Neurofeedback for ADHD, Anxiety, and Depression
Neurofeedback should not be used as a treatment for ADHD, anxiety, or depression in clinical practice, as the most recent high-quality evidence demonstrates it is no more effective than sham treatment and substantially inferior to established first-line therapies.
Evidence Against Neurofeedback for ADHD
The 2019 American Academy of Pediatrics guidelines explicitly state that neurofeedback (EEG biofeedback) has "too little evidence to recommend" for ADHD treatment, listing it alongside cognitive training, diet modification, and supportive counseling as interventions that "have been found to have little or no benefit" 1. This represents a significant departure from older characterizations.
The definitive 2017 triple-blind, randomized controlled trial in The Lancet Psychiatry demonstrated that neurofeedback was no better than sham neurofeedback for treating adult ADHD 2. In this rigorous study of 118 adults:
- All three groups (neurofeedback, sham neurofeedback, and meta-cognitive therapy) showed equivalent symptom reduction
- There was no statistically significant difference between neurofeedback and sham (B=-0.89,95% CI -2.14 to 0.37, p=0.168) 2
- This directly contradicts the efficacy claims from earlier, less rigorous studies 2
Why Earlier Studies Were Misleading
Older reviews from 2005 characterized neurofeedback as "probably efficacious" for ADHD 1, but these predated the 2017 sham-controlled trial that exposed fundamental methodological flaws in the neurofeedback literature 2. The 2019 meta-analysis acknowledges that while three protocols (theta/beta, sensorimotor rhythm, and slow cortical potential) appeared efficacious in earlier studies, "the practical implementation of neurofeedback as a clinical treatment is currently not regulated" 3.
Evidence for Anxiety and Depression
For anxiety and depression, the evidence is even weaker. One small 2011 clinical trial (N=24) showed heart rate variability biofeedback reduced anxiety and depressive symptoms 1, but this represents peripheral biofeedback, not neurofeedback, and lacks replication in larger controlled trials. The 2016 comprehensive review notes that neurofeedback applications for anxiety and depression are "not conclusive" and that "current research does not support conclusive results about its efficacy" 4.
What Actually Works: Evidence-Based Alternatives
For ADHD
- Stimulant medications (methylphenidate or amphetamines) are the gold standard first-line treatment, with 70-80% response rates and effect sizes of 1.0 1, 5, 6
- Cognitive Behavioral Therapy (CBT) is the psychotherapy of choice, specifically targeting executive functioning deficits that underlie ADHD symptoms 5, 6, 7
- Combination therapy (medication + CBT) produces superior outcomes compared to either treatment alone, particularly for functional impairment 5, 6
- Atomoxetine is the primary second-line option when stimulants are contraindicated 5, 6
For Anxiety and Depression
- CBT is equally effective as second-generation antidepressants for depression, with lower relapse rates and fewer adverse effects 7
- For comorbid depression and ADHD, CBT combined with pharmacotherapy is most effective for moderate to severe presentations 7
- Mindfulness-based interventions have emerging evidence as adjuncts for emotion regulation 7
Critical Clinical Pitfalls
Do not delay evidence-based treatment by attempting neurofeedback first. The 2017 Lancet Psychiatry trial showed that even after 30 sessions over 15 weeks, neurofeedback provided no benefit beyond placebo 2. This represents months of lost time during which patients could have received effective treatment.
Do not be misled by older literature or patient requests based on internet research. The neurofeedback field suffers from publication bias, lack of standardization, and absence of regulatory oversight 3, 4. The 2022 Molecular Psychiatry review notes that while neurofeedback is "a neurotherapeutic approach where an individual learns to modify their brain function," its "efficacy remains unknown" even in pilot studies using sophisticated whole-brain models 1.
Recognize the cost-benefit analysis strongly favors established treatments. Neurofeedback is expensive, time-consuming (requiring 30+ sessions), and lacks long-lasting benefits 4. In contrast, stimulant medications for ADHD show rapid onset (within days) and robust effect sizes 5, while CBT provides durable skills with lower relapse rates than medication alone 7.
When Patients Request Neurofeedback
If patients specifically request neurofeedback based on anecdotal reports or marketing claims, explain that:
- The highest quality evidence shows it performs no better than placebo 2
- Current medical guidelines explicitly recommend against it 1
- Effective, evidence-based treatments are available that work faster and more reliably 5, 6, 7
- The 2022 retrospective study showing improvement with app-based neurofeedback 8 lacks a control group and cannot establish causation beyond natural symptom fluctuation or placebo effects