An analysis of the risk for depressive disorder (negative or positive) showed no significant difference between the 2 institutions, either for a positive (P = 0.44) or negative risk (P = 0.20) (Fig. 4). No significant difference was found between the risk of a depressive disorder and the type of surgery requested or between those women who received (P = 0.12) or did not receive (P = 0.33) breast implants at either of the 2 institutions (Table 6). Table 7 shows the number of positive responses on item number 9 and that deals explicitly with suicidal ideation. Question 2 was answered positively 34 times (18.4%) and question 9 was answered positively 13 times, meaning 7.0% of all patients.
Cosmetic plastic surgery is an essential component of plastic surgery and has grown to be extremely popular in several countries as a result of the improvements offered by the procedures in various realms.16 , 17
Depression (or depressive disorder) can be considered one of the major challenges in medicine in view of their high and steadily increasing prevalence, their chronicity, and their implications for populations worldwide.18 , 19 Depression currently affects over 350 million individuals around the world and is the second cause of disease in terms of disability-adjusted life years in the 15–44 year age group for both sexes.20 It is estimated that in 2020, depressive disorders will be the principal cause of disability in both sexes in any age group in developing countries and the second most common cause in developed countries, followed by ischemic heart disease. By 2030, depression is projected to be the most common disease worldwide, in any age and sex.18–20
Various studies have shown that the prevalence of DD is greater in cosmetic surgery patients than in the general population.1 , 3 , 5–9 , 18–22 In some patients, the DD develops in response to a genuine dissatisfaction with their body image, and such individuals may benefit from surgery.23–30 Nevertheless, in some patients, the DD is the result of some personal dissatisfaction, sadness, or emptiness. In these cases, the frustrated expectation that the surgery would solve their problems and make them feel better about themselves may be catastrophic, in extreme cases resulting even in suicide. The suicide rate in individuals with depression is 30-fold that of the general population.31–34
An exponential increase has been seen in the number of patients with this profile in plastic surgeons’ offices. The key to a successful cosmetic surgery procedure lies in the selection of the patients.9 , 11 , 16 , 17 In view of the widespread use of the BDI-II in research, and the practicality, good acceptability, and accuracy of the instrument, it was chosen in this study to screen patients before surgery for possible indicators of DD.7 , 8 , 26 , 29 , 30 , 35
Although the sociodemographic data of the patients at the 2 institutions were heterogeneous, the distribution of the 4 types of cosmetic surgery was homogenous. There were differences, however, in the distribution of the BDI-II scores within both, with the pattern at the private clinic being more homogeneous.
Although outliers may lead to errors and generate misleading results,36 a patient with a high BDI-II score (46 points) and positive responses to the statements on suicidal ideation was maintained in the analysis, because this is exactly the profile of patient that professionals seek to identify before surgery. They represent potential risks of postoperative dissatisfaction and of aggression against the surgeon, leading in numerous cases to legal suits.37–40 Extreme cases have been reported in which patients with psychosomatic disorders have threatened their doctors40 , 41 and indeed of doctors having been killed by patients.39–41
The possible association between suicide and breast implants has led to a number of investigations into the alarming suicide rates in this population for whom the relative risk of suicide is up to 4 times greater than that of the general population.42–48 Some authors17 , 49–51 attribute it, to the demographic and lifestyle traits of this population that could potentially alter their risk for suicide. Although this study was not conducted with this specific objective, the BDI-II statements on the suicide ideation of were answered positively alarmingly by 7% of the women evaluated, with a greater prevalence in patients with an indication for breast implants (augmentation mammoplasty and mastopexy with implants).
There were statistically significant differences between the 2 institutions for all the sociodemographic variables. The profile of the patients consulting at the public institution was of predominantly older, non-white, with no steady partner, 9–12 years of schooling, and income between 1 and 5 minimum salaries/mo. In the private clinic, the patients were younger, predominantly white, with a steady partner, >13 years of schooling, and an income >10 minimum salaries/mo.
Breiting et al.,52 however, found no significant difference in the sociodemographic data of patients consulting at a private and a public institution. Our data are similar to the sociodemographic profiles described in some studies4 , 6 , 53 but diverge from others.4 , 6 , 54 , 55 This may be due to differences in evaluation moments, study populations, or socioeconomic and cultural conditions. In Brazil, the aforementioned data are similar to those published by Beraldo-Cardoso.30
Poorer education levels may offer fewer opportunities for professional growth, resulting in lower income.56 , 57 Patients with less education and lower income are more likely to seek public institutions where they will not have to pay for the surgical procedure. In agreement with other reports in the literature, the frequency of patients with a university education in this study was lower in the public sector and higher in the private, whereas income was also significantly lower in the public sector (P < 0.001).
The finding that 86.9% of the patients requesting cosmetic surgery had some possible sign of DD at their presurgical evaluation is concerning, but it is in agreement with other studies.1 , 4 , 6–9 , 17 , 20–22 , 26 , 27 , 30 , 52 , 55 The DDR+ was much higher in the patients consulting at the public hospital (25.8%) than at the private clinic (11.4%), with a relative risk of 2.3. The prevalence rates of moderate and severe DS were, respectively, 120% and 242% higher in the patients consulting at the public institution, than the clientele at the private clinic.
