Mental Health Guidance Material (GM)

(a) Comprehensive Mental Health assessment shall form part of the initial class 1 aero-medical examination.

(b) Drugs and alcohol screening shall form part of the initial class 1 aero-medical examination.

CLASS 1 - AMC1 MED.B.055

(a) Mental health assessment as part of the initial class 1 aero-medical examination

(1) A comprehensive mental health assessment should be conducted and recorded taking into account social, environmental and cultural contexts.

(2) The applicant's history and symptoms of disorders that might pose a threat to flight safety should be identified and recorded.

(3) The mental health assessment should include assessment and documentation of:

(i) general attitudes to mental health, including understanding possible indications of reduced mental health in themselves and others;

(ii) coping strategies under periods of psychological stress or pressure in the past, including seeking advice from others;

(iii) childhood behavioural problems;

(iv) interpersonal and relationship issues;

(v) current work and life stressors; and

(vi) overt personality disorders.

(4) Where there are signs or is established evidence that an applicant may have a psychiatric or psychological disorder, the applicant should be referred for specialist opinion and advice.

CLASS 1 - AMC1 MED.B.055

(b) Mental health assessment as part of revalidation or renewal class 1 medical examination

(1) The assessment should include review and documentation of:

(i) current work and life stressors;

(ii) coping strategies under periods of psychological stress or pressure in the past, including seeking advice from others;

(iii) any difficulties with operational crew resource management (CRM);

(iv) any difficulties with employer and/or other colleagues and managers; and

(v) interpersonal and relationship issues, including difficulties with relatives, friends, and work colleagues.

(2) Where there are signs or is established evidence that an applicant may have a psychiatric or psychological disorder, the applicant should be referred for specialist opinion and advice.

(3) Established evidence should be verifiable information from an identifiable source related to the mental fitness or personality of a particular individual. Sources for this information can be accidents or incidents, problems in training or proficiency checks, behaviour or knowledge relevant to the safe exercise of the privileges of the applicable licence(s).

CLASS 2 - AMC2 MED.B.055

(a) Mental health assessment as part of class 2 aero-medical examination

(1) A mental health assessment should be conducted and recorded taking into account social, environmental and cultural contexts.

(2) The applicant's history and symptoms of disorders that might pose a threat to flight safety should be identified and recorded.

(3) Where there are signs or is established evidence that an applicant may have a psychiatric or psychological disorder, the applicant should be referred for specialist opinion and advice.

(4) Established evidence should be verifiable information from an identifiable source related to the mental fitness or personality of a particular individual. Sources for this information can be accidents or incidents, problems in training or proficiency checks, behaviour or knowledge relevant to the safe exercise of the privileges of the applicable licence(s).

CLASS 1 - AMC1 MED.B.055

(d) Psychoactive substance testing

(1) Drug tests should screen for opioids, cannabinoids, amphetamines, cocaine, hallucinogens and sedative hypnotics. Following a risk assessment performed by the competent authority on the target population, screening tests may include additional drugs.

(2) For renewal/revalidation, random psychoactive substance screening test may be performed based on the risk assessment by the competent authority on the target population. If random psychoactive substance screening test is considered, it should be performed and reported in accordance with the procedures developed by the competent authority.

(3) In the case of a positive psychoactive substance screening result, confirmation should be required in accordance with national standards and procedures for psychoactive substance testing.

(4) In case of a positive confirmation test, a psychiatric evaluation should be undertaken before a fit assessment may be considered by the medical assessor of the licensing authority.

CLASS 1 - GM1 MED.B.055 Mental health

Symptoms of concern may include but are not limited to:

• use of alcohol or other psychoactive substances
• loss of interest/energy
• eating and weight changes
• sleeping problems
• low mood and, if present, any suicidal thoughts
• family history of psychiatric disorders, particularly suicide
• anger, agitation or high mood
• depersonalisation or loss of control

The following aspects should be taken into consideration when conducting the mental health examination:

• appearance
• attitude
• behaviour
• mood
• speech
• thoughts process and content
• perception
• cognition
• insight
• judgement

CLASS 2 - GM3 MED.B.055 Mental health

The mental health assessment for class 2 applicants should include assessment and documentation of:

• General attitudes to mental health, including understanding possible indications of reduced mental health in themselves and others.
• Coping strategies under periods of psychological stress or pressure in the past, including seeking advice from others.
• Childhood behavioural problems.
• Interpersonal and relationship issues, including difficulties with relatives, friends, and work colleagues.
• Current work and life stressors, including difficulties with aviation operational environment.
• Overt personality disorders.

