Shawnna M. Chee, PsyD, ABPP, and Daniel P. De Cecchis, MD
Mental health professionals and patients in sensitive employment situations, such as aviators, police officers, national security personnel, and surgeons, worry about the potential consequences of a psychiatric diagnosis and psychological treatment. Such “fitness for duty” evaluations are examples of mixed or dual agency clinical work. Using data about military aviators as an example, this project found that over 93% of the personnel who received mental health care received a medical recommendation (or “waiver”) to return to flying. Research with civilian aviators shows that 98% are granted approval to return to flying.
Major Smith (a fictitious character) is a 35-year-old male United States Marine Corps officer and a pilot in a tactical performance aircraft. After returning home from his latest deployment, his wife of several years filed for divorce and requested full custody of their young children. While initially shocked, he soon sought legal advice. After a few weeks of difficulty sleeping, angry outbursts and decreased appetite, he sought supportive counseling at the on-base support center. As the legal and financial pressures mounted over the next few months, Major Smith’s consumption of alcohol increased. This caused him to oversleep and miss an important pre-flight briefing at work. After missing this briefing, Major Smith’s flight surgeon was notified. After evaluating Major Smith, the flight surgeon entertained a diagnosis of an Adjustment Disorder, but decided not to formally diagnose the condition at the time given the command’s operational tempo. In coordination with the “Air Boss,” the flight surgeon decided to let Major Smith continue to fly, while monitoring his symptoms. Major Smith’s symptoms worsened over the next few months so the flight surgeon placed a referral for an appointment at the local Military Treatment Facility’s Behavioral Healthcare Department, knowing he may have to ground the aviator from flight duties. Six months after returning from deployment Major Smith was diagnosed with a Mood Disorder, Not Otherwise Specified by the uniformed military psychologist. After learning of the diagnosis, the flight surgeon formally “grounded” the aviator from further flights until his symptoms resolve.
Mental health professionals and clinicians worry when required to record a mental health diagnosis for someone in a safety-sensitive employment situation, such as a pilot, when that diagnosis could result in a temporary or permanent loss of employment (Kennedy & Zillmer, 2012). Military providers specifically may be tempted to utilize an alternative diagnosis (such as marital difficulties or child guidance issues) due to an internal ethical dilemma regarding the nature of the dual-agency within a military environment (Johnson, 2008). Dr. Johnson describes this dual-agency dilemma as “military psychologists may experience concerted pressure from both commands and military members themselves to downplay or ignore evidence of genuine pathology,” (p. 56). This pragmatic consideration might sway the compassionate practitioner to consider if there is a sufficient degree of subjectivity in the reported symptoms to allow for the application of a more “benign” diagnosis. This concern may also not be intentional, as “clinicians may inadvertently introduce bias through errors stemming from excessive sympathy or countertransference,” or from a lack of education or cultural competence in the specifics of the occupation they are trying to predict the potential ramifications of their symptoms (Bor, Erickson, Oakes & Scragg, 2017, p. 8).
This clinical challenge may face practitioners serving police officers, surgeons, national security personnel, and others in safety-sensitive positions where decision-making and performance are critical factors. Patients who are employed in such position shave a similar fear of perceived or actual stigma attached to seeking psychological services—and the consequences on their employment and income. This is a major concern expressed by Navy and Marine Corps aviators (Acosta, et. al., 2014). If one practices near a military base, this may be a clinical challenge faced weekly.
The stigma of mental health has been well-researched in civilian populations as well as with US military populations (Schreiber & McEnany, 2015) with regard to the negative occupational impact. Recent research has shown that despite significant efforts to enhance mental health programs for military service members on active duty (e.g., DoDI 6490.08) many service members are not seeking care when they experience psychological symptoms because of the perceived stigma of seeking mental health treatment—and out of fear that their careers will be jeopardized (Ben-Zeev, et al., 2012; Voyt, 2011). This fear, or stigma, of being labelled with a mental health diagnosis, and “real world” consequences, has fueled a perception among US Navy and Marine Corps aviation personnel that seeking treatment for even benign symptoms will permanently end their aviation careers. While we know that aviators do experience bouts of depression (Lollis, Marsh, Sowin & Thompson, 2009) and even have suicidal thoughts (Wu et al., 2016), many choose not to seek treatment for these symptoms, when, in fact, without appropriate treatment, these symptoms can have wide-ranging negative impacts on the quality of life and the social, emotional, and cognitive functioning of affected service members (Acosta, et. al., 2014). Furthermore, psychological problems have been reported to be a major cause of in-flight incapacitation and loss of license (Bor, Erickson, Oakes & Scragg, 2017).
