If people fear losing their jobs, they may be more inclined to conceal their symptoms, says Ashraf Kagee and Jason Bantjes.
Cape Town - When Andreas Lubitz crashed the Germanwings Flight 9525 he was piloting, killing 144 passengers and six crew members in the process, the world reacted with shock and horror. It rapidly came to light that Lubitz may have been suffering from depression, which ostensibly accounted for his actions.
In response to the tragedy, some psychiatrists and psychologists have called for the routine screening of pilots so that those suffering from depression can be relieved of their duties. However, several assumptions are made that warrant closer scrutiny, for example that depression in and of itself causes people to end their lives, that suicidal thoughts are associated with homicidal impulses, that suicidal individuals are invariably mentally ill, that suicide risk can be accurately and reliably assessed and that screening pilots for depression will make flying safer.
Major depressive disorder is a serious psychiatric condition that affects between 10 percent and 15 percent of the population. Typical symptoms associated with major depression are depressed mood, diminished interest in activities, appetite and sleep disturbance, fatigue, poor concentration, feelings of guilt and worthlessness, and thoughts of death and suicide. There is a distinct difference between having thoughts of suicide and taking action to end one’s life. The gap between motivation and volition is significant. Many people suffering from depression do not have suicidal thoughts, but some do. Of these, a minority may make one or more suicide attempts. Studies suggest that only about 15 percent of people with depression die by suicide, most of whom were not receiving treatment at the time of their deaths.
The World Health Organisation estimates that 1 million people die by suicide each year. While rates of suicide globally are high and rising, it is rare for people to act aggressively by killing others along with themselves.
Rather than being associated with mood disturbance, homicidal behaviour is more likely to be a consequence of psychotic illness. Homicide-suicide usually occurs within a family context and may involve children, but typically the perpetrator and victims are lovers or spouses. Rates of homicide-suicide vary across countries. The incidence in the US is reported to be as low as 0.2 to 0.3 per 100 000.
We know comparatively little about the incidence of murder-suicide in South Africa, although one study suggested that the rate may be as high as 0.9 per 100 000, which is considerably higher than the international average.
Depression is not the only form of mental illness associated with suicide. Suicidal behaviour is also associated with symptoms of psychotic illnesses, substance abuse, personality disorders and post-traumatic stress disorder. Some people also engage in suicidal behaviour in the absence of any psychiatric illness. Suicidal behaviour can also be the result of chronic illness, intolerable feelings of shame and guilt, a loss of identity, interpersonal conflict and a reaction to socio-economic and situational factors.
While the careful selection of pilots and others who perform duties in which they are responsible for the lives of others is obviously a necessity, screening for depression is fraught with problems. Firstly, screening for depression entails asking the person about their symptoms and relies on their self-report of their emotional state. There are no biological markers for depression as there are for conditions such as cancer, HIV or tuberculosis. Self-report of depressive symptoms is an imperfect method of detecting the condition as it is easy for the person to deny or exaggerate symptoms. The most effective way to diagnose depression is through careful observation and a detailed clinical interview.
The second problem with routine screening for depression is that individuals endorse symptoms of depression because they may be upset or distressed but not clinically depressed at the time they are screened. Think of someone who has failed an examination or has ended a romantic relationship. These are distressing experiences but they are different from the psychiatric illness of major depression. High scores on depression questionnaires thus may not necessarily indicate clinical depression and may instead signal temporary distress, which is often situation-specific and self-limiting. Conversely, individuals who are indeed depressed may obtain low scores on screening instruments because of the way the questions are asked or because of under-reporting of symptoms. To this extent, screening instruments may not be as effective as one would think in identifying persons suffering from this clinical depression.
A third problem associated with screening for depression is that there can be marked fluctuations in symptoms from one day to the next. Depressive symptoms can also develop insidiously and emerge over a period of a few weeks. Even if screening tools were accurate, they would have to be administered fairly regularly to detect depression effectively.
Accurately determining suicide risk is even more difficult and imprecise. Despite considerable research in this area we still do not have a meaningful list of risk factors or warning signs that would accurately identify all individuals who are likely to kill themselves. Common risk factors, such as being male and having made a previous suicide attempt, as well as typical warning signs, such as insomnia, agitation, hopelessness, a loss of purpose and meaning in life and feeling trapped, might predict suicide at an aggregate population level, but they are less helpful at the level of the individual. Sometimes people complete suicide in the absence of risk factors and without exhibiting warning signs.
Another problem is that suicidality fluctuates from moment to moment and thus any assessment of suicide is only valid for a brief period of time.
Impulsivity is another factor that compounds the problem of assessing suicide risk. Some individuals engage in suicidal behaviour impulsively without protracted periods of psychological distress or carefully thought through plans. To determine risk of suicide we thus need to make allowances for the influence of impulsivity, which is very difficult to measure. The problem is compounded by the fact that there are unfortunately no reliable screening tools that can be used to accurately and reliably assess suicide risk.
It is easy to understand why people might respond to the Germanwings Flight 9525 tragedy by calling for pilots to be screened for depression. After all, screening is simple and relatively inexpensive but such a response may not result in the actual detection of major depression, nor will it positively identify those pilots most at risk for suicide, especially if they wish to keep this hidden from their employers. It will certainly not result in identifying future murderous behaviour, such as deliberately crashing a plane with scores of passengers on board. In fact, such a measure may actually prevent pilots in need of treatment from obtaining it.
Psychiatric illness for centuries has been highly stigmatised. If people fear that being identified as having a psychiatric illness such as major depression may result in losing their jobs, they may be more inclined to conceal their symptoms and not seek treatment. Calls for routine screening may easily be interpreted as a way to rout out disturbed individuals from functioning in society, and may serve to exacerbate stigma and discrimination against people living with a psychiatric condition. The struggle against stigma associated with disability – psychiatric or otherwise – has been a long and arduous one and an end does not appear to be in sight.
Flying in planes makes many of us anxious and of course we all want to feel safe while in the air.
However screening pilots for depression will only create the illusion of increased safety and may reinforce myths and prejudices about mental illness and suicide which are ultimately unhelpful.
There is another matter we wish to raise. If Lubitz had been a Muslim, the world media would not be speculating with such intensity about his mental condition. He would be deemed a terrorist in no uncertain terms and his religion would have been blamed for his actions. Little consideration would have been given to his psychiatric state. The unspoken assumption is that, as Lubitz was a white German man, he must have been mad. If he had been a brown or black Muslim man, he would have been bad. As an individual Lubitz is easily pathologised. If he had been Middle Eastern or Pakistani, Muslims as a religio-cultural group would have been the subject of pathology.
* Professor Kagee and Dr Bantjes are in the Department of Psychology at Stellenbosch University.
** The views expressed here are not necessarily those of Independent Media.
Cape Times