2020 Volume 2 Issue 1 Article ID: 2020-0010-PR
Objectives: To narratively review the presence and treatments of mental health problems among high-level political leaders. These questions have been noted in few epidemiologically sound studies and in the media. Methods: The literature search was performed and it resulted well-described cases and case series, but lacks properly designed studies focusing on medical issues. Results: High-level political leadership is a high-risk occupation, especially during crises and wartime, but also stressful in modern, democratic society. Leadership positions do not necessary facilitate the early detection of and intervention in mental disorders. In the media, psychiatrists should ensure that leaders with mental disorders are treated in a manner that preserves their dignity. Commonly accepted ethical principles stress that psychiatrists should not make announcements to the media about presumed psychopathology and diagnosis of any individuals. Conclusions: Current top leaders are mostly in midlife and rarely seriously mentally ill, but many are prone to anxiety, depression, addictions or stress-related disorders. The care of these eminent persons presents a clinical challenge that requires experience, clinical skills and multidisciplinary team work, usually within the occupational health system which is familiar with the working conditions and state of health of each patient.
Emperor Nero burned Rome — modern leaders may burn the whole world. While mad dictators and autocrats mainly belong in history books, democracy and decentralized power do not always offer protection against unstable or vulnerable modern leaders.
The state of health of those working in demanding positions can be monitored. The state of health of soldiers1,2) and airplane pilots3), including their mental health, must fulfill specific requirements. Most likely, no standard models to monitor or treat the mental health problems of high-level leaders exist.
There exist previous articles on the mental problems of top executives from the Finnish perspective4,5). Here I aim to narratively review the mental problems of high-level politicians: how to diagnose, discuss in public, and to treat. In this article, high-level politicians include mainly presidents and ministers but also some other prominent political figures (e.g., old top politicians or young “rising stars”).
I and two qualified information scientists searched the relevant published literature on the mental health of high-level politicians in June 2020. The search was directed to standard search fields in PubMed, Scopus, Web of Science and Ebsco databases (APA PsycArticles, Historical Abstracts, America: History & Life). The following search terms were used: (“mental health” OR “mental dis*” OR “mental illness*” OR psychotic OR psychosis OR “bipolar disorder*” OR schizophren* OR “depressive disorder*” OR depression OR “personality disorder*” OR neurosis OR “performance anxiety” OR “public speaking anxiety” OR “psychiatric diagnos*” OR psychopathology OR “mood disorder*” OR “anxiety disorder*” OR “hubris syndrome” OR dementia OR burnout OR “occupational stress”) AND (“political leader*” OR politician* OR “prime minister*” OR (president* AND politic*) OR (“administrative personnel” AND politic*) OR (biograph* AND politic*)). In PubMed the search was conducted with MeSH-terms: (“Burnout, Professional”[Mesh] OR “Occupational Stress”[Mesh] OR “Mental Disorders”[Mesh] OR “Dementia”[Mesh]) AND (“Famous Persons”[Mesh] OR “Leadership”[Mesh]) AND “Politics”[Mesh].
All identified studies were screened based on the title and abstract and defined as eligible/ineligible. The articles dealing with top politicians were included in the analyses and clustered to meet the following eligibility criteria: psychiatric diagnostics and problems, their prevalence, media debate, and options for assessment and treatment. Articles dealing with non-political leadership and its health issues were excluded. There were no restrictions regarding language, publication date, publication status, or study design. The reference lists of articles, reviews and books/book chapters to identify all relevant studies were also used.
The search produced results in PubMed (n=97), Scopus (n=1,025), Web of Science (n=419), and EBSCO databases (n=749). After the removal of duplicates (n=366) and ineligible articles based on title (n=858), 1,066 abstracts were screened and, among them, 55 full-text sources identified for comprehensive evaluation. We included 32 articles, documents, or books from the search and other sources that met the eligibility criteria. Next, the findings of these studies in each cluster were summarized by highlighting unique information to each study.
