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Evidence Report Psychiatric Disorders and Commercial Motor Vehicle Driver Safety Presented to The Federal Motor Carrier Safety Administration August 29, 2008 Prepared for Prepared by MANILA Consulting Group, Inc. ECRI Institute 1420 Beverly Road, Suite 220 5200 Butler Pike McLean, VA 22101 Plymouth Meeting, PA 19462 Evidence reports are sent to the Federal Motor Carrier Safety Administration’s (FMCSA) Medical Review Board (MRB) and Medical Expert Panels (MEP). MRB and MEP make recommendations on medical topics of concern to the FMCSA. The FMCSA will consider all MRB and MEP recommendations; however, all proposed changes to current standards and guidance (guidelines) will be subject to public notice and comment and relevant rule-making processes. Psychiatric Disorders and CMV Driver Safety Policy Statement This report was prepared by ECRI Institute under subcontract to MANILA Consulting Group, Inc., which holds prime GS-10F-0177N/DTMC75-06-F-00039 with the Department of Transportation’s Federal Motor Carrier Safety Administration. ECRI Institute is an independent, nonprofit health services research agency and a Collaborating Center for Health Technology Assessment of the World Health Organization. ECRI Institute has been designated an Evidence-based Practice Center by the United States Agency for Healthcare Research and Quality. ECRI Institute’s mission is to provide information and technical assistance to the healthcare community worldwide to support safe and cost-effective patient care. The results of ECRI Institute’s research and experience are available through its publications, information systems, databases, technical assistance programs, laboratory services, seminars, and fellowships. The purpose of this evidence report is to provide information regarding the current state of knowledge on this topic. It is not intended as instruction for medical practice or for making decisions regarding individual patients. Psychiatric Disorders and CMV Driver Safety Table of Contents EXECUTIVE SUMMARY ......................................................................................................................................... 1 PURPOSE OF EVIDENCE REPORT ................................................................................................................................. 1 IDENTIFICATION OF EVIDENCE BASES ........................................................................................................................ 1 GRADING THE STRENGTH OF EVIDENCE ..................................................................................................................... 2 ANALYTIC METHODS ................................................................................................................................................. 2 PRESENTATION OF FINDINGS ...................................................................................................................................... 2 EVIDENCE-BASED CONCLUSIONS ............................................................................................................................... 3 Key Question 1: Are individuals with a psychiatric disorder at an increased risk for motor vehicle crash? If so, are there specific psychiatric disorders that present a particularly high risk? ............................... 3 Key Question 2: Are individuals using psychotherapeutics for a psychiatric disorder at an increased risk for crash when compared to comparable individuals who are not using psychotherapeutics? ..................... 4 Key Question 3: What traits associated with personality disorders are associated with reductions in motor vehicle driver safety? ................................................................................................................................. 5 Overall Summary .................................................................................................................................................. 6 PREFACE .................................................................................................................................................................... 7 ORGANIZATION OF REPORT ........................................................................................................................................ 7 SCOPE ........................................................................................................................................................................ 7 BACKGROUND .......................................................................................................................................................... 8 THE CLASSIFICATION OF PSYCHIATRIC DISORDERS ................................................................................................... 9 PSYCHIATRIC DISORDERS CONSIDERED IN PRESENT EVIDENCE REPORT ................................................................. 12 Why Are Cognitive Disorders not Considered Further in this Evidence Report? .............................................. 12 Why Are Substance-related Disorders not Considered Further in this Evidence Report? ................................. 13 KEY FEATURES OF THE DISORDERS CONSIDERED IN PRESENT EVIDENCE REPORT .................................................. 13 Psychotic Disorders ............................................................................................................................................ 13 Mood Disorders .................................................................................................................................................. 16 Anxiety Disorders ............................................................................................................................................... 21 Personality Disorders ......................................................................................................................................... 27 THE BURDEN OF PSYCHIATRIC DISORDERS .............................................................................................................. 33 TREATMENTS FOR PSYCHIATRIC DISORDERS ........................................................................................................... 34 MEDICAL FITNESS-FOR-DUTY REGULATIONS .......................................................................................................... 40 Current Federal Physical Qualification Standards ............................................................................................ 40 Current Guidance to Medical Examiners ........................................................................................................... 41 Medical Fitness Standards from Other Transportation Agencies in the United States ...................................... 42 i Psychiatric Disorders and CMV Driver Safety Regulatory Medical Fitness Standards for CMV Drivers in Other Countries .................................................... 44 Regulatory Standards and Certification Guidelines from Select Countries ....................................................... 44 METHODS ................................................................................................................................................................. 47 KEY QUESTIONS ....................................................................................................................................................... 47 IDENTIFICATION OF EVIDENCE BASES ...................................................................................................................... 47 Searches .............................................................................................................................................................. 48 Retrieval Criteria ................................................................................................................................................ 49 Inclusion and Exclusion Criteria ........................................................................................................................ 50 EVALUATION OF QUALITY AND STRENGTH OF EVIDENCE ........................................................................................ 50 STATISTICAL METHODS ........................................................................................................................................... 51 EVIDENCE SYNTHESIS ......................................................................................................................................... 53 KEY QUESTION 1: ARE INDIVIDUALS WITH A PSYCHIATRIC DISORDER AT AN INCREASED RISK FOR MOTOR VEHICLE CRASH? IF SO, ARE THERE SPECIFIC PSYCHIATRIC DISORDERS THAT PRESENT A PARTICULARLY HIGH RISK? ........................................................................................................................................................................ 53 Identification of Evidence Base .......................................................................................................................... 53 Evidence Base ..................................................................................................................................................... 54 Findings .............................................................................................................................................................. 60 Findings .............................................................................................................................................................
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