In regard to symptoms of concern and aspects to be taken into consideration when conducting mental health examination for class 2 applicants, guidance presented in GM1 MED.B.055 should be used.

Further information on the assessment will be made available to Aeromedical Examiners (AMEs) on the Civil Aviation Authority (CAA) e-learning platform.

Fear of flying

Although fear of flying affects about 15% of the general population, it is unlikely those affected will opt for a career as a pilot and, if they do, habituation with consequent resolution of anxiety will have taken place during training. The development of fear of flying in experienced fliers is normally due to the development of an underlying psychiatric disorder such as adjustment disorder, acute stress disorder, PTSD, agoraphobia, with or without panic disorder, or depression. Management should be appropriate to the diagnosis.

Class 1 (and Class 3) certificate holders should be assessed by a CAA consultant advisor in psychiatry. For Class 2 and LAPL, before returning to flying, pilots should provide their AME with a report from a consultant psychiatrist.

Further guidance is available on Dyslexia, Asperger syndrome and Attention Deficit Hyperactivity Disorder.

There is guidance on the content of Mental Health medical reports.

Initial class 1 psychoactive substance testing

Screening should normally be performed using simple hand-held non-invasive procedures, for example, breath alcohol and saliva swab testing. Additional drugs should be tested on clinical indication and/or following declaration of use by the applicant).

The UK CAA has determined that testing at renewal/revalidation examinations is not required unless determined by or the UK CAA following periodic review of testing data.

Confirmatory testing procedures should be based on UK Home Office or European Workplace Drug Testing Society (EWDTS) guidance or equivalent, and evidential-quality test equipment for alcohol breath level, or laboratory blood alcohol analysis. Saliva, urine, blood or hair sampling may be used for accredited laboratory confirmatory testing.

All positive tests should be referred to the CAA.

Applicants referred to the CAA for specialist assessment should make arrangements for an appointment within 2 months of the positive testing. Medium-to long-term consumption will be assessed at that appointment by means of blood and/or hair testing. Failure to provide samples within this timeframe may result in further surveillance and testing

Disorders due to alcohol or other substance use

• CAA Guidance Material for Initial Class 1 Drugs and Alcohol Screening flow chart
• UK CAA Alcohol and Substance misuse flow chart

(c) Applicants with a mental or behavioural disorder due to use or misuse of alcohol or other psychoactive substances shall be assessed as unfit pending recovery and freedom from psychoactive substance use or misuse and subject to satisfactory psychiatric evaluation after successful treatment.

(d) Applicants with a clinical diagnosis or documented medical history of any of the following psychiatric conditions shall undergo satisfactory psychiatric evaluation before they may be assessed as fit:

(1) mood disorder;

(2) neurotic disorder;

(3) personality disorder;

(4) mental or behavioural disorder;

(5) misuse of a psychoactive substance.

(e) Applicants with a documented medical history of a single or repeated acts of deliberate self-harm or suicide attempt shall be assessed as unfit. However, they may be assessed as fit after satisfactory psychiatric evaluation.

(f) Aero-medical assessment

(1) Applicants for a class 1 medical certificate with any of the conditions specified in point (c), (d) or (e) shall be referred to the medical assessor of the licensing authority.

(2) The fitness of applicants for a class 2 medical certificate with any of the conditions specified in point (c), (d) or (e) shall be assessed in consultation with the medical assessor of the licensing authority.

(g) Applicants with a documented medical history or clinical diagnosis of schizophrenia, schizotypal or delusional disorder shall be assessed as unfit.

CLASS 1 - AMC1 MED.B.055

(c) Assessment of holders of a class 1 medical certificate referenced in MED.B.055(d)

Assessment of holders of a class 1 medical certificate referenced in MED.B.055(d) may require psychiatric and psychological evaluation as determined by the medical assessor of the licensing authority. A SIC limitation should be imposed in case of a fit assessment. Follow-up and removal of SIC limitation, as necessary, should be determined by the medical assessor of the licensing authority.

CLASS 1 - AMC1 MED.B.055

(f) Specialist opinion and advice

(1) In case a specialist evaluation is needed, following the evaluation, the specialist should submit a written report to the AME, AeMC or medical assessor of the licensing authority as appropriate, detailing their opinion and recommendation.

