Suicidal Ideation at 35,000 feet: Duty to Warn versus Right to Privacy

Suicides are always tragic, but the nightmarish crash of Germanwings Flight 4U9525, in which co-pilot Andreas Lubitz killed himself and 149 others on March 24, raises issues of special concern to psychiatry. Aircraft-assisted suicides are rare and usually involve middle-aged men dying alone in private planes. Much rarer are suicide-homicides by commercial airline pilots. Only a few have ever been reported (none by American pilots), but despite the rarity of what he did, Lubitz's actions raise questions for all of us.

What if you were the psychiatrist, and Lubitz told you, as he allegedly did a former girl friend, that “One day I will do something that will change the whole system, and then all will know my name and remember it.” That alone probably wouldn't qualify for a Tarasoff-based "duty to warn," but, combined with a history of severe depression, it would certainly merit further exploration. Most narcissistically-injured patients (and virtually all would-be mass murderers) like to talk about their victimhood and dreams of vengeance. Paranoid features and determination to act without interference may, of course, result in concealment of specific intent, but when clinical judgment sounds the alarm, it is a major challenge to decide when and how to cease being a supportive ally and to act against what the patient believes to be in his or her best interests.

Our UCLA colleague Dr. Roderic Gorney taught that feeling the hair standing up on the back of one's neck was a useful diagnostic signal. "Gorney's Sign," while never subjected to randomized controlled studies, is definitely worthy of attention --  as is the anxiety that a patient might harm others or oneself. Being trained to value intuition and subjectivity along with scientific evidence is the best preparation for cases such as these. Prior experience in handling dangerous individuals helps too. Consultation with more experienced colleagues and with legal advisors before involving outside authorities is highly recommended. 

Unfortunately, the medical evaluations of unfitness to fly and antidepressant treatments received by Andreas Lubitz before March 24th, failed to avert disaster. He hid all of it apparently for fear of losing his job and his cherished freedom to fly. What kind of system would expect otherwise? Where is the airline physicians' "duty to warn," on which passengers lives may depend? In modern Germany the right to privacy seems to have trumped all in the wake of past totalitarian regimes. The Germanwings tragedy suggests that there has to be a secure way for doctor-patient communication (and cockpit doors) to be opened when innocent lives are at stake. 

There was more going on to add to Lubitz's stresses and more will undoubtedly be revealed as the investigation continues. However, when a high visibility crime is committed by someone undergoing psychiatric treatment, a hue and cry inevitably arises at both poles of the treatment advocacy spectrum -- "not enough" versus "too much." As psychiatrists we have no difficulty recognizing that society usually errs on the side of "not enough," but many disagree with us.

Two airplane pilots in my own practice offer examples (details altered):

Case 1: DF, a 24 year old man in treatment for mild to moderate depression, had, like Lubitz, wanted to be an airplane pilot since childhood. He obtained a general aviation pilot's license while undergoing psychotherapy and receiving antidepressants. His depression remitted, and he soon became employed in the airline industry as a mechanic. He now flies private planes recreationally and still nourishes hopes of flying passenger jets. He is not a danger to himself or others at this time. 

Case 2: In 2004 ML, a 58 year old moderately depressed commercial airline pilot, refused antidepressant treatment because, if the airline doctors found out, it would have prevented his being medically cleared to keep flying. As soon as he was qualified for retirement, ML began taking antidepressants and his depression improved. All this happened before 2010, when the FAA began allowing pilots in remission from depression "Special Issuance" medical certificates to fly while receiving one of the SSRIs fluoxetine, sertraline, citalopram or escitalopram. ML was never actively suicidal, but having to forego receiving antidepressants to keep his job increased his risk.

Even under the new policy, the restriction to four SSRIs is not ideal. There is no evidence that patients in remission using SNRIs or NDRIs or combinations of SSRIs with other agents are a greater risk in the cockpit than those taking only one of the FAA endorsed SSRIs. In some cases, where remission might be even more assured on another regimen, it would be illogical not to allow it. An example might be the pilot who experiences reduced motivation or increased tiredness on an SSRI. He or she might achieve better remission by augmenting with or switching to a more activating class of antidepressant.

What role should psychiatry play in influencing FAA policies such as this one? Some would say "as little as possible." They are the vocal minority who believe that people receiving antidepressants are in danger of becoming suicidal as a side-effect of the treatment. (The FDA has promoted this group's agenda with the controversial "black box" warning that antidepressants can cause suicidality.)  People are already proclaiming online that antidepressants were the cause of Lubitz's deadly act. Most studies suggest that in adults old enough to qualify for a pilot's license the opposite is much more likely -- antidepressants such as SSRIs reduce rather than increase the probability of suicide. Even so, it is standard practice in our profession to monitor patients taking psychiatric medications regularly to ensure that their treatment is optimal and side-effects are minimal. Assessing suicidality is part of standard care for depressed patients. Symptom rating scales are being used  with increasing frequency to assist clinicians in this practice. 

While there is ample evidence that treatment for depressed patients reduces suicides and suicide-homicides, mass murderers are a separate category, typically less amenable to the treatments at our disposal. The higher the level of sociopathy (I think the term "psychopath" still captures it best), the more difficult it is to gain leverage over dangerousness. In the worst cases the opposite dynamic from depression rules, although the outcomes may be superficially indistinguishable. In depressive suicide-homicide, despair leads to the wish for self-annihilation and secondarily the killing of one's dependents such as children and/or spouses. In mass murderers, the intense desire to wreak vengeance on others is primary. The killer's own death while doing so may be a concomitant objective rendered desirable by the fantasy of perpetual notoriety. It  might have been this piece of the diagnostic picture that rendered Lubitz's depression so much more dangerous than others. He may therefore have perpetrated a rare type of human tragedy, but it was a perfect storm of personal, medical and economic factors that are not at all rare. Any threat to cherished hopes and dreams can start people on a steep descent which may, in the end, become their chosen path. 

We can help society deal with these issues by becoming better at discovering and communicating root causes and providing treatments. Root causes will inevitably involve complex interplays of biological, psychological and sociocultural forces. Valid treatments will correspondingly require the skills of many kinds of professionals, supported by enlightened economic and social policies. Nightmarish events sometimes inspire positive change. We should support any that might help avert tragedies such as this one.