Correlation Between Medically Diagnosed Anxiety and Depression Disorder and Self-Reported Breast Implant Illness

Abstract

Background

Anxiety disorders, both with and without comorbid depression, are widespread globally. In this study we investigate the intersection of anxiety, depression, and self-reported breast implant illness (BII) in females undergoing aesthetic breast surgery.

Objectives

The objective of our research was to enhance understanding about mental health history, psychotropic medication use, and its relation to BII symptoms.

Methods

A cohort of 240 consecutive female patients undergoing elective breast surgery was studied. In the study we categorized patients by groups based on the presence of self-reported BII symptoms and the type of breast surgery performed. Mental health history, psychotropic medication use, and time spent in treatment for mental illness were scrutinized. Statistical analyses were conducted, including multiple regression analysis.

Results

Results revealed that patients with self-reported BII symptoms often had a preexisting anxiety/depression disorder treated medically before obtaining breast implants, and this disorder predicted the occurrence of BII symptoms. These patients tended to be diagnosed with anxiety and depression at a younger age, initiate medication therapy earlier, take more medications for their condition, and spend more time in therapy compared with others undergoing elective breast surgery.

Conclusions

Implications of this study highlight the need for comprehensive counseling between plastic surgeons and patients with self-reported BII symptoms. Understanding the role of anxiety/depression in the pathogenesis of self-reported BII is crucial, and collaboration with psychiatrists and other mental health professionals can ensure improved supportive care. The findings contribute to a better understanding of the psychological aspects surrounding breast implant surgery and self-reported BII and emphasize the importance of preoperative mental health assessments in appropriate patient selection for elective breast surgery.

Level of Evidence: 3

Anxiety disorders, with or without depression, are prevalent worldwide, affecting up to 19% of adults.¹ This is particularly notable in the United States, where the co-occurrence of anxiety and depression is observed in up to 60% of adults diagnosed with an anxiety disorder.² Many females grappling with anxiety-related disorders opt for aesthetic surgery, often seeking elective breast augmentation to enhance self-esteem and overall quality of life.³ Numerous studies suggest that anxiety rates among cosmetic breast augmentation surgery patients approach 22%, with anxiety and depression rates at 11%.⁴ These figures, while slightly elevated, align closely with general population rates reported by the World Health Organization and the US population per the National Institutes of Health, which reflect the prevalence of anxiety disorder at 16% and anxiety and depression disorder at 10% .⁵

Breast implant illness (BII) is a term coined on social media to encompass a range of self-reported symptoms by patients. While the etiology remains unclear, several studies indicate an association between anxiety, depression, and BII.^6-10 Glicksman et al demonstrated elevated levels of anxiety and depression, assessed through PROMIS questionnaires, in a cohort of females reporting BII symptoms.^9,10 Other researchers have similarly identified heightened anxiety levels in patients attributing symptoms to their breast implants. Our focus is to delve deeper into the correlation between anxiety disorders, depression, and co-occurring anxiety and depression and BII through an investigation into the mental health history of studied patients.

Currently, there is little known about the mental health history and medical management of patients reporting BII symptoms. To enhance our understanding of the interplay between anxiety and depression and self-reported BII, we have scrutinized the mental health history and medication use of patients with self-reported BII symptoms and breast implants, comparing them to various cohorts undergoing aesthetic breast surgery without reported BII. Our investigation extended to the timing of anxiety and depression diagnoses and their relationship to breast implantation and self-reported BII symptoms. Other mental health parameters examined across different patient cohorts included the number and type of psychotropic medications, age at initial diagnosis and treatment, and cumulative time spent in therapy for mental illness.

METHODS

A retrospective review and patient survey were conducted on a cohort of 240 consecutive biologically female patients who underwent elective breast surgery. The selected patients were females aged 30 to 60, having undergone surgery between 2018 and 2022 under the care of a single surgeon. Participants in the study completed a mental health survey if they reported medical treatment for an anxiety or depression-related disorder at the time of their breast surgery. The survey was conducted as an interview and contained questions about mental health history (Appendix). Patients engaged in nonmedical treatment for anxiety- and depression-related disorders, such as therapy without medication, were excluded. Data were collected between March 2023 and December 2023 and were approved by Tier IRB (Kansas City, MO).

In the study we categorized patients by 4 groups, each with 60 patients, as follows: Group 1 included patients undergoing breast implant removal with total capsulectomy, mastopexy, and self-reporting BII symptoms; Group 2 comprised patients undergoing implant removal with capsulectomy, mastopexy, and not reporting BII symptoms; Group 3 was made up of patients undergoing implant exchange and mastopexy without BII symptoms; and Group 4 consisted of patients undergoing mastopexy without breast implants.

