Interesting thing about the FAA using it's own definition instead of the DSM, I spoke with a substance abuse counselor who said he would never do an assessment of alcohol abuse/dependence for the FAA because it would be a breach of ethics to his profession and grounds for license revocation. His explanation made perfect sense.
The FAA uses its own standard of alcoholism. They absolutely have the right to do that. No dispute there.
As he pointed out, IF the FAA trained their own evaluators to do substance abuse evaluations based on their own criteria, that would also be perfectly fine. No dispute there.
The problem comes in when the FAA uses a licensed Psychiatrist but asks them to perform an evaluation by a criteria other than the DSM definition. As this counselor pointed out, he is not allowed by medical standards to have his own definition of alcoholism (or bipolar or anti-social or any other mental disorder). For him to diagnose someone as alcoholic (or any mental disorder as this is not limited to alcoholism), the subject MUST meet the CURRENT DSM criteria. Random example, alcoholics often get beligerent and get into fights. Someone could have a well established pattern of getting into physical altercations while intoxicated but a psychiatrist cannot cite this as a reason for his diagnosis because it's not a DSM criteria (the doctor's words not mine). Bottom line, it's malpractice for a psychiatrist to make a diagnosis for any reasons other than those in the DSM.
The counselor's point is when the FAA hires a Psychiatrist to perform an evaluation but "handcuffs" them to using an alternative definition other than the DSM definition, the FAA is giving the false impression that the pilot has a psychiatric diagnosis of substance abuse/substance dependance when, in fact, he/she does not because a diagnosis that doesn't follow the DSM is not a valid diagnosis.
I agree with your concerns in principle. I don't want to see any government agency getting in the business of defining medical conditions and I think the regs around substance abuse/dependence could use a refresh. I also think HIMS is being diluted/harmed with the latest lifetime monitoring stuff for dependence, but it's the best we have right now.
Here's the rub. The FAA is the government expert on safety of flight, and that includes medical certification. That's not going to change. Even with BasicMed they're still the authority. The key is the difference between a
clinical evaluation and a
forensic evaluation.
Clinical evaluations are performed as part of the treatment of the patient at the behest of the patient. The patient is the "customer". They are performed to help treat a patient for a condition at the request of the patient.
Forensic evaluations are performed to evaluate an individual at the behest of the requestor. The
requestor (FAA) is the customer even though the patient is paying for it in this case. The FAA isn't treating the airman. They're asking for an unbiased determination of whether the airman meets the criteria for substance abuse/dependence as define by the FARs. These regulations were produced after extensive rule making processes, and they're pretty clear in their criteria. The problem is AMCD wants to keep changing their interpretation of the regs, or enacting rules by closed door policy rather than public rule making.
Because the evaluation isn't clinical in nature, isn't being used by a clinician for treatment purposes, and the patient isn't the "customer" the requestor (FAA) is well within their rights to define how they want the evaluation performed. That said, the clinician is also well within their rights to refuse to perform the evaluation for ethical reasons or simply because they have better things to do that day. The airman can also refuse to be subject to the forensic evaluation (although there will most likely be medical certificate and possibly airman certificate repercussions)
If you want to see this in action, consider an airman requesting their "full" medical file under PBOR. If that file contains psychiatric evaluations they will not receive copies of those evaluations. They're not the customer and they have limited rights to that information. They have to request a "blue ribbon" certified copy of their record (used for legal purposes) to get the true full record.
It's similar to pre-employment drug testing or pre-employment psychological testing (think security clearance).
When these evaluations are performed they have to be done by professionals that have background in aviation, otherwise they'll be of little use in the process. When these professional produce their evaluation they will always be clear about which criteria is being used for the result. If they're not clear, they're worthless to the FAA. You'll see language like:
(Meets/does not meet) DSM-V criteria for alcohol use disorder (mild/moderate/severe) (in/not in) (early/sustained) remission.
(Meets/does not meet) CFR part 67 criteria for alcohol (dependence/abuse) (with/without) evidence of recovery.
My opinion is there is a justifiable reason to get upset up about how HIMS airmen have to select mental health professionals. Someone who gets involved with HIMS HAS to use the FAA's short list of psychiatrists and neuropsychologists. These people make A LOT of money performing these evaluations (+$3k for nueropsych eval, +$2.5k substance abuse eval, +$800/year follow up), and the FAA is providing them a steady stream of airmen. The supply of services is artificially limited and the airmen are a coerced captive audience. The pricing is simple economics. Airmen determined to be dependent/abusive are also a source of recurring revenue for at least a few years, and sometimes for as long as they hold a medical. It raises the question as to whether there is a conflict of interest, and if these professionals are truly independent evaluators and not influenced by a strongly coupled relationship to the requesting agency.
I won't say cash is running the show. I will say that I have first hand knowledge of a HIMS mental health professional getting involved in the program at the urging of another HIMS medical professional partially due to the revenue generating potential. It's also no unheard of that paying for these services must be in cash. No credit cards, no insurance claims.
The FAA's position is these professionals have to go through the agency's training otherwise they're not smart enough to extrapolate how the patient's substance use could impact aviation. That's why they're short listed. I have to believe that anyone smart enough to make it through medical school/psychology graduate school is capable of reaching reasonable conclusions without obtaining the agency's royal seal of approval after a few days at a government seminar.
