Drivers' psychiatric disorders and fatal motor vehicle accidents in Finland

Journal of Psychiatric Research 84 (2017) 227e236

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Drivers' psychiatric disorders and fatal motor vehicle accidents in Finland € Hakko b, Juha Kanamüller b, Antti Kujansuu a, 1, Simo Rautiainen a, *, 1, Helina Niina Sihvola c, Pirkko Riipinen a a b c

Department of Psychiatry, Research Unit of Clinical Neuroscience, University of Oulu, P.O. Box 5000, Peltolantie 17, 90014 Oulu, Finland Department of Psychiatry, Oulu University Hospital, P.O. Box 26, 90029 Oulu, Finland Finnish Motor Insurers' Centre, Bulevardi 28, 00120 Helsinki, Finland

a r t i c l e i n f o

a b s t r a c t

Article history: Received 1 April 2016 Received in revised form 10 October 2016 Accepted 14 October 2016

Relatively little is known about fatal motor vehicle accidents (FMVA) involving drivers with psychiatric disorders. In this study of all drivers killed in FMVAs in Finland between 1990 and 2011, we aimed to study drivers' death rate trends in FMVAs, with special focus on drivers with a history of psychiatric disorders. Prevalence of drivers' hospital treated psychiatric disorders, and characteristics of drivers with psychiatric disorders were also studied. For the purpose of this study, three national registers were accessed. Drivers' hospital treated psychiatric disorders were screened in a five-year period prior to death. Drivers with (n ¼ 425) and without (n ¼ 3856) psychiatric disorders were compared, female and male drivers separately. The main outcome measure was any psychiatric disorder in drivers within the five-year timescale. Socio-demographic factors, use of intoxicants and medication at the time of death, recent adverse life events, and drivers' physical and emotional states were used as covariates in the statistical analyses. During the study period, death rates increased for females with psychiatric disorders, and decreased for females without psychiatric disorders. Death rates for males with psychiatric disorders decreased between the years 1990e2000 and 2007e2011, and increased between the years 2000e2007. Death rates decreased over the whole study period in males without psychiatric disorders. Alcohol related disorders and affective disorders were the most prevalent hospital treated psychiatric disorders among drivers involved in FMVAs. Use of medications at the time of death, and committing suicide in traffic both associated with being a driver with psychiatric disorders involved in FMVAs for both genders. As FMVAs involving drivers with psychiatric disorders have increased, a more focused and detailed evaluation of the driving performance of drivers with psychiatric disorders is recommended. These evaluations should also be extended to drivers with non-psychotic disorders. © 2016 Elsevier Ltd. All rights reserved.

Keywords: Traffic accidents Mental disorders Mortality Risk factors

1. Introduction Although some effort has been made to study the effect of psychiatric disorders on driving performance, relatively little is still known about the subject. Previous literature suggests that an association may exist between psychiatric disorders (e.g. schizophrenia and depression) and impaired driving performance (Bulmash et al., 2006; De Las Cuevas and Sanz, 2008; De Las Cuevas et al., 2010; St Germain et al., 2005; Wickens et al., 2014). However,

* Corresponding author. E-mail address: [email protected].fi (S. Rautiainen). 1 These authors contributed equally to the manuscript. http://dx.doi.org/10.1016/j.jpsychires.2016.10.010 0022-3956/© 2016 Elsevier Ltd. All rights reserved.

it remains unclear to what extent psychiatric disorders impact on driving performance given that psychiatric medication can also have a deleterious effect on driving. For an example, in many studies anxiolytics such as benzodiazepines, and tricyclic antidepressants are found to associate with higher risk for traffic accidents (Chang et al., 2013; Hetland and Carr, 2014; Orriols et al., 2009; Ravera et al., 2011). A recent study also found evidence that selective serotonin re-uptake inhibitors (SSRI) increases the risk for traffic accidents (Chang et al., 2013). However, as contradictory evidence exists (see reviews: Hetland and Carr, 2014; Orriols et al., 2009), the impact of SSRIs on traffic accident risk is not yet clearly established. In addition to having an effect on driving performance, psychiatric disorders per se may increase the risk of death in motor vehicle accidents (Crump et al., 2013; Dumais et al.,

