Mental Health

Appendix C: Return-to-Work Guidance for Safety-Sensitive Workers by Disorder

Several authorities have issued guidance concerning return to work for safety-sensitive employees suffering from mental health disorders. For ease of use, these are listed below, by disorder:

Depressive Disorder

The U.S. Federal Motor Carrier Safety Administration (FMCSA) recommends that commercial drivers with major depressive disorder should not be certified until they have been asymptomatic for 6 months, 12 months if they were suicidal or psychotic features were present. Certification is not recommended for patients who display active psychosis, compromised judgment, attentional difficulties, suicidal behavior or ideation, a personality disorder which is repeatedly manifested by overt, inappropriate acts, or experiencing treatment adverse effects which interfere with driving.36

The S. Air Force (USAF) specifies that a waiver is considered after depressive disorder is completely resolved and medications and psychotherapy have been discontinued for 6 months. Recurrent episodes are disqualifying.37

The Australian Federal Police do not consider candidates until they have been stable, off of all treatment for a period of time up to 2 years following use of psychotropic medication, which includes SSRI and SNRI antidepressants by their definition. The waiting period depends on prior treatment duration. The minimum is 6 months.38

The U.S. Federal Aviation Administration (FAA) has a specific selection process for individuals treated for depressive disorder with SSRIs who wish to fly. To qualify for consideration, pilots must have been on stable dose of a listed anti-depressant for 6 months. There can be no symptoms or history of: psychosis, suicidal ideation, electro convulsive therapy, treatment with multiple SSRIs concurrently, multi-agent drug protocol use (prior use of other psychiatric drugs in conjunction with SSRIs.39

The Canadian Railway Association’s railway medical guidelines of requires that railway personnel with depressive disorder who serve in safety critical positions must undergo evaluation by a physician, and, at the discretion of the railway’s chief medical officer, by a psychiatrist, who will produce a written report. This report should include an assessment of the individual’s judgment, attention, insight, alertness, and also on the adverse effects of any medication. The length of the monitoring period follow-up, the frequency of assessments and the stringency of observation required may vary depending on the individual’s diagnosis and degree of disability. Fitness for duty requirements of all individuals with mental disorders will be established on a case-by-case basis at the discretion of the chief medical officer..40

The National Transport Commission of Australia notes that for persons with any mental disorder, a conditional license may be considered by the driver-licensing authority, subject to periodic review and accounting for the nature of the driving task and information provided by a psychiatrist as to whether the following criteria are met41:

• condition is well controlled and;
• person is compliant with treatment over a substantial period; and
• person has insight into the potential effects of their condition on safe driving; and
• no adverse medication effects that may impair their capacity for safe driving; and
• impact of co-morbidities has been considered (e.g. substance abuse).

The U.S. Army, which is the lead agency for DoD Civilian security officers, states security officers should have no presence or history of, or signs associated with, the following diagnoses42:

• Delirium, dementia, and amnestic and other cognitive disorders
• Major depressive disorder
• Manic-depressive disorder (bipolar)
• Dissociative disorders
• Kleptomania
• Panic disorder and other anxiety disorders (depending upon etiology, duration and severity of clinical expression)
• Pathological gambling
• Pyromania
• Schizophrenia and other psychotic disorders
• Personality disorders
• Mental retardation
• Alcohol or drug dependence
• Other diagnoses not listed which may impair the performance of duties or which might endanger the lives of themselves or others

The Army further states that: “Psychiatric disorders, which could affect safe and efficient job performance, require additional evaluation to determine whether the individual is able to safely and successfully perform the essential job functions. The presence of any psychiatric disorders, or a history of such, warrants referral for further evaluation by a psychologist or psychiatrist.”42

Bipolar Disorder

The U.S. Federal Motor Carrier Safety Administration (FMCSA) recommends that commercial drivers with bipolar disorder not be certified until they have been asymptomatic for 6 months; 12 months if they were suicidal or psychotic features were present. Certification is not recommended for patients who display active psychosis, compromised judgment, attentional difficulties, suicidal behavior or ideation, a personality disorder which is repeatedly manifested by overt, inappropriate acts, or experiencing treatment adverse effects which interfere with driving. Recommendations specific to use of lithium, commonly utilized in treatment of this spectrum of disorders, are:36

• Recommend to certify if the driver:
  • Is asymptomatic.
  • Has lithium levels that are maintained in the therapeutic range.
  • Has no impairment that interferes with safe driving.
• Recommend not to certify if the driver has:
  • Disqualifying underlying condition.
  • Disqualifying symptoms.
  • Lithium levels that are not in the therapeutic range.

