A couple of weeks before New Year’s Eve 2018, after hours on NYU Langone’s dermatology floor, I received Botox in my forehead for the first time. This was not because I wanted to fix any lines—I have a few, and they are fine—nor because I love the feeling of a needle piercing my skin eight times in succession, but because I am kind of sad most of the time, and I would like not to be.
Beneath the ambient hum of the building’s HVAC system, Evan Rieder, he of the round tortoiseshell glasses and dual board certification in dermatology and psychiatry, was trying to cure my depression. First we tried some breathing techniques, then an exercise in which I clenched every part of my body really hard for a few minutes and then released all of the tension (it works, kind of). Next came the Botox, which has cleared phase-two trials as a treatment for major depressive disorder, for reasons I do not yet understand. Dr. Rieder explained that it may be effective among people who have experienced depressive episodes, which means I am a very good candidate.
When examining the lines of my face, the doctor asked me to contort my features into a variety of different non-sad expressions, which made me feel as though I was rehearsing for a new period of my life in which I feel a variety of different non-sad emotions. Dr. Rieder asked me to “look surprised,” and my eyebrows jumped into my hairline. In order to properly inject the muscles directly above the bridge of my nose, I had to contract every muscle in my face at once, like a hobgoblin.
Afterward, I called my mom to tell her the good news: In a couple of days, my forehead wrinkles will be ironed smooth, and this will make me palpably happier—again, for reasons I do not yet understand. “It’s for a story about whether or not Botox can treat depression,” I told her.
“Oh,” she replied. “Well, how do you feel?”
My forehead hurt. “I guess I feel OK?”
“That’s good!” she chirped. “I always feel happier after getting Botox.”
About six years ago, the company that produces Botox-brand botulinum toxin-A injections, was in the midst of clinical trials for its star product as a treatment for depression. (In 2022, Allergan was acquired by AbbVie; I’ll use Botox to refer to AbbVie’s product, and neurotoxin to refer to comparable injections at large.) Two small but promising studies, one in Europe and the other in the US, had excited Allergan enough to test small amounts of Botox versus a placebo on about 250 patients in the United States, measuring the improvement of their depression based on results from the Montgomery-Asberg Depression Rating Scale. The results disappointed some experts. Allergan was inspired enough to move forward with Phase III clinical trials, but postponed them in 2019. A spokesperson for AbbVie confirmed to Allure that in 2024 the company “currently does not have any ongoing studies with Botox for major depressive disorder.”
If research has slowed, the notion that these injections can positively influence mood has nevertheless persisted. In 2020, researchers at University of California San Diego found “significant” antidepressant effects after reviewing around 40,000 entries about neurotoxin in the FDA’s Adverse Effects Reporting System, which catalogs consumer feedback; most compellingly, these effects were observed regardless of whether it was injected into eleven lines or crows feet or the fine folds around the mouth. While no particular brand of neurotoxin was discussed, one of the study’s three authors, a German psychiatrist named Marc Axel Wollman, disclosed having consulted for Allergan.
A number of patient studies have since been published, though often their authors disclose relevant conflicts of interest. A 2021 meta-analysis of those studies that emphasized the antidepressant effectiveness of neurotoxin, published in the Journal of Psychiatric Research, was authored in part by Wollman, a few other doctors who had consulted for AbbVie, and one who held a patent for neurotoxin administered for psychiatric use-cases. A letter to the editor, written by two psychiatry professors and published in the Journal of Psychiatric Research, expressed concern over the study’s framing after its authors repeated the analysis with much less optimistic results. Critical reviews of these studies have concluded that evidence is preliminary but promising. For some of us, promising is all we need.
I have Major Depressive Disorder, diagnosed by a licensed clinical psychologist. A chemical imbalance in my brain infrequently makes me prone to periods of emotional despondency, which my therapist refers to as depressive episodes—an emotional flu that happens upon me a few times a year. My depression is not monstrous, but it is Major; it lives with me kind of like a song that plays at a low volume, threatening to crescendo if I take my finger off of the dial.