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2005). Studies have found that comorbidity between substance use disorders and psychiatric disorders, such as anxiety and mood disorders, is common (European Monitoring Centre for Drugs and -Llopis and Matytsina, 2006). It has Drug Addiction, 2013; Jane also been found that psychiatric disorders, such as anxiety disorder, bipolar disorder and depression, associate with driving under the influence (DUI) of alcohol and/or drugs (Karjalainen et al., 2013; Lapham et al., 2001). Alcohol and drug use disorders have been shown to increase the risk for fatal motor vehicle accidents (FMVA) by over twofold (Callaghan et al., 2013). In this study we aim to analyze the trends in death rates of drivers killed in FMVAs in Finland, with a special focus on drivers with a history of psychiatric disorders. Additionally, the prevalence of drivers' hospital treated psychiatric disorders in a five-year period prior to their death, and driving related risk factors including alcohol, illicit drugs and medications, and their association with being a driver with history of psychiatric disorder, are studied. 2. Methods 2.1. Study population The initial study population (n ¼ 4930) consisted all drivers killed in motor vehicle accidents in Finland between the years 1990 and 2011, and whose deaths were investigated by Finnish road accident investigation teams. From the initial study population we selected a sample population which included only Finnish citizens. This was in order to ensure the availability of drivers' health related information. We studied drivers aged 16 years and above at their time of death because 16 is the minimum age to obtain a driver's license for a small motorcycle in Finland. Only fatal motor vehicle accidents (FMVA) involving small (engine size between 50 cm3 and 125 cm3) or regular sized motorcycles, cars and vans (including combination with trailers) were studied. A final total of 4281 drivers (3552 (83%) male and 729 (17%) female), fulfilled all of our inclusion criteria and were included in this study. 2.2. Data 2.2.1. The investigation of FMVAs and the database of road and cross-country traffic accidents We had access to data from three national registers which we combined using personal identity codes (Population Register Centre, n.d). The main data in this study was obtained from the Finnish database of road and cross-country traffic accidents, which is maintained by The Finnish Motor Insurers' Centre (LVK). This database contains results from investigations conducted by twenty independent road accident investigation teams (RAIT). In Finland, special RAITs have been responsible for investigating road and cross-country traffic accidents involving fatalities since 1968. This work has been statutory since 2001 (“Act on the investigation of road and cross-country traffic accidents No. 24/2001,” 2001, “Council of State decree on the investigation of road and crosscountry traffic accidents No. 740/2001,” 2001) and these investigations are steered and supervised by the Road Accident Investigation Delegation set up by the Ministry of Transport and Communications. The intention of the RAITs are to conduct comprehensive and method based investigations of FMVAs (The Finnish Motor Insurers' Centre, 2004). This is done primarily for traffic safety purposes. The teams consist of specialists from various disciplines, including police, medicine, vehicle technology, road maintenance and behavioral sciences, thus ensuring that the various factors that could explain the course and the cause of the

FMVA are acquired. RAITs also aim to interview the people involved, eyewitnesses and next-of-kin of the parties involved. Additionally, members of the RAITs are entitled to acquire information from various registers to complement their investigations. The Finnish Motor Insurers' Centre provided the main data in this study and approved its use (10/16/2013). A detailed description of the investigation method of FMVAs in Finland has been published elsewhere (Salo et al., 2006; The Finnish Motor Insurers' Centre, 2004). A summary of the investigation is also provided at the Finnish Motor Insurers' Centre's website (The Finnish Motor Insurers' Centre, 2015). 2.2.2. Health care register data We obtained drivers' health records from the Care Register for Health Care (CRFHC, previously Hospital Discharge Register), which has existed since 1969. CRFHC is a national health care register maintained by the National Institute of Health and Welfare in Finland (THL) and contains information on patients treated in hospitals, health centers and other inpatient care institutions (National Institute for Health and Welfare, 2014). Information gathered in the register includes treatment diagnoses (main and subsidiary diagnoses) and the length of hospital treatment. The Finnish Classifications of Diseases, which is based on the International Classification of Diseases (ICD) versions 8, 9 and 10, has been used since 1969, 1987 and 1996, respectively (Tautiluokitus, 1969, 1987, Tautiluokitus ICD-10, 1995). Using CRFHC data, we screened for drivers' psychiatric inpatient hospital diagnoses within a five-year time-period prior to the driver's death. Table 1 presents the psychiatric diagnoses and their categorization. THL approved our access of the CRFHC and provided the health care data (THL/1270/5.05.00/2013, 3/12/2014). 2.2.3. Cause of death data Cause of death information was obtained from the official death certificates of drivers killed in FMVAs. In Finland, all suicides and unintentional injuries leading to death are examined by forensic medicine specialist physicians (“Act on the Inquest into the Cause of Death No. 459/1973,” 2011). Official death certificates are completed after the examination and eventually archived by Statistics Finland (Statistics Finland, n.d). Statistics Finland provided the official death certificates for this study and approved their use (TK53-1422-13, 11/20/2013). 2.3. Outcome The outcome variable in this study was any driver's hospital treated psychiatric disorder within the five-year time-period prior to their FMVA (yes/no). Psychiatric disorders were either main or subsidiary diagnoses in the CRFHC data. After initial analyses, we made a follow-up analysis while excluding drivers with alcohol related disorder or drug use disorders from the outcome variable. 2.4. Covariates 2.4.1. Socio-demographics Using the database of road and cross-country traffic accidents, we studied the following socio-demographic variables: driver's age, marital status, education, and employment status at the time of death. Driver's marital status was categorized as: unmarried, married or cohabiting, divorced or separated, widowed, other/unknown. Education, either completed or ongoing, was categorized as: basic (elementary/junior high), intermediate (vocational/upper secondary education), high (university/university of applied sciences education), and other/unknown. Employment status was categorized as: employed (any job), unemployed, and other/

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Table 1 Classification of disorder groups according to ICD-8, ICD-9 and ICD-10 diagnoses. Disorder

ICD-8 (since 1969)

ICD-9 (since 1987)

ICD-10 (since 1997)

Any Affective Alcohol related Anxiety Drug use Personality Psychotic Other

290e319 296 291, 303 300, 305, 306, 308, 309 2943, 304 301 295, 297, 298, 299 Those diagnoses not included in other groups.

