Driving impairment in depressed patients receiving long-term antidepressant treatment

Driving performance of long-term users of sedating antidepressants and benzodiazepines

OBJECTIVE

Using benzodiazepines and certain antidepressants is associated with an increased risk of motor vehicle crashes due to impaired driving skills. Hence, several countries prohibit people who use these drugs from driving. Traffic regulations for driving under the influence of these drugs are, however, largely based on single-dose studies with healthy participants. The effects of drugs on chronic users may be different because of potential development of tolerance or by adapting behavior. In this study, we test the effects of anti-depressants, hypnotics, or anxiolytics use on driving performance in patients who use these drugs for different durations and compare the effects to healthy controls' performance.

METHODS

Sixty-six healthy controls and 82 medication users were recruited to perform four drives in a driving simulator. Patients were divided into groups that used anti-depressants, hypnotics, or anxiolytics, for shorter or longer than 3 years (i.e. LT3- or LT3+, respectively). The minimum term of use was 6 months. Driving behavior was measured in terms of longitudinal and lateral control (speed variability and Standard Deviation of Lateral Position: SDLP), brake reaction time, and time headway. Impaired driving performance was defined as performing similar to driving with a Blood Alcohol Concentration of 0.5‰ or higher, determined by means of non-inferiority analyses.

RESULTS

Reaction time analyses revealed inconclusive findings in all groups. No significant performance differences between matched healthy controls, LT3- (n = 2), and LT3+ (n = 8) anxiolytics users were found. LT3+ antidepressants users (n = 12) did not perform inferior to their matched controls in terms of SDLP. LT3- hypnotics users (n = 6) showed more speed variability than their matched healthy controls, while this effect was not found for the LT3+ group (n = 14): the latter did not perform inferior to the healthy controls. Regarding Time Headway, no conclusions about the LT3- hypnotics group could be drawn, while the LT3+ group did not perform inferior compared to the control group.

CONCLUSIONS

The small number of anxiolytics users prohibits drawing conclusions about clinical relevance. Although many outcomes were inconclusive, there is evidence that some elements of complex driving performance may not be impaired (anymore) after using antidepressants or hypnotics longer than 3 years.

Driving Behaviour in Depression Based on Subjective Evaluation and Data from a Driving Simulator

Road traffic collisions are a major issue for public health. Depression is characterized by mental, emotional and executive dysfunction, which may have an impact on driving behaviour. Patients with depression (N = 39) and healthy controls (N = 30) were asked to complete questionnaires and to drive on a driving simulator in different scenarios. Driving simulator data included speed, safety distance from the preceding vehicle and lateral position. Demographic and medical information, insomnia (Athens Insomnia Scale, AIS), sleepiness (Epworth Sleepiness Scale, ESS), fatigue (Fatigue Severity Scale, FSS), symptoms of sleep apnoea (StopBang Questionnaire) and driving (Driver Stress Inventory, DSI and Driver Behaviour Questionnaire, DBQ) were assessed. Gender and age influenced almost all variables. The group of patients with depression did not differ from controls regarding driving behaviour as assessed through questionnaires; on the driving simulator, patients kept a longer safety distance. Subjective fatigue was positively associated with aggression, dislike of driving, hazard monitoring and violations as assessed by questionnaires. ESS and AIS scores were positively associated with keeping a longer safety distance and with Lateral Position Standard Deviation (LPSD), denoting lower ability to keep a stable position. It seems that, although certain symptoms of depression (insomnia, fatigue and somnolence) may affect driving performance, patients drive more carefully eliminating, thus, their impact.

A Systematic Review of the Risks of Motor Vehicle Crashes Associated with Psychiatric Disorders

OBJECTIVE

Psychiatric disorders and their treatments have the potential to adversely impact driving skills. However, it is unclear to what extent this poses a public health risk by increasing the risk of motor vehicle crashes (MVCs). The aim of this systematic review was to synthesize and critically appraise evidence on the risk of MVC for drivers with psychiatric disorders.

METHOD

We conducted a systematic review of the MVC risk associated with psychiatric disorders using seven databases in November 2019. Two reviewers examined each study and extracted data. The National Heart, Lung, and Blood Institute Quality Assessment tools were used to assess each study's quality of evidence.

RESULTS

We identified 24 studies that met the inclusion criteria, including eight cohort, 10 case-control, and six cross-sectional designs. Quality assessment ratings were "Good" for four studies, "Fair" for 10, and "Poor" for 10. Self-report or questionnaires were used in place of objective measures of either MVC, psychiatric disorder, or both in 12 studies, and only seven adjusted for driving exposure. Fifteen studies reported an increased risk of MVC associated with psychiatric disorders, and nine did not. There was no category of disorder that was consistently associated with increased MVC risk.

CONCLUSION

The available evidence is mixed, not of high quality, and does not support a blanket restriction on drivers with psychiatric disorder. An individualized approach, as recommended by international guidelines, should continue. Further research should include objective assessments of psychiatric disorders and MVC risk and adjust for driving exposure.

Suitability of SoToxa® Oral Fluid Screening Over Time: Re-examination of Drugged Driving in Wisconsin

Drug impaired driver detection is a critical element of traffic safety. However, shifting drug use patterns over time and geography may limit long-term reliability of assay-based screening tools. In this work, we compare qualitative results from the Abbott SoToxa® oral fluid (OF) screening device to Quantisal™ OF and whole blood. Our objective was to examine these three qualitative toxicological approaches, scope applicability of OF collection at the roadside, and compare to a previous analysis of SoToxa® in Wisconsin. OF specimens were screened with the SoToxa® for six drugs or drug classes including amphetamine, benzodiazepines, cocaine, methamphetamine, opioids, and tetrahydrocannabinol (THC). OF and blood specimens were collected from 106 participants. Quantisal™ OF and blood specimens were screened for drugs on ultra-performance liquid chromatography coupled to quadrupole time-of-flight high-resolution mass spectrometry (UPLC-QToF-HRMS) using a data independent acquisition mode. UPLC-QToF-HRMS data was compared to comprehensive spectral libraries and drugs were qualitatively identified. Drug Recognition Expert evaluations were performed, and face sheets submitted for 21 participants in this work. In general, the SoToxa® results were consistent with the combined qualitative results observed in Quantisal™ OF specimens and whole blood specimens. Limitations were uncovered for benzodiazepines, opioids, and THC. The SoToxa® benzodiazepine assay has high cutoff concentrations for diazepam and clonazepam, limiting its sensitivity and positive predictive value when considering these drugs. SoToxa® opioid screening did not detect fentanyl, which is increasingly prevalent among drug users. Finally, ∆9-THC and its major metabolite 11-nor-9-carboxy-∆9-THC are lipophilic, limiting partitioning into oral fluid. Despite these limitations, the SoToxa® instrument may be useful in assisting law enforcement with identifying individuals driving under the influence of drugs and establishing probable cause at roadside for making impaired driving arrests. Furthermore, Quantisal™ OF may be useful as screening specimens due to their ease of collection and results consistent with whole blood.

Mortality among family members of patients with amyotrophic lateral sclerosis - a Swedish register-based study

Objective: To test two hypotheses: (1) partners of ALS patients have higher mortality due to outcomes related to psychological distress, and (2) parents and siblings of ALS patients have higher mortality due to diseases that co-occur with ALS.Methods: We performed a nationwide, register-based cohort study in Sweden. We included ALS-free partners, biological parents and full siblings (N = 11,704) of ALS patients, as well as ALS-free partners, biological parents and full siblings (N = 14,460,150) of ALS-free individuals, and followed them during 1961-2013. Hazard ratios (HRs) and 95% confidence intervals (CIs) of overall and cause-specific mortality were derived from Cox regression.Results: Partners of ALS patients, compared to partners of ALS-free individuals, displayed higher mortality due to external causes (HR 2.14; 95% CI 1.35-3.41), including suicide (HR 2.44; 95% CI 1.09-5.44) and accidents (HR 2.09; 95% CI 1.12-3.90), after diagnosis of the ALS patients. Parents of ALS patients had a slightly higher overall mortality (HR 1.03; 95% CI 1.00-1.07), compared with parents of ALS-free individuals. This was driven by mortality due to dementias and cardiovascular, respiratory, and skin diseases. Parents of ALS patients had, however, lower mortality than parents of ALS-free individuals due to neoplasms. Siblings of ALS patients had higher mortality due to dementias, and digestive and skin diseases.Conclusions: Increased mortality due to suicide and accidents among partners of ALS patients is likely attributable to severe psychological distress following the ALS diagnosis. Increased mortality due to dementias among parents and full siblings of ALS patients suggests shared mechanisms between neurodegenerative diseases.

