Everything is mental health these days. Universities cannot hire enough counselors
The relationship with my FAA doctor is very limited, it is a professional accreditation renewal even though I am an unpaid amature, not a commercial pilot.
I have a non FAA doctor that I discuss everything else with on a 6 month basis. He would have zero issues calling my FAA doctor and pointing out a problem because I told his predecessor to put that in my file do that before I soloed. The hull insurance company is a much bigger stake holder than the FAA in my situation, 55 year olds becomming landscaping while dragging their buddies to a football game isnt really their problem.
Both doctors opinion is the FAA needs to know if I am more likely than any other patient to pass out at the controls of an small aircraft and since my blood panel is hum drum average they cannot say I am more of a risk. As a pilot in charge of 6 tons of aircraft the error factor is 1.7 people per fatal accident. Everything else is acute mental risks brought on by divorce courts that nobody has ever figured out to prevent.
As a ATP, my southwest pilot friend has two factors that modify the equation. An ATP pilot fatal accident is with a 150 TON aircraft and kills 120 people per fatal accident. It is mitigated that pilots work in pairs with Crew Resource Management so one can accomplish the tasks of 2 if one is incapacitated.
Random or on request mental health screening and random drug testing seems like it would be prudent. At this point, US pilots have been so incredibly better than EU pilots, the risk just has not been in US pilots medicals or mental fitness. ATP pilots still have a FAA doctor and personal doctors. They also hire professionals to communicate between the sets of specialists when a class 1 medical problem occurs. The FAA has a tradition of knocking ATP pilots out of flight ready for an average of 18 months, doctors average 7 months. The USAF averages 13 months up from 4 months 30 years ago and each pilot is 100 times more valuable for a flight slot than a ATP pilot on the line.
The numbers need to be considered outside of the Drug and DUI recovery programs... the data sets for ATP pilots are large enough to make some good choices, but mentally ill pilots holding USA medicals have not caused a large event in 30 years.
There is no risk drive to do anything unless the DOT has been hiding something really big.