Depressive disorders in patients who seek cosmetic surgery : a broad and updated view

Introdução: A cirurgia estética pode melhorar a qualidade de vida de pacientes, porém alguns que se apresentam para o procedimento são portadores de transtornos depressivos (TD) e podem evoluir, no pós-operatório, de forma desastrosa do ponto de vista psicológico e até mesmo evoluir para o suicídio. A prevalência de TD em pacientes de cirurgia plástica estética é em média de 20%, podendo chegar até 70%. Este artigo tem por objetivo fazer uma revisão sobre depressão e cirurgia estética bem como alertar e conscientizar os cirurgiões plásticos sobre o crescente aumento destes pacientes nos consultórios. Objetiva, ainda, orientar os cirurgiões quanto a abordagem adequada e condutas específicas perante estes. Métodos: Realizou-se busca nos bancos de dados MEDLINE/ PubMed e Embase e cruzamento de palavras chaves, incluindo “cirurgia plástica estética”, “depressão”; “transtornos de humor”, “transtorno depressivo”, “sintomas depressivos”, “suicídio e cirurgia plástica”. Resultados: O sucesso de uma cirurgia plástica depende em muito da seleção dos pacientes para o procedimento. Pacientes suspeitos, pacientes com sintomas depressivos elevados nos questionários (como o BDI) e pacientes com “marcadores” de psicopatologia deverão ser encaminhados ao psiquiatra para avaliação adequada. Conclusão: Pela elevada prevalência de TD em cirurgia plástica estética, todo paciente de cirurgia plástica deverá ser avaliado adequadamente para identificação daqueles com possíveis TD no pré-operatório e encaminhado ao psiquiatra, para assim tentar se evitar evolução psicológica desfavorável pós-operatória. ■ RESUMO


INTRODUCTION
Body image is one of the constructors of selfesteem, which is influenced by a variety of historical, temporal, cultural, social, individual, biological, and religious factors that operate at variable intervals 1 .Dissatisfaction with this body image is the most relevant factor and the main motivator of demand for cosmetic surgery procedures 2 .Thus, aesthetic surgery is an essential component of plastic surgery due to its capacity not only to restore function at the physical level but, equally important, to stimulate positive changes in the personality and behavior of an individual as well as several favorable postoperative psychological reactions, including individual/social well-being and self-confidence [2][3][4][5][6][7][8] .
Nevertheless, it is difficult to quantify the exact benefit that plastic surgery may have for the patient's psyche 3 .Of the patients who seek a consultation for an aesthetic procedure, up to 47.7% fit the criteria for a mental disorder 8 .They seek in surgery the illusion of achieving an ideal body image with the purpose of decreasing their anguish and feelings of constant dissatisfaction 9,10 .Several studies have demonstrated that patients who seek cosmetic surgery present larger psychological alterations when compared to the general population [2][3][4]11,12 , and the most common disorder found was depression [11][12][13] . Depession is a generic term and can encompass depressive symptoms, depressive episodes, and/or depressive disorders (DDs).
This article aims to review DDs and plastic surgery and to alert and educate plastic surgeons on the growing number in these patients during a medical consultation.It also aims to guide surgeons regarding the appropriate approach and practices for these patients and thus avoid possible unfavorable developments in terms of postoperative function and psychological adaptation, regardless of a technically satisfactory result.

History
Mood disorders (which include depression) have been known for approximately 2,500 years and were long called melancholy.In the 19th century, the term "depression" found a place in the medical literature with the use of the translation of "melancholy" from the Latin word "deprimere" meaning to lower or depress 14 .
One of the first descriptions of psychological changes related to a surgical procedure was observed in a patient of the psychiatrist Sigmund Freud who underwent an aesthetic surgical procedure in 1918.His obsession, related to a trivial scar left by removing a cyst, became a focus of one of the most famous cases in the annals of psychiatry 14 .
Surgical advances obtained in the First World War (1914-1918) and reports of emotional relief observed in scarred individuals served as fuel for the growth of aesthetic surgery 15 .
Some surgeons performed the first psychiatric evaluations of patients who sought aesthetic surgery in the '40s, '50s, and '60s and described these patients as having highly psychopathological profiles, becoming cautious with insatiable and male patients 15 .However, these first evaluations did not use adequate methodology, analysis, and standardization, affecting the quality of results and benchmarking of the relationship between DDs and plastic surgery 15 .

