This is a third re-post of an earlier blog; Here is a discussion of Neurofeedback as a treatment, authored by Dr. Michelle Cochran.
There continues to be a lot of buzz in Nashville about Neurotherapy, Neurofeedback, or EEG with neurofeedback for brain illnesses such as Major Depressive Disorder (MDD), Post-Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder (GAD) and Attention Deficit Hyperactivity Disorder (ADHD).
Our clinicians in our office get a lot of questions about this topic; in fact, I am doing yet another blogpost on this topic because another patient who came to our clinic spent over $2800.00 for neurofeedback treatment for MDD and ADHD. The patient didn’t get better, and I found this so sad because there is little evidence, other than case reports, to support neurofeedback as a treatment.
First, it is important to know that I am not giving specific medical advice for an individual who might be reading my blog today. This is my opinion based upon my review of the literature to date – January 2022. Individual patients and their clinicians must decide what is best for themselves. What I am attempting to convey is, hopefully, some helpful facts that can assist a patient and family members to decide what is best for themselves and to give information which can help individuals ask questions and make decisions with the assistance of their own clinician. My hope is that you will be able to critcally weight the risks (loosing money and not getting well) vs the potential benefits of options for care.
Second, the NS-TMS Centers are evidence-based clinics with clinicians who offer many in-network insurance services. We have an arrangement to offer in-network services within another clinic in order to help patients get appropriate insurance coverage for TMS & Spravato, both FDA cleared/approved treatments for depression covered by insurance.
As a psychiatrist who understands the brain and embraces Brain technologies like Transcranial Magnetic Stimulation (TMS) and Electro-Convulsive Treatment (ECT) for patients, I really want to support the technology of Neurofeedback as a treatment, but unfortunately, at present, like I concluded first in 2019, then in 2020 and now, I still cannot support this NON-FDA cleared treatment. Insurance companies do not pay for the treatment for depression because it doesn’t have evidence.
It is important to note that Neurofeedback was FDA cleared, only, to help aid the diagnosis, but, NOT the treatment of ADHD. There is presently a lack of significant evidence which supports the expense and use of this treatment for conditions such as MDD, PTSD, GAD and ADHD.
There is however, now, a brain device approved for the treatment of ADHD in children which is called the Neurosigma, http://www.neurosigma.com/pipeline.html; this company is also doing trials in Depression, PTSD, and Epilepsy. The Neurosigma is not Neurofeedback, it is an eTNS unit (electric Trigeminal Nerve Stimulation unit). At present, even though the NeuroSigma is FDA cleared, it is still not covered by insurance.
On my appraisals of the scientific literature over the last five years and again this last week, most studies published about neurofeedback are of poor evidence. Many past studies are case reports of one or a few patients. Most the studies that have been published are not large, are not controlled, and do NOT have significant findings. By controlled, I mean that the authors, and patients were blinded to the treatment they were receiving. Another way to say this is that neither party knew if the patient was receiving active neurofeedback or a sham neurofeedback; this is called placebo controlled in medication studies or sham controlled with devices. For the few studies that were blinded, there is not significant evidence that the treatment worked better than placebo and the treatment did NOT work better than existing, less expensive evidence-based treatments.
You might say, well what’s wrong if the neurofeedback works for me? Neurofeedback is expensive, and time consuming and it can take time and money away from pursuing treatments that do have good evidence (double blind controlled evidence). The financial loss means that the person receiving the neurofeedback treatment will have a likelihood of staying UNWELL longer. As clinicians, we inform our patients on the facts, the data that is available so that they can make decisions with the best, cost-effective care to get better more quickly.
Because we see severe treatment resistant patients at times, there are occasions when we have exhausted FDA-cleared options and other times when the FDA-cleared options are unacceptable; only in these scenarios would I consider Neurofeedback for a patient.
Would it hurt physically hurt you if you did Neurofeedback for ADHD?
Neurofeedback would, likely, not hurt you. Certain licensed clinicians are allowed to use particular devices as defined by state and federal laws, and while these devices likely will not hurt you physically, there is always the potential “hurt” to your wallet and loss of confidence in your treatment team; loss of money and loss of confidence in others that are supposed to help you.
In 2016, some well known authors published a meta-analysis in the Journal of the American Academy of Child & Adolescent Psychiatry which FAILED to show evidence that Neurofeedback was effective for Attention Deficit Hyperactivity Disorder (ADHD). The link for the meta-analysis is here: https://www.ncbi.nlm.nih.gov/pubmed/27238063
Also in 2016, in the British Journal of Psychiatry, authors published a study comparing neurofeedback plus treatment as usual (TAU), medications and cognitive behavioral therapy – CBT, to TAU (medications and CBT alone. The patients were followed at one year and the results showed that the Neurofeedback plus TAU group DID NO BETTER than the TAU group; the authors concluded that neurofeedback could not be supported. This means, save your money and do medications and CBT, not neurofeedback. The link to this study is here: https://www.cambridge.org/core/services/aop-cambridge-core/content/view/735226CEC2B82B9F729B04B1EDB14AA5/S2056472400001241a.pdf/1year_followup_of_neurofeedback_treatment_in_adolescents_with_attentiondeficit_hyperactivity_disorder_randomised_controlled_trial.pdf
A few years ago in 2019, other researchers compared a common stimulant medication (Ritalin) to neurofeedback and found that neurofeedback could not be recommended because the medication performed better on core ADHD symptoms and because with neurofeedback there was a risk of bias, here is a link to this article: https://ebmh.bmj.com/content/22/3/111.full.
Unfortunately, neurofeedback is much more expensive than medications and did not show long lasting results in the study for ADHD, so from a cost-benefit analysis, neurofeedback still doesn’t make sense for patients. For more information on neurofeedback for ADHD, an easy to read article can be found here, https://www.medicalnewstoday.com/articles/315261.php
For Post Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder (GAD), Obsessive Compulsive Disorder (OCD) and depressive disorders like Major Depressive Disorder (MDD), neurofeedback has even less evidence than for ADHD; there is NOT enough data to support that neurofeedback for brain disorders is as effective as the typical treatments we already have available (medications, psychotherapies, and neuromodulation like TMS, Spravato, VNS and ECT).
Neurofeedback sounds scientific and desirable to patients and families because there are no medications involved, however, for MDD, PTSD, GAD, OCD and even ADHD, most all US health insurance companies will NOT pay for neurofeedback, and I cannot say that I blame them at this point (for those that know me, I often challenge insurance companies’ opinions, but I happen to agree with them here).
I am hopeful that at some point, the researchers studying neurofeedback will be able structure a large double blind, sham-controlled study to produce more convincing findings than we have now; my hope is that we do have evidence eventually because we need more treatments for patients. At this point, I recommend that patients save their money for treatments that have better evidence like medications, CBT for ADHD, TMS, ECT and even the new NeuroSigma (eTNS) device. If evidence based treatments fail for patient care, then perhaps, neurofeedback might be a reasonable option.
For further skeptic analysis of Neurofeedback, see this link for the author’s review on Neurofeedback as well as other topics: https://skeptoid.com/episodes/4214
Dr. Cochran