FormalPara Key Summary Points

Why carry out this study?

In 2010 the economic burden of major depressive disorders in the USA was estimated at US$210.5 billion, rising to US$326.2 billion in 2020.

Several studies reported that adults who take care of their appearance and use makeup achieved improved self-esteem and quality of life, but limited studies have objectively measured this effect.

This study aimed to test the hypothesis that frequent use of makeup can contribute to a better quality of life for Brazilian women with medium–low purchasing power, objectively measuring the reduction in depressive symptoms following the introduction of this practice.

What was learned from the study?

A positive relationship was shown between the introduction of frequent use of makeup and sustained reduction of depressive symptoms.

Adopting the simple routine of caring for one’s appearance through the frequent use of makeup (a simple and low-cost practice) can effectively and sustainably contribute to improvement in the well-being and mental health of a significant portion of the population.

Introduction

Depression has been identified by the World Health Organisation (WHO) as a global health challenge that accounts for 10% of the total non-fatal disease burden [1]. In 2010 the economic burden of major depressive disorders in the USA was estimated at US$210.5 billion; in 2020, this had risen to US$326.2 billion [2]. Depression is characterised by a depressed mood or lack of pleasure and/or interest in activities for prolonged periods. It negatively affects all aspects of life, including relationships, education, work productivity and self-worth. It can contribute to or worsen physical co-morbidities and can lead to self-harm and suicide.

Depression disproportionally affects women and girls, with the incidence approximately 50% higher than in males [3]. The gender difference in depression, with twofold more women diagnosed than men, was first reported in the 1970s [4] and has since been supported by a large body of epidemiological studies. A recent meta-analysis focussed on the incidence of depression throughout the lifespan and demonstrated that the gender difference in terms of a diagnosis of depression is present as early as 12 years of age, peaks at 13–15 years and persists throughout the lifespan of the individual [5]. Developmental and hormonal changes associated with puberty, premenstrual problems, pregnancy and post-partum and menopause can all be associated with increased incidence of depression in women. Given the disparity in the incidence of depression, there is a need for gender-specific management of the condition.

Management of depressive disorder is multifactorial and includes psychological treatment (commonly cognitive behavioural therapy [CBT]) and antidepressive medications. The WHO also describes the role that self-care can play in managing symptoms and promoting overall well-being [3], including getting regular exercise, improving nutrition, reducing stress, improving sleep patterns and engaging in positive social interactions. The research presented here focusses on the aspect of self-care in depression management.

Advances in the field of mental health, and especially in psychodermatology, demonstrate that the pathophysiology of mental disorders is not limited to biological components and involves a strong influence of psychosocial factors, with special importance on charismaphobia, defined as the fear of unattractiveness (fear of not being or no longer attractive) [6]. While this phobia can affect both men and women, its effects have been considered to have a strong influence on women's mental health and self-esteem [7, 8].

Positive self-esteem and self-image are important considerations in good mental health. Skin care and beauty routines are often advocated by self-help groups [9], online influencers and magazines. Several studies have demonstrated positive trends in psychological measures in response to beauty-related interventions. This is particularly the case when the presence of a disease state is often associated with a reduction in self-image, such as in patients with breast cancer [10, 11].

As makeup involves three of the human senses (touch, smell and vision), it’s use can induce pleasure, sensory and psychological feelings. In addition, the application of makeup modifies the appearance, helping the individual to cope with self-image, emotions and mood. Cosmetics promote well-being by modifying the appearance and stimulating attractiveness, and makeup has been shown to provide supporting effects on the mental health of women affected by serious diseases [12]. In our recent survey of 2400 Brazilian women, we demonstrated that the regular use of makeup was associated with a lower incidence of mild depression and lower intensity of depressive symptoms [13]. To further examine this finding, in the present study we investigated the effect of introducing the frequent use of makeup on depressive symptoms in adult women of medium–low purchasing power who were not previously in the habit of regularly applying makeup. Products and instructions were provided to encourage the frequent use of makeup. The evolution of depressive symptoms was measured using the Zung Self-Assessment Scale for Depressive Symptoms (ZSDS) [14].