Epidemiology
Depression is a highly lethal disease that often initiates in individuals between 20 and 40 years old with a ratio of up to 2:1 between women and men 2,16 .
In Brazil, approximately 10% of the adult population presents depressive symptoms.In this group, only 28.1% received a diagnosis for the syndrome (DDs), and an even smaller portion (15.6%) used medications prescribed by specialists for their clinical control 16 .
According to the World Health Organization (WHO), DDs currently affect more than 350 million people in the world and are already the second cause of Disability Adjusted Life Years in the age range of 15 to 44 years old in both genders.It is estimated that, in 2020, DDs will occupy the first position in developing countries and the second in developed countries and will be the most important cause of disability in both genders, in any age group, followed by coronary diseases.In 2030, DD is calculated to be the most common disease in the world 16 .
Depression is already the most common disease in children and adolescents between 10 and 19 years old and is the main cause of disability in both genders.Suicide is one of the three main causes of death in that age range 16 .
More than 90% of patients who use psychotropic medication use antidepressants with a predominance of women 3,11,13 .
The association between DDs and suicide is consistent and significant, and the average risk of suicide observed among patients with depression is around 30 times higher than in the general population 8,17 .It is possible to establish a diagnosis of depression among 20.8% to 35.8% of completed suicides (WHO), and a 60% increase in the rates of suicide in the last decades was observed, considering global data.It is estimated that 90% of the suicides in older adults are associated with some type of mental disease, and the most frequent is depression 2,13,16,17 .

Etiology
Depression is a mental disorder due to internal conflict and a biochemical alteration in neurons responsible for controlling the mood state and can be triggered by heritable genetic, psychological, environmental, and biochemical factors 4 .
Associated factors such as urban life; unemployment; physical diseases; prior affective changes; stressful events; loss of loved ones; and use of medication, alcohol, and other drugs may be factors triggering or aggravating DDs 11 .
In spite of all efforts, the etiology and pathophysiology of DDs are not yet well defined.Imaging studies related to the analysis of the neurobiological and genetic mechanisms of depression have shown promising results.

Diagnosis
Depression is a difficult affective condition to assess.As a clinical entity, it is classified in the ICD-10 and DSM-V in the mood disorder categories 18 .Its diagnosis should be done clinically by a psychiatrist during an accurate and consistent clinical examination of the patient 1,4,9,13,15 .
However, in the day-to-day routine, the plastic surgeon, as well as the entire medical class, should be attentive, trained, and prepared to identify not only the physical complaints but also possible psychological symptoms presented by the patient during the consultation.
vary according to the sample and the purpose of the examiner" 19,20 .

