April 2023"Systematic Review: A Systematic Review of the Risks of Motor Vehicle Crashes Associated with

A Systematic Review of the Risks of Motor Vehicle Crashes Associated with Psychiatric DisordersUne revue systématique des risques d’accidents de véhicules automobiles associés à des troubles psychiatriquesMark J. Rapoport, MD^1,2, Justin Nathaniel Chee, PhD³, Thadshagini Prabha, BSc³

, Jamie Dow, MD⁴, Ian Gillespie, MD⁵

, Sjaan Koppel, PhD⁶, Judith L. Charlton, PhD⁶,DesmondO’Neill, MD⁷, Paul C. Donaghy, PhD⁸, Angela Onkay Ho, MD²

, John-Paul Taylor, PhD⁸ and Mark Tant, PhD⁹img1

The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie2023, Vol. 68(4) 221‐240 © The Author(s) 2022 img4

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DOI: 10.1177/07067437221128468
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AbstractObjective: 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.Objectif : Les troubles psychiatriques et leurs traitements ont le potentiel d’avoir un effet adverse sur les compétences au volant. Toutefois, la mesure dans laquelle ceci pose un risque de santé publique, en accroissant le risque d’accidents de véhicules automobiles (AVA). n’est pas claire. Le but de la présente revue systématique était de synthétiser et d’évaluer d’un œil critique les données probantes sur le risque d’AVA pour les conducteurs souffrant de troubles psychiatriques.Méthode : Nous avons mené une revue systématique du risque d’AVA associé aux troubles psychiatriques à l’aide de sept bases de données en novembre 2019. Deux réviseurs ont examiné chaque étude et les données extraites. Les outils d’évaluation de la qualité de l’Institut national du cœur, des poumons et du sang ont servi à évaluer la qualité des données probantes de chaque étude.Résultats : Nous avons identifié 24 études qui satisfaisaient aux critères d’inclusion, notamment huit cohortes, dix castémoins, et six méthodes transversales. Les cotes d’évaluation de la qualité étaient « bonnes » pour quatre études, « équitables » pour dix, et « mauvaises » pour dix. L’auto-rapport ou des questionnaires ont été utilisés au lieu de mesures objectives de soit l’AVA ou le trouble psychiatrique, ou les deux dans 12 études, et seulement sept s’ajustaient à l’exposition à la conduite. Quinze études ont rapporté un risque accru d’AVA associé aux troubles psychiatriques, et neuf n’ont rien rapporté. Il n’y avait pas de catégorie de trouble associé de façon constante à un risque accru d’AVA.Conclusion : Les données probantes disponibles sont mixtes, non d’une grande qualité et ne soutiennent pas une restriction globale sur les conducteurs souffrant de troubles psychiatriques. Une approche individualisée, telle que recommandée par les guides internationaux, devrait se poursuivre. D’autres recherches devraient inclure les évaluations objectives des troubles psychiatriques et du risque d’AVA et ajuster pour l’exposition à la conduite.Keywords
psychiatric disorders, mental disorders, mood and anxiety disorders, fitness to drive, motor vehicle crashesIntroductionPsychiatric disorders encompass a wide range of conditions, as characterized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).¹ Lifetime prevalence of psychiatric disorders has been estimated as high as 46% in the United States,² and 25% in Europe,³ with one year prevalence of 20% in Canada⁴ and 17% in the United Kingdom.⁵ Previous reviews suggest that drivers with psychiatric disorders are at a higher risk of motor vehicle crashes (MVCs), albeit with limited and conflicting evidence.^6–10 Two of the reviews used the Newcastle Ottawa Scale to assess study quality^8,9 but did not report actually study quality of the identified studies. Two other reviews assessed study quality but only identified four studies each pertaining to MVC risk.^6,10 The final review, published 15 years ago, identified seven studies pertaining to MVC risk but did not assess study quality.⁷ Since driving is often an essential aspect of quality of life and for maintaining social ties, for people with and without psychiatric disorders, it is imperative for clinicians and policy-makers to be able to weigh the risks and benefits of driving before issuing restrictive guidelines.Some experimental studies have shown individuals with psychiatric disorders to have slower reaction time and increased lane position deviation on driving tasks.