0
Original Investigation |

Mortality and Suicide Among Danish Women With Cosmetic Breast Implants FREE

Poul Harboe Jacobsen, MD; Lisbet R. Hölmich, MD; Joseph K. McLaughlin, PhD; Christoffer Johansen, MD, DMSc; Jørgen H. Olsen, MD, DMSc; Kim Kjøller, MD; Søren Friis, MD
[+] Author Affiliations

Author Affiliations: Department of Plastic Surgery, Private Hospital Hamlet, Copenhagen, and Department of Plastic and Reconstructive Surgery, Odense University Hospital, Odense, Denmark (Dr Jacobsen); Institute of Cancer Epidemiology, Danish Cancer Society, Copenhagen (Drs Hölmich, Johansen, Olsen, Kjøller, and Friis); Department of Plastic and Reconstructive Surgery, Herlev University Hospital, Herlev, Denmark (Dr Hölmich); International Epidemiology Institute, Rockville, Md (Dr McLaughlin); and Department of Medicine, Vanderbilt University Medical Center, Vanderbilt-Ingram Comprehensive Cancer Center, Nashville, Tenn (Drs McLaughlin and Olsen).


Arch Intern Med. 2004;164(22):2450-2455. doi:10.1001/archinte.164.22.2450.
Text Size: A A A
Published online

Background  Epidemiologic studies indicate that women with cosmetic breast implants have a significantly increased risk of suicide. Our objectives were to examine mortality among Danish women who underwent cosmetic breast implant surgery and to evaluate the baseline prevalence of psychopathological disorders as measured by admission to a psychiatric hospital among women seeking cosmetic surgery.

Methods  Cohort study of 2761 women who underwent cosmetic breast implant surgery at private clinics of plastic surgery or public hospitals, 7071 women who underwent breast reduction surgery at public hospitals, and 1736 women who attended private clinics for cosmetic surgery other than breast implantation, between 1973 and 1995. Causes of death through 1999 were identified through the Danish Mortality Files. Information on admission to psychiatric hospitals prior to cosmetic surgery was obtained from the Danish Psychiatric Central Register.

Results  Women with cosmetic breast implants had significantly elevated standardized mortality ratios (SMRs) for death overall (SMR, 1.4; 95% confidence interval [CI], 1.1-1.7), nonmalignant lung disease (3.4; 95% CI, 1.4-6.9), and suicide (SMR, 3.1; 95% CI, 1.7-5.2). Women who underwent breast reduction exhibited low SMRs for death overall (0.7; 95% CI, 0.7-0.8) and several specific causes, including breast cancer (0.4; 95% CI, 0.2-0.6), whereas death from suicide was moderately above expectation (SMR, 1.6; 95% CI, 1.0-2.5). The prevalence of psychiatric admission prior to cosmetic surgery was higher among women who underwent cosmetic breast implant surgery (8.0%; 95% CI, 7.0%-9.0%) than among women who underwent breast reduction (4.7%; 95% CI, 4.2%-5.2%) or other cosmetic procedures (5.5%; 95% CI, 4.5%-6.7%). When compared with all control groups, women with cosmetic implants had an odds ratio for prior psychiatric admission of 1.7 (95% CI, 1.4-2.0).

Conclusions  Danish women with cosmetic breast implants experienced higher overall mortality compared with women in the general population owing in part to a 3-fold increase in suicide. Women with breast reduction had a low total and cause-specific mortality but a moderate excess risk of suicide. For the first time, to our knowledge, we found evidence of an increased prevalence of mental illness as measured by admission to a psychiatric hospital prior to implant surgery among women receiving cosmetic breast implants. Studies are needed to clarify the underlying reasons for the consistently reported 2- to 3-fold excess of suicide among women with cosmetic breast implants.

The epidemiologic evidence to date does not support an association between silicone breast implants and specific diseases, including cancer, connective tissue disease, or neurologic disorders.16 However, recent studies suggest that women who have undergone cosmetic breast augmentation may have a different mortality pattern than women in the general population.79 In particular, a 2- to 3-fold excess risk of suicide has consistently been reported among women with cosmetic breast implants compared with the general population.10

Women with cosmetic breast implants differ from women in the general population with respect to several characteristics that may influence their mortality risks,1114 but specific reasons for the higher risk of suicide among these women have not been elucidated.10 It has been suggested that women with breast implants may have a more frequent history of mental illness than women in general15,16; however, published data on underlying psychopathological disorders among women seeking cosmetic breast implantation has been largely absent.10

In the present study, we report on cause-specific mortality among Danish women who underwent cosmetic breast implant surgery at private clinics of plastic surgery or public hospitals. For comparison, we also examined the mortality of women who underwent breast reduction surgery at public hospitals and among women who attended private clinics for reasons other than breast implantation. In an attempt to ascertain any underlying psychopathological disorders among women undergoing cosmetic surgery, we examined their preoperative history of hospitalization for psychiatric disorders using the unique Danish nationwide psychiatric register.

