Mental Health and Driver Fitness
We often focus on our physical abilities to drive, neglecting the importance of our mental health and its impact on driving ability. Mental illnesses are considered as clinical conditions that would affect one’s fitness-to-drive.
Mental health is too often associated with a few people in straight-jackets, psychiatric institutions, and hours on the couch of a psychiatrist. The truth is that many suffer from some type of mental illness that could affect their driving. In research carried out in 2017 by Mercedes-Benz, it was found that of 2000 van drivers surveyed, 1 in 5 describes their current state of mental health as poor.
Driving is one of the most stressful activities we undertake as part of our working day. It is probably one which requires one of the highest levels of concentration. In this section, we will explore the importance of mental health on driver fitness and steps to be taken to ensure increased safety among those who suffer from mental health issues as well as their fellow road users.
What are the Mental Health Issues affecting Driver Fitness?
People with mental illnesses are associated with a higher risk of vehicle crashes. Not all psychiatric disorders, however, appear to carry an increased degree of accident vulnerability. When referring to driver fitness, much focus is placed on the use of alcohol, co-morbid medical conditions (diabetes mellitus, Parkinson's disease, Alzheimer's disease, epilepsy), and adverse drug reactions among the risk factors for road traffic accidents.
There are many other health issues that are important risk factors for road traffic crashes. Psychiatric disorders can lead to impairment in the level of cognitive and executive functioning required for safe driving, and medications used to treat them can also potentially cause disruption in perception, information processing, and overall psychomotor activity.
Some of the most important threats to safe driving from a mental health side include:
- Schizophrenia is reported to have a risk of car accidents approximately two times greater than that of age-matched controls.
- A person suffering an acute psychotic episode totally engulfed in delusions is likely to be dangerous while driving.
- A person severely ill with anxiety or depression.
- Among patients with major depressive disorder higher levels of sleepiness were found when driving, irrespective of medication use.
- Severe bipolar disease is linked to reckless driving.
- People suffering from suicidal ideation.
It is important to recognize that we do not imply that all individuals with anxiety or depression or schizophrenia or bipolar disease should refrain from driving. It applies to those people who have an ongoing serious occurrence of their mental illness, which may include a regular pattern of episodes where their ability to drive safely may be affected by their mental condition.
Those who are assessed as unfit to drive due to their mental health status should be advised not to drive until:
- They have been satisfactorily treated, or
- The factors that were considered to make them unfit to drive are no longer present or are no longer at a level that would affect the individual's ability to drive safely.
Mental Health, Medication and Driver Fitness
It is not only an illness that could affect driving ability - but also the medication used to address such physical or mental health issue.
- People using psychotropic medications often experience functional deficits that would affect their driving performance and may increase the risk of road crashes.
- Their driving capacity is affected by their respective symptoms, including psychomotor impairment and the side effects of medication.
- When starting most psychotropic medication or increasing a dose, a person should not drive until the side effects, such as perceptual or motor skills difficulties, are unlikely to affect the individual's ability to drive safely.
The effect of medication should be carefully assessed, including the individual's likely compliance with their medication and any impacts on the individual's ability to drive safely. We should consider:
- how medication can control any factors of an individual's condition that may impair their ability to drive safely.
- side effects of sedation, e.g. risk of somnolence, impaired reactions, or ability to process information.
- side effects on motor skills, such as impaired coordination.
- specific side effects, such as blurred vision, hypotension, or dizziness.
- Each patient should be individually assessed, considering the known profile of effects of the drug, the dose and the degree to which the illness is controlled.
How do Mental Health illnesses impact our Ability to Drive?
Driving is a complex task requiring a range of skills, such as cognitive, sensorimotor and psychosocial skills. Several research studies have been conducted to establish how mental health can affect driving ability:
- The most prevalent driving skill deficit identified during the simulated road assessment was hazard handling, followed by observation, planning and judgment, and vehicle positioning.
- Perceptual disorders impair the capacity to accurately see, hear or comprehend the driving environment.
- Individuals with paranoid disorders may have misperceptions about the behaviour or intent of other road users.
- Individuals suffering from hallucinations are constantly too preoccupied to be a safe driver.
- Impairment to information processing, such as cognitive impairment, excessive preoccupation, poor concentration or the thought disorder of active psychosis, may impair the ability to drive safely.
- Poor judgement, recklessness and a sense of invulnerability are seen in manic mood states.
- Memory problems may impair driving ability if more than trivial.
- Acute symptoms of anxiety or panic attacks may be dangerous in high traffic environments.
- Increased Impulsivity or risk-taking.
- Excessively aggressive, erratic, or irritable behaviour.
