Trump needs a psychiatric test now. He's evaded it for years, and COVID-19 can affect the brain long after the illness fades.

• If or how COVID-19 and its treatments affected President Trump's cognition is hard to tell. Some typical cognitive consequences are characteristic of Trump himself.
• The public remains in the dark about the president's true mental state since commanders-in-chief aren't required to undergo the types of assessments common in jobs from air-traffic control to reality TV.
• Trump is his doctors' boss, which likely influenced his return to work post-COVID despite having been on drugs linked to especially erratic and bizarre behavior.
• A coalition of psychiatrists says it's their duty to warn the public about what they call the president's dangerous mental state, despite a controversial ethical standard to keep quiet.

Three days after a 55-year-old coronavirus patient was discharged from the hospital, the patient in a case study began hallucinating that lions and monkeys had invaded her house and clones were posing as people she knew.

The health journalist Jessica Firger's lingering coronavirus symptoms also clouded her brain, she wrote, leading her to nearly sear her hand on a hot burner, somehow forgetting she'd been heating it for tea, weeks after her telltale symptoms subsided.

For the CNN editor-at-large Richard Quest, the cognitive lapses — appearing months after he recovered from COVID-19 — caused him to trip over curbs and blank on simple thoughts and words, he wrote.

These are just some of the frightening cognitive issues blamed on COVID-19: delirium, memory lapses, and poor coordination.

How might they appear for the American president? Impaired decision-making? Dangerous, reckless behavior? An unstable relationship with reality?

While those behaviors could signal lingering effects of COVID-19 and its treatments, it's hard to tell since they're characteristic of President Donald Trump himself.

And yet the person whose daily decisions affect billions of lives and livelihoods (and, by one estimate, have killed more than 100,000 Americans in the past seven months alone) appears to have never undergone the types of cognitive tests that experts told Insider were common among military personnel, some doctors and lawyers, and even reality-TV contestants.

Trump also seems to have eluded psychiatric evaluation during his latest hospital stay, despite what's known about COVID-19's potential cognitive effects and his powerful therapies' known ones.

"Here is someone with overwhelming symptomatology, with dangerous presentation to self and others, and already provable [poor mental capacity] in multiple domains over the years," Dr. Bandy Lee, a forensic psychiatrist and president of the World Mental Health Coalition, which launched in 2017 to raise alarm about what members viewed as Trump's dangerous mental state, told Insider. "That he did not get a proper psychiatric evaluation is just unbelievable."

And while outside mental-health professionals like Lee have attempted to fill in gaps such as these, many keep mum to honor a controversial professional rule.

The coronavirus is leading to frightening cognitive symptoms in some patients

Early in the coronavirus pandemic, doctors thought COVID-19 was a respiratory disease. But it's become increasingly clear that it can affect many body systems, the most troubling of which may be the brain.

In one recent study, researchers found that more than 80% of people who were hospitalized with COVID-19 — as Trump was for three nights — experienced neurological symptoms including head and muscle aches, confusion, and dizziness.

About a third of patients in the recent study experienced the most severe cognitive consequence, encephalopathy, a broad term describing altered brain function or structure, which was associated with an increased risk of additional complications and even death.

Those who experienced encephalopathy tended to be male, older (65 years old, on average), and admitted to the hospital soon after symptoms set in. Trump is 74, and he was admitted to Walter Reed National Military Medical Center less than 24 hours after announcing his diagnosis on October 1.

It's possible Trump did have a mild case of COVID-19 and was simply admitted to the hospital and given an unprecedented combination of powerful drugs because he's commander in chief. That doesn't mean the virus couldn't have affected his brain, however, as thousands of never-hospitalized patients have reported scary memory lapses and persistent brain fog.

One study published in July in the journal Brain found some patients developed brain swelling and delirium, others developed nervous-system disorders like Guillain-Barré syndrome that can cause paralysis, and a few experienced life-threatening strokes — even if they'd had relatively mild illnesses.

Even if the virus has spared Trump's nervous system, the hefty cocktail of experimental therapeutics surely affected his cognition. The steroid dexamethasone alone has been linked to side effects that can last for days, ranging from sleep disturbances to psychosis.

For someone with Trump's "personality structure," they can also include poor impulse control, manic behavior, and poor judgment, Dr. Justin Frank, a former clinical professor of psychiatry at the George Washington University Medical Center, told Insider.

Observers pointed to the president's bizarre rants, rejection and then re-acceptance of relief-bill talks, and decisions about whether and how to debate his Democratic opponent, Joe Biden, as evidence of the drug's effects. His eldest son is said to have described him as "acting crazy" for riding in an airtight SUV with members of the Secret Service while still surely contagious.

Trump has "always challenged reality," Frank told Insider, "but never to the degree of disinhibition he's shown since his hospitalization and discharge."

The Trump presidency caused a rift in the psychiatric community right away

Trump's mental health alarmed experts long before he contracted COVID-19, reigniting an ongoing professional controversy about whether it's ethical to comment on a public figure's mental health without an in-person examination.

