The crash last week of the Germanwings plane has shocked many. In view of the apparent mental health record of the co-pilot Andreas Lubitz, questions have been asked about the screening policies of airlines. The focus has generally been on the conditions pilots may have or the arguments they might be having with partners or other situational factors that might make them unstable.
Even when the issue of the medication a pilot may be taking is raised, as an article by Erica Goode in the New York Times makes clear, it is in the context of policies that permit pilots to continue on drugs like antidepressants to ensure any underlying conditions are effectively treated.
Clearly if a drug is effective in clearing up an underlying condition, its use should make the pilot – or driver of a coach carrying 50 or more passengers – safer. But fewer treatments in medicine are effective in this sense than people might think and even when effective they come with effects that need to be balanced against the likely effects of the underlying condition.
Doxycyline, for instance, a widely used medicine for acne and for malaria prophylaxis, can be very effective for acne. But doxycycline can also make someone depressed, suicidal and homicidal, while acne doesn’t do this.
Other antibiotics like Levaquin and Cipro can cause a range of serious and enduring problems including psychosis but are ordinarily given for problems that are unlikely to compromise a pilot’s ability to fly and keep her passengers safe.
So what about depression? The risks of suicide or homicide from mild to moderate depression or anxiety are almost nil. Think of it this way – what we call depression today in nine cases out of ten was called anxiety 30 years ago before the development of the SSRIs and anxiety was not thought of as a significant risk factor for suicide or homicide.
Difficulties with a partner or at work can lead to precipitate action including suicide or homicide. They can also lead to anxiety or depression but the anxiety or depression linked to these events don’t for the most part cause problems except in so far as sleeplessness on the one side or a sedative drug on the other might cause an accident.
Whatever the risks of suicide or homicide linked to such anxiety or depressive states might be, in clinical trials antidepressants close to double them – and not just in younger adults. They do so by causing psychosis, or by producing an agitation laced with suicidal or homicidal thoughts, or by producing an almost lobotomized state in which people will do things they would ordinarily never do, or by increasing blood alcohol levels if the person has had a drink.
GSK data suggest these drugs appear to make someone more likely rather than less likely to “act out” if they have just had a partner break up with them. See Kraus – Clinical features of patients with treatment-emergent suicidal behavior following Paroxetine.
All of this has been relatively well known for decades. We could have made things much safer by discussing the changes treatment can trigger openly much earlier and permitting patients and doctors to identify problems and find solutions – such as switching to a drug of a different class. Doctors and patients have been left flying by the seat of their pants.
There are likely to be a number of features to the current debate.
First an impression will be created that we know more about these drugs than we in fact do.
We know almost nothing about what antidepressants actually do – we still don’t know what they do to serotonin.
Rather than being effective like an antibiotic, these drugs have effects – as alcohol does. Their primary effect is to emotionally numb. Patients on them walk a tightrope as to whether this emotional effect is going to be beneficial or disastrous.
We know even less about other drugs Lubitz might have been on such as mood-stabilizers. These too can produce suicidality and homicidality but they have a different signature to that of antidepressants. The trouble is that, unlike the case of the SSRIs, no doctor giving any patient a mood-stabilizer can tell them what to watch out for or what the timeframe of problems is likely to be.
Second there are a lot of powerful interests at stake.
Some of these will think nothing of playing the personality card in the case of Lubitz to create the impression this was all about his instability rather than an instability in him created by treatment.
Third these powerful interests employ the best public relations on the planet.
These companies will in a variety of ways play the card that anyone suggesting treatment may have been part of what went wrong are just conspiracy theorists.
Fourth efforts to manage the problem will be portrayed as effective.
We will hear that the Federal Aviation Authority in the US only permits pilots to fly on a selected number of antidepressants when they have been stable on treatment for six months. Sounds good. But no mention of the problems that happen on withdrawal – which are as great as those that happen on starting. See Antidepressant Withdrawal: A Prozac Story – on RxISK. Prozac is one of the selected antidepressants.
Once treated with a drug, a pilot is never the same again. Even if the underlying condition clears, he may not be able to stop. The risks are not eliminated. The only way to manage these risks is to have a close relationship between the pilot and her doctor in which the doctor is fully informed as to what the risks are – a doctor who acts like a pilot in the sense that she doesn’t take risks that will bring her down along with her pilot–patient.
Let them Burn
In lectures for several years – see Professional Suicide — I have compared the roles of doctors and pilots saying that we are all safer flying than we are in the hands of our doctors because the pilot knows if the system isn’t safe and you die, she will also, whereas doctors can always and routinely do blame your condition or your circumstances.
This idea has now crashed into Andreas Lubitz and his doctors. We are all wondering about Lubitz and what motivated him. What about the doctors who may have unintentionally primed him?
At the moment it is difficult to see Lubitz as a victim but he may be. His doctors may also be victims. They may have joined a string of doctors who agonize over horrific events they are party to.
Treatment may not have precipitated what happened in this case but there are many people in the pharmaceutical industry who have known for a long time that something like this can happen on their medication and they have done nothing to put in place systems to manage these risks or to dismantle the system that gives rise to risks like this at a much greater rate than we should have to tolerate.
That corporations might do this is not a conspiracy theory. In the famous Ford Pinto case, a Ford executive made aware of risks that their car would lead to a regular number of drivers and passengers being incinerated each year – a problem that could have been inexpensively put right – famously wrote
The powers that be have been winging it for decades.