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Neurofeedback For Depression: An Effective Treatment?

Neurofeedback is a technique that involves training an individual to consciously alter the electrical activity (brain waves) within their brain.  The technique can be used as an intervention to improve symptoms of a variety of psychological conditions, including depression.  Individuals with depression tend to have abnormal brain wave activity compared to those without any preexisting psychological condition.

The technique of neurofeedback involves hooking electrodes up to a person’s scalp, and determining their current electrical activity.  This is accomplished via a “QEEG” (quantitative electroencephalograph) which records brain wave activity for a practitioner to visibly see.  They then use this data to determine regions of the brain (“sites”) that are likely to be most responsible for a person’s depressive symptoms.

The practitioner will then work with a client and train them to consciously manipulate brain wave activity in the most problematic areas (in attempt to normalize their EEG).  In cases of depression, normalization of an EEG has potential to significantly reduce depressive symptoms or in highly-responsive cases, eliminate the need for medication.  Altering brain waves via neurofeedback can influence arousal, neurotransmission, and cognitive function.

Neurofeedback for Depression (The Research)

Neurofeedback should be considered a relatively safe, and high-tech treatment for depression.  While correcting brain wave abnormalities may not serve as a natural cure for depression, neurofeedback may be a highly effective antidepressant augmentation strategy.  A majority of the research suggests that neurofeedback is a highly effective and under-researched treatment option for those suffering from major depression.

2015: In a new study published in 2015, researchers analyzed whether neurofeedback would provide benefit to individuals suffering from depression and fatigue as a result of MS (multiple sclerosis).  Psychomotor slowing, depression, and fatigue are all considered common symptoms of MS, a demylenating neurological disease associated with poor quality of life.  The study recruited 24 patients with multiple sclerosis (MS) characterized primarily by depression and fatigue.

The study was considered randomized, and participants were divided into 2 groups: one received 16 neurofeedback sessions and the other received standardized treatment.  Symptomatic evaluations were conducted at baseline (pre-treatment), after treatment (post-treatment), and at 2-month follow-ups.  Measures were taken using the FSS (Fatigue Severity Scale) and HADS (Hospital Anxiety and Depression Scale).

Results from the study demonstrated that both depressive symptoms and fatigue were significantly reduced among the MS patients receiving neurofeedback compared to the control group receiving standardized treatment.  Perhaps most promising is that the mood improvement was maintained at the 2-month follow-up.  This provides evidence that proper neurofeedback training has potential to significantly reduce depression and comorbid fatigue.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/25362584

2014: It is well known that those suffering from depression also suffer from severe brain fog or inability to focus.  This is likely a result of an array of complex influences, one of which may be brain waves.  When a person is depressed, their brain’s electrical activity is often slower than usual (characterized by theta waves).

Correcting slowed brain waves that may cause cognitive deficits associated with depression is important for a person’s quality of life, including ability to perform school work or occupational functions.  A study published in 2014 analyzed whether neurofeedback training could improve working memory in people diagnosed with major depressive disorder (MDD).

A total of 60 participants with major depressive disorder were assigned to one of two groups including: a neurofeedback group or a non-interventional control group. The neurofeedback group consisted of 40 individuals exposed to 8 neurofeedback sessions, while the non-interventional group consisted of 20 individuals.  The specific protocol of neurofeedback targeted increasing upper alpha waves specifically in the parieto-occipital site of the brain.

Measures of working memory were recorded at baseline (pre-training) and following training (post-training) along with other measures such as attention and executive performance.  EEGs were recorded in both eyes-open during task performance and eyes-closed resting states; recordings were conducted at baseline and following neurofeedback training.  Outcomes showed that the 40 individuals that had undergone neurofeedback training improved in processing speed and performance during working memory tasks.

QEEG recordings showed significant increases in upper alpha rhythms (8 Hz to 12 Hz) following training which was most evident in eyes-open EEG measures.  The increases were noted as being localized in the anterior cingulate cortex.  It was also demonstrated that beta power increased during working memory tasks – this was confirmed with sensory recordings.  While results didn’t indicate whether mood improved, they did suggest that cognitive performance improved among those with major depressive disorder, which could have significant implications.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/25228864

2014: Researchers have long speculated that reducing asymmetrical activity of alpha waves in the prefrontal cortex may be an effective intervention for those with major depressive disorder.  In 2014, a pilot study was conducted to determine whether this particular protocol of asymmetrical alpha reduction could mitigate depressive symptoms.  The study consisted of 9 participants fitting the DSM criteria for major depression.

