Practice in Clinical & Health Psychology
What is Cranial Electrotherapy Stimulation?
A Unique Non-Drug Therapy

 

 
 
 

 

 

What is Cranial Electrotherapy Stimulation?

Cranial Electrotherapy Stimulation (CES) is a process which utilizes extremely small levels of electrical stimulation across the head for therapeutic treatment of anxiety, depression, insomnia and chronic pain.

CES is approved in the United States by the Federal Drug Administration (FDA) within a category for medical devices using microcurrent levels of electrical stimulation across the head via transcutaneous electrodes for the treatment of anxiety, depression, and insomnia.

CES was originally developed in the Soviet Union in 1949, its primary focus being the treatment of sleep disorders—hence, its original designation as “electrosleep”. The treatment of insomnia was soon overshadowed by psychiatric applications for anxiety and depression.

The treatment of anxiety and depression with CES began in the United States in the early 1960s and it is currently routinely prescribed by thousands physicians and mental health practitioners in the US and Canada for a variety of brain-related psychiatric conditions, although it has yet to achieve full acceptance as a mainstream medical treatment. This is probably because sufficient information has not been made available to the majority of medical practitioners regarding the safety and efficacy of CES and the pharmaceutical industry spends a great deal of money every year promoting the use of medications instead of such alternative therapies as CES.

While there are over 150 published scientific research studies on the use of CES. The overwhelming majority of these studies support the safety and efficacy of CES in the treatment of a number of psychological disorders; particularly anxiety, depression and insomnia. Yet the majority of Canadian physicians in general medical practice are simply unaware of them. Unlike pharmaceuticals, there is no large industry promoting CES to physicians.

While CES is FDA-approved solely for the treatment of anxiety, depression and insomnia, there is scientific data showing promise in the treatment of other conditions such as pain, tension/migraine headaches, fibromyalgia, and substance dependencies (i.e., may reduce symptoms associated with alcohol, drug or tobacco withdrawal), as well as for calming agitated and aggressive patients with neuropsychiatric conditions.

To see a brief YouTube video on the use of the AlphaStim CES device to treat depression, GOTO: http://www.youtube.com/watch?v=tsaeTlzvHwk&feature=related 

How does CES work?

CES is a relatively simple treatment employing a small, battery-powered device that is similar in size and appearance to transcutaneous electrical nerve stimulators (TENS) devices commonly used in physical therapy for pain relief, but produce very different waveforms at a much lower current level. The CES device sends pulses of very low amperage (i.e., less than 1.0 milliampere) electricity through thin wires attached to electrodes clipped to the ear lobes or stuck to the skin over  the bony prominences just to the front of, or behind each ear. The frequency of the electrical pulses can be adjusted— usually from 0.5 Hz to 100 Hz— depending on the treatment effect desired.

CES devices function differently from other biomedical electronics, such as deep brain stimulating electrodes (used to prevent seizures and hand tremors) and heart pacemakers. While those instruments require surgical implantation, CES operates non-invasively. CES is also quite different from electroconvulsive therapy (ECT) or electroshock therapy, a therapeutic modality sometimes used in hospitals to treat severe depression that is not responsive to medication. Where ECT uses a steady, strong electrical current applied directly to the scalp under anesthesia to cause a controlled brain seizure, CES applies a pulsing current that is over a thousand times weaker to the earlobes to induce changes in the excitability and average firing frequency of brain neurons. CES is painless and non-invasive and many CES devices are designed for home-use.

As with most medications for psychological problems, the actual mechanism by which CES works remains unclear but it is increasingly being viewed as an adaptogen, in that CES reduces stress that underpins many emotional disorders. Research to date suggests a number of possible mechanisms of action, including direct action on the brain at the level of the limbic system, the reticular activating system and the hypothalamus, increased release of various neurotransmitters and endorphins in the brain, increased parasympathetic nervous system dominance, and changes in blood flow and the electrical rhythms (EEG) of the brain. Rat studies have shown as much as a three-fold increase in endorphins (natural pain killer) with even relatively brief exposure to CES. Some researchers have reported rapid increases in serotonin, a brain neurotransmitter associated with relaxation and calmness, and decreases in cortisol, one of the primary stress-related hormones in patients treated with CES. As well, CES is known to increase levels of the brain neurotransmitters norepinephrine and dopamine, both associated with alertness and feelings of pleasure. Interestingly, serotonin, norepinephrine and dopamine are the same neurotransmitters that most antidepressant medications attempt to activate.