Retrospective data encompassed patient age, body mass index (BMI), implant characteristics (saline vs silicone, texture, size, shape, age, integrity noted at surgery), and capsular contracture. Mental health history was assessed through patient interviews, covering anxiety and depressive disorders, psychotropic medication details (type, history, medications at the time of breast surgery), and cumulative time in mental health counseling or therapy.

All patients claiming a history of prescribed medication for anxiety, depression, or anxiety and depression were diagnosed by a qualified psychiatrist or primary care physician with the Diagnostic Statistical Manual of Mental Disorders (DSM-IV or DSM-5). Prescribed psychotropic medications were categorized by drug classes, including selective serotonin reuptake inhibitors (SSRIs), selective serotonin and norepinephrine reuptake inhibitors (SNRIs), serotonin antagonist reuptake inhibitors (SARIs), norepinephrine and dopamine reuptake inhibitors (NDRIs), benzodiazepines, and other agents. We also evaluated cumulative time in mental health therapy, encompassing medication management and psychotherapy.

Statistical Analysis

Chi-square analysis served to compare independent groups on categorical variables. Frequencies and percentages were reported for the chi-square analyses. Unpaired samples t test was conducted to compare the groups on normal, continuous outcomes, with means and standard deviations reported for the t test analyses. For continuous outcomes inconsistent with statistical assumptions, Mann-Whitney U tests were executed to compare the groups, and medians and interquartile ranges were reported for the nonparametric analyses. Last, multiple regression analysis was utilized to control for (1) the total number of psychiatric medications taken (continuous parameter); (2) the age of diagnosis for a mental health disorder (continuous parameter, years); (3) the cumulative years of professional therapy (continuous parameter); and (4) a formal dual-diagnosis of both anxiety and depression (binary, categorical parameter; absence of dual diagnoses as the reference), when examining the association between the grouping variable (polychotomous, categorical variable; psychiatric symptoms—explantation/capsulectomy as the reference group, the second group of no symptoms—explantation/capsulectomy, the third group of no symptoms—exchanging implants, and the fourth group denoting breast lift—no implants) and the continuous level outcome of number of BII symptoms. All analyses were performed with SPSS Version 29 (IBM Corp, Armonk, NY), and statistical significance was set at an alpha value of .05.

RESULTS

Patient Demographics and Breast Implant Factors

Table 1 presents the demographics of the studied patients. No significant differences were observed in patient age, BMI, and menstruation status when comparing those undergoing explant and capsulectomy with or without self-reported BII symptoms. Females opting for implant exchange or mastopexy without implants tended to be younger, and fewer were in menopause.

Table 2 outlines breast implant–related data. Breast implant size, shape, surface type, and the presence of capsular contracture did not show statistically significant differences among the groups. Patients desiring implant exchange had fewer implant ruptures compared to those desiring explantation (with or without symptoms). However, patients opting for implant exchange had more recently placed breast implants than the explantation groups. No differences in implant ruptures were noted between patients undergoing explantation, with or without symptoms.

Patient Age at Time of First Breast Augmentation and Initial Diagnosis of an Anxiety and/or Depression Disorder

Table 3 displays the mean age of females undergoing initial breast augmentation and the age of the initial diagnosis of anxiety, depression, or anxiety and depression disorder. Females self-reporting BII symptoms had a mean age of anxiety-related disorder diagnosis at 22 years, while the mean age of the initial breast augmentation procedure was 29 years. In 88% of cases, the mental health diagnosis preceded the breast augmentation procedure.

Mental Health Diagnoses and Medications

Table 4 illustrates the percentage of patients in the groups studied diagnosed with anxiety, depression, or anxiety and depression and currently under treatment. A statistically significant increase in the prevalence of medically treated anxiety and depression was observed in the self-reported BII group (P < .001) compared to the other groups, while no differences were noted for isolated anxiety (P < .89) or depression (P < .93).

Table 5 presents the number of medications taken for anxiety, depression, or anxiety and depression, along with the distribution of medication types taken by patients. A significant difference in the total number of medications taken by patients (Rx) with self-reported BII compared to the other groups was noted (P < .003), although no differences were observed between the groups in specific drug classifications. SSRIs were the most prescribed medication for mental health treatment. Patients undergoing explantation with self-reported BII symptoms tended to take benzodiazepines more commonly than patients in other cohorts, with 32% of patients utilizing benzodiazepines. However, the difference between the cohorts was not statistically significant (P < .052).