No epidemiologically-sound and representative samples were found, but 18 articles reported psychiatric problems and 3 reported prevalence data. Media debate was discussed in 3 papers, and assessments and treatments was discussed in 8 articles. Six studies with more than five cases, relevant data, and discussion were reviewed in detail in Table 1. Such diverse data are difficult to analyze in a systematic review. Therefore, a narrative review was constructed, which highlights new and unanswered topics that focus on studies based on author selection6).
| References | Study design, period, participants | Main results | Comments |
|---|---|---|---|
| Post F. Creativity and psychopathology: a study of 291 world-famous men. Br J Psychiatry 1994;165:22–34 10) | ▪Retrospective case series of the psychopathology (DSM-III-R criteria) of 46 top politicians (mainly dictators, presidents and prime ministers) ▪Participants were historical figures in 18th and 19th century and having enough biographical data | ▪Significant amount (58%) had mild-to-severe lifelong psychopathology, mainly depression (41%), somatic symptom disorders (33%), anxiety disorders (22%), alcoholism (17%) ▪63% had traits of DSM-III-R cluster B-C personality disorders ▪63% were sexually “normal” ▪54% had outwardly stable marriage | ▪Only men were included ▪Also famous men in science, thought, politics, and art were investigated and comparable ▪Major effort to apply DSM-III-R criteria but some retrospective diagnoses are not plausible (e.g. Hitler’s sexual problems) ▪Some measurements and categorizations were non-standardized: mild-to-severe psychopathology categorization and mild symptoms and character features not meeting DSM-III-R criteria |
| Ludwig A. King of the mountain: the nature of political leadership. Lexington USA: University Press of Kentucky; 2002 15) | ▪Retrospective case series of eminent rulers mainly 19th and 19th century ▪377 world leaders: monarchs (10%), tyrants (6%), visionaries (7%), authoritarians (18%), transitionals (13%), democrats (47%) ▪Retrospective ICD-9 diagnoses | ▪Large amount (55%) had some psychiatric syndrome, mainly depression (32%), alcoholism (15%), paranoia or paranoid episode (13%), pathological anxiety (8%), mania (7%), suicide attempts (3%). | ▪Textbook with multiple and uneven discussion about politicians and their challenges ▪Data collection and variable construction minimally structured and reported. ▪Diagnostic validity and accuracy not reported. ▪Statistical results are given in separate chapter but are partly difficult to interpret |
| Davidson JR, Connor KM, Swartz M. Mental illness in U.S. presidents between 1776 and 1974: a review of biographical sources. J Nerv Ment Dis. 2006;194:47–51 13) | ▪Retrospective case series of 37 US presidents between 1776–1974 ▪retrospective DSM-IV diagnoses from biographic data | ▪49% were diagnosed with a lifetime psychiatric disorder ▪In 27% of cases, a disorder was evident during presidential office, which in most cases impaired job performance. ▪Most common diagnoses were depression (24%), anxiety (8%), bipolar disorder (8%), alcoholism (8%) | ▪Most presidents old (and sick) men ▪Level of confidence was given for each diagnosis ▪Methodological limitations of using biographies and retrospective diagnostics to determine psychopathology are discussed ▪The authors conclude that a politically neutral examination of the president’s capacity should be considered |
| Owen D. In sickness and in power. Illnesses in heads of government during the last 100 years. London: Methuen Publishing; 2008 16) | ▪Descriptive case series: 31 heads of government 1901–2007 (despots, presidents, prime ministers) and four detailed case histories (prime minister Eden, president Kennedy, the Shah of Iran, president Mitterrand) ▪Also recent leaders analyzed: George W. Bush, Tony Blair, Margaret Thatcher ▪Physical and mental illnesses, and political career/events reported in detail | ▪Most cases had physical and/or mental disorders impairing political performance ▪Unique and detailed medical and political data (e.g. president Kennedy’s medical records) ▪Data reveals possible associations between impaired health and political capacity | ▪The author is eminent politician (e.g. former British foreign secretary 1977–79) and physician ▪No structured diagnostics or any diagnostic validation for existing diagnostic systems were performed ▪Important discussion on intoxication of power and Hubris Syndrome as occupational hazard ▪Lessons to future and safeguards against illnesses in heads presented |