- Mood, including suicidal ideation, may result in impulsiveness and aggressive driving.
- Those with poor mental health are as vulnerable to distraction as somebody consuming excessive alcohol.
- The deficits in physical control of vehicle and reaction time were relatively less common.
- Depressive patients were also found to have slower steering reaction times
The Rules of the Road
In most countries’ drivers must declare any diseases or conditions that are likely to render them incapable of driving safely and effectively. Many drivers are however unaware of the responsibility to declare. Worries about the license removal after reporting would likely reduce their motivation to declare their health status or to sit for a driving assessment.
Education on the legal responsibility to report is extremely important and should be the key focus of a driver assessment.
A person is disqualified from driving in the RSA:
If he or she is suffering from one of the following diseases or disabilities:
- Uncontrolled epilepsy.
- Sudden attacks of disabling giddiness or fainting due to hypertension or any other cause.
- Any form of mental illness to such an extent that it is necessary that he or she be detained, supervised, controlled and treated as a patient in terms of the Mental Health Act, 1973 (Act No. 18 of 1973);
- Any condition causing muscular incoordination.
- Uncontrolled diabetes mellitus.
- Defective vision ascertained in accordance with a prescribed standard.
- Any other disease or physical defect which is likely to render him or her incapable of effectively driving and controlling a motor vehicle of the class to which such licence relates without endangering the safety of the public: Provided that deafness shall not of itself be deemed to be such a defect;
- If he or she is addicted to the use of any drug having a narcotic effect or the excessive use of intoxicating liquor; or
What are the Challenges to Recognizing Mental Health as an important factor for Driver Fitness?
- We should be mindful of the abundance of inaccurate information about mental illness that remains in the community.
- More research is needed on the effects of different conditions on fitness-to-drive.
- Most people shy away from talking about mental health.
- Men, specifically, do not want to make others worry, whether it is their partner or family and, crucially, they don’t know how to talk about what they’re feeling.
- Less attention is given to wellbeing than to safety.
- Safety brings instant rewards while wellbeing is a slow burn.
- It is much more difficult to spot problems and sometimes it can take a long time to see the benefit of interventions.
How do we assess whether Mental Health is a threat to Driver Fitness?
- Suffering from a mental illness is not necessarily a disqualification to drive.
- Fitness-to-drive of individuals with mental illness should be examined carefully before they drive.
- The assessment of individuals with mental disorders is one of the more difficult aspects of determining fitness to drive.
- The effect of mental disorders on the ability to drive safely has not been determined with any degree of certainty, and fluctuations that may occur during a course of clinical illness make it difficult to set rigid rules.
- A specialised driver assessment that addresses the unique characteristics of mental illnesses is certainly needed.
- There is however no single assessment that can be used to accurately predict the driving ability of people with psychiatric illnesses.
- Driving assessment practices vary greatly and there is no universally accepted guidance on what exactly constitutes a ‘suitable’ or the ‘best’.
- It is recommended that a series of assessment methods including medical and occupational therapy assessments, neuropsychological tests, on-road assessment, and car driving simulator tests should be used to reach a conclusion regarding fitness-to-drive.
The Role of the Medical Practitioner/ Medical Doctor
- Individuals with a mental disorder should not automatically be considered unfit to drive: Medical practitioners should assess each individual and the manifestations of their mental disorder or treatment to determine if they are fit or unfit to drive.
- There is a clear need for education and guidelines to assist psychiatrists in decision making about driving fitness.
- Driving is often omitted or ignored during the assessment and ongoing work with consumers of mental health services.
- This may be due to the low confidence of clinicians in determining client’s fitness-to-drive.
- There is most often a significant level of trust is established between a medical practitioner and their patient. In these circumstances, medical practitioners may wish to refer their patient to another medical practitioner for assessment, rather than risk damaging their practitioner-patient relationship.
Challenges for our medical doctors include inadequate awareness of driving-related legislation or standards; limited resources for the clinicians, clients and families. Insufficient knowledge in driving-related practice is another challenge that impedes the development of driving assessment service for those with mental illnesses.
The Role of the Occupational Therapist
- Mental health occupational therapy is leading the charge to improve clinical practice related to safe driving.
- Driving assessment is imbedded in occupational therapy practice.
- Occupational therapists specialised in both mental health practice and driver assessment play a vital role in this emerging area.
- Policies and practice guidelines are developed for the driving assessment of people with mental illness.
- These services are however rather scarce and require specially trained professionals.
- Driving assessment service should be expanded in the psychiatric field.