290e319 296 291, 303, 300, 306, 292, 304, 301 295, 297,

F F30-F39 F10 F40-F48 F11-F16, F18-F19 F60-F62, F21 F20, F22-F29

3050 308, 309 3052e3057, 3059 298

ICD ¼ International Classification of Diseases. Disorder groups were formed using either main or subsidiary diagnoses from the Care Register For Health Care. Disorder groups are not mutually exclusive and single driver may belong to several groups.

unknown (housewife, retired, student, unknown). 2.4.2. Intoxicants and medications Information regarding intoxicants and medications was acquired from the database of road and cross-country traffic accidents. Details of alcohol use (blood alcohol concentration, BAC, ‰) was derived from the variable “BAC measured either from blood or breath sample” (breath samples can be taken if the driver did not die immediately as a result of the accident) and was categorized as: no alcohol/unknown, <0.5‰, 0.5e1.9‰, 1.2‰ or above. The variables illicit drugs (yes/no), medications (yes/no) and other substance findings (e.g. caffeine, carbon monoxide, blood sugar level; yes/no) were based on data gathered in medico-legal examinations. 2.4.3. Recent adverse life events Information regarding recent adverse life events are gathered by the members of RAITs during their investigation by asking the people involved or drivers' next-of-kin whether the driver had any recent problems/concerns and, if so, what kind of problems. We studied the following recent life events: financial problems (yes/ no), health problems (yes/no), illness or death of next-of-kin (yes/ no), relationship problems (yes/no), and workplace issues/work stress (yes/no). 2.4.4. Other covariates Other covariates studied were related to the drivers' physical or emotional state at the time of the accident. These were gathered by RAITs during their investigations. Atypical emotional state was categorized as following: normal/unknown, angry/agitated/ annoyed, depressed/distressed/withdrawn, happy/riotous or defiant, and other. The variable “strain affecting ability to drive” was categorized as: nothing special/unknown, emotional stress, physical stress, and other. The variable tiredness (yes/no) is an estimation made by the police member of the RAIT. The primary cause of death was used as a covariate to indicate the driver's intention during the accident (ie. did the driver die by accident or purposely due a suicide). Causes of death were acquired from the official death certificates and were categorized as follows: accident, acute illness, suicide, and other/unknown. We also conducted further analyses based on the variables: medication affecting driving performance (yes/no, evaluated by the RAITs) and previous driving under the influence (DUI) offenses. Accident database included drivers' DUI offenses within 5 years prior to their death. DUI and aggravated DUI offences were combined and categorized as follows: no, and one or more. 2.5. Statistical analyses We used chi square test (c2) and Fisher's Exact test (FET) to evaluate the statistical significances in categorical variables. The average annual population in Finland for persons aged 16 years and

above was obtained from Statistics Finland (Statistics Finland, 2015) and was used to calculate the three year moving averages in death rates per 100,000 population. Drivers' death rate trends were analyzed using Joinpoint Regression Program (National Cancer Institute, 2015). The models suggested by the Joinpoint program were used for male and female drivers with psychiatric disorders, and for male drivers without psychiatric disorders. The model suggested by the program for female drivers without psychiatric disorders was considered to be unreliable due to the small sample size with very little variance in the annual death rates. It was, therefore, rejected and a model with zero joinpoints was chosen. The likelihood of being a driver with psychiatric disorder(s) was analyzed with gender-specific age-adjusted logistic regression using the following covariates: socio-demographics, intoxicants and medications, recent adverse life events and other covariates. Variables for the model were selected using the stepwise forward method. The goodness-of-fit for the models were tested using HosmereLemeshow test. Odds ratios (OR) with 95% confidence intervals (CI) and P values are reported. Statistical analyses were conducted using IBM SPSS Statistics version 22 (Mac OS X and Windows versions) and Joinpoint Regression Program 4.1.0. All statistical tests were two-tailed. A limit for statistical significance was set at P values under 0.05. 3. Results 4281 drivers (aged between 16 and 93 years) died in fatal motor vehicle accidents (FMVA) in Finland between the years 1990 and 2011. Of these, 83% were male (n ¼ 3552) and 17% (n ¼ 729) were female. Of the study population, 24.9% were aged between 16 and 24 years, 31.6% were 25e44 years, 26.0% were 45e64 years, and 17.4% were 65 years or above. 3.1. Trends in FMVA drivers' death rates in Finland between the years 1990e2011 In the study population, 10.1% (n ¼ 360) of male and 8.9% (n ¼ 65) of female drivers had at least one hospital treated psychiatric disorder in the five-year time-period prior to their death. Death rates for male drivers with psychiatric disorders were falling between 1990 and 2000 (Annual Percentage Change ¼ 4.84, p < 0.001) (Fig. 1a). As of 2000, death rates started to increase, first more steeply (APC ¼ 19.76, p ¼ 0.02) up to the year 2003, and from there, more gradually up to 2007 (APC ¼ 2.25, p ¼ 0.53). Since then the death rates for male drivers with psychiatric disorders have been decreasing again (APC ¼ 7.97, p ¼ 0.003). In male drivers without a history of psychiatric disorders, death rates decreased throughout almost the entire study period (Fig. 1b). The decreasing trend was first observed between 1990 and 1994 (APC ¼ 7.85, p¼<0.001). From 1994, a slight but statistically nonsignificant increase was observed (APC ¼ 0.05, p ¼ 0.88) until 2006 onwards,

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Fig. 1. Trends in death rates of drivers of fatal motor vehicle accidents a) with and b) without hospital treated psychiatric disorders in Finland between years 1990 and 2011. Caret (^) signifies that Annual Percentage Chance (APC) differs statistically significantly from zero (p < 0.05). Note the scaling difference on Y-axes.

