Thursday, April 2, 2009

Uneasy Lies the Head

Picking up from a Shrink Rap post, I was thinking more about the often asked question of whether we could deal with someone in high office (let's say President, Vice-President, Cabinet Secretary, Senator, or Governor) with a significant history of an Axis I mental disorder. The most likely examples would probably be panic disorder, obsessive-compulsive disorder, depression, or bipolar disorder. As much as I detest stigmatization of mental disorders, I would have to say no, for two reasons: the art of prognosis in psychiatry remains shaky, and psychiatric impairment is often subtle and difficult to demonstrate objectively.

Even if such a candidate for high office had gone years without an episode, or had been stable on medications for a very long time, these kinds of mental disorders are apt to recur without warning. Obviously we know something about psychiatric prognosis: someone who has been hospitalized six times for depression can be expected to have a tougher time of it than someone who has been stable on Prozac for five years. But of the latter person, could I say with any confidence that he or she will likely go the next four or eight years without a major episode (even, of course, considering the major additional stress that elected office would bring)? No.

Most other chronic or recurring disorders are not like this. Hypertension, diabetes, or even heart disease tend to be more predictable over time based on fairly objective criteria. It is the very randomness of mental disorders, at least at our current level of understanding, that makes them so hard to deal with. A medication that has worked for a person for years could stop working tomorrow, and we often don't know why.

The second major concern is that while medical disability from a heart attack or (a la Chief Justice Roberts) a seizure is pretty much evident for all to see, impairment from mental disorders is often open to contentious interpretation. If anxiety, depression, or mania were affecting an elected official's performance, it would likely be subtle, gradual and subjected to partisan debate. This would be very much complicated if the official in question had little insight into the impairment, and chaotic impeachment proceedings might be necessary.

All this could change eventually of course. If or when our understanding of mental disorders progresses to the point where we can more reliably predict and modify their course, then a major mood or anxiety disorder might survive the vetting process. But unfortunately my guess is that we'll see the first female president, and probably even the first gay president, long before we see the first bipolar president.

12 comments:

Gerard said...

Short form: Can psychiatry deal with someone in high office with a history of an Axis I mental disorder? Are you crazy?

Of course, sometimes it is not all that bad -- Churchill.

Other times it is worse than you think. I think of "The Madness of King George."

Retriever said...

How about Abraham Lincoln? Whose friends had to forcibly restrain from killing himself for months on end when he was young? You are wrong here. Better someone with an admitted and treated illness than someone immoral or dishonest.

When such views are held by the people whose life work it is to treat the mentally ill, is it any wonder our society at large still discriminates against them with impunity?

Clinton, with his alleycatting was a far higher security risk than somebody with a managed or remitted Axis I disorder.

Plus, mental health is over-rated (I am being mischievous, you know I am not totally irresponsible)

Would you like to express your views to the ghosts of Alexander, Saul, David, Mark Anthony, WIlliam the Conqueror, most of the British royal family...oh hell, back to my oar in the galleys.

Novalis said...

Oh come on, I'm not endorsing the absolute exclusion of the mentally ill from high office, only saying that concerns would exist that are may be more valid than the sexism, homophobia, and (heretofore) racism that have barred other groups.

Pulling out Lincoln isn't fair, as he is always the exception that proves the rule (should Presidents have completed elementary school?).

Novalis said...

I'm also looking at this in the context of today's virtually paranoid (ironic, isn't it) vetting process, which many great world leaders of the past wouldn't have survived. I'm also talking about significant disorders, not charming eccentricity.

Gerard said...

"I'm also looking at this in the context of today's virtually paranoid (ironic, isn't it) vetting process..."

Well, that's true for people appointed. For people elected the vetting process will, I am sure, prove not paranoid enough.

Novalis said...

I'm sure I have no idea what (or whom) you're talking about...

Gerard said...

Oh, just spitballin' here.

As the Japanese are fond of saying, "History will tell."

Anonymous said...

Past behaviour is a good indicator of future behaviour. Some people have an extraordinary ability to integrate their peripheral mental aberrations into their core beings without major overall disruptive/chaotic effects; others are not so charmed. Each case should be judged on its own merits.

And how can you exclude future possibility of something going mentally/physically/spiritually awry?

Life is very contingent. You can only extrapolate from experience/knowledge to date. What eventuates is anyone's guess.

Novalis said...

Well yes, that's what makes prognosis so tricky. The past tends to predict the future, and yet...as you say, anything could happen. Could, but will it? Still waiting for that crystal ball that I ordered to arrive...

the psycho therapist said...

Not that it matters, I agree with you 100%. Razor sharp "insider" wisdom.

And I'll gladly take an administrator dealing with Major Depressive Disorder over one facing the challenges of Bipolar Disorder any day. If you work in the trenches/live and breathe the differences, this is a no-brainer.
Please.

the psycho therapist said...

Anonymous, whoever you are, stunningly brilliant. Also, again.

Roy said...

Can't disagree more. First, we've already had our first bipolar president. As for the subtle cognitive effects, same goes for prez with diabetes (hypoglycemia), epilepsy, stroke, carotid artery disease, thyroid condition, etc. Sure, need to have some monitoring built in by First Doctor, but I would not simply rule out candidates with a history. And what about Axis 2 disorders?