We previously identified 3 groups of women who underwent cosmetic breast surgery: 1653 women who received cosmetic breast implants at 8 private clinics of plastic surgery between 1973 and 1995, 1135 women who underwent cosmetic breast implant surgery at public hospitals between 1977 and 1992, and 7071 women who underwent breast reduction surgery at public hospitals between 1977 and 1992. From the files of the private clinics, we also identified a fourth study group consisting of 1736 women who attended the private clinics for cosmetic surgery other than breast implantation, matched on age (±3 years) and calendar year (±18 months) at procedure or consultation to the women who underwent breast implant surgery. The procedures in the latter group included breast reduction and mastopexy (23%), facial surgery (21%), skin excisions (21%), and liposuction (15%), while 19% had a consultation but no surgical procedure at the clinics. Details on the identification of the 4 study cohorts, including specific information on types of surgery and breast implants, have been described previously.1719

Information on mortality among the 4 study cohorts was obtained by linkage to the Danish National Mortality Files,20 which contains computerized records of all causes of death in Denmark since 1943. The linkage was performed by use of the personal identification number, a unique number assigned to all Danish residents since 1968 that encodes date of birth and sex. Follow-up for death began on the date of implantation, breast reduction or other treatment or consultation, and continued until date of emigration, date of death or December 31, 1999, whichever occurred first. The number of deaths in the standard cause of death categories observed among the cohort members was compared with the number of deaths expected among the general female population of Denmark. To obtain the expected number of deaths, female-specific death rates, calculated according to 5-year age groups and 1-year calendar periods, were multiplied with the corresponding person-years of the cohort members. The standardized mortality ratio (SMR), calculated as the ratio of the observed to the expected number of deaths, served as an estimate of relative risk, and 95% confidence intervals (CIs) were calculated based on the assumption that the observed number of deaths followed a Poisson distribution. We also calculated odds ratios (ORs) and 95% CI comparing the prevalence of prior psychiatric hospitalization among women with implants with that among the controls groups.

To identify preexisting psychopathological disorders among women seeking cosmetic breast surgery, we linked the 4 study cohorts to the files of the nationwide Danish Psychiatric Central Register.21 This register holds records on all admissions to psychiatric hospitals since April 1969. The admission record includes the hospital, hospital department, date of admission, date of discharge, 1 primary psychiatric diagnosis, and up to 3 auxiliary diagnoses (classified according to the International Classification of Diseases, Eighth Revision [ICD-8] until 1993 and the 10th revision [ICD-10] from 1994 onwards). All registered psychiatric diagnoses are based on an evaluation by a psychiatrist. For the purpose of this study, we obtained information on psychiatric admissions prior to cosmetic surgery among women in the 4 study cohorts. The psychiatric diagnoses were grouped according to a previously used categorization based on ICD-8.22

The 2 breast implant cohorts were analyzed separately and combined. For 27 women who appeared in both breast implant cohorts, the earliest date of implantation was used in the combined analysis.

The age distribution at time of breast surgery was similar for the 2 implant cohorts and the reduction cohort (median age, 31 years), whereas women in the private clinic control cohort were slightly older at treatment (median age, 33 years) (Table 1). On average, women in the public hospital implant cohort had received their implants earlier in the study period compared with women in the private clinic implant cohort, so follow-up of the public hospital implant cohort (mean, 14.1 years; range, 7-22 years) was longer than that of the private clinic implant cohort (mean, 9.7 years; range, 4-26 years).

