2024.07.03 - Psychiatry (De Rooy).pdf

PSYCHIATRY ESAM BASIC TRAINING COURSE JULY 2024 DIEDERIK DE ROOY, LLM, MD, PHD FOR THE VIDEO Please click on the link if you have difficulties playing it Psychiatry - De Rooy 3-7-2024 2 DISCLOSURES Paid expert advisor of MESAFE p...

PSYCHIATRY ESAM BASIC TRAINING COURSE JULY 2024 DIEDERIK DE ROOY, LLM, MD, PHD FOR THE VIDEO Please click on the link if you have difficulties playing it Psychiatry - De Rooy 3-7-2024 2 DISCLOSURES Paid expert advisor of MESAFE project by EASA With regards to MESAFE-project: personal opinion of team, NOT of EASA (but still useful to learn about!) Psychiatry - De Rooy 3-7-2024 3 CONTENTS Introduction Mental complaints, mental disorders and diagnosis and classification and risks How to identify mental health risks? History Mental status examination Questionnaires Questions and Break Collaboration with mental healthcare professionals New development: EASA MESAFE and new approach to risk assessment (If time) some cases to discuss & Questions Psychiatry - De Rooy 3-7-2024 4 INTRODUCTION – ABOUT ME Psychiatrist, also studied law Clinical director GGZ Transparant, Leiden, the Netherlands Independent consultant for occupational medicine specialists Aviation psychiatrist EASA MESAFE project Mental Health Working Group and Research group of AsMA Active participant in other aerospace medicine projects Psychiatry - De Rooy 3-7-2024 5 AND YOU? Please tell me Where are you from? What is your professional background? Psychiatry - De Rooy 3-7-2024 6 WHAT DO WE WANT TO IDENTIFY? Mental health complaints or functional impairments? Mental disorders? A classification of symptoms according to the DSM or ICD? Risks caused by mental disorders? All of the above? Psychiatry - De Rooy 3-7-2024 7 WHAT’S IN A NAME? Mental complaints not necessarily indicate a mental disorder It is common practice to classify mental disorders (eg by DSM or ICD) Diagnosing a mental disorder is different from making a classification Although regulations primarily mention mental disorders, in aerospace medicine it is actually about the aviation related risks caused by mental disorders Psychiatry - De Rooy 3-7-2024 8 EASA SAYS: Mental health assessment as part of class 2 aero-medical examination (1) A mental health assessment should be conducted and recorded taking into account social, environmental and cultural contexts. (2) The applicant's history and symptoms of disorders that might pose What is the difference? a threat to flight safety should be identified and recorded. (3) Where there are signs or is established evidence that an applicant may have a psychiatric or psychological disorder, the applicant should be referred for specialist opinion and advice. 4) Established evidence should be verifiable information from an identifiable source related to the mental fitness or personality of a particular individual. Sources for this information can be accidents or incidents, problems in training or proficiency checks, behaviour or knowledge relevant to the safe exercise of the privileges of the applicable licence(s). Psychiatry - De Rooy 3-7-2024 9 FROM AN AVIATION PSYCHIATRIST’S PERSPECTIVE The ultimate goal of the examination is to identify risks caused by mental health problems To this end, it is primarily important to identify symptoms of mental disorders For practical reasons, it is good to assume that if there is a significant risk caused by one or more mental health problems, there is also a diagnosis that can be made Preferably, this diagnosis can be replicated by others and in different circumstances To this end, the use of a classification system is useful Psychiatry - De Rooy 3-7-2024 10 HOW TO IDENTIFY MENTAL PROBLEMS - HISTORY No strict order, most important: to create a trusted atmosphere If possible: try to establish some casual conversation first or even try to interweave questions with regards to mental function with it Are there any mental complaints? Any mental health problems in the past? Discuss someone’s normal life, for example, can he/she describe a regular day? And what does he/she like to do when free of work? Any hobbies? If positive or negative events are reported, what emotion did the applicant feel? Did it make him/her sad, angry, or didn’t he/she feel any emotion at all? Used peer support program? Psychiatry - De Rooy 3-7-2024 11 SOME SYMPTOMS TO CHECK: Symptoms of the major mental health conditions like depressive and anxiety disorders are checked, with questions on Mood, sleep, appetite, concentration, feelings of anger and guilt, suicidal feelings Anxiety, panic, obsessive-compulsive complaints Psychotic symptoms (hearing voices, thinking conspiracies or supernatural things are