The U.S. Air Force (USAF) waiver guide specifies that any aviator with any of the bipolar disorders is permanently disqualified due to the risk of recurrence, the presenting symptoms of loss of insight, tenuous reality-testing, and the unlikely-hood of self-referral, poor judgment and poor treatment compliance.37

The Australian Federal Police do not consider candidates with mental health disorders until they have been stable, off of all treatment for a period of time up to 2 years following use of psychotropic medication, which includes SSRI and SNRI antidepressants by their definition. The waiting period depends on prior treatment duration. The minimum is 6 months.38

The U.S. Federal Aviation Administration (FAA) advises that all applicants with a diagnosis of bipolar disorder must be denied or deferred. Those with a diagnosis of cyclothymia are included. The rationale is that “even if the bipolar disorder does not have accompanying symptoms that reach the level of psychosis, the disorder can be so disruptive of judgment and functioning (especially mania) as to pose a significant risk to aviation safety. Impaired judgment does occur even in the milder form of the disease.” 39

The Railway Medical Guidelines of The Canadian Railway Association requires that railway personnel with bipolar disorder who serve in safety critical positions should undergo evaluation by a psychiatrist who will produce a written report. This report should include an assessment of the individual’s judgment, attention, insight, alertness, and also on the adverse effects of any medication. The length of the monitoring period follow-up, the frequency of assessments and the stringency of observation required may vary depending on the individual’s diagnosis and degree of disability. Fitness-for-duty requirements of all individuals with mental disorders will be established on a case-by-case basis at the discretion of the chief medical officer.

A person with bipolar disorder must be in remission for 1 year or longer – if indicated by medical evidence. Prior to return to work, individuals with this diagnosis must be evaluated by a psychiatrist. The chief medical officer may request regular follow-up reports once the individual has returned to work.40

The National Transport Commission of Australia notes that for persons with any mental disorder, a conditional license may be considered by the driver licensing authority, subject to periodic review and accounting for the nature of the driving task and information provided by a psychiatrist as to whether the following criteria are met41:

• The condition is well controlled and;
• The person is compliant with treatment over a substantial period; and
• The person has insight into the potential effects of their condition on safe driving; and
• There are no adverse medication effects that may impair their capacity for safe driving; and
• The impact of co-morbidities has been considered (e.g., substance abuse).

The U.S. Army, which is the lead agency for DoD Civilian security officers, states officers should have no presence or history of, or signs associated with, the following diagnoses42:

• Delirium, dementia, and amnestic and other cognitive
• Major depressive disorder
• Manic-depressive disorder (bipolar)
• Dissociative disorders
• Kleptomania
• Panic disorder and other anxiety disorders (depending upon etiology, duration and severity of clinical expression)
• Pathological gambling
• Pyromania
• Schizophrenia and other psychotic disorders
• Personality disorders
• Mental retardation
• Alcohol or drug dependence
• Other diagnoses not listed which may impair the performance of duties or which might endanger the lives of themselves or others

The Army further states that: “Psychiatric disorders, which could affect safe and efficient job performance, require additional evaluation to determine whether the individual is able to safely and successfully perform the essential job functions. The presence of any psychiatric disorders, or a history of such, warrants referral for further evaluation by a psychologist or psychiatrist.”42

Anxiety Disorders

The U.S. Federal Motor Carrier Safety Administration (FMCSA) does not directly address anxiety disorders and does not offer specific advice to examiners regarding any waiting period for certification. Specific recommendations concerning use of anxiolytic medications are as follows: “You should not certify the driver until the medication has been shown to be adequate/effective, safe, and stable…”36

Recommend to certify if the driver uses:

• A hypnotic, if the medication is:
  • Short-acting (half-life of less than 5 hours).
  • The lowest effective dose.
  • Used for a short period of time (less than 2 weeks).
• Non-sedating anxiolytic…

