Can’t Be Trusted: A Book Review Review

A review of my book, Can’t Be Trusted, appears in the March 2023 issue of The Journal of the American Academy of Psychiatry and the Law:  JAAPL Can’t Be Trusted book review.  I encourage everyone to read it.

My book is a memoir written around the denial of my medical certificate required to fly light aircraft for mental health reasons.

Inasmuch as I am critical of forensic psychiatry as practiced, I have been treated fairly by the AAPL and their journal.  The reviewer, Kathryn Baselice, MD, was scrupulously correct in mentioning all of the important issues and was very evenhanded.  I am not surprised by her minor objections to my writing style.

As she points out, the book can be jarring, alternating between my life in technology and mental health issues.  I have training in photonics with a PhD from MIT.  Today I design lasers for optical coherence tomography.  One audience I am trying to capture is computer nerds.  I browse the Slashdot and Hacker News websites.  Very often mental health stories are featured between the usual digital fare.  Computer professionals are very interested in mental health in my estimation.  Programming is one of my earliest interests.  I document that in my book, and it is a skill I make great use of in my work today.

Dr. Baselice points out that “Dr. Johnson claims that an expert used the second edition of the Diagnostic and Statistical Manual (DSM-II) to diagnose him with schizophrenia. The author points out that the DSM-II was outdated at the time of his evaluation, thus leading to an erroneous diagnosis.” That indeed is my claim. However, her description of this event is a little anodyne to my way of thinking.  I also claim that this is much more than a simple “error.”

I may have made a mistake by relegating the FAA material to an appendix of my book rather than covering it at length in a regular chapter.  In Appendix A I reproduce photostats of psychiatric opinions from the FAA, Yale University (the FAA’s consultant), and from my psychiatrist.

The written documentation shows that my doctor found that my psychiatric diagnosis was “296.24 (DSM_III_R) Major depression, single episode, psychotic, now in remission.” It is not a good diagnosis but a far cry from schizophrenia.  With this clear and simple statement, the FAA had enough to deny me a medical certificate.  Instead, they chose dishonesty, obfuscation, innuendo, and defamation.  My doctor was an assistant professor of psychiatry at the Washington University School of Medicine and a Fellow of the American Psychiatric Association.

The FAA’s Chief Psychiatrist disagreed with the diagnosis, saying that I had “what would in the past have been called a chronic schizophrenic condition with paranoid delusions of persecution.”  He dismissed any depressive symptoms as “mild catatonic features.”

A letter of support to the FAA written on Yale Medical School stationery by a prominent Yale psychiatrist attacked me personally and my objections that the FAA was being dishonest in its mixing and matching of conflicting DSM standards.  The Yale opinion stated that “Under the circumstances of not having complete, reliable observation of his clinical condition, I can neither confirm or refute the diagnosis of schizophrenia.”  That left schizophrenia as a “possibility” in the FAA’s eyes and in their further records and decisions.

There is no concept of a psychotic depression in pre-DSM-III standards.  In 1992, neo-Kraepelinian thought had not reached the FAA or Yale.

The cover letter from the FAA to Yale shows that only my letter of objection and the FAA’s opinion were in the materials Yale reviewed.  The FAA Chief Psychiatrist’s cover letter states, “If need be, I can make the whole file available to you.”

The complete file was not requested by Yale.  I do not know what was in the hearts of these two doctors but think about appearance:  The diagnosis of schizophrenia could not be refuted for lack of records.  The FAA did not submit them, and Yale did not request them.  Whether this was an “oversight” arranged by the two parties in advance or not, at a minimum I view not requesting the records as a lack of due diligence on Yale’s part.

I am guessing that this was personal consulting on the part of the Yale doctor and that Yale, the organization, had no financial relationship with the FAA.  Then why is this opinion written on the Yale letterhead?  I find that inappropriate in that the Yale letterhead gives this opinion undue “weight.”  Yale as an organization should prohibit this kind of abuse in the future, if only to protect itself.

The Yale doctor had a “Consultation contract with the Federal Aviation Administration for teaching, expert testimony, clinical evaluations, and policy development” [from the doctor’s CV].  I understand that consultants deserve to be paid but this is another class of reimbursement.  I think the forensic psychiatric community should have discussions regarding arrangements such as this.  When consulting fees expand into a stream of continuing income there may be a tendency to provide only the “right” answers in medical opinions.

