Overcoming Pain

Why people experience chronic pain, and the power they have to de-intensify it

Botox and Depression: The Frownless Face of Happiness

Botox to remove frowns, and reduce depression. Keep smiling, Joan Rivers.

If you frown all the time, it is likely you feel a certain amount of pain, or at least discomfort; because, after all, you are using many more muscles to maintain that frown, compared to what is needed to light up the world with a smile. Your face becomes physically drained, literally weighed downward by whatever weight of the world you choose to experience that day. Chances are, also, that you are not a happy person—what, with all that frowning going on.

But is it the frown causing the depression? Or is it the depression causing the frown?

A recent article in the Journal of Psychiatric Research reports that in a randomized, placebo-controlled trial, Botox injections utilized to disable the facial muscles responsible for frowning were effective in relieving clinical depression.

Among the 33 patients meeting DSM-IV criteria for major depression who were assigned to receive Botox injections, 17 (52 percent) showed decreases of at least 50 percent from baseline in Montgomery-Asberg Depression Rating Scale (MADRS) scored six weeks after treatment, compared with six of 41 (15 percent) injected with the control treatment, saline.

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More compelling, clinical remission, defined as a MADRS score of 10 or less at final evaluation, was achieved by 27 percent of the Botox group versus 7 percent of the placebo group.

While this is not a novel finding, it is important in that this latest Botox study confirms what was found after a European trial published in the Journal of Psychiatric Research in 2012: In that trial, patients with both observable frowns and persistent depression despite conventional treatments who received Botox injections showed significantly greater reductions in Hamilton Depression Rating Scale scores than a placebo group.

The latest study, however, was more robust, as there were more subjects, a greater clinical mix of subjects, and a clearer demonstration of remission of symptoms of depression: In the current study, the researchers recruited a total of 85 patients with major depression as diagnosed from a standard clinical interview. Inclusion criteria also included a MADRS score indicative of significant depression, as well as a clearly unfavorable Clinical Global Impression-Severity score.

So now scholars, patients suffering from depression, and Botox devotees have two studies providing evidence that facial expressions may affect mood. Recall that past studies have found that forcing smiles can lead to subjective mood improvements. Now, simply incapacitating the muscles responsible for producing unhappy expressions can have a similar effect:

The injections were delivered at five locations in the corrugator and procerus muscles between the eyebrows, roughly defining a letter V on the face.

Dermatologists analyzed the appearance of frowns on the faces of subjects, based on photographs provided by the study team, rating them with a "frown score" before and after treatment. In just under two-thirds of cases, the presence or absence of significant changes in frown score corresponded to a clinical depression response or nonresponse.

Analyses of these data against MADRS scores indicated that the effects on depression were the same in those guessing correctly versus those who guessed incorrectly.

The investigators, in their conclusions, identified several potential advantages of Botox as a depression treatment:

• Improved compliance

• Cost-effective (compared to newer psychotropic medications)

• Few drug interactions

• Well-documented safety

Still, there were several limitations of the study. Because more than 90 percent of participants were women, conclusions about the treatment's effectiveness in men are speculation at this point. The study's six-week duration meant the antidepressant effect's durability remains in question. And, a mean of nine days elapsed between screening and treatment, during which participants' depression may have changed; and thus the study might not have captured the emotional reality for a given subject.

I cannot help but wonder how happy I would feel after seeing fewer wrinkles after a Botox injection. Perhaps a beneficial side effect is the phenomenon responsible for all those happy study participants?

Mark Borigini, M.D., is a board-certified rheumatologist who has devoted his career to treating illnesses that cause chronic pain and disability.

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