The Gift of Anguish—Psychiatrist Nassir Ghaemi on Leadership and Mental Illness

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

It seems reasonable to assume that the mentally healthiest people make the best leaders.  However, in his provocative new book A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness (Penguin Press), psychiatrist Nassir Ghaemi, MD, MPH, posits a provocative inverse law of sanity: the best crisis leaders are either mentally ill or mentally abnormal; the worst crisis leaders are mentally healthy.       

An expert on mood disorders, Dr. Ghaemi finds that historical leaders such as Abraham Lincoln, Winston Churchill, John F. Kennedy, Adolf Hitler, Franklin Roosevelt, Mahatma Gandhi and Dr. Martin Luther King all suffered from mental illness, particularly depression or mania.  These mood problems, according to Dr. Ghaemi, are characterized by four traits that enhance effective crisis leadership:  creativity, realism, empathy, and resilience. 

He further contends that mentally normal leaders such as Richard M. Nixon, Neville Chamberlain and Tony Blair may do well in times of peace and prosperity, but their mental normalcy is a liability in times of crisis when divergent thinking and realism are critical.

Dr. Ghaemi’s challenging book has been praised for its scientific approach to a controversial thesis and its fine writing and meticulous research.  Renowned author and journalist Stephen Kinzer wrote: ''No one who reads this brilliantly insightful book will ever look at history or politics the same way.  Ghaemi uses his deep knowledge of medicine and psychiatry to take readers on a fascinating voyage into the minds of great leaders.  His conclusions are startling, provocative, disturbing and deeply persuasive.''  A First-Rate Madness has also ignited some controversy and debate.

Dr. Ghaemi is a professor of psychiatry at Tufts University School of Medicine and the director of the Mood Disorders Program at Tufts Medical Center in Boston.  He trained in psychiatry at Harvard Medical School where he teaches now.  He also has degrees in history (BA, George Mason University), philosophy (MA, Tufts), and public health (MPH, Harvard).  He has published dozens of scientific articles and his other books include The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry (2009); A Clinician's Guide to Statistics and Epidemiology in Mental Health (2009); The Concepts of Psychiatry (2007); and Mood Disorders: A Practical Guide (2007        

Dr. Ghaemi recently commented extensively on his controversial new book from his office in Boston.

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What was it that sparked your book A First-Rate Madness?

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 [and] 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.    So it’s partly from my clinical experience and my research knowledge about the costs and benefits of these conditions.

Did you have a background in history as well?

Yes.  I’ve always been interested in history and have a bachelor’s degree in it, and later earned a master’s degree in philosophy.  I always have been interested in these various leaders for historical and cultural reasons, and I saw that you could understand them better based on some aspects of their psychology that I understood from my own clinical and research work.  I realized that this was a story of history and psychology that hadn’t been told, so I decided to try to tell it.

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?

Direct examination is overrated.  Most people don’t understand how psychiatric diagnosis happens.  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 not solely obtained from the patient.  In fact, it’s poorly obtained if it’s solely from the patient.  Many people do not realize what psychiatric symptoms they have.  For instance, particularly with mania, some of my own research shows that about 50 percent of people who have mania do not have insight into their illness.  That means they don’t realize that they have mania.  So if one is to rely on the direct interview of the patient, one will misdiagnose mania 50 percent of the time.

So direct interview of the patient is only part of the diagnostic process, not the whole, and sometimes it is mistaken and leads you down the wrong track.  As clinical psychiatrists, what we must do is talk to family members, friends and other people to get outside information about the patient in addition to talking with the patient.  Frequently that’s enough to make a diagnosis, and frequently we make the diagnosis even though what the patient says is the opposite of what all the other sources of information say.

In a sense then, making the diagnosis of mania and depression does not require a direct interview with the patient, and frequently we have to discount the direct interview with the patient.  Nonetheless, 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.  And in these sources they are telling us their symptoms.  I have these sources with most of these leaders.

Did you do a lot of archival research for the book?

