UNDERSTANDING DEPRESSION

Depression is a long term change in mood where a person finds it difficult to feel content or happy even in the presence of things that have made them content in the past. For example, a person can be surrounded by positive, supporting relationships, in a career that they love and they still struggle to feel happy. There are many factors related to depression like someone’s genetic predisposition, environment, life events, but depression does not have to be linked to any event or logical origin. It is important to note that depression is not a choice, issue with motivation, character flaw. These stereotypical notions can be very damaging and prevent people from getting the help they need and deserve.

Depression can manifest as emotional symptoms (feeling hopeless, sad, uninterested in things they used to enjoy,), physical symptoms (fatigue, fluctuations in weight, changes in appetite, pain in the body, etc.), behavioural symptoms (avoiding people and events, reduced interest in sex, reduction in self-care activities), and cognitive symptoms (struggling with concentration and alertness, issues with planning and organization, forgetting things, etc.). Individuals may also feel anxious. See our section on anxiety.

Depression can also affect a person’s instrumental activities of daily living (IADLs) which can be simply defined as a person’s daily self care activities. Some IADLs include cooking, cleaning, communication, accessing transportation, laundry, shopping, and managing personal finances. Depression is usually diagnosed by a clinical psychologist or psychiatrist, but can also be diagnosed by your family physician. It is usually diagnosed after the symptoms related to Depression do not go away after 6 months.

OUR APPROACH TO DEPRESSION

We start with a Clinical Intake Interview to review background history, medical history, identify specific symptoms and their severity, review previous assessments and interventions, and identify if any other assessments are required. The next step is to complete a QEEG (Quantitative Electroencephalogram) assessment to analyze your brainwave patterns. The best way to understand brain waves is to compare them to each section of an orchestra. Every section of an orchestra needs to work together to make sure the music sounds good. Sometimes one section of the orchestra is more dominant than the other, but all sections are necessary to produce beautiful music. In the same way all brain waves are necessary to balance each other out, complement each other, and become dominant when necessary. For example, when you need to analyze and engage in higher level thinking you want your brain to be dominant in faster brain wave patterns to accomplish this task. When you are getting ready for sleep you want your brain to gradually slow down and be dominant in slower brain wave patterns.

People who usually have depression usually demonstrate an imbalance of alpha brain patterns in the prefrontal areas of the brain. This means that there is usually an excess or deficit of alpha in front of the left and right hemispheres of the brain. Prefrontal areas of the brain are the most associated with mood and this imbalance of can cause disruptions in mood. There can also be global imbalance in other brain patterns that lead to poor signalling and communication and can also contribute to issues in mood. Once we figure out what brain wave patterns are related to your symptoms we can design a personalized program to target and improve them. During each session we monitor your brain waves in real time and when there is greater balance of brain wave patterns we reward you with video and sound. These audio and visual rewards help train and guide your brain to have improved balance and improve your symptoms.

Sometimes clients require additional support in conjunction with neurofeedback training. Some options are psychotherapy and somatic experiencing therapy.

RESEARCH ARTICLES ON DEPRESSION

This section is meant to highlight research that has been done in the field. The following brief summaries are resources that we have gathered for the public. For an in-depth look at each research article we recommend using the citation to find and read the original article. We hope to add additional resources when possible!

Wang, S., Lin, I., Fan, S., Tsai, Y., Yen, C., Yeh, Y., Huang, M., Lee, Y., Chiu, N., Hung, C., Wang, P., Liu, T., Lin, H. (2019). The effects of alpha symmetry and high-beta down training neurofeedback for patients with the major depressive disorder and anxiety symptoms. Journal of Affective Disorders, 257 (2019) 287-296

Previous studies in neurophysiology have found a higher beta activity of electroencephalography (EEG) at the posterior cortex among patients with comorbid major depressive disorder and anxiety symptoms. Thus, this present study aimed to examine the effect of alpha-symmetry neurofeedback (ALAY) and high-beta down-training (beta) neurofeedback in symptoms of depression and anxiety. Eighty-seven patients with comorbid MDD and anxiety symptoms were allocated to the ALAY, Beta, or control groups. Both neurofeedback groups received ten-sessions of neurofeedback and all three groups partook in various psychological tests. The results showcased that both neurofeedback groups displayed decreased symptoms of depression and anxiety. The Beta group specifically was more effective in decreasing high-beta power at the parietal cortex compared to other groups. This study concludes that the non-invasive psychological intervention of neurofeedback can be used to aid patients with comorbid MDD and anxiety symptoms.

