To our best knowledge, this study is the first to investigate symptoms of anxiety and depression in patients with low-grade meningiomas (WHO Grade I or II) using a mixed-methods design. Our study captured quantitative data to assess the prevalence of mild and clinically relevant symptoms of depression and anxiety and complemented this with rich qualitative data from semi-structured interviews, allowing for comprehensive analysis of patient mental health. Our findings demonstrate that patients with low-grade meningiomas experience many of the same challenges as individuals with high-grade tumors, especially in the short term; thus, they may share similar needs and suffer from similar psychologic and psychiatric morbidity.
Prevalence and intensity of anxiety and depression
The prevalence of anxiety amongst the cohort was 40% (n = 12). It is difficult to compare point prevalence with lifetime or annual prevalence, metrics often cited in literature; however, our findings suggest a greater prevalence of depression and/or anxiety than compared to the general Canadian population, whose prevalence of generalized anxiety and/or major depression ranges from 9.4% to 11.3% . Further broken down into anxiety and depression, we observed a prevalence of 40% (n = 12) for anxiety and 6.67% (n = 2) for depression.
Analysis of anxiety in patient cohort
We found that 50% (n = 8) and 28.6% (n = 4) of participants within the WW and Surgery subgroups, respectively, demonstrated moderate/high HADS anxiety scores (> 7). These values are well above the annual and lifetime prevalence of generalized anxiety in Canada, which, according to the Statistics Canada Canadian Community Health Survey on Mental Health (CCHS-MH), are 2.6% and 8.7% respectively . This finding confirms what others have shown; despite their benign nature, meningiomas are associated with significant psychiatric comorbidity, specifically symptoms of anxiety [5, 19]. The prevalence of anxiety amongst our cohort is also comparable to levels described in malignant tumor patient cohorts [5, 8, 11, 30, 31]. However, studies that compared the difference in prevalence of anxiety over time between malignant and benign brain tumor patients have found that, amongst meningioma patients, rates of anxiety decrease and normalize within 5 years [19, 32]. Overall, our findings are in accordance with the literature, and describe rates of anxiety similar to those suffered by malignant brain tumor patients around the period of initial diagnosis [30, 33].
Interestingly, there was no significant difference in the mean HADS anxiety scores between the Surgery and WW subgroups. This finding could suggest three important points: (1) in patients with slow-growing tumors, curative treatment may not be the driving factor influencing improvements in mental and emotional well-being; (2) the benefits of curative surgery on anxiety may be counteracted by the detrimental effects of post-operative recovery, healing, and residual deficits; and (3) the watchful waiting approach may be associated with significant stress and psychiatric co-morbidity over time, despite only being implemented for cases with favourable prognoses.
Analysis of depression in patient cohort
The prevalence of depression in the Surgery and WW subgroups were 7.14% (n = 1) and 6.25% (n = 1), respectively. These scores indicate a potentially higher burden of depression in patients with low-grade meningiomas than in the general Canadian population, where the annual prevalence of depressive episodes has been determined to be approximately 5% [29, 34]. Our findings are in line with previous data published by Goebel and Mehdorn , who described a prevalence of depression of 8% in their meningioma patient study cohort.
While there is consensus that rates of depression are higher in patients with intracranial tumors than the general population—ranging as high as 38%—data comparing differences between tumor grade is less uniform [9, 10, 30, 34]. Pringle et al.  found that patients with meningiomas had higher depression scores when compared to patients with high-grade tumors; conversely, several studies have shown the opposite [8, 9, 11]. These inconsistencies may reflect the effect of time on patients’ mental health throughout their treatment course. There may be a peak in the rate of depressive symptoms in patients with meningiomas around the time of diagnosis, pre-operatively and perioperatively, as reported by Bommakanti et al.  and Simoca et al. . This peak in symptoms was followed by an improvement in depression scores post-operatively [36,37,38]. This contrasts with findings discussed by D’Angelo et al.  and Litofsky et al. , who demonstrated an increase in prevalence of depression over time in high-grade tumor patients [7, 33]. Our findings are congruent with other studies demonstrating stable depression levels over time in meningioma patients . Moreover, our analysis did not reveal any significant difference in the prevalence of depression or mean depression scores when comparing the Surgery and WW subgroups. Our findings suggest that in patients with meningioma, symptoms of depression are caused not only by the mere presence of the tumor, and that struggles during recovery and the management of lingering symptoms following surgery may mask any benefit of cure on rates of depression.
