Just for the Health of Pilots

Good news and bad news:

First, the Bad News: The bad news is that depression is now so common that it is called "the common cold of psychiatry." Between 10 and 20 million people in our privileged and affluent country suffer from it to the degree that they need treatment. Suffer is surely the proper word. One man in ten and one in four women will be affected (afflicted) by it at some time during their lifetime.

Depression covers a huge spectrum. It does not just refer to the days when we feel "blue," have the "blahs," or "down in the dumps." Everyone has days like this. The question to ask in evaluating depression is, "What is the degree of impairment in one's life that depression is causing?"

The American Psychiatric Association has clearly defined some of the cluster of symptoms that occur in clinical depression (the type that definitely needs treatment) and major depression (one so severe that the patient may have to be hospitalized and certainly has difficulty carrying on even a fairly normal life):

• Feeling depressed most of the day, starting on awakening. Worse in the morning; gets better as the day goes on. The feeling of depression may be overwhelming, disabling, dominating and devastating.
• Loss of interest in activities that usually cause enjoyment (the ten-dollar word is anhedonia-or lack of fun). Social withdrawal.
• Tearful.
• Fatigue, loss of energy.
• Change in sleep patterns. Trouble in falling asleep. Waking up early two or more hours in the morning and not being able to get back to sleep. Sometimes wanting to sleep or lie down most of the day.
• Pervasive feelings of sadness and grief, maybe leading to a feeling of helplessness. If it progresses to hopelessness, suicide is a major threat. If the patient mentions suicide, consider it a psychiatric emergency. Get help-fast. Suicide is the eighth cause of death in adults, and is number three in adolescents and young adults, both boys and girls
• Noticeable change of appetite, usually decreased, with some resulting weight loss.
• Irritability (this, more than sadness, is the major symptom in children and adolescents.).
• Feelings of undeserved guilt, worthlessness, or sinfulness.
• Inability to concentrate or think clearly.
• Indecisiveness.
• Illogical thought patterns and misinterpretation of reality.
• All sorts of physical symptoms can be caused by depression: headaches, stomachaches, and backaches (the big three).
• Sometimes there is agitation, pacing the floor, inability to sit still. This is called agitated depression.

Another category, called Dysthymic Disorder ("Depression Lite") is used to describe people who do not have major depressive symptoms, but who seem to have been mildly depressed all their life, in a low-level funk. They might not even recognize it ("I've always been this way.") But their family and friends note that they never have much fun or excitement, and always seem "down."

Most of us have a happiness set point just as we have a set point in weight or basal metabolism. But, things can add up until we have "too much on our emotional plate." Just as an aircraft can stall from too great an angle of attack, too little power, too heavy a load, a person can develop a "mental stall." Most of our mood pattern, and definitely our tendency toward depression, is hereditary. But, regardless of this, loss of a loved one, loss of a job, financial problems, divorce, illness, alcoholism and drug abuse, unhappy marriages, and nowhere jobs can push a person into depression. This type of depression is called Exogenous Depression (caused from outside factors), whereas Endogenous Depression (from internal causes) is probably inherited, probably chemical in nature, and often unavoidable (but not untreatable). Endogenous depression may suddenly develop for no apparent reason.

Think of the brain as a skull-enclosed, three-pound, electrochemical analog computer. This leads us to some of…

The Good News

Depression is not only the most common mental disorder but also the most treatable, with an 80-90 percent success rate. The foundation of all treatment is a combination of psychotherapy (talk therapy) and psychopharmacology-both complement each other.

Psychopharmacology is the new wave of psychiatry. One of the newer texts contains over 500 pages describing some of the medications used in treating mental disorders.

The most common medications used today to treat depression -we all know someone on them-are the Selective Serotonin Reuptake Inhibitors (SSRIs). Serotonin is a chemical the brain needs for maintaining a good mood-SSRIs keep the level from being depleted. Prozac, Zoloft, and Paxil are among the most prescribed SSRIs. The FAA does not presently certify persons who use mood-altering medication. The reasoning is twofold: the underlying condition that requires the medication and the potential adverse side effects from the medication itself. The good news is that the FAA is willing to return virtually all clinically depressed pilots back to flying after successful treatment.

If depression seems likely or even if you are just not enjoying your life as you used to, seek out a therapist whom you like and develop a therapeutic alliance. (True story: "My psychiatrist is great, but she's an awfully hard person to talk to.") You cannot analyze or intellectualize your problems away alone, or even see them objectively-seek a mental-health professional.

Four ways to strengthen your defenses

1. Avoid booze. Alcohol abuse is probably just an attempt at self-medicating feelings of depression. Alcohol always makes depression worse. It is used not so much to feel good as it is to avoid feeling bad. Many depressed people with hangovers jump out of hotel windows on Sunday mornings. Avoid it.
2. Exercise more. All studies positively stress the use of exercise. Exercise releases endorphins-the body's joy juice. It is probably responsible for the "runners' high." Large-muscle activity (thighs) may help discharge feelings of pent-up frustration, anger, and hostility. (Anger turned inwardly is a major cause of fatigue and depression.) The downside of this wonderfully effective treatment is that most depressed people just don't have the energy or motivation to get up and exercise.
3. Forgive yourself. Don't try to be perfect. Remember that there are more than 6 billion people on Earth, and hundreds of thousands of them can do even better what you do best.
4. Open up more. Men just don't want to admit of anything that takes away from the macho image. Depression is thought of as a wimp disorder. Men may just tough it out until the Smith & Wesson cure seems the only solution. Harvard Medical School psychologist Dr. William Pollack said, "Men are limited pretty much to a menu of three strong feelings: rage, triumph, and lust. Anything else and you risk being seen as a sissy." Men (pilots?) have a tendency to self-destruct. The Macho Marlboro Man would do better to open his feelings up, show some intimacy, and admit that things are not going so well for him. Women outlive us by an average of seven years. Some of this may be not only from estrogen, but also from a willingness to talk intimately to friends about problems-even to admit that they have problems.
   

Humor! Our emotional parachute

"Sense of humor is a measurement of the extent to which you realize that you are trapped in a world almost totally devoid of reason. Laughter is how you release the anxiety you feel about this."-Dave Barry

Joy is defined in all dictionaries, but tells us nothing about what it really is. If you want to know what pure fun, joy and happiness are, just watch a young Labrador retriever play in the field for an hour, running for the hell of it, chasing leaves and butterflies and then come running to you when you call, shaking all over, slobbering and licking your face. Unconditional love; dogs don't carry grudges.

A criminal was sentenced to 20 years. He said, "Judge there's no way I can do 20 years!" The judge looked down for a couple of seconds and said, "Well, just do the best you can."

Do the best you can, and…try to have more fun in your life. If you find no humor in things-can't laugh (especially at yourself) and enjoy life, remember that you can usually find the right answer if you ask the right person. This person is probably a competent mental-health professional. In the meantime, spend a lot of time with people who love you, your family and good friends.

Yours for good mental and physical health, and safe flying,

Glenn Stoutt

Note: The views and recommendations made in this article are those of the author and not necessarily those of the Federal Aviation Administration.

The Federal Air Surgeon's Medical Bulletin • Summer 2000