Methods

This study was designed as a randomized, prospective, open, controlled trial. The study was carried out in accordance with the Declaration of Helsinki of 1964 and its subsequent amendments, and was approved by the Research Ethics Committee of the Federal University of São Paulo (UNIFESP; Opinion No. 3,912,288) and registered on Plataforma Brasil under number 28057119.5.0000.5505 according to Brazilian laws, this is all that is required for a study involving cosmetics. Prior to any study activity, all participants signed an informed consent form (ICF), agreeing to participate and authorizing the dissemination of the results.

Population

The sample size was defined by the maximum error criterion (3 points on the average of the ZSDS). A total of 240 participants were identified and recruited from a previous national survey conducted by our group (observational, cross-sectional, population-based study) based on a representative sample of the target population (n = 2400). The aim of this earlier survey was to estimate the prevalence of depressive symptoms, and the results demonstrated the existence of an association between a lower prevalence of symptoms suggestive of mild depression among participants who frequently used makeup [13].

Instruments Used for Assessment

The ZSDS (also referred to here as the Zung Scale) was used to assess the presence and intensity of depressive symptoms, constituting the primary endpoint of the study. The Zung Scale was developed by the psychiatrist William Zung, from Duke University, in 1965 [14, 15] and continues to be substantially used [16]. It is based on self-reporting the frequency (Likert scale: almost never/sometimes/a lot of the time/most of the time) of 20 different feelings and emotions, of which ten are negative (points given range from 1 to 4 according to the answer obtained) and ten are positive (points given range from 4 to 1 according to the answer obtained). Ultimately, the raw score can vary between 20 and 80 points and is then converted to a percentage index [17]. In a subgroup of participants, a mirror test was also carried out to assess self-image, as well as salivary cortisol measurement to assess stress levels. The rationale underlying the mirror test is to confront the subject with their own reflection, which is relevant for studies involving cosmetics as it is a powerful psychological trigger and has a significant emotional charge, activating aspects related to self-acceptance and thereby characterizing itself as a mild stressor [18]. Salivary cortisol functions as a biomarker in stress research, as a measure of the adaptation of the hypothalamic–pituitary–adrenal axis to stress, contributing to the way in which environmental events predispose an individual to depression [19].

The inclusion criteria were: self-reported infrequent use of makeup (never or almost never/only on special occasions/only on weekends) and a Zung Scale score between 30 and 60, indicating minimum depressive symptoms (in order to measure the effect of introducing frequent use of makeup).

The exclusion criteria were a self-report of having received from a doctor, at some point of life, a diagnosis of mood disorders, current or previous use (90 days before the interview) of any medication with action on the central nervous system (for this approach, non-technical language was used, asking them about the use of medicines considered to be “soothing”, to “facilitate sleep” or any other medicine for “some emotional problem”).

In addition, those presenting with an initial gross score of < 30 or > 60 on the Zung Scale (first application of Zung Scale [Zung 1] of between 0.38 and 0.75), were excluded, as illustrated in Fig. 1.

Fig. 1
figure 1

Schematic representation of the range of scores on the Zung Depressive Symptoms Self-Assessment Scale used to select the study population

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The recruited participants were randomized (simple alternation of groups according to order of recruitment, carried out centrally in the Data Processing centre) between “test” and “control” groups. Among the 120 participants recruited for inclusion the test (intervention) group, 95 were ultimately included in the study. Those who lived in São Paulo City were invited to constitute a subgroup for "in-person" participation (n = 22); the remaining 73 participants were allocated to the subgroup for remote/online participation. Using the same approach, from the 120 participants randomized for the control group, 50 were ultimately included in the study. Those from São Paulo City were invited to participate in the "in-person" subgroup (n = 16), and 34 were part of the subgroup for “remote/online participation" (Fig. 2).

Fig. 2
figure 2

Flow chart of the clinical trial. Makeup workshops:1Sending video lesson + product kit; 2in-person class + first makeup + sending video lesson and product kit. Zung 2, 3: Second and third applications of the Zung Scale, respectively. Cortisol 1, 2, 3: First, second and third cortisol level measurements, respectively. Mirror 1, 2: First and second mirror tests, respectively. 1A, 1D: results of the "Before" and “After” tests of the makeup workshop, respectively. SEC Socio-economic class

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Intervention

After signing the ICF, participants in the test group (both in-person and online) received an incentive to adopt the routine of frequently using makeup (intervention) after attending a makeup workshop and being supplied with a sufficient variety and volume of makeup products to comply with the study guidelines for 60 days.

