Manipulating facial musculature with functional electrical stimulation as an intervention for major depressive disorder: a focused search of literature for a proposal

Ilya Demchenko; Naaz Desai; Stephanie N Iwasa; Fatemeh Gholamali Nezhad; José Zariffa; Sidney H Kennedy; Nicholas O Rule; Jeffrey F Cohn; Milos R Popovic; Benoit H Mulsant; Venkat Bhat

doi:10.1186/s12984-023-01187-8

Manipulating facial musculature with functional electrical stimulation as an intervention for major depressive disorder: a focused search of literature for a proposal

J Neuroeng Rehabil. 2023 May 16;20(1):64. doi: 10.1186/s12984-023-01187-8.

Authors

Ilya Demchenko^{1

2}, Naaz Desai^{3

4}, Stephanie N Iwasa^{4

5}, Fatemeh Gholamali Nezhad¹, José Zariffa^{4

5

6

7

8}, Sidney H Kennedy^{1

2

9}, Nicholas O Rule¹⁰, Jeffrey F Cohn¹¹, Milos R Popovic^{2

4

5

7

8}, Benoit H Mulsant^{9

12}, Venkat Bhat^{13

14

15

16

17

18}

Affiliations

¹ Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael's Hospital - Unity Health Toronto, Toronto, ON, M5B 1M4, Canada.
² Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada.
³ Krembil Research Institute - University Health Network, Toronto, ON, M5T 0S8, Canada.
⁴ KITE, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, M5G 2A2, Canada.
⁵ CRANIA, University Health Network, Toronto, ON, M5G 2C4, Canada.
⁶ Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5G 1V7, Canada.
⁷ Institute of Biomedical Engineering, Faculty of Applied Science & Engineering, University of Toronto, Toronto, ON, M5S 3E2, Canada.
⁸ The Edward S. Rogers Sr. Department of Electrical & Computer Engineering, Faculty of Applied Science & Engineering, University of Toronto, Toronto, ON, M5S 3G8, Canada.
⁹ Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5T 1R8, Canada.
¹⁰ Department of Psychology, Faculty of Arts & Science , University of Toronto, Toronto, ON, M5S 3G3, Canada.
¹¹ Department of Psychology, Kenneth P. Dietrich School of Arts & Sciences, University of Pittsburgh, Pittsburgh, PA, 15260, USA.
¹² Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, M6J 1H4, Canada.
¹³ Interventional Psychiatry Program, Mental Health and Addictions Service, St. Michael's Hospital - Unity Health Toronto, Toronto, ON, M5B 1M4, Canada. venkat.bhat@utoronto.ca.
¹⁴ Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada. venkat.bhat@utoronto.ca.
¹⁵ Krembil Research Institute - University Health Network, Toronto, ON, M5T 0S8, Canada. venkat.bhat@utoronto.ca.
¹⁶ KITE, Toronto Rehabilitation Institute - University Health Network, Toronto, ON, M5G 2A2, Canada. venkat.bhat@utoronto.ca.
¹⁷ CRANIA, University Health Network, Toronto, ON, M5G 2C4, Canada. venkat.bhat@utoronto.ca.
¹⁸ Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5T 1R8, Canada. venkat.bhat@utoronto.ca.

Abstract

Background: Major Depressive Disorder (MDD) is associated with interoceptive deficits expressed throughout the body, particularly the facial musculature. According to the facial feedback hypothesis, afferent feedback from the facial muscles suffices to alter the emotional experience. Thus, manipulating the facial muscles could provide a new "mind-body" intervention for MDD. This article provides a conceptual overview of functional electrical stimulation (FES), a novel neuromodulation-based treatment modality that can be potentially used in the treatment of disorders of disrupted brain connectivity, such as MDD.

Methods: A focused literature search was performed for clinical studies of FES as a modulatory treatment for mood symptoms. The literature is reviewed in a narrative format, integrating theories of emotion, facial expression, and MDD.

Results: A rich body of literature on FES supports the notion that peripheral muscle manipulation in patients with stroke or spinal cord injury may enhance central neuroplasticity, restoring lost sensorimotor function. These neuroplastic effects suggest that FES may be a promising innovative intervention for psychiatric disorders of disrupted brain connectivity, such as MDD. Recent pilot data on repetitive FES applied to the facial muscles in healthy participants and patients with MDD show early promise, suggesting that FES may attenuate the negative interoceptive bias associated with MDD by enhancing positive facial feedback. Neurobiologically, the amygdala and nodes of the emotion-to-motor transformation loop may serve as potential neural targets for facial FES in MDD, as they integrate proprioceptive and interoceptive inputs from muscles of facial expression and fine-tune their motor output in line with socio-emotional context.

Conclusions: Manipulating facial muscles may represent a mechanistically novel treatment strategy for MDD and other disorders of disrupted brain connectivity that is worthy of investigation in phase II/III trials.

Keywords: Amygdala; Depressive disorder; Facial expression; Facial muscles; Functional electrical stimulation; Interoception; Myofunctional therapy; Neurological rehabilitation; Neuromodulation; Neuroplasticity.

Publication types

Review

MeSH terms

Brain
Depressive Disorder, Major* / therapy
Electric Stimulation
Emotions / physiology
Facial Muscles
Humans
Magnetic Resonance Imaging