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Medical Aspects Fitness to Drive cover.

Medical aspects of fitness to drive

Published: 07 2009

This guide is to assist medical practioners in assessing the fitness to drive of any individual. It also sets out the responsibilities and obligations of medical practioners.

8. Mental disorders


This section covers:

Summary table

The table below summarises the information outlined in this section. Practitioners should ensure that they are familiar with the guidance outlined in the entire section rather than relying solely on the table. The recommended minimum stand-down periods from driving and guidelines only apply where an individual's medical condition has been adequately treated and stability has been achieved so that road safety is unlikely to be compromised.

Medical condition Class 1 or class 6 licence and/or a D, F, R, T or W endorsement (see appendix 3) Class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement
Mental disorder that may impair an individual's ability to drive safely Whether an individual should or should not drive will be based on the assessment of the following factors, and how they affect an individual's ability to drive safely:

1 psychomotor functioning
2 behaviour
3 mood (including suicidal ideation)
4 medication
5 insight
Same factors to consider as lower licence classes and endorsement types, except consideration should be given to the type of driving the individual undertakes, and any personal safety risks to others. Generally higher standards apply to these drivers.
Severe chronic mental disorder Driving should cease where an individual's ability to drive safely may be impaired. The individual is generally unfit to drive until effective treatment is in place, and a period of observation, usually six months, has been undertaken. Driving should cease where an individual's ability to drive safely may be impaired. The individual is generally unfit to drive until effective treatment is in place, and a period of observation, usually 12 months, has been undertaken.

Legal obligations on medical practitioners

The law requires:

  • medical practitioners to advise the Agency (via the Chief Medical Adviser) of any individual who poses a danger to public safety by continuing to drive when advised not to (section 18 of the Land Transport Act 1998 - see section 1.4)
  • medical practitioners to consider Medical aspects of fitness to drive when conducting a medical examination to determine if an individual is fit to drive
  • medical practitioners to comply, where appropriate, with the requirements and responsibilities of section 19 of the Land Transport Act 1998 relating to driver licensing matters for patients subject to a Compulsory Inpatient Treatment Order, or special patients 2 (see section 8.2).

Section 18 of the Land Transport Act 1998 also provides that a medical practitioner or registered optometrist who gives notice in good faith under section 18 will not be subject to civil or professional liability because of any disclosure of personal medical information in that notice.

Dealing with individuals who are unfit to drive

Individuals other than those subject to section 19 of the Land Transport Act 1998: Medical practitioners can usually successfully negotiate short-term cessation of driving with patients. However, if longer periods are necessary, we recommend that medical practitioners advise their patients both verbally and in writing. We also recommend that the patient be told how soon they might expect to have this situation reviewed. If a practitioner suspects that a patient is continuing to drive against medical advice, they are legally obliged to inform the Agency under section 18 of the Land Transport Act 1998 (see section 1.4).

Introduction

There have been rapid major advancements in the treatment of mental illnesses in recent years. However, it is unfortunately necessary to be mindful of the abundance of inaccurate information about mental illness that remains in the community. This misinformation is the legacy of an environment that socially excluded and removed people with mental illness. The government's Mental Health Strategy seeks to address this and reduce the negative impact of mental disorders by ensuring unwarranted barriers to participation in all aspects of life for people with mental illness are removed.

Individuals with a mental disorder should not automatically be considered unfit to drive: Medical practitioners should assess each individual and the manifestations of their mental disorder or treatment, considering the guidance in this section, to determine if they are fit or unfit to drive. Where appropriate, medical practitioners may need to refer the individual to a specialist or a mental health service provider.

The assessment of individuals with mental disorders is one of the more difficult aspects of determining fitness to drive. The effect of mental disorders on the ability to drive safely has not been determined with any degree of certainty, and fluctuations that may occur during a course of clinical illness make it inappropriate to set rigid rules. There are only a few recent studies in this area, which makes the medical practitioner's task in determining fitness to drive difficult.

While there is evidence that the prevalence of psychiatric disorders in crash victims is greater than estimates for the general population, not all psychiatric disorders appear to carry an increased degree of accident vulnerability (McDonald and Davey 1996). Personality disorders and alcohol abuse are seen in elevated numbers in crash victims, whereas anxiety and depressive disorders are not seen to be more prevalent than in the general population.