For the subgroup “in-person”, the makeup workshop was carried out in a face-to-face class on self-makeup with a professional teacher/makeup artist. The participants were encouraged to perform a first makeup application, assisted by students of the Aesthetics Course and they received a product kit, as shown in Fig. 3. They also received a link [20] for a 20-min video lesson on self-makeup taught by the same teacher. This lesson contained explanations on the use of the products and the techniques for applying the products, with three makeup options: basic application for day-to-day use; basic application with eye enhancement; application for nights. This video lesson also encouraged them to view videos sent to them 15 and 45 days after the workshop, each lasting 10 s, to reinforce the use of makeup and to rewatch the video class in case of doubts.

Fig. 3
figure 3

Makeup kit provided to each participant

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For the subgroup with online participation, after signing the ICF, the same product kit and a video lesson were sent. After 15 and 45 days, the videos of encouragement were also sent.

After signing the ICF, participants in the control group received only guidance on completing follow-up questionnaires, without any encouragement to use products or change habits.

Outcomes

A review of the existing depression screen guidelines and instruments [21] concluded that the 2-item Patient Health Questionnaire (PHQ-2) provided a suitable primary screening tool for depression that was reliable, brief and easy to administer. If positive, this should be followed by a suitable instrument, such as the Patient Health Questionnaire (PHQ-2 and PHQ-9), the General Health Questionnaire (GHQ-28) or the “Zung Self-Rating Depression Scale (ZSDS). The authors of the review concluded that the first three instruments were more sensitive and that the fourth (ZSDS) was the most specific [21]. The ZSDS was chosen for the present study based on its extensive use and validation in female health [22], including its Brazilian Portuguese translation [23]. The primary outcome was therefore the change in the level of depressive symptoms measured by the ZSDS at baseline and after 30 and 60 days. All participants answered the online questionnaire with the ZSDS, at the time points indicated in Table 1.

Table 1 Time points of answers to self-assessments of depressive symptoms
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Cortisol is a hormone released in stress situations [24]. Its role in the genesis of depression is considered to be important, including a temporal dimension related to the phases of life and specific variations during environmental events. Cortisol level can also predispose to or trigger the beginning of a depression episode [19].

Saliva was collected in a saliva collection device (Salivette®) for cortisol measurement following the ingestion of water and slight rinsing with mouthwash to eliminate any food residues. Participants were instructed not to touch the collection cotton of the device, but to chew it for 2 min and then deposit it in the proper sterile container and add some additional saliva. The samples were collected by qualified personnel, properly packed and transported, then centrifuged at 3000 rpm for 10 min at room temperature; the supernatant was transferred into the sample cup and measured in a CObas 8000 modular analyzer (Roche Diagnostics, Basel, Switzerland) for cortisol level, including immunoassay with electrochemiluminescence reading (Roche Diagnostics).

The mirror test was originally developed by American psychologist Gordon Gallup Jr. for testing animal cognition [25]. Although the purpose used in the present study has not been validated, we considered its use as an opportunity to assess its applicability in such studies as it has been frequently used by companies in the field of beauty and aesthetics. The rationale underlying mirror testing relates to the person’s confrontation with their own reflection. This confrontation is relevant for studies involving cosmetics because it is a powerful psychological trigger characterized as a mild stressor, with significant emotional load and activation aspects related to self-acceptance [18].

The mirror test was applied in a neutral room with air conditioning and the participants answered the following open questions: (1) What do you see in front of the mirror? Describe; and (2) How would someone else describe you on a first date? The answers were recorded and transcribed. The adjectives contained in the answers were organised and associated with scores, as shown in Table 2, for statistical analysis. Higher scores were attributed to the most positive adjectives.

Table 2 Time points of cortisol dosage and mirror test (times and answers)
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The secondary outcomes were only measured in the in-person participants: salivary cortisol concentration, at baseline and after 30 and 60 days, and self-perception of the image from the mirror test, at baseline and after 60 days.

Analysis of Data

The results were analysed using SPSS v.21 software (SPSS IBM Corp., Armonk, NY, USA). Student's t-test was used to assess two means of independent samples; the paired t-test was used to assess the means of dependent samples; and the repeated measures analysis of variance (ANOVA) was used for intragroup comparisons between more than two means of dependent samples. The significance level was set at 5%.

