07/16/2014 02:42 pm ET | Updated Sep 15, 2014

Looking Depression In the Face: Botox as Antidepressant

Face Facts

In a peculiar about-face, psychiatry has taken a page from the aesthetician's playbook. Recent research suggests that the frown of depression is anything but superficial and should not be taken at face value. Wiping that expression off your face is the latest treatment for depression. And Botox, America's favorite neurotoxin, allows for this therapeutic loss of face.

You might wonder how someone thought they could get funding to research the idea that if depressed people didn't look so sad they'd feel better. It turns out that they were onto something. Their findings happen to be grounded in some of the most fascinating neuroscience.

Interest in facial expressions and emotion has a long and illustrious history. Charles Darwin (1872) was the first to propose that facial expressions of the basic emotions (happiness, sadness, fear, disgust, surprise, anger) are universal, hardwired, inform the emotions and serve important communication functions. His novel observation of facial expression in animals, babies, the blind, and people from different cultures formed the basis for his theory.

William James (1884) believed that the thing triggering an emotion causes a physiological reaction, which in turn sends feedback to the brain, resulting in the conscious experience of emotion. Constriction of specific facial muscles causing a particular expression is such a physiological reaction.

We feel sorry because we cry, angry because we strike, afraid because we tremble, and not that we strike, cry, or tremble because we are sorry, angry, or fearful. -- William James 1884

These ideas gave rise to the notion that facial expressions have a dual function: a means of communication to others and an internal feedback system to inform the self. The facial feedback hypothesis suggests that the muscles of facial expression can regulate emotional experience.

A wide range of studies has legitimized this theory.

In 2002, Saussignan tested the hypothesis by asking some subjects to hold a pencil between their teeth in such a way that their lips were pulled back as they would in a full‐faced smile. Another group was asked to hold a pencil between their lips in a way that prevented smiling.

Subjects holding it like the person on the right were more likely to report feeling happy than the those holding it like the person on the left.


In 2009, Matsumoto and Willingham demonstrated the similarity of facial expressions in congenitally blind and sighted people by studying photographs from the Judo competition in the 2004 Olympic Games. A blind (left) and sighted (right) athlete are shown after losing their match.This supported Darwin's idea that facial expressions are hardwired.


Functional MRI observations documented the neural connection between the facial musculature and the area of the brain related to emotion. And finally, the paralysis of facial muscles with botulinum toxin has been shown to block emotion.

Building on this data, psychiatric researchers investigated the effect of paralyzing the facial muscles of the forehead that are most active in depressed individuals. In a randomized, double-blind (neither the subject nor the researcher knows who is getting placebo or drug) placebo- controlled trial, subjects received either Botox or saline injections. All patients had reported incomplete responses to standard depression treatments. The HAM-D, a well-regarded depression rating scale was used to assess response. After 6 weeks of treatment, the Botox group score had improved by 47.1 percent compared with a 9.2 percent improvement in the placebo group.


One problem with this study, and Botox studies in general, is they cannot be double-blind. Saline does not paralyze muscle and therefore anyone without a change in facial expression would be identifiable as a member of the placebo group.

Keeping a Straight Face: Pros and Cons

Depression affects approximately 350 million people globally. Over 15% of Americans experience a major depressive episode at some time in their lives. Our armamentarium for treating this disorder affords only partial and temporary relief in most cases.

Any progress in the understanding and treatment of depression is a good thing. However we must always look at the potential negative consequences of a therapeutic intervention.

If we propose to compromise facial feedback, we should think about its function. The benefits of this system extend into unanticipated arenas. For example, fearful facial expressions enhance visual field perception as well as both air velocity and nasal volume during inspiration. Such data demonstrate the adaptive quality of facial expression and suggests that we may lose more than we know in blocking these circuits.

As we've seen, facial musculature both expresses emotion and regulates mood states.

From an intrapersonal perspective, feedback from facial muscles affects the elaboration of one's emotional process. From an interpersonal perspective, facial feedback allows the transfer of emotional states between people through unconscious mimicking. This emotional resonance appears to be central to the intimate attachment between parent and child. In fact, a blank maternal face is distressing and detrimental to the developing infant.

The mirroring involved in facial mimicking allows for a type of emotional contagion and seems to be essential for any empathic process. One school of thought suggests that the interpersonal difficulties of autistic people stem from an impaired facial feedback system.

Depression is characterized by feelings of isolation. The depressive has lost a sense of human connection, something that provides so much of our sanity and wellbeing. Do we want to diminish the capacity of a system that provides meaning, connection, and expression? Granted the depressive already has a problem here. But to blunt this instrument seems akin to blinding the individual who is overwhelmed by the sight of suffering.