Table Graphic Jump LocationTable 1. Characteristics of the Study Cohorts of Danish Women

Overall, 88 deaths were observed among women with breast implants as opposed to 63.6 expected deaths based on mortality rates in the general female population (SMR, 1.4; 95% CI, 1.1-1.7) (Table 2). Women who underwent breast implant surgery at private clinics experienced somewhat higher mortality (SMR, 1.7; 95% CI, 1.2-2.3) compared with women who received their implants at public hospitals (SMR, 1.2; 95% CI, 0.9-1.6). Increased SMRs were seen in both implant cohorts for suicide and nonmalignant lung diseases (ie, bronchitis, emphysema, asthma, and unspecified chronic obstructive pulmonary disease [COPD]), yielding overall SMRs of 3.1 (95% CI, 1.7-5.2) and 3.4 (95% CI, 1.4-6.9), respectively, for these causes of death. In the combined implant cohort, we found slightly elevated SMRs for ischemic heart disease (SMR, 1.6; 95% CI, 0.6-3.5) and cancer of the respiratory organs (SMR, 1.5; 95% CI, 0.6-3.0), whereas there was no excess death from other cancers, including breast cancer (SMR, 1.0; 95% CI, 0.4-2.0), hematopoietic malignancies (SMR, 1.1; 95% CI, 0.1-4.1), and brain cancer (no observed cases vs 1.1 expected; 95% CI, 0-3.4).

Table Graphic Jump LocationTable 2. Total Mortality and Selected Causes of Death Among Danish Women With Cosmetic Breast Implants

Decreased SMRs for all-cause mortality were observed in both the breast reduction (SMR, 0.7; 95% CI, 0.7-0.8) and private clinic control (SMR, 0.8; 95% CI, 0.5-1.1) cohorts (Table 3). Among women who underwent breast reduction, decreased SMRs were seen for cancer (SMR, 0.6; 95% CI, 0.5-0.8), in particular cancer of the breast (SMR, 0.4; 95% CI, 0.2-0.6) and respiratory organs (SMR, 0.5; 95% CI, 0.3-0.8), ischemic heart disease (SMR, 0.7; 95% CI, 0.5-1.0), cerebrovascular disease (SMR, 0.4; 95% CI, 0.2-0.8), and smoking-related nonmalignant lung disease (SMR, 0.5; 95% CI, 0.3-0.9). The SMR for suicide was increased (SMR, 1.6; 95% CI, 1.0-2.5). No significant decreases or increases in cause-specific mortality, including suicide, were found in the private clinic comparison cohort; however, the statistical power was limited for this group.

Table Graphic Jump LocationTable 3. Total Mortality and Selected Causes of Death Among Danish Women in the Breast Reduction and Private Clinic Control Cohorts

Table 4 presents SMRs for overall mortality and for suicide among women with breast implant or reduction surgery, stratified by time since surgery. Among women with breast implants, there was a tendency toward decreasing SMRs with increasing length of follow-up for total death. No clear trend was observed for suicide, except for the highest SMR (4.0; 95% CI, 1.5-8.8) occurring in the combined breast implant cohort within the first 4 years of follow-up. Among women with breast reduction, there were no specific patterns with length of follow-up, except for an elevated SMR (2.3; 95% CI, 1.1-4.3) for suicide in the 1- to 4-year follow-up period.

Table Graphic Jump LocationTable 4. Total Mortality and Suicide Among Danish Women With Breast Implant or Reduction Surgery by Time Since Surgery

Women who underwent breast implant surgery had a significantly higher prevalence of psychiatric admission prior to cosmetic surgery compared with women who underwent breast reduction or other cosmetic procedures (OR, 1.7; 95% CI, 1.4-2.0); when compared with women who underwent breast reduction surgery only, the OR for prior psychiatric admission was 1.8 (95% CI, 1.5-2.1). Nearly 10% (9.4%; 95% CI, 7.8%-11.3%) of women who underwent breast implant surgery at public hospitals had previously been admitted to a psychiatric hospital, while 6.8% (95% CI, 5.7%-8.2%) of women who received implants at private clinics had a history of psychiatric admission (Table 5). Lower and about equal prevalences of prior psychiatric admission were seen among women with breast reduction (4.7%; 95% CI, 4.2%-5.2%) and women who attended private clinics for reasons other than breast implantation (5.5%; 95% CI, 4.5%-6.7%). In the combined breast implant cohort, 7 (50%) of the 14 women who committed suicide had been hospitalized for psychiatric disorders prior to implant surgery, compared with 6 (27%) of 22 women with breast reduction who committed suicide. The most frequent psychiatric diagnoses among women with cosmetic breast implants were neurosis and personality disorders (27%), transient maladaptation (20%), substance or alcohol abuse (11%), and affective disorders (7%).

Table Graphic Jump LocationTable 5. Prevalence of Psychiatric Admission Prior to Cosmetic Surgery Among Danish Women

We found that Danish women who underwent cosmetic breast implant surgery had a higher overall mortality compared with women in the general population. This increased mortality was due primarily to an increased risk of death from suicide and smoking-related diseases. Women who underwent breast reduction surgery had lower total and cause-specific mortality compared with women in the general population; however, these women also exhibited an increased risk of death from suicide. No excess of suicide was observed among women with other types of cosmetic surgery.

