAS recommended that

CMB convene a Symposium to discuss the possible use of SSRI

medication in CF aircrew. This Symposium was held at DCIEM 6

December 1999, with presentations by Dr. S. Kennedy, Professor of

Psychiatry at the University of Toronto, Dr. Flynn, previous

USAF Chief of Psychiatry at the USAFSAM Aeromedical Consult Service

and currently NASA Flight Surgeon and Chairman of the International

Space Station Human Behaviour and Performance Working Group, and Dr.

Marvin Lange, ex-CF aircrew and previous Chief of Psychiatry at NDMC

and currently the psychiatric consultant to the Civil Aviation

Medicine Aviation Medical Review Board.

Based on the information presented at the seminar and the following

discussions which addressed flight safety and operational concerns

in the various aircrew roles, the Central Medical Board has

recommended the following policy regarding the use of SSRI/SNRI

medications in CF aircrew, based on accredited medical opinion.

Indications For Use

Major depression (or recurrence) including post-partum

Uncomplicated illness

No psychosis

No suicidal behaviour

No significant anxiety component

[index of Flight Surgeon's Guidelines]

[Top]

AIRCREW ELIGIBILITY FOR RETURNING TO FLYING DUTIES

ELIGIBLE UNDER SPECIFIC PROTOCOL ELIGIBLE WITH CASE MANAGEMENT AT

WING INELIGIBLE FOR FLYING DUTIES ON SSRIs

Pilots – transport pilots, strategic airlift only; maritime patrol

pilots on non-ASW missions only Flight Nurses All other pilot roles

Navigators

Non-Tac roles only??? Flight Med As SAR Techs

Flight Engineers Non Tac Hel roles only??? Flight Surgeons

AECs/ACOPs

AMTOs/AMTs

AESOPs

Flight Attendants

Loadmasters

[index of Flight Surgeon's Guidelines]

[Top]

PROTOCOL

Eligible aircrew will be managed initially at Wing/Base level by the

Flight Surgeon with a psychiatric consultation to provide assessment

and treatment recommendations. At this stage, the aim is to provide

optimal clinical management and support. At this stage, During

initial treatment , aircrew will be grounded and geographically

restricted to allow appropriate treatment and follow-up (G4 (T6) –

requires specialist follow-up; unfit deployment, A7 (T6) – unfit

aircrew duties). During this period, the Flight Surgeon should

liaise with the Head/Central Medical Board regarding the

individual's status and potential consideration for return to flying

duties.

Recommended Medications

Sertraline

Bupropion

For consideration for return to flight status, the above two

medications are recommended based on side-effect profiles including

lack of drowsiness and CNS depression. If in the opinion of the

psychiatrist providing clinical management a different medication is

preferable on clinical grounds, priority should clearly be given to

providing optimal clinical management.

Six months following resolution of clinical symptoms of depression

as confirmed by the attending Flight Surgeon and psychiatric

consultant, consideration can be given to return to flight duties.

This will require the following:

Referral to DCIEM/Medical Assessment Section for

Clinical aeromedical review

Neurocognitive testing (Cogscreen Aeromed)

Referral to Dr. Marvin Lange at the Royal Ottawa Hospital. This

referral ideally should be co-ordinated with the visit to DCIEM.

Appointments with Dr. Lange can be arranged by contacting his

secretary at 613.722-6521 extension 6306, indicating the referral is

for a CF aircrew for SSRI flight status assessment.

It is imperative that these referrals be accompanied by a detailed

clinical referral letter from the attendingg Flight Surgeon as well

as copies of all consultation information from the consultant

clinical psychiatrist.

Ops assessment and Command endorsement. This should be arranged once

a " good-to-go " decision has been approved from the Central Medical

Board based on the above assessments.

Once these conditions have been satisfied, aircrew may be returned

to restricted duties. A CF2033/CF2088 should be raised and forwarded

to DCIEM/CMB, to include the Ops assessment and Command endorsement.

GEOGRAPHIC & OPERATIONAL FLYING RESTRICTIONS WHILE ON TREATMENT

While on treatment with SSRI/SNRI medications for treatment/control

of depression, aircrew should be assigned the following temporary

restrictions:

Air Factor

Pilots

A3(T6) – restricted to fly with or as copilot, restricted to

strategic transport operations or non-ASW Aurora operations only

with a pilot/copilot not on SSRI/SNRIs

Other Aircrew

No operational flying restriction required

Geographic

G4 (T6) – requires medical follow-up at minimum of three monthly

intervals, unfit deployments exceeding 8 weeks. Annual follow-up at

DCIEM/CMB and by Dr. Lange required while on medication.

