Better MH Screening Urged Before Breast Augmentation

A recent review of six epidemiological studies examining outcomes in women who have breast augmentation surgery show that they have about twice the odds of committing suicide as women in the general population, prompting researchers to call for increased mental health screening of candidates before surgery.

“There may have been psychopathology in these women who committed suicide that went unrecognized by plastic surgeons at the time of the operation,” first author David Sarwer, Ph.D., told Psychiatric News in an interview.

“My colleagues and I believe that plastic surgeons, just like any other medical professionals, should complete a basic screening of psychiatric status prior to surgery” to screen for problems such as body dysmorphic disorder and depression, he continued.

Sarwer's review appeared in the July American Journal of Psychiatry. Sarwer is an associate professor of psychology at the Center for Human Appearance at the University of Pennsylvania School of Medicine.

The association between suicide and cosmetic breast augmentation was first identified not because researchers were looking for it, but because they were studying the causes of death among women who underwent the surgery. Silicone breast implants were removed from the U.S. market by the Food and Drug Administration (FDA) in 1992 due to health safety concerns related to the rupture of silicone-gel implants and the leaked silicone's potentially contributing to problems such as cancer and autoimmune disorders, according to Sarwer. In 2006 the FDA once again allowed silicone-gel implants to be used in the United States.

In 2001, in the first study to find an association between suicide and cosmetic breast augmentation, Louise Brinton, Ph.D., M.P.H., and colleagues at the National Cancer Institute reviewed the medical records of 13,488 women who received breast implants and 3,936 women who received other forms of cosmetic surgery.

At an average of 13 years after surgery, women who had received breast implants had more than twice the odds of committing suicide as women in the general population.

When in 2006 Brinton examined these samples again, she found that the highest risk of suicide was among women who had received breast augmentation at age 40 or older. “The risk of suicide increased after the first postoperative decade,” Sarwer noted in his review.

Two subsequent Scandinavian studies published in 2003 also noted an increase in suicide rates among women who had cosmetic breast augmentation, according to the report.

In the first, researchers reviewed death records of more than 3,500 Swedish women who had cosmetic breast augmentation between 1965 and 1993 and found that 15 committed suicide, whereas the expected suicide rate would have been 5.2 suicides, according to the study.

In the second study, researchers reviewed the death records of 2,166 Finnish women who received breast implants between 1971 and 2001; they found that 10 women had committed suicide, whereas only 3.13 suicide deaths would have been expected.

A 2004 study by Poul Jacobsen, M.D., and colleagues of more than 2,700 Danish women who had cosmetic breast augmentation between 1973 and 1995 found that they had three times the odds of committing suicide as women who had breast reduction surgery or other types of cosmetic surgery.

Jacobsen also found that 8 percent of women in the sample who had breast augmentation had a prior psychiatric hospitalization, compared with 4.7 percent who underwent breast reductions and 4.5 percent who underwent other cosmetic surgical procedures. That study appeared in the December 13/27, 2004, Archives of Internal Medicine.

According to Sarwer, this study provided the first link between breast augmentation surgery and a risk factor for suicide—a prior psychiatric hospitalization.

The largest study in Sarwer's meta review was conducted by Paul Villeneuve, Ph.D., and colleagues last year. Villeneuve compared the death records of a cohort of 24,558 Canadian women who underwent cosmetic breast augmentation between 1974 and 1989 with the death records of 15,893 women who underwent other cosmetic surgical procedures during that time frame.

The findings, which appeared in the August 2006 American Journal of Epidemiology, indicated that 58 women who had received the breast augmentation surgery committed suicide. Moreover, they had 1. 8 times higher odds of committing suicide than women in the general population.

Among those who had other types of cosmetic surgery, there were 33 suicides. These women had 1.6 higher odds of committing suicide than women in the general population.

Although the rate of suicide between women who had received breast implants and those who underwent other forms of cosmetic surgery did not differ, Villeneuve found that suicide risk was higher for women who had breast implants after turning 40 or who had had their implants for a longer time in comparison with the other cosmetic surgery groups.

Across the six studies, Sarwer noted, there were 126 suicides. Women who received breast implants had twice the odds of committing suicide as did women in the general population.

A number of factors could predispose women who receive breast implants to a greater risk of suicide, according to Sarwer.

Jacobsen's finding that women who underwent breast augmentation surgery had higher rates of psychiatric hospitalization than women who underwent breast reduction surgery or other cosmetic surgical procedures may suggest that there is more psychopathology among this group, he noted.

Some women who receive the surgery may have high levels of body-image dissatisfaction or meet criteria for body dysmorphic disorder (BDD), according to Sarwer, who noted that retrospective studies of those who had received cosmetic surgery found that more than 90 percent experienced either no change or a worsening of BDD symptoms after the procedures.

Another possibility is that women seeking breast augmentation have unrealistic expectations about the outcome of the surgery, he said. “If a woman is having the surgery because she is trying to save a failing marriage which ultimately ends in divorce anyway, the divorce could trigger a depressive episode that could potentially lead to suicide,” Sarwer noted.

In addition, studies have found that up to 25 percent of women who receive breast augmentation surgery may experience a postoperative complication such as leakage or rupture of the implant, which could lead to physical discomfort and depressed mood, for instance.

Sarwer recommended that plastic surgeons routinely screen women who are interested in cosmetic surgery for mental health problems to identify those who are inappropriate for the surgery. Each year, Sarwer attends the annual meeting of the American Society of Plastic Surgeons to conduct an instructional course on identifying psychiatric illnesses, such as BDD, among potential cosmetic surgery patients.

“We need to do a better job of identifying patients with psychiatric problems prior to surgery,” he noted.

“Cosmetic Breast Augmentation and Suicide” is posted at<ajp.psychiatryonline.org/cgi/content/164/7/1006>.▪