when the death rates began to decrease significantly again (APC ¼ 4.50, p ¼ 0.001). In females, an increasing trend in death rates was observed for drivers with psychiatric disorders (APC ¼ 2.94, p ¼ 0.03) (Fig. 1a) during the entire study period, while a decreasing trend was observed for females without a history of psychiatric disorders (APC ¼ 2.68, p < 0.001) (Fig. 1b). 3.2. Prevalence of hospital treated psychiatric disorders in male and female drivers Alcohol related disorders (with 4.3% prevalence), affective disorders (3.8%), and anxiety disorders (2.8%) were the most prevalent hospital treated psychiatric disorders in the drivers involved in FMVAs (Table 2). When proportioned to all drivers in FMVAs, male drivers had statistically significantly more alcohol related disorders, whereas female drivers had more affective disorders and

personality disorders. 3.3. Factors associated with being a driver of FMVAs with psychiatric disorders Table 3 presents the frequency distributions of variables used in the stepwise logistic regression. Table 4 summarizes significant results from the analysis predicting the likelihood of being a driver of FMVAs with psychiatric disorders. In the case of socio-demographic characteristics, being unmarried or divorced and having a basic-level education increased the risk of being a male driver with psychiatric disorders, whereas being unemployed increased the risk of being a female driver with psychiatric disorders. In both males and females, the likelihood of being a driver with psychiatric disorders increased with illegal levels of blood alcohol concentrations (BAC, 0.5‰) and post-

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Table 2 Prevalence of drivers' hospital treated psychiatric disorders among drivers involved in FMVAs. Disorder

Any Affective Alcohol related Anxiety Drug use Personality Psychotic Other

Total (n ¼ 4281)

Male (n ¼ 3552)

Female (n ¼ 729)

n (%)

n (%)

n (%)

425 (9.9) 162 (3.8) 184 (4.3) 119 (2.8) 49 (1.1) 75 (1.8) 85 (2) 72 (1.7)

360 (10.1) 125 (3.5) 165 (4.6) 98 (2.8) 42 (1.2) 55 (1.5) 73 (2.1) 59 (1.7)

65 (8.9) 37 (5.1) 19 (2.6) 21 (2.9) 7 (1) 20 (2.7) 12 (1.6) 13 (1.8)

P-value

0.316 0.045 0.013 0.856 0.607 0.025 0.471 0.815

FMVA ¼ fatal motor vehicle accident. Disorder groups are not mutually exclusive and single driver may belong to several groups. Drivers' disorders were screened from the Care Register for Health Care in a five-year time-period prior to their death.

mortem found medications at the time of death. According to the RAITs reports, the proportion of drivers who were evaluated to have taken medication that could affect their driving ability was statistically significantly higher in drivers with psychiatric disorders (Table 3). Of drivers with psychiatric disorders, 19.4% (n ¼ 70) of male and 24.6% (n ¼ 16) of female victims were evaluated to have taken medications that could affect their driving ability. Additionally, the proportion of drivers with previous driving under the influence (DUI) offences was higher in drivers with psychiatric disorders when compared to drivers without psychiatric disorders (Table 3). 33.9% (n ¼ 122) of male and 18.5% (n ¼ 12) of female victims with psychiatric disorders were found to have one or more previous DUI offences within the five years prior to their death. Recent financial and health problems were also found to associate with being a male driver with psychiatric disorders. For both male and female victims, the likelihood of being a driver with psychiatric disorders increased over threefold with suicide as a primary cause of death. After the initial analysis, a follow-up logistic regression was made while excluding drivers with alcohol related disorders or drug use disorders from the sample. Results from this analysis are presented in Table 5. After excluding drivers with substance use disorders, 208 drivers with psychiatric disorders remained. Of the socio-demographic variables, basic level education and unemployment were factors that associated with being a male driver with psychiatric disorders. Medication use at the time of death remained a statistically significant risk factor for both genders. Alcohol use at the time of death did not associate with being a driver with psychiatric disorders in the follow-up analysis. The proportion of drivers with one or more previous DUI offences remained statistically significantly higher in male drivers with psychiatric disorders (n ¼ 32, 19%) when compared to males without psychiatric disorders (n ¼ 383, 12%) (c2 ¼ 7.33, df ¼ 1, p ¼ 0.007), whereas the same comparison between female drivers with (n ¼ 3, 7.5%) and without (n ¼ 14, 2.1%) psychiatric disorders was not statistically significant (Fisher's Exact test, p ¼ 0.07). Of the recent adverse life events, health problems associated with male drivers and relationship problems associated with female drivers. Suicide as the primary cause of death remained a risk factor to associate with being a driver with psychiatric disorders in the follow-up analysis.