An explorative approach to understanding individual differences in driving performance and neurocognition in long-term benzodiazepine users

OBJECTIVE

Previous research reported cognitive and psychomotor impairments in long-term users of benzodiazepine receptor agonists (BZRAs). This article explores the role of acute intoxication and clinical complaints.

METHODS

Neurocognitive and on-road driving performance of 19 long-term (≥6 months) regular (≥twice weekly) BZRA users with estimated plasma concentrations, based on self-reported use, exceeding the therapeutic threshold (C_BZRA +), and 31 long-term regular BZRA users below (C_BZRA -), was compared to that of 76 controls.

RESULTS

BZRA users performed worse on tasks of response speed, processing speed, and sustained attention. Age, but not C_BZRA or self-reported clinical complaints, was a significant covariate. Road-tracking performance was explained by C_BZRA only. The C_BZRA  + group exhibited increased mean standard deviation of lateral position comparable to that at blood-alcohol concentrations of 0.5 g/L.

CONCLUSIONS

Functional impairments in long-term BZRA users are not attributable to self-reported clinical complaints or estimated BZRA concentrations, except for road-tracking, which was impaired in CBZRA + users. Limitations to address are the lack of assessment of objective clinical complaints, acute task related stress, and actual BZRA plasma concentrations. In conclusion, the results confirm previous findings that demonstrate inferior performance across several psychomotor and neurocognitive domains in long-term BZRA users.

Associations Between Workplace Factors and Depression and Anxiety in Australian Heavy Vehicle Truck Drivers

INTRODUCTION

A number of health issues have been identified as prevalent within the Australian heavy vehicle driving population. Mental illnesses, such as depression and anxiety, are among those disorders that have been regularly reported, however, the contributing factors are yet to be elucidated.

METHODS

This study aimed to assess the associations between workplace factors such as years of employment, social interaction and shift length, with depressive and anxious symptomology in a cohort of 60 Australian heavy vehicle drivers.

RESULTS

Significant positive associations were identified between depression and alcohol use (P = 0.044), coffee consumption (P = 0.037), number of accidents during career (P = < 0.004), and number of hours driving per shift (P ≤ 0.001). Anxiety was found to be positively associated with a number of hours driving per week (P ≤ 0.001), and the number of accidents or near misses during a driving career (P = 0.039).

CONCLUSION

Several workplace factors were identified as being correlated to depression or anxiety within this cohort, suggesting potential changes to rostering systems and education regarding alcohol use may benefit the mental health of this driver population.

Driving Performance Under Treatment of Most Frequently Prescribed Drugs for Mental Disorders: A Systematic Review of Patient Studies

BACKGROUND

Mobility is important for daily life functioning, with particular challenges regarding road safety under pharmacological treatment in patients with a psychiatric disease.

METHODS

According to PRISMA guidelines, a systematic literature search on PubMed database (January 1970 to December 2020) was performed. Primary endpoints were driving performance in on-road tests, driving simulator performance, or psychomotor and visual perception functions assessed to estimate fitness to drive according to legal regulations in patient studies.

RESULTS

Forty studies were identified (1533 patients, 38% female, median age 45 years), of which more than 60% were cross-sectional and open-label trials. Under steady-state medication, 31% (range 27%-42.5%) of schizophrenic or schizoaffective patients under antipsychotics and 18% (range 16%-20%) of unipolar and bipolar patients under antidepressants showed severe impairment in skills relevant for driving. Data point to an advantage of second-generation antipsychotics compared with first-generation antipsychotics as well as modern antidepressants over tricyclic antidepressants with respect to driving. Most patients significantly improved or stabilized in driving skills within 2-4 weeks of treatment with non-sedative or sedative antidepressants. Diazepam significantly worsened driving the first 3 weeks after treatment initiation, whereas medazepam (low dose), temazepam, and zolpidem did not impair driving. In long-term users of sedating antidepressants or benzodiazepines, impairments in on-road tests were not evident.

CONCLUSION

The available evidence suggests that psychopharmacologic medicines improve or at least stabilize driving performance of patients under long-term treatment when given on clinical considerations. To enhance treatment compliance, existing classification systems of medicinal drugs concerning impact on driving performance should also incorporate information about effects of long-term-treatment.

Driving with Tic Disorders: An International Survey of Lived Experiences

Background

Little is known about the lived experiences of individuals with tic disorders when driving vehicles or trying to obtain a driving license.

Objective

To survey the driving‐related experiences of adults with tic disorders.

Methods

A global survey was disseminated via social media, international patient organizations, and experts between April 27, 2020 and July 20, 2020.

Results

Participants were 228 adult individuals self‐reporting a confirmed diagnosis of Tourette syndrome or chronic tic disorder. Of these, 183 (87.7%) had a driver's license. A minority (9%) reported that they had found it hard to pass the driving test. Tics only interfered with driving “a bit” (58.5%) or “not at all” (33%). A majority of participants reported being able to suppress their tics (39.5%) or that their tics are unchanged (28.5%) while driving. Nearly half of the participants (46.5%) had been involved in accidents, but only a negligible percentage (3.2%) considered that these were linked to the tics. Participants without a driver's license (n = 28, 12.3%) reported significantly more severe tics, compared to those with a license. The majority of these (60.7%) identified their tics as the main reason for not having a license and 64.3% said that they would like to receive support to obtain one.

Conclusions

The majority of surveyed participants with chronic tic disorders reported minimal difficulties with driving. However, a non‐negligible minority of more severe cases struggle with driving or refrain from driving altogether and would benefit from additional support. The results have implications for clinicians and vehicle licensing agencies.

Psychosocial Factors and Tobacco Use Among Commercial Truck Drivers

OBJECTIVES

To explore the relationships between tobacco, social support, job satisfaction, and depression among truck drivers.

METHODS

Cross-sectional data were collected from 797 truck drivers in six US states. Data collected included self-reported medical history and biological samples. Modified Zung depression scale and Work Apgar scores were used to measure depression and social support. Adjusted logistic regression models were used to calculate odds ratios (OR).

RESULTS

24.0% of tobacco users were in the least depressed category and 18.2% were most depressed. 22.8% of the tobacco users had the most social support compared with 27.9% of the non-users. Drivers in the two most depressed categories were significantly less likely to use tobacco (OR = 0.62, 95% confidence interval [CI] = 0.39-0.96, and OR = 0.64, 95% CI = 0.41-0.99).

CONCLUSIONS

Drivers with low social support or low levels of depression are more likely to be tobacco users.

Trends in Antidepressants Use in Spain between 2015 and 2018: Analyses from a Population-Based Registry Study with Reference to Driving

Antidepressants are considered driving-impairing medicines (DIM). This is a population-based registry study that shows the trend in the use of antidepressants in Castile and León, Spain, from 2015 to 2018. Data on antidepressant dispensations at pharmacies and the adjusted use of these medicines by the driver population are presented. For the purposes of analysis, population distribution by age and gender has been taken into account, as well as the three Driving Under the Influence of Drugs, alcohol, and medicines (DRUID) categories. Antidepressants were used by 8.56% of the general population and 5.66% of drivers. Antidepressants were used more commonly by females than by males (12.12% vs. 4.87%, χ² = 1325.124, p = 0.001), and users increased as the age increased, even if women who drive used less antidepressants after turning 60 years of age. Chronic use of antidepressants was relevant (8.28%) in the same way as daily use (3.15%). Most of the consumption included SSRIs (4.99%), which are also known as "other antidepressants" (3.71%). Regardless of antidepressants consumed, users took 2.75 ± 1.19 DIMs, which are mainly anxiolytics (58.80%) and opioids (26.43%). Lastly, regarding consumption of antidepressants according to the DRUID classification, category I predominated over categories II and III. Our findings should serve as a starting point for health and traffic authorities to raise awareness of the risk for traffic accidents, especially involving SSRIs.

