Context is important, and mental health problems aren't always dangerous for a person's job – but in the depths of my own depression, I wouldn't consider myself safe to practice. Equally, imagine your father has a heart attack and then decides to go back to his job as a pilot of a commercial airliner early. What is your responsibility? Not so long ago a group of psychiatrists broke new ground. The team of experts declared, publicly, that President Donald Trump has a “ ”. An illness which may make him unsafe to lead the US. New concerns suggest that he may have dementia. Now don’t get me wrong:
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no one should be stigmatised for disease. Would such a measure lead to harm, be misused and become political? Probably. Would you declare your opposition insane just to keep them out of office? Perhaps. But equally, can we afford to ignore clear signs of illness in man with his finger on the nuclear button? Long has Trump’s irregular attitude been a source of fascination. Oft described by supporters as “refreshing”, his tumultuous outbursts are now finding new judgement. “Narcissistic, juvenile and dangerous” are just a few words that come to mind. All leaders must make difficult choices, but most are predictable. What seems to separate Trump from his contemporaries is a complete lack of control. In short, Trump does not act like an adult. Naturally, questions have been asked. Is he mad? What is his plan? These are important questions. But so is this one: is it right to question a leader’s mental health publicly? The team of psychiatrists from Yale obviously think so. And I agree. There are pragmatic safety issues concerned. If Trump is suffering from an undiagnosed mental illness, as unfortunate as it may be, he may not be fit for office. The rationality required to make complex decisions may be simply beyond his grasp. The main crux of the argument can be broken down to three questions: Within medicine, there are certain rules. One is to respect a patient’s autonomy and confidentiality.
By these two mantras, one may argue that satellite diagnosis is always wrong. But equally, we must consider that a large number of mental health cases are brought to doctor’s attention by this very process. Often it is a concerned family member who raises the alarm. Or a member of the public. Or in the case of Donald Trump, millions. From a societal perspective, it is completely fair to question someone’s ability based on their health. I will make it clear here that I am talking only in situations where the safety of the individual or those they serve are at risk. There is no judgement made of the character of the individual, only a functional assessment. If I had a heart condition I may be offended at undergoing a medical for a desk job but could understand if I was asking to climb a mountain. Context is important. When it comes to mental health, the waters are yet murkier. Can you be too depressed to be a doctor? Can you be too elated to be a comedian? Both questions can be ultimately answered “Yes” when the extremes are considered. Severe depression slows your cognitive ability, and within the depths of my own, I would not consider myself safe. A comedian sparking public outrage for a joke is another example. Once again, context. But suggesting that a history of anxiety means you can’t be a teacher? Absurd. A public leader should be held to the same standards. If there is a significant concern, then that concern should be heard. So: can you make a diagnosis on speculation? Believe it or not, medicine, like all science, is speculative. Certain tests may decrease clinical uncertainty, often to zero. But a patient presenting with chest pain may have one out of 655 problems.
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Doctors ask questions, order tests and trial treatments based on the best evidence. A diagnosis may only become evident when a treatment begins to work. There are a whole range of conditions where the same treatment works, so a clear diagnosis may never be made. Such examples include a host of neurological and motor neurone diseases. But it is crucial to point out that these diagnoses, or treatment plans, are made on good evidence. Speculation from afar is not good evidence. It is at best well-meaning concern or badly meant conjecture. Psychiatric disease may be hard to spot often creative comedians showing signs of mania are missed for years, because their symptoms don’t appear abnormal in context. If your accountant ran around the office joking and jumping, you may begin to ask questions. Equally, if your favourite comedian began to do your taxes, you may begin to ask more. Speculation is only useful when teamed with an investigation. Satellite diagnosis is a poor diagnosis. So: what are the next steps? In medicine, if you feel unwell, you see a doctor. If you are concerned that a family member is unwell, you ask them to see a doctor. If they will not see a doctor, you may make them. Or if you feel they are in danger, you may seek professional help. This happens regularly. When dad collapses with chest pain, you call an ambulance. You don’t think about his decision-making – you act in what you perceive as his best interests. The same could be said of a suicidal friend. Now imagine that dad has had a heart attack. He has been warned not to undertake strenuous activity. He then decides to go back to work, as a pilot of a large commercial airline. You see him leaving for work, a grimace of pain on his face.
One was licorice root. Smearing on a placebo gel didn’t appear to help much with clearing redness or itchiness after one week or two weeks, but a 6% licorice gel, and especially a 7% gel, did seem to clear the symptoms in most patients. They conclude that licorice extract could be considered an effective [eczema treatment] agent. The other successful trial was with St. John’s wort cream, showing a reduction in eczema severity scores week by week superior to that of placebo. So, it works better than nothing, but the question is: Does it work better than drugs, better than topical steroids? That we don’t know. Sometimes, the drugs don’t work, though: so-called recalcitrant atopic dermatitis. So, these researchers in Japan asked patients to try drinking four cups of oolong tea every day for a month, and most patients showed marked [or at least] moderate improvement, starting after one or two weeks, and then, most remained better even five months after they stopped. The problem is that there was no control group. So, we don’t know how many would have gotten better on their own. But, since drinking tea is healthy anyway, why not give it a try? Back to topical treatments: a vitamin B67 cream beat out the same cream without the B67. Most of the patients and doctors rated the results of the B67 cream as good better than they rated the placebo cream. Regardless of what topical agent you use, steroid or otherwise, [f]irst and foremost, though, it is essential that the skin barrier [be] protected and maintained with the use of emollients, meaning moisturizers, ideally once or twice a day, especially right after showering, to lock in the moisture. Petroleum jelly, like Vaseline, is highly effective, but it’s kind of greasy and messy. What about something like coconut oil, which is less greasy? It was found to improve skin dryness, though no better than mineral oil, which is cheaper. Is mineral oil safe, though? Exposure to mineral oil was found to be associated with rheumatoid arthritis, but that was occupational exposure to industrial mineral oils, like hydraulic fluid. The same group of researchers subsequently found that cosmetic-grade mineral oil did not seem to carry the same risk. In general, topically applied mineral oil shouldn’t present any health risk. That doesn’t mean you can safely inject it into your penis, as that “may have devastating cosmetic and sexual function consequences.