As happens not infrequently, the other day I was shown an article on brain research from: “Brain Training for Anxiety, Depression and Other Mental Conditions”. Initially, I simply refused to read it, but this was met with a verbal description of the article that continued until I said “fine, I’ll read it and write a blog post about why it’s wrong.” This, O Best Beloved, is that blog post.
The WSJ article concerned something called “neurofeedback”, and focused mainly on the study “Real-Time fMRI Neurofeedback Training of Amygdala Activity in Patients with Major Depressive Disorder”. In short, neurofeedback involves some kind of neuroimaging equipment that allows participants to see a measure of their brain function in real time and attempt to alter it (e.g., increase or decrease neural activity in some region). This is done via different cognitive methods, such as focusing on certain memories, and then seeing (in real time) whether the desired changes in brain function occur. Many claims made in the WSJ article are consistent with many made in the research literature, including the paper linked to above. That is, many researchers claim that neurofeedback methods can help with a variety of mental health issues.
However, according to the article, neurofeedback is superior to other therapies (e.g., medication or psychotherapy) because it doesn’t have the side-effects of pills and it “directly targets the brain dysfunctions and emotional and cognitive processes that are understood to underlie psychiatric disorders.” First, it doesn’t “directly target brain dysfunctions” at all. Nobody is really sure what “brain dysfunctions” underlie any mental disorders (i.e., those in the DSM-V), and some don’t think any exist. Second, to the extent we have identified brain function correlated with particular mental disorders like depression (MDD), medication is vastly more direct than neurofeedback. In fact, neurofeedback doesn’t differ that much from talk therapy. It’s been known for years that simple changes in one’s thinking, from therapy to mental imagery, change brain function (see e.g., How psychotherapy changes the brain – the contribution of functional neuroimaging; Mind does really matter: Evidence from neuroimaging studies of emotional self-regulation, psychotherapy, and placebo effect; & “Change the mind and you change the brain”: effects of cognitive-behavioral therapy on the neural correlates of spider phobia).
Finally, it’s highly questionable whether or not neurofeedback is anything more than a placebo effect. Most studies (like the one the article describes) don’t use adequate controls and are instead more concerned with “proof-of-concept”. This study used better controls than many, but even the authors admit their sample sizes were too small (and the control group, n=7, was half the size of the experimental group). Also, the differences between the two groups weren’t that significant. Once again, (null) hypothesis significance testing raised its ugly head, telling us that even though both groups seemed to have improved across the board just by focusing on happy memories, the slightly higher improvement in some measures in the experimental legitimizes calling these significant (and not the improvements experienced by the control group.
Unlike more traditional neurofeedback research, many modern studies (including the one in question) use a new fMRI technique. Most fMRI studies, such as those I’ve performed, don’t provide any immediate feedback signal suitable of the type needed for neurofeedback methods. Instead, you get hundreds of small, black-and-white photos that tell you nothing much apart from whether or not the participant is moving around too much, screwing up the imaging. All the nice, neat pictures with colors to indicate “significant” activity are added later using signal processing and statistical methods. However, more recently “real-time” fMRI (rtfMRI) has come to play a major role in neurofeedback research, as it allows “real-time” feedback information on the effect of cognitive processes on brain activity. However, despite the increased promise provided by this new method, there is little evidence to warrant the optimism found in the WSJ article. A great deal of interest was sparked by deCharms and co-authors, and in particular a 2005 study “Control over brain activation and pain learned by using real-time functional MRI”. However: “In 2005, deCharms et al. published an fMRI-nf study that employed a careful design and reported robust findings, sparking enthusiasm for this seemingly promising technique…This well-controlled study remains the strongest piece of evidence supporting fMRI-nf as an effective tool for self-regulating the brain and improving clinical conditions. However, the impact of this one promising study has become shrouded by decade-long skepticism; question marks have turned into exclamation points after a string of independent replication efforts, including by the original authors, was unable to corroborate the reported findings” (emphasis added; a draft of the actual, peer-reviewed paper may be found here).
A better understanding of the promises of neurofeedback for depression and mental disorders more generally can be found in this conclusion from a 2016 literature review: “While neurofeedback appears to help some participants gain the capacity for brain modulation, the relative contribution of specific feedback compared to ulterior factors remains unclear. At the moment, sparse behavioral measures, little follow-up sessions, and many methodological caveats preclude formal endorsement of neurofeedback as a clinical treatment vehicle. Although the jury is still out, additional judicious experiments and more compelling findings will have to further demonstrate the seductive, albeit yet unconfirmed, clinical promise of neurofeedback.” (The self-regulating brain and neurofeedback: Experimental science and clinical promise).