On Trump's mental fitness, the experts are silenced and the public's in the dark This is not 'armchair psychiatry.' It's a call for a responsible, thorough and accurate assessment that prevents irresponsible conclusions.

Bandy X. Lee and Norman Eisen | Opinion contributors

Many Americans are asking questions about Donald Trump’s mental fitness for the heavy duties of the presidency and coming to their own answers. The topic has become so prevalent that the president himself asked his doctor to administer a cognitive test as part of his physical. Yet mental health experts who have been trying simply to raise this legitimate inquiry and contribute to its informed discussion have been chastised by those who wish to silence them. Now that Trump himself has opened up the issue, those professionals' voices are needed in the public discourse more than ever.

The subject of the debate is Trump’s behavior — impulsive, inappropriate, offensive, reckless and shocking — which we as a nation have tolerated. Is it something more than a mere departure from decency and historical norms? How concerned should America and the world be if the nation’s chief executive acts this way?

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As a forensic psychiatrist and a government ethicist, we believe those questions of public health concern should be asked publicly. Indeed, to some extent the president seems to agree with us. Not to frame and discuss these questions leaves public officials, the press and the people — the president’s ultimate employers — to fend for themselves without the benefit of the special expertise of psychiatrists, psychologists and other mental health professionals. That can only raise anxiety levels. Nothing is more disconcerting than being left in the dark.

When psychiatric professionals see signs of danger and alert the public about the need for a full evaluation of a government official, that is not “armchair psychiatry.” It is, instead, a call for a responsible, thorough and accurate assessment that prevents irresponsible conclusions. Accordingly, given what we have all observed over the past year, the president’s request for testing in his annual physical should have been met with an in-depth neuropsychiatric evaluation by experts.

Unfortunately, all that he received was a brief screen, the Montreal Cognitive Assessment, used to determine whether additional testing is needed for cognitive or Alzheimer’s issues. Here, there are already ample indicators that additional testing is indicated, and the results prove little more than the limitations of a single simple screen. Better tests for intricate frontal lobe function include the California Verbal Learning Test, the Stroop Test, the Wisconsin Card Sorting Test and others. An MRI or PET scan would also have been helpful.

And this is just on the neurological side. It does not even touch the psychological side, where urgent concerns also lie and an assessment should have been done starting with a full history and standardized battery of testing. Experts have, furthermore, been calling for a capacity evaluation to determine Trump’s ability to function in his position, regardless of diagnosis.

In this context, the limited screen Trump received can even be harmful, by giving the public a false sense of reassurance. While we understand his physician’s strong public advocacy for his patient from the White House podium, we note that he is neither a psychiatrist nor a psychologist. It is therefore incumbent on mental health professionals to raise awareness on what the minimally appropriate testing consists of. Moreover, some of his other statements raised eyebrows, such as when he went out of his way to guarantee the president’s health not just at present, but for the remainder of his current term, and a second one as well. Questions are also now being raised about whether the president’s heart disease was soft-pedaled and whether his height was overstated at 6-3 because his weight, coupled with the 6-2 height on his driver's license,would have classified him as obese.

This critique of the president's cognitive exam is itself an example of the role mental health professionals have to play, working with government experts, in informing the public. It is unfortunate that the critics do not appreciate this need. Some, for example, have attacked The Dangerous Case of Donald Trump, a book of essays that mental health professionals (including Lee, one of the authors of this op-ed) put together in order to inform the public. The contributors have been accused of diagnosing without properly examining the patient. The book does no such thing. It actually avoids diagnoses. It simply addresses the same public evidence that all of us see, and its possible implications for the risks we all face.

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While that book went no further than the limits of the American Psychiatric Association’s so-called Goldwater rule, we deplore that the rule has since the onset of this administration been modified to act in effect as a gag rule on APA members. History teaches us that silence can be just as harmful as active cooperation with a dangerous regime. That was the reason for the World Medical Association’s Declaration of Geneva. This universal declaration clarified the humanitarian goals of medicine shortly after silence on the part of psychiatrists, and active participation on the part of other doctors, had assisted some of the worst atrocities under Nazism.

Warning about signs of mental disorder in an individual whose decisions could have dangerous public health consequences, and alerting people about what they need to know to further their safety, is a public duty. It is also a public service to point out omissions of information. If there is disagreement about these issues, the solution is not to shut down the debate, or to bar expert voices from contributing to it.

The late Supreme Court justice Louis Brandeis said it best. In the matter of Trump's mental fitness, as in any other matter of great concern, “Sunlight is ... the best of disinfectants.”

Bandy X. Lee is an assistant clinical professor in law and psychiatry at the Yale School of Medicine and a project leader for the World Health Organization. Norman Eisen, a senior fellow at the Brookings Institution and chairman of Citizens for Responsibility and Ethics in Washington, was President Obama's ethics czar from 2009 to 2011. Follow him on Twitter: @normeisen