Mental Health and Performance in Aviation

“If you’re really interested in high performance, you are going to require a certain level of cognitive literacy, meaning you have to understand what is going on in your brain and your body when you’re performing.” – Steven Kotler

Mental health and wellness have become important topics in aviation, the Air Force, the military, and American society as a whole. The morbidity and mortality costs of untreated mental health disorders are incredibly high, and considerable resources have been directed toward combating those effects. Although there are resources available to support Airmen asking for specialty mental health treatment, few exist for the non-clinical or everyday concerns, meaning that aviators are expected to rely on internal or social resources to navigate the stressors of life. In other words, specialty treatment exists for clinical depression, but the individual is expected to coordinate his or her own resources (including social, spiritual, or other opportunities to reach out to others) to address, for example, the sadness of being apart from their family for the holidays. Before focusing on how to address such concerns, it is important to understand the impacts that variations in mental health have on performance. This article will highlight some of the factors resulting in performance variations.

Mental health disorders are maintained in the Diagnostic and Statistics Manual of Mental Health Disorders (DSM-5-TR).^[1]Although many disorders share characteristics that allow them to be classified in various categories, they all require functional impairment before consideration as a true disorder. In other words, mental health diagnoses require both specific symptoms (such as anxiety, flashbacks, or low mood) AND functional impairment either at work, at home, academically, or socially. Although that is an important distinction, it leaves open the fact that functioning is a moving target, and functioning can be reduced without crossing the line to impairment. Alcohol use is a good example of this spectrum of functioning. Reductions in reaction time, fine motor skills, reasoning, and information processing can be detected at blood alcohol (BAC) levels as low as 0.02 percent. This finding indicates that measurable degradation in performance is detectable after a single drink for an average adult male. However, impaired driving is not identified until 0.08 percent BAC in most states. This variance does not mean that safe driving between 0.02 and 0.08 percent BAC should not include some safety measures, such as slowing down, avoiding difficult driving environments, limiting distractions, or asking someone else to drive. A similar spectrum of performance degradation can be seen across other mental and cognitive states prior to reaching impairment.

Two of this month’s Aviation Safety Action Program (ASAP) reports identify fatigue as a factor impacting the potential safety of the event. Most people have experience with considerable fatigue bordering on impairment. The existence of crew rest highlights the importance of alertness, attention, and many of the positive benefits of a full sleep period on performance and safety in flight. What about performance degradation prior to impairment associated with fatigue? Using BAC as an ongoing example, studies have calculated that staying awake for seventeen hours results in performance changes similar to a BAC of 0.05 percent (meaning, within the detectable range of loss of cognitive capability). A seventeen-hour awake period (e.g., waking up at 0600, falling asleep at 2300) can be considerably worsened by night shifts, alcohol consumption, stress, or other factors that interfere with the restful effects of sleep. Recognition of unraveling sleep habits is a necessary step toward mitigating the potential risk of delayed cognitive functioning in flight.

Stress represents another example of a non-clinical but relevant factor degrading performance. The typical eustress-distress dichotomy has been largely discarded by the psychology field due to the considerable value judgments placed on each term (i.e., one person’s “good stress” is another person’s “bad stress;” our values also change over time and what used to be a “good stress” may become a “bad stress” in retrospect. Weddings are a great example of both). Instead, stress can be viewed as events that strain our cognitive, emotional, or behavioral responses to some degree. If the strain overwhelms an ability to function normally, then a mental health concern may be appropriate (consult with a medical provider, chaplain, or other resource if you believe this to be the case). However, what about the strains that may not impair one’s overall ability to function? Stress of any type activates the hypothalamic-pituitary-adrenal (HPA) axis, resulting in a surge of hormones to key organs throughout the body. Appropriate activation of the HPA axis results in heightened attention, mood, energy, and even pain tolerance. However, excessive or lengthy HPA axis activation leads to what is typically known as the fight-flight-freeze response, which can lead to degradations in attention, concentration, vigilance, judgment, decision-making, sleep, digestive health, and the ability to manage future stress. Therefore, while a minor strain may not require specialty mental health treatment, when combined with task saturation, mission pressure, environmental conditions, or any other aspects of performance and human factors, that initially minor strain may result in a potentially fatal performance failure. As an individual experiences increasing stress, the degradation in performance will continue to worsen, leading to increased risk. It is critical that aircrews build the self-awareness skills needed to monitor their stress prior to experiencing an in-flight emergency. Doing so provides the opportunity to engage in preventive measures to mitigate the performance risk.