CES has also been demonstrated to increase brain electrical patterns known as “alpha rhythms”. Increases in the amount and power of alpha waves in the brain are associated with meditation and increased feelings of relaxation and calm focus.

What does CES feel like?

Applied to the ear lobes or to the mastoid, just behind the ear, CES causes the patient to experience nothing more than a faint tingling sensation. As the treatment continues, most patients begin to feel less anxious, less distressed, and more relaxed and, yet, mentally alert and focused. Patients with positive response to CES generally sleep better and report improved concentration, increased learning abilities, enhanced recall and a heightened state of well-being after one or a series of CES treatments. Most people can resume normal activities immediately after treatment. Some people may experience a euphoric feeling, or a state of deep relaxation that may temporarily and minimally impair their mental and/or physical abilities for the performance of potentially hazardous tasks, such as motor vehicle operation. In some cases, this may last for up to several hours after treatment. Users may do other things during treatment such as read, watch TV, engage in conversation, or work on a computer.

CAUTIONARY NOTE: Until you have experienced CES for yourself and are certain of how you will react to treatment, it is best that you do operate a motor vehicle or other motorized equipment or engage in potentially hazardous activities immediately after treatment.

Most patients are left feeling relaxed and alert after a CES session— in what psychologists call an “alpha state”. This state differs from pharmaceutical treatments in that people report feeling that their bodies are lighter and more relaxed and their minds more alert and clear. The results tend to be cumulative and lasting.

What are the adverse effects of CES?

Unlike the United States, where CES devices are sold by prescription only, there are no specific restrictions in Canada on the purchase or home-use of CES devices by the consumer. Canada Health does not recognize CES for the treatment of any medical condition and, therefore, no one selling CES devices can make any direct claims for their effectiveness in treating any medical condition. That said, no one is actually proscribed from using a CES device to treat any condition.

CES has a proven track record of safety, especially in comparison to alternative pharmaceutical treatments for the same conditions. There have been no reports of lasting adverse effects, significant side-effects, or any serious contraindications to CES treatment. CES treatment has not been shown to interact negatively with any medications and may be used adjunctively with psychoactive medications.

That said, labeling of CES devices contains precautions seen on all electromedical devices against use by pregnant women and persons with implanted medical devices such as cardiac pacemakers. Due to the relaxing effect of CES treatment, patients are cautioned in the use of hazardous machinery or driving. Despite the known safety of CES, it is advisable to only use CES to treat clinical conditions under the direction and supervision of a health professional.

What is the evidence for the effectiveness of CES?

Research studies of CES that been published to date reveal significant changes associated with relaxation responses such as reduced muscle tension, positive changes in brain wave activity, increased vasodilation, reductions in gastric acid output, and reductions in blood pressure, pulse, respiration, and heart rate. CES research has also shown significant reductions in clinical depression (Gilula & Kirsch, 2005), anxiety (Klawansky, et al., 1995) and fibromyalgia symptoms (Cork, et al., 2004; Lichtbroun, et al., 2001; Taylor, et al., 2011).

More than 25 clinical research studies examining the efficacy of CES for the treatment of depression have been published, with over 80% of these studies reporting significant clinical improvements in the symptoms of depression (Gilula & Kirsch, 2005).

A recent meta-analysis of 22 placebo-controlled CES research studies involving a total of 1075 patients found that the average treatment effect beyond that attributable to placebo was 57% (Gilula & Kirsch, 2005). This compares very favourably with the often claimed 40-60% average treatment effects beyond placebo for antidepressant medications.

The book— Cranial Electrotherapy Stimulation— by Dr. R.B. Smith (2007) reviews the results from over 100 studies involving over 4000 subjects and reports that CES is highly effective in the treatment of insomnia, anxiety, depression, drug abuse, anxiety and cognitive dysfunction with an average of 67% of patients reporting significant improvement in their symptoms.

CES has been shown to significantly improve symptoms and increase the functional status of individuals with diagnosed fibromyalgia (Cork, et al., 2004; Lichtbroun, et al., 2001; Taylor, et al., 2011).

CES has also been shown to improve sleep and memory consolidation during sleep (Born, et al. 2006; published in Nature).

How is CES treatment actually done?

Although CES devices are relatively inexpensive (generally about $300-$450) and anyone in Canada can purchase their CES device for home use from a local or internet speciality store, it is best to use CES under the advisement or supervision of a qualified health care professional when treating a clinical condition such as an anxiety disorder, depression, insomnia, or chronic pain.