| Davidson J. Downing Street Blues. A history of depression and other mental afflictions in British prime ministers. Jefferson USA: McFarland & Comp; 2011 9) | ▪Retrospective case series of the psychiatric problems of 51 British prime ministers 1721–2007. ▪Detailed biographical data and mainly DSM-IV criteria but also milder symptoms not fulfilling DSM-IV criteria are presented | ▪37 (72%) experienced mental afflictions or significant symptoms at some time in their lives. Psychiatric problems were important in the resignation of nine (18%). Most common were depression (43%), bipolar spectrum (12%), anxiety disorders (28%), alcohol and other substance abuse and dependence (12%), sleep problems (24%). 12 (24%) experienced public speaking anxiety. | ▪Detailed data on biographical facts, symptoms and illness history ▪This impressive textbook includes also political conclusions ▪Some treatment issues presented |
| Isohanni M. Mental health of high-level politicians and soldiers in Finland: diagnostics, public discussion and treatment. Psychiatria Fennica 2019;50:154–63 5) | ▪Descriptive case series of eight first presidents in Finland 1919–1981 ▪General level comments on four presidents after 1981 ▪Detailed biographical data ▪Retrospective diagnoses using DSM-IV and ICD-10 criteria | ▪Three of the eight presidents were ill during the final stages of their presidency ▪Somatic brain disease (two) or high age and somatic illnesses (one) decreased their cognitive performance and fulfilment of duties. | ▪Most presidents were old men ▪President studied held significant powers and long term (six years) which caused delayed diagnostics, treatments and political actions ▪Due to limited data and ethical reasons, the health of four presidents after 1981 were analyzed only on general level. No substantial health problems were detected. All have reported in media their health regularly using occupational health expertise |
An expert description of the medical history of influential persons can offer valuable information about the content of diagnoses and treatment and the impact of illnesses. In some countries the obligation to keep medical records confidential continues even after the patient has died. Then descriptions must be based on public biographies and registers7,8) and their strict source criticism.
One methodological challenge is to reduce the inaccuracy of retrospective psychiatric diagnoses8). Even clinical and research diagnoses are not necessarily concordant or accurate, even though they use prospective data and clinical documents7). In some analyses (e.g., Davidson9)) abnormal psychiatric distress and related impairment are also recorded, not fulfilling any DSM or ICD diagnostic criteria. Such methods increase the prevalence but may be relevant regarding functional capacity. Similarly, lifetime prevalence is different in contrast to transversal or during on-duty period diagnoses9,10,11).
The proper use of psychiatric diagnosticsCurrent psychiatric classifications of diseases (mainly DSM and ICD) have been prepared for diagnostics, treatment, and scientific study. Psychiatric diagnoses are criteria-defined questions based on symptoms, the amount of suffering, and decreases in functional capacity. Psychiatric diagnoses can rarely explain political insanity. There are exceptional leaders who do not meet diagnostic criteria. Such individuals seem to be increasingly successful when new political leaders are selected.
Psychiatric diagnoses should be reserved and applied to clinical and scientific work: the study of the mental state, the assessment of the functional capacity, privilege and responsibility, the development of treatment, and the assessment and comparison of epidemiological measures5). Any improper use will lower their value and increase stigmatization. A proper diagnosis is based on clinical competence, reliable documented data, and thorough clinical research: psychiatrist William Carpenter was oriented to all data and interviewed John Hinckley, who tried to kill President Reagan, 45 hours before his testimony in court.
Different forms of psychosis often involve the loss of the sense of reality and cognitive deterioration. These usually have a significant impact on functional capacity. Non-psychotic disorders are common, and they may involve a notable decrease in functional capacity. For instance, Post10) (Table 1) analysed the psychopathology (DSM-III-R criteria) of 46 top politicians (mainly dictators, presidents, and prime ministers) using biographical data and discovered a significant amount (58%) of mild-to-severe psychopathology.