OTHER AIRCREW – MANAGEMENT AT THE WING

Flight Nurses, Flight Med As and Flight Surgeons once stabilized on

treatment may be returned to A4 status with the same temporary G4

geographic restrictions as noted above ie requires regular follow-up

at minimum three monthly intervals, unfit deployment.

Neurocognitive Laboratory Assessment Of SSRIs:

In parallel with this limited introduction of of SSRIs in aircrew,

DCIEM will undertake a study of the neurocognitive effects of one or

more selected SSRI medications in a controlled laboratory

environment. This, along with information gained from the restricted

clinical use in aircrew, will hopefully allow more in-depth

conclusions to be made as to the potential for use in other aircrew

such as pilots in other operational roles, or for other clinical

indications.

[index of Flight Surgeon's Guidelines]

Last Updated: 2003-05-26 Important Notices

[Guest guest]

LIMITED USE OF SSRI/SNRI MEDICATION IN CF AIRCREW

BACKGROUND

Depressive illnesses are not uncommon in the general population,

occuring with an incidence lifetime prevalence of 5- 20% depending

on the population studied, and it is likely that the prevalence in

the aircrew population is within this range and this incidence is

reflected in the aircrew population. Because of various factors

including the stigma associated with psychiatric diagnoses, the

prolonged grounding period required for pharmacologic treatment, and

the delay in returning to flight duties even after treatment is

completed, aircrew are generally reluctant to come forward to

discuss depressive symptoms with their Flight Surgeon, and

depression is infrequently diagnosed. Depressive symptoms are often

camoflaged beneath somatic complaints, or self-treated with

available drugs such as alcohol. This situation often results in

aircrew trying to " tough it through " a significant depressive

illness, with resulting significant degredation of performance.

Once medically diagnosed and pharmacologic treatment has been

initiated, current therapeutic guidelines recommend up to a year of

treatment with antidepressant medications, which for aircrew is

followed by a further period of up to three months of observation

before a return to flight duties is recommended. Fifteen months off

flying duties for most aircrew means a significant retraining period

before being operationally qualified again. This amounts to quite a

chunk out of an operational tour, complicated by the fact that since

the aircrew is not on MPHL, a replacement can not be posted in

against his/her position.

Further, if an aircrew recovers from one episode of depression and

is unlucky enough to be one of the 50% who suffer a second episode

sometime later, the current psychiatric recommendation is to treat

again with medications, but then to leave the individual on life-

long prophylactic medication. Given the current aeromedical

approach, this essentially means the end of a flying career.

Previous anti-depressive medications generally had side-effects

quite incompatible with flying duties including fatigue, drowsiness,

and marked anti-cholinergic effects including dry mouth. In the past

decade, increasing experience has been gained with a new generation

of anti-depressants including selective serotinin reuptake

inhibitors (SSRIs), selective noradrenalin reuptake inhibitors

(SNRIs), and related other other related medications whose effect is

to modulate the intracellular action of neurotransmitters in various

parts of the brain whose imbalance is thought to be a causative

factor in depression.

There is aan increasing consensus of growing groundswell of medical

opinion that it might be is possible to define conditions which

would to allow the use of anti-depressive medications in aircrew in

certain very specific and limited circumstances which would not

compromise flight safety or operational effectiveness, and would

allow the preservation trained aircrew resources.

A symposium debating discussing this issue was held at the 1999

Annual Scientific Meeting of the Aerospace Medical Association, and

although the position taken by formal licencing agency

representatives such as the FAA was that it was " against

regulations " , much of the input focussed on the depth of the problem

in aircrew, the operational considerations, and the requirement for

specific guidelines to consider the limited use of such medications

With this information and repeated requests for SSRI use in aircrew

from Flight Surgeons, the Central Medical Board including the 1CAD

Flight Surgeon and the Medical Advisor to the CAS recommended that

CMB convene a Symposium to discuss the possible use of SSRI

medication in CF aircrew. This Symposium was held at DCIEM 6

December 1999, with presentations by Dr. S. Kennedy, Professor of

Psychiatry at the University of Toronto, Dr. Flynn, previous

USAF Chief of Psychiatry at the USAFSAM Aeromedical Consult Service

and currently NASA Flight Surgeon and Chairman of the International

Space Station Human Behaviour and Performance Working Group, and Dr.