^11–14 However, given the high prevalence of psychiatric disorders, it is important to know whether these skills-based differences and clinical features translate to an increased MVC risk.The aim of this systematic review was to synthesize and critically appraise evidence on the risk of MVC for drivers with psychiatric disorders.MethodsThe systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). We conducted a systematic review of primary research pertaining to MVC risk with psychiatric disorders (including mood disorders, anxiety disorders, psychotic disorders, personality disorders, and combined “mental disorders”). For this review, MVC risk was assessed by the frequency of crashes involving motor vehicles for drivers with psychiatric disorder as identified by official crash records, self-reported data or MVCs occurring on on-road driving tests. We included: original research, published in English in a peer-reviewed journal which were available in full-text, and which specifically reported on MVC risk for drivers with a psychiatric disorder and a comparison group without psychiatric disorder (for cohort studies), and psychiatric disorders in groups of drivers with MVC compared with drivers without MVC (for case-control studies). Cross-sectional studies examined the association between MVC and psychiatric disorder. Studies aiming at assessing psychiatric disorder resulting from MVC were excluded. Although Attention Deficit Hyperactivity Disorder (ADHD) and dementia are potentially important risk factors for MVC, we did not include them within the current review because of our recent publication of MVC risk in dementia,¹⁵ and recent good-quality reviews of ADHD and MVC risk.^16,17 Studies of the effects of psychotropic medications that did not include groups of cases with a psychiatric disorder and controls without a psychiatric disorder were excluded. Other excluded study designs are described in online Supplementary Material 1. The synthesis strategy was registered on Prospero.¹⁸Seven electronic database searches were conducted between November 13 and 15, 2019 using Cochrane Library, Medline, PsycINFO, EMBASE, CINAHL, TRANSPORT, and TRID to identify studies from the first available year until the search date (Supplementary Material 2). No time limits were applied. A set of “goldset” studies (those known to the authors) was identified to ensure that our search strategy incorporated them, validating the strategy.After duplicates were removed, studies were then exported into Abstrackr¹⁹ for title review, then Covidence²⁰ for abstract and full-text review. At the title, abstract, and full-text stage, two reviewers deliberated independently based on a priori inclusion and exclusion criteria, with conflicts resolved by a third reviewer.Data were extracted into a pre-tested data extraction sheet by two reviewers independently, including details of each study and the quality of evidence assessment, using the National Heart, Lung, and Blood Institute Quality Assessment tools.²¹ Reviewers independently assessed components of bias and agreed on an overall rating of “Good,” “Fair,” or “Poor” quality. The completed data extraction sheets were reviewed and finalized by the expert panel during a series of eight videoconferences over a two-day period in April 2020. Discrepancies between the two reviewers were resolved by consensus. The review author (J.D.) who was also a lead author of an included study did not review or participate in the discussion of his own paper.Narrative synthesis of the results is presented, dividing the studies into “mood/anxiety disorders” or “other psychiatric disorders” categories. In general, most studies fell into one of these categories, although we did note some overlap. Specifically, older studies tended to group people with “psychoneurotic disorders” with all psychiatric disorders including schizophrenia. In this case, although “psychoneurotic disorders” is an older term for what are now characterized as depressive or anxiety disorders, we kept these in the “other psychiatric disorders” category, as data were not separable from other psychiatric disorders (with three exceptions in which data were presented in both categories).^22–24 A quantitative synthesis was precluded due to the heterogeneity of study designs.ResultsWe identified 37,837 studies from the seven databases, and after excluding duplicates, missing abstracts, irrelevant reviews, non-human studies and wrong publication types, 23,457 underwent title and abstract screening. We excluded 21,788 studies at title screening, and 1,557 at the abstract review stage. We assessed 130 full text studies and identified 47 that appeared to meet our inclusion criteria. A further 23 were excluded at this later data extraction stage because they were simulator studies (n = 2) or because we could not extract data on MVC risk (n = 21). Twenty-four studies were included in our final synthesis (see Figure 1). None of the studies measured MVCs occurring during on-road driving evaluations.Methodological Details of the StudiesIncluded studies were conducted between 1965 and 2018. Of the 24 studies, we identified eight with cohort designs,^21,24–30 10 with case-control designs,^{22,23,31–38} and six with crosssectional designs.