The influence of clozapine and typical neuroleptics on information processing of the central nervous system under clinical conditions in schizophrenic disorders: implications for fitness to drive

Exploratory` study on driving ability of people with schizophrenia: Relationships among cognitive function, symptoms, and brain activity

BACKGROUND

This study aimed to examine the relationships among cognitive function, symptoms, prefrontal activation, basic driving skills, and collision risk factors using a hazard prediction task in simulated driving.

METHODS

Participants included 42 people with schizophrenia aged 20-50 years who had actual experience of driving. The Trail making test (TMT) A and TMTB, Wechsler Memory Test-Revised (WMS-R), and Zoo Map test (ZMT) were used to evaluate cognitive function. Positive and negative syndrome scale was used to assess symptoms, and brain activity was assessed by evaluating cerebral blood flow during a visual working memory task using functional near-infrared spectroscopy. Driving tasks that tested basic skills, such as brake reaction, steering wheel skills, and standard deviation of lateral position, were analyzed using multiple regression analysis. Three hazard prediction tasks were performed using discriminant analysis.

RESULTS

Brake reaction associated with cerebral blood flow and TMT-A. Steering wheel skills associated with WMS-R, driving experience and depression. Significant differences were found between the collision and noncollision groups in the hazard prediction task, as shown by the ZMT, driving experience, and brake reaction.

CONCLUSIONS

Brain activity in the frontal lobe during a desk task may be useful data for driving assessment. Assessment of processing speed and learning ability may be particularly important in the evaluation of basic skills for safe driving. In addition, for people with schizophrenia, foresight, as represented by proactive planning, experience, and quick braking may be an essential characteristic to anticipate danger and react quickly enough to avoid collisions.

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.

Driving fitness in clinically stable outpatients with chronic schizophrenia

INTRODUCTION

Driving motorized vehicles is an integral part of individual mobility and a key parameter for employment and social integration. This naturalistic, cross-sectional study investigated the associations between driving fitness, residual symptomatology, olanzapine equivalent, and extrapyramidal symptoms (EPS) in long term stable outpatients with schizophrenia.

METHODS

Beside sociodemographic data, and driving habits, residual symptoms, and EPS were assessed using the Positive and Negative Syndrome Scale (PANSS), and the Modified Simpson Angus Scale (MSAS). PANSS symptoms were analyzed using the Wallwork/Fortgang five-factor model. MSAS cut-off scores ≥3 were defined as positive for EPS. Driving skills were assessed using the Vienna Test System and an expert evaluation.

RESULTS

50 patients were included into the study. Mean PANSS total scores indicated mild residual symptomatology and EPS were not present in 48% of study participants. 44% passed the driving fitness assessment and were considered as competent to drive, 20% were judged to be partially competent and 36% to be incompetent to drive. With the exception of disorganization (r = -0·287, p = 0·048) residual symptoms of schizophrenia did not correlate with driving fitness. However, moderate negative correlations were detected between driving fitness and the severity of EPS (r = -0·554, p = 0·000), age (r = -0·413, p = 0·003) as well as olanzapine equivalent doses (r = -0·432, p = 0·002). These results were not corrected for multiple comparison.

DISCUSSION

The present findings indicate that up to two thirds of clinically stable outpatients with chronic schizophrenia may be (partially) competent to drive. Both the presence of EPS as well as the dosage of antipsychotic medication seem to be of particular relevance in this regard.

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.

Effects of various antipsychotics on driving-related cognitive performance in adults with schizophrenia

The aim of this study was to determine whether the driving-related cognitive performance differs among adults with schizophrenia taking different types of antipsychotics. Neurocognitive performance was assessed using the Cognitive Perceptual Assessment for Driving (CPAD), a computerized battery of tests of visual perception, attention, working memory, reaction time, and inhibitory control for driving ability. One hundred and two adults with schizophrenia who were on antipsychotic monotherapy participated in the study. Of these, 15 were on haloperidol, 28 on risperidone, 14 on olanzapine, 28 on aripiprazole, and 17 on paliperidone. Sixty-four (63%) of the 102 subjects were regarded as competent to drive. Of the subjects taking haloperidol, 33% passed the CPAD, while the passing rates of subjects taking risperidone, olanzapine, aripiprazole, and paliperidone were 57%, 57%, 75%, and 82%, respectively, with a significant difference between the haloperidol and aripiprazole groups (p = 0.005) and between the haloperidol and paliperidone groups (p = 0.001). Additionally, scores on CPAD depth perception (number of correct responses), divided attention, digit span test, and trail-making test B subtests were significantly better for the aripiprazole and paliperidone groups than for the haloperidol and risperidone groups. In this cross-sectional design study, adults with schizophrenia treated with aripiprazole or paliperidone antipsychotic monotherapy demonstrated superior driving-related cognitive performance than those treated with haloperidol or risperidone antipsychotic monotherapy.

