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

Background To date, only one systematic review and meta-analysis of randomized controlled trials (RCTs) has evaluated the effect of neurofeedback in PTSD, which included only four studies and found an uncertainty of the effect of EEG-NF on PTSD symptoms. This meta-analysis is an update considering that numerous studies have since been published. Additionally, more recent studies have included fMRI-NF as well as fMRI-guided or -inspired EEG NF Methods Systematic literature searches for RCTs were conducted in three online databases. Additional hand searches of each study identified and of systematic reviews and meta-analyses published were also undertaken. Outcomes evaluated the effect of neurofeedback vs. a control (active, sham, and waiting list) on their effects in reducing PTSD symptoms using various health instruments. Meta-analytical methods used were inverse variance random-effects models measuring both mean and standardized mean differences. Quality and certainty of the evidence were assessed using GRADE. Adverse events were also evaluated. Results A total of 17 studies were identified evaluating a total of 628 patients. There were 10 studies used in the meta-analysis. Results from all studies identified favored neurofeedback's effect on reducing PTSD symptoms including BDI pretest-posttest [mean difference (MD): 8.30 (95% CI: 3.09 to 13.52; P = 0.002; I (2) = 0%)]; BDI pretest-follow-up (MD: 8.75 (95% CI: 3.53 to 13.97; P < 0.00001; I (2) = 0%); CAPS-5 pretest-posttest [MD: 7.01 (95% CI: 1.36 to 12.66; P = 0.02; I 2 = 86%)]; CAPS-5 pretest-follow-up (MD: 10 (95% CI: 1.29 to 21.29; P = 0.006; I (2) = 77%); PCL-5 pretest-posttest (MD: 7.14 (95% CI: 3.08 to 11.2; P = 0.0006; I (2) = 0%); PCL-5 pretest-follow-up (MD: 14.95 (95% CI: 7.95 to 21.96; P < 0.0001; I (2) = 0%). Other studies reported improvements using various other instruments. 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. Conclusion 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. This clinically meaningful effect appears to be driven by newer fMRI-guided NF and deeper brain derivates of it.