SSRI Decision Path I and incorrect condition listed by AME

[MFF25]

Has anyone received a request for additional information when following SSRI Pathway I? I took Lexapro for 20 months following the death of my father and got off it at the beginning of March. Went to the AME for my initial 3rd class with a letter from my doctor and the AME issued my medical on June 1st. On July 12th, I received a letter dated July 6th asking for a progress note and all treatment notes for my anxiety. The problem is, I was never diagnosed with anxiety, it was depression, which is what I told the AME. I am not sure how to proceed. I can send the requested information for depression, but I have nothing that says anxiety. I guess I am naive, but I thought I followed pathway I to a T, and apparently so did my AME because he issued my certificate, so I am lost on why they are asking for more. Finally, is there a way to make an argument that the diagnosis of depression was incorrect? I really think I was just grieving, and stayed on the meds longer than I should have. Thanks for any help or tips.

 

[craig d]

SSRI Path I doesn’t actually give the AME the authority to issue, certainly without speaking with a doc at AMCD or the RFS. If this was your first FAA Medical it’s unlikely they would give a verbal authorization since they don’t have a file on you.

Lexapro can be used for depression and anxiety, and many other things. Most patients with depression have some anxiety component and vice versa. Without seeing the records that were actually sent to AMCD, and knowing what your AME noted in Block 60 of the 8500-8, it’s hard to say where the “anxiety” diagnosis came from. If your treating MD uses EHR, it could be as simple as a ICD-10 diagnosis code that was listed, or an older “inactive” diagnosis. I’d call your AME first and see what reports were already sent as well as what he added to your application regarding your diagnosis.

I agree you were going thru a grieving process only and the brief course of Lexapro isn’t significant, but the FAA is going to want to verify that by looking at your previous reports, especially those from when the diagnosis was made initially. Everything should be fine, but be sure to let your AME look at everything before you send it off to OKC.

 

[MFF25]

SSRI Path I doesn’t actually give the AME the authority to issue, certainly without speaking with a doc at AMCD or the RFS. If this was your first FAA Medical it’s unlikely they would give a verbal authorization since they don’t have a file on you.

Lexapro can be used for depression and anxiety, and many other things. Most patients with depression have some anxiety component and vice versa. Without seeing the records that were actually sent to AMCD, and knowing what your AME noted in Block 60 of the 8500-8, it’s hard to say where the “anxiety” diagnosis came from. If your treating MD uses EHR, it could be as simple as a ICD-10 diagnosis code that was listed, or an older “inactive” diagnosis. I’d call your AME first and see what reports were already sent as well as what he added to your application regarding your diagnosis.

I agree you were going thru a grieving process only and the brief course of Lexapro isn’t significant, but the FAA is going to want to verify that by looking at your previous reports, especially those from when the diagnosis was made initially. Everything should be fine, but be sure to let your AME look at everything before you send it off to OKC.

Thank you so much for taking to time to respond. I will talk with my AME. I have also requested a copy of my record from OKC to see what exactly is in there.

 

[WingmanMed]

Unfortunately a normal grieving process should never require medication. The fact that you were on medication, especially as long as you were, has the FAA concerned about just how bad your reaction to the situation was. That is why they want all of the documentation.

 

[bbchien]

But fortunately, the authority of the PCP over a reactive disorder lasts 24 months.
They ask for the record but what they really want are eight items- if your PCP is cappable of writing a lettter that does not miss ANY of the the following, you should succeed:

State the doctors' formal diagnosis.
Stimulus for the need for the medication
Name the medication
If any others meds used, say if concurrent and name the med(s), this is a negative factor.
Date of onset
Date of end of treatement
That to his knowledge this was the ONLY encounter with psych. support in your entire life
That there was no suicidality
That he has seen you at > 60 days (state the date) since discontinuation, and that there are no symptoms left to treat.

He cannot miss a ONE item. But if he hits all eight, this is really what they need, for a <24 month run of an SSRI.

Wingman is correct, these should be under a year. DSM5 limits the defintion of a reactive anxiety /depression diagnosis only for 24 months. Anything longer and by definition is was NOT by definition not reactive, but also more a part of your innate makeup. And you should know that reactive depression and reactive anxiety are half siblings. FAA does indeed "lump" them together.

 

[Kenny Phillips]

Unfortunately a normal grieving process should never require medication. The fact that you were on medication, especially as long as you were, has the FAA concerned about just how bad your reaction to the situation was. That is why they want all of the documentation.

Kind of a "yikes" reply, given the "should never require medication". Perhaps we have a different definition of "normal grieving process".

 

[dbahn]

Unfortunately a normal grieving process should never require medication.

Kind of a "yikes" reply, given the "should never require medication". Perhaps we have a different definition of "normal grieving process".

As a retired M.D. I've got to agree with WingmanMed and others, and I blame both the physicians and the drug companies for not letting grief be a natural response to a loss rather than a pathological response that happens to fit well in the drug company's description of the med on its advertising schemes. The whole debacle with the Sackler family and its marketing of Oxycontin is a more dramatic example of how that all works to create a problem much bigger than the natural history of the untreated condition, i.e. "normal" grieving.

 

[WingmanMed]

Kind of a "yikes" reply, given the "should never require medication". Perhaps we have a different definition of "normal grieving process".

You may not like my reply, but there are psychiatric standards for what is considered "normal" grieving and bereavement. Seeking help from a counselor, psychologist or physician does not mean that someone has exceeded the "normal" processes. But in general only a physician can prescribe psychotropic medication. It is incumbent upon the physician to evaluate the individual and determine if they are outside of the "normal" grieving and bereavement process and may benefit from advanced psychotherapy and/or medication. Then, the patient should be monitored for recovery and, possibly, cessation of therapy and/or medication.