(2) Psychiatric evaluations should be conducted by a qualified psychiatrist having adequate knowledge and experience in aviation medicine.

(3) The psychological opinion and advice should be based on a clinical psychological assessment conducted by a suitably qualified and accredited clinical psychologist with expertise and experience in aviation psychology.

The psychological evaluation may include a collection of biographical data, the administration of aptitude as well as personality tests and clinical interview.

CLASS 2 - AMC2 MED.B.055

(b) Assessment of holders of a class 2 medical certificate referenced in MED.B.055(d)

Assessment of holders of a class 2 medical certificate referenced in MED.B.055(d) may require psychiatric and psychological evaluation as determined by the AME, AeMC or medical assessor of the licensing authority. Follow-up, as necessary, should be determined in consultation with the medical assessor of the licensing authority.

CLASS 2 - AMC2 MED.B.055

(e) Specialist opinion and advice

(1) In case a specialist evaluation is needed, following the evaluation, the specialist should submit a written report to the AME, AeMC or medical assessor of the licensing authority as appropriate, detailing their opinion and recommendation.

(2) Psychiatric evaluations should be conducted by a qualified psychiatrist having adequate knowledge and experience in aviation medicine.

(3) The psychological opinion and advice should be based on a clinical psychological assessment conducted by a suitably qualified and accredited clinical psychologist with expertise and experience in aviation psychology.

(4) The psychological evaluation may include a collection of biographical data, the administration of aptitude as well as personality tests and clinical interview.

CLASS 1 - AMC1 MED.B.055

(e) Assessment and referral decisions

(1) Psychotic disorder

Applicants with a history, or the occurrence, of a functional psychotic disorder should be assessed as unfit. A fit assessment may be considered if a cause can be unequivocally identified as one which is transient, has ceased and the risk of recurrence is minimal.

(2) Organic mental disorder

Applicants with an organic mental disorder should be assessed as unfit. Once the cause has been treated, an applicant may be assessed as fit following satisfactory psychiatric evaluation.

(3) Psychoactive medication

Applicants who use psychoactive medication likely to affect flight safety should be assessed as unfit. If stability on maintenance psychoactive medication is confirmed, a fit assessment with an OML may be considered. If the dosage or type of medication is changed, a further period of unfit assessment should be required until stability is confirmed.

(4) Schizophrenia, schizotypal or delusional disorder

Applicants with an established history or clinical diagnosis of schizophrenia, schizotypal or delusional disorder may only be considered for a fit assessment if the medical assessor of the licensing authority concludes that the original diagnosis was inappropriate or inaccurate as confirmed by psychiatric evaluation, or, in the case of a single episode of delirium of which the cause was clear, provided that the applicant has suffered no permanent mental impairment.

(5) Mood disorder

Applicants with an established mood disorder should be assessed as unfit. After full recovery and after full consideration of the individual case, a fit assessment may be considered, depending on the characteristics and severity of the mood disorder.

(6) Neurotic, stress-related or somatoform disorder

Where there are signs or is established evidence that an applicant may have a neurotic, stress-related or somatoform disorder, the applicant should be referred for psychiatric or psychological opinion and advice.

(7) Personality or behavioural disorders

Where there are signs or is established evidence that an applicant may have a personality or behavioural disorder, the applicant should be referred for psychiatric or psychological opinion and advice.

(8) Disorders due to alcohol or other psychoactive substance(s) use or misuse

(i) Applicants with mental or behavioural disorders due to alcohol or other psychoactive substance(s) use or misuse, with or without dependency, should be assessed as unfit.

(ii) A fit assessment may be considered after a period of two years of documented sobriety or freedom from psychoactive substance use or misuse. At revalidation or renewal, a fit assessment may be considered earlier with an OML. Depending on the individual case, treatment and evaluation may include in-patient treatment of some weeks and inclusion into a support programme followed by ongoing checks, including drug and alcohol testing and reports resulting from the support programme, which may be required indefinitely.

CLASS 2 - AMC2 MED.B.055

(c) Assessment and referral decisions

(1) Psychotic disorder

Applicants with a history, or the occurrence, of a functional psychotic disorder should be assessed as unfit. A fit assessment may be considered if a cause can be unequivocally identified as one which is transient, has ceased and the risk of recurrence is minimal.

