Licence Appeal Tribunal File Number: 15973/MED

An appeal under subsection 50(1) of the Highway Traffic Act, R.S.O. 1990, c. H.8, from a decision of the Registrar of Motor Vehicles to suspend a licence pursuant to Section 47(1) of the Act.

Between:

Muhammad Salman Anis

Appellant

and

Registrar of Motor Vehicles

Respondent

DECISION

ADJUDICATOR: Dr. Isla McPherson, Member

APPEARANCES:

For the Appellant: Muhammad Sulman Anis, Appellant

For the Respondent: Leila Pereira, Agent

Held by teleconference: July 5, 2024

OVERVIEW

1Muhammad Sulman Anis (the “appellant”) appeals from the decision of the Registrar of Motor Vehicles (“Registrar”) to suspend his Class G licence under s. 47(1) of the Highway Traffic Act, R.S.O. 1990, c. H.8 (the “Act”) after the Registrar received an unsolicited Medical Condition Report stating that the appellant suffers from a medical condition that may affect his ability to drive a motor vehicle safely.

2The Registrar has the authority under s. 47(1)(g) of the Act to suspend or cancel a driver’s licence for any sufficient reason. Section 14(1)(a) of O. Reg. 340/94 under the Act (the “Regulation”) states that a holder of a driver’s licence must not suffer from any mental, emotional, nervous or physical condition or disability likely to significantly interfere with their ability to safely drive a motor vehicle of the applicable class safely. Under s. 14(2)(b) of the Regulation, the Registrar may require a driver to provide satisfactory evidence that they are able to drive safely.

3The Registrar takes the position that the appellant suffers from a medical condition, namely a mental health condition, that is likely to significantly interfere with his ability to drive safely and that this provides sufficient reason to suspend his licence under s. 47(1)(g) of the Act.

4The appellant appeals the suspension under s. 50(1) of the Act. He agrees that he suffers from a mental health condition but denies that his mental health condition interferes with his ability to drive safely.

5Pursuant to section 50(2) of the Act, after a hearing the Tribunal may confirm, modify, or set aside the decision or order of the Registrar.

ISSUES

6The issue in this appeal is whether the appellant suffers from a medical condition that is likely to significantly interfere with his ability to drive a motor vehicle safely.

7To resolve that issue, I will address the following questions:

i. Does the appellant suffer from a mental health condition?

ii. If so, is this likely to significantly interfere with his ability to drive a motor vehicle safely?

8The Registrar bears the burden of proving on a balance of probabilities that the answer to each of the above questions is “yes.”

RESULT

9Having considered all the evidence and submissions and for the reasons that follow, I find that the Registrar has satisfied its burden to establish that the appellant suffers from a medical condition that is likely to significantly interfere with his ability to drive a motor vehicle safely and I confirm the Registrar’s decision to suspend the appellant’s driver’s licence.

ANALYSIS

Does the appellant suffer from a mental health condition?

10The evidence presented at the hearing establishes that the appellant suffers from a medical condition, namely a mental health condition.

11The Registrar’s position is supported by:

i. a Medical Condition Report (MCR) dated, April 23, 2024, from Dr. K;

ii. a Mental Health Disorder Form dated May 16, 2024, from Dr. K.

12The MCR from the appellant’s psychiatrist, Dr. K, supports the Registrar’s position that the appellant suffers from a mental health condition. Dr. K has checked the box on the form indicating that the appellant suffers from a psychiatric condition and has written in the comments, “psychosis”. Dr. K has also checked a box on the MCR indicating that the appellant suffers from a substance use disorder due to alcohol and cannabis.

13Following the receipt of the MCR the Registrar suspended the appellant’s licence due to a mental health condition and alcohol use disorder and requested completion of a Mental Health Disorder Form and Substance Use Assessment Form. The Substance Use Assessment Form was completed by Dr. K on May 16, 2024 and reported moderate substance use disorder secondary to both alcohol and cannabinoid use. Following the receipt of the Substance Use Disorder Form the Registrar lifted the suspension for Alcohol Use Disorder.

14The completed Mental Health Disorder Form supports the Registrar’s ongoing suspension of the appellant’s licence due to a mental health condition as Dr. K indicated on this form that the appellant suffers from bipolar disorder with his most recent illness episode occurring within the last 3 months.

15The appellant testified that he agrees with Dr. K that he does suffer from a mental health condition and agreed that this condition is bipolar disorder. He testified that this was his first episode of psychosis and a new diagnosis.

16The medical evidence before the Tribunal comprises two medical forms completed by the appellant’s psychiatrist that confirm a mental health condition and the appellant agrees that he has a mental health condition.

17The medical evidence in this case is clear and the diagnosis is not under dispute. Based on the information available, I find that the Registrar has established on a balance of probabilities that the appellant suffers from a mental health condition.

Is the appellant’s medical condition likely to significantly interfere with his ability to drive a motor vehicle safely?

