ICAO Preliminary Unedited Version — November 2009 III-9A2-1
Appendix 2
SPECIFIC GUIDANCE CONCERNING USE OF ANTIDEPRESSANT MEDICATION
1. Introduction
This section provides guidance concerning Recommendation 6.3.2.2.1, introduced in 2009:
6.3.2.2.1 Recommendation.- An applicant with depression, being treated with antidepressant
medication, should be assessed as unfit unless the medical assessor, having access to the details of
the case concerned, considers the applicant’s condition as unlikely to interfere with the safe exercise
of the applicant’s licence and rating privileges.
2. Background
The use of antidepressant medication in aircrew and air traffic controllers (ATCO) has traditionally been
disqualifying for medical certification due to the underlying medical condition and the potential safety
relevant side-effects of the available medications to treat it 1, 2
. In the United States, in accordance with
Federal Aviation Administration (FAA) rules, antidepressant usage must have ceased for at least
three months before a fit assessment may be considered 3, while in Europe the Joint Aviation Authorities’
policy is that no certification can be considered whilst using psychoactive medication4,5.
Depression is a common, worldwide disorder in the adult population, although reported prevalence varies
quite widely 6
. In the United States the lifetime prevalence of major depressive disorder was found to be
16.2 per cent, which would involve almost 34 million US adults, and for a twelve-month period the figure
was 6.6 per cent 7.
Many patients require long term treatment with antidepressants to reduce the risk of recurrence. One
systematic review 11 found that continuing antidepressant medication treatment after recovery
dramatically reduced the proportion of patients who relapsed over one to three years, compared with
placebo. The average rate of relapse on placebo was 41 per cent, compared with 18 per cent on active
treatment.
There is emerging evidence in the literature that policies which disqualify pilots from flying whilst on
antidepressant medications may lead to pilots flying when depressed and untreated, or flying on
antidepressant medication but not reporting it to the regulatory authority 12, 13, 14. An Aerospace Medical
Association position paper 12 stated that, according to the Aviation Medicine Advisory Service database
of pilots’ telephone inquiries, approximately 15 per cent of pilots who had been advised by their
physicians to take antidepressant medication showed an intention to take the medication and continue
flying without informing the Federal Aviation Administration.
Canfield et al. 13 reported on post-mortem toxicological evaluations performed on 4 143 pilots.
Psychotropic medications were found in 223 pilots but only fourteen of these pilots had reported a
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