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with depressed mood, reduced energy, impaired concentration and memory, loss of interest in
surroundings, slowed cerebration, difficulty in making decisions, alteration of appetite and sleep, guilt
feelings, and low self esteem. Suicide is common; the incidence varies with cultural background, but may
approach 20 per cent per depressive episode. The illness is usually of insidious onset and persists for
many months when not treated adequately. Depression may be accompanied by a number of somatic
symptoms. There may be diurnal variation in the symptoms, and many persons with depression may have
some good days in between. It is not unusual for sufferers to try to modify their symptoms (especially the
dysphoria and insomnia) by the use of alcohol and/or drugs.
Depression leads to subtle (and sometimes obvious) incapacitation, mainly due to the decreased ability to
concentrate as well as to distractibility and indecision, which are frequent features of the illness. It is these
symptoms, along with the risk of suicide, which make a depressed individual unsuitable to work in the
aviation environment. Because the symptoms wax and wane during a depressive episode, there may be
days when the individual is relatively well and may appear to be fit to fly. However, the impaired
concentration and the lack of cognitive agility are always more or less present and may interfere with the
ability to integrate the multiple sensory inputs required to make decisions in an emergency.
Depression is by nature a recurrent disorder and, although single episodes do occur, the history of a
depressive episode should alert the medical examiner to ask specific questions to ensure that the applicant
does not currently have the illness. Those persons who have had one serious depressive episode have
approximately a 50 per cent risk of experiencing a second episode.
Response to treatment of depressive episodes may be very good and the sufferer may wish to return to his
aviation position while still under treatment. It should be noted that even with good responses, there is
usually some impairment of cognition and decision making ability which may impair performance in an
emergency, primarily by increasing the response time. The pronouncement of “being well” may refer only
to relative improvement in comparison with the untreated state.
ICAO Preliminary Unedited Version — October 2008 III-9-4
Because depressive mood disorders are recurring disorders, it is imperative that the “recovered” patient be
monitored closely for signs of recurrence for a period of time following recovery. There is evidence that
recurrence is most likely to happen during the first two years. An educative approach may help the
individual recognize the earliest signs and thus facilitate early intervention. Ordinarily pilots should not
be allowed to return to flying unless they have been off medication for at least some months after having
returned to their euthymic state of health. In recent years, the use of SSRI (selective serotonin re-uptake
inhibitors) has become widespread and there is indication that such treatment, aimed at preventing a new
depressive episode, may be compatible with flying duties in carefully selected and monitored cases.
A history of mania, whether occurring in isolation or as part of a bipolar disorder, should lead to longterm
disqualification. Mania is an unpredictably recurring disorder, which presents with grandiosity,
increased energy, euphoria, reduced sleep, distractibility, and poor judgement. It may progress to overt
delusions with marked irritability, anger, and danger to self and to others. Substance abuse is a fairly
common consequence. Although this condition may respond moderately well to mood stabilizing agents,
the risk of recurrence is significant and the degree of disruption of performance too great to allow a return
to flying or air traffic control duties. When the episode of mania has remitted, the patient often feels as
well as before and the reason why he should not assume an aviation career requires a great deal of
explanation. However, the significant risk of recurrence even with mood stabilizing medication, along
with the degree of disruption of mental function when there is a recurrence, precludes an aviation career.
Hypomania is a clinical condition that does not meet the full criteria of mania. It involves the same
symptoms, but at a lesser degree of intensity. It usually includes expansive mood (may progress to
euphoria), heightened sense of self (may progress to grandiosity), decreased need for sleep, increased
energy, and distractibility. Judgement may be altered by the expansive mood and feeling of
self-importance. Persons with hypomanic episodes have unstable moods and are prone to developing
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Manual of Civil Aviation Medicine 2(14)
