brain tumors , either primary or metastatic , typically cause development of focal neurologic deficits such as hemiparesis , sensory deficit and aphasia . functional imaging studies have repeatedly reported abnormalities in the neural activation patterns in depressive conditions . these abnormalities provide compelling evidence that specialized frontal brain structures such as orbitofrontal cortex and medial prefrontal cortex underlie various cognitive and emotional functions with an implication in mood control , such as regulation of responses to aversive emotional experiences and interpretation of social and emotional cues . the frontal lobes of the brain are notoriously  silent  : benign tumors such as meningiomas that compress the frontal lobes from the outside may not produce any symptoms other than progressive change of personality and intellect until they are large . patients with such tumors are often referred first to psychiatrists , and the correct diagnosis may emerge only when the tumor has grown large and has begun to displace the brain . a 52-year - old male patient came to psychiatry outpatient department ( opd ) with a 1-month history of depressive symptoms . the condition was characterized by sadness of mood , fatigue , hopelessness , withdrawal from social activities and sleep disturbance . he met the international classification of diseases-10 ( icd-10 ) criteria for a major depressive episode ( depressive episode without psychotic features , icd-10 : f32.0 ) . the general physical , as well as neurological examination , showed no neurological deficit . he was prescribed tablet escitalopram 10 mg / day and asked for follow - up in psychiatry opd . even after 1-month , patient 's depression did not improve and he complained of headache . his wife also complained that he forgets things easily but patient showed relative lack of insight to these complaints . patient was advised contrast - enhanced computed tomography ( cect ) head and it showed an extraxial dural based well defined circumscribed lobulated mass involving bilateral frontal regions , which showed intense homogenous enhancement suggestive of frontal meningioma [ figure 1 ] . contrast - enhanced computed tomography head case 1 a 43-year - old married male patient came to psychiatry opd at rajindra hospital , patiala for consultation . for the last 2 months , patient had complaints of remaining sad for most of the day . patient visited a private psychiatrist and was diagnosed as a case of moderate depressive disorder without psychotic features ( f-32.1 as per icd-10 ) . patient 's condition did not improve , and he came to rh , patiala for consultation . the general physical , as well as neurological examination , showed no abnormality . on mental status examination , patient was advised cect head which showed a large extra - axial hyperdense mass measuring approx . the lesion showed heterogeneous enhancement with areas of necrosis in it suggestive of right frontal meningioma with malignant transformation [ figure 2 ] . a 52-year - old male patient came to psychiatry outpatient department ( opd ) with a 1-month history of depressive symptoms . the condition was characterized by sadness of mood , fatigue , hopelessness , withdrawal from social activities and sleep disturbance . he met the international classification of diseases-10 ( icd-10 ) criteria for a major depressive episode ( depressive episode without psychotic features , icd-10 : f32.0 ) . the general physical , as well as neurological examination , showed no neurological deficit . he was prescribed tablet escitalopram 10 mg / day and asked for follow - up in psychiatry opd . even after 1-month , patient 's depression did not improve and he complained of headache . his wife also complained that he forgets things easily but patient showed relative lack of insight to these complaints . patient was advised contrast - enhanced computed tomography ( cect ) head and it showed an extraxial dural based well defined circumscribed lobulated mass involving bilateral frontal regions , which showed intense homogenous enhancement suggestive of frontal meningioma [ figure 1 ] . a 43-year - old married male patient came to psychiatry opd at rajindra hospital , patiala for consultation . for the last 2 months , patient had complaints of remaining sad for most of the day . patient visited a private psychiatrist and was diagnosed as a case of moderate depressive disorder without psychotic features ( f-32.1 as per icd-10 ) . patient 's condition did not improve , and he came to rh , patiala for consultation . the general physical , as well as neurological examination , showed no abnormality . on mental status examination , patient was advised cect head which showed a large extra - axial hyperdense mass measuring approx . the lesion showed heterogeneous enhancement with areas of necrosis in it suggestive of right frontal meningioma with malignant transformation [ figure 2 ] . both cases represented depressive episodes due to a frontal lobe tumor without accompanying neurologic deficits . in case report 1 , cect head shows meningioma affecting bilateral frontal lobes arising near sphenoidal sinus which is a common site of origin of meningioma . in case report 2 , cect head shows meningioma with malignant transformation affecting right frontal region . intracranial tumors , notably frontal meningiomas , may present with psychological symptoms resembling depression , anxiety states , hypomania , and schizophrenia . psychiatric symptoms may be the only initial manifestations of meningiomas of the brain in a significant number of cases ( 21% ) occurring in the fifth decade of life . hence , when a middle aged person with no past history of psychiatric disorder , develops a slowly progressive psychological change , a frontal meningioma should be considered . headache , papilledema , and focal neurological signs may develop only when the tumor has reached an advanced stage . hunter et al . have reported cases of excitement and hallucinosis seen in association with a basal frontal lesion , and psychotic syndromes like hypomania and schizophrenia with tumor encroaching on the third ventricle and adjacent structures . the association between slow growing frontal lobe tumors , anosmia , and personality change is one of the most celebrated in behavioral neurology . cases such as ours emphasize the necessity for psychiatrists to remember that psychological symptoms may be a mode of presentation of organic disease of the brain . symptoms like headache , recent memory loss and relative lack of insight should warn about organic disease like frontal meningioma and thus brain imaging should be considered .
the frontal lobes of the brain are notoriously  silent  : benign tumors such as meningiomas that compress the frontal lobes from the outside may not produce any symptoms other than progressive change of personality and intellect until they are large . 
 we present two cases with symptoms suggestive of depressive episodes , which on further investigations showed space occupying lesions suggestive of frontal meningiomas .