The aviation medicine aspects related to psychiatric conditions are based on the potential effect that an individual with psychiatric symptoms or condition may have on safety of flight and mission accomplishment.  Unlike other clinical areas, the unique environment of aviation does not directly effect psychiatric conditions other than present a unique set of stressors.

The basic evaluation and treatment of all individuals who present with a symptom that may relate to a psychiatric condition should be based on the general standard of care for assessment of these conditions.

The unique aspect of aerospace psychiatry lies in the differing disposition of individuals when diagnosed with certain conditions, with a higher standard applied than for a “fit for full duty and suitable for service” disposition under general duty.  A summary of these dispositions and recommendations follows:

All AXIS I diagnoses/conditions, with the exception of Adjustment Disorders and V. Codes, are considered disqualifying for aviation duty.  Individuals with these conditions will require a waiver.  The general guidance is that a waiver for Axis I conditions will be considered when the individual is out of treatment, off medication, and symptom-free for a period of one year.  Waivers are considered on a case-by-case basis.  Psychotic conditions or recurrent depressive/ anxiety conditions also will not generally be waivered.

The exception to the above is the diagnosis of alcohol abuse or dependence.  The very specific waver requirements for these conditions are presented at the end of this chapter.

Anyone requiring psychotropic medication to remain symptom-free may not be waivered.

As with any active duty member on flight status who presents with symptoms or behaviors that may negatively effect safety of flight, the IDC or GMO should immediately ground that person IAW higher authority guidance.  The Dept of the Navy Manual of the Medical Department CLEARLY states in Article 15-65 3.b:

“The Aeromedical Grounding Notice (NAVMED 6410/1) is the means to communicate recommendations for fitness to fly to the aviation unit’s commanding officer.  All aviation personnel admitted to the sick list, hospitalized, or determined to have a medical problem that could impair duties involving flight performance shall be issued an Aeromedical Grounding Notice.  This grounding notice shall remain in effect until the member has been examined by a flight surgeon and issued an Aeromedical Clearance Notice.”  

The above is clearly reiterated in OPNAVINST 3710.7R in section 8.3.2.6:

“Acute minor illnesses such as upper respiratory infections, vomiting, or diarrhea can produce serious impairment of flight personnel. All illnesses shall be evaluated by competent medical authority.  Recommendations for grounding shall be accomplished by the submission of a grounding notice.” 

The IDC/GMO should not wait to determine the actual diagnosis before they ground an individual.  An example would be a member presenting with insomnia and decreased concentration.  Although they MAY be experiencing a depression (or may have a normal response to a personal loss), the important issue is to ground the person for the symptoms they have that may negatively effect their ability to safely carry out their mission.

AXIS II diagnoses relate to the diagnosis of either a personality disorder or personality traits.  Although a member on general duty may have the diagnosis of a personality disorder and maintain their ability to do their job, this diagnosis is incompatible with aviation duty.  Anyone on flight status diagnosed with a personality disorder is, by definition, not aeronautically adaptable (NAA).  There are no waivers for this condition and final recommendations for disposition are determined by NOMI.  Additionally, the presence of personality traits that are documented to be maladaptive to safety of flight, mission execution, and/or aircrew coordination  are also NAA.  If an AXIS II condition is suspected, refer the member (following proper administration of their rights IAW SECNAV 6320.24a) to your nearest psychologist or psychiatrist.  A full evaluation may also be required at NOMI for a member recommended as NAA.  At minimum a full review of the paperwork will be required.

All questions about aerospace psychiatry may be directed to the NOMI Psychiatry Department Staff at:

DSN: 922-2257 ext 1081

Commercial:  850-452-2257 ext 1081

Or:

Code210@nomi.med.nav.mil, Code211@nomi.med.nav.mil, or

Code216@nomi.med.nav.mil,

Additional information may be gleaned from the NOMI website:

In addition to all of our psychiatric lectures there are also “go-bys” for the paperwork required by SECNAVINST 6320.24a and a psychiatric interview and write-up. 

http://www.nomi.navy.mil/code02/21page.htm

and from the Aeromedical Waiver Guide (also at the NOMI website.

ALCOHOL ABUSE AND DEPENDENCE

AEROMEDICAL CONCERNS

Alcohol has both acute and chronic effects on both cognitive and physical performance. Cognitive effects will impair short-term memory, degrade reasoning and decision-making, and cause inattentiveness. Psychomotor dysfunction will increase reaction time and procedural errors. These damaging effects can occur at low blood alcohol levels (0.02 mg/dl). In addition, after moderate alcohol consumption, these effects can persist for many hours after the blood alcohol level has returned to zero.

