To the Clinicians of the Co-Pilot of Germanwings Flight 9525

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PSYCHIATRIC VIEWS ON THE NEWS

Dear German Medical Colleagues,

Please bear with me through this rather long letter. There is so much that I have been wondering and worrying about-including you.

I may never know who you are, but if you provided medical or psychiatric care for Andreas Lubitz, co-pilot of Germanwings Flight 9525, we are colleagues. Whether you saw Mr Lubitz years ago or more recently, or whether you saw him privately or as an airline-appointed medical examiner, you had some responsibility for his care.

And you too are his victims, of sorts. I hope your reputation does not suffer unduly. I hope PTSD does not develop as a result of his apparent suicide. If you provided ethical care (ie, competent care), I hope you are not scapegoated. “Monday morning quarterbacking”-an American football saying about reviewing a game the day after it is played-is always so much easier than preventing problems in real time.

After all, if reports of Mr Lubitz taking an injectable antipsychotic during training in 2009 are true, that doesn’t for sure mean that he had an ongoing or intermittent psychosis. Maybe, just maybe, it could have been a short-acting injection for acute agitation due to extreme stress and/or drug abuse. Similarly, treatment back then for an “episode” of “severe” depression could have seemed to be a one-time episode.

On the other hand, there are reports that Lubitz saw psychotherapists “over a long period of time.” Those psychotherapists probably knew the patient best, especially if he had a particular personality disorder or significant traits of concern (eg, undue narcissism, paranoia).

We have not yet heard anything about whether Lubitz had PTSD, but people with this disorder can appear normal. Perhaps the co-pilot dissociated as he crashed the airplane, which would have allowed him to ignore for minutes the passengers’ screams and the banging on the door of the cockpit. That could account for the fact that voice recording picked up no triumphal shouts, only his steady breathing.

This analysis is all speculation, of course. Maybe it’s the kind of “wild analysis” that Freud so deplored.

I do not know how prominent so-called “anti-psychiatrists” are in Germany, but if they are anything like they are here in the US, they are likely to blame psychiatric medication for the co-pilot’s bizarre and tragic behavior. Of course, they could well have a point. Some antidepressants, which can cause visual side effects, were prescribed for Mr Lubitz, agents perhaps, that we don’t in the US.

We know he was concerned about his vision, but speculation so far is that this complaint was psychosomatic. In addition, sudden withdrawal from some antidepressants can lead to increased agitation. Moreover, antidepressants can trigger a (hypo)manic episode, although of course a manic episode can occur that leads to grandiosity and agitation. On the other hand, no one seems to have described such changes in Mr Lubitz before the crash.

Therefore, I hope your medical documentation was good-better than mine usually was. I hope you documented your risk assessment adequately. If you were unsure of what to do, I hope you obtained consultation and/or supervision. If you worked in a system of care, I hope they adequately monitored the quality of care you provided.

I understand that your medical privacy laws are much more stringent than our patchwork of state and national privacy laws are here in the US, both in life and in death. I heard that you can be imprisoned for up to 5 years for not following strict standards of patient confidentiality. Perhaps that prevented you from contacting Lufthansa instead of just giving the patient an unfit-for-work note, which he subsequently tore up. That, and other reasons, may be causing you to bite your tongue to offer further explanation.

I wonder if your stringent privacy laws are a reaction to the breaches of physicians when the Nazis ruled, as well as the subsequent invasion of privacy in East Germany. Are they an overreaction that needs some degree of correction? After all, airline safety is good, and this may have been a perfect confluence of various factors. Further, to exacerbate our existential anxiety, we have the unexplained disappearance of the Malaysian airliner from just about 2 years ago. Was there a copycat aspect to the Germanwings crash?

All medical colleagues must weigh risk to others against the need for patient confidentiality. This can include whether to divulge patient information such as highly contagious diseases like AIDS or Ebola; abuse of a minor or domestic violence; driving while impaired; carrying a gun; running a nuclear power plant; and being responsible for all kinds of public transportation and safety.

Maybe you wish you could talk and give condolences to those who lost family and friends on the doomed airliner. That would be the human thing to do, but perhaps you can’t?

As psychiatrists, suicide and homicide are essentially our only life and death challenges. So when a patient commits suicide and kills 149 others at the same time, what could feel professionally worse?

Yet we all know that we are not particularly successful at predicting actual suicide or homicide. Complicating that, someone troubled who decides that his or her solution is suicide and/or homicide often seems surprisingly well right before the act. He or she is relieved, having decided on the solution to his problems. We must appreciate our limitations.

Everyone wants to know the co-pilot’s motivation. So do I. But nothing is convincing yet about why he would make sure to kill everyone on board. Way back when, I was taught that in general, suicide was motivated by a desire to to die, to kill, and/or be killed. This is a rare example of all-a triple play.

We may need system and cultural changes to how we approach some aspects of mental illness, such as the Air Force Suicide Prevention Program in the US. This program has significantly reduced suicide attempts as well as violence to others.

We and our psychiatric patients are stigmatized in many countries. If such stigma can cause inadequate attention to mental health in routine annual check-ups, no wonder mental health examinations are inadequate for airline pilots.

Complicating our work is the denial, lack of insight, and/or loss of memory among some of our patients. The people that we (clinicians and the public) need to fear most (ie, sociopaths) can be the best at hiding the risk they pose. Periodic research about faking psychiatric symptoms in the emergency department indicates how easily we, in our quest to be helpful, can be fooled. We don’t have corroborating lab tests to fall back on, unlike in other areas of medicine.

During my career, I evaluated and treated a fair number of pilots. Almost always, we grappled with the implications of getting treatment and taking medication. What might help their mental problems might, at the same time, cost them their job, and thereby worsen their mental health. No wonder so many pilots hide psychiatric treatment from their employers.

Who knows? Maybe some of you who treated him didn’t even know that Andreas Lubitz was a pilot. We often know little about the real day to day lives of our patients. Maybe we need to know more.

About a century ago, Freud concluded that his was “an impossible profession.” This may well still be so. The burnout rate of physicians and psychiatrists in the US is over 50%.¹ Know that.

I appreciate why we may never hear your side of the story. That may be a shame, for you probably have much to teach us and can transform some of our fantasies into reality.

In terms of our ethical responsibilities to each other, we are indeed our brothers'-and sisters'-keepers. In that regard, let me know if there is anything more I should know or do.

Your colleague,
H. Steven Moffic, MD (Steve)

References:

1. Phillips D. Burnout rates soar among family physicians. Medscape. January 28, 2015. http://www.medscape.com/viewarticle/838878. Accessed April 10, 2015.