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      Black Swan Pandemic and the Risk of Pilot Suicide

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      Frontiers in Public Health
      Frontiers Media S.A.
      aviation, pilot, mental health, suicide, COVID-19, unemployment

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          Abstract

          Summary The medical risks to pilots, whether to their physical or mental health, are clearly theoretically raised during the COVID-19 pandemic for the reasons outlined in this paper, and access to medical and psychological support should be improved in order to address pilot stress, distress and the potential for increased pilot suicides as a direct result of economic effects of the pandemic. The links between pilot suicides and social change, such unemployed threats and financial recession, have not been studied. Significant and sudden changes in society may increase suicide risk and serious mental health problems may affect pilots equally. After the 9/11 terrorist attacks, for example, the risk of suicide by aircraft in the year following the attack was almost four times the average risk in the 5 years prior to the terrorist attack. This paper discusses the potential causes of mental health problems to pilots resulting from COVID-19. Pilot aircraft-assisted suicide in commercial aviation is a rare phenomenon. In general aviation in the United States, pilot aircraft-assisted suicide rates in a 20-year period was positively determined in 0.33% (24/7,244) of fatal aircraft accident cases (1). Pilot murder-suicides, where it has been concluded through post-accident analysis and investigation that the pilot deliberately crashed a commercial aircraft killing the pilot and all others on board have occurred in six instances over the past 30 years (2). The most recent of these was the Germanwings pilot murder-suicide crash in 2015 on a commercial flight between Barcelona and Dusseldorf (3), an incident which brought this phenomenon to public attention and led to the regulator, the European Aviation Safety Authority, to require that airline pilots in the EU be psychologically assessed prior to joining an airline and for crew to have access to pilot peer support programmes. The regulator also required aviation medical examiners to focus greater attention on pilot mental health and well-being in their annual pilot assessments (4). It is noteworthy that the pilot of the Germanwings aircraft suffered with financial problems in addition to other significant mental health problems. The links between pilot suicides and social change, such unemployed threats and financial recession, have not been studied, given the low numbers of pilot suicide cases as well as the unpredictability and infrequency of recession, coupled with methodological challenges such as suitable comparison groups and the absence of baseline measures. However, it has been found that significant sudden changes in society may increase the number of pilot suicides. For example, after the 9/11 terrorist attacks in New York, the risk of suicide by aircraft in the year following the attack was almost four times the average risk in the 5 years prior to the terrorist attack (5). Although we are unable to precisely determine a causal link between societal changes on pilot suicide, it is arguably feasible that significant, sudden and adverse changes in society can have an impact on pilot mental health. Due to the deleterious effects of COVID-19 on society generally, and on aviation specifically, we are living through the most significant and enduring aviation crisis in the history of modern commercial aviation. Thousands of air crew worldwide including pilots and cabin crew, are threatened with redundancy, unwelcome changes to their employment contracts such as increased duty times and lower pay, and the prospect that some may never fly for a living again. Currently a large proportion of pilots are furloughed or out of work. As they find employment, it is very likely that their job demand and workload will increase. Additionally, some pilots are self-employed and continue to work on zero-hours contracts and are without employment protection or health care support. A study of 424 pilots over 35 years ago has shown that during an occupational dispute, the stress experienced by pilots had a significant impact on their mental health (6). This study also demonstrated that the combination of factors including career development, autonomy at work, organizational climate and family support and cohesion are important regarding job satisfaction, but also potentially increase the risk of accidents if work and personal stress levels are left unchecked. It has been shown that economic crises increase the mental burden on work and workload (7). In addition to this, it is well established that an economic downturn is associated with an increase in suicides in the general population (8, 9). The social, economic, employment and personal challenges of COVID-19 in society threatens several factors important for pilots' mental well-being. The current situation is compounded by the additional social stress brought about by social and physical distancing measures brought in to contain the spread of infection. A recent position paper by the UK Academy of Medical Sciences offers a strategy for how to study and to take account of the psychological, social and neuroscientific aspects of the pandemic (10). It is recognized that the pandemic may increase suicide rates just as Acute Respiratory Syndrome (SARS) did in 2003 (11–13). This risk is increased due to economic prolonged downturn, which particularly affects aviation. The most significant and concerning effects may only become apparent in the future. Another threat concerns pilots who themselves have suffered with infection with COVID-19. Although infection may be asymptomatic in many instances, it may lead to serious mental and neurological problems in those who have been hospitalized due to the effects of the virus and also side-effects of hospitalization and treatment (10, 14). It has been reported that those people who suffered serious infection with SARS were at increased risk of post-traumatic stress disorder and depression (11, 12). Post-traumatic stress disorder has been shown to be associated with fatal aircraft accidents (15). COVID-19 data from a national sample of over 10,000 U.S. adults gathered on March 2020 showed that about 15% of respondents had high risk on the Suicide Behaviors Questionnaire-Revised survey (16). One challenge in health care generally, and in aviation medicine specifically, is how to best prevent or mitigate the risk of mental health problems and especially suicide risk during the COVID-19 pandemic whilst airline employees suffer a threat to their job and livelihoods due to economic effects. It is important to note that each time a pilot visits their aeromedical examiner (AME) or aviation psychologist, there may be a fear the loss of their medical certification (17). It has been shown that pilots may be reluctant to report to their AME conditions that could affect crew licensing due to their concerns that this could affect their livelihoods (18). Private medical insurance and support and company-organized occupational healthcare is not available to many pilots. It is not yet possible to determine how physical health, routine medical checks and AME visits by pilots have been affected by the COVID-19 pandemic and it is possible some pilots will have avoided seeking health care during this time for economic, infection risk and occupational threat reasons. Some regulators, such as European Aviation Safety Agency (EASA) have allowed pilots to renew their medical certificates by accessing AME's remotely and by extending the validity of their licenses, reducing contact between airline crew and medical specialists. The medical risks to pilots, whether to their physical or mental health, are clearly theoretically raised during the COVID-19 pandemic for the reasons outlined in this paper, and access to medical and psychological support should be improved in order to address pilot stress, distress and the potential for increased pilot suicides as a direct result of economic effects of the pandemic. As there are no standardized clinical scales for assessing suicide risk, the focus of support should target all pilots who are distressed, have experienced severe life-events in their own life, have depressive symptoms or express hopelessness (19). Thus, all pilots with any risk should receive psychoeducation, information on stress management and needs-based care. This requires also informing and educating health care staff working with the pilots. Author Contributions All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication. Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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          Most cited references16

