AME Guide Grand Rounds October 2026 Session

Hello and welcome to session two of the October FAA AME Grand Rounds. My name is Christy Risley. I'm with the Aviation Medical Examiner Education Branch of the FAA. I'm going to turn this over to the Deputy Federal Air Surgeon, Dr. Brett Wyrick, for the welcome. Dr. Wyrick. Thank you, Kristin. Good afternoon, good evening, good morning, and hello to everybody all around the world, and thank you for joining us here. I'm Dr. Brett Wyrick, Deputy Federal Air Surgeon. We have also Dr. Northrup, our Federal Air Surgeon. She'll be joining us for some closing remarks after tonight's presentation. You're going to find tonight's presentation very interesting, and it will be very helpful for you with your practice as an aviation medical examiner. But we would be remiss if we didn't say thank you for being here, and thank you for your interest in aviation safety. And without further ado, let me turn it back over to Christy, and we're glad you're here. Thank you, Dr. Wyrick. Next slide, please. Our objectives for this evening. First off, we're going to review some minor AME guide updates that were released today. We have a new disposition table for kidney transplants. We have an update to the congenital sucrase isomaltase deficiency disposition table that we released, I believe, last month, and then also we're going to talk briefly about the weight loss management or prediabetes status report. After that, we are going to preview, this is something we haven't done before, but we're going to preview some upcoming changes to mental health item 47. And for that, I would like to ask Dr. Chad Bergdorf, who is the FAA's chief psychiatrist, to go ahead and come on camera and unmute. And he's going to talk for just a minute about that before he turns it over to our other speaker, Dr. Dumsdorff. Well, thank you so much, Ms. Risley. I appreciate the introduction and a huge thanks to our aviation medical examiners and stakeholders who are taking an hour out of their evening to hear about our upcoming changes and our current updates. You might ask yourself, why? Why now? And why should we update the mental health policy? Well, the answer is simple. Historically, we've been looking at primarily two things. What's the underlying diagnosis and is the individual on or off medications? This has worked well, but it can work even better. As you've seen, there have been some challenges. How do people get off meds exactly? And what about those cases where there's multiple diagnoses? It gets confusing. So we're going to zoom out and look now at the whole person and appreciate two more factors. First of all, let's appreciate how long the individual has been in stable remission. We're building a policy that looks very clearly at that. And the second thing is the case-specific factors that help to mitigate the risks. show the resilience of the individual. So we're adding these two tools into the matrix. What you'll find is the policy you're going to hear about that we're releasing next month actually looks and feels a lot like what we already have, but it adds these two tools, which give it the ability to appropriately evolve going forward and appreciate the whole person in a much more effective manner. That said, I want to introduce to you. Tonight, Dr. David Gregory. Some of you have met him before. He's a RAM with an extensive career experience in aviation medicine, and he has a long history of high-level policy and program development. Dr. Gregory has been leading our new mental health specialty team at the Air Medical Certification Division for the last six months. Think of Dr. Dumsdorf leading the drug and alcohol team. Dr. Gregory leads our new mental health team. And he's going to be showing us the way through a preview of our upcoming mental health changes tonight. He's also going to talk to you tonight about our AME guide updates for this month. Dr. Gregory, over to you. All right. Thanks, Dr. Bergdorf. Thanks, everyone, for being here. I have enjoyed talking with many of you on the phone, so it's nice to be able to present to you on some of these important updates. And as Christy mentioned, these are updates that, at least from the mental health perspective, are going to be coming out in November. Or because there's so much to it, We decided it's important to have multiple briefings. So that people could adjust a little bit to what they had heard, they need to ask some questions, and they can do that, but they won't actually be enacted until the November 18 AME Guide release after the AME Grand Rounds in a couple weeks. But before then, we got a couple of other things to briefly go over. So you can see for renal transplant, we converted all the information that was previously in a protocol and put it into a disposition table. So column B shows all the same information, but it's in the familiar format of the disposition table. All these people need to be deferred. Let's hear what you need to provide to the FAA for review with that deferral. Otherwise, the information is the same, just a new look. C.S.I. CSID, there are a couple opportunities here, either issue or deferral. As you can see, this was released previously, but the change that we did here was that we reduced the time from seven days to 48 hours. So that's the only significant change that you can see here. If the people are well-controlled, no significant side effects from the medication, the USAME can issue a certificate for this condition using just the clinical notes that you have at your hand. If there's any severe complications, then you need to defer. Last update before the mental