B ritish Journal of Neurosurgery 1999;13(1):46± 51
ORIGINAL ARTICLE
Anxiety and depression in patients with an intracranial neoplasm
before and after tumour surgery
A-M. PRINGLE, R. TAYLOR & I. R. WHITTLE
Department of Clinical Neurosciences,Western General Hospital, Edinburgh, UK
Abstract
The aims of this prospective study were to investigate levels of anxiety and depression in patients with a solitary intracranialneoplasm before and after surgery, and to determine if relationships exist between high levels of anxiety or depression andthe hemispheric location of the tumour, the tumour type or patient gender. Patients aged between 17 and 79 years with asolitary intracranial neoplasm completed the Hospital Anxiety and Depression Scale (HAD) before and after biopsy orresective tumour surgery. A control group of non-brain-damaged subjects also completed the HAD before and after lumbarspinal surgery. Of the 109 patients with a brain tumour 30 and 16% demonstrated the likely presence of anxiety anddepression, respectively, according to HAD scoring criteria. A greater proportion of females with a left hemisphere tumourreported higher levels of emotional disturbance than any other group of patients; relationships between dysphasia and levelsof anxiety or depression were not signi® cant. Patients with a meningioma had higher levels of anxiety and depression asmeasured by the HAD than those with any other tumour types. Levels of both anxiety and depression were signi® cantlylower after tumour surgery according to the HAD. There were no signi® cant differences in HAD scores between (a) left andright hemispheric tumour groups, and (b) the tumour and control (n = 20) groups. This study has found that anxiety anddepression as measured by the HAD are relatively uncommon in patients with an intracranial neoplasm, and that levels ofmood disturbance do not differ signi® cantly from those in patients undergoing lumbar spinal surgery. Levels of anxiety anddepression become lower after surgery in patients with a brain tumour. Patterns of anxiety and depression in patients with abrain tumour appear to differ from those reported in stroke.
Key words: B rain tumour, Hospital Anxiety and Depression Scale, mood disorders.
Introduction
Disturbances of mood or affect have been identi® ed
as common sequelae of stroke and other brain
diseases.1 ± 3 In some stroke patients such disorders
may be severe, often occurring 6 months after stroke
and persisting for up to 2 years.1 A relationship
between location of stroke and mood change has
been demonstrated by some workers: patients with
left anterior strokes were identi® ed as predominantly
depressed, while patients with right anterior strokes
were often inappropriately cheerful or apathetic.1 ,4
In contrast little has been published on the relation-
ship between brain tumours and mood disorders.3 As
there are fundamental differences in the pathophysi-
ology and epidemiology of stroke and intracranial
tumours, there are also likely to be different neuro-
physiological and psycholog ical reactions in the
different patient cohorts.3 In addition, most stroke
stud ies have fo cused on depression while the
com m onest sym ptom of m ood d isturbance in
patients with an intracranial tumour may be anxiety.5
The aims of the present study were therefore to
evaluate prospectively levels of anxiety and depres-
sion as measured by the Hospital Anxiety and Depres-
sion Scale (HAD)6 in patients presenting with a
solitary supratentor ial intracranial neoplasm ; to
investigate the acute effects of tumour surgery on
these levels; and to determine whether hemispheric
location, type of tumour or patient gender were associ-
ated with type or extent of mood disturbance.
Methods
Patient cohort
Patients aged between 17 and 79 years, with a solitary
supratentorial intracranial tumour demonstrated by
CT or MRI were recruited following admission to
the Department of Clinical Neurosciences (DCN).
Language function was assessed as par t of an
additional study. Exclusion criteria were: ® rst language
Correspondence to: Dr A-M. Pringle, Department of Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh EH42XU, UK.
Received for publication 8th June 1998. Accepted 30th June 1998.
0268-869 7/99/010046 ± 06 $9.50 ½ The Neurosurgical Foundation
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not English; uncorrected impairments of hearing and
vision; or past medical history of psychiatric disorder,
alcoholism, head injury or other known brain disease.
Patien ts were a lso excluded if they were not
sufficiently well to cope with formal testing. The
cohort was essentially a consecutive series of brain
tumour patients with no apparent selection bias.
Tumour neuropathology was categorized according
to the WHO classi ® cation.
Twenty non-brain-damaged patients admitted for
elective lumbar spinal surgery were also assessed to
provide a measure of psychological reaction to the
stress of admission and operation. These control
subjects were matched for age and educational level.
The study was approved by the appropriate ethics
committee, and all patients and subjects gave written
consent to participate.