All participants were treated with up to 30 neurofeedback sessions specifically targeting reduction of asymmetrical alpha waves.  The sessions were conducted over the course of 10 weeks, meaning participants were receiving approximately 3 sessions per week.  Changes in antidepressant treatment regimens were not permitted during the study.

The QIDS (Quick Inventory of Depressive Symptoms) was utilized to assess depressive symptoms in the format of a self-report.  Results from the study demonstrated significant responses in a total of 5 out of 9 participants; 1 experienced a noticeable response and 4 experienced remission.  Interestingly, this protocol appeared most effective for female participants.

Despite the fact that this was an open-label pilot study, it should be noted that results were promising.  Researchers suggest that reducing frontal asymmetry of alpha waves may mitigate depressive symptoms.  It is clear that larger sample sizes and randomized controlled trials are necessary to bolster credibility of these findings.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/24642756

2014: A new type of neurofeedback utilizing real-time fMRIs (functional magnetic resonance imagery) was investigated for alleviating symptoms of depression.  Researchers devised a study based on the fact that individuals with major depressive disorders tend to experience decreased blood flow to the amygdala when exposed to positive stimuli.  MRI neurofeedback is a technique that can be used to consciously manipulate activation of certain brain regions (in this case the amygdala).

The goal of the study was to determine whether MRI neurofeedback could increase amygdala response to positive autobiographical memories, and then to determine whether enhancement of this ability improves depressive symptoms.  The study included a total of 21 participants diagnosed with major depressive disorder, all of whom were unmedicated.

A total of 14 participants received MRI neurofeedback targeting the left amygdala, while the 7 participants in the control group had targeted a horizontal segment of the intraparietal sulcus.  All participants were told to recall autobiographical memories associated with feelings of happiness.  Results discovered that the group targeting the left amygdala learned to upregulate their amygdala responses during autobiographical memory recall.

By upregulating amygdala responses, significant decreases in anxiety and increases in happiness were noted; these changes were not apparent in the control group.  Authors noted that those receiving MRI neurofeedback targeting the left amygdala had increased activity in the left superior temporal gyrus, temporal polar cortex, and right thalamus compared to the control group.

This study suggests that MRI neurofeedback shows promise, perhaps more than EEG neurofeedback. Participants were able to regulate their amygdala responses and consciously improve their mood.  While further evidence is necessary to support preliminary efficacy, MRI neurofeedback training may serve as a novel treatment for depression.

  • http://www.ncbi.nlm.nih.gov/pubmed/24523939

2014: A report published in 2014 noted that advances in fMRI imaging technology is capable of providing individuals with real time feedback in regards to activation.  This real-time feedback of regional activation or “neurofeedback” allows people to learn how to consciously self-regulate various circuitry.  It was noted that fMRI neurofeedback may serve as a complementary intervention to EEG-based neurofeedback.

Research involving EEG neurofeedback for the treatment of depression has typically focused on changing hemispheric activation or altering asymmetry.  Authors of this publication note that fMRI neurofeedback for depression has shown promise in preliminary studies.  They note that it will be a challenging endeavor to design clinical trials, protocols, and sustain results derived from neurofeedback interventions.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/24733975

2014: A case study investigated the effects of neurofeedback training on a 39 year old with alcohol dependence syndrome.  He was noted as exhibiting a variety of symptoms including: sleep problems, decreased appetite, aggressive behavior, abusive tendencies, and roaming behaviors.  Researchers documented his level of depression with the BDI (Beck Depression Inventory) with a score of 23.

Researchers established rapport with this individual prior to using a multi-channel neurofeedback device.  Before the neurofeedback sessions, he was taught how to relax via a progressive relaxation method.  Following the progressive relaxation training, he engaged in 40 minute sessions of neurofeedback for a total of 10 sessions (3 to 4 times per week).

After the neurofeedback sessions, he was assessed with the same measures used at baseline.  Following the 10 sessions, his depressive symptoms had plummeted to a score of 19 on the BDI.  He also experienced significant improvement in cognitive function, memory, and anxiety levels.

The individual had also significantly reduced his consumption of alcohol following treatment.  This case study demonstrates the potential therapeutic efficacy of neurofeedback for alcohol dependence syndrome, and various symptoms associated with the condition including depression, anxiety, and cognitive impairment.

  • Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4361982/

2013: Researchers published a report documenting whether increasing alpha waves as a result of neurofeedback could improve cognitive symptoms associated with depression.  It is known that training upper alpha rhythms in healthy individuals with neurofeedback can enhance cognition.  That said, it wasn’t well-documented whether similar effects could be noted among individuals with diagnosable psychiatric conditions like depression.

