I wanted to discuss Neurofeedback as a treatment today

I wanted to discuss Neurofeedback as a treatment today. There is a lot of buzz in Nashville about neurofeedback for Major Depressive Disorder (MDD), Post-Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder (GAD) and Attention Deficit Hyperactivity Disorder (ADHD). 

At Nashville Center of Hope and Healing (NCHH), all the clinicians in our office get a lot of questions about this topic; in fact, I am doing a blogpost
on it today because one of my patients and her outside therapist wanted to consider the treatment for the patient. 

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- November 9, 2018.  Individual patients and their clinicians can decide what is best for them.  What I am attempting to convey today are hopefully, helpful facts that can assist a patient and family members to decide what is best with the assista
nce of their clinician. 

Second, NCHH is an evidence-based clinic of out-of-network providers which means that we are not in insurance panels for patient care.  We do help patients bill their insurance for services in the Nashville Center for Hope and Healing.  We do refer to clinics for insurance-based care, and even share part of our space with the NeuroScience and TMS treatment centers in the office in order to help patients get appropriate insurance coverage for this FDA cleared treatment. 

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, I presently cannot support this non-FDA cleared treatment. There is a lack of significant evidence which supports the expense and use of this treatment for conditions such as MDD, PTSD, GAD and ADHD. 

On my appraisals of the scientific literature over the last four years and again this last six weeks, most of 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.  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 it works?
What is wrong is that Neurofeedback is expensive, and time consuming for the patient and doesn't always work. It can take time and money away from pursuing treatments that do work and that cost the patient valuable time.   As clinicians at NCHH, we inform our patients on the facts, the good data that is out there so that they can make decisions with us on the best, cost-effective care. 

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 recommend Neurofeedback. 

Would it hurt physically hurt you if you did Neurofeedback for ADHD?
Neurofeedback would, likely, not hurt you.  Which is likely why the FDA has not intervened and fined clinics and clinicians who use the treatment and advertise for the non-FDA cleared treatment. 

It is important to note, that there is some evidence that Neurofeedback is not worse than treatment as usual for ADHD (BMJ 2017). Unfortunately, neurofeedback is much more expensive than medications and did not show long lasting results in ADHD, so from a cost-benefit analysis, it still doesn't make sense. For anxiety disorders such as PTSD and GAD, and MDD, neurofeedback does not have the data to support that it is as efficacious as the typical treatments we already have (medications, therapies, and neuromodulation like TMS and ECT). 

Neurofeedback sounds cool because there are no medications involved, however, for MDD, PTSD, GAD, and ADHD, insurance companies will not pay for neurofeedback, and I cannot say that I blame them at this point.  For those of you that know me well, I don’t usually side with insurance companies. 

I am hopeful that at some point, the researchers studying Neurofeedback will be able to produce more convincing findings because the treatment sounds enticing.  At this point, I would save my money for treatments that have better evidence.