In all cases, the health care professional will need to see you for at least one or two appointments to assess your condition, evaluate your initial response to the CES treatment within the safe and controlled environment of their office, and show you how to properly use the device. In some cases, the health care practitioner will offer a series of regular CES treatments in his/her office; often in conjunction with other treatments such as counselling or psychotherapy. In other cases, the health practitioner will provide you with a CES device for use at home for a period of time or will encourage you to purchase your own device for use at home.

While there certainly may be situations in which it is both practical and sensible to include CES treatments as part of regular clinical visits, in most situations it is far more cost-effective for the patient to use CES on a daily basis at home for a period of time and only see the health practitioner in the clinic for follow-up and any other related treatments.

In the treatment of anxiety or depressed mood, the research has generally shown that approximately 30-60 minutes of CES daily for a period of 2-4 weeks is effective in alleviating symptoms for extended periods of time. However, some patients find that their symptoms will slowly return over time and they benefit from one or more follow-up series of CES treatments. Other patients find that regular use of the CES device for 30-60 minutes a few times a week will effectively maintain treatment gains indefinitely or successfully manage chronic anxiety, depressed mood, insomnia, pain, or stress.

What results can I expect?

Individual results depend on a variety of factors, including the severity and chronicity of the condition, what medication has been prescribed (if any), the presence of other concurrent medical factors and, ultimately, your level of motivation. Some disorders can be successfully treated in 8-15 sessions; others require more extensive treatment. In the case of more chronic conditions, CES may be required on a regular basis indefinitely to manage symptoms.

For those patients with more severe acute or chronic conditions there is extra benefit to combining CES with counselling or psychotherapy as well as other forms of neurotherapy such as Audio Visual Entrainment (AVE) therapy or certain biofeedback therapies such as Heart Rate Variability (HRV) biofeedback.

The graphs above show data from studies conducted by Neurofitness LLC using the CES Ultra device

 

For more information on purchasing CES devices…

Mind Alive Inc. in Edmonton manufactures and sells a number of different CES devices  GOTO: www.mindalive.com

Optimum Health in Edmonton is the Canadian distributor for the AlphaStim 100 Microcurrent Stimulator  GOTO: www.optimumhealth.ca

Natural Pain Products Inc. is a Canadian Distributor for AlphaStim products: GOTO: www.naturalpainproducts.ca

Neurofitness LLC in Seattle manufactures the CES Ultra device  GOTO: www.cesultra.com

 
Selected Bibliography
Cork, R.,  Wood, P., Ming, N., et al. (2004). The effect of cranial electrotherapy stimulation on pain associated with fibromyalgia. Internet Journal of Anesthesiology, 8(2):
Gilula, M.F. (2004). Cranial Electrotherapy Stimulation: A Safe Neuromedical Treatment for Anxiety, Depression and Insomnia. (Letters to the Editor). Southern Medical Journal, 97(12):1269.
Gilula, M.F., Kirsch, D.L. (2005). Cranial Electrotherapy Stimulation Review: A Safer Alternative to Pharmaceuticals in the Treatment of Depression. Journal of Neurotherapy, 9(2):7-26.
Gilula, M.F. (2007). Cranial Electrotherapy Stimulation and Fibromyalgia. Expert Reviews of Medical Devices, 4(4):489-495.
Kirsch, D.L., Gilula, M.F. (2007). Cranial electrotherapy Stimulation in the Treatment of Insomnia: A Review and Meta-Analysis. Practical Pain Management, October 2007, pp. 28-37.
Klawansky, S., Yeung, A., Berkey, C., Shah, N., et al. (1995). Meta-analysis of Randomized Controlled Trials of Cranial Electrostimulation: Efficacy in the Treatment of Selected Psychological and Physiological Conditions. Journal of Nervous and Mental Diseases, 183(7):478-484. 
Lichtbroun, A., Raice, M., Smith, R. (2001). Treatment of fibromyalgia with cranial electrotherapy stimulation. Journal of Clinical Rheumatology, 7(2): 72-78.
Schroeder, M.J., Barr, R.E. (2001). Quantitative Analysis of Electroencephalogram During Cranial Electrotherapy Stimulation. Clinical Neurophysiology, 112(11):2075-2083. 
Smith. R. (2007). Cranial Electrotherapy Stimulation - Its First Fifty Years, Plus Three. A Monograph.
Taylor, A., Anderson, J., Riedel, S., Lewis, J., et al. (2011). Cranial electrical stimulation improves symptoms and functional status in individuals with fibromyalgia. Pain Management Nursing, 12(1): 1-9.