4. Discussion Between the years 1990 and 2011, 4281 drivers were killed in fatal motor vehicle accidents (FMVA) in Finland. Of these drivers, 9.9% had been hospitalized due to psychiatric disorders within the five years prior to their death. The major finding in our study was that the trend in death rates in drivers with psychiatric disorders

has been increasing recently, particularly from 2000 until 2007 for male, and during the whole study period for female victims. A decreasing trend in death rates was observed for drivers without a history of psychiatric disorders. In addition, medication use at the time of death, and committing suicide in traffic were both risk factors that associated with being a driver of FMVAs with psychiatric disorders. While recent EU statistics have shown that road fatalities have decreased in Europe (European Commission. Road safety, 2015), a similar trend has not been evident in Finland for death rates in FMVAs. The Finnish Motor Insurers' Centre has reported that death rates in FMVAs were decreasing until 1993 (Liikennevakuutuskeskus, 2010). Death rates then remained relatively stable until 2008 when the death rates in FMVAs started decreasing again (Liikennevakuutuskeskus, 2014). This trend was also observed in our findings concerning death rates for drivers without psychiatric disorders. However, while the death rates of drivers without psychiatric disorders have been generally declining during the study period, the opposite trend was found for drivers with psychiatric disorders and this certainly requires some attention. It appears that the positive development behind the decreasing trend might not completely apply to drivers with psychiatric disorders. It is possible that the de-institutionalization of psychiatric care, a reduction of inpatient psychiatric hospital beds (Wahlbeck et al., 2011) and decreased hospitalization in specialized level psychiatric care (Kouvonen et al., 2014) may have played a part in the increase of death rates among drivers with psychiatric disorders. Outpatient and primary health care might not have sufficient resources to evaluate the driving performance of patients with psychiatric disorders, particularly those with non-psychotic psychiatric disorders. Additionally, modern psychiatric medication might be less debilitating overall, and may even improve driving performance in some people with psychiatric disorders. This may lead patients and physicians to become less concerned about a patient's fitness-to-drive. Further studies are required to explore the risk of drivers with psychiatric disorders dying in FMVAs compared to those without psychiatric disorders. Gender differences in the prevalence rates of psychiatric disorders found in our study are similar to those found in other studies and among a representative sample of the Finnish general population, this being that females have more affective disorders and anxiety disorders, whereas males have more alcohol related disorders (Pirkola et al., 2005; Seedat et al., 2009). Interestingly, in our study personality disorders were almost twice as prevalent in female drivers than in male drivers while, among the general population, personality disorders are more prevalent among males (Huang et al., 2009). Furthermore, in our study, committing suicide in traffic was related to the presence of psychiatric disorders. This finding was expected, since suicide risk is increased in many

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Table 3 Characteristics of drivers involved in FMVAs with and without psychiatric disorders.

Total Socio-demographics Agea 16e24 25e44 45e64  65 Education Basic Intermediate High Other/unknown Employment status Employed Unemployed Other Marital status Married/cohabiting Unmarried Divorced Widoved Other/unknown Intoxicants and medicationb Alcohol (BAC, ‰) No alcohol/unknown < 0.5 0.5e1.19  1.2 Illicit drugs Medications Medication affecting driving performancec Other substances Recent adverse life events Financial problems Health problems Next of kins illness or death Relationship problems Workplace issues/work stress Other Atypical emotional state Normal/unknown Angry, agitated Depressed, distressed, withdrawn Happy, riotous, defiant Other Strain affecting ability to drive Nothing special/unknown Emotional stress Physical stress Other Tiredness Previous DUI offences (prior 5 years): one or morec Primary cause of deathd Accident Acute illness Suicide Other/unknown

Male drivers of FMVAs

Female drivers of FMVAs

With psychiatric disorders

With psychiatric disorders

Without psychiatric disorders

Without psychiatric disorders

n (%)

n (%)

P-value

n (%)

n (%)

P-value

360 (10.1)

3192 (89.9)

e

65 (8.9)

664 (91.1)

e

87 (24.2) 149 (41.4) 101 (28.1) 23 (6.4)

829 931 792 640

13 (20) 30 (46.2) 22 (33.8) 0 (0)

137 (20.6) 244 (36.7) 199 (30) 84 (12.7)

142 (39.4) 83 (23.1) 33 (9.2) 102 (28.3)

1101 (34.5) 958 (30.0) 391 (12.2) 742 (23.2)

15 19 11 20

176 219 122 147

173 (48.1) 32 (8.9) 155 (43.1)

1606 (50.3) 80 (2.5) 1506 (47.2)

94 (26.1) 159 (44.2) 55 (15.3) 4 (1.1) 48 (13.3)

1375 (43.1) 1190 (37.3) 198 (6.2) 107 (3.4) 322 (10.1)

175 (48.6) 10 (2.8) 28 (7.8) 147 (40.8) 19 (5.3) 131 (36.4) 70 (19.4) 35 (9.7)

2282 (71.5) 64 (2.0) 109 (3.4) 737 (23.1) 75 (2.3) 445 (13.9) 126 (3.9) 82 (2.6)

31 66 19 62 17

81 (2.5) 148 (4.6) 99 (3.1) 232 (7.3) 100 (3.1)

(8.6) (18.3) (5.3) (17.2) (4.7)

(26) (29.2) (24.8) (20.1)

243 (67.5) 18 (5) 57 (15.8) 27 (7.5) 15 (4.2)

2634 (82.5) 98 (3.1) 175 (5.5) 155 (4.9) 130 (4.1)

274 (76.1) 31 (8.6) 14 (3.9) 41 (11.4) 76 (21.1) 122 (33.9)

2611 (81.8) 125 (3.9) 176 (5.5) 280 (8.8) 541 (16.9) 383 (12)

231 (64.2) 8 (2.2) 70 (19.4) 51 (14.2)

2498 (78.3) 244 (7.6) 173 (5.4) 277 (8.7)

<0.001

0.003

(23.1) (29.2) (16.9) (30.8)

(26.5) (33) (18.4) (22.1)

0.019

0.473

<0.001

32 (49.2) 6 (9.2) 27 (41.5)

372 (56.0) 5 (0.8) 287 (43.2)

