RX AVIATION — SSRIs and the Airman…..

Stan Musick | stan@agairupdate.com

SSRIs (Selective Serotonin Uptake Reinhibitors) have become very commonly used in today’s medical practice. They have been shown effective in treating chronic pain, premenstrual syndrome (PMS), depression, anxiety, and have been used in smoking cessation therapy. Typical ones are Prozac, Lexapro, Zoloft, Celexa, and Wellbutrin.

Apart from the obvious jokes about “aerial application can be depressing”, it is all too common for a healthcare provider to quickly put a pilot on one of these medications without considering the aeromedical implications. I hope to provide an overview that will help if you have been put on one of these medications, or perhaps have need of one.

There are two areas of concern in the use of SSRIs. One is the diagnosis itself…many of the indications for use of an SSRI reflect potential mental impairment, which in and of itself is medically disqualifying. The second is the effect that SSRIs have on the central nervous system (CNS). CNS effects can be debilitating…headache, drowsiness, agitation…which obviously can interfere with safe flying.

Two pathways exist for someone on an SSRI. One is to discontinue the medication, the other is to go through the Special Issuance process to continue to take the medication and still fly. The path chosen will depend on diagnosis, medication, and your response to the medication.

If you choose to discontinue the use of an SSRI, you must be off the medication for 60 days. After that 60s days (this is important…you must be off the medication for 60 days prior to evaluation), your treating physician will need to generate a report noting stable mood and no adverse effects. Application can then be made for regular issuance of a medical. Note, however, that the FAA may still require reports from your treating physician.

Continuing the SSRI is an option, if it is one of the acceptable four medications…Prozac, Lexapro, Zoloft or Celexa. Note that Wellbutrin is NOT acceptable! To continue the medication you must be on the medication for at least six months, with stable dosage and no side effects. One of four diagnoses are acceptable…major depression, dysthymic disorder, adjustment disorder with depressed mood, or use of the SSRI for a nondepression related disorder.

If there is a history of suicidal ideation (consideration of suicide), psychosis, electroconvulsive therapy (shock therapy), multiple simultaneous SSRIs or use of other psychoactive medications with the SSRI, issuance is not allowed. Important to note is that even if an airman meets all the above criteria, issuance will still be on a case-by-case basis.

To proceed, the airman must be evaluated by a HIMS (Human Intervention Motivational Specialist) AME. The HIMS AME must review all your records, including the records from when you were having symptoms, and not treated, through the treatment. Evaluation by a board-certified psychiatrist is necessary for initial issuance, as is an evaluation by a neuropsychologist. Specific reports are required from your treating physician. In addition, a report from your chief pilot/operator is required. All of the above must be reviewed by the FAA, and then the HIMS AME can issue. ➤

In addition, a statement from the airman is required, reviewing the symptoms, the providers you have seen (including the dates), and any medications you have taken in the past. Any hospitalizations due to mental health conditions, as well as a current status statement must be included. All of this must be reviewed, and approved by the FAA, and then the HIMS AME can issue.

Repeat issuance has specific requirements…a HIMS AME evaluation and psychiatric evaluation every six month. A chief pilot report is required every three months, as well as an annual neuropsychologist evaluation. If the HIMS AME finds the above to be acceptable, he can reissue the certificate every year.

If a medication is prescribed for you, it is very important to ensure that there are no aeromedical implications prior to taking it! Consult with your AME, and be especially careful with any medication that affects your mood or level of consciousness. Medications which disqualify a pilot are sometimes prescribed inadvertently, when the prescribing healthcare provider doesn’t understand the aeromedical implications.

What about anxiolytics (Valium, Xanax (alprazolam),etc?) The underlying diagnosis would need to be reported, and the medication use reported. Medications that can cause drowsiness require a “five half-lives” wait from the last dose until the airman can fly. Xanax has a 11.5 hour half life, so almost 60 hours would need to elapse before flying after taking the last dose. Routine, regular use is not allowed.

“Human Factors” being what they are, it is known that some airmen use medications that aren’t approved, and simply don’t report them. Simply put, the downside is that if an incident/ accident occurs, toxicology will likely reveal their use…with subsequent potential certificate action and insurance issues.

Full details of the requirements for SSRIs can be found at the following FAA link: https://www. faa.gov/about/office_org/headquarters_offices/ avs/offices/aam/ame/guide/app_process/exam_ tech/item47/amd/antidepressants/

Medications which disqualify a pilot are sometimes prescribed inadvertently, when the prescribing healthcare provider doesn’t understand the aeromedical implications.