Thread by @hyderabaddoctor

Me: "Mr Raj, your wife needs operation, and it needs to be done soon."
Mr Raj: "But none of the previous doctors who treated her depression even remotely hinted at this possibility (of surgery)".

1. 55-year old Mrs Viji had started feeling sad in August 2022.
#MedTwitter

2. Their only daughter had moved to the UK for higher studies. It was assumed that her sadness was related to missing her daughter. However, the feeling of sadness increased over time. She became withdrawn and stopped participating in get-togethers with family and friends.

3. Mrs Viji did not improve even after one month, she was taken to a psychiatrist.
After detailed history, she was diagnosed to have severe depression, and was started on anti-depressant medications.
Counseling by a psychologist was also started.
#psychtwitter #psychology

4. Another month passed by, but Mrs Viji failed
to show any improvement. Now, she had no interest in living and expressed suicidal thoughts to her husband.
On one occasion, she took an overdose of sleeping pills and was rushed to emergency. She received inpatient treatment.

5. Medicines were adjusted. Anti-psychotic drugs were also added. However, Mrs Viji was showing no signs of improvement, whatsoever.
Out of desperation, Psychiatrist referred her to a neurologist to rule out organic causes.
Mr Raj and Mrs Viji were in my OPD in December 2022.

6. I reviewed the clinical history, which was compatible with a diagnosis of severe depression, and it was refractory even to the best medical treatment and psychotherapy.
Moreover, Mrs Viji's mental illness was deteriorating despite treatment.
I ordered for a brain scan.

7. MRI brain showed a large brain tumor occupying left frontal lobe, with mass effect on surrounding brain.
Final diagnosis: Left frontal lobe brain tumor causing severe depression.
In view of significant brain swelling, an early surgery was recommended by the neurosurgeon.

8. Neurosurgeon explained the possible risks and expected benefits of the surgery to the couple. They wanted reassurance from my side too.
Surgery was successful and to everyone's relief, it was not cancer! It was meningioma- a benign brain tumor that arises from brain covering.

9. After surgery, radiation therapy was also given to Mrs Viji.
She recovered well, and had only mild depressive symptoms one month after surgery.
Three months post surgery, she had no depressive symptoms.
The ordeal that started in August 2022, finally ended in March 2023.

10. Depression can be the sole manifestation of brain tumors. Moreover, depression is seen in 21% of patients with brain tumors. However, one can not order brain scan in every patient with depression. There are no guidelines available regarding which cases of depression need MRI.

11. Brain imaging (CT or MRI) should be performed, particularly in late onset of depressive syndrome (after 50 years of age), treatment-resistant depression or in apathy with a reduced emotional response or without dysphoric manifestations.
doi.org/10.1136%2Fbcr-…