Patients' Fitness to Drive a Growing Issue for Psychiatrists

Megan Brooks

May 05, 2012

May 5, 2012 (Philadelphia, Pennsylvania) — Determining when it is time for a patient to stop driving and hand over the keys is a growing issue for psychiatrists.

A poster presented here at the American Psychiatric Association's 2012 Annual Meeting highlights the fact that psychiatrists are "increasingly" faced with patients whose driving ability may be impaired by excessive daytime sleepiness due to primary sleep disorders or to sleep disturbance associated with medical and psychiatric illness, such as dementia, epilepsy, or substance abuse.

Lead author Christine Marchionni, MD, psychosomatic medicine fellow in the Department of Psychiatry and Human Behavior at the Thomas Jefferson University in Philadelphia told Medscape Medical News that psychopharmacologic interventions for psychiatric illness may also reduce a person's driving ability and that drowsy driving is associated with fatality rates and injury severity on par with that of alcohol-related crashes.

In addition, patients with dementia are 3 to 5 times more likely to be involved in a motor vehicle accident than age-matched control individuals, and epilepsy is one of the most frequently implicated medical causes for motor vehicle accidents.

"There isn't a whole lot of guidance" on the psychiatrist's role and responsibility in assessing fitness to drive, Dr. Marchionni said, "and it's an issue that we see every day in practice."

"It comes up more and more in the aging population," she added. "If you suspect dementia or some sort of cognitive impairment, how do you address that in terms of the patient's driving ability, and really, legally, what is our responsibility as clinicians in this regard?"

In some states, mandatory-reporting laws require physicians to report persons with disorders that may make driving hazardous, such as epilepsy.

Currently, 6 states — California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania — have such laws, though each state's approach differs in terms of disorders covered, legal protections for physicians, and administrative requirements.

Potential Legal Liability

Typically, in states with mandatory-reporting laws, the physician notifies the state's Department of Motor Vehicles (DMV) of the person's name, age, and address. The DMV then determines whether driving privileges should be suspended or revoked.

"In other states [without mandatory-reporting laws], it is questionable if you absolutely need to, but it is suggested," Dr. Marchionni said.

She also noted that shift workers or people who work long or uneven hours and those with sleep apnea or narcolepsy may also be unsafe drivers.

"If you do suspect that someone has either fallen asleep at the wheel or could doze off at the wheel, you need to document that you asked appropriate questions and counsel them appropriately," Dr. Marchionni said.

She advises "talking with your hospital's legal department to find out what your liability is."

"There are objective tests that show how severe a patient's daytime sleepiness is. However, the tests we have aren't cut and dry; they are basically guidelines that tell you whether a person has an impairment that might impact their ability to drive, but there is no specific number or threshold that, once reached, you should take away the keys," said Dr. Marchionni.

"It's always better if physicians are proactive. Sometimes family will bring up the concern about driving, but people may be reluctant to come out and say they can no longer drive, and there is always a concern that symptoms are being minimized, so clinical judgment is important. It's always safer to report if you think someone is at risk to themselves or others," she added.

Assessing fitness to drive may be different, depending on which disease you're dealing with, Dr. Marchionni noted.

"With dementia, cognitive testing to see how bad their dementia is may be appropriate. You can get occupational therapy involved to see how slow their reaction times are or how impaired their visual acuity is. Counseling the family on what to do is also important."

Dr. Marchionni has disclosed no relevant financial relationships.

The American Psychiatric Association's 2012 Annual Meeting. Abstract NR2-03. Presented May 5, 2012.