Just days after being prescribed a powerful cocktail of drugs to treat his coronavirus infection, President Trump returned to the Oval Office on Wednesday as he delivered a barrage of incendiary tweets that referred to a “treasonous plot” and “coup” against him.
Trump’s behavior, which included tweets about ending negotiations with Democrats over an economic stimulus package and then more tweets about resuming those negotiations, appeared erratic even by his standards and raised questions among some medical professionals about the effect of the treatment on his mental state and whether it impacted his ability to govern.
Among the drugs Trump was prescribed is a potent steroid known as dexamethasone, which has shown benefits in patients with severe cases of COVID-19. While the drug helps reduce inflammation, it has a variety of possible side effects, such as blurred vision, headaches, and “psychic derangements,” including insomnia, mood swings, and “frank psychotic manifestations,” according to the drug’s label.
Similar drugs, known as corticosteroids, have also been linked to a wide range of other psychiatric symptoms, including anxiety, depression, and various cognitive difficulties, said Dr. Jacob Appel, a psychiatrist at the Mount Sinai School of Medicine in New York City.
“Doctors would want to keep a careful eye on any patient using dexamethasone to make certain that he is not behaving erratically or displaying mood or memory symptoms,” Appel said.
But such treatment would not “automatically disqualify an individual from carrying out the duties of the presidency," he added.
“The president’s own doctors would be wise to monitor all of his actions, public and private, including Twitter postings, to determine whether there is a possibility of psychosis,” he said. “If they have any significant concerns, then direct evaluation by an independent psychiatrist would certainly be appropriate.”
In a letter released Wednesday by the White House, Dr. Sean Conley, the president’s personal physician, wrote that Trump’s oxygen saturation and respiratory rate “remain stable and in a normal range.”
He added that Trump has not had a fever for more than four days and hasn’t required supplemental oxygen for several days.
“The president this morning says, ‘I feel great,’ ” wrote Conley, who provided no additional information about Trump’s treatment, including whether he is still taking dexamethasone or other medication.
Patients given dexamethasone for COVID-19 should take the steroid for seven to 10 days, according to the World Health Organization, which recommends prescribing the medication only for severe cases.
Doctors have long used dexamethasone to treat infections in the central nervous system that produce brain swelling, such as meningitis, said Dr. Mark Siedner, an infectious disease physician at Massachusetts General Hospital.
While dexamethasone and similar corticosteroids can produce concerning side effects, Siedner said doctors rarely see those problems at the lower dose typically given to COVID-19 patients.
“Certainly high-dose steroids can do that, and we have all seen that,” Siedner said. “But it would be uncommon for this dose to be the cause of a neuropsychiatric side effect.”
In the early days of the pandemic, there were concerns that dexamethasone might suppress a patient’s immune system, making things worse instead of better. But a large trial, known as the RECOVERY study out of the United Kingdom and published in July in the New England Journal of Medicine, found it helped lower the number of deaths among hospitalized COVID-19 patients receiving oxygen, compared to those who didn’t receive the drug.
“This drug has been an incredibly powerful tool,” Siedner said. “One of the few we have with COVID.”
None of the doctors interviewed has personally treated Trump, so their observations were based on their understanding of the drugs and patients who have been diagnosed with COVID-19.
David Juurlink, an internist and the head of the division of clinical pharmacology at the University of Toronto, said it may be hard to tell whether Trump’s recent behavior, which includes leaving Walter Reed National Military Medical Center while still recovering from serious symptoms of the disease, is significantly beyond his usual comportment.
“People can and do work while taking steroids,” he said. “In the president’s case, the main concern would be whether the side effects influenced his decision making.”
While such an impact isn’t likely, Juurlink said, “it’s far from unthinkable, and it’s relevant because a president’s actions can have global implications.”
If there is clear evidence that Trump’s cognitive abilities were compromised, Juurlink said, it would “make sense for powers to be transferred” to the vice president.
He suggested that such evidence may be visible in Trump’s barrage of tweets.
“As someone who has followed Trump’s Twitter account since 2016, it’s been hard not to wonder if his recent tweetstorms were influenced by dexamethasone,” Juurlink said. “Of course there are lots of confounding factors at play, but it’s definitely possible.”
Dr. Matthew Wynia, director of the Center of Bioethics and Humanities at the University of Colorado Anschutz Medical Campus, noted that a recent study found that 80 percent of hospitalized patients with COVID-19 have exhibited “neurological manifestations" and "encephalopathy-associated” symptoms, meaning substantial changes or damage to the brain.
Other symptoms of dexamethasone, he said, include agitation, mood swings, and euphoria. As a potential example of the latter, Wynia cited a tweet this week in which Trump wrote, “I feel better than I did 20 years ago!”
It’s unclear whether there might be a similar impact from other drugs Trump was given. Among them, Remdesivir can harm the kidneys and liver. And little is known about the effects of an antibody cocktail from Regeneron Pharmaceuticals, which has produced an experimental drug still in clinical trials that has been provided only to a small number of patients.
In a video he released later in the day on Twitter, Trump called the unapproved drug “unbelievable."
“It just made me better," he said. "I call it a cure.”
Regeneron’s drug is a treatment for the virus that alleviates symptoms; it’s not a vaccine.
“I want everybody to be given the same treatment as your president, because I feel great,” Trump added. “To me it wasn’t therapeutic, it just made me better, OK?”
Trump added that he believed his brush with the virus was “a blessing from God” because it gave him firsthand experience with Regeneron’s drug, which he described as “key” to his recovery.
But Trump still remains at risk from the virus, and many COVID-19 patients have experienced ups and downs through the course of the disease.
Wynia noted that older patients, such as the 74-year-old Trump, are more likely to experience confusion and disorientation.
While Trump may be tolerating the drugs without psychological impact, it’s important that he designate someone to evaluate him and empower them to take action if they determine he is impaired, Wynia said.
“A common problem with neuropsychiatric impairment is that once it’s happening, the person experiencing it might not know they are experiencing it,” he said. “So it’s not reasonable to expect him to make the call on if he’s experiencing these side effects, and if they are severe enough to compromise his ability to serve in the role.”