Mental Health & Aviation Medical Clearances

Aviation Rulemaking Committee

Recommendation Report

April 1, 2024
I. EXECUTIVE SUMMARY................................................................................................................2
II. BACKGROUND ...........................................................................................................................3
III. AVIATION RULEMAKING COMMITTEE (ARC) COMMENTS ..............................................................4
IV. CURRENT REGULATORY LANDSCAPE..........................................................................................5
V. INDUSTRY OVERVIEW ................................................................................................................6
VI. ARC CHARTER – TASKS AND OBJECTIVES ....................................................................................8
TASK A – Identify factors that prevent individuals who hold FAA medical certificates or clearance from
reporting mental health issues. Develop recommendations for actions that the FAA or other
organizations should take to overcome or reduce the barriers............................................................. 8
TASK B – Discuss and develop recommendations for how the FAA should address a mental health
diagnosis. ........................................................................................................................................ 9
TASK C – Develop recommendations for steps that the FAA may take to mitigate aviation safety issues
during the time between the disclosure of a mental health diagnosis by a pilot or an FAA air traffic
controller and the subsequent issuance of an aeromedical decision by the FAA. ............................... 10
TASK D – Review how other civil aviation authorities address pilot and air traffic controller mental health
issues and develop recommendations for best practices that the FAA should adopt. ......................... 11
TASK E – Discuss and develop recommendations for mental health education programs for individuals
who hold medical certificates or clearances that the FAA and the aviation industry could implement to
improve awareness and recognition of mental health issues, reduce stigmas, and promote available
resources to encourage voluntary self-disclosure in a confidential and protected environment, and
assist with resolving mental health problems................................................................................... 16
VII. BARRIER NARRATIVES .............................................................................................................. 17
Figure A: Mental Health Process Flowchart & Identified Barriers ....................................................... 17
A. CULTURE ..................................................................................................................................... 18
B. TRUST ......................................................................................................................................... 19
C. FEAR .......................................................................................................................................... 22
D. STIGMA ....................................................................................................................................... 23
E. FINANCIAL ................................................................................................................................... 26
F. PROCESS ..................................................................................................................................... 27
G. KNOWLEDGE & INFORMATION GAP ..................................................................................................... 29
Figure B: Mental Health Literacy Framework .................................................................................... 31
Figure C: Notional Timeline for Initial Authorization for Antidepressant Medication Use ...................... 33
VIII. ARC RECOMMENDATIONS – INTENT, RATIONALE, AND APPROACH ............................................ 34
REC1 – Disclosure Requirements for Psychotherapy ........................................................................ 34
REC2 – Regulatory Pathway - Reporting Mental Health Conditions & Medications .............................. 36
REC3 – Expanded Use of Peer Support Programs ............................................................................. 38
REC4 – Disclosure Requirements for Peer Support Programs............................................................ 39
REC5 – Requirements for Neurocognitive Testing ............................................................................. 40
REC6 – Requirements for Depression & Anxiety................................................................................ 41
REC7 – Requirements for Attention Deficit Hyperactivity Disorder (ADHD) ......................................... 43
REC8 – Requirements for Post Traumatic Stress Disorder (PTSD) ...................................................... 44
REC9 – Aeromedical Screening - Proportionate & Publicized Decisions ............................................. 45
REC10 – Aeromedical Screening - Safety Management Systems (SMS) .............................................. 46

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 REC11 – Aeromedical Screening - Relevancy & Effectiveness ........................................................... 48
REC12 – Aeromedical Screening - Safety Continuum........................................................................ 49
Figure D: Safety Continuum and Societal Expectations .................................................................. 50
REC13 – Information Management – Applicant Guide ....................................................................... 51
REC14 – Information Management - System Modernization .............................................................. 52
REC15 – Information Management – Accurate Documentation ......................................................... 53
REC16 – Information Management - Data Submission ...................................................................... 54
REC17 – Mental Health Awareness – Aviation Stakeholders .............................................................. 55
REC18 – Mental Health Awareness - Annual Summit ........................................................................ 57
REC19 – Mental Health Training – AME............................................................................................. 58
REC20 – Mental Health Training - Aviation Stakeholders ................................................................... 60
REC21 – Mental Health Training – Initial & Recurrent......................................................................... 61
REC22 – Regulatory Pathway - Operational Limitations on Certificates & Clearances ......................... 63
REC23 – Mental Health Parity – Legislative Amendments .................................................................. 65
REC24 – Mental Health Parity – Disability Insurance ......................................................................... 66
IX. DEFINITIONS AND GLOSSARY OF TERMS................................................................................... 67
A. DEFINITIONS................................................................................................................................. 67
B. ACRONYMS .................................................................................................................................. 69
X. APPENDICES ........................................................................................................................ APP
APPENDIX A – TALK THERAPY PROCESS FLOWCHART .........................................................................................A
APPENDIX B – SAMPLE MENTAL HEALTH PROVIDER REPORT CHECKLIST .................................................................B
APPENDIX C – CASA AND CAA NZ SAFE HAVEN PATHWAY DRAFT POLICY ............................................................ C
APPENDIX D- EXAMPLES OF CONFLICTING FAA INFORMATION FOR MEDXPRESS INSTRUCTIONS .................................. D
APPENDIX E – AEROMEDICAL UPDATE ............................................................................................................ E
APPENDIX F – ARC PARTICIPANTS ................................................................................................................ F
APPENDIX G– ARC MEMBER VOTING RESPONSES AND BALLOTS ......................................................................... G

I. Executive Summary
The Mental Health & Aviation Medical Clearances Aviation Rulemaking Committee (Mental Health ARC
or the ARC) was chartered by the Federal Aviation Administration (FAA) on December 4, 2023. The ARC
provided a forum for the United States (US) aviation community to discuss the barriers preventing pilots
and air traffic controllers (controllers) from reporting and seeking care for mental health issues and provide
recommendations to the FAA to address these barriers to mitigate potential aviation safety risks.

The ARC members, observers, and contributors consisted of a broad representation of people,
including aerospace medicine, psychiatric and psychological medical experts from the FAA Office
of Aerospace Medicine (AAM), 1 FAA Flight Standards Service (AFS), the National Transportation
Safety Board (NTSB), US aviation industry trade associations, pilot/controller representative
organizations, academia, and international aviation industry associations and civil aviation
authorities (CAAs). The ARC established two working groups, Peer Support & Operations and
Medical, to identify and provide recommendations to address the barriers to reporting mental

1
AAM includes Designated Aviation Medical Examiners. See Aviation Medical Examiner (AME) Designee
Information (faa.gov)

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health concerns and the steps needed to mitigate aviation safety risks. The groups worked
collaboratively to identify barriers and develop consensus recommendations.

The ARC working groups addressed the following major issues:

• The FAA's handling of mental health diagnoses,

• Current aeromedical mental health screening processes,
• Barriers preventing pilots/controllers from reporting mental health issues and seeking
mental health care, and
• Education, training, and awareness of pilot/controller mental health issues.

In-person ARC plenary meetings were held in Fort Worth, TX (Jan 9-11), McLean, VA (Feb 5-7), and
Seattle, WA (Mar 13-15). Virtual attendance options were also available for remote participants.
Co-chair and working group meetings were held multiple times each week, and on an ad hoc basis
in person or virtually throughout this ARC’s compressed timeline.
A summary of the ARC's Recommendations is below:

• Create a non-punitive pathway for disclosing mental health conditions and treatments;
• Revise and evaluate the requirements for reporting and certification/qualification of
psychotherapy (talk therapy), depression/anxiety; attention deficit hyperactivity disorder, and
post-traumatic stress disorder;
• Ensure that aeromedical screening protocols and requirements are based on Safety
Management System principles (i.e., proportionate, relevant, and risk-based), and
appropriately communicated to applicants;
• Expand the use and promotion of Peer Support Programs;
• Develop mental health literacy, education, and awareness campaigns;
• Increase mental health training and improve quality assurance for Aviation Medical
Examiners (AMEs); and
• Modernize the FAA's information management system/Aviation Medical Certification
Subsystem.

Details and supporting text for all recommendations are in Section VIII.

II. Background
Pilots are required to obtain and maintain an FAA Medical Certification to operate aircraft, and for
those in commercial operations, it is a condition of their employment. Similarly, controllers are
required to obtain and maintain an FAA Medical Clearance, and for those working in Air Traffic
Organization (ATO), it is a condition of their employment. The impact of mental health conditions
on pilot/controllers’ ability to obtain and maintain medical certification/clearance is a growing
concern within the aviation community.
In 2015, the FAA established the Pilot Fitness ARC (2015 ARC) to assess pilot mental health
following the Malaysia 370 and Germanwings 9525 incidents. 2 The 2015 ARC found that the primary

2
Pilot Fitness ARC Recommendation Report (faa.gov), November 2015.

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factors that discourage reporting of mental health conditions are the stigma associated with
mental health, the potential impact on the person’s career, and fear of financial hardship.
In the ensuing years, the FAA acted on several of the 2015 ARC’s recommendations, including
expanding coverage of mental health issues in the training provided to AMEs in basic and refresher
seminars; and encouraging Peer Support Programs (PSPs) organized by airlines and unions to
provide mental health training to peer support volunteers. However, there remained much work to
do, as noted by the Department of Transportation’s (DOT) Office of the Inspector General (OIG) in
their July 2023 report. 3 The OIG report found that although the FAA has comprehensive procedures
to evaluate pilots’ psychological health, the FAA’s ability to mitigate safety risks is limited by pilots’
reluctance to disclose mental health conditions. In response to the OIG’s report and recent events
highlighting pilot mental health concerns, 4 the FAA established the Mental Health ARC in
December 2023 with taskings aimed at supporting the FAA’s efforts to implement the OIG’s
recommendations. Specifically, the OIG recommended that the FAA:

• Collaborate with airlines, airline pilot unions, and the aerospace medical community to
assess ways to address barriers that discourage pilots from disclosing and seeking
treatment for mental health conditions, based on the latest data and evidence; and
• Develop and implement policy and protocol revisions recommended in the assessment.
The establishment of the Mental Health ARC is the FAA’s response to both the OIG’s first
recommendation and recent high-profile incidents 5 related to pilot mental health. The ARC’s work
will also inform the FAA’s efforts to address the OIG’s second recommendation.

III. Aviation Rulemaking Committee (ARC) Comments

A part of the FAA mission is to regulate aviation safety, which includes medical certification of
pilots and medical clearance of controllers. Recent events have heightened awareness throughout
society of the risk of untreated mental health concerns of aviation safety professionals, including
pilots and controllers (pilot/controller). Concurrent with the attention on recent events, the aviation
industry has been calling for a major change in how the FAA manages pilot/controller mental health
conditions. 6 The ARC believes that this change must include risk-based processes and pathways to
allow for the non-prejudicial reporting, treatment, and safe return to operation for both
pilots/controllers experiencing or diagnosed with mental health conditions. Improvements should
also include greater accessibility to mental health education, treatment, and resources.

The Mental Health ARC Charter might inadvertently imply a direct link between the ARC’s work and
the future ability to mitigate safety risks associated with pilot/controller mental health issues in the
National Airspace System (NAS). The ARC’s influence on reducing safety risks in the NAS is
significant, but indirect. The ARC expects that breaking down barriers for pilots/controllers to
acknowledge, seek care/treatment, and report mental health concerns, will lead to increased
reporting and certifications/clearances for healthy pilots/controllers to remain or return to the

3
OIG Report and Recommendations (dot.gov), July 12, 2023.
4
Navigating Mental Health in Aviation (ntsb.gov), December 2023.
5
Malaysia Airlines Flight 370 or Germanwings Flight 9525.
6
NTSB Mental Health in Aviation-Aviation Safety Summit, Dec 6, 2023. The summit's purpose was to examine
the unintended consequences of the current system for evaluating mental fitness in the aviation workforce,
identify how to better support those in the aviation industry, and ultimately make aviation safer for all.

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workforce. Breaking down these barriers will then reduce the risk that an untreated pilot/controller
enters or remains in the workforce without needed mental health care. However, the ARC’s focus is
on pilot/controller mental health literacy, wellness, and performance, rather than solely focusing
on mitigating safety risks associated with specific past incidents. The ARC sees its’ primary goal is
to provide a strategy to enhance pilot/controller wellness, which, in turn, can lead to providing
more accurate information for health-related decision-making, an improved safety culture, and
better operational outcomes.

Pilots/controllers have been avoiding treatment for a variety of reasons. The Mental Health ARC
identified seven overarching barriers to reporting and seeking treatment for mental health concerns
(See section VII). The ARC then developed a set of recommendations intended to address the
identified barriers that pilots/controllers face when dealing with mental health concerns.

The ARC notes that airlines, the FAA, Air Navigation Service Providers (ANSP), labor unions,
regulatory bodies, pilot advocacy groups, business aviation, general aviation, the Aerospace
Medical Association, 7 academia, and many other organizations (collectively and hereinafter
aviation stakeholders), in conjunction with the international community have taken steps over the
last several years to address mental health issues and wellness initiatives in the aviation
community. These efforts have included:

• Public outreach via articles, symposia, webinars, podcasts;

• Review of existing science and regulatory policy;
• Updating policy to streamline issuance of certificates and clearances;
• Expanding peer support and wellness programs across aviation;
• Synchronizing international policy where possible; and
• Increased research initiatives and collaboration.

The ARC includes representatives and resources from all these aviation stakeholders to ensure
that solutions are the result of the contribution and buy-in of all parties. These recommendations
should be considered collectively to positively impact safety culture and emphasize the well-being
of pilots/controllers and aviation stakeholders.

IV. Current Regulatory Landscape

The FAA Office of Aerospace Medicine (referred to as AAM) is responsible for a broad range of
medical programs and services for the US and international aviation communities. As part of these
responsibilities, AAM manages the medical certification program that issues medical certificates
to pilots, or medical clearances to controllers as evidence of medical fitness. The medical
certification process, which includes a physical exam and may include a general mental status
evaluation, 8 contributes to keeping pilots, controllers, air travelers, and the general public safe.
During this process, AMEs 9 and AAM personnel issue, defer, or deny applications for medical

7
The Aerospace Medical Association (AsMA) is organized exclusively for charitable, educational, and
scientific purposes. It is the largest, most-representative professional membership organization in the fields
of aerospace medicine and human performance.
8
2024 Guide for Aviation Medical Examiners Item 47. Psychiatric Conditions.
9
14 CFR 183.21(c).

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certificates in accordance with the relevant statutes, regulations, and guidelines. Applications
deferred or denied by an AME are reviewed by AAM’s Medical Certification Division (AAM-300) or a
Regional Flight Surgeon (RFS). These offices may refer applicants with a significant medical history
to the Medical Specialties Division (AAM-200) to determine the applicants’ qualifications on behalf
of the Federal Air Surgeon. 10 This is typically done for “dual diagnosis” 11 cases that involve
comorbidities, such as substance abuse and Attention Deficit Hyperactivity Disorder (ADHD) or
substance abuse and the use of Selective Serotonin Reuptake Inhibitor (SSRI) antidepressants.
AAM-200 also maintains and updates guidelines for evaluating pilot/controller qualifications for
obtaining a medical certificate or clearance.

V. Industry Overview

In any given year, about 1 in 5 US adults has a diagnosable mental health condition, and more than
50% will experience some occurrence over the course of their lifetimes. 12 Most of these events are
not severe, but there is a very real stigma associated with mental health conditions, especially in
aviation, which can make it difficult to ask for help. This difficulty is one of the many reasons
mental health events go unreported. In the US, less than half of people with a diagnosable mental
health condition ever receive treatment. 13 The ARC collectively acknowledges similar concerns
about untreated diagnosable mental health conditions across the aviation workforce. There are
many obstacles between needing help and getting it, such as lack of education, stigma, access to
mental health support, financial concerns, and job security — all of which bring more stress to a
person that may already be struggling.

For many years, being honest about mental health struggles has been viewed within the aviation
community as a risky endeavor. There is a misconception that reporting a mental health issue will
result in permanent grounding for pilots, or permanent removal from duties for controllers. The fact
is that the initial disqualification rate for all mental health diagnoses is ~20%, 14 meaning the
pilot/controller is without certification/clearance until the disqualification is resolved. Only about
0.1% of applicants who disclose any health issue and complete the process are ultimately denied a
medical certificate, and then only after an exhaustive attempt to “get to yes.” However, “getting to
yes” can be very time consuming, which may result in a significant financial penalty for the
applicant even if the certificate/clearance is ultimately granted. The widespread belief in aviation is
that you are, in effect, disadvantaged for following the disclosure rules. A system that incentivizes
people to remain silent will cause pilots/controllers to avoid seeking help, leading to unacceptable
safety risks.

Aviation is facing a challenging time. The effects of the pandemic still linger, and controllers and
pilots in all types of operations are facing staffing issues, equipment, infrastructure, and
technology issues, and increased overtime. The current strain on the aviation system and its
workforce should not be underestimated. Everyone needs to feel safe seeking the mental health

10
14 CFR Part 67.
11
Dual diagnosis refers to the simultaneous presence of two or more diseases or medical conditions in a
single patient.
12
National Institute of Mental Health, Mental Health Statistics.
13
The State of Mental Health America, 2023 Key Findings.
14
See Appendix E Aeromedical Update. Remarks by Dr. Brett Wyrick, FAA Deputy Federal Air Surgeon.
General Aviation Joint Safety Committee Meeting. August 30, 2023.

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support that they need and deserve. Mental health issues do not affect those in aviation any
differently than they affect others in safety-sensitive roles. The ARC intends its recommendations
to be the foundation for a regulatory, policy, and cultural shift that will provide a safe space for
pilots/controllers to seek treatment without the fear of losing their livelihoods.

The medical certification/clearance process, AME education and oversight, process timeline and
transparency all need to be addressed. The ARC notes that there have been some recent
improvements, such as expanding training in mental health issues provided to AMEs in the AME
Basic and Refresher seminars and encouraging Pilot Peer Support programs organizations by
airlines and unions, 15 but more needs to be done. The important thing to stress is creating an
environment, a ‘Culture of Wellness,’ where aviation professionals seek help when any symptoms
begin, and underlying conditions are treated before their health degrades.

US Healthcare System Concerns

The unique challenges in the US Healthcare System can make it more difficult to address the
issues surrounding mental health in aviation. The paucity of mental health providers and their
geographic dispersion present a significant challenge for those seeking mental health support.
Depending on their specialty, some physicians may receive one month of psychiatry training in
medical school and none after that. Similarly, depending on where they were educated, mid-level
providers may be well-trained in treating mental health problems, while others will have no formal
training. Even if an individual has a primary physician well-educated in treating mental health
problems, the wait time for obtaining any health care appointments can be lengthy, with availability
sometimes measured in weeks to months.

Furthermore, the US health insurance system typically only pays for “illness” if it pays at all. Parity
for mental health care is still an issue, as outlined by the National Alliance on Mental Illness
(NAMI). 16 Most typically, if someone seeks care for something that is not an “illness” (e.g., dealing
with the death of a child, marriage counseling, or work stress), it is not covered by
insurance. Consequently, individuals either need to pay out of pocket, or the provider ends up
attaching a diagnosis code to an individual’s bill so that the insurer will pay, resulting in the
individual being labeled with an illness they may not actually have. This “upcoding” can be
especially problematic for pilots/controllers with respect to recertification because they may have
been “diagnosed” with a mental illness far more severe than what they were experiencing.

15
Pilot Mental Fitness - Additional FAA Oversight (faa.gov).
16
National Alliance on Mental Illness – What is Mental Health Parity?

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 VI. ARC Charter – Tasks and Objectives
The ARC was charged with several tasks in its Charter. Each task is briefly discussed below.

TASK A – Identify factors that prevent individuals who hold FAA medical
certificates or clearance from reporting mental health issues. Develop
recommendations for actions that the FAA or other organizations should
take to overcome or reduce the barriers.

The ARC spent considerable time identifying the factors that hinder disclosure and developing
recommendations to overcome or reduce them. These factors, or “Barriers,” were consolidated
into seven broad categories:

• Culture
• Trust
• Fear
• Stigma
• Financial
• Process
• Knowledge and Information Gap

The ARC membership recognizes that Culture, Trust, Fear, and Stigma are large overarching
barriers that cannot be fixed with a single recommendation. These barriers and the associated
recommendations are complementary and fundamentally interrelated. Implementing the
recommendations associated with these barriers will set the stage for a seismic shift in how the
industry perceives and manages the risks associated with mental health conditions. This shift in
perception will take time and will only occur after the recommendations have been implemented,
allowed to gain traction, and embraced by pilots/controllers. An awareness and education
campaign with consistent and accurate messaging will be necessary to ensure we achieve our
goals over time.

The ARC membership also recognizes that the Process, Financial, and Knowledge and Information
Gap barriers can only be overcome with input, collaboration, education, and communication
among all aviation stakeholders. The ARC notes that some of the work identified in these
recommendations to address the barriers is already underway or can be implemented quickly. For
example, the FAA has taken some steps to improve its electronic submission and transmission
capabilities, but there remains a heavy reliance on hardcopy documentation and mailing packages
of documents, so continued improvement of the electronic portals is needed. In other cases,
implementing the recommendation will require significant time and effort, such as implementing
the comprehensive recommendations for improved information systems described in REC 16.
Most importantly, communication of such changes must be distributed throughout the aviation
industry through every available avenue.

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 TASK B – Discuss and develop recommendations for how the FAA should
address a mental health diagnosis.

