SSRI usage with no history of counseling

[David Stites]

Hi,

I have a question about SSRI Decision Path 2. I understand that the FAA does not differentiate on why the SSRI was/is taken. I also understand that any application is going to require any records related to counseling or psychiatry assistance. However, in my case, I have none. What do I do?

I earned my PPL back in 2003 (and held a 3rd class medical back then). In 2008, my PCP started me on Celexa due to generalized anxiety. In addition, it just made me a nicer person (not as snappy, etc). Around 2009, I stopped flying for about 10 years. In 2020, I picked up flying again (and got my instrument rating October 2021). Since I had been issued a 3rd class medical prior to the cut-off date, I was eligible for BasicMed, which is what I fly under today. I still take Celexa to this day and the dosage is stable (has been for years).

I have a goal of getting my commercial certificate, which would require a 2nd or 3rd class medical depending on what you're doing.

Some key decision points

• What is/was the diagnosis for the SSRI?

In 2008, I reported being anxious of having a stressful job and life. I lived in a different state (Colorado) and PCP when it was originally prescribed, so I am not sure what the original diagnosis was. When I moved to California, the prescription came with me and the physician here just renewed it. I don't have a history of multiple SSRIs or psychiatric treatment or counseling.

• What kind of symptoms did the pilot have before the antidepressant?

Anxiety and "meanness" but nothing like what is described in the FARs (depression, overt manifestations or acts of psychosis, bi-polar, ideation of suicide, etc.).

• How effective is/was the medication?

Good. My dosage is stable and has been for years. Flying is actually my ANTI-anxiety.

• If the pilot has already quit the medicine, how long did the pilot take the therapy?
• If the pilot has already quit the medicine, how long ago did the prescription lapse?

I haven't quit. I would like to continue flying and take the medication which is why I am looking into Decision Path 2.

• Did the SSRI cause any aeromedically significant side effects?

No.

I would think that this would be a pretty cut and dry case where I could get an SI, but I am scared that they're looking for any reason to deny a medical due to SSRI usage, which would end flying for me, even on BasicMed. Is it worth the risk to try or talk to a HIMS AME?

 

[kath]

I have a goal of getting my commercial certificate, which would require a 2nd or 3rd class medical depending on what you're doing.

I have no medical expertise or answers to those questions, but I can say that the above statement isn't true. You can earn the commercial certificate with BasicMed, as long as you can serve as PIC for whatever aircraft you're using for the training and checkride. You just can't exercise commercial privileges without the 2nd.

 

[David Stites]

I have no medical expertise or answers to those questions, but I can say that the above statement isn't true. You can earn the commercial certificate with BasicMed, as long as you can serve as PIC for whatever aircraft you're using for the training and checkride. You just can't exercise commercial privileges without the 2nd.

Ah, yes, you are correct. I'll clarify: I have a goal of getting my commercial certificate and being paid for flying, which would require a 2nd class medical.

 

[Lindberg]

When I moved to California, the prescription came with me and the physician here just renewed it.

What's the diagnosis that your current physician used to justify the prescription?

 

[David Stites]

What's the diagnosis that your current physician used to justify the prescription?

I'll find out.

 

[David Stites]

Depressive disorder (ICD-10 diagnosis code F32.9).

The symptoms: ongoing feelings of sadness, despair, loss of energy, feelings of worthlessness and hopelessness, loss of pleasure in activities, changes in eating or sleeping habits, and thoughts of death or suicide.

The symptoms don't describe me at all, so much so that it feels malpractice-ish. 41.9 would be a closer fit, but apparently it wasn't "invented" until 2016. 41.9 explicitly mentions irritability.

• A category of psychiatric disorders which are characterized by anxious feelings or fear often accompanied by physical symptoms associated with anxiety.
• A disorder characterized by apprehension of danger and dread accompanied by restlessness, tension, tachycardia, and dyspnea unattached to a clearly identifiable stimulus.
• Disorders characterized by anxiety or dread without apparent object or cause. Symptoms include irritability, anxious expectations, pangs of conscience, anxiety attacks, or phobias.

