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Evaluation of comorbid psychiatric disorders in patients with primary brain tumors before and after surgery
Neurology, Psychiatry and Brain Research 36 (2020) 8–13
Contents lists available at ScienceDirect
Neurology, Psychiatry and Brain Research journal homepage: www.elsevier.com/locate/npbr
Evaluation of comorbid psychiatric disorders in patients with primary brain tumors before and after surgery
T
Robabeh Farzaneha, Ayyoub Maleka,*, Farhad Mirzaeib, Shahrokh Amiria, Firooz Salehpourb, Ali Meshkinib, Zahra Musavia, Sara Farhanga, Saeed Dastgiric, Ali Farzaned, Fatemeh Ghanbarie a
Research Center of Psychiatry and Behavioral Sciences, Tabriz University of Medical Sciences, Tabriz, Iran Department of Neurosurgery, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran c Tabriz Health Services Management Research Centre, Tabriz University of Medical Sciences, Iran d Department of Health Information Management, School of Allied Medical Sciences, Tehran, Iran e School of Medicine, Tehran University of Medical Sciences, Tehran, Iran b
A R T I C LE I N FO
A B S T R A C T
Keywords: Brain tumor Psychiatric disorder Depressive disorder Anxiety disorder
Background: A range of psychiatric disorders are associated with brain tumors. The aim of this study was to assess the frequency of psychiatric disorders in adults with primary brain tumors before and after surgery. Methods: The study was conducted on 120 adult patients diagnosed with primary brain tumors (age ≥18 years). Patients with recent diagnosis (less than 6 months) who were hospitalized in Imam Reza Hospital of Tabriz between December 2016 and November 2017 were included. The diagnostic interview was performed based on DSM-IV criteria using a semi-structured interview with SCID-I before and one month after surgery. The frequency of psychiatric disorders in patients was then compared pre- and post-operation. Results: Pre-surgical studies revealed that 26.66 % of patients with primary brain tumors had symptoms of psychiatric disorders. The most prevalent disorders found in patients were depressive disorders (13.07 %), adjustment disorder (9/15 %) and anxiety disorders (5.88 %). Post-surgical evaluations indicated that the frequency of psychiatric disorders was reduced to 22.5 %. However, there was no significant difference between pre- and post-surgical outcomes. Among patients with psychiatric disorders, the most common location of brain tumors was frontal lobe and the most common pathology was meningioma. Further analysis also revealed that tumor location and pathology was not associated with the incidence and type of psychiatric disorders. Conclusion: In adults with primary brain tumors, the most common psychiatric disorder was depressive disorder.
1. Introduction Brain tumors are divided into primary and metastatic groups. Primary tumors include benign and malignant forms that occur in all areas of the brain and might have a large difference in their invasion and growth characteristics. Brain tumors occur in all ages and both sexes (Surawicz et al., 1999; BJSVAS, 2016). The annual incidence of primary and metastatic brain tumors previously reported were about 12.8 and 52.4 per 100,000 people, respectively (Surawicz et al., 1999). Primary brain tumors are more common in women than men (58 % versus 42 %), However, women are more likely to develop benign tumors (Wrensch, Minn, Chew, Bondy, & Berger, 2002). Brain tumors are associated with a wide range of behavioural and psychiatric symptoms.
⁎
In some cases, these symptoms are the initial manifestation of underlying illness that is not yet known (Sadock & Ruiz, 2015; Uribe, 1986; Madhusoodanan, Danan, Brenner, & Bogunovic, 2004). A series of epidemiological studies on large populations have been shown that among all cancers, the risk of psychiatric hospitalization in the prediagnosis period was highest for the brain tumors. Therefore, in the case of new mental, cognitive or emotional changes in any patient older than 40 years, brain imaging studies should be performed (Madhusoodanan et al., 2004; Perkins & Liu, 2016). In a study, the frequency of depression in frontal lobe tumors and psychosis in temporal lobe neoplasms were higher. Patients with temporal lobe tumors had a higher frequency of schizophrenia-like illness. In this meta-analysis, it has been mentioned that no major prospective study has been designed to investigate the neuropsychiatric symptoms
Corresponding author at: Department of Psychiatry, Razi Psychiatric University Hospital, El Goli Boulevard, P.O. Box 5456, Tabriz, Iran. E-mail address: [email protected] (A. Malek).
https://doi.org/10.1016/j.npbr.2020.02.003 Received 20 July 2019; Received in revised form 28 December 2019; Accepted 5 February 2020 0941-9500/ © 2020 Elsevier GmbH. All rights reserved.
Neurology, Psychiatry and Brain Research 36 (2020) 8–13
R. Farzaneh, et al.
was calculated to be 0.81, using the Alpha coefficient (Anonymous, 2007).
of brain tumors. Several problems involved including atypical and different manifestations of psychiatric symptoms, low lifetime of patients with glioma after diagnosis, stigma due to psychiatric diagnosis (Filley & Kleinschmidt-DeMasters, 1995; Madhusoodanan et al., 2010). Brain tumors may cause various psychological symptoms such as depression, personality changes, abulia, hallucination, mania, panic attacks, and forgetfulness (Madhusoodanan et al., 2004). In this study, we investigated the prevalence and frequency of psychiatric disorders before and after surgery in adult patients with primary brain tumors referred to the Neurosurgery Clinic. We also aimed to compare the frequency of psychiatric disorders by determining the relationship between psychiatric disorders and anatomical location and pathology of the tumors.
2.3. Data analysis Data were analysed based on descriptive analytical methods using SPSS software, version 23. Frequencies were presented in numbers and percent. McNemar test was used to compare the presence of psychiatric disorder before and after tumor surgery (nominal variables). Chi-square test was used to investigate the relationship between psychiatric illness and pathology or location of the tumor and logistic regression analysis was used to investigate the relationship between psychiatric illness and pathology or tumor location.
2. Method and materials 3. Results This cross-sectional study was done to investigate the prevalence of comorbid psychiatric disorders in adult patients with primary brain tumors before and after surgery in Imam Reza Hospital, Tabriz. The target population was all adult patients over 18 years old who had received primary brain tumor diagnosis at the neurosurgery department of Imam Reza Hospital for less than 6 months and was candidates for brain tumor surgery. Exclusion criteria were physical illness other than brain tumor, psychiatric treatment, and a Mini-Mental State Examination (MMSE) test score below 25. Of 167 patients, 120 patients participated in both stages and 42 were excluded (including 6 patients with vision problems, 8 patients with low MMSE score, 9 people with low education, and 24 patients which were not participated in the second stage of the study).
