Download Driving and Mental Health

Formulary and Clinical Guideline Document
Pharmacy Department Medicines Management Services
DRIVING AND MENTAL HEALTH CONDITIONS AND TREATMENTS
General information
Driving while impaired by a physical or mental health condition or the influence of drugs
can seriously impact on safe control of a vehicle and increase the risk of accidents.
Mental disorders can affect judgement, concentration and reaction times.
Pharmacological treatments can reduce the driving-related risks associated with mental
disorders; however, they can also impair driving skills due to the side-effect profile.
Drugs can impair driving performance as a consequence of adverse effects such as
drowsiness, poor coordination, impaired or slowed thinking, dizziness, or visual problems
Alcohol, even in small amounts, will significantly potentiate the effects of medication on
the central nervous system impairing safe driving
It is an offence to drive or attempt to drive whilst unfit to do so due to alcohol and/or
drugs, whether illegal drugs or legally prescribed medicines.
All drugs that act on the central nervous system can impair alertness, concentration and
driving performance. This is particularly so at initiation of treatment and when the dose is
increased or if another drug is added that could also impair driving ability. Driving must
be avoided if adversely affected
From March 2015, it is now an offence to drive with certain specified controlled drugs
above specified limits in the blood. These include illegal drugs and medicines.
Some medical conditions can affect a person’s fitness to drive and in some cases need
to be notified to the Driver and Vehicle Licensing Agency DVLA.
Drivers with psychiatric illnesses are usually safer when well and on regular psychotropic
medication than when they are ill. However, inadequate treatment or lack of compliance
may render the driver impaired by both illness and medication.
Notification to the DVLA
Doctors and other healthcare professionals should: advise individual drivers of the
impact of their condition on fitness to drive; advise the individual on their legal
requirement to notify the DVLA; treat, manage and monitor the individual’s condition with
on-going consideration of the impact on driving.
Health professionals prescribing or dispensing medication should consider the risk
associated with that medicine or combination of medicines, and driving and take the
opportunity to appropriately advise their patients.
It is the duty of the license holder or license applicant to notify DVLA of any illness, injury
or medication, which may affect safe driving and comply with any requirements indicated
by the DVLA including any periodic medical reviews. They should also adhere, with
ongoing consideration of fitness to drive, to prescribed medical treatment, and to monitor
and manage the condition and any adaptations.
On occasions however, there are circumstances in which the license holder cannot, or
will not notify the DVLA. In such cases, it may be necessary for the healthcare
professional to contact the DVLA if there is concern for road safety for the benefit of the
individual and the wider public.
Medico-legal implications make it necessary for doctors and psychiatrists to be aware of
the GMC guidance and also advice of the Royal College of Psychiatrists.
http://www.gmc-uk.org/guidance/ethical_guidance/30117.asp
http://www.rcpsych.ac.uk/
Mersey Care Formulary and Clinical Guideline Document
Driving and Mental Health Conditions and Treatments
Prepared:
January 2017
Next Review
June 2017
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Medical conditions, medication and driving
Driving is a complex information –processing task which can be divided in 3 steps:
perception (detection and identification), decision and reaction which may be affected by
mental health disorders due to :
o Poor cognition – reduced attention, memory problems
o Impaired motor function – slower reaction times, loss of coordination
o Altered thoughts and behaviours, impaired judgement including ability to
predict and anticipate
o Emotional states eg agitation, irritation, depression have a detrimental
influence on perception and information processing
Anyone with a medical condition likely to cause a sudden disabling event at the wheel, or
who is unable to control their vehicle safely for any other reason, must not drive.
Medical conditions such as diabetes mellitus, cardiac disorders, epilepsy, visual
impairments and renal and respiratory conditions are subject to DVLA rules for fitness to
drive.
The rules relating to mental health conditions and alcohol or substance misuse and
dependence are summarised in the tables below. If psychiatric illness has been
associated with substance misuse, continued misuse contraindicates driving and
licensing.
The latest guidance is always available at:
https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-formedical-professionals
Medication can improve driving performance in individuals with well-controlled conditions
but side effects must be considered. Effects of medication that can impair driving ability
include:
o Sedation and dizziness
o Concentration difficulties
o Postural hypotension
o Blurred vision
o Impaired coordination
o Extrapyramidal adverse effects, eg muscle stiffness
Drivers taking prescribed drugs subject to the drug-driving legislation will need to be
advised to carry confirmation that these were prescribed by a registered medical
practitioner.
Licence holders are legally required to notify the DVLA of any injury or illness that would
have a likely impact on safe driving ability.
By law, driving licences are classified into Group 1 (motorcycles and cars) and Group 2
(heavy goods vehicles and passenger vehicles). The rules that apply may be different
depending on the group involved.
