
==== Front
J Occup Med Toxicol
J Occup Med Toxicol
Journal of Occupational Medicine and Toxicology (London, England)
1745-6673
BioMed Central London

39227866
435
10.1186/s12995-024-00435-4
Research
Navigating the skies: a cross-sectional study of depression among Saudi Arabian airline pilots
AlMuammar Sarah muammar.sarah@gmail.com

Alkhaldi Rahaf
Alsharif Roaa
Allbdi Daniah
Alasmari Mashael
Alasmari Bashair
Alkhaldi Afaf
Aldealij Refaal
Ismail Nabeela
https://ror.org/02ma4wv74 grid.412125.1 0000 0001 0619 1117 Family Medicine Department, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
3 9 2024
3 9 2024
2024
19 364 5 2024
28 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Depression poses a significant challenge globally, including in safety-critical industries such as aviation. In Saudi Arabia, where the aviation sector is rapidly expanding, pilots encounter unique stressors inherent to their profession. However, research on pilot mental health, particularly within the Saudi context, remains limited despite its critical role in flight safety.

Methods

This cross-sectional survey was designed to estimate the self-reported prevalence of depression in a convenience sample of airline pilots in Saudi Arabia. Participants were recruited from various commercial airlines in Saudi Arabia. Recruitment efforts utilized targeted outreach on social media platforms, focusing on pilot forums and groups. The survey was administered online for accessibility and convenience. The structured questionnaire, developed through a literature review and expert consultation, comprises sections on demographic and professional characteristics, occupational information, health habits, and depression assessment via the Patient Health Questionnaire-9 (PHQ-9).

Results

This study enrolled 310 participants, with the largest cohort (34.8%, n = 108) falling within the 30–39 years age group, closely followed by individuals under 30 years (30.0%, n = 93). Males dominated the sex distribution (99.0%, n = 307). The mean PHQ-9 score was 8.2 ± 5.4. Notably, 40.6% (n = 126) of the participants had a score of 10 or higher, indicating the potential for moderate, moderate-severe, or severe depression. Multivariable binary logistic regression analysis revealed that pilots with 11–15 years of experience had greater odds of experiencing depression than did those with 0–10 years of experience did (odds ratio [OR]: 3.0, 95% confidence interval [CI]: [1.1–8.4], p = 0.04). Pilots with rest times exceeding 24 h had lower odds of depression than did those with rest times less than 1 h (OR: 0.3, 95% CI: [0.1–0.8], p = 0.02). Engaging in regular exercise was associated with reduced odds of depression (OR: 0.3, 95% CI: [0.2–0.5], p < 0.01), as was longer sleep duration (> 8 h) (OR: 0.2, 95% CI: [0.1–1.0], p = 0.04).

Conclusion

Our study estimates the prevalence and severity of self-reported depressive symptoms among airline pilots in Saudi Arabia, surpassing global estimates. The identified factors, including lack of regular exercise, short sleep duration, and insufficient rest between flights, underscore the complex mental health challenges faced by pilots in this region. Addressing these issues is crucial not only for pilot well-being but also for flight safety.

Keywords

Depression
Airline pilots
Occupational stress
Mental health
Prevalence
Saudi Arabia
Sleep duration
Exercise
Flight safety
Cross-sectional study
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmcBackground

Depression is a pervasive mental health disorder with profound implications for individuals, communities, and societies worldwide, representing a leading cause of disability and contributing significantly to the global burden of disease [1]. Its impact spans diverse populations and professions, drawing particular attention to its ramifications within safety-critical industries [2].

The aviation sector serves as a cornerstone of modern transportation systems, facilitating global connectivity and economic growth. In Saudi Arabia, a country experiencing rapid growth in its aviation sector, pilots play a crucial role in ensuring the safety of air travel. However, operating within the aviation industry entails a complex and demanding environment characterized by irregular working hours, long flights, time zone changes, and extended periods away from home [3–5]. These factors can disrupt circadian rhythms, exacerbate sleep disturbances, and contribute to chronic fatigue, which are recognized risk factors for depression [6, 7].

Pilots are exposed to various physical stressors, including cosmic radiation and electromagnetic fields, which may increase their cancer risk. Chemical stressors, such as pollutants from jet fuels and aircraft materials, can impact air quality. Additionally, the associated biological risks include exposure to foodborne pathogens and airborne microorganisms, further complicating health management. Environmental factors such as acceleration forces, hypoxia, and noise also pose significant health risks [8, 9].