Correlation Among Behavior, Personality, and Electroencephalography Revealed by a Simulated Driving Experiment

Drivers play the most important role in the human-vehicle-environment system and driving behaviors are significantly influenced by the cognitive state of the driver and his/her personality. In this paper, we aimed to explore the correlation among driving behaviors, personality and electroencephalography (EEG) using a simulated driving experiment. A total of 36 healthy subjects participated in the study. The 64-channel EEG data and the driving data, including the real-time position of the vehicle, the rotation angle of the steering wheel and the speed were acquired simultaneously during driving. The Cattell 16 Personality Factor Questionnaire (16PF) was utilized to evaluate the personalities of subjects. Through hierarchical clustering of the 16PF personality traits, the subjects were divided into four groups, i.e., the Inapprehension group, Insensitivity group, Apprehension group and the Unreasoning group, named after their representative personality trait. Their driving performance and turning behaviors were compared and EEG preprocessing, source reconstruction and the comparisons among the four groups were performed using Statistical Parameter Mapping (SPM). The turning process of the subjects can be formulated into two steps, rotating the steering wheel toward the turning direction and entering the turn, and then rotating the steering wheel back and leaving the turn. The bilateral frontal gyrus was found to be activated when turning left and right, which might be associated with its function in attention, decision-making and executive control functions in visual-spatial and visual-motor processes. The Unreasoning group had the worst driving performance with highest rates of car collision and the most intensive driving action, which was related to a higher load of visual spatial attention and decision making, when the occipital and superior frontal areas played a very important role. Apprehension (O) and Tension (Q4) had a positive correlation, and Reasoning (B) had a negative correlation with dangerous driving behaviors. Our results demonstrated the close correlation among driving behaviors, personality and EEG and may be taken as a reference for the prediction and precaution of dangerous driving behaviors in people with specific personality traits.

Associations between emotional symptoms and self-reported aberrant driving behaviors in older adults

OBJECTIVE

To examine associations between internalizing symptoms and self-reported aberrant driving behaviors in a large sample (n = 341) of older adults (mean age = 62.6 years, SD = 4.8).

DESIGN

Cross-sectional survey.

RESULTS

Multiple regression analyses revealed that greater symptoms of emotional distress (i.e., higher scores on the Expanded Version of the Inventory of Depression and Anxiety Symptoms (IDAS-II) emotional distress composite) were associated with greater aberrant driving behaviors (i.e., higher scores on the Driving Behavior Questionnaire). In contrast, neither obsessions/fears nor emotional well-being were associated with greater aberrant driving behaviors. Follow-up regression analyses examining specific IDAS-II subscales revealed that greater suicidality, appetite gain, appetite loss, panic, and ill temper were associated with greater aberrant driving behaviors. Individuals reporting greater suicidality and appetite loss reported greater tendencies to unintentionally commit errors behind the wheel, while individuals reporting greater ill temper and appetite loss reported greater tendencies to intentionally engage in unsafe driving behaviors that may put other drivers in harm's way.

CONCLUSION

Older adults reporting emotional distress may be at risk for engaging in aberrant driving behaviors. In particular, certain symptoms of emotional distress (e.g., suicidality, ill temper) are tied to higher rates of aberrant driving behaviors within this population.

The association between antidepressant use and deaths from road traffic accidents: a case-crossover study

PURPOSE

Antidepressants are some of the most commonly used psychiatric medications, but little information is available about the effects of antidepressant treatment on the risk of traffic accidents across classes of antidepressants or associated with each substance individually. To investigate the relationship between exposure to antidepressants and risk of fatality in road traffic accidents.

METHODS

We used a Korean national road traffic authority database linked with a national health insurance database between January 1, 2010 and December 31, 2014 and applied a case-crossover design. The study subjects were drivers in South Korea who died from traffic accidents and who had prescriptions for antidepressants within 1 year prior to the date of the accident. We compared the status of prescription for antidepressants with the hazard period and four matched control periods using conditional logistic regression, adjusting for other drug use. The trends of antidepressant utilization were described in terms of the number of prescriptions. A case-case-time-control design was applied to drugs with an increasing trend in use and a significant case-crossover odds ratio (OR).

RESULTS

A total of 1250 antidepressant-using drivers were included, and an increased risk was observed during the 30-day hazard period (adjusted OR 1.30; 95% CI 1.03-1.63). Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) showed significant risks, but tricyclic antidepressants did not. However, the associations of all antidepressants, SSRIs, SNRIs, escitalopram, and duloxetine did not remain significant after adjusting for trends in utilization. Paroxetine and milnacipran were associated with increased risks, with no obvious increase in their utilization, but the possibility of confounding by indication could have affected the results for milnacipran.

CONCLUSION

Considering the trends of antidepressant prescription and utilization, the use of paroxetine increased the risk of fatal traffic accidents.

Evaluation method regarding the effect of psychotropic drugs on driving performance: A literature review

Although automobile driving is necessary for many people, including patients with mental disorders, the influence of psychotropic drugs on driving performance remains unclear and requires scientific verification. Therefore, the objective of this study was to conduct a review of the literature in order to aid the development of a valid evaluation method regarding the influence of medication on driving performance. We conducted a literature search using two sets of terms on PubMed. One set was related to psychotropic drugs, and the other to driving tests. We excluded reviews and case studies and added literature found on other sites. A total of 121 relevant reports were found. The experiments were roughly divided into on-the-road tests (ORT) and driving simulators (DS). Although highway driving tests in ORT are most often used to evaluate driving performance, DS are becoming increasingly common because of their safety and low cost. The validity of evaluation methods for alcohol should be verified; however, we found that there were few validated tests, especially for DS. The scenarios and measurement indices of each DS were different, which makes it difficult to compare the results of DS studies directly. No evaluation indices, except for SD of lateral position, were sufficiently validated. Although highway ORT are the gold standard, DS were shown to have an increasing role in evaluating driving performance. The reliability of DS needs to be established, as does their validation with alcohol in order to accumulate more high-quality evidence.

Police documentation of drug use in injured drivers: Implications for monitoring and preventing drug-impaired driving

INTRODUCTION

Most countries have laws against driving while impaired by drugs. However, in many countries, including Canada and the United States, police must have individualized suspicion that the driver has recently used an impairing substance before they can gather the evidence required for laying a criminal charge. This report studies police documentation of drug involvement among drivers who had a motor-vehicle crash after using an impairing substance.

METHODS

We obtained blood samples and police reports on injured drivers treated in participating British Columbia trauma centres following a crash. Blood was analyzed for alcohol, cannabinoids, other recreational drugs, and impairing medications. Corresponding police reports were examined to determine whether police recorded that the driver's ability was impaired by alcohol, drug or medication, or that one of these substances was a possible contributory factor in the crash.

RESULTS

We obtained blood samples and corresponding police reports on 1816 injured drivers. Mean driver age was 44 years, 63.2% were male, and 25.8% were admitted to hospital. Alcohol was detected in 272 drivers (15.0%), THC (tetrahydrocannabinol - the principal psychoactive ingredient in cannabis) in 136 (7.5%), other recreational drugs in 166 (9.1%), and potentially impairing medications in 363 (20.0%). Police reported that the driver's ability was impaired by alcohol or that alcohol was a possible contributory factor in 64.1% of the crashes involving alcohol-positive drivers. Drug impairment or drugs as a possible contributory factor was reported in 5.9% of the crashes involving THC-positive drivers, and in 16.9% of the crashes involving drivers who tested positive for other recreational drugs. Medication impairment was reported in only 2.2% of the crashes involving medication-positive drivers.

CONCLUSION

Police seldom document drug involvement in drivers who were in a crash after using cannabis, other recreational drugs or potentially impairing medications. This finding raises serious concerns about the ability of the police to effectively enforce current drug-impaired driving laws and public health officials' continued reliance on police crash reports to monitor the prevalence of drug-impaired driving.