There is evidence that civilian pilots have similar concerns regarding how a history of reporting mental health symptoms may impact their careers. Wu, et. al. reported that “mental health diagnoses are probable among airline pilots due to the public stigma of mental illness and fear among pilots of being ‘grounded’ or determined ‘not fit for duty,’” (2016, pg. 2). They utilized an anonymous survey to query nearly 3,500 civil aviation trained pilots about their physical and mental health, citing the method as necessary to avoid “underreporting of mental health symptoms” that otherwise would likely not be disclosed.
. . . mental health diagnoses are probable among airline pilots due to the public stigma of mental illness and fear among pilots of being "grounded" or determined "not fit for duty" . . .
Aviators’ fear of being “grounded” over receiving mental health treatment has a degree of validity to it. The Psychiatry section of the US Navy’s Aeromedical Reference and Waiver Guide (ARWG), which covers all Marine Corps personnel as well, currently requires that any service member on flight status who is diagnosed with any physically disqualifying condition (Major Depressive Disorder, Anxiety Disorder, Alcohol Use Disorder, etc.), depending on the severity of the disorder, must be immediately grounded due to “aeromedical concerns include safety of flight, mission completion, and crew coordination [and] these deficits may jeopardize both safety and mission execution in the highly dynamic aviation environment,” (US Navy, 2016, pg 4). However, it is important to note the qualifying phrase within that standard, namely, “depending on the severity of the disorder.” Thus, a mental health diagnosis is not an automatic and unconditional disqualifying condition.
What is not well publicized to fleet aviators (and the mental health professionals who treat them) is that after successful treatment of symptoms, they can request to return to flying through a “waiver” process initiated by their flight surgeon. For example, the ARWG has published typical waiting periods ranging from six to 12 months for depressive and anxiety diagnoses respectively before a service member of aviation status is eligible for waiver consideration (US Navy, 2016). In comparison, however, if a service member is diagnosed with an adjustment disorder, there is no prescribed waiting period. The service member is eligible to request waiver consideration once treatment is complete, if symptoms resolve within 60 days and they have been returned to full/unrestricted duty by the treating mental health provider. Thus, there are some “mixed signals” in the policies and procedures which support to some degree the concerns and worries of aviators and mental health professionals.
An understanding of the procedural context regarding waiver consideration is useful. For example, all Navy and Marine Corps active duty service members on flight status who have completed the recommended course of treatment and are no longer symptomatic (or meet criteria for a diagnosis) are required to request a waiver for that condition prior to returning to duties involving flight. After the waiver package is generated by the service member’s flight surgeon, it is submitted electronically through the Aeromedical Electronic Resource Office (AERO) to the Naval Aerospace Medical Institute (NAMI) for review. Each waiver package is reviewed by an aeromedical specialty care provider(s) who will then reach one of the following consensus decisions: (1) Waiver Granted (WG) to return to flight duties; (2) Waiver Denied (WD); or (3) more information is needed (DI).
. . . there are some "mixed signals" in the policies and procedures which support to some degree the concerns and worries of aviators and mental health professionals.
The perception is that the majority of waiver requests for mental health diagnoses are not recommended; an action which would permanently impact a military aviator’s ability to return to flight status. However, there are no published empirical data to support this perception for military personnel. For civil aviation, recent data released by the Federal Aviation Administration showed that, in 2015, 98% of all requests for a special issuance medical certificate (waiver) for psychiatric diagnoses were granted to return to flying (Giovanetti, 2016). This information prompted the current project regarding return to duty for Navy and Marine Corps aviators.
