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Tough times call for troubled minds

No excellent soul is exempt from a mixture of madness. —Aristotle

Newt Gingrich’s sinking, soaring, and now sinking presidential candidacy has revived talk of a wild card in politics: the oft-murmured but only rarely broached question of leaders’ mental health. During the 2000 and 2008 Republican primaries, some adversaries of the famously hot-tempered John McCain circulated rumors that he was dangerously unstable, perhaps afflicted with PTSD from his ordeal as a POW. Now similar questions have hovered around the brazen, defiant, mercurial, and immodest Gingrich: Is this man too crazy to be president? Gingrich even has a family history; he teared up at an Iowa campaign event recalling his mother’s depression and bipolar disorder.

Dr. Nassim Ghaemi has some very interesting things to say about Newt Gingrich’s mental health and leadership qualities (see below). But he might turn the question on its head: Is this man crazy enough to be president in a troubled time?

Ghaemi, a professor of psychiatry at Tufts University School of Medicine and the director of the Tufts Medical Center’s Mood Disorders Program, made a stir last summer with his provocative book A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness. It challenged the assumption that healthy minds make good leaders, positing instead an inverse law of sanity: “The best crisis leaders are either mentally ill or mentally abnormal; the worst crisis leaders are mentally healthy.” Abraham Lincoln, Winston Churchill, John F. Kennedy, Adolf Hitler, Franklin Roosevelt, Mahatma Gandhi, Martin Luther King, Jr. — all suffered from depression and/or mania. By contrast, mentally balanced leaders such as Neville Chamberlain, Tony Blair, and (no kidding) Richard Nixon might fare well in times of peace and prosperity, but their normalcy is a liability in tough times, when realism and divergent thinking are critical.

The 2012 presidential election approaches at a time that cries out for bold, innovative crisis leadership, yet it appears the race will come down to the conspicuously even-keeled President Barack Obama and a dull, gray, Republican, perhaps the consummate manager Mitt Romney or the stolid ideologue Rick Santorum. It’s all fair game for Ghaemi, who also holds degrees in history, philosophy, and public health. We spoke extensively in November, and he interrupted his New Year’s Eve to comment further on the presidential contenders.

Nassir Ghaemi: Basically I’ve been treating and doing research on bipolar disorder and depression for almost two decades, and I knew from my own clinical experience and from my experience with other experts in the field that many of our patients were highly successful people: business people, politicians, professors, doctors, lawyers. But because of confidentiality issues and stigma, we often don’t know about these people. We think of mental illnesses like manic depression and depression as only harmful because we don’t hear about those who have them who are doing well.

I decided to bring out this link between depression and mania and success through public figures from the past because their information would be publicly available.

Lindley:  In your introduction, you compare your work as a psychiatrist with that of a historian. How is it possible to make a diagnosis of a historical person when you don’t have a direct examination?

Ghaemi: Direct examination is overrated. The most important aspect of psychiatric diagnosis is the history, and it’s almost completely dependent on the history of the patient, [but] the history of the patient is poorly obtained if it’s solely from the patient. Many people do not realize what psychiatric symptoms they have. As clinical psychiatrists, what we must do is talk to family members, friends and other people to get outside information….

With historical figures, I would add that we have all these other sources of information and we can directly interact with the patient because we have their autobiographies, their memoirs and their letters.… I had primary sources and didn’t engage in psychoanalytic speculation.

Lindley:  How can people with a mental illness be better leaders than people without mental illness? 

Ghaemi: One important thing to do is show the association of the leaders and these conditions. The science is stronger in some aspects, and less strong in others, but it shows that four traits seem to stand out. One is realism, which is enhanced in depression, and this probably the most proven scientific positive trait.  Many studies over 20 years show that people with a little depression are more realistically able to assess their surroundings and their environment and their control over their environment than people who are not depressed at all—people who are normal.

Empathy is a second trait enhanced by depression. There’s less research on this in terms of psychiatric work, but some research connects depression and empathy in psychiatric studies . Also neurobiological research I describe about how empathy is wired in the brain and has a biological aspect, which could be linked to biological conditions like depression.

