Medical Examiner

A Doctor Weighs In on What Steroids Might Be Doing to Trump’s Brain

They have side effects, but that’s not even close to the only thing going on with the president.

Donald Trump standing on the White House balcony.
Donald Trump at the White House on Monday. Nicholas Kamm/Getty Images

On Sunday, President Donald Trump’s doctor announced that Trump had been given dexamethasone to treat his case of COVID-19. Monday, still at the hospital, Trump sent a lot of tweets in all caps (a representative tweet: “SPACE FORCE. VOTE!”). In the days that followed, he axed a stimulus bill, spread misinformation about the flu, and issued an infomercial (basically) declaring that one of the experimental drugs he took had cured him. Thursday morning, he issued a video dispatch addressed “TO MY FAVORITE PEOPLE IN THE WORLD!”

“I went into the hospital a week ago, I was very sick,” he explains standing in front of the White House. He went on to say, again, that he has now been cured and that he wants everyone to have “the same care that I got,” for free. “I do know what I’m doing,” he concluded. Is this incredible confidence that he can save people when he has otherwise utterly failed at containing the virus a side effect of the drugs? It’s a little unclear if Trump is still on the steroids specifically—the recommendation is to give dexamethasone for 10 days, or until the patient leaves the hospital. But since the mania continues, we checked in with physician Esther Choo about what steroids do to the body, and what they could be putting Trump’s brain through. Our conversation has been condensed and edited for clarity.

Shannon Palus: What was your first thought when you heard that Trump was taking steroids?

Esther Choo: Well, the first thought at that point was that he definitely has COVID lung disease, has been hypoxic [has low oxygen levels] for sure, and is probably sicker than we thought. And if you remember, that was the third medication that dropped, over, I think, a two or three day period. So it just had this feeling of an escalating and aggressive treatment course.

For the average person with COVID, are steroids something that would be advisable at some point in the illness to prescribe?

Only if you’re sick. For patients with cough and fatigue, we normally send people home without any treatment at all, except for symptomatic treatment, things like Tylenol and ibuprofen for their symptoms. If you’re not as sick, it’s better to avoid them. Steroids can interfere with your immune system, they can cause mental health effects, they can make your blood sugars go awry.

When you’re prescribing steroids to a patient, what do you tell them about the potential mental health effects?

We tell people that it can make them feel really hyper. It can make them behave very strangely. I’ll warn family members that they may see a personality change just so that people are aware. If somebody already has a preexisting condition like anxiety or a psychotic disorder, we’re very, very careful about that decision to prescribe steroids, because for some patients, it’s actually not worth it. I’ve had patients who say, “I have terrible anxiety and steroids, even though I need it for my asthma exacerbation, steroids are actually worse.”

What might it feel like for someone who already has anxiety to then go on the steroids?

It can really ramp up those symptoms. And then of course, people without anxiety can feel those symptoms newly. And you can be totally manic. You can feel hyperactive and you can feel a different drive to do things and you just cannot stop. It can really amp you up, which is part of the reason you feel so great, and people can feel really euphoric. The one time I was on steroids, I cleaned out every drawer in my house every night. I could not stop moving.

Would you counsel a patient against making any big decisions or being in a position where they might have to talk to a group of people while they’re on steroids?

I’ve never really thought about it in that context. And usually you’re telling people about this in a setting where you assume they’re not going to work. Generally, the thing that you’re treating is bad enough that they can’t go to work. But certainly that makes total sense.

It’s not the same for everybody. There’s so many people who are going to come forward and say, “Look, I’m on steroids all the time for X, Y, and Z. And I’m fine.” Because there’s no side effect that occurs in 100 percent of people. It’s definitely frequent enough that I will tell people you may not feel yourself.

How confident would you be in saying that what we’re seeing from Donald Trump saying that he’s feeling better, saying that he wants everybody to be getting this antibody cocktail that he’s on—does that seem like very clearly the side effects of steroids to you?

No, it’s not absolutely clear. Some of the grandiosity is just him. Anytime he’s doing a Twitter storm in all caps, it looks a little manic. I think that it’s so part of who he is intermittently that it’s really hard to tell if it’s more of him because of the steroids.

Also, the context is so unusual. He’s on all these medications, he’s on that monoclonal antibody cocktail that we don’t even know the side effects to, because it hasn’t been well studied. Then he’s on the remdesivir, which is really a brand new medication in the context of COVID, which itself can cause alterations to your brain and your behavior. And then add on the steroids. It’s just very hard to parse out in the context of lots of different things happening and having a potential effect on his brain right now.

Is it possible that having all of those therapies at once ends up harming him?

A lot of us in the medical community were actually wondering, when they rushed him to the hospital and he had low-grade fever and was having difficulty breathing, we actually wondered if that was a side effect of the monoclonal antibody cocktail he got, rather than early effects of COVID. So it’s possible that it has already harmed him. We’ve never seen the combination of these medications circulated in one person with his particular physiologic profile. And so we will see some of the side effects. I mean, when you’re doing a study of a new drug, you tend to follow out for side effects for many weeks, sometimes even months. So, certainly there still could be adverse side effects, even the ones we don’t anticipate, in front of us.

He’s turned himself into a guinea pig.

He’s a presidential guinea pig.