Background: Electroconvulsive therapy (ECT) is used as an augmentation strategy in treatment-resistant schizophrenia, but real-world data on individualized seizure threshold-guided treatment remain limited. This study evaluated clinical outcomes of seizure threshold-titrated ECT and described seizure expression and technical treatment parameters during acute ECT courses. Methods: A retrospective naturalistic study included acute ECT courses performed between March 2022 and December 2025 at the ECT Department of the Dr. Gh. Preda Clinical Psychiatric Hospital, Sibiu, Romania. We assessed clinical outcomes at baseline and post-treatment using the PANSS Positive Subscale (PANSS-P), Global Assessment of Functioning (GAF), and Mini-Mental State Examination (MMSE). ECT was delivered using individualized seizure threshold titration alongside stable psychotropic treatment. Electrode placement, stimulation parameters, and motor and electroencephalographic (EEG) seizure characteristics were recorded throughout the treatment course. Results: Seventeen acute ECT courses with paired assessments were analyzed. Median PANSS-P scores decreased from 45 (IQR, 39–48) at baseline to 16 (IQR, 14–20) following ECT (p < 0.001), with a Hodges–Lehmann estimated paired reduction of 26 points. Median GAF scores increased from 44 (IQR, 40–45) to 60 (IQR, 60–65), while median MMSE scores changed from 26 (IQR, 26–28) to 29 (IQR, 28–30). Motor and EEG seizure durations varied substantially across courses and sessions. Right unilateral and bilateral electrode placements were used with similar frequency. Discussion: Our results align with the existing literature on ECT as an augmentation strategy for persistent positive symptoms in treatment-resistant schizophrenia. Improvement in positive psychotic symptoms was accompanied by better global functioning, while the MMSE detected no deterioration in global cognitive performance. The considerable variability in motor and EEG seizure durations further suggests that seizure duration alone may provide limited information regarding clinical improvement. Conclusions: In this retrospective naturalistic cohort, individualized seizure threshold-titrated ECT alongside stable pharmacotherapy was associated with substantial improvement in positive psychotic symptoms and global functioning, without detectable deterioration in global cognitive performance. Given the small sample, the observational design, and absence of a control group, these findings remain preliminary and require confirmation in larger prospective controlled studies.
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Anghel et al. (2026) studied this question.