For some of these leaders.  I did a lot of archival research on John Kennedy.  I’m the first psychiatrist to go through his medical records and one of only a few physicians to look at it.  A lot of that information is new.  The amount of detail in the book on Kennedy and in the endnotes is at a level that’s never been published in previous biographies.  A lot of that medical information can’t be photocopied, so I hand copied it and put it in the endnotes so this is important primary material on President Kennedy’s medical and psychiatric state.

 I also did some interviewing on Martin Luther King of the only psychiatrist who was with him at the time, Dr. Alvin Poussaint, and that’s primary source material that’s never been [published] before.

Some of the research in the book was my own archival primary source research, but I emphasize that every leader in this book who was diagnosed with depression or bipolar disorder or any variation of it—those diagnoses were based on primary source material in each case, both from the letters or memoirs of the leaders themselves, or from medical records of their treatment, and first-person memoirs of those who knew the leaders.

Can you talk about the structure you use in arriving at a diagnosis?

I used a basic structure that’s standard in contemporary psychiatry and scientific research in psychiatric diagnosis today. 

There are four lines of diagnostic evidence to use to identify if a diagnosis is present and if it’s valid.  One is symptoms, which is obvious, such as symptoms of mania defined as decreased need for sleep, increased activity, increased talkativeness.  The second line of evidence is family history or genetics.  This is especially important in the case of mania because bipolar disorder is highly genetic, so it’s almost always present in some family members when it’s present in anyone.  The third line of evidence is course of illness, and this is extremely important because this independent line of evidence is separate from saying someone feels sad or happy.  The average age of illness [onset] for bipolar disorder is nineteen, and the average episode lasts a few months, and each episode lasts a year or two.  This is the kind of course we see with these leaders if they have bipolar disorder.  The fourth line of evidence is treatment—that someone has severe enough symptoms to be treated for it.

What I did to identify the diagnoses was not just to identify the symptoms but to also look at these four sources of evidence, just as we do with contemporary psychiatric treatment and research.  This is not psychohistory in the traditional sense.  This is not a psychoanalytic approach where one speculates about psychoanalytic ideas like narcissism and paranoia or about childhood experiences.  This is much more objective and gives us evidence beyond just symptoms. 

So to answer your question about how I could diagnose these people is that I applied these four diagnostic validators that are scientifically accepted.  I had primary sources and didn’t engage in psychoanalytic speculation.

Also, I didn’t select the leaders in a haphazard way. I started fifty years ago as my most recent period because we need that amount of time to get the primary source documentation on things like medical history and psychiatric history, which tend to be confidential and private.  For instance, with Kennedy, his medical records didn’t come out until ten years ago.  With Churchill, no one knew he had depression until at least a decade after he died when his doctor published his medical diaries against the objections of his family. 

So we need about fifty years to make these assessments, so I started fifty years ago and went back about a century looking at the major military and political crises of that century from the mid-1800s to the mid-1900s.  I look at the major leaders in the U.S. and a few from abroad that were a part of the same crises.  I left out World War I, but included the Civil War, the Depression, World War II and the Cold War [and] chose the major leaders from that period, which is why there are no women in that group. 

In your book you set forth an inverse law of sanity and the idea that the best crisis leaders had some form of mental illness such as bipolar disorder.  How can people with a mental illness make better crisis leaders than people without mental illness? 

One important thing to do is show the association of the leaders and these conditions, as I discussed.  The other part of the book is showing the science of how these mental illnesses—depression and bipolar disorder—have some positive aspects.  As I said, I was aware of the science before I did the research, and I tried to find how this research would be relevant in the lives of the individuals I studied.  I also describe the science in the book. 

The science is stronger in some aspects, and less strong in others, but it shows that four traits [related to depression or mania] seem to stand out.  One is realism, which is enhanced in depression, and this probably the most proven scientific positive trait.   Many studies over [the past] twenty 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.  Psychologists call this mild positive delusion. 

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 based on rating scales where depressed patients score better than non-depressed persons.  There’s 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. 

Aren’t the empathy studies fairly recent?

Yes.  Empathy is the least proven of the four in terms of lots of replication or many years of research.  It’s probably the newest idea of the four, but there is research to support the notion.  And another aspect of what I’m doing in this book is not saying here’s all this scientific research and historical evidence and everything is 100 percent absolute and you all should agree with me.  That’s not the way science works.  Science is about looking at the evidence we have and making our best probable judgments and then looking at what further needs to be done to strengthen those judgments or change them.  In the case of empathy, the evidence is there but I hope this will spur more work to look at what enhances empathy and what doesn’t and whether depression enhances empathy or not.  The case for realism has already been well proven.