Age of Mental Health Diagnosis/Treatment

Patients with self-reported BII symptoms were diagnosed with anxiety and/or depression disorders at a younger age than other cohorts. A statistically significant difference was noted between patients self-reporting BII symptoms undergoing explantation and those undergoing mastopexy alone without implants (P < .008). Supplemental Table 1, located online at www.aestheticsurgeryjournal.com, outlines the age at which prescription medication was first prescribed and the duration of cumulative mental health counseling/therapy. Patients with self-reported BII undergoing explantation initiated pharmacologic therapy earlier than other cohorts, but the differences were not significantly different (P < .52), and showed more years of cumulative counseling and therapy compared to the other cohorts (P < .001).

Multivariate Analysis

We conducted a multivariate analysis with a multiple regression model to predict BII symptoms. The analysis predicted for BII symptoms a continuous, numerical outcome. The categorical grouping variable contained the 4 patient groups, and the analysis utilized the BII symptoms—explantation/capsulectomy group as the reference category, with the 3 other patient groups compared with it. The grouping variable was a significant predictor of BII symptoms when controlling for other variables. See Supplemental Table 2, located online at www.aestheticsurgeryjournal.com. The B (unstandardized beta coefficient) for each of the other 3 patient groups was −5.29, −5.49, and −5.63, respectively, all with P < .001. This implies that each of those groups had significantly fewer BII symptoms than the BII symptoms—explanation/capsulectomy group, when controlling for other variables.

DISCUSSION

Anxiety and depression are worldwide mental health issues and are known to play a role in many medical disease entities, as well as being known causes of somatic symptoms.^11-17 The findings of Glicksman and coinvestigators have highlighted that high levels of anxiety are found in patients with self-reported symptoms which they attribute to their breast implants. In our surgical treatment of patients with breast implants, we noted a significant number of patients who were currently under treatment for anxiety and/or depression. We became interested in studying the intersection between breast implants, anxiety and depression, and self-reported breast implant illness symptoms. Our focus was on investigating the timing of the anxiety and/or depression diagnosis in relation to breast surgery as well as the mental health history of patients with and without somatic symptoms which they felt were due to their breast implants.

One of the most interesting findings of this study was that patients who self-reported BII symptoms and desired explantation exhibited a mean age of an anxiety and/or depression diagnosis that preceded their initial breast augmentation. The majority of the patients who self-reported BII symptoms (88%) had a diagnosis of anxiety, depression, or a combination of both before they underwent breast implantation. This finding suggests that the anxiety and depression in our patient groups were not caused by breast augmentation surgery. However, our data do not address other questions, such as whether breast implants placed after the diagnosis of an anxiety-related disorder exacerbate a preexisting mental health condition or the diagnosis of anxiety/depression plays a role in the patient choosing to undergo breast surgery.

The effects of anxiety and depression hold potential implications for patient selection and presurgical counseling before breast surgery. Often patients with anxiety- and depression-related conditions participate extensively on social media before surgery, potentially heightening their anxiety.¹⁸ These patients may be more susceptible to heightened anxiety symptoms following a surgical procedure, especially if the outcome is suboptimal or if stressors exacerbate preexisting anxiety or depression symptoms. Anxiety levels can be enhanced in the postoperative period when patients search the Internet and social media to investigate postoperative issues and questions, rather than discussing these with their physician. Surgeons may consider counseling patients with historical anxiety and depression about the potential stress associated with surgical procedures, emphasizing that the outcome of breast surgery or interaction with social media may amplify symptoms of anxiety or depression. Patients with significant anxiety or depression under care may benefit from preoperative consultations between the plastic surgeon and the treating mental health professional to discuss optimal care and support related to the surgical procedure.

