Is lorazepam (Ativan) effective for treating acute psychosis?

From the Guidelines

Lorazepam should not be used as a primary treatment for acute psychosis, but it can be considered as an adjunctive treatment in certain cases, particularly when combined with antipsychotic medications. When considering the use of lorazepam for acute psychosis, it is essential to prioritize the patient's overall treatment plan, which should include evidence-based nonpharmacological and pharmacological treatments, as recommended by the American Psychiatric Association 1. The primary goal of treatment should be to reduce morbidity, mortality, and significant psychosocial and health consequences of the psychiatric condition. In cases where lorazepam is used, it is crucial to limit the duration of treatment to short-term use (days to weeks) due to the risks of dependence and tolerance. Lorazepam can be useful when psychosis is accompanied by severe agitation, anxiety, or catatonia, and it works by enhancing the inhibitory effects of GABA in the brain, which helps reduce anxiety, agitation, and muscle tension. However, side effects, such as sedation, dizziness, and respiratory depression, especially when combined with other CNS depressants, must be carefully monitored, particularly when administered parenterally. For elderly patients or those with hepatic impairment, lower doses (0.5-1 mg) are recommended. It is also important to note that lorazepam does not treat the underlying psychotic disorder, so antipsychotic medication remains the primary treatment for psychosis, as recommended by the American Psychiatric Association 1. In the emergency department setting, a benzodiazepine (lorazepam or midazolam) or a conventional antipsychotic (droperidol or haloperidol) can be used as effective monotherapy for the initial drug treatment of the acutely agitated undifferentiated patient, as suggested by the Annals of Emergency Medicine 1. Ultimately, the decision to use lorazepam for acute psychosis should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances, and with careful consideration of the potential benefits and risks. Key points to consider when using lorazepam for acute psychosis include:

• Limiting the duration of treatment to short-term use (days to weeks)
• Combining lorazepam with antipsychotic medications
• Monitoring for side effects, such as sedation, dizziness, and respiratory depression
• Using lower doses (0.5-1 mg) for elderly patients or those with hepatic impairment
• Prioritizing antipsychotic medication as the primary treatment for psychosis.

From the Research

Lorazepam for Acute Psychosis

• Lorazepam is often used in combination with antipsychotics for the treatment of acute psychotic agitation due to its sedative properties and relatively benign adverse effect profile 2.
• A study compared the efficacy and safety of oral treatment with risperidone plus lorazepam with those of standard intramuscular treatment with haloperidol plus lorazepam, and found that both treatments were effective and well tolerated 3.
• Another study found that olanzapine, risperidone, and quetiapine were as effective as haloperidol in the treatment of psychotic agitation, with fewer extrapyramidal symptoms 4.
• Lorazepam is also used in combination with haloperidol and promethazine for the treatment of acute agitation, with the combination of haloperidol and promethazine being a possible best choice based on empirical evidence 5.
• A recent study found that intramuscular olanzapine was effective for rapid sedation in acute undifferentiated agitation, and was as efficacious as haloperidol with lorazepam in agitation due to psychiatric diseases 6.

Treatment Options

• The treatment of acute agitation in psychiatric patients often involves the use of benzodiazepines, antipsychotics, and other medications 5.
• The choice of treatment depends on various factors, including the underlying cause of the agitation, the patient's medical history, and the clinician's experience 5.
• Lorazepam is a commonly used benzodiazepine for the treatment of acute agitation, due to its rapid onset of action and relatively short half-life 2.
• Atypical antipsychotics, such as olanzapine and risperidone, are also effective in the treatment of acute agitation, with fewer extrapyramidal symptoms compared to typical antipsychotics 4, 6.

Efficacy and Safety

• The efficacy and safety of lorazepam in combination with antipsychotics for the treatment of acute psychotic agitation have been established in several studies 3, 2, 6.
• Lorazepam is generally well tolerated, with minimal side effects, although it can cause sedation and respiratory depression in high doses 2.
• The combination of lorazepam with antipsychotics, such as haloperidol and risperidone, can increase the risk of extrapyramidal symptoms and other adverse effects 4, 5.