health section is the weight loss management. So as you mostly know, this is a KAKI and we have updated the The form here, it's important to highlight that we do not need the KAKI document uploaded. If they are eligible, you just have to note it on block 60. It's also very important to note that the hemoglobin A1c of 6.5% is the threshold. So if they ever had that level previously in the past before they were on medications, then they're not eligible for this CACI. They're considered to be. diabetic, even if they had a more recent A1C that's less than 6.5 because they're either on medication or they had weight loss or diet. So you can only use this CACI if their highest A1C was less than 6.5. So please make sure to document that if you start using this CACI form. All right, now let's get to the main show for this evening or morning, I guess, depending on As we noted, this is currently just a preview. There will be, because there's lots of changes here, we wanted to give you opportunities for some repeated exposures and, as I said, ability to ask questions. So everything you see here should be considered just in a draft format. We will likely do some minor changes or modifications before we release in a couple weeks, but what you'll see is more or less what we're going to be rolling forward with. So tune in in three weeks, again, for it to actually be released. Okay, these are the things I'm going to talk about. I'm going to talk about some of the new processes, some screenshots of the disposition tables, checklists, and decision tools that we'll be using. And then I also want to highlight that mental health is very important, even though it's something that does not like to be talked about by a variety of people for many different reasons. So there's a lot of predisposed kind of thoughts about mental health. We want everyone to take a look at this table and realize that it is important and there's lots of true facts about it and many things that are not true about it just based off of what's out there in public commentary. This is a graphic showing that mental health is a continuum, and just like many conditions, you can be healthy and then ill and somewhere in between, and because of that, it is very challenging to diagnose and to treat. But then also along those same lines, the evaluation for mental health from an aeromedical perspective is also difficult. It's hard to pinpoint exactly where someone is at. We as an aeromedical community have to do the best that we can to identify risk factors based off a variety of considerations so that we can understand if someone is safe to fly. But just it's important that we all recognize that mental health symptoms are difficult, treatment is difficult, and the aeromedical evaluation is challenging. So we're all doing the best that we can Okay. What are some of the improvements that we feel like we have done with the changes that are coming up here? Just some things that we want to message to people. First of all, we feel like that we simplified the processes. We removed some documentation about confusing pathways. We made documentation within the AME guide clearer as to who is eligible for certain situations. What is needed for us to do a review, what you need to do to make a decision. As I said just previously, it is difficult, so there are still some challenges with it, but we feel like we've made improvements to make it easier for people to move forward. We have reduced the time. For processing, both for the initial antidepressant special issuances, because we're going to be processing them at AMCD and not at the headquarters level, we've reduced required visits to go see specialists. So there's a reduction in time and needed items on a variety of levels. We think that those are some big wins. We felt it was important to put control into the hands of both you as AMEs, but then also for the airmen. And the way that we have done that is we have provided the AMEs a couple of different fast track pathways so that if you have all the information that we have outlined, then you are able to provide a certificate for them as long as they are identified as being low risk. Based off of either clinical records or a current progress note and then using the checklist that we provided. We also felt like it was important to recognize that many airmen are going to have changes in their symptoms and they might be subtle and we want to encourage them to go get treatment. And if they can quickly get a kind of handle on their symptoms with the slight dose change in their medication, that should not require informing the FAA by submitting new documentation because that will take more time and it'll likely mean that airmen are not likely to go get the help that they need. So we gave the airmen an opportunity to kind of control their symptoms and their management. In a way that they haven't before. And overall, it's still very important that safety is the heart of what we do for all medical certification. And so we feel like we found an improved balance on understanding aviation medical risk while still getting as many people flying as possible. So I want to make sure that only people who are stable on their... With their symptoms and their treatment are able to fly, but we can get as many of those people up in the air as possible, as soon as possible as well. Okay, let's talk about some of the updated processes. So first, we're going to start off with some just terminology. Um, that. The HIMS terminology is still going to be out there because the HIMS program is out there. But HEMS psychiatrists and psychologists and HEMS neuropsychologists