^39–44 The total sample size of these studies ranged from 60 to 687,228 participants. In terms of the quality of evidence assessments, four studies were rated “Good,” 10 rated “Fair,” and 10 rated “Poor” (see Supplementary Material 3). Fifty-six percent of the studies finding no association between psychiatric disorders and MVC risk were rated “Poor,” compared with 33% of the studies finding an increased risk of MVC.Four of the 24 studies used subjective measures of psychiatric disorder and MVC (eg, self-report or questionnaires).^39,40,42,45 Five of the studies used subjective measures of psychiatric disorder but objective measures of MVC (eg, police reports, administrative data),^{25,27,29,30,45} and two of the studies used subjective measures of MVC but objective measures of psychiatric disorder (eg, psychiatric interview, administrative data).^{42, 44} Thirteen of the studies used objective measures of both MVC and psychiatric disorder^{22–24,26,31–38}; however, only two of these were rated “Good,”^36,38 whereas three of them relied on proxy psychiatric interviews with relatives of deceased drivers killed in MVCs.^23,24,33 Only four studies referenced use of the DSM in diagnostic categorization.^23,26,42,44MVCs Associated with Mood and Anxiety Disorders (Table 1A and B)Cohort Studies. Two cohort studies with “Good” quality ratings^25,29 and one with a “Fair” quality rating²² found relationships between depression and MVC risk, whereas two cohort studies with “Fair” quality ratings did not.^27,30 Aduen et al.²⁵ conducted a prospective cohort study of drivers enrolled in a naturalistic driving study. MVCs were captured by the software installed by instrumented vehicles, and “depression” was based on endorsement of a psychological diagnosis of depression on a questionnaire. Those who reported a history of depression had an increased MVC risk over one to two years of an incidence rate ratio (IRR) of 1.34 (95% CI: 1.05-1.72). Notably, the increased MVC risk was only significant for those who discontinued antidepressants during the study (IRR: 2.35, 95% CI: 1.29-4.27), not for those who were unmedicated, started on or continued on antidepressants. That study was the only one to assess the role of medication in the relationship between psychiatric disorders and MVC risk. Foley at al.²⁹ conducted a study of community dwelling adults aged 65 years and older and ascertained MVCs from data available in the Iowa Department of Motor Vehicles. Those who endorsed over the 80^th percentile of depressive symptom score, based on a structured interview that included an abbreviated version of the Center for Epidemiologic Studies Depression scale, were more likely to be involved in a MVC (RR: 1.5, 95% CI: 1.1-2.1). They did not specifically address the impact of cognitive impairment or dementia on this association, which may have been a confound as they also found that poor performance on free word recall was associated with MVC risk. Alavi et al.²² examined heavy truck and lorry drivers in Iran and found that those who had MVCs, as captured by police reports, were more likely to have depression (OR: 2.4, 95% CI: 1.2-6.6), “neuroticism” (OR: 1.1, 95% CI: 1.01-1.13), and obsessions (OR: 2.7, 95% CI: 2.7-19.4), on semi-structured interviews by psychologists. In contrast, Margolis et al.³⁰ found no increase in self-reported MVC among female drivers aged 65-84 years with higher depressive symptoms compared with lower depressive symptoms on the Geriatric Depression Scale. Similarly, Cross et al.²⁷ did not find an association between self-reported depression and MVC ascertained using state records.Fig1Tab1Tab1aTab1bTab1cCase-Control Studies. We identified four case-control studies on this topic, including two studies with “Poor” quality ratings that found an association between MVC and anxiety or depression,^24,45 and two studies with “Fair” quality ratings that found no association.^23,37 Sagberg⁴⁵ conducted a case-control culpability study in which all participants had a MVC as reported to an insurance company in the last six months. They found that those who self-reported being “at-fault” were more than twice as likely as those who did not to have also self-reported feeling anxious (OR: 3.15, 95% CI: not reported, p = 0.03) or depressed (OR: 2.43, 95% CI: not reported, p = 0.03) more than once a week. Selzer et al.