Marvin Lange, ex-CF aircrew and previous Chief of Psychiatry at NDMC

and currently the psychiatric consultant to the Civil Aviation

Medicine Aviation Medical Review Board.

Based on the information presented at the seminar and the following

discussions which addressed flight safety and operational concerns

in the various aircrew roles, the Central Medical Board has

recommended the following policy regarding the use of SSRI/SNRI

medications in CF aircrew, based on accredited medical opinion.

Indications For Use

Major depression (or recurrence) including post-partum

Uncomplicated illness

No psychosis

No suicidal behaviour

No significant anxiety component

[index of Flight Surgeon's Guidelines]

[Top]

AIRCREW ELIGIBILITY FOR RETURNING TO FLYING DUTIES

ELIGIBLE UNDER SPECIFIC PROTOCOL ELIGIBLE WITH CASE MANAGEMENT AT

WING INELIGIBLE FOR FLYING DUTIES ON SSRIs

Pilots – transport pilots, strategic airlift only; maritime patrol

pilots on non-ASW missions only Flight Nurses All other pilot roles

Navigators

Non-Tac roles only??? Flight Med As SAR Techs

Flight Engineers Non Tac Hel roles only??? Flight Surgeons

AECs/ACOPs

AMTOs/AMTs

AESOPs

Flight Attendants

Loadmasters

[index of Flight Surgeon's Guidelines]

[Top]

PROTOCOL

Eligible aircrew will be managed initially at Wing/Base level by the

Flight Surgeon with a psychiatric consultation to provide assessment

and treatment recommendations. At this stage, the aim is to provide

optimal clinical management and support. At this stage, During

initial treatment , aircrew will be grounded and geographically

restricted to allow appropriate treatment and follow-up (G4 (T6) –

requires specialist follow-up; unfit deployment, A7 (T6) – unfit

aircrew duties). During this period, the Flight Surgeon should

liaise with the Head/Central Medical Board regarding the

individual's status and potential consideration for return to flying

duties.

Recommended Medications

Sertraline

Bupropion

For consideration for return to flight status, the above two

medications are recommended based on side-effect profiles including

lack of drowsiness and CNS depression. If in the opinion of the

psychiatrist providing clinical management a different medication is

preferable on clinical grounds, priority should clearly be given to

providing optimal clinical management.

Six months following resolution of clinical symptoms of depression

as confirmed by the attending Flight Surgeon and psychiatric

consultant, consideration can be given to return to flight duties.

This will require the following:

Referral to DCIEM/Medical Assessment Section for

Clinical aeromedical review

Neurocognitive testing (Cogscreen Aeromed)

Referral to Dr. Marvin Lange at the Royal Ottawa Hospital. This

referral ideally should be co-ordinated with the visit to DCIEM.

Appointments with Dr. Lange can be arranged by contacting his

secretary at 613.722-6521 extension 6306, indicating the referral is

for a CF aircrew for SSRI flight status assessment.

It is imperative that these referrals be accompanied by a detailed

clinical referral letter from the attendingg Flight Surgeon as well

as copies of all consultation information from the consultant

clinical psychiatrist.

Ops assessment and Command endorsement. This should be arranged once

a " good-to-go " decision has been approved from the Central Medical

Board based on the above assessments.

Once these conditions have been satisfied, aircrew may be returned

to restricted duties. A CF2033/CF2088 should be raised and forwarded

to DCIEM/CMB, to include the Ops assessment and Command endorsement.

GEOGRAPHIC & OPERATIONAL FLYING RESTRICTIONS WHILE ON TREATMENT

While on treatment with SSRI/SNRI medications for treatment/control

of depression, aircrew should be assigned the following temporary

restrictions:

Air Factor

Pilots

A3(T6) – restricted to fly with or as copilot, restricted to

strategic transport operations or non-ASW Aurora operations only

with a pilot/copilot not on SSRI/SNRIs

Other Aircrew

No operational flying restriction required

Geographic

G4 (T6) – requires medical follow-up at minimum of three monthly

intervals, unfit deployments exceeding 8 weeks. Annual follow-up at

DCIEM/CMB and by Dr. Lange required while on medication.

OTHER AIRCREW – MANAGEMENT AT THE WING

Flight Nurses, Flight Med As and Flight Surgeons once stabilized on

treatment may be returned to A4 status with the same temporary G4

geographic restrictions as noted above ie requires regular follow-up

at minimum three monthly intervals, unfit deployment.