Our findings suggest a correlation between the combination of anxiety and depression and patients reporting BII symptoms who desire breast implant removal. Moreover, multivariate analysis, which controlled for potential confounding factors and other variables, suggests that the combined diagnosis of anxiety and depression was statistically predictive of BII symptoms in the patients studied. Previous studies have described evaluation of patients with psychological testing, questionnaires, or interviews that proved helpful in evaluating psychological states preoperatively and postoperatively.^9,19 It was demonstrated in these studies that patients with self-reported BII symptoms were more anxious than other patients and that anxiety levels diminished after surgical intervention. In our study, we were particularly interested in a subset of patients who had been formally diagnosed with an anxiety-related disorder before surgery and were under current pharmacological treatment. These patients were of interest because they often have a mental health issue long established, a predisposition for more severe anxiety and depression, and a track record of treatment that includes both psychological and pharmacological modalities.²⁰

Anxiety and depression together present with comorbidities that make patients susceptible to worry and general mood dysfunction, and sensitive to negative stimuli.²⁰ Previous research has shown that patients with underlying anxiety disorders may be predisposed to environmental stressors, such as safety concerns, which can exacerbate anxiety, depression, or both.²¹ The presence of breast implants in patients with anxiety and depression can lead to a strong environmental stressor because the Internet and social media feed into the stress that these patients experience. For example, Internet-based anti–breast implant groups have been known to publish alarmist, anecdotal information meant to pressure patients to remove their own breast implants as a “health precaution” and to promote resolution of their “BII symptoms.” These interactions may lead to mood dysregulation in patients with underlying anxiety disorders, worsening anxiety.²¹ In patients with anxiety and depressive disorders, severe anxiety and depression can lead to increased somatic symptoms, including pain and pain tolerance as well as malaise, fatigue, and worsening mental health symptoms.¹⁵ Somatic symptoms developing in the presence of anxiety and depression can lead to exacerbation of the anxiet and /depression, creating a feedback loop. The body and the mind are interconnected, and it makes sense that BII patients with a preexisting anxiety or depression diagnosis are more susceptible to the self-reported illness. We believe that our data support the link between medically diagnosed anxiety and depression and BII symptoms, and we hypothesize that patients with anxiety and depression are particularly susceptible to negative interpretation of external and internal stimuli with nocebo-type effects.^10,22

Patients with self-reported BII symptoms desiring explantation tended to have earlier diagnoses and initiation of medication therapy for anxiety and/or depression than other cohorts. Earlier diagnosis of anxiety and depression means a longer duration of anxiety and depression for the patient. This trend is congruent with studies showing that comorbid anxiety and depression patients are diagnosed and treated a younger age than either anxiety or depression patients with a singular diagnosis.¹⁷ The severity of these comorbid conditions are higher than those of patients with isolated anxiety or depression diagnoses. In addition to earlier diagnosis, anxiety and depression patients have a lower rate of treatment success and more psychosocial impairment than isolated anxiety or depression cases.²³ Our data are consistent with these findings and suggest that patients with self-reported BII and anxiety and depression follow the trend of early diagnosis and early initiation of medication therapy when compared to other patients with isolated anxiety or depression.

Polypharmacy is the use of 2 or more medications for treatment of a patient's condition.²⁴ It is common for patients treated for anxiety-related disorders to be treated with 2 or more medications, especially for patients with comorbidities or more severe symptoms. Often, a second or third medication is utilized to treat symptoms not effectively treated with 1 medication, or to counteract the side effects of the primary agent. In our study, we found that patients with self-reported BII symptoms took significantly more medications for their mental health condition than patients in other cohorts. The total number of medications taken for the treatment of anxiety and depression was also statistically predictive of BII symptoms among the patients studied. Patients with self-reported BII evaluated in our study were typically managed with psychotropic polypharmacy. This can be explained by cumulative time spent in treatment since initial diagnosis, requirement of more than 1 psychotropic agent to address both anxiety and depressive symptoms, and increased likelihood of multiple medical trials over an extended period. Patients were typically prescribed a medication for anxiety or depression, such as an SSRI, then supplemented with an antidepressant. Often a third medication was prescribed for breakthrough anxiety or acute anxiety. These findings make sense due to the comorbidity of anxiety and depression, often requiring the treatment of each condition with medications that do not necessarily overlap. In addition, the increased number of prescribed medications for these patients may also suggest more severe forms of anxiety and depression compared to other cohorts, more refractory disease, the need to manage side effects, or the need for an acute antianxiety agent.²⁵ What is potentially relevant for plastic surgery practice is that patients who are taking more than 1 medication for anxiety and depression can be identified presurgically and preemptive treatment interventions can be performed, such as reducing the appearance or severity of self-reported BII symptoms.