Psychiatric problems in 51 British prime ministers from 1721–2007Using detailed biographical data and mainly DSM-IV criteria Davidson9) (Table 1) assessed the psychiatric problems of 51 British prime ministers, 37 (72%) of whom experienced mental afflictions or significant symptoms at some time in their lives. Psychiatric problems were important in the resignation of nine (18%). Most common were mood and anxiety disorders and alcohol and other substance abuse and dependence disorders. Performance anxiety was surprisingly common for such a position: 12 (24%) of prime ministers experienced public speaking anxiety. The estimated high rate (72%) exceeds the lifetime rates (in most studies about 30–50%) found in most major epidemiological studies in the general population, likely due to differences in methods (inclusion of significant symptoms without diagnosis) and very detailed life-course analyses.
The results also remind of the links between creativity and mental disorder, especially bipolar disorders. The topos of “genius and madness” has some scientific evidence on the interaction between charisma, giftedness, political leadership, and mental illness10,12). Six prime ministers could be classified as having “bipolar spectrum” disorder, or hypomania or bipolar II. Their active and volatile personality at best increased energy, self-confidence, minimal sleep, and rapid decision-making, important especially during crises. However, they were also prone to insomnia, depression, and addiction9).
Mental health disorders and functional capacity of US presidents from 1776–1974A study of 37 United States presidents13) (Table 1) was based on biographical data. Two experienced evaluators defined diagnoses and prepared a structured and independent estimate of their reliability and impact on functional capacity. A psychiatric disorder (DSM-IV) was diagnosed in 49% of presidents. In 27% of cases, a disorder was evident during presidential office, which in most cases impaired job performance. The most common diagnoses were depression, anxiety, bipolar disorder, and alcoholism. These findings do not largely differ from the prevalence in the general population.
The authors concluded that the common occurrence of mental illness linked to the extensive powers of the president and the potentially major impact of impaired judgment due to illness, or perhaps an additional mechanism, a politically neutral examination of the president’s capacity should be considered.
The health of Finnish presidents 1919–1981In Finland, the president has held significant powers. Finland has had 12 presidents. I conducted a diagnostic assessment of Finland’s first eight presidents (1919–1981) using psychobiographical studies4,5) (Table 1). I did not discover any disorders that would have satisfied the DSM-IV or ICD-10 criteria, at the beginning of the term. Three presidents had lowered functional capacity towards the end of their term, mainly due to physical illnesses, stress, and aging.
Poor health since 1938 started to put a strain on poorly educated but politically experienced Kyösti Kallio (1873–1940, term of office 1937–1940) after he turned 60. After the Winter War (1939–1940), Kallio suffered cerebral infarction in August 1940 and was unable to work for 4 months and forced to step down from his position in November 1940.
The presidency of Carl Gustav Emil Mannerheim (1867–1951, term of office 1944–1946), Marshal and commander-in-chief 1939–1944, was characterized by Finland’s heavy peace negotiations. Nervousness, capriciousness, indecisiveness, states of fear, continuous illnesses, impaired memory, and defective judgment, in particular, shadowed the end of his term. His physician found Mannerheim to be unable to continue in office at the end of 1944. However, Mannerheim stepped down from office, reluctantly, in March 1946.
The later years of the excessively long presidency of Urho Kekkonen (1900–1986, term of office 1956–1981) was coloured by an increasingly visible memory disorder, which progressed into severe brain disease5,14).
In summary, three of the eight studied presidents were ill during the final stages of their presidency in a manner that decreased their fulfilment of duties. This is roughly the same percentage as in American presidents13). Physical illnesses were the main causes of a deteriorated capacity, not psychiatric disorders, as was observed among American presidents.
Since Kekkonen stepped down from office in 1981, Finland has had four presidents. I do not consider it to be ethically acceptable to evaluate their state of health. I do not have proper authorisation. However, the existing public information strongly suggests that health has not limited their functional capacity during their term. The first three fully served presidents had a strong societal presence after their presidency. Three were elected for a second term, while Martti Ahtisaari decided not to run for re-election but won the Nobel Peace Prize.
Previously, the health of a president was largely a forbidden topic. Kekkonen’s concealed health problems were surrounded by rumours and insinuated media debate. After his resignation, extensive discussion started in the media about the health of his successors and other top politicians. An expert group settled by the government recommended in 1989 that the presidents should report on their health and working capacity regularly in public. All four last presidents have reported shortly their state of health and functional capacity in public utilizing mainly the occupational health care system.
