A Shot at Happiness

Everybody knows that Botox can make you look better. Now, doctors are learning that it can make you feel better, too.

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Relief came with a postcard in the mail.

The North Potomac woman, who had suffered from clinical depression for most of her life, was being invited to participate in a study that would investigate whether botulinum toxin, better known by the trade name Botox, alleviated symptoms of clinical depression.

Naturally, she was intrigued. Despite years of antidepressants and therapy, she still experienced feelings of hopelessness and worthlessness, as well as bouts of low energy.

So she contacted the researchers, had several sessions with a therapist, and then, in December 2011, received several injections into her forehead. At the time, she didn’t know if she was being given Botox or a placebo.

“The wintertime is the worst for me, so I thought I had nothing to lose,” says the 63-year-old dental hygienist.

After receiving the initial set of injections, she returned every few weeks for a follow-up assessment by a therapist.

“My mood felt lighter and more upbeat,” the woman says, “and I started cutting back on my medication.”

Eventually she learned that she had indeed been given Botox. And because she was feeling so good, she decided to continue to get injections on her own.

“It’s been a real positive for me. I’m completely off antidepressants now, and I feel really good,” she says. “I’m going to stick with Botox as long as it keeps working.”

For years, dermatologists and plastic surgeons have used Botox—and its newer market rivals, Dysport and Xeomin—to smooth wrinkles and soften frown lines, thereby making a person look younger. But the cosmetic uses are merely the top layer of the therapeutic tool kit.

When injected into key areas of the face or body, botulinum toxin—a powerful poison present in nature and associated with botulism outbreaks from poorly canned food in the early 20th century—can improve mood, relieve migraine headaches, reduce excessive sweating (aka hyperhidrosis), prevent the leakage of urine that comes from a condition called urge incontinence, and help people with cerebral palsy and other movement disorders.

In short, botulinum toxin effectively treats an array of conditions that share one primary thing in common: muscular involvement. By stopping the nerve impulses that trigger muscle movement, the injections can treat various conditions throughout the body.

“Even if the disease itself isn’t a muscle disease, if there’s a muscle involved, we can go in with botulinum toxin and calm down that nerve that’s firing the muscle,” says Dr. Eric Finzi, a dermatologic surgeon in Chevy Chase who co-conducted the study in which the North Potomac woman took part.

“That’s why botulinum toxin seems to be this miracle drug. Muscles are everywhere, and they may be involved with more diseases than we thought,” Finzi says. “I think the diversity of clinical uses for botulinum toxin will only increase as we discover more maladies that can be remedied by treating a specific muscle.”

When it comes to treating depression, preliminary results are encouraging. The 2011 study conducted by Finzi and Dr. Norman Rosenthal, a psychiatrist based in North Bethesda, involved 74 people. Half were given Botox and half received a placebo of saline injections. Of those who received Botox, 27 percent saw their depression go into remission, compared with 7 percent of those who were given the placebo. And 51 percent of those who received Botox experienced improvements in their depressive symptoms, compared with only 15 percent in the placebo group.

In a similar study published in the Journal of Psychiatric Research in 2012, researchers from Switzerland found that patients who received botulinum toxin injections for frown lines experienced a 47 percent reduction in depressive symptoms after six weeks. Those in the placebo group (who were given saline injections) had a 9 percent improvement in depressive symptoms.

It was his mother’s experience that inspired Finzi to study the effects of botulinum toxin on depression. For years, she had suffered from treatment-resistant depression—meaning that medications didn’t make a difference—and her condition deteriorated in 2000.

Eventually she underwent electric shock therapy, which “destroyed her memory and precipitated a terminal slide from which she never recovered,” Finzi says. “The mother I knew was replaced by a ghost who needed complete care, eventually dying in a nursing home.”

Losing his mother to depression motivated Finzi to explore new treatments. “From everything I’d read, I thought that if I could inhibit the expression of fear and anger and sadness, maybe I could influence the expression of fear and anger and sadness in other people,” he says. “Botox was what I knew I could use to affect people’s looks. I just thought this should work—and it did.”

Earlier this year, Finzi came out with a book, The Face of Emotion (Palgrave Macmillan), that details his mother’s experience with depression, some of his research and his clinical findings.

Though some observers might assume that depressed people feel better simply because they look better and more relaxed after receiving botulinum toxin injections, that’s not what’s happening, Finzi says. Rather, what’s known as the facial feedback theory comes into play.

The theory “states that the relationship between internal emotional states and facial expressions is a bilateral one,” says Rosenthal, a clinical professor of psychiatry at the Georgetown University School of Medicine. “If you’re sad, it will be reflected on your face.”

But if your face takes on a sad or distressed expression because of something you’ve seen, for example, it will reflect back to your brain and trigger the actual feeling. It’s the flip side of the phenomenon where forcing yourself to smile with your mouth and eyes (what’s known as a Duchenne smile) can actually make you feel better than you did previously.

In other words, “the expressions you make on your face will influence your thoughts and feelings,” as Finzi puts it.  

By paralyzing key muscles in the brow and forehead, injections of botulinum toxin make it impossible for someone to frown. As a result, his or her face can’t transmit signals of anger, sadness or other negative emotions to the brain. Because of that, the person starts feeling better and depression eases.

“After I had the Botox injections, it felt like a calming wave had been pressed on my forehead, relaxing all the tension in my face,” recalls a lobbyist from Silver Spring who participated in Finzi and Rosenthal’s study. “The injections literally smoothed out the emotional rough edges I’d been experiencing.”

