{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T15:25:27Z","timestamp":1787153127733,"version":"build-2736575974"},"reference-count":49,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T00:00:00Z","timestamp":1779667200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Psychiatry"],"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Facial feedback mechanisms can modulate affective states. A series of clinical trials have shown that injection of botulinum toxin A can improve the symptoms of depression, probably via the disruption of proprioceptive afferences from the glabellar region to the brain. In extension of this research, we developed a physiotherapeutic program for the facial rehabilitation of wellbeing in depression (FaReWell Depression) with the objective to relax key facial muscles involved in the expression and experience of negative emotions and to tone and strengthen key facial muscles for the expression and experience of positive emotions. The program comprises a massage module with a focus on the glabellar (corrugator supercilii and procerus muscles) and perioral (mentalis and depressor anguli oris muscles) regions and a strength-training module with a focus on the cheek region (zygomaticus and orbicularis oculi muscles). We tested the therapeutic potential of this program in a randomized controlled trial.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We assigned 49 patients with mild to moderate depression to either do a daily 15 minutes training session with the FaReWell Depression program or a rest exercise for the same duration as a control condition. The primary endpoint of the study was the change on the Montgomery-\u00c5sberg Depression Rating Scale (MADRS) from the baseline to the point in time six weeks later.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      The repeated measures analysis of covariance (ANCOVA) of the MADRS scores showed a significant group \u00d7 time interaction effect (\n                      <jats:italic>F<\/jats:italic>\n                      \u00a0=\u00a06.37,\n                      <jats:italic>p<\/jats:italic>\n                      \u00a0= .017,\n                      <jats:italic>partial \u03b7\u00b2<\/jats:italic>\n                      \u00a0= .166), indicating lower depression severity in the intervention group (mean\n                      <jats:sub>pre<\/jats:sub>\n                      = 20.64, SD\n                      <jats:sub>pre<\/jats:sub>\n                      = 5.56, mean\n                      <jats:sub>post<\/jats:sub>\n                      = 13.29, SD\n                      <jats:sub>post<\/jats:sub>\n                      = 7.76) compared to the control group (mean\n                      <jats:sub>pre<\/jats:sub>\n                      = 20.10, SD\n                      <jats:sub>pre<\/jats:sub>\n                      = 7.23, mean\n                      <jats:sub>post<\/jats:sub>\n                      = 18.26, SD\n                      <jats:sub>post<\/jats:sub>\n                      = 6.78) after the training. Secondary outcome measures of among others anhedonia, short-term mood changes, facial self-perception, and facial appearance did not show significant group differences over time.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Discussion<\/jats:title>\n                    <jats:p>These findings provide preliminary evidence that a self-applied facial physiotherapeutic intervention can improve the symptoms of depression and warrants further investigation into this novel treatment approach.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpsyt.2026.1798454","type":"journal-article","created":{"date-parts":[[2026,5,25]],"date-time":"2026-05-25T06:05:05Z","timestamp":1779689105000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["FaReWell Depression \u2013 a randomized controlled trial of a physiotherapeutic program for the facial rehabilitation of wellbeing in depression"],"prefix":"10.3389","volume":"17","author":[{"given":"M. Axel","family":"Wollmer","sequence":"first","affiliation":[{"name":"Asklepios Clinic North - Ochsenzoll, Medical Faculty, Semmelweis University","place":["Hamburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hannah","family":"Lemke","sequence":"additional","affiliation":[{"name":"Asklepios Clinic North - Ochsenzoll, Medical Faculty, Semmelweis University","place":["Hamburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Patricia","family":"Waldvogel","sequence":"additional","affiliation":[{"name":"Centre for Anxiety and Depression Treatment Zurich ZADZ","place":["Zurich, Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Insa","family":"Neumann","sequence":"additional","affiliation":[{"name":"Asklepios Clinic North - Ochsenzoll, Medical Faculty, Semmelweis University","place":["Hamburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kayleigh","family":"Keller","sequence":"additional","affiliation":[{"name":"Centre for Anxiety and Depression