Lorazepam for Psychosis: Role and Recommendations
Lorazepam is not recommended as a first-line treatment for psychosis but can be used as an adjunctive treatment for psychosis with agitation at a dose of 0.05-0.15 mg/kg (maximum single dose: 5 mg). 1
Role in Psychosis Management
- Lorazepam should not be used as a primary treatment for psychosis without agitation, as benzodiazepines are not indicated for treating the core symptoms of psychotic disorders 1
- Lorazepam is specifically indicated for psychosis with agitation as noted in pediatric emergency guidelines, where it can help manage the acute agitation component 1
- Benzodiazepines like lorazepam should be employed only if behavioral interventions have failed or are not possible, and ongoing use should be evaluated daily 1
Dosing and Administration
- For psychosis with agitation: IM/IV dosing at 0.05-0.15 mg/kg, may repeat hourly as necessary with a maximum single dose of 5 mg 1
- When used, lorazepam should be administered at the lowest effective dose for the shortest possible duration to minimize risks 1
- Caution is warranted as repeated doses can prolong QT interval and potentially precipitate torsades de pointes 1
Combination Therapy Approach
- Oral risperidone plus oral lorazepam has been shown to be at least as effective as intramuscular conventional neuroleptics in the emergency treatment of acute psychosis 2
- This combination (risperidone 2 mg plus lorazepam 2 mg) rapidly reduces symptoms, including aggression, and causes fewer extrapyramidal symptoms compared to standard intramuscular treatment 2, 3
- Studies have demonstrated that oral risperidone (2 mg) plus lorazepam (2 mg) is as effective as parenteral haloperidol plus lorazepam for rapid control of agitation and psychosis 4
Warnings and Precautions
- The FDA warns that lorazepam use exposes patients to risks of abuse, misuse, and addiction, which can lead to overdose or death 5
- Lorazepam is not recommended for use in patients with a primary depressive disorder or psychosis without agitation 5
- Pre-existing depression may emerge or worsen during use of benzodiazepines including lorazepam 5
- Abrupt discontinuation can lead to withdrawal reactions, which can be life-threatening (e.g., seizures) 5
Clinical Considerations and Alternatives
- Antipsychotic medications, not benzodiazepines, are the recommended first-line treatment for the psychotic symptoms of schizophrenia 1
- For patients with cardiomyopathy or cardiac concerns, risperidone combined with lorazepam may be considered for cooperative patients with agitation 6
- In older adults with postoperative delirium, benzodiazepines should not be used as first-line treatment except when specifically indicated (e.g., alcohol or benzodiazepine withdrawal) 1
Important Clinical Pitfalls
- Avoid using lorazepam as monotherapy for psychosis without agitation, as there is no evidence supporting this practice 1
- Be aware that lorazepam can cause hypotension and dystonic reactions 1
- Monitor for signs of respiratory depression, especially when combined with other CNS depressants 5
- Prescribe the lowest effective dosage and avoid or minimize concomitant use of CNS depressants and other substances associated with abuse and misuse 5
When treating psychosis, antipsychotic medications should be the foundation of pharmacological management, with lorazepam reserved primarily as an adjunctive treatment for managing agitation in the acute setting.