Carl Eisen, 60, vividly remembers his first panic attack: Sept. 11, 2001. He was at Home Depot buying a new pump for his home’s water well when he heard that a plane had hit the World Trade Center.

Immediately, the pilot’s thoughts turned to his wife and son, who was 9 months old at the time. He dropped to the floor of the aisle, hyperventilating. It felt like “an elephant was sitting on my chest.”

He didn’t fully comprehend at the time that he was experiencing a panic attack. Once he caught his breath, Eisen stood up and walked out of the store.

“You would think that a person having a panic attack would seek help from a therapist, but I didn’t,” said Eisen, who flew for a major commercial airline at the time but requested his former employer be kept confidential.

It wasn’t until much later that he recognized that incident for what it was. He’d always thought his anxiety was normal, and when he developed symptoms of depression, he tried to manage them on his own. During the years following Sept. 11, however, his symptoms of depression and anxiety worsened. He finally realized he needed help.

But getting help for mental health could also threaten his career. Seeing a therapist or psychiatrist under company insurance requires a diagnosis, Eisen said. And pilots must report any mental health diagnosis to the Federal Aviation Administration (FAA). 

In a recent interview, Eisen pulled out a copy of his FAA first-class medical, which is the medical clearance form required for both commercial and cargo pilots. Pilots must be in peak health to earn that clearance, both mentally and physically. He read aloud from the document listing potentially disqualifying health issues like heart problems, neurological disorders, diabetes and substance dependence.

One particular question stood out: “Answer yes or no. Mental disorders of any sort: depression, anxiety, etc.?” 

“What happens if I say yes to that?” Eisen asked. “I’m grounded.” 

The FAA has strict rules about the mental health of pilots, prohibiting those with severe personality disorder, psychosis and bipolar disorder from flying. Even fairly common concerns like anxiety and depression can put them off the job, which keeps many pilots like Eisen from seeking help. 

Little data exists on pilot mental health, most likely because of the stigmatization and fear of the repercussions, Eisen said. A 2016 Harvard University survey found that 12.6% of the 1,848 airline pilots who completed the survey were clinically depressed, and 4% reported having suicidal thoughts within the past two weeks. While there is little data available, anecdotal evidence suggests that the pandemic and its toll on the airline industry has only furthered job stress.  

In 2016, Eisen created Mindful Aviator, an online course that uses meditation to help pilots handle anxiety. “What frequently happens with pilots is they put off seeking help until they’re actually hospitalized,” he said. His course teaches pilots stress management practices and connects them with professionals before they reach the point of needing to be hospitalized.

But he worries that the pandemic has exacerbated the industry’s existing problems with mental health. Pilots were under more stress than usual, but at the same time, Eisen said, traffic to his website “dropped to nearly zero.” He fears pilots just returned to burying their feelings for the sake of retaining their jobs. 

“When it comes to pilots struggling with anxiety and depression, once they reach a tipping point, they resort to their old habits of coping regardless of how maladaptive or harmful they are,” Eisen said via email. “I believe a big part of this is fear of being grounded for medical reasons.” 

FAA rules require pilots to obtain medical clearance to fly annually until the age of 40, and every six months after that. Aviation medical examiners, or AMEs, conduct the exams, and many AMEs are pilots themselves.

“There was a time, when I started, that if you had mental health issues, like depression, and you were on medication, you could not get a medical certificate,” said Dr. David Feldman, an AME based in New York. “It was just prohibited.”

(Feldman made clear that he does not speak for “the federal government or the FAA.”)

The FAA updated its standards in 2010 to allow pilots to take certain antidepressants, but still instructs AMEs to reject most pilots on anti-anxiety drugs, mood stabilizers or other antidepressants. Only a handful of selective serotonin reuptake inhibitors (SSRIs) are allowed, such as Prozac, Zoloft, Celexa and Lexapro — and even then, they’re only allowed on a case-by-case basis. 

Pilots who disclose that they are taking an SSRI must obtain certification from an AME and their prescribing physician indicating that they are “stable with no symptoms or side effects and on the same dose of medication for six months.” 

In practice, that means pilots are grounded for at least six months after starting a new prescription. How much they’re paid during that time depends on their employers’ long-term disability insurance benefits. Some major airlines offer it, but others direct pilots to obtain disability insurance through their union. 