ADHD, depression, and motor vehicle crashes: A prospective cohort study of continuously-monitored, real-world driving

ADHD is associated with automobile crashes, traffic fatalities, and serious road trauma, but it is unclear whether this risk is (a) driven by ADHD symptoms specifically, and (b) unique to ADHD or transdiagnostic across psychiatric disabilities, such as depression, that also have concentration problems as core symptoms. The current study provides the first prospective, continuously-monitored evaluation of crash risk related to ADHD symptoms, including the first on-road comparison of ADHD with another high-prevalence psychiatric disability (depression). A probability-based sample of 3226 drivers from six U.S. sites, including subsamples with self-reported ADHD (n = 274) and depression (n = 251), consented to have their vehicles outfitted with sophisticated data acquisition technologies to continuously monitor real-world, day-to-day driving from 'engine-on to engine-off' for 1-2 years (Mean = 440 consecutive days/driver, Mean = 9528 miles/driver). Crashes and near-crashes were objectively identified via software-based algorithms and double-coded manual validation (blinded to clinical status). Miles driven, days monitored, age, gender, education, and marital status were controlled. ADHD symptoms portended 5% increased crash risk per increase in symptom severity score (IRR = 1.05). This risk corresponded to approximately 1 biennial crash and 1 annual near-crash per driver with ADHD; crash risk doubled for drivers reporting ADHD symptom severity near the sample's maximum. Analyses based on self-reported clinical status indicated similarly elevated rates for ADHD (IRR = 1.46) and depression (IRR = 1.34) that may be related, in part, to both groups' inattention/concentration symptoms. Risk was not attenuated by ADHD usual treatment, but varied according to antidepressant medication status. Previous studies have significantly underestimated the risk for traffic crashes conveyed by ADHD and depression.

Driving performance of stable outpatients with depression undergoing real-world treatment

AIM

Although the effects of psychotropics on driving ability have received much attention, little research is available on driving performance of stable outpatients with depression undergoing real-world treatment. This observational study investigated driving performance, cognitive functions, and depressive symptomatology of partly remitted outpatients with depression under daily-practice psychopharmacologic treatment.

METHODS

Seventy stable outpatients with depression and 67 healthy volunteers were enrolled. Patients' prescriptions were not controlled in order to capture the real-world treatment environment. Participants underwent three driving tasks - road-tracking, car-following, and harsh-braking - using a driving simulator, and three cognitive tasks - Continuous Performance Test, Wisconsin Card Sorting Test, and Trail-Making Test. The Symptom Assessment Scale - Structured Interview Guide for the Hamilton Depression Rating Scale, Beck Depression Inventory-II, Social Adaptation Self-Evaluation Scale, and Stanford Sleepiness Scale were also completed.

RESULTS

Although many patients received various pharmacologic treatments, there were no significant differences in the three driving tasks between outpatients with depression and healthy controls. Difficulty of maintaining set in the Wisconsin Card Sorting Test was significantly increased in patients with depression. Results on the Social Adaptation Self-Evaluation Scale were significantly associated with road-tracking and car-following performance, in contrast to results on the Hamilton Depression Rating Scale and the Beck Depression Inventory-II.

CONCLUSION

We conclude that partly remitted depressive patients under steady-state pharmacologic treatment do not differ from healthy controls with respect to driving performance, which seems to be more affected by psychosocial functioning than by pharmacologic agents. This, however, should be investigated systematically in an off/on study.

Antidepressant use and risk of adverse outcomes in people aged 20-64 years: cohort study using a primary care database

BACKGROUND

Antidepressants are one of the most commonly prescribed medications in young and middle-aged adults, but there is relatively little information on their safety across a range of adverse outcomes in this age group. This study aimed to assess associations between antidepressant treatment and several adverse outcomes in people aged 20-64 years diagnosed with depression.

METHODS

We conducted a cohort study in 238,963 patients aged 20-64 years registered with practices across the UK contributing to the QResearch primary care database. Only patients with a first diagnosis of depression were included. Outcomes were falls, fractures, upper gastrointestinal bleed, road traffic accidents, adverse drug reactions and all-cause mortality recorded during follow-up. Cox proportional hazards models were used to estimate hazard ratios associated with antidepressant exposure adjusting for potential confounding variables.

RESULTS

During 5 years of follow-up, 4651 patients had experienced a fall, 4796 had fractures, 1066 had upper gastrointestinal bleeds, 3690 had road traffic accidents, 1058 had experienced adverse drug reactions, and 3181 patients died. Fracture rates were significantly increased for selective serotonin reuptake inhibitors (adjusted hazard ratio 1.30, 95% CI 1.21-1.39) and other antidepressants (1.28, 1.11-1.48) compared with periods when antidepressants were not used. All antidepressant drug classes were associated with significantly increased rates of falls. Rates of adverse drug reactions were significantly higher for tricyclic and related antidepressants (1.54, 1.25-1.88) and other antidepressants (1.61, 1.22-2.12) compared with selective serotonin reuptake inhibitors. Trazodone was associated with a significantly increased risk of upper gastrointestinal bleed. All-cause mortality rates were significantly higher for tricyclic and related antidepressants (1.39, 1.22-1.59) and other antidepressants (1.26, 1.08-1.47) than for selective serotonin reuptake inhibitors over 5 years but not 1 year, and were significantly reduced after 85 or more days of treatment with selective serotonin reuptake inhibitors. Mirtazapine was associated with significantly increased mortality rates over 1 and 5 years of follow-up.

CONCLUSIONS

Selective serotonin reuptake inhibitors had higher rates of fracture than tricyclic and related antidepressants but lower mortality and adverse drug reaction rates than the other antidepressant drug classes. The association between mirtazapine and increased mortality merits further investigation. These risks should be carefully considered and balanced against potential benefits for individual patients when the decision to prescribe an antidepressant is made.

A systematic review of evidence for fitness-to-drive among people with the mental health conditions of schizophrenia, stress/anxiety disorder, depression, personality disorder and obsessive compulsive disorder

BACKGROUND

Limited evidence exists regarding fitness-to-drive for people with the mental health conditions of schizophrenia, stress/anxiety disorder, depression, personality disorder and obsessive compulsive disorder (herein simply referred to as 'mental health conditions'). The aim of this paper was to systematically search and classify all published studies regarding driving for this population, and then critically appraise papers addressing assessment of fitness-to-drive where the focus was not on the impact of medication on driving.

METHODS

A systematic search of three databases (CINAHL, PSYCHINFO, EMBASE) was completed from inception to May 2016 to identify all articles on driving and mental health conditions. Papers meeting the eligibility criteria of including data relating to assessment of fitness-to-drive were critically appraised using the American Academy of Neurology and Centre for Evidence-Based Medicine protocols.

RESULTS

A total of 58 articles met the inclusion criteria of driving among people with mental health conditions studied, and of these, 16 contained data and an explicit focus on assessment of fitness-to-drive. Assessment of fitness-to-drive was reported in three ways: 1) factors impacting on the ability to drive safely among people with mental health conditions, 2) capability and perception of health professionals assessing fitness-to-drive of people with mental health conditions, and 3) crash rates. The level of evidence of the published studies was low due to the absence of controls, and the inability to pool data from different diagnostic groups. Evidence supporting fitness-to-drive is conflicting.

CONCLUSIONS

There is a relatively small literature in the area of driving with mental health conditions, and the overall quality of studies examining fitness-to-drive is low. Large-scale longitudinal studies with age-matched controls are urgently needed in order to determine the effects of different conditions on fitness-to-drive.

Driving in mild cognitive impairment: The role of depressive symptoms

OBJECTIVES

Previous studies indicate a negative association between depression and driving fitness in the general population. Our goal was to cover a gap in the literature and to explore the link between depressive symptoms and driving behavior in individuals with mild cognitive impairment (MCI) through the use of a driving simulator experiment.

METHODS

Twenty-four individuals with MCI (mean age = 67.42, SD = 7.13) and 23 cognitively healthy individuals (mean age = 65.13, SD = 7.21) were introduced in the study. A valid driving license and regular car use served as main inclusion criteria. Data collection included a neurological/neuropsychological assessment and a driving simulator evaluation. Depressive symptomatology was assessed with the Patient Health Questionnaire (PHQ-9).