Recommend not to certify if the driver:

• Uses a sedating anxiolytic.
• Has symptoms or adverse effects that interfere with safe driving.36

The U.S. Air Force (USAF) specifies that a waiver is considered after an anxiety disorder is completely resolved and medications and psychotherapy have been discontinued for 6 months. In some cases continued treatment with SSRIs may be permissible.37

The Australian Federal Police do not consider candidates until they have been stable, off of all treatment for a period of time up to 2 years following use of psychotropic medication, which includes SSRI and SNRI anti-depressants by their definition. The waiting period depends on prior treatment duration. The minimum is 6 months.38

The U.S. Federal Aviation Administration (FAA) requires additional history taking for persons with history of anxiety symptoms or disorders. The examiner is required to defer issuance to the FAA. With regard to medication use: “The use of a psychotropic drug is disqualifying for aeromedical certification purposes – this includes all antidepressant drugs, including selective serotonin reuptake inhibitors (SSRIs), antianxiety drugs and sedative hypnotics.”39

However, FAA has determined that airmen requesting first-, second-, or third-class medical certificates while being treated with one of four specific SSRIs may be considered (see Item 47, Psychiatric Conditions – Use of Antidepressant Medications). The authorization decision is made on a case by case basis by the FAA, the Examiner may not issue. To qualify for consideration, individuals treated for with SSRIs who wish to fly must have been on stable dose of a listed medication for 6 months. There can be no symptoms or history of: Psychosis, Suicidal ideation, Electro convulsive therapy, Treatment with multiple SSRIs concurrently, Multi-agent drug protocol use (prior use of other psychiatric drugs in conjunction with SSRIs.39

The Railway Medical Guidelines of The Canadian Railway Association requires that railway personnel with Anxiety Disorders who serve in safety critical positions must undergo evaluation by a physician, and, at the discretion of the railway’s chief medical officer, by a psychiatrist, who will produce a written report. This report should include an assessment of the individual’s judgment, attention, insight, alertness, and also on the adverse effects of any medication.

The length of the monitoring period follow-up, the frequency of assessments and the stringency of observation required may vary depending on the individual’s diagnosis and degree of disability. Fitness-for-duty requirements of all individuals with mental disorders will be established on a case-by-case basis at the discretion of the chief medical officer.

Specific diagnoses differ in regard to the asymptomatic post-treatment period required, and special considerations40:

The National Transport Commission of Australia notes that for persons with any mental disorder, a conditional license may be considered by the driver-licensing authority subject to periodic review and taking into account the nature of the driving task and information provided by a psychiatrist as to whether the following criteria are met41:

• condition is well controlled and;
• person is compliant with treatment over a substantial period; and
• person has insight into the potential effects of their condition on safe driving; and
• no adverse medication effects that may impair their capacity for safe driving; and
• impact of co-morbidities has been considered (e.g., substance abuse).

The U.S. Army, which is the lead agency for DoD Civilian security officers, states officers should have no presence or history of, or signs associated with, the following diagnoses42:

1. Delirium, dementia, and amnestic and other cognitive
2. Major depressive disorder
3. Manic-depressive disorder (bipolar)
4. Dissociative disorders
5. Kleptomania
6. Panic disorder and other anxiety disorders (depending upon etiology, duration and severity of clinical expression)
7. Pathological gambling
8. Pyromania
9. Schizophrenia and other psychotic disorders
10. Personality disorders
11. Mental retardation
12. Alcohol or drug dependence
13. Other diagnoses not listed which may impair the performance of duties or which might endanger the lives of themselves or others

The Army further states that: “Psychiatric disorders, which could affect safe and efficient job performance, require additional evaluation to determine whether the individual is able to safely and successfully perform the essential job functions. The presence of any psychiatric disorders, or a history of such, warrants referral for further evaluation by a psychologist or psychiatrist.”42

Psychoses

The U.S. Federal Motor Carrier Safety Administration (FMCSA) recommends that commercial drivers with psychoses should not be certified until they have been asymptomatic for 6 months, 12 months if they were suicidal or psychotic features were present. Certification is not recommended for patients who display active psychosis, compromised judgment, attentional difficulties, suicidal behavior or ideation, a personality disorder which is repeatedly manifested by overt, inappropriate acts, or experiencing treatment adverse effects which interfere with driving.

