Is lorazepam (Ativan) a suitable daily medication for a patient with bipolar disorder, Attention Deficit Disorder (ADD), and anxiety?

Lorazepam Is Not Recommended as a Daily Medication for Patients with Bipolar Disorder, ADD, and Anxiety

Benzodiazepines like lorazepam should not be used as daily medications for patients with bipolar disorder, ADD, and anxiety due to significant risks of tolerance, addiction, cognitive impairment, and potential mood destabilization. 1, 2

Concerns with Daily Lorazepam Use

• Regular use of benzodiazepines can lead to tolerance, addiction, depression, and cognitive impairment 1
• Approximately 10% of patients treated with benzodiazepines experience paradoxical agitation 1
• Benzodiazepines should be avoided in patients with comorbid bipolar disorder, as they may worsen mood instability 2
• Long-term benzodiazepine use is particularly problematic for patients with substance use disorders, which are common in bipolar disorder (affecting up to 60% of individuals) 2, 3
• Benzodiazepines are recommended only as third-line therapy according to the Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines 2

Preferred Treatment Approach for This Complex Presentation

First Priority: Mood Stabilization

• Establish mood stabilizer therapy before addressing anxiety symptoms 2
• FDA-approved options for bipolar disorder include:
  • Lithium (approved for ages 12+ for acute mania and maintenance therapy) 1
  • Valproate, aripiprazole, olanzapine, risperidone, quetiapine, and ziprasidone (approved for acute mania in adults) 1
  • Lamotrigine and olanzapine (approved for maintenance therapy) 1

Second Priority: ADHD Treatment

• After mood stabilization, address ADHD symptoms with caution 4
• Non-stimulant options may be safer in bipolar disorder:
  • Atomoxetine may be effective for ADHD symptoms in bipolar patients when used with mood stabilizers, though it carries a modest risk of (hypo)manic switches 4
• Stimulants should be used cautiously and only after mood stabilization, as they may potentially trigger manic episodes 4

Third Priority: Anxiety Management

• For anxiety symptoms, consider the following alternatives to benzodiazepines:
  • Mood stabilizers with anti-anxiety properties:
    • Valproate (initial dosage: 125 mg twice daily; titrate to therapeutic blood level of 40-90 mcg/mL) 1
    • Lamotrigine addition to lithium has shown efficacy in reducing anxiety symptoms in bipolar patients 5
  • Second-generation antipsychotics:
    • Olanzapine addition to lithium has demonstrated effectiveness for anxiety in bipolar disorder 5
    • Quetiapine has anxiolytic properties and is approved for bipolar disorder 1
    • Cariprazine shows promise for treating both mood symptoms and cognitive dysfunction in bipolar disorder 3
  • Non-benzodiazepine anxiolytics:
    • Buspirone (initial dosage: 5 mg twice daily; maximum: 20 mg three times daily) may be useful for mild to moderate anxiety but may take 2-4 weeks to become effective 1

Psychotherapeutic Approaches

• Cognitive-behavioral therapy (CBT) is effective for anxiety symptoms in euthymic bipolar patients 2
• Interpersonal and relaxation therapy can also help manage anxiety symptoms 2
• Sleep hygiene therapy and stimulus control may help with insomnia components of anxiety 1

Monitoring and Precautions

• Monitor for mood switches if any antidepressant is used 1, 2
• If a benzodiazepine must be used short-term (not recommended as daily medication):
  • Use infrequent, low doses of agents with short half-lives 1
  • Consider for acute management only, such as during severe agitation 6
  • Closely monitor for tolerance, dependence, and cognitive effects 1
• Regularly assess for substance use disorders, which complicate treatment 2, 3

Special Considerations

• Patients with bipolar disorder and comorbid anxiety have more severe symptoms, worse course of illness, and poorer outcomes 2, 4
• The risk of suicidality is increased in patients with comorbid bipolar disorder and anxiety 2
• Treatment should follow a hierarchical approach, with mood stabilization preceding treatment of ADHD and anxiety symptoms 4