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.

Driving skills in unmedicated first- and recurrent-episode schizophrenic patients

The present study was designed to examine driving skills according to regulations of the German guidelines for road and traffic safety in unmedicated schizophrenic inpatients. A total of 13 first-episode (FES) and 13 recurrent-episode (RES) schizophrenic inpatients were included in the analysis and compared with a group of 20 healthy controls (HC). Data were collected with the computerised Wiener Testsystem measuring visual perception, reactivity and stress tolerance, concentration and vigilance. Analysis of data indicates that a great proportion (58 %) of schizophrenic patients were impaired in psychomotor functions related to driving skills. FES and RES significantly differed with respect to driving ability with a greater proportion in the FES (38 %) showing severe impairments when compared with RES (25 %). Differences with respect to HC performance were most pronounced in concentration and for the FES additionally in visual perception. Analysis of our data indicates that a great proportion of schizophrenic patients are impaired in psychomotor functions related to driving skills that cannot be attributed to adverse side effects of psychopharmacological treatment. Besides, we cannot confirm a chronical decline of psychomotor functions related to driving skills at least in the early course of schizophrenic illness.

Perazine for schizophrenia

BACKGROUND

Perazine is an old phenothiazine derivative used for the treatment of people with schizophrenia and is reputed to have a low level of extrapyramidal adverse effects. As far as we are aware, its use is limited to Germany, Poland, the former Yugoslavia and the Netherlands.

OBJECTIVES

To examine the effects of perazine for those with schizophrenia or related psychoses in comparison with placebo, no treatment or other antipsychotic medications.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register, which includes relevant randomised controlled trials from the bibliographic databases Biological Abstracts, CINAHL, The Cochrane Library, EMBASE, MEDLINE, PsycLIT, LILACS, PSYNDEX, Sociological Abstracts and Sociofile. We searched the references of all included studies for further trials. We contacted pharmaceutical companies and authors of trials. We updated this search on 16th July 2012.

SELECTION CRITERIA

We selected all randomised controlled trials that compared perazine with other treatments for people with schizophrenia or schizophrenia-like psychoses, or both.

DATA COLLECTION AND ANALYSIS

The review authors (SL, BH, BHe) independently inspected the citations and where possible abstracts and ordered papers for re-inspection and quality assessment. We independently extracted data. We calculated the risk ratio (RR) and 95% confidence interval (CI) using a random-effects model. For continuous data, we calculated mean differences (MD). We inspected all data for heterogeneity, assessed trials for risk of bias and created summary of findings tables using GRADE.

MAIN RESULTS

The review now includes seven trials with a total of 479 participants. In only one trial, with 95 participants, perazine appeared superior to 'active placebo' (trimipramine) at five weeks for the outcome of 'no important global improvement' (n = 95, RR 0.43 CI 0.2 to 0.8, low quality evidence), but there was no statistically significant difference in most measures of mental state. Perazine did not induce more general adverse events than placebo but more participants received at least one dose of antiparkinson medication (n = 95, RR 4.50 CI 1.0 to 19.5, very low quality evidence).Six small trials comparing perazine with other antipsychotics, including 384 participants in total, were incompletely reported and the outcomes were presented in various ways so that meta-analysis was not possible on most occasions. In the six studies, a similar number of participants receiving perazine or comparator antipsychotics (amisulpride, haloperidol, olanzapine, ziprasidone, zotepine) left the studies early (n = 384, RR 0.97 CI 0.68 to 1.38, low quality evidence). The results on efficacy could not be meta-analysed because the authors presented their results in very different ways. No obvious differences in adverse events between perazine and other antipsychotics could be derived from the limited data. Two haloperidol comparisons did not present extrapyramidal side-effects in a way that was suitable for use in meta-analysis, but three small comparisons with the second-generation antipsychotics zotepine and amisulpride showed no higher risk of akathisia (n = 111, RR 0.31 CI 0.1 to 1.1), dyskinesia (n = 111, RR 0.47 CI 0.1 to 3.5), parkinsonism (n = 81, RR 1.21 CI 0.5 2.8) or tremor (n = 40, RR 0.80 CI 0.3 to 2.6) with perazine.