I’ve taken a mezze dose of an SNRI (Effexor-brand venlafaxine) for the past eight years. In flush times, I’ve indulged in weekly talk therapy and biweekly acupuncture. Most of my emotional health is devoted to strengthening my immunity against depressive episodes and other mood-disorder symptoms, and, like any other person seeking a cure for their strange and insoluble affliction, I also have tried a lot of frankly wacko things in search of a cure. I have floated in a sensory deprivation tank. I have convection-cooked my body using infrared therapy on both coasts of the United States. Even if these treatments didn’t work, I told myself, they would give me anecdotes for days. Whenever I was sad, I could just think of the time I got saltwater in my eye in the middle of a pitch-black tank buried deep within a midtown-Manhattan office building, and I could experience a kind of delight on demand.
But depression doesn’t work in this way. Even the pills, which I am very grateful for, fail sometimes. My appointment with Dr. Rieder in 2018 dovetailed with a particularly nasty depressive episode, so I was particularly open to seeing if “psychodermatology” could teach anybody anything about mood disorders and why they work the way they do. The way we look is so fraught, so heavy with implication, so bound to our greater self-esteem that it seems impossible that it doesn’t have a measurable influence on the way our brains work.
That Journal of Psychiatric Research letter to the editor also pointed out an “ongoing uncertainty about mechanism of action” meaning even those who are convinced of neurotoxin’s antidepressant power cannot tell you, exactly, how it works. Allergan’s Phase II clinical trial was based on the proposition made by Charles Darwin in his “Facial Feedback Hypothesis”: If you are unable to frown, you could be more likely to keep your expression neutral (or even smile!), and are therefore more likely to feel happy.
A few days after my first Botox injections, the neurotoxin calcified, rendering my forehead useless. My emotional inventory was limited to a handful of available expressions: closed-mouth smile, open-mouth smile, enormous cartoon grin. But instead of unbridled happiness and joy bursting forth from my every nose pore, I didn’t feel a thing. I didn’t feel bad, but I didn’t feel fantastic, either. To strangers, I looked like I was either feeling happy or nothing at all.
Despite the relative newness of psychodermatology as a field of study, the connection between your mind and your skin is neither novel nor medically experimental. In the human embryo, the central nervous system and the cutaneous (skin) system descend from the same layer of cells. We’ve known about it “since embryologists figured that out a century or so ago,” says Amy Wechsler, another one of the handful of psychodermatologists (board-certified MDs in both specialties) in the United States. “There are many physical neurological connections between the brain and the skin, and they’re bidirectional. I just don’t think that people focused on it for a long time.”
The term “psychodermatology” was coined as early as the ’70s (in Dutch and French medical literature). It was more recently defined in a 2001 report published by the American Academy of Family Physicians that outlines a series of skin disorders that are aggravated by emotional stress, including eczema and psoriasis, and skin-related psychiatric disorders, like delusions of parasitosis, or Morgellons disease, characterized by the feeling that bugs or other foreign creatures are living under your skin.
In 2006, the same year Allure first covered psychodermatology, the National Institutes of Health published a study linking problem acne and increased rates of depressive tendencies in teens. A little over a decade later, a report in the Journal of the American Medical Association found that dermatology patients with atopic dermatitis were 44 percent more likely to have suicidal thoughts than those without; they were 36 percent more likely to act on those thoughts. Atopic dermatitis is the most common type of eczema, afflicting about 30 million Americans.
And then there was the Botox and depression study in 2014, scientifically rooted in the psychiatric connection between our moods and our face. If the Darwinian theory holds, it’s worth noting that Botox isn’t making you happier but is in theory making you less sad—taking peaks and valleys and bringing them closer to baseline, which is similar in effect to antidepressants that have proven benefits for people with major depressive disorder. Since 2019, scholarship on psycho-dermatologic topics, from alopecia to eczema, has more than doubled.