The number of patients enrolled in this study was 120. Among them, 32 patients (26.66 %) had psychiatric symptoms at clinical level. Of 120 patients with brain tumors, 63 of them (52.5 %) were female and 57 of them (47.7 %) were male. Psychiatric disorders were more common in female patients than male (20.3 % of women, compared to 8.8 % of men with brain tumors). Furthermore, brain tumors were most commonly found within the age group of 51–60 years. Moreover, the percentage of psychiatric disorders in this group was higher than other age groups (10.5 %). Of the total number of patients, 9 of them (7.5 %) were single and 111 of them (92.5 %) were married. Patients were assessed for psychiatric disorders based on DSM-IV criteria and the severity of depression and subtypes in the adjustment disorders were determined before and after surgery for comparison. Before surgery, the highest frequency was related to the major depressive disorder (10.5 %). The frequency of psychiatric disorders was as follow: depressive disorder 6.2 %, anxiety disorder 5.3 %, panic disorder 0.7 %, obsessivecompulsive disorder 0.2 %, depressed mood disorder 3.9 %, and adjustment disorder with anxiety and combined symptoms, each 6.2 %. In post-surgical examinations, the symptoms of 5 patients who had clinical psychiatric symptoms before the surgery had been resolved. In general, 28 patients (22.5 %) received a diagnosis of psychiatric disorder in the post-surgical stage. The results of the survey of psychiatric disorders in patients before and after surgery are shown in Fig. 1. The subtypes and characteristics of psychiatric disorders in patients were compared based on the criteria and characteristics of DSM-IV, before and after surgery (Fig. 2). McNemar test was used to measure the difference in the frequency of psychiatric disorders in patients with brain tumor before and after surgery which was not statistically significant (p = 0.125). Considering the 95 % confidence interval, the null hypothesis of equal frequency of
2.1. Procedure The study was approved by the Regional Medical Ethics Committee of Tabriz University of Medical Sciences and was conducted from 21 st December 2016 to the 21 st December 2017, in Tabriz Imam Reza hospital. A written informed consent was obtained from all patients participated in the study. On the first day of admission, MMSE was performed for all eligible patients to investigate the initial cognitive status. Then, if the score was higher or equal to 25, semi-structured diagnostic interviews were conducted based on Structured Clinical Interview for DSM Disorders-I (SCID-I) and DSM-IV criteria. The purpose of the interview was to determine the symptoms of psychiatric illness and diagnosis based on DSM criteria. One month after surgery and removal of surgical sutures, the MMSE test was performed again, and in the event of a score equal to or greater than 25, semi-structured interviews with SCID-I were repeated. After surgery, the exact location of the tumor was determined based on the surgeon's report and the type of pathology was detected on the samples taken from the tumor and examined by a pathologist. Patients who had psychiatric symptoms were referred to the psychosomatic clinic for treatment. 2.2. Study tools The tools used in this study were Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-I) and Mini-Mental State Examination (MMSE). SCID-I is a standardized tool for assessing major psychiatric disorders, based on the definitions and criteria of DSM-IV. In Iran, Sharifi et al. studied the reliability and feasibility of the Persian version of this tool. Their findings showed that the diagnostic agreement for most specific and general diagnoses was moderate to high (Kappa greater than 0.6) (Sharifi et al., 2004). The Mini Mental State Examination (MMSE) is widely used to screen and diagnose cognitive impairments. It tests areas of orientation, registration, attention and calculation, recent memory, various linguistic functions, and spatial thinking. Internal consistency of this test in Farsi
Fig. 1. Comparison of the frequency of psychiatric disorders spectrum in patients before and after surgery. 9
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Fig. 2. Frequency of psychiatric disorders in patients with brain tumor based on the type of disorder before and after surgery.
The most frequent site for brain tumors was frontal lobe and the lowest was posterior and intertrochial fossa, as shown in Table 3. It was observed that the highest frequency of psychiatric disorders was in frontal, temporal and occipital tumors, successively. Patients were separated and analysed according to the location of the tumor on the left or right side of the brain, which is presented in Table 4. There was no significant relationship between the tumor location and presence or absence of psychiatric disorder (Chi-Square test, Pvalue > 0.05). Furthermore, the relationship between the type of psychiatric disorders and tumor location was investigated. The results revealed that there was no significant relationship between type of psychiatric disorder and the tumor site (P-value > 0.05).
Psychiatric disorders in patients with brain tumors before and after surgery was not rejected. Frequency of psychiatric disorders in patients with brain tumors was not ruled out before and after surgery and there was no significant difference between the number of patients with preoperative and postoperative psychiatric disorders (P-value > 0.05). After surgery, the type of the tumors was determined based on pathological studies on the sample taken from the tumors. The existence of a possible relationship between the presence and type of psychiatric disorders and the type of pathology of the tumors are presented in Tables 1 and 2. Based on the type of pathology, the most common type of the brain tumor was meningioma and the least common type of the tumor was schwanoma in patients with psychiatric disorders. There was no significant correlation between the type of pathology of the tumor with psychiatric disorder (Chi-square test, P-Value of 0.445). Also, there was no significant relationship between the presence of psychiatric disorders and the pathology of the tumor. Another goal of this study was to determine the relationship between the type of psychiatric disorder and the type of tumor pathology. There was no significant relationship between the type of psychiatric disorders and tumor pathology (P-value > 0.05). Using the results of neuroimaging studies and the surgeon's report, the existence of a possible relationship between the presence and type of psychiatric disorders with anatomical location of the tumors was investigated.
