Tackling Aviation's Mental Health Paradox

I want to seek help more than anything. I really do. I want to get better. I just know if I try, I will have to give up on aviation, and frankly, I'd rather not be here than to do that. So here I am.

Those were the words that John Hauser left for his mother, Anne Suh, and his father, Alan Hauser, before he drove a Piper Archer TX into the ground near Buxton, North Dakota, on Oct. 18, 2021, and died by suicide. He was 19 at the time and a student at the University of North Dakota John D. Odegard School of Aerospace Sciences.

John's parents, both medical doctors, had appeared before a National Transportation Safety Board (NTSB) Navigating Mental Health in Aviation Summit in December to share their story. “Our goal is to give a voice to the voiceless those who are silently struggling,” Suh told the summit audience and participants.

Suh said her son was among those silently struggling. He was a young man who always had a passion for all things that moved—cars, trains, and aircraft. But by 11, it was aviation that drew him in, possibly because he lived within the flight path to Chicago O’Hare International Airport, she supposed. By the time he had turned 18, he had earned his private pilot’s license, a $10,000 cost that he worked numerous jobs to cover. “He was very proud of this accomplishment. He worked so hard for it, and he paid for it himself,” Suh recalled.

In late summer of 2020, Hauser began his freshman year at UND on a presidential scholarship to study commercial aviation. “At school, he flew whenever he had the chance. He was doing well in his classes. He was passing his check rides,” she said.

In the spring of his freshmen year, he shared an online petition to support pilot mental health. His family all agreed to sign it, but they were unaware of his accompanying struggles. The family didn’t see him much the summer before his sophomore year. He remained at UND to continue flight classes, but they did have a vacation together. “We were really grateful for the time we had,” Suh said, describing the time with a clear, but pained voice.

On Oct. 18, 2021, John Hauser texted his parents that he was going to practice takeoffs and landings; this was typical. The next communication was not. About 40 minutes later they received another text that essentially was saying goodbye. His girlfriend had received a similar text. Panic set in, and about 90 minutes later—after desperately trying to track him down—his aircraft was found.

“John did not have a known history of depression nor any mental health conditions,” Suh said. “We did not know he was suffering from feelings of emptiness and sadness prior to his death.”

But Suh and Alan Hauser would learn that he was not alone. She pointed to a 2016 University of Harvard study of nearly 2,000 pilots, which found that 13 percent met the criteria for clinical depression and 4 percent had suicidal thoughts.

Suh also shared more of her son’s final words that he wrote to his parents: “If there's anything you can do for me, get the FAA to change the rules on pilots seeking help with their mental health. I know it would change a lot of things for the better and would help a lot of people.”

In the time since, John Hauser’s family has worked to raise visibility on mental health in aviation, including establishing a fund at UND to provide support and education and joining a nonprofit, the Pilot Mental Health Campaign, among many other efforts.

She further recalled that, not long after her son’s death, Alan Hauser attended a mental health and aviation summit in Chicago in which the FAA administrator at the time had expressed concern about addressing the perceived barriers pilots have surrounding seeking help. 

“With all due respect,” Suh told attendees of the more recent NTSB summit, “I do not think we would all be gathered here today if these barriers were merely a perception.”

The Long and Costly Process

Reinforcing that message were others on the NTSB summit panel sharing their journeys of attempting to obtain special issuance medicals as they addressed mental health issues.

Troy Merritt, a first officer for United Airlines, said he’s “become very familiar with the challenges that pilots face in managing their mental health.” A year earlier, he decided to ground himself and seek treatment for depression and anxiety after alternative actions, such as meditation, did not help.

“For many, including myself, the choice to use an antidepressant can be a very difficult one. It was especially difficult because I knew what was ahead of me; I faced months to years out of work navigating the complicated certification process to get my medical back and the possibility of being told I could never fly again.” This only worsened his anxiety and depression, he continued.

Merritt notified his chief pilot’s office and union and found an FAA-trained psychiatrist for treatment to ensure that he would use an agency-approved antidepressant and would have detailed clinical notes on hand to satisfy requirements. The treatment worked, and within three months of using the mediation, “I’d become a new person…I knew I made the right decision.”

