From the Editor
He’s not well but insists that he can still drive his car. Should you report him to the Ministry of Transportation?
As clinicians, we often struggle with such issues, which touch on clinical judgment, as well as legal requirements. In Ontario, half a decade ago, the government changed the law, requiring mandatory reporting for several conditions, including “acute” psychosis. Yet other provinces continue to leave major decisions to the discretion of providers. What does the literature say about motor vehicle crashes and mental disorders? In the first selection, Dr. Mark J. Rapoport (of the University of Toronto) and his co-authors do a systematic review for The Canadian Journal of Psychiatry, drawing on 24 studies. “The available evidence is mixed, not of high quality, and does not support a blanket restriction on drivers with psychiatric disorder.” We consider the paper and its implications.
In the second selection, Dr. Joshua S. Siegel (of Washington University in St. Louis) and his co-authors look at US state legislation for psychedelic drugs in a new JAMA Psychiatry Special Communication. They note a sharp uptick in legislative activity and draw comparisons to cannabis. “After decades of legal restriction, US states have been swiftly moving toward increased access to psychedelics.”
And in the third selection, Michael F. Hogan (of Case Western Reserve University) writes about coercion and mental health care in JAMA Psychiatry. He considers the proposals of New York City Mayor Eric Adams which would expand efforts to hospitalize those with several, persistent mental illness. “Mayor Adams’ proposal for a more vigorous police response leading to inpatient care is well intended but incomplete. It would be preferable for New York to implement comprehensive crisis programs, including intensive care options that reduced the burden on police.”
Selection 1: “A Systematic Review of the Risks of Motor Vehicle Crashes Associated with Psychiatric Disorders”
Mark J. Rapoport, Justin Nathaniel Chee, Thadshagini Prabha, et al.
The Canadian Journal of Psychiatry, May 2023
Psychiatric disorders encompass a wide range of conditions, as characterized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-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. Two of the reviews used the Newcastle Ottawa Scale to assess study quality 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. The final review, published 15 years ago, identified seven studies pertaining to MVC risk but did not assess study quality. 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.
So begins a paper by Rapoport et al.
Here’s what they did:
“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.”
Here’s what they found:
- They included 24 studies in the analysis.
- Types of studies. “We identified eight with cohort designs, 10 with case-control designs, and six with cross-sectional designs.”
- Sample size. “The total sample size of these studies ranged from 60 to 687,228 participants.”
- Quality. “In terms of the quality of evidence assessments, four studies were rated ‘Good,’ 10 rated ‘Fair,’ and 10 rated ‘Poor’.”
- Association. “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.”
- Mood. The authors find several cohort, case-control, and cross-sectional studies. For example, a cohort study: “Aduen et al. 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… Notably, the increased MVC risk was only significant for those who discontinued antidepressants during the study (IRR: 2.35…), not for those who were unmedicated, started on or continued on antidepressants.” And a case control study: “Selzer et al. 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.”
- Other disorders. They also found various studies for other disorders. For example, a cohort study: “Eelkema et al. 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.”
A few thoughts:
1. This is a good and timely paper.
2. A one-sentence summary of the paper: “No disorder was consistently linked to MVC risk.” (!)
3. There were many studies to review, yes – but, again, the quality was uneven. The authors suggest that further work is needed in the area. (Given the public safety issues, it’s surprising that this area isn’t better researched.)
4. They describe various limitations, including: “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.”
6. The public policy considerations? They recommend an “individualized approach.” (!)
7. It’s important for us to balance the desire of patients to drive with the need for our roads to be safe. That said, simple approaches to such complex issues are rarely satisfying.
The full CJP paper can be found here:
Selection 2: “Psychedelic Drug Legislative Reform and Legalization in the US”
Joshua S. Siegel, James E. Daily, Demetrius A. Perry, et al.
JAMA Psychiatry, 7 December 2022
In May 2019, Denver, Colorado, became the first US city to decriminalize psilocybin. By the end of 2019, many cities were considering initiatives to decriminalize psychedelics. A review panel appointed by the Denver City Council issued a report in November 2021 that did not identify any significant negative association of decriminalization with public safety. They recommended training for first responders, public health education and messaging, data collection, and ongoing safety reporting. In late 2020, Oregon became the first state to both decriminalize psilocybin and legalize it for therapeutic use…
So begins a paper by Siegel et al.
Here’s what they did:
“Data were compiled from legislative databases (BillTrack50, LexisNexis, and Ballotpedia) from January 1, 2019, to September 28, 2022. Legislation was identified by searching for terms related to psychedelics (eg, psilocybin, MDMA, peyote, mescaline, ibogaine, LSD, ayahuasca, and DMT). Bills were coded by an attorney along 2 axes: which psychedelic drugs would be affected and in what ways (eg, decriminalization, funding for medical research, and right to try).”