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          Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science

          Summary The coronavirus disease 2019 (COVID-19) pandemic is having a profound effect on all aspects of society, including mental health and physical health. We explore the psychological, social, and neuroscientific effects of COVID-19 and set out the immediate priorities and longer-term strategies for mental health science research. These priorities were informed by surveys of the public and an expert panel convened by the UK Academy of Medical Sciences and the mental health research charity, MQ: Transforming Mental Health, in the first weeks of the pandemic in the UK in March, 2020. We urge UK research funding agencies to work with researchers, people with lived experience, and others to establish a high level coordination group to ensure that these research priorities are addressed, and to allow new ones to be identified over time. The need to maintain high-quality research standards is imperative. International collaboration and a global perspective will be beneficial. An immediate priority is collecting high-quality data on the mental health effects of the COVID-19 pandemic across the whole population and vulnerable groups, and on brain function, cognition, and mental health of patients with COVID-19. There is an urgent need for research to address how mental health consequences for vulnerable groups can be mitigated under pandemic conditions, and on the impact of repeated media consumption and health messaging around COVID-19. Discovery, evaluation, and refinement of mechanistically driven interventions to address the psychological, social, and neuroscientific aspects of the pandemic are required. Rising to this challenge will require integration across disciplines and sectors, and should be done together with people with lived experience. New funding will be required to meet these priorities, and it can be efficiently leveraged by the UK's world-leading infrastructure. This Position Paper provides a strategy that may be both adapted for, and integrated with, research efforts in other countries.
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            Are we facing a crashing wave of neuropsychiatric sequelae of COVID-19? Neuropsychiatric symptoms and potential immunologic mechanisms ☆

            Highlights • The COVID-19 pandemic is a significant source of psychological distress globally. • The novel coronavirus and host immunologic response may also directly affect brain and behavior. • Acute and delayed neuropsychiatric sequelae have been associated with past viral pandemics. • Prospective monitoring of COVID-19 patients is needed to determine neuropsychiatric outcomes. • A psychoneuroimmunology perspective will aid in promoting post-pandemic public mental health.
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              Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution.