When individuals diagnosed with major depression were trained to increase upper alpha rhythms, they improved in cognitive function.  Authors of this report noted that the patients had improved in behaviors and cognitive tasks including: attention span, executive functions, and working memory.  This provides evidence that training upper alpha may alleviate some cognitive deficits associated with depression.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/24111179

2011: Back in 2011, researchers published a report reviewing all scientific publications regarding neurofeedback protocols for the treatment of depression.  They also suggested a potentially new protocol that would attempt to combine the best practices from older protocols.  In addition, they documented results from a small trial with the newly engineered training protocol.

Results suggested that there were 6 experiments conducted using neurofeedback to treat depression.  All experiments report therapeutic efficacy with the technique, and most have utilized protocols targeting inter-hemispheric alpha asymmetry and theta/beta ratios in the left-prefrontal cortex.  The newly devised protocol incorporates both practices into one “circuit” plus adds an additional program that trains an individual to decrease Beta-3 activity for anxiety reduction.

In the small experiment, the new protocol was found to demonstrate efficacy, and warrants further investigation.  This research suggests that with certain protocols, depressive symptoms will significantly decrease.  That said, newer protocols should be devised and investigated.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/21568194

2011: Research has shown that increasing alpha rhythms in the right prefrontal region with an asymmetrical neurofeedback protocol could reduce depression.  In a study published in 2011, researchers investigated whether increasing alpha bands in the right prefrontal region could reduce depressive symptoms among individuals with behavioral, cognitive, and emotional dysfunction.  Results from the study showed that asymmetrical neurofeedback to enhance right frontal alpha rhythms successfully increased right frontal alpha power.

The increases in right frontal alpha power were sustained after the completion of neurofeedback training.  By comparison, a placebo group (used as the control) didn’t show any significant difference.  Those that received the right frontal asymmetrical neurofeedback training improved in cognition, emotion, and most notably – depressive symptoms.

It was noted that asymmetrical training may be helpful for emotional regulation and depression.  It should be noted that left frontal activity was initially enhanced and also reduced depressive symptoms.  Asymmetrical neurofeedback training (or training separate hemispheric activation) may be beneficial for those who are depressed.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/21063132

1995: In the mid-1990s, researchers conducted an experiment with 14 individuals suffering from alcoholism.  They used the “Peniston and Kulkosky” protocol of brainwave treatment for alcohol abuse.  First the patients engaged in a body temperature regulation biofeedback task prior to neurofeedback.

They then were assigned 20 sessions of alpha-theta rhythm neurofeedback.  Each session lasted approximately 40 minutes.  Depressive symptoms were analyzed pre-treatment with the BDI (Beck Depression Inventory) as well as post-treatment.  The individuals experienced significant reductions in depression as noted by the BDI, as well as a host of other symptoms.

Results were sustained at 21-month follow ups and relapse rates were significantly reduced.  This data suggests that neurofeedback may provide additional benefits for those suffering from depression stemming from alcohol dependence.  Evidence suggests that therapeutic benefit is maintained long after treatment ends.

  • Source: http://www.ncbi.nlm.nih.gov/pubmed/8801245

Does any evidence suggest inefficacy of neurofeedback for depression?

Based on the entire body of research analyzing neurofeedback for depression, no results suggest that it is an ineffective intervention.  While most studies are considered small-scale and vary in regards of protocols utilized, all have suggested that neurofeedback successfully alleviates depressive symptoms.  Despite the fact that no evidence suggests inefficacy of neurofeedback, more evidence is necessary to get a better understanding of this intervention.

Furthermore, the entire body of research suggests no significant safety concerns or neurofeedback side effects.  That said, most researchers are using protocols such as alpha rhythm asymmetry prefrontal training for depression.  It is unknown whether this protocol should be considered a universally effective option for depressive symptoms.

It would be better to first conduct a QEEG (quantitative electroencephalograph) and personalize the neurofeedback training sessions.  Not all people with depression are likely to have the exact same brain wave abnormalities.  Therefore to improve psychiatric treatment outcomes and prevent adverse outcomes, QEEGs should always be conducted among those with depression prior to neurofeedback.

Potential Benefits of Neurofeedback for Depression

Below are some potential benefits of using neurofeedback for the treatment of depression.