<0.001

<0.001

25 (38.5) 16 (24.6) 13 (20) 3 (4.6) 8 (12.3)

304 (45.8) 177 (26.7) 60 (9.0) 43 (6.5) 80 (12.0)

0.083

0.001 <0.001 <0.001 <0.001

37 (56.9) 3 (4.6) 7 (10.8) 18 (27.7) 1 (1.5) 32 (49.2) 16 (24.6) 8 (12.3)

601 (90.5) 6 (0.9) 6 (0.9) 51 (7.7) 3 (0.5) 89 (13.4) 21 (3.2) 10 (1.5)

0.312 <0.001 <0.001 <0.001

<0.001 <0.001 0.029 <0.001 0.109

4 (6.2) 14 (21.5) 2 (3.1) 16 (24.6) 4 (6.2)

11 28 26 42 21

(1.7) (4.2) (3.9) (6.3) (3.2)

0.037 <0.001 0.999 <0.001 0.269

<0.001

37 (56.9) 3 (4.6) 15 (23.1) 5 (7.7) 5 (7.7)

565 (85.1) 18 (2.7) 25 (3.8) 25 (3.8) 31 (4.7)

<0.001

47 (72.3) 10 (15.4) 1 (1.5) 7 (10.8) 11 (16.9) 12 (18.5)

582 (87.7) 20 (3.0) 25 (3.8) 37 (5.6) 77 (11.6) 14 (2.1)

36 (55.4) 1 (1.5) 18 (27.7) 10 (15.4)

570 (85.8) 15 (2.3) 27 (4.1) 52 (7.8)

<0.001

<0.001

0.048 <0.001

<0.001

<0.001

<0.001

0.208 <0.001

<0.001

FMVA ¼ Fatal motor vehicle accident, BAC ¼ Blood alcohol concentration, DUI ¼ Driving under the influence. Variables presented in this table are used as explanatory variables in the stepwise logistic regression. In dichotomous variables, no-answers are omitted from the table. NB: Percentages may not add up to 100 due to rounding. a Categorical age is presented here for additional information. Logistic regression is adjusted with continuous age. b Alcohol use at the time of death is based on blood/breathalyzer test, medications and other findings at the time of death are from the post-mortem examination. c Variable (from the RAITs reports) is presented here for additional information. Variable in itself is excluded from the logistic regression due the possibility of overlap/ correlation with other variables in the regression model. d From the death certificates.

psychiatric disorders, including anxiety, affective and alcohol related disorders (Chesney et al., 2014; Harris and Barraclough,

1997). Previous studies have found that psychiatric disorders, such as

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Table 4 Risk factors associated with being a driver of FMVAs with psychiatric disorders. a) Male drivers

Socio-demographic Education Intermediate Basic High Other/unknown Employment status Employed Unemployed Other Marital status Married/cohabiting Unmarried Divorced Widoved Other/unknown Intoxicants and medicationb Alcohol (BAC, ‰) No alcohol <0.5 0.5e1.19 1.2 Medications Other Recent adverse life events Financial problems Health problems Other Primary cause of deathc Accident Acute illness Suicide Other/unknown Constant

b) Female drivers

OR (95% CI)a

P-value

1.0 1.98 (1.44e2.73) 1.47 (0.92e2.33) 1.83 (1.30e2.59)

<0.001 0.106 0.001

1.0 1.64 2.73 0.82 2.08

(1.17e2.31) (1.82e4.10) (0.28e2.38) (1.38e3.13)

0.004 <0.001 0.714 <0.001

1.0 1.23 2.23 1.97 3.39 2.97

(0.58e2.60) (1.36e3.67) (1.50e2.58) (2.57e4.46) (1.88e4.69)

0.59 0.001 <0.001 <0.001 <0.001

1.67 (1.02e2.74) 3.01 (2.07e4.39)

0.042 <0.001

1.0 0.43 (0.20e0.92) 3.38 (2.39e4.77) 1.95 (1.37e2.78) 0.03

0.030 <0.001 <0.001 <0.001

OR (95% CI)a

P-value

1.0 7.68 (1.73e34.05) 1.22 (0.66e2.25)

0.007 0.533

1.0 3.06 (0.56e16.77) 11.15 (2.93e42.39) 4.03 (1.87e8.67) 7.27 (3.75e14.1) 3.42 (1.06e11.03)

0.198 <0.001 <0.001 <0.001 0.04

1.0 1.28 (0.15e10.83) 3.84 (1.69e8.71) 2.27 (0.96e5.36) 0.05

0.822 0.001 0.061 <0.001

FMVA ¼ fatal motor vehicle accident, OR ¼ odds ratio, CI ¼ confidence interval, BAC ¼ blood alcohol concentration. Presented in this table are significant ORs with 95% CIs from the final step of the stepwise logistic regression. Omitted are reference groups from dichotomous variables (e.g. Medications: no (reference)/yes). HosmereLemeshow test results for the final steps: a) c2 ¼ 17.840, df ¼ 8, p ¼ 0.022, b) c2 ¼ 10.387, df ¼ 8, p ¼ 0.239. a Adjusted for age (continuous). b Alcohol use at the time of death is based on blood/breathalyzer test, medications and other findings at the time of death are from the post-mortem examination. c From the death certificates.

