Pilot mental health during the COVID-19 pandemic: prevalence rates from semi-structured interviews, and associated vulnerability and protective factors

**Background:** Pilot mental health has gained attention since Germanwings Flight 9525, but prior research relied heavily on questionnaires focusing on depression and suicide, potentially missing other disorders. The COVID-19 pandemic severely disrupted aviation, increasing stressors. This study aimed to comprehensively assess pilot mental health using a diagnostic interview and explore vulnerability and protective factors within a diathesis-stress framework.

**Methods:** 73 commercial pilots (58 male, 14 female, 1 unreported; mean age 39.70 years, SD 10.70) were recruited via the Australian Federation of Air Pilots. Participants completed the DIAMOND semi-structured diagnostic interview (covering 33 DSM-5 disorders) and a battery of questionnaires: PHQ-9, Holmes-Rahe Social Readjustment Stress Scale (SRSS), Work Stress Questionnaire (WSQ), Health-Promoting Lifestyle Profile II (HPLII), Coping Inventory for Stressful Situations (CISS), Passion Scale, and NEO-PI-R. Data were collected during the pandemic (March 2020–2022). A binomial logistic regression examined predictors of diagnosis (yes/no) based on the diathesis-stress model.

**Key Results:** 95% of pilots reported COVID-19 impact. Mean SRSS score was 188.56 (SD 129.93), placing pilots at ≥50% risk for stress-related illness; 9 pilots scored >300 (80% risk). 27 pilots (37%) met criteria for at least one current diagnosis: 12 had a single diagnosis, 15 had multiple (2–4). Most common diagnoses: anxiety disorders (14 cases, 19.18%), ADHD (10 cases, 13.70%), adjustment disorder (8 cases), depressive disorders (6 cases, 8.22%). PHQ-9 (cutoff ≥10) identified 11 clinical cases, but only 5 aligned with DIAMOND depressive disorder diagnoses; 2 depressive cases were missed by PHQ-9. Suicidal ideation was reported by 3 pilots on DIAMOND (none with plan/intent) and 6 on PHQ-9; only 2 overlapped. Stress scores did not differ between diagnosis and no-diagnosis groups (largest t=1.10, p=0.314). Pilots with diagnoses had higher obsessive passion (t=3.03, p=0.003, d=0.829), higher neuroticism (t=3.081, p=0.003, d=0.750), lower agreeableness (t=3.415, p=0.001, d=0.831), and lower conscientiousness (t=2.417, p=0.018, d=0.588) than those without. On HPLII, pilots without diagnoses scored higher on nutrition (t=3.169, p=0.002, d=0.771), spiritual growth (t=3.027, p=0.003, d=0.737), and interpersonal relations (t=2.194, p=0.032, d=0.534). Logistic regression identified three significant predictors: agreeableness (OR for no diagnosis=1.060 per unit, p=0.103 in final model), obsessive passion (OR for diagnosis=1.105 per unit, p=0.018), and nutrition (OR for no diagnosis=4.234 per unit, p=0.049). The model correctly classified 79.2% overall (66.7% of diagnoses, 86.7% of no diagnoses).

**Clinical Implications:** This study demonstrates that pilots experience a range of mental health disorders beyond depression and suicide, with anxiety and ADHD being common. Stress alone does not explain who develops disorders; personality (low agreeableness), obsessive passion, and poor nutrition are key factors. The findings support a diathesis-stress model and suggest that interventions targeting nutrition and reducing obsessive passion may be protective. The discrepancy between PHQ-9 and DIAMOND highlights the need for comprehensive diagnostic interviews rather than brief questionnaires. Importantly, many pilots with disorders reported no impairment, and suicidal ideation did not equate to risk. The authors recommend shifting licensing focus from diagnosis to functional impairment, and adopting flexible, supportive mental health policies to encourage reporting.