In the absence of clear information on the potential road safety risks, a commonsense approach should be undertaken. For instance, a person suffering an acute psychotic episode totally engulfed in delusions is likely to be dangerous while driving. Similarly, a person severely ill with anxiety or depression, whose reactions are retarded and who cannot concentrate or make decisions and who is absorbed in worries and problems, is unlikely to be a safe driver.

In some areas of mental health provision, a significant level of trust is established between a medical practitioner and their patient. In these circumstances, medical practitioners may wish to refer their patient to another medical practitioner for assessment, rather than risk damaging their practitioner-patient relationship.

8.1 Mental disorders that may impair safe driving

This section outlines general advice on how to assess and determine fitness to drive for an individual with a mental disorder. Individuals who are assessed as unfit to drive using the assessment criteria below should be advised not to drive until:

  • they have been satisfactorily treated, or
  • the factors that were considered to make them unfit to drive are no longer present, or are no longer at a level that would affect the individual's ability to drive safely.

The following checklist may be useful for medical practitioners to consider, in addition to the assessment above.

Does the individual have:

  • an absence of major symptoms known to impair driving, including conditions other than their mental disorder
  • an absence of enduring, residual impairment to driving
  • self-awareness and control of state of mind and symptoms
  • willingness and ability to seek and act on advice about their fitness to drive
  • compliance with previous recommendations to temporarily stop driving when medically unfit to drive.

8.1.1 Psychomotor and cognitive functioning

Medical practitioners should consider the following factors, if appropriate:

  • Level of arousal - excessive arousal may impair performance and judgement. Underarousal (eg the psychomotor retardation of depression) can impair the ability to drive safely
  • An individual's perceptions - perceptual disorders can impair the capacity to accurately see, hear or comprehend the driving environment. Individuals suffering from hallucinations who are constantly preoccupied should not drive, nor should those whose hallucinations are likely to make them an unsafe driver
  • Information processing - any impairment to information processing, such as cognitive impairment, excessive preoccupation, poor concentration or the thought disorder of active psychosis, may impair the ability to drive safely
  • Memory problems may impair driving ability if more than trivial
  • Impaired reactions may impair driving ability
  • Anxiety or panic attacks need not prevent driving, but the patient should be advised not to drive at times when acute symptoms occur.

8.1.2 Behaviour

The ability to drive safely may be impaired by:

  • excessively aggressive or irritable behaviour
  • misperceptions about the behaviour or intent of other road users, eg some individuals with paranoid disorders
  • erratic or irresponsible behaviour
  • poor judgement, recklessness and a sense of invulnerability seen in manic mood states.

8.1.3 Mood, including suicidal ideation

Individuals who are subject to elevated or depressed moods, and the behavioural manifestations of these, should be carefully assessed. Particularly consider whether:

  • the manifestation of the mood will affect the individual's concentration when driving
  • the effect of the mood could alter their ability to drive safely, eg if they consider they are invincible and indicate that they drive aggressively because of this
  • the individual has sudden onsets of changes of mood that could result in their driving behaviour being unsafe for periods.

Note: the effects of medications that may sedate are discussed below.

Individuals should be advised not to drive during periods of active suicidal behaviour or intent. The presence of suspected suicidal ideation should be carefully assessed, considering the intensity of suicidal ideas, impulsiveness, likelihood of attempt and imminence. Suicidal thinking may be an acute phase that subsides quickly, or may be ongoing.

8.1.4 Medication

The effect of medication should be carefully assessed, including the individual's likely compliance with their medication and any impacts on the individual's ability to drive safely. Consider:

  • how medication can control any factors of an individual's condition that may impair their ability to drive safely
  • side effects of sedation, eg risk of somnolence, impaired reactions or ability to process information
  • side effects on motor skills, such as impaired coordination
  • specific side effects, such as blurred vision, hypotension or dizziness.

Each patient should be individually assessed, taking into account the known profile of effects of the drug, the dose and the degree to which the illness is controlled.

Psychotropic medication can temporarily impair an individual's ability to drive safely. When starting most psychotropic medication or increasing a dose, a person should not drive until the side effects, such as perceptual or motor skills difficulties, are unlikely to affect the individual's ability to drive safely.