RESULTS

Significant interaction effects indicating a greater negative impact of depressive symptoms in drivers with MCI than in cognitively healthy drivers were observed in the case of various driving indexes, namely, average speed, accident risk, side bar hits, headway distance, headway distance variation, and lateral position variation. The associations between depressive symptoms and driving behavior remained significant after controlling for daytime sleepiness and cognition.

CONCLUSIONS

Depressive symptoms could be a factor explaining why certain patients with MCI present altered driving skills. Therefore, interventions for treating the depressive symptoms of individuals with MCI could prove to be beneficial regarding their driving performance.

Effect of chronic opioid therapy on actual driving performance in non-cancer pain patients

RATIONALE

Chronic non-cancer pain (CNCP) is a major health problem. Patients are increasingly treated with chronic opioid therapy (COT). Several laboratory studies have demonstrated that long-term use of opioids does not generally impair driving related skills. But there is still a lack of studies investigating on-the-road driving performance in actual traffic.

OBJECTIVES

The present study assessed the impact of COT on road-tracking and car-following performance in CNCP patients.

METHODS

Twenty CNCP patients, long-term treated with stable doses of opioid analgesics, and 19 healthy controls conducted standardized on-the-road driving tests in normal traffic. Performance of controls with a blood alcohol concentration (BAC) of 0.5 g/L was used as a reference to define clinically relevant changes in driving performance.

RESULTS

Standard Deviation of Lateral Position (SDLP), a measure of road-tracking control, was 2.57 cm greater in CNCP patients than in sober controls. This difference failed to reach statistical significance in a superiority test. Equivalence testing indicated that the 95% CI around the mean SDLP change was equivalent to the SDLP change seen in controls with a BAC of 0.5 g/L and did not include zero. When corrected for age differences between groups the 95% CI widened to include both the alcohol reference criterion and zero. No difference was found in car-following performance.

CONCLUSIONS

Driving performance of CNCP patients did not significantly differ from that of controls due to large inter-individual variations. Hence in clinical practice determination of fitness to drive of CNCP patients who receive opioid treatments should be based on an individual assessment.

Prevalence of alcohol and drug use in injured British Columbia drivers

OBJECTIVES

Determine the prevalence of drug use in injured drivers and identify associated demographic factors and crash characteristics.

DESIGN

Prospective cross-sectional study.

SETTING

Seven trauma centres in British Columbia, Canada (2010-2012).

PARTICIPANTS

Automobile drivers who had blood obtained within 6 h of a crash.

MAIN OUTCOME MEASURES

We analysed blood for cannabis, alcohol and other impairing drugs using liquid chromatography/mass spectrometry (LCMS).

RESULTS

1097 drivers met inclusion criteria. 60% were aged 20-50 years, 63.2% were male and 29.0% were admitted to hospital. We found alcohol in 17.8% (15.6% to 20.1%) of drivers. Cannabis was the second most common recreational drug: cannabis metabolites were present in 12.6% (10.7% to 14.7%) of drivers and we detected Δ-9-tetrahydrocannabinol (Δ-9-THC) in 7.3% (5.9% to 9.0%), indicating recent use. Males and drivers aged under 30 years were most likely to use cannabis. We detected cocaine in 2.8% (2.0% to 4.0%) of drivers and amphetamines in 1.2% (0.7% to 2.0%). We also found medications including benzodiazepines (4.0% (2.9% to 5.3%)), antidepressants (6.5% (5.2% to 8.1%)) and diphenhydramine (4.7% (3.5% to 6.2%)). Drivers aged over 50 years and those requiring hospital admission were most likely to have used medications. Overall, 40.1% (37.2% to 43.0%) of drivers tested positive for alcohol or at least one impairing drug and 12.7% (10.7% to 14.7%) tested positive for more than one substance.

CONCLUSIONS

Alcohol, cannabis and a broad range of other impairing drugs are commonly detected in injured drivers. Alcohol is well known to cause crashes, but further research is needed to determine the impact of other drug use, including drug-alcohol and drug-drug combinations, on crash risk. In particular, more work is needed to understand the role of medications in causing crashes to guide driver education programmes and improve public safety.

The Influence of Depression on Cognitive Control: Disambiguating Approach and Avoidance Tendencies

Dysfunctions of approach and avoidance motivation play an important role in depression, which in turn may affect cognitive control, i.e., the ability to regulate thoughts and action to achieve internal goals. We use a novel experimental paradigm, i.e. a computer simulated driving-task, to study the impact of depression on cognitive control by measuring approach and avoidance actions in continuous time. In this task, 39 subjects with minimal to severe depression symptoms were instructed to use a joystick to move a virtual car as quickly as possible to a target point without crossing a stop-sign or crashing into a wall. We recorded their continuous actions on a joystick and found that depression 1) leads to further stopping distance to task target; and 2) increases the magnitude of late deceleration (avoidance) but not early acceleration (approach), which was only observed in the stop-sign condition. Taken together, these results are consistent with the hypothesis that depressed individuals have greater avoidance motivation near stopping target, but are minimally affected by approach motivation.

Comparing treatment effects of oral THC on simulated and on-the-road driving performance: testing the validity of driving simulator drug research

RATIONALE

The driving simulator provides a safe and controlled environment for testing driving behaviour efficiently. The question is whether it is sensitive to detect drug-induced effects.

OBJECTIVE

The primary aim of the current study was to investigate the sensitivity of the driving simulator for detecting drug effects. As a case in point, we investigated the dose-related effects of oral ∆(9)-tetrahydrocannabinol (THC), i.e. dronabinol, on simulator and on-the-road driving performance in equally demanding driving tasks.

METHOD

Twenty-four experienced driver participants were treated with dronabinol (Marinol®; 10 and 20 mg) and placebo. Dose-related effects of the drug on the ability to keep a vehicle in lane (weaving) and to follow the speed changes of a lead car (car following) were compared within subjects for on-the-road versus in-simulator driving. Additionally, the outcomes of equivalence testing to alcohol-induced effects were investigated.

RESULTS

Treatment effects found on weaving when driving in the simulator were comparable to treatment effects found when driving on the road. The effect after 10 mg dronabinol was however less strong in the simulator than on the road and inter-individual variance seemed higher in the simulator. There was, however, a differential treatment effect of dronabinol on reactions to speed changes of a lead car (car following) when driving on the road versus when driving in the simulator.

CONCLUSION

The driving simulator was proven to be sensitive for demonstrating dronabinol-induced effects particularly at higher doses. Treatment effects of dronabinol on weaving were comparable with driving on the road but inter-individual variability seemed higher in the simulator than on the road which may have potential effects on the clinical inferences made from simulator driving. Car following on the road and in the simulator were, however, not comparable.

Mirtazapine as positive control drug in studies examining the effects of antidepressants on driving ability

The development of effective and safe antidepressant medications is ongoing, and driving studies are critical to assess a drug's safety. The current review summarizes the effects of a sedating effective antidepressant, mirtazapine, on driving ability, and its potential to serve as positive control drug in future driving studies. Three on-road driving studies and four driving simulator studies of mirtazapine were identified. The studies, conducted in healthy volunteers, showed a significant dose-dependent driving impairment, the first day following bedtime administration of mirtazapine. The magnitude of impairment after a single dose of 15 mg or 30 mg mirtazapine was comparable to that observed with a blood alcohol concentration of 0.05%, the legal limit for driving in many countries. After 1 or 2 weeks of daily treatment with mirtazapine, partial tolerance developed to mirtazapine's effects on driving. Driving studies conducted in patients were less informative, as the effect on driving caused by mirtazapine was obscured by a drug-disease interaction and increased variability in patient groups. In conclusion, mirtazapine is useful as positive control drug to assess the potential effects of new antidepressant drugs on driving. Studies in normal healthy volunteers are more sensitive to drug effects than studies in patient populations.

