Systematic review and meta-analysis of neurofeedback and its effect on posttraumatic stress disorder. 

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/ Voigt JD, Mosier M, Tendler A.  Front. Psychiatry 15:1323485.

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Neurofeedback (NF) technologies in the treatment of posttraumatic stress disorder (PTSD) have evolved over the years. Prior systematic reviews and meta-analyses on randomized controlled trials (RCTs) have shown promising results using electroencephalogram (EEG) NF for PTSD but used traditional EEG NF technologies and with very small numbers of patients.

 

This meta-analysis is an update to include several RCTS (using newer forms of deep brain feedback—functional magnetic resonance imaging [fMRI] NF and fMRI informed EEG NF).
Systematic literature review was conducted using the electronic databases PubMed Central, Cochrane CENTRAL, and EBSCO/CINAHL and used the following search terms: [(neurofeedback AND random*) AND trial] AND PTSD. 

Results from all studies identified favored neurofeedback’s effect on reducing PTSD symptoms. GRADE assessments of CAPS, PCL, and BDI demonstrated a moderate/high level in the quality of the evidence that NF has a positive clinical effect for treating PTSD. Authors conclude that based on newer published studies and the outcomes measured, NF has demonstrated a clinically meaningful effect size, with an increased effect size at follow-up. ​​

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To read the full article in Frontiers in Psychiatry - https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2024.1323485/full

FAQ 

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1. What is the scope of the systematic review/meta-analysis and what neurofeedback modalities were considered?

The review was an updated systematic review and meta‐analysis of neurofeedback (NF) in the treatment of Post‑traumatic Stress Disorder (PTSD). It included randomized controlled trials (RCTs) and specifically incorporated newer deep-brain NF modalities such as functional magnetic resonance imaging (fMRI) and fMRI-informed EEG NF (in addition to traditional EEG NF) to evaluate their effect on PTSD symptoms. 

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2. What were the key clinical findings and quality of the evidence?
The meta‐analysis found that all the studies identified showed a favourable effect of NF on reducing PTSD symptoms. Importantly, the GRADE assessment for primary outcomes (such as CAPS, PCL, BDI) indicated a moderate to high level of evidence quality. The authors concluded NF has demonstrated a clinically meaningful effect size, with increased effect size at follow-up. 

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3. How should psychiatrists interpret the implication of NF for PTSD treatment?
For clinical psychiatrists, the findings suggest that NF, particularly advanced modalities (fMRI and fMRI‐informed EEG NF) may serve as a valuable adjunctive intervention in PTSD. Given the moderate/high evidence and meaningful effect sizes, NF can be considered to augment standard care (psychotherapy, pharmacotherapy) especially in patients who may benefit from neuromodulation‐based approaches. One of the benefits in using NF is that it has been studied as an adjunct with existing therapies—with one US Food and Drug Administration (FDA) cleared technology (GrayMatters Health, 510K#K222101), which is indicated for use as an adjunctive therapy with other therapies such as psychotherapy and pharmacotherapy.

 

4. What important limitations or caveats did the review note that psychiatrists must keep in mind?
While the evidence is positive, psychiatrists should note:

• The review acknowledges heterogeneity among modality types (EEG only vs fMRI/fMRI-informed EEG), meaning effect sizes may vary by technology.
   

• The concept of increased effect size at follow-up is encouraging, but long‐term durability, implementation in diverse clinical settings, cost‐effectiveness and integration with other treatments remain to be further clarified.
   

• Although evidence quality is moderate to high, the field is evolving; thus NF should be integrated in a comprehensive treatment plan.
   

5. What scientific rationale does the review provide for the efficacy of neurofeedback modalities in PTSD?
The review highlights that newer NF approaches target deeper brain circuits (via fMRI/fMRI-informed EEG) which are implicated in PTSD pathology (e.g., limbic circuits, amygdala, prefrontal regulation). By leveraging biomarkers tied to these brain regions and enabling patients to self-modulate their neural activity, NF may more directly influence dysregulated neural networks in PTSD. The article emphasises that these advanced modalities represent an evolution in NF toward more precision.