PSYCHOPATHOLOGY OF DEPRESSIVE DISORDER AND PLASTIC SURGERY
Currently, DD is considered one of the great challenges of medicine due to its high and growing prevalence, chronicity, and therapeutic implications in the world population 16,[19][20][21]23,24,26 . Until th advent of AIDS, depression held the incontestable title of "Evil of the Century."However, even devoid now of this pointless honor, it continues to increase without hindrance throughout the world, along with several other mental illnesses.
Some authors have demonstrated that improvements related to cosmetic surgery are confined solely to the physical domain, providing little or no change in psychological functions 5,15,25,26 .However, a large number of articles have shown that aesthetic surgery can provide benefits to people not only in the relief of physical symptoms but also in the degree of satisfaction with body image, quality of life, self-esteem, social confidence, sexual function, behavior, and reduction of depressive symptoms [5][6][7][8][9][10][11][12][13]15,[21][22][23] .
From a philosophical point of view, the result and level of satisfaction (often subjective) regarding surgery are more directly related to cultural factors and temporal patterns of beauty than an appreciation of the beauty of patients' own body results.
A strong correlation is observed in the day-to-day between the preoperative psychological history and postoperative psychological complications.There is a belief that aesthetic surgery is psychologically safe, and it is not.Psychological complications may occur at rates equal to or greater than physical complications in daily practice.Patients who present physical complications are prone to undergo psychological complications simultaneously 22,23 .
Patients can progress improperly or even disastrously in the postoperative period, even with an adequate surgical result.Altered psychological states or negative body image can irreparably affect One must observe the nature of the symptoms, use of some type of substance, personal and family history of depression, history of psychiatric hospitalization, use of psychotropic drugs (and who prescribed them), psychotherapy, or even apathetic behavior alternating with euphoria 1,4,5,8,9,11-13 .
Scales, questionnaires, and inventories contribute substantially in the medical office towards the screening of possible mental diseases including DDs 19 .
Beck et al. 19 developed a questionnaire, the Beck Depression Inventory (BDI), to evaluate the intensity of depression symptoms; the questionnaire presented internal consistency and reliability.It is a practical instrument with a high rate of acceptance, credibility, and accuracy and was translated, adapted, and validated for use in Brazil 20 .This is a self-reporting scale containing 21 groups of statements, each item showing symptoms and attitudes at varying intensities from 0 to 3, suggesting increased degrees of depressive symptom severity (Annex 1) 20 .
The total score is the result of the sum of all item scores and allows the classification of symptomatic intensity levels of depression with a minimum score of 0 and a maximum of 63 points.The operating manual of the BDI proposes a stratification in which the presence of 1 to 9 positive points corresponds to the symptoms of minimal depression (from 10 to 16: mild symptoms of depression, from 17 to 29: symptoms of moderate depression, and 30 or more: symptoms of severe depression).The limit between symptoms of mild and moderate depression (≥ 17 positive responses) is used as the cut-off point among negative and positive cases as significant risk of depression; however, the manual itself guides that "the cutoff points may Candidates for breast augmentation surgery with implants feature striking personal characteristics with a higher number of depressive symptoms 13,23,33,38 , psychiatric history 39 , psychotherapy 2,11 , psychiatric hospitalization 32,39 , suicide [32][33][34][35][36][37][38][39] , and greater use of psychotropic drugs -in particular, antidepressants which are used up to seven times more, when compared with other plastic surgery patients or women in the general population 11,22,35 .Underlying risk factors and complementary psychopathological characteristics are also observed in this population, including low educational level 24,36 , behavior disorders, and higher prevalence of eating disorders 5,11,22,23 .

Patient selection
It is known that the key to success with plastic surgery lies in the preoperative selection of patients, and the key is prevention instead of treatment.
Some authors defend that the psychiatric evaluation should always be performed routinely in all aesthetic surgery patients 13 .
However, the request for a psychiatric evaluation can, for some individuals, cause distance and malaise in the doctor-patient relationship, creating an embarrassing situation with increased time for preoperative preparation and costs and may seem like an insult or even an aggression 8,23 .
Not all candidates for aesthetic surgeries have a high probability of psychiatric problems.On the contrary, the great majority presents a high degree of postoperative satisfaction 11 .The difficulty, then, is to recognize which patients who seek these surgeries have psychological stability, have an established psychiatric disorder (controlled or not), or are even close to being triggered and if these individuals are more prone to experience an exacerbation of psychiatric symptoms in the postoperative period.Recognition and awareness of these profiles (preoperative) constitute the first line of defense of the surgeon in the prevention of postoperative psychological complications 11 .
Plastic surgeons must be alert to the possible patients who present for the different surgical procedures by means of a well-clarified consultation about their symptoms and their (real) motivations and clinical history, including mental health and some investigative method (questionnaire) in all patients.
The BDI as a self-evaluation measure of depressive symptoms is a useful instrument for the non-specialist, taking an average time of 5 minutes to be answered.Although without diagnostic accuracy (reserved for the psychiatrist), its use may assist in screening and identifying possible patients with DDs perceptions of satisfaction with a surgical intervention.Postoperative dissatisfaction is generally caused by emotional disappointment through breakage or violation of their expectations or through a psychopathologic façade unnoticed by the surgeon and (usually) not through technical failure 3,5 .
Patients with lower preoperative psychological alterations seem to obtain better postoperative satisfaction with aesthetic surgery.On the other hand, patients identified with signs of depression in the preoperative period may present up to five times more dissatisfaction with their surgical results in the postoperative period 3,4,11,13,15,21,24,25 .
Depressive patients may have simple psychosomatic complaints, claims, general dissatisfactions, slight or larger depressive clinical pictures, anger, aggressiveness, and medical processes 27,28 and, in extreme cases, may progress to suicide based on the high correlation of depression and suicide 16,[27][28][29][30] .
Moved by constant dissatisfaction, some patients request repeated procedures, generating problems for the surgeon such as anguish and burnout.More extreme situations can occur against the professional such as exposure, risk of persecution, body threat, physical violence, and legal actions.The literature even reports cases of surgeons who were murdered by patients who presented symptoms consistent with psychosomatics alterations 27,31 .