              The outbreak of SARS in 2003 had a dramatic effect on the health care system in Toronto. The main objective of this study was to investigate the psychosocial effects associated with working in a hospital environment during this outbreak. Questionnaires were distributed to all willing employees of Sunnybrook and Women's College Health Sciences Centre between Apr. 10 and 22, 2003. The survey included questions regarding concern about SARS, precautionary measures, personal well-being and sociodemographic characteristics; a subsample also received the 12-item version of the General Health Questionnaire (GHQ-12). Of the 4283 questionnaires distributed, 2001 (47%) were returned, representing 27% of the total hospital employee population of 7474. The proportions of respondents who were allied health care professionals, nurses and doctors and who worked in areas other than patient care were representative of the hospital staff population as a whole. Of the 2001 questionnaires, 510 contained the GHQ-12. Two-thirds of the respondents reported SARS-related concern for their own or their family's health. A total of 148 respondents (29%) scored above the threshold point on the GHQ-12, indicating probable emotional distress; the rate among nurses was 45%. Masks were reported to be the most bothersome infection control precaution. Logistic regression analysis identified 4 factors as being significantly associated with increased levels of concern for personal or family health: perception of a greater risk of death from SARS (adjusted odds ratio [OR] 5.0, 95% confidence interval [CI] 2.6-9.6), living with children (adjusted OR 1.8, 95% CI 1.5-2.3), personal or family lifestyle affected by SARS outbreak (adjusted OR 3.3, 95% CI 2.5-4.3) and being treated differently by people because of working in a hospital (adjusted OR 1.6, 95% CI 1.2-2.1). Four factors were identified as being significantly associated with the presence of emotional distress: being a nurse (adjusted OR 2.8, 95% CI 1.5-5.5), part-time employment status (adjusted OR 2.6, 95% CI 1.2-5.4), lifestyle affected by SARS outbreak (adjusted OR 2.2, 95% CI 1.4-3.5) and ability to do one's job affected by the precautionary measures (adjusted OR 2.9, 95% CI 1.9-4.6). Our findings indicate that the SARS outbreak had significant psychosocial effects on hospital staff. These effects differed with respect to occupation and risk perception. The effect on families and lifestyle was also substantial. These findings highlight the need for interventions to address psychosocial distress and concern and to provide support for employees during such crises.
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                Author and article information

                Contributors
                Journal
                Front Public Health
                Front Public Health
                Front. Public Health
                Frontiers in Public Health
                Frontiers Media S.A.
                2296-2565
                29 October 2020
                2020
                29 October 2020
                : 8
                : 573006
                Affiliations
                [1] 1Mehiläinen Airport Health Care Centre, Vantaa and University of Helsinki , Helsinki, Finland
                [2] 2Centre for Aviation Psychology, Royal Free Hospital , London, United Kingdom
                Author notes

                Edited by: Irina Mordukhovich, Harvard University, United States

                Reviewed by: Shawn A. Pruchnicki, The Ohio State University, United States; Jyrki Korkeila, University of Turku, Finland

                *Correspondence: Alpo Vuorio alpo.vuorio@ 123456gmail.com

                This article was submitted to Occupational Health and Safety, a section of the journal Frontiers in Public Health

                Article
                10.3389/fpubh.2020.573006
                7671189
                33224917
                cb58bee8-16da-4061-86b8-7c3f08bc04a1
                Copyright © 2020 Vuorio and Bor.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 15 June 2020
                : 09 September 2020
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 19, Pages: 3, Words: 2119
                Categories
                Public Health
                Opinion

                aviation,pilot,mental health,suicide,covid-19,unemployment
                aviation, pilot, mental health, suicide, covid-19, unemployment

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