The findings of an excess of suicide in this and the 3 previous epidemiologic studies of mortality among women with breast implants have been remarkably consistent.79 All 4 studies, conducted in different populations, have found significant 2- to 3-fold increased risks of suicide among women with breast implants compared with the general female population. A history of mental illness requiring hospital admission is regarded as the strongest risk factor for suicide,2325 which is consistent with our finding of a relatively high prevalence of psychiatric admissions among Danish women prior to seeking breast implant surgery. In a nationwide Danish study of risk factors for suicide, Mortensen et al26 reported a population attributable risk of nearly 50% for prior hospitalization for mental illness.

To our knowledge, this is the first study to report an increased prevalence of prior hospitalization for psychiatric disorders among women who chose to undergo cosmetic breast implantation. Some studies have reported varying degrees of preoperative depression, anxiety, or low self-esteem among women seeking breast implantation,15,16,2729 but most of these studies had methodological limitations, and a recent review of the literature found little reliable evidence of increased prevalence of psychopathological disorders among women with breast implants.30 However, the presence of previous serious mental illness among women electing breast implantation has not been adequately studied. Our finding of preoperative psychiatric admissions in a sizable proportion of Danish women who underwent cosmetic breast implant surgery supports the notion that the excess risk of suicide among women with breast implants reflects an increased prevalence of underlying psychopathological disorders rather than a causal association with breast implants.10

Women with breast implants have also been shown to differ from women in general with respect to nonpsychiatric factors, including cigarette smoking, alcohol intake, reproductive factors, and marital status,1114 which may influence their risk of suicide.25,26,3134 The mortality pattern among women with breast implants in our study is compatible with our previous finding of a higher smoking frequency among Danish women with breast implants than among women in the general population.14 In contrast, the low mortality among women with breast reduction indicates that these women may smoke less and be more health conscious compared with women in general. Even so, their risk of suicide was significantly increased compared with the general female population. This may indicate that although women with breast reduction had a lower prevalence of psychiatric admissions prior to surgery compared with women with breast implants, some of these women may share psychological characteristics associated with risk of suicide.

Women with breast implants experienced no excess death from breast cancer, or other cancer sites, including hematopoietic malignancies and brain cancer. However, we had limited power to assess site-specific cancer mortality. Among women with breast reduction, the risk of death from breast cancer was significantly reduced. We observed a total of 11 deaths from breast cancer among these women as opposed to 30 expected deaths. Several studies have reported a reduced risk of breast cancer among women who have undergone breast reduction.3538 Possible explanations include reductions in breast size and, in particular, glandular tissue after surgery; however, the underlying biological mechanisms remain unclear.3739

The main strengths of our study were the cohort design with complete register-based follow-up for death and the linkage to the unique nationwide Danish Psychiatric Central Register, which enabled us to examine the history of psychiatric admission among all study subjects. Another advantage was the inclusion of comparison cohorts of women from the same public hospitals and private clinics as the women with breast implants, although some of the women in the comparison cohorts underwent procedures that cannot be termed strictly cosmetic, such as excision of benign skin tumors and breast reduction mainly because of physical complaints.

Limitations of our study include the relatively small number of deaths in the implant and private control cohorts and the lack of information on nonpsychiatric factors possibly associated with risk of suicide, including demographic and lifestyle characteristics. Also, in our register-based approach we had no information on less severe psychiatric conditions treated outside the hospital setting with a possible relation to risk of suicide. Although women in the private and public breast implant cohorts both underwent surgery for cosmetic reasons, these women are likely to differ, which was also indicated by their somewhat different mortality pattern. Our finding of a more frequent preoperative history of psychiatric admission among women who underwent breast implant surgery in public hospitals than among women who received implants at private clinics is consistent with the fact that during the 1970s and 1980s some public hospital departments in Denmark required a psychological indication and evaluation for breast implant surgery before the government health service would pay for the procedure (oral communication, Vibeke Breiting, MD, Holte Clinic of Plastic Surgery, Holte, Denmark, 2004). Another explanation for the discrepancy in preoperative psychiatric history might be that women who had surgery at private clinics were more likely to be treated for serious mental illness by private psychiatrists; however, such practice is rare in Denmark.

