The other day, I wrapped up the second season of Nathan Fielder’s show "The Rehearsal.” The season highlighted aviation safety, tackling the subject in ways both sincere and absurd. In his casual investigation of prior aviation accidents, Fielder concludes that cockpit communication was a key factor in many preventable crashes. First officers, he argues, were often hesitant to overrule the actions of the captain. Amid heavy doses of satire and theatrics, the series explores the ways in which pilots tend to avoid expressions of emotions and reinforce a culture that eschews vulnerability.
As a psychiatrist, I was struck by the series and began exploring the rules for pilots reporting mental health diagnoses in more detail than I ever had before. Pilots are legally required to disclose any mental health diagnosis on their recurring medical certifications. And if they list a current condition such as major depressive disorder and begin treatment with an antidepressant, they embark on a particularly stressful odyssey. Pilots are grounded from flying until they have been clinically stable for a minimum of three months on an unchanged dose of a Federal Aviation Administration (FAA)-approved medication. During the process, they must be evaluated by a specially-trained aviation medical examiner, submit a supporting psychiatric report, and, at least for initial certification, complete proprietary computerized cognitive testing, which costs up to $2,500 out of pocket. Aviation evaluations are also considered occupational, so health insurance does not cover them. The FAA has tried to streamline elements of the review, but the whole process can take several months and often stretches well beyond a year. As a physician, I find it hard to fathom a medical review sidelining me or one of my colleagues for over a year.
Given such a daunting process, one can understand how many pilots avoid discussing their mental health altogether. In a 2022 survey of 3,765 U.S. pilots, 56% reported at least one healthcare avoidance behavior driven by a fear of losing their flight clearance. In the study, 46% had sought informal care outside the medical system, and 27% admitted to misrepresenting or withholding information on a health questionnaire. Less formally, in a pilot community on the website Reddit, under a topic entitled “Curious about how pilots handle mental health treatment,” the most upvoted response was: "No pilot has ever needed mental help for anything, ever. All pilots are in perfect physical, emotional, and mental health. That's the story and I'm sticking to it." Snarky for sure, but the sentiment hints at a world of self-stigma that many pilots inhabit. It is a space that becomes visible only when the stakes are removed: in an earlier anonymous survey of airline pilots, 12.6% met criteria for likely depression and 4.1% reported suicidal thoughts within the previous two weeks, a burden that rarely surfaces when flight clearance is on the line.
Reading through the regulations for grounded pilots to resume flying, I was surprised by how much of the guidance runs against clinical practice. For starters, only nine antidepressant medications are currently approved for use by pilots. The list consisted of just four SSRIs from 2010 until 2023, when the FAA began adding to the list piecemeal. Mirtazapine, a medication often effective for depression, is not allowed due to its sedative properties, though that sedation is more prominent at lower doses and certainly not present in all patients at higher antidepressant doses. Last year, a federal appeals court agreed that the FAA's reasoning on mirtazapine was shaky. In Solondz v. FAA, the D.C. Circuit found the agency had acted in an "arbitrary and capricious" manner by denying a special issuance to an airline pilot solely because mirtazapine was not on the approved list. The pilot had been medically cleared to fly airliners for nearly two decades and had been tolerating the drug well.
Given the uniquely high-risk nature of aviation, there is indeed a need for clear standards for prescribing and mental health monitoring among pilots in general. However, the current rules go well beyond those applied to other high-stakes fields. No state medical board maintains a formulary of permissible antidepressants for surgeons, for example. The onerous rules raise the question, how many pilots forgo care altogether in order to preserve their livelihood? In 2023, the scale of concealment became public, after a Washington Post investigation revealed that the FAA had examined roughly 4,800 pilots, nearly all veterans, and found they had received VA disability benefits for conditions, including mental health disorders, that they had never disclosed on their medical applications. About 60 pilots were ordered to stop flying immediately. Most striking of all: some pilots reported that FAA-contracted physicians had themselves advised nondisclosure.
To its credit, the FAA has begun to recognize that its current approach is failing. In April 2024, the agency's own Mental Health and Aviation Medical Clearances Aviation Rulemaking Committee concluded that the current system pushes pilots to stay quiet — and that silence is itself a danger. The committee convened after an off-duty pilot attempted to shut down a jet's engines mid-flight during what he later described as a psychiatric crisis, days after taking psilocybin. Its initial recommendations included allowing pilots to pursue psychotherapy without any requirement of disclosure, shortening the waiting period after starting an antidepressant from six months to two, reducing the use of neurocognitive testing, and creating a non-punitive pathway for pilots to disclose previously unreported diagnoses and treatment. That pathway would be an amnesty of sorts, modeled on confidential reporting systems the FAA already uses for operational errors.
The FAA's response so far has been selective. It expanded the medication list, and in late 2025 it reduced the required stabilization period to three months, rather than the two its own committee recommended. The harder structural reforms remain on the shelf. Therapy for a mental health condition is still a reportable event, and the pilot who concealed a depression diagnosis five years ago still has no safe way to come forward, since disclosure remains an admission of federal falsification.
There is a natural tension between the protocolized guidelines of a risk-averse organization like the FAA and the subjective, nuanced realities of outpatient psychiatric practice. Many psychiatrists, admittedly, would be wary of clearing pilots to fly without such overhead guidance, as the responsibility for determining who is safe would rest on the psychiatrists themselves. However, I believe the guidelines must align much more closely with how we actually treat our patients. Current rules require pilots to remain on monotherapy at a consistent dose, in maintained remission, for three months before they can fly again. But we have known since the STAR*D study that only about a third of patients with major depressive disorder remit on their first monotherapy trial. Augmentation and combination strategies are now guideline-supported standard of care, not rare exceptions. Under FAA rules, a history of treatment with multiple concurrent antidepressants can itself be disqualifying. The protocol thus penalizes pilots for having received care consistent with standard psychiatric care. And the stakes compound the pressure: a pilot who doesn't respond to a first- or second-line medication may lose their livelihood entirely.
Countertherapeutically, the quickest path back to the cockpit is to stop medication entirely. A pilot who has been off antidepressants for 60 days, with a favorable physician's report, can bypass the special issuance process outlined above altogether. This is precisely the opposite of what we would counsel for patients with recurrent depression.
So what would a solution look like? Part of the answer belongs to the FAA, which, as the Solondz ruling suggests, should judge pilots one at a time rather than banning drugs wholesale. That means weighing a pilot's actual course and functioning rather than relying on a checklist of approved drugs and fixed timelines. But physicians don't merely have to wait for the FAA. We should ask about our patients' occupation before choosing an antidepressant the way we ask about pregnancy, and we should educate ourselves on what goes into safe certification for pilots. Few of us have heard of the FAA's antidepressant protocol, and a well-meaning prescriber can ground a patient for a year with a single reasonable choice, such as starting mirtazapine. And the more doctors chime in, the more likely the FAA is to recognize that many pilots get their care from ordinary clinicians, not just from aviation specialists. Likewise, the more that pilots themselves can open up about their mental health, the more robustly they can advocate for things like safer shift practices and ample recovery time between flights.
Over the past several decades, psychiatry has worked to listen more closely to patients and to reckon with our own blinkered, paternalistic past. Mental health for pilots should be no different. While the responsibilities and the pressures that pilots face may be exceptional, their lives outside of work are just as complicated as the rest of ours, and they should feel as comfortable receiving help as anyone else.
