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

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.