In summary, Danish women with cosmetic breast implants experienced a higher overall mortality compared with women in the general population, which was owing mainly to increased mortality from suicide and smoking-related disease. Women who underwent breast reduction surgery had lower total and cause-specific mortality compared with women in the general population, but a moderate excess risk of suicide. Compared with the control groups, we found evidence of an increased prevalence of prior psychiatric hospital admission among women undergoing cosmetic breast implantation, which may relate to their subsequent higher risk of suicide. This finding, the first of its kind, to our knowledge, to provide empirical evidence of preimplant psychiatric status, emphasizes the need for careful preoperative psychological screening among women seeking cosmetic breast surgery.40 Additional studies are urgently needed to further our knowledge of the underlying reasons for the increased risk of suicide among women who undergo cosmetic breast surgery.

Correspondence: Joseph K. McLaughlin, PhD, International Epidemiology Institute, 1455 Research Blvd, Suite 550, Rockville, MD 20850-3127 (jkm@iei.ws).

Accepted for Publication: July 19, 2004.

Financial Disclosure: None.

Funding/Support: This study was supported by the International Epidemiology Institute, Rockville, which received funds from the Dow Corning Corporation, Midland, Mich, and the Danish Cancer Society.

Acknowledgment: We thank Andrea Bautz, MSc, Copenhagen, for help with data management.