  • Brain wave regulation: Perhaps the biggest benefit derived from neurofeedback training is the ability to consciously alter brain waves. Assuming a person with depression was trained with a protocol devised to alleviate depressive symptoms, this ability should prove useful.
  • Cognitive function: There is evidence to suggest that neurofeedback training improves cognitive function in healthy individuals, and also among those with depression. Cognitive enhancement for those with depression is a major benefit considering the fact that depressive symptoms can interfere with the ability to concentrate, think critically and affect recall (e.g. working memory).
  • Less reliant on medications: Some people may find that neurofeedback may mitigate the need for antidepressant medications. While not everyone will find that neurofeedback significantly reduces their depressive symptoms, certain people may report unexpectedly positive results.  In this case, a person may be able to function without antidepressant medications associated with unwanted side effects like weight gain and/or sexual dysfunction.
  • Mood improvement: Many studies have shown that neurofeedback significantly improves mood among those that are depressed. Studies were conducted on individuals formally diagnosed with major depressive disorder (MDD) and all showed benefit associated with neurofeedback training.  Even studies investigating neurofeedback for alcohol dependence and multiple sclerosis found the training to reduce depression.
  • Neurotransmission: Some speculate that altering brain waves via neurofeedback can alter neurotransmission. Brain waves influence physiological arousal, which in turn has cascade effects upon neurotransmission and hormone production.  While it may not affect neurotransmission as significantly as a medication, it is logical to suggest a cascade effect.
  • Regional activation: Utilizing real-time fMRI neurofeedback, there is evidence that individuals can consciously manipulate brain activation. One study found that consciously learning to activate the amygdala resulted in less depressive symptoms.  As more fMRI neurofeedback studies are conducted, we will find which regions provide most relief from depressive symptoms.
  • Sustained efficacy: It appears as though neurofeedback training provides sustained efficacy. In all studies with follow-up analyses, those that had received neurofeedback training were still less depressed than individuals who hadn’t received neurofeedback training.  This suggests that once you learn how to alter your brain waves, constant re-training is not required.

Why it’s difficult to interpret research of neurofeedback for depression…

There are numerous reasons regarding why it’s difficult to research neurofeedback for the treatment of depression.  Perhaps the biggest difficulty is the lack of consistency in study designs and the failure to account for individual differences.  There also aren’t any large-scale double-blind, randomized, placebo-controlled studies – which are necessary to confirm preliminary evidence suggesting therapeutic efficacy.

  • Depression evaluation: It would be helpful if researchers stuck to a single depression scale such as the Beck Depression Inventory (BDI) in all research. This would help determine degrees of improvement from various neurofeedback protocols devised for depression.  Having different measures for depression increases difficulty of comparative analyses between studies.
  • Individual differences: Researchers should be considering individual differences when studying neurofeedback for depression. Individual differences in brain wave patterns should be documented with QEEGs prior to research.  This will help determine areas that should be targeted with neurofeedback training.  Not all cases of depression are likely to present the exact same brain wave abnormalities, and personalized neurofeedback for depression warrants investigation.
  • Lack of research: Although some research is better than none, there is a need for considerably more research of neurofeedback for depression before clinical recommendations can be made. Several studies suggesting therapeutic benefit of neurofeedback for depression weren’t even directly studying major depressive disorder, rather were analyzing depressive symptoms among those with conditions such as: alcohol dependence or multiple sclerosis. More targeted research needs to be conducted among those diagnosed with major depressive disorder.
  • Participants: In some cases, age of participants may matter in regards to benefit from neurofeedback for depression. It is well-known that the brain isn’t fully developed until age 25, and that those under the age of 25 may not derive full benefit from neurofeedback training [OR they may derive extra benefit due to increased plasticity].  That said, in the research of neurofeedback for ADHD, children were found to get benefit from training with one caveat: the younger the age, the less benefit.
  • Sample sizes: There is a need for larger sample sizes in future studies. None of the studies incorporated more than double-digit numbers of participants.  It would be better to conduct studies with hundreds of participants diagnosed with major depressive disorder rather than continue with small-scale numbers.
  • Study designs: To get a better idea of neurofeedback’s efficacy for depression, it would be helpful to have randomized, placebo-controlled, double-blind studies. While some studies are randomized, there is a need for more scientifically accepted designs.  With better designs, neurofeedback would gain more credibility in the scientific community should the results indicate efficacy.
  • Training protocols: The protocols presented in the aforementioned research are subject to variation. While most implement the alpha asymmetry prefrontal training for depression, others differ and target beta waves.  Furthermore, the neural locations (training “sites”) may differ based on the study.  Due to the variance in protocols, it is difficult to determine whether certain protocols are more effective than others.
  • Types of neurofeedback: There are many types of neurofeedback including EEG neurofeedback, fMRI neurofeedback, and others like HEG neurofeedback (which wasn’t discussed). Some types of neurofeedback involve targeting brain waves, while others target regional activation, and others focus on enhancement of blood flow.  Another system called “NeurOptimal” focused on improving efficiency of the nervous system.  Due to the array of different neurofeedback types, efficacy needs to be investigated for each type.

