2016 AMDA Scientific meeting Psychological testing a UAE

2016 AMDA Scientific meeting Psychological testing - a UAE perspective Dr Nomy Ahmed Senior Aeromedical Examiner and Trainer UAE

Disclosures • I own and manage Flying. Medicine. uk • I previously worked for Emirates Airline in the UAE • The views and opinions are my own and don’t necessarily reflect the position any organisation/ Emirates or the GCAA • I have not been paid or gained any financial benefit from any external organisations in producing this presentation AMDA 23 rd April 2016 www. flyingmedicine. uk

I’m not a psychologist… AMDA 23 rd April 2016 www. flyingmedicine. uk

Outline of today’s talk • Background • How mood disorder assessment has evolved in the UAE • Which tests and why and when • Show an audit into mood disorders • Summary and thoughts • Q+A AMDA 23 rd April 2016 www. flyingmedicine. uk

WHO statements on Depression • Depression is the leading cause of disability worldwide • Estimated 350 million people affected. • Affected person function poorly at work, at school and in the family. • At its worst, depression can lead to suicide. • Suicide is the second leading cause of death in 15 -29 -year-olds. Barriers to effective care include • lack of resources, • lack of trained health care providers, and • social stigma associated • inaccurate assessment -people who are depressed are often not correctly diagnosed, and others who do not have the disorder are too often misdiagnosed and prescribed antidepressants. http: //www. who. int/mediacentre/factsheets/fs 369/en/ AMDA 23 rd April 2016 www. flyingmedicine. uk

AMDA 23 rd April 2016 www. flyingmedicine. uk

Background Simply put • Mood disorders common and getting more so • Pilots have and are at risk of mood disorders contrary to myth • Mood disorders in pilots are associated with significant aeromedical and economic issues • Mood disorders in pilots have been shrouded due to misconceptions, perceptions, cultural issues, lack of awareness, lack of focus and assessment AMDA 23 rd April 2016 www. flyingmedicine. uk

How’s life? … “Its fine doc” AMDA 23 rd April 2016 www. flyingmedicine. uk

AMDA 23 rd April 2016 www. flyingmedicine. uk

Case Study (10 years ago) • Pilot in his mid thirties • Military background • Recent command upgrade • Marital disharmony • No previous psychiatric history • c/o anxiety and irritability AMDA 23 rd April 2016 www. flyingmedicine. uk

• Seen by a community psychiatrist • Referred for in-house counselling • Initial improvement • Relapse • SSRI withdrawn after 2 months so he could RTW • Further relapse • Extension of SSRI to 6 months treatment • Eventually returned to work with on-going reviews • Off work for 14 months AMDA 23 rd April 2016 www. flyingmedicine. uk

Not untypical of other cases • Mood disorder but…… • Main trigger to rtw was the pilot stating they were better i. e. subjective and not objective • Drive to return to work before being treated effectively • But this ‘poor’ management led to long periods of being unproductive • ‘Uncomfortable for the airline and regulator’ AMDA 23 rd April 2016 www. flyingmedicine. uk

AMDA 23 rd April 2016 www. flyingmedicine. uk

Process developed from 2008 for the GCAA (special mentions) • • • Dr Nabila Al. Awadhi – Head of Aeromedical Section GCAA Dr Tony Evans Chief AMS ICAO Dr Marvin Lange Consultant Psychiatrist - TC/ ICAO Dr Ian Hosegood ex CASA now CMO Qantas Dr Paul Collins- Howgill UK CAA Prof Gordon Turnbull UK Consultant Psychiatrist Dr Gordon Culbert UK Clinical Psychologist Dr David Powell ex CMO Air. NZ Dr Gary Kay – Cog. Screen Dr Matthew Gould – Clinical Psychologist- Emirates Airline AMDA 23 rd April 2016 www. flyingmedicine. uk

Underlying theme was “Doveryai no proveryai” Russian proverb, "doveryai no proveryai" Trust, but verify AMDA 23 rd April 2016 www. flyingmedicine. uk

AMDA 23 rd April 2016 www. flyingmedicine. uk

GCAA INFORMATION BULLETIN 08/2010 • 4 -Psychometric testing to be done at presentation /diagnosis • 4. 1 Psychometric test, to be used as a method for objective testing of mood. This will be required as a baseline analysis. • 4. 2 The Psychometric testing to include but not limited to Neo. PIR, MMPI-2, Rorschach Inkblot, POMS, CISS. • 4. 3 The type of the testing will depend on the Approved GCAA Psychologist decision. AMDA 23 rd April 2016 www. flyingmedicine. uk

What is a Psychological test? • Psyche- Greek word for ‘spirit, soul and breath’ • Logia- Greek word for studying something • Psychological tests are tests used to assess ability, personality and behaviour. AMDA 23 rd April 2016 www. flyingmedicine. uk

Neo-PIR • Personality test • Recognised internationally as the gold standard for personality tests • Its a measure of the five major domains of personality as well as the six facets that define each domain. • Taken together, the five domain scales and thirty facet scales of the NEO PI-R facilitate a comprehensive and detailed assessment of normal adult personality http: //www. unifr. ch/ztd/HTS/inftest/WEB-Informationssystem/en/4 en 001/d 590668 ef 5 a 34 f 17908121 d 3 edf 2 d 1 dc/hb. htm