 

[mcmanigle]

I have lots of comments about this, but, in no particular order:

1. Of all of the diagnosis codes to continue an anti-depressant medication when moving from another state, 32.9 -- "Major depressive disorder, single episode, unspecified" -- is a relatively benign one to pick. The fact that it says "single episode" right in there is good from an aeromedical standpoint, and it stands to reason that an antidepressant would be prescribed for depression. That being said, I agree that a physician probably should have taken the time to dive into why you were on a medication in the first place before prescribing it, but the world, and your situation, are what they are.

2. In some ways, having a diagnosis (whether by your original prescriber or by your strong opinion of what your medical issue is) of anxiety might turn out to make things a little trickier. My (relatively uninformed) understanding is that the FAA considers anxiety to be more "trigger-able" by things like in-flight emergencies or spacial disorientation than depression is. So you'll not be in the "boring" (read: easy) category of "has minor depression, on an antidepressant" but instead in the slightly weirder (read: let's investigate this further) category of "anxiety, on an antidepressant."

3. As much as the above is my vague view on how the FAA may or may not see things, in reality it really doesn't matter much what you think your diagnosis is. As I'm sure you've seen, the "Decision Path 2" is pretty involved, and will require all-new, relatively detailed psychiatric and neuro-cognitive evaluations. That will be informed by the "current treating physician's" opinion, and based on what you wrote above, will probably also involve getting records from the person who originally prescribed the med. But when you go through this process, the diagnosis code on your current prescription and/or that you come in saying you have will be a starting point, but "the process" (HIMS AME taking into account the reports of the treating physician, psychiatrist, and neuropsychologist) will come up with its own evaluation of you. So don't stress over one data point; the fact that you're on an SSRI means you're beyond the "one data point" kind of evaluation that some other conditions get.

If your Google-fu hasn't turned it up yet, this document gives the run-down on all of the parts of this evaluation and how they fit together. The SSRI pathway seems like a giant pain, but it's also a giant leap forward from the previous "SSRI = never fly again" mentality at the FAA.

 

[bbchien]

ugh. lots of "not quite to the point" advice here.

Look, the crtical thing to understand is you can do path 1 -discontinuation, and then apply ONLY if you have had a SINGLE episode, or duration less than 5 years (usually).... Longer = presumption of recurrent disease that your doc's didn't want to discontinue for fear it would return.

The recurrent disease path has restrictions (single episode with breaks and resumption or more than one episode), e.g never had any dual drug Rx, no suicidality, no congnitive instability....anyplace in the record. That includes the pharmacy 10 year report. That's Decision path 2. Why those exclusions? They are "severity indicators" and the agency is not interested in that situation.

The diangosis code isn't as important as what the HIMS psychiatrist (and to a lesser extent, the HIMS AME) thinks of the whole situation. I have had HIMS pscyhicatry evals in which the expert wrote, "i find no evidence that teh subject ever had ANYTHING.

 

[David Stites]

ugh. lots of "not quite to the point" advice here.

Look, the crtical thing to understand is you can do path 1 -discontinuation, and then apply ONLY if you have had a SINGLE episode, or duration less than 5 years (usually).... Longer = presumption of recurrent disease that your doc's didn't want to discontinue for fear it would return.

The recurrent disease path has restrictions (single episode with breaks and resumption or more than one episode), e.g never had any dual drug Rx, no suicidality, no congnitive instability....anyplace in the record. That includes the pharmacy 10 year report. That's Decision path 2. Why those exclusions? They are "severity indicators" and the agency is not interested in that situation.

The diangosis code isn't as important as what the HIMS psychiatrist (and to a lesser extent, the HIMS AME) thinks of the whole situation. I have had HIMS pscyhicatry evals in which the expert wrote, "i find no evidence that teh subject ever had ANYTHING.

Thanks for responding @bbchien. With regard to:

apply ONLY if you have had a SINGLE episode, or duration less than 5 years (usually)

The duration has been 13 years consistently on a single drug (Celexa, 2008-2021, no on/off, no dual drugs, no suicidality, no cognitive instability). I assume this means “single episode”? I reported my irritability to the PCP, he prescribed and I’ve been getting refills ever since. In fact, he’s never “checked back in.” Would this duration disqualify me for stopping the medication in path 1? Does taking the medication this long mean its a “recurrent disease”?

I would ideally like to continue taking the medication, unless there is an approved medication that would treat irritability. I thought my case was “easier” because I don’t have the “severity indicators” as you mentioned. Perhaps its not?

Would you advise to contact you through your website? I certainly have no problem paying for a consultation.