American Airlines, for example, offers long-term disability coverage that provides 67% of a full-time employee’s regular salary. If the employee is on disability for a mental illness, the maximum it will cover is 24 months off the job. Southwest directs pilots to their union for disability insurance, which also covers 67% but ends after 18 months for mental illness. 

United Airlines provides the same coverage for both physical and mental health issues, but at 50% of their regular salary.

Before 2010, pilots taking medication typically didn’t disclose it to their employers at all, Feldman said. Use of anything other than those few approved drugs is still not allowed, which creates a similar disincentive to disclose. Pilots could be fired if their employer finds out they’ve hidden a prescription, but many run that risk to keep flying. 

Honesty can be career-ending, as one Delta Air Lines pilot discovered. Alex, who requested his real name not be used due to a pending legal dispute with his former employer, had been a military aviator before joining Delta in 2018. As part of the medical examinations required for receiving veterans benefits, he had to undergo a 20-minute meeting with a mental health professional. 

Alex told the counselor he was dealing with some stress about switching jobs and having a young family. Venting helped him feel a little better, but he said the visit wasn’t really notable overall. 

A year later, he got a call from someone in the Veterans Affairs Office of Investigation. “He said, ‘You’re being federally indicted,’” Alex recalled. “I was like, ‘Is this some kind of a joke?’”

The investigators said Alex had failed to disclose a “major depressive disorder,” for which he received a portion of his veterans disability benefits. Those benefits, awarded in the fall of 2017, covered his knee strain, tinnitus and “depressive disorder unspecified with bruxism” — aka grinding his teeth. 

Alex was aware of the knee strain, tinnitus and teeth-grinding, but thought the unspecified depressive disorder was odd, since he was never treated for that diagnosis. However, with the chaos of his life transitions, Alex said he didn’t think much of the wording at the time. 

Alex requested copies of the VA counselor’s notes, which he showed HuffPost. The counselor had written that “there appears to have been a remote history of adjustment reaction with depressed mood that appears to have resolved.” 

“Does that sound like masking major depression to you?” Alex said.

Delta fired him, and his medical certification was revoked. He pleaded guilty to providing “a false statement” to a government agency, which infuriated him but kept him out of jail. He then entered a post-plea diversion program for 12 months, which essentially left him on probation.

Delta did not respond to a request for comment. 

The whole affair was baffling. He suspected the FAA was using him as an example to others, a warning not to hide mental issues. But he found that counterintuitive, because he was honest when the VA counselor asked how he was doing. 

“Let’s say you have a guy that might’ve been toying with the idea of getting help. Now he’s like ‘Nope, I’m just going to suck it up, push it down deep, let it fester,’” Alex said. “The guy thinks, ‘I didn’t get help, and I felt I couldn’t because I would be persecuted.’” 

The limitations on which medications are allowed also restricts pilots’ treatment options, said Matt McNeil, a former commercial pilot and founder of LiftAffect, a company that helps professional pilots with mental health issues.

Of the dozens of SSRIs and another class of antidepressants known as serotonin-norepinephrine reuptake inhibitors (SNRIs) on the market, pilots are only allowed to use four of the oldest, McNeil said. And they can only use one at a time. 

People struggling with anxiety or depression often need a combination of medications for their symptoms. Express Scripts, a major pharmacy benefit manager, surveyed more than 31.5 million commercially insured Americans between January and March 2020. The data showed that nearly 50% of individuals who take anti-anxiety medication also take an antidepressant.   

“Some people need two to feel better, but no, you can only be on one,” McNeil said. And the six-month stabilization policy means pilots can’t change drugs or adjust their dosage without resetting the clock of when they can return to work. 

“They have to go through a neurocognitive assessment with a neuropsychologist, and go through a psychological profile workup, at their own expense,” he said. “Companies don’t pay for this.” 

And they’ll need to repeat those assessments every year, which can be another source of stress. 

“So, what does the pilot do?” McNeil asked. “They take the medication and they don’t report it.”

McNeil said he was always interested in what causes accidents, specifically the intersection of “the human, the environment and the machine.” After being a professional pilot for one year, McNeil went to graduate school to study psychological counseling and human factors in aviation.