About seven months later, he began working to get his medical back. This has included extensive computer testing of his neuropsychological abilities and a lengthy personality assessment. Then, there was a two-hour assessment with an FAA-trained psychiatrist who had to furnish a detailed report and recommendation to the FAA. The process further involved the services of an aviation medical examiner (AME) to prepare the paperwork and further evaluation.

This was completed by September 2023 at a cost of $8,000 out of pocket.

In addition, while he waits, Merritt needs regular continued evaluations. “I am now waiting for the review of my application for a special issuance medical from the FAA,” he said in December, adding that he was told this process could take six months to a year.

He noted that he is fortunate because his union has an excellent disability insurance plan that covers medical leave for mental health care.

“I am…optimistic that I will fly again,” Merritt said, “and I'm confident that when I do return to work, I will be a happier, healthier, and better pilot than I was before.”

But, he further said, “Had the barriers that are in place today not been there, I know I would have sought treatment earlier. I was terrified of navigating a mental health diagnosis as a pilot and while the process is certainly thorough, for pilots it is also a time-consuming, onerous, and expensive one that many avoid.”

The process has been even more complicated for Stephanie Day, a flight attendant with Horizon Air and employee assistance program representative with the Association of Flight Attendants. Day had been hoping to transition into the flight deck and began flight training in 2015 but was denied a medical certificate because of past mental health and substance use issues. Sober since September 2016 and medication-free, Day submitted a medical certification request in January 2020. She was denied. And then denied again in 2021. She restarted the process in March 2022.

In the interim, Day worked towards a bachelor’s degree in aeronautical science with her capstone on the human intervention motivation study (HIMS) special issuance medical certification process. “I believe the current FAA special issuance medical certification process inadequately addresses mental health,” she said.

Pointing to the incident last October of Horizon Air Flight 2059—in which an off-duty pilot, Joe Emerson, had attempted to deploy the engine fire suppression system while allegedly on psychedelics—she conceded that it “hit home on many levels. We are all here because Joe Emerson was allegedly self-medicating his mental health. He's an example of the unintended consequences of the current mental health special issuance process. I am hopeful positive change will come as a result of this tragedy.”

Day noted that she is seven years in recovery from alcoholism and is in recovery from depression, anxiety, and post-traumatic stress syndrome. She also was incorrectly diagnosed with bipolar II disorder. “With that kind of history, you are never going to get a medical, right? Those were the exact words my HIMS psychiatrist said during my first evaluation, and then he said, while shaking his head, ‘Do you want to continue?’”

She did, and she moved forward with determination. “Over the past seven years, I have complied with everything FAA has asked me to do. I've gone to hundreds of recovery support meetings, met with a therapist, completed required testing...breathalyzer, hair, and nail tests,” Day said. “I completed the neuropsychological and cognitive screen testing as well as numerous HIMS psychiatrist evaluations.” 

Now, she is on her third application process and knows that many doctors don’t want her case. “They are not all created equal.” All along the way, she has spent more than $20,000 on the process.

She is submitting new information regarding the misdiagnosis, and said, “I do believe I will be successful in receiving a special issuance. However, once I submit my case, it will still nearly be a year before I receive that determination. Is it worth it? This is my journey, and it is worth it to me. It has pushed me to stop taking medications, quit drinking, and work the tools of recovery today. I'm healthier than ever I've been.”

Thousands of Untold Stories

“I think it's important to note that it's not just our stories, but it's thousands of untold and yet-to-be-told stories, too,” said Tim Sisk, a principal operations inspector for the FAA, who has a background as an A&P mechanic and flight instructor for helicopters and fixed-wing aircraft.

On March 1, 2022, after being a pilot for nearly three decades, Sisk received a deferral following a routine medical exam. That deferral turned into a denial over his use of a psychoactive prescription medication.

“This medication was nothing extraordinary. It has been in the market and FDA-approved for 40 years,” he said. “It’s very safe with very few side effects but yet disqualifying. It's now been 21 months, and…I've spent over $10,000 on specialists, repeat tests and assessments, and legal assistance. I've submitted 297 pages of medical records.”

But despite this transparency, the FAA asks for more and more records, Sisk said. This includes his Veterans Affairs records. “The problem with that is that I'm not a veteran, and if the FAA had looked at those 297 pages, they might know that.”