Hamilton, J., Glover, G., Hsu, J., Johnson, R., Gotlib, I. (2019). Modulation of subgenual anterior cingulate cortex activity with real-time neurofeedback. Human Brain Mapping, DOI: 10.1002/hbm.20997

Real-time neurofeedback techniques allow one to map the controllability of sensory, cognitive and affective centres in the brain. The subgenual anterior cingulate cortex (sACC) is thought to be involved in the generation of affective states. In this study, researchers examined whether individuals could use real-time fMRI neurofeedback to modulate sACC activity. An experimental group of eight women partook in the study. Initially a localizer task was used to identify an sACC region of interest, followed by four scans: (1) a pretraining scan in which they were asked to decrease activity in the sACC without neurofeedback; (2) two training scans in which sACC neurofeedback was presented along with instruction to decrease sACC activity; and (3) a neurofeedback-free post-training scan. In addition to this a control group was made so as to compare results across the board. Post-training results showcased significantly reduced activity in the sACC during neurofeedback training in the experimental group, but not in the control group. The findings that individuals can down-modulate sACC activity shows that neurofeedback training can aid in controlling a primary emotion centre in which functional abnormalities have a strong implication in affective disorders.

Zotev, V., Yuan, H., Misaki, M., Phillips, R., Young, K., Feldner, M., Bodurka, J. (2015). Correlation between amygdala BOLD activity and frontal EEG asymmetry during real-time fMRI neurofeedback training in patients with depression. NeuroImage:Clinical, 11 (2016) 224-238

Real-time fMRI neurofeedback (rtfMRI-nf) is an emerging novel approach to the treatment of major depressive disorder (MDD). EEG performed simultaneously with an rtfMRI-nf procedure allows an independent evaluation of rtfMRI-nf brain modulation effects. Frontal EEG asymmetry in the alpha band is a widely used measure of emotion and motivation that shows profound changes in depression. In this study MDD patients in the experimental group learned to upregulate BOLD activity of the left amygdala using an rtfMRI-nf during a happy emotion induction task. Conversely MDD patients in the control group were provided with a sham rtfMRI-nf. Throughout the sessions correlations between frontal EEG asymmetry in the upper alpha band and BOLD activity across the brain were examined. The average asymmetry changes significantly correlated with the amygdala BOLD laterality. Temporal correlations between frontal EEG asymmetry and BOLD activity were significantly enhanced, during the rtfMRI-nf task, for the amygdala and many regions associated with emotion regulation. This study demonstrates an important link between amygdala BOLD activity and frontal EEG asymmetry during emotion regulation. The results suggest that rtfMRI-nf training targeting the amygdala is beneficial to MDD patients. A combination of EEG-nf based on frontal EEG asymmetry in the alpha band and amygdala-based rtfMRI-nf, could enhance emotion regulation training and benefit MDD patients.

Kim, J., Park, E., Oh, N. (2016). Effects of Neurofeedback training on Life Stress and Depression in Female college students. Journal of Digital Convergence, DOI: 10.14400/JDC.2016.14.3.299

Stress is a normal response to situational pressures and demands. This study aims to investigate the effects of employing brainwave neurofeedback training on life stress and depression in female college students. Twenty-six subjects were chosen and randomly assorted into the experimental group and the control group. The neurofeedback sessions ran for a total of 8 weeks, after which post-training results were taken. The results showed a statistically significant difference between both the experimental group and the control group for life stress and depression. In both cases, the experimental group showed significantly decreased life stress and depression levels than the control group. The results observed from this study allow researchers to conclude that neurofeedback training for the decrease of life stress and depression, has a positive effect.

Linden, D., Habes, I., Johnston, S., Linden, S., Tatineni, R., Subramanian, L., et al. (2012). Real-Time Self-Regulation of Emotion Networks in Patients with Depression. PLoS ONE, 7(6): e38115. https://doi.org/10.1371/journal.pone.0038115

At least 30% of patients with major depressive disorder (MDD) do not respond to standard pharmacological and/or psychological treatments, and a considerable number of those who do respond to standard treatment go on to develop a chronic remission cycle. Through this study researchers explore the feasibility of a brain self-regulation technique that utilizes neurofeedback with functional magnetic resonance imaging (fMRI). Eight patients with depression learned to upregulate brain areas involved in the generation of positive emotions. This was done over the span of four neurofeedback sessions. Their clinical symptoms were assessed using the 17-item Hamilton Rating Scale for Depression (HDRS), and showed significant improvement. This study supports the notion that neurofeedback may in fact be a useful adjunct to current therapies for depression.

Hammond, D. C. (2005). Neurofeedback treatment of depression and anxiety. Journal of Adult Development, 12, 131-137.

In this report, the author details the biological component associated with anxiety, depression and obsessive compulsive disorder, noting the findings from a robust body of research, including EEG studies. In addition to documenting biological predispositions that exist for anxiety, depression, and obsessive compulsive disorders, new research has also shown that medication is only mildly effective in the treatment of these problems when compared to a placebo. This report offers a detailed review of available research of uncontrolled studies that investigate the efficacy of neurofeedback treatment. Although the findings from these uncontrolled studies are promising, the author notes that there is a need for controlled research due to the fact that the current pool of research only represents uncontrolled studies. The author concludes by providing his own impressions from incorporating neurofeedback into private practise, noting the significant and enduring improvements seen in clients who have the same kind of alpha frontal symmetry that reflects a biological predisposition to depression.

