Meningioma Presenting With Treatment-Refractory Depression

To the Editor: A 60-year-old woman without previous mental illness had presented symptoms of insomnia, somatic discomforts (including soreness of the teeth, epigastralgia, and soreness of the bilateral arms), decreased energy, poor appetite, diminished functionality, and a feeling of hopelessness, worthlessness, frequent weeping, and suicidal ideation for 1 year. She was treated with antidepressants under the diagnosis of major depression. Because of resistance to serial antidepressant treatments and persistent suicidal ideation, three successive courses of electroconvulsive therapy (ECT), with 27 fractions in total, were administered at a local mental institution. Although a dramatic response to the ECT was reported by her family, she soon relapsed into the same depressive state 1 week after the ECT. When she was referred to our hospital for further treatment, she was found to have psychomotor agitation and impaired cognition, including apraxia (e.g., she could not sew and cook as before) and obvious errors in the Clock-Drawing Test (Figure 1). Under the impression of organic mental disorder or dementia, the patient was examined with cerebral computed tomography (CT), which revealed an intracranial mass in the left anterior temporal base. The mass was 40 mm in maximum diameter, with perifocal edema and a midline shift to the right hemisphere (Figure 2). The intracranial mass was completely removed with neurosurgical intervention, and pathological examination confirmed the diagnosis of meningioma. However, most of the depressive symptoms, including somatic complaints, restlessness, feelings of worthlessness and hopelessness, and suicidal ideation, persisted for at least 9 months after the surgery, when only partial improvement in daily life activity, such as folding clothes, washing dishes, and talking about TV shows, was noted by her family.