Beyond Depression: Suicidality As the First Clue to a Silent Brain Tumor in the Elderly.
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Depression can be difficult to identify in the elderly due to the high prevalence of comorbid medical conditions and underlying neurological pathology. Consequently, there is a risk of diagnostic overshadowing in patients with pre-existing psychiatric or cognitive disorders. This case reports a woman with intellectual disability and a longstanding history of depression who developed sudden-onset fleeting suicidal ideation, initially attributed to the acute onset of a depressive episode. The dramatic appearance of suicidal thoughts was accompanied by regression to a childlike demeanor and an incongruent affect, prompting neuroimaging workup that revealed a large, centrally necrotic mass in the right temporal lobe. This case underscores the diagnostic challenges in distinguishing primary psychiatric illness from neuropsychiatric presentations of brain tumors, which can remain neurologically silent and present early on with psychiatric symptoms. It calls the attention of all clinicians to the importance of maintaining a high index of suspicion for organic etiologies in older patients with atypical psychiatric presentations.