²⁴ conducted interviews on drivers or their survivors found responsible for a fatal MVC and found that they were twice as likely to have clinical depression, and more than nine times as likely to have had suicidal acts or preoccupation prior to MVC. However, it is not explicitly clear how post-injury symptoms were differentiated from pre-MVC symptoms. In contrast, Koepsell,³⁷ based on hospital administrative data, found that those who had received care for MVC were no more likely to have had a history of depression compared with a control group of other drivers in the same health care cooperative.Dumais et al.²³ found that young male drivers killed in a MVC were no more likely than matched living young male drivers to have a history of mood or anxiety disorder based on psychological autopsies.Cross-Sectional Studies. We found one study with a “Fair” quality rating⁴³ and two studies with “Poor” ratings^40,41 that showed an association between psychiatric disorders and MVC, and one study with a “Poor” rating³⁹ that did not. Wickens et al.⁴³ conducted a large telephone survey and found that drivers who self-reported a MVC were more likely to also have high scores on the General Health Questionnaire suggestive of “Probable Mood or Anxiety Disorder” (OR: 1.78, 95% CI: 1.37 to 2.31). Dula et al.⁴⁰ found that students who self-reported high anxiety on the Beck Anxiety Inventory were more likely to self-report at-fault MVCs than those who had lower scores. Duric and Filipovic⁴¹ found that public health clients in Serbia who had an at-fault MVC (it was uncertain how this was ascertained) were more likely to have self-reported highly on the Cornell Index, to a level suggestive of “neurosis” (20/30 in the at-fault MVC group vs 8/30 in control, t = 3.82 and p < 0.01). Aduen et al.³⁹ reported that drivers who reported depression on a questionnaire did not have an increased risk of self-reported MVC, multiple MVCs, single vehicle MVC, or at-fault MVC, although they did have double the risk of injury from MVC (RR: 2.25, 95% CI: 1.05-4.82, p < 0.05). Owing to the cross-sectional nature of these studies, no conclusions can be drawn on causality.MVCs Associated with Other Psychiatric Disorders (Table 2A and B)Cohort Studies. We identified three cohort studies, each published more than 50 years ago, with “Fair” quality ratings that found individuals with a variety of psychiatric diagnoses had an increased MVC risk compared with controls^26,28,31 and no negative cohort studies. Eelkema et al.²⁸ found that while drivers hospitalized with psychotic, “psychoneurotic,” and especially personality disorders had a greater MVC risk (based on driving records) than the general population before discharge from a state hospital: after discharge, they were safer drivers compared to the general population. However, no statistical analysis was conducted. They identified important gender differences—specifically, in both the experimental group and matched comparisons, MVC risk increased posthospitalization for men and decreased for women. Crancer and Quiring²⁶ found that drivers hospitalized with personality and psychoneurotic disorders had higher MVC rates on driving records (114% and 49% higher, respectively) compared to the general population, but those with schizophrenia had the same rates, although no statistical analysis was reported. Waller³¹ found that Californian drivers who had reported mental illness (with diagnosis made or verified by a physician), largely schizophrenia and manic depression, averaged twice as many MVCs per 1,000,000 miles driven, on driving records, compared to the general population over 10 years. Alavi et al.²² described above in the section on mood and anxiety disorders, did not find an association between other psychiatric problems on semi-structured interviews and MVCs coded on police reports for heavy truck and lorry drivers in Iran.Case-Control Studies. We identified three case-control studies that showed that those with MVCs were more likely to have mixed psychiatric conditions, one study with a “Good” quality rating,³⁶ and two studies with “Poor” quality ratings,^24,33 whereas there were three case-control studies, each with “Poor” quality ratings that did not.^32,34,35Dow et al.³⁶ linked administrative collision data with health data and found that drivers with psychiatric conditions had a 32% increased MVC risk compared to drivers without psychiatric conditions. Brenner and Selzer³³ compared individuals involved in fatal MVCs with randomly selected drivers and conducted interviews with subjects (if they survived) or other collateral informants, finding a four-fold risk of having psychopathology such as “suicidal or violent proclivities,” depression, or psychosis, although no statistical analysis was provided. Selzer et al.