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This paper reviews the problems of psychiatric assessment and the prediction of incapacity in the pilot population. It reviews the difficulty of providing evidence based standards and the interaction of intermittent stressors with performance as well as the difficulties of diagnosis and prediction in a population who may not fully disclose significant histories. Also reviewed are possible biases toward under-attribution of psychiatric causation in accidents and incidents. The significance and treatment of depression and substance abuse are reviewed and some general principles of the assessment of risk in relationship to the impact of psychiatric disturbance and the likelihood of pilots encountering a situation in which this will become significant are considered. The application of these principles to the problem of attention deficit disorders is demonstrated and discussed.