Mental illness is regarded as a disability in many countries, including Malaysia.
Though many people are affected by the condition, little attention is given to the disease, or the people who suffer from its effects.
Until, of course, it affects our society in a big way – and everyone suddenly notices it.
Germanwings flight 9525, which crashed in the French Alps killing 144 passengers and six crew members nearly three weeks ago, is one example.
The crash is believed to have been intentionally caused by the co-pilot, Andreas Lubitz, who was previously treated for suicidal tendencies.
As ongoing investigations into the co-pilot suicide continue, I recently took the opportunity to talk to Datuk Dr Andrew Mohanraj and ask him more about mental health and airline pilots.
Dr Andrew is a consultant psychiatrist with special interest in aviation psychiatry. He collaborates with Dr Nicollo De la Penna who is an aviation psychiatrist at the Johns Hopkins Hospital in the United States of America.
"Although the Germanwings airlines tragedy indicates pilot suicide, ultimately nobody can ever be totally certain as to all the implicating factors which transpired," said Dr Andrew.
"There have been several plane crashes that have been 'proven' to be due to the pilot intentionally bringing down the plane, but pilot suicide remains a very rare phenomenon – especially involving commercial planes," he added.
Dr Andrew went on to quote aviation psychologist professor Robert Bor in his book, “Aviation Mental Health: Psychological Implications for Air Transportation”, estimating that that between 0.72% and 2.4% of general aviation accidents of such nature are as a result of pilot suicide where a history of psychiatric or domestic problems have been found in such post-crash inquiries and investigations.
Last month's crash has prompted calls for more rigorous mental health screening and evaluation for pilots.
But are such calls justified?
Dr Andrew said that psychological assessments are currently done routinely as part of the overall medical examination as a requirement for continuity of licences to fly.
Although these examinations are in line with internationally accepted standards, no detailed mental state examination is done.
"Often, the system relies on reports of odd or difficult behaviour exhibited by the pilot who has been examined, as reported by colleagues or subordinates. Rarely would the employee being examined seek psychiatric help voluntarily for reasons of risking invalidating the licence to fly," he said.
"The fear of losing their jobs would override their admission of a mental health problem."
Dr Andrew said that any psychiatric examination should look out and pay particular attention to the presence of conditions like depression and psychosis.
In addition, disruptive personality disorders and substance abuse may exist as a separate issue or as a cause or effect of depression.
To the question of whether pilots are more susceptible to developing psychological distress compared to many other professions, the answer is a resounding "Yes!"
Dr Andrew went on to point out that work load and unreasonable duty rosters, disruption to personal relationships, safety and survival fatigue, jet lag and prolonged close proximity to colleagues on board, can all result in mental health issues.
"There have been many cases of acute alcohol intoxication, sudden psychosis or unruly behaviour noticed and reported by conscientious and alert cabin crew.
"Such incidents have on many occasions caused the pilot to be 'off loaded' or denied permission to fly the plane. Such cases are not always known outside the airline industry."
Why crash a plane full of people when there are other ways to commit suicide without involving the lives of passengers?
Dr Andrew said there could be broadly three main reasons for this:
1) To make a “statement”: for the terrorist, it is an act of altruism based on his anger with the system. For the employee, an opportunity to demonstrate his resentment against the stress of the job or his deep-seated grudge against the airline.
2) Financial, namely to enable the family to claim the life insurance. In his book, Dr Bor suggests that the evidence it was a suicide might be thus destroyed, so protecting the family by ensuring an insurance pay out. It also spares the family of the “shame” of suicide.
3) Pilot suicide (the most common reason) would be psychological distress like depression. The person could be so troubled in the mind, that he hatches a plan to end his suffering by leaving the world that causes him so much pain, that is the world of flying, to the “other” world, beyond the cockpit.
As mentioned above, Dr Andrew said that this is usually seen in solo flights without passengers on board, but there have been mysterious mishaps in the past involving commercial planes which also point towards pilot suicide.
"A suicidal act is hardly impulsive. The plan is usually made very meticulously. In a person suffering from psychological distress, his mental state would have changed much before making such a decision.
"He would have appeared morose or would have given some clues about his hopelessness to others indicating that he is troubled. In some cases, once the suicidal plans are formulated and rehearsed in the mind, the appearance of the individual could be slightly euphoric because he is at peace with the decision made and is eager to end his suffering in 'this world'.
"This is called 'smiling depression' as was the case with the late Robin Williams where he was noted to have been cheerful just a day before killing himself."
Dr Andrew went on to say that many argue for more rigorous mental health assessment, not only for pilots, but flight engineers, cabin crew and control tower operators as well.
He added that a history of taking psychotropic medication, relationship problems, alcohol abuse, alarming pattern of spending and borrowing leading to financial ruin and the presence of a life event like divorce or death, all must ring alarm bells in a routine medical examination.
This is in addition to the usual detectable change in mood.
"Routine and detailed psychiatric assessment and review of flight records, reports, and medical history and life events would normally give some clues on the mental state of the pilot, because suicidal intent emerges over a long period of time.
"It is extremely rare for someone to suddenly decide to kill themselves."
The call for stringent psychological assessments, however, must be balanced by in-house psychological support.
"This is indeed a delicate situation. On one hand pilots are expected to be honest and forthcoming with their distress during examination but the very act of seeking help could invalidate their licenses."
Dr Andrew said that solutions must be found to help the distressed employee, while keeping in mind that passenger safety is of utmost importance.
"The decision to use the plane as the instrument of death is a complicated thought process, entwined with psychological distress and a bizarre mental state.
"We will never fully understand the workings of the mind of the pilot in this latest crash, although black box findings and medical history of the pilot strongly point in the direction of psychological distress causing suicide.
“The airline industry and civil aviation authorities must do everything it takes, including reassessing the current medical examination procedures, to prevent such painful tragedies from recurring in future.” – April 13, 2015.
* This is the personal opinion of the writer or publication and does not necessarily represent the views of The Malaysian Insider.