²⁴ conducted interviews on drivers found responsible for a fatal MVC and found that they were more than three times as likely to have symptoms of paranoia relative to those found not-responsible.Tab2Tab2aTab2bTab2cTab2dArmstrong and Whitlock³² did not find an increased MVC rate among patients admitted to a psychiatric hospital ward compared with those admitted to wards for physical illness, except for those under the age of 30 years. MVC was determined by interview, and the rates in the control group for those under age 30 were not presented. Buttiglieri et al.^34,35 reported two studies of collision records of patients following admission to neuropsychiatric hospital wards and found no increased MVCs compared to the general driver population. Although MVCs were reduced in “schizophrenic reaction,”³⁵ details were not provided for how diagnoses were made in the case groups and the 1969 study provided no statistics.We identified two case-control studies that showed positive associations between MVCs and personality disorders, one study with a “Good” quality rating³⁸ and one study with a “Fair” quality rating.²³ Orriols et al.³⁸ reported that drivers responsible (according to police reports) for MVCs with injuries were more likely to have “specific personality disorders” compared in health databases with those who were in MVCs and not found to be responsible (OR: 1.35, 95% CI: 1.05-1.74). Those drivers who were at-fault were also more likely (21.1%) to have “long term psychiatric disorders” in general (vs 13.3% in the non-responsible MVC), but statistics were not provided. Dumais et al.²³ reported that young male drivers aged 26 to 36 years who died in an MVC were more than three times as likely to have borderline and/or antisocial personality disorder based on psychological autopsies, although this was not found for male drivers aged 18 to 25 years.Cross-sectional StudiesEdlund et al.⁴² in a cross-sectional study with a “Fair” quality rating found that outpatients with schizophrenia (diagnosed using DSM III-R criteria) were no more likely to self-report MVCs than a control group of staff from the clinic, although the authors also noted that the controls were more likely than patients to drive at all (99% of controls vs 68% of patients, p < 0.00001), or to drive more than 100 miles per year (98% of controls vs 40% of patients, p < 0.00001).Yates et al.,⁴⁴ in a cross-sectional study with a “Poor” quality rating, reported that alcoholic drivers admitted to an alcohol treatment centre with antisocial personality disorder (diagnosed using DSM III criteria) were almost twice as likely to self-report a personal-injury MVC than those without antisocial personality disorders (45.5% vs 25.7%, p < 0.05).Again, because of the cross-sectional nature of these studies, causality is indeterminate.Other Study FeaturesGender. Seven of the 24 studies did not report on the gender distribution of participants.^{24,26,28,33–36} Four studies included only males,^22,23,41,44 and one study only included females.³⁰ In the six studies that reported gender distribution by driver cohort, there was an average of 47.7% males among the psychiatric populations and 48.4% males among the comparison populations.^{25,31,32,37,40,42} Fifteen of the 24 studies adjusted or matched for gender in their analyses.^{23–29,32,33,36–40,43} Edlund et al.⁴² reported that males were over-represented in the MVC group among patients, but not among controls. As mentioned previously, Eelkema²⁸ found that MVCs increased post-psychiatric discharge for men, but decreased for women. No other studies reported gender-specific findings.At-Fault MVCs. Of the 24 studies identified, only three that were not rated “Poor” in quality examined the relationship between psychiatric illness and at-fault MVC. Cross et al.,²⁷ in a cohort study with a “Fair” quality rating, found no relationship between depression and at-fault MVCs. In contrast, in case-control studies with “Good” quality ratings, Orriols et al.³⁸ found “specific personality disorders” to be associated with an increased at-fault MVC risk, and Dow et al.³⁶ found psychiatric illness to be associated with at-fault MVC. There were an additional seven studies with “Poor” quality ratings, three of which were of cross-sectional design^39–41 and four of case-control design^24,32,33,45 which showed varied results: At-fault MVC was associated with depression and anxiety,⁴⁵“neurosis,”⁴¹ anxiety,⁴⁰ depression and psychosis and suicidal ideation,²⁴ psychiatric hospital admission,³² and “psychopathology”³³ in one study each, and was not associated with depression³⁹ in another.Other Confounds. Only seven of the 24 studies adjusted for driving exposure in their analyses.