Mood is a third example of a factor degrading performance and will be the last one discussed in this article. Major Depressive Disorder (MDD) is defined by a period of at least two weeks with significantly low mood or disinterest in once-enjoyable activities. MDD has been associated with significant reductions in mental capabilities, including difficulty thinking, poor concentration, emotion dysregulation, and limited decision-making capacity. Oftentimes, MDD is recognized by others via slower physical actions, rapid fluctuations in appetite, and drastic changes in sleep patterns. If you or someone you know is struggling with depression, it is important to seek help from a medical professional or chaplain. For those experiencing the doldrums for a few days or just cannot seem to pull themselves together for the day, performance degradation can still exist, despite not reaching the concern of MDD. A low mood can act similar to stress, as the mind responds to internal inputs akin to real-world events. When considering the risks to performance, aircrews need to recognize the effects that a poor mood may have in the air as well as options for mitigating that risk as necessary.

Life does not happen in a vacuum, and it is possible, and indeed likely, that an individual could experience poor sleep, stress, and a low mood at the same time. The ASAP (and mishap) database contains a multitude of Airmen working through stress and fatigue to accomplish the mission. Risk Management (RM) worksheets are completed before every mission, attempting to identify and mitigate the hazards and risks of a given flight (when completing your next RM worksheet, consider which items are evaluating your degraded performance and which risks may be appropriate to inform your aircraft commander so that they can make appropriate risk management decisions). Just as aircraft knowledge is critical to overcoming mechanical issues in the air, psychological knowledge is necessary to mitigate risks prior to an in-flight emergency. Aircrews must be able to differentiate between impairment and degraded performance and the potential sources of that degradation if they are going to effectively mitigate any associated safety risks.

Knowing When to Seek Professional Medical Care

Taking a moment to address the elephant in the room, I am aware of the concerns that aircrews have about reaching out to mental health professionals. As an aviation psychologist, I understand there are downstream effects of potential grounding for months at a time. I further recognize that a mental health clinic can seem like a “Black Box”—where someone walks in, and it is unclear what will happen when they walk out. It is not my job to convince you about what to do with your life. It is not my job to drag you into treatment against your will. It is my job to provide you with the information and transparency to make an informed decision for yourself. This article addresses the potential risks to performance with non-clinical concerns associated with changes in mental health. The simple fact is that nearly all humans have performed effectively without optimized capabilities. The problem comes when our brains start to associate “effective” with “safe,” and we stop mitigating risk (this mindset is the “I have driven drunk before and did not die, so I can do it again” effect). If you or someone you know is or has been struggling with mental health concerns, consider ways to mitigate the risk.

As a provider, we talk about seeking specialty mental health treatment as being similar to seeking care for a hurt foot. There is a point that you know it is hurt, and if you know you need help, then you should seek it quickly. It might just be a sprain (low mood) that needs a bit of ice and rest (chaplain or social support). However, if you keep running on it (ignoring the pain), it is susceptible to worsened outcomes. Once it worsens, you will be forced to take more drastic measures to maintain your career and life. Please know there are scientifically supported methods supporting the “Black Box” of mental health treatment, and the goal is to keep/return you to flying in a safe and, hopefully, more resilient manner. If medical care is still unpalatable, social, spiritual, and organizational systems are available to support you. No matter what the problem, the answer is always asking for help.

^[1] American Psychiatric Association. 2025. Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). https://www.psychiatry.org/psychiatrists/practice/dsm