Evaluation method regarding the effect of psychotropic drugs on driving performance: A literature review

Utilizing Technology to Enhance the Ecological Validity of Cognitive and Functional Assessments in Schizophrenia: An Overview of the State-of-the-Art

Cognitive impairment is a core feature of schizophrenia and a key determinant of functional outcome. Although conventional paper-and-pencil based cognitive assessments used in schizophrenia remained relatively static during most of the 20th century, this century has witnessed the emergence of innovative digital technologies that aim to enhance the ecological validity of performance-based assessments. This narrative review provides an overview of new technologies that show promise for enhancing the ecological validity of cognitive and functional assessments. We focus on 2 approaches that are particularly relevant for schizophrenia research: (1) digital functional capacity tasks, which use simulations to measure performance of important daily life activities (e.g., virtual shopping tasks), delivered both in-person and remotely, and (2) remote device-based assessments, which include self-administered cognitive tasks (e.g., processing speed test) or functionally-focused surveys regarding momentary activities and experiences (e.g., location, social context), as well as passive sensor-based metrics (e.g., actigraphy measures of activity), during daily life. For each approach, we describe the potential for enhancing ecological validity, provide examples of select measures that have been used in schizophrenia research, summarize available data on their feasibility and validity, and consider remaining challenges. Rapidly growing evidence indicates that digital technologies have the potential to enhance the ecological validity of cognitive and functional outcome assessments, and thereby advance research into the causes of, and treatments for, functional disability in schizophrenia.

Driving performance of euthymic outpatients with bipolar disorder undergoing real-world pharmacotherapy

OBJECTIVE

Medications for the treatment of bipolar disorder (BD) could affect patients' cognitive function. Patients with BD present with neurocognitive impairment even in a remission state. Little research is available on the daily functioning, especially driving performance, of stable outpatients with BD under pharmacological treatment.

METHODS

In total, 58 euthymic outpatients with BD undergoing real-world pharmacotherapy and 80 sex- and age-matched healthy controls (HCs) were enrolled. Three driving tasks using a driving simulator-road-tracking, car-following, and harsh-braking-and three cognitive tasks-Continuous Performance Test, Wisconsin Card Sorting Test, and Trail-Making Test-were evaluated. Symptom assessment scales-Young Mania Rating Scale, Structured Interview Guide for the Hamilton Depression Rating Scale, Beck Depression Inventory-II, Social Adaptation Self-evaluation Scale, and Stanford Sleepiness Scale-were also completed.

RESULTS

Car-following and road-tracking performance were significantly impaired in patients with BD compared with HCs after adjusting for demographic variables, but these performances generally overlapped. Broad neurocognitive functions were significantly lower in the patients with BD compared to HCs, but car-following performance was significantly negatively correlated with sustained attention only. Although most patients received multiple medications rather than monotherapy, no relationship between prescriptions and driving performance was found.

CONCLUSION

Euthymic patients with BD under steady-state pharmacotherapy had impaired driving performance compared with HCs, but the overlapping distributions of driving performance suggested that driving performance is not always deteriorated in patients with BD. Therefore, attentional function may be a useful clinical feature for judging driving aptitude in patients with BD.

Impact of antiepileptic drugs on simulated driving in patients with epilepsy

OBJECTIVE

Results of observational investigations have demonstrated that the risk of a traffic accident is independent of use of AEDs. However, no reports of driving tests conducted with patients administered AEDs have been presented. This study examined this scenario in a simulated driving setting.

METHODS

Driving performance of 43 patients with epilepsy (PWE) and prescribed an AED, who were licensed to drive and drove regularly (subject group), was assessed, with the results compared to 40 age- and gender-matched healthy volunteers (control group). Daily driving skills associated with a traffic accident were examined using two different tests provided by a driving simulator software package, road-tracking and car-following. Standard deviation of lateral position (SDLP) and distance coefficient of variation (DCV) were determined as primary and exploratory outcomes, respectively.

RESULTS

There was no statistically significant difference for primary outcome shown by SDLP between the subject and control groups (p = 0.906), nor for exploratory outcome shown by DCV (p = 0.063). Multiple regression analysis revealed that age (ß=0.967, p = 0.001), female gender (ß=0.469, p<0.001), and duration of driving experience (ß=-0.583, p = 0.038) were correlated with SDLP.

SIGNIFICANCE

The present results demonstrated that the driving performance of PWE taking AEDs was not different from that of healthy volunteers.