^{25,30,37,39,43,45} Only three of the studies adjusted for drugs or alcohol,^23,38,43 and one study excluded those with drug or alcohol abuse.⁴¹ Treatment with psychotropic medication was addressed in only one of the identified studies.²⁵ All but two of the studies^40,41 adjusted for age.DiscussionThis systematic review identified 24 studies that investigated the MVC risk for drivers with a psychiatric disorder. No disorder was consistently linked to MVC risk. However, only four of these studies (16.7%) were rated as having a “Good” quality of evidence. In the studies with “Good” quality ratings, one reported a 34% increased risk of MVC among drivers with depression compared to the general population, although the risk was only evident among those who stopped taking their antidepressants.²⁵ The other studies found a 50% increased risk of MVC among drivers aged 65 years and older with depression compared to those without depression,²⁹ a 32% increased risk of MVC among those with a psychiatric disorder,³⁶ and a 35% increased likelihood of having a personality disorder among those found responsible (vs not responsible) for an MVC.³⁸Ten studies (41.6%) had “Poor” quality ratings, and 11 studies (45.8%) used a subjective measure of MVC, a subjective (ie, self-report or questionnaire) measure of psychiatric disorder, or both, which are significant limitations for these studies. The failure of 20 of the studies (83.3%) to use standardized diagnostic criteria to define psychiatric disorders poses concern about the generalizability of the findings. Additionally, six studies (25%) used cross-sectional designs, in which it is impossible to rule out the possibility of reverse causality. More than half of the studies did not assess at-fault status, and those that did showed variable results.The use of questionnaires or self-report of psychiatric symptomatology in more than a third of the studies is an important limitation, as symptoms are not necessarily indicative of disorder. Depression diagnosis, but not depressive symptoms, have been associated with on-road test failure among cognitively intact older adults.⁴⁶ Less than a third of the studies adjusted for driving exposure in their analyses, an important limitation, since depression and other psychiatric illnesses have been associated with self-regulated reduction of driving,⁴⁷ which may mitigate the road risks. Only four studies adjusted for or excluded those with use of drugs or alcohol, which are associated with psychiatric disorder^48,49 and MVC risk.^50–52 Since depression is associated with increased odds of reporting driving after drinking,⁵³ the inter-relationships between alcohol, psychiatric disorders, and MVCs need to be carefully explored in future studies of road risks associated with psychiatric illness.An additional major limitation was the failure to assess for the positive or negative effects of psychotropic medication on MVC in psychiatric populations. In the one study that assessed medication status, MVC risk associated with depression was only significant for those who discontinued their antidepressants.²⁵ Hill et al.,⁸ in their review on the topic, found that studies of antidepressants and MVCs rarely adjusted for the role of depression, and conversely, studies of depression and MVCs rarely controlled for antidepressants. Although antidepressants can be associated with an increased MVC risk in some epidemiological studies^8,54 and driving performance on antidepressants is more impaired than placebo in healthy controls,^14,55,56 antidepressants have also been noted to improve the driving ability of adults with depression within driving simulators^57,58 and on the road.^14,55 We identified only one study looking at schizophrenia as distinct from other “psychiatric disorders” and found no relationship with MVC involvement,⁴² but again no assessment of treatment was noted. Most experimental studies showed that skills pertaining to driving are significantly impaired in people with schizophrenia compared to controls,^11–13,59 but antipsychotics can improve driving skills.⁵⁹ Benzodiazepines are among the most commonly prescribed psychotropic medication^60–62 and pose a significant risk of MVC and driving impairment,⁶³ but these were not assessed in any of the studies.Compared with the general population, suicide risk is higher among patients with a variety of psychiatric disorders,⁶⁴ and suicidal ideation has been associated with a four-fold one year increased MVC risk.⁶⁵ More than 2% of traffic crashes were found to have been suicide attempts,⁶⁶ and almost one-third of head-on crashes with oncoming vehicles have been associated with suicide.