Aeromedical Deliberations in the Germanwings Tragedy

The Germanwings tragedy this week brought to the forefront the mental health assessment for commercial airmen.  There are reports that the copilot had another serious health issue with his vision.   I would like to raise the possibility that there is a connection between the suicide, mental health issues, change in vision, and perhaps a brain tumor that was not detected. Flight surgeons and aviation authorities will seek to avert another tragedy if airmen with serious mental health issues continue to fly.   My expertise as a senior aviation medical examiner over the last 27 years with thousands of commercial airmen gives me some perspective on the screening process in the United States. I have also attended European aviation conferences some of which were sponsored by the Lufthansa aeromedical service. Commercial airline pilots have both physical and mental examination to maintain their medical certification every six months after the age of forty and younger airmen are examined every year. The basic examination is straightforward. The pilot completes an online medical application containing a detailed health questionnaire that includes medications, doctors’ visits, and arrests or legal infractions. The airmen are also expected to self-report if there any mental health issues by answering if they have had any visits with psychologist or psychiatrist we’re taking any medication.  These questions are answered every six months and are often one of the tripwires to detecting a pilot with alcohol or drug problems. Airmen are required by law to answer truthfully. There is an exchange between the FAA database and government registries for serious driving offenses such as DWI and DUI infractions. The physical examination is comprehensive particularly involving vision.  There is a urine analysis but it is not a toxicology screen or drug screen.  The FAA monitors the online questionnaire and the medical examination so that all medical certifications are confirmed by their medical staff in both the federal medical division in Oklahoma City and by the regional flight surgeons. My ability to detect emotional or psychological instability is fundamentally based in detecting any aberration in their well-being. Many airmen come twice a year, often for the duration of their professional career. While there is no specific mental status examination that is a routine part of the examination, I do engage the pilot in conversation asking their schedule and days off. I look for eye contact, facial expressions, and in particular, the facial muscles will reveal their state of mind. Simple questions such as when they last flew and their next trip gives me some indication of stress or fatigue.  I like to ask about family, kids, and vacations.  Sometimes this leads to news of divorce or an illness in the family. Sometimes I find out through there are financial problems or a need to relocate. At times airmen are based in another city from where they live. This requires them to commute to an airport far from home. This situation contributed to the Colgan Air Flight 3407 in February 2009 in Buffalo, NY. The extra travel can make their workday extremely long and stressful. New duty rules adopted after the Colgan Air mishap addressed some of these concerns but airmen are often have non-restorative sleep by traveling through many time zones without proper acclimation.  Commercial airline pilots may be away from home for several days at a time while some airmen flying a corporate jet maybe away for 2 to 3 weeks. I am intrigued by the constellation of symptoms of altered personality, depression, and some vision disturbance that may affect his ability to continue as a professional pilot.  Why would a commercial airline pilot intentionally committed suicide and murdered 149 other souls. Is there a common medical causation to explain these findings?  We should have a high index of suspicion when there is a new illness and subtle neurologic changes are currently in an individual who was otherwise asymptomatic. There are three health issues currently being mentioned in the news: mental illness, personality disorder, and vision difficulty.  Each of them occurs sporadically in the general population. However some conditions are more likely in his mid-20s age group. One of the most common conditions is the onset of schizophrenia. While there may have been significant mental health issues previously, we don’t have enough detail to know if he fits the criteria for new onset schizophrenia. However the manifestations of schizophrenia include auditory or visual hallucinations. Features of paranoia are also well-known. The personality disorder has features which may correspond to the disrupted social relations that a young adult would experience at the onset of schizophrenia. It is difficult to maintain personal relationships and there is often an element of paranoia or a tendency to distrust a close friend or family.  Hence reports in the media of his girlfriends’ ending relationships. The incidence of mood disorders is also compatible with news reports and are a common mental health issue in this age group. Frequently this takes the form of an anxiety or panic disorder. They may self-medicate either self-medicate with alcohol or through a prescription that is not revealed to authorities such anxiolytic drugs such as Xanax or Valium. A severe form of a mood disorder may be major depression. This condition likely to affect somebody attempting suicide.  These individuals typically have dysfunctional social interactions and would have a great deal of difficulty maintaining an uninterrupted work schedule. News reports indicate that he appeared physically healthy. He also had an eye disorder.  If he was to self-report visual disturbances, the most common would be blurred vision, double vision, or loss of peripheral vision. Proper examination by a medical doctor or ophthalmologist could reveal the disorder. Some reports have said that he had a problem with his lens. This condition may have been floppy lens has been associated with Marfan’s syndrome. This condition has been associated rarely with familial mental disorders such as schizophrenia and personality disorders. If we consider structural abnormalities of the brain or organic brain lesions we should consider the ideology as emanating from cerebrovascular injuries, demyelinating conditions, inflammatory, infectious, or miscellaneous causes. My synthesis of the mental and psychiatric conditions brings me to consider an underlying brain lesion. In clinical practice, any patient presenting with new psychiatric illness over the age of 40 would merit referral for brain imaging such as an MRI. This would include older individuals at risk for Alzheimer’s. However in this case of a young adult, we are considering a neurologically silent organic brain lesion manifesting it’s presence with mental illness. There are a number of common features to organic brain lesions occurring in a specific part of the brain. Lesions of the temporal lobe commonly cause depression. Temporolimbic lesions may present as auditory and visual hallucinations, panic or anxiety disorders. So in reviewing the preliminary reports about the airman fitness to fly, I find the symptoms and history to be intriguing.  Was there a common denominator to his illness?  Can we learn from this tragedy? We are all asking ourselves why a doctor would write a note to keep him from flying but not notify the airline or authorities.  Is it reasonable to expect a pilot to self-report his mental problem to his employer?  Did the doctor not know that the copilot was still continuing to fly after the previous warnings and notes went unheeded and unused?  Why wasn’t there a holistic approach to this pilot’s wellbeing that might bring together other health issues such as his vision disturbance and personality changes? The accident investigation is also a criminal investigation now. For the flight surgeons and aviation medical examiners, we should pay very close attention.