METHODS

The Aerospace Medical Association (AsMA) Executive Committee established the Mental Health Research Subgroup (MHRSg) under the broader Mental Health Working Group on March 3, 2023. The objective of this subgroup was to accomplish a knowledge gap analysis and formulate research priorities. Solicitation for MHRSg members began with the Mental Health Working Group followed by snowball recruitment to create the final subgroup membership. Individuals with experience and interest in aviation SSP mental health were specifically sought to participate. MHRSg membership included 53 individuals with a broad range of backgrounds and work experience, including aviation psychiatry, aviation psychology, aerospace medicine research, civil aviation regulation, neuropsychology, aerospace academia and flight instruction, aircrew, military and civilian aviation, primary care and aerospace medicine physicians, and peer support program leaders. Working group medical and mental health professionals included 15 physicians, 2 aviation psychiatrists (one a Federal Aviation Administration Human Intervention Motivation Study Aviation Medical Examiner), 2 master’s degree-level clinical aviation psychologists, and 3 Ph.D.-level clinical aviation psychologists. Members represented nine countries including the United States, Australia, Norway, Finland, England, Switzerland, Germany, South Africa, and Iceland in both military and civilian aviation settings.

The MHRSg used the Delphi method⁸ to generate consensus aviation SSP mental health research priorities.⁸ The MHRSg consulted with two qualitative researchers within the working group experienced in the Delphi method prior to starting the effort. Five rounds of electronic surveys were distributed to members between April and October 2023. Google Forms was used as the survey platform and links were distributed via email. Instructions for each round included the scope and objectives of the effort. One in-person meeting occurred on May 24, 2023, at the AsMA Annual Scientific Meeting in New Orleans, LA, United States.

Round one took place in April 2023, where opinions about the scope and objectives were collected. The scope and objectives were subsequently finalized at the in-person meeting in May 2023. Subsequently, attendees of the in-person meeting were divided into five groups. Each group was asked to independently generate a list of research categories (i.e., research themes) and an associated definition under which knowledge priorities would be included. The founders of the MHRSg then aggregated these five lists into a single list including six categories using a consensus-based approach. Round two took place in June 2023, where feedback on the six research categories, the definitions, and prioritization (using a voting method to rank the categories in priority order) was collected. Round three asked members to propose research priorities (i.e., research topics) for each research category.

To generate the preliminary list of research priorities for each category, six groups consisting of one to four volunteers were designated. Each group was assigned a specific research category based on their experience, academic qualifications, and interest. Knowledge priorities for each category obtained during the second round of Delphi were provided to the respective group. The groups then: 1) consolidated their list into 5–10 priorities statements; 2) condensed questions when able; 3) defined terms; 4) reviewed the relevant literature to ensure no similar studies had already been published; and 5) reviewed their priorities with an additional expert in the field. A MHRSg leader then met with all six teams individually to provide guidance and ensure efforts were mirrored between groups. There was no specification on what constituted a comprehensive literature search or expert review. The final list of research priorities was submitted electronically in the fourth round in August 2023.

The submissions from round four were reviewed and edited by the MHRSg. This included: 1) ensuring use of uniform terminology, 2) reallocating priorities into appropriate categories, 3) clarifying priority statements, 4) removing redundant priorities, and 5) formatting the document. This task was completed independently by two of the leading researchers of the MHRSg and then a final document was generated using a consensus approach. Disagreements were resolved through the guidance of other subgroup members. The document was then reviewed by an oversight team of three experts. Feedback from round five was incorporated in the document. The final document was reviewed by the chair of the AsMA Mental Health Working Group prior to submission. The process is summarized in Fig. 1.

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A list of terms requiring definition was identified. A member of the MHRSg conducted a literature review on relevant terms and generated the final list of definitions. When possible, definitions from the ICAO⁹ list of definitions were used or were otherwise referenced. The list of definitions is included in Appendix A (available at https://doi.org/10.3357/amhp.6442sd.2024).

RESULTS

The methods described above produced the AsMA MHRSg Research Priorities Version 1.0 (current as of January 1, 2024), which are presented below. Table I shows the collection dates and number of responses for each round. Six teams were established to oversee each of the six research categories. Table II lists the six research categories, the number and background of the team members, and the number of group members who voted the category as being among the three most important.

