Saturday, April 04, 2009

Should People With Mental Illnesses Hold Public Office?

After my post Depressed and Running for Governor post, one commenter (MWAK) asked if people with depression should run for governor. Novalis responded with his own post, Uneasy Lies the Head where he says No and gives his reasons for his thoughts.

It got me thinking. As a psychiatrist, we generally feel mental illness should be destigmatized, and life should be more 'fair' for those who suffer from mental illnesses. I have to say, sometimes I struggle with this--- it's nice to be accommodating, but if the symptoms of one's mental illness make one's companionship intolerable, or one's job performance erratic and inefficient, or one's behavior disruptive or dangerous, how much should others be expected to bend?

So Governor or Doug Duncan's case, it seems he personally decided that the campaign itself was too stressful while he was actively symptomatic. Let's suppose that we can agree that we don't want someone with a symptomatic mental illness running our country. Actually, I don't want them driving my bus, train or airplane either, not while they're thinking about how to suicide or dealing with slowed reaction times or poor judgment.

For the sake of argument, let's say our would-be President or Governor, or pilot or bus driver or armed soldier or police officer has a history of mental illness. Let's suppose it was treated with full remission of symptoms and he hasn't been ill for a while.

Novalis says No: psychiatric illnesses are chronic and recurring (and for some reason he thinks hypertension and diabetes are more likely to stay control or be predictable, but I'm not going there), symptoms can be insidious, gradual, and hidden.

I agree, they can be all of these things and I don't want someone in the midst of an episode running a ship if there really are those buttons one can push to blow up the world. Or decisions that need to be made quickly. Here's my sort-of/maybe beef with this logic: people without mental illnesses can : 1) suddenly get them, 2) have bad judgment or make bad decisions in the absence of a psychiatric illness, 3) keel over and die or become disabled with no warning. We need to have provisions for such things, and the fact that it's higher probability with a history of mental illness doesn't change that we need to have perimeters to check on people involved.

One thing seems clear: If you take away someone's job simply because they seek treatment, then you limit the ability of someone to get treatment. I'd rather have a pilot on Prozac who is being closely monitored, then a pilot who's been afraid to tell anyone his dark thoughts about the plane I'm on.

Novalis says, "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."

We can't predict the behavior of anyone (remember that W guy?). If we know someone has a history and an increased likelihood of recurrence, at least it can be openly discussed and some checks can be put into place.

So no answers here. I do wonder why it is that people have been required to have psychiatric evaluations before all sorts of procedures (in vitro, bariatric surgery) and we don't require our presidential candidates to spend a couple of hours being evaluated by a psychiatrist before we let them run.

I will point out that many of our presidents have had serious mental illnesses, including some of the most popular of presidents.

I'm rambling. Hope I didn't say anything too objectionable.

[Edit 4/5/09 11:30: This is Roy. I just wanted to clarify something here. When I first read Dinah's post, I thought "OMG, she's saying people with, say, a history of bipolar disorder shouldn't fly planes or be President." After reading some comments, esp Nonstandard's comments, and then Dinah's reply, I realized that what she wrote does not clearly state what she seems to intend. So, as a way of either clarifying or distancing from what she said, here is what I think : A 'diagnosis' of anything should not -- in and of itself -- prevent someone from taking on a high-responsibility position (IMHO). The question should be about how they are currently functioning. And if a position carries enough high risk (say, the nuclear button-pusher job, prez, airline pilot), then there should be built-in safeguards that require some sort of ongoing assessment of functional capacity, regardless of one's presence or absence of diagnostic labels. Come on, even dealing with, say, a divorce or your daughter's breast cancer could have a negative impact on one's performance in certain positions. I'll put more in the comments, esp asking why the legal system has put us in the situation that Nonstandard Mind points out in the first place. Back to your regularly scheduled program.]
Dinah's Addendum
Arg From Dinah! See my clarifying remarks in the comment sections.
Regarding pilots: I'm not the one who said they can't fly with a history of bipolar disorder, it's the FAA's idea. And the FAA is pretty picky about what meds pilots can take and still fly, psychotropics in general are not allowed, so this pretty much eliminates anyone with a chronic or recurring mental illness. Benedryl is a no-go as well, so no acutely allergic pilots. What surprised me is that they can be on blood thinners or anti-arrhythmics and people who need those medicines generally have underlying illnesses that make them susceptible to strokes or sudden death.