Research on pilot mental health has garnered increasing attention in recent years because of its profound implications for flight safety. The mental well-being of pilots is crucial because it directly affects their cognitive function, decision-making ability, situational awareness, and overall performance during flight operations, thereby compromising flight safety [10].

Limited research has been conducted on mental health disorders among commercial pilots globally. A systematic review by Terouz et al. [11] in 2018 included 20 studies, shedding light on the prevalence and types of mental health challenges faced by commercial airline pilots. The review revealed a wide range of depression prevalence rates, ranging from 1.9 to 12.6%. The study also identified various contributing factors to pilots’ mental health challenges, including substance abuse, exposure to verbal or sexual abuse, disrupted sleep patterns, and chronic fatigue. However, none of the studies included in the review were conducted in Saudi Arabia or the broader Middle East region, indicating a significant research gap within this specific geographical context.

Understanding the unique challenges shaping pilot mental health in Saudi Arabia is crucial not only for ensuring the well-being of these individuals but also for safeguarding the safety of air travel passengers and crews. This study aimed to address this knowledge gap by requesting self-reported data on depressive symptom prevalence and severity in a convenience sample of pilots in Saudi Arabia.

Methods

Study design and settings

This cross-sectional survey was designed to estimate the self-reported prevalence of depression in a convenience sample of airline pilots in Saudi Arabia and identify associated demographic, occupational, and health behavior factors.

In Saudi Arabia, the General Authority of Civil Aviation (GACA) is responsible for establishing and overseeing health surveillance protocols for pilots. Saudi aviation medical examiners conduct thorough evaluations during mandatory occupational health visits. These examinations are typically performed at least annually for medical certification [12].

Study participants

Participants were recruited from various commercial airlines in Saudi Arabia. The inclusion criterion included active pilots. Pilots were recruited through targeted outreach on social media platforms, with a focus on pilot forums and groups to ensure diverse representations. Referrals within professional networks were encouraged, and no incentives were provided for referrals to maintain voluntary participation. Approximately 500 pilots were estimated to be targeted for recruitment.

Survey administration

To ensure accessibility and convenience, the questionnaire was administered online. A survey link was disseminated through social media platforms, including LinkedIn, Twitter, and Facebook, allowing diverse types of participation. This mode accommodates pilots’ busy schedules, with an estimated completion time of 7 min. The data were collected over 6 weeks, from August 1, 2023, to September 12, 2023.

Questionnaire development

A structured questionnaire was developed through a literature review and expert consultation. The questionnaire comprises sections on demographic and professional characteristics, occupational information, health habits, and the Patient Health Questionnaire-9 (PHQ-9) questionnaire for depression assessment [13]. Prior to the main study, the questionnaire underwent preliminary testing through a pilot study involving 20 participants to ensure its clarity, relevance, and comprehensiveness.

Content of questionnaire

Exposure variables

The questionnaire covered various demographic variables, such as age group (< 30 years, 30–39 years, 40–49 years, ≥ 50 years), sex (male or female), marital status (single, married, divorced), self-reported weight (kg), height (cm), and the presence of chronic disease. Occupational information included position (captain or senior officer), years of experience, total flying hours (< 3,000, 3,000–5,000, 5,000–10,000, > 10,000), flying hours in the past year (< 500, 500–700, > 700), rest time between flights (< 1 h, 1–4 h, 4–24 h, > 24 h), and flight route duration (< 6 h, 6–12 h, > 12 h). The health behavior habit questions included whether the participant engaged in regular exercise, defined as exercising at least 3 times per week, exercise intensity (low, moderate, or high), smoking status (nonsmoker or smoker), and sleep duration (< 5 h, 5–8 h, or > 8 h). The survey questionnaire also included a section about musculoskeletal complaints, which were reported separately.

Outcome variables

Depression severity was assessed via the PHQ-9 questionnaire, which categorizes scores into different severity levels. The PHQ-9 scores were categorized into five distinct severity levels: minimal depression (scores ranging from 0 to 4), mild depression (scores between 5 and 9), moderate depression (scores ranging from 10 to 14), moderately severe depression (scores ranging from 15 to 19), and severe depression (scores falling within the range of 20–27). The cutoff point for significant depression on the PHQ-9 questionnaire was defined as a score of 10 or higher, indicating the presence of moderate to severe depressive symptoms requiring clinical attention [13]. The primary outcome was the prevalence of depression among pilots. The secondary outcomes included associations between depression and demographic, occupational, and health behavior factors.