are no longer going to be using that term. The new term will be FAA recognized or FAR psychiatrists, psychologists and neuropsychologists. This change will take place in a couple of weeks and we're informing. All of these folks in the coming weeks about these this change. So at HEMS AME and the HEMS program still exists to monitor those with substance abuse problems. But for the psychiatrists, psychologists and neuropsychologists, they will no longer be referred to as HEMS psychiatrists, psychologists and neuropsychologists, but FAR or FAA recognized. And this is to ensure that they are kept separate from the HEMS program and they do independent psychiatric evaluations for the FAA. We will include them in our evaluations, but they are not only a part of the HEMS program. So if you see a term of HEMS psychiatrist, think of a FAR psychiatrist and know that the HEMS program still exists. Okay, what else did we change? For the SSRI decision pathways, we got rid of those all together. There are no longer any decision pathways one and two. The problem we felt is that too many people were deciding to come off of their medication because they felt like the FAA wanted it that way, and they can only fly if they got off their medication. And so we just decided to get rid of that altogether. And you'll see what the new antidepressant pathway looks like. Next thing, this is actually a change that we made earlier in the year, but we think it's still worth continuing to educate people and to promote in that if someone is on a special issuance for antidepressants, they no longer have to see a HEMS AME. They can see a. regular AME to be followed, just like AMEs follow pilots for all sorts of medical conditions, you know, neurologic and cardiologic, etc. So AMEs can follow pilots who have an SI or even an AASI, and we want to highlight that we're calling it an antidepressant pathway and not an SSRI. So no longer need to see HEMS AMEs and not just SSRI use, we're saying Regular AMEs can be followed on AASIs for antidepressants. Now, some folks will still be on an SI, but for those who are stable, they will likely be moved to an AASI. And to clarify, people who are currently on a special issuance, if they want to be moved over to an AASI, then we will look at these people when it's time for their regular renewals. So they should just continue what's outlined in their SA and their SI for the time being until it's time for the renewal as a part of their normal timing, and then when it comes up to AMCD for evaluation. then we will see if they're stable enough to put them on an AASI. And frankly, most of those people are. There's only, it's a minority of the time that we say they need to be on an SI for some reason or another. Another change that we made earlier in the summer was that the SSRI folks on special issuance needed to see a psychiatrist and a HIMS AME. And their treating provider twice a year. And now we're saying if you're eligible for an ASI, then you only need to see your you need to see your treating provider twice a year, but we only need the documentation once a year. And they need to have just the status summary sheet signed. So no longer HIMS AME is required. And no longer do they have to see a psychiatrist unless that's their treating physician. Okay, so here's where we get into some additional changes. Currently, the process, if someone has been off an antidepressant for two years or greater, the threshold is that the AME can issue a certificate if they have appropriate documentation that says that they're stable. What we have added is another section, and the time frame is off-treatment between two and five years and off-treatment for greater than five years. Greater than five years is more or less the same as the previous version of greater than two years, where an AME can issue if the documentation says that there are... free of symptoms and they also use a fast-track decision tool. It does not need to be uploaded but the AME will use this decision tool to make sure that they're still low risk and they don't have any concerning issues such as a suicide attempt or symptoms of bipolar or psychosis or anything like that. So the AME can issue that at greater than five years. In the two to five year time frame It's the same process, except that we also want a current clinical progress note from their treating provider. That treating provider can be a psychiatrist. That would certainly give us the most information and most reliable information, but it can also be their primary care provider, and so we're not requiring that it has to be a Bar psychiatrist, board-certified psychiatrist, it can just be their treating provider. So in a two- to five-year window, current clinical notes, current clinical evaluation, and that fast-track decision tool. If they've been off antidepressants for less than two years, they have to be off their meds for at least 90 days, and then they need to get an evaluation. Previously, they just needed to be off their meds for at least 90 days. Now we're saying it has to be off their meds for 60 days, and then they get a note from a FAR psychiatrist. So people who had symptoms within two years at a higher risk of having a risk of recurrence, and so the evaluation by a FAR psychiatrist will help clarify to the FAA just what that risk is. and documenting their stability. And so getting that extra psychiatry evaluation will be critical for us. Okay, we also removed the PTSD disposition table, we felt like this is something that could be just absorbed into the anxiety, depression related conditions disposition table. So the concept is still there