[Driving ability with affective disorders and under psychotropic drugs]

There are only few data available regarding the effects of depressive disorders on road safety due to methodological shortcomings. Patients with acute severe depression or manias are unqualified for driving but after clinical remission driving ability can be attested under psychiatric supervision in most cases. So far there are only few data available about a patient's fitness to drive under psychotropic medication. Regarding the effects of antidepressants on road safety depressed patients obviously benefit from treatment with newer antidepressants; however, at least some subgroups of patients do not reach the performance level of healthy subjects. Approximately 17 % of remission bipolar patients must be regarded as unable to drive and 27 % of patients with schizophrenia on discharge from hospital. Benzodiazepines are clearly associated with increased risk of road traffic accidents. Impaired driving ability of young attention deficit hyperactivity disorder (ADHS) patients is improved under treatment with methylphenidate. Counselling patients with respect to driving ability must be carried out individually taking into account factors of the illness, personality, attitudes and coping strategies as well as different psychopharmacological effects.

Medications and impaired driving

OBJECTIVE

To describe the association of specific medication classes with driving outcomes and provide clinical recommendations.

DATA SOURCES

The MEDLINE and EMBASE databases were searched for articles published from January 1973 to June 2013 on classes of medications associated with driving impairment. The search included outcome terms such as automobile driving, motor vehicle crash, driving simulator, and road tests.

STUDY SELECTION AND DATA EXTRACTION

Only English-language articles that contained findings from observational or interventional designs with ≥ 10 participants were included in this review. Cross-sectional studies, case series, and case reports were excluded.

DATA SYNTHESIS

Driving is an important task and activity for the majority of adults. Some commonly prescribed medications have been associated with driving impairment measured by road performance, driving simulation, and/or motor vehicle crashes. This review of 30 studies identified findings with barbiturates, benzodiazepines, hypnotics, antidepressants, opioid and nonsteroidal analgesics, anticonvulsants, antipsychotics, antiparkinsonian agents, skeletal muscle relaxants, antihistamines, anticholinergic medications, and hypoglycemic agents. Additional studies of medication impact on sedation, sleep latency, and psychomotor function, as well as the role of alcohol, are also discussed.

CONCLUSIONS

Psychotropic agents and those with central nervous system side effects were associated with measures of impaired driving performance. It is difficult to determine if such associations are actually a result of medication use or the medical diagnosis itself. Regardless, clinicians should be aware of the increased risk of impaired driving with specific classes of medications, educate their patients, and/or consider safer alternatives.

On-the-road driving performance and driving-related skills in older untreated insomnia patients and chronic users of hypnotics

RATIONALE

Many older adults report sleep problems and use of hypnotics. Several studies have shown that hypnotics can have acute adverse effects on driving the next morning. It is unclear however whether driving of chronic hypnotic users is impaired. Therapeutic effects on insomnia and development of tolerance may reduce the residual effects on driving.

OBJECTIVES

The present study aimed to compare actual driving performance and driving-related skills of chronic hypnotic users to good sleepers. To determine whether insomnia itself affects driving performance, driving and driving-related skills were compared between insomnia patients who do not or infrequently use hypnotics and good sleepers.

METHODS

Twenty-two frequent users of hypnotics (using hypnotics ≥ 4 nights per week for more than 3 months), 20 infrequent users (using hypnotics ≤ 3 nights per week), and 21 healthy, age-matched controls participated in this study. On the night before testing, all subjects were hospitalized for an 8-h sleep recorded by polysomnography. Frequent hypnotic users used their regular medication at bedtime (2330 hours), while infrequent users and controls received no medication. Cognitive performance (word learning, digit span, tracking, divided attention, vigilance, and inhibitory control) was assessed 8.5 h and driving performance between 10 and 11 h after bedtime and dosing.

RESULTS

Polysomnographic recordings did not significantly differ between the groups, but the insomnia patients, treated or untreated, still reported subjective sleep complaints. Results show no differences in driving performance and driving-related skills between both groups of insomnia patients and controls.

CONCLUSIONS

Driving performance in chronic users of hypnotics and untreated insomnia patients is not impaired. For chronic users, this may be due to prescription of relatively safe drugs and low doses. For untreated insomniacs, this corroborates previous findings showing an absence of neuropsychological deficits in this group of patients.

Psychotropic drugs and risk of motor vehicle accidents: a population-based case-control study

AIM

To examine comprehensively the relationship between exposure to four classes of psychotropic drugs including antipsychotics, antidepressants, benzodiazepines (BZDs) and Z-drugs, and motor vehicle accidents (MVAs).

METHOD

The authors conducted a matched case-control study of 5183 subjects with MVAs and 31 093 matched controls, identified from the claims records of outpatient service visits during the period from 2000 to 2009. Inclusion criteria were defined as subjects aged equal to or more than 18 years and involved in MVAs. Conditional logistic regressions with covariates adjustment (including urbanity, psychiatric and non-psychiatric outpatient visits and Charlson comorbidity score) were applied to examine the effect of four classes of psychotropic drugs on MVAs.

RESULTS

Significant increased risk of MVAs was found in subjects taking antidepressants within 1 month (adjusted odds ratio (AOR) 1.73, 95% confidence interval (CI) 1.34, 2.22), 1 week (AOR 1.71, 95% CI 1.29, 2.26), and 1 day (AOR 1.70, 95% CI 1.26, 2.29) before MVAs occurred. Similar results were observed in subjects taking benzodiazepines (BZDs) (AOR 1.56, 95% CI 1.38, 1.75 for 1 month; AOR 1.64, 95% CI 1.43, 1.88 for 1 week, and AOR 1.62, 95% CI 1.39, 1.88 for 1 day) and Z-drugs (AOR 1.42, 95% CI 1.14, 1.76 for 1 month, AOR 1.37, 95% CI 1.06, 1.75 for 1 week, AOR 1.34, 95% CI 1.03, 1.75 for 1 day), but not antipsychotics. Moreover, significant dose effects of antidepressants (equal to or more than 0.6-1.0 DDD), BZDs (equal to or more than 0.1-0.5 DDD) and Z-drugs (more than 1 DDD) were observed, respectively, on the risk of experiencing an MVA.

CONCLUSION

Taken together, subjects taking antidepressants, BZDs and Z-drugs, separately, should be particularly cautioned for their increasing risk of MVAs.

Role of severity and gender in the association between late-life depression and all-cause mortality

BACKGROUND

Mortality associated with depression may be influenced by severity of depression and gender. We investigated the differential impacts on all-cause mortality of late-life depression by the type of depression (major depressive disorder, MDD; minor depressive disorder, MnDD; subsyndromal depression, SSD) and gender after adjusting comorbid conditions in the randomly sampled elderly.

METHODS

One thousand community-dwelling elderly individuals were enrolled. Standardized face-to-face clinical interviews, neurological examination, and physical examination were conducted to diagnose depressive disorders and comorbid cognitive disorders. Depressive disorders were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria and SSD to study-specific operational criteria. Five-year survivals were compared between groups using Cox proportional hazards models.

RESULTS

By the end of 2010, 174 subjects (17.4%) died. Depressive disorder (p = 0.001) and its interaction term with gender (p < 0.001) were significant in predicting five-year survival. MDD was an independent risk factor for mortality in men (hazard ratio = 3.65, 95% confidence interval = 1.67-7.96) whereas MnDD and SSD were not when other risk factors were adjusted.

CONCLUSIONS

MDD may directly confer the risk of mortality in elderly men whereas non-major depression may be just an indicator of increased mortality in both genders.

The effects of most commonly prescribed second generation antidepressants on driving ability: a systematic review : 70th Birthday Prof. Riederer

Driving a car is vital for the functional autonomy of patients to take part in activities of daily living. Both psychopathologic symptoms and psychopharmacologic treatment may impair driving ability. This article provides a systematic review of published studies (1980-2011) on commonly prescribed newer antidepressants and driving performance. A total of 21 studies could be included in the review, indicating that there is a lack of controlled patient studies. Investigations on newer antidepressants were frequently undertaken in healthy subjects focusing on acute or subchronic effects of application, predominately in young male participants, with dosages usually given in an ambulatory setting. No data, according to selection criteria, were found with respect to agomelatine, duloxetine, bupropion and viloxazine. There is evidence that the SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, sertraline, paroxetine) and the SNRI venlafaxine have no deleterious effects on driving ability. Acute use of mirtazapine does produce impairments that diminish to some degree when given as a nocturnal dose and cannot be seen after repeated dosing in healthy controls. Patients obviously benefit from treatment with newer antidepressants; however, at least a subgroup does not reach performance level of healthy subjects. More patient studies are needed that elaborate specific relationships between clinical subtypes of the illness and response to different antidepressants, considering course and duration of illness, co-morbidities and not least neuropsychological and neurobiological characteristics.