4. Discussion This study was conducted to investigate psychiatric disorders in patients with brain tumors before and after surgery. The mean age of participants was 47.5 years consisting 52.3 % female and 47.7 % male patients. In this study, there was a relatively lower frequency of psychiatric disorders (26.6 %) compared to other studies. Post-surgical evaluation revealed a decline in the frequency of psychiatric disorders (22.5 %) among the patients, although it was not statistically significant. This result is in line with the literature, stating that psychiatric symptoms persist after tumor resection in most of the brain tumor
Table 1 Frequency of patients with brain tumor according to the tumor pathology and psychiatric disorder. Pathology
Normal
Depressive disorder
Anxiety disorder
Obsessive compulsive disorder
Adaptive disorder
Total
Astrocytoma
18 (11/7 %) 10 (6.5 %) 2 (1.3 %) 43 (28.1 %) 21 (13.7 %) 8 (5.2 %) 5 (3/3 %) 107 (69.9 %)
4 (2/7 %) 3 (2.0 %) 0 (0.0 %) 4 (2.6 %) 4 (2.6 %) 4 (2.6 %) 1 (0/7 %) 20 (13.1 %)
1 (0/7 %) 3 (2.0 %) 0 (0.0 %) 4 (2.6 %) 0 (0.0 %) 1 (0.7 %) 0 (0.0 %) 9 (5.9 %)
1 (0/7 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 1 (0.7 %) 0 (0.0 %) 1 (0.7 %) 3 (2.0 %)
1 (0.7 2 (1.3 0 (0.0 7 (4.6 0 (0.0 3 (2.0 1 (0.7 14 (9.2
25 (16/4 %) 18 (11.8 %) 2 (1.3 %) 58 (37.9 %) 26 (17.0 %) 16 (10.5 %) 8 (5/3 %) 153 (100 %)
Glioblastoma Lymphoma Meningioma Pituitary adenoma Oligodendroglioma Schwanoma Total
10
%) %) %) %) %) %) %) %)
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Table 2 Frequency of patients with brain tumors with and without psychiatric disorders according to the tumor pathology. Pathology
Frequency of patients without psychiatric disorders
Percentage of patients without psychiatric disorder
Frequency of patients with psychiatric disorders
Percentage of patients with psychiatric disorder
Total
Total percentage
Astrocytoma Glioblastoma Lymphoma Meningioma Pituitary adenoma Oligodendroglioma Schwanoma Total
18 10 2 43 21 8 5 107
11/8 6/5 1/3 28/1 13/7 5/2 3/3 69/9
7 8 0 15 5 8 3 46
4/6 5/2 0.0 9/8 3/3 5/2 2/0 30/1
25 18 2 58 26 16 8 153
16.4 11.8 1.3 37.9 17.0 10.5 5/2 100.0
Table 3 Frequency of patients with brain tumors with and without psychiatric disorders based on the tumor location. Tumor location
Frequency of patients without psychiatric disorders
Percentage of patients without psychiatric disorders
Frequency of patients with psychiatric disorders
Percentage of patients with psychiatric disorders
TOTAL
TOTAL (percentage)
Frontal Temporal Parietal Occipital Intraventricular Posterior fossa Pituitary Total
30 23 8 11 11 9 15 107
19.61 15.03 5.23 7.19 7.19 5.88 9.80 69.93
12 10 6 8 2 4 4 46
7.84 6.54 3.92 5.23 1.31 2.61 4.61 30.07
42 33 14 19 13 13 19 153
27.45 21.57 9.15 12.42 8.50 8.50 12.42 100
psychiatric disorders in our patients were higher than the general population. Further analysis revealed that severity of symptoms was reduced in a number of patients, although they still had clinical symptoms. However, the type of psychiatric disorder was not changed in patients. In this study, the prevalence of brain tumors and psychiatric disorders was high in women which was consistent with previous studies (Madhusoodanan et al., 2010). Furthermore, in the age group of 51–60, the highest prevalence of brain tumors and the highest frequency of psychiatric disorders were observed. Retirement, anxiety due to loneliness and biological changes can be attributed to the higher frequency of symptoms in this age group. The frequency of psychiatric disorders in various studies has been
patients (BJSVAS, 2016). The most frequent preoperative disorder was depression (13.07 %), which was reduced to 12.4 after surgery. Likewise, adjustment disorder was decreased from 9.15 % to 6.5 %. However, anxiety and obsessive-compulsive disorders did not change after surgery (Fig. 1). In a comprehensive study, 12-month prevalence of major depressive disorder in the general population was reported to be 3.5 %. The 12month prevalence of generalized anxiety disorder (GAD) was about 2.1 %, reported in several studies (BJSVAS, 2016). In Iran, the prevalence of psychiatric disorders in general population was 10.81 %, among them 1.3 % had GAD. In this extensive study, the prevalence of the depression disorder was 4.29 % and major depressive disorder was 2.98 % (Mohammadi et al., 2005). Comparing the 12-month prevalence of these disorders in the general population with our study results,
Table 4 Comparison of patients with brain tumor based on tumor laterality and psychiatric disorder. Tumor location
Normal
Depressive disorder
Anxiety disorder
Obsessive compulsive disorder
Adaptive disorder
Total
Right Frontal
15 (9.8 %) 15 (9.8 %) 14 (9.2) 9 (5.9 %) 6 (3.9 %) 2 (1.3 %) 5 (3.3 5) 6 (3.9 %) 11 (7.2 %) 9 (5.9 %) 15 (9.8 %) 107 (69.9 %)
3 (2.0 %) 1 (0.7 %) 2 (1.3 %) 2 (1.3 %) 1 (0.7 %) 1 (0.7 %) 1 (0.7 %) 2 (1.3 %) 2 (1.3 %) 2 (1.3 %) 3 (2.0 %) 20 (13.1 %)
3 (2.0 1 (0.7 1 (0.7 0 (0.0 1 (0.7 0 (0.0 3 (2.0 0 (0.0 0 (0.0 0 (0.0 0 (0.0 9 (5.9
0 (0.0 0 (0.0 0 (0.0 1 (0.7 0 (0.0 0 (0.0 0 (0.0 0 (0.0 0 (0.0 1 (0.7 1 (0.7 3 (2.0
3 (2.0 %) 1 (0.7 %) 3 (2.0 %) 1 (0.7 %) 2 (1.3 %) 1 (0.7 %) 0 (0.0 %) 2 (1.3 %) 0 (0.0 %) 1 (0.7 %) 0 (0.0 %) 14 (9.2)
24 (15.7 %) 18 (11.8 %) 20 (13.1 %) 13 (8.5 %) 10 (6.5 %) 4 (2.6 %) 9 (5.9 %) 10 (6.5 %) 13 (8.5 %) 13 (8.5 %) 19 (12.4 %) 153 (100 %)
Left Frontal Right Temporal Left Temporal Right Parietal Left Parietal Right Occipital Left Occipital Intraventricular Posterior fossa Pituitary Total
%) %) %) %) %) %) %) %) %) %) %) %)
11
%) %) %) %) %) %) %) %) %) %) %) %)
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5. Conclusion
reported from 50 % to 78 % (Madhusoodanan et al., 2010). In these studies, primary and secondary tumors have not been investigated separately, and due to the higher frequency of psychiatric disorders in association with metastatic tumors, this difference can be justified. The frequency of major depression in a study was 16 %, 10 % and 15 %, before surgery, 3 months and one year after surgery, respectively, which is similar to our findings (Mainio, Hakko, Niemelä, Koivukangas, & Räsänen, 2011). The discrepancy between different studies in reporting the prevalence of psychiatric disorders in brain tumor patients seems to be due to the low reliability and validity of diagnostic systems in the diagnosis of psychiatric disorders, especially in brain tumor patients (Aboraya, Rankin, France, El-Missiry, & John, 2006). We used the DSM system in this study, whose rigid operational approach challenges the identification and naming of psychological and behavioural symptoms in our brain tumor patients (BJSVAS, 2016). According to the results, none of the anatomical locations of the tumor in the frontal, temporal, parietal, occipital, pituitary, posterior fossa and intra-ventricular regions had a meaningful relationship with depression, anxiety and adjustment disorders, both spectrally and in separate diagnoses of each spectrum. Despite studies that have shown evidence of association of brain tumors in different anatomical sites with psychiatric disorders (Madhusoodanan et al., 2010), we could not find any association. Some studies that have focused on the anatomical association of brain tumors with the type of psychiatric disorders have reported the association between depressive disorder with left hemisphere tumors (Madhusoodanan, Danan, & Moise, 2007; Mainio et al., 2011). While our study with a higher sample size rejected any association between psychiatric disorders in patients with brain tumors with anatomical location of the tumor. According to the results, none of the pathological types including astrocytoma, glioblastoma, lymphoma, meningioma, pituitary tumor, schwannoma and oligodendruma were associated with psychiatric disorders. In previous studies, the relationship between types of psychiatric symptoms and the type of tumor pathology has not been widely discussed. In a study, 21 % of meningioma patients presented with psychiatric symptoms did not have neurological symptoms (Gupta & Kumar, 2004). In our study, this finding has not been achieved. Our findings were similar to other studies suggesting that there was no relationship between psychological problems and the type of tumour’s pathology (Madhusoodanan et al., 2007; Mainio et al., 2011). It seems that the etiology of psychiatric disorders is multifactorial in brain tumor patients. Our findings are in line with the evidence that does not consider the cause of depression in cancer patients just as a single factor, but other factors, such as biological and biochemical factors, should also be considered in pathophysiology of depression and psychological symptoms. Several studies suggested that patients’ cytokine levels and changes in the hypothalamic pituitary axis could influence the development of psychological symptoms. In general, it can be suggested that other factors such as the location and histology of the tumor, family background, social, psychological and biological factors such as cytokines level and hormonal changes might be involved in psychological response of the patients (Madhusoodanan, Ting, Farah, & Ugur, 2015; Seddighi, Seddighi, Ashrafi, & Nohehsara, 2010). Our study had some limitations such as the lack of long-term followup of patients. Also the SCID interview and the MMSE test required active participation of the patients in the study to complete the questionnaires and tolerate the long interview time. The patients should also receive a MMSE test score equal to or greater than 25, which resulted in the exclusion of a number of patients with a psychiatric disorder, such as a psychotic disorder during the study.
