Annotated Abstracts of Journal Articles
2015, 4th Quarter


Annotations by J. Jewel Shim, MD, FAPM
January 2015

  1. Treating depression with botulinum toxin: a pooled analysis of randomized controlled trials

Also of interest:

  • Accordino RE, Lucarelli J, Yan AC: Cutaneous disease in autism spectrum disorder: a review
    Pediatr Dermatol 2015; 32(4):455-460This is a review of the cutaneous diseases often associated with autism spectrum disorders (ASD) and describes their possible links as well as a treatment approach for such patients. The authors note that an increased rate of children with ASD have eczema or skin allergy compared to children without a developmental disorder. They discuss that individuals with ASD have dysfunction in tactile sensation and may have hyper or hyposensitivity to tactile stimuli. This may pose problems in dermatological conditions where the stimuli may be experienced as more distressing and people with ASD may be poorly able to tolerate any topical treatments. One study found as many as 69% of people with ASD have this difficulty with sensory processing.
        There is genetic evidence to support this association; the GABRB3 gene is a candidate gene for ASD that has been associated with tactile sensitivity. Further, there are a number of genetic syndromes with dermatological symptoms that have been linked to ASD, such as Angelman’s syndrome, Prader Willi Syndrome, Tuberous Sclerosis, neurofibromatosis type 1, and hypomelanosis of Ito. Individuals with ASD also have a high incidence of trichotillomania and excoriation disorder which may lead to secondary cutaneous effects including scars, keloids, and postinflammatory hypo/hyperpigmentation. Moreover, those with ASD may have more difficulty adhering with a treatment plan and maintaining personal hygiene, which could exacerbate and/or prolong the course of a dermatological condition. Finally, the authors offer advice on best practices for how to approach a patient with ASD with a dermatological condition as well as for long term management.


PUBLICATION #1 — Psychodermatology
Treating depression with botulinum toxin: a pooled analysis of randomized controlled trials
Magid M, Finzi E, Kruger TH, et al
Pharmacopsychiatry 2015; 48(6):205-210

ANNOTATION (J. Jewel Shim)

The Finding:  The authors undertook a pooled analysis of all the randomized controlled trials examining the use of botulinum toxin A (BTA) injected in the glabellar region for major depressive disorder (MDD). The rationale for use of this novel treatment for depression is based on the facial feedback hypothesis which posits that contraction of the facial muscles sends messages to areas of the brain that process emotion. The authors theorize that paralyzing the muscles involved in frowning interrupts a proprioceptive feedback loop from the face to the emotion centers in the brain and inhibits the ability to feel negative emotions. The sample included 3 trials totalling 59 subjects who received BTA and 75 placebo subjects. All 3 trials studied BTA as an adjunctive therapy to antidepressants. One trial also analyzed BTA as a monotherapy for MDD. Outcomes were measured using the Hamilton Depression Rating Scale (HAM-D) and the Montgomery Asberg Depression Rating Scale (MADRS) 6 weeks after administration of BTA. They also measured the severity of frown lines at baseline and at 6 weeks using the Clinical Severity Score for Glabellar Frown Lines (CSS-GFL). They found a response rate of 54.2% for the BTA group vs. 10.7% for placebo, and a remission rate of 30.5% for the BTA group vs. 6.7% for placebo. Response rates did not differ significantly between subjects who received BTA as an adjunctive therapy vs as monotherapy. Interestingly, higher baseline CSS-GFL scores were predictive of less improvement in depression though this relationship was not statistically significant. It was hypothesized that subjects with greater baseline CSS-GFL scores indicated a longer period of being depressed and could be a marker of treatment resistance.

Strengths and Weaknesses: This study pools the data from 3 individual controlled studies, and in this achieves greater statistical power and significance. However, the overall number of subjects was still quite small and the improvement in CSS-GFL scores did not correlate significantly with improvements in mood. A major weakness of the study highlighted by the authors was the difficulty to effectively blind the subjects to group allocation as the presence/absence of cosmetic changes would be clear to the participant. Thus, the comparatively low placebo response rates may reflect this and make the estimation of the true effect size difficult.

Relevance: This analysis calls attention to a very interesting novel approach to the treatment of depression that is generally well tolerated with few side effects. Further studies are definitely warranted to explore the effectiveness of this option for the treatment of depression.


Introduction: Botulinum toxin A (BTA) injection into the glabellar region is currently being studied as a treatment for major depressive disorder (MDD). Here we explore efficacy data of this novel approach in a pooled analysis.

Methods: A literature search revealed 3 RCTs on this topic. Individual patient data and clinical end points shared by these 3 trials were pooled and analyzed as one study (n=134) using multiple regression models with random effects.

Results: In the pooled sample, the BTA (n=59) and the placebo group (n=75) did not differ in the baseline variables. Efficacy outcomes revealed BTA superiority over placebo: Improvement in the Hamilton Depression Rating Scale or Montgomery-Asberg Depression Rating Scale 6 weeks after baseline was 45.7% for BTA vs. 14.6% for placebo (p<0.0001), corresponding to a BTA response rate of 54.2% (vs. 10.7%) and a BTA remission rate of 30.5% (vs. 6.7%).

Discussion: Equalling the status of a meta-analysis, this study increases evidence that a single treatment of BTA into the glabellar region can reduce symptoms of MDD. Further studies are needed to better understand how BTA exerts its mood-lifting effect.

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