Getting to Yes
By Dr. Susan Northrup, FAA Federal Air Surgeon
In the May/Jun 2024 issue of the FAA Safety Briefing, I reviewed some fatal accidents where either a mental health diagnosis and/or drug (some illicit) contributed. These were examples of why we do not authorize some diagnoses and treatments for flying.
Now I would like to review what we have done over the past decades to allow more pilots with formerly disqualifying conditions to fly (after appropriate evaluation and treatment).
Before we do that, recall that the FAA medical examination can differ from a clinical evaluation. The FAA exam is more akin to an occupational exam. Our goal is to determine if someone can safely operate in the National Airspace System (NAS). As such, we sometimes ask for testing, which would not be requested for routine clinical management. We also do not allow some treatment options, which may adversely impact aviation safety.
Long ago, the professional aviation community recognized that alcohol abuse was a significant safety issue; however, it was often hidden due to concerns that disclosure was career-ending. In the 1970s, the FAA, industry, and the unions collaborated to develop the current HIMS (Human Intervention Motivational Study) program. FYI, the program was purposely called HIMS to avoid any negative attention since it was designed to return pilots to the cockpit despite a known substance abuse disorder once in satisfactory recovery. To date, thousands of pilots have successfully been treated, monitored, and returned to both the flight deck and sobriety. The 85% success rate is among the highest of similar programs.
Significant cardiac disease was once a permanent grounding item. If you had a heart attack, you could not fly again as a crew member. Since the early 1980s, coronary bypass graft surgeries, balloon angioplasty, stenting, and valve replacement have become almost routine, and thousands of pilots with these procedures have been returned to flight status. We convene a team of cardiologists to review these cases on a regular basis. We often request additional testing, but remember, we are not evaluating just your clinical care, but the risk to aviation safety.
Insulin-treated diabetes mellitus was also permanently disqualifying for many years. Both a low blood sugar and one too high can impair cognition. In the 1980s, the FAA first authorized non-insulin treatment of diabetes for pilots. In 1996, the FAA approved a protocol for the use of insulin by pilots holding a Class III medical. Technology continued to advance, and the FAA began authorization of insulin-treated pilots with diabetes for Class I and II medical certificates in 2019 if they demonstrate excellent control. To date, more than 250 pilots have been authorized for a Class I or II medical despite using insulin to control their diabetes.
ADHD, attention deficit hyperactivity disorder, is a diagnosis seen much more frequently now than a few decades ago. Some of this is due to better recognition; unfortunately, some is due to overdiagnosis. We have recently looked at our records of those with this diagnosis and the outcomes of the evaluations that we required. As a result, we have been able to institute a fast-track pathway to more rapid approval for those who are off medications and have functioned well (such as occupational or academic success without accommodation) for at least four years.
Depression and the use of anti-depressants have been particularly challenging for the FAA to approve. Why? Both the medications and the underlying diagnosis can impair executive functions such as problem-solving and decision-making. In other words, both can impair one’s ability to recognize self-impairment. After careful research and discussion, we authorized four SSRIs (selective serotonin reuptake inhibitors) under a specific protocol in 2010. This program has been very successful. Over the past year, we have added an additional four medications as acceptable treatments of depression and anxiety.
While we cannot approve everyone, we have steadily increased the number of conditions that we can approve after appropriate evaluation and treatment. Both the treatment and condition must be aeromedically acceptable; this has been and will remain challenging. Nonetheless, we will continue our efforts to get to “yes” when it is safe to do so.
Dr. Susan Northrup received a bachelor’s degree in chemistry, a medical degree from The Ohio State University, and a master’s degree in public health from the University of Texas. She is double board-certified by the American Board of Preventive Medicine in Aerospace Medicine and Occupational Medicine. She is a retired U.S. Air Force colonel and a former regional medical director for Delta Air Lines. She is also an active private pilot.
