ABSTRACTProblem: There are currently limited options for nonpharmacological treatment of PTSD. Although cranial electrotherapy stimulation (CES) has been studied and used to treat many of the symptoms of PTSD, CES has not been studied in individuals with PTSD. Purpose: The goal of this project is to discover whether CES is effective in treating patients with symptoms of PTSD with related diagnoses. The project also consists of information available online: http://sites.google.com/view/ces-research/home

Methods: Results of 35 randomized controlled trials were evaluated in the context of outcomes (symptoms) and population criteria (diagnosis). Results: The strongest body of evidence indicates that CES is effective in treating anxiety symptoms in populations with anxiety disorders. Conclusion: CES may be effective in treating a subgroup of patients with PTSD whose symptoms are primarily anxiety related.

PICO QUESTIONIn adults with symptoms of PTSD, does cranial electrotherapy stimulation (CES) compared to inactive CES reduce symptoms of PTSD? In what specific diagnostic populations? What symptoms?

LITERATURE REVIEWCES is effective in treating anxiety symptoms in populations with anxiety disorders 1,23,34,56. • Anxiety Symptoms/ Anxiety Disorders1,2,3,4

CES also holds promise for treating the following combination of symptom/ population, but more research is needed. • Depression/ Bipolar II5

• Anxiety, Depression, and Sobriety/ Substance Use Disorders 6,7,8,9,10

• Pain/ Chronic Headache 11,12,13,14

• Pain/ Fibromyalgia 15,16,17

Cranial Electrotherapy:Treating Posttraumatic Stress Disorder

Nicole Melling, BSN, RN, MSN-FNP Student

DeliverablesIn order to share the conclusions of the research with patients and practitioners, a website was created.Accessible and Understandable• The information on the webpage is

presented at a 7th grade reading level, so it can be understood in 5 minutes.

Implications are Clear• The chart (shown below) clarifies the

conclusions and implications of the research at a glance.

Facilitates Evidence-Based Practice• By providing links to original studies, the

site facilitates provider research review.

Limitations of the Literature• No studies utilize patients with PTSD.22

• Study parameters are inconsistent. 24

• Most studies have neglected measuring adverse events.22

• Many studies had quality problems.22,23

• The blinding procedures have never been validated.22,24

• Much of the literature is outdated.2,3,4,7,9,10

THEORETICAL FRAMEWORKThe context of Bandura’s social cognitive theory sheds light on how CES may support recovery from PTSD.25 CES may support the individual’s ability to cognitively process trauma without becoming psychologically or physiologically overwhelmed by the fear response. The availability of a non-pharmacological treatment option that aligns with patient values also contributes to the individual’s sense of empowerment. Both of these mechanisms support the brain in recovering from PTSD.

CONCLUSIONSCES holds promise as a treatment option for PTSD. Further research on the effects of CES on individuals with PTSD should focus on a subgroup of patients whose most prevalent symptoms of PTSD are anxiety related.

REFERENCES1. Barclay, T. H., & Barclay, R. D. (2014). A clinical trial of cranial electrotherapy stimulation for anxiety and

comorbid depression. Journal of Affective Disorders, 164, 171-177.

2. Gibson, T. H., & O’Hair, D. E. (1987). Cranial application of low level transcranial electrotherapy vs. relaxation instruction in anxious patients. American Journal of Electromedicine, 4(1), 18-21.

3. Ryan, J. J., & Souheaver, G. T. (1976). Effects of transcerebral electrotherapy (electrosleep) on state anxiety according to suggestibility levels. Biological Psychiatry, 11(2), 233-237.

4. Scallet, A., Cloninger, R., & Othmer, E. (1976). The management of chronic hysteria: A review and double-blind trial of electrosleep and other relaxation methods. Diseases of the Nervous System, 37(6), 347-353.

5. McClure, D., Greenman, S. C., Koppolu, S. S., Varvara, M., Yaseen, Z. S., & Galynker, I. I. (2015). A pilot study of safety and efficacy of cranial electrotherapy stimulation in treatment of bipolar II depression. The Journal of Nervous and Mental Disease, 203(11), 827-835. doi:10.1097/NMD.0000000000000378

6. Bianco, F. (1994). The efficacy of cranial electrotherapy stimulation (CES) for the relief of anxiety and depression among polysubstance abusers in chemical dependency treatment (Unpublished doctoral dissertation, University of Tulsa, Oklahoma).

7. Gomez, E., & Mikhail, A. R. (1978). Treatment of methadone withdrawal with cerebral electrotherapy (electrosleep). The British Journal of Psychiatry: The Journal of Mental Science, 134, 111-113.Gomez

8. Schmitt, R., Capo, T., & Boyd, E. (1986). Cranial electrotherapy stimulation as a treatment for anxiety in chemically dependent persons. Alcoholism: Clinical and Experimental Research, 10(2), 158-160.

9. Smith, R. B., & O'Neill, L. (1975). Electrosleep in the management of alcoholism. Biological Psychiatry, 10(6), 675-680.

10. Tomsovic, M., & Edwards, R. V. (1973). Cerebral electrotherapy for tension-related symptoms in alcoholics. Quarterly Journal of Studies on Alcohol, 34(4), 1352-1355.

11. Solomon, S., Elkind, A., Freitag, F., Gallagher, R. M., Moore, K., Swerdlow, B., & Malkin, S. (1989). Safety and effectiveness of cranial electrotherapy in the treatment of tension headache. Headache: The Journal of Head and Face Pain, 29(7), 445-450.

12. Solomon, S., & Guglielmo, K. M. (1985). Treatment of headache by transcutaneous electrical stimulation. Headache: The Journal of Head and Face Pain, 25(1), 12-15.