Here’s what they found:
- “We found that 25 states considered 74 bills proposing reform of existing laws restricting access to psychedelic drugs or proposing further research into reform legislation. Of those bills, 10 (14%) were signed into law.”
- States. “Those 10 laws were from 7 states (Colorado, Connecticut, Hawaii, New Jersey, Oregon, Texas, and Washington) and included 1 passed by a ballot initiative (Oregon ballot measure 109).”
- Numbers by year. “The number of psychedelic reform bills introduced during each calendar year increased steadily from 5 in 2019 to 6 in 2020, 27 in 2021, and 36 in 2022.”
- Substances. “Nearly all bills specified psilocybin (90%), and many also included MDMA (36%).”
- Content. “While bills varied in their framework, most (58%) proposed decriminalization, of which few delineated medical oversight (23%) or training and/or licensure requirements (35%).”
A few thoughts:
1. This is a good summary of the changing legislative landscape.
2. The authors note the role and enthusiasm of business: “In 2021, companies invested more than $730 million in the development of psychedelic drugs and novel drug delivery systems; in contrast, just $4 million was invested by the NIH in the same year.”
3. The authors look at cannabis, and make a projection. “Based on data from cannabis legalization, we projected that most states will have passed legislation legalizing psychedelics by 2034 to 2037. It is possible that psychedelic reform will occur even more rapidly than cannabis reform…” We can debate the years in this prediction, but the push to legalization gains strength.
4. This paper focuses on legislation in the United States. Of course, in Canada, we are also seeing more discussion of changes, with Alberta leading the way.
The full JAMA Psych Special Communication can be found here:
Selection 3: “Another Effort to Get People With Mental Illness Experiencing Homelessness Off the Streets – A Sound Idea?”
Michael F. Hogan
JAMA Psychiatry, 12 April 2023
Another plan to use police officers to arrange hospitalization of people with mental illness experiencing homelessness in New York City has been announced. Critics have objected. Viewed from perspectives of evidence and experience, does the plan make sense? This Viewpoint assesses the plan and suggests improvements and alternatives.
Following a fatal incident involving a person with mental illness, New York City Mayor Eric Adams recently announced that police officers would expand efforts to hospitalize individuals with mental illness experiencing homelessness and expand inpatient psychiatric capacity by 50 beds. One might say, here we go again.
So begins a paper by Hogan.
He notes the strong reaction: “Advocates have promptly objected. Loosening commitment laws will violate civil rights. The police should not do street mental health work. The solution is not hospital beds but more housing and voluntary community services. And on cue, these responses are countered by others.”
He feels that the proposal is on the wrong side of history. “For starters, the 2 prongs of the plan – increasing police intervention and expanding inpatient beds – each push against current trends. Spurred by tragedies (including police shootings of individuals with mental illness) and by recognition that the law enforcement and criminal justice systems have become the de facto mental health crisis system, a movement to ‘decriminalize mental illness’ has emerged.”
He goes further, arguing from a policy perspective that “the New York City plan is a step backward.” He continues: “Contemporary thinking emphasizes mental health crisis teams instead of expanding the duties of police, and mental health crisis facilities instead of additional inpatient units in psychiatric centers. Developing this array of services, already in place in Arizona and other locations, would be a preferable strategy.”
He also argues on the grounds of practicality: “A more substantial limitation of the proposal is the fact that access to ‘aftercare,’ principally stable housing and flexible treatment and support, is not ensured in the mayor’s plan. Without these, any value achieved through hospitalization is temporary, providing only time-limited clinical benefit. Ensuring access to housing – preferably permanent supported housing – and continued treatment that is persistent, clinically competent, and engaging are needed to make the approach effective.”
He taps the literature:
- “Permanent supported housing (essentially a decent place to live and some supports) is the gold standard for addressing homelessness.”
- “In a randomized clinical trial, Raven et al found that supported housing reduced psychiatric emergency department visits and increased use of outpatient mental health care, confirming findings made in many prior studies.”
- “[P]roviding continuous and competent clinical care to people admitted and discharged under the plan is essential. The need for this kind of care for people with serious and unremitting mental illness is also obvious. What is not so obvious is that most outpatient care – even for people with serious mental illness – fails this test.”
A few thoughts:
1. This is a well-written paper.
2. “Coercive care is having a moment,” notes Anna Mehler Paperny in a recent Globe essay. Hogan focuses on New York City, but a push to re-balance patients’ rights occurs across North America, including Alberta, British Columbia, and California.
3. The comment about aftercare is particularly strong.
4. The larger debate is complicated and nuanced. In recent weeks, we have considered selections that have included the perspectives of those with lived experience, their families, and providers. For instance, earlier this month, we looked at the Mehler Paperny essay, which you can find here:
The full JAMA Psych Viewpoint can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.