The long-term risk of suicide is tripled for women who have undergone cosmetic breast implant surgery, according to a new study led by Loren Lipworth, Sc.D., of the International Epidemiology Institute in Rockville, Md, and the Vanderbilt University Medical Center, Nashville, Tenn. This long-term study further confirms the link between breast implants and a strikingly high risk of suicide and other related causes of death.

The increased suicide risk, together with a similar increase in deaths from alcohol or drug dependence, suggests that plastic surgeons should consider mental health screening and follow-up for women who seek breast implants, according to the new study.

Dr. Lipworth and colleagues performed an extended follow-up study of 3,527 Swedish women who underwent cosmetic breast implant surgery between 1965 and 1993. Death certificate data were used to analyze causes of death among women with breast implants, compared to the general female population.

At an average follow-up of nearly 19 years, the suicide rate was three times higher for women with breast implants, compared to the general population (based on 24 deaths among implant recipients). The risk was greatest—nearly seven times higher—for women who received their breast implants at age 45 or older. (The average age at breast implant surgery was 32 years.)

Suicide risk was not significantly increased for the first ten years after implant surgery. After that, however, suicide risk increased with time since surgery—risk was 4.5 times higher from 10 to 19 years' follow-up, and six times higher after 20 years.

Women with breast implants also had higher rates of death from psychiatric disorders, including a three-fold increase in deaths resulting from alcohol and drug dependence. Several additional deaths, classified as accidents or injuries, might have been suicides or involved psychiatric disorders or drug/alcohol abuse as a contributing cause. "Thus at least 38 deaths (22% of all deaths) in this implant cohort were associated with suicide, psychologic disorders, and/or drug and alcohol abuse/dependence," the researchers write.

There was no increase in the risk of death from cancer, including breast cancer, among women with breast implants. Increases in deaths from lung cancer and respiratory diseases such as emphysema likely reflected higher smoking rates among women with breast implants.

Several epidemiological studies have found an increased suicide rate among women with cosmetic breast implants. The current study provides extended follow-up data on a previous nationwide study of Swedish women with breast implants, more than doubling the number of deaths analyzed. The use of Swedish national health care and death certificate records ensures near-complete identification of women undergoing breast implant surgery and information on causes of death.

The increases in suicide and in deaths related to alcohol and drug dependence suggest that a "nontrivial proportion of women undergoing breast augmentation undergoing cosmetic breast augmentation may bring with them—or develop later—serious long-term psychiatric morbidity and eventually mortality," Dr. Lipworth and colleagues write.

Since the study includes only deaths, the true rates of psychological and substance abuse problems among women with cosmetic implants are likely much higher. The researchers conclude, "Such findings warrant increased screening, counseling, and perhaps postimplant monitoring of women seeking cosmetic breast implants."

In an invited discussion, David B. Sarwer, PhD, Associate Professor of Psychology at the University of Pennsylvania School of Medicine recommends that plastic surgeons assess the mental health status and history of women desiring breast augmentation. In addition to mood disorders such as depression, screening should focus on body image disorders, such as body dysmorphic disorder.

"In cases where the patient is currently in mental health treatment, the surgeon should contact the mental health professional to confirm that the patient is psychiatrically stable and appropriate for surgery at this time," Dr. Sarwer writes. "[U]ntil we know more about the relationship between breast implants and suicide, this conservative approach is recommended with both the patient's and surgeon's well-being in mind."