Mood assessment
The HAD was used to evaluate mood. It was designed
for use in non-psychiatric hospital departments to
screen for both anxiety and depression. By eliminating
questions relating to physical disorder the authors of
the HAD attempted to obtain a relatively `pure’ mood
score uncontaminated by pr imary symptoms of
physical illness (which can overlap with physical
symptoms of depression and anxiety). The instruc-
tion to patients to complete the questionnaire with
reference to how they have been feeling in the past
week is particularly appropriate to the patient group
in the study who have often been aware of impending
brain surgery and having a potentially life-threatening
condition for only a short period of time. Fourteen
items are included, seven of which relate to anxiety
and seven to depression. According to the authors’
guidelines a score of less than 8, between 8 and 10,
and higher than 10 on each scale were taken to
indicate, respectively, the probable absence, the
possible presence, and the probable presence of
anxiety or depression. Questionnaires were completed
prior to tumour biopsy or resective surgery when
language function was also being assessed, and before
and after lumbar spinal surgery in the control group.
Scores were recorded for both anxiety and depres-
sion. Data were not recorded for patients whose
language comprehension was found during testing to
be too impaired to permit reliable completion of the
scale. Where dyslexic difficulties prevailed each item
was read aloud to the patient and where language
difficulties were severe the HAD was not used. This
was not thought likely to skew results greatly as only
six patients were excluded on the grounds of severe
comprehension de® cit.
Statistical analysis
Paired and unpaired t-tests, and Pearson r correla-
tions were used as appropriate.
Results
Patients
Between September 1992 and June 1995, 109 patients
completed the HAD before biopsy or resection of an
intracranial tumour. Patients were assessed a mean of
6.7 days (median 7 days) after radiological diagnosis
of an intracranial neoplasm . The majority were
receiving dexamethasone (mean 8.1 mg/day). Of these
109 patients, 56 had a left and 49 had a right
hemisphere tumour.The HAD scores of four patients
which could not be localized by hemisphere were
omitted from the analysis of possible relationships
between emotional disturbance and hemispheric loca-
tion. Neuropathological diagnoses included 32 glio-
blastoma muliforme (GBM), 22 anaplastic astrocytoma
(AA) or anaplastic oligodendroglioma (AO), 14 astro-
cytoma or oligodendroglioma, 17 meningioma and
20 metastatic tumours.Two patients had a pineoblas-
toma and one each had a craniopharyngioma and
glioneuronal hamartom a. Following surgery, 94
patients were reassessed on the HAD. Of the 15 who
were not reassessed the clinical condition of ® ve
patients had deteriorated markedly after surgery; four
patients were lost to follow-up; three patients failed
to return their HAD questionnaires; two patients did
not have the planned surgical intervention and were
therefore assessed on only one occasion; and one
patient refused to complete the HAD after surgery.
The second assessment was conducted prior to
discharge, usually 7 days after initial evaluation.
Preoperative HAD scores in patients with a supratento-
rial intracranial neoplasm
The ® ndings on the HAD scale for anxiety are shown
in Table I. Fifty-one per cent of the cohort had scores
suggesting no signi® cant anxiety (i.e. 0 ± 7); 19% were
possibly anxious (8± 10); and 30% were probably
anxious (11 or more). Mean scores for depression are
shown in Table II. Sixty-six per cent of patients had
scores suggesting no signi® cant depression; 18%
obtained scores indicative of possible depression; and
16% had scores suggesting the likely presence of
depression.
A greater number of female patients obtained scores
indicating the probable presence of either anxiety or
depression, with the group of female patients with a
tumour of the left hemisphere containing the highest
percentage of patients demonstrating possible or likely
mood disturbance. As a group, female patients had
signi® cantly higher scores for anxiety, depression and
total HAD score (all p < 0.001) compared with males.
However, when tumour laterality was included in the
gender analysis only females with a left-sided tumour
had higher levels of anxiety, depression and total HAD
score (all p < 0.001) than males. The differences
between male and female patients with a tumour of
the right hemisphere did not reach signi ® cance for
any HAD score.
Anxiety and depression in intracranial tumours 47
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Patien ts w ith a m en ing ioma obtained higher
scores for both anxiety and depression than groups
of patients with other types of brain tumour (Table
III), desp ite there being no difference between
groups in the length of time between initial scans
and diagnosis (a mean of 6.6 days, median 7 days,
for patients with a glioma; mean 7.1 days, median 6
days, for patients with a meningioma), and preop-
erative assessment. The majority of patients with
a m en ing iom a were fem ale (1 2 out o f 17).
