As suggested by the six epidemiological studies, there appears to be an association between cosmetic breast augmentation and suicide. The specific nature of this relationship, however, is unknown. It is at least theoretically possible that some biological characteristic of the breast implants may be contributing to neurological changes that lead to suicidal behavior. Nevertheless, most of the focus on understanding the relationship between cosmetic breast implants and suicide has fallen upon the psychological characteristics and preexisting psychopathology of the women.

Clearly, additional research is needed. The epidemiological investigations to date have provided only limited information on the psychosocial status of women with breast implants. As proposed by McLaughlin and colleagues, a case-control study within a large existing cohort of women with breast implants could provide an ideal comparison for the preoperative characteristics and related psychosocial variables that may differentiate between women who died by suicide and those who did not. Such studies would be difficult, if not impossible, to conduct without the use of medical data registries as are often found in European countries.

These studies would likely provide the best opportunity to determine if the increased suicide rate is associated with preoperative psychopathology. As part of the FDA’s recent decision to reapprove silicone breast implants, manufacturers are required to track and report on any suicides in their postmarket approval studies. These reports may provide additional information on the occurrence of suicide in women who receive breast implants.

Although numerous studies have investigated the preoperative characteristics and symptoms of psychopathology found in breast augmentation candidates, they typically have used substandard psychometric measures. Large prospective studies that include standardized assessment methods such as the Structured Clinical Interview for the DSM-IV are needed to most appropriately characterize the relationship between preoperative psychopathology and postoperative outcome. Use of other measures of suicide risk, such as hopelessness and suicidal ideation, also are warranted.

While we wait for additional research on the relationship between breast implants and suicide, the results of the existing studies should be considered in the clinical care of women interested in cosmetic breast augmentation. Given the popularity of the procedure, all of the psychiatric diagnoses are likely found within the patient population. With the exception of body dysmorphic disorder, there is a dearth of information on the relationship between preoperative psychopathology and postoperative outcomes. Furthermore, a relatively large body of research suggests that most women are satisfied with their postoperative outcomes and experience improvements in some psychosocial domains, particularly body image. As a result, there is currently little evidence to support a recommendation that all women who present for cosmetic breast augmentation be required to undergo a psychiatric evaluation before surgery.

Thus, the burden of screening for psychopathology falls to the plastic surgeon. As detailed elsewhere, plastic surgeons should assess three areas during the initial consultation: motivations and expectations, body image dissatisfaction and body dysmorphic disorder, and general psychiatric status and history.

As in any medical consultation, the plastic surgeon should assess a new patient’s mental health status and history. It is unclear if this is the current standard of care in plastic surgery. Ideally, such an assessment should include a general review of the patient’s presentation and demeanor but also should focus on disorders with a body image component, such as body dysmorphic disorder and eating disorders. The symptoms of mood disorders also should be assessed. An untreated mood disorder may contribute to the motivation for surgery (because patients may believe that they will feel better about themselves if they look better) as well as dissatisfaction with their postoperative results (likely as a result of unmet expectations). The risk of suicide is elevated in patients suffering from mood disorders, the development of which often precedes the suicide by several years, a finding that potentially may explain the elevated suicide rate in the epidemiological studies of women with breast implants.

In addition to assessing current mental health status, the treating surgeon should obtain a psychiatric treatment history as part of the patient’s general medical history. This should include directed questions about outpatient treatment, both psychopharmacological and psychotherapeutic, as well as psychiatric hospitalizations. Approximately 20% of cosmetic surgery patients report ongoing psychiatric treatment, most commonly pharmacological treatment with antidepressant medications, at the time of surgery. In cases in which the surgeon does not believe that the depressive symptoms are well controlled, referral for additional psychiatric assessment is warranted. This is consistent with the recommendation from the Institutes of Medicine for the management of medical patients with suicide risk factors.

Women who report a history of psychopathology and who are not currently engaged in mental health treatment warrant a preoperative psychiatric consultation to further assess their psychological status and appropriateness for breast augmentation. Patients currently in treatment should be asked if their mental health professional is aware of their interest in surgery. Surgeons should contact these professionals to confirm that breast augmentation is appropriate at the present time.

Given the popularity of cosmetic breast augmentation, psychiatrists and psychologists may encounter these women in a variety of contexts. Women in a general outpatient practice, particularly those with body image concerns, may be considering breast augmentation. A plastic surgeon also may ask a mental health professional to consult on a patient suspected of having some form of psychopathology.

As described in detail elsewhere, a general cognitive behavior assessment of patients’ current functioning is recommended. This assessment should focus on the thoughts, behaviors, and experiences that have contributed to their dissatisfaction with their breasts as well as the decision to seek breast augmentation. Like the plastic surgeon, the mental health professional also should focus on patients’ motivations for, and expectations about, breast augmentation, appearance and body image concerns, and their psychiatric status and history. The expertise of the mental health professional will allow for a more detailed assessment of these issues than will have been undertaken by the plastic surgeon, who likely will have completed only a rudimentary evaluation of patients’ psychiatric status.

In assessing motivations and expectations for breast augmentation, the mental health professional may want to begin by asking, “When did you first think about breast augmentation surgery?” In addition to providing important clinical information, this question may reveal the presence of some obsessive or delusional thinking. The role of patients’ social relationships in the decision to seek surgery also should be assessed. Breast augmentation patients typically report that their decision to seek surgery was influenced more by their own feelings about their appearance than by the thoughts of romantic partners. Patients who seek breast augmentation specifically to please a current romantic partner or to attract a new one are believed to be less satisfied with their postoperative outcomes.

Breast augmentation candidates typically report increased dissatisfaction with their breast size and shape compared to women not interested in seeking breast augmentation. Women who report significant dissatisfaction with average-sized breasts may be suffering from body dysmorphic disorder. The degree of emotional distress and behavioral impairment, rather than specific breast size, may be the better indicators of body dysmorphic disorder. Asking patients about the amount of time they spend each day thinking about their breasts, comparing the appearance of their breasts to other women, or researching breast augmentation surgery may reveal the presence of the obsessive thoughts typically seen in persons with body dysmorphic disorder. Inquiring about avoidance of social and sexual situations or the excessive use of clothing to camouflage the appearance of their breasts also may suggest the presence of a mood or anxiety disorder. Patients should be asked about symptoms of major depression, including suicidal ideation, past and present. If patients acknowledge current suicidal ideation, they should be asked about a current plan and potential intent. The provider also should inquire about a history of suicide attempts because it is one of the biggest risk factors for suicide.

The assessment of patients’ psychiatric history and status, as would be done in any mental health consultation, is a central part of the evaluation. As noted above, it is likely that all of the major psychiatric diagnoses can be found among women who seek cosmetic breast augmentation. The presence of a specific disorder, however, should not be judged as an absolute contraindication to breast augmentation. In the absence of sound data on the relationship between specific forms of psychopathology and surgical outcomes, appropriateness for surgery should be decided on a case-by-case basis and include close collaboration between the mental health professional and the plastic surgeon.

Until the relationship between breast implants and suicide is more fully understood, women interested in breast augmentation who report a history of psychopathology (particularly a history of psychiatric hospitalizations) or those who are suspected of having some form of psychopathology by the plastic surgeon should undergo a mental health consultation before surgery.

David B. Sarwer, Ph.D., Gregory K. Brown, Ph.D. and Dwight L. Evans, M.D.

Am J Psychiatry 164:1006-1013, July 2007
doi: 10.1176/appi.ajp.164.7.1006
American Psychiatric Association
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