Statistical analysis

The data were analyzed via IBM SPSS Statistics version 26 (IBM Corp., Armonk, NY, USA). The chi-square test was used for comparisons between variables. Multivariable logistic regression analysis was conducted to identify independent factors associated with depression, with odds ratios (ORs) and 95% confidence intervals (CIs) estimated. All p values were calculated via two-tailed tests with an alpha level of 0.05.

To assess the potential confounding effects of age on the relationships between flying hours, years of experience, and depression, a sensitivity analysis was performed. This analysis included interaction terms between age groups and years of experience to explore whether age influenced these relationships. The results of the sensitivity analysis revealed no significant interactions, indicating that age did not substantially confound the associations between flying hours, years of experience, and depression.

Ethical considerations

Ethical approval was obtained from the Ethics Committee of King Abdulaziz University. Informed consent was obtained, ensuring voluntary participation and confidentiality. Stringent data privacy and security measures were implemented to uphold ethical standards. The participants were informed that the survey was not a diagnostic tool and encouraged them to consult their healthcare provider if they were concerned about their mental health.

Results

Demographic characteristics of the participants

The study included 310 participants. The largest cohort comprised 34.8% (108 participants) of the 30–39 age group, closely followed by individuals under 30 years, constituting 30.0% (93 participants) of the sample. Males heavily dominated the sex distribution, representing 99.0% (307 participants) of the cohort. Marital status analysis revealed that 59.7% (185 individuals) were married. Regarding body mass index categories, the majority of participants were classified as normal (42.6%, 132 participants), followed by overweight (39.7%, 123 participants) and obese (17.1%, 53 participants) (Table 1).

Table 1 Participant demographic characteristics and occupational information (N = 310)

Category	Variable	N	(%)	
Demographic Information	Age Group	< 30 Years	93	(30.0)	
30–39 Years	108	(34.8)	
40–49 Years	61	(19.7)	
≥ 50 Years	48	(15.5)	
Gender	Male	307	(99.0)	
Female	3	(1.0)	
Marital Status	Single	118	(38.1)	
Married	185	(59.7)	
Divorced	7	(2.3)	
BMI Category	Underweight	2	(0.6)	
Normal	132	(42.6)	
Overweight	123	(39.7)	
Obesity	53	(17.1)	
Occupational Information	Position	Captain	141	(45.5)	
Senior Officer	169	(54.5)	
Experience Years	0–10	179	(57.7)	
11–15	43	(13.9)	
> 15	88	(28.4)	
Flying Hours (Total)	< 3,000	148	(47.7)	
3,000–5,000	49	(15.8)	
5,000–10,000	62	(20.0)	
> 10,000	51	(16.5)	
Flying Hours (Past Year)	< 500	96	(31.0)	
500–700	116	(37.4)	
> 700	98	(31.6)	
Rest Time Between Flights	< 1 h	152	(49.0)	
1–4 h	68	(21.9)	
4–24 h	58	(18.7)	
> 24 h	32	(10.3)	
Flight Routes Duration	< 6 h	203	(65.5)	
6–12 h	33	(10.6)	
> 12 h	74	(23.9)	
Abbreviations: N: number of participants, BMI: body mass index

Occupational characteristics of the participants

Occupationally, the distribution between captains and senior officers was fairly balanced, with senior officers slightly outnumbering captains at 54.5% (169 participants) and 45.5% (141 participants), respectively. The number of years of experience varied, with the majority (57.7%, 179 participants) having between 0 and 10 years of experience. Flying hours were diverse, with nearly half of the participants (47.7%, 148 participants) accumulating fewer than 3,000 flying hours. Approximately one-third of the participants (31.0%, 96 participants) logged less than 500 h in the past year. The remaining time between flights varied as well, with 49.0% of participants (152 individuals) having less than 1 h of rest, 21.9% (68 individuals) having 1–4 h, 18.7% (58 individuals) having 4–24 h, and 10.3% (32 individuals) having more than 24 h. The flight route duration data revealed that the majority of flights (65.5%, 203 participants) lasted less than 6 h, followed by 23.9% (74 participants) lasting more than 12 h and 10.6% (33 participants) lasting between 6 and 12 h (Table 1).

Participants’ health behaviors

Regarding the health habits of the participants, 194 participants (62.6%) identified as smokers. With respect to exercise, 158 participants (51.0%) engaged in physical activity regularly 3–5 times per week. The majority, 176 individuals (56.8%), reported exercising at a low intensity, whereas 86 participants (27.7%) exercised at a medium intensity. Additionally, 48 participants (15.5%) engaged in high-intensity exercise. The sleep duration among the participants varied, with 259 participants (83.5%) reporting a sleep duration of 5–8 h, 32 participants (10.3%) reporting more than 8 h, and 19 participants (6.1%) reporting less than 5 h (Fig. 1).