Mean anxiety and depression scores obtained by
patients with a glioblastoma were higher than those
obtained by patients with either anaplastic glioma,
low grade glioma or cerebral metastases, but were
not high enough to indicate probable emotional
disturbance.
The HAD scores did not correlate signi® cantly
with steroid dosage at initial assessment. There was
also no signi® cant correlation between any language
score (Aphasia Quotient and Language Quotient
derived from the Western Aphasia Battery7 or the
score for word ® nding obtained from the Boston
Naming Test8 and anxiety, depression or HAD total
at initial assessment.
TABLE I. Mean HAD scores and numbers of patients (also shown in percentages) whose scores indicate probable absence(score <8), possible presence (score between 8 and 10) or probable presence of anxiety (score >10) prior to surgery for asolitary supratentorial intracranial neoplasm. The scores of four patients with midline or central tumours have been omittedfrom the analysis according to side of lesion
Mean(SD)
Probable absence(% of total)
Possible presence(% of total)
Probable presence(% of total)
Whole group (n = 109) 8.3 55 21 33
(4.7) (51%) (19%) (30%)
All left hemisphere (n = 56) 8.7 28 10 18(5.0) (50%) (18%) (32%)
All right hemisphere (n = 49) 7.9 26 9 14
(4.6) (53%) (18%) (29%)All male patients (n = 62) 6.8 40 13 9
(4.0) (64%) (21%) (15%)
All female patients (n = 47) 10.3 15 8 24(4.9) (32%) (17%) (51%)
Male left hemisphere (n = 33) 6.7 22 8 3
(3.8) (67%) (24%) (9%)Female left hemisphere (n = 23) 11.7 6 2 15
(5.0) (26%) (9%) (65%)
Male right hemisphere (n = 28) 7.0 17 5 6(4.4) (61%) (18%) (21%)
Female right hemisphere (n = 21) 9.0 9 4 8
(4.8) (43%) (19%) (38%)
TABLE II. Mean HAD scores and numbers of patients (also shown in percentages) whose scores indicate probable absence(score <8), possible presence (score between 8 and 10) or probable presence of depression (score >10) prior to surgery fora solitary supratentorial intracranial neoplasm. The scores of four patients with midline or central tumours have beenomitted from the analysis according to side of lesion
Mean(SD)
Probable absence(% of total)
Possible presence(% of total)
Probable presence(% of total)
Whole group (n = 109) 5.6 72 20 17
(4.1) (66%) (18%) (16%)
All left hemisphere (n = 56) 6.0 36 8 12(4.4) (64%) (14%) (22%)
All right hemisphere (n = 49) 5.2 34 10 5
(3.9) (69%) (21%) (10%)All male patients (n = 62) 4.4 49 6 7
(3.8) (79%) (10%) (11%)
All female patients (n = 47) 7.3 23 14 10(4.0) (49%) (30%) (21%)
Male left hemisphere (n = 33) 4.5 26 2 5
(4.1) (79%) (6%) (15%)Female left hemisphere (n = 23) 8.2 10 6 7
(4.0) (44%) (26%) (30%)
Male right hemisphere (n = 28) 4.4 22 4 2(3.5) (79%) (14%) (7%)
Female right hemisphere (n = 21) 6.2 12 6 3
(4.2) (57%) (29%) (14%)
48 A-M . Pringle et al.
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Postoperative HAD scores in patients with a supratento-
rial intracranial neoplasm
At the time of second assessment following either
stereotactic biopsy, or craniotomy and resection of
intracranial tumour there were reductions in levels of
both anxiety and depression, in both males and
females, whether they had left (anxiety: p < 0.001;
depression: p = 0.001) or right (anxiety: p = 0.004;
depression: p = 0.028) hemispheric tumours. Scores
obtained by patients who had tumour biopsy did not
differ signi® cantly from those who underwent crani-
otomy and tumour resection. After surgery there were
reductions in the percentages of patients with likely
anxiety (30 to 16%) and depression (16± 6%), and in
mean daily dexamethasone dosage (preoperative:
8.1 mg/day; postoperative: 1.4 mg/day; p < 0.001).
Change in HAD scores (from ® rst to second assess-
ment) did not correlate signi® cantly with change in
steroid dosage.
HAD scores prior to elective lumbar spinal surgery
The presurgery HAD scores obtained by the control
group for anxiety and depression are shown in Tables
IV and V, respectively. The majority of subjects
obtained scores suggesting either probable absence
or possible presence of emotional disturbance before
surgery.There were no signi® cant differences in scores
between the control group and any of the patient
groups. The differences in both anxiety and depres-
sion that were present between male and female
tumour patients is not apparent in the control group,
although the size of the latter group is substantially
smaller. Postoperative HAD scores did not differ
signi® cantly from scores obtained at initial assess-
ment.
