'Botox and Depression' -the evidence

DUBLIN - May 6, 2013 - PRLog -- We have all seen individuals whose mood has changed positively following BTX-A injection in the brow area. Now there is growing evidence that treatment of the glabellar area may actually be used to treat depression. In this paper Dr. Patrick Treacy Ailesbury Clinic Dublin looks at the current data to support this theory.

Depression affects over 120 million people globally, making it one of the leading causes of disability in the world. Although there are various effective treatments, therapeutic response remains unsatisfactory and depression can develop as a chronic condition in a considerable proportion of patients. Negative emotions, such as anger, fear, and sadness are prevalent in depression and also are associated with hyperactivity of the corrugator and procerus muscles in the glabellar region of the face.

In 1872, Charles Darwin recognised these features as a very specific expression of sadness and attributed them to the activity of so-called ‘grief muscles’ in the glabellar region. He also formulated a new theory called the ‘facial feedback hypothesis’, which implied a mutual interaction between emotions and facial muscle activity. More recently, Larsen et al. have shown experimental evidence that voluntary contraction of facial muscles can channel emotions, which are conversely expressed by activation of these muscles.

        Heckmann and others (1992) have published data suggesting that treatment of the glabellar region with botulinum toxin produces a change in facial expression from angry, sad, and fearful to happy and this can impact on emotional experience. Many therapists, including Sommer (2003) have shown that patients who have been treated in the glabellar area reported an increase in emotional wellbeing and reduced levels of fear and sadness beyond what would be expected from the cosmetic benefit alone. Hennenlotter (2009) went one stage further and showed that botulinum toxin treatment to the glabellar area stopped the activation of limbic brain regions normally seen during voluntary contraction of the corrugator and procerus muscles. This indicated that feedback from the facial musculature in this region in some way modulated the processing of emotions. This is where things were until recently with many authors suggesting that this capacity to counteract negative emotions could be put to some clinical use during the treatment of depression.

       There were some papers; including preliminary data from an open case series with ten female patients in the Journal of Derm. Surgery by Finzi and Wasserman (2006) that postulated that botulinum toxin in the glabellar actually demonstrated a reduction in the symptoms of depression. More recently, two centers, the Psychiatric University Hospital of the University of Basel, Switzerland and the Medical School Hannover, Germany conducted a randomised, placebo-controlled, double-blind trial. The authors hypothesised that facial psychomotor features associated with depression are not just epiphenomena but integral components of the disorder and may be targeted in its therapy. Participants in the study were recruited from local psychiatric outpatient units and psychiatrists in private practice. Exclusion criteria included psychotic symptoms, suicidal tendency and clinical severity requiring immediate intervention. The same injection scheme was applied in the open case series (Finzl and Wasserman, 2006). At each study visit participants were assessed using the Hamilton Depression Rating Scale with Atypical Depression Supplement (SIGH-ADS), the Beck Depression Inventory (BDI) self-rating questionnaire and the Clinical Global Impressions Scale (CGI). To conceal cosmetic changes from psychometric raters, participants wore an opaque surgical cap, which covered glabella and forehead during the examinations.

 The study concluded for the first time that a single botulinum treatment of the glabellar region with could reduce the symptoms of major depression. This effect developed within few weeks and persisted until the end of the sixteen-week follow-up period. The effect sizes in the study were large and the response and remission rates were high.

        It is still unknown how botulinum toxin actually reduces depression and it is postulated that several mechanisms may actually be involved: Because of the clinical data relating to botulinum toxin treatment on emotional perception, it is assumed that reduced proprioceptive feedback from the paralyzed facial muscles is a relevant mechanism of mood improvement. It is reasonable to assume an aesthetic benefit as the major cause of mood improvement, because the authors did not include patients who were cosmetically concerned about their frown lines. There is a small possibility of either placebo effect or central pharmacological botulinum toxin effects including possible pharmacodynamics or pharmacokinetic interactions with the concomitant antidepressant therapy.

        In summary, there is growing evidence that botulinum toxin injection to the glabellar region may be an effective, safe, and sustainable intervention in the treatment of depression. The reason for this has not yet been fully evaluated but we must consider the concept that the facial musculature not only expresses, but also regulates, mood states. Because of the long treatment intervals it may also be an economic treatment option and the safety and tolerability record of botulinum toxin injections to the glabellar region is excellent.

Further studies are required, including focus on muscles in lower sections of the face. It is possible that treatment of the depressor angularis oris and the mentalis muscles, for example, may also have mood-elevating effects and may enhance the clinical effect of the glabellar injection of botulinum toxin. Modulation of mood states with botulinum toxin may also be effective in the treatment of other clinical conditions involving negative emotions, like anxiety disorders. There also have been recent studies investigating the possibility of botulinum toxin for bipolar disorder and post-traumatic stress disorder. PTSD. There is a certain irony to the fact that soldiers returning from combat zones at risk of chemical warfare been treated for PTSD may be now treated with botulinum toxin. Even to the uninitiated, it would appear to have turned the full circle.

Facing depression with botulinum toxin: a randomized controlled trial.  Journal of psychiatric research May 2012  Wollmer MA, de Boer C, Kalak N, Beck J, Götz T, Schmidt T, Hodzic M