Table I. Survey Collections.

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Table II. Delphi Round 4 Team Members.

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DISCUSSION

This study employed the Delphi method to generate a consensus list of aviation SSP mental health research priorities. Members believed investigating these priorities would help aviation stakeholders optimize SSP mental health states, understand the role of various metal health states on performance, and also identify and mitigate safety threats. This effort is not intended to be exhaustive or serve as a statement of the current state of knowledge. Other publications like those available thorough the European Union Aviation Safety Agency MESAFE project should serve this function.⁷ Instead, this effort aims to guide researchers in selecting research topics, encourage use of shared terminology, and facilitate advocacy for investing in research on this topic based on the opinions of a range of subject matter experts. This document should be seen as part of an ongoing and evolving discussion.

While there are many possible research questions, this effort identified priorities that were felt by the working group to be of greatest relevance to aviation stakeholders facing complex questions related to SSP mental health. These include questions about safety and performance, mental health and peer support programs, clinical care and certification, epidemiology, and natural history. These topics should be explored in the context of evolving technology and in a way that is inclusive of traditionally underrepresented populations. Outcome measures were intentionally selected in hopes of increasing the likelihood that the broader objectives of this effort are accomplished. For example, priorities about peer support programs suggested a financial outcome measure to better understand the return on investment for such programs. More broadly, it is critical that these topics be investigated in a way that will not result in unintended harm to aviation SSP. For this reason, a broader discussion about how to conduct research related to mental health in aviation is necessary. This discussion should be continuous and include aviation SSP, operators, regulators, researchers, and ethicists to ensure the aeromedical system of the future focuses on meeting the unique mental healthcare needs of SSP while optimizing safety. An additional consideration is the difference between the science related to various interventions related to mental health and the policy and practice of those interventions. For example, investigating the sensitivity of a mental health screening tool in airline pilots requires different research methods than investigating the optimal application or use of such a tool. These types of questions should be investigated separately and with due consideration of culture, access, and practice. Lastly, the depth and complexity of mental health in aviation must be acknowledged. While the current effort primarily focuses on factors on the level of the individual SSP, the cumulative systems-level implications are complicated by policy, culture, practice, and access. The scoping of research projects, the selection of outcomes, and the interpretation of results should be considered within this context.

Any conclusions drawn from this study should be within the context of the limitations. It is significant to note that all the group members were volunteers, and the results may therefore reflect the opinions of their varied degrees of participation. Furthermore, the results are limited by the volunteers’ experience and expertise. There were no formal criteria for membership beyond interest in the topic and meeting a broad definition for experience with aviation SSP mental health. Each round of Delphi included survey responses from fewer than half of the group members, which may have resulted in response bias toward those who participated the most. Further, nonpilot SSP had limited representation within this working group, including ground crew, air traffic controllers, flight attendants, and other professionals. This could have resulted in priorities preferentially focused on pilots. These points were partially mitigated by seeking external subject matter expert opinions and guidance from members of ICAO and the AsMA Mental Health Working Groups. Additionally, while representation from nine ICAO countries could be viewed as a strength, the generalizability of the results to all ICAO nations is limited for many reasons. Further efforts should focus on encouraging the participation of the 193 ICAO nations. The authors acknowledge that identified priorities are broad and lack individual research questions, making it difficult to determine if and how a priority might be fully addressed. Further, priorities are prioritized by large categories, limiting the ability to determine the priority of individual research questions. Future iterations should: 1) focus on definitions of terms, 2) conduct a systematic gap analysis, 3) prioritize gaps, and 4) make the focus of gap statements into research questions. As it relates to methods, there was no formal process to guide teams on how to conduct a literature review and no dedicated oversight or quality check of reviews. The listed knowledge priorities are also broad, making it difficult to fully review all literature potentially relevant to any one priority. Consequently, there may be previous studies that address some priorities listed in this document, so this document should not be seen as a current state of knowledge. There were no experts on the Delphi method within the subgroup. While external consultation and guidance from previously published work were used, group leaders employed this method to the best of their knowledge and ability. Additionally, the questions, science, and practice of mental health in aviation is rapidly evolving and these research priorities and definitions pertain to the state of the science at the time of writing. Therefore, future updates or iterations will be necessary to keep this document up to date.