AUTHORS' CONCLUSIONS

The number, size and reporting of randomised controlled perazine trials are insufficient to present firm conclusions about the properties of this antipsychotic. It is possible that perazine is associated with a similar risk of extrapyramidal side-effects as some atypical antipsychotics but this is based on small comparisons. This should be clarified in larger, well-designed trials.

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.

Car driving in schizophrenia: can visual memory and organization make a difference?

PURPOSE

Driving is a meaningful occupation which is ascribed to functional independence in schizophrenia. Although it is estimated that individuals with schizophrenia have two times more traffic accidents, little research has been done in this field. Present research explores differences in mental status, visual working memory and visual organization between drivers and non-drivers with schizophrenia in comparison to healthy drivers.

METHODS

There were three groups in the study: 20 drivers with schizophrenia, 20 non-driving individuals with schizophrenia and 20 drivers without schizophrenia (DWS). Visual perception was measured with Rey-Osterrieth Complex Figure test and a general cognitive status with Mini-Mental State Examination.

RESULTS

The general cognitive status predicted actual driving situation in people with schizophrenia. No statistically significant differences were found between driving and non-driving persons with schizophrenia on any of the visual parameters tested, although these abilities were significantly lower than those of DWS.

CONCLUSION

The research demonstrates that impairment of visual abilities does not prevent people with schizophrenia from driving and emphasizes the importance of general cognitive status for complex and multidimensional everyday tasks. The findings support the need for further investigation in the field of car driving for this population - a move that will considerably contribute to the participation and well-being. Implication for Rehabilitation Unique approach for driving evaluation in schizophrenia should be designed since direct applications of knowledge and practice acquired from other populations are not reliable. This research demonstrates that visual perception deficits in schizophrenia do not prevent clients from driving, and general cognitive status appeared to be a valid determinant for actual driving. We recommended usage of a general test of cognition such as Mini-Mental State Examination, or conjunction number of cognitive factors such as executive functions (e.g., Trail Making Test) and attention (e.g., Continuous Performance Test) in addition to spatial-visual ability tests (e.g., Rey-Osterrieth Complex Figure test) for considering driving status in schizophrenia.

Psychomotor performance and fitness to drive: the influence of psychiatric disease and its pharmacological treatment

Both psychiatric disorders and psychiatric drug treatments produce changes of psychomotor performance which can disturb and/or interfere with the ability to drive safely. We studied the influence of current psychiatric drug treatments on psychomotor functions and on driving performance of 77 consecutive psychiatric outpatients in two different clinical situations: at admission, when patients are destabilized and their mental disorders untreated, and after 6 weeks of pertinent psychotropic treatment. Fitness to drive and psychomotor performance were assessed using the electronic LNDETER 100 battery. Treatment effects on global functioning were assessed using the Clinical Global Impression of Change (CGIC) scale. One-way repeated measures analysis of variance and post hoc comparisons with the Bonferroni correction were performed. At the time of diagnosis, 90% of the patients failed to achieve scores sufficient to renew their driving licenses. After 6 weeks of adequate treatment, 83% improved their mental condition, and 17% either remained unchanged or deteriorated. Of those who improved, 25% had scores sufficiently high for them to drive legally, and the rest improved their performance from baseline assessment. Three of the four sub-tests were able to discriminate between patients with different clinical conditions. The study clearly suggests that medical treatment of psychiatric problems has a positive effect on driving tests.

Mental health services utilization and driving violations

Abstract Objective. The objective of this study was to determine whether there is a relationship between the past utilization of four mental health services (i.e. ever been seen by a psychiatrist, ever been in a psychiatric hospital, ever been in counseling, ever been on psychotropic medication) and different types of driving citations during one's lifetime. Methods. Using a consecutive, cross-sectional, primary care sample, we surveyed participants about their past use of four mental health services and lifetime incidence of 29 different types of driving citations (charges, not convictions). Results. The total number of different types of moving violations was statistically significantly related to a history of psychiatric hospitalization. The total number of different types of non-moving violations was statistically significantly related to all mental health services variables. Conclusions. In this study, general non-specific queries about the past utilization of mental health services were correlated with both moving violations (past psychiatric hospitalization) and non-moving violations (all mental health services variables). These findings suggest that patients who have received mental health treatment are at a higher risk for being cited for driving violations than those who have not received mental health treatment. However, among the mental health variables under study, only past psychiatric hospitalization was associated with moving violations.