Five weeks after his latest submission, he was informed that a checklist was missing. “Thankfully I've been able to retain my job as an aviation safety inspector, and I have the support of the people within my agency and organization. If I was a line pilot out there doing Part 91, Part 135, and Part 121 work, I don't know how I would cover not only the additional expenses that this process has brought on but how would I take care of my family.”

This is an issue that affects millions of Americans, he continued, and not just in aviation. “I want to talk about the risk that we're facing here, the hazard that we're facing, in the national airspace system,” Sisk warned. “It’s not about the people who recognize and treat their mental health—they are not the risk. They are, in fact, probably in a better place for it. It's those who are afraid, and quite understandably, to get help because they've heard stories like ours.”

Laila Stein, a recent graduate of Western Michigan University’s College of Aviation, CFI at Jeff Air Pilot Services, and adjunct professor at Ivy Tech Community College, said she was hit hard by the news of John Hauser. “My heart was instantly ripped out of my chest. John and I lived parallel lives. He could have been me. I could have been him…He had the same drive to be a pilot and love of the sky as every other aviation student I knew.”

Stein provided insight into the problem from the standpoint of university students. She began her first year at Western Michigan in the fall of 2019. “Yes, I'm one of that unlucky cohort whose college experience was derailed by the pandemic.” As a community learning assistant in the aviation house mentoring hundreds of freshmen pursuing aviation careers, Stein said, “I saw firsthand when the unprecedented mental health crisis swept our campus that year. Our lives were completely upended, and we all struggled.”

Therapists were booked completely nationwide, overwhelmed by the demand. Confusion reigned over how mental health affected aviation medicals, she said, with stories circulating such as that even an attention-deficit/hyperactivity disorder (ADHD) diagnosis in the third grade means disqualification. Nobody knew what was the truth.

“Meanwhile, I watched more than one of my classmates self-medicate with alcohol because they could not afford to stop school and deal with a deferred medical issue due to asking for help,” Stein said.

As a result, she joined a group of students to host two town halls on mental health access and policies. “Both town halls yielded unbelievable interest and engagement and a million more questions. But the professionals didn't have good answers. They said there was no clear directive on what was or wasn't allowed and that anything would have to be deferred to the dreaded Oklahoma City.”

A symposium held later did little to provide more clarity. But after learning of John Hauser’s crash, “I knew,” she said, “that shining a spotlight on this issue is life or death for so many pilots.”

She devoted her honors thesis to the issue, studying aviation students’ perceptions of the FAA’s rules governing mental health. Some 75 percent of students surveyed deemed the FAA‘s rules on getting mental health help while keeping a medical as either restrictive or very restrictive, and more than half said they would not believe someone—even if they trusted that person—who told them that they could see a mental health professional and keep their medical. And nearly half said the rules negatively affected their desire to seek professional assistance.

While some may argue that these numbers are narrowly focused on college students, Stein said, “Need I remind you that these are the people who are going to be flying five, 10, and 20 years from now. We were being forced to choose between doing what we love…and our own health. I would rather have someone next to me in the flight deck who's getting mental health support than someone who has felt forced to hide it or not seek it in the first place.”

The Statistics

These were among the many stories shared with the NTSB when word of the summit began circulating, said chair Jennifer Homendy. Numerous people reached out offering to tell the stories.

Emanuel Robinson, director of the board on human-systems integration at the National Academies of Sciences, Engineering, and Medicine, gave a snapshot of how pervasive the mental health crisis has become. Citing the Substance Abuse and Mental Health Services Administration, Robinson noted that the prevalence of mental health illness has risen steadily over nearly a decade from 18 percent of the population in 2015 to 23 percent in 2021. “That’s 18 million more people and more than 50 million total,” he noted.

While not surprising against the backdrop of the pandemic, he added, “This is something that's affecting almost everyone's life.”

Robinson also pointed to a recently released report from the American Psychological Association, which found that one-third of adults feel stressed no matter what they do to manage it, and 62 percent do not want to burden others by discussing those feelings. Further, 52 percent wish they had someone they could turn to for support.

While this is a general study affecting everybody, “You can imagine [the impact on] folks who are on the front lines, and especially on pilots and others in the aviation sector.”

Homendy recited a litany of external pressures that could affect mental health: from racism, sexual harassment or assault, and microaggressions to the death of loved ones, violence, financial stress, and marital trouble or divorce.