“Except for a confirmed diagnosis of schizophrenia, determination may not be based on diagnosis alone. The actual ability to drive safely and effectively should not be determined solely by diagnosis but instead by an evaluation focused on function and relevant history.”36

A minimum 6-month symptom-free period is required if the diagnosis is brief reactive psychosis or schizophreniform disorder. A minimum of 1-year symptom free is required for any other psychotic disorder, except schizophrenia, which is disqualifying. The maximum period of certification is 1 year.

Recommend to certify if the driver:

• Completes an appropriate symptom-free waiting period.
• Complies with treatment program.
• Tolerates treatment without disqualifying adverse effects (e.g., sedation or impaired coordination).
• Has a comprehensive evaluation from an appropriate mental health professional who understands the functions and demands of commercial driving.

Recommend not to certify if the driver has:

• Diagnosis of schizophrenia.
• Active psychosis.
• Prominent negative symptoms, including:
  • Substantially compromised judgment.
  • Attentional difficulties.
  • Suicidal behavior or ideation.
• Personality disorder that is repeatedly manifested by overt, inappropriate acts.
• Treatment adverse effects that interfere with safe driving.

The U.S. Air Force (USAF) considers schizophrenia, schizoaffective disorder, delusional disorder, brief psychotic disorder without marked stressor(s), and shared psychotic disorder permanently disqualifying for flying duties. For other psychoses, a waiver is considered after the patient has been free of psychotic symptoms and off all mental health treatment including psychotropic medications for 1 year. A psychotic episode caused by alcohol, and occurring during the course of alcohol abuse or alcohol dependence, is considered for waiver in accordance with the waiver requirements for alcohol abuse or dependence. A psychotic episode caused by alcohol, but not in the setting of alcohol abuse or dependence, is considered for waiver according to the guidance in [the] waiver guide. In cases of psychotic disorder due to a general medical condition waiver may be considered once the psychosis and the medical condition have completely resolved and are unlikely to recur, and if the medical condition itself is waiverable.37

The Australian Federal Police do not consider candidates until they have been stable, off of all treatment for a period of time up to 2 years following use of psychotropic medication, which includes SSRI and SNRI anti-depressants by their definition. The waiting period depends on prior treatment duration (minimum is 6 months).38

The U.S. Federal Aviation Administration (FAA) advises that any applicant with a history or clinical diagnosis of Psychosis must be declined or deferred.39

The Railway Medical Guidelines of The Canadian Railway Association requires that railway personnel with psychosis who serve in safety critical positions must undergo evaluation by a psychiatrist who will produce a written report. This report should include an assessment of the individual’s judgment, attention, insight, alertness, and also on the adverse effects of any medication. Schizophrenia spectrum and other psychotic disorders other than brief psychotic disorder and delusional disorder are contraindications to employment in safety-sensitive positions. Regular follow-up reports indicating fitness for duty may be requested at the discretion of the chief medical officer.40

The National Transport Commission of Australia notes that for persons with any mental disorder, a conditional license may be considered by the driver-licensing authority, subject to periodic review, and accounting for the nature of the driving task and information provided by a psychiatrist as to whether the following criteria are met: 41

• The condition is well controlled and;
• The person is compliant with treatment over a substantial period; and
• The person has insight into the potential effects of their condition on safe driving; and
• There are no adverse medication effects that may impair their capacity for safe driving; and
• The impact of co-morbidities has been considered (e.g., substance abuse).

The U.S. Army, which is the lead agency for DoD Civilian security officers, states officers should have no presence or history of, or signs associated with, the following diagnoses42:

• Delirium, dementia, and amnestic and other cognitive disorders
• Major depressive disorder
• Manic-depressive disorder (bipolar)
• Dissociative disorders
• Kleptomania
• Panic disorder and other anxiety disorders (depending upon etiology, duration and severity of clinical expression)
• Pathological gambling
• Pyromania
• Schizophrenia and other psychotic disorders
• Personality disorders
• Mental retardation
• Alcohol or drug dependence
• Other diagnoses not listed which may impair the performance of duties or which might endanger the lives of themselves or others