According to our study, the prevalence of psychiatric disorders in patients with brain tumors was higher than the general population. Therefore, it seems necessary to pay attention to underlying causes such as brain tumors in the emergence of psychological symptoms, especially atypical and new occurrences. Considering the mechanisms that contribute to the development of psychological symptoms caused by tumors, more extensive studies are required to understand these mechanisms and identify pathophysiology of psychological symptoms in patients with brain tumors. Ethical statement This study was approved by the Research Council of the Faculty of Medicine and the Regional Ethics Committee under the code of 5/d/ 514602 at Tabriz University of Medical Sciences. An informed consent was also obtained from all participants in this research. Financial disclosure This study was financially supported by Tabriz University of Medical Sciences. CRediT authorship contribution statement Robabeh Farzaneh: Visualization, Investigation, Writing - review & editing. Ayyoub Malek: Conceptualization, Methodology, Project administration. Farhad Mirzaei: Resources, Supervision. Shahrokh Amiri: Data curation. Firooz Salehpour: Conceptualization, Resources. Ali Meshkini: Resources. Zahra Musavi: Investigation. Sara Farhang: Investigation. Saeed Dastgiri: Validation, Software. Ali Farzane: Formal analysis. Fatemeh Ghanbari: Writing - original draft. Declaration of Competing Interest The authors have no conflict of interest to be declared in this work. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.npbr.2020.02.003. References Aboraya, A., Rankin, E., France, C., El-Missiry, A., & John, C. (2006). The reliability of psychiatric diagnosis revisited: The clinician's guide to improve the reliability of psychiatric diagnosis. Psychiatry (Edgmont), 3(1), 41. Journal of Medical Council of Islamic Republic of Iran25(4), 408–414. BJSVAS (Ed.). (2016). Kaplan & Sadocks comprehensive textbook of psychiatry(tenth edition). Philadelphia: Lippincott Williams & Wilkins. Filley, C. M., & Kleinschmidt-DeMasters, B. K. (1995). Neurobehavioral presentations of brain neoplasms. The Western Journal of Medicine, 163(1), 19. Gupta, R. K., & Kumar, R. (2004). Benign brain tumours and psychiatric morbidity: a 5years retrospective data analysis. The Australian and New Zealand Journal of Psychiatry, 38(5), 316–319. Madhusoodanan, S., Danan, D., Brenner, R., & Bogunovic, O. (2004). Brain tumor and psychiatric manifestations: A case report and brief review. Annals of Clinical Psychiatry, 16(2), 111–113. Madhusoodanan, S., Danan, D., & Moise, D. (2007). Psychiatric manifestations of brain tumors: Diagnostic implications. Expert Review of Neurotherapeutics, 7(4), 343–349. Madhusoodanan, S., Opler, M. G., Moise, D., Gordon, J., Danan, D. M., Sinha, A., et al. (2010). Brain tumor location and psychiatric symptoms: Is there any association? A meta-analysis of published case studies. Expert Review of Neurotherapeutics, 10(10), 1529–1536. Madhusoodanan, S., Ting, M. B., Farah, T., & Ugur, U. (2015). Psychiatric aspects of brain tumors: A review. World Journal of Psychiatry, 5(3), 273. Mainio, A., Hakko, H., Niemelä, A., Koivukangas, J., & Räsänen, P. (2011). Depression in relation to anxiety, obsessionality and phobia among neurosurgical patients with a primary brain tumor: a 1-year follow-up study. Clinical Neurology and Neurosurgery, 113(8), 649–653. Mohammadi, M.-R., Davidian, H., Noorbala, A. A., Malekafzali, H., Naghavi, H. R.,
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DSM-IV (SCID). Surawicz, T. S., McCarthy, B. J., Kupelian, V., Jukich, P. J., Bruner, J. M., & Davis, F. G. (1999). Descriptive epidemiology of primary brain and CNS tumors: Results from the Central Brain Tumor Registry of the United States, 1990-1994. Neuro-oncology, 1(1), 14–25. Uribe, V. M. (1986). Psychiatric symptoms and brain tumor. American Family Physician, 34(2), 95–98. Wrensch, M., Minn, Y., Chew, T., Bondy, M., & Berger, M. S. (2002). Epidemiology of primary brain tumors: Current concepts and review of the literature. Neuro-oncology, 4(4), 278–299.
