Treatment choice in neuroleptic malignant syndrome

A literature review of patients with symptomatic neuroleptic malignant syndrome (NMS) treated with electroconvulsive therapy (ECT) yielded 26 cases, to which we add five cases. ECT was associated with a positive outcome in 26 of 31 cases with one unclear outcome and a poor outcome in four cases, including two deaths. ECT appeared to be effective in eight of nine patients previously treated with dantrolene and/or bromocriptine; no difference in time to apparent response was seen between those treated with medication first and those undergoing ECT first. The mean time to clinical response after the first ECT was 1.46 +/- 2.38 days, with 19 of 20 having a clinical response by 72 h. The possible relationship of ECT to the two deaths is discussed. Given this experience, the suggested treatment sequence is medication (dantrolene or bromocriptine) for 48 h; if no clinical response is seen, ECT should be initiated. ECT may be used earlier in response to specific clinical situations.