Results

Participant Compliance

Among the 95 participants in the test group, despite stimuli and guidance, only 82 participants reported an increase in the frequency of makeup use, and only 66 of these effectively reached the level of “frequent use”. In comparison, from the 50 participants in the control group, none of whom received stimulus or guidance, 20 participants reported a spontaneous increase in the frequency of makeup use, with 11 of them achieving the level of “frequent use”. The diagram in Fig. 4 shows that the procedures “change or not” the frequency of makeup use determined new subgroups. The analysis was kept for the originally defined subgroups only in those cases where the change in frequency of makeup use over time would not be a determining factor of bias.

Fig. 4
figure 4

Composition of subgroups and results on the use of makeup. 1Increase, to any degree, in the frequency of makeup use, not necessarily reaching the level of "frequent use”. 2Increased frequency of makeup use, reaching the level of “frequent use”. The single asterisk indicates a procedure different from that advised/predicted; the double asterisk indicates the procedure as expected, but not achieving the level requested/advised

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Zung Depression Scale

Regarding depressive symptoms, Fig. 5 shows that, considering the total number of participants and comparing the averages of the three ZSDS measurements, significant reductions (P = 0.04) were identified in the intragroup comparison between the second and third measures compared to the first, in the subgroup that did increase their frequency of makeup use. No difference was observed among the participants who did not increase the frequency of makeup use.

Fig. 5
figure 5

Average (range) variation in Zung Self-Assessment Scale for Depressive Symptoms (Zung Index) between measurements: comparison between subgroups. ANOVA, Analysis of variance

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Considering the total number of participants and analyzing the subgroups “adopted or not the frequent use of makeup”, Fig. 6 shows a significant reduction between the average of the second (P = 0.04) and third (P = 0.003) measurements compared to the first, among those who started frequently using makeup. Additionally, for this subgroup a significant reduction (P = 0.04) was identified in the average between the third versus the second measurement. No difference was observed among the participants who did not reach frequent use of makeup (3 or more times per week).

Fig. 6
figure 6

Average variation in the Zung Self-Assessment Scale for Depressive Symptoms (Zung Index) between Measurements: comparison between subgroups. ANOVA, Analysis of variance

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Salivary Cortisol

Comparison of average salivary cortisol levels in the test group revealed a significant reduction in cortisol level after the makeup workshop + first makeup compared to before these interventions (paired t-test, P = 0.000) (Fig. 7). Comparison of average salivary cortisol levels between the test and control groups revealed a significant reduction in cortisol level in the test group after the makeup workshop + first makeup compared to the control group (Student’s t-test, P = 0.019). This result indicates that the interventions had an impact on the participants.

Fig. 7
figure 7

Average salivary cortisol levels before versus after the makeup workshop and first makeup application. Dosage 1A, measurement taken before the workshop and first makeup application, dosage 1D, measurement was taken after the workshop + first makeup application

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Analysis of the variation of these average levels at the follow-up time points of 30 and 60 days revealed no significant differences (Fig. 8, suggesting that the effect generated by the makeup workshop and first makeup application was not maintained over time, being restricted to the period of the activities. The role of cortisol, especially in its proximal dimension [19], was notable between the dosages before and after the makeup workshop and first makeup application. The non-routine situation in which the participants took part may be related to this result, as the effect did not last into the follow-up period.

Fig. 8
figure 8

Average salivary cortisol levels after 30 and 60 days in the test group. Measure 1D, Measurement taken after the makeup workshop + first makeup application. The single asterisk indicates an increased frequency of use, but not reaching “frequent use” status. The double asterisks indicate the achievement of “frequent use” status (≥ 3 times per week)

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Mirror Test

In the mirror test, there was a significant increase in the score obtained in the test group before and after the makeup workshop and first makeup application (paired t-test, P = 0.000) and compared to the control Group (t-est, P = 0.002) (Fig. 9). The two comparisons indicate that there was a positive impact of the intervention, reinforced by the fact that the initial average in the test group was lower than that in the control group.

Fig. 9
figure 9

Average mirror test score. Dosage 1A, Measurement before the workshop and first makeup application. Dosage 1D, measurement made after the makeup workshop and first makeup application

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Figure 10 shows no significant variation in the average score between the first and second measurements in the subgroups that do not increase the frequency of makeup use. On the other hand, in the group that did increase the frequency of makeup use, there was a significant increase (P = 0.000) between the first and second measurements. This was also observed among the second measurements of the subgroup that reached the frequent use status of makeup use (P = 0.000), compared to those that did not.