Many of the barriers identified by the ARC involve the FAA’s handling of mental health diagnoses.
Fear of temporary or permanent certificate/clearance loss is the most prevalent and serious barrier
identified. The ARC’s view is that there is a widespread perception amongst pilots/controllers that
the FAA's processes for adjudicating mental health cases are complicated, excessive, and
inconsistent with accepted protocols and treatment practices. Moreover, in many cases, there
does not appear to be an obvious relevant connection between the FAA’s processes and flight
safety. A recent study involving collegiate pilots showed that they have the perception that the
FAA's current policies on mental health are restrictive and negatively impact their desire to seek
out treatment. 17 These perceptions drive a lack of trust in the aeromedical certification process
and present a barrier to pilots/controllers to seek and/or report treatment.

The ARC engaged the expertise of the operational community, academia, foreign CAAs, and the
FAA to evaluate this tasking. A key theme of these discussions was creating a regulatory
environment that encourages applicants to seek treatment while still assuring safety. The ARC
recognized that in general, the overarching priority for the safety of the NAS should be to reduce the
rate of healthcare-avoidant behavior. Although enhancements in message and culture can
contribute to advancing this aim, they will lack effectiveness without substantial modifications to
aeromedical standards and procedures.

The ARC is recommending several significant, risk-based reforms to aeromedical policy. These
reforms are made with the recognition that treatment is the key benefit to the safety of the NAS,
and that aeromedical evaluation is only one of many means of mitigating risks from a Safety
Management System (SMS) perspective.

Among these recommendations are changes to reportability of treatment for certain conditions
without fear of immediate revocation; reductions of the stabilization period for many medications;
placing more decision-making authority in the hands of the AME; and allowing operational
performance measurements to be used as part of certification assessments where appropriate.

The ARC also recommends that the FAA continually evaluate its standards and procedures against
the latest research to ensure treatment practices are contemporary, and communicate the
processes, expectations, and timelines to applicants in an easy and understandable manner.

The ARC recognizes AAM’s important role in assuring the safety of the NAS via aeromedical
evaluation of all safety-critical personnel in the system. The ARC’s aim in addressing Task B is to
utilize the authority and expertise of AAM within a system in which pilots/controllers feel secure in
their ability to seek appropriate treatment, and in turn, trust the system to treat them fairly.

Stein, Laila, "Mental Health in Aviation: A Study of Aviation Students on Their Perceptions of the Federal
17

Aviation Administration’s Rules Governing Mental Health" (2023). Honors Theses, 3674.

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 TASK C – Develop recommendations for steps that the FAA may take to
mitigate aviation safety issues during the time between the disclosure
of a mental health diagnosis by a pilot or an FAA air traffic controller and
the subsequent issuance of an aeromedical decision by the FAA.

To mitigate the safety risks that may arise between the identification, disclosure, and treatment of
a mental health symptom/diagnosis, the ARC provides individual recommendations to address
each barrier outlined in this report. Further, the ARC acknowledges that aeromedical certification
is only one risk control among many that can limit the potential hazards related to pilot/controller
mental health. Other risks are specific to operational environments, including automation,
recurrent training, periodic flight reviews, multi-pilot operations, crew resource management, and
other emergent technologies. The ARC recommends that the FAA investigate whether current
control measures achieve acceptable levels of risk related to pilot/controller mental health and
assess newer measures using SMS tools as outlined in many of the ARC's Recommendations.

The purpose of mental health screening is to ensure that hazards related to pilot/controller mental
health do not create an undue risk or adverse event within the NAS. The FAA’s aeromedical
certification process is the primary tool currently employed to ensure medical hazards are
controlled, including mental health hazards. This process where pilots/controllers report
symptoms, diagnoses, or use of medical services could result in certificate/clearance loss and
grounding/removal from operations. Task C focuses on mitigating safety hazards during the time
between disclosure and certification/clearance. However, this assumes that the pilot/controller
actually reported the mental health concern in the first place. The ARC contends that non-reporting
of mental health concerns is also a risk to the NAS that must be addressed as there are several
factors impacting non-reporting and ultimately safety. These include barriers related to
pilot/controllers’ ability to:

• Identify symptoms (i.e., Culture, Knowledge),

• Seek mental healthcare services to address those symptoms/diagnoses (Culture, Fear,
Knowledge, Stigma); and
• Report symptoms/diagnoses during aeromedical certification (Fear, Financial, Process,
Trust).

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 TASK D – Review how other civil aviation authorities address pilot and air
traffic controller mental health issues and develop recommendations for
best practices that the FAA should adopt.

The ARC reviewed aviation mental health practices from CAAs in Australia, Canada, China, Europe,
India, New Zealand, Singapore, the United Arab Emirates (UAE), and the United Kingdom (UK).
Additionally, the Chief Medical Officers from the Civil Aviation Safety Authority of Australia (CASA),
Transport Canada (TC), the European Aviation Safety Authority (EASA), and the Civil Aviation
Authority of New Zealand (CAA NZ) participated in the ARC’s Medical Working Group with frequent
and valuable inputs.

The ARC’s Recommendations were developed with consideration of international policies on

mental health from other CAAs, as well as guidance from the International Civil Aviation
Organization’s (ICAO) Standards and Recommended Practices (SARPs). Annex 1 of the ICAO
SARPs delineates common standards, 18 and the ICAO Manual on Civil Aviation Medicine
(Document 8984) 19 contains detailed descriptions of a spectrum of mental health conditions and
the use of medications. Document 8984 was published in 2012 and is currently being rewritten.
Several members, observers, and participants of the ARC’s Medical Working Group are
contributing to the new edition.

Chapter 9 of Document 8984 addresses the use of medication and provides that:

“States’ certification of pilots and controllers taking medications accepted

by the Licensing Authority should be conditional on the following:

a. The applicant should be under the care of a medical practitioner

experienced in the management of depression.
b. The applicant should:

1. be stable on an established and appropriate dose of medication for

at least four weeks before returning to flying/controller duties and exhibiting:

i. minimal, acceptable side-effects.

ii. no medication interactions or allergic response.

2. be subject to regular clinical review by the medical practitioner with

progress reports provided to the medical section of the Licensing Authority.
The applicant may be involved in other concurrent treatment (e.g.
psychotherapy).
3. have no other significant psychiatric co-morbidities.
4. require no other psychoactive medications.

c. demonstrate symptoms of depression being well controlled, without

evidence of psychomotor retardation.
d. have no suicidal ideation or intent.

18
ICAO SARPS Annex 1 – Personnel Licensing, Chapter 6, Medical Assessments.
19
ICAO Manual of Civil Aviation Medicine (Document 8984), Chapter 9, Mental Fitness.

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 e. have no history of psychotic symptoms.
f. have no features of arousal (e.g. irritability or anger).
g. have a normal sleep pattern.
h. have resolution of any significant precipitating factors of depression.
i. ongoing cognitive-behavioral, rational-emotive or similar therapy is
desirable, but not necessarily required for certification.

EASA’s publications on Mental Health in Aviation Safety (ME SAFE) 20 published in 2023 and 2024
also contain extensive research, recommendations, and rationale regarding mental health
diseases, assessment, treatment, certification, and surveys of pilot, controller, and aviation
medical assessors’ experiences with aviation mental health issues.

CASA and CAA NZ have also drafted a Safe Haven Pathway to encourage certificate holders to seek
help and self-disclose mental health problems. The Safe Haven Pathway provides support and the
opportunity to remain on duty while participating in the assessment process. The intent is to
“develop a safety culture that enhances help-seeking for and self-disclosure of mental health and
other problems.” 21

Tables 1 and 2 below illustrate evolving trends in the certification of pilots/controllers who use
medication to treat mental health conditions. The ARC specifically notes there are significant
differences between FAA requirements and other countries’ CAAs for:

• Consideration and authorization of categories and types of medications.

• Observation periods to demonstrate stability once medication is started or dosage is
changed (notably the US and Singapore CAAs observation times for anti-depressants
exceed other referenced CAAs, see Table 1).
• Use of neuropsychological testing (e.g., other CAAs only use neuropsychological testing in
cases of significant co-morbidities or operational deficiencies).
• The use of peer support committees with an independent mental health provider working
directly with the pilot/controller to determine fitness to return to duty after initiation of
treatment without prior clearance by the CAA.
• Operational observations to assist in safety and fit-to fly determinations.
• Mental health literacy training and education for safety sensitive personnel, especially
those with self-identified mental wellness stressors.

The ARC also highlights some unique practices in the US and some recent changes to FAA policies.
For example, under the original 2010 special issuance procedure, a minimum twelve-month period
(later reduced to six months) 22 on a single dose of one of the allowed medications was required,
along with satisfactory completion of annual neuropsychological testing and semi-annual
psychiatric assessments (among other requirements). Similarly, a change in the medication
dosage required an additional six-month observation period, during which certification was invalid,

20
European Union Aviation Safety Agency 2025 – Medical.
21
See Appendix C – CASA and CAA NZ draft policy – Safe Haven Pathway.
22
Durham, J., & Bliss, T. (2019). Depression and Anxiety in Pilots: A Qualitative Study of SSRI Usage in U.S.
Aviation and Evaluation of FAA Standards and Practices Compared to ICAO States. Collegiate Aviation
Review International, 37(2), 78-109. Retrieved from
http://ojs.library.okstate.edu/osu/index.php/CARI/article/view/7908/7304.

Page 12 of 69
and recertification could not be considered. 23 However, in 2023, the FAA removed the requirement
for annual neuropsychological testing after initial certification for most cases. The FAA’s decision
was based on an internal follow up study 24 that showed that in the absence of clinical findings,
repeat neurocognitive testing did not influence the ultimate decision to renew a special issuance.
The FAA found that 20% of initial certifications in this sample were impacted by neuropsychological
testing results in some way, but further study needs to be conducted reviewing a population of all-
comers for initial certification. Also in 2023, the FAA allowed another antidepressant, that was not
an SSRI, 25 to be used by pilots/controllers to treat depression. This newly approved medication is in
addition to the four SSRIs that the FAA allowed in 2010 for depression and certain other medical
and psychiatric conditions under the special issuance procedure requirements that were in place
at that time. As illustrated below, these recent changes in policy regarding certain antidepressants
are consistent with international trends.

23
Guide for Aviation Medical Examiners Item 47. Psychiatric Conditions.
24
The study was based on 12 years of clinical data and review. The FAA was resource limited, but the addition
of specialist staff enabled completion of the study. The ARC commends the FAA in its efforts to proactively
manage applicants with unique issues and notes that additional resources would be helpful in this regard,
specifically with respect to initial certification as well as with recertification.
25
See Airman Information - SSRI Initial Certification, FAA Certification Aid for SSRI Initial Certification, and
FAA Certification Aid – SSRI Recertification/Follow Up Clearance.

Page 13 of 69
Tables 1 and 2 - Differences in Approach for Pilot Antidepressant Use
Table 1* - FAA/CAA Approval Process
Agency Time Grounded Initial Monitors Additional Follow-Up Neurocognitive Testing

HIMS AME +
Board Certified
HIMS AME (every 6
Psychiatrist +
months face-to-face /
Treating Physician (if
every 1-3 months
not board cert
virtual) + psychiatrist Initial Certification
psychiatrist) +
every 6 months) ALL
Chief Pilot/Air Traffic
Chief Pilot/Air Traffic
Manger (1st & 2nd
Manger (every 3 Follow-up - every 12 months
class only) +
months) + (limited number of cases if
Additional providers
FAA Min. 6 months Additional Providers clinically indicated)

GP and CAA
Specialist Advisor in
Psychiatry1. "Buddy"
Min. 1 month (2 on Initially every 3
reports.
UK CAA fluoxetine) months. Can change None

GP, Psychiatrist, or
Min. 2-4 weeks Psychologist. Chief
pilot or fleet manager
CAA NZ Periodic follow-ups. None*

GP. Psychologist, or
Min. 2-4 weeks
Psychiatrist1
CASA Not specified None*
Mental health care
Min. 4 weeks. provider and
Realistiically 3 ocupational
months physician2 Family
member contact.
EASA Not specified None

1
Min. 4 months GP and Psychiatrist
TC Every 6 months. None

Treating Psychiatrist,
Min. 4 weeks Secondary
GCAA Psychiatrist Initially monthly. Can
UAE change. Psychometric

CAA Treating Psychiatrist,

Singapore Min. 6 months CAAS Physician Every 3 Months None
*Data accurate as of March 30, 2024
1
If deemed necessary.
2
If applicable/available.

Page 14 of 69
Table 2* - FAA/CAA Antidepressant Medication Approvals

Name Type FAA CAA Singapore

1
UK CAA CAA NZ CASA EASA

Fluoxetine (Prozac) SSRI

Sertraline (Zoloft) SSRI

Citalopram (Celexa) SSRI

Escitalopram (Lexapro) SSRI

Paroxetine (Paxil) SSRI

Fluvoxamine (Luvox) SSRI

Not Not
Bupropion (Wellbutrin) Aminoketones Licensed Licensed
in New in
Zealand Australia

Mirtazapine (Remeron) Atypical Tetracyclic

Venlafaxine (Effexor)2 SNRI

Desvenlafaxine (Pristiq)2 SNRI

Duloxetine (Cymbalta)2 SNRI

Amitriptyline (Elavil) Tricyclic

MAO Inhibitor MAO Inhibitor (All)

*Data accurate as of March 30, 2024

1
CAA Singapore considering Vortioxetine
2
FAA Approval Expected April 2024
Green = Allowed
Yellow = Case-by-case basis
Red =Not Allowed

Page 15 of 69
 TASK E – Discuss and develop recommendations for mental health
education programs for individuals who hold medical certificates or
clearances that the FAA and the aviation industry could implement to
improve awareness and recognition of mental health issues, reduce
stigmas, and promote available resources to encourage voluntary self-
disclosure in a confidential and protected environment, and assist with
resolving mental health problems.

Task E provides the ARC its greatest opportunity to correct misinformation, narrow information
gaps, improve the overall mental health literacy of pilots/controllers and begin the work to effect a
change to the cultural barrier to mental health reporting. This task is widely seen as the direct
continuation and development of Recommendation 4 from the 2015 Pilot Fitness ARC Report, 26
and is expected to have the most significant and lasting impact on the aviation ecosystem.
Consistent with that effort, the Recommendations in this report are intended to expand mental
health education beyond what is already occurring at Part 121 air carriers. The goal is for the
Recommendations to be adapted to every type of aviation operation, coupled with increased
efforts to better engage with multi-generational aviation stakeholders. Specific attention should be
given to the various ways that different generations acquire, share, and use information to ensure
effective outreach for a range of target audiences.

All aviation stakeholder groups should be party to the development, distribution, and marketing of
this new aviation mental health education paradigm. This will require a coordinated effort to
effectively address the different sectors of the aviation community and engage with its various
member groups. Although this ARC does not detail the program specifics of this outreach, it
remains ready to assist in the creation of a precise communication plan, cohesive strategy, and
effective distribution methods of mental health education for aviation stakeholders. Continuing
this work is crucial for the sustained success of transforming the mental health culture in the
aviation sector.

26
See Pilot Fitness ARC Recommendation Report (faa.gov) Recommendation 4. AIR CARRIER EDUCATION Air
carrier operators should be encouraged to implement mental health education programs for pilots and
supervisors that improve awareness and recognition of mental health issues, reduce stigmas, and promote
available resources to assist with resolving mental health problems. Rationale: Improved mental health
literacy is associated with earlier reporting and improved treatment outcomes.

Page 16 of 69
VII. Barrier Narratives
The following section contains narratives that help define the full meaning of each identified barrier that pilots/controllers face as they
confront the challenges of a mental health condition.

Figure A: Mental Health Process Flowchart & Identified Barriers

Page 17 of 69
 A. Culture
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, professional
reputation, 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.

Another facet of aviation Culture further exacerbating the problem with reporting is distrust in the
FAA’s aviation medical process. Much of the distrust is fueled by a lack of information or
misinformation about FAA policies and processes. This is manifested, not only through a lack of
reporting, but also through individual healthcare-avoidance and/or firewalling of physical and
mental health information. Firewalling is a term used when medical concerns, treatment, and
records are kept separate and not reported to the FAA on an individual’s medical application or
discussed with the AME. There is also a lack of mental health literacy within the aviation
community that creates a sense of apprehension and further contributes to a culture of healthcare
avoidance. Many people believe the FAA requires extreme evaluations and assessments for any
disclosed mental health issue. 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 an injury or
illness. Moreover, pilots/controllers are apprehensive to talk about conditions related to mental
health issues across their entire spectrum of professional interactions. Whether they’re talking
with fellow pilots/controllers, friends, managers, AMEs, or other medical professionals, fear tends
to drive these conversations underground, resulting in non-reporting and a reluctance to seek help.

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.

The Culture barrier to mental health reporting is the most wide-ranging barrier that will require the
greatest effort to overcome. All aviation stakeholders will need to work together to make
sustainable and meaningful change. 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. 27

27
Examples include: NASA Aviation Safety Reporting System, FAA Aviation Safety Action Program, FAA
Human Intervention Motivation Study. These programs have greatly increased the aviation reporting culture
and benefited the safety of the NAS.

Page 18 of 69
 B. Trust
Trust requires open communication, shared
expectations, transparency with a commitment to
reliability, and credibility by all parties. Justified or not,
pilots/controllers lack trust that the FAA will manage the
medical certification application process fairly and in a
timely manner. This lack of trust is largely attributed to a
perceived broad criterion for what is considered a safety
risk related to mental health (i.e. imprecision), the
inconsistent application of those criteria, and
administrative inefficiencies. The current FAA
aeromedical process is a principal 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.

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.

FAA
With respect to the ARC’s work, the largest trust issue exists between pilots/controllers and the
FAA. In many cases, there is an overlap between trust and other barriers identified in this report,
including: the perception that FAA excessively scrutinizes a particular medical condition (Stigma),
the costs involved with FAA-mandated procedures or testing to achieve recertification/clearance
(Financial), and the time required to resolve a medical issue to the FAA’s satisfaction and return to
duty (Process). The challenges, complexities, and lack of transparency with the FAA-defined
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.

Page 19 of 69
Aviation Medical Examiner
Similar to the FAA concerns stated above, a pilot/controller’s lack of trust in the AME is
demonstrated by a reluctance to report symptoms or conditions due to concerns about how the
AME’s response might impact their medical certificate/clearance. The lack of trust is due to
variations in AMEs’ experience, administrative capability, application and understanding of FAA
policy and procedures, and an unwillingness to engage with harder cases. Additionally, AMEs who
need guidance or have questions during an appointment, are often unable to reach the FAA
physician on duty during the exam, which can lead to a delay in issuance of a certificate/clearance
or a deferral.

FAA technological limitations and AMEs limited administrative capabilities can slow the
certification or recertification process due to the extensive documentation required. An AME
presented with a mental health case must be prepared and willing to take the additional time
required to navigate the application process. AME duties are typically only a fraction of most AMEs
primary medical practice as most AMEs have other clinical practices. Any additional time required
to process a complicated pilot/controller case involving mental health concerns comes at a cost to
the primary practice, which the AME may not be willing to absorb.
This AME variability creates a challenge for the applicant in finding and choosing a suitable AME.
Each time an application is deferred, or a pilot/controller must find a new AME, the associated
Fear, Stigma, Financial, and Process barriers again come into play.

The Medical System

There is an underlying patient trust challenge in the US healthcare system. For many reasons, some
people do not like meeting with a medical provider, and research has shown that when
encountering a mental illness, most people opt for self-help or turn to friends and family, rather
than mental health professionals. 28 In addition, concerns about affordability, payment options,
healthcare inequities, and lack of access to timely, high-quality care negatively impacts patient
trust in the US healthcare system. 29

Trust is highest between a patient and provider with an established therapeutic relationship. In the
aviation framework, the pilot/controller has the highest level of trust with their personal treating
provider, be that a primary care physician or mental health provider. The primary care provider is
also likely to have had greater patient contact with the applicant and is best positioned to observe
how the applicant is responding to medication.
A pilot/controller may have, or gain, a limited level of trust with their AME depending upon the
reputation of the AME, the experience of a pilot/controller during their visits, and the relationship
developed during the certification/clearance visits. Trust can be difficult to establish between a
pilot/controller and a HIMS psychiatrist or HIMS trained neuropsychiatrist performing an evaluation
on behalf of the FAA.

28
Lien YJ, Chen L, Cai J, Wang YH, Liu YY. The power of knowledge: How mental health literacy can overcome
barriers to seeking help. Am J Orthopsychiatry. 2024;94(2):127-147. doi: 10.1037/ort0000708. Epub 2023 Nov
2. PMID: 37917500. (Lien et al., 2023).
29
See discussion above at Section V. – Industry Overview.

Page 20 of 69
The most challenged relationship for Trust is between the regulator (FAA) and the individual
pilot/controller due to the lack of a physician-patient relationship or in-person interface, and the
inherent conflict between the applicant and the agency that judges the application.

Primary care providers (e.g., family physicians, internists, physician assistants, or nurse
practitioners), undergo mental health training and are authorized to treat patients, including
prescribing antidepressant medications. Pilots/controllers have the most Trust in these providers
and often seek help on these issues. However, current FAA policies on antidepressant use require a
clinical finding summary from both the primary care provider and a board-certified psychiatrist. 30
Having to meet with a new and unfamiliar healthcare provider (psychiatrist) can increase the
applicant’s apprehension or anxiety.

Misdiagnosis of mental health conditions by medical, paramedical, or mental health professionals,

as well as diagnostic escalation to support better insurance reimbursement for treatment
providers, create many problems for aviation professionals. Moreover, the FAA's approach to
clarifying a diagnosis involves seeking a second assessment from a mental health specialist with
acceptable qualifications. This approach frequently entails a substantial financial burden for the
pilot/controller or company and creates delays in receiving proper treatment or useful medications
that could help alleviate symptoms and improve performance.