For years, Rosenthal has been prescribing Botox to some of his depressed patients in an off-label capacity. “It’s not a first-line treatment,” he says, “but if someone is not responding to primary antidepressants, if they don’t want to take medication or if they’re taking a complex combination of drugs, they’re a decent candidate for Botox.”

Since the injections have only a localized effect on the facial muscles, they’re not absorbed systemically and won’t interact with other medications. However, the effects aren’t permanent. The mood boost typically lasts a matter of months, though some people may need less frequent injections over time.

“Feeling better is a self-perpetuating state,” Rosenthal says. “It propels people to do a lot of positive things for themselves. They may become motivated to meditate, exercise or become more social, for example,” which can have a positive effect on their mental health.   

The medical benefits of botulinum toxin aren’t anything new. The neurotoxin originally was used in the 1970s for neurological purposes, treating such conditions as blepharospasm, the uncontrollable blinking of the eyes. In the late 1980s, patients noted its wrinkle-smoothing benefits as the furrows between their brows disappeared, and the substance became better known for its cosmetic applications than for its medicinal benefits.

Then another perk became apparent: the treatment of migraines. It was “an accidental discovery, which is how most good things happen in medicine,” says Dr. Elizabeth Latimer, a neurologist in Bethesda and a member of the clinical faculty at Georgetown University School of Medicine. “All these patients who had injections for wrinkles came in and said they used to have headaches and didn’t anymore.

“It doesn’t work at all for people who have migraines once or twice a month,” Latimer says. But it does “for people who have migraines very frequently. Their central nervous systems become sensitized, and anything will trigger a migraine.”

When injected into the neck, the temples, across the forehead, and/or around the jaw, botulinum toxin essentially calms the central nervous system so that people with chronic migraines aren’t constantly on the verge of getting one.

A 60-year-old social worker in Potomac has used Botox to help treat the chronic migraines she has experienced since age 6. “When I have Botox and take Topamax [an anti-seizure medication], I don’t get the bad headaches that would last three to four days,” she says. “I still get some headaches; they’re just not severe and they don’t last that long.

“Botox is a good addition—it definitely helps—but it’s not a panacea,” she adds. “I really see the treatment of migraines as working out a combination that’s right for every individual. Right now, this is the combination that’s best for me.”  

These days, physicians also use botulinum toxin to treat cervical dystonia (a neurological disorder that causes severe muscle spasms in the neck and shoulders), spasmodic dysphonia (a vocal disorder involving involuntary spasms of the larynx), and some movement disorders such as cerebral palsy, Parkinson’s disease and restless legs syndrome.

A 44-year-old librarian from Silver Spring has been getting botulinum toxin injections to treat the Bell’s palsy she developed at the end of her pregnancy in 2003. “It has permanently partially paralyzed some of the muscles on the right side of my face,” she says. “So when I smile, it’s not full on the right side and it causes unwanted muscle movement in the chin area. Botox quiets the muscles wherever the shots are put—and it does lessen the severity of those unwanted movements for two or three months.”  

“If you think of it [botulinum toxin] as a muscle relaxant to the nth degree, it will be useful wherever there are spasms,” says Dr. Susan Meikle, program director of pelvic floor disorders at the Eunice Kennedy Shriver National Institute of Child Health and Human Development in Bethesda.

With cerebral palsy, for example, one set of muscles is weak and an opposing set is tight and active, Latimer says. “Botox injections would relax the tight ones that were spastic so other muscles could start working. Kids [with cerebral palsy] can often get up out of their wheelchairs and walk after this.”

Because it inhibits muscle contractions, botulinum toxin also has a long history as a treatment for excessive sweating. Though the muscles around the sweat glands in your armpits don’t cause underarm sweating, “you need those little muscles to propel your sweat from under your skin to the skin surface,” Finzi says. So if those muscles are inhibited from moving, you won’t be able to sweat there anymore.

A 49-year-old sales executive from Potomac says, “I always sweated a lot—it wasn’t like the guy in Broadcast News, but it was enough to bug the crap out of me. I’d wear suits a lot for work and it was uncomfortable.”

In 2009, he got his insurance plan to cover Botox injections in his armpits, and the results were amazing. “It’s hard to notice a negative—something that’s not happening—but I wasn’t sweating at all,” he says. Since then, he has gotten injections every three to nine months as needed.

Earlier this year, the Food and Drug Administration approved the use of Botox as a treatment for adults with an overactive bladder, a condition that results in leakage or the frequent need to urinate. To treat urge (urinary) incontinence, Botox is injected inside the bladder to cause it to relax, Meikle says.

In a recent study involving nearly 250 women with urge incontinence, Meikle and her colleagues compared the effects of Botox with anticholinergic medications, which are used to treat the condition. Though both groups experienced fewer episodes of leakage, twice as many women in the Botox group had their problems disappear after six months at the study’s end. A higher percentage of women receiving Botox also developed urinary tract infections and had to use a catheter to empty their bladders completely. But “a lot of women would rather do that than leak,” Meikle says.

Not surprisingly, some people shy away from having a neurotoxin injected into their bodies. But what’s “a poison to some [is] a miracle to others,” Finzi says. And with its widespread use for wrinkles—and the fact it’s made in highly regulated factories, Latimer says—people have increasingly been accepting its use for other purposes.

“Once something becomes normalized, it changes the societal perception of it,” Latimer says.

Stacey Colino frequently writes about health for national magazines such as Real Simple.

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