Will neurofeedback cure your depression?

In some cases, neurofeedback may serve as a natural cure for depression, but for most individuals, it will simply help reduce depressive symptoms.  Certain individuals may find that neurofeedback provides complete symptomatic relief, while others may find that it only provides partial relief.  This is due to the fact that brain wave abnormalities are only one component of depression.

For some people, brain wave abnormalities may be a big contributing factor to depression, while for others these brain waves may be less of an influence.  Many cases of depression likely stem from certain genetic polymorphisms.  Therefore the root cause is likely embedded in genetics and these genes may create a multitude of physiological abnormalities, including: neurotransmission, hormones, regional activation, and brain waves.

By training an individual to correct abnormal brain waves with neurofeedback, one component of depression is being targeted.  Despite the fact that this isn’t the root cause, having abnormal brain waves can significantly impair mental performance and increase depressive symptoms.  With neurofeedback training, most people are likely to experience varying degrees of symptomatic benefit, but not a full cure unless neuroelectrical abnormalities happen to be the root cause.

Are all neurofeedback protocols for depression the same?

Clearly not all neurofeedback protocols for depression are the same.  If you’re working with a professional neurofeedback practitioner, they should always be conducting a QEEG (quantitative electroencephalograph) with eyes-open and eyes-closed to determine your unique brain wave signature.  After your QEEG has been collected, it can then be analyzed to determine brain wave activation that is likely abnormal and contributing to your depression.

If practitioners fail to conduct a QEEG, they’re essentially playing neuroelectrical roulette with neurofeedback – potentially training your brain to produce suboptimal activity.  While some protocols such as prefrontal alpha asymmetry training may have more success than others, they shouldn’t be considered universally utopian interventions.  It is likely better to personalize treatment after the QEEG has been analyzed.

  • Alpha waves: The most common protocol is that of prefrontal alpha asymmetry training for depression. This protocol has been successful in reducing depression and anxiety, while improving cognitive deficits associated with depression.
  • Beta waves: Some individuals with depression are thought to have deficient beta activity in certain regions. Beta waves are associated with alertness, and a brain that fails to produce beta, especially in the prefrontal regions may experience ADHD-like symptoms and brain fog.
  • Theta waves: Those with depression may have too many theta waves often associated with daydreaming and emotional dysfunction. It is too many theta waves in regions like the left prefrontal cortex that can impair our ability to think logically and feel happier.
  • Gamma waves: While no formal protocols have investigated the potential of gamma waves for the treatment of depression, there is reason to believe that gamma training may be beneficial for reducing depressive symptoms. Advanced meditators in “blissful” states have been shown to produce gamma in the prefrontal cortex.

Can neurofeedback reduce antidepressant medication dosage?

It is possible that neurofeedback could reduce your need for an antidepressant.  Those who have mild depression and are taking medications like SSRIs may feel significantly better after neurofeedback and consider lowering the dosage of their medication.  Neurofeedback could theoretically lower the minimal effective dose of your antidepressant and/or serve as a highly effective antidepressant augmentation strategy.

It may also provide relief if you notice that your antidepressant stops working.  Keep in mind that neurofeedback targets your brain waves (electrical activity), but doesn’t directly target neurotransmission.  That said, it is logical to surmise that altering brain waves in certain regions could alter arousal, hormones, and ultimately neurotransmitter levels.

This may result in some perceiving that their antidepressant tolerance has been reduced.  In reality, the medication tolerance is unlikely to have been reduced.  The neurofeedback simply has alleviated depressive symptoms in a different way, likely acting as a synergistic intervention for depression.  Some people may be able to discontinue their medication as a result of neurofeedback, while others will notice that the practice simply provides additional relief from depressive symptoms.

Have you used neurofeedback for depression?

If you’ve engaged in neurofeedback for the treatment of depression, be sure to leave a comment sharing your experience.  Mention whether you had a QEEG conducted prior to neurofeedback training to determine the most problematic areas of electrical activity.  Share the number of sessions you completed, the specific type of neurofeedback utilized (e.g. EEG), the protocol (e.g. alpha asymmetry training), the “sites” trained (scalp regions), and the subjective degree of improvement you noticed in regards to depressive symptoms.

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