Validity and reliability of a driving simulator for evaluating the influence of medicinal drugs on driving performance

RATIONALE

Although driving simulators (DS) are receiving increasing attention due to concern over traffic accidents under the influences of drugs, few DS are recognized for their reliability and validity. Therefore, the development of an evaluation system using DS for driving performance is urgently needed.

OBJECTIVES

To investigate whether the standard deviation of lateral position (SDLP) increases with blood alcohol concentration (BAC) using a DS with reliability and calculate the SDLP threshold from the difference between BAC levels of 0 and 0.05%.

METHODS

Twenty healthy Japanese men performed the DS tasks up to 60 min in Study 1 and DS tasks twice at 1-week intervals in Study 2. Twenty-six healthy men conducted the same DS tasks under BAC level (0, 0.025, 0.05, and 0.09%) in double-blind, randomized, crossover trial in Study 3. The primary outcome was SDLP in a road-tracking test. The test-retest reliability of DS data was assessed, and the estimated difference in SDLP between BAC levels of 0 and 0.05% was calculated using a linear regression model.

RESULTS

The cumulative SDLP values at 5-min intervals were stable, and the intraclass correlation coefficient for its values was 0.93. SDLP increased with BAC in a concentration-dependent manner. The predicted ΔSDLP value for the difference between BAC levels of 0 and 0.05% was 9.23 cm. No participants dropped out because of simulator sickness.

CONCLUSIONS

The new DS used in these studies has reliability, validity, and tolerability and is considered suitable for evaluating the influence of drugs on driving performance.

The use of machine learning improves the assessment of drug-induced driving behaviour

RATIONALE

Car-driving performance is negatively affected by the intake of alcohol, tranquillizers, sedatives and sleep deprivation. Although several studies have shown that the standard deviation of the lateral position on the road (SDLP) is sensitive to drug-induced changes in simulated and real driving performance tests, this parameter alone might not fully assess and quantify deviant or unsafe driving.

OBJECTIVE

Using machine learning we investigated if including multiple simulator-derived parameters, rather than the SDLP alone would provide a more accurate assessment of the effect of substances affecting driving performance. We specifically analysed the effects of alcohol and alprazolam.

METHODS

The data used in the present study were collected during a previous study on driving effects of alcohol and alprazolam in 24 healthy subjects (12 M, 12 F, mean age 26 years, range 20-43 years). Various driving features, such as speed and steering variations, were quantified and the influence of administration of alcohol or alprazolam was assessed to assist in designing a predictive model for abnormal driving behaviour.

RESULTS

Adding additional features besides the SDLP increased the model performance for prediction of drug-induced abnormal driving behaviour (from an accuracy of 65 %-83 % after alprazolam intake and from 50 % to 76 % after alcohol ingestion). Driving behaviour influenced by alcohol and alprazolam was characterised by different feature importance, indicating that the two interventions influenced driving behaviour in a different way.

CONCLUSION

Machine learning using multiple driving features in addition to the state-of-the-art SDLP improves the assessment of drug-induced abnormal driving behaviour. The created models may facilitate quantitative description of abnormal driving behaviour in the development and application of psychopharmacological medicines. Our models require further validation using similar and unknown interventions.

The Drives for Driving Simulation: A Scientometric Analysis and a Selective Review of Reviews on Simulated Driving Research

Driving behaviors and fitness to drive have been assessed over time using different tools: standardized neuropsychological, on-road and driving simulation testing. Nowadays, the great variability of topics related to driving simulation has elicited a high number of reviews. The present work aims to perform a scientometric analysis on driving simulation reviews and to propose a selective review of reviews focusing on relevant aspects related to validity and fidelity. A scientometric analysis of driving simulation reviews published from 1988 to 2019 was conducted. Bibliographic data from 298 reviews were extracted from Scopus and WoS. Performance analysis was conducted to investigate most prolific Countries, Journals, Institutes and Authors. A cluster analysis on authors' keywords was performed to identify relevant associations between different research topics. Based on the reviews extracted from cluster analysis, a selective review of reviews was conducted to answer questions regarding validity, fidelity and critical issues. United States and Germany are the first two Countries for number of driving simulation reviews. United States is the leading Country with 5 Institutes in the top-ten. Top Authors wrote from 3 to 7 reviews each and belong to Institutes located in North America and Europe. Cluster analysis identified three clusters and eight keywords. The selective review of reviews showed a substantial agreement for supporting validity of driving simulation with respect to neuropsychological and on-road testing, while for fidelity with respect to real-world driving experience a blurred representation emerged. The most relevant critical issues were the a) lack of a common set of standards, b) phenomenon of simulation sickness, c) need for psychometric properties, lack of studies investigating d) predictive validity with respect to collision rates and e) ecological validity. Driving simulation represents a cross-cutting topic in scientific literature on driving, and there are several evidences for considering it as a valid alternative to neuropsychological and on-road testing. Further research efforts could be aimed at establishing a consensus statement for protocols assessing fitness to drive, in order to (a) use standardized systems, (b) compare systematically driving simulators with regard to their validity and fidelity, and (c) employ shared criteria for conducting studies in a given sub-topic.