Pouretemad, H. R., et al. (2005). An epidemiological survey of psychiatric disorders in Iran. Clinical Practice and Epidemiology in Mental Health, 1(1), 16. Perkins, A., & Liu, G. (2016). Primary brain tumors in adults: Diagnosis and treatment. American Family Physician, 93(3). Sadock, B., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences. Walters Kluwer. Seddighi, A., Seddighi, A., Ashrafi, F., & Nohehsara, S. (2010). Neuropsychological disorders in patients with brain tumor. Iranian Journal of Cancer Prevention, 3(1), 42–47. Sharifi, V., Asadi, S., Mohammadi, M., AMINI, H., Kaviani, H., Semnani, Y., et al. (2004). Reliability and feasibility of the Persian version of the structured diagnostic interview for
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Contents lists available at ScienceDirect
Neurology, Psychiatry and Brain Research journal homepage: www.elsevier.com/locate/npbr
Evaluation of comorbid psychiatric disorders in patients with primary brain tumors before and after surgery
T
Robabeh Farzaneha, Ayyoub Maleka,*, Farhad Mirzaeib, Shahrokh Amiria, Firooz Salehpourb, Ali Meshkinib, Zahra Musavia, Sara Farhanga, Saeed Dastgiric, Ali Farzaned, Fatemeh Ghanbarie a
Research Center of Psychiatry and Behavioral Sciences, Tabriz University of Medical Sciences, Tabriz, Iran Department of Neurosurgery, School of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran c Tabriz Health Services Management Research Centre, Tabriz University of Medical Sciences, Iran d Department of Health Information Management, School of Allied Medical Sciences, Tehran, Iran e School of Medicine, Tehran University of Medical Sciences, Tehran, Iran b
A R T I C LE I N FO
A B S T R A C T
Keywords: Brain tumor Psychiatric disorder Depressive disorder Anxiety disorder
Background: A range of psychiatric disorders are associated with brain tumors. The aim of this study was to assess the frequency of psychiatric disorders in adults with primary brain tumors before and after surgery. Methods: The study was conducted on 120 adult patients diagnosed with primary brain tumors (age ≥18 years). Patients with recent diagnosis (less than 6 months) who were hospitalized in Imam Reza Hospital of Tabriz between December 2016 and November 2017 were included. The diagnostic interview was performed based on DSM-IV criteria using a semi-structured interview with SCID-I before and one month after surgery. The frequency of psychiatric disorders in patients was then compared pre- and post-operation. Results: Pre-surgical studies revealed that 26.66 % of patients with primary brain tumors had symptoms of psychiatric disorders. The most prevalent disorders found in patients were depressive disorders (13.07 %), adjustment disorder (9/15 %) and anxiety disorders (5.88 %). Post-surgical evaluations indicated that the frequency of psychiatric disorders was reduced to 22.5 %. However, there was no significant difference between pre- and post-surgical outcomes. Among patients with psychiatric disorders, the most common location of brain tumors was frontal lobe and the most common pathology was meningioma. Further analysis also revealed that tumor location and pathology was not associated with the incidence and type of psychiatric disorders. Conclusion: In adults with primary brain tumors, the most common psychiatric disorder was depressive disorder.
1. Introduction Brain tumors are divided into primary and metastatic groups. Primary tumors include benign and malignant forms that occur in all areas of the brain and might have a large difference in their invasion and growth characteristics. Brain tumors occur in all ages and both sexes (Surawicz et al., 1999; BJSVAS, 2016). The annual incidence of primary and metastatic brain tumors previously reported were about 12.8 and 52.4 per 100,000 people, respectively (Surawicz et al., 1999). Primary brain tumors are more common in women than men (58 % versus 42 %), However, women are more likely to develop benign tumors (Wrensch, Minn, Chew, Bondy, & Berger, 2002). Brain tumors are associated with a wide range of behavioural and psychiatric symptoms.
⁎
In some cases, these symptoms are the initial manifestation of underlying illness that is not yet known (Sadock & Ruiz, 2015; Uribe, 1986; Madhusoodanan, Danan, Brenner, & Bogunovic, 2004). A series of epidemiological studies on large populations have been shown that among all cancers, the risk of psychiatric hospitalization in the prediagnosis period was highest for the brain tumors. Therefore, in the case of new mental, cognitive or emotional changes in any patient older than 40 years, brain imaging studies should be performed (Madhusoodanan et al., 2004; Perkins & Liu, 2016). In a study, the frequency of depression in frontal lobe tumors and psychosis in temporal lobe neoplasms were higher. Patients with temporal lobe tumors had a higher frequency of schizophrenia-like illness. In this meta-analysis, it has been mentioned that no major prospective study has been designed to investigate the neuropsychiatric symptoms
Corresponding author at: Department of Psychiatry, Razi Psychiatric University Hospital, El Goli Boulevard, P.O. Box 5456, Tabriz, Iran. E-mail address: [email protected] (A. Malek).
https://doi.org/10.1016/j.npbr.2020.02.003 Received 20 July 2019; Received in revised form 28 December 2019; Accepted 5 February 2020 0941-9500/ © 2020 Elsevier GmbH. All rights reserved.
Neurology, Psychiatry and Brain Research 36 (2020) 8–13
R. Farzaneh, et al.
was calculated to be 0.81, using the Alpha coefficient (Anonymous, 2007).
of brain tumors. Several problems involved including atypical and different manifestations of psychiatric symptoms, low lifetime of patients with glioma after diagnosis, stigma due to psychiatric diagnosis (Filley & Kleinschmidt-DeMasters, 1995; Madhusoodanan et al., 2010). Brain tumors may cause various psychological symptoms such as depression, personality changes, abulia, hallucination, mania, panic attacks, and forgetfulness (Madhusoodanan et al., 2004). In this study, we investigated the prevalence and frequency of psychiatric disorders before and after surgery in adult patients with primary brain tumors referred to the Neurosurgery Clinic. We also aimed to compare the frequency of psychiatric disorders by determining the relationship between psychiatric disorders and anatomical location and pathology of the tumors.
2.3. Data analysis Data were analysed based on descriptive analytical methods using SPSS software, version 23. Frequencies were presented in numbers and percent. McNemar test was used to compare the presence of psychiatric disorder before and after tumor surgery (nominal variables). Chi-square test was used to investigate the relationship between psychiatric illness and pathology or location of the tumor and logistic regression analysis was used to investigate the relationship between psychiatric illness and pathology or tumor location.
2. Method and materials 3. Results This cross-sectional study was done to investigate the prevalence of comorbid psychiatric disorders in adult patients with primary brain tumors before and after surgery in Imam Reza Hospital, Tabriz. The target population was all adult patients over 18 years old who had received primary brain tumor diagnosis at the neurosurgery department of Imam Reza Hospital for less than 6 months and was candidates for brain tumor surgery. Exclusion criteria were physical illness other than brain tumor, psychiatric treatment, and a Mini-Mental State Examination (MMSE) test score below 25. Of 167 patients, 120 patients participated in both stages and 42 were excluded (including 6 patients with vision problems, 8 patients with low MMSE score, 9 people with low education, and 24 patients which were not participated in the second stage of the study).