MMPI-2 • Minnesota Multiphasic Personality Inventory (MMPI) (1940) • MMPI-2—Second revised version (1989). • It is the most widely used psychometric test for measuring adult psychopathology in the world. • Its used in mental health, medical and employment settings http: //occmed. oxfordjournals. org/content/59/2/135. full AMDA 23 rd April 2016 www. flyingmedicine. uk

Rorschach • The inkblot test (also called the "Rorschach" test) is a method of psychological evaluation. • Used to examine the personality characteristics and emotional functioning of patients. • Often employed in diagnosing underlying thought disorders and differentiating psychotic from non-psychotic thinking in cases where the patient is reluctant to openly admit to psychotic thinking http: //theinkblot. com/ AMDA 23 rd April 2016 www. flyingmedicine. uk

POMS • • Profile of Mood states The POMS 2® instruments assess the mood states of individuals. They are self-report scales Quick assessment of transient, fluctuating feelings, and enduring affect states. • The tool is applicable in clinical, medical, research, and athletic settings, where its sensitivity to change makes the assessment ideal for treatment monitoring and evaluation http: //www. mhs. com/product. aspx? gr=cli&id=overview&prod=poms 2 AMDA 23 rd April 2016 www. flyingmedicine. uk

CISS • Coping Inventory for Stressful Situations • The CISS measures three types of coping styles. • It helps determine the preferred coping style of an individual and contributes to your overall understanding of the relationship between that individual’s coping style and his or her personality. • Results are useful for treatment and intervention planning. http: //www. mhs. com/product. aspx? gr=cli&id=overview&prod=ciss AMDA 23 rd April 2016 www. flyingmedicine. uk

Hamilton • The Hamilton Depression Rating Scale is the most widely used interview scale • Developed in 1960 • Clinician administered • In the original scale the first 17 items are tallied for the total score, while items 18 -21 are used to further qualify the depression. • Scores of 0 -7 are considered normal, and scores greater than or equal to 20 indicate moderately severe depression • Sensitivity: 86. 4% ; Specificity: 92. 2% Strik J, et al. Psychosomatics. 2001; 42: 423– 428 AMDA 23 rd April 2016 www. flyingmedicine. uk

Key requirements of the testing üReferral to an APPROVED Psychologist for Psychometric testing at diagnosis üBaseline testing with a number of psychometric tests but NOT limited to the ones published üHamilton scale repeated at each AME / Psychiatrist review üOther tests repeated when indicated AMDA 23 rd April 2016 www. flyingmedicine. uk

Audit data • 20 cases in 3 years 2011 -2014 • All male • Age range 24 -59 years old • Average 41. 8 years old • Bimodal distribution AMDA 23 rd April 2016 www. flyingmedicine. uk

• 55% Escitalopram (Cipralex), 20% Citalopram (Lexapro), 20% Sertraline (Zoloft), 5% Fluoxetine (Prozac) • Range for length of treatment 2 -45 months • Average months off work 5. 5 months, range was 2 -11 months • No side effects noted by the simulator checks • Number of months back at work with continuing use of SSRI =251 • No safety incidents occurred in those pilots returned to work on SSRI medication. • 7500 ‘lost days’ saved by returning pilots back to work safely AMDA 23 rd April 2016 www. flyingmedicine. uk

More in-depth review • Newer cases less likely to need SSRI as presented earlier • Or SSRIs not needed for prolonged periods • Psychological testing didn’t match the proposed plan • All medical reports were not robust enough • The GW tragedy and other significant cases focused attention • So it was decided to relook at the evidence, tests and reports (knowns) • Av. Med trained specialists –formalised assessments and reports AMDA 23 rd April 2016 www. flyingmedicine. uk

New psychological testing and assessment process At a minimum : • Review of all available records (medical, psychological, operational, training, selection etc. ) • Clinical interview (including with family members, colleagues etc. ) • Mental status examination. • Interpretation of a full battery of psychological tests including but not limited to the minimum dataset (specified below). • An integrated summary of findings and recommendations with a clear opinion regarding clinically or aero-medically significant findings and the potential impact on aviation safety. AMDA 23 rd April 2016 www. flyingmedicine. uk

Minimum data set • Cog. Screen- Aeromedical Evaluation (Cog. Screen-AE) • Minnesota Multiphasic Personality Inventory-2 (MMPI-2) • Trail Making Test Parts A & B (TMT) • Alcohol questionnaire (e. g. A. U. D. I. T) • To assess for neurocognitive decline in the older pilots baseline testing to be completed at age 55 and at age 60 and include: • The minimum data set + Wechsler Memory Scale Fourth Edition (WMS-IV) AMDA 23 rd April 2016 www. flyingmedicine. uk

