http://www.cnn.com/video/#/video/health/2008/10/06/gupta.fit.to.lead.cnn

May 12, 2002

By Alen J. Salerian, MD

Few stories jump to the top of the front pages as quickly as the president going to the hospital. Even the commander in chief’s annual checkup is covered in the press, with public disclosure of conditions such as skin cancer or clogged arteries. But a big part of the evaluation is missing each year: A checkup that doesn’t include the president’s mental health is no more useful than reviewing Air Force One’s flight readiness without checking the cockpit. Yet psychiatric testing has never been part of the presidential exam.

The importance of such examinations is recognized for individuals such as astronauts and professional pilots who (like the president) are subjected to unusual stress. These examinations are also routine for CIA and FBI agents, who (like the president) are responsible for our national security. They are simply accepted as a basic entry requirement for all of those careers. While pilots and members of the FBI have no regular follow-ups, tests of emotional well-being continue on a regular basis for CIA agents, and their results can have concrete consequences for an individual’s career path.

You might think that the symptoms of mental illness or cognitive disability would be detected during the thorough annual physical that we know every president undergoes. But psychiatric literature provides ample documentation of the fact that internists typically miss depression, Alzheimer’s and other disorders that can impair an individual’s performance. As a psychiatrist and a citizen, I would like some assurance that the president is in a fit mental condition to represent the United States — just as I expect an update on his physical fitness. I’m not suggesting that our current president is in need of treatment or even that he is at particular risk. Far from it. It’s simply time to acknowledge, in this era of modern psychiatry, that there is no need to repeat the past.

Historians tell us that while they were in the White House, Abraham Lincoln, Franklin D. Roosevelt and Ronald Reagan all suffered from brain disorders. Not one of them appears to have been evaluated by a psychiatrist. If they were, that information was kept from the American public.

Lincoln is known to have struggled with depression for years and, according to accounts from some of his closest friends, may also have had petit mal seizures or a mood disorder, possibly the result of a concussion he suffered as a child.

The story of Roosevelt’s declining mental health, especially during the crucial stages of the 1945 Yalta summit, has been recounted many times. Historians argue over whether Russian leader Joseph Stalin outsmarted Roosevelt, resulting in the Eastern European windfall for the Russians and establishing the Soviet Union as a superpower in the beginning of the Cold War. “We parted affectionately. I felt the he had a slender contact with life,” recalled British Prime Minister Winston Churchill, right after Yalta. Harry Hopkins, Roosevelt’s chief political adviser, remarked that the president had not followed half of what was going on at Yalta. The White House physician echoed those concerns after Roosevelt returned from Europe, noting, “The president was depressed.”

We also know that Reagan was in the early stages of a debilitating brain disease while serving as president. Although Alzheimer’s has a notoriously long pre-clinical period while the brain is slowly destroyed, reports have long circulated about Reagan’s symptoms, such as dozing off during Cabinet meetings and forgetting the names of close advisers.

We shall never know for certain how — or whether — history might have been written if these conditions had not affected these presidents. But, while 19th-century medicine may have been too primitive to diagnose or treat the maladies that Lincoln battled, Roosevelt’s depression would probably be treatable with modern psychotropic drugs; and Reagan’s periodic waves of drowsiness and memory loss should have prompted a psychiatric and neurological evaluation. Breakthroughs in medicine have made most brain maladies — from low-grade depression to schizophrenia — treatable. But did Reagan’s doctors ever administer a neuropsychiatric exam (such as the Montgomery Asberg Depression Rating Scale) or a Mini-Mental Status Examination (the standard medical screening test for Alzheimer’s disease) while he was in the White House? There is no evidence to suggest so, despite the remarkable reliability of those tests and the ease with which they can be administered.

The obstacles to such a sound mental health policy at the White House are clear. The primary culprit is fear: fear, in this political context, of the opposition making hay out of any perceived weakness — real or not — in the president’s mental health; fear of political disaster with the treatment required; and fear of removing the veil of strength that rests on the leader of the free world. These fears spring from a lingering stigma associated with mental disorders — a vestige of a time when such illnesses were thought to be demonic and were treated as such. In spite of the radical advances made in medicine over the past several decades, it remains difficult for many people to come to terms with mental illness.

My experience tells me that had Lincoln, Roosevelt or Reagan gone through a thorough modern psychiatric exam during certain periods of their presidency, their mental impairments could have been easily and clearly diagnosed, and perhaps even treated. Thanks to advances in psychiatry, we can do better. We all deserve the assurance that our highest elected official is of sound mind, as well as body.

Alen Salerian is the director of Washington Psychiatric Center. A former consultant to the FBI, he currently teaches at George Washington University.