Are selective serotonin reuptake inhibitors safe for drivers? What is the evidence?

BACKGROUND

Selective serotonin reuptake inhibitors (SSRIs) are widely used medications to treat several psychiatric diseases and, above all, depression. They seem to be as effective as older antidepressants but have a different adverse effect profile. Despite their favorable safety profile, little is known about their influence on traffic safety.

OBJECTIVE

To conduct a literature review to summarize the current evidence on the role of SSRIs in traffic safety, particularly concerning undesirable effects that could potentially impair fitness to drive, experimental and pharmacoepidemiologic studies on driving impairment, 2 existing categorization systems for driving-impairing medications, and the European legislative procedures for assessing fitness to drive before issuing a driver's license and driving under the influence of medicines.

METHODS

The article search was performed in the following electronic databases: MEDLINE, PsycINFO, ScienceDirect, and SafetyLit. The English-language scientific literature was searched using key words such as SSRIs and psychomotor performance, car crash or traffic accident, and adverse effects. For inclusion in this review, papers had to be full-text articles, refer to possible driving-related adverse effects, and be experimental or pharmacoepidemiologic studies on SSRIs and traffic accident risks. No restrictions concerning publication year were applied.

RESULTS

Ten articles were selected as background information on driving-related adverse effects, and 15 articles were selected regarding experimental and pharmacoepidemiologic work. Regarding SSRI adverse effects, the most reported undesirable effects referring to driving impairment were anxiety, agitation, sleep disturbances, headache, increased risk of suicidal behavior, and deliberate self-harm. Regarding the remaining issues addressed in this article, inconsistencies were found between the outcomes of the selected experimental and epidemiologic studies and between the 2 existing categorization systems under evaluation. Some pitfalls of the current legislative scenario were identified as well.

CONCLUSIONS

Based on the current evidence, it was concluded that more experimental and epidemiologic research is needed to elucidate the relationship between SSRI use and traffic safety. Furthermore, a revision of the existing categorization systems and harmonized European legislation in the field of medication use and driving were highly recommended.

The prevalence and nature of stopped on-the-road driving tests and the relationship with objective performance impairment

INTRODUCTION AND OBJECTIVES

The on-the-road driving test in normal traffic is applied to examine the impact of drugs on driving performance. Although participants are accompanied by a licensed driving instructor, under Dutch law, the driver is primarily responsible for safe driving and is not permitted to continue driving when it is judged that the drug compromises safety. This review examined the prevalence and nature of stopped driving tests, and the relationship with Standard Deviation of Lateral Position (SDLP), i.e. the "weaving of the car".

MATERIALS AND METHODS

A literature search was conducted to gather all publications on clinical trials that applied the on-the-road driving test, examining the effects of Central Nervous System (CNS)-drugs such as anxiolytics, antidepressants, antihistamines, analgesics, and hypnotics.

RESULTS

47 papers reported on 50 Dutch clinical trials in which 1059 subjects participated (903 healthy volunteers and 156 patients). A total of 7232 driving tests were performed; 5050 after drug treatment and 2042 after placebo. 3.1% of all driving tests were terminated before completion: 4.1% after drug treatment, and 0.7% after placebo. The decision to stop a driving test was 3-4 times more often made by the driving instructor than the subject. The most common reasons for stopping were the driver feeling tired or sleepy, or the driving instructor noticing signs of drowsiness and performance impairment. Although SDLP values of stopped driving tests are sometimes high, there is no clear relationship between SDLP (changes from placebo) and the decision to stop a driving test. Based on 8 studies that reported exact data, 39.6% of stopped drivers had a lower and 60.4% had a higher SDLP than 35 cm, i.e. the cut-off point of safe driving. This confirms that perception of the driver as well as judgment by the instructor of driving to be 'unsafe' differs between individuals.

CONCLUSION

Driving tests are sometimes stopped after drug treatment or placebo. The decision to stop driving is not a good correlate of objective performance.

At-fault motor vehicle crash risk in elderly patients treated with antidepressants

OBJECTIVE

To assess whether antidepressant treatment is associated with a temporary increase in the risk of a motor vehicle crash among older adults.

DESIGN

Population-based case-only time-to-event analysis.

SETTING AND SUBJECTS

Data from transportation and healthcare databases for adults age 65 and older in Ontario, Canada, between January 1, 2000, and October 31, 2007. Consecutive adults who had a motor vehicle crash anytime following their 66th birthday.

MEASUREMENTS

The primary exposure variable was treatment with antidepressant medication, and the primary outcome measure was a motor vehicle crash.

RESULTS

A total of 159,678 individuals had a crash during the study, of whom 7,393 (5%) received an antidepressant in the month prior to the crash. The hazard ratio (HR) of crash associated with second-generation antidepressants was 1.10 (95% confidence interval [CI]: 1.07-1.13, χ² = 41.77, df = 1, p <0.0001), adjusted for gender, license suspensions, and other medications, but the risk for first-generation antidepressants was not significant. The increased risk was restricted to those who were also concurrently prescribed a benzodiazepine (adjusted HR: 1.23, 95% CI: 1.17-1.28, χ² = 85.28, df = 1, p <0.0001) or a strong anticholinergic medication (adjusted HR: 1.63, 95% CI: 1.57-1.69, χ² = 627.31, df = 1, p <0.0001), and was confined to crashes where the patient was at fault. The increased risk was apparent for the first 3-4 months following initiation of an antidepressant and returned to baseline thereafter.

CONCLUSIONS

Prescriptions for second-generation antidepressants in older adults are associated with a modest increased risk of motor vehicle crashes, when combined with other medications that can impair cognition.

Psychotropic medications and crash risk in older drivers: a review of the literature

OBJECTIVE

. An extensive review of Australian and international literature was undertaken, examining the association between psychotropic medications and crash risk involving older drivers.

METHODS

. The review summarizes the findings in experimental and epidemiological studies related to (a) prevalence of psychotropic medication use among older drivers; (b) side effects of driving under the influence of psychotropic medications; and (c) association between psychotropic medications and crash risk for older drivers.

RESULTS

. Current evidence indicates that several types of psychotropic medications have the potential to impair driving ability and increase the risk of crash involvement. A major limitation is that few studies have specifically examined the effects on older drivers, despite the fact that the majority of the population using psychotropic medications are older. Discussion. More knowledge about the safety of therapeutic use of psychotropic medications is needed. Large-scale, whole-population, epidemiological studies, such as data linkage studies, may be the optimal study design.

Road traffic accidents and psychotropic medication use in The Netherlands: a case-control study

AIM

To examine the association between the use of commonly prescribed psychotropic medications and road traffic accident risk.

METHODS

A record-linkage database was used to perform a case-control study in The Netherlands. The data came from three sources: pharmacy prescription data, police traffic accident data and driving licence data. Cases were defined as drivers, who had a traffic accident that required medical assistance between 2000 and 2007. Controls were defined as adults, who had a driving licence and had no traffic accident during the study period. Four controls were matched for each case. The following psychotropic medicine groups were examined: antipsychotics, anxiolytics, hypnotics and sedatives, and antidepressants stratified in the two groups, SSRIs and other antidepressants. Various variables, such as age, gender, medicine half-life and alcohol use, were considered for the analysis.

RESULTS

Three thousand nine hundred and sixty-three cases and 18,828 controls were included in the case-control analysis. A significant association was found between traffic accident risk and exposure to anxiolytics (OR = 1.54, 95% CI 1.11, 2.15), and SSRIs (OR = 2.03, 95% CI 1.31, 3.14). A statistically significant increased risk was also seen in chronic anxiolytic users, females and young users (18 to 29 years old), chronic SSRI users, females and middle-aged users (30 to 59 years old), and intermediate half-life hypnotic users.