8.1.5 Insight and judgement

This is particularly important in conditions that fluctuate or are episodic, eg if the patient is able to judge when it is safe or not safe to drive. This should include consideration of the individual's history, eg whether they have a history of sudden unexpected onset of symptoms that could impair their ability to drive safely.

8.1.6 Public safety risks

While not relating to the ability to drive safely, section 18 of the Land Transport Act 1998 requires medical practitioners to report any individual who poses a public safety risk by driving when advised not to. This can include the risk to individuals other than the driver for personal safety reasons.

For P, V, I or O endorsement holders, medical practitioners should consider any possible public safety risks that may occur because of the nature of work these endorsements entail. For example, all these endorsements can involve substantial contact with many strangers, a high-stress working environment and dealing with an individual in isolated circumstances. Medical practitioners should advise those individuals who may pose a risk to others, from a personal safety perspective, not to drive in these endorsement capacities.

8.2 Severe chronic mental disorders

The diagnostic criteria in section 8.1 should be used to assess individuals with severe chronic mental disorders that affect an individual's ability to drive safely. Examples of mental conditions that could impact on an individual's ability to drive safely are severe and ongoing anxiety or depression, severe chronic schizophrenia and severe bipolar disease. Individuals with severe chronic mental conditions should be given the recommended periods to refrain from driving outlined below.

Note that this section does not imply that all individuals with anxiety or depression or schizophrenia or bipolar disease should refrain from driving. This section only applies to those individuals who:

  • have an ongoing serious occurrence of their mental illness, which may include a regular pattern of episodes where their ability to drive safely may be affected by their mental condition
  • do not respond well to treatment or are non-compliant with treatment over extended periods of time, such as over several months, and this may impair their ability to drive safely.

Medical standards for individuals applying for or renewing a class 1 or class 6 licence and/or a D, F, R, T or W endorsement

Where an individual's mental condition is severe and chronic and affects their ability to drive safely for extended periods, the individual is considered unfit to drive until effective treatment is in place and a period of observation, usually six months, has been undertaken. However, the time away from driving will depend on how the individual responds to treatment, and the likelihood of further relapses. A psychiatric assessment is required before allowing the patient to drive again.

Medical standards for individuals applying for or renewing a class 2, 3, 4 or 5 licence and/or a P, V, I or O endorsement

Commercial driving can involve additional stresses that private drivers do not encounter, such as tight schedules, contact with the public and long hours. Any severe and chronic mental condition that impairs an individual's ability to drive safely for an extended period will render the individual unfit to drive for a period, usually 12 months. In exceptional circumstances, the return to commercial driving can be significantly less than 12 months but this will depend on:

  • a satisfactory period of being stable and symptom free
  • a full, supportive, relevant psychiatric opinion
  • a low risk of recurrence or relapse
  • absence of residual impairment.

Where it is recommended that an individual be granted a driving restriction of less than nine months, the medical practitioner may wish to write to the Chief Medical Adviser and outline the patient's circumstances, including the nature of the commercial driving that is generally undertaken, and the patient's prognosis.

Section 19 of the Land Transport Act 1998

Very few people who experience mental disorder or suicidal ideation are subject to the Mental Health (Compulsory Assessment and Treatment) Act 1992. The spirit of the Act is to facilitate treatment in the community wherever possible, to enable people to participate in their normal day-to-day activities. An individual can still drive under this Act unless:

  • the responsible clinician assesses the person as unfit to drive and recommends that they not drive for a specific reason and period of time, or
  • the individual is detained in hospital or is a special patient.

Section 19 of the Land Transport Act 1998 (see appendix 2) applies to individuals subject to a Compulsory Inpatient Treatment Order or special patients, as defined in the Mental Health (Compulsory Assessment and Treatment) Act 1992. Section 19 places legal responsibilities on ‘persons in charge of a hospital’ and ‘Directors of Area Mental Health Services’ as follows:

Persons in charge of a hospital

Where a patient is subject to section 19 of the Land Transport Act 1998, the person in charge of a hospital is required to advise the Agency. An example notification letter is outlined in appendix 6.

Directors of Area Mental Health Services (DAMHS)

DAMHS have a range of actions to take, depending on the patient's circumstances and the type of licence the patient holds. Flowcharts A and B in appendix 7 outline the processes for section 19 of the Land Transport Act 1998 in respect to the two categories of licence classes and endorsement types.