18I find that the Registrar has proven on a balance of probabilities that the appellant’s medical condition is likely to significantly interfere with his ability to drive a motor vehicle safely.

19The Registrar’s position is supported by:

i. The Mental Health Disorder Form completed May 16, 2024, by Dr. K.

ii. The Canadian Council of Motor Transport Administrators Medical Standards for Drivers [February 2021] (the “CCMTA Standards”).

20The Registrar relies on the CCMTA Standards Chapter 14 along with internal policies at the Registrar of Motor Vehicles. Chapter 14 of the Standards documents that psychiatric disorders can result in either a persistent or episodic impairment of the functions necessary for driving and highlights that a driver’s level of insight is a critical consideration when assessing the risk of an episodic impairment of functional ability due to a psychiatric disorder.

21The Registrar relies on Standard 14.6.1. This Standard indicates a driver is eligible for a licence if the condition is stable, the driver has sufficient insight to stop driving if the condition becomes acute, the functional abilities necessary for driving are not impaired, and a treating physician supports a return to driving. In addition to this Standard, the Registrar relies on their internal policies when they require confirmation of six months of mental and emotional stability before considering reinstatement of the appellant’s driver’s licence. The Registrar highlights in the appellant’s case that he has required two hospitalizations in the past three months for his mental health condition.

22Section 14(2)(a) of the Regulation allows the Registrar to consider the CCMTA Standards when determining whether the requirements of s. 14(1) are met. The Tribunal may take the CCMTA Standards into consideration but are not bound by them.

23The appellant argues that his licence should be reinstated for the following reasons: his medical condition is stable, he takes the medication prescribed by his physician, this was an isolated event, and he is not at risk for recurrent episodes that would impact his ability to drive. He reports that although he was hospitalized twice for mental health concerns in April 2024, both hospitalizations were for the same mental health episode.

24Under cross-examination about the events leading to hospitalization, the appellant testified his roommates had notified the police regarding his behaviour and the police had visited his apartment on two occasions prior to his first admission to hospital. Following the second visit by police he proceeded to the hospital, and he describes being placed on a form while in hospital mandating a psychiatric assessment. He reports being prescribed an anti-psychotic and discharged home with no follow up appointment with any physician or clinic to monitor the effectiveness of the anti-psychotic. Following this hospital visit he described his symptoms persisted and escalated to the point that his roommates notified the police again approximately two weeks later, and at that time the police escorted the appellant to the emergency department where he was admitted for 14 days under psychiatric care and the MCR was completed.

25Under cross-examination the appellant testified regarding his use of medications to treat his psychotic symptoms. The appellant testified that he has been prescribed three different anti-psychotics, palperidone, risperidone, aripiprazole, and a mood stabilizer, lithium, since the onset of his illness in April of this year. Palperidone, risperidone and lithium have all been discontinued due to being ineffective or due to intolerable side effects. The appellant testified that he is currently taking the latest anti-psychotic prescribed, aripiprazole (Abilify), and the dose recently changed at the appellant’s latest appointment with Dr. K on June 27, 2024.

26The appellant testified he is now under the care of Dr. K and has monthly appointments with him. The appellant testified that Dr. K understands his mental health condition much better than the Registrar could ever understand, and he has the full support of Dr. K for reinstatement of his driving privileges. The appellant emphasized that his episode of psychosis was an isolated event with no risk of recurrence and thus poses no future risk to driving.

27The appellant testified regarding the financial hardships of losing his driver’s licence as he currently is employed as an Uber Eats delivery driver and is unable to work without his licence. Under cross-examination the appellant testified that he did not realise his licence was under suspension following discharge from hospital the second time and he drove his vehicle while under suspension for several days before being pulled over by the police where he described he was informed that his licence was under suspension.

28Under cross-examination, the Registrar questioned the appellant about his history of substance use. The appellant denied having used any cannabis or alcohol in the period leading up to the April hospital admissions. He reported that he has not used cannabis since he had a one-week admission to hospital for cannabis use four years ago. He described that he was advised during this hospitalization to abstain from using cannabis. He reported having attended a support group for substance use following the admission to hospital but not requiring these services for several years.

29I appreciate that the appellant’s psychotic episode was treated with medications, and he is now under care of a psychiatrist. I also take note that psychotic episodes due to psychiatric illness may be the most urgent psychiatric situation regarding fitness to drive and an acute psychotic episode is incompatible with safe driving. This is considered when taking into consideration the appellant’s insight into his diagnosis of bipolar disorder. Insight is an important consideration when considering safety to drive. Insight means that a driver is aware of their medical condition, understands how the condition may impair their functional ability to drive and has the judgment and willingness to comply with a suggested treatment regimen. I am concerned about the level of insight and understanding the appellant has into his diagnosis, specifically the chronic, relapsing course that often occurs with bipolar disorder. The appellant’s insight appeared poor when he repeatedly emphasized that his psychosis was a strictly isolated episode that will not recur and thus poses no future risk to driving. Insight into having a chronic disease means that that you understand that the disease may fluctuate over time and therefore monitoring for those periods where the disease state may be incompatible with driving is necessary, and the appellant did not demonstrate an understanding of this in his testimony. Further, I note that when the appellant was experiencing his active symptoms, he did not seek out medical assistance on his own, but instead required intervention of the police on three occasions and in the third occasion, they escorted him to hospital.

