Another brief comment on breast implants and suicide rates

The image at right is by artist Sheila Chambers entitled "Before Suicide"

It's funny the way the media seizes on medical issues sometimes. In late July, another analysis of suicide rates among breast augmentation patients was published and it generated enough attention to percolate thru most media services. This study was (I think) the 5th or 6th epidemiological study in the literature flagging breast augmentation as a risk factor for suicide. I wrote about this before here & here, discussing this issue in context to what we do know.


These kind of hyped stories about breast implants inevitably generate questions from patients in the week or two after they break. They're also siezed upon by activists in the breast implant debate as a priori evidence that implants are evil, predictably generating a slew of implausible theories about how breast implants must be causing ______ (cancer, autoimmune disease, suicide, global warming, etc.....)


In the July Annals of Plastic Surgery published a Swedish study titled, "Excess Mortality From Suicide and Other External Causes of Death Among Women With Cosmetic Breast Implants". Almost 3,527 women out of Sweden were followed from as far as forty plus years ago (1965-1993), and what was observed was that there's an increased risk of suicide in women, especially 10 years after the implant surgery.

How big are the numbers we're talking about? Of 175 deaths among study participants, 24 were suicides which was something like twice the expected 12 if you assume that this group was similar to the population as a whole. However, this group of patients is clearly NOT representative of the larger pool of women for risk factors for suicide. In fact, one researcher working "backwards" from suicide rates towards known risk factors suggested that in fact an expected 5x increase in suicide rates should have been observed and speculated that the surgery had actually lowered observed rates of suicide. I don't buy that neccessarily, but it's an interesting hypothesis.

So what are the problems with trying too read much into this if you're asserting some causal relationship?

1. The group of patients and cultural norms in 2007 are arguably different from a group of patients nearly 30-40 years ago. As surgery has become more "democratized" (ie. more people can afford it) and plastic surgery is more mainstream, I'd bet you'll see a dilution effect somewhat down the line as the % of high risk patients shrinks relative to the numbers undergoing the procedure.


2. These databases from (mostly) western Europe don't include patients who were implanted for breast cancer reconstruction or who had surgery done by non plastic surgeons. We have not observed increased rates of suicides in implant breast reconstructions.


3. The largest one of these kind of studies saw differences in suicide rate disappear when the control group was other cosmetic surgery patients rather then the population as a whole.


4. Several dozen large studies have failed to establish any clear mechanism for breast implants causing systemic disease. The United States, Canada, Great Britain, and the European Union have all reaffirmed their positions on this in the last 18 months.


5. These studies weren't designed to prospectively study suicide rates and offer few clues as to the nature of the relationship between breast implants and suicide.

Like several other studies in this area, they found problems with an increased number of women who were substance abusers, alcoholics and had underlying depression. In fact, they found almost a 3x greater rate of deaths attributed to alcohol or substance abuse, or attributed to accidents or injuries that could have been associated with alcohol or drug use.

What's a plausible "wild card" in the mix? Body dysmorphic disorder (BDD). Defined as a preoccupation with a slight or imagined defect in appearance that leads to significant psychological distress, BDD has been found in up to 5%–15% of all cosmetic surgery patients. These patients bring rates of suicidal ideation and suicide attempts that are 10x higher (or more) to the table.

Meredith Vieira discussed the study on the Today show last week with NBC's chief medical editor Dr. Nancy Snyderman who had an excellent summary of this study and how it's applied in day to day practice,

"Now, is this great science? No. Is there sort of an implied link? Maybe. But I don't think this is an indictment of plastic surgery and certainly not breast implants. It may be that if you'd roll back to the '60s when doctors really started doing a lot of these, they weren't screening patients so well. And if a woman has unrealistic expectations or she's psychiatrically not sound, she's not a good surgical candidate. And I think in 2007, you'll have doctors screen plastic surgery patients much differently than they did 30 or 40 years ago...

Good surgeons say no because they don't want problem patients on the back end. If you have a patient with unrealistic expectations, you're going to have a patient who will be unhappy with you forever and ever. And no surgical fee is worth that. So you look at the good--the good plastic surgeons, they're always trying to get the temperature of patients and what they expect, and they'll tell patients no"

Rob