Correlation of implant breast augmentation with depression and suicide
A series of important studies from different countries has been published with the goal of increasing the awareness of the possible mental health problems related to breast implants.Intriguing and alarming data have demonstrated potential risks of increase of suicide in patients submitted to breast augmentation compared to the general population.These findings demonstrated relative risk for suicide in all these studies and may reach up to 4 times higher risk [32][33][34][35][36][37][38] .
However, a cause and effect relationship could not be identified, and nor could the presence of potential preoperative risk factors or psychopathological profiles that could put these women at greatest risk of suicide.It is suggested that this probably occurs due to the sociodemographic traits, psychopathologic history, and specific lifestyles of these patients rather than the presence of the implant itself.Among them, smoking, excessive alcohol consumption, drug dependencies, civil status/divorce, and parity are the main risk factors associated with depression and, consequently, a greater risk for suicide 2,3,5,21,23,27,30,32 .and the appropriate forwarding for mental health evaluation by a qualified professional 4,13,19,20 .
It is suggested that all patients with the above characteristics be forwarded to the psychiatrist (preferably with the surgeon's confidence) for a more detailed and enlightening assessment, and a psychiatric opinion should be added to the patient's record, releasing him or her for the surgical act from the point of view of mental health, along with the signed Free and Informed Consent Form.Patients dissatisfied with their postoperative results can use their psychiatric history as part of their judicial action against the surgeon, claiming that their psychiatric framework prevented them from understanding the surgery, limitations, complications, and potential results 2,5,11,23,31 .
The presence of a history of psychiatric hospitalization represents a strong and important predictive factor of postoperative complications and suicide when compared with the general population 30,39 .
The impact of surgical procedures in the areas of psychological function remains poorly known, and the relationship between the treatment of DDs and postoperative evolution is unknown 5,21 .Thus, as long as there are sufficient data for the triage of these patients with well-defined risk factors for psychopathology and suicide, it is prudent to assess each case and forward for psychiatric evaluation patients identified as high risk before the surgical procedure for a more consistent and rigorous evaluation.The psychiatrist shall decide if the patient can undergo the procedure or not and at what moment or if they need specific treatment (psychotherapy and/or drug therapy).The success of the surgery in this population depends on a successful treatment of depression.
For patients who develop DDs in the postoperative period, it is imperative that they be referred immediately to a psychiatrist to limit or control this adverse experience and, thus, promote their well-being.
Contraindicating or postponing a cosmetic surgery in a patient with a possible DD does not mean insecurity or lack of skills or lack of respect for the patient.It means caution, concern, and well-being for the patient and especially wisdom and professional maturity.

CONCLUSION
Cosmetic surgery patients should be evaluated properly for the identification of those with possible DDs preoperatively, thus avoiding an unfavorable postoperative evolution.

COLLABORATIONS PRP
Writing of the manuscript and critical review of its contents.

RFJ
Final approval of the study.

MP
Conception and design of the study.
CGLN Analysis and interpretation of the data.

FCFA Statistical analysis.
VEBV Critical review of contents.