Discussion
This study has assessed anxiety and depression using
the HAD Scale in a cohort of inpatients awaiting
cranial tumour surgery. The HAD was chosen for the
reasons outlined in the methods section and is, in
addition, easy and quick to administer and can be
used in patients with a dominant hem ispher ic
neoplasm even though approximately half may have
some language impairment.9 ,1 0 It is an index of how
the patient felt in the past week: in many of these
patients the radiological or clinical diagnosis was not
known at the time of ® rst assessment, but the patients
wou ld undoubted ly have been aware of the ir
symptoms and the possible implications of these.
Using an extensive, structured interview to assess
mood would have been inappropriate in this cohort
as the mood disorder assessment was only a small
pa r t of a large r s tudy invest igat ing langua ge
disorders in brain tumour patients.9 ± 1 2 Addition-
ally, as items in the HAD assess fatigue or `feeling
slowed down’ , and inability to enjoy activities, which
may frequently be endorsed in medically ill patients,
one might have expected a slight bias towards high
rather than low HAD scores.
Given the above constraints and limitations, this
study has demonstrated that, according to HAD
scoring criteria, relatively low levels of either prob-
able anxiety (30%) or probable depression (16%) are
found in patients with a solitary supratentorial intrac-
ranial neoplasm admitted to a clinical neuroscience
depar tment and that their HAD scores did not differ
signi® cantly from a group of patients admitted to the
same department for elective lumbar spinal surgery.
It has been estimated that between 9 and 19% of the
general population could be diagnosed as actual or
borderline cases of psychiatric disorder.13 Although
TABLE III. Preoperative HAD scores for 109 patients with a solitary supratentorial tumour according to tumour type
GBM(n = 32)
AA or AO(n = 22)
Glioma(n = 14)
Mening(n = 17)
Metast(n = 20)
Others(n = 4)
Mean anxiety 8.7 7.6 5.7 11.2 7.4 9.8Range of scores 1± 19 11± 18 1± 9 2± 19 2± 17 6± 14Mean depression 5.8 4.2 4.1 7.9 5.2 7.0Range of scores 0± 15 0± 13 0± 10 0± 14 1± 14 1± 11
Abbreviations: GBM = glioblastoma; AA = anaplastic astrocytoma; AO = anaplastic obligodendroglioma; glioma= astro-cytoma, oligodendroglioma or mixed oligoastrocytoma; Mening = meningioma; Metast = cerebral metastasis; other =craniopharyngioma, glioneural hamartoma and pineoblastoma.2
TABLE IV. Mean HAD scores obtained prior to elective lumbar spinal surgery for 20 control subjects whose scores indicateprobable absence (score <8), possible presence (score between 8 and 10) or probable presence of anxiety (score >10)
Mean (SD) Probable absence(% of total)
Possible presence(% of total)
Probable presence(% of total)
All control group (n = 20) 7.9 10 6 4(3.9) (50%) (30%) (20%)
Male control group (n = 10) 7.4 4 4 2(3.1) (40%) (40%) (20%)
Female control group (n = 10) 8.3 6 2 2(4.7) (60%) (20%) (20%)
Anxiety and depression in intracranial tumours 49
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such ® gures will depend on the assessment measures
used, the patients in this study appeared to be remark-
ably well-adjusted emotionally. A plausible interpreta-
tion of these results is that since the diagnosis of
brain tumour was very recent at the time of initial
HAD assessment emotional reaction to the diagnosis
may not have had sufficient time to evolve.
