The rekindled the debate over whether psychiatrists should speak publicly and candidly on the state of President Trump's mental health, in a pair of articles published Wednesday.
Facing off were Claire Pouncey, MD, PhD, a psychiatrist for Eudaimonia Associates in Philadelphia, and Jeffrey Lieberman, MD, past president of the American Psychiatric Association (APA), which has long promulgated a rule for members strictly forbidding them from commenting on any individual's mental health without having performed a personal examination.
Technically Section 7.3 of the APA's code of ethics, it's often called "." The APA issued it following a successful lawsuit by then-Sen. Barry Goldwater (R-Ariz.) against a magazine named Fact that published an article quoting psychiatrists who gave him mental illness diagnoses based solely on Goldwater's public statements.
When psychiatrists began openly defying the rule earlier this year, the APA doubled down. It declared that "any opinion on the affect, behavior, speech or other presentation of an individual that draws on the skills, training, expertise and/or knowledge inherent in the practice of psychiatry" can only be provided in the context of a formal, in-person procedure.
In her Perspective article, Pouncey defended another psychiatrist, Bandy Lee, MD, MDiv, of the Yale School of Medicine's Law and Psychiatry Division, who recently published a collection of essays entitled , setting off a new wave of discussion around the issue.
"[T]awdry, indulgent, fatuous tabloid psychiatry:" that was Lieberman's succinct review of the book in Psychiatric Times.
Pouncey objected. "The APA keeps reiterating that in order to make a formal psychiatric diagnosis, you have to have a sit-down formal diagnostic interview and you have to get a release of information to share the information," she said.
Such rules are "paternalistic" and tantamount to a "gag order," she said in a phone call with 鶹ý.
"Everyone uses psychiatric terminology except for us, because the APA says that for us to use it constitutes a formal diagnosis, and I'm saying, 'No, it doesn't," she said.
While her use of diagnostic language carries more weight than that of, for instance, a reporter for 鶹ý, Pouncey said, that shouldn't preclude psychiatrists from using such terms -- and it doesn't stop them being citizens.
Moreover, she said the association's rules are "outdated." Comments to the press, "middle-of-the-night tweets" and public statements, are all sources of information from which psychiatrists and others can evaluate public figures, she said.
While it's important to be mindful, Pouncey said, "We can't stop being the people that we are and wearing the various social hats that we wear, and we shouldn't have to."
As for the book, Pouncey said, it isn't about diagnosis at all.
"This book is about dangerousness. What the author is doing is saying these neuropsychiatric patterns show someone who doesn't have the ability to make safe decisions," she told 鶹ý in a phone call.
In her NEJM article, she wrote, "I believe that the APA, in the interest of promoting public health and safety, should encourage rather than silence the debate the book generates. And it should take caution not to enforce an annotation that undermines the overriding public health and safety mandate that applies to all physicians."
Pouncey was not entirely dismissive of the rule, saying it "reminds us to remain humble about the claims we can reasonably make and to present ourselves responsibly for the sake of our patients and our profession."
But the APA's continued insistence on the rule contradicts the "moral obligation" language of Section 7 of the American Medical Associations' Principles of Medical Ethics, which stresses physician's duty to promote public health and safety, Pouncey argued.
In response, Lieberman, of the Department of Psychiatry for the Columbia University College of Physicians and Surgeons in New York City, firmly backed the APA position.
Lieberman wrote that "brand[ing] elected officials with neuropsychiatric diagnoses" is "political partisanship disguised as patriotism." He cited historical examples of psychiatrists' unsavory involvement in politics, including "collusion in Nazi eugenics" and "the involuntary confinement in mental hospitals of dissidents and religious groups in the People's Republic of China."
He also noted there is an existing mechanism by which the president can have a psychiatric diagnosis made or ruled out: the 25th Amendment, under which the vice president and cabinet can require it.
While Lee and Pouncey may be acting in "good faith" they espouse a "misguided and dangerous morality," Lieberman asserted.
For more discussion on "misdiagnosing Trump" see 鶹ý's exclusive interview with prominent psychiatrist Allen Frances, MD, who led creation of diagnostic criteria for narcissistic personality disorder.