Sunday, May 21, 2006

Huh? Botox for Depression?

Medscape News has an interesting item: Botox Injections May Be Useful for Major Depression (free registration required).
Botox Injections May Be Useful for Major Depression
Laurie Barclay, MD

May 16, 2006 — Botulinum toxin A injections can treat major depression, according to the results of a small case series reported in the May issue of Dermatologic Surgery.

"Major depression is a common and serious disease that may be resistant to routine pharmacologic and psychotherapeutic treatment approaches," write Eric Finzi, MD, PhD, and Erik A. Wasserman, PhD, from Dermatology and Cosmetic Surgery Associates in Greenbelt, Maryland, and Chevy Chase Cosmetic Center in Maryland. "There is a body of evidence that suggests that the facial expression of emotion may play a causal role in the subjective experience of emotion. We initiated a small open pilot trial to determine whether inhibiting the expression of facial frowning commonly associated with depression could help ameliorate depressive symptoms."
This was an extremely small study, involving only ten patients, without, and with double- or single-blind condition.  That means that it is not possible to draw any valid conclusions, other that to say that a larger, double-blind, placebo-controlled study might be worthwhile.  

The idea is not without precedent.  It is known that people with anxiety tend to be overly vigilant concerning somatic symptoms that are correlated with anxiety.  When they notice such symptoms, it tends to increase their anxiety, which increases the symptoms: a classic positive feedback loop.  Sometimes, patients with anxiety disorders can learn to interrupt the feedback loop, resulting in clinical improvement.  As far as I know, nobody has tried anything like that with mood disorders, until now.
A total of 10 patients who met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for ongoing major depression refractory to pharmacologic or psychotherapeutic treatment were evaluated with the Beck Depression Inventory II (BDI-II) before receiving botulinum toxin A to their glabellar frown lines.

Two months later, all patients were reevaluated clinically and with the BDI-II. Nine of 10 patients were no longer depressed, and the 10th patient had an improvement in mood.

"These findings are very promising and show that Botox has the ability to work in ways we don't expect," Alastair Carruthers, MD, president-elect of the American Society for Dermatologic Surgery and head of Carruthers Dermatology in Vancouver, British Columbia, Canada, says in a news release.
Personally, I would be astonished if this turned out to work in a large, randomized, double-blind, placebo-controlled study.  On the other hand, it would be pretty neat if it did work.  What is more likely is that it either will not pan out at all; or it will turn out to be of great benefit to a few people, partial benefit to a few more, and no benefit to everyone else.  Even so, stranger things have happened.  The first discovery of medication occurred when an antitubercular antibiotic, iproniazid, was found to relieve melancholia in patients being treated for tuberculosis.  

None of this indicates that is likely to work for treatment of depression, but it shows that it is, at least, remotely possible.

Update: The Washington Post picked up the story, and has a testimonial from one patient.  From a scientific standpoint, one testimonial is meaningless.  What it does do, though, is give you an idea of what the experience is like from the patient's point of view.