Emergent themes from patient interviews
Positive impacts on patient well-being
In our study, factors that tended to contribute to a positive patient experience and mental well-being included personal resilience and strong social support. This is unsurprising, as resilience has been noted to play an important role in the restoration of physical and emotional well-being in cancer patients and has been thought to be associated with the adoption of coping strategies that improve quality of life [39,40,41]. Social support is a major contributor to resilience, and there is substantial evidence that it is essential for maintaining both physical and psychological health . Interviewed participants expressed immense gratitude for the emotional support of friends and family. Nonetheless, it was indicated that there was occasionally a lack of understanding or empathy from these support figures, suggesting a role for peer support . Participants indicated that talking to others with analogous experiences would be helpful . Prior studies have found that the sense of camaraderie and kinship that develops from peer support intervention increases hope, decreases loneliness, and encourages a positive change in perspective and values [44,45,46].
Negative impacts on patient well-being
Uncertainty, lack of support from the healthcare system, and managing difficulties during recovery contributed negatively to patient well-being. Uncertainty has been shown to be detrimental to health-related quality of life in patients with high-grade brain tumors; our study supports the conclusion that uncertainty is also a major contributor to stress and anxiety in patients with benign tumors [47, 48]. All patients also reported a period of adjustment to physical and cognitive deficits. Acceptance of the “new normal” was associated with a better self-rated mental health. The acknowledgement of overcoming a life-defining event such as a meningioma diagnosis significantly improves self-perception and decreases anxiety; however, prolonged deficits may hamper this self-perception of strength and resilience .
Impact of time on well-being
Time was an overarching factor that played a dynamic role in the patient experience. Most pertinently, the amount of time that had passed since diagnosis was an important factor in the patients’ well-being. While the quantitative results did not reveal a significant difference in HADS scores as a function of time since diagnosis, interviewees reported having an initial period during recovery that was both physically and emotionally challenging. Previous reports have shown that objective measures of anxiety decrease over time in meningioma patients who have undergone resection, and this was reflected in our interviews [19, 49].
Implications for clinical practice and health systems planning
Several suggestions for improving future clinical practice and health systems planning can be inferred from the results of this study. Firstly, peer support should be offered to patients early on in diagnosis. Linking individuals to established programs would prove beneficial at the patient level and may be instituted practically at a systems level, rather than establishing small-scale supports unique to each hospital. Participants indicated that this support would be most useful early on after diagnosis, but it would likely also be helpful in promoting optimism and overcoming difficulties during recovery. Additionally, individualized care and subsequent tailoring of resources should be emphasized by physicians. The creation and dissemination of health literate and plain language resources should also be a goal. Going forward, well established metrics already used by many cancer treatment centers, such as the Hospital Anxiety and Depression Scale, could be implemented into care plans. As rehabilitation services are paramount to recovery, access to these resources—particularly in the outpatient setting—should be secured for all patients who require them. Finally, despite the lack of prolonged clinical anxiety or depression, we found that patients often experienced a period of emotional difficulty for several months after resection, and patients should be made aware of this possibility.
Our study was a retrospective analysis with a small sample size, which impedes the generalizability of findings and may influence assessment of the study’s outcome measures. Furthermore, the study was completed at a single center with patients under the care of a single surgeon. The patient experience may differ at other centers and thus impact the accuracy of our results. In addition, HADS scores were collected at a single time-point during the patients’ follow-up, rather than at several points, precluding the opportunity to study changes in mental health status over time. Moreover, only one subset of patients with brain tumors was analyzed with no comparison to patients with higher-grade tumors, or to healthy controls. Recruiting both high-grade brain tumor and healthy control groups would highlight meningioma specific conclusions. Finally, larger cohorts are essential to decipher the impact of presenting symptoms, such as headache and visual deficits, on mental health.