Driving simulator performance and psychomotor functions of schizophrenic patients treated with antipsychotics

The objective of the study is to compare schizophrenic inpatients under antipsychotic monotherapy regarding simulated driving behaviour and psychomotor functions related to driving ability. Schizophrenic inpatients (n = 80) were tested before discharge to outpatient treatment. Data were collected with the computerized Act & React Testsystem and the Wiener Testsystem measuring visual perception, reaction time, attention, vigilance and stress-tolerance. Besides, patients underwent various driving simulations on a static driving simulator (FT-SR 200). Before discharge to outpatient treatment, about 25% of schizophrenic patients must be considered as severely impaired with respect to driving skills. Differences between treatment groups could be shown both in psychomotor measures and in driving simulator performance with a better test performance of patients treated with atypical antipsychotics. Controlling for age, psychopathologic symptoms and extrapyramidal signs, differences in psychomotor measures were most pronounced in concentration and vigilance. As mental disorders itself pose an increased risk of accidents, counselling patients with respect to differential effects of antipsychotic treatment is of great relevance. In addition to psychomotor tests computer-simulated driving seems to be a useful tool in assessing traffic safety under pharmacologic treatment.

Perazine for schizophrenia

BACKGROUND

Perazine is an old phenothiazine derivative used for the treatment of people with schizophrenia and is reputed to have a low level of extrapyramidal adverse effects. As far as we are aware, its use is limited to Germany, Poland, the former Yugoslavia and the Netherlands.

OBJECTIVES

To examine the effects of perazine for those with schizophrenia, and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register which includes relevant randomised controlled trials from the bibliographic databases Biological Abstracts, CINAHL, The Cochrane Library, EMBASE, MEDLINE, PsycLIT, LILACS, PSYNDEX, Sociological Abstracts and Sociofile (last update of the review March 2005). We searched references of all included studies for further trials. We contacted pharmaceutical companies and authors of trials.

SELECTION CRITERIA

We selected all randomised controlled trials that compared perazine with other treatments for people with schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

We independently (SL, BH) inspected citations and where possible abstracts and ordered papers for re-inspection and quality assessment. We independently extracted data. We excluded data if loss to follow up was greater than 50%. For homogeneous dichotomous data we calculated the Relative Risk (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD). We inspected all data for heterogeneity.

MAIN RESULTS

We included six trials with a total of 288 participants. In only one trial with 95 participants, perazine appeared superior to 'active placebo' (trimipramine) at five weeks for the outcome of 'no important global improvement' (n=95, RR 0.43 CI 0.2 to 0.8, NNT 4 CI 2 to 13), but there was no statistically significant difference in most measures of mental state. Perazine did not induce more general adverse events than placebo, but more participants received at least one dose of antiparkinson medication (n=95, RR 4.50 CI 1.0 to 19.5, NNH 6 CI 4 to 33). Five small trials comparing perazine with other antipsychotics, including in total only 193 participants, were incompletely reported and the outcomes were presented in various ways so that meta-analysis was not possible in most occasions. A similar number of participants receiving perazine or comparator antipsychotics left the studies early (n=193, RR 0.85, CI 0.5 to 1.4). The results on efficacy were controversial and need further assessment by randomised controlled trials. No obvious differences in adverse events between perazine and other antipsychotics could be derived from the limited data. Two haloperidol comparisons did not present extrapyramidal side-effects in a suitable way for use in meta-analysis, but three small comparisons with the atypical antipsychotics zotepine and amisulpride showed no higher risk of akathisia (n=111, RR 0.31 CI 0.1 to 1.1), dyskinesia (n=111, RR 0.47 CI 0.1 to 3.5), parkinsonism (n=81, RR 1.21 CI 0.5 2.8) or tremor (n=40, RR 0.80 CI 0.3 to 2.6) with perazine.

AUTHORS' CONCLUSIONS

The number, size and reporting of randomised controlled perazine trials is insufficient to present firm conclusions about the properties of this antipsychotic. It is possible that perazine is associated with a similar risk of extrapyramidal side-effects as some atypical antipsychotics, and this should be clarified in larger, well-designed trials.