In addition, the FAA’s certification standards stipulated in 14 CFR Part 67 are different from the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). As a result of these differences,
the FAA encourages, and occasionally requires, pilots/controllers to seek evaluation from mental
health professionals who have completed specialized FAA training to render a complete
psychological diagnostic evaluation, according to accepted standards of clinical care and
regulatory requirements. In some cases, diagnoses can get lost in translation between 14 CFR Part
67 and DSM-5-TR, and errors and omissions can occur in testing and documentation.
Sometimes mental health professionals attempt to provide a regulatory diagnosis and/or safety
recommendation that is outside of their scope of practice or experience. If an accurate DSM-5-TR
diagnosis is provided, the FAA then continues with the regulatory diagnosis and safety risk
assessment. It is common for mental health professionals to provide both clinical and regulatory
diagnoses along with safety recommendations that may conflict with each other. These situations
lead to greater time spent reviewing the case file, often requiring an FAA psychiatrist to ‘correct the
record’. These issues often result in delays in recertification/clearance that further compromise
the trust between the pilot/controller and the specialist.

Employer
Trust issues can also arise between a pilot/controller and their employer over the management of
the medical certificate/clearance holder's interests. An employer may have an inherent conflict
between prioritizing the well-being of the individual and ensuring safety and operational
responsibilities. Unlike pilots, the FAA is most often an air traffic controller’s employer and medical
clearance authority, making that relationship unique. This dynamic creates a challenging balance
for the FAA as an employer.

30
See FAA Certification Aid for SSRI Initial Certification.

Page 21 of 69
The Process
Lastly, the medical certification process can also breed distrust. The process disincentivizes
honesty due to the often-immediate grounding/removal from duty until recertification/clearance
from the FAA is received. The MedXPress User’s Guide 31 and the 8500 Form Help Instructions 32
have conflicting guidance regarding when medical professional visits must be reported (e.g.,
family/marital counseling, or life coaching). 33 Individuals may also have privacy concerns about
sharing personal information with the government, their employer, or a training organization that
may be required for mental health visit reporting. Likewise, the requirement to report conditions
that “have you ever in your life” 34 had, as opposed to reporting the transient nature of mental health
symptoms, can seem excessively conservative to a pilot/controller. Psychological avoidance 35 is
common in pilots/controllers’ action-oriented culture making them less likely to address known
mental health issues. The perceived or actual consequences of reporting a mental health
condition/medication that was not previously reported can make the process seem unfair and
punitive, which further erodes trust.

C. Fear
Fear is the 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. 36 This is common in pilots/controllers, which can
negatively impact individual health, aeromedical screening, and ultimately the safety of the NAS. 37

The pilot/controller’s fears are further fueled by aeromedical decisions that appear to be
subjective. Pilots/controllers are aware of the small numbers/percentages of individuals who are
not recertified and are often left without a clear understanding of ‘why’ a medical
certification/clearance was not granted. For the individual, certain questions can be daunting and
may stoke fear that it’s too risky to disclose the condition or treatment, such as, Can I fly with this
diagnosis? What treatments are allowed? Will they work? If I disclose my condition and my medical
was deferred, what would be required, how much would it cost, and how long would it realistically
take to return to duty? As stated previously, pilots/controllers often see themselves and their
profession as inseparable. Thus, losing their medical certification/clearance is a loss of both
career and identity. This would be devastating for anyone, and even more so for goal-driven
individuals like pilots/controllers.

31
See FAA MedXpress Users Guide.
32
See FAA MedXpress Instructions for Completing the Airman Medical Certificate Application, FAA Form
8500-8.
33
See also Appendix D.
34
Supra note 32.
35
Definition of Psychological Avoidance: by admitting a mental health concern, there is a personal realization
that one must address it, therefore leading to the natural defense mechanism of denial of the issue.
36
Hoffman WR, Aden J, Barbera RD, Mayes R, Willis A, Patel P, Tvaryanas A. (2022). Healthcare Avoidance in
Aircraft Pilots Due to Concern for Aeromedical Certificate Loss: A Survey of 3765 Pilots. J Occup Environ Med.
64(4):e245-e248. doi: 10.1097/JOM.0000000000002519. Epub 2022 Feb 15. PMID: 35166258.
37
Id.

Page 22 of 69
While we tend to look at pilots/controllers as a homogeneous group, healthcare avoidance
behavior due to fear of loss of certification is not uniform. In fact, the data 38 suggest unique
subpopulations within these groups face uniquely high rates of healthcare anxiety and avoidance,
including young, female, and student pilots, when compared to other populations. These data
suggest subpopulations may face unique barriers, which may become more pressing as the
aviation workforce becomes increasingly diverse. 39

Further, if a pilot/controller chose to conceal a mental health condition, the fear of potential
certificate action, enforcement, or disciplinary action may further deter the individual from future
disclosure. The specter of criminal or civil penalties because of a legal enforcement action, the
possibility of certificate actions or permanent medical disqualifications, and/or the threat of
disciplinary actions for violations of employer policies create a fraught landscape and plays a key
role in pressing the pilot/controller to keep any underlying mental health condition hidden.

One tool to combat Fear is education, and an overarching goal of the ARC’s Recommendations 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.

D. Stigma

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. 40 Internalized stigma and public stigma associated with mental health issues have
contributed to unfavorable attitudes about seeking psychological help. 41 Particularly within the
aviation community, mental health stigma is a pervasive barrier that often has profound
implications for pilots, controllers, and other aviation professionals. 42 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. 43

38
Hoffman WR, Barbera RD, Aden J, Bezzant M, Uren A. (2021). Healthcare related aversion and care seeking
patterns of female aviators in the United States. Arch Environ Occup Health. 2022;77(3):234-242. doi:
10.1080/19338244.2021.1873093. Epub 2021 Feb 3. PMID: 33533702.
39
Id.
40
Corrigan P. How stigma interferes with mental health care. Am Psychol. 2004 Oct;59(7):614-625. doi:
10.1037/0003-066X.59.7.614. PMID: 15491256. (Corrigan, 2004); Vogel, D. L., Wade, N. G., & Haake, S.,
Measuring the self-stigma associated with seeking psychological help. Journal of Counseling Psychology,
53(3), 325–337. (Vogel et al. 2006).
41
Williston SK, Vogt DS. Mental health literacy in veterans: What do U.S. military veterans know about PTSD
and its treatment? Psychol Serv. 2022 May;19(2):327-334. doi: 10.1037/ser0000501. Epub 2021 Mar 18.
PMID: 33734727. (Williston & Vogt, 2022).
42
Santilhano, Wendy, Robert Bor and Lia M.M. Hewitt. (2019). The Role of Peer Support and Its Contribution
as an Effective Response to Addressing the Emotional Well-Being of Pilots. Aviation Psychology and Applied
Human Factors.
43
Vogel et al. Stigma of Seeking Psychological Services: Examining College Students Across Ten
Countries/Regions, The Counseling Psychologist, sagepub.com/journalsPermissions.nav, doi:
10.1177/0011000016671411 journals.sagepub.com/home/tcp. (Vogel et al. 2017)

Page 23 of 69
Pilots/controllers often worry that disclosing mental health concerns will jeopardize their careers or
stunt career growth and professional credentialing, leading to discrimination, loss of employment
opportunities, or damage to their standing within the industry. This could result in a pilot/controller
not seeking help and/or reporting until after their symptoms are already moderate or higher in
severity. The phenomenon known as reverse malingering, which is presenting oneself as healthy as
possible or “faking good,” further complicates the psychological assessment of what true
impairment the applicant had or is having. Research has also shown that individuals with mental
illness may internalize stigma leading to reduced self-esteem, reduced self-efficacy, and lower
confidence in their future. 44 Promotion of mental health concerns, such as a Pilot/Controller Mental
Fitness campaign, can further intensify Stigma, especially if this promotion is not part of broader
awareness and educational efforts. Additionally, the existing FAA regulations tend to address
mental health problems using a standardized approach that is more appropriate for severe
psychiatric disorders. The current aeromedical screening process does not account for varying
levels of impairment associated with different mental health conditions, which can be problematic
for a pilot/controller seeking help with only mild or mild/moderate mental health concerns.
Moreover, the current understanding of disqualifying mental health issues among pilots/controllers
is limited, leading to anxiety and the perpetuation of Stigma within the sector. 45

Under current FAA policy, AMEs are limited in the types of mental health conditions where they are
allowed to issue a medical certification/clearance. There are FAA standards and guidelines
regarding when an AME may issue; however, these standards/guidelines lack sufficient specificity
for them to be applied in a uniform manner. This can result in different outcomes for
pilots/controllers based upon the willingness of an AME to issue versus deferring a medical
certificate/clearance.

The FAA has made some progress by defining several mental health-related situations where an
AME can issue a certificate during the exam via the FAA’s Conditions AMEs Can Issue (CACI)
process. The ARC believes the FAA could expand use of CACIs for mental health concerns, where
appropriate. The FAA should recognize the spectrum of mental health conditions and the varying
degrees of impairment they may cause. Additional measures should be implemented to prevent
any undue and disproportionately adverse impact on pilots/controllers. Transparency from the FAA
may include developing clarity within a disease spectrum to identify impairment issues that lead to
medical certification deferrals and/or loss of license. This can lead to reduced Stigma by
differentiating severe symptoms/states from transient/temporary symptoms.

The disparity in social perception and medical treatment between physical and mental health
issues further contributes to Stigma. Pilots/controllers are also aware of the vast difference in the
way mental health issues are treated in aviation when compared to other safety sensitive
industries. As an example, other high-risk, high-reliability occupations do not face mandatory wait

44
Corrigan. (2004).
45
See also Knowledge and Information Gap Barrier discussion at Section VII.G. below.

Page 24 of 69
times following the disclosure of mental health conditions or when starting/changing
antidepressant medications. 46

Moreover, the FAA mandates a six-month wait time when starting/changing an approved
antidepressant or following a change in dose. While it is true that other professions have
requirements to reveal mental health conditions, treatment, or the use of medications (usually for
initial or recurrent state board licensing, or occupation-specific regulations and standards), this
disclosure typically does not result in an interruption to the person’s ability to remain in an active
work status. Even if it does, a return to normal duties is based on the person’s behaviors (not a
specified timeline), and typically occurs within a much shorter window than six months. In some
cases, the person may be given an alternate temporary assignment while addressing the mental
health condition or medication. These arrangements are handled on a case-by-case basis, but
these options are not always available to pilots/controllers. These examples highlight the extent to
which pilots/controllers perceive that they are held to a much more stringent standard and may
feel stigmatized by their mental health condition.

The ARC recognizes that managing conditions associated with anxiety and/or depression are
challenging. This affects many pilots/controllers, particularly younger applicants who are more
likely to acknowledge anxiety and depression due to generational changes, greater awareness and
social acceptability. The ARC also notes the increasing number of young people that have been
diagnosed with neurodevelopmental disorders 47 like ADHD who are considering careers in aviation.
Specifically, the diagnosis, and perhaps over-diagnosis, of ADHD and the subsequent medication
for that diagnosis is an issue of concern. Under current FAA regulations, pilots/controllers are
disqualified when being treated for ADHD or taking any ADHD medication. The ARC encourages the
FAA to explore how safety can be maintained while allowing pilots/controllers managing an ADHD
diagnosis with medication to maintain their certification/clearance.
Addressing mental health Stigma in the aviation community requires a multifaceted approach that
includes education, advocacy, and policy reform. Future initiatives should come from an
institutional and organizational structure that encompasses all aspects of aviation and promotes
improvement processes throughout the sector. One such approach may include peer-led mental
health literacy education. Peer educators (PE) offer a mechanism for working directly with
pilots/controllers. By providing relevant information from a trusted source and improving attitudes
about mental health treatment, PEs may serve to reduce the impact of internalized stigma as a

46
Henderson, Williams, Mental Health and Final Security Clearances, Mar 29, 2022, noting that federal form
SF-86 (Questionnaire for National Security Positions) states that “[m]ental health treatment and counseling,
in and of itself, is not a reason to revoke or deny eligibility for access to classified information or for holding a
sensitive position, suitability or fitness to obtain or retain Federal or contract employment, or eligibility for
physical or logical access to federally controlled facilities or information systems. Seeking or receiving
mental health care for personal wellness and recovery may contribute favorably to decisions about your
eligibility.”
47
Mullin AP, Gokhale A, Moreno-De-Luca A, Sanyal S, Waddington JL, Faundez V. Neurodevelopmental
disorders: mechanisms and boundary definitions from genomes, interactomes and proteomes. Transl
Psychiatry. 2013 Dec 3;3(12):e329. doi: 10.1038/tp.2013.108. PMID: 24301647; PMCID: PMC4030327.
Neurodevelopmental disorders (NDDs) are multifaceted conditions characterized by impairments in
cognition, communication, behavior and/or motor skills resulting from abnormal brain development.
Examples include ADHD and autism spectrum disorder.

Page 25 of 69
significant barrier to service utilization. 48 In addition, reducing Stigma can be achieved by offering a
confidential, caring, and trustful relationship with peer volunteers, who provide accurate and
reliable information through credible mental health resources. 49
Further Stigma reduction can be accelerated by anti-Stigma campaigns and clear messaging to
differentiate between mental illness and pilot/controller mental fitness. Research suggests that
implementation of strategies to decrease mental health stigma should include educational videos
that provide information about mental illness, its symptoms, and treatment options. 50 A thematic
analysis of TED Talks featuring personal experiences with mental illness highlighted the need for
first-person narratives to reduce stigma. 51 Hence, the use of video testimonies from first person
narratives of recovery should incentivize pilots/controllers to proactively engage in an enhanced
level of mental fitness and well-being.
Fostering a culture of openness, understanding, and support will create an environment where
aviation professionals feel empowered to prioritize their mental health without Stigma or fear of
discrimination.

E. Financial
Financial concerns are a significant barrier to reporting. Under the current process the
pilot/controller faces an uncertain financial future once a mental health condition/diagnosis is
reported with the immediate loss of medical certification/clearance. This can include potential
loss of income, as well as the costs of testing and treatment. 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 the loss of medical certification/clearance and the return to work.
Sick leave varies by employer and is typically limited in duration, so the disruption or loss of income
may be immediate or may slowly erode over time. Individuals with the benefit of a disability
program have a financial safety net that preserves some income after sick leave ends. However,
this is typically at a reduced level of income that may not sufficiently cover living expenses. For
those with no ability to transition to a disability program, or a guarantee of alternative work, income
can cease entirely when sick leave ends. Moreover, the duration of disability coverage varies, and
many policies offer only limited benefits for mental health conditions. The ARC also notes that
personal or supplemental disability coverage can be cost prohibitive for individuals seeking to
mitigate the potential financial impact of a mental health-related job loss. Therefore, financial
concerns play a significant role in the decision to withhold reporting a mental health condition.

The cost of treatment and testing for recertification/clearance is another financial barrier to
reporting a healthcare concern. Some mental health providers accept insurance for treatment,
while others do not, requiring the pilot/controller to pay out-of-pocket for services. Providers that
accept health insurance must issue a diagnosis following the initial evaluation and treatment to
receive continued payment from the insurance provider. Providing escalating levels of diagnosis

48
Connor et al. (2015).
49
Id.
50
Morton et al. (2024).
51
Lien et al., (2023), p. 172 noting that “recognition of mental disorders may eliminate mental health stigma
or improve help-seeking efficacy, thereby increasing positive help-seeking attitudes”.

Page 26 of 69
are usually required to continue insurance payments for the prescribed treatment plan. This can
complicate FAA medical certification by leaving pilots/controllers to pay for treatment directly to
avoid this undesirable scenario.

Moreover, the cost of required testing to return to duty is often not covered by insurance. In many
cases, the required treatment and testing cannot be performed close to the pilot’s/controller’s
home. This can result in additional expenses for travel and lodging to and from the testing site or to
visit a specialist outside of their local area. This further exacerbates the financial impact on the
individual, most often at a time when their income has already been reduced. It can also be difficult
to find, and schedule required appointments and treatment with the necessary medical specialist.
This can further extend time on reduced income or without pay.

Aspiring aviation professionals also face similar financial implications related to the cost and time
for treatment, testing, and certification/clearance. Treatment costs, testing required by the FAA’s
certification process, and travel costs for treatment/testing are borne by the aspiring aviation
professional, who likely does not have the financial resources and protections as someone already
in the industry. This may delay starting or progression through training, which ultimately delays
completion of training and entry into the workforce. This can also lead to the loss of the G.I. Bill or
other financial aid to cover the cost of training, as well as costs incurred on servicing loans, and
loss of income and earning potential.

In the rare event of permanent medical disqualification, pilots/controllers choosing to appeal the
decision would likely incur significant additional medical and legal costs as they move through that
process. To a greater extent than many professions, pilots/controllers develop highly specialized
skills and are generally compensated well for their years of technical experience. Industry
employment interruptions (furlough, strike, lockout, cessation of operations) have shown that
pilots/controllers are not as readily successful in transferring their skills to another industry at a
similar level of compensation. Thus, the possibility of a significant loss of income while awaiting
treatment, testing, and completion of the FAA process for medical recertification/clearance
presents a daunting potential financial risk to pilots/controllers. It is understandable why many
aviation professionals see these financial considerations as a significant factor in their decision to
seek help or report. Simply stated, if aviation professionals feel forced to choose between
maintaining their family's financial viability or seeking help for a mental health issue, many will
choose the former.

F. Process
The ARC identified the Process of obtaining a medical certificate/clearance as an obstacle to
reporting a mental health condition. The FAA Aeromedical Certification Division’s (AMCD)
processes are unclear, complex, and sometimes overly conservative. The ARC believes that a
broad process flow description would be helpful in explaining the certification/clearance
requirements to applicants. The current system could also benefit from an incorporated feedback
loop to provide information to end users during the process, as well as after a decision has been

Page 27 of 69
made. The ARC also notes the extremely slow pace of the process 52 due to the FAA’s heavy reliance
on the US Mail and limited ability to receive/submit documentation electronically. For
professionals accustomed to making time critical decisions, waiting weeks to months for feedback
is demoralizing and can adversely impact many mental health issues. Other obstacles discussed in
more detail below include access to AMEs and clarity around the documentation required and
standards for aeromedical approval.

Access to AMEs
Lack of access to medical professionals trained and qualified in aviation medicine is another
component of the Process barrier. Across the US, there can be vast distances between
experienced AMEs willing to work complex mental health cases. Access and availability to HIMS
AMEs, who are required for certifying pilots/controllers using acceptable antidepressant
medications, can be equally challenging. FAA policies requiring testing or evaluations from FAA-
approved neuropsychologists and psychiatrists pose yet another access issue in many locations.
Also, mental health professionals in general, especially those familiar with the FAA processes, are
limited in quantity and location. Across the industry, a variability of financial resources, mobility,
and time impedes access to the required healthcare resources.

Documentation & Standards

The documentation required for recertification following a medical diagnosis can be extensive and
difficult to navigate. Moreover, the documentation required seems skewed towards the severest
disease state, and does not appear to consider the individual case, varying degrees of impairment,
or previous history of certification. For example, many pilots that previously served in the US
Uniformed Services with a mental health diagnosis and were subsequently re-certified, faced
deferral as civilians pending FAA review of documented treatment, and verification they are
symptom free. This results in the appearance that the FAA standards are overly conservative both
in the treatment protocols and in the timelines in returning to wellness. Moreover, the process for
reconsideration/appeal is ambiguous, and there can be variations in the outcomes of similar cases
that make the process appear arbitrary and unfair.

To a pilot/controller, there also appears to be a specious link between a diagnosis and how the
condition may adversely affect flight safety. Under the FAA’s current requirements, applicants are
required to report any visit to a mental health professional. From the laymen’s perspective, many of
these types of therapies have little to no impact on aviation safety, making the requirement to
report feel like an invasion of privacy. This is often perceived as excessive reporting of non-safety
related information, which stands in stark contrast to most pilot/controller’s experience with SMS
programs that rely on affirmative reporting of self-identified safety hazards or threats. Lastly,
pilots/controllers have limited knowledge of any available quantitative mental health self-
assessment tools that could help in the decision-making process to self-ground or continue
operating. In sum, the FAA’s current process is an overly complicated system that would benefit
from simplification, increased relevance, and transparency.

52
See also Figure C below, a Notional Timeline for FAA Initial Authorization for Antidepressant Medication
Use, illustrating a timeline of more than 500 days for assessment and decision of pilots/controllers using
antidepressant medications.

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 G. Knowledge & Information Gap
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,” 53 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. 54

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.