The computerized database system, AERO, is a web-based DOD system used jointly by the U.S. Army, Coast Guard, and Navy. AERO is implemented as the expected method for aeromedical submissions to NAMI and was the source of all psychiatric medical records used in this investigation. This is a comprehensive database that also contains all supporting documents such as treatment notes and physical examination results. The clinical advisory subsection of AERO contains waiver requests data on all aviation personnel who have been found not physically qualified or not aeronautically adapted on a standard flight physical examination. Subsequent physical examinations on an individual previously granted a waiver will also be contained here. All waiver data entries for psychiatrically disqualifying conditions for aviation personnel including designated personnel and applicants for pilot, naval flight officer, air traffic controller and air crew contained in the database for one fiscal year (October 2015 through September 2016) were examined in this initial study. A de-identified computer spreadsheet containing the International Classification of Diseases, Ninth Revision and Tenth Revision (ICD-9 and ICD-10) codes for the following physically disqualifying conditions for which waivers are most typically requested at NAMI as identified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) included: anxiety disorders, alcohol use disorders (all severities), adjustment disorders (all types), major depressive disorder (all levels), other unspecified depression, PTSD, other trauma, and unspecified trauma. Currently, for the Navy and Marine Corps, there are no waiver considerations for those with serious mental illness such as recurrent depression, bipolar disorder, psychotic disorders or those currently on psychotropic medications.
For individuals who had more than one waiver database entry, all waiver entries for each individual were reviewed in their historical context. It was then determined whether the waiver for that physically disqualifying condition was granted (WG), denied (WD) or delayed due to more information being needed (DI). In some cases, insufficient information was present, therefore 17 were excluded from the study population. Since the investigators are aware that not all waiver packages submitted are representative of the total number of aviation personnel diagnosed with a mental health condition, the number of grounding physicals submitted for each ICD-9/10 code (which is required for all physically disqualifying conditions upon discovery) was also examined to compare to the overall number of waivers recommended in an effort to decrease bias in the sample collection. This selection process resulted in a final study group of 97 unique individuals.
Records were then categorized into two major groups, consisting of those who were recommended for a waiver of the applicable aeromedical standards (the “waiver” group), and those who were not recommended for a waiver (the “Waiver Not Recommended” group). The overall number of waivers granted and denied was analyzed using simple descriptive statistics for each of the ICD-9/10 codes associated with the diagnoses listed above.
The purpose of this study was to explore the extent to which there is a factual basis for military aviators to fear being permanently “grounded” by examining the return to duty rates among US Naval and Marine Corps aviation personnel who have sought mental health treatment. The findings present the descriptive epidemiology of disqualifying psychiatric conditions in these personnel.
|AUD, moderate/ severe||15||0||100|
|Unspecified Alcohol-Related Disorder||1||0||100|
|Major Depressive Disorder||6||0||100|
|PTSD & Other Trauma||4||0||100|
Table 1: Number of Waivers Granted, USN/ USMC Aviation Personnel, 2015-2016
Table 1 presents the overall number of waivers granted (WG = 90) and waivers denied (WD = 7) for specific psychiatric diagnoses during the timeframe the study analyzed. After accounting for the number of Grounding Physicals and Incomplete records, a total return to duty (RTD) percentage was calculated. Figure 1 shows the percentage of the total number of waiver requests submitted for each diagnostic category. Figure 2 shows the overall percentages of those personnel whose waiver packages were granted and were returned to duty after completion of treatment for each of the psychiatric diagnoses listed in Table 1. As shown, 15 waivers were granted Anxiety Spectrum Disorders with only 3 being denied; this category was the least likely to have waivers granted, although the return to duty rate was still 83%. There were 14 waivers granted for unspecified Depression, with only 2 being denied, bringing the RTD percentage to 88. The data also appear to show that a diagnosis of unspecified Depression was less likely to receive a waiver (88%), even when compared to those diagnosed with Major Depressive Disorders (100%). Alcohol Use Disorders (AUD) were examined separately to determine if there was a difference between waivers granted for varying severities of the disorder. Interestingly, 100% of the 15 total waivers submitted for Moderate or Severe AUD were granted compared to 91% (20 of the 22 waivers submitted) for Mild AUD. The RTD rate for the remaining categories was 100%. Waivers were granted for all 15 of the Adjustment Disorders, all 6 of the Major Depressive Disorders and 4 of the PTSD and other Trauma Disorders that were submitted. As can be seen, the overwhelming majority of waivers that were requested (93%) were granted.