going on) Traumatic events and if these still give complaints Manic symptoms Deliberate self-harm Problems with eating (binge-eating, deliberate excessive weight loss, induced vomiting etc) Always: substance use and addictions , family history for mental complaints, (somatic symptoms) Psychiatry - De Rooy 3-7-2024 12 SOCIAL AND BIOGRAPHICAL HISTORY Relationship, children, and how relations with friends and families and work are Many mental disorders may cause problems in relationships with other people, but especially personality problems deeply influence social functioning Professional education and work history are addressed Later relationships, someone’s current relationship and someone’s current relationships with family and friends Biographical information Psychiatry - De Rooy 3-7-2024 13 BIOGRAPHY Any problems and complications during gestation, at birth or in infancy First memories and relationships with the parents and brothers and sisters Going to kindergarten and primary school (friends, if someone had any problems with learning, if there were any problems with teachers, and if someone had been bullied) Secondary school If family relations changed during this period, if someone’s parents stayed together or got divorced, etcetera Psychosexual development and possible early relationships, (may be discussed in a superficial way as questions about this may be perceived as being intrusive) Upon indication, for example if someone reports having experienced negative events or other problems with this, more extensively Psychiatry - De Rooy 3-7-2024 14 SOME TIPS: Develop your own routine! Try to make it a smooth conversation, not just checking symptoms When you need to check symptoms: explain this A lot of information comes from non-verbal sources, especially during history taking! Not al (aspiring) pilots will be completely honest So watch your applicant! Psychiatry - De Rooy 3-7-2024 15 POSSIBLE INDICATIONS SOMEONE IS NOT TELLING THE TRUTH Discrepancies and inconsistencies Things that are highly uncommon Giving very short answers Giving unclear answers Refusal to share information form healthcare providers Refusal to allow using other sources of information (e.g. hetero-anamnesis) As a doctor: only conclude information is unclear, discrepancies exists etc. No judgements, no accusations! Psychiatry - De Rooy 3-7-2024 16 MENTAL STATUS EXAMINATION Perhaps most important: first impressions! Is your applicant: well-cared, wearing any remarkable clothing, making good contact? Friendly, formal, hostile etc? Difficulties in establishing some casual talk about work, family or hobbies may indicate the presence of a mental disorder (of course, some tension may be normal) Note the speech Psychiatry - De Rooy 3-7-2024 17 WHO IS THE BIGGEST CHALLENGE FOR THE AVIATION PSYCHIATRIST? https://www.youtube.com/watch?v=qUmI4A7VKyk Psychiatry - De Rooy 3-7-2024 18 Psychiatry - De Rooy 3-7-2024 19 COGNITIVE FUNCTIONING AND MOOD Which disorders? Alertness, memory and concentration are assessed. In most cases, this is done implicitly, but in case of any doubt direct questions (eg “Do you know which day it is today?”). Intelligence and insight in the mental functioning. Hallucinations (hearing voices, seeing, feeling, tasting or smelling things someone else cannot)? Thinking Form (fast, slow, associations) and content (preoccupations, delusions) Often implicitely, in case of doubt specific questions (eg. “Do you feel that a conspiracy is going on towards you? Do you feel that you have any supernatural powers?”). Psychiatry - De Rooy 3-7-2024 20 MOOD AND AFFECT Mood: longer term Affect: short term (visible and audible expression of the emotional reaction of the patient on internal and external stimuli and occurrences) Most times mood and affect are in line How would you describe mood and affect here? https://www.youtube.com/watch?v=qUmI4A7VKyk Psychiatry - De Rooy 3-7-2024 21 Psychiatry - De Rooy 3-7-2024 22 SUICIDAL FEELINGS Always good to ask! Which disorders? “Do you sometimes feel so bad that you think you would be better off dead?” à explore what the patient actually thinks Thinking of dead is not uncommon Suicide risk assessment: quality of the contact and epidemiological risk factors Psychiatry - De Rooy 3-7-2024 23 EPIDEMIOLOGICAL RISK FACTORS FOR SUICIDE Previous suicide attempt and self-harm/ self-destructive behaviour Lethality of the attempt Suicidal thoughts and intentions, any preparations made for a suicide attempt Means available for suicide attempt Older age Male gender Loss of friends and relatives; bereavement Negative life-events Somatic disease and pain Unemployment Psychiatry - De Rooy 3-7-2024 24 AGRESSION AND OTHER CONDUCT PROBLEMS