Loren Lipworth, ScD, Joseph K. McLaughlin, PhD, and colleagues analyzed data on 3,527 Swedish women. The women had voluntary cosmetic silicone breast-implant surgery an average of 19 years earlier.
"It appeared there was no excess risk of suicide in the first 10 years after receiving a breast implant," Lipworth tells WebMD. "But after that, the risk went up and continued to go up. There was a 4.5-fold risk for 10 years after surgery and a sixfold risk for 20 or more years."
The women also had a threefold higher risk of alcohol or drug dependence and an excess of drug/alcohol-related deaths from accident or injury.
Nobody is saying that silicon breast implants themselves make women commit suicide, although scientists cannot yet totally rule out that remote possibility, says Louise A. Brinton, PhD, MPH, chief of the hormonal and reproductive epidemiology branch of the U.S. National Cancer Institute.
"Probably this is not related to silicone toxicity, but we cannot entirely rule that out. It probably is more likely that it is an underlying psychological predisposition," Brinton tells WebMD.
Lipworth, along with every expert contacted by WebMD, agrees that the most likely explanation is that a small but substantial proportion of women seeking cosmetic breast implants have deep-seated psychological problems.
"What our data suggests to us is there is a subset of women choosing to get cosmetic breast implants who have psychiatric illness prior to implantation. This results in high risk of unnatural cause of death -- suicide and deaths related to alcohol dependence and drug abuse," says Lipworth, an assistant professor of medicine at Vanderbilt University, Nashville, Tenn.
The findings appear in the August issue of Annals of Plastic Surgery.
Plastic Surgery No Substitute for Mental Health Treatment
The current study isn't the first to find an increased risk of suicide after cosmetic breast augmentation surgery. Other studies too, show a link between breast implants and suicide.
Brinton led the first study to detect an increased risk of suicide in breast-implant patients.
"There could be a host of explanations," Brinton tells WebMD. "It could be these women have unrealistic expectations about how implants are going to change their lives. There could be complications of breast implants that affect quality of life. Or there could be underlying personality predispositions that lead both to seeking implants and to suicide. We can't tell which, although anecdotal evidence points to the third possibility."
Despite this link, it's clear that breast augmentation results in improved self-esteem for many women, notes Atlanta plastic surgeon Foad Nahai, MD, president of the American Society for Aesthetic Plastic Surgery.
"The flip side of this is a number of studies that show improvement in self-esteem and self-worth following breast augmentation. It has that effect, but it is not a substitute for mental health care," Nahai tells WebMD.
Sarwer, associate professor of psychology at the University of Pennsylvania's Center for Human Appearance, says any rise in self-esteem after breast augmentation cannot permanently offset underlying suicidal tendencies.
"I would not want to say breast implants fix this underlying predisposition to suicide," Sarwer says. "We do not say plastic surgery is a treatment for any kind of illness."
Psychological Screening for Women Seeking Breast Implants?
Sarwer has analyzed the research linking breast implants to suicide. He notes that the data come from silicone breast-implant safety studies. At the time researchers designed the studies, they were mainly looking for evidence of cancer and immune dysfunction.
The studies were reassuring about those worries. But when evidence of a suicide link emerged, it left researchers with very little information on the women's mental state and psychiatric history of psychiatric treatment.
What little evidence there is suggests that prior psychiatric hospitalization -- a major risk factor for suicide -- is disproportionately common among women who get cosmetic breast implants.
"Plastic surgeons need to do a better job of screening patients for psychological illnesses," Sarwer says. "My colleagues at the University of Pennsylvania and I have recently reviewed these findings, and we argue that plastic surgeons should evaluate the psychological status of all patients. If they encounter a patient in psychiatric treatment or with a history of psychiatric hospitalization, they should insist that those patients get a mental health consultation prior to surgery."
Nevertheless, Sarwer admits that there's too little evidence right now to develop specific screening guidelines. Lipworth agrees.
"I really don't know what screening would look like," she says. "We really need to describe these underlying disorders to know what to look for. So there is more work to be done before making recommendations."
Nahai, a leading plastic surgeon, says that plastic surgeons evaluate patients based on two major factors. The first is motivation for having the procedure.
"If a woman is getting breast implants to save a marriage, or they want to attract more men when they go into a singles bar, this isn't going to work," he says. "But if a woman is doing it for herself, for her self-esteem, and wants to look better in her clothes, we are seeing someone who is doing it for the right reasons."
The second factor is a woman's expectation.
"The key things are whether the patient has realistic expectations about the implants," Nahai says. "Does this patient understand that having her breasts enlarged is not going to change her life? Because it is only what she does with the change in appearance that can change her life."
Nahai also says it is the responsibility of the plastic surgeon to assess every patient.
"Frankly, most of the women who come in to see us for breast implants are on some sort of mood-elevating drug, and it becomes a little difficult to sort them out," he says. "Sometimes I ask them, 'Have you discussed this with your psychiatrist?' If I have a high level of suspicion that you may have a psychological problem, I will also ask the patient for permission to discuss this with your therapist and ask whether this is the right thing for you at this time of your life."
Lipworth, however, does not think that all plastic surgeons maintain Nahai's high standards.
"With over 300,000 women getting implants in the U.S. last year, I am not sure how much screening is going on," she says.