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Psychosomatics 45:277-280, August 2004
© 2004 The Academy of Psychosomatic Medicine

Perspective

Increased Risk of Suicide Among Patients With Breast Implants: Do the Epidemiologic Data Support Psychiatric Consultation?

Joseph K. McLaughlin, Ph.D., Thomas N. Wise, M.D., and Loren Lipworth, Sc.D.

Received Dec. 29, 2003; accepted Jan. 6, 2004. From the International Epidemiology Institute; the Department of Medicine, Department of Preventive Medicine, and Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, Tenn.; the Departments of Psychiatry, Inova Fairfax Hospital, Fairfax, Va.; and the Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore. Address correspondence to Dr. McLaughlin, International Epidemiology Institute, 1455 Research Blvd., Suite 550, Rockville, MD 20850; jkm{at}iei.ws (e-mail).

ABSTRACT

Four epidemiologic studies have examined mortality among women with cosmetic silicone gel-filled breast implants and have found that risk of death from suicide is two- to threefold higher in this group than among women of comparable age in the general population. The authors review the literature on the psychological and psychiatric hypotheses concerning women undergoing plastic surgery, although these hypotheses do not specifically address the association with suicide. Epidemiologic research is urgently needed to evaluate whether this association is an artifact of a higher prevalence of underlying and unreported psychopathology and other risk factors for suicide among women receiving breast implants or whether implants have an actual causal role in the risk of suicide. Until such studies are completed, psychiatric consultation should be considered before breast augmentation, especially for patients perceived to be at high risk by the plastic surgeon.

In the 23 years since publication of Goin and Goin's monograph on the psychological effects of plastic surgery,1 there has been a dearth of literature on emotional problems that occur before or after cosmetic procedures.2 An exception to this lack of research has been the growing number of studies of body dysmorphic disorder that indirectly suggest that individuals with this disorder may seek such surgery.3 Borah et al.4 found psychological complications to be more common than postoperative infections or hematomas in a cohort of patients who had undergone various cosmetic plastic surgery procedures. In an ideal situation, a consultation-liaison psychiatrist would evaluate such patients preoperatively, but in actual practice such evaluations happen infrequently.5 Recent interest in the safety of silicone gel-filled implants for breast augmentation has generally not included concern about the potential role of psychological factors in complications from this procedure. The following data suggest the need for increased attention to potential psychiatric risks before and after such surgery.

Four epidemiologic studies conducted in different countries have found that women with cosmetic silicone gel-filled breast implants have a higher rate of death from suicide than women of comparable age in the general population (Table 1).6–9 Overall, a total of 58 deaths from suicide were observed in the four studies, compared with the expected number of 25.2 deaths in the general population, yielding a significantly elevated relative risk of 2.3 (95% confidence interval=1.7–3.0). Before these epidemiologic studies of mortality among women with cosmetic breast implants, the literature had no case reports or anecdotal reports of suicide among women with breast implants. It remains unknown whether the higher risk of suicide among women with cosmetic breast implants reflects particular underlying psychiatric or other characteristics of these women or whether it represents a cause-and-effect relation.


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TABLE 1. Epidemiological Studies of Suicide Rates Among Women With Cosmetic Breast Implants, Compared With Expected General Population Suicide Rates



The prevalence and severity of psychiatric illness among women who seek cosmetic breast implantation has not been adequately studied, and the extent to which previous mental illness may explain the higher risk of suicide among these women remains unknown. Some reports have described body image concerns among women who seek breast augmentation,10 and some studies10–19 have indicated varying degrees of anxiety, low self-esteem, or preoperative depression, including severe depression or suicidal thoughts,12–15 in these women. However, the results of many of these studies are likely to have been affected by interviewer and/or respondent bias, since they were based on unstructured clinical interviews rather than standardized assessment. Recent reviews of the literature on the psychological characteristics of women who seek breast augmentation have found that the limited number of methodologically superior studies, which utilized standardized psychometric measures, showed little evidence of underlying psychopathology in these women.2,20 With respect to postoperative psychopathology, most reports have indicated high levels of satisfaction with the results of breast augmentation as well as improvements in psychological functioning.14,15,18,21–23 However, continued psychiatric instability after augmentation cannot be excluded,17,21 and immediate satisfaction with the effects of the operation may lessen over time.

The strongest risk factor for suicide, particularly among women, consistently appears to be a history of psychiatric diagnosis requiring hospital admission.24–28 A nationwide Danish study reported that more than 40% of the risk of suicide in the general population is attributable to a history of psychiatric admissions.29 Risk of suicide has been shown to be particularly high immediately after hospital admission for a psychiatric disorder, and a relative risk of 6.5 during the year after discharge has been reported.29 Moreover, in a registry-based study in Denmark, 66% of the people who died by suicide had contacted their physician within the last month before death and about 15% were discharged from a psychiatric or general hospital within the last month before death.30 Clearly, a valid epidemiologic study of suicide risk among women with cosmetic breast implants can be undertaken only by accounting for the preoperative history of psychopathology in those women.

The epidemiologic evidence regarding suicide among women with breast implants appears remarkably consistent, as is the strength of the general association between prior psychiatric illness and suicide. This evidence supports the need for preoperative psychiatric assessment of women who seek cosmetic breast augmentation. Psychiatric epidemiologic studies are needed to determine whether a history of psychiatric illness or other factors before breast augmentation surgery may place some women with cosmetic breast implants at high risk for suicide. Women who choose to undergo cosmetic breast implantation have also been shown to differ from women in the general population or women receiving other types of cosmetic surgery with respect to several demographic and lifestyle characteristics,31–34 including cigarette smoking, alcohol intake, marital status, and parity, which are likely to influence their risk of death from suicide.24,25,29,35–42 Thus, a valid psychiatric epidemiologic study will need to collect information on preimplant factors, including lifestyle characteristics, medication history, and psychiatric history, as well as information on psychiatric and other hospital admissions for illnesses related to risk of suicide both before and after implantation, including the dates and diagnoses for those admissions, and information on outpatient physician encounters immediately preceding the suicide. It would be valuable also to obtain psychiatric hospitalization histories for close relatives of study subjects in order to assess possible familial or genetic contributions.

Thus, consideration should be given to providing psychological screening for patients who request breast augmentation. Careful historical appraisal of past psychiatric symptoms and disorders should be considered part of any evaluation of such patients. Breast augmentation is currently the only cosmetic procedure for which there is strong epidemiological evidence of a link with suicide, and these findings raise the question of whether other cosmetic procedures may have psychosocial sequelae. Research on such issues is most effectively conducted through large, population-based studies rather than through studies with small samples. Because of privacy issues and fear of litigation, population-based investigations are difficult if not impossible to perform in North America, although such studies have been efficiently and validly conducted in Scandinavian countries that have a long tradition of high-quality registry-based psychiatric research and virtually complete follow-up of study subjects.43–46 Even in the absence of data, however, the consultation psychiatrist should have ongoing clinical collaboration with cosmetic surgeons.

In summary, valid etiologic studies are necessary and should be initiated to determine whether the higher risk for suicide observed among women with breast implants can be explained by preexisting (preimplantation) psychiatric conditions or illnesses or other preexisting risk factors, as well as to shed light on possible risk factors for suicide that may occur specifically among women seeking cosmetic breast implants. In addition, serious consideration should be given to providing psychiatric consultation for patients who are considered by the plastic surgeon to be at high risk for psychiatric disorder or suicide.

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