Page 12 - Volume 10 Number 11

Diagnosing Mental Illness, Medication and
Certification
by Dr. Jerrold Seckler
Consider two patients. Patient A develops abdominal pain and visits his doctor, who notes the patient has a low-grade fever and tenderness localized to the lower right side of the abdomen. Additionally, if the doctor presses slowly on the lower abdomen and then suddenly lets go of the pressure, the patient winces. A CT scan or other imaging study is ordered and it’s obvious that there is fluid surrounding the appendix, which is itself swollen.
The patient is taken to the operating room where the appendix is removed. When examined by the pathologist, the removed appendix shows the typical findings of acute inflammation. The next day the patient feels fine. This patient had a clearly defined anatomic condition that could be objectively demonstrated by physical examination, radiographic imaging and then confirmed by pathologic examination of the abnormal tissue that was removed.
He had acute appendicitis. Furthermore, this patient could have gone to any of hundreds of doctors and all of them would have reached the same diagnosis and recommended the same treatment.
Patient B, on the other hand, complains of feeling tired, sad, and sometimes out of control. He is having trouble sleeping. His work performance is suffering and he is drinking or smoking more in an effort to relax and “get a grip” on it. If he sees a doctor, the physical examination will be normal. Any lab or imaging studies will be normal as well. The patient has no objective evidence of any disease, yet he will be given a diagnosis.
10 • KING AIR MAGAZINE
What’s more, that diagnosis might vary from doctor to doctor depending on how they interpret his subjective symptoms or how the patient himself explains them. The severity of the condition can only be based on those same subjective symptoms. Patient B is suffering from some sort of depression.
Why should this matter to pilots? The FAA is quite concerned about depression and other diagnoses that fall under the general category of mental or psychiatric disturbances. FARs 67.107, 67.207, and 67.307 list “mental conditions” and substance abuse issues that must result in the denial of a medical certificate. Because the diagnosis of these conditions are in large part highly subjective, how a given practitioner describes and classifies the condition can make a great deal of difference in how the FAA will react. Furthermore, the medications usually prescribed for psychiatric disturbances all work on the chemistry of the brain, modify behavior, and therefore are viewed with great suspicion by the FAA.
To add insult to injury, the conditions classified as “mental illnesses” vary with societal norms, which change over time. Yesterday’s psychiatric condition is today’s non- pathological lifestyle choice. For example, homosexuality was classified as a mental disease until fairly recently; and conditions that were previously classified as laziness, malingering, etc. are now bona fide mental “conditions” with specific diagnoses. In the classification of mental conditions, the only constant is change.
In an attempt to rationalize the methodology used to diagnose mental disorders, the American Psychiatric
NOVEMBER 2016