Turn That Frown Upside Down June 7, 2011

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This article originally appeared in the May 2011 of NSIDE Medical

Major depression affects 16 percent of the adult population in the United States. When medications and psychotherapy fail, physicians are left with few options.

Dr. Michelle Magid, a psychiatrist, was recently awarded a prestigious grant from the National Alliance for Research on Schizophrenia and Depression, or NARSAD, to conduct the first placebo-controlled clinical trial of treating depression with botulinum Type A, otherwise known as Botox.

"We are fortunate to have Dr. Magid's innovative thinking and leadership here in Central Texas," said Alan Isaacson, vice president and chief operating officer at Seton Shoal Creek Hospital. "Through Seton's partnership with the University of Texas Southwestern, we are committed to researching and uncovering valuable improvements in patient care. Grants like this are vitally important to advancing mental-health research."

Magid first learned of using Botox to treat depression in 2006, when her husband, Dr. Jason Reichenberg, a dermatologist, shared an article published in his dermatologic surgery journal. The article outlined an informal study conducted by dermatologist Dr. Eric Finzi that showed a dramatic decrease in depression symptoms in nine out of 10 patients after receiving Botox injections.

Many psychiatrists believe that feeling depressed subsequently leads to looking depressed. Patients who suffer from depression can often be recognized by their melancholic appearance: The brow is furrowed, creating a scowl, and the mouth is angled downward, creating a frown. Several experts have suggested the reverse may be true. Looking depressed may itself lead to feeling depressed. People who naturally appear angry or depressed are received more negatively by those they encounter. This may cause individuals to consider themselves unlikeable, causing them to withdraw and leading to feelings of depression.

The facial feedback hypothesis, initiated in the late 19th century by well-known American psychologist and philosopher William James, suggests that facial expression plays a large role in emotional experience. For example, a person who is forced to smile during a comedy movie will find the experience more enjoyable than a person who is forced to frown during the same movie.

The areas of the brain affected by facial expression - the amygdala and the brainstem - are known for their roles in emotional processing and experience. It is speculated that positive biochemical changes occur in the brain when people smile, and negative changes occur when they frown.

Magid hypothesizes that for a subset of the population who has naturally appearing unhappy facial expressions, depression can be treated simply by turning frowns upside down.

To test this theory, Magid will study 30 patients who present with major depression and who appear depressed, exhibited by vertical wrinkles in the forehead region and an upward, inward peaking of the eyelids. Patients with these visible signs suffer from a sustained contraction of the muscle in their foreheads, which can, in theory, lead to stress, depression and anger. These patients also have significant frown lines and eyebrow furrowing.

So what do Botox and depression have in common? Treatment with Botox can rid patients of their negative facial expressions, halting both the biological and psychological effects that lead to depression.

"Instead of the patient's face having a negative expression at rest, it will have a neutral or positive expression," Magid said. "Botox in the facial muscles should prevent those muscles from continuously straining in the anguished position, which can cause deleterious effects on the brain's biochemistry."

A few recent papers have been published on this subject, but only a few studies have used experimental controls to test their hypothesis on the correlation of Botox injections and emotion. Magid and her team - including Reichenberg, who will administer the injections - will add to the growing literature using a placebo-controlled approach.

Each patient will receive two injections during the 24-week study. At the start of the study, half will receive Botox, while the other half will receive the placebo. The patients' second injections will be the reverse.

All participants will undergo significant psychological testing at the start of the program and receive psychiatric assessments every three weeks. Mood symptoms will be closely monitored throughout the study.

Magid believes correcting the patient's negative expression improves mood in two ways. First, people will perceive them as more friendly and open, and will be more inclined to engage with them. Second, by correcting the negative expression on someone's face, you can increase the levels of serotonin and dopamine, neurotransmitters that are known contributors to feelings of well-being, ultimately improving mood.

The prediction is that patients will be significantly less depressed in the weeks following treatment with Botox. If the theory proves true, Magid hopes to implement larger studies to further investigate the neurophysiology and mechanism of action behind this phenomenon.

In addition to the most recent clinical trials, Dr. Michelle Magid specializes in the treatment of mood and anxiety disorders at Seton Shoal Creek Hospital. She also serves as clinical assistant professor for the University of Texas Southwestern and the University of Texas Medical Branch.

For more information about the clinical trial, call 512-324-3380.

Michelle Magid, MD


Dr. Magid received her undergraduate and medical school degree from Boston University, and completed her psychiatry residency at the Mayo Clinic in Rochester, MN. She received specialized ECT training at the Mayo Clinic and at Seton Shoal Creek in Austin, Tx.

Dr. Magid is board certified in psychiatry. She has won various awards for her dedication to the field of Psychiatry, including the Laughlin Fellowship and George Ginsberg Fellowship. She was recently voted Teacher of the Year by the Austin psychiatry residency program, and holds ranking as an assistant professor. She specializes in mood and anxiety disorders, and is currently involved in resident education and mood disorder research.

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