Misunderstandings exist throughout society regarding mental health conditions, knowledge, and
stigmatization. Research shows that the variables of self-stigma and mental health literacy have a
significant and distinct impact on help-seeking attitudes and behaviors among the general
population. 55 Within the aviation community, inaccuracies and misconceptions persist
surrounding mental health. Pilots/controllers often share FAA medical certification ‘war stories,’
which can perpetuate misinformation about the mental health certification/clearance process.
Thus, it is essential to provide factual, positive personal narratives to counter misinformation,
reduce stigma, and increase help-seeking attitudes. 56

Peer Support Programs & Expanded Communication Methods

Usually, the first misstep in a mental health journey by a pilot/controller is to consult non-peer
support trained co-workers to gather information on the regulations, processes, and potential
pitfalls. These conversations include topics such as: exploring ways to navigate the landscape of
mental health treatment options, information on the medical certification/clearance process, and
the ability to return to flight/duty. Anecdotal knowledge shared within the pilot/controller networks
may create misconceptions that are widely believed to be accurate. Exposure to these mistaken
beliefs can be experienced as early as initial flight training where inaccuracies are passed among

53
Jorm AF, Korten AE, Jacomb PA, Christensen H, Rodgers B, Pollitt P. "Mental health literacy": a survey of the
public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Med J
Aust. 1997 Feb 17;166(4):182-6. doi: 10.5694/j.1326-5377.1997.tb140071.x. PMID: 9066546, p. 182.
54
O'Connor M, Casey L. The Mental Health Literacy Scale (MHLS): A new scale-based measure of mental
health literacy. Psychiatry Res. 2015 Sep 30;229(1-2):511-6. doi: 10.1016/j.psychres.2015.05.064. Epub 2015
Jul 16. PMID: 26228163.; (Williston & Vogt, 2022).
55
Cheng, H.-L., Wang, C., McDermott, R. C., Kridel, M., & Rislin, J. L. (2018). Self-stigma, mental health
literacy, and attitudes toward seeking psychological help. Journal of Counseling & Development, 96(1), 64–
74. Kitchener BA, Jorm AF. (2002). Mental health first aid training for the public: evaluation of effects on
knowledge, attitudes and helping behavior. BMC Psychiatry. 2002 Oct 1;2:10. doi: 10.1186/1471-244x-2-10.
PMID: 12359045; PMCID: PMC130043.
56
Lien et al., (2023).

Page 29 of 69
fellow students and their instructors and subsequently perpetuated throughout their aviation
career. Proper education and well-trained peer support programs are needed to disseminate truths
about mental health reporting and treatment, and reduce false perceptions from gaining traction
and causing mental health care avoidance.

Current methods of disseminating 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. FAA communications are even less likely to
reach younger generations of pilots/controllers who use social media outlets for their information
gathering. The role of electronic communications/social media in reaching and appealing to all
generations of aviation professionals should not be underestimated. Using social media outlets to
disseminate factual, unambiguous, relatable information about mental health issues, treatment
options, requirements for certification/clearance, and timelines associated with the journey may
allow for the narrative around this topic to be discussed with honesty and transparency.

There is significant evidence that sharing narrative-driven accurate information is an effective

approach to educating and communicating with others in aviation. 57 Peer-to-peer programs are an
effective means to provide pilots/controllers with a forum to share knowledge in a reliable and
trusting way. 58 Transparency of the process by which medical certification/clearance decisions are
made will also help improve the Knowledge and Information Gap. This transparency should be
evident at every stage of the process, from application to appeal. 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 the inaccurate narratives that they lean
on today. See Figure B below for more information on the Mental Health Literacy Framework.

57
Hoffman WR, McNeil M, Tvaryanas A. (2024). The Untapped Potential of Narrative as a Tool in Aviation
Mental Health and Certification. Aerosp Med Hum Perform. 2024 Mar 1;95(3):165-166. doi:
10.3357/AMHP.6281.2024. PMID: 38356134.
58
Santilhano et al. (2019).

Page 30 of 69
Figure B: Mental Health Literacy Framework 59

O’Connor, M., Casey, L., & Clough, B. (2014). Measuring mental health literacy – a review of scale-based
59

measures. Journal of Mental Health, 23(4), 197-204. doi:10.3109/09638237.2014.910646.

Page 31 of 69
Increased Knowledge to Reduce Healthcare Avoidance Behaviors or Treatment Modification
The FAA depends on pilots/controllers to self-report physical and mental issues, but
pilots/controllers are often unaware of an existing problem, its severity, or the most effective
treatment. Increasing pilot/controller’s mental health literacy contributes to a better awareness
which in turn may lead to earlier reporting and help-seeking behavior. Likewise, early intervention
can effectively mitigate more serious mental health conditions. Therefore, increased mental health
literacy will ultimately lead to better outcomes for the pilot/controller.
Pilots/controllers should educate themselves with aviation medical terminology as there is often a
misunderstanding of the terminology. Moreover, in some cases, the differences between the
clinical definitions in the DSM-5-TR and the FAA definitions used for regulatory determinations
under 14 CFR Part 67 can be significant. Typically, the regulatory definition is more conservative
because of the aviation context. For example, under the Federal Aviation Regulations, substance
dependence is defined as meeting at least one of four criteria defined in Part 67. In contrast, under
the DSM-5-TR, mild substance use disorder requires meeting at least 2 of 11 criteria; and moderate
and severe substance use disorders require meeting at least 4 and 6 criteria respectively.

Confusion around aeromedical standards can also cause some applicants with mental health
diagnoses to self-modify pharmacological treatment due to real or perceived differences in how
their application will be handled. For example, there are currently no ADHD medications allowed
by the FAA. Therefore, many applicants with ADHD discontinue taking medication for the condition
in the hopes of being certified/cleared. What these individuals seemingly misunderstand is that
ADHD in and of itself is a disqualifying condition, regardless of the use of medication. Therefore,
discontinuing the medication does nothing to increase the applicant’s chances of being
certified/cleared and may only serve to worsen their symptoms if the ADHD diagnosis is correct.
Similar behaviors regarding changes in pharmacological treatment are also seen in applicants with
other commonly diagnosed mental health conditions, such as anxiety, depression, and PTSD.
Many applicants with anxiety or depression will voluntarily discontinue use of approved SSRIs
because they believe it will lead to a more streamlined approval. This is reinforced (perhaps
unintentionally) by FAA literature that appears to show a truncated approval pathway when a
person is off medication for a specified period. 60 See Figure C below for more information on the
approval process for applicants taking antidepressants.

60
The ARC notes that whether on or off antidepressant medications, the timeline for certification/approval is
excessive and inconsistent with international standards. See Tables 1 and 2 above in Section VI. Task D
discussion.

Page 32 of 69
Figure C: Notional Timeline for Initial Authorization for Antidepressant Medication Use

Notes: Timeline assumes first medication used and dosage remains stable for 180 days, an FAA-defined
minimum. Medication or dosage changes restart the 180-day observation period.

FAA review process timeline is variable, e.g. FAA Psychiatrist Review in DC (AAM-200) currently ranges between
150-180 days. The FAA aims for psychiatry review within 30 days of receipt at FAA AAM-200. This chart is based
on current timeline estimates.

Air Traffic Controllers experience a similar process and timeline for initial authorization of antidepressant
medication use.

Taking care of one’s mental health is an important element to overall health and wellness and
improving mental health literacy will enhance proactive mental health service use. 61

61
Corrigan. (2004); Kitchener & Jorm. (2002); Shields et al. (2023); Williston & Vogt. (2022).

Page 33 of 69
 VIII. ARC Recommendations – Intent, Rationale, and Approach
The following section contains detailed information on each recommendation, including the ARC’s
intent, supporting rationale, research, examples, and suggested regulatory approach. The ARC
would like to reemphasis that the following recommendations are interdependent and all need to
be implemented to fully overcome the barriers identified earlier.

REC1 – Disclosure Requirements for Psychotherapy

The FAA should change its policy and medical application instructions to allow
pilots/controllers to participate in psychotherapy (talk therapy) 62 without requiring disclosure
during aeromedical screening.

INTENT: To minimize barriers to obtaining non-pharmacological based mental health therapy for
mental health concerns.

RATIONALE: The FAA requirement to disclose talk therapy has had unintended consequences.
Presumably, the requirement was based on the FAA’s view that the use of talk therapy served as a
marker for identifying an operational hazard or an impairment to work performance. However, not
only is there limited data to support this view, but there is also robust data to the contrary. 63

Studies show that barriers to seeking mental health care can produce additional stressors and
anxiety, which can ultimately create aviation safety hazards that would not otherwise exist. For
example, a pilot/controller desiring to engage in talk therapy to manage a life event (e.g., divorce),
could be deterred from doing so due to the requirement to report it to the FAA. In these instances,
the pilot/controller has recognized the need for help and has the desire to obtain it but may be
concerned about the potential adverse impact on their livelihood and career. Consequently, not
only is the person not obtaining help with the mental health issue related to the triggering event
(i.e., the divorce), but the person is now also managing the stress and anxiety surrounding the
decision to either:
• get help and disclose to the FAA (risking loss of certification pending the FAA review
process),
• get help and not disclose to the FAA (risking loss of certification, civil/criminal penalties,
and most likely an unnecessary financial burden of having to self-pay for mental health
care because the person cannot access insurance benefits without disclosing); or
• not get help risking the development of a more serious mental health issue because the
person was unable to take advantage of early intervention when the symptoms were mild
or mild/moderate in nature and linked to a transient life event.

62
Psychotherapy is an approach for treating mental health issues by talking with a psychologist, psychiatrist,
or another mental health provider. It also is known as “talk therapy,” counseling, psychosocial therapy or,
simply, therapy. It can include cognitive behavioral therapy, supportive therapy, family, marital, life coaching,
or bereavement counseling.
63
Hoffman WR, Aden J, Barbera RD, Mayes R, Willis A, Patel P, Tvaryanas A. (2022). Healthcare Avoidance in
Aircraft Pilots Due to Concern for Aeromedical Certificate Loss: A Survey of 3765 Pilots. J Occup Environ
Med. 2022 Apr 1;64(4):e245-e248. doi: 10.1097/JOM.0000000000002519. Epub 2022 Feb 15. PMID:
35166258.

Page 34 of 69
It is indisputable that the requirement to disclose talk therapy leads to healthcare avoidance
and/or non-disclosure. 64 This alone should be sufficient to support a change in FAA policy because
many pilots/controllers go without care, leaving their symptoms untreated, which poses its own
aviation safety risks. Moreover, seeking talk therapy is a poor hazard identification tool from an
aviation safety perspective. Thus, if the FAA is going to assign it any significance, it should view it as
a marker of safety, wellness, and self-awareness instead of a marker for risk. Medical guidelines 65
advise evidence-based talk therapy as first line therapy, and many people participate in talk
therapy, even in the absence of any acute stressors or triggering events, for preventive mental
health purposes. Given the barriers identified above and the fact that work related stress is
common and increasing among pilots/controllers, 66 the ARC recommends that talk therapy should
no longer require disclosure.

APPROACH: The FAA should amend the instructions on medical applications to exclude mental
health talk therapy services as a required reportable medical professional visit. 67 While the three
examples of the instructions in Appendix D differ on what is reportable, it should be noted that the
Guide for Aviation Medical Examiners-Version 03/27/2024 does state “The applicant should list
visits for counseling only if related to a personal substance abuse or psychiatric condition.” During
a periodic health assessment, pilots/controllers should be asked by the AME about personal,
social, and occupational issues to identify relevant mental health hazards. Obtaining this
information, directly from the pilot/controller, instead of a mental health provider, will reduce the
behavior of non-reporting and increase safety. If the AME senses a mental health concern during the
screening process, additional information will be requested. 68

Barriers Addressed: Trust, Fear, Stigma, Process

64
Hoffman WR, Patel PK, Aden J, Willis A, Acker JP, Bjerke E, Miranda E, Luster J, Tvaryanas A. (2023).
Multinational comparison study of aircraft pilot healthcare avoidance behaviour. Occup Med (Lond). 2023
Oct 20;73(7):434-438. doi: 10.1093/occmed/kqad091. PMID: 37658781.
65
https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf.
66
Cahill, J., Cullen, P., Anwer, S., Wilson, S., & Gaynor, K. (2021). Pilot Work Related Stress (WRS), Effects on
Wellbeing and Mental Health, and Coping Methods. The International Journal of Aerospace Psychology, 31,
87 - 109.
67
See Appendix D.
68
See Flowchart at Appendix A and Sample Checklist at Appendix B.

Page 35 of 69
REC2 – Regulatory Pathway - Reporting Mental Health Conditions & Medications
The FAA should develop a non-punitive 69 pathway for reporting previously undisclosed
mental health conditions, treatments, or medications.

INTENT: To increase trust in the FAA medical certification/clearance process by establishing a non-
punitive pathway for applicants to report previously undisclosed conditions and medications. The
process should incentivize compliance, minimize financial and occupational jeopardy, and
encourage pilots/controllers to seek appropriate mental health care, which will improve the safety
of the NAS.

RATIONALE: As explained in the barrier narratives, Fear inhibits reporting of previously identified or
diagnosed conditions and medications. Individuals undergoing unreported mental health treatment
are not subject to monitoring by the FAA AAM. Without monitoring, it is impossible to gather data
regarding the magnitude, severity, and operational impact of mental health conditions. This creates
a potential safety hazard within the NAS, as well as for the individual who may not be receiving
appropriate treatment and adequate support for their condition.

The FAA does not have the authority to offer immunity from criminal prosecution under 18 USC
1001 for making any materially false, fictitious, or fraudulent statement or entry on the medical
application form because immunity can only be offered by the Department of Justice. However, the
FAA and the OIG (the office through which the FAA makes referrals for possible criminal
prosecution), can agree that the FAA will not refer cases of apparent intentional falsification or
misrepresentation for criminal investigation or prosecution. The ARC recognizes the need for a
sunset clause to this non-referral period, but the period must be of sufficient duration to allow trust
to be developed and culture to change. The ARC believes that a program of this type will allow the
greatest number of individuals to come forward.

APPROACH: The FAA should create a process whereby pilots/controllers who currently hold a
medical certificate/clearance are encouraged to report previously undisclosed mental health
conditions, diagnoses, and/or treatment. The person should be able to disclose without fear of
immediate revocation or referral for disciplinary or administrative/criminal prosecution for
falsification, misrepresentation, or omission of information on the required disclosure documents.
The non-revocation protections should extend to the medical certificate/clearance, as well as to
any other certificates, ratings, clearances, or qualifications the person holds. This process should
also allow pilots/controllers to maintain aeromedical certification/clearance, with appropriate
restrictions as needed, when the condition/treatment is aeromedically acceptable, and there is
evidence of present ability to function well.

Any pathway developed would require a good faith effort by the certificate/clearance holder to
provide all information required by the FAA to render a determination on the status of the medical
clearance/certificate. To be eligible for this pathway, the certificate/clearance holder must
disclose the information prior to the FAA discovering the withheld information through other
means.

69
Non-punitive implies relief from both civil and criminal penalties, including medical/pilot certificate action,
loss of medical clearance for controllers, referral to OIG for criminal prosecution, and/or any other
disciplinary action.

Page 36 of 69
The ARC recommends that the ‘grace period’ be at least two years from date of recommendation
implementation. The certificate/clearance holder should report within the two-year period or in the
case of the 3rd Class Medical Certificate holder at the time of the next medical application if it falls
outside the end of that two-year ‘grace period.’ This would allow time for the promotion and
training of the proposed mental health awareness initiatives described in Recommendations
17,18, 20 & 21 below to reach the widest possible group of aviation professionals. The ARC clarifies
that this pathway does not guarantee continued issuance of the medical clearance/certificate if
the person is unable to meet aeromedical standards either through the standard application
process or through special issuance or special conditions. 70

Caveats to the Guarantee of Non-Revocation and Non-Referral:

• the pilot/controller provides all medical and pharmacy records of treatment;

• the self-disclosure must be made before any FAA investigation. If the FAA discovers the
undisclosed condition or treatment before self-disclosure, there is no guarantee of non-
revocation or non-referral for prosecution; and
• if a currently disqualifying medical condition is identified, the medical certificate/clearance
may be revoked until the person meets the conditions for medical certification or special
issuance/special conditions, but the person’s employment and the person’s non-medical
certificates, clearances, ratings, or other qualifications should not be in jeopardy.

This approach incentivizes widespread self-disclosure while allowing the FAA to adequately assess
the individual’s current medical status, and preserving the FAA’s authority to prosecute those who
continue to conceal/falsify medical applications despite the opportunity to self-disclose with
protection.
The ARC reiterates that pilots/controllers will remain reluctant to disclose during the ‘grace period’
unless there is meaningful effort among all aviation stakeholders to address the identified barriers.
The ARC notes that previous attempts at encouraging disclosure were met with minimal
engagement due to lack of Trust in the aeromedical system. 71 The ARC strongly encourages the
FAA to modify its previous approach if it decides to institute a grace period. This will instill
confidence in pilots/controllers that the system has changed and that disclosures will be fairly
assessed and not result in automatic loss of medical certification/clearance in every case.
Barriers Addressed: Trust, Fear, Stigma, Process

70
See CASA and CAA NZ – Safe Haven Draft Policy Appendix C.
71
See FAA Compliance and Enforcement Bulletin No. 2010-1. 75 FR 17200 (2010) announcing the FAA’s
policy to forgo enforcement action for persons who disclose previous falsification on medical certification
applications of the use of antidepressant medication, the underlying condition for which the antidepressant
was prescribed, and visits to health professionals in connection with the antidepressant use or underlying
condition. See also Special Issuance of Airman Medical Certificates to Applicants Being Treated With
Certain Antidepressant Medications, 75 FR 17047 (2010).

Page 37 of 69
REC3 – Expanded Use of Peer Support Programs
Aviation stakeholders should develop, implement, and participate in effective Peer Support
Programs (PSP) or enhance other existing programs.

INTENT: To establish and enhance PSPs throughout the aviation community.

RATIONALE: Pilots/controllers should feel comfortable disclosing mental health issues. PSPs
should provide the opportunity for a pilot/controller to disclose a mental health concern and if
appropriate, receive temporary relief from operational duties, and/or be referred to a mental health
professional. It should be noted that an Employee Assistance Program (EAP) is different than a Peer
Support Program. EAP employs accredited mental health care workers, not peers.

The successful implementation of PSPs requires commitment and support from all stakeholders,
including senior management, pilot/controller representative organizations, and peer volunteers.
The trusting relationship with a fellow pilot/controller in a peer-supported program may provide the
best opportunity to identify and engage an individual requiring assistance. To encourage use,
pilots/controllers must be handled in a confidential, non-stigmatized, and safe environment. If a
culture of mutual trust and cooperation is maintained, pilots/controllers are less likely to conceal a
condition, and more likely to report and seek help for mental health concerns.

APPROACH: Aviation stakeholders should consider best practices from mature PSPs and adapt
them to meet their individual and organizational needs. These programs should include protocols
based on the type of operation, the number of employees involved, the ability to consult with
professional mental health service providers, and escalation processes where additional support
is warranted. The ARC recognizes that for solo or smaller operators, ‘peers’ may not be readily
available in-house. In these cases, the ARC recommends pooling resources with similarly situated
individuals or organizations to create an effective network of support. Simply put, the program
should provide adequate training and include access to peers and mental health professionals.

The ARC notes that many professional organizations have mental health PSPs for pilots with
varying degrees of support from employers, and although the FAA has a Critical Incident Stress
Management (CISM) program for post-traumatic workplace event counseling and a Professional
Standards Committee to deal with performance and conduct issues in the workplace, no mental
health PSP exists for controllers for issues not involving traumatic workplace events. The ARC
encourages these entities to explore opportunities to expand and improve these PSP initiatives and
to leverage existing resources to provide comprehensive support for aviation professionals.

Barriers Addressed: Culture, Trust, Fear, Stigma

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REC4 – Disclosure Requirements for Peer Support Programs
The FAA should allow pilots/controllers working with a Peer Support Program to receive
mental health professional care with less restrictive reporting and grounding requirements.

INTENT: To destigmatize seeking mental health assistance and use aviation-savvy resources to
assist in arriving at a “Fly/No-Fly” determination without requiring the certificate/clearance holder
reporting mental health professional (MHP) care to FAA.

RATIONALE: There is anecdotal evidence that a significant portion of individual contacts with
mental wellness challenges can be resolved without involving a mental health professional. 72
Moreover, when escalation to a mental health professional is required, the trusted opinion of a PSP
advocate helps destigmatize the condition and provides better support for the individual as they
navigate the FAA processes. Specifically, the individual is encouraged when seeking help by:

• being reassured that many other pilots/controllers have had similar issues resolved
successfully;
• having support to develop a plan and a timeline for getting help;
• having assistance with their decision to remain on duty or self-remove for safety reasons;
and
• being provided information about resources available for medical, financial, and
operational support. 73

Ultimately, this will improve the safety of the NAS via increased mental healthcare seeking
behaviors.

APPROACH: Reporting MHP care to the FAA would only be required if the individual pilot/controller
is no longer participating in a PSP. In addition, any consultation with the PSP’s mental health
professional about seeking mental health treatment would not be reportable.

The ARC further recommends that all aviation stakeholders without an existing PSP work
collaboratively and expeditiously to develop and implement such a program. This includes
coordinating with mental health organizations, existing PSP managers, and employee bargaining
representatives (as needed) to review best practices and create programs to support and assist all
pilots/controllers.

Barriers Addressed: Fear, Stigma, Financial

72
Peer Support Programs such as Allied Pilots Association- Project Wingman and United ALPA-SOAR
(Support Outreach Assistance Resources) report that greater than greater than 80% of PSP calls are resolved
by peers without escalation to mental health providers or other counselors/clergy.
73
See CASA and CAA NZ – Safe Haven Draft Policy Appendix C.

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REC5 – Requirements for Neurocognitive Testing
The FAA should minimize the requirement for neurocognitive testing for pilots/controllers.

INTENT: To reduce fear of loss of medical certification, process delays, and excessive costs by
employing neuropsychological screening or full battery testing only when clinically indicated.

RATIONALE: The FAA is the only CAA that requires neurocognitive testing in every case involving
medical certificate/clearance holders who use approved monotherapy medications. These
evaluations must be performed by a HIMS trained neuropsychologist, which requires the
pilot/controller to meet with a HIMS trained AME to obtain a referral, and then often wait several
months for physician availability. The evaluations can also be costly in some cases.