The number of patients enrolled in this study was 120. Among them, 32 patients (26.66 %) had psychiatric symptoms at clinical level. Of 120 patients with brain tumors, 63 of them (52.5 %) were female and 57 of them (47.7 %) were male. Psychiatric disorders were more common in female patients than male (20.3 % of women, compared to 8.8 % of men with brain tumors). Furthermore, brain tumors were most commonly found within the age group of 51–60 years. Moreover, the percentage of psychiatric disorders in this group was higher than other age groups (10.5 %). Of the total number of patients, 9 of them (7.5 %) were single and 111 of them (92.5 %) were married. Patients were assessed for psychiatric disorders based on DSM-IV criteria and the severity of depression and subtypes in the adjustment disorders were determined before and after surgery for comparison. Before surgery, the highest frequency was related to the major depressive disorder (10.5 %). The frequency of psychiatric disorders was as follow: depressive disorder 6.2 %, anxiety disorder 5.3 %, panic disorder 0.7 %, obsessivecompulsive disorder 0.2 %, depressed mood disorder 3.9 %, and adjustment disorder with anxiety and combined symptoms, each 6.2 %. In post-surgical examinations, the symptoms of 5 patients who had clinical psychiatric symptoms before the surgery had been resolved. In general, 28 patients (22.5 %) received a diagnosis of psychiatric disorder in the post-surgical stage. The results of the survey of psychiatric disorders in patients before and after surgery are shown in Fig. 1. The subtypes and characteristics of psychiatric disorders in patients were compared based on the criteria and characteristics of DSM-IV, before and after surgery (Fig. 2). McNemar test was used to measure the difference in the frequency of psychiatric disorders in patients with brain tumor before and after surgery which was not statistically significant (p = 0.125). Considering the 95 % confidence interval, the null hypothesis of equal frequency of
2.1. Procedure The study was approved by the Regional Medical Ethics Committee of Tabriz University of Medical Sciences and was conducted from 21 st December 2016 to the 21 st December 2017, in Tabriz Imam Reza hospital. A written informed consent was obtained from all patients participated in the study. On the first day of admission, MMSE was performed for all eligible patients to investigate the initial cognitive status. Then, if the score was higher or equal to 25, semi-structured diagnostic interviews were conducted based on Structured Clinical Interview for DSM Disorders-I (SCID-I) and DSM-IV criteria. The purpose of the interview was to determine the symptoms of psychiatric illness and diagnosis based on DSM criteria. One month after surgery and removal of surgical sutures, the MMSE test was performed again, and in the event of a score equal to or greater than 25, semi-structured interviews with SCID-I were repeated. After surgery, the exact location of the tumor was determined based on the surgeon's report and the type of pathology was detected on the samples taken from the tumor and examined by a pathologist. Patients who had psychiatric symptoms were referred to the psychosomatic clinic for treatment. 2.2. Study tools The tools used in this study were Structured Clinical Interview for DSM-IV Axis 1 Disorders (SCID-I) and Mini-Mental State Examination (MMSE). SCID-I is a standardized tool for assessing major psychiatric disorders, based on the definitions and criteria of DSM-IV. In Iran, Sharifi et al. studied the reliability and feasibility of the Persian version of this tool. Their findings showed that the diagnostic agreement for most specific and general diagnoses was moderate to high (Kappa greater than 0.6) (Sharifi et al., 2004). The Mini Mental State Examination (MMSE) is widely used to screen and diagnose cognitive impairments. It tests areas of orientation, registration, attention and calculation, recent memory, various linguistic functions, and spatial thinking. Internal consistency of this test in Farsi
Fig. 1. Comparison of the frequency of psychiatric disorders spectrum in patients before and after surgery. 9
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Fig. 2. Frequency of psychiatric disorders in patients with brain tumor based on the type of disorder before and after surgery.
The most frequent site for brain tumors was frontal lobe and the lowest was posterior and intertrochial fossa, as shown in Table 3. It was observed that the highest frequency of psychiatric disorders was in frontal, temporal and occipital tumors, successively. Patients were separated and analysed according to the location of the tumor on the left or right side of the brain, which is presented in Table 4. There was no significant relationship between the tumor location and presence or absence of psychiatric disorder (Chi-Square test, Pvalue > 0.05). Furthermore, the relationship between the type of psychiatric disorders and tumor location was investigated. The results revealed that there was no significant relationship between type of psychiatric disorder and the tumor site (P-value > 0.05).
Psychiatric disorders in patients with brain tumors before and after surgery was not rejected. Frequency of psychiatric disorders in patients with brain tumors was not ruled out before and after surgery and there was no significant difference between the number of patients with preoperative and postoperative psychiatric disorders (P-value > 0.05). After surgery, the type of the tumors was determined based on pathological studies on the sample taken from the tumors. The existence of a possible relationship between the presence and type of psychiatric disorders and the type of pathology of the tumors are presented in Tables 1 and 2. Based on the type of pathology, the most common type of the brain tumor was meningioma and the least common type of the tumor was schwanoma in patients with psychiatric disorders. There was no significant correlation between the type of pathology of the tumor with psychiatric disorder (Chi-square test, P-Value of 0.445). Also, there was no significant relationship between the presence of psychiatric disorders and the pathology of the tumor. Another goal of this study was to determine the relationship between the type of psychiatric disorder and the type of tumor pathology. There was no significant relationship between the type of psychiatric disorders and tumor pathology (P-value > 0.05). Using the results of neuroimaging studies and the surgeon's report, the existence of a possible relationship between the presence and type of psychiatric disorders with anatomical location of the tumors was investigated.