Development and validation of a driving simulator for evaluating the residual effects of drugs on driving performance - sensitivity analysis using zopiclone as a positive control: Study Protocol Clinical Trial (SPIRIT Compliant)

INTRODUCTION

Drugs acting on the central nervous system (CNS), especially hypnotics, can impair driving. The US Food and Drug Administration started requiring pharmaceutical companies to evaluate the residual influence of CNS agents on driving performance to review their recommended doses. Although it is important for physicians to discuss automobile driving while on medication with patients to promote traffic safety, the package inserts of most CNS agents in Japan uniformly prohibit patients from driving. Although more evidence-based information regarding the effects of drugs on driving performance is needed, the current evaluation methods for driving performance abroad cannot be applied directly to Japanese drivers because of differences in traffic environments, laws, and constitutions. Therefore, we plan to establish a new driving simulator (DS) that would enable the next-day residual effects of drugs on driving performance to be examined.

METHODS

In this double-blind, randomized, placebo-controlled, crossover trial, we plan to recruit 26 healthy Japanese males aged 21 to 64 years through advertisements. During the test periods, which will take place twice every other week, the participants will undergo a DS evaluation in the hospital for 2 days/1 night after the first and last doses of the study drug following 8 days of administration. The participants in the study drug group will take zopiclone 7.5 mg at bedtime on the first and eighth days in the hospital, and placebo on the other days. The DS evaluation consists of road tracking, car following, and harsh braking tests. The primary outcome is the standard deviation of lateral position (SDLP), which is a gold standard evaluation item, in the 60-min road-tracking test. The exploratory outcomes are other evaluation items in the DS tests, in the Karolinska Sleepiness Scale sleep questionnaire, and the Profile of Mood States Second Edition rating scale. The estimated difference in the SDLP between the zopiclone and placebo groups will then be calculated.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov NCT04108351, on September 30, 2019. Ethics approval was obtained from the Ethics Committee at Hakata Clinic and the Nagoya University Medical School Hospital Bioethics Review Committee.

Protocol for the development and validation of a driving simulator for evaluating the influence of drugs on driving performance

INTRODUCTION

Although automobile driving is often necessary in daily life, most package inserts for psychotropic drugs in Japan prohibit patients from driving under the influence of medication. This may be partially because no system to evaluate the influence of drugs on driving performance has been established. Standardized evaluation methods have been established in the Netherlands and the United States, but these cannot be implemented in Japan because of differences in road situations, traffic laws, and ethnicities. Therefore, to establish a method to evaluate the influence of drugs on driving performance in Japan, we planned a validation study using alcohol and a driving simulator (DS) and set a clinically meaningful threshold involving the standard deviation of lateral position (SDLP), which is a criterion standard evaluation item.

METHODS

This study was designed as a double-blind, placebo-controlled, randomized, 4-way, fourth-order crossover trial (Williams design). Twenty-four healthy Japanese men aged 21 to 64 years will be recruited through advertisements. The participants will be required to drive daily for over 3 years and to carry the active-type aldehyde dehydrogenase (ALDH) gene polymorphism (ALDH 2*1/*1). Participants will be randomly assigned to 4 groups based on blood alcohol concentration (BAC): 0% (placebo), 0.025%, 0.05%, and 0.09%. The amount of alcohol intake will be calculated based on Widmark formula using a beverage that is a mixture of 40% vodka and orange juice. After a practice period, each examination period will be set with 6-day intervals. The primary outcome is SDLP in a 60-minute road-tracking test using the DS. The secondary outcomes are other evaluation items in the DS tasks and DS sickness and sleepiness according to questionnaire responses. The estimated difference in SDLP between BAC levels of 0.05% and 0% will be calculated using a linear model.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee at Hakata Clinic and the Nagoya University Medical School Hospital Bioethics Review Committee. The trial results will be disseminated through peer-reviewed publications and international conferences.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov NCT 03572985 on June 28, 2018.