Assessing Fitness to Drive

In this section

7.2.1. General considerations

7.2.2. Reporting patients

7.2.3. Mental state examination

7.2.4. Treatment

7.2.5. Comorbidities

7.2.6. Insight

7.2.7. Acute psychotic episodes

7.2.8. Severe chronic conditions

7.2.9. Psychogenic nonepileptic seizures

7.2.10. Personality disorders

7.2.11. Post-traumatic stress disorder

7.2.12. Other psychiatric conditions

In assessing the impact of mental illness on the ability to drive safely, the focus should be on assessing the severity and significance of likely functional effects, rather than the simple diagnosis of a mental illness. Information relevant to the assessment may be gained from case workers and others involved in the ongoing management of the person. The review period should be tailored to the likely prognosis or pattern of progression of the condition in an individual. Commercial vehicle licences warrant greater concern and a lower threshold for intervention.

Mild mental illness does not usually have a significant impact on functioning. Moderate levels of mental illness commonly affect functioning, but many people will be able to manage usual activities, often with some modification. Severe mental illness often impairs multiple domains of functioning, and it is this category that is most likely to affect the functions and abilities required for safe driving. A person’s medication requirements should not be used as the only measure of disease severity.

Contraindications to driving

A person seen or reported to have any of the following problems can be advised not to drive until the condition has been evaluated and treated:

• condition relapses sufficient to impair perceptions, mood or thinking
• lack of insight or lack of cooperation with treatment
• an intent to use a vehicle to cause self-harm
• an intent to use a vehicle to harm others.

If a patient appears unwilling or unable to accept advice about restricting their driving, the health professional should consider if it is appropriate to report directly to the driver licensing authority and, if so, determine how best such a notification can be made while continuing to engage the person in treatment that is beneficial to them. It may also be appropriate to notify the police cases where there is an immediate threat to public safety or high risk – for example, drivers with a history of reckless driving, crashes or intentions to cause harm involving motor vehicles. Refer to Part A section 3.3.1. Confidentiality, privacy and reporting to the driver licensing authority and Appendix 3.2. Legislation relating to reporting by health professionals.

The mental state examination can be usefully applied in identifying the following areas of impairment that may affect fitness to drive:

• Appearance. Appearance is suggestive of general functioning (e.g. attention to personal hygiene, grooming, sedation, indications of substance use).
• Attitude. This may, for example, be described as cooperative, uncooperative, hostile, guarded or suspicious. While subjective, it helps to evaluate the quality of information gained in the rest of the assessment and may reflect personality attributes.
• Behaviour. This may include observation of specific behaviours or general functioning including ability to function in normal work and social environments.
• Mood and affect. This includes elevated mood (increase in risk taking) and low mood (suicidal ideation, particularly if past attempts, current ideation or future plans involve driving vehicles). Suicide involving motor vehicles is relatively common.
• Thought form, stream and content. This relates to the logic, quantity, flow and subject of thoughts that may be affected by mania, depression, schizophrenia or dementia. Delusions with specific related content may have an impact on driving ability.
• Perception. This relates to the presence of disturbances, such as hallucinations, that may interfere with attention or concentration, or may influence behaviour.
• Cognition. This relates to alertness, orientation, attention, memory, visuospatial functioning, language functions and executive functions. Evidence from formal testing, screening tests and observations related to adaptive functioning may be sought to determine if a psychiatric disorder is associated with deficits in these areas that are relevant to driving.
• Insight. Insight relates to self-awareness of the effects of the condition on behaviour and thinking. Assessment requires an exploration of the person’s awareness of the nature and impacts of their condition and has major implications for management.
• Judgement. The person’s ability to make sound and responsible decisions has obvious implications for road safety. As judgement may vary, it should not be assessed in a single consultation.

The effects of prescribed medication should also be considered for the individual including:

• how medication may help to control or overcome aspects of the condition that may affect driving safety
• what medication side effects may affect driving ability including risk of sedation, impaired reaction time, impaired motor skills, blurred vision, hypotension and dizziness.