4. Discussion This study was conducted to investigate psychiatric disorders in patients with brain tumors before and after surgery. The mean age of participants was 47.5 years consisting 52.3 % female and 47.7 % male patients. In this study, there was a relatively lower frequency of psychiatric disorders (26.6 %) compared to other studies. Post-surgical evaluation revealed a decline in the frequency of psychiatric disorders (22.5 %) among the patients, although it was not statistically significant. This result is in line with the literature, stating that psychiatric symptoms persist after tumor resection in most of the brain tumor
Table 1 Frequency of patients with brain tumor according to the tumor pathology and psychiatric disorder. Pathology
Normal
Depressive disorder
Anxiety disorder
Obsessive compulsive disorder
Adaptive disorder
Total
Astrocytoma
18 (11/7 %) 10 (6.5 %) 2 (1.3 %) 43 (28.1 %) 21 (13.7 %) 8 (5.2 %) 5 (3/3 %) 107 (69.9 %)
4 (2/7 %) 3 (2.0 %) 0 (0.0 %) 4 (2.6 %) 4 (2.6 %) 4 (2.6 %) 1 (0/7 %) 20 (13.1 %)
1 (0/7 %) 3 (2.0 %) 0 (0.0 %) 4 (2.6 %) 0 (0.0 %) 1 (0.7 %) 0 (0.0 %) 9 (5.9 %)
1 (0/7 %) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) 1 (0.7 %) 0 (0.0 %) 1 (0.7 %) 3 (2.0 %)
1 (0.7 2 (1.3 0 (0.0 7 (4.6 0 (0.0 3 (2.0 1 (0.7 14 (9.2
25 (16/4 %) 18 (11.8 %) 2 (1.3 %) 58 (37.9 %) 26 (17.0 %) 16 (10.5 %) 8 (5/3 %) 153 (100 %)
Glioblastoma Lymphoma Meningioma Pituitary adenoma Oligodendroglioma Schwanoma Total
10
%) %) %) %) %) %) %) %)
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Table 2 Frequency of patients with brain tumors with and without psychiatric disorders according to the tumor pathology. Pathology
Frequency of patients without psychiatric disorders
Percentage of patients without psychiatric disorder
Frequency of patients with psychiatric disorders
Percentage of patients with psychiatric disorder
Total
Total percentage
Astrocytoma Glioblastoma Lymphoma Meningioma Pituitary adenoma Oligodendroglioma Schwanoma Total
18 10 2 43 21 8 5 107
11/8 6/5 1/3 28/1 13/7 5/2 3/3 69/9
7 8 0 15 5 8 3 46
4/6 5/2 0.0 9/8 3/3 5/2 2/0 30/1
25 18 2 58 26 16 8 153
16.4 11.8 1.3 37.9 17.0 10.5 5/2 100.0
Table 3 Frequency of patients with brain tumors with and without psychiatric disorders based on the tumor location. Tumor location
Frequency of patients without psychiatric disorders
Percentage of patients without psychiatric disorders
Frequency of patients with psychiatric disorders
Percentage of patients with psychiatric disorders
TOTAL
TOTAL (percentage)
Frontal Temporal Parietal Occipital Intraventricular Posterior fossa Pituitary Total
30 23 8 11 11 9 15 107
19.61 15.03 5.23 7.19 7.19 5.88 9.80 69.93
12 10 6 8 2 4 4 46
7.84 6.54 3.92 5.23 1.31 2.61 4.61 30.07
42 33 14 19 13 13 19 153
27.45 21.57 9.15 12.42 8.50 8.50 12.42 100
psychiatric disorders in our patients were higher than the general population. Further analysis revealed that severity of symptoms was reduced in a number of patients, although they still had clinical symptoms. However, the type of psychiatric disorder was not changed in patients. In this study, the prevalence of brain tumors and psychiatric disorders was high in women which was consistent with previous studies (Madhusoodanan et al., 2010). Furthermore, in the age group of 51–60, the highest prevalence of brain tumors and the highest frequency of psychiatric disorders were observed. Retirement, anxiety due to loneliness and biological changes can be attributed to the higher frequency of symptoms in this age group. The frequency of psychiatric disorders in various studies has been
patients (BJSVAS, 2016). The most frequent preoperative disorder was depression (13.07 %), which was reduced to 12.4 after surgery. Likewise, adjustment disorder was decreased from 9.15 % to 6.5 %. However, anxiety and obsessive-compulsive disorders did not change after surgery (Fig. 1). In a comprehensive study, 12-month prevalence of major depressive disorder in the general population was reported to be 3.5 %. The 12month prevalence of generalized anxiety disorder (GAD) was about 2.1 %, reported in several studies (BJSVAS, 2016). In Iran, the prevalence of psychiatric disorders in general population was 10.81 %, among them 1.3 % had GAD. In this extensive study, the prevalence of the depression disorder was 4.29 % and major depressive disorder was 2.98 % (Mohammadi et al., 2005). Comparing the 12-month prevalence of these disorders in the general population with our study results,
Table 4 Comparison of patients with brain tumor based on tumor laterality and psychiatric disorder. Tumor location
Normal
Depressive disorder
Anxiety disorder
Obsessive compulsive disorder
Adaptive disorder
Total
Right Frontal
15 (9.8 %) 15 (9.8 %) 14 (9.2) 9 (5.9 %) 6 (3.9 %) 2 (1.3 %) 5 (3.3 5) 6 (3.9 %) 11 (7.2 %) 9 (5.9 %) 15 (9.8 %) 107 (69.9 %)
3 (2.0 %) 1 (0.7 %) 2 (1.3 %) 2 (1.3 %) 1 (0.7 %) 1 (0.7 %) 1 (0.7 %) 2 (1.3 %) 2 (1.3 %) 2 (1.3 %) 3 (2.0 %) 20 (13.1 %)
3 (2.0 1 (0.7 1 (0.7 0 (0.0 1 (0.7 0 (0.0 3 (2.0 0 (0.0 0 (0.0 0 (0.0 0 (0.0 9 (5.9
0 (0.0 0 (0.0 0 (0.0 1 (0.7 0 (0.0 0 (0.0 0 (0.0 0 (0.0 0 (0.0 1 (0.7 1 (0.7 3 (2.0
3 (2.0 %) 1 (0.7 %) 3 (2.0 %) 1 (0.7 %) 2 (1.3 %) 1 (0.7 %) 0 (0.0 %) 2 (1.3 %) 0 (0.0 %) 1 (0.7 %) 0 (0.0 %) 14 (9.2)
24 (15.7 %) 18 (11.8 %) 20 (13.1 %) 13 (8.5 %) 10 (6.5 %) 4 (2.6 %) 9 (5.9 %) 10 (6.5 %) 13 (8.5 %) 13 (8.5 %) 19 (12.4 %) 153 (100 %)
Left Frontal Right Temporal Left Temporal Right Parietal Left Parietal Right Occipital Left Occipital Intraventricular Posterior fossa Pituitary Total
%) %) %) %) %) %) %) %) %) %) %) %)
11
%) %) %) %) %) %) %) %) %) %) %) %)
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5. Conclusion
reported from 50 % to 78 % (Madhusoodanan et al., 2010). In these studies, primary and secondary tumors have not been investigated separately, and due to the higher frequency of psychiatric disorders in association with metastatic tumors, this difference can be justified. The frequency of major depression in a study was 16 %, 10 % and 15 %, before surgery, 3 months and one year after surgery, respectively, which is similar to our findings (Mainio, Hakko, Niemelä, Koivukangas, & Räsänen, 2011). The discrepancy between different studies in reporting the prevalence of psychiatric disorders in brain tumor patients seems to be due to the low reliability and validity of diagnostic systems in the diagnosis of psychiatric disorders, especially in brain tumor patients (Aboraya, Rankin, France, El-Missiry, & John, 2006). We used the DSM system in this study, whose rigid operational approach challenges the identification and naming of psychological and behavioural symptoms in our brain tumor patients (BJSVAS, 2016). According to the results, none of the anatomical locations of the tumor in the frontal, temporal, parietal, occipital, pituitary, posterior fossa and intra-ventricular regions had a meaningful relationship with depression, anxiety and adjustment disorders, both spectrally and in separate diagnoses of each spectrum. Despite studies that have shown evidence of association of brain tumors in different anatomical sites with psychiatric disorders (Madhusoodanan et al., 2010), we could not find any association. Some studies that have focused on the anatomical association of brain tumors with the type of psychiatric disorders have reported the association between depressive disorder with left hemisphere tumors (Madhusoodanan, Danan, & Moise, 2007; Mainio et al., 2011). While our study with a higher sample size rejected any association between psychiatric disorders in patients with brain tumors with anatomical location of the tumor. According to the results, none of the pathological types including astrocytoma, glioblastoma, lymphoma, meningioma, pituitary tumor, schwannoma and oligodendruma were associated with psychiatric disorders. In previous studies, the relationship between types of psychiatric symptoms and the type of tumor pathology has not been widely discussed. In a study, 21 % of meningioma patients presented with psychiatric symptoms did not have neurological symptoms (Gupta & Kumar, 2004). In our study, this finding has not been achieved. Our findings were similar to other studies suggesting that there was no relationship between psychological problems and the type of tumour’s pathology (Madhusoodanan et al., 2007; Mainio et al., 2011). It seems that the etiology of psychiatric disorders is multifactorial in brain tumor patients. Our findings are in line with the evidence that does not consider the cause of depression in cancer patients just as a single factor, but other factors, such as biological and biochemical factors, should also be considered in pathophysiology of depression and psychological symptoms. Several studies suggested that patients’ cytokine levels and changes in the hypothalamic pituitary axis could influence the development of psychological symptoms. In general, it can be suggested that other factors such as the location and histology of the tumor, family background, social, psychological and biological factors such as cytokines level and hormonal changes might be involved in psychological response of the patients (Madhusoodanan, Ting, Farah, & Ugur, 2015; Seddighi, Seddighi, Ashrafi, & Nohehsara, 2010). Our study had some limitations such as the lack of long-term followup of patients. Also the SCID interview and the MMSE test required active participation of the patients in the study to complete the questionnaires and tolerate the long interview time. The patients should also receive a MMSE test score equal to or greater than 25, which resulted in the exclusion of a number of patients with a psychiatric disorder, such as a psychotic disorder during the study.