The third trait is creativity, which I associated with mania.  There’s a good deal of work connecting bipolar disorder prevalence with creative professions in the arts: writers, artists, musicians.  There’s also some psychological research looking at creativity in psychological tests of creativity in people who have bipolar disorder and those who don’t.  There’s again room for more studies of this kind, but there’s a general finding of increased creativity among those who have bipolar disorder versus not, and mania is an important aspect of that.

In terms of divergent thinking concept, 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 realism and post traumatic stress disorder {PTSD), and it’s clear that some people have factors that make them less likely to develop PTSD after a severe trauma.  In fact, about 90 percent of people who have trauma don’t develop PTSD—only 10 percent do.  Of the 90 percent who don’t develop PTSD, people have looked at resilience factors and the most prominent resilience factors include underlying personality traits.  Among these underlying traits, the one that seems the least helpful is neuroticism, which is being more anxious and is not helpful for resilience in PTSD.  But mania or manic symptoms or, as I describe it, hyperthymic temperament which is mild manic symptoms as part of one’s personality is protective against trauma and is a major factor for resilience.  That’s reasonably well proven, although again resilience is a relatively new idea too, and only in the last decade or so have people been studying it carefully.

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.

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. 

Many people over the years have thought of Lincoln as a vague idealist and visionary.  Really, when he ran for president, he was a compromise candidate because he was willing to let the South continue have slavery as long as it wasn’t extended to the new territory.  He was a proponent of sending blacks back to Africa and viewed blacks as inferior to whites.  It wasn’t until the middle of the war when he favored abolition and emancipation, and even that was largely a realistic response to the fact that 10 percent of the Union Army was then black and it would be very difficult to force them back into slavery after they had they became part of a liberating army.  Even at the end of the war he was very realistic toward Southern whites in terms of his initial thoughts about Reconstruction as best as we can tell with very compliant attitudes toward them realizing that would be better in the long run than a more difficult period of occupation.  His realism is something characteristic of his leadership.  That’s also true of Churchill.

Does realism get to Lincoln’s pessimism or optimism?

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 and we consider him a great leader, and that goes against a lot of our current assumptions.

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?

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 aspects of good and bad or both.  In fact, the distinctions that we make between sanity and insanity or mental illness and mental health are not all or nothing.  There’s gradations.  Certainly at the extremes, we can identify severe mental illnesses like schizophrenia where people are psychotic all the time or severe mania where people can be quite impulsive or severe depression where people can be quite suicidal.  Those are not functional states [but] are dangerous and harmful and quite different from normal mental health.  But 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. 

Then you can get to mild versions of mania in particular where it becomes part of one’s temperament.  It’s not something that comes and goes as in classic manic depression with episodes of depression or mania that last a few months, then they go away often for years and then one has one’s normal personality.  But in the case of hyperthymic temperament, one’s normal personality is to be a little bit high or manic—not to an extreme amount, just a little, so these are the highly energetic, extraverted, outgoing, highly optimistic people that are often very productive and very successful.  These are the kind of patients we often see among businessmen and politicians and other leaders.

The examples I used in A First-Rate Madness are Franklin Roosevelt and John Kennedy.  Also, hyperthymic temperament is biologically and genetically related to bipolar disorder so having a family history of other people with this temperament or with frank bipolar disorder is another confirmation, which is something I tried to assess, especially with President Kennedy.

Can you talk about how FDR and JFK displayed hyperthymia?

Sure.  FDR was a very confident person.  Sometimes he would have meetings where he would talk nonstop for almost an hour, and a general would be sitting there, the general would leave without having been able to say a world.  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 who tired much more easily.  He was very charismatic with a high libido, a part of a hyperthymic temperament, [and] very extroverted and outgoing and hated being alone.  