Relevant guidelines
Assessing fitness to drive: a guide for medical professionals:
https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-formedical-professionals
GMC guidance from www.gmc-uk.org
Royal College of Psychiatrists guidance from https://www.rcpsych.ac.uk/
Mersey Care Formulary and Clinical Guideline Document
Driving and Mental Health Conditions and Treatments
Prepared:
Review
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June 2017
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Mental Health Condition and Fitness to Drive
ADHD
Notes
May be able to drive but must notify the DVLA
Licensing may continue provided no factors that render driving dangerous
Consider factors such as impulsivity, lack of awareness of the impact of own behaviours on self or others need.
Anxiety disorders
Notes
Poor concentration and attention may impair driving. Other symptoms that may affect driving include suicidal
ideation.
Notify the DVLA only if severe with significant memory and concentration problems, agitation, behavioural
disturbance or suicidal thoughts
Relicensing will depend on the outcome of the DVLA enquiry
Group 2 driver should have recovered and be stable for a period of six months before resuming driving.
Bipolar affective disorder:
Notes
Several symptoms of this disorder may affect driving: suicidal ideation, impaired judgment with over confidence
and risk-taking behaviour, poor concentration and attention, etc.
Must notify the DVLA and driving must cease
Relicensing may be considered if all DVLA conditions met
There must be no driving during any acute illness
Mersey Care Formulary and Clinical Guideline Document
Driving and Mental Health Conditions and Treatments
Prepared:
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Mental Health Condition and Fitness to Drive - continued
Depression:
Notes
The cognitive impairment caused by severe depression can be important and involves all cognitive abilities
including slowing of reaction time. Other symptoms that may affect driving include suicidal ideation
In non-complicated, minor or short-lived depressive episodes without significant memory problems, concentration
difficulties, agitation, behavioural disturbance or suicidal thoughts, the DVLA need not be notified and driving may
continue. However, the effects of medication should be considered.
Where there are moderate to severe symptoms of depression: notify the DVLA and stop driving pending the
outcome. Driving may only resume following a period of stability of six months for group 2 drivers.
Patients should not drive during a course of ECT.
Dementias
Notes
Mild Cognitive Impairment
May drive and need not notify the DVLA – but see note below.
Notification to the DVLA of mild cognitive impairment is not required unless there are objective indicators of
possible driving impairments or a diagnosis of mild dementia, in which case driving must cease pending
individual DVLA enquiry.
Dementia
It is difficult to assess driving ability in people with dementia. Progressive deterioration in memory, reactions and
perception will interfere with driving skills
Notify the DVLA.
Depending on the outcome of enquiry, Group 1 drivers may be able to drive but must notify the DVLA.
Group 2 drivers must not drive and must notify the DVLA. Licensing will be refused or revoked.
Regular formal driving assessments may be necessary
Mersey Care Formulary and Clinical Guideline Document
Driving and Mental Health Conditions and Treatments
Prepared:
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Mental Health Condition and Fitness to Drive- continued
Neurological Disorders
Notes
Epilepsy/Seizures
Epileptic seizures are the most common medical cause of collapse at the wheel.
Must not drive and must notify
Depending on the circumstances and outcome of DVLA medical enquiry, driving may resume following a period
of stability. See DVLA.
Must not drive and must notify and await DVLA decision.
Licensing will be refused or revoked if there is serious disturbance – for example, violent behaviour or alcohol
abuse likely to be a source of danger at the wheel
Post Head Injury
Learning disabilities
Notes
Mild learning disability
Notify DVLA
In mild learning disability, provided there are no other relevant problems, it may be possible to hold a driving
licence, but it will be necessary to demonstrate adequate functional ability at the wheel.
There should not be any comorbid mental or physical illness affecting driving ability.
Severe learning disability
Notify the DVLA and must not drive
Severe learning disability is not compatible with driving and licensing will be refuse.
Autism, Asperger’s syndrome
May be able to drive but must notify
Patients with a diagnosis of autism, Asperger’s syndrome may be permitted to drive provided they do not suffer
from factors that render driving dangerous.
Personality disorders
Aggressive and impulsive behaviour may affect driving. Other traits exhibited in these disorder will also interfere
eg intolerance or frustration
Group 1 drivers may be able to drive but must notify the DVLA and await outcome.
Group 2 drivers must not drive and must notify the DVLA and await outcome.
Licences will be revoked or refused for patients who suffer from personality disorders with marked impulsivity, as
this may affect driving
Mersey Care Formulary and Clinical Guideline Document
Driving and Mental Health Conditions and Treatments
Prepared:
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June 2017
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Mental Health Condition and Fitness to Drive - continued
Psychosis and Schizophrenia
Notes
Several symptoms of this disorder may affect driving: suicidal ideation, impaired concentration and memory,
impaired judgment, delusions, hallucinations, confused thinking, agitated behaviour, etc.