According to our study, the prevalence of psychiatric disorders in patients with brain tumors was higher than the general population. Therefore, it seems necessary to pay attention to underlying causes such as brain tumors in the emergence of psychological symptoms, especially atypical and new occurrences. Considering the mechanisms that contribute to the development of psychological symptoms caused by tumors, more extensive studies are required to understand these mechanisms and identify pathophysiology of psychological symptoms in patients with brain tumors. Ethical statement This study was approved by the Research Council of the Faculty of Medicine and the Regional Ethics Committee under the code of 5/d/ 514602 at Tabriz University of Medical Sciences. An informed consent was also obtained from all participants in this research. Financial disclosure This study was financially supported by Tabriz University of Medical Sciences. CRediT authorship contribution statement Robabeh Farzaneh: Visualization, Investigation, Writing - review & editing. Ayyoub Malek: Conceptualization, Methodology, Project administration. Farhad Mirzaei: Resources, Supervision. Shahrokh Amiri: Data curation. Firooz Salehpour: Conceptualization, Resources. Ali Meshkini: Resources. Zahra Musavi: Investigation. Sara Farhang: Investigation. Saeed Dastgiri: Validation, Software. Ali Farzane: Formal analysis. Fatemeh Ghanbari: Writing - original draft. Declaration of Competing Interest The authors have no conflict of interest to be declared in this work. Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.npbr.2020.02.003. References Aboraya, A., Rankin, E., France, C., El-Missiry, A., & John, C. (2006). The reliability of psychiatric diagnosis revisited: The clinician's guide to improve the reliability of psychiatric diagnosis. Psychiatry (Edgmont), 3(1), 41. Journal of Medical Council of Islamic Republic of Iran25(4), 408–414. BJSVAS (Ed.). (2016). Kaplan & Sadocks comprehensive textbook of psychiatry(tenth edition). Philadelphia: Lippincott Williams & Wilkins. Filley, C. M., & Kleinschmidt-DeMasters, B. K. (1995). Neurobehavioral presentations of brain neoplasms. The Western Journal of Medicine, 163(1), 19. Gupta, R. K., & Kumar, R. (2004). Benign brain tumours and psychiatric morbidity: a 5years retrospective data analysis. The Australian and New Zealand Journal of Psychiatry, 38(5), 316–319. Madhusoodanan, S., Danan, D., Brenner, R., & Bogunovic, O. (2004). Brain tumor and psychiatric manifestations: A case report and brief review. Annals of Clinical Psychiatry, 16(2), 111–113. Madhusoodanan, S., Danan, D., & Moise, D. (2007). Psychiatric manifestations of brain tumors: Diagnostic implications. Expert Review of Neurotherapeutics, 7(4), 343–349. Madhusoodanan, S., Opler, M. G., Moise, D., Gordon, J., Danan, D. M., Sinha, A., et al. (2010). Brain tumor location and psychiatric symptoms: Is there any association? A meta-analysis of published case studies. Expert Review of Neurotherapeutics, 10(10), 1529–1536. Madhusoodanan, S., Ting, M. B., Farah, T., & Ugur, U. (2015). Psychiatric aspects of brain tumors: A review. World Journal of Psychiatry, 5(3), 273. Mainio, A., Hakko, H., Niemelä, A., Koivukangas, J., & Räsänen, P. (2011). Depression in relation to anxiety, obsessionality and phobia among neurosurgical patients with a primary brain tumor: a 1-year follow-up study. Clinical Neurology and Neurosurgery, 113(8), 649–653. Mohammadi, M.-R., Davidian, H., Noorbala, A. A., Malekafzali, H., Naghavi, H. R.,
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R. Farzaneh, et al.
DSM-IV (SCID). Surawicz, T. S., McCarthy, B. J., Kupelian, V., Jukich, P. J., Bruner, J. M., & Davis, F. G. (1999). Descriptive epidemiology of primary brain and CNS tumors: Results from the Central Brain Tumor Registry of the United States, 1990-1994. Neuro-oncology, 1(1), 14–25. Uribe, V. M. (1986). Psychiatric symptoms and brain tumor. American Family Physician, 34(2), 95–98. Wrensch, M., Minn, Y., Chew, T., Bondy, M., & Berger, M. S. (2002). Epidemiology of primary brain tumors: Current concepts and review of the literature. Neuro-oncology, 4(4), 278–299.
Pouretemad, H. R., et al. (2005). An epidemiological survey of psychiatric disorders in Iran. Clinical Practice and Epidemiology in Mental Health, 1(1), 16. Perkins, A., & Liu, G. (2016). Primary brain tumors in adults: Diagnosis and treatment. American Family Physician, 93(3). Sadock, B., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences. Walters Kluwer. Seddighi, A., Seddighi, A., Ashrafi, F., & Nohehsara, S. (2010). Neuropsychological disorders in patients with brain tumor. Iranian Journal of Cancer Prevention, 3(1), 42–47. Sharifi, V., Asadi, S., Mohammadi, M., AMINI, H., Kaviani, H., Semnani, Y., et al. (2004). Reliability and feasibility of the Persian version of the structured diagnostic interview for
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