Beyond “Fit to Fly”: Why Mental Health Needs Equal Weight in Aviation Medicals

For more than twenty years, I went through the familiar cycle of renewing my Category 1 aviation medical. Every year, I sat through the ECG, completed the forms and other tests and patted myself on the back for the results. Coming from a family where heart disease runs deep, I took some reassurance in that annual test. Passing it felt like proof: I was “fit to fly.”

Looking back, I realize how naïve that sense of reassurance was. The aviation medical system, in Canada and around the world, has historically focused on the physical body while giving far less weight to mental health except to have a “do not enter” sign for many conditions. The truth is, a clean ECG never said anything about how my mind was holding up under the pressures of professional flying.

The Silence Around Mental Health in the Cockpit

The aftermath of tragedies like the 2015 Germanwings crash forced regulators worldwide (and the flying public) to pay closer attention to the link between mental health and aviation safety. Despite that wake-up call, professional pilots still live under a culture of silence.

Work in this industry long enough and it is likely you will know a colleague who has died by suicide. Hopefully not “suicide by airplane” as in the devastating way the Germanwings copilot ended his own life — but the loss is real. Research shows that transport workers face a higher rate of suicide compared to the general population 【EHJ†source】 【PMC†source】.

And yet:

• Many pilots avoid disclosure of mental health struggles altogether.

• Others turn to self-medication, fearing the professional consequences of honesty.

• Too many suffer in silence, worried that raising a hand for help could ground them permanently.

When I think about flying on an airline today — with my own family sitting in the back — I would want the pilots at the controls to be actively cared for: under professional supervision, getting therapy if needed, perhaps on medication, and supported by a regulatory system that encourages disclosure. Instead, what we too often have is avoidance and denial.

Automatic Disqualification: How the System Creates Fear

In Canada, both Category 1 medicals (required for commercial pilots) and Category 2 medicals (required for Air Traffic Controllers) include strict disclosure rules. Declaring certain current or past psychological conditions — or receiving a formal diagnosis — is automatically disqualifying until further assessments are completed 【Transport Canada†source】.

I understand the reasoning: aviation safety depends on ensuring that anyone in a safety- critical role is fit to perform. But this structure also sets up a powerful disincentive to disclose. The very system designed to keep the skies safe often drives pilots underground, convincing them that staying silent about mental health is the safer career move.

My Own Blind Spot

For years, I resisted the idea that I could be anxious. My spouse — a psychologist — gently but persistently pointed it out. I dismissed her observations. In my mind, “anxious” looked like something very different from the way I carried myself.

At one point, considering that I might have adult ADHD, I paid for a full psychological assessment. The tests confirmed that I didn’t meet the criteria for ADHD. What those assessments didn’t capture — because they weren’t designed to — was my underlying anxiety. The psychologist sharing the report suggested that I may have anxiety. Still, I brushed it off.

The truth was that my fear of losing my medical license was stronger than my willingness to accept help. I believed that admitting to anxiety could end my career. That fear kept me in denial far longer than it should have.

A Narrow Definition of “Fitness”

In many ways, the aviation medical system reinforced my denial. By passing those physical exams year after year, I could tell myself I was “healthy.” The structure of the system — focused on detecting physical abnormalities — left the psychological side largely invisible.

This blind spot doesn’t just affect individuals like me. It ripples across the profession. Regulators such as Transport Canada, the FAA in the U.S., the CAA in the U.K. and throughout the world all face the same fundamental challenge: balancing public safety with the well-being of pilots. In practice, too often, the system tilts toward fear and restriction, creating barriers that prevents some from entering the profession and discourage active pilots from seeking treatment.

Signs of Progress — But Canada Risks Falling Behind

In the U.S., there are early signs of progress. The proposed Mental Health in Aviation Act of 2025 is aimed at modernizing FAA regulations and creating clearer pathways for pilots to receive care while retaining their medical certificates 【Congress†source】 【AvWeb†source】. This kind of forward movement matters — it signals to pilots that regulators can support both safety and human well-being.

Canada should be following this lead. One way forward could be for Transport Canada to expand its internal staffing or having credential approved psychologists and psychiatrists, just as they do with Civil Aviation Medical Examiners (CAMEs). By widening the pool of qualified professionals authorized to assess mental health fitness, TC could drastically reduce the bottlenecks and delays that discourage pilots from disclosing or seeking help.

The Cost of Denial

My own denial had real consequences. Yes, I managed the routines of flying well: the irregular schedules, the check rides, the unpredictable weather, even the occasional emergency. But what truly wore me down was not the flying itself — it was the anxiety of how I was perceived, whether I was competent enough, and how I came across to superiors.

That kind of anxiety is invisible to a medical examiner with an ECG machine. It doesn’t show up in a blood test. But it affects performance, decision-making, and long-term health just as much as any physical condition.

Moving Forward: A Call for Change

If aviation regulators want to protect both pilots and the public, mental health must be given equal weight to physical health in the medical system. Caring for the pilots improves aviation safety! That means:

• Creating clear, supportive pathways for disclosure and treatment.

• Reducing the stigma around conditions like anxiety and depression.

• Increasing staffing or accrediting mental health professionals to speed up

  reinstatement decisions.

• Recognizing that untreated mental health concerns pose more risk than treated

  ones.

  Transport Canada, as the regulator, holds a dual responsibility. It must keep the skies safe — but it must also promote the health and well-being of the professionals entrusted with that safety. Right now, the power to “approve” or “disqualify” sets up a culture where pilots feel they cannot disclose. That culture needs to change.

  When professional pilots feel safe to come forward, get therapy, or take prescribed medication without fear of losing their livelihood, we will all be safer — in the cockpit and in the cabin.

References

• Transport Canada. Medical Fitness for Aviation. Retrieved from https://tc.canada.ca/en/aviation/medical-fitness-aviation

• Transport Canada. Handbook for Civil Aviation Medical Examiners (TP 13312). Retrieved from https://tc.canada.ca/en/aviation/publications/handbook-civil- aviation-medical-examiners-tp-13312

• Aerospace Medicine Specialists of Canada. FSG 1400-01 Mental Health Disorders. Retrieved from https://www.aerospacemedicine.ca/FSG1400-01.pdf

• Lee, J. E., et al. (2019). Depression and Anxiety in Pilots: A Qualitative Study of SSRI Usage in U.S. Aviation and Evaluation of FAA Standards and Practices Compared to ICAO States. ResearchGate. Retrieved from https://www.researchgate.net/publication/335779940

• Mental Health in Aviation Act of 2025. Retrieved from https://www.congress.gov/bill/119th-congress/house-bill/2591

• Bertorelli, J. (2025). What’s Next: Mental Health in Aviation Bill. AVweb. Retrieved from https://avweb.com/insider/whats-next-mental-health-in-aviation-bill/

• Evans, J., et al. (2016). Germanwings flight 9525: The mental health and well-being of airline pilots. Environmental Health, 15(87). Retrieved from https://ehjournal.biomedcentral.com/articles/10.1186/s12940-016-0200-6

• Milner, A., et al. (2023). Suicide risk in transport workers: A systematic review and meta-analysis. Occupational and Environmental Medicine, 80(11), 621–629. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC10546617/