(2) Organic mental disorder

Applicants with an organic mental disorder should be assessed as unfit. Once the cause has been treated, an applicant may be assessed as fit following satisfactory psychiatric evaluation.

(3) Schizophrenia, schizotypal or delusional disorder

Applicants with an established history or clinical diagnosis of schizophrenia, schizotypal or delusional disorder may only be considered for a fit assessment in consultation with the medical assessor of the licensing authority if the original diagnosis was inappropriate or inaccurate as confirmed by psychiatric evaluation, or, in the case of a single episode of delirium of which the cause was clear, provided that the applicant has suffered no permanent mental impairment.

(4) Mood disorder

Applicants with an established mood disorder should be assessed as unfit. After full recovery and after full consideration of the individual case, a fit assessment may be considered, depending on the characteristics and severity of the mood disorder.

(5) Neurotic, stress-related or somatoform disorder

Where there are signs or is established evidence that an applicant may have a neurotic, stress-related or somatoform disorder, the applicant should be referred for psychiatric opinion and advice.

(6) Personality or behavioural disorders

Where there are signs or is established evidence that an applicant may have a personality or behavioural disorder, the applicant should be referred for psychiatric opinion and advice.

(7) Psychoactive medication

Applicants who use psychoactive medication likely to affect flight safety should be assessed as unfit. If stability on maintenance psychoactive medication is confirmed, a fit assessment with an OSL or OPL may be considered. If the dosage or type of medication is changed, a further period of unfit assessment should be required until stability is confirmed.

(8) Disorders due to alcohol or other psychoactive substance(s) use or misuse

(i) Applicants with mental or behavioural disorders due to alcohol or other psychoactive substance(s) use or misuse, with or without dependency, should be assessed as unfit.

(ii) Drug and alcohol tests

(A) In the case of a positive drug or alcohol result, confirmation should be required in accordance with national procedures for drugs and alcohol testing.

(B) In case of a positive confirmation test, a psychiatric evaluation should be undertaken before a fit assessment may be considered.

(iii) A fit assessment may be considered after a period of two years of documented sobriety or freedom from psychoactive substance use or misuse. At revalidation or renewal, a fit assessment may be considered earlier with an OSL or OPL. Depending on the individual case, treatment and evaluation may include in-patient treatment of some weeks and inclusion into a support programme followed by ongoing checks, including drug and alcohol testing and reports resulting from the support programme, which may be required indefinitely.

CLASS 1 - AMC1 MED.B.055

(e)(9) Deliberate self-harm and suicide attempt

Applicants who have carried out a single self-destructive action or repeated acts of deliberate self-harm or suicide attempt should be assessed as unfit. A fit assessment may be considered after full consideration of an individual case and may require psychiatric or psychological evaluation. Neuropsychological evaluation may also be required.

CLASS 2 - AMC2 MED.B.055

(c)(9) Deliberate self-harm

Applicants who have carried out a single self-destructive action or repeated acts of deliberate self-harm or suicide attempt should be assessed as unfit. A fit assessment may be considered after full consideration of an individual case and may require psychiatric or psychological evaluation. Neuropsychological evaluation may also be required.

CLASS 1 - AMC1 MED.B.055

(e) (10) Assessment

The assessment should take into consideration if the indication for the treatment, side effects and addiction risks of such treatment and the characteristics of the psychiatric disorder are compatible with flight safety.

Disorders due to alcohol or other substance use

• UK CAA Alcohol and Substance misuse flow chart

Mood disorder

• UK CAA flow chart for depression and related disorders 
• UK CAA guidance for psychiatric reports 
• Medical Flight Test - Medication 

Hypnotics

Temazepam has been used in military and civilian aircrew for the short-term treatment of insomnia associated with circadian rhythm disturbance for many years. Specific treatment should be directed towards other underlying causes of insomnia such as adjustment disorder. Temazepam is short acting and hangover effects are uncommon. However, drowsiness or light-headedness the next day, confusion, ataxia and amnesia are possible side-effects so the medication should be started for the first time when it is certain licence privileges will not be exercised the following day. Thereafter, it should be taken no less than eight hours before exercising licence privileges. Aircrew should not take Temazepam continuously for more than one week because of the risk of dependency developing.

Zaleplon is also acceptable for medical certification subject to the same considerations as Temazepam.

All other hypnotics, including Zolpidem, Zopiclone and “over the counter” preparations such as Diphenhydramine and Promethazine are disqualifying for medical certification.