Driving ability in schizophrenic patients: effects of neuroleptics

Recent studies indicate that individuals with schizophrenia have a two-fold incidence of traffic accidents. Cognitive and psychomotor impairment as a core feature of schizophrenia and the effects of neuroleptic treatment play an essential role in this respect. Few experimental studies have been conducted so far looking at the effects of neuroleptics on driving ability in schizophrenia. Controlled, randomised trials are totally missing. The limited database indicates that most schizophrenic patients show significant impairment in cognitive functions relevant for driving ability compared to healthy controls. There is some but limited evidence that patients under novel atypical neuroleptics show less impairment compared to conventional neuroleptics. More clinical and experimental studies are warranted.

Effects of haloperidol and risperidone on psychomotor performance relevant to driving ability in schizophrenic patients compared to healthy controls

The effects of antipsychotic treatment on the psychomotor performance and driving ability of schizophrenic patients is subject of investigation. The present study was designed to evaluate the effects of an atypical neuroleptic (risperidone) in comparison to a conventional dopamine antagonist neuroleptic (haloperidol) on several dimensions of psychomotor performance (visual perception, attention, reaction time, and sensorimotor performance) considered to be of relevance in evaluating driving fitness. Psychomotor performance was assessed by means of the ART 90 (act-and-react test), a computerized test battery which is frequently used in diagnosis of psychomotor performance. The 40 participating patients were examined at discharge following psychopathological stabilisation; 20 received haloperidol medication, 20 received the atypical neuroleptic risperidone. Nineteen healthy individuals were studied as a control group. Our findings indicate a remarkably reduced psychomotor performance in both groups of schizophrenic patients compared to healthy controls. We did find a significant but low correlation between age and some items of the RST3 and between age and the tracking performance on the PVT. The younger patients showed a better test performance than older patients. The BPRS-score was significantly correlated with only two items of the RST3. However, patients under treatment with risperidone showed significantly better results compared to patients treated with haloperidol. Only one (5%) subject passed all subtests without major failures and could be regarded as competent to drive. Among patients with risperidone, seven patients (35%) passed all test parameters without major failures. Clinical implications of these findings are discussed.

The impact of antipsychotics on psychomotor performance with regards to car driving skills

Cognitive and psychomotor impairments are a core feature of most patients with schizophrenia and may have an important influence on driving ability. The present study investigated the effects of neuroleptic monotherapy on psychomotor functions related to car driving skills in schizophrenic patients. Consecutively admitted schizophrenic inpatients (n = 120) were tested under steady state plasma level conditions before discharge to outpatient treatment. Patients met the International Classification of Diseases, Tenth Revision criteria for schizophrenia. The study followed a naturalistic nonrandomized design. Data were collected with the computerized Act & React Testsystem and were analyzed according to medication, severity of illness, and age. Only 32.5% of the schizophrenic inpatients passed the tests without major impairments. Patients treated with atypical neuroleptics or clozapine showed a better test performance on skills related to driving ability when compared with patients on typical neuroleptics. Differences were most pronounced in measures of divided attention, stress tolerance, and attention. Data also suggest that treatment with clozapine had an overall positive impact on measures of reactivity and stress tolerance. These results show that even under steady state pharmacologic conditions psychomotor functions of most schizophrenic patients partly remitted must be considered as impaired. To evaluate these effects, a systematic neuropsychologic examination is recommended.

Fahrtüchtigkeit und psychische Erkrankung

Zusammenfassung: Psychische Erkrankungen gehen oft mit Störungen der Informationsverarbeitung einher, die bei den Betroffenen zu Beeinträchtigungen in weiten Bereichen des alltäglichen Lebens führen können. Ein Beispiel für die vielfältigen Alltagsrisiken stellt der Straßenverkehr dar. Die epidemiologische Datenlage in Bezug auf Unfallrisiken von psychiatrischen Patienten unter Psychopharmaka ist jedoch dünn und von einer Reihe von methodischen Problemen gekennzeichnet. Einige Untersuchungen weisen auf ein erhöhtes Risiko von psychiatrischen Patienten hin, in einen Verkehrsunfall verwickelt zu werden. Eine pauschale Bewertung von Arzneimitteln, die die Fahrtüchtigkeit beeinträchtigen können ist nicht möglich. Unter den potenziell verkehrsbeeinträchtigenden Psychopharmaka stehen Tranquilizer und Hypnotika an erster Stelle. Im Gegensatz zu vielen trizyklischen Antidepressiva führen neuere selektive Antidepressiva zu keinen signifikanten Beeinträchtigungen psychomotorischer und kognitiver Funktionen. Neuere atypische Antipsychotika scheinen hinsichtlich Vigilanz und Psychomotorik Vorteile gegenüber konventionellen Neuroleptika zu haben. Die Beratung und Aufklärung von Patienten zu Fragen der Fahrtauglichkeit muss individuell, unter Berücksichtigung des Krankheitsbildes, pharmaka-differenzieller Aspekte sowie beruflichen und sozialen Wiedereingliederungsbemühungen erfolgen.