Fig. 10
figure 10

Average mirror test score. comparison between measurements. Asterisk indicates an increased frequency of makeup use, but not reaching “frequent use” status. Double asterisks indicate “frequent use” status (≥ 3 times per week)

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Discussion

The findings of this study suggest that persistent and frequent use of makeup could progressively contribute to the reduction of depressive symptoms in a follow-up period. Our results corroborate those described in a study involving 39 patients with breast cancer [10], which demonstrated improved outcomes in depressive symptoms from brief and low-cost interventions involving beauty care. Stotland discussed concepts related to depression recovery, stating that fewer patients return to the mood they had prior to episodes of depression and questioned factors that could improve treatment results, applied alone or in combination [26]. Our results showed that the answer may not be unique and definitive, but at least in part, we may suggest that an affordable intervention, such as makeup, has the potential to contribute to the improvement of depressive symptoms, mood swings and low self-esteem.

An analysis performed with a sample of psychology students indicated a positive correlation between makeup use and low physical self-esteem [12], reinforcing the notion that makeup is an available resource. However, little scientific data have been generated to measure the impact of makeup use, especially in the general population. We reviewed the literature and found only three other studies that have addressed the theme of interest in our study.

A review article on the role of cortisol in situations of competitive stress [27] concluded that there is an increase in cortisol production triggered by stressful situations, with an evident "anticipatory" effect. This finding justifies the higher average cortisol level in the test group prior to the makeup workshop (anticipatory effect) compared to the average level obtained in the control group and suggests that we may be seeing a stress-reducing effect.

We noted significant improvements in mirror test scores in the test (intervention) group, indicating improved self-perception. A search of the literature did not lead to the identification of studies and data for comparisons with our findings from the mirror test. This is an area that requires further investigation.

Controlling extraneous variables (self-reported diagnosis and use of central nervous system-acting drugs) suggests greater internal validity of the results. This type of research should be expanded to other segments of the population or to subjects with specific profiles as it has the potential to demonstrate the benefits of the interventions we have described. A relevant perspective which has been discussed in the literature would be the objective evaluation of the role of makeup, even light, in women with chronic inflammatory dermatoses (acne, rosacea, discoid lupus erythematosus, seborrheic dermatitis) or with pigmentation changes (melasma, post-inflammatory macules, vitiligo etc.) that affect the face [28,29,30,31,32,33]. The negative impact of these conditions on quality of life is well documented. Focus on the use of makeup and camouflage is already considered part of the therapeutic management [34]. For acne, for example, it has been shown that makeup can be compatible with the topical treatments [35]. Additionally, three benefits are determined by makeup in facial acne: (1) avoidance of the need to handle lesions; (2) contribution to photoprotection; and (3) due to effective covering, improved quality of life and self-esteem, with positive social and professional repercussions, particularly in adult women [36, 37].

The sample used in this study, despite representing a significant portion of the population, allows inferences to be drawn on a profile that is equivalent to approximately 25% of the Brazilian female population, leaving open the opportunity to expand this investigation to other profiles, involving, for example, other segments of the general population or even specific profiles with the potential to benefit from the effects described by this research. The application of additional tests to the scale used with the total sample of participants would contribute to obtaining even more robust results but would imply that all assessments and procedures would be carried out in person, which, in a country with continental dimensions like Brazil, would lead to excessively high costs, making this a difficult limitation to overcome.

The complexity of mood disorders, and the identification of factors that can alleviate their symptoms, suggest that studies such as the one reported here should be repeated, with the aim to consolidate findings and mitigate the limitations (typical of any experiment) identified.

Conclusion

A positive relationship has been proven between the introduction of the frequent use of makeup and a sustained reduction of depressive symptoms, with significant improvement in self-perception of the image and a short-term influence on salivary cortisol levels. Translational research aims to benefit people by generating scientifically solid knowledge and new therapeutic concepts with real practical applicability. By identifying that simple actions, such as encouraging the frequent use of makeup, can effectively and sustainably contribute to improving the well-being and mental health of a significant portion of the population, our research group is convinced that this purpose was adequately and completely fulfilled.