According to new research, the cosmetic application of Botox seems to lower symptoms of depression in some patients, possibly because it inhibits frowning. Previous research has demonstrated that physically expressing an emotion first can trigger subsequent feelings and that people who laugh or smile regularly can improve their mood. Studies have also shown that people find jokes funnier when a pencil is placed between their teeth lengthwise, which forces a smile, than when they hold it pointing outwards, which doesn’t. This is the second study to compare Botox to placebo. Although the results have not yet been thoroughly reviewed enough for publication in a scientific journal, the findings suggest that it may hold promise.

1. Dr Patrick Treacy
Dr Patrick Treacy is Medical Director
of Ailesbury Clinics Ltd and Ailesbury
Hair Clinics Ltd. He is Chairman of
the Irish Association of Cosmetic
Doctors and is Irish Regional
Representative of the British
Association of Cosmetic Doctors. Dr
Treacy is a renowned international
guest speaker and features regularly
on Irish breakfast television (TV3),
RTE and as an expert panelist with
the BBC World Service. He had
a series on Discovery Health and
the Discovery Channel (New York)
recently filmed a programme about
his work. He is an active member of
many international medical societies
and is a Fellow of The Royal Society
of Medicine.
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CLINICAL - Botulinum toxin
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
Tears of
a frown
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. Dr Patrick Treacy
looks at the current data to support this theory.
22 www.cosmeticnewsuk.com

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REFERENCES
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
way modulated the processing of emotions.
Many other researchers have continued down
this road with Havas (2010) noting that the
processing time for sentences with negative
affective connotation was prolonged in women
after glabellar botulinum toxin treatment and
Neal and Chartrand (2011) speculating that
the treatment interfered with the ability to
decode the facial expression of other people.
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. However a footnote
by editor Alastair Carruthers stated that the
report must be considered anecdotal as there
were no appropriate methods of control utilized.
In addition, there were other methodological
weaknesses including limited follow-up, lack of
randomization, the absence of blind evaluation,
and especially the small number of individuals
included. It was considered by many that the
method evaluating depression should have been
more rigorous. I noted by letter at the time that
patients’ self-report of depressive symptoms
by administration of the BDI-II introduced
a significant self-report bias. This is of more
concern because of the potential for secondary
cosmetic gain. While the BDI-II is an accepted
method of evaluating an individual’s level of
symptoms over time, self-report in isolation
was not considered an acceptable method of
diagnosing depression. It was concluded that
in order to ensure that patients’ psychiatric
symptoms are accurately classified; a thorough
psychiatric interview must be conducted.
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. To
explore, if attenuation of these features may
produce alleviation in the affective symptoms,
they conducted a randomized controlled trial of
botulinum toxin injection to the glabellar region as
an adjunctive treatment of major depression. The
study was investigator-initiated and was carried
out independently of any commercial entity.
Participants in the study were recruited
from local psychiatric outpatient units and
psychiatrists in private practice. In order to
avoid attracting candidates who were primarily
motivated by receiving this treatment for
cosmetic reasons, botulinum toxin treatment,
was not explicitly mentioned. 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.
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