Alcohol can cause problems with visual acuity, oculovestibular dysfunction (positional alcohol nystagmus) and vertigo. This susceptibility exists long into the "hangover" period. In addition, alcohol reduces Gz tolerance by 0.1-0.4 G.

 Acute alcohol intoxication produces ataxia, vertigo, nausea, and can produce dysrhythmias that usually disappear quickly but can leave moderate conduction delays for up to one week (the "holiday heart" syndrome). Acute alcohol intoxication is implicated in about 16% of general aviation fatal accidents.

HISTORY OF ALCOHOL ABUSE OR DEPENDENCE TREATMENT

To properly identify and follow all aviation personnel with a history of alcohol abuse or dependence, all aviation physical exams shall include the following question on the appropriate medical history questionnaire (SF 93 or 6120/2):

"Have you ever been diagnosed or had any level of treatment for alcohol abuse or dependence?"

• Former Treatment Levels            

Level I –      PREVENT/IMPACT for an alcohol related incident or prevention.

Level II –      OUTPATIENT for a diagnosis of alcohol abuse.

Level III –      INPATIENT for a diagnosis of alcohol dependence.

• Current Treatment Levels

Level 0.5 –   IMPACT for an alcohol related incident or mild alcohol abuse.*

Level 1 –      OUTPATIENT for a diagnosis of alcohol abuse.

Level 2 –      INTENSIVE OUTPATIENT for a diagnosis of alcohol dependence.

Level 3 –      DORMITORY for junior enlisted assigned to a barracks with a “buddy” system.

Will attend level 1 or 2 outpatient treatment and live in the barracks at night.

Level 4 –      INPATIENT (medical ward) for those at risk for withdrawal.

Will attend level 2 or 3 treatment once medically cleared.

*Please note Level 0.5 is not adequate treatment for aviation personnel diagnosed with alcohol abuse requesting a waiver. They must receive at least Level 1 treatment for alcohol abuse.

 Alcohol related incident is not considered disqualifying (NCD).

Alcohol abuse and/or dependence are considered disqualifying (CD) and require a waiver.

 PREVIOUS DIAGNOSIS OF ALCOHOL ABUSE OR DEPENDENCE

• If the member has a previous diagnosis of alcohol abuse or dependence and a waiver has not been granted, follow the guidelines for New Diagnosis of Alcohol Abuse or Dependence.

• If the member has a previous diagnosis of alcohol abuse or dependence and has been granted a waiver, follow the guidelines for Annual Waiver Continuance Process.

NEW DIAGNOSIS OF ALCOHOL ABUSE OR DEPENDENCE

• Flight Surgeon must submit grounding physical to NOMI Code 42.

• Waiver is possible 90 days after the patient has:

1. Successfully completed the appropriate treatment program (Level 1,2,3, or 4).*

2. Maintained a positive attitude and an unqualified acknowledgment of his alcohol disorder.

3. Remained abstinent without the need for Antabuse-type medications.

4. Met all the aftercare requirements (see below).

AFTERCARE REQUIREMENTS

• The member must document participation in an organized alcohol recovery program, alcoholics anonymous (AA), as follows:

  • First year: Three (3) meetings per week.

  • Second and third year: One (1) meeting per week.

• The member must meet with the following professionals as follows:

  • First year

1. Flight Surgeon – Monthly.

2. DAPA – Monthly.

3. Privileged Psychiatrist/Psychologist – Annually.

• Second and third year

1. Flight Surgeon – Quarterly.

2. DAPA – Monthly.

3. Privileged Psychiatrist/Psychologist – Annually.

• Fourth year and after

1. Flight Surgeon – Annually.

INITIAL WAIVER PROCESS

As with any other waiver, the member should initiate the request. In the waiver request letter, the member must acknowledge the specific aftercare requirements listed above. Further, the member must provide specific evidence of current compliance.  This will avoid claims that the member was were never advised of all the requirements for requesting and maintaining an alcohol-related waiver.

"I have read and received a copy of BUMEDINST 5300.8 series. I understand that I must remain abstinent.  I must meet with my flight surgeon monthly for the first year, then quarterly for the next two years of aftercare. I must meet with the DAPA monthly and receive an annual mental health evaluation for the first three years of aftercare. And I must document required attendance at alcoholics anonymous (AA)."

