Systematic Review of Dose Titration in ECT

Out on Pubmed, from researchers in Montreal, Quebec, Canada is this systematic review:

The clinical relevance of dose titration in electroconvulsive therapy: A systematic review of the literature.

Landry M, Lafrenière S, Patry S, Potvin S, Lemasson M.Psychiatry Res. 2020 Oct 3;294:113497. doi: 10.1016/j.psychres.2020.113497. Online ahead of print.PMID: 33039882
The abstract is copied below:

Electroconvulsive therapy is a highly effective treatment of several psychiatric disorders. The debate regarding which charge dosing method offers the most favorable risk-benefit ratio remains. Our objective was to review the comparative evidence regarding efficacy and tolerability of dose titration (DT) vs other charge dosing methods, such as the age-based method (ABM) and the fixed dose method. Our secondary objective was to examine which populations would most benefit from DT. We conducted a systematic review of the literature in March 2020. Studies comparing DT to another charge dosing method were included. Fourteen articles depicting hypothetical comparisons between DT and another dosing method were found and seven articles made hypothetical comparisons without measurement of clinical outcomes.**Although there is a trend in favor of DT in these articles, no clear recommendations could be drawn regarding the clinical superiority of one method. Older patients could be at higher risk of overstimulation with ABM, especially older women. The lack of high-quality prospective trials was a limitation as well as the fact that many studies used suprathreshold stimulus intensity deemed insufficient according to recent guidelines. This review emphasizes that more studies are needed to establish the differential clinical relevance of each method.

Keywords: Age-based method; ECT; Efficacy; Fixed high dose; Half-age method; Side effects; Stimulus intensity.

On the one hand this review is a hot mess, reflecting the variable quality and diverse methodologies used in the studies reviewed. On the other hand, clinical ECT is so reliably effective and well tolerated, that electrical stimulus dosing strategies in the real world must be working.
This review shows that the research base for dose titration is pretty thin; in my opinion, the widely accepted dogma of the need for RUL to be 6X ST was accepted way prematurely. Has clinical use of this formula proven it to be correct? Possibly, but larger, well-designed studies would need to be done to be sure.
Since efficacy is paramount with ECT, in general it would seem prudent to err on the side of being somewhat liberal with stimulus dosing, rather than obsessionally stingy.

**(I believe this is an error in the abstract: the text says they found 14 articles with hypothetical comparisons of dosing methods  and 7 articles with clinical comparisons.)







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