Rapid tranquilization: antipsychotics or benzodiazepines?

With the advent of rapid tranquilization (RT), psychiatrists were able to intervene quickly and effectively with psychotic, agitated, and potentially assaultive patients. As RT often obviated the need for physical restraints, it became a mainstay in emergency psychiatry. While studies have repeatedly demonstrated the safety and efficacy of antipsychotic medication to achieve RT, there has been some concern about potential untoward side effects, such as neuroleptic malignant syndrome, tardive dyskinesia, and extrapyramidal symptoms. As a result, many investigators have begun exploring alternatives to the use of antipsychotics for RT. Benzodiazepines are among the classes of drugs most often discussed. The author reviews the current literature on both antipsychotics and benzodiazepines and summarizes the results of several extensive reviews of RT that have appeared in the past few years. The author also critically examines the literature on the use of benzodiazepines for RT, with emphasis on lorazepam and clonazepam. Finally, the author proposes tentative guidelines for RT and directions for future clinical research.