With the objective of evaluating the factors involved in the greater number of positive responses in the BDI-II questionnaire at the public institution, the variables age, skin color/race, marital status, type of surgery, education level, and income were dichotomized and compared with DDR+ at each institution. The variable found to be statistically significant was institution, education, and income. Women with low education level and incoming were 2.9 and 2.3 times, respectively, more likely to have a DD. Less schooling and incoming suggest the possible influence of this factor as a predictor of DS. Nevertheless, this cannot be stated categorically because stratification resulted in an insufficient number of patients and data on income were partial, with no information available on the number of individuals in the household, thus rendering calculation of the per capita income impossible. Furthermore, some of the patients (29.5% of those in the private clinic and 6.2% of those in the public institution) failed to provide any answer to the question on income.
Individuals who live alone are up to 80% more likely to suffer from depression,4 , 6 , 16–21 , 58 whereas those who live with another person are more tranquil, more self-assured, and more self-confident, hence less likely to suffer from depression.4 , 6 , 16–22 Analyzing only the cases with DDR+ (BDI-II score ≥15), 54.3% of those were shown to have no steady partner, although this difference was not significant.
Various investigators1 , 4 , 6 , 16 , 17 , 26 , 27 , 52–55 have reported that patients requesting breast implants are more likely to present with more DD. In this study, a separate analysis of the type of surgery in each institution showed no significant association between any specific type of surgery and the development of DD. Likewise, when the presence of DD was analyzed separately, no statistically significant association was found between the patients with or without DD and implants, in either of the institutions.
The 4 types of aesthetic breast surgery conducted in the 2 clinics were reexamined in an attempt to verify whether any certain type of surgery involved a DDR+, with no statistically significant differences being found in the groups evaluated; however, of the 35 patients with DDR+, 17 (48.6%) were reduction mammoplasty and 18 patients (51.4%) were candidates for breast implant surgery augmentation mammoplasty and mastopexy with breast implants. There was no case of positive risk for depressive disorder in mastopexy without implant (both public and private). When all the patients scheduled for surgery that included breast implants (augmentation mammoplasty and mastopexy with breast implants) were grouped together and all the patients scheduled for surgery that did not involve breast implants (reduction mammoplasty and mastopexy without breast implants) were grouped together, their distribution was found to be homogenous, with no significant association being found that would confirm that the presence (P = 0.12) or absence (P = 0.33) of breast implants as part of the surgical procedure was a predictive factor for DD.
There is no doubt with respect to the usefulness and efficacy of cosmetic surgery or to the genuine benefits resulting from it in view of the capacity of these techniques to change an individual’s body image, conferring positive changes, both physical and emotional, and improving the patient’s quality of life. Nevertheless, in some patients requesting the procedure, there may be a considerable likelihood of psychiatric problems.
Cosmetic surgery patients with minor psychological alterations appear to experience greater positive changes after surgery,3 , 5 , 9 , 24 , 26 , 27 , 59 whereas patients identified as having signs of depression before surgery are around 5 times more likely to be dissatisfied with the surgical outcome,1 , 3–7 , 20 , 24 , 26 , 59–62 with all the possible consequences that may result from that dissatisfaction.
The literature shows that there is a greater likelihood of a poor psychosocial outcome after surgery when patients have unreal expectations regarding the procedure; when deformities are minimal; when the patient is unhappy with the results of a previous, otherwise successful cosmetic surgery; when the motivation for the surgery was based on relationship problems; or when surgery was scheduled at the request of others. Other factors include low self-esteem; a history of depression; prior admission to a psychiatric hospital; previous/present use of antidepressants; history of suicide; high BDI-II scores; an anxiety or personality disorder; no steady partner; poor education level; and low income.1 , 3–8 , 11 , 17 , 18 , 20 , 21 , 23–26 , 32–34 , 58–62 Some of these factors were present in patients in this study. The difficulty, therefore, lies in recognizing which of the patients requesting cosmetic surgery are stable from a psychological viewpoint and which are not, in which cases, a psychiatric disorder is already present (controlled or uncontrolled) or even close to being triggered and whether the psychiatric symptoms of these individuals are more likely to be exacerbated after surgery.
Any patient presenting with those possible predictive factors for depressive disorder described above or suspicious circumstances, should be referred to a psychiatrist before surgery, for further investigation and evaluation regarding whether or not they should be submitted to the proposed surgical treatment and the ideal moment for surgery.
Further studies should increase the understanding and definition of these patients to avoid unfavorable outcome.
The profile of patients requesting cosmetic breast surgery in the public sector is significantly different from that of patients consulting in the private sector. The prevalence of indicators of depressive disorder in this population is high (18.9%), with the patients consulting at the public clinic being 2.3 times more likely to develop a possible DD. Age, low income, and schooling were a possible risk factors for a depressive disorder. Patients for breast implants showed a higher score for suicide ideation.
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