Fig. 1 Health habits of the participants (N = 310)

PHQ-9 score and depression severity

The mean PHQ-9 score among the study participants was 8.2 ± 5.4. Notably, 126 participants (40.6%) had a score of 10 or higher, indicating significant depression. Analysis of the PHQ-9 score distribution revealed that 88 participants (28.4%) exhibited minimal depression, 96 (31.0%) reported mild depression, 87 (28.1%) indicated moderate depression, 30 (9.7%) had moderately severe depression, and 9 (2.9%) had severe depression (Fig. 2).

Fig. 2 Categorization of depression severity on the basis of PHQ-9 scores (N = 310)

Associations with depression: bivariate analysis

Table 2 presents the bivariate associations of depression with demographic, occupational, and health behavior factors. A total of 59.0% of the pilots aged 40–49 years presented with depression, whereas 34.4% of those aged < 30 years presented with depression (p = 0.01). In terms of occupational factors, pilots with 0–10 years of experience had a lower prevalence of depression than did those with 11–15 years of experience (35.8% vs. 58.1%, p = 0.03). Similarly, pilots with 3,000–5,000 and 5,000–10,000 flying hours presented greater proportions of depression than did those with fewer flying hours (< 3,000) (49.0% and 51.6% vs. 37.2%, respectively; p = 0.04). Additionally, pilots with shorter rest times between flights (< 1 h) had a greater prevalence of depression than did those with longer rest times of 24 h (48.0% vs. 21.9%, p = 0.03).

Table 2 Bivariate associations of depression with demographic and occupational factors

Category	Variable	Moderate to Severe Depression	P value	
N	(%)	
Demographic Information	Age Group	< 30 Years	32	(34.4)	0.01	
30–39 Years	44	(40.7)	
40–49 Years	36	(59.0)	
≥ 50 Years	14	(29.2)	
Gender	Male	124	(40.4)	0.36	
Female	2	(66.7)	
Marital Status	Single	44	(37.3)	0.19	
Married	77	(41.6)	
Divorced	5	(71.4)	
BMI Category	Underweight	2	(100.0)	0.08	
Normal	45	(34.1)	
Overweight	56	(45.5)	
Obesity	23	(43.4)	
Occupational Information	Position	Captain	59	(41.8)	0.70	
Senior Officer	67	(39.6)	
Experience Years	0–10	64	(35.8)	0.03	
11–15	25	(58.1)	
> 15	37	(42.0)	
Flying Hours (Total)	< 3,000	55	(37.2)	0.04	
3,000–5,000	24	(49.0)	
5,000–10,000	32	(51.6)	
> 10,000	15	(29.4)	
Flying Hours (Past Year)	< 500	38	(39.6)	0.97	
500–700	48	(41.4)	
> 700	40	(40.8)	
Time Between Flights	< 1 h	73	(48.0)	0.03	
1–4 h	25	(36.8)	
4–24 h	21	(36.2)	
> 24 h	7	(21.9)	
Flight Routes Duration	< 6 h	86	(42.4)	0.25	
6–12 h	9	(27.3)	
> 12 h	31	(41.9)	
Health Habits	Smoking Status	Non-Smoker	44	(37.9)	0.45	
Smoker	82	(42.3)	
Regular Exercise	No	82	(53.9)	< 0.01	
Yes	44	(27.8)	
Sleep Duration	< 5 h	8	(42.1)	0.01	
5–8 h	113	(43.3)	
> 8 h	5	(15.6)	
Abbreviations: N: number of participants, BMI: body mass index

Statistical significance was defined as a p value less than 0.05

In examining the associations between health habits and the prevalence of moderate to severe depression among the study participants, several noteworthy patterns emerged. With respect to smoking status, no significant difference was observed between nonsmokers (37.9%, 44 individuals) and smokers (42.3%, 82 individuals) in terms of experiencing depression (p = 0.45). However, a statistically significant association was found between regular exercise and depression status (p < 0.01). The participants who engaged in regular exercise presented a lower prevalence of depression (27.8%, 44 individuals) than did those who did not (53.9%, 82 individuals). Those engaging in low-intensity exercise had a greater prevalence of depression (51.1%, 90 individuals), followed by individuals engaging in moderate-intensity exercise (26.7%, 23 individuals) and those engaging in high-intensity exercise (27.1%, 13 individuals). Additionally, sleep duration was significantly associated with depression (p = 0.01). Individuals reporting less than 5 h of sleep had a greater prevalence of moderate to severe depression (42.1%, 8 individuals), whereas those reporting 5–8 h of sleep presented a slightly greater prevalence (43.3%, 113 individuals), and individuals reporting more than 8 h of sleep had a lower prevalence (15.6%, 5 individuals).