Treatment Zurich ZADZ","place":["Zurich, Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Veronika","family":"N\u00f6lle","sequence":"additional","affiliation":[{"name":"Centre for Anxiety and Depression Treatment Zurich ZADZ","place":["Zurich, Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nathalie","family":"Dittmer","sequence":"additional","affiliation":[{"name":"Asklepios Clinic North - Ochsenzoll, Medical Faculty, Semmelweis University","place":["Hamburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maksim","family":"Lucic","sequence":"additional","affiliation":[{"name":"Asklepios Clinic North - Ochsenzoll, Medical Faculty, Semmelweis University","place":["Hamburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Barbara","family":"Walss","sequence":"additional","affiliation":[{"name":"Centre for Anxiety and Depression Treatment Zurich ZADZ","place":["Zurich, Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tillmann H.C.","family":"Kr\u00fcger","sequence":"additional","affiliation":[{"name":"Center for Systems Neuroscience","place":["Hannover, Germany"]},{"name":"Department of Psychiatry, Social Psychiatry and Psychotherapy, Division of Clinical Psychology and Sexual Medicine, Hannover Medical School","place":["Hannover, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Josef","family":"H\u00e4ttenschwiler","sequence":"additional","affiliation":[{"name":"Centre for Anxiety and Depression Treatment Zurich ZADZ","place":["Zurich, Switzerland"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,5,25]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","DOI":"10.1002\/wcs.1370","article-title":"Embodied emotion: the influence of manipulated facial and bodily states on emotive responses","volume":"6","author":"Price","year":"2015","journal-title":"Wiley Interdiscip Rev Cognit Sci"},{"key":"B2","doi-asserted-by":"publisher","DOI":"10.31234\/osf.io\/svjru","article-title":"A meta-analysis of the facial feedback literature: effects of facial feedback on emotional experience are small and variable","volume":"145","author":"Coles","year":"2019","journal-title":"Psychol Bull"},{"key":"B3","doi-asserted-by":"publisher","DOI":"10.31234\/osf.io\/cvpuw","article-title":"A multi-lab test of the facial feedback hypothesis by the Many Smiles Collaboration","volume":"6","author":"Coles","year":"2022","journal-title":"Nat Hum Behav"},{"key":"B4","doi-asserted-by":"publisher","DOI":"10.1126\/science.1257786","article-title":"Facial muscle patterning to affective imagery in depressed and nondepressed subjects","volume":"192","author":"Schwartz","year":"1976","journal-title":"Science"},{"key":"B5","article-title":"Agitated depression in clinical practice","volume":"46","author":"Greden","year":"1985","journal-title":"J Clin Psychiatry"},{"key":"B6","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpsychires.2012.01.027","article-title":"Facing depression with botulinum toxin: a randomized controlled trial","volume":"46","author":"Wollmer","year":"2012","journal-title":"J Psychiatr Res"},{"key":"B7","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.jpsychires.2013.11.006","article-title":"Treatment of depression with onabotulinumtoxinA: a randomized, double-blind, placebo controlled trial","volume":"52","author":"Finzi","year":"2014","journal-title":"J Psychiatr Res"},{"key":"B8","doi-asserted-by":"publisher","DOI":"10.4088\/jcp.13m08845","article-title":"Treatment of major depressive disorder using botulinum toxin A: a 24-week randomized, double-blind, placebo-controlled study","volume":"75","author":"Magid","year":"2014","journal-title":"J Clin Psychiatry"},{"key":"B9","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpsychires.2021.01.016","article-title":"Botulinum toxin for the management of depression: an updated review of the evidence and meta-analysis","volume":"135","author":"Schulze","year":"2021","journal-title":"J Psychiatr Res"},{"key":"B10","doi-asserted-by":"publisher","DOI":"10.1016\/j.jpsychires.2016.06.009","article-title":"Emotional proprioception: treatment of depression with afferent facial feedback","volume":"80","author":"Finzi","year":"2016","journal-title":"J Psychiatr Res"},{"key":"B11","doi-asserted-by":"publisher","first-page":"840","DOI":"10.3390\/medicina61050840","article-title":"Effect of intensive face yoga on facial muscles tonus, stiffness, and elasticity in middle-aged women: a pre-experimental clinical trial","volume":"61","author":"G\u00fczel","year":"2025","journal-title":"Med (Kaunas)"},{"key":"B12","doi-asserted-by":"publisher","DOI":"10.2220\/biomedres.29.317","article-title":"The facial massage reduced anxiety and negative mood status, and increased sympathetic nervous activity","volume":"29","author":"Hatayama","year":"2008","journal-title":"BioMed Res"},{"key":"B13","doi-asserted-by":"publisher","DOI":"10.1080\/10669817.2021.2018102","article-title":"Does combined individualized orofacial manual therapy, pain neuroscience education, and