Sturrock  RDBatchelor  JRHarpwood  V  et al.  Silicone Gel Breast Implants: The Report of the Independent Review Group.  Cambridge, England Jill Rogers Associates1998;
Diamond  BAHulka  BSKerkvliet  NITugwell  P Silicone breast implants in relation to connective tissue diseases and immunologic dysfunction: a report by a National Science Panel to the Honorable Sam C. Pointer Jr, Coordinating Judge for the Federal Breast Implant Multi-District Litigation.  November30 1998;Available at: http://www.fjc.gov/BREIMLIT/SCIENCE/report.htm. Accessed September 30, 2004
International Agency for Research on Cancer, Silicone breast implants. Surgical Implants and Other Foreign Bodies. Lyon, France International Agency for Research on Cancer1999;IARC Monographs on the Evaluation of Carcinogenic Risks to Humans; vol 74
Bondurant  SErnester  VRHerdman  RCommittee on the Safety of Silicone Breast Implants, Division of Health Promotion and Disease Prevention, Safety of Silicone Breast Implants.  Washington, DC National Academy Press2000;
Tugwell  PWells  GPeterson  J  et al.  Do silicone breast implants cause rheumatologic disorders? a systematic review for a court-appointed national science panel. Arthritis Rheum 2001;442477- 2484
PubMed
Lipworth  LTarone  REMcLaughlin  JK Silicone breast implants and connective tissue disease: an updated review of the epidemiologic evidence. Ann Plast Surg 2004;52598- 601
PubMed
Brinton  LALubin  JHBurich  MCColton  THoover  RN Mortality among augmentation mammoplasty patients. Epidemiology 2001;12321- 326
PubMed
Koot  VCPeeters  PHGranath  FGrobbee  DENyrén  O Total and cause specific mortality among Swedish women with cosmetic breast implants: prospective study. BMJ 2003;326527- 528
PubMed
Pukkala  EKulmala  IHovi  SL  et al.  Causes of death among Finnish women with cosmetic breast implants, 1971-2001. Ann Plast Surg 2003;51339- 342
PubMed
McLaughlin  JKLipworth  LTarone  RE Suicide among women with cosmetic breast implants: a review of the epidemiologic evidence. J Long Term Eff Med Implants 2003;13445- 450
PubMed
Cook  LSDaling  JRVoigt  LF  et al.  Characteristics of women with and without breast augmentation. JAMA 1997;2771612- 1617
PubMed
Brinton  LABrown  SLColton  TBurich  MCLubin  J Characteristics of a population of women with breast implants compared with women seeking other types of plastic surgery. Plast Reconstr Surg 2000;105919- 927
PubMed
Fryzek  JPWeiderpass  ESignorello  LB  et al.  Characteristics of women with cosmetic breast augmentation surgery compared with breast reduction surgery patients and women in the general population of Sweden. Ann Plast Surg 2000;45349- 356
PubMed
Kjøller  KHölmich  LRFryzek  JP  et al.  Characteristics of women with cosmetic breast implants compared with women with other types of cosmetic surgery and population-based controls in Denmark. Ann Plast Surg 2003;506- 12
PubMed
Beale  SHambert  GLisper  HOOhlsen  LPalm  B Augmentation mammaplasty: the surgical and psychological effects of the operation and prediction of the result. Ann Plast Surg 1984;13279- 297
PubMed
Schlebusch  L Negative bodily experience and prevalence of depression in patients who request augmentation mammoplasty. S Afr Med J 1989;75323- 326
PubMed
Friis  SMellemkjær  LMcLaughlin  JK  et al.  Connective tissue disease and other rheumatic conditions following breast implants in Denmark. Ann Plast Surg 1997;391- 8
PubMed
Mellemkjær  LKjøller  KFriis  S  et al.  Cancer occurrence after cosmetic breast implantation in Denmark. Int J Cancer 2000;88301- 306
PubMed
Kjøller  KFriis  SMellemkjær  L  et al.  Connective tissue disease and other rheumatic conditions following cosmetic breast implantation in Denmark. Arch Intern Med 2001;161973- 979
PubMed
Juel  KHelweg-Larsen  K The Danish registers of causes of death. Dan Med Bull 1999;46354- 357
PubMed
Munk-Jørgensen  PMortensen  PB The Danish Psychiatric Central Register. Dan Med Bull 1997;4482- 84
PubMed
Ross  LJohansen  CDalton  SO  et al.  Psychiatric hospitalizations among survivors of cancer in childhood or adolescence. N Engl J Med 2003;349650- 657
PubMed
Goldacre  MSeagroatt  VHawton  K Suicide after discharge from psychiatric inpatient care. Lancet 1993;342283- 286
PubMed
Appleby  LDennehy  JAThomas  CSFaragher  EBLewis  G Aftercare and clinical characteristics of people with mental illness who commit suicide: a case-control study. Lancet 1999;3531397- 1400
PubMed
Qin  PAgerbo  EMortensen  PB Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981-1997. Am J Psychiatry 2003;160765- 772
PubMed
Mortensen  PBAgerbo  EErikson  TQin  PWestergaard-Nielsen  N Psychiatric illness and risk factors for suicide in Denmark. Lancet 2000;3559- 12
PubMed
Sihm  FJagd  MPers  M Psychological assessment before and after augmentation mammaplasty. Scand J Plast Reconstr Surg 1978;12295- 298
PubMed
Birtchnell  SWhitfield  PLacey  JH Motivational factors in women requesting augmentation and reduction mammaplasty. J Psychosom Res 1990;34509- 514
PubMed
Schlebusch  LMahrt  I Long-term psychological sequelae of augmentation mammoplasty. S Afr Med J 1993;83267- 271
PubMed
Sarwer  DBNordmann  JEHerbert  JD Cosmetic breast augmentation surgery: a critical overview. J Womens Health Gend Based Med 2000;9843- 856
PubMed
Miller  MHemenway  DBell  NSYore  MMAmoroso  PJ Cigarette smoking and suicide: a prospective study of 300,000 male active-duty Army soldiers. Am J Epidemiol 2000;1511060- 1063
PubMed
Malone  KMWaternaux  CHaas  GLCooper  TBLi  SMann  JJ Cigarette smoking, suicidal behavior, and serotonin function in major psychiatric disorders. Am J Psychiatry 2003;160773- 779
PubMed
Murphy  GEWetzel  RD The lifetime risk of suicide in alcoholism. Arch Gen Psychiatry 1990;47383- 392
PubMed
Qin  PAgerbo  EWestergard-Nielsen  NEriksson  TMortensen  PB Gender differences in risk factors for suicide in Denmark. Br J Psychiatry 2000;177546- 550
PubMed
Boice  JD  JrFriis  SMcLaughlin  JK  et al.  Cancer following breast reduction surgery in Denmark. Cancer Causes Control 1997;8253- 258
PubMed
Brown  MHWeinberg  MChong  NLevine  RHolowaty  E A cohort study of breast cancer risk in breast reduction patients. Plast Reconstr Surg 1999;1031674- 1681
PubMed
Boice  JD  JrPersson  IBrinton  LA  et al.  Breast cancer following breast reduction surgery in Sweden. Plast Reconstr Surg 2000;106755- 762
PubMed
Brinton  LAPersson  IBoice  JD  JrMcLaughlin  JKFraumeni  JF  Jr Breast cancer risk in relation to amount of tissue removed during breast reduction operations in Sweden. Cancer 2001;91478- 483
PubMed
Tarone  RELipworth  LYoung  VLMcLaughlin  JK Breast reduction surgery and breast cancer risk: does reduction mammoplasty have a role in primary prevention strategies for women at high risk of breast cancer? Plast Reconstr Surg 2004;1132104- 2110
PubMed
McLaughlin  JKWise  TNLipworth  L Increased risk of suicide among patients with breast implants: do the epidemiologic data support psychiatric consultation? Psychosomatics 2004;45277- 280
PubMed