Effects of haloperidol and atypical neuroleptics on psychomotor performance and driving ability in schizophrenic patients. Results from an experimental study

The influence of antipsychotic treatment on the neuropsychological and psychomotor performance of schizophrenic patients is still a subject of investigation. The present study was designed to evaluate the effects of atypical neuroleptics in comparison with a conventional dopamine antagonist neuroleptic (haloperidol) on several dimensions of psychomotor performance (visual perception, attention, reaction time, and sensorimotor performance) considered to be of relevance in evaluating driving fitness. Psychomotor performance was assessed by means of the ART 90, a computerized Act and React Test which is generally used in diagnosis of psychomotor performance. The 49 participating patients were examined at discharge following psychopathological stabilisation; 20 received haloperidol, 29 received an atypical neuroleptic. Our findings demonstrate a remarkably reduced psychomotor performance in the haloperidol-treated group of schizophrenic patients compared with patients treated with atypical neuroleptics. Only 1 (5%) subject passed all subtests without major failures and could be regarded as competent to drive. Among patients with atypical neuroleptics, 7 patients (24%) passed all test parameters without major failures.

Perazine for schizophrenia

BACKGROUND

Perazine is an old phenothiazine derivative used for the treatment of people with schizophrenia which has a reputed low level of extrapyramidal side-effects. However, its use is restricted in the sense that - to the best knowledge of the reviewers - it is only marketed in Germany, Poland, Yugoslavia and the Netherlands.

OBJECTIVES

To examine the effects of perazine for those with schizophrenia, and schizophrenia-like psychoses.

SEARCH STRATEGY

Electronic searches of the Cochrane Schizophrenia Group's register which includes relevant randomised controlled trials from the bibliographic databases Biological Abstracts, CINAHL, The Cochrane Library, EMBASE, MEDLINE, PsycLIT, LILACS, PSYNDEX, Sociological Abstracts and Sociofile were undertaken. References of all included studies were searched for further trials. Pharmaceutical companies and authors of trials were contacted.

SELECTION CRITERIA

All randomised controlled trials that compared perazine with other treatments for people with schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by two reviewers, papers ordered, re-inspected and quality assessed. Data were independently extracted. Data were excluded if loss to follow up was greater than 50%. For homogeneous dichotomous data the Relative Risk (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, weighted mean differences were calculated (WMD). All data were inspected for heterogeneity.

MAIN RESULTS

Six trials with a total of 288 participants are included. According to only one trial with 95 participants perazine appeared superior to active placebo (trimipramine) at five weeks for the outcome of 'no important global improvement' (n=95, RR 0.6, CI 0.3-0.9, NNT 4, CI 2-17), but there was no difference in various measures of mental state. The side-effect risk of perazine compared to placebo could not be estimated because they were not reported. Five small trials including only 193 participants which compared perazine with other antipsychotics were incompletely reported and the outcomes were presented in various ways so that meta-analysis was not possible in most occasions. A similar number of participants receiving perazine or comparator antipsychotics left the studies early (n=193, RR 0.9, CI 0.5-1.4). The results on efficacy were controversial and need further assessment by randomised controlled trials. No obvious differences in adverse events between perazine and other antipsychotics could be derived from these limited data. Two haloperidol comparisons did not present extrapyramidal side-effects in a way usable for meta-analysis, but three small comparisons with the atypical antipsychotics zotepine and amisulpride showed no higher risk of akathisia (n=111, RR 0.3, CI 0.1-1.1), dyskinesia (n=111, RR 0.5, CI 0.1-3.5), parkinsonism (n=81, RR 1.2, CI 0.5-2.8) or tremor (n=40, RR 0.8, CI 0.3-2.3) with perazine.

REVIEWER'S CONCLUSIONS

The number, size and reporting of randomised controlled perazine trials is insufficient to present firm conclusions about the properties of this antipsychotic. It is possible that perazine is associated with a similar risk of extrapyramidal side-effects as some atypical antipsychotics, and this should be clarified in larger, well-designed trials.