Figure 1: Percentage of Total Waiver Requests by Diagnosis, USN/ USMC Aviation Personnel, 2015-2016
Figure 2: Percentage of Waivers Granted, USN/ USMC Aviation Personnel, 2015-2016
Key Findings and Discussion
The purpose of this project was to describe the frequency of waivers granted versus waivers denied in 2015-2016 for US Navy and Marine Corps aviation personnel overall and by mental health diagnosis. In contrast with the prevailing perception among US Navy and Marine Corps aviation personnel, the data show that waiver requests for most mental health disorders are granted—enabling return to flight status for these members. These data help to dispel the fear associated with seeking treatment for mental health symptoms among active duty service members (and their mental health professionals), with the hope that service members will seek help for mental health concerns without fear of career-related ramifications.
Additionally, mental health treatment providers are encouraged to seek additional knowledge about occupationally specific competencies of special duty jobs about which they are called to make fitness for duty dispositions. After all, such mental health providers are being asked to make complex predictions for future functioning in positions that involve public safety. All providers of health services should seek to understand the specific nature and idiosyncrasies of the occupation in which the patient they are diagnosing and treating is employed, which can be referred to as “cultural competence” of sorts (Reger, Ethridge, Reger & Gahm, 2008). We also hope that mental health providers reiterate to their patients that mental illness is treatable and they can be returned to duty in order to establish buy-in of the treatment plan. They should also avoid downplaying diagnoses or shortening treatment lengths for fear that it could permanently disrupt the aviation service member’s career. This way, we hope those who recognize mental health symptoms will get the evidence-based treatment known to have a more lasting impact on recovery.
Limitations and Future Directions
The period of time covered by the study was somewhat short. Not all waivers were likely captured. The small sample size limits the power of this study and the potential generalizability of the results. However, this study was designed to be an initial investigation and does not appear to support the anecdotal worries in the fleet that treatment for a mental health condition is tantamount to ending one’s flight career. With that in mind, the plan is to continue to collect and analyze data in the coming years in an effort to provide more transparency to the fleet and encourage service members to seek treatment. We assumed the prevalence of all mental health disorders are captured by the number of grounding physicals submitted into AERO, however, not all flight surgeons submit grounding physicals into AERO, which suggests that the overall prevalence of mental health diagnoses could be higher. Also, some patients who had a grounding physical submitted could still be in treatment or decided not to return to a flight status, therefore no waiver was submitted. Perhaps not every aviator wishes to pursue a return to flight status, therefore artificially decreasing the number of waivers submitted. Also, many of the waiver packages were incomplete and therefore removed from analysis.
The Broader Context of Sensitive Employment Situations
Safety-sensitive occupations can include security officers, health care professionals, attorneys, and airline pilots. By definition, all safety-sensitive employees have a responsibility to the public. The extent to which their performance has an effect on the public depends not only the size of the population affected by their potential impairment, but also by the amount of public trust that is implied in that safety-sensitive position. For providers and clinicians who treat individuals in safety-sensitive occupations, it is critically important to recognize the role they play in the context of specific occupations. Not only must psychologists strive to have a detailed, informed understanding (cultural competence) of the occupational requirements of the job the patient holds, but also how the results of the evaluation and recommendations could affect their status. In addition, psychologists must appreciate and identify the potential impact of positive countertransference when treating a patient whose occupational responsibilities are of a safety sensitive nature. While the unconscious urge to “minimize” the diagnosis is likely to be driven by the beneficent nature of the provider, doing so risks not allowing the patient to engage in the most robust forms of treatment. Perhaps the most important change that needs to take place is recognition amongst mental health providers and patients that well-established protocols exist for returning these high-functioning people to their jobs. As is seen in this study, when the impairment is identified and treated with evidence-based therapies applied as soon as practicable, a positive outcome can be achieved and the overwhelming majority of the patients studied, 93% of them specifically, returned to work after completing treatment.
When one undertakes dual agency clinical evaluations, it is essential that the psychologist get a detailed statement from the requesting authority on what data, information, diagnosis and so forth is expected from the evaluation (including whether or not notes and test data are required). In the ideal situation, this letter would also include information on what specific aspects of job performance the requesting authority is seeking information regarding. In a parallel manner, it is essential that the psychologist insures that the patient is fully and completely informed on the limits of confidentiality, dual agency status of the psychologist, and the nature of the information which will be provided to the requesting authority. This should be written out in a more extended informed consent form than is routinely used—and, of course, signed by the patient. The psychologist should consider whether or not they need specific training or continuing education of these occupational specialties and/or special liability coverage for the type of evaluations they are performing and whether or not the requesting authority can or will provide such coverage.
