Mania

Pilot Suicide: A Likely Scenario

Not simple, but explainable, by putting aside biases against manic-depression

Posted Mar 31, 2015

Suicide doesn't lend itself to sound bites. The wisest comment about it comes from a classic article by the psychiatrist Leston Havens:

"Suicide is the final common pathway of diverse circumstances, of an interdependent network rather than an isolated cause, a knot of circumstances tightening around a single time and place, with the result, sign, symptom, trait, or act."

There is no single reason for the recent German airplane tragedy; but there is an interconnection of causes where key factors can be identified, and their interplay leading to a fatal outcome explained. 

It's not simple, but it is understandable, if we are willing to put aside some biases. 

There are many theories out there about why a pilot would commit suicide, including the theory that we just can’t predict it. This is the status quo view: psychiatrists and psychologists cannot know, at any one time, which individual will commit suicide tomorrow. This is true. But it misses the point that we know major risk factors for suicide, and we can predict which groups of persons will be more likely than others to commit suicide.

In the case of the recent airplane tragedy, I would like to suggest one likely scenario that is almost completely ignored in public discussions. Here are some facts of the case: the pilot had past severe depression; he was 27 years old; he took antidepressants; he loved to fly; he engaged in other high-energy activities like marathon running; he had an active sexual life; he was sociable and had friends.

Many have focused on his depression; they assume he just had “depression”, or the DSM phrase “major depressive disorder”, and for some reason he was more depressed, hence his suicide. Others point to the antidepressants, seen as nefariously harmful, and suggest the drugs had evil effects. What both groups miss is the overall picture:

Depression in a young man in his early 20s is not “depression” or “major depressive disorder” (MDD).  The whole concept of MDD was that it began around age 30, not a decade earlier, in contrast to bipolar illness which began around age 20. In one study, about one-half of young adults with severe depression (but on manic or hypomanic episodes) in their early 20s, when followed for 15 years, eventually develop manic or hypomanic episodes. In other words, if these data are correct, about one-half of young depressed adults have bipolar illness. That’s not a small probability.

DSM ignores mild manic symptoms, because of a cultural ideology that is opposed to diagnosing bipolar illness, as made clear in some debates on this website between me and the leader of DSM-IV. In the process, one can have manic symptoms for one, two, or three days, and DSM (including the 5th revision) still fools clinicians into requiring the diagnosis of “MDD”, not hypomanic episodes (which would change the diagnosis to bipolar illness type II).  

Mild mood symptoms can exist as part of a person’s temperament or personality; this is accepted for mild depression, called dysthymia. But it is rejected by DSM for mild manic symptoms, called “hyperthymia.” Mild mood swings back and forth all the time between depressive and manic symptoms is included in DSM as “cyclothymia”.  These mood temperaments were always seen by psychiatric researchers as mild manifestations of depression and mania, which occurred as part of person’s personality, in between mood episodes.

If someone has hyperthymia or cyclothymia, such that they have mild manic symptoms as part of their personality, those mild manic symptoms can manifest in being highly sociable, very active (like running marathons), having high sexual drive, and being highly curious, thrill-seeking, and even risk-taking—like flying airplanes. 

It is possible that the pilot had hyperthymic or cyclothymic temperament, as his baseline personality, and also had recurrent depressive episodes beginning around age 20, as happens in bipolar illness. (It’s also possible he even had clear hypomanic or manic episodes, which are missed and misdiagnosed as MDD in about one-half of persons who experience them. For this discussion, we'll assume that such misdiagnosis did not happen to make the point that manic mood temperaments are ignored in current psychiatric practice.)  In our research in people with bipolar illness, about one-half had mood temperaments in between mood episodes, most commonly cyclothymic temperament.  These mood temperaments are common in persons with depressive or bipolar illness.

The last set of facts:  There are data that antidepressants are ineffective for depression in persons with bipolar illness type I or type II, and less effective in persons with these other features of bipolar illness (like early age of onset of depression and cyclothymic temperament).  The presence of cyclothymia also increases the odds of antidepressants causing mania multiple-fold. Often these antidepressant induced manic states are mixed with the current depressive episode so that the result is a “mixed episode” where both manic and depressive symptoms occur together.

Mixed episodes are known to be the most likely mood state to lead to suicidality.  A person is depressed and despairing and energetic and impulsive at the same time. It is a lethal mix of symptoms.

If the facts of the case turn out to be that this person had mild manic symptoms as part of his personality, with recurrent depressive episodes, it is possible that antidepressants either were simply ineffective, and despite seeking help, the pilot's depression worsened; or the antidepresssants caused a mixed mood state.  In either case, suicidal thinking would have worsened.

If this was the case, a medical solution could have been lithium, even perhaps in low dose, which is the only medication proven repeatedly in 48 randomized clinical trials to prevent completed suicide. 

There are a few major obstacles to that simple solution:

One is the DSM system, which is only partly based on science and is very strongly influenced by cultural, professional, and social wishes on the part of the leadership of the American psychiatric profession.  Since mild manic symptoms are legislated away, clinicians are unable to make the judgments I describe above in terms of assessing suicidal risk and treating it adequately.

Another is our cultural and social antipathy to psychiatry in general, to mental illnesses, and in particular to manic-depressive illness.  The discrimination and bias in our society against psychiatric conditions is especially harsh in relation to bipolar illness.  Even psychiatric leaders, like the head of DSM-IV, are explicitly discriminatory against this diagnosis. One often hears psychiatrists making anti-bipolar statements, as if this diagnosis is somehow morally worse than others.  If we don’t become honest in how we deal with mood conditions, and become more objective and fair about accept manic symptoms as well depressive conditions, we won’t be able to clinically and scientifically manage these conditions well.

The FAA requires that persons with bipolar illness be denied in medical examination for aviation safety.  But if DSM limits the diagnosis of manic symptoms to such an extent that  almost one-half of persons with so-called MDD have multiple manic symptoms—and DSM leaders refuse to allow us to diagnose them with bipolar illness of any variety—where does this leave the medical community in assessing risk of mood illness in airline pilots?

As this tragedy shows, these debates are not limited to professional turf wars.  They have major social consequences, and innocent people are involved. 

Finally—and most importantly from a public policy perspective—it is obvious that a systematic approach to psychiatric evaluation of pilots is needed, early in their career development, such that persons with mood illnesses are identified and interventions made, whether through more medical oversight or through directing such persons to career activities that do not involve responsibility for the lives of hundreds of civilians.