Is Botox useful for more than just an aesthetic purpose?

When people opt for botulinum toxin injections to smooth out fine lines and wrinkles on their face, they can expect to look more rested, more relaxed, and even a little younger. You may be surprised to find that you end up feeling calmer as well, and not just because of the changes you see in the mirror. Research has looked into the effects of botulinum toxin A injections on depressed mood and anxiety and found that they can lead to significant improvements in these symptoms.

Botulinum toxin is a poisonous biological substance produced by bacteria. Clostridium botulinum It occurs naturally in plants, soil and water. When used as a therapeutic injectable neurotoxin, it temporarily paralyzes muscles, thereby reducing or eliminating unwanted lines or expression lines. Common brands include Botox, Dysport, Xeomin and Jeuveau. But many people don’t know that botulinum toxin injections are also used to treat non-cosmetic conditions such as chronic migraine, hyperhidrosis (excessive sweating), cervical dystonia (a painful condition accompanied by involuntary contractions of the neck muscles), and an overactive bladder.

Now doctors and scientists are studying the effect of the toxin on mood disorders. Experts say that while botulinum toxin injections are not approved for the treatment of depression or anxiety, preliminary research is encouraging, although more clinical trials are needed to support their use in these disorders.

“Depression is a serious illness, and a third of patients with depression do not respond to antidepressants,” says Michelle Magid, assistant professor of psychiatry at the University of Texas Dell School of Medicine. “When this happens, we have to think outside the box. We are all looking for additional tools to our healing toolkit.”

In a study published in the June 2023 issue of the journal toxinsThe researchers found that 53% of men and women who sought treatment for depression and received injections of botulinum toxin A into the glabellar muscles (glabellar muscles) experienced a significant improvement in symptoms.

In a previous study published in Brain and behavior people with depression who were injected with botulinum toxin A into various muscles between the eyebrows were found to have a reduction in depression comparable to that of those who took sertraline (an antidepressant, a selective serotonin reuptake inhibitor) after 12 weeks; however, with the injections, mood improvement was faster and there were fewer side effects than with the antidepressant.

With results like these, it’s suggested that “beauty treatments improve your appearance, which makes you feel better,” says Magid. “But there is more.

In fact, there are several theories about what happens below the surface. One has to do with the so-called “facial feedback hypothesis,” the idea “that the relationship between internal emotional states and facial expressions is bidirectional,” explains Norman Rosenthal, a clinical professor of psychiatry at Georgetown University who has studied the effects of botulinum toxin injections on depression and social anxiety. “If you are sad, it will show on your face. But if your face takes on a sad or pained expression, it will reflect in your brain and cause a real feeling.

So if the muscles involved in expressing anger or sadness can’t frown or create an unhappy facial expression, your brain won’t get the signal that you feel that way. In other words, both muscle and cognitive memory are involved in emotional experiences: the facial muscles remember a certain mood, while the mind relies on the muscles to evoke feelings.

When botulinum toxin injections “sever the link between your muscle memory and your psychological state, you can have a therapeutic effect” if you’re prone to depression or anxiety, says Ruben Abagian, a physical and computational chemist and professor at UC Skaggs School of Pharmacy and Pharmaceutical Sciences.

In a review of three randomized controlled trials involving a total of 134 people, Magid and colleagues found that a single injection of botulinum toxin A into the brow area reduced symptoms of major depressive disorder. This resulted in improved mood, improved sleep, and increased energy and hope in 54% of the subjects, including remission of depression in 31% of the participants.

Further evidence of effects on the brain comes from a study Scientific reports in which the researchers used botulinum toxin injections to induce temporary paralysis of the frowning muscles and used functional magnetic resonance imaging (fMRI) to measure participants’ brain activity while viewing images of happy and angry faces. The researchers found that by preventing the brow muscles from contracting and thus preventing them from frowning, the injections altered the participants’ amygdala response to emotional faces.

