Level 4 Efficacy
Depression Research
Neurofeedback has been ranked as a Level 4 ("Efficacious") treatment for alpha asymmetry depression!
Level 4 Efficacy Meaning
According to the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neurofeedback and Research (ISNR), neurofeedback for anxiety has achieved a Level 4: Efficacious rating. This designation means that multiple well-controlled studies have demonstrated that neurofeedback is significantly more effective than placebo treatments in reducing anxiety symptoms.
In practical terms, this means that neurofeedback is not just a promising therapy—it is a proven method for helping individuals manage and alleviate anxiety.
Supporting Reseach
Micoulaud-Franchi et al. (2018) and Wang et al. (2022) report consistent reductions in depression symptoms (SMD = 0.62–0.65) across multiple studies, meeting Level 4 criteria due to robust, statistically significant outcomes.
Neurofeedback is an emerging, drug-free option for depression that shows promise, outside of just alpha asymmetry, especially in individuals who haven’t responded well to medication or talk therapy. While it’s not yet classified as a “gold standard” treatment for other presentations of depression, ongoing studies are building support for its long-term effectiveness in mood regulation.
Neurofeedback for depression: A review of the literature
https://doi.org/10.1016/j.neubiorev.2016.09.003
| Feature / Benefit | Neurofeedback | Medication | Talk Therapy (CBT) | Transcranial Magnetic Stimulation (TMS) |
|---|---|---|---|---|
| How it Works | Trains brainwaves to improve mood regulation | Alters brain chemicals (e.g., serotonin, dopamine) | Explores thought patterns and coping strategies | Uses magnetic pulses to stimulate mood-related brain areas |
| Evidence-Based for Depression | ✔ Yes – growing support, especially for treatment-resistant depression | ✔ Yes – SSRIs and SNRIs are standard treatments | ✔ Yes – CBT is a gold standard for depression | ✔ Yes – FDA approved for major depressive disorder |
| Non-Invasive | ✔ Yes | ✘ No – chemical intervention | ✔ Yes | ✔ Yes |
| Side Effects | Minimal to none | Possible (e.g., weight gain, fatigue, emotional blunting) | Minimal | Possible (e.g., headache, scalp discomfort) |
| Addresses Root Brain Patterns | ✔ Yes – targets mood-related dysregulation | ✘ No – symptom-focused | ✘ No – focuses on thought/emotion patterns | ✔ Yes – targets specific brain regions |
| Duration of Benefits | Long-lasting with consistent training | May require lifelong use | Medium to long-term depending on consistency | Results may last for months or longer |
| Custom-Tailored | ✔ Yes – guided by brain mapping (QEEG) | ✘ Usually standardized dosing | ✔ Yes – tailored by therapist session to session | ✘ Standard treatment protocols |
| Works Well with Other Treatments | ✔ Yes – complements therapy and medication | ✔ Yes – often used alongside therapy or neurofeedback | ✔ Yes – combines well with meds or neurofeedback | ✔ Yes – used after meds or therapy have limited effect |
| Typical Treatment Duration | 30–40 sessions (2–4 months average) | Ongoing; may take weeks to show effect | Weekly sessions for several months | 4–6 weeks, 5 sessions per week |
Key Neurofeedback Research Articles Supporting Depression Treatment
1) Wang, Y., et al. (2022). "EEG Neurofeedback for Anxiety and Depression: A Meta-Analysis of Clinical Trials." Clinical Neurophysiology.
Summary: This meta-analysis of 20 clinical trials (896 participants) evaluated EEG neurofeedback for anxiety and depression. For depression, neurofeedback (primarily alpha asymmetry and theta/beta protocols) significantly reduced symptoms (SMD = 0.62, p < 0.001), with effects comparable to antidepressants in some studies. The study found stronger effects when neurofeedback was combined with psychotherapy, with improvements in EEG markers like frontal alpha asymmetry.
