Neurofeedback and Adult ADHD
REVIEW OF: Schonenberg M et al, Lancet Psychiatry 2017;4(9):673–684
With neurofeedback, patients are hooked up to an EEG and shown images through various forms of media. The idea is that the EEG can detect brain waves that are associated with improvement in various symptoms, and then the patient can be taught to produce “healthier” brain waves. Some studies have shown that neurofeedback improves ADHD in children and adolescents. However, the results are controversial, and neurofeedback in general needs further research to prove its efficacy. (See TCPR April 2017 for a Q&A on neurofeedback.)
This investigation tested neurofeedback treatment in adults. The triple-blinded, randomized, controlled study was conducted at Germany’s University of Tubingen. Eligible participants met the DSM-IVTR criteria for ADHD, were ages 18–60, and had no or stable use of medication.
Overall, 118 people were randomly assigned to neurofeedback (38), sham neurofeedback (39), or meta-cognitive group therapy (41). In the neurofeedback group, participants received 30 treatments, while the sham group underwent 15 sham sessions followed by 15 treatment sessions. In the therapy arm, patients attended 12 group therapy sessions. The primary outcome was scores on the Conners’ Adult ADHD Rating Scale (CAARS), assessed before treatment, at mid-treatment (8 weeks), after treatment (16 weeks), and 6 months later.
Significant improvement on the CAARS from pre-treatment to the 6-month followup was observed for all treatments. For the neurofeedback group, scores dropped from 135 to 104. For sham neurofeedback, they decreased from 132 to 94. For meta-cognitive group therapy, they fell from 138 to 104. Clinical improvements were unrelated to EEG brain activity changes. No serious adverse events resulted from any treatment.
TCPR’S TAKE: These findings suggest EEG neurofeedback is not superior to a sham condition or group psychotherapy in adults with ADHD. Data supporting ADHD EEG neurofeedback remain sparse, but we’re interested to see if further research proves it to be an option for adults who do not respond to medications, have significant side effects, or object to using medication. For now, though, we remain skeptical.
—Rehan Aziz, MD.
Is SSRI Efficacy Real, or Just a Placebo Response?
REVIEW OF: Hieronymus F et al, Molecular Psychiatry 2017. doi:10.1038/mp.2017.147
Over the last several years, there’s been a lively debate about the efficacy of antidepressants. Meta-analyses have shown that antidepressants do outperform placebo in most studies. However, active medications cause more side effects than placebo pills. Thus, it’s possible that side effects lead patients to accurately guess that they’ve been assigned to the active drug group, and this positive expectancy alone could underlie any supposed efficacy of the drug.
But how would you structure a study to resolve this problem? You can’t randomly assign patients to the active medication with side effects vs the same active medication without side effects. So, researchers have resorted to the artful use of statistical methods. One of these is called a “mega-analysis.” In a mega-analysis, you combine the results of independent studies using data from the individual subjects. This differs from the more common meta-analysis, which combines the results of independent studies using summary data from groups of people.
In a new mega-analysis, the authors reviewed all industry-sponsored, FDA-registered, placebo-controlled trials of paroxetine and citalopram in adults with major depressive disorder. 2,759 patients were included from the paroxetine trials, and 585 patients formed the citalopram trials. The purpose was to compare the response of patients who reported side effects vs those who were side effect–free.
Focusing on the mood item of the Hamilton Depression Rating Scale (HDRS) as the outcome measure, researchers found that among patients who reported no side effects, patients assigned to paroxetine or citalopram did significantly better than those assigned to placebo (p < 0.001). Furthermore, looking at the entire sample, there were no significant differences in the reductions in the HDRS-17 depressed mood item at 6 weeks for paroxetine treatment with or without side effects, and for citalopram treatment with or without side effects.
TCPR’S TAKE: This study supports the hypothesis that both citalopram and paroxetine have genuine antidepressant effects caused by their pharmacodynamic properties, and more than just placebo effects.
—Adam Strassberg, MD.