CONCLUSIONS

The results of this study support previous findings and confirm that psychoactive medications can constitute a problem in traffic safety. Both health care providers and patients should be properly informed of the potential risks associated with the use of these medicines.

Psychoactive medications and crash involvement requiring hospitalization for older drivers: a population-based study

OBJECTIVES

To determine the association between psychoactive medications and crash risk in drivers aged 60 and older.

DESIGN

Retrospective population-based case-crossover study.

SETTING

A database study that linked the Western Australian Hospital Morbidity Data System and the Pharmaceutical Benefits Scheme.

PARTICIPANTS

Six hundred sixteen individuals aged 60 and older who were hospitalized as the result of a motor vehicle crash between 2002 and 2008 in Western Australia.

MEASUREMENTS

Hospitalization after a motor vehicle crash.

RESULTS

Greater risk for a hospitalization crash was found for older drivers prescribed benzodiazepines (odds ratio (OR)=5.3, 95% confidence interval (CI)=3.6-7.8, P<.001), antidepressants (OR=1.8, 95% CI=1.0-3.3, P=.04), and opioid analgesics (OR=1.5, 95% CI=1.0-2.3, P=.05). Crash risk was significantly greater in men prescribed a benzodiazepine (OR=6.2, 95% CI=3.2-12.2, P<.001) or an antidepressant (OR=2.7, 95% CI=1.1-6.9, P=.03). Women prescribed benzodiazepines (OR=4.9, 95% CI=3.1-7.8, P<.001) or opioid analgesics (OR=1.8, 95% CI=1.1-3.0, P=.03) also had a significantly greater crash risk. Subgroup analyses further suggested that drivers with (OR=4.0, 95% CI=2.9-8.1, P<.001) and without (OR=6.0, 95% CI=3.8-9.5, P<.001) a chronic condition who were prescribed benzodiazepines were at greater crash risk. Drivers with a chronic condition taking antidepressants (OR=3.4, 95% CI=1.3-8.5, P=.01) also had a greater crash risk.

CONCLUSION

Psychoactive medication usage was associated with greater risk of a motor vehicle crash requiring hospitalization in older drivers.

Problems associated with long-term treatment with selective serotonin reuptake inhibitors

Although the selective serotonin reuptake inhibitors (SSRIs), which are now widely used as a first-line treatment for depression and many other psychiatric conditions, are generally well tolerated, they are not devoid of side effects. Most short-term treatment-related side effects of SSRIs are transient and disappear after a few days or weeks. However, following long-term treatment with the SSRIs, some serious adverse events may occur. Some of them can be difficult to recognise because they can resemble residual symptoms of depression. The most serious can be life threatening. They all have a negative influence on the patient's quality of life and are frequently a prime reason for a lack of long-term compliance with the associated increased risk of recurrence of a depressive episode. This article is an overview of the more common adverse events, which are seen with non-acute treatment with the SSRIs.

The impact of mental health symptoms on heavy goods vehicle drivers' performance

High levels of psychological distress in fulltime employees are prevalent (4.5% per month). Symptoms of impaired mental health include difficulties with attention, concentration, motivation, decision-making, visuo-motor control, and psychomotor reaction times. There is limited research on the impact these symptoms have on heavy goods vehicle (HGV) drivers' performance. In this study 1324 HGV drivers were surveyed using the Depression, Anxiety, Stress Scale (DASS) and the Health and Performance at Work Questionnaire (HPQ). Depression, anxiety and stress had little effect on driver absenteeism rates or self-rated driving performance. However, severe (1.5% of drivers) and very severe (1.8% of drivers) depression was associated with an increased odds ratio (OR=4.5 and 5.0, respectively) for being involved in an accident or near miss in the past 28 days. This odd ratio is akin to driving with a blood alcohol content of about 0.08%. Given the number of HGV vehicles and the prevalence of depression this equates to 10,950 HGV drivers with an increased statistical risk of an accident or near miss. As the impact of HGV accidents is potentially large, including loss of life, it would be sensible to extend the research findings here into an action plan.

Effect of fluoxetine on some cognitive functions of patients of depression

BACKGROUND

This study was carried out to evaluate the effect of long-term administration of a commonly prescribed antidepressant, fluoxetine from different group on memory and psychomotor functions in patients of various psychiatric disorders using a battery of simple tests that can be conveniently applied to the Indian population.

MATERIALS AND METHODS

Memory was evaluated using the PGI memory scale and psychomotor functions were evaluated using six letter cancellation test. Statistical analysis was carried out using Wilcoxon signed-rank test.

RESULTS AND CONCLUSION

The results of the study reveal that there was significant improvement in some cognitive function. Cognitive functions are improved at first follow-up and they improved continuously up to last follow-up that is at one month. It is observed that there was improvement in the primary disease. So, final score of the cognitive parameters is because of the resultant activity of direct drug action and improvement in the underlying disease.

The effects of acute treatment with paroxetine, amitriptyline, and placebo on driving performance and cognitive function in healthy Japanese subjects: a double-blind crossover trial

OBJECTIVE

To assess the effects of antidepressants on driving performance from a different methodological viewpoint in light of the recent traffic accidents.

METHODS

In this double-blinded, 3-way crossover trial, 17 healthy males received acute doses of 10 mg paroxetine, 25 mg amitriptyline, and placebo. The subjects were administered three driving tasks--road tracking, car following, and harsh braking--performed using a driving simulator and three cognitive tasks--Wisconsin Card Sorting Test, Continuous Performance Test, and N-back test at baseline and at 1 h and 4 h post-dosing. The Stanford Sleepiness Scale scores were also assessed.

RESULTS

At 4 h post-dosing, amitriptyline significantly impaired road-tracking and car-following performance, reduced driver vigilance, and caused subjective somnolence. Paroxetine impaired neither driving performance nor cognitive function.

CONCLUSIONS

Acute doses of amitriptyline significantly impaired driving performance in the context of driving on crowded urban roads at relatively low speeds. This setting is important with respect to skills necessary for daily driving and may be difficult to measure in actual driving tests. This simulator-based study replicated the results of previous studies and could be considered complementary to them. This method may enable easy and safe screening of the driving hazard potential of drugs.

The impaired hypothyroid patient: ethical considerations and obligations

OBJECTIVES

Analyze the ethical duties and dilemmas involved in treating the severely hypothyroid patient.

DESIGN

A critical review of the literature was conducted with respect to clinical ethics issues pertaining to severe hypothyroidism; legal and ethical guidelines for consent and capacity in the context of severe hypothyroidism; health case law involving the duty to warn third parties; and comparable clinical conditions resulting in impaired driving and the performance of critical tasks.

MAIN OUTCOME

Neuropsychological studies and accepted clinical experiences verify the variable degrees of intellectual and neurological impairment consequent to severe hypothyroidism. Thus, severely hypothyroid patients are considered impaired in the performance of specific tasks, such as driving. Consequent to that, they may be agents of harm as a result of their impairment if they are not warned against driving or performing other duties affecting public safety. Severely hypothyroid patients may lack the capacity to make an informed decision, even when warned against driving or other tasks, and some may ignore such warnings.

CONCLUSIONS

The legal and ethical "duty to warn" may trump confidentiality and HIPAA in cases where the activity of impaired patients seriously affects public safety. Not only do health care providers have a clear duty to warn patients not to drive, but in some extreme cases, may have a duty to warn third parties when a patient's driving or occupational duties place the public in harm's way.

Recent understandings in geriatric affective disorder

PURPOSE OF REVIEW

This article focuses on recent research into depression, bipolar disorder and anxiety in older people.

RECENT FINDINGS

Many physical illnesses are associated with a high prevalence of depression but overall medical burden may largely account for this. The relationship between depression and vascular disease is two way. Frontal brain dysfunction may underlie depression both in cerebrovascular disease and neurodegenerative disorders. Besides antidepressants, psychological treatments, psychosocial interventions and enhanced primary care services are effective. Longer-term outcomes are poor but preventive strategies show promise. Medical and psychiatric comorbidity are also important themes in later-life anxiety and bipolar disorders.

SUMMARY

Improving prognosis is a key concern and more research into novel pharmacological approaches (including vasoprotection), psychological interventions and prevention is needed.