The authors compared the efficacy of titrated, moderate-dose and fixed, high-dose strategies for right unilateral (RUL) electroconvulsive therapy (ECT) in a group of elderly patients. Nineteen depressed patients (mean age 76 years) were randomized to receive either fixed, high-dose RUL ECT (n = 10) or titrated, moderate-dose RUL ECT (n = 9). Blind Hamilton Rating Scale for Depression ratings were made before and after each treatment. Patients on the fixed, high-dose regimen responded faster and received fewer treatments (mean = 5.7) than the titrated, moderate-dose group (mean = 8.0). The fixed, high-dose group received greater cumulative stimulus charge but less cumulative EEG seizure time. Final depression ratings and memory self-ratings were similar for the two groups.