30I am also concerned that the appellant required two hospitalizations for the same psychotic episode, and this brings into question whether the medical recommendations were followed after the first hospitalization. It would be highly unusual to not schedule a follow up appointment with a patient experiencing psychosis who has just been started on a new anti-psychotic medication, which is the case described by the appellant following the first hospitalization. In addition, I am concerned that the appellant continued to drive following discharge from hospital before being advised by police that his licence was under suspension.

31I also recognize there are risks associated with substance use in the presence of a mental health condition and Dr. K has documented in the medical submissions his recommendation that the appellant abstain from all substances. I find the appellant’s testimony regarding his cannabis use inconsistent with the medical evidence submitted from Dr. K. While the appellant testified that he has not used cannabis since his weeklong admission to hospital related to cannabis use 4 years ago, Dr. K has indicated in the medical submissions that the appellant has a moderate cannabis use disorder, and checked the box indicating it has been less than 6 months since he has abstained from cannabis. Dr. K has additionally written on the Mental Health Disorder Form, “no use of cannabis since discharge”, which was May 3, 2024. If the appellant has continued to use cannabis as Dr. K has described, this gives rise to concern regarding his insight into the importance of following medical advice regarding cannabis use and the risks associated, particularly in light of prior cannabis use precipitating a weeklong hospitalization. The appellant responded to these discrepancies between his oral testimony and the written medical submissions as Dr. K having a “misunderstanding” of his actual cannabis use. I further note there are discrepancies in the appellant’s testimony of his alcohol use and Dr. K’s submissions. The appellant testified that he has consumed alcohol during his life but does not have a substance use disorder and only uses alcohol “occasionally” with friends. Dr. K has indicated on the Substance Use Assessment Form that the appellant has a moderate substance use disorder due to alcohol and written, “reports abstinence from alcohol May 5 onwards”. I take note that this is 2 days after his discharge from hospital on May 3, 2024, suggesting he was consuming alcohol immediately following his discharge from hospital and not following Dr. K’s medical advice of abstaining from substances.

32I acknowledge the appellant’s argument that Dr. K has documented in the latest letter dated June 27, 2024, the improvement in his mental health and judgment has occurred, “judgment appears improved” and that there is “just under 2 months of stability”. And I appreciate that the appellant argues that he has the full support of his psychiatrist to reinstate his driving privileges. However, I disagree with the finding that Dr. K supports the reinstatement of driving privileges. I find the language used by Dr. K in the medical submissions regarding the appellant’s driving privileges to be vague, non-committal and ultimately at the discretion of the Registrar’s judgment when he says he supports the appellant’s driving privileges, “sooner rather than later, if deemed appropriate by the MTO”.

33What the CCMTA standards highlight prior to considering reinstatement is a period of stability. I appreciate that the medical evidence has documented stability for less than two months at this point, which is significantly short of the six-month time frame requested by the Registrar. I further note that there is a much shorter period of stability in the appellant’s prescribed medications, and it appears it has been difficult to find a medication that is both effective and tolerated. In the three months since the onset of his illness, there are 4 different medications started and 3 discontinued. Furthermore, Dr. K reduced the dose of the latest anti-psychotic medication as recently as the week prior to the hearing during an appointment June 27, 2024. I do not find that 1 week on a new dosage of medication would be a meaningful period of time to confirm stability on that medication.

34I appreciate the hardships that the appellant is undergoing with the loss of his driver’s licence but given the medical evidence and the individual merits of this case, I believe a longer period of stability is reasonable and prudent for road safety given the risks associated with driving during a psychotic episode.

35Although this Tribunal is not bound by the CCMTA Standards, they can be considered when making the decision for the reason that these Standards are the result of a lengthy and intensive process to provide medical standards based on the best evidence available and with a focus on functional ability to drive rather than exclusively on medical diagnoses.

36As such, for the reasons cited, I am satisfied on a balance of probabilities that the appellant’s medical condition is likely to significantly interfere with his ability to drive safely.

Conclusion

37I find that the Registrar has discharged the onus of establishing on a balance of probabilities that the appellant suffers from a medical condition, namely a mental health condition, and that condition is likely to significantly interfere with his ability to drive a motor vehicle safely.

ORDER

38For the reasons set out above, pursuant to subsection 50(2) of the Act, I confirm the Registrar’s decision to suspend the appellant’s driver’s licence.