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Does change in ECT electrode placement help temporomandibular joint pain?

Nagy A. Youssef, MD

Charlie Norwood VA Medical Center, Department of Psychiatry and Human Behavior, Medical College of Georgia, Georgia Regents University, Augusta, Georgia, USA, Durham VA Medical Center, Durham, North Carolina, USA

Richard D. Weiner, MD, PhD

Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham VA Medical Center, Durham, North Carolina, USA

KEYWORDS: temporomandibular joint electroconvulsive therapy, electrode placement, depression



Because of the high efficacy of electroconvulsive therapy (ECT), the field progresses mostly by mitigating adverse effects, rather than improving efficacy of ECT. We present the case of a man with medication-resistant depression who had exacerbation of temporomandibular joint disorder (TMJ) pain during a course of ECT. A PubMed search did not retrieve any reports that help guide clinical decision-making in this situation.

Case report

Mr. Z, age 32, was referred for ECT by his psychiatrist for a severe major depressive episode with suicidal ideation and significant functional impairment diagnosed according to DSM-IV. He is right-handed, and experienced onset of major depressive disorder at age 18 that did not respond to treatment. On presentation, Mr. Z’s Montgomery-Åsberg Depression Rating Scale (MADRS) score was 38.

Medications prescribed when Mr. Z presented for ECT consultation were methylphenidate extended-release, 30 mg/d, modafinil, 200 mg/d, clonazepam, 1 mg at bedtime, levothyroxine, 88 mcg/d, and ketorolac, 50 mg as needed. For several years, Mr. Z did not respond to psychotherapy or trials of psychotropic medications of adequate strength and duration—including several selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors, and augmentations with lithium, divalproex, aripiprazole, and dextroamphetamine. Mr. Z’s medical history included TMJ, hypothyroidism, and inflammatory bowel disease. He had no other psychiatric comorbidities.

Because of treatment-resistance, the consulting psychiatrist decided that Mr. Z should start an index course of right unilateral ultra brief ECT followed by maintenance ECT to prevent depressive relapse. Six index sessions resulted in remission of depression (MADRS = 1). Severe right jaw pain developed and worsened after the ECT sessions. Mr. Z’s 0 to 10 Numeric Pain Rating Scale (NRS) score was 10 by the sixth session, despite use of ketorolac, 30 mg IV, before each session. Mr. Z decided to stop ECT.

Mr. Z’s primary care physician and maxillary facial surgeon confirmed TMJ exacerbation. After 2 weeks, depressive symptoms recurred (MADRS = 18). Mr. Z received 2 more ECT treatments but could not continue because his jaw pain returned, with no decrease in MADRS score.

After 2 months, Mr. Z’s depressive symptoms worsened (MADRS = 36) and he decided to undergo further ECT. Only 3 right unilateral treatments were given before his severe jaw pain returned. Therefore, Mr. Z’s treating psychiatrist decided to switch to non-standard bilateral electrode placement: 1 inch above standard placement (standard being 1 inch above the midline of the tragus and eye canthus). Mr. Z’s jaw pain resolved (NRS = 0). Depressive symptoms remitted (MADRS = 2) by the fifth index treatment. He received 4 maintenance sessions before Mr. Z decided to stop (MADRS = 3). Mr. Z continued to do well at 1-month follow-up and at the time this report was written (3 months after follow-up).


In this case, increasing the muscle relaxant dose would not prevent pain caused by direct nerve stimulation. There are concerns that using non-standard electrode placement would reduce or abate ECT efficacy.1,2 This case demonstrates that modification in placement as described above could mitigate TMJ pain and allow continuation of ECT without compromising efficacy. Similarly, focal electrically administered seizure therapy (FEAST) seems to reduce cognitive adverse effects.3,4 Further research is needed to study the benefit and efficacy of these investigational placements.

DISCLOSURE: Dr. Youssef receives support from the National Institute of Mental Health, grant No. 1U01 MH084241. Dr. Weiner receives support from the National Institute of Mental Health, grant No. 1U01 MH084241, and the VA Mid-Atlantic Mental Illness Research Education and Clinical Center. He also is a coinventor on a Duke University patent (U.S. Patent 5,626,627) that is licensed to Mecta Corp but does not personally receive royalties.


  1. Kellner CH, Tobias KG, Wiegand J. Electrode placement in electroconvulsive therapy (ECT): a review of the literature. J ECT. 2010;26:175–180.
  2. Kellner CH, Knapp R, Husain MM, et al. Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial. Br J Psychiatry. 2010;196:226–234.
  3. Nahas Z, Short B, Burns C, et al. A feasibility study of a new method for electrically producing seizures in man: focal electrically administered seizure therapy [FEAST]. Brain Stimul. 2013;6:403–408.
  4. Spellman T, Peterchev AV, Lisanby SH. Focal electrically administered seizure therapy: a novel form of ECT illustrates the roles of current directionality polarity, and electrode configuration in seizure induction. Neuropsychopharmacology. 2009;34:2002–2010.

CORRESPONDENCE: Nagy A. Youssef, MD, 1 Freedom Way, Augusta, GA 30904, USA, E-MAIL: nagy.youssef@va.gov