brain training change orofacial pain, chronic face dysfunction, (facial) body perception and pain? An observational mixed methods case series study","volume":"30","author":"Von Piekartz","year":"2022","journal-title":"J Man Manip Ther"},{"key":"B14","doi-asserted-by":"publisher","DOI":"10.1001\/jamadermatol.2017.5142","article-title":"Association of facial exercise with the appearance of aging","volume":"154","author":"Alam","year":"2018","journal-title":"JAMA Dermatol"},{"key":"B15","doi-asserted-by":"publisher","DOI":"10.1093\/asj\/sjx238","article-title":"Effect of a facial muscle exercise device on facial rejuvenation","volume":"38","author":"Hwang","year":"2018","journal-title":"Aesthet Surg J"},{"key":"B16","doi-asserted-by":"publisher","DOI":"10.1177\/17455057241286201","article-title":"The effects of online facial muscle training with resonance vocalization on mental health in postpartum women: a single-arm pilot study","volume":"20","author":"Okamoto","year":"2024","journal-title":"Womens Health (Lond)"},{"key":"B17","doi-asserted-by":"publisher","DOI":"10.1007\/s002669900312","article-title":"Specific impairment of smiling increases the risk for depression","volume":"23","author":"VanSwearingen","year":"1999","journal-title":"Aesthet Plast Surg"},{"key":"B18","doi-asserted-by":"publisher","DOI":"10.5507\/bp.2013.014","article-title":"Central facial paresis and its impact on mimicry, psyche and quality of life in patients after stroke","volume":"158","author":"Konecny","year":"2014","journal-title":"Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub"},{"key":"B19","doi-asserted-by":"publisher","DOI":"10.4040\/jkan.2016.46.4.542","article-title":"Effects of facial muscle exercise program on facial function and depression in patients with facial palsy","volume":"46","author":"Choi","year":"2016","journal-title":"J Korean Acad Nurs"},{"key":"B20","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph182212216","article-title":"Effects of facial muscles exercise on mental health: a systematic review","volume":"18","author":"Okamoto","year":"2021","journal-title":"Int J Environ Public Health"},{"key":"B21","doi-asserted-by":"publisher","DOI":"10.1037\/0022-3514.54.6.1063","article-title":"Development and validation of brief measures of positive and negative affect: the PANAS scales","volume":"54","author":"Watson","year":"1988","journal-title":"J Pers Soc Psychol"},{"key":"B22","volume-title":"Fitness-Training f\u00fcrs Gesicht","author":"H\u00f6fler","year":"2016"},{"key":"B23","volume-title":"The New Facercise","author":"Maggio","year":"2002"},{"key":"B24","volume-title":"The Art of Indian Face Massage","author":"Mehta","year":"2001"},{"key":"B25","unstructured":"Happy Face Yoga\n          \n          \n            \n              Sikorski\n              G\n            \n          \n          \n          2019"},{"key":"B26","volume-title":"Face Yoga Method","author":"Takatsu","year":"2015"},{"key":"B27","volume-title":"Interaktives Skillstraining f\u00fcr Borderline-Patienten","author":"Bohus","year":"2013"},{"key":"B28","doi-asserted-by":"publisher","DOI":"10.1192\/bjp.134.4.382","article-title":"A new depression scale designed to be sensitive to change","volume":"134","author":"Montgomery","year":"1979","journal-title":"Br J Psychiatry"},{"key":"B29","doi-asserted-by":"publisher","DOI":"10.1016\/s0165-0327(01)00451-7","article-title":"Defining remission by cut off score on the MADRS: selecting the optimal value","volume":"72","author":"Hawley","year":"2002","journal-title":"J Affect Disord"},{"key":"B30","doi-asserted-by":"publisher","DOI":"10.1046\/j.1525-1497.2001.016009606.x","article-title":"The PHQ-9: validity of a brief depression severity measure","volume":"16","author":"Kroenke","year":"2001","journal-title":"J Gen Intern Med"},{"key":"B31","doi-asserted-by":"publisher","first-page":"99","DOI":"10.1192\/bjp.167.1.99","article-title":"A scale for the assessment of hedonic tone: the Snaith\u2013Hamilton Pleasure Scale","volume":"167","author":"Snaith","year":"1995","journal-title":"Br J Psychiatry"},{"key":"B32","doi-asserted-by":"publisher","DOI":"10.1037\/t12446-000","article-title":"Der mehrdimensionale befindlichkeitsfragebogen (MDBF)","volume":"43","author":"Steyer","year":"1997","journal-title":"Diagnostica"},{"key":"B33","doi-asserted-by":"publisher","DOI":"10.1016\/j.neubiorev.2021.05.030","article-title":"Stop touching your face! a systematic review of triggers, characteristics, regulatory functions and neuro-physiology of facial self touch","volume":"128","author":"Spille","year":"2021","journal-title":"Neurosci Biobehav Rev"},{"key":"B34","doi-asserted-by":"publisher","DOI":"10.1001\/jamapsychiatry.2025.0085","article-title":"Expectancy effects, failure of blinding integrity, and placebo response in trials of treatments for psychiatric disorders: a narrative review","volume":"82","author":"Huneke","year":"2025","journal-title":"JAMA