The third trait is creativity, which I associate with mania. There’s a good deal of work connecting bipolar disorder prevalence with creative professions in the arts: writers, artists, musicians. In terms of divergent thinking, the idea that one’s thoughts go in many directions and this enhances creativity, or flight of ideas as psychiatrists call it, is one of the cardinal symptoms of mania.  That’s better established than empathy, but there’s more work that needs to be done on mania and creativity.

The fourth trait, resilience, is probably better established than the others except maybe realism. There’s a lot of research on resilience and post-traumatic stress disorder and mania or manic symptoms. Hyperthymic temperament, which is mild manic symptoms as part of one’s personality, is protective against trauma and is a major factor for resilience.

Lindley:  To go back to the history, it seems Lincoln, for example, manifested each of those enhanced traits in his leadership although he was morbidly depressed at times.

Ghaemi: Yes. I think Lincoln and Churchill are probably the most incontrovertible cases of severe depression among these leaders. General William Sherman is a prototype for both depression and mania.  

All of them displayed probably all of these traits, although some to a lesser degree than others. For instance, I describe Lincoln as very realistic, which I relate to his depression. Obviously, he is known for being empathic toward black slaves, which might have been related to his depression as well. But the realism is underappreciated.

Lindley:  Does realism get to Lincoln’s pessimism or optimism?

Ghaemi: He clearly wasn’t optimistic. That gets to another aspect. We tend to think it’s good to have optimistic leaders – “It’s morning in America,” as President Reagan said, and President Obama talking about hope. But Lincoln clearly was not optimistic.

Lindley:  And you talk about hyperthymic personalities, especially with Franklin Roosevelt and John Kennedy. Do hyperthymia and dysthymia represent a set of personality traits rather than major psychiatric disorders?

Ghaemi: Right, and I think that’s a concept that’s difficult for people to understand. Everyone would like things to be black and white, but part of the message of A First-Rate Madness is that insanity is not all bad, insanity is not all good. There are gradations. You can have mild and moderate symptoms of depression and mania, which is a lot of what I’m describing the book, in which a person can be better functioning than a normal person.

Lindley:  How did FDR and JFK display hyperthymia?

Ghaemi: FDR was a very confident person. He had a lot of energy for campaigning. He traveled hundreds of thousands of miles by train even though he had polio and would outlast physically healthier candidates. [His hyperthymic temperament] enhanced his resilience when he faced polio personally, but also his resilience when he faced the Depression and the Second World War.

John Kennedy had similar extroversion, energy, very high libido as well as extreme sociability, all basic traits of a personality associated with hyperthymic temperament. He had these traits since childhood and early adulthood. But he also had major physical illness, like Roosevelt. He had Addison’s disease with multiple hospitalizations and [several] near-death experiences. He was treated with steroids for Addison’s, but steroids also can cause mania, so there was this complication that his hyperthymic temperament put him at increased risk of getting more manic on steroids, which apparently happened in the 1950s and in the first year of his presidency. These were times when he had a lot of reckless sexual behavior as well as erratic, impulsive judgment, which were probably from an interaction of steroids—including anabolic steroids that athletes use, which I documented based on primary sources—and his underlying hyperthymic temperament.

In his last year or two, when his steroid use got under control by his doctors, his judgment and his leadership improved because he was no longer severely manic, which was harmful, but only mildly manic, which was helpful.

Lindley:  You compare his handling of the disastrous Bay of Pigs invasion in 1961 to his management of the Cuban Missile crisis in 1962.

Ghaemi: Right. I think that’s the best analogy. One could also compare his handling of civil rights crises from 1961 to 1963. With the Cuban Missile crisis he literally saved tens of millions of peoples lives by playing it just right. He didn’t go to war in an impulsive, straightforward way like he did with the Bay of Pigs, like a lot of his military advisors wanted. And he didn’t back off like the normal, mentally healthy Chamberlain did when faced with such an extreme situation [in Munich in 1938], thinking you could rationally get someone to agree with you if you backed off.  He played it right in between.

