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.

de sit aut et hiliaturio te quundi as ent lab ipsape volor simi, id magnimusam sant

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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