Two case seriesLudwik15) published a book with a case series of eminent rulers (Table 1). Most (55%) had some psychiatric syndrome. Owen16) analyzed (Table 1) 35 heads of government, their physical and mental disorders, and their influence on political performance. Most had physical and/or mental disorders impairing political performance. For instance, President Kennedy’s medical records were utilized. The data reveal links between his illnesses and the Vienna summit failure, the Bay of Pigs invasion fiasco in 1961, and the solution of the Cuban missile crisis in 1962.
Even though both studies include methodical limitations (e.g., limited diagnostic accuracy), they contain interesting debate on intoxication effects and occupational hazards of political power, as also administrative and treatment issues.
The effects of old and young ageProblematically aging heads of state have had a major impact on the course of history, especially before the 1990s. Lenin, Paul Deschanel, Woodrow Wilson, Franklin D. Roosevelt, Heinrich Lübke, Mao Tse-Tung, Dwight Eisenhower, Ronald Reagan, Pope John Paul II, and Robert Mugabe were in power when showing remarkable cognitive impairment9). Communist sclerocrats Andropow, Breshnew, Ceausescu, Honecker, Mielke, and others adapted the doctrine of marxism-senilism into effect and contributed to the fall of Soviet Union and its allies.
At best aging means experience, wisdom, and tolerance. However, the prevalence of brain disorders, such as strokes and memory disorders, or of their pre-condition, cognitive impairment, increases. Age-associated impairments will increase with growing life expectancy. The older age and long terms expose to increased risks of disorders during their term of office. Common symptoms among the older population include mild memory loss, an uneven or impaired cognitive state, impulsiveness, and mood swings. These symptoms can be part of the normal aging process, but also as signs of a memory disorder, substance abuse, or depression.
The current trend, especially after the last 2 decades, is to have younger leaders in power. As an example: Finland’s Sanna Marin, the world’s youngest female head of government (in December 2019) was 34 years old, and three other main party leaders in her ministry were also women in their early 30s. They were (as of summer 2020) encountering the coronavirus pandemic and economic crisis. In June 2020, one of them, party leader and minister of finance Katri Kulmuni, a 32 year-old, resigned after a political scandal. She had illegally used taxpayers’ money to have training to get relief for her anxiety due to public speaking and lack of political expertise.
Most top leaders are currently talented and well-trained males and females in midlife, usually fit and heathy but having risks of extreme stress, exhaustion, and burn-out. Young top leaders will inevitably meet crises, misfortunes, and political and personal downhills. Their political future depends on their ability to learn from these events, pool boldness with sensitivity, and develop skills at negotiation and compromises needed in modern political leadership. Nations should have the mechanisms to pool political wisdom from all generations, genders and ages.
The challenges of modern top leadersThe challenges facing current top leaders are many17): global problems, climate change, pandemics, terrorism, military tensions, and rapid speed and changes in the political and operating environment. Even more serious threats are possible, making this profession potentially dangerous: delusional fixations or direct threats leading to public figure persecution, harassment, physical violence, and even assassination attempts. Top politicians need to process massive amounts of information and reach optimal decisions in complex, emotionally charged and unclear situations, surrounded by conflictual, manipulative lobbying bodies, often when being tired and busy.
Responses from modern media, the Internet, and demonstrations are often biased, arrogant, and voyeuristic. Words are often used as weapons, not as a means of communication and understanding. Scandals around health, sex, money, or corruption are common. Rumors, sensations, stormy elections, and scandals tend to be the norm. Being constantly under the public eye and needing to comment instantly on complex, difficult, and emotionally charged issues may cause extreme stress. One or two poorly considered and formulated sentences or a single conflictual political act may lead to public scandal, even resignation. Even 24% of British prime ministers experienced public speaking anxiety9).