Adherents of the Goldwater Rule, an American Psychiatric Association principle established in 1973 to prevent armchair diagnoses, say assessments can't be made based on public behavior and making them tarnishes and misuses the organization's diagnostic bible, the DSM. Some argue that speculation about Trump is politically, not professionally, motivated and that providing diagnoses from a distance can be stigmatizing and dangerous.

But others see Trump's behavior as so glaringly dangerous to society that they've argued it's their duty to warn the public. Lee's organization, which has grown from 27 to thousands around the world, spawned out of a meeting concluding just that.

"It is spelled out in our ethical guidelines that we have a responsibility to our patients, as well as to society," Lee, an author of "The Dangerous Case of Donald Trump," told Insider.

She and others doubled down on that stance when APA doubled down on its own, with the organization clarifying in 2017 that the Goldwater Rule didn't just forbid psychiatrists from diagnosing people at a distance but from commenting on them at all.

Goldwater opponents argue that is unduly heavy-handed. Unlike speculation about what a celebrity's wild night out says about their mental health or pontificating on a candidate's intentions, the clinical psychologist Ramani Durvasula told Insider, "this is actually talking about [observable behavioral] patterns that have ramifications, not only for everybody in this country, but for everybody in this world."

She and other experts argue that many psychiatric evaluations don't require an in-person assessment, since they're largely based on observations of people's behavior and testimony from those around them.

Interviewing the patient, in contrast, isn't always effective because "when your mind is disordered, you become a less reliable source of information," Lee said.

Psychiatric professionals have long said Trump's behaviors are indicative of a range of mental illnesses

Those unhindered by the Goldwater Rule have made a range of observations about Trump's mental health beginning even before he took office, the most common being his displays of narcissistic personality disorder, which is characterized by an exaggerated sense of importance and exploitation of others without guilt or shame.

"My cats could look at Trump's behavior and know that this is a narcissistic personality," Durvasula told Insider. Others have speculated that Trump may also meet criteria for antisocial personality disorder and paranoid personality disorder.

No matter what the president's condition, he's mentally unfit to serve as commander in chief, Lee's organization concluded in 2019 after conducting a mental capacity evaluation, a common exam used to help determine whether people are fit for a task, be it leading a company or, in this case, a country.

While some such evaluations might look at traits like integrity, empathy, and leadership skills, this evaluation looked only at the ability to make rational decisions. It also used evidence more rigorous than would be possible for a layperson undergoing the same test: sworn testimony from dozens of people in close, regular contact with him, documented in the Mueller report.

The president failed every measure "to a level where even we were surprised to see," Lee said.

"It basically tested soundness of mind, and he didn't have that," she added. "So theoretically, he would not be deemed fit for any job, and there's no chance he could be fit for the presidency."

US presidents aren't required to undergo cognitive tests

On October 3, when Trump was still hospitalized with COVID-19, his lead physician, Dr. Sean Conley, said he'd avoided answering questions about whether the president had been on oxygen because he was "trying to reflect the upbeat attitude of the team [and] the president."

The statement revealed a truth about White House physicians: They're not just presidents' doctors — they're presidents' subordinates.

"Presidents make these decisions [about who to hire as their doctor] based on politics over medicine," Matthew Algeo, the author of "The President Is a Sick Man," told The New York Times. "And there is an inherent conflict between politics and medicine."

That means that commanders in chief historically get by without the type of mental-health assessments required for "highly sensitive jobs," Durvasula told Insider, like air-traffic control and toxic-waste handling. As their fields age, Lee added, clinicians and lawyers are increasingly required to pass such tests too. Even applicants of some reality-TV shows are screened using similar evaluations, said Durvasula, who starred in Bravo's "Thintervention."

The sole cognitive test Trump seems to have taken, and in his words, "aced" in 2018, is a 10-minute early-dementia screening tool on which people with full-blown Alzheimer's often score a 30 out of 30, and those with schizophrenia score in the normal range, Lee told Insider, adding: "It is entirely irrelevant when it comes to mental capacity."

Trump's hospitalization was a chance to give him a thorough psychiatric evaluation

The president's recent hospitalization seems to have been another missed opportunity for professionals to investigate his mental state. And yet, when pressed by a reporter about whether the president was experiencing any neurological side effects while hospitalized, Conley said no, pointing to Trump's tweets as evidence that he was mentally "back."

But Trump still isn't "out of the woods," to use Conley's term, when it comes to how the virus may have affected his cognition in the long term. The country isn't out of the woods either, Lee contends: Trump's reign, she says, has infected his followers, not just with COVID-19, but with mental instability.

"One of the greater dangers right now is when a severely mentally impaired person has been in a position of influence for a length of time, then the person's mental symptoms become contagious to the public," Lee told Insider, citing violence, delusions, and paranoia continuing to build among Trump's followers.

"You don't wait for them to turn around," she said. "You fix the situation promoting the pathology." That means removing Trump from power, her organization contends.

"We urge our fellow citizens to support [our] demand that a man clearly mentally disturbed and demonstrably unfit to lead our country, be removed from power or otherwise be restrained."

Editor's note: This article has been updated to remove reference to John Gartner, a psychologist who has misrepresented his goals and training when speaking out against President Trump.

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• More than 80% of people hospitalized for COVID-19 suffer neurological symptoms, from confusion to altered brain function