is just we remove that disposition table. For the situational depression or adjustment disorder disposition table that still exists, we just kind of clarified it and made it a little bit easier to understand and use Thank and then added a decision tool as well to help the AME understand whether or not this tool can be used for specific situations. And for this is a this next line is something that we feel should be really celebrated because we feel we heard some comments you. from a lot of AMEs that this was not necessarily agreed for those who are taking psychotropic medications for a non mental health condition. The current process is required that they have to go through the full antidepressant protocol, such as getting neurocognitive evaluation, seeing a psychiatrist and Just doing that whole full workup. And what we're saying is that if the AME can evaluate the medical records and see that there's clear documentation that there is no mental health diagnosis and there is no mental health association with the underlying diagnosis, then the AME can. either issue the certificate or really what they need to do is follow the kind of the decision guide for whatever the underlying condition is. So, for example, a common one is if someone has peripheral neuropathy and they're taking duloxetine, which is an SNRI, then the AME does not have to send the airman to get neurocognitive evaluation and psychiatric evaluation, but they If they need a clear document from the treating provider to say, yes, this is peripheral neuropathy from their diabetes or not, and there's no mental health association. So then the AME then just needs to follow the decision guide for peripheral neuropathy. So you may not be able to issue a certificate at that time, but at least you don't have to get the additional evaluation. Okay, next. Updated process. So currently there's a fast track decision tool, but it is only for currently deferred cases. We've created two decision tool that can be used for the mental health symptoms that are greater than two years. So it can be used for both the two to five years and also the greater than five years. But it's not for cases that are only deferred. It's for current. So this will allow you as an AME to be able to provide some certificates if it's determined that they are without any high risk conditions so that mental health clinical will really be helpful to clarify who's high risk or who's not. OK, if someone is on a currently approved. SI or AASI, as I said, we wanted to allow the airmen to have some ability to change their dosing if they had a slight change in their symptoms and it needed to be improved without having documentation sent to the FAA before they're able to fly. If they're on an AASI specifically, they can go get help. They have to be grounded for 30 days. They work with their treating provider to say, yes, I'm good for 30 days. And then after that 30 days of documented stability, then they can return to fly. And ideally, they communicate with you as an AME, but there's no documents that have to come to the FAA. If they're changing their dose and they're currently on an SI, meaning we think that they're a little bit higher risk, then they still have to ground in document stability for 30 days, and then we will require documents sent up to us for evaluation before returning to fly. The same thing if someone has a change in their medication. So, for example, they go from Zoloft to Celexa or Celexa to Wellbutrin or something. And it doesn't matter if they're on an AASI or an SI, they will still need to be grounded for 90 days before they have. And then they can have their documents sent up to the FAA. And then we will update their issuance before they can return to fly. In that regard, that hasn't really changed a whole lot. We may get to the point that it's not 90 days and maybe it's less than 90 days, but that's currently the situation where we're at. Okay, what has not changed very much with the updated chapter that will be coming out? First and foremost is our commitment to encourage all people to get the treatment that they need, regardless of their concern for how it's going to affect their ability to fly and get a medical certificate. If we all encourage people to get treated appropriately first, then Then people will get healthy and then they will be stable and a medical certificate is likely to follow. A large majority of people who are stable on their treatment for anxiety, depression or related conditions can get a medical certificate once they have been documented. So it's important that we continue to message that and we get your help as AMEs to message that as well. Additionally, we want to continue to emphasize that those who are getting therapy alone without any antidepressant treatment, they have no requirement to report this therapy to the FAA. Of course, that depends on the underlying condition and situation. So they may have to report if they get a diagnosis of, you know, severe major depressive disorder and it's significantly affecting their ability to have normal relationships and work. So if they have significant... underlying impact, then they do need to self-report, and that's something that we need to communicate. But aside from that, if they're having some stress in their life and they want therapy, then they do not need to report to the FAA. The ADHD process has not really changed. The only updates that we did are changing the requirements to see a HIMS neuropsychologist to a FAR neuropsychologist. So any kind of nomenclature with HIMS, we updated to FAR. Otherwise, the process for ADHD is pretty much the