Karen Weintraub, Special for USA TODAY
If Eric Finzi is right, we should all take the expression "put on a happy face" more seriously.
Finzi, a dermatologist in Chevy Chase, Md., believes that people with tense frown muscles - the ones between the eyebrows - are more likely to be depressed. When he treats depressed people with Botox shots in that area, the muscles unclench, the people stop frowning, and, he says, their emotional cloud lifts.
Several small, preliminary studies now support Finzi's idea of treating depression with Botox, and more are underway.
It may seem crazy to address something as serious as depression with a cosmetic treatment, but several mental health experts say the theory makes sense.
"I don't think it's a far-fetched idea," says Philip Levendusky, director of the psychology department at McLean Hospital in Belmont, Mass., and an associate professor at Harvard Medical School.
Paul Ekman, whose research first established the idea that emotions and expressions are linked, said he thinks it's perfectly plausible that changing people's facial expressions will change their mood.
"Depression is a neural circuit and if you interrupt that circuit in any way, you lessen its impact," said Ekman, an emeritus professor of psychology at the University of California San Francisco Medical School.
Both men say they'd wait for more research before trying Botox or other versions of botulinum toxin on their patients.
The treatment is considered safe; the most common side effect is bruising at the injection site. But at $400 for a five-shot treatment between the eyebrows - not reimbursed by insurance - patients should wait until there is more evidence before spending their money, Levendusky says.
Gabriela Cora, a Miami-based psychiatrist and distinguished fellow of the American Psychiatric Association, says she was impressed with the success of the early trials, though somewhat surprised. She says she has patients who choose Botox before psychiatric treatment and end up in her office, still depressed.
Cora says she thinks it's possible that changing someone's facial expression may change how others respond to them. If they stop facing the world with a frown, perhaps the attitudes they get back will help improve their mood, she says.
Finzi, author of a new book, The Face of Emotion: How Botox Affects Our Mood and Relationships,says he hopes to eventually win federal approval so that insurance will cover the procedure. He holds the U.S. patent for using botulinum toxin to treat depression.
It's not clear yet whether repeat treatments will be needed. Ekman says he doesn't think Botox should ever be the first remedy someone tries to treat depression, but he expects that future research will confirm its usefulness in connection with talk therapy and medication.
Botox is already federally approved for cosmetic uses, such as smoothing out wrinkles, and medical treatments, including migraine, eye twitching, neck spasms and severe underarm sweating.
Finzi's mother was depressed when he was a child, and he says he remembers seeing the sadness on her face. He's also a painter, and he particularly likes to paint portraits of people with mental illness. Again, he said, he was struck by the melancholy evident in their faces. It made him wonder which came first, the expression or the depression.
In Europe, psychiatrist Axel Wollmer was thinking along the same lines, when he stumbled across a small study Finzi had done, and decided to do one of his own.
Wollmer's research, published last year in the Journal of Psychiatric Research, showed that Botox significantly improved the mood of 15 moderately depressed patients over the 16 weeks of the study.
Wollmer also gave shots to an equal-sized control group to make sure the improvement wasn't just a placebo effect from getting treatment. He didn't know which patients were receiving the real Botox treatment and which an empty solution. "In the end, those who became better were those who had gotten the Botox injections," he says.
When he sought out volunteers for the study, he didn't tell them they might be getting Botox - to make sure they didn't volunteer for cosmetic reasons.
In another, still-unpublished study in Austin, husband-and-wife researchers dermatologist Jason Reichenberg and psychiatrist Michelle Magid found similarly positive and long-lasting results among their 30 trial subjects.
"That makes you wonder if we're changing something chemically, breaking the cycle of active depression," said Reichenberg, of the University or Texas Southwestern in Austin.
Both studies were funded by foundations not connected to the pharmaceutical industry or makers of botulinim toxin.
Though his study was not definitive in saying who might benefit most from the treatment, Wollmer says in his experience, it works best in people who have an agitated form of depression and a lot of activity in their frown-line area.
Wollmer says he thinks Botox's effect on moods might have something to do with its cosmetic popularity.
"If you ask the aesthetic dermatologists, they can tell you that there must be something about this Botox that goes beyond the mere aesthetic benefits," he says. "There must be some kind of feel-good factor that makes people come back."