Lieutenant Commander Shawnna M. Chee, PsyD, ABPP, is the second only Aerospace Clinical Neuropsychologist in the US Navy, currently serving on Active Duty in the Psychiatry Department at the Naval Aerospace Medical Institute (NAMI) in Pensacola, FL. Dr. Chee received her Doctorate of Clinical Psychology from Argosy University, Honolulu in 2007 and is Board Certified in Clinical Psychology. She completed a Clinical Neuropsychology Fellowship at the University of Virginia in 2012. During her 16 years of military service, Dr. Chee has deployed to Iraq, Cuba and Afghanistan. She is a member of the National Academy of Neuropsychology, the American Psychological Association Division 19 Military Psychology and has been credentialed as a health service psychologist since 2011.
Lieutenant Commander Daniel De Cecchis, MD, is the Navy's only active duty Aerospace Psychiatrist at the Naval Aerospace Medical Institute (NAMI) in Pensacola, FL. He is a 2007 graduate of the USUHS F. Edward Hebert School of Medicine and a Fellow of the American Psychiatric Association. As a flight surgeon from 2008 through 2011, he deployed extensively throughout the western Pacific area of operations. After completing his psychiatric residency at the Naval Medical Center Portsmouth in 2014, he deployed to the Fifth Fleet area of operations.
Aeromedical Electronic Resource Office (AERO) obtained online at http://www.med.navy.mil/sites/nmotc/nami/arwg/Pages/AeromedicalElectronicResourceOffice(AERO).aspx
Acosta, J., et.al. (2014). Mental Health Stigma in the Military. Santa Monica, CA: RAND Corporation. http://www.rand.org/pubs/research_reports/RR426.html. Also available in print form.
Ben-Zeev, Corrigan, P.W., Britt, T. W., Langford. L., et.al. (2012). Stigma of mental illness and service use in the military. Journal of Mental Health, 21, 264-73.
Bor, R., Eriksen, C., Oakes, M. & Scragg, P. (2017) (Eds) Pilot Mental Health Assessment and Support: A Practitioner’s Guide. New York, NY, Routledge.
DoDI 6490.08 Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members. (Aug 17, 2011). Retrieved from http://www.jag.navy.mil/distrib/instructions/DODI6490.08Cmd_Notification_Mental_Health.pdf
Giovanetti, P. “FAA Policy and Regulations.” Sept 17, 2016. Presentation given at the 4th Annual Aerospace Psychology Seminar, Denver, CO.
Johnson, W. B. (2008). Top ethical challenges for military clinical psychologists. Military Psychology, 20, 49-62.
Kennedy, C. H., & Zillmer, E. A. (Eds.). (2012). Military Psychology: Clinical and Operational Application. Second Edition. New York, NY: Guilford Press.
Lollis, B. D., Marsh, R. W., Sowin, T. W., & Thompson, W. T. (2009). Major depressive disorder in military aviators: A retrospective study of prevalence. Aviation, Space, and Environmental Medicine, Vol 80 (8), 734-737.
Reger, M. A., Etherage, J. R., Reger, G. M., & Gahm, G. A. (2008). Civilian psychologist in an Army culture: the ethical challenge of cultural competence. Military Psychology: 20, 21-36.
Schreiber, M. & McEnany, G. P. (2015). Stigma, American military personnel and mental health care: Challenges from Iraq and Afghanistan. Journal of Mental Health, 24(1), 54-59.
U.S. Navy Aeromedical Reference and Waiver Guide. (April 19, 2016) Retrieved from http://www.med.navy.mil/sites/nmotc/nami/arwg/Documents/Complete_Waiver_Guide.pdf
Wu, C. A., Donnelly-McClay, D., Weisskopf, M. G., McNeely, E., Betancourt, T. S., & Allen, J. G. (2016). Airline pilot mental health and suicidal thoughts: A cross-sectional descriptive study via anonymous web-based survey. Environmental Health, retrieved online from DOI 10.1186/s12940-016-0200-6.
Vogt, D. (2011). Mental health-related beliefs as a barrier to service use for military personnel and veterans: A review. Psychiatric Services, 62, 135-42.