Mentally Ill in a High-Stakes Job

In medicine, law, and aviation—and other fields responsible for people's lives and livelihoods—strict regulations attempt to promote safety, but may discourage people from getting the help they need.

With the crash of Germanwings Flight 9525, caused by a rogue pilot with a history of depression, people are calling for better mental-health screenings for pilots. But it’s not just in aviation where mental-health treatment is a concern.

Consider also doctors, dentists, lawyers. They have trained for years, passed tough exams, been licensed and deemed fit by a stringent set of regulations; they’re needed at their best. Yet many of these high-responsibility, high-risk career fields have high rates of suicide. That means many of these highly trained workers could be showing up at work in a compromised condition.

Seeking help for depression, anxiety, or another mental condition can be difficult for anyone. People may be embarrassed to discuss their symptoms, they might not know what kind of healthcare provider to see, or they might hope the problem will go away on its own. But in some fields, visiting a therapist for a diagnosis or starting medications can endanger the licensing and career someone has often worked a decade or more to achieve.

The most recent National Health and Nutrition Survey from the Centers for Disease Control and Prevention (CDC), published in 2014, found that 7.6 percent of Americans ages 12 and up fit the description for moderate or severe depression. Among people with severe depression, 35 percent reported seeking help from a mental-health professional. Only 20 percent of those with moderate symptoms sought help, and 13 percent of those with mild symptoms.

Those statistics account for depression. Add to them the spectrum of anxiety disorders and more severe mental-health conditions—bipolar disorder, personality disorders, schizophrenia, psychosis—and a significant percentage of people reporting symptoms are going untreated. According to the Association for Psychological Science, in 2011, 59.6 percent of people with any kind of mental illness reported receiving treatment.

The ramifications of untreated mental illness are bad enough for the sufferers, but in certain professional fields where people’s lives or livelihoods are at stake, the questions become more complicated. Could a lawyer with social anxiety fumble a case in the courtroom—not badly enough to get a mistrial, just enough to lose? What if a doctor hasn’t slept in days because of depression and is making decisions about dosages and specialty care?

Legally, there are very few instances when employers are allowed to ask employees direct questions about specific conditions or medications, and medical records are protected by HIPAA laws, but some people still fear being “found out” for not reporting a mental condition. People post questions on forums for medical students, pilots, and police officers, worrying about the consequences they could incur for their conditions.

Licensing boards bear a different weight of responsibility than employers. Though their mission statements vary slightly state by state, they are charged with regulating practitioners in a field; protecting consumers from unethical, incompetent, and unfit professionals. But does having ever been treated for a mental illness qualify one as forever unfit? For a lifelong condition, how long must ongoing treatment be successful before someone can stop being viewed as a potential risk? One year? Five? Ten?

Anyone who seeks treatment puts a great deal of trust in others. Clinical notes from therapists and psychiatrists could ultimately determine the fate of a license. The Americans with Disabilities Act should protect anyone’s job as long as he seeks out and finds successful treatment; but what qualifies as “successful” isn’t always clear, and the consequences of concealing a mental-health condition from a licensing board can be stiff. In medicine, according to the Federation of State Medical Boards, it can be up to and including loss of license if someone is found to be practicing while impaired. But different professions screen for, and approach mental illness differently.

Medicine

According to the National Occupational Mortality Surveillance Report from the CDC, which studied nearly 500 different professions, physicians have one of the highest rates of suicide in the U.S., coming in at 16th. Why, in a field designed to heal, are so many people suffering? Despite all their knowledge of what the body and mind need, physicians may struggle to care for themselves under increasing pressure to see more patients in less time, a litigious culture, and the expectation to always be available.