Research published in 2022 in the journal Belgian neurological law investigated the effects of botulinum toxin injections on people with hemifacial spasm, a neuromuscular disorder that involves frequent muscle spasms on one side of the face and is often accompanied by psychological distress. The researchers found that the injections dramatically improved the participants’ emotional state, especially their depression, anxiety, and ability to accurately perceive and respond to other people.

There is even scientific evidence from MRI that the injection of botulinum toxin into the forehead reduces the activity of the amygdala, which is activated when experiencing fear, depression, anger and other negative emotions. This may be one reason why people with agitated depression — a “mixed” form of depression characterized by irritability, restlessness, and anxiety, as well as sadness or low mood — “respond better to Botox than to drugs,” Magid says. “When people get excited about depression, it’s very difficult to treat depression.”

Mood swings associated with botulinum toxin injections do not only occur with injections into the forehead and face. When Abagyan and colleagues examined post-marketing safety data for botulinum toxin injections for various indications (cosmetic use, migraine, muscle spasticity, neck pain, increased sweating, etc.), they found lower rates of anxiety and depression among those who received the injections than among the control group. “It doesn’t matter where Botox is injected, the effect is the same,” says Abagyan. “It was unexpected.”

Another unexpected result is that botulinum toxin injections can have a positive effect on other people. Study described in the journal Journal of Cosmetic Dermatology suggests that when botulinum toxin injections smooth out a person’s wrinkles, or “11s,” they can change how other people react to it, i.e., reduce their negative emotions.

“Your facial expressions and mood affect those around you,” explains lead study author Mark Nestor, a dermatologist and director of the Aventura Cosmetic Clinical Research Center, Florida. This effect is related to “the theory of embodied emotions: the idea that social interactions are associated with emotional contagion,” he explains. “When you’re around people who frown, you get sick.” On the other hand, when you are with people who seem relaxed and happy, you may feel that way too.

Naturally, some psychologists are skeptical about the effectiveness of botulinum toxin injections for mood disorders. Nicholas Coles, a social psychologist and researcher at Stanford University in the US who has reviewed some of the published literature on the topic, says “the evidence seems too good to be true.” On the one hand, he points out that these studies do not control for placebo effects because saline injections have no measurable effect on patients’ appearance or ability to contract their facial muscles.

In addition, “it must be remembered that sadness and other negative feelings are more a symptom of depression than one of its root causes,” adds Jeff Larsen, professor of psychology at the University of Tennessee (USA), who collaborated with Coles on this study. “Even if Botox injections can help reduce feelings of sadness in the short term, it’s far from clear how they can affect the cognitive biases (catastrophe, all-or-nothing thinking, and the like) that cause these feelings in the first place.” As a result, he adds, “we can expect any effect of Botox injections on negative feelings to be short-lived.”

However, according to proponents of this approach, injections have already shown some advantages over other treatments for mood disorders. According to experts, injections have fewer side effects than antidepressants (the main one is temporary irritation at the injection site). Also, they do not interact with other medications such as antidepressants or anxiolytics.

Unfortunately, the mood-enhancing effects of botulinum toxin injections are not permanent, just as they are not permanent for cosmetic purposes. They usually last three to four months, although some people may need less frequent injections over time. These injections are not cheap either: injections of 30 units of botulinum toxin can cost between 400 and 500 euros, says Magid. But some believe that the effect is worth it.

Magid recalls a patient with seasonal affective disorder who tried antidepressants to ease her symptoms, but they didn’t help. On her 40th birthday, she had botulinum toxin injections in her forehead for cosmetic reasons and was surprised to find that she was starting to feel better emotionally. Since then, the woman has continued to receive Botox injections twice a year, says Magid, and “has been six years without depression.”

Botulinum toxin injections can also have long-term psychological effects. After all, “feeling better is a self-perpetuating state,” says Rosenthal. “It encourages people to do positive things for themselves: for example, they may be motivated to meditate, exercise, or be more social.” The cumulative effect of these changes can lead to a more upbeat and lasting mood.

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