Figures

Tables

Table Graphic Jump LocationTable 1. Characteristics of the Study Cohorts of Danish Women
Table Graphic Jump LocationTable 2. Total Mortality and Selected Causes of Death Among Danish Women With Cosmetic Breast Implants
Table Graphic Jump LocationTable 3. Total Mortality and Selected Causes of Death Among Danish Women in the Breast Reduction and Private Clinic Control Cohorts
Table Graphic Jump LocationTable 4. Total Mortality and Suicide Among Danish Women With Breast Implant or Reduction Surgery by Time Since Surgery
Table Graphic Jump LocationTable 5. Prevalence of Psychiatric Admission Prior to Cosmetic Surgery Among Danish Women

References

Sturrock  RDBatchelor  JRHarpwood  V  et al.  Silicone Gel Breast Implants: The Report of the Independent Review Group.  Cambridge, England Jill Rogers Associates1998;
Diamond  BAHulka  BSKerkvliet  NITugwell  P Silicone breast implants in relation to connective tissue diseases and immunologic dysfunction: a report by a National Science Panel to the Honorable Sam C. Pointer Jr, Coordinating Judge for the Federal Breast Implant Multi-District Litigation.  November30 1998;Available at: http://www.fjc.gov/BREIMLIT/SCIENCE/report.htm. Accessed September 30, 2004
International Agency for Research on Cancer, Silicone breast implants. Surgical Implants and Other Foreign Bodies. Lyon, France International Agency for Research on Cancer1999;IARC Monographs on the Evaluation of Carcinogenic Risks to Humans; vol 74
Bondurant  SErnester  VRHerdman  RCommittee on the Safety of Silicone Breast Implants, Division of Health Promotion and Disease Prevention, Safety of Silicone Breast Implants.  Washington, DC National Academy Press2000;
Tugwell  PWells  GPeterson  J  et al.  Do silicone breast implants cause rheumatologic disorders? a systematic review for a court-appointed national science panel. Arthritis Rheum 2001;442477- 2484
PubMed
Lipworth  LTarone  REMcLaughlin  JK Silicone breast implants and connective tissue disease: an updated review of the epidemiologic evidence. Ann Plast Surg 2004;52598- 601
PubMed
Brinton  LALubin  JHBurich  MCColton  THoover  RN Mortality among augmentation mammoplasty patients. Epidemiology 2001;12321- 326
PubMed
Koot  VCPeeters  PHGranath  FGrobbee  DENyrén  O Total and cause specific mortality among Swedish women with cosmetic breast implants: prospective study. BMJ 2003;326527- 528
PubMed
Pukkala  EKulmala  IHovi  SL  et al.  Causes of death among Finnish women with cosmetic breast implants, 1971-2001. Ann Plast Surg 2003;51339- 342
PubMed
McLaughlin  JKLipworth  LTarone  RE Suicide among women with cosmetic breast implants: a review of the epidemiologic evidence. J Long Term Eff Med Implants 2003;13445- 450
PubMed
Cook  LSDaling  JRVoigt  LF  et al.  Characteristics of women with and without breast augmentation. JAMA 1997;2771612- 1617
PubMed
Brinton  LABrown  SLColton  TBurich  MCLubin  J Characteristics of a population of women with breast implants compared with women seeking other types of plastic surgery. Plast Reconstr Surg 2000;105919- 927
PubMed
Fryzek  JPWeiderpass  ESignorello  LB  et al.  Characteristics of women with cosmetic breast augmentation surgery compared with breast reduction surgery patients and women in the general population of Sweden. Ann Plast Surg 2000;45349- 356
PubMed
Kjøller  KHölmich  LRFryzek  JP  et al.  Characteristics of women with cosmetic breast implants compared with women with other types of cosmetic surgery and population-based controls in Denmark. Ann Plast Surg 2003;506- 12
PubMed
Beale  SHambert  GLisper  HOOhlsen  LPalm  B Augmentation mammaplasty: the surgical and psychological effects of the operation and prediction of the result. Ann Plast Surg 1984;13279- 297
PubMed
Schlebusch  L Negative bodily experience and prevalence of depression in patients who request augmentation mammoplasty. S Afr Med J 1989;75323- 326
PubMed