A 2007 nationwide study of medical licensing procedures in the U.S. in the Journal of Medical Licensing and Discipline found that 40 of the state licensing boards directly asked about mental-illness diagnosis and treatment, 20 asked about impairment due to mental illness, and 20 asked about diagnosis, outpatient treatment, or hospitalization. According to the report, “questions regarding diagnosis, treatment and/or admission to a treatment facility usually take the form of: ‘Have you (within a certain amount of time) been diagnosed, treated or admitted to a treatment facility for a mental illness or disease?’ … If an applicant responds ‘yes’ to any mental-health question, additional information [is] usually requested.” According to the study, 26 states ask for a written explanation, but do not elaborate on what to include; five states request contact information for current or past treatment providers; and five states request a letter from the treatment provider covering “diagnosis, treatment, prognosis, and further recommendations for treatment or supervision.”

In a follow-up survey to further examine the issue, to which 35 boards responded, 13 stated that any report of mental illness is sufficient for imposing consequences, such as revocation or restriction of license, probation, or requiring completion of a treatment regimen. When asked if the board is required to sanction physicians for reporting their mental illness, 34 said no, one said it depended on the circumstances. When asked if the board deals differently with physicians receiving psychiatric care versus medical care, 13 said yes, 21 said they deal with medical and psychiatric issues the same way, one replied that it depended on circumstances.

On a web forum for medical students, one member who chose the name “Broken Doctor” for a screen name offered his or her experience:

Your fears about professional stigma and discrimination from medical licensing boards are well-founded.

I have been treated for depression for many years. When my state medical board found out (I reported it myself after taking a brief medical leave of absence), they chose to publicly discipline me simply for getting sick. In my case, there have never been any allegations of misconduct, incompetence, or practicing while impaired. Overall, this has been the most humiliating experience of my life. The professional damage is staggering and irreversible. [...] So, my advice to you would be to NEVER EVER EVER admit to your licensing board anything that could even remotely be considered mental illness. Until the professional stigma of mental illness is squarely addressed by organized medicine, your honesty will only get you in trouble.

Yet others counter with their own experience:

I've heard of many such circumstances. Most of the time, the program's response is the opposite of what you're describing - rather than chiding/punishing them, they'll usually make special accommodations to help the person deal with the illness. If you're particularly worried about your co-workers not understanding, just go into psychiatry - not only are we well-acquainted with the difficulties associated with mental illness, but it's also a specialty that tends to attract people with a background of various mental illnesses, so you won't feel like you're different from everybody else in your field.

In 2011, the Federation of State Medical Boards, a non-profit group which represents 70 U.S. medical and osteopathic boards, released an extensive Policy on Physician Impairment covering physical and mental impairment, as well as substance abuse. It clarifies definitions, and serves to establish best practices in helping physicians seek treatment through the Physician’s Health Program structure, established in the 1970s to assist addicted doctors, now expanded to cover psychiatric care for all healthcare professionals, including dentists and pharmacists.

Law

The American Bar Association (ABA) has been working hard to increase conversation on stress and mental health in the legal profession by promoting state level assistance programs, speakers, and helplines. But it’s an ongoing battle. Lawyers often overwork: 80 hours and up for weeks at a time, leading to isolation and sleep deprivation. In the CDC’s ranking of suicide rates by profession, lawyers and judges together come in 29th.

Dan Lukasik is an attorney and founder of the website LawyersWithDepression.com. In a blog post on judges and depression, he writes:

Judges are supposed to be problem solvers in black robes; not human beings with psychological problems of their own.

Given the position that judges occupy in our society, the stigma around disclosure to others –and perhaps getting treatment for clinical depression — is much, much greater.

One psychiatrist I know who treats judges told me that judges request very early or very late weekday or weekend appointments.  Moreover, they ask not to be scheduled before or after another lawyer or judge and pay in cash so as not to attract attention or leave a paper trail.   