APPROACH: The ARC notes that the FAA has previously removed the requirement for
neurocognitive testing for routine renewals in cases involving antidepressants. The ARC
recommends a similar approach for all applicants to reduce the use of
neurocognitive/neuropsychological testing as much as possible.

Barriers Addressed –Trust, Fear, Stigma, Financial

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REC6 – Requirements for Depression & Anxiety
The FAA should revise the requirements for pilots/controllers on approved monotherapy
antidepressants for the treatment of uncomplicated 74 depression or uncomplicated anxiety.

INTENT: To set a new, reduced minimum wait time for reconsideration of medical certification
following any initiation or change to an approved monotherapy antidepressant/anxiety medication.

RATIONALE: The ARC wishes to remove barriers that discourage initiating or adjusting
pharmacological treatment with approved monotherapy antidepressant medications, thereby
allowing pilots/controllers to function in a healthier mental state. Individuals with uncomplicated
depression or uncomplicated anxiety, and without a history of psychiatric complications, have a
higher likelihood of responding positively to a single antidepressant medication. In fact, studies
indicate the most common neurocognitive effects of antidepressant usage in individuals with
depression is improved cognitive function over time. Under international standards, individuals
who start or change medications to treat depression have minimum observation periods before
they can be considered for reinstatement of medical qualification. 75 These observation periods
vary from two weeks to six months. Evidence-based practice guidelines state:

Improvement with pharmacotherapy can be observed as early as the first 1–2 weeks of
treatment, and improvement continues up to 12 weeks. Many patients may show partial
improvement as early as the end of the first week. Others achieve improvement within the
first 2–4 weeks. In short-term efficacy trials, all antidepressant medications appear to
require at least 4–6 weeks to achieve maximum therapeutic effects. 76 Caution and
monitoring are required. An FDA-mandated “black box” warning 77 on antidepressants notes
an increased risk of suicidal ideation and treatment-emergent suicidal ideation” at the
onset of treatment, particularly in younger patients. 78
The ARC reiterates that consideration for issuance of medical certification is not the same as
issuance of a medical certificate. This requires ongoing physician-level monitoring to document a
period of stability, as opposed to being in a temporary state of stability. Further in-depth assurance
is achieved through post-issuance review with AMCD, using an “AME-Issued with Review (AIR)”
model. This approach is similar to what is presently done for applicants with Obstructive Sleep
Apnea (OSA).

The current six-month observation period may create a financial hardship for pilots/controllers and
introduces a safety risk by discouraging initiation of antidepressant medication or if under
treatment of changing the dosage. The result is that pilots/controllers are reluctant to seek help for

74
For the purposes of this report, uncomplicated means without co-morbid psychiatric illnesses; treated
with a single medication; not requiring hospitalization, electroconvulsive therapy, or similar treatments; and
not associated with suicidal ideation, actions, or self-injurious actions.
75
See Tables 1 and 2 above in Section VI. Task D discussion.
76
Pilot specific data found in the EASA MESAFE D-1.2, 3.1 Pilots (Class 1), 3.1.1 Biological Treatments
77
See Food and Drug Administration regulation 21 CFR 201.57(c)(1) requiring certain contraindications or
serious warnings, particularly those that may lead to death or serious injury, to be presented as a warning on
the box containing the medication.
78
See https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf.

Page 41 of 69
mental health conditions, even if the condition can be successfully treated in a primary care setting
with monotherapy antidepressant medication and/or psychotherapy (when available and if
affordable). Adopting this protocol would reduce the time without a medical
certification/clearance for pilots/controllers.

APPROACH: The ARC recommends the FAA adopt a program modeled on “Decision Path 2 for
Depression.” 79 Specifically, the FAA should reduce the special issuance consideration minimum
wait time from six-months to two-months. The two-month time frame is predicated on the amount
of time typically required to respond to a medication, as well as concerns for the appearance of
suicidal ideation as noted in the Food and Drug Administration’s black-box warning. The FAA
should also allow the certificate/clearance to be issued under the AIR process.
This approach would allow pilots/controllers who have major depressive disorder, generalized
anxiety disorder, or are using an SSRI for a non-psychiatric condition without any of the “SSRI rule-
outs,” 80 to be considered by the AME for issuance of a medical certificate/clearance two months
after starting or changing the dose of an allowed antidepressant medication. The following
conditions would apply:

• an in-person assessment by the AME that the applicant is stable and fit for duty;
• there has been adequate monitoring by the prescribing physician and documentation of
stability over time; and
• the AME has reviewed the prescribing physician’s evaluations.
The ARC emphasizes that this approach is similar to how OSA is presently handled. 81 When
developing the protocol and procedure, consideration should be given to whether a checklist and
attestation for the prescribing physician would be beneficial in simplifying the process and
reducing the time required to provide clinical information to the AME. A sample checklist is
provided at Appendix B.

Barriers Addressed: Financial, Process

79
See SSRI Decision Path II.
80
See FAA Certification Aid for SSRI Initial Certification.
81
See Decision Considerations & Disease Protocols for Obstructive Sleep Apnea.

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REC7 – Requirements for Attention Deficit Hyperactivity Disorder (ADHD)
The FAA should evaluate the feasibility of permitting pilots/controllers with an ADHD
diagnosis to use appropriate and acceptable medications while on duty.

INTENT: To establish whether circumstances and conditions exist under which pilots/controllers
may operate while taking approved medications for the treatment of their properly diagnosed
ADHD.

RATIONALE: Untreated ADHD raises indisputable safety concerns. Accordingly, under current FAA
policy, the diagnosis of ADHD, as well as all FDA approved medication options used to treat ADHD,
are disqualifying. However, adults with active ADHD are estimated to be as high as 4.4% of the
population, 82 and the diagnosis among children is also increasing, which may have implications for
future pilot/controller ranks. While misdiagnosis may partly be a factor in this phenomenon, there is
no reason to doubt there are pilots/controllers operating in the NAS with unreported or untreated
ADHD. Thus, a renewed look at FAA policies regarding treatment and clearance of controlled ADHD
would help normalize safety-enhancing treatment and contribute to the perception of the
aeromedical system as fair and just.

As noted above, 83 many current and aspiring pilots/controllers are known to alter their ADHD
treatment specifically to meet FAA certification standards due to the mistaken belief that it is the
medication only, and not the condition itself, that is disqualifying. However, the ARC notes that
certain ADHD medications are demonstrably well tolerated and known to improve some cognitive
function and performance in correctly diagnosed ADHD patients. 84

APPROACH: The ARC recommends that the FAA reexamine its ADHD certification/clearance
policies to determine the potential aeromedical effects of ADHD. This reexamination should be
consistent with contemporary treatment options and protocols and appropriately prescribed
medications to mitigate symptoms of ADHD in various operational environments. This should
include a study designed in conjunction with research experts to determine appropriate
assessment methodologies and operational performance outcomes.

Barriers Addressed: Fear, Process, Knowledge and Information Gap

82
Id.
83
See ADHD discussion above at Section VII.G. Knowledge and Information Gap.
84
McKenzie et al. (2022), The Effects of Psychostimulants On Cognitive Functions In Individuals With
Attention-Deficit Hyperactivity Disorder: A Systematic Review, Journal of Psychiatric Research, Volume 149,
Pages 252-259.

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REC8 – Requirements for Post Traumatic Stress Disorder (PTSD)
The FAA should reevaluate its decision grid on PTSD to liberalize the criteria for issuing a
medical certificate/clearance.

INTENT: To allow an AME-Issued with Review (AIR) protocol to issue certification/clearances for
mild or complex PTSD, while also enabling post issuance review at AMCD and referral to AAM-
200/300 for severe cases.

RATIONALE: The current FAA policy requiring applicants with PTSD to have “no symptoms or
treatment for two years” 85 to be eligible for AME issue, is unrealistic for most PTSD cases and
difficult to apply. This results in nearly all applicants with PTSD being deferred to the FAA, which
causes significant delays and contributes to the Process barrier. Moreover, the FAA policy
encourages pilots/controllers to conceal the condition or avoid treatment in order to reach the two-
year milestone. This inevitably results in undertreatment, suboptimal care, and increased
healthcare avoidance behaviors.

APPROACH: The ARC recommends the FAA reconsider the PTSD decision grid 86 and adopt a policy
for PTSD that is similar to the policy for OSA. This approach would allow the AME to issue medical
certificates/clearances to applicants with mild or complex PTSD with appropriate restrictions.
Specifically, the AME should be allowed to issue certification when the condition has been in
remission for more than two months; and the applicant currently or previously participated in
psychotherapy or used a single approved antidepressant. The ARC further recommends a
requirement for appropriate supporting information, including reports from:
• the treating clinician,
• a doctorate level mental health clinician,
• the applicant’s flight instructor or supervisor,
• the medication transcript, and
• other information deemed clinically necessary. 87

The information should be forwarded to the FAA for post-issuance review within a specified period
(e.g., similar to the Specification Sheet 88 provided to pilots/controllers for OSA).

The FAA should also instruct AMEs to only defer the applicant if the criteria for severe PTSD are met
(e.g., recurrence of disabling symptoms with or without loss of work, or original traumatic trigger of
such severity as to prevent normal function in the aviation environment). For cases that are not
severe, the FAA should reiterate its expectation that medical certification should not be withheld.

Barriers Addressed: Fear, Stigma, Financial, Process

85
See PTSD Decision Tool for the AME (faa.gov).
86
Id.
87
See Appendix B for Sample Mental Health Provider Checklist.
88
See Obstructive Sleep Apnea Specification Sheet A .

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REC9 – Aeromedical Screening - Proportionate & Publicized Decisions
The FAA should ensure medical certification/clearance decisions are proportional to the
aviation safety risks, and the supporting justification communicated to aviation
stakeholders.

INTENT: To enhance use of the assessment of aviation safety risk in the certification/clearance
process.

RATIONALE: The current aeromedical approach to mental health is clinically/diagnosis based.

Thus, pilots or controllers diagnosed with a mental health condition or using mental health services
are assumed to pose an undue safety risk. The wide range and spectrum of mental health
symptoms and conditions include those that are mild, mild to moderate, or severe.
Pilots/controllers with mild or mild to moderate mental health symptoms, (which also includes a
significant portion of the US population), are stigmatized by the regulatory consequences of being
grounded/removed from duty and deemed unsafe due to their mental health status. The ARC
recognizes that a diagnosis of a mild/mild to moderate mental health condition may still be
aeromedically significant and will vary by the individual. As such, there may be cases where
individuals with a clinically mild condition may not be aeromedically certified; while in other cases,
individuals with clinically moderate conditions can be safely certified because the condition is in
remission on treatment or is not otherwise aeromedically significant. 89 The FAA’s current policies
default to an assumption of a hazardous state of illness, which creates a barrier of Fear around the
potential loss of medical certification and the Stigma associated with a mental health condition. As
a result, pilots/controllers are hesitant to disclose their symptoms or conditions and will refrain
from seeking care for their symptoms in the early stages of recognition.

APPROACH: The nature and severity of a mental health symptom or condition should be the basis
by which medical certification decisions are made by the FAA. Ideally, a pilot/controller performing
to the current standard of their job as determined by operational assessments, should only be
grounded or removed from duty if available evidence indicates a likely safety risk to the NAS.

There is evidence that a relevant proportion of pilots are operating with undisclosed health
information, and that reconsidering screening and certification criteria would not increase system
risk but would address latent risk in the system. Drawing people into the system and lowering the
barriers to reporting and seeking care has the potential to improve mental health outcomes and
decrease risk to the NAS.

Furthermore, the FAA should communicate the standards and increase transparency surrounding
certification decisions, especially in those instances where similar cases resulted in notably
different outcomes. This could be done through Peer Support Programs or by sharing accurate
narrative-driven information to educate and communicate with aviation stakeholders.

Barriers Addressed: Trust, Fear, Stigma, Process

89
See discussion above in Section VII. G. Knowledge and Information Gap regarding differences in the clinical
definitions found in the DSM-5-TR and FAA definitions used for regulatory determinations under 14 CFR Part
67.

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REC10 – Aeromedical Screening - Safety Management Systems (SMS)
Mental health screening functions should be performance based upon and managed within
an SMS framework.

INTENT: To employ SMS principles when making medical certification decisions about a mental
health condition or treatment and the potential threat of degraded performance. The focus should
be on mitigating threats to performance capability relative to occupational standards rather than on
the diagnosis per se.

RATIONALE: Current FAA policies assume that a mental health diagnosis presents an undue safety
risk to the NAS. In many cases, the mere fact of a diagnosis (no matter how mild or operationally
insignificant) will result in the pilot/controller being removed from duty pending FAA review of
extensive documentation on the testing and treatment regarding the person’s mental health. This
approach discourages mental health care seeking and reporting, and if reported often results in
loss of certification/clearance that is disproportional to the purported risk and detrimental to the
person.

The ARC considers a better approach to be the use of SMS principles to assess the pilot/controller
in a performance operational context in conjunction with their AME. SMS programs rely on non-
punitive reporting, hazard identification, threat assessment, and proportional mitigation. By
focusing on objective evidence of occupationally significant degraded performance, rather than the
diagnosis itself, the FAA can reduce stigma and reframe the relevance of a mental health diagnosis
into a safety framework. This would ensure a performance-based approach using safety risk
management of mental health concerns instead of a prescriptive approach that does not focus on
the individual and skews mitigation efforts toward the most severe disease state.

APPROACH: The FAA should conduct a safety risk assessment of the hazard of pilot/controller
mental health conditions focusing on the identification and management of performance-based
risks arising from an underlying mental health condition. Rather than a presumptive

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disqualification of pilots/controllers reporting a mental health condition, the FAA should consider
allowing certification/clearance determinations to be made following relevant operational
assessment when appropriate (See Appendix B). These assessments should be made by
operational evaluators (e.g., check and training pilots, flight instructors, or air traffic controller
managers) following the initial AME evaluation if concerns exist. Upon successful completion of the
operational assessment, the AME may issue a medical certificate/clearance. This should reduce
the time delay in making determinations and the costs of obtaining additional medical testing.

Barriers Addressed: Culture, Trust, Stigma, Financial, Process

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REC11 – Aeromedical Screening - Relevancy & Effectiveness
The FAA should establish a recurrent evaluation process to assess whether its policies,
aeromedical screening protocols, and mental health risk controls are evidence-based and
consistent with SMS principles.

INTENT: To ensure that aeromedical screening efforts related to mental health are as precise as
possible while limiting unnecessary processes. Processes should be reviewed periodically to
ensure hazards are controlled to acceptable levels without undue burden on the applicant.

RATIONALE: Aeromedical screening efforts related to mental health aim to optimize safety in the
system by identifying hazards to control the risk of an adverse event. These efforts come at a
financial, operational, and social cost to pilots/controllers and aviation organizations. All
aeromedical screening efforts should be justified with safety/performance data and reviewed on a
recurrent basis. This will require dedicated human, financial, and organizational resources to
accomplish in a systematic way. The ARC recommends the FAA establish a recurrent process to
review policies, screening interventions and actions related to mental health to ensure hazards are
controlled to acceptable levels with evidence-based and outcome-focused measures. If a process
or procedure is not meaningfully contributing to the objective, it should be removed or modified.

APPROACH: The FAA should use its SMS to:

• establish a comprehensive model that identifies:
o the hazards related to mental health,
o the aeromedical and non-aeromedical safeguards that protect against those
hazards becoming mishaps,
o clear performance standards for these safeguards, and
o the factors that either strengthen or weaken those safeguards.
• establish acceptable levels of safety (i.e., acceptable level of risk) based on the safety
continuum as well as the collection of necessary data to measure safety performance
through collaboration with operators, and
• conduct recurrent assessments to determine whether safeguards are controlling risk to an
acceptable level (i.e. safety assurance), and adjust safeguards to ensure they are neither
overly restrictive nor ineffective. These assessments should occur at least every year and
be overseen by aeromedical and operational personnel.

Barriers Addressed: Trust, Fear, Financial, Process

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REC12 – Aeromedical Screening - Safety Continuum
The degree of regulation and oversight related to pilot and controller mental health should
mirror the demand for safety assurance framed within the safety continuum.

INTENT: To ensure that the FAA’s approach to managing mental health risk is proportionate to the
level of risk and consistent with the public’s expectation that the FAA will honor its safety mission.
RATIONALE: Tailoring the level of regulation and oversight will allow the FAA to allocate regulatory
resources to the hazards with the highest risk of large-scale mishap. This is consistent with a risk-
based regulatory approach and reflects the demand for safety assurance, particularly for
commercial operations where the risk tolerance is lower when compared to the risk tolerance for
general/recreational aviation. Indeed, the existing safety continuum reflects the lower level of safety
assurance that is already accepted in these sectors. Generally, pilot medical fitness oversight (e.g.,
certification standards) is incrementally reduced, beginning with each class of medical certificate
(e.g., Class 1 v. Class 3), type of operation (e.g., air carrier v. recreational), and aircraft type (e.g.,
turbine powered v. light sport aircraft), then proceeding down the safety continuum. The oversight
of pilot/controller mental health hazards should be similarly tailored for aircraft sectors above light
sport aircraft.

APPROACH: This requires right sizing the acceptable level of safety and establishing medical
certification standards and criteria. The standards should be developed within the concept of a
safety continuum and based on the hazard presented by the individual’s mental health condition
and the aviation sector in which the person intends to operate.

The FAA should:

• establish acceptable levels of safety for the hazard of pilot/controller mental health
conditions based on the safety continuum;
• conduct safety risk assessments to refine the risk controls and oversight approach for each
sector necessary to achieve the acceptable level of safety;
• collect the necessary data to measure safety performance relative to the acceptable level
of safety in each sector through safety assurance activities; and
• adjust risk controls (i.e. standards) and oversight based on safety assurance data through
SRM.

Barriers Addressed: Trust, Fear, Financial, Process

Page 49 of 69
 Figure D: Safety Continuum and Societal Expectations 90

90
The Safety Continuum – A Doctrine for Application, (2014) (faa.gov).

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REC13 – Information Management – Applicant Guide
The FAA should publish practical medical certification/clearance guidance for applicants.

INTENT: To ensure applicants have the information necessary to allow pilots/controllers to

successfully navigate the medical certification/clearance and special issuance pathways.
RATIONALE: The AME Guide is a valuable, public resource, but as the name suggests, it is written
for medical personnel and not applicants. As such, it does not always contain usable information
an applicant needs, especially for cases requiring detailed evaluation. Applicants need explicit
information about the certification/clearance process, such as the expected timeline for approval,
the types of evaluations that may be required, or how a particular diagnosis or medication has been
handled in the past; but in many cases, the AME Guide simply says, “requires FAA decision.”

APPROACH: AAM should work with other relevant FAA lines-of-business and aviation stakeholders
to develop comprehensive guidance for applicants. The guidance material should outline best
practices for certification/clearance, and describe the steps applicants are expected to follow,
information they are expected to provide, and helpful resources they can use. The guidance should
also contain information about the estimated timeline for the special issuance pathway based on
reporting criteria, diagnosis, and medication. This FAA should use the Medical Matters Guide
developed by CAA NZ as a model for its applicant guide. 91 This guidance should be a standalone
document and its target audience should be applicants, not AMEs. The ARC also recommends that
the guidance material undergo a formal assessment to confirm its suitability for end users.

To that end, the ARC recommends the FAA develop layman-friendly guidance material to educate
applicants on all aspects of the medical certification process. The guidance material should
include information about the aeromedical concern of the diagnosis, conditions of the diagnosis
for which an AME can issue a medical certificate/clearance, whether special issuance will be
required based on a specific diagnosis, what test(s) might be required, and the expected timelines
for medical review and recertification. The guidance material is intended to be an enhancement of
the current AME Guide, which is written for medical professionals but not easily interpreted by
individuals without medical training.

Barriers Addressed: Trust, Knowledge and Information Gap

91
See CAA NZ –Medical Matters – Good Aviation Practices.

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REC14 – Information Management - System Modernization
The FAA should modernize its information management systems.

INTENT: To modernize the FAA’s information management system for medical

certification/clearance to reduce processing times and improve decision making.

RATIONALE: The FAA’s current information management systems and processes are too slow,
resulting in avoidable delays and negative financial impact to applicants and their employers.
Delayed responses from the FAA about whether information has been received, was adequate, or
whether additional information is required fuels uncertainty about the aeromedical process and
leads to underreporting of mental health concerns.

In most cases, information submitted to the FAA must be submitted via US Mail then manually
scanned into the system. The FAA acknowledges that manual scanning adds many days to the
processing time due to FAA mail security protocols and leads to errors, as documents are
sometimes scanned into the incorrect section of an applicant’s medical file. Moreover, scanned or
‘flat’ electronic files and hardcopy documents are not searchable. Non-searchable information is
of limited value for organizational learning and undermines the FAA’s efforts to continuously
improve aeromedical assessment practices.

The ARC believes that the ability of applicants, AMEs, HIMS Specialists, and others to easily submit
information to an FAA-industry shared portal would promote more efficient processing, effective
communication, and enhanced quality control and quality assurance of the information. The ARC
acknowledges that the MedXPress 92 electronic upload feature is an improvement over scanned
documents, but MedXPress is still very limited in its capability and does not allow information to be
transferred between the AME and the HIMS Specialist. An expedited transition to a modernized
electronic information management system would provide greater efficiency, improved speed and
accuracy of responses, and easy sharing of clinical information. This would also provide better
learning opportunities for the FAA and AMEs/HIMS Specialists, by having easy access to
searchable relevant information from previous cases.

