Europeanhhm

Covid-19 and Aviation Mental Health

Robert Bor, Professor of Clinical Psychology, Royal Free Hospital, London

Alpo Vuorio, Adjunct Prof, Specialist in Occupational Medicine, AME, Master of Aviation Medicine, Mehilinen Airport Healthcare Centre

The risks to pilots regarding their overall health have been raised due to COVID-19 pandemic. The links between negative mental health consequences and unemployed threats have been shown in the general population. Access to medical and mental support should be noted and improved.  This may help pilots to manage better manage personal challenges and decrease some of the negative economic effects of the pandemic and could also indirectly improve aviation safety. We discuss issues related to the potential increased risk of suicide, self-harm and long COVID-19 symptoms among aviation personnel.

While globally the aviation industry is gradually recovering from the COVID-19 pandemic it is not yet totally clear how badly pilots and cabin crew mental health suffered during this exceptional period. Some of the concerns regarding flying personnel mental health are supported by studies carried among them and some of the concerns come from the general population-specific mental health problems during the pandemic. The systematic review including 247 studies of COVID-19 pandemic shows that it was correlated for poorer mental health during COVID-19 pandemic was associated among other things with pre-existing medical conditions, financial stress and loneliness in the general population (Leung et al., 2022). Among cabin crew the early phase of the COVID-19 pandemic with work restrictions was associated with severe impairment of mental health (Görlich and Stadelmann, 2020).  Already during the early phase of pandemic it was recommended that extensive mental health-related preventive measures be promoted in society (Holmes et al., 2020).

Risk of pilot suicide

It is known that the risk of suicide in commercial aviation is very rare. In general aviation in the United States this risk has been shown to be about 0.33% in fatal aviation accidents (Vuorio et al., 2014). While the association between pilot suicide and substantial social change is not studied, it has been shown that sudden changes in the society may have significant impact on mental well-being. This has been shown in one study which found that pilot suicide increased in the year following the 9/11 terrorist attack in New York (Vuorio et al., 2018). It can be argued that it is possible that ongoing pandemic effects may also include self-harm among pilots either during the off-duty or in the worst scenario during the duty (Vuorio et al., 2020). Currently, there is one commercial aircraft accident case under investigation which may be associated with deliberate pilot actions related to mental health. It is recommended that any pilot with risk of self-harm needs early access to support and healthcare. Healthcare personnel need to aware of this risk when treating pilots.

Self-harm in aviation

Several mental health problems like borderline personality disorder, depression, bipolar disorder and drug and alcohol-use disorders are associated with self-harm (Knipe et al., 2022). Unfortunately, the impact of self-harm in aviation has not been studied in aviation. It is not clear what is the impact of COVID-19 is to self-harm (Farooq et al., 2021). It has been postulated that it is possible that when COVID-19 pandemic final ends, self-harm and suicide rates may yet increase (World Psychiatric Association, 2020). The European Aviation Safety Authority (EASA) recommends individual-based risk analysis in self-harm suspected cases (EASA, 2022). Protective factors such as resilience training can be seen to strengthen aeromedical mental health care systems and occupational health well-being services (World Psychiatric Association, 2020; Vuorio&Bor, 2021).

Flight crew mental health and down-route quarantine

While it is accepted that international flight traffic is essential for transportation, there is a concern that in fluctuating pandemic situations flight crew are quarantined in physical circumstances which may cause mental harm (Vuorio et al., 2022). There is currently no international agreement as to how crew quarantine measures need to be carried out for the mental health protection of flight crew. It has been shown in a systematic review that mental health improved for depressive disorders and anxiety disorders when the quarantine lasted over one week (Henssler et al., 2021). Because of this risk, it is important to establish an international agreement for the minimal physical conditions for the flight crew who experiences quarantine to avoid mental health problems (Vuorio et al., 2022).

Conclusion
COVID-19 pandemic poses actual and theoretical increased risk of mental health issues, especially for flight personnel. There is a need to increase mental health services and keep aero-medical occupational health care protective and active. The awareness of the potential increased risk of mental health problems among flight crew needs to be recognized among all doctors and psychologists working with this personnel.

