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the aviation environment only with the greatest degree of judiciousness and caution.
Aviation examiners must also be aware that their patients will not always volunteer information about
taking medicine. As some of these medicines have few side effects, it may at times be difficult to detect
their use. Medical examiners should therefore educate licence holders about the risks of psychoactive
medicines.
— — — — — — — —
ICAO Preliminary Unedited Version — November 2009 III-9A1-1
Appendix 1
MINI MENTAL STATUS EXAMINATION
The Mini Mental Status Examination (MMSE) is a widely used brief, standardized method for assessing
cognitive mental status. It allows a gross assessment of orientation, attention, immediate and short-term
recall, language, and the ability to follow simple spoken or written commands. It can be administered in
the office whenever there is reason to suspect cognitive impairment. It takes about 20 minutes to
administer. The maximum score is 30, and 95 per cent of persons should score 23 to 30. Anyone who
scores less than 25 should undergo more sophisticated tests of cognition.
References to Appendix 1
Means-Christensen AJ, Sherbourne C, et al. Using five questions to screen for five common mental
disorders in primary care: diagnostic accuracy of the anxiety and depression detector. General Hospital
Psychiatry. 28(2): 108-18, Mar-Apr 2006.
Pignone MP, Gaynes BN, et al. Screening for depression in adults: a summary of the evidence for the
U.S. Preventive Services Task Force. Annals of Internal Medicine, Vol 136(10), 765-776, 21 May 2002.
Pignone MP, Questionnaires for depression and anxiety. British Medical Journal, Letters. Vol 323(7305),
167-169, 21 Jul 2001.
Fiellin, DA, Reid MC, O'Connor PG. Screening for alcohol problems in primary care: a systematic
review. Archives of Internal Medicine. Vol 160, 16 July, 2006.

ICAO Preliminary Unedited Version — November 2009 III-9A2-1
Appendix 2
SPECIFIC GUIDANCE CONCERNING USE OF ANTIDEPRESSANT MEDICATION
1. Introduction
This section provides guidance concerning Recommendation 6.3.2.2.1, introduced in 2009:
6.3.2.2.1 Recommendation.- An applicant with depression, being treated with antidepressant
medication, should be assessed as unfit unless the medical assessor, having access to the details of
the case concerned, considers the applicant’s condition as unlikely to interfere with the safe exercise
of the applicant’s licence and rating privileges.
2. Background
The use of antidepressant medication in aircrew and air traffic controllers (ATCO) has traditionally been
disqualifying for medical certification due to the underlying medical condition and the potential safety
relevant side-effects of the available medications to treat it 1, 2
. In the United States, in accordance with
Federal Aviation Administration (FAA) rules, antidepressant usage must have ceased for at least
three months before a fit assessment may be considered 3, while in Europe the Joint Aviation Authorities’
policy is that no certification can be considered whilst using psychoactive medication4,5.
Depression is a common, worldwide disorder in the adult population, although reported prevalence varies
quite widely 6
. In the United States the lifetime prevalence of major depressive disorder was found to be
16.2 per cent, which would involve almost 34 million US adults, and for a twelve-month period the figure
was 6.6 per cent 7.
Many patients require long term treatment with antidepressants to reduce the risk of recurrence. One
systematic review 11 found that continuing antidepressant medication treatment after recovery
dramatically reduced the proportion of patients who relapsed over one to three years, compared with
placebo. The average rate of relapse on placebo was 41 per cent, compared with 18 per cent on active
treatment.
There is emerging evidence in the literature that policies which disqualify pilots from flying whilst on
antidepressant medications may lead to pilots flying when depressed and untreated, or flying on
antidepressant medication but not reporting it to the regulatory authority 12, 13, 14. An Aerospace Medical
Association position paper 12 stated that, according to the Aviation Medicine Advisory Service database
of pilots’ telephone inquiries, approximately 15 per cent of pilots who had been advised by their
physicians to take antidepressant medication showed an intention to take the medication and continue
flying without informing the Federal Aviation Administration.
Canfield et al. 13 reported on post-mortem toxicological evaluations performed on 4 143 pilots.
Psychotropic medications were found in 223 pilots but only fourteen of these pilots had reported a
　
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