Melatonin is a hormone produced nocturnally by the pineal gland. It serves as a circadian time cue promoting sleep. With age, melatonin production declines and the prevalence of sleep disorders, particularly insomnia, increases. Prolonged release melatonin has shown good results in treating insomnia in older adults and the Medicines & Healthcare Products Regulatory Agency has approved Circadin 2mg (prolonged-release melatonin) for patients aged 55 or over for the short-term treatment of primary insomnia. However, there is no evidence that melatonin is effective in treating secondary sleep disorders or sleep disorders accompanying sleep restriction, such as jet lag. Melatonin preparations are not always pure pineal extract and may contain herbs such as valerian and chamomile, together with amino acids, calcium and magnesium. It is not acceptable for medical certification.

CNS stimulants

Modafinil is a central nervous system stimulant prescribed for narcolepsy and daytime sleepiness due to obstructive sleep apnoea. Common side-effects (>1:100) include anxiety, depression, dizziness and impaired concentration. Both obstructive sleep apnoea associated with significant daytime drowsiness despite CPAP treatment and narcolepsy are disqualifying and so any applicant taking this medication is unfit for flying duties.

Smoking cessation medication

Nicotine replacement therapy is acceptable.

Varenicline is a selective nicotine receptor partial agonist used for smoking cessation. Common side effects include drowsiness, dizziness and sleep disorder. Less commonly (1:1000 - 1:100) it can cause atrial fibrillation, palpitations, panic attacks, mood swings, incoordination, visual disturbance, myocardial infarction, anxiety, depression, irrational behaviour, psychosis and suicidal ideation. Varenicline is not compatible with aeromedical certification.

Bupropion is used for smoking cessation though its mode of action is unknown. Common side effects include anxiety, depression, dizziness and impaired concentration. Less commonly it can cause confusion and visual disturbance. Applicants are 'unfit whilst taking this medication.

Antidepressants

The SSRIs Sertraline, Citalopram, Escitalopram and Fluoxetine are the only antidepressants permitted for medical certification. The Depression flow chart offers further guidance. Citalopram and Escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with congenital long QT syndrome, known pre-existing QT interval prolongation or in combination with other medicines that prolong the QT interval. ECG measurements should be considered and electrolyte disturbances should be corrected before starting treatment. For Citalopram, the maximum daily doses are: 40mg for adults and 20mg for patients older than 65 years. For Escitalopram, the maximum daily doses are: 20mg for adults and 10mg for patients older than 65 years.

St John's Wort can be purchased without prescription and is used for the treatment of depression though it is not licensed for this purpose. It interacts with other medicines and the quality and quantity of active ingredient in the various preparations available is variable. An applicant or certificate holder on this treatment should be assessed as unfit and follow guidance in the Depression flow chart.

The half-life of Amitriptyline is 18 to 24 hours and active metabolites have a longer half-life. Sedation occurs at all dose levels. It is not compatible with medical certification even at the low doses used for treating neuropathic pain. The same applies to other tricyclic medications.

Antiepileptics and Medications for Neuropathic Pain

Epilepsy is disqualifying so these drugs are incompatible with medical certification. Gabapentin, Pregabalin and Carbamazepine prescribed for neuropathic pain and Valproate for migraine prophylaxis are disqualifying for medical certification because of the risk of unacceptable side effects.

Antipsychotic drugs

Antipsychotic drugs are not usually compatible with medical certification because the condition for which they are prescribed is likely to be disqualifying. However, low dose Sulpiride (less than 400mg daily) is acceptable for the treatment of Tourette's syndrome (unlicensed indication) provided a clinical report confirms treatment is successful without significant side-effects and a medical flight test gives a satisfactory result. The use of Clonazepam for treating tics is disqualifying.

Cannabidiol products

The use of cannabis, including any cannabidiol (CBD) derivatives, is not compatible with medical certification. This includes the use of any CBD products, whether prescribed or not.

Anxiety, insomnia, chronic pain, or addiction are among the common indications for using CBD products, each of which would normally mean an unfit assessment.
Whilst there is insufficient evidence to suggest that CBD products can impact on skilled task performance, the difficulties in isolating CBD from other psychoactive compounds, including tetrahydrocannabinol (THC), can result in non-negligible doses of these compounds being present in currently available formulations. This potential contamination also carries the risk of a positive drug screening test.