⁶⁷ Only two studies noted suicidal ideation among various psychopathologies^24,33; one reported “suicidal acts or preoccupation” to be more likely among drivers found responsible for fatal MVCs,²⁴ while the other study did not identify how suicidal ideation affected the risk of MVC.³³ Another study that did not meet our inclusion criteria found that drivers in single car MVCs were not deemed to have had higher suicidal intent compared to drivers not involved in MVCs, although they more often expressed “tiredness of being alive.”⁶⁸Bipolar disorder is seen at high frequency in clinical populations⁶⁹ but only two of the studies we identified included bipolar disorder among other psychiatric disorders.^31,32 Regular use of lithium, the preferred treatment for bipolar disorder, was associated with a doubling of injurious MVC risk in a nested case-control study in Quebec, whereas carbamazepine (an alternative treatment for bipolar disorder, but also for epilepsy amongst other potential uses) was not.⁷⁰ Nonetheless, the authors had no information about psychiatric diagnosis, so it was impossible to conclude whether it was bipolar disorder or lithium that conferred the risk. In a qualitative study, participants with bipolar disorder expressed perceptions that Irish fitness-to-drive guidelines were discriminatory to those with bipolar disorder, and they desired to implement their own compensatory strategies when unwell, by self-regulating driving.⁷¹Another significant limitation was the lack of control or adjustment for gender in more than a third of the studies, and gender-specific analysis in only two of the studies. Since psychiatric disorders are more common in women than men,^3,5 and MVCs are more common in men than women,⁷² credible future research needs to take into account the interplay between gender and MVC risk among people with a psychiatric disorder.Beyond these limitations, it is important to identify that causality cannot be firmly concluded based on these studies. It is relatively more certain in the cohort studies and studies that examined psychiatric precursors of those fatally injured that the MVC followed the psychiatric disorder. However, in case-control studies and cross-sectional studies, positive findings may be explained as psychiatric sequelae of MVCs.There are many possible ways that psychiatric disorders may theoretically confer an increased risk of MVC. First, the symptoms of psychiatric disorders may impair driving. For example, the fatigue, difficulty concentrating, psychomotor slowing and executive dysfunction associated with Major Depressive Disorder may impair requisite skills for responding quickly to road hazards. Second, some types of disorders may intermittently increase or reduce MVC risk. For example, drivers with anxiety disorders may reduce their driving time during times of stress which will lower their MVC risk, but their risk may be increased while driving because of lack of practice or from panic attacks. Third, psychiatric medications may have adverse effects that include sedation, cognitive impairment or psychomotor slowing, posing hazards on the road. For example, benzodiazepines have consistently been associated with MVCs and with wider standard deviation of lateral position during on-road experiments.⁶³ Conversely, psychiatric medications may reduce the risk of MVC by treating the underlying symptoms of the psychiatric disorder that impair driving. Some of the mixed results in the present systematic review may stem not only from methodological limitations but from the nuances of these theoretical links between psychiatric, medication, and driving status.The available evidence is limited in the number of studies, with heterogenous study designs, and is not of high quality. For the studies with “Good” quality ratings (two studies for depression, one study for personality disorders, and one study for psychiatric disorders), the point estimates of risk of MVC range from 1.32 to 1.50, which would be considered “mildly higher”⁶ in patients with psychiatric disorders than controls. Given some good evidence for a mildly higher MVC risk with psychiatric disorders, clinicians should maintain vigilance and consider fitness to drive in their assessments of patients, on an individualized basis.The characteristics of people with a psychiatric disorder most at risk of MVCs have not been clearly identified However, as with any medical condition that may theoretically impact cognition, judgement, and insight, the individualized case-by-case approach recommended by international guidelines should continue.