13. Gabis, L., Shklar, B., Baruch, Y. K., Raz, R., Gabis, E., & Geva, D. (2009). Pain reduction using transcranial electrostimulation: A double blind "active placebo" controlled trial. Journal of Rehabilitation Medicine, 41(4), 256-261. doi:10.2340/16501977-0315

14. Tietjen, G., Thotakura, S., Singh, J., Utley, C., Ramsey-Williams, V., Khubchandani, J., & Khuder, S. (2013). Headache prevention with cranial electrotherapy stimulation in chronic migraine. A randomized controlled trial. Cephalalgia, 33(11), 963-964.

15. Cork, R. C., Wood, P., Ming, N., Clifton, S., James, E., & Price, L. (2004). The effect of cranial electrotherapy stimulation (CES) on pain associated with fibromyalgia. The Internet Journal of Anesthesiology, 8(2).

16. Lichtbroun, A. S., Raicer, M. M., & Smith, R. B. (2001). The treatment of fibromyalgia with cranial electrotherapy stimulation. Journal of Clinical Rheumatology: Practical Reports on Rheumatic & Musculoskeletal Diseases, 7(2), 72-78.

17. Taylor, A. G., Anderson, J. G., Riedel, S. L., Lewis, J. E., Kinser, P. A., & Bourguignon, C. (2013). Cranial electrical stimulation improves symptoms and functional status in individuals with fibromyalgia. Pain Management Nursing: Official Journal of the American Society of Pain Management Nurses, 14(4), 327-335. doi:10.1016/j.pmn.2011.07.002

18. Hearst, E. D., Cloninger, C. R., Crews, E. L., & Cadoret, R. J. (1974). Electrosleep therapy: A double-blind trial. Archives of General Psychiatry, 30(4), 463-466.

19. Moore, J. A., Mellor, C. S., Standage, K. F., & Strong, H. (1975). A double-blind study of electrosleep for anxiety and insomnia. Biological Psychiatry, 10(1), 59-63.

20. Passini, F. G., Watson, C. G., & Herder, J. (1976). The effects of cerebral electric therapy (electrosleep) on anxiety, depression, and hostility in psychiatric patients. The Journal of Nervous and Mental Disease, 163(4), 263-266.

21. Klawansky, S., Yeung, A., Berkey, C., Shah, N., Phan, H., & Chalmers, T. C. (1995). Meta-analysis of randomized controlled trials of cranial electrostimulation: Efficacy in treating selected psychological and physiological conditions. Journal of Nervous and Mental Disease, 183, 478-485.

22. Shekelle, P., Cook, I., Miake-Lye, I. M., Mak, S., Booth, P. M. S., Shanman, R., & Beroes, M. J. M. (2018). The effectiveness and risks of cranial electrical stimulation for the treatment of pain, depression, anxiety, PTSD, and insomnia: A systematic review, Project #05-226. Portland, OR: Veterans Affairs Evidence-based Synthesis Program (VA ESP). Retrieved from https://www.hsrd.research.va.gov/publications/esp/CES.pdf

23. O’Connell, N. E., Wand, B. M., Marston, L., Spencer, S., & Desouza, L. H. (2011). Non-invasive brain stimulation techniques for chronic pain: A report of a Cochrane systematic review and meta-analysis. European Journal of Physical and Rehabilitation Medicine 47(2), 309-326.

24. Kavirajan, H. C., Lueck, K., & Chuang, K. (2014). Alternating current cranial electrotherapy stimulation (CES) for depression. Cochrane Database of Systematic Reviews, 2014(7). doi:10.1002/14651858.CD010521.pub2

25. Bandura, A. (1982). Self-efficacy mechanisms in human agency. American Psychologist, 37, 122-147.

Methodology: Symptom and DiagnosisEarly CES research tended to measure the effects of CES on a particular symptom outcome (such as depression) with a variety of diagnoses.18,19,20 Previous meta-analyses have followed the same pattern.21,22 By considering both the specific diagnosis (population criteria) and the symptom (outcome criteria) in the grouping of studies, this project demonstrates the efficacy of CES more clearly and conclusively.

Symptom Diagnosis Effective #Study #Participant Results ReliabilityDepression Unipolar Depression No 2 50 Not effective ConsistentDepression Bipolar II Maybe 1 16 Effective Small, high qualityDepression Mixed Psychiatric No 3 105 Mixed Outdated studiesDepression Healthy Adults No 4 293 Mixed High quality studiesAnxiety Anxiety disorder Yes 4 220 Effective High qualityAnxiety Mixed Psychiatric No 3 105 Not effective Outdated studiesAnxiety Healthy Adults No 3 253 Mixed Inconsistent designsAnxiety Substance Use Maybe 5 268 Effective Outdated studiesDepression Substance Use Maybe 3 161 Effective Outdated studiesSobriety Substance Use Unknown 1 28 Effective One outdated studyInsomnia Primary Insomnia No 3 84 Not effective Inconsistent resultsInsomnia Secondary Insomnia No 3 101 Mixed Inconsistent designChronic Pain Headache Maybe 4 234 Effective Inconsistent designsChronic Pain Fibromyalgia Maybe 3 191 Effective Low quality, consistentChronic Pain Neuro-Musc-Skeletal No 2 30 Not effective ConsistentChronic Pain Spinal Injury Unknown 3 173 Effective Low quality, inconsistentChronic Pain Back Pain Unknown 2 95 Mixed Low quality, inconsistentChronic Pain Joint Pain Unknown 2 94 Effective Low quality, inconsistent

Research Recommendations• Specify diagnostic criteria.24

• Carefully consider study parameters.24

• Avoid bias using GRADE criteria.22

• Use validated instruments for adverse effects.22

• Validate the blinding procedure.22,24

Photo by Nicole Melling