“Odds are you've faced more than one in any given year. About one in five U.S. adults has a diagnosable medical mental health condition [and] more than half of us will over the course of our lifetime,” she said. “The vast majority are not severe, but the stigma around mental wellness is real. It can make asking for help hard. It can take real strength.”

This is why less than half of people with diagnosable mental health conditions receive treatment. “There are already so many obstacles between needing help and getting it,” Homendy continued, “[that] no one should have to think twice about their job before seeking help. And yet here we are today because that's not currently the case in aviation. It's somewhat of an open secret that current rules incentivize people to either lie about their medical history when it comes to mental health or avoid seeking help in the first place.

“Let me be clear,” she said, “the safety risk comes from a culture of silence around mental health. A culture that empowers people to get the care they deserve to be healthy in mind and in body…will strengthen safety.”

According to the FAA, only 0.1 percent of medical certificate applicants are denied (for any health issue), she noted, but added, “Those who do report the use of medication are sidelined for no less than six months. Those who seek professional counseling can be caught in the frustrating maze of federal bureaucracy to get back to work. It's an unacceptably long wait.”

She further said that people cannot underestimate the toll on the aviation system.

The FAA

The FAA has been increasingly focusing on the issue, and Homendy said she has been encouraged by interactions she’s had with Administrator Michael Whitaker on the issue. The Federal Air Surgeon Susan Northrup has acknowledged the problem and is taking steps to address it.

“There's this belief in the pilot community that once you've been diagnosed with a mental health condition that you will never fly again and that the process for getting back to flying is expensive, onerous, and takes forever. So, there's this real resistance to even talking about mental health and accepting that somebody might need help,” she said during a podcast on mental health.

As a result of all of this, misinformation prevails. “So, we have to figure out how to get the message to the individuals in such a way that…that they act on obtaining the help that they need.”

But more than just educating, the FAA is also increasing its staff to handle mental health issues. Until just three to four years ago, the agency only had a single chief psychiatrist to work on these cases. “That was it,” she said, adding that the tough cases would go to the psychiatrist, and “it might take a minute.”

Since then, the FAA has added two PhD psychologists, a neuropsychologist, and three psychiatrists in the FAA’s behavioral sciences division. The agency also has broadened the number of consultants that it works with on mental health issues.

Additionally, the FAA is reviewing its procedures and approaches to testing, as well as acceptable medications, she said. “I have tasked my staff to look at in the next couple of years what's the best combination of neuropsychiatric testing,” she cited as an example. She pointed to ADD and ADHD and noted “We're beginning to see a body of science that says for the young kids that get this diagnosis, many of them truly grow out of it. But what do we need to do? Teasing those out is one of the things we hope to do in the coming years so that we're limiting the expense [and] at the same time, we're ensuring safety.”

She noted that medications continue to evolve and the staff needs to continue to evaluate them. “We're actively looking at the newer medications…and I've charged my folks to take a good look at [if] we could add to the list of medications and get the broader spectrum of interventions.”

In all, the goal is to improve the policies to make them more transparent.

In addition, following up on a recommendation of the Department of Transportation Office of Inspector General (OIG), the FAA has established a Mental Health and Aviation Medical Clearances Rulemaking Committee (ARC) tasked with providing recommendations on breaking down any remaining barriers to discourage pilots and air traffic controllers from seeking mental health care.

The OIG conducted a study of the FAA’s approach to mental health at the behest of Congress following the March 24, 2015, Germanwings Flight 9525 crash that was attributed to the deliberate actions of a copilot who suffered from severe depression. All 150 aboard perished.

The watchdog found that the FAA was comprehensive in its approach to evaluating mental health but barriers existed: namely, the willingness of pilots to come forward with their mental health issues.

As for the ARC, the agency initially created a tight timeline, with recommendations due by the end of this month, but also established a two-year charter for the body.

The ARC essentially has five major areas of focus: factors that prevent pilots and controllers from reporting mental health issues; how the FAA should address a mental health diagnosis; steps the FAA can take to mitigate aviation safety issues during the time between disclosure of a mental health diagnosis and subsequent issuance of an aeromedical decision; how other civil aviation authorities address pilot/controller mental health issues; and development of mental health education programs.

Penny Giovanetti, director of the medical specialties division for the FAA—who also participated in the NTSB forum—reiterated that the agency is working to dispel myths about seeking help. “We have a huge task in front of us,” she said.