The Simulator and Assessing Driving Ability
- The simulated driving test is now an emerging evaluation method being applied to different conditions such as Alzheimer’s disease, traumatic brain injury, stroke, attention deficit, hyperactivity disorder, autism spectrum disorder and mental illness.
- There are numerous advantages to using a simulator to evaluate driving capacity.
- Simulated driving is particularly suitable for assessing the driving fitness of people with mental illness, in which driving-related cognitive deficits are quite prevalent.
- Studies on elderly at-risk drivers and a comparison study using on-road tests have demonstrated that a simulator seems to be a reliable, valid and practical tool for identifying at-risk drivers.
- Real-life traffic and specific road conditions can be simulated, and this is especially useful to assess clients’ behaviour in hazardous situations which cannot be controlled during on-road evaluation.
- Instant feedback can be provided to clients, allowing them to ‘visualise’ their driving ability and improving insight into their driving capacity.
- In the simulated road assessment, clients drive a standardised route with common road situations such as roundabouts, unmarked lanes, different speed limit, etc.
- Basic driving skills and road hazard handling are evaluated throughout the driving simulation.
- This provides a situational assessment to assess clients’ ability to handle traffic under a safe and controlled environment.
Fleet Management, Commercial and Fleet Drivers and Mental Health
The mental health of our professional commercial fleet and truck drivers is of vital importance! Transport psychologists have found that poor attitudes and a negative state of mind among drivers can have a detrimental effect on driver safety.
There are useful procedural steps, at the recruitment stage, and when assessing and monitoring drivers, that employers can take to help identify attitudes and state of mind, while also developing an organisational culture that values and prioritises people and their welfare.
What are the major challenges and why do we need to be more attentive to the mental wellbeing of these drivers?
- There still is a stigma around mental health which means drivers may not want to discuss it with managers, or may not want to mention medications they could be taking, which could have side effects that could affect their driving, such as drowsiness or difficulty concentrating.
- A survey of more than 2,000 van operators and drivers by Mercedes-Benz Vans UK found that 56% said there is a stigma attached to discussing mental health at work, while only 28% of managers said an employee had spoken to them about the issue.
- “Men talk about their injuries; they don’t talk about their health.”
- Fleet managers should consider the mental health of their drivers in the same way they would the maintenance of their vehicles when it comes to safety.
- With telematics it easy and quick to measure driving style deficiencies such as speeding that contributed to a road crash.
- In post-crash reviews, fleet managers should also be looking for mental health conditions that could have contributed to a road crash.
The Major Mental Health Risks for Commercial Fleet and Truck Drivers
The life of a van and truck driver driver is always a solitary one and many commercial drivers are experiencing an increased rate of poor mental health. The mental welfare of drivers should be assessed before they are allowed behind the wheel.
Potentially risky conditions for drivers include:
- Depression, which could make them unconcerned for their own and others' safety.
- Anxiety, which could cause sufferers to experience periods of unintended helplessness close to a state of paralysis - potentially dangerous when drivers may need to make split-second decisions to avoid a crash.
- Stress - together with fatigue - is a major factor in the mental well-being of a driver.
Education, Training and Advice
- Fleet Managers can create safeguards to identify vulnerable drivers and ensure they receive the professional help and support they need.
- Procedural steps can be implemented, at the recruitment stage, that identify attitudes and state of mind.
- Fleet managers can develop steps to promote a culture that values and prioritises people and their welfare.
- Steps can include creating a safe environment for drivers to share their problems without feeling threatened; monitoring and assessing driver risk by introducing tools that profile key behaviour risk characteristics; implementing cross-departmental strategies that address mental health and aim to meet best practice standards; and communicating company policy on mental well-being to all employees.
- Managers can be trained to recognise signs of health changes, including sudden mood or behaviour changes, unusual irritability or aggression, worsening relationships with colleagues and others, impaired job performance or an increase in poor timekeeping and short-term sickness absence.
- Managers can also educate employees about mental health conditions via regular emails and training workshops, run targeted interventions that promote and familiarise employees with internal support networks, encourage good driving habits among employees and to be aware of the signs of mental health issues, in the workplace and among individual employees.
- We need to ensure drivers are comfortable talking about their emotions and asking people how they are feeling without making it seem to be criticising in some way.
- Some fleet managers have trained staff to be mental health first aid ambassadors to give them the skills to spot signs of stress and anxiety among drivers.
It is important that we pay close attention to the wellbeing of drivers - Not only their physical but also mental wellbeing. It is not only about their own safety and the lowering the costs of road crashes - we all share the roads and need to share them with kindness to the best of our ability, recognizing that some are faced with more challenges than we might be aware of!