Flying While Depressed? The FAA’s Troubling New Antidepressant Standards

Earlier this year President Biden signed into law: H.R. 3935, the “FAA Reauthorization Act of 2024,” intended to modernize the airline industry’s approach to mental health and other safety issues. It followed the Federal Aviation Administration’s April 2024 loosening of restrictions on modern antidepressants. But expanding pilot use of antidepressants flies in the face of mounting evidence of serious adverse effects associated with antidepressants. There is ample reason to question whether any antidepressants should be approved for pilots.

After Joseph Emerson’s October 2023 attempt to crash an Alaskan Airlines plane with 83 other passengers onboard, the FAA convened the Mental Health & Aviation Medical Clearances Aviation Rulemaking Committee, ARC. ARC recommended that “the FAA continually evaluate its standards and procedures against the latest research.” Nevertheless, it overlooked critical research developments regarding the safety and effectiveness of antidepressants.

When the FAA approved antidepressants in 2010, its decision aligned with published research. Beginning in the late 1980s, modern antidepressants were heralded as “wonder drugs.” But, as antidepressant prescriptions soared, Dr. David Healy, a internationally-renowned psychiatrist, demonstrated that modern antidepressants can induce violence and suicidality.

Other researchers established that for mild to moderate depression, antidepressants are no more effective than inert sugar pills. Dr. Irving Kirsch, a lecturer at Harvard Medical School, was the first among numerous researchers to document the antidepressant placebo effect. He dubbed antidepressants “the emperor’s new drugs” and “placebos with side effects.”

By 1995, a comprehensive review of well-controlled studies had established that psychological interventions “are at least as effective as medication in the treatment of depression.” Because antidepressant safety and effectiveness had become so important but debatable, the government spent $35 million on the STAR*D trial—the most significant randomized controlled study of antidepressants in real-world settings.

The 2006 STAR*D outcomes report, which received vast media attention, claimed that antidepressants resolved depression in 67 percent of patients which furthered antidepressant prescribing. However, multiple academics suggested that the report had overstated the drugs’ effectiveness, especially longterm remission rates, due to subsequently verified protocol violations, omissions, and errors.

Under the Restoring Invisible and Abandoned Trials guidelines, several antidepressant researchers accessed the STAR*D data. Their 2023 paper demonstrated that when the STAR*D data were properly analyzed per the approved study protocol, the antidepressant initial remission rate was only 35 percent. Furthermore, the long-term remission rate was merely three percent (3%). While STAR*D researchers stand by the initial outcomes report, their perspective is unconvincing given the group’s extensive pharma-related conflicts of interest.

A 2022 paper, “Davids versus Goliaths,” described 26 cases of “publicly documented threats after communicating safety, efficacy, or data integrity findings contrary to corporate interests.” It recounted that secret government documents eventually surfaced, which revealed the Food and Drug Administration had prevented one of its own scientists from reporting that antidepressants doubled the risk of suicide in young patients.

Also in 2023, a major meta-analysis confirmed that research had long refuted the notion that depression is caused by chemical imbalances which modern antidepressants were purported to treat. No research has ever undercut the robust evidence that nonmedical alternatives, even exercise, can be as effective as antidepressants.

According to psychiatrist Mark Horowitz, editor of the definitive handbook on deprescribing mental health medications, “We now recognize that withdrawal symptoms from antidepressants are common, and can be severe and long-lasting.” For example, stopping an antidepressant can cause panic attacks, irritability, anger, difficulty concentrating, and/or suicidality.

By the time ARC released its report, the FDA Adverse Events Reporting System had amassed 101,457 voluntary medical reports for the three antidepressants newly approved for pilot use (Cymbalta, Pristiq, and Effexor). Eighty-seven percent of these FAERS reports represented psychiatric problems (e.g., confusion, aggression, hallucinations, etc.), including 10,322 suicide-related incidents and 939 completed suicides. Yet, FAERS data capture only an estimated 10 percent of actual adverse drug events.

The FAA should consider FAERS data for all antidepressants, especially because, in 2015, a pilot who had been treated for depression deliberately crashed a plane into the French Alps, killing 149 people.

While many pilots fear that seeking mental health services could cause them to be grounded or end their careers, ARC noted that only about 20 percent of depressed pilots are grounded long-term. Per ARC, “This is typically done for ‘dual diagnosis’ cases that involve comorbidities,” such as depression and substance abuse. Pilot grounding is not required for nonpharmacological treatment of uncomplicated depression.

Like the broader public, pilots are unlikely to know that antidepressants are no more effective than psychological interventions or that getting off an antidepressant can precipitate severe and long-term withdrawal symptoms that would necessitate grounding.

By dispelling misconceptions about FAA standards and antidepressants while also promoting effective nonpharmacological treatment of depression, the FAA could improve pilot mental health and reduce pilot grounding. Given the serious adverse effects and limited effectiveness of antidepressants, the FAA should reconsider pilot use of antidepressants.