Hammond, D. C. (2005). Neurofeedback with anxiety and affective disorders. Child and Adolescent Psychiatric Clinics of North America, 14, 105-123. This article engages with existing research on functional brain abnormalities associated with depression, anxiety, and obsessive-compulsive disorder. The authors describe, in detail, the neurophysiological basis for various symptoms and differentiate these factors from biological predisposition. It is argued that despite psychiatry’s strong reliance on the use of medication for the treatment of depression and anxiety; current evidence seems to suggest that pharmacologic treatment may not be as effective as was previously believed. The authors provide a brief overview of the research done to determine the efficacy of more traditional treatment models and stress the point that an increasing number of patients seem interested in less invasive treatment than medication. Neurofeedback is introduced as an alternative treatment option for modifying dysfunctional, biologic brain patterns that are associated with various psychiatric conditions and the advantages are discussed.

Escolano, C., Navarro-Gil, M., Garcia-Campayo, J., Congedo, M., Riffer, D. D., & Minguez, J. (2014). A controlled study on the cognitive effect of alpha neurofeedback training in patients with major depressive disorder. Frontiers in Behavioural Neuroscience, 8(296), 1-12. 33% of patients taking medication for major depressive disorder fail to achieve remission. This study investigates the impact of neurofeedback on working memory performance in 60 patients with major depressive disorder. Participants were not randomly assigned a group; rather they were purposely allocated to the neurofeedback group or control group. Neurofeedback protocol aimed to increase individual upper alpha power in the parieto-occipital area of the scalp. Results suggest that the stronger effect of neurofeedback training is specifically found in working memory performance and processing speed, whereas the improvement in episodic memory, executive functions and verbal fluency was marginal and likely explained by an enhancement of cognitive processing as a whole. Furthermore, participants in the neurofeedback group showed pre-post enhancement in the upper alpha power of the training, better visible in task-related activity as compared to resting state.

Choi, S. W., Chi, S. E., Chung, S. Y., Kim, J. W., Ahn, C. Y., & Kim, H. T. (2011). Is alpha wave neurofeedback effective with randomized clinical trials in depression? A pilot study. Neuropsychobiology, 63, 43-51. This study examines whether neurofeedback training designed to increase the relative activity of the right frontal alpha band would have an impact on the symptoms of depressive subjects suffering from emotional, behavioural and cognitive problems. Research proposes that frontal asymmetric activation is the underlying mechanism for depression; therefore enhancement of a relative right frontal alpha activity by asymmetry neurofeedback training leads to improvement in depressive symptoms. To test this, the authors’ randomly assigned 24 participants who meet the DSM-IV criteria for depressive disorders into 2 groups. One group underwent neurofeedback training twice a week for 5 weeks for a total of 10 sessions. The other group did not receive neurofeedback; instead they underwent psychotherapy placebo training for 5 weeks. The results of this study indicate that asymmetry neurofeedback training increased the relative right frontal alpha power, and it remained effective even after the end of treatment. The authors’ preliminary conclusion is that asymmetry training is important for controlling and regulating emotion and it may facilitate the left frontal lobe functions.

White, E. K., Groeneveld, K. M., Tittle, R. K., Bolhuis, N. A., Martin, R. E., Royer, T. G., & Fotuhi, M. (2017). Combined neurofeedback and heart rate variability training for individuals with symptoms of anxiety and depression: A retrospective study. NeuroRegulation, 4(1), 37–55. This report is the first of its kind to observe the impact of concurrent neurofeedback (NFB) and heart rate variability (HRV) training as a viable intervention strategy for symptoms of anxiety and depression. 183 children and adults with anxiety and/or depression symptoms underwent treatment consisting of concurrent NFB and HRV training for a total of 30 sessions within a time period of 6 to 24 weeks. Results showed that symptoms of anxiety and depression reduced in both adults and children. Both questionnaire assessment and changes in EEG, breathing rate and HRV were of clinical significance. The authors concluded that NFB and HRV training is an effective, non-pharmaceutical option for intervention to reduce symptoms of anxiety and depression. It was also concluded that NFB and HRV may improve EEG, blood pressure, resting breathing rate and HRV.

Ghaziri, J., Tucholka, A., Larue, V., Blanchette-Sylvestre, M., Reyburn, G., Gilbert, G., . . . Beauregard, M. (2013). Neurofeedback Training Induces Changes in White and Gray Matter. Clinical EEG and Neuroscience, 44(4), 265-272. doi:10.1177/1550059413476031

In this study, Health university students were randomly assigned to the experimental group, sham group or control group. Participants in the experimental group trained to enhance beta waves at F4 and P4. Attentional performance and MRI data were recorded one week before training and one week after training. Higher scores on auditory and visual sustained attention were present in experiment group. Gray matter volume increases were detected in cerebral structures involved in this type of attention. This study constitutes the first empirical demonstration that neurofeedback training leads to microstructural changes in white and gray matter.

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