Section 6: Psychiatric Diseases

1. Affective disorders

  1. Depression
  2. Bipolar disorder

2. Anxiety disorders

3. Psychotic illness

  1. Acute episodes
  2. Chronic illness

4. Personality disorders

5. Substance abuse

6. Attention deficit disorder (ADD)/attention deficit hyperactivity disorder (ADHD)

7. Tourette’s syndrome

Patients should not drive while they are in the acute phase of a psychiatric illness. In general, driving may resume once the condition is stable, although side effects from medications and compliance with the medication regimen may need to be taken into consideration. (For recommendations on medications and driving, see Section 5.)

Psychiatrists may wish to consult the American Psychiatric Association’s Position Statement on the Role of Psychiatrists in Assessing Driving Ability.29


Section 6: Psychiatric Diseases


Affective disorders

Physicians should advise the patient not to drive during the acute phase of illness. Physicians should also be aware that certain medications used in the treatment of affective disorders have the potential to impair driving performance. (See Section 5 for more information on medication side effects.)

Depression

No restrictions if the condition is mild and stable. The physician should always specifically ask about suicidal ideation and cognitive and motor symptoms. Patients should not drive if they are actively suicidal or experiencing significant mental or physical slowness, agitation, and/or impaired concentration. Patients who seek care for these conditions should be counseled not to drive themselves to the clinic or hospital.

Bipolar disorder
No restrictions if the condition is stable. Patients should not drive if they are actively suicidal or in an acute phase of mania. Patients who seek care for these conditions should be counseled not to drive themselves to the clinic or hospital.

Anxiety disorders Patients should not drive during acute episodes of anxiety. Otherwise, there are no restrictions if the condition is stable.

Physicians should also be aware that certain medications used in the treatment of anxiety disorders have the potential to impair driving performance. (See Section 5 for more information on medication side effects.)

Psychotic illness Physicians should advise the patient not to drive during the acute phase(s) of illness. Physicians should also be aware that medications used in the treatment of psychotic illness have the potential to impair driving performance. (See Section 5 for more information on medication side effects.)

Acute episodes
Patients should not drive during acute episodes of psychosis. Patients who seek care for acute psychosis should be counseled not to drive themselves to the clinic or hospital.

Chronic illness
No restrictions if the condition is stable and there are no other factors (eg, medication side effects) that can affect driving performance.

Personality disorders No restrictions unless the patient has a history of driving violations and his/her psychiatric review is unfavorable. This includes—but is not limited to—uncontrolled erratic, violent, aggressive, or irresponsible behavior.

Due to the high co-morbidity of substance abuse with personality disorders, physicians are urged to be alert to substance abuse in these patients and counsel them accordingly. (See recommendations for substance abuse below.)

Substance abuse Driving while intoxicated is not only highly dangerous to the driver, passengers, and other road users, but it is also illegal. Drunk driving is the most common crime in the United States, and it is responsible for thousands of traffic deaths each year.

Alcohol is not the only cause of intoxicated driving. Substances including, but not limited to, marijuana, cocaine, amphetamines (including amphetamine analogs), opiates, and benzodiazepenes may also impair driving skills. Physicians should always screen for alcohol and other drug abuse as part of the routine medical history. Questionnaires such as CAGE,30 MAST, 31 TWEAK,32 and AUDIT33, 34 are useful in screening for alcohol abuse, and such questionnaires may be adapted to screen for other substance abuse.

Physicians should follow up all positive screens with appropriate interventions, including brief interventions or referral to support groups, counseling, and substance abuse treatment centers. Physicians should strongly urge substance abusers to temporarily cease driving while they seek treatment, and to refrain from driving while under the influence of intoxicating substances. A nonjudgmental and supportive attitude and frequent follow-up may aid substance abusers in their efforts to achieve and maintain sobriety.

Physicians should also familiarize themselves with any state laws holding them responsible for detaining intoxicated patients who have driven to the hospital or clinic until they are legally unimpaired.

Attention deficit disorder (ADD)/ attention deficit hyperactivity disorder (ADHD) Adolescent drivers have a high rate of driving offenses, and adolescent drivers with attentional difficulties have even higher rates of crashes, traffic violations, and drinking and driving. Given these findings, physicians are advised to counsel adolescents with ADD/ADHD to take care when driving, and strongly caution them against drinking and driving.35-37 In addition, physicians should be aware that a comorbid learning disability may interfere with the patient’s ability to learn how to drive. For patients with a learning disability, referral to a driver rehabilitation specialist or driver education specialist for one-on-one instruction is highly recommended.

For recommendations regarding the medications used to treat this disorder, see Section 5.

Tourette’s syndrome See Section 4.


29 American Psychiatric Association. Position statement on the role of psychiatrists in assessing driving ability. Approved by the Board of Trustees, December 1993. Available at: http://www.psych.org/pract_of_psych/driving_p state.cfm. Accessed January 9, 2003.

30 Mayfield D, McLeod G, Hall P. The CAGE questionnaire: Validation of a new alcoholism instrument. American Journal of Psychiatry. 1974;131:1121-1123.

31 Selzer ML. The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry. 1971;127:1653-1658.

32 Russell M, Martier SS, Sokol RJ, Jacobson S, Jacobson J, Bottoms S. Screening for pregnancy risk drinking: TWEAKING the tests. Alcoholism: Clinical and Experimental Research. 1991;15(2):638.

33 Babor TF, de la Fuente JR, Saunders JB, Grant M. AUDIT: The alcohol use disorders identification test: Guidelines for use in primary health care. Geneva, Switzerland: World Health Organization; 1992.

34 Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Development of the alcohol use disorders screening test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption. II. Addiction. 1993;88:791-804.

35 Nada-Raja S, Langley JD, McGee R, Williams SM, Begg DJ, Reeder AI. Inattentive and hyperactive behaviors and driving offenses in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry. 1997;36(4):515-522.

36 Barkley RA, Guevremont DC, Anastopoulos AD, DuPaul GJ, Shelton TL. Driving-related risks and outcomes of attention deficit hyperactivity disorder in adolescents and young adults: A 3-5 year follow-up survey. Pediatrics. 1993;92:212-218.

37 Woodward LJ, Fergusson DM, Horwood LJ. Driving outcomes of young people with attentional difficulties in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry. 2000;39(5):627-634.


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