Round-the-clock readiness, travelling, shift work, and different time zones challenge good sleep habits. Some hypomanic persons have a biological advantage in needing little sleep9). However, even these people may reach their limits. Normal physiological exhaustion or fatigue may be a consequence and cause more serious problems. The consequence may be clinically significant distress and altered behavior, as well as deviations in moral and ethical compasses, all leading to less effective leadership.
Earlier, the rule was that high authorities (e.g., Lenin, John F. Kennedy, Urho Kekkonen, Francois Mitterrand, the Shah of Iran) had secrets of health16). The consequences of hidden medical information may be that sick rulers continue to hold their positions in spite of their disability, often with serious consequences. Misleading people and media is not easy today. Openness and transparency are mainly positive but may in health issues seriously hurt one’s intimacy.
Top leadership is a very challenging task. Problems in other areas of life (e.g., health problems, dysfunctional marriage) jeopardize full functional capacity if the balancing of work and private life fails. Too many top leaders still carry their round-the-clock workloads alone, without support from teams or shared decision-making.
Physicians in media: careful or bold?Official supervision and free media do not always offer protection against illness in high-level leaders. Medical and psychiatric knowledge may increase self-protection of democracy. But how this can happen in an ethically correct manner?
In 1964, a group of American psychiatrists stated that presidential candidate Barry Goldwater was psychologically unfit to become the president, partly due to his ideas regarding the use of nuclear weapons. The Goldwater Rule (1973) of the American Psychiatric Association states that it is unethical if a psychiatrist presents a professional opinion of a person who they have not examined or whose mental state they are not authorized to study.
Debate over the Goldwater Rule continues18). The American Psychoanalytic Association considers that its members can issue a general opinion of public persons. Psychiatrist Bandy X. Lee organized a meeting over President Trump’s mental health and edited The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President (2017).
The 2011 rules of the World Psychiatric Association19) consider it to be unethical if a psychiatrist presents a diagnosis-related and psychopathological opinion in public. Public comments must be scientifically sound, and they must facilitate the position of patients.
On social media, physicians must form their opinions based on medical knowledge and experience. In general, physicians can cautiously comment, for example, on the relationship between the state of health and functional capacity, but they cannot state any public opinions of the state of health of any individual. A politically active physician must keep separate their role as a medical expert and their role as a political influencer.
However, history has taught us that great reformers often break the rules. Might criticisms based on psychiatry, even though unethical according to current standards, have some positive influence to the politics of Barry Goldwater or Donald Trump? Physicians have the right, an obligation even, to express their views in public regarding matters that are hazardous to the health, well-being and safety of the population.
Relationship between a physician/therapist and an influential patientThe sweet taste of power can be intoxicating. Difficult decisions, conflicting expectations, and an unhealthy lifestyle may add bitterness to that power. It is lonely at the top, and power can always be lost. Falling down can hurt, and wisely stopping and retiring is not easy. Many successful people do not know when to quit or how to be a good loser if they have no safety net or backup plan.
A physician/therapist may be needed, particularly when failing or losing power. Therapists require special skills when they have an influential patient. The care of these eminent persons presents a clinical challenge that requires experience, clinical skills, and multidisciplinary team work, usually within the occupational health system. Confidentiality, boundaries, maintenance of professionalism, and limited clinical decision-making power may set challenges for the physician/patient relationship. The grandiose self-esteem of top leaders may prevent them from adopting the role of patient. This is especially true in hubris syndrome, or exaggerated pride, where overwhelming self-confidence often leads to the abuse of power, inability to response to environmental feed-back, and contempt for the advice or criticism of others20,21).
The golden rules of preventive medicine do not always come true: the diagnosis and treatment of risks or the prevention, alleviation or postponement of disease. Physicians of John F. Kennedy22) and Adolf Hitler23) were unable to subject their patients to treatment, leading to a drug addiction. In his last years, Stalin’s life-long suspiciousness became florid paranoia and untreated hypertension and cerebral hemorrhage lead to his death24).
A patient in a high position may cause countertransference problems which increase the risk to compromise proper medical standards and treatment recommendations. Behind it can be a hubristic misinterpretation of a physician’s medical skills and exceeding the real competence. Treating such eminent persons means large responsibility, which may cause excess fear and non-rational decision making. Help from a colleague, teamwork, and family and spousal cooperation may help to make difficult decisions and to convince patients to accept them.