Female patients with an intracranial tumour had
higher levels of anxiety and depression than male
patients, and females with a left-sided intracranial
tumour obtained higher HAD scores than females
with right sided tumours. Although these ® ndings are
similar to those reported by Irle and colleagues3 it is
surprising that such disparity should exist between
male and female patients with a tumour of the left
hemisphere when HAD scores were relatively similar
for males and females with a right hemispheric
tumour, and the male and female subjects in the
control group. It might be expected that dysphasic
patients would experience greater levels of emotional
distress than those with normal language. In this
study, however, using assessments administered at
the same time pre- and postoperatively as the HAD,
language ability in the female patients did not differ
signi® cantly from that of the males and, in fact, the
trend was for language function in the male group to
demonstrate slightly greater impairment. In addition,
correlational analysis did not identify signi® cant
relationships between HAD and language scores, in
contradiction of the ® ndings of one study of stroke
patients which demonstrated a relationship between
acute aphasia and depression.4 A number of patients
with a right-sided intracranial tumour had been
diagnosed as depressed by their general practitioner
prior to admission and tumour diagnosis. In view of
the low levels of depression identi® ed using the HAD,
it is likely that the preliminary clinical diagnosis of
depression had been in¯ uenced by observation of the
signs of disordered non-verbal communication, such
as reduced facial expression, few alterations in intona-
tion and poor eye contact, which often accompany
right hemisphere disease.14 ± 16 These clinical observa-
tions are also at variance with indications that patients
with a left-sided anterior stroke may be depressed,
while those with a right anterior stroke may be inap-
propriately cheerful or apathetic.1 ,4 Findings con-
cerning mood disorders in stroke are often
contradictory, however, as House and colleagues17 did
not ® nd any link between mood symptoms and
hemispheric location of the stroke and concluded in
another large study1 8 that undue emphasis had been
placed on mood disorders that largely resolved after
12 months. Variations in ® ndings of mood disorders
in brain disease may also be in¯ uenced by the applica-
tion of different assessment and diagnostic criteria,
where patients displaying episodic emotionalism or
lability are categorized as depressed in one series of
studies but not in another. Differences in patient
selection, particularly as regards ratios of hospital
inpatients to outpatients18 may also bias results in
different series.
The type and grade of tumour did not have as
much impact on preoperative HAD scores as might
be expected. Paradoxically, patients with the most
favourable prognosis, i.e. those with a meningioma,
appeared to demonstrate the highest levels of both
anxiety and depression. It is possible that the relatively
high ratio of female patients with a left hemispheric
meningioma might have had some impact on the
mean scores as there was no other obvious difference
between patients with a meningioma and those with
a glioma in the length of time intervening between
diagnosis and preoperative HAD assessment, or in
the neurosurgical and nursing staff involved in patient
care. The lack of correlation between language and
HAD scores does not suggest any systematic relation-
ship between level of distress and (i) frustration caused
by language disturbance or (ii) lack of insight as a
component of mental impairment.
Following surgery there were signi® cant reduc-
tions in the levels of anxiety and depression as
measured by the HAD in patients with an intracra-
nial tumour.This is somewhat surprising as over 67%
of patients in the brain tumour cohort would have
been informed that they had a malignant intracranial
tumour. Again, it is possible that the diagnosis of
brain tumour was too recent at the time of re-
assessment for emotions to have had sufficient time
to evolve. Irle et al.3 showed that depressive states
emerged in some oncological patients either during
radiotherapy or at home several weeks after diagnosis.
Nonetheless, in a separate study of mood disorders
in brain tumour patients undergoing chemotherapy,19
few patients obtained HAD scores suggestive of
possible or likely mood disorders despite their
questionnaires being completed in the knowledge that
TABLE V. Mean HAD scores obtained prior to elective lumbar spinal surgery for 20 control subjects whose scores indicateprobable absence (score <8), possible presence (score between 8 and 10) or probable presence of depression (score >10)
Mean (SD) Probable absence(% of total)
Possible presence(% of total)
Probable presence(% of total)
All control group (n = 20) 5.6 14 4 2(3.0) (70%) (20%) (10%)
Male control group (n = 10) 4.7 8 1 1(3.2) (80%) (10%) (10%)
Female control group (n = 10) 6.5 6 3 1(2.7) (60%) (30%) (10%)
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the disease had recurred. Patients with likely mood
disorders as assessed by the HAD were also in the
minority amongst a brain tumour group being treated
with radiotherapy.19 A link has been identi® ed in
studies of other cancer groups between physical status
and psychological distress.20 ,2 1 Persistent pain or
physical disability was relatively uncommon among
the patients in the present study, perhaps contributing
to the relatively low HAD scores.
Response bias is a recognized problem with self-
rating scales such as the HAD; therefore, it must be
acknowledged that some patients may have opted for
socially acceptable rather than accurate responses,
possibly in¯ uencing reported levels of mood distur-
bance in the whole group or in subgroups of patients.
Patients were usually well prepared by medical and
nursing staff in advance of treatment; it is likely that
explanation and discussion would have contributed
to a reduction in apprehension during the inpatient
stay. In general, however, the patients with an intrac-
ranial tumour in this study demonstrated very little
disturbance of mood as assessed by the HAD in the
perioperative period, with scores for anxiety and
depression very often within normal limits.
Acknowledgements
This study was supported by a grant from the
Disability and Continuing Healthcare Committee of
the Scottish Office.
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