Friis  SMellemkjær  LMcLaughlin  JK  et al.  Connective tissue disease and other rheumatic conditions following breast implants in Denmark. Ann Plast Surg 1997;391- 8
PubMed
Mellemkjær  LKjøller  KFriis  S  et al.  Cancer occurrence after cosmetic breast implantation in Denmark. Int J Cancer 2000;88301- 306
PubMed
Kjøller  KFriis  SMellemkjær  L  et al.  Connective tissue disease and other rheumatic conditions following cosmetic breast implantation in Denmark. Arch Intern Med 2001;161973- 979
PubMed
Juel  KHelweg-Larsen  K The Danish registers of causes of death. Dan Med Bull 1999;46354- 357
PubMed
Munk-Jørgensen  PMortensen  PB The Danish Psychiatric Central Register. Dan Med Bull 1997;4482- 84
PubMed
Ross  LJohansen  CDalton  SO  et al.  Psychiatric hospitalizations among survivors of cancer in childhood or adolescence. N Engl J Med 2003;349650- 657
PubMed
Goldacre  MSeagroatt  VHawton  K Suicide after discharge from psychiatric inpatient care. Lancet 1993;342283- 286
PubMed
Appleby  LDennehy  JAThomas  CSFaragher  EBLewis  G Aftercare and clinical characteristics of people with mental illness who commit suicide: a case-control study. Lancet 1999;3531397- 1400
PubMed
Qin  PAgerbo  EMortensen  PB Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981-1997. Am J Psychiatry 2003;160765- 772
PubMed
Mortensen  PBAgerbo  EErikson  TQin  PWestergaard-Nielsen  N Psychiatric illness and risk factors for suicide in Denmark. Lancet 2000;3559- 12
PubMed
Sihm  FJagd  MPers  M Psychological assessment before and after augmentation mammaplasty. Scand J Plast Reconstr Surg 1978;12295- 298
PubMed
Birtchnell  SWhitfield  PLacey  JH Motivational factors in women requesting augmentation and reduction mammaplasty. J Psychosom Res 1990;34509- 514
PubMed
Schlebusch  LMahrt  I Long-term psychological sequelae of augmentation mammoplasty. S Afr Med J 1993;83267- 271
PubMed
Sarwer  DBNordmann  JEHerbert  JD Cosmetic breast augmentation surgery: a critical overview. J Womens Health Gend Based Med 2000;9843- 856
PubMed
Miller  MHemenway  DBell  NSYore  MMAmoroso  PJ Cigarette smoking and suicide: a prospective study of 300,000 male active-duty Army soldiers. Am J Epidemiol 2000;1511060- 1063
PubMed
Malone  KMWaternaux  CHaas  GLCooper  TBLi  SMann  JJ Cigarette smoking, suicidal behavior, and serotonin function in major psychiatric disorders. Am J Psychiatry 2003;160773- 779
PubMed
Murphy  GEWetzel  RD The lifetime risk of suicide in alcoholism. Arch Gen Psychiatry 1990;47383- 392
PubMed
Qin  PAgerbo  EWestergard-Nielsen  NEriksson  TMortensen  PB Gender differences in risk factors for suicide in Denmark. Br J Psychiatry 2000;177546- 550
PubMed
Boice  JD  JrFriis  SMcLaughlin  JK  et al.  Cancer following breast reduction surgery in Denmark. Cancer Causes Control 1997;8253- 258
PubMed
Brown  MHWeinberg  MChong  NLevine  RHolowaty  E A cohort study of breast cancer risk in breast reduction patients. Plast Reconstr Surg 1999;1031674- 1681
PubMed
Boice  JD  JrPersson  IBrinton  LA  et al.  Breast cancer following breast reduction surgery in Sweden. Plast Reconstr Surg 2000;106755- 762
PubMed
Brinton  LAPersson  IBoice  JD  JrMcLaughlin  JKFraumeni  JF  Jr Breast cancer risk in relation to amount of tissue removed during breast reduction operations in Sweden. Cancer 2001;91478- 483
PubMed
Tarone  RELipworth  LYoung  VLMcLaughlin  JK Breast reduction surgery and breast cancer risk: does reduction mammoplasty have a role in primary prevention strategies for women at high risk of breast cancer? Plast Reconstr Surg 2004;1132104- 2110
PubMed
McLaughlin  JKWise  TNLipworth  L Increased risk of suicide among patients with breast implants: do the epidemiologic data support psychiatric consultation? Psychosomatics 2004;45277- 280
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 38

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
PubMed Articles
Mortality and suicide among Danish women with cosmetic breast implants. Arch Intern Med 2004 Dec 13-27;164(22):2450-5.