Neurocognitive Laboratory Assessment Of SSRIs:

In parallel with this limited introduction of of SSRIs in aircrew,

DCIEM will undertake a study of the neurocognitive effects of one or

more selected SSRI medications in a controlled laboratory

environment. This, along with information gained from the restricted

clinical use in aircrew, will hopefully allow more in-depth

conclusions to be made as to the potential for use in other aircrew

such as pilots in other operational roles, or for other clinical

indications.

[index of Flight Surgeon's Guidelines]

Last Updated: 2003-05-26 Important Notices

[Guest guest]

LIMITED USE OF SSRI/SNRI MEDICATION IN CF AIRCREW

BACKGROUND

Depressive illnesses are not uncommon in the general population,

occuring with an incidence lifetime prevalence of 5- 20% depending

on the population studied, and it is likely that the prevalence in

the aircrew population is within this range and this incidence is

reflected in the aircrew population. Because of various factors

including the stigma associated with psychiatric diagnoses, the

prolonged grounding period required for pharmacologic treatment, and

the delay in returning to flight duties even after treatment is

completed, aircrew are generally reluctant to come forward to

discuss depressive symptoms with their Flight Surgeon, and

depression is infrequently diagnosed. Depressive symptoms are often

camoflaged beneath somatic complaints, or self-treated with

available drugs such as alcohol. This situation often results in

aircrew trying to " tough it through " a significant depressive

illness, with resulting significant degredation of performance.

Once medically diagnosed and pharmacologic treatment has been

initiated, current therapeutic guidelines recommend up to a year of

treatment with antidepressant medications, which for aircrew is

followed by a further period of up to three months of observation

before a return to flight duties is recommended. Fifteen months off

flying duties for most aircrew means a significant retraining period

before being operationally qualified again. This amounts to quite a

chunk out of an operational tour, complicated by the fact that since

the aircrew is not on MPHL, a replacement can not be posted in

against his/her position.

Further, if an aircrew recovers from one episode of depression and

is unlucky enough to be one of the 50% who suffer a second episode

sometime later, the current psychiatric recommendation is to treat

again with medications, but then to leave the individual on life-

long prophylactic medication. Given the current aeromedical

approach, this essentially means the end of a flying career.

Previous anti-depressive medications generally had side-effects

quite incompatible with flying duties including fatigue, drowsiness,

and marked anti-cholinergic effects including dry mouth. In the past

decade, increasing experience has been gained with a new generation

of anti-depressants including selective serotinin reuptake

inhibitors (SSRIs), selective noradrenalin reuptake inhibitors

(SNRIs), and related other other related medications whose effect is

to modulate the intracellular action of neurotransmitters in various

parts of the brain whose imbalance is thought to be a causative

factor in depression.

There is aan increasing consensus of growing groundswell of medical

opinion that it might be is possible to define conditions which

would to allow the use of anti-depressive medications in aircrew in

certain very specific and limited circumstances which would not

compromise flight safety or operational effectiveness, and would

allow the preservation trained aircrew resources.

A symposium debating discussing this issue was held at the 1999

Annual Scientific Meeting of the Aerospace Medical Association, and

although the position taken by formal licencing agency

representatives such as the FAA was that it was " against

regulations " , much of the input focussed on the depth of the problem

in aircrew, the operational considerations, and the requirement for

specific guidelines to consider the limited use of such medications

With this information and repeated requests for SSRI use in aircrew

from Flight Surgeons, the Central Medical Board including the 1CAD

Flight Surgeon and the Medical Advisor to the CAS recommended that

CMB convene a Symposium to discuss the possible use of SSRI

medication in CF aircrew. This Symposium was held at DCIEM 6

December 1999, with presentations by Dr. S. Kennedy, Professor of

Psychiatry at the University of Toronto, Dr. Flynn, previous

USAF Chief of Psychiatry at the USAFSAM Aeromedical Consult Service

and currently NASA Flight Surgeon and Chairman of the International

Space Station Human Behaviour and Performance Working Group, and Dr.

Marvin Lange, ex-CF aircrew and previous Chief of Psychiatry at NDMC

and currently the psychiatric consultant to the Civil Aviation

Medicine Aviation Medical Review Board.

Based on the information presented at the seminar and the following

discussions which addressed flight safety and operational concerns

in the various aircrew roles, the Central Medical Board has

recommended the following policy regarding the use of SSRI/SNRI

medications in CF aircrew, based on accredited medical opinion.