Associations with depression: multivariable analysis

Table 3 presents the findings from the multivariable analysis examining the relationships between various factors and depression among airline pilots. Notably, pilots with 11–15 years of experience had markedly greater odds of experiencing depression than did those with 0–10 years of experience (OR: 3.0, 95% CI: [1.1–8.4], p = 0.04). Additionally, pilots who had rest times between flights exceeding 24 h had significantly lower odds of depression than did those who had rest times less than 1 h (OR: 0.3, 95% CI: [0.1–0.8], p = 0.02). Furthermore, engaging in regular exercise was significantly associated with reduced odds of depression (OR: 0.3, 95% CI: [0.2–0.5], p < 0.01). Similarly, individuals with longer sleep durations (> 8 h) had a significantly lower likelihood of depression than did those with shorter sleep durations did (OR: 0.2, 95% CI: [0.1–1.0], p = 0.04).

Table 3 Factors associated with depression: multivariable analysis

Category	Variable	Univariable Analysis	Multivariable Analysis	P value	
OR	95% CI	OR	95% CI	
Demographic Information	Age Group	< 30 Years	Reference Group	
30–39 Years	1.3	[0.7–2.3]	1.2	[0.6–2.3]	0.69	
40–49 Years	2.7	[1.4–5.3]	2.1	[0.7–6.4]	0.19	
≥ 50 Years	0.8	[0.4–1.7]	1.1	[0.2–4.9]	0.91	
Marital Status	Single	Reference Group	
Married	1.2	[0.7–1.9]	0.6	[0.3–1.2]	0.15	
Divorced	4.2	[0.8–22.6]	2.4	[0.4–15.1]	0.36	
Health Habits	Regular Exercise	No	Reference Group	
Yes	0.3	[0.2–0.5]	0.3	[0.2–0.5]	< 0.01	
Sleep Duration	< 5 h	Reference Group	
5–8 h	1.1	[0.4–2.7]	0.8	[0.3–2.4]	0.74	
> 8 h	0.3	[0.1–1.0]	0.2	[0.1–1.0]	0.04	
Occupational Information	Experience Years	0–10	Reference Group	
11–15	2.5	[1.3–4.9]	3.0	[1.1–8.4]	0.04	
> 15	1.3	[0.8–2.2]	3.2	[0.9–11.4]	0.07	
Total Flying Hours	< 3,000	Reference Group	
3,000–5,000	1.6	[0.8–3.1]	1.1	[0.5–2.4]	0.82	
5,000–10,000	1.8	[1.0–3.3]	0.6	[0.2–1.6]	0.34	
> 10,000	0.7	[0.4–1.4]	0.5	[0.1–1.7]	0.26	
Time Between Flights	< 1 h	Reference Group	
1–4 h	0.6	[0.4–1.1]	0.6	[0.3–1.2]	0.15	
4–24 h	0.6	[0.3–1.1]	0.8	[0.4–1.7]	0.57	
> 24 h	0.3	[0.1–0.7]	0.3	[0.1–0.8]	0.02	
Abbreviations: OR: odds ratio; CI: confidence interval

Statistical significance was defined as a p value less than 0.05

Discussion

The present study revealed an alarmingly high prevalence of depression among airline pilots, with 40.6% of the sample screening positive for depression via the PHQ-9. This figure is notably higher than the rates reported in previous studies, which range from 1.9 to 12.6% [11, 14]. This substantial discrepancy raises important questions regarding the factors contributing to such elevated rates.

A key consideration is the screening tool used. Our study employed the PHQ-9, whereas other studies in the field have utilized different measures, including the Beck Depression Inventory-II (BDI-II) [10], Symptoms of Stress Questionnaire [15], Symptom Checklist 90 (SCL 90) [16], New Zealand Health Survey [17], and Self-Reporting Questionnaire-20 items (SRQ-20) [18]. The variation in tools across studies may partly account for differences in reported prevalence rates.