So yes, your definition of "normal grieving process" is likely different than the formal medical definition. But physicians should be dealing with the formal medical definition and that is what should be guiding treatment. The FAA assumes that physicians are following established protocols and guidelines. So when a physician prescribes psychotropic medication for grieving then the FAA assumes that the patient had a disproportionate response to the situation requiring medication. They also assume that if the patient was outside of normal grieving then therapy and/or medication should be initiated with a well documented follow up plan to resolution. Therefore when the FAA asks for the documentation it should all easily be available.

The problem is when a physician does not follow established guidelines and there is no good documentation. Now the pilot is mad at the FAA, but the real problem was likely their own treating physician.

As a corollary:
Say you sprain your ankle and go to an orthopedic surgeon. Instead advising you to follow RICE: (rest, ice, compression and elevation) with slow return to full activity the surgeon decides to operate on you, drilling holes in your bones and affixing plates. This is the kind of thing that should only be done to repair an actual fracture, not a sprain. Then, the surgeon also fails to document the valid reason for the surgery, the type of equipment used, or have you return for any post operative follow up. Do you think that is acceptable?

When doctors play fast and lose with mental health, this is exactly what they are doing. And no one calls them out on it. And the patient suffers.

The FAA is at fault for not having enough people trained to process the volume of mental health related cases. However, the FAA is not at fault for treating these cases seriously and requiring proper documentation. People want to think that the FAA treats mental health differently. They don't. They treat it exactly how they treat physical health. If you have a heart attack you have to actually recover, follow all their guidelines and prove your heart is fit to fly. If you have depression you have to actually recover, follow all of their guidelines and prove your brain is fit to fly.

 

[MFF25]

Thank you all for the replies and information. Unfortunately, the documentation I have is quite thin. I have the original diagnosis and prescription which was done through Teladoc in about 20 minutes. Then I have a follow up appointment with my PCP where he took over the prescription, and then an annual physical after that. By the next physical I was off the medication.

I do think I was misled and probably never needed the medication, or diagnosis but nonetheless here I am. Fingers crossed.

Thanks again for the help!

 

[WingmanMed]

Thank you all for the replies and information. Unfortunately, the documentation I have is quite thin. I have the original diagnosis and prescription which was done through Teladoc in about 20 minutes. Then I have a follow up appointment with my PCP where he took over the prescription, and then an annual physical after that. By the next physical I was off the medication.

I do think I was misled and probably never needed the medication, or diagnosis but nonetheless here I am. Fingers crossed.

Thanks again for the help!

What documentation you do have will help show that this was likely a poor diagnosis in the first place and inappropriate continuation of therapy. Coupled with a well done current evaluation, you will likely be in a good position.

 

[MFF25]

What documentation you do have will help show that this was likely a poor diagnosis in the first place and inappropriate continuation of therapy. Coupled with a well done current evaluation, you will likely be in a good position.

This is what my PCP wrote in the note I got last week, I think it does show that if grief should not be treated with SSRIs that I was incorrectly treated:

"There has been confusion with his mental health diagnosis history. He has had one episode of grief reaction that caused depression secondary to a life event (father passing away) that was successfully treated with pharmacotherapy for approximately 20 months and has been off of it for the past 4 months. He denies any symptoms of anxiety or depression. No panic attacks, no self harm thoughts. no thoughts of harming others, no feeling down, no lack of motivation or interest, no decreased concentration."

I will have to work with him to make sure all the points that Dr. Chien mentioned above are addressed.

 

[lbfjrmd]

as from this thread ... the FAA is serious about mental health!

 

[bbchien]

He has had one episode of grief reaction

MFF25:
"....and to my knowledge, no other episode requiring psychiatry support, in his life"....is the most important revision. FAA treats a second episode VERY DIFFERENTLY that a "one and only". The second most important wold be to name the drug (hopefully only one) that was used.

 

[Andy Bader]

SSRI Path I doesn’t actually give the AME the authority to issue, certainly without speaking with a doc at AMCD or the RFS. If this was your first FAA Medical it’s unlikely they would give a verbal authorization since they don’t have a file on you.

Can you expand on this please? The SSRI Decision Path I flowchart says that after 60 days off of medication, with a favorable report from the treating physician, the pilot can apply for a regular issuance. It sounds like the AME has the authority to issue.

Or is the deferral a required part of the process (so that the FAA can acquire information) and then only after 60 days can the pilot apply for a regular issuance?

 

[WingmanMed]

Can you expand on this please? The SSRI Decision Path I flowchart says that after 60 days off of medication, with a favorable report from the treating physician, the pilot can apply for a regular issuance. It sounds like the AME has the authority to issue.

Or is the deferral a required part of the process (so that the FAA can acquire information) and then only after 60 days can the pilot apply for a regular issuance?

Unfortunately this is an area of conflicting guidance from the FAA in what is published. We have discussed this at length with they psychiatric team at the FAA. Effectively if the pilot was on medications less than six months and the AME can determine that it probably shouldn't have needed meds, or they have properly gone off meds, then the AME can issue. But over 6 months of medication use should be a deferral. But deferral does not mean special issuance. It could still come out of the FAA with a regular issuance.

 

[Andy Bader]

Unfortunately this is an area of conflicting guidance from the FAA in what is published. We have discussed this at length with they psychiatric team at the FAA. Effectively if the pilot was on medications less than six months and the AME can determine that it probably shouldn't have needed meds, or they have properly gone off meds, then the AME can issue. But over 6 months of medication use should be a deferral. But deferral does not mean special issuance. It could still come out of the FAA with a regular issuance.

Thank you for the info and the quick reply!

 

[MFF25]

Just wanted to say thank you to everyone, particularly @bbchien. I received a letter of eligibility recently. Anyone in a similar situation follow the advice given by @bbchien it worked for me.