Major depressive disorder with religious struggle and completed suicide after hair transplantation.

OBJECTIVES: Psychological outcomes of aesthetic surgical procedures like hair transplantation are mostly positive including decreased anxiety, depression and social phobia and increased general well-being, self-efficacy and self-esteem. However, some patients may suffer from post-surgical depression and post-surgical increased suicide rates have been reported for breast augmentation patients. Difficulty adapting to the new image, unfulfilled psychological needs expected to be met by the surgery, side effects of the surgery like tissue swelling or bruising, uncontrolled pain, presence of body dysmorphic disorder and previous history of mood disorder may be some of the risk factors for post-surgical depression.
METHODS: Here, we present a case without prior psychiatric history who developed major depressive disorder after hair transplantation and died of suicide.
RESULTS: He started experiencing religious struggle related to his decision about the hair transplant which he interpreted as acting against God's will. While religious involvement has been reported to be a protective factor against depression, spiritual struggle, which includes religious guilt, has been described as an important risk factor for depression, hopelessness and suicidality which might explain the severity of depression in our patient.
CONCLUSIONS: This case highlights the importance of a detailed psychiatric evaluation and exploration of religious concerns of any patient before any type of aesthetic surgery. Major depressive disorder is a treatable condition; however, mild depression can go unnoticed. Religious belief and related religious practices affect an individual's personal health attitudes; therefore, we think that every physician is needed to explore the religious concerns of any patient during any medical examination or surgical procedure. Relevant religious authorities should be consulted when necessary.

Introduction

Hair loss is common among men worldwide and can potentially decrease the quality of life (QoL), reduce self-confidence, and if visible, may even cause depression.[1,2] On the other hand, patients who undergo hair restoring procedures have reported increased self-esteem.[3,4] Hair transplantation is a treatment option for hair loss in patients who have failed to respond to medical treatments such as minoxidil or finasteride.[5] However, hair transplantation may also have adverse effects. Pain, pruritus, bacterial folliculitis, numbness or paresthesia, subdermal cyst formation, and crusting or necrosis at the recipient or donor site are some of the reported complications of the procedure.[6] We have not found any reported cases of psychopathology that developed or worsened after hair transplantation in the literature. Here, we present the case of a person without prior psychiatric history who developed major depressive disorder (MDD) after hair transplantation and committed suicide. He started experiencing an inner struggle based on religious beliefs related to his decision about the hair transplant, which he interpreted as acting against God’s will, and this religious struggle aggravated his MDD.

Case

A 47-year-old male, Turkish-Muslim patient living in Germany received a hair transplant for baldness. Three months after the operation, he started having feelings of guilt, reluctance, decreased interest in life, inability to accomplish his religious responsibilities and had decreased levels of energy. He had no previous history of psychiatric disease. He believed that his state of baldness was how God had created him; therefore, he was feeling sinful for having acted against God’s will by receiving a hair transplantation. He talked about his religious struggle with a Turkish imam in Germany but that did not comfort him. The imam advised him to see a psychiatrist. However, the patient did not want to see a non-Muslim physician. Therefore, he was brought to Turkey for psychiatric treatment by his brother in order for a Turkish-Muslim physician to be able to persuade him and change these religious guilt–related thoughts. He was examined by the first author. He was looking older than his age and had decreased eye contact. He had depressed affect congruent with his depressed mood. His speech was monotonous. He had ruminations about having made a sin with his decision to have a hair transplant. He stated that, he was self-conscious when he made his decision to get the operation without anyone forcing him to do so. He believed he was guilty because getting the operation was not an unforeseen event but a planned rebellious act against the way God had wanted him to be. The physician tried to reframe these thoughts as cognitive distortions related to depressive disorder and offered antidepressant drug treatment combined with cognitive psychotherapy. However, the patient refused any treatment because he believed he had deserved this suffering as a way of punishment. He returned to Germany; therefore, he was referred to a German psychiatrist who suggested hospitalization of the patient. Unfortunately, the patient declined all treatment options and killed himself via hanging.

Discussion

Aesthetic surgical procedures like hair transplantation are elective and the reported psychological outcomes are mostly positive including decreased anxiety, depression and social phobia and increased general well-being, self-efficacy and self-esteem.[7] However, some patients may suffer from post-surgical depression and post-surgical increased suicide rates have been reported for breast augmentation patients.[4] Difficulty adapting to the new image, unfulfilled psychological needs expected to be met by the surgery, side effects of the surgery like tissue swelling or bruising, uncontrolled pain, presence of body dysmorphic disorder and previous history of mood disorder may be some of the risk factors for post-surgical depression. Our patient had none of these risk factors.

Aesthetic operations are not essential for the somatic well-being of the person and are generally negatively criticized by the general public which may provoke feelings of guilt. Our patient was feeling guilty of acting against God’s will because he believed he had been destined by God to become bald. In his point of view, receiving a hair transplant was choosing how he wanted to be and in a way creating his way of being which was like denying God’s role as the sole creator which is a sin. Excessive feelings of guilt is a symptom of MDD and those who are more prone to feel excessive self-blaming emotions may have increased risk of MDD.[8] Therefore, the patient’s religious interpretations were symptoms of his MDD.

Religious involvement has been reported to be a protective factor against depression.[9,10] In contrast, spiritual struggle, which includes religious guilt, has been described as an important risk factor for depression, hopelessness and suicidality which might explain the severity of depression in our patient.[11-13]

Hair loss has a negative impact on self-esteem which might have caused a mild depressive disorder in our patient that was not recognized by anyone before the transplantation. After the operation, some members of the Turkish-Muslim community he belonged to had criticized him which might have provoked religious guilt. The religious struggle had probably deepened his depression. He believed he had deserved some form of punishment that’s why he had rejected any form of treatment. In the vicious cycle of untreated MDD and religious struggle he eventually committed suicide, which might seem contradictory with the religious struggle hypothesis given that suicide is forbidden in Islam. We suggest that this contradictory action is the result of cognitive dysfunction and hopelessness symptoms of MDD.

This case highlights the importance of a detailed psychiatric evaluation and exploration of religious concerns of any patient before any type of aesthetic surgery. MDD is a treatable condition; however, mild depression can go unnoticed. Religious belief and related religious practices affect an individual’s personal health attitudes; therefore, we think that every physician is needed to explore the religious concerns of any patient during any medical examination or surgical procedure. Relevant religious authorities should be consulted when necessary.