Mental Health Screening Wouldn't Have Saved Germanwings 9525

Routine screening can't pick up hidden pathology.

Posted Mar 30, 2015

// via Wikimedia Commons
Source: Juergen Lehle ( via Wikimedia Commons

Given the recent horrifying Germanwings tragedy, people have understandably asked what can be done to prevent other rogue pilots from committing senseless acts. There are different safety angles, such as cockpit access and staffing issues, and of course, mental health screening for the important role of commercial pilot, someone who is responsible for hundreds of lives daily. Similar questions have come up with regard to other areas of higher responsibility, like gun ownership, high-security jobs, and more.

Mental health screening unfortunately is an inexact science, and there is limited evidence available that correlates it with any successful prevention or outcomes. If anything, the rarity of such terrible events indicates current levels of reasonable common-sense screening might even be working, and unusual suicidal pilot cases are, by current standards, probably impossible to predict or prevent. But it might be helpful and reassuring to examine what standards do exist.

Fitness for duty standards come into play in some high-stress, high-responsibility fields like piloting, air traffic control, and also military or security duty. There are some screening criteria pre and post deployment to war zones which were instituted by the U.S. Department of Defense (DoD) in 2006 after media concerns that mentally unfit soldiers were being deployed. These include no history of psychotic or bipolar conditions, a period of stability (no acute changes in treatment or symptoms) lasting at least 3 months prior to deployment, and use of only certain types of psychotropic medications (avoiding those that require lab monitoring, that cause withdrawal when stopped, and so forth.) A study published in the American Journal of Psychiatry in April 2011 by Christopher Warner MD et al demonstrated that these screenings did reduce mental health encounters and evacuations from deployment from Iraq and overall suicidal ideation rates.

Similar and even more rigid standards are present in several other federal agencies such as FAA for pilots and NOAA commissioned corps, IRS criminal investigators, and more; the standards are publicly available online. The mental health screening standards for FAA are actually quite high, requiring submission of all pertinent medical reports and medication usage within the last 3 years, and disqualifying people even with milder forms of bipolar disorder (like cyclothymia) and strict guidelines when an airman is on antidepressant medication (can only be on one of four specific SSRI as monotherapy, with a very specific algorithm and timeline of usage and discontinuation, regular follow-up reports and screenings, etc.) Personality disorders and psychotic disorders and serious substance abuse conditions are strictly disqualified.

The dilemma with these screening standards is the same dilemma with any medical screening program: how to avoid catching “false positive” and missing “false negative” results. There is significant pushback in the general community for greater acceptance and accommodation of people with mental illness, and the Americans with Disabilities Act also protects discrimination against people with said conditions if they are able and willing to work. The vast majority of people with depression and anxiety and even many with more serious conditions are fully functional and capable, even excellent at their jobs and surround you in every field, even high pressure and high achieving ones like law, medicine, police, teaching, etc. If anything, stigma remains a huge issue in disclosing and treating and acknowledging any mental health condition, and the notion that its disclosure may cause you to lose your job, let alone open you to the judgment of your colleagues, is a valid concern.

Indeed, this stigma does prevent many people who do have worrisome symptoms or conditions from seeking help or disclosing their issues to their employers. A lot of mental health screening programs rely heavily on self-report. HIPAA and other privacy laws also protect people from having to reveal their conditions or treatment history without their permission. So many screeners may not even have access to concerning information about the people they monitor, such as past hospitalizations or the like. A mental status examination, even by an experienced clinician, will likely only pick up serious and obvious psychopathological symptoms, and not anyone who functions externally in an appropriate way. By most reports, there were no obvious or outward signs to his coworkers that Andreas Lubitz showed depression or psychosis, and he hid his ongoing treatment from his employer. He allegedly had a history of a more serious depressive episode 6 years ago; but many screening protocols only focus on more recent history as they take into account the potential for onward stability and recovery. (If it was a psychiatric hospitalization though, which usually indicates a more severe level of mental illness, that information might designate the patient’s condition as a higher-risk category that should be considered more carefully. This particular standard isn’t evident in the current FAA regulations, and again, would often be limited by self-report and privacy laws anyway.)

Overall, mental health screening is of limited utility in preventing any similar disasters to this one. We as a society continue to be baffled by those who appear perfectly ordinary to those around us but turn out to be serial killers, mass shooters, spouse abusers, drug addicts, and more. We continue to act shocked by individual hidden demons. But it is human nature to be as resilient as possible and to keep a functional face out to the world, even when one is privately suffering or privately evil. We also want to continue to protect and accept the vast majority who do push against the odds and succeed, and do the best they can even while fighting mental illnesses; these people are far more commonplace than your occasional psychopathic or desperate killer.

Screening too closely may actually have the opposite effect and dissuade someone in need from reaching out or getting help, for fear of external consequences. My suspicion is that this high-achieving young pilot got caught in a troubling gray zone, with his worsening illness kept under wraps; he may have already realized his beloved career was about to end and that he could not hide his balancing act much longer. Sadly, the pressure of the razor’s edge of fighting depression with a smiling face caused catastrophe. But why he decided to take countless others with him is something his condition alone cannot explain, and that mental health screening would not be able to detect.

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