APPROACH: The ARC recommends the FAA implement an integrated electronic information
management system that is accessible to applicants, AMEs, HIMS Specialists, and the FAA. The
system should allow information to be uploaded in a searchable format and be capable of
immediately confirming receipt of information submitted. The system should also, when queried,
provide information (ideally in less than one week), as to the adequacy of the submission, the
status of the application, and whether any additional information is required. This would improve
the quality of the application packages prior to FAA review, which would facilitate faster and better-
informed decisions regarding pilot/controller fitness for duty. The FAA should also conduct an in-
depth systems analysis of its information management systems to identify other shortcomings and
areas of improvement.

Barriers Addressed: Fear, Financial, Process

92
The MedXPress system allows anyone requesting a medical certificate/clearance to electronically
complete an application. Information entered into MedXPress is available to the applicant’s AME for review
at the time of your medical examination. (https://medxpress.faa.gov).

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REC15 – Information Management – Accurate Documentation
The FAA should ensure that information and documentation made available to aviation
stakeholders is correct and consistent.

INTENT: To encourage the FAA to develop a well-functioning quality assurance program to ensure
continuity in its documentation and consistency in aeromedical decision-making practices and
outcomes.

RATIONALE: There is currently an inadequate quality assurance function at the FAA to ensure that
information sources such as the AME Guide, MedXPress, and internal FAA guidance are consistent
and correct. (See Appendix D for examples of inconsistencies in MedXPress instructions). In
addition, there is currently no standard usability testing to assure that the internal and external
tools and procedures are fit for purpose and driving efficient, effective, and desirable outcomes
that facilitate a robust cycle of continuous improvement. This is evidenced by inconsistencies
within the AME Guide.

APPROACH: A robust quality assurance program should be implemented that is capable of not
only identifying quality issues but is also capable of implementing systems-based changes that
address usability and other technical issues. The program should inform upper FAA management
and other oversight entities so shortcomings can be appropriately addressed, and effective
practices can be expanded to other lines of business as appropriate.

Barriers Addressed: Trust, Process, Knowledge and Information Gap

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REC16 – Information Management - Data Submission
The FAA should develop a templated electronic submission platform to reduce errors and
omissions in information submitted to the FAA by AMEs.

INTENT: To improve the quality, content, and management of data submitted to the FAA by AMEs
and improve processing times.

RATIONALE: The FAA reports that AMEs often provide incomplete information, requiring repeated
rounds of communication to obtain the information necessary to evaluate an applicant. AMEs
would benefit from a clear description of what is required and the ability to submit it electronically.
Electronic communication (rather than the current process of using the US mail) would greatly
reduce the decision-making timeline, create a searchable database, and allow the FAA to provide
real-time feedback about the completeness of the certification package. This would also improve
quality control of required data prior to FAA review.

APPROACH: The ARC recommends the FAA create electronic templates with input fields for each
case type (e.g., depression/anxiety, PTSD, drug/alcohol, cardiac arrythmia, or head injury). The
AME would be required to input information into each field or document to minimize errors and
omissions. The information would be automatically verified to the level of detail and quality the FAA
requires before it could be transmitted to the FAA, with immediate feedback if the required
elements are not included in the template. The system should also be capable of providing, as
close to real-time as possible, information about the status of the application and the anticipated
timeline for review and disposition. The FAA should specify what applicants need to provide (see
REC13) and provide training to AMEs to help them better communicate with applicants. AMEs
should also be evaluated to assess their ability to provide the desired quality and content of
information.

Barriers Addressed: Process

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REC17 – Mental Health Awareness – Aviation Stakeholders
The FAA should work collaboratively with aviation stakeholders to raise awareness of mental
health.

INTENT: To ensure that medical applicants are informed of the advancements in the mental health
regulatory system and encourage applicants who may have a mental health condition to self-
report.

RATIONALE: The FAA currently has several methods of disseminating information on mental health,
including the Pilot Minute, presentations at industry events/mental health forums, articles in
aviation magazines, and updates to the AME Guide. The ARC commends the FAA’s frequent and
admirable efforts to engage with the aviation community, but notes that these efforts are unlikely
to reach younger generations of pilots using social media as a primary information source. There is
significant evidence that sharing narrative-driven information is an effective approach to educating
and communicating with people. 93 Sustained educational efforts will reach more aviation
professionals, especially those who only obtain medical certificates every two to five years. Many
of these individuals do not regularly access FAA informational sources or read print media. By
utilizing the power of social media and information campaigns, a broader audience will be more
educated about the changes to the aeromedical system, as well as about how they can
successfully navigate them.

APPROACH: The FAA should work with aviation stakeholders to develop and execute a multi-year,
narrative-driven information campaign that utilizes traditional media, social media, live events, and
industry partnerships to raise awareness about advancements in the mental health regulatory
system and FAA policies. The campaign should include individuals with various common mental
health conditions who successfully navigated the certification process (e.g., SSRI special issuance
pathway). The FAA should recognize Mental Health Awareness Month and increase activity during
that period as part of this campaign.

Conventional and unconventional ambassadors should be engaged to help convey and

disseminate relevant, narrative-based information, including peer storytelling, stress-reducing tips
and practices, success with PSPs, the Green Bandana Project, 94 and updated fast-track options.
The campaign should not be limited to social media but should also include in-person events,
advertisements, video productions, print media, and podcasts. The industry-embedded
ambassadors must span all aspects of the industry and highlight the diverse experiences of many
pilots/controllers. This will help ensure that current and future applicants who do not routinely
engage with FAA content, receive updated information about changes to the aeromedical
system. It will also increase the knowledge base of current pilots/controllers.

FAA senior leadership should also be involved in the campaign to promote awareness of new
approaches in FAA policies so that individuals are encouraged to come forward and feel

93
Lien et al., (2023)
94
The Green Bandana Project is a program dedicated to preventing suicide through promoting help-seeking
behavior and increasing awareness of vital mental health resources. After a short orientation and basic
suicide prevention training, student participants can proudly attach or display a lime-green bandana on their
backpack, bag, or person, signifying they have pledged to be a safe individual to approach for mental health
and suicide prevention information and resources.

Page 55 of 69
comfortable doing so. Sharing information about how common mental health conditions are, and
how the FAA is adapting to better manage them, will increase awareness, and reduce Stigma. The
FAA should also partner with other thought leaders to provide education on mental health-related
conditions and tools to help pilots/controllers assess symptoms and promote wellness.
The ARC further recommends that the FAA analyze public sentiment, knowledge, and education on
mental health to establish a baseline education level and continue to regularly monitor the target
population to ensure the information campaign is effective. This campaign should be in effect for at
least 3 years.

Barriers Addressed: Trust, Stigma, Knowledge and Information Gap

Page 56 of 69
REC18 – Mental Health Awareness - Annual Summit
The FAA should partner with aviation stakeholders to hold an annual summit on mental
health.

INTENT: To be current with best practices on managing, testing, and treating mental health
conditions and ensure contemporary and effective regulatory standards are applied.

RATIONALE: The fields of psychology, psychiatry, and psychopharmacology are areas that change
over time based on clinical research and resulting data. Recent advances in wearable digital
health technologies in managing depression are one example. 95 Providing an annual forum to
present and discuss the current medical literature would promote inter-specialty collaboration and
greater communication between fields and professions, as well as updated relevant information.
An annual summit will facilitate information sharing, mental health awareness, and greater
educational opportunities to support the FAA’s efforts to reduce barriers to reporting mental health
conditions or seeking help.

APPROACH: The FAA should partner with aviation stakeholders to hold an annual mental health
awareness summit. The summit should bring together interdisciplinary fields and experts on mental
health (e.g., psychiatry, psychology, neuropsychology, and pharmacology) to present the latest
research, clinical data, and therapeutic updates on mental health conditions. The summit should
have broad FAA and aviation stakeholder representation.

Barriers addressed: Trust, Stigma, Knowledge and Information Gap

95
Fedor S, Lewis R, Pedrelli P, Mischoulon D, Curtiss J, Picard RW. Wearable Technology in Clinical Practice
for Depressive Disorder. N Engl J Med. 2023 Dec 28;389(26):2457-2466. doi: 10.1056/NEJMra2215898. PMID:
38157501.

Page 57 of 69
REC19 – Mental Health Training – AME
The FAA should improve mental health training, quality assurance, and oversight of AMEs to
improve mental health literacy.

INTENT: To ensure that AMEs have verified knowledge and capability to address mental health
issues of pilots/controllers comfortably and competently, particularly during the time of
assessment and examination.

RATIONALE: Mental health conditions represent the most common, potentially disqualifying, but
nuanced condition an AME may see during an exam. 96 Unlike many other medical conditions that
can be measured quantitatively, the qualitative and variable aspects of mental wellness are more
difficult to diagnose and are subject to denial and minimization because of stigma and fear.
Pilots/controllers are unlikely to openly admit to mental health problems on standardized
questionnaires during a medical exam, and AMEs have reported lacking the confidence to perform
mental health assessments or to meaningfully inquire about these topics with pilots/controllers. 97
As more fully explained below, this lack of confidence can be attributed to training, notification,
and variations in AME capability. This lack of confidence also undermines Trust between the
pilot/controller and AMEs.

AME Training
EASA’s ME SAFE document states that AME interviewing techniques and social engagement are the
most effective methods of evaluating pilot/controller mental health and support systems. 98 Thus,
an AME’s assessment of an applicant’s mental health is enhanced by their ability to engage in
conversation with the applicant about social, familial, and occupational status in a supportive
manner, rather than just administering questionnaires. Unfortunately, training in interviewing skills
and establishing rapport does not lend itself well to the lecture format that is foundational to AME
training; and even if it did, once initial training is complete, formal AME training only occurs once
every three years.

AME oversight is also less than ideal, with limited opportunities for the FAA to assess the AME
ranks in between recurrent training. Currently, oversight is conducted by the Regional Flight
Surgeons (RFS), as the Designee Managers for AMEs. It includes a one-year mentoring program
(following designation), ongoing performance monitoring (with routine review of a percentage of
issued certificates), and recurrent site visits every five years unless more frequent visits are
warranted.

AME Notifications
The FAA currently uses several methods to notify AME’s of the latest changes to policy and
guidance. Notifications about routine interim policy updates are transmitted monthly via the
Aerospace Medical Certification Subsystem (AMCS). Urgent notifications are also transmitted via

96
Fitness to Fly – A Medical Guide for Pilots, p.13, noting that mental and nervous disorders are the leading
cause of disability payouts for North American pilots.
97
This lack of confidence has been expressed by AMEs in both the US and Europe. See Mental Health
Assessment: A survey to Collect Aeromedical Examiners and Assessors Point of View - A Booklet of Results.
See also EASA ME SAFE project highlighting the desire of European AMEs to have improved mental health
training and fluency at EASA MESAFE (Mental health).
98
See EASA MESAFE - D-1.1 - Report on the Review of Diagnostic Measures.

Page 58 of 69
AMCS but are done in real time and supplemented with emails. Both routine and urgent AMCS
notifications require acknowledgement of receipt and confirmation that the material has been
read. Further education occurs via the Federal Air Surgeon’s Medical Bulletin, AME Minutes, and
during surveillance visits.

Variations in AME Capability

The AME program has evolved to account for AME differences. Each AME brings a different
background and experience to the position by design, but this may result in an AME being less
familiar with the current diagnoses and treatments for mental health conditions. Applicants may
also not fully understand the various capabilities and regulatory privileges that AMEs hold, resulting
in them engaging with an AME that may be ill-suited or unwilling to effectively manage their case.
For example, AME categorizations include HIMS AMEs, Senior AMEs, FAA employee examiners, and
regular AMEs; all of whom have different certification privileges and limitations.
APPROACH: The FAA should increase mental health instruction in AME training to ensure that
AMEs have the requisite knowledge and ability to evaluate pilots/controllers in accordance with the
relevant criteria and guidelines. AME initial and recurrent training courses should be designed to
raise mental health awareness and improve interviewing techniques and related rapport building
skills. The FAA should also offer online training to provide contemporary courses and refresh skills
between recurrent training due dates that AMEs can complete at their convenience. The EASA ME
SAFE documents can be used as a guide for course development. With improved training, the FAA
can expand conditions eligible for CACI and increase AME assisted special issuances in the realm
of mental health. This will lead to greater AME comfort in issuing, rather than deferring,
applications involving mild/moderate mental health conditions. This will also reduce processing
time, lower costs, and increase trust between pilot/controllers, AMEs, and the FAA.
The ARC further recommends the FAA improve training for its own staff to better assess AMEs’
mental health literacy and ability to provide appropriate mental health screenings. The training
should emphasize proven mental health assessment techniques and qualification determinations
during medical examinations.

Barriers Addressed: Culture, Trust, Stigma, Knowledge, and Information Gap

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REC20 – Mental Health Training - Aviation Stakeholders
The FAA should collaborate with aviation stakeholders and medical professionals to develop
training courses on Aviation Mental Health.

INTENT: To increase knowledge and mutual understanding of all aviation stakeholders regarding
mental health issues, policies, procedures, and their critical role in aviation safety.
RATIONALE: The well-documented success of the HIMS education process derives from the FAA’s
endorsement and collaboration with aviation stakeholders at HIMS seminars. However, HIMS only
focuses on substance use disorders, and does not address mental health conditions. This creates
a knowledge gap for individuals who attend HIMS seminars seeking greater insight into mental
health. A separate course with focused mental health training and industry-wide collaboration will
increase knowledge of the spectrum of mental health disorders and aid in destigmatizing periods of
mental unwellness. Industry knowledge of the FAA criteria and decision making for mental health
conditions will also increase transparency in trust and define certification pathways for those
seeking help for mental health conditions.

APPROACH: The FAA should partner with aviation stakeholders to create a training course to
develop qualified aviation-savvy mental health providers and advance training for AMEs. This will
increase the ranks of aviation savvy MHP and AME’s fluent in mental health concerns. The training
course should include the differences between 14 CFR Part 67 and DSM-5-TR, all FAA protocols
relating to mental health, and common mistakes in application submissions.

This approach would assist applicants who require mental health assessments, but do not live
near mental health trained AMEs. This would also increase the number and diversity of locations of
aviation savvy mental health providers available to competently assist pilots/controllers who seek
care for mental health issues.

AMEs that complete the training course (and all other required training) could be recognized by the
FAA as having enhanced mental health awareness in the aviation context. These AMEs should be
authorized to issue medical certificates, under yet to be developed CACI’s, for applicants with
mental health conditions. AMEs that are in the process of completing the mental health training
course would be allowed to perform mental health exams and issue certificates/clearances under
CACI if:

• there are no AMEs available that have completed the course; and
• the CACI-like checklist has no unfavorable responses from the applicant.
The FAA should secure adequate Congressional funding to host a 1-2 day “Mental Wellness in
Aviation” course at least three times per year, with a syllabus developed by AAM, Office of Safety
Standards (AFS), and other aviation stakeholders. The FAA should also consider the feasibility of
virtual and in-person course offerings and create an Advisory Board to ensure continuous
improvement of the program.

Barriers Addressed: Trust, Stigma, Process, Knowledge, and Information Gap

Page 60 of 69
REC21 – Mental Health Training – Initial & Recurrent
The FAA should partner with aviation stakeholders to incorporate mental health literacy and
awareness training in initial/recurrent training and/or checking/testing events.

INTENT: To disseminate mental health literacy and awareness training to all certificate/clearance
holders.

RATIONALE: Certificate holders, training providers and instructors teach students to meet the
Airman Certification Standards (ACS) & Practical Test Standards (PTS) for all licenses and aircraft
ratings. There are also training elements required as part of the Flight Review and Flight Instructor
refresher courses. Including mental wellness information in FAA publications, testing standards,
and approved course syllabi for required aviation knowledge will ensure that mental health
awareness is taught in all phases of pilot/controller training. It will also ensure that
pilots/controllers are assessed on mental wellness during practical tests.
Increased mental health knowledge and awareness will support standardized self-evaluations and
fellow crewmember evaluations as a key component of pre-flight/operational assessments. It will
also provide individuals with information about available pathways to pursue if they need mental
health treatment or counseling, including how to contact an AME and comply with existing
regulations.
APPROACH: The ARC recommends that the FAA include mental health training in the Aeronautical
Knowledge requirements in FAR parts 61, 121, 125, 135, and 141. The requirements should be
applicable to all pilots, instructors, and controllers. The training should emphasize mental health
and physical wellness as a critical component of aviation safety. All relevant FAA publications
should be amended in support of this recommendation, and mental wellness should also be added
as an element in the ACS/PTS for all airmen ratings in either the Pre-Flight Preparation or
Aeronautical Decision-Making Tasks.
The training should be comprehensive and recurrent, with standardized module content regularly
reviewed to ensure continuity across all platforms of training and exposure. Online training and/or
testing should be available to all pilots/controllers, and the training should be incorporated at
regular intervals.
The ARC further recommends that the FAA increase visibility and utilization of the FAA Safety Wings
program, 99 and allow documentation of course completion for pilots/controllers pursuing special
issuance or special consideration for medical certification/clearance. The Wings program is a
widely accepted AFS program available to any airman free of charge. It is a safety educational tool
with hundreds of knowledge courses that can be used to update currency of a flight review
available and completed at the pilot/controller’s convenience. The FAA should design three
courses and corresponding tests for inclusion in the Basic, Advanced, and Master phases of the
Wings program. Suggested topics include mental health as a safety factor, effects of medications
and dangers of self-medication, and resiliency techniques to optimize performance.

The FAA should also consider incorporating mental health awareness into pre-medical
certification/clearance training for pilots/controllers. This could include informational videos, such

99
The WINGS Program consists of learning activities and tasks selected to address the documented causal
factors of aircraft accidents. See FAA Advisory Circular AC 61-91J.

Page 61 of 69
as those provided through the Wings Program, to disseminate mental health knowledge that
applicants would need to know prior to completing a MedXPress application.

Barriers Addressed: Trust, Fear, Stigma, Knowledge, and Information Gap.

Page 62 of 69
REC22 – Regulatory Pathway - Operational Limitations on Certificates & Clearances
The FAA should clarify whether it is empowered to issue medical certificates/clearances
with operational limitations.

INTENT: To determine when it would be appropriate for an applicant's medical condition to be

mitigated by having another equally qualified person available in the immediate vicinity, and
whether the FAA has the authority to issue the medical certificate/clearance with that limitation
rather than denying the special issuance.

RATIONALE: The ARC’s review of the 1980 memorandum opinion in the matter of Delta Airlines v.
United States 100, calls into question the current FAA position that it is prohibited from issuing
medical certificates restricted to two pilot operations. The FAA’s position is based on the text of
the memorandum opinion, which distinguishes between functional limitations and operational
limitations:

[C]onditions on medical certificates of the type referred to herein as "functional

limitations," which specify the job an airman may hold in a cockpit, such as "not
valid for pilot-in-command duties," "valid for first officer duties only," or "valid for
flight engineer duties only." These "functional limitations" are readily distinguishable
from the "operational limitations" which are expressly authorized by 14 C.F.R. §
67.19(c). (The latter, instead of specifying job functions, specifies conditions which
would operate to compensate for a medical deficiency, e. g., requiring corrective
lenses or requiring that a pilot with night blindness fly only in the daytime.) The
operational limitations are specifically provided for in the Regulations and by the
explicit language of 14 C.F.R. § 67.19(d) do not apply to airmen with any of the
absolutely disqualifying conditions.

The specific order reads "The Federal Air Surgeon is further enjoined from placing any limitation on
the medical certificate of an airman that describes the flight functions that such airman may
perform."

The ARC submits that it is unclear whether this order prohibits the FAA from setting the
operational limitation of only being valid when another equally capable individual is in the
immediate vicinity. Allowing such an operational limitation opens the door to the FAA being able to
grant special issuances to pilots/controllers who otherwise might not be able to obtain medical
certification. Title 14 CFR § 67.401(d)(3) specifically states:

State on the Authorization or SODA, and any medical certificate based upon it, any
operational limitation needed for safety; or (emphasis added).

This is of particular importance to pilots operating in two-pilot operations (e.g., many Part
135 operations and all Part 121 operations), who may be allowed to return to work sooner,
as these pilots are already functioning in a situation consistent with this limitation and no

https://law.justia.com/cases/federal/district-courts/FSupp/490/907/1905311/ Delta Air Lines, Inc. v.

100

United States, 490 F. Supp. 907 (N.D. Ga. 1980).

Page 63 of 69
further action would be required to comply with the limitation. ICAO SARP’s (Standards and
Recommended Practices) allow this practice and nearly all international CAA’s make use of
this option to increase safety mitigation barriers for pilots with physical and mental health
conditions.

APPROACH: The ARC recommends the FAA undertake a legal analysis to determine whether it has
the authority to issue operational limitations on medical certificates/clearances in all operating
environments, and to specifically limit the validity of the medical certificate when there is at least
another equally qualified 101 person in the immediate vicinity of the ‘limited’ certificate holder.

Barrier Addressed: Financial, Process

101
With respect to both adequate pilot/controller certificate and appropriate medical certificate.

Page 64 of 69
REC23 – Mental Health Parity – Legislative Amendments
Non-governmental aviation stakeholders and mental health advocacy organizations should
petition Congress to expand the Mental Health Parity Act to include affordable access to
disability insurance benefits for mental health diagnoses.

INTENT: To encourage Congress to expand mental health parity beyond medical insurance to
include disability insurance. This will help address the financial barrier to mental health reporting.