anxiety disorders, bipolar disorder, depression, and substance use disorders associate with DUI (Karjalainen et al., 2013; Lapham et al., 2001). Our results are partly in line with previous findings and add evidence to support the existence of this association. Initially, blood alcohol concentration levels above the legal driving limit [BAC  0.5‰, according to the Finnish law (“The Finnish Criminal Act. On traffic offences. No. 545/1999,” 1999)] increased the likelihood of being a driver of FMVAs with psychiatric disorders. However, this association was diminished after excluding drivers with substance use disorders from our analysis. It seems that among FMVA drivers with psychiatric disorders, only those with substance use disorders seem to die while driving under the influence of alcohol. Medication use at the time of death, however, was associated with being a driver with psychiatric disorders even after excluding drivers with substance use disorders. Psychiatric disorders might also associate with DUI recidivism. When compared to the general population, recidivistic DUI offenders were reported to have higher lifetime and 12-month prevalence of psychiatric disorders, such as substance use disorders and generalized anxiety disorder (Shaffer et al., 2007). In our study, the proportion of drivers with previous DUI offences was higher in male drivers with psychiatric disorders when compared to males without psychiatric disorders, even after excluding drivers with substance use disorders from the sample. In Finland, police officers can request a physician's evaluation of a driver's fitness-to-drive when

encountering a driver with health related problems that may impair in their driving performance. This raises questions of whether the Police should be ordering DUI drivers to have medical assessments more frequently, and additionally, whether a comprehensive psychiatric evaluation of DUI driver's fitness-todrive should be considered more often. 4.1. Strengths and limitations The major asset of our study was the utilization of data from three national registers, which were reliably combined using personal identity codes (Population Register Centre, n.d). The database of road and cross-country traffic accidents provides unique opportunities to study FMVAs, as it is gathered by multidisciplinary investigation teams using structured investigation methods. Subsequently, we were able to gather comprehensive details concerning the course of all fatal accidents in the whole of Finland. This large data, representative of the whole nation, allows more generalized conclusions to be drawn from our results. In addition, the Care Register for Health Care (CRFHC) allowed us to gather all drivers' inpatient psychiatric diagnoses for our study population. As these are real treatment diagnoses assessed by physicians, it adds significant value to our results. Further, as a medico-legal examination of unintentional injuries and suicides is obligated by the law in Finland (“Act on the Inquest into the Cause of Death No. 459/

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Table 5 Risk factors associated with being a driver of FMVAs with psychiatric disorders after excluding drivers with alcohol related disorders or drug use disorders from the sample. a) Male drivers

Socio-demographic Education Intermediate Basic High Other/unknown Employment status Employed Unemployed Other Intoxicants and medicationb Medications Recent adverse life events Health problems Other Primary cause of deathc Accident Acute illness Suicide Other/unknown Constant b) Female drivers

Cases (n ¼ 168)

Controls (n ¼ 3192)

n (%)

n (%)

OR (95% CI)a

P-value

44 60 16 48

(26.2) (35.7) (9.5) (28.6)

958 (30.0) 1101 (34.5) 391 (12.2) 742 (23.2)

1.0 1.72 (1.12e2.64) 1.42 (0.76e2.64) 1.90 (1.21e2.98)

0.014 0.268 0.005

68 (40.5) 14 (8.3) 86 (51.2)

1606 (50.3) 80 (2.5) 1506 (47.2)

1.0 2.31 (1.18e4.52) 1.51 (1.07e2.13)

0.015 0.018

57 (33.9)

445 (13.9)

3.11 (2.13e4.55)

<0.001

32 (19)

148 (4.6)

3.61 (2.22e5.85)

<0.001

101 (60.1) 3 (1.8) 39 (23.2) 25 (14.9)

2498 (78.3) 244 (7.6) 173 (5.4) 277 (8.7)

1.0 0.37 (0.11e1.22) 4.36 (2.83e6.73) 2.04 (1.27e3.28) 0.04

0.102 <0.001 0.003 <0.001

Cases (n ¼ 40) n (%)

Controls (n ¼ 664) n (%)

OR (95% CI)a

P-value

21 (52.5)

89 (13.4)

8.05 (3.83e16.95)

<0.001

9 (22.5)

42 (6.3)

2.66 (1.05e6.75)

0.039

23 (57.5) 1 (2.5) 9 (22.5) 7 (17.5)

570 (85.8) 15 (2.3) 27 (4.1) 52 (7.8)

1.0 1.88 (0.22e16.49) 3.50 (1.31e9.33) 3.02 (1.18e7.73) 0.06

0.567 0.012 0.021 <0.001

b

Intoxicants and medication Medications Recent adverse life events Relationship problems Other Primary cause of deathc Accident Acute illness Suicide Other/unknown Constant

FMVA ¼ fatal motor vehicle accident, OR ¼ odds ratio, CI ¼ confidence interval. Presented in this table are significant ORs with 95% CIs from the final step of the stepwise logistic regression. Omitted are reference groups from dichotomous variables (e.g. Medications: no (reference)/yes). HosmereLemeshow test results for the final steps: a) c2 ¼ 8.137, df ¼ 8, p ¼ 0.42, b) c2 ¼ 10.433, df ¼ 8, p ¼ 0.24. a Adjusted for age (continuous). b From the post-mortem examination. c From the death certificates.