Franklin Roosevelt had pure hyperthymic temperament.  He never had any depression or any other symptoms.  One of his friends once said he must have been psychoanalyzed by God.  That was how happy and energetic he was.  But that was part of his natural biology.  This enhanced his resilience when he faced polio personally, but also his resilience when he faced the Depression and the Second World War.   That’s what made him so unique.

John Kennedy had similar extraversion, 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.

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

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 [British Prime Minister Neville] Chamberlain did (with Munich compromise of 1938) when faced with such an extreme situation thinking you could rationally get someone to agree with you if you backed off.   He played it right in between.  Of course, he may have learned at a personal level from a year in office and other factors, including excellent advice from his brother Robert.  But it’s rather clear that the president himself psychologically was in a very different place in 1962 and much more stable than he was in 1961, and this was important for the world [because] the Cuban Missile Crisis did not become a major nuclear disaster.

What is Addison’s disease and how did it affect President Kennedy?

Addison’s disease is an autoimmune illness where, for unknown reasons, the adrenal glands, which produce steroids in the body, are attacked by the immune system and destroyed.  If you don’t have steroids, when you get infections—which happens all the time because there are bacteria all over the place—your body can’t mount an adequate immune response to the infection because steroids are part of that response.  Then the infection would get out of control and you’d get septic shock, go into a coma, and die.  These [reactions] happened to Kennedy repeatedly and are called Addisonian crises where you get various infections.  Each looked like an ear infection or throat infection or venereal disease or urinary tract infections in his case.  This would spread throughout his body and he’d go to the hospital semi-comatose.  He would receive antibiotics and steroid injections for a couple days to a week.  He’d come out of the hospital and look fine, but he’d literally almost have died.  He had about a half a dozen hospitalizations like this in the 1950s. 

He had an incredible amount of resilience, and he hid all of this from the whole world while he was a senator, a vice presidential nominee and a presidential candidate.  Nobody knew.  And even when he was president, he had a major Addisonian crisis in the first year of his presidency that’s hardly been noted in any of the Kennedy biographies.  He literally almost died in July 1961, and he came back from that.  I think the public didn’t realize how resilient and strong President Kennedy was, and at the same time, they didn’t realize how sick he was.  That’s the paradox:  that illness and strength can actually go together. 

It seems that a hyperthymic temperament may be an asset for a politician, and it appears that Theodore Roosevelt and Bill Clinton also displayed some of those traits.  Can you comment on those leaders?

I think in the case of Theodore Roosevelt it’s highly likely.  I didn’t look into his history in enough detail to be definitive, partly because I wasn’t sure he met the definition of a crisis leader.  That’s another aspect here that’s important to emphasize. I’m talking about how these conditions can be helpful for crisis leadership, but that doesn’t mean they’re generally helpful most of the time in non-crisis situations, which is the usual. 

Many other leaders who were mentally healthy like Chamberlain and [Gen. George] McClellan during the Civil War are perfectly fine and successful leaders during peacetime and prosperity, and it’s during crises that they don’t as well.  The reverse is the case for many of our leaders:  Churchill, Lincoln.  These are leaders who are not successful or famous or powerful during times of peace, but it’s during crises that they shine.

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 W. 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.

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?

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.  The memoirs of a friend from adolescence, which are generally regarded as historically valid, are quite supportive of mania and depression, as I document in A First Rate Madness.  

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.  

The key here is not that Hitler was just mentally ill, as some have said, nor that he was an “amphetamine addict,” as others have said.  The key is the interaction between bipolar disorder, which was somewhat helpful to him, and high dose long-term intravenous amphetamine treatment, which markedly worsens bipolar disorder.  What is clear is that he was not a normal mentally healthy person, but neither can we simply say that he was crazy and therefore evil.  I should also make clear that none of this absolves him from responsibility for his evil actions; mental illness and ethical or legal responsibility for crimes are two different issues.

I thought I was fairly well read but your term homoclite for a mentally normal person was new to me.

Homoclite is not a well-known word even among psychiatrists.  It’s not a standard concept, but it’s one I thought was relevant because as I got into this issue of thinking about the positive benefits of at least mild to moderate mania and depression, the flip side is something one cannot deny.  When we say there are some benefits to mania and depression compared to normal people, it’s the same as saying normal people are somewhat less effective that manic or depressive people as crisis leaders, and that would mean there are some limitations to mental health.