Despite all of this, there are still far fewer psychodermatologists than UFOlogists or chemtrail conspiracy theorists. The psychodermatologists I have spoken to tell me that most of their practice comprises cosmetic and medical dermatology: good, old-fashioned mole removal and filler injections. (When I asked Dr. Rieder about treating my eczema, the psychodermatologist’s approach bore a striking resemblance to the regular dermatologist’s approach: Use fewer moisture-stripping soaps and apply a corticosteroid. Wear tights when running. Don’t scratch your legs, even if they are begging to be scratched.) Most of these doctors’ psych cases are appraised and then referred elsewhere—they simply don’t have the time to take on weekly 45-minute cognitive behavioral therapy sessions. Instead, a psych-derm will look at your acne, put you on a treatment plan, ask about your sleep patterns and any major life events or stressors that could exacerbate skin conditions like acne, teach you some breathing exercises.
“You would think people go to a doctor’s office just to have a diagnosis and get a treatment,” says Dr. Wechsler. “They also want to be understood.”
At many points during this reporting process, I cannot help one question from bouncing off the walls of my brain: Are beautiful people more likely to be happy?
I know that it shouldn’t be true; that despite the fragrance ads and the deluge of income bestowed on our nation’s hottest people, mood disorders do not discriminate. But if a person is constantly exalted for their appearance, would they have higher self-esteem and therefore an easier time dealing with anxiety and depression? Could Botox improve my mood because it makes me more attractive?
James Murrough, MD, a psychiatrist and associate professor of psychiatry and neuroscience at Mount Sinai Hospital in New York City, does not seem to think so. Self-esteem, he says, is not clinically defined by any one aspect of self-image; it’s a combination of many things. (He believes most baseline self-esteem levels develop in early childhood through adolescence.) But, he concedes, a negative physical perception of self affects a not- insignificant portion of depressive patients—around 20 percent.
“Positive self-image has been shown to be very important—a protective or resilient factor against stressors that may otherwise trigger major depression or a clinical anxiety disorder,” he says. It doesn’t happen overnight, but with “positive self- care, through healthy relationships,” self-image can be improved.
My therapist tells me the five aspects of self-care: intellectual, physical, spiritual, social, and emotional. He is not, personally, a fan of the idea that doing a face mask qualifies as an act of self-preservation. But if treating your skin brings you joy, excellent—that’s one-fifth of the puzzle. The rest includes things like gathering a support system of loved ones, engaging with a community of people like you—that all amounts to what we consider “positive self-care.”
There is also room for weird stress-relief treatments. For example, on my third visit, Dr. Rieder asks if I am open to being hypnotized.
Hypnosis, according to Dr. Rieder, is “a lost medical art”: the arcane magic of suggestion. It replaces negative stimuli with positive stimuli, embedded into a calming meditative practice. He mentions a video he’d seen as a medical student of a woman undergoing surgery without anesthesia—her face registered the amount of pain associated with taking a warm bath. She had been hypnotized to feel nothing.
Yes, I would be down to try this. (I’m told that I’m a “great candidate” for this, too.)
With the doctor’s instruction, I roll my eyes back slowly while closing them. He tells me to pretend there is a balloon under my wrist, and I should let it rise toward the ceiling. He tells me I am floating. He asks me to project my stresses and insecurities onto a blank screen, then to part with them. Next I am supposed to come back to earth. Dr. Rieder writes directions—a prescription for a hypnotic trance—so I can do it before bed, or whenever I’m feeling overwhelmed.
Four months after my initial experiment, as I wrested back control of my forehead, I discovered that my brow lines were exactly where I left them. In the mirror, my cheeks were wind-whipped and pink from winter weather; my eyes were soft and blue. How did I look? I looked fine. I can’t tell you if I felt any better during that period of time, other than to say that, if I really wanted to know, I should have kept it up. (That was my first and thus far last experience with Botox.) But I can tell you that it didn’t feel nearly as good in the mirror as it did in the office, when I was talking through it, instead of just looking at it.
A version of this story originally ran in the May 2019 issue of Allure, and was updated in June 2024 to include new developments on neurotoxin injections for treating major depressive disorder.
Read more about neurotoxins like Botox:
- My Botox Doesn’t Work Like It Used To
- The Myth of Preventative Botox
- There’s Now a Buy Now, Pay Later Plan for Botox
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