Although the types of medications taken by patients did not significantly differ between the groups, certain trends were noted, consistent with current evidence-based guidelines for treatment of anxiety and depressive disorders.²⁶ SSRIs were the most frequent treatment for anxiety and depression (for singular and combined diagnoses), with over 80% of patients utilizing these medications. SNRIs were also commonly taken, with up to 16% of patients reportedly receiving these medications. Patients with self-reported BII symptoms had the highest utilization of benzodiazepines, with 32% of patients taking these medications for severe anxiety symptoms or breakthrough events. Benzodiazepines have fallen out of favor as a primary anxiety treatment due to addiction potential and are recommended for finite use in times of severe symptom burden.^27,28 The common use of benzodiazepines, up to 32% in the cohort self-reporting BII symptoms, suggests a potential correlation between severity of presurgical anxiety symptoms with BII symptom report.

One of the more interesting findings was the evaluation of cumulative years of counseling and therapy reported by patients with anxiety and/or depression in the treatment of their condition. Patients with self-reported BII symptoms showed significantly more years of cumulative counseling and therapy than the other cohorts, and the total length of time in counseling or therapy was predictive of self-reported BII symptoms. The majority of patients with self-reported BII symptoms and anxiety-related disorder indicated that they were being treated for anxiety and depression. When anxiety and depression are paired, treatments such as cognitive behavioral therapy (CBT), single-drug pharmacological therapy, and other treatments are less effective than when treating isolated anxiety or depression.²⁹ Past research has revealed that when compared to a patient with isolated anxiety, an anxiety patient struggling with comorbid depression has more impairment and a higher likelihood of a poor response to anxiety treatment.^30,31 The most successful treatment combination for patients with anxiety and depression has been combination therapy, linking CBT, medication therapy, and counseling.^25,26 It is logical that patients with an anxiety and depression diagnosis require a longer duration of treatment, because they are often diagnosed and treated earlier and their condition may be more resistant to therapeutic intervention.

Suri and Billick recently reported evidence that supports the value of a psychiatric approach for the treatment of patients with self-reported breast implant illness symptoms, as well as other diseases that may be comorbidities, such as fibromyalgia and chronic fatigue syndrome.³² Although the authors emphasized the psychological components of reported symptoms and the value of psychiatric treatment for patients with self-reported breast implant illness symptoms, they did not offer a mental health diagnosis for these patients. In the present study, we noted that many of the patients reported longer-term somatic symptoms, lasting at least 6 months or more. These patients described a strong focus on, anxiety about, and preoccupation with their symptoms. We believe that these findings suggest a possible link to somatic symptom disorder (SSD), a DSM-5 diagnosis established in 2013.³³ The diagnostic criteria for SSD includes 3 specific criteria, including 1 or more somatic symptoms that are distressing, high levels of anxiety and worry about health, and symptom duration of more than 6 months. Many patients reporting somatic symptoms that they believe are caused by their breast implants typically possess all of the features of somatic symptom disorder. SSD does not require formal diagnosis of an anxiety or depressive disorder, but patients may present with an anxiety disorder comorbidity. Patients with BII symptoms and high levels of anxiety may possess a subtype of somatic symptom disorder. The implications of this diagnosis are that treatment can be directed toward SSD, rather than surgical explantation, which may not be necessary in some patients.

Future Studies

Future studies should include prospective evaluation of mental health and correlation with self-reported BII symptoms. We believe that it will be helpful if studies in which medication and other treatment for anxiety and depression are evaluated include drug dosing and details of nonpharmacologic therapy for treatment of patients with self-reported BII symptoms. We suggest that a geographically heterogenous patient population of greater sample size be studied to provide the most representative national data. Finally, future studies should include further exploration of the relationship between somatic symptoms disorder (SSD) and self-reported BII.

CONCLUSIONS

The findings of this study suggest that patients presenting with self-reported BII symptoms often have preexisting anxiety and depression disorders that are medically treated before obtaining breast implants, and this anxiety and depression diagnosis predicts the occurrence of self-reported BII symptoms. We observed that patients with self-reported BII symptoms received a diagnosis of an anxiety-related disorder at an earlier age and initiated medication therapy earlier than other patients. Additionally, patients with self-reported BII symptoms took a higher number of medications per patient and spent longer durations in therapy and counseling compared with other patients undergoing elective breast surgery.

Given these findings, we recommend that patients with self-reported BII symptoms undergo counseling with their plastic surgeon before proceeding with surgery. This counseling should aim to provide the patient with a comprehensive understanding of the role of anxiety and depression in the pathogenesis of self-reported BII. Furthermore, consulting with the patient's mental health professional may prove beneficial to ensuring the provision of optimal supportive care.

Supplemental Material

This article contains supplemental material located online at www.aestheticsurgeryjournal.com.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

Author notes