Approaches for difficult-to-induce-seizures electroconvulsive therapy cases (DEC): a Japanese expert consensus

Seizure threshold increases with age and the frequency of electroconvulsive therapy (ECT). Therefore, therapeutic seizures can be difficult to induce, even at maximum stimulus charge with available ECT devices. Such cases are known as difficult-to-induce-seizures electroconvulsive therapy cases (DECs). However, no clinical guidelines exist for DECs; thus, clinicians often face difficulties determining treatment strategies. This study aimed to obtain a consensus among clinical experts regarding the treatment of DECs. We asked Japanese ECT experts to rate 14 approaches under six conditions of DECs on a 9-point Likert scale (1 = "disagree" to 9 = "agree"). Based on responses from 195 experts, the approaches were classified as first-line (95% confidence interval mean ≥ 6.5), second-line (mean, 3.5-6.5), or third-line strategies (mean