Motor Carrier Questioning PTSD meds

Guy was diagnosed with PTSD and prescribed Trazodone, risperdal, and Prozac. Motor vehicle carrier is questioning meds, specifically risperdal. To my knowledge he should be fine. He is feeling good. Good after one week on meds. I know they have to be effective and safe. I guess my question is ……risperdal is not one of those medications prohibited to take while driving a commercial vehicle.

Although a medication is not specifically “prohibited,” any medication which causes sedation or other side effects that interfere with the safe operation of a commercial motor vehicle can be considered disqualifying by the medical examiner. In this case both Trazodone and Risperdal can indeed be sedating. You have to look at the whole picture of polypharmacy as well as the stability of the underlying disorders. One week on these meds, IMO, is not enough time to ascertain either stability of the underlying condition, nor the side effects of the medication. Pertinent FMCSA guidance is copied below: The FMCSA guidance is:

49 CFR 391.41(b)(9)

“Has no mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with his/her ability to drive a commercial motor vehicle safely.”

Psychological Disorders (b)(9)

Safe and effective operation of a commercial motor vehicle (CMV) requires high levels of physical strength, skill, and coordination as well as the ability to maintain adequate attention and react promptly and appropriately to traffic, emergency situations, and other job-related stressors.

Some psychological or personality disorders can directly affect memory, reasoning, attention, and judgment. Somatic and psychosomatic complaints should be thoroughly examined when determining overall fitness to drive. Disorders of a periodically incapacitating nature, even in the early stages of development, may warrant disqualification.

Advisory Criteria/Guidance

There are three categories of risk associated with psychological disorders.

• The mental disorder, including symptoms and/or disturbances in performance that are anintegral part of the disorder and may pose hazards for driving.

• Residual symptoms occurring after time-limited reversible episodes or initial presentation of the full syndrome that can interfere with safe CMV driving.

• Psychopharmacology, as many psychotropic medications can compromise performance to the degree that CMV driving would be hazardous.

The recommendations do not support automatic exclusion from CMV driving based solely on the diagnosis. Typically, the more serious the diagnosis, the more likely it is that the driver will be medically disqualified. Careful consideration should also be given to the side effects and interactions of medications in the overall qualification determination.Many of the medications used to treat psychological disorders have effects and/or side effects that render driving unsafe.The recommendations use the degree of impairment produced by a 0.04 percent blood alcohol concentration as a benchmark. This standard was chosen based on the FMCSA exclusionary rule related to alcohol usage.

Antidepressant Therapy

Guidelines recommend case-by-case assessment of drivers treated with antidepressant medication. Evidence indicates that some antidepressant drugs significantly interfere with skills performance and that these medications vary widely in the degree of impact.
With long-term use of antidepressants, many drivers will develop a tolerance to the sedative effects.
Your evaluation must consider both the specific medicine used and the pertinent characteristics of the patient.
First-generation antidepressants have consistently been shown to interfere with safe driving. First-generation antidepressants include tricyclics such as amitriptyline (Elavil) and imipramine (Tofranil).

Second-generation antidepressants have fewer side effects and are generally safe; however, these medications can still interfere with safe driving and require case-by-case evaluation. Second-generation antidepressants include selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and sertraline (Zoloft); serotonin and norepinephrine reuptake modulators such as venlafaxine (Effexor); and unicyclic aminoketones such as bupropion (Wellbutrin). You should consider the underlying reason for treatment when determining certification.

Anxiolytic and Sedative Hypnotic Therapy

Anxiolytic drugs used for the treatment of anxiety disorders and to treat insomnia are termed sedative-hypnotics. Studies have demonstrated that benzodiazepines, the most commonly used anxiolytics, and sedative-hypnotics, impair skills performance in pharmacologically active dosages. The effects of benzodiazepines on skills performance generally also apply to virtually all non- benzodiazepines sedative-hypnotics, although the impairment is typically less profound.
However, barbiturates and other sedative hypnotics related to barbiturates cause greater impairment in performance than benzodiazepines. Epidemiological studies indicate that the use of benzodiazepines and other sedative hypnotics are probably associated with an increased risk of automobile crashes.

Recommend not to certify if:

The driver:
• Uses a sedating anxiolytic.
• Has symptoms or side effects that interfere with safe driving.

Bipolar Mood Disorder

Mood disorders are characterized by their pervasiveness and symptoms that interfere with the ability of the individual to function socially and occupationally. The two major groups of mood disorders are bipolar and depressive disorders. Bipolar disorder is characterized by one or more manic episodes and is usually accompanied by one or more depressive episodes.

The onset of manic episodes may be sudden or gradual. Symptoms include excessively elevated, expansive, or irritable moods. During a manic episode, judgment is frequently diminished, and there is an increased risk of substance abuse. Some episodes may present with delusions or hallucinations. Treatment for bipolar mania may include lithium and/or anticonvulsants to stabilize mood and antipsychotics when psychosis manifests.

Symptoms of a depressive episode include loss of interest and motivation, poor sleep, appetite disturbance, fatigue, poor concentration, and indecisiveness. A severe depression is characterized by psychosis, severe psychomotor retardation or agitation, significant cognitive impairment (especially poor concentration and attention), and suicidal thoughts or behavior. In addition to the medication used to treat mania, antidepressants may be used to treat bipolar depression.

Other psychiatric disorders, including substance abuse, frequently coexist with bipolar disorder.

NOTE: Cyclothymia is a mild form of bipolar disorder that causes brief episodes of depression or elevated mood, but typically does not cause marked impairment. Treatment may include medication.
Determination is not based on diagnosis alone. The actual ability to drive safely and effectively should not be determined solely by diagnosis but instead by an evaluation focused on function and relevant history.

Waiting Period

Minimum — 6 months symptom free following a nonpsychotic major depression unaccompanied by suicidal behavior
Minimum — 1 year symptom free following a severe depressive episode, a suicide attempt, or a manic episode

NOTE: If more than one waiting period applies (because of multiple conditions or other comorbid diseases), examine the driver for certification after the completion of the longest waiting period.

Decision

Maximum certification — 1 year

Recommend to certify if:

The driver:
•Completes an appropriate symptom-free waiting period.
•Complies with treatment program.
•Tolerates treatment without disqualifying side effects (e.g., sedation or impaired coordination).
•Has a comprehensive evaluation from an appropriate mental health professional who understands the functions and demands of commercial driving.

Recommend not to certify if: The driver has:

•Active psychosis.
•Prominent negative symptoms, including:
◦Substantially compromised judgment.
◦Attentional difficulties.
◦Suicidal behavior or ideation.
◦Personality disorder that is repeatedly manifested by overt inappropriate acts.
◦Treatment side effects that interfere with safe driving.

Monitoring/Testing

At least every 2 years the driver with a history of a major mood disorder should have evaluation and clearance from a mental health specialist, such as a psychiatrist or psychologist, who understands the functions and demands of commercial driving. Advise the certified driver with a major mood disorder to report any manic or severe major depressive episode within 30 days of onset to the driver’s employer, medical examiner, or appropriate health care professional and to seek medical intervention. So the question really is whether the polypharmacology in this case is sedating enough to interfere with safe driving, and the stability of the underlying disorder(s). I would have to have detailed documentation from treating psychiatrists and psychologists indicating they are confident the medications are not causing any significant sedation, that the underlying conditions are stable, and that they are completely familiar with the job of commercial driving before I would feel comfortable qualifying a driver on these medications. A one-week period of time on new meds for these conditions is clearly not enough time for me to form this opinion, in general, I have not qualified such individuals.