While it might be tempting to attribute this difference to the screening tool used—in our case, the PHQ-9—a deeper examination reveals that this explanation may not be sufficient. For example, Wu et al. [19] conducted a cross-sectional study focusing on mental health among airline pilots and utilized the PHQ-9. Their findings indicated that 12.6% of pilots met the depression threshold according to the PHQ-9 and that 4.1% reported suicidal thoughts within the past two weeks. A recent study by Minoretti et al. [14] investigated the impact of mild depressive symptoms on executive functions in airline pilots and revealed that 12% of the study population experienced mild depression according to the BDI-II. In fact, a previous study comparing the PHQ-9 and the BDI-II often categorized a greater proportion of participants with severe depression than did the PHQ-9.

Given this, the elevated depression rate observed in our study likely results from other factors. These could include unique characteristics of our sample, such as higher exposure to occupational stressors, fatigue, or other environmental and psychological factors specific to the airline pilot population in our country. In particular, occupational factors have emerged as significant contributors to the mental health outcomes of airline pilots in Saudi Arabia. Rest time between flights, in particular, has emerged as a critical determinant of mental health among pilots. Pilots with shorter intervals between flights demonstrated a greater prevalence of moderate to severe depression than did those with longer rest times exceeding 24 h. Sleep duration has emerged as another critical determinant of mental health among airline pilots. Sleep plays a pivotal role in regulating mood, cognitive function, and emotional stability [20]. Prolonged sleep deprivation can disrupt neurobiological processes, exacerbate stress responses, and increase vulnerability to mental health disorders [21]. Pilots who reported participating in regular physical activity presented lower prevalence rates of moderate to severe depression than did those who did not engage in regular exercise. It is unclear from our results whether those who exercised more frequently had fewer/milder depressive symptoms or whether those with more depressive symptoms felt less motivated to exercise.

Our findings reveal a concerning prevalence of depression among Saudi airline pilots. According to the GACA standards for Class 1 medical certification, pilots are disqualified if they have a history or clinical diagnosis of mood disorders, including clinical depression. The GACA guidelines explicitly state that mood disorders are grounds for disqualification [12]. The high prevalence of depression observed in our study raises questions about the fitness-to-fly licensing of pilots in Saudi Arabia. Given that pilots with severe depression may be at risk of disqualification under these standards, it is crucial to investigate whether affected pilots are being appropriately evaluated and treated. The reluctance to pursue treatment due to concerns about medical certification may result in pilots remaining untreated, potentially compromising their safety and performance. This issue underscores the need for a supportive framework that encourages pilots to seek help without fear of negative repercussions for their careers.

While our study provides valuable insights into the prevalence and correlates of depression among airline pilots in Saudi Arabia, several limitations should be acknowledged to contextualize the findings and guide future research endeavors. First, the cross-sectional nature of the survey design restricts our ability to establish causal relationships between variables. Although we can identify associations between certain factors and depression incidence, we cannot infer causation or temporal sequencing. Second, self-reporting biases may have influenced the accuracy and reliability of the data collected in our study. The participants may have underreported or overreported their symptoms of depression due to social desirability bias or recall errors. Third, the sampling strategy employed in our study may limit the generalizability of the results to the broader population of airline pilots in Saudi Arabia. Convenience sampling via online recruitment methods may have introduced selection bias, favoring participation among certain demographic groups or individuals with specific characteristics. Fourth, self-reported measures of depression relied upon the use of the PHQ-9. While the PHQ-9 is a validated screening tool for depression, it does not substitute for a comprehensive clinical evaluation conducted by trained mental health professionals. Finally, the questionnaire did not undergo formal validation, which should be considered a limitation of the study.

Conclusion

In conclusion, this study recruited pilots to self-report their depressive symptoms, and a greater percentage of the pilots experienced more severe symptoms than the authors expected on the basis of their background research. The identification of associated factors such as lack of regular exercise, short sleep duration, and inadequate rest between flights underscores the multifaceted nature of the mental health challenges faced by pilots in this region. Addressing these issues is paramount not only for safeguarding the well-being of pilots but also for ensuring flight safety. In the future, targeted interventions and policy initiatives should be implemented to promote mental health awareness, facilitate access to support services, and mitigate occupational stressors within the aviation industry. By prioritizing the mental well-being of pilots, stakeholders can contribute to a safer and healthier aviation environment for all.

Acknowledgements

We would like to thank AJE’s Curie platform for their assistance in preparing and reviewing this manuscript. Their support was invaluable in enhancing the clarity and quality of our work.

