Can Quetiapine (quetiapine) help manage hallucinations induced by Trazodone (trazodone) and Ativan (lorazepam)?

Quetiapine for Drug-Induced Hallucinations: Not the Right Approach

The priority should be to discontinue or reduce the offending medications (trazodone and lorazepam) rather than adding quetiapine to treat drug-induced hallucinations, as benzodiazepines like lorazepam are known to cause paradoxical agitation and delirium in approximately 10% of patients, and both agents can contribute to cognitive impairment. 1

Critical First Step: Identify and Remove the Cause

• Benzodiazepines, including lorazepam (Ativan), are recognized as deliriogenic agents that can cause tolerance, addiction, depression, cognitive impairment, and paradoxical agitation in about 10% of treated patients 1
• Trazodone is classified as a mood-stabilizing agent that can contribute to hallucinations and delirium, particularly when combined with other sedating medications 1
• The appropriate management is to taper and discontinue these medications rather than adding another psychoactive agent 1

Why Adding Quetiapine Is Problematic

While quetiapine is indicated for managing hallucinations and delusions in specific contexts (Alzheimer's disease, Parkinson's disease, primary psychotic disorders), using it to treat medication-induced hallucinations creates several problems:

• Polypharmacy increases risk: Adding quetiapine (starting dose 12.5 mg twice daily, maximum 200 mg twice daily) to an already problematic medication regimen compounds sedation, orthostatic hypotension risk, and cognitive impairment 1
• Recent safety data raises concerns: A 2025 study demonstrated that low-dose quetiapine in older adults is associated with significantly increased mortality (HR 3.1), dementia (HR 8.1), and falls (HR 2.8) compared to trazodone 2
• Quetiapine itself can cause delirium: Case reports document prolonged delirium following quetiapine use, with antimuscarinic effects contributing to confusion 3

The Correct Management Algorithm

Step 1: Medication Review and Reduction

• Immediately assess for other causes of hallucinations (metabolic disturbances, infections, other medications) 4
• Taper lorazepam gradually to avoid withdrawal seizures while eliminating its deliriogenic effects 1
• Reduce or discontinue trazodone, which may be contributing to the hallucinations 1

Step 2: Non-Pharmacological Interventions

• Provide reorientation and cognitive stimulation regularly 4
• Implement good sleep hygiene practices 4
• Educate family members about the nature of drug-induced delirium to reduce distress 1, 4

Step 3: If Hallucinations Persist After Medication Withdrawal

• Only then consider quetiapine if hallucinations continue after offending agents are removed and represent a primary psychiatric condition rather than drug-induced symptoms 4
• Start at 25 mg at bedtime with careful titration 4
• Monitor closely for sedation, orthostatic hypotension, and metabolic effects 1, 4

Important Caveats

• Quetiapine is effective for primary psychotic symptoms (positive and negative symptoms of schizophrenia, hallucinations in Parkinson's disease and dementia) but is not indicated for treating iatrogenic hallucinations 5, 6, 7
• The sedating properties of quetiapine may seem appealing but actually worsen the underlying problem when combined with trazodone and benzodiazepines 1
• In elderly patients, the mortality and dementia risks of quetiapine are particularly concerning and should prompt extreme caution 2

The fundamental error in this scenario is treating a medication side effect with another medication rather than removing the causative agents.