Could antidepressants have caused the Germanwings tragedy?

The New York Times reported yesterday that German authorities recovered “antidepressants” from Lubitz’s apartment on Thursday. This fact has renewed concerns that some drugs used to treat depression may increase suicidal ideations, aggression, and violence in some patients. Several SSRIs carry black box warnings about the potential for increased suicide risk when starting the drugs, particularly in adolescents and young adults.

During any one year, 6.9 percent of Americans will experience depression, a multi-faceted disorder characterized by some combination of prolonged or recurrent episodes of intense sadness and emptiness, lack of self-worth, and inability to enjoy previously rewarding activities, among others. That’s about 22 million people among the current U.S. population. While depression occurs more frequently in women, the disease strikes across socioeconomic boundaries, due likely to a combination of genetic and environmental causes.

The challenge is that the disorder is often accompanied by suicidal ideations and suicide attempts, accounting for why several years passed after SSRI drug approvals before an increased risk of suicide could be shown statistically.

Major aviation concern is sedative and cognitive side effects

The aviation industry is not immune to pilots experiencing depression. But each country’s central aviation authority has been operating under policies and procedures for all manner of medical issues to ensure that aircraft, especially commercial aircraft, are operated by the most competent and uncompromised professionals.

Before the SSRIs, airline pilots were disqualified from operating aircraft if being treated for depression. The first drugs to treat depression, the tricyclic antidepressants, had strongly sedating side effects and could also cause problems with balance, concentration, and blood pressure. The liability of pilots taking tricyclics, such as imipramine or amitriptyline, was these side effects that could interfere with operating an airplane.

The SSRIs, first introduced in 1987 by Eli Lilly as Prozac (fluoxetine), were a major advance because of their reduced side effect profile relative to tricyclics or another drug class, the monoamine oxidase inhibitors. As early as 1989, the Australian aviation authority, CASA, allowed pilots with depression to fly who were well-managed on an antidepressant drug.

U.S. pilots successfully treated for depression can fly under certification procedure

But the U.S. Federal Aviation Administration was concerned that these drugs still had sedating and cognitive effects that might interfere with the safe operation of commercial aircraft. In 2006, the Aircraft Owners and Pilots Association (AOPA) petitioned the FAA to recognize that pilots equally suffer from depression and can be treated successfully by proposing a detailed medical and psychological strategy to qualify such pilots with a medical certificate.

It took until 2010 for the FAA to formally enact such guidelines. In short, pilots with major depressive disorder and some related conditions could apply for such medical certification if they wre evaluated to have stable disease while taking one of four antidepressants: fluoxetine (Prozac), sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro). When these rules were established, the FAA gave a six-month amnesty period for pilots to come forward who were already being treated for depression.

Pilots are evaluated by independent aviation medical examiners (AMEs), often pairs of psychiatrists and psychologists around the country who have passed FAA medical practice certification. This medical system dates back to 1974 when the FAA began addressing the issue of pilots impaired by alcohol and their recovery. Together with the NIH National Institute on Alcohol Abuse and Alcoholism instituted the Human Intervention Motivation Study (HIMS) to establish a system to rehabilitate pilots with alcoholism. By 2004, the system could boast a 85 to 90 percent two-year sobriety rate among pilots in recovery; estimates for Alcoholic Anonymous among the general population is five to 10 percent.

The FAA’s Decision Path II illustrates the process to FAA medical certification for a pilot with depression who is taking an SSRI antidepressant. Source: Federal Aviation Administration

The FAA decision path for pilots on an acceptable SSRI is detailed in the figure above. The pilots must have a clear diagnosis of major depression or related mood disorders from a HIMS-certified AME and agree to take one of the four listed drugs. But – and it’s a big “but” – the diagnosis must be uncomplicated in that a pilot would be ineligible if they also had psychosis, suicidal ideations, previous electroconvulsive therapy, or treatment with multiple SSRIs and psychotropic drugs. While not explicitly delineated, most cases of bipolar disorder would also preclude a pilot from seeking the “special issuance” of a medical certificate.

The major criterion for applying for the medical certificate is that the pilot has been on a stable SSRI dose and devoid of symptoms for at least six months. Pilots who have also discontinued SSRIs and have a documented lack of depressive symptoms are also eligible. The pilots must also pass a series of cognitive (memory) and computerized performance tests for manual dexterity called the CogScreen – Aeromedical Edition. Developed by former Georgetown University neuropsychologist, Gary Kay, PhD, the CogScreen is described as, “a computer-administered and scored cognitive-screening instrument designed to rapidly assess deficits or changes in attention, immediate- and short-term memory, visual perceptual functions, sequencing functions, logical problem solving, calculation skills, reaction time, simultaneous information processing abilities, and executive functions.”

A SSRI Special Issuance granted to a commercial pilot is active for a year and is renewable. The airman is required to send their AME their psychiatric consultation status report every six months, a letter from airline management every three months, and retake the CogScreen-AE each year. While much of the documentation focuses on cognition, problem solving, and information management, the pilot is interviewed deeply on the nature of their depressive disorder and required to submit their own written history of their disease.

One could still worry that a pilot with homicidal or suicidal tendencies could evade this screening process to maintain their commercial certification, but the process in place in the U.S. appears to be more stringent than that of Australia or European countries.

Andreas Lubitz and SSRIs

A variety of conspiracy theorists often found online have suggested a role of psychotropic drugs used to treat mental illness and the behavior of mass murderers, dating back to the 1998 Columbine High School killings in Littleton, Colorado. Even CBS News presented a case that considered whether Zoloft (sertraline) was responsible for a 12-year-old South Carolina boy shooting his grandparents to death and setting their home on fire.

The problem with conclusively identifying a drug as a cause of homicidal behavior is that the diseases being treated are so varied in their causes and that the underlying disease might, itself alone, be a major driver of committing murder. Investigators, and family and friends of the victims, undoubtedly want answers for how this particular tragedy could have occurred and been prevented.

Assuming that Lubitz was taking an SSRI drug, we still have no way to conclude that the drug contributed to what appears to be his intentional act of mass murder and suicide. For one, we don’t yet know if what investigators are calling “depression” was complicated by any symptoms of psychosis that might have compromised or confused Lubitz’s reasoning and perspective on reality. Unless DNA testing could identify human tissue belonging to Lubitz at the crash site, we don’t even know if he was taking the drug or drugs at the time of the crash.

http://www.forbes.com/sites/davidkroll/2015/03/29/faa-procedures-for-pilots-with-depression-taking-ssris/

According to French news (but not reported in any English-language article), the injection that Andreas Lubitz recieved in 2010 was Olanzapine.

According to Wikipedia, Olanzapine is an antipsychotic used to treat Schizophrenia and Bipolar Disorder.

Additional information about Olanzapine:

This medicine is classified as an antipsychotic medication and is used to treat patients that suffer from delusions, hallucinations, unorganized thought and hostility. This medicine may also be prescribed to treat severe behavioral problems in children.