Manic Depression Often Gets Misdiagnosed

SACRAMENTO, Calif. — Kent Mulkey got a divorce, moved to California and took antidepressants to deal with his depression. Still, he couldn’t control his reckless behavior. “When it all comes down to it, and the jig is up, I’ll kill myself,” is what he figured. “That was my default. I saw it as my way out.”

Fortunately, a solution came 10 years into Mulkey’s mental illness, he said, when his doctor determined he wasn’t suffering from depression alone, but had a milder form of bipolar disorder — also known as manic-depressive illness. Mulkey is among the 35 percent of people whose accurate mental health diagnosis is delayed for a decade, and among the 60 percent of adults with bipolar disorder who are misdiagnosed as just being depressed.

Teasing apart psychiatric symptoms, finding the right medications and dosages to treat them — and getting the patient to comply with the regimen — are the fundamental challenges of psychiatry, the medical specialty that focuses on mental illness.

David Lauren Crespi, arrested last month in the stabbing deaths of his twin 5-year-old daughters in North Carolina, may offer a tragic example. A successful banker and former Sacramento resident, the 45-year-old had a history of depression and, more recently, insomnia, family have said.

Crespi is being held at the North Carolina Department of Correction’s Central Prison in Raleigh under a “safe keeping order,” that classifies him as suicidal. Crespi faces two counts of murder, but has not yet entered a plea. Although Crespi was treated on and off for several years, some family members now wonder if an undiagnosed and untreated bipolar disorder worsened to the point of psychosis. Unlike with diabetes or heart disease, no blood test or high-tech scanning device can prove the existence of a particular mental illness. Instead, doctors rely on a psychiatric diagnostic manual and their own expertise to assess a patient’s symptoms, find a diagnosis and choose a treatment. “That’s the problem with psychiatry,” said Dr. Charles Schaffer, a Sacramento psychiatrist specializing in bipolar disorder. “Our diagnoses are not as valid or reliable as in other specialties.”

Mulkey, now 49, said he was diagnosed with depression in 1994 after deciding to leave a job as a mental health counselor at a psychiatric hospital to start a private practice. He was put on the antidepressant drug Paxil. “What felt like a step off the curb to anyone else felt to me like stepping off the Grand Canyon,” he said. “I was free-falling into severe depression.” Compounding the depression, he said, was restlessness and boredom. “I was acting out sexually and keeping it hidden. I was really spinning. The cycle for me was in order to combat depression, there was the thrill of acting out, which leads to more depression because of the guilt and shame.”

Spending sprees and heavy drinking added to the ferocity of his life, he said. While his highs were often self-destructive, he also put his boundless energy and drive to work. At one point, he orchestrated the building of a lucrative senior housing project that led to other demanding opportunities. “I made money I had never made,” he said. “I didn’t know it at the time, but I was driving myself into the ground.”

The cycle continued: “I’d be on the road, come home and crash for three days, then get back out and do it again and be the party guy,” he said. “The average person sees me as very gregarious and engaging, but those same people would never guess I go home and close my door and hibernate.”

Dr. Joseph Sison, a Sacramento psychiatrist who specializes in treatment of mentally ill children, said that in some patients antidepressants increase a patient’s agitation, restlessness and explosiveness. “If that’s the case, you probably should re-look at the diagnosis because it may be bipolar disorder,” he said. Dr. Linda Schaffer, a psychiatrist who shares an office with her husband, Charles Schaffer, said she discovered that depressed patients who weren’t getting better on antidepressants improved when the drug lithium — for mood disorders — was added to the mix. She said while the diagnosis of depression was accurate, the doctors were missing the other side of the illness — the nervous energy, anxiety and irritability. “If you treat that side, they get better.”

Patients, too, neglect to describe those other symptoms when they see their doctors, in part because the manic moods and behaviors can be a welcome respite from the depression. The stigma of bipolar disease, often perceived as far more serious and chronic than depression, also prevents patients and their doctors from arriving at the appropriate diagnosis, Charles Schaffer said. “You are more crazy (with bipolar),” he said. “It’s more acceptable to be depressed.”

Two and a half years ago, Mulkey told his regular doctor about his irritability, his fiery temper, edginess and anxiety. When the doctor suggested he might have bipolar disorder after all, Mulkey cried. “The more honest I was and more willing to describe my internal world and my behavior,” he said, “the more he could help me.” A psychiatrist later confirmed the diagnosis and put Mulkey on a new drug that stabilized his mood but contributed to a 40-pound weight gain. 

As with most psychiatric diagnoses, finding the right drugs in the right dosages took time. Today, although he suffers some from insomnia, Mulkey said he is stable. He has quit drinking and lost 20 of the added pounds. He lives in Gold River, has a fulfilling job operating a Sacramento residential home for seniors and enjoys a happy relationship.

Mulkey said he is relieved that his disorder never progressed to the point of psychosis, which can occur with any significant mental illness. A psychotic person may be driven by delusions or hallucinations to do something totally out of character — perhaps violent or criminal. “I can imagine, to some extent, the darkness that enveloped this man’s life,” Mulkey said of Crespi. “It’s so devastatingly sad that effective treatment did not come his way soon enough.”

As a survivor, Mulkey urges others with mental illnesses not to think they are broken. “Be willing to get messy and dirty in dealing with this condition,” he said. “There is often considerable collateral damage that goes with the illness. Do not minimize it or trivialize or spiritualize it away. It will not go away on it’s own.”

c.2006 The Sacramento Bee