1973,” 2011), the rate of medico-legal autopsies in aforementioned cases has been shown to be high (Lunetta et al., 2007). Thus, the cause-of-deaths are physician assessed and reliable. The validity of CRFHC and the cause-of-death register has also proven to be €, 2001; adequate for scientific purposes (Lahti and Penttila Miettunen et al., 2011; Sund, 2012). However, some limitations should be considered when interpreting our results. In our study, different psychiatric diagnoses were consolidated into a single psychiatric disorders category. We acknowledge that specific psychiatric symptoms and disorders might associate with different types of driving related risk factors. However, we took this approach because a great deal of comorbidity exists between the various diagnoses (e.g. depression and anxiety disorders) and analyzing specific diagnoses separately would not have been statistically feasible in the present study. A major limitation is the fact that the drivers' specific pharmacological profile was not available for our use. Therefore, while we found that medication use at the time of death associated with being a driver with psychiatric disorders, we could not assess what type of medication caused the association. Another limitation arises from the use of psychiatric inpatient diagnoses only. Disorders mainly treated in primary or outpatient care, such as depression, are probably underrepresented in our study. We also acknowledge that drivers with outpatient or primary care treated psychiatric

disorders are considered to be without psychiatric disorders in this study, and thus our results might be applicable only to drivers with severe psychiatric disorders. Additionally, in the logistic regression the number of cases in some subgroup analyzes were small. Therefore, results from these cases should be interpreted with great caution. Limitations also apply to date gathering. As the interest of the RAITs is to obtain all possible details related to the FMVAs, interviews are used to gather some of the information. Interviews are prone to include some recall errors, biases and fabrications. Misinterpretations can also arise from the fact that RAITs allow the possibility for subjective opinions for some details based on the level of expertise of the person conducting the investigation. However, this should be a minor issue as their work is mainly guided by the investigation procedure. 4.2. Conclusion Death rates for drivers with a psychiatric disorder have recently increased. In particular, medication use at the time of death and committing suicide in traffic were found to associate with being a driver with a psychiatric disorder involved in a FMVA. This study emphasizes the importance of comprehensively evaluating the fitness-to-drive of patients with a psychiatric disorder, including

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those with non-psychotic disorders. Future studies should focus on the possible multifactorial reasons underlying the increased trend in death rates of drivers with psychiatric disorders. There is also a need for studies analyzing the association between different driving related risk factors, different psychiatric symptoms, and specific psychiatric disorders. In studying factors contributing to FMVAs, the effect of the current status of a driver's psychiatric disorder, and the use of psychotropic medication at the time of death, should be studied in further detail. Additionally, studies using a longer observation period are needed to determine whether the decrease in death rates observed between 2007 and 2011 for male drivers with psychiatric disorders is a permanent development. Role of the funding source This study was financially supported with grants from The Traffic Safety Committee of Insurance Companies (VALT) (Riipinen), Henry Ford Foundation (Kujansuu, Rautiainen) and The Finnish Medical Foundation (Rautiainen). Funding sources had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article of publication. Conflict of interest None. Contributors All authors contributed to the study design, analysis and interpretation of data, and drafting of the manuscript. Statistical analyses were conducted by HH, JK, AK, and SR. Study was overall supervised by HH and PR. AK and SR contributed equally to the manuscript. Acknowledgement The authors would like to thank The Finnish Motor Insurers' Centre (LKV), National Institute of Health and Welfare, and Statistics Finland for providing the data used in this study. Additionally, Docent Kaisa Riala, MD, PhD, of the Division of the Adolescent Psychiatry, Helsinki University Central Hospital, is thanked for her valuable and insightful comments after reviewing the manuscript. References Act on the Inquest into the Cause of Death No. 459/1973, 2011. https://www.finlex. fi/fi/laki/ajantasa/1973/19730459 (accessed 1.1.15). Act on the Investigation of Road and Cross-country Traffic Accidents No. 24/2001, 2001. http://www.finlex.fi/fi/laki/alkup/2001/20010024 (accessed 7.20.15). Bulmash, E.L., Moller, H.J., Kayumov, L., Shen, J., Wang, X., Shapiro, C.M., 2006. Psychomotor disturbance in depression: assessment using a driving simulator paradigm. J. Affect. Disord. 93, 213e218. http://dx.doi.org/10.1016/ j.jad.2006.01.015. Callaghan, R.C., Gatley, J.M., Veldhuizen, S., Lev-Ran, S., Mann, R., Asbridge, M., 2013. Alcohol- or drug-use disorders and motor vehicle accident mortality: a retrospective cohort study. Accid. Anal. Prev. 53, 149e155. http://dx.doi.org/10.1016/ j.aap.2013.01.008. Chang, C.-M., Wu, E.C.-H., Chen, C.-Y., Wu, K.-Y., Liang, H.-Y., Chau, Y.-L., Wu, C.-S., Lin, K.-M., Tsai, H.-J., 2013. Psychotropic drugs and risk of motor vehicle accidents: a population-based case-control study. Br. J. Clin. Pharmacol. 75, 1125e1133. http://dx.doi.org/10.1111/j.1365-2125.2012.04410.x. Chesney, E., Goodwin, G.M., Fazel, S., 2014. Risks of all-cause and suicide mortality in mental disorders: a meta-review. World Psychiatry 13, 153e160. http:// dx.doi.org/10.1002/wps.20128. Council of State Decree on the Investigation of Road and Cross-country Traffic Accidents No. 740/2001, 2001. http://www.finlex.fi/fi/laki/alkup/2001/20010740 (accessed 10.21.15). Crump, C., Sundquist, K., Winkleby, M.A., Sundquist, J., 2013. Mental disorders and

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