Author contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

This research received no specific funding from any external source. All the authors contributed their time and resources voluntarily.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and informed consent

The study was conducted in strict adherence to the principles outlined in the Declaration of Helsinki, with ethical clearance obtained from the Institutional Review Board at King Abdulaziz University. The informed consent process included a comprehensive explanation of the voluntary nature of participation, with a particular emphasis on measures taken to ensure the confidentiality of participant information.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. Collaborators GBDMD Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of Disease Study 2019 Lancet Psychiatry 2022 9 2 137 50 10.1016/S2215-0366(21)00395-3 35026139
Collaborators GBDMD. Global, regional, and national burden of 12 mental disorders in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of Disease Study 2019. Lancet Psychiatry. 2022;9(2):137–50.35026139 10.1016/S2215-0366(21)00395-3
2. Laditka JN Laditka SB Arif AA Adeyemi OJ Psychological distress is more common in some occupations and increases with job tenure: a thirty-seven year panel study in the United States BMC Psychol 2023 11 1 95 10.1186/s40359-023-01119-0 37004123
Laditka JN, Laditka SB, Arif AA, Adeyemi OJ. Psychological distress is more common in some occupations and increases with job tenure: a thirty-seven year panel study in the United States. BMC Psychol. 2023;11(1):95.37004123 10.1186/s40359-023-01119-0
3. Aljurf TM Olaish AH BaHammam AS Assessment of sleepiness, fatigue, and depression among Gulf Cooperation Council commercial airline pilots Sleep Breath 2018 22 2 411 9 10.1007/s11325-017-1565-7 28884322
Aljurf TM, Olaish AH, BaHammam AS. Assessment of sleepiness, fatigue, and depression among Gulf Cooperation Council commercial airline pilots. Sleep Breath. 2018;22(2):411–9.28884322 10.1007/s11325-017-1565-7
4. O’Hagan AD Issartel J Nevill A Warrington G Flying Into Depression Workplace Health Saf 2017 65 3 109 17 10.1177/2165079916659506 27578874
O’Hagan AD, Issartel J, Nevill A, Warrington G. Flying Into Depression. Workplace Health Saf. 2017;65(3):109–17.27578874 10.1177/2165079916659506
5. Venus M Holtforth MG Short and long Haul pilots rosters, stress, sleep problems, fatigue, Mental Health, and well-being Aerosp Med Hum Perform 2021 92 10 786 97 10.3357/AMHP.5812.2021 34641999
Venus M, Holtforth MG. Short and long Haul pilots rosters, stress, sleep problems, fatigue, Mental Health, and well-being. Aerosp Med Hum Perform. 2021;92(10):786–97.34641999 10.3357/AMHP.5812.2021
6. Fang H Tu S Sheng J Shao A Depression in sleep disturbance: a review on a bidirectional relationship, mechanisms and treatment J Cell Mol Med 2019 23 4 2324 32 10.1111/jcmm.14170 30734486
Fang H, Tu S, Sheng J, Shao A. Depression in sleep disturbance: a review on a bidirectional relationship, mechanisms and treatment. J Cell Mol Med. 2019;23(4):2324–32.30734486 10.1111/jcmm.14170
7. Mendoza J Circadian insights into the biology of depression: symptoms, treatments and animal models Behav Brain Res 2019 376 112186 10.1016/j.bbr.2019.112186 31473283
Mendoza J. Circadian insights into the biology of depression: symptoms, treatments and animal models. Behav Brain Res. 2019;376:112186.31473283 10.1016/j.bbr.2019.112186
8. Kim JN Lee BM Risk factors, health risks, and risk management for aircraft personnel and frequent flyers J Toxicol Environ Health B Crit Rev 2007 10 3 223 34 10.1080/10937400600882103 17454553
Kim JN, Lee BM. Risk factors, health risks, and risk management for aircraft personnel and frequent flyers. J Toxicol Environ Health B Crit Rev. 2007;10(3):223–34.17454553 10.1080/10937400600882103
9. Minoretti P Emanuele E Health in the skies: a narrative review of the issues faced by Commercial Airline pilots Cureus 2023 15 4 e38000 37223152
Minoretti P, Emanuele E. Health in the skies: a narrative review of the issues faced by Commercial Airline pilots. Cureus. 2023;15(4):e38000.37223152