As I started to research the topic of mental health, I came across the work of psychiatrist Roy Grinker from the 1950s and 1960s.  Grinker had done this work looking for average, mentally healthy individuals in Chicago, and he coined the term homoclites to describe those who were really average, smack-dab in the middle of the normal range when you looked at a statistical curve.  For instance, for personality traits, they’re in the fiftieth percentile.  These people he called homoclites from the Latin term meaning following the common rule.  I thought of a lot of the mentally healthy leaders as being potentially homoclites in the sense that they’re always trying to show they’re like the common man, the average man.  Indeed, they often are like the average person.  Having a beer with George W. Bush is another way of saying that he’s like you and me, and he’s an average person, which means he’s a mentally healthy person and may mean he’s an average person, a homoclite leader.

The relevance of this I found in the work of Lord David Owen, a neurologist and a former foreign minister for the United Kingdom.  I consulted with him and he’s written a couple of books. One was The Hubris Syndrome about Tony Blair, in which Lord Owen remarked on how Prime Minister Blair seemed to change once he was in office.  Before he was a very open-minded, thoughtful person listening to other ideas, while later in office when the Iraq War was about to happen, he was much more close-minded, much more convinced of the truth of his own views, almost messianic.  Owen called this hubris syndrome and wondered if this was a personality change that happened to people after they came to office and wondered why some people develop this condition whereas others don’t.

When I researched this issue, I came to the hypothesis that mentally healthy homoclite leaders are more prone to develop hubris syndrome in office because normal people would react that way.  Most of us, if given lots of power, lots of prestige, lots of attention, would tend to think better and better of ourselves and get somewhat hubristic, whereas if someone has some depression and somewhat low self-esteem, he or she would be less likely to think that way.  That’s why I thought I could explain even Richard Nixon’s tragedy of Watergate as how a normal person would develop so much hubris from so much power and then get very defensive about it and lie about it as opposed to thinking he must have been mentally ill in some way.  That gets to the stigma against mental illness.  We don’t like his behaviors so we say he must be mentally ill, whereas we like Kennedy’s behavior so we say he must be mentally healthy.  In fact, purely on medical grounds, it’s the opposite.  Kennedy had many psychiatric and medical symptoms and treatments, and Richard Nixon never had severe depression or mania and hardly ever any psychoactive medications.

So it seems hubris is a weakness in normal or homoclite leaders?

I think it is and I think it’s one aspect where depression is useful.  Think about how Lincoln responded to the success of the Civil War with that extremely generous second inaugural address, and compare that with how President George W. Bush responded to the early successes of the Iraq War.  The differences were not necessarily between their politics, but between a person who was extremely empathic and humble, and another person [President Bush]—who I wouldn’t blame—because he’s just normal.  That’s the way most normal people would react.  They’d be very pumped up and see things as us against them and they would try to defeat the enemy.

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. 

It’s a surprise to most people, and I’ve had some positive and negative feedback on that.  People aren’t able to deny the severe depression of Lincoln and Churchill, or the disease of Sherman, or even Ted Turner, who was diagnosed with bipolar disorder.  Some critics have issues with mild symptoms from hyperthymic temperament, which are hard to understand, as well as limitations [related to] mental health, which is so counterintuitive to most people.

The other aspect is that some critics have a hard time comprehending this notion that Gandhi and King might have had depression mainly because this is new information.   This is not information that has been discussed in prior biographies or histories.  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.  98 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 thirteen 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 then 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 thirty and 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.  I think that’s what they were trying to do with their philosophy of nonviolent resistance.  And it’s a very difficult philosophy to accept or to implement partly because most of us don’t have that much empathy, not as much as they did.  This is a new way of thinking about what they were trying to do and maybe understanding it better.

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?

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.

Do you have any further comments on what you hope readers take from your book?

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.  Going back to the concept of homoclites, one of the things Grinker found was that 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, but it’s worse in a way because it’s much less conscious and we’re less aware of it now than racism or sexism.

And a final point is the historical and political point of the book.  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, and that’s an important message I want to get across.  It’s a matter of historical fact but also it can help us with our current attempts to find good leaders.