Must notify the DVLA. Driving should cease during any acute illness and will only be considered if all DVLA
conditions are met. Group 2 will require a period of wellness and stability before relicensing.
Drivers with a history of instability or relapse and/or poor engagement with treatment will be required not to drive
for a longer period before any relicensing.
Substance Misuse
Alcohol
Alcohol can affect a driver’s behaviour and body in all sorts of dangerous and unpredictable ways. Driving while
on the influence of alcohol substances will lead to licence refusal or revocation.
Persistent harmful alcohol misuse - Must not drive and must notify the DVLA.
A Group 2 licence will only be issued after a stable period of at least one year of abstinence or controlled drinking
and at least six months for Group 1 drivers.
Alcohol dependence-- Must not drive and must notify the DVLA.
A diagnosis of alcohol dependence would normally result in the licence being revoked or refused until a one-year
alcohol-free period has been achieved for Group 1 drivers and a three-year period for Group 2 drivers.
People with alcohol related disorders like cirrhosis with neuropsychiatric impairment or alcohol-induced psychosis
may not drive until recovery is demonstrated satisfactorily.
Alcohol related solitary seizure - Must not drive and must notify the DVLA. (If more than 1 seizure, as for
epilepsy)License will be refused or revoked for a minimum of six months from the date of the seizure in Group 1
drivers and five years for Group 2 drivers. The stricter epilepsy regulations will apply if there has been more than
one seizure.
Mersey Care Formulary and Clinical Guideline Document
Driving and Mental Health Conditions and Treatments
Prepared:
Review
January 2017
June 2017
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Mental Health Condition and Fitness to Drive - continued
Substance Misuse
Drug misuse
Must not drive and must notify the DVLA with persistent misuse or dependence.
Persistent harmful use of cannabis, amphetamines, ecstasy (MDMA), ketamine, LSD and other hallucinogens will
lead to licence refusal or revocation until a minimum six-month period of abstinence has been attained in Group 1
drivers and a minimum one-year period in Group 2 drivers. There are different rules for ketamine.
Drug dependence
heroin
morphine
methadone
cocaine
methamphetamine
Must not drive and must notify the DVLA with persistent misuse or dependence.
Persistent misuse of or dependence on opiates will lead to licence refusal or revocation until a minimum one-year
period of abstinence in Group 1 drivers and at least three years in Group 2 drivers.
Full compliance with an oral methadone maintenance programme supervised by a consultant specialist may
allow licensing subject to favourable assessment and, usually, annual medical review. Similar criteria may apply
for an oral buprenorphine programme. There should be no evidence of continued use of other substances,
including cannabis.
Drug-induced solitary seizure: Must not drive and must notify the DVLA.
Licence will be refused or revoked for a minimum of 6 months after the seizure for group 1 and 5 years for group
2 drivers.
Benzodiazepines: If a person misuses benzodiazepines or has been prescribed supra-therapeutic doses, a
Group 1 licence will be revoked for a period of one year and a Group 2 licence for three years.
The prescribed use of these drugs at the therapeutic doses listed in the BNF, without evidence of impairment,
does not amount to misuse or dependence for licensing purposes.
Mersey Care Formulary and Clinical Guideline Document
Driving and Mental Health Conditions and Treatments
Prepared:
Review
January 2017
June 2017
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Psychotropic medication and Fitness to Drive
Antipsychotics:
Notes
Antipsychotics
They may cause varying levels of motor and extrapyramidal adverse effects, sedation and poor
concentration. In susceptible individuals, drugs with antimuscarinic may potentially precipitate or worsen
glaucoma, blurred vision and mydriasis. Epileptogenic effects should be considered.
Pronounced sedative effects and moderate antimuscarinic and extrapyramidal side-effects. They may
cause hypotension and blurred vision.
Chlorpromazine,
levomepromazine, and
promazine
Pericyazine and pipotiazine
Fluphenazine, perphenazine,
prochlorperazine, and
trifluoperazine
Haloperidol
Flupentixol and
zuclopentixol
Pimozide and sulpiride
Clozapine
Quetiapine
Olanzapine
Risperidone
Antidepressants
Tricyclic antidepressants
Moderate sedative effects and extrapyramidal side-effects
Low sedative and antimuscarinic effects, high incidence of extrapyramidal side-effects
Low sedative and antimuscarinic effects, high incidence of extrapyramidal side-effects
Moderate sedative, antimuscarinic effects, and extrapyramidal effects
Reduced sedative, antimuscarinic, and extrapyramidal effects.