RATIONALE: The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) 102 requires group
health plans and health insurance issuers to ensure that financial requirements (such as co-pays,
deductibles) and treatment limitations (such as visit limits) applicable to mental health or
substance use disorder (MH/SUD) benefits are no more restrictive than the predominant
requirements or limitations applied to substantially all medical/surgical benefits. 103The MHPAEA
does not apply to disability insurance, leaving a gap in benefit coverage for pilots/controllers
diagnosed with a mental health condition once they transition to long-term disability. As this is an
issue of national importance, mental health advocacy organizations, such as the National Alliance
on Mental Illness, the National Association for Behavioral Healthcare, the American Psychiatric
Association and the Depression and Bipolar Support Alliance are natural partners.
APPROACH: Non-governmental aviation stakeholders and mental health advocacy organizations
should petition the government to require mental health parity with physical health diagnoses. This
should specifically include coverage for any FAA required test deemed medically necessary, for
medical certification/recertification decisions, as well as disability insurance coverage like the
MHPAEA. The tests should be covered by any employer-provided or privately purchased healthcare
plan.

Barriers Addressed: Financial

102
29 USC Ch. 18: Employee Retirement Income Security Program, (Subchapter I, Subtitle B, Part 7). The
MHPAEA ensures that group health plans (or health insurance coverage associated with such plans) provide
equal coverage for mental health and substance use disorder benefits as they do for medical and surgical
benefits.
103
Centers For Medicare & Medicaid Services, Fact Sheet - Mental Health Parity and Addiction Equity Act of
2008.

Page 65 of 69
REC24 – Mental Health Parity – Disability Insurance
Aviation stakeholders should consider providing mental health disability insurance
programs for their employees.

INTENT: To encourage aviation stakeholders to provide job-specific disability insurance programs

that include coverage for mental health conditions, preferably to retirement age.

RATIONALE: The ARC recognizes that the lack of a disability insurance program that includes
coverage for mental health conditions is a significant barrier to the reporting of mental health
concerns. The potential loss of income for a pilot is associated with being unable to perform their
job and could extend from the time of disclosure of a mental health condition requiring grounding
through the process of medical recertification. For controllers, the potential loss of income could
extend from the time of disclosure of a mental health condition resulting in a loss of medical
clearance through the process of achieving a renewed medical clearance. This timeline can be
negatively affected by the length of treatment, the delay in scheduling any specific test that may be
required by the FAA and prior to submission of required documentation. Most disability carriers do
not recognize the medical certification clearance requirement for pilots/controllers and may not
pay benefits if the individual is clinically stable, but still not able to maintain FAA medical
qualification. See Section VII.E. ‘Financial’ above for a detailed discussion of the Financial barrier.

APPROACH: The ARC understands that many of the mechanisms to fulfill the goals of this
recommendation would be established during the collective bargaining process between working
groups and their bargaining agents or through the pooling of resources within member
organizations and/or trade associations. The ARC highlights the importance of such disability
benefits in lowering the barrier to self-reporting. During the collective bargaining process, both
aviation industry entities and the representative bargaining agents should recognize the
importance of needed financial stability in a pilot/controller’s decision to self-report a possibly
mental health issue that may cause a loss of certification/clearance.

Barriers Addressed: Stigma, Financial

Page 66 of 69
 IX. Definitions and Glossary of Terms

A. Definitions
Term Definition
An aeromedical professional who assists pilots/controllers with health
Aeromedical concerns by providing specialized aeromedical advice and works as a liaison
advisor with the Federal Aviation Administration (FAA) to help pilots maintain or regain
their medical certification.
A business that undertakes directly by lease, or other arrangement, to engage
Air carrier
in air transportation.
An FAA-designated physician authorized to receive airman medical certificate
Aviation Medical
applications, perform airman physical examinations, and to issue airman
Examiner
medical certificates.
Airlines, the FAA, Air Navigation Service Providers (ANSP), labor unions,
Aviation
regulatory bodies, pilot advocacy groups, business aviation, general aviation,
Stakeholders
the Aerospace Medical Association, academia, and many other organizations
A workplace benefit program designed to provide confidential and professional
Employee assistance to employees who are dealing with personal or work-related
Assistance problems that could affect their well-being and job performance. EAPs are
Program (EAP) offered by employers to support their employees’ mental health, emotional
well-being, and overall productivity.
Physicians, physician assistants, nurse practitioners, psychologists, and
Medical
clinical social workers or substance abuse specialists (all “health
professional
professionals” as defined on FAA Form 8500, the medical application form).
Mental health Knowledge and beliefs about mental disorders which aid their recognition,
literacy management, or prevention.
A mental health professional is a health care practitioner or social and human
Mental Health
services provider who offers services for the purpose of improving an
Provider
individual's mental health or to treat mental disorders.
Disorders are generally characterized by dysregulation of mood, thought,
Mental illness
and/or behavior.
Peer A person who shares professional qualifications and experience.
A confidential peer-led program designed to support mental health and
wellness. The Program aims to provide pilots/controllers with the tools needed
Peer Support
to support and restore their mental wellbeing and direct them to appropriate
Program (PSP)
resources if needed. At the heart of the program are trained peers ready to help
in a confidential and non-punitive way.
Pilot mental Issues affecting a pilot’s emotional state, mental health, or cognitive ability to
fitness safely conduct their duties.
Pilot An official or ad hoc organization representing pilot interests at an air carrier
Representative such as labor unions, nonunion organized pilot groups, or professional
Organizations associations.
Admitting a mental health concern and the personal realization that one must
Psychological
address it, which leads to the natural defense mechanism of denial of the
Avoidance:
issue.

Page 67 of 69
Public safety The welfare and protection of the general public.
A set of policies and procedures that an organization uses to reduce workplace
Safety accidents and illnesses. An SMS is a formal, top-down approach that includes
Management systematic procedures, practices, and policies for managing safety risk. It can
System (SMS) be tailored to the size and complexity of an organization and can fit any
business type and/or industry sector.
At the discretion of the Federal Air Surgeon, a Statement of Demonstrated
Ability (SODA) may be granted, instead of an Authorization, to a person whose
SODA
disqualifying condition is static or nonprogressive and who has been found
capable of performing airman duties without endangering public safety.
WINGS Criteria FAA Pilot Proficiency course as per AC 61.91J

Page 68 of 69
B. Acronyms
Acronyms
AAM Office of Aerospace Medicine
ACS Airman Certification Standards
AIR AME-Issued with Review
Aerospace Medical Certification
AMCD
Division (AAM-300)
AME Aviation Medical Examiners
ANSP Air Navigation Service Provider
ARC Aviation Rulemaking Committee
ASAP Aviation Safety Action Programs
AsMA Aerospace Medical Association
ATO Air Traffic Organization
CAA Civil Aviation Authority
CACI Certificates AMEs Can Issue
CBA Collective Bargaining Agreement
CIRP Critical Incident Response Programs
CISM Critical Incident Stress Management
Diagnostic and Statistical Manual of
DSM-5-TR Mental Disorders, Fifth Edition, Text
Revision
EAP Employee Assistance Programs
FAA Federal Aviation Administration
HIMS Human Intervention Motivation Study
FAA Senior AME completed HIMS
HIMS AME
Training and Testing
MHP Mental Health Professional
NAS National Airspace System
NTSB National Transportation Safety Board
OSA Obstructive Sleep Apnea
PTS Practical Test Standards
RFS Regional Flight Surgeon
Standards and Recommended
SARP
Practices
SMS Safety Management System
SODA Statement of Demonstrated Ability
SSRI Selective Serotonin Reuptake Inhibitor

Page 69 of 69
 X. Appendices

Appendix A – Talk Therapy Process Flowchart

This diagram pertains to Recommendations REC1, REC5, REC6, REC10, & REC19.

Wings Criteria – Completing one Phase of the FAA Wings Program with Knowledge and Flight
credits documented in the FAA AFS Pilot Proficiency Wings Program and providing Completion
certificate.

Appendix A Page 1 of 1
Appendix B – Sample Mental Health Provider Report Checklist
Potential Items to include on the mental health provider checklist that the pilot/controller would
give to the AME:
• Name of individual
• Name and credentials of therapist
• Type of therapy
• Date of initial therapy
• Frequency of therapy
• Date of termination of therapy if not ongoing
• Results of therapy
• Medication used currently if any (date of initiation)
• Medications previously used, (list date range of use, if known)

Does this individual have any of the following?

1. A personality disorder repeatedly manifests by overt acts
2. A history of psychosis manifested delusions, hallucinations, grossly bizarre or disorganized
behavior, or other commonly accepted symptoms of this condition
3. Bipolar disorder
4. A Substance Use Disorder
5. Personality disorder, neurosis, or other mental condition that makes the person unable to
safely perform the duties.
6. History of suicidal plans or attempts
7. Have you been prescribed or recommended to take multiple simultaneous psychoactive
medication related to the therapy? If so, list name(s) of medication(s)
8. Has there been a recommendation or referral to a psychiatrist or psychologist because of
the severity of the mental health condition?
9. History of non-compliance with treatment recommendations
10. History of psychiatric hospitalization
11. History of non-trivial criminal behaviors
12. Do you have any other concerns about the individual ability to function in a safety sensitive
role?
Signed
Dated
License # and State

Appendix B Page 1 of 1
Appendix C – CASA and CAA NZ Safe Haven Pathway Draft Policy
Overview

CASA and CAA NZ are developing a pathway by which certificate-holders with mental health
problems are encouraged to self-disclose and supported when they do so. The intent is to develop
a safety culture that enhances help-seeking for and self-disclosure of mental health and other
problems.

Policy principles

Certificate holders who meet clearly defined criteria are allowed to maintain medical qualification
status under supervision by an aviation medical examiner (as defined by ICAO). Certificate holders
have the options of disclosure directly to the regulator (CAA and CASA) or through the alternative
Safe Haven pathway. Through the conventional direct-disclosure pathway the medical certificate is
suspended pending final determination from the Aviation Medicine Section at CASA or the CAA NZ
Medical Unit. For those medical certificate holders who use the Safe Haven pathway such
determinations are made by Safe Haven medical examiners, and only referred to the CAA Medical
Unit or CASA Aviation Medicine Section using a designated escalation pathway.

Safe Haven eligibility for maintaining qualification pending determination and for the ongoing
certification pathway is contingent on the pilot or controller:

- providing all available medical treatment records to the supervising AME

- meeting the CASA and CAA NZ-defined diagnostic and medication criteria (confirmed
by the AME)
- continuing compliance with the requirements of the Safe Haven pathway throughout
the period of their certification.

Certificate-holders who meet the criteria and are subsequently managed under this pathway will
not be subject to referral for administrative or enforcement action due to any prior non-disclosure
of illness or medication use. Certificate-holders who do not meet the criteria or are not eligible for
or compliant with the pathway remain subject to the normal processes for administrative and
enforcement action.

Eligibility for the pathway does not depend on the way in which the certificate-holder’s mental
health problem or its treatment is disclosed to CASA or CAA NZ. However, where the CASA and
CAA NZ become aware of the diagnosis and/or treatment, continued certification is contingent
upon the certificate-holder’s ongoing engagement in the CASA’s or CAA NZ’s certification
processes.

Supporting documents and processes

CASA and CAA NZ will develop a suite of documents to guide certificate-holders and AMEs on the
implementation of the program. These include:

- Eligibility criteria and evidence requirements for demonstration of eligibility

- AME checklist for confirming eligibility for the certificate-holder
- AME forms for documenting and reporting compliance

Appendix C Page 1 of 2
- Escalation pathways for non-compliance or change in risk assessment
- Guidance for the certificate-holder
- Guidance for development of a Safe Haven Plan with which the certificate-holder must
comply, covering:
• Therapeutic compliance
• Healthcare provider contact requirements
• PSP role and contact requirements
• AME contact and reporting requirements
- Guidance for qualifications and competencies for AMEs, healthcare providers and PSPs
participating in Safe Haven programs

Appendix C Page 2 of 2
Appendix D- Examples of Conflicting FAA Information for MedXpress Instructions
MedXPress Question 19 Further Information Box

FAA 8500-8 Instructions for Question 19 104

No NOTE provided in the 8500-8 Instructions document.

104
MedXpress Help Instructions

Appendix D Page 1 of 2
Guide for Aviation Medical Examiners 105

105
2024 Guide for Aviation Medical Examiners

Appendix D Page 2 of 2
$33(1',;(

Federal Aviation
Administration
Aeromedical
Update

resented to S
y rett . yrick, . .,M , S
ate ugust ,

Appendix E Page 1 of 64

Federal Aviation
Administration
Aviation Safety AVS

Appendix E Page 2 of 64
Federal Aviation
Administration
 Job # 1:
Safety of the National Air Space
• San Diego, California PSA Flight 182
• Sept. 25, 1978
• B-727 / Cessna 172
• Fatalities = 144

Appendix E Page 3 of 64
Federal Aviation
Administration
 Job # 1:
Safety of the National Air Space
• San Diego, California PSA Flight 182
• Sept. 25, 1978
• B-727 / Cessna 172
• Fatalities = 144

Appendix E Page 4 of 64
Federal Aviation
Administration
 Risk Assessment

• How likely is the condition to occur again?

• If it occurs again, how serious is it likely to
be?

Appendix E Page 5 of 64
Federal Aviation
Administration
 •Aeromedical Risks

• Sudden incapacitation e.g. seizure, sudden

cardiac death
• Rapid incapacitation e.g. hypoglycemia, MI,
stroke
• Impairment (subtle incapacitation) e.g. fatigue,
cognitive deficits, depression, pain, medication
effects, disturbances of sensory input

Appendix E Page 6 of 64
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Administration
 What Is Acceptable Risk?

• No risk = No flying
• Flying public – zero on my flight
• 1% Rule – complex assumptions
• Tilton Rule: The risk of adverse medical
event approximates that of unscreened
population.

Appendix E Page 7 of 64
Federal Aviation
Administration
 The Next Evolution

• Tap into Big Data

• Adapt artificial intelligence
• Evaluate system risk
• Predictive analytics

Appendix E Page 8 of 64
Federal Aviation 8
Administration
 Challenging Realities
• “The runway is not age
adjusted” -- Gary Kay, PhD
• The weather does not
provide reasonable
accommodation
• You can’t just pull over
and stop
• “Aviation… is terribly
unforgiving” – Capt. A.G.
Lamplugh

Appendix E Page 9 of 64
Federal Aviation
Administration
Myth: Flying Same as Driving

• Acceleration
• 3 Axes of motion – spatial disorientation
• Altitude
– Hypoxia
– Barometric pressure changes
• Can’t just pull over and stop

Appendix E Page 10 of 64
Federal Aviation
Administration
Where Do I Start?

AME Guide

Appendix E Page 11 of 64
Federal Aviation
Administration
Medical Certification Process

• Med Express – medical history

• AME exam
• Transmission to FAA
• New tracking tool
• Certification decision
– Unrestricted
– Special Issuance
– Denial

Appendix E Page 12 of 64
Federal Aviation
Administration
Decision Levels in Civil Aviation

Level 1: Individual Pilot

14 CFR 61:53
“…shall not act as pilot in command…while
that person knows or has reason to know of
any medical condition that would make the
person unable to operate the aircraft in a safe
manner.”

Appendix E Page 13 of 64
Federal Aviation
Administration
Decision Levels in Civil Aviation
Level 2: Aviation Medical Examiner
• Issue Medical Certificate ~95%
- No significant findings on history/exam
- Common medical conditions specified
in the AME Guide if stable
- Medical conditions cleared with
completion of CACI worksheet (May require
review of additional information)
• Defer

Appendix E Page 14 of 64
Federal Aviation
Administration
 Decision Levels in Civil Aviation

Decision Level 3: AMCD or Regional FS

- Issue Unrestricted Medical Certificate
- Authorization for Special Issuance Medical
Certificate
- Deny
- Defer to Headquarters

Appendix E Page 15 of 64
Federal Aviation
Administration
Decision Levels in Civil Aviation

Decision level 4: Federal Air Surgeon

• Any complex case deferred by AMCD or RFS
• All special issuances for SSRI program
• All FAS Appeals
• All Class 1 & 2 ITDM
• All formal HIMS cases

Appendix E Page 16 of 64
Federal Aviation
Administration
 Decision Levels in Civil Aviation

• Decision level 5:
National Transportation Safety Board
- Only unrestricted medical certificates

Appendix E Page 17 of 64
Federal Aviation
Administration
“I didn’t know where
I was in the air.”

Appendix E Page 18 of 64
Federal Aviation
Administration
A Tale of Two Olympians

Appendix E Page 19 of 64
Federal Aviation
Administration
 The Message

• Mental status is a performance issue and a

safety issue.

• Communication promotes recognition

• Recognition prerequisite to action

Appendix E Page 20 of 64
Federal Aviation
Administration
Mental Health Continuum

Appendix E Page 21 of 64
Federal Aviation
Administration
In a pilot, with a mental health
diagnosis… return him/her to
flying…as soon as it is safe to do so.

22
Appendix E Page 22 of 64
Federal Aviation
Administration
Mental Health Issues Are Common

• 21% prevalence in U.S. population

• Rates of anxiety & depression 4 times
higher than prepandemic
• 5.9% of Class 3 certificate holders in 2020
had at least one mental health code
• Currently AMCD estimates 30-40% of
general review cases have mental health
component

Appendix E Page 23 of 64
Federal Aviation
Administration
 History

• 1970 First FAA Chief Psychiatrist

• 1974 HIMS Program
• 2010 SSRI Program
• 2016 ARC on Pilot Mental Health
• 2018 First FAA Neuropsychologist
• 2019 Second FAA psychiatrist
• 2021 Third FAA psychiatrist
• 2022 Recruiting fourth psychiatrist

Appendix E Page 24 of 64
Federal Aviation
Administration
“No established medical history or
clinical diagnosis of …”
(1) Personality Disorder severe enough
to have repeatedly manifested itself by
overt acts
(2) Psychosis
(3) Bipolar Disorder
(4) Substance dependence
Appendix E Page 25 of 64
Federal Aviation
Administration
• Depression
• ADD/ADHD
• OCD
• Anxiety
• Other Personality Disorders

Appendix E Page 26 of 64
Federal Aviation
Administration
 Rarely Waivered Conditions

• Psychosis
• Bipolar disorder
• Untreated recurrent major depression
• ADHD either on medication or with
persistent signs/symptoms

Appendix E Page 27 of 64
Federal Aviation
Administration
 ADHD
• Contributing factor in fatal mishaps in 2017
and 2020
• Medication controls but does not eliminate
underlying condition
• Overdiagnosis common
• Medications prescribed for performance
enhancement without a diagnosis
• Medscape survey – 29% of physicians
would prescribe psychostimulant solely for
performance enhancement

Appendix E Page 28 of 64
Federal Aviation
Administration
 Special Mental Health Programs

• Human Intervention Motivation Study

(HIMS)
• Selective Serotonin Reuptake Inhibitors
(SSRI)

Appendix E Page 29 of 64
Federal Aviation
Administration
 Impact in 2023

• 522 pilots flying while taking SSRI

antidepressants
• 2,996 pilots flying with history of substance
dependence

Appendix E Page 30 of 64
Federal Aviation
Administration
HIMS Program
• Success story
• Prior to 1974 - permanent grounding for
substance dependence – no exceptions
• Coordinated effort between management,
unions, volunteers, medical professionals
and FAA
• ~85% relapse free

Appendix E Page 31 of 64
Federal Aviation
Administration
 HIMS Team
• Employers
• Pilot Unions
• FAA
• HIMS AMEs
• Treatment Facilities
• Psychiatrists
• Peer Support Groups
• Peer Pilots
• Aftercare Providers

Appendix E Page 32 of 64
Federal Aviation
Administration
 Role of the HIMS AME

• Coordinate care
• Administratively manage case
• Regular meetings with pilot
• Evaluate the quality of the recovery
• Make a recommendation regarding safety
for special issuance and step down

Appendix E Page 33 of 64
Federal Aviation
Administration
 FAA Program
• Dependence vs. abuse vs. one-time stupid
• Formal treatment program – 28 day
inpatient or intensive outpatient
• Group aftercare
• Peer support group e.g. AA
• Compliance testing
• Evaluation by HIMS psychiatrist
• Initial neurocognitive assessment
• Maintain abstinence
• Step-down plan
Appendix E Page 34 of 64
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Administration
Appendix E Page 35 of 64
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Administration
 Goals of Step Down Plan

• Support strong recovery program

• Extended follow up of life-long disease
• Responsible fact-based use of resources
• Satisfy as many stakeholders as possible

Appendix E Page 36 of 64
Federal Aviation
Administration
 DSM 5

Alcohol Use Disorder

• A problematic pattern of alcohol use
leading to clinically significant impairment
or distress as manifested by at least two
of the following, occurring within a 12
month period.