Indications For Use

Major depression (or recurrence) including post-partum

Uncomplicated illness

No psychosis

No suicidal behaviour

No significant anxiety component

[index of Flight Surgeon's Guidelines]

[Top]

AIRCREW ELIGIBILITY FOR RETURNING TO FLYING DUTIES

ELIGIBLE UNDER SPECIFIC PROTOCOL ELIGIBLE WITH CASE MANAGEMENT AT

WING INELIGIBLE FOR FLYING DUTIES ON SSRIs

Pilots – transport pilots, strategic airlift only; maritime patrol

pilots on non-ASW missions only Flight Nurses All other pilot roles

Navigators

Non-Tac roles only??? Flight Med As SAR Techs

Flight Engineers Non Tac Hel roles only??? Flight Surgeons

AECs/ACOPs

AMTOs/AMTs

AESOPs

Flight Attendants

Loadmasters

[index of Flight Surgeon's Guidelines]

[Top]

PROTOCOL

Eligible aircrew will be managed initially at Wing/Base level by the

Flight Surgeon with a psychiatric consultation to provide assessment

and treatment recommendations. At this stage, the aim is to provide

optimal clinical management and support. At this stage, During

initial treatment , aircrew will be grounded and geographically

restricted to allow appropriate treatment and follow-up (G4 (T6) –

requires specialist follow-up; unfit deployment, A7 (T6) – unfit

aircrew duties). During this period, the Flight Surgeon should

liaise with the Head/Central Medical Board regarding the

individual's status and potential consideration for return to flying

duties.

Recommended Medications

Sertraline

Bupropion

For consideration for return to flight status, the above two

medications are recommended based on side-effect profiles including

lack of drowsiness and CNS depression. If in the opinion of the

psychiatrist providing clinical management a different medication is

preferable on clinical grounds, priority should clearly be given to

providing optimal clinical management.

Six months following resolution of clinical symptoms of depression

as confirmed by the attending Flight Surgeon and psychiatric

consultant, consideration can be given to return to flight duties.

This will require the following:

Referral to DCIEM/Medical Assessment Section for

Clinical aeromedical review

Neurocognitive testing (Cogscreen Aeromed)

Referral to Dr. Marvin Lange at the Royal Ottawa Hospital. This

referral ideally should be co-ordinated with the visit to DCIEM.

Appointments with Dr. Lange can be arranged by contacting his

secretary at 613.722-6521 extension 6306, indicating the referral is

for a CF aircrew for SSRI flight status assessment.

It is imperative that these referrals be accompanied by a detailed

clinical referral letter from the attendingg Flight Surgeon as well

as copies of all consultation information from the consultant

clinical psychiatrist.

Ops assessment and Command endorsement. This should be arranged once

a " good-to-go " decision has been approved from the Central Medical

Board based on the above assessments.

Once these conditions have been satisfied, aircrew may be returned

to restricted duties. A CF2033/CF2088 should be raised and forwarded

to DCIEM/CMB, to include the Ops assessment and Command endorsement.

GEOGRAPHIC & OPERATIONAL FLYING RESTRICTIONS WHILE ON TREATMENT

While on treatment with SSRI/SNRI medications for treatment/control

of depression, aircrew should be assigned the following temporary

restrictions:

Air Factor

Pilots

A3(T6) – restricted to fly with or as copilot, restricted to

strategic transport operations or non-ASW Aurora operations only

with a pilot/copilot not on SSRI/SNRIs

Other Aircrew

No operational flying restriction required

Geographic

G4 (T6) – requires medical follow-up at minimum of three monthly

intervals, unfit deployments exceeding 8 weeks. Annual follow-up at

DCIEM/CMB and by Dr. Lange required while on medication.

OTHER AIRCREW – MANAGEMENT AT THE WING

Flight Nurses, Flight Med As and Flight Surgeons once stabilized on

treatment may be returned to A4 status with the same temporary G4

geographic restrictions as noted above ie requires regular follow-up

at minimum three monthly intervals, unfit deployment.

Neurocognitive Laboratory Assessment Of SSRIs:

In parallel with this limited introduction of of SSRIs in aircrew,

DCIEM will undertake a study of the neurocognitive effects of one or

more selected SSRI medications in a controlled laboratory

environment. This, along with information gained from the restricted

clinical use in aircrew, will hopefully allow more in-depth

conclusions to be made as to the potential for use in other aircrew

such as pilots in other operational roles, or for other clinical

indications.

[index of Flight Surgeon's Guidelines]

Last Updated: 2003-05-26 Important Notices