Lindley:  It appears that Theodore Roosevelt and Bill Clinton also displayed some of those traits.

Ghaemi: I think Theodore Roosevelt had a bipolar disorder or a hyperthymic temperament but I didn’t go into his case because of the issue of whether he was dealing with a major crisis. And President Clinton and more recent leaders I didn’t get into because of not having documentation to definitively say that they had such conditions. I do talk about people like George Bush and Tony Blair who I thought were mentally healthy because mental health is the presumption and there’s no other evidence available now that they had mania or depression.  But even in their cases, one can’t be definitive until future decades.

It is possible that President Clinton may have hyperthymic temperament and that might explain some of his sexual activity as well as his charisma.

Lindley:  Previous writers disagree about Hitler’s mental condition. What is your opinion about his mental status, and how does he fit into your theory on crisis leaders?

Ghaemi: My research indicates that it’s highly likely that Hitler had a mental illness, specifically bipolar disorder. He had severe manic and depressive episodes, well documented through multiple sources of those who knew him before and after his rise to power.

His bipolar disorder served him well in many ways into the mid 1930s, I think. He was widely viewed until that time as a successful and charismatic leader; even Churchill, in a book written around 1935, spoke highly of Hitler’s political skills and leadership qualities. However, because of his severe depressions, Hitler began to receive amphetamines, and from 1937 onward, he received amphetamines intravenously on a daily basis. IV amphetamines given to someone with bipolar disorder leads to marked mood instability, more and more severe manic and depressive episodes, and even psychosis. In fact chronic amphetamines at high doses are used in animal models of psychosis.

Thus, Hitler became more and more unstable into the 1940s and throughout the war. His closest allies saw the major psychological change, and even tried to get him committed to a psychiatric hospital. But in a totalitarian state, there wasn’t much others could do.

Lindley:  I didn’t know that both Gandhi and Dr. King had attempted suicide as adolescents and that they both probably were dealing with depression or bipolar disorder.

Ghaemi: It’s a surprise to most people, and I’ve had some positive and negative feedback on that. Some critics have a hard time comprehending this notion that Gandhi and King might have had depression mainly because this is new information.  

It has been known and documented that they both made suicide attempts when they were adolescents, but this has been written off by previous historians and biographers. The statistics make this improbable as unimportant. Ninety-eight percent of children do not make suicide attempts. Of those who make suicide attempts, 90 percent of those are diagnosable with clinical depression. The mere fact that both of them made suicide attempts makes it extremely likely that they both had clinical depression. Again, if you think about the way I approach psychiatric diagnosis with the standard scientific approach, having clinical depression at age 13 makes you very prone to having clinical depression in later life as well. It’s not the nature of depression that it would happen once, then never happen again.

I documented [mental illness] for both of them from primary sources. There was a time for both of them in middle life when they each had a period of depression that meets our current definition of depression: no interest, no activities, sleeplessness, no appetite and even suicidal thoughts. Gandhi was convinced that he was going to die any day and his medical doctors told him he was physically healthy, then one told him he had a nervous breakdown. This lasted a few weeks or a few months and then it got better, and that’s the standard, natural history of depression. This happened to Mahatma Gandhi in middle age, and it happened to Dr. King when he was about 30 when he was medically hospitalized.

And they each had very severe depressions just before they were killed very well described by the memoirs of their friends and associates. In the case of Dr. King, his associates even tried to convince him to get psychiatric help.

These facts have been there, but people have not put these facts together to show how this is consistent with the diagnosis of depression, and I try to do this in these cases. Since it’s new, I think people have more difficulty accepting the idea, but it’s very important because their politics really reflects a politics of radical empathy that links to their depression.

If we really want to understand what Dr. King and Mahatma Gandhi were trying to do, we have to understand how empathy can play out in the political world.

Lindley:  Now we have President Obama who is seen as calm, steady, reasonable, and probably mentally healthy. He’s been criticized recently for a perceived failure of leadership. Do you think his ostensible normal mental health is a problem for him in these times?