Pay attention to a history of agression problems, conduct problems etc. Previous aggressive behaviour Conduct problems before the age of 12 Antisocial or impulsive behaviour Substance abuse Lack of intimate relationships & social abilities Lack of coping mechanisms Psychiatry - De Rooy 3-7-2024 25 SUBSTANCE USE/ ABUSE What are disorders due to….? EASA: 8) Disorders due to alcohol or other psychoactive substance(s) use or misuse (i) Applicants with mental or behavioural disorders due to alcohol or other psychoactive substance(s) use or misuse, with or without dependency, should be assessed as unfit. (A) In the case of a positive drug or alcohol result, confirmation should be required in accordance with national procedures for drugs and alcohol testing. (B) In case of a positive confirmation test, a psychiatric evaluation should be undertaken before a fit assessment may be considered. (iii) A fit assessment may be considered after a period of two years of documented sobriety or freedom from psychoactive substance use or misuse. At revalidation or renewal, a fit assessment may be considered earlier with an OSL or OPL. Depending on the individual case, treatment and evaluation may include in-patient treatment of some weeks and Inclusion into a support programme followed by ongoing checks, including drug and alcohol testing and reports resulting from the support programme, which may be required indefinitely. Psychiatry - De Rooy 3-7-2024 26 SUBSTANCE USE/ ABUSE: CHALLENGES Alcohol use/ misuse vs substance use disorder Requirements for aviation are more strict than diagnostic criteria As doctors: - Substance use disorder - Comorbidity or substance use a symptom of another disorder Always ask, in case of doubt: repeat questions in different ways. If applicable, other sources of information. Testing? Psychiatry - De Rooy 3-7-2024 27 PROTECTIVE FACTORS Very important to address! Good social support Having responsibilities towards others Active involvement in religious community Good therapeutic relationship Psychiatry - De Rooy 3-7-2024 28  QUESTIONNAIRES AND STRUCTURED INTERVIEWS Can be useful to support the assesment, not to replace the interview! Answers will often not be honest Pilots often found questions unclear Use a questionnaire that is well-studied and validated (eg. SQ-48, PHQ-9) Preferably often used in the county you are practicing in Use of a structured interview may be considered Psychiatry - De Rooy 3-7-2024 29 QUESTIONS AND BREAK Psychiatry - De Rooy 3-7-2024 30 INFO FROM MENTAL HEALTHCARE PROVIDERS Always obtain information on previous mental health examinations/ treatments (Written) consent from the applicant Eg. Letters to GP. If necessary, obtain information from provider directly Only ask factual information (diagnosis made, treatment, treatment results, any complaints still existing etc) No judgement on flying capabilities Psychiatry - De Rooy 3-7-2024 31 PLEASE REMEMBER The applicant’s own GP, psychiatrist, psychologist is NOT completey impartial and may be biased Be careful when consent is retracted or not given! Psychiatry - De Rooy 3-7-2024 32 REFERRAL TO A MENTAL HEALTH EXPERT In case of doubt Preferably with some interest in/ knowledge of aviation If possible, discuss referral and questions first Factual questions What to do when consent is Is there a mental disorder? retracted? If so, which one and classification Is there is no conclusion due to lack of info/ cooperation? (Aviation related risks) (Written) consent from the applicant A doctor can never determine someone’s piloting capabilities Psychiatry - De Rooy 3-7-2024 33 REFERRAL ACCORDING TO EASA RULES: (1) In case a specialist evaluation is needed, following the evaluation, the specialist should submit a written report to the AME, AeMC or medical assessor of the licensing authority as appropriate, detailing their opinion and recommendation. (2) Psychiatric evaluations should be conducted by a qualified psychiatrist having adequate knowledge and experience in aviation medicine. (3) The psychological opinion and advice should be based on a clinical psychological assessment conducted by a suitably qualified and accredited clinical psychologist with expertise and experience in aviation psychology. (4) The psychological evaluation may include a collection of biographical data, the administration of aptitude as well as personality tests and clinical interview. Psychiatry - De Rooy 3-7-2024 34  MESAFE Funded by EU Horizon project/ EASA for new medical developments for the early diagnosis as well as treatment of mental health conditions which could pose a safety risk for aviation and would consequently lead to pilot and air traffic controller (ATCO) unfitness or