Trail Making Test • Neuropsychological test for visual attention and task switching • The purpose of the TMT is to test for the presence of cognitive impairment • The TMT is a measure of attention, visual speed, recognition, recall, mental flexibility and executive functioning. https: //www. health. utah. edu/occupational-therapy/files/evalreviews/tmt. pdf AMDA 23 rd April 2016 www. flyingmedicine. uk

Plus -as needed • MMSE, Mo. CA, NEO-PI-R, 16 - PF WAIS-IV, MMPI-2, MCMI- III, BDI, BAI, WMS-IV, Rey Complex Figure Test, TMT, BADS, DKEFS, Rorschach. • Substance Abuse – WAIS-IV, Rey Complex Figure Test • (This is not an exclusive list, other assessments may be needed depending on the individual’s presentation) AMDA 23 rd April 2016 www. flyingmedicine. uk

Assessment must be done by • A psychologist with a Master’s degree in clinical psychology • A minimum of 5 years practice in addition to all other fitness-to-practice standards. • All psychologists providing these expert assessments must be able to evidence they have acted within their area of expertise. • Examples of relevant aeromedical training include Postgraduate Course in Aviation Medicine (accredited by the GCAA) and the Annual Aeromedical Psychology Seminar (offered by the US FAA and accredited by the American College of Professional Neuropsychology). AMDA 23 rd April 2016 www. flyingmedicine. uk

AME psychological tests (known unknowns) • Patient Health Questionnaire (PHQ) 2 “screening questions” were added to the aeromedical examination Q 1 “Over the past 2 weeks, have you had feeling of little interest or pleasure in doing things? ” Q 2 “Over the past 2 weeks, have you had feeling down, depressed, or hopeless? ” • If yes to any of these then the full PHQ 9 done • The value of these are not necessary the answer but the discussion generated with the pilot • AMEs required to electronically sign they have completed this AMDA 23 rd April 2016 www. flyingmedicine. uk

Also • Edinburgh Post Natal Depression scale used for all female crew returning to work following any pregnancy • Simple office based test which takes 5 minutes to complete • This area of mental health not previously looked at in Av. Med • Again significant value in the discussion • Several cases of mood disorder picked up by this assessment already http: //www 2. aap. org/sections/scan/practicingsafety/toolkit_resources/module 2/epds. pdf AMDA 23 rd April 2016 www. flyingmedicine. uk

Summary • Mood disorders are common and getting more common • Assessments for aircrews need to be more objective, evidence based, robust, standardised and legally defensable. • Psychological tests have proved essential and cost effective in the process of assessment and safe relicensing of aircrews in the UAE • Psychological tests should be relevant, targeted but not onerous • They must be undertaken and reported by suitably trained staff • Aircrews ‘buy into’ the process if the above is managed well AMDA 23 rd April 2016 www. flyingmedicine. uk

Recent email from an Australian pilot assessed last week in the UK • “I must be honest and say I've always been a sceptic when it came to the usefulness of psychology in aviation. • I thought it was subjective and dependent on the subject being cooperative. • I found the tests done by Dr Gould anything but subjective. • The results he obtained mirrored some of the basic self assessments that I did online when it came to basic results like depression and alcohol dependency etc. where it far exceeded these tests were in establishing my baseline honesty and openness and in identifying more specific problem areas. • I was amazed how accurately the areas where I had elevated scores reflected my personality, actions and reactions and at the same time pinpointed the factors that were contributing to this. • The way he was then able to give his subjective assessment an objective foundation gave his opinion great credibility. AMDA 23 rd April 2016 www. flyingmedicine. uk

• Dovetailing that with the Cogscreen test and relating those scores to aspects like alcohol consumption and stress further ensured that I walked out of the assessment utterly convinced that the tests I did should not only form part of assessing a pilots suitability to return to work, but become part of our medical assessments in the same way we do blood tests. • I walked out of there with renewed confidence in my own abilities and with enough faith in the results to find motivation to make some significant personal lifestyle changes. • As a qualified aviation safety officer and CRM facilitator, I will incorporate what I have learned and experienced in the flight safety programs I am involved in and champion the cause of getting a science that I believe has finally matured to be incorporated in our broader aviation safety culture. ” AMDA 23 rd April 2016 www. flyingmedicine. uk

My final thoughts on Mood Disorders in Aircrew • T. R. E. A. T. (Train, Research, Evaluate, Audit, Test – using suitable tools) • Develop and continue to work on a non-punitive environment • Improve awareness by educating colleagues – Training departments, Pilots, EAP, HR, Av. Med nurses as well as AMEs AMDA 23 rd April 2016 www. flyingmedicine. uk

Thank you nomy@flyingmedicine. uk AMDA 23 rd April 2016 www. flyingmedicine. uk

AMDA 23 rd April 2016 www. flyingmedicine. uk

AMDA 23 rd April 2016 www. flyingmedicine. uk

AMDA 23 rd April 2016 www. flyingmedicine. uk

AMDA 23 rd April 2016 www. flyingmedicine. uk

AMDA 23 rd April 2016 www. flyingmedicine. uk

AMDA 23 rd April 2016 www. flyingmedicine. uk

AMDA 23 rd April 2016 www. flyingmedicine. uk