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ICAO Preliminary Unedited Version — November 2009 III-9A2-3
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. 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.
Historically, pilots have not been allowed to return to flying unless they have ceased taking medication
for at least some months after having returned to their euthymic state of health. Whilst there is no
evidence that selective serotonin reuptake inhibitors (SSRI) medications are more efficacious than older
antidepressant medications, this new generation of antidepressants is better tolerated by patients and has
an improved side effect profile 8, 9, 10 . In recent years, the use of SSRIs has become widespread in the
general population and there is reason to believe that such treatment may be compatible with flying duties
in carefully selected and monitored cases. This may be in a situation of an initial successful response to
treatment of acute depressive episode, or where treatment is aimed at the prevention of recurrences.
It should be noted that even with good responses, there may be the potential for impairment of cognition
and decision making ability from either an incomplete response to treatment or from safety relevant side
effects of medications. From the patient’s perspective, the pronouncement of “being well” may refer only
to relative improvement in comparison with the untreated state. Applicants therefore need to be carefully
assessed for the presence of any residual symptoms and any performance relevant side effects of the
medication.
3.2 The assessment of pilot and air traffic controller applicants treated with antidepressants
States may, on a case-by-case basis, certificate applicants who are prescribed (and are taking) an
approved SSRI antidepressant medication for an established diagnosis of depression which is in
remission. Conditions necessary for air safety may be imposed on the certificate as appropriate, for
example "holder to fly as or with co-pilot", thus limiting operations to multi-crew aircraft. Pilots and
ATCOs taking other types of anti-depressants should not usually be considered for certification.
States’ certification of pilots and ATCOs taking medications accepted by the Licensing Authority should
be conditional on the following:
a) The applicant should be under the care of a medical practitioner experienced in the management
of depression
b) The applicant should:
1) be stable on an established and appropriate dose of medication for at least four weeks
before returning to flying/ATC duties and exhibiting:
i) minimal, acceptable side-effects
ii) no medication interactions or allergic response
2) be subject to regular clinical review by the medical practitioner with progress reports
provided to the medical section of the Licensing Authority. The applicant may be
involved in other concurrent treatment (e.g. psychotherapy).
3) have no other significant psychiatric co-morbidities
4) require no other psychoactive medications
ICAO Preliminary Unedited Version — November 2009 III-9A2-4
c) demonstrate symptoms of depression being well controlled, without evidence of psychomotor
retardation
d) have no suicidal ideation or intent
e) have no history of psychotic symptoms
f) have no features of arousal (e.g. irritability or anger)
g) have a normal sleep pattern
h) have resolution of any significant precipitating factors of the depression
Ongoing cognitive-behavioural, rational-emotive or similar therapy is desirable, but not necessarily
required for certification.
Pilots or ATCOs authorized to fly or perform duties when taking SSRIs or related antidepressant
medications must cease exercising the privileges of their licences if their antidepressant medication is
altered or if the dose changes. Their supervising medical practitioner may return them to duty when they
are assessed as stable and without unacceptable side effects.
Pilots and ATCOs whose medication is being reduced with a view to cessation should stop exercising the
privileges of their licences for the entire period during which they are weaned off medication, plus an
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Manual of Civil Aviation Medicine 2(20)