Psychiatry"},{"key":"B35","doi-asserted-by":"publisher","DOI":"10.1037\/pst0000117","article-title":"Behavioral activation as a common mechanism of change across different orientations and disorders","volume":"54","author":"Dimaggio","year":"2017","journal-title":"Psychother (Chic)"},{"key":"B36","doi-asserted-by":"publisher","first-page":"362","DOI":"10.3988\/jcn.2024.0148","article-title":"Behavioral activation and brain network changes in depression","volume":"20","author":"Jung","year":"2024","journal-title":"J Clin Neurol (Seoul Korea)"},{"key":"B37","doi-asserted-by":"publisher","DOI":"10.3390\/jcm13216481","article-title":"The effectiveness of emotional freedom techniques for depressive symptoms: a meta-analysis","volume":"13","author":"Seok","year":"2024","journal-title":"J Clin Med"},{"key":"B38","doi-asserted-by":"publisher","DOI":"10.1007\/s11920-024-01548-7","article-title":"Mind-Body Medicine in the treatment of depression: a narrative review of efficacy, safety and mechanisms","volume":"26","author":"Kucukosmanoglu","year":"2024","journal-title":"Curr Psychiatry Rep"},{"key":"B39","doi-asserted-by":"publisher","DOI":"10.3390\/brainsci10100676","article-title":"Effects of psychoactive massage in outpatients with depressive disorders: a randomized controlled mixed-methods study","volume":"10","author":"Arnold","year":"2020","journal-title":"Brain Sci"},{"key":"B40","doi-asserted-by":"publisher","first-page":"894","DOI":"10.4088\/jcp.09r05009blu","article-title":"Treatment effects of massage therapy in depressed people: a meta-analysis","volume":"71","author":"Hou","year":"2010","journal-title":"J Clin Psychiatry"},{"key":"B41","doi-asserted-by":"publisher","DOI":"10.3389\/fpsyt.2021.705559","article-title":"The effects and mechanisms of exercise on the treatment of depression","volume":"12","author":"Xie","year":"2021","journal-title":"Front Psychiatr"},{"key":"B42","doi-asserted-by":"publisher","DOI":"10.1136\/bmj-2023-075847","article-title":"Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials","volume":"384","author":"Noetel","year":"2024","journal-title":"BMJ"},{"key":"B43","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0317610","article-title":"A 10 years update of effects of exercise on depression disorders\u2014in otherwise healthy adults: a systematic review of meta-analyses and neurobiological mechanisms","volume":"20","author":"Budde","year":"2025","journal-title":"PloS One"},{"key":"B44","doi-asserted-by":"publisher","first-page":"26474","DOI":"10.4088\/JCP.13097TX1C","article-title":"Residual symptoms in depression: prevalence and impact","volume":"76","author":"Nierenberg","year":"2015","journal-title":"J Clin Psychiatry"},{"key":"B45","doi-asserted-by":"publisher","DOI":"10.1016\/j.euroneuro.2010.11.004","article-title":"Early improvement in positive rather than negative emotion predicts remission from depression after pharmacotherapy","volume":"21","author":"Geschwind","year":"2011","journal-title":"Eur Neuropsychopharmacol"},{"key":"B46","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2019.02.018","article-title":"Laughter-inducing therapies: systematic review and meta-analysis","volume":"232","author":"van der Wal","year":"2019","journal-title":"Soc Sci Med"},{"key":"B47","doi-asserted-by":"publisher","first-page":"79","DOI":"10.31234\/osf.io\/vec8f","article-title":"Smiling and frowning induced by facial neuromuscular electrical stimulation (fNMES) modulate felt emotion and physiology","volume":"25","author":"Efthimiou","year":"2024","journal-title":"Emotion"},{"key":"B48","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1186\/s12938-019-0730-6","article-title":"Functional electrical stimulation of the facial muscles to improve symptoms in individuals with major depressive disorder: pilot feasibility study","volume":"18","author":"Kapadia","year":"2019","journal-title":"BioMed Eng Online"},{"key":"B49","doi-asserted-by":"publisher","DOI":"10.1016\/j.yebeh.2013.05.008","article-title":"Trigeminal nerve stimulation in major depressive disorder: acute outcomes in an open pilot study","volume":"28","author":"Cook","year":"2013","journal-title":"Epilepsy Behav"}],"updated-by":[{"DOI":"10.3389\/fpsyt.2026.1959551","type":"correction","label":"Correction","source":"publisher","updated":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T00:00:00Z","timestamp":1787097600000}}],"container-title":["Frontiers in Psychiatry"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyt.2026.1798454\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T14:28:23Z","timestamp":1787149703000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyt.2026.1798454\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,25]]},"references-count":49,"alternative-id":["10.3389\/fpsyt.2026.1798454"],"URL":"https:\/\/doi.org\/10.3389\/fpsyt.2026.1798454","relation":{},"ISSN":["1664-0640"],"issn-type":[{"value":"1664-0640","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,25]]},"article-number":"1798454"}}