^73,74 These guidelines generally suggest considering several factors as pre-requisites for safe driving, such as presence and adequacy of treatment, adherence to treatment, absence of cognitive impairment or sedating medications, sufficient periods of stability after acute episode of illness, lack of impact on daily functioning, and insight. Extra caution is warranted at times of starting and changing medications.The current research evidence does not support blanket driving restrictions. There are often incorrect stigmatizing assumptions made about patients with psychiatric disorders, and restrictive legislation should be tied to empiric data, with sensitivity around the issue of stigma impeding human rights. Driving cessation is associated with a wide array of negative psychological and social consequences.⁷⁵ Driving is considered a privilege rather than a right in most international legislation around medical illness and driving, and although some psychiatric conditions may significantly increase road risk, patients who have been adequately treated and are stable should be allowed to enjoy the freedom and convenience associated with driving.Further research should include objective assessments of psychiatric disorder and MVC risk. Studies should measure driving exposure and psychiatric treatment and assess their impact on MVC risk. It would be clinically useful to have empiric information about risk factors for collision among those with psychiatric disorder. Given the limitations of evidence, a consensus-based approach to reassessing the recommendations of Fitness-to-Drive Guidelines would be warranted for psychiatric disorders, such as one recently completed on the topic of driving and dementia.⁷⁶Authors’ NoteA report containing an overall summary of the results of this review has been included in an integrated report that has been submitted to Road Safety Victoria, Department of Transport/VicRoads. Charlton, J.L., Di Stefano, M., Dow, J., Rapoport, M.J., O’Neill, D., Odell, M., Darzins, P., & Koppel, S. (2021). Influence of chronic Illness on crash involvement of motor vehicle drivers: 3^rd edition. Melbourne, Australia: Monash University Accident Research Centre.The protocol for this systematic review was registered with PROSPERO in November 2019 and published by PROSPERO in March 2020 (CRD42020157675).AcknowledgmentsWe gratefully acknowledge Tamara Rader of Ask a Librarian, Joule, a CMA Company, for helping develop the literature search strategy and Henry Lam of Sunnybrook Health Sciences Centre for implementing the search using the CINAHL database. We acknowledge Frances Ilari and Yoassry Elzohairy of the Ministry of Transportation of Ontario for their support for this project and comments on the manuscript. We acknowledge Dr Marilyn Di Stefano from Road Safety Victoria, Department of Transport/VicRoads (Melbourne, Australia) for her scholarly comments, and Dr Andrew Zullo of Brown University, Providence, Rhode Island, for assisting with title screening and feedback on an earlier draft of the literature review.Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Dr Mark J. Rapoport receives research support from Sunnybrook Psychiatrists and has grant funding from Canadian Institute of Health Research, and Canadian Consortium on Neurodegeneration and Aging. All other authors have no conflicts of interest.FundingThe author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by the Canadian Council of Motor Transportation Administrators with the participation of the Société de l’assurance automobile du Québec, The Ontario Ministry of Transportation, and the Canadian Medical Association Journal. JPT and PCD are supported by the NIHR Newcastle Biomedical Research Centre (BRC).ORCID iDsThadshagini Prabha

https://orcid.org/0000-0003-0468-9047Ian Gillespie

https://orcid.org/0000-0002-7551-962XAngela Onkay Ho

https://orcid.org/0000-0001-9039-7715Supplemental MaterialSupplemental material for this article is available online.References

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¹ Sunnybrook Health Sciences Centre, Toronto, ON, Canada² Faculty of Medicine – Department of Psychiatry, University of Toronto, Toronto, ON, Canada³ Ontario Ministry of Transportation, Toronto ON, Canada⁴ Société de l’assurance automobile du Québec, Gatineau, QC, Canada⁵ Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada⁶ Monash University Accident Research Centre, Monash University, Clayton, VIC, Australia⁷ National Office for Traffic Medicine, Dublin, Ireland⁸ Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK⁹ CARA, Vias Institute, Brussels, BelgiumCorresponding author:
Mark J. Rapoport, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room FG 37, Toronto, ON, M4N3M5, Canada.
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