Lorazepam Dose Escalation for Psychosis in Adolescents
No, do not increase lorazepam beyond 1 mg three times daily (3 mg/day total) for managing psychosis in a 17-year-old, as this exceeds the maximum recommended daily dose of 2 mg/24 hours for adolescents and young adults, and benzodiazepines are not appropriate monotherapy for psychotic symptoms. 1, 2
Maximum Dosing Limits in Adolescents
The pediatric guideline from the American Academy of Pediatrics specifies a maximum single dose of 5 mg for lorazepam in psychosis with agitation, with doses repeated hourly as necessary, but does not support chronic dosing at 1 mg TDS (3 mg/day total) in adolescents. 1
Standard adult dosing is 0.5-1 mg four times daily with a maximum of 4 mg/24 hours, but elderly or debilitated patients require reduced doses of 0.25-0.5 mg with a maximum of 2 mg/24 hours. 1, 2 A 17-year-old should be treated more conservatively, closer to the reduced dosing parameters.
Your current regimen of 1 mg TDS (3 mg/day) already approaches or exceeds safe limits for this age group. 2
Why Benzodiazepines Are Inappropriate for Psychosis Management
Lorazepam is indicated for acute agitation associated with psychosis, not for treating the underlying psychotic symptoms themselves. 1, 3, 4 The research evidence consistently shows benzodiazepines are used as adjuncts to antipsychotics, not as primary treatment for psychosis. 3, 5, 6
When lorazepam is used for psychotic agitation, it should be limited to the acute episode only, not continued chronically. 2 The guideline explicitly states treatment duration should be "limited to the acute episode only."
Regular benzodiazepine use leads to tolerance, addiction, depression, and cognitive impairment. 2 This is particularly concerning in a developing adolescent brain.
Critical Safety Concerns at Higher Doses
Approximately 10% of patients experience paradoxical agitation with benzodiazepines, which could worsen rather than improve the clinical picture. 2
There is increased risk of respiratory depression when benzodiazepines are combined with other sedatives or antipsychotics. 2, 7
Hypotension and dystonic reactions may occur with lorazepam administration. 1
Appropriate Management Strategy
If the patient requires ongoing management of psychotic symptoms, initiate or optimize antipsychotic medication (such as risperidone 2-6 mg/day), not increase benzodiazepine dosing. 3, 5 Research demonstrates that risperidone plus lorazepam is effective for acute psychotic agitation, but the antipsychotic is the primary therapeutic agent. 3, 5
If acute agitation persists despite current lorazepam dosing, consider single PRN doses of lorazepam 0.5-1 mg (not scheduled increases) while addressing the underlying psychosis with appropriate antipsychotic therapy. 1
If lorazepam has been used beyond 1-2 weeks, plan for gradual taper rather than dose escalation to minimize withdrawal symptoms. 2
Common Pitfall to Avoid
The most critical error would be treating psychosis with escalating benzodiazepine monotherapy. This approach fails to address the underlying pathophysiology, exposes the adolescent to significant risks of dependence and cognitive impairment, and delays appropriate antipsychotic treatment. 2, 4 Benzodiazepines have a role in acute behavioral control but should never substitute for definitive antipsychotic therapy in managing psychotic disorders.