Cranial Electrical Stimulation (CES)

Background:

Different types of brain stimulation are sometimes helpful in the treatment of depression. Electroconvulsive therapy (ECT) is a treatment that is sometimes used for severe, refractory depression. It works too. One meta-analysis found that the chance of response was four times greater with ECT compared to antidepressant medications.¹ But, there are some downsides to ECT. The person is under anesthesia to be given the shock that produces the controlled seizure. The total procedure takes time – usually an hour or two when accounting for time in the recovery room post-procedure. Finally, ECT can cause headaches and memory loss.

Transcranial magnetic stimulation (TMS) is another type of brain stimulation for the treatment of depression. It is a non-invasive procedure during which the patient is awake. It produces magnetic pulses that stimulate neurons in the brain to activate. Side effects are usually mild. There are some difficulties with TMS. Even though it is a simple procedure, it still requires someone to come in for an hour, five times per week for four weeks. That is a big time commitment. Also, ECT’s efficacy is favored over TMS.²

A third type of stimulation for treating depression is called vagus nerve stimulation. Vagus nerve stimulators are implanted in the chest and electrodes are threaded up to the vagus nerve. This creates pulses that stimulate the vagus nerve and can be helpful in treating depression. Non-invasive devices are being produced.

This sparked my interest in finding a brain stimulation device that could be done at home. I found a product called a cranial electrical stimulation (CES) device. This is FDA approved for depression, anxiety, and insomnia.

It was invented in the 1950s in the Soviet Union and arrived in the United States in the 1960s. The best part about this treatment option is that it can be done right in the comfort of your own home. Some people even bring them to work and use them when they are feeling stressed. I was surprised to find out that the veterans affairs (VA) hospitals will provide the devices for veterans. I have worked in two VAs in different states and I had never seen or even heard of this as a treatment option.

The way in which CES devices work are still being investigated. It may:

  • Decrease ruminating thought loops by causing changes in a network in the brain called the “default mode network”
  • It decreases delta waves, which are associated with deep sleep and increases alpha waves, which are seen during meditation. This may cause a calm but alert state.
  • CES increases endorphins and serotonin, while CES decreases the stress hormone cortisol

Adverse effects are rare. There are not any contraindications but it should not be used during pregnancy. The most common side effects are skin irritation, and headaches.

Effectiveness:

(3) A trial from the United States looked to see if CES is effective in treating patients with anxiety and depression. The patients were given a real CES device or a sham device that they used for one hour daily for five weeks. The anxiety score (HAM-A) was around 6 points lower in the active group as compared to the sham group. The depression score (HAM-D) was three points lower in the active group as compared to the sham device. Subjects reported no adverse effects from the treatment.

(4) Doctors from Massachusetts General Hospital conducted a trial to see if CES would be helpful in treatment-resistant depression. The patients in this trial had an inadequate response to traditional antidepressants. The patients were randomized to get CES for 20 minutes, 5 days per week for 3 weeks total or use a sham device that didn’t do anything. Both groups had improvements in their HAM-D-17 depression score by 3-5 points. There was no difference seen between the sham device and the real CES device.

Even though this device is FDA approved, there are not many studies determining how effective it is. Treating treatment-resistant depression is especially hard and CES did not show a benefit here. More studies can help to solidify CES’s place in treatment.

My experience: 

Finding a CES device was an interesting experience. I found unregulated homemade products available for around $100 dollars. I found flashy products with a price tag of $700. I needed something in between. I ended up going with the CES Ultra. It is available on this website https://www.cesultra.com/index.php. CES devices are only available with a prescription, but you can buy a consultation and prescription from the CES Ultra website for an additional $20.

I received the package in the mail a week later. The components all came in a carrying case. I was surprised to see so many parts. Included with the device were 2 sets of wires, ear-clip electrodes, a small water bottle to wet the ear-clip electrodes, a 9V battery, gel-pad electrodes, and an operating manual. All the parts made it seem complicated but after reading the instructions, I found it easy to use. There are two ways to use the device. One way is to wet the ear-clips and attach them to the device. The second and recommended way is to attach the sticky gel-pad electrodes under the ears and behind the jaw-line. This method does not require wetting of the pads. 

The device is about the size of a thick cell phone. It easily fits into my pocket so that I can walk around while the device is on. There is a dial to turn the device on and adjust the strength. There is also a light to let you know the device is on, and three-time settings. The device can be set for a 30-minute, 45-minute or a continuous session.

I put the 9V battery in, attached the wires and I was ready for my first treatment. I washed my neck with soap and water to remove excess oil. Oil on the skin can act as an insulator and decrease the effectiveness of the device. I then placed the gel-pads under my ears and behind my jaw-line. The pads stuck well to my neck and didn’t hurt to put on or remove.

I turned the dial and with a click, the device was on. I continued to turn the dial until I could feel the device.  It felt like pins and needles in my ears but it wasn’t unpleasant. 

I did notice some decrease in irritability and improvements in sleep after a few weeks of use. I wonder if this is an active placebo effect or if the device itself is actually helping. Regardless, I find myself going back and using the device quite often.

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ces device
My CES kit

References:

1. Pagnin D, de Queiroz V, Pini S, et al. Efficacy of ECT in depression: a meta-analytic review. J ECT. 2004 Mar;20(1):13-20.

2. Health Quality Ontario. Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Ont Health Technol Assess Ser. 2016 Mar 1;16(5):1-66. eCollection 2016.

3. Barclay T, Barclay R.  A clinical trial of cranial electrotherapy stimulation for anxiety and comorbid depression. Journal of Affective Disorders, 164, 171–177.

4. Mischoulon D, De Jong M, Vitolo O, et al. Efficacy and safety of a form of cranial electrical stimulation (CES) as an add-on intervention for treatment-resistant major depressive disorder: A three week double blind pilot study. Journal of Psychiatric Research, 70, 98–105.

5. Kirsch DL, Nichols F. Cranial electrotherapy stimulation for treatment of anxiety, depression, and insomnia. Psychiatr Clin North Am. 2013;36(1):169-176.

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