Options to assessment and care in occupational care servicesThe health problems of top politicians described in this article mainly took place in the past, largely during wars and under exceptional circumstances. Medicine, diagnostics, and treatment were under-developed, and different media services were important influences. Psychological disorders suffered by top leaders often had serious consequences, leading to delays in decisions and actions. For instance, The 25th Amendment to the United States Constitution has rarely been exercised in the case of any loss of the president’s functional capacity13).
An optimal occupational healthcare team (from the Finnish perspective) consists of an occupational healthcare physician, an occupational healthcare nurse, an occupational healthcare psychologist, and a consulting psychiatrist. A standard practice should be defined for monitoring the health of top leaders, consisting of regular health check-ups conducted mainly by occupational healthcare services and the evaluation of mental health.
A standard practice should be defined for monitoring the top leaders, consisting of regular health check-ups, conducted mainly by occupational healthcare, and the evaluation of mental health and cognitive performance. The goal should be the prevention of, or early intervention in, serious problems, such as psychosis, delirium, substance abuse, memory disorder, severe depression, stress disorder or impulsiveness, and other highly abnormal behavior. Such extreme situations are unusual today: the main problems are associated with slowly advancing depression, anxiety, stress disorders, exhaustion, or substance abuse.
Most crises faced by top leaders are most likely mild and can be treated by occupational healthcare services5). The strength of occupational healthcare is the comprehensive examination and treatment. Service providers are familiar with the working conditions, the somatic and psychological state of health and, at best, the background situation of each patient.
The threshold of influential persons to accept psychological interventions may be high. However, most democratic top rulers are currently gifted, talented, and well-trained. These persons are often intelligent and ready for self-reflection: indications of a positive response to psychotherapies25).
Despite efforts to destigmatize the psychiatric field, the stigmatization may lead to deterioration of symptoms and not realized treatment. The stigma may exist after successful treatment. The return to business is not easy and fear of negative career impact is common. Positive experiences are Norwegian prime minister Kjell Bondevik, who recovered from depression and returned to power9,16).
This narrative review revealed that no epidemiologically-sound studies on psychiatric problems of current top politicians were found, but rather older case series, summarized in Table 1. Prevalence data (usually not lower than in general population) were presented only in a few case series (mainly of American and Finnish presidents and British prime ministers), and treatments were presented only in few cases. There are extensive media discussion on top executives (e.g., U.S. President Trump), but this debate has minimal scientific and clinical relevance.
Practical conclusionsPsychological disorders suffered by top leaders often have serious consequences, leading to delays in decisions and actions. Models of early intervention should be improved by developing laws and occupational healthcare.
Current high-level political leaders are often mentally strong, albeit some of them fall ill as a result of stress, vulnerability, or older age. Dictators and autocrats suffered mostly on paranoia, bipolar or personality disorders, or age-related problems5). Such serious illnesses seem to be rare among democratically-elected and modern leaders, who encounter multiple external and intrapersonal stressors5,15). Current top leaders are mostly younger and somatically healthier and rarely seriously mentally ill — but many are prone to multiple stress-related disorders15). Increasingly, guidelines for primary prevention for mental health at work are proposed26), also in the Asian and Pacific region27), but evidence-based models and recommendations to meet mental problems of top leaders are sparse.
This narrative review was not focused on resilience or coping. Epidemiological studies and psychobiographies tend to study the ugly face of life28). My studies of top leaders have raised admiration of how many have been able to withstand stress and to recover from diseases (e.g., Winston Churchill, Marshal Mannerheim, President Kennedy during Cuban Crisis).
Most top policy-makers do not live in Wailing Wall, but enjoy many advantages linked to high position: admiration, patriotism, money, job satisfaction, and achieving political and ethical values. Clever and healthy rulers with good functional capacity are essential elements in the success of humanity and political improvements.
Research involving human participants and informed consent, approval of research protocol, registration of the study: not applicable for this kind of narrative review.
There are no financial support, external funding, other financial benefit or interests.