“I started to get more and more into the clinical side of pilot mental health and realized there was this massive issue,” he said.

That led him to found LiftAffect, which specifically works with pilots who are experiencing anxiety, depression and other mental health concerns. McNeil said he’s treated more than 3,000 pilots. 

The FAA didn’t respond to HuffPost’s request for comment on this piece, though it has previously acknowledged the fundamental issues. “U.S. commercial pilots undergo vigorous and regular medical screening. While some conditions automatically disqualify someone from flying, many pilots have treatable conditions,” said former FAA Administrator Michael Huerta in a 2016 statement. “We need to do more to remove the stigma surrounding mental illness in the aviation industry so pilots are more likely to self-report, get treated, and return to work.”

The pilots interviewed for this piece felt that current FAA rules are designed to insulate airlines from liability, not to promote mental health. 

“There’s a lot of public scrutiny. Every time there’s an aircraft, especially a commercial aircraft accident, it’s big news,” Feldman said. 

The agency wants to avoid tragedies like the 2015 Germanwings crash, when a professional pilot intentionally crashed an Airbus 320 carrying 149 passengers into the French Alps. 

“The FAA’s job is to manage liability and public perception,” McNeil said. “They have an archaic, 1950s mentality approach to mental health. Their policies are non-scientific and outdated, and their policies drive pilots underground.”

Since the FAA relies significantly on self-reporting, seeking therapy is tricky. 

Pilots experiencing or receiving treatment for depression, anxiety, or other mental health concerns are supposed to self-report it on their medical form.

They are also asked to list any health professionals they have visited in the previous three years, including psychiatrists, psychologists and therapists. 

Terrified of losing their jobs, many pilots either don’t disclose or disclose inaccurately, said both Eisen and McNeil.

“When the pilots finally realized that they can’t fly anymore safely, they go out for another reason. They claim that they have a back injury or something,” Eisen said. “They’re not going to admit that they have an anxiety disorder or depression.”

The moment pilots mark “yes” for a mental disorder on a medical form, they are required to answer “yes” every time they fill out that form in the future, giving the FAA more opportunities to ground them, Eisen noted. 

“They’ve created a system where receiving a diagnosis for mental health basically brands you as defective for the rest of your airline career,” he said. 

Rather than lying, however, Eisen told the truth — a risky career move. The FAA took away his permission to fly in January 2008, and Eisen saw his first therapist.

His goal was to return after a year. He loved his job and missed flying. He started taking an antidepressant and aimed to get off it by September, so he could get back on the job by December. (At that time, the FAA required that he be off any meds for 90 days before coming back to work.)

Eisen was lucky enough to have disability insurance, so he received partial pay over that period. If he hadn’t, he may never have disclosed his mental health issues. “If you were in my position and you didn’t have that protection, would you self-disclose?” Eisen said. “No, of course not.”

He stopped medication cold-turkey, but knew he needed to develop other coping mechanisms. He tried meditation. 

“I thought it was stupid at first; I thought I was doing it wrong,” Eisen said. “But I kept doing it because I’m pig-headed and stubborn, and after the first four weeks, for the first time in my adult life, I was pretty much anxiety free.”

Eisen said he hasn’t suffered severe anxiety since then. But he was required to disclose his previous mental illness on medical forms until he retired last fall. In the comment section, he’d write, “Previously reported, no change,” hoping the FAA wouldn’t flag him. 

Inspired by his positive experience with meditation, Eisen launched Mindful Aviator. Through the online courses, he introduces pilots to meditation techniques that help calm anxieties.

Since he’s not a medical professional, he can’t give pilots seeking out his program a diagnosis — and “if they don’t have a diagnosis, they don’t have to answer ‘yes’ on the medical questionnaire.”

McNeil had similar motivations in creating LiftAffect. 

“Pilots come to LiftAffect because we understand how to navigate the FAA,” McNeil said. “So if they do report, we understand how to do the paperwork, what kind of assessments need to be done, and how things need to be languaged to get them through.”

As a psychotherapist, McNeil offers therapy, but does not prescribe medicine. He said he “isn’t in the business of keeping pilots in the air that shouldn’t be,” but he does his best to help pilots get help and stay on the job. 

“If you have policies that drive people underground,” he said, “maybe they’re not good policies.”