One 2009 study of mental-health treatment and licensing for lawyers found confusing and uncertain systems in place across the nation. The study examined state-level compliance with a resolution issued by the American Bar Association in 1994 to observe the spirit of the ADA. Of the 54 jurisdictions surveyed (all 50 states, the District of Columbia, and three territories), 39 had licensing applications that asked a question similar to: “Do you currently have any condition or impairment (including, but not limited to, substance abuse, alcohol abuse, or a mental, emotional, or nervous disorder or condition) which in any way currently affects, or if untreated could affect, your ability to practice law in a competent and professional manner?” Of those 39, 10 provided no clarification of the term “currently”; the rest either set a number of years or, more commonly, simply defined “currently” as something recent enough to affect professional performance. The study concludes that states still need to draw a tighter circle of compliance with the ABA mandate by narrowing the time frame as well as defining more clearly the “ability to practice law,” which only nine jurisdictions have done.

The legal profession may be changing though. Lori Shaw, dean of students and professor at University of Dayton School of Law, wrote in her advice to law students getting ready for the bar that “treatment is viewed as a plus, not a minus. Taking responsibility for your life evidences strength of character.”

Aviation

The Federal Aviation Administration (FAA) holds a hard line on all pilots with health conditions, requiring annual physical exams for pilots younger than 40 years old and exams every 6 months for pilots older than 40. Psychiatric exams are not conducted in the U.S., though Aviation Medical Examiners are instructed to “form a general impression of the emotional stability and mental state of the applicant” during their routine examinations.

If pilots have been diagnosed with one of the FAA’s 15 disqualifying medical conditions, or have a history of another psychiatric condition like a personality disorder or attention deficit disorder requiring medication, they may be denied a medical certificate that allows them to fly. In some cases, however, the FAA may grant a “special-issuance authorization” (SIA) when a pilot has passed required medical testing and been deemed “low-risk.”

The use of antidepressants is considered a disqualifying condition, though the FAA currently allows SIAs for pilots taking one of four approved medications for the treatment of depression and mood disorders. Federal aviation regulations require pilots taking these antidepressants to notify their employer, report to a specially trained aviation medical examiner, and remain grounded until they have spent six months on a stable dosage without side effects. After that time, reports must be filed by the treating physician, the pilot, and a specially trained aviation medical examiner, and the pilot must undergo neurocognitive psychological tests. Once the paperwork is done, the pilot is issued a medical waiver and must follow up with a psychiatrist every six months to maintain it.

Men and women who love to fly may understandably be disinclined to self-report when doing so would keep them from flying for at least six months, if not indefinitely. It’s an imperfect system, one that depends on the pilots to seek out the help they need.

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Antidepressants are one of the most prescribed medications in the U.S. According to the New York Times, one in 10 Americans is on one. For the vast majority of people who are managing mental-health conditions, those conditions should not affect their job status. Stigma still exists in the work place, though, and disclosing a condition could lead to judgment. A paper in Occupational Medicine found that employers may unfairly micro-manage the employee, or attribute mistakes to the condition.

Careers in medicine, law, and aviation, however, involve a contract of trust with the public. People depend on their skills, and the expectation is that they will be completely honest with themselves, and the authorities who govern them, about anything that could affect their ability to do their jobs, which could potentially include mental conditions.

The Germanwings case is an anomaly. There’s always a great deal of talk about the need for better mental-health interventions when tragedies happen, but the vast majority of people dealing with mental-health conditions are nonviolent. Whether people are dealing with their condition successfully becomes a private matter between them, their family, and doctors. It’s also important to note the conclusions drawn by the Treatment Advocacy Center, a non-profit focused on mental health, from the results of many studies of the mentally ill: “Most acts of violence committed by individuals with serious mental illness are carried out when they are not being treated.” This underscores the importance of allowing and encouraging people to seek and receive treatment.

Licensing boards and employers in highly skilled fields are balancing a difficult but necessary weight: Creating rules that protect the public, while providing an environment in which employees are confident they can get the help they need, without penalty. In professions strict about licensing, attempts to make sure people are mentally fit could currently be discouraging some from coming forward, keeping them from the help they need.