The Army further states: “Psychiatric disorders, which could affect safe and efficient job performance, require additional evaluation to determine whether the individual is able to safely and successfully perform the essential job functions. The presence of any psychiatric disorders, or a history of such, warrants referral for further evaluation by a psychologist or psychiatrist.”42

Post-Traumatic Stress Syndrome (PTSD)

The U.S. Federal Motor Carrier Safety Administration (FMCSA) does not directly address PTSD or its treatment (see Anxiety above).36

The U.S. Air Force (USAF) specifies that no waiver is required for the diagnosis of PTSD if patient is able to return to full duty within 60 days with minimal symptoms at most. A waiver is required for the following patients:37

• Those who are assigned DNIF (duties not including flying) for more than 60 days;
• Those who experience a recurrence of debilitating symptoms on return to the operational environment;
• Those for whom the original symptom severity was such that in the opinion of the flight surgeon, return to the operational environment would entail high risk to the member, the mission or flight safety should the symptoms recur; and
• Most waivers granted have been for those with 6 months free of symptoms off of all pharmacotherapy.

The Australian Federal Police do not consider candidates until they have been stable, off of all treatment for a period of time up to 2 years following use of psychotropic medication, which includes SSRI and SNRI anti-depressants by their definition. The waiting period depends on prior treatment duration (minimum is 6 months).38

The U.S. Federal Aviation Administration (FAA) has no specific guidance for assessment of pilots with PTSD. There is a specific selection process for individuals treated for depressive disorder with SSRIs who wish to fly, which may be applicable to PTSD patients who use SSRIs. To qualify for consideration, they must have been on stable dose of a listed anti-depressant for 6 months. There can be no symptoms or history of: psychosis, suicidal ideation, electro-convulsive therapy, treatment with multiple SSRIs concurrently, and/or multi-agent drug protocol use (prior use of other psychiatric drugs in conjunction with SSRIs.39

The Railway Medical Guidelines of The Canadian Railway Association lists PTSD with anxiety conditions. See the entry under this heading above.40

The National Transport Commission of Australia notes that for persons with any mental disorder, A conditional license may be considered by the driver licensing authority subject to periodic review, taking into account the nature of the driving task and information provided by a psychiatrist as to whether the following criteria are met41:

• The condition is well controlled and:
• The person is compliant with treatment over a substantial period; and
• The person has insight into the potential effects of their condition on safe driving; and
• There are no adverse medication effects that may impair their capacity for safe driving; and
• The impact of co-morbidities has been considered (e.g., substance abuse).

The U.S. Army, which is the lead agency for DoD Civilian security officers, states officers should have no presence or history of, or signs associated with, the following diagnoses42:

1. Delirium, dementia, and amnestic and other cognitive disorders
2. Major depressive disorder
3. Manic-depressive disorder (bipolar)
4. Dissociative disorders
5. Kleptomania
6. Panic disorder and other anxiety disorders (depending upon etiology, duration and severity of clinical expression)
7. Pathological gambling
8. Pyromania
9. Schizophrenia and other psychotic disorders
10. Personality disorders
11. Mental retardation
12. Alcohol or drug dependence
13. Other diagnoses not listed which may impair the performance of duties or which might endanger the lives of themselves or others

The Army further states: “Psychiatric disorders, which could affect safe and efficient job performance, require additional evaluation to determine whether the individual is able to safely and successfully perform the essential job functions. The presence of any psychiatric disorders, or a history of such, warrants referral for further evaluation by a psychologist or psychiatrist.”42

Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder (ADD/ADHD)

The U.S. Federal Motor Carrier Safety Administration (FMCSA) recommends that commercial drivers with ADD/ADHD should not be certified until the etiology is confirmed and treatment has been shown to be adequate/effective, safe, and stable.

Prior to certification, the driver should have a comprehensive evaluation from an appropriate mental health professional who understands the functions and demands of commercial driving. The driver must be compliant with the treatment program, and tolerate treatment without disqualifying adverse effects (e.g., sedation or impaired coordination). No specific waiting period is recommended.