Ghaemi: One of the implications of the ideas in A First-Rate Madness is that we should not be seeking presidents necessarily who are just average, mentally healthy and normal. Maybe in normal times of peace and prosperity it doesn’t matter to have presidents who are average people. But the concept of “the beer test”—having a beer with somebody, although it instinctively feels good, may not be the way to do it, as we discussed.

To some extent, I think President Obama and his campaign have been going along with this general impression in our society that this is attractive—to choose a leader who, to the public, seems average and normal.  Especially in 2008 with the economic crisis and two wars, this calm President seemed attractive to people. One has to be careful about knowing whether this is the reality, or if this is the campaign packaging. As I said, we won’t know that for decades.

It’s possible it’s not reality, but if it is reality, then President Obama may not turn out to be as strong and effective a leader as people had hoped. But if it’s only partly reality, and the other reality is more complex and nuanced, maybe he’s a person with more anxiety than we know of. Maybe he even has depression, as some people have already speculated. I think that would hold him in good stead. President Obama has said Lincoln is one of his heroes and he has talked about Lincoln’s empathic leadership. If he wants to be that way, actually some depression would be helpful to him.

Lindley:  In an interview with Stephen Colbert last August you said the leading Republican candidates for president all seemed normal. Is that still your sense of Mitt Romney, Newt Gingrich, Rick Perry, and Ron Paul?

Ghaemi: My thoughts have changed a bit since the Colbert interview. Romney and Perry certainly try hard to appear very normal, and as far as we know, they are. This bodes ill for their ability to rise to our current crises. As in the pattern I found, Romney in particular was quite a success in good economic times, but this does not predict success in crisis. I don’t have any specific thoughts or knowledge about Paul.

In contrast, Gingrich has only functioned well as a crisis leader, such as when he brought his party to power in the House for the first time in four decades. He was great as the leader of an insurrection, but once in power, all his strengths became flaws and he could not run the House as a normal manager. He has many traits that are consistent with hyperthymia or manic symptoms: talkativeness, creativity, high self-esteem, risk-taking, curiosity, even possibly overspending and sexual indiscretions. It is notable that his mother has been diagnosed with bipolar disorder, which would biologically increase the chances that a child would be predisposed to that condition. We do not know if he has that condition, but his observable personal and leadership traits are consistent with it. If so, the historical pattern suggests that he could be a creative crisis leader. 

A caveat though before we compare him to Franklin Roosevelt or Kennedy or Churchill. A weakness of mania is an absence of empathy for others; Roosevelt and Kennedy had the perfect cocktail of leadership. They combined creativity and resilience, growing out of mania, with empathy and realism, growing out of the experience of trauma, and even some depression. Churchill had even more severe depression when he wasn’t mildly manic. 

My concern about Gingrich, not knowing more about him personally, is that if he hasn’t struggled with depression or great personal trauma – and we know of no such aspects to his life – then he may not have the empathy towards others that marks the greatest leaders.

Lindley:  What do you hope readers take from your book?

Ghaemi: There are a few take-home points. One is that there are benefits to these mental illnesses. Another is that there are limitations of mental health. An important example of mentally healthy leaders who were a problem is the Nuremberg Nazi leaders, the second-rank leaders after Adolf Hitler. They were studied very carefully with psychological and psychiatric tests for years, and basically found to be normal and mentally healthy. That tells us that evil does not equal mental illness and that mental health is not protective against evil ideologies. Healthy, average people tend to be very conformist, and the Nazi leaders in that environment were probably healthy, average people who conformed with a radical, harmful ideology.

Another point is the stigma against mental illness. It’s analogous to racism and sexism, in my view.

And a final point – we need to understand our historical leaders in a human way, including faults and flaws and illnesses, not in some iconic way or as an ideal against which we measure normal human beings [who] will never be able to reach those ideals. In other words, we should view them as heroes, not superheroes. It’s a matter of historical fact but also it can help us with our current attempts to find good leaders.

Another version of this article with more details on Dr. Ghaemi’s research appeared on the History News Network in November 2011.

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