Obfuscating the truth, or flat-out lying, is a well-known Oval Office fall back; think Reagan and the Contras, LBJ and the Bay of Tonkin; FDR with his personal, physical hell.

Hiding, or even attempting to hide, personal shortcomings is another forte of elected presidents. Kennedy, for example, had his pain medications. Eisenhower’s temper was the stuff of legend in the White House.

But whether they let these shortcomings affect their decision-making capabilities is another matter. One study that looked at 37 former presidents from 1776 to 1974 found that 18 of them had some form of mental illness and that of the 18, 10 had “a disorder [that] was evident during presidential office.” The researchers theorized these mental illnesses may have affected these presidents’ service to the country. The lead author, noting the job’s capacity to create stress, wrote: "The pressures of such a job can trigger issues in someone that have been latent… nobody has unlimited capacity to take it forever and ever.”

Four years of friction

At the moment, the electorate has no reassurance that the last four years of impulsive, often withdrawn decisions will not be repeated; that a newspaper fact checker will not find 30,573 exaggerated, fabricated and unsubstantiated statements over the course of one presidency; or that personal obsessions will not impact public safety. Between July 2015 and Jan. 8, 2021, when he lost tweeting privileges, Mr. Trump used Twitter more than 34,000 times. Statista.com said in the first six months of his presidency, he tweeted about 6 times a day. By the second half of 2020, the average number grew to 35 times a day.

No presidential candidate has had to submit to a mental health evaluation, because none is required, unlike for those who handle nuclear weapons; they undergo yearly extensive checks, said Yale University psychiatry professor Bandy X. Lee, MD. Nor is a track record of significant decisions required to judge a candidate’s fitness. And, as the nation witnessed a few weeks ago, trying to remove a president under the 25th Amendment will likely never happen when the removal process is politically fraught.

Before, during and after the Trump presidency, health care professionals and elected officials waved red flags concerning Mr. Trump’s capacity to handle the job. Nobody got anywhere. In 2017, mental health professionals warned that at some point in the Trump administration, violence would result because of the president’s words and deeds. Those same people are still speaking out.

In December 2017, Congress invited Dr. Lee to evaluate Mr. Trump's behavior. The acceleration of his tweeting, she said, is an indication of “his falling apart under stress.” The signs of unraveling are becoming apparent. She warned in Politico that eventually he would “become uncontainable with the pressures of the presidency.”

A few months before that, 67 members of the House wanted to put up so-called guardrails should a sitting president show signs he or she couldn’t adequately handle the job. The proposed legislation is still just proposed. Whether the bill’s sponsor, Jamie Raskin, Democrat of Maryland, plans to reintroduce the bill to the new Congress is unknown; a phone call to his office was not returned.

Dr. Lee told MedicalDaily that an expert panel was put together in 2019 to screen for mental capacity; members are still available for any consultation or mental capacity screening. Congress has yet to call. The panel has members from George Washington, Harvard, Yale and North Carolina, Chapel Hill.

“What good is expertise if it cannot buttress what the public is seeing?" she asked. Many people saw he was unfit, but psychiatrists have methods of measurement, knowledge gleaned from decades of research and hundreds of clinical cases to bring into the discussion, she said. “We can measure the severity of what is likely to happen.”

The psychiatrists insist they are not diagnosing from the sidelines.

“I haven’t diagnosed Donald Trump, I haven’t put a mental health label on him,” said Leonard Glass, MD. “I have only addressed his ability to hold high office.” In 2018, Dr. Glass, an associate professor of Psychiatry, Harvard Medical School, and peers pleaded with the American Psychiatric Association to lift its rule that disallowed mental health professionals from speaking out about anyone whom they hadn’t personally assessed. The APA would not do so, so some psychiatrists, including Dr. Glass, resigned.

The hurdles of high office

Mental health doesn’t disqualify a person from high office, numerous psychiatrists have said. President Lincoln and England’s Prime Minister Winston Churchill were both depressive, Dr. Glass explained, but they had a firm grasp of what they were dealing with. “They could assess reality. They weren’t detached from unpleasantness. Instead, they grappled, consulted, problem solved.” They used their mental analytical functions to absorb the enormous problems they were confronted with, like the Civil War or WWII.