Alternative treatments including ‘talking therapies’ may be useful as an alternative or supplement to medication and lessen the risk of medication affecting driving. The health professional could advise non-driving periods to allow time for the patient to adjust to medication and for the health professional to evaluate the patient’s response and their adherence to treatments. Refer to Part A section 2.2.9. Drugs and driving for further guidance to consider the effects of prescribed medication when performing an assessment.

People with a psychiatric condition and substance misuse (section 9. Substance misuse) or chronic pain (section 5. Musculoskeletal conditions) comorbidities may be at higher risk and warrant careful consideration.

The assessment should identify the potential relevance of:

• problematic alcohol consumption
• use of illicit substances
• chronic pain
• prescription drug abuse (e.g. increased use of benzodiazepines, sedatives or painkillers).

The presence or absence of insight has implications for management.

• The person with insight may recognise when they are unwell and self-limit their driving.
• Limited insight may be associated with reduced awareness or deficits and may result in markedly impaired judgement or self-appraisal.
• The person might exhibit significantly impaired insight and appear unwilling to accept advice about restricting their driving.

A person suffering an acute episode of mental illness (e.g. psychosis, moderate–severe depression or mania) may pose a significant risk. The health professional should advise a person in this situation not to drive until their condition has stabilised and a decision can be made about their future licence status. This is particularly relevant to commercial vehicle drivers.

A person with a severe chronic or relapsing psychiatric condition needs to be assessed for the effect of the illness on impairment and the skills needed to drive and the impairments that may arise. This may include a clinical assessment (e.g. neuropsychological) and may also include an on-road driving assessment (refer to Part A section 2.3.1. Practical driver assessments).

Some transient episodes of apparently impaired consciousness, awareness or motor control resemble epileptic seizures or syncope, yet have a psychological cause. These episodes are usually termed psychogenic nonepileptic seizures (PNES), although they are sometimes known as dissociative, functional or pseudoseizures. Most patients diagnosed with PNES self-report loss of responsiveness or loss of awareness that may place them at an increased risk of causing a motor vehicle accident.^{8, 9}

The safety risk is sufficiently low after a three- month period, with no further psychogenic seizures, to allow a return to driving. People with active PNES should generally not be allowed to drive if they lose awareness or responsiveness with their psychogenic seizures, have a history of seizure related injuries, or if the semiology suggests that ability to drive would be impaired during a psychogenic seizure.

People with active PNES may be considered for driving under the private standards after 12 months if PNES only occurs when the person could not be driving or after exposure to specific triggers that cannot be encountered when driving. This must be well established without exceptions and corroborated by reliable witnesses.

Diagnosis of PNES must establish that such episodes are psychogenic only. This may require recording an episode with video or video-EEG. Approximately 20 per cent of people with PNES have a history of epilepsy. In such patients, it is important to distinguish between the two types of attack and to establish whether an epileptic seizure has occurred. The seizure and epilepsy standards may apply in these cases (refer to section 6.2. Seizures and epilepsy). If there is uncertainty regarding the type of attack, the blackouts of uncertain mechanism (refer to section 1. Blackouts) standards may apply. If more than one standard applies, the longer non- driving period prevails.

It is good medical practice for any person with initial PNES to be referred to a specialist, where available, for accurate diagnosis so that appropriate treatment is instituted and all the risks associated with PNES, including driving, can be explained.

With regard to licensing, the treating doctor/ general practitioner may liaise with the driver licensing authority about whether the criteria are met for driving a private vehicle, but only a specialist may do so for a commercial vehicle driver.

Some people with a personality disorder may display aggressive, irresponsible or erratic behaviour and could benefit from psychiatric interventions. Their licence status may also need to be managed through administrative, police or legal channels.

Post-traumatic stress disorder may arise following motor vehicle crashes. Return to safe, competent driving may be assisted by therapy such as cognitive behaviour therapy and by driving rehabilitation courses.

Specialist advice may need to be sought for drivers who have a psychiatric condition not covered here.

Where a psychiatric condition is associated with epilepsy or illicit drug use, the relevant section should also be referenced.