same. As I noted, 90 days documented clinical stability on an approved antidepressant is still needed for an initial application for a special issuance. We may change this in the future, but not until we get to the point where we feel like we have enough data and literature to support decreasing that. And we might get there, but we're not there yet. Recurrent symptoms of major depressive disorder or any kind of anxiety-depression-related conditions will likely require treatment before we provide an issuance. There are always exceptions, and so there certainly are scenarios that we may not apply that guidance, but we tell everyone that, hey, we're going to look at every case individually, and so you guys send them up, and we'll take a look at them. But if someone asks you, know that recurrent anxiety, depression-related conditions, if they're recurrent, that we will likely require treatment before an issuance. And then finally, if someone has a true, accurate diagnosis of psychosis or bipolar, if they've had repeated suicide attempts, these are the folks that are considered to be excessive risk or medical risk for getting a special issuance. So we will likely not provide a special issuance for them. But again, you guys, you document and defer it and we'll take a look at it. And we may ask for more information, but depending on documentation, we may not. But sometimes these people have inaccurate diagnoses, and so they do actually get special issuances or warnings because it was not a true diagnosis. But by and large, we're not going to provide special issuance for these folks. OK, what are the processes for antidepressant use for an initial evaluation or initial certification has to be one of the approved diagnoses of anxiety, depression or related condition they need to be on. One of the FAA-approved antidepressant medications for at least 90 days documented clinical stability. We are not accepting dual treatment, multiple medications. There are always exceptions to that if there's kind of as-needed dual medication use. But by and large, if they are on two medications regularly, chronically, then they need to, then we are not. Providing issuances for that. So just try and get people on one medication if that's acceptable for their treatment. The things that we need to see for submission for us to records for review, fairly similar to what we've asked for previously, all the appropriate medical records, a personal statement, which is what we use to look at insight into their condition. Treating provider note, if their treating provider is not a board-certified psychiatrist, then they will need a separate evaluation by a board-certified psychiatrist. And then additionally, they will need a neurocognitive evaluation by a PAR neuropsychologist. That last bullet is also something that we're evaluating to see if it may be removed in the future. But we again. We need to just take a deeper dive on the literature and the aeromedical data to see if this is appropriate to continue or not. So know that we're considering that, but for now, it is something that is going to stick. Okay, for follow-ups, again, if someone is currently on an SI that's approved for antidepressant use, they just continue doing what their SI says, and then when their time is up for a re-evaluation, and when the documents get submitted up to AMCD, we will review it. If we think that it's appropriate, we'll transfer it over to an AASI. Mid-cycle, they don't have to do anything to get on AASI. Just wait until their cycle is over. Most of the cases, for those who will be on an AASI, all we need for follow-up is the mental health condition status summary sheet, and they will require semi-annual visits with their treating provider and an annual note from their treating provider. What's not listed on there but is something that we are requiring is that if their treating provider is a mid-level, namely a nurse practitioner or a physician assistant, then one of those semiannual visits needs to be a mid-level. Okay. So those who are on an SI will be slightly at higher risk. And so we're going to require more evaluation each year for those folks. And that may be more frequent visits with their treating provider. It may be seeing a psychiatrist if their treating provider is not already a psychiatrist. We may. Request people to be seen by a counselor therapist. So there's no specific mandate of what they need. And we evaluate these on a case by case basis. Okay, let's talk about we're going to give you some screenshots of what some of the updated disposition tables will look like. And as I said, Because this is still a draft version, there might be some slight changes to this, but this is by and large what we're looking at. We've broken up the ADRC into an on-treatment section and an off-treatment section, and you can see if someone is currently on a medication, all of these people need to be deferred, and the middle column discusses exactly what they need to submit for evaluation, and I've previously discussed these things. If they are off treatment, we have a couple of different rows. And again, it's the timeframe that we have separated because the risk for recurrence and impact is different for those who've been off medications for different time periods. So row A is five years or more off treatment. All the AME needs is clinical records documented that they've been off treatment for five years. They use the fast track decision tool. In two to five years, they do the same thing as row A, except they also need a current clinical progress note in addition to the fast-track pathway, and then row C, less than two