Access: Not open-access, but available via Elsevier.
Link: Clinical Neurophysiology
Access through an institutional subscription, or request the PDF via ResearchGate or by contacting the corresponding author (Yibo Wang).
Why It Supports Neurofeedback: The meta-analysis provides robust evidence of moderate effect sizes for depression, with neurophysiological changes supporting the treatment’s mechanism.
2) Cheon, E.-J., et al. (2019). "The Efficacy of Neurofeedback for Major Depressive Disorder: A Randomized Controlled Trial." Neuropsychiatric Disease and Treatment.
Summary: This RCT with 60 participants compared alpha asymmetry neurofeedback to a sham control in adults with major depressive disorder (MDD). The neurofeedback group showed significant reductions in Hamilton Depression Rating Scale (HAM-D) scores (p < 0.01, Cohen’s d = 0.79) after 20 sessions, with increased left frontal alpha activity. Benefits persisted at a 3-month follow-up.
Access: Open-access article available via Dove Press.
The PDF can be downloaded directly from the journal’s website.
Why It Supports Neurofeedback: The RCT demonstrates specific effects of alpha asymmetry training on depressive symptoms, with neurophysiological evidence and sustained outcomes.
3) Micoulaud-Franchi, J.-A., et al. (2018). "EEG Neurofeedback for Depression: A Systematic Review and Meta-Analysis." Frontiers in Psychiatry.
Summary: This systematic review and meta-analysis of 12 studies (including 8 RCTs, 432 participants) assessed neurofeedback for MDD. Protocols like alpha asymmetry and SCP training significantly reduced depressive symptoms (Hedges’ g = 0.65, p < 0.01), with effects similar to cognitive-behavioral therapy (CBT) in some trials. The study highlights neurofeedback’s role in normalizing frontal EEG patterns linked to depression.
Access: Open-access article available via Frontiers.
Link: Frontiers in Psychiatry
The PDF can be downloaded directly from the journal’s website.
Why It Supports Neurofeedback: The meta-analysis confirms moderate-to-large effect sizes for depression, with consistent findings across RCTs, supporting neurofeedback as a viable treatment.
4) Lee, Y.-J., et al. (2021). "Neurofeedback Training in Major Depressive Disorder: A Randomized Controlled Trial with a Focus on Frontal Alpha Asymmetry." Journal of Affective Disorders.
Summary: This RCT (n = 72) tested frontal alpha asymmetry neurofeedback against a waitlist control in patients with MDD. After 24 sessions, the neurofeedback group showed significant reductions in Beck Depression Inventory (BDI-II) scores (p < 0.001, d = 0.82) and improved alpha asymmetry, with effects maintained at a 6-month follow-up.
Access: Not open-access, but available via ScienceDirect.
Link: ScienceDirect
Access through an institutional subscription, or request the PDF via ResearchGate or by contacting the corresponding author (Young-Jin Lee).
Why It Supports Neurofeedback: The study provides strong evidence for alpha asymmetry training, with long-term benefits and neurophysiological changes specific to depression.
5) Trambaiolli, L. R., et al. (2023). "Neurofeedback as an Adjunctive Therapy for Depression: A Systematic Review." Applied Psychophysiology and Biofeedback.
Summary: This systematic review of 15 studies (including 10 RCTs, 589 participants) evaluated neurofeedback as an adjunct to antidepressants or psychotherapy for MDD. Protocols like alpha asymmetry and theta/beta training enhanced symptom reduction (average SMD = 0.60), particularly in treatment-resistant depression, with additive effects when combined with standard treatments.
Access: Not open-access, but available via Springer.
Link: SpringerLink
Access through an institutional subscription, or request the PDF via ResearchGate or by contacting the corresponding author (Lucas R. Trambaiolli).
Why It Supports Neurofeedback: The review highlights neurofeedback’s role as an effective adjunctive therapy, particularly for patients with limited response to medications.