References

European Aviation Safety Authority (EASA). (2022). Available online: www.easa.europa.eu
Farooq, S., Tunmore, J., Wajid Ali, M., &Ayub, M. (2021). Suicide, self-harm and suicidal ideation during COVID-19: A systematic review. Psychiatry Research, 306, 114228.
Farooq, S., Tunmore, J., Wajid Ali, M., &Ayub, M. (2021). Suicide, self-harm and suicidal ideation during COVID-19: A systematic review. Psychiatry Research, 306, 114228.
Görlich, Y., &Stadelmann, D. (2020). Mental health of flying cabin crews: depression, anxiety, and stress before and during the COVID-19 pandemic. Frontiers in Psychology, 11, 581496.
Henssler, J., Stock, F., van Bohemen, J., Walter, H., Heinz, A., & Brandt, L. (2021). Mental health effects of infection containment strategies: quarantine and isolation-a systematic review and meta-analysis. European Archives of Psychiatry and Clinical Neuroscience, 271(2), 223–234.
Holmes, E. A., O'Connor, R. C., Perry, V. H., Tracey, I., Wessely, S., Arseneault, L., Ballard, C., Christensen, H., Cohen Silver, R., Everall, I., Ford, T., John, A., Kabir, T., King, K., Madan, I., Michie, S., Przybylski, A. K., Shafran, R., Sweeney, A., Worthman, C. M., … Bullmore, E. (2020). Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry, 7(6), 547–560.
Knipe, D., Padmanathan, P., Newton-Howes, G., Chan, L. F., &Kapur, N. (2022). Suicide and self-harm. Lancet, 399(10338), 1903–1916.
Leung, C., Ho, M. K., Bharwani, A. A., Cogo-Moreira, H., Wang, Y., Chow, M., Fan, X., Galea, S., Leung, G. M., & Ni, M. Y. (2022). Mental disorders following COVID-19 and other epidemics: a systematic review and meta-analysis. Translational Psychiatry, 12(1), 205.
Vuorio, A., Laukkala, T., Navathe, P., Budowle, B., Eyre, A., &Sajantila, A. (2014). Aircraft-assisted pilot suicides: lessons to be learned. Aviation, Space, and Environmental Medicine, 85(8), 841–846.
Vuorio, A., Laukkala, T., Junttila, I., Bor, R., Budowle, B., Pukkala, E., Navathe, P., & Sajantila, A. (2018). Aircraft-assisted pilot suicides in the general aviation increased for one-year period after 11 September 2001 attack in the United States. International Journal of Environmental Research and Public Health, 15(11), 2525.
Vuorio, A., &Bor, R. (2020). Black swan pandemic and the risk of pilot suicide. Frontiers in Public Health, 8, 573006.
Vuorio, A., &Bor, R. (2021). Self-harm in aviation medicine- acomplex challenge during a pandemic. Frontiers in Public Health, 9, 681618.
Vuorio, A., Bekker, A., Suhonen-Malm, A. S., &Bor, R. (2022). Promoting flight crew mental health requires international guidance for down-route quarantine circumstances. Frontiers in Public Health, 10, 854262.
World Psychiatric Association (2020). Suicide prevention during and after the COVID-19 pandemic evidence based recommendation. Available online: https://www.wpanet.org/post/suicide-prevention-during-and-after-the-covid-19-pandemic-evidence-based-recommendations-2020

Robert Bor

Robert Bor (DPhil) is Professor of Clinical Psychology, Royal Free Hospital, London, an aviation psychologist, and Director of the Centre for Aviation Psychology, London. He serves on the Board of the European Association for Aviation Psychology and runs the British Psychological Society course on Clinical Skills in Aviation Psychology. He is Honorary Fellow of the Royal Aeronautical Society and a Winston Churchill Fellow.

Alpo Vuorio

Alpo Vuorio (MD, PhD) Adjunct Professor is a specialist in occupational medicine. He has completed MSc in Aviation Medicine, MSc in Human Factors and System Safety, MSc in Air Safety Management, MSc in International and Travel Medicine and MSc in Aircraft Accident Investigation. He works as an AME at Helsinki Airport and in Finnish SIA. His research efforts focus on diseases affecting performance in aviation.

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