In A First Rate Madness, I diagnosed depression or bipolar disorder - or their temperaments - in historical leaders.  One question raised, especially by some major media reviews, was how one can legitimately make such diagnoses historically.  How can one document such diagnoses?

This legitimate question was sometimes tied to the observation of minor historical errors, thereby throwing into doubt the historical research of the book.  The text probably contains over 1000 historical and psychiatric facts; if there were even a dozen minor errors of historical fact, this would reflect a >99% accuracy rate. I appreciate that such minor errors need to be corrected, but they do not relate to the major pieces of historical evidence that relate to the psychiatric diagnoses of depression or bipolar disorder. 

In fact, in all cases where I make such diagnoses, I rely almost entirely on primary source material: direct observations of family or friends, contemporary newspaper accounts, personal letters, or medical records, including original scholarship for this book. For instance, I believe I am the first psychiatrist to analyze and document John F. Kennedy's medical records; those records are not allowed to be copied, and I hand wrote and then typed many important medical documents into the endnotes. These include the following: a) the verbatim transcript of Kennedy's medical discharge from the Navy in World War II, which shows that he was not discharged mainly for war injuries; b) the verbatim transcript of his back x-rays in the White House which show that he did not have major non-surgical bone disease to explain his pain; c) verbatim nursing notes from his first year in the White House documenting a serious Addisonian crisis, something not reported in most recent Kennedy biographies (a fact also documented in the endnote by reference to multiple highly cited biographies) d) documentation of the urine culture which proves a high-fatality sexually transmitted bacterium as the cause for the above infection; e) documentation of the frequency and amounts and types of steroid injections given throughout the White House years, and through most of the prior decade. None of this information is found, either in content or this level of detail, in most Kennedy biographies, including the one by Robert Dallek which, until now, had provided the most medical documentation on President Kennedy.

This brings me to the 50 Year Rule: In the five years of research that went into this work, I found that sufficient historical documentation tended to become available to be able to make psychiatric diagnoses about 50 years after a leader's lifetime.  Because of stigma against mental illness, public figures hide psychiatric symptoms or diagnosis or treatment, if present, and so do their families adn friends.  It takes a few generations for the truth to come out. (Kennedy's medical records, for instance, weren't release until four decades after his death, and, even now, few physician-scholars have studied them.)  This is why most of the leaders I studied were active 50 years ago or earlier, and also the reason why women were not represented - a reflection of those years.  When I discussed recent leaders - like  George W. Bush or Tony Blair or Richard Nixon - I did not diagnose them with psychiatric illness, but with normality, always with the awareness that psychiatric assessments of current or recent leaders are more provisional than older leaders.

The text of a First Rate Madness is 273 pages; the endnotes comprise 51 smaller font pages. For every five to six pages of text, there is a page of documentation, much of which involves primary sources.  Documentation is provided for almost every page of text, in much more detail than many other lengthier biographies filled with many more statements of fact. 

One may not agree with the hypothesis that mental illness sometimes enhances crisis leadership; but absence of reasonably careful historical documentation is not a valid rationale.

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