My view is that the FAA and Yale opinions are unethical.  I leave it to the psychiatric community to form their own views.

These are my thoughts on these matters.  I know many feel that the presumed safety issues in my case override all my nit-picking.  However, consider the decision making of a pilot required to reveal any interactions with any medical professionals.  Many choose to not be treated at all [Hoffman], especially in mental health cases.  My case goes beyond conservativism into dishonesty and defamation.  Dishonesty like this breeds fear and contempt of the system and its personnel by pilots.  No doubt supposed “conservativism” is popular with the general public.  I think the FAA correctly understands the politics of the issue.  However, I feel the FAA is more concerned about its own bureaucratic safety than the public’s physical safety.

There are three tiers of medical certificates for airline pilots (First class), commercial pilots (Second class), and private pilots (Third class).  Despite very different levels of responsibility the decision-making processes in psychiatry are virtually the same.  I applied for a private pilot medical certificate.  With my denial, I will never be able to fly an aircraft similar to a Cessna 172.  Nor can I fly a light sport aircraft less than 1320 pounds or a sailplane or a hot-air balloon.

The FAA aeromedical system has many challenges.  They are chronically underfunded.  The system is famous for its paper-based bureaucracy.  They need to be brought into the computer age.  Pilots are subjected to a system that can take years to resolve a medical issue and there is no way to track cases through the paper-choked bureaucratic morass.  In that sense I am an FAA aeromedical cheerleader:  They need more funding.

However, in my opinion, the FAA is decades behind medical practice in all fields of medicine, especially psychiatry.  They have doctors that make regulatory decisions, but do not have strategic thinkers or good policy people.  I believe congress should fund the National Institute of Mental Health (NIMH) to study and make recommendations to the FAA on psychiatric policy.  They would ensure that these decisions are statistically based, not stigma based.  The NIMH has thinkers that are not always in a defensive crouch worried about their own jobs if they make a statistically reasonable but wrong call on a particular case.

An example of poor policy is the FAAs stance on selective serotonin reuptake inhibitor (SSRI) use.  There is a blanket prohibition on the use of SSRIs in flight.  Exceptions, called a special issuance, can be made but are rarely given out.  Here are the SSRI special issuance statistics from the FAA’s 2018 Aerospace Medical Certification Statistical Handbook:

It is very difficult to obtain an SSRI special issuance.  It seems backward that it is “easier” for an airline pilot (First-class) to get an SSRI clearance than for a private pilot (Third-class).  If these statistics are correct, I believe some policy changes are in order.  I suspect the onerous and expensive application procedures are to blame.  You would have to convince me that statistically, the safety threat from third-class pilots justifies this result. There is very little difference in regulations and decision points between a first-class medical and a third-class, despite the very different levels of responsibility these pilots take on.

You hear a lot these days about how we need to reduce the shame and stigma in mental health treatment.  You should get the treatment you need.  It is a nice sentiment, and the FAA says it a lot.  The idea makes sense safety-wise assuming an enlightened FAA, but they are not.  What was the point of my schizophrenia diagnosis?  The point was not accurate diagnosis and prognosis.  The stigma encased in the word “schizophrenia” was the point.  They wield stigma effectively.  The forensic psychiatry community needs to call out doctors that practice this way whether they are in government or in the private sector, obscure or prominent.

People may claim that my experience is outdated, and that the FAA and aeromedicine has changed.  There are still bad actors in forensic psychiatry and aviation, such as this fairly recent case: [Delta pilot fights back].  There are also abuses by aeromedical psychiatrists and bureaucrats involved in alcoholism treatment [HIMS nightmare].

Many people think I should not be piloting light aircraft.  Their wish has been granted.  However, my book is about more than the disposition of my particular case.  It is about whether the aeromedical system is fair and honest.  It is about whether pilots will comply with the law and regulations and whether they have incentive to comply.  Whatever my fate, the FAA needs to clean up its act and move into the modern era.  My case is an example of why pilots do not comply.  This diagnosis of schizophrenia was made unethically.  The FAA owes me an apology.  Yale University owes me an apology.  And these organizations need to take stock and change.