Hypotension and sedation. Antimuscarinic effects
Hypotension and sedation
Causes sedation and dizziness
Minor or moderate influence on the ability to drive and use machines due to potential nervous system and
visual effects
Notes
Have pronounced anticholinergic and antihistaminic effects. They may cause varying levels of sedation,
concentration difficulties and postural hypotension. These symptoms may impair psychomotor skills and
therefore driving.
In susceptible individuals, drugs with antimuscarinic may potentially precipitate or worsen glaucoma,
blurred vision and mydriasis
Mersey Care Formulary and Clinical Guideline Document
Driving and Mental Health Conditions and Treatments
Prepared:
Review
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Psychotropic medication and Fitness to Drive (continued)
Trazodone
Mirtazapine
MAOI
SSRIs, venlafaxine,
duloxetine
ECT
Mood Stabilisers:
It has sedating properties, it can also cause confusional states and blurred vision
Has sedating properties that may affect driving by reducing concentration and alertness
Small or no effect on orthostatic hypotension, sedation or psychomotor impairment but like with any
psychoactive medicinal product patients should still be cautioned about their ability to drive or operate
hazardous machinery.
Small or no effect on orthostatic hypotension, sedation or psychomotor impairment but like with any
psychoactive medicinal product patients should still be cautioned about their ability to drive or operate
hazardous machinery.
Consider effects from the ECT treatment itself, from the anaesthesia and from the underlying condition.
Driving must stop during an acute course of treatment with ECT and is not permitted until the relevant
medical standards and observation periods associated with underlying conditions have been met
Notes
Lithium
Lithium slows reaction time and may cause dizziness, memory problems, impaired consciousness and
extrapyramidal disorders
Antiepileptic drugs
They may produce CNS-related adverse effects, including dizziness, drowsiness and ataxia. Antiepileptic
drugs have been associated with visual effects such as diplopia, blurred vision and impaired eye
accommodation.
Antidementia medication:
Notes
Rivastigmine
It may induce syncope or delirium.
Donepezil
It can induce fatigue, dizziness and muscle cramps
Galantamine
Others
It can cause dizziness and somnolence
Notes
Benzodiazepines
Benzodiazepines are the psychotropic medication most likely to impair driving performance. The effects
are particularly severe with the long-acting compounds such as diazepam.
Subjected to drug screening driving excess limits from 2015.
Mersey Care Formulary and Clinical Guideline Document
Driving and Mental Health Conditions and Treatments
Prepared:
Review
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Psychotropic medication and Fitness to Drive (continued)
Opioid analgesics
Opioids may reduce cognitive performance especially at the start of treatment; cause sedation and affect
the driving ability by causing impaired coordination, slow reflexes and miosis and blurred vision. Subject to
drug screening driving excess limits from 2015.
Methadone
Notify the DVLA. Driving may be allowed while taking methadone, only after regular assessment which will
include urine screen for drugs. Subject to drug screening driving excess limits from 2015.
Buprenorphine
Notify the DVLA. Driving may be allowed while taking buprenorphine, only after regular assessment which
will include urine screen for drugs.
Zopiclone, zolpidem,
zaleplon
They may have residual effects the next day which include sedation, amnesia, impaired concentration and
impaired muscular function which may adversely affect the ability to drive. Patient should be advised not to
drive if affected.
ADHD medication
They may have a variety of adverse effects that may impair driving including: dizziness, drowsiness and
visual disturbances including difficulties with accommodation, diplopia and blurred vision.
Bupropion
Bupropion may impair performance of skilled tasks (e.g. driving)
Varenicline
Varenicline may have minor or moderate influence on the ability to drive and use machines. It may cause
dizziness and somnolence and therefore may influence the ability to drive and use machines. Patients are
advised not to drive, operate complex machinery or engage in other potentially hazardous activities until it
is known whether this medicinal product affects their ability to perform these activities.
Mersey Care Formulary and Clinical Guideline Document
Driving and Mental Health Conditions and Treatments
Prepared:
Review
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June 2017
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References
Assessing fitness to drive: a guide for medical professionals: https://www.gov.uk/government/publications/assessing-fitness-to-drive-aguide-for-medical-professionals
Driver and Vehicle Licensing Agency (DVLA). https://www.gov.uk/government/organisations/driver-and-vehicle-licensing-agency
Drugs and driving: the law. https://www.gov.uk/drug-driving-law
GMC guidelines at www.gmc-uk.org
Royal College of Psychiatrists https://www.rcpsych.ac.uk/
SPCs for all the drugs referred to in this guideline can be found in the Electronic Medicines Compendium (http://emc.medicines.org.uk/)
Mersey Care Formulary and Clinical Guideline Document
Driving and Mental Health Conditions and Treatments
Prepared:
Review
January 2017
June 2017
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