years. And all these folks are deferred, and you can see what is required in that middle column, most notably a FAR psychiatry evaluation. Here's the situational depression or adjustment disorder table. Five or more years, five or less years, and then there's a row C for all others because these are the folks who have any kind of high risk symptoms noted on their decision tool, regardless of their time period. So these folks should be able to get an issuance if they have no risk factors noted. I do want to point out that one change that we have done is that to be eligible for this, they have to have their symptoms resolved within six months of symptom onset, not necessarily six months from when the stressor was. The reason is because there's plenty of people who can have a stressor in their life that was. A long time ago, but they didn't develop symptoms necessarily right away. And so what we feel like is most important is the duration of their symptoms, not from starting the clock from when they initially had their stressor. And then here's the last decision disposition table for kind of all the other concerning diagnoses out there. And all of these are defer and you can see the middle column of what we need by and large. It's just, yeah. Clinical or documentation, we may ask for an additional psychiatric evaluation, but if all the information is available for us and it seems like it's appropriate documentation, then we'll make a disposition with what we have. Okay, a couple more slides here. Here is what the mental health history checklist looks like. By and large, it's a document that asks about risk factors for concerning mental health symptoms, and if the answer is all no for this table, then by and large they're stable, and so you're able to provide a certificate for those who have been off medication before. Two to five years or over five years on the right, that's a table just outlining what you as an AME need to review for those who or and make sure that the airman has prior to submitting up to the FAA for review if they're on an antidepressant and looking for an initial certification. Just a basic checklist for you. Finally, here is a fast track pathway for anxiety, depression. Related condition and this is for those off treatment and it's basically saying, did you review the tool that was on the previous page and you signed this thing? Yes, I reviewed it. Yes, all the documents are here. There were no, no answers and you don't have any other concerns. That's not outlined. We do have a separate decision tool for situational depression, and it's a basic tool just outlining that their symptoms resolve in less than six months and they don't have any other red flag concerns. And with that, I will turn it back over to Christy. Okay. Thank you, Dr. Gregory. Can you please go ahead and reshare your screen, though? I'm going to wrap it up with those ending slides. I'd like to say thank you while he's pulling those slides back up. Thank you to Dr. Bergdorf, to Dr. Billy Pruitt, to Dr. Gregory, and all the people that were putting things in the answering the questions in the Q&A. As always, we like to show this email address. This is the email inbox that you can send AME guide improvements. And they do read these, and they have made a lot of changes and updates to the AME guide as a result of some of the things that you guys have sent in. That email address is ameguide at faa.gov. Keep in mind that that email inbox does not answer case questions. Next slide, please. Just a quick reminder that the November Grand Rounds and the November AME Guide Updates will be released on Wednesday, November 18th due to the Thanksgiving holiday here in the United States. Normally, our AME Grand Rounds and AME Guide Updates are released the last Wednesday of the month. However, the caveat is if we have any pending holidays or other things going on, we do change those just a bit. So please join us for next month's Grand Rounds. Next slide. On behalf of Dr. Northrup, thank you. Actually, I believe she's still on. I'll let her come on camera. Oh, I am. Hold on. Thank you, everyone, for attending. We hope you are beginning to cogitate on some of the changes that we're making. We wanted to be sure that you had time for the next couple of weeks to really dig into this, and it also allows us to make sure that we've got everybody ready on the inside as we get ready to roll these out. But suffice it to say, I need everybody to understand our policies are not static. Lots of good questions asked tonight. Lots of things we're considering. This is not the end of the changes to the mental health criteria. Just pay attention and give us a second to go do the actual SMS. Risk assessments as we move forward. So again, please show up. These are really, really important for us to pass the information. If you have friends that are AMEs that aren't on tonight, if you would help us encourage them to attend, that would be incredibly helpful. And without further ado, Christy, close us out. Okay. And one other thing, we did have some comments earlier in the day about the recordings. Can we please get them up faster on the YouTube playlist? Please keep in mind that we have an approval process that actually goes outside of aerospace medicine, so we will get the recording loaded as quickly as possible, and we appreciate your patience in that. So at this time, thank you all for being AMEs. Thank you for help keeping travel safe. Thank you for attending Grand Rounds. If you're not an FAA employee, please log out of the Zoom. This session is concluded. FAA employees, stand by to go into the breakout. Good night.