the limitation of their medical certificate for safety purposes. Evidence-based recommendations for updating the mental health requirements in Part-MED and Part-ATCO.MED in line with the medical developments Evidence-based recommendations for mental health assessment methods suitable for aeromedical fitness assessments An impact assessment of the recommended regulatory changes and guidance material Just finished (April 2024) Psychiatry - De Rooy 3-7-2024 35 MESAFE Main focus on commercial pilots and ATCO’s, results may also be applicable to class 2 pilots Interesting developments to read, many information materials Check the website: https://www.easa.europa.eu/en/research-projects/mesafe-mental-health https://de.linkedin.com/company/mesafe-project?trk=public_post_follow-view-profile New way of assessing risks Psychiatry - De Rooy 3-7-2024 36 RISK ASSESSMENT BY MESAFE Towards a more tailored approach of risk assessment Focus on risks of mental health events, not on disorders Just culture approach to mental health Medication: focus on risk in individual, instead of type of medication Proposal determination by medical board complicated risks MIRAP process à Risk matrix Psychiatry - De Rooy 3-7-2024 37  The MIRAP steps Gate 2 Gate 1 Gate 3 Step 7 Step 6 Step 5 Step 4 Step 3 Step 1 Identify any Step 2 Determine Assess the Apply risk Issue limitations (including post real or the Severity MIEs risk mitigation traumatic stress potential of MIEs level measures mitigation measures) MIEs Determine Risk is not Assess the Risk is not MIEs the acceptable new risk acceptable probability of level NO MIEs occurrence Risk is Risk is Provide fitness of MIEs acceptable acceptable certification STEP 1 – IDENTIFY ANY REAL OR POTENTIAL MIE STEP 1 OUTPUT INPUT Identify any real or potential MIE(s) Any example of an MIE? Professional Psychosocial history: history: simulator data PROFESSIONALS APPROACH NO REAL OR life stressors incidents/accidents TO CALL FOR ADVICE POTENTIAL MIEs protective factors work-related Just-culture stressors oriented focus LIST OF REAL OR Mental health on safety risk POTENTIAL MIEs Previous Independent specialist MHS’ records: in which the applicant aeromedical records certified mental SUPPORT TOOLS could incur to in the near AMES’ disorders REQUIREMENTS future prescribed Interview treatment checklist & Interview skills & target Mental Health questionnaires knowledge STEP 2 – DETERMINE THE MIE(s)’ SEVERITY LEVEL STEP 2 OUTPUT INPUT Determine the MIE(s)’ severity level PROFESSIONALS TO BE DIRECTLY INVOLVED List of MIEs APPROACH Classification of the identified in Step 1 Mental health Link between the MIE(s) identified in specialist MIE(s) identified Step 1 into Instructors / and mental examiners disorders (already catastrophic, certified / hazardous, major, potentially SUPPORT TOOLS AMES’ unnoticed) minor or negligible REQUIREMENTS Evaluation of Epidemiology potential biological Clinical information Interview skills & treatment’s side- Previous certification Mental Health effects Operational knowledge Evaluation of environment protective factors information STEP 3 – DETERMINE THE MIE(s)’ PROBABILITY LEVEL STEP 3 OUTPUT INPUT Determine the MIE(s)’ probability level List of MIEs PROFESSIONALS APPROACH Classification of the identified in TO BE DIRECTLY Step 1 INVOLVED Link between the MIE(s) identified in MIE(s) identified Step 1 into frequent, Mental health and mental specialist disorders (already occasional, remote, certified / improbable, potentially SUPPORT TOOLS AMES’ unnoticed) extremely improbable REQUIREMENTS Evaluation of Timeline of past MIEs potential biological Epidemiology Interview skills & treatment’s side- Clinical information Mental Health effects knowledge Evaluation of protective factors STEP 4 – ASSESS THE MIE(s)’ RISK LEVEL STEP 4 OUTPUT INPUT Assess the MIE(s)’ risk level Severity and probability PROFESSIONALS APPROACH Determine if the risk levels of MIEs TO CALL FOR identified in ADVICE Risk assessment associated with the Step 1 MIE(s) identified in The Aeromedical Step 1 is acceptable Operational SUPPORT TOOLS Board (AMOB) AMES’ REQUIREMENTS The MESAFE matrix Risk Assessment & Mental Health knowledge MIE 2 MIE 1 STEP 5 – APPLY RISK MITIGATION MEASURES STEP 5 OUTPUT INPUT Any example of Apply risk mitigation measures an MIE? MIE(s) scores PROFESSIONALS APPROACH Scenarios in which on the MESAFE TO CALL FOR matrix ADVICE Risk assessment the limitations are implemented The Aeromedical Operational SUPPORT TOOLS Board (AMOB) AMES’ REQUIREMENTS List of individual, organisational and Risk medical limitations Assessment & Mental Health knowledge STEP 6 – ASSESS THE NEW RISK LEVEL STEP 6 OUTPUT INPUT Assess the new risk