Is It Time to Assess the Mental Fitness of Our Presidents?


Since the early days of Donald Trump’s campaign, mental health professionals have come forth in unprecedented ways to warn against entrusting the U.S. presidency to someone whose mental fitness for the Oval Office was more than suspect.  In early 2017, I organized an ethics conference at Yale School of Medicine to clarify our public health duty, later publishing with 27 similarly concerned colleagues The Dangerous Case of Donald Trump (Macmillan, 2017 and 2019), a New York Times bestseller – which suggests that the concerns of the American people matched ours.

When the coronavirus reached our shores, we stated in January 2020 that Donald Trump’s handling of the crisis would result in a large number of unnecessary deaths. Two months later, we issued a “Prescription for Survival” urging that the removal of the president may be necessary to avoid a national tragedy.  We predicted step by step how Mr. Trump would disastrously mismanage the pandemic, as a major Lancet article recently confirmed.

We also  predicted violent events would at some point occur, for example  the massacre of our Kurdish allies, and the assassination of a top Iranian general. Far before the January 6, 2021, violent insurrection at the Capitol, which disrupted our democratic foundation, we stated that the period after the November election would be “the most dangerous period of this presidency.”

Finally, we warned that, without intervention, Donald Trump’s destructive psychology would spread and become uncontainable. Now, the acceleration of right-wing propaganda, lawmakers mimicking his ways, and the burgeoning of QAnon conspiracy theories continue to threaten the republic.

Despite the advanced scientific and clinical knowledge we possess, the public could not protect itself; first, no fitness requirements exist for a U.S. president before he or she takes office. In contrast, all other military officers, law enforcement personnel and other important decision-makers have to pass psychological testing before going to work, but not a president before having his or her finger on the nuclear button!

Secondly, the American Psychiatric Association imposed a gag order, not allowing mental health professionals to speak out about what they were observing. This was anomalous: legal experts, for example, are not required to represent a public figure personally and to obtain consent before sharing general information that would be useful to the public.  But unlike any other field, and any other medical specialty, the APA made this a requirement with the start of Mr. Trump’s presidency, essentially banning any expert comment on his fitness for office.

Psychiatric knowledge ought to be shared with the public more frequently, not less so, when there are signs of danger in the political realm, especially since the spread of symptoms makes intervention very difficult. The greater contagion of symptoms such as delusions, compared to strategic lies, is a well-documented phenomenon that has been variably termed “shared psychosis,” “folie à deux, plusieurs, ou millions” (madness among two, several, or millions), or “induced delusions.”  Mental health professionals who have practiced in prisons, like I have, or public-sector settings often experience how severely impaired, untreated influential figures can spread their symptoms rapidly to vulnerable, previously healthy individuals who are emotionally bonded to them.

A typical example might be a family I once treated in the outskirts of Boston that believed outer-space aliens were invading their neighborhood. The parents both worked, and the five children ranged in ages from 8  to 16. They seemed respectable in public, but in private they were convinced that an alien force had taken over their neighbors, heralding the end of the world.  They thought they were the only “sane” ones left.

The mother, a domineering personality, castigated the only non-believing member, her 16-year-old daughter.  The daughter called the emergency room when her parents started barricading doors and sleeping with knives by their beds.  She feared that their paranoia could escalate into an aggressive attack, as they falsely believed themselves under assault. The mother, identified as the “primary” patient with schizophrenia, was taken to the emergency room and hospitalized.  Within days, the “secondary” family members dramatically improved.

Powerful emotional pressures facilitate the spread of symptoms, especially coming from influential persons, as I have witnessed numerous times among gang members, co-conspirators, and cell-block inmates in my 22-year career in prisons. This phenomenon is similar to what occurred in Jonestown or other cults I have previously researched and written about. And I believe it will continue as long as the spell of Mr. Trump remains unbroken with continual rewards and the absence of a referendum

Because of these dangers, applying standards for mental fitness before a U.S. president takes office could not be more important—and, if this fails, harnessing mental health professionals so they can apply their experiences and skills in identifying difficult-to-detect psychiatric conditions.

Would we question in the same way a neurologist or cardiologist sharing relevant knowledge, for example, if a president suffered a stroke or a heart attack?  Would we censor a legal or Constitutional expert from educating the public about the societal implications of a public figure’s misdeeds?  Of course not.  Yet, for arguably more dangerous psychiatric conditions that have greater consequences—the usurping of family, friends and fellow citizens and the loss of hundreds of thousands of lives —we as a nation accepted the gagging of experts.

Prevention is always vastly easier than trying to intervene after the situation has gotten out of hand.  Since it is difficult to foresee things that have not yet happened, we rely on educating the public, essentially on sharing the research and scientific evidence that signal danger and stipulate action.

If the public had been informed sooner and given access to the science-based knowledge mental health professionals had, then it might have stepped in, possibly greatly reducing suffering and death. In a recent interview with CNN, Dr. Deborah Birx, former member of the Trump Covid Task Force, said that had the Trump administration acted earlier, numerous deaths might have been averted.  “The first time we have an excuse,” meaning the original surge. “All of the rest of them, in my mind, could have been mitigated or decreased substantially.”

This is also true of the growing culture of violence, another highly contagious phenomenon.

The fitness test a panel of us performed as a public service in April 2019 fully predicted the outcome of the coronavirus pandemic eleven months earlier —but without media exposure, it was ignored. It demonstrates the usefulness of fitness screening before allowing anyone to assume an office as awesomely important as U.S. president.

Bandy X. Lee, MD, is an American psychiatrist who specializes in violence prevention programs in prisons and in the community.  She has been active in prison reform in at least five states, and helped initiate reforms at Rikers Island in New York City.





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