Can electroconvulsive therapy (ECT) induce neuroleptic malignant syndrome (NMS)?

Electroconvulsive Therapy and Neuroleptic Malignant Syndrome

Yes, electroconvulsive therapy (ECT) can be used to treat neuroleptic malignant syndrome (NMS) and is considered an effective therapeutic option, especially when pharmacological treatments fail. 1

Understanding Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome is a potentially lethal condition characterized by:

• A tetrad of symptoms including mental status changes, fever, muscle rigidity/hypertonicity, and autonomic dysfunction 1
• Pathophysiology involving deficiency of central dopaminergic activity, primarily affecting D2 receptors 1
• Occurrence due to dopamine antagonists, dopamine receptor blockade, dysfunction of dopamine receptors, or withdrawal of dopamine agonists 1

ECT as Treatment for NMS

ECT is specifically indicated for NMS in the following circumstances:

• When the condition is severe and persistent 1
• When pharmacological treatments (such as dantrolene or bromocriptine) have failed 2, 3
• When the patient has concurrent psychiatric conditions that would also benefit from ECT 1

Effectiveness of ECT for NMS

• Clinical response is typically observed after the first or second ECT session 2
• Complete resolution of NMS symptoms often occurs by the third or fourth session 2
• The mean time from initial ECT to complete resolution is approximately 6 days 2
• ECT has shown effectiveness even in cases where drug therapy has failed 3

Treatment Algorithm for NMS

1. First-line treatment: Pharmacotherapy with dantrolene or bromocriptine for 48 hours 4
2. If no clinical response after 48 hours of medication: Initiate ECT 4
3. Consider earlier ECT initiation in specific clinical situations such as:
   • Life-threatening symptoms 1
   • When the underlying psychiatric diagnosis is psychotic depression or catatonia 3
   • When lethal catatonia cannot be ruled out 3

Safety Considerations

• ECT is generally well-tolerated in NMS patients 2, 5
• The mortality rate for ECT-treated NMS (10.3%) is substantially lower than for untreated NMS (21%) 6
• Bitemporal electrode placement may be preferred for treating NMS 5
• Patients should be monitored for potential cardiovascular complications 3
• Neuroleptic medications should be discontinued during ECT treatment for NMS 6

Treatment Course

• Clinical response typically occurs within 72 hours after the first ECT in most patients 4
• An average of 4-6 ECT treatments may be needed for initial response 3, 5
• Extended treatment (average 17.7 treatments) may be necessary to minimize recurrence of catatonic signs 5

Monitoring and Follow-up

• Close monitoring during and after treatment is essential until the patient is fully recovered 1
• Monitoring should include observation of seizure duration, airway patency, vital signs, and adverse effects 1
• Patients should be monitored for at least 24 hours for potential tardive seizures 1
• A neurology consultation should be obtained if recurrent prolonged seizures or tardive seizures occur 1

ECT represents an important treatment option for NMS, particularly in cases refractory to pharmacotherapy, with evidence supporting its safety and efficacy in this potentially life-threatening condition.