OPINION | DEPRESSION |


limited follow-up, lack of randomisation, the absence of blind evaluation, and in particular, the small number of subjects included. Many felt that the methodology of evaluating depression should have been more rigorous. At the time, I noted by letter that


patients’ self-report of depressive symptoms by administration of the BDI-II (Beck Depression Inventory) introduced a significant bias. This is of more concern because of the potential for secondary cosmetic gain. While the BDI-II is an accepted method of evaluating an individual’s level of symptoms over time, self-report in isolation was not considered an acceptable method of diagnosing depression. It was concluded that in order to ensure that patients’ psychiatric symptoms are accurately classified, a thorough psychiatric interview must be conducted. In 2012, the Psychiatric University


Havas et al


noted that the processing time for sentences with negative affective connotation was prolonged in women after botulinum toxin treatment to the glabellar.


glabellar area stopped the activation of


limbic brain regions normally seen during voluntary contraction of the corrugator and procerus muscles. This indicated that feedback from the facial musculature in this region in some way modulated the processing of emotions. Many other researchers continued on this track, with Havas et al6


noting that the processing


time for sentences with negative affective connotation was prolonged in women after botulinum toxin treatment to the glabellar, and Neal and Chartrand7 speculating that the treatment interfered with the ability to decode the facial expression of other people. This is where things remained, until recently, when some authors suggested that this capacity


68 ❚ June 2013 | prime-journal.com


to counteract negative emotions could be put to some clinical use during the treatment of depression.


Reducing symptoms of depression A seminal article by Finzi and Wasserman2


Hospital of the University of Basel, Switzerland, and the Medical School Hanover, Germany, conducted a randomised,


double-blind trial8


placebo-controlled, . The authors


hypothesised that facial psychomotor features associated with depression are not just epiphenomena, but integral components of the disorder, and may be targeted in its therapy. To explore whether attenuation of these features produces alleviation in the affective symptoms, they conducted a randomised controlled trial of botulinum toxin injection to the glabellar region as an adjunctive treatment of major depression. The study was investigator-initiated and carried out independently of any commercial entity. Participants in the study were recruited


postulated that botulinum


toxin injected into the glabellar reduced the symptoms of depression. The authors provided data from an open case series of 10 female patients. The article contained a footnote from editor Alastair Carruthers, who stated that the report must be considered anecdotal as there were no appropriate methods of control used. In addition, there were other methodological weaknesses, including


from local psychiatric outpatient units and psychiatrists in private practice. In order to avoid attracting candidates who were primarily motivated by receiving this treatment for cosmetic reasons, botulinum toxin treatment was not explicitly mentioned. Exclusion criteria included psychotic symptoms, suicidal tendency, and clinical severity requiring immediate intervention. The same injection scheme was applied as that of the open case series2


. At each study visit,


participants were assessed using the Hamilton Depression Rating Scale with Atypical Depression Supplement (SIGH-ADS), the BDI


self-rating


questionnaire, and the Clinical Global Impressions (CGI) Scale. To conceal


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