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available substances such as alcohol.
ICAO Preliminary Unedited Version — October 2008 III-9-7
Significant insomnia, if persistent, will lead to decreased function in many aspects of the insomniac’s life.
The consequences of the insomnia may be magnified by the presence of a psychiatric or medical illness.
Insomnia may exist without the presence of an underlying psychiatric disorder or substance abuse. Such
cases are diagnosed as non-organic insomnia (ICD-10) or primary insomnia (DSM-IV).
Polysomnographic studies will usually show increased stage 1 sleep and decreased stages 3 and 4 sleep.
Primary insomnia is a difficult condition to treat. Insomniacs frequently use hypnotics, prescribed or not,
with little or no beneficial effect on the insomnia, but which may result in decreased alertness the
following day. However, the use of hypnotics is normally disqualifying for those who need alertness to
perform safely in an aviation environment.
Because of the decreased ability to function, persons with persistent insomnia pose a particular risk in the
aviation environment. The risk is compounded by their frequent use of sedative medication and
substances (especially alcohol) to relieve their distress. Because of the chronicity and complexity of the
problem in many persons, this clinical problem is best managed by a psychiatrist or a psychologist with
expertise in the treatment of insomnia.
Occasional sleeplessness or transient insomnia (usually difficulty initiating sleep) is a common disorder
and is most often associated with situational concerns. This sleep disorder should not last for more than
days and only if it persists beyond that will a more in-depth inquiry be required. Many sleep hygiene
techniques may be helpful in alleviating brief periods of insomnia. These techniques include reduced
intake of caffeine and alcohol, avoidance of heavy meals or vigorous exercise prior to sleep, a relaxing
and comfortable sleep environment, and perhaps a non-stimulating warm drink prior to sleep.
Occasional sleeplessness may be managed with small doses of short acting sedatives with the proviso that
no aviation related activity may be undertaken until the effects of the medication have passed. With short
acting medications such as temazepam (Restoril®), zolpidem (Ambien®), or zopiclone (Imovane®), there
should be a period of 8 to 12 hours after intake of a single dose of the medicine before undertaking
aviation related tasks. Such medicines should only be taken under the direct supervision of a physician
having specialist knowledge of aviation.
Changes in circadian rhythm may also lead to periods of insomnia. This rhythm disruption may be related
to travel over several time zones or night duty and rotating-shift schedules at the place of work. Although
insomnia associated with circadian rhythm changes is usually of short duration, the dysfunction may be
more extreme and longer lasting in some people. In some controlled situations, there may be some value
in the use of very short acting sedatives to aid in the adjustment of the circadian rhythm. There is some
evidence that the use of melatonin may be helpful by accelerating the resynchronisation of the circadian
rhythm, but because this substance is not an approved pharmaceutical medicine and its safety, purity and
effectiveness have not been established by any government agency, its use in aviation is not
recommended.
ICAO Preliminary Unedited Version — October 2008 III-9-8
FLYING AND PSYCHOACTIVE MEDICINES
With each passing year, physicians and patients are inundated with an ever wider range of psychoactive
medicines which all promise better clinical response and fewer side effects. In many cases the marketing
of these medicines implies that side effects are either not present or so minimal as to be insignificant.
Although advances in psychopharmacology have been of great benefit in the treatment of psychiatric
disorders, they rarely (if ever) return the patient to a pre-illness level of functioning. Most patients, on
intensive examination, will report that although they feel much improved over their untreated state, they
are aware that they have not had a total resolution of symptoms. Most will also report that although they
have few side effects, they do experience some unwanted effects of the medication.
Because most psychiatric illnesses affect the ability to process information, to make a decision after the
information processing, and then to undertake a course of action, any decrement in functioning could
have a serious impact in an environment where events usually occur at a swift pace and where human
beings are far from their natural habitat. It is for these reasons that psychoactive medicines may be used in
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Manual of Civil Aviation Medicine 2(17)
