Dosing methods in electroconvulsive therapy: should the Scandinavian time-titration method be resumed?

Abstract

Aim

To describe and evaluate the different dosing methods in ECT, and bringing back into focus the Scandinavian time-titration method.

Method

A narrative, unsystematic, and selective review and discussion.

Results

There are five dosing methods: 1) The Scandinavian time-titration to tonic convulsion, using low-frequency pulses and a long maximal pulse train duration, was highly efficacious with right unilateral (RUL) ECT, comparable to bitemporal (BT) ECT. However, the device used went out of production in the 1990s. Because US devices until 1990 had a short maximal pulse train duration, time-titration went out of use. 2) Fixed high dosing at 50–100% of the device’s maximal output, and 3) Formula-based dosing, initially the Age method, long prevailed in USA. Later, the Half-Age method was introduced for BT ECT. 4) Charge-dosing as a multiple of titrated seizure threshold (ST) demonstrated RUL and BT ECT to have comparable outcomes when dosed about six and two times the ST, respectively. 5) Dosing from benchmark is based on a high dose at the first session, to ensure a high peak heart rate and tonic-clonic convulsions. In later sessions the lowest dose producing similar outcomes is chosen.

Conclusions

No dosing method is documented superior to the others. Seizure threshold-based and benchmark dosing seems to be more accurate than fixed high and formula-based dosing. However, time-titration dosing makes it possible to adjust the dose at every session, and may be the most efficient method.

Keywords:

• Electroconvulsive therapy
• dosing
• titration
• pulse train
• pulse frequency

Disclosure statement

There are no conflicts of interest associated with this publication, and there has been no financial support for this work that could have influenced its outcome.

Data availability statement

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Notes on contributors

Per Bergsholm

Per Bergsholm (b. 1945) is a Norwegian specialist in neurology, clinical neurophysiology, and psychiatry. He has a dissertation on ECT guided by Giacomo d'Elia, and has published about 50 papers, mostly on mood disorders and ECT. He participates in providing national courses on ECT for Norwegian clinicians.

Tor Magne Bjølseth

Tor Magne Bjølseth (b. 1965) has since 2002 worked as a senior consultant in geriatric psychiatry at Diakonhjemmet Hospital, Oslo. He is in charge of the ECT clinic at the hospital. In 2016 he defended his thesis on predicting the treatment outcome of ECT, emphasizing the post-ictal reorientation time.