10. Minoretti P Santiago Sáez AS García Martín ÁF Liaño Riera M Gómez Serrano M Emanuele E Mild depressive symptoms in Airline pilots Associated with impaired executive functions Cureus 2023 15 7 e41616 37565100
Minoretti P, Santiago Sáez AS, García Martín ÁF, Liaño Riera M, Gómez Serrano M, Emanuele E. Mild depressive symptoms in Airline pilots Associated with impaired executive functions. Cureus. 2023;15(7):e41616.37565100
11. Pasha T Stokes PRA Reflecting on the Germanwings Disaster: a systematic review of depression and suicide in Commercial Airline pilots Front Psychiatry 2018 9 86 10.3389/fpsyt.2018.00086 29615937
Pasha T, Stokes PRA. Reflecting on the Germanwings Disaster: a systematic review of depression and suicide in Commercial Airline pilots. Front Psychiatry. 2018;9:86.29615937 10.3389/fpsyt.2018.00086
12. Aviation GAC. GACA Regulation: Sect. 1, Personnel Licensing. Edition 4.0. In. Kingdom of Saudi Arabia; 2014.
13. Kroenke K Spitzer RL Williams JB The PHQ-9: validity of a brief depression severity measure J Gen Intern Med 2001 16 9 606 13 10.1046/j.1525-1497.2001.016009606.x 11556941
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13.11556941 10.1046/j.1525-1497.2001.016009606.x
14. Minoretti P Liaño Riera M Gómez Serrano M Santiago Sáez A García Martín Á: brushing away the blues: self-reported oral Hygiene practices are Associated with mild depressive symptoms in Airline pilots Cureus 2024 16 5 e60695 38903287
Minoretti P, Liaño Riera M, Gómez Serrano M, Santiago Sáez A. García Martín Á: brushing away the blues: self-reported oral Hygiene practices are Associated with mild depressive symptoms in Airline pilots. Cureus. 2024;16(5):e60695.38903287
15. Little LF Gaffney IC Rosen KH Bender MM Corporate instability is related to airline pilots’ stress symptoms Aviat Space Environ Med 1990 61 11 977 82 2256885
Little LF, Gaffney IC, Rosen KH, Bender MM. Corporate instability is related to airline pilots’ stress symptoms. Aviat Space Environ Med. 1990;61(11):977–82.2256885
16. Widyahening IS High level of work stressors increase the risk of mental-emotional disturbances among airline pilots Med J Indonesia 2007 16 2 117 21 10.13181/mji.v16i2.267
Widyahening IS. High level of work stressors increase the risk of mental-emotional disturbances among airline pilots. Med J Indonesia. 2007;16(2):117–21.10.13181/mji.v16i2.267
17. Sykes AJ Larsen PD Griffiths RF Aldington S A study of airline pilot morbidity Aviat Space Environ Med 2012 83 10 1001 5 10.3357/ASEM.3380.2012 23066624
Sykes AJ, Larsen PD, Griffiths RF, Aldington S. A study of airline pilot morbidity. Aviat Space Environ Med. 2012;83(10):1001–5.23066624 10.3357/ASEM.3380.2012
18. Feijó D Luiz RR Camara VM Common mental disorders among civil aviation pilots Aviat Space Environ Med 2012 83 5 509 13 10.3357/ASEM.3185.2012 22606868
Feijó D, Luiz RR, Camara VM. Common mental disorders among civil aviation pilots. Aviat Space Environ Med. 2012;83(5):509–13.22606868 10.3357/ASEM.3185.2012
19. Wu AC Donnelly McLay D Weisskopf MG McNeely E Betancourt TS Allen JG Airplane pilot mental health and suicidal thoughts: a cross-sectional descriptive study via anonymous web-based survey Environ Health 2016 15 1 121 10.1186/s12940-016-0200-6 27974043
Wu AC, Donnelly McLay D, Weisskopf MG, McNeely E, Betancourt TS, Allen JG. Airplane pilot mental health and suicidal thoughts: a cross-sectional descriptive study via anonymous web-based survey. Environ Health. 2016;15(1):121.27974043 10.1186/s12940-016-0200-6
20. Vandekerckhove M Wang YL Emotion, emotion regulation and sleep: an intimate relationship AIMS Neurosci 2018 5 1 1 17 10.3934/Neuroscience.2018.5.1 32341948
Vandekerckhove M, Wang YL. Emotion, emotion regulation and sleep: an intimate relationship. AIMS Neurosci. 2018;5(1):1–17.32341948 10.3934/Neuroscience.2018.5.1
21. Medic G Wille M Hemels ME Short- and long-term health consequences of sleep disruption Nat Sci Sleep 2017 9 151 61 10.2147/NSS.S134864 28579842
Medic G, Wille M, Hemels ME. Short- and long-term health consequences of sleep disruption. Nat Sci Sleep. 2017;9:151–61.28579842 10.2147/NSS.S134864