Dr Lee agreed; by itself a mental disorder does not pose any more danger to the public than those without a mental illness. In the study of the former presidents, the authors wrote: “No national calamities appear to have occurred due to presidential mental illness.”

People who are preoccupied with how they appear to others, Dr. Glass said, can’t solve problems in the lives of others. Mr. Trump’s comments regarding the pandemic – it’s a hoax, don’t be concerned about it – showed he was “without empathy.” His lack of fitness for the office, he said, and the inherent danger he posed to the country “was obvious before he took office.”

Dr. Lee told MedicalDaily that her group also did not diagnose Mr. Trump, as diagnosis would indicate potential treatment. But an assessment of mental capacity, she said, serves the public interest. It can indicate if the person can make rational decisions that are based on the person’s ability to absorb and process what the information means. Also, reaching a rational, informed decision takes thought and deliberation, with the decision-maker comprehending the consequences of making that decision. Another important consideration is whether the person is a threat to himself, others, or the public at large. The former president, she said, failed all criteria.

But the pandemic is a national calamity; lack of leadership and a national strategy to confront the tragedy has led to many preventable deaths, noted Columbia University, Weill Cornell Medical School and UN researchers in a paper published in October. Then, the calculated number of avoidable deaths was 130,000. The authors came to this figure by comparing them against those from other wealthy nations. As of this writing, some 433,000 people have died directly or indirectly from Covid-19 in this country; Germany has had nearly 56,000 deaths; France, 75,000; Canada, almost 20,000. But put more accurately, the US has had 78,304 cases per 1 million people; Germany, 26,393; France, 42,864; and Canada, 20,172.

Traits of an effective leader

The historians sound just like the psychiatrists.

Presidential historian Doris Kearns Goodwin, who has studied Oval Office leadership extensively, told NPR that Mr. Trump possesses no humility, an indication that temperament can be volatile. "The ability to control impulses and emotions is a really important part of temperament of any leader, not just a president," she said, citing Mr. Trump’s extensive tweeting history as an example. "These tweets get him into trouble, and despite everyone saying, 'Stop,' he cannot stop."

Historian Richard H. Immerman, the Edward Buthusium Distinguished Faculty Fellow in History, Emeritus at Temple University, didn’t always teach. His CV includes serving as assistant deputy director of National Intelligence in the second term administration of George W. Bush; he stayed on shortly when President Obama began his first term in 2007. He too has written about presidents and those qualities and characteristics that make them effective while earning others’ respect.

“The respected presidents used a formalized plan to make decisions,” said Dr. Immerman. Presidents like Obama and George Bush the senior “had a voracious appetite for information,” regardless of the source or party affiliation. Their goal was to make informed decisions and that takes self-confidence, “because the information you get may not jibe.”

By no means are effective presidents always cool, calm and collected. President Eisenhower knew he had a temper. But pounding fists and spewing vitriol did not make for good Oval Office conduct. “He had a horrific temper, but he worked on it,” said Dr. Immerman. “It was better for a leader, the president said, not to project anger.”

President Obama, he continued, apparently understood that he needed to learn how to make enormous decisions, as past roles lacked that type of experience. So he studied how the former occupants of his chair made decisions.

“[His advisers] had tremendous confidence in him because of his intellect,” Professor Immerman said. In many ways, the models that Obama used were Eisenhower and the first George Bush. Political moderation is a tremendous asset when making informed decisions. Obama’s worldview was moderate, Profesor Immerman said. So he took in the “long view” of issues before him. “He was a Democratic president and would use any information regardless of ideology that served national interest.” As did Lincoln, a Republican.

Effective presidents, in the mind of the late political scientist Fred Greenstein, all possessed another quality -- emotional intelligence. It is this quality that allows a president to control his emotions and use them for good, instead of allowing those emotions to dominate him, thereby impacting his leadership.

As for Mr. Trump, he blew off all the mental health criticism in one particularly memorable tweet:

"Actually, throughout my life, my two greatest assets have been mental stability and being, like, really smart," Trump tweeted, noting: "I went from VERY successful businessman, to top T.V. Star ... to President of the United States (on my first try). I think that would qualify as not smart, but genius ... and a very stable genius at that!"

Christine Bahls is editor of Medical Daily. Additional reporting from Sabrina Emms and Sean Marsala.