level Scenarios in PROFESSIONALS APPROACH which the TO CALL FOR Determine if the limitations are ADVICE Risk assessment limitations are able to implemented mitigate the MIE(s) The Aeromedical risk Operational SUPPORT TOOLS Board (AMOB) AMES’ REQUIREMENTS The MESAFE matrix Risk Assessment & Mental Health knowledge STEP 7 – FINAL DECISION STEP 7 OUTPUT INPUT Final decision PROFESSIONALS APPROACH TO CALL FOR Certification New risk levels ADVICE Risk assessment Limitations Licence suspension The Aeromedical Operational SUPPORT TOOLS Board (AMOB) AMES’ REQUIREMENTS The MESAFE matrix Risk Assessment & Mental Health knowledge STEP 7 It is important to discuss with the applicant the results of the aeromedical mental health assessment, especially when limitations are applied or the license has to be suspended. To mitigate the post-traumatic stress effects of the license suspension, such discussion should cover the following: · Transparent communication on the risk identified and reasons underlying the decision of issuing limitations/suspension; · Clear identification and agreement about next steps, that should cover financial aspects, professional reorientation and mental health treatment. The same can be applied when reduced acceptance of limitations is probable. Treatment In general (stable) treatment will mitigate risks, may be mitigating risks Tailored approach, risks vs side-effects Risks caused by disorder and side-effects treatment Total compatibility with flight duties = compatibility of the underlying disorder x compatibility of the biological treatment (risks and side-effects) x benefits of the biological treatment. CASE 1 Male, 22 years old, initial class 2 examination Starts flying as a hobby, student aeronautical sciences Diagnosed at age 12 with Asperger syndrome (autism spectrum disorder). Only treatment then social communication training. No further treatment. At this moment no mental complaints. Lives in a student home, has some friends, good contact with family. Impression: maybe a bit shy, but feels like talking to a normal student. No abnormalities on mental examination. What do you do? Psychiatry - De Rooy 3-7-2024 49 CASE 2 Female pilot, captain A320, 43 years, annual visit class 1 medical Reports no complaints. When asked about mood, ‘it’s OK, nothing special’. Admits feeling tired because of bad sleeping. Also having some stress due to work, afraid of loosing her job. Teenage sons cause a lot of trouble. Then, she starts crying, but a minute later, she says, ‘it’s OK’, nothing wrong. Mental examination: tired appearance, speech soft and a bit slow, little mimic. Mood maybe depressed. What do you do? Psychiatry - De Rooy 3-7-2024 50 CASE 3 Male pilot, 62 years, annual class 2 medical Medical history of hypertension. Has his own business, but flying his vintage airplane has been most important thing in his life for decades You know him well, always talking actively about recent flying trips and airshows. Now, no physical or mental complaints. However, tells you he has not been vaccinated against covid. Covid is one big conspiracy of supra-governmental agencies and commercial parties. The want to create a dependency on vaccines. He will never do that. Upon mental examination: friendly, talking a lot, some idiosyncratic thoughts about covid, not delusional but very typical. No indication of mood disturbances. What do you do? Psychiatry - De Rooy 3-7-2024 51 CASE 3 Male, 47 years old airline pilot calls you in between two examinations. Experiencing a lot of stress because of a divorce he is in. Had some talks to PSP of airline. Peer advised to contact you. “No worries, I’m flying safely. But I had to promise them I would call you”. Not feeling depressed, but stressed, difficulties sleeping. Last recurrent simulator assessment went uneventful. What do you do? Psychiatry - De Rooy 3-7-2024 52  CASE 4 Male pilot, 69 years, annual class 2 medical, no medical history Arrives 5 minutes late. Apologizes, took plenty of time but got lost. “I’m so sorry, I’ve been coming to this practice for 20 years now, and still I got lost, how stupid of me”. No complaints, but has been a very busy day. Had to go to the bank, to the supermarket, and this appointment. The bank was necessary because digital banking did not work. Life is so busy. Maybe he is having some burn-out or something. Difficult to describe his mood. When asking: depressed, anxious, angry, normal, happy, he answers ‘maybe’ several times. Upon mental examination: friendly but uncertain, making a tense appearance. Mood maybe a bit anxious. What do you do? Psychiatry - De Rooy 3-7-2024 53 QUESTIONS? Thank you for your attention! [email protected] Psychiatry - De Rooy 3-7-2024 54