Certification is not recommended for patients who display active psychosis, compromised judgment, attentional difficulties, suicidal behavior or ideation, a personality disorder which is repeatedly manifested by overt, inappropriate acts, or experiencing treatment adverse effects which interfere with driving. Annual recertification is recommended.36

The U.S. Air Force (USAF): A confirmed diagnosis of ADHD was disqualifying for all classes of flying until 2009. Since then, ADHD is no longer considered disqualifying if the individual can demonstrate passing academic performance and there has been no medication use in the past 12 months. With the policy change and the increased incidence of diagnosis in the community, aviators with a diagnosis of ADHD or a history of such are more common. ADHD is only disqualifying for flying duties in the USAF if the applicant requires the use of medication or if there is demonstrated academic performance failure.37

The Australian Federal Police do not consider candidates until they have been stable, off all treatment for a period of time up to 2 years following use of psychotropic medication, which includes SSRI and SNRI anti-depressants by their definition. Waiting period depends on prior treatment duration (minimum is 6 months).38

The U.S. Federal Aviation Administration (FAA) Pilots with ADHD must be deferred by the examiner and FAA has a specific disease protocol for evaluation of ADHD patients which includes detailed specifications for neuro-psychological evaluation.39 The following must be submitted to the FAA for consideration:

• Review of all available records, including academic records, records of prior psychiatric hospitalizations, and records of periods of observation or treatment (e.g., psychiatrist, psychologist, or pediatric neuropsychiatrist treatment notes). Records must be in sufficient detail to permit a clear evaluation of the nature and extent of any previous mental disorders.
• A thorough clinical interview to include a detailed history regarding psychosocial or developmental problems; academic and employment performance; legal issues; substance use/abuse (including treatment and quality of recovery); aviation background and experience; medical conditions, and all medication use; and behavioral observations during the interview and testing.
• Mental status examination.
• Interpretation of a full battery of neuropsychological and psychological tests including but not limited to the core test battery (specified below).
• An integrated summary of findings with an explicit diagnostic statement, and the neuropsychologist’s opinion(s) and recommendation(s) regarding clinically or aeromedically significant findings and the potential impact on aviation safety consistent with the Federal Aviation Regulations.
• Results of a urine drug screening test for ADD/ADHD medications, including psychostimulant medications. The sample must be collected at the conclusion of the neurocognitive testing or within 24 hours afterward.
• Specific neuropsychological tests are listed.

The Railway Medical Guidelines of The Canadian Railway Association states that individuals suffering from ADD/ADHD cannot work in a safety critical position if their symptoms affect their ability to perform their duties in a safe, predictable manner. They must be assessed by their own physician or a psychiatrist who is required to submit a written report to the chief medical officer. This report must include an assessment of the individual’s judgement and attention and also on the adverse effects of any medication. Regular follow-up reports indicating fitness for duty may be requested at the discretion of the chief medical officer.40

The National Transport Commission of Australia notes that for persons with any mental disorder, a conditional license may be considered by the driver licensing authority, subject to periodic review and accounting for the nature of the driving task and information provided by a psychiatrist as to whether the following criteria are met41:

• The condition is well controlled and;
• The person is compliant with treatment over a substantial period; and
• The person has insight into the potential effects of their condition on safe driving; and
• There are no adverse medication effects that may impair their capacity for safe driving; and
• The impact of co-morbidities has been considered (e.g., substance abuse).

The U.S. Army, which is the lead agency for DoD Civilian security officers, states officers should have no presence or history of, or signs associated with, the following diagnoses42:

1. Delirium, dementia, and amnestic and other cognitive disorders
2. Major depressive disorder
3. Manic-depressive disorder (bipolar)
4. Dissociative disorders
5. Kleptomania
6. Panic disorder and other anxiety disorders (depending upon etiology, duration and severity of clinical expression)
7. Pathological gambling
8. Pyromania
9. Schizophrenia and other psychotic disorders
10. Personality disorders
11. Mental retardation
12. Alcohol or drug dependence
13. Other diagnoses not listed which may impair the performance of duties or which might endanger the lives of themselves or others

The Army further states that: “Psychiatric disorders, which could affect safe and efficient job performance, require additional evaluation to determine whether the individual is able to safely and successfully perform the essential job functions. The presence of any psychiatric disorders, or a history of such, warrants referral for further evaluation by a psychologist or psychiatrist.”42