Giovanetti stressed that pilots who demonstrate successful treatment will get their medical back. Pointing to the FAA’s examination of its list of acceptable medications, she said the agency has already begun addressing low-risk conditions.

Further, the FAA has issued three guides to AMEs with information on what she called “low-risk” situations. As part of that, the agency expanded what the AMEs could approve without needing to get another level of review with the agency, including certain cases involving ADHD and situational depression.

But Giovanetti also acknowledged the “elephant in the room,” which is the lengthy time it takes for special issuance, and noted that cases have significantly jumped since the pandemic. The FAA is adding staffing but needs to do more, she conceded.

The AME Prism

As for the problems surrounding working with the FAA, NTSB member Bruce Landsberg noted a lack of clarity around acceptable medications, the special issuance process, and the data in determining the approach to mental health issues.

“We need to be very transparent now about what the medical requirements are and the evaluation process and that needs to be shared in total with the AMEs,” Landsberg said. “I think we need to train and empower your AMEs because you're never going get enough money out of the government to sufficiently staff for this. That's the only way we're going to get the timelines down to anything reasonable.”

Landsberg also stressed the need for a collaborative, non-punitive process for people to self-report.

Brent Blue, who has been a senior AME for more than 40 years and is a medical consultant to the Aircraft Owners and Pilots Association, agreed that the FAA should rely more on the AME system.

“Everyone's interested in safety but when arduous and ineffective requirements discourage pilots from disclosing or seeking mental health treatment, those requirements are harmful and actually a threat to aviation safety,” Blue said, “and the lack of trust by the FAA medical division in its AMEs and the pilot's local medical and psychological providers is one of the cruxes of the problem.”

Blue, who is HIMS certified, called the evaluation system broken and disagreed that stigma is a deterrent for pilots to seek help. It’s the fear of losing or not being able to obtain flying privileges.

And, he further stressed—and drawing applause from the audience—“We keep talking or we keep hearing about this 0.1 percent that is denied, but that 0.1 percent does not include the people who give up in the middle of the process or the people who never start the process at all. That’s a significant number of people.”

He reviewed many of the processes for a mental health special issuance and noted that finding an approved psychiatrist along with an approved neuropsychologist is difficult since both are scarce. Further, he called the interactive computer test that applicants must take unproven and biased against older pilots “and pilots who don't play computer games.”

Then there’s the time. “My absolute record: I just got somebody certified. It took him six years. Many of these criteria for passing the examinations are based on Freudian theories that have been replaced by modern brain chemistry.”

Once granted, pilots still have to go through an expensive and time-consuming reevaluation of “dubious value” from a safety standpoint.

“Trust is key, and what I mean by that is trust in the AMEs. The FAA does not trust their AMEs,” he contended, but he added that the medical accident rates show that AMEs are doing their jobs.

This trust takes its toll. Many AMEs are hesitant to furnish approvals, noted Quay Snyder, president and CEO of Virtual Flight Surgeons, which provides medical certification and aviation safety guidance for pilot and air traffic controller unions as well as business and general aviation pilots. “We still have AMEs who are reluctant to work with a pilot or to issue a certificate even if the condition is resolved,” Snyder said, and he called for additional AME education. 

Exacerbating all of this is the lack of aviation-savvy mental health professionals, he added, suggesting finding ways to encourage more to go into that discipline. Snyder also strongly promoted the effectiveness of peer counseling. While some airlines have adopted such an approach, more needs to be done. And more needs to be available to business and general aviation, he added, noting that NBAA is among those exploring that path.

Ultimately, the time of review needs to be shortened, he said. However, Snyder was also encouraged by the attention the FAA is giving to it.

As for the FAA, Giovanetti told attendees that she had taken four pages of notes from the day-long NTSB summit to contemplate going forward. “It's clear; everybody's been very open and honest,” Giovanetti said of the participants.

Then, she recalled a note she received thanking her for her help in getting a pilot back in the cockpit and said, “I won't be happy until everybody who has an interaction with us over these issues feels the same way about it.”

Editor's note:  From the FAA, "The National Suicide Prevention Lifeline has changed to an easy-to-remember three-digit number. If you or someone you know needs support now, call or text 988 or chat 988Lifeline.org. 988 connects you with a trained crisis counselor who can help."