Appendix E Page 37 of 64
Federal Aviation
Administration
(3) Misuse of a substance that the Federal Air
Surgeon, based on case history and
appropriate, qualified medical judgment relating
to the substance involved,
finds ….
Makes the person unable to safely perform…

Appendix E Page 38 of 64
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Administration
HIMS AME Checklist

Appendix E Page 39 of 64
Federal Aviation
Administration
•
#5 NEUROPSYCHOLOGIST EVALUATION AND RAW TEST DATA

Appendix E Page 40 of 64
Federal Aviation
Administration
 HIMS Document Links
HIMS-TRAINED AME CHECKLIST
Drug and Alcohol Monitoring – INITIAL Certification
https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/media
/HIMS_DA_Monitoring_Initial_Certification.pdf

FAA CERTIFICATION AID

HIMS Drug and Alcohol Monitoring – INITIAL Certification
https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/media
/FAACertificationAid-HIMSDrugandAlcohol-Initial.pdf

HIMS-Trained AME CHECKLIST

Drug and Alcohol Monitoring - RECERTIFICATION
https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/media
/HIMS_Drug_Alcohol_Monitoring_Checklist.pdf

FAA CERTIFICATION AID

HIMS Drug and Alcohol Monitoring – RECERTIFICATION
https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/media
/Drug_Alcohol_Monitoring_Recertification_Aid.pdf

Appendix E Page 41 of 64
Federal Aviation
Administration
 HIMS Program Issues

• Incorrect regulatory determination

• Drug/alcohol monitoring test results
• Drug assisted recovery e.g. antabuse,
suboxone, ibogaine
• FAA delays for initial Special Issuance

Appendix E Page 42 of 64
Federal Aviation
Administration
• General observation that pilots on
antidepressants were doing well
• General awareness that mild/moderate
depression is very common
• Publication in Federal Register April 5, 2010
• 4 approved medications chosen for most
favorable side effect profile (fluoxetine,
sertraline, citalopram or escitalopram)

Appendix E Page 43 of 64
Federal Aviation
Administration
 SSRI Program

• Mild/moderate depression or other

diagnosis
• Stable 6 months
• No history psychosis, suicidal ideation,
multiple meds, electroconvulsive therapy
• Follow up by psychiatry, treating physician,
HIMS AME, neuropsychology
• Recurrent major depressive disorder must
be treated

Appendix E Page 44 of 64
Federal Aviation
Administration
 Diagnoses Treated with SSRI’s

• Depression 61%
• Anxiety 39%
• Major depression 12%
• Obsessive/compulsive 0.05%
• PTSD 0.02%
• Dysthymia 0.02%

Appendix E Page 45 of 64
Federal Aviation
Administration
 SSRI Program

• Ongoing monitoring by psychiatry, treating

physician, HIMS AME
• Bupropion now acceptable medication
• Dosage changes will invalidate special
issuance authorization
• Changes of medical monitor require prior
coordination with FAA
• Changes in condition must be reported to
HIMS AME and FAA immediately

Appendix E Page 46 of 64
Federal Aviation
Administration
 Yellow Flags
• Psychosis
• Suicidal ideation
• History of electroconvulsive therapy (ECT)
• Concurrent use of multiple antidepressants
• History of use of antidepressant plus other
psychiatric drugs
• Psychiatric hospitalizations
• Bipolar spectrum disorders
• Affective instability

Appendix E Page 47 of 64
Federal Aviation
Administration
 Airliner Assisted Suicide

• Germanwings flight 9525

• March 24, 2015
• French Alps
• 150 fatalities

Appendix E Page 48 of 64
Federal Aviation
Administration
 Airliner Assisted Suicide

• LAM Airlines ERJ 190; Namibia 11/29/2013

• EgyptAir B767; Atlantic Ocean 10/31/1999
• Silk Air B737; Indonesia 12/19/1997
• Royal Air Maroc ATR42; Morocco 8/21/1994
• Japan Airlines DC-8; Japan 2/9/1982

Appendix E Page 49 of 64
Federal Aviation
Administration
 Germanwings

• Very small percentage of mental illness is

dangerous
• Mishap pilot had track record of depression
• Treating physician recommended not flying
• No indication of crew concern on outgoing
leg
• Failure to disclose/failure to report

Appendix E Page 50 of 64
Federal Aviation
Administration
 Failure to Disclose

• Airman does not recognize problem

– Diagnosis associated with poor insight
– Symptoms minimized/mischaracterized
• Airman chooses to conceal
– Financial hardship
– Career impact
– Stigma

Appendix E Page 51 of 64
Federal Aviation
Administration
 The Challenge

• Dispel the Myths

• Destroy the Barriers

Appendix E Page 52 of 64
Federal Aviation
Administration
Myth: Denial Is a Common Event

• Initial DQ rate for all mental health

diagnoses is ~20%
• In an aviator with substance dependence,
we return them to the cockpit once they are
in satisfactory recovery
• In an aviator with uncomplicated anxiety, we
return them to the cockpit once they are in
remission

Appendix E Page 53 of 64
Federal Aviation
Administration
 Dispelling Myths

• Increase Outreach -- presentations, articles,

Pilot Minute videos, UND Summit, AOPA
webinar
• Increased mental health content in AME
training
• Champion Pilot Peer Support Programs

Appendix E Page 54 of 64
Federal Aviation
Administration
• Published decision grids on PTSD and
Adjustment disorders
• Hired additional psychiatrist to decrease
case review backlog
• Decreased cognitive testing in SSRI
program
• Added acceptable medication

Appendix E Page 55 of 64
Federal Aviation
Administration
 Regulatory Challenges

• Scarcity of relevant clinical research

• Incomplete/poor quality records
• Excessive advocacy
• Inconsistent history
• Minimization
• Poor recollection of past symptoms

Appendix E Page 56 of 64
Federal Aviation
Administration
 Cognitive Concerns

• SSRI
• HIV
• ADHD
• Substance
dependence
• Brain injury
• Aging aviator
• Neurodegenerative
disease
Appendix E Page 57 of 64
Federal Aviation
Administration
 Insulin-Treated Diabetes

• Based on continuous glucose monitoring

technology
• 75+ Class 1 & 2 pilots currently flying
• Coefficient of variance < 33
• Time in range > 70%
• No end organ disease
• Followed by endocrinologist

Appendix E Page 58 of 64
Federal Aviation
Administration
 Elusive Solutions

• Color Vision – NTSB Rec A-04-47

• “…develop a standard battery of tests to be

performed at least once on each applicant for a
Class 1 or 2 medical certificate that would
prevent applicants with color vision deficiencies
that could impair their ability to perform color-
related critical aviation tasks from being
certificated without limitations.”

Appendix E Page 59 of 64
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Administration
Color vision

Appendix E Page 60 of 64
Federal Aviation
Administration
Color Vision

Appendix E Page 61 of 64
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Administration
 New Color Vision Tests

• Colour Assessment and Diagnosis (CAD)

• Rabin Cone Contrast Test (RCCT)
• Waggoner Computerized Color Vision Test
(CCVT)
• All computer based
• All evaluated at CAMI

Appendix E Page 62 of 64
Federal Aviation
Administration
 Takeaways

• Mental status is a performance and safety

issue
• Mental health issues are common
• Permanent grounding is rare
• Issues are best addressed early
• Failure to disclose and failure to seek
appropriate care is a growing concern
• Aeromedical risk analysis is evolving

Appendix E Page 63 of 64
Federal Aviation
Administration
Questions?

There are many challenges ahead.

Appendix E Page 64 of 64
Federal Aviation
Administration
Appendix F – ARC Participants 106
FAA Co-Chair Organization
Mark Steinbicker FAA
Industry Co-Chairs Organization
Charles Curreri International Pilot Peer Assist Coalition
(IPPAC) & Center for Aviation Mental Health
Capt. Travis Ludwig Air Line Pilots Association

William McDonald Airlines for America

Members Organization

Dr. Steven Altchuler Emeritus, Mayo Clinic

Dr. Jim Bagian University of Michigan
Dr. Beth Bjerke University of North Dakota
Mr. Tom Charpentier Experimental Aircraft Association
Mr. Lee Collins National Flight Training Alliance
Mr. Jim Coon Aircraft Owners and Pilots Association
Ms. Jana Denning Professional Aviation Safety Specialists
Capt. Rondeau Flynn Coalition of Airline Pilots Association
Ms. Jennifer Iversen Regional Airline Association
Mr. Mark Larsen National Business Aviation Association
Mr. Andrew LeBovidge National Air Traffic Controllers Association
Capt. Mary Ann Schaffer United Aviate Academy
Capt. Keith Sikes International Brotherhood of Teamsters
Dr. Quay Snyder Aviation Medicine Advisory Service
Dr. Alan Stolzer Embry-Riddle Aeronautical University
Capt. Matt Sturgis National Air Carrier Association
Ms. Suz Viljoen National Air Transportation Association
Observers Organization

Mr. William Bramble National Transportation Safety Board

Dr. Tyler Brooks Transport Canada
Dr. William Hoffman US Air Force
Dr. Cristian Iount Panait EASA
Dr. Anne Suh John A. Hauser Mental Health in Aviation
Initiative Endowment/Northwestern Medicine
Contributors Organization
Dr. Kate Manderson Principal Medical Officer – CASA
Dr. David Rogers Senior HIMS AME
Dr. Timothy Sprott Chief Medical Officer – CAA NZ
Ms. Laila Stein Certified Flight Instructor

106
In alphabetical order by participant name.

Appendix F Page 1 of 1
Appendix G– ARC Member Voting Responses and Ballots 107
The ARC believes this report fulfills the tasks in the mission of the Charter. The recommendations
contained in this report were robustly debated and the report was accepted by the full ARC prior to
submission to the FAA.
In support of a transparent ARC process, members were offered the opportunity to include a (2
page) concurrence or non-concurrence on the final document. All submissions are included in this
report.
The ARC completed its deliberations and report drafting on March 28, 2024. Ballots were
distributed to the 20 voting ARC members. The tally is as follows:
17 – Concur as Written

3 – Concur with Comment

0 – Concur with Exception

0 – Non-Concur

Organization Primary Representative Voting Response

Aircraft Owners and Pilots Concur

Mr. Jim Coon
Association

Air Line Pilots Association Capt. Travis Ludwig Concur with

Comment
Airlines for America William McDonald Concur

Aviation Medicine Advisory Concur

Dr. Quay Snyder
Service

Coalition of Airline Pilots Concur

Capt. Rondeau Flynn
Association

Embry-Riddle Aeronautical Concur

Dr. Alan Stolzer
University

Concur with
Emeritus, Mayo Clinic Dr. Steven Altchuler
Comment

Experimental Aircraft Concur

Mr. Tom Charpentier
Association

107
In alphabetical order by organization name.

Appendix G Page 1 of 23
International Brotherhood of Concur
Capt. Keith Sikes
Teamsters

International Pilot Peer Assist Charles Curreri Concur

Coalition (IPPAC) & Center for
Aviation Mental Health
Concur
National Air Carrier Association Capt. Matt Sturgis

National Air Traffic Controllers Concur

Mr. Andrew LeBovidge
Association

National Air Transportation Concur

Ms. Suz Viljoen
Association

National Business Aviation Concur with

Mr. Mark Larsen
Association Comment

Concur
National Flight Training Alliance Mr. Lee Collins

Concur
Professional Aviation Safety
Ms. Jana Denning
Specialists

Concur
Regional Airline Association Ms. Jennifer Iversen

United Aviate Academy Capt. Mary Ann Schaffer Concur

University of Michigan Dr. Jim Bagian Concur

Concur
University of North Dakota Dr. Beth Bjerke

Appendix G Page 2 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Travis Ludwig

Voting Member Organization ALPA-International

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written

Voting Member Signature: Date: 28 March 2024

My personal belief is that the goal of this Mental Health ARC is to better the life of all pilots and
controllers both current and aspiring. I know this towering aspiration was shared by all those that
participated in the ARC. This ARC strived to save a life, a job, a family. If we accomplish this lofty goal
even once, the amount of work thrown into this project with be worth it.

The current document you hold in front of you was produced between Jan 9th, our first plenary session,
and our final vote on March 28th. In just 57 working days, this mammoth text with the possibility to
generate generational aviation cultural change was produced. This could not have been done without
the dedicated, passionate, focused efforts of all the ARC Members and Observers and the excellent
support from The Regulatory Group. I have been humbled by the sheer dedication of all parties
involved. During the ARC, weekly videoconferencing routinely extended to more than 8 hours. Between
which, various versions of this document and graphics where produced, vetted, and debated. The
volume of ideas and conversations that were distilled down into the current document could fill
volumes.

It has been an honor and a privilege to work alongside all these brilliant individuals. My solemn wish is
that this document be the start of a much-needed change within the aviation community with regards
to mental wellness. While this change will not happen quick, this document clearly shows a path
forward, and that dedicated individuals stand ready to help the aviation community welcome in a new
era.

In Unity,

Travis Ludwig
ALPA-International Pilot Assistance Chair

Appendix G Page 3 of 23
2. Concur with Comment or Exception(s):

Provide comment or exception in the text box above or submit a separate paper on company letterhead if additional space is
required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date:

3. Non-Concur. Letter of Dissent must be provided.

Voting Member Signature: _______________________________________ Date: _________________

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 4 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Jim Coon

Voting Member Organization Aircraft Owners and Pilots Association (AOPA)

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written:

Voting Member Signature: James Coon Date: March 28, 2024

2. Concur with Comment or Exception(s):

Provide comments or exceptions in the text box above or submit a separate paper on company letterhead if additional space
is required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date:

3. Non-Concur. Letter of Dissent must be provided.

Voting Member Signature: Date:

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 5 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name William McDonald

Voting Member Organization Airlines for America

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written

Voting Member Signature: William McDonald Date: March 27, 2024

2. Concur with Comment or Exception(s):

Provide comment or exception in the text box above or submit a separate paper on company letterhead if additional space is
required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date:

3. Non-Concur. Letter of Dissent must be provided.

Voting Member Signature: _______________________________________ Date: _________________

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 6 of 23
Appendix G Page 7 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Quay Snyder, MD MSPH

Voting Member Organization Aviation Medicine Advisory Service

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written:

Voting Member Signature: Date: March 28; 2024

2. Concur with Comment or Exception(s):

Provide comments or exceptions in the text box above or submit a separate paper on company letterhead if additional space
is required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date: March 28, 2024

3. Non-concur. Letter of Dissent must be provided.

Voting Member Signature: Date: March 28, 2024

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 8 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Rondeau Flynn

Voting Member Organization Coalition of Airline Pilots Association

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written Conur

Voting Member Signature: R. Flynn Date: March 27th, 2024

2. Concur with Comment or Exception(s):

Provide comment or exception in the text box above or submit a separate paper on company letterhead if additional space is
required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date:

3. Non-Concur. Letter of Dissent must be provided.

Voting Member Signature: Date: _________________

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 9 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Alan J. Stolzer

Voting Member Organization Embry-Riddle Aeronautical University

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written

Voting Member Signature: Date: March 26, 2024

2. Concur with Comment or Exception(s):

Concur!

Provide comment or exception in the text box above or submit a separate paper on company letterhead if additional space is
required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date:

3. Non-Concur. Letter of Dissent must be provided.

Voting Member Signature: _______________________________________ Date: _________________

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 10 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Tom Charpentier

Voting Member Organization Experimental Aircraft Association

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written:

Voting Member Signature: Date: March 28, 2024

2. Concur with Comment or Exception(s):

Provide comments or exceptions in the text box above or submit a separate paper on company letterhead if additional space
is required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date:

3. Non-concur. Letter of Dissent must be provided.

Voting Member Signature: Date:

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 11 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Keith Sikes

Voting Member Organization International Brotherhood of Teamsters

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written

Voting Member Signature: Keith Sikes Date: March 26, 2024

2. Concur with Comment or Exception(s):

Concur!

Provide comment or exception in the text box above or submit a separate paper on company letterhead if additional space is
required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date:

3. Non-Concur. Letter of Dissent must be provided.

Voting Member Signature: _______________________________________ Date: _________________

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 12 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Charlie Curreri

Voting Member Organization International Pilot Peer Assist Coalition (IPPAC) and Center for Aviation Mental Health

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written

Voting Member Signature: Charlie Curreri Date: 15 March 2024

2. Concur with Comment or Exception(s):

Concur.

Provide comment or exception in the text box above or submit a separate paper on company letterhead if additional space is
required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Charlie Curreri Date: 15 March 2024

3. Non-Concur. Letter of Dissent must be provided.

Voting Member Signature: _______________________________________ Date: _________________

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 13 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Steven I. Altchuler, Ph.D., M.D.

Voting Member Organization Emeritus, Mayo Clinic

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

2. Concur with Comment or Exception(s):

The members of the ARC have an excellent understanding of the barriers that prevent their constituencies
from reporting and seeking care for mental health issues. They have been creative and strong advocates
for ways to address these challenges. I am the only psychiatrist who is an official member of the ARC and
the -depth knowledge of the nature and course of
psychiatric illnesses and the symptoms associated with them.

An underlying theme is the stigma associated with mental illness and occupational difficulties for individuals
with mental illnesses. This is a broad international issue, not unique to the aviation community or to the
United States. While there are some unique features for pilots and air traffic controllers, the broader
problem is the foundation upon which the stigma and many of the barriers rest. It is worthy for the FAA as
well as the entire aviation community to try and reduce these barriers. We must recognize there is a
reason so many mental health advocacy organizations have efforts to fight stigma. The issue is bigger than
what any one organization by itself can solve. To be ultimately successful, all aviation stakeholders will
need to work along side and in an ongoing fashion with other advocacy groups.

The views expressed are solely those of the author and do not reflect the position or policy of Mayo Clinic.

Provide comment or exception in the text box above or submit a separate paper on company letterhead if additional space is
required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Steven I. Altchuler, Ph.D., M.D. Date: 28 March 2024

Appendix G Page 14 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Andrew LeBovidge

Voting Member Organization National Air Traffic Controllers Association

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written

Voting Member Signature: Date: March 26, 2024

2. Concur with Comment or Exception(s):

Concur!

Provide comment or exception in the text box above or submit a separate paper on company letterhead if additional space is
required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date:

3. Non-Concur. Letter of Dissent must be provided.

Voting Member Signature: _______________________________________ Date: _________________

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 15 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Suz Viljoen

Voting Member Organization NATA

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written

Voting Member Signature: Suz Viljoen Date: March 28, 2024

2. Concur with Comment or Exception(s):

Concur

Provide comment or exception in the text box above or submit a separate paper on company letterhead if additional space is
required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Suz Viljoen Date: March 28, 2024

3. Non-Concur. Letter of Dissent must be provided.

Voting Member Signature: _______________________________________ Date: _________________

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 16 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Mark Larsen

Voting Member Organization National Business Aviation Association

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written:

Voting Member Signature: Date:

2. Concur with Comment or Exception(s):

I concur with this ARC final report which reflects the broad sentiment that pilot/controller mental health is of great
importance to the aviation industry. I am grateful to my fellow ARC members and contributors for sharing their
knowledge, practical insights, and passion for mental health as well as their dedication in a relatively short
timeframe to create this significant report. I believe our substantial contributions indicate the extent to which
pilot/controller mental health is an industry-wide challenge and the need for aviation stakeholders to continue
working together to enact these recommendations. By doing so, we can reduce the barriers that keep
pilots/controllers from getting mental healthcare and bring about positive changes for the mental health and lives
of current and future generations of pilots and controllers.

Provide comments or exceptions in the text box above or submit a separate paper on company letterhead if additional space
is required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date: March 28, 2024

3. Non-concur. Letter of Dissent must be provided.

Voting Member Signature: Date:

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 17 of 23
Appendix G Page 18 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Jana Denning

Voting Member Organization Professional Aviation Safety Specialists, AFL-CIO

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written:

Voting Member Signature: Jana Denning Date: March 28, 2024

2. Concur with Comment or Exception(s):

Provide comments or exceptions in the text box above or submit a separate paper on company letterhead if additional space
is required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date:

3. Non-concur. Letter of Dissent must be provided.

Voting Member Signature: Date:

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 19 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence
Voting Member Name Jennifer Iversen

Voting Member Organization Regional Airline Association

As a voting member and full participant of the Mental Health and Aviation Medical Clearances
ARC, I hereby acknowledge that I have reviewed the Final Report and recommendations and make
the following statement:
1. Concur with the Final Report as written

Voting Member Signature: Date: March 26, 2024

2. Concur with Comment or Exception(s):

Provide comment or exception in the text box above or submit a separate paper on company letterhead if
additional space is required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date:

3. Non-Concur. Letter of Dissent must be provided.

Voting Member Signature: Date:

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 20 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Mary Ann Schaffer

Voting Member Organization United Aviate Academy

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written:

Voting Member Signature: Date: March 28; 2024

2. Concur with Comment or Exception(s):

Provide comments or exceptions in the text box above or submit a separate paper on company letterhead if additional space
is required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date: March 28, 2024

3. Non-concur. Letter of Dissent must be provided.

Voting Member Signature: Date: March 28, 2024

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 21 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name James P. Bagian, MD

Voting Member Organization University of Michigan

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written:

Voting Member Signature: James P. Bagian, MD Date: March 28, 2024

2. Concur with Comment or Exception(s):

Provide comments or exceptions in the text box above or submit a separate paper on company letterhead if additional space
is required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date:

3. Non-concur. Letter of Dissent must be provided.

Date:
Voting Member Signature:

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 22 of 23
 Mental Health and Aviation Medical Clearances
Aviation Rulemaking Committee (ARC)
Statement of Concurrence / Non-Concurrence

Voting Member Name Elizabeth Bjerke

Voting Member Organization University of North Dakota

As a voting member and full participant of the Mental Health and Aviation Medical Clearances ARC, I hereby
acknowledge that I have reviewed the Final Report and recommendations and make the following statement:

1. Concur with the Final Report as written:

Voting Member Signature: Date: March 28; 2024

2. Concur with Comment or Exception(s):

Provide comments or exceptions in the text box above or submit a separate paper on company letterhead if additional space
is required. Separate papers may not exceed 2 pages in length.

Voting Member Signature: Date: March 28, 2024

3. Non-concur. Letter of Dissent must be provided.

Voting Member Signature: Date: March 28, 2024

Letter of Dissent must be on company letterhead and may not exceed 2 pages in length.

Appendix G Page 23 of 23