Our stimulus setting for the initial treatment took into account the recommendations of the half-age formula but also accounted for other factors that may have affected seizure threshold. Our patient's age and gender may have reduced her seizure threshold, while recent benzodiazepine treatment, possible dehydration, and use of bilateral electrode placement may have raised it. These complexities preclude a precise dosage determination. Furthermore, Kellner et al.'s suggestion that a more aggressive (suprathreshold) stimulus would have produced a more therapeutic seizure reflects research relevant to unilateral ECT treatment (1). There is no evidence that suprathreshold bilateral ECT yields a more rapid or robust clinical response. The suggestion of en bloc ECT in this setting is interesting but not one we would currently endorse. The evidence base for this treatment approach is anecdotal and includes cases of neuroleptic malignant syndrome. The only prospective, randomized comparison of single- and double-ECT stimulations studied treatment-resistant depressed populations (2). Indeed, catatonic patients are often exquisitely responsive to ECT and may even show response after one treatment (3), making the initial administration of multiple seizures unnecessarily aggressive.