Information required:

1.      Complete flight physical, including Mental Status Exam (SF 88 and SF 93 or 6120/2).

2.      Flight Surgeon’s narrative (Flight Surgeon’s waiver endorsement) to include:

a.       Detailed review of all factors pertaining to the diagnosis, including events preceding and after the initial clinical presentation.

b.      Statements concerning safety of flight, performance of duties, potential for recovery, and any symptoms of comorbid diseases or significant stressors.

c.       Documentation of compliance with aftercare requirements including abstinence, and AA attendance.

3.      Level 1,2,3,or 4 treatment summary.*

4.      DAPA's statement documenting aftercare including AA attendance.

5.      Psychiatric evaluation by a privileged psychiatrist or clinical psychologist. (SECNAVINST 6320.24 (Boxer Law) does not apply in these cases.)

6.      Internal Medicine evaluation (if indicated).

7.      Command endorsement is essential.

8.      Local Board of Flight Surgeons must reference BUMEDINST 5300.8 series.

*Please note Level 0.5 is not adequate treatment for aviation personnel diagnosed with alcohol abuse requesting a waiver. They must receive at least Level 1 treatment for alcohol abuse.

ANNUAL WAIVER CONTINUANCE PROCESS

Information required during first three years of aftercare:

1.      Flight physical on BUMED approved Abbreviated Physical Exam (Short Form).

2.      Flight Surgeon’s statement on SF 88, SF 93 or 6120/2 with information:

a.       Concerning safety of flight, performance of duties, potential for sustained recovery, and any symptoms of comorbid diseases.

b.      Documentation of  compliance with aftercare requirements including abstinence, and AA attendance.

3.      DAPA's statement documenting aftercare including AA attendance.

4.      Psychiatric evaluation by a privileged psychiatrist or clinical psychologist.(SECNAVINST 6320.24 (Boxer Law) does not apply in these cases.)

Information required after three years of aftercare:

1.      Flight physical on BUMED approved Abbreviated Physical Exam (Short Form).

2.      Flight Surgeon’s statement on SF 88, SF 93, or 6120/2 with information:

a.       Concerning safety of flight, performance of duties, potential for sustained recovery, and any symptoms of comorbid diseases.

b.      Documentation of compliance with aftercare requirements including abstinence and AA attendance.

NONCOMPLIANCE OR AFTERCARE FAILURE

The following pertains to any member in denial of an alcohol problem, failing to abstain, or not compliant with all aftercare requirements of BUMEDINST 5300.8 series. This diagnosis is considered disqualifying (CD).

1.      Ground the member immediately! Grounding period is a minimum of 6-12 months.

2.      Flight Surgeon must submit grounding physical to NOMI Code 42 (MED-236).

3.      Re-evaluation by Flight Surgeon, DAPA, and Alcohol Treatment Facility to determine potential for re-treatment.

The member’s command must recommend a revocation of the current waiver in accordance with BUMEDINST 5300.8.  If member requests waiver after the 6-12 month grounding period, follow the Initial Waiver Process (above). Please discuss these waiver requests with NOMI Psychiatry Department Code-21 before submission. NOMI will consider waiver following noncompliance requests only on a case by case basis.

DISCUSSION

Use the current American Psychiatric Association’s Diagnostic Statistics Manual (DSM-IV) criteria to diagnose the alcohol-related disorders.   No difference exists in the waiver process or aftercare requirements for a member diagnosed with alcohol abuse versus alcohol dependence.

The evidenced-based aftercare requirements (above) will help a member, diagnosed with alcohol dependence, maintain long-term sobriety/abstinence. According to Fiorentine 1999, weekly or more frequent AA participation is associated with drug and alcohol abstinence. Also, less than weekly AA participation is not associated with favorable drug and alcohol outcomes. According to Trent 1998, in his study of the Navy’s alcohol treatment programs, the single best predictor of success at one-year is the number of months of aftercare participation. Also, the best predictor of long-term success is one-year of sobriety/abstinence.

Physicians often do not recognize the disease or ignore it. Alcohol related disorders should be considered in any patient with trauma, mood disorders, anxiety, sexual dysfunction, hypertension, gastritis, or recurrent infections.  In the United States, there are at least 12 million alcoholics, and 76 million adults who have been exposed to alcoholism in the family.  64% of high school seniors have been drunk, and alcohol is a factor in 41% of automobile fatalities and up to 50% of suicides. Surveys of United States pilots concerning use of alcohol, reported that 22% would fly within one hour of drinking and 